gms | German Medical Science

Objectives/Interrogation: We present our experience with the use of a free vascularized bone graft from the medial femoral condyle (MFC) in the treatment of long-standing scaphoid non-union.

Methods: We report the clinical and radiological outcome of 38 treated scaphoid non-unions in 37 patients. Due to a fragmentented, unstable or avascular proximal pole or failed previous antegrade screw fixation 9 patients out of 37 were treated with an osteocartilagineous graft (proximal pole replacement). The other patients were treated with an osteoperiosteal graft. The mean age at the time of the procedure was 26 years (range 17-42 years). 15 (39,5%) patients underwent previous surgery with persistent non-union. 36 (97%) of the patients were male and one (3%) was female.

Preoperative gadolinium enhanced MRI scans were available for 31 (84%) patients and showed a compromised perfusion or avascularity of the proximal scaphoid pole in all cases. The mean time of persisting non-union until surgery using MFC graft was 51 months (range 6-184 months). The mean post-operative follow-up time was 16 months (range 6-53 months).

Results and Conclusions: Bone union was achieved in 9 out of 9 (100%) cases treated with a osteocartilaginous MFC graft and in 25 out of 29 (86%) cases treated with a osteoperiosteal MFC graft. Overall union rate was 89,5%. We saw a decreased union rate associated with previous screw fixation and with a combined volar and dorsal surgical approach. We observed no major donor site morbidity and all minor donor site symptoms wore off within one year. In terms of the clinical outcome we saw an improvement of the average grip strength (preoperative mean value 34kg, final follow up 44kg). The scapholunate and radiolunate angle improved as well (SL average 6° improvement, RL average 10° improvement). The range of motion of the wrist at final follow-up remained about the same. Within one year after the surgery 31 (83,7%) of the patients reported complete pain relief. The mean preoperative DASH score was 58,6 points and decreased to 18,8 points at final follow-up. The mean PRWE score decreased from 62,4 points before surgery to 29,6 points at final follow-up.

We see the advantages of this method in the possibility of a proximal pole replacement with an osteocartilagineous graft, the high union rate, the moderate donor site morbidity, the consistant vascular anatomy in the MFC area with a long pedicle, the possibility of harvesting a rather big graft and the comparably easy shaping since its a free vascularized graft.