Internal Bone Grafting for the Treatment of Scaphoid Nonunions

Management of Scaphoid Pseudoarthrosis Surgery With Wide-Awake Local Anesthesia No Tourniquet (WALANT) Versus Axillary Block Anesthesia: Comparison of Patient Satisfaction

Objectives: We aimed to compare clinical and functional results of treatment of scaphoid pseudoarthrosis between patients undergoing wide-awake local anesthesia no tourniquet (WALANT) versus axillary block anesthesia. Methods: The patients diagnosed with scaphoid non-union who underwent pseudoarthoris surgery were divided into WALANT group ( n  =  12) and axial block group ( n  =  11). Visual analog scores (VAS) were measured by calling the patients via phone on postoperative days 1, 2, 3, and 7. The VASs were also measured on the 14th day during patient check-ups. At the end of 12 months, Michigan Hand Questionnaire was used to assess clinical recovery. Bone union rate and surgery time were also investigated. Radiological and clinical examinations were compared between the groups. Results: Eleven patients (91.7%) in the WALANT group and 10 patients (90.9%) in the axillary block group achieved bone union ( P  =  .94). Although there was no significant difference in preoperative VAS score between the groups, the WALANT group had significantly lower VAS score of the first 3 days postoperatively. However, there was no significant difference in VAS score between the groups on the seventh and 14th day postoperatively. There was no significant difference between the groups regarding Michigan score, time to surgery, time to union and operation time. Conclusion: The scaphoid pseudoarthrosis surgery can be done safely with WALANT technique which has significant lower VAS score on the first 3 days postoperatively.

Enxerto percutâneo e fixação de parafusos em pacientes com não consolidação do escafoide

Objective  The aim of the present study was to analyze the clinical and radiological results of patients with type-V cystic scaphoid nonunion who were treated with percutaneous grafting and screw.

Methods  A total of 11 patients were treated with a percutaneous bone graft with screw fixation. The criteria for inclusion in the study were a type-V scaphoid nonunion and age > 18 years old. Those with humpback deformity, arthritis, ligament damage determined on magnetic resonance imaging, or avascular necrosis (AVN) in the nonunion fragment were excluded from the study.

Results  The mean follow-up time was 36 months (range: 15–53 months). At the final follow-up examination, the mean visual analogue scale score was 1.06 (range: 0–2.3). Postoperatively, the mean extension was 61.6° (44–80°), flexion 66° (60–80°), radial deviation 12° (7–20°), and ulnar deviation 25° (20–34°). The mean grip strength of the operated hand was found to be 94%, compared with the healthy side. The results obtained in the Mayo Modified Wrist Score were poor in 2 patients, good in 2 and excellent in 7 (64%). With the exception of 2 patients, union was obtained radiologically in 9 patients, with a mean of 12.6 weeks (range, 8–16 weeks).

Conclusion  Percutaneous grafting and screw fixation cannot replace open surgery in cases with deformity, shortening, humpbacking, or in long term nonunions; however, it is a reliable and effective treatment method in selected cases, such as Slade & Dodds type-V cystic nonunion.

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.

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

PURPOSE

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.

METHODS

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.

RESULTS

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% healed by 18 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.

CONCLUSIONS

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 procedures for the treatment of scaphoid nonunion.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Scaphoid nonunion: what is the role of the Zaidemberg 1,2 intercompartmental supraretinacular arterial flap?

The reported results for the treatment of scaphoid nonunions with non-vascularized grafts are based on observational studies with a high variability in union rates from 38%-100% and time to union from 6-18 weeks, and there is also a lack of a standard classification. Meta-analyses and systematic reviews have been presented to better support conclusions from large pools of data (604 to 5246 cases), but their interpretation remains limited because of lack of uniformity in the studies analysed. Several authors have presented results from the Zaidemburg flap, with highly variable outcomes despite using the same technique; union rates have ranged from 27%-100% achieved between 6.5-19 weeks. Technical details that may be responsible for the discrepancies are discussed. There is a need for a validated prognostic classification system for scaphoid nonunions that can allow comparisons between outcome studies.