TriHealth Hand Surgery Specialists, Department of Orthopedic Surgery, University of Cincinnati, Cincinnati, OH.
Telluride, CO.
J Hand Surg Am. 2020 Apr;45(4):298-309. doi: 10.1016/j.jhsa.2019.10.037. Epub 2020 Feb 14.
The most challenging scaphoid nonunion is the unstable nonunion with humpbacked collapse coupled with an avascular proximal pole. Dorsal distal radius pedicled vascularized bone grafts (VBGs) are contraindicated in cases of humpback deformity. The free medial femoral condyle VBG is an excellent option but it is an extensive microsurgical procedure with lengthy operative times and dual-limb incisions. In search of a local, volar, vascularized source of bone to treat this challenging subset of scaphoid nonunions, we analyzed our results with a volar distal radius bone graft based on the pedicled palmar radiocarpal artery (PRCA).
A prospective cohort of 15 unstable nonunions with avascular proximal pole fragments was treated with the PRCA graft and open reduction internal fixation. Preoperative carpal indices revealed a high degree of instability. All 15 lacked punctate bleeding from the proximal pole. All 15 patients were treated with the PRCA VBG technique and scanned with computed tomography at approximately 6 and 12 weeks to assess for interval healing.
All nonunions healed with an average cross-sectional trabeculation score of 70% at week 6 and 84% at week 12. Sagittal intrascaphoid angles improved from 50° to 27°, radiolunate angle improved from -20° to -7°, scapholunate angle improved from 86° to 64°, and revised carpal height ratio improved from 1.45 to 1.53, indicating correction of the humpback collapse deformity. Patients were observed an average of 22 months to have no sign of further avascular necrosis.
Pedicled PRCA-VBG successfully addresses the dual needs of the humpbacked scaphoid nonunion with an avascular proximal pole while simultaneously limiting dissection to one limb and avoiding the additional complexities of free tissue transfer.
TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.
最具挑战性的舟骨骨不连是不稳定的骨不连，伴有驼峰样塌陷和近端无血管化。背侧桡骨远端带蒂血管化骨移植（VBG）在存在驼峰畸形的情况下是禁忌的。游离内侧股骨髁 VBG 是一个很好的选择，但它是一种广泛的显微外科手术，手术时间长，需要双下肢切口。为了寻找一种局部的、掌侧的、有血管的骨源来治疗这种具有挑战性的舟骨骨不连亚组，我们分析了基于带蒂掌侧桡腕关节动脉（PRCA）的掌侧桡骨骨移植治疗不稳定伴近端无血管化骨块的结果。
前瞻性纳入 15 例不稳定伴近端无血管化骨块的舟骨骨不连患者，采用 PRCA 移植物和切开复位内固定治疗。术前腕骨指数显示高度不稳定。所有 15 例患者近端均无点状出血。所有 15 例患者均采用 PRCA VBG 技术治疗，并在大约 6 周和 12 周时进行计算机断层扫描扫描，以评估愈合情况。
所有骨不连均愈合，平均横截面骨小梁评分在第 6 周时为 70%，在第 12 周时为 84%。矢状位舟骨内倾角从 50°改善至 27°，桡月角从-20°改善至-7°，舟月角从 86°改善至 64°，修正后的腕骨高度比从 1.45 改善至 1.53，表明驼峰样塌陷畸形得到了矫正。患者平均观察 22 个月，未见进一步发生无血管性坏死的迹象。
带蒂 PRCA-VBG 成功地满足了伴有近端无血管化的驼峰样舟骨骨不连的双重需求，同时将解剖范围限制在一条肢体上，并避免了游离组织移植的额外复杂性。
研究类型/证据水平：治疗性 II 级。
