Metaphyseal Core Decompression and Anterograde Fixation for Scaphoid Proximal Pole Fracture Nonunion without Avascular Necrosis

Abstract

Objective To report the consolidation rate and the results of a series of 22 patients with metaphyseal core decompression of the distal radius and an antegrade compression screw.

Methods We present a prospective series of patients with scaphoid proximal pole nonunion in whom the presence of intraoperative bleeding was confirmed in both fragments. Patients with displacement, degenerative changes, fragmentation of the proximal pole, cavitation of the focus, loss of height, and necrosis, as well as those with carpal instability, were excluded. The patients were evaluated with X-rays and computed tomography to evaluate their consolidation; their mobility and fist strength were recorded and an analog visual scale (VAS) of pain at rest, pain in activity, subjective functional status, and DASH questionnaire were completed.

Results Of the 23 patients, 21 accomplished union. The average follow-up was 19 months and the average final range of motion was flexion 86%, extension 85%, radial deviation 79%, ulnar deviation 84%, and grip strength 84%. The average VAS for pain at rest was 1 point, the average VAS for activity pain was 2 points, the average VAS for function was 9 points, and the average DASH score was 8.

Conclusions Using this simple and reliable technique, we obtained 91% union and very good functional results. Metaphyseal core decompression of the distal radius associated with an antegrade scaphoid screw is a reasonable and effective option for the treatment of proximal pole scaphoid nonunions without avascular necrosis in carefully selected patients.

Level of Evidence This is Level IV study.

Keywords

scaphoid - proximal pole - nonunion

Note

Protection of Human and Animal Subjects: The authors declare that no experiments were performed on humans or animals for this study.

Confidentiality of Data: The authors declare that no patient data appear in this article.

Right to Privacy and Informed Consent: The authors declare that no patient data appear in this article.

• References

• 1 Gelberman RH, Menon J. The vascularity of the scaphoid bone. J Hand Surg Am 1980; 5 (05) 508-513
• 2 Vender MI, Watson HK, Wiener BD, Black DM. Degenerative change in symptomatic scaphoid nonunion. J Hand Surg Am 1987; 12 (04) 514-519
• 3 Botte MJ, Mortensen WW, Gelberman RH, Rhoades CE, Gellman H. Internal vascularity of the scaphoid in cadavers after insertion of the Herbert screw. J Hand Surg Am 1988; 13 (02) 216-220
• 4 Illarramendi AA, Schulz C, De Carli P. The surgical treatment of Kienbock's disease by radius and ulna metaphyseal core decompression. J Hand Surg Am 2001; 26 (02) 252-260
• 5 Filan SL, Herbert TJ. Herbert screw fixation of scaphoid fractures. J Bone Joint Surg Br 1996; 78 (04) 519-529
• 6 Slade III JF, Dodds SD. Minimally invasive management of scaphoid nonunions. Clin Orthop Relat Res 2006; 445 (445) 108-119
• 7 Schernberg F, Elzein F. [Fracture types and fragment dislocations of the scaphoid bone of the hand]. Handchir Mikrochir Plast Chir 1987; 19 (02) 59-66
• 8 De Carli P, Zaidenberg EE, Alfie V, Donndorff A, Boretto JG, Gallucci GL. Radius core decompression for Kienbock disease stage IIIA: outcomes at 13 years follow-up. J Hand Surg Am 2017; 42 (09) 752.e1-752.e6
• 9 Dindo D, Demartines N, Clavien P-A. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004; 240 (02) 205-213
• 10 Merrell GA, Wolfe SW, Slade III JF. Treatment of scaphoid nonunions: quantitative meta-analysis of the literature. J Hand Surg Am 2002; 27 (04) 685-691
• 11 Kazmers NH, Thibaudeau S, Levin LS. A scapholunate ligament-sparing technique utilizing the medial femoral condyle corticocancellous free flap to reconstruct scaphoid nonunions with proximal pole avascular necrosis. J Hand Surg Am 2016; 41 (09) e309-e315
• 12 Sotereanos DG, Darlis NA, Dailiana ZH, Sarris IK, Malizos KN. A capsular-based vascularized distal radius graft for proximal pole scaphoid pseudarthrosis. J Hand Surg Am 2006; 31 (04) 580-587
• 13 Lim TK, Kim HK, Koh KH, Lee HI, Woo SJ, Park MJ. Treatment of avascular proximal pole scaphoid nonunions with vascularized distal radius bone grafting. J Hand Surg Am 2013; 38 (10) 1906-12.e1
• 14 Bürger HK, Windhofer C, Gaggl AJ, Higgins JP. Vascularized medial femoral trochlea osteocartilaginous flap reconstruction of proximal pole scaphoid nonunions. J Hand Surg Am 2013; 38 (04) 690-700
• 15 Sherman GM, Spath C, Harley BJ, Weiner MM, Werner FW, Palmer AK. Core decompression of the distal radius for the treatment of Kienbock's disease: a biomechanical study. J Hand Surg Am 2008; 33 (09) 1478-1481
• 16 Kam B, Topper SM, McLoughlin S, Liu Q. Wedge osteotomies of the radius for Kienbock's disease: a biomechanical analysis. J Hand Surg Am 2002; 27 (01) 37-42
• 17 Matsuki H, Ishikawa J, Iwasaki N, Uchiyama S, Minami A, Kato H. Non-vascularized bone graft with Herbert-type screw fixation for proximal pole scaphoid nonunion. J Orthop Sci 2011; 16 (06) 749-755
• 18 DeMaagd RL, Engber WD. Retrograde Herbert screw fixation for treatment of proximal pole scaphoid nonunions. J Hand Surg Am 1989; 14 (06) 996-1003
• 19 Inoue G, Shionoya K, Kuwahata Y. Ununited proximal pole scaphoid fractures. Treatment with a Herbert screw in 16 cases followed for 0.5-8 years. Acta Orthop Scand 1997; 68 (02) 124-127
• 20 Krimmer H. Management of acute fractures and nonunions of the proximal pole of the scaphoid. J Hand Surg [Br] 2002; 27 (03) 245-248
• 21 Herbert TJ, Filan SL. Proximal scaphoid nonunion-osteosynthesis. Handchir Mikrochir Plast Chir 1999; 31 (03) 169-173
• 22 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 (Suppl. 04) 20-32
• 23 McCallister WV, Knight J, Kaliappan R, Trumble TE. Central placement of the screw in simulated fractures of the scaphoid waist: a biomechanical study. J Bone Joint Surg Am 2003; 85-A (01) 72-77
• 24 Dodds SD, Panjabi MM, Slade III JF. Screw fixation of scaphoid fractures: a biomechanical assessment of screw length and screw augmentation. J Hand Surg Am 2006; 31 (03) 405-413
• 25 Trumble TE, Clarke T, Kreder HJ. Non-union of the scaphoid. Treatment with cannulated screws compared with treatment with Herbert screws. J Bone Joint Surg Am 1996; 78 (12) 1829-1837
• 26 Chan KW, McAdams TR. Central screw placement in percutaneous screw scaphoid fixation: a cadaveric comparison of proximal and distal techniques. J Hand Surg Am 2004; 29 (01) 74-79