Outcomes of Scaphoid Nonunion with Segmental Defect Treated with Plate Fixation and Autogenous Cancellous Graft: First Clinical Report
Jill A Goodwin, MD1; Sean M Mitchell, MD1; Ryan M DiGiovanni, MD1; Erin Stockwell, BS1; Scott G Edwards, MD2; (1)University of Arizona College of Medicine Phoenix, Phoenix, AZ, (2)The CORE Institute, Phoenix, AZ
Introduction: Treatment of scaphoid nonunion with segmental defect presents a challenging clinical problem. Various techniques have been proposed, usually involving vascularized bone grafting with or without structural bone. Outcomes of these complex procedures have been inconsistent in the medical literature. The authors hypothesize that similar or perhaps better clinical and radiographic outcomes are possible with a relatively simplified technique of volar plate fixation augmented with autogenous pure cancellous graft.
Materials & Methods: The authors performed a retrospective chart review of 34 consecutive patients with scaphoid nonunion with segmental defect treated with plate fixation and pure cancellous bone grafting. Surgical management included a single volar incision, reduction, insertion of bone graft from ipsilateral olecranon and/or distal radius, and application of a volar locking plate. Post-operative outcome measures included time to union based on computerized tomography (CT), return to work, patient-reported pain and disability scores, grip strength, and range of motion (ROM).
Results: 34 patients with an average age of 31 years (range, 16-55) were treated with volar plate fixation and cancellous grafting an average of 34 months after initial injury. 26 patients (76%) were treated for nonunion at the scaphoid waist, 7 (21%) at the proximal pole, and 1 (3%) at the distal pole. Mean final follow-up was 18.7 months (range, 12-34). Union was achieved in all patients and average time to union was 63 +/- 18 days post-operatively. Mean DASH score improved from 27.1 +/- 7.3 pre-operatively to 11.8 +/- 5.8 post-operatively. Mean visual analogue scale (VAS) improved from 6.7 +/- 0.7 pre-operatively to 1.7 +/- 0.7 post-operatively. All employed patients returned to work, although 3 (9%) did not return to full capacity. Grip strength improved from 81.2% of the non-operative side pre-operatively, to 94.5% post-operatively. At final follow-up, ROM including wrist flexion, extension, ulnar deviation, and radial deviation improved 128%, 168%, 115%, and 183%, respectively, compared to pre-operative ROM.
Conclusions: The combination of scaphoid plate fixation and pure cancellous bone grafting for scaphoid nonunion with segmental defects yields reliable union rates and good patient outcomes. Autogenous cancellous bone grafting is a reliable alternative to more technically demanding or morbid grafting procedures for the treatment of scaphoid nonunion with segmental bone defects.
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