The Authors' Technique for Volar Plating of Scaphoid Nonunion

Traditional Bone Grafting in Scaphoid Nonunion

Management of scaphoid nonunion remains challenging despite modern fixation techniques. Nonvascularized bone graft may be used to achieve union in waist and proximal pole fractures with good success rates. Technical aspects, such as adequate debridement and restoration of scaphoid length, and stable fixation are critical in achieving union and functional wrist usage. Rigid fixation can be achieved with compression screws, K-wires, and plate constructs. The surgeon has a choice of various bone graft options including corticocancellous, cancellous, and strut grafts to promote healing and correct the humpback deformity.

Scaphoid Plate Osteosynthesis in Complex Fractures and Wrist Trauma: A Case Series

Introduction Treatment of scaphoid fracture is challenging due to its unique blood supply and geometry. Traditionally, a headless compression screw is the standard treatment for unstable scaphoid fracture. Some fractures are complex, for example, comminution with bone loss. A scaphoid plate is an option in these difficult fractures providing adequate rotational stability. Aim To share our experience in using scaphoid plates in complex wrist trauma and comminuted fractures. Method and material Complex wrist trauma involving scaphoid fractures that were comminuted and multi-fragmentary fractures treated with plate osteosynthesis were retrospectively reviewed between July 2019 and September 2021. Patient demographic data, preoperative radiographs, CT scans, pain, wrist range of motion, and fracture union rate to union were reviewed. Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH®) score was recorded at 1-year postoperative follow-up.  Results Nine patients associated with complex wrist trauma were included in this case series. The mean follow-up was 2.5 years (13-30 months). The union rate was 100%. The mean arc of motion was 105° (95-110°). QuickDASH® score was 19.96 at 1-year postoperative follow-up. Four patients had good outcomes, four satisfactory, and one poor outcome. One hardware complication was observed which was the impingement of the plate proximally over the articular surface of the distal radius. Conclusion A scaphoid plate is a reliable option for treating complex and difficult fractures. It provides adequate stability, especially in comminution, bone loss, or multi-fragmentary fractures which are not amendable using other fixation methods. We recommend the expansion of plate osteosynthesis beyond scaphoid nonunion into complex wrist trauma.

Volar Plating of Scaphoid Fractures: A Retrospective Case Series

BACKGROUND

The purpose of this study was to evaluate the rate of union of scaphoid fractures managed with volar plating and assess postoperative complications.

METHODS

Retrospective consecutive case series of 28 patients with scaphoid fractures, 9 acute and 19 chronic nonunions, undergoing surgical fixation with volar scaphoid plating by a single surgeon between 2013 and 2019. Patients were followed up for a minimum of 3 months with scaphoid bony union being confirmed on radiograph or computed tomography. Postoperative complications and need for plate removal were recorded.

RESULTS

Overall union rate of 96% with all 19 chronic nonunions demonstrating radiological union and 1 of 9 acute fractures not uniting and requiring revision surgery. The only postoperative complication identified was symptomatic plate impingement which necessitated plate removal in 57% of cases.

CONCLUSIONS

This case series demonstrates volar plating of scaphoid fractures can be used as an alternative technique to achieve union.

Double screw versus angular stable plate fixation of scaphoid waist nonunions in combination with intraoperative extracorporeal shockwave therapy (ESWT)

INTRODUCTION

Over the past years, different fixation techniques focused on rotational stability in order to increase stability and stimulate union rates. Additionally, extracorporeal shockwave therapy (ESWT) has gained importance in the treatment of delayed and nonunions. Purpose of this study was to compare the radiological and clinical outcome of two headless compression screws (HCS) and plate fixation in scaphoid nonunions, in combination with intraoperative high energy ESWT.

MATERIALS AND METHODS

Thirty-eight patients with scaphoid nonunions were treated by using a nonvascularized bone graft from the iliac crest and stabilization with either two HCS or a volar angular stable scaphoid plate. All patients received one ESWT session with 3000 impulses and energy flux per pulse of 0.41 mJ/mm² intraoperatively. Clinical assessment included range of motion (ROM), pain according to the Visual Analog Scale (VAS), grip strength, disability of the Arm Shoulder and Hand Score, Patient-Rated Wrist Evaluation Score, Michigan Hand Outcomes Questionnaire and modified Green O'Brien (Mayo) Wrist Score. To confirm union, a CT scan of the wrist was performed.

RESULTS

Thirty-two patients returned for clinical and radiological examination. Out of these, 29 (91%) showed bony union. All patients treated with two HCS compared to 16 out of 19 (84%) patients treated by plate showed bony union on the CT scans. The difference was not statistically significant. However, at a mean follow-up interval of 34 months, no significant differences could be found in ROM, pain, grip strength and patient-reported outcome measurements between the two HCS and plate group. Height-to-length ratio and capitolunate angle improved significantly in both groups compared to preoperative.

CONCLUSIONS

Scaphoid nonunion stabilization by using two HCS or angular stable volar plate fixation and intraoperative ESWT results in comparable high union rates and good functional outcome. Due to the higher rate for a secondary intervention (plate removal), HCS might be preferable as first choice, whereas the scaphoid plate fixation should be reserved for recalcitrant (substantial bone loss, humpback deformity or failed prior surgical intervention) scaphoid nonunions.

The progress in the classification and treatment of scaphoid nonunion

Scaphoid fracture is the most common carpal fracture, accounting for 50%-80% of all carpal fractures in the Youngers and manual workers. The nonunion rate of scaphoid fractures was approximately 10-15%. Scaphoid nonunion can lead to wrist deformity, wrist collapse, ischemic necrosis, and traumatic osteoarthritis resulting in the loss of wrist function and seriously influence the patients' lives. Achieving bony union is essential for the treatment of scaphoid nonunion. Although many surgical procedures including various forms of bone grafting have been developed to improve bony union, there is no conclusion about which method is the most effective and optimal. In this review, we provide an overview of the diagnostic, classification and progress in the treatments of scaphoid nonunion fractures.

Plate fixation in challenging traumatic carpal scaphoid lesions

BACKGROUND

Complex fractures of the carpal scaphoid with poles fragmentation, edges comminution, bone loss and non-union of fractures previously treated by screw fixation remain challenging for hand surgeons. The authors present the indications, advantages and results of scaphoid plating, underlining the importance of correct plate positioning well shaped onto the bone.

MATERIALS AND METHODS

The study includes 11 patients presenting acute fracture with distal pole fragmentation, acute fracture with comminution and non-union after prior failure of screw fixation. All patients were treated with volar locked plate fixation, adding a cortical bone graft in cases of non-union.

RESULTS

Bone consolidation was achieved in all cases; excellent outcomes in fracture healing and relevant improvement in symptoms and functions were obtained in non-union group that are consistent with the literature. Only one patient underwent early further surgery (first row carpectomy) with poor results.

CONCLUSION

The treatment of the selected scaphoid lesions with volar locked plate is a surely efficient technique. The plate can be easily adjusted to the shape of the scaphoid and can achieve an adequate correction of bone deformity and high degree of stability both in non-union and fractures.

Scaphoid plating for recalcitrant scaphoid fractures: a systematic review

We conducted a systematic review of scaphoid plating for recalcitrant scaphoid fractures using EMBASE, Pubmed, Cochrane and MEDLINE. Thirteen studies were included. Ninety-three per cent of cases reported were male with a mean age of 27 years. Bony union was reported in eleven studies and achieved in 72% to 100% of cases. Scaphoid plates showed no significant difference in union incidence compared with headless compression screws. Mean removal incidence of plates was 21%. Postoperative flexion-extension arc was 119°. Grip strength improved by 14% postoperatively over that before surgery. There was a general improvement in patient-reported outcome measures. Eighty-six per cent of reported participants returned to their previous work. In these clinical reports, plates frequently required removal more frequently than headless compression screws.

Mid-term outcome of volar plate fixation for scaphoid nonunion

AIMS

Fixation of scaphoid nonunion with a volar locking plate and cancellous bone grafting has been shown to be a successful technique in small series. Few mid- or long-term follow-up studies have been reported. The aim of this study was to report the mid-term radiological and functional outcome of plate fixation for scaphoid nonunion.

METHODS

Patients with a scaphoid nonunion were prospectively enrolled and treated with open reduction using a volar approach, debridement of the nonunion, and fixation using a locking plate and cancellous bone grafting, from the ipsilateral iliac crest. Follow-up included examination, functional assessment using the patient-rated wrist/hand evaluation (PRWHE), and multiplanar reformation CT scans at three-month intervals until union was confirmed.

RESULTS

A total of 49 patients with a mean age of 31 years (16 to 74) and a mean duration of nonunion of 3.6 years (0.4 to 16) were included. Postoperatively, the nonunion healed in 47 patients (96%) as shown on CT scans. The mean time to union was 4.2 months (3 to 12). Due to impingement of the plate on the volar rim of the radius and functional limitation, the hardware was removed in 18 patients. At a median follow-up of 38 months in 34 patients, the mean active range of motion (ROM) improved significantly from 89° to 124° (SD 44°; p = 0.003). The mean grip strength improved significantly from 52% to 79% (SD 28%; p < 0.001) of the contralateral side. The mean PRWHE score improved significantly from 66 to 17 points (SD 25; p < 0.001).

CONCLUSION

Locking plate fixation supplemented with autologous cancellous bone grafting is a successful form of treatment for scaphoid nonunion. Functional outcomes improve with the passage of time, and mid-term results are excellent with a significant improvement in ROM, grip strength, and functional outcome as measured by the PRWHE. Cite this article: Bone Joint J 2020;102-B(12):1697-1702.

Modified Matti-Russe technique using a "butterfly bone graft" for treatment of scaphoid non-union

Introduction

Autologous bone grafts are used to treat scaphoid non-union with shortening and humpback deformity. The superiority of internally fixed bone graft to embedded bone graft has not been clearly proven.

Methods

Retrospectively analyzed 42 cases of scaphoid waist non-union treated using the "butterfly bone graft" (modified Matti-Russe technique).

Results

Complete healing was reached by all patients, with an average time of 4.4 (SD ± 0.7) months. Mayo Wrist Score improved from and QuickDASH score significantly improved in all patients after treatment.

Conclusions

Butterfly bone graft is effective and reliable in treating scaphoid non-union with shortening and humpback deformity.