[Free vascularized iliac bone graft for the treatment of scaphoid nonunion with avascular proximal fragment].

OBJECTIVE

The goal of the procedure is osseous healing of the scaphoid in an anatomic position and replacement of necrotic bone at the site of the scaphoid nonunion by a vascularized iliac bone graft.

INDICATIONS

Scaphoid nonunion with necrotic fragment in SNAC (scaphoid nonunion advanced collapse) < 1. Nonunion following previous surgery.

CONTRAINDICATIONS

Pattern of advanced carpal collapse (SNAC > 1). Malformation, disease or previous injury of the vascular system. Poor compliance. Reduced general health.

SURGICAL TECHNIQUE

Principles of the surgical technique according to Pechlaner et al.: harvesting of a corticocancellous bone graft from the anterior iliac crest with a nutrient vascular bundle from the deep circumflex iliac artery, debridement of the necrotic scaphoid, press-fit fixation of the tailored graft, pin fixation, and microvascular anastomosis to the radial artery.

POSTOPERATIVE MANAGEMENT

Fixation in an upper-arm cast for 4 weeks, followed by lower-arm cast fixation including the thumb to the interphalangeal joint until week 12. Physiotherapy. Wrist splinting in patients enforced to heavy manual load.

RESULTS

The described procedure has been practiced at the own institution since 1985 and evaluated in different studies. Using a free vascularized iliac bone graft, union could be achieved in 85% of patients with avascular scaphoid nonunion and in 80% with avascular proximal pole nonunion. The nonunion can be bridged in 93% following failed previous scaphoid screw fixation.