Purpose
Currently, there is no consensus on the optimal treatment for scaphoid nonunion with
avascular necrosis (AVN). Various techniques, often involving vascularized corticocancellous
bone grafting, have been proposed. The authors hypothesized that similar outcomes
might be possible with volar plate fixation augmented with autogenous pure cancellous
graft.
Methods
The authors performed a retrospective chart review of 13 cases of scaphoid nonunions
with AVN in 12 patients treated with plate fixation and pure cancellous bone grafting.
Surgical management included a volar incision, reduction, impaction of cancellous
bone graft from the ipsilateral olecranon and/or distal radius, and application of
a volar locking plate. Postoperative outcome measures included time to union based
on computed tomography, patient-reported pain and disability scores, grip strength,
range of motion, and return to work and sports.
Results
The average patient was 32 years old (range, 17–50 years) and treated an average of
18 months after initial injury (range, 6–49 months). Two of 12 patients (15.7%) were
female, 3 of 12 patients (25%) were smokers, and 5 of 12 patients (41.7%) had failed
union with previous screw fixation. Twelve scaphoids (92.3%) were treated for AVN
associated with a proximal pole fracture, and 1 (7.7%) for AVN proximal to a scaphoid
waist fracture. Mean follow-up was 19.5 months (range, 12–29 months). Union was achieved
in all patients. Two scaphoids (15%) achieved union by 12 weeks, 7 scaphoids (54%)
by 18 weeks, 2 scaphoids (15%) by 24 weeks, and 2 scaphoids (15%) by 30 weeks (range,
8.9–28 weeks). Mean Disabilities of the Arm, Shoulder, and Hand score improved from
30.6 ± 6.2 before surgery to 17.2 ± 6.5 after surgery. All 11 employed patients returned
to work, although 3 (27.2%) did not return to full capacity.
Conclusions
Scaphoid plate fixation and pure nonvascularized cancellous bone grafting for scaphoid
nonunion with AVN yields excellent union rates and good patient-reported and functional
outcomes.
Type of study/level of evidence
Therapeutic IV.
Key words
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Article info
Publication history
Published online: August 10, 2018
Accepted:
June 22,
2018
Received:
September 13,
2017
Footnotes
S.G.E. is a consultant for Medartis AG (Basel, Switzerland). The rest of the authors declare that no benefits in any form have been received or will be received related directly or indirectly to the subject of this article.
Identification
Copyright
© 2019 by the American Society for Surgery of the Hand. All rights reserved.
