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Scaphoid Nonunions with Segmental Defects Treated with Locking Plate Fixation and Pure Cancellous Grafting: First Clinical Report
Scott G. Edwards, MD;
Department of Orthopaedic Surgery, The CORE Institute, 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. Volar locking plates may offer several advantages over headless screws for fixation for scaphoid nonunion management: (1) preserved intraosseous vascularity; (2) increased surface area for bony healing; and (3) maintenance of a gap for pure cancellous grafts. 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. Scaphoid volar locking plates may allow for cancellous grafts to be used as opposed to the more invasive, expensive and perhaps less physiologic grafting options.

Methods: 27 consecutive patients were prospectively enrolled that met inclusion criteria of having an established scaphoid nonunion with segmental defect or bone loss with or without the presence of avascular necrosis. In addition to routine radiographs, all patient were assessed by MRI for vascular status. All patients were treated with locked volar plating with cancellous graft from the distal radius and/or olecranon. SNAC II-IV were excluded. Patients were immobilized until radiographic evidence of bony healing which was confirmed on CT scan. Time to healing was recorded as well as preoperative and postoperative motion, grip strengths, analog pain scores, and DASH scores.

Results: 22 males and 5 females with a mean age of 33.2 years were enrolled. The mean time from initial injury was 72 months (range: 14 weeks to 28 years). 9 patients presented with proximal pole nonunion, 7 of which had AVN. Mean follow up was 19 months (range 9 to 24 months). 3 patients failed previous scaphoid fracture fixation with headless screws. At the final follow up, all patients demonstrated bony healing. Mean time for bony healing was 84 days (range: 46 to 196 days). Mean grip strengths increased 14% and was 87% of the contralateral side, mean DASH scores increased 32.4 points, and motion remained relatively unchanged from the preoperative measurements. Mean operative time was 42 minutes.

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. Avascular necrosis does not appear to be a contraindication to this procedure, in fact success healing can be expected. This technique may offer faster and more predictable union with less morbidity, expense, and expertise required.

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