A Comparative Analysis of Scaphoid Nonunion Healing: Assessing Different Bone Grafting Types in Volar Plating Treatment
James C Gainer, MD1, Michael J Stoltz, MD1 and Luke P Robinson, MD2, (1)University of Louisville, Louisville, KY, (2)Norton Healthcare, Louisville, KY
Scaphoid waist fracture nonunions pose unique challenges. Bone graft options, including cancellous and corticocancellous types, have been evaluated with headless screw fixation. However, healing outcomes with volar locking plates and different bone grafting techniques remain unexplored. Our hypothesis is that cancellous grafting enhances healing compared to corticocancellous graft as confirmed on CT scan when utilized with volar plating of scaphoid waist nonunions.
After IRB approval, we conducted a retrospective chart review of 36 patients with scaphoid waist fracture nonunions who underwent surgical treatment using volar locking plates and bone grafting. The procedures were performed by seven hand surgeons at a single institution from April 2020 to March 2023. Inclusion criteria included a minimum 90-day post op follow-up for scaphoid plate procedures and an available post op CT scan. Graft selection was based on surgeon preference. Corticocancellous graft from the radius or iliac crest was compared to packed cancellous autograft from the radius or iliac crest. Postop CT scans were reviewed independently by three hand surgeons to determine the percentage of healing. Analysis of data was performed using SPSS.
Using inclusion criteria, 23 patients with scaphoid fractures were evaluated. Fracture union rate was 96 % (22/23). CT scans reviewed were obtained at an average of 116 days post op. The cancellous group had an average age of 27.4 years with a mean time from injury to surgery of 6.3 months (range: 1-18). Conversely, the corticocancellous group had an average age of 26.4 years, and a longer average time from injury to surgery of 10.4 months (range: 1-36). The cancellous graft group displayed significantly higher healing percentages compared to the corticocancellous graft group (80.7 ± 17% versus 47.8 ± 35%, p = 0.006). This is despite a shorter time from surgery to CT scan in the cancellous group (110 ± 61 days for cancellous grafts, 134 ± 73 days for corticocancellous grafts (one-sided p value = 0.22). Overall healing score displayed good interrater reliability (ICC = 0.89).
Volar plating combined with bone grafting achieves a high union rate for scaphoid nonunions. The packed cancellous grafting technique promotes earlier healing at the nonunion site. Corticocancellous grafts are typically used when utilizing a screw for scaphoid fractures to withstand compressive forces. However, with a volar plate acting as a buttress, there is no need to counteract compressive forces. Therefore, we recommend cancellous grafting for volar plating of scaphoid waist nonunions.
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