corticocancellous grafting and an ao/asif lag screw ... - Semantic Scholar

4 downloads 0 Views 642KB Size Report
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

of the

carpal

of fracture of the 1937 ; 19:1099-109.

carpal

the

fractured

Eng/ 1970;

scaphoid. 46:63-76.

ofthe

scaphoid

HOber, Swanson

carpalnavicular(scaphoid) pathology. J Trauma

1969;

Taleisnik

for non-union 28:749-56.

of the

carpal

results of 22 cases of operated old fractures of the scaphoid bone of the hand. Z Orthop

stabiisierung

carpal

scaphoid

am handske/ett.

AB. Silicone

rubber in the

F/exib/e St Louis:

implants hand.

imp/ant CV

Surg

: a report Bern

J. Subtotal

for C/in

replacement N Am

1968

resection arthrop/asty Mosby Co. 1973.

Swanson AB, De Croot Swanson arthroplasty of the radiocarpal term study. C/in Orthop 1984;

J Hand

Br J Surg

scaphoid.

of 64

: Verlag

Hans

1973.

Swanson AB. extremities.

des

carpal

of the carpal navicular : diagnosis, non-operative operative treatment. J Bone Joint Surg [Am] l960b;

destroyedjoints

Hunterian bone.

study

Segm#{252}ller C. Operative

37:276-87.

pseudarthrose

Zb/

operation.

22 :63-8.

Sashin

vascularity

arthrodeses

of arthritic ;

in the

hand

C, Maupin BK. Flexible joint. Surgical technique 187:94-106. of the

wrist

joint.

or

48:1113-27.

C/in

and

implant

and

Orthop

long-

1984;

187 :81-8. veralteten

als behandlungsmassnahme Z Orthop 1951 ; 80:597-605. Arthrodesis 1967

J Bone Joint Surg [Am] Helfet

C. Bone-graft

0. Fracture treatment, and 42-A :759-68.

Die Ergebnisse der Nagelung bei der hand. Chirurg 1943 ; IS :638-46.

H. Die

Gieseking und HaMad

H.

upon

Russe

Zur entstehungder 1977; 22:513-8.

instability and Ann R Co//Surg

based

treatment of scaphoid pseudarafter soft tissue arthroplasty and 1984; 9-A :378-82. Soft

Pseudarthrose

Fractureofthe

in therapy

0. Follow-up and pseudarthroses l960a; 93 :5-14.

on treatment

M.

meiner

Russe

Joint Surg

ChirPraxis

of

by the Unfa//-

J Hand

hand.

Celberman

C. End results of bone-grafting navicular. J Bone Joint Surg 1946;

A, Balslev

1966;

Scand

Murray

scaphoid.

F.

der

RH, Yu E. The natural history J Bone Joint Surg [Am] 1984; 66-A :504-9.

hand.

Murray

Busch P, Hoist-Nielsen for scaphoid non-union.

B, Kjaer

Acta Orthop

carpal

Thesis,

der

HL, ParkesJC.

1934;

of the

os scaphoideum.

Meekison DM. Some remarks on three common fractures. 1 . Fractures of the carpal scaphoid ; 2. Fractures of the head of the radius ; 3. Fractures of the medial malleolus. J Bone Joint Surg 194; 27:80-5.

in the surgical : a preliminary

of scaphoid non-union treatment using compressed cancellous bone.

Boeckstyns MEH, Busch P. Surgical throsis : evaluation of the results inlay bone grafting. J Hand Surg

Borgeskov

fracture

a

nach verschraubungen Handchirurgie 1970; 2:205-9.

der

H. Technik und Resultate Chir 1936; 63:1442-53. bone : gradations 9:311-9.

het

HC. Ergebnisse

non-union.

McLaughlin REFERENCES

AdamsJD,

MJ,

van

using

W. The surgical non union of

der Kahnbeinpseudarthrose 91 :190-2.

;

E, Coymann V, Hans kahnbeinpseudarthrose scaphoid

No benefits commercial article.

DMKS. Pseudarthrose of Amsterdam, 1987.

E. Die verschraubung Hefte Unfa//heilk 1967

Mack

operations.

WE. Management of the fractured scaphoid J Bone Joint Surg [Br] 1984; 66-B :114-23.

WJ, House JH, Custillo RB, Kleven L, Thompson approach and source of bone graft for symptomatic the scaphoid. C/in Orthop 1976; 11:241-7.

Koob

is not suitable

bone

Kaulesar Sukul University

arthritis.

Type D4 nonunion

R. K. MARTI

TJ, Fisher

Herbert new

as follows: nonunion

.

the

SUKUL,

operation

for 1952;

;

49-A

of the wrist :950-4.

ununited 34-B:329.

fracture

: a surgical of the

beim

Kahn-

Taleisnik ofthe

frischen

Wagner

scaphoid.

scaphoid CJ.

1952; technique.

J, Kelly

PJ.

The bone.

extraosseous

and

intraosseous

J Bone Joint Surg [Am]

Fractures of the 34-A :774-84.

carpal

navicular.

blood

1966; 48-A

supply :1125-37.

J Bone Joint Surg [Am]

Wilhelm J

A. Die gelenkdenervation und ihre anatomischen grundlagen. Em neues behandlungsprinzip in der handschirurgie. Zur behandlung der spatstadien der lunatummalacie und navicularepseudarthrose. Hefte Unfa//hei/k 1966; 86:1-109.

THE

JOURNAL

OF BONE

AND

JOINT

SURGERY