Scaphoid nonunion treated with bone graft and Herbert screw. 23 of 28 fractures healed

Outcome of Scaphoid Nonunion Using Open Reduction and Internal Fixation With Iliac Crest Bone Graft (Fisk-Fernandez Technique)

Introduction The scaphoid is the most common carpal bone to be fractured and has a high propensity for nonunion. Restoration of scaphoid length mitigates the chances of long-term complications. The aim of this study was to assess the functional outcome of the Fisk-Fernandez technique for the treatment of scaphoid nonunion by using open reduction and internal fixation with trapezoidal iliac crest bone graft.  Materials and methods Fisk-Fernandez technique was used to manage scaphoid nonunion in 31 patients at a tertiary care hospital with follow-up at six weeks, 12 weeks, and 24 weeks. An objective assessment of the outcome was done using a comparison of the pre- and postoperative scaphoid score, QuickDASH, and visual analog score. Discussion The scaphoid is one of the most common carpal bones to get fractured. Anatomical factors, late presentation, and delay in diagnosis render it to usually land in nonunion. A comparison of the preoperative scaphoid, QuickDASH, and VAS scores with six-week, 12-week, and 24-week postoperative scores was made and was found to be statistically significant (p<0.001). Ninety-three percent of patients subjectively reported satisfaction after treatment. Though revascularization was not assessed, the bony union was observed in all the patients. Conclusion The operative technique proposed by Fisk-Fernandez is effective in correcting deformity of the scaphoid as well as providing satisfactory functional outcomes in patients with scaphoid nonunion.

Predictors of Failure for Vascularized and Nonvascularized Bone Grafting of Scaphoid Nonunions: A Systematic Review

Objective This article compares predictors of failure for vascularized (VBG) and nonvascularized bone grafting (NVBG) of scaphoid nonunions.

Methods We conducted a systematic literature review of outcomes after VBG and NVBG of scaphoid nonunion. Fifty-one VBG studies (N = 1,419 patients) and 81 NVBG studies (N = 3,019 patients) met the inclusion criteria. Data were collected on surgical technique, type of fixation, time from injury to surgery, fracture location, abnormal carpal posture (humpback deformity and/or dorsal intercalated segmental instability [DISI]), radiographic parameters of carpal alignment, prior failed surgery, smoking status, and avascular necrosis (AVN) as defined by punctate bleeding, magnetic resonance imaging (MRI) with contrast, MRI without contrast, X-ray, and histology. Meta-analysis of proportions was conducted with Freeman–Tukey double arcsine transformation. Multilevel mixed-effects analyses were performed with univariable and multivariable Poisson regression to identify confounders and evaluate predictors of failure.

Results The pooled failure incidence effect size was comparable between VBG and NVBG (0.09 [95% confidence interval [CI] 0.05–0.13] and 0.08 [95% CI 0.06–0.11], respectively). Humpback deformity and/or DISI (incidence-rate radios [IRRs] 1.57, CI: 1.04–2.36) and lateral intrascaphoid angle (IRR 1.21, CI: 1.08–1.37) were significantly associated with an increased VBG failure incidence. Time from injury to surgery (IRR 1.09, CI: 1.06–1.12) and height-to-length (H/L) ratio (IRR 53.98, CI: 1.16–2,504.24) were significantly associated with an increased NVBG failure incidence, though H/L ratio demonstrated a wide CI. Decreased proximal fragment contrast uptake on MRI was a statistically significant predictor of increased failure incidence for both VBG (IRR 2.03 CI: 1.13–3.66) and NVBG (IRR 1.39, CI: 1.16–1.66). Punctate bleeding or radiographic AVN, scapholunate angle, radiolunate angle, and prior failed surgery were not associated with failure incidence for either bone graft type (p > 0.05).

Conclusion Humpback deformity and/or DISI and increasing lateral intrascaphoid angle may be predictors of VBG failure. Time from injury to surgery may be a predictor of NVBG failure. AVN as defined by decreased contrast uptake on MRI may be a marker of increased failure risk for both bone graft types.

In Scaphoid Non-Union, Does the Source of Graft Affect Outcome? Iliac Crest Versus Distal End of Radius Bone Graft

Iliac crest bone grafts are sometimes preferred to other bone grafts for the treatment of non-unions of fractures of the scaphoid as they are claimed to have better osteogenic potential and biomechanical properties. We retrospectively studied a consecutive cohort of 68 symptomatic established scaphoid non-unions treated by bone grafting. An iliac crest graft was used in 44 cases and a distal radius graft in the other 24. The two treatment groups were comparable in terms of location of the fracture, duration of the non-union and the fixation implants used. Overall union was achieved in 45 of the 68 patients (66%) and the union rate was not influenced by the type of bone graft used. Twenty-nine of the 44 treated with iliac crest bone graft (66%) and 16 of the 24 (67%) treated with distal radial graft united. Donor site pain over the iliac crest was present in nine of the 44 patients in this group.

The Effect of Screw Design on Union Rates in Scaphoid Nonunions

BACKGROUND

The purpose of this study is to compare the outcome of the conical fully threaded headless screw to that of a smooth shaft headless screw in a series of scaphoid nonunions requiring screw fixation to determine if screw design had an influence on union rates.

METHODS

We retrospectively reviewed 104 cases of surgically treated scaphoid nonunions. After eliminating cases with our exclusion criteria, the study cohort had 40 cases for analysis. A comparison and analysis of union rates was undertaken between the fully threaded Acutrak 2 mini screw and the smooth shaft Herbert screw.

RESULTS

Overall union rate for screw fixation was 88%. The fully threaded conical screw fixation had a significantly lower union rate of 50% compared to 97% for the smooth shaft screws.

CONCLUSIONS

Our data revealed that the fully threaded conical screws were associated with significantly lower union rate compared to the smooth shaft Herbert type screws.

[Results of surgical treatment of carpal scaphoid pseudarthrosis using the Fisk-Fernández technique]

AIM

The aim of the study was to evaluate the clinical and radiological results obtained in the treatment of carpal scaphoid non-union treated at the University Hospital of Valladolid using the Fisk Fernandez technique.

MATERIAL AND METHODS

A review was performed on 43 cases of surgically treated non-union using Fisk Fernandez technique with a minimum of 6 months follow-up. The time until surgery, previous treatment, the mechanism of injury, type of non-union, and the existence of radio-carpal arthrosis were evaluated. A subjective evaluation was performed using the "Scaphoid Score" and the DASH, plus an objective assessment with the modified Green & O'Brien, together with the measurement of the intra-scaphoid, radioulnar, scapholunate angles, and carpal height.

RESULTS

The median time to healing in the series was between 16 to 24 weeks, except in 3 patients who failed to heal and required salvage surgery. There was a statistically significant variation between the preoperative and postoperative angles and carpal height measured in the X-rays.

DISCUSSION

There are different osteosynthesis techniques and materials for the treatment of non-union. The evaluation of results performed using objective and subjective scales showed variable results between studies. Different techniques are aimed at preventing the progression of the disease.

CONCLUSION

The Fisk Fernandez technique enables the deformity of the scaphoid to be corrected by wedge grafting and internal fixation with Kirschner wires or screws.

Local distal radius bone graft versus iliac crest bone graft for scaphoid nonunion: a comparative study

The aim of the study is to find whether there is any superiority of the iliac crest bone graft over the distal radius bone graft, in surgery of nonunion of scaphoid fractures. This is a prospective randomized controlled trial comparing 50 patients treated with internal fixation and distal radius bone graft (group 1) and 50 patients in whom iliac crest bone graft was used instead (group 2). The patients donor site pain in the postoperative period was assessed using visual analogue scale. At each follow-up, each patient was evaluated using Quick DASH score and Mayo's scoring system. Minimum follow-up was 3 years. Mean value of visual analogue scale for pain was 7.1 for group 2 and 4.2 for group 1. There was no statistically significant difference between the two groups in terms of range of wrist joint motion, functional scores, union rate and fracture reduction. There is no advantage of the iliac crest over the distal radius graft to justify its greater morbidity.

Ilizarov treatment of scaphoid nonunion

INTRODUCTION

This is single centre retrospective review of a consecutive series of patients with scaphoid nonunion (SNU) treated using the Ilizarov technique without bone graft. Fifteen of the original 18 patients were available for clinical and radiological examination at a minimum follow-up of 5 years (range 5-10 years). An evaluation was made of the late functional results, satisfaction scores, residual symptoms, grip strength and the presence of radiocarpal and scaphoid degenerative changes.

METHODS

The series consisted of 15 patients; 14 males; 1 female, with a mean SNU duration of 15.7 months, and a mean age of 23.6 years. Patients with carpal instability, humpback deformity, carpal collapse, avascular necrosis or marked degenerative change, were excluded from this treatment method. Following frame application the treatment consisted of three stages: distraction, compression and immobilisation. The technique is detailed herein.

RESULTS

Radiographic (CT) and clinical bony union was achieved in all 15 patients after a mean of 88 days (70-130 days). Mean modified Mayo wrist scores initially improved from 21 preoperatively to 86 at previous review, and were 96 at a mean follow-up of 81 months (62-120 months), with excellent results in 10, and good results seen in 5 patients. At latest review the mean grip strengths had returned to 96% of the uninjured hand, and 7 patients had regained full strength; mean wrist flexion/extension arc of motion had also continued to improve to 136° from 131°. All patients returned to their pre-injury occupations and levels of activity at a mean of 117 days. Three patients suffered superficial K-wire infections, which resolved with oral antibiotics. One patient continues to suffer intermittent mild aching in the wrist. No patient suffered loss of scaphoid height, humpback deformity, DISI instability or collapse of the regenerate bone.

CONCLUSION

In these selected patients this technique safely achieved bony union without the need to open the SNU site and without the need for bone graft. These patients also had the capacity to continually improve their wrist function beyond 3 years following their treatment.

Four-corner arthrodesis--does the source of graft affect bony union rate? Iliac crest versus distal radius bone graft

Four-corner arthrodesis is an accepted surgical option for treatment of scapholunate advanced collapse, scaphoid non-union advanced collapse and midcarpal instability. A preferred source of bone graft for performing four-corner arthrodesis is the iliac crest. An alternative and more convenient donor site is the distal radius. The aim of this study was to investigate whether the union rate after four-corner arthrodesis is influenced by the source of bone graft, that is, iliac crest or distal radius. In a retrospective analysis, charts and radiographs of 180 patients were identified. In 109 patients, iliac crest bone grafts were used, whereas 71 patients received distal radius bone grafts. In the iliac crest bone graft group, 101 out of 109 patients obtained a solid radiographic union of the arthrodesis at an average of 10 weeks after surgery, and non-union in eight patients (7.3%). In the distal radius bone graft group, X-rays of 66 patients showed bone union after an average of 10 weeks after surgery as well and five patients with non-union (7.0%) respectively. There was no statistical difference in bone union. Our data show that distal radius bone graft compares equally to iliac crest bone graft in performing four-corner arthrodesis. The advantages of the distal radius bone graft include a minor surgical exposure and the avoidance of using a distant anatomic site with associated donor-site morbidity.

A biomechanical comparison of scaphoid fixation with bone grafting using iliac bone or distal radius bone

PURPOSE

Although many scaphoid fractures may be treated by immobilization, complex scaphoid fractures generally require bone grafting with internal fixation. A preferred source of bone graft for scaphoid grafting is the iliac crest. Donor site morbidity from iliac crest harvest, however, is a known complication, and the comparable strength and osteogenic properties of bone harvested from other sites are unclear. To this end, we have conducted a cadaveric comparative investigation of the strength of scaphoid nonunions with bone graft and internal fixation using either iliac crest bone or distal radius bone.

METHODS

Ten paired, human, fresh-frozen cadaveric wrists were used to create a standard midwaist wedge osteotomy into which identically shaped distal radius or iliac crest bone wedges were internally fixed using headless compression screws. After bone density and computed tomography assessment of the bones, benchtop biomechanical testing was conducted to compare the strength of the scaphoids after iliac and distal radius grafting, at 2-mm displacement, and at failure.

RESULTS

Analysis of scaphoid length, width, height, weight, density, and screw placement revealed no statistical differences between both bone graft groups. Although not significant, scaphoid nonunions grafted with distal radius bone evidenced a reduced load (3.23 +/- 0.26 Nm) to 2-mm displacement compared with iliac crest bone (5.97 +/- 0.68 Nm). Similarly, though not significant, scaphoids grafted with distal radius bone showed a reduced load (4.18 +/- 0.30 Nm) to failure compared with iliac crest bone grafting (6.42 +/- 0.66 Nm). Although no significance was found between the 2 grafting methods, a trend toward greater strength in the iliac crest graft group was observed.

CONCLUSIONS

Given the comparable biomechanical strength shown between iliac and distal radius bone in this study and the simplified surgical technique of distal radius harvesting, the data justify use of distal radius bone as a viable alternative donor source in scaphoid fracture treatment.

Most scaphoid non-unions heal with bone chip grafting and Kirschner-wire fixation. Thirty-nine patients reviewed 10 years after operation

BACKGROUND

Many recommend to operate scaphoid pseudarthroses with wedge grafts and screw fixation. These are difficult operations. We have employed a simpler procedure and wished to review our results with regard to healing and long-term clinical results.

PATIENTS AND METHODS

We reviewed 39 unselected scaphoid pseudarthroses which had been operated with Kirschner-wire fixation and bone chip transplantation 10 (3.5-12) years previously. Postoperative cast treatment was 15 (11-30) weeks.

RESULTS

Four pseudarthroses failed to unite, one of which was after a trans-scaphoid perilunar dislocation. In another the pins were dislocated by an injury while the arm was in plaster. There were no other complications. All 14 proximal pseudarthroses united. There was no loss of grip strength but some loss of key-pinch strength and wrist mobility. Most patients reported no or little pain and none used analgesics because of wrist pain. The disability of the arm, shoulder and hand (DASH) score was 2 (0-33). Very few cases of mild arthrosis had arisen after operation. Three patients would not have consented to operation if they had known the outcome in advance.

CONCLUSIONS

Kirschner-wire fixation and bone chip grafting of scaphoid pseudarthroses is an undemanding operation with few complications that produces good long-term results. Results are excellent also for proximal pole pseudarthroses.

Treatment of scaphoid nonunions: quantitative meta-analysis of the literature

We conducted a systematic quantitative meta-review of the literature to provide evidence-based suggestions for the treatment of scaphoid nonunion. This search identified 1,121 articles of which 36 met eligibility requirements. In unstable nonunions, screw fixation with grafting at 94% union was superior to K-wires and wedge grafting (77% union). Immediate mobilization versus 6 weeks or more of casting showed the same union rate of 74%. For avascular necrosis of the proximal fragment, union was achieved in 88% of those patients with a vascularized graft versus 47% with screw and wedge fixation. These results suggest that established unstable nonunions should be treated with screw fixation and wedge grafting. There is not evidence supporting the need for postoperative immobilization in patients with solid screw fixation. A vascularized graft may be preferable for patients with avascular necrosis of the proximal fragment or with a previously failed surgery.

Trephine bone grafting technique for the treatment of scaphoid nonunion

A simple, minimally invasive trephine bone grafting technique for the treatment of scaphoid fracture nonunions is described. The method has a short surgical time, good results, and minimal donor site morbidity.

The Herbert screw for delayed union and non-union of scaphoid fractures: a review of twenty-two cases

We retrospectively reviewed 22 patients with delayed or non-union of scaphoid fractures treated with the Herbert screw. In 15 cases, we used an additional bone graft, taken from the iliac crest in all but two cases. The mean follow-up was 18 months (range: 6-40 months). Twelve of the 14 non-unions and 7 of the 8 delayed unions healed. Eleven patients were pain-free, 7 had minor symptoms, one had major symptoms but still considered his situation to be improved and two did not obtain any clinical improvement.