TECHNIQUE: VASCULARIZED BONE GRAFTS FROM THE VOLAR DISTAL RADIUS TO TREAT SCAPHOID NONUNION

BY CHRISTOPHE L. MATHOULIN, MD The use of vascularized bone grafts to treat scaphoid nonunion has been proposed by various investigators. We examined the blood supply to the palmar surface of the distal radius in 40 fresh cadavers that were injected with a colored latex solution and determined that the radial portion of the palmar carpal arterial arch can serve as a pedicle for vascularized grafts. Scaphoid nonunions with a humpback deformity can be corrected by harvesting a wedge of vascularized bone from the palmar cortex of the distal radius, providing easier access to the scaphoid deformity compared with the use of dorsal distal radius vascularized grafts. We also review our series of 72 patients treated by this technique.

onvascularized autogenous bone grafts com bined with internal fixation have become the preferred treatment for scaphoid nonunions for many surgeons. In 1965 Judet and Roy-Camille1 suggested using a bone graft harvested from the pal mar aspect of the radius with a vascular supply from fibers of the pronator quadratus muscle. Braun2 and Kawai and Yamamoto3 reported excellent results in

treating scaphoid nonunions by using this source of vascularized bone. Other vascularized grafts from the radial and dorsal aspects of the wrist and hand have been described, with similarly encouraging results.4-11 In this review, we describe the technical aspects of the vascular supply to the palmar aspect of the radius based on cadaver dissections and report on our expe rience using a vascularized palmar graft in a series of patients with scaphoid nonunions.

ANATOMIC BASIS FOR VOLAR VASCULARIZED

From Institut de la Main, Paris, France. Address reprint requests to Christophe L. Mathoulin, MD, Institut de la Main, 6 Square Jouvenet75016, , Paris, France. E-mail: I nspired by the work of Kuhlman et al,12 we de mathoulin@wanadoo.fr scribe a vascularized graft harvested from the an terior aspect of the radius based on the volar carpal artery. This pedicle is long enough to reach the scaph 1

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FIGURE 1. Cadaver dissection showing the volar carpal ar tery running along the distal edge of the pronator quadratus before anastomosing with the anterior interosseous artery and a branch of the ulnar artery. Abbreviations: R, radial artery; U, ulnar artery.

FIGURE 2. Magnified cadaver dissection showing the origin of the volar carpal artery, the lateral part of which is detached from the radius.

oid without excessive tension (Fig 1). An arterial network located on the palmar aspect of the distal radius and ulna perfuses the graft. In 40 cadaver dissections, we were able to confirm the presence of a volar carpal artery. This vessel originates from the radial artery at the level of the radial styloid and runs along the palmar aspect of the radius (Fig 2). The artery follows the distal edge of the pronator quadra tus and forms a T-shaped anastomosis with the anterior interosseous artery adjacent the distal radio ulnar joint (Fig 3). After branching from the radial artery, the volar carpal artery travels along the radial third of the distal radius and penetrates the radius at the radial epiphysis.

FIGURE 3. Magnified cadaver dissection showing the anas tomosis zone forming the vascular T. Red, volar carpal artery; yellow, distal branch of the anterior interosseous ar tery; blue, branch of the ulnar artery.

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FIGURE 4. Diagram showing the anterior surgical approach with a medial palmar extension.

FIGURE 6. With wrist flexion and retraction of the flexor carpi radialis and flexor pollicus longus tendons, the volar carpal artery often can be located running along the distal edge of the pronator quadratus.

TECHNIQUE

he scaphoid and radius are exposed in the interval between the radial artery and the tendon of the flexor carpi radialis (Figs 4, 5, and 6). With the wrist in extension and ulnar deviation, the anterior capsule is reflected, exposing the scaphoid and distal margin of the radius. Fibrous tissue and devascularized bone are removed from the site of the nonunion using a small curved curette. Restoring the scaphoid to its appropriate length is facilitated by traction on the thumb and by using a narrow osteotome to separate the 2 poles of the scaphoid at the nonunion site. Intraoperative radiographs can help confirm the ade quacy of the reduction. The dimensions of the defect in the scaphoid are measured while the osteotome maintains separation of the fracture fragments. If nec

essary, the provisional reduction can be maintained by placing a pin through the distal pole of the scaphoid into the capitate and a second pin through the prox imal pole into the lunate. Harvesting Vascularized Bone Dissection of small arteries may result in damage to the vessel unless it is harvested with a cuff of adjacent tissue. The volar carpal artery has a predictable loca tion between the periosteum of the radius and distal margin of the pronator quadratus. The fascia and muscle of the pronator quadratus are incised 1 cm from its distal margin along the full width of the muscle. The periosteum is incised along the distal and proximal margins of this 1-cm strip of fascia and muscle. The radial half of this strip is elevated, with

FIGURE 5. Diagram showing the location of the flexor carpi radialis tendon and radial artery.

FIGURE 7. Diagram showing subperiosteal dissection of the lateral part of the pedicle.

FIGURE 8. Harvesting the graft using osteotomes (A). XXXXXXXXXXXXXXXXXXXXXXXX (B).

FIGURE 10. (A, B) The graft fills the palmar defect without excessive tension on the pedicle (A). XXXXXXX (B).

FIGURE 9. Reduction and screw fixation of the scaphoid. Note the palmar bone loss (A). XXXXXXXXXXX (B).

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FIGURE 11. Anteroposterior radiograph of a stage IIA (Alnot) pseudarthrosis of the scaphoid. Note the extensive bone loss (A). Perioperative view showing the harvested bone graft and extensive palmar bone loss (B). Perioperative view showing the vascularized bone graft filling the defect. Note the absence of tension on the pedicle despite the extended position of the wrist (C). Radiograph showing union at 45 days. The graft has been well integrated (D). Tomography at 3 months after removal of a painful screw. The hole left by the passage of the screw can be seen within the reconstructed scaphoid (E). Anteroposterior radiograph of the same scaphoid 2 years after reconstruction by vascularized bone grafting (F).

its periosteum off the palmar cortex of the radius, by using a combination of scalpel and osteotome (Fig 7). Dimensions of the graft are marked on the radius, and the graft is harvested using 10-mm osteotomes. The axes of the osteotome are oblique on the distal and proximal part of the graft to create a pyramid-shaped graft. The pedicle and bone are elevated using two

5-mm osteotomes (Fig 8). The graft and its pedicle then are dissected to the origin of the volar carpal artery. The most lateral attachments of the pronator quadratus fascia can be divided without hesitation to create a 4- to 5-cm pedicle. The scaphoid is stabilized with a screw inserted anteriorly and directed distal to proximal. The screw

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FIGURE 12. Anteroposterior radiograph of a stage IIB (Alnot) pseudarthrosis of the scaphoid. Note the bone loss with displacement at this stage (A). Radiograph showing union at 45 days (B). Magnetic resonance image at 1 year. The scaph oid appears of normal contour (C).

is inserted as dorsal as possible to minimize interfering with placement of the graft. We also avoid the scapho trapezial joint to avoid future discomfort (Fig 9). The bone graft is placed to fill the defect on the palmar aspect of the scaphoid. If the surgeon is suc cessful in matching the graft to the defect, no addi tional graft is necessary. Small residual defects can be

filled with cancellous bone from the distal radius. The graft can be stabilized by tightening the screw or with a pin inserted from the distal tubercle into the graft. This pin should be parallel to the screw to avoid damaging the vascular pedicle (Fig 10). The capsule, particularly the radioscaphocapitiate ligament, is repaired with care to avoid compressing

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the pedicle. The skin is closed over a suction drain. The wrist is immobilized in a palmar short-arm splint with the wrist in about 40 of extension. If a pin is used to stabilize the graft, it is removed in 3 weeks. Wrist immobilization is continued until there is ra diographic and clinical evidence of union.

days, based on the radiographic appearance. Represen tative cases are illustrated in Figs 11 and 12.

CONCLUSION
natomic dissections and our clinical experience have shown the utility of vascularized bone grafts based on the volar carpal artery to treat scaphoid nonunions. Graft harvested from the palmar aspect of the radius facilitates correction of the humpback de formity that frequently is seen in scaphoid nonunion. Although this technique was described initially for persistent nonunion after surgical treatment, the rate of union and ultimate wrist function compels us to propose palmar vascularized bone grafts as a primary treatment for scaphoid nonunion.

OUR EXPERIENCE

e used a volar vascularized bone graft in a series of 72 patients presenting with scaphoid non unions and a significant humpback deformity, which we believed would be difficult to treat using vascu larized bone grafts from the dorsal distal radius be cause of pedicle length. Average time to union was 60

REFERENCES
1. Judet R, Rot-Camille R. Fractures et pseudarthroses du scaphode carpien. Utilisation dun greffon vascularis. Ac de Chirurgie Orthopdique 1965;4:196-214. 2. Braun RM. Viable pedicle bone grafting in the wrist. In: Urbaniak JR, ed. Microsurgery for major limb reconstruction, St. Louis, MO: Mosby, 1987:220-229. 3. Kawai H, Yamamoto K. Pronator quadratus pedicled bone graft for old scaphoid fractures. J Bone Joint Surg Br 1998; 70:829-831. 4. Brunelli F, Mathoulin C, Saffar P. [Description of a vascular ized bone graft taken from the head of the second metacarpal bone]. Ann Chir Main 1992;11:40-45. 5. Zaidemberg C, Siebert JW, Angrigiani. A new vascularized bone graft for scaphoid nonunion. J Hand Surg 1991; 16A: 6. Sheetz KK, Bishop AT, Berger RA. The arterial blood supply of the distal radius and ulna and its potential use in vascu larized pedicled bone grafts. J Hand Surg 1995;20A:902 914. 7. Yuceturk A, Isikar ZU, Tuncay C, Tandogan R. Treatment of scaphoid nonunions with a vascularized bone graft based on the first dorsal metacarpal artery. J Hand Surg 1997;22B: 425-427. Mathoulin C, Haerle M. Vascularized bone graft from the palmar carpal artery for treatment of scaphoid nonunion. J Hand Surg 1998;23:318-323. Mathoulin C, Brunelli F. Further experience with the index metacarpal vascularized bone graft. J Hand Surg 1998;23B: 311-317. Mathoulin C, Gilbert A. Vascularized bone transplants in upper limbs. In: Tubiana R, ed. Surgery of the skin and skeleton of the hand. London: Dunitz, 2001:93-106. Shin AY, Bishop AT. Vascularized bone grafts for scaphoid nonunions and Kienbocks disease. Orthop Clin North Am 2001;32:263-277. Kuhlman JN, Mimoun M, Boabighi A, Baux S. Vascularized bone graft pedicled on the volar carpal artery for nonunion of the scaphoid. J Hand Surg 1987;12B:203-210. Haerle M, Schaller HE, Mathoulin C. Vascular anatomy of the palmar surfaces of the distal radius and ulna: its relevance to pedicled bone grafts at the distal palmar forearm. J Hand Surg 2003;28B:131-136.

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