HAND/PERIPHERAL NERVE Scaphoid Nonunions: Management with Vascularized Bone Grafts from the Distal Radius: A Clinical and Functional Outcome Study Konstantinos N. Malizos, M.D. Vasileios Zachos, M.D. Zoe H. Dailiana, M.D. Charalampos Zalavras, M.D. Socratis Varitimidis, M.D. Michael Hantes, M.D. Apostolos Karantanas, M.D. Larissa and Heraklion, Greece Background: Scaphoid nonunions remain controversial with regard to optimal management, especially for those located at the proximal third. In this study, the authors aim to assess the union rate, avascular proximal pole revascular- ization, and functional outcome of scaphoid nonunions managed with distal radius vascularized bone grafts. Methods: Thirty patients were treated with vascularized bone grafts between 1999 and 2003 and prospectively followed up. The average nonunion chronicity was 3.3 years. Nine patients (30 percent) had avascular necrosis of the proximal pole, five had unsuccessful previous surgical procedures, and four had ra- dioscaphoid arthritis (Lichtman type III). Twenty proximal third nonunions were managed with dorsal radius bone graft, whereas 10 waist nonunions had palmar grafts. Union was assessed clinically and radiologically and, in 67 percent of the patients, by means of magnetic resonance imaging. Results: All cases were united by 12 weeks, and magnetic resonance imaging confirmed that all necrotic proximal poles were revascularized. On at least 24 months’ follow-up, 90 percent of patients achieved complete pain relief. Wrist flexion-extension and radial-ulnar deviation arcs did not change. The postop- erative grip strength was 82 percent of the contralateral side. The Mayo Modified Wrist Score increased significantly from 58 to 85 points and, overall, 77 percent of patients had an excellent or good outcome. No risk factors for compromised wrist function were identified. The scapholunate angle, the scaphoid length, and the Nattrass index improved significantly. Conclusions: This series demonstrates the efficacy of distal radius vascularized bone grafts in union enhancement, proximal pole revascularization, pain relief, improved wrist function, and carpal alignment. Vascularized bone grafts are a reliable therapeutic alternative for scaphoid nonunions. (Plast. Reconstr. Surg. 119: 1513, 2007.) M anagement of scaphoid nonunion is a challenging problem, and several tech- niques have been proposed. The union rate of scaphoid nonunions treated with a Her- bert screw and a palmar interpositional bone graft ranges from 53 to 100 percent and depends on the stage of the nonunion and the vascularity of the proximal pole. 1–21 Vascularized pedicled grafts from the distal ra- dius have been used as a treatment alternative. 22–39 Some authors have reported a 100 percent union rate in scaphoid nonunions treated with a bone graft from the dorsal distal radius pedicled on the 1,2- intercompartmental supraretinacular artery 30,34,35,37,39 or with a bone graft pedicled on the palmar carpal epiphyseal artery. 29,31 However, vascularized bone grafts have not consistently resulted in a high rate of union, and union rates as low as 27 percent have been reported. 22,36,40 Studies in the literature on vascularized bone grafts 22–32,34 – 41 are not only characterized by con- siderable variability in union rates (27 to 100 percent) but are also limited by the small num- ber of patients, the inadequate assessment of From the Department of Orthopedics, School of Health Sci- ences, University of Thessalia, and Department of Radiology, University of Crete. Received for publication December 27, 2005; accepted March 23, 2006. Copyright ©2007 by the American Society of Plastic Surgeons DOI: 10.1097/01.prs.0000256144.52654.da www.PRSJournal.com 1513