Löw Steffen, Kiesel Sebastian, Spies Christian K, Erne Holger
Praxis für Handchirurgie und Unfallchirurgie, Ledermarkt 8-10, 97080, Bad Mergentheim, Deutschland.
Klinik für Handchirurgie, Rhön-Klinikum Campus Bad Neustadt, Bad Neustadt, Deutschland.
Oper Orthop Traumatol. 2022 Aug;34(4):261-274. doi: 10.1007/s00064-022-00765-8. Epub 2022 Apr 8.
Minimally invasive arthroscopically assisted reconstruction of scaphoid nonunions.
Delayed union or nonunion of the scaphoid with sclerosis and with indication for bone transplantation. Limited arthritic changes at the radial styloid.
Severe humpback deformity with dorsal intercalated segment instability. Midcarpal arthritic changes.
Supine position with the forearm upright and in neutral position, the elbow flexed by 90°, axial traction of 3 to 4 kg. Standard wrist arthroscopy via the 3-4 and the 4-5 portal and the midcarpal joint via the radial and ulnar portal, respectively, with sodium chloride as arthroscopy medium. Change of the optic to the ulnar midcarpal portal and opening of the nonunion with an elevator via the radial midcarpal portal. Resection of the sclerosis with a 3.0 mm burr while irrigating the joint. Harvesting of cancellous bone via the second extensor compartment. On the hand table, closed reduction by joy-stick K‑wires if needed and insertion of K‑wires for the scaphoid screw. Insertion of the screw without entering of the distal thread into the bone. Arthroscopic insertion of the bone transplant by a blunt drill sleeve via the radial portal with steady compression by the obturator. Complete insertion of the screw under arthroscopic control of the compression of the nonunion space with arthroscopic control of stability with the probe.
Six weeks forearm cast including the thumb metacarpophalangeal joint, radiographic control and non-load bearing movements for two more weeks, CT scan in the oblique sagittal plane after 8 weeks, and increase of load, as well as physiotherapy on demand depending on the radiographic results.
To date, 17 patients with a mean age of the nonunion of 18 months were treated. In 14 patients, bony union was achieved after 8 weeks. In one patient, an extraosseous screw placement was corrected. In another patient with extraosseous screw placement, persisting nonunion was treated with an angular stable plate. One scaphoid demonstrated an asymptomatic tight nonunion after 14 months, while one scaphoid with sclerosis of the proximal pole did not heal.
微创关节镜辅助下舟骨不愈合的重建。
舟骨延迟愈合或不愈合伴硬化且有骨移植指征。桡骨茎突处有关节炎改变但程度较轻。
严重驼背畸形伴背侧中间节段不稳定。腕中关节关节炎改变。
仰卧位，前臂伸直并处于中立位，肘部屈曲90°，轴向牵引3至4千克。分别经3-4和4-5通道进行标准腕关节镜检查，经桡侧和尺侧通道进行腕中关节镜检查，以氯化钠作为关节镜检查介质。将镜头转换至尺侧腕中通道，经桡侧腕中通道用骨膜剥离器打开不愈合处。用3.0毫米磨钻切除硬化组织，同时冲洗关节。经第二伸肌间隙采集松质骨。在手术台上，必要时用操纵杆克氏针进行闭合复位，并插入克氏针以便置入舟骨螺钉。置入螺钉时远端螺纹不进入骨质。经桡侧通道用钝头钻套 arthroscopically插入骨移植块，用填塞器进行稳定加压。在关节镜控制下，在不愈合间隙加压的情况下完全置入螺钉，并用探针关节镜控制稳定性。
前臂石膏固定六周，包括拇指掌指关节，进行影像学检查并再过两周进行不负重活动，8周后进行斜矢状面CT扫描，根据影像学结果增加负重，并根据需要进行物理治疗。
迄今为止，共治疗17例平均不愈合时间为18个月的患者。14例患者在8周后实现骨愈合。1例患者纠正了骨外螺钉位置。另1例骨外螺钉置入患者持续不愈合，采用角稳定钢板治疗。1例舟骨在14个月后出现无症状的紧密不愈合，而1例近端极硬化的舟骨未愈合。
