Use of vascularized and non-vascularized bone grafting in scaphoid non-union: A prospective randomized control trial
Nina Suh, MD, FRCSC, Roth McFarlane Hand & Upper Limb Centre, London, ON, Canada, Stacy Fan, MD, Western University, London, ON, Canada, Ruby Grewal, MD, MSc, Hand and Upper Limb Center, University of Western Ontario, London, ON, Canada and Joy Macdermid, BSc, BScPT, MSc, PhD, University of Western Ontario, Roth|MacFarlane Hand and Upper Limb Centre, Canada, London, ON, Canada
Introduction: Scaphoid non-union is a difficult clinical condition that if left untreated results in progressively debilitating arthritic changes commonly referred to as scaphoid non-union advanced collapse (SNAC). Patients may be treated surgically with bone grafting provided they have minimal signs of arthritis, otherwise a salvage procedure may be indicated. We hypothesize that vascularized bone grafting in scaphoid non-union results in more rapid union in comparison to non-vascularized bone grafting.
Methods: A single-blind prospective, randomized control trial was performed at a tertiary specialized hand and upper limb institution. All patients with scaphoid non-union from January 2008 to June 2016 were assessed for enrollment into our study. Exclusion criteria included skeletal immaturity, radiographic evidence of significant scaphoid non-union advanced collapse wrist arthritis, fragmentation of the proximal pole of the scaphoid, or avascular necrosis of the proximal pole on a pre-operative magnetic resonance imaging scan.
Patients were randomized to receive either a vascularized (1,2-intercompartmental supraretinacular artery) or non-vascularized (trapezoidal iliac crest) bone graft. Those enrolled completed pre-operative patient reported outcome questionnaires and wrist range-of-motion and grip strength assessments. Patients were followed for 1 year post-operatively.
Union rate and time to bony union were the main outcomes of interest assessed using CT scans at 4 to 6-week intervals.
Results: Forty-eight patients were enrolled in the study. Three patients declined operative intervention and were withdrawn. With the intention-to-treat model, 24 patients were randomized to the vascularized bone graft (1,2-intercompartmental supraretinacular artery bone graft) group, and 22 to the non-vascularized bone graft (iliac crest trapezoidal graft) group.
Time from injury to surgery was similar between groups (10.9 ± 13.1 weeks vs. 10.3 ± 6.5 weeks, respectively). Post-operatively, average time to union was 7 weeks faster in the vascularized bone graft group (12.2 ± 7.2 weeks with the vascularized graft vs. 19 ± 32.3 weeks with the non-vascularized graft) however this did not reach statistical significance. When smoking status was controlled, patients who received vascularized bone graft were 72% more likely to achieve union compared to the non-vascularized bone graft group. Furthermore, those who were smokers were 60% less likely to achieve union when compared to non-smokers.
Conclusions: Vascularized bone grating using the 1,2-intercompartmental supraretinacular artery graft demonstrated a higher likelihood of scaphoid union, as compared to non-vascular bone grafting using the iliac crest bone graft in scaphoid non-union. Additionally, smoking was associated with a reduction in union.
Level of Evidence: Level I
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