Comparative outcome analysis of internal screw fixation and Kirschner wire fixation in the treatment of scaphoid nonunion.

In cases with difficult scaphoid screw placement due to small, fragile bone fragments, or transplants and insufficient space, the internal Kirschner wire fixation is a fallback option; however, controversy remains regarding its stability, safety, and outcome. Between 2001 and 2011, 95 patients were treated in our center (n = 80 with cannulated compression screws and n = 15 with Kirschner wires), and retrospectively analyzed. The outcome measurements included the analysis of patient data, union rate and analysis of functional measures, and quality of life. Bony reconstructions were performed with Vascularized Bone Grafts (VBG) based on the 1,2-Intercompartmental Supraretinacular Artery (ICSRA) , Medial Femoral Condyle (MFC)-VBG, cancellous bone, and iliac crest grafts. Bony healing and functional outcome showed no significant differences between Kirschner wire fixation and cannulated compression screws, although significantly more 1,2-ICSRA-VBG were treated with Kirschner wires. Although predominantly used as an intraoperative fallback option, our data demonstrate that Kirschner wire internal fixation can be safe and reliable, with comparable bony union rates and excellent functional outcomes.

Vascularized versus non-vascularized bone grafts in the treatment of scaphoid non-union.

INTRODUCTION: Conventional non-vascularized bone grafts as well as vascularized bone grafts are used to treat scaphoid non-union (SN). Due to limited available studies, the field of application using both grafts for SN still remains controversial. The aim of this study was to evaluate a treatment algorithm for the use of both vascularized versus non-vascularized bone grafts based on clinical outcomes and quality of life (QoL) to improve the level of evidence. MATERIALS AND METHODS: Based on a retrospective cohort study, including 28 patients with vascularized and 45 patients with conventional bone grafts, functional parameters, radiological outcome, Mayo-wrist-score, and QoL by SF-36 were applied to statistically compare the outcome of these two techniques. RESULTS: Time between last procedure or trauma and study group scaphoid reconstruction was almost double in the vascularized bone grafting group. Comparable union rates were achieved with vascularized as well as non-vascularized bone grafts. Significant differences were observed between both groups for grip strength and radial-ulnar active range of motion. Further functional outcomes, radiological outcomes as well as QoL were found similar for both techniques in patients with surgical union. DISCUSSION AND CONCLUSIONS: In order to achieve comparable and appropriate treatment results, vascularized bone grafts are recommended for patients with delayed treatment, impaired scaphoid vascularity, and revision surgery. Even in preselected, complex cases, the results are comparable to conventional grafts, which are the basis for further patient education and approve the powerful role of surgical angiogenesis of vascularized bone grafts.

A comparative study on autologous bone grafting combined with or without posterior interosseous nerve neurectomy for scaphoid nonunion treatment.

BACKGROUND AND AIM: Scaphoid nonunion (SN) is a challenging state after scaphoid fracture. The posterior interosseous nerve neurectomy (PINN) is often performed adjunctively with scaphoid reconstruction using autologous bone grafts. However, it remains unclear whether PINN has a prophylactic or therapeutic value, and thus it results superior to patients with SN without PINN. METHODS: A retrospective study was performed to evaluate patients with SN who were treated with autologous bone grafts with (cohort 1) or without PINN (cohort 2) between 1996 and 2010. Clinical outcomes, Mayo-wrist score, quality of life by Short Form (SF)-36 questionnaire, and analysis of risk factors were included. RESULTS: A total of 151 patients with SN met the inclusion criteria, and 48 were lost in follow-up. The mean follow-up was 71.3 ± 39.0 months. Out of the remaining 103 patients, the union rate was without a statistical difference (P = 0.847) between cohorts 1 and 2. Functional results and the Mayo score were comparable in patients with bone union between both cohorts (P > 0.05). The results of wrist-pain measurements, including visual pain scales and wrist tenderness, were found to be similar (P > 0.05). Additionally, there was no significant difference in the quality of life. CONCLUSION: The comparative study on autologous bone grafts for scaphoid reconstruction revealed comparable results for both patients with and without PINN independent from the choice of bone graft. We anticipate a prophylactic value of PINN due to a potential injury or an irritation during dissection of the wrist capsule. Further research on PIN, its sensory characteristics, and its impact on wrist function is required.

The 1,2-intercompartmental supraretinacular artery vascularized bone graft for scaphoid nonunion: management and clinical outcome.

PURPOSE: To evaluate the clinical outcome of 1,2-intercompartmental supraretinacular artery pedicled vascularized bone graft for scaphoid nonunion (SN). METHODS: A retrospective study was performed to evaluate patients with SN and treated with 1,2-intercompartmental supraretinacular artery pedicled vascularized bone graft between 1997 and 2010. Functional measures, quality of life by Short Form SF-36 questionnaire, and analysis of risk factors were included. RESULTS: Out of 39 patients who were eligible for the study, 11 were lost to follow-up. Out of the remaining 28 patients, union was achieved in 21 (75%). The mean length of follow-up was 63 ± 45 months. In hands with scaphoid union, the grip strength and the radioulnar active range of motion were less than the contralateral side but greater compared with patients with nonunion. Active extension-flexion was less compared with the noninjured hand but similar to patients with nonunion. Disabilities of the Arm, Shoulder and Hand (DASH) score decreased from 58 to 23 in dominant hands and from 46 to 13 in nondominant hands. Smoking was found to be a risk factor for nonunion. Patients with scaphoid union tended to higher scores in 8 domains of SF-36-Item Health Survey quality of life without significant difference. CONCLUSIONS: Surgical treatment of SN with 1,2-intercompartmental supraretinacular artery pedicled vascularized bone graft provided a union rate comparable with other vascularized bone graft techniques. Previous scaphoid reconstruction with standard iliac crest bone graft was not associated with higher risk for secondary nonunion. There was an upward tendency seen in DASH score and quality of life after scaphoid union. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Functional results and quality of life after bilateral scaphoid reconstruction: a case series.

Unilateral scaphoid non-union remains a major problem, which can lead to major functional limitations. Until now there is no evidence of outcome of the rare case of bilateral scaphoid non-unions and in how far two-stage bilateral reconstruction affects functional results and the quality of life. Between 1997 and 2010, altogether four bilateral scaphoid non-unions were treated in the centre and retrospectively analyzed. The mean follow-up was performed 36.8 months after reconstruction. The measures included analysis of patient data, analysis of functional measures and quality of life after follow-up. The reconstructions were performed with implantation of a free, non-vascularized iliac crest bone graft (4), osteosynthesis with implantation of a pedicled vascularized bone graft (3) and osteosynthesis with cancellous bone graft (1). The mean range of motion of the wrist was extension/flexion 111.3°. The average grip strength by JAMAR dynamometer showed right versus left sight 32.7 kg (±3.5) versus 33.7 (±2.9). The evaluation of the DASH score resulted in 11.6 (±12.5), the SF36 scale in 87.1 (±9.2) points. The present case series for the first time demonstrated functional mid-term results of the rare event of bilateral scaphoid reconstruction after non-union. With respect to the impact on one affected hand, functional results, DASH score and quality of life are excellent and thus justify good prognosis in patient education after injury.