Acutrak versus Herbert fixation for scaphoid non-union and delayed union. Item Type Article Authors Oduwole, Kayode O;Cichy, Benedikt;Dillon, John P;Wilson, Joan;O'Beirne, John Citation Acutrak versus Herbert fixation for scaphoid non-union and delayed union. 2012, 20 (1):61-5 J Orthop Surg (Hong Kong) Journal Journal of orthopaedic surgery (Hong Kong) Rights Archived with thanks to Journal of orthopaedic surgery (Hong Kong) Download date 22/09/2018 17:03:32 Link to Item http://hdl.handle.net/10147/239993 Find this and similar works at - http://www.lenus.ie/hse
Journal of Orthopaedic Surgery 2012;20(1):61-5 Acutrak versus Herbert fixation for scaphoid non-union and delayed union Kayode O Oduwole, 1 Benedikt Cichy, 1 John P Dillon, 1 Joan Wilson, 2 John O Beirne 1 1 Departments of Orthopaedic Surgery, Waterford Regional Hospital, Waterford, Ireland 2 Department of Occupation Therapy, Waterford Regional Hospital, Waterford, Ireland ABSTRACT Purpose. To compare the treatment outcome of Acutrak versus Herbert fixation for scaphoid non-union and delayed union. Methods. Records of 132 patients who underwent Herbert fixation (n=61) or Acutrak fixation (n=71) with or without bone grafting for scaphoid non-union and delayed union by a single surgeon were reviewed. The most common fracture site was the waist of the scaphoid (n=95), followed by the proximal pole (n=31) and the distal pole (n=6). Screw placement was considered accurate (n=120) when the was placed in the central one-third (axially) of the scaphoid; otherwise it was eccentric (n=12). Bone union was assessed radiographically and clinically. Functional outcome was assessed using the modified Mayo wrist score. Results. Respectively in the Herbert and Acutrak groups, the mean patient ages were 25.3 and 27.3 years (p=0.28), the mean intervals between injury and fixation were 12.2 and 17 months (p=0.38), the mean durations to bone union were 2.1 and 1.8 months (p=0.63), and the union rates were 77% and 93% (p=0.01). The union rate was significantly higher in fractures of the waist of the scaphoid than in the proximal and distal poles (94% vs. 71% vs. 33%, p=0.001). The union rate was significantly higher when the was placed accurately (axially) than eccentrically (Herbert : 84% vs. 40%, p=0.006; Acutrak : 96% vs. 0%, p=0.004). 84% of the Herbert s were placed axially, compared to 97% for the Acutrak s. Respectively, 67% and 85% of patients had satisfactory functional outcomes (p=0.03), whereas 23% and 7% of the patients had persistent non-union (p=0.05). Conclusion. The Acutrak enabled more accurate placement and achieved higher union rates and modified Mayo wrist scores than the Herbert did. Key words: bone s; fracture fixation, internal; scaphoid bone Address correspondence and reprint requests to: Dr Kayode O Oduwole, 2 Rossberry Park, Lucan Co, Dublin, Ireland. E-mail: odukayolajide@yahoo.com
62 KO Oduwole et al. Journal of Orthopaedic Surgery INTRODUCTION Non-union rates of scaphoid fractures treated with a plaster cast were 5 to 10% 1 to up to 50%. 2 Surgical intervention is needed to achieve stable union, restore scaphoid anatomy, and prevent/reverse carpal collapse. Fixation with a Herbert with or without bone grafting is commonly performed. Cannulated s (e.g. Acutrak) are superior to the Herbert in terms of compression force, 3 6 which enables rigid fixation, prevents displacement, and shortens the time of immobilisation, and thus improve functional outcome. In addition to the compromised blood supply, the persistent bending force applied to the scaphoid as a result of its position between the proximal and distal carpal rows may lead to non-union. This bending force tends to cause dorsal angulation when the scaphoid is fractured. 7,8 The number of loading cycles required to displace a Acutrak is 1.6 times more than that for the Herbert. 5 Accurate placement of the is important in restoring the bone alignment and in preventing malrotation. The union time is shorter when the proximal threads are located in the centre of the proximal pole. 9 The Acutrak is cannulated for easy placement over a guide wire. This avoids the need for jigs, which may malrotate the fragments during insertion. 10 We compared the treatment outcome of Acutrak versus Herbert fixation for scaphoid non-union and delayed union. (a) (b) MATERIALS AND METHODS Records of 132 patients with scaphoid non-union and delayed union who underwent Herbert fixation (n=61, between July 1996 and June 2000) or Acutrak fixation (n=71, between July 2000 and December 2005) with or without iliac crest bone grafting by a single surgeon were reviewed (Fig.). Patients with acute scaphoid fractures, degenerative changes, or incomplete peri-operative or functional outcome data were excluded. Scaphoid fractures were categorised according to the fracture sites 11 ; the most common was the waist (n=95), followed by the proximal pole (n=31) and the distal pole (n=6). The Russe approach was used for waist fractures, whereas the dorsal approach was used for proximal pole fractures. Sclerotic and fibrous tissues were resected. Corticocancellous bone grafts from the iliac crest were used to restore the length and to correct any hump back deformity after resection of pseudoarthrosis. Bone grafts were placed in the centre Figure (a) Acutrak and (b) Herbert fixations for scaphoid non-union or delayed union. of the defect. The Herbert was inserted using a Huene jig, whereas the Acutrak was inserted over a guide wire. Any gap between the graft and fracture ends was packed with cancellous bone chips. Screw placement was considered accurate (n=120) when the was placed in the central one-third (axially) of the scaphoid; otherwise it was eccentric (n=12). 9 The final position of the was confirmed by fluoroscopy. Capsular repair was performed for all patients. Postoperatively, a Plaster of Paris back slab was applied for 10 to 14 days and then the sutures were removed. A full cast was used for further 4 to 6 weeks.
Vol. 20 No. 1, April 2012 Acutrak versus Herbert fixation for scaphoid non-union and delayed union 63 Clinical and radiographic outcomes were assessed at weeks 6, 12, and 24. All patients had a minimum follow-up of 2 years. Clinical bone union was defined as no tenderness, whereas radiological union was evaluated using the Fillan and Herbert criteria. 12 A modified Mayo wrist score was used for functional assessment (Table 1). Screw failure was defined as revision for non-union, regardless of the reason. The Herbert and Acutrak groups were compared using the Mann-Whitney U test, Fisher s exact test, or Chi-squared test, as appropriate. A p value of <0.05 was considered statistically significant. proximal and distal poles (94% vs. 71% vs. 33%, p=0.001, Table 3). The union rate was significantly higher when the was placed accurately (axially) than eccentrically (Herbert : 84% vs. 40%, p=0.006; Acutrak : 96% vs. 0%, p=0.004; Table 3). 84% of the Herbert s were placed axially, compared to 97% of the Acutrak s. The union rate was significantly lower in the Herbert than Acutrak group (77% vs. 93%, p=0.01, Fisher s exact test). Patient age and the interval between injury and fixation did not affect the union rate. Respectively in the Herbert and Acutrak groups, functional outcomes were excellent in 41% RESULTS Respectively in the Herbert and Acutrak groups, the mean patient ages were 25.3 and 27.3 years (p=0.28, Table 2), the mean intervals between injury and fixation were 12.2 (range, 3 144) and 17 (range, 4 180) months (p=0.38), and the mean durations to bone union were 2.1±3.6 and 1.8±3.6 months (p=0.63). The union rate was significantly higher in fractures of the waist of the scaphoid than in the Table 1 Modified Mayo wrist score* Category Score Pain No pain 25 Mild pain with vigorous activities 20 Pain only with weather changes 20 Moderate pain with vigorous activities 15 Mild pains with activities of daily living 10 Moderate pain with activities of daily living 5 Pain at rest 0 Satisfaction Very satisfied 25 Moderately satisfied 20 Not satisfied but working 10 Not satisfied, unable to work 0 Range of motion 100% normal 25 75 99% normal 15 50 74% normal 10 25 49% normal 5 0 24% normal 0 Grip strength 100% normal 25 75 99% normal 15 50 74% normal 10 25 49% normal 5 0 24% normal 0 * Excellent, 90 100; good, 80 89; fair, 65 79; and poor, <65 Table 2 Comparison of Herbert and Acutrak fixations Parameter Herbert (n=61) Acutrak (n=71) Mean±SE patient age (years) 25.3±1.0 27.3±1.1 No. of males:females 56:5 62:9 No. of patients with dominant hand 37 34 injured Occupation (no. of patients) Heavy manual 22 22 Light manual 12 15 Clerical/skilled 27 34 Injury mechanism (no. of patients) Fall 30 38 Sports 18 19 Work-related 7 9 Road traffic accident 5 2 Fight 1 3 Previous treatment (no. of patients) Unrecognised/missed 40 31 Plaster of Paris 20 39 Physiotherapy/chiropractic 1 1 Fixation (no. of patients) Screw + bone grafting 57 66 Screw alone 4 5 Table 3 Union rates in terms of fracture site and placement Parameter No. of patients (no. [%] of union) Herbert Acutrak Screw placement Eccentric 10 (4 [40]) 2 (0 [0]) Axial 51 (43 [84]) 69 (66 [96]) p Value 0.006 0.004 Fracture site Waist 44 (38 [86]) 51 (51 [100]) Proximal pole 17 (9 [53]) 14 (13 [93]) Distal pole 0 6 (2 [33]) p Value 0.01 0.001
64 KO Oduwole et al. Journal of Orthopaedic Surgery Table 4 Revision for both Herbert and Acutrak fixations Parameter Herbert Acutrak Non-union 14 5 Revision 10 4 Regrafting 2 2 Exchange to Acutrak 4 1 Salvage procedure (wrist fusion and 4-corner fusion) 4 1 and 60% of the patients, good in 26% and 25%, fair in 22% and 10%, and poor in 11% and 5% (p=0.03). 23% and 7% of the patients had persistent non-union (p=0.05) [Table 4]. Two from each group were due to avascular necrosis; all 4 failed to unite after revision surgery, except for one Acutrak patient who (despite union) eventually underwent 4-corner fusion owing to persistent pain from carpal instability of the scapholunate joint. Four other patients in the Herbert group and one patient in the Acutrak group also underwent fusion owing to progressive wrist pain (Table 4). One patient in the Herbert group had persistent paraesthesia due to injury to an aberrant branch of the radial nerve. DISCUSSION The union rate for cannulated fixation and pedicle vascularised bone grafting can be as high as 96%, 13 which is similar to the 93% in our Acutrak fixation group. In our study, the union rate for Herbert fixation was 77%, which is comparable to that reported in another study. 14 Outcomes of the 2 fixation systems are similar. 11 Bone union strongly correlates with technical factors related to the procedure. 10 Adequate realignment and proper length are essential. In our study, the was placed accurately (axially) in 97% of the patients in the Acutrak group, compared to 84% in the Herbert group. Eccentric placement lowers the union rate 9 and may lead to breakage. The Acutrak is cannulated, which facilitates placement over a guide wire. 9 The use of the Huene device or other jigs may potentially malrotate fragments during compression. 10,15 Failure can also be due to inadequate length and inaccurate jig placement. 15 Application of a jig may damage the scaphotrapezial joint and lead to secondary arthritis. 16 Herbert fixation is technically more demanding and requires more skill and experience. 12,15 In cases of failure, repeat bone grafting and internal fixation is advised if feasible. Salvage procedure should be reserved for those with carpal collapse. There were 2 limitations in our study. Smoking affects the union rate after fixation for scaphoid non-union. 17,18 Nonetheless, patient characteristics of the 2 groups were very similar. The surgeon may have attained more skills and experience in the later group of patients. A cannulated variety of the Herbert (Herbert-Whipple ) may provide equal advantage as the Acutrak. Furthermore, the fluoroscopy had also improved with time and achieved better visualisation in cannulated wire placement. The superiority of Acutrak fixation to Herbert fixation in terms of the union rate was partly due to more accurate placement. REFERENCES 1. Proctor MT. Non-union of the scaphoid: early and late management. Injury 1994;25:15 20. 2. Herbert TJ, Fisher WE. Management of the fractured scaphoid using a new bone. J Bone Joint Surg Br 1984;66:114 23. 3. Bailey CA, Kuiper JH, Kelly CP. Biomechanical evaluation of a new composite bioresorbable. J Hand Surg Br 2006;31:208 12. 4. Faran KJ, Ichioka N, Trzeciak MA, Han S, Medige J, Moy OJ. Effect of bone quality on the forces generated by compression s. J Biomech 1999;32:861 4. 5. Toby EB, Butler TE, McCormack TJ, Jayaraman G. A comparison of fixation s for the scaphoid during application of cyclical bending loads. J Bone Joint Surg Am 1997;79:1190 7. 6. Rankin G, Kuschner SH, Orlando C, McKellop H, Brien WW, Sherman R. A biomechanical evaluation of a cannulated compressive for use in fractures of the scaphoid. J Hand Surg Am 1991;16:1002 10. 7. Cooney WP, Dobyns JH, Linscheid RL. Fractures of the scaphoid: a rational approach to management. Clin Orthop Relat Res 1980;149:90 7. 8. Amadio PC, Berquist TH, Smith DK, Ilstrup DM, Cooney WP 3rd, Linscheid RL. Scaphoid malunion. J Hand Surg Am 1989;14:679 87. 9. Trumble TE, Clarke T, Kreder HJ. Non-union of the scaphoid. Treatment with cannulated s compared with treatment with Herbert s. J Bone Joint Surg Am 1996;78:1829 37.
Vol. 20 No. 1, April 2012 Acutrak versus Herbert fixation for scaphoid non-union and delayed union 65 10. Adams BD, Blair WF, Reagan DS, Grundberg AB. Technical factors related to Herbert fixation. J Hand Surg Am 1988;13:893 9. 11. Gregory JJ, Mohil RS, Ng AB, Warner JG, Hodgson SP. Comparison of Herbert and Acutrak s in the treatment of scaphoid non-union and delayed union. Acta Orthop Belg 2008;74:761 5. 12. Filan SL, Herbert TJ. Herbert fixation of scaphoid fractures. J Bone Joint Surg Br 1996;78:519 29. 13. Tu YK, Chen AC, Chou YC, Ueng SW, Ma CH, Yen CY. Treatment for scaphoid fracture and nonunion the application of 3.0 mm cannulated s and pedicle vascularised bone grafts. Injury 2008;39(Suppl 4):S96 106. 14. Christodoulou LS, Kitsis CK, Chamberlain ST. Internal fixation of scaphoid non-union: a comparative study of three methods. Injury 2001;32:625 30. 15. Ford DJ, Khoury G, el-hadidi S, Lunn PG, Burke FD. The Herbert for fractures of the scaphoid. A review of results and technical difficulties. J Bone Joint Surg Br 1987;69:124 7. 16. Barton NJ. Twenty questions about scaphoid fractures. J Hand Surg Br 1992;17:289 310. 17. Dinah AF, Vickers RH. Smoking increases failure rate of operation for established non-union of the scaphoid bone. Int Orthop 2007;31:503 5. 18. Little CP, Burston BJ, Hopkinson-Woolley J, Burge P. Failure of surgery for scaphoid non-union is associated with smoking. J Hand Surg Br 2006;31:252 5.