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.

Manejo artroscópico de pseudoartrosis de escafoides con deformidad en joroba: técnica quirúrgica y serie de casos / Arthroscopic treatment for scaphoid pseudarthrosis with humpback: surgical technique and case series

INTRODUCCIÓN: La pseudoartrosis de escafoides con deformidad en joroba es una patología compleja que si no recibe tratamiento oportuno puede llevar a una deformidad avanzada, con colapso del carpo produciendo un deterioro significativo en la función de la muñeca. En la actualidad se considera como tratamiento estándar la reducción abierta de la deformidad utilizando injerto estructural. El OBJETIVO del presente trabajo es describir una técnica de reducción artroscópica, utilizando injerto no estructural para la no-unión de escafoides con deformidad en joroba. Se muestran los resultados obtenidos en una serie de casos manejados con la técnica propuesta. MATERIAL Y MÉTODO: Estudio retrospectivo de una serie de casos de pacientes diagnosticados con pseudoartrosis de escafoides con deformidad en joroba manejados con la técnica propuesta. Se describe la técnica quirúrgica. Se utiliza el programa STATA 15 para el análisis estadístico de los resultados, al igual que test de Wilcoxon para variables no paramétricas. RESULTADOS: Once pacientes de sexo masculino, con edad promedio de 23,4 años, completaron seguimiento promedio de 12 meses. En todos los pacientes se comprobó consolidación de la no-unión mediante Tomografía Computada en un tiempo promedio de 9,1 semanas. Todos los pacientes mejoraron sus rangos de movilidad y ángulos imagenológicos de manera significativa y mejoraron en la prueba funcional de DASH (p » 0.0033). DISCUSiÓN: Se muestra una técnica de reducción percutánea con asistencia artroscópica utilizando injerto no estructural para corregir la no-unión de escafoides con deformidad en joroba produciéndose buenos resultados clínicos con consolidación, en todos los pacientes de nuestra serie, similar a lo encontrado en la literatura internacional. Creemos que esa técnica permite una corrección parcial de la anatomía del carpo y favorece la consolidación ósea al tener las ventajas teóricas de una técnica mínimamente invasiva.

INTRODUCTION: Scaphoid pseudoartrosis with humpback deformity is a complex pathology that if not treated promptly can lead to an advanced deformity with collapse of the carpus producing a significant deterioration in wrist function. At present, open reduction of the deformity using structural bone graft is considered the gold standard of treatment. The AIM of the present study is to describe a surgical technique of percutaneous reduction with arthroscopic assistance using non-structural bone graft for scaphoid non-union with humpback deformity. We present a case series of patients treated with the proposed technique. MATERIAL AND METHODS: Retrospective study of a case series of patients diagnosed with scaphoid pseudarthrosis with humpback deformity treated with the proposed technique. We describe the surgical technique. We used STATA 15 for the statistical analysis and Wilcoxon test for non-parametric variables. RESULTS: 11 male patients, with an average age of 23.4 years, completed an average follow-up of 12 months. Bone healing was confirmed with Computed Tomography in an average time of 9.1 weeks in all of our patients. All patients improved their range of mobility and radiographic measurements significantly and all improved in the DASH functional test (p » 0.0033). DISCUSSION: We describe a technique of percutaneous reduction with arthroscopic assistance using non-structural graft to correct scaphoid non-union with humpback deformity. We found good clinical results and high union rate in all the patients of our series. Similar to what is found in international literature, we believe that this technique allows a partial correction of carpal anatomy and favors bone consolidation by having the advantages of a minimally invasive technique.

Artrodesis total de muñeca en paciente con síndrome de Hajdu Cheney: reporte de caso / Total wrist arthrodesis in a patient with Hajdu-Cheney syndrome: a case report

El síndrome de Hajdu-Cheney, es una patología infrecuente caracterizada por alteraciones esqueléticas que se manifiestan con acro-osteolisis y osteoporosis generalizada. Su frecuencia es extremadamente rara y existen escasos reportes en la literatura a nivel mundial. Se presenta un caso de un paciente con colapso avanzado del carpo producto de una no unión de escafoides no tratada. Se describen características clínicas y radiográficas del paciente y la resolución del caso con artrodesis total de muñeca.

Hajdu-Cheney syndrome is an uncommon skeletal disorder characterized by acroosteolysis and generalized osteoporosis. It is an extremely rare condition and few reports have been published in worldwide literature. We present a case of a patient with advanced carpal collapse product of a scaphoid non-union with Hajdu-Cheney syndrome. We describe clinical and radiographic characteristics and resolution of the case with total wrist arthrodesis.

The Role of Lunate Morphology on Scapholunate Instability and Fracture Location in Patients Treated for Scaphoid Nonunion

BACKGROUND: To determine the association between lunate morphology and the scapholunate instability using radiographic images, and investigate the association between lunate morphology and scaphoid fracture location. METHODS: Between January 2003 and December 2011, we retrospectively evaluated the plain radiographs and computed tomography (CT) images of 70 patients who underwent surgical intervention for a scaphoid nonunion, in order to determine the association between lunate type (I or II) and scapholunate instability or scaphoid fracture location. We determined the scaphoid fracture location using the fragment ratio and measured the radiolunate angle and capitate-triquetrum (C-T) distance. RESULTS: A type II lunate was present in 68.6% (48 of 70 cases). Mean fragment ratio of fracture location was 50.6% in the type II lunate group and 56.2% in the type I lunate group (p = 0.032). Sixteen of the 70 patients had dorsal intercalated segmental instability (DISI) deformities. Nine of 22 cases showed DISI deformity in type I lunate and 7 of 48 cases showed DISI deformity in type II lunate (p = 0.029). However, there were no significant differences between the presence of DISI deformity and fracture location (p = 0.15). Morphologic comparisons by both plain radiography and CT indicated a mean C-T distance in the type I lunate group (22 cases) of 2.3 mm and 5.0 mm in the type II lunate group (48 cases). The C-T distances were significantly correlated with lunate morphology (p = 0.001). CONCLUSIONS: A type II lunate was associated with low incidence of DISI deformity and proximal location of fracture in patients presenting with a scaphoid nonunion.

The Role of Lunate Morphology on Scapholunate Instability and Fracture Location in Patients Treated for Scaphoid Nonunion

BACKGROUND: To determine the association between lunate morphology and the scapholunate instability using radiographic images, and investigate the association between lunate morphology and scaphoid fracture location. METHODS: Between January 2003 and December 2011, we retrospectively evaluated the plain radiographs and computed tomography (CT) images of 70 patients who underwent surgical intervention for a scaphoid nonunion, in order to determine the association between lunate type (I or II) and scapholunate instability or scaphoid fracture location. We determined the scaphoid fracture location using the fragment ratio and measured the radiolunate angle and capitate-triquetrum (C-T) distance. RESULTS: A type II lunate was present in 68.6% (48 of 70 cases). Mean fragment ratio of fracture location was 50.6% in the type II lunate group and 56.2% in the type I lunate group (p = 0.032). Sixteen of the 70 patients had dorsal intercalated segmental instability (DISI) deformities. Nine of 22 cases showed DISI deformity in type I lunate and 7 of 48 cases showed DISI deformity in type II lunate (p = 0.029). However, there were no significant differences between the presence of DISI deformity and fracture location (p = 0.15). Morphologic comparisons by both plain radiography and CT indicated a mean C-T distance in the type I lunate group (22 cases) of 2.3 mm and 5.0 mm in the type II lunate group (48 cases). The C-T distances were significantly correlated with lunate morphology (p = 0.001). CONCLUSIONS: A type II lunate was associated with low incidence of DISI deformity and proximal location of fracture in patients presenting with a scaphoid nonunion.

Scaphoid Fractures and Nonunion

Fracture of scaphoid is relatively common, and accurate and prompt diagnosis leads to bony union with good clinical outcome. However, it can be easily missed due to vague symptomatic complaints by patients, which in turn leads to negligence of a doctor in making the diagnosis or anatomical shape of scaphoid that causes minute fracture to be ignored while viewing simple radiography. When missed, nonunion of scaphoid gradually progresses to arthritic change in the wrist. Thus when fracture of the scaphoid is suspected, further evaluation should be initiated with care, and if the diagnosis is confirmed, a proper treatment plan must be set with assessment of stability of the fracture fragment. Internal fixation is usually proposed since solid fixation of the fracture provides early return to daily activity. When nonunion of the scaphoid is present, most patients can achieve bony union with avascular bone graft and internal fixation. However, if there is sclerotic change, large bone cyst or avascular necrosis of the fracture fragment, internal fixation with bone graft that includes vascular supply should be introduced in order to achieve bony union.

Preservation of Scaphoid in Scaphoid Nonunion Advanced Collapse Stage II and III / 대한정형외과학회잡지

PURPOSE: The purpose of this study is to investigate the outcome of open reduction and internal fixation with a headless screw and auto iliac bone graft for patients of scaphoid nonunion advanced collapse (SNAC) stage II and III. MATERIALS AND METHODS: A retrospective analysis was conducted for 10 patients diagnosed with stage II or III SNAC, and consequently treated with open reduction and internal fixation with a headless screw and auto iliac bone graft with or without radial styloidectomy between 2010 and 2013. Radiographic results were evaluated by bone union, the scapholunate angle and lateral intrascaphoid angle. Clinical results were evaluated by range of motion, pain, grip strength, Mayo wrist score, and assessment of Maudsley. RESULTS: All patients showed union after the operation. Final follow-up X-rays show smoothening of the articular surface with improvement of sclerotic lesions of the articular surface, cystic lesions and osteopenic lesions. Pain decreased after the operation compared with preoperative status, grip strength and Mayo wrist score showed significant improvement. Scapholunate angle and lateral intrascaphoid angle decreased after the operation, but it was not significant. According to assessment of Maudsley, among 10 cases, there were 4 excellent cases, 4 good cases and 2 fair cases. CONCLUSION: Restoration of stability of scaphoid is important to SNAC stage II and III, open reduction and internal fixation with a headless screw and auto iliac bone graft shows satisfactory clinical and radiologic outcomes. Thus it is considered a recommendable operation.

Flexor Pollicis Longus Tendon Rupture due to Scaphoid Nonunion

Flexor pollicis longus rupture due to scaphoid nonunion is very rare complication. It has never been reported in the Korean literatures. We reported a case of flexor pollicis longus rupture due to scaphoid non union that was treated by tendon graft with palmaris longus and osteosynthesis with bone graft.

Scaphoid Nonunions Treated with 1, 2-Intercompartment Supraretinacular Artery Pedicled Vascularized Bone Graft and Headless Compression Screw Fixation

PURPOSE: The purpose of this study was to evaluate the clinical results of scaphoid nonunions treated with 1, 2-intercompartment supraretinacular artery (ICSRA) pedicled vascularized bone grafting (VBG) and headless compression screw fixation. METHODS: Since August 1, 2005, 11 scaphoid nonunions with avascular necrosis or bone marrow edema of proximal fragments were managed with 1, 2-ICSRA pedicled VBG combined with headless compression screw fixation. The mean age was 37.1 years (range, 21-66 years). 8 patients had avascular necrosis (AVN) of proximal fragments and 3 patients had bone marrow edema in proximal fragments. Serial radiographic evaluations were performed in every 4-8 weeks for bone union and follow up computed tomography scanning were checked in 8 patients. RESULTS: Bone unions were obtained in all 11 patients at 4.9 months (range, 3-9 months) after operation. At last follow up, the average range of motion was 82.5% and the grip power was 84.1% compared to the contralateral side. The mean New York Orthopaedic Hospital wrist score at last follow up was 83.2 (range, 58.1-93.3). CONCLUSION: Combined 1, 2-ICSRA pedicled VBG and headless compression screw fixation were reliable methods for managements of scaphoid nonunions even with AVN at proximal fragments.

Arthroscopically assisted Cancellous Bone Grafting and Percutaneous K-Wires Fixation for the Treatment of Scaphoid Nonunions

PURPOSE: The purpose of this study was to analyze the clinical results of patients with scaphoid nonunions treated with arthroscopically assisted bone grafting and percutaneous K-wires fixation. METHODS: We retrospectively reviewed 20 patients with a scaphoid nonunions which was treated with arthroscopically assisted bone grafting and percutaneous K-wires fixation from November 2008 to July 2012. Time from injury to treatment was 74 months (range, 3-480 months) in average. Functional outcome was evaluated using the modified Mayo wrist score and visual analogue scale (VAS) for pain, which were measured before operation and at the last follow up. RESULTS: All nonunions were healed successfully. The average radiologic union time was 9.7 weeks (range, 7-14 weeks). The average VAS score improved from 6.3 (range, 4-8) preoperatively to 1.6 (range, 0-3) at the last follow up. The average modified Mayo wrist score increased from 62.5 preoperatively to 85.7 at the last follow-up. CONCLUSION: Arthroscopically assisted bone grafting and percutaneous K-wires fixation is an effective treatment method for a scaphoid nonunion. It may provide more biological environment than open surgery as a minimally invasive procedure.

Arthroscopic Bone Grafting and Percutaneous K-Wires Fixation for the Treatment of Scaphoid Nonunion: Surgical Technique

Various bone grafting techniques have been reported for scaphoid nonunions. We describe surgical technique of osteosynthesis with bone graft using arthroscopic technique and percutaneous fixation as a minimal invasive procedure. Nine patients with scaphoid nonunion were treated with this technique, resulting in successful union at a mean of 10 weeks.

Surgical Outcome of Stable Scaphoid Nonunion without Bone Graft

PURPOSE: To evaluate the results of Acutrak-screw fixation without bone-graft for the treatment of stable scaphoid nonunion and to assess its prognostic factors. MATERIALS AND METHODS: Fifteen patients who underwent internal fixation using Acutrak-screw without bone graft for stable scaphoid nonunion were studied. Standard radiographs and CT were analyzed for degenerative changes (presence of cystic change and periscaphoid osteoarthritis), the nonunion site using fragment ratio and union. Clinically, patients age and the interval to surgery were evaluated. RESULTS: Mean follow-up duration was 31 months and 11 of 15 (73.3 percentages) cases healed at mean time of 12.8 weeks. Fragment ratio of nonunion site was 37.2 percentages in nonunion group and 54.2 percentages in union group (p=0.016). Presence of cystic change and periscaphoid osteoarthritis showed no singnificant statistical difference in both groups. Younger age lower than 20 years was closely related with bone union (p=0.001). But there were little correlation between bone union and interval to surgery. CONCLUSION: Internal fixation without bone graft showed 73.3 percentages of overall union rate in the treatment of stable scaphoid nonunion. And young patients who have distally located stable scaphoid nonunion can be successfully treated with internal fixation without bone graft.

A Comparative Study on the Treatment of Scaphoid Nonunion with Matti-Russe Technique and Fisk-Fernandez Technique / 대한정형외과학회잡지

PURPOSE: Established scaphoid nonunion may lead to carpal instability and osteoarthritis. The purpose of this study is to compare the clinical and radiological results of the osteosynthesis between Matti-Russe group and Fisk-Fernandez group. MATERIALS AND METHODS: Our retrospective study included 21 nonunion cases in 20 patients treated by Matti-Russe or Fisk-Fernandez technique from September 2001 to August 2006. The mean duration of follow up was 31 months. Based on the questionnaire which included clinical information and the radiologic evaluation, we compared the objective and subjective results between two surgical groups. RESULTS: There were no significant differences between two groups in respect of the postoperative satisfaction and the pain. Both the range of motion and the grip power decreased compared to that of the unaffected side, but there were no significant differences between two groups. Also, there were no significant differences in the union rate and the rate of successful correction of DISI deformity. In all cases in which DISI deformity was detected preoperatively, the deformity was corrected postoperatively. There were 7 cases of osteoarthritis, but among them only one case appeared newly after the surgery. CONCLUSION: There were no significant differences between two surgical groups in clinical and radiological results. Both techniques were effective in achieving bony union and functional recovery.

Treatment of Scaphoid Nonunions with Autogenous Cancellous Bone Grafting Combined with Threaded K-wire Fixation

PURPOSE: To evaluate the results of surgical treatment of autogenous cancellous bone grafting combined with threaded K-wire fixation for scaphoid nonunions. MATERIALS AND METHODS: We retrospectively reviewed the 13 patients with scaphoid nonunion, which was follow up at least 12 months from March 1999 to June 2003. According to the Mayo classification, two cases were type P (proximal third), eight cases were type W (waist) and three cases were type D (distal third). According to the Russe classification, eight cases showed horizontal oblique type, another two cases were transverse, and last three belonged to vertical oblique type. We assessed the radiologic bony union, correction of humpback deformity and lateral intrascaphoid angle and degenerative change of radioscaphoid joint, clinical results were evaluated using assessment of Maudsley. RESULTS: Radiologic union was obtained in all cases, mean time of union was 15.4 weeks (13~17.4 weeks), and there was no radiological evidence of postoperative humpback deformity, intercarpal instability, proximal osteonecrosis and degenerative changes. According to assessment of Maudsley, there were 7 excellent cases, 4 good cases, 1 fair case and 1 poor case among these 13 cases. The final clinical results were 11 excellent cases, 2 good case in the aspect of wrist pain and tenderness. All range of motion was satisfactory to patients except 4 cases (3 fair, 1 poor) and every patients could return to work except 1 poor case. CONCLUSION: The surgical treatment using a autogenous cancellous bone grafting combined with threaded K-wire fixation for scaphoid nonunion was a relatively straightforward technique, which provides simplicity, and high union rate.

Treatment of Nonunion of Proximal Scaphoid Fractures Using Vascularized Bone Graft / 대한정형외과학회잡지

PURPOSE: To evaluate the radiographic and clinical results of the treatment of nonunion of scaphoid proximal fractures using vascularized bone graft and internal fixation, and to present the surgical procedures in detail. MATERIALS AND METHODS: Six patients with established nonunion of scaphoid proximal fractures who had been treated by vascularized bone graft and internal fixation from the year of 2000 to 2003 were analyzed retrospectively. The mean ages were 27.8 years old (18-45) and all the patients were male. The average follow up period was 13 months (8-18), and the causes of injuries were fall down in 4 cases, and motor vehicle accident in 2 cases. The 1, 2-intercomparmental supraretinacular artery was used as a vascular pedicle for the bone graft and fixed with a Herbert screw. RESULTS: All the non-unions had united at a mean period of 8.7 weeks (7-11). According to the Maudsley and Chen's criteria, 4 and 2 cases showed excellent and good results, respectively. There was one case of dysesthesia on the superficial branch of the radial nerve after surgery, which was resolved in 2 months. CONCLUSION: A vascularized bone graft is an useful method for treating a nonunion of scaphoid proximal fractures without severe arthritic changes, and can achieve a shorter immobilization and improved bone healing.

Treatment or scaphoid nonunion using transfer of vascular pedicled radius with the 1st, 2nd intercom-partmental supraretinacular arteries / 中华创伤骨科杂志

Objective To investigate an effective method for treatment of scaphoid nonunion.Methods Based on the applied anatomy study of 12 fresh upper limb specimens of human adult cadavers,a new transfer of vascular pedicled radius with the 1st,2nd intercompartmeiilal supraretinacular arteries has been designed to treat nonunion of scaphoid fractures in 23 cases since 1997.Results All cases were followed up from 6 months to 3 years and their fractured seaphoids got united 3 to 7 months after the operation.The bony union rate was 100%.Rate of excellent and good restoration of normal wrist function was 95.7%.Conclusion This method for treatment of nonunion of scaphoid fractures is re commendable,for it is simple to manage,less invasive,and effective.

Anterior Interpositional Grafting for Scaphoid Nonunion with Dorsal Instability Rattern / 대한정형외과학회잡지

In thirteen adult male patient with scaphoid nonunion associated with DISI(Dorsal intercalated Segment Instability) defined as scapholunate angle is greater than 70 degrees of the radiolunate angle is greater than 10 degrees, anterior interpostitional bone grafting has been performed. Surgical procedure: 1) Closed reduction of lunate(reduction of DISI) by volar flexing of the wrist and holding the position by Kirschner wire inserted obliquely through the radial styloid to lunate. 2) Radical curettage of nonunion site and intraoperative measurement of the gap in the scaphoid through volar approach. 3) A bicortical wedge shaped graft from the iliac crest was then impacted between the fragments. 4) Temporary K-wire fixation of the grafted scaphoid from the scaphoid tubercle to prevent distortion of nonunion site and loss of fixation. 5) A Herbert screw was then inserted. Results: Mean patient age was 24.5 years, and mean duration of nonunion before surgery was 19.4 months. Mean follow-up time was 22.6 months. The nonunion involved the middle one-third of scaphoid in 11 patients and distal one-third in 2 patients. The mean postoperative grip strength was 39.4kg by Dynamometer(PC-5303J). The mean postoperative range of motion was volar flexion 50.5 degrees; dorsiflexion 47.3 degrees. The scaphlunate angle decreased from a mean of 78.8 preoperatively to 52.9 degrees postoperatively. The radiolunate angle was decresed from a mean of 16.8 degrees prope- ratively to a mean of 1.8 degrees postoperatively. Union was obtained in all 13 cases, According to Herbert and Fisher's formulation, 2 excellent, 10 good and 1 fair results were obtained from our study. The results of the series suggest that treatment of scaphoid nonunion associated with DISI by this method is an effective method that reconstitutes scaphoid anatomy and promotes excellent wrist function.