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Vascularized Bone Grafts in the Treatment of Preiser’s Disease

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ABSTRACT

The treatment of Preiser’s disease remains controversial. Multiple treatment options have been suggested. Recently, vascularized bone grafts have been successful in the treatment of scaphoid nonunions and Kienböck’s disease. This study examined the outcome of vascularized bone grafts for the treatment of Preiser’s disease and made recommendations for treatment based on the stage of presentation.

Between 1992 and 2002, eight pedicled vascularized bone grafts were performed as treatment for Preiser’s disease. Average patient age was 41 years (range: 31-61 years). All patients had preoperative magnetic resonance imaging (MRI) confirming the diagnosis of avascular necrosis of the scaphoid prior to surgery. All patients underwent a reverse-flow pedicled vascularized bone graft from the distal radius based on the described anatomy.

Concomitant unloading procedures were used in two of eight patients. Mean follow-up was 17 months. Postoperative evaluation included range of motion, grip strength, pain evaluation, and Mayo wrist scores. Radiographic evaluation included measurements of carpal height, scapholunate angle, and postoperative changes on MRI.

Wrist motion averaged 52% of the unaffected side postoperatively. Grip strength remained stable. Pain improvement occurred in 88% of patients. Mayo wrist scores averaged 65, with 4 patients rated as good, 3 as fair, and 1 as poor. Six of 8 patients underwent follow-up MRI at mean 6 months postoperatively. All MRIs showed evidence for revascularization, with improvement in T2-, T1-signal, or both; however, a consistent finding on MRI was the inability to revascularize the proximal pole. One frank reconstructive failure resulting in a proximal row carpectomy occurred ,1 year postoperatively. Radiocarpal arthritis was present radiographically in 50% of patients at final follow-up.

In this series, vascularized bone graft provided an improvement in pain and preserved radiocarpal wrist motion in the majority of patients. All patients were able to avoid wrist fusions. Inability to revascularize the proximal pole of the scaphoid and ongoing wrist arthritis appear to persist despite revascularization attempts. Vascularized salvage of Preiser’s patients should be limited to early cases without evidence of radiocarpal arthritis and no evidence of carpal instability. Otherwise, scaphoid excision with midcarpal fusion or proximal row carpectomy is recommended.