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artery. This pedicle is long enough to reach the scaph

terior aspect of the radius based on the volar carpal

Inspired by the work of Kuhlman et al,12 we de

scribe a vascularized graft harvested from the an

ANATOMIC B ASIS FOR V OLAR V ASCULARIZED

From Institut de la Main, Paris, France. Address reprint requests to Christophe L. Mathoulin, MD, Institut dela Main, 6 Square [email protected]

,75016, Paris, France. E-mail:

treating scaphoid nonunions by using this source of vascularized bone. Other vascularized grafts from theradial and dorsal aspects of the wrist and hand havebeen 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 experience using a vascularized palmar graft in a series of patients with scaphoid nonunions.

onvascularized autogenous bone grafts combined with internal fixation have become theNpreferred 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 andKawai and Yamamoto3 reported excellent results in

also review our series of 72 patients treated by this technique.

deformity compared with the use of dorsal distal radius vascularized grafts. We

from the palmar cortex of the distal radius, providing easier access to the scaphoid

humpback deformity can be corrected by harvesting a wedge of vascularized bone

can serve as a pedicle for vascularized grafts. Scaphoid nonunions with a

solution and determined that the radial portion of the palmar carpal arterial arch

the distal radius in 40 fresh cadavers that were injected with a colored latex

by various investigators. We examined the blood supply to the palmar surface of

The use of vascularized bone grafts to treat scaphoid nonunion has been proposed

BY CHRISTOPHE L. MATHOULIN, MD

TECHNIQUE: V ASCULARIZEDBONE GRAFTS FROM THE VOLAR

DISTAL R ADIUS TO TREAT

SCAPHOID NONUNION

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

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

.

Harvest i ng Vascul ar i zed Bone

Dissection of small arteries may result in damage tothe vessel unless it is harvested with a cuff of adjacenttissue. The volar carpal artery has a predictable loca

tion between the periosteum of the radius and distalmargin of the pronator quadratus. The fascia andmuscle of the pronator quadratus are incised 1 cmfrom its distal margin along the full width of themuscle. The periosteum is incised along the distal andproximal margins of this 1-cm strip of fascia andmuscle. The radial half of this strip is elevated, with

he scaphoid and radius are exposed in the interval T between the radial artery and the tendon of theflexor carpi radialis (Figs 4, 5, and 6). With the wristin extension and ulnar deviation, the anterior capsuleis reflected, exposing the scaphoid and distal marginof the radius. Fibrous tissue and devascularized boneare removed from the site of the nonunion using asmall curved curette. Restoring the scaphoid to its

appropriate length is facilitated by traction on thethumb and by using a narrow osteotome to separatethe 2 poles of the scaphoid at the nonunion site.Intraoperative radiographs can help confirm the adequacy of the reduction. The dimensions of the defectin the scaphoid are measured while the osteotomemaintains separation of the fracture fragments. If nec

essary, the provisional reduction can be maintained by placing a pin through the distal pole of the scaphoidinto the capitate and a second pin through the proximal pole into the lunate.

TECHNIQUE

FIGURE 6. With wrist flexion and retraction of the flexor carpiradialis and flexor pollicus longus tendons, the volar carpalartery often can be located running along the distal edge of

the pronator quadratus.

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

VASCULARI ZED BONE GRAFTS MATHOULI N 3

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

FIGURE 10. (A, B) The graft fills the palmar defect withoutexcessive tension on the pedicle (A). XXXXXXX (B).

(A).osteotomesFIGURE 8. Harvesting the graft usingXXXXXXXXXXXXXXXXXXXXXXXX (B).

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5-mm osteotomes (Fig 8). The graft and its pediclethen are dissected to the origin of the volar carpalartery. The most lateral attachments of the pronatorquadratus fascia can be divided without hesitation tocreate a 4- to 5-cm pedicle.

The scaphoid is stabilized with a screw insertedanteriorly and directed distal to proximal. The screw

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, andthe graft is harvested using 10-mm osteotomes. Theaxes of the osteotome are oblique on the distal andproximal part of the graft to create a pyramid-shapedgraft. The pedicle and bone are elevated using two

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 thevascularized 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).

5MATHOULI NVASCULARI ZED BONE GRAFTS

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filled with cancellous bone from the distal radius. Thegraft can be stabilized by tightening the screw or witha pin inserted from the distal tubercle into the graft.

This pin should be parallel to the screw to avoiddamaging the vascular pedicle (Fig 10).

The capsule, particularly the radioscaphocapitiateligament, is repaired with care to avoid compressing

is inserted as dorsal as possible to minimize interfering ith 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 successful in matching the graft to the defect, no additional graft is necessary. Small residual defects can be

FIGURE 12. Anteroposterior radiograph of a stage IIB (Alnot)pseudarthrosis of the scaphoid. Note the bone loss withdisplacement at this stage (A). Radiograph showing union at

45 days (B). Magnetic resonance image at 1 year. The scaphoid appears of normal contour (C).

MATHOULI NVASCULARI ZED BONE GRAFTS6

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VASCULARI ZED BONE GRAFTS MATHOULI N 7

the pedicle. The skin is closed over a suction drain.

The wrist is immobilized in a palmar short-arm splint

ith 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. Representative cases are illustrated in Figs 11 and 12.

CONCLUSION

natomic dissections and our clinical experience A have shown the utility of vascularized bonegrafts based on the volar carpal artery to treat scaphoidnonunions. Graft harvested from the palmar aspect of the radius facilitates correction of the humpback deformity that frequently is seen in scaphoid nonunion.

Although this technique was described initially forpersistent nonunion after surgical treatment, the rateof union and ultimate wrist function compels us topropose palmar vascularized bone grafts as a primary

treatment for scaphoid nonunion.

OUR EXPERIENCE

e used a volar vascularized bone graft in a series W of 72 patients presenting with scaphoid non

unions and a significant humpback deformity, which

e 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

R EFERENCES

the first dorsal metacarpal artery. J Hand Surg 1997;22B:425-427.Mathoulin C, Haerle M. Vascularized bone graft from thepalmar carpal artery for treatment of scaphoid nonunion. Hand Surg 1998;23:318-323.

Mathoulin C, Brunelli F. Further experience with the indexmetacarpal 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 andskeleton of the hand. London: Dunitz, 2001:93-106.Shin AY, Bishop AT. Vascularized bone grafts for scaphoidnonunions and Kienbock’s disease. Orthop Clin North Am2001;32:263-277.Kuhlman JN, Mimoun M, Boabighi A, Baux S. Vascularizedbone 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 othe palmar surfaces of the distal radius and ulna: its relevanceto pedicled bone grafts at the distal palmar forearm. J HandSurg 2003;28B:131-136.

1. udet R, Rot-Camille R. Fractures et pseudarthroses duscaphoïde carpien. Utilisation d’un greffon vascularisé. Ac

´ de Chirurgie Orthopédique 1965;4:196-214.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.Kawai H, Yamamoto K. Pronator quadratus pedicled bonegraft for old scaphoid fractures. J Bone Joint Surg Br 1998;70:829-831.

Brunelli F, Mathoulin C, Saffar P. [Description of a vascularized bone graft taken from the head of the second metacarpalbone]. Ann Chir Main 1992;11:40-45.Zaidemberg C, Siebert JW, Angrigiani. A new vascularizedbone graft for scaphoid nonunion. J Hand Surg 1991; 16A: Sheetz KK, Bishop AT, Berger RA. The arterial blood supply of the distal radius and ulna and its potential use in vascularized pedicled bone grafts. J Hand Surg 1995;20A:902914. Yuceturk A, Isikar ZU, Tuncay C, Tandogan R. Treatment oscaphoid nonunions with a vascularized bone graft based on

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