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Technique of Olecranon Bone Grafting for Surgical Fixation of Scaphoid Fractures
SURGICAL TECHNIQUE
Technique of Olecranon Bone Grafting for Surgical Fixation of Scaphoid Fractures Harvey Chim, MRCS, Fuat Malkoc, MRCS, Shian-Chao Tay, FRCS, Andrew Yam, FRCS, Lam-Chuan Teoh, FRCS
Surgical Technique
Currently described sources of bone graft, such as iliac crest and distal radius, for supplemental fixation of scaphoid fractures are suboptimal. In our experience, olecranon bone has the advantage of providing a convenient source of corticocancellous block graft that can be harvested within the same sterile operative field used for fixation of the scaphoid fracture, and it also causes less postoperative pain compared to that obtained from iliac crest. Here, we describe our surgical technique for harvest and use of olecranon bone graft for fixation of scaphoid fractures. (J Hand Surg 2011;36A:1220–1223. Copyright © 2011 by the American Society for Surgery of the Hand. All rights reserved.) Key words Bone graft, hand, nonunion, olecranon, scaphoid fractures.
ONE GRAFTING OF scaphoid fractures with cancellous bone chips or corticocancellous strut grafts is indicated in nonunions with cystic degenera1 In acute fractures or nonunion with bone loss at tion. the fracture site resulting in a “humpback” flexion deformity of the scaphoid, a palmar corticocancellous wedge graft is recommended.2 This restores the scaphoid height and intrascaphoid angle, corrects the deranged wrist kinematics, and decreases risk of longterm osteoarthritis. A variety of bone graft options have been described by various authors, including nonvascularized iliac crest1,3 or distal radius,4 as well as cancellous bone chip grafting.5 In patients with nonunion with avascular necrosis of the proximal pole, vascularized bone grafting has gained increasing popularity in recent years.6,7 Nevertheless, treatment strategies for scaphoid nonunions remain controversial.8 In our institution, we have been using the ipsilateral olecranon as a source of bone graft for fixation of scaphoid fractures since 1988. The olecranon provides
B
FromtheÖzelMarmaraHastanesi,Turkey;DepartmentofPlasticSurgery,CaseWesternReserveUniversity, Cleveland, OH; Department of Hand Surgery, Singapore General Hospital, Singapore; Department of Orthopedic Surgery, Tan Tock Seng Hospital, Singapore. Received for publication June 28, 2010; accepted in revised form April 27, 2011. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Correspondingauthor:Shian-ChaoTay,FRCS,SingaporeGeneralHospital,DepartmentofHand Surgery, Outram Road, Singapore 169608; e-mail: [email protected]. 0363-5023/11/36A07-0020$36.00/0 doi:10.1016/j.jhsa.2011.04.012
1220 䉬 © ASSH 䉬 Published by Elsevier, Inc. All rights reserved.
a convenient source of corticocancellous block graft that can be harvested within the same sterile operative field used for fixation of the scaphoid fracture. In our experience, patients report less postoperative pain and are more mobile than patients who have iliac crest bone grafting. We also feel that the quality of the corticocancellous block is much better than that obtained from the distal radius. We describe our surgical technique with olecranon wedge bone grafting and Herbert screw (Zimmer, Warsaw, IN) fixation9 of scaphoid fractures. SURGICAL TECHNIQUE We used the palmar approach as described by Fernandez2 for all cases of scaphoid fixation. In nonunions, any fibrous or necrotic tissue and the sclerotic edges of the fracture are resected with a small osteotome and a bone rongeur. The scaphoid is stretched to length by deviating the wrist in an ulnar direction, and the size of the palmar osseous defect is measured using osteotomes of different widths as sizers. A longitudinal incision is made over the olecranon, starting from the tip and extending distally by about 5 cm. The periosteum is incised from a point 1 cm distal to the tip of the olecranon. This is usually the flatter part of the olecranon before the appearance of the crest. The cortical bone is exposed by sharply elevating the periosteum, taking care to keep the periosteal flaps intact to allow a good periosteal closure after harvesting the bone graft. A typical size of the block is 5 mm ⫻10 mm for scaphoid bone grafting, although dimensions of up
to 20 mm ⫻ 30 mm can be achieved, depending on the size of the olecranon, as long as the lateral cortices are not violated. Next, the cortex over the bone graft donor site is thinned down by shaving it off with a sharp osteotome. Cortical bone thinning is considered sufficient when tiny punctate bleeding is seen coming from the bone. A sharp osteotome is then used to make the cuts, starting with the transverse cuts before making the longitudinal cuts. To ensure the integrity of the corticocancellous bone block, it is crucial that the osteotome contacts the anterior cortex of the olecranon along the length of all 4 sides of the graft before attempting to extricate the block (Fig. 1A). To facilitate extraction, a triangular cavity can be made at the distal end of the bone block, so that a small osteotome can be inserted deep into the cavity to lever the bone block away from the anterior cortex. After the bone block is extricated, it is fashioned with a small oscillating saw into a trapezoidal wedge to fit the defect in the scaphoid (Figs. 1B, 1C). If necessary, loose cancellous bone graft curetted from the olecranon donor site after removal of the bone block can be used to pack cystic cavities in the scaphoid before insertion of the wedge bone graft. The periosteal flaps are meticulously closed over the donor cavity, using a double layer of running sutures to create a water-tight seal to prevent postoperative hematoma or seroma formation. We do not use bone wax in the cavity. With the fracture reduced, a Kirschner wire is used to maintain temporary reduction before inserting the Herbert screw. After inserting the screw, the Kirschner wire is removed or left in place to provide supplementary fixation, as indicated. With cannulated scaphoid screws, the guide wire can be used in place of the Kirschner wire, eliminating 1 step of the procedure. The wrist is splinted in neutral position for 4 weeks. Thereafter, interval splinting in between active wrist joint mobilization exercises is instituted until fracture union. Progressive resistive exercises are allowed after radiographs show fracture union.
RESULTS We reviewed our series of 81 patients treated with this technique from 1988 to 1996, of whom 21 patients were available for a long-term outcome study. Bone grafting was performed when there was a bone loss at the fracture site or when the fracture had resulted in a flexion deformity of the scaphoid. Twenty patients were male and 1 was female. Their age range at the time of
1221
Surgical Technique
OLECRANON BONE GRAFTING FOR SCAPHOID FRACTURES
FIGURE 1: Technique of olecranon bone graft harvest and inset. A Corticocancellous block of bone is extracted from the olecranon following exposure with longitudinal incision. B Defect following preparation at site of scaphoid waist fracture nonunion. C Following inset of bone graft, which has been shaped as a trapezoidal wedge.
surgery was 17 to 43 years (mean, 25 y). The right wrist was affected in 11 patients and the left in 10. Fractures involved the waist of the scaphoid in 18, were proximal in 2, and distal oblique in 1 patient. Of the patient population, the reason for surgery included unstable acute fractures (n⫽7), delayed union (n⫽4) or non-
JHS 䉬 Vol A, July
1222
OLECRANON BONE GRAFTING FOR SCAPHOID FRACTURES
FIGURE 2: A Radiograph of a 43-year-old man with established sclerotic nonunion at the site of a previous scaphoid waist fracture. B Radiograph at 10.8 years after surgery shows complete union, with no evidence of degenerative wrist changes.
Surgical Technique FIGURE 3: A Radiographs of a 25-year-old man with a scaphoid waist fracture non-union 18 months after fixation with Herbert screw. He was treated with olecranon bone grafting and repeat Herbert screw fixation. B Radiograph 8.8 years after surgery shows complete union, with no degenerative changes.
union (n⫽10). Nineteen patients achieved fracture union by 3 months. Of the 2 patients who failed to achieve union, a repeat operation with anterior wedge bone grafting was performed for 1 patient, who achieved union 8 weeks after surgery. The remaining patient who did not achieve fracture union declined further surgery. Patients had repeat radiographs of the wrists at 6.3 to 14.3 years after the initial surgery. Of the 21 patients, 6 showed degenerative changes. According to the classification described by Filan and Herbert, 3 patients had
mild changes (subtle pointing of styloid/scaphoid), 1 patient had moderate change (slight joint narrowing) and 2 patients had severe degenerative changes (large osteophytes, narrow joint space).10 The patient who declined further surgery had a persistent scaphoid nonunion with severe degenerative changes and decreased carpal height ratio. There were no degenerative changes seen at the scaphotrapezium-trapezoid joint for all patients (n⫽21). Representative patients with radiographs from long-term follow-up are illustrated in Figures 2 and 3.
JHS 䉬 Vol A, July
OLECRANON BONE GRAFTING FOR SCAPHOID FRACTURES
reported for treatment of nonunions in the distal phalanx.13 The olecranon is a desirable option for nonvascularized bone graft in scaphoid fractures and hand reconstruction and is our donor site of choice in these situations. REFERENCES 1. Russe O. Fracture of the carpal navicular. Diagnosis, non-operative treatment, and operative treatment. J Bone Joint Surg 1960;42A: 759 –768. 2. Fernandez DL. A technique for anterior wedge-shaped grafts for scaphoid nonunions with carpal instability. J Hand Surg 1984;9A: 733–737. 3. Bindra R, Bednar M, Light T. Volar wedge grafting for scaphoid non-union with collapse. J Hand Surg 2008;33A:974 –979. 4. Tambe AD, Cutler L, Murali SR, Trail IA, Stanley JK. In scaphoid non-union, does the source of graft affect outcome? Iliac crest versus distal end of radius bone graft. J Hand Surg 2006;31B:47–51. 5. Stark HH, Rickard TA, Zemel NP, Ashworth CR. Treatment of ununited fractures of the scaphoid by iliac bone grafts and Kirschnerwire fixation. J Bone Joint Surg 1988;70A:982–991. 6. Tambe AD, Cutler L, Stilwell J, Murali SR, Trail IA, Stanley JK. Scaphoid non-union: the role of vascularized grafting in recalcitrant non-unions of the scaphoid. J Hand Surg 2002;31B:185–190. 7. Waitayawinyu T, Pfaeffle HJ, McCallister WV, Nemechek NM, Traumble TE. Management of scaphoid nonunions. Orthop Clin North Am 2007;38:237–249. 8. Kawamura K, Chung KC. Treatment of scaphoid fractures and nonunions. J Hand Surg 2008;33A:988 –997. 9. Herbert TJ, Fisher WE. Management of the fractured scaphoid using a new bone screw. J Bone Joint Surg 1984;66B:114 –123. 10. Filan SL, Herbert TJ. Herbert screw fixation of scaphoid fractures. J Bone Joint Surg 1996;78B:519 –529. 11. Murata Y, Takahashi K, Yamagata M, Sameda H, Moriya H. Injury to the lateral femoral cutaneous nerve during harvest of iliac bone graft, with reference to the size of the graft. J Bone Joint Surg 2002;84B:798 – 801. 12. Bruno RJ, Cohen MS, Berzins A, Sumner DR. Bone graft harvesting from the distal radius, olecranon, and iliac crest: a quantitative analysis. J Hand Surg 2001;26A:135–141. 13. Ozecelik IB, Kabakas F, Mersa B, Purisa H, Sezer I, Erturer E. Treatment of nonunions of the distal phalanx with olecranon bone graft. J Hand Surg 2009;34B:638 – 642.
JHS 䉬 Vol A, July
Surgical Technique
DISCUSSION Harvesting bone graft from the ipsilateral olecranon confines the surgical field to a single limb, both limiting postoperative pain and allowing surgery to be performed under regional anesthesia. Potential complications include hematoma formation, pathological fracture of the olecranon, infection, and pain or tenderness on resting the elbow on a hard surface. We encountered none of these problems. In our experience, we have had no pathological fractures of the olecranon following bone graft harvest. There is no risk of nerve injury, unlike iliac bone grafts, in which an 8% rate of injury to the lateral femoral cutaneous nerve was reported in 1 study,11 or distal radius grafts, in which the superficial radial nerve branches are at risk. A corticocancellous bone block of good quality can be obtained if care is taken to harvest the bone as described, which has resulted in high union rates in all applications. However, the size of the graft is limited by the size of the olecranon. Also, less cancellous bone can be harvested at this site compared to the iliac crest.12 In our experience, older patients, above 50 years of age in particular, have little cancellous bone at this location. It is therefore not advisable to use the olecranon if only cancellous bone graft is needed. Finally, we do not recommend olecranon graft in patients with severe osteopenia or osteoporosis, in which the risk of pathological fracture is high. This graft is also ideal for reconstruction of small to medium bone defects in the phalanges or metacarpals, when a cortical strut or wedge graft is required for immediate structural support. Examples would include defects following resection of benign bone tumors, atrophic nonunion, and corrective osteotomy for malunion with severe angulation and shortening. It has also been
1223
Technique of Olecranon Bone Grafting for Surgical Fixation of Scaphoid Fractures Harvey Chim, MRCS, Fuat Malkoc, MRCS, Shian-Chao Tay, FRCS, Andrew Yam, FRCS, Lam-Chuan Teoh, FRCS
Surgical Technique
Currently described sources of bone graft, such as iliac crest and distal radius, for supplemental fixation of scaphoid fractures are suboptimal. In our experience, olecranon bone has the advantage of providing a convenient source of corticocancellous block graft that can be harvested within the same sterile operative field used for fixation of the scaphoid fracture, and it also causes less postoperative pain compared to that obtained from iliac crest. Here, we describe our surgical technique for harvest and use of olecranon bone graft for fixation of scaphoid fractures. (J Hand Surg 2011;36A:1220–1223. Copyright © 2011 by the American Society for Surgery of the Hand. All rights reserved.) Key words Bone graft, hand, nonunion, olecranon, scaphoid fractures.
ONE GRAFTING OF scaphoid fractures with cancellous bone chips or corticocancellous strut grafts is indicated in nonunions with cystic degenera1 In acute fractures or nonunion with bone loss at tion. the fracture site resulting in a “humpback” flexion deformity of the scaphoid, a palmar corticocancellous wedge graft is recommended.2 This restores the scaphoid height and intrascaphoid angle, corrects the deranged wrist kinematics, and decreases risk of longterm osteoarthritis. A variety of bone graft options have been described by various authors, including nonvascularized iliac crest1,3 or distal radius,4 as well as cancellous bone chip grafting.5 In patients with nonunion with avascular necrosis of the proximal pole, vascularized bone grafting has gained increasing popularity in recent years.6,7 Nevertheless, treatment strategies for scaphoid nonunions remain controversial.8 In our institution, we have been using the ipsilateral olecranon as a source of bone graft for fixation of scaphoid fractures since 1988. The olecranon provides
B
FromtheÖzelMarmaraHastanesi,Turkey;DepartmentofPlasticSurgery,CaseWesternReserveUniversity, Cleveland, OH; Department of Hand Surgery, Singapore General Hospital, Singapore; Department of Orthopedic Surgery, Tan Tock Seng Hospital, Singapore. Received for publication June 28, 2010; accepted in revised form April 27, 2011. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Correspondingauthor:Shian-ChaoTay,FRCS,SingaporeGeneralHospital,DepartmentofHand Surgery, Outram Road, Singapore 169608; e-mail: [email protected]. 0363-5023/11/36A07-0020$36.00/0 doi:10.1016/j.jhsa.2011.04.012
1220 䉬 © ASSH 䉬 Published by Elsevier, Inc. All rights reserved.
a convenient source of corticocancellous block graft that can be harvested within the same sterile operative field used for fixation of the scaphoid fracture. In our experience, patients report less postoperative pain and are more mobile than patients who have iliac crest bone grafting. We also feel that the quality of the corticocancellous block is much better than that obtained from the distal radius. We describe our surgical technique with olecranon wedge bone grafting and Herbert screw (Zimmer, Warsaw, IN) fixation9 of scaphoid fractures. SURGICAL TECHNIQUE We used the palmar approach as described by Fernandez2 for all cases of scaphoid fixation. In nonunions, any fibrous or necrotic tissue and the sclerotic edges of the fracture are resected with a small osteotome and a bone rongeur. The scaphoid is stretched to length by deviating the wrist in an ulnar direction, and the size of the palmar osseous defect is measured using osteotomes of different widths as sizers. A longitudinal incision is made over the olecranon, starting from the tip and extending distally by about 5 cm. The periosteum is incised from a point 1 cm distal to the tip of the olecranon. This is usually the flatter part of the olecranon before the appearance of the crest. The cortical bone is exposed by sharply elevating the periosteum, taking care to keep the periosteal flaps intact to allow a good periosteal closure after harvesting the bone graft. A typical size of the block is 5 mm ⫻10 mm for scaphoid bone grafting, although dimensions of up
to 20 mm ⫻ 30 mm can be achieved, depending on the size of the olecranon, as long as the lateral cortices are not violated. Next, the cortex over the bone graft donor site is thinned down by shaving it off with a sharp osteotome. Cortical bone thinning is considered sufficient when tiny punctate bleeding is seen coming from the bone. A sharp osteotome is then used to make the cuts, starting with the transverse cuts before making the longitudinal cuts. To ensure the integrity of the corticocancellous bone block, it is crucial that the osteotome contacts the anterior cortex of the olecranon along the length of all 4 sides of the graft before attempting to extricate the block (Fig. 1A). To facilitate extraction, a triangular cavity can be made at the distal end of the bone block, so that a small osteotome can be inserted deep into the cavity to lever the bone block away from the anterior cortex. After the bone block is extricated, it is fashioned with a small oscillating saw into a trapezoidal wedge to fit the defect in the scaphoid (Figs. 1B, 1C). If necessary, loose cancellous bone graft curetted from the olecranon donor site after removal of the bone block can be used to pack cystic cavities in the scaphoid before insertion of the wedge bone graft. The periosteal flaps are meticulously closed over the donor cavity, using a double layer of running sutures to create a water-tight seal to prevent postoperative hematoma or seroma formation. We do not use bone wax in the cavity. With the fracture reduced, a Kirschner wire is used to maintain temporary reduction before inserting the Herbert screw. After inserting the screw, the Kirschner wire is removed or left in place to provide supplementary fixation, as indicated. With cannulated scaphoid screws, the guide wire can be used in place of the Kirschner wire, eliminating 1 step of the procedure. The wrist is splinted in neutral position for 4 weeks. Thereafter, interval splinting in between active wrist joint mobilization exercises is instituted until fracture union. Progressive resistive exercises are allowed after radiographs show fracture union.
RESULTS We reviewed our series of 81 patients treated with this technique from 1988 to 1996, of whom 21 patients were available for a long-term outcome study. Bone grafting was performed when there was a bone loss at the fracture site or when the fracture had resulted in a flexion deformity of the scaphoid. Twenty patients were male and 1 was female. Their age range at the time of
1221
Surgical Technique
OLECRANON BONE GRAFTING FOR SCAPHOID FRACTURES
FIGURE 1: Technique of olecranon bone graft harvest and inset. A Corticocancellous block of bone is extracted from the olecranon following exposure with longitudinal incision. B Defect following preparation at site of scaphoid waist fracture nonunion. C Following inset of bone graft, which has been shaped as a trapezoidal wedge.
surgery was 17 to 43 years (mean, 25 y). The right wrist was affected in 11 patients and the left in 10. Fractures involved the waist of the scaphoid in 18, were proximal in 2, and distal oblique in 1 patient. Of the patient population, the reason for surgery included unstable acute fractures (n⫽7), delayed union (n⫽4) or non-
JHS 䉬 Vol A, July
1222
OLECRANON BONE GRAFTING FOR SCAPHOID FRACTURES
FIGURE 2: A Radiograph of a 43-year-old man with established sclerotic nonunion at the site of a previous scaphoid waist fracture. B Radiograph at 10.8 years after surgery shows complete union, with no evidence of degenerative wrist changes.
Surgical Technique FIGURE 3: A Radiographs of a 25-year-old man with a scaphoid waist fracture non-union 18 months after fixation with Herbert screw. He was treated with olecranon bone grafting and repeat Herbert screw fixation. B Radiograph 8.8 years after surgery shows complete union, with no degenerative changes.
union (n⫽10). Nineteen patients achieved fracture union by 3 months. Of the 2 patients who failed to achieve union, a repeat operation with anterior wedge bone grafting was performed for 1 patient, who achieved union 8 weeks after surgery. The remaining patient who did not achieve fracture union declined further surgery. Patients had repeat radiographs of the wrists at 6.3 to 14.3 years after the initial surgery. Of the 21 patients, 6 showed degenerative changes. According to the classification described by Filan and Herbert, 3 patients had
mild changes (subtle pointing of styloid/scaphoid), 1 patient had moderate change (slight joint narrowing) and 2 patients had severe degenerative changes (large osteophytes, narrow joint space).10 The patient who declined further surgery had a persistent scaphoid nonunion with severe degenerative changes and decreased carpal height ratio. There were no degenerative changes seen at the scaphotrapezium-trapezoid joint for all patients (n⫽21). Representative patients with radiographs from long-term follow-up are illustrated in Figures 2 and 3.
JHS 䉬 Vol A, July
OLECRANON BONE GRAFTING FOR SCAPHOID FRACTURES
reported for treatment of nonunions in the distal phalanx.13 The olecranon is a desirable option for nonvascularized bone graft in scaphoid fractures and hand reconstruction and is our donor site of choice in these situations. REFERENCES 1. Russe O. Fracture of the carpal navicular. Diagnosis, non-operative treatment, and operative treatment. J Bone Joint Surg 1960;42A: 759 –768. 2. Fernandez DL. A technique for anterior wedge-shaped grafts for scaphoid nonunions with carpal instability. J Hand Surg 1984;9A: 733–737. 3. Bindra R, Bednar M, Light T. Volar wedge grafting for scaphoid non-union with collapse. J Hand Surg 2008;33A:974 –979. 4. Tambe AD, Cutler L, Murali SR, Trail IA, Stanley JK. In scaphoid non-union, does the source of graft affect outcome? Iliac crest versus distal end of radius bone graft. J Hand Surg 2006;31B:47–51. 5. Stark HH, Rickard TA, Zemel NP, Ashworth CR. Treatment of ununited fractures of the scaphoid by iliac bone grafts and Kirschnerwire fixation. J Bone Joint Surg 1988;70A:982–991. 6. Tambe AD, Cutler L, Stilwell J, Murali SR, Trail IA, Stanley JK. Scaphoid non-union: the role of vascularized grafting in recalcitrant non-unions of the scaphoid. J Hand Surg 2002;31B:185–190. 7. Waitayawinyu T, Pfaeffle HJ, McCallister WV, Nemechek NM, Traumble TE. Management of scaphoid nonunions. Orthop Clin North Am 2007;38:237–249. 8. Kawamura K, Chung KC. Treatment of scaphoid fractures and nonunions. J Hand Surg 2008;33A:988 –997. 9. Herbert TJ, Fisher WE. Management of the fractured scaphoid using a new bone screw. J Bone Joint Surg 1984;66B:114 –123. 10. Filan SL, Herbert TJ. Herbert screw fixation of scaphoid fractures. J Bone Joint Surg 1996;78B:519 –529. 11. Murata Y, Takahashi K, Yamagata M, Sameda H, Moriya H. Injury to the lateral femoral cutaneous nerve during harvest of iliac bone graft, with reference to the size of the graft. J Bone Joint Surg 2002;84B:798 – 801. 12. Bruno RJ, Cohen MS, Berzins A, Sumner DR. Bone graft harvesting from the distal radius, olecranon, and iliac crest: a quantitative analysis. J Hand Surg 2001;26A:135–141. 13. Ozecelik IB, Kabakas F, Mersa B, Purisa H, Sezer I, Erturer E. Treatment of nonunions of the distal phalanx with olecranon bone graft. J Hand Surg 2009;34B:638 – 642.
JHS 䉬 Vol A, July
Surgical Technique
DISCUSSION Harvesting bone graft from the ipsilateral olecranon confines the surgical field to a single limb, both limiting postoperative pain and allowing surgery to be performed under regional anesthesia. Potential complications include hematoma formation, pathological fracture of the olecranon, infection, and pain or tenderness on resting the elbow on a hard surface. We encountered none of these problems. In our experience, we have had no pathological fractures of the olecranon following bone graft harvest. There is no risk of nerve injury, unlike iliac bone grafts, in which an 8% rate of injury to the lateral femoral cutaneous nerve was reported in 1 study,11 or distal radius grafts, in which the superficial radial nerve branches are at risk. A corticocancellous bone block of good quality can be obtained if care is taken to harvest the bone as described, which has resulted in high union rates in all applications. However, the size of the graft is limited by the size of the olecranon. Also, less cancellous bone can be harvested at this site compared to the iliac crest.12 In our experience, older patients, above 50 years of age in particular, have little cancellous bone at this location. It is therefore not advisable to use the olecranon if only cancellous bone graft is needed. Finally, we do not recommend olecranon graft in patients with severe osteopenia or osteoporosis, in which the risk of pathological fracture is high. This graft is also ideal for reconstruction of small to medium bone defects in the phalanges or metacarpals, when a cortical strut or wedge graft is required for immediate structural support. Examples would include defects following resection of benign bone tumors, atrophic nonunion, and corrective osteotomy for malunion with severe angulation and shortening. It has also been
1223