Busch. 1984 ; Boeckstyns et a! 1985), prosthetic replacement. (Swanson. 1968,. 1973; ... (Wilhelm. 1966). That there are so many types of operation for the same.
CORTICOCANCELLOUS SCREW
GRAFTING
FOR
NONUNION
From
types
S.
Rotterdam
Using
the operation
of the proximal
SUKUL,
using
a grading
The
internal
former
fixation
McLaughlin
for the treatment
employ
or a combination
and
Koob,
Haas 1970; Segmu!!er 1973; Herbert Bili#{233} and Korzinek 1987). The latter
desis
of
De Groot
Swanson
adjacent
joints
(Adams
indications
and Fisher 1984; operations include
Amsterdam Department Amsterdam, Correspondence
MD, of The
MD,
Professor
Orthopaedic Netherlands. should
be sent
and
Maupin
(Helfet
1952;
suggests preferred,
General
1984),
arthro-
Haddad
Dijkzigt,
Surgery,
that there is no nor upon the
Rotterdam,
The
Surgery, Academic
1990
and
Joint
Netherlands. University
Medical
to Dr D. M. K. S. Kaulesar
1990 British Editorial Society ofBone O30l-62OX/90/5l71 $2.00 J Bone Joint Surg [Br] 1990; 72-B :835-8.
VOL. 72-B, No. 5, SEPTEMBER
the Academic
Medical
bone
we analysed
Surgery
We bone
grafts
Amsterdam
lag screw
and
the suitability nonunion,
MARTI
Centre,
fixation
of the method
except
have
of Centre,
Sukul.
evaluated
grafting
with
where
the
there
Following treated for bone grafts documented
results
lag screw
PATIENTS
for
for three is avascular
AND
AO/ASIF
of corticocancellous
fixation.
METHODS
principles,
42
patients
scaphoid nonunion with in combination with lag at the
AO
centre
have
corticocancellous screws. All
in Berne,
Switzerland
analysis. 35 males,
been were and
their
ages
ranging from 1 8 to 54 years (mean 27.8 years). In nine patients the fracture was on the left, in 33 on the right. In 31 patients the dominant hand was involved. Forced dorsiflexion
caused
the
sustained direct trauma could not give a description
and of the types of
Surgeon
of Orthopaedic
©
REN#{201} K.
the data was used for a retrospective There were seven females and
procedures.
D. M. K. S. Kaulesar Sukul, E. J. Johannes, Resident University Hospital Rotterdam
R. K. Marti,
and
and Randlov-Madsen 1984 ; Boeckstyns et a! (Swanson 1968, 1973;
for the same problem on which is to be for these
and
Goymann
Riordan 1967 ; Taleisnik 1984) and denervation wrist (Wilhelm 1966). That there are so many operation agreement
JOHANNES,
grafting,
1945 ; Sashin 1946 ; Wagner (Barnard and Stubbins 1948),
soft-tissue arthrop!asty (Bentzon 1945 ; Boeckstyns and Busch 1985), prosthetic replacement Swanson,
bone
of both
1969;
fragment excision (Meekison 1952), radial styloidectomy
J.
of scaphoid
1934, 1946; Matti 1936; Geissen1951 ; Russe 1960a,b; Koob 1967;
Parkes
SCAPHOID
LAG
pole.
methods
Leonard 1928; Murray d#{246}rfer1943; Gieseking
THE
corticocancellous
Several methods have been advocated for the surgical treatment ofsymptomatic nonunion ofthe scaphoid. The operations aim either to achieve bony union or to obtain a good functional wrist, without pain, in the absence of union.
and
system,
AO/ASIF
ANALYSIS
ERNST
Dtjkzigt
in 42 patients,
fractures.
of nonunion. We recommend
KAULESAR
Hospital
our experience
scaphoid
necrosis
K.
the University
We report un-united
M.
AN
OF
A RETROSPECTIVE
DINESH
AND
Pre-operatively, either wrist
localised (20). Pain
29 patients,
but
all
fracture
in
29
patients,
to the wrist, and of their injury. patients
presented
four with
nine patients pain,
to the ‘anatomical snuffbox’ (22) or in the resulted from any form of movement in only
between fracture and 1 1 years. Follow-up
from
heavy
operation ranged
use
in 1 3. The
ranged from from 12 to
interval
19 weeks to 120 months
postoperatively. Although 21 patients (50%) had a radiograph taken immediately after the initial injury, the scaphoid fracture was not recognised at that time and no treatment was provided, unti!they presented with established nonunion. Six patients did not seek any medical advice immediately after their injuries, and they were unsuccessfully treated by conservative methods after having persistent complaints for some time. Another group of six patients, who had no initial radiographic examination after injury, were treated by primary operation on presenting with a
835
D. M. K. S. KAULESAR
836
painful established nonunion. conservative treatment for time of operative Technique. from
Nine patients had fractures recognised
injury, but nonunion immobilisation ranged The corticocancellous
the
iliac
anatomical
crest.
snuffbox
SUKUL,
primary at the
an 1937)
incision
over
it was driven
the
between
the un-united fragments from the dorsolatera! aspect. After positioning the graft, an AO/ASIF cortical screw was inserted from the distal to the proximal of the (Kaulesar used
scaphoid Sukul
to position
or 2.7 mm
2.7 mm 2.7 mm
cortical
screw.
had
was
cortical
a 4.0 mm
cases
used.
screw
cancellous
cast was applied until radiographs
worn
In four
screw
a 3.5 mm
plaster Fig.
the
compression 1). An image In
three
Fig.
1
bone
graft
2.0 mm cases
in four
two
Corticocancellous
inlay
with
screw
fixation.
(9%) one
inserted. In 22 used alone, and
was
screw.
lag pole
and stability intensifier was a single
cortical screws were used, and and one 3.5 mm screws were
patients nine
to obtain 1987, Fig.
R. K. MARTI
resulted. In these, prefrom 6 to 74 weeks. graft was fashioned
Through (Burnett
E. J. JOHANNES.
Postoperatively,
to include the revealed union
a
thumb, and was (4 to 32 weeks,
2).
Evaluation. The
Sites ofthe fractures type of nonunion was
classification
of Herbert
and
are listed in Table defined according Fisher
(1984)
I. to the
as modified
by one of the present authors (Kaulesar Sukul 1987). In this classification, fractures of the scaphoid are listed as type A if they are stable, type B if unstable, and type C if they exhibit (nonunion) Table
II.
delayed union. Our 42 cases and their further classification Careful
review
of the
whole
were
all type is shown
group
D in
failed
to
reveal
carpal instability (D3) in any cases. The clinical evaluation at follow-up was based on pain, wrist mobility, grip strength and functional capacity, using the graphic union bony
trabecu!ae
uninjured hand was considered were
(Russe 1960b). The radiographic results
seen
system is shown
for comparison. to have occurred to
cross
of grading in Table
the the III.
Time
line
clinical
was achieved Four patients
taken
dystrophy
did
not
(weeks)
bony
union
after
operation.
and Table I. Sites ofscaphoid number andper cent
occur.
DISCUSSION Our union rate of 90% was achieved in an unselected group of patients in which even those cases with a small and avascular proximal fragment were included. It has been our policy to perform this operation, even when it
fractures,
one-third
Waist
of 26.9 to unite.
Tables IV, V and VI show that our method was most appropriate for types Dl and D2 nonunions but that it is not suitable for the D4 type. In two patients a permanent lesion of the sensory branch ofthe superficial radial nerve was found but other complications such as wound infection, haematoma or Sudeck’s
to achieve
Distal
at an average (9%) failed
17-18
union
Fig. 2
RESULTS Radiographic union weeks postoperatively.
to bony
Radiowhen
fracture
13-16
9-12
Time
Proximal
one-third
Multiple
fragments
Tablell. nonunions
Modified of type
Herbert D
Nonunion (possibly)
with a distinct dislocation
and
fracture
Dl
Fibrous union with little or no deformity
D2
Sclerotic surfaces, arthritis
D3
as in D2,
D4
as in D2, but with (n = 2, 5%)
14
15
36
18
43 3
7
Fisher(l984)classification
gap,
cystic
for scaphoid
degeneration,
no distinct fracture line or cystic and/or mobility at the fracture
nonunion, with a distinct fracture cysts and instability at the fracture may be present, but without carpal but with
6
carpal
instability
avascular
THE
necrosis
JOURNAL
sclerosis
and
changes and site (n = 25, 59%)
line, sclerotic fracture site. Radiocarpal instability (n = 1 5, 36%)
(none) ofthe
OF BONE
proximal
AND
fragment
JOINT
SURGERY
CORTICOCANCELLOUS
GRAFTING
Table
III.
AND
System
AN AO/ASIF
of grading
results
LAG
SCREW
of treatment
FOR
NONUNION
of scaphoid
OF THE
SCAPHOID
837
nonunion
Assessment Crade
Subjective
0
Very satisfied asymptomatic
I
Clinical
Improved,
3
#{149}l , pain tloss
Table versus
IV. Subjective type of nonunion Subj ective
2, pain : 1,
on movement
9
Corticocancel!ous
bone,
joint
at rest
3,
;
severe
14
procedures
cortical
Doubtful union, with obviousjoint changes
uset
3, pain
with changes
0
clear
some
;
joint
No union, degeneration
2, 1 5 to 30’
no
union
minimal
Severe functional loss, limited uset
or extension
assessment
Probable
uset
and
Dl
seems to us better the carpus rather
styloid
;
Good union joint changes
functional
unlimited
Moderate functional loss, mildly limited
severe
work
and
Type
D4
was
on heavy
of flexion
loss,
with symptoms*
Worse with symptoms
function use
Minimal
symptoms
Unchanged, moderate
Radiographic
Normal unlimited
with
minimal
2
and
were
operation
for
nonunion
a good functional late arthritis (Mack
achieved
(Fig.
of
the
wrist
without Ct a! 1984).
3) in 35 of our
patients
Radioraphs 13 weeks operation, immediately corticocancellous
prior to after grafting
and screw
fixation,
and one
year later, occurred.
when
union
had
D. M. K. S. KAULESAR
838
(83%).
We
now
operation are 1 symptomatic
consider
that
indications
for
E. J. JOHANNES,
this
after
conservative
Hull
treatment
has failed, 2.
symptomatic
nonunion
fracture, and 3. symptomatic
after
nonunion
with
neglected
early
signs
scaphoid
Koob
of radiocarpal
tive
for such
screw.
reconstruc-
CR,
Bosse
in any party
form have been related directly
received or will be received or indirectly to the subject
from a of this
Maui
Leonard of treatment 401-4.
Barnard
RD. Fracture with
L, Stubbins
treatment of report. J Bone Bentzon
PGK,
Acta Orthop Bilk
ofthe of one
a report
carpal scaphoid : a new method case. N Eng/ J Med 1928 ; 198:
SC. Styloidectomy of the radius non-union of the carpal navicular Joint Surg [Am] 1948 ; 30-A :98-102.
Randlov-Madsen Scand 1945;
R, Korzinek K. Results Matti-Russe procedure chirurg 1987; 90:134-8.
A. On 16:30-9.
Boeckstyns MEH, Kjer L, interposition arthroplasty 1985; lO-A:l09-l4.
5, airistiansen
bones.
JH. Further
Burnett
observations (navicular). J Bone
scaphoid Fasol Fisk
P, Munk handkahnbeins.
CR.
P, Strickner
Carpal 1968.
Lecture
RH, Menon J. The Surg 1980; 5-A :508-13.
Celberman
Ceissend#{246}rler beinbruchen alten RJ,
Nagelung kahnbeinbruch.
Riordan
DC.
AJ.
A new
BoneJointSurg[BrJ
for non-union
of the
D. Treatment of fractures of the cases. Arch Surg 1946; 52 :445-65.
I. Fractures
tissue
Surg
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carpal
the
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Eng/ 1970;
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HOber, Swanson
carpalnavicular(scaphoid) pathology. J Trauma
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1968
resection arthrop/asty Mosby Co. 1973.
Swanson AB, De Croot Swanson arthroplasty of the radiocarpal term study. C/in Orthop 1984;
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Swanson AB. extremities.
des
carpal
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destroyedjoints
Hunterian bone.
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Segm#{252}ller C. Operative
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pseudarthrose
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operation.
22 :63-8.
Sashin
vascularity
arthrodeses
of arthritic ;
in the
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C, Maupin BK. Flexible joint. Surgical technique 187:94-106. of the
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or
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Orthop
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Die Ergebnisse der Nagelung bei der hand. Chirurg 1943 ; IS :638-46.
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meiner
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THE
JOURNAL
OF BONE
AND
JOINT
SURGERY
