The treatment of scaphoid nonunion using the Ilizarov fixator without bone graft, a study of 18 cases

Marko Bumbaširević,Zoran Rakočević,Aleksandar Lešić,Slavko Tomić,Vesna Bumbaširević,Henry D Atkinson

doi:10.1186/1749-799x-6-57

Abstract

ObjectivesEvaluating the safety and efficacy of the Ilizarov fine-wire compression/distraction technique in the treatment of scaphoid nonunion (SNU), without the use of bone graft.DesignA retrospective review of 18 consecutive patients in one centre.Patients and Methods18 patients; 17 males; 1 female, with a mean SNU duration of 13.9 months. Patients with carpal instability, humpback deformity, carpal collapse, avascular necrosis or marked degenerative change, were excluded. Following frame application the treatment consisted of three stages: the frame was distracted 1 mm per day until radiographs showed a 2-3 mm opening at the SNU site (mean 10 days); the SNU site was then compressed for 5 days, at a rate of 1 mm per day, with the wrist in 15 degrees of flexion and 15 degrees of radial deviation; the third stage involved immobilization with the Ilizarov fixator for 6 weeks. The technique is detailed herein.ResultsRadiographic (CT) and clinical bony union was achieved in all 18 patients after a mean of 89 days (70-130 days). Mean modified Mayo wrist scores improved from 21 to 86 at a mean follow-up of 37 months (24-72 months), with good/excellent results in 14 patients. All patients returned to their pre-injury occupations and levels of activity at a mean of 117 days. Three patients suffered superficial K-wire infections, which resolved with oral antibiotics.ConclusionsIn these selected patients this technique safely achieved bony union without the need to open the SNU site and without the use of bone graft.

Highlights

First described by Causin and Destor in 1895, injuries to the scaphoid account for 70% of all carpal fractures [1], and with appropriate initial treatment the majority unite without complication [2,3]
There is still no accepted “gold standard” for the treatment of scaphoid nonunion (SNU), and failures occur in up to 25% of cases [3,10]; influencing factors include: the time elapsed since injury, the type of operative treatment, the anatomical location of the SNU, the development of scaphoid avascular necrosis (AVN), having had a previous styloidectomy (1), and the presence of a scaphoid humpback deformity [11]
SNU treatment options are:(i) fracture fixation alone, without bone grafting [12]; (ii) the use of non-vascularized bone grafting without internal fixation [13,14]; (iii) non-vascularized bone grafting with internal fixation [3,7,15,16,17]; (iv) the use of vascularized bone grafts, with or without internal fixation [18,19,20], with a recent systematic review reporting union rates of 80% using bone graft without fixation, 85% using bone graft with fixation, and 91%100% using vascularized bone grafts [4,13,19]

Summary

Introduction

First described by Causin and Destor in 1895, injuries to the scaphoid account for 70% of all carpal fractures [1], and with appropriate initial treatment the majority unite without complication [2,3]. Up to 45% of these fractures [4,5], often those occurring in young active patients [6], progress to a nonunion. The most common causes of scaphoid nonunion (SNU) relate to inadequate fracture immobilization (in terms of duration and type of immobilization), patient non-compliance with. Bony healing is achieved though the application of compression and distraction at the fracture sites which is thought to improve local micro-circulation [20,21,22,23,24]

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