Volar Scaphoid Plate Fixation with Vascularized Bone Graft for Treatment of Scaphoid Nonunion
Seth D Dodds, MD; Max N Seiter, MD; John Barton Williams, MD; Clark Jia Chen, BS; University of Miami, Miami, FL
Purpose: Scaphoid nonunions present difficult clinical challenges, particularly in the setting of avascular necrosis, significant deformity, or bone loss. While headless screw fixation has been the previous treatment standard, new fixation methods have been proposed, particularly for humpback deformity which benefits from a volar approach. This study aims to evaluate the outcomes of scaphoid nonunion treatment utilizing volar scaphoid buttress plating with pedicled volar carpal artery bone graft from the distal radius.
Methods: We conducted retrospective review of 16 consecutive patients with scaphoid nonunions treated by one surgeon with volar buttress plating. Patients presented with different characteristics of nonunion: avascular necrosis identified on CT scan (11 patients) and severe humpback deformity; or cystic bone loss of >7mm on CT (7 patients) including nonunion of >1.5 years, or failed internal fixation with persistent deformity. Patients were treated with 1.5 mm Medartis Volar Scaphoid Buttress plate and vascularized bone graft from volar distal radius using radial portion of the palmar carpal arch as an arterial pedicle, through the same incision. We assessed radiographic union, range of motion, and grip strength.Radiographic evidence of fracture-healing was defined as >50% bridging trabecular bone on CT scan, or if unavailable, plain radiographs were coupled with clinical evidence of union of pain-free ROM and non-tenderness over anatomic snuffbox.
Results: Of 16 patients, 14 (87.5%) progressed to union. Of the 2 patients without union, one patient had proximal without distal union, and did not require revision; the other patient was lost to follow-up at 6 weeks, and returned at 14 months with persistent nonunion and multiple loose screws, and underwent revision surgery. In the 15 patients not requiring revision: average change in flexion was +7.3 deg (p=.121), and change in extension +13.4 deg (p=.089). Average postoperative grip strength for affected wrist was 31.5 kg compared with 38.6 kg for contralateral wrist (p= <.05). Three patients with union experienced intermittent clicking with maximal wrist flexion, and underwent plate removal due to impingement at 1 year, after confirmation of scaphoid healing on CT scan.
Conclusions: Our study presents a consecutive series of scaphoid waist nonunions treated with volar scaphoid plating and vascularized bone grafting. We show a high rate of radiographic union and improved grip strength with a low level of complications. A subset of patients required hardware removal secondary to prominence. Volar scaphoid plating presents a viable alternative to headless scaphoid screw fixation for difficult scaphoid nonunions.
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