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Outpatient Free Vascularized Bone Grafts for Management of Scaphoid Nonunion
Benjamin A Sarac, MD
1; Hisham M. Awan, MD
2; Ryan Schmucker, MD
31The Ohio State University Wexner Medical Center, Columbus, OH; 2Hand & Upper Extremity Center, Ohio State University, Columbus, OH; 3The Ohio State University Medical Center, Columbus, OH
Introduction:Fractures of the scaphoid are the most common carpal bone fracture and have high rates of nonunion. Management of nonunion to prevent the predictable pattern of arthritis seen with scaphoid nonunion advanced collapse has a wide variety of treatment options. Free vascularized bone grafting from the medial femoral condyle (MFC) or trochlea (MFT) have become a popular option for management of recalcitrant nonunions. However, free tissue transfer often requires inpatient stay for postoperative flap monitoring. We analyzed our experience of outpatient free MFC/MFT for management of scaphoid nonunion.
Materials & Methods:A retrospective review of a two-surgeon approach to reconstruction of scaphoid nonunion without postoperative flap monitoring was performed. Baseline demographic details, injury history, pre- and post-operative radiographic analysis, operative details, and postoperative union were collected. Patients were discharged either the day of surgery or the follow morning if they did not have adequate support at home or anticipated difficulty with postoperative pain control.
Results:Ten patients met inclusion criteria. Demographics are shown in Table 1. Nine patients (90%) had pre-operative dorsal intercalated segment instability (DISI) with scapholunate angle >60 degrees. Four patients had involvement of the proximal pole and therefore received an MFT as opposed to an MFC. Mean operative time was 215±39 minutes. Eight patients were discharged on the day of surgery, and the remaining two were discharged on the first postoperative day. Nine patients (90%) showed postoperative union on imaging, with no residual DISI deformity. The sole nonunion occurred in a patient who removed their splint and began range of motion on the first postoperative day.
Conclusions:Vascularized bone grafting for the management of recalcitrant scaphoid nonunion may be successfully performed without postoperative monitoring, and in select patients with same day discharge. This series is the first to report on ambulatory free MFC/MFT, and to our knowledge the second reported in the literature describing free vascularized tissue transfer of any kind performed with same day discharge.
Table 1. Demographics
| Age | 28±7 |
| BMI | 27±3 |
| Smoking History | 5 (50%) |
| Injury to Diagnosis (years) | 2.5 (1.7) |
| Pre-Op DISI deformity | 9 (90%) |
| Involvement of Proximal Pole | 4 (40%) |
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