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Vascularized Bone Grafting and Distal Radius Osteotomy for Scaphoid Nonunion Advanced Collapse
SCIENTIFIC ARTICLE
Vascularized Bone Grafting and Distal Radius Osteotomy for Scaphoid Nonunion Advanced Collapse Konstantinos N. Malizos, MD, PhD, Antonios Koutalos, MD, Loukia Papatheodorou, MD, PhD, Sokratis Varitimidis, MD, PhD, Vasileios Kontogeorgakos, MD, PhD, Zoe Dailiana, MD, PhD
Purpose To determine the outcome of an alternative treatment for wrists with stages I to III scaphoid nonunion advanced collapse using a closing-wedge osteotomy of the distal radius and a vascularized bone graft for scaphoid reconstruction. Methods Twelve patients with scaphoid nonunion advanced collapse (stage I, 3; stage II, 7; stage III, 2) treated with a vascularized bone graft interposition for the scaphoid and a closingwedge osteotomy for the distal radius were retrospectively reviewed. Data were obtained and analyzed from the radiographs, and we assessed the pre- and postoperative range of motion, grip strength, visual analog scale pain score, as well as the Mayo and Disabilities of the Arm, Shoulder, and Hand (DASH) functional scores. Results Follow-up ranged from 2 to 11 years. All scaphoid nonunions united after an average of 9 weeks, and all osteotomies united after an average of 8 weeks. Although there was radiographic progression of the scaphoid nonunion advanced collapse stage in 5 of 12 cases, there was major improvement in visual analog scale pain score (from 6.1 to 0.8) and in both Mayo (from 64 to 85) and DASH (from 40 to 9) functional scores. The range of motion remained unchanged, and grip strength trended toward minor improvement. The carpal height was preserved, and the dorsal intercalated segmental instability was corrected. Conclusions Scaphoid reconstruction with vascularized bone graft combined with closingwedge distal radius osteotomy preserved wrist function for scaphoid nonunion advanced collapse. The method offers pain relief and does not compromise wrist motion or grip strength. (J Hand Surg Am. 2014;39(5):872e879. Copyright Ó 2014 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic IV. Key words Distal radius osteotomy, scaphoid nonunion, SNAC wrist, vascularized bone graft, radiocarpal arthritis.
From the Department of Orthopaedic Surgery and Musculoskeletal Trauma, Faculty of Medicine, University of Thessalia, Larissa, Greece. Received for publication July 11, 2013; accepted in revised form January 24, 2014. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Zoe Dailiana, MD, PhD, Department of Orthopaedic Surgery and Musculoskeletal Trauma, Faculty of Medicine, University of Thessalia, Biopolis, 41500, Larissa, Greece; e-mail: [email protected]. 0363-5023/14/3905-0006$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2014.01.045
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unite if they are diagnosed early and treated properly; however, failure rates as high as 15% have been reported.1 Treatment options for scaphoid nonunions include conventional bone grafting or vascularized bone grafts (VBG) through a dorsal or palmar approach depending on the type and the location of the nonunion and the presence of avascular necrosis (AVN).2,3 AVN of the proximal pole presents a particular challenge. Treatment of this subgroup with HE MAJORITY OF SCAPHOID FRACTURES
SNAC WRIST: VASCULARIZED BONE GRAFT AND OSTEOTOMY
conventional bone grafting may be inadequate, whereas VBG, from either the dorsal or the palmar distal radius, offers higher union rates.4e9 Scaphoid nonunion advanced collapse (SNAC) represents the end stage of a progressive deformity following an untreated scaphoid nonunion and is classified in 4 stages ranging from arthritis at the radial styloid to pancarpal arthritis.10,11 The treatment options are related to the stage of the disease. For stage I, reconstructive procedures of the scaphoid with or without styloidectomy are preferred. For stages II and III, salvage procedures such as proximal row carpectomy (PRC) or 4 corner arthrodesis (FCA) are indicated.12 However, these salvage procedures have several technical concerns. Both PRC and FCA can result in reduced motion. Four-corner arthrodesis may result in hardware problems, and PRC has a high failure rate in young manual workers. In addition, both procedures may reduce grip strength, and PRC may lead to capitoradial joint arthritis.13,14 A closing-wedge osteotomy of the distal radius was proposed by Giannikas and Papachristou15 for the treatment of painful scaphoid nonunions. Sixtyfour percent of patients in their series had arthritic changes in the radiocarpal joint. The procedure led to improved function, decreased pain, and in some patients, scaphoid union. We present the outcome of an alternative salvage procedure with VBG of the scaphoid from the distal radius, combined with a closing-wedge osteotomy of the distal radius for the treatment of stages I to III SNAC.
with a standardized method using a goniometer. Grip strength was measured with a Jamar dynamometer, and the results were expressed as a percentage of the affected to the contralateral nonaffected hand. Radiographic evaluation Older analog radiographs were photographed with a digital camera and, together with the newer digital radiographs, transferred to a personal computer. An open source Digital Imaging and Communications in Medicine/Picture Archiving and Communication System image processing software for Macintosh OS X (Osirix; downloaded from http://www.osirixviewer.com/) was used for further measurements. The SNAC stage was classified according to Krimmer et al.10 Three wrists were stage I (Fig. 1), 7 were stage II (Fig. 2), and 2 were stage III. Scaphoid union was determined according to the criteria proposed by Dias16 and by the assessment of trabeculae crossing the nonunion site.6,8 The radiolunate and scapholunate angles were measured with the axis tool of the Osirix software in lateral radiographs and in neutral wrist flexionextension (Fig. 3). We considered a radiolunate angle over 15 (in the dorsal direction) to be suggestive of residual dorsal intercalated segment instability (DISI) deformity and a scapholunate angle of greater than 70 to be highly suggestive of DISI deformity.17 Carpal height was measured according to Nattrass et al’s method,18 and pre- and postoperative ulnar variance was measured according to Gelberman et al.19 Lateral migration according to McMurtry et al20 and radial inclination were measured and recorded. Time to union in the grafted scaphoid and osteotomy as well as the pre- and postoperative SNAC stages were assessed by 2 orthopedic surgeons who had not operated on the patients. Preoperative radiographs and, if obtained, preoperative computed tomography (CT) scans and magnetic resonance imaging (MRI) studies were reviewed for characteristics of AVN. During surgery, the curetted surface of the scaphoid proximal pole was evaluated for punctate bleeding.21
MATERIALS AND METHODS Data collection and clinical evaluation From a cohort of 155 scaphoid nonunions treated surgically between 2000 and 2011, 14 patients received VBG and closing-wedge osteotomy of the distal radial metaphysis and gave informed consent to participate in the study. The study was approved by our institutional review board. Two patients were lost to follow-up, leaving 12 patients available for final evaluation. Their average age was 33 years 6 years. Twelve were men, 4 were manual workers, and 5 injuries were to the dominant hand. The time to surgery averaged 4.9 years (range, 2e13 y). A visual analog scale (VAS) was used for the assessment of pain before surgery and at the latest follow-up. Function was assessed with the Mayo modified wrist score and the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire employed both before and after surgery. Active range of motion was also recorded J Hand Surg Am.
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Surgical technique The surgical technique of scaphoid reconstruction with VBG has been described previously.6e8,11 All the operations were carried out under axillary block anesthesia, tourniquet control, and loop magnification. When the nonunion was in the proximal pole (8 cases), a VBG from the dorsal-radial aspect of the distal radius, based on the 1,2 intercompartmental supraretinacular artery, was used (Figs. 1C and 2C).22,23 For r
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FIGURE 1: A A 32-year-old man with proximal third scaphoid nonunion (right hand) of 2 years’ duration who presented with a stage I SNAC wrist. B Lateral view of the same patient. C Postoperative view depicts the reconstruction of the scaphoid nonunion with vascularized bone graft, the osteotomy of the distal radius, and the donor site (dorsal-radial region of distal radius) for the vascularized bone graft. D Five-year follow-up radiograph depicts union of the scaphoid and the distal radius osteotomy and mild progression of arthritis to a stage II SNAC. E Lateral view depicts correction of DISI deformity.
waist nonunions (4 cases), a VBG from the palmarulnar side of the distal radius, based on the palmar carpal artery, was selected.7,9 The graft had 10-mm depth, and the vessels were dissected together with a 3- to 5-mm strip of periosteum and fascia to avoid avulsion or kinking of the pedicle. The donor site was filled with allograft. The VBG was interposed in the scaphoid and fixed with 1 or 2 Kirschner wires. In cases with a small proximal scaphoid fragment, the distal scaphoid was fixed to the lunate or capitate with Kirschner wires. The procedure continued with a closing-wedge osteotomy of the distal radius with the removal of a 3-mm wedge from the radial aspect, proximal to the donor site of the VBG.15 The goal of the osteotomy was to shorten the radial column and, J Hand Surg Am.
thus, theoretically, to shift the stress and load away from the scaphoid and radial column. The osteotomy was secured with 2 or 3 Steinmann pins through the styloid and the dorsal rim of the radius (Figs. 1 and 2) or with a plate. A long-arm cast including the thumb metacarpophalangeal joint was worn for 6 weeks, after which the Kirschner wires and Steinmann pins were removed. A short-arm thumb spica cast was applied for an additional 3 to 5 weeks.6 Statistical analysis The statistical analysis was carried out using the nonparametric Wilcoxon test. The Spearman rank correlation coefficient was used to compare the DASH scores and the modified Mayo wrist scores with r
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FIGURE 2: A A 28-year-old man with a failed reconstruction using a headless screw for a scaphoid proximal third fracture and a nonunion of 4 years’ duration presented with stage II SNAC. B Lateral view of the same patient. C Postoperative view depicts the reconstruction of the scaphoid nonunion with vascularized bone graft from the dorsal-radial region of the distal radius and the osteotomy of the distal radius. D Eight-year follow-up radiograph depicts union of the scaphoid and the distal radius osteotomy and stabilization of arthritis at stage II SNAC. E Lateral view of the same patient.
respect to the SNAC stage both before surgery and at the final examination. Significance was set to P less than .05.
2e11 y). The presence of AVN was confirmed during surgery by the absence of punctate bleeding at the curetted surface of the proximal pole in 7 cases.21 AVN was suspected by sclerosis or cyst formation of the proximal pole in radiographs or CT scans in 6 of these 7 cases. AVN was detected by the presence of reduced signal in T1- and in T2-weighted MRI and by the diminished contrast uptake in all 5 cases when a gadolinium-enhanced MRI study was performed. Clinical results are presented in Table 1. The VAS pain score, Mayo modified wrist score, and DASH score all improved significantly. Before surgery, 3 patients
RESULTS Prior to surgical treatment, all patients had a painful wrist with limited motion and considerable loss of grip strength that was not responding to symptomatic treatment, which included the use of splints or surgery (with compression screws in 2 cases) without success. The mean follow-up was 6.6 years (range, J Hand Surg Am.
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FIGURE 3: Measurement of the scapholunate angle (upper left corner) and radiolunate angle (upper right corner) before surgery, and radial inclination (lower left corner) and ulnar variance (lower right corner) after surgery, in 2 different patients.
TABLE 1.
Clinical Outcome of Osteotomy and VBG for SNAC Wrist Preoperative
Final Follow-Up
Wilcoxon Signed Rank Test
VAS score
6.1 2.1
0.8 0.8
P ¼ .03*
Mayo score
64 14
85 11
P ¼ .016*
DASH score
40 23
9 10
P ¼ .006*
Extension ( )
51 26
53 24
P ¼ .797
Flexion ( )
48 28
53 17
P ¼ .481
Ulnar deviation ( )
22 14
29 11
P ¼ .136
Radial deviation ( )
10 6
85
P ¼ .705
Supination ( )
65 30
86 5
P ¼ .068
Pronation ( )
64 30
86 4
P ¼ .027*
Grip strength (% of contralateral)
74 21
77 13
P ¼ .574
*P < .05 statistically significant.
had a poor Mayo wrist score, and none had excellent function. At the last evaluation, 5 patients had an excellent score, and none had poor function. The measured functional improvement according to the DASH score was greater than 17 points, which is considered clinically significant.24 No correlation was found between the DASH score and the SNAC stage, both before surgery and at the final follow-up (Spearman correlation, P ¼ .371 and .086, respectively). With the exception of a patient with a Tinel sign J Hand Surg Am.
over the anatomical snuffbox (potential neuroma of a distal sensory branch of the radial nerve), no other complications were recorded. Although range of motion and grip strength improved after surgery, this improvement was statistically significant only for pronation. The osteotomies of the distal radius united at 8 weeks 1 weeks (range, 6e10 wk), and the scaphoid nonunions united at 9 weeks 3 weeks (range, 6e12 wk). Five of 12 patients had radiographic progression r
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TABLE 2.
Radiographic Outcome of Osteotomy and VBG for SNAC Wrist Preoperative
Final Follow-Up
Wilcoxon Signed Rank Test
Radiolunate angle ( )
16 22
10 8
P ¼ .139
Scapholunate angle ( )
55 20
51 11
P ¼ .514
Carpal height
1.49 0.09
1.49 0.05
P ¼ .798
Ulnar variance (mm)
1.3 1.4
0.6 2.2
P ¼ .214
20 12
12 9
P ¼ .004*
0.33 0.06
0.38 0.07
P ¼ .008*
Radial inclination ( ) Lateral migration (McMurtry index) *P < .05 statistically significant.
of the SNAC stage from stage I to II (2 cases), from stage I to III (1 case), and from stage II to III (2 cases). Seven patients had no radiographic SNAC stage progression (Figs. 1 and 2). All patients except 1 presented with DISI deformity, and although not statistically significant, at the time of the last follow-up, the radiolunate angle decreased with the angle trending toward normal (< 15 ) (Table 2 and Fig. 1). Scapholunate angle remained within normal values (< 70 ). Carpal height remained unchanged, indicating that carpal collapse did not progress.18 Osteotomy of the radius resulted in a statistically significant decrease of radial inclination but did not change the ulnar variance. A statistically significant decrease in lateral migration was also noted at final follow-up.
increases the likelihood of union and restores perfusion to the avascular proximal pole.5,6,9 However, Chang et al26 did not consider the graft based on 1,2 intercompartmental supraretinacular artery suitable for the treatment of scaphoid nonunions with proximal pole necrosis or humpback deformity. In our series, the graft was shaped as a trapezoid and was interposed in the scaphoid nonunion site with the larger surface of the graft facing volarly, so as to reverse the humpback deformity. In cases with a small proximal fragment and weak bone that was inadequate for direct secure and stable fixation, we chose to fix the distal scaphoid to the lunate or capitate and take advantage of the undamaged interosseous ligaments to provide extra stability to our fixation. Concerning the progression of arthritis, long-term follow-up studies suggest that this is commonly slower in patients who have achieved union of the scaphoid than in patients who have an untreated nonunion.27 In addition, the closing-wedge osteotomy of the radius may induce changes in the blood supply of the carpal bones28,29 and reduce the loads exerted on the radioscaphoid joint,17 which may delay the progression of arthritis. Giannikas and Papachristou15 concluded that the reduction of the pressure in the radioscaphoid joint from the closing-wedge osteotomy created a mechanical environment suitable for union of the scaphoid. Monreal30 demonstrated union in 5 of 6 scaphoid nonunions with radioscaphoid arthritic changes after closing-wedge osteotomy of the distal radius. Kent et al,31 in an observational study with short-term follow-up, found favorable results in patients with SNAC with only bone grafting and fixation of scaphoid nonunions without an osteotomy. Although the use of pedicled vascular grafts in scaphoid nonunions with radiocarpal or midcarpal arthritis may be contraindicated,32 our method (combining VBG and osteotomy) may have contributed to symptomatic improvement in our patients.
DISCUSSION The management of an untreated nonunion of the scaphoid with SNAC in young individuals is a challenging problem, in particular when the proximal segment of the scaphoid is avascular. We believe that several problems need to be addressed at the same time: the nonunion occasionally associated with an avascular proximal segment, the angular malalignment with subsequent bone loss of the scaphoid, and the arthritic changes of the joint. In this series, we attempted to salvage the wrist with reconstruction of the scaphoid and with decompression of the radiocarpal joint through a closing-wedge osteotomy of the distal radius. Despite the presence of an avascular proximal segment in 7 of 12 cases, radiographic union was achieved in all cases in a mean of 9 weeks with the use of this technique. Although assessment of scaphoid union is rather difficult with the use of VBG, several series report times to union ranging from 5 to 12 weeks.4e6,8,9 According to a meta-analysis, the use of VBG significantly improves the rate of union for AVN of the proximal pole when compared with nonvascularized grafts.25 The preserved intrinsic vascularity of the graft J Hand Surg Am.
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We observed mild radiographic progression of arthritic lesions but not any clinical deterioration. Pain relief and functional scores improved while patients retained overall range of motion and grip strength. In comparison with salvage procedures for the wrist, a review of outcomes after FCA and PRC noted a mild decrease of wrist flexion (FCA and PRC) and extension (FCA) after surgery,33 whereas in our series, there was a slight, although not statistically significant, increase in both flexion and extension. After surgery, the mean DASH score in our series (9 points) was lower when compared with other treatment options such as midcarpal arthrodesis, PRC, or total wrist fusion. In midcarpal arthrodesis and PRC, DASH scores ranged from 21 to 33 points in different series,13,34e36 whereas for total wrist fusion, the mean DASH score ranged from 46 to 51.37,38 The postoperative improvement in the present series exceeded the minimal score for clinical difference (17 points) in the DASH, suggesting that the procedure resulted in true functional gain. Even if our procedure cannot be compared directly with other salvage procedures, we postulate that the combination of scaphoid reconstruction and a closing-wedge osteotomy of the distal radius may result in superior functional outcome. In the present series, DISI deformity, as measured by radiolunate angle correction, trended toward normal values, and carpal height was preserved, which may contribute to the improved Mayo score despite radiographic deterioration. According to Daly et al,39 correction of the DISI and adequate restoration of scaphoid length (secondary to correction of the humpback deformity) results in better functional scores, including range of motion arcs. This is supported by the findings of Eggli et al,40 who achieved normal carpal height and alignment through anterior wedge bone grafting procedures with good clinical outcomes and mild radiographic changes. The limitations of our study are the small number of patients, the percentage of patients who were lost to follow-up (w14%), and the retrospective evaluation. In addition, this study lacked a control group, which limited the strength of our findings. An additional limitation of this study was the lack of systematic pre- and postoperative CT scans, which would have better defined the pre- and postoperative radiographic nonunion and union criteria. Finally, it is difficult to clarify which of the 3 main components (restoration of scaphoid anatomy, VBG, radius wedge osteotomy) contributed most in the improvement of the wrist function. We presume that the beneficial effect of the procedure came from the alteration of the mechanical J Hand Surg Am.
environment at the wrist and from the augmentation of the biological component across the nonunion site. REFERENCES 1. Kuschner SH, Lane CS, Brien WW, Gellman H. Scaphoid fractures and scaphoid nonunion. Diagnosis and treatment. Orthop Rev. 1994;23(11):861e871. 2. Inoue G, Shionoya K, Kuwahata Y. Ununited proximal pole scaphoid fractures. Treatment with a Herbert screw in 16 cases followed for 0.5-8 years. Acta Orthop Scand. 1997;68(2):124e127. 3. Green DP. The effect of avascular necrosis on Russe bone grafting for scaphoid nonunion. J Hand Surg Am. 1985;10(5):597e605. 4. Zaidemberg C, Siebert JW, Angrigiani C. A new vascularized bone graft for scaphoid nonunion. J Hand Surg Am. 1991;16(3):474e478. 5. Malizos KN, Zachos V, Dailiana ZH, et al. Scaphoid nonunions: management with vascularized bone grafts from the distal radius: a clinical and functional outcome study. Plast Reconstr Surg. 2007;119(5):1513e1525. 6. 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 Br. 2001;26(4):330e334. 7. Kuhlmann JN, Mimoun M, Boabighi A, Baux S. Vascularized bone graft pedicled on the volar carpal artery for non-union of the scaphoid. J Hand Surg Br. 1987;12(2):203e210. 8. Mathoulin C, Haerle M. Vascularized bone graft from the palmar carpal artery for treatment scaphoid nonunion. J Hand Surg Br. 1998;23(3):318e323. 9. Dailiana ZH, Malizos KN, Zachos V, Varitimidis SE, Hantes M, Karantanas A. Vascularized bone grafts from the palmar radius for the treatment of waist nonunions of the scaphoid. J Hand Surg Am. 2006;31(3):397e404. 10. Krimmer H, Krapohl B, Sauerbier M, Hahn P. Post-traumatic carpal collapse (SLAC- and SNAC-wrist)—stage classification and therapeutic possibilities. Handchir Mikrochir Plast Chir. 1997;29(5):228e233. 11. Weiss KE, Rodner CM. Osteoarthritis of the wrist. J Hand Surg Am. 2007;32(5):725e746. 12. Strauch JR. Scapholunate advanced collapse and scaphoid nonunion advanced collapse arthritis—update on evaluation and treatment. J Hand Surg Am. 2011;36(4):729e735. 13. Dacho A, Grundel J, Holle G, Germann G, Sauerbier M. Long-term results of midcarpal arthrodesis in the treatment of scaphoid nonunion advanced collapse (SNAC-Wrist) and scapholunate advanced collapse (SLAC-Wrist). Ann Plast Surg. 2006;56(2): 139e144. 14. Kiefhaber TR. Management of scapholunate advanced collapse pattern of degenerative arthritis of the wrist. J Hand Surg Am. 2009;34(8):1527e1530. 15. Giannikas AC, Papachristou G. Wedge osteotomy of the lower end of the radius in the treatment of painful pseudarthrosis of the carpal scaphoid bone. Clin Orthop Relat Res. 1989;246:16e21. 16. Dias JJ. Definition of union after acute fracture and surgery for fracture nonunion of the scaphoid. J Hand Surg Br. 2001;26(4): 321e325. 17. Kuo CE, Wolfe SW. Scapholunate instability: current concepts in diagnosis and management. J Hand Surg Am. 2008;33(6):998e1013. 18. Nattrass GR, King GJ, McMurtry RY, Brant RF. An alternative method for determination of the carpal height ratio. J Bone Joint Surg Am. 1994;76(1):88e94. 19. Gelberman RH, Salamon PB, Jurist JM, Posch JL. Ulnar variance in Kienböck’s disease. J Bone Joint Surg Am. 1975;57(5):674e676. 20. McMurtry RY, Youm Y, Flatt AE, Gillespie TE. Kinematics of the wrist: II. Clinical applications. J Bone Joint Surg Am. 1978;60(7):955e961. 21. Kakar S, Bishop AT, Shin AY. 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;36(4):722e725.
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32. Geissler WB, Adams JE, Bindra RR, Lanzinger WD, Slutsky DJ. Scaphoid fractures: what’s hot, what’s not. J Bone Joint Surg Am. 2012;94(2):169e181. 33. Mulford JS, Ceulemans LJ, Nam D, Axelrod TS. Proximal row carpectomy vs four corner fusion for scapholunate (SLAC) or scaphoid nonunion advanced collapse (SNAC) wrists: a systematic review of outcomes. J Hand Surg Eur Vol. 2009;34(2):256e263. 34. Krimmer H, Lanz U. Der posttraumatische karpale Kollaps. Verlauf und Therapiekonzept. Unfallchir. 2000;103(4):260e266. 35. Kitzinger HB, Löw S, Karle B, Lanz U, Krimmer H. Der posttraumatische karpale Kollaps Langzeitresultate nach mediokarpaler Teilarthrodese. Handchir Mikrochir Plast Chir. 2003;35(5): 282e287. 36. Bisneto EN, Freitas MC, Paula EJ, Mattar R Jr, Zumiotti AV. Comparison between proximal row carpectomy and four-corner fusion for treating osteoarthrosis following carpal trauma: a prospective randomized study. Clinics (Sao Paulo). 2011;66(1):51e55. 37. Sauerbier M, Kluge S, Bickert B, Germann G. Subjective and objective outcomes after total wrist arthrodesis in patients with radiocarpal arthrosis or Kienböck’s disease. Chir Main. 2000;19(4): 223e231. 38. Kalb KH, Ludwig A, Tauscher A, Landsleitner B, Wiemer P, Krimmer H. Behandlungsergebnisse nach operativer Handgelenkversteifung. Handchir Mikrochir Plast Chir. 1999;31(4):253e259. 39. Daly K, Gill P, Magnussen PA, Simonis RB. Established nonunion of the scaphoid treated by volar wedge grafting and Herbert screw fixation. J Bone Joint Surg Br. 1996;78(4):530e534. 40. Eggli S, Fernandez DL, Beck T. Unstable scaphoid fracture nonunion: A medium-term study of anterior wedge grafting procedures. J Hand Surg Br. 2002;27(1):36e41.
22. Sheetz KK, Bishop AT, Berg RA. The arterial blood supply of the distal radius and ulna and its potential use in vascularized pedicled bone grafts. J Hand Surg Am. 1995;20(6):902e914. 23. Dailiana ZH, Malizos KN, Urbaniak JR. Vascularized periosteal flaps of distal forearm and hand. J Trauma. 2005;58(1):76e82. 24. Smith MV, Calfee RP, Baumgarten KM, Brophy RH, Wright RW. Upper extremity-specific measures of disability and outcomes in orthopaedic surgery. J Bone Joint Surg Am. 2012;94(3):277e285. 25. Merrell GA, Wolfe SW, Slade JF III. Treatment of scaphoid nonunions: quantitative meta-analysis of the literature. J Hand Surg Am. 2002;27(4):685e691. 26. 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 Am. 2006;31(3):387e396. 27. Jiranek WA, Ruby LK, Millender LB, Bankoff MS, Newberg AH. Long-term results after Russe bone-grafting: the effect of malunion of the scaphoid. J Bone Joint Surg Am. 1992;74(8):1217e1228. 28. Blanco RH, Blanco FR. Osteotomy of the radius without shortening for Kienböck disease: a 10-year follow-up. J Hand Surg Am. 2012;37(11):2221e2225. 29. Illarramendi AA, Schulz C, De Carli P. The surgical treatment of Kienböck’s disease by radius and ulna metaphyseal core decompression. J Hand Surg Am. 2001;26(2):252e260. 30. Monreal R. Treatment of scaphoid nonunions with closed-wedge osteotomy of the distal radius: report of six cases. Hand (N Y). 2008;3(2):91e95. 31. Kent ME, Rehmatullah NNT, Young L, Chojnowski AJ. Scaphoid nonunion in the presence of a degenerate carpus: don’t rush to salvage surgery. J Hand Surg Eur Vol. 2012;37(1):56e60.
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Vascularized Bone Grafting and Distal Radius Osteotomy for Scaphoid Nonunion Advanced Collapse Konstantinos N. Malizos, MD, PhD, Antonios Koutalos, MD, Loukia Papatheodorou, MD, PhD, Sokratis Varitimidis, MD, PhD, Vasileios Kontogeorgakos, MD, PhD, Zoe Dailiana, MD, PhD
Purpose To determine the outcome of an alternative treatment for wrists with stages I to III scaphoid nonunion advanced collapse using a closing-wedge osteotomy of the distal radius and a vascularized bone graft for scaphoid reconstruction. Methods Twelve patients with scaphoid nonunion advanced collapse (stage I, 3; stage II, 7; stage III, 2) treated with a vascularized bone graft interposition for the scaphoid and a closingwedge osteotomy for the distal radius were retrospectively reviewed. Data were obtained and analyzed from the radiographs, and we assessed the pre- and postoperative range of motion, grip strength, visual analog scale pain score, as well as the Mayo and Disabilities of the Arm, Shoulder, and Hand (DASH) functional scores. Results Follow-up ranged from 2 to 11 years. All scaphoid nonunions united after an average of 9 weeks, and all osteotomies united after an average of 8 weeks. Although there was radiographic progression of the scaphoid nonunion advanced collapse stage in 5 of 12 cases, there was major improvement in visual analog scale pain score (from 6.1 to 0.8) and in both Mayo (from 64 to 85) and DASH (from 40 to 9) functional scores. The range of motion remained unchanged, and grip strength trended toward minor improvement. The carpal height was preserved, and the dorsal intercalated segmental instability was corrected. Conclusions Scaphoid reconstruction with vascularized bone graft combined with closingwedge distal radius osteotomy preserved wrist function for scaphoid nonunion advanced collapse. The method offers pain relief and does not compromise wrist motion or grip strength. (J Hand Surg Am. 2014;39(5):872e879. Copyright Ó 2014 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic IV. Key words Distal radius osteotomy, scaphoid nonunion, SNAC wrist, vascularized bone graft, radiocarpal arthritis.
From the Department of Orthopaedic Surgery and Musculoskeletal Trauma, Faculty of Medicine, University of Thessalia, Larissa, Greece. Received for publication July 11, 2013; accepted in revised form January 24, 2014. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Zoe Dailiana, MD, PhD, Department of Orthopaedic Surgery and Musculoskeletal Trauma, Faculty of Medicine, University of Thessalia, Biopolis, 41500, Larissa, Greece; e-mail: [email protected]. 0363-5023/14/3905-0006$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2014.01.045
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unite if they are diagnosed early and treated properly; however, failure rates as high as 15% have been reported.1 Treatment options for scaphoid nonunions include conventional bone grafting or vascularized bone grafts (VBG) through a dorsal or palmar approach depending on the type and the location of the nonunion and the presence of avascular necrosis (AVN).2,3 AVN of the proximal pole presents a particular challenge. Treatment of this subgroup with HE MAJORITY OF SCAPHOID FRACTURES
SNAC WRIST: VASCULARIZED BONE GRAFT AND OSTEOTOMY
conventional bone grafting may be inadequate, whereas VBG, from either the dorsal or the palmar distal radius, offers higher union rates.4e9 Scaphoid nonunion advanced collapse (SNAC) represents the end stage of a progressive deformity following an untreated scaphoid nonunion and is classified in 4 stages ranging from arthritis at the radial styloid to pancarpal arthritis.10,11 The treatment options are related to the stage of the disease. For stage I, reconstructive procedures of the scaphoid with or without styloidectomy are preferred. For stages II and III, salvage procedures such as proximal row carpectomy (PRC) or 4 corner arthrodesis (FCA) are indicated.12 However, these salvage procedures have several technical concerns. Both PRC and FCA can result in reduced motion. Four-corner arthrodesis may result in hardware problems, and PRC has a high failure rate in young manual workers. In addition, both procedures may reduce grip strength, and PRC may lead to capitoradial joint arthritis.13,14 A closing-wedge osteotomy of the distal radius was proposed by Giannikas and Papachristou15 for the treatment of painful scaphoid nonunions. Sixtyfour percent of patients in their series had arthritic changes in the radiocarpal joint. The procedure led to improved function, decreased pain, and in some patients, scaphoid union. We present the outcome of an alternative salvage procedure with VBG of the scaphoid from the distal radius, combined with a closing-wedge osteotomy of the distal radius for the treatment of stages I to III SNAC.
with a standardized method using a goniometer. Grip strength was measured with a Jamar dynamometer, and the results were expressed as a percentage of the affected to the contralateral nonaffected hand. Radiographic evaluation Older analog radiographs were photographed with a digital camera and, together with the newer digital radiographs, transferred to a personal computer. An open source Digital Imaging and Communications in Medicine/Picture Archiving and Communication System image processing software for Macintosh OS X (Osirix; downloaded from http://www.osirixviewer.com/) was used for further measurements. The SNAC stage was classified according to Krimmer et al.10 Three wrists were stage I (Fig. 1), 7 were stage II (Fig. 2), and 2 were stage III. Scaphoid union was determined according to the criteria proposed by Dias16 and by the assessment of trabeculae crossing the nonunion site.6,8 The radiolunate and scapholunate angles were measured with the axis tool of the Osirix software in lateral radiographs and in neutral wrist flexionextension (Fig. 3). We considered a radiolunate angle over 15 (in the dorsal direction) to be suggestive of residual dorsal intercalated segment instability (DISI) deformity and a scapholunate angle of greater than 70 to be highly suggestive of DISI deformity.17 Carpal height was measured according to Nattrass et al’s method,18 and pre- and postoperative ulnar variance was measured according to Gelberman et al.19 Lateral migration according to McMurtry et al20 and radial inclination were measured and recorded. Time to union in the grafted scaphoid and osteotomy as well as the pre- and postoperative SNAC stages were assessed by 2 orthopedic surgeons who had not operated on the patients. Preoperative radiographs and, if obtained, preoperative computed tomography (CT) scans and magnetic resonance imaging (MRI) studies were reviewed for characteristics of AVN. During surgery, the curetted surface of the scaphoid proximal pole was evaluated for punctate bleeding.21
MATERIALS AND METHODS Data collection and clinical evaluation From a cohort of 155 scaphoid nonunions treated surgically between 2000 and 2011, 14 patients received VBG and closing-wedge osteotomy of the distal radial metaphysis and gave informed consent to participate in the study. The study was approved by our institutional review board. Two patients were lost to follow-up, leaving 12 patients available for final evaluation. Their average age was 33 years 6 years. Twelve were men, 4 were manual workers, and 5 injuries were to the dominant hand. The time to surgery averaged 4.9 years (range, 2e13 y). A visual analog scale (VAS) was used for the assessment of pain before surgery and at the latest follow-up. Function was assessed with the Mayo modified wrist score and the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire employed both before and after surgery. Active range of motion was also recorded J Hand Surg Am.
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Surgical technique The surgical technique of scaphoid reconstruction with VBG has been described previously.6e8,11 All the operations were carried out under axillary block anesthesia, tourniquet control, and loop magnification. When the nonunion was in the proximal pole (8 cases), a VBG from the dorsal-radial aspect of the distal radius, based on the 1,2 intercompartmental supraretinacular artery, was used (Figs. 1C and 2C).22,23 For r
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FIGURE 1: A A 32-year-old man with proximal third scaphoid nonunion (right hand) of 2 years’ duration who presented with a stage I SNAC wrist. B Lateral view of the same patient. C Postoperative view depicts the reconstruction of the scaphoid nonunion with vascularized bone graft, the osteotomy of the distal radius, and the donor site (dorsal-radial region of distal radius) for the vascularized bone graft. D Five-year follow-up radiograph depicts union of the scaphoid and the distal radius osteotomy and mild progression of arthritis to a stage II SNAC. E Lateral view depicts correction of DISI deformity.
waist nonunions (4 cases), a VBG from the palmarulnar side of the distal radius, based on the palmar carpal artery, was selected.7,9 The graft had 10-mm depth, and the vessels were dissected together with a 3- to 5-mm strip of periosteum and fascia to avoid avulsion or kinking of the pedicle. The donor site was filled with allograft. The VBG was interposed in the scaphoid and fixed with 1 or 2 Kirschner wires. In cases with a small proximal scaphoid fragment, the distal scaphoid was fixed to the lunate or capitate with Kirschner wires. The procedure continued with a closing-wedge osteotomy of the distal radius with the removal of a 3-mm wedge from the radial aspect, proximal to the donor site of the VBG.15 The goal of the osteotomy was to shorten the radial column and, J Hand Surg Am.
thus, theoretically, to shift the stress and load away from the scaphoid and radial column. The osteotomy was secured with 2 or 3 Steinmann pins through the styloid and the dorsal rim of the radius (Figs. 1 and 2) or with a plate. A long-arm cast including the thumb metacarpophalangeal joint was worn for 6 weeks, after which the Kirschner wires and Steinmann pins were removed. A short-arm thumb spica cast was applied for an additional 3 to 5 weeks.6 Statistical analysis The statistical analysis was carried out using the nonparametric Wilcoxon test. The Spearman rank correlation coefficient was used to compare the DASH scores and the modified Mayo wrist scores with r
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FIGURE 2: A A 28-year-old man with a failed reconstruction using a headless screw for a scaphoid proximal third fracture and a nonunion of 4 years’ duration presented with stage II SNAC. B Lateral view of the same patient. C Postoperative view depicts the reconstruction of the scaphoid nonunion with vascularized bone graft from the dorsal-radial region of the distal radius and the osteotomy of the distal radius. D Eight-year follow-up radiograph depicts union of the scaphoid and the distal radius osteotomy and stabilization of arthritis at stage II SNAC. E Lateral view of the same patient.
respect to the SNAC stage both before surgery and at the final examination. Significance was set to P less than .05.
2e11 y). The presence of AVN was confirmed during surgery by the absence of punctate bleeding at the curetted surface of the proximal pole in 7 cases.21 AVN was suspected by sclerosis or cyst formation of the proximal pole in radiographs or CT scans in 6 of these 7 cases. AVN was detected by the presence of reduced signal in T1- and in T2-weighted MRI and by the diminished contrast uptake in all 5 cases when a gadolinium-enhanced MRI study was performed. Clinical results are presented in Table 1. The VAS pain score, Mayo modified wrist score, and DASH score all improved significantly. Before surgery, 3 patients
RESULTS Prior to surgical treatment, all patients had a painful wrist with limited motion and considerable loss of grip strength that was not responding to symptomatic treatment, which included the use of splints or surgery (with compression screws in 2 cases) without success. The mean follow-up was 6.6 years (range, J Hand Surg Am.
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FIGURE 3: Measurement of the scapholunate angle (upper left corner) and radiolunate angle (upper right corner) before surgery, and radial inclination (lower left corner) and ulnar variance (lower right corner) after surgery, in 2 different patients.
TABLE 1.
Clinical Outcome of Osteotomy and VBG for SNAC Wrist Preoperative
Final Follow-Up
Wilcoxon Signed Rank Test
VAS score
6.1 2.1
0.8 0.8
P ¼ .03*
Mayo score
64 14
85 11
P ¼ .016*
DASH score
40 23
9 10
P ¼ .006*
Extension ( )
51 26
53 24
P ¼ .797
Flexion ( )
48 28
53 17
P ¼ .481
Ulnar deviation ( )
22 14
29 11
P ¼ .136
Radial deviation ( )
10 6
85
P ¼ .705
Supination ( )
65 30
86 5
P ¼ .068
Pronation ( )
64 30
86 4
P ¼ .027*
Grip strength (% of contralateral)
74 21
77 13
P ¼ .574
*P < .05 statistically significant.
had a poor Mayo wrist score, and none had excellent function. At the last evaluation, 5 patients had an excellent score, and none had poor function. The measured functional improvement according to the DASH score was greater than 17 points, which is considered clinically significant.24 No correlation was found between the DASH score and the SNAC stage, both before surgery and at the final follow-up (Spearman correlation, P ¼ .371 and .086, respectively). With the exception of a patient with a Tinel sign J Hand Surg Am.
over the anatomical snuffbox (potential neuroma of a distal sensory branch of the radial nerve), no other complications were recorded. Although range of motion and grip strength improved after surgery, this improvement was statistically significant only for pronation. The osteotomies of the distal radius united at 8 weeks 1 weeks (range, 6e10 wk), and the scaphoid nonunions united at 9 weeks 3 weeks (range, 6e12 wk). Five of 12 patients had radiographic progression r
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TABLE 2.
Radiographic Outcome of Osteotomy and VBG for SNAC Wrist Preoperative
Final Follow-Up
Wilcoxon Signed Rank Test
Radiolunate angle ( )
16 22
10 8
P ¼ .139
Scapholunate angle ( )
55 20
51 11
P ¼ .514
Carpal height
1.49 0.09
1.49 0.05
P ¼ .798
Ulnar variance (mm)
1.3 1.4
0.6 2.2
P ¼ .214
20 12
12 9
P ¼ .004*
0.33 0.06
0.38 0.07
P ¼ .008*
Radial inclination ( ) Lateral migration (McMurtry index) *P < .05 statistically significant.
of the SNAC stage from stage I to II (2 cases), from stage I to III (1 case), and from stage II to III (2 cases). Seven patients had no radiographic SNAC stage progression (Figs. 1 and 2). All patients except 1 presented with DISI deformity, and although not statistically significant, at the time of the last follow-up, the radiolunate angle decreased with the angle trending toward normal (< 15 ) (Table 2 and Fig. 1). Scapholunate angle remained within normal values (< 70 ). Carpal height remained unchanged, indicating that carpal collapse did not progress.18 Osteotomy of the radius resulted in a statistically significant decrease of radial inclination but did not change the ulnar variance. A statistically significant decrease in lateral migration was also noted at final follow-up.
increases the likelihood of union and restores perfusion to the avascular proximal pole.5,6,9 However, Chang et al26 did not consider the graft based on 1,2 intercompartmental supraretinacular artery suitable for the treatment of scaphoid nonunions with proximal pole necrosis or humpback deformity. In our series, the graft was shaped as a trapezoid and was interposed in the scaphoid nonunion site with the larger surface of the graft facing volarly, so as to reverse the humpback deformity. In cases with a small proximal fragment and weak bone that was inadequate for direct secure and stable fixation, we chose to fix the distal scaphoid to the lunate or capitate and take advantage of the undamaged interosseous ligaments to provide extra stability to our fixation. Concerning the progression of arthritis, long-term follow-up studies suggest that this is commonly slower in patients who have achieved union of the scaphoid than in patients who have an untreated nonunion.27 In addition, the closing-wedge osteotomy of the radius may induce changes in the blood supply of the carpal bones28,29 and reduce the loads exerted on the radioscaphoid joint,17 which may delay the progression of arthritis. Giannikas and Papachristou15 concluded that the reduction of the pressure in the radioscaphoid joint from the closing-wedge osteotomy created a mechanical environment suitable for union of the scaphoid. Monreal30 demonstrated union in 5 of 6 scaphoid nonunions with radioscaphoid arthritic changes after closing-wedge osteotomy of the distal radius. Kent et al,31 in an observational study with short-term follow-up, found favorable results in patients with SNAC with only bone grafting and fixation of scaphoid nonunions without an osteotomy. Although the use of pedicled vascular grafts in scaphoid nonunions with radiocarpal or midcarpal arthritis may be contraindicated,32 our method (combining VBG and osteotomy) may have contributed to symptomatic improvement in our patients.
DISCUSSION The management of an untreated nonunion of the scaphoid with SNAC in young individuals is a challenging problem, in particular when the proximal segment of the scaphoid is avascular. We believe that several problems need to be addressed at the same time: the nonunion occasionally associated with an avascular proximal segment, the angular malalignment with subsequent bone loss of the scaphoid, and the arthritic changes of the joint. In this series, we attempted to salvage the wrist with reconstruction of the scaphoid and with decompression of the radiocarpal joint through a closing-wedge osteotomy of the distal radius. Despite the presence of an avascular proximal segment in 7 of 12 cases, radiographic union was achieved in all cases in a mean of 9 weeks with the use of this technique. Although assessment of scaphoid union is rather difficult with the use of VBG, several series report times to union ranging from 5 to 12 weeks.4e6,8,9 According to a meta-analysis, the use of VBG significantly improves the rate of union for AVN of the proximal pole when compared with nonvascularized grafts.25 The preserved intrinsic vascularity of the graft J Hand Surg Am.
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We observed mild radiographic progression of arthritic lesions but not any clinical deterioration. Pain relief and functional scores improved while patients retained overall range of motion and grip strength. In comparison with salvage procedures for the wrist, a review of outcomes after FCA and PRC noted a mild decrease of wrist flexion (FCA and PRC) and extension (FCA) after surgery,33 whereas in our series, there was a slight, although not statistically significant, increase in both flexion and extension. After surgery, the mean DASH score in our series (9 points) was lower when compared with other treatment options such as midcarpal arthrodesis, PRC, or total wrist fusion. In midcarpal arthrodesis and PRC, DASH scores ranged from 21 to 33 points in different series,13,34e36 whereas for total wrist fusion, the mean DASH score ranged from 46 to 51.37,38 The postoperative improvement in the present series exceeded the minimal score for clinical difference (17 points) in the DASH, suggesting that the procedure resulted in true functional gain. Even if our procedure cannot be compared directly with other salvage procedures, we postulate that the combination of scaphoid reconstruction and a closing-wedge osteotomy of the distal radius may result in superior functional outcome. In the present series, DISI deformity, as measured by radiolunate angle correction, trended toward normal values, and carpal height was preserved, which may contribute to the improved Mayo score despite radiographic deterioration. According to Daly et al,39 correction of the DISI and adequate restoration of scaphoid length (secondary to correction of the humpback deformity) results in better functional scores, including range of motion arcs. This is supported by the findings of Eggli et al,40 who achieved normal carpal height and alignment through anterior wedge bone grafting procedures with good clinical outcomes and mild radiographic changes. The limitations of our study are the small number of patients, the percentage of patients who were lost to follow-up (w14%), and the retrospective evaluation. In addition, this study lacked a control group, which limited the strength of our findings. An additional limitation of this study was the lack of systematic pre- and postoperative CT scans, which would have better defined the pre- and postoperative radiographic nonunion and union criteria. Finally, it is difficult to clarify which of the 3 main components (restoration of scaphoid anatomy, VBG, radius wedge osteotomy) contributed most in the improvement of the wrist function. We presume that the beneficial effect of the procedure came from the alteration of the mechanical J Hand Surg Am.
environment at the wrist and from the augmentation of the biological component across the nonunion site. REFERENCES 1. Kuschner SH, Lane CS, Brien WW, Gellman H. Scaphoid fractures and scaphoid nonunion. Diagnosis and treatment. Orthop Rev. 1994;23(11):861e871. 2. Inoue G, Shionoya K, Kuwahata Y. Ununited proximal pole scaphoid fractures. Treatment with a Herbert screw in 16 cases followed for 0.5-8 years. Acta Orthop Scand. 1997;68(2):124e127. 3. Green DP. The effect of avascular necrosis on Russe bone grafting for scaphoid nonunion. J Hand Surg Am. 1985;10(5):597e605. 4. Zaidemberg C, Siebert JW, Angrigiani C. A new vascularized bone graft for scaphoid nonunion. J Hand Surg Am. 1991;16(3):474e478. 5. Malizos KN, Zachos V, Dailiana ZH, et al. Scaphoid nonunions: management with vascularized bone grafts from the distal radius: a clinical and functional outcome study. Plast Reconstr Surg. 2007;119(5):1513e1525. 6. 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 Br. 2001;26(4):330e334. 7. Kuhlmann JN, Mimoun M, Boabighi A, Baux S. Vascularized bone graft pedicled on the volar carpal artery for non-union of the scaphoid. J Hand Surg Br. 1987;12(2):203e210. 8. Mathoulin C, Haerle M. Vascularized bone graft from the palmar carpal artery for treatment scaphoid nonunion. J Hand Surg Br. 1998;23(3):318e323. 9. Dailiana ZH, Malizos KN, Zachos V, Varitimidis SE, Hantes M, Karantanas A. Vascularized bone grafts from the palmar radius for the treatment of waist nonunions of the scaphoid. J Hand Surg Am. 2006;31(3):397e404. 10. Krimmer H, Krapohl B, Sauerbier M, Hahn P. Post-traumatic carpal collapse (SLAC- and SNAC-wrist)—stage classification and therapeutic possibilities. Handchir Mikrochir Plast Chir. 1997;29(5):228e233. 11. Weiss KE, Rodner CM. Osteoarthritis of the wrist. J Hand Surg Am. 2007;32(5):725e746. 12. Strauch JR. Scapholunate advanced collapse and scaphoid nonunion advanced collapse arthritis—update on evaluation and treatment. J Hand Surg Am. 2011;36(4):729e735. 13. Dacho A, Grundel J, Holle G, Germann G, Sauerbier M. Long-term results of midcarpal arthrodesis in the treatment of scaphoid nonunion advanced collapse (SNAC-Wrist) and scapholunate advanced collapse (SLAC-Wrist). Ann Plast Surg. 2006;56(2): 139e144. 14. Kiefhaber TR. Management of scapholunate advanced collapse pattern of degenerative arthritis of the wrist. J Hand Surg Am. 2009;34(8):1527e1530. 15. Giannikas AC, Papachristou G. Wedge osteotomy of the lower end of the radius in the treatment of painful pseudarthrosis of the carpal scaphoid bone. Clin Orthop Relat Res. 1989;246:16e21. 16. Dias JJ. Definition of union after acute fracture and surgery for fracture nonunion of the scaphoid. J Hand Surg Br. 2001;26(4): 321e325. 17. Kuo CE, Wolfe SW. Scapholunate instability: current concepts in diagnosis and management. J Hand Surg Am. 2008;33(6):998e1013. 18. Nattrass GR, King GJ, McMurtry RY, Brant RF. An alternative method for determination of the carpal height ratio. J Bone Joint Surg Am. 1994;76(1):88e94. 19. Gelberman RH, Salamon PB, Jurist JM, Posch JL. Ulnar variance in Kienböck’s disease. J Bone Joint Surg Am. 1975;57(5):674e676. 20. McMurtry RY, Youm Y, Flatt AE, Gillespie TE. Kinematics of the wrist: II. Clinical applications. J Bone Joint Surg Am. 1978;60(7):955e961. 21. Kakar S, Bishop AT, Shin AY. 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;36(4):722e725.
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32. Geissler WB, Adams JE, Bindra RR, Lanzinger WD, Slutsky DJ. Scaphoid fractures: what’s hot, what’s not. J Bone Joint Surg Am. 2012;94(2):169e181. 33. Mulford JS, Ceulemans LJ, Nam D, Axelrod TS. Proximal row carpectomy vs four corner fusion for scapholunate (SLAC) or scaphoid nonunion advanced collapse (SNAC) wrists: a systematic review of outcomes. J Hand Surg Eur Vol. 2009;34(2):256e263. 34. Krimmer H, Lanz U. Der posttraumatische karpale Kollaps. Verlauf und Therapiekonzept. Unfallchir. 2000;103(4):260e266. 35. Kitzinger HB, Löw S, Karle B, Lanz U, Krimmer H. Der posttraumatische karpale Kollaps Langzeitresultate nach mediokarpaler Teilarthrodese. Handchir Mikrochir Plast Chir. 2003;35(5): 282e287. 36. Bisneto EN, Freitas MC, Paula EJ, Mattar R Jr, Zumiotti AV. Comparison between proximal row carpectomy and four-corner fusion for treating osteoarthrosis following carpal trauma: a prospective randomized study. Clinics (Sao Paulo). 2011;66(1):51e55. 37. Sauerbier M, Kluge S, Bickert B, Germann G. Subjective and objective outcomes after total wrist arthrodesis in patients with radiocarpal arthrosis or Kienböck’s disease. Chir Main. 2000;19(4): 223e231. 38. Kalb KH, Ludwig A, Tauscher A, Landsleitner B, Wiemer P, Krimmer H. Behandlungsergebnisse nach operativer Handgelenkversteifung. Handchir Mikrochir Plast Chir. 1999;31(4):253e259. 39. Daly K, Gill P, Magnussen PA, Simonis RB. Established nonunion of the scaphoid treated by volar wedge grafting and Herbert screw fixation. J Bone Joint Surg Br. 1996;78(4):530e534. 40. Eggli S, Fernandez DL, Beck T. Unstable scaphoid fracture nonunion: A medium-term study of anterior wedge grafting procedures. J Hand Surg Br. 2002;27(1):36e41.
22. Sheetz KK, Bishop AT, Berg RA. The arterial blood supply of the distal radius and ulna and its potential use in vascularized pedicled bone grafts. J Hand Surg Am. 1995;20(6):902e914. 23. Dailiana ZH, Malizos KN, Urbaniak JR. Vascularized periosteal flaps of distal forearm and hand. J Trauma. 2005;58(1):76e82. 24. Smith MV, Calfee RP, Baumgarten KM, Brophy RH, Wright RW. Upper extremity-specific measures of disability and outcomes in orthopaedic surgery. J Bone Joint Surg Am. 2012;94(3):277e285. 25. Merrell GA, Wolfe SW, Slade JF III. Treatment of scaphoid nonunions: quantitative meta-analysis of the literature. J Hand Surg Am. 2002;27(4):685e691. 26. 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 Am. 2006;31(3):387e396. 27. Jiranek WA, Ruby LK, Millender LB, Bankoff MS, Newberg AH. Long-term results after Russe bone-grafting: the effect of malunion of the scaphoid. J Bone Joint Surg Am. 1992;74(8):1217e1228. 28. Blanco RH, Blanco FR. Osteotomy of the radius without shortening for Kienböck disease: a 10-year follow-up. J Hand Surg Am. 2012;37(11):2221e2225. 29. Illarramendi AA, Schulz C, De Carli P. The surgical treatment of Kienböck’s disease by radius and ulna metaphyseal core decompression. J Hand Surg Am. 2001;26(2):252e260. 30. Monreal R. Treatment of scaphoid nonunions with closed-wedge osteotomy of the distal radius: report of six cases. Hand (N Y). 2008;3(2):91e95. 31. Kent ME, Rehmatullah NNT, Young L, Chojnowski AJ. Scaphoid nonunion in the presence of a degenerate carpus: don’t rush to salvage surgery. J Hand Surg Eur Vol. 2012;37(1):56e60.
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