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Pedicled Vascularized Bone Grafts for Disorders of the
Carpus: Scaphoid Nonunion and Kienböck’s Disease
Alexander Y. Shin, MD, and Allen T. Bishop, MD
Abstract
The use of reverse-flow pedicled vascularized bone grafts from the dorsal distal
radius makes it possible to transfer bone with a preserved circulation and viable
osteoclasts and osteoblasts. The resultant primary bone healing without creeping
substitution within the dead bone is an alternative to conventional bone grafting
in aiding or accelerating healing, replacing deficient bone, and/or revascularizing
ischemic bone. Recent advances in understanding the anatomy and physiology
of vascularized pedicled bone grafts have increased their use in treating a
variety of carpal maladies. A basic understanding of the vascular anatomy, as
well as the surgical principles and experimental and clinical results of pedicled
vascularized bone grafts from the dorsal distal radius, is critical to understanding
the use of these grafts in the treatment of scaphoid nonunions and
Kienböck’s disease.
J Am Acad Orthop Surg 2002;10:210-216
The use of pedicled vascularized
bone grafts (VBGs) in the reconstruction
of bone defects or osteonecrosis
is nearly a century old. In
1905, Huntington transferred a fibula
with its nutrient artery pedicle in
the reconstruction of a tibial defect. 1
Sixty years later, Roy-Camille transferred
a pedicled VBG (scaphoid
tubercle) on an abductor pollicis
brevis muscle pedicle to a delayed
scaphoid fracture union. 2 VBGs,
unlike conventional bone grafts,
preserve the circulation as well as
viable osteoclasts and osteoblasts,
which allows primary bone healing
without creeping substitution within
the dead bone. 3 Use of pedicled
VBGs in a variety of carpal maladies,
including scaphoid nonunions,
Kienböck’s disease, and
failed arthrodesis, may aid or accelerate
healing, replace deficient bone,
and/or revascularize ischemic bone.
The results reported to date have
been promising, 4-15 especially in the
treatment of scaphoid nonunions
and Kienböck’s disease.
Background
Sheetz et al 16 published a comprehensive
study of the extraosseous
and intraosseous blood supply of
the distal radius and ulna in 1995.
Based on their descriptive anatomy
of the radial blood supply, they
identified several new reverse-flow
pedicled VBGs from the dorsal distal
radius and clarified the anatomy
of pedicled VBGs. The use of these
reverse-flow pedicled VBGs in the
treatment of difficult scaphoid
nonunions and Kienböck’s disease
has been clinically promising. 17,18
The technical ease of harvesting
these dorsal grafts, the reliability
and robustness of the bone nutrient
vessel blood supply, and the long
vascular pedicle length have all
been factors in increasing the clinical
use of these grafts.
Experimental studies have provided
scientific validation for the
use of reverse-flow pedicled grafts
from the radius. Using a canine
forelimb model, which closely models
the human vascular anatomy, a
variety of retrograde-flow pedicled
VBGs were fashioned. 19 Immediately
after graft elevation, bone
blood flow measurements were
obtained in undisturbed bone and
in free grafts without a vascular
pedicle, at the time of surgery, and
after a 2-week survival period. 20
Immediate blood flow in a pedicled
graft was 51% of the undisturbed
contralateral radius (8.42 versus
16.53 mL/min/100 g, respectively).
A hyperemic response at 2 weeks
increased the flow fourfold, to twice
the undisturbed radius value (33.72
versus 16.53 mL/min/100 g, respectively)
and 54 times the minimal
flow seen in an identical conven-
Dr. Shin is Assistant Professor, Orthopedic
Surgery, Division of Hand and Microvascular
Surgery, Mayo Clinic, Rochester, MN. Dr.
Bishop is Professor, Orthopedic Surgery, and
Chair, Division of Hand and Microvascular
Surgery, Mayo Clinic.
Reprint requests: Dr. Bishop, 200 First Street
SW, Rochester, MN 55905.
Copyright 2002 by the American Academy of
Orthopaedic Surgeons.
210
Journal of the American Academy of Orthopaedic Surgeons

Alexander Y. Shin, MD, and Allen T. Bishop, MD
tional nonvascularized graft (33.72
versus 0.62 mL/min/100 g, respectively).
20 These data demonstrate
that after elevation, reverse-flow
pedicled grafts from the canine dorsal
distal radius have significant
immediate blood flow that is not
only maintained but that substantially
increases over time. Application
of such grafts to experimental
osteonecrosis and nonunion in a
canine model has demonstrated
their superiority to conventional
grafting techniques. 21 These important
experimental data, together
with published clinical results, validate
the use of such grafts for carpal
pathology.
Vascular Anatomy of the
Dorsal Distal Radius
RA
dRCA
1,2 ICSRA
2,3 ICSRA
4 th ECA
5 th ECA
aAIA
AIA
dICA
UA
dSRA
PIA
pAIA
Figure 1 Vascular anatomy of the dorsal
distal radius. RA = radial artery, dRCA =
dorsal radiocarpal arch, 1,2 ICSRA and 2,3
ICSRA = 1,2 and 2,3 intercompartmental
supraretinacular arteries, 4th and 5th ECA
= fourth and fifth extensor compartmental
arteries, aAIA and pAIA = anterior and
posterior divisions of the interosseous
arteries, AIA = anterior interosseous artery,
PIA = posterior interosseous artery, dSRA
= dorsal supraretinacular arch, UA = ulnar
artery, dICA = dorsal intercarpal arch.
(Adapted with permission from the Mayo
Foundation, Rochester, MN.)
Sheetz et al 16 demonstrated a constant
pattern of dorsal radius blood
vessels with consistent spatial relationships
to surrounding anatomic
landmarks. Proximal arteries contributing
to the distal radial and ulnar
blood supply include the radial,
ulnar, anterior interosseous, and
posterior interosseous arteries (Fig. 1).
Of these, the posterior divisions of
the anterior interosseous artery and
the radial artery form the primary
sources of orthograde blood flow to
the dorsal distal radius. Four vessels,
branches of these arteries, are
important in the design of pedicled
grafts. Two of these are superficial
to the extensor retinaculum (supraretinacular),
supplying nutrient
branches to the bone underlying
bony tubercles between extensor
tendon compartments (intercompartmental).
The other two are
deep vessels, located on the floor of
extensor compartments (compartmental).
The two superficial intercompartmental
vessels, the 1,2 and
2,3 intercompartmental supraretinacular
arteries (1,2 and 2,3 ICSRAs),
are located between their numbered
compartments. The two deep vessels
on the floor of the fourth and
fifth compartments are the fourth
and fifth extensor compartment
arteries (fourth and fifth ECAs).
The 1,2 ICSRA courses from the
radial artery approximately 5 cm
proximal to the radiocarpal joint
and lies beneath the brachioradialis
muscle to emerge on the dorsal surface
of the extensor retinaculum. In
the anatomic snuffbox, the 1,2
ICSRA anastomoses with the radial
artery and/or the radiocarpal arch.
Like all dorsal distal radius arteries,
the 1,2 ICSRA is accompanied by
two venae comitantes. The origin of
the distal portion of the 1,2 ICSRA is
the ascending irrigating branch
described by Zaidemberg et al. 15
However, the vessels lie superficial
to the extensor retinaculum rather
than directly on the periosteum, as
originally described. This location
makes its dissection straightforward.
Its pedicle has a short arc of
rotation, and the number and caliber
of its nutrient artery branches
to bone are small (average, 3.2 nutrient
arteries and

Pedicled Vascularized Bone Grafts
tiple anastomoses make it a desirable
source of retrograde blood
flow. However, unlike the other
three dorsal vessels, the fifth ECA
seldom provides direct nutrient
branches to the radius. As such, it is
often used as a conduit in conjunction
with the fourth ECA.
A very important series of three
arterial arches crosses the dorsum of
the hand and wrist and provides the
distal anastomotic network for the
intercompartmental and compartmental
arteries: the dorsal intercarpal
arch, dorsal radiocarpal arch,
and dorsal supraretinacular arch.
The dorsal intercarpal arch is an
important part of several potential
grafts because of its anastomotic
connections with the 1,2 ICSRA, 2,3
ICSRA, fourth ECA, and dorsal
radiocarpal arch. The dorsal intercarpal
arch can be used as a source
of retrograde arterial flow after
proximal vessel ligation and graft
mobilization.
Three criteria must be met for a
pedicled VBG to be successful.
First, the pedicle must be of sufficient
length to reach the recipient
site without undue tension. Second,
the pedicle must include nutrient
vessels supplying both cortical and
cancellous bone. Finally, the vessels
must have sufficient blood flow to
maintain bone viability. The VBGs
of the dorsal distal radius successfully
meet all three of these requirements
and, based on the vascular
anatomy of the dorsal distal radius,
allow for a number of potential
pedicled VBGs to be fashioned (Fig.
2). The arc of rotation of harvested
grafts varies based on location and
selection of vessels utilized (Fig. 3).
osteonecrosis of the proximal pole
fragment, and osteonecrosis of the
scaphoid (Preiser’s disease). Nonunions
through the scaphoid waist
with foreshortening and carpal collapse
are best treated with a volar
wedge graft (conventional or vascularized).
The value of VBG in acute
fractures remains unproven.
Figure 2 A number of VBGs can be harvested
from the dorsal distal radius based
on the nutrient arteries that perforate the
radius and the robust anastomotic vascular
network. The circled areas are the potential
sites of VBG donors and their respective
pedicles. (Adapted with permission
from the Mayo Foundation, Rochester,
MN.)
Technique
The most useful pedicled VBG
for a scaphoid nonunion is that
based on the 1,2 ICSRA. Before
exposure, the arm is elevated for
exsanguination. Use of an Esmarch
bandage is to be avoided because
vessel identification and dissection
are more difficult when the bandage
is used. A gentle curvilinear dorsal
radial incision is used to expose the
scaphoid and bone graft donor site
(Fig. 4). Subcutaneous tissues are
gently retracted, and the superficial
radial nerve is identified and protected.
The 1,2 ICSRA and its two
venae comitantes are visualized on
the surface of the retinaculum between
the first and second extensor
tendon compartments. The vessels
are traced toward their distal anastomosis
with the radial artery (toward
the anatomic snuff box). Next,
the first and second dorsal extensor
compartments are opened at the
Clinical Application
Scaphoid Nonunion
The indications for pedicled VBG
for scaphoid problems include
nonunions, failed previous bone
graft, small proximal pole fracture,
A
Figure 3 The arc of reach of various distal radius pedicled bone grafts is notable. A, Graft
based on the 1,2 ICSRA and its branch to the second extensor compartment. B, Graft based
on the fourth ECA with retrograde flow through the fifth ECA from the dorsal intercarpal
arch. (Adapted with permission from the Mayo Foundation, Rochester, MN.)
B
212
Journal of the American Academy of Orthopaedic Surgeons

Alexander Y. Shin, MD, and Allen T. Bishop, MD
I
II
III
S
R
RA
1,2 ICSRA
SBRN
A
B
Figure 4 Pedicled VBG for scaphoid nonunion. A, The incision (dashed line) exposes the scaphoid and bone graft donor site.
Subcutaneous tissues are raised from the extensor retinaculum, and the 1,2 ICSRA is identified. RA = radial artery, S = scaphoid, R =
radius. B, Branches (I, II, III) of the superficial branch of the radial nerve (SBRN) are identified and protected. Dashed lines = incisions of
the first and second extensor compartments. (Adapted with permission from the Mayo Foundation, Rochester, MN.)
level of the bone graft site to create a
cuff of retinaculum containing the
vessels and their nutrient arteries to
bone. The graft is centered approximately
1.5 cm proximal to the radiocarpal
joint to include the nutrient
vessels. Before elevation of the bone
graft, and while protecting the 1,2
ICSRA pedicle, a transverse dorsalradial
incision is made to expose the
scaphoid nonunion site.
In most proximal pole fracture
nonunions and more distal fractures
without carpal collapse, the dorsal
inlay graft is most appropriate.
Osteotomes are used to prepare a
rectangular slot that spans the fracture
site to receive the bone graft.
Curettes are used to remove any
fibrous tissue from the nonunion
site. In very small proximal pole
fragments, the graft may be shaped
to lie within the concavity of the
proximal pole as an alternative.
After preparation of the nonunion
site, the graft is elevated. The center
of the graft is located approximately
1.5 cm from the radiocarpal joint.
Graft elevation begins with proximal
ligation of the 1,2 ICSRA and
accompanying veins proximal to the
graft. The appropriate graft size is
measured and marked. The vessels
are mobilized distal to the graft to
separate them from the styloid tip
and joint capsule. The radial, ulnar,
and proximal osteotomies of the
graft are made with sharp osteotomes.
The distal cut is done in two
steps, moving the pedicle first radially
and then ulnarly to prevent its
injury. The graft is then gently levered
out to create a distally based,
reverse-flow pedicle (Fig. 5, A).
With the tourniquet deflated, circulation
to the graft is confirmed by the
observation of a pulsatile pedicle
and bleeding bone surface. The
A
graft is resized with bone cutters or
a burr and is transposed beneath the
radial wrist extensors to the nonunion
site.
If the scaphoid nonunion is relatively
stable, internal fixation is not
required. However, if the nonunion
is unstable, fixation with multiple
Kirschner wires (K-wires) or a
scaphoid screw before graft placement
is recommended. The choice
of K-wires or screw depends on the
fracture location as well as on the
technical abilities of the surgeon.
All hardware should be placed as
Figure 5 A, With the graft levered out, the tourniquet is deflated and the vascularity of
the graft is checked. B, The graft is gently press-fit into the scaphoid nonunion site.
Supplemental fixation with K-wires or placement of scaphoid screws may be done at this
time. (Adapted with permission from the Mayo Foundation, Rochester, MN.)
B
Vol 10, No 3, May/June 2002 213

Pedicled Vascularized Bone Grafts
far volar as possible to avoid interference
with graft placement. The
graft is then press-fit into the prepared
slot on the dorsal surface
spanning the nonunion (Fig. 5, B).
The wrist capsule and extensor retinaculum
are replaced without
suture reapproximation. A bulky
long-arm plaster thumb spica splint
is then applied.
Postoperatively, digital range of
motion and edema control measures
are used. Between 10 and 14
days postoperatively, the dressing
is removed, and a long-arm thumb
spica cast is applied for the first 6
weeks. A short-arm thumb spica
cast is then placed until fracture
union is achieved.
Results
Fifteen patients with established
nonunions were treated with reverseflow
pedicled distal radius VBGs, as
described. 18 All patients were
males, with an average age of 27.6
years (range, 17 to 42 years) and an
average interval between injury and
surgery of 36.2 months (range, 3
months to 10 years). Six patients
had fractures through the scaphoid
waist and nine in the proximal third.
Five patients had a previous conventional
bone graft that failed. Six
patients demonstrated radiographic
and magnetic resonance imaging
evidence of proximal pole osteonecrosis.
Fourteen patients underwent
VBG using the 1,2 ICSRA from the
dorsal aspect of the radius. Twelve
patients had the graft placed as a
dorsal inlay, and three had an interpositional
wedge graft placed to correct
scaphoid malalignment. Fracture
fixation was with K-wires or
Herbert screws. All patients were
initially immobilized with a longarm
thumb spica cast, followed by a
short-arm cast until healing was
demonstrated by trispiral tomograms.
Follow-up averaged 2.5 years
(range, 1 to 4 years). All patients
achieved fracture union, with time
to union averaging 11.1 weeks
(range, 5.5 to 16 weeks). Two thirds
of the patients (10 of 15) were very
satisfied with the results of surgery.
Seventy-three percent (11 of 15) had
occasional pain or discomfort with
strenuous activity, and 53% (8 of 15)
returned to their previous occupation
and leisure activity with mild
limitations. Eighty percent of patients
(12 of 15) demonstrated a flexion/extension
arc averaging 90° and
a radial/ulnar deviation arc of 42°.
The scapholunate and capitolunate
angles averaged 58.3° and 8.8°,
respectively. The average carpal
height index was 0.54. The interscaphoid
angulation averaged 23.6°
posteroanteriorly and 24.6° laterally.
Kienböck’s Disease
The treatment of Kienböck’s disease
depends on the stage of the disease,
the ulnar variance, and the
condition of the cartilaginous shell
of the lunate. Options for treatment
include load-altering surgeries, such
as radial shortening or scaphocapitate
arthrodesis; revascularization
with VBG or arteriovenous pedicles;
or salvage procedures for advanced
disease. Revascularization with
VBG can be done even in advanced
(stage IIIB) cases, provided that the
cartilage shell is intact, that is, without
fracture or fragmentation, and
that no arthrosis is found. Revascularization
with pedicled bone grafts
is an alternative to load-altering
procedures and is especially attractive
in ulnar neutral or plus variance
cases when radial shortening is
contraindicated. Vascularized bone
grafting from the distal radius can
be a useful adjunctive procedure to
radial shortening in patients with an
ulnar negative variant. Contraindications
include stage IV disease and
lunate fragmentation.
Technique
The fourth and fifth ECA graft is
the workhorse pedicle in the treatment
of Kienböck’s disease. Although
either the 2,3 ICSRA or the
fourth ECA can be used as a single
pedicle alone, the combination of the
fourth and fifth ECAs is preferred.
In such a graft, retrograde flow from
the fifth ECA then flows orthograde
into the fourth ECA via their common
anterior interosseous artery origin.
The combined fourth and fifth
ECA pedicle has several unique
advantages: the large diameter of
the fifth ECA allows for robust
blood flow; the pedicle is ulnar to
any planned arthrotomy; and the
combined pedicle, because of its
great length, can reach anywhere in
the carpus.
Harvesting of the fourth and fifth
ECA graft requires identification of
the fourth ECA by opening the
fourth dorsal extensor compartment
(Fig. 3, B). The fourth ECA and
venae comitantes are visualized on
the radial aspect of the compartment,
lying adjacent to the posterior
interosseous nerve. The fourth ECA
is traced proximally to its origin
from the posterior division of the
anterior interosseous artery. Here
the fifth ECA is also identified arising
from the same vessel and traced
distally. The fifth ECA may be
found partially within the septum
separating the fourth and fifth
extensor compartments but more
commonly lies entirely within the
fifth extensor compartment. A bone
graft centered 1.1 cm proximal to
the radiocarpal joint and overlying
the fourth ECA will include radius
nutrient vessels.
Once the graft is marked, the
anterior interosseous artery is ligated
proximal to the fourth and fifth
ECAs. Graft elevation is completed,
and the pedicle is elevated to allow
tension-free placement of the graft.
During the surgery, the lunate must
be inspected. This may be done
best by an arthrotomy once the fifth
ECA is mobilized and protected. If
the cartilage shell of lunate is not
compromised or fragmented, vascularized
bone grafting is feasible.
214
Journal of the American Academy of Orthopaedic Surgeons

Alexander Y. Shin, MD, and Allen T. Bishop, MD
Otherwise, a salvage procedure
should be done. Under direct visualization
and fluoroscopic image,
necrotic bone is removed from the
lunate with a burr or curettes, leaving
a shell of intact cartilage and
subchondral bone through a dorsal
opening. If collapsed, the lunate is
gently expanded to normal dimensions
with a small blunt-ended
spreader. At this time, the tourniquet
is deflated to verify blood flow
to the graft. Cancellous bone graft
harvested from the distal radius
bone graft defect is packed into the
lunate, followed by insertion of the
VBG, orienting the pedicle vertically
with the cortical surface placed in a
proximal-distal orientation. This
allows the graft to serve as a strut to
help maintain lunate height during
revascularization (Fig. 6). Internal
fixation of the graft to the lunate is
unnecessary.
Unloading of the lunate is important
during the revascularization
process and may be accomplished
by external fixation, capitate shortening,
intercarpal arthrodesis, or
temporary pinning of the intercarpal
joint. Although external fixation
was commonly used as a method of
unloading the lunate, we favor
scaphocapitate pinning with two
percutaneously placed 0.0625-inch
K-wires, which are cut subcutaneously,
for 8 to 12 weeks. The temporary
scaphocapitate pinning
avoids the pin site problems associated
with prolonged external fixation.
The wrist capsule is replaced,
the extensor retinaculum repaired,
and a long-arm bulky hand dressing
applied.
Postoperatively, the bulky hand
dressing is removed at 10 to 14 days
and is replaced with a long-arm cast
for 2 to 3 weeks. At 3 weeks postoperatively,
the cast is removed and
gentle, supervised, limited wrist
flexion and extension is begun. The
wrist is protected with a custommade
plastic splint for the next 8 to
9 weeks. The scaphocapitate K-wire
A
Figure 6 Pedicled VBG for Kienböck’s disease. A, The anterior interosseous artery is ligated
proximal to the fourth and fifth ECAs, and graft elevation is completed. After verifying
blood flow, the graft is shaped to fit the dorsal opening to the lunate. B, Cancellous
bone is packed into the lunate. The VBG is inserted with the pedicle placed vertically and
the cortical surface oriented proximal-distal. (Adapted with permission from the Mayo
Foundation, Rochester, MN.)
fixation is removed under local anesthetic
at 12 weeks.
Results
The results of nine VBGs obtained
from the radial metaphysis in
patients with stage IIIA Kienböck’s
disease, using reverse-flow pedicles,
have been reported. 17 The grafts
were based on the 2,3 ICSRA in two
patients, fourth ECA in four, fifth
and fourth ECAs in two, and palmar
radiocarpal arch in one. The procedure
was used without joint leveling
in four patients who had ulnar neutral
or positive variance, while three
patients with ulnar negative variance
had a concomitant radial shortening.
All but one patient had external
fixation for temporary lunate
unloading. Follow-up averaged 32
months (range, 7 to 90 months). Grip
strength improved 25%, ultimately
measuring a mean of 86% of the
opposite side (range, 60% to 100%).
Range of motion was not significantly
different from preoperative status.
Radiographic measurements demonstrated
no change in the modified
carpal height ratio, lunate index, or
scapholunate angle. Only two
patients were without collapse preoperatively,
based on carpal height
ratio values. Both progressed postoperatively,
although absolute numeric
change was slight. Magnetic resonance
imaging data demonstrated
progressive signs of revascularization
over time, with normalization
of T2 images seen initially by 18
months, followed by normalization
of T1 images by 36 months.
Summary
Vascularized bone grafts from the
dorsal distal radius can be effectively
applied to treat carpal problems
such as scaphoid osteonecrosis and
nonunion as well as Kienböck’s disease.
Although the vascular anatomy
of the distal radius provides the surgeon
with several alternative grafts,
we have found the 1,2 ICSRA pedicle
to be most useful for the scaphoid
and the fourth and fifth ECAbased
graft desirable for lunate
B
Vol 10, No 3, May/June 2002 215

Pedicled Vascularized Bone Grafts
revascularization. Experimental
studies have demonstrated robust
blood flow to bone maintained over
2 weeks in similar canine radial
grafts. Clinical series have demonstrated
the grafts’ ability to promote
healing of recalcitrant scaphoid
nonunions and to provide symptomatic
relief and eventual revascularization
of the lunate in Kienböck’s
disease. Use of pedicled VBGs from
the distal radius adds an effective
tool to the armamentarium of the
orthopaedic surgeon treating these
difficult carpal maladies.
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