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Scaphoid Malunion: Outcomes of Corrective Osteotomy Compared to Salvage Procedures
Blake Paul Gillette, MD1; Sanjeev Kakar, MD, MRCS, MBA2; Peter C. Amadio, MD1
1Orthopaedic Surgery, Mayo Clinic, Rochester, MN; 2Orthopaedics, Mayo Clinic, Rochester, MN

Introduction: Scaphoid fractures are common and many times require prolonged immobilization or surgical fixation for union. Although a nonunion often complicates this fracture, union alone may not be sufficient enough for good clinical outcomes.

Methods: A retrospective review was conducted analyzing the outcome of all scaphoid malunions treated at single institution over a 20 year period. All patients were diagnosed with a scaphoid malunion by radiographs/tomograms. Standardized preoperative and postoperative assessments included wrist range of motion, grip strength, and the Mayo Wrist Score. Intrascaphoid and carpal angles as well as arthritis of the wrist were evaluated preoperatively and at final follow up.

Results: Thirty patients were diagnosed with a scaphoid malunion.  21 patients underwent surgical intervention; and of those, 18 had appropriate follow up for an average of 29.7 months (range 2 to 140 months). Nine patients had undergone previous intervention of bone grafting for treatment of scaphoid nonunion. Ten patients underwent corrective intrascaphoid osteotomy with nine autografts from the iliac crest and one vascularized medial femoral condyle autograft. Five patients underwent cheilectomy and/or radial styloidectomy; five had a scaphoidectomy with a midcarpal fusion. Nine patients opted against surgical intervention. The average initial lateral intrascaphoid angle (LISA) was 46° and did not significantly differ between groups. Average preoperative to postoperative change in grip strength and Mayo wrist scores respectively for corrective osteotomy were 4 kg (range -15 to 23) and 6.1 (range -20 to 30), for less invasive procedures 11.3 kg(range 4 to 20) and 25 (range 20 to 30), and for scaphoidectomy with midcarpal fusion 7.3 kg (range 2 to 16) and 25 (range 15 to 35). 

Conclusion: An attempt at restoring wrist biomechanics with an osteotomy may not improve long term clinical outcomes when compared to salvage procedures.  Proceeding with osteotomy in the younger patient with a malunion but minimal to moderate symptoms continues to present a particular dilemma to the surgeon.

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