Scaphoid Non-Union Current Treatment Options

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1 Scaphoid Non-Union Current Treatment Options Peter J. Evans, MD, PhD, FRCSC Director Upper Extremity Center, Peripheral Nerve Center, Cleveland Combined Hand Fellowship Cleveland Clinic

2 Outline The Basics Anatomy Presentation/Natural Hx Treatment options The Specifics Algorithm Fixation Bone graft options Results Discussion

3 Salvage Options

4 Scaphoid Basics Anatomic points Dipped in cartilage Peculiar shape Link proximal & distal rows Ligamentous attachments Extension moment prox. pole Flexion moment distal pole

5 Scaphoid Basics Blood supply Gelberman/Menon et al 2 vascular supplies 70-80% 20-30%

6 Scaphoid Basics Blood supply Gelberman/Menon et al 2 vascular supplies dorsal/volar Proximal pole intra-articular & covered w/ cartilage intra-osseous blood supply (retrograde)

7 Presentation Often vague symptoms Pain Stiffness Weakness minor injury/sprain Often long-standing Incidental finding now what?

8 Risk Factors Delay in diagnosis Inadequate initial treatment Proximal location AVN Associated carpal instability Patient factors

9 Mack GR, Bosse MJ, Gleberman RH, Yu E (1984). The natural history of scaphoid non-union. The Journal of Bone and Joint Surgery, 66A: Untreated/displaced Progressive DJD Predictable SNAC wrist Limitation? selection bias

10 Inoue G, Sakuma M. The natural history of scaphoid non-union. Radiographical and clinical analysis in 102 cases. Arch Orthop Trauma Surg 1996;115(1): 1 4. Retrospective review 102 non-unions Prevalence Arthritis duration non-union 22% - < 5 years 75% years 100% - > 10 years

11 Evaluation Symptomatic patient Plain x-ray SALVAGE!

12 Evaluation Symptomatic patient Plain x-ray Location Density Geometry DISI

13 Evaluation Symptomatic patient CT (evaluate humpback deformity) <35 <0.65

14 Evaluation Symptomatic patient CT (evaluate humpback deformity)

15 Evaluation Symptomatic patient MRI (AVN) Contrast Low signal on T1 & T2 = greatest compromise

16 Check-list Arthritis salvage Location Waist/proximal Collapse Humpback AVN Evaluation

17 Treatment Groups Waist Fracture Non-displaced Volar DRBG Percutaneous Arthroscopic Displaced (ie. Humpback ) No AVN AVN Volar reduction (cancellous or corticocancellous) VBG (palmar/mfc/1,2 ICSRA)

18 Treatment Groups Proximal Pole No AVN Dorsal approach DRBG AVN Dorsal VBG (1,2 ICSRA, thumb met )

19 Waist No AVN - Humpback Standard Volar Approach

20 Waist No AVN - Humpback Standard Volar Approach Meticulous debridement non-union Avoid violation dorsal cortex

21 Waist No AVN - Humpback Standard Volar Approach Meticulous debridement non-union Avoid violation dorsal cortex

22 Waist No AVN - Humpback Standard Volar Approach Meticulous debridement non-union Avoid violation dorsal cortex DISI Correction

23 Waist No AVN - Humpback Standard Volar Approach Meticulous debridement non-union Avoid violation dorsal cortex

24 Bone Graft Selection Source DR vs. ICBG Stanley et al no difference in 68 cases Corticocancellous vs Cancellous

25 Waist AVN - Humpback Challenging with 1,2 ICSRA My current choice Volar distal radius via palmar carpal artery Mayo Clinic choice Free medial femoral condyle bone graft

26 VBG Palmar Carpal Artery Waist AVN - Humpback Menck et al: confirmed periosteal and endosteal vascularization

27 VBG Palmar Carpal Artery Waist AVN - Humpback

28 VBG Palmar Carpal Artery Waist AVN - Humpback Advantages: 1. Single approach 2. Adequate pedicle length 3. Correct Humpback

29 VBG Palmar Carpal Artery The Evidence Mathoulin C, Haerle M. Vascularized bone graft from the palmar carpal artery for treatment scaphoid nonunion. J Hand Surg 1998;23B: (17/17) Dailiana Z, Hantes M, Karantanas A. Vascularized bone grafts from the palmar radius for the treatment of waist non unions of the scaphoid. J Hand Surg 2006;31A: (9/9)

30 Free Medial Femoral Condyle Superficial femoral a. Descending geniculate Articular branch

31 Free Medial Femoral Condyle Indications Waist AVN humpback 1,2 ICSRA Standard volar approach 2 teams

32 Free Medial Femoral Condyle

33 Limited experience? Practical

34 Free Medial Femoral Condyle Shin et al Waist non-union w/ AVN & collapse 1,2 ICSRA 4/10 healed (19 wks) Free MFC 12/12 healed (12 wks)

35 Discussion Points Adjuncts to treatment Bone stimulators Does Anyone think VBG BS? Percutaneous/Arthroscopic? CT all patients to confirm healing

36 References Tambe A, Cutler S, Stanley J. In scaphoid non-union, does the source of graft affect outcome. J Hand Surg;31B: Mathoulin C, Haerle M. Vascularized bone graft from the palmar carpal artery for treatment of scaphoid non-union. J Hand Surg;23B: Jones D, Bishop A, Shin A. Treatment of scaphoid waist non-unions with an avascular proximal pole and carpal collapse A comparison of two vascularized bone grafts. JBJSA;90: Bindra R, Bednar M, Light T. Volar wedge grafting doe scaphoid non-union with collapse. J Hand Surg;33A: Bain G, Richards R, Roth J. Measurement of the scaphoid humpback deformity using longitudinal CT: Intra and interobserver variability using various measurment techniques. J Hand Surg;23A:76-81.

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