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SCAPHOID NONUNION
ISSH MONTHLY MEETINGFarivar Lahiji M.D
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• Goal of treatment : consolidation of fracture in anatomical alignment
• Failure of union leads to predictable arthritis
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)
• (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
Special circumstances
• Proximal pole, AVN, humpback– ORIF + Tricortical BG– Vascularized Bone graft• More surgical dissection• Generous capsulotomy• Non-rigid fixation (often)
Matti-Russe• Well aligned
Scaphoid segments• Contraindication:– OA– Proximal pole with
AVN– Dorsal instability– Large cyst
Pedicle bone graft
Vascularized Bone Grafting
• Local– 1, 2 IC SRA– Base of the 2nd
metacarpal– P. quadratus based
• Free– Medial femoral condyle– İliac crest
Excision
Proximal Row Carpectomy
• Advanced SNACK• Salvage procedure• Motion preserved
50-60%• Short period of
immobilization• Grip strength 70-
80%• Old patient
Intercarpal fusion• Stabilized
midcarpal joint • Capitate, hamate,
triquetrum, lunate fusion +excision scaphoid
Procedure pearls• Adequate
decortications of the joints
• Proper apposition• Proper fixation(rigid)• Correction of the
extension of lunate• Post op immobilization•
STT fusion
Denervation
Indication
• When traditional, nonopertaive, musculoskeletal approaches fail, the surgical approaches may require joint fusion or replacement arthroplasty
Farivar Lahiji 2009 peripheral nerve seminar 19
History
• J. Geldmacher• 1972 (hand clinic)• 85% satisfactory reduction of
pain
Farivar Lahiji 2009 peripheral nerve seminar 20
History
• Dieter Buck-Gramcko• 1977 ( JHS)• 69% complete absence of pain
Farivar Lahiji 2009 peripheral nerve seminar 21
When you DO/Do not
• SLAC• SNAC• ARTHRITIS• KIENBACH (IV)
• RA• DRFX
Pitfalls• Wrist instability
with clunking• Active inflammatory
arthritis• No useful
movement stiffness• Dystrophic wrist
pain
Farivar Lahiji 2009 peripheral nerve seminar 22
Patient Selection
• Local anesthetic blocks with postinjection assessment of pain relief and functional improvement
Farivar Lahiji 2009 peripheral nerve seminar 23
Example52-y-o north-sea shore
farmer, the only money maker of the 7-mems. family
Fx scaphoid 10 years PTA
Does not wish to undergo any extensive wrist salvage procedure
Good ROMCC= pain
Farivar Lahiji 2009 peripheral nerve seminar 24
Treatment Options
Denervation• Partial
denervation(PIN & AIN)
• Full denervation• PIN denervation
+other procedures
Alternatives• Arthroscopic /open
debridment• Radial
styloidectomy• Partial inter-carpal
arthrodesis• Proximal row
carpectomy• Wrist arthrodesis
Farivar Lahiji 2009 peripheral nerve seminar 25
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
PIN & AIN
Farivar Lahiji 2009 peripheral nerve seminar 27
Surgical Incision
Farivar Lahiji 2009 peripheral nerve seminar 28
incisions
Farivar Lahiji 2009 peripheral nerve seminar 29
PIN & AIN Denervation
PIN AIN
Farivar Lahiji 2009 peripheral nerve seminar 30
P SDUN• Perforating branch
of Ulnar sensory nerve
• Some surgeons do it bluntly by finger
Farivar Lahiji 2009 peripheral nerve seminar 31
PCMN
Farivar Lahiji 2009 peripheral nerve seminar 32
Recurrent Articular Branch
Farivar Lahiji 2009 peripheral nerve seminar 33
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
Fragment ratio
Predictive factors
• TABLE 19-3 -- Distribution of Fractures and Rate of Union by Fracture Site as Determined by Fragment Ratio
Fracture Site No. of Fractures No. United(%) 0.15−0.30 15 4 (27) 0.31−0.45 33 19 (58) 0.46−0.60 48 40 (83) 0.61−0.75 30 27 (90)
Summary
• Try to get union• Revise if needed• Salvage if moderate-severe
osteoarthritis