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Dean G. Sotereanos , MD Clinical Professor of Orthopaedic Surgery

Proximal Pole Scaphoid Nonunion: Vascularized Bone Graft is the Only way to Go. Dean G. Sotereanos , MD Clinical Professor of Orthopaedic Surgery University of Pittsburgh School of Medicine Orthopaedic Specialists - UPMC Pittsburgh , PA. Scaphoid Fractures.

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Dean G. Sotereanos , MD Clinical Professor of Orthopaedic Surgery

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  1. Proximal Pole Scaphoid Nonunion: Vascularized Bone Graft is the Only way to Go Dean G. Sotereanos, MD Clinical Professor of Orthopaedic Surgery University of Pittsburgh School of Medicine OrthopaedicSpecialists - UPMC Pittsburgh, PA

  2. Scaphoid Fractures • 10-20% involve the proximal third • 70-80% involve the body or waist • Small number of tuberosity fractures

  3. Scaphoid Nonunions • 5-15% nonunion rate despite treatment • tenuous blood supply

  4. Fracture Locationan important issue!!! • Vascular supply enters distal pole and runs retrograde to the proximal scaphoid • The more proximal the fracture, the more likely are healing complications

  5. Fracture Locationan important issue!!! • Osteonecrosis develops in approximately 3% • Significantly higher risk in proximal third fractures

  6. Conventional vs Vascularized Bone Graft • 36 studies • 7 studies (64 pts) with AVN of proximal fragment • 88% union rate with VBG vs47% with wedge bone graft + screw fixation (p<0.0005) “Dead bone added to dead bone does not produce live bone”

  7. Conventional vs Vascularized Bone Graft Non-unions in all parts of the scaphoid: • Bone graft w/o internal fixation: 80% union rate • Bone graft with internal fixation:84% • Vascularized bone graft: 91%

  8. Conventional vs Vascularized Bone Graft • 48 studies (1602 pts) 92% union rate with VBG vs88% with non VBG • 6 studies only AVN of proximal fragment 91% union rate with VBG J Hand Surg Am. 2015;40(9):1797-1805

  9. Vascularized Bone Grafts Superior Biologic & Mechanical Properties • Direct bone healing • No creeping apposition • Heal faster and more reliably • Stronger preserve live osteocytes and osteoblasts Better Union Rate

  10. VBGs from the Dorsal Radius • 1,2 ICSRA Graft • Capsule-based Vascularized Graft • 4 & 5 ECA Graft

  11. Capsule-based Vascularized Graft

  12. Capsule-based Vascularized Graft VBG from the distal aspect of the dorsal radius attached to a wider distally based strip of the dorsal wrist capsule 4 ECA

  13. Capsule-based Vascularized Graft • Screw is placed volarlyto enable dorsal trough for the VBG • Secure the VBG with a suture anchor into the trough to avoid dislodgement

  14. Capsule-based Vascularized Graft Insertion of VBG press fit into the dorsal trough across the non-union with minimal capsular rotation (10 – 30°) • Graft is tied down loosely

  15. suture anchor Venouziou AI, Sotereanos DG, J Hand Surg Am 2012

  16. Capsule-based Vascularized Graft 2000 - 2016 89 pts: symptomatic non-union of the proximal pole of the scaphoid 58/89 pts: avascular necrosis • Age: mean 28 yrs (19 - 44) • Time from Injury to Surgery: mean 24 m (12 - 51) • No fragmentation or collapse of the proximal pole • No humpback deformity

  17. Capsule-based Vascularized Graft • 76/89 pts: Solid union (85.4%) 12.3 w (6-24) mean time to union 49/58 pts with AVN: Solid union (84.5%) 66 pts: pain free completely 10 pts: slight pain with strenuous activities • 13/89 pts: 11 pts: persistent non-union 2 pts: fibrous union (CT scan) Sotereanos DG, Darlis NA, Dailiana ZH, Sarris IK, Malizos KN J Hand Surg Am 2006 Papatheodorou LK, Sotereanos DGEur J Orthop Surg Traumatol 2018 (in press)

  18. Capsule-based Vascularized Graft • No arthritic changes at the dorsal ridge of the radius (harvest site of the graft) • No donor site morbidity • Nograft extrusion Sotereanos DG, Darlis NA, Dailiana ZH, Sarris IK, Malizos KN J Hand Surg Am 2006 Papatheodorou LK, Sotereanos DGEur J Orthop Surg Traumatol 2018 (in press)

  19. M 27y RDH Case

  20. Case 24 m post –op

  21. Summary Capsule-based Vascularized Graft • Simple technique • Eliminates the need for dissection of small caliber pedicle • No microsurgical anastomoses • No donor site morbidity • Results compare favorably to those of other pedicled or free vascularized grafts

  22. Thank You

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