TECHNIQUES OF (VASCULARIZED)

BONE GRAFTING FROM DISTAL RADIUS

FOR SCAPHOID FRACTURES AND
KIENBOCKS DISEASE

Christian Dumontier, MD, PhD

Centre de la Main, Guadeloupe, France

www.diuchirurgiemain.org
Some illustrations belong to Drs Haerle, Kozin, Lebreton, Mathoulin, Trumble, Saint Cast, Shin, Sheetz -
Thanks to them

I have no conflict of interest or disclosure in relation to this presentation

 HISTORICAL
Roy-Camille and Judet (1965)

Kuhlman (1987) described the volar vascularization of the distal radius

Braun (1983) and Kawai (1988) used the pronator quadratus pedicled bone graft
for scaphoid

Beck (1971) and Saffar used the vascularized pisiform as a graft

Zaidemberg (1991) then the Mayo team (1995) described the vascularization of
the dorsal radius

Pierer (1992), Brunelli (1992), Bertelli (1992), Yuceturk (1997) described the
vascularization of the metacarpals and their use as VBGs
Zaidemberg, JHS 1991;16A:474 ; Sheetz JHS 1995;20A:902 ; Kawai JBJS 1988 70B:829 ; Pierer SRA 1992;14:103 ; Brunelli ACMS
1992;11:40 ; Bertelli SRA 1992;14:275; Kuhlmann JHS 1987;12B: 203-10; Braun Orthop Trans 1983;7:35.
 VBGS

The rationale (experimental

and anatomical)

The available VBGs-VBGs

from the distal radius

The surgical techniques of

VBGs from the distal radius

Indications and outcomes

THE RATIONALE FOR USING
VASCULARIZED BONE
GRAFTS
WHY USING VBGS ?

Non union rate in wrist

Authors Graft source
surgery

Cooney 24% Iliac

Barton 27% Radius/iliac

Daly 5% Iliac

Warren Smith 30% Iliac

Christodoulou 15-45% Radius/iliac

Davis 25-34% Iliac

 WHY USING VBGS ? (2)
Revascularization of necrotic bones ?

Kienbcks disease

Preisers disease, other carpal bone

necrosis

Treatment of difficult (vascular)

conditions ?
 IS THERE ANY RATIONALE FOR VBGS ? : AT
LEAST TWO

Living bone heals faster than nonvascularized autografts and does so

without creeping substitution of necrotic bone Potential advantages
of a shorter period of immobilization and a higher union rate.

Conventional bone grafts loose a significant part of their solidity in

the process of creeping substitution and only recover it very
slowly, in one year or two (Puckett)

Conservation of the endostal vascularization authorizes an osseous

healing of first intention by osteogenesis (Alberktsson)
 EXPERIMENTAL WORKS
VBGs
In a dog radius model of scaphoid non-
union with proximal pole avascular necrosis
comparing VBGs and non-vascularized grafts

VBGs allow for healing (73% vs 0%)

At 6 weeks proximal pole blood flow

was significantly higher (71.5 +/- 12.0 non VBGs
mL/min/100 g tissue vs 37.3 +/- 29.4 mL/
min/100 g tissue)

At 8 weeks the amount and area of 6 wks 12 wks

osteoid synthesis and woven bone
formation spread to a greater extent.

Sunagawa T et al. Role of Conventional and Vascularized Bone Grafts in Scaphoid Nonunion With Avascular Necrosis: A
Canine Experimental Study. J Hand Surg 2000;25A:849859
 EXPERIMENTAL WORKS: DOG
RADIUS MODEL
VBGs preserve circulation:

Immediate blood flow was

51% of the circulation in
the contralateral radius

Hyperemic response at 2
weeks doubles the flow VBGs preserve viable
(compare to contralateral osteoclasts and osteoblasts
wrist) and multiplies it by that allows primary bone
54 compare to healing without creeping
conventional grafts substitution
Sunagawa T et al. Role of Conventional and Vascularized Bone Grafts in Scaphoid Nonunion With Avascular Necrosis: A Canine Experimental
Study. J Hand Surg 2000;25A:849859
 EXPERIMENTAL WORKS
Animal works have
shown their
superiority compare
to conventional grafts

52 wks 6 wks
Is it the same for humans ?
What are the indications ?
Intercalary graft Zaidenbergs VBG
 EXPERIMENTAL WORKS
Second rationale: a grafted bone with adequate blood supply
may aid the revascularization of an avascular (dead) segment of
bone This may improve the outcome of the treatment of
scaphoid nonunion, avascular necrosis, and Kienbcks disease

The main function of vascularized grafts in treating AVN appears

to be the provision of vessels into avascular bone

Necrotic bones can be re-vascularized used vascular bone grafts

(Sunagawa, Gonzales del Pino, Bishop)
Uchida Y, Sugioka Y. Effects of vascularized bone graft on surrounding necrotic bone: an experimental study. J Reconstr Microsurg 1990;6:101
107.
 ANATOMICAL WORKS

Have shown that anatomy is

quite constant

Sheetz KK et al. The arterial blood supply of the distal radius and Ulna and its potential use in Vascularized pedicled Bone grafts. J Hand Surg.
20A: 902-914.
 ANATOMICAL WORKS

Have shown that both cortical and cancellous bone were

richly vascularized by those vessels and could be taken as
grafts
Sheetz KK et al. The arterial blood supply of the distal radius and Ulna and its potential use in Vascularized pedicled Bone grafts. J Hand Surg.
20A: 902-914.
 ANATOMICAL WORKS

Have shown that anatomical landmarks make

their dissection secure

Have shown that it is possible to raise VBGs that

can reach the carpal bones without undue tension
 THE AVAILABLE
VASCULARIZED BONE
GRAFTS
 AVAILABLE VBGS (1)

Autogenous bone graft + free pedicles (Hori, Fernandez)

Pronator quadratus based (Roy-Camille, Kawai)

 AVAILABLE VBGS (2)
THE RADIUS AS A DONOR

Transverse carpal artery (Kuhlman, Haerle)

I-II intercompartimental (supraretinacular) artery

(Zaidemberg)

IV-V intercompartimental artery (Sheetz)

 AVAILABLE VBGS (3)
First dorsal inter-metacarpal artery

1st metacarpal bone (Yuceturk)

2nd metacarpal bone (Bertelli, Brunelli)

Pisiform (Beck, Saffar)

Joint transfer (radio-ulnar, Trapezio-metacarpal joint)

(Roux)

Ulnar artery (Guimberteau)

 AVAILABLE VBGS (4)
Iliac Crest (Gabl 1999)

27 cases, 85% union (9 yrs FU)

Donor site morbidity : 55% incidence of

hyperostosis of the iliac crest, 8.3%
incidence of deformity of the iliac crest
and a 31.7% incidence of nerve
hypoesthesia.

Supracondylar ridge (Doi, 2000)

10 cases, 100% union (3,2 yrs FU)

VBGS FROM THE DISTAL
RADIUS
VBGS FROM THE DORSAL RADIUS

Four vessels
contribute to the
vascularization of
the dorsal radius
VBGS FROM THE DORSAL RADIUS

Multiple anastomoses
between those arteries
allow for mobilization of
multiple VBGs
 VBG using the 1,2 VBG using the 4th
supraretinacular artery compartment artery
VBGS FROM THE VOLAR RADIUS

The transverse carpal artery comes

from the radial artery

Is parallel to the distal fibers of the

pronator quadratus

And anastomoses with the anterior

branch of the anterior interosseous
artery and branches from the ulnar
artery
ANATOMY AND SURGICAL
TECHNIQUES
 THE 1-2 SUPRA-RETINACULAR ARTERY
(ZAIDEMBERG)
The graft is based on a retrograde
branch from the radial artery that
provides blood supply to the
dorsoradial aspect of the distal
radius.

At the level of the radiocarpal joint,

a branch of the radial artery ascends
deep to the first dorsal extensor
compartment.

The irrigating vessel turns to lie over

the retinaculum extensorum
between the 1st and 2nd extensor
compartments.
Zaidemberg C, Siebert JW, Angrigiani C. A new vascularized bone graft for scaphoid nonunion. J HAND SURG 1991;16A:474-8.
 MANY VARIATIONS OF ORIGIN HAVE BEEN
DESCRIBED

Trumbles team described 3 types of origin

with respect with the branch for the
scaphoid (10 cadavers)

Separate (60%)

Combined (30%)

Shared (10%)

In type II and III, it may be impossible to

adequately mobilize the 1,2 ICSRA without
disrupting the dorsal scaphoid branch.

Waitayawinyu T et al. The Detailed Anatomy of the 1,2 Intercompartmental Supraretinacular Artery for Vascularized Bone
Grafting of Scaphoid Nonunions. J Hand Surg 2008;33A:168174.
 Distal Proximal

Combined, type II with

anastomosis of the 1,2 ICSRA and
the dorsal scaphoid branch (black
arrow), before dividing to supply
the distal radius and scaphoid. 1,2
ICSRA (white arrow)

Type III: Shared origin (black

arrow) of the 1,2 ICSRA
(white arrow) and the
dorsal branch of the
scaphoid

Waitayawinyu T et al. The Detailed Anatomy of the 1,2 Intercompartmental Supraretinacular Artery for Vascularized Bone
Grafting of Scaphoid Nonunions. J Hand Surg 2008;33A:168174.
 VARIATIONS OF ORIGIN THAT
HAVE BEEN DESCRIBED
ECRL/ECRB 1,2 ICSRA

Saint Cast, over 30

dissections, described 4
types according to the
position of the artery with
the tendons of the
anatomical snuffbox

Radial artery in the snuffbox APL & EPB

Saint Cast Y et al. Simplified scaphoid reconstruction technique with Zaidembergs vascularized radial graft. Orthopaedics & Traumatology:
Surgery & Research (2012) 98, S66S72
 TYPE I

7 cases of 30: the 1,2-ICSRA originates from the radial artery, volar to
the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons,
and makes a long curve from front to back to reach the distal part of the
radius between the first and second dorsal extensor compartments;
 TYPE II

12 cases of 30: The1,2-ICSRA originates from the radial artery deep to

the APL and EPB tendons. The trajectory is much shorter than in type 1
arteries. In Types 1 and 2, the 1,2-ICSRA can pass close to the styloid or
actually come in contact with it;
 TYPE III

6 cases of 30: The1,2-ICSRA originates from the radial

artery dorsal to the APL and EPB tendons, and has a
direct, ascending trajectory
 TYPE IV

5 cases of 30: The1,2-ICSRA originates from a dorsal collateral articular

branch of the radial artery and ascends towards the distal part of the
radius between the first and second extensor compartments.
 1,2 ICSRA
The origin of the 1,2 ICSRA from the
radial artery was found 1.9 mm proximal
to the tip of the radial styloid on average,
(range 6.3 mm proximal to 3.2 mm distal
to radial styloid.).

The average pedicle length of the 1,2

ICSRA was 22.5 mm (range 1531 mm)
or between 14 and 23 mm long.

Its diameter is 0.3 to 0.8 mm at its origin

and 0.2 to 0.4 mm near the distal end of
the radius.

The first collateral branches penetrating

the bone originated 5 to 8 mm proximal
to the distal margin of the radius.
 SURGICAL TECHNIQUE (1)
Lazy S incision

Straight, longitudinal, centered

over the radio-carpal joint line.

Curved, along the EPL

 SURGICAL TECHNIQUE (2)

Protection of the radial

nerve

Small perforating vessels

going to the nerves on the
skin must be coagulated
with bipolar forceps

Visualization of the 1,2

supraretinacular artery
 SURGICAL TECHNIQUE (3)

Longitudinal incision over

the first and second
extensor compartments

A narrow strip from the

extensor retinaculum is left
intact on either side of the
arterys trajectory
 SURGICAL TECHNIQUE (4)
Longitudinal arthrotomy is
performed over the length
of the second
compartment to
harvest a capsular-
periosteal flap that is
continuous on the radial
side, and used to
protect the graft
pedicle;
 SURGICAL TECHNIQUE (5)

Styloidectomy is performed to prepare the scaphoid (some

do not use it).

The non-union site is freshened

 SURGICAL TECHNIQUE

Freshening of scaphoid
nonunion edges
 SURGICAL TECHNIQUE (6)
The periosteum is removed
from the radius styloid
down to the bone to
protect the 1,2- ICSRA,

An postage-stamp
osteotomy is done then an
oscillating saw is used to
perform the osteotomy,
while making sure to
protect the graft pedicle.
 One trick to raise
a VBG
 Graft is placed
longitudinally if there is no
bone loss

And introduced, transversally

into a defect, however this is not
designed to be used as a wedge
graft
 One series reported good results with the 1,2 IC-SRA used
as a wedge graft with 15 bone healing in 15 patients

Henry M. Collapsed scaphoid non-union with dorsal intercalated segment instability and
avascular necrosis treated by vascularised wedge-shaped bone graft and fixation. J Hand Surg
Eur Vol 2007;32-2:14854.
 6 weeks

12 weeks 6 months
 TH TH
DORSAL 2,3 IC-SRA, 4 ECA AND 5 ECA

Apart from the 1,2-ICSRA,

there are three other distal
radius pedicles available for
a VBG

The 2,3-ICSRA, 4thECA, and

5thECA which is the largest
are distal branches of the
Anterior interosseous
artery.
ANATOMY OF THE IOA AT THE WRIST

The IOA runs deep in the forearm over the interosseous

membrane
 The IOA ends at the level
of the wrist in a T fashion
joining branches from the
ulnar and radial arteries to
form the proximal carpal
arch (see below)

It also gives a posterior

branch that pierces the
IOM proximal to the
pronator quadratus
POSTERIOR BRANCH OF THE IOA

It divides in three arteries

that runs in the 2-3, the 4th
and 5th compartments.

Using this anatomical

disposition, different grafts
can be raised

R: radial artery, U: Ulnar artery, AIA: anterior interosseous artery, PIA: posterior interosseous artery. 1:
dorsal supraretinacular arch, 2: dorsal carpal arch, 3: 5th compartment artery, 4: 4th compartment
artery, 5: 2,3 IC-SRA, 6: 1,2 IC-SRA.
 SURGICAL TECHNIQUE
Dorsal longitudinal skin incision

The extensor retinaculum is incised overlying the 5th

compartment and elevated as a radially based flap to
the second compartment.

The 5th ECA is identified at the radial base of the fifth

compartment, either partially within or against the
septum between the fourth and fifth compartments.
 SURGICAL TECHNIQUE
It is traced proximally to its
origin from the posterior
branch of the AIA.

The 4th ECA takes origin

from the posterior branch of
the AIA, near its junction with
the 5th ECA. The 4th ECA is
followed distally along the
floor of the fourth
compartment, radial to the
posterior interosseous nerve.
SURGICAL TECHNIQUE

The bone graft is marked

out along the 4th ECA,
approximately 1 cm from
the radiocarpal joint.

The AIA is ligated (prox-

imal to the 5th and 4th
ECA origins), and the graft
is elevated
 AN ORIGINAL TECHNIQUE

Dorsal capsular-based
VBG from the distal
radius for proximal pole
scaphoid nonunions

10 success out of 13
patients reported at 1
year FU

Sotereanos DG, Darlis NA, Dailiana ZH, Sarris IK, Malizos KN. A capsular-based vascularized distal radius graft for proximal pole scaphoid
pseudarthrosis. J Hand Surg 2006;31A:580587
 SURGICAL
TECHNIQUE
A 4-cm straight, dorsal incision
centered just ulnar to the Lister
tubercle

Third and fourth compartments are

released,

The capsular-based VBG is designed

as a 1x 1-cm bone block slightly ulnar
and distal to the Lister tubercle,
including the 3,4- intercompartmental
septum and includes the dorsal ridge
of the radius, attached to a capsular
flap that widens from 1.0 cm
proximally to 1.5 cm at its distal base.
 VOLAR BONE GRAFT

There is an arterial network on the volar surface of the

radius joining the radial artery, the ulnar artery and the
anterior interosseous artery
 VOLAR BONE GRAFT

Transverse carpal artery (red) comes from the radial artery and is
parallel to the distal fibers of the pronator quadratus. It
anastomoses with the anterior branch of the anterior interosseous
artery (yellow) and branches from the ulnar artery (blue).
 SURGICAL TECHNIQUE (1)
Volar Henrys approach
extended to the scaphoid
tubercle

First spotting of F.C.R. and radial

artery
 SURGICAL TECHNIQUE
Identification of the pedicle
(by opening the palmar
fascia of the PQ)

Dissection of the pedicle

surrounded by a 5-mm
wide strip of fascia and
periosteum provides
surgical safety and
convenience in graft
manipulation
The graft is fixed by a K-wire,
parallel to the scaphoid screw
that is removed at 3 weeks
 VBG from the volar radius
for scaphoid non-union after
failed conventional
technique
 TECHNIQUE

Identical for Kienbcks disease

INDICATIONS AND
OUTCOMES
 SCAPHOID NON-UNION
5 to 15% of scaphoid fractures end up
with nonunion

Possible risk factors for the development

of scaphoid nonunion include delayed or
missed diagnosis, proximal location of the
fracture, fracture displacement >1 mm,
osteonecrosis, and associated carpal
instability.

Avascular necrosis has been estimated to

occur in 3% of all scaphoid fractures
 TREATMENT OF SCAPHOID
NONUNION INCLUDES
Screw fixation
(percutaneous or open)

Inlay graft (Matti-Russe)

Intercalary graft (Fisk-

Fernandez)

VBGs
 MATTI-RUSSE INLAY GRAFT
Matti 1936: Excavation concept +
cancellous graft

Russe 1960: Anterior approach

Verdan 1968: Osteosynthesis

improves consolidation rate
 INTERCALARY GRAFT

Fisk (1968) then Fernandez

(1984) noticed that with
time the scaphoid shape
was going to change and
should be corrected during
surgery

This needed the use of an

intercalary wedge graft
BASIC PRINCIPLES FOR TREATMENT

Scar tissue excision +

excavation

Correction of the scaphoid

malalignment (use K-wire as
joystick as the deformity is in
many planes)

Bone grafting

Bone fixation during the

consolidation period
Case of Scott Kozin
For proximal pole scaphoid nonunion, graft is placed
through a dorsal approach
2.6 ans
 RISK FACTORS FOR FAILURE OF SCAPHOID
NONUNION TREATMENT YOU CANNOT CHANGE

Age

Female

Delay between initial

fracture and nonunion
fixation

Localisation of nonunion

AVN proximal pole

 Prediction Model
>0.65

12%

30%

50%

Union
rate
approaches
66% 100%
The effect of age of the irrespective
fracture on probability of of the age of
union increases as the the fracture
fracture site moves proximally
 RISK FACTORS FOR FAILURE OF SCAPHOID
NONUNION TREATMENT YOU MAY CHANGE

Smoking (RR 7)- [Hirche]

Humpback deformity (64%

of failures in the presence
of humpback deformity
and/or DISI) - [Chang].

Chang MA et al: The outcomes and complications of 1,2-intercompartmental supraretinacular artery pedicled vascularized bone grafting of
scaphoid nonunions. J Hand Surg Am 31: 387-396, 2006
Hirche C. et al . The 1,2-Intercompartmental Supraretinacular artery Vascularized Bone Graft for Scaphoid Nonunion: Management and
Clinical Outcome.. J Hand Surg Am. 2014;39(3):423-429
 TOBACCO USE
Smoking impairs angiogenesis
by down-regulating the
expression of endothelial
nicotinic acetylcholine receptor
and reduction of bone
morphogenetic protein
transcription in the periosteum.

Smoking has a negative effect on fracture union, especially in

those requiring bone grafts.

Konishi H, Wu J, Cooke JP. Chronic exposure to nicotine impairs cholinergic angiogenesis. Vasc Med. 2010;15(1):47-54.
Chassanidis CG, Malizos KN, Varitimidis S, et al. Smoking affects mRNA expression of bone morphogenetic proteins in human peri-
osteum. J Bone Joint Surg Br. 2012;94(10):1427-1432.
Al-Hadithy N, Sewell MD, Bhavikatti M, Gikas PD. The effect of smoking on fracture healing and on various orthopaedic procedures.
Acta Orthop Belg. 2012;78(3):285-290.
 THERE IS TWO TYPES OF SCAPHOID
NONUNION - VOLAR AND DORSAL

According to the location of the fracture

relative to the dorsal apex of the ridge of
the scaphoid

Volar type is seen in distal scaphoid

waist fractures in which the scaphoid
forms a humpback deformity and the bone
defects are large and triangular and are
mostly seen along with a DISI deformity.

The dorsal type is seen in relatively

proximal waist fractures in which the bone
defects are much smaller and a flat,
crescent-shaped pattern is seen

Moritomo H, Viegas SF, Elder KW, Nakamura K, Dasilva MF, Boyd NL, et al. Scaphoid nonunions: a 3-dimensional analysis of patterns of
deformity. J Hand Surg 2000;25A:520528.
 UNION RATE OF 90 SCAPHOID NON-
UNION (STANLEY 2004)

Iliac Radius VBGs Total

34 18 6 58
United
65.38% 66.66% 54.54% 64.64%

Not United 18 9 5 32

Total 52 27 11 90

Tambe AD1, Cutler L, Murali SR, Trail IA, Stanley JK.n scaphoid non-union, does the source of graft affect outcome? Iliac crest versus distal end
of radius bone graft. J Hand Surg Br. 2006 Feb;31(1):47-51.
 SCAPHOID NON-UNION TREATED WITH
PEDICLED VBGS
Number
% healing
of cases
Mathoulin 87 93% 3 Sdecks

95% 2 temporary
Saint-Cast 38 87% < 12w paresthesiae
Steinman 14 100% (11 w) 2/3 good results

Malizos 22 100% All improved

Malizos 30 100% (12w) 77% good/excellent

Waitayawinyu 30 93%

Chen 11 100% (13w) 10/11 good/excellent

SCAPHOID NON-UNION TREATED WITH 1,2 ICRSA VBG

Authors % of healing
Straw, 2002 6 of 22 (27%)
Jones, 2008 4 of 10 (40%)
Boyer, 1998 6 of 10 (60%)
Hirche, 2014 21 of 28 (71%)
Lim, 2013 18 of 21 (83%)
Waitayawinyu, 2009 28 of 30 (93%)
Saint Cast, 2010 36 of 38 (95%)
Waters, 2002 3 of 3 (100%)
Chen 11 of 11 (100%)
Henry, 2007 15 of 15 (100%)
Zaidemberg, 1991 11 of 11 (100%)
Uerpairojkit, 2000 10 of 10 (100%)
Malizos, 2001 22 of 22 (100%)
Steinman, 2002 14 of 14 (100%)
Tsai, 2002 5 of 5 (100%)
 VBGS INCREASED THE
LIKELIHOOD OF SUCCESS
Meta- analysis of 5,246 cases of scaphoid non-
union
80% consolidation rate (7882) for non-
vascularized bone graft without osteosynthesis,
84% (8285) with osteosynthesis,
91% (8794) for vascularized graft.
Munk B, Larsen CF. Bone grafting the scaphoid nonunion: a systematic review of 147 publications including 5,246 cases of scaphoid nonunion.
Acta Orthop Scand 2004;75(5): 61829.
 AS A REMINDER
VBG increases the likelihood of success IF

All other factors are corrected (freshened

edges, scaphoid length reconstruction, stable
fixation,)

There is no technical difficulties (protect

vascularity)
 EXAMPLE OF THE OPPOSITE
One randomized, controlled trial compared 35 patients with 1,2-ICSRA VBGs
to 45 patients with nonvascularized iliac crest graft (Braga-Silva).

All patients in the nonvascularized group healed, whereas 3 patients in the

vascularized group failed to heal, all of which were related to technical
difficulties.

One retrospective study showed a significantly higher union rate (P .005) and
shorter time to healing (P .001) for non- unions treated with the medial
femoral condyle graft compared to the 1,2-ICSRA pedicle graft (Jones).

Jones DB Jr, Burger H, Bishop AT, Shin AY. Treatment of scaphoid waist nonunions with an avascular proximal pole and carpal collapse. A
comparison of two vascularized bone grafts. J Bone Joint Surg 2008;90A:2616 2625.
Braga-Silva J, Peruchi FM, Moschen GM, Gehlen D, Padoin AV. A comparison of the use of distal radius vascularised bone graft and non-
vascularised iliac crest bone graft in the treatment of non-union of scaphoid fractures. J Hand Surg 2008;33E:636 640.
 SCAPHOID NONUNION TREATED WITH
VOLAR VBG
Scaphoid waist non-union, 9 cases. All united with 80-90% of
contralateral wrist motion and strength (Dailana)

98 cases, including 65 1st time surgery. Union rates of 96% and

89.5%.

8% complications in group 1. 4% non-union, 4% stiffness

26% complications in group 2. 10.5% non-union; 2.5% stiffness ,

8% CPRS.

Dailana ZH et al. Vascularized Bone Grafts From the Palmar Radius for the Treatment of Waist Nonunions of the Scaphoid. J Hand Surg
2006;31A:397404.
Gras M, Mathoulin C. Vascularized bone graft pedicled on the volar carpal artery from the volar distal radius as primary procedure for scapho
non-union. Orthopaedics & Traumatology: Surgery & Research (2011) 97, 800806
 SCAPHOID NONUNION TREATED WITH
VOLAR VBG

One series reported a low consolidation rate

(73%)- [Jessu]

Risk of perioperative articular fracture of the

radius.

Jessu M, Wavreille G, Strouk G, Fontaine C, Chantelot C. Pseudarthroses du scaphode traites par greffon vascularis de Kuhlmann : rsultats
radiographiques et complications. Chir Main 2008;27(23):8796.
Levadoux MPJ, Samson P. Complications spcifiques aprs ralisation de greffons pdiculs du radius distal : propos dune srie de 36 greffons
raliss. Chir Main 2004;23(6):326.
 WHAT ABOUT SCAPHOID
NONUNION AND AVN ?

VBGs seem to improve the

results

Conventional graft & screw

47% union

VBG 88% union

Merrell GA, Wolfe SW, Slade 3rd JF. Treatment of scaphoid nonunions: quantitative meta-analysis of the literature. J Hand Surg [Am] 2002;27-
4:68591.
 HOWEVER
SCAPHOID NON-UNION AND
AVN TREATED WITH VBGS Number of cases % healing

12% if AVN proximal

Straw 22 27% pole

Jessu 30 73% 0% for proximal AVN

Chang 48 34 (71%) 50% if AVN

ROM and grip

Lim 21 86% strength unchanged

10 Zaidemberg / 40% / Free VBG healed in

Jones 12 MFC all cases
100%
 THE MAJOR PROBLEM
The definition of necrosis

A (real) dead bone is probably really dead !

Increased radiodensity of the proximal pole

on CT scans (sensitivity 60%, specificity
100%, accuracy 74%) [Smith]

MRI accuracy is 68 %, increasing to 83 %

with gadolinium injection [Kakar]. Diagnostic
criteria include areas of low signal intensity
on T1and high signal intensity on T2.

Kakar S, Bishop A, Shin A. Role of vascularized bone grafts in the treatment of scaphoid nonunions associated with proximal pole avascular
necrosis and carpal collapse. J Hand Surg Am. 2011;36A:7225.
Smith ML, Bain GI, Chabrel N, Turner P, Carter C, Field J. Using computed tomography to assist with diagnosis of avascular necrosis
complicating chronic scaphoid nonunion. J Hand Surg 2009;34A:1037 1043.
Proposed algorithm for scaphoid nonunion
Proposed algorithm for scaphoid nonunion
Proposed algorithm for scaphoid nonunion
OTHER BONE NECROSIS
DISEASES
 KIENBCKS DISEASE
An unknwon disease
with bone necrosis, of
unknown
pathophysiology

Whose natural history,

evolution and best Kienbck R. ber
traumatische malazie des
treatment is also mondbeis und ihre
folgesustande:
unknown entartungsformen und
kompressions fracturen -
Frtschr. Geb. Rentgen
1910, 16; 77-115

Innes L, Strauch R. Systematic review of the treatment of Kienbcks disease in its early and late
stages. J Hand Surg Am. 2010;35A:7137.
Dias J, Lunn P. Ten questions on Kienbcks disease of the lunate. J Hand Surg Eur. 2010;35B:53843
 VBGS IN KIENBCKS DISEASE
As there is bone necrosis,
some authors have thought
of vascularized grafts to treat
Kienbcks

The first attempt was from

Beck who fulfilled the lunate
with a vascularized pisiform

While Saffar replaced the

lunate by the vascularized
pisiform
Beck E. Die Verpflanzung des Os Pisiforme am Gefstiel zur Behandlung der lunatummalazie. Handchir Mikrochir Plast chir 1971; 3: 64-67.
Saffar P. Replacement of the semilunar bone by the pisiform. Description of a new technique for the treatment of Kienboeck's disease. Ann
Chir Main. 1982;1:2769.
 VASCULARIZED PISIFORM FOR
REINFORCEMENT
At 12years follow-up,

Pain improved in 20 of 23 patients.

Range of motion was 80% of opposite side.

Grip power was 84%

DASH was 15.3 +/- 17.9 ; Cooney score was 82.4 +/- 10.0.

Lichtman stage was unchanged in 11, improved in 3, and progressed in 6 patients.

At FU mild osteoarthritis was found in 7 of 22 patients.

Daecke W, Lorenz S, Wieloch P, et al. Vascularized os pisiform for reinforcement of the lunate in Kienbcks disease: an average of 12years of
follow-up study. J Hand Surg Am. 2005;30A:91522.
Replacement of the lunate by a pedicled
pisiform

10 years FU
 VASCULARIZED PISIFORM
Pain was improved in 16 of 21 patients

ROM did not improved (68% of the opposite hand)

Grip power was 80%

DASH 22.3 +/- 17.9 ; Cooney score was 75.4 +/-13.2.

At FU osteoarthritis was found in 50% of patients. The majority of

degenerative changes were associated with carpal collapse.

Daecke W, Lorenz S, Wieloch P, et al. Lunate resection and vascularized os pisiform transfer in Kienbock disease: an average of 10years of
follow-up study after Saffars procedure. J Hand Surg Am. 2005;30A:67784.
KIENBCKS DISEASE TREATED WITH VOLAR RADIUS VBG

Major limitations:

Vascular pedicle may not

be long enough to reach
the ulnar part of the
lunate

The anterior margin of

the radius acts as a tent
for the pedicle
 KIENBOCKS DISEASE TREATED WITH
DORSAL RADIUS VBG

Because it provides a
large, long pedicle, the
4 + 5 ECA VBG is
used mainly for
Kienbcks

Moran S, Cooney W, Berger R, et al. The use of the 4+5 extensor compartmental vascularized bone graft for the treatment of Kienbcks
disease. J Hand Surg Am. 2005;30A:508
 KIENBCKS DISEASE
Number of
% Painfree % healing
cases

23%
Mathoulin 22 91% 72% stabilized,
5% failure
100% at 36
Mazur 9 ?
months

Pain
5 Ex, 4 Go, 1
Ozur 11 diminished ?
Fa, 1 Po
considerably

Moran 26 92% 71%

 HOWEVER

Due to the unknown natural evolution of such a

disease, comparison of results is difficult

No difference at 5 years (clinically or radiological)

between 9 radius shortening and 7 VBG with the
4,5 ECA.

Afshar A, Eivaziatashbeik K. Long-Term Clinical and Radiological Outcomes of Radial Shortening Osteotomy and Vascularized Bone Graft in
Kienbck Disease. J Hand Surg 2013;38A:289296
 OTHER INDICATIONS
Some case reports of the use of VBGs for Preisers
disease

Kalainov reported on 9 out of 19 patients with

Preisers that received a VBG. Fragmentation and
scaphoid collapse could not be prevented in any
with type I disease (four out of nine). Disease
progression was halted in three out of five patients
with type II disease, at an average follow-up of 17
months. The other two patients with type II disease
demonstrated progression to stage III, with one
patient requiring a proximal row carpectomy (PRC)
after the VBG failed to provide pain relief.

Kalainov D, Cohen M, Hendrix R, et al. Preisers disease: identification of two patters. J Hand Surg Am. 2003;28A:76778.
 OTHER INDICATIONS
Some case reports of the use of VBGs for Preisers
disease

Moran et al. reviewed their results in eight patients. At

36 months average follow-up, pain resolution was
incomplete. Despite encouraging evidence of
revascularization in all MRIs obtained postoperatively, the
proximal pole consistently remained incompletely
revascularized.
Moran S, Cooney W, Shin A. The use of vascularized grafts from the distal radius for the treatment of Preisers disease. J Hand Surg Am.
2006;31A:70510.
 CONCLUSION (1)

VBGs are contraindicated in the setting of a carpal

bone without an intact cartilaginous shell, in
advanced carpal collapse with degenerative
changes, and in attempts to salvage small or
collapsed bone fragments.

I have no conflict of interest or disclosure in relation to this

presentation
 CONCLUSION (2)
VBGs are justified from experimental works

Are they superior to conventional grafts for scaphoid non-union

without histologically proven bone necrosis ?

Can they revascularise histologically proven bone necrosis ?

This has yet to be proven

However facing a difficult situation, VBGs may probably help if all

other technical details are correctly treated.
I have no conflict of interest or disclosure in relation to this presentation
 THANK YOU FOR
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