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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