Percutaneous screw fixation without bone grafting for established scaphoid nonunion with substantial bone loss

Mahmoud, Mostafa; Koptan, Wael

doi:10.1302/0301-620x.93b7.25418

Cited by 43 publications

(52 citation statements)

References 29 publications

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“…Por otro lado, es importante destacar que, el trabajo presentado, ofrece debilidades: el tamaño muestral, el tiempo exacto de la consolidación, la falta de randomización y/o comparación con un grupo control, la falta de identificación de los verdaderos factores o moduladores de la osteogénesis actuantes en el foco seudoartrósico, y el reconocimiento de que la técnica exige una habilidad quirúrgica apropiada. No obstante, la originalidad en un tema tan controvertido y el resultado de algunas reciente publicaciones 42,44,46,51 genera una apertura a una futura línea de investigación. Los resultados altamente alentadores, las bondades de la cirugía mini invasiva y los beneficios de la asistencia artroscópica son resaltados como fortalezas de la técnica, destacando que no invalida la utilización de otras técnicas ulteriores necesarias ante el fracaso de la misma cumpliendo con el aforismo de "not burn bridges".…”

Section: Discussionunclassified

Arthroscopic Treatment of Scaphoid Pseudoarthrosis without Bone Graft: Is it Really Feasible?

Caloia

Scotti

Fernández³

2020

Revista Iberoamericana de Cirugía de la Mano

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Introduction The current management of scaphoid pseudoarthrosis remains controversial, with a failure rate of up to 40% and no “gold standard” treatment. Based on innovative concepts about the osteogenic potential of cells from scaphoid pseudoarthrosis, encouraging results from increased vascularization by radial and ulnar metaphyseal decompression for Kienböck disease therapy and the advantages of minimal surgical trauma provided by percutaneous and arthroscopic techniques, we analyzed prospective outcomes from scaphoid pseudoarthrosis arthroscopic treatment with no bone graft (ATSPsWBG) to determine its feasibility. Materials and Methods Eighty-four non-union scaphoid prospectively treated for ATSPsWBG were evaluated. Patients had, on average, 32.42 years old. The dominant limb was affected in 77.5% of the cases (65 patients). Mean time from injury to surgical intervention was 20.57 months. Twenty-three fractures were initially treated conservatively with orthopedic cast for an average period of 6.3 weeks, including 17 already immobilized at the time of the visit. All patients were grouped according to the classification proposed by the authors (MC & DF), which is based on perioperative studies. Results Bone consolidation was obtained in 77 cases (91.66%) and documented by computed tomography (CT) scans. Seven cases presented no bone consolidation 9 months after the procedure, and four cases required a new surgery. In cystic pseudoarthrosis, the bone defect was filled with a new bone growth even when the cyst exceeded 10 mm. Single photon emission computerized tomography (SPECT) scans revealed an unique pattern, documenting the biological effect of metaphyseal decompression, which is characterized by increased nonspecific irrigation of the radial column. Average postoperative pain assessed using the visual analog scale was 1.04 (range, 0 to 2). Average postoperative functional range was 65.3° for extension (range, 46° to 88°), 69.2° for flexion (range, 55° to 88°), 10.7° for radial deviation (range, 5° to 20°) and 26° for ulnar deviation (range, 20° to 37°). Average Mayo Clinic score was 95. Conclusion The arthroscopic treatment of scaphoid pseudoarthrosis with no bone graft is recommended in young to middle-aged, non-smokers patients with no scaphoid consolidation, with hemorrhagic peteqchiae (arthroscopic Green’s Sign) at the arthroscopic evaluation and in which a CT scan excluded the presence of an excessive sclerosis focus or revealed a very small proximal bone fragment not suitable for screw placement for stable internal fixation. Our experience proved that this is a reproducible and feasible technique. Level of Evidence IV

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Section: Discussionunclassified

Arthroscopic Treatment of Scaphoid Pseudoarthrosis without Bone Graft: Is it Really Feasible?

Caloia

Scotti

Fernández³

2020

Revista Iberoamericana de Cirugía de la Mano

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“…Other studies of arthroscopically assisted techniques have reported good or excellent union rates and functional results. 16,18,20 Mahmoud and Koptan 11 have reported achieving 100% union rate in 27 patients at a mean of 12 weeks using a percutaneous technique without bone grafting where patients with humpback deformity did not undergo the treatment. The authors found a correlation between the time from injury to surgery and healing time.…”

Section: Discussionmentioning

confidence: 99%

“…The union rate and healing potential with percutaneous [11][12][13][14][15] and arthroscopically assisted [16][17][18][19][20] techniques for the treatment of scaphoid nonunion have not been discussed at length. Indeed, comparative studies of different treatment options are rare in the literature.…”

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confidence: 99%

Arthroscopically Assisted Bone Grafting Reduces Union Time of Scaphoid Nonunions Compared to Percutaneous Screw Fixation Alone

et al. 2019

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Purpose Minimally invasive techniques have been recommended in the treatment of painful but stable scaphoid nonunions. The purpose of this study was to determine if arthroscopically assisted bone grafting provided superior results in healing as compared to percutaneous screw fixation. Materials and Methods One hundred sixty-four consecutive patients with scaphoid nonunions were retrospectively analyzed. One hundred forty-eight patients were treated with the open grafting techniques either with iliac or distal radius bone, leaving 16 patients treated with minimally invasive surgery. In the group treated percutaneously (n = 8), the time from injury to surgery was 2.5 months (range: 2–4 months) and it was 27.3 months (range: 3–180 months) in the arthroscopic group (n = 8). The mean age was 39 years (range: 20–66) in the percutaneous group and 22 years (range: 16–32) in the arthroscopic group. In all cases, the Mini Acutrak headless fully threaded compression screw was used. Healing was assessed clinically and radiographically at a minimum follow-up of 12 weeks, mean 7 months (range: 3–12 months). Data were calculated with two-tailed Mann–Whitney U test based on p-value of < 0.05 that was considered statistically significant. Results We recorded no complications in any of the groups. Patients treated arthroscopically received cancellous bone grafting from the distal radius and all patients but one healed at a median of 7.8 weeks (range: 5–18 weeks). Seven patients in the percutaneous group healed at a mean of 10.5 weeks (range: 7–24 weeks), thus leaving one patient from each group without achieving union. Mann–Whitney U test showed the U value of 11, the critical value of U to be 13 (p < 0.05), thus significantly faster healing was observed in the arthroscopically treated group. Conclusions Arthroscopically treated patients achieved faster healing despite shorter time to surgery in the percutaneous group. Local bone grafting is considered as the main reason for this outcome. Younger population in the arthroscopically treated group may have influenced the result. Level of Evidence This is a Level III comparative study.

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“…10 Interestingly, Mahmoud and Koptan suggested that bone grafting might not be necessary even in grade IV and V nonunions, as evidenced by their series of 27 patients who all healed with volar percutaneous cannulated screw fixation alone. 20 With a mean follow-up of 24.6 months, they reported fracture union at a mean of 11.6 weeks as confirmed by CT scan. To our knowledge, no studies have examined the effect of repeated drilling and autograft packing on autograft distribution within the scaphoid.…”

Section: Is Repeated Drilling and Graft Packing A Safe Technique Thatmentioning

confidence: 90%

Drill and Fill Technique for the Treatment of Scaphoid Delayed Unions and Nonunions

Lee

Uppuganti

et al. 2019

Jnl Wrist Surg

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Background This article reviews the results of a surgical technique using three iterations of drilling, autologous cancellous bone grafting (filling), and use of an intraosseous compression screw for the treatment of nondisplaced or minimally displaced scaphoid delayed unions or nonunions. Methods Part 1—Cadaveric study: Three cadaveric scaphoids underwent stained cancellous bone graft packing and headless cannulated compression screw placement using a single iteration of drilling and graft packing. Three additional scaphoids were allocated to the triple “drill and fill” group, and underwent three iterations of drilling and graft packing before screw insertion. Graft particle distribution on mid-sagittal sections was assessed under fluorescence microscopy. Comparison of normalized areas between the single and triple “drill and fill” groups was performed using repeated measures ANOVA and Tukey's post hoc test.Part 2—Clinical study: Twelve patients with minimally displaced scaphoid delayed unions and nonunions treated between April 2007 and December 2013 with the triple “drill and fill” technique were included. The average follow-up was 60.4 weeks. Two fellowship-trained musculoskeletal radiologists independently reviewed images for fracture healing. Results By the histomorphometric analysis, there was improved autograft distribution along the screw tract, particularly within the proximal pole, with three iterations of drilling and filling. Clinically, 11 of 12 delayed unions and nonunions had healed. Conclusion Our results support the use of the “drill and fill” technique as an option for the treatment of select nondisplaced or minimally displaced scaphoid nonunions and delayed unions at the waist without avascular necrosis of the proximal pole. Level of Evidence This is a Level IV study.

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Percutaneous screw fixation without bone grafting for established scaphoid nonunion with substantial bone loss

Cited by 43 publications

References 29 publications

Arthroscopic Treatment of Scaphoid Pseudoarthrosis without Bone Graft: Is it Really Feasible?

Arthroscopic Treatment of Scaphoid Pseudoarthrosis without Bone Graft: Is it Really Feasible?

Arthroscopically Assisted Bone Grafting Reduces Union Time of Scaphoid Nonunions Compared to Percutaneous Screw Fixation Alone

Drill and Fill Technique for the Treatment of Scaphoid Delayed Unions and Nonunions

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