Abstract
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Dear Sir,
We appreciate Dr Mathoulin’s interest and comments on our paper. We note that he and others now favour vascularized bone grafts taken from the palmar aspect of the distal radius which can be inserted into the scaphoid fracture nonunion through a palmar approach rather than those harvested from the dorsum of the distal radius, such as the one which we utilized which was originally described by Zaidemberg.
When writing our paper, we were particularly careful to restrict our findings and conclusions to the vascularized bone graft which we used and which is based on the 1/2 intercompartmental supraretinacular artery. We fully accept that other pedicled vascularized bone grafts may have better vascularity and provide stronger bone such that they produce better results than those which we reported. Alternatively, we accept that our results, which are much the worst reported in the literature for vascularized bone grafts, may reflect poor surgical technique though the fact that both the senior surgeons obtained similar results in different centres makes this less likely: this was the reason why we published our results.
Regardless of the potential failings of our study, we feel that the role of vascularized bone grafts in the management of scaphoid fracture nonunion is still unclear. If the proximal fragment of the scaphoid nonunion is vascular, then it is our opinion that standard bone grafting, whether using corticocancellous graft from the distal radius or the iliac crest, works satisfactorily with a high success rate. It is only when the proximal pole is avascular (though has not collapsed) that standard bone grafts have high failure rates in our experience, and this is why we almost exclusively utilized vascularized bone grafts for such cases. We fully agree that vascularized bone grafts cannot be regarded as a miracle remedy and, as reported in our study, we rarely achieved union of avascular proximal poles. However, what we did not report was our clinical impression that a significant number of patients obtained symptomatic improvement. In addition, the plain radiographic appearances of some of our cases suggested union, though CT scanning confirmed failure.
We have not dismissed vascularized bone grafts as a technique for the management of scaphoid fracture nonunion. However, we continue to use standard bone grafts for nonunions with vascular proximal poles and are considering the use of alternative vascularized bone grafts for scaphoid fracture nonunions with avascular, though not fragmented, proximal poles. We entirely agree with Dr Mathoulin that there are considerable advantages to the use of a graft which can be inserted through a palmar approach.