Arthroscopic treatment of scaphoid nonunion, a new algorithm after six years practice

Abstract

Introduction: Scaphoid nonunion is still a challenging problem in hand surgery. Till now most of the patients have been treated with open revision, bone grafting and internal stabilization. Arthroscopy plays an increasing role in hand surgery since the last decade. In this retrospective study, we want to present our results and current treatment protocol, adapted after midterm analysis.

Material and methods: In 2017, arthroscopic treatment of scaphoid nonunion was started at our department. Debridement is done arthroscopically as well as insertion of radius cancellous bone graft. Fixation has been accomplished with K-wires and/or head compression screws percutaneously, by help of fluoroscopy. Till 2020, 24 patients were treated, observing three delayed unions, treated successfully by extra corporal shockwave therapy and modifying the fixation. A subsequent analysis of the results yielded the modification of our fixation methods, and consequently, all patients received shockwave therapy as well.

Results: Comparing the success rate with the 28 operated after 2020, the adaption of our algorithm showed an improvement of the healing rate from 87 to 96%. There we found only one ongoing nonunion in the proximal 1/3. The median time to bony healing was comparable in the two groups, operation time showed no significant difference. After a median follow-up of 30 months, an excellent range of motion could be found, as well as a significant reduction in pain and grip strength matchable with the unaffected hand in all 52 patients. DASH and Mayo Wrist Score showed satisfactory results, and 45 patients came back to their earlier occupation and sports.

Conclusion: Arthroscopy has a fix place in the algorithm for scaphoid nonunion in our institution. It is hypothesized that the implementation of an adequate and stable fixation on the section of the nonunion is indispensable. The distal radius is a sufficient donor-site for cancellous bone grafting. Extra corporal shockwave therapy is from now on used routinely in arthroscopic treatment of scaphoid nonunion.

Level of evidence: IV.

Keywords: Extra corporal shockwave; Internal fixation; Radius bone graft; Scaphoid nonunion; Wrist arthroscopy; Wrist injuries.