Screw fixation without bone grafting for scaphoid fracture nonunion

IntroductionWe previously reported the classification of the scaphoid fracture nonunions as linear, cystic, and sclerotic or displaced types based on radiographic findings. We have been treating the linear and cystic type fractures via screw fixation without bone grafting and the sclerotic or displaced type fractures via screw fixation with bone grafting. In this retrospective study, we report the treatment outcomes of the linear and cystic types of scaphoid fracture nonunions.MethodsNineteen patients with linear and cystic type scaphoid fracture nonunions were included. Two patients had linear type and 17 had cystic type fractures. All the patients were male, their mean age was 29.2 years. All patients were treated with screw fixation alone by a single surgeon.ResultsBone union was achieved in 17 cases. The mean time to bone union was 3.7 months. Bone union was not achieved in one case of linear type and one case of cystic type fracture. The former was thought to be due to misdiagnosis of displaced type as linear type fracture; however, no obvious reason could be found for the latter.DiscussionScrew fixation alone could help achieve bone union in linear type scaphoid fracture nonunions. However, if the type of the fracture is difficult to diagnose based on plain radiography, evaluation using computed tomography should be performed. The cystic type fractures may need to be subclassified according to the location or size of the cyst as well as the viability of the proximal bone fragment.     

Dorsal percutaneous screw fixation of delayed or nonunion of scaphoid fractures

Purpose

The purpose of the present study is to evaluate scaphoid delayed fractures or nonunions treated by percutaneous fixation with MRI correlations.

Methods

We evaluated 33 consecutive scaphoid delayed unions or nonunions treated by dorsal percutaneous fixation at a mean 16 months (range, seven to 48 months) after the operation. There were 31 male and two female patients with an average age of 29 years (range, 25–33 years).

Results

Pre-operative MRI revealed no signs of avascular necrosis. At the latest follow-up, all patients had good or excellent results.

Conclusion

We suggest dorsal percutaneous screw fixation for scaphoid delayed fractures or nonunions after eliminating the presence of AVN by pre-operative MRI examination.     

Incorrect radiographic evaluation after vascularized bone grafting for scaphoid fracture or nonunion

PURPOSE:

The present study is a review of patients with scaphoid non-unions treated with a dorsal vascularized bone graft. The study highlights a subset of patients incorrectly diagnosed as graft failures.

METHODS:

A retrospective review of patients who received vascularized grafts for scaphoid nonunions was performed over a four-year period. The vascularized graft of choice for this group was the dorsal radial extensor compartment artery.

RESULTS:

Five patients from a scaphoid fracture group who were treated with vascularized grafts were diagnosed as being failures (average of five months). None of these patients had tenderness on palpation of the scaphoid, and they were scheduled for revised vascularized grafts. All patients at the time of surgery were found to have healed. These patients were treated with arthrolysis, resulting in healing and full range of motion.

CONCLUSIONS:

Scaphoid vascularized grafts may have a markedly delayed radiographic healing time. Reoperation to perform secondary vascularized procedures may result in unnecessary surgery. Early imaging following a scaphoid vascularized graft may be inaccurate and may demonstrate a continued nonunion.     

Percutaneous screw fixation without bone grafting for established scaphoid nonunion with substantial bone loss

Ununited fractures of the scaphoid with extensive bone resorption are usually treated by bone grafting and internal fixation, using either an open or a minimally invasive technique. We studied the feasibility of percutaneous fixation without bone grafting in a consecutive series of 27 patients with established nonunion of an undisplaced fracture of the scaphoid and extensive local resorption of bone. They were treated by a single surgeon with rigid fixation alone, using a headless cannulated screw inserted through a volar percutaneous technique. Clinical examination, standard radiographs and CT confirmed that the fracture had united in all patients at a mean of 11.6 weeks (8 to 16), and that their functional scores had improved. We concluded that extensive resorption at the fracture site is not an absolute indication for bone grafting, and that percutaneous fixation alone will eventually produce healing of ununited undisplaced fractures of the scaphoid regardless of the size of the gap.     

带蒂骨膜瓣移位修复手舟骨骨不连

目的 探讨带蒂骨膜瓣在手舟骨骨折后骨不连治疗中的临床效果。方法 采用带骨间前动脉腕背支血管蒂的骨膜瓣转位治疗26例手舟骨骨不连患，并做临床观察。结果 本组术后随访4个月一18个月，优19例，占73％；良7例，占27％。结论 以骨间前动脉腕背支为蒂的骨膜瓣转位修复手舟骨骨不连，疗效满意。     

加压螺钉治疗舟骨骨折的临床疗效

目的　评价加压螺钉内固定治疗舟骨骨折的临床疗效。方法　对 46例 (4 7侧 )舟骨骨折采用切开复位加压螺钉内固定治疗的患者 ,术后进行随访。从术后疼痛程度、腕关节活动度、手部握力、影像学检查、Krimmer腕关节评分和DASH(DisabilityofArm Shoulder Hand)问卷调查表等进行随访和疗效评估。结果　术后腕关节疼痛程度静息时为 2 ,用力时为 13。腕关节屈伸活动度 12 4°(达健侧 92 % ) ,尺桡偏5 7°(达健侧 91% ) ,平均握力 47kg(达健侧 90 % )。X线片及CT检查 :6例螺钉穿透骨皮质 ,4例发生腕关节炎 ,1例舟骨骨折不愈合及 1例畸形愈合。Krimmer评分总体疗效 :优 3 9侧 ,良 5侧 ,满意 3侧。DASH值为8 3。DASH问卷调查表结果显示 ,术后腕关节功能良好 ,仅有轻微不适症状。结论　应用切开复位加压螺钉内固定治疗舟骨骨折手术操作简便、疗效可靠。     

腕关节镜下植骨经皮内固定治疗舟骨骨折不愈合

目的探讨腕关节镜辅助微创植骨内固定治疗舟骨骨折不愈合手术方法和疗效。 方法2015年10月至2018年10月,采用腕关节镜辅助微创方法治疗外固定未愈合的不稳定型舟骨骨折9例,9例患者均为舟骨骨折不愈合,无合并舟月分离及舟骨近极塌陷。所有患者根据术前影像学检查评估舟骨骨折移位情况,骨折端硬化和骨质吸收缺损情况。术中从腕中关节入路刨除硬化骨后复位植骨内固定。收集患者术前及术后Mayo评分和疼痛视觉模拟评分(VAS评分),两组间数据比较采用配对t检验。 结果9例患者均获得随访,随访时间平均(11±4)个月。所有患者末次随访之时均获得骨性愈合,Mayo腕关节评分(89.4±5.8)分,与术前(52.2±6.7)分相比(t＝19.8,P<0.001),优8例,良1例。VAS评分由术前(5.2±0.7)分降至(1.6±0.7)分(t＝15.6,P<0.001)。 结论腕关节镜辅助微创治疗不稳定型舟骨骨折不愈合是一种有效的治疗选择,采用腕关节镜技术去除硬化骨,取髂骨碎屑植骨内固定能取得较为理想的临床效果。     

A systematic review of mechanical stabilization by screw fixation without bone grafting in the management of stable scaphoid non-union

IntroductionSixty percent of all carpal fractures affect the scaphoid bone, with an annual incidence of 4.3/10,000. Displacement and instability are the main risk factors for non-union, but missed diagnosis, location of fracture and poor blood supply are also risk factors. Non-union is defined as non-healed fracture on radiographs 6 months after the injury and this can lead to degenerative wrist arthritis. Treatment options vary from internal fixation with bone grafting to salvage procedures including arthrodesis of carpals. We aimed to determine the effectiveness of screw fixation without bone grafting for the treatment of stable well-aligned scaphoid non-union.MethodsIn this systematic review, MEDLINE, Science Direct, Web of Science and CINHAL were searched from inception to May 2019. All clinical studies that examined the functional and radiological outcomes of screw fixation without bone grafting to treat stable scaphoid non-union were included.Results838 articles were retained of which 6 case series, describing 95 patients who had undergone scaphoid non-union fixation without bone grafting, were included. Favourable functional outcomes were reported by the 6 included studies using validated functional outcome measures ROM improved to weighted mean of 67.5° (±13°) and 62.12° (±13°) for flexion and extension respectively. The fracture had united in 91 out of 95 participants with a union rate of 95.7% (95%, CI 89.5 to 98.8) and the weighted mean time to union was 3.8 (±1.5) months.ConclusionRigid screw fixation without bone grafting can be suggested for the treatment of selected well aligned scaphoid nonunions to achieve healing and good functional outcomes. However, adequately powered clinical studies with good methodology are essential to draw an accurate conclusion.     

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.     

Minimal invasive management of scaphoid fractures: from fresh to nonunion

The peculiar shape of scaphoid hinders a precise evaluation of its fracture configuration, displacement and accuracy of screw placement. Its tenuous vascular supply risks the complications of delayed union, nonunion and avascular necrosis. Scaphoid is the focus of ligamentous attachment governing carpal kinematics. Preservation of its anatomy and vascularity is critical for normal wrist function. A new fracture classification clearly denoting every fracture type and guiding the management is introduced. The minimal invasive management of different scaphoid fracture conditions, including acute non-displaced and displaced fracture, delayed presentation, and nonunion are discussed. Role of arthroscopy is emphasized. Detailed surgical techniques are shared here.     

Percutaneous screw fixation for scaphoid nonunion in skeletally immature patients: a report of two cases

Nonunion of the scaphoid waist in skeletally immature patients is rarely diagnosed. We report 2 cases of scaphoid nonunion in skeletally immature patients who underwent percutaneous screw fixation without bone graft. In stable nonunions with minimal sclerosis, percutaneous screw fixation without bone graft can be an alternative to the conventional open procedure in skeletally immature patients, with successful union and clinical outcome.     

1，2伸肌室间支持带上动脉为蒂骨瓣移植治疗舟骨骨折不愈合

目的探讨1,2伸肌室间支持带上动脉（1,2 intracompartmental supraretinacular artery 1,2 ICSRA）的解剖特点及治疗舟骨骨折不愈合的临床疗效。方法2008年7月-2010年9月共收治确诊的舟骨骨折不愈合患者11例,均采用逆行的1,2ICSRA为蒂骨瓣植入术结合Herbert螺钉内固定进行治疗,观察患者的骨折愈合情况及并发症,并以DASH评分对腕关节功能进行评价。结果所有患者均获6～33个月随访,平均17个月。11例患者均获骨性愈合,骨折愈合时间为9～14周。平均12周。术后6个月DASH评分平均为6．5分,腕关节功能接近正常。结论慎重的选择适应证,熟悉相关解剖知识,仔细的手术操作,采用逆行的1,2ICSRA为蒂骨瓣植入术结合Herbeft螺钉内固定治疗舟骨骨折不愈合可取得满意的临床疗效。     

Bicolumnar fusion for scaphoid nonunion advanced collapse without bone grafting

Scaphoid nonunion advanced collapse leading to wrist osteoarthritis is treated by 4-corner fusion, capitolunate arthrodesis, and 3-corner fusion with a variety of hardware and bone grafting techniques as reported in the literature. However, such procedures have been associated with complications such as nonunion, hardware failure, and deep infection. On the basis of the same concept of these intercarpal fusions with the aim to transmit the load of the wrist, we present bicolumnar fusion to fuse the capitolunate articulation and the triquetrohamate articulation and preserve the articulation between the 2 columns, maintaining much of the normal anatomy and physiology of the normal wrist. This technique has allowed the use of screws for compression of both articulations and achieve union without the use of bone grafting.     

Autologous bone grafting without screw fixation for tibial defects in total knee arthroplasty

We evaluated 30 knees with autologous bone grafts, performed without screw fixation, for tibial defects in total knee arthroplasty (TKA). The tibial defects were classified into three types: contained, flat peripheral, and slant peripheral. The resected femoral condyle was fixed with a combination of bone cement and the tibial component, without using screws. The patients were followed for an average of 6 years and 10 months. In all knees except 1, the grafted bone united and formed good continuity with the tibial floor. Autologous bone grafting without screw fixation is a simple and effective method to deal with the tibial defects in primary TKA, especially for contained and flat peripheral defects. Received: November 24, 2000 / Accepted: June 25, 2001     

Screw fixation of scaphoid fractures: a biomechanical assessment of screw length and screw augmentation

PURPOSE: To assess the biomechanical stability relative to screw length and K-wire augmentation in scaphoid fracture fixation using a flexibility testing protocol and cadaver scaphoids whose soft tissue attachments remained undisturbed. Our hypothesis was 2-fold: increasing screw length and augmenting fixation with a K-wire would improve fracture fragment stability, individually and in combination. METHODS: Flexion and extension loading applied through wrist tendons was performed on 10 cadaveric wrists after volar wedge scaphoid osteotomy and internal fixation. Each wrist participated in 3 experimental groups: short screw, long screw, and long screw augmented with a K-wire transfixing the distal pole to the capitate. Interfragmentary displacements were measured. RESULTS: Analysis of variance showed significantly less fracture fragment motion with longer screws than with short screws in 4 of the 6 displacement axes. The flexion/extension axis rotations for the short, long, and augmented long-screw groups were 8.2 degrees +/- 4.8 degrees, 3.9 degrees +/- 1.6 degrees, and 1.8 degrees +/- 1.3 degrees, respectively. Although K-wire augmentation reduced displacement of the fracture fragments it did not decrease interfragmentary motion significantly when compared with the long-screw group. CONCLUSIONS: Under physiologically applied loading of cadaveric wrists with unstable scaphoid waist fractures the long screw provided significantly greater stability than the short screw. Although K-wire augmentation in the long-screw group did improve stability the improvements were not significant. Based in part on the biomechanical data from this study it is our recommendation that the optimally placed screw for scaphoid fracture fixation stability is a long screw positioned down the central axis of the scaphoid deep into subchondral bone.     

Non-vascularized bone graft with Herbert-type screw fixation for proximal pole scaphoid nonunion

Background  

Since proximal pole fractures of the scaphoid are frequently overlooked, the poor vascularity in the proximal pole fragment often leads to nonunion. Vascularized bone grafts have been recently tested in cases with scaphoid proximal pole nonunion, but the indication for this treatment has not been well established. Alternatively, we have been treating such patients with a non-vascularized iliac bone graft and Herbert-type screw fixation with considerable success. The purpose of this investigation is to evaluate these cases retrospectively and clarify the surgical efficacy of our procedure.     

Dorsal approach for screw fixation and bone grafting of scaphoid nonunions

Objective Restitution of continuity, shape and length of scaphoid and of painless wrist function in proximal pole nonunion of the scapoid. Indication Proximal third nonunion of the scaphoid in absence of osteoarthrosis. Contraindications Fragmented and soft proximal pole fragment type D4 according to Filan and Herbert. Carpal collapse (SNAC wrist). Surgical Technique Dorsal S-shaped incision on wrist. Dorsal approach to scaphoid with insertion of Mini Herbert screw. Cancellous bone graft from radius or iliac crest. Results From June 1992 to June 1996, 26 patients had Herbert screws inserted via dorsal approach. 23 turned up for follow-up. 17 showed radiologic union, 4 showed signs of fibrous union and 2 were left with an unstable nonunion. Pain and grip strength improved postoperatively. Pain was tested with a visual analog scale from 1 to 10 and showed improvement from 4.8 preoperatively to 1.9 postoperatively. Grip strength increased by 10 kPa. 21 patients had little or no restriction of hand function of the affected hand postoperatively. Assessment of hand function using the DASH score resulted in an average postoperative value of 10.     

Vascularized bone grafting and mini-acutrak fixation of scaphoid non-unions with avascular proximal pole

Objectives

We studied the use of vascularized bone graft as described by Zaidemberg et al. in combination with a fixation as described by Carter et al. in patients with scaphoid non-union and avascular proximal poles. We modified this method using a cannulated mini-acutrak screw.

Methods

Between January 2006 and June 2010, we treated 12 male patients with symptomatic scaphoid non-union with avascular proximal poles. Their average age was 26 years (range 18–47 years). The average follow-up was 16 months (range 6–52 months). All the patients were assessed for any persistent pain including grade of pain, any restriction of daily activities, and osteoarthritis.

Results

All patients achieved union within an average of 15 weeks (range 6–32 weeks). In all cases we encountered the 1, 2 intercompartmental supraretinacular artery (1, 2 ICSRA) intraoperative. X-rays and CT showed a complete osseous union in all patients.

Conclusions

We have found that the technique described which combines vascularized bone graft with cannulated mini-acutrak screw, is reliable and successful in treating patients with scaphoid non-unions with avascular poles. We prefer to use the vessel described by Zaidemberg et al. as the 1, 2 ICSRA. If this vessel is occasionally absent (present in 94%), as noted by Sheetz et al., other pedicles may be used.     

带旋前方肌桡骨膜瓣移植治疗腕舟骨骨不连

目的 报告采用带旋前方肌挠骨膜瓣移植治疗腕舟骨骨不连的方法和疗效.方法于腕挠掌侧切取带旋前方肌的近端挠骨膜 5cm x 2cm,将桡骨膜翻转包裹适宜的挽骨块植入舟骨骨槽内.术后管型石膏固定3个月.结果1991～1998年共治疗20例,术后随访8个月～6年,平均1.8年,骨性愈合达到100%.愈合时间2～4个月,腕关节功能完全恢复正常.结论 该手术方法疗效甚好,操作方便,特别适合于基层医院推广.