Abstract：
BACKGROUND: Free vascularized bone grafting (FVBG) has become one of the essential methods for treating scaphoid nonunion complicated by avascular necrosis. However, commonly used bone graft, including the medial femoral condyle bone graft and iliac crest bone graft, still present challenges such as a high rate of donor site complications and variations of vascular pedicle. In this study, we have introduced a novel bone graft-the lateral humeral condyle bone graft with the posterior branch of the radial collateral artery (PBRCA) as the vascular pedicle-as an alternative option, with the aim of overcoming some of the limitations of previously described FVBG procedures.
METHODS: Nine patients who had a nonunion of the scaphoid that had been present for an average of 16.8 months (range 9-35 months) were managed with use of a free vascularized bone graft obtained from the lateral humeral epicondylar region. Avascularity of the scaphoid, as assessed on preoperative magnetic resonance imaging and intraoperative bone marrow puncture test. Postoperatively, regular X-ray and CT scans examinations were conducted to assess the progress of fracture healing. Active motion of the wrist, and grip strength recovery were measured periodically. Wrist pain was graded using the Visual Analogue Scale (VAS), while wrist joint functionality was evaluated using the Quick Disabilities of the Arm, Shoulder, and Hand (Quick-DASH) questionnaire and the Patient-Rated Wrist Evaluation (PRWE) scale. The elbow functional outcome was evaluated by the Mayo Elbow Performance Score (MEPS).
RESULTS: All of nine lateral humeral epicondylar bone grafts were successfully harvested. The blood supply of the graft during surgery was excellent in six cases and good in three cases. The size of the bone grafts ranges from 1.0 cm × 0.5 cm × 0.5 cm to 2.0 cm × 1.0 cm × 0.5 cm. The average vascular pedicle length was 3.4 cm (range 2.0-6.0 cm). There were no early complications in either the donor or recipient areas after surgery. Union was successfully achieved in all nine patients, with an average time to union of 14.3 weeks (range 11-20 weeks) after surgery. The average follow-up period was 31.2 months (range 26-40 months). At the final follow-up, the average palmar flexion, dorsal extension, radial deviation, and ulnar deviation angles of the injured wrist joint were 56.1° (range 45°-70°), 56.1° (range 40°-80°), 10.6° (range 5°-20°), and 22.2° (range 15°-35°), respectively, which reached 79.0%, 82.1%, 59.4%, and 72.8% of the average activity of the contralateral normal side. The average grip strength of the injured side was 35.2 kg (range 22-51 kg), which was equivalent to 81.3% of the average grip strength of the contralateral side. The average VAS score for wrist joint pain was 1.0 point (range 0-2 points); the Quick-DASH score was 9.2 points (range 6-18 points); and the PRWE score was 13.1 points (range 9-16 points), the Mayo Elbow Performance Index was 100 points (range 100-100 points). One patient reported a feeling of friction during movement but no pain. One patient reported numbness in the donor site. One patient complained of pain when applying force to the scar in the donor area. During the follow-up period, these complications showed improvement without any treatment.
CONCLUSIONS: The FVBG technique has been considered an effective method for treating scaphoid nonunion with avascular necrosis. Compared to traditional FVBG, the lateral humeral epicondylar bone graft exhibits a higher union rate, fewer complications, and easier accessibility, making it a favorable choice.
METHODS: Nine patients who had a nonunion of the scaphoid that had been present for an average of 16.8 months (range 9-35 months) were managed with use of a free vascularized bone graft obtained from the lateral humeral epicondylar region. Avascularity of the scaphoid, as assessed on preoperative magnetic resonance imaging and intraoperative bone marrow puncture test. Postoperatively, regular X-ray and CT scans examinations were conducted to assess the progress of fracture healing. Active motion of the wrist, and grip strength recovery were measured periodically. Wrist pain was graded using the Visual Analogue Scale (VAS), while wrist joint functionality was evaluated using the Quick Disabilities of the Arm, Shoulder, and Hand (Quick-DASH) questionnaire and the Patient-Rated Wrist Evaluation (PRWE) scale. The elbow functional outcome was evaluated by the Mayo Elbow Performance Score (MEPS).
RESULTS: All of nine lateral humeral epicondylar bone grafts were successfully harvested. The blood supply of the graft during surgery was excellent in six cases and good in three cases. The size of the bone grafts ranges from 1.0 cm × 0.5 cm × 0.5 cm to 2.0 cm × 1.0 cm × 0.5 cm. The average vascular pedicle length was 3.4 cm (range 2.0-6.0 cm). There were no early complications in either the donor or recipient areas after surgery. Union was successfully achieved in all nine patients, with an average time to union of 14.3 weeks (range 11-20 weeks) after surgery. The average follow-up period was 31.2 months (range 26-40 months). At the final follow-up, the average palmar flexion, dorsal extension, radial deviation, and ulnar deviation angles of the injured wrist joint were 56.1° (range 45°-70°), 56.1° (range 40°-80°), 10.6° (range 5°-20°), and 22.2° (range 15°-35°), respectively, which reached 79.0%, 82.1%, 59.4%, and 72.8% of the average activity of the contralateral normal side. The average grip strength of the injured side was 35.2 kg (range 22-51 kg), which was equivalent to 81.3% of the average grip strength of the contralateral side. The average VAS score for wrist joint pain was 1.0 point (range 0-2 points); the Quick-DASH score was 9.2 points (range 6-18 points); and the PRWE score was 13.1 points (range 9-16 points), the Mayo Elbow Performance Index was 100 points (range 100-100 points). One patient reported a feeling of friction during movement but no pain. One patient reported numbness in the donor site. One patient complained of pain when applying force to the scar in the donor area. During the follow-up period, these complications showed improvement without any treatment.
CONCLUSIONS: The FVBG technique has been considered an effective method for treating scaphoid nonunion with avascular necrosis. Compared to traditional FVBG, the lateral humeral epicondylar bone graft exhibits a higher union rate, fewer complications, and easier accessibility, making it a favorable choice.
摘要：
背景：游离血管化植骨（FVBG）已成为治疗舟骨骨不连并发缺血性坏死的重要方法之一。然而,常用的植骨，包括股骨内侧髁骨移植和髂骨移植，仍然存在挑战，例如供体部位并发症的高发生率和血管蒂的变异。在这项研究中,我们引入了一种新型的骨移植物-肱骨外侧髁骨移植物，以桡侧副动脉后支（PBRCA）作为血管蒂-作为替代选择，目的是克服先前描述的FVBG程序的一些限制。
方法：9例舟骨骨不连平均存在16.8个月（范围9-35个月）的患者使用从肱骨外侧上髁区获得的游离血管化骨移植物进行治疗。舟骨的血管形成,根据术前磁共振成像和术中骨髓穿刺试验评估。术后,定期进行X线和CT扫描检查以评估骨折愈合的进展。手腕的主动运动，并定期测量握力恢复。使用视觉模拟评分（VAS）对腕痛进行分级，虽然腕关节功能是使用手臂的快速残疾评估的，肩膀,手（Quick-DASH）问卷和患者评分腕部评估（PRWE）量表。通过Mayo肘关节性能评分（MEPS）评估肘关节功能结果。
结果：所有9个肱骨外侧上髁骨移植物均获成功。手术期间移植物的血液供应良好的有6例，良好的有3例。骨移植物的大小范围为1.0cm×0.5cm×0.5cm至2.0cm×1.0cm×0.5cm。血管蒂平均长度为3.4cm（范围2.0-6.0cm）。手术后供体或受体区域均无早期并发症。所有9名患者都成功实现了联合，手术后平均愈合时间为14.3周（范围11-20周）。随访时间26～40个月,平均31.2个月。在最后的后续行动中，平均手掌屈曲,背侧伸展,径向偏差,受伤腕关节的尺骨偏角为56.1°（范围为45°-70°），56.1°(范围40°-80°),10.6°(范围5°-20°),和22.2°（范围15°-35°），分别,达到79.0%，82.1%,59.4%,和对侧正常侧平均活动量的72.8%。受伤侧的平均握力为35.2kg（范围22-51kg），相当于对侧平均握力的81.3%。腕关节疼痛的平均VAS评分为1.0分（范围0-2分）；Quick-DASH评分为9.2分（范围6-18分）；PRWE评分为13.1分（范围9-16分），梅奥弯头表现指数为100点（范围为100-100点）。一名患者报告在运动期间有摩擦感，但没有疼痛。一名患者报告供体部位麻木。一名患者在向供体区域的疤痕施加力时抱怨疼痛。在后续期间,这些并发症在没有任何治疗的情况下表现出改善。
结论：FVBG技术被认为是治疗伴有缺血性坏死的舟骨骨不连的有效方法。与传统的FVBG相比,肱骨外侧上髁骨移植表现出更高的愈合率，并发症少,和更容易的可访问性，使它成为一个有利的选择。
方法：9例舟骨骨不连平均存在16.8个月（范围9-35个月）的患者使用从肱骨外侧上髁区获得的游离血管化骨移植物进行治疗。舟骨的血管形成,根据术前磁共振成像和术中骨髓穿刺试验评估。术后,定期进行X线和CT扫描检查以评估骨折愈合的进展。手腕的主动运动，并定期测量握力恢复。使用视觉模拟评分（VAS）对腕痛进行分级，虽然腕关节功能是使用手臂的快速残疾评估的，肩膀,手（Quick-DASH）问卷和患者评分腕部评估（PRWE）量表。通过Mayo肘关节性能评分（MEPS）评估肘关节功能结果。
结果：所有9个肱骨外侧上髁骨移植物均获成功。手术期间移植物的血液供应良好的有6例，良好的有3例。骨移植物的大小范围为1.0cm×0.5cm×0.5cm至2.0cm×1.0cm×0.5cm。血管蒂平均长度为3.4cm（范围2.0-6.0cm）。手术后供体或受体区域均无早期并发症。所有9名患者都成功实现了联合，手术后平均愈合时间为14.3周（范围11-20周）。随访时间26～40个月,平均31.2个月。在最后的后续行动中，平均手掌屈曲,背侧伸展,径向偏差,受伤腕关节的尺骨偏角为56.1°（范围为45°-70°），56.1°(范围40°-80°),10.6°(范围5°-20°),和22.2°（范围15°-35°），分别,达到79.0%，82.1%,59.4%,和对侧正常侧平均活动量的72.8%。受伤侧的平均握力为35.2kg（范围22-51kg），相当于对侧平均握力的81.3%。腕关节疼痛的平均VAS评分为1.0分（范围0-2分）；Quick-DASH评分为9.2分（范围6-18分）；PRWE评分为13.1分（范围9-16分），梅奥弯头表现指数为100点（范围为100-100点）。一名患者报告在运动期间有摩擦感，但没有疼痛。一名患者报告供体部位麻木。一名患者在向供体区域的疤痕施加力时抱怨疼痛。在后续期间,这些并发症在没有任何治疗的情况下表现出改善。
结论：FVBG技术被认为是治疗伴有缺血性坏死的舟骨骨不连的有效方法。与传统的FVBG相比,肱骨外侧上髁骨移植表现出更高的愈合率，并发症少,和更容易的可访问性，使它成为一个有利的选择。
