Scaphoid nonunion in the presence of a degenerate carpus: don't rush to salvage surgery

APSI scaphoid hemiarthroplasty – long-term results

Objective

This study is aimed at evaluating the long-term results of proximal scaphoid hemiarthroplasty for post-traumatic avascular necrosis at this institution.

Methods

Twelve patients who underwent this procedure were identified, and the mean follow-up time was 6.5 years (range: 5–8 years). All patients were male, with a mean age of 39 years (range: 28–55 years). In eight patients, the non-dominant limb was affected. The procedure was carried out through a dorsal approach and all patients underwent the same rehabilitation protocol. Cases were evaluated regarding complications, pain, range of motion, functional status (Mayo Wrist Score), and disability (QuickDASH Score).

Results

No immediate post-operative complications, such as infection or dislocation of the implant, were observed. All patients presented with peri-implant osteolysis at follow-up, on a radiograph study. None of the patients was forced to abandon their previous professional activity, although about 50% required some type of adaptation at their workplace. The mean functional capacity was, according to the Mayo Wrist Score, of 67.5 points (range: 50–80), corresponding to a satisfactory degree of function. The QuickDASH disability score presented a mean of 25 (range: 3–47.7).

Conclusion

The results of this series are in line with previously published studies about this technique. Hemiarthroplasty with a pyrocarbon implant is a safe technique for the treatment of post-fracture avascular necrosis of the scaphoid proximal pole. This technique allowed for satisfactory functional results at a mean follow-up of 6.5 years.

Management of a 15-year-old scaphoid non-union

Scaphoid non-union affects wrist joint function and is often associated with a predictable pattern of degenerative change. A 30-year-old man presented with a symptomatic 15-year-old right scaphoid fracture with secondary scaphoid non-union advanced collapse of his right wrist. There was no evidence of avascular necrosis. The initial injury was from a fall onto his outstretched hand. We performed a right scaphoid open reduction, internal fixation and iliac crest bone graft. One year after the operation, the patient had good wrist function and grip strength. A CT scan showed union of the fracture. Studies have shown that if the time between initial fracture and treatment of non-union exceeds 5 years, the chances of healing of the non-union are markedly reduced. In our case, despite the long duration between timing of injury and surgery, there was union and good return of function.

Modified Murray Technique for Carpal Navicular Nonunion

The authors report the results of long-term follow-up in 29 patients treated for non-union of the carpal navicular with a modified Murray technique performed through a lateral approach. Mean patient age at surgery was 22.5 years. Average time from injury to surgery for nonunion was 18 months. In 5 cases, mild signs of osteoarthritis of the radioscaphoid joint (scaphoid nonunion advanced collapse [SNAC] stage I) were present before surgery, and in 2 cases, radiographic signs of avascular necrosis of the proximal nonunion fragment were evident. In all cases, a corticocancellous nonvascularized bone graft taken from the distal part of the ipsilateral radius was used. Mean follow-up was 11.2 years. Nonunion had healed in 93.1% of cases. At follow-up, the 2 patients in whom nonunion had not healed had severe painful osteoarthritis of the wrist (SNAC stage IV). Twenty patients were asymptomatic, and 5 had occasional pain in the wrist. Wrist range of motion was restricted in all patients compared with the contralateral side. Mild osteoarthritis was observed in 6 patients (SNAC stage I). The average Disabilities of the Arm, Shoulder and Hand score was 8.7 of 100. The modified Murray technique is reliable for treating nonunion of the carpal navicular. The union rate is high, and the incidence of wrist osteoarthritis is low compared with other studies. Early diagnosis and treatment of nonunion (a short interval between fracture and surgery) can minimize the risk of degenerative joint disease. Avascular necrosis of the proximal fragment is not an absolute contraindication to surgery.

A scoping review of disabilities of the arm, shoulder, and hand scores for hand and wrist conditions

PURPOSE

To evaluate the variability of reported baseline Disabilities of the Arm, Shoulder, and Hand (DASH) scores for non-acute hand and wrist conditions. We hypothesized that DASH scores for evaluation of hand and wrist pathology would provide a map of scores that would correspond to severity. In addition to providing a catalog of DASH scores for various upper extremity pathologies, we hypothesized that this review would support the validity of the DASH instrument.

METHODS

A literature search was performed using 3 databases (MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials) from the earliest available date through January 1, 2013. Search terms included "DASH" and "hand" and combinations of conditions found in the initial search. The search was restricted to studies with baseline DASH scores and DASH scores for isolated conditions, and written in the English language.

RESULTS

Our search identified 1,770 citations; 136 full-text articles were reviewed and 85 studies were included in the scoping review. This provided 100 DASH scores mapped for 24 different diagnoses. Most articles (67%) included chronic conditions for inflammatory or degenerative pathologies rather than posttraumatic disorders. Posttraumatic DASH score reporting ranged from 4 months to 11 years after injury, and final outcome scores varied among studies assessing the same pathology. The greatest variation and highest scores were for de Quervain tendinitis (range, 29-93) and scapholunate advance collapse (range, 17-89). These scores indicated higher disability in de Quervain tendinitis and wrist osteoarthritis compared with conditions such as thumb amputation and upper extremity replantation.

CONCLUSIONS

Substantial variation in the DASH scores and methodology was found and indicates a need for further study of the DASH to allow for standardized interpretation.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Vascularized bone grafting and distal radius osteotomy for scaphoid nonunion advanced collapse

PURPOSE

To determine the outcome of an alternative treatment for wrists with stages I to III scaphoid nonunion advanced collapse using a closing-wedge osteotomy of the distal radius and a vascularized bone graft for scaphoid reconstruction.

METHODS

Twelve patients with scaphoid nonunion advanced collapse (stage I, 3; stage II, 7; stage III, 2) treated with a vascularized bone graft interposition for the scaphoid and a closing-wedge osteotomy for the distal radius were retrospectively reviewed. Data were obtained and analyzed from the radiographs, and we assessed the pre- and postoperative range of motion, grip strength, visual analog scale pain score, as well as the Mayo and Disabilities of the Arm, Shoulder, and Hand (DASH) functional scores.

RESULTS

Follow-up ranged from 2 to 11 years. All scaphoid nonunions united after an average of 9 weeks, and all osteotomies united after an average of 8 weeks. Although there was radiographic progression of the scaphoid nonunion advanced collapse stage in 5 of 12 cases, there was major improvement in visual analog scale pain score (from 6.1 to 0.8) and in both Mayo (from 64 to 85) and DASH (from 40 to 9) functional scores. The range of motion remained unchanged, and grip strength trended toward minor improvement. The carpal height was preserved, and the dorsal intercalated segmental instability was corrected.

CONCLUSIONS

Scaphoid reconstruction with vascularized bone graft combined with closing-wedge distal radius osteotomy preserved wrist function for scaphoid nonunion advanced collapse. The method offers pain relief and does not compromise wrist motion or grip strength.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Reproducibility of radiographic classification of scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) wrist

The aim of this study was to measure inter- and intra-observer agreement on the radiographic classification of scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) wrist. Radiographs of 41 patients with SLAC wrist and 47 patients with SNAC wrist were graded on two separate occasions by four orthopaedic consultants specializing in hand and wrist surgery. Inter-observer agreement was evaluated using the multi-rater kappa value. Landis and Koch criteria were used to assess the level of agreement. Intra-observer agreement was tested by re-grading the radiographs after an interval of 2 to 4 weeks and calculating the weighted kappa value. For SLAC wrist, the inter-observer agreement was moderate (kappa value = 0.59) and intra-observer agreement substantial (kappa value = 0.65). For SNAC wrist, the inter-observer agreement was slight (kappa value = 0.20) and intra-observer agreement was fair (kappa value = 0.29). Radiographic classification of SLAC wrist has moderate reliability and reproducibility, whereas classification of SNAC wrist has limited reliability.