JJM MEDICAL COLLEGE JOURNAL ON First experience with a new adjustable plate for Osteosynthesis of SCAPHOID NONUNIONS.MODERATORS: PRESENTED BY:DR NAGBHUSHAN D M DR ROHIT KUMAR PROFFESOR PG IN ORTHOPAEDICSDR SRINATH S R DATED:19.01.12ASSOCIATE PROFESSOR
INTRODUCTION• Scaphoid is one of the smallest bone of human body.• Its derived from greek word SKAPHOS meaning boat.• It acts as a link between proximal and distal carpal rows.• Scaphoid fractures constitute 2.9% of all bone fractures.• Second only to the distal radius in frequency.
RULE OF 70’S FOR SCAPHOID• 70% of all carpal fractures occur at scaphoid.• 70% of blood supply is by the dorsal branch of the radial artery.• 70% of fractures occur at the waist of scaphoid.• 70% of the scaphoid fractures unite .
TYPES OF NON UNION OF SCAPHOID• TYPE NAME CHARACTER• 1. SIMPLE NO DISPLACEMENT WITH NO DEGENERATIVE CHANGE• 2. UNSTABLE DIAPLACEMENT> 1mm OR SL ANGLE >70 DEG• 3. EARLY ARTHRITIS RADIO-SCAPHOID ARTHRITIS• 4. S N A C WRIST III + MID CARPAL ARTHRITIS• 5. S N A C PLUS ARTHRITIS THROUGHOUT WRIST
• CONSERVATIVE and a number of surgical options are availaible for treatment of scaphoid fractures.• Nonunions of scaphoid fractures need surgical management .• In this investigation, all patients who underwent surgery for fractures of scaphoid were treated with fixation of HERBERT SCREWS .• Nonunion of fractures were treated with iliac crest bone grafting & implantation
• of HERBERT SCREW after resection of the bony parts of the fracture .• The cannulated self tapping headless bone screw system permits easy implantation of the screw.• Bony consolidation was achieved in a large number of cases, only in few healing was not achieved after primary treatment and also after treatment of pseudoarthrosis.
• In past few years surgeons used titanium plate osteo-synthesis in such cases which provide fragment stability , particularly rotational stability , finally leads to consolidation of the fracture after these second or third surgeries…
PATIENT AND METHODS• Between JAN 2007 AND AUGUST 2009 , we treated 7 men and 4 women of mean age 37 years (22-53 years) by scaphoid plate osteosynthesis .• Most of the cases were secondary referrals to our hospital for treatment of nonunions.• All the patient had #’s at the waist of the scaphoid with established nonunion persisting for atleast 6 months after the causative injury , with wrist pain
weakness or both.• Patients with severe degenerative changes in the wrist were considered unsuitable and thus were excluded .• 6 patient had previous unsuccessful surgery with herbert or AO screws in place before our plating . (fig 1-4)• 3 patients previously had bone grafting & radiological apperance was classified according to Herbert and Fisher classification before surgery.
PREVIOUS UNSUCCESSFUL SURGERY WITH HERBERTSCREW X RAY AP VIEW AFTER 3 MONTHS LATERAL VIEW AFTER 3 MONTHS
CT SCAN VIEW AFTER 13 MONTHS OF HERBERT SCREW ANTERO POSTERIOR VIEW LATERAL VIEW
• Clinical assessment used a standard proforma, which included range of movement ,grip strength in Kilograms measured using a hydraulic dynamometer.• The results were graded as showing either full function, allowing return to pre fracture activity without any pain or as reduced function in which there was a subjective feeling of stiffness or weakness or objective return of range of movement.
• In addition we used DASH score which ranges from 0-100 (0 being no limitation of movement and 100 as maximum).• Radiological union was achieved when the trabeculae traversed the graft from proximal to distal pole on atleast 2 out of 4 standard scaphoid views.• In 4 patients CT was used to clear the doubt.
• The scaphoid is accessed by volar approach on the radial side of flexor carpi radialis.• The wrist capsule is opened and scaphoid is seen ,by the use of small Hohmann hooks , which are introduced at the radial cortex surface , the scaphoid can now be set .• The pseudoarthrosis is scraped with a spherical cutter at a rotation speed under adequate irrigation ..(fig 5)
INTRAOPERATIVE SITUS AFTER SCRAPING OFF OF PSEUDO-ARTHROSIS
• The two fragment are then brought in anatomical position under control with two 1mm drill wires and then a 3-d titanium plate was bent and fixed with at- least 6 screws.
• Then the bone defect was filled with autogenous spongy bone from the iliac crest .• Because of the divergent position the screws , stable fixation was achieved .• The plate is small and adjust well to the shape of the scaphoid that one may expect minimum impingement of the adjacent radial lip .
• Finally drill wires were removed and wrist is immobilized using a wooden spatula –FILMULIN and PEHA adhesive dressing with thumb ring for 6 weeks .• Heavy manual loads were to be avoided for a period of 16 weeks ..
RESULTS• All 11 patients had clinical and radiological follow up for at least 6 months . The mean period was 13 months (6-23) .• The range of wrist movements and grip strength was recorded for all patients .• All the fractures united at a median time of operation for about 4 months .• All patients reported improvement in their symptoms and function.
• The mean DASH score was 28 points this value indicate a good outcome .• 4 patients had minor symptoms such as aching wrist, cold intolerance, or scar tenderness. 8 patients had full function and 3 had reduced function .• 6 of the 8 patients with full function showed mild to moderate degenerative changes on the pre operative radiograph when compared with 3 patients with reduced function .
X RAY IMAGES- 2 MONTHS AFTER PLATINGANTERO-POSTERIOR VIEW LATERAL VIEW
RANGE OF MOVEMENT AFTER 2 MONTHS SUPINATION PRONATION
DISCUSSION• The treatment of scaphoid fractures has a long history.• After massage and extirpation of fracture scaphoid which was the treatment in last century.• Lorenz bohler introduced immobilization with padded plaster splint for 6 weeks for uncomplicated transverse #’s.
• For complex #’s such as oblique ones , he recommended a further immobilization for 6 weeks .• However treating pseudoarthrosis with a long period of immobilization was futile and did not lead to fracture healing .• A reliable method of obtaining stable union of an unhealed scaphoid was rendered possible only after surgical dissection and stabilizing by spongy bone repair .
• Although Matti suggested excavation of scaphoid from the dorsal aspect and filling with autologous spongy bone ,Russe performed a blockage by the use of the volar chip plasty .• He further introduced modification –Russe II which is based on removal of the necrotic proximal fragment and introduction of the mushroom shaped bone chip from the iliac bone ..
• An alternate procedure for pseudo arthrosis was given by Ender in 1977, using a scaphoid –beaked plate .• After iliac crest bone grafting , the plate is fixed in the distal portion of the scaphoid with the screw and in the proximal fragment with staved hook.• The screw fixation of Mc Laughlin proved advantageous for unstable #’s and shortened the period of immobilization.
• Streli introduced cannulated drill compression screw in 1970 through a previously introduced k wire .• Nevertheless , the majority of isolated scaphoid was treated with conservative management until few years ago.• Only after introduction of Herbert screw in 1984 and its double threaded system , we had commercially available implant which led to its widespread use .
• The Herbert screw is suitable for the treatment of recent #’s and in combination with bone chip plasty for fracture pseudoarthrosis.• This construction was adopted by many manufacturers and subsequently modified .• Its now available as cannulated screw and a mini Herbert screw.
• The cannulated screw facilitates the technique of osteosynthesis and permits minimally invasive percutaneous osteosynthesis of scaphoid fractures.• In rare cases, healing is delayed or does not occur at all . This has been observed after screw osteosynthesis, double screw osteosynthesis, or alternative procedures even after folding a vessel pedicle bone chip whether from pisiform bone or radius .
CONCLUSION• Assuming that the main reason for failed healing is lack of stability, particularly rotational stability (apart from poor vascularization of the proximal fragment ), improving the osteosynthesis material seems to be one of the most important factor for successful healing .• Thus, we consider stable scaphoid pseudoarthrosis, which has been previously treated with screw osteosynthesis and failed, as one of the main indication for stable plate osteosynthesis with spongy bone repair.
X RAY VIEW AFTER 8 MONTHS OF PLATING LATERAL VIEW ANTERO POSTERIOR