Treatment Of Scaphoid Nonunion Research Articles

Extracorporeal Shockwave Therapy for the treatment of scaphoid delayed union and nonunion: a retrospective analysis examining the rate of consolidation and further outcome variables

Operative procedures are considered gold standard in the treatment of scaphoid nonunion, albeit their considerable complexity and the risk of intraoperative complications. High energy extracorporeal shockwave therapy (ESWT) offers a non-invasive treatment option for scaphoid nonunion. The aim of this study was to explore the rate of bony consolidation and further outcome variables in patients with delayed union of scaphoid fractures and scaphoid nonunion treated with ESWT. Due to delayed union (21) or nonunion (21) of a scaphoid fracture 42 patients (37 men, and 5 women) with an average age of 48,3 (15-66) years underwent ESWT followed by immobilization in a forearm cast including the proximal phalanx of the thumb for 6 to 8 weeks. In 13 patients the fracture was initially treated, 8 with immobilization, 5 with screw fixation. In 5 of the 29 patients without an initially treatment, the fracture resp. nonunion was secondarily treated with screw fixation (2) or a medial femur condyle (3) but failed to heal. 10 to 12 weeks after the ESWT bony healing was controlled with computed scanning in the long axis of the scaphoid. If 50 % of diameter of the scaphoid showed trabecula bony healing was considered. Factors with potential influence on bony healing (site of the fracture/nonunion, scapholunate angle, patient´s age, Body Mass Index, smoking and alcohol consume) were analyzed. In addition, 34 patients underwent a clinical follow-up examination including DASH and Mayo Wrist Score, pain analyzes (VAS). Seventy-one per cent of patients showed scaphoid fracture consolidation using ESWT. In 7 out of 8 patients with conservative treatment and in 4 out of 5 patients with screw fixation of the initial fracture bony healing was achieved. From the 5 patients with secondary surgical treatment of the scaphoid only 1 patient, treated with a medial femur condyle, failed to heal the scaphoid. 15 out of the 24 initially non-treated scaphoid fractures healed. The time between ESWT and the documented bony healing averaged 8.4 months (256 days). Neither fracture site, nor the scapholunate angle, alcohol and tobacco use, as well as biometric factors, such as age and BMI had influence on the success rate of the ESWT. Side effects of the ESWT were limited to local skin irritations and petechial bleedings. ESWT has a positive effect regarding bony healing of scaphoid fracture with delayed fracture healing and nonunion with a success rate of 71 %. The complication rate is low, and the clinical results regarding wrist motion and pain are satisfying. Further investigations are necessary to evaluate the input of fracture/nonunion characteristics like the morphological appearance on bony healing.

Arthroscopic bone grafting with percutaneous fixation in treating scaphoid nonunion

Objective To analyze the clinical effects of arthroscopic autologous bone grafting and percutaneous fixation in treating scaphoid nonunion. Methods From May 2013 to August 2017, a total of 25 cases of patients including 20 males and 5 females with unilateral scaphoid fractures and nonunion were reviewed, with mean age of 35.80±2.41 years (18-65 years). The duration from injury to treatment was averaged 11.70±1.90 months (5-18 months). All of the cases sustained waist and proximal end fractures. X-ray and CT scan showed sclerosis and bone resorption without any callus at the fracture sites. However, there were no serious deformities and wrist arthritis. The patients suffered pain and weakness at the radial side of the wrist. The type of the fractures were Slade-Geissler's III-VI, including grade III 4 cases, grade IV 13 cases, grade V 7 cases and grade VI 1 case. The patients were treated with arthroscopic debridement of the sclerotic bone, autologous bone grafting, percutaneous screw (9 cases) or K-wires fixation (16 cases) and immobilization by plaster for 3 weeks after operation, followed by functional rehabilitation training. Bone union was assessed by serial plain radiographs and CT scan regularly. The functional effects were evaluated by comparing the modified Mayo wrist score with the visual analogue scale (VAS) for pain, range of motion (ROM) and the grip strength, which were measured before operation and at 18 months after operation. Results All cases were followed up. Bone union was achieved in all of 25 nonunion. The average radiological union duration was 10.24±2.10 weeks (6-20 weeks). The average VAS score decreased from 6.75±1.10 preoperatively to 1.33±0.21. The mean ROM of wrist was improved to 168.48°±12.41° (92.90% of that of the normal side), compared to that of 135.24°±17.47° preoperatively (79.80% of that of the normal side). The mean grip strength showed improvement from an average of 35.68±3.81 kg (80.46% of that of normal side) preoperatively to 48.75±4.42 kg (90.65% of that of normal side). The average modified Mayo wrist score improved from 61.52±6.32 preoperatively to 85.88±8.37. Conclusion Arthroscopic autologous bone grafting with percutaneous cannulated screw and K-wires fixation is an effective and minimally invasive treatment for scaphoid nonunion, which could protect the blood supply of the fracture sites, decrease the surgical complications, promote bone healing and lead to a faster recovery. Key words: Arthroscopy; Bone transplantation; Scaphoid bone; Fractures, ununited; Fracture fixation, internal

Resection arthroplasty for treatment of nonunion and avascular necrosis of the distal scaphoid

Background Posttraumatic osteonecrosis of distal pole of scaphoid is extremely rare, with only few reported cases so far. The purpose of this study was to evaluate the clinical and radiographic results of treatment of distal scaphoid nonunion and avascular necrosis with resection arthroplasty in adult patients. Patients and methods From 2008 to 2013, seven patients presented to the authors for treatment of nonunion and avascular necrosis of the distal part of the scaphoid following distal pole fracture. Pain was evaluated by means of the visual analog scale. The time to return to previous activities and work status were documented. Wrist function was measured according to the Mayo Modified Wrist Score. Carpal height index (Nattrass modification) and radiolunate angle were recorded. Results Follow-up period ranged from 24 to 60 months. Three patients had an excellent result (43%), and four had a good result (57%). There is significant postoperative improvement of pain, range of wrist motion, and Mayo Modified Wrist Score. All patients returned to their previous occupations within 2 months. There were statistically significant increases in the radiolunate angle and no significant decrease in Nattrass carpal height. Conclusion Resection of the distal scaphoid appears to be a valid technique and to constitute an alternative to vascularized bone graft or limited intercarpal arthrodesis for the treatment of scaphoid nonunion with avascular necrosis of distal pole. Level of evidence: level IV, case series.

The role of vascularized flaps in the treatment of proximal pole avascular necrosis in scaphoid non-unions.

Objectives: The purpose of this study is to evaluate the clinical and radiological outcomes of scaphoid non unions surgically treated with bone graft versus medial condyle corticoperiosteal free flaps. Materials and Methods: 32 patients were divided in 2 groups. Group A (17 patients 12male, 5 females, mean age 35 years old) treated with bone grafts; Group B (15patients 11 male, 4 females, mean age 33 years old) treated with medial condyle cortico periosteal free flap. A radiological follow up was performed about every 30 days after surgery until the complete healing and at 12-month follow-up. The clinical follow up was performed at 6 and 12 months from surgery. Functional assessment was provided by Mayo wrist score and Visual Analogic Scale (VAS). Results: The average length of follow up was 12.52 months ± 1.36. In group A 60% of patients healed in 4.4 ± 1months with a reduction of 28.4% of healing times in group B (p<0.05). In Group B all nonunion sites healed primarily at an average time period of 3.2 ± 1 months. Statistical analysis showed a significant difference (p<0.001) about the preoperative and the postoperative VAS and Mayo Wrist Score evaluation in both groups at 6 and 12-month follow-up, moreover we recorded a statistical difference between groups at the 6-month and 12-month follow-up (p<0.05). Conclusion: The present study showed that the free flaps showed better clinical and radiographic results for the surgical treatment of scaphoid nonunions. In fact, despite the good results of the bone graft, the flaps seems to be preferable in the treatment of these nonunions. (www.actabiomedica.it)

Comparative study between usage of Herbert screw versus Kirschner wires in the management of nonunited fracture scaphoid

Purpose This study aimed to compare between the usage of Herbert screw versus Kirschner wires (K-wires) in the treatment of nonunited fractured scaphoid regarding the most effective and less complicating procedure. Patients and methods It is a retrospective, comparative study that compared the usage of Herbert screw versus K-wires with bone graft from iliac crest in the management of patients with nonunited scaphoid fractures who were admitted in the Department of Orthopedic Surgery in Alzahraa University Hospital during the period from October 2016 to June 2018. Twenty patients were included in the study. Among them, 10 were subjected to internal fixation using Herbert screws, while 10 patients were subjected to internal fixation using K-wires. Results Patients subjected to K-wires achieved a union rate (80%) superior to patients subordinated to Herbert screw (60%) as a method of internal fixation. Moreover, patients subjected to Herbert screw suffered more complications in the form of impingement with pain and progressive degeneration. Patients subjected to K-wires had a better functional outcome when compared with those exposed to the Herbert screw. In multivariate regression analysis, only male patients appeared to be independent predictors of time to bone healing. Conclusion A combination of thorough impaction of iliac bone graft, and internal fixation with K-wires, and Herbert screws provides a good option for the treatment of scaphoid nonunion with superiority of K-wires regarding safety, feasibly, and outcomes when compared with Herbert screw especially in the absence of avascular necrosis of the proximal fragment.

MR angiogram confirms sustained blood flow in 1,2 ICSR artery of vascularized bone grafting in scaphoid nonunion treatment.

To evaluate the functioning of 1,2 intercompartmental supraretinacular artery (ICSRA) in vascularized bone grafting (VBG) of scaphoid nonunions with avascular necrosis of proximal pole. Fourteen patients with scaphoid nonunion were treated operatively with 1,2 ICSRA VBG. Viability of the pedicle artery was evaluated by MR angiography with intravenous contrast agent. In 13 out of 14 patients, the 1,2 ICSR artery was found to be patent and functional. Revascularization of scaphoid proximal pole was revealed in all cases, and nonunion healing was confirmed as well. 1,2 ICSRA VBG in scaphoid nonunion is an effective surgical technique. It combines the advantages of bone grafting and vascular supply via the transferred pedicle artery which seems to be functional postoperatively if a meticulous operative technique is used.

Surgical Strategy for Scaphoid Nonunion Treatment.

Scaphoid fracture is the most common carpal fracture. Nonunion rate has been reported around 10 to 15% of scaphoid fractures. Risk factors for scaphoid nonunion are known as location, displacement, poor vascularity, time to treatment etc. The goals of surgical treatment for scaphoid nonunion are to achieve bony union, to correct carpal deformities and also to prevent progressive carpal instability and arthritis. Scaphoid nonunion can cause scaphoid nonunion advanced collapse (SNAC) which is a pattern of progressive degenerative radiocarpal and midcarpal arthritis secondary to posttraumatic pathomechanics of the scapholunate joint. Achieving bony union is essential to prevent carpal collapse or arthritis. To improve bony union, many surgical procedures including various forms of bone grafting have been developed and attempted. However, there is a controversy about which procedure is the most effective. In this review, we provide an overview of surgical treatment methods for scaphoid nonunion and discuss proper surgical strategies for scaphoid nonunion which requires surgical management.

Vascularized Thumb Metacarpal Periosteal Flap for Scaphoid Nonunion in Adolescents: A Prospective Cohort Study of 12 Patients

To evaluate clinical and radiological outcomes after surgical treatment of scaphoid nonunion in adolescents with a vascularized thumb metacarpal periosteal pedicled flap (VTMPF). Twelve patients younger than 18 years with scaphoid nonunion, who underwent a VTMPF procedure without bone grafting, were included for this prospective cohort study, at a mean follow-up of 10.2 months. Patients were operated on by 3 different hand surgeons at 3 hand surgery institutions. All patients received a VTMPF, but with different scaphoid internal fixation modalities, in 10 cases using 1 or 2 retrograde 2-mm headless compression screws and in 2 cases without internal fixation. In 11 boys and 1 girl, the mean age was 15.6 years. There were 1 type D1 nonunions (Herbert classification), 6 type D2, 2 type D3, and 2 type D4. Six patients had previously undergone an unsuccessful surgical attempt to treat their nonunion. The mean anterior bone defect was 3.5 mm in length. The patients experienced no postoperative complications. Successful consolidation was achieved in all cases, with 79% cross-sectional trabecular bridging at 12 weeks. Pain subsided after surgery and patients experienced improvements in both their Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and Modified Mayo Wrist Score (MMWS) results. Overall, 34% and 40% gains in strength and wrist motion, relative to the contralateral normal side, were observed. In this study, the use of VTMPF for scaphoid nonunion in children and adolescents is associated with generally good outcomes. Therapeutic IV.

Clinical and Radiologic Outcomes of the Matti-Russe Technique for Scaphoid Nonunions in Pediatric Patients.

Scaphoid fractures are a common injury, and a known complication is nonunion. One option to treat this nonunion is with the Matti-Russe technique, which takes a corticocancellous graft and fits it into the defect without internal fixation. The advent of modern methods of fixation has led the classic Matti-Russe technique to fall out of favor. In this study, we describe the classic technique and evaluate the results of the Matti-Russe method for treatment of scaphoid nonunions specifically for the pediatric population. Our purpose was to evaluate the long-term clinical and radiologic outcomes after surgery for scaphoid nonunion using the Matti-Russe technique in the pediatric population. A retrospective review was performed of patients less than 17 years of age, with a scaphoid nonunion that was treated with the Matti-Russe technique. This technique consisted of open reduction with intercalated bone graft and no internal fixation with hardware. Union was determined by radiographic evaluation. Computed tomography was obtained in 7 of 10 patients in this series and showed bony bridging in more than 50% of the scaphoid width in 3 different views. Intrascaphoid, scapholunate, and radiolunate angles were calculated. We reviewed wrist range of motion and complications. We obtained postoperative Mayo and Disabilities of the Arm, Shoulder and Hand (DASH) scores. There were 10 patients who underwent the Matti-Russe technique. The average age was 14.7 years old (±1.34, range: 13-17). All 10 of these patients had a scaphoid waist nonunion. There were 9 males and 1 female with an average follow-up of 13 months. The average amount of time to surgery from the date of injury was 12.3 months. All 10 patients went on to radiographic union at or before 6 months from surgery. Preoperative intrascaphoid, scapholunate, and radiolunate angles were 29° (±5.38), 62° (±18.28), and 20° (±9.22). Postoperative intrascaphoid, scapholunate, and radiolunate angles improved to 16° (±6.89), 38° (±8.50), and 10° (±4.69), which was significant. Seven out of 10 patients completed postoperative outcomes measures. The average postoperative Mayo wrist score was 87.9 (±14.10, range: 60-100). The average postoperative DASH score was 1.9 (±2.03, range: 0-4.5). There were no associated complications nor reoperations. The Matti-Russe technique is a safe and effective treatment for scaphoid nonunion in the pediatric population. It facilitates scaphoid union without the need for screw fixation and avoiding potential complications with hardware.

LOCAL EXPERIENCE IN TREATMENT OF SCAPHOID NONUNION WITH AND WITHOUT AVASCULAR NECROSIS

Early _&#x0D; detection and_ proper adequate treatment of scaphoid fractures are essential to avoid complications of ma lunion1 delayed union, nonunion and the avascular necrosis, with their disabling &#x0D; sequelae The aim of this study is to assess prospectively the clinical and radiological results using &#x0D; the modified Matt1:Russe technique , for the treatment of scaphoid nonunion with and without &#x0D; questionable viability of the proximal fragment. With our experience of the numerous procedures &#x0D; and techniques proposed for the treatment of this complex problem, we are reporting our results in &#x0D; 23 cases, 8 of which were associated with avascular necrosis of their proximal fragments. Although &#x0D; the data were hm11ed for cases of nonunion scaphoid fracture, with proximal pole avascular necrosis, we noticed that mcreased bone density is a reliable sign of a vascularity. Our success rate in &#x0D; cases without avascular necrosis was (93%) , while it was (75%) in the presence of avascular necrosis. Hence the conclusion was: The modified free bone grafting technique of Matti-Russe, which was &#x0D; normally recommended for the treatment of scaphoid nonunion, is yet effective even in presence &#x0D; of avascular necrosis; and with this technique fixation seems unnecessary.

Free Vascularized Medial Femoral Condyle Bone Graft After Failed Scaphoid Nonunion Surgery.

Outcomes following revision surgery for scaphoid nonunions with osteonecrosis are guarded. We hypothesized that use of free vascularized medial femoral condyle (MFC) bone grafts can lead to healing of the nonunion, increase vascularity of the proximal pole, and restore scaphoid architecture, resulting in acceptable functional outcomes. We performed a retrospective review of 49 patients who were treated with an MFC bone graft, between May 2005 and September 2016, after prior failure of operative treatment for scaphoid nonunion. The mean time from the injury to the revision surgery with the MFC bone graft was 24 months, and the mean time from the prior, failed surgery was 15 months. Thirty-six of the 49 patients had had a prior bone graft procedure and 6 patients had had 2 previous surgical procedures for the nonunion. The initial internal fixation of the scaphoid fracture was with a scaphoid screw in 43 patients. All patients had documented osteonecrosis of the proximal pole at the time of our surgery. Carpal indices, time to union, pain scores, functional outcomes, and complications were recorded. Forty-one (84%) of the 49 previously operated on scaphoid nonunions healed at a mean of 16 weeks (range, 9 to 31 weeks) after the MFC bone-grafting as confirmed on computed tomography (CT). Radiographs demonstrated significant improvement in carpal alignment following the surgery with the MFC bone graft. Comparison between preoperative and postoperative values showed a trend toward improved grip strength and no important change in total wrist range of motion. Subsequent procedures were performed in 29 patients, 21 of whom had planned Kirschner wire removal. All 24 patients in whom scaphoid union had been achieved and who were available for follow-up were able to work or attend school full-time, and 88% were satisfied or very satisfied with their wrist function. Age, smoking status, body mass index, time to surgery, and preoperative radiographic findings were not found to be significant predictors of failure. MFC grafts increase vascularity and restore scaphoid architecture, promoting union in most patients with the combination of proximal pole osteonecrosis, carpal collapse, and failed prior scaphoid nonunion surgery. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Clinical research of the open surgery and arthroscopic minimally invasive surgery in the treatment of scaphoid nonunion

Objective To retrospectively analyze the clinical efficacy of traditional open surgery and arthroscopic minimally invasive surgery in the treatment of scaphoid nonunion. Methods A retrospective study was conducted on 42 cases (met the inclusion criteria) of scaphoid nonunion who treated in our hospital from 2008 to 2015, including 22 cases in traditional open surgery group and 20 cases in arthroscopic minimally invasive surgery group. The time of fracture healing, wrist function (according to the modified Mayo wrist function scoring system), visual analogue scale (VAS) were analyzed. Results Postoperatively, the average follow-up time of the open surgery group and arthroscopic minimally invasive surgery group was 27.5 months and 20 months respectively, the healing rate was 95.5% and 95%, and the average healing time was 14.1 weeks and 13.4 weeks. The difference was not statistically significant (P<0.05). The operation time of the open group was significantly shorter than that of the arthroscopy group (P<0.01). The excellent and good rate of modified Mayo wrist function score from the arthroscopy group (94.4%) was higher than that from the open group (80.0%). The VAS of the arthroscopy group 0.7±0.8 was lower than that of the open group 1.1±1.1. There was 1 case of complication in the open group and no in the arthroscopy group. Conclusion Both of the operation methods can achieve satisfactory fracture healing. The wrist function after the arthroscopic minimally invasive surgery is better than that after open surgery with lower pain, less complications and better appearance. However, the technique of arthroscopy surgery is difficult and the operation time is long. Key words: Scaphoid bone; Fractures, ununited; Surgical procedures,operative; Arthroscopes

Plate Fixation With Cancellous Graft for Scaphoid Nonunion With Avascular Necrosis

Currently, there is no consensus on the optimal treatment for scaphoid nonunion with avascular necrosis (AVN). Various techniques, often involving vascularized corticocancellous bone grafting, have been proposed. The authors hypothesized that similar outcomes might be possible with volar plate fixation augmented with autogenous pure cancellous graft. The authors performed a retrospective chart review of 13 cases of scaphoid nonunions with AVN in 12 patients treated with plate fixation and pure cancellous bone grafting. Surgical management included a volar incision, reduction, impaction of cancellous bone graft from the ipsilateral olecranon and/or distal radius, and application of a volar locking plate. Postoperative outcome measures included time to union based on computed tomography, patient-reported pain and disability scores, grip strength, range of motion, and return to work and sports. The average patient was 32 years old (range, 17-50 years) and treated an average of 18 months after initial injury (range, 6-49 months). Two of 12 patients (15.7%) were female, 3 of 12 patients (25%) were smokers, and 5 of 12 patients (41.7%) had failed union with previous screw fixation. Twelve scaphoids (92.3%) were treated for AVN associated with a proximal pole fracture, and 1 (7.7%) for AVN proximal to a scaphoid waist fracture. Mean follow-up was 19.5 months (range, 12-29 months). Union was achieved in all patients. Two scaphoids (15%) achieved union by 12 weeks, 7 scaphoids (54%) by 18 weeks, 2 scaphoids (15%) by 24 weeks, and 2 scaphoids (15%) by 30 weeks (range, 8.9-28 weeks). Mean Disabilities of the Arm, Shoulder, and Hand score improved from 30.6 ± 6.2 before surgery to 17.2 ± 6.5 after surgery. All 11 employed patients returned to work, although 3 (27.2%) did not return to full capacity. Scaphoid plate fixation and pure nonvascularized cancellous bone grafting for scaphoid nonunion with AVN yields excellent union rates and good patient-reported and functional outcomes. Therapeutic IV.

Primary medial femoral condyle vascularized bone graft for scaphoid nonunions with carpal collapse and proximal pole avascular necrosis.

This study aimed to determine the outcome of free vascularized medial femoral condyle bone grafts in the primary treatment of scaphoid nonunions with scaphoid foreshortening or carpal collapse and intraoperatively documented avascular necrosis. Thirty-two patients (28 male, four female) met the inclusion criteria. Median time from injury to surgery was 70 weeks. Thirty of 32 patients healed at a median of 12 weeks. There was significant improvement from preoperative to postoperative lateral intrascaphoid angle, scapholunate angle, and radiolunate angle. Two scaphoids failed to unite; one patient underwent scaphoidectomy and four-corner fusion 15 months postoperatively after suffering a subsequent injury. Another patient underwent 1,2-intercompartmental supraretinacular artery-based vascularized bone grafting at 4 months postoperatively and then scaphoid excision with four-corner fusion 4 years later. The free vascularized medial femoral condyle bone graft restores scaphoid vascularity and architecture while promoting union in a subset of scaphoid nonunions that has historically been a clinical challenge. Level of evidence: IV.

Correlation of CT imaging and histology to guide bone graft selection in scaphoid non-union surgery

IntroductionFor the treatment of scaphoid non-unions (SNU), different surgical techniques, including vascularized and non-vascularized bone grafts, are applied. Besides stability, vascularity, and the biological situation at the non-union site are important for healing and the appropriate choice of treatment. We assessed the healing potential of SNUs by histological parameters and compared it to CT parameters of bone structure and fracture location. Based on the results, we developed a CT classification and a treatment algorithm to impact graft selection in SNU surgery.Patients and methodsPreoperative 2D-CT reformations of 29 patients were analyzed for trabecular structure, sclerosis, and fragmentation of the proximal fragment. The fracture location was assessed on 3D-CT reconstructions and grouped in three zones depending on the potential blood supply. Samples were taken during surgery for histological evaluation. Histological parameters of bone healing were defined and a bone healing capacity score (BHC), reflecting histological bone viability, was calculated. CT findings were compared to BHC, age of SNU, and time to union.ResultsCases with trabecular structure and without fragmentation showed a statistically significant higher BHC. Time to union was significantly faster if trabecular structure was present and sclerosis was absent. In intraarticular proximal pole non-unions, where no blood supply is assumed, the BHC was statistically significantly lower and time to union was longer compared to SNUs of the other locations. A statistically significant correlation between BHC and time to union was found in the proximal and distal fragment with higher BHC associated with faster healing.ConclusionsCT parameters of bone structure and fracture location can reflect histological healing capacity of SNUs. This can guide bone graft selection in SNU surgery.

Outcomes of Unstable Scaphoid Nonunion With Segmental Defect Treated With Plate Fixation and Autogenous Cancellous Graft.

Treatment of scaphoid nonunion with a segmental defect presents a challenging clinical problem. Various techniques have been proposed, often involving structural grafting with vascularized and nonvascularized bone. The authors hypothesize that satisfactory clinical and radiographic outcomes are possible with a relatively simplified technique of volar plate fixation with autogenous, purely cancellous graft. The authors performed a retrospective review of 34 patients with scaphoid nonunions with segmental defects, treated with plate fixation and purely cancellous bone grafting. Cases with avascular necrosis were excluded. Surgical management included a volar incision, reduction, bone grafting from the ipsilateral distal radius and/or olecranon, and application of a volar locking plate. Postoperative outcome measures included time to union based on computed tomography, return to work and sports, patient-reported pain and disability scores, grip strength, and range of motion. Thirty-four patients with an average age of 31 years (range, 16-55 years) were treated with volar plate fixation and cancellous grafting, an average of 34 months after initial injury. Twenty-six patients (76%) were treated for nonunion at the scaphoid waist, 7 (21%) at the proximal pole, and 1 (3%) at the distal pole. Mean final follow-up was 18.7 months (range, 12-34 months). When union was defined by computed tomography evidence of healing, 2 (6%) scaphoids healed by 6 weeks after surgery, 28 (82%) healed by 12 weeks, and 100% healedby18 weeks. Mean Disabilities of the Arm, Shoulder, and Hand score improved from 27.1 ± 7.3 before surgery to 11.8 ± 5.8 after surgery. Grip strength, corrected for hand dominance, improved from 77.5% of the nonsurgical side before surgery to 90.5% after surgery. All employed patients returned to work, although 3 (9%) did not return to full capacity. The combination of scaphoid plate fixation and pure cancellous bone grafting for scaphoid nonunion with segmental defects yields reliable union rates and good patient outcomes. Autogenous cancellous grafting may be an alternative to more technically demanding or morbid grafting proceduresfor the treatment of scaphoid nonunion. Therapeutic IV.

Progress in the treatment of scaphoid nonunion

There is a high probability of scaphoid nonunion after scaphoid fracture, which can lead to wrist arthritis and further to progressive aggravation of joint function, seriously affecting daily life and work. Currently, there are a variety of treatment methods for scaphoid bone nonunion at home and abroad , and surgical treatment is the major option, which includes open surgery and arthroscopy assisted minimally invasive surgery. Different operative methods have corresponding indications and contraindications with different therapeutic effects. Arthroscopic assisted technique is novel, minimally invasive, and reliable. This article reviews the treatment methods of scaphoid nonunion, including screw internal fixation, non vascularized bone graft, vascularized bone graft, anastomotic vascularized bone graft, bone block resection, arthrodesis, and arthroscopic minimally invasive surgery, so as to provide references for clinical treatment of scaphoid nonunion. Key words: Scaphoid bone; Fractures, ununited; Surgical procedures, operative

Clinical and functional outcomes of vascularized bone graft in the treatment of scaphoid non-union.

IntroductionScaphoid non-union is a challenging and complex problem. Various methods have been proposed for the management of patients with scaphoid non-union and to reduce the risk of complications. In this study, our aim was to evaluate the clinical and functional outcomes of using a vascularized bone graft in the treatment of scaphoid non-union.MethodsPatients with scaphoid non-union who underwent 1,2 intercompartmental supraretinacular artery pedicled vascularized bone graft between January 2005 and January 2011 were enrolled. The parameters assessed included clinical and functional outcomes, radiological measures, and potential risk factors.ResultsForty-one patients were finally included. Thirty patients achieved union (73%) and 11 did not. Smoking was a significant risk factor for non-union after the surgery. In patients who achieved union, grip strength and radioulnar abduction were greater in comparison to that in patients who did not achieve union. Functional measures, including the Disabilities of Arm and Shoulder score and the Modified Mayo Wrist Score, improved in patients with scaphoid union. The scaphoid length also improved significantly postoperatively in these patients.ConclusionSurgical treatment of scaphoid non-union using vascularized bone graft led to a high union rate with good clinical and functional outcomes. Smoking is a risk factor for non-union, even with the use of a vascularized bone graft. Avascular necrosis was not associated with an increased risk for non-union.

Distal Scaphoid Excision in Treatment of Symptomatic Scaphoid Nonunion: Systematic Review and Meta-analysis.

Background: Current treatment options for persistent scaphoid nonunion are limited to salvage procedures such as proximal row carpectomy (PRC) or 4-corner fusion (4CF). Several small studies have demonstrated that distal scaphoid excision may provide a simpler alternative with faster recovery. The purpose of this study was to determine the efficacy of distal scaphoid excision as a treatment option for symptomatic scaphoid nonunion. Methods: The MEDLINE and PubMed databases were searched for the use of distal scaphoid excision in scaphoid nonunions. Studies included reported on either the functional or patient-centered outcomes following distal scaphoid excision for symptomatic scaphoid nonunion. Results: Six articles described the outcomes of 70 patients with an average of 11.7 patients per study. Functional outcomes including flexion-extension arc, radial-ulnar deviation, and grip strength improved by an average of 98.95%, 58.96%, and 131.08%, respectively. Patient-derived outcomes included the Modified Mayo Wrist Score, which improved by 92.6%, and the Disabilities of the Arm, Shoulder and Hand, which improved by 137.17%. An average of 68.75% of patients experience complete relief of pain with 20.83% of patients experiencing pain with strenuous activity. The average postoperative visual analog scale (0-10) was 0.71. On average, 93.33% of patients returned to work with an average time of return being 6.89 weeks. Complete satisfaction was reported by 87.80% of patients. Complications included progression into 4CF or PRC and newly developed midcarpal arthritis. Conclusions: Given favorable outcomes, our analysis suggests that distal scaphoid excision may be a favorable, low-risk treatment for scaphoid nonunion without eliminating more extensive options such as 4CF and wrist arthrodesis.

Cylinder-Shaped Bone Graft for Scaphoid Nonunion.

Wedge-shaped bone grafts that are internally fixed by a Herbert-type screw are a well-established surgical treatment for scaphoid nonunion. A procedure using cylinder-shaped bone grafts was also reported, but preoperative wrist functions were not assessed. In addition, it was not reported whether the humpback deformity of the scaphoid nonunion was corrected. The purpose of the current study was to compare preoperative wrist functions in cases of scaphoid nonunion with those observed at final follow-up, using cylinder-shaped bone grafts The humpback deformity of the scaphoid nonunion was also evaluated. We conducted a retrospective study to examine operative outcomes from 2008 to 2015. Twelve wrists in 12 patients (average age, 41 years; range, 17-67), with a mean follow-up of 19 months, were included in the current study. Cylinder-shaped bone grafts were obtained from the iliac crest with a newly designed trephine and fixed with a Herbert-type screw. We reviewed both the preoperative wrist functions and those obtained at final follow-up. Union was achieved in 11 of 12 nonunion cases. Preoperative wrist functions, except for the range of wrist motion, significantly improved by final follow-up. We conclude that the use of cylinder-shaped bone grafts improves preoperative wrist functions in cases of scaphoid nonunion.