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Is Free Vascularized Bone Grafting Superior for Scaphoid Nonunion?
William Aibinder, MD; Eric R. Wagner, MD; Allen Bishop, MD; Alexander Y. Shin, MD
Mayo Clinic, Rochester, MN

Introduction: Symptomatic scaphoid nonunion occurs in 10 to 15% of fractures. Nonvascularized bone grafting (NVBG), and pedicled and free vascularized bone grafts (VBG) have been employed with variable success. Regarding VBG, while the traditional 1,2-intercompartment supraretinacular artery (1,2-ICSRA) distal radius bone graft is limited by its pedicle, the free medical femoral condyle (MFC) graft permits greater deformity correction. We thus sought to compare our institution's experience using NVBG via structural iliac crest bone graft (ICBG), 1,2-ICSRA, and MFC grafts to treat scaphoid nonunions.

MATERIALS AND METHODS: We performed a retrospective review between 2000 and 2013 of all scaphoid nonunions treated at our institution. After excluding patients with less than 6 months of follow-up were excluded, there were 35 that underwent ICBG, 43 that underwent 1,2-ICSRA, and 41 that underwent MFC bone grafting. Mean time to follow-up was 16 months (range 6 to 164). Patients that underwent reoperation prior to 6 months were included. Mean age at surgery was 24 years (range 11 to 66). Males comprised 87% and the dominant extremity was involved in 60% of cases. Tobacco use was noted in 21% of subjects. Outcomes included time to healing, range of motion, complications, and reoperations.

Results: Union rates and mean time to union were 69% and 20 weeks for ICBG, 71% and 45 weeks for 1,2-ICSRA, and 95% and 16 weeks for MFC, respectively. The use of an MFC graft, absence of tobacco use, younger age, and male gender were correlated with healing (p = 0.004, 0.002, 0.005, and 0.01, respectively). Time from injury to surgery did not affect healing (p = 0.30). There was no significant difference between the 3 groups in regards to change in wrist flexion, wrist extension, radial deviation, ulnar deviation, and grip strength. There were 28 overall reoperations, including 26% in the ICBG group, 15% in the 1,2-ICSRA group, and 32% in the MFC group.

Conclusions: The use of a free vascularized MFC graft has demonstrated promising results in the literature. This comparative study demonstrates superior union rates with a more rapid time to union compared to NVBG and pedicled dorsal distal radius VBG. Clinical outcomes are similar, and when excluding reoperation for hardware removal, the reoperation rates are not dissimilar. In cases of symptomatic scaphoid nonunion with osteonecrosis and carpal collapse, the MFC is a viable and reliable surgical option, even as salvage for prior failed structure grafting procedures.

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