Our Summary

This research paper is about how to decide between two methods of treating a particular type of wrist fracture that hasn’t healed properly, known as scaphoid nonunion. The two methods are vascularized bone grafting (VBG), which is when a piece of bone with its blood supply is transferred from one part of the body to another, and nonvascularized bone grafting, which is when a piece of bone without its blood supply is transferred.

In the past, the main reason to choose VBG was if the bone was dead due to lack of blood supply (avascular necrosis). However, this is not the only factor to consider, and identifying avascular necrosis can be tricky and imprecise, making it a less reliable way to make the decision.

There are many other things to think about before surgery that could affect whether it is successful, such as where exactly in the wrist the fracture is, how long it has been since the fracture happened, whether other treatments have been tried and failed, whether the patient smokes, and whether the bone has moved or collapsed. These factors all need to be studied carefully and systematically.

The authors argue that more research is needed, with a large number of patients and a well-designed study, to figure out what should guide the decision between using VBG or nonvascularized bone grafting for the best outcome after this kind of wrist surgery.

FAQs

  1. What is the primary indication for using vascularized bone grafting in the treatment of scaphoid nonunion?
  2. What are some of the preoperative risk factors for scaphoid nonunion surgery failure?
  3. How can the detection of scaphoid avascular necrosis be improved for more accurate decision-making in treatment?

Doctor’s Tip

A helpful tip a doctor might tell a patient about scaphoid fracture surgery is to follow post-operative instructions carefully to ensure proper healing and recovery. This may include keeping the affected wrist immobilized, attending physical therapy sessions, and avoiding activities that could put strain on the healing bone. It is important to communicate any concerns or changes in symptoms to your healthcare provider to ensure the best possible outcome.

Suitable For

Patients who are typically recommended scaphoid fracture surgery are those with scaphoid nonunion, particularly those with risk factors such as avascular necrosis, nonunion in the proximal pole of the scaphoid, previous failed nonunion surgery, smoking, and fracture nonunion displacement or collapse. These patients may benefit from vascularized bone grafting to improve outcomes of surgery. However, further research is needed to determine the best approach for each individual case.

Timeline

Before scaphoid fracture surgery:

  • Patient sustains a scaphoid fracture, which may or may not be diagnosed immediately
  • Patient experiences pain, swelling, and limited range of motion in the wrist
  • Patient undergoes imaging tests such as X-rays or MRI to confirm the fracture and assess the extent of the injury
  • Treatment options such as casting, bracing, or surgery are discussed with the patient
  • If surgery is recommended, preoperative tests and evaluations are performed to ensure the patient is a suitable candidate for surgery

After scaphoid fracture surgery:

  • Patient undergoes surgery to repair the scaphoid fracture, which may involve nonvascularized or vascularized bone grafting
  • Patient is monitored in the hospital for a period of time post-surgery
  • Patient undergoes physical therapy and rehabilitation to regain strength and range of motion in the wrist
  • Follow-up appointments are scheduled to monitor the healing process and assess the effectiveness of the surgery
  • Patient may require additional surgeries or treatments depending on the success of the initial surgery and the presence of any complications

What to Ask Your Doctor

  1. What are the potential risks and benefits of scaphoid fracture surgery?
  2. How long will the recovery process take and what can I expect during this time?
  3. Will I require physical therapy after the surgery and for how long?
  4. What are the success rates for vascularized bone grafting versus nonvascularized bone grafting in treating scaphoid nonunion?
  5. Are there any specific factors in my case that make me a better candidate for one type of grafting over the other?
  6. What is the likelihood of complications such as infection or avascular necrosis following surgery?
  7. How many scaphoid fracture surgeries have you performed and what is your success rate?
  8. Will I need to modify my activities or lifestyle after the surgery?
  9. What is the long-term outlook for my wrist function after scaphoid fracture surgery?
  10. Are there any alternative treatments or procedures that I should consider before making a decision about surgery?

Reference

Authors: Higgins JP, Giladi AM. Journal: J Hand Surg Am. 2021 Sep;46(9):801-806.e2. doi: 10.1016/j.jhsa.2021.05.014. Epub 2021 Jun 26. PMID: 34183203