Scaphoid nonunion reconstructed with vascularized bone-grafting pedicled on 1,2 intercompartmental supraretinacular artery and external fixation.

BACKGROUND Vascularized bone-grafting pedicled on 1,2 intercompartmental supraretinacular artery (1,2 ICSRA) has been recommended as a treatment alternative for established scaphoid nonunion complicated with proximal pole avascular necrosis (AVN). Previous reports focused the studies on the union rate and the revascularization of the transferred graft. However, the postoperative wrist stiffness still a challenging problem and remaining to be solved. The purpose of our study was to determine whether the combination of vascularized bone-grafting pedicled on 1,2 ICSRA and wrist external fixator immobilization provides a more effective strategy for treating established scaphoid nonunion complicated with AVN and improving postoperative range of motion (ROM) of the injured wrist. PATIENTS AND METHODS We retrospectively reviewed a consecutive series of 11 patients who had cases of established scaphoid nonunion involving AVN of the proximal pole were treated with vascularized bone-grafting pedicled on 1,2 1,2 ICSRA, internal fixation, and wrist external fixator immobilization. Procedure of wrist arthrolysis was performed before vascularized bone graft transferring. Preoperative and postoperative evaluation included measurement of clinical (wrist ROM and grip strength), radiographic (intrascaphoid angle, scapholunate angle) and functional (Mayo wrist score) parameters. RESULTS Osseous union was achieved in all of the 11 cases within an average period of 11.4 weeks. On an average 6.1 years follow-up, there were three excellent, six good and two fair results. Significant improvements were found for Mayo wrist score, wrist ROM, and grip strength (p < 0.01). Intrascaphoid angle and scapholunate angle were significantly improved postoperatively, and there was no significant difference between the postoperative values and the values at the last follow-up. Early functional rehabilitation of the injured wrist under the protection of the fixator did not result in displacement of the transferred graft. CONCLUSIONS The results of the present investigation support the use of the vascularized bone graft pedicled on 1,2 ICSRA in the treatment of scaphoid nonunion complicated with proximal pole AVN. Procedures of wrist arthrolysis and early institution of wrist functional rehabilitation under the protection of the external fixator play important role in the restoration of range of motion of the injured wrist.