Scaphoid Nonunion With Poor Prognostic Factors

Abstract

Background: To report on the results of free medial femoral condyle (MFC) vascularized bone graft for scaphoid nonunions with 1 or more poor prognostic factors. Methods: We have used the free MFC vascularized bone graft for scaphoid nonunions that have 1 or more factors associated with a poor prognosis. These were, a delay in presentation of over 5 years, a proximal pole nonunion, the presence of avascular necrosis (AVN), or previous nonunion surgery. We used this technique on 20 patients over a 4.5-year period. Results: Our overall union rate was 88.5% (17 of 19 patients), with 1 patient failing to attend for follow-up. Our mean union time was 7 months (2-18). All patients had at least 1 poor prognostic factor and over half had 2 or more. Of those with AVN with or without other factors, the union rate was 85% (11 of 13). There were 2 donor site complications that required a further procedure and 2 patients with residual wrist pain that required a scapho-trapezio-trapezoid joint fusion and a radial styloidectomy, respectively. Both nonunions were offered further surgery, and 1 elected to undergo successful revision surgery. Conclusions: Overall, this technique showed good results, in a subgroup of patients that typically have poorer outcomes, with a low incidence of donor site morbidity. Our union rate compares favorably with other techniques for this difficult subset of patients with 1 or more poor prognostic factors, although results are clearly not as good as those of studies using the MFC graft for all scaphoid nonunions. We continue to reserve this technique for nonunions with 1 or more poor prognostic factors, and we believe that this technique should at least be considered in these patients.

Free Vascularized Medial Femoral Condyle Bone Graft for Scaphoid Nonunion with Poor Prognosis Factors

“…The well-known poor prognostic factors in scaphoid nonunion are proximal pole nonunion, chronicity, unstable fixation, and AVN [4,9]. Jones et al [16] analyzed the prognostic factors that may influence the outcome of scaphoid nonunion and determined AVN and previous surgery for nonunion as poor prognostic factors.…”

“…Jones et al [16] analyzed the prognostic factors that may influence the outcome of scaphoid nonunion and determined AVN and previous surgery for nonunion as poor prognostic factors. Another study reported that outcomes are less favorable when nonunion is older than 5 years and in the presence of advanced degenerative changes [4]. The most important factors are known to be the site of pseudoarthrosis and the viability of the proximal pole due to the particularities of dual blood supply.…”

“…Doi et al [18] reported that the free MFC cortico-periosteal flap has been used as an anterior inlay graft, and achieving union 12 weeks after surgery in 100% of 10 patients with the scaphoid nonunion. Chaudhry et al [4] found that the union rate after MFC VBG compares favorably with other techniques for a difficult subset of patients with one or more poor prognostic factors in scaphoid nonunion. Jones et al [16] reported that 40% of scaphoid nonunions treated with the distal radial pedicle graft healed at a median of 19 weeks, and 100% of scaphoid nonunions treated with the free MFC graft healed at a median of 13 weeks.…”

“…Several surgical procedures have been developed for the treatment of nonunion, including vascularized bone graft (VBG) and non-VBG, with or without internal fixation [4][5][6][7]. Although the Russe bone graft technique has provided the mainstay of operative treatment for scaphoid nonunion, non-VBG has been less beneficial in cases of AVN [6].…”

“…In addition, VBG can fill in larger skeletal defects with harder bones. Therefore, among these, MFC VBG can be a good option for the treatment of scaphoid nonunion with poor prognostic factors such as proximal pole AVN, a delay in a presentation, or previous nonunion surgery [4,9,[12][13][14]. The purpose of this study was to evaluate the clinical and radiographic results of MFC VBG in the treatment of scaphoid nonunion with poor prognostic factors.…”