Outcomes of Local Bone Graft and Fixation of Proximal Pole Scaphoid Nascent Nonunions and Nonunions

Abstract Background Fractures of the proximal pole of the scaphoid have an increased risk of nonunion due to its tenuous blood supply. The optimal treatment of proximal pole scaphoid nonunions remains controversial. Objectives To review a single surgeon's experience with proximal pole scaphoid nascent nonunions (delayed unions) and nonunions that underwent surgical fixation with a cannulated headless compression screw and local autologous bone graft from the distal radius. Patients and Methods After obtaining Institutional Review Board approval, the electronic medical record of one tertiary care center was queried for patients with the diagnosis of “proximal pole scaphoid fractures” who underwent surgical fixation by a single surgeon over an 11-year period (2006–2017). Fifteen patients met initial query criteria; upon review of records, four patients were excluded due to the acute nature of the fracture, and one was excluded as surgical fixation included a vascularized bone graft. Results The final study cohort consisted of 10 patients with a total of 10 proximal pole scaphoid nonunions. Almost all of the patients in this study were male (9/10 [90%]), and sporting activities were the most common mechanism of injury (8/10 [80%]). Volumetric measurements of the scaphoid fractures on computed tomography (CT) revealed that the mean total volume of the scaphoid was 2.4 ± 0.48 cm3 and the mean volume of the proximal pole fragment was 0.38 ± 0.15 cm3. Postoperative CT scans were performed at a mean of 12.4 weeks (range: 8–16 weeks), with seven (7/10 [70%]) showing signs of complete union and three (3/10 [30%]) demonstrating partial union. None of the patients required additional procedures and there were no complications. Conclusions Our results suggest that proximal pole scaphoid fractures with delayed union and nonunion treated with surgical fixation and autologous local bone graft heal without the need for more complex vascularized procedures. The volume of the proximal pole fragment did not correlate with increased risk of ongoing nonunion after the index procedure. Level of Evidence This is a Level IV, case series study.

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Distraction subtalar arthrodesis for calcaneal malunion

The Bone & Joint Journal ◽

10.1302/0301-620x.101b5.bjj-2018-1306.r1 ◽

2019 ◽

Vol 101-B (5) ◽

pp. 596-602 ◽

Cited By ~ 3

Author(s):

A. El-Hawary ◽

Y. R. Kandil ◽

M. Ahmed ◽

A. Elgeidi ◽

H. El-Mowafi

Keyword(s):

Bone Graft ◽

Donor Site ◽

Donor Site Morbidity ◽

Control Group ◽

Study Group ◽

Control Groups ◽

Local Bone ◽

Iliac Bone Graft ◽

Calcaneal Malunion ◽

The Mean

Aims We hypothesized that there is no difference in the clinical and radiological outcomes using local bone graft versus iliac graft for subtalar distraction arthrodesis in patients with calcaneal malunion. In addition, using local bone graft negates the donor site morbidity. Patients and Methods We prospectively studied 28 calcaneal malunion patients (the study group) who were managed by subtalar distraction arthrodesis using local calcaneal bone graft. The study group included 16 male and 12 female patients. The median age was 37.5 years (interquartile range (IQR) 29 to 43). The outcome of the study group was compared with a control group of ten patients previously managed by subtalar distraction arthrodesis using iliac bone graft. The control group included six male and four female patients. The median age was 41.5 years (IQR 36 to 44). Results The mean American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score improved significantly in the study and the control groups (p < 0.001). Fusion was achieved in 27 patients in the study group at a median time of 13 weeks (IQR 12 to 14), while all the patients in the control group achieved fusion at a mean time of 13.2 weeks (11 to 15). The mean talocalcaneal height and talar declination angle improved significantly in both the study and the control groups (p < 0.001). There was no significant difference between both groups concerning the preoperative or the postoperative clinical and radiological measurements. Donor site morbidity was reported in four out of ten patients in the control group. Conclusion Local calcaneal bone graft can successfully be used to achieve subtalar distraction arthrodesis with appropriate correction of alignment and calcaneal malunion. We recommend using local instead of iliac bone graft as it gave comparable results and avoids the possibility of donor site morbidity. Cite this article: Bone Joint J 2019;101-B:596–602.

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Acute scaphoid fractures: making decisions for treating a troublesome bone

Journal of Hand Surgery (European Volume) ◽

10.1177/17531934211053441 ◽

2021 ◽

pp. 175319342110534

Author(s):

Joseph J. Dias ◽

David Ring ◽

Ruby Grewal ◽

Martin Clementson ◽

Geert Alexander Buijze ◽

...

Keyword(s):

Current Evidence ◽

Proximal Pole ◽

Cast Immobilization ◽

Fracture Displacement ◽

Scaphoid Fractures ◽

Surgical Fixation

Seven aspects of the management of acute scaphoid fractures are open to debate: Diagnosis of true fractures among suspected fractures, assessment of fracture displacement, cast immobilization strategies, the role of surgical fixation, proximal pole fractures, assessment of union, and the underlying objective of treatment. We reviewed current evidence, and our varied interpretations of it, to highlight areas of uncertainty where more evidence might be helpful.

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Primary Vascularized Distal Radius Bone Graft for Nonunion of the Scaphoid

Journal of Hand Surgery (European Volume) ◽

10.1054/jhsb.2000.0378 ◽

2000 ◽

Vol 25 (3) ◽

pp. 266-270 ◽

Cited By ~ 58

Author(s):

C. UERPAIROJKIT ◽

S. LEECHAVENGVONGS ◽

K. WITOONCHART

Keyword(s):

Bone Graft ◽

Avascular Necrosis ◽

Distal Radius ◽

Pinch Strength ◽

Type I ◽

Vascularized Bone Graft ◽

Proximal Pole ◽

The Mean ◽

Mean Time ◽

Vascularized Bone

A vascularized bone graft from the dorsoradial aspect of the distal radius was used with internal fixation to treat nonunion of the scaphoid in ten patients who had not received any previous surgical treatment. Five cases were classified as Lichtman type I and five as type II. The average age was 30 years (range, 18–40 years). Associated avascular necrosis was observed in five cases. Post-operatively pain was relieved and union was achieved in all cases. The mean time to union was 6.5 weeks. Range of motion, grip strength and pinch strength were also restored satisfactorily. These results suggest that this vascularized bone graft should be used as the primary procedure in Lichtman type I and II of scaphoid nonunions, regardless of the presence of avascular necrosis of the proximal pole.

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Pronator quadratus pedicled bone graft for scaphoid non-unions

International Surgery Journal ◽

10.18203/2349-2902.isj20203960 ◽

2020 ◽

Vol 7 (10) ◽

pp. 3414

Author(s):

Harsha Vardhan ◽

Anto Francis

Keyword(s):

Bone Graft ◽

Fracture Healing ◽

Scaphoid Fracture ◽

Fracture Site ◽

Vascularized Bone Graft ◽

Proximal Pole ◽

Pronator Quadratus ◽

Scaphoid Fractures ◽

Fracture Nonunion ◽

Vascularized Bone

Scaphoid fractures frequently present with nonunion and proximal pole necrosis, the treatment of which is bone grafting. Pronator quadratus pedicled vascularized bone graft is an option especially in the setting of proximal pole necrosis. We describe our experience of managing such scaphoid non-unions using pronator quadratus pedicled vascularized bone graft. Six patients were managed using pronator quadratus pedicled vascularized bone graft following scaphoid fracture nonunion with proximal pole necrosis. All patients had good fracture healing and symptom resolution. Mild deficit in wrist extension was noted in all patients. Pronator quadratus pedicled vascularized bone graft is an attractive option for managing scaphoid nonunion. Lying adjacent to the fracture site, bone can be harvested and transferred without making any other incisions. This procedure introduces another source of blood supply to the fracture site and hence improves fracture healing.

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MO459RENAL FUNCTION AMONG PATIENTS WITH NEW DIAGNOSIS OF ATRIAL FIBRILLATION - RESULTS FROM THE NATIONWIDE FINACAF- STUDY

Nephrology Dialysis Transplantation ◽

10.1093/ndt/gfab090.0021 ◽

2021 ◽

Vol 36 (Supplement_1) ◽

Author(s):

Heini Jyrkilä ◽

Kati Kaartinen ◽

Leena Martola ◽

Olli Halminen ◽

Jari Haukka ◽

...

Keyword(s):

Atrial Fibrillation ◽

Renal Function ◽

Glomerular Filtration Rate ◽

Glomerular Filtration ◽

Filtration Rate ◽

Study Cohort ◽

Number Of Patients ◽

Increased Risk ◽

Combining Data ◽

The Mean

Abstract Background and Aims Chronic kidney disease (CKD) is a global public health problem with increasing number of patients due to obesity, hypertension, diabetes, and aging. CKD is an independent risk factor for atrial fibrillation (AF) and the incidence of AF in patients with CKD is two- to threefold higher compared to the general population. Relationship between CKD and AF is bidirectional, and the incidence of impaired renal function is higher in patients with AF. Both AF and CKD are associated with increased risk of stroke and systemic thromboembolism, and also bleeding. The Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) is a nationwide study among AF patients conducted as a retrospective register-based linkage study combining data from several Finnish health care registers. We aimed to characterize demographics and comorbities of AF patients included in FinACAF according to stages of renal function. Method FinACAF- study collects data from 411 000 patients covering all Finnish AF patients from 1 January 2004 to 31 December 2018. Using national unique personal identification number, individual patients’ data from ten nationwide population registries and six regional laboratory databases (∼282 000, 77% of the patients) are linked together. Inclusion criteria of this substudy were all patients who had new ICD-10 AF diagnosis (code I48) between January 2010 and December 2018 and measured estimated glomerular filtration rate (eGFR) within the proximity of AF the diagnosis. Results Of the whole study cohort, 128 538 were included in this substudy. The mean age at the time of AF diagnosis was 73 years (range 18 to 107 years) and 48.9 % of the patients were female. The age of AF patients increased (Figure 1) and eGFR decreased (Figure 2) in various stages of glomerular filtration at the cohort entry during 2010-2018 are shown in Figures 1 and 2. Prevalence of various comorbidities and the mean age at the baseline are shown in the Table. Most of the comorbidities were more common in patients with lower eGFR levels. Conclusion During 2010-2018 the mean age of new AF patients increased in Finland, and simultaneously the renal function decreased. Also, patients with impaired glomerular filtration rate had more often comorbidities increasing the risk of thromboembolism and bleeding. The findings emphasize appropriate control of these risks in AF patients, especially with reduced renal function.

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Combined Fractures of the Scaphoid and Distal Radius: Evaluation of Early Surgical Fixation (21 Patients with 22 Wrists)

Journal of Wrist Surgery ◽

10.1055/s-0037-1603319 ◽

2017 ◽

Vol 07 (01) ◽

pp. 011-17

Author(s):

Tahir Sügün ◽

Murat Kayalar ◽

Yusuf Gürbüz

Keyword(s):

Distal Radius ◽

Screw Fixation ◽

Functional Results ◽

High Energy ◽

Activity Level ◽

Type B ◽

Fixation Technique ◽

Scaphoid Fractures ◽

Surgical Fixation ◽

The Mean

Introduction The purpose of this retrospective study, is to evaluate the clinical and functional results of early surgical fixation of the ipsilateral distal radius and scaphoid fractures in 22 of 21 patients. Patients and Methods Overall, 22 combined ipsilateral scaphoid, and distal radius fracture treatments between 2002 and 2015 were evaluated. The mean age was 34.9 (range: 19–82) years. One patient had bilateral injuries. In 17 patients the injury was due to a fall from a height, and in 4 patients due to a motorcycle accident. According to the AO classification, there were 2 type B and 20 type C fractures of the distal radius. The volar locking plate fixation technique was applied in 14 wrists, screw fixation technique in 1, external fixation combined with Kirschner wires (K-wire) stabilization technique was used in 3 wrists, and only K-wire pinning technique was used in 4 wrists. All scaphoid fractures were type B (21 type B2, 1 type B1) according to the Herbert–Fischer classification. K-wire fixation was applied in 2 and cannulated screw fixation was performed in 20 fractures. Clinical evaluation was performed with measuring the pinch power, grip power, and range of motions. Functional evaluation was performed using patient-rated wrist evaluation score (PRWE). Results The average follow-up period was 25 (range: 12–97) months. All radius and scaphoid fractures healed. The mean active wrist motions were found to be 45 degrees of flexion, 48.5 degrees of extension, 20 degrees of radial deviation, and 43 degrees ulnar deviation. Mean grip/pinch strengths were 31/8.5 kg. Mean PRWE score was 5.5 (range: 0–8.5). All patients returned to preoperative activity level and can do preinjury jobs. Conclusion Combined ipsilateral fractures of distal radius and scaphoid are complex and rare injuries due to high energy traumas. Stable early primary fracture fixation in these injuries can be expected with good functional results. Level of Evidence Level IV.

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Micro Screw Fixation for Small Proximal Pole Scaphoid Fractures with Distal Radius Bone Graft

Journal of Wrist Surgery ◽

10.1055/s-0038-1660445 ◽

2018 ◽

Vol 07 (04) ◽

pp. 319-323 ◽

Cited By ~ 2

Author(s):

Joseph Schreiber ◽

Lana Kang ◽

Krystle Hearns ◽

Tracy Pickar ◽

Michelle Carlson

Keyword(s):

Bone Graft ◽

Distal Radius ◽

Fragment Size ◽

Case Series ◽

Small Diameter ◽

Proximal Pole ◽

Compression Screw ◽

Level Of Evidence ◽

Scaphoid Fractures ◽

Flexion Extension

Background Achieving adequate fixation and healing of small proximal pole acute scaphoid fractures can be surgically challenging due to both fragment size and tenuous vascularity. Purpose The purpose of this study was to demonstrate that this injury can be managed successfully with osteosynthesis using a “micro” small diameter compression screw with distal radius bone graft with leading and trailing screw threads less than 2.8 mm. Patients and Methods Patients with proximal pole scaphoid fragments comprising less than 20% of the entire scaphoid were included. Fixation was accomplished from a dorsal approach with a micro headless compression screw and distal radius bone graft. Six patients were included. Average follow-up was 44 months (range, 11–92). Results Mean proximal pole fragment size was 14% (range, 9–18%) of the entire scaphoid. The mean immobilization time was 6 weeks, time-to-union of 6 weeks, and final flexion/extension arc of 88°/87°. All patients had a successful union, and no patient had deterioration in range of motion, avascular necrosis, or fragmentation of the proximal pole. Conclusion Small diameter screws with a maximal thread diameter of ≤ 2.8 mm can be used to fix the union of proximal pole acute scaphoid fractures comprising less than 20% of the total area with good success. Level of Evidence Therapeutic case series, Level IV.

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Wrist Arthrodesis with Excision of the Proximal Carpal Bones Using the AO/ASIF Wrist Fusion Plate and Local Bone Graft

Journal of Hand Surgery (European Volume) ◽

10.1054/jhsb.2000.0488 ◽

2001 ◽

Vol 26 (3) ◽

pp. 247-251 ◽

Cited By ~ 23

Author(s):

B. J. HARTIGAN ◽

D. J. NAGLE ◽

M. J. FOLEY

Keyword(s):

Clinical Outcome ◽

Bone Graft ◽

Carpal Bones ◽

Secondary Surgery ◽

Wrist Arthrodesis ◽

Local Bone ◽

Outcome Scores ◽

Wrist Fusion ◽

The Mean

We present our series of 17 patients who underwent wrist arthrodesis with excision of the proximal row carpal bones using the AO wrist fusion plate and local bone graft obtained from the excised proximal carpal row. All patients were evaluated using a questionnaire to assess pain, function, ability to perform an occupation and satisfaction with the procedure. The mean follow-up was 17 months, at which time all the fusions had united. Clinical outcome scores showed that 14 and 15 of the 17 patients achieved good or excellent results with regard to their current condition and clinical improvement, respectively. Four patients required secondary surgery, two for fractures and two for instability of the distal radio-ulnar joint unrelated to the wrist fusion.

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TECHNIQUES FOR VASCULARISED BONE GRAFTING IN SCAPHOID NONUNION

Hand Surgery ◽

10.1142/s0218810499000149 ◽

1999 ◽

Vol 04 (01) ◽

pp. 21-31 ◽

Cited By ~ 1

Author(s):

D. J. Wheen ◽

M. Robinson ◽

S. Prachaporn ◽

S. Visvanathan

Keyword(s):

Internal Fixation ◽

Bone Graft ◽

Avascular Necrosis ◽

Bone Grafting ◽

Bone Grafts ◽

Significant Problem ◽

Scaphoid Nonunion ◽

Proximal Pole ◽

Scaphoid Fractures

Nonunion of the scaphoid remains a significant problem in the management of scaphoid fractures. Recurrent persistent nonunion following attempts at internal fixation, and nonunions with sclerosis or avascular necrosis of the proximal pole of the scaphoid are particularly challenging. However, the aims of restoration of scaphoid anatomy and the achievement of union of the scaphoid remain the foundation pillars of scaphoid treatment. In recent years, several techniques for using vascularised bone grafts in the treatment of these difficult problems have been described. This article will review the currently described treatments, provide an overview of our unit experience with these techniques, and also describe a technique for in situ vascularisation of a conventional bone graft.

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Outcome of vascularised muscle pedicle bone graft for scaphoid non-union

International Journal of Research in Orthopaedics ◽

10.18203/issn.2455-4510.intjresorthop20180122 ◽

2018 ◽

Vol 4 (2) ◽

pp. 203

Author(s):

Rajat Charan ◽

Pankaj Kumar Verma

Keyword(s):

Bone Graft ◽

Screw Fixation ◽

Proximal Pole ◽

Hardware Failure ◽

Non Union ◽

Herbert Screw ◽

Vascularised Bone Graft ◽

Full Correction ◽

The Mean

Background: The objective of the study was to assess the outcome of vascularised muscle pedicle bone graft for scaphoid non-union.Methods: 14 men and 6 women aged 18-45 (mean 25) years with non-union of scaphoid involving proximal pole (n=4), waist (n=14), distal pole (n=2) were randomized to undergo vascularised muscle pedicle bone graft with Herbert screw fixation. The mean duration of non-union was 10 months (range 4-14 months).Results: The mean follow up duration was 24 months. 17 of 20 achieved union. 12 of 20 achieved correction of both scapholunate and radiolunate angle. 5 of 20 did not achieve full correction of sacpholunate and radiolunate angle. 3 of 20 did not achieve union. 2 of these 3 were associated with proximal pole absorption. There was no hardware failure or any iatrogenic fracture during pedicle dissection. Conclusions: The use of vascularised bone graft has proved to be an effective method for treating scaphoid non-union, especially non-union with an avascular proximal pole and those that have failed to heal after previous procedure.

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