Bone Grafting for Scaphoid Nonunion / Malunion   

- See: Scaphoid Frx Menu:
           - scaphoid nonunions:

- Discusssion:
    - bone grafting may be indicated for scaphoid malunion or non union;
    - malunion:
           - indicators of scaphoid malunion: classic findings are a dorsal humpback deformity and DISI deformity;
           - indications for bone grafting include radiographic deformity along with pain, weakness, and loss of motion;
           - note that the proximal fragment may lie supinated, extended and radially deviated relative to the distal fragment;
           - even small degrees of malunion will result in a significant loss of extension;
    - Russe used a volar approach to the scaphoid, believing that it was less disruptive to the blood supply as well as allowing insertion
           of graft from front to correct the angulatory deformity;
    - contra-indications:
           - operative treatment with Matti-Russe grafting does not reliably lead to union of proximal pole nonunion with AVN
           - this technique is contra-indicated if proximal pole is avascular
           - vascularity of the scaphoid cannot always be predicted by radiographs;
           - best way to determine vascularity is to look for punctate bleeding at the time of surgery;
           - relative contra-indication is a severe DISI deformity, since adequate correction of deformity may not be achieved;

- Surgical Approach:
     - when performing a volar approach, radioscaphocapitate ligament and palmar radiolunate-triquetral ligament must be partially or
            totally divided;
            - if inadequately repaired, the natural tendency of the lunate to extend and the scaphoid to flex under axial compression may
                   lead to a  DISI deformity;
     - radial styloidectomy:
            - radial styloidectomy may help decrease postoperative radial sided tenderness;
            - may be performed through a separate posterolateral incision;
            - attempt to preserve the radiocapitate ligament;
     - pseudarthrosis is resected back to healthy bone where possible;
            - this is best done using small osteotome to square off both frx faces;


- Bone Graft:
    - bone graft must be taken from iliac crest;
    - 1.5-cm block of corticocancellous bone is removed from outer table of iliac crest after apex has been hinged off;
    - graft is shaped to fill defect left following resection of pseudarthrosis & correction of deformity by dorsiflexion of wrist;
    - consider applying the inner wall of the ileal graft toward the capitate for better congruence;
    - cortical component should lie flush w/ anterior surface of scaphoid to provide mechanical stability on compression;
    - whenever possible, a soft-tissue hinge should be preserved posteriorly to retain the graft and provide extra stability;
    - alternative graft technique:
         - harvest two cortico-cancellous grafts, which are inserted into the excavated scaphoid, w/ the cancellous sides facing internally;

- Hardware Insertion:
     - cannulated screw fixation:
     - herbert screw insertion technique:
           - wherever possible, jig should be applied in such a way that screw will be perpendicular to fracture.
           - if obliquity of frx line makes this impossible, supplementary K wire fixation should be used to prevent shearing displacement
                    under compression;
           - drill guide is placed across the distal pole, and the blade is placed across the proximal pole;
           - frx site is compressed by jig prior to screw placement;
           - jig is compressed as tightly as possible after any remaining gaps between the graft and frx faces have been filled with
                    cancellous bone chips;
           - measure screw size, and insert screw below surface of scaphoid

Fixation and Grafting After Limited Debridement of Scaphoid Nonunions

Hybrid Russe Procedure for Scaphoid Waist Fracture Nonunion With Deformity

Long-term results after Russe bone-grafting: the effect of malunion of the scaphoid.

Scaphoid nonunion treated with the Matti-Russe technique. Long-term results.

The effect of avascular necrosis on Russe bone grafting for scaphoid nonunion

Corrective Osteotomy for scaphoid malunion: technique and long term follow up evaluation.

In scaphoid non-union, does the source of graft affect outcome? Iliac crest versus distal end of radius bone graft.

Scaphoid Waist Nonunion With Humpback Deformity Treated Without Structural Bone Graft

Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Tuesday, June 21, 2016 6:56 am