31 Open Reduction and Internal Fixation of Scaphoid Nonunion with Vascularized Bone Graft

Indications

• Proximal pole scaphoid nonunion, especially in cases of an avascular proximal pole and after failed open reduction and, internal fixation (ORIF) with autogenous nonvascularized graft.

Technique

Figure 31-1

Figure 31-2

• Loosely wrap the arm with an elastic wrap prior to elevating the tourniquet. This will leave the vessels partially filled and easier to identify.
• Use a dorsal approach to expose the wrist and distal radius.
• Identify the supraretinacular artery between the first and second extensor compartments (Fig. 31-1).
• Harvest a block of corticocancellous bone from the dorsum of the distal radius along with periosteum and the vascular pedicle (Fig. 31-2).
• Mobilize the pedicle you have chosen by elevating the artery and its vein(s) along with a cuff of adjacent tissue (Fig. 31-3).
• Debride the site of the scaphoid nonunion, creating an oval-shaped defect in the nonarticular surface of the dorsal cortex.
• Contour the vascularized bone to fit the shape of the defect.
• Press fit the vascularized graft into the defect in the scaphoid (Fig. 31-4).
• Choose a form of scaphoid fixation. In most instances the scaphoid can be fixed with a screw and the graft secured as the two poles of the scaphoid are compressed. If the proximal pole is too small to accept a screw, place one or two 0.045 in. pins through the scaphoid and graft directed from proximal to distal. The pins will exit the skin superficial to the scaphoid tubercle and can be withdrawn to ensure that the tips of the pins are contained within the proximal pole.
• Fill gaps between the scaphoid and the vascularized graft with cancellous bone from the distal radius.
• Close the capsule and extensor retinaculum over the extensor digitorum communis (EDC) tendons. Leave the extensor pollicis longus (EPL) free in the subcutaneous tissues.
• Release the tourniquet and cauterize bleeding vessels. Close skin after irrigation with interrupted sutures. Apply a bulky dressing with a palmar splint.

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