Used routinely in maxillofacial reconstructive surgery, the chondrocostal graft is also applied to hand surgery in traumatic or pathologic indications. The purpose of this overview was to analyze at long-term follow-up the radiological and histological evolution of this autograft, in hand and wrist surgery. We extrapolated this autograft technique to the elbow by using perichondrium.

Since 1992, 148 patients have undergone chondrocostal autograft: 116 osteoarthritis of the thumb carpometacarpal joint, 18 radioscaphoid arthritis, 6 articular malunions of the distal radius, 4 kienbock's disease, and 4 traumatic loss of cartilage of the proximal interphalangeal (PIP) joint. Perichondrium autografts were used in 3 patients with elbow osteoarthritis.

Magnetic Resonance Imaging (MRI) was performed in 19 patients with a mean follow-up of 68 months (4–159). Histological studies were performed on: i) perioperative chondrocostal grafts (n=3), ii) chondrocostal grafts explanted between 2 and 48 months after surgery (n=10), and iii) perioperative perichondrium grafts (n=2).

Whatever the indication, the reconstruction by a chondrocostal/ostochondrocostal or perichondrium graft yielded satisfactory clinical results at long-term follow-up. The main question was the viability of the graft.

-

For rib cartilage grafting: The radiological study indicated the non-wear of the graft and a certain degree of ossification. The MRI and histology confirmed a very small degree of osseous metaplasia and graft viability. The biopsies showed neo-vascularization of the cartilage that had undergone morphological, constitutional and architectural changes. Comparison of these structural modifications with perioperative chondrocostal graft histology is in progress.

Despite the strong mechanical strain in the hand and wrist, chondrocostal graft is a biological arthroplasty that is trustworthy and secure over the long term, although it can cause infrequent complications inherent to this type of surgery. Despite the inevitable histological modification, the cartilage remains alive and is of satisfactory quality at long term follow-up and fulfills the requirements for interposition and reconstruction of an articular surface.

The perichondrium graft constitutes a new arsenal to cure cartilage resurfacing. The importance of perichondrium for the survival of the grafted cartilage, as previously reported, as well as its role in resurfacing, is being investigated.

The treatment for trochanteric femoral fractures is still challenging. Since 2005, we are using 2 new implants: Gamma3™ nail and the PFN-A™.

All patients with a fracture of the trochanteric area were included in an observational study during 3 years.

Objectives were radiographics and clinics (complications) comparaison of these 2 new devices.

We included 426 patients (236 Gamma3™ nails, 190 PFN-A™). We faced the epidemiological data, per and post-operative complications. The tip-apex distance and the position of the cephalic implant were studied.

The 2 implants were well positionned in more than 80%, with no statistic diffferencie. We found a a cut-out rate of 1,4 % and a re-operation rate of 4,9 %. These rates of usual complications are very low in comparaison with litterature. We did not found a statistic difference between these 2 differents nails.

But, we observed 2 unusual complications: for the Gamma3™ nail, a high rate of automatic distal locking failure, and for the PFN-A™, many patients complained of thigh pain resulting from a prominent cephalic blade. These 2 new complications can be avoided by small changes in the operative procedure.

In our mind these 2 implants can be used for treating all patients with trochanteric fracture, but we need other studies to compare these nails with the new generation of sliding plate

Purpose of the study: The purpose of this work was to analyse the respective complications of nail fixations for trochanteric fractures. Since January 2005, we have used the Gamma3™ and the PFN-A™ in routine practice. These nails have evolved and we wanted to compare the latest generation models.

Material and methods: This was a prospective consecutive series of 426 files in a single centre (January 2005 to October 200) reviewed at mean 19 months (3–36 months). All patients with a fracture of the trochanter treated by osteosynthesis were included. Eight senior operators implanted Gamma3™ nails (4 operators) or PFN-A™ nails (4 operators). During this period, 236 Gamma3™ and 190 short PNF-A™ nails were implanted. The two cohorts were statistically comparable regarding: mean age, body weight, ASA score, preoperative autonomy, repair of fracture type.

Results: There was no significant difference between the two implants for: implant position (correct position for 80%), early mortality (5.5%), rate of sepsis (1.6%), which were comparable with the literature. In these two groups, the operative time was shorter than in the literature with an advantage for the PFN-A™ (40 min versus 35 min). Sliding was minimal (1.3% for Gamma3™ versus 1.1% for PFN-A™), as was revision (5.1% versus 4.7%). Conversely, the technical complications were implant dependent: defective automatic distal locking for the Gamma3™ (n=24, 10.2%) with fracture on nail for four patients, and protrusion of the cephalic blade for the PFN-A™ (n=11, 5.8%) due to insufficient impaction and to back glide after excessive distraction followed by impaction.

Discussion: There is a rich body of knowledge on the different nail and screw-plate models. Mean sliding is to the order of 4% and mean revision about 8–9%. We could not find a study comparing the new implant generations. These implants enable a reduction of the general complications for trochanteric surgery, but to ensure persistent results, care must be taken for the distal locking of the Gamma3™ and the intraoperative protrusion of the PFN-A™ blade.

Introduction: Humerus non union is unfrequent, and reported series short. New fixation with or without autograft remain the gold standard to achieve bone union in 95% of cases. But no report are published in case of failure of that new procedure. 9 patients with a failure of autograft in humerus non union have been treated by new fixation an adjonction of BMP

Matériel et méthodes: 9 patients with an average age of 53,8 yo (24–71) have been treated and followed prospectively for a minimum time of 3 years. The delay between the fracture and the secon procedure was 31 months (6–103). The number of procedure after the fracture fixation was 1,4 (1–5). In 6/9 cases a technical pitfall during the initial procedure was pointed. In 3/9 cases a radial palsy associated with the initial fracture, a septic condition of the non union, general risk factors of non union (diabetes, tabac) and a non collaborative patient were reported.

Bone union was defined as the continuity of 4/4 cortex on Xray (AP and sagital plane) and or with ct scan. Osigraft^® (BMP7) was implanted in the resected zone of non union which was fixed with 2 plates after reaming and decortication.

Résults: No complication have been reported. One case failed (septic non union, 3 procedures, very active patient). The 8 last patients achieved bone union with a delay of 11,1 mois (6–14) without any additive procedure. The 3 septic cases have been solved. Shoulder and elbow function were good without nerves complications.

Discussion:: Autograft remains the gold standard in term of treatment of non union. But nothing is reported in humerus non union if iliac crest autograft have failed to achieve non union. In such an indication (failure after an autograft) and in such a level (humerus can be shorten) a stable fixation an a growth factor allowed to solve resistant cases of non union even in septic conditions.

The failure of the initial treatment of the fracture (unstable fixation, unfilled bone’s defect) remain the main cause of non union.

Introduction: Occult fractures of carpal bones are underestimed. To be treated succesfully fractures of the scaphoid must be identified at an early stage. A delay in detection may result in non union. We validated with 3 prospective studies a new tool using scintigraphy : The quantitative Xray bone scan (QRS)

Material and Methods: A previous preliminary prospective study with 60 patients was performed and published to valid the QRS as a step in diagnosis of wrist occult bones fractures equal to RMI. This exam is a bone scan with 2 improvments.

1) A quantification of the fixation spot : If the spot is two times more important on the injuried wrist (than controlateral side) the fracture is sure.

Result: Between november 97 and march 04, 667 patients were enrolled in a prospective continue study. 40% (260/667) of patients with an injury of the wrist with normal X ray sustained an occult fracture. QRS was performed at an average of 17,7 days after the injury and after clinical exam and repeat set of scaphoid view. Scaphoid fractures were most frequent. Fixation was most important if scintigraphy was performed between 11 and 20 days after the injury. Fixation did not depend on age, sex, volume of the bone, and delay (after 15 days).

Discussion: As Dikson, Dias, Thompson, and Kuckla, repeat set of scaphoid view are unable to improve significativally the number of occult fractures of the wrist. RMI as reported by Kuckla can reduce the need for further imaging procedure. RMI and scintigraphy are both the best exam to diagnose surely an occult fracture of the wrist. But QRS does not over diagnose, as RMI, bones fracture’s.

Conclusion: “Plaster cast and wait” is not the treatment for occult carpal bones fracture’s. The quantitative Xray bone scan is able to diagnose such fractures with short delay.

Objective: 6 cases of postraumatic arthritis of the distal radius treated by chondro costal graft are reported with a minimum follow up of 2 years

Material and methods: 6 patients (One 22 years old patient with a dislocated radiocarpal joint 6 months after an injury, 3 patients (48, 52 and 53 years old) respectively 1, 1,5 and 2 years after a intraarticular fracture of distal radius and a patient (74 years old) with radio lunate arthritis reported two mains complaints : pain and stiffness. The last patient was a female with a destruction of radio scaphoid joint after septic complication of scaphoid surgery. Location of the cartilage defect was central in two cases and palmar in the others. A dorsal approach in one case, a palmar approach in the five others allowed reduction and reconstruction of the destroyed radial part of joint. An osteochondro costal graft harvested on the eight’s rib was inserted and fixed by plate in place of the articular impaction. Plaster cast of 3 months in the first case and 1 month in the others cases followed the articular reconstruction

Results : No complication have been pointed. Union was achieved in all 6 cases. Integration and viability of the graft were evaluated with RMI. At the highest follow up functionnal result are excellent in the youngest first case (male, 22 years old) where motion and grasp are similar than the controlateral side. In the 4 others cases of mal union patients were pain free in daily activity with a functionnal wrist score of 72/100 (54–82) and a DASH of 38,3 (22,5–51,7). Only the case with the septic problem failed with pain at follow up.

Conclusion: Reconstruction of a partially destroyed articular surface by a costal graft is reliable and allows filling and resurfacing an articular cartilage void. If chondro costal graft is currently used in maxillo facial surgery it is the first report in post traumatic arthritis secondary to intra articular mal union.

Objective: The purpose of the present study was to report on the author’s experience using injectable cement as a bony substitute in distal radius corrective osteotomies. The interest of such a bone substitute is the real capacity to adapt itself to the bone defect. Harvesting a trapezoidal cortico spongious graft which can fill very precisely the void and not more remains a challenging objective in treating extra articular mal union.

Material and Methods: 5 patients with an average age of 57 yo (42–74) had a corrective osteotomy for a malunited distal radius fracture using Injectable bone substitute (Eurobone, Jectos, Kasios Inc) as an alternative to an autogenous bone graft. Internal fixation of the osteotomy was achieved by using one plate without post operative immobilisation. Two patients were stiff at preoperative time.

Results: At an average follow-up evaluation of 26 months (14–37 mo) all the osteotomies united. Wrist flexion-extension motion improved from 56° to 110°, forearm rotation increased from 112° to 142°, and grip strength had an average increase of 120% at the time of the final follow-up evaluation. All patients were satisfied but there one report of persistent pain. Radiographic evaluation showed an average volar tilt improvement from a preoperative dorsal angulation shifting into a neutral position in the sagittal plane; Radiographically the injectable cement showed evidence of progressive re-absorption over time but with no complete disappearance.

Conclusions: On the basis of this preliminary experience it is reasonable to consider injectable cement as a viable alternative to bone grafting in conjunction with surgical correction and internal fixation of extra articular distal radius malunion.

Purpose of the study: Reinsertion of the brachial biceps on the radial tubercle has been an effective method for recovering cyclic supination. Several surgical techniques have been proposed but only one clinical evaluation of operated patients has been published. We report the first study of a clinical and magnetic resonance imaging (MRI) assessment of brachial biceps reinsertion in the anatomic position using an anchorage system. The purpose of this work ws to determine whether the reinserted biceps remains inserted and to analyze the zone of insertion.

Material and methods: Nine manual laborers underwent surgery between 1999 and 2003 for repair of a ruptured brachial biceps by reinsertion on an anchor. The patients were reviewed by an independent operator (measurement of force and flexion). A 3-Tesla MRI machine was used to evaluate the position of the reinserted biceps. Reinsertion was performed within 5 days of injury (range 3–9 days) using the same technique of anchorage in the radial tubercle in all cases. A longitudinal incision measuring 3–5 cm along the medial border of the radial brachial was made to localize the ruptured biceps and the radial tubercle and drill two or three insertion holes for the anchors. The suture threads were used to bring the brachial biceps tendon progressively to the anchor used as a pulley before knotting. The patients were immobilized for three weeks, limiting flexion to 0–90°, then 45–130° the three following weeks.

Results: For the nine patients, there were no cases of sepsis nor radioulnar synostosis. Three cases of calcification were noted and to cases of nervous complications which resolved totally. Six patients, mean age 44.8 years (range 34–54 years) (two patients had moved away from the region) were reviewed at mean 19.2 months (range 10–33 months). Force at maximum flexion was 94.6% of the opposite side (range 58–131.5%). Repeated supination was somewhat bothersome for two patients. None of the patients complained of work impairment and all resumed their activity at the same level within 4.6 months on average. The MRI analysis (available in five patients) demonstrated that the reinserted tendon was in contact with the bone and that ther was a visible bone-tendon junction: the anterior and posterior borders of the tendon, as well as the fivers, showed a regular configuration. The terminal part of the tendon was enlarged in 3/5 cases. The tendon signal from the last 3 cm was variable: low intensity signal on T1 and T2 sequences or discrete high intensity signal on T1 and T2. There was no evidence of peritendinous effusion. At the time of the MRI evaluation, the anchors had not been resorbed.

Discussion: Several studies have reported the usefulness of reinserting the branchial biceps in manual laborers. The half-approach techniques, especially by anchorage, avoid the double-approach, enabling less traumatic reinsertion. The branches of the radial nerve must be carefully identified (we observed only resolutive cases of nervous deficit). Nevertheless, this type of reinsertion has not been evaluated. There is no proof that the reinserted biceps remains in an anatomic position. Our MRI findings are in favor of continuing the single-strand suture technique since the evidence demonstrated the validity of this type of transosseous suture.

Purpose of the study: Functional recovery afte displaced cephalotuberosity fracture of the proximal humerus in pateints aged over 70 years is a major surgical challenge. Reconstuction with an inversed prosthesis avoids the problems of tuberosity fixation. We report a prospective consecutive series of reversed prostheses used of 3 and 4 fragment displaced and non-displace fractures in patients aged over 70 years.

Material and methods: Between January 2001 and June 2004, 19 patients aged over 70 years were included in this study, 16 women and 3 men, mean age 74.9 years (range 58–94 years, median 76 years). All presented 3- or 4-fragment fractures. An independent operator established the Constant and Dash scores. The position of the implants, loosening, presence of a glenoid notch (Nerot) were noted on plain x-rays.

Results: Sixteen of the 19 patients (13 women, 3 men), mean age 73.9 years (range 58–94 years) were reviewed at mean 12.6 months follow-up (range 6–18 months). There were no cases of dislocation. Hematogenous sepsis occurred at 16 months in one patient and led to implant removal. The raw Constant score was 53 (34–76) and the weighted Constant score 76.1 (41–110.1). The Dash score was 37.4 (34–76). Active abduction reached 91.2° (10–150°), active elevation 97.5° (20–150°), active RE1 6.6° (0–50°), active RE2 9.4° (0–90°) and active internal rotation 31.2° (0–60°). There was a humeral lucent line in five cases and a grade 0 glenoid line in one, grade 1 and 2 in six, and grade 3 in three.

Discussion: The only series of fracture of the proximal humerus in patients aged over 70 years was a retrospective study of prosthesis patients reported by Wretenberg in 1997. To date, there has not been a published series on use of the reversed prosthesis for fracture. For the short term in a population with frail bone and minimal functional requirements, reversed implants provide the best subjective and objective functional results. The absence of postoperative immobilization and independence from the rotator cuff enables rapid recovery of useful motion. Range of motion is reduced only to a small extent for rotation. Thus when possible, we reinsert the tuberosities with the reversed implant. Even if the tuberosity assembly dismounts (agitation in a context of temporospatail disorientation), there is no consequence on the reversed prosthesis. The large number of lucent lines with no clinical impact is a point to be examined carefully, showing that further improvement can be achieved with the existing implants.

Purpose of the study: Spastic hypertony of the upper limb produces pronation of the forearm with flexion of the wrist and fingers. Treatment is generally based on injections of botulinum toxin and sometimes on selective neurotomy.

Material and methods: In order to achieve better selection of the motor branches innervating the muscles requires a precise knowledge of the extramuscular innervation. Similarly, for botulinum toxin, injections must be made as close as possible to zones with the greatest density of intramuscular nerve endings, considered as the zones having the greatest number of neuromuscular junctions. Knowledge of these zones is currently insufficient. We therefore conducted a macroscopic then microscopic dissection of the muscles of the ventral forearm in 30 specimens to study extra- and intra-muscular innervations and the distributions of the nerve endings.

Results: Surface maps were drawn to describe the precise localization of the motor branches for each muscle. These maps were designed as guides for surgical approaches for selective neurotomy. Then for each muscle, the zones with the greatest density of nerve endings were delimited in segments which could be used to define optimal zones of injection of botulinum toxin.

Purpose of the study: Appropriate treatment for fractures of the distal radius with dorsal displacement remains a subject of debate. Intrafocal pinning is the most widely used technique in France. Plate fixation has been developed to avoid secondary displacement and stiffness sometimes observed after pinning. We compared three osteosynthesis techniques for the same type of fracture (extra-articular with dorsal displacement).

Material and methods: Sixty-two consecutive patients underwent osteosynthesis using the following techniques successively: posterior plates [20 patients mean age 59.9 years (range 25–87 years)], intra and extra-focal pînning [22 patients mean age 55.6 years (range17–83 years)], the anterior plate [20 patients mean age 57.1 years (range 17–78 years)]. An independent operator evaluated all patients using the Herzberg, Gartland and Werley and Dash scores. The radial slope in the frontal plane, sagittal tilt, and ulnar variance were measured and compared between the preoperative and last follow-up values. Kruskall-Wallis or ANOVA were applied as appropriate for continuous variables and the chi-square test for non-continuous variables. P< 0.05 was considered significant.

Results: Mean operative time was equivalent for the two plate fixation techniques and twice as long as for pinning. There were more complications in the posterior plating group (32%) and less satisfactory function score despite a two-fold longer follow-up and a smaller number of operators. The best results were obtained with the anterior plating group in terms of range of motion (flexion-extension), Dash, preservation of ulnar variance and presence of a largest number of excellent and very good outcomes according to Gartland. The pinning group provided the best results in terms of sagittal slope. The pinning and anterior plating groups had equivalent range of motion for supination pronation and the same rate of complications (5%). Irrespective of the treatment arm, the Herzberg scores and the Gartland and Dash scores were better: in men, in patients aged less than 30 years, in patients with an associated fracture of the apex of the ulnar syloid process rather than its base.

Discussion: While posterior plate fixation is logical (approach on the side of the injury), the technique is difficult and can lead to nerve and tendon complications. For these extra-articular fractures, pinning like anterior plating can provide good functional results. Pinning is a rapid procedure and anterior plates do not have to be removed, allowing more rapid recovery of total independence.

Purpose of the study: Occult fractures of the carpal bone are underestimated. An undetected fracture of the scaphoid will not be immobilized and will lead to nonunion and osteoarthritic degradation. In order to avoid late diagnosis and functional loss, in addition to lost chances and legal suites, we validated a quantitative radioscin-tigraphic (QRS) tool in a randomized prospective trial conducted from 1997 to 2003 in a routine practice setting. The series included 667 patients with wrist trauma presenting a normal plain x-ray one day 0. After day 8 these patients underwent QRS.

Material and methods: The principle of the technique consists in a classical technetium scintigraphy with two technical improvements:

quantification of uptake: uptake two-fold greater on the injured side is a sign of «certain» fracture;

Results: Forty percent of the wrist trauma patients (260/667) with a normal plain x-ray presented an occult fracture (uptake > 2 on QRS). QRS was performed on day 17.7 on average. Fractures of the scaphoid were the most frequent (42%). The uptake ratio was higher if the QRS was performed from day 11 to day 20. Statistical analysis showed that uptake ratio > 2 was independent of age, gender, bone volume, and time to QRS.

Discussion: As demonstrated by Dikson, Dias, Thomp-son and Kuckla, repeated x-ray images do not increase the rate of diagnosis of carpal bone fractures. Spitz demonstrated that scintigraphic uptake on the trauma side more than twice that on the healthy side is a sign of fracture. Garbuio, NOvert and Lepage validated QRS as a sensitive and specific diagnostic tool for occult fractures. They demonstrated that QRS is less costly, more reliable than MRI and that there are no false positives.

Conclusion: Exploration of a «bone problem» in a patient with wrist trauma must not ignore sensitive and specific tests. Ultrasonography is operator-dependent and requires validation. We thought that QRS would not resist the development of routine MRI, but observed the contrary. QRS remains the gold standard diagnostic tool for ruling out a fracture of the carpal bones.

Aim: Treatment of unrecons tructible comminuted fractures of the radial head remains a therapeutic challenge. There is limited information on the outcome of management of these injuries with metal radial head implant. Before choosing one of them, two groups of patients were rewieved in a retrospective study comparing resection and Swanson implant.

Material and methods: 39 patients sustained unreconstructible radial head fracture between 1969 and 1992. Two groups of 24 patients were reviewed clinically and radiologically by a surgeon not involved in treatment. Functionnal outcomes of the elbow (morrey scoring – SOO scoring system, instability, cubitus valgus) and involvement of the wrist (pain, grasp, RUD instability) were evaluated with a mean follow up of 15 years (6–27,7). Elbow or wrist arthritis, ulnar variance, and evolution of Swanson implant’s were evaluated on standard Xray. 1/2 patient was a man and 1/3 cases consisted in a professional injury. Resec tion group: 16 patients with a mean age of 39 (19–65), treated with a mean preoperative delay of 29,6 days (0–150) were rewieved with a mean follow up of 18,9 years (6–27,7). There were 75% Mason type-III injuries associated with dislocation of the elbow in 18% cases. Swanson group: 8 patients with a mean age of 36 (21–57), treated with a mean preoperative delay of 4,1 days (0–15) were rewieved with a mean follow up of 12 years (8,1–20). There were 88% Mason type-III injuries with no dislocation in that group.

Results: The following criteria did not show any significant differences between both groups: Morrey scoring 77/100, SOO scoring 7,4/11, mean flexion was 130°, mean deficient extension was 18°, mean pronation 60°, mean supination 67°, grasp reached 90% of the contralateral side. Arthritis was pointed in same frequency at the elbow level (87%), and wrist level (66%) in each group. 94% of pa tients in resection group and 89% in Swanson group were satisfied. Excellent and good results are reported most frequently in Swanson group (37% resection group, 51% Swanson group). In resection group following complications were significantly more frequent: ulnar nerve irritation (2x), ulnar head dislocation (2x), ulnar head instability (3x), paraarticular ossification (5x), ulnar variance positive in all cases (mean value 3,20 mm). In the Swanson group only one implant was destroyed at the follow up.

Aim: The purpose of the study was to evaluate the feasibility of Norian SRS bone cement injected into a distal radius following reduction and stable fixation in preventing shortening and loss of pronation-supination.

Material and methods: Between 1998 and 2000 48 patients with a mean age of 65 (54–82) sustained distal radius fracture (AO classification stage A in 26 cases, B in 15 cases, C in 7 cases) with metaphyseal comminution. Functionnal and radiological outcomes of the wrist (O’ Brien scorring, Gartland and Werley scoring, DASH) were evaluated with a mean follow up of 46 months (36–56) by a surgeon not involved in treatment. Fixation was performed in 34 cases by pins, in 14 cases by dorsal plate, in 2 cases by external fixator.

Results: 4 patient lost of follow up and 5 mal union were excluded of final evaluation. 3 RSD were pointed on the 39 evaluated patients. O’ Brien scoring reached 84/100 (54–100), Gartland and Werley scoring reached 4,6 (0–11) with 89% excellent and good results, DASH reached 23,6 (5,8–62,7). Ulnar variance changed less than 2mm between postoperative time and maximal follow up in 88%. There were no clinically adverse effects but one case of volar extrusion of injected Norian was pointed with resolutive evolution. Bone substitute was always in place at the longest follow up.

Discussion: Adams, Pogue, Mc Queen pointed the bio-mecanical and clinical advantage to fill the void secondary to the comminution to avoid the shortening of the radius. First cases reported by Kopylov and Jupiter, and prospective series of Kopylov, Sanchez Sotello and Cassidy proved the interest of an adaptative injectable cement in case of comminution. Injectable bone substitute allows to maintain the ulnar variance in competition with bone graft or bio ceramic.

Conclusion: Norian is able to fill a metaphyseal void but fixation of the fracture remains necessary.

Purpose: We report our experience with costal osteochondral autografts of the scaphoid for the treatment of radioscaphoid osteoarthritis complicating chronic scapholunate non-union or dissociation.

Material and methods: The technique was used for nine patients from 1994 to 2001 (eight men and one woman, mean age 45 years, age range 26–62). The proximal two-thirds of the scaphoid were resected. An osteocartilaginous graft was harvested from the ninth rib and after remodelling to the scaphoid cavity was fixed to the base of the scaphoid with a Kirshner wire.

Results: Mean follow-up was 2.5 years. Pain improved significantly in all patients. Force was 80% on average compared with the healthy side. Mean wrist motion in flexion and extension was 91° (70–150°).

Conclusion: This technique has provided encouraging preliminary results in terms of restored force and wrist motion. It is an interesting alternative to conventional techniques.