Treatment of scaphoid waist nonunion by one, two headless compression screws or plate with or without additional extracorporeal shockwave therapy
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Scaphoid nonunion remains challenging for hand surgeons. Several treatment options are available such as: non-vascularized or vascularized bone grafting, with or without additional stabilization. In the last few decades, extracorporeal shockwave therapy (ESWT) has become an established procedure for treating delayed and nonunions. Purpose of this retrospective follow-up study was (a) to investigate union rate and clinical outcome of the different implants [either one/two headless compression screws (HCS) or a plate] and (b) union rate and clinical outcome using only surgery, or a combination of surgery and ESWT.
Materials and methods
The study included 42 patients with scaphoid nonunions of the waist with a mean follow-up of 52 months. All patients received a non-vascularized bone graft from the iliac crest and stabilization was achieved by using one, two HCS or a plate. ESWT was performed with 3000 impulses, energy flux density per pulse 0.41 mJ/mm2 within 2 weeks after surgery. 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. In addition, each patient had a CT scan of the wrist.
A total of 33/42 (79%) patients showed union at the follow-up investigation. Patients treated with additional ESWT showed bony healing in 21/26 (81%) and without ESWT in 12/16 (75%). Patients that were stabilized using one HCS showed bony healing in 6/10 (60%), with two HCS 10/12 (83%) and by plate 17/20 (85%). The ESWT group had a significantly lower pain score according to the VAS and better modified Green O’Brien (Mayo) Score. No differences could be found in respect of ROM, grip strength, functional outcome score depending of which stabilization method was used.
Stabilization of scaphoid waist nonunions with two HCS or plate showed higher union rates than a stabilization using only one HCS. In addition, ESWT combined with a nonvascularized bone graft from the iliac crest seems a suitable option for treating scaphoid nonunions.
KeywordsCombined treatment Headless compression screw Extracorporeal shockwave therapy Nonunion Non-union Outcome Pseudarthrosis Scaphoid Shockwave therapy Surgery Plate
We thank Rose-Marie Sedlacek for proof reading this article. Without her help, this English publication would not have been possible.
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Compliance with ethical standards
Conflict of interest
Dr. Schaden reports other financial activities apart from the submitted study. [Shareholder of Tissue Regeneration Technology (TRT, Atlanta).] In addition, Dr. Schaden has issued several patents with some still pending, for example: stimulating the regeneration of biological tissue using shockwaves.
All other authors of this manuscript certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.
Institutional review board approval was obtained for this retrospective follow-up study.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Institutional review board approval was obtained for this study.
- 3.Schmidle G, Ebner HL, Klauser AS et al (2018) Correlation of CT imaging and histology to guide bone graft selection in scaphoid non-union surgery. Arch Orthop Trauma Surg. 1–11Google Scholar
- 8.Cooney WP, Dobyns JH, Linscheid RL (1980) Fractures of the scaphoid: a rational approach to management. Clin Orthop Relat Res 149: 90–97Google Scholar
- 9.Dias JJ, Brenkel IJ, Finlay DB (1989) Patterns of union in fractures of the waist of the scaphoid. Bone Joint J 71–B:307–310Google Scholar
- 23.Stankovic P, Burchhardt H (1993) Experience with the Ender hooked plate in the management of 42 scaphoid pseudarthroses. HandchirMikrochir Plast Chir 25:217–222Google Scholar
- 29.Wang FS, Wang CJ, Sheen-Chen SM et al (2002) Superoxide mediates shock wave induction of ERK-dependent osteogenic transcription factor (CBFA1) and mesenchymal cell differentiation toward osteoprogenitors. J Biol Chem 277:10931–10937. https://doi.org/10.1074/jbc.M104587200 CrossRefPubMedGoogle Scholar
- 43.Bain GI, Bennett JD, MacDermid JC et al (1998) Measurement of the scaphoid humpback deformity using longitudinal computed tomography: Intra- and interobserver variability using various measurement techniques. J Hand Surg Am 23:76–81. https://doi.org/10.1016/S0363-5023(98)80093-2 CrossRefPubMedGoogle Scholar
- 44.Greenspan A (2011) Orthopedic imaging: a practical approach. Lippincott Williams & Wilkins, PhiladelphiaGoogle Scholar
- 46.Hudak PL, Amadio PC, Bombardier C (1996) Development of an upper extremity outcome measure: The DASH (disabilities of the arm, shoulder, and head). Am J Ind Med 29:602–608. https://doi.org/10.1002/(SICI)1097-0274(199606)29:6%3C602::AID-AJIM4%3E3.0.CO;2-L CrossRefPubMedGoogle Scholar
- 47.Hemelaers L, Angst F, Drerup S et al (2008) Reliability and validity of the german version of “the patient-rated wrist evaluation (PRWE)” as an outcome measure of wrist pain and disability in patients with acute distal radius fractures. J Hand Ther 21:366–376. https://doi.org/10.1197/j.jht.2008.03.002 CrossRefPubMedGoogle Scholar
- 52.Schädel-Höpfner M, Marent-Huber M, Gazyakan E et al (2010) Acute non-displaced fractures of the scaphoid: earlier return to activities after operative treatment. A controlled multicenter cohort study. Arch Orthop Trauma Surg 130:1117–1127. https://doi.org/10.1007/s00402-009-1004-8 CrossRefPubMedGoogle Scholar
- 73.Stark A, Brostrom LA, Svartengren G (1987) Scaphoid nonunion treated with the Matti–Russe technique. Long-term results. Clin Orthop Relat Res. 214 175–180Google Scholar
- 83.Notarnicola A, Moretti L, Tafuri S et al (2010) Extracorporeal shockwaves versus surgery in the treatment of pseudoarthrosis of the carpal scaphoid. Ultrasound Med Biol 36:1306–1313. https://doi.org/10.1016/j.ultrasmedbio.2010.05.004 CrossRefPubMedGoogle Scholar