Orthopaedics & Traumatology: Surgery & Research (2011) 97, 800—806

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ORIGINAL ARTICLE

Vascularized bone graft pedicled on the volar carpal

artery from the volar distal radius as primary
procedure for scaphoid non-union
M. Gras a,∗, C. Mathoulin b

a
Nollet Locomotor System Institut, 23, rue Brochant, 75017 Paris, France
b
Hand Institute, Jouvenet Clinic, 75016 Paris, France

Accepted: 23 August 2011

KEYWORDS Summary
Scaphoid non-union; Introduction: The treatment of scaphoid non-union with non-vascularized bone graft leads to
Vascularized bone non-union in 10 to 20% of cases and up to 50% in case of proximal pole necrosis. Vascularized bone
graft graft improves consolidation rates, but is generally restricted to secondary scaphoid non-union.
Hypothesis: This study assessed the value of a primary vascularized bone graft pedicled on the
transverse volar carpal artery from the volar aspect of the distal radius as donor site.
Patients and methods: This retrospective study included 111 cases of vascularized bone graft
for scaphoid non-union as primary procedure in 73 cases and secondarily in 38. The procedures
were performed through a single incision.
Results: Mean delay before surgery was 25.5 and 33 months respectively, with union rates of
96% and 89.5%. Results showed improvement in both groups, but were better in primary surgery
in terms of range of motion, strength, pain, function, satisfaction and return to work. There
were more complications with secondary surgery.
Discussion: All reports agree that union is better with vascularized bone graft. This technique
performed as a day of admission surgery through a single incision under locoregional anesthesia
seems feasible as a primary intervention.
Level of evidence: IV — retrospective study.
© 2011 Elsevier Masson SAS. All rights reserved.

Introduction and carpal collapse with dorsal intercalated segment insta-

Five to 30% of scaphoid fractures evolve towards non-union
[1,2]. Without treatment, this leads to periscaphoid arthritis
∗ Corresponding author.
E-mail address: drmathildegras@gmail.com (M. Gras).
bility (DISI) deformity of the lunatum [3]. Non-vascularized
bone graft gives non-union in up to 20% of cases [4—6],
and in more than 50% in case of proximal pole necro-
sis [7]. Vascularized bone graft seems to be associated
with a better rate of consolidation, but is generally
restricted to secondary intervention or proximal pole necro-
sis [5,8].

1877-0568/$ – see front matter © 2011 Elsevier Masson SAS. All rights reserved.
doi:10.1016/j.otsr.2011.08.008
Vascularized bone graft for scaphoid non-union 801

Table 1 Alnot classification of scaphoid non-union.

Grade Description

I Linear non-union without altered scaphoid

Figure 1 Cadaver dissection showing the volar carpal artery
following the distal edge of the pronator quadratus before anas-
tomosing with the anterior interosseous artery and a branch of
the ulnar artery (R: radial artery; U: ulnar artery).
Several vascularized grafts have been described [9—18],
including graft pedicled on the palmar carpal artery [19].
Mathoulin [14,19] adopted Kuhlmann’s graft harvested from
the volar radius [16], vascularized by the volar carpal artery
with anastomosis between the radial and ulnar arteries [20],
following a cadaver study [19] (Fig. 1).
This retrospective study compared results of vascular-
ized bone graft from the volar radius for scaphoid non-union
as a primary intervention in 73 cases and secondarily in
38 cases.
form, instability or intracarpal
malalignment
IIA Stable non-union with incipient bone
resorption at fracture line, without
instability or malalignment
IIB More or less mobile non-union with anterior
defect and proximal pole flexion on distal
tubercle inducing DISI
III More or less mobile displacement non-union
with instability or reducible malalignment
with
IIIA: isolated styloscaphoid arthritis
IIIB: radial and/or intracarpal arthritis
IV Proximal fragment necrosis with
IVA: malalignment
IVB: radioscaphoid and/or intracarpal
arthritis
screw in 21 cases (55%); and staples in three cases (8%).
Non-union was grade 2A, 2B, or 3A, with associated sty-
loidectomy.
Table 2 shows data for the two groups.
Surgical technique [14,21]
Surgery was performed as a day case procedure under
locoregional anesthesia, through a single incision: the Henry
approach was extended by a distal lateral limb towards the
scaphoid tubercle (Fig. 2).

Patients and method

Inclusion and exclusion criteria

This retrospective single-surgeon series included patients

operated on for scaphoid non-union between January 1994
and September 2008. Non-unions of grade 1 or 3B or grade
4 with necrosis were excluded.

Homogeneous patient groups

Two homogeneous groups of vascularized bone graft from

the volar radius were identified.
Group 1 comprised 73 patients with primary vascu-
larized graft for non-union. Thirty-three were initially
managed conservatively by 1—24 weeks’ immobilization
(mean 10.3 weeks). Non-union was classified using the Alnot
classification (Table 1), as grade 2A, 2B, or 3A. Associated
radial styloidectomy was performed in the same sitting.
Group 2 comprised 38 patients with secondary vascular- Figure 2 Surgical approach for treatment of scaphoid non-
ized graft. The primary treatment was non-vascularized iliac union: Henry approach extended by a lateral limb toward the
crest bone graft in 14 cases (37%), revised in two cases; a scaphoid tubercle.
802 M. Gras, C. Mathoulin

Table 2 Patient characteristics.

Primary treatment patients (n = 73) Secondary treatment patients (n = 38)

Sex 89% ♂ (65), 11% ♀ (8) 87% ♂ (33), 13% ♀ (5)

Mean age (years) 30.41 ± 11.2 (15 to 61 yrs) 31.16 ± 8.6 (19 to 47 yrs)
Dominant involvement 64% (47) 66% (25)
Occupation 26% manual workers (19) 71% manual workers (27)
74% sedentary (54) 29% sedentary (11)
Fracture-surgery interval (months) 20.51 (4 to 120) 23.38 (10 to 72)
Initial treatment 55% non-diagnosed
45% (33) conservative treatment 92% (35) immobilization (15.4 weeks)
(10.3 weeks immobilization)
Type of fracture 26% proximal pole (19) 13% proximal pole (5)
74% waist (54) 87% waist (33)
Type of non-union (Alnot 2A: 67% (49) 2A: 39.5% (15)
classification) 2B: 30% (22) 2B: 52.5% (20)
3A: 3% (2) 3A: 8% (3)

In some cases where the scaphoid showed a ‘‘humpback’’

deformity, reduction was performed using a chisel and
maintained by temporary pins. The volar carpal artery lies
between the palmar periosteum of the radius and the distal
part of the superficial aponeurosis of the pronator quadra-
tus, the last distal centimeter of which was opened; then
the periosteum was sectioned using a knife for about 1 cm
on either side of the pedicle. The lateral half of the pedi-
cle was released subperiosteally up to the radial artery
(Fig. 3).
The graft was harvested from the radius using a
chisel. The pedicle was then dissected up to the ori-
gin of the volar carpal artery (Fig. 4). The scaphoid
was screwed from distal to proximal. The bone graft
was fitted to fill the defect on the volar aspect of the
scaphoid (Fig. 5), and stabilized by tightening the screw
(Fig. 6) or using a temporary pin (Fig. 7). The cap-
sule was sutured without compressing the pedicle, and
the radioscaphocapitate ligament was repaired. A pal-
mar splint with the wrist in 40◦ extension was kept
until consolidation was achieved. The pin was removed at
Figure 3 Dissection of the volar carpal artery.
3 weeks.

Figure 4 Harvesting pyramidal graft and exposure of scaphoid bone defect. Drawing and photograph.
Vascularized bone graft for scaphoid non-union
Figure 5 Positioning graft with respect to defect.
Figure 6 Stabilization of graft by tightening screw.
Evaluation methods
Range of motion, force and pain were measured preop-
eratively and at last follow-up. Motion was measured in
flexion, extension and radial and ulnar inclination. Muscle
Figure 7 Stabilization of graft by temporary pin, taking care
not to damage the pedicle.
803
force was measured in kilogram using a Jamar dynamome-
ter. Consolidation time was determined using control X-rays.
Complications, return to work, functional recovery on the
Mayo Wrist Score and overall patient satisfaction were
recorded. All data were collected by a single observer
(C.M.).
Results were evaluated using descriptive statistical anal-
ysis.
Results
None of the patients were lost to follow-up. Mean follow-
up (FU) was 25.5 months (10—65 months) in group 1 and
33 months (10—63 months) in group 2. Table 3 shows data
for the two groups.
Complications
There were six complications (8%) in group 1. Three patients
(4%) showed non-union; two had proximal pole (PP) fractures
(10.5% of PPs) initially and the third a waist fracture (W)
(1.8% of Ws). Three patients (4%) showed stiffness requiring
tenoarthrolysis; they had proximal pole fracture (15.8% of
PPs).
There were 10 complications (26%) in group 2. Four
patients (10.5%) showed non-union; one PP (20% of PPs) and
three Ws (9% of Ws). Two underwent secondary four-corner
arthrodesis and scaphoidectomy, and were not satisfied by
their operations. The other two refused further surgery. One
patient (2.5%) with waist fracture initially (3% of Ws) showed
stiffness requiring tenoarthrolysis. Three patients (8%) had
complex regional pain syndrome.
Subjective and functional results
There was significant pain relief. In group 1 with PP, pain
passed from severe in 10.5% of cases and moderate in 89.5%
initially, to 10.5% moderate and 89.5% pain-free. In W, pain
passed from severe in 7.4% of cases and moderate in 92.6%
initially, to 1.8% moderate and 98.2% pain-free.
In group 2, pain levels were markedly higher, both pre-
and postoperatively. In PP, pain was initially severe in 60%
of cases and moderate in 40%, and decreased to 60% mod-
erate and 40% pain-free. In W, pain was initially severe in
60.6% of cases and moderate in 39.4%, and decreased to
3% severe, 39.4% moderate and 57.6% pain-free. Although
there was clear improvement in pain, these results were
less satisfactory than for first-line treatment.
In group 1, the functional results on the Mayo Wrist Score
were excellent or good in 94.5% of cases; 98.5% of patients
were completely satisfied or had only minor reservations.
One patient with initial PP fracture was dissatisfied. He had
a poor functional score, showed non-union, and was the only
one who would not have the operation again.
In group 2, the functional results were 73.2% excellent or
good and 26.5% moderate or poor (PP: 40% excellent, 40%
good, 20% poor; W: 42.5% excellent, 30.3% good, 18.2% mod-
erate and 9% poor). Overall, functional results were worse
than in group 1. Seventy-six percent of patients were com-
pletely satisfied or had only minor reservations, 16% had
804 M. Gras, C. Mathoulin

Table 3 Clinical and radiological results per group.

Primary treatment patients (n = 73) Secondary treatment patients (n = 38)

Follow-up (months) 25.5 ± 14.5 (10 to 65) 33 ± 18.3 (10 to 63)

Radiologic consolidation 96% 89.5%
Mean time to consolidation (weeks) 9.7 ± 4.9 (6 to 24) 10.8 ± 4.2 (6 to 24)
Flexion (degrees) +10.6 ± 13.7 (−30 to 40) +11.3 ± 12.2 (−10 to 40)
Extension (degrees) +7.8 ± 10.4 (−5 to 40) +16.3 ± 14.6 (0 to 50)
Radial deviation (degrees) +5.3 ± 5.5 (−8 to 20) +6.3 ± 6.3 (−5 to 15)
Ulnar deviation (degrees) +5.6 ± 5.9 (−5 to 20) +7.4 ± 6.8 (0 to 20)
Muscle force (Kg) +16.4 ± 9.5 (0 to 35) +18.2 ± 12 (−6 to 45)
Preoperative Postoperative Preoperative Postoperative
Pain
Severe 8% (6) 0% 60.5% (23) 2.5% (1)
Moderate 92% (67) 4% (3) 39.5% (15) 42% (16)
None 0% 96% (70) 0% 55.5% (21)
Complications
Non-union 4% 10.5%
Stiffness 4% 2.5%
CRPS 0% 8%
Functional results (Mayo Wrist score)
Excellent 83.5% (61) 42% (16)
Good 11% (8) 31.5% (12)
Moderate 4% (3) 16% (6)
Poor 1.5% (1) 10.5% (4)
Overall satisfaction
Completely satisfied 85% (62) 44.5% (17)
Minor reservations 13.5% (10) 31.5% (12)
Major reservations 0% 16% (6)
Dissatisfied 1.5% (1) 8% (3)

major reservations and 8% were dissatisfied. The three dis-
satisfied patients had poor functional results and non-union
on X-ray, and were the only patients to say they would not
have the operation again; two had had W fractures (6% of
Ws) and one PP (20% of PPs).
In group 1, patients returned to work at a mean
9.7 ± 5.7 weeks, except for one patient who never returned
and remained on disability benefit for work accident. Three
patients (4%) had to change jobs (5.3% of PPs and 3.7% of
Ws). In group 2, patients returned to work at a mean of
17.5 ± 12 weeks (PP, 14.6 weeks; W, 18 weeks), except for
one patient who never returned and who was one of the
four showing non-union.. Six patients (16%) had to change
jobs; two PPs (40% of PPs); four W (12.1% of Ws).
which remained stable at a mean 46.3 and 45.4 kg, respec-
tively): i.e. a gain of 16.4 kg (PP, 15.4 kg; W, 16 kg).
Results for motion and force showed similar improvement
in secondary grafting, but at lower levels. Mean flexion rose
from 35◦ to 46.3◦ , gain = 11.3◦ (PP, 8◦ ; W, 11.9◦ ), extension
from 41.6◦ to 58.5◦ , gain = 16.3◦ (PP, 22◦ ; W, 16.2◦ ), radial
deviation from 13.3◦ to 19.8◦ , gain = 6.3◦ (PP, 1.7◦ ; W, 6.9◦ ),
and ulnar deviation from 14.8◦ to 22◦ , gain = 7.4◦ (PP, 5◦ ; W,
7.4◦ ). There was clear improvement in force on the Jamar,
although less than in group 1, from 20.4 kg to 39.5 kg (com-
pared to the contralateral control values which remained
stable at a mean 45.3 and 45 kg, respectively, similar to in
group 1): i.e., a gain of 18.2 kg (PP, 18.7 kg; W, 19.5 kg).
Radiology results

In group 1, radiologic consolidation was achieved in 70 cases

Clinical results
Range of motion and force improved, with greater gain in
the primary group.
In group 1, mean flexion rose from 51.4◦ to 62◦ ,
gain = 10.6◦ (PP, 11.3◦ ; W, 0.4◦ ), extension from 61.2◦ to
69.3◦ , gain = 7.8◦ (PP, 10◦ ; W, 7.4◦ ), radial deviation from
15.5◦ to 20.2◦ , gain = 5.3◦ (PP, 4.5◦ ; W, 4.8◦ ), and ulnar devi-
ation from 24.6◦ to 30◦ , gain = 5.6◦ (PP, 5.8◦ ; W, 5.3◦ ). There
was clear improvement in force on the Jamar, from a mean
26.8 to 42.3 kg (compared to the contralateral control values
i.e., 96% (PP, 89.5%, W, 98.2%) at a mean of 9.7 weeks (PP
11.3 weeks; W 9.2 weeks).
In group 2, radiologic consolidation was achieved in 34
cases i.e., 89.5% (PP, 80%, W, 91%) at a mean of 10.8 weeks
(PP, 17 weeks, W, 10 weeks).
Discussion
Bone graft from the volar radius vascularized by the volar
carpal artery is a good treatment for moderate scaphoid
Vascularized bone graft for scaphoid non-union
defects (Alnot grades IIA, IIB or IIIA). The anterior approach
allows graft harvesting and treatment of the non-union to
be performed as a single procedure. Although harvesting
may seem difficult at first, it is in fact a simple technique
that provides excellent results. The surgery is performed
under locoregional anesthesia through a single incision with
reduced surgery time as a day case, thus reducing hospi-
tal stay and overall costs. It was first described for failure
of classical techniques. However, given the quality of the
functional results and the speed of consolidation, we rec-
ommend it as primary treatment of scaphoid non-union.
The present study is the first to report results of vascular-
ized grafts as a primary treatment for scaphoid non-union.
It shows improvement for all evaluation criteria in these
cases.
Various factors seem to affect consolidation. The mean
age of patients who failed to show union after pri-
mary non-union treatment was 40 years, versus 30 in
case of successful union. Age has been identified as
a factor of poor prognosis by other authors [7,22].
Likewise, the greater the delay between fracture and
surgery the poorer is the consolidation. The mean delay
in patients without consolidation was 48.3 months, ver-
sus 19 months in case of consolidation. Several studies
[22,23] correlated smoking and non-consolidation. A study
conducted in 2008 [24] reported a lower consolida-
tion rate (73%) with vascularized grafts from the volar
radius; these findings highlight the difficulties encoun-
tered in harvesting and osteosynthesis, especially for
less experienced surgeons. There was notably a risk of
perioperative articular fracture of the radius [24,25],
which seemed greatest at the beginning of the learning
curve.
Although the conventional Matti-Russe graft remains
an excellent option, many studies reported better conso-
lidation rates using vascularized bone graft: union was
achieved in 70% to 90% of non-vascularized grafts [26,27]
and more than 90% of vascularized grafts [2,16,19,28—34].
Munk and Larsen [35] confirmed these findings in a meta-
analysis of 5,246 cases of scaphoid non-union, with an
80% consolidation rate (78—82) for non-vascularized bone
graft without osteosynthesis, 84% (82—85) with osteosyn-
thesis, and 91% (87—94) for vascularized graft. In non-union
with avascular necrosis of the proximal pole, however, sur-
geons seem to agree that a primary vascularized graft
is the best conservative management [7,36—38], due
to the very poor consolidation rate obtained with non-
vascularized grafts (< 50%). Dailiana [39] reported that union
on MRI was achieved faster with a vascularized graft.
Some authors recommend other vascularized free grafts,
from the supracondylar region of the femur [40,41], base
of the third metatarsal [42], iliac crest [43], rib [44],
etc.
Primary treatment by vascularized graft — depending on
the series — showed equally good or better consolidation,
recovery of motion and pain relief compared to secondary
treatment or non-vascularized graft. Vascularized graft from
the volar radius is thus a good alternative for primary
treatment of scaphoid non-union. The present retrospective
findings should be confirmed with longer follow-up. A larger
trial is required to validate the use of vascularized graft for
primary treatment of scaphoid non-union.
805
Disclosure of interest
The authors declare that they have no conflicts of interest
concerning this article.
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