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Dean G Sotereanos - One of the best experts on this subject based on the ideXlab platform.
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dorsal capsular based vascularized distal radius graft for proximal pole scaphoid Nonunion with avascular necrosis
Injury-international Journal of The Care of The Injured, 2021Co-Authors: Loukia K Papatheodorou, Dimitrios V Papadopoulos, Micaela M Graber, Dean G SotereanosAbstract:Abstract Background Scaphoid Nonunion involving the proximal pole with the presence of avascular necrosis is difficult to reconstruct. We aimed to determine the efficacy of surgical treatment of proximal pole scaphoid Nonunion with avascular necrosis using a dorsal capsular-based vascularized distal radius graft. Methods Between 2000 and 2018, 64 patients with established proximal pole scaphoid Nonunion with avascular necrosis were treated using a dorsal capsular-based vascularized distal radius graft. This graft was harvested from the dorsal aspect of the distal radius with its dorsal wrist capsule attachment. Fixation of the scaphoid Nonunion was performed with a small cannulated screw, followed by insertion of the vascularized graft into the dorsal trough at the scaphoid Nonunion site. In the last 47 patients of this series, a micro suture anchor was placed into the scaphoid to augment graft fixation. Results Union rate was 86% (55 of 64 scaphoid Nonunions with avascular necrosis) at a mean time of 12 weeks. Persistent non-union was noted in eight patients and fibrous union in one patient. No patients developed donor site morbidity. No graft dislodgment was noted. There was significant improvement of the wrist functional outcomes at the final follow up. Conclusions The dorsal capsular-based vascularized distal radius graft is a safe and effective treatment in patients with scaphoid Nonunion with avascular necrosis of the proximal pole. This pedicle vascularized bone graft is derived from a location that can easily reach the proximal third of the scaphoid avoiding microsurgical dissection or anastomosis.
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a capsular based vascularized distal radius graft for proximal pole scaphoid pseudarthrosis
Journal of Hand Surgery (European Volume), 2006Co-Authors: Dean G Sotereanos, Nickolaos A Darlis, Zoe H Dailiana, Ioannis Sarris, Konstantinos N MalizosAbstract:Purpose To evaluate the clinical results of the application of a capsular-based dorsal distal radius vascularized bone graft in scaphoid proximal pole Nonunions. Methods Thirteen patients with symptomatic Nonunion at the proximal pole of the scaphoid (10 with avascular necrosis) were treated and reviewed retrospectively. The vascularized bone graft was harvested from the distal aspect of the dorsal radius and was attached to a wide distally based strip of the dorsal wrist capsule. It was inserted press-fit into a dorsal trough across the Nonunion site after scaphoid fixation with a Herbert screw. Results After a mean follow-up period of 19 months 10 of the 13 Nonunions (8 of the 10 with avascular necrosis) achieved solid bone union. No complications other than the 3 persistent Nonunions occurred. Conclusions Results of the use of a capsular-based vascularized bone graft from the distal radius for proximal pole scaphoid Nonunions compare favorably with the results of pedicled or free vascularized grafts. It is a simple technique that eliminates the need for dissection of small-caliber pedicle or microsurgical anastomoses. No donor site morbidity was observed. Type of study/level of evidence Therapeutic, Level IV.
Grant R Steen - One of the best experts on this subject based on the ideXlab platform.
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healing of fracture Nonunions treated with low intensity pulsed ultrasound lipus a systematic review and meta analysis
Injury-international Journal of The Care of The Injured, 2017Co-Authors: Ross Leighton, Andrew Harrison, Grant R Steen, Tracy J Watson, Peter V Giannoudis, Costas PapakostidisAbstract:Abstract Introduction Bone fractures fail to heal and form Nonunions in roughly 5% of cases, with little expectation of spontaneous healing thereafter. We present a systematic review and meta-analysis of published papers that describe Nonunions treated with low-intensity pulsed ultrasound (LIPUS). Methods Articles in PubMed, Ovid MEDLINE, CINAHL, AMED, EMBASE, Cochrane Library, and Scopus databases were searched, using an approach recommended by the Methodological Index for Non-Randomized Studies (MINORS), with a Level of Evidence rating by two reviewers independently. Studies are included here if they reported fractures older than 3 months, presented new data with a sample N ≥ 12, and reported fracture outcome (Heal/Fail). Results Thirteen eligible papers reporting LIPUS treatment of 1441 Nonunions were evaluated. The pooled estimate of effect size for heal rate was 82% (95% CI: 77–87%), for any anatomical site and fracture age of at least 3 months, with statistical heterogeneity detected across all primary studies (Q = 41.2 (df = 12), p 2 = 0.006, I 2 = 71). With a stricter definition of Nonunion as fracture age of at least 8 months duration, the pooled estimate of effect size was 84% (95% CI: 77%–91.6%; heterogeneity present: Q = 21 (df = 8), p 2 = 0.007, I 2 = 62). Hypertrophic Nonunions benefitted more than biologically inactive atrophic Nonunions. An interval without surgery of Conclusions LIPUS treatment can be an alternative to surgery for established Nonunions. Given that no spontaneous healing of established Nonunions is expected, and that it is challenging to test the efficacy of LIPUS for Nonunion by randomized clinical trial, findings are compelling. LIPUS may be most useful in patients for whom surgery is high risk, including elderly patients at risk of delirium, or patients with dementia, extreme hypertension, extensive soft-tissue trauma, mechanical ventilation, metabolic acidosis, multiple organ failure, or coma. With an overall average success rate for LIPUS >80% this is comparable to the success of surgical treatment of non-infected Nonunions.
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treatment of chronic 1 year fracture Nonunion heal rate in a cohort of 767 patients treated with low intensity pulsed ultrasound lipus
Injury-international Journal of The Care of The Injured, 2015Co-Authors: Robert D Zura, Gregory J Della Rocca, Samir Mehta, Andrew Harrison, Christopher Brodie, John Jones, Grant R SteenAbstract:Abstract Background Established fracture Nonunions rarely heal without secondary intervention. Revision surgery is the most common intervention, though non-surgical options for Nonunion would be useful if they could overcome Nonunion risk factors. Our hypothesis is that low-intensity pulsed ultrasound (LIPUS) can enhance heal rate (HR) in fractures that remain Nonunion after one year, relative to the expected HR in the absence of treatment, which is expected to be negligible. Methods We collated outcomes from a prospective patient registry required by the U.S. Food & Drug Administration. Patient data were collected over a 4-year period beginning in 1994 and were individually reviewed and validated by a registered nurse. Patients were only included if they had four data points available: date when fracture occurred; date when LIPUS treatment began; date when LIPUS treatment ended; and a dichotomous outcome of healed vs. failed, assessed by clinical and radiological criteria. Data were used to calculate two derived variables: days to treatment (DTT) with LIPUS, and days on treatment (DOT) with LIPUS. Every validated chronic Nonunion patient (DTT > 365 days) with complete data is reported. Results Heal rate for chronic Nonunion patients (N = 767) treated with LIPUS was 86.2%. Heal rate was 82.7% among 98 patients with chronic Nonunion ≥5 years duration, and 12 patients healed after chronic Nonunion >10 years (HR = 63.2%). There was more patient loss to follow-up, non-compliance, and withdrawal, comparing chronic Nonunion patients to all other patients (p Conclusions Low-intensity pulsed ultrasound enhanced HR among fractures that had been Nonunion for at least 1 year, and even healed fractures that had been Nonunion >10 years. LIPUS resulted in successful healing in the majority of Nonunions without further surgical intervention.
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treatment of chronic 1 year fracture Nonunion heal rate in a cohort of 767 patients treated with low intensity pulsed ultrasound lipus
Injury-international Journal of The Care of The Injured, 2015Co-Authors: Robert D Zura, Gregory J Della Rocca, Samir Mehta, Andrew Harrison, Christopher Brodie, John Jones, Grant R SteenAbstract:Abstract Background Established fracture Nonunions rarely heal without secondary intervention. Revision surgery is the most common intervention, though non-surgical options for Nonunion would be useful if they could overcome Nonunion risk factors. Our hypothesis is that low-intensity pulsed ultrasound (LIPUS) can enhance heal rate (HR) in fractures that remain Nonunion after one year, relative to the expected HR in the absence of treatment, which is expected to be negligible. Methods We collated outcomes from a prospective patient registry required by the U.S. Food & Drug Administration. Patient data were collected over a 4-year period beginning in 1994 and were individually reviewed and validated by a registered nurse. Patients were only included if they had four data points available: date when fracture occurred; date when LIPUS treatment began; date when LIPUS treatment ended; and a dichotomous outcome of healed vs. failed, assessed by clinical and radiological criteria. Data were used to calculate two derived variables: days to treatment (DTT) with LIPUS, and days on treatment (DOT) with LIPUS. Every validated chronic Nonunion patient (DTT > 365 days) with complete data is reported. Results Heal rate for chronic Nonunion patients (N = 767) treated with LIPUS was 86.2%. Heal rate was 82.7% among 98 patients with chronic Nonunion ≥5 years duration, and 12 patients healed after chronic Nonunion >10 years (HR = 63.2%). There was more patient loss to follow-up, non-compliance, and withdrawal, comparing chronic Nonunion patients to all other patients (p Conclusions Low-intensity pulsed ultrasound enhanced HR among fractures that had been Nonunion for at least 1 year, and even healed fractures that had been Nonunion >10 years. LIPUS resulted in successful healing in the majority of Nonunions without further surgical intervention.
Konstantinos N Malizos - One of the best experts on this subject based on the ideXlab platform.
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a capsular based vascularized distal radius graft for proximal pole scaphoid pseudarthrosis
Journal of Hand Surgery (European Volume), 2006Co-Authors: Dean G Sotereanos, Nickolaos A Darlis, Zoe H Dailiana, Ioannis Sarris, Konstantinos N MalizosAbstract:Purpose To evaluate the clinical results of the application of a capsular-based dorsal distal radius vascularized bone graft in scaphoid proximal pole Nonunions. Methods Thirteen patients with symptomatic Nonunion at the proximal pole of the scaphoid (10 with avascular necrosis) were treated and reviewed retrospectively. The vascularized bone graft was harvested from the distal aspect of the dorsal radius and was attached to a wide distally based strip of the dorsal wrist capsule. It was inserted press-fit into a dorsal trough across the Nonunion site after scaphoid fixation with a Herbert screw. Results After a mean follow-up period of 19 months 10 of the 13 Nonunions (8 of the 10 with avascular necrosis) achieved solid bone union. No complications other than the 3 persistent Nonunions occurred. Conclusions Results of the use of a capsular-based vascularized bone graft from the distal radius for proximal pole scaphoid Nonunions compare favorably with the results of pedicled or free vascularized grafts. It is a simple technique that eliminates the need for dissection of small-caliber pedicle or microsurgical anastomoses. No donor site morbidity was observed. Type of study/level of evidence Therapeutic, Level IV.
Allen T Bishop - One of the best experts on this subject based on the ideXlab platform.
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treatment of scaphoid waist Nonunions with an avascular proximal pole and carpal collapse a comparison of two vascularized bone grafts
Journal of Bone and Joint Surgery American Volume, 2008Co-Authors: David B Jones, Allen T Bishop, Heinz Burger, Alexander Y ShinAbstract:BACKGROUND: Surgically, it is difficult to achieve union of a scaphoid Nonunion that is associated with osteonecrosis of the proximal pole, and those with carpal collapse are especially difficult to treat. A variety of vascularized bone grafts can be used. The purpose of this study was to compare the effectiveness of two types of vascularized bone graft--a distal radial pedicle graft and a free vascularized medial femoral condyle graft--in the treatment of scaphoid waist Nonunions associated with proximal pole osteonecrosis and carpal collapse. METHODS: A retrospective review was conducted at two institutions to identify all patients with a scaphoid waist Nonunion associated with an avascular proximal pole and carpal collapse. Between January 1994 and June 2006, twenty-two such Nonunions were identified in twenty-two patients. Ten were treated with a distal radial pedicle vascularized graft and twelve, with a free vascularized medial femoral condyle graft. Patient demographics were similar between the groups, and the duration of follow-up averaged twelve months. Union was determined with use of plain radiographs and computed tomography or trispiral tomograms. In addition, carpal angles, time to union, union rates, and complications were recorded. RESULTS: Four of the ten Nonunions treated with the distal radial pedicle graft healed, at a median of nineteen weeks, and all twelve Nonunions treated with the free medial femoral condyle graft healed, at a median of thirteen weeks. The rate of union was significantly higher (p = 0.005) and the median time to healing was significantly shorter (p < 0.001) for the Nonunions treated with the medial femoral condyle graft. CONCLUSIONS: A vascularized interposition graft from the medial femoral condyle is the recommended vascularized bone graft for the surgical treatment of scaphoid waist Nonunion with avascularity of the proximal pole and carpal collapse.
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free medial femoral condyle bone grafting for scaphoid Nonunions with humpback deformity and proximal pole avascular necrosis
Techniques in Hand & Upper Extremity Surgery, 2007Co-Authors: Annalise N Larson, Allen T Bishop, A Y ShinAbstract:Treatment of scaphoid Nonunions remains a challenging problem, especially in the setting of proximal pole avascular necrosis or humpback deformity. Conventional bone grafting techniques have demonstrated unpredictable results in the setting of collapse deformities, whereas pedicled dorsal distal radius vascularized bone grafts have recently been reported to have nearly a 50% failure rate when used in scaphoid Nonunions with proximal pole Nonunion. Free vascularized medial femoral condyle bone grafting is one option for the treatment of scaphoid Nonunions with proximal pole avascular necrosis associated with a humpback deformity. The indications, contraindications, and technique of free vascularized medial femoral condyle bone grafting are presented for the treatment of scaphoid Nonunions associated with proximal pole avascular necrosis and humpback deformities.
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use of the 1 2 intercompartmental supraretinacular artery as a vascularized pedicle bone graft for difficult scaphoid Nonunion
Journal of Hand Surgery (European Volume), 2002Co-Authors: Scott P Steinmann, Allen T Bishop, Richard A BergerAbstract:Fourteen patients with established scaphoid Nonunion were treated with vascularized pedicle bone grafting. All Nonunions healed at a mean of 11.1 weeks (range, 8-16 weeks). Wrist motion was minimally affected by surgery. Intercarpal and scaphoid angles were improved after surgery, particularly in patients with preoperative humpback deformity who had previous interposition grafting. Outcome, based on a self-assessment questionnaire administered at a mean 30 months of follow-up (range, 19-53 months), showed 2 excellent, 7 good, 4 fair, and 1 poor result. Three patients showed progressive radioscaphoid arthrosis. Vascularized bone grafts are indicated in proximal pole fracture Nonunions, in the presence of avascular necrosis, and after conventional grafts. Radiocarpal arthritis, if present before surgery, is a poor prognostic sign.
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role of conventional and vascularized bone grafts in scaphoid Nonunion with avascular necrosis a canine experimental study
Journal of Hand Surgery (European Volume), 2000Co-Authors: Toru Sunagawa, Allen T Bishop, Keiichi MuramatsuAbstract:The effectiveness of vascularized and conventional bone grafts in the treatment of carpal fracture Nonunion with avascular necrosis was evaluated in 12 adult dogs. The proximal third of the radiocarpal bone was removed bilaterally and frozen in liquid nitrogen. Its replacement, leaving a 4-mm gap, simulated a scaphoid fracture Nonunion with avascular necrosis. A dorsal radius inlay graft was placed across the gap. The graft was nonvascularized, or conventional on one side, and vascularized with a reverse-flow arteriovenous pedicle on the other. Following a healing period, quantitative assessment of bone blood flow, fracture healing, and bone remodeling was conducted. Seventy-three percent of the vascularized grafts and none of the conventional grafts healed. At 6 weeks, bone blood flow in the proximal pole was significantly higher on the side of the vascularized graft. Quantitative histomorphometry of the avascular proximal segment demonstrated significantly higher levels of fluorochrome-labeled osteoid- and osteoblast-covered trabecular surfaces on the vascularized graft side. These experimental data support the potential clinical application of pedicled reverse-flow vascularized grafts in the treatment of carpal fracture Nonunions with avascular necrosis, including proximal pole scaphoid Nonunions.
Alexander Y Shin - One of the best experts on this subject based on the ideXlab platform.
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vascularized medial femoral condyle corticoperiosteal flaps for the treatment of recalcitrant humeral Nonunions
Microsurgery, 2011Co-Authors: Sanjeev Kakar, Alexander Y Shin, Ahmet Duymaz, Scott P Steinmann, Steven L MoranAbstract:Background: Several methods have been used in the management of humeral Nonunions. With the advent of modern microsurgical techniques, vascularized bone grafting is becoming increasingly used to improve local biology. We report our experience in the use of a vascularized corticoperiosteal bone flap from the medial femoral supracondylar region in the treatment of recalcitrant humeral Nonunions. Methods: A retrospective review was performed of all patients treated with this technique over a 4-year period within our institution. Patient demographics, Nonunion characteristics, complications, and long-term outcomes were analyzed. Results: Six patients underwent vascularized periosteal graft reconstruction. Prior to this, all had failed an average of three procedures with the length of Nonunion ranging from 6 to 68 months. All six Nonunions healed by an average of 6.8 months (range 2–12 months). Two patients required additional secondary procedures. Functional outcome improved in all patients as adjudged by disabilities of the arm, shoulder, and hand, Mayo elbow performance, and Constant Murley scores. Conclusions: The vascularized medial femoral condyle corticoperiosteal flap provides an additional treatment option for the management of humeral Nonunions. © 2011 Wiley-Liss, Inc. Microsurgery, 2011.
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treatment of scaphoid waist Nonunions with an avascular proximal pole and carpal collapse a comparison of two vascularized bone grafts
Journal of Bone and Joint Surgery American Volume, 2008Co-Authors: David B Jones, Allen T Bishop, Heinz Burger, Alexander Y ShinAbstract:BACKGROUND: Surgically, it is difficult to achieve union of a scaphoid Nonunion that is associated with osteonecrosis of the proximal pole, and those with carpal collapse are especially difficult to treat. A variety of vascularized bone grafts can be used. The purpose of this study was to compare the effectiveness of two types of vascularized bone graft--a distal radial pedicle graft and a free vascularized medial femoral condyle graft--in the treatment of scaphoid waist Nonunions associated with proximal pole osteonecrosis and carpal collapse. METHODS: A retrospective review was conducted at two institutions to identify all patients with a scaphoid waist Nonunion associated with an avascular proximal pole and carpal collapse. Between January 1994 and June 2006, twenty-two such Nonunions were identified in twenty-two patients. Ten were treated with a distal radial pedicle vascularized graft and twelve, with a free vascularized medial femoral condyle graft. Patient demographics were similar between the groups, and the duration of follow-up averaged twelve months. Union was determined with use of plain radiographs and computed tomography or trispiral tomograms. In addition, carpal angles, time to union, union rates, and complications were recorded. RESULTS: Four of the ten Nonunions treated with the distal radial pedicle graft healed, at a median of nineteen weeks, and all twelve Nonunions treated with the free medial femoral condyle graft healed, at a median of thirteen weeks. The rate of union was significantly higher (p = 0.005) and the median time to healing was significantly shorter (p < 0.001) for the Nonunions treated with the medial femoral condyle graft. CONCLUSIONS: A vascularized interposition graft from the medial femoral condyle is the recommended vascularized bone graft for the surgical treatment of scaphoid waist Nonunion with avascularity of the proximal pole and carpal collapse.
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the vascularized medial femoral condyle periosteal bone flap for the treatment of recalcitrant bony Nonunions
Annals of Plastic Surgery, 2008Co-Authors: Umar Choudry, Steven L Moran, Karim Bakri, Zeynep Karacor, Alexander Y ShinAbstract:The purpose of this study was to examine our experience with this flap for the treatment of recalcitrant Nonunions of the extremities. A retrospective chart review was performed on 11 consecutive patients treated with the medial femoral periosteal bone flap from June 2003 to March 2005. Patient demographics, Nonunion characteristics, complications, and long-term outcome based on radiographic and clinical parameters were analyzed. Nine free transfers and 3 pedicled flaps were used for a total of 12 Nonunion sites in 11 patients. The average age of the patient population was 49 years (21-64 years). The location of the Nonunion sites were femur (n = 4), tibia (n = 2), humerus (n = 3), clavicle (n = 2), and radius (n = 1). The Nonunion sites were secondary to traumatic fractures complicated by osteomyelitis (n = 10) and tumor extirpation (n = 2). The time period of Nonunion prior to the use of vascularized periosteal bone graft ranged from 10 months to 23 years (median = 23 months). All patients had previous attempts at debridement with or without antibiotic bead placement, and all underwent rigid fixation with or without nonvascularized bone grafts prior to vascularized grafting. Following flap placement, 9 (75%) of the Nonunion sites healed primarily without complication at an average period of 3.8 months (2-7 months). Two Nonunions healed secondarily following hardware modification. There was only 1 flap failure secondary to arterial thrombosis, resulting in a below-knee amputation. The rate of limb salvage was 91%. Donor-site morbidity was minimal, with postoperative seromas occurring in 3 patients.