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Supplemental Graft Fixation for Distal Radius Vascularized Bone Graft
SURGICAL TECHNIQUE
Supplemental Graft Fixation for Distal Radius Vascularized Bone Graft
Vascularized bone grafts from the distal radius have been used successfully for the treatment of scaphoid nonunions. Typically, the harvested graft is secured into the scaphoid with a press-fit technique. This type of fixation may lead to graft extrusion in the early postoperative period, and thus to treatment failure. In this technical note, we describe the use of micro bone suture anchors for supplemental fixation of the vascularized bone graft into the scaphoid. It is a simple and quick technique and provides an enhanced fixation of the vascularized bone graft, which is beneficial during the early critical period of bone healing. (J Hand Surg 2012;37A:1475–1479. Copyright © 2012 by the American Society for Surgery of the Hand. All rights reserved.) Key words Distal radius, nonunion, scaphoid, suture anchors, vascularized bone graft.
UMEROUS BONE-GRAFTING TECHNIQUES have been used for the treatment of scaphoid nonunions. Vascularized bone grafts (VBGs) have demonstrated superior biological and mechanical properties in experimental studies. Animal models have shown that VBGs are incorporated in a faster, more predictable manner, especially when placed in a poorly vascularized bed.1,2 To date, several authors have achieved high union rates with the use of VBGs for the treatment of scaphoid nonunions. Zaidemberg et al3 described the use of a VBG based on the first recurrent branch of the radial artery (1,2-intercompartmental artery). Numerous authors have used this graft with high success rates.4 –13 Sotereanos et al14 reported good results with a dorsal capsular-based VBG from the distal radius for proximal pole scaphoid nonunions. This graft is nourished by the fourth extensor compartmental artery and is harvested from a position that allows easy access to the proximal scaphoid pole.
N
FromtheDepartmentofOrthopaedicSurgery,HandandUpperExtremitySurgery,AlleghenyGeneral Hospital, Pittsburgh, PA. Received for publication March 9, 2011; accepted in revised form April 19, 2012. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Correspondingauthor:DeanG.Sotereanos,MD,DepartmentofOrthopaedicSurgery,Handand Upper Extremity Surgery, Allegheny General Hospital, Drexel University College of Medicine, 1307 Federal Street, 2nd Floor, Pittsburgh, PA 15212; e-mail: [email protected]. 0363-5023/12/37A07-0030$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2012.04.024
The VBGs from the distal radius can be used either as structural grafts to correct an anatomic deformity and promote bone healing or as inlay grafts to enhance the biology of bone healing. Although the structural VBGs can be fixed securely with the use of screws or K-wires, fixation of the grafts used as inlays is challenging. Traditionally, inlay grafts are secured with a press-fit technique that sometimes may be loose, and thus can lead to graft extrusion and treatment failure. Chang et al11 reported 4 cases of graft extrusion in a series of 48 scaphoid nonunions treated by the 1,2-intercompartmental artery VBG. Fixation of an inlay graft into the scaphoid represents the weakest link of those reconstructive procedures. To avoid dislodging the graft in the early postoperative period, we currently use a suture anchor for additional fixation. This technical note describes the use of a micro suture anchor for secure fixation of the VBG, harvested from the dorsal, distal radius, into the scaphoid. SURGICAL TECHNIQUE Supplemental fixation of the graft with the use of a micro suture anchor can be applied to every VBG harvested from the dorsal or distal radius when the graft is used as an inlay. We currently use the dorsal capsular-based VBG from the distal radius for scaphoid proximal pole nonunions, which we have described in detail in a previous report. This technique can also be applied for VBGs based on the 1,2-intercompartmental artery.14
© ASSH 䉬 Published by Elsevier, Inc. All rights reserved. 䉬 1475
Surgical Technique
Aaron I. Venouziou, MD, Dean G. Sotereanos, MD
1476
SUPPLEMENTAL FIXATION FOR DISTAL RADIUS VBG
Surgical Technique
FIGURE 1: A The distal radius (R) and dorsal capsule (C) are accessed through a dorsal incision just ulnar to the Lister tubercle. The extensor pollicis longus (EPL) is retracted radially and the extensor digitorum communis is retracted ulnarly. The capsularbased vascularized distal radius graft is outlined with a skin marker on the dorsal wrist capsule. B Schematic illustration. (Adapted from 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:580 –587, with permission from Elsevier.)
In brief, the procedure is performed under tourniquet control because no vascular pedicle dissection is necessary. A 4-cm straight, dorsal incision centered just ulnar to the Lister tubercle is performed. The third and fourth compartments are released, exposing the wrist capsule and distal radius. The capsular-based VBG is designed as a 1 ⫻ 1-cm bone block slightly ulnar and distal to the Lister tubercle, including the 3,4intercompartmental septum (Fig. 1). The bone block is harvested approximately 7 mm deep 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. The graft is elevated with a thin osteotome, maintaining 2 to 3 mm of distal radius cortex intact to prevent propagation into the joint. The capsular flap is outlined sharply with a scalpel, with care taken to preserve the scapholunate ligament. Then, the pseudarthrosis is debrided and compressive fixation of the scaphoid is performed under fluoroscopic control with the use of a cannulated, variable-pitch, threaded, headless screw. The screw should be placed volarly, allowing the creation of a dorsal trough and placement of the graft. After fixation of the nonunion site has been deemed solid, a trough is created dorsally across the nonunion site with a side-cutting burr. At this point, before placing the graft into the trough, the tourniquet is released to verify the vascularity of the bone graft and assess the vascular status of the proximal pole of the
FIGURE 2: Placement of a micro bone suture anchor deep into the trough, which serves as a socket for the VBG.
scaphoid. Usually the capsular flap shows abundant revascularization immediately, but punctate bleeding from the bone block itself lags behind for a few minutes. The trough serves as a socket for the graft; it should be slightly smaller in size than the graft, approximately 1 mm, to achieve press-fit fixation. The graft is placed into the trough as an inlay. Currently, we use micro suture anchors for supplemental fixation of the graft to avoid dislodgment.
JHS 䉬 Vol A, July
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FIGURE 3: A Posteroanterior and B lateral x-ray showing the screw and the anchor.
FIGURE 4: The micro suture anchor has been placed into the scaphoid and is loaded with two 2-0 sutures.
FIGURE 5: A mattress stitch is passed through the perimeter of the VBG periosteum.
We secure the VBG in the trough with a micro bone suture anchor (Micro Corkscrew FT; Arthrex, Inc., Naples, FL) (Fig. 2). This bone anchor, which is loaded with two 2-0 sutures, is placed at the floor of the trough and radial to the cannulated screw (Figs. 3, 4). There is more than enough room for this small anchor. A mattress stitch is passed through the perimeter of the VBG periosteum and the graft is gently inserted into the scaphoid trough (Fig. 5). The mattress stitch is tied over the graft, applying even tension on the sutures in such a way so
as not to compromise graft circulation (Figs. 6, 7). First, we throw a provisional knot over the graft and check the graft perfusion, because the tourniquet is still deflated. If bleeding from the graft stops, that means the knot is tight and we need to loosen it. If the graft demonstrates adequate bleeding, the knot is completed and the wrist is placed through a full range of motion, with caution, to verify that the graft is secured in position. Meticulous hemostasis is then obtained and a routine closure of the wound is performed.
JHS 䉬 Vol A, July
Surgical Technique
SUPPLEMENTAL FIXATION FOR DISTAL RADIUS VBG
1478
SUPPLEMENTAL FIXATION FOR DISTAL RADIUS VBG
Surgical Technique
FIGURE 6: The VBG is placed into the scaphoid. The mattress stitch is tied over the graft in such a way so as not to compress the pedicle.
DISCUSSION Scaphoid nonunions require bone grafting procedures to achieve healing. Vascularized bone grafts enhance the vascular supply to facilitate union.15–18 We previously reported a series of 13 patients with pseudarthrosis of the scaphoid, who underwent dorsal radius vascularized bone grafting, 10 of whom had an avascular proximal pole. With a minimum follow-up of 1 year, 10 of 13 patients achieved union.14
Failure to achieve healing may result from patient factors (tobacco use or prior surgical procedures) or technical errors. Technical factors that may contribute to treatment failure include damage to the vascular pedicle, inadequate scaphoid fixation, and extrusion of the graft. Meticulous harvesting of the capsular-based VBG minimizes the risk of injury to the vascular pedicle. On the other hand, rigid fixation of the scaphoid nonunion with compressive screws results in improved healing rates.15,17 In a series with 48 scaphoid nonunions treated with VBG, Chang et al11 found that screw fixation had a statistically favorable effect on scaphoid union. In the same series, they also reported 4 cases in which the vascularized bone graft had been extruded.11 Although the failures in our first series did not result from graft extrusion, we believe that fixation of the VBG is the weakest link of this reconstructive procedure. In our early series, we used a press-fit technique to secure the graft into the scaphoid trough. This is a demanding technique, because it is based on a size discrepancy of 1 mm between the trough and the graft. Failure to accomplish the appropriate size difference, and thus a press-fit fixation of the graft, may lead to graft extrusion in the early postoperative period. There was a case of graft extrusion in our early series with the
FIGURE 7: Diagram of the completed capsular graft in the anteroposterior and lateral planes.
JHS 䉬 Vol A, July
press-fit technique, but this did not affect the healing of the scaphoid nonunion. To eliminate the risk of graft displacement, we currently use micro suture anchors as supplemental fixation to secure the graft to the scaphoid. The anchor is placed deep in the trough and the graft is secured with a mattress stitch. The stitch should be tight enough to hold the graft in place, but loose enough to allow unrestricted blood flow. To date, our series with this new technique includes 28 patients with scaphoid nonunion, 21 of whom have an avascular proximal pole. Solid bone union has been achieved in 24 patients. We noted a history of tobacco use and the presence of proximal pole avascular necrosis in the patients with persistent nonunion. We found no graft extrusion in those 28 cases. This is a simple and quick technique that enhances the security of graft fixation. Although this technique represents an extra intraoperative step, it provides enhanced fixation of the VBG, which is beneficial during the critical early period of bone healing. REFERENCES 1. Muramatsu K, Bishop AT. Cell repopulation in vascularized bone grafts. J Orthop Res 2002;20:772–778. 2. Sunagawa T, Bishop AT, Muramatsu K. Role of conventional and vascularized bone grafts in scaphoid nonunion with avascular necrosis: a canine experimental study. J Hand Surg 2000;25A: 849 – 859. 3. Zaidemberg C, Siebert JW, Angrigiani C. A new vascularized bone graft for scaphoid nonunion. J Hand Surg 1991;16A:474 – 478. 4. Waitayawinyu T, McCallister WV, Katolik LI, Schlenker JD, Trumble TE. Outcome after vascularized bone grafting of scaphoid nonunions with avascular necrosis. J Hand Surg 2009;34A: 387–394. 5. Malizos KN, Zachos V, Dailiana ZH, Zalavras C, Varitimidis S, Hantes M, et al. Scaphoid nonunions: management with vascularized bone grafts from the distal radius: a clinical and functional outcome study. Plast Reconstr Surg 2007;119:1513–1525.
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6. Steinmann SP, Bishop AT, Berger RA. Use of the 1,2 intercompartmental supraretinacular artery as a vascularized pedicle bone graft for difficult scaphoid nonunion. J Hand Surg 2002;27A:391– 401. 7. Straw RG, Davis TR, Dias JJ. Scaphoid nonunion: treatment with a pedicled vascularized bone graft based on the 1,2 intercompartmental supraretinacular branch of the radial artery. J Hand Surg 2002; 27B:413– 416. 8. Malizos KN, Dailiana ZH, Kirou M, Vragalas V, Xenakis TA, Soucacos PN. Longstanding nonunions of scaphoid fractures with bone loss: successful reconstruction with vascularized bone grafts. J Hand Surg 2001;26B:330 –334. 9. Uerpairojkit C, Leechavengvongs S, Witoonchart K. Primary vascularized distal radius bone graft for nonunion of the scaphoid. J Hand Surg 2000;25B:266 –270. 10. Boyer MI, von Schroeder HP, Axelrod TS. Scaphoid nonunion with avascular necrosis of the proximal pole. Treatment with a vascularized bone graft from the dorsum of the distal radius. J Hand Surg 1998;23B:686 – 690. 11. Chang MA, Bishop AT, Moran SL, Shin AY. The outcomes and complications of 1,2-intercompartmental supraretinacular artery pedicled vascularized bone grafting of scaphoid nonunions. J Hand Surg 2006;31A:387–396. 12. Waters PM, Stewart SL. Surgical treatment of nonunion and avascular necrosis of the proximal part of the scaphoid in adolescents. J Bone Joint Surg 2002;84A:915–920. 13. Tsai TT, Chao EK, Tu YK, Chen AC, Lee MS, Ueng SW. Management of scaphoid nonunion with avascular necrosis using 1, 2 intercompartmental supraretinacular arterial bone grafts. Chang Gung Med J 2002;25:321–328. 14. 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:580 – 587. 15. 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;75:618 – 629. 16. Payatakes A, Sotereanos DG. Pedicled vascularized bone grafts for scaphoid and lunate reconstruction. J Am Acad Orthop Surg 2009; 17:744 –755. 17. Merrell GA, Wolfe SW, Slade JF III. Treatment of scaphoid nonunions: quantitative meta-analysis of the literature. J Hand Surg 2002;27A:685– 691. 18. Malizos KN, Dailiana ZH, Innocenti M, Mathoulin CL, Mattar R Jr, Sauerbier M. Vascularized bone grafts for upper limb reconstruction: defects at the distal radius, wrist, and hand. J Hand Surg 2010;35A: 1710 –1718.
JHS 䉬 Vol A, July
Surgical Technique
SUPPLEMENTAL FIXATION FOR DISTAL RADIUS VBG
Supplemental Graft Fixation for Distal Radius Vascularized Bone Graft
Vascularized bone grafts from the distal radius have been used successfully for the treatment of scaphoid nonunions. Typically, the harvested graft is secured into the scaphoid with a press-fit technique. This type of fixation may lead to graft extrusion in the early postoperative period, and thus to treatment failure. In this technical note, we describe the use of micro bone suture anchors for supplemental fixation of the vascularized bone graft into the scaphoid. It is a simple and quick technique and provides an enhanced fixation of the vascularized bone graft, which is beneficial during the early critical period of bone healing. (J Hand Surg 2012;37A:1475–1479. Copyright © 2012 by the American Society for Surgery of the Hand. All rights reserved.) Key words Distal radius, nonunion, scaphoid, suture anchors, vascularized bone graft.
UMEROUS BONE-GRAFTING TECHNIQUES have been used for the treatment of scaphoid nonunions. Vascularized bone grafts (VBGs) have demonstrated superior biological and mechanical properties in experimental studies. Animal models have shown that VBGs are incorporated in a faster, more predictable manner, especially when placed in a poorly vascularized bed.1,2 To date, several authors have achieved high union rates with the use of VBGs for the treatment of scaphoid nonunions. Zaidemberg et al3 described the use of a VBG based on the first recurrent branch of the radial artery (1,2-intercompartmental artery). Numerous authors have used this graft with high success rates.4 –13 Sotereanos et al14 reported good results with a dorsal capsular-based VBG from the distal radius for proximal pole scaphoid nonunions. This graft is nourished by the fourth extensor compartmental artery and is harvested from a position that allows easy access to the proximal scaphoid pole.
N
FromtheDepartmentofOrthopaedicSurgery,HandandUpperExtremitySurgery,AlleghenyGeneral Hospital, Pittsburgh, PA. Received for publication March 9, 2011; accepted in revised form April 19, 2012. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Correspondingauthor:DeanG.Sotereanos,MD,DepartmentofOrthopaedicSurgery,Handand Upper Extremity Surgery, Allegheny General Hospital, Drexel University College of Medicine, 1307 Federal Street, 2nd Floor, Pittsburgh, PA 15212; e-mail: [email protected]. 0363-5023/12/37A07-0030$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2012.04.024
The VBGs from the distal radius can be used either as structural grafts to correct an anatomic deformity and promote bone healing or as inlay grafts to enhance the biology of bone healing. Although the structural VBGs can be fixed securely with the use of screws or K-wires, fixation of the grafts used as inlays is challenging. Traditionally, inlay grafts are secured with a press-fit technique that sometimes may be loose, and thus can lead to graft extrusion and treatment failure. Chang et al11 reported 4 cases of graft extrusion in a series of 48 scaphoid nonunions treated by the 1,2-intercompartmental artery VBG. Fixation of an inlay graft into the scaphoid represents the weakest link of those reconstructive procedures. To avoid dislodging the graft in the early postoperative period, we currently use a suture anchor for additional fixation. This technical note describes the use of a micro suture anchor for secure fixation of the VBG, harvested from the dorsal, distal radius, into the scaphoid. SURGICAL TECHNIQUE Supplemental fixation of the graft with the use of a micro suture anchor can be applied to every VBG harvested from the dorsal or distal radius when the graft is used as an inlay. We currently use the dorsal capsular-based VBG from the distal radius for scaphoid proximal pole nonunions, which we have described in detail in a previous report. This technique can also be applied for VBGs based on the 1,2-intercompartmental artery.14
© ASSH 䉬 Published by Elsevier, Inc. All rights reserved. 䉬 1475
Surgical Technique
Aaron I. Venouziou, MD, Dean G. Sotereanos, MD
1476
SUPPLEMENTAL FIXATION FOR DISTAL RADIUS VBG
Surgical Technique
FIGURE 1: A The distal radius (R) and dorsal capsule (C) are accessed through a dorsal incision just ulnar to the Lister tubercle. The extensor pollicis longus (EPL) is retracted radially and the extensor digitorum communis is retracted ulnarly. The capsularbased vascularized distal radius graft is outlined with a skin marker on the dorsal wrist capsule. B Schematic illustration. (Adapted from 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:580 –587, with permission from Elsevier.)
In brief, the procedure is performed under tourniquet control because no vascular pedicle dissection is necessary. A 4-cm straight, dorsal incision centered just ulnar to the Lister tubercle is performed. The third and fourth compartments are released, exposing the wrist capsule and distal radius. The capsular-based VBG is designed as a 1 ⫻ 1-cm bone block slightly ulnar and distal to the Lister tubercle, including the 3,4intercompartmental septum (Fig. 1). The bone block is harvested approximately 7 mm deep 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. The graft is elevated with a thin osteotome, maintaining 2 to 3 mm of distal radius cortex intact to prevent propagation into the joint. The capsular flap is outlined sharply with a scalpel, with care taken to preserve the scapholunate ligament. Then, the pseudarthrosis is debrided and compressive fixation of the scaphoid is performed under fluoroscopic control with the use of a cannulated, variable-pitch, threaded, headless screw. The screw should be placed volarly, allowing the creation of a dorsal trough and placement of the graft. After fixation of the nonunion site has been deemed solid, a trough is created dorsally across the nonunion site with a side-cutting burr. At this point, before placing the graft into the trough, the tourniquet is released to verify the vascularity of the bone graft and assess the vascular status of the proximal pole of the
FIGURE 2: Placement of a micro bone suture anchor deep into the trough, which serves as a socket for the VBG.
scaphoid. Usually the capsular flap shows abundant revascularization immediately, but punctate bleeding from the bone block itself lags behind for a few minutes. The trough serves as a socket for the graft; it should be slightly smaller in size than the graft, approximately 1 mm, to achieve press-fit fixation. The graft is placed into the trough as an inlay. Currently, we use micro suture anchors for supplemental fixation of the graft to avoid dislodgment.
JHS 䉬 Vol A, July
1477
FIGURE 3: A Posteroanterior and B lateral x-ray showing the screw and the anchor.
FIGURE 4: The micro suture anchor has been placed into the scaphoid and is loaded with two 2-0 sutures.
FIGURE 5: A mattress stitch is passed through the perimeter of the VBG periosteum.
We secure the VBG in the trough with a micro bone suture anchor (Micro Corkscrew FT; Arthrex, Inc., Naples, FL) (Fig. 2). This bone anchor, which is loaded with two 2-0 sutures, is placed at the floor of the trough and radial to the cannulated screw (Figs. 3, 4). There is more than enough room for this small anchor. A mattress stitch is passed through the perimeter of the VBG periosteum and the graft is gently inserted into the scaphoid trough (Fig. 5). The mattress stitch is tied over the graft, applying even tension on the sutures in such a way so
as not to compromise graft circulation (Figs. 6, 7). First, we throw a provisional knot over the graft and check the graft perfusion, because the tourniquet is still deflated. If bleeding from the graft stops, that means the knot is tight and we need to loosen it. If the graft demonstrates adequate bleeding, the knot is completed and the wrist is placed through a full range of motion, with caution, to verify that the graft is secured in position. Meticulous hemostasis is then obtained and a routine closure of the wound is performed.
JHS 䉬 Vol A, July
Surgical Technique
SUPPLEMENTAL FIXATION FOR DISTAL RADIUS VBG
1478
SUPPLEMENTAL FIXATION FOR DISTAL RADIUS VBG
Surgical Technique
FIGURE 6: The VBG is placed into the scaphoid. The mattress stitch is tied over the graft in such a way so as not to compress the pedicle.
DISCUSSION Scaphoid nonunions require bone grafting procedures to achieve healing. Vascularized bone grafts enhance the vascular supply to facilitate union.15–18 We previously reported a series of 13 patients with pseudarthrosis of the scaphoid, who underwent dorsal radius vascularized bone grafting, 10 of whom had an avascular proximal pole. With a minimum follow-up of 1 year, 10 of 13 patients achieved union.14
Failure to achieve healing may result from patient factors (tobacco use or prior surgical procedures) or technical errors. Technical factors that may contribute to treatment failure include damage to the vascular pedicle, inadequate scaphoid fixation, and extrusion of the graft. Meticulous harvesting of the capsular-based VBG minimizes the risk of injury to the vascular pedicle. On the other hand, rigid fixation of the scaphoid nonunion with compressive screws results in improved healing rates.15,17 In a series with 48 scaphoid nonunions treated with VBG, Chang et al11 found that screw fixation had a statistically favorable effect on scaphoid union. In the same series, they also reported 4 cases in which the vascularized bone graft had been extruded.11 Although the failures in our first series did not result from graft extrusion, we believe that fixation of the VBG is the weakest link of this reconstructive procedure. In our early series, we used a press-fit technique to secure the graft into the scaphoid trough. This is a demanding technique, because it is based on a size discrepancy of 1 mm between the trough and the graft. Failure to accomplish the appropriate size difference, and thus a press-fit fixation of the graft, may lead to graft extrusion in the early postoperative period. There was a case of graft extrusion in our early series with the
FIGURE 7: Diagram of the completed capsular graft in the anteroposterior and lateral planes.
JHS 䉬 Vol A, July
press-fit technique, but this did not affect the healing of the scaphoid nonunion. To eliminate the risk of graft displacement, we currently use micro suture anchors as supplemental fixation to secure the graft to the scaphoid. The anchor is placed deep in the trough and the graft is secured with a mattress stitch. The stitch should be tight enough to hold the graft in place, but loose enough to allow unrestricted blood flow. To date, our series with this new technique includes 28 patients with scaphoid nonunion, 21 of whom have an avascular proximal pole. Solid bone union has been achieved in 24 patients. We noted a history of tobacco use and the presence of proximal pole avascular necrosis in the patients with persistent nonunion. We found no graft extrusion in those 28 cases. This is a simple and quick technique that enhances the security of graft fixation. Although this technique represents an extra intraoperative step, it provides enhanced fixation of the VBG, which is beneficial during the critical early period of bone healing. REFERENCES 1. Muramatsu K, Bishop AT. Cell repopulation in vascularized bone grafts. J Orthop Res 2002;20:772–778. 2. Sunagawa T, Bishop AT, Muramatsu K. Role of conventional and vascularized bone grafts in scaphoid nonunion with avascular necrosis: a canine experimental study. J Hand Surg 2000;25A: 849 – 859. 3. Zaidemberg C, Siebert JW, Angrigiani C. A new vascularized bone graft for scaphoid nonunion. J Hand Surg 1991;16A:474 – 478. 4. Waitayawinyu T, McCallister WV, Katolik LI, Schlenker JD, Trumble TE. Outcome after vascularized bone grafting of scaphoid nonunions with avascular necrosis. J Hand Surg 2009;34A: 387–394. 5. Malizos KN, Zachos V, Dailiana ZH, Zalavras C, Varitimidis S, Hantes M, et al. Scaphoid nonunions: management with vascularized bone grafts from the distal radius: a clinical and functional outcome study. Plast Reconstr Surg 2007;119:1513–1525.
1479
6. Steinmann SP, Bishop AT, Berger RA. Use of the 1,2 intercompartmental supraretinacular artery as a vascularized pedicle bone graft for difficult scaphoid nonunion. J Hand Surg 2002;27A:391– 401. 7. Straw RG, Davis TR, Dias JJ. Scaphoid nonunion: treatment with a pedicled vascularized bone graft based on the 1,2 intercompartmental supraretinacular branch of the radial artery. J Hand Surg 2002; 27B:413– 416. 8. Malizos KN, Dailiana ZH, Kirou M, Vragalas V, Xenakis TA, Soucacos PN. Longstanding nonunions of scaphoid fractures with bone loss: successful reconstruction with vascularized bone grafts. J Hand Surg 2001;26B:330 –334. 9. Uerpairojkit C, Leechavengvongs S, Witoonchart K. Primary vascularized distal radius bone graft for nonunion of the scaphoid. J Hand Surg 2000;25B:266 –270. 10. Boyer MI, von Schroeder HP, Axelrod TS. Scaphoid nonunion with avascular necrosis of the proximal pole. Treatment with a vascularized bone graft from the dorsum of the distal radius. J Hand Surg 1998;23B:686 – 690. 11. Chang MA, Bishop AT, Moran SL, Shin AY. The outcomes and complications of 1,2-intercompartmental supraretinacular artery pedicled vascularized bone grafting of scaphoid nonunions. J Hand Surg 2006;31A:387–396. 12. Waters PM, Stewart SL. Surgical treatment of nonunion and avascular necrosis of the proximal part of the scaphoid in adolescents. J Bone Joint Surg 2002;84A:915–920. 13. Tsai TT, Chao EK, Tu YK, Chen AC, Lee MS, Ueng SW. Management of scaphoid nonunion with avascular necrosis using 1, 2 intercompartmental supraretinacular arterial bone grafts. Chang Gung Med J 2002;25:321–328. 14. 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:580 – 587. 15. 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;75:618 – 629. 16. Payatakes A, Sotereanos DG. Pedicled vascularized bone grafts for scaphoid and lunate reconstruction. J Am Acad Orthop Surg 2009; 17:744 –755. 17. Merrell GA, Wolfe SW, Slade JF III. Treatment of scaphoid nonunions: quantitative meta-analysis of the literature. J Hand Surg 2002;27A:685– 691. 18. Malizos KN, Dailiana ZH, Innocenti M, Mathoulin CL, Mattar R Jr, Sauerbier M. Vascularized bone grafts for upper limb reconstruction: defects at the distal radius, wrist, and hand. J Hand Surg 2010;35A: 1710 –1718.
JHS 䉬 Vol A, July
Surgical Technique
SUPPLEMENTAL FIXATION FOR DISTAL RADIUS VBG