游离带血管蒂的股骨内侧髁骨瓣治疗手舟骨骨不连的疗效分析

目的:探讨游离带血管蒂的股骨内侧髁骨瓣治疗手舟骨骨不连的临床疗效。方法:自2012年5月至2016年5月,采用游离股骨内侧髁骨瓣移植治疗手舟骨骨不连15例,其中男10例、女5例,年龄18~63岁,平均（43.5±15.5）岁。术中清创骨折段后,将骨瓣移至手舟骨处充填骨缺损,将骨瓣动脉与桡动脉端侧或端端吻合,伴行静脉与桡...     

桡动脉旋前方肌支血管蒂桡骨瓣治疗舟骨骨不连

目的探讨应用桡动脉单一旋前方肌支血管蒂桡骨瓣治疗舟骨骨不连的效果。方法自2017年2月至2021年5月, 我科应用桡动脉单一旋前方肌支血管蒂桡骨瓣转移治疗8例舟骨骨不连患者。术前X线片显示手舟骨骨折处均有超过2 mm的间隙, 骨折端周围骨质硬化或吸收, 其中1例骨折远、近端均广泛囊性变。手术于腕掌侧作两个不连续切口, 游离桡动脉血管束, 使骨瓣血管蒂远移, 完成骨折内固定和骨瓣转移。术后随访骨折愈合时间、腕痛、腕关节活动度及握力等情况。结果术后随访9～22个月, 平均15个月。所有病例X线片显示舟骨均获得骨性愈合, 平均13.6周。7例术后疼痛均消失, 腕关节活动好, 局部无压痛。1例腕部重体力活动后出现中度疼痛。腕关节屈曲(50.5±3.7)°, 背伸(47.1±5.7)°, 握力(26.2±3.7)kg。根据改良的Mayo腕关节功能评分标准评定:优6例, 良1例, 可1例。结论桡动脉单一旋前方肌支血管蒂桡骨骨瓣, 具有血管解剖恒定、血运丰富等优点, 是治疗舟骨骨不连的理想方法。     

应用桡动脉茎突返支为蒂的桡骨骨瓣或骨膜瓣移植治疗腕舟骨骨折不连接

目的观察以桡动脉返支为蒂的桡骨骨瓣或骨膜瓣移植对腕舟骨骨折不连接的治疗作用.方法20例腕舟骨骨折骨不连,应用桡动脉返支为蒂的桡骨骨瓣移植加桡骨茎突切除治疗12例,应用桡动脉返支为蒂的桡骨骨膜瓣移植加桡骨茎突切除治疗8例.测量手术前后腕关节屈伸和尺桡偏活动度、握力,应用腕舟评分对患者的自觉功能恢复情况进行评定.结果20例腕舟骨骨折骨不连均愈合,愈合时间平均为7±0.2周(6～12周).腕舟骨评分结果为:优16例,良3例,可1例.结论以桡动脉返支为蒂的桡骨骨瓣或骨膜瓣移植加桡骨茎突切除是治疗腕舟骨骨折骨不连的有效方法.     

游离膝降血管蒂骨瓣移植治疗舟骨骨不连

目的 观察游离膝降血管蒂骨瓣移植对舟骨骨折不连接的治疗作用.方法 2007年1月至2009年8月,对6例舟骨骨不连,应用游离膝降血管蒂骨瓣移植治疗.疗效的评定包括骨折愈合、疼痛、握力和腕关节活动度,运用改良Mayo腕关节评分对患者的自觉功能恢复情况进行评定,术后舟骨的血供采用彩色多普勒超声检查.结果 术后随访时间平均为18个月,6例舟骨骨不连均愈合,平均时间为12周(11 ～ 16周);采用视觉模拟评分法,平均评分为1.0(0～2.2);术后握力平均恢复至健侧的85％;腕关节活动度:屈伸(115±10)°,尺桡偏(54±14)°;腕关节评分:优4例,良1例,可1例.彩色多普勒超声证实舟骨血供良好.结论 游离膝降血管蒂骨瓣移植是治疗植骨失败或伴近极缺血坏死的舟骨骨不连的有效方法.     

CT血管成像联合彩色多普勒超声设计游离股骨内侧髁骨瓣治疗难治性手舟骨骨折不愈合

目的探讨术前CT血管成像(CTA)联合彩色多普勒超声(CDU)血管定位技术辅助下游离带血管蒂的股骨内侧髁骨瓣的手术方法治疗难治性手舟骨骨折不愈合的临床效果。方法回顾性分析2018年1月至2022年6月华北医疗健康集团邢台总医院骨三科应用以膝降动脉为血供的游离股骨内侧髁骨瓣转移修复手舟骨陈旧性骨折合并骨坏死患者病例资料。术前采用CTA联合CDU技术定位膝降动脉, 依照定位结果及骨质缺损情况设计股骨内侧髁骨瓣并修复手舟骨陈旧性骨折。采用门诊和电话方式进行随访, 依照视觉模拟评分(VAS)评价腕关节疼痛程度, 依照改良Mayo评分法评价腕关节功能, 手舟骨弓背畸形程度根据舟骨角评价, 腕骨间稳定程度根据舟月角评价。正态分布计量资料以±s表示, 采用配对样本t检验比较术前CDU测定及术中实际测定的膝降动脉起始处血管管径、起始处至股骨内侧髁下缘距离, 并比较手术前后疼痛VAS评分、腕功能Mayo评分、握力、腕关节活动度、舟月角、舟骨角。结果共纳入12例患者, 其中男9例, 女3例;年龄23～56岁, 平均36岁;右侧骨折7例, 左侧5例;手舟骨腰部骨折8例, 近极骨折4例。比较术前CDU测定和术...     

桡动脉返支为蒂桡骨茎突骨瓣植入治疗舟骨骨折不愈合

目的分析以桡动脉返支为蒂的桡骨茎突骨瓣移位治疗舟骨骨折不愈合的临床效果。方法对18例舟骨骨折不愈合的患者,我们以桡动脉返支为蒂在桡骨茎突掀起1.5 cm×3.5 cm×0.5 cm的骨瓣,植入沿舟骨纵轴跨越骨折线所凿同等大小的骨槽内进行治疗。舟骨腰部骨折11例,近侧骨折7例,其中5例舟骨近端骨折块伴缺血坏死。腕关节活动疼痛,尤以背伸及桡偏时明显,鼻烟窝处有压痛,腕关节活动受限,X线片示10例患者有骨折端硬化及囊性变,骨折线明显加宽。结果术后18例舟骨骨折均愈合,其中5例合并缺血坏死的舟骨骨折块重新成活,骨折平均愈合时间为4个月。术后获随访12年,患者腕关节活动良好,腕背伸时无疼痛,日常生活和工作无影响。结论采用桡动脉返支为蒂的桡骨茎突骨瓣移位治疗舟骨骨折不愈合及近端骨折块缺血坏死,操作简便,治疗有效,具有一定临床应用价值。     

掌侧入路带桡动脉茎突返支骨瓣移植治疗腕舟骨骨不连

目的探讨掌侧入路带桡动脉茎突返支骨瓣移植治疗腕舟骨骨不连的方法及临床疗效。方法自2004年1月～2011年2月期间,采用掌侧入路带桡动脉茎突返支骨瓣移植联合克氏针内固定术治疗腕舟骨骨不连患者27例,回顾性分析其临床效果。结果本组26例术后获随访,平均随访时间18(6～25)个月。伤口均Ⅰ期愈合,X线检查提示26例腕舟骨术后平均3.2(3～4)个月获骨性愈合。术后腕关节功能按Krimmer评分:优20例,良4例,满意2例,优良率92.3%。结论掌侧入路带桡动脉茎突返支骨瓣移植克氏针内固定术治疗腕舟骨骨不连,可重建腕舟骨骨折端血运,促进骨折愈合,疗效肯定,该手术入路显露术野充分,便于手术操作,微创美观,值得临床推广。     

带血管蒂骨瓣移植治疗腕舟骨骨不连

目的：总结带血管蒂骨瓣移植治疗腕舟骨骨不连的疗效。方法：以带桡动脉茎突返支桡骨瓣移植治疗3例,桡骨远端背外侧带血管蒂的骨瓣移植4例,带第2掌背动脉掌骨基底骨瓣移植1例。通过平均10个月的随访,观察骨折愈合和腕关节功能改善情况。结果：骨折全部愈合。腕关节功能评价：优6例,良1例,可1例。结论：该手术疗效较好,操作简单,副损伤小,是治疗腕舟骨骨不连的有效方法之一。     

桡动脉茎突返支为蒂桡骨茎突骨瓣植入术治疗舟骨骨折不愈合

目的总结以桡动脉茎突返支为蒂的桡骨茎突骨瓣移位治疗舟骨骨折不愈合的临床效果。方法2000年3月~2005年6月,对18例舟骨骨折不愈合的患者,以桡动脉茎突返支为蒂在桡骨茎突掀起1.5cm×3.5cm×0.5cm的骨瓣,植入沿舟骨纵轴跨越骨折线所凿同等大小的骨槽内进行治疗。其中男15例,女3例。年龄18~39岁。舟骨腰部骨折11例,近侧1/3骨折7例,其中5例舟骨近端骨折块伴缺血坏死。腕关节活动疼痛,尤以背伸及桡偏时明显,鼻烟窝处有压痛,腕关节活动受限,X线片示10例患者有骨折端硬化及囊性变,骨折线明显加宽。结果术后18例舟骨骨折均愈合,其中5例合并缺血坏死的舟骨骨折块重新成活,骨折平均愈合时间为4个月。术后获随访1~5年,患者腕关节活动良好,腕背伸时无疼痛,日常生活和工作无影响。结论采用桡动脉茎突返支为蒂的桡骨茎突骨瓣移位治疗舟骨骨折不愈合及近端骨折块缺血坏死,操作简便,治疗有效,具有一定临床应用价值。     

桡动脉茎突返支蒂桡骨瓣移植治疗舟骨骨折不愈合

目的观察桡动脉茎突返支为血管蒂的桡骨茎突骨瓣移植术治疗舟骨骨折不愈合的临床效果。方法 2005年7月至2011年3月,采用桡动脉茎突返支蒂桡骨瓣植入垂直于舟骨骨折线的相等大小骨槽的方法治疗18例舟骨骨折不愈合患者。结果所有18例舟骨骨折不愈合患者均获10～48个月,平均17个月随访。骨折愈合时间2～6个月,平均4个月。根据Herbert-Fisher舟骨骨折分级评价,患者满意度0级16例,1级2例;临床腕关节功能评分0级17例,1级1例;影像学检查结果0级18例。结论桡动脉茎突返支蒂桡骨瓣移植术治疗舟骨骨折不愈合,具有解剖学可靠、易于操作、预后良好的临床应用价值。     

Free medial femoral condyle bone grafting for scaphoid nonunions with humpback deformity and proximal pole avascular necrosis

Treatment of scaphoid nonunions remains a challenging problem, especially in the setting of proximal pole avascular necrosis or humpback deformity. Conventional bone grafting techniques have demonstrated unpredictable results in the setting of collapse deformities, whereas pedicled dorsal distal radius vascularized bone grafts have recently been reported to have nearly a 50% failure rate when used in scaphoid nonunions with proximal pole nonunion. Free vascularized medial femoral condyle bone grafting is one option for the treatment of scaphoid nonunions with proximal pole avascular necrosis associated with a humpback deformity. The indications, contraindications, and technique of free vascularized medial femoral condyle bone grafting are presented for the treatment of scaphoid nonunions associated with proximal pole avascular necrosis and humpback deformities.     

Medial femoral condyle vascularized bone grafts for scaphoid nonunions

Free vascularized bone grafts from the medial femoral condyle provide both structural support and blood supply to promote union in the difficult subset of scaphoid nonunions complicated by humpback deformity and proximal pole avascular necrosis. These nonunions have not consistently achieved union when treated with grafts which fail to restore scaphoid geometry or vascularity. The rationale, indications, contraindications, technique and results of bone grafting scaphoid nonunions with grafts harvested from the medial femoral condyle are presented.     

Scaphoid nonunions. Pitfalls and pearls.

Our ability to treat scaphoid nonunions has improved dramatically. The degree of collapse and bone loss can be accurately assessed in waist fractures using sagittal images on CT scans. These nonunions require reduction and bone grafting to re-establish the normal geometry of the scaphoid. Magnetic resonance imaging helps evaluate whether or not avascular necrosis is present in the proximal pole. Because of the poor prognosis of conventional bone grafts, a vascularized bone graft is recommended as the primary treatment when AVN is present. The volar collapse of the humpback deformity is best corrected with a volar approach and the proximal pole nonunion is best approached using a dorsal approach. Nearly all proximal pole nonunions require a vascularized bone graft and all acute proximal pole fractures require open reduction and internal fixation. Using specially designed cannulated screws, the nonunions can be stabilized accurately to decrease the time to resolution of the nonunion and minimize the amount of time in a cast. Stable fixation requires that the screw fixation target the central portion of the scaphoid regardless of the type of screw design used. Using these techniques, the hand surgeon should be able to provide a reasonable prognosis for patients presenting with a scaphoid nonunion, and the treatment should result in functional range of motion, grip strength, and relief of pain.     

Scaphoid reconstruction with vascularized bone grafts from the distal radius

The aim of the present technical report is to describe the alternative solutions for the reconstruction of scaphoid nonunions with pedicled vascularized bone grafts from the distal radius. The surgical technique for the reconstruction A. of proximal scaphoid nonunions with pedicled bone grafts (based on the 1,2 or on the 2,3 intercomparmtental arteries) or with capsular bone grafts from the dorsal distal radius and B. of waist nonunions of the scaphoid with grafts from the palmar distal radius, pedicled on the palmar carpal arch, is presented. Vascularized bone grafts from the adjacent radius are used for the treatment of scaphoid nonunions to enhance union and to revascularize a nonviable proximal pole. The most suitable graft is selected according to the location of the nonunion (at the waist or the proximal pole of the scaphoid) and to the previous procedures/scars at the wrist level.     

A capsular-based vascularized distal radius graft for proximal pole scaphoid pseudarthrosis

PURPOSE: To evaluate the clinical results of the application of a capsular-based dorsal distal radius vascularized bone graft in scaphoid proximal pole nonunions. METHODS: Thirteen patients with symptomatic nonunion at the proximal pole of the scaphoid (10 with avascular necrosis) were treated and reviewed retrospectively. The vascularized bone graft was harvested from the distal aspect of the dorsal radius and was attached to a wide distally based strip of the dorsal wrist capsule. It was inserted press-fit into a dorsal trough across the nonunion site after scaphoid fixation with a Herbert screw. RESULTS: After a mean follow-up period of 19 months 10 of the 13 nonunions (8 of the 10 with avascular necrosis) achieved solid bone union. No complications other than the 3 persistent nonunions occurred. CONCLUSIONS: Results of the use of a capsular-based vascularized bone graft from the distal radius for proximal pole scaphoid nonunions compare favorably with the results of pedicled or free vascularized grafts. It is a simple technique that eliminates the need for dissection of small-caliber pedicle or microsurgical anastomoses. No donor site morbidity was observed. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.     

Role of conventional and vascularized bone grafts in scaphoid nonunion with avascular necrosis: A canine experimental study

The effectiveness of vascularized and conventional bone grafts in the treatment of carpal fracture nonunion with avascular necrosis was evaluated in 12 adult dogs. The proximal third of the radiocarpal bone was removed bilaterally and frozen in liquid nitrogen. Its replacement, leaving a 4-mm gap, simulated a scaphoid fracture nonunion with avascular necrosis. A dorsal radius inlay graft was placed across the gap. The graft was nonvascularized, or conventional on one side, and vascularized with a reverse-flow arteriovenous pedicle on the other. Following a healing period, quantitative assessment of bone blood flow, fracture healing, and bone remodeling was conducted. Seventy-three percent of the vascularized grafts and none of the conventional grafts healed. At 6 weeks, bone blood flow in the proximal pole was significantly higher on the side of the vascularized graft. Quantitative histomorphometry of the avascular proximal segment demonstrated significantly higher levels of fluorochrome-labeled osteoid- and osteoblast-covered trabecular surfaces on the vascularized graft side. These experimental data support the potential clinical application of pedicled reverse-flow vascularized grafts in the treatment of carpal fracture nonunions with avascular necrosis, including proximal pole scaphoid nonunions.     

Dorsal capsular-based vascularized distal radius graft for proximal pole scaphoid nonunion with avascular necrosis

BackgroundScaphoid nonunion involving the proximal pole with the presence of avascular necrosis is difficult to reconstruct. We aimed to determine the efficacy of surgical treatment of proximal pole scaphoid nonunion with avascular necrosis using a dorsal capsular-based vascularized distal radius graft.MethodsBetween 2000 and 2018, 64 patients with established proximal pole scaphoid nonunion with avascular necrosis were treated using a dorsal capsular-based vascularized distal radius graft. This graft was harvested from the dorsal aspect of the distal radius with its dorsal wrist capsule attachment. Fixation of the scaphoid nonunion was performed with a small cannulated screw, followed by insertion of the vascularized graft into the dorsal trough at the scaphoid nonunion site. In the last 47 patients of this series, a micro suture anchor was placed into the scaphoid to augment graft fixation.ResultsUnion rate was 86% (55 of 64 scaphoid nonunions with avascular necrosis) at a mean time of 12 weeks. Persistent non-union was noted in eight patients and fibrous union in one patient. No patients developed donor site morbidity. No graft dislodgment was noted. There was significant improvement of the wrist functional outcomes at the final follow up.ConclusionsThe dorsal capsular-based vascularized distal radius graft is a safe and effective treatment in patients with scaphoid nonunion with avascular necrosis of the proximal pole. This pedicle vascularized bone graft is derived from a location that can easily reach the proximal third of the scaphoid avoiding microsurgical dissection or anastomosis.     

Reconstruction of scaphoid non-union and total scaphoid avascular necrosis in a pediatric patient: a case report

Background

The medial femoral condyle vascularized bone graft has grown in popularity for treating recalcitrant fracture non-unions and has become particularly useful in treating scaphoid non-union with avascular necrosis of the proximal pole. The medial femoral condyle is an excellent source of dense, well-vascularized bone and results in minimal donor site morbidity.

Methods

We describe an unusual case of chronic scaphoid non-union and total scaphoid avascular necrosis in a skeletally immature patient. Scaphoid reconstruction was performed with a vascularized medial femoral condyle graft, with successful graft incorporation, and restoration of pain-free wrist motion.

Conclusions

Technical considerations for harvest of the medial femoral condyle bone graft in the skeletally immature patient are discussed.     

Management of scaphoid nonunions

Scaphoid nonunions result in a predictable pattern of wrist arthrosis. To minimize the incidence of arthrosis, the goal of treatment should be consolidation of the fracture with the scaphoid in anatomic alignment. Computed tomography and magnetic resonance imaging scans can aid evaluation of carpal collapse, scaphoid collapse, scaphoid nonunion, bone loss, and detection of osteonecrosis. Nonunion of the scaphoid waist may result in a humpback deformity, increasing the chances of further collapse and arthrosis. This collapse deformity must be approached volarly with an intercalary bone graft and internal fixation. A dorsal approach to proximal scaphoid nonunions allows easier access for removing the necrotic bone from the proximal pole and applying accurate screw or pin fixation. Vascularized bone graft is recommended to manage scaphoid nonunions with osteonecrosis.