Surgical Treatment Of Pseudarthrosis Of Carpal Scaphoid (About 30 Cases)

Keywords

Carpalscaphoïd pseudarthrosis; Nonunion, Surgery.

Introduction

Scaphoid nonunion is the failure of a scaphoid fracture to heal after 6 months. This problem has attracted the attention of many authors for a long time, and continues to be the subject of frequent work [1, 2]. Five to ten percent of scaphoid carpal fractures do not permanently heal [1, 3], and untreated progress inevitably leads to osteoarthritis and functional degradation of the wrist due to pain, stiffness and loss of strength [4]. We report a series of 23 cases of pseudarthrosis of the carpal scaphoid, treated surgically in order to analyze the diagnostic, therapeutic and prognostic characteristics.

Aim: The aim of our study was to evaluate a series of non-union of the carpal scaphoid treated surgically.

Material and Methods

Our work consists of a retrospective study of 23 cases of pseudarthrosis of the carpal scaphoid treated surgically. Adult patients with pseudarthrosis of the carpal scaphoid regardless of the initial treatment were included in our study. Patients were examined bilaterally and comparatively at both wrists, and this focused on pain, joint mobility and muscle strength. The radiological examination was also done bilaterally and comparatively comprising an X-ray of the wrists from the front and a X-ray of the front with the handle closed giving a spread view of the scaphoid allowed us to study the pseudarthrosis using the Alnot classification (Fig. 1) [3]. MRI was performed in a single patient to assess the viability of the proximal fragment. Our work consists of a retrospective study of 23 cases of pseudarthrosis of the carpal scaphoid treated surgically.

Results

Twenty-three carpal scaphoid pseudarthrosis were treated surgically. There were 7 women for 16 men (30.43% vs. 69.57%). The average age was 35 (between 21 and 57). The average time between fracture and graft was 27 months (between 4 months and 55 months). The fracture involved the body of the scaphoid in 87% of cases and in 9% of cases the proximal pole. Using the ALNOT classification we found 56.52% stage I, 39.13% stage IIA, 21.73% stage IIB, and 13.04% stage IIIA.

All the patients were operated on by the MATTI-RUSSE technique and in 2 patients a preoperative DISI was reducible and fixed with a provisional radiolunar pin using the Cooney technique [5]. The graft was stabilized by internal fixation in all patients, Herbert screwing in 22 cases, pinning in 1 case. The mean follow-up was 18 months with extremes of 2 months to 25 months. 21 patients consolidated unmistakably except in 2 patients with a short follow-up that did not allow a judgment to be made on the state of consolidation.

The mean follow-up was 18 months (between 2 months and 25 months). 17 patients no longer presented with pain. The other 6 had mild pain once or twice during the month or after heavy labor. Postoperative joint mobility was improved in 19 patients, the mean range of motion increased from 60°/50° preoperatively to 80°/60° postoperatively. 91% of our patients were able to resume their activities. As for grip strength, its assessment was primarily subjective, based on patient reports, and was generally satisfactory. Obvious radiological union was obtained in 21 cases (91.30%) with a mean delay of 11 weeks (between 6 and 14 weeks) (Fig 2, 3).

Among the 2 cases of DISI (Dorsal intercalated segment instability) found preoperatively with a radiolunar angle measured at 22 °, radiological consolidation without DISI was obtained. The carpal height was restored in the 3 patients who presented a preoperative decrease. Analysis of the radiographic images revealed 5 cases of radioscapholunate osteoarthritis, which remained stationary, with no notable radiological evolution after 25 months of follow-up. The diagnosis of the initial fracture was unrecognized in 10 patients (43.47%). Taking into account the Mayo clinic score according to Alnot stages, the overall functional results are summarized in Table I.

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Figure 1 & 2:

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Figure 1-2: Sagittal ( figure 1) and axial ( figure2) CT images.

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Figure 3 & 4:

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Figure 3-4: sagittal (figure3) and axial (figure4) MRI images.

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Figure 5 & 6:

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Figure 5-6: Intraoperativeview of the cyst after hemilaminectomy.

Discussion

The diagnosis of pseudarthrosis of the scaphoid does not seem to pose a problem, unlike that of the initial fracture, which should always be borne in mind in front of any traumatic wrist, even if it is not deformed and asymptomatic.

Overall, any non-union, even asymptomatic one, should be treated, as it will inevitably progress to worsening over time [1, 6]. Its treatment is difficult and controversial [1, 5, 7, 8]. However, there are several therapeutic methods of which it is necessary not only to master the technique but also to know the indication according to the evolutionary stage of the lesions [8]. The corticosteroidcancellous graft according to the Matty-Russe technique is a good technique that gives good results provided you follow a few rules [5-7, 9]:

- Iliac harvest.

- Good stabilization of the graft and the carpal scaphoid by stableosteosynthesis.

- Wrist immobilization until final consolidation (3 months).

The use of a vascularized bone graft is a good treatment for small loss of substance from the carpal scaphoid. Its use was first proposed for the treatment of necrosis of the proximal pole, a questionable indication; and for the treatment of failures of classical techniques [2, 4]. However, this graft is technically more difficult to make than a conventional graft [5].

Several series in the literature show great variability in relation to the rate of union between non-vascularized and vascularized grafts. Nevertheless, in view of the literature and the meta-analysis by Ditsios K and Merrell, vascularized grafts seem to be the most logical and most suitable solution in cases of necrosis of the proximal pole [3].

Conclusion

Pseudarthrosis of the carpal scaphoid are lesions of often late discovery. The therapeutics indications depend on the anatomopathological classification. Hence the value of treating recent pseudarthrosis. The results depend on the stage of development and the type of treatment.