IC45-R: The Fragmented Scaphoid Proximal Pole Nonunion ...

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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]

http://www.assh.org/

mailto:[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


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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


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]


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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

17-Jul-20

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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


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)

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Year of Operation

Rib Graft Patient Follow Up

Patients

Follow up

Proximal Scaphoid


Long term experience

1991 2011

2003

Nov 2005

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Proximal Scaphoid


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



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



Subjective Grip Strength

The Same 18 48.5%

Slightly reduced 15 40.5%

Significantly less 4 11.0%

89%

Proximal Scaphoid



SatisfactionVery Satisfied 22 59.5%

Moderately Satisfied 12 32.0%

Slightly Satisfied 1 3.0%

Unsatisfied 2 5.5%

91%

Proximal Scaphoid



Further TreatmentNo 32 86.5%

Yes 5 13.5%

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Proximal Scaphoid



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



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



Chest Problems

No 34 91.5%

Yes 1 3.0%

Minor 2 5.5%

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Proximal Scaphoid


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


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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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


Carpal Height Ratio

Carpal Height3rd MC Length

Normal Range:0.51-0.57

Radiolunate Angle

Normal Range:-15º to +15º



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


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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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


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)



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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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

[email protected], MD

Thank YouJames Higgins, MD

[email protected], 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


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


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?


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


CASE 225 yo male, RA, renal transplant, AVN. Arthritic L PRC.

COCA MFT HH OTHER


12m postop,no pain

“Window” capsulotomies

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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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THANK YOU!

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IC45-R: The Fragmented Scaphoid Proximal Pole Nonunion ...

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