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Ultra Small Proximal Pole Scaphoid Nonunion Reconstruction with 1,2 Intercompartmental Supraretinacular Artery Vascularized Graft and Micro Screw Fixation
Mark S Morris, MD; Jeffrey N. Lawton, MD; Andy F Zhu, MD; Kagan Ozer, MD
University of Michigan, Ann Arbor, MI

Scaphoid fractures can be successfully treated with cast immobilization in most cases; however, there is an estimated 5-15% nonunion rate with these fractures. More proximal fractures have a higher risk of avascular necrosis (AVN) given the more limited blood supply of this region. The results of the 1,2 ICSRA vascularized graft for scaphoid non-unions has had varying success in the literature, ranging from 27% to 100%. When we look closer at the published articles, there is substantial inconsistency in the fractures that are being treated, modalities for assessing healing, and fixation methods used. We hypothesized that small proximal pole scaphoid fractures could be managed successfully with fixation achieved by using a 1,2 ICSRA vascularized graft and a smaller diameter (? 2.5 mm diameter) compression screw.

Methods
This is a retrospective case series of 12 patients with ultra-small proximal pole scaphoid fracture nonunions that were treated at our institution with 1,2 ICSRA vascularized grafts and compression screws. Calculations of the size of the proximal pole fragment relative to the total scaphoid were performed using Posterior-Anterior Scaphoid view radiographs with the wrist in ulnar deviation and flat on the cassette. Analyses were repeated three times per subject, and the average ratio of proximal pole fragment relative to the entire scaphoid was calculated. We reviewed medical records, radiographs, and CT scans of these 12 patients. CT scans that were performed after an average of 12 weeks were ultimately used to confirm union of the scaphoid fractures.

Results
12/12 (100%) scaphoid fractures healed at an average of 11.45 weeks as shown by CT scan. The mean proximal pole fragment size was 18% (range 7-27%) of the entire scaphoid.

Conclusion
The 1,2 ICSRA vascularized graft and compression screw is an effective operation for patients with very small proximal pole scaphoid fractures. Previous studies have unsuccessfully used this surgery for waist fractures and have included a mix of patients treated with Kirschner wires and screws. The benefit of this study is that we included only patients with proximal pole fractures and included only patients treated with a compression screw and were able to show the success of the proposed operation.


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