Internal fixation of scaphoid non-union: a comparative study of three methods
Introduction
Scaphoid non-union occurs mainly in young males following an unrecognised injury or failed conservative treatment after the initial injury. Many authors from all over the world have reported their experience of internal fixation of scaphoid non-union with various techniques, but the ‘best’ surgical treatment is yet to be found. Mc Laughlin [1] is credited with being the first to recommend open reduction and screw fixation of the fractured scaphoid. Herbert and Fisher [2] described the Herbert screw fixation in 1984. Fernandez [3] described a method of fixation using a volar wedge bone graft secured with Kirschner (K) wires in 1984 and in 1990 he reported his results using the 2.7 mm AO lag screw [4].
In this article we present a retrospective study of the radiological union results for three internal fixation devices used in scaphoid non-union in tertiary referral patients to the Pulvertaft Hand Centre. The implants we have used over the last 9 years were the AO mini fragment 2 mm screw, the Herbert screw and K-wires.
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Patients and methods
Between 1990 and 1999, 132 patients with scaphoid fractures underwent open reduction and internal fixation in the Pulvertaft Hand Centre. Nineteen patients were lost to follow-up. Four-shot scaphoid radiographs were taken preoperatively and the fractures were classified according to the modified Filan and Herbert classification (1996) [5]. Twelve patients with type B fractures (acute fractures <6 weeks), as well as six patients requiring a vascularised bone graft procedure for the treatment of
Results
The results are presented in Table 1. The dorsal approach was used in 18% of the patients, mainly for non-unions of the proximal pole. The mean follow up was 14 months (range 8–24). Radiological union was achieved in 85% of cases (22 out of 26) in group A, 77% of cases (44 out of 58) in group B and 55% of cases (5 out of 9) in group C.
The overall failure rate was 23% (four cases in group A, 14 in group B and four in group C). In five out of nine cases in group C, Kirschner wire fixation was
Discussion
Internal fixation of the scaphoid is recommended for acute fractures which are unstable or displaced and for those with delayed healing or established non-union. The majority of the patients in this study were initially treated in other units.
Union rates alone are not an absolutely valid criterion for assessing the results of the treatment of scaphoid non-union. Restoration of carpal anatomy, as well as function should be taken into consideration [5], [9]. Although radiological union does not
Conclusions
The AO and Herbert screw groups showed comparable results in terms of rate and speed of radiological union. The mechanical strength of the implant and the compression achieved did not seem to be a major factor influencing fracture union. The type of graft did not affect the union rates significantly. The use of K-wires either as a primary method or as a salvage procedure produced inferior results.
Acknowledgements
We wish to thank Carlos Heras-Palou FRCS (Orth) for the advice on statistical analysis of this article.
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Early mobilization vs delayed mobilisation following the use of a volar locking plate with non-vascularized bone graft in scaphoid non-union. A multicentred randomised controlled-trial
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