Percutaneous Fixation for Scaphoid Nonunion With Bone Grafting Through the Distal Insertion Hole of a Fully Threaded Headless Screw

Abstract

Introduction: Avascular necrosis of the lunate in Systemic Lupus Erythematous (SLE) and rheumatoid arthritis (RA) are not rare. Our study aimed to describe the histopathology of the lunates after removing them in the operating room in patients with rheumatoid diseases and lunate palmar dislocation. We correlated the histopathological findings with magnetic resonance imaging (MRI), radiological parameters, and blood test parameters. Methods: From January 2006 to January 2015, 12 patients were operated for rheumatoid disorders, 8 RA, 1 SLE, and 3 psoriatic arthritis (PA). There were 8 female and 4 male with a mean age 65 (53-79) years. Antinuclear antibodies and other relevant tests were performed. Anticardiolipin antibody, anti-double-stranded DNA, and anti-β-2 glycoprotein I were measured by enzyme-linked immunosorbent assay (ELISA). All patients underwent MRI study. T1-weighted images were evaluated for bone necrosis of the lunate. In the operating room, we excised whole lunates and we studied the macroscopical aspect inside and outside. We evaluated the size, cartilage surfaces, number of foraminas, and ligament insertions. After that, we cut the bone and showed the bleeding bone and collapse areas. Histopathological analysis was performed with lunate sections. The lunates were fixed in formalin, decalcified, embedded in paraffin, and cut in 5 microm sections, and stained with hematoxylin and eosin. We visualized lunates sections by microscope. The surgical treatment was a wrist arthrodesis in 8 cases and wrist arthroplasty in the other 4 cases. We evaluated x-rays data such as lunate morphology, Stahl Index, Carpal Height ratio (CHR), and Carpal Ulnar distance ratio (CUDR). We correlated preoperative x-rays and MRI data with histopathological findings. We correlated blood test parameters with the histology. Statistical analysis of data was performed with chi-square test (significance level P < .05). Results: In 2 cases, we showed a lunate flattening associated with a partial hypointensity in coronal sections in T1-weighted images in MRI. Microscopic analysis showed synovial hyperplasia, fatty marrow, and fibrovascular tissue. We did not find avascular necrosis in any complete lunate but we found a focal necrosis (empty lacunae) in 2 cases. Mean CHR was 0.385, CUDR 0.301, Index Stahl 56.95, and radio-scaphoid angle 76°. We showed more ulnar translation in RA than in other rheumatoid disorders (CUDR P = .002). The correlation focal lunate necrosis with MRI was P = .371. The correlation focal lunate necrosis with scapholunate ligament rupture was P = .640. We showed 2 blood test parameters statistically significant with focal lunate necrosis (C reactive Protein P = .046 and Rheumatoid Factor P = .053).

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

“…12 Existem dois estudos na literatura com técnica semelhante à nossa. Ohta et al 13 relatam excelentes resultados de seis não consolidações escafoides tratadas por fixação percutânea com curetagem e enxerto ósseo através do orifício de inserção distal de um parafuso totalmente roscado sem cabeça. Similarmente, Bokhari et al 14 usaram agulha de trocarte Jamshidi para enxerto percutâneo para 15 não consolidações fibrosas escafoides.…”

“…A diferença entre esses dois estudos e o nosso é que eles foram realizados em pacientes com não consolidação fibrosa (Slade e Dodds tipo 2) em vez de não consolidação cística. 13,14 Em outro estudo, 33 pacientes sem deformidade corcunda, NAV no polo proximal ou artrite, foi aplicado enxerto percutâneo com pino corticoespojoso, enxerto esponjoso colhido da ala ilíaca e sem fixação adicional, e a consolidação foi obtida a uma taxa de 76%. 15 No presente estudo, a consolidação foi obtida em 9 dos 11 pacientes.…”

“…12 There are two studies in the literature that used a technique similar to ours. Ohta et al 13 report excellent results of six scaphoid fibrous nonunion treated by percutaneous fixation with curettage and bone grafting through the distal insertion hole of a fully threaded headless screw. Similarly, Bokhari et al 14 used a Jamshidi trocar needle for percutaneous grafting for 15 scaphoid fibrous nonunion.…”

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

“…Vanhees et al 15 have reported achieving 94% union in a case series of 16 patients treated using a percutaneous technique where the mean time to union was 4 months (17 weeks). Recently, favorable results and high union rates with percutaneous techniques have been reported in multiple studies, [12][13][14] although the exact time to union has not been reported in all the studies. The major risk factors involved in the failure of treatment for this condition are the duration between the injury and the surgical treatment, as well as the localization of the nonunion in the proximal pole 25 (►Fig.…”

“…The union rate and healing potential with percutaneous [11][12][13][14][15] and arthroscopically assisted [16][17][18][19][20] techniques for the treatment of scaphoid nonunion have not been discussed at length. Indeed, comparative studies of different treatment options are rare in the literature.…”