|Year : 2018 | Volume
| Issue : 3 | Page : 388-391
Volar percutaneous screw fixation for scaphoid nonunion
M Gurger1, M Yilmaz1, E Yilmaz1, S Altun2
1 Department of Orthopaedics and Traumatology, Firat University School of Medicine, Elazig, Turkey
2 Department of Plastic Reconstructive and Aesthetic Surgery, Firat University School of Medicine, Elazig, Turkey
|Date of Acceptance||20-Jun-2017|
|Date of Web Publication||09-Mar-2018|
Dr. M Gurger
Department of Orthopaedics and Traumatology, Firat University School of Medicine, Elazig
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Percutaneous screw fixation is widely used in acute fractures of the scaphoid. In this study, we aimed to present our results with volar percutaneous screw fixation in patients with scaphoid nonunions. Methodology: A total of 12 patients with scaphoid nonunion (≥13 weeks) that underwent volar percutaneous screw fixation were evaluated retrospectively. Two of the patients were female, and 10 were male. Mean age was 27 years (range = 19–41). The mean time that elapsed between the fracture and surgical procedure was 7.5 months (range = 4–12). According to the anatomic location, 33.3% were proximal pole, and 67.7% were waist fractures. All of the patients underwent percutaneous fixation with a headless cannulated screw from volar part under fluoroscopic guidance. Clinical evaluation was performed according to the modified mayo wrist scoring system (MMWS). The absence of a radiolucent fracture line on the radiographs was considered “union” on radiological evaluation. Results: The mean follow-up time was 18 weeks (range = 8–36). Union was achieved in all patients (91.6%), except one. The mean time to union was 15.5 weeks (range = 8–30). Based on MMWS system, 8 patients were interpreted as excellent, 3 patients as good. Conclusion: Percutaneous fixation in appropriate patients provides satisfactory results with high union and minimal complication rates in scaphoid nonunions.
Keywords: Nonunion, percutaneous fixation, scaphoid, volar
|How to cite this article:|
Gurger M, Yilmaz M, Yilmaz E, Altun S. Volar percutaneous screw fixation for scaphoid nonunion. Niger J Clin Pract 2018;21:388-91
| Introduction|| |
Scaphoid fractures tend to cause healing problems such as nonunion and avascular necrosis. Having a poor blood supply, being covered mostly by cartilage and surrounded by synovial fluid create a negative environment for fracture healing. In addition, scaphoid fractures are very unstable fractures as they form a connection between the proximal and distal carpal bones.
Casting in the treatment of scaphoid fractures is currently less favored due to longer immobilization required, failure to provide a stable fixation alone, and particularly reported high-failure ratio in displaced fractures. Open reduction and internal fixation are the standard treatment of displaced acute scaphoid fractures. This method is also a preferred method for the treatment of nonunions. Although open surgery has many advantages such as direct observation of the fracture line, revitalization of the fracture ends, correction of deformities, and allowing grafting in necessary cases, stripping the soft tissue around the bone may devitalize the bone and may cause additional problems.
Volar percutaneous screw fixation is a commonly used method in the treatment of nondisplaced or minimally displaced acute scaphoid fractures and high union rates, low complication rates, and excellent functional results were obtained with this method.,,
The treatment of scaphoid nonunions requires careful preoperative assessment and planning, and the purpose of the treatment is ensuring reduction and a stable fixation without compromising blood supply. To achieve these goals, volar or dorsal percutaneous screw fixation methods that can be combined with arthroscopic techniques and allow biological grafting have been developed., In addition, the percutaneous technique has additional advantages, such as protection of the carpal ligaments and causing less scarring of tissues.
In this study, we present the radiological and clinical results of scaphoid nonunions that were treated by percutaneous screw fixation.
| Methodology|| |
A total of 12 patients with scaphoid nonunion (≥13 weeks) that underwent volar percutaneous screw fixation between 2010 and 2015 were evaluated retrospectively. Volar percutaneous fixation was performed in patients without cystic degeneration, avascular necrosis, osteoarthritis, and more than 1 mm displacement and sclerosis on preoperative radiological images. Patients had never been operated before. Patients underwent preoperative posteroanterior, lateral, semi-pronated oblique radiographs, computed tomography, and magnetic resonance imaging (MRI) of the affected wrist. Fracture location, displacement, and lateral intrascaphoid angle were determined by computed tomography. The viability of the proximal part was determined by MRI.
Surgery was performed under general anesthesia or regional anesthesia. C– arm fluoroscopy was used to determine the axis of the scaphoid and the entry point of the guide wire before proceeding with surgery. Under fluoroscopic guidance, the guide wire of headless cannulated screw was advanced through volar entry point along the longitudinal axis of the scaphoid to pass the fracture line [Figure 1]. A guide wire that is same in length as the first wire was used to determine the appropriate screw length. An antirotation guidewire was positioned to allow drilling in scaphoid in parallel to the first wire. An approximately 0.5 cm skin incision was made at the entry point of the first wire to permit the passage of the drill and the screw. After blunt dissection with a hemostat, the scaphoid was drilled over the guide wire. A 3.3 mm screw was inserted over the guide wire, and the final screw position was checked by fluoroscopy. Then, the guide wire and antirotation wire were removed, and skin incision was closed. Short-arm circular cast including the thumb was applied. After 3 weeks, cast was removed and exercises were started. Patients were called for follow-up by 15-day periods, and union was evaluated by radiographs. The absence of pain over the scaphoid bone by palpation and presence of callus in at least three cortices on radiographs was defined as union. Patients in whom radiographic features were inconclusive were further evaluated with computed tomography.
|Figure 1: Twenty-year-old male patient, right scaphoid nonunion (15 weeks); (a) Preoperative radiograph of scaphoid nonunion, (b) Preoperative magnetic resonance imaging, (c and d) Intraoperative views (e) postoperative (4 months) posteroanterior and (f) lateral radiographs|
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Grip strength, wrist motion range of motion (ROM), and modified mayo wrist score (MMWS) were used in the clinical evaluation. Grip strength was measured using a dynamometer while the elbow was flexed to 90 degrees with the forearm in the neutral position. Wrist ROMs (extension and flexion) were measured using a goniometer. Postoperative osteoarthritis and osteonecrosis were evaluated radiologically.,
| Results|| |
Two of the patients were female, and 10 were male. Mean age was 27 years (range = 19–41). Four patients (33%) had scaphoid fracture of the right wrist, and eight patients (67%) had scaphoid fracture of the left wrist. The mean time that elapsed between the fracture and surgical procedure was 7.5 months (range = 4–12). On physical examination, all of the patients had tenderness on palpation and during wrist extension. Nearly 58.3% of the fractures were horizontal oblique, and 42.7% were transverse. According to the anatomic location, 33.3% were proximal pole and 67.7% were waist fractures. The mean lateral intrascaphoid angle was measured as 30° (range = 25°–35°). None of the patients had perioperative complications. During the postoperative follow-up period, stiffness or complex regional pain syndrome in the fingers was observed in none of the patients. The mean follow-up time was 18 weeks (range = 8–36). Union was achieved in all patients (91.6%), except one. The patient with nonunion then underwent grafting with nonvascularized bone graft and union was achieved at 10 weeks. This patient was excluded from this study while the clinical outcomes of the patients were evaluated. The mean time to union was 15.5 weeks (range = 8–30). The mean flexion of the wrist of patients at the last control was 68° ± 3°, extension was 66° ± 3°, radial deviation was 20° ± 2°, and ulnar deviation was 24° ± 2°. The mean grip strength was found to be 35 ± 2 kg. The mean MMWS was 95 ± 5 points. Based on MMWS system, 8 patients were interpreted as excellent, 3 patients as good. Wound infection or Sudeck's atrophy was not observed in any of the patients. The mean time to return to preoperative level of activity was found to be 12 weeks (range = 8–18). Postoperative osteoarthritis or scaphoid osteonecrosis was not observed in any of the patients.
| Discussion|| |
There are many studies arguing that scaphoid nonunions can heal only with rigid fixation in appropriate cases.,,,,,, The arrest of union in the early stages due to micromotions cause fibrous union, and union can be achieved if micro motions are prevented with rigid fixation. Cosio and Camp applied multiple pinning with 2 or 4 wires without using bone graft in symptomatic scaphoid nonunions, immobilized the wrist until union was observed and achieved union in 77% of the patients. Slade et al. fixed fifteen scaphoid nonunions under arthroscopic guidance with percutaneous screws without using bone grafts and achieved radiographic and clinical improvement in 14 weeks. Mahmoud and Koptan fixed 27 scaphoid nonunions with percutaneous screws without bone grafts and identified union in all patients in a mean time of 11.6 weeks. In our case, series that we applied percutaneous fixation without using bone graft, radiological, and clinical union were achieved in 11 (91.6%) of 12 patients in a mean time of 15.5 weeks (range = 8–30).
Factors such as the patient's age, degree of deformity, and the presence of secondary arthritis should be considered when surgery is decided in scaphoid nonunions. According to Herbert classification, the presence of well-circumscribed fibrous union that does not cause deformation of the scaphoid is defined as stable nonunion. The unstable nonunions are almost always accompanied by carpal collapse. Slade and Dodds have defined a classification for scaphoid nonunions. This classification is especially important for the applicability of minimally invasive procedures. Minimally invasive surgery has been proposed, especially for nonunions that have no cystic bone resorption, no deformity, and no signs of avascular necrosis in the proximal pole. These criteria were considered in inclusion of patients in our study.
Shah and Jones analyzed the prognostic factors that may influence the outcome of 50 patients with scaphoid nonunion that was treated with Herbert screws and determined avascular necrosis and previous surgery for nonunion as poor prognostic factors. We recruited our patients by taking these poor prognostic factors into account, so none of our patients had avascular necrosis preoperatively and none had been operated before.
Open surgery has some obvious advantages such as direct observation of the fracture line and allowing grafting in necessary cases. However, radiocarpal ligaments, especially radioscaphocapitate and radioscapholunate ligaments, might be injured and iatrogenic instability can occur consequently. Therefore, especially in patients with stable scaphoid non-union, percutaneous screw fixation is an appropriate treatment option.
| Conclusion|| |
Volar percutaneous screw fixation in scaphoid nonunions yields satisfactory results with high union rates, rapid functional recovery, and minimal complications in appropriate patients.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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