Scaphoid nonunion

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Scaphoid nonunion

  1. 1. SCAPHOID NONUNION ISSH MONTHLY MEETING Farivar Lahiji M.D
  2. 2. Click to add title
  3. 3. • Goal of treatment : consolidation of fracture in anatomical alignment • Failure of union leads to predictable arthritis
  4. 4. Classification • Slade and Geissler • 1-(1) early nonunion without substantial bone resorption – Grade I: fibrous union, minimal sclerosis(<1mm) Late presentation(>4 weeks) – Grade II fibrous union apparently united in xray, but is symptomatic – Grade III minimal resorption, minimal sclerosis(<2mm)
  5. 5. • (2) chronic nonunion with substantial bone resorption – Grade IV: well perfused, substantial bone loss(2-5mm) – Grade V: well perfused , substantial bone loss (5-10) – Grade VI: pseudoarthrosis W/O AVN
  6. 6. Special circumstances • Proximal pole, AVN, humpback – ORIF + Tricortical BG – Vascularized Bone graft • More surgical dissection • Generous capsulotomy • Non-rigid fixation (often)
  7. 7. Matti-Russe • Well aligned Scaphoid segments • Contraindication: – OA – Proximal pole with AVN – Dorsal instability – Large cyst
  8. 8. Pedicle bone graft
  9. 9. Vascularized Bone Grafting • Local – – – 1, 2 IC SRA Base of the 2nd metacarpal P. quadratus based • Free – Medial femoral condyle – İliac crest
  10. 10. Excision
  11. 11. Proximal Row Carpectomy • Advanced SNACK • Salvage procedure • Motion preserved 50-60% • Short period of immobilization • Grip strength 7080% • Old patient
  12. 12. Intercarpal fusion • Stabilized midcarpal joint • Capitate, hamate, tri quetrum, lunate fusion +excision scaphoid
  13. 13. Procedure pearls • Adequate decortications of the joints • Proper apposition • Proper fixation(rigid) • Correction of the extension of lunate • Post op immobilization •
  14. 14. STT fusion
  15. 15. Denervation
  16. 16. Indication • When traditional, nonopertaive, musculosk eletal approaches fail, the surgical approaches may require joint fusion or replacement arthroplasty Farivar Lahiji 2009 peripheral nerve seminar 19
  17. 17. History • J. Geldmacher • 1972 (hand clinic) • 85% satisfactory reduction of pain Farivar Lahiji 2009 peripheral nerve seminar 20
  18. 18. History • Dieter Buck-Gramcko • 1977 ( JHS) • 69% complete absence of pain Farivar Lahiji 2009 peripheral nerve seminar 21
  19. 19. When you DO/Do not • SLAC • SNAC • ARTHRITIS • KIENBACH (IV) • RA • DRFX Farivar Lahiji 2009 Pitfalls • Wrist instability with clunking • Active inflammatory arthritis • No useful movement stiffness • Dystrophic wrist pain peripheral nerve seminar 22
  20. 20. Patient Selection • Local anesthetic blocks with postinjection assessment of pain relief and functional improvement Farivar Lahiji 2009 peripheral nerve seminar 23
  21. 21. Example  52-y-o north-sea shore farmer, the only money maker of the 7mems. family  Fx scaphoid 10 years PTA  Does not wish to undergo any extensive wrist salvage procedure  Good ROM  CC= pain Farivar Lahiji 2009 peripheral nerve seminar 24
  22. 22. Treatment Options Denervation • Partial denervation(PIN & AIN) • Full denervation • PIN denervation +other procedures Farivar Lahiji 2009 Alternatives • Arthroscopic /open debridment • Radial styloidectomy • Partial inter-carpal arthrodesis • Proximal row carpectomy • Wrist arthrodesis peripheral nerve seminar 25
  23. 23. Preoperative Nerve Blockade • Denervation of the wrist is indicated only after confirmation that blockade of the affected nerve (S) by local anesthetic relieves the symptoms • 1 ml Marcaine 0.5% Farivar Lahiji 2009 peripheral nerve seminar 26
  24. 24. PIN & AIN Farivar Lahiji 2009 peripheral nerve seminar 27
  25. 25. Surgical Incision Farivar Lahiji 2009 peripheral nerve seminar 28
  26. 26. incisions Farivar Lahiji 2009 peripheral nerve seminar 29
  27. 27. PIN & AIN Denervation PIN Farivar Lahiji 2009 AIN peripheral nerve seminar 30
  28. 28. P SDUN • Perforating branch of Ulnar sensory nerve • Some surgeons do it bluntly by finger Farivar Lahiji 2009 peripheral nerve seminar 31
  29. 29. PCMN Farivar Lahiji 2009 peripheral nerve seminar 32
  30. 30. Recurrent Articular Branch Farivar Lahiji 2009 peripheral nerve seminar 33
  31. 31. Predictive factors • • • • • • • • Vascularity of scaphoid fragment Site of the fracture Patient age Smoking Previous surgery Duration of nonunion Vascularized vs. nonvascularized Iliac crest vs. distal radius
  32. 32. Fragment ratio
  33. 33. Predictive factors • TABLE 19-3 -- Distribution of Fractures and Rate of Union by Fracture Site as Determined by Fragment Ratio Fracture Site 0.15−0.30 0.31−0.45 0.46−0.60 0.61−0.75 No. of Fractures 15 33 48 30 No. United(%) 4 (27) 19 (58) 40 (83) 27 (90)
  34. 34. Summary • Try to get union • Revise if needed • Salvage if moderate-severe osteoarthritis

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