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Abstract：
Objective This article compares predictors of failure for vascularized (VBG) and nonvascularized bone grafting (NVBG) of scaphoid nonunions. Methods We conducted a systematic literature review of outcomes after VBG and NVBG of scaphoid nonunion. Fifty-one VBG studies ( N = 1,419 patients) and 81 NVBG studies ( N = 3,019 patients) met the inclusion criteria. Data were collected on surgical technique, type of fixation, time from injury to surgery, fracture location, abnormal carpal posture (humpback deformity and/or dorsal intercalated segmental instability [DISI]), radiographic parameters of carpal alignment, prior failed surgery, smoking status, and avascular necrosis (AVN) as defined by punctate bleeding, magnetic resonance imaging (MRI) with contrast, MRI without contrast, X-ray, and histology. Meta-analysis of proportions was conducted with Freeman-Tukey double arcsine transformation. Multilevel mixed-effects analyses were performed with univariable and multivariable Poisson regression to identify confounders and evaluate predictors of failure. Results The pooled failure incidence effect size was comparable between VBG and NVBG (0.09 [95% confidence interval [CI] 0.05-0.13] and 0.08 [95% CI 0.06-0.11], respectively). Humpback deformity and/or DISI (incidence-rate radios [IRRs] 1.57, CI: 1.04-2.36) and lateral intrascaphoid angle (IRR 1.21, CI: 1.08-1.37) were significantly associated with an increased VBG failure incidence. Time from injury to surgery (IRR 1.09, CI: 1.06-1.12) and height-to-length (H/L) ratio (IRR 53.98, CI: 1.16-2,504.24) were significantly associated with an increased NVBG failure incidence, though H/L ratio demonstrated a wide CI. Decreased proximal fragment contrast uptake on MRI was a statistically significant predictor of increased failure incidence for both VBG (IRR 2.03 CI: 1.13-3.66) and NVBG (IRR 1.39, CI: 1.16-1.66). Punctate bleeding or radiographic AVN, scapholunate angle, radiolunate angle, and prior failed surgery were not associated with failure incidence for either bone graft type ( p > 0.05). Conclusion Humpback deformity and/or DISI and increasing lateral intrascaphoid angle may be predictors of VBG failure. Time from injury to surgery may be a predictor of NVBG failure. AVN as defined by decreased contrast uptake on MRI may be a marker of increased failure risk for both bone graft types.
摘要：
目的比较血管化（VBG）和非血管化骨移植（NVBG）治疗舟骨骨不连失败的预测因素。方法我们对VBG和NVBG治疗舟骨骨不连的结果进行了系统的文献综述。51项VBG研究（N=1,419例患者）和81项NVBG研究（N=3,019例患者）符合纳入标准。收集了有关手术技术的数据，固定类型,从受伤到手术的时间，骨折位置,异常的腕骨姿势（驼背畸形和/或背侧插层节段性不稳定[DISI]），腕骨对准的射线照相参数，之前手术失败,吸烟状况,和由点状出血定义的无血管坏死(AVN)，磁共振成像（MRI）与对比，MRI无造影,X光片,和组织学。采用Freeman-Tukey双反正弦变换进行比例的Meta分析。使用单变量和多变量泊松回归进行多级混合效应分析，以识别混杂因素并评估失败的预测因素。结果VBG和NVBG的合并失败发生率效应大小相当（0.09[95%置信区间[CI]0.05-0.13]和0.08[95%CI0.06-0.11]，分别)。座头鲸畸形和/或DISI（发生率无线电[IRRs]1.57，CI：1.04-2.36）和肩关节外侧角度（IRR1.21，CI：1.08-1.37）与VBG失败发生率增加显着相关。从受伤到手术的时间（IRR1.09，CI：1.06-1.12）和身高长度比（H/L）（IRR53.98，CI：1.16-2,504.24）与NVBG失败发生率增加显着相关，尽管H/L比显示出较宽的CI。MRI上近端碎片对比剂摄取减少是VBG（IRR2.03CI：1.13-3.66）和NVBG（IRR1.39，CI：1.16-1.66）失败发生率增加的统计学显着预测因子。点状出血或放射学AVN，肩胛骨角,放射状角度，和先前失败的手术与两种植骨类型的失败发生率无关（p>0.05）。结论座头鲸畸形和/或DISI和增加的肩关节外侧角度可能是VBG衰竭的预测因素。从受伤到手术的时间可能是NVBG失败的预测因素。由MRI上造影剂摄取减少定义的AVN可能是两种骨移植类型的失败风险增加的标志。
