Eur J Trauma Emerg Surg DOI 10.1007/s00068-017-0773-y

ORIGINAL ARTICLE

Clinical outcome after alternative treatment of scaphoid fractures and nonunions A. L. Sander1,4 · K. Sommer1 · D. Schäf1 · C. Braun2 · I. Marzi1 · T. Pohlemann3 · J. Frank1 

Received: 29 December 2016 / Accepted: 8 February 2017 © Springer-Verlag Berlin Heidelberg 2017

Abstract  Purpose  Achieving stable fixation of scaphoid fractures and nonunions continues to be a challenge. Compression screw fixation has been the current standard surgical procedure. However, in some cases, bone healing cannot be achieved and requires further revision. Recent series reintroduced volar plating as valid option for stable fixation. The aim of the study was to review clinical outcome of alternative scaphoid treatment. Methods  From 2011 to 2014, nine patients with scaphoid fracture were treated by Headless Compression Screw (HCS) and seven patients with scaphoid nonunion by HCS or volar mini condylar plate with bone graft. The average age was 34.4 years and the average time to follow-up was 19.3 months. From 1996 to 1998, 38 patients with scaphoid nonunion were treated using compression screw (S-group) or volar mini condylar plate (P-group) with bone graft. The

Electronic supplementary material  The online version of this article (doi:10.1007/s00068-017-0773-y) contains supplementary material, which is available to authorized users. * A. L. Sander [email protected] 1

Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Johann Wolfgang Goethe-University, Frankfurt/Main, Germany

2

Department of Trauma, Hand and Reconstructive Surgery, St.-Antonius-Hospital, Kleve, Germany

3

Department of Trauma, Hand and Reconstructive Surgery, Saarland University Medical Center, Homburg, Germany

4

Klinik für Unfall‑, Hand‑ und Wiederherstellungschirurgie, Universitätsklinikum Frankfurt, Theodor‑Stern‑Kai 7, 60590 Frankfurt, Germany





average age was 39.6 years and the average time to followup was 26.2 months. Results  The union rate was 100%. For scaphoid fractures, the mean Modified Mayo Wrist Score (MMWS) was 94.1 and the DASH score 7.4. From 2011 to 2014, the MMWS was 87.9 and the DASH score 7 in scaphoid nonunions. In the period between 1996 and 1998, the MMWS was 67.2 in the P-group and 58.6 in the S-group, and the DASH score 16.8 and 28.2. Conclusions  Our study demonstrated that appropriate application of the HCS was able to produce very satisfactory results in scaphoid fractures and nonunions. In our opinion, however, the method of scaphoid plate osteosynthesis can achieve a higher degree of stability, particularly rotational stability, in case of multifragmentary avascular scaphoid nonunions. Keywords  Scaphoid fracture · Scaphoid nonunion · Compression screw · Mini condylar plate · 1,2-ICSRA

Introduction Several surgical techniques for the optimal treatment of scaphoid fractures and established nonunions have been described. The use of compression screw fixation is considered to be the current standard surgery [1–12]. Herein, continuous development of implants has led to various screw systems. The aim of all implants is to provide rigid fragment fixation per high interfragmentary compression [4]. Differences between the various systems are the screw size and threads as well as cannulated versus non-cannulated screws. However, even with vascularized bone grafts (VBG), it is not always possible to achieve consolidation. Particularly, in these situations,

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poor interfragmentary stability seems to be the reason for failed healing promoting the development of new techniques [13]. Recent series reintroduced plate osteosynthesis as biomechanically more favorable as the compression screws for the fixation of unstable, multifragmentary scaphoid nonunions [13, 14]. The use of plate osteosynthesis has been described earlier with the Ender compression hooked blade plate system and the volar buttress plate [15–17]. Whereas Ender hook plate functioned by fixing the main bone fragments and exerting pressure on the inbetween lying bone transplant, the volar buttress plate was used to stabilize the reduced scaphoid fragments and buttress the relevant compression or axial forces [15–18]. This study was undertaken to review clinical outcome of alternative scaphoid treatment with Headless Compression Screw (HCS) for scaphoid fractures and HCS or mini condylar plate for scaphoid nonunions, and to demonstrate the application of VBG for scaphoid nonunions with avascular necrosis (AVN).

Materials and methods

Fig.  1  a CT: Scaphoid nonunion after wrist trauma 1 year previously. b Intraoperative situs: The pseudarthrosis was debrided with a spherical drill. c Intraoperative situs: Mini condylar plate. d, e Postoperative

X-ray. f, g X-ray after 1 year: patient obtained free ROM after implant removal

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Selection of patients and variables From 12/2011 to 08/2014, we treated nine scaphoid fractures and seven scaphoid nonunions by osteosynthesis. The ratio between men and women was 15:1. The average age was 34.4 years. The mean period of follow-up was 19.3 months. Between 01/1996 and 12/1998, 38 patients with scaphoid nonunions were treated operatively. The ratio between men and women was 34:4. The average age was 39.6 years and the average time of the follow-up 26.2 months. All scaphoid nonunions were secondary referrals to our clinic. All these patients had an established nonunion persisting for at least 6 months after injury, with wrist pain, weakness, or both. Patients with open wrist fracture, transscaphoid perilunate fracture dislocation, ipsilateral distal radius fracture, or advanced wrist arthritis prior to injury were excluded from our study. One patient had previous unsuccessful surgery with screw in place before our plating (Fig. 1).

Clinical outcome after alternative treatment of scaphoid fractures and nonunions

Clinical assessment

Postoperative care

Clinical assessment used a standard proforma, which included pain, range of motion (ROM), and grip strength in kilograms measured by a ­BASELINE® Hydraulic Hand Dynamometer (Fabrication Enterprises, Inc., White Plains, New York, USA). We used the Disabilities of Arm and Shoulder (DASH) questionnaire (0: no limitation, 100: maximum limitation) and the Modified Mayo Wrist Score (MMWS; 91–100: excellent, 80–90: good, 65–79: fair, < 65: poor) for evaluating our clinical results.

A forearm cast with thumb spica was applied postoperatively allowing unrestricted thumb interphalangeal motion while maintaining the wrist in slight extension. Cast immobilization was discontinued after 14 days and converted to a closed scotch cast for a total of 8 weeks for scaphoid fractures and 10 weeks for scaphoid nonunions. Full weightbearing was allowed after a total period of 12 weeks. Plates were removed after 4 months. Until removal of the implant, an orthosis was recommended at night-time to prevent wrist flexion.

Radiographic assessment

Statistical analysis

The diagnosis of scaphoid fracture was obtained by the conventional X-ray examinations and preoperative computer tomography (CT) scans with multiplanar reconstructions. In cases of scaphoid nonunion, the presence of scaphoid proximal pole AVN was examined by additional magnetic resonance (MR) imaging. The criteria used to establish healing were the absence of pain, radiographic evidence of bridging bony trabeculae across the graft with standard scaphoid views, and no signs of implant loosening. In case of doubt, a CT was performed.

Statistical evaluation was performed using the Mann–Whitney test. Values of P < 0.05 were considered statistically significant.

Surgical technique Scaphoid fractures were treated by 2.4 mm HCS (Synthes GmbH, Oberdorf, Switzerland) through volar or dorsal approach depending on fracture type. A guide wire was carefully inserted under fluoroscopic control. The screw length was measured and a cannulated reamer was inserted over the wire. The reamer was then removed and the HCS of the appropriate length was inserted. The screw position was verified with fluoroscopic methods. Scaphoid nonunions were accessed with a volar approach on the radial side of the flexor carpi radialis. The nonunion was scraped with a spherical drill at low rotation speed under adequate irrigation (Fig. 1). During the period between 2011 and 2014, iliac crest non-VBG (43%) or distal radius autogenous spongy bone graft (14%) was used in simple nonunions. 1,2-Intercompartmental supraretinacular artery (1,2-ICSRA) pedicled VBG (43%) was used when there was AVN demonstrated on gadolinium enhanced MR imaging. Internal fixation was then accomplished either with HCS (86%) or with 1.5 mm mini condylar plate (Synthes GmbH, Oberdorf, Switzerland; 14%) (Fig.  1). From 1996 to 1998, iliac crest non-VBG was used in all cases (100%). Internal fixation occurred either with compression screw (S-group; 47%) or with volar mini condylar plate (P-group; 53%).

Results Successful bone union was obtained in all cases. Postoperative complications such as wound infections, hardware failure or loosening, malunions, or AVN were not observed. Radiographic evidence of scapholunate instability was equally absent. For scaphoid fractures, postoperative pain symptoms on the visual analogue pain scale (VAS) were measured with 0.3 points at rest. The maximally achieved grip strength was 94% compared to the uninjured side. The average motion of the wrist in extension was 64° (91%; compared to the uninjured side), flexion was 65° (92%), pronation 89° (100%), and supination 89° (100%). At the final examination, the mean DASH score was 7.4. The functional outcomes evaluated by the MMWS were excellent in 67% and good in 33%. For scaphoid nonunions in the period between 2011 and 2014, postoperative pain symptoms were measured with 0.7 points at rest. The maximally achieved grip strength was 86%. The average motion of the wrist in extension was 59° (86%), flexion was 58° (87%), pronation 88° (100%), and supination 88° (100%). At the final examination, the mean DASH score was 7. The functional outcomes evaluated by the MMWS were excellent in 43%, good in 43%, and fair in 14%. The excellent and good results were found in 86%, respectively. From 1996 to 1998, the maximally achieved grip strength was 84% in the P-group and 69% in the S-group compared to the uninjured side (*P < 0.05). The average motion of the wrist in extension compared to the uninjured side was 87% and 72% in flexion for the P-group, respectively, 71% and 56% for the S-group. At the final

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examination, the mean DASH score was 16.8 in the P-group and 28.2 in the S-group (*P < 0.05) and the MMWS 67.2 and 58.6.

Discussion Scaphoid fractures are increasingly being managed surgically with the compression screw fixation as current standard surgery to decrease long-term consequences, including nonunion, AVN, and arthritis [19]. Even for undisplaced scaphoid waist fractures, a trend towards operative treatment is occurring [20]. The continued development of implants for scaphoid fixation has led to a host of different screw systems with comparable good outcomes. Exemplary, Singisetti et al. established bony healing in all patients with scaphoid fractures type B2-B3 treated with internal fixation by HCS in a mean of 8 weeks [21]. Gehrmann et al. evaluated the clinical results of the HCS when used for treatment of 21 acute scaphoid waist fractures type B2. All fractures united after a mean time of 7.2 weeks. The mean DASH score was 7.1 and the average motion of the wrist in extension 61°, flexion 46°, radial abduction 25°, and ulnar abduction 31°. The maximally achieved grip strength was 86% compared to the uninjured side [4]. Our results using the HCS implant are similar obtaining successful bone union in all cases. At the final examination, the mean DASH score was 7.4. The average motion of the wrist in extension was 64°, flexion 65°, pronation 89°, and supination 89°. The maximally achieved grip strength was 94% compared to the uninjured side. Furthermore, in addition to recent fractures, the compression screw is also suitable for the treatment of pseudarthrosis in combination with bone graft [11, 19]. Ahmed et  al. performed a retrospective review of 56 consecutive scaphoid fixations using this device in patients with both acute and chronic fractures. Union rates were 100% in acute and 87% in chronic fractures [19]. Tu and colleagues achieved an union rate of 90% and satisfactory function rate of 82% in scaphoid nonunions treated with 3.0  mm cannulated screws with an average follow-up of 5 years [11]. These outcomes are congruent with the results in the present study, demonstrating even 100% union rates for scaphoid nonunions with HCS implant. Despite the well-established treatment option of screw osteosynthesis, it is not always possible to achieve consolidation in rare cases due to poor interfragmentary stability, inadequate bone graft fixation, as well as failure in correcting humpback deformity [13]. In this mechanical situation, plating seems to be the most consistent biomechanical form of osteosynthesis with high level of fragment stability, particularly rotational stability and safe bone graft fixation. Whereat, reduction of dorsal intercalated

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segment instability (DISI) simultaneously corrects humpback deformity and yields a straighter scaphoid [15–18]. Stanković and Burchhardt used the Ender hooked plate in 39 cases with 95% consolidation of the bone [18]. Braun et  al. performed operations with volar buttress plate osteosynthesis and cancellous bone grafting in addition in 16 cases. In all but one, the pseudarthrosis united. Metal slackening with erosion and rupture of the flexor pollicis longus tendon occurred in one patient [15]. Leixnering et  al. treated 11 patients by volar three-dimensional titanium miniplate and autogenous spongy bone from the iliac crest with follow-up for at least 6 months. All the nonunions united at a median time of ~4 months. All patients reported an improvement in their symptoms and function. The mean DASH score was 28 [13]. Ghoneim treated 14 patients by insertion of anterior wedge graft and internal fixation with the use of volar buttress plate and screws in a mean follow-up time of 11 months. Thirteen (93%) of the fourteen nonunions healed with sound radiographic union [14]. Equally, in the present study, successful bone union was obtained in all patients using a volar mini condylar plate in combination with bone graft. To avoid radiocarpal plate impingement and tendon rupture, plates were removed after 4 months. The maximally achieved grip strength was 84% compared to the uninjured side. The average motion of the wrist in extension was 87% and in flexion 72%. At the final examination, the mean DASH score was 16.8 and the MMWS 67.2. Beside the various methods of fixation, several procedures for obtaining bone grafts, including vascularized and non-vascularized, have been developed for treatment of nonunions [22, 23]. The reported union rates vary [11]. Using a non-vascularized iliac crest bone graft and fixation with a compression screw, Fernandez achieved 95% consolidation in 20 cases, Eggli et  al. 95% in 37 cases, and Braga-Silva et  al. 100% in 45 cases [22, 24, 25]. However, the conventional bone graft is not likely to be successful if the proximal pole is totally avascular [23]. Green’s results of 45 patients with scaphoid nonunion treated with Russe bone grafting strongly support this contention. 24 (92%) of 26 patients with good vascularity in the proximal pole achieved solid union. In patients in whom the vascularity of the proximal pole was spotty or diminished, the rate of union dropped to 71% (10 of 14). Most important, none of the five patients in whom the proximal pole was totally avascular achieved successful union [26]. Therefore, in case of severe ANV of the proximal pole, VBG should be strongly considered [23]. Many different methods have been reported for obtaining VBG such as grafts with vascular pedicle from the pronator quadratus or the ulna and free VBG from the iliac crest or the femoral supracondyle [27–30]. Zaidemberg et  al. presented a VBG from the radial aspect of the distal part of the radius. The vascular pedicle was based on the recurrent branch of the radial

Clinical outcome after alternative treatment of scaphoid fractures and nonunions

artery [31]. In the meantime, several different types of pedicled VBG harvested from the dorsal distal radius in human have been designed, including grafts based on 1,2-ICSRA, 2,3-ICSRA, the 4th extensor compartment artery (ECA), and the 5th ECA [11]. Whereas some have achieved very satisfactory results for scaphoid union using a distal radius VBG based on the 1,2-ICSRA, such as Zaidemberg et al. (100%), Steinmann et al. (100%), and Braga-Silva et al. (91%), some investigators, such as Chang et al. (68%), Boyer et al. (60%), and Straw et  al. (27%), have reported less satisfactory outcomes [22, 31–35]. The varying union rates seem to result predominantly from inadequate methods of internal fixation, extending the flap’s range of indications and technical difficulties [36]. The results of the present study are congruent with the outcomes of Zaidemberg et al. with 100% consolidation using the 1,2-ICSRA VGB [31]. In conclusion, proper application of cannulated screws can obtain quite satisfactory results in the treatment of scaphoid fractures and nonunions. Herein, the development of screw design has led to an improved outcome in our S-group over time. In our opinion, scaphoid plate osteosynthesis should be regarded as a salvage procedure in cases of multifragmentary avascular scaphoid nonunions due to more rigid fixation of both the nonunited scaphoid and the VBG. Disadvantage is certainly the necessity for implant removal after 4 months to prevent radiocarpal plate impingement and tendon rupture. Whereas, non-VBG is indicated in the correction of delayed unions that are not associated with AVN or collapse, VBG should be used in scaphoid nonunions with AVN in the proximal pole, and when the previous attempt for surgical fixation has failed. Although these are favorable results, further biomechanical and clinical studies are needed to establish a generally accepted treatment algorithm. Compliance with ethical standards  Conflict of interest  A. L. Sander, K. Sommer, D. Schäf, C. Braun, I. Marzi, T. Pohlemann, and J. Frank declare that they have no conflict of interest. Ethical approval  All procedures performed in the study involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent  Informed consent was obtained from all individual participants included in the study.

References 1. Adams BD, Blair WF, Reagan DS, Grundberg AB. Technical factors related to Herbert screw fixation. J Hand Surg Am. 1988;13:893–9.

2. Bunker TD, McNamee PB, Scott TD. The Herbert screw for scaphoid fractures. A multicentre study. J Bone Joint Surg Br. 1987;69:631–4. 3. Ford DJ, Khoury G, el-Hadidi S, Lunn PG, Burke FD. The Herbert screw for fractures of the scaphoid. A review of results and technical difficulties. J Bone Joint Surg Br. 1987;69:124–7. 4. Gehrmann SV, Grassmann JP, Wild M, Jungbluth P, Kaufmann RA, Windolf J, Hakimi M. Treatment of scaphoid waist fractures with the HCS screw. GMS Interdiscip Plast Reconstr Surg DGPW. 2014; doi:10.3205/iprs000051. 5. Herbert TJ, Filan SL. Proximal scaphoid nonunion-osteosynthesis. Handchir Mikrochir Plast Chir. 1999;31:169–73. 6. Herbert TJ, Fisher WE. Management of the fractured scaphoid using a new bone screw. J Bone Jt Surg Br. 1984;66:114–23. 7. Krimmer H, Kremling E, van Schoonhoven J, Prommersberger KJ, Hahn P. Proximal scaphoid pseudarthrosis—reconstruction by dorsal bone screw and spongiosa transplantation. Handchir Mikrochir Plast Chir. 1999;31:174–7. 8. Leyshon A, Ireland J, Trickey EL. The treatment of delayed union and non-union of the carpal scaphoid by screw fixation. J Bone Jt Surg Br. 1984;66:124–7. 9. Manske PR, McCarthy JA, Strecker WB. Use of the Herbert bone screw for scaphoid nonunions. Orthopedics. 1988;11:1653–61. 10. Pring DJ, Hartley EB, Williams DJ. Scaphoid osteosynthesis: early experience with the Herbert bone screw. J Hand Surg Br. 1987;12:46–9. 11. Tu YK, Chen AC, Chou YC, Ueng SW, Ma CH, Yen CY. Treatment for scaphoid fracture and nonunion—the application of 3.0 mm cannulated screws and pedicle vascularised bone grafts. Injury. 2008;39:S96–106. 12. Wozasek GE, Moser KD. Percutaneous screw fixation for fractures of the scaphoid. J Bone Jt Surg Br. 1991;73:138–42. 13. Leixnering M, Pezzei C, Weninger P, Mayer M, Bogner R, Lederer S, Schauer J, Figl M. First experiences with a new adjustable plate for osteosynthesis of scaphoid nonunions. J Trauma. 2011;71:933–8. 14. Ghoneim A. The unstable nonunited scaphoid waist fracture: results of treatment by open reduction, anterior wedge grafting, and internal fixation by volar buttress plate. J Hand Surg Am. 2011;36:17–24. 15. Braun C, Gross G, Bühren V. Osteosynthesis using a buttress plate—a new principle for stabilizing scaphoid pseudarthroses. Unfallchirurg. 1993;96:9–11. 16. Ender HG. A new method of treating traumatic cysts and pseudoarthrosis of the scaphoid. Unfallheilkunde. 1977;80:509–13. 17. Huene DR, Huene DS. Treatment of nonunions of the scaphoid with the Ender compression blade plate system. J Hand Surg Am. 1991;16:913–22. 18. Stanković P, Burchhardt H. Experience with the Ender hooked plate in the management of 42 scaphoid pseudarthroses. Handchir Mikrochir Plast Chir. 1993;25:217–22. 19. Ahmed U, Malik S, David M, Simpson C, Tan S, Power D. The Headless compression screw—technical challenges in scaphoid fracture fixation. J Orthop. 2015;12:S211–6. 20. Ram AN, Chung KC. Evidence-based management of acute nondisplaced scaphoid waist fractures. J Hand Surg Am. 2009;34:735–8. 21. Singisetti K, Aldlyami E, Middleton A. Early results of a new implant: 3.0 mm headless compression screw for scaphoid fracture fixation. J Hand Surg Eur Vol. 2012;37:690–3. 22. Braga-Silva J, Peruchi FM, Moschen GM, Gehlen D, Padoin AV. A comparison of the use of distal radius vascularised bone graft and non-vascularised iliac crest bone graft in the treatment of non-union of scaphoid fractures. J Hand Surg Eur Vol. 2008;33:636–40.

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23. Dehghani M, Soltanmohamadi M, Tahririan MA, Moezi M, Daneshpajouhnejad P, Zarezadeh A. Management of scaphoid nonunion with avascular necrosis using 1,2 intercompartmental supraretinacular arterial bone graft. Adv Biomed Res. 2014;3:185. 24. Eggli S, Fernandez DL, Beck T. Unstable scaphoid fracture nonunion: a medium-term study of anterior wedge grafting procedures. J Hand Surg Br. 2002;27:36–41. 25. Fernandez DL. Anterior bone grafting and conventional lag screw fixation to treat scaphoid nonunions. J Hand Surg Am. 1990;15:140–7. 26. Green DP. The effect of avascular necrosis on Russe bone grafting for scaphoid nonunion. J Hand Surg Am. 1985;10:597–605. 27. Doi K, Oda T, Soo-Heong T, Nanda V. Free vascularized bone graft for nonunion of the scaphoid. J Hand Surg Am. 2000;25:507–19. 28. Gabl M, Reinhart C, Lutz M, Bodner G, Rudisch A, Hussl H, Pechlaner S. Vascularized bone graft from the iliac crest for the treatment of nonunion of the proximal part of the scaphoid with an avascular fragment. J Bone Jt Surg Am. 1999;81:1414–28. 29. Guimberteau JC, Panconi B. Recalcitrant non-union of the scaphoid treated with a vascularized bone graft based on the ulnar artery. J Bone Jt Surg Am. 1990;72:88–97. 30. Lee JC, Lim J, Chacha PB. The anatomical basis of the vascularized pronator quadratus pedicled bone graft. J Hand Surg Br. 1997;22:644–6.

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A. L. Sander et al. 31. Zaidemberg C, Siebert JW, Angrigiani C. A new vascular ized bone graft for scaphoid nonunion. J Hand Surg Am. 1991;16:474–8. 32. Boyer MI, von Schroeder HP, Axelrod TS. Scaphoid nonunion with avascular necrosis of the proximal pole. Treatment with a vascularized bone graft from the dorsum of the distal radius. J Hand Surg Br. 1998;23:686–90. 33. Chang MA, Bishop AT, Moran SL, Shin AY. The outcomes and complications of 1,2-intercompartmental supraretinacular artery pedicled vascularized bone grafting of scaphoid nonunions. J Hand Surg Am. 2006;31:387–96. 34. Steinmann SP, Bishop AT, Berger RA. Use of the 1,2 intercompartmental supraretinacular artery as a vascularized pedicle bone graft for difficult scaphoid nonunion. J Hand Surg Am. 2002;27:391–401. 35. Straw RG, Davis TR, Dias JJ. Scaphoid nonunion: treatment with a pedicled vascularized bone graft based on the 1,2 intercompartmental supraretinacular branch of the radial artery. J Hand Surg Br. 2002;27:413. 36. Ditsios K, Konstantinidis I, Agas K, Christodoulou A. Comparative meta-analysis on the various vascularized bone flaps used for the treatment of scaphoid non-union. J Orthop Res. 2016. doi:10.1002/jor.23242.