Arch Hand Microsurg.  2020 Jun;25(2):90-100. 10.12790/ahm.20.0015.

Arthroscopic Bone Grafting and Kirschner-Wires Fixation for Scaphoid Nonunion

Affiliations
  • 1Department of Orthopedic Surgery, Jeonbuk National University Medical School, Jeonju, Korea
  • 2Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, Korea

Abstract

Various surgical techniques, such as corticocancellous or cancellous bone graft and other vascularized bone grafting techniques have been developed to treat scaphoid nonunion. However, open grafting with dissection of wrist capsule and ligaments damages the joint and hence can lead to increased stiffness of the wrist and hand. Arthroscopic assisted bone grafting and percutaneous fixation have advantages such as minimal surgical trauma to the scaphoid blood supply and its ligament connection and provide a thorough wrist assessment, comprehensive approach for scaphoid nonunion and its sequelae in a minimally invasive manner. This article briefly discusses the characteristic anatomy of the wrist and scaphoid, and reviews the technique of arthroscopic bone grafting and percutaneous fixation for the treatment of scaphoid nonunion.

Keyword

Scaphoid nonunion; Arthroscopy; Bone graft; K-wire

Figure

  • Fig. 1. The appearance of scaphoid from the mid-carpal joint (A, plain radiographs; B, cadaveric specimen) shows gentle curvature of the waist and the proximal portion that allows fairly stable platform for the surgeon.

  • Fig. 2. Basic instrumentation. (A) 2.5 mm and 1.9 mm video arthroscope, (B) 2.0 mm and 2.9 mm shavers, 3.0 mm burr and radiofrequency probe for surgical instrument. (C) Two custom-made cannulas (3.8 mm and 3.0 mm) and 2 custom-made trocars (3.2 mm and 2.7 mm) for percutaneous bone grafting.

  • Fig. 3. Arthroscopic portals marked in the radio-carpal and mid-carpal joints. MCU, mid-carpal ulnar; MCR, mid-carpal radial; ACC, accessory portal.

  • Fig. 4. A 46-year-old male patient with nonunion of the left scaphoid fracture. Preoperative left wrist plain scaphoid. (A) A view showing nonunion at the waist of the scaphoid. (B) Same patient’s left wrist, mid-carpal arthroscopy image of scaphoid nonunion site shows large gap and sclerotic margins of both fragments. P, proximal fragment; D, distal fragment; MCR, mid-carpal radial.

  • Fig. 5. Left wrist, mid-carpal arthroscopy images of nonunion site of 2 patients after debridement. (A) Showing punctate bleeding from the proximal and distal fragments. (B) Showing no punctate bleeding from the proximal fragment. P, proximal fragment; D, distal fragment; MCR, mid-carpal radial; MCU, mid-carpal ulnar.

  • Fig. 6. After preparing the bone graft, we reduce the scaphoid with traction, gentle passive ulnar deviation, hypersupination and extension of the wrist with a surgical towel placed under the forearm and a 1.2 mm Kirschner-wire is inserted percutaneously from the tubercle of the scaphoid to the proximal pole for provisional scaphoid fixation.

  • Fig. 7. (A) In the presence of a dorsal intercalated segmental instability deformity and extended lunate, the wrist is first flexed to realign the extended lunate with the radius for deformity correction. (B) The radio-lunate joint is then transfixed with a percutaneous 1.2-mm Kirschner-wire inserted from the dorsal distal radius. (C) We then percutaneously fix the scaphoid with a 1.2-mm Kirschner-wire.

  • Fig. 8. (A) Cancellous bone graft is harvested from the iliac crest. (B) The bone graft is then cut into small chips using scissors.

  • Fig. 9. (A) Left wrist, mid-carpal arthroscopy images of percutaneous autogenous iliac cancellous bone grafting at the nonunion site using cannula and trocar. (B) Same patient’s left wrist, mid-carpal arthroscopy image showing finished bone graft to the nonunion site percutaneously using cannula and trocar. MCR, mid-carpal radial; MCU, mid-carpal ulnar.

  • Fig. 10. Immediate postoperative plain scaphoid radiographs of stable nonunion (A) and unstable nonunion (B) show internal fixation with Kirschner-wires and grafted bone at the nonunion site.

  • Fig. 11. Postoperative 49 months after follow-up plain left wrist scaphoid radiograph shows complete bony union.

  • Fig. 12. The mean scapho-lunate angle in 15 scaphoid nonunion advanced collapse patients shows significant improvement from an average 66°±7.9° preoperatively (A) to 50.4°±7.5° at the final follow-up (B).


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