Surgical treatment of infected bones with vascularised bone grafts is well established as an efficient strategy since several years. Nevertheless orthopaedic and trauma surgeons seem to apply vascularised bone grafts as the last treatment option only. Two strategies exist for treatment of chronically infected bones with vascularised bone grafts. First: Complete resection of the infected, often non-united part of the bones and reconstruction with large vascularised bone grafts, mostly fibular grafts. Second: Augmentation of the kept and intact parts of the bones with vascularised bone grafts. Two small series of patients are presented to illustrate both techniques and to show the results and outcome. Resection of big parts of the tibia and reconstruction with mostly ipsilateral fibular grafts – single barrel in children and double barrel in adults – led to uneventful healing in all cases. Augmentation of radius, femur and calcaneus with vascularised grafts from the iliac crest or the scapula was followed by primary healing, too. All patients were disburdened from infection up to now and regained full extremity function. The presented vascularized bone grafts did not only salvage the extremities but also could maintain their functionality. The procedure is demanding, but reliable and safe at a low rate of complications. Thus vascularised bone grafts should not only be used as ultimative salvage procedures, but as early as possible whenever standard treatments for osteomyelitis fail

Aim: To determine the viability and long term survival of a unique Patellar reconstruction technique, using the posterior femoral condyle, at primary TKR, in patients with previous patellectomy. Methods: The posterior lateral femoral condyle cut during total knee replacement was used as a non- vascularised bone graft to reconstruct the patella. A medial para- patellar incision was used to create a Patellar pouch. The patient was examined clinically at operation, 6 weeks, 12 months, 2 years and 4 years from operation. Clinical examination and radiographic evidence of patellar position and survival were used. Results: The patient has a stable, well positioned patella, with no pain from the graft and no clinical evidence of Mal- tracking. Radiographs show excellent survival of the graft and good position at 4 years. Conclusion: Patellar reconstruction using non- vascularised bone graft via a medial patellar pouch is a viable alternative surgical option to aid stability in those patients undergoing primary TKR with previous patellectomy

Introduction. The purpose of this study is to evaluate the radiological and clinical outcomes in Northern Ireland of free vascularised fibular bone grafting for the treatment of humeral bone loss secondary to osteomyelitis. Upper limb skeletal bone loss due to osteomyelitis is a devastating and challenging complication to manage for both surgeon and patient. Patients can be left with life altering disability and functional impairment. This limb threatening complication raises the question of salvage versus amputation and the associated risk and benefits of each. Free vascularised fibula grafting is a recognised treatment option for large skeletal defects in long bones but is not without significant risk. The benefit of vascularised over non-vascularised fibula grafts include preservation of blood supply lending itself to improved remodeling and osteointegration. Materials & Methods. Sixteen patients in Northern Ireland had free vascularised fibula grafting. Inclusion criteria included grafting to humeral defects secondary to osteomyelitis. Six patients were included in this study. Patients were contacted to complete DASH (Disabilities of the Arm, Shoulder and Hand) questionnaires as our primary outcome measure. Secondary outcome measures included radiological evaluation of osteointegration and associated operative complications. Complications were assessed via review of Electronic Care Record outpatient and in-patient documents

Background Scaphoid non-union remains a difficult problem to treat effectively. Screw fixation and standard bone grafting techniques are good options with union reported in approximately 90% of cases. Studies of the vascular supply to the distal radius have revealed a consistent vascular bone graft source from the dorsal radius. This allows for a pedicled vascularised bone graft to be fashioned, further enhancing the local blood supply to the fracture site. Methods 14 male patients with a mean age of 30 years (21 to 51 years) and a mean duration of injury of 57 months (15 – 348 months) underwent vascularised bone grafting of established non–union of the scaphoid. The graft was vascularised with a pedicle based on the 1, 2 intercompartmental supraretinacular branch of the radial artery. In addition the long standing deformity resulting from the non-union was corrected by a tri-cortical iliac crest bone graft. (The results were assessed with regard to evidence of union at the fracture site and resolution of pain with return of function). Some of the cases had previous operations with conventional bone graft and failed. Results Fracture healing was demonstrated radiologically in 9 of 14 cases (64%). 12 of 14 cases (86 %) showed resolution of pain and improvement in function. Conclusion This technique shows promising results for treating established non-union of the scaphoid, even after long intervals between initial injury and the grafting procedure

Introduction: We report on our experience of using a vascularised bone graft harvested from the volar face of the radius in the treatment of Kienböck’s disease, with an average follow up of 79 months and a minimum of 5 years. Materials: We treated 22 patients with Kienböck’s disease. There were 8 women and 14 men whose average age was 31.4 years old (range 18–63 years). Pain was always present and incapacitating in 19 cases. All patients underwent pre-operative tomodensitometry and an MRI, based on LICHTMAN’s classification there were 8 stage II, 10 stage IIIA and 4 stage IIIB. Methods: The volar carpal artery of the carpus originates from the radial artery and vascularises medial part of the radial epiphysis. Using the same anterior surgical approach it was possible to harvest the pedicled bone graft from this artery and to place it into the lunate for revascularisation. Shortening of the radius was carried out in all cases, as was immobilisation until union of the radius. Results: Our average follow up is 79 months (range 60–138 months). Pain disappeared completely in 20 cases, and was moderate and tolerable in 2 cases. The average active range of motion was higher than 71°. The average period for return to work was 3.5 months. Post-operative MRI at an average of more than 8 months showed 16 complete revascularisations of the lunate, 5 stabilizations of lesions and one failure which necessitated secondary palliative treatment. There were 4 delayed unions of the radius and one Südeck’s dystrophy. There was a clear correlation between the stage of Kienböck’s disease and the final outcome of surgery. Discussion: The use of a vascularised bone graft harvested from the anterior face of the radius for the revascularisation of the lunate associated with shortening of the radius has given encouraging results. A longer-term study is necessary

To determine union rate in complicated nonunions of the scaphoid treated with a vascularised bone graft. Vascularised bone grafting for scaphoid nonunions (1–2 ICSRA, Zaidemberg technique) has shown initial enthusiasm. Its usefulness has been challenged in cases where the proximal pole of the scaphoid is avascular. Complicated nonunions where the proximal pole is highly likely to be avascular occur in revision surgery and proximal pole nonunions. Fourteen patients were retrospectively followed up. Eight had nonunion following previous scaphoid surgery (two previous ORIF, two previous nonvascular grafting, and four with two previous surgeries). Six patients had no previous surgery for a proximal pole nonunion of 12.5 months’ duration. All patients were male with an average age of twenty-four. Delay from fracture to vascularised bone grafting was twenty months. Graft harvesting was done according to the Zaidemberg technique by two orthopaedic surgeons. CT-scan was used to confirm union in all patients except two who were lost of the follow-up. Twelve patients were followed up by an independent surgeon at a postoperative minimal period of four months. Functional status was assessed with the DASH questionnaire and follow x-rays were performed to determine the presence of degenerative changes. Union was confirmed by CT-scan in eleven of twelve followed patients (92%) at an average time of six months following vascularised graft. Radio-scaphoid osteoarthritis was seen in the one patient that didn’t achieve union. This series suggests that the Zaidemberg graft is useful and may be proposed in situations of revision surgery and proximal pole non-unions. We achieved a high union rate in these complicated nonunions even though there was high likelihood that the proximal pole was avascular. This study stresses the importance of protective immobilization until documented union by CT-scan in this difficult subset of patients

Purpose. Scaphoid non-unions can result in debilitating wrist problems. This study compared treatment of scaphoid non-unions using either a non vascularised (NVBG) or a vascularised bone graft (VBG). Method. Twenty one cases of scaphoid non-unions were treated by two surgeons between 2005 and 2008 using either a NVBG from the iliac crest or a VBG from the radius based on a 1,2 intercompartmental supraretinacular artery pedicle. Results. Of the 21 cases only 19 were available followed up at a minimum of 3 months with 12 cases available for clinical follow-up 2–5 years postoperatively. Union was achieved in 9 of 11 cases in the VBG group and in 6 of the 8 cases in the NVBG group with no statistically significant difference in average time to union. Wrist range of motion was compared at the time of consolidation and at the follow-up showing no significant difference between the two groups. 11 patients completed the Dash-score and the Mayo-wrist-score with similar results in both groups. Conclusion. This study could not demonstrate any significant differences in clinical and functional outcome at the time of confirmed fracture union or at a late follow-up

Introduction. Scaphoid nonunions remain controversial with regard to optimal management. The objective of this article is to compare our clinical experience in the treatment of patients with scaphoid nonunion using distal radius non vascularised bone graft with that of iliac crest bone graft. Material & Methods. We conducted a prospective randomized study comparing the clinical, functional and radiographic results of 42 patients treated for scaphoid nonunion using a non-vascularised bone graft from the dorsal and distal aspect of the radius (group I), relative to 46 patients treated by means of a conventional non-vascularised bone graft from the iliac crest (group II). All nonunions were stabilized with single Herbert screw. Results. Bone fusion was achieved in 87.1% of group I and 86.5% of group II patients. Functional results were good to excellent in 76.0% of the patients in group I and 72.5% in group II. The average grip power, as well as wrist flexion and extension were similar in both groups. However, the donor site morbidity was much higher in group II (4 cases of hematoma, 6 cases of chronic pain and 1 anterior superior iliac spine avulsion) fracture. No complication was seen in group I. Conclusion. We conclude that nonvascularized distal radius bone grafting yields similar union rate as well as functional outcome as compared to iliac crest bone graft with no donor site morbidity

The Authors report their experience in the treatment of scaphoid non-union recurring to the vascularised bone graft technique as described by Zeidemberg. The patients have been treated between the 1999 and 2004. The authors report 22 cases (21 males and 1 female) with an average age of 31 years (from 17 to 42). 10 cases the involved wrist was the right one and in the other 12 cases was the left one. 18 patients presented an avascular necrosis of the proximal fragment of the scaphoid, recognised by the MNR. Two patients have been previously treated by the traditional bone graft technique as described by Matti-Russe, using a cannulated screw for the stabilization of the graft. 16 patients have been controlled at the follow-up (mean 23 months, from 3 to 65). The authors, looking at the good results obtained at the follow-up, feel that this technique might be a very useful one in the treatment of the established scaphoid non-union, mainly in presence of an avascular necrosis of the proximal third of the scaphoid. This technique might also be useful in the treatment of the failure of the classic bone graft technique

Following a laboratory rat study where iliac crest was removed, the femoral vessels were placed as a pedicle through the centre of the graft which was wrapped in silastic sheeting and transplanted to the subcutaneous abdominal wall, which showed in all cases bone revascularisation and viability within three weeks. A human study followed in two patients with chronic complex scaphoid non unions where iliac crest was placed in the anterior interosseous pedicle in the proximal forearm. The pedicle was ligated proximally. Four months later, the graft was dissected on its pedicle distally to the scaphoid. In both cases, the scaphoid united and in both cases the bone was viable at biopsy. Rather than this tedious two stage procedure, Russe and Fisk grafts are routinely pedicled with the superficial radial vessels flowing retrograde at scaphoid bone grafting. At the same time of our rat study, Zaidemberg published his dorso-radial radius vascularised pedicled bone graft on the “irrigating artery”. The details were scant as they were at the oral presentation three years later. The irrigating artery was subsequently beautifully demonstrated in Zancolli’s Atlas of Hand Surgery and this and other dorsal pedicled bone grafts of the radius have been well described by Bishop and colleagues at the Mayo Clinic. The technique of 1-2 SRA (Zaidemberg) pedicled bone grafting is described in detail together with the indications for prefabrication and vascularised pedicled bone grafting and the necessary pre operative imaging information to plan and select the correct procedure

Objectives: To analyse functional outcome of giant cell tumor (GCT) distal radius treated with en bloc excision and reconstruction with ulnar translocation and wrist arthrodesis. Methods: Between June 2005 and March 2008 fourteen patients of Campanacci grade 3 GCT distal radius treated with en bloc excision were reconstructed with ulnar translocation (radial transposition of ulna) and wrist arthrodesis. Seven (50%) patients had recurrent disease. Average resection length was 7.9 cm (range 5.5cm–15 cm). Twelve cases were fixed with a plate and in 2 an intramedullary nail was used. Union at both junctions was evaluated and functional assessment done using MSTS score. Results: All 14 patients had followed up till bony union. Eleven patients were available at time of final review with an average follow up of 24.5 months (range 13–48 months). Average time for union at ulnocarpal junction was 4 months and ulnoradial junction was 5 months. No case required any additional procedure to augment union. Three cases had a soft tissue recurrence and one had pulmonary metastasis. Average range of prono supination was 80 degrees, one patient with synostosis had complete restriction of prono supination. Average MSTS Score at last follow up was 26 (86.6%). Conclusions: Ulnar translocation provides a local vascularised bone graft to bridge the defect after excision of distal end radius tumors without the need for microvascular procedures. Unlike centralization of the ulna it retains prono supination while maintaining good hand function

Background: The reconstructive surgery of the upper limb is able to avoid an amputation and a severe functional impairment. Nevertheless the therapeutic challenge is difficult because of the diversity of the injuries and the complex function of the upper limb. Aim: The aim of this study is to assess the results of vascularised fibular bone graft in the immediate and secondary post traumatic reconstructive surgery of the upper limb. Material and method: Between 1985 and 2006, 16 vascularised fibular bone grafts were performed for 15 post traumatic reconstructions of the upper limb. In this study there were 7 females and 8 males, with an average age of 42 years (20–79). The fibular bone grafting was performed in 9 cases in the immediate post traumatic reconstructive surgery. In 7 cases the fibular bone graft was performed after a first failed surgery, as salvage reconstructive surgery. The transfer was composed of bone and skin in 2 cases, of bone and muscle in 6 cases and of only bone in 8 cases. Results: The percentage of bone union was 80%. Eight fibular bone graft healed spontaneously, 2 after a additional iliac crest bone grafting. The average duration of bone healing was 6,5 months, from 4 to 12 months. The functional result was good for 10 patients allowing them to go back to their initial activities. Discussion: In severe bone and soft tissues destruction of the upper limb, a complete reconstruction in one operative session may be performed in order to reduce the time of bone healing and rehabilitation. The micro-vascularized fibular bone grafting may be an excellent therapeutic option. The other techniques as amputation or conventional bone grafting techniques are usually proposed when the vital status of the patient is not compatible with a to extended surgery. The fibular bone grafting appeared as a very reliable technique with a small morbidity on the donor site. Malunions are frequently described in the literature. It might be partially due to the difficulty in having a stable internal fixation. It has to be as less aggressive a possible on the fibular bone graft vascularisation but has also to offer a good stability. The internal fixation used in these cases was not perfectly adapted for this bifocal fixation of the fibular bone graft on the upper limb. A better device should be developed, with an endomedullary fixation and an axial compression effect. Conclusion: We recommend this technique in severe trauma cases of the upper limb as salvage procedure at an early stage when is compatible with the initial general status of the patient

We are presenting the outcome of a young adult with extensive epithelioid hemangioendothelioma of the femur treated with wide excision and vascularised fibular graft. An 18-year-old builder was referred with an aggressive primary bone tumor of the right femur. Initial staging showed no evidence of distant disease but tumor confined to a 26.5cm diaphyseal segment of the femoral shaft. The patient’s pre-operative Oxford knee score was 28 and the AKSS scores were 74 (observational) and 65 (functional). True cut open biopsy confirmed low grade angiosarcoma. The patient underwent a wide excision of the lesion through a lateral approach leaving a generous cuff of bone and muscle tissue around the tumor. Clear resection margins were assessed intraoperatively. Histologically, the tumor was found to be epithelioid hemangioendothelioma. The 29.5cm defect was filled with a vascularised bone graft of the ipsilateral fibula. The graft was secured with a 22-hole DCS bridging plate and screws at both ends. Intraoperative knee range of motion was from 0 to 125 degrees without recurvatum and graft movement. The patient had an unremarkable recovery. At the latest follow-up, one year after his operation, the patient had made an excellent functional recovery with non-symptomatic full weight bearing and had also returned to his work as a builder. He demonstrated a knee range of motion of 0 to 115 with a slight genu varum. The patient’s post-operative Oxford knee score was 40 and the AKSS scores were 70 (observational) and 90 (functional). Radiographs showed excellent union at the distal aspect of the graft and a healing stress fracture of the fibula graft at the proximal aspect. Vascularized fibular graft with plating is a safe reconstruction limb salvage option for defects of long bones after tumor resection

Purpose: We report our experience with vascularised bone grafts harvested from the anterior aspect of the radius for the treatment of Kienböck disease. We reviewed our patients at minimum three years, average 67 months. Material and methods: We treated 22 patients with Kienböck disease, eight women and fourteen men, mean age 31.4 years (18–63). Pain was present in all cases and was disabling in nineteen. After systematic computed tomography and magnetic resonance imagine (MRI), the Büchler classification was stage II=8, stage IIA=10 and stage IIIB=4. The transverse anterior artery of the carpus arises from the radial artery and supplies blood to the medial part of the radial epiphysis. The pediculated bone graft fed by this artery can be harvested via the same anterior approach as used to position it in the semilunate for revascularisation. Radial shortening was performed in all cases. The patients were immobilised until the radius healed. Results: Mean follow-up was 67 months (36–104). Pain resolved completely in all twenty patients. Two patients nevertheless reported moderate pain occasionally. Mean active motion was greater than 71°. Mean time to resumption of former activities was 3.5 months. Postoperative MRI, performed at mean 8 months, demonstrated complete revascularisation of the semilunate in six cases, stable lesions in five, and one failure requiring secondary palliation. There were four cases of late healing of the radial osteotomy and one reflex dystrophy. There was a direct correlation between Kienböck disease stage and final outcome. Conclusion: Use of a vascularised graft harvested from the anterior aspect of the radius for revascularisation of the semilunate associated with radial shortening has provided encouraging results. Long-term follow-up is needed to verify these results

Vascularised bone grafts have been most commonly applied in reconstructions of the lower extremities. However, the indications for vascularised bone grafts in the upper extremities have now been expanded, as this technique is becoming more widely appreciated. Between 1993 and 2000, 12 patients who had segmental bone defects following trauma of the forearm received vascularised fibular grafts, among them six men and six women. The average age was 39 years (range 16–65 years). The reconstructed sites were the radius in eight patients and the ulna in four. The length of the bone defect ranged from 6 to 13 cm. In four cases the fibular graft was raised as a vascular osteoseptocutaneous fibular graft. For fixation of the grafted fibula, plates were used in ten cases, screws and Kirschner wires in two. In these two cases an external skeletal fixator was used for immobilisation of the extremity. The follow-up period ranged from 93 to 10 months. In 11 patients grafting was successful. There were no instances of fractures of the grafted bone; however, non-union occurred at the proximal site in one case and only one patient required an additional bone graft. No patient showed evidence of resorption of the graft or symptoms related to the donor leg. No recurrence of local infection was encountered in the patients with previous osteomyelitis. The mean period to obtain radiographic bone union was 4.8 months (range 2.5–8 months). With the use of fibular grafts a segment of diaphyseal bone can be transferred that is structurally similar to the radius and ulna and that is of sufficient length for the reconstruction of most skeletal defects in the forearm. A vascularised fibular graft is indicated in patients with intractable non-unions, where conventional bone grafting has failed or for large bone defects (in excess of 6 cm) in the radius or ulna

Purpose: Reconstruction of long bones with significant loss of bone stock is a major challenge particularly if the gap is greater than 5 cm. Complementary bone resection is often necessary. A conventional cancellous graft may be used when loss of bone substance is not too extensive, but when the defect extends over several centimeters a vascularised bone graft with a microanastomsed fibular graft may be indicated. This technique is widely used for the lower limb but rarely applied for the forearm. The purpose of this work was to examine the modalities and report our experience. Material and methods: This retrospective study included six microvascularised free fibular grafts performed to reconstruct the forearm bones after massive loss of bone stock. The mean age of the five men and one woman was 34 years. Bone loss (mean 10 cm, range 6 – 18 cm) involved the radius in five cases and the ulna in one. All six patients were victims of crush injuries with open fractures and expulsion of part of the forearm skeleton. Initial treatment included debridement, wound closure, and temporary external fixation. The fibular graft was performed eight weeks (mean) after trauma in five patients and six months after trauma in the sixth patient who also had multiple autologous cancellous grafts which left a nonunion of the ulna and an 18 cm defect. The Meyer method using a saphenous loop was used for vessel anastomosis in five cases. A vascularised fibular bypass was used in one. Osteosynthesis was achieved with screw or plate fixation. Results: Bone healing was achieved in all patients four to six months after grafting. Mean follow-up was three years (range 1–5). There were no secondary fractures. Mean flexion-extension of the elbow was 100° at last follow-up. Mean pronation-supination was 100°. Discussion and conclusion: Free fibular transfer enabled reconstruction of the forearm skeleton after massive bone loss. The vascularised graft shortened time to bone healing for these extensive defects with a mechanical quality superior to that obtained with conventional non-vascularised grafts. These vascularised grafts can be indicated for infected nonunion because the vascularised graft favours antibiotic diffusion

For decades the treatment of chronic post-traumatic osteomyelitis associated with bone exposure has been one of the most serious problems in the field of orthopaedic surgery. “Sterilisation” of the osteomyelitic site, that is radical débridement of all infected tissue, is the basic requirement of the treatment; in the past, the remaining defect of the débrided area was closed with skin grafts, which were removed in a further stage when the infection had cleared; then the defect was filled with muscle flap and bone graft of various types. Both soft tissue and osseous reconstruction took a relatively long period of time, requiring several-stage treatment. Over the years, introduction of microsurgery led to free muscle flaps and skin graft in one reconstruction setting in the 1970s and thin fascio-cutaneous flap reconstruction in the 1980s, allowing a shorter period of hospitalisation and an improvement in patients’ lifestyle. We performed a retrospective study of 22 patients treated for chronic osteomyelitis (middle or distal 1/3 of the leg, n=10; tarsus, n=6; forearm, n=6) by means of free vascularised bone graft or composite grafts between 1992 and 2003. In most of them a two-stage treatment was performed (resection and sterilisation in the first stage and bone transfer in the second one); in others a one-stage treatment was performed. In 78.5% of cases the infection was cured without requiring secondary procedures; revision of the flap was carried out in 12.3% of cases. In only one case leg amputation under the knee was necessary. In spite of advanced treatment protocols, persisting infection and residual functional deficit is not rare. Over the years the approach has changed. The application of microsurgical tissue transfers for reconstruction of the extremities allows repair of significant bone and soft-tissue defects. A wide variety of free flaps offers the potential to reconstruct nearly any defect of the limbs. The total array of flaps and their indications is beyond the scope of a single discussion, but this paper focuses on a few flaps that have found application for coverage and functional restoration of the limbs. Microsurgical transfers allow more radical débridement of the area affected by osteomyelitis with low peri-operative morbidity, reducing the number of procedures required to obtain bony union and subsequently effect a quick “return to work”. In management of chronic, post-traumatic osteomyelitis with soft-tissue loss, we prefer a well-vascularised muscle flap rather than a fascio-cutaneous flap (its important vascular supply helps reduce bacterial contamination)

Various kinds of bone have been used as a donor for vascularised bone grafts (VGF) to the upper extremities; among them the fibula has been widely used because of its structural characteristics and low donor site morbidity. Vascularised fibular graft is indicated in patients with large bone defects, bone tumour resection, established or infected non-union, congenital pseudarthrosis, avascular necrosis or bone defects surrounded by scarred, infected and poorly vascularised soft tissue or failure of conventional techniques. Between 1994 and 2003 nine patients were treated with vascularised fibular graft (VFG) and five for reconstruction of upper extremities defects, following trauma of the forearm with failure of conventional treatments. Four were male and one were female; the mean age was 32 years; the reconstructed sites were four radius and one ulna. The mean lengths of the bone defect was 9 cm. All patients were evaluated pre-operatively with angiography and/or magnetic resonance imaging. Two patients had a concomitant arthrodesis of the wrist. The bone graft was stabilised with plates (AO/LCP), screws, K-wires and the forearm was immobilised in plaster or with external fixation for several months. Cancellous iliac bone graft was packed about the proximal and distal junctions. In two recent cases autologous platelet gel was added at the sites of fixation. Bone healing was assessed clinically by the absence of pain and mobility on stress, and radiologically. Patients’ satisfaction and function results were assessed by the DASH questionnaire. After an average duration of follow-up of 48 months (from December 1996 to December 2003), all but one of the patients had radiographic evidence of osseous union of both bone junctions. All wounds healed primarily and no patient had problems related to the donor leg. Three patients had returned to their pre-injury occupation. Vascularised fibula transfer is a valuable technique for the reconstruction of extensive long-bone defects in the upper extremities. The fibula allows a transfer of a bone that is structurally similar to the radius and is of sufficient length for the reconstruction of most skeletal defects in the forearm. In these serious forearm injuries, rapidity of fracture healing is not the primary issue, but rather control of infection and bone stability. The only disadvantage of VFG is that it is more costly; because more technical expertise is required for the microvascular work and the operating time is extended. The reliability and the value of vascularised fibula transfer will increase, with further experience, careful patient selection and appropriate pre and post-operative technical details

This study reviews the results of the treatment of non-union of fractures of the scaphoid by the use of micro-surgical, vascular pedicle grafts (VPG). The indications for VPG included long-standing non-union of a fracture of the scaphoid, avascular necrosis of the proximal pole and failed conventional grafting. The contraindications were periscaphoid degenerative changes (scaphoid non-union advanced collapse) and vascular damage from previous surgery. The technique in each involved harvesting a vascularised bone graft from the distal radius based on a vascular pedicle with retrograde flow from one of a number of described vessels that constitute the vascular plexus over the carpus. The scaphoid was prepared to receive an inlay graft and then the graft was positioned and its stability was determined. Some were secured with a single 0.7mm diameter Kirschner wire. The wrist was then immobilised in a plaster cast until either the fracture had healed or it was evident that the procedure had failed to result in union. Fourteen patients have undergone VPG over 30 months. Of these eight have healed (four fractures of the waist and four of the proximal poles), four have failed (one waist and three proximal poles) and two are still in plaster casts. The mean time to healing was 20.6 weeks (range: 12.7–28.7 weeks). Of the eight that healed, seven were aged between 21 and 27 years. The four failures were aged between 34 and 44 years. The mean time since the fracture in the healed group was 2.9 years (range: 1.2 years to five years) and in the failed group it was 6.5 years (range: two years to 20 years). The first failure was related to deep infection and a subsequent Matte-Russe procedure has also failed. In the second failure the graft healed to the distal pole but the very small proximal pole collapsed resulting in a wrist arthrodesis. The graft in the third failure healed to the distal pole but failed to unite with the small proximal pole. No further treatment has been planned. The fourth failure was a non-union of the waist of 20 years standing. The graft became dislodged from the scaphoid but no further surgery has been carried out. One of the successful unions had a poor result because of degeneration in the scaphoid-trapezoid-trapezium (STT) joint secondary to damage done at the time of previous surgery (Herbert screw). A successful STT arthrodesis was done subsequently. VPG is technically challenging. Careful patient selection is vital as is preoperative planning and vessel selection. VPG can be used successfully to salvage obstinate non-unions of fractures of the scaphoid

Introduction: Scaphoid non union probably occurs more frequently than we realise. That means that a significant ‘unknown’ population with this condition exists – people who carry on with life with some restrictions, but not enough to seek help. This wide variety of ‘expression’ of the symptoms needs to be borne in mind when considering how best to manage each patient. Diagnosis: Diagnosis is often obvious. In most cases, plain radiographs are all that are necessary to make the diagnosis confidently. However, whilst radiographs will usually tell you if the scaphoid is healed or not, they will not give you any reliable information on vascularity of the fragments. MRI with contrast is needed to confidently describe the vascularity status, and so give the patient an accurate prognosis for surgery. In cases where union/non union is uncertain, CT will provide unequivocal information if the scan slices are orientated correctly. I routinely request MRI with contrast before bone graft surgery so that I can give the patient an idea of the likely success of that surgery beforehand. Decision making: Surgery is not always the best option for patients. Some patients have functioned perfectly well for many years with an un-united scaphoid, and the condition may only have come to light after a moderate re-injury. It is reasonable, in these cases, to treat with an expectant period of splintage. A number of these patients will become comfortable again – although still have an un-united scaphoid. You then have an opportunity to discuss the risks/benefits in a calmer atmosphere. When a recent scaphoid fracture (proven) has progressed to non union, I will always discuss grafting in some detail with each patient. This option is best employed when no degenerative changes have appeared, and therefore recent fractures (younger than 3–5 years) would be considered for grafting. If the non-union is older or of indeterminate age, care should be taken before recommending grafting. Indeed, a ‘successful’ bone grafting of an established and mature non-union with associated degenerative changes is likely to make the patient’s symptoms worse. Remember, one of the main reasons for recommending bone grafting is to reduce the risk of early degenerative disease (SNAC). If degenerative disease is already present, the main indication for grafting is no longer present. There are other surgical alternatives to bone grafting. These will be discussed under their broad categories of ‘motion preserving’ and ‘motion eliminating’ procedures. Bone grafting: A choice exists between non-vascular-ised and vascularised bone grafting. Traditionally, graft has been harvested from the iliac crest, although, in my own Day Surgery practice, this is no longer possible for operational reasons. This enforced restriction means that all my bone grafts now come from the distal radius. There is good evidence to support the use of graft from this site – especially in the younger male. As a result, I developed the technique of employing vascularised grafts for all my scaphoid non-unions. Not necessarily because I thought they were any better, but because they were straightforward to perform, offered no disadvantages, and may actually offer an advantage. I favour the palmar grafts described by Mathoulin because of the biomechanics of the humpback deformity. Scaphoid waist non unions need a palmar wedge to restore their length and shape. Using a corticocancellous palmar wedge graft from the distal radius provides this. Proximal pole non unions do demand a different approach (both surgically and in decision making). The Zaidemberg dorsal graft is usually more appropriate for these cases, but I recommend developing skills in both techniques to use the right graft for the right indication. I will illustrate the surgical and rehabilitation techniques I employ in some detail, and discuss the results of these treatments in my personal series. Salvage: No discussion about ‘management’ of scaphoid non union would be complete without some mention of salvage. However, salvage (in my opinion) is more than just dealing with a failed bone graft. ‘Salvage’ refers to the rescue of whatever function is available and appropriate for each patient. In some cases, I would recommend a plan that some people may regard as ‘salvage’ if it best suited an individual patient. I will illustrate and justify the salvage techniques I consider in scaphoid non union