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

Abstract

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.

Keywords

autograft - delayed union - scaphoid nonunion - scaphoid - scaphoid fracture

Ethical Approval

The Vanderbilt University Institutional Review Board exempted the cadaveric portion of this study from IRB approval (IRB# 120525) and approved the chart review portion of the clinical study (IRB# 120754). Informed consent was waived for the chart review portion of the clinical study.

• References

• 1 Gaebler C, McQueen MM. Carpus fractures and dislocations. In: Bucholz RW, Heckman JD, Court-Brown CM, Tornetta P. Rockwood and Green's Fractures in Adults. Philadelphia, PA: Lippincott Williams & Wilkins; 2010: 788-804
• 2 Geissler WB, Adams JE, Bindra RR, Lanzinger WD, Slutsky DJ. Scaphoid fractures: what's hot, what's not. Instr Course Lect 2012; 61: 71-84
• 3 Arora R, Gschwentner M, Krappinger D, Lutz M, Blauth M, Gabl M. Fixation of nondisplaced scaphoid fractures: making treatment cost effective. Prospective controlled trial. Arch Orthop Trauma Surg 2007; 127 (01) 39-46
• 4 Buijze GA, Doornberg JN, Ham JS, Ring D, Bhandari M, Poolman RW. Surgical compared with conservative treatment for acute nondisplaced or minimally displaced scaphoid fractures: a systematic review and meta-analysis of randomized controlled trials. J Bone Joint Surg Am 2010; 92 (06) 1534-1544
• 5 Davis EN, Chung KC, Kotsis SV, Lau FH, Vijan S. A cost/utility analysis of open reduction and internal fixation versus cast immobilization for acute nondisplaced mid-waist scaphoid fractures. Plast Reconstr Surg 2006; 117 (04) 1223-1235 , discussion 1236–1238
• 6 McQueen MM, Gelbke MK, Wakefield A, Will EM, Gaebler C. Percutaneous screw fixation versus conservative treatment for fractures of the waist of the scaphoid: a prospective randomised study. J Bone Joint Surg Br 2008; 90 (01) 66-71
• 7 Kawamura K, Chung KC. Treatment of scaphoid fractures and nonunions. J Hand Surg Am 2008; 33 (06) 988-997
• 8 Trumble TE, Salas P, Barthel T, Robert III KQ. Management of scaphoid nonunions. J Am Acad Orthop Surg 2003; 11 (06) 380-391
• 9 Slade III JF, Gutow AP, Geissler WB. Percutaneous internal fixation of scaphoid fractures via an arthroscopically assisted dorsal approach. J Bone Joint Surg Am 2002; 84-A (01) (Suppl. 02) 21-36
• 10 Capo JT, Orillaza Jr NS, Slade III JF. Percutaneous management of scaphoid nonunions. Tech Hand Up Extrem Surg 2009; 13 (01) 23-29
• 11 Merrell G, Slade J. Technique for percutaneous fixation of displaced and nondisplaced acute scaphoid fractures and select nonunions. J Hand Surg Am 2008; 33 (06) 966-973
• 12 Slade JF, Lozano-Calderón S, Merrell G, Ring D. Arthroscopic-assisted percutaneous reduction and screw fixation of displaced scaphoid fractures. J Hand Surg Eur Vol 2008; 33 (03) 350-354
• 13 Yassaee F, Yang SS. Mini-incision fixation of nondisplaced scaphoid fracture nonunions. J Hand Surg Am 2008; 33 (07) 1116-1120
• 14 Osterman AL, Mikulics M. Scaphoid nonunion. Hand Clin 1988; 4 (03) 437-455
• 15 Slade III JF, Dodds SD. Minimally invasive management of scaphoid nonunions. Clin Orthop Relat Res 2006; 445 (445) 108-119
• 16 Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977; 33 (01) 159-174
• 17 Slade III JF, Jaskwhich D. Percutaneous fixation of scaphoid fractures. Hand Clin 2001; 17 (04) 553-574
• 18 Slade III JF, Geissler WB, Gutow AP, Merrell GA. Percutaneous internal fixation of selected scaphoid nonunions with an arthroscopically assisted dorsal approach. J Bone Joint Surg Am 2003; 85-A (01) (Suppl. 04) 20-32
• 19 Geissler WB. Percutaneous and arthroscopic management of scaphoid nonunions. In: Capo JT, Tan V. , eds. Atlas of Minimally Invasive Hand and Wrist Surgery. New York, NY: Informa Healthcare USA; 2008: 105-115
• 20 Mahmoud M, Koptan W. Percutaneous screw fixation without bone grafting for established scaphoid nonunion with substantial bone loss. J Bone Joint Surg Br 2011; 93 (07) 932-936
• 21 Schuind F, Haentjens P, Van Innis F, Vander Maren C, Garcia-Elias M, Sennwald G. Prognostic factors in the treatment of carpal scaphoid nonunions. J Hand Surg Am 1999; 24 (04) 761-776