Arthroscopic Treatment of Stable Scaphoid Nonunion

J Orthop Spine Trauma. 2015 September; 1(1):e1774. Published online 2015 September 23. Brief Report Arthroscopic Treatment of Stable Scaphoid Nonunion Yousef Fallah, 1,* Reza Shahriar Kamrani, 1,2 and Leila Oryadi Zanjani 1 1 Department of Orthopedic Surgery, Joint Reconstruction Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, IR Iran 2 Joint Reconstruction Research Center, Tehran University of Medical Sciences, Tehran, IR Iran *Corresponding author: Yousef Fallah, Department of Orthopedic Surgery, Joint Reconstruction Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, IR Iran. Tel: +98-2161192767, Fax: +98-2166581653, E-mail: fallah2us@yahoo.com Received: March 18, 2015; Revised: April 26, 2015; Accepted: April 28, 2015 Background: Open bone grafting has been the standard procedure for treatment of scaphoid nonunion. Arthroscopic bone grafting and fixation is a minimally invasive method, which is effective as open procedure with minimal complications. Objectives: The purpose of this study was to assess the results of arthroscopic treatment by refreshing and bone grafting on clinical wrist function and radiographic outcome in patients with stable scaphoid nonunion. Patients and Methods: Between June 2012 and May 2014, 17 patients received arthroscopic refreshing and bone grafting for treatment of stable waist scaphoid nonunion. The mean follow-up was 13 months (ranged 6-18 months). Results: The mean flexion/extension of the wrist was 72 degrees (ranged 50-160 degrees) compared with the pre-operation 53 degrees (ranged 35-160 degrees) (P < 0.04). Grip strength at final follow-up averaged 28 kg (ranged 12-455 kg) indicating a significant improvement from 21kg (ranged 5-41 kg) before the operation (P < 0.026). The mean Quick DASH scores showed a significant improvement from 48 (ranged 27-90) preoperatively to 84 (ranged 76-100) postoperatively (P < 0.05). The mean VAS score showed a significant improvement from 4.3 (ranged 2-7) preoperatively to 1.03 (ranged 0-4) postoperatively (P < 0.04). Conclusions: Arthroscopic treatment of stable scaphoid nonunion is an effective alternative to the conventional treatment of stable Scaphoid nonunion. Keywords: Hand Bones; Carpal Bones; Scaphoid Bone 1. Background The natural history of untreated scaphoid nonunion is progression to carpal collapse resulting to carpal arthritis and chronic painful disability. For these reasons, bony union and restoring the normal anatomy of scaphoid have been emphasized. The procedure may need cancellous bone graft and fixation with either screws or k-wire (1-7). Several recent studies have shown that arthroscopic technique for the treatment of stable scaphoid nonunion is effective as conventional bone graft (8-11). The advantages of this approach are less morbidity, less stiffness and better functional outcomes. This method is limited to early stage of nonunion or stable fibrous union with minimal sclerosis (12-14). To evaluate the results of this approach and to find its advantages and disadvantages in our patients, we reviewed our patients who underwent arthroscopic treatment of stable scaphoid nonunion. 2. Objectives The purpose of this study was to assess the results of arthroscopic treatment by refreshing and bone grafting on clinical wrist function and radiographic outcome in patients with stable scaphoid nonunion. 3. Patients and Methods Between June 2012 and May 2014, 19 patients received arthroscopic refreshing and bone grafting for stable scaphoid waist nonunion at our institution. The inclusion criteria were scaphoid waist nonunion and minimal sclerosis without malalignment. Exclusion criteria were: 1) unstable scaphoid nonunion, 2) carpal arthritis and carpal collapse sign, 3) severe sclerosis, 4) plain radiographies signs of avascular necrosis, 5) humpback deformity, and 6) follow-up less than six months. All surgical procedures were performed by the same surgeon (k.rs) after informed consent was obtained from all patients. 3.1. Clinical and Radiographic Evaluation Clinical outcomes were investigated by an independent observer who did not participate in the surgical procedure. Range of motion was measured using a hand-held goniometer. Grip strength was measured using a Jamar hydraulic hand dynamometer. Shoulder and Hand (Quick DASH) and VAS questionnaire were used. All the measurements were performed preoperative and at the last follow-up. Intraoperative complications like cartilage injury, tendon tearing, and cutaneous nerve injury and postoperative complications like algoneurodystrophy and failure were documented. Radiographic evaluation included union in augmented posteroanterior and lateral views and degenerative changes. Copyright 2015, Persian Orthopedic Trauma Association. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non- Commercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.

3.2. Surgical Technique An arthroscopic procedure was performed with tourniquet on upper arm, holding the hand in 5 kg of traction under general anesthesia. Standard radial and ulnar midcarpal portals were used. Once the location and alignment of the fracture were seen through radial portal using a probe, we made a working portal through the ulnar portal (Figure 1). If any doubt existed about nonunion site, we used operative fluoroscopy with a guide to find the fibrous nonunion site. The ulnar portal was useful for removing sclerotic or devitalized tissue from nonunion site with a motorized 2 mm burr under wet arthroscopy (Figure 2). Sometimes we had to change the working portal and debride the proximal segment with better access. Cancellous bone graft was removed from the ipsilateral iliac crest and pushed to the nonunion site through the working portal through an arthroscopic sheath. It was then packed into the gap with increasing firmness using a probe without escape out into the joint. The hand released from traction and put on a radiolucent hand table. Two 1.2 mm K-wires were inserted percutaneously from distal to proximal segment of scaphoid under fluoroscopy control (Figure 3). The wrist was immobilized in a short-arm thumb Spica splint. After one week, it changed to a short thumb Spica cast. After twelve weeks of operation, the cast and the pins were removed and digital posteroanterior and lateral radiography were obtained. If bridging bone was not identified by 12 weeks, a rigid short-arm thumb Spica splint was applied for an additional six weeks. If bridging bone was not identified by 18 weeks, we considered the treatment as failure. Patients with union were visited every three months and wrist range of motion and grip strength and plain radiographs were evaluated at the final follow up. Figure 2. Cp, Capitate; Sc-D, Distal Segment of Scaphoid; and Sc-P, Proximal Segment of Scaphoid Figure 3. Scaphoid Nonunion Was Fixed With K-Wires Figure 1. MCR, Mid Carpal Radial Portal; and MCU, Mid Carpal Ulnar Portal 4. Results This study assessed finally 17 of 19 patients who underwent arthroscopic treatment for stable scaphoid nonunion because 2 patients were excluded due to incomplete follow-up. There were six women and 11 men at the final evaluation with a mean age of 27.5 years (ranged 19-43 years). The mean follow-up was 13 months (ranged 6-18 Months). The mean flexion/extension of the wrist was 72 degrees (ranged 50-160 degrees) in comparison with the pre-operation 53 degrees (ranged 35-160 degrees) (P < 0.04). Grip strength at final follow-up averaged 28 kg (ranged 12-455 kg) indicating a significant improvement from 21 kg (ranged 5-41 kg) before the operation (P < 0.026). The mean Quick DASH scores showed a significant improvement from 48 (ranged 27-90) preoperatively to 84 (ranged 76-100) postopera- 22

tively (P < 0.05). The VAS score showed a significant improvement from 4.3 (ranged 2-7) preoperatively to 1.03 (ranged 0-4) postoperatively (P < 0.04). All patients achieved a successful bony union by a mean 3.3 months (ranged 3-4.5 months). We had a complication of escaped out of the bone graft in one patient who showed degenerative changes at follow-up radiography and underwent styloidectomy one year after index operation with relief of the pain (Figure 4). Three patients showed symptoms of algoneurodystrophy treated by prolonged physical therapy. All of them healed without complication at the final follow-up. We had not any cutaneous nerve injury, tendon injury or intraoperative cartilage injury. Figure 4. A 37-Year-Old Man Treated With an Arthroscopic Technique for Scaphoid Nonunion (A) That complicated with escaped out of the graft resulted in degenerative changes (B) at follow-up radiography and underwent styloidectomy (C And D) 23

5. Discussion The development of arthroscopies brings a significant breakthrough in the history of wrist surgeries like scaphoid nonunion. It provides a thorough wrist biological environment for the union and minimal surgical trauma to the ligamentous architecture and vascularity. The present study showed a significant improvement with arthroscopic management of the stable nonunion of scaphoid in Grip strength and flexion/extension of the wrist. The overall functional outcomes for patients who achieved bony union were excellent or good like Kim et al. (15) report. We had a union rate of 100% like vascular bone graft that produced a 90% - 100% union rate, which may be due to relatively small number of patients (7). Arthroscopic management of scaphoid nonunion techniques continues to evolve. The present study showed the advantage of this method to achieve a more probably bone union (100%) with no delay union. The overall complication rate was 23.5%, which was higher than other studies; this may be due to the duration of the procedure or due to low skills. Kim et al. (15) reported a 7% complication rate in their study (arthroscopic surgery) and Slade and Gillon (16) reported a 9% complication rate and 96% union rate of nonunion group by nine months and 9% delay union. In another study performed by Kolodziej et al. (17), nonunion rate after the Matti-Russe surgery method was 28% after a long-term follow-up of 2-27 years (mean: 8.8 years) and no complication reported. Our procedure also can preserve cartilage and tendon and sensory cutaneous nerve, which consequently preserves wrist motion and gripe and patient satisfaction (Figure 5). Figure 5. A 24-Year-old man Treated With an Arthroscopic Technique for Scaphoid Nonunion (And B) that Treated Completely Without any Complication and Had Full Wrist Motion (C and D) 24

Shaving of bony sclerosis is probably the main step in treating stable scaphoid nonunion and usually performed with cortical window at the nonunion site (1). Therefore, our procedure includes removing bony sclerosis until normal cancellous bone with punctate bleeding is seen. For a fixation device in providing rigid fixation of stable scaphoid nonunion, it must be able to resist complex forces during normal functional loading (shearing or translation forces) (18, 19). The mechanical effectiveness of internal fixation is determined by five independent variables: bony quality, fragment geometry, reduction, implant and implant placement. While all the five variables are of importance, bone quality and fragment geometry depend on the patient. Reduction, implant placement and implant selection are the variables which the surgeon can manipulate. Implant placement in the biomechanically ideal position for the biomechanically ideal position for patient is probably the single most important one of the five variables (20). In this study, we used two k-wire for nonunion fixation and found it sufficient in stable scaphoid nonunion. Arthroscopic refreshing and bone grafting and osteosynthesis of stable scaphoid nonunion have positive effects on the recovery of clinical wrist function and can be an effective alternative to the conventional method with few complication. 5.1. Limitation This study had several limitations. It was a retrospective case study with no control group, the number of cases was relatively small. CT scan was not performed for assessing union of scaphoid as CT provides better accuracy than the plain radiographs. References 1. Buijze GA, Ochtman L, Ring D. Management of scaphoid nonunion. J Hand Surg Am. 2012;37(5):1095 100. 2. 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