AUVA Trauma Hospital Lorenz Böhler - European Hand Trauma and Replantation Center, Donaueschingenstrasse 13, 1200, Vienna, Austria.
Ludwig Boltzmann Institute for Experimental Und Clinical Traumatology, AUVA Research Center, 1200, Vienna, Austria.
Arch Orthop Trauma Surg. 2023 Jul;143(7):4565-4574. doi: 10.1007/s00402-023-04806-0. Epub 2023 Feb 17.
Over the past years, different fixation techniques focused on rotational stability in order to increase stability and stimulate union rates. Additionally, extracorporeal shockwave therapy (ESWT) has gained importance in the treatment of delayed and nonunions. Purpose of this study was to compare the radiological and clinical outcome of two headless compression screws (HCS) and plate fixation in scaphoid nonunions, in combination with intraoperative high energy ESWT.
Thirty-eight patients with scaphoid nonunions were treated by using a nonvascularized bone graft from the iliac crest and stabilization with either two HCS or a volar angular stable scaphoid plate. All patients received one ESWT session with 3000 impulses and energy flux per pulse of 0.41 mJ/mm intraoperatively. Clinical assessment included range of motion (ROM), pain according to the Visual Analog Scale (VAS), grip strength, disability of the Arm Shoulder and Hand Score, Patient-Rated Wrist Evaluation Score, Michigan Hand Outcomes Questionnaire and modified Green O'Brien (Mayo) Wrist Score. To confirm union, a CT scan of the wrist was performed.
Thirty-two patients returned for clinical and radiological examination. Out of these, 29 (91%) showed bony union. All patients treated with two HCS compared to 16 out of 19 (84%) patients treated by plate showed bony union on the CT scans. The difference was not statistically significant. However, at a mean follow-up interval of 34 months, no significant differences could be found in ROM, pain, grip strength and patient-reported outcome measurements between the two HCS and plate group. Height-to-length ratio and capitolunate angle improved significantly in both groups compared to preoperative.
Scaphoid nonunion stabilization by using two HCS or angular stable volar plate fixation and intraoperative ESWT results in comparable high union rates and good functional outcome. Due to the higher rate for a secondary intervention (plate removal), HCS might be preferable as first choice, whereas the scaphoid plate fixation should be reserved for recalcitrant (substantial bone loss, humpback deformity or failed prior surgical intervention) scaphoid nonunions.
在过去的几年中，为了提高稳定性和刺激愈合率，不同的固定技术侧重于旋转稳定性。此外，体外冲击波疗法（ESWT）在治疗延迟性和非愈合性骨折方面的重要性日益增加。本研究的目的是比较两种无头加压螺钉（HCS）和钢板固定在舟状骨不愈合中的放射学和临床结果，并结合术中高能 ESWT。
38 例舟状骨不愈合患者采用髂嵴带血管骨移植，分别采用 2 枚 HCS 或掌侧角稳定型舟状骨钢板固定。所有患者均接受术中 3000 次冲击和 0.41 mJ/mm 脉冲能量通量的单次 ESWT 治疗。临床评估包括活动范围（ROM）、视觉模拟量表（VAS）疼痛、握力、手臂肩手功能障碍评分、患者腕部评估评分、密歇根手部结果问卷和改良 Green O'Brien（Mayo）腕部评分。为了确认愈合，对腕关节进行 CT 扫描。
32 例患者返回进行临床和放射学检查。其中 29 例（91%）显示骨性愈合。与 19 例（84%）接受钢板治疗的患者相比，所有接受 2 枚 HCS 治疗的患者在 CT 扫描上均显示骨性愈合。差异无统计学意义。然而，在平均 34 个月的随访中，两组在 ROM、疼痛、握力和患者报告的结果测量方面均无显著差异。与术前相比，两组的高度与长度比和头月角均有显著改善。
使用 2 枚 HCS 或掌侧角稳定钢板固定并术中 ESWT 治疗舟状骨不愈合可获得相似的高愈合率和良好的功能结果。由于二次干预（钢板取出）的发生率较高，HCS 可能是首选，而对于难治性（明显骨质丢失、驼峰畸形或先前手术干预失败）舟状骨不愈合，应保留使用掌侧角稳定钢板固定。
