Objectives: Evaluating the efficacy of the Ilizarov fine-wire distraction/compression technique in the treatment of scaphoid nonunion (SNU), without the use of bone graft. Design: A retrospective review of 15 consecutive patients in one centre. Patients and Methods: 15 patients; 14 males, with a mean SNU duration of 13.9 months. Following frame application the treatment consisted of three stages: stage one – the frame was distracted 1mm per day until radiographs showed a 2–3mm opening at the SNU site (mean 10 days); the SNU site was then compressed for 5 days, until the fragments were in contact., the third stage involved immobilization with the Ilizarov fixator for 6 weeks. Results: Radiographic and clinical bony union was achieved in all 15 patients after a mean of 89 days (70–130 days). Mean modified Mayo wrist scores improved from 21 to 86 at a mean follow-up of 37 months (24 –72 months), with good/excellent results in 12 patients. 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. Conclusions: In these study group with this technique we achieved bony union without the need to open the SNU site and without the use of bone graft

The surgical treatment of scaphoid nonunion is controversial. The purpose of this study is to present our experience from the surgical treatment of 16 scaphoid nonunions in heavy manual workers. Sixteen patients with sixteen nonunions of the scaphoid were treated during the last 6 years (13 male and 3 female). Established nonunion was present in 7 months to 7 years. Five nonunions were Alnot stage I, 5 were IIa, 5 were IIb and 1 nonunion was stage IIIa. One case considered the distal pole and 15 the proximal pole of the scaphoid. In 5 patients there was avascular necrosis of the scaphoid and in 6 patients DISI was present. All sixteen patients complained about pain, resulting to disability to work. All patients were treated with an autocompression screw and small autologus cancellus bone grafts. In one case with a proximal third non-union, screw fixation was not achieved. The mean time of union was 70 days. Mean follow up was 3 years. All patients returned early to their occupation without pain. Grip strength reached 90% (70% preoperatively) and range of motion reached 95% (80% preoperatively), compared to the contralateral side. Excellent functional results were in eleven patients, good in four and average in one patient. In four cases there was a previous carpal dislocation. Symptoms of non-union of the scaphoid appear earlier in heavy manual workers and their surgical treatment should not be delayed. We believe that the use of autocompression screws and cancellous bone grafts is the first choice of treatment for nonunions (Alnot stage I and II) of middle and distal third of the scaphoid

Purpose: We report the long-term outcome after treatment of scaphoid nonunion using a graft harvested on the anterior aspect of the radius and vascularised with the anterior carpus artery. Material and methods: We treated 72 patients, 11 women and 61 men. Mean age was 31.4 years (15–61) and mean delay from initial fracture of the scaphiod to treatment of nonunion was 22 months (4–120 months). Twenty-seven patients had had prior tratments (11 Mati-Russe, 16 screw fixations). Alnot classification was 40 grade 2A, 28 grade 2B and 4 grade 3A. the patients were generally treated as out-patients under locoregional anaesthesia. A single approach was needed. After reduction and fixation of the scaphoid, the graft was harvested from the anterior aspect of the radius and inserted in the bone gap, usually fixed with a temporary pin. A palmar brace was maintained until bone healing. Results: Bone healing was achieved in 66 patients (91.6%). Mean delay to healing was 9.8 weeks (6–24). Pain relief was achieved in all patients; 59 were completely pain free. Mean flexion improved from 45° to 56° and mean extension from 54° to 65°. Muscle force improved from 50% to 90% of the healthy side. There were three cases of reflex dystrophy, two cases of styloid radial osteoarthritis and three cases of postoperative stiffness requiring secondary arthrolysis. Functional outcome was excellent in 46 patients, good in 13, fair in 9 and poor in 4. Discussion: The vascularised graft advocated by Judet as early as 1964 has proven its efficacy for repeated nonunions of the scaphoid. In our series, there was a direct correlation between the grade of the nonunion and the final outcome, the best results being obtain for grade 2A. Conclusion: Use of a bone graft vascularised with the anterior carpus artery only requires on approach, and provides a high rate of bone healing. We recommend this method for first line treatment of nonunion of the scaphoid

Abstract

The aim of this study was to compare the results of Matti-Russe (MR) procedure and interpositional techniques (IT) in the management of scaphoid non-union.

50 scaphoid non-unions were included in this retrospective study. Demographics, initial management of fracture, location of non-union, time to surgery, procedure done and immobilisation time were recorded. Radiographs were analysed for union and deformity correction. Functional outcome was analysed using the Herbert's grading system.

The mean age and time to surgery were 26.7 years and 15.9 months. Twenty-one patients had the MR procedure and twenty-nine patients had interpositional procedures with internal fixation. DISI was present in 17 patients. The mean postoperative change in the scapholunate angle with the MR procedure was 7.9° compared to 8.0° (p>0.05) for the IT procedures. Union rate was 76% for both procedures. The mean follow-up was 9.9 months. Functional results were Herbert 0 or 1 in 42 cases.

The only significant prognostic variables were location of non-union and time to surgery. Similar deformity correction was achieved using both IT and MP procedures. MP procedure can be used in the management of scaphoid non-union even in the presence of deformity with good functional results.

Scaphoid fractures accounts for approximately 15% of all fractures of hand and wrist. Proximal pole fractures represent 10–20% of scaphoid fractures. Non –operative treatment shows high incidence of non-union and avascular necrosis. Surgical intervention with bone graft is associated with better outcome. The aim of this study was to evaluate the radiological and functional outcome of management of proximal pole scaphoid non-union with internal fixation and bone grafting.

We included 35 patients with proximal pole scaphoid non-union (2008–2015). All patients underwent antegrade headless compression screw fixation and bone grafting at King's College Hospital, London (except one, who was fixed with Kirschner wire). 33 patients had bone graft from distal radius and two from iliac crest. Postoperatively patients were treated in plaster for 6–8 weeks, followed by splinting for 4–6 weeks and hand physiotherapy. All the patients were analysed at the final follow-up using DASH score and x-rays.

Mean age of the patients was 28 years (20–61) in 32 men and 3 women. We lost three patients (9%) to follow up. At a mean follow up of 16 weeks (12–18) twenty three patients (66%) achieved radiological union. All patients but three (91%) achieved good functional outcome at mean follow up of 14 weeks (10–16).

A good functional outcome can be achieved with surgical fixation and bone graft in proximal pole scaphoid fractures non-union. Pre-operative fragmentation of proximal pole dictates type of fixation (screw or k wire or no fixation). There was no difference in outcome whether graft was harvested from distal radius or iliac crest.

Background

Despite the known multifactorial nature of scaphoid wrist fracture non-union, a possible genetic predisposition for the development of this complication remains unknown. This pilot study aimed to address this issue by performing Single Nucleotide Polymorphisms (SNPs) analysis of specific genes known to regulate fracture healing.

The Authors report their experience in the treatment of scaphoid non-union recurring to the vascularised bone graft technique as described by Zeidemberg. The patients have been treated between the 1999 and 2004. The authors report 22 cases (21 males and 1 female) with an average age of 31 years (from 17 to 42). 10 cases the involved wrist was the right one and in the other 12 cases was the left one.

18 patients presented an avascular necrosis of the proximal fragment of the scaphoid, recognised by the MNR. Two patients have been previously treated by the traditional bone graft technique as described by Matti-Russe, using a cannulated screw for the stabilization of the graft. 16 patients have been controlled at the follow-up (mean 23 months, from 3 to 65). The authors, looking at the good results obtained at the follow-up, feel that this technique might be a very useful one in the treatment of the established scaphoid non-union, mainly in presence of an avascular necrosis of the proximal third of the scaphoid. This technique might also be useful in the treatment of the failure of the classic bone graft technique.

Intraoperative range of motion (ROM) radiographs are routinely taken during scaphoidectomy and four corner fusion surgery (S4CF) at our institution. It is not known if intraoperative ROM predicts postoperative ROM. We hypothesize that patients with a greater intra-operativeROM would have an improved postoperative ROM at one year, but that this arc would be less than that achieved intra- operatively. We retrospectively reviewed 56 patients that had undergone S4CF at our institution in the past 10 years. Patients less than 18, those who underwent the procedure for reasons other than arthritis, those less than one year from surgery, and those that had since undergone wrist arthrodesis were excluded. Intraoperative ROM was measured from fluoroscopic images taken in flexion and extension at the time of surgery. Patients that met criteria were then invited to take part in a virtual assessment and their ROM was measured using a goniometer. T-tests were used to measure differences between intraoperative and postoperative ROM, Pearson Correlation was used to measure associations, and linear regression was conducted to assess whether intraoperative ROM predicts postoperative ROM. Nineteen patients, two of whom had bilateral surgery, agreed to participate. Mean age was 54 and 14 were male and 5 were male. In the majority, surgical indication was scapholunate advanced collapse; however, two of the participants had scaphoid nonunion advanced collapse. No difference was observed between intraoperative and postoperative flexion. On average there was an increase of seven degrees of extension and 12° arc of motion postoperatively with p values reaching significance Correlation between intr-operative and postoperative ROM did not reach statistical significance for flexion, extension, or arc of motion. There were no statistically significant correlations between intraoperative and postoperative ROM. Intraoperative ROM radiographs are not useful at predicting postoperative ROM. Postoperative extension and arc of motion did increase from that measured intraoperatively

Introduction. Scaphoid nonunions remain controversial with regard to optimal management. The objective of this article is to compare our clinical experience in the treatment of patients with scaphoid nonunion using distal radius non vascularised bone graft with that of iliac crest bone graft. Material & Methods. We conducted a prospective randomized study comparing the clinical, functional and radiographic results of 42 patients treated for scaphoid nonunion using a non-vascularised bone graft from the dorsal and distal aspect of the radius (group I), relative to 46 patients treated by means of a conventional non-vascularised bone graft from the iliac crest (group II). All nonunions were stabilized with single Herbert screw. Results. Bone fusion was achieved in 87.1% of group I and 86.5% of group II patients. Functional results were good to excellent in 76.0% of the patients in group I and 72.5% in group II. The average grip power, as well as wrist flexion and extension were similar in both groups. However, the donor site morbidity was much higher in group II (4 cases of hematoma, 6 cases of chronic pain and 1 anterior superior iliac spine avulsion) fracture. No complication was seen in group I. Conclusion. We conclude that nonvascularized distal radius bone grafting yields similar union rate as well as functional outcome as compared to iliac crest bone graft with no donor site morbidity

In treatment of scaphoid nonunions age of nonunions, stability of reconstructions and particularly vitality of proximal fragments are regarded as important prognostic factors for healing. The value of preoperative MRIscans in predicting intraoperative vitality and final osseous union prospectively was investigated. Scaphoid nonunions in 60 patients (7 female, 53 male, mean age 30 years) primarily were reconstructed between 1/2000 and 7/2003. Preop they underwent a standardized MRIscan using i.v. Gadolinium to assess vitality of proximal fragments. The scaphoids were reconstructed per palmar or dorsal approach implanting nonvascularized iliac-crest or distal radius bone grafts stabilized with cannulated or mini Herbert screws. Intraop vascularity (vital/nonvital) was documented estimating blood spots occurring on the debrided fragments cancellous surface (none/medium/many). After immobilization for 6–8 weeks osseous union was ruled out performing repeated radiographic and CT studies up to 6 months. Apart from demographic data, age and type of nonunion, intraop fragment vitality and postop osseous union were correlated to vitality stated in preop MRIs. A p-value of 0.5 was regarded as significant. 50 proximal fragments preoperatively were stated vital. Overall fragment vitality was predicted correctly in 52 patients. 5 were false negative, 3 false positive. No significant correlation between age or type of nonunion and the predicted vitality could be obtained. Osseous union was gained in 55 scaphoids. Patients with predicted avital fragments had no significantly higher incidence of osseous union than those with avital fragments. Preop MRIscans are of value in detecting avascular proximal fragments in scaphoid nonunions. In these cases reconstruction with vascularized bone grafts is proposed. Our data however indicate that vascularity of proximal fragments is not predictive of bony healing. High rates of osseous union can be achieved even with nonvascularized grafts in pateients having avascular proximal fragments

The June 2013 Wrist & Hand Roundup. 360 . looks at: whether size is a limitation; cancellous bone grafting in scaphoid nonunion; the Kienböck’s dichotomy; late displacement of the distal radius; flexor slide for finger contracture; aesthetic syndactyly; flexor tendon repair; and fixation of trapeziometacarpal cups

Introduction: Radial styloidectomy as procedure has gained recognition over the last 60 years since its initial description for scaphoid nonunions. It is a recognised procedure in the treatment of distal radioscaphoid joint arthritis on its own or as an adjunct to another carpal procedure. There has been a debate regarding the length of styloid osteotomy and the risk of instability due to the damage of volar ligaments. Aim: We set out to evaluate the anatomical variation of the volar ligament attachments. Methods: We performed dissection of 22 wrists in 11 embalmed cadavers (7 females, 4 males). Using dorsal approach we dissected down to the wrist and then to the volar ligaments. Measurements were taken from the tip of the radial styloid to the insertion of the volar ligaments, using digital vernier callipers. Measurements were carried out by two assessors and intra-observer and inter-observer variations were not found to be significant. Results: Average age was 86.8 years (range 81–94). The average length of the volar ligament was found to be 7.19mm (range 5.37–10.01). No significant side dependant variation in measure was found. Predictably volar ligament length in females was found slightly lower compared to males. Conclusion: Based on a standard 3–4mm radial styloidectomy recommended we do not feel that there would be any compromise of the volar wrist ligaments

Introduction and purpose: The most commonly found degenerative changes in the wrist can be included in two basic patterns of advanced carpal collapse: On the one hand scapholunate advanced collapse (SLAC) and on the other scaphoid nonunion advanced collapse (SNAC). To treat this collapse, Watson described the so-called four-corner arthrodesis, which includes the lunate, capitate, pisiform and hamate bones. The aim of this study is to assess the results obtained using fixation with a Spider plate. Materials and methods: In this study we included a series of 20 patients that underwent 4-corner arthrodesis with a Spider plate. These cases had stage II or III advanced degeneration of the wrist both SLAC and SNAC. We have also used this technique for other indications such as osteochondral lesions of the head of the capitate, mediocarpal arthritis or mediocarpal instability. Results: Mean follow-up was 16 (7–25) months. An important decrease in pain was seen in all cases and postoperative values were as follows: palmar flexion, 38° (range: 12–46); dorsal flexion, 30° (range: 12–45); radial deviation, 12° (range: 0–16); ulnar deviation, 24° (range: 15–40). An increase in fist force was seen after surgery. The arthrodesis healed in all cases, with a slight decrease in carpal height index after surgery. Conclusions: This surgical technique has allowed us to obtain good results determined clinically and by means of X-rays, as well as early motion after surgery

Introduction. It is well established that non-union of the scaphoid requires operative intervention to achieve stable union, restore scaphoid anatomy and prevent further degenerative change. Acutrak screw has been shown to have better biomechanical compression properties than the Herbert screw in the laboratory setting. The aims of the study were to assess the rate of union, the functional outcome and post- operative complications of patients with the two different screw systems. Methods. A retrospective review of the patients who had undergone surgery for non-union of scaphoid treated by a single surgeon. The first group consisted of 61 patients who were treated with Herbert screw and iliac crest bone graft between July 1996 and June 2000. The rate and time to union were assessed clinically and radiologicaly. Their post-operative functional outcome was assessed with modified Mayo wrist score. Results were compared to second group of 71 patients treated with Acutrak screw plus iliac crest bone graft between July 2000 and December 2005. Results. The mean ages of patients (25yrs in Herbert Vs 27yrs in Acutrak) were similar in both groups. The mean time interval between injury and surgery was 12.2months for Herbert group and 17months in Acutrak group. Herbert group had 77% (47) union rate compared to 93% (66) for the Acutrak group. There was persistent nonunion in 14 (22.9%) and 5 (7%) patients in Herbert and Acutrak groups respectively. Functional outcome were excellent in 41% of cases, good in 26% of cases, fair in 22%, and poor in 11 % of cases in Herbert group. For Acutrak group, the outcome score were better with excellent 60% of cases, good in 25%, fair in 10% and poor in 5% of the cases. Wrist fusion was performed in 4 and 1 cases for Herbert and Acutrak group respectively due to progressive wrist pain. Conclusion. Acutrak screw offer better union rate and functional outcome following surgery for scaphoid nonunion

Aims

The underlying natural history of suspected scaphoid fractures (SSFs) is unclear and assumed poor. There is an urgent requirement to develop the literature around SSFs to quantify the actual prevalence of intervention following SSF. Defining the risk of intervention following SSF may influence the need for widespread surveillance and screening of SSF injuries, and could influence medicolegal actions around missed scaphoid fractures.

Background: Bone morphogenetic proteins (BMPs) induce new bone in patients with bone defects and at extraskeletal sites in animals. Standard treatment for symptomatic scaphoid non-unions is bone graft with or without internal fixation by a screw or wires. We tested the ability of human recombinant osteogenic protein-1 (OP-1, BMP-7) with compressed autologous or allogeneic bone graft to accelerate the healing of scaphoid non-union. Study Design: Randomized and controlled pilot study in 17 patients with a scaphoid nonunion. Methods: Patients were randomly assigned to one of three groups: (1) Autologous iliac graft (n=6), (2) Autologous iliac graft + OP-1 (n=6) and (3) Allogeneic iliac graft + OP-1 (n=5). Radiographic, scintigraphic and clinical outcomes were assessed throughout the follow-up period of 24 months. Results: OP-1 improved the performance of both autologous and allogeneic bone implants. Three dimensional helical CT scans and scintigraphy showed that the pre-existing sclerotic bone within proximal scaphoid poles was mainly replaced in OP-1 treated patients with well vascularized new bone. Addition of OP-1 to allogeneic bone implant equalized the clinical outcome with the autologous graft procedure and enabled circumventing the second donor graft harvest procedure resulting in less blood loss, shorter anesthesia and no pain at the donor side. Conclusion: This is the first evidence that a recombinant human BMP accelerates scaphoid bone non-union repair and resorption of sclerotic bone in this specific microenvironment. Clinical Relevance: OP-1 might be successfully used in healing of scaphoid non-union

To determine union rate in complicated nonunions of the scaphoid treated with a vascularised bone graft. Vascularised bone grafting for scaphoid nonunions (1–2 ICSRA, Zaidemberg technique) has shown initial enthusiasm. Its usefulness has been challenged in cases where the proximal pole of the scaphoid is avascular. Complicated nonunions where the proximal pole is highly likely to be avascular occur in revision surgery and proximal pole nonunions. Fourteen patients were retrospectively followed up. Eight had nonunion following previous scaphoid surgery (two previous ORIF, two previous nonvascular grafting, and four with two previous surgeries). Six patients had no previous surgery for a proximal pole nonunion of 12.5 months’ duration. All patients were male with an average age of twenty-four. Delay from fracture to vascularised bone grafting was twenty months. Graft harvesting was done according to the Zaidemberg technique by two orthopaedic surgeons. CT-scan was used to confirm union in all patients except two who were lost of the follow-up. Twelve patients were followed up by an independent surgeon at a postoperative minimal period of four months. Functional status was assessed with the DASH questionnaire and follow x-rays were performed to determine the presence of degenerative changes. Union was confirmed by CT-scan in eleven of twelve followed patients (92%) at an average time of six months following vascularised graft. Radio-scaphoid osteoarthritis was seen in the one patient that didn’t achieve union. This series suggests that the Zaidemberg graft is useful and may be proposed in situations of revision surgery and proximal pole non-unions. We achieved a high union rate in these complicated nonunions even though there was high likelihood that the proximal pole was avascular. This study stresses the importance of protective immobilization until documented union by CT-scan in this difficult subset of patients

Introduction: To assess the value of MR imaging (MRI) with regard to union, graft viability and proximal pole bone marrow status, after use of vascularized bone grafts (VBG) for treating scaphoid nonunions (SN). Methods: VBG from the distal radius were used to treat 52 SN. Clinical and imaging evaluation was used for the pre- and postoperative assessment of all patients. Apart of radiographs obtained in all cases, 19 patients were also assessed postoperatively with MRI at 3 months (15 of 19 were assessed preoperatively with MRI) and 15 had serial MRI evaluations (6–12 months). The clinical follow-up time of this subgroup of 19 patients ranged from 6 to 27 months. Results: All patients showed clinical signs of union within 12 weeks from the procedure. 3-months MRI showed viability of the bone graft in all cases. At 3 months union was established with plain radiographs in 14 patients; plain MRI showed union in 13 patients but contrast-enhanced MRI revealed union in all cases. Eight patients were considered to have osteonecrosis of the proximal pole intraoperatively: 4 showed proximal pole necrosis with postoperative plain radiographs and 5 of them with plain postoperative MRI. Contrast-enhanced MRI at 3 months showed postoperative reversal of necrotic changes in all 8 scaphoids. Serial MRI at 6 and 12 months, revealed resolution of the bone marrow oedema of the surrounding bones and full graft incorporation in all cases. Conclusions: Contrast-enhanced MRI is able to assess the viability of the proximal pole and to demonstrate the early union after treatment of SN with VBG allowing thus earlier mobilisation

Aims

The evidence demonstrating the superiority of early MRI has led to increased use of MRI in clinical pathways for acute wrist trauma. The aim of this study was to describe the radiological characteristics and the inter-observer reliability of a new MRI based classification system for scaphoid injuries in a consecutive series of patients.