Arch Hand Microsurg.  2019 Mar;24(1):40-49. 10.12790/ahm.2019.24.1.40.

Dorsal Approach for Management of Scaphoid Nonunion

• Choi JH
• Lee YM
• Na KT
• Kang HV
• Lee SH
• Song SW

• KMID: 2440610
• DOI: http://doi.org/10.12790/ahm.2019.24.1.40

Abstract

PURPOSE
To evaluate the clinical and radiological outcomes of scaphoid nonunion patients who had treated by open reduction and internal fixation with iliac bone graft through dorsal approach.
METHODS
We retrospectively reviewed medical records and radiographs of 53 patients who underwent an iliac crest bone graft and internal fixation through dorsal approach for scaphoid nonunion between 2003 and 2017. Bony union was confirmed in radiographs, and scapholunate, radiolunate, posteroanterior, intrascaphoid, and lateral intrascaphoid angles were measured on preoperative and last follow-up radiographs. Functional results were evaluated by range of motion, visual analogue scale, and modified Mayo wrist score.
RESULTS
There were 51 men and 2 women with average age of 31.2 years (range, 13-61 years). The mean time from initial injury to surgery was 16.8 months (range, 3-50 months) and mean follow-up period after the operation was 26.2 months (range, 12-76 months). Fifty of 53 patients (94.3%) showed radiographic union at an average time of 15.1 weeks (range, 8-50 weeks). The mean scapholunate angle was significantly changed from 69.3° preoperatively to 54.0° at last follow-up. The mean radiolunate angle was significantly changed from 14.3° preoperatively to 7.2° at last follow-up. The mean posteroanterior intrascaphoid angle was significantly changed from 33.2° preoperatively to 30.2° at last follow-up. The mean lateral intrascaphoid angle was significantly changed from 42.9° preoperatively to 28.8° at last follow-up.
CONCLUSION
Dorsal approach with iliac bone graft and internal fixation was a reliable method for scaphoid nonunion to achieve bony union with satisfactory clinical and radiological outcomes.

Keyword

Scaphoid; Nonunion; Dorsal approach; Iliac bone graft

MeSH Terms

Female
Follow-Up Studies
Humans
Male
Medical Records
Methods
Range of Motion, Articular
Retrospective Studies
Transplants
Wrist

Figure

• 

  Fig. 1 Surgical approach. (A) Skin incision line of dorsal approach for the exposure of nonunion site of scaphoid. (B) A 3rd and 4th extensor compartment covered by extensor retinaculum was exposed. (C) Interligamentous sparing approach involving the dorsal intercarpal ligament and the dorsal radiocarpal ligament. (D) Interligamentous sparing capsulotomy was used to expose nonunion site.

• 

  Fig. 2 Surgical procedures. (A) The distal radius and the scaphoid was exposed through an interligamentous sparing approach. The K-wire was inserted into the proximal and distal fragments of scaphoid, and the deformity was corrected by a joystick manipulation. Sclerotic border of the nonunion site was removed by a burr. (B) The cancellous bone was packed tightly at nonunion site, and the cortical bone defect was covered with a cover made of the cortical bone. And then headless compression screw was fixed. S: scaphoid, C: capitate, R: radius, Sb: scaphoid bone graft.

• 

  Fig. 3 Representative case of a scaphoid nonunion in 31-year-old patient. (A) Preoperative radiographs show a nonunion of the waist of the scaphoid and humpback deformity. Scapholunate angle is 56°. (B) Preoperative computed tomography scans show a nonunion of the waist of the scaphoid with humpback deformity and bony cyst. Intrascaphoid angle is 67°. (C) Radiographs at 18 months after surgery show complete bone union and no deformity. Scapholunate angle is 51°.

Reference

1. Leslie IJ, Dickson RA. The fractured carpal scaphoid. Natural history and factors influencing outcome. J Bone Joint Surg Br. 1981; 63-B:225–230.

2. Kozin SH. Incidence, mechanism, and natural history of scaphoid fractures. Hand Clin. 2001; 17:515–524.

3. Dunn AW. Fractures and dislocations of the carpus. Surg Clin North Am. 1972; 52:1513–1538.

4. Hove LM. Epidemiology of scaphoid fractures in Bergen, Norway. Scand J Plast Reconstr Surg Hand Surg. 1999; 33:423–426.

5. Dias JJ, Brenkel IJ, Finlay DB. Patterns of union in fractures of the waist of the scaphoid. J Bone Joint Surg Br. 1989; 71:307–310.

6. Cooney WP, Linscheid RL, Dobyns JH. Scaphoid fractures. Problems associated with nonunion and avascular necrosis. Orthop Clin North Am. 1984; 15:381–391.

7. Buijze GA, Ochtman L, Ring D. Management of scaphoid nonunion. J Hand Surg Am. 2012; 37:1095–1100. quiz 1101.

8. Mack GR, Bosse MJ, Gelberman RH, Yu E. The natural history of scaphoid non-union. J Bone Joint Surg Am. 1984; 66:504–509.

9. Ruby LK, Leslie BM. Wrist arthritis associated with scaphoid nonunion. Hand Clin. 1987; 3:529–539.

10. Cooney WP 3rd, Dobyns JH, Linscheid RL. Nonunion of the scaphoid: analysis of the results from bone grafting. J Hand Surg Am. 1980; 5:343–354.

11. Fernandez DL. A technique for anterior wedge-shaped grafts for scaphoid nonunions with carpal instability. J Hand Surg Am. 1984; 9:733–737.

12. Sayegh ET, Strauch RJ. Graft choice in the management of unstable scaphoid nonunion: a systematic review. J Hand Surg Am. 2014; 39:1500–1506.e7.

13. Russe O. Fracture of the carpal navicular. Diagnosis, non-operative treatment, and operative treatment. J Bone Joint Surg Am. 1960; 42-A:759–768.

14. Fisk GR. Carpal instability and the fractured scaphoid. Ann R Coll Surg Engl. 1970; 46:63–76.

15. Lee SK, Byun DJ, Roman-Deynes JL, Model Z, Wolfe SW. Hybrid Russe procedure for scaphoid waist fracture nonunion with deformity. J Hand Surg Am. 2015; 40:2198–2205.

16. Han SH, Lee HJ, Hong IT, Kim U, Lee SJ. Non-structural cancellous bone graft and headless compression screw fixation for treatment of scaphoid waist non-union. Orthop Traumatol Surg Res. 2017; 103:89–93.

17. Gelberman RH, Menon J. The vascularity of the scaphoid bone. J Hand Surg Am. 1980; 5:508–513.

18. Taleisnik J, Kelly PJ. The extraosseous and intraosseous blood supply of the scaphoid bone. J Bone Joint Surg Am. 1966; 48:1125–1137.

19. Kozin SH. Internal fixation of scaphoid fractures. Hand Clin. 1997; 13:573–586.

20. Polsky MB, Kozin SH, Porter ST, Thoder JJ. Scaphoid fractures: dorsal versus volar approach. Orthopedics. 2002; 25:817–819.

21. dos Reis FB, Koeberle G, Leite NM, Katchburian MV. Internal fixation of scaphoid injuries using the Herbert screw through a dorsal approach. J Hand Surg Am. 1993; 18:792–797.

22. Watson HK, Pitts EC, Ashmead D 4th, Makhlouf MV, Kauer J. Dorsal approach to scaphoid nonunion. J Hand Surg Am. 1993; 18:359–365.

23. Gereli A, Nalbantoglu U, Sener IU, Kocaoglu B, Turkmen M. Comparison of headless screws used in the treatment of proximal nonunion of scaphoid bone. Int Orthop. 2011; 35:1031–1035.

24. Luchetti TJ, Rao AJ, Fernandez JJ, Cohen MS, Wysocki RW. Fixation of proximal pole scaphoid nonunion with non-vascularized cancellous autograft. J Hand Surg Eur Vol. 2018; 43:66–72.

25. Park JH, Kwak DH, Park JW. Treatment of scaphoid non-union using 2 small diameter (2.2 mm) headless compression screws. J Korean Soc Surg Hand. 2017; 22:180–188.

26. Dias JJ. Definition of union after acute fracture and surgery for fracture nonunion of the scaphoid. J Hand Surg Br. 2001; 26:321–325.

27. Slutsky DJ. Outcomes assessment in wrist surgery. J Wrist Surg. 2013; 2:1–4.

28. Kawamura K, Chung KC. Treatment of scaphoid fractures and nonunions. J Hand Surg Am. 2008; 33:988–997.

29. Pinder RM, Brkljac M, Rix L, Muir L, Brewster M. Treatment of scaphoid nonunion: a systematic review of the existing evidence. J Hand Surg Am. 2015; 40:1797–1805.e3.

30. Hackney LA, Dodds SD. Assessment of scaphoid fracture healing. Curr Rev Musculoskelet Med. 2011; 4:16–22.

31. Kang HJ, Lee SH, Song KW, Hahn SB, Kang ES. Retrograde Herbert screw fixation in treatment of nonunion of proximal scaphoid fractures. J Korean Soc Surg Hand. 2002; 7:8–14.

32. Lee SH, Oh JS, Seo CH, Kim YJ. Scaphoid nonunion: Herbert screw fixation through dorsal approach. J Korean Soc Surg Hand. 2013; 18:49–58.

33. Vender MI, Watson HK, Wiener BD, Black DM. Degenerative change in symptomatic scaphoid nonunion. J Hand Surg Am. 1987; 12:514–519.

34. Nagle DJ. Scaphoid nonunion. Treatment with cancellous bone graft and Kirschner-wire fixation. Hand Clin. 2001; 17:625–629.

35. Lecoq FA, Sébilo A, Bellemère P. The radial approach to the wrist with styloidectomy: a cadaver study. Hand Surg Rehabil. 2017; 36:255–260.

36. Nakamura T, Cooney WP 3rd, Lui WH, et al. Radial styloidectomy: a biomechanical study on stability of the wrist joint. J Hand Surg Am. 2001; 26:85–93.

37. Green DP. The effect of avascular necrosis on Russe bone grafting for scaphoid nonunion. J Hand Surg Am. 1985; 10:597–605.

38. Fernandez DL. Anterior bone grafting and conventional lag screw fixation to treat scaphoid nonunions. J Hand Surg Am. 1990; 15:140–147.