**5. Conclusion**

*Clinical Implementation of Bone Regeneration and Maintenance*

93% using the technique described by Zaidenberg.

only cases of necrosis of the proximal pole.

of VBG based on the circulation of the dorsal radius, particularly with the use of the extensor intercompartmental supraretinacular artery between 1 and 2 [1,2 ICSRA]. Supporting this data in a recent publication, [19] published a meta-analysis study which showed a consolidation rate of 88 versus 47% using VBG and NVBG, respectively. The 1,2 ICRSA runs superficially on the retinaculum of the extentions and heads distally to the radial metaphyseal bone. According to the studies using this technique, easy identification and dissection of the artery are the major advantages. This came accordingly to the work of [35], which showed a consolidation rate of

In [21, 23, 24], the 1,2 ICRSA technique was also used in their work, all reaching a consolidation rate of 100%. The three authors consider this a technically easier procedure, compared with other VBG techniques, also for being limited to only one incision. In addition, the correction DISI (dorsal intercalated segment instability) was obtained, caused by the curvature of the humpback scaphoid, a factor that helps increasing the range of motion postoperatively. Opposed to these studies, [7], the restoration of carpal geometry is essential for the consolidation, however the techniques that use bone graft derived from the distal radius, would provide a too small bone graft for humpback correction, i.e., the DISI. Thus, a means of achieving VBG that met this condition was the use of bone graft originated from the medial femoral condyle. The disadvantage of this technique would be the need of microsurgical technique usage for small vessel anastomosis, on the other hand, a graft with excellent quality would be obtained, that would offer greater rigidity when compared to graft taken from the distal radius. However, it should be noted that the technique that uses graft free from the femoral condyle requires microsurgical technique mastery, requiring specific training and long learning curve [30].

Jones et al. [30] compared two groups: VBG from the femoral condyle based on the VBG versus 1,2 ICSRA with consolidation rates of 100 and 40%, respectively. Ribak et al. [28] obtained consolidation of 89% using VBG based on 1,2 ICSRA versus consolidation of 72% using NVBG obtained from the distal radius. But for [25] using the VBG based on the 1,2 ICSRA concluded that this technique was ineffective in the series, with consolidation rates of 27% and reducing to 12.5% if we consider

Bertelli et al. [27] observed consolidation rates in 21 of 24 patients using the VBG based on the first metacarpal artery. These authors prefer to use of VBG due to the greater effectiveness in promoting bone consolidation compared to nonvascularized bone grafts, even in difficult situations such as avascular necrosis of the proximal pole. The use of VBG using the capsular movement of the distal radius was described by [26] in which obtained consolidation rates of 80%. For these authors, this is a relatively simple technique that eliminates the need for dissection of small vessels or microanastomoses, and lead to a lower risk of vascular injury. A limitation of this technique, however, lies in failing to correct the humpback scaphoid deformity. Jessu et al. [29] used VBG based on the anterior transverse carpal artery, i.e., vascularized bone grafts proposed by [34], obtained consolidation rate of 73% in 30 patients with nonunion of the scaphoid, however the two cases of proximal pole necrosis were not consolidated. The authors considered the consolidation rate disappointing, but still consider this to be an advantageous technique, mainly for its unique volar approach that reduces morbidity, but its realization requires long learning curve. All the studies that use the 1,2 ICSRA technique highlight the easy viewing and dissection of the pedicle, which make this technique extremely useful for the treatment of nonunion of the scaphoid with necrosis of the proximal pole [21–25, 28]. The studies that use NVBG, basically used cortical cancellous bone grafts, simple techniques that have as an advantage the easy material removal. But there was an important change in consolidation rates, where [31] achieved great overall

**88**

There is preference for the use of vascularized bone graft in relation to nonvascularized bone grafts, although the surgical technique is more detailed and demanding specific training, mainly in cases requiring vascular microsurgery, works using the technique for vascularized bone grafts reflect a better reproduction of positive results compared to conventional bone grafts. Therefore, according to this systematic review, there is no consensus in the literature that the use of vascularized bone graft can be effective in all cases for scaphoid consolidation with necrosis of the proximal pole.
