Table 1 Summary of all articles included in this systematic review ( N = 12)
From: The use of the free vascularised bone graft for nonunion of the scaphoid: a systematic review
Reference | Study type | Number of patients = 245 | Technique | Union rate (%) | Average time to union (weeks) | Complications | Average follow-up (years) | Immobilisation (weeks) | Comments |
|---|---|---|---|---|---|---|---|---|---|
Pechlaner et al. [25] | Retrospective | 25 | Resection of the pseudarthrosis or the necrotic bone. Insertion and Kirschner wire fixation of corticocancellous graft from the iliac crest isolated on its vascular pedicle and anastomosed to the radial artery | 25 (100%) | - | - | - | 8 | AVN proximal pole preoperatively |
Fernandez et al. [26] | Retrospective | 11 | Resection of the necrotic bone and inserting a corticocancellous bone graft from the iliac crest; the second dorsal intermetacarpal artery is implanted into the proximal fragment of the scaphoid | 10 (91%) | 10 | Nonunion and cystic area increased in 1 patient | 5Â years | 10 | Six patients had had previous unsuccessful operative attempts to obtain union |
Eight nonunions were in the proximal one third, and three at the waist of the scaphoid | |||||||||
Gabl et al. [23] | Retrospective | 15 | Microvascular pedicled iliac crest bone graft anastomosed to the radial artery after debridement of nonunion | 12 (80%) | - | 20% patients who failed to unite progressed to carpal collapse | 6Â years 1Â month | 12 | Patients undergoing union had an average grip strength of 107Â kg-force versus 73Â kg-force in patients failing to unite |
Gabl et al. [24] | Retrospective | 56 | Microvascular pedicled iliac crest bone graft anastomosed to the radial artery after debridement of nonunion | 47 (85%) | - | 15% patients failed to unite and progressed to carpal collapse. Arthrosis developed in all these patients | 8Â years 9Â months follow-up | 12 | In those undergoing union, grip strength was 95% and range of motion 75% compared to the noninvolved wrist. Carpal collapse did not occur. Arthrosis was reduced in 25% |
Harpf et al. [22] | Retrospective | 60 | Microvascular pedicled iliac crest bone graft anastomosed to the radial artery after debridement of nonunion. Kirschner wire fixation | 55 (92%) | - | 8.3% who failed to unite progressed to carpal collapse | 7Â years 5Â months | 12 | 61.37% of patients had bone deformations detected radiologically at the donor site, and 31.7% of patients had impairment of the lateral cutaneous nerve of the thigh |
Doi et al. [21] | Retrospective | 10 | Free vascularised periosteal bone graft harvested from the supracondylar region of the femur and nourished by the articular branch of the descending genicular artery and vein. Kirschner wire fixation | 10 (100%) | 12 | 1 patient suffered transient knee joint stiffness, 1 patient suffered transient saphenous nerve dysaesthesias and 2 patients developed ectopic bone formation requiring resection | 3Â years 6Â months | 6 | All patients had preoperative AVN proximal pole |
Mayo wrist scoring system used to score outcome and showed 8 patients with excellent or good outcomes. Grip strength returned to 33Â kg-force on the affected side versus 40Â kg-force on the unaffected. All patients resumed activities | |||||||||
Doi et al. [29] | Retrospective | 11 | Free vascularised periosteal bone graft consisting of periosteum, cortex and underlying cancellous bone harvested from the supracondylar region of the femur and nourished by the articular branch of the descending genicular artery and vein. Kirschner wire fixation | 11 (100%) | - | - | - | Until bony union achieved | Recommends use of iliac crest donor site if large bone graft required or injury to donor site |
Lanzetta [28] | Case report | 1 | Osteochondral-free vascularised graft from the rib based on the inferior and superior intercostal arteries. Kirschner wire fixation | 1 (100%) | 4 | - | 5Â years | 4 | No donor site morbidity. Bone formation occurred at the radioscaphoid joint from the graft requiring radiocarpal arthrolysis. Grip strength improved by 30% |
Jones et al. [30] | Retrospective | 12 | Free vascularised bone graft harvested from the medial supracondylar region of the femur and nourished by the articular branch of the descending genicular artery and vein. Scaphoid screw or Kirschner wire fixation | 12 (100%) | 13 | Ectopic bone formation noted | 1 year | Until bony union achieved | Comparative study against pedicled VBGs showing a significantly short time to union in free VBGs (p < 0.001) and a significantly higher rate of union (p < 0.005) |
Larson et al. [31] | Retrospective | 11 | Free vascularised bone graft harvested from the medial supracondylar region of the femur and nourished by the articular branch of the descending genicular artery and vein. Scaphoid screw or Kirschner wire fixation | 11 (100%) | 12 | Ectopic bone formation at periosteal flap in 2 patients | - | Until bony union achieved | Final 12th patient only 2Â months postsurgery and so excluded from results |
Mayo wrist scoring system showed excellent or good results in 8 patients. No donor site morbidity | |||||||||
Arora et al. [27] | Retrospective | 21 | Microvascular pedicled iliac crest bone graft anastomosed to the radial artery after debridement of nonunion. Kirschner wire fixation | 16 (76%) | 19 | - | 5 years 7 months | 12 | Difference in pre- and postoperative grip strength statistically significant in patients undergoing union (p < 0.03). 11 of 16 patients with union showed no signs of osteoarthritis, and 5 patients showed stage 1 signs of osteoarthritis. All patients with persistent nonunion showed signs of osteoarthritis |
Jones et al. [32] | Retrospective | 12 | Free vascularised bone graft harvested from the medial supracondylar region of the femur and nourished by the articular branch of the descending genicular artery and vein. Scaphoid screw or Kirschner wire fixation | 12 (100%) | 13 | 1 concurrent donor-site stitch abscess debridement | - | Until bony union achieved | Radial styloidectomy required after union in 1 patient |