11/13/2017 Non Vascular Bone grafting for Proximal Pole ... · •50 scaphoid non union •Treated...
26
11/13/2017 1 Non Vascular Bone grafting for Proximal Pole Non Unions Nader Paksima, DO, MPH Clinical Professor of Orthopedic Surgery NYU/Hospital for Joint Diseases Good Carpentry Is Better than Good Biology ! Risk of osteonecrosis goes up with proximal fractures
Transcript of 11/13/2017 Non Vascular Bone grafting for Proximal Pole ... · •50 scaphoid non union •Treated...
11/13/2017
1
Non Vascular Bone grafting for Proximal Pole Non Unions
Nader Paksima, DO, MPH
Clinical Professor of Orthopedic Surgery
NYU/Hospital for Joint Diseases
Good Carpentry Is Better than Good Biology !
Risk of osteonecrosis goes up with proximal fractures
11/13/2017
2
How proximal ?
Blood Supply
• Main blood supply: dorsal branch of the radial artery– Enters through dorsal ridge – ~80% of blood supply– Supplies proximal portion by retrograde blood flow
• Secondary blood supply: Superficial palmar branch of radial artery – 20‐30% of the scaphoids blood supply– Supplies distal portion
• Proximal pole of the scaphoid relies entirely on the intramedullary blood flow
•
Does Osteonecrosis mean it cannot heal?
Does osteonecrosis mean you MUST do a vascularized bone Flap?
11/13/2017
3
ASSH 2017
Scott Wolfe et al, paper 59 36 scaphoid non‐unions23 evaluated for osteonecrosis ( proximal pole)50% histologic evidence of avascularity91% of these and 94% over all healed. Non vascular bone graft and screw fixation
Is time a factor?
• Chronic Scaphoid Nonunion of 28‐Year Duration Treated with Nonvascularized Iliac Crest Bone Graft
• John T. Capo, MD,1 Ben Shamian, MD,1 and Steve Rivero, BS1
Merrell et al JHS 2002
• Meta‐analysis 2002
• > 1100 articles
• 88% union with vascular grafts
• Better than non vascular
11/13/2017
4
Chang et al 2006 JHS
• 50 scaphoid non union • Treated with 1,2 ICSRA flap• 34 healed ( 68%)• Difficult fixation, graft extrusion and loss
Proximal pole non‐union Why go non‐vascular?
• Vascular rates of healing not as good as initially reported
• Difficult to do good carpentry
• Can excise small fragments, if its big enough to bone graft , bone graft. If not excise!
• Good carpentry is better than good biology !
Options
• Fixation without bone graft
• Fixation with non‐vascular bone graft
• Bone graft without hardware
• Osteochondral graft
• BMP
• Excision of the Proximal fragment
11/13/2017
5
Options
• Fixation without bone graft
• Fixation with non‐vascular bone graft
• Bone graft without hardware
• Osteochondral graft
• BMP
• Excision of the Proximal fragment
From John Capo, MD
21 y.o. male, fell 6 weeks ago
Very small proximal fragment
11/13/2017
6
Options
• Fixation without bone graft
• Fixation with non‐vascular bone graft
• Bone graft without hardware
• Osteochondral graft
• BMP
• Excision of the Proximal fragment
95% of cancellous grafts and 92% of cortico‐cancellous grafts heal.
11/13/2017
7
11/13/2017
8
11/13/2017
9
Dorsal Approach and Bone grafting for Scaphoid Nonunion
Case from Joseph Gower MD
11/13/2017
10
11/13/2017
11
In Situ HCS with bone graft for scaphoid nonunion
11/13/2017
12
Case from Joseph Gower MD
11/13/2017
13
11/13/2017
14
11/13/2017
15
Options
• Fixation without bone graft
• Fixation with non‐vascular bone graft
• Bone graft without hardware
• Osteochondral graft
• BMP
• Excision of the Proximal fragment
Proximal pole non union 25 Year old
11/13/2017
16
Proximal pole non union 25 Year old
Inlay graft, Radial Styloidectomy
Inlay bone graft, must Burr out all the dead bone
11/13/2017
17
Healed
Healed
11/13/2017
18
Case from Martin Posner MD
Case from Martin Posner MD
Options
• Fixation without bone graft
• Fixation with non‐vascular bone graft
• Bone graft without hardware
• Osteochondral graft
• BMP
• Excision of the Proximal fragment
11/13/2017
19
Sandow et al 47 patients 2001 Tech Hand Upp Ext SurgVeitch et al 14 patients 2007 JBJS Br
Options
• Fixation without bone graft
• Fixation with non‐vascular bone graft
• Bone graft without hardware
• Osteochondral graft
• BMP
• Excision of the Proximal fragment
11/13/2017
20
Options
• Fixation without bone graft
• Fixation with non‐vascular bone graft
• Bone graft without hardware
• Osteochondral graft
• BMP
• Excision of the Proximal fragment
11/13/2017
21
11/13/2017
22
Options:Redo , with vascular graft
Excise the fragment and take out the screw!
5 year follow up
11/13/2017
23
Case from Steve Heithoff, DO
11/13/2017
24
Case from Martin Posner MD
11/13/2017
25
Maybe we should just….
11/13/2017
26
Thank You
