Abstract
Due to the unique morphology and tenuous vascularity, proximal pole fractures of the scaphoid are prone to nonunion if neglected. The vascular anatomy and the understanding that the blood flow to the proximal pole is retrograde in nature, has supported the concept of disruption of blood flow to the proximal pole with the possibility of avascular necrosis in a nonunited proximal pole. Historically, surgical management at this stage has favored the use of a vascularized bone graft over a nonvascularized bone graft to achieve union and good outcomes. However, the current literature seems to deviate from the long-standing understanding of proximal pole nonunion and its relationship to avascular necrosis. Not only does it state that avascular necrosis is extremely rare, but it also advocates arthroscopic bone grafting of proximal pole nonunions using morselized nonvascularized bone graft which has been proven to be a highly successful operation. Here, in our paper, we present a short series of some unique but surgically challenging cases of proximal pole nonunion and our successful management by bone grafting and fixing them arthroscopically. Our experience and invariably the experience of many may indicate that arthroscopic bone grafting and fixation may be the correct choice of surgery for proximal pole nonunion of the scaphoid bone.
Keywords: arthroscopy, bone graft, proximal pole, nonunion
The scaphoid bone is shaped like a boat but in a three-dimensional sense, the above description though, is an oversimplification of its actual bodily nature. 1 As Wong and Ho describe it to the likeness of a twisted peanut, it occupies an even more complex space in the wrist bringing around communication and articulation between the proximal and distal row, performing the delicate kinetics and kinematics of the wrist. Hyaline cartilage covers the scaphoid in near entirety with a few areas spare for the entrance of its nourishing vessels namely around the dorsal crest and the tuberosity. 2 Considering the unique vascular and morphological nature of the scaphoid bone, proximal pole fractures of the scaphoid are not only associated with high rates of nonunion as high as 30% 3 but also are supposedly prone to develop avascular necrosis with an estimated occurrence of 3% in all cases of scaphoid fractures happening predominantly in the proximal pole. 4 Though bone grafting is considered the preferred method to ensure union in nonunion cases, 5 the prevailing concept that vascularized bone grafting is necessary to ensure success in cases of impaired vascularity has been challenged by many surgeons. 6 7 8 9 At the same time it has also been advocated that open procedures required to deliver a vascularized bone graft can endanger the already precarious blood supply to the proximal pole and even more in the very proximal, proximal pole nonunion. Minimally invasive procedures such as arthroscopic management of the nonunion can circumvent compromising any remnant vascularity when there is a concern of impairment of the blood flow. 10
Recently, there have been reports of successful outcomes after open surgery to bone graft and internally fixing the proximal pole of the scaphoid and that avascularity of the proximal pole of the scaphoid did not adversely impact the outcome of surgery 11 12 13 A recent paper by Ecker et al 14 had also shown arthroscopic bone graft and internal fixation of proximal nonunion of the scaphoid had more than 96% union rates. In this study of 30 cases, all but one of the nonunion united albeit however small the size of the proximal pole fragment was. The paper gives an excellent description of the procedure that we have incorporated into our practice and have successfully implemented in a series of challenging and unique proximal pole fractures leading to successful union thus further bolstering the need for arthroscopic bone grafting in such difficult cases.
Materials and Methods
From 2021 to 2023, we came across 4 unique cases of proximal pole nonunion, each of them noteworthy in their presentation and subsequent management. Case number 1 was a case of failed union after screw fixation. Case 2 presented 9 years after the established nonunion of the proximal pole with evidence of arthritis and avascular necrosis on the latest MRI scan. Cases 3 and 4 were both the very proximal, proximal pole nonunions. These cases were subsequently treated arthroscopically using a nonvascularized bone graft from the iliac crest successfully. We will be presenting the surgery employed in each case and the technical deviations required in dealing with such unique cases.
Case 1: Nonunion after Failed Fixation of a Proximal Pole Fracture
Video 1 Midcarpal arthroscopy showing the fracture nonunion site—a needle being used to probe it.
Video 2 Probing the nonunion site to ascertain the corrected direction of burring.
Video 3 Sclerotic bone is excised on both sides of the screw shaft with a thin layer of bone left behind inferiorly to contain the bone graft.
Video 4 Punctate bleeding from both ends.
Video 5 Packing the bone graft with a freer elevator.
Our first case is a 30-year-old gentleman, lawyer by profession who sustained a proximal pole fracture of the right scaphoid. The scaphoid was fixed with a compression screw in the acute setting ( Figs. 1 and 2 ). Persistent tenderness of the anatomical snuffbox and radiological signs on serial radiographs led to a computed tomography at 4 months after the primary procedure showing nonunion with bone resorption ( Fig. 3A–C ). After discussion with the patient, it was decided to conduct an arthroscopic inspection of the scaphoid bone and the site of the union and to proceed with bone grafting without removing the screw if the fixation was noted to be stable.
Fig. 1.
Compression screw fixation of the acute proximal pole fracture.
Fig. 2.
Failed union postfixation.
Fig. 3.
( A–C ) CT scan showing established nonunion.
The procedure was conducted under general anesthesia with the patient supine and the involved wrist was suspended with finger traps from a traction tower with approximately 15 lbs of traction. A midcarpal ulnar portal was created for viewing and a 1.9-mm scope was inserted to locate the fracture nonunion site. The fracture nonunion site appeared as a depression on the surface of the scaphoid adjacent to the scapholunate joint 14 ( Fig. 4A ). An 18G needle was used to pierce the capsule and the assumed fracture site ( Fig. 4B and Video 1 ) and fluoroscopy was conducted for confirmation ( Fig. 4C ). The working portal was made at the site of the needle insertion after a skin incision and blunt dissection as described by Ecker at el. 14 An arthroscopic shaver was then used to excise the cartilage along the visualized depression, deepening the depression and exposing the bone below the cartilage followed by burring the sclerotic bone with an arthroscopic burr ( Fig. 5A ). Keeping sight of the scapholunate interval ( Fig. 5B ) ensured us to prevent unnecessary burring along the proximal pole which might have led to destabilizing the fixation and disintegration of the proximal pole. To ensure that the burring continued along the nonunion, regular probing with a needle helped us guide the direction of the burr ( Fig. 6 and Video 2 ). Jamming of the burr and overheating was prevented by regular irrigation and suctioning to remove the debris. The sclerotic bone was excised along the margins of the nonunion until the shaft and then around the shaft until a layer of cortex remained inferiorly ( Video 3 and Fig. 7 ). At this point, the tourniquet was deflated, and it was noted that the proximal pole showed punctate bleeding, evidence of its retained vascularity ( Video 4 ).
Fig. 4.
( A ) Arthroscopic view from the midcarpal joint showing the nonunion site. ( B ) Artistic depiction of identifying the nonunion site with a needle. ( C ) Identifying the nonunion site using fluoroscopy.
Fig. 5.
( A ) Burring the sclerotic bone with an arthroscopic burr. ( B ) Keeping sight of the scapholunate interval ensured to prevention of unnecessary burring along the proximal pole.
Fig. 6.
Regular probing with a needle helped us guide the direction of the burr.
Fig. 7.
The sclerotic bone was excised along the margins of the nonunion until the shaft and then around the shaft until a layer of cortex remained inferior.
Our site of harvesting the bone graft was from the ipsilateral iliac crest. The cancellous bone graft was morselized and then loosely packed into the stem of a 2.7-mm cannula (2.7 mm arthroscope system). The cannula was then inserted through the working portal into the nonunion and the bone graft extruded into the nonunion. The bone was pushed into the nonunion site with a 1.6-mm diameter Kirschner wire (K-wire) and firmly packed into the defect using a Freer elevator ( Video 5 ). Radiographs were taken to confirm the adequacy of the bone grafting. Fibrin glue was applied thereafter to seal the bone-grafted site.
Postoperatively, the patient was followed up in the clinic with check X-rays taken at week 1 ( Fig. 8 ), then at 6 weeks after the surgery, and finally a CT scan performed 3 months after the surgery showed good union 4 ( Fig. 9A–C ). He has returned to his normal life since.
Fig. 8.
Check X-rays taken at week 1.
Fig. 9.
( A–C ) CT scan performed 3 months after the surgery showed good union.
Case 2: A Proximal Pole Scaphoid Nonunion Presenting 9 Years after Injury
Video 6 Radiocarpal joint shows fairly intact cartilage.
Video 7 Midcarpal joint arthroscopy shows a nonunion site.
Our second case was a 35-year-old gentleman with a background history of gout and frequent gout flares involving both wrist joints. He had sustained a fall 9 years back and suffered a nonunion of the proximal pole of the left wrist which was left untreated for 8 years until he sought medical treatment due to persistent wrist pain. Clinical examination showed tenderness of the anatomical snuffbox but the midcarpal and radiocarpal joints were pain-free. Plain radiographs showed a displaced nonunion of the proximal pole with some dorsal intercalated segment instability (DISI) deformity and MRI showed signs of avascular necrosis of the proximal and mild radiocarpal arthritis ( Fig. 10A–C ). The patient was still suffering from frequent gout flares and initially, we sought control of his gout before embarking on any form of surgical intervention. Once his gout was under control for a period of 3 months, the patient was counselled for surgery in view of his persistent wrist pain and decreased grip strength. The plan was for wrist arthroscopy to inspect the wrist joint and the viability of the scaphoid proximal pole. In case of extensive arthritis, salvage options would be implemented. In case of absence or minimal arthritis and a nonviable or avascular proximal pole, we planned to proceed with a vascularized bone graft. Arthroscopic bone grafting was to be done only if there was minimal arthritis and a viable proximal pole.
Fig. 10.
( A ) Plain radiographs showing nonunion. ( B, C ) MRI showing signs of avascular necrosis of the proximal and mild radiocarpal arthritis.
The surgical setup was similar to what was described in Case 1. A radiocarpal scope was conducted first which revealed intact cartilage and very minimal signs of arthritis ( Video 6 ). The viewing portal and the working portal were created in the same position as for Case 1 and arthroscopy inspection revealed a clear-cut nonunion ( Video 7 ). The fibrous tissue at the nonunion was cleared using a shaver followed by deploying an arthroscopic burr to excise the sclerotic bone from both the proximal and distal margin of the nonunion until healthy-looking bone was reached. Regular irrigation and suctioning were employed to remove bone debris from time to time. The tourniquet was then deflated, and obvious bleeding was seen from the proximal pole which had been in nonunion for the past 9 years! The wrist was brought down from the traction tower and a Linschield maneuver was conducted to correct the DISI deformity. Placing the wrist in dorsiflexion and ulnar deviation, the deformity in the scaphoid bone was reduced and the bone was fixed with three 1.2-mm K-wires under fluoroscopic guidance ( Fig. 11A, B ). While the above was conducted, a bone graft was harvested from the ipsilateral iliac crest. The wrist was mounted back on the traction tower and bone grafting was conducted in the same manner as Case 1 and fluoroscopy was done to ensure adequacy of the bone grafting ( Fig. 12A, B ). The patient was subsequently followed up in the clinic with serial radiographs. The time to final union was 4 months as noted on a computed tomography scan done at that time ( Fig. 13A–D ). The K-wires were removed, and the patient was started on proprioceptive exercises and subsequent strengthening exercises ( Fig. 14A, B ). The patient was last seen 1 year postsurgery with no further pain, good wrist range of motion, and a significantly increased grip strength.
Fig. 11.
( A, B ) Fixation of the bone with K-wires after correcting the DISI deformity.
Fig. 12.
( A, B ) Fluoroscopy to confirm adequacy of bone grafting.
Fig. 13.
( A–D ) Computed tomography scan confirming union.
Fig. 14.
( A, B ) Radiographs showing union after removal of K-wires.
Case 3 and 4: The Very Proximal, Proximal Pole Nonunion
Video 8 Creating a bone window from the midcarpal joint to access the nonunion site followed by resection of sclerotic bone.
How do we define a proximal pole fracture to be considered very proximal? The Mayo classification is commonly used to define the fracture in scaphoids by dividing it into thirds, but it does not distinctly define the very proximal or the small proximal pole fractures which may be considered nonviable or difficult to treat with arthroscopic bone grafting. 15 Wong and Ho have deftly addressed this shortcoming in their paper, 1 defining the very proximal, proximal pole fractures to be the ones with fracture lines passing beyond the scaphocapitate facet calling them class C fractures. We came across two such fractures—our case numbers 3 and 4 ( Fig. 15 ). Now, if we look at Fig. 15 , surgeons intending to treat them arthroscopically will be confronted by the same dilemma we faced—how do we access the fracture site as the visualization of the nonunion site will be difficult from the midcarpal joint as the superior edge of the fracture may lie below the scapholunate interval or even in the scapholunate joint? Thus, in addition to the steps described by senior authors for arthroscopic bone grafting, we decided to incorporate an additional step of using a burr to create a bone window adjacent to the scapholunate (SL) joint to expose the fracture nonunion site ( Video 8 and Fig. 16A, B ). Once the required access to the fracture site was created by the above method, we carried on with the process of taking down the nonunion site. The next necessary step for such small proximal pole fragments was to ensure that the proximal pole fragment at the site of the nonunion was not burred aggressively, but in small increments with frequent inspections until normal trabeculae of the bone were encountered considering the small size of the fragment and the risk of fragmentation. Both cases showed punctate bleeding after the removal of the sclerotic bone. The challenge of fixing the small proximal was circumvented by passing the wires from proximal to distal in case number 3 ( Fig. 17 ) and by advancing into the SL joint while passing the wires from distal to proximal ( Fig. 18 ) and catching the small fragment between the main body of the scaphoid and the lunate in case number 4. Both cases healed as confirmed with serial radiographs ( Fig. 19 ) and a computed tomography scan done at 3 months. Case 3 showed 90% bony union and case 4 showed 70% bony union. The K-wires were removed a week after the CT scan. Both patients were noted to have recovered completely with pain-free wrists and near full range of motion. Dorsiflexion and palmar flexion for both cases of the operated wrist were 60 degrees. The ulnar deviation for case 3 was 27 degrees whereas for case 4, it was 25 degrees. The radial deviation for both cases was 17 degrees. Both cases had pronation and supination of 85 degrees.
Fig. 15.
The very proximal, proximal pole fracture or type C fracture.
Fig. 16.
( A ) Burr to create a bone window. ( B ) Nonunion site exposed.
Fig. 17.
Retrograde fixation with K-wires.
Fig. 18.
Antegrade fixation and pinning of the SL joint.
Fig. 19.
Union after 3 months.
Discussion
Nonunion of the proximal pole of the scaphoid has been associated with arthritis of the wrist and disintegration and fragmentation of the proximal pole. In the past, this was attributed to a lack of blood supply in the proximal pole of the scaphoid with the need for vascularized bone grafting to ensure successful union. Recently, this concept has been challenged and is now considered that avascularity rarely plays a role in bone grafting and fixation of such cases.
Many different ways have been described to bone graft and internally fix the proximal pole of the scaphoid. 16 17 18 19 20 All have been reported to be successful with varying complications and nonunion rates. Recently, Rancy et al 11 reported on a series with a 100% union rate where rigid fixation of scaphoid nonunion was performed via an open technique in 35 patients using a nonvascularized bone graft. Nine of the 23 proximal poles showed ischemia on MRI and 28 of the total number showed impaired vascularity intraoperatively. Thirty-three scaphoids healed by an average of 12 weeks (range 6–22) and 34 of 35 healed overall. One patient was lost to follow-up at 8 weeks. This study confirms that a similar result can be expected after arthroscopic bone graft and internal fixation and that impaired vascularity is rarely an issue and vascularized bone graft is not a necessity.
Following Rancy et al's study, 11 Ecker et al's 14 series of arthroscopic bone grafting of the proximal pole fracture nonunion fractures showed extremely promising results with a very high success rate! Twenty-nine of their 30 proximal pole nonunions united without any complications. The time to complete healing was comparable to Rancy et al's study 11 averaging at 12 weeks. Overall, this study has extremely significant implications for the future management of the nonunions of the scaphoid bone. As we can see from the current literature, there rarely is the need for a vascularized bone graft for fracture nonunion of the scaphoid, be it a more tenuous proximal fracture. In our short case series, we have showcased the versatility and the successful application in the difficult proximal pole fracture nonunions which conventionally may be considered for vascularized bone grafting only.
The advantages of arthroscopic bone graft and internal fixation have been stated clearly by Wong and Ho 1 and Ecker et al. 14 It can be done with two midcarpal joint arthroscopic portals which does not damage the capsule of the wrist and the innervation of the wrist. There is minimal disruption to the blood supply of the scaphoid and anecdotally less pain and swelling in the postoperative period. The bone is internally fixed with K-wires, a procedure that can be done with ease and speed without damaging the proximal pole if correction is needed. An incorrectly placed screw, on the other hand, may cause irreparable damage to the proximal pole of the scaphoid. Also, multiple K-wires apparently hold the proximal pole of the scaphoid better than the screw considering the small size of the proximal pole and the even smaller type C fracture with the fracture line beyond the scaphocapitate facet. The usage of multiple K-wires also ensures that the loss of a K-wire due to distal migration would not jeopardize the fixation. The K-wires are inserted in multiple planes and directions to ensure the stability of the fixation. For case 4, the proximal pole fragment was transfixed to the lunate to add to the stability. 21
Cancellous bone graft from the iliac crest is used for bone grafting with good results. Our decision to use the iliac crest as the source of the bone graft was based upon the fact that the volume needed in general is usually three to five times that of the bone defect created after excision of the sclerotic bone 10 and that the iliac crest can provide large amounts of bone graft if needed. As such, we noted that in our cases, the amount required was much less and could have been easily harvested from the distal radius. Though we did not encounter any complications of iliac crest bone grafting in any of our cases, we do acknowledge that complications may arise, and it is safer to bone graft from the distal radius. 22
All the above had been administered in our four unique and difficult proximal pole nonunion cases successfully with variations of technique as described. A failed screw fixation was treated successfully with arthroscopic bone grafting negating the need for an open procedure of vascularized bone graft. A very old proximal pole nonunion which shows the absence of avascular necrosis and turns out amenable to the procedure in question. Surgery on small proximal pole nonunion which is difficult using open techniques with extensive soft tissue dissection and possible disruption of blood supply and stabilizing structures of the wrist 10 23 done successfully using arthroscopic technique ensuring the integrity of these structures giving the nonunion a higher chance of healing.
Additionally, debridement of the nonunion site is more meticulous and controlled as the arthroscope provides better visualization of the nonunion site ensuring measured and adequate removal of the fibrous tissue and sclerotic bone and preservation of the small fracture fragment. Good visualization also equates to meticulous and excellent packing of the nonunion site with morselized cancellous bone. In our experience, this technique is much easier than an open technique once arthroscopic skill has been mastered.
But is this something new? As early as 2006, Slade and Dodds 24 have already stated that not all proximal pole nonunions with avascular necrosis require vascularized bone grafting. Minimally invasive debridement of the fracture site, percutaneous bone grafting, and rigid fixation can result in bone healing. A further paper by Slade and Gillon in 2008 25 reported good results of arthroscopic bone grafting in scaphoid nonunion. We believe that its applicability in even the difficult proximal pole nonunion can save the surgeon from the technically difficult exercise of harvesting a vascularized bone graft and the probable need for microsurgical skills as compared with the straightforward harvesting of nonvascularized bone grafts. Also, apart from the technical issues, vascularized bone grafts have been reported to have a 16% complication rate which includes deep infection, superficial infection, graft extrusion, hardware failure, wrist stiffness, complex regional pain syndrome, and neuropathic pain. 6
Conclusion
The arthroscopic bone graft of nonunited fracture of the proximal pole of the scaphoid is a reliable safe technique once the surgical technique has been mastered. The technique should only be used on nonunions where there is an intact proximal pole.
Our experience clearly shows that even difficult proximal pole nonunions can be treated arthroscopically using nonvascularized bone grafts with good bone healing, cosmetically favorable scars, lesser postoperative pain, and faster wound healing. Arthroscopic bone graft internal fixation of the scaphoid proximal nonunion is a safe and reliable surgical technique for all forms and presentations.
Footnotes
Conflict of Interest None declared.
References
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