Speaker: Dorsoradial approach best for vascularized bone grafting of scaphoid nonunions
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Adequate stability of vascularized bone graft constructs is critical to successful treatment of proximal pole of the scaphoid nonunions, a presenter said at the American Society for Surgery of the Hand Annual Meeting.
Ezequiel E. Zaidenberg, MD, discussed his use of a 1.2 intercompartmental supraretinacular artery vascularized bone graft during a symposium at the meeting, which was held virtually. He said he always performs this technique via a dorsoradial approach that exposes the radius and scaphoid.
“We use the 1.2 vascularized bone graft for small, proximal pole nonunions and for patients with previous surgical failures,” he said.
Zaidenberg, of Louisville, Kentucky, described steps of the procedure, which include release of the first and second dorsal compartments to identify the 1.2 artery and reach the radial artery.
“We design a graft centered on the artery, and we perform an osteotomy using a sharp osteotome. Next, we carefully release the pedicle from the radial styloid, and this is one of the key steps of the procedure. Once the pedicle has been released, we complete the osteotomy and we check the reach of the vascularized bone graft to ensure that it’s not going to be too much tension on the pedicle,” he said.
To increase the pedicle length, if needed, and to improve distal fixation of the scaphoid, Zaidenberg performs a styloidectomy. He then thoroughly debrides the nonunion, removes the graft from the radius and impacts it on the defect, after which fixation is done with screws or K-wires.
When 1.2 vascularized bone grafting is performed for previous surgical failures, Zaidenberg said these steps may be modified. A dorsoradial approach and styloidectomy are still performed as is done for a typical nonunion case. However, at the time the original screw is removed, he said he debrides the nonunion, impacts cancellous bone along the full length of the screw and places the vascularized bone graft as a bridge.
“We fix it, again, with either screws or K-wires,” which enhances stability of the construct, he said.
“Currently, we are limiting our indications for the 1.2 vascularized bone graft to small, proximal pole nonunions with no fragmentation of the proximal pole and for patients with previous surgical failures,” Zaidenberg said.
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Zaidenberg EE. Vascularized bone graft from distal radius. Presented during SYM14 at: American Society for Surgery of the Hand Annual Meeting; Oct. 1-3, 2020 (virtual meeting).
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