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ORIGINAL ARTICLE ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ NONUNION OF THE SCAPHOID WITH AVASCULAR NECROSIS TREATED WITH A PEDICLED VASCULARIZED BONE GRAFT BASED ON THE 1,2INTERCOMPARTMENTAL SUPRARETINACULAR BRANCH OF THE RADIAL ARTERY UNDER ULTRASOUND GUIDEDINFRACLAVICULARBRACHIAL PLEXUS BLOCK Rashed E. Rashed and Mohamed H. Hamada. Orthopedic Department ,Faculty Of Medicine,Al-Azhar University, Cairo And Anesthesia Department,Faculaty Of Medicine, Al-Azharuniversity,Cairo. ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ ABSTRACT Background: The use of vascularized bone grafts from the dorsum of the distal radius for the treatment of nonunited fracture of the scaphoid with avascular proximal fragment. When pre-operative suggestion of avascular necrosis is confirmed by intra-operative evaluation, conventional bone graft is not enough and a vascularized bone graft is recommendedespecially under sympathetic block with regional anesthesia. Patient and methods: From May 2010 to November 2014, Ten patients with nonunited fracture of the scaphoid with avascular proximal fragment were treated with pedicled vascularized bone graft based on the 1,2Intercompartmentalsupraretinacular artery (1,2 ICSRA). All cases was done in Sayed Galal university hospital. All surgical procedures were done under ultrasonic guided infraclavicular brachial plexus block. Postoperative visual analogue score (VAS) at 1, 3, 6, 12, 24 hours, first analgesic request and total analgesic consumption after 24 hours were recorded. Results:at a mean follow-up period of 29.3 months, all patients were clinically improved. Seven patients (70%) reported the absence of pain and only two (25%) reported slight discomfort after hard work and only one case (10%) reported pain with light work. The wrist range of motion improved, with extension improved from 58° to 73° postoperatively and flexion improved from 59.5° to 75° postoperatively. The hand grip strength also improved from 17.2 Kg to 25.2 kg postoperatively. In seven patients, the bones united within 3 months, the other three patients union was achieved after 6 months. The mean scapholunate angles were 60.5 degrees and improved to 47.5 degrees postoperatively. Postoperative VAS was 20.8 ±1.4 at 24 postoperatively, first analgesic request was 17.4±15.16 hours and analgesic consumption were 2.8±1.2 mg and 200±80 mg for morphine and paracetamol respectively. Conclusion:1, 2 ICSRA is superficial to the extensor retinaculum and is a proper pedicle of vascularized bone graft due to the ease of visibility and dissection. The functional results and union rates were satisfactory in our study. The duration of postoperative analgesia was more than 12 hours postoperatively. INTRODUCTION entirely on intraosseous blood flow. This Scaphoid fractures constitute 60% to 70% tenuous blood supply to the proximal pole of the of all carpal bone fractures. These fractures scaphoid helps to explain the increased have a well documented tendency to progress to frequency of delayed union, nonunion, and nonunion.(1)The importance of a correct avascular necrosis (AVN) of scaphoid fractures. diagnosis and appropriate treatment of scaphoid Avascular necrosis is reported to occur in 13% fractures lie in the scaphoid’s blood supply. The to 50% of scaphoid fractures, with an even main blood supply to the scaphoid is from the higher incidence in those involving the proximal radial artery. More than 80% of the scaphoid one-fifth of the scaphoid.(3) surface is covered with articular cartilage. The Both clinical and biological factors dorsal scaphoid branches from the radial artery contribute to the development of nonunion. enter the nonarticular portion of the scaphoid at Biological factors include the degree of fracture the dorsal ridge at the level of the waist and displacement, the fragile vascular supply of the supply the proximal 70% to 80% of the scaphoid, and its complex anatomy.Clinical scaphoid.(2)The volar scaphoid branches from factors include variable patient symptoms such either the radial artery or the superficial palmar as minimal pain and swelling, compliance with branch enter at the distal tubercle and supply the immobilization, lack of medical and distal 20% to 30% of the scaphoid. Thus, the radiological diagnosis, and delays in vascularity of the proximal pole depends treatment.(4)Langhoff and Andersen(5) found that 50 | P a g e

Moussa A. Hussein and Ibrahim S. Ibrahim VOL 13 , NO 1 , JANUREY 2015 the nonunion rate was 40% when diagnosis and ranged from 27 years to 43 years with an treatment was delayed by 4 weeks.(5) average of 35.2 years. There were 8 males and 2 Most symptomatic scaphoid nonunions females. The dominant hand was affected in 5 eventually develop a collapse, or “humpback” patients and the nondominant hand in 5 patients. deformity, followed by onset of wrist arthrosis. Wrist pain and limitation of wrist movement If left untreated, scaphoid nonunions are was the presenting symptom in all the patients predisposed to premature carpal arthrosis and and was present for an average of 18 months long-term disability.(1) The conventional Russe (range12 to 36 months) preoperatively. Six bone grafting procedure is a reliable method for patients had previous conservative treatment to the treatment of symptomatic nonunion of the the acute fracture in the form of below elbow scaphoid.(6)Interpositional wedge grafts or scaphoid cast; only one patient had previous Maltese cross bone grafts have been suggested mattiRusse inlay graft trial to the nonunion eight for patients with humpback deformities or months before the procedure and three patients significant gaps were present.(7) When had no previous treatment and neglected any preoperative suggestion of avascular necrosis form of immobilization to the acute fracture. All (AVN) of the proximal pole and confirmed by patients were available for follow-up at an intraoperative evaluation, vascularized bone average of 29 months (range 18 months to 40 grafts are strongly recommended.(8) months) after the procedure. When a massive free bone graft has to be Table (1): Ten Patients with nonunited incorporated into a large bone defect in the fracture scaphoid; Materials and Methods Duratio presence of a poor vascular recipient bed, the Follow n of up risks of absorption and failure of the graft to Cas gend ag Sid Fractu nonuni Previous period e er e e re site on treatment revascularize are high. Studies have confirmed (month (month that a bone graft that is transferred to a recipient s) s) site with an intact pedicle of blood supply conservati 1 M 34 RT Waist 18 40 remains viable, in addition, it unites directly ve 2 F 27 LT p. pole 12 neglected 39 with the recipient bone without necessity of conservati 3 M 36 LT Waist 24 36 revascularization or replacement by creeping ve substitution. It also provides a live bone bridge 4 M 40 RT Waist 24 neglected 36 Russe 5 M 35 RT Waist 36 30 for reconstruction of a massive bone defect, and inlay graft is a ready source of vascular osteogenic tissue 6 M 43 LT p. pole 12 neglected 26 conservati which sprouts new outgrowths to revascularize 7 F 38 RT Waist 12 26 (8) ve avascular recipient bone tissue. conservati 8 M 33 RT Waist 12 24 Dexamethasone was proposed as safe ve conservati adjuvant to local anesthetic but there was a 9 M 29 RT p. pole 18 18 ve study comparing this drug in ultrasound guided conservati 10 M 37 LT Waist 12 18 (US) peripheral nerve blocks; we would to ve reevaluate this combination (lidocaine and Pre- and postoperative clinical and dexamethasone)(9). radiographic evaluation was done. Clinical The purpose of our study was to evaluate evaluation involves assessment of pain, range of the long term results of implantation of pedicled motion of the wrist and grip strength. The range vascularized bone graft from the dorsum of the of motion was measured with a goniometer distal radius based on the 1,2 including flexion, extension, radial and ulnar Intercompartmentalsupraretinacular artery (1,2 deviation. The grip strength was measured with ICSRA) in patients with nonunited fracture of a dynamometer. Postoperatively clinical and the scaphoid with avascular proximal fragment. functional results were reported according modified mayo wrist scoring system (table 2). PATIENTS AND METHODS From May 2010 to November 2014, Ten patients with nonunited fracture of the scaphoid with avascular proximal fragment were treated with pedicled vascularized bone graft from the dorsum of the distal radius based on the 1,2Intercompartmentalsupraretinacular artery (1,2 ICSRA) (Table 1). All cases was done in Sayed Galal university hospital. Patient age 51 | P a g e

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Table 2: Mayo Wrist Scoring System. exsanguinate the extremity before tourniquet Category Score Findings inflation. This will allow for better visualization No pain Mild pain with vigorous activities of the donor vessels during operation. Operative 25 Pain only with weather changes 20 field was approached through a curvilinear Moderate pain with vigorous 20 dorsoradial incision (Figure 1) Once the Pain activities 15 (25 points) Mild pain with activities of daily subcutaneous tissues were gently raised from 10 living 5 the extensor retinaculum, the 1, 2 ICSRA was Moderate pain with activities of 0 daily living visualized on the surface of the extensor Pain at rest retinaculum between the first and second 25 Very satisfied extensor compartments (figure 2). an interval Satisfaction 20 Moderately satisfied (25 points) 10 No satisfied, but working was developed between the first and second 0 No satisfied, unable to work dorsal compartments that were opened at the 25 100% percentage of normal 15 75%-99% percentage of normal graft elevation site. Range of Motion 10 50%-74% percentage of normal (25 Points) 5 25%-49% percentage of normal 0 0%-24% percentage of normal 15 75%-99% percentage of normal Grip strength 10 50%-74% percentage of normal (25 points) 5 25%-49% percentage of normal 0 0%-24% percentage of normal 90- Excellent Final Result 100 Good (total points) 80-89 Fair 65-79 <65 Poor The radiographic evaluation involves plain radiograph, PA and lateral views pre- and Figure (1): approach to the 1,2 ICSRA postoperative. The scapholunate angle (SL) was through curvilinear dorsoradial incision measured. The presence of AVN was diagnosed using magnetic resonance imaging (MRI). Areas of low signal intensity on T1- weighted images and high signal or iso-signal intensity on T2-weighted images were the criteria for the diagnosis of avascular necrosis. The final confirmation of avascular necrosis was the absence of punctate bleeding in the proximal pole intraoperatively. Anesthetic procedure: All procedures were done under ultrasonic guidedinfraclavicular brachial plexus block Figure (2): the1,2 ICSRA appears on the with15 ml lidocaine 2% plus 2 ml of surface of the extensor retinaculum between dexamethasone (8 mg) and the patients were the first and second extensor compartments routinely monitored with electrocardiogram The tendons of the first compartment are (ECG), non-invasive blood pressure (NIBP) retracted radially and the tendons of the second measurement, and pulse oximetry (SpO2) during compartment are retracted ulnarly (figure 3). procedures. The postoperative analgesia was The pedicle was dissected gently to its distal assessed at 1, 3, 6, 12, and 24 h using Verbal radial artery anastomosis and proximally to the Analog Scale (VAS) and the duration of level of the harvest site. The center of the graft analgesia were recorded (the time between the was 1.5 cm proximal to the radiocarpal joint to end of LA administration and the first analgesic include the nutrition vessels (figure 4). Before request). The patient received, if VAS ≥ 30, IV the graft was elevated, the scaphoid nonunion paracetamol 500 mg and 0.1 mg/Kg morphine site was prepared. Smallosteotome and small intravenously). curette were used to remove fibrous tissue from Operative procedure:All patient were the nonunion site and removing sclerotic bone placed supine on the operating table while from the proximal and distal fragments (figure placing his or her arm pronated on the hand 5). The absence of punctate bleeding in the table. A tourniquet is used but inflated only to proximal pole confirmed the diagnosis of 250 mm Hg. the Esmarch is not used to avascular necrosis. a dorsal trough is made in 52 | P a g e

Moussa A. Hussein and Ibrahim S. Ibrahim VOL 13 , NO 1 , JANUREY 2015 the dorsal cortex of the scaphoid bridging the nonunion site to fit the graft (figure 6).

Figure 6: a dorsal trough is made in the Figure (3): The tendons of the first dorsal cortex of the scaphoid bridging the compartment are retracted radially and the nonunion site to fit the graft and the scaphoid tendons of the second compartment are was fixed with one or two K- wires retracted ulnarlyand the1,2 ICSRA appears A graft sufficiently large to fill the in the septum between the compartments scaphoid defect was raised containing the vessels and cuff of the retinaculum between the first and second compartments (figure 4). Before implantation of the graft, multiple cancellous bone chips were taken from the graft site bed to help filling the defect in the fracture site. The graft is implanted in the prepared site and the scaphoid is fixed with one or two smooth Kirschner wiresdepending on the size of the proximal fragment. The tourniquet was deflated to ensure hemostasis. The capsule is closed without strangulating the pedicle and the skin is closed Figure 4:The center of the graft was 1.5 cm Postoperative care: a below elbow volar slab is proximal to the radiocarpal joint to include applied for 6-8 weeks and replaced with the nutrition vessels removable splint. The Kirschner wires were removed after complete bone healing under local anesthesia. RESULTS Clinical and functional results:The average follow-up period was 29.3 months (range, 18 to 40 months). The Clinical and functional results are summarized in (table 3). All patients complained of pain before surgery. All patients were clinically improved. seven patients (70%) reported the absence of any discomfort and only two (25%) reported slight Figure 5: The nonunion site was prepared discomfort after hard work and only one case with smallosteotome and small curett to (10%) reported pain with light work, this case remove fibrous tissue from the nonunion site required radial styloidectomy ten months after and removing sclerotic bone from the the grafting procedure for arthritic proximal and distal fragments. radioscaphoid joint. The wrist range of motion improved significantly, the mean preoperative wrist extension was 58° (range 45:65 degrees) and improved to 73°postoperatively ( range65:80 degrees). The mean preoperative flexion was 59.5° (range 50: 65) and improved

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to75°postoperatively (range 60:80). The hand of bone revascularization (figure grip strength also improved; with the average 9).Postoperative VAS was 20.8 ±1.4 at 24 preoperative grip strength was 17.2 Kg (range postoperatively (Table 5), first analgesic 14:20 kg) and postoperatively the average grip request was 17.4±15.16 hours and strength was Kg 25.2 kg (range20:30 kg). analgesic consumption were 2.8±1.2 mg according to the modified Mayo Wrist Scoring and 200±80 mg for morphine and Chart, were rated as excellent in seven cases , paracetamolrespectively (Table 6). good in two cases and fair in one case of the Table 4: preoperative and postoperative patients assessment of the scapholunate angle Table (3): Ten cases with fracture scaphoid Preoperative SL Postoperative SL angle Case no. nonunion angle (in degrees) (in degrees) Grip Clinic pain Range of motion 1 65 45 strength al 2 60 40 extensio results flexion 3 70 50 Fract n (mayo ca 4 65 40 ure wrist se Pr po Pr po site scorin 5 65 45 e- st Pre Po Pr Po e- st g 6 55 40 - st- e- st- syste 7 60 45 m 8 55 40 Excell 1 Waist + - 60 80 55 75 18 25 9 50 40 ent 10 60 45 p. Excell 2 + - 60 80 60 75 20 26 pole ent Table 5: postoperative assessment of pain Excell 3 Waist + - 55 75 60 80 16 25 visual analogue scale (VAS) (mean ± SD) ent 4 Waist + +/- 60 75 55 70 15 23 Good VAS Mean±SD(n=10) 5 Waist ++ + 50 60 45 65 14 20 Fair After 1h. 2±1 p. Excell 6 + - 65 75 65 75 18 28 After 3h. 2±0.2 pole ent After 6h. 2.1±0.1 Excell 7 Waist + - 60 75 60 70 17 26 ent After 12h. 2±0.1 Excell After 24h. 2.8±1.4 8 Waist + - 60 80 65 80 18 27 ent p. Table 6: First analgesic request&total 9 + +/- 60 70 55 65 16 22 Good pole postoperative Excell 10 Waist + - 65 80 60 75 20 30 morphine¶cetamolconsumption ent (mg/24h) Radiographic results: In the early postoperative period all patients had plain Variable Mean±SD (n=10) radiograph (posteroanterior and lateral) First analgesic request 17.4±15.16 every four weeks.In seven of the ten Morphine 2.8±1.2 Paracetamol 200±80 patients, the bones united and the A trabeculaeappeared bridged within 3 B months after surgery (figures 7,8). The other three patients trabecular bridging of the scaphoid fracture was achieved 6 months after surgery. The mean union time was 4.5 months (range, 3-6 months). The preoperative severity of the collapse and postoperative correction of the deformities were measured and comparatively reviewed with the results summarized in

(Table 4). The mean preoperative SL angles were 60.5 degrees (range, 50-70 degrees) and postoperatively it improved to

47.5 degrees (range, 40-50 degrees).All patients had preoperative MRI for assessment of vascularity of the proximal fragment, but only six patients had postoperative MRI and all showed improvement in T1 and T2 signal as a sign C D 54 | P a g e

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Figure (7): A 27-year-old female patient with In a meta-analysis of the literature, scaphoid nonunion. (A,B) Radiographs show vascularized bone grafting of scaphoid scaphoid nonunion; treated with 1, 2 ICSRA nonunions with osteonecrosis was found to be pedicled bone graft. (C,D) Radiographs at 6 associated with a union rate of 88% compared months after operation show trabecular with 47% in association with conventional bridging of the nonunion site. (nonvascularized) grafting.(9) Green(10) reported a prospective study of patients with nonunion of A the scaphoid treated using the Russe bone grafting method. Twenty-four of 26 patients (92%) with good vascularity in the proximal pole achieved solid union, but none of the five patients in whom the proximal pole was totally avascular achieved successful union. He concluded that the absence of intraoperative BB punctate bleeding points on the cancellous surface indicated avascularity of the proximal pole and may explain the failure of bonegrafting procedures. When pre-operation suggestions of severe AVN of the proximal pole are confirmed intra-operatively, a vascularized pedicle bone graft should be strongly considered.(10) Living bone heals faster than nonvascularizedautografts and does so without creeping substitution of C D necrotic bone. This offers a shorter period of immobilization and a higher union rate. A Figure (8): A 29-year-old male patient with grafted bone with adequate blood supply may scaphoid waist nonunion, with failed aid the revascularization of an avascular previous mattiRusse graft fixed with Herbert segment of bone.(8) screw. (A,B)PA and oblique radiograph Many different methods have been showing the nonunion site and the graft reported for obtaining vascularized grafts. One fragment , erosion of the trapezium by the of the earliest reports of a vascularized pedicled screw head. It was treated with 1, 2 ICSRA bone graft applied to carpal pathology was by pedicled bone graft. (C)PA radiograph 4 Roy-Camille in 1965.(11) Using the scaphoid weeks postoperative. (C) Radiographs at 6 tubercle on an abductor pollicisbrevis muscle months after the operation show trabecular pedicle, Roy-Camille performed a vascularized bridging of the nonunion site. bone graft to assist successfully in the healing of (11) B a scaphoid waist delayed union. In 1983, Braun,(12)described a volar distal radius bone graft based on a pronator quadratus muscle/anterior interosseous artery pedicle and successfully treated five scaphoid nonunions.(12) Similarly, Kuhlmann et al,(13) described a palmar distal radius graft based on a branch of the palmar radiocarpal arch used successfully in three scaphoid nonunions after failed conventional grafts.(13) The volar distal radius grafts have significant limitations, however, including variable nutrient vessel position and A diameter, a short arc of rotation, and potential for ligamentous injury and carpal instability Figure (9) : MRI of the case in figure (7); (A) resulting from carpal exposure from a palmar preoperative MRI showing low signal approach.(14)Guimberteau and Panconi,(15) intensity denoting AVN. (B) eight months described a distal ulna pedicled graft based on a postoperative MRI showing union and reverse-flow ulnar artery pedicle and revascularization of the proximal pole successfully treated 8 established scaphoid DISCUSSION nonunions that failed conservative bone 55 | P a g e

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grafting. These authors reported the technique inflammatory effects. Stan et al.(28) stipulated as demanding and recommended an ulnar that the steroids suppress the synthesis of arterial reconstruction with a vein graft.(15) various inflammatory mediators, which In 1991, a pedicled vascularized distal prolongs the period of analgesia up to 48 hours. radius bone graft was described by Zaidemberg Attardi et al.(29) showed that dexamethasone acts et al,(16) based on the ascending irrigating branch on nociceptive C-fibers via glucocorticoid of the radial artery and reported 100% union of receptors increasing the inhibitory potassium 11 established scaphoid nonunions. The dorsal channels activity. Another possibility is that radial location of this graft allowed a single prolongation of LA block occurs because of surgical incision for graft harvest, carpal systemic effects of dexamethasone. Some exposure, and placement in scaphoid authors believe that analgesic properties of nonunions.(16) Because of its location, the vessel steroids are the result of their systemic was named the 1, 2 effect.(30,31) intercompartmentalsupraretinacular arteries (1, We concluded that vascularized 2 ICSRA). It is easily visible after retraction of bone graft with 1, 2 ICSRA is useful to the skin and subcutaneous tissues. The arc of repair a nonunion with AVN of a scaphoid rotation was sufficient to reach the scaphoid fracture. No patient needs postoperative bone area.(8) analgesia until 12 hours postoperatively. Tu et al.(17,18) reported an animal study REFERENCES and demonstrated that the pedicle vascularized 1. AnandPanchal,ErikKubiak, Mitchell bone grafts maintained enhanced bone Keshner, Eric Fulkerson, Nader circulation long-term, and the data supported the Paskima. Comparison of fixation clinical use for scaphoid avascular necrosis.(17,18) methods for scaphoid nonunions: a Boyer et al.(19) reported scaphoid nonunion with biomechanical model. Joint Dis. Rel. AVN of the proximal pole that was managed Surg. 2007;18(2):66-71 with a vascularized dorsal interposition graft 2. Gelberman RH, Menon J. The from the distal radius.(19) The procedure resulted vascularity of the scaphoid bone. J Hand in the union of 6 of 10 fractures. Uerpairojkit et Surg 1980;5:508 –513. al.(20) also reported a vascularized bone graft 3. Kenji Kawamura, Kevin C. Chung. from the dorsoradial aspect of the distal radius Treatment of Scaphoid Fractures and used with internal fixation to treat nonunion of Nonunion. J Hand Surg 2008;33A: 988 – the scaphoid in 10 patients who had not 997. received any previous surgical treatment.(20) 4. King Wong, Herbert P. von Schroeder. Associated AVN was observed in five patients. Delays and Poor Management of Postoperatively pain was relieved and union Scaphoid Fractures: Factors Contributing was achieved in all cases. Range of motion, grip to Nonunion. J Hand Surg strength and pinch strength were also 2011;36A:1471–1474. satisfactorily restored. The 1, 2 ICSRA is 5. Langhoff O, Andersen JL. superficial to the retinaculum and runs directly Consequences of late immobilization of into the bony tubercle. It is a proper pedicle of scaphoid fractures. J Hand Surg vascularized bone graft due to the ease of 1988;13B:77–79. visibility and dissection. As regard 6. Stark A, Brostrom LA, Svartengren G. postoperative analgesia our study showed that Scaphoid nonunion treated with the the VAS was less than 3 at 24 postoperatively, Matti-Russe technique. Longterm results. first analgesic request was more than 17 hours ClinOrthop 1987;214:175-80. and analgesic consumption were less than 3 mg 7. Smith BS, Cooney WP. Revision of for morphine and about 200 mg for paracetamol failed bone grafting for nonunion of the during 24 hours postoperatively. scaphoid. Treatment options and results. Several studies showed that ClinOrthop 1996;327:98-109. dexamethasone.(22-25), when added to peripheral 8. Tsung-Ting Tsai; En-Kai Chao1; nerve block, extend the duration and to improve Yuan-Kun Tu; Alvin Chao-Yu Chen; the quality of postoperative analgesia.The Mel Shiuann-Sheng Lee; Steve Wen- mechanism of the analgesia induced by steroids NengUeng. Management of Scaphoid is not clear. Previous works.(26,27)demonstrated Nonunion with Avascular Necrosis Using that it is suspected to be mediated by their anti- 1, 2 IntercompartmentalSupraretinacular 56 | P a g e

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Arterial Bone Grafts.(Chang Gung Med J the canine distal radius and ulna. J Hand 2002;25:321-328) Surg Am 2000;25:34-45. 9. WalidTrabelsi, AnisLebbi, 19. Tu YK, Bishop AT, Kato T, Adams ChihebeddineRomdhani, Imen Naas, ML, Wood MB. Experimental carpal WalidSammoud, HaythemElaskri, reverse-flow pedicle vascularized bone IhebLabbene and Mustapha Ferjani; grafts. Part II: bone blood flow Dexamethasone Provides Longer measurement by radioactive-labeled Analgesia than Tramadol when Added to microspheres in a canine model. J Hand Lidocaine after Ultrasound Guided Surg Am 2000;25:46-54. Supraclavicular Brachial Plexus 20. Boyer MI, von Schroeder HP, Axelrod Block.AnalgResusc: Curr Res 2013, 2:2 TS. Scaphoid nonunion with avascular 10. David B. jones jr.,heinz burger, allen T. necrosis of the proximal pole. Treatment bishop,and alexander Y. shin. with a vascularized bone graft from the Treatment of Scaphoid Waist Nonunions dorsum of the distal radius. J Hand Surg with an Avascular Proximal Pole and Br 1998;23:686-90. Carpal Collapse. A Comparison of Two 21. Uerpairojkit C, Leechavengvongs S, Vascularized Bone Grafts. J Bone Joint Witoonchart K. Primary vascularized Surg Am. 2008;90:2616-2625. distal radius bone graft for nonunion of 11. Green DP. The effect of avascular the scaphoid. J Hand Surg Br necrosis on Russe bone grafting for 2000;25:266-70. scaphoid nonunion. J Hand Surg Am 22. Movafegh A, Razazian M, 1985;10:597-605. Hajimaohamadi F, Meysamie A. 12. Roy-Camille Dexamethasone added to lidocaine R.Fracturesetpseudarthroses du prolongs axillary brachial plexus scaphoidemoyen: Utilisation dun blockade. AnesthAnalg2006; 102: 263- greffopedicule. Actual ChirOrthop R 267. Poincare 4:197-214,1965. 23. Kim YJ, Lee GY, Kim DY, Kim CH, 13. Braun RM: Viable pedicle bone grafting Baik HJ, et al. Dexamathasone added to in the wrist. In Urbaniak JR (ed): levobupivacaine improves postoperative Microsurgery for Major Limb analgesia in ultrasound guided Reconstruction. St Louis, CV Mosby, interscalene brachial plexus blockade for 1987, pp 220-229 arthroscopic shoulder surgery. Korean J 14. Kuhlmann JN: Vascularized bone graft Anesthesiol2012; 62: 130-134. pedicled on the volar carpal artery for 24. Vieira PA, Pulai I, Tsao GC, non-union of the scaphoid. J Hand Surg Manikantan P, Keller B, et al. 12203-210,1987 Dexamethasone with bupivacaine 15. Alexander Y. Shin, and Allen T. increases duration of analgesia in Bishop. Vascularized bone graft for ultrasound-guided interscalene brachial scaphoid nonunion and kienbock's plexus blockade. Eur J disease. Orthopaedic clinics of north Anaesthesiol2010;27: 285-288. america; volume 30, Number 2. April 25. Parrington SJ, O’Donnell D, Chan 2001: 263-277. VW, Brown-Shreves D, Subramanyam 16. Guimberteau JC, Panconi B: R, et al. Dexamethasone added to Recalcitrant non-union of the scaphoid mepivacaine prolongs the duration of treated with a vascularized bone graft analgesia after supraclavicular brachial based on the ulnar artery. J Bone Joint plexus blockade. RegAnesth Pain Med Surg Am 72:88-97,1990 2010;35: 422-426. 17. Zaidemberg C, Siebert JW, Angrigiani 26. McCormack K.The spinal actions of C. A new vascularized bone graft for nonsteroidal anti-inflammatory drugs and scaphoid nonunion. J Hand Surg the dissociation between their anti- Am1991;16:474-8. inflammatory and analgesic effects. 18. Tu YK, Bishop AT, Kato T, Adams Drugs 1994;47: 28-45. ML, Wood MB. Experimental carpal 27. Ahlgren SC, Wang JF, Levine JD. C- reverse-flow pedicle vascularized bone fiber mechanical stimulus-response grafts. Part I: the anatomical basis of functions are different in inflammatory vascularized pedicle bone grafts based on 57 | P a g e

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versus neuropathic hyperalgesia in the rat. Neuroscience 1997;76: 285-290. 28. Stan T, Goodman EJ, Bravo- Fernandez C, Holbrook CR. Adding methylprednisolone to local anesthetic increases the duration of axillary block. RegAnesth Pain Med 2004;29: 380-381. 29. Attardi B, Takimoto K, Gealy R, Severns C, LevitanES.Glucocorticoid induced up-regulation of a pituitary K+ channel mRNA in vitro and in vivo. Receptors Channels1993; 1: 287-293. 30. Aasboe V, Raeder JC, GroegaardB . Betamethasone reduces postoperative pain and nausea after ambulatory surgery. AnesthAnalg1998;87: 319-323. 31. Baxendale BR, Vater M, Lavery KM. Dexamethasone reduces pain and swelling following extraction of third molar teeth. Anaesthesia1993;48: 961- 964.

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Moussa A. Hussein and Ibrahim S. Ibrahim VOL 13 , NO 1 , JANUREY 2015

عالج تنكزس العظمت الشورقيت بسبب الكسور غيز الملتئمت ببستخذام رقعت مذممت مغذاه بفزع مه الشزيبن الكعبزي مه أسفل عظمت الكعبزة راشذ امبم راشذ و محمذ حسيه حمبده قسٌ جشاحخ اىعظبً & قسٌ اىزخذٝش ٗاىشعبٝخ اىَشمضح ) طت االصٕش ثْجِ ( اىقبٕشح ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ ٝحذس عذً اىزئبً مسش اىعظَخ اىضٗسقٞخ ٗ رْنشصٕب ثسجت ٍحبٗىخ االصالح غٞش اىَزقِ ىينس٘س ، أٗ عذً اصالح اىنس٘س غٞش اىَسزقشح . ٗ عْذٍب ٝضجذ ٍِ اىزشخٞص رْنشص اىقطت اىقشٝت ىيعظَخ اىضٗسقٞخ اىَنس٘سح قجو إجشاء جشاحخ إصالحٖب فإّٔ ٝنُ٘ ٍِ األفضو اسزخذاً سقعخ عظَٞخ ٍذٍَخ ىضٝبدح احزَبىٞخ ّجبح اىجشاحخ ٗ اىزئبً اىنسش ٗ رفضٞيٖب عِ اسزخذاً اىشقعخ اىعظَٞخ اىعبدٝخ ) غٞش اىَذٍَخ (. رٌ اّجبص ٕزٓ اىذساسخ فٜ اىفزشح ٍب ثِٞ عبً 2009 ٗ حزٚ عبً 2013 حٞش قَْب ثبسزخذاً اىشقعخ اىعظَٞخ اىَذٍَخ ٍِْ أسفو عظَخ اىنعجشح ٗ رضجٞذ اىنسش ثأسالك ٍعذّٞخ . حٞش مبُ عذد اىَشضٚ ٍحو اىجحش 10 حبالد ميٌٖ ٍصبة ثزْنشص اىقطت اىقشٝت ىينسش ثبىعظَخ اىضٗسقٞخ. ٗ مبُ رقٌٞٞ اىْزبئج ثعَو قٞبط ىيَذٙ اىحشمٜ ىيشسغ ٗ ق٘ح قجضخ اىٞذ ٗ رقٌٞٞ حذح األىٌ ٍع عَو األشعخ اىسْٞٞخ ٗ أشعبد ثيشِّٞ اىَغْبطٞسٜ قجو ٗ ثعذ اىجشاحخ. ٗقذ خيصذ ّزبئج اىجحش إىٚ اٟرٜ : فٜ خاله ٍعذه اىَزبثعخ 29.3 شٖش ثعذ اىجشاحخ أشبسد اىْزبئج إىٚ رحسِ جَٞع اىَشضٜ ٍحو اىجحش حٞش أُ 70 % ٍِ اىَشضٚ شعشٗا ثعذً ٗ ج٘د أٛ أىٌ ثَْٞب شعش 25 % ٌٍْٖ ثعذ اسرٞبح ثسٞط ثعذ أداء اىعَو اىشبق.ٗ مبّذ شنٙ٘ ٍشٝض ٗاحذ فقط) 5 %( ٜٕ اىشع٘س ثأىٌ أصْبء اىعَو اىخفٞف. مَب رحسِ اىَذٙ اىحشمٜ ىيشسغ ثشنو ٍيح٘ظ عْذ ٍعظٌ اىَشضٚ ٗ مزىل رحسْذ ق٘ح قجضخ اىٞذ إرا ٍب ق٘سّذ ثق٘رٖب قجو اىجشاحخ. ٗ قذ اسزعْب ثَقٞبط ) ٍبٝ٘ سن٘س ( اىَعْٜ ثزقٌٞٞ ّزبئج جشاحبد اىٞذ ٗ اىشسغ ، ٗ اىزٛ دىْب عيٚ اىْزبئج اىزبىٞخ :  مبُ رصْٞف 7 ٍِ اىَشضٜٕ ٚ دسجخ ٍَزبص ) ٍبٝ٘ سن٘س (، ٗ مبُ رقذٝش جٞذ ٕ٘ رقذٝش ) 2 ٌٍْٖ ( ٗ مبُ رقذٝش ٍقج٘ه ٕ٘ ىيَشٝض اى٘حٞذ ٍِ اىعششح ٍشضٚ .  ٗ ثبسزخذاً األشعخ ٍب ثعذ اىجشاحخ ر٘صيْب إىٚ اإلىزئبً اىنبٍو ىنس٘س اىعظَخ اىضٗسقٞخ عْذ سجعخ ٍِ اىَشضٚ فٜ خاله 3 أشٖش ٍب ثعذ اىجشاحخ ، ثَْٞب رأخش اإلىزئبً اىنبٍو إىٚ اىشٖش اىسبدط ثعذ اىجشاحخ فٜ صالصخ ٍشضٚ .  لذلك فقذ أفبدتنب الذراست بأفضليت استخذام الزقعت العظميت المذممت في حبلت تنكزس العظكت الشورقيت المكسورة عه استخذام الزقعت العظميت التقليذيت .

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