Arthroscopically assisted Cancellous Bone Grafting and Percutaneous K-Wires Fixation for the Treatment of Scaphoid Nonunions

Young-Keun Lee; Sang-Hyun Woo; Pak Cheong Ho; Ji-Gang Park; Joo-Yong Kim

doi:10.12790/jkssh.2014.19.1.19

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Lee, Woo, Ho, Park, and Kim: Arthroscopically assisted Cancellous Bone Grafting and Percutaneous K-Wires Fixation for the Treatment of Scaphoid Nonunions

ORIGINAL ARTICLE

J Korean Soc Surg Hand 2014;19(1):19-28.

Published online: 11 March 2014

DOI: https://doi.org/10.12790/jkssh.2014.19.1.19

Arthroscopically assisted Cancellous Bone Grafting and Percutaneous K-Wires Fixation for the Treatment of Scaphoid Nonunions

Young-Keun Lee¹, Sang-Hyun Woo², Pak Cheong Ho³, Ji-Gang Park⁴, Joo-Yong Kim^5,

¹Department of Orthopaedic Surgery, Dason Orthopaedic Clinic, Jeonju, Korea

²Chen and Woo's Institute for Hand Surgery and Reconstructive Microsurgery, W Hospital, Daegu, Korea

³Department of Orthopaedic and Traumatology, Prince of Wales Hospital, Chinese University, Hong Kong

⁴Department of Orthopaedic Surgery, Chungbuk National Universiry Hospital, Chungbuk National University College of Medicine, Chungju, Korea

⁵Department of Orthopaedic Surgery, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Korea

Correspondence to: Joo-Yong Kim, Department of Orthopaedic Surgery, Inje University Busan Paik Hospital, Inje University College of Medicine, 75 Bokji-ro, Busanjin-gu, Busan 614-735, Korea, TEL: +82-51-890-6129, FAX: +82-51-892-6619, E-mail: trueyklee@naver.com

Received 2 January 201428 February 2014 Accepted 28 February 2014

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose:

The purpose of this study was to analyze the clinical results of patients with scaphoid nonunions treated with arthroscopically assisted bone grafting and percutaneous K-wires fixation.

Methods:

We retrospectively reviewed 20 patients with a scaphoid nonunions which was treated with arthroscopically assisted bone grafting and percutaneous K-wires fixation from November 2008 to July 2012. Time from injury to treatment was 74 months (range, 3-480 months) in average. Functional outcome was evaluated using the modified Mayo wrist score and visual analogue scale (VAS) for pain, which were measured before operation and at the last follow up.

Results:

All nonunions were healed successfully. The average radiologic union time was 9.7 weeks (range, 7-14 weeks). The average VAS score improved from 6.3 (range, 4-8) preoperatively to 1.6 (range, 0-3) at the last follow up. The average modified Mayo wrist score increased from 62.5 preoperatively to 85.7 at the last follow-up.

Conclusion:

Arthroscopically assisted bone grafting and percutaneous K-wires fixation is an effective treatment method for a scaphoid nonunion. It may provide more biological environment than open surgery as a minimally invasive procedure.

Keywords: Scaphoid nonunion, Arthroscopy, Bone graft, K-wire

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Fig. 1.

A 46-year-old male patient with nonunion of the left scaphoid fracture. Preoperative left wrist plain scaphoid (A) view show nonunion at the waist of the scaphoid. (B) Same patient's left wrist, midcarpal arthroscopy image of scaphoid nonunion site shows large gap and sclerotic margins of both fragments. P, proximal fragment; D, distal fragment; MCR, midcarpal radial.

Fig. 2.

Provisional K-wire fixation.

Fig. 3.

(A) Left wrist, midcarpal arthroscopy image which is finished bone graft to the nonunion site percutaneously using cannula and trocar. (B, C) Same patient's left wrist, midcarpal arhroscopy images of percutaneous autogenous iliac cancellous bone grafting at the nonunion site using cannula and trocar. MCR, midcarpal radial.

Fig. 4.

Immediate postoperative plain left wrist anteroposterior (A) and scaphoid (B) radiographs show internal fixation with K-wires and grafted bone at the nonunion site.

Fig. 5.

Postoperative 49 months later follow-up plain left wrist scaphoid (A) and photographs (B, C) show complete bony union and excellent clinical result.

Table 1.

Treatment classification system for scaphoid nonunion¹³

I	Scaphoid fractures with delayed presentation for treatment: 4 weeks-12 weeks
II	Fibrous union: minimal fracture line at nonunion interface, no cyst or sclerosis
III	Minimal sclerosis: bone resorption at nonunion interface less than 1 mm
IV	Cystic formation and sclerosis: bone resorption at nonunion interface greater than 1 mm but less than 5 mm, cyst, no deformity of lateral radiographs
V	Deformity and/or pseudoarthrosis: bone resorption at nonunion interface greater than 5 mm, cyst, fragment motion, deformity on lateral radiographs
VI	Wrist arthrosis: scaphoid nonunion with radiocarpal and/or midcarpal arthrosis
Special circumstances
PP	Proximal pole nonunion. The proximal pole of the scaphoid has a tenuous blood supply and a mechanical disadvantage, which places it at greater risk of delayed or failed union. Because of these difficulties, this injury requires aggressive treatment to ensure successful healing.
AVN	Scaphoid nonunion with necrosis is suggested by magnetic resonance imaging demonstrating a decrease or absence of vascularity of one or both poles. Bone biopsy can confirm necrosis. Intraoperative inspection of the scaphoid for punctate bleeding is considered definitive.
LI	Ligament injury is suggested by static and dynamic imaging of the carpal bones. Arthroscopy is the most sensitive tool for detecting carpal ligament injury.

Table 2.

Demography of the patients

Patient No.	Age (yr)	Sex	Intervals between injury and surgery (mo)	Causes of Injury	Location of Facture	Slade and Geissler classification	Associated lesions	Punctate bleeding
1	25	M	6	Fall down	Waist	Grade 2	None	D,P +
2	33	M	8	Sport	Waist	Grade 2	None	D,P +
3	17	M	4	Sport	Prox. pole	Grade 4	Grade II S-L	D+,P-
4	49	M	360	Fall down	Waist	Grade 4	SNAC stage I	D,P +
5	18	M	12	Sport	Waist	Grade 4	Grade II S-L	D+,P-
6	15	M	18	Sport	Waist	Grade 2	Grade II S-L	D,P +
7	15	M	12	Sport	Waist	Grade 2	Grade II S-L	D,P +
8	23	M	4	Sport	Waist	Grade 2	None	D,P +
9	40	M	Unkown	Unkown	Waist	Grade 4	Grade II S-L, L-T, SNAC stage \|	D,P +
10	43	M	192	Traffic	Waist	Grade 4	SNAC stage I	D+,P-
11	35	M	24	Traffic	Waist	Grade 4	Grade II S-L, 1-ATFC	D,P +
12	21	M	6	Sport	Waist	Grade 3	Grade II S-L	D,P +
13	28	M	12	Sport	Prox. pole	Grade 4	Grade II S-L	D,P +
14	52	M	120	Sport	Waist	Grade 6	Grade II S-L, SNAC stage \|	D,P +
15	46	M	Unkown	Unkown	Waist	Grade 6	SNAC stage I	D,P +
16	51	F	Unkown	Unkown	Waist	Grade 6	Grade II S-L, SNAC stage \|	D,P +
17	61	M	480	Fall down	Prox. pole	Grade 6	Grade II S-L, SNAC stage \|	D,P +
18	21	M	11	Sport	Waist	Grade 2	Grade II S-L	D,P +
19	53	M	3	Fall down	Waist	Grade 1	Grade II S-L	D,P +
20	46	M	4	Fall down	Waist	Grade 2	Grade in S-L, 1-ATFC	D,P +

D,P +, there was punctate bleeding in the proximal and distal fragment; Prox.pole, proximal pole; S-L, Scapholunate ligament; D+,P-, there was no punctate bleeding in the proximal fragment; L-T, lunotriquetral ligment; SNAC, scaphoid nonunion advanced collapse; TFC, triangular fibrocartilage.

Table 3.

Demography of the patients

Patient No.	Time to union (wk)	Last follow-up (mo)	VAS (pre/last f-u)	Grip strengh (% of normal side) (pre/last f-u)	Range of motion (% of normal side) (pre/last f-u))	Mayo wrist score (pre/last f-u))
1	9	15	7.5/1	93/100	87/100	70/100
2	7	14	7.5/1	76/100	87/100	55/100
3	11	12	7.3/1	81/85	98/100	65/80
4	8	12	5/2	66/85	73/73	55/75
5	8	24	5/1	90/90	93/100	65/90
6	10	13	7/2.8	86/100	85/93	60/90
7	9	37	5/2	71/92	70/100	65/90
8	9	15	7.5/2.5	89/100	85/100	65/100
9	9	13	7.5/2.5	30/60	76/80	50/70
10	10	15	5/2.8	89/85	68/89	40/70
11	11	12	7.4/2	100/100	90/86	80/85
12	9	12	5/3	90/90	89/100	70/90
13	9	20	8/2.8	88/87	78/71	45/70
14	13	18	8/2.5	100/82	87/68	55/65
15	13	49	7.3/2.5	100/100	97/94	65/90
16	9	22	7/0	71/100	73/92	55/90
17	9	14	4/0	100/100	78/92	80/90
18	14	14	5/0	80/83	94/97	70/80
19	8	13	5/1	100/100	100/100	75/95
20	10	24	5/0	52/100	79/100	65/100

VAS, visual analogue scale; Pre/last f/u, preoperative/last follow-up.

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