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Skaphoidpseudarthrose

Komplexe Rekonstruktionen mithilfe vaskularisierter Knochentransplantate

Scaphoid pseudarthrosis

Complex reconstruction using vascularized bone grafts

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Zusammenfassung

Die wichtigsten Ziele der Skaphoidrekonstruktion bei Pseudarthrosen sind die Beseitigung der „Humpback“-Deformität, die Wiederausrichtung der proximalen Handwurzelreihe und die stabile knöcherne Heilung des Skaphoids. Zu diesem Zweck ist in den meisten Fällen die Insertion eines Knochentransplantats erforderlich. Um die Heilungsrate zu erhöhen und die Durchblutung zu verbessern, wurden verschiedene Formen vaskularisierter Knochentransplantate entwickelt. Gefäßgestielte Transplantate werden vorzugsweise von der Dorsal- oder Palmarseite des distalen Radius entnommen, mit Heilungsraten zwischen 27 % und 100 %. Freie vaskularisierte Transplantate können vom Beckenkamm und von der medialen oder der lateralen Femurkondyle gehoben werden, mit Fusionsraten zwischen 60 % und 100 %. Für ihre Anwendung ist eine mikrochirurgische Ausrüstung erforderlich. Osteochondrale Transplantate von den Femukondylen bieten bisher die einzige Möglichkeit, Transplantate zu gewinnen, die Teile der Gelenkfläche des unbelasteten Patellagleitlagers tragen und damit einen vaskularisierten Gelenkflächenersatz ermöglichen. Die Anwendung vaskularisierter Knochentransplantate wird kontrovers diskutiert, weil ihre Überlegenheit gegenüber nichtvaskularisierten Knochentransplantaten, die in einzelnen Serien ebenfalls bis100 %ige Ausheilungsraten erreichen, nicht belegt ist. Sie sind indiziert bei Zweiteingriffen nach fehlgeschlagenen Rekonstruktionen und bei Pseudarthrosen mit kleinen avaskulären proximalen Polfragmenten. Da bisher keine evidenzbasierten Leitlinien existieren, wird ein erfahrungsbasierter Behandlungsalgorithmus für Skaphoidpseudarthrosen unter besonderer Berücksichtigung vaskularisierter Transplantate dargestellt.

Abstract

The most important goals of scaphoid reconstruction in pseudarthrosis are correction of the humpback deformity, the realignment of the proximal carpal row and the bony union of the scaphoid. Therefore, in most cases bone grafting is required. To increase the healing rate and to improve vascularization, several kinds of vascularized bone grafts have been developed. Pedicled grafts are preferably harvested from the dorsal or palmar side of the distal radius with fusion rates between 27% and 100%. Free microvascular grafts can be obtained from the iliac crest and the medial or lateral femoral condyle with fusion rates between 60% and 100%. For their application microsurgical equipment and skills are required. Up to now osteochondral grafts from the femoral condyle offer the only chance for joint surface replacement by transferring part of the surface of the femoropatellar joint. The use of vascularized grafts is still a matter of controversy, since their superiority is still unproven compared to nonvascularized grafts, which also achieved 100% fusion rates in several series. They are indicated in secondary procedures after failed reconstruction and nonunion with small avascular proximal pole fragments. Since no evidence-based guidelines exist, this article provides an experience-based treatment algorithm for scaphoid nonunion with special consideration to vascularized bone grafts.

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Authors and Affiliations

  1. Klinik für Handchirurgie, Salzburger Leite 1, 97616, Bad Neustadt an der Saale, Deutschland

    K. H. Kalb, J. van Schoonhoven &  T. Pillukat

  2. Klinik und Poliklinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Westfälische Wilhelms-Universität, Münster, Deutschland

    M. Langer

  3. Klinik für Unfall- und Handchirurgie, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland

    J. Windolf

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  1. K. H. Kalb
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  2. M. Langer
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  4. J. van Schoonhoven
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  5. T. Pillukat
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Correspondence to T. Pillukat.

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K.H. Kalb, M. Langer, J. Windolf, J. van Schoonhoven und T. Pillukat geben an, dass kein Interessenkonflikt besteht.

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

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M. Schädel-Höpfner, Neuss

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Kalb, K.H., Langer, M., Windolf, J. et al. Skaphoidpseudarthrose. Unfallchirurg 122, 200–210 (2019). https://doi.org/10.1007/s00113-019-0609-9

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