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A technique for anterior wedge-shapedgrafts for scaphoid nonunions withcarpal instability

This article presents a brief description of the following modifications of the original Fisk proce-dure for navicular nonunions with carpal instability: (1) preoperative calculation of exactscaphoid length and form based on comparative roentgenograms of the opposite wrist, (2) the useof a palmar approach, (3) the insertion of a wedge-shaped corticocancellous graft from the lilaccrest after resection of the pseudarthrosis, and (4) the use of internal fixation. Preoperativeplanning is considered essential to restore the anatomic length, analyze the angular deformity,evaluate the pathologic scapholunate angle, and calc~alate the resection and size of the graftneeded. The palmar approach reduces the danger of ialtrogenic damage of the vascular supply ofthe scaphoid and accidental lesions of the superficial branches of the radial nerve. Furthermore itprovides a better exposure of the scapholunate joint to correct lunate rotation. Iliac bone ispreferred to the radial styloid graft, as proposed by Fisk, because of its better ability to resistcompression forces. Internal fixation adds rotational stability so that continued postoperativeplaster immobilization can be reduced to a minimum of 8 weeks. (J HAND SURG 9A:733-7, 1984.)

Diego L. Fernandez, M.D., Aarau, Switzerland

he association of fractures or nonunionsthe scaphoid with dorsal carpal instability patterns is

recognized entity and has been extensively analyzedvarious authors.1-7 In these cases a pathologic dor-rotation of the lunate with increased scapholunate

angle is invariably seen in the lateral wrist x-rayFisk6 has stressed the point that, in established

with carpal instability, correction of the flex-deformity and restoration of normal scaphoid length

normal tension in the palmar radiocarpalwhich in turn corrects the pathologic rota-

of the lunate. He proposed radial wedge grafting ofnavicular to achieve union and overcome instabil-In his technique,8 a radial exposure with osteotomy

the radial styloid is used, and after reduction of theof the carpus, the palmar radial wedge-

defect of the navicular is filled in with a graftfrom the osteotomized stytoid process. No inter-

fixation material is used.

,gy Section, Department of Surgery, Kantonsspi-tal, Aarau, Switzerland.

Received for publication Oct. 14, 1983; accepted in revised formDec. 14, 1983.

Reprint requests: Diego L. Fernandez, M.D., Department of Sur-gery, Kantonsspital, CH-5001 Aarau, Switzerland.

On the other hand, the Russe9’ 10 palmar inlay graft-ing procedure is a reliable and universally acceptedmethod for achievement of union of the scaphoid, evenin the presence of avascular necrosis of the proximalfragment. Russe has reported a 100% union rate in aseIies of 40 cases treated operatively during 1973 and1979.1° In our department, this is the preferred methodof treatment for scaphoid waist nonunions without car-pail instability. -

However, in cases with severe scaphoid shortening,cystic nonunions with bone resorption, and importantflexion deformity, we have found it difficult to restoreaccurate scaphoid length with .inlay grafting tech-niques. Insertion of a longer graft usually distracts thenonunion site, creating a ring-like bone defect that ren-ders the nonunion unstable, therefore increasing thefailure rate because of recurrence of the flexion de-formity.

In six consecutive cases, resection of the nonunionsi~!e and insertion of a tight-fitting wedge-shaped cor-ticocancetlous graft has rendered satisfactory results interms of union and correction of the dorsal instabilitypattern (Table I).

In a recent report, Linscheid et al. 11 presented sixcases of palmar wedge grafting combined with cancel-lc,us bone grafting of the proximal and distal fragments.

THE JOURNAL OF HAND SURGERY 733

734 Fernandez HAND SURGFI~

Comparative x-ray films also help to determine ~1).

Fig. 1.Preoperative planning: (top) tracing of uninjured wris:tand measurement of scaphoid length and SL angle; (middle)calculation of size of resection area and form of graft; (bot-tom) definitive diagram of operation.

They advocated transfixation of the reduced lunate tothe radius, and additional Kirschner wires were used tostabilize the intercarpal joint. With radial wedge graft-ing, Fisk~ obtained union in 27 of 37 nonunions. De-tailed information on restoration and maintenance ofcarpal alignment with roentgenographic measurementsof the SLangleis not given.

The purpose of this article is to describe four techni-cal modifications of the original Fisk procedure, thesebeing: (1) the use of a preoperative plan based on com-parative roentgenograms of the opposite wrist, (2) theuse of a palmar approach, (3) the resection of the."nonunion site and insertion of an iliac graft, and (4) theuse of internal fixation. We will also discuss their ad-vantages.

Technique

To restore the exact anatomic length and form of thenavicular, the amount of resection and size of the graftneeded as well as the angular deformity are calcu-lated preoperatively on tracing paper by means ofroentgenographic findings of the unin~ured wrist (Fig,

degree of intercarpal collapse of the affected wrist ~the normal SL and lunocapitate angles for each parti~

lar patient. The scaphoid is approached between ~flexor carpi radialis and the radial artery accordingthe classic Russe procedure. The palmar capsule of ~iwrist is then incised longitudinally in line with the ski~!incision and the incision is extended to the scapho~tubercle. This gives a clear exposure of the nonunion~the proximal and distal fragments, and the SL juncti~.(Fig. 2). Then the resection is carried out w~th an oscfl~lating saw according to the preoperative plan. If ther~

are s~gns of avascular necros~s of the proximal frag~i~ment, multiple 1 mm drill holes are placed wi’,hin theisclerotic cancellous bone. Then the flexion de’:%rmity’~and shortening are corrected by distracting the os~i!teotomy site on the palmar-radial aspect with two smallbone hooks or a spreader clamp. As this is done, the.!!assistant simultaneously corrects the dorsal rotation of:)the lunate by pushing the palmar pole toward the radius:i

with a fine bone spike. The corticocancellous graft ob-:,!,i~tained from the iliac crest is shaped to fit the defect. In ¯most instances the graft is triangular. However,cases in which considerable lengthening is desired,graft will be trapezoidal to bridge the defect thatpears on the dorsal aspect of the navicular (Fig. 3). The.~.,graft is oriented so that its cortical part lies palmarly(Fig. 2, C). After insertion of the graft, theedges are shaped flush with the proximal and distalfragments. The image intensifier is usedrection of lunate rotation. Then internal fixationscaphoid is carried out with two or three 1.2Kirschner wires, which are power driven percutane-:ously into the palmar aspect of the distal fraementacross the graft into the dorsal aspect of the proximalfragment. Again the image intensifier is used to guara ,tee the correct placement of the internal fixationrial. Careful closure of the palmar capsule completesthe operation, and the Kirschner wires are cut short, 5 :!mm below the palmar skin of the thenar area.

After operation a palmar plaster splint that includes ~.the thumb is applied for 2 weeks, at which timesutures are removed. Thereafter the wrist and thumbare immobilized in a short navicular cast for 6Immobilization is discontinued 8 weeks after operationand a palmar Orthoplast removable splint is applied,with which the patient can perform active exercisesthe wrist three times a day for 15 minutes. Tomogramsof the navicular are obtained at the tenth week, and ifbony union is confirmed, the internal fixation materialis removed through a small incision under local anes-thesia.

5784 Wedge-shaped grafts for scaphoid nonunions 735

:ted

~ each

:ap:,t~!e ofwith thethe

hee SLwith anplan. If

’oximal

3nring theithistlrd the

3ushe

!ect ~iaatFiges

ation

iZig. 2. A, Wide exposure of whole scaphoid and palmar pole of lunate through Russe’s palmarapproach. Hypertrophic nonunion with flexion deformity .shown with bone hook. B, Wedge-shapedtriangular iliac graft to fit the resected nonunion. C, Graft in place. Notice that the cortical part ofthe graft faces palmarly. D, Position of Kirschner wires used for internal fixation.

data

Age(yr)/sex

Duration ofnonunion

(mo) Localization

Preop. SL angle(degrees)

Injured Uninjuredwrist wrist

Postop.SL angle(degrees)

Time tohealing(wk)

31/M 12 Waist 50 38 40 1017/M 8 Distal one third 72 43 41 8

¯ 21/M 14 Waist, avascular necrosis, 60 45 47 10(perilunate dislocation)

22/M 6 Waist 55 47 45 1123/M 10 Waist 42 35 32 10.522/M 7 Proximal one third, avas- 63 52 55 12

~ cular necrosis

22.6 9.5 10.2

first six cases treated with this tech-1981, with an average follow-up of 12.1

I), showed that correction_ of thetilt of the lunate with normalization of

the SL angle and union of the pseudarthrosis in anaverage of 10.2 weeks was achieved in all six caseswith the proposed postoperative management.

All malunions had a dorsal instability pattern with anaverage increase of the SL angle of 13.6° as compared

736. FernandezThe Jourr~!

HAND

Fig. 3. Cystic unstable nonunion with avascutar necrosis ofproximal pole after transscaphoperilunate dislocation (case 3,Table I). Nonunion healed with satisfactory correction of lu-nate rotation with interposed trapezoidal graft after resectionof pseudarthrosis.

with the uninjured wrist. Four nonunions were locatedat the waist, one in the distal third and one in theproximal third of the scaphoid. Two had avascularchanges in the proximal fragment. As shown in Table I,postoperative restoration of the SL angle resulted inmeasurements comparable to those of the oppositewrist, producing near symmetry. Intraoperative simul-taneous correction of the dorsiflexed lunate and resto-ration of scaphoid length with tightening of the palmarradiocarpal ligaments resulted in spontaneous stable re-duction of the lunate in all cases.

In none of the cases was additional Kirschner-wirefixation of the lunate to the radius necessary to maintainthe corrected rotation of the lunate.

The roentgenographic follow-up showed that correc-tion of the instability with serial measurements of theSL angle remained unchanged (Figs. 3 to 5).

We believe that the comparative x-ray films of theuninjured wrist are essential to determine the normalSL angle for each particular patient, as it may vary

between 30° and 60° in normal wrists, with an av~of 46°? The palmar approach is preferredprovides adequate exposure of the whole scaphoidand the SL junction and avoids both iatroof the nutrient arteries of the scaphoid and accinjuries to the superficial branches of the radialFurthermore, most of the cases of scaphoid nonuniqwith a pattern of dorsified intercalated segmentedstability of the carpus result in a palmar flexionmity of the scaphoid that requires a palmar owedge grafting rather than a palmar-radial grafting.believe that, for this purpose, the palmar approach :~more direct, easier, and less traumatizing than aincision ~vith radial styloid osteotomy. Iliac boneis preferred to local grafts taken from the diszalbecause of the better quality and compression resi:tance of the cancellous bone. Furthermore thestyloid has a limited bone stock if larger graftsneeded. Since the graft is inserted under distractionthe scaphoid fragments, the nonunion is perfectlybilized by capsular and ligament tension,there is perfect apposition of the osteotomizedA simple form of internal fixation with two orKirschner wires ensures rotational stability so thattinued postoperative immobilization is reducedminimum of 8 weeks in a short navicular cast.believe that preoperative planningamount of resection and size of the graft neededon the study of the x-ray films of the oppositeessential to restore the exact anatomy and length of the~caphoid.

Conclusions

Normal realignment and restoration oflength of the scaphoid is a measure to preventintercarpal collapse in established nonunions withsociated dorsal instability patterns. In our hands,ventional Russe procedure has provedrestore anatomic length without creating abone defect and instability. Initial results of apalmar wedge grafting technique of the scaphoidbined with internal fixation, based on the original Fiprocedure, are encouraging.

REFERENCES

1. Gilford WW, Bolton RH, Lambrinudi C: Thenism of the wrist joint with speof the scaphoid. Guy’s Hosp Rep 92:53, 1943

2. Fisk GR: Carpal instability and the fracturedAnn R Coil Surg Engl 46:63, 1970

3. Linscheid RL, Dobyns JH, Beabout JW, BryanTraumatic instability of the i,vrist. Diagnosis, classifica-

9A. No. 5bet 1984 Wedge-shaped grafts for scaphoid nonunions 737

~n

because

¯ tic darnt

aented,:loll

afting.z~proachan aDone¯ ~ta! radit~iO~thegrafts

traction’fectly

!:) or

~ that~ced tocast.the

~ed

gth

ventwiths,a

icient

,idhal

’racturesi

:aphoid

an

~ssifica-

Fig. 4. Nonunion of distal third of the scaphoid. Oblique,. view (top middle) shows palmar displace-ment of distal fragment. Nonunion healed with 30° corzection of SL angle (case 2, Table I).

Oblique waist nonunion of the scaphoid. Frontal to-clearly shows palmar displacement of the distalNonunion healed with correct carpal alignment

1, Table I).

tion and pathomechanics. J Bone Joint Surg [Am]54:1612-32, 1972

4. Weber ER: Bio~nechanical implications of scaphoidwaist fractures. Clin Orthop 149:83-9, 1980

5. Cooney WP, Dobyns JH, Linscheid RL: Fractures of thescaphoid: A rational approach to management. CIin Or-thop 149:90-7, 1980

6. Fisk GR: Overview of wrist injuries. Clin Orthop149:137-43, 1980

7. Cooney WP, Dobyns JH, Linscheid RL: Non-union oft̄he scaphoid: Analysis of the results from bone grafting.J HAND SURG 5:343-54, 1980

8. Fisk GR: Operative surgery, part II. In Bentley G, editor:Ortfiopaedics. Kent, 1979, Butterworths, p 540

9. Russe O: Fracture of the carpal navicular: Diagnosis,nonoperative treatment, and operative treatment. J BoneJoint Surg [Am] 42:759, 1960

I0. Russe O: Die kahnbeinpseudarthrose, behandlung undergebnisse. Hefte Unfallheilkd 148:129-34, 1980

11. Linscheid RL, Dobyns JB, Cooney WP: Volar wedgegrafting of the carpal scaphoid in non-union associatedwith dorsal instability patterns. In Proceedings of theSeventh Combined Meeting of the Orthopaedic Associ-ations of the English Speaking World, Cape Town,South Africa, March 1982. J Bone Joint Surg [Br]64:632-3, 1982

12. Fisk GR: Volar wedge grafting of the carpal scaphoid innon-union associated with dorsal instability patterns(discussion). In Proceedings of the Seventh Combinedrneeting of the Orthopaedic Associations of the EnglishSpeaking World, Cape Town, South Africa, March1982. J Bone Joint Surg [Br] 64:632-3, 1982