Management Of Scaphoid Nonunions Research Articles

Round table discussion. The management of proximal scaphoid nonunion.

The management of scaphoid nonunion, although relatively common, continues to pose challenges, especially if complicated by avascular necrosis of the proximal pole, humpback or dorsal intercalated segment instability deformities, and early scaphoid nonunion advanced collapse. In this round table article, four surgeons were asked to answer key questions on a clinical example of a proximal scaphoid nonunion to outline their approach and rationale in their preferred treatment choices. The current panel of experts leans towards arthroscopic methods of treatment and most agree that arthroscopic bone grafting has become an important and revolutionary treatment option, which has yielded excellent results. However, both open and arthroscopic grafting are validated methods of treatment and which is to be performed is largely based on the surgeon's preference.

Arthroscopic Scaphoid Bone Graft Combined with Percutaneous Fixation versus Open Scaphoid Fixation with Non Vascularized Graft in Scaphoid Non-Union

Abstract Background Consensus about Management of scaphoid nonunion is controversial, many procedures have been described. This study compares between 2 modalities for management of scaphoid nonunion either arthroscopic scaphoid bone grafting from iliac bone combined with percutaneous fixation versus open scaphoid fixation and non-vascularized bone graft from iliac bone in management of scaphoid nonunion to identify if one technique is better as regards union rate, time to union and functional outcome. Patients and Methods A prospective randomized control trial held to recruit the patients between September 2019 and December 2020 between open grafting group (group O) for scaphoid non union (15 patient) and arthroscopic group (group A) ( 15 patients), randomization was done by using computerized random allocation. The mean follow up was 17.2 months(12- 24 months). We evaluated the results as regards union rate, time to union, complications, grip strength functional outcome according to disability of arm, shoulder and hand questionnaire (DASH) score and modified mayo wrist score (MMWS). We analyzed the results by using Statistical Package for the Social Sciences software (SPSS) version 25. Results union rate for group A was 100 % with time to union mean of 9.73 weeks (±2.4 weeks), union rate for group O was 93.33% with time to union mean of11.64 weeks(±1.82 weeks) which was significantly faster to union for group A(p value<0.05) . The open group showed significantly less operative time, the mean operative time was59.2 min±11.01, 90.6min±11.77 for group O and group A respectively. Grip strength, range of motion, VAS, MMWS and DASH score improved post operative for both groups with no statistical difference between them with comparable complication rate. Conclusion arthroscopic grafting technique for scaphoid non unions showed comparable results as regard union rate, complications, range of motion and functional outcomes with significantly faster time to union however, significantly longer operative time.

Cancellous compression bone grafting using headless screw as a strut in scaphoid nonunion by a single volar approach

PurposeAn array of fixation and grafting techniques for scaphoid nonunion have been described over time, achieving varied results pertaining to union and scaphoid alignment. The aim of this study was to check for union rates and correction of scaphoid parameters achieved by our technique of using screw as a strut and cancellous compression grafting harvested from the distal radius by a single volar approach.MethodsRetrospective analysis of all patients operated by the said technique was done from 2013 to 2019. Thirty-eight patients including 36 males and two females in the age range of 20–56 years were analyzed. Union rates, change in scaphoid alignment parameters and graft site characteristics were documented.ResultsOf the patients analyzed, 5/38 were nonunions of proximal pole, 19/38 of waist and 14/38 were of distal pole which included nonunions of cystic type or with humpback deformity. Patients were followed up for an average of 22.2 months and union was achieved in all cases with a mean period of 15.7 ± 3.7 weeks. There was significant improvement in the scaphoid alignment postoperatively. One case of implant migration and one case of scaphoid nonunion advanced collapse were noted. The mean duration of donor site healing was noted to be 16.9 ± 2.5 weeks except two outliers which took longer time. There were no cases of donor site fracture or other complications.ConclusionUnion rates, correction of scaphoid parameters and minimal complications justifies this technique as a novel one in the management of scaphoid nonunion at all levels, with minimal donor site morbidity and attained by the single volar approach.

The Functional Outcomes of Scaphoid Nonunion with Deformity Treated with Anterior Wedge Bone Grafting: A Case Series

Introduction. Scaphoid nonunion is one of the most difficult fractures to treat. Restoration of carpal alignment and fracture stability can provide good outcomes in the management of scaphoid nonunion.
 Objective. The purpose of this study was to determine the functional outcomes of scaphoid nonunion associated with humpback deformity treated with anterior wedge bone grafting and internal fixation.
 Methods. A retrospective review of all patients with scaphoid nonunion treated with anterior wedge bone grafting from January 1, 2014 to December 31, 2019 was done. Outcome measurements were time to union, pre- and postoperative FIL-DASH scores, grip, pinch, and scapholunate angle improvement. The other outcome measures were pain and complications.Results. A total of 12 patients were included in the study. All were males with an average age of 27.4 years (SD,9.6). The average delay to surgery was 9.5 months (SD, 10). All fractures were at the waist, except for three proximal pole fractures, none had established avascular necrosis. Eleven out of 12 scaphoids healed at an average of 11.5 weeks (SD, 3.2). There was a significant improvement in the FIL-DASH score and scapholunate angle after surgical reconstruction. Grip strength averaged 83% of the contralateral side. All returned to previous normal activities. One patient with persistent proximal pole nonunion was managed with a 4-corner arthrodesis.Conclusion. Anterior wedge bone grafting for scaphoid nonunion restored the scapholunate angle and was able to establish union in 11 of 12 scaphoid nonunions with good outcomes.

Single Versus Dual Headless Compression Screw Fixation of Scaphoid Nonunions: A Biomechanical Comparison.

Management of scaphoid nonunions with bone loss varies substantially. Commonly, internal fixation consists of a single headless compression screw. Recently, some authors have reported on the theoretical benefits of dual-screw fixation. We hypothesized that using 2 headless compression screws would impart improved stiffness over a single-screw construct. Using a cadaveric model, we compared biomechanical characteristics of a single tapered 3.5- to 3.6-mm headless compression screw with 2 tapered 2.5- to 2.8-mm headless compression screws in a scaphoid waist nonunion model. The primary outcome measurement was construct stiffness. Secondary outcome measurements included load at 1 and 2 mm of displacement, load to failure for each specimen, and qualitative assessment of mode of failure. Stiffness during load to failure was not significantly different between single- and double-screw configurations (P = .8). Load to failure demonstrated no statistically significant difference between single- and double-screw configurations. Using a qualitative assessment, the double-screw construct maintained rotational stability more than the single-screw construct (P = .029). Single- and double-screw fixation constructs in a cadaveric scaphoid nonunion model demonstrate similar construct stiffness, load to failure, and load to 1- and 2-mm displacement. Modes of failure may differ between constructs and represent an area for further study. The theoretical benefit of dual-screw fixation should be weighed against the morphologic limitations to placing 2 screws in a scaphoid nonunion.

Functional outcome of scaphoid nonunion treated with herbert screw and bone grafting

The symptomatic nonunion of the scaphoid is disabling condition and the majority of patients are of young working-class and hence surgical intervention to get union in these cases are very important. Our study analyses the early functional outcome of scaphoid nonunion treated with bone grafting and Herbert screw fixation. The study was conducted in The Department of Orthopedics, Government Medical College, Thrissur from December 2017 to May 2018 and study included 12 patients whose wrist function evaluated with modified mayo’s wrist score. Our series resulted in 58.3% excellent, 33.3% good and 8.3% fair functional outcomes. The average time from injury to surgical fixation was 13 months and mean age of the patients was 27.9 years. Our study concluded that the management of scaphoid non unions with the herbert screw and bone grafting can provide enough stability to allow fracture healing without much external splintage. The wrist function improvement is more satisfactory and the fixation reduces the progression of wrist osteoarthritis. Keywords: Scaphoid nonunion, Herbert screw, Wrist function, Bone grafting, Internal fixation.

Role of Wrist Arthroscopy in the Management of Established Scaphoid Nonunion

Introduction Patients with scaphoid nonunion and wrist pain may have a wide spectrum of potential concomitant pathologies that may be diagnosed and potentially managed arthroscopically. The aim of this study is to assess the usefulness of wrist arthroscopy in the assessment and treatment of scaphoid nonunion and any associated injuries.Materials and Methods We retrospectively reviewed 34 consecutive patients with established scaphoid nonunion between January 2006 and December 2012 who had undergone arthroscopic assessment. The average age of the patients was 40 years (range: 25–64), and all the patients had arthroscopic assessment of the wrist joint before definitive surgery. The patients with associated intra-articular problems, which could be addressed along with the scaphoid open reduction internal fixation (ORIF) and bone grafting (BG), had definite procedure in the same sitting. However, if the patients had major intra-articular pathology that needed change in the management plan, they had staged definitive treatment after discussing with them about the arthroscopic findings.Results Arthroscopic assessment of the 34 joints showed varying degrees of arthritis affecting radioscaphoid joint (41%) followed by injuries to the triangular fibrocartilage complex (TFCC) (35%), lunotriquetral ligament (LTL) tears (32%), and scapholunate ligament (SLL) injuries (26%). Concomitant procedures performed during the wrist arthroscopy included debridement of synovitis (62%), TFCC debridement (32%), loose body removal (17%), and DRUJ stabilization and TFCC repair (3%). Twenty-nine patients had arthroscopy and definitive procedure in the same sitting, and the remaining had staged or delayed definitive treatment.Conclusion Our study highlights the usefulness of wrist arthroscopy in assessment and management of the scaphoid nonunion and associated pathologies. Besides in 18% of our patients, the initial management plan changed after arthroscopy.Level of Evidence This is a Level IV study.

Internal Bone Grafting for the Treatment of Scaphoid Nonunions.

Scaphoid fracture is the most common carpal fracture of the upper extremity and a significant proportion of these can eventually progress to nonunion. Excision of pseudoarthrosis and fibrous scar tissue at the nonunion site is regarded as one of the important steps in management of scaphoid nonunions. We describe a technique of internal bone grafting, where curettage of the nonunion site was performed through a drill hole in the scaphoid and bone graft was packed through this same hole before fixation with a headless compression screw. We have been able to achieve a union rate of 86% using this technique. The advantage of the technique is that it does not disturb the external fibrocartilaginous shell that would have formed around the nonunion site, thus leaving the articular surface undisturbed.

Management of scaphoid nonunions with vascularized bone grafts from the distal radius: mid- to long-term follow-up.

Scaphoid nonunion represents a challenging problem that leads to disability if neglected. Vascularized bone grafts are proposed to augment the local biology and increase the likelihood of union but long-term outcomes are sparse. In this work, we present the mid- to long-term outcome of 140 scaphoid nonunions managed with vascularized bone grafts from the distal radius. Sixteen patients underwent concomitant closed wedge osteotomy of the distal radius because of arthritic changes. There were 130 males and ten females, with mean time from injury to surgery 3.3years. Delayed presentation was associated with arthritic changes. Forty-two patients had avascular necrosis of the proximal pole and sixteen had more severe arthritic changes. The mean follow-up was 10years. Pain decreased postoperatively but range of motion did not improve but only in early reconstructions. Grip strength reached 79% of the non-injured hand. Mayo modified wrist score improved from 56 to 84 (p<0.001). Except one, all the rest 139 nonunions healed in a mean time of 9weeks. MRI evaluation in 77 patients revealed healing at a mean of 3months postoperatively even in cases of avascular necrosis. Scaphoid length, carpal height, and scapholunate angle increased, but capitolunate did not change significantly. The presence of arthritis preoperatively was associated with progression of arthritic changes after 10years. Treatment of scaphoid nonunions with vascularized bone grafts from distal radius reliably led to highest rate of bone healing with good mid- to long-term outcomes. Enhancement of the local biology and reconstitution of scaphoid and carpal height resulted in improved function mostly in early interventions.

Arthroscopic Treatment of Scaphoid Nonunion Without Bone Graft and Distal Radius Core Decompression

Introduction: The scaphoid bone is the most commonly broken carpal bone and an untoward characteristic of this bone is its unpredictable union. The management of scaphoid nonunion still remains controversial with a reported failure rate up to 40% and absence of a “gold standard” of treatment. Based on the new concepts of the potential osteogenic capacity of the nonunion cells with the ability to heal, the encouraging results generated by increasing vascularization within the metaphyseal radius, and ulna decompression used in the treatment of Kienböck disease as well as the advantages of minimal surgical trauma using percutaneous and arthroscopic techniques, we propose to treat scaphoid nonunions with (a) arthroscopic-assisted reduction and internal fixation (AASSIF) and adding (b) metaphyseal core decompression of the distal radius (MCDDR) in advanced stages, without bone graft. Material and Methods: We evaluated retrospectively 48 patients with scaphoid nonunions treated prospectively by (AASSIF) with (MCDDR) in 48 cases. The average age was 30.63 years. The right side was affected in 31 patients, and 79.7% corresponded to the dominant extremity. The mean time from injury to surgery was 22.93 months. The nonunions were grouped according to the Slade-Dodds classification. Results: Scaphoid union was obtained in 44 patients, 4 patients failed to obtain healing. One patient decided to not be operated again, because of the lack of symptoms. Three required a new surgical procedure 9 months later. In 2 patients, the failures were by improper placement of the screw, although these patients had no symptoms. In cystic and/or magnitude bone nonunion defects with large zones of necrosis, defect filling was observed, even in those cases in which the loss of bone stock exceeded 10 mm. The biological effect of the metaphyseal decompression characterized by an increased hyperemia over the radial column was demonstrated with SPECT studies. The visual analogue scale showed an average of 1.04 (0-2) postoperative pain. The average postoperative range of function was 65.3° extension (range, 46° to 88°), 69.2° flexion (range, 55° to 88°), 10.7° radial deviation (range, 5° to 20°), and 26° ulnar deviation (range, 20° to 37°). The average Mayo score was 95 ± 6. Conclusion: We recommend arthroscopic-assisted internal fixation without bone grafting and core decompression of the distal radius for young or middle-aged nonsmoking patients with scaphoid nonunions including cystic and deformed types, typical of advanced stages. The method is not recommended for nonunions with significant sclerosis or in those with a very small proximal fragment in which solid screw fixation would be questionable.

Treatment of Scaphoid Nonunion: A Systematic Review of the Existing Evidence

To determine by systematic review the optimal treatment of scaphoid nonunion. We conducted a systematic review of the literature with a meta-analysis of proportions to investigate the comparative effectiveness of different surgical techniques. A total of 48 publications (1,602 patients) met the eligibility criteria. Vascularized and nonvascularized bone grafts had an estimated union incidence of 92% and 88%, respectively. Distal radius and iliac crest bone grafts had similar union rates (89% and 87%, respectively) but harvesting of iliac crest bone grafts had more complications. Both screw and K-wire fixation had a higher incidence of union (88% and 91%, respectively) than no fixation (79%). No approach was statistically different. Patients fixed with screws were mobilized earlier than those with K-wire fixation. Current evidence does not demonstrate a significantly superior method for the treatment of scaphoid nonunion. A multicenter randomized trial would be ideal but the large numbers that would be required may make this unrealistic. We recommend the continued reporting of series with specific assessments and outcome measures to optimize future comparisons in an attempt to determine the best management of scaphoid nonunion. The use of bone grafts and the methods of their fixation for scaphoid nonunion are debated issues in hand and wrist surgery, with multiple methods employed. There is no current consensus on optimal treatment. A meta-analysis of proportions of available data from recent studies was deemed the most appropriate way to assimilate the available evidence with the view to inform surgeons of the optimal treatment according to the evidence base.

Management of Nonunion Following Surgical Management of Scaphoid Fractures: Current Concepts

Management of scaphoid nonunion after failed surgery for acute scaphoid fracture presents a unique treatment challenge. Prior surgery complicates patient evaluation and increases the technical difficulty of future procedures. Healing of nonunion is crucial to prevent carpal collapse and progressive arthritis. A thorough workup is required to identify technical factors or treatment decisions that may have resulted in a poor outcome after initial fixation attempts. CT is particularly useful for characterizing nonunion and planning revision surgery. Several studies have described the use of bone grafts and fixation devices for scaphoid nonunion repair, including nonvascularized and vascularized bone grafts, screws, pins, and plates. Reliable rates of union have been achieved using nonvascularized bone graft supplemented with screw or wire fixation, particularly in the absence of osteonecrosis. Although vascularized grafts are more technically challenging, they improve the odds of union in the setting of osteonecrosis.

Arthroscopically Assisted Use of Injectable Bone Graft Substitutes for Management of Scaphoid Nonunions

Arthroscopically Assisted Use of Injectable Bone Graft Substitutes for Management of Scaphoid Nonunions

Bilateral Scaphotrapezium Coalition with Bilateral Scaphoid Nonunion in a Patient with Klippel–Feil Syndrome: A Case Report

The purpose of this case report is to discuss the evaluation and management of scaphoid nonunion in patients with congenital musculoskeletal syndromes. Klippel–Feil syndrome (KFS) is a rare disorder characterized by the presence of congenital synostosis of some or all cervical vertebrae [26] caused by a failure in the normal segmentation of the cervical vertebrae during the third to the eighth week of gestation [25]. The classic clinical triad of KFS consists of a short neck, low posterior hairline, and limited neck range of motion due to cervical synostosis [26]. Abnormalities of the hand have been associated with KFS [2, 4, 8, 15, 25] and are predominantly preaxial [2, 4, 15, 25]. One instance of a postaxial anomaly in a patient with KFS has been reported [2]. A prior identification of capitohamate coalition in a patient with Klippel–Feil syndrome was suggested to be a manifestation of a new clinical syndrome [14]. Additional carpal coalitions have not been reported nor have scaphoid abnormalities secondary to the carpal coalitions been described that are associated with Klippel–Feil syndrome.

The assessment and management of acute scaphoid fractures and non-union

Abstract The management of scaphoid fractures can be challenging. The diagnosis of a fracture should be made following a suggestive mechanism of injury, positive clinical findings and confirmatory radiographs. In the case of normal radiographs the patient should be immobilized and re-examined in 2 weeks. If a scaphoid fracture is still clinically suspected but repeat radiographs are normal, further imaging is indicated. The gold standard is an MRI scan, but this is dependent on the facilities available in the local hospital. An MRI has the added benefits of not only identifying a potential scaphoid fracture but also other causes for the symptoms such as a ligament injury. Stable fractures can be safely treated by immobilizing in a cast; usually a simple below elbow cast with the wrist in slight extension and the thumb left free is adequate. If a patient elects to have a proximal pole fracture treated non-operatively then the thumb should probably be included. The cast should be continued for a maximum of 12 weeks and then removed regardless of clinical or radiological features. Surgical treatment should be considered for unstable fractures of the scaphoid, which includes displaced waist and proximal pole fractures. The surgical approach will depend upon the fracture location and preference of the individual surgeon. Compression screws should be used whenever possible. There are occasions in which fixation of undisplaced waist fractures using percutaneous techniques may be beneficial and this should be considered on a case-by-case basis. The management of scaphoid non-unions can be daunting and controversial. The best treatment of non-unions is to prevent them from developing by identifying those fractures which are unlikely to unite and treating them properly acutely. Whilst the development of non-union can be anticipated in approximately 10% of all fractures, it is more common in proximal fractures, displaced fractures, comminuted fractures, and those which have a delayed presentation. The decision of who and when to treat can be difficult and the patient must be involved in this process. Once it is decided that operative treatment is necessary the available options depend upon the presence of arthritis and the blood supply of the proximal pole. Union is most reliably achieved with a cortico-cancellous bone graft and headless compression screw fixation. If avascular necrosis (AVN) is evident then the best results are achieved with a vascularized graft. Despite grafting 20% will still not unite and a salvage procedure may prove necessary.

Treatment of chronic scaphoid nonunion with vascularized bone grafts from dorsal distal radius

Objective To evaluate the medium and long term follow-up results of vascularized bone grafts dorsal distal radius in treatment of chronic scaphoid nonunion. Methods A retrospective study was carried out in 13 patients with chronic scaphoid nonunion treated with vascularized bone grafts dorsal distal radius in our hospital from 1995 to 2006. Nine patients were accompanied by avascular necrosis of the proximal pole. The vascular pedicle was 1,2 intercompartmental supraretinacular artery. The nonunion was stabilized by screws or external fixators. Radiographic finding and Mayo scoring system on wrist mobilization were used to evaluate the clinical outcomes. Results The interval between injury and treatment was average 22.2 months. All patients were followed up for average 76.6 months, which showed that 12 patients obtained fracture union, with average union time of 11.2 weeks. Functional evaluation results were defined as excellent in three patients, good in eight and fair in two. The last follow-up revealed significant improvement of the range of motion of the wrist, Mayo scores, grip strength, intrascaphoid angles and scapholunate angles. Conclusions Vascularized bone grafts from dorsal distal radius has relatively surgical procedure and can achieve satisfactory results in management of scaphoid nonunion. The perioperative arthrolysis and early postoperative mobilization of the wrist under exernal fixation play critical role in restoration of wrist function. Key words: Scaphoid bones; Fracture fixation,internal; External fixators; Bone transplantation

Vascularised Bone Grafting in the Management of Scaphoid Non-Union – A Review of 34 Cases

We reviewed the outcomes of 34 patients who had undergone vascularised bone grafting for a chronic scaphoid non-union. Mean age was 27 years (range 16-46 years). The dominant hand was involved in 17 cases. Eleven patients were smokers. In 18 cases the fracture involved the proximal and in 16 cases the middle third of the scaphoid. In 26 patients the proximal scaphoid fragment was deemed avascular. Sixteen patients had previously undergone scaphoid fixation and non-vascularised bone grafting. At a follow-up of 1 to 3 years (mean 1.6 years), 15 of the 34 scaphoid non-unions had united. Injury to the dominant hand and duration of the non-union significantly increased the risk of failure. Persistent non-union was more common in proximal third fractures and in the presence of an avascular proximal pole but these findings did not reach statistical significance.

Management of Scaphoid Nonunions

Scaphoid nonunions result in a predictable pattern of wrist arthrosis. To minimize the incidence of arthrosis, the goal of treatment should be consolidation of the fracture with the scaphoid in anatomic alignment. Computed tomography and magnetic resonance imaging scans can aid evaluation of carpal collapse, scaphoid collapse, scaphoid nonunion, bone loss, and detection of osteonecrosis. Nonunion of the scaphoid waist may result in a humpback deformity, increasing the chances of further collapse and arthrosis. This collapse deformity must be approached volarly with an intercalary bone graft and internal fixation. A dorsal approach to proximal scaphoid nonunions allows easier access for removing the necrotic bone from the proximal pole and applying accurate screw or pin fixation. Vascularized bone graft is recommended to manage scaphoid nonunions with osteonecrosis.