Graft choice for managing scaphoid non-union: umbrella review

Abstract

Introduction

Since the introduction of the non-vascularized bone graft by Matti and Russe, followed by vascularized grafts and more recently by free vascularized bone grafts, the choice of technique in scaphoid non-union has been controversial. The purpose of the present study was to address the following questions in an umbrella review: Do union rates differ between techniques? Is there any evidence that one technique is superior to another?

Methods

An umbrella review conducted during September 2023 month included systematic reviews and meta-analyses. The primary criterion was mean union rate according to technique. The secondary criterion was indication according to type of non-union. The PubMed, Cochrane, and MEDLINE databases were searched using a predefined methodology according to the criteria of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA version 2020). The quality of the systematic reviews included was evaluated by the “Assessing the Methodological Quality of Systematic Reviews” instrument (AMSTAR 2).

Results

Nine studies (systematic reviews or meta-analyses) were included. Quality ranged between low and high. A Table was constructed to summarize the qualitative findings of each article. There was no significant difference in union rates between vascularized and non-vascularized bone grafts in 8 of the 9 studies: vascularized bone graft, 84–92%; non-vascularized bone graft, 80–88%. One study found higher union rates with vascularized bone graft (RR 1.1; 95% CI 1.0–1.2; P = 0.02), but no significant difference in functional results. However, vascularized bone graft was more effective in case of avascular necrosis of the proximal pole (74–88% union for vascularized bone graft vs. 47–62% for non-vascularized bone graft) and in revision cases, while non-vascularized bone graft showed fewer failures in case of humpback deformity and/or dorsal intercalated segment instability (IRR 0.7 ± 0.09; P = 0.01).

Conclusions

This umbrella review provides an overview for management of scaphoid non-union. There were no significant global differences between techniques. Thus, various factors need to be considered when selecting the appropriate technique.