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Treating Scaphoid Nonunions with Plate Fixation and Cancellous Grafting: First Clinical Report
Scott G. Edwards, MD
Banner University Medical Center, Phoenix, AZ

Background: Scaphoid nonunions have traditionally been treated with headless screw or pin fixation with vascular or non-vascular corticocancellous graft to add structural integrity. Cancellous grafts have been proposed by many investigators as being physiologically superior to corticocancellous grafts. Vacularized grafts carry the added burden of increased costs and morbidity over non-vascuarlized grafts. It would seem advantageous to devise a technique that would allow for cancellous grafts to be used as opposed to the more invasive, expensive and perhaps less physiologic grafting options. Locked volar plating of scaphoids with segmental defects allows the physiologic superior cancellous graft to be used without concerns to structural compromise.

Hypothesis: Scaphoid nonunions with segemental defects treated with volar locked plating and cancellous grafting will heal as fast, if not faster, than other more traditional techniques with comparable functional outcomes.

Methods: 14 consecutive patients with established scaphoid nonunions were treated with locked volar plating with cancellous graft from the distal radius and/or olecranon. All patients were screened with MRI to assess vascularity, but were not excluded if they demonstrated AVN. SNAC II-IV were excluded. Average age of patient was 33.2 years, and all were male. Operative time, complications and time to union was recorded. Bony union was confirmed with CT scan. Grip strengths, DASH and Mayo wrist scores were obtained.

Results: 5 patients presented with AVN of the proximal pole confirmed with MRI. All patients had segmental defects following intraoperative debridement. Average time from initial injury was 72 months (range: 14 weeks to 28 years). One patient had a previous surgery for the acute fracture with a headless screw which progressed to established nonunion. Average operative time was 40 minutes. Average time to union was 84.4 days (range: 46 to 196 days). At final follow up, grip strengths were 87% the contralateral side. DASH and Mayo wrist scores were better than previously reported values.

Conclusions: Locked volar plate fixation with cancellous graft compare favorably to previous reports of more traditional techniques that involve vascularized or non-vascularized corticocancellous grafting. Although randomized controlled trials are required, this technique may offer faster and more predictable union with less morbidity, expense, and expertise required.

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