Angular Stable Miniplate Fixation of Chronic Unstable Scaphoid Nonunion
12 December 2016
17 April 2017
10 May 2017 (eFirst)
Background Around 5 to 15% of all scaphoid fractures result in nonunion. Treatment of long-lasting scaphoid nonunion remains a challenge for the treating surgeon. Healing of scaphoid nonunion is essential for prevention of scaphoid nonunion advanced collapse and the subsequent predictable pattern of radiocarpal osteoarthritis.
Purpose The purpose of this study was to investigate the feasibility of fixation of the scaphoid nonunion with a volar angular stable miniplate and cancellous bone grafting. We hypothesized that this technique could be successful, even in patients with previous surgery for nonunion and in patients with a long duration of nonunion.
Patients and Methods A total of 21 patients enrolled in a single-center prospective cohort study. Healing of nonunion was assessed on multiplanar computed tomography scan of the wrist at a 3-month interval. Functional outcome was assessed by measuring grip strength, range of motion, and by means of the patient-rated wrist and hand evaluation (PRWHE) questionnaire.
Results During follow-up, 19 out of 21 patients (90%) showed radiological healing of the nonunion. The range of motion did not improve significantly. Postoperative PRWHE scores decreased by 34 points. Healing occurred regardless of the length of time of the nonunion (range: 6–183 months) and regardless of previous surgery (38% of patients).
Conclusion Volar angular stable miniplate fixation with autologous cancellous bone grafting is a successful technique for the treatment of chronic unstable scaphoid nonunion, even in patients with long-lasting nonunion and in patients who underwent previous surgery for a scaphoid fracture. Rotational interfragmentary stability might be an important determining factor for the successful treatment of unstable scaphoid nonunion.
Level of Evidence Level IV.
- 1 Hove LM. Epidemiology of scaphoid fractures in Bergen, Norway. Scand J Plast Reconstr Surg Hand Surg 1999; 33 (04) 423-426
- 2 Clementson M, Jørgsholm P, Besjakov J, Björkman A, Thomsen N. Union of scaphoid waist fractures assessed by CT scan. J Wrist Surg 2015; 4 (01) 49-55
- 3 Leslie IJ, Dickson RA. The fractured carpal scaphoid. Natural history and factors influencing outcome. J Bone Joint Surg Br 1981; 63-B (02) 225-230
- 4 Eastley N, Singh H, Dias JJ, Taub N. Union rates after proximal scaphoid fractures; meta-analyses and review of available evidence. J Hand Surg Eur Vol 2013; 38 (08) 888-897
- 5 Singh HP, Taub N, Dias JJ. Management of displaced fractures of the waist of the scaphoid: meta-analyses of comparative studies. Injury 2012; 43 (06) 933-939
- 6 Grewal R, Suh N, Macdermid JC. Use of computed tomography to predict union and time to union in acute scaphoid fractures treated nonoperatively. J Hand Surg Am 2013; 38 (05) 872-877
- 7 McLaughlin HL. Fracture of the carpal navicular (scaphoid) bone; some observations based on treatment by open reduction and internal fixation. J Bone Joint Surg Am 1954; 36-A (04) 765-774
- 8 Herbert TJ, Fisher WE. Management of the fractured scaphoid using a new bone screw. J Bone Joint Surg Br 1984; 66 (01) 114-123
- 9 Daly K, Gill P, Magnussen PA, Simonis RB. Established nonunion of the scaphoid treated by volar wedge grafting and Herbert screw fixation. J Bone Joint Surg Br 1996; 78 (04) 530-534
- 10 Filan SL, Herbert TJ. Herbert screw fixation of scaphoid fractures. J Bone Joint Surg Br 1996; 78 (04) 519-529
- 11 Braun C, Gross G, Bühren V. Osteosynthesis using a buttress plate--a new principle for stabilizing scaphoid pseudarthroses [in German]. Unfallchirurg 1993; 96 (01) 9-11
- 12 Huene DR, Huene DS. Treatment of nonunions of the scaphoid with the Ender compression blade plate system. J Hand Surg Am 1991; 16 (05) 913-922
- 13 Ghoneim A. The unstable nonunited scaphoid waist fracture: results of treatment by open reduction, anterior wedge grafting, and internal fixation by volar buttress plate. J Hand Surg Am 2011; 36 (01) 17-24
- 14 Dodds SD, Patterson JT, Halim A. Volar plate fixation of recalcitrant scaphoid nonunions with volar carpal artery vascularized bone graft. Tech Hand Up Extrem Surg 2014; 18 (01) 2-7
- 15 Bain GI, Turow A, Phadnis J. Dorsal Plating of Unstable Scaphoid Fractures and Nonunions. Tech Hand Up Extrem Surg 2015; 19 (03) 95-100
- 16 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 [Br] 2006; 31 (02) 185-190
- 17 Fox MG, Wang DT, Chhabra AB. Accuracy of enhanced and unenhanced MRI in diagnosing scaphoid proximal pole avascular necrosis and predicting surgical outcome. Skeletal Radiol 2015; 44 (11) 1671-1678
- 18 Hoang-Kim A, Pegreffi F, Moroni A, Ladd A. Measuring wrist and hand function: common scales and checklists. Injury 2011; 42 (03) 253-258
- 19 Sanders WE. Evaluation of the humpback scaphoid by computed tomography in the longitudinal axial plane of the scaphoid. J Hand Surg Am 1988; 13 (02) 182-187
- 20 Singh HP, Forward D, Davis TR, Dawson JS, Oni JA, Downing ND. Partial union of acute scaphoid fractures. J Hand Surg [Br] 2005; 30 (05) 440-445
- 21 Matti H. Uber die behandlung der navicularfracture und der refractura patellae durch Plombierung mit Spongiosa [in German]. Zentralbl Chir 1937; 64: 2353-2359
- 22 Russe O. Fracture of the carpal navicular. Diagnosis, non-operative treatment, and operative treatment. J Bone Joint Surg Am 1960; 42-A: 759-768
- 23 Tambe ADCL, Cutler L, Murali SR, Trail IA, Stanley JK. In scaphoid non-union, does the source of graft affect outcome? Iliac crest versus distal end of radius bone graft. J Hand Surg [Br] 2006; 31 (01) 47-51
- 24 Zarezadeh A, Moezi M, Rastegar S, Motififard M, Foladi A, Daneshpajouhnejad P. Scaphoid nonunion fracture and results of the modified Matti-Russe technique. Adv Biomed Res 2015; 4: 39 . Doi: 10.4103/2277-9175.151248
- 25 Kołodziej RKBJ, Blacha J, Bogacz A, Mazurkiewicz T. Long-term outcome of scaphoid nonunion treated by the Matti-Russe operation. Ortop Traumatol Rehabil 2006; 8 (05) 507-512
- 26 Payatakes A, Sotereanos DG. Pedicled vascularized bone grafts for scaphoid and lunate reconstruction. J Am Acad Orthop Surg 2009; 17 (12) 744-755
- 27 Kawai H, Yamamoto K. Pronator quadratus pedicled bone graft for old scaphoid fractures. J Bone Joint Surg Br 1988; 70 (05) 829-831
- 28 Mathoulin C, Haerle M. Vascularized bone graft from the palmar carpal artery for treatment of scaphoid nonunion. J Hand Surg [Br] 1998; 23 (03) 318-323
- 29 Christodoulou LS, Kitsis CK, Chamberlain ST. Internal fixation of scaphoid non-union: a comparative study of three methods. Injury 2001; 32 (08) 625-630
- 30 Croutzet P, Ferreira B, Gaston-Nouvel A. , et al. Benefits of a double antirotation screw fixation performed with arthroscopy for scaphoid fractures: A prospective series of 9 cases. J Hand Surg [Br] 2014; 39 (09) 41-42
- 31 Slutsky DJ, Trevare J. Use of arthroscopy for the treatment of scaphoid fractures. Hand Clin 2014; 30 (01) 91-103
- 32 Stanković P, Burchhardt H. [Experience with the Ender hooked plate in the management of 42 scaphoid pseudarthroses]. Handchir Mikrochir Plast Chir 1993; 25 (04) 217-222
- 33 Dodds SD, Halim A. Scaphoid plate fixation and volar carpal artery vascularized bone graft for recalcitrant scaphoid nonunions. J Hand Surg Am 2016; 41 (07) e191-e198
- 34 Elliott DS, Newman KJ, Forward DP. , et al. A unified theory of bone healing and nonunion: BHN theory. Bone Joint J 2016; 98-B (07) 884-891
- 35 Jurkowitsch J, Dall'Ara E, Quadlbauer S. , et al. Rotational stability in screw-fixed scaphoid fractures compared to plate-fixed scaphoid fractures. Arch Orthop Trauma Surg 2016; 136 (11) 1623-1628