ic45-r: the fragmented scaphoid proximal pole nonunion
TRANSCRIPT
All property rights in the material presented, including common-law copyright, are expressly reserved to the speaker or the ASSH. No statement or presentation made is to be regarded as dedicated to the public domain.
IC45-R: The Fragmented Scaphoid
Proximal Pole Nonunion: What Now?
Moderator(s): Scott W. Wolfe, MD
Faculty: Emily Altman, PT, DPT, CHT, Bassem T. Elhassan, MD, James P. Higgins,
MD, Terrence Jose Jerome Joseph, FRCS, DNB, MNAMS, FNB, EDHS, and Michael J.
Sandow, BMBS, FRACS, FAOrthA
Session Handouts
75TH VIRTUAL ANNUAL MEETING OF THE ASSH
OCTOBER 1-3, 2020
822 West Washington Blvd
Chicago, IL 60607
Phone: (312) 880-1900
Web: www.assh.org
Email: [email protected]
8/6/2020
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Scott W. Wolfe, MD
Royalty: Trimed, Inc, Extremity Medical, Elsevier
Consulting Fees: Extremity Medical
Speakers Bureau: Trimed, Inc.
THE FRAGMENTED SCAPHOID PROXIMAL POLE: WHAT NOW?
IC45-R 75th Annual Meeting: American Society for Surgery of the Hand October 2, 2020
Terrance Jose Jerome
Michael J. Sandow
James P. Higgins
Bassem T. Elhassan
Emily Altman
Scott W. Wolfe
71ST Annual Meeting, ASSH ICL 09 Nightmare Scaphoid Nonunions IV Austin TX Sept. 29, 2016IC45-R 75th Annual Meeting: American Society for Surgery of the Hand October 2, 2020
“Nightmare” Scaphoid Nonunions V: The Fragmented Proximal Pole
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Recurrent Nightmare Cases
62 yo male, active, 2y post minor fall.
Refused PRC.
25 yo male, RA, renal transplant, AVN. Arthritic L PRC.
37 yo male, 9m post FOOSH
basketball
Similarities
• Avascular
• Tiny fragments, too small for ORIF
• Fragmentation precludes standard vascular graft
Challenges
• Case 1 & 3: too old for MFT?
• Case 1 & 2: too young for PRC/4CF?
• Case 2 & 3: r/o Preisser disease? Will scaphoid heal?
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• Is a vascular graft necessary? T. Jerome (10 mins)
• 30 year experience with costo-osteochondral autograft M. Sandow (10 mins)
• 10 year outcomes: Vasc. medial femoral trochlear graft J. Higgins (10 mins)
• Locally sourced: Hemi-hamate autograft replacement B. Elhassan(10 mins)
• Rehabilitation for chronic scaphoid nonunion E. Altman (10 mins)
• Nightmare Cases –The panel’s tricks to maximize success S. Wolfe (10 mins)
“Nightmare” Scaphoid Nonunions V: The Fragmented Proximal Pole
IC45-R 75th Annual Meeting: American Society for Surgery of the Hand October 2, 2020
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J. Terrence Jose Jerome, FRCS, DNB, MNAMS, FNB, EDHS
Speaker has no relevant financial relationships with commercial interest to disclose.
Is a Vascular Graft Necessary for Proximal Pole Replacement?
Diagnostic Workup and Long-Term Implications
J. Terrence Jose JeromeEditor in chief- Journal of Hand and Microsurgery
Disclaimer
• Nil• No Funding• No Conflicts of Interest• Acknowledgments
– Olympia Hospital, Trichy, India
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The parable of the Blind Men and an Elephant
Scaphoid
Is scaphoid nonunion needs treatment?
>50 years of Scaphoid nonunion/ Diabetes/ minimal restriction of activities
NVBG/ VBG for proximal pole AVN ?
• Unimpaired vascularity– NVBG (82% union)
• Proximal pole AVN/ nonunion– VBG (75% Union)
C. Hirche, et al.Vascularized versus non-vascularized bone grafts in the treatment of scaphoid non-union. J Orthop Surg (Hong Kong), 25 (1) (2017)
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Is Vascularized graft necessary for proximal pole AVN?
• No evidence to support absolute indications– Rancy SK et. Hand clinics 2019
Histology defined proximal pole AVN
Fragmentation/ AVN
Necrotic bone debridement/ NVBG/ Rigid fixation
Vascularized osteochondral replacement
Vascularized Bone Grafts (VBG)
• Osteogenic progenitors/ inherent blood supply / fast graft incorporation /durability/ remodeling/stability
Augat P, Morgan EF, Lujan TJ, MacGillivray TJ, Cheung WH. Imaging techniquesfor the assessment of fracture repair. Injury 2014; 45 Suppl 2: S16-22.
Creeping substitution
• Preserved distal fragment vascularity facilitated advancing revascularization of proximal fragments– Kulkarani JBJS Br 1999.
• Depends on vascularization of the host bed– Mechanical/ vascular
Distal pole vascularity: Crucial prognostic factor in SNU healing
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Retrograde blood supplyDisruption of interosseous blood supply (distal to proximal)
Proximal pole- NO blood supply
Ischemia AVN
Buchler U, Nagy L. The issue of vascularity in fractures and nonunion of the scaphoid. J Hand Surg Br. 1995, 20: 726–35.
Terminology Term Definition
Ischemia Insufficient blood supply to support physiological function
Ischemic Pathological changes reflecting ischemia
Necrosis/ AVN Bone death from absence of blood supply. Focal
Infarction Diffuse osteonecrosis with empty lacuna and granular degeneration of marrow fat
Rancy SK, Swanstrom MM, DiCarlo EF, et al. Success of scaphoid nonunion surgery is independent of proximal pole vascularity. J Hand Surg Eur Vol. 2018;43(1):32-40.
Assessment of AVNInvestigations Sensitivity Specificity PPV NPV
Xray(Radiographic density)
64% 88% 88% 64%
CT 72% 62% 72% 62%
MRI (Gadolinium)
72% 100% 100% 73%
Punctate bleeding
82% 88% 90% 78%
Bervian, et al. Scaphoid fracture nonunion: correlation of radiographic imaging, proximal fragment histologic viability evaluation, and estimation of viability at surgery. International Orthopaedics (SICOT) 39, 67–72 (2015).
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How Common is AVN?
• 13-50% of all scaphoid fractures develop proximal pole AVN
Pao VS et al. Plast Reconstr Surg ,2003Kim J et al JHS Eur 2018
Etiology
• Mechanical vascular disruption• Thrombosis and embolism• Injury to a vessel• Pressure on a vessel, or venous occlusion
Mankin H.J et al Metabolic bone disease in patients with Gaucher’s disease.in: AvioliL.V Krane S.M Metabolic bone disease and clinically related disorders. 2nd ed. WB Saunders, Philadelphia1990: 730-752
Pathogenesis
• Vascular impairment (dynamic)– Ranges from transient ischemia to frank anoxia– 14% cases
Mulder, J. D. (1968). The results of 100 cases of pseudarthrosis in the scaphold Bone treated by the matti-russe operation.JBJS 50B: 110-115
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Experimental studies- AVN
(Hours)
Bone anoxia
Bone marrow & Fat necrosis
7 days
Osteocytic lacuna emptyGranulation tissue forms
Repair from adjacent viable bone
Macrophage activityOsteoclastic removal of dead trabeculae
New bone- De novo osteogenesis
14 days
21-28 days
Malizos, et.al (1993).Journal of Orthopaedic Research
Avascular necrosis
"death of bone substance from anoxia and its sequelae".• Class I: revascularization/ union/viable
integration. [Duppe et al JBJS 1994]• Class 2A: bone resorption, fragmented, cystic• Class 2B: necrosis, slow healing/ nonunion?
Duppe et al Long-term results of fracture of the Scaphoid. JBJS (1994).
Preiser disease- ischemic necrosis of scaphoid
• No significant trauma• Clinical findings +• Reason
– Vascular insufficiency– Repetitive mechanical stress– Steroid use for systemic illness– Smoking/ alcohol/infection
No Consensus on optimal treatment
Lin JD, Strauch RJ. Preiser disease. J Hand Surg Am 2013;38:1833–4.
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2 distinct patterns of scaphoid vascular compromise- MRI
• Type 1 (complete)– diffuse necrosis and/or ischemia of the scaphoid– Entire scaphoid fragmented/ collapsed
• Type 2 (partial)– segmental vascular impairment of the scaphoid– Architecture minimally altered
Kalainov, David M et al. Preiser’s disease: identification of two patterns. Journal of Hand Surgery, Volume 28, Issue 5, 767 - 778
Treatment
Type 1• Vascularized/ non
vascularized bone grafts (VBG)
• Mid-carpal fusion/ total arthrodesis
Type 2• Wrist immobilization• VBG
• PRC
Kalainov, David M et al. Preiser’s disease: identification of two patterns. Journal of Hand Surgery, Volume 28, Issue 5, 767 - 778
Outcome
• No improvement in pain• 1/16 returned to job• Grip strength [69%- type 1; 97% -type 2]• Flex/Exten [69°- type 1; 114°- type 2]
Kalainov, David M et al. Preiser’s disease: identification of two patterns. Journal of Hand Surgery, Volume 28, Issue 5, 767 - 778
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Secondary scaphoid proximal pole fractures
• 3 cases• Stress risers
secondary to screw
• CT has not confirmed union / initial surgery
Rancy SK, Zelken JA, Lipman JD, Wolfe SW. Scaphoid Proximal Pole Fracture Following Headless Screw Fixation. J Wrist Surg. 2016;5(1):71-76.
3D CT scan of secondary fracture fragments
• Consistent shape, location• Distinct from original healed nonunion• Fragments contiguous with screw site
Antegrade screw insertion ? Prophylactic screw removal for adults?
Initial delay treatmentchanges vascularity and mechanical properties potentially to secondary fracture.
Treatment options• COCA (Costo-osteochondral graft)• MFT (medial femoral trochlear vascularized
graft)• Hemi-hamate autogenous graft (proximal
hamate)
Steinmann, J Orthop Sci, 11 (4) (2006)
Non- VBGs: 36%-89% union
VBGs: 84%-100% union
W.R. Aibinder, et al. Bone grafting for scaphoid nonunions: is free vascularized bone grafting superior for scaphoid nonunion?Hand (N Y), 14 (2) (2019), pp. 217-222
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Diagnostic work up
Histology • Objective & reproducible• Subtotal curettage: proximal pole
viability• Bone biology linked to
microarchitecture – denser bone and increased trabecular
structure on the proximal side.
• Microstructural aberrations – Nonunion site with new bone
formation (hardware superior)
Qu G, von Schroeder HP. Trabecular microstructure at the human scaphoid nonunion. J Hand Surg 2008;33(5):650–5.
3D CT scan• WW, Proximal- no
separate blood supply ( Intra-cartilaginous site)
• RW (red/white)- some cartilage free areas/ blood supply
• RR- good blood supply
Schmidle Get al. Correlation of CT imaging and histology to guide bone graft selection in scaphoid non-union surgery. Arch Orthop Trauma Surg. 2018;138(10):1395-1405. doi:10.1007/s00402-018-2983-0
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Inference
• CT better than MRI for surgical planning
• Sclerosis- sign of AVN– May have fragment vascularity– Potential healing with Herbert screw
• Fragmentation- true AVN– No blood supply, osseous disintegration– Vascularized osteochondral grafts to reconstruct
fragment proximal pole
COCA (Costo-osteochondral graft)
• Sandow- 47 patients 2001– Fragmented/ necrotic
proximal pole
• Veitch et al JBJS 2007– 14 patients
• Retains carpal alignment• Restore mechanical
integrity
Rule out Congenital or acquired chest wall abnormalities
Concerns • Pneumothorax/ pleural injury• SL ligament not secured to COCA
Veitch S., Blake S. M., and David H.. Proximal scaphoid rib graft arthroplasty. JBJS Br. 2007 89-B:2, 196-201
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CT scan for hemi-hamate autograft
• Simulation of proximal scaphoid with proximal hamate
• Hamate aligned with scaphoid & rotated 180°
• Level osteotomy 1/3rd
height of scaphoidCapitohamate articular surface
Scaphocapitate articular surface
Inference
Poor fitting-31% of cases
Mean height of scaphoid proximal pole excision &proximal hamate
autograft height =9.3 mm.
Obtain preoperative X-ray-carpal collapse, humpback deformity
• Revised carpal height ratio < 1.52• Lateral Intra-scaphoid angle > 45°• Radio-lunate angle > 15°
Structural VBG (correct scaphoid geometry and carpal alignment)
B.M. Derby, P.M. Murray, A.Y. Shin, et al. Vascularized bone grafts for the treatment of carpal bone pathology. Hand, 8 (2013), pp. 27-40
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Obtain preoperative CT scan
• To Contour graft at the dorsal radial corner • Assess donor and recipient harvest site
morphology and fit.
Chan AHW, Elhassan BT, Suh N. The Use of the Proximal Hamate as an Autograft for Proximal Pole Scaphoid Fractures: Clinical Outcomes and Biomechanical Implications. Hand Clin. 2019;35(3):287-294.
MFT work up
Copyright 2012 The Curtis National Hand Center. Reproduced by kind permission of the Curtis National Hand Center from Buerger HK et al., 2013.
Helical artho-CT scan study, femur vs wrist
Transverse curvature
Sagittal curvature
MFT 7.98mm 25.56 (mean radius)
Scaphoid 7.97mm 26.99
Lunate 9.92mm
Capitate 6.65mm
Hugon S, Koninckx A, Barbier O. Vascularized osteochondral graft from the medial femoral trochlea: anatomical study and clinical perspectives. Surg Radiol Anat. 2010;32(9):817-825.
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MFT- donor morbidity (18.6%)• Knee joint arthrotomy, harvest, recovery • 27 mo Follow up
– excellent knee outcome scores – NO knee arthritis.
• Postoperative therapy can make return to pre-injury sport and occupational activities
2 -3 months of knee discomfort, slight limp, knee stiffness, swelling, squatting difficulty- reported complications
Windhofer C, Wong VW, Larcher L, Paryavi E, Buerger HK, Higgins JP. Knee donor site morbidity following harvest of medial femoral trochlea osteochondral flaps for carpal reconstruction. J Hand Surg Am. 2016, 41: 610–4.
Limitations
• Immunohistochemical studies- diagnosis• Donor site morbidity• Microvascular anastomoses• Compromise of scapholunate (SL) ligament
Conclusions
• Fragmented proximal pole difficult to treat – Small fragments can be excised and SL
ligament advanced to remaining scaphoid – Large proximal pole requires
reconstruction/replacement
Elhassan B, Noureldin M, Kakar S. Proximal Scaphoid Pole Reconstruction Utilizing Ipsilateral Proximal Hamate Autograft. Hand (N Y). 2016;11(4):495-499.
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“Despite a wealth of existing knowledge,we have not yet come very far in the understanding of AVN scaphoid and further research is needed”.
-Buchler U, 1995
Thank you
Questions
1. Is there a diagnostic method to accurately predict vascularity (eg,ischemia/AVN/infarction)?
2. Can creeping substitution replace VBG?3. How to predict which scaphoid nonunion/ AVN
benefits from VBG/non VBG?
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A 30 Year Experience With
Costo-osteochondral (Rib) Autograft
Costo-Osteochondral autograft
for proximal scaphoid deficiency
– long term review
Michael J. SANDOW BMBS, FRACS, PhD
Wakefield Orthopaedic Clinic
&
Centre for Orthopaedic and Trauma Research
University of Adelaide
Adelaide, Australia
I declare that in the past three years I have:
• held shares in: True Life Anatomy (3D Imaging Technology)
Macropace Products
RuBaMAS
• received royalties from: nil
• done consulting work for: nil
• given paid presentations for: nil
• received institutional support from: nil
Signed: Michael JSandow
Declaration of Interest
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Proximal Scaphoid
Necrosis / Collapse
Type I - subchondral plate intact
articular envelope preserved
→ vasc / std bone graft
Type II - articular surface collapsed
poor subchondral support
Beuchler (1995)
Costal Osteo-chondral
(Rib Bone-Cartilage) Graft
Type II - articular surface collapsed
poor subchondral support
➢ Medial Column Fusion
➢ Proximal Row Carpectomy
➢ Replacement – Tendon / Bone graft
*** Vascularised MFT ***
Costal Osteo-chondral
(Rib Bone-Cartilage) Graft
Gilles (1920) - Temporomandibular
joint reconstruction - WW I
Lindquist et al (1986) 67%
good / exc in TMJ reconstruction
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Rib Cartilage
Rib Bone
Scaphoid Costo osteo-chondral Autograft
D.R. pre opEarly post op
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Lunate
Scaphoid
Rib Graft
29 yo labourer, failed 3 X grafting and fixation
18 mo post rib graft
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S.C. 28 yo
3 previous scaphoid Surgery
RTW (Brick layer) 4 months post op
Proximal Scaphoid
Costo-osteochondral Graft
23 Patients: (M:F 21:2)
22 reviewed (96%) follow up
failed primary graft 8
primary AVN (#) 5
small proximal pole # 9
Journal Hand Surgery (British) Jan 1998
Pain 25Function 25ROM 25Grip 25
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Proximal Scaphoid
Costo-osteochondral Graft
4 patients - Reoperation:
pain, poor motion → arthrotomy / arthroscopy
debride, radial styloidectomy → improved function
1 patient - radio-carpal fusion
No major Complications:
2 minor Haemo-thoraces
no Pneumo-thoraces
Scapho-lunate junction
Articular Surface
Scaphoid
Lunat
e
Right Wrist
Chondral (Rib)
Grafts in the Wrist
1991 - 2011
50 patients prior to 2005 > 10 years
Questionnaire or clinic review
in 37 of 50 = 74% FU
(17 of 25 patients > 15 years)
87
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Year of Operation
Rib Graft Patient Follow Up
Patients
Follow up
Proximal Scaphoid
Costo-osteochondral Graft
Long term experience
1991 2011
2003
Nov 2005
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Proximal Scaphoid
Costo-osteochondral Graft
37 of 50 patients > 10 years FU
Subjective PainNo Pain 6 16.5%
Mild/Occasional 21 56.5%
Mild/Regular 2 5.5%
Moderate 3 8.0%
Severe 5 13.5%
73%
Proximal Scaphoid
Costo-osteochondral Graft
37 of 50 patients > 10 years FU
Subjective Wrist Movement
The Same 7 19.0%
About 2 thirds 18 48.5%
About half 9 24.0%
Not much 3 8%
67%
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Proximal Scaphoid
Costo-osteochondral Graft
37 of 50 patients > 10 years FU
Subjective Grip Strength
The Same 18 48.5%
Slightly reduced 15 40.5%
Significantly less 4 11.0%
89%
Proximal Scaphoid
Costo-osteochondral Graft
37 of 50 patients > 10 years FU
SatisfactionVery Satisfied 22 59.5%
Moderately Satisfied 12 32.0%
Slightly Satisfied 1 3.0%
Unsatisfied 2 5.5%
91%
Proximal Scaphoid
Costo-osteochondral Graft
37 of 50 patients > 10 years FU
Further TreatmentNo 32 86.5%
Yes 5 13.5%
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Proximal Scaphoid
Costo-osteochondral Graft
37 of 50 patients > 10 years FU
Further surgery (5):
Radio-carpal fusion (pre-op OA)
Radio-carpal fusion (pre-op OA + DISI)
Medial column fusion (Cap-Lunate OA)
2 x Radial styloidectomy - both satisfied
Proximal Scaphoid
Costo-osteochondral Graft
37 of 50 patients > 10 years FU
Activity
Not Limited 15 40.5%
Normal/some changes 18 48.6%
Light Duties 3 8.1%
Unable to work 1 2.7%
89%
Proximal Scaphoid
Costo-osteochondral Graft
37 of 50 patients > 10 years FU
Chest Problems
No 34 91.5%
Yes 1 3.0%
Minor 2 5.5%
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Proximal Scaphoid
Costo-osteochondral Graft
Advantages:
Auto-graft
Extensive maxillo-facial experience
Cheap / easily sculptured
Viable
Good incorporation / adaptation
No short term deterioration
Durable long term
Many Advantages over other options
Useful stand-by reconstruction
Regular use for carpal bone loss
Chondral (Rib)
Grafts
in the Wrist
Satisfactory as the
final (Salvage) procedure
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James P. Higgins, MD
Speaker has no relevant financial relationships with commercial interest to disclose.
MFT IndicationsMFT Indications Non salvageable prox
pole Age<40, BMI<35: MFT
OA changes are very rare Lunate extension is not a
contraindication
Age >40, BMI>34: Salvage procedure
PRC MCF
Osteochondral graft Costochondral Hamate
Non salvageable proxpole Age<40, BMI<35: MFT
OA changes are very rare Lunate extension is not a
contraindication
Age >40, BMI>34: Salvage procedure
PRC MCF
Osteochondral graft Costochondral Hamate
“Non salvageable”: Primary surgery with proximal
pole <2mm on CT scan sagittal images
Secondary surgery with comminution of remaining proximal pole
Any tertiary surgery
“Non salvageable”: Primary surgery with proximal
pole <2mm on CT scan sagittal images
Secondary surgery with comminution of remaining proximal pole
Any tertiary surgery
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Cartilage-bearing convex flapsfrom the
medial femoral trochlea (MFT)
Cartilage-bearing convex flapsfrom the
medial femoral trochlea (MFT)
Deficient proximal poleDeficient proximal pole
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© Curtis National Hand Center 2012
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4 weeks postop4 weeks postop
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Bürger H, Windhofer C, Gaggl A, Higgins, JP. Jour Hand Surg (A) April 2013
1 year postop 4 years postop1 year postop 4 years postop
16 y/o s/p ORIF dorsal 16 y/o s/p ORIF dorsal
kimmett
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4 months4 months
24 y/o mechanic 27 months s/p dorsal drbg + screw
24 y/o mechanic 27 months s/p dorsal drbg + screw
Aaron Robinson
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intraopintraop
CT at 4 months CT at 4 months
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8 months postop8 months postop
18 months18 months
2 years2 years
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20 y/o F s/p DRBG with dorsal screw
20 y/o F s/p DRBG with dorsal screw
kucheruk
2 years postop2 years postop
DASH score = 1 (0-100) KOOS score =97(100-0)
16 consecutive cases Minimum 6 month, avg 14 month f/u (6-72mo) Mean age 30. Mean previous procedures 1 15/16 united 12/16 complete pain relief, 4/16 partial 440 flexion, 460 extension SL preop 520 postop 490
16 consecutive cases Minimum 6 month, avg 14 month f/u (6-72mo) Mean age 30. Mean previous procedures 1 15/16 united 12/16 complete pain relief, 4/16 partial 440 flexion, 460 extension SL preop 520 postop 490
April 2013
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Pre-Operative Characteristics of Patients Undergoing Medial Femoral Trochlea Flap for Reconstruction of the Proximal Scaphoid
N 41
Male 35
Female 6
Age at Surgery 24.1 (16-40)
Dominant Side Injury 19
BMI 27.5 (22-40)
Previous Pedicled VBG 7
Prior Failed Scaphoid ORIF Requiring Removal of Hardware
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April 2020
Proximal Scaphoid ArthroplastyFollow-Up Summary
Proximal Scaphoid ArthroplastyFollow-Up Summary
Patient RecruitmentPatient Recruitment
Study Visit – 11
Chart Review and Remote PRO Battery-10
Chart Review and Limited PROs- 20
Study Visit – 11
Chart Review and Remote PRO Battery-10
Chart Review and Limited PROs- 20
Follow-Up DurationFollow-Up Duration
Radiographic Follow-Up 1.5 Years
Examination Follow-Up 2.4 Years
Patient Reported Otucomes Follow-Up 2.8-2.9 Years
Radiographic Follow-Up 1.5 Years
Examination Follow-Up 2.4 Years
Patient Reported Otucomes Follow-Up 2.8-2.9 Years
Proximal Scaphoid ArthroplastySurgical Complications
Proximal Scaphoid ArthroplastySurgical Complications
Early Thrombosis and revision arterial anastomosis Recipient Site dehiscence requiring operative closure
Late Removal of migrated headless compression screw
Recalcitrant scaphoid non-union Asymptomatic
Patellofemoral pain Arthroscopic debridement
Early Thrombosis and revision arterial anastomosis Recipient Site dehiscence requiring operative closure
Late Removal of migrated headless compression screw
Recalcitrant scaphoid non-union Asymptomatic
Patellofemoral pain Arthroscopic debridement
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Proximal Scaphoid ArthroplastyRadiographic Outcomes
Proximal Scaphoid ArthroplastyRadiographic Outcomes
Carpal Height Ratio
Carpal Height3rd MC Length
Normal Range:0.51-0.57
Radiolunate Angle
Normal Range:-15º to +15º
Proximal Scaphoid ArthroplastyRadiographic Outcomes
Proximal Scaphoid ArthroplastyRadiographic Outcomes
Pre-Operative and Post-Operative Radiographic Assessment of the Carpus
n Pre-Operative Post-Operative Difference p
Radiolunate Angle 30 -9.7º 0.7º 10.4º 0.0002
Carpal Height Ratio 30 0.49 0.51 0.02 0.016
Radioscaphoid Arthritis 34 1 3
Mean Radiographic Follow-Up: 1.5 Years Post-Operative
Proximal Scaphoid ArthroplastyFunctional Outcomes
Proximal Scaphoid ArthroplastyFunctional Outcomes
Comparing Affected and Unaffected Wrist Function After Proximal Scaphoid Arthroplasty
nUnaffected
SideAffected Side
Post-OperativePercentage of
Unaffected
Wrist Flexion (°) 19 64.2 41.6 65%Wrist Extension (°) 19 64.9 43.8 67%
Radial Deviation (°) 17 22.6 10.4 46%
Ulnar Deviation (°) 17 37.4 27.9 75%Pronation (°) 11 65 61.4 94%Supination (°) 11 60 62.7 105%Key Pinch (kg) 11 9.7 8.6 89%
Grip Strength (kg) 20 39.7 33 83%
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Proximal Scaphoid ArthroplastyFunctional Outcomes
Proximal Scaphoid ArthroplastyFunctional Outcomes
Wrist Flexion/Extension Before and After Proximal Scaphoid Arthroplasty
nAffected Side Pre-Operative
Affected Side Post-Operative Difference p
Wrist Flexion (°) 14 46.9 42.8 -4.1 0.42
Wrist Extension (°) 14 48 44.8 -3.2 0.32
Proximal Scaphoid ArthroplastyPatient Reported Outcomes Battery
Proximal Scaphoid ArthroplastyPatient Reported Outcomes Battery
Upper Extremity
DASH PRWE PROMIS-Upper Extremity
Lower Extremity
KOOS WOMAC IKDC Kujala/AKPS
Upper Extremity
DASH PRWE PROMIS-Upper Extremity
Lower Extremity
KOOS WOMAC IKDC Kujala/AKPS
Global
PROMIS Physical Function PROMIS Global Health PROMIS- Pain Intensity PROMIS-Pain Interference PROMIS- Pain Behavior
Global
PROMIS Physical Function PROMIS Global Health PROMIS- Pain Intensity PROMIS-Pain Interference PROMIS- Pain Behavior
Results – UE Functional outcomesResults – UE Functional outcomesDASH SCORE:- Mean post-operative DASH score: 10.7 12 (For 27 patients)
- Mean DASH score: 23 (preop) 8 (postop) with more than 10-point for the minimum clinically important difference (MCID). (For the 11 patients with complete data, avg 3.4 year f/u)
PROMIS Upper Extremity SCORE:Mean post-operative PROMIS-UE score: 50 (indicating UE function at general population average).
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Proximal Scaphoid ArthroplastyPatient Reported Outcomes: Lower Extremity
Proximal Scaphoid ArthroplastyPatient Reported Outcomes: Lower Extremity
Post-Operative Patient Reported Outcomes: Lower Extremity
nMean Post-Operative
Score Follow-up (y)IKDC 21 82.1 2.9
Kujala/AKPS 21 90.2 2.9KOOS-Pain 27 91.5 2.8
KOOS-Symptoms 27 86.8 2.8KOOS-ADL 27 93.9 2.8
KOOS-Sports and Recreation 27 80.2 2.8
KOOS- QOL 27 82.6 2.8WOMAC 27 93.4 2.8
Zero (Worst)-----------------100 (Best)
Proximal Scaphoid ArthroplastyPatient Reported Outcomes: Lower Extremity
Proximal Scaphoid ArthroplastyPatient Reported Outcomes: Lower Extremity
Patient Reported Outcomes Before and After Proximal Scaphoid Arthroplasty
n Follow-up (y)Mean Pre-Op Score
Mean Post-Op Score Difference p
KOOS-Pain 11 3.4 97.7 93.2 -4.5 0.07KOOS-Symptoms 11 3.4 90.6 91.9 1.3 0.7KOOS-Activities of
Daily Living 11 3.4 98.1 95.9 -2.2 0.059KOOS-Sports and
Recreation 11 3.4 95 84.9 -10.1 0.017KOOS- Quality of Life 11 3.4 94.9 89.8 -5.1 0.32
WOMAC 11 3.4 98.2 95.2 -3 0.05
* *-4.5 +1.3 -2.2 -10.1 -5.1 -3.0
KOOS and WOMAC
MCID = 10
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Proximal Scaphoid ArthroplastyPatient Reported Outcomes: Lower Extremity
Proximal Scaphoid ArthroplastyPatient Reported Outcomes: Lower Extremity
Establishing a P.A.S.S. threshold for a PRO can aid in the interpretation of clinical or outcomes research By providing a reference value at which the majority of the population feels “well” .
* *
-4.5 +1.3 -2.2 -10.1 -5.1 -3.0
Results – LE Functional outcomesResults – LE Functional outcomes
PRO – Lower extremity- Clinical improvement and statistically significant decrease of
KOOS Sports/Recreation (-10.1 points, p=0.0017) and WOMAC (-3%, p=0.05) scales at 3.4 years.
- KOOS postoperative scores remained well above the Patient Acceptable Symptom State (PASS) thresholds at which the majority of the population “feels well” in a given PRO domain.
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Results – Predictors of PROs Results – Predictors of PROs Univariate analysis: BMI, sex, age, dominance of the injured side, previous ORIF, and pre-operative RL angle- Male sex predicted superior post-operative PROMIS-UE scores.- Higher BMI predicted worse clinical outcomes with WOMAC,
KOOS, IKDC and PROMIS scores.
Multivariate analysis: BMI, sex, and age- BMI was significantly predictive of worse post-operative lower
extremity scores when controlled for age and sex
Proximal Scaphoid ArthroplastyPredictors of Outcome: BMI
Proximal Scaphoid ArthroplastyPredictors of Outcome: BMI
BMI Less Than 34BMI Greater than or
Equal to 34Student's T Test
n Mean n Mean Difference p
IKDC 16 89 5 60 -29 0.001Kujala/AKPS 16 93 5 83 -10 0.09KOOS-Pain 22 95 5 76 -19 <0.001
KOOS-Symptoms 22 91 5 68 -23 <0.001KOOS-ADL 22 97 5 81 -16 <0.001
KOOS-Sports and Recreation 22 85 5 60 -25 0.009
KOOS- QOL 22 88 5 60 -28 0.001WOMAC 22 96 5 81 -15 <0.001
Results – BMI and LE PROsResults – BMI and LE PROs
Our heaviest patients had worse reported LE outcomes
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Proximal Scaphoid ArthroplastyAlternatives to MFT
Proximal Scaphoid ArthroplastyAlternatives to MFT
4CF PRC MFT
Flexion-Extension Arc 54 73 86
Grip Strength 65% 54% 83%
DASH 32 19 11
PRWE 27 28 17
Does this hold promise for the future?Does this hold promise for the future?
Complexity: is the microsurgery needed?
Durability: Will it outperform our conventional procedures? Prospective collection of salvage and MFT
procedures 84 MFT scaphoids
36 MFT lunate
Complexity: is the microsurgery needed?
Durability: Will it outperform our conventional procedures? Prospective collection of salvage and MFT
procedures 84 MFT scaphoids
36 MFT lunate
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Thank YouJames Higgins, MD
Thank YouJames Higgins, MD
Study purposeStudy purpose
Compare the histologic characteristics of cartilage of osteochondral grafts supported by synovial
imbibition alone
osteochondral flaps that have both synovial and vascular pedicle perfusion.
Compare the histologic characteristics of cartilage of osteochondral grafts supported by synovial
imbibition alone
osteochondral flaps that have both synovial and vascular pedicle perfusion.
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Adana, TurkeyAdana, Turkey
Ҫukurova University Medical CenterҪukurova University Medical Center
Mehmet Emre Benlidayi
Sait Polat
Mehmet Emre Benlidayi
Sait Polat
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When deprived of subchondral perfusion from
underlying bone, osteochondral vascularized
flaps in an intrasynovialenvironment demonstrate superior cartilage quality
and survival when compared to nonvascularized grafts. J Hand Surg Am. 2018, 43: 188.e1-188.e8.
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Bassem Elhassan, MDProfessor of Orthopedics
Mayo Clinic, Rochester, MN
Locally Sourced: The Hemi-Hamate Autograft Replacement
Bassem T. Elhassan, MD
Speaker has no relevant financial relationships with commercial interest to disclose.
ASSH DISCLOSURES
• 18M RHD left scaphoid nonunion
• ORIF and Bone Graft 12 months ago
• Failed bone stimulator
• Wanted to be in the Army but can’t because of his hand
• Was offered elsewhere scaphoid excision and 4 corner fusion (But he wanted another opinion)
Case Example
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Reliable Treatment Options to Manage Fragmented Avascular Scaphoid
• 16 pts (2 centers)
• What’s the long-term morbidity of this to a young knee?
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• Sandow 2001 & Veith 2007: success 60/61 pts
Can we Think about an Alternative Simpler and Less Morbid Option????
Is there an Option of a Local Osteochondral Bone Autograft that is Similar in Shape to the Proximal Scaphoid that we can Use Instead of Going to
the Chest or the Knee????
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Is there an Option of a Local Osteochondral Bone Autograft that is Similar in Shape to the Proximal Scaphoid that we can Use Instead of Going to
the Chest or the Knee???? YES
Can we Use the Proximal Hamate?????
Proximal Hamate Resection (HALT Lesion) with Good Outcome
Palmer et al
Why Not???????
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But Wait, are you Going to Use a Dead Bone to Reconstruct the Proximal Scaphoid????
• The Proximal Hamate bone Autograft is NOT DEAD Bone, it is a Living, Non-Vascularized Bone Graft
Living Cells in the Proximal scaphoid
Proximal Hamate
Rib CostoChondral Medial Femoral Condyle
Comparing the Three Types of Bone Grafts, the Proximal Hamateis the Closest Anatomically and Histologically to the Proximal Scaphoid
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How Does the Proximal Hamate Transfer Look in the Lab???
It Looks Sexier in Vivo
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Fluoroscopyy
Healed Scaphoid Nonunion
Healed Lateral Xray
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Post Op CT Showing Union
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38M LHD 4 yr hx scaphoid nonunion
Bone Models
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Fragmented Proximal Pole
Hamate Harvest
Hamate Turned 1800
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Healed
Union Happy Patient
Elhassan, Holmes
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Results
the mean surface to surface area was below 1 mm
Biomechanical Testing
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No statistically significant differences in the lunocapitate kinematics between intact & post‐hamate osteotomy during wrist radial/ulnar deviation
Does Hamate To Scaphoid Transfer Restore Carpal Kinematics
Burnier, Gill, Hooke, Elhassan, Kakar
Scaphoid motion in the coronal plane duringwrist flexion extension
Hamate to scaphoid reconstruction significantly corrected the abnormal motion of the scaphoid
relative to the lunate in the coronal plane (p<0.05)
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Burnier, Gill, Hooke, Elhassan, Kakar
•Biomechanics of Rib Graft vs MFT vs Hamate to
Scaphoid Transfer
All 3 grafts perform relatively the same and none of them resulted in notably drastic kinematic changes
Proximal Hamate Seems to be a Promising Potential Option to Reconstruct Proximal Scaphoid
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- Hand Center in Paris Did 8-Three Different surgeons have done 4 - All healed and preliminary outcome is very encouraging
Few Cases are Done So Far from Different Places
We Did 9 and have been Happy with Results
• Many treatment options for the fragmented proximal pole scaphoid nonunion with AVN
• Hamate to scaphoid transfer:• Same donor site• ?Address SL instability
• Topographic & biomechanical studies are encouraging
• Need larger series with long-term follow up
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Emily Altman, PT, DPT, CHT
Speaker has no relevant financial relationships with commercial interest to disclose.
Principles of Rehabilitation for Chronic Scaphoid Non-Union
Emily Altman, PT, DPT, CHT
ASSH Annual Meeting 2020
Fragmented Scaphoid and Hand Therapy
Not a high-volume diagnosis
Not an acute injury
Not seen immediately postoperatively in the clinic
Magic is in surgical procedure
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Understand the Case
How did the carpus present preoperatively?
Understand carpal mechanics
Presence of DISI deformity
Presence of scaphoid flexed posture (“humpback deformity”)
Carpal Instability
AVN
Pain
Functional deficits
Understand the Case
Review and understand the surgical procedure
Multiple techniques
Vascularized bone graft?
Free?
Pedicled?
Nonvascularized bone graft?
Structural? Inlay?
Fixation
Pins
Plates
Understand the Case
Communication with the surgeon
Post operative cast immobilization is lengthy
Short arm thumb spica for 6 weeks
Full time removable thumb spica for 4 weeks
3-4 months of immobilization for long standing non-unions
CT scan at 3 months:
50% trabecular bone bridging before beginning weaning from splint/return to full activities (Elzinga, Chung 2019)
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Understand the Case
What is limiting progression? Pain Global capsular stiffness Altered carpal mechanics
Realistic expectations Best tools
AROM, AAROM, PROM Dart Thrower’s Motion Proprioception Training Sport Specific Interventions
Photo: Rehab for a Better Life
• Wrist extension + radial deviation• Wrist flexion + ulnar deviation• Functional motion of the wrist• Minimal scapholunate motion• Primarily midcarpal motion
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Exercise Ideas
Air filled beach ballFoam Nerf ballWeighted ballLacrosse ball
Melplié G. et al. Rehabilitation of distal radioulnar joint instability. Hand Surg and Rehab. 2017;36:314-321.
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References
Hand Clinics August 2019
Elzinga K, Chung KC. Volar radius vascularized bone flaps for the treatment of scaphoid nonunion. Hand Clin. 2019;35(3);353-363
Sgromolo NM, Rhee PC. The role of vascularized bone grafting in scaphoid nonunion. Hand Clin. 2019;35(3):315-322.
Buijze G, Jupiter J (eds). Scaphoid Fractures. Evidence-Based Management. Elsevier. 2018.
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THE FRAGMENTED SCAPHOID PROXIMAL POLE: WHAT NOW?
IC45-R 75th Annual Meeting: American Society for Surgery of the Hand October 2, 2020
SOLUTIONS
Recurrent Nightmare Cases
62 yo male, active, 2y post minor fall.
Refused PRC.
25 yo male, RA, renal transplant, AVN. Arthritic L PRC.
37 yo male, 9m post FOOSH
basketball
THE PANELIST’S CHOICESCASE 137 yo male, 9m post FOOSH basketball
COCA MFT HH OTHER
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CASE 137 yo male, 9m post FOOSH basketball
3y postop, full activities
THE PANELIST’S CHOICESCASE 137 yo male, 9m post FOOSH basketball
CASE 225 yo male, RA, renal transplant, AVN. Arthritic L PRC.
COCA MFT HH OTHER
CASE 225 yo male, RA, renal transplant, AVN. Arthritic L PRC.
12m postop,no pain
“Window” capsulotomies
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THE PANELIST’S CHOICESCASE 137 yo male, 9m post FOOSH basketball
CASE 225 yo male, RA, renal transplant, AVN. Arthritic L PRC.
CASE 362 yo male, active, 2y post minor fall. Refused PRC.
COCA MFT HH OTHER
CASE 362 yo male, active, 2y post minor fall. Refused PRC.
Hemi-hamate simulationNeo proximal pole
9m postop, full activities
9 mos postop playing golf 3-
4x/week
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IC45-R 75th Annual Meeting: American Society for Surgery of the Hand October 2, 2020
THANK YOU!
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