Outcome After Vascularized Bone Grafting of Scaphoid Nonunions With Avascular Necrosis

Purpose Vascularized bone grafting has been proposed as a treatment for scaphoid nonunions with avascular necrosis of the proximal pole. The purpose of this investigation is to report the results of vascularized hone graft and internal fixation for established scaphoid nonunions with proximal pole avascular necrosis as measured by validated outcome instruments. Methods From 1996 to 2004, 30 consecutive patients with established scaphoid nonunion, proximal pole avascular necrosis, and no prior surgery were treated with open reduction and internal fixation in addition to a vascularized bone graft based on 1,2 intercompartmental supraretinacular artery. A total of 19 patients had nonunions of the scaphoid waist and 11 had nonunions of the proximal pole of the scaphoid. Preoperative and postoperative evaluation included measurement of clinical (grip strength and range of motion), radiographic (scapholunate angle, scaphoid height-to-length ratio, and radioscaphoid arthritis), function (Disabilities of the Arm, Shoulder, and Hand questionnaire) and satisfaction parameters. We recorded union and return to activity and analyzed data both in the aggregate and stratified by nonunion location. Results Union rate was 28 of 30 (93%) and time to union was 5.1 months (+/-2.4). Significant improvements were found for grip strength, Disabilities of the Arm, Shoulder, and Hand score, satisfaction score, and scaphoid height-to-length ratio (p <.01). No significant difference was found for composite wrist range of motion. Two patients experienced complications and required a second procedure to achieve union. A total of 28 of 30 (93%) of patients returned to work or sports activity at their preinjury level. Conclusions The results of this investigation support the use of a vascularized bone graft for the treatment of scaphoid nonunions with avascular necrosis of the proximal pole. (J Hand Surg 2009;34A:387-394. (C) 2009 Published by Elsevier Inc. on behalf of the American Society for Surgery of the Hand.)