Scaphoid non-union: Vascularised graft based on the volar carpal artery surgical technique
Subscribe to get full access to this operation and the extensive Upper Limb & Hand Surgery Atlas.
Learn the Scaphoid non-union: Vascularised graft based on the volar carpal artery surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Scaphoid non-union: Vascularised graft based on the volar carpal artery surgical procedure.
Approximately 10% of scaphoid fractures will proceed to a non-union. The incidence is higher for fractures involving the proximal pole (up to 90%) and also is increased if there is a delay to diagnosis, inadequate immobilisation or significant displacement of the fracture.
There are two anatomical factors in particular that predispose the scaphoid to non-union. The first is that it is almost entirely intra-articular with limited soft tissue attachment for vascular inflow. With respect to the proximal pole it is served by an intra-medullary vessel that enters the dorsal distal waist which makes proximal pole fractures particularly prone to non-union due disruption of this vessel. The second that the scaphoid has no periosteum and so requires primary bone healing. Furthermore the scaphoids shape and articulations makes it difficult to immobilise. Fractures across its waist having a tendency to displace into a flexed position.
Scaphoid non-union represents a difficult surgical problem. Although some authors report satisfactory union rates following standard bone grafting techniques, others report failure rates as high as 65%.
A variety of techniques have been described to treat scaphoid non-union but the use of a vascularised rather than a non-vascularised graft has been shown to improve overall union rates especially where there is doubt about the vascularity of the proximal pole. One RCT directly comparing union rates in proximal pole non-union demonstrated an 89% union rate using vascularised bone graft compared to 72% with non-vascularised graft.
Various vascularised bone graft techniques are described in the literature. These include a dorsal distal radius bone graft raised upon the 1/2 inter-compartmental supraretinacular artery found between the 1st and second dorsal extensor compartments first described by Zaidemburg in 1988.
Another technique described is the use of a free vascularised bone graft taken from the medial femoral condyle. A summary of the techniques available is listed in the references at the end.
In this case a vascularised graft from the volar aspect of the distal radius is was used to fix a scaphoid non-union using a volar approach.
The mini Acutrak headless screw system is used in this case. It offers a tapered, fully threaded designed with a variable pitch and thus offers compression and sits beneath the bone surface.
The history, presentation, imaging and surgical decision making are described in the next section.
Readers will also find of use the following OrthOracle techniques:
Author: Tahseen Chaudhry ,Consultant hand and peripheral nerve surgeon
Institution: University Hospital Birmingham, Birmingham, UK.
- Each operation and the questions associated become a named course in the CPD section
- The operative technique itself is read as a lesson as is any company implant information if this is being assessed.
- You’ll need to tick the box to confirm this has been done and can do this immediately if you have already read the op tech.
- The vast majority of operations have a 10-15 MCQ quiz covering all aspects of the decision making and the technique
- There are four possible answers of which one is correct (or on occasion more correct) than the others.
- There are additional quiz modules on the surgical steps, the implants and problem cases being added continually
- The course is completed once all the lessons are read and quizzes submitted and passed.
- On successful completion of each quiz you will receive validated CPD points that add to the certificate in your CPD folder.
- Your dashboard also will contain a record of the time you have spent logged onto and using the site.
- The timer suspends after 5 minutes though if there is no activity.
- When you restart you will resume at the same point in the module.
- Once you have completed each quiz you will need to feedback on the module first then click “submit” and your paper will be marked.
The pass mark is 75%.
- If you fall below this level you will be directed back to re-read the slides where you’ve tripped up.
- Once these have been read you can re-do just the questions you failed on.
- Once you have passed the quiz you can return at a future stage & resit .
- Operation Quiz – 1 CPD point
- Surgical steps Quiz – 1/4 CPD point
- Implants Quiz – 1/4 CPD point
- Problem case Quiz – 1/2 CPD point
One CPD point equates to one hour of academic activity
Welcome to the Professional Development question section. The objective of taking these tests is to demonstrate that you have understood all aspects of the assessment and management of patients requiring surgical intevention. On successful completion you will receive a certificate accredited by both the Royal College of Surgeons of both England and Edinburgh as well as the British Orthopaedic Association.
Our content is designed for both Surgeons in independent practice and Surgeons in training.