Using volar vascular grafts for scaphoid nonunions yielded 53% excellent results

Investigators: Bone grafts harvested from the radius are indicated for scaphoid nonunions.

Issue: November 2008

French hand surgeons studying their short-term results treating scaphoid fracture nonunions that had limited bone loss reported good success using vascularized autograft bone harvested from the palmar aspect of the radius. Union was seen early, at an average of about 8 weeks after implantation, they said.

Graft vascularization comes from the volar carpal artery, investigators explained.

“We think it is a very good technique for the primary treatment of scaphoid nonunion,” according to Christophe L. Mathoulin, MD, of Paris, who reported outcomes in 103 of his patients at the American Society for Surgery of the Hand (ASSH) 63rd Annual Meeting in Chicago.

Vascularization of the volar graft is indicated by red markers for the volar carpal artery from the radial artery, yellow markers for the distal branch of the volar interosseous artery and blue markers for the lateral branch of the ulnar artery.

Images: Mathoulin CL

$The origin of the scaphoid fracture in this 6-year-old boy was unknown$
The origin of the scaphoid fracture in this 6-year-old boy was unknown. His nonunion produced disabling pain, making him a candidate for a volar vascularized bone graft based on the indications, according to Mathoulin.

The boy’s scaphoid graft was fixed with a single screw and his wrist was casted until union occurred about 45 days later.

Outpatient procedure

The surgical grafting technique was also effective for some of his challenging cases. For example, it produced bone union in three of five cases involving scaphoids with necrotic proximal poles.

Jesse B. Jupiter, MD, who discussed the paper at the meeting, said, “There are many reasons to come to this ASSH meeting, but to hear a paper like this from such an experienced and talented surgeon has to be one of them.”

During the fractures and dislocation section of the meeting, Mathoulin reported his results with the technique in a cohort of mostly young patients with a mean age of 30.6 years (range 15 to 61 years). He showed several photographs of the surgical technique, which he performs using regional anesthesia.

Mathoulin has had the best success using a volar approach to the scaphoid and then harvesting the vascularized graft from the volar aspect of the radius.

Among the 12 women and 91 men Mathoulin operated on, 34 patients or 33% underwent previous surgery at the same site to fix the fracture or resolve the nonunion. That earlier treatment typically involved applying other types of grafts or screws, he said.

In 90 cases, the fracture nonunion was in the waist of the scaphoid and it was in the proximal pole in 13 cases.

Patients were examined at about 30 months on average with excellent results in 53% and good results in 30% of cases. The overall union rate was 94%.

The surgeon harvests the vascularized graft from the volar aspect of the radius. The graft is vascularized by the volar carpal artery.

Once the scaphoid is reduced appropriately, the graft is placed in the area of volar scaphoid bone loss.

Increased ROM

According to results of postoperative flexion and extension testing, mean preoperative flexion of 45° increased to 56° and extension increased from 54° to 65°.

“Our statistical analysis showed us that there is no relation with pseudarthrosis or location of the previous surgery,” Mathoulin said.

When Jupiter asked about the cases of complex regional pain syndrome noted in the investigators’ paper, Mathoulin was unsure exactly what caused them, but thought they might be related to the large size of the incision.

For more information:

Jesse B. Jupiter, MD, can be reached at Yawkey Center, 55 Fruit St., Suite 2011, Boston, MA 02114; 617-726-5100; e-mail: JJupiter1@partners.org. He has no direct financial interest in any products or companies mentioned in this article.

Christophe L. Mathoulin, MD, can be reached at Institut de la Main, Clinique Jouvenet, 6 Square Jouvenet, 75016 Paris, France; 33-1-42-15-4208; e-mail: mathoulin@wanadoo.fr. He has no direct financial interest in any products or companies mentioned in this article.

Reference:

Mathoulin CL, Sallen V, Haerle M. Volar vascularized bone graft for treatment of scaphoid nonunion. Paper #42. Presented at the American Society for Surgery of the Hand 63rd Annual Meeting. Sept. 18-20, 2008. Chicago.