Scaphoid nonunion

SCAPHOID NONUNION

ISSH MONTHLY MEETINGFarivar Lahiji M.D

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• Goal of treatment : consolidation of fracture in anatomical alignment

• Failure of union leads to predictable arthritis

Classification

• Slade and Geissler• 1-(1) early nonunion without substantial

bone resorption– Grade I: fibrous union, minimal

sclerosis(<1mm)Late presentation(>4 weeks)– Grade II fibrous union apparently united in

xray, but is symptomatic– Grade III minimal resorption, minimal

sclerosis(<2mm)

• (2) chronic nonunion with substantial bone resorption– Grade IV: well perfused, substantial

bone loss(2-5mm)– Grade V: well perfused , substantial

bone loss (5-10)– Grade VI: pseudoarthrosis W/O AVN

Special circumstances

• Proximal pole, AVN, humpback– ORIF + Tricortical BG– Vascularized Bone graft• More surgical dissection• Generous capsulotomy• Non-rigid fixation (often)

Matti-Russe• Well aligned

Scaphoid segments• Contraindication:– OA– Proximal pole with

AVN– Dorsal instability– Large cyst

Pedicle bone graft

Vascularized Bone Grafting

• Local– 1, 2 IC SRA– Base of the 2nd

metacarpal– P. quadratus based

• Free– Medial femoral condyle– İliac crest

Excision

Proximal Row Carpectomy

• Advanced SNACK• Salvage procedure• Motion preserved

50-60%• Short period of

immobilization• Grip strength 70-

80%• Old patient

Intercarpal fusion• Stabilized

midcarpal joint • Capitate, hamate,

triquetrum, lunate fusion +excision scaphoid

Procedure pearls• Adequate

decortications of the joints

• Proper apposition• Proper fixation(rigid)• Correction of the

extension of lunate• Post op immobilization•

STT fusion

Denervation

Indication

• When traditional, nonopertaive, musculoskeletal approaches fail, the surgical approaches may require joint fusion or replacement arthroplasty

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History

• J. Geldmacher• 1972 (hand clinic)• 85% satisfactory reduction of

pain

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History

• Dieter Buck-Gramcko• 1977 ( JHS)• 69% complete absence of pain

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When you DO/Do not

• SLAC• SNAC• ARTHRITIS• KIENBACH (IV)

• RA• DRFX

Pitfalls• Wrist instability

with clunking• Active inflammatory

arthritis• No useful

movement stiffness• Dystrophic wrist

pain

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Patient Selection

• Local anesthetic blocks with postinjection assessment of pain relief and functional improvement

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Example52-y-o north-sea shore

farmer, the only money maker of the 7-mems. family

Fx scaphoid 10 years PTA

Does not wish to undergo any extensive wrist salvage procedure

Good ROMCC= pain

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Treatment Options

Denervation• Partial

denervation(PIN & AIN)

• Full denervation• PIN denervation

+other procedures

Alternatives• Arthroscopic /open

debridment• Radial

styloidectomy• Partial inter-carpal

arthrodesis• Proximal row

carpectomy• Wrist arthrodesis

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Preoperative Nerve Blockade

• Denervation of the wrist is indicated only after confirmation that blockade of the affected nerve (S) by local anesthetic relieves the symptoms

• 1 ml Marcaine 0.5%

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PIN & AIN

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Surgical Incision

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incisions

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PIN & AIN Denervation

PIN AIN

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P SDUN• Perforating branch

of Ulnar sensory nerve

• Some surgeons do it bluntly by finger

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PCMN

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Recurrent Articular Branch

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Predictive factors

• Vascularity of scaphoid fragment• Site of the fracture• Patient age• Smoking • Previous surgery• Duration of nonunion• Vascularized vs. nonvascularized• Iliac crest vs. distal radius

Fragment ratio

Predictive factors

• TABLE 19-3   -- Distribution of Fractures and Rate of Union by Fracture Site as Determined by Fragment Ratio

Fracture Site No. of Fractures No. United(%) 0.15−0.30 15 4 (27) 0.31−0.45 33 19 (58) 0.46−0.60 48 40 (83) 0.61−0.75 30 27 (90) 

Summary

• Try to get union• Revise if needed• Salvage if moderate-severe

osteoarthritis