Arthroscopically Assisted Bone Grafting Reduces Union Time of Scaphoid Nonunions Compared to Percutaneous Screw Fixation Alone

Abstract

Purpose Minimally invasive techniques have been recommended in the treatment of painful but stable scaphoid nonunions. The purpose of this study was to determine if arthroscopically assisted bone grafting provided superior results in healing as compared to percutaneous screw fixation. Materials and Methods One hundred sixty-four consecutive patients with scaphoid nonunions were retrospectively analyzed. One hundred forty-eight patients were treated with the open grafting techniques either with iliac or distal radius bone, leaving 16 patients treated with minimally invasive surgery. In the group treated percutaneously (n = 8), the time from injury to surgery was 2.5 months (range: 2–4 months) and it was 27.3 months (range: 3–180 months) in the arthroscopic group (n = 8). The mean age was 39 years (range: 20–66) in the percutaneous group and 22 years (range: 16–32) in the arthroscopic group. In all cases, the Mini Acutrak headless fully threaded compression screw was used. Healing was assessed clinically and radiographically at a minimum follow-up of 12 weeks, mean 7 months (range: 3–12 months). Data were calculated with two-tailed Mann–Whitney U test based on p-value of < 0.05 that was considered statistically significant. Results We recorded no complications in any of the groups. Patients treated arthroscopically received cancellous bone grafting from the distal radius and all patients but one healed at a median of 7.8 weeks (range: 5–18 weeks). Seven patients in the percutaneous group healed at a mean of 10.5 weeks (range: 7–24 weeks), thus leaving one patient from each group without achieving union. Mann–Whitney U test showed the U value of 11, the critical value of U to be 13 (p < 0.05), thus significantly faster healing was observed in the arthroscopically treated group. Conclusions Arthroscopically treated patients achieved faster healing despite shorter time to surgery in the percutaneous group. Local bone grafting is considered as the main reason for this outcome. Younger population in the arthroscopically treated group may have influenced the result. Level of Evidence This is a Level III comparative study.

Enxerto percutâneo e fixação de parafusos em pacientes com não consolidação do escafoide

“…Another minimally invasive method is arthroscopic-assisted bone grafting. Gvozdenovic et al 8 compared arthroscopically-assisted bone grafting with percutaneous screw fixation. They achieved similar high union rates in both groups but stated that the operation time was significantly higher in the arthroscopic group due to the learning curve of this technically more advanced method.…”

“…They achieved similar high union rates in both groups but stated that the operation time was significantly higher in the arthroscopic group due to the learning curve of this technically more advanced method. 8 A disadvantage of the percutaneous technique is that it requires the frequent use of fluoroscopy. For this reason, possible harmful effects of radiation on the patient and surgical team should be kept in mind.…”

“…6 Portanto, fixações feitas com menos dissecção de tecido mole com uma técnica minimamente invasiva tornaram-se mais amplamente preferidas nos últimos anos. 7,8 A perfuração fechada na linha de não consolidação usando técnica percutânea estimula a cicatrização removendo tecido fibroso da linha de pseudoartrose, e nos casos em que há ressorção óssea excessiva, ela permite enxerto fechado sem danificar a superfície escafoide. 9-11 De acordo com a classificação de Slade e Dodd de não consolidações escafoides, que é de grande uso em tratamento cirúrgico minimamente invasivo, a fixação rígida sem enxerto é recomendada para más consolidações escafoides precoces sem ressorção óssea significativa (tipos 1-3), enquanto para más consolidações tardia com ressorção óssea significativa (tipos 4-5), recomenda-se que o enxerto seja aplicado além da fixação rígida.…”

“…No entanto, em pacientes com fratura muito proximal e um pequeno fragmento, outras opções de tratamento podem ser consideradas. 8 As principais vantagens desta técnica são que não há necessidade de dissecção de tecido mole, e a fixação e enxerto podem ser aplicados sem danificar a superfície escafoide ou a membrana fibrocartilaginosa ao redor da linha de não consolidação. Assim, o suprimento de sangue do escafoide, que já é pobre, não é mais interrompido.…”

“…6 Therefore, fixations made with less soft-tissue dissection with a minimally invasive technique has become widely preferred in recent years. 7,8 Closed drilling in the nonunion line using a percutaneous technique stimulates healing by removing fibrous tissue from the pseudoarthrosis line, and in cases in which there is excessive bone resorption, it allows closed grafting without damaging the scaphoid surface. [9][10][11] According to the Slade and Dodds classification of scaphoid nonunions, which is of great use in minimally invasive surgical treatment, rigid fixation without grafting is recommended for early scaphoid nonunions without significant bone resorption (types I-III), while for late nonunions with significant bone resorption (types IV-V), it is recommended that grafting be applied in addition to rigid fixation.…”