Purpose
The most challenging scaphoid nonunion is the unstable nonunion with humpbacked collapse
coupled with an avascular proximal pole. Dorsal distal radius pedicled vascularized
bone grafts (VBGs) are contraindicated in cases of humpback deformity. The free medial
femoral condyle VBG is an excellent option but it is an extensive microsurgical procedure
with lengthy operative times and dual-limb incisions. In search of a local, volar,
vascularized source of bone to treat this challenging subset of scaphoid nonunions,
we analyzed our results with a volar distal radius bone graft based on the pedicled
palmar radiocarpal artery (PRCA).
Methods
A prospective cohort of 15 unstable nonunions with avascular proximal pole fragments
was treated with the PRCA graft and open reduction internal fixation. Preoperative
carpal indices revealed a high degree of instability. All 15 lacked punctate bleeding
from the proximal pole. All 15 patients were treated with the PRCA VBG technique and
scanned with computed tomography at approximately 6 and 12 weeks to assess for interval
healing.
Results
All nonunions healed with an average cross-sectional trabeculation score of 70% at
week 6 and 84% at week 12. Sagittal intrascaphoid angles improved from 50° to 27°,
radiolunate angle improved from –20° to –7°, scapholunate angle improved from 86°
to 64°, and revised carpal height ratio improved from 1.45 to 1.53, indicating correction
of the humpback collapse deformity. Patients were observed an average of 22 months
to have no sign of further avascular necrosis.
Conclusions
Pedicled PRCA–VBG successfully addresses the dual needs of the humpbacked scaphoid
nonunion with an avascular proximal pole while simultaneously limiting dissection
to one limb and avoiding the additional complexities of free tissue transfer.
Type of study/level of evidence
Therapeutic II.
Key words
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Article info
Publication history
Published online: February 13, 2020
Accepted:
October 30,
2019
Received:
February 7,
2019
Footnotes
No benefits in any form have been received or will be received related directly or indirectly to the subject of this article.
Identification
Copyright
© 2019 by the American Society for Surgery of the Hand. All rights reserved.
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