Scaphoid non union- by Hussain Algawahmed
- 1. Scaphoid Non-Union Hussain Algawahmed, MD, FRCSC
- 2. Sources
- 3. Case Scenario • A 18 year old presents with wrist pain. Pain has been persistent since a “wrist sprain” approximately 1 year ago. • Physical examination reveals tenderness in the anatomical snuffbox. • Radiographs confirm an established scaphoid nonunion
- 4. Top 5 Questions 1. What is the natural history of scaphoid nonunions? 2. What factors increase the risk of developing a scaphoid nonunion? 3. What are the operative options for scaphoid nonunions? 4. Are there any modalities that can improve union rates? 5. Which salvage procedures offer the best results for scaphoid nonunion advanced collapse?
- 5. What is the natural history? • Current opinion: – Scaphoid nonunions follow a predictable pattern of arthritis and carpal collapse, generally within 10 years after fracture.
- 6. What is the natural history?
- 7. What is the natural history?
- 8. What is the natural history? • Quality of the evidence – Level IV • 7 retrospective reviews with methodologic limitations • 1 systematic review with methodologic limitations
- 9. What is the natural history? • Findings: – Patients with scaphoid nonunions, regardless of symptoms, can expect to develop a predictable pattern of carpal degeneration – Factors that correlate with earlier progression: • Displacement of the nonunion • Carpal instability (DISI) • Time from injury • Mack GR, Bosse MJ, Gelberman RH, Yu E. The natural history of scaphoid non-union. J Bone Joint Surg Am 1984;66(4): 504–9 • Inoue G, Sakuma M. The natural history of scaphoid non-union. Radiographical and clinical analysis in 102 cases. Arch Orthop Trauma Surg 1996;115(1):1–4.
- 10. DISI vs VISI
- 11. DISI
- 12. Which factors increase the risk? • Current Opinion: – Proximal pole fractures – Displaced fractures – Delay to intervention – Associated carpal instability – Smoking
- 13. Which factors increase the risk? • Quality of the evidence – Level IV – 5 lower-quality retrospective reviews and case series with methodological limitations
- 14. Which factors increase the risk? • Fracture Location: – Proximal pole nonunion up to 75% – Waist 15% – Distal pole 2% • Sauerbier M GG, Dacho A. Current concepts in the treatment of scaphoid fractures. Eur J Trauma 2004;30:80–92 • Merrell GA, Wolfe SW, Slade JF, 3rd. Treatment of scaphoid nonunions: quantitative meta-analysis of the literature. J Hand Surg Am 2002;27(4):685–91
- 15. Which factors increase the risk?
- 16. Which factors increase the risk? • Fracture displacement: – Gap of 1 mm or more – Scapholunate > 60 – Radiolunate > 15 – Intrascaphoid angle > 35 degrees
- 18. Patterns of displacement • Volar: – More distal waist fractures – Humpback deformity – DISI • Dorsal: – More proximal waist fractures – Dorsal rim arthritis
- 20. Types of Waist Fractures
- 21. Which factors increase the risk? • Fracture displacement: – Gap of 1 mm or more – Scapholunate > 60 – Radiolunate > 15 – Intrascaphoid angle > 35% • These lead to humpback deformity and increase the nonunion rate to 50% and AVN rate to 55% • Dabezies EJ MR, Faust DC. Injuries to the carpus: Fractures of the scaphoid. Orthopedics 1982;5:1510–15. • Leslie IJ, Dickson RA. The fractured carpal scaphoid. Natural history and factors influencing outcome. J Bone Joint Surg Br 1981;63(2):225–30. • Szabo RM, Manske D. Displaced fractures of the scaphoid. Clin Orthop Relat Res 1988;230:30–8.
- 22. Which factors increase the risk? • Delay in treatment: – delaying immobilization > 4 weeks is a significant risk factor for progression to nonunion – Langhoff O, Andersen JL. Consequences of late immobilization of scaphoid fractures. J Hand Surg Br 1988;13(1):77–9.
- 23. Which factors increase the risk?• Patient factors: • smokers are 3 times more likely to have persistent nonunions after autologous bone grafting and internal fixation • Female gender and DISI also increase the risk of nonunion • Dinah AF, Vickers RH. Smoking increases failure rate of operation for established non-union of the scaphoid bone. Int Orthop 2007;31(4):503–5. • Steinmann SP, Adams JE. Scaphoid fractures and nonunions: diagnosis and treatment. J Orthop Sci 2006;11(4):424– 31.
- 24. What operative options are available? • Current opinion – Nonvascularized bone grafting is sufficient for the majority of scaphoid nonunions; however, proximal pole nonunions or those with associated AVN are usually treated with vascularized bone grafting.
- 25. What operative options are available? • Quality of the evidence • Level I: – prospective randomized trial with methodologic limitations • Level III: – 9 retrospective comparative study with methodologic limitations – 1 case-control study with methodologic limitations – 2 systematic review of uncontrolled comparative studies and case series • Level IV – 75 prospective and retrospective case series with methodologic limitations
- 26. What operative options are available? • Source of cancellous BG? – no significant differences between ICBG and grafts harvested at the dorsal distal radius • Tambe AD, Cutler L, Stilwell J, Murali SR, Trail IA, Stanley JK. Scaphoid non-union: the role of vascularized grafting in recalcitrant non-unions of the scaphoid. J Hand Surg 2006;31B:185–190.
- 27. What operative options are available? • Vascularized BG – 1979 Hori technique: superficial radial artery – 1988 Kawai-Yamamuto: volar PQ pedicle – 1991 Zaidemberg: 1,2 ICSRA • Wide variation in the reported success rate • Free vascularized BG: – Medial femoral epicondyle or Iliac Crest vascularized BG
- 30. What operative options are available? • Vascularized vs nonvascularized? – Braga-Silva et al (2008) – RCT; 35 had 1,2 ICSRA and 45 had NVBG – There were no significant differences between the groups in union rates, time to union, and functional results
- 31. What operative options are available? • Source of the Vascularized Graft? – Retrospective series (22 patients) – DR pedicle vascularized grafts 40% – Vascularized medial femoral condyle grafts 100% • Jones DB Jr BH, Bishop AT, Shin AY. Treatment of scaphoid waist nonunions with an avascular proximal pole and carpal collapse. A comparison of two vascularized bone grafts. J Bone Joint Surg Am 2008;90:2616–25.
- 33. What operative options are available? • Nonunion with AVN of the proximal pole? • 89.1% vascularized grafting – 72.5% nonvascularized bone graft – Ribak S, Medina CE, Mattar R, Jr., Ulson HJ, de Resende MR, Etchebehere M. Treatment of scaphoid nonunion with vascularised and nonvascularised dorsal bone grafting from the distal radius. Int Orthop 2010;34(5):683–8. – 88% vs. 47% – Merrell GA, Wolfe SW, Slade JF, 3rd. Treatment of scaphoid nonunions: quantitative meta-analysis of the literature. J Hand Surg Am 2002;27(4):685–91.
- 35. What operative options are available? • Method of fixation? – Meta-analysis of 127 patients – K-wires 77% – Compression Screws 94% • Merrell GA, Wolfe SW, Slade JF, 3rd. Treatment of scaphoid nonunions: quantitative meta- analysis of the literature. J Hand Surg Am 2002;27(4):685–91
- 36. Internal fixation w/o Grafting • What about stable, well aligned fracture? Slade et al (2003): – Case series 15 patients – Percutaneous fixation – 100% union at 14 weeks – Slade JF III, Geissler WB, Gutow AP, Merrell GA. Percutaneous internal fixation of selected scaphoid nonunions with an arthroscopically assisted dorsal approach. J Bone Joint Surg 2003;85A(Suppl 4):20 –32.
- 37. Are there any modalities that can improve union rates? • Current opinion – The efficacy of pulsed electromagnetic field stimulation and/or ultrasound lacks sufficient evidence in the literature to support its widespread use
- 38. Are there any modalities that can improve union rates? • Quality of the evidence • Level I – 1 randomized double-blind controlled study with methodologic limitations • Level IV – 7 case series with methodologic limitations
- 39. Are there any modalities that can improve union rates? • RCT of 21 scaphoids – vascularized bone graft + low-intensity ultrasound therapy vs. placebo – Healing was accelerated by 38 days Ricardo M. The effect of ultrasound on the healing of musclepediculated bone graft in scaphoid non- union. Int Orthop 2006; 30(2):123–7
- 40. What salvage procedures are available for SNAC? • SNAC 1 scaphoid ORIF +/- styloidectomy • SNAC 3 4 Corner vs. wrist fusion • SNAC 2 PRC vs. 4 corner?
- 42. What salvage procedures are available for SNAC? • Current opinion – Both procedures can successfully relieve pain, but PRC allows for a greater postoperative wrist range of motion while four-corner fusion allows greater recovery of grip strength
- 43. PRC vs. 4 Corner • Quality of the evidence • Level III – 5 retrospective comparative study with methodologic limitations – 1 systematic review with methodologic limitations • Level IV – 44 retrospective reviews and case series with methodologic limitations – 2 biomechanical studies with methodologic limitations
- 44. PRC vs. 4 Corner • Mulford et al: systematic review of 52 articles – No difference in pain relief – No difference in grip strength – Better ROM in PRC – Higher rate of OA in PRC at 10 yrs • Wyrick et al. (1995) – PRC had a significantly higher grip strength and ROM in SLAC wrist - Wyrick JD, Stern PJ, Kiefhaber TR. Motion-preserving procedures in the treatment of scapholunate advanced collapse wrist: proximal row carpectomy versus four-corner arthrodesis. J Hand Surg Am 1995;20(6):965–70. - Mulford JS, Ceulemans LJ, Nam D, Axelrod TS. Proximal row carpectomy vs four corner fusion for scapholunate (Slac) or scaphoid nonunion advanced collapse (Snac) wrists: a systematic review of outcomes. J Hand Surg Eur 2009;34(2):256–63
- 45. Thank you!