Dustmann Moritz, Bajinski Ralf, Tripp Alexander, Gülke Joachim, Wachter Nikolaus
Department for Traumatology, Orthopaedic Surgery and Sportsmedicine, Klinikum am Steinenberg Reutlingen, Steinenbergstrasse 31, 72764, Reutlingen, Germany.
Department for Hand-, Plastic and Microsurgery, Katharinenhospital Stuttgart, Kriegsbergstrasse 60, 70174, Stuttgart, Germany.
Arch Orthop Trauma Surg. 2017 Jun;137(6):867-873. doi: 10.1007/s00402-017-2680-4. Epub 2017 Apr 1.
In treatment of scaphoid non-union bone healing requires beside vital tissue and stability, enduring compression and a good interface between the graft and scaphoid fragments. While fixation techniques show a good primary stability, they reduce sintering and thus compression of fragments in the long term. Therefore, a modified technique optimising the cancellous interface between graft and scaphoid but still providing enough stability without fixating implants should be evaluated.
A corticocancellous bone graft from iliac crest was shaped ellipsoid and was implanted in a modified Matti-Russe press fit-technique. Thereby the cancellous side contacts the scaphoid fragments. In a retrospective design, we reviewed 52 patients with documented non-unions of the scaphoid. The average length of follow-up was 8.6 months. Range-of-motion, pain and grip-strength was measured and compared with contralateral wrist. Radiological assessment included beside X-rays CT scans. Results were further measured by DASH score and Mayo wrist score.
The average postoperative pain was 0.9 based on NRS-Score. The mean range-of-motion was satisfactory with a dorsal-palmar arch of 115.3°, radial-ulnar: 48.2° and pro-supination: 171.3°. Mayo Wrist Score showed with 91.2 out of 100 an excellent result. The analysis of DASH score revealed a mild subjective constriction (9.2/100). Regarding roentgenographic findings complete union was confirmed in 44 of the 52 patients (84.6%). Patients with non-union were significantly older than patients with union (p < 0.05). Grip-strength on average was equal to that of the uninjured hand although in failure cases a slightly reduced grip-strength was seen.
The modified technique of Matti-Russe provided a good contact of the cancellous part of the bone graft to the scaphoid in grafting a scaphoid pseudarthrosis with a high healing rate. However, since age, previous failed surgery and a proximal fracture line are the most important handicaps for bone healing in this study, for patients at risk gadolinium-enhanced MRI scan could be helpful to estimate vascularisation preoperatively. In cases of poor vitality, vascularised bone grafting should be considered.
在舟骨不愈合的治疗中，骨愈合除了需要有活力的组织和稳定性外，还需要持久的加压以及植骨与舟骨碎片之间良好的界面。虽然固定技术显示出良好的初始稳定性，但从长远来看，它们会减少烧结，从而降低碎片的压缩。因此，应评估一种改良技术，该技术可优化植骨与舟骨之间的松质骨界面，但仍能在不使用固定植入物的情况下提供足够的稳定性。
取自髂嵴的皮质松质骨移植块被塑形为椭圆形，并采用改良的马蒂-鲁斯（Matti-Russe）压配技术植入。由此，松质骨面与舟骨碎片接触。在一项回顾性研究中，我们回顾了52例有舟骨不愈合记录的患者。平均随访时间为8.6个月。测量了活动范围、疼痛和握力，并与对侧手腕进行比较。影像学评估除X线外还包括CT扫描。结果进一步通过DASH评分和梅奥腕关节评分进行测量。
基于数字评分量表（NRS），术后平均疼痛评分为0.9分。平均活动范围令人满意，背掌侧弧度为115.3°，桡尺侧为48.2°，旋前-旋后为171.3°。梅奥腕关节评分在满分100分中达到91.2分，结果优异。DASH评分分析显示有轻度主观受限（9.2/100）。关于影像学检查结果，52例患者中有44例（84.6%）确认完全愈合。不愈合患者明显比愈合患者年龄大（p＜0.05）。平均握力与未受伤手相当，不过在失败病例中握力略有降低。
改良的马蒂-鲁斯技术在移植舟骨假关节时，使骨移植的松质骨部分与舟骨有良好接触，愈合率高。然而，由于年龄、既往手术失败以及近端骨折线是本研究中骨愈合的最重要障碍，对于有风险的患者，钆增强MRI扫描有助于术前评估血管化情况。在活力较差的情况下，应考虑采用带血管蒂骨移植。
