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Chronic scaphoid non-union recommendation

I fractured my scaphoid 9-10 months ago. Initial xrays didn't reveal the fracture, and after 9 months of "dealing with it", I went to see a hand specialist who was able to diagnose the fracture. I've also had an MRI, which is the basis of my question.

The MRI reported:

- Fracture at the waist of the scaphoid (proximal two-thirds and distal one-third) with fluid signal intensity and adjacent sclerosis along the fracture line
- Mild dorsal flexion at the fracture (humpback deformity)
- Partial tear of the scapholunate ligament
- Patchy subcortical sclerosis along the proximal pole of the scaphoid
- Diffuse edema noted throughout the proximal two-thirds of the scaphoid, consistent with ischemia without osteonecrosis
- Patchy marrow edema is present along the distal pole adjacent to the fracture line

My hand surgeon is recommending a structural bone graft (from the radius) to correct the scaphoid fracture (and humpback deformity), along with internal fixation, and felt confident that the bone would heal without a vascularized bone graft (he felt the MRI showed an adequate blood supply to the proximal pole). He also seemed to feel that the vascularized grafts were a little overhyped and often just clotted up. He also said that the fracture location makes it difficult to graft in a blood supply.

In addition, it sounds like he's more familiar and confident with the normal graft procedure (he does 2-3 each month) as opposed to the vascularized graft, which it seemed he doesn't do nearly as much.

Do you find his recommendation to be consistent with the MRI findings? The vascularized bone graft is a more invasive procedure, but seems like it would increase the likelihood of healing. If the bone doesn't heal, the scaphoid will die and then I'll be looking at a salvage procedure (scaphoid removal and partial wrist fusion). As a piano player of 25 years, basketball player, mountain biker, and computer programmer, I would do pretty much anything to avoid a salvage procedure.

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replied October 16th, 2011
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Frenchy44,

All scaphoid fractures that go onto a delayed or non union are difficult to treat. The fact that you do not have AVN of the proximal pole on MRI is a good sign. However, the only way to actually tell if the pole is vascular is to look for punctate bleeding at the time of surgery.

Vascularized bone grafts are touted by those surgeons who do them. However, there is little research to show that the graft actually stays vascularized, after its pedicle has been twisted back on itself, routed under the fascia of the wrist and into the joint. Does it really stay vascular, or does it just become a regular graft?

Nonvascularized, structural grafts have been used with great success for many decades. Most hand surgeons can do them easily and quickly, with no more dissection of the tissues than necessary. Until the late 90's, most of the structural grafts where shaped to fit into the defect, correcting the deformity. Then the patient was placed into a long arm cast. But, with the development of the Herbert screw, and others based on the same principles, internal fixation can now be done, so the patient is not required to be immobilized for long periods.

A vascularized graft could also be attempted if the regular graft did not work.


You also have a partially torn scapholunate ligament. That will have to be assessed during surgery, to see if it is of significance. If you have dynamic SL instability, you may have to have something done about that also. Unfortunately, treatment of SL ligament injuries is difficult. And, unfortunately, during the treatment of this tiny ligament, a significant amount of scar tissue can form. This is where patients often lose ROM in the wrist.

But, an surgery on the wrist can result in loss of ROM. And usually, this is a patient determined factor. Some patients will heal without any loss of motion, and another, who had exactly the same procedure, will become very stiff and lose a significant amount of motion. It's a just a matter of how the patient's body reacts to the trauma of the surgery.


So, basically, it is a matter of how you feel about the surgery. Nonvascularized grafts have been done successfully for many decades. However, if you want to go with the newest, greatest, thing on the block, then you might want to go for the vascularized graft. There is no consensus on the "best" method as of yet.


Good luck. Hope you do well. Work hard in rehab.
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replied October 16th, 2011
Thank you so much for your thoughtful reply. It's obviously been a source of worry for me, and it's nice to hear some confirmation of the path I'm on.

The torn scapholunate ligament is a fairly new discovery, and I've been so focused on the fracture that I haven't paid much attention. Also, as you suggested, the surgeon indicated that he'd have to look at the tear at the time of the operation. The MRI did mention that the ligament had widened to 4mm, with a tear at the membranous portion (not sure what that means). It was noted that the dorsal segment was intact. The surgeon didn't seem too worried about it.

I'm definitely very concerned about ROM loss. As this injury is now almost 10 months old, I've already lost a significant amount of wrist mobility, particularly in my wrist extension. Obviously, a fractured scaphoid is going to prevent a lot of range of motion, but I'm anxious to see if I regain any mobility after the surgery.

The funny thing is that I actually went through about 10 weeks of physical therapy with the fractured scaphoid (several months ago). It was quite painful - now I understand why - but I figure (hope) that therapy after surgery will be better. Thanks for the encouragement - I'll definitely be working hard...

Thanks again for your reply. I really appreciate it.
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replied October 17th, 2011
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Frenchy44,

As to the scapholunate ligament. The fact that the dorsal portion is intact is a very good thing. The dorsal part is the strongest and most important portion.

The SL ligament is shaped like a horseshoe. With very stout dorsal (on the back of the wrist) and volar (palmar side) segments. These two parts are actually the ligament, as they are the parts responsible for keeping the two bones together, but also allowing some physiological rotation. There is a little "give" in the ligament. If there was no motion at all, it would be very easy to treat an SL tear, you could just fuse the two bones together. But, of course, it is not that easy.

The membranous portion of the ligament is the bottom of the horseshoe. In the case of the ligament, this portion is towards the radius. And it is just that, a membrane. There is a vascular pedicle that runs through it. When doing a wrist arthroscopy, it is the main landmark that the surgeon looks for, to get oriented. It is not uncommon for the membranous portion to be torn, and cause pain. So, if the dorsal part is okay, the membranous part is just debrided (shaved down), during an arthroscope.

Tear of the membranous portion of the SL ligament is a common cause for dye to leak from the midcarpal row into the proximal carpal row, during an arthrogram of the wrist.


But, anyways...Hope your surgery goes well. If good fixation can be obtained, then usually minimal or no post-op immobilization has to be used. That way you can start on ROM exercises as soon as possible. You are motivated to get your motion back and that is very important. It can sometimes make the difference.

Luckily, most activities of daily living do not require a full ROM at the wrist. But, some athletic events do (ie push ups, bench press).

Wishing you the best. Hope you get your ROM back. Good luck.
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replied October 18th, 2011
I was able to get a second opinion today. The doctor came highly recommended from another physician and has over 30 years of experience. He was extremely helpful and spent a lot of time explaining everything to me.

He wasn't a big fan of the Herbert screw, and rather suggested a Matti Russe graft (iliac crest) with pins. I've read up what I can and it seems like the Matti Russe graft is the predecessor to the wedge graft/Herbert screw procedure. Most of the literature I've read indicates that patients see a slightly higher union rate with the wedge/Herbert, but that the Matti Russe is still a very viable option.

His reasons for favoring the Matti Russe with iliac:

- Wedge graft often not fully correcting the humpback
- The size of the screw in comparison to the relatively small bone
- He preferred the iliac crest graft over the radial graft because he felt the radial graft would create a slight vulnerability in the radius. Due to my hobbies (ATV and mountain biking) he felt this might introduce risk.
- Matti Russe is able to better bridge the proximal and distal poles
- He felt the Matti Russe was more "natural" - less hardware involved (my words, not his). He said it would be a longer healing period waiting for the bone to naturally heal, but that it would be better and less invasive in the long run.

He didn't say it, but I also suspect that he's more "old school", and is probably favoring the procedure he's more familiar with and better at.

I felt more comfortable with the second opinion surgeon, despite his extremely odd demeanor, but not sure about the advice.

Is there a case where the Matti Russe is a better option? Or is it just a matter of physician choice? Is there anywhere I could read up on the subject?

Thanks,
Eric
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replied October 19th, 2011
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Eric,

Yes, it is a matter of surgeon's preference. And yes again, the Russe graft and pinning is a much older technique, developed before the buried, double threaded screws came into being. In the days when straight K-wires were the only thing there was to help hold the graft in place till it was incorporated. The graft is a sculpted graft, so it does fit better into the defect/deformity. But, there is a certain amount of morbidity associated with an iliac crest graft. It is not a benign as often made out to be. Surgeons will often sort of skip over it, and just say, oh we'll take the graft from the crest, and keep going, without telling the patient exactly what it entails.

Though harvesting the graft is often given to the junior resident, if it is not done properly, the patient can have significant problems from it. With the Russe graft, the surgeon has to take a tricortical section. So, that will include a portion of the inner and outer tables, and the top of the crest that connects the two tables. The surgeon tries to peel the periosteum off with the muscles so that it can be closed over the defect, but there is still a "chunk" or "rat bite" taken out of the crest. It is usually taken from a section just posterior to the anterior superior iliac spine (ASIS). You don't want to disrupt or weaken the ASIS because some strong muscles attach there. The forces generated by the muscles can pull the attachment off, if it is weakened too much.

Some patients, especially those who are fit and thin, who do not have a lot of padding over the crest, have some problems with the graft site. Their trousers waist band or belt often rub on it, causing irritation. You have to watch out for the lateral femoral cutaneous nerve, which supplies sensation to the lateral thigh, as it runs through this area. A neuroma here can be very bothersome and drive some patients bonkers.

A complication which is really not good, and fortunately doesn't occur too often, is violation of the inner table. There are a lot of blood vessels just inside the pelvis, that bleed like stink if injured. And it is impossible to just reach in and clamp it. That would require opening the pelvis. Again, this is a very rare occurrence.

However, a common complaint among patients, is that the harvest site hurts worse than the wrist. It is another surgical site, with its own set of possible risks and complications. And, unfortunately, some patients have more problems with the iliac crest graft site than they do with the main operative site. And this is with just the ones that bore a small hole in the crest to get out cancellous bone. The Russe actually takes structural, cortical bone. The defect left has to fill in with osteoid and then calcify. This can take some time. Often, patients will liken the discomfort to a severe hip pointer, that doesn't go sway.

But, there have been many iliac crest grafts done down through the years and it is a tried and true procedure. But, because of the above mentioned problems, many surgeons have trended away from using it. Going rather to local grafts (distal radius) or using one of the artificial bone graft materials with the patient's cancellous bone or use BMP (bone morphogenic protein). But, again, it is surgeon and patient preference. And has pros and cons for each.


As to the screws used in the scaphoid, the original Herbert screw is really not used anymore. It's jig system was a pain to use. But the concept of having threads at each end of different pitch, causing compression of the bones, has been used by other implant manufacturers. There are screws that are very tiny, made specifically for use in the wrist and hand. They are headless and are buried in the bone. Acutrak and Synthes are just a couple of companies that make the variable pitch screws.


With the screw fixation, usually it is not necessary to immobilize the patient for very long, if at all. Thus the patient gets their range of motion back much faster. With the Russe, the patient usually has to be immobilized for an extended period of time. If the pins are place, minimal motion can be performed while they are in, depending upon how long the surgeon leaves them. The longer ones preclude motion, but are easier to remove. If they are cut short, then motion is sometimes allowed after the graft is incorporated, but they are harder to remove.


The amount of bone taken from the distal radius is usually not enough to weaken the bone. The graft should be taken as a rounded piece, so that there are no sharp corners to act as stress risers. But, the removal of a small piece of cortical bone and the cancellous bone beneath it does not cause any problems, since this regenerates while the patient is healing the scaphoid surgery. Since the patient is not putting a lot of stress on the wrist anyways, the radius has time to heal. But, as with anything, if not done properly, there can be some problems. I have never seen a distal radius fracture, but it is a theoretical complication. There are nerves and arteries that have to be protected.

But, usually, since the incision for the scaphoid is already there, it just needs to be extended a little to harvest the graft. So, there is no separate incision or surgical site. It make the surgery quicker also.



So, you have to go with what you feel is best. As you can see (and I sure you have read) there is no real consensus on how scaphoid fractures should be treated, and thus, it is the same for treatment of the non-union. About the only thing surgeons agree on, is that they need to be treated surgically.

The structural grafts were some of the first procedures done. The hand fellows now days, may see some of the emeritus professors do them, but they are really not done that often anymore. The compression that can be obtained with the variable pitch screws is so good, that it is probably the most common procedure done. But, that is not to say, that the older procedures won't work also.

The iliac crest probably provides the best grafting material. However, the risks have to be weighed against the benefits.


Sorry to ramble on. Again, you will have to take all the information you have obtained, and go with what you feel is best for you and your lifestyle.

Good luck. Wish you the best.
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