Dodds Seth D, Halim Andrea
Yale University Department of Orthopaedics and Rehabilitation, New Haven, CT.
Yale University Department of Orthopaedics and Rehabilitation, New Haven, CT.
J Hand Surg Am. 2016 Jul;41(7):e191-8. doi: 10.1016/j.jhsa.2016.04.021. Epub 2016 May 20.
We sought to evaluate the clinical and radiographic outcomes after treatment of symptomatic, recalcitrant scaphoid nonunions using a novel combination of volar scaphoid buttress plating with a pedicled vascularized bone graft.
We retrospectively followed 9 patients with recalcitrant scaphoid waist nonunions, characterized by failed prior surgery, long duration of nonunion, avascular necrosis of the proximal pole, or considerable bone loss at the nonunion site. We treated these persistent nonunions through a single volar incision with a pedicled vascularized bone graft, based on the volar carpal artery, and a 1.5-mm precontoured, scaphoid-specific, volar buttress plate. Postoperatively, we assessed objective and subjective outcomes as well as radiographs and computed tomography scans.
The median duration of nonunion was 15 months, ranging from 6 to 96 months. Postoperative follow-up ranged from 11 to 19 months. Computed tomography scans demonstrated union in 8 of 9 cases. Complications included 1 minor hematoma that spontaneously resolved. One scaphoid failed to unite, requiring revision surgery. Three patients experienced problems with the plate. One plate was removed from a patient who noted persistent clicking, and 2 plates have caused symptomatic clicking, likely requiring future removal. Eight of nine patients reported satisfaction with the procedure, with QuickDash scores averaging 8.2.
We present a series of recalcitrant scaphoid nonunions treated with a novel technique of volar buttress plating and vascularized bone graft. In this series, we found a high rate of union, with consistent radiographic improvement and symptomatic relief. This procedure can be performed using a single incision and with minimal donor site morbidity. Volar plating of a scaphoid nonunion comes with the risk of articular prominence, but offers a new alternative to headless screw fixation. Our early results from this series are promising and support this protocol as a viable alternative for challenging nonunions.
TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.
我们试图评估采用一种新型的掌侧舟骨支撑钢板联合带蒂血管化骨移植治疗有症状的、顽固性舟骨不愈合后的临床和影像学结果。
我们回顾性随访了9例顽固性舟骨腰部不愈合患者，其特点为既往手术失败、不愈合时间长、近极缺血性坏死或不愈合部位有大量骨质丢失。我们通过单一掌侧切口，采用基于掌侧腕动脉的带蒂血管化骨移植以及一块1.5毫米预塑形的、舟骨特异性的掌侧支撑钢板，治疗这些持续性不愈合。术后，我们评估了客观和主观结果以及X线片和计算机断层扫描。
不愈合的中位持续时间为15个月，范围为6至96个月。术后随访时间为11至19个月。计算机断层扫描显示9例中有8例愈合。并发症包括1例自行消退的小血肿。1例舟骨未愈合，需要翻修手术。3例患者出现钢板相关问题。1例患者因持续弹响取出了钢板，2例钢板导致了有症状的弹响，可能需要在未来取出。9例患者中有8例对手术表示满意，QuickDash评分平均为8.2。
我们展示了一系列采用新型掌侧支撑钢板和血管化骨移植技术治疗的顽固性舟骨不愈合病例。在本系列中，我们发现愈合率高，影像学持续改善且症状缓解。该手术可通过单一切口进行，供区并发症极少。舟骨不愈合的掌侧钢板固定有导致关节突出的风险，但为无头螺钉固定提供了一种新的选择。我们从本系列得出的早期结果很有前景，支持该方案作为治疗挑战性不愈合的一种可行选择。
研究类型/证据水平：治疗性IV级。
