SCAPHOID NONUNION

State-of-Art

Ch. MATHOULIN

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Scaphoid Fracture

Between 8 and 40 cases / 100 000

inhabitants
80% are males
mean age was 25 years old
2% of all fractures, 11% of hand
fractures and 60% of all carpal
fractures

X-Rays ?

AP and lateral views

are necessary but not
sufficient for diagnosis
-

Due to the spatial

conformity of the
scaphoid

To enhance sensibility
-

Orientate the beam perpendicular

to the long axis of the scaphoid
(Schnek 1 & 2)

Other imaging techniques

Bone scan
Scintigraphy
CT-scan
MRI

CT SCAN ?

Use of CT-Scan modified perspectives

CT seems to be the best technique

MRI ?

Moderate displacement

Good reproducibility inter and intra-observer

Severe displacement

WRIST ARTHROSCOPY ?

Herberts classification
Type A: stable,
orthopaedic TTT

Type B: unstable,
surgical TTT

Surgical treatment in undisplaced stage B1,B2

Orthopaedic treatment

Classical orthopaedic treatment : 6-12 w

(elbow-thumb?)

Orthopaedic treatment

plaster or synthetic cast

(4-8 w)
Below elbow
Thumb free
ONLY IN REAL UNDISPLACED
FRCTURE!!!

Scaphoid Non-Union
Natural History

Group 1 8.2 yrs

Group 2 17.0 yrs

Group 3 31.6 yrs

Mack G R et al. : JBJS 66A:504-509, 1984

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Scaphoid Non-union: Herbert Classification

Fibrous
(I Alnot)

Sclerotic
Cystic
(IIA Alnot) (IIB Alnot)

Avascular
(IV Alnot)
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SCAPHOID NON-UNION : Treatment Algorithm

Fibrous non-union: stable, no deformity, no collapse
excellent prognosis, repair all. Grafting not always
necessary. Percutaneous fixation possible.

Mobile non-union: unstable, early collapse, DISI

good prognosis. Anterior wedge grafting.

Sclerotic non-union: unstable,moderate to marked

collapse and OA, ischaemic proximal pole, fair
prognosis. Treat according to age and symptoms.

Avascular non-union: fragmented proximal pole,

poor prognosis, not reconstructable. Salvage?
Revascularization trial?

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Arthroscopic management
of D1 nonunion
The aim of treatment is to achieve
accurate articular apposition of the two
fragments, taking care that they are

correctly aligned
and that no malrotation exists.
Tim Herbert
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Technique
Local-regional anaesthesia
Tourniquet
Outpatient surgery
Short distal palmar approach

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Technique
Temporary Kirshner wire to stabilize the fracture
with fluoroscopic control

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Technique
Arthroscopic control, radio and medio carpal
(sometimes reduction with a small 3-5mm chisel)

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Technique

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Technique
Arthroscopic midcarpal control,
(sometimes reduction with a probe or a small chisel
after K-wire removal from proximal scaphoid)

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Technique

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Technique
Arthroscopic midcarpal control,
Fixing of the proximal scaphoid with the pin
after reduction

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Technique

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Technique
inserting screw

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Technique
Arthroscopic midcarpal control for the
reduction, and particularly the right position of
the screw in radio carpal joint

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Technique
Arthroscopic midcarpal control for the reduction

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Technique
Right position of the screw in radio carpal joint

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Technique
Postoperative Management
- Joint motion started as soon as possible
- Volar splint between exercises +/-

- Follow-up X-rays at 3, 6 and 12 weeks

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Material

75 patients
11 female 64 male

21 left 54 right : 59 dominant hands

31 manual workers 44 sedentaries
Mean Age :

32.8 y.o.(17-58)

Average period before surgery : 8 months

Average follow-up: 18.54 m (range 6 to 42)

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Results
Time to union : 6.5 weeks (4-12 w)
Nonunion :
3
Range of motion

Increase in mean flexion :

40 65

Increase in mean extension : 43 70

Grip strength

62% 98% of controlateral wrist

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Conclusion 1
Provided that the operation has been carried out
fast and correctly, complications are rare.
The use of cannulated screw with arthroscopic assistance
and a short distal approach
allows correct reduction of scaphoid
and obtain union in short time.
The problem is to see correctly the screw position.

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RUSSE GRAFT

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Good vascularization of proximal pole

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1,5 ans
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VASCULARIZED BONE GRAFT

DORSAL
SHEETZ, BISHOP, BERGER (MAYO CLINIC)
1995-2002

Conclusion

T. Balaguer, M. Verga, E. Lebreton

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VASCULARIZED BONE GRAFT

LATERAL
ZAIDEMBERG
1991

Conclusion

T. Balaguer, M. Verga, E. Lebreton

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VASCULARIZED BONE GRAFT

VOLAR CARPAL ARTERY

Robert Judet (1964-65)

Mencke (1970)
Braun (1987) Kulhman
(1987)
Kawai (1988)

1964 R Judet; R Roy-Camille

Anatomical background
and technical description
Mathoulin , Haerle (1995)
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VASCULARIZED BONE GRAFT

Volar carpal artery arises from the radial
artery and runs along the volar aspect of the radius

It branches on the palmar side of DRUJ forming

anastomoses with a branch of interosseus artery
and a branch of ulnar artery

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Technique
Local-regional anaesthesia
Tourniquet
Outpatient surgery
Palmar approach

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Technique
First spotting of F.C.R. and radial artery

Kienbck
Scaphoid

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Technique

Flexing the wrist to release tension of FCR and FPL

Palmar carpal artery in front of and along the edge
of Pronator Quadratus
Dissection of superficial aponeurosis of PQ
until periosteum

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Technique
Temporary proximal retraction of PQ

Lateral half of pedicle subperiosteally dissected

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Technique
Harvesting of graft with an osteotome
Medial half of pedicle attached to the graft
was not detached

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Technique
Graft and pedicle were dissected back to the radial artery
Then the tourniquet is released

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Technique
Opening fracture site

Freshening the bone ends

Scaphoid osteosynthesis with screw

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Technique
Opening fracture site
Freshening the bone ends
Scaphoid osteosynthesis with screw

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Technique
Graft placed at the anterior site of bone loss

Scaphoid osteosynthesis with screw

Graft fixed by 10 mm K-wire parallel to screw

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Technique
Graft placed at the anterior site of bone loss

Scaphoid osteosynthesis with screw

Graft fixed by 10 mm K-wire parallel to screw

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Technique
Pin removal at 3 weeks
Below elbow plaster cast until union

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Technique

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Clinical case

Adaptative DISI
Stage D2

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Clinical case

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Clinical case

D + 21

D + 45
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Clinical case

D + 6 months

No DISI
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Material
103 patients
12 female 91 male Previous surgery: 31 patients

39 left 64 right : 67 dominant hands

51 manual workers 52 sedentaries
Mean Age :
30.6 y.o.(15-61)
Average period before surgery : 23 months

Average follow-up: 28.98 m (range 10 to 65)

8 years of follow-up

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Clinical case 2

Stage D3

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Clinical case 2

DISI Adaptative

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Clinical case 2

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Clinical case 2

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Clinical case 2

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Results
Time to union : 8.6 weeks (6-14 w)
Nonunion :
7
Range of motion

Increase in mean flexion :

45 58

Increase in mean extension : 54 67

Grip strength
52% 90% of controlateral wrist

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Results
Mayo wrist score

Excellent

55

Good

31

Fair

10

Poor

7
----103

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Complications

D+1

Sdecks dystrophy :

Styloid arthritis:

Stiffness :

Nonunion :

7
D+90

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Statistical analysis
Outcome was significantly related to

Age (better outcome in younger patients)

Alnots stage
Occupation (better outcome in sedentary patients)
Delay surgery (better outcome if small delay)

Outcome was not related to :

Pseudarthrosis location
Previous surgery

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Conclusion 2
93 % union in 7 weeks
97 % satisfied patients
89 % excellent or good results
Vascularized bone graft give good union in
short delay, even in failure of previous surgery

Palmar approach is enough simple to be

recommanded as primary treatment of
scaphoid nonunion
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Arthroscopic Bone Grafting

For Scaphoid Nonunion:
A new option
Local regional anaesthesia, Tourniquet
Outpatient basis
No stitches
Graft harvested from distal radius

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TECHNIQUE
ABG in Scaphoid nonunion
Arthroscopic midcarpal control

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TECHNIQUE
ABG in Scaphoid nonunion
Cleaning of both ends of scaphoid nonunion area

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TECHNIQUE
ABG in Scaphoid nonunion
Cleaning of both ends of scaphoid nonunion area

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TECHNIQUE
ABG in Scaphoid nonunion
Harvesting the graft on lateral aspect of distal radius

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TECHNIQUE
ABG in Scaphoid nonunion
Filling the bone-loss with the cancellous bone graft

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TECHNIQUE
ABG in Scaphoid nonunion
Filling the bone-loss with the cancellous bone graft

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TECHNIQUE
ABG in Scaphoid nonunion
Filling the bone-loss with the cancellous bone graft

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TECHNIQUE
ABG in Scaphoid nonunion

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Material
35 patients

9 female 26 male
8 left 27 right : 32 dominant hands
18 manual workers 17 sedentaries

22 proximal pole - 13 waist fracture

Mean Age :

33 y.o.(12-60)

Average follow-up: 8 (range 6 to 13)

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Results
Time to union : 7 weeks (6- 10 w)
Nonunion :
1 (waist)
Range of motion

Increase in mean flexion :

40 75

Increase in mean extension : 60 80

Grip strength
47% 98,5% of controlateral wrist
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Clinical case

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Clinical case

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Clinical case
Preop

45 days
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CONCLUSION 3

Arthroscopic bone grafting in scaphoid nonunion,

seems a reliable and safe procedure,
particularly in proximal fracture.
A large series with a long follow-up is requested
in order to confirm these encouraging results

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IInd Metacarpal
Brunelli 1988
Mathoulin, Brunelli, Saffar 1992

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Technique
2 approaches dorsal and
palmar
Scaphoid reconstruction
(palmar)
Bone graft harvesting
(dorsal)
Graft is filled in
scaphoid bone loss

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Technique
2 approaches dorsal and
palmar
Scaphoid reconstruction
(palmar)
Bone graft harvesting
(dorsal)
Graft is filled in
scaphoid bone loss

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Technique
2 approaches dorsal and
palmar
Scaphoid reconstruction
(palmar)
Bone graft harvesting
(dorsal)
Graft is filled in
scaphoid bone loss

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Technique
2 approaches dorsal and
palmar
Scaphoid reconstruction
(palmar)
Bone graft harvesting
(dorsal)
Graft is filled in
scaphoid bone loss

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Technique

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Material
17 patients (1988-1999)
10 males

7 females

Mean age : 34 y.o. (26 - 44)

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Material
Always waist fractures
Number of previous surgery : 2 (range 1 to 6)

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Union
Union obtained in 16 cases (1 failure)
Average delay of union : 3 months
(range 2 to 6 months)

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Results : pain
Average follow-up : 7.6 y ( range 2 to 13 y )
No pain :

10

Climatic :

FLEXION-EXTENSION
> 120 : 12

Permanent tolrable : 1

60 to 120 : 5

Incapacitating :

< 60 : 0

PRONO-SUPINATION
> 120 : 15
60 to 120 : 2
< 60 : 0

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Complications
No problem with IInd mtacarpal
Radio-scaphoid arthritis : 2 cases
Lesion of radial nerve : 2 cases
Secondary fracture : 1 case

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Conclusion 4
The use of vascularized bone graft havested from
second metacarpal is a precise and difficult procedure,
but it is a safe and reliable salvage procedure in
scaphoid reconstruction.

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CONCLUSION
Scaphoid Nonunion State-of-art
STAGE 1 Alnot, D1 Herbert: Percutaneous fixation
STAGE 2A Al., D2 Herb. : Matti-Russe grafting

STAGE 2BAl., D3 Herb. : Anterior wedge grafting

STAGE D4 Herbert : Vascularized bone graft

BUT NOW !!!!!

STAGE 1, D1 : Arthroscopic Percutaneous fixation

Other cases: ABG

Or vascularized bone graft
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