Volar Plate Fixation of Recalcitrant Scaphoid Nonunions With Volar Carpal Artery Vascularized Bone Graft

Abstract

Chronic scaphoid fracture nonunion continues to present a significant challenge to the treating orthopedic surgeon. Internal fixation with threaded compression screws leads to high union rates, and is currently the gold standard, but there are certainly circumstances where a scaphoid screw does not provide the stability necessary for nonunion repair. Results using a volar buttress plate have been promising, but have not been described in conjunction with the use of vascularized bone graft. Vascularized bone grafts have been shown to be highly effective in achieving rapid and reproducible rates of union. We describe a novel combination of a vascularized volar distal radius wedge autograft pedicled on the volar carpal artery and volar buttress plating for salvage treatment of chronic scaphoid nonunion.

A Biomechanical Comparison of Screw and Plate Fixations for Scaphoid Fractures

“…Thirty-four cases of volar plate fixation of scaphoid nonunion with vascularized or iliac crest bone graft have been described among Dodds et al, Ghoneim, and Leixnering et al Those authors report two failed union among these 34 cases. 5,12,13 For biomechanical reasons alone, the authors propose that locking plate fixation should be considered at least equivalent to screw fixation for scaphoid nonunion. Based on the superior performance of locking plates in simulated osteoporotic bone, and other clinical considerations, the authors believe that locking plate fixation merits consideration in cases of scaphoid nonunion with segmental defect.…”

“…11 Recently, plate fixation has been described as a surgical option when nonunion occurs after screw fixation, when a nonunion presentation is delayed >2 years, where there is bone loss, or where screw purchase is suboptimal with a segmental bone defect. 12 Some authors have suggested that scaphoid plating may provide superior fixation in cases of avascular necrosis of the proximal pole. 12 These plates act as bridging plates and may be fixed with either locking or nonlocking screws.…”

“…12 Some authors have suggested that scaphoid plating may provide superior fixation in cases of avascular necrosis of the proximal pole. 12 These plates act as bridging plates and may be fixed with either locking or nonlocking screws. The plate may improve fixation of a scaphoid fracture by resisting axial compression, rotation, and shear.…”

“…The plate may improve fixation of a scaphoid fracture by resisting axial compression, rotation, and shear. 12 Axial collapse is the most frequent cause of failure in a collapsed scaphoid due to loss of cortical opposition with a segmental defect. 13,14 Scaphoid nonunion fixation is frequently augmented with bone grafting.…”

Angular Stable Miniplate Fixation of Chronic Unstable Scaphoid Nonunion

“…The use of plates to treat the nonunion of the scaphoid has been described previously. [11][12][13][14][15] There are numerous factors that can adversely affect the outcome of surgery for scaphoid nonunion. Besides the radiological and anatomical aspects such as a sclerotic nonunion, humpback deformity, and the vascularization of the proximal fragment, certain patient characteristics, such as age, smoking, and occupation adversely affect the outcomes of surgical treatment.…”