Scaphoid Non Union

Scaphoid Non Union

SCAPHOID NON UNION

Scaphoid  nonunion  continues  to  be  a  challenge  for  the  orthopaedic  surgeon, since  there  are  a  lot  of  methods  of  treatment and union  rate  is  not  always  certain. The  incidence  of  scaphoid  fractures  is  about 70% of carpal  bones and  2%  of  all  bones. 5%-10%  of  them  fail  to  unite  after  conservative  treatment. This depends on the fracture type, the method of immobilization, the avascular necrosis of the  fragments  and the associated carpal instability.

Diagnosis of  scaphoid  nonunion is  frequently delayed, as 54%  of  nonunions  by  Radford,  and  65%  by  Gupta,  did  not  receive  adequate  treatment. Langloff  & Anderson,  in  1988,  said that  the  age  of  fracture  is  very  important. If  the delay  in  diagnosis  is  less  than  4  weeks  time,  the union  rate   is  the  same  as  in  fresh  Fx.  Delay  in  diagnosis  and  treatment   for  more  than   4  weeks  has  a  high  rate  of  nonunion.

 The  etiology  of  the  fracture  usually  is  a  dorsiflexion  injury  of  the  wrist.

The  Fx  can disturb the bloody supply, therefore avascular   necrosis    may  present  in  13% – 50%  of cases, more often in the proximal pole.

For many years a lot of Orthopaedic surgeons  believed that an asymptomatic scaphoid nonunion is  not a serious problem,  saying: “there is no difference between 8 or 9 carpal bones”! And …  this was the result!   Pancarpal  Arthritis! Scaphoid  nonunion  leads  to  carpal  instability, and  then  to  scapholunate  advanced  collapse. The  final  result  is  carpal  arthritis. In  1984,  Mack  described  the  history  of  a  scaphoid  nonunion. The  first  10  years  we  have  changes only in the scaphoid. Between  10  and  20  years    radio- scaphoid  arthritis appears. After  20  years  we  have  pancarpal  arthritis We  can  see   these  steps  on  the  slide. Only  scaphoid  nonunion, Scaphoid  nonunion  and  radio-scaphoid  arthritis and  the  final  result  with  serious  wrist  arthritis. However, sometimes  the  story  is  different.  Here  is  a  case  of  a  65  year  old  man  with  a  35 year  old  scaphoid  nonunion,  and  radio-scaphoid   arthritis. He  has    painless  functional  range  of  motion. The  question  is:  Must we treat him? The  answer  is  difficult!  If  we  operate,  we  must  know  that union  is  not  100 % guaranteed, and  we  may   have  post-op   symptoms,   like  stiffness  or  pain.

The  anatomy  of  the  carpal  bones  is  showed: Left  is  the  dorsal  view  and  right  the  palmar. In  this  anatomic  picture  we  can  see  the  axial  anatomy  of  the  wrist  and  on  the  left  the  scaphoid  bone  and  its  dimensions: 2  to  3  cm  in  length. The  blood  supply  of  the  scaphoid  is  very  important. The  vascular  anatomy  comes   from  the radial artery.  There  are  dorsal and volar scaphoid branches. The  dorsal branches give the 70% – 80% of the blood flow. The  distal  20%  of  the  bone  is  supplied  by  palmar vessels  entering  the  tubercle   and   distal  pole,  and there  is,  also,   retrograde blood flow to  the  proximal pole.

Normal  Carpal  Alignment  includes   radial  inclination  of  about  30 degrees, and  dorsal  tilt  of  the  radius  which  is  about  zero  to  15 .The  Carpal  Height  Ratio  is  the  distance  between  distal  articular  surface  of  capitate   to  distal  articular  surface  of  radius. It  counts  the  relationship  between  the  carpal  bones  and  the  3rd  metacarpal,  and  must  be  about  0,5. The  scapho-lunate  angle  must  be  55  to 65 degrees ,  and  the  radio-lunate  and  luno-capitate  angle  the  same  with  the  dorsal   tilt  of  the  radius,  zero  to  15 degrees .

The  classification of scaphoid fractures  as  described  by  Herbert   and  Fisher  is:

Type  A  is  an  acute  stable  fracture. A1  is  a  tubercle  Fx,  and A2  a incomplete waist Fx

Type  B  is  an  unstable  fracture. B1 is a  complete waist Fx, B2 is a complete transverse waist  Fx, B3   is  a  proximal pole Fx,  and B4 is a  trans-scaphoid perilunate dislocation.

Type   C  is  a  delayed union,  and

Type D  is nonunion. The D1 is stable  with fibrous union, and  the  D2  is  unstable  with  Pseudarthrosis.

Another  classification  by  Herbert  is  shown  on  the  next  slide. It  has  5  types:

Type  1  with  fibrous  union,

Type  2  with  mild  pseudoarthrosis,

 Type 3  with  moderate  pseudarthrosis,  and

 Type  4  with  severe  pseudarthrosis.

Type  5  has  avascular  necrosis  of  the  proximal  pole.

This  classification  describes  the  radiographic  appearance,  fracture  mobility,  the  lack  of  wrist  motion,  the  presence  of  arthritis  and  the  likelihood  of  healing.

Before  1960  the  treatment  was  only cast immobilization. The  evolution  of  treatment  of  a  scaphoid  nonunion  is  as  follows: Between  1960  and  1980  the  literature  suggested  inlay bone graft as  described  by  Russe. From 1980 till today  bone graft  +  screw fixation  was  the  treatment  of  choice  for   most  cases. On  the  other  hand,  since  1990, vascularized bone graft  has  been  used  by  a  lot  of  surgeons,  especially  in  cases  with  an  avascular  proximal  pole. We  could  say  there  that  today,  the  treatment  of  a  scaphoid  nonunion  can  be  conservative  or  surgical.

Non-operative treatment includes splinting and electrical stimulation. Ultrasound and electrical stimulation for undisplaced proximal pole fractures and nonunion has also been  used and  a  few  authors  believe  that  it  is  an  effective  technique.

Surgical  treatment  includes simple excision, radial osteotomy, soft tissue interposition  as  described  by  Bentzon, simple fixation and corticocancellous graft (Russe  procedure). Wrist denervation is also  recommended  for  patients  who  don’t  want  to  undergo  a  bone  procedure,  for pain relief. But,  we  do  not  have  functional  improvement.

Scaphoid  nonunion  treated  with  simple  excision  of  the  proximal  pole,  and  with  simple  fixation This  is  a  case  of  a  scaphoid  nonunion  treated  by  Matti – Russe  technique  with  the  use  of  cortico – cancellous  bone  chips. Radius  osteotomy  was  very  popular  in  Greece  in  the  decades  of  ’60s,  and  ‘70s.  Giannikas ,  a  great  Greek  Hand  Surgeon,  suggested  the  method,  and  his  results  were  acceptable. We  can  see  on  the  following   pictures  a  scaphoid  nonunion   which  was  treated  with  radial  osteotomy.  Three  months  after  the  operation,  the  scaphoid  is  starting  to  unite.

More  recent  techniques  are: Interposition trapezoidal graft and fixation  as  described  by Fisk,  Fernandez  et. al, Vascularized graft (volar or dorsal), Limited or complete fusion, Proximal  Row  Carpectomy,  and Implant Arthroplasty.

The  aim of treatment in a scaphoid  nonunion  must  be  the  reconstruction of the scaphoid   both  concerning,   its  axis  and length, along  with  stable compressive fixation. Mack  and  Lichtman  have  suggested  a  staging  System  for  scaphoid  reconstruction. According to bone  loss, carpal  collapse deformity, secondary osteoarthritis, loss  of  motion and degree  of disability, there  are  4  stages:

Stage  I   Is  a  Simple  Stable  Nonunion. This  stage   is characterized   by a  firm  fibrous  union  that prevents  deformity. The  length  of  the  scaphoid  remain  well  preserved  and  the  risk  of  osteoarthritis  is  minimal. Pain  and  discomfort  are  present  only  when  stressing  the wrist. Even  if  the  patient  is  asymptomatic  the  fibrous  union  is likely  to  became  unstable  over  time  if  left  untreated. In  these  cases  we  must  do: Resection of all fibrous tissue, bone grafting and/ or screw fixation.

But,  which  are  the  points  showing   that  a  scaphoid  fracture  is  stable  or  unstable? Well,  a  scaphoid  fracture  is  unstable  if  it  has: S-L angle   more  than  70, C-L angle more  than   15,  and more  than   1-2 mm  displacement.

Stage II    By  Mack   staging  is  an   Unstable  Nonunion. In  stage  II  the  bone  ends  tend  to  became  sclerotic  with fibrous  cysts  extending  into  both  bone  fragments. Depending  on  the  age  of  the  fracture,  it  may  be  associated with  some  degree  of  carpal  collapse  deformity  and  secondary  osteoarthritis. We  must  perform: complete resection of the pseudarthrosis, correction of the deformity, restoration of scaphoid length, bone graft and internal fixation.

Stage III      Is  a  Nonunion  with   Early  SLAC. In  stage  III,  the   radiograph  shows  a  long  standing pseudarthrosis  with  marked  deformity  and  discrepancy  in the  size  of  two  fragment  associated  with  radiological osteoarthritis. Against  all  odd,   some  of  these  cases  can  be reconstructed  using  sufficient  bone  graft  with  radial styloidectomy  at  the  same  time  or  later. Other  options  are closed wedge radial osteotomy, which  sometimes  offers   pain  relief  and  significant improvement  of  hand  function, limited wrist fusion  or PRC.

Stage IV      Is  a  Nonunion  with  late  SLAC. In  stage  IV,  carpal  collapse  deformity  is  well  established,  cystic  change  and  deformity  of  the  whole  scaphoid  is present  not . suitable  for  reconstruction! The  only   available  treatment  options  are  partial or complete wrist fusion.

In   our  practice,  we  use  the  follow  algorithm: For  a  stable  scaphoid  fracture  less  than  six  months    old,  we  do  only  compressive  fixation. If  the  scaphoid  fracture  is  more  than  6  months  old,  and  if  it  is  unstable,  we  do   interposition  trapezoidal  iliac  crest  graft,  and  compressive  screw  fixation. For  avascular  proximal  pole  fracture,  we  are  using  interposition  graft  in  the   first  operation. For  revision  cases,  we  do  vascularized   graft. In  cases,  with  scaphoid  nonunion  and  radio – scaphoid  arthritis,  we  do  interposition  graft  plus  styloidectomy. Finally,   in  cases  with  scapho – capitate ,  and  luno – capitate   arthritis  we  perform  4  bone  fusion. Total fusion   is  performed  only in rare cases,  especially   in  young  patients   who  are  heavy  manual  workers.

Interposition trapezodial iliac crest bone gragt  and  compressive  fixation,  is the technique,  that we use, especially in unstable nonunions,  because  we  believe that it is a reliable method  which  permits  universal  treatment  of  scaphoid  nonunions.  This   technique,  I’ll  describe  in  the  next  few  minutes,  just  as   we  do  in  our  everyday practice. Interposition bone graft  has  been  first  described  by  Fisk,  in  1979. He  did  styloid  osteotomy   and  reconstruction  of  the  scaphoid  with  wedge  graft  from  the  radius,  and  without  fixation. In  1984,  Fernandez  used  palmar approach, iliac crest graft,  and   K-wire fixation. The  same  year,   Herbert  suggested  palmar approach, trapezoidal iliac crest graft  and screw fixation.

Pre-operative  planning  includes: Plain radiographs,  with Face  view, lateral wrist view, scaphoid  view and oblique  views  with  45˚- 60˚ of  pronation. On   the  radiographs  we  can  see  sclerosis, cystic changes, bone resorption and collapse.  It  is  important  to  have  x-rays  of  both  hands,  for  the  evaluation  of  the  dimensions  of  the  opposite  scaphoid. On  the  other  hand,  we  must  examine  the  other  hand  for  an  additional  disorder,  (as  we  can  see  on  the  picture),  where  there  is  an  asyptomatic  scaphoid  nonunion  in  both  hands. CT-scan  is  very  useful,  as  it  can  detect a  scaphoid nonunion or incoplete union,  the location of nonunion,  a humpback deformity,  and cysr formation. In  this  case  with  scaphoid   nonunion,  we  can  see  on  the  CT-scan  the  cyst  formation  and   the humpback deformity. This  is  another case,  with  a  serious  humpback deformity,  and  avascular  necrosis  of  the  proximal  pole. The  MRI  is  the  modality  of  choice   for  avascular necrosis and  it  can  also  detect  other  disorders  such as  a   Preser’s  disease. Arthroscopy   is  sometimes   very  useful,  because  it  offers  better  view of the scapho-capitate joint.  The evaluation of the radial styloid arthritic changes,  and  the associated ligaments and  TFCC  injuries  are  better,  too. In  addition,  we  can   confirm the  proper screw placement. First,  we  must  measure the length and   S-L  angle of the normal scaphoid. Next  step,  is   to  measure the bone gap and the angular deformity. Measuement of the bone graft dimensions,  is  very  important. The  surgical  technique  that  we  use  is  the  following. We  use  palmar  exposure  for  all  scaphoid  fractures,  except  for  the  very  small  fractures  of  the  proximal  pole,  where  we  use  dorsal. The  Palmar  approach  is: Safe, Simple, Fast,  and  permits Wide exposure  of  the  scaphoid. The  advandages  are: less injury to vascular supply, more safe for superficial branches of the radial nerve, easier to correct scaphoid collapse  and  you can  also  correct lunate rotation,  when  needed. Here  is  a  case  of  a  scaphoid  non-union.You  can  see  Both  hands,  and  the  involved  hand. On  the  CT  we  can  see  the  humpback  deformity,  and  the  cyst  formation.

The  palmar   incision. The  dissection  involves  releasing  the  flexor  carpi  radialis   from  its  fascial  tendon  sheath, ligating  or  protecting  the  recurrent  radial  artery. It  is  important  to  protect the neurovascular structures. After  this,  the  scaphoid  is  exposed  after careful  division  of  ligamentous  and  capsular  structures. In  this  picture   we  can  see  the  fracture  line. All  fibrous  tissue  and  sclerotic  bone  are  carefully  resected  back  to  viable  bleeding  bone. Care  must  be  taken  to  preserve  the  dorsal  cortex, because  it  provides  the  dorsal  blood  supply  to  both  the proximal  and   distal   poles. Secondly  it  gives  some  stability  for  the  scaphoid , making the  placement  of  the  graft  between  the  two  fragments, as  well  as  of  the  screw  placement  technically  easier. If    cystic  areas  are  present,  they  are  curretted  to obtain  a  good  cancellous  bed  in  both  the  proximal  and distal  pole.  Then  the  tourniquet  is  deflated  and  both poles  are  inspected  to  identify  adequate  bleeding. This  finding  is  recorded  in  the  surgical  report. The  distal  end  of  the  scaphoid  is  exposed  and  mobilized by  a  transverse  incision  of  the  capsule  of  the scaphoid-trapezium  joint. A  small  piece  of  bone  is  removed  from  the  trapezium  to allow  the  screw  to  be  inserted. A  corticocancellous  iliac  crest  bone  graft  is  then  obtained  with  some  chips  of  cancellous  bone. Be  careful  with  the  lateral  femoral  cutaneous  nerve, If  injured,  loss  of  sensation  will  occur  in  the  shaded  area. We  have  never  used  a  radial  graft  or  an  allograft. The  corticocancellous  iliac  bone  graft  is  fashioned  to fill exactly   into   the  scaphoid  defect. The  cortical  graft  surface  is  placed  facing  the  palmar non  articular  surface,  between  the  proximal  and  distal  part  of  the  scaphoid. This  position  allows  further  cortical  support. Internal  fixation  is  then  applied  using  a  cannulated  Herbert  bone  screw  following  the  original   technique. Fluoroscopy  is  used  to  determine  the   placement  of  the  guide  wire,  first,  and  of  the  screw  position,  finally. By  using  a  burr,  the  surface  of  the  bone  graft   smoothened and,  this  is  the  final  result. You  can  see  the  smoothened  graft, the  correct  placement  of  the  screw,  and the  adequate  reduction  of  the  scaphoid.

There are few papers comparing iliac bone graft to other bone grafts.The majority of them considers iliac graft to have more advantades.   Iliac cancellous – cortical bone graft is preferred because the cancellous part has better osteogenic potential and the cortical part has better biomechanical properties and allows compressive fixation.

A  few  words  about  screw  selection! There  are  a  lot  of  screws  for  scaphoid  fixation  as: ACCUTRAK, AO/ ASIF  SCREW, ASNIS, LITTLE  GRAFTER, BOLD, MINI  ACUTRAK, HERBERT  WHIPLE and HERBERT. The  Herbert  screw  was  specifically  designed  for  fixation of scaphoid  fractures  and  it  can  be  inserted  using  special instrumentation. The  same  technique  is  used  in  conjunction  with  bone grafting  for  nonunion. Although, the mechanical properties are better in all the others types of screws, we still prefer to use the Herbert screw as the screw design allows compression between the scaphoid fragments and the graft. The greater compression pf the fully threaded screws may increase the risk of proximal fragment comminution. In  order  to  apply  compression  the  thread  on  the  leading end  of  the  screw  has  a  greater  pitch  than  that   of   the trailing  end,  so  that  fragments  are  drawn  together  as  the screw  is  inserted,  compressing  the  interposition  graft. The  absence  of  protrusive  head  allows  the  screw  to  be inserted  through  articular  cartilage. In addition, the use of the special designed  “JIig”  allows easier screw placement, and in our experience the disadvantages are minor. In revision cases the ACCUTRAK  screw is used, as the greater hole size does not permit adequare compression with the Heebert screw.

Overall,  there  are  a  lot  of  critical  points  to  take  care  during  the  procedure,  such  as:

• Wide exposure of the whole scaphoid
• Wide excision of the pseudarthrotic tissue
• Restoration of the anatomic length of the scaphoid
• Correction of the flexion deformity
• Removal of cyst formation
• Removal of sclerotic fragments ends
• Reduction can be easier with dorsal flexion of the wrist
• Lunate reduction
• Iliac bone graft
• Cancellous bone chips between the graft and fracture ends
• Partial Trapezoid excision for easier screw insertion
• Reduction and wire placement unter fluoroscopy
• Central position of the quide
• Reaming up to proximal cortex
• If necessary use a second antirotational K-wire
• Correct size of the screw
• Stable fixation
• If not, additional k-wire or screw fixation and longer immobilization
• Radial styloidectomy when needed

Here  are  some  technical tips for scaphoid reduction,  such  as:

• Do dorsiflexion of the wrist with the use of a rolled towel
• Use small osteotomies and bone hooks
• The interposition graft must have the pre-operative measured size

For lunate reduction, the technical tips are:

• Use k-wire as joystick
• Reduce the lunate to radius first and fix it with k-wire
• Reduce the scaphoid and capitate, next
• Always fluroscopically confirmed

The  avascular  proximal  pole  of  a  scaphoid  nonunion  is  a  special  condition,  and  the  results  of   surgical  treatment  are  not  often  predictable. Fractures  through  the  proximal  pole  of  the  scaphoid  are less  common  and  comprise  approximately  20%  of  all scaphoid  fractures. Up   to  one  third  of  all  proximal  pole  scaphoid  fractures may  result  in  nonunion. The  treatment  options  are: excision of proximal pole, retrograde screw fixation, interposition iliac bone graft, vascularized bone graft, and
bone morphogenetic proteins. The  excision of proximal pole can  be  used  only  for  small   fragment, less than 20%,  and  it  is  necessary  to  have  the  Scapho-Lunate  ligament intact. Other  indication  is  a  sclerotic and fragmented  proximal  pole,  but  the  method  can  lead  to  carpal collapse. The  retrograde screw fixation  is  indicated only for nonunion without bone resorption. Cases  with  bone  loss  and   Humpback deformity,  lead  to  carpal collapse. The role of  bone Morphogenetic  Proteins  has not been clarified  well  yet.

Vascularized bone graft is the gold standard method, but there a lot of difficulties in scaphoid reduction and osteosynthesis.

In  our  practice,  we  still  use  the  Interposition Iliac  bone graft technique,  for  the  first  operation  of  a  proximal  pole  nonunion,  although  there  is poor vascularity  of  the  scaphoid,  and  the possibility for graft resorption and  failure  of  union  is  theoretically  high. In  revision  cases,  we  perform  only  vascularized  grafts. For  the  reconstruction  of  the  proximal  pole  nonunion,  with  or  without  avascular  necrosis  we  use  both  palmar  or  dorsal  approach. Palmar  approach  for  the  most  of  the  cases,  and  dorsal  approach  only  for  very  small  fragments. In  this  case  With  proximal  pole  fracture  and  avasculal  necrosis, As  you  can  see  on  the  CT, we  used  palmar  approach.  The  graft  is  shown  on  the  left  picture,  and  the  union  on  the  right,  although,   the  screw  is  short.  This  is  a  case  with  a  very small  proximal  fracture. On  the  CT  it  looks  like  it  is  avascular. We  used  dorsal  approach. You  can  see  the  fracture  line! We  use  a  small  k-wire,  first,  to  keep  the  reduction. Wide  excision  of  the  pseudarthrotic  tissue  is  performed,  and  a  second  k-wire  is  necessary  for  better  debridement  without  loss  of  the  reduction. The  final  result  with  the  graft  placement,  and  the  screw  fixation.  You  can  see  the  union  of  the  fracture!  Another  case  with  a  very  small  fracture,  which  was  treated  in  the  same  way,  and  you  can  see  the  union. In   few  cases  we  used  other  materials  of  fixation,  for  example  simple  k-wires,  because   the  dimensions  of  the  proximal  fragment  did  not  allow  placement   of  a    Herbert  screw.

Complications of the trapezoidal interposition graft in the treatment of scaphoid nonunion can be: scaphoid fracture, failure of fixation, mal reduction, or vascular injury.

All these can have as a result failure of union or malunion. The failure of fixation includes: poor scaphoid realignment, inaccurate jig placement and incorrect screw length, which can lead to screw migration. Other complications are infection , which is rare, and graft extrusion or resorption. All these also result in failure of union.
The post-operative management includes: splint for 3 to 6 weeks, and then physical therapy. Free activities are permitted after callus appearance. It should be noted that stable fixation allows for an early and functional recovery. The majority of authors agree that the immobilization must last until callus appearance. We believe that, if the scaphoid fixation is stable, immobilization for 3 weeks is enough, just for capsular healing.
The results for scaphoid nonunion with interposition graft report a rate of union from 75% to 100%, as described by a lot of authors, (Nakamura, Herbert, Fernandez, Green, Beris, Hull, etc).

In 2002, Merel in a Meta-analysis of 1.121 reviewed articles, found that : the union rate with screw + graft was 94%. The union rate for AVN proximal pole with screw + graft was only 47%, but the union with vascularized graft for AVN proximal pole was 88%. In a recent article in 2005, Chao Huang, described his results with interposition graft. In his data with 49 patients and 5 years Fu, the union rate was 93.9% and 46 pts had excellent or good result based on Cooney’s scoring system.

In  my  personal  series  with  more  than  100  cases  in  20  years,  the  union  rate  is  92%. D.  Efstathopoulos,  from  “KAT” Accident  Hospital  in  Athens  maybe  has  one  of  the  biggest  series  in  the  world. He  has  operated  the  last  25  years  more  than  1000  cases,  and  his  union  rate    is  almost  95%  The  Average  Time  to  Radiological  Union  is  6  to  9  Months (Range  1,5  to  15   Months). The  Average  Time  for  Return  to Work  is  7  Weeks (3 -14 weeks)  in Patients  who  Were  not  Heavy  Manual  Workers  and  10 – 20  Weeks  in  Those  who  Were  Heavy  Manual Workers. The  Range  of  Motion  and  the  grip  Strength  usually  is  similar  to  the  normal  limits. Unfortunally,  these  data  is unpublished as we have not finished the evaluation of the data yet, about the type of fracture, chronicity of nonunion, sex, tobacco use, etc. We hope that we will be able to present the final results in the near future.

We  use  the  same  technique   for  revision  cases  too,  but  it  is  more  difficult. We  do  more aggressive debridement of the pseudarthrotic tissue, and we try to use the same approach and to keep the previous hole. bigger screw is used in the majority of cases.

The vascularized graft is used in cases with poor vascularity area with a lot of previous operations and significant fibrous tissue formation. The major indication for vascularized graft is the poor vascularity of the scaphoid and the major contra-indication is a humpback deformity, as reduction and compressive fixation have some difficulties. Dean Sotereanos has a great experience with vascularized grafts for scaphoid nonunion, and we all know his excellent results. When compared, with the vascularized graft, the advantages of the interposition graft are: it is simple technique, it is safe, allows better scaphoid reconstruction and has similar percentage of union. On  the  other  hand, the vascularized graft offers better vascularization, has no morbidity from the donor site, seems ideal for revision cases and you can also do it with regional anesthesia, which is easier to operate the patient in a day clinic.

The  disadvantages  of  the  interposition  graft  are  the  following: It has poor vascularization especially in revision cases, there is morbidity from the donor site, and it requires general anesthesia. The  disadvantages  of  the  vascularized  graft are: It is a more demanding technique, it has some difficulties for reduction, the fixation is usually unstable , and longer time of immobilization is needed.  Here,  we  used   a  dorsal  based  vascularized  graft  from  the  radius,  as  the  previous  operations  for  the  scaphoid  nonunion  and  the  distal  radius  fracture  did  not  permit    safe  harvesting   of   a   Volar  pedicled  flap.  You  can  see  the  blood  supply  of  the  graft.

We’ ll  see  some  cases  now. In  This  scaphoid  nonunion,   union  occurred  4  months  post-operatively.  You  can  see  the  excellent  compressive  fixation. Another  case,  3  months  post-op,  there  is  radiological  union  of  the  proximal  pole,  but  not  of  the  distal  pole. The  union  is  complete  3  months  later,  6  months  in  total. In  this  case,  it  is   5  months  post-op,  we  have  union  of  the  scaphoid,  but  complete  revascularization  of  the  graft  appears  in  a  total  of  6.5  months. Another  case,  of  a   serious  delayed  nonunion,  with  cyst  formation,  the  graft, and  the  union  7  months  post-op. In  this  case,  there  is  a  nonunion  with  avascular  necrosis  of  the  proximal  pole.  You  can  see  the   cyst  formation  and  the  humpback  deformity.  We  used  the  standard  technique.  The  Herbert   screw  fixation  was  unstable,  and   two  k-wires  were  used   for  additional  fixation. You  can  see  the  revascularization  of  the  graft  and  of  the  proximal  pole,  and  finnaly  the  scaphoid  union.  This  is  a  case  with  a  very  proximal  avascular  fragment. We  used  dorsal  approach  and  interposition  graft,  with  a  good   result. The  union  appears  complete,  11  months  post-op. On  this  picture  we  can  see   excellent  Correction  of  the  Deformity  and  Restoration  of  the  Height. This  a  rare  case  with  Reconstruction  of  Both  Scaphoids. Reconstruction  of  Long  Standing  Cases,  is  another  difficult  situation.   In  this  case  of nonunion,  we  can  see  the  sclerotic  bone  and  the  deformity.  After  wide  debridement  a  large  piece  of  bone  is  used,  for   restoration  of  the  scaphoid  length, and ,  a  solid   union. In  this  comminuted  fracture,  we  also  used  a  large  trapezoidal  graft,  and   union  was  achieved.  In  this  revision  case,  we  used  the  same  dorsal   approach,   the   same  hole,  and  the same  type  of  screw.  The  Accutrak.  You  can  see  the  united  trapezoidal  graft.

Now,  let’s  talk  about  some  cases  of  failures! In  this  case,  although  the  graft  and  the  screw  had   good  placement,  there  has  been  a  resorption  of  the  graft  and  nonunion. The  same  applies  to  this  case  with  proximal  AVN pole,  in  which  the  incorrect  placement  of  the  screw  had  as  result  the  failure  of    treatment. Cases  with  screw  malposition   and  union  failure. In  this  case,  although  the  graft  and   screw  placement  was  correct,  the  result  was  graft  resorption  and  screw  migration. Another  revision  case  with  Nonunion,   and  Graft  Resorption, but  the  Wrist   is  Painless! Screw  Offers  Stability,  But  for  How  Long?

Here  are  some  Technical  Factors  Related  to  Herbert  Screw  Fixator. Incorrect  height  reduction. This  is  another   case  with  eccentric  screw  placement,  which  however  did  not  prevent  union. Similar  case,  with  union  although  the  screw  was  eccentrical. Screw  placement  Out  of  the  scaphoid,   yet  it  resulted  in  painless  solid  union. Short  screw,  but  it  did  not  prevent  fracture  healing. Short  screw,  with  union. Long  screw  with  union.

For reconstruction of scaphoid nonunion advanced collapse, the treatment options are: styloidectomy, proximal row carpectomy, 4 bone fusion, and total fusion. Styloidectomy is preferred if only the styloid is affected and must be no more than 3-4 mm, to avoid carpal instability. An oblique osteotomy is better than a transverse for the same reason. Proximal  Row  Carpectomy  is  an Effective   Technique. It  is  simple, safe, has  fast  recovery,  and has  good  range  of  motion. But,  it  is  necessary  to  have Capitate  without  arthritis. On  the  other  hand,  Capitate   is   incongruent  with  Lunate  Fossa. The  procedure  results in  transient  loss  of  grip  strength. The  majority  of  the  authors  agree  that  PRC  has  excellent  long  term  results.

Four  bone  fusion  was  described  by   Η.Κ.Watson, in 1980, with scaphoid excision, and arthrodesis of the lunate, capitate, hamate and triquetrum. It is a reliable treatment method, provides better congruity, but it is associated with a long time to union, and has high percentage of nonunion. On the other hand, perhaps it has better long term results. The  standard  surgical  technique  includes:

• Dorsal longitudinal approach
• Dissection of the extensor retinaculum
• Incision of the wrist capsule
• Scaphoid excision
• Wrist reduction
• k-wires fixation
• Meticulous decortication of the articular surface of the four bones, and
• Iliac bone graft
• Radial styloid excision (must be performed in all cases)
• Capsular repair
• Dissection and cauterization of the terminal branch of posterior interoseous nerne

On  these  pictures,  we  can  see  the  K-wire  fixation,  the  decortications,  the  capsular  repair,  and  the  cauterization  of  the  PIN. Recently, new fixation devices, such as screws, staplers, or Spider and Button plates have been used. Review of the literature reports the following: 10% non union, 60-70% range of motion, 70-80% radial / ulnar deviation and 80% grip strength.

In my personal experience with 14 patients (11 male , and 3 female), average age 38 yrs (28-56) , and average duration of symptoms 2,4 yrs (6 months to 7 years). In a follow – up of 3.6 yrs (range 9 months to 14 years), all the patients had union of the arthrodesis (with iliac bone graft!), had complete relief of pain or only minimal pain and had the same occupation as before. The grip strength was 80% of the normal, and the range of motion 60%. The average time of treatment was 4.5 months. No-one asked for additional therapy, and all the patients would have undergone the same operation again, had they knew the result in advance. This  is  a case  of  scaphoid  nonunion, in  a  heavy  manual  worker    51  year  old  man,   with  excision  of  the  proximal  pole,  and  SLAC  wrist. We  performed  4  bone  fusion,  and  the  results  2  years  post-op,  and  14  years  post-op  were  excellent  with  a   stable  wrist  and  no  progressive  arthritis.

For scaphoid malunion we use the same surgical technique with trapezoidal interposition graft and compressive fixation. The osteotomy must be central and open wedge and it is necessary to reduce the lunate deformity first, before the graft placement.

IN  CONCLUSION:

• Scaphoid non unions are not rare
• Location, comminution, avascular necrosis, associated injuries and surgeon’s experience, all these are factors to consider for the best result
• Upper limb surgeons must be familiar with all methods of treatment
• Trapezoidal interposition iliac bone graft and compressive screw fixation gives excellent results, especially in unstable cases
• There is a significant discrepancy between various studies for scaphoid nonunion.
• The choice of the treatment method, the surgical technique, and the patients selection are all very important for a successful result!

“It  Has  always  Been  our  Policy  to Carry  Out  a Reconstruction  Whenever Possible”

 I  would  like  therefore  to    finish  my  talk  with  some  words  by  Herbert:

“Nothing  is  More  Depressing than  Having  to  Fuse  the  Wrist of  a  Young  Patient  who  a  Few Years  Earlier  Suffered  a  Simple  Fracture  of  the Scaphoid”

You  can  decide!  Do  you  want  to  treat  a  scaphoid  nonunion  like  this  with  a  good  result, or  you  would  like  to  see  a  scaphoid  nonunion  25  year  old  (left  picture),  or  on  right    50  year  old.

Thank  you  very  much  for  you  kind  attention!

 

PANAGIOTIS N GIANNAKOPOULOS MD

 

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Αρχική

ΠΑΝΑΓΙΩΤΗΣ Ν. ΓΙΑΝΝΑΚΟΠΟΥΛΟΣ

ΟΡΘΟΠΑΙΔΙΚΟΣ,  ΧΕΙΡΟΥΡΓΟΣ ΧΕΡΙΟΥ - ΑΝΩ ΑΚΡΟΥ

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