////

Scaphoid fracture- Arthroscopic assisted grafting of non-union and fixation using Acutrak screw

    Overview

    Learn the Scaphoid fracture: Arthroscopic assisted grafting of non-union and fixation using Acutrak screw surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Scaphoid fracture: Arthroscopic assisted grafting of non-union and fixation using Acutrak screw surgical procedure.
    This procedure is designed to follow on from the Diagnostic Wrist Arthroscopy technique published in OrthoOracle.
    This is a detailed step by step instruction through the procedure of an arthroscopic graft and mini-open screw fixation of a scaphoid non-union using the Acumed TM ARC Tower traction system and Mini Acutrak TM screw.
    Scaphoid non-unions are best diagnosed and morphology assessed on a CT scan if subtle, although they are usually clearly seen in a scaphoid series of radiographs. An MRI can be used to try to assess the vascularity of the proximal fragment in proximal pole fractures however MRI scans (with or without Gadolinium) are far from infallible and the gold standard test for vascularity remains punctate bleeding from the bone intra-operatively.
    When an non-union is established, in the absence of associated arthritis, and is symptomatic it usually requires treatment for which there are a number of options available.
    Treatment options will often vary depending on the amount of collapse of the scaphoid, sclerosis or cyst formation around the non-union, location of the non-union within the scaphoid and the skill and preferences of the surgeon.
    Options include – simple screw or k-wire fixation with or without graft. Grafting open or arthroscopic and can be vascularised or non-vascularised, cancellous or cortico-canecellous with the most common donor sites being distal radius and iliac crest.
    Arthroscopic scaphoid grafting is an evolving technique and is best attempted once the surgeon is already confident and adept in more routine arthroscopic procedures such as joint debridements and Triangular fibro-cartilage complex (TFCC) repairs.
    When embarking on this procedure for the first time it is best to attempt a non-union with minimal bony deformity which does not need correcting and located in the waist of the scaphoid. This means the fracture site can be easily accessed, there are large fragments with good vascularity proximally and distally to hold a screw and no manipulation of the fragments is required intra-operatively.
    The main theoretical advantage of this technique is the preservation of vascularity by minimal soft tissue dissection which as there is no clear evidence proving the benefit of vascular over non-vascularised grafting techniques then it is a very attractive option. It also aims to reduce scarring around the joint and try to preserve mobility post-operatively.
    Following an arthroscopic scaphoid grafting and mini open screw fixation patients are usually placed in plaster cast for 6-8 weeks with physio therapy of the fingers and thumb followed by cast removal and physiotherapy of the wrist once union is confirmed radiologically and clinically.
    Complications in this procedure include non-union, metalwork issues, infection, iatrogenic cartilage injuries and tendon and nerve injuries.

    Indications

    Indications
    Scaphoid non-unions, if left untreated, are know to progress on to Scaphoid non-union advanced collapse (SNAC). What is unclear is how many patients with SNAC wrists are symtpomatic enough to require intervention. This is why scaphoid non-union surgery is only indicated in symptomatic non-unions and not on those patients where the non-union is an incidental finding e.g. on a radiograph for a metacarpal fracture.
    If they are asymptomatic, a surgeon can only make them worse or the same!
    Arthoscopic scaphoid grafting and mini open screw fixation is indicated for scaphoid non-unions without associated arthrtis. An additional open or arthroscopic radial styloidectomy can be supplemented in cases of SNAC grade I.
    This technique can theorectically be used for the vast majority of scaphoid non-unions however the greater the scaphoid deformity requiring correction and the more proximal the non-union site, the more complex the procedure becomes.
    A surgeon undertaking this procedure should be able to perform open techniques of grafting and fixation and be able to convert to these techniques if the arthroscopic method becomes too difficult to complete.

    Symptoms
    The symptoms experienced will often depend on the deformity of the scaphoid.
    Pain is usually a feature and this may be continuous and even disturb sleep or occur only during specific activities such a wrist extension and loading.
    A reduced range of movement is also common and will depend on the severity of the pain and the amount of scaphoid collapse. Although pain from the non-union or surrounding synovitis can limit movement there is also a restriction when the scaphoid is flexed along the non-union site and a hump back deformity is present. This deformity can create a Dorsal intercalated segement instability (DISI) and with this, abnormal wrist mechanics and a reduction in the range of movement.
    With pain and loss of movement also comes weakness usually associated with underuse, particularly in heavy loading tasks.
    The impact these symptoms have on a patient will depend on hand dominance, occupation and hobbies ( in particular sports).
    Examination
    Inspection –
    Look for any scars from previous surgeries, this may also include donor sites if a bone graft has previously been used (distal radius, olecranon, iliac crest). These may be very small in the case of a volar percutaneous screw placement. Look for muscle wasting and and changes in the callosities or state of the skin which may signal disuse or even Chronic regional pain syndrome (CRPS). A very important positive finding is nicotine staining on the fingers.
    Palpation –
    Systematic palpation (usually starting with the normal wrist) – starting away from the most painful site and progressing around the wrist generally over the radio-carpal, mid-carpal and distal radio-ulna joint lines but also more specifically over bony prominences such as the scaphoid tubercle, pisiform and hook of hamate. Palpation may also yield more information with different wrist positioning i.e. in flexion more of the scapho-lunate ligament is exposed to palpation and in ulnar deviation more of the waist of the scaphoid is palpable beyond the radial styloid. On the ulna side of the wrist tenderness over the Extensor carpi ulnaris (ECU) may actually be deeper pain within the TFCC and can be differentiated by palpation in supination where the tendon lies more dorsally and pronation where it lies more ulnarly
    In the case of scaphoid non-union pain it is often elicited at the scaphoid tubercle, anatomical snuff box and dorsally over the scaphoid and scapholunate ligament just distal to Lister’s tubercle.
    Movement-
    Following palpation the range of movement is assessed – flexion (75), extension (70), supination (85), pronation (70) and radial (20) and ulnar deviation (35) – normal ranges in degree provided in brackets.
    All ranges except pronation and supination are often reduced.
    Special tests-
    Telescoping of the thumb
    Kirk-Waston test for scapholunate instability which can be associated
    Kleinman shear test and Reagan test for Luno-triquetral instability – may be present in trans-scaphoid perilunate non-unions
    Strength testing using pinch or grip dynamometers

    Investigations
    Investigations include a 5 shot scaphoid series of radiographs – Posterior-anterior, lateral, semi 45 degree prone, semi 45 degree supine and elongated scaphoid (Zitter) view.
    A CT may be useful for the morphology of the scaphoid and extent of cysts.
    3T MRI scan (with or without Gadolinium) can advise regarding likely vascularity of a proximal pole however the gold standard is still intra-operative assessment of punctate bleeding. It may also reveal associated inter-carpal ligament injuries.

    Non-operative Management
    Non-operative management will depend completely on the pathology and symptoms.
    Symptomatic non-union can be treated with analgesia, splintage, wrist strengthening physiotherapy and activity modification to help manage symptoms.
    One non-operative treatment which may actual promote union, although is currently unproven for scaphoid fractures, is low intensity ultra-sound wave such as the Exogen TM machine. The machine is used 20 minutes daily for up to 4 months to promote bone healing.

    Alternative operative Management
    Common alternative operative methods include open grafting with screw or k-wire fixation.
    The grafts can be cancellous or cortico-cancellous.
    They can be non-vascularised (most common – iliac crest, distal radius and olecronon), vascular pedicled (most common distal radius – Kuhlmann, Zaidemberg) or free vascular (most common – iliac crest, medial femoral condyle).
    Contraindications
    Relative contra-indications include a tight wrist which a difficult to perform arthroscopy on, SNAC grade 2-3 and an asymptomatic non-union. Absolute contra-indications include infection and ongoing untreated CRPS.

    Setup

    Pre-operative preparations and Equipment
    The operation can be performed under general (GA) or regional anaesthetic.
    As additional ligament injuries can accompany scaphoid non-union it is essential to perform an examination under anaesthetic (EUA) then an EUA with fluoroscopy to gain as much information as possible to aid additional diagnoses. The clinical examination in the outpatients department, the EUA and the operative findings are then all combined to assess what findings are clinically relevant.
    NB – Only surgically treat findings which correlate with clinical findings e.g. If a patient presents with pure radial sided wrist pain and an arthroscopy finds only a TFCC tear – DO NOT TREAT – as this is not symptomatic.
    A single dose of antibiotics are given pre-operatively and no thromboprophylaxis is used unless the patient is under a GA.
    With experience, the duration of a diagnostic wrist arthroscopy is around 15mins.
    A simple grafting and fixation may then take a further 60-90 minutes and possibly longer for more complex fractures or during the learning curve of this operation.
    Patients under axillary block often notice tourniquet discomfort between 90-120 minutes (this can be delayed with use of local infiltration beneath the tourniquet and/or distraction techniques such as watching a film or listening to music on a portable device).
    The patient is lay supine with an arm on the arm board, the arm prepped and draped, a sterile tourniquet applied, the hand held in traction and the skin markings completed PRIOR to exsanguination with a sterile Esmarch.
    Kit
    Arthroscopy tower or gantry, finger traps, sterile tourniquet, sterile Esmarch, Wrist arthroscope 30 degree (1.9, 2.4 or 2.7mm), shaver, white needle 16 gauge, adhesive tape (around base of finger traps), straight artery clip, 11 blade for knife, wrist arthroscopy probe, saline in 50ml syringe and connector to attach to arthroscopy trochar.
    Kit for the grafting and fixation – small curette, additional wrist arthroscope trochart, Watson-Cheyne dissector, Fibrin glue such as Tisseel TM, Acutrak Mini TM screw and set , additional 1.25 or 1.6mm k-wires, Mini C-arm for intra-operative radiographs.


    Operation – 1

    Diagnostic wrist arthroscopy set up and portal are performed
    This procedure follows on from the ‘Diagnostic Wrist Arthroscopy’ published on OrthoOracle. It therefore presumes the traction, skin marking and exsanguination are complete and the 3-4 radiocarpal (RC), 6R RC, ulnar midcarpal (UMC) and radial midcarpal (RMC) portals or already sited.
    This procedure is a dry wrist arthroscopy with occasional use of fluid to rinse out the joint or allow debris clearance when shaving.
    Working through the review of the radiocarpal joint this picture reveals –
    1. Lunate on the left,
    2. Scapholunate ligament top centre,
    3. Scaphoid on the right,
    4. Ligament of Testut and Keunz centrally
    5. Long radio-lunate ligament bottom right

    Radio-carpal arthroscopy to view scaphoid fracture proximally Working radially across the radio-carpal joint the proximal surface of the scaphoid can be assessed up to the dorsal ridge and capsular attachment.
    This picture show the irregularity in the scaphoid cartilage correlating with the fracture non-union site.
    Fracture line
    Radial styloid

    TFCC assessed for concomitant injuriesAssessment of the TFCC with the trampoline test can be seen with the lunate at the top and the volar ulnar carpal ligaments centrally
    1. Lunate
    2. Volar ulnar carpal ligaments
    3, TFCC

    Luno-triquetral ligament assessed for concomitant injuriesIn the mid-carpal joint the scope is placed in the radial mid-carpal joint and the joint assessed with a probe systematically from ulnar to radial.
    The picture reveals the probe entering the abnormal, Geissler Grade 3, Luno-triquetral joint and the presence of a Type 2 lunate is also noted.
    The Type 2 lunate is seen by the 2 clear articular surfaces of the distal lunate (A & B). The second smaller facet (A) which articulates with the Hamate should not be confused for a step and therefore instability in the Luno-triquetral joint.

    Scapho-lunate ligament assessed for concomitant injuriesThe scapho-lunate joint is then assessed with the probe and is normal.
    Lunate
    Scaphoid

    Fracture identified from mid carpal joint The scope is then panned radially to see the capitate articulation with the scaphoid and the non-union site is easily identified.
    Capitate
    Proximal scaphoid
    Distal scaphoid

    Fracture probed for stability and extentThe scope is the moved to the UMC portal where it will remain during the non-union preparation and a probe is placed into the non-union site as shown.

    A curette is then passed into the RMC portal.

    Curette used to open fracture and remove fibrous non-union tissueTo gain access to the non-union site a small amount of often unstable cartilage is removed from both the proximal and distal fragment either side of the non-union site and then the curette is used to scoop out the fibrous content of the non-union.

    The fibro-cartilage pearlescent material is then curetted out.
    With non-unions where the overall shape of the bone is acceptable the surgeon will try not to breach the proximal, volar or dorsal cortices of the scaphoid and try to create a cavity with a defect only in the distal captitate articulation of the scaphoid.
    This will achieve 2 objectives –
    The scaphoid will remain relatively stable and retain its shape during the procedure as the 3 non breached cortices will remain attached with fibrous tissue.
    The graft can be packed tightly into the cavity created with less risk of graft extrusion during screw insertion and compression.
    Clearly this is not possible when the surgeon is correcting a significant deformity in the scaphoid, however the bone correction will often hinge on the dorsal cortex providing one surface to compress the bone against.

    More fibrous tissue is curetted out.

    After inital curetting the debris is cleared and the joint washed out using saline and a shaver.
    On review of the defect there appears to be punctate bleeding on the distal scaphoid non-union surface but little bleeding otherwise.

    Further curettage is undertake. Although monotonous it is essential to clear as much granulation and fibrous tissue as possible to promote bleeding and aid bone healing. The 2 surfaces of the non-union should be worked around systematically to clear the whole of the surface (while protecting the most peripheral tissue supporting the scaphoid shape as discussed).

    Curettage continue to bleeding bone edges.More convincing bleeding from the prepared non-union site.

    The bone surface can be clearly seen and is bleeding.
    Once at this stage the debris needs to be once again removed with saline, suction and a shaver.

    Shaver used to washout joint, smooth derided cartilage edges and clear any debris.The shaver is inserted into the RMC joint and fluid attached.
    A small flush of fluid is all that is required. Once the suction on the shaver starts to suck the fluid out of the joint the negative pressure will then continue to pull more fluid in from the 50ml syringe. Your assistant should not need to keep any pressure on the syringe risking excess fluid in the joint or surrounding tissues.

    The shaver having cleaned the debris and excess fluid.

    Prepared non-union site.

    Debrided site inspected from UMC portal. Once happy with the non-union site from the UMC portal the camera is sited in the RMC portal to look directly into the non-union site and in particular achieve a clear view of the debrided surface of the proximal fragment.

    Some pearlescent fibrous tissue remains on the proximal fragment and requires further debridement.
    Fibrous tissue

    Probe used to confirm presence of bony or fibrous tissue on wall on scaphoid.Through the UMC portal the raw scaphoid surfaces are felt to assess roughness and help discern whether the debridement is down to bone or not.

    Site for bone graft harvest marked.Once satisfied with the debridement the hand is removed from traction and laid on the arm board to harvest the distal radius bone graft.
    Although graft can be harvested from the distal radius or olecranon with the arm in traction, the use of the ARC Tower TM makes it very quick to drop the arm onto the table for easier graft harvest.
    A longitudinal incision is marked in line with and just proximal to Lister’s tubercle. Around a 2 cm incision is sufficient or just big enough to accommodate a West self retaining retractor.

    The skin is sharply incised and then blunt dissection is used down to the deep fascia.The incision is made and fat cleared from the extensor retinaculum.
    The incision is parallel to and between the superfical radial nerve and dorsal branch of the ulna nerve and therefore unlikely to encounter or injure either of these cutaneous nerves.

    The extensor retinaculum is incised between the 2nd and 3rd extensor compartments and the 2nd compartment elevated subperiosteally.The periosteum on the ridge between the compartments is preserved.

    A trap door is cut in the bone on 3 sides with a sharp osteotome or small saw.

    Operation – 2

    The cortex is then lifted and hinged on the periosteum of the inter-compartmental ridge.

    Cancellous graft is harvested.Bone graft is harvested with an narrow osteotome to slice into the cancellous bone and sweep sheets of it into the hole from each direction. This is then retrieved carefully with non-toothed forceps.
    This technique gives much better graft maintaining its cancellous structure than using a curette which often crushes the cancellous matrix.

    Graft elevated from radius.

    The trapdoor of cortex is then gently pressed shut.This closure provides a smooth surface for the tendons to lie within their sheath and reduce bleeding from the donor site.
    If this cortical flap collapses, bone wax can be used to seal the defect and reduce bleeding.

    The graft is placed into a dry pot (not a wet swab which delays retrieving it and risks loss of graft as it get tangles in the fibres).


    Graft inserted retrograde into a second arthroscopy trochar.The graft is the placed piece by piece and if placed in the direction the camera is usually inserted the graft tends to compact and jam in the lumen making a smooth delivery into the wrist very difficult.
    Around 4 decent pieces are usually adequate for each delivery. If the trochar is over stuffed the graft compact in the lumen and is difficult to push into the wrist.

    The graft loaded trochar is inserted into the RMC portal.The camera is in the UMC to see the entry of the second trochar.
    We usually try not to introduce a trochar into the joint without the blunt central stylus in place as it can damage the dorsal cartilage and can be difficult to atraumatically slide it into a tight mid-carpal joint.
    In this technique we have no choice as the stylus would push out the graft. Once trick to ease the passage of the trochar is to place the camera on the dorsal lip of the lunate just ulnar to the RMC portal and this will distract the dorsal aspect of the joint. It can be useful to place the stylus in the RMC portal and put the camera up to meet it so that t is very close to the portal but not blocking entry of the trochar when it is introduced.
    Another tip is, once through the capsule if the joint is too tight DONT just push harder as this will chip the back of the lunate, instead aim the trochar in a radial direction and swing it between the bone sideways so the rounded edge opens the joint rather than the sharp circular lumen.

    The trochar in situ before graft delivery.

    The stylus is inserted slowly and fully to push graft into debrided non-union site.

    After each delivery of graft a Watson-Cheyne dissector is used to compress the graft.

    Compression of the graft into the corners of the debrided defect.

    Non-union cavity full of graft and impacted.

    An optional step of using a fibrin glue on the graft can be undertaken at this point.To provide a smooth surface and try to maintain the graft insitu during screw insertion a Fibrin glue such as Tisseel TM is injected into the joint over the graft.
    REMEMBER this is stored in the fridge and takes 10mins to be ready for use so must be called for earlier in the procedure.

    The glue is left for 2 mins and the wrist gentle mobilised to contour it.
    The picture shows the result once the scope is reintroduced after this process.

    A longitudinal 1.5cm incisoin is made just distal and ulnar to Lister’s tubercle for the screw insertion.This lies over the scapholunate ligament and cant be checked with the Image intensifier if necessary.

    The fat and superficial veins are bluntly dissected to reveal the extensor retinaculum.
    At this level is the very distal extent of the retinaculum and therefore only a small amount needs to be divided and it does not need to be repaired on closing.
    On the picture the Extensor pollicis longus (EPL) can been seen already heading radially having turned towards the thumb within the retinaculum and it is at minimal risk.
    EPL

    The retinaculum then capsule are split to reveal the proximal scaphoid.The fibres of the dorsal wrist capsule made of the Dorsal radiocarpal ligament (DRC) run from the distal radius to the triquetrum obliquely.
    Once down to capsule a pair of tenotomy scissor can be popped through the ligament and standing vertically can be opened in line with the fibres of the DRC and split it without cutting any of its fibres.
    Although through the capsule this will not immediately reveal the scaphoid as the often thick synovitic synovial lining is in the way and needs to be cleared for and optimal view. If minimal this can be split like the DRC with the scissors, if inflamed it is usually best to remove a section with scissors or a blade while and assistant uses 2 skin hooks or Ragnell retractors to protect the DRC.
    Once removed a clear view of the scaphoid and scapholunate ligament should be present best seen with the wrist flexed over a kidney dish. If in doubt either make the incision larger or use the image intensifier to confirm the location.

    The k-wire for the mini AcutrakTM screw is then inserted under image guidance.The ideal entry point is usually just over the dorsal lip of the radius with the wrist almost in full flexion and at the junction of the scaphoid and the scapho-lunate ligament.
    The ligament and contour of the scapho-lunate joint can be felt best with the closed scissors or blunt end of the k-wire.
    The k-wire is then aimed towards the scaphoid tubercle which can be palpated and drilled into the bone. The angle is usually 45 degrees elevation and 45 degree towards the thumb.
    The wire can also be checked on the image intensifier and is driven into the scaphoid about 1cm – enough to get a good hold and be able to estimate the remaining trajectory on the radiographs.
    If soft tissue retraction is difficult there is a soft tissue guide on the screw set which is not show in these images.
    Although the k-wire is on the edge of the scapho-lunate ligament, with the wrist flexed, only the proximal portion of the ligament which has minimal structural or stabilising function is damaged.

    NB – When taking radiographs and drilling be sure to keep the wrist flexed to avoid bending the wire – these fine 1.1mm wires bend easily and can cause major problems over-drilling and may even snap if slightly bent.

    Once the check radiographs are acceptable the wire is measured.NB – ensure the measure is directly onto bone to avoid overestimating the length.

    The k-wire has a black laser mark which lines up with markings on the measuring device. Standard and Mini on the top and Micro on the bottom.
    This patient measured at a 27mm Mini.
    An awareness of common screw sizes is essential and this particular patient was an average sized male who I expected to use a 22mm screw in.
    From 27mm we remove 2mm to bury the screw though the cartilage and 3mm for compression at the graft site – a 22mm Mini screw was used.

    The k-wire is over-drilled whilst using a soft tissue guide.
    NB – The guide on the set is unfortunately slightly long and therefore it is difficult to drill past 20mm through the guide. The last few mm require drilling with no guide.
    Keep the wrist very still when removing the drill and it can often be useful to have a spare wire to hand to quickly site back in the scaphoid to avoid losing the tract if the drill removes the wire when withdrawn.
    Tip – if having difficult resiting the wire, try to pass it down blunt end first to avoid it catching on the cancellous bone in the tunnel but beware the sharp end which can then be a hazard.

    Drilling the final few mm without the tissue guard as the guard is too long and block drilling for longer length screws.

    The entry hole is over-reamed.As the screw core is funnel shaped the entry point needs to be widened with a second reamer by hand not on power. This should be gently advance and when withdrawing keep the clockwise motion of the handle – this will avoid rubbing off the reamed bone from the flutes and therefore you can check that you have reamed the whole depth of the reamer.

    Flutes of the reamer full to the end showing an adequate reaming depth achieved.

    The screw is the sited.
    The screw is advanced until the hexagonal part of the screw driver (a few mm seen here where it enters the screw) cannot be seen beneath the cartilage – this will have buried the proximal end 2mm below the cartilage in the cortex and subchondral bone.

    Operation – 3

    Prominence of the screw is checked.Wire in situ through the buried screw beneath the cartilage just visible as a blue glint.
    It will often look like the screw is out of the bone on the radiographic images as the cartilage in this area is quite thick and therefore still covers the screw even if not completely embedded in bone.
    It is acceptable if the screw is well sunken in the cartilage under direct vision.

    All wounds including portals are closed with 4/0 monocryl.The capsule fibres have been split but not cut and the retinaculum distal most portion can be left open therefore only the skin is closed.

    Occlusive dressings and plaster cast are applied.The tourniquet is released and we wait 5mins for initial swelling before applying the plaster cast.
    The wool is applied as standard for a below elbow plaster cast however the circumferential wool around the wrist is split then covered with a layer of non circumferential wool to allow for swelling and reduce painful constriction of the dressings.
    A dorsal plaster slab is then applied and wrapped in a crepe bandage.

    PA radiograph showing scaphoid waist non-union

    Ulnar Deviation PA radiograph showing scaphoid waist non-union.
    The scaphoid appears to have maintained its length and have mainly cystic changes around the non-union which is ideal for this arthroscopic technique.

    PA CT slice revealing cystic changes in the scaphoid waist non-union and preservation of bone length.

    Lateral CT slice revealing cystic changes in the scaphoid waist non-union and a very mild inter-scaphoid flexion deformity.

    Intra-operative PA radiograph to show position of screw. The donor site can also be seen in the distal radius.

    Intra-operative Semi supinated radiograph to show position of screw.

    Intra-operative lateral radiograph to show position of screw.

    Post Operative

    The post operative plan for patients undergoing a fixation for non-union surgery such as this case are to be performed as an Day Case procedure and be discharged the same day with a Bradford sling, Paracetamol, Codeine, Oral Morphine, Senna and Cyclizine.
    In the initial post operative phase the patient is in a plaster cast for 1 week and then the wounds are reviewed and the cast replaced for a further 5-7 weeks depending on complexity of non-union.
    During these weeks the patient must regain full movement of their finger and thumb with the physiotherapists to allow focused wrist physiotherapy and strengthening to commence once the cast is removed and a radiograph confirms union. A splint may be provided for comfort at nights and in crowds once the plaster is removed.
    If a non-union is suspected the plaster cast is replaced to complete a total of 10-12 weeks in cast and an urgent CT scan is organised to confirm progress of union.
    For the majority of patients the bone heals in 6-8 weeks and they should be back to most activities by 3 months and heavy lifting and sports by 6 months.

    Recommended Reading

    It is important that a surgeon is aware of the potential complications of intervention. As well as doing all he can to minimise the risk of them occurring the patient should be informed of them and understand their implications
    All complications are rare and with simple fractures the non-union rate is around 3% however this may change the more complex the fracture is.
    The “common” complications are iatrogenic cartilage damage, tendon injury, nerve injury (PIN – 4-5 RC portal, dorsal sensory ulnar branch – 6U portal), infection, CRPS, failure of procedure and conversion to open procedure, scaphoid non-union, metal work issues such as joint penetration and damage.
    Is Arthroscopic Bone Graft and Fixation for Scaphoid Nonunions Effective?
    Ho Jung Kang, MD, Yong-Min Chun, MD, Il Hyun Koh, MD, Jae Han Park, MD, and Yun Rak Choi, MD. Clin Orthop Relat Res. 2016 Jan; 474(1): 204–212.
    This paper discusses a series of 33 patients who underwent scaphoid arthroscopic grafting and screw fixation for fractures with no arthritis or scaphoid collapse and with 2 years follow up. Results – 97% union and good functional results. No complications were seen in this group.
    It is important that a surgeon is aware of the potential complications of intervention. As well as doing all he can to minimise the risk of them occurring the patient should be informed of them and understand their implications
    All complications are rare and with simple fractures the non-union rate is around 3% however this may change the more complex the fracture is.
    The “common” complications are iatrogenic cartilage damage, tendon injury, nerve injury (PIN – 4-5 RC portal, dorsal sensory ulnar branch – 6U portal), infection, CRPS, failure of procedure and conversion to open procedure, scaphoid non-union, metal work issues such as joint penetration and damage.
    Below are a couple of papers we recommend reading to gain a greater a overview of the outcomes of this procedure and of scaphoid non-unions in general.
    Treatment of Scaphoid Nonunion: A Systematic Review of the Existing Evidence.
    Pinder RM1, Brkljac M2, Rix L2, Muir L3, Brewster M4.J Hand Surg Am. 2015 Sep;40(9):1797-1805.e3. doi: 10.1016/j.jhsa.2015.05.003. Epub 2015 Jun 24.
    This systematic review looked at 48 publications and 1602 patients and concluded that there is no strong evidence for screw fixation over k-wire fixation or vascularised grafts over non-vasculasrised grafts in scaphoid non-union surgery.




    Reference

    • orthoracle.com

    Tags:

    You might be interested in

    Dark mode powered by Night Eye