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Non-Vascularized Bone Grafting in the Surgical Treatment of Pediatric Scaphoid Nonunion with Avascular Necrosis
Casey C. Kuka, BS
1, Sayaka Mori, BA
1, Scott J. Mahon, BS
1, Eric R Taleghani, MD
2, Kaitlynn N Jackson, BS
2, Kevin J. Little, MD
2; Apurva S. Shah, MD, MBA
1(1)Children's Hospital of Philadelphia, Philadelphia, PA, (2)Cincinnati Children's Hospital Medical Center, Cincinnati, OH
Introduction: There is increasing preference for vascularized bone grafting over non-vascularized bone grafting (NVBG) for scaphoid nonunion with avascular necrosis (AVN) in adults. However, the efficacy of NVBG for treating pediatric patients with scaphoid nonunion and AVN remains poorly reported. We hypothesized that NVBG would yield excellent union rates and reliably restore carpal alignment in children.
Materials & Methods: This was a multicenter, retrospective cohort study of all patients <21 years old with scaphoid fracture nonunion and evidence of AVN managed operatively with non-vascularized autograft. Pre- and postoperative scapholunate (SL), radiolunate (RL) angles, wrist range of motion (ROM), and evidence of radiographic union (bridging cortex visible on three of four cortices on radiographs) at final follow-up were recorded. Patients with nonunion but no evidence of AVN intraoperatively or on preoperative imaging were excluded. Statistical analysis was performed in IBM SPSS Statistics v29.
Results: 24 wrists with scaphoid nonunion and documented AVN across 24 patients (2 [8%] female) with a mean age of 14.9 ± 2.5 years at injury were analyzed. 11 were managed with non-vascularized iliac crest (six corticocancellous, five cancellous) and 13 with non-vascularized distal radius (one corticocancellous, 10 cancellous). Nearly all (23/24) cases were managed with concomitant fixation utilizing headless compression screws. Radiographic union was achieved in 23 cases (96%). One patient managed with cancellous NVBG from the iliac crest and headless compression screw fixation developed a nonunion six months postoperatively due to hardware failure. Despite adequate postoperative immobilization and adherence to activity restrictions, this case required revision fixation with repeat NVBG from the distal radius. After repeat surgery, the patient achieved radiographic union without further complications. Overall, operative management with NVBG improved carpal alignment, though this difference was only significant for SL angle (mean preoperative SL angle 71.1° ± 9.5° versus 60.9° ± 11.3° postoperatively, p=0.002). Mean postoperative wrist ROM was excellent, including flexion of 66.2° ± 12.1° and extension of 63.1° ± 11.4°; however, the improvement in postoperative wrist ROM was not statistically significant.
Conclusions: Non-vascularized bone grafting yields excellent union rates in children and adolescents and should generally be the preferred initial approach given the morbidity associated with vascularized bone grafting. The observed residual carpal malalignment suggests that greater use of structural (corticocancellous) bone grafting could be beneficial. Future research should also compare the restoration of carpal alignment following NVBG from the iliac crest versus the distal radius, given known differences in structural properties.
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