Nonvascularized vs Vascularized Grafting for Scaphoid Bone Nonunion: A Systematic Review and Cost-Effectiveness Study

The scaphoid is the most commonly fractured of the carpal bones. Scaphoid fractures which do not heal are termed scaphoid nonunion. Scaphoid nonunions have been traditionally treated with nonvascularized bone grafting with or without bony fixation. In recent decades, vascularized bone grafting has gained popularity, particularly in cases of proximal pole involvement. We conducted a systematic review of recent experimental studies to determine the strength of evidence supporting one procedure over the other. We found just 3 randomized controlled trials in the literature, all of which were deemed to be at high risk of bias. In addition, these studies were inconsistent in their results with one supporting nonvascularized grafting and two supporting vascularized grafting. We conclude that the evidence is insufficient to definitively support the use of one procedure over the other. We also performed a cost-effectiveness analysis comparing the two procedures from a societal perspective. We used primary data from three regional surgical centers to generate our effectiveness values and cost data derived from Medicare and the National Bureau of Labor and Statistics. We found that while neither technique had a significantly greater union rate than the other (vasc=0.75, nonvasc=0.73), vascularized grafting was the more cost-effective procedure primarily due to reduced costs from lost productivity. The average cost to society for one vascularized procedure was $31,968.45 compared to $35,111.18 for nonvascularized grafting. Each successful union for vascularized grafting costs $42,624.60 compared to $48,429.21 for nonvascularized grafting. The dominance of vascularized grafting also applied to proximal pole cases. In addition, we found that nonunions treated with vascularized grafting instead of nonvascularized grafting achieved radiographic union an average of 89 days earlier (P=0.06). We conclude that vascularized bone grafting is a more cost-effective alternative than nonvascularized bone grafting for the treatment of scaphoid nonunion.Master of Public Healt