Surgical treatment of scaphoid nonunion

Summary The management of scaphoid pseudarthrosis is still controversial. The numerous methods that have been proposed can be roughly classified according to their aim — relief of pain or healing of bone. Following a review of the literature, and guided by personal experience with the Matti-Russe technique and McLaughlin internal fixation, the authors present recommendations for treatment according to clinical presentation of the condition.     

Surgical treatment results in scaphoid nonunion

Fracture of the scaphoid is the most common fracture in the wrist. We retrospectively reviewed 42 cases of established nonunion of the scaphoid that had been treated by four methods: with two Kirschner wires (K wires) and pronator quadratus pedicled bone graft in 5 patients; AO cannulated screw and graft in 8 patients; Herbert screw and graft in 19 patients; and two K wires and graft in 10 patients. Follow-up ranged from 1 to 5 years (between January 1995 and January 2000). Radiographs and computed tomography (CT) scans were analyzed for confirmation of osseous union. The average period of clinical and radiologic union was 13.2 weeks (range, 10 to 33 weeks). There was a significant improvement in the grasping power, radiologic healing, clinical satisfaction, and pain relief in the patients who had operation.     

舟状骨稳定性骨不连手术治疗体会

<正>舟状骨稳定性骨不连(又称Herbert DI型)其特点是具有坚强的纤维连接阻止畸形的发生,由于舟状骨在损伤早期长度和形状保持良好,临床上漏诊及误诊率高。自2007年1月至2008年12月共诊治舟状骨稳定性骨不连4例,通过手术治疗,取得良好的效果,现做回顾性总结报告如下。     

手术治疗腕舟状骨骨折不愈合的研究进展

舟状骨骨折是腕骨最常见的骨折之一,在临床诊断中由于常被延误或未被诊断,进而直接或间接地影响舟状骨骨折的愈合效果,导致延迟愈合和骨不连的发生率较高。国内外学者通过临床实验探索多种可治疗和减少舟状骨骨折延迟愈合和不愈合的手术方法,其中有些手术方法为目前研究的热点。本文就其具体手术治疗方式进行详细阐述,以期探索手术治疗腕舟状骨骨折不愈合的最佳途径,以期对临床有指导意义。     

The progress in the classification and treatment of scaphoid nonunion

Scaphoid fracture is the most common carpal fracture, accounting for 50%–80% of all carpal fractures in the Youngers and manual workers. The nonunion rate of scaphoid fractures was approximately 10–15%. Scaphoid nonunion can lead to wrist deformity, wrist collapse, ischemic necrosis, and traumatic osteoarthritis resulting in the loss of wrist function and seriously influence the patients’ lives. Achieving bony union is essential for the treatment of scaphoid nonunion. Although many surgical procedures including various forms of bone grafting have been developed to improve bony union, there is no conclusion about which method is the most effective and optimal. In this review, we provide an overview of the diagnostic, classification and progress in the treatments of scaphoid nonunion fractures.     

Pediatric scaphoid nonunion

PURPOSE: To report the outcome of pediatric scaphoid nonunions treated with a Herbert screw and bone graft. METHODS: This is a retrospective review of 12 cases of scaphoid nonunion in 12 skeletally immature patients treated with a uniform approach consisting of open reduction, iliac crest bone grafting and Herbert screw fixation. All patients were boys and presented with nonunions of the scaphoid waist. The final follow-up evaluation was at a mean of 32 months, ranging from 22 to 45 months, and consisted of assessing anatomic snuffbox tenderness, wrist arc of motion, grip strength, calculation of the Modified Mayo Wrist score, and assessment of union based on plain radiographs. RESULTS: At the latest follow-up evaluation, all patients were pain free (including absence of snuffbox tenderness) except one who experienced slight discomfort during extreme activities. There was no statistically significant difference in the arc of motion between the surgically treated and healthy sides, and the average grip strength was 96% that of the contralateral extremity. Clinical and radiographic union was present in all cases at a mean of 3.4 months after surgery. The Modified Mayo Wrist score was excellent in 11 patients and good in 1. There were no complications. CONCLUSIONS: Open reduction and internal fixation with a Herbert screw reliably obtained union in all patients. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.     

Arthroscopic evaluation and treatment of scaphoid nonunion.

Scaphoid fractures are one of the most common carpal fractures and heal without complication in a majority of cases. Nonunion of the scaphoid, unfortunately, can occur secondarily to several reasons; namely, delay in treatment, delay in diagnosis, the intra-articular nature of the fracture, the precarious vascular supply of the scaphoid, and significant biomechanical stresses across the fractured scaphoid.     

Surgical treatment for nonunion of the carpal scaphoid

Between 1978 and 1982, 23 male patients were operated on for delayed union or nonunion of scaphoid fractures. The average age of these patients at follow-up examination was 32.5 years. Twenty patients were treated by bone grafting using the Matti-Russe technique; in 2 patients the proximal fragment was excised for avascular necrosis, and in one patient a Swanson prosthesis was used. Bony union occurred in 18 patients treated with the Matti-Russe technique. The patients' subjective evaluations agreed with radiological results. Ten of the patients had no pain; 8 had pain only during strenuous activity, and 2 patients with subsequent nonunion had pains with moderate activity. Bony union with minor dislocation did not influence the results. Results according to radiological and clinical findings were judged to be excellent in 2 patients and good in 13 patients. According to the patients' own subjective evaluation, 7 assessed the results as excellent and 11 as good. At the follow-up examination 4 patients had normal gripping power, 9 had greater than 75% normal, 6 had greater than 50% and less than 75% normal, and 1 had less than 50% normal gripping power. In the 2 patients who underwent excision of the proximal pole of the scaphoid the result was good in one and poor in the other. For the patient whose scaphoid was replaced with an implant the result was good. Nineteen of the 23 patients returned to their previous work within 6 months of the operation.     

Management of scaphoid nonunion

The primary risk factor for nonunion of the scaphoid is displacement/instability, but delayed or missed diagnosis, inadequate treatment, fracture location, and blood supply are also risk factors. Untreated nonunion leads to degenerative wrist arthritis-the so-called scaphoid nonunion advanced collapse wrist. However, the correlation of symptoms and disease is poor; the true "natural history" is debatable because we evaluate only symptomatic patients presenting for treatment. It is not clear that surgery can change the natural history, even if union is attained. The diagnosis of nonunion is made on radiographs, but computed tomography or magnetic resonance imaging scans can be useful to assess deformity and blood supply. Treatment options vary from percutaneous fixation to open reduction and internal fixation with vascularized or nonvascularized bone grafting to salvage procedures involving excision and/or arthrodesis of carpals.     

Intercarpal fusion for the treatment of scaphoid nonunion.

Salvage of the ununited scaphoid may not always be feasible or advisable, hence the availability of a number of alternative techniques which prioritize restoration of pain relief and range of motion. The role of intercarpal fusion reflects the importance of midcarpal stabilization when the scaphoid is resected. While scaphocapitate and scaphocapitolunate fusions have been described, these techniques provide less pain relief than midcarpal fusion with scaphoid excision, and are associated with an increased risk of radioscaphoid arthritis. In this article, the author will address the rationale for, technique of, and outcome after midcarpal arthrodesis and scaphoid excision.     

Distal scaphoid resection arthroplasty for the treatment of degenerative arthritis secondary to scaphoid nonunion

Nineteen patients with chronic scaphoid nonunion and associated degenerative arthritis between the distal fragment and the radial styloid were treated by resection of the distal fragment. All patients had a dorsal intercalated segment instability wrist collapse pattern with an average radiolunate angle of -32 degrees and a 10% reduction in the carpal height, both of which changed minimally during the follow-up period. The duration of the nonunion averaged 12 years and the follow-up period averaged 49 months. Range of motion improved 85% and grip improved 134%. Thirteen of the patients experienced complete pain relief. One patient required additional surgery and elected wrist arthrodesis. Resection of the distal fragment is not recommended for patients with capitolunate arthritis. Two of the 4 patients with capitolunate arthritis had persistent symptoms; 3 had progressive degenerative changes.     

The relationship between the site of nonunion of the scaphoid and scaphoid nonunion advanced collapse (SNAC).

We studied retrospectively the radiographs of 33 patients with late symptoms after scaphoid nonunion in an attempt to relate the incidence of scaphoid nonunion advanced collapse (SNAC) to the level of the original fracture. We found differing patterns for nonunion at the proximal, middle and distal thirds. The mean intervals between fracture and complaint were 20.9, 6.7 and 12.6 years and obvious degenerative changes occurred in 85.7%, 40.0% and 33.3%, for the six proximal-, eight middle- and two distal-third nonunions, respectively. Nonunion at the proximal and middle thirds showed the first degenerative changes at the radioscaphoid joint, and this was followed by narrowing of the scaphocapitate and then the lunocapitate joints. In our two nonunions of the distal third degenerative changes were seen only at the lunocapitate joint. Most patients with SNAC and nonunion of the middle or distal third showed dorsal intercalated instability; few patients with nonunion of the proximal third developed this deformity. We discuss the initial management of nonunion of the scaphoid at different levels in the light of our findings, and make recommendations.     

Trephine bone grafting technique for the treatment of scaphoid nonunion

A simple, minimally invasive trephine bone grafting technique for the treatment of scaphoid fracture nonunions is described. The method has a short surgical time, good results, and minimal donor site morbidity.     

Proximal row carpectomy for the treatment of scaphoid nonunion.

Nonunion of the scaphoid bone may occur even with early diagnosis of fracture and modern internal fixation techniques. A pattern of degenerative instability termed scaphoid nonunion advanced collapse may lead to collapse of the carpus with irreversible articular damage initially isolated to the radiostyloid joint. Proximal row carpectomy (PRC), which removes the intercalary proximal row and creates a radiocapitate articulation, is a motion preserving salvage procedure which unloads the areas of articular pathology, and creates a new articulation that allows motion and is able to bear compressive forces over time. Although results of PRC specifically for scaphoid nonunion are clearly not reported in the article, several studies demonstrate that PRC provides a pain relieving and motion-sparing salvage option particularly suited for this condition.     

Scapholunate gap with scaphoid nonunion

Ten of 64 patients reviewed with scaphoid nonunion were found to have scapholunate gaps (SLG). A roentgenographic study of the entire group who were symptomatic, but had no prior surgery, showed the SLG. The SLG indicated severe ligamentous injury and instability, and was always associated with the presence of Doral Intercalated Segment Instability (DISI) and an increased scapholunate angle. Instability was progressive and associated with the early onset of arthritis. In the entire group of nonunions, high frequency of arthritis occurred with a predictable sequence of radioscaphoid and midcarpal degenerative changes. Terminal wrist arthritis in scaphoid nonunion developed in the scapholunate articulation, as a manifestation of rotary subluxation of the distal scaphoid fragment.     

Resection of the scaphoid distal pole for symptomatic scaphoid nonunion after failed previous surgical treatment

PURPOSE: To evaluate the results of resection of the scaphoid distal pole for symptomatic scaphoid nonunion after failed prior surgical treatment. METHODS: Thirteen patients who were treated with resection of the scaphoid distal pole for persistent nonunion after previous surgical treatment were included in this study. The mean follow-up period was 5 years. Evaluation included measurement of wrist range of motion, assessment of pain, and evaluation of radiographic parameters. The Disabilities of the Arm, Shoulder, and Hand score was used to determine the functional outcome after the excision. RESULTS: Before surgery all but 1 patient reported pain. After surgery 2 patients presented with mild pain during strenuous activity. Mean wrist flexion and extension increased significantly, by 23 degrees and 29 degrees, respectively. The postoperative Disabilities of the Arm, Shoulder, and Hand score was 25 +/- 19 points. There was a significant increase in the radiolunate angle, indicating dorsal intercalated segment instability deformity in 6 patients. CONCLUSIONS: Scaphoid distal pole excision remains a valuable treatment option for patients for whom multiple attempts at union have failed previously and who have no associated complete scapholunate ligament tears. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.