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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 ?

Herbert’s 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

Kienböck
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

• Südeck’s dystrophy :

5

• Styloid arthritis:

4

• Stiffness :

4

• Nonunion :

7
D+90

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Statistical analysis
Outcome was significantly related to

– Age (better outcome in younger patients)
– Alnot’s 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 :

6

FLEXION-EXTENSION
• > 120° : 12

• Permanent tolérable : 1

• 60° to 120° : 5

• Incapacitating :

• < 60° : 0

0

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

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Complications
• No problem with IInd métacarpal
• 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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