A Hand Surgeon Looks BackThe focus of this study was the treatment of a nonunion (didn't heal) fracture of the scaphoid bone in the wrist. A loss of blood supply to the area led to a condition called avascular necrosis (AVN). Avascular means without blood and necrosis refers to the death of bone.
After immobilization with a cast did not yield a healed fracture and necrosis was identified, 30 patients with a nonunion scaphoid fracture had surgery. None of the patients had a previous surgery for this problem. This was the first or index procedure. The hand surgeon conducting the study looked back over a period of eight years and reviewed the charts of all his patients who had the same operation for the same problem.
The primary (main) author did all of the operations. The broken bone was put back together and held in place with a screw. This procedure is called internal fixation. In the second part of the surgery, the surgeon performed a vascularized bone-graft. This means the surgeon used a branch of the radial artery as a graft to bring blood to the nonunion site. The surgical technique was fairly simple with a single incision to open the site. The results were impressive.
All but two of the patients returned to work and recreation (including sports). The two who did not heal after the vascularized bone graft were smokers. There is a known link between tobacco use and delayed wound healing or nonunion in bone fractures. A second surgery was done with successful healing after these two patients had quit smoking (confirmed by a urine test before the operation).
The value of this study is in the fact that there were 30 total participants and before and after measures of motion, strength, and function were recorded. Most other studies done in the past have included a handful of patients. Validated measures before and after were not taken for those other studies.
Results of all 30 patients in this study for grip strength, wrist and forearm range-of-motion, and the Disabilities of the Arm, Shoulder, and Hand (DASH) test were compared before and after treatment. Patient satisfaction was also measured.
The surgeon used X-rays, CT scans, and MRIs to measure bone angles, height-to-length ratios, and width of the joint space. The bone angles and height-to-length ratio are ways to measure how much the bone fragments has collapsed on itself or how far apart the pieces of bone have shifted or moved.
Imaging studies were also used to document the presence of avascular necrosis. The authors provide photographs of a few of these images to help show the reader the location of the bone, the nonunion fracture, the necrosis, and the pin holding the bone together.
The data was also analyzed for any differences between patients based on the location of the nonunion fracture. Two-thirds of the patients had nonunions of the waist (middle) of the scaphoid bone. In the other one-third, the proximal pole (upper portion of the bone) was involved.
The results did not show a significant difference before and after surgery in function between patients with nonunions of the waist versus nonunions of the proximal pole. Total wrist range-of-motion did not change. Patients in both groups did have improved grip strength from before surgery. Patients with both kinds of nonunions were very happy with the overall improvement they experienced after surgery and successful healing
The authors support the continued use of the particular surgical technique they used to perform this bone fixation and vascularized graft procedure. They suggest that advising all patients to quit smoking before surgery really made a difference in the results. Only the two nonquitters failed to heal (until after they quit smoking and had a second surgery). Patients can expect a four to five month period of time before complete bone healing occurs.
Thanapong Waitayawinyu, MD, et al. Outcome After Vascularized Bone Grafting of Scaphoid Nonunions with Avascular Necrosis. In The Journal of Hand Surgery. March 2009. Vol. 34A. No. 3. Pp. 387-394.
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