Arthroscopic bone graft and fixation for proximal scaphoid nonunions

Abstract

Aims This study aims to report the outcomes in the treatment of unstable proximal third scaphoid nonunions with arthroscopic curettage, non-vascularized bone grafting, and percutaneous fixation. Methods This was a retrospective analysis of 20 patients. All cases were delayed presentations (n = 15) or failed nonoperatively managed scaphoid fractures (n = 5). Surgery was performed at a mean duration of 27 months (7 to 120) following injury with arthroscopic debridement and arthroscopic iliac crest autograft. Fracture fixation was performed percutaneously with Kirschner (K)-wires in 12 wrists, a headless screw in six, and a combination of a headless screw and single K-wire in two. Clinical outcomes were assessed using grip strength, patient-reported outcome measures, and wrist range of motion (ROM) measurements. Results Intraoperatively, established avascular necrosis of the proximal fragment was identified in ten scaphoids. All fractures united within 16 weeks, confirmed by CT. At a mean follow-up of 31 months (12 to 64), there were significant improvements in the Patient-Rated Wrist Evaluation, Mayo Wrist Score, abbreviated Disabilities of the Arm, Shoulder and Hand score, wrist ROM, grip strength, and the patients’ subjective pain score. No peri- or postoperative complications were encountered. Conclusion Our data indicate that arthroscopic bone grafting and fixation with cancellous autograft is a viable method in the treatment of proximal third scaphoid nonunions, regardless of the vascularity of the proximal fragment. Cite this article: Bone Joint J 2022;104-B(8):946–952.

Arthroscopic Bone Grafting and Robot‐assisted Fixation for Scaphoid Nonunion

“…Wong and Ho 18 defined the lack of punctate bleeding of the proximal scaphoid fragment as avascular necrosis but they were still able to achieve 81.8% union rate in such patients. Similarly, this finding was also supported by other reports in the literature, 19,[35][36][37] and presence of scaphoid proximal pole avascularity did not appear to correlate with fracture healing potential. 35,38…”

“…Follow-up Assessment All the patients were followed up at regular intervals with serial radiographic imaging to confirm bony union. Standard scaphoid X-rays were taken at 4-week intervals to monitor the progress of graft incorporation and fracture union 19 and eventual bony union was confirmed by CT imaging. At the final follow-up, the bilateral wrists' range of motion (ROM) and grip strength were measured.…”

“…Non‐vascularized bone grafts with internal fixation are reported to have an 88% union rate for scaphoid nonunion, 15 however open surgery theoretically does additional damage to important structures such as the joint capsule, ligaments, and potentially threatens the already tenuous blood supply 16,17 . Arthroscopic bone grafting (ABG) allows for a minimally invasive (MIS) surgical approach and also achieves satisfactory clinical outcomes for scaphoid nonunion 18,19 . Another issue to highlight is that accurate fixation of scaphoid fractures can be technically demanding under fluoroscopy, 20 and suboptimal placement of implants can occur even for experienced hand surgeons.…”

360-degree Arthroscopic Management of Scaphoid Pseudarthrosis: Description of Technique and Indications

“…For this reason, some authors have already described the use of portals located in the volar and radial regions in the treatment of scaphoid pathologies, although always in isolation and adjuvant to dorsal portals. 15,18,24,25 Golubev 26 showed the use of the volar portal, located between the flexor carpi radialis tendon and the radial artery, to obtain scaphoid elongation in his arthroscopic technique for the treatment of SPA without compression of the site of the injury. He even emphasized that with the use of an accessory volar portal, correction of the scaphoid deformity is achieved in a more effective, safe, and predictable way.…”

“…With technical improvement, volar and radial portals were described to compensate for limitations found in visualization through dorsal portals, with the access and repair of dorsal structures that are inaccessible through dorsal portals being our main purpose. For this reason, some authors have already described the use of portals located in the volar and radial regions in the treatment of scaphoid pathologies, although always in isolation and adjuvant to dorsal portals 15,18,24,25 . Golubev 26 showed the use of the volar portal, located between the flexor carpi radialis tendon and the radial artery, to obtain scaphoid elongation in his arthroscopic technique for the treatment of SPA without compression of the site of the injury.…”