Download PDF
J Wrist Surg
DOI: 10.1055/s-0044-1800948
Special Review Article

Scaphoid Non-union Arthroscopic treatment without Bone Graft: Is it Possible?

Caloia M. F.
1   Upper Extremity and Hand Surgery Section, Orthopaedic Department, Austral University Hospital, School of Medicine, Austral University, Buenos Aires, Argentina
,
Bozoghlian M. F. 
2   Shoulder and Elbow Surgery Service, Orthopedics and Rehabilitation Department, University of Iowa, Iowa City, Iowa
,
González Scotti D.
3   Upper Extremity and Hand Surgery Section, Orthopaedic Department, Austral University Hospital, Buenos Aires, Argentina
,
Fernández D. L.
4   Bern University, Bern, Switzerland
› Author Affiliations
› Further Information
    Permissions and Reprints

Abstract

Scaphoid fractures are the most frequent fractures of carpal bones, accounting for 70 to 80% of all carpal fractures. Appropriate and early diagnosis of scaphoid fractures is imperative.

To relieve symptoms and prevent degenerative changes, scaphoid non-union surgery should aim at healing and restoration of the normal anatomy, and correction of carpal deformities.

Since the scaphoid non-unions are a heterogeneous group, and categorization is not easy, the management remains controversial with a reported failure rate as high as 40% and the absence of a “gold standard” treatment.

Based on (a) Qu and Von Schroeder's new concepts on the osteogenic ability of the non-union cells stimulated by osteoinductive bone factors; (b) the encouraging results obtained by Illarramedi et al on decompression of the distal radius and ulna in Kiënbock disease treatment; and (c) along with the minimal surgical trauma of percutaneous and arthroscopic techniques, the authors have begun treating scaphoid non-unions without bone graft by using arthroscopic-assisted reduction and internal fixation with metaphyseal core decompression of the distal radius. The technique has also been used in advanced cases with “humpback” deformity and long-standing non-unions. Resting on the observations of CT scans and arthroscopic findings, we have introduced a new comprehensive classification of scaphoid non-union for better categorization and typification and provide an improved treatment approach. We recommend arthroscopic-assisted treatment in young and middle-aged non-smoking patients with scaphoid non-unions. Percutaneous fixation alone is sufficient for stable stages I and II, whereas additional core decompression of the distal radius can be used for unstable stages, for bone defects greater than 10 mm, and for the proximal pole non-unions. This method is not suggested in non-unions with significant sclerosis, with a complete absence of punctate bleeding of the proximal pole, and in those with a very small proximal fragment.

Keywords

scaphoid - non-union - arthroscopic treatment - bone graft


Publication History

Received: 25 March 2024

Accepted: 18 November 2024

Article published online:
18 February 2025

© 2025. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Cooney WP. The wrist: diagnosis and operative treatment. 2nd ed. Rochester, MN: Lippincott Williams and Wilkins; 2010
    Search in Google Scholar
  • 2 Hackney LA, Dodds SD. Assessment of scaphoid fracture healing. Curr Rev Musculoskelet Med 2011; 4 (01) 16-22
    CrossrefPubMedSearch in Google Scholar
  • 3 Kozin SH. Incidence, mechanism, and natural history of scaphoid fractures. Hand Clin 2001; 17 (04) 515-524
    CrossrefPubMedSearch in Google Scholar
  • 4 Bond CD, Shin AY, McBride MT, Dao KD. Percutaneous screw fixation or cast immobilization for nondisplaced scaphoid fractures. J Bone Joint Surg Am 2001; 83 (04) 483-488
    CrossrefPubMedSearch in Google Scholar
  • 5 Elgayar L, Elmajee M, Aljawadi A, Abdelaal A, Khan S, Pillai A. A systematic review of mechanical stabilization by screw fixation without bone grafting in the management of stable scaphoid non-union. J Clin Orthop Trauma 2021; 17: 112-117
    CrossrefPubMedSearch in Google Scholar
  • 6 Ramamurthy C, Cutler L, Nuttall D, Simison AJ, Trail IA, Stanley JK. The factors affecting outcome after non-vascular bone grafting and internal fixation for nonunion of the scaphoid. J Bone Joint Surg Br 2007; 89 (05) 627-632
    CrossrefPubMedSearch in Google Scholar
  • 7 Fan S, Suh N, MacDermid JC, Ross D, Grewal R. Vascularized versus non-vascularized bone grafting for scaphoid nonunion without avascular necrosis: a randomized clinical trial. J Hand Surg Eur Vol 2023; 48 (07) 648-653
    CrossrefPubMedSearch in Google Scholar
  • 8 Pinder RM, Brkljac M, Rix L, Muir L, Brewster M. Treatment of scaphoid nonunion: a systematic review of the existing evidence. J Hand Surg Am 2015; 40 (09) 1797-1805.e3
    CrossrefPubMedSearch in Google Scholar
  • 9 Qu G, von Schroeder HP. The osteogenic potential of pseudoarthrosis tissue and bone from human scaphoid non-unions. J Hand Surg Eur Vol 2008; 33 (04) 449-456
    CrossrefPubMedSearch in Google Scholar
  • 10 Slade III JF, Dodds SD. Minimally invasive management of scaphoid nonunions. Clin Orthop Relat Res 2006; 445 (445) 108-119
    CrossrefPubMedSearch in Google Scholar
  • 11 Illarramendi AA, Schulz C, De Carli P. The surgical treatment of Kienböck's disease by radius and ulna metaphyseal core decompression. J Hand Surg Am 2001; 26 (02) 252-260
    CrossrefPubMedSearch in Google Scholar
  • 12 Caloia MF, Gallino RN, Caloia H, Rivarola H. Incidence of ligamentous and other injuries associated with scaphoid fractures during arthroscopically assisted reduction and percutaneous fixation. Arthroscopy 2008; 24 (07) 754-759
    CrossrefPubMedSearch in Google Scholar
  • 13 Slade III JF, Dodds SD. Minimally invasive management of scaphoid nonunions. Clin Orthop Relat Res 2006; 445 (445) 108-119
    CrossrefPubMedSearch in Google Scholar
  • 14 Mahmoud M, Koptan W. Percutaneous screw fixation without bone grafting for established scaphoid nonunion with substantial bone loss. J Bone Joint Surg Br 2011; 93 (07) 932-936
    CrossrefPubMedSearch in Google Scholar
  • 15 De Bie A, Louis P, Cognet JM. Correction of residual humpback deformity after arthroscopic treatment of scaphoid non-union. Orthop Traumatol Surg Res 2022; 108 (07) 103294
    CrossrefPubMedSearch in Google Scholar
  • 16 Delgado-Serrano PJ, Jiménez-Jiménez I, Nikolaev M, Figueredo-Ojeda FA, Rozas-López MG. Arthroscopic reconstruction for unstable scaphoid non-union. Rev Esp Cir Ortop Traumatol 2017; 61 (04) 216-223
    PubMedSearch in Google Scholar
  • 17 Reed AA, Joyner CJ, Brownlow HC, Simpson AH. Human atrophic fracture non-unions are not avascular. J Orthop Res 2002; 20 (03) 593-599
    CrossrefPubMedSearch in Google Scholar
  • 18 Herbert TJ, Fisher WE. Management of the fractured scaphoid using a new bone screw. J Bone Joint Surg Br 1984; 66 (01) 114-123
    CrossrefPubMedSearch in Google Scholar
  • 19 Slade III JF, Dodds SD. Chapter 22: Percutaneous fixation of scaphoid fibrous/nonunion with and without percutaneous bone graft. In: The Scaphoid. Thieme; 2011: 175-187
    Search in Google Scholar
  • 20 Alnot JY. Fractures and pseudarthroses of the carpal scaphoid. The various stages of pseudarthrosis [in French]. Rev Chir Orthop Repar Appar Mot 1988; 74 (08) 714-717
    PubMedSearch in Google Scholar
  • 21 Büchler U, Nagy L. The issue of vascularity in fractures and nonunion of the scaphoid. J Hand Surg Br 1995; Dec; 20 (06) 726-735 PMID: 8770730
    CrossrefPubMedSearch in Google Scholar
  • 22 Slutsky DJ, Trevare J. Use of arthroscopy for the treatment of scaphoid fractures. Hand Clin 2014; 30 (01) 91-103
    CrossrefPubMedSearch in Google Scholar
  • 23 Slade 3rd JF, Gutow AP, Geissler WB. Percutaneous internal fixation of scaphoid fractures via an arthroscopically assisted dorsal approach. J Bone Joint Surg Am 2002; 84-A Suppl 2: 21-36 . PMID:12479336
    CrossrefPubMedSearch in Google Scholar
  • 24 Caloia MF, Scotti DG, Fernández DL. Arthroscopic treatment of scaphoid pseudoarthrosis without bone graft: is it really feasible?. Revista Iberoamericana de Cirugía de la Mano 2020; 48 (01) 031-041
    Thieme ConnectPubMedSearch in Google Scholar
  • 25 Yeo JH, Kim JY. Surgical strategy for scaphoid nonunion treatment. J Hand Surg Asian Pac Vol 2018; 23 (04) 450-462
    CrossrefPubMedSearch in Google Scholar
  • 26 Barton NJ. Experience with scaphoid grafting. J Hand Surg [Br] 1997; 22 (02) 153-160
    CrossrefPubMedSearch in Google Scholar
  • 27 Dawson JS, Martel AL, Davis TR. Scaphoid blood flow and acute fracture healing. A dynamic MRI study with enhancement with gadolinium. J Bone Joint Surg Br 2001; 83 (06) 809-814
    CrossrefPubMedSearch in Google Scholar
  • 28 Downing ND, Oni JA, Davis TR, Vu TQ, Dawson JS, Martel AL. The relationship between proximal pole blood flow and the subjective assessment of increased density of the proximal pole in acute scaphoid fractures. J Hand Surg Am 2002; 27 (03) 402-408
    CrossrefPubMedSearch in Google Scholar
  • 29 Dias JJ, Dhukaram V, Abhinav A, Bhowal B, Wildin CJ. Clinical and radiological outcome of cast immobilisation versus surgical treatment of acute scaphoid fractures at a mean follow-up of 93 months. J Bone Joint Surg Br 2008; 90 (07) 899-905
    CrossrefPubMedSearch in Google Scholar
  • 30 Cosio MQ, Camp RA. Percutaneous pinning of symptomatic scaphoid nonunions. J Hand Surg Am 1986; 11 (03) 350-355
    CrossrefPubMedSearch in Google Scholar
  • 31 Beamer B, Hettrich C, Lane J. Vascular endothelial growth factor: an essential component of angiogenesis and fracture healing. HSS J 2010; 6 (01) 85-94
    CrossrefPubMedSearch in Google Scholar
  • 32 Patterson ED, Elliott C, Dhaliwal G, Sayre EC, White NJ. Risk factors for the development of persistent scaphoid non-union after surgery for an established non-union. Hand (N Y) 2024; 15 589447231219523
    PubMedSearch in Google Scholar
  • 33 Liu B, Wu F, Ng CY. Wrist arthroscopy for the treatment of scaphoid delayed or nonunions and judging the need for bone grafting. J Hand Surg Eur Vol 2019; 44 (06) 594-599
    CrossrefPubMedSearch in Google Scholar