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Skaphoidpseudarthrose

Indikationsbereiche für das avaskuläre Beckenkamm- oder Radiustransplantat

Scaphoid pseudarthrosis

Indications for avascular iliac crest or radius bone grafts

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Zusammenfassung

Hintergrund

Für die rekonstruktive operative Therapie der Skaphoidpseudarthrose stehen neben den avaskulären kortikospongiösen und rein spongiösen Transplantaten gestielte und freie gefäßgestielte kortikospongiöse Transplantate zur Verfügung. Insbesondere letztere erfordern einen hohen Anspruch an operative Fertigkeit und mikrochirurgische Erfahrung.

Fragestellung

Welche Kriterien werden zur Entscheidungsfindung für oder gegen ein avaskuläres Transplantat zur Rekonstruktion der Skaphoidpseudarthrose herangezogen? Reichen insbesondere unsere bisherigen Klassifikationen der Skaphoidpseudarthrose aus, um die Vielfalt der inzwischen möglichen diagnostischen Verfahren sowie der operativen Möglichkeiten abzubilden und Empfehlungen auszusprechen?

Material und Methode

Darstellung und Auswertung der aktuellen Literatur.

Ergebnisse

Avaskuläre Transplantate zeigen bei gutem Wirtslager mit entsprechender suffizienter Durchblutung eine hohe Einheilungsquote. Die Patienten profitieren im Regelfall von einer sehr guten postoperativen Beweglichkeit. Auch Revisionsoperationen sind bei entsprechend guter Fragmentdurchblutung keine Kontraindikation gegenüber dem avaskulären Transplantat. Grenzen der Einsetzbarkeit des Verfahrens bestehen bei unzureichender vaskulärer Versorgung, insbesondere des proximalen Poles, sowie dem Vorliegen einer ausgedehnten Pseudarthrose mit Sklerose oder Resorption. Bisherige Klassifikationen der Skaphoidpseudarthrose spiegeln die Möglichkeiten der Diagnostik unzureichend wider und erschweren die Therapieempfehlungen.

Schlussfolgerungen

Zur operativen Rekonstruktion der Skaphoidpseudarthrose hat das avaskuläre Transplantat weiterhin seine Berechtigung. Aktuelle Klassifikationen erlauben jedoch derzeit keine eindeutige Zuordnung, welches die Vergleichbarkeit der Ergebnisse erschwert.

Abstract

Background

Operative treatment of the scaphoid nonunion includes avascular corticocancellous and cancellous bone grafts and increasingly the use of vascular pedicled and free vascular corticocancellous grafts. Especially the latter require a fair amount of operative expertise and experience in microsurgical techniques.

Objective

Which criteria lead to the decision for or against an avascular graft used for reconstruction of scaphoid nonunion? Is our current classification system of a scaphoid pseudarthrosis able to illustrate our diagnostic potential in a way that makes us refer to operative procedures?

Methods

Evaluation of current literature and expert opinions

Results

Avascular bone grafts show a high union rate as long as a sufficient vascularisation of the remaining fragments is present. In general, patients benefit from a very good functional outcome. Even revisions of failed scaphoid union may be successfully treated with an avascular bone graft. Failures of union are repeatedly experienced in treating proximal pole fractures with critical vascularisation or extensive bone loss, especially including avascular necrosis of the proximal pole (AVN). Current classification systems do not allow description and correlation of morphologic findings so as to compare results profoundly and to recommend specific procedures.

Conclusions

As long as sufficient vascularisation of remaining fragments is seen, the avascular bone graft is eligible for reconstructing scaphoid nonunion. Classification systems do not seem to reflect the status quo of diagnostic possibilities and make it difficult to provide guidelines for state-of-the-art operative procedures.

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Authors and Affiliations

  1. Abt. Hand-, Replantations- und Mikrochirurgie, Unfallkrankenhaus Berlin, Warener Str. 7, 12683, Berlin, Deutschland

    A. Asmus, B. Schacher & A. Eisenschenk

  2. Abt. Hand- und funktionelle Mikrochirurgie, Universitätsmedizin Greifswald, Ferdinand-Sauerbruchstr, 17475, Greifswald, Deutschland

    S. Kim & A. Eisenschenk

  3. Handchirurgie, obere Extremität und Fußchirurgie, Zentrum für Orthopädie und Unfallchirurgie, Krankenhaus Waldfriede e.V., Argentinische Allee 40, 14163, Berlin, Deutschland

    M. Lautenbach

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Correspondence to A. Asmus.

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A. Asmus, M. Lautenbach, B. Schacher, S. Kim und A. Eisenschenk geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

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Asmus, A., Lautenbach, M., Schacher, B. et al. Skaphoidpseudarthrose. Orthopäde 45, 951–965 (2016). https://doi.org/10.1007/s00132-016-3337-7

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