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Occurrence of Carpal Osteoarthritis After Treatment of Scaphoid Nonunion With Bone Graft and Herbert Screw: A Long-Term Follow-Up Study
Occurrence of Carpal Osteoarthritis After Treatment of Scaphoid Nonunion With Bone Graft and Herbert Screw: A LongTerm Follow-Up Study Wolfgang Daecke, MD, Peter Wieloch, MD, Panagiotis Vergetis, MD, Martin Jung, MD, Abdul-Kader Martini, PhD, Heidelberg, Germany
Purpose: To determine the occurrence, progression, and clinical results of osteoarthritis (OA) after bone grafting and Herbert screw fixation for scaphoid nonunion. Methods: Fifty patients were reviewed (mean follow-up period, 12.0 ⫾ 1.6 y) to analyze degenerative changes of the wrist after use of Herbert screws for scaphoid nonunion. Results: Radiologic signs of OA were observed in 15 of 50 patients before surgery and in 23 of 50 after 10 years or more. The majority of degenerative changes were low grade. No OA at follow-up evaluation was seen in 27 of 35 patients with no preoperative degenerative changes. In 6 of 8 patients with OA its occurrence was either subsequent to concomitant injury, occurred after incorrect scaphoid reconstruction, or was caused by persistent nonunion. Of 15 wrists with OA at the time of surgery 9 remained unchanged and 6 increased in severity. Healing of nonunion was achieved in 42 of 50. Range of motion, however, was reduced to 88% of that of the opposite hand. At follow-up evaluation the mean Disabilities of the Arm, Shoulder, and Hand score was 9 ⫾ 13 and the mean Cooney score was 80 ⫾ 10. Conclusions: The results show high patient satisfaction and good function after healing of scaphoid nonunion. In the long term correct anatomic reconstruction of the nonarthritic carpus with a Herbert screw prevents onset of OA in most patients. (J Hand Surg 2005;30A:923–931. Copyright © 2005 by the American Society for Surgery of the Hand.) Key words: Scaphoid nonunion, Herbert screw, osteoarthritis, long term, wrist.
Twenty years ago, Herbert and Fisher1 introduced their screw fixation for scaphoid fracture and nonunion and since that time the Herbert screw and From the Department of Orthopaedic Surgery, University of Heidelberg, Heidelberg, Germany. Received for publication February 16, 2005; accepted in revised form May 30, 2005. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Corresponding author: W. Daecke, MD, Orthopädische Universitätsklinik Heidelberg, Sektion Hand- und Mikrochirurgie, Schlierbacher Landstrasse 200, 69118 Heidelberg, Germany; e-mail: [email protected]. Copyright © 2005 by the American Society for Surgery of the Hand 0363-5023/05/30A05-0006$30.00/0 doi:10.1016/j.jhsa.2005.05.017
similar fixation systems have become popular for the treatment of scaphoid nonunion.2– 4 Although little is known about the extent to which the Herbert screw fixation—in combination with bone grafting— can prevent osteoarthritis (OA) of the wrist in the long term, Ruby et al,5 Mack et al,6 and Martini7 showed that untreated symptomatic nonunion of the scaphoid results in carpal OA, the radiographic evidence of which usually was present by 5 to 10 years after injury. For the Matti-Russe procedure,8,9 Stark et al10 found slight carpal osteoarthrosis in 41% and severe degeneration in 26% in a series of 27 patients with a mean follow-up period of 12 years. Only 33% of the patients in the study by Stark et al10 did not have The Journal of Hand Surgery
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progression of OA. After a mean follow-up period of 10 to 11 years Jiranek et al11 and Martini and Otto12 observed OA in 56% and 69% of patients, respectively, after Russe bone grafting. In another study,13 28 years after the Matti-Russe procedure radiocarpal arthrosis could be seen in 82% and mediocarpal arthrosis in 35% of patients. The purpose of this retrospective long-term study was to determine the occurrence, progression, and clinical results of OA after bone grafting and Herbert screw fixation for scaphoid nonunion.
Patients and Methods Patients Data on 70 patients (70 wrists) who had reconstruction of scaphoid nonunion using the Herbert screw between December 1988 and December 1993 were assessed retrospectively. Two patients who had revision surgery (hook plate14) because of persistent nonunion after initial fixation with the Herbert screw were excluded from the analysis. Another patient with cerebral palsy in whom union was achieved was excluded because of general impairment. One patient died and 14 were lost to or were unable to return for follow-up evaluation, leaving 52 for review. Two further patients were excluded because of absent preoperative x-rays. In total 50 patients (47 men, 3 women) were assessed clinically at a mean of 12.0 ⫾ 1.6 years (range, 9.7–15.2 y) after surgery. The right wrist was involved in 24 patients and the left was involved in 26. Age at time of surgery ranged from 16 to 56 years (mean, 28.1 ⫾ 8.7 y). The mean interval between fracture and surgery was 4.1 ⫾ 4.5 years (range, 0.6 –16.0 y). In 2 patients the date of injury could not be determined. Most nonunions were located at the waist of scaphoid. Exact distribution according to the classification system by Schernberg et al15 is shown in Figure 1. The radiologic appearance of pseudarthrosis was sclerotic in 49 patients and fibrous in 1. Bone resorption at pseudarthrosis was not present in 2 patients and was moderate in 28 . Twenty patients had severe cystic resorption at pseudarthrosis before surgery.16 Before surgery a humpback deformity was obvious on lateral x-rays in 9 patients. Intrascaphoid angle was not applied because of the high variability of measurement.17 X-rays showed possible necrosis of the proximal scaphoid pole in 6 patients; in 44 patients radiodensity appeared normal.
Figure 1. Localization of scaphoid nonunion according to Schernberg classification. Most nonunions are at the waist of scaphoid (II–IV).
Evaluation of Osteoarthritis The following features were analyzed on preoperative and follow-up x-rays to evaluate OA: (1) radiographic evidence of OA at the radial styloid–scaphoid, radial-scaphoid, scaphotrapeziumtrapezoid, scaphocapitate, and lunocapitate joints and (2) grade of wrist OA (grade 1, slight narrowing of the joint space of 1 joint; grade 2, moderate narrowing or involvement of more than 1 joint; grade 3, osteophytes, subchondral sclerosis, cysts; grade 4, OA including midcarpal joint). Because OA was evaluated by x-ray assessment in comparable long-term studies for untreated scaphoid nonunions and for the Matti-Russe procedure, computed tomography scans were not applied in this study.
Assessment of Clinical and Further Radiologic Data Data on complications and further surgeries at the affected site were obtained from hospital records and were confirmed by each patient. The preoperative range of motion (ROM) concerning flexion, extension, and radial and ulnar deviation of the wrist was documented in 45 patients. Evaluation of preoperative grip strength was excluded because of incomplete documentation. Pain, subjective assessment, and function were assessed at follow-up evaluation.18 Clinical assessment at follow-up evaluation included the ROM of the wrist and forearm (measured with a goniometer) and grip strength (Jamar dynamometer; Asimov Engineering, Los Angeles, CA). The contralateral wrist was used for comparison of ROM and grip strength. No patient was excluded because of previous injuries of the contralateral wrist. We used different scores for better
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comparison with results from the literature. Combined postoperative results were evaluated by the Disabilities of the Arm, Shoulder, and Hand questionnaire score,19 the subjective and objective Jiranek scores,11 the Cooney score,20 and the Martini score.18 The last score includes subjective, clinical, and radiologic features. One patient was excluded from objective scores because of an acute metacarpal fracture of the opposite hand at follow-up evaluation. Standard posteroanterior and lateral preoperative and postoperative x-rays of the wrist were obtained in every patient (except postoperative x-rays in 1 patient) and were compared with the final follow-up x-rays. Postoperative x-rays were assessed for position of the screw (correct; too short, does not secure both fragments; too long, penetrating adjacent joint) and reconstruction of the scaphoid (normal, malrotation of scaphoid, poor alignment of scaphoid, humpback). The follow-up x-rays were evaluated for union (definite, trabeculae across the nonunion site on all projections; possible, no gap visible; none, gap within scaphoid) and signs of avascularity of the proximal fragment (none, normal appearance of radiodensity; possible, different density to distal scaphoid; definite, sclerosis and fragmentation). Furthermore follow-up x-rays were analyzed for screw position (secondary displacement, radiolucent line around the screw). Carpal reconstruction was determined by using the following parameters before surgery and at follow-up evaluation: carpal height ratio per Youm et al21 (carpal height/length of third metacarpal), tangential scapholunate angle (SLA), and radiolunate angle. Dorsal intercalated segment instability (DISI) was considered present if the SLA angle was more than 70°.21 All radiographic assessments and measurements were performed by 2 of the investigators, who were blinded to the clinical results.
Surgical Technique and Postoperative Management All surgeries were performed by the consultant or by a trainee under his supervision. A tourniquet was used and the surgery was performed under general anesthesia. On the basis of localization of nonunion a palmar approach was used in 42 patients, a dorsal approach in 5 patients, and a combination of both in 3 patients. Noncanulated regular Herbert screws were used for all cases. Resection of the sclerotic bone and fibrous tissue of both fragments facing the
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nonunion was performed using a small curved osteotome until viable bleeding began. The cortical shell of the scaphoid was preserved despite a small rounded palmar defect as a seating for the graft. A cylindric cancellous bone graft was harvested at the ipsilateral iliac crest using a tube saw of 10 mm in diameter as described by Maruthainar et al.22 Because of the rigid consistency of the harvested bone graft its cortical surface was removed to improve the incorporation. An ellipsoid graft was formed and inserted into the defect, similar to the standard palmar wedge corticocancellous graft.23,24 The size and shape of the bone graft were determined by the defect in slight ulnar deviation. To pry open the palmar defect, replace the missing bone, and correct the scaphoid deformity the graft was placed from between the 2 borders of the palmar cortical shell (seating) to the dorsal inner cortical surface. The dorsal border was lengthened only in severe defects with scaphoid shortening. The Herbert screw was inserted according to the original description using an elevator for the scaphotrapezial joint and a jig.1 The wrist was immobilized in a palmar splint. The dorsal approach was used for small proximal fragments (classifications I and II according to Schernberg et al15) with placement of the Herbert screw in a free-hand technique16. A combination of both approaches was used for complicated nonunion with humpback deformity.25 In 6 cases styloidectomy additionally was performed. In both approaches a forearm cast was applied after swelling had decreased. The forearm was immobilized until radiologic evidence showed union, or for a maximum of 12 weeks, with an average time of 5.9 ⫾ 1.9 weeks (range, 3–12 wk). Physiotherapy was started after removal of the cast and was continued for approximately 2 months.
Statistical Methods Means and SDs were calculated for the continuous parameters: age, time, ROM, scores, and radiologic indexes and angles. The association between 2 continuous variables was tested by the unpaired Student t test. The paired t test was applied to compare intraindividual continuous parameters and the Pearson chi-square test was used to compare discrete variables. A logistic regression analysis was applied to estimate the influence of incorrect anatomic reconstruction of the scaphoid, persistent nonunion, or necrosis of the proximal fragment on occurrence of OA. A 2-tailed p value less than or equal to .05 was considered significant. All tests were without alpha
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Table 1. Severity of OA Before Surgery and at Follow-Up Evaluation for all 50 Patients
Severity of OA
Before Surgery: All Patients (n ⴝ 50)
At Follow-Up Evaluation: All Patients (n ⴝ 50)
At Follow-Up Evaluation: of Patients Without Preoperative OA (n ⴝ 35)
35 9 4 1 1
27 14 3 3 3
27 8 0 0 0
No OA Grade 1 Grade 2 Grade 3 Grade 4
NOTE. Additionally radiologic outcome for patients without radiologic evidence of OA before surgery is shown.
adjustment. Data analysis was performed with statistical software (SPSS for Windows 11.0.1; SPSS Inc. Chicago, IL)26.
Results Evidence of Osteoarthritis Before surgery 35 of 50 patients had no radiologic evidence of OA but at follow-up evaluation this number had decreased to 27 of 50 patients. For all patients the incidence of OA increased significantly between preoperative and follow-up x-rays (p ⱕ .001). The severity of OA before surgery and at follow-up evaluation is shown in Table 1. The grade of OA at the time of surgery compared with that at follow-up evaluation persisted in 36 patients. Patients with incorrect reconstruction of the scaphoid, persistent nonunion, or necrosis of the proximal fragment had a significantly increased risk for OA (odds ratio, 5.4; p ⫽ .007). Patients with OA at the time of surgery (n ⫽ 15) tended to have an increase in the grade of OA at follow-up evaluation (p ⫽ .084). Nine of these patients remained unchanged but in 6 patients an increase in severity was observed. Two of the 6 patients with progressive OA had persistent nonunion (with radiolucent line around the screw). Another
patient had malalignment of the scaphoid and in 2 others the time interval between fracture and surgery was long (15 and 16 y). In the remaining patient no reason for the increase in severity could be found. Of the 35 patients who had no degenerative changes at the time of surgery 27 had no evidence of OA at follow-up evaluation. The 8 patients who developed radiologic signs of OA had low grade changes (grade I, n ⫽ 8) (Table 1). Two of these 8 patients had a concomitant injury (transscaphoid perilunate dislocation, second metacarpal fracture) and in 2 other patients nonunion persisted. In 1 patient the screw was too long; in 1 of 2 other patients with preoperatively increased SLA the DISI deformity persisted. The remaining patient from this group was 43 years old. For all patients progression of degenerative changes between preoperative and follow-up x-rays was significant for the radial styloid–scaphoid, radial-scaphoid, scaphocapitate, and lunocapitate joints (Table 2). Patients with OA of the scaphotrapezium-trapezoid (STT) joint had no significant difference in age compared with the remaining patients (41.1 vs. 40.1 y; p ⫽ .80). They experienced very few symptoms (3 were free of pain, 2 experienced pain only during heavy manual labor; subjective assessment of surgical outcome was rated as excellent in all
Table 2. Number of Patients With Radiologic Evidence of OA by Joint for All Patients Before Surgery and at Follow-Up Evaluation
Evidence of OA
Before Surgery: All Patients (n ⴝ 50)
At Follow-Up Evaluation: All Patients (n ⴝ 50)
2 (n ⴝ 50)
At Follow-Up Evaluation: of Patients Without Preoperative OA (n ⴝ 35)
Radial styloid–scaphoid joint Radial scaphoid joint Scaphocapitate joint STT joint Lunocapitate joint
12 6 1 0 1
18 16 8 5 3
0.001 0.001 0.021 — 0.001
4 5 1 2 0
NOTE. Additionally radiologic outcome for patients without radiologic evidence of OA before surgery is shown. All 6 patients who had additional styloidectomy were classified as having OA at the radial styloid-scaphoid joint.
At follow-up evaluation the mean Disabilities of the Arm, Shoulder, and Hand questionnaire score (range, 0 –100) was 9.2 ⫾ 12.7 points for all patients. The average subjective and objective Jiranek scores (range, 0 –100) were 75.6 ⫾ 18.8 and 85.7 ⫾ 10.9,
9.2 9.2 1.8 3.5 3.7 8.7 ⫾ ⫾ ⫾ ⫾ ⫾ ⫾ 71 67 25 33 88 85 .180 .065 .005 .430 — — 12.9 12.0 3.8 4.3 4.0 6.2 ⫾ ⫾ ⫾ ⫾ ⫾ ⫾ 59 60 23 31 88 86 ⫾ 9.5 ⫾ 9.3 ⫾ 4.7 ⫾ 3.5 — — 57 56 21 30
NOTE. Preoperative ROM was documented in 45 patients. One patient was excluded for ROM of opposite wrist at follow-up evaluation because of an acute fracture.
Combined Results
Flexion Extension Radial deviation Ulna deviation Supination Pronation
Except for radial deviation no significant differences in ROM before surgery and at follow-up evaluation were noted (Table 3). At follow-up evaluation ROM for flexion (p ⱕ .001), extension (p ⱕ .001), and radial (p ⱕ .001) and ulnar (p ⫽ .001) deviation of the wrist was decreased significantly compared with the opposite healthy wrist (Table 3). Flexion/extension and radial/ulnar deviation were reduced compared with the opposite arm (mean, 19° and 5°, respectively). No differences in supination (p ⫽ .811) or pronation (p ⫽ .579) of the forearm were found between both arms. The exact ROM of both forearms and wrists is shown in Table 3. Grip strength of the affected arm was 28.7 ⫾ 6.2 kg versus 30.6 ⫾ 6.5 kg for the opposite arm. Differences in grip strength between both arms were significant (p ⱕ .001).
ROM ⴞ SD (deg) of Injured Wrist at Follow-Up Evaluation (n ⴝ 50)
Clinical Assessment
ROM ⴞ SD (deg) of Injured Wrist Before Surgery (n ⴝ 45)
At follow-up evaluation 20 patients were free of pain and 23 experienced pain only during heavy manual labor. Pain during daily activity was reported in 6 patients and 1 patient reported pain at rest. Subjective assessment of the surgical outcome was rated as excellent in 24 patients, improved in 25, and worse in 1. In terms of function 34 patients reported having no limitation on stress at the affected site. A further 15 patients stated that they were careful not to overexert their arm and experienced restrictions during sports. One patient had to change jobs.
Table 3. Range of Motion of Injured Wrist Before Surgery and of Both Wrists at Follow-Up Evaluation
Pain, Subjective Assessment, and Function
t test Before Surgery vs Follow-Up Evaluation p Value (n ⴝ 45)
ROM ⴞ SD (deg) of Opposite Wrist (n ⴝ 49)
t Test Injured vs Opposite Wrist p Value (n ⴝ 49)
5 patients). None of the 5 patients with the dorsal approach experienced OA at the STT joint. The interval between fracture and surgery was significantly longer for patients with preoperative (p ⱕ .001) and follow-up (p ⫽ .005) evidence of carpal OA. In 15 patients the interval between the fracture and surgery exceeded 5 years. Within an average period of 8.6 years from trauma to surgery 14 of 50 patients developed carpal OA; however, only 8 of 35 patients without OA at time of surgery developed early degenerative changes within the following 12.1 years.
ⱕ.001 ⱕ.001 ⱕ.001 .001 .811 .579
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Table 4. Distribution of Patients According to the Subjective and Objective Jiranek, Cooney, and Martini Scores Score
Excellent
Good
Fair
Poor
Subjective Jiranek (n ⫽ 50) Objective Jiranek (n ⫽ 49) Cooney (n ⫽ 49) Martini (n ⫽ 49)
16 29 13 23
10 14 19 21
5 4 14 5
19 2 3 0
NOTE. One patient was excluded from objective scores (Jiranek, Cooney, Martini) because of an acute fracture of the opposite hand.
respectively. The mean Cooney score (range, 0 –100) was 79.6 ⫾ 10.0 and the average Martini score (range, 0 –29) was 23.5 ⫾ 4.4. The distribution of different scores is shown in Table 4.
Radiologic Assessment of the Scaphoid According to the postoperative x-rays of the 50 patients 47 screws were placed correctly. For 1 patient no postoperative x-ray was available. The Herbert screw was too short in 1 wrist and too long (or even penetrating the adjacent joint) in 2 wrists. Those 2 patients had subsequent removal of the screw. Reconstruction of the scaphoid was classified as correct in 44 of 50 patients based on postoperative x-rays. Malrotation of the scaphoid was found in 1 patient and malalignment (with step) between both fragments was seen in 2 patients. A further 3 scaphoids appeared to be fused in a humpback deformity. Compared with normal distribution the humpback deformity was associated with decreased Youm carpal height ratio (0.521) and an increased SLA (68°). On follow-up x-ray scaphoid nonunion fused in 42 of the 50 patients in this study. Definite radiologic signs of persistent pseudarthrosis were observed in 6 patients. A further 2 patients showed possible signs of nonunion. In 2 patients displacement of the Herbert screw occurred because of persistent nonunion. In 4 patients with possible or definite nonunion, however, no radiolucent line around the Herbert screw was noted. The grade of OA persisted in 3 of the 4 patients and progressed in 1 patient from grade 1 to grade 3. At follow-up evaluation 46 scaphoid proximal poles had a normal appearance, 2 had possible avascularity (Schernberg classification II/III), and a further 2 had definite avascularity (sclerosis, fragmentation) (Schernberg classification II/III). Nonunion persisted in 3 of those 4 patients with possible or definite necrosis of the proximal pole.
Radiologic Assessment of the Carpus For all patients the SLA and radiolunate angle decreased significantly from 55° ⫾ 13° to 51° ⫾ 11° (p
⫽ .035) and from 11° ⫾ 10 to 8° ⫾ 9 (p ⫽ .047), respectively. Dorsal intercalated segment instability deformity was found in 6 patients before surgery and in 1 patient at follow-up evaluation. The Youm carpal height ratio was not influenced by surgery (normal, 0.54 ⫾ 0.03; before surgery, 0.54 ⫾ 0.04; at follow-up evaluation, 0.54 ⫾ 0.04; p ⫽ .20).
Further Surgery and Complications Eight patients in this analysis had possible or definite nonunion at follow-up evaluation. In none of these 8 patients was a second surgical attempt performed to achieve union. Five patients had a secondary surgery other than scaphoid reconstruction: removal of a malpositioned Herbert screw (2 patients), arthroscopic resection of loose bodies (2 patients), and denervation (1 patient).
Discussion Although there are many inherent limitations to such a retrospective analysis, we have used it to report long-term results after bone graft and Herbert screw fixation for scaphoid nonunion. According to our analysis this procedure can prevent the occurrence of OA in most patients (27 of 35) who had no degenerative changes at the time of surgery. None of those patients developed midcarpal (lunocapitate) OA. In 8 of 14 patients with early preoperative changes, the arthritic progression seemed to persist. Early forms of radiocarpal OA, especially at the radial styloid– scaphoid and radial scaphoid joints, were typical findings in patients who had arthritic progress. Of all patients analyzed, only 12% (6 of 50) had moderate or severe forms of degeneration with 6% (3 of 50) including the midcarpal joint. Thirty percent of our patients already showed minor degenerative changes before surgery, a result that in part was caused by the high number of patients with a long interval between fracture and surgery. In the Matti-Russe procedure 10 to 12 years after surgery, carpal osteoarthrosis has been reported to develop in 41% to 69% of patients.10 –13 Osteoarthri-
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tis between the scaphoid and radial styloid process was described in 58% to 100% and severe forms with midcarpal involvement were found in 26% of patients.10 –12 According to Martini and Otto12 radiocarpal OA exists in 28% of all patients without preoperative degeneration 12.1 years after the MattiRusse procedure. More than 10 years after Herbert screw fixation we found an OA rate of 11% (4 of 35) at the radial styloid–scaphoid joint and 14% (5 of 35) at the radiocarpal joint for patients without evidence of OA before surgery (Table 2). According to these data Herbert screw fixation shows superior results in terms of OA compared with the Matti-Russe procedure. As shown by Jiranek et al,11 carpal reconstruction by the Matti-Russe procedure is limited. In 62% of the patients from the study byJiranek et al11 carpal collapse was present at follow-up evaluation and was associated with progression of OA. According to Hooning van Duyvenbode et al13 a DISI deformity after the Matti-Russe procedure can be seen in 32% of patients. For humpback deformity of the scaphoid Amadio et al27 found an increase in the progression of OA when compared with normal scaphoid anatomy. After an average follow-up period of 45 months 54% of their patients with malunion had OA of the wrist but only 22% had a correct scaphoid union. As a result corrective osteotomy for scaphoid malunion has been proposed.17 In the case of scaphoid angulation and shortening, consistent with an increased SLA after Herbert screw fixation, the clinical results also were found to be inferior.28,29 Therefore the question arises as to whether bone graft with Herbert screw fixation is a reliable procedure for preventing scaphoid malunion and the associated progression of carpal OA. Several researchers have pointed out the predictable reconstruction of scaphoid angulation and carpal alignment by bone graft and Herbert screw. According to Inoue et al30 only 26 of 144 patients and 10 of 105 patients in a study by Preisser et al31 showed a persistent DISI deformity after surgery. Carpal alignment was achieved in 32 of 38 cases with DISI deformity in a study by Nakamura et al.28 In our analysis, 5 of 6 preoperative DISI deformities were corrected. The SLA and carpal height ratio were corrected, respectively, from 65° and 0.51 before surgery to 54° and 0.54 after surgery, as reported by Cooney et al.32 A decrease in the SLA was described by Richards and Regan33 (from 73° to 61°) and by Tsuyuguchi et al29 (from 65° to 55°) and also was seen in our study (from 55° to 51°). The reliable
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stabilization of a correctly reconstructed scaphoid by insertion of an adequate bone graft can be considered the chief advantage of the Herbert screw fixation in scaphoid nonunion. According to our data incorrect scaphoid reconstruction, failure to achieve union, or occurrence of necrosis of the proximal fragment resulted in a nearly 6-fold increased risk for OA. The alignment of the carpus by Herbert screw fixation must be considered the main reason for the decreased rate of OA compared with untreated nonunion or even after the Matti-Russe procedure. Other factors, however, such as the duration of postoperative immobilization also are prognostic factors for the progression of OA.34,35 Successful alignment of the carpus and short immobilization of the wrist are in conformity with the low rate of severe OA after 10 years in our study. One third of patients without preoperative carpal OA, however, have at least slow arthritic progression despite surgery. Progression was related mostly to failed anatomic reconstruction of the scaphoid or initial concomitant injury. In contrast to Callanan et al36 and in agreement with Preisser et al,31 Nicholl and Buckland-Wright,37 and Kehoe et al38 we found a high percentage of OA at the STT joint. In all of these patients the elevator was used to pry open the STT joint to gain access for the jig, which could explain the comparably high number of arthroses.37 On the other hand, mild STT arthrosis might have been present because of the process of aging, an effect we were not able to exclude in our study. Most patients, however, were young (mean age, 40.2 ⫾ 8.6 y; range, 27.9 – 65.3 y) and patients with STT OA were of the same age as the remaining patients. Our long-term results (145 mo), in conformity with other studies28 –33,39 – 43 with short or intermediate follow-up periods (14 – 48 mo), indicate that healing of scaphoid nonunion by Herbert screw fixation leads to good and excellent subjective and clinical results in most patients. Concerning postoperative pain the vast majority of patients in our study (86%) (43 of 50) and in others (80%–92%)31,43 had excellent or good results after Herbert screw reconstruction. A high average subjective Jiranek score confirms our good subjective result, although a reasonable number of patients were rated with poor outcomes in the last score. Healing of scaphoid nonunion by Herbert screw fixation is achieved at the cost of wrist motion (flexion/extension), which was decreased to 76% to 86% that of the opposite wrist.31,33,40 Similar to ROM the grip strength of the injured wrist cannot be restored totally by this pro-
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cedure, remaining at 75% to 97% that of the ipsilateral hand.28,32,33,40 We also observed a significant decrease of flexion (to 88%) and radial deviation (to 91%) similar to decreased grip strength (to 94%) compared with the opposite hand. Compared with preoperative values the ROM remained unchanged after surgery, except for radial deviation. The Cooney score was rated as excellent or good in 67% by Inoue et al,30 in 58% by Nakamura et al,28 and in 67% (32 of 49) in our study with a high average level of 79.7 points. Most of the nonunions healed after bone graft in combination with Herbert screw fixation in our study (84%; 42 of 50). Again the union rate was comparable with that of Inoue et al30 (90%), Preisser et al31 (89%), Cooney et al32 (71%), Shah and Jones43 (80%), Rajagopalan et al42 (86%), Daly et al40 (95%), Richards and Regan33 (90%), and Nakamura et al28 (94%). Most patients with persistent nonunion but a firmly affixed and stabilizing Herbert screw had a low pain level and good function, resulting in high score levels. This was in contrast to patients who presented with a radiolucent line around the Herbert screw and who had poor clinical results. Different devices presently used for fixation and use of vascularized bone transplants in cases of avascularity of the proximal pole could increase the union rate.2,4,44 Reconstruction of the scaphoid by screw fixation, however, is a technically demanding procedure with multiple pitfalls.34,45 We also experienced a considerable number of complications and failures in our study (ie, incorrect screw length, improper reconstruction of the scaphoid); this mainly was because we assessed all consecutive patients from the time of the introduction of this procedure in the late 1980s. Furthermore ours is a teaching hospital and we included the learning curve of this procedure in our cohort. With sufficient experience we expect the complication rate to be notably lower and the outcome better. The authors thank Leonard Bodell PhD, MD, for his critical review and helpful suggestions and Sven Schneider DPhil, MA, for statistical support.
References 1. Herbert TJ, Fisher WE. Management of the fractured scaphoid using a new bone screw. J Bone Joint Surg 1984;66B: 114 –123. 2. Kujala S, Raatikainen T, Kaarela O, Ashammakhi N, Ryhänen J. Successful treatment of scaphoid fractures and nonunions using bioabsorbable screws: report of six cases. J Hand Surg 2004;29A:68 –73. 3. Merrell GA, Wolfe SW, Slade JF 3rd. Treatment of scaphoid
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nonunions: quantitative meta-analysis of the literature. J Hand Surg 2002;27A:685– 691. Trumble TE, Salas P, Barthel T, Robert KQ 3rd. Management of scaphoid nonunions. J Am Acad Orthop Surg 2003; 11:380 –391. Ruby LK, Stinson J, Belsky MR. The natural history of scaphoid non-union. A review of fifty-five cases. J Bone Joint Surg 1985;67A:428 – 432. Mack GR, Bosse MJ, Gelberman RH, Yu E. The natural history of scaphoid non-union. J Bone Joint Surg 1984;66A: 504 –509. Martini AK. Der Spontanverlauf der Kahnbeinpseudarthrose. [Natural course in pseudarthrosis of the scaphoid.] Orthopade 1994;23:249 –254. ¨ ber die Behandlung der Navikularefraktur und der Matti H. U Refractura patellae durch Plombierung mit Spongiosa. Zentralbl Chir 1937;64:2353–2359. Russe O. Behandlungsergebnisse der Spongiosaauffüllung bei Kahnbeinpseudarthrosen. [Therapeutic results with cancellous bone filling in pseudoarthrosis of the navicular bone.] Z Orthop Ihre Grenzgeb 1951;81:466 – 473. Stark A, Broström LA, Svartengren G. Scaphoid nonunion treated with the Matti-Russe technique. Long-term results. Clin Orthop Relat Res 1987;214:175–180. Jiranek WA, Ruby LK, Millender LB, Bankoff MS, Newberg AH. Long-term results after Russe bone-grafting: the effect of malunion of the scaphoid. J Bone Joint Surg 1992; 74A:1217–1228. Martini AK, Otto H. Langzeitergebnisse der Matti-RussePlastik unter besonderer Berücksichtigung der arthrotischen Spätschäden am Handgelenk. [Long-term outcome of MattiRusse-plasty with special reference to late arthrotic damage of the wrist joint.] Handchir Mikrochir Plast Chir 1995;27: 208 –213. Hooning van Duyvenbode JF, Keijser LC, Hauet EJ, Obermann WR, Rozing PM. Pseudarthrosis of the scaphoid treated by the Matti-Russe operation. A long-term review of 77 cases. J Bone Joint Surg 1991;73B:603– 606. Ender HG. Zur Behandlung von veralteten Brüchen und Pseudarthrosen des Kahnbeines mit der Kahnbeinplatte. [A new method of treating traumatic cysts and pseudoarthrosis of the scaphoid.] Unfallheilkunde 1977;80:509 –513. Schernberg F, Elzein F, Gérard Y. Etude anatomo-radiologique des fractures du scaphoïde carpien. Problèmes des cals vicieux. [Anatomo-radiological study of fractures of the carpal scaphoid bone. Problems of abnormal callus.] Rev Chir Orthop Reparatrice Appar Mot 1984;70(Suppl 2)55– 63. Dobyns JH, Linscheid RL, Cooney WP III. Fractures and dislocations of the wrist and hand, then and now. J Hand Surg [Am] 1983;8(5 Pt 2):687– 690. Smith DK, An KN, Cooney WP 3rd, Linscheid RL, Chao EY. Effects of a scaphoid waist osteotomy on carpal kinematics. J Orthop Res 1989;7:590 –598. Martini AK. Bewertungsschemata zur Beurteilung des Handgelenkes. [Evaluation protocol for assessment of the wrist joint.] Handchir Mikrochir Plast Chir 1999;31:153– 154. Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder, and hand) [corrected]. The Upper Extrem-
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ity Collaborative Group (UECG). Am J Ind Med 1996;29:602– 608. Cooney WP, Bussey R, Dobyns JH, Linscheid RL. Difficult wrist fractures. Perilunate fracture-dislocations of the wrist. Clin Orthop Relat Res 1987;214:136 –147. Youm Y, McMurtry RY, Flatt AE, Gillespie TE. Kinematics of the wrist. I. An experimental study of radial-ulnar deviation and flexion-extension. J Bone Joint Surg 1978;60A: 423– 431. Maruthainar N, Rasquinha VJ, Gallagher P. The treatment of scaphoid nonunion. A review of a novel technique using precision bone grafting compared with Herbert screw fixation and bone graft. J Hand Surg 2000;25B:427– 430. Fisk GR. An overview of injuries of the wrist. Clin Orthop Relat Res 1980;149:137–144. Fernandez DL. A technique for anterior wedge-shaped grafts for scaphoid nonunions with carpal instability. J Hand Surg 1984;9A:733–737. del Piñal F. Treatment of nonunion of the scaphoid by a limited combined approach. J Bone Joint Surg 2001;83B: 78 – 82. Griffin D, Audige L. Common statistical methods in orthopaedic clinical studies. Clin Orthop 2003;413:70 –79. Amadio PC, Berquist TH, Smith DK, Ilstrup DM, Cooney WP 3rd, Linscheid RL. Scaphoid malunion. J Hand Surg 1989;14A:679 – 687. Nakamura R, Horii E, Watanabe K, Tsunoda K, Miura T. Scaphoid non-union: factors affecting the functional outcome of open reduction and wedge grafting with Herbert screw fixation. J Hand Surg 1993;18B:219 –224. Tsuyuguchi Y, Murase T, Hidaka N, Ohno H, Kawai H. Anterior wedge-shaped bone graft for old scaphoid fractures or non-unions. An analysis of relevant carpal alignment. J Hand Surg 1995;20B:194 –200. Inoue G, Shionoya K, Kuwahata Y. Herbert screw fixation for scaphoid nonunions. An analysis of factors influencing outcome. Clin Orthop 1997;343:99 –106. Preisser P, Rudolf KD, Partecke BD. Die operative Behandlung der Kahnbeinpseudarthrose—Langzeitergebnisse mit der Herbert-Schraube. [Surgical treatment of scaphoid pseudarthrosis—long term outcome with the Herbert screws.] Handchir Mikrochir Plast Chir 1998;30:45–51. Cooney WP, Linscheid RL, Dobyns JH, Wood MB. Scaphoid nonunion: role of anterior interpositional bone grafts. J Hand Surg 1988;13A:635– 650. Richards RR, Regan WD. Treatment of scaphoid nonunion
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by radical curettage, trapezoidal iliac crest bone graft, and internal fixation with a Herbert screw. Clin Orthop 1991;262:148 –158. Radford PJ, Matthewson MH, Meggitt BF. The Herbert screw for delayed and non-union of scaphoid fractures: a review of fifty cases. J Hand Surg 1990;15B:455– 459. Schuind F, Haentjens P, Van Innis F, Vander Maren C, Garcia-Elias M, Sennwald G. Prognostic factors in the treatment of carpal scaphoid nonunions. J Hand Surg 1999;24A: 761–776. Callanan I, Lahoti O, McElwain JP. Herbert screw insertion in the scaphotrapezial joint. A cause of degenerative change? J Hand Surg 1996;21B:775–777. Nicholl JE, Buckland-Wright JC. Degenerative changes at the scaphotrapezial joint following Herbert screw insertion: a radiographic study comparing patients with scaphoid fracture and primary hand arthritis. J Hand Surg 2000;25B:422– 426. Kehoe NJ, Hackney RG, Barton NJ. Incidence of osteoarthritis in the scapho-trapezial joint after Herbert screw fixation of the scaphoid. J Hand Surg 2003;28B:496 – 499. Birchard D, Pichora D. Experimental corrective scaphoid osteotomy for scaphoid malunion with abnormal wrist mechanics. J Hand Surg 1990;15A:863– 868. Daly K, Gill P, Magnussen PA, Simonis RB. Established nonunion of the scaphoid treated by volar wedge grafting and Herbert screw fixation. J Bone Joint Surg 1996;78B: 530 –534. Manske PR, McCarthy JA, Strecker WB. Use of the Herbert bone screw for scaphoid nonunions. Orthopedics 1988;11: 1653–1661. Rajagopalan BM, Squire DS, Samuels LO. Results of Herbert-screw fixation with bone-grafting for the treatment of nonunion of the scaphoid. J Bone Joint Surg 1999;81A:48 – 52. Shah J, Jones WA. Factors affecting the outcome in 50 cases of scaphoid nonunion treated with Herbert screw fixation. J Hand Surg 1998;23B:680 – 685. Gabl M, Reinhart C, Lutz M, Bodner G, Rudisch A, Hussl H, et al. Vascularized bone graft from the iliac crest for the treatment of nonunion of the proximal part of the scaphoid with an avascular fragment. J Bone Joint Surg 1999;81A: 1414 –1428. Trumble TE, Nyland W. Scaphoid nonunions. Pitfalls and pearls. Hand Clin 2001;17:611– 624.
Purpose: To determine the occurrence, progression, and clinical results of osteoarthritis (OA) after bone grafting and Herbert screw fixation for scaphoid nonunion. Methods: Fifty patients were reviewed (mean follow-up period, 12.0 ⫾ 1.6 y) to analyze degenerative changes of the wrist after use of Herbert screws for scaphoid nonunion. Results: Radiologic signs of OA were observed in 15 of 50 patients before surgery and in 23 of 50 after 10 years or more. The majority of degenerative changes were low grade. No OA at follow-up evaluation was seen in 27 of 35 patients with no preoperative degenerative changes. In 6 of 8 patients with OA its occurrence was either subsequent to concomitant injury, occurred after incorrect scaphoid reconstruction, or was caused by persistent nonunion. Of 15 wrists with OA at the time of surgery 9 remained unchanged and 6 increased in severity. Healing of nonunion was achieved in 42 of 50. Range of motion, however, was reduced to 88% of that of the opposite hand. At follow-up evaluation the mean Disabilities of the Arm, Shoulder, and Hand score was 9 ⫾ 13 and the mean Cooney score was 80 ⫾ 10. Conclusions: The results show high patient satisfaction and good function after healing of scaphoid nonunion. In the long term correct anatomic reconstruction of the nonarthritic carpus with a Herbert screw prevents onset of OA in most patients. (J Hand Surg 2005;30A:923–931. Copyright © 2005 by the American Society for Surgery of the Hand.) Key words: Scaphoid nonunion, Herbert screw, osteoarthritis, long term, wrist.
Twenty years ago, Herbert and Fisher1 introduced their screw fixation for scaphoid fracture and nonunion and since that time the Herbert screw and From the Department of Orthopaedic Surgery, University of Heidelberg, Heidelberg, Germany. Received for publication February 16, 2005; accepted in revised form May 30, 2005. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Corresponding author: W. Daecke, MD, Orthopädische Universitätsklinik Heidelberg, Sektion Hand- und Mikrochirurgie, Schlierbacher Landstrasse 200, 69118 Heidelberg, Germany; e-mail: [email protected]. Copyright © 2005 by the American Society for Surgery of the Hand 0363-5023/05/30A05-0006$30.00/0 doi:10.1016/j.jhsa.2005.05.017
similar fixation systems have become popular for the treatment of scaphoid nonunion.2– 4 Although little is known about the extent to which the Herbert screw fixation—in combination with bone grafting— can prevent osteoarthritis (OA) of the wrist in the long term, Ruby et al,5 Mack et al,6 and Martini7 showed that untreated symptomatic nonunion of the scaphoid results in carpal OA, the radiographic evidence of which usually was present by 5 to 10 years after injury. For the Matti-Russe procedure,8,9 Stark et al10 found slight carpal osteoarthrosis in 41% and severe degeneration in 26% in a series of 27 patients with a mean follow-up period of 12 years. Only 33% of the patients in the study by Stark et al10 did not have The Journal of Hand Surgery
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progression of OA. After a mean follow-up period of 10 to 11 years Jiranek et al11 and Martini and Otto12 observed OA in 56% and 69% of patients, respectively, after Russe bone grafting. In another study,13 28 years after the Matti-Russe procedure radiocarpal arthrosis could be seen in 82% and mediocarpal arthrosis in 35% of patients. The purpose of this retrospective long-term study was to determine the occurrence, progression, and clinical results of OA after bone grafting and Herbert screw fixation for scaphoid nonunion.
Patients and Methods Patients Data on 70 patients (70 wrists) who had reconstruction of scaphoid nonunion using the Herbert screw between December 1988 and December 1993 were assessed retrospectively. Two patients who had revision surgery (hook plate14) because of persistent nonunion after initial fixation with the Herbert screw were excluded from the analysis. Another patient with cerebral palsy in whom union was achieved was excluded because of general impairment. One patient died and 14 were lost to or were unable to return for follow-up evaluation, leaving 52 for review. Two further patients were excluded because of absent preoperative x-rays. In total 50 patients (47 men, 3 women) were assessed clinically at a mean of 12.0 ⫾ 1.6 years (range, 9.7–15.2 y) after surgery. The right wrist was involved in 24 patients and the left was involved in 26. Age at time of surgery ranged from 16 to 56 years (mean, 28.1 ⫾ 8.7 y). The mean interval between fracture and surgery was 4.1 ⫾ 4.5 years (range, 0.6 –16.0 y). In 2 patients the date of injury could not be determined. Most nonunions were located at the waist of scaphoid. Exact distribution according to the classification system by Schernberg et al15 is shown in Figure 1. The radiologic appearance of pseudarthrosis was sclerotic in 49 patients and fibrous in 1. Bone resorption at pseudarthrosis was not present in 2 patients and was moderate in 28 . Twenty patients had severe cystic resorption at pseudarthrosis before surgery.16 Before surgery a humpback deformity was obvious on lateral x-rays in 9 patients. Intrascaphoid angle was not applied because of the high variability of measurement.17 X-rays showed possible necrosis of the proximal scaphoid pole in 6 patients; in 44 patients radiodensity appeared normal.
Figure 1. Localization of scaphoid nonunion according to Schernberg classification. Most nonunions are at the waist of scaphoid (II–IV).
Evaluation of Osteoarthritis The following features were analyzed on preoperative and follow-up x-rays to evaluate OA: (1) radiographic evidence of OA at the radial styloid–scaphoid, radial-scaphoid, scaphotrapeziumtrapezoid, scaphocapitate, and lunocapitate joints and (2) grade of wrist OA (grade 1, slight narrowing of the joint space of 1 joint; grade 2, moderate narrowing or involvement of more than 1 joint; grade 3, osteophytes, subchondral sclerosis, cysts; grade 4, OA including midcarpal joint). Because OA was evaluated by x-ray assessment in comparable long-term studies for untreated scaphoid nonunions and for the Matti-Russe procedure, computed tomography scans were not applied in this study.
Assessment of Clinical and Further Radiologic Data Data on complications and further surgeries at the affected site were obtained from hospital records and were confirmed by each patient. The preoperative range of motion (ROM) concerning flexion, extension, and radial and ulnar deviation of the wrist was documented in 45 patients. Evaluation of preoperative grip strength was excluded because of incomplete documentation. Pain, subjective assessment, and function were assessed at follow-up evaluation.18 Clinical assessment at follow-up evaluation included the ROM of the wrist and forearm (measured with a goniometer) and grip strength (Jamar dynamometer; Asimov Engineering, Los Angeles, CA). The contralateral wrist was used for comparison of ROM and grip strength. No patient was excluded because of previous injuries of the contralateral wrist. We used different scores for better
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comparison with results from the literature. Combined postoperative results were evaluated by the Disabilities of the Arm, Shoulder, and Hand questionnaire score,19 the subjective and objective Jiranek scores,11 the Cooney score,20 and the Martini score.18 The last score includes subjective, clinical, and radiologic features. One patient was excluded from objective scores because of an acute metacarpal fracture of the opposite hand at follow-up evaluation. Standard posteroanterior and lateral preoperative and postoperative x-rays of the wrist were obtained in every patient (except postoperative x-rays in 1 patient) and were compared with the final follow-up x-rays. Postoperative x-rays were assessed for position of the screw (correct; too short, does not secure both fragments; too long, penetrating adjacent joint) and reconstruction of the scaphoid (normal, malrotation of scaphoid, poor alignment of scaphoid, humpback). The follow-up x-rays were evaluated for union (definite, trabeculae across the nonunion site on all projections; possible, no gap visible; none, gap within scaphoid) and signs of avascularity of the proximal fragment (none, normal appearance of radiodensity; possible, different density to distal scaphoid; definite, sclerosis and fragmentation). Furthermore follow-up x-rays were analyzed for screw position (secondary displacement, radiolucent line around the screw). Carpal reconstruction was determined by using the following parameters before surgery and at follow-up evaluation: carpal height ratio per Youm et al21 (carpal height/length of third metacarpal), tangential scapholunate angle (SLA), and radiolunate angle. Dorsal intercalated segment instability (DISI) was considered present if the SLA angle was more than 70°.21 All radiographic assessments and measurements were performed by 2 of the investigators, who were blinded to the clinical results.
Surgical Technique and Postoperative Management All surgeries were performed by the consultant or by a trainee under his supervision. A tourniquet was used and the surgery was performed under general anesthesia. On the basis of localization of nonunion a palmar approach was used in 42 patients, a dorsal approach in 5 patients, and a combination of both in 3 patients. Noncanulated regular Herbert screws were used for all cases. Resection of the sclerotic bone and fibrous tissue of both fragments facing the
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nonunion was performed using a small curved osteotome until viable bleeding began. The cortical shell of the scaphoid was preserved despite a small rounded palmar defect as a seating for the graft. A cylindric cancellous bone graft was harvested at the ipsilateral iliac crest using a tube saw of 10 mm in diameter as described by Maruthainar et al.22 Because of the rigid consistency of the harvested bone graft its cortical surface was removed to improve the incorporation. An ellipsoid graft was formed and inserted into the defect, similar to the standard palmar wedge corticocancellous graft.23,24 The size and shape of the bone graft were determined by the defect in slight ulnar deviation. To pry open the palmar defect, replace the missing bone, and correct the scaphoid deformity the graft was placed from between the 2 borders of the palmar cortical shell (seating) to the dorsal inner cortical surface. The dorsal border was lengthened only in severe defects with scaphoid shortening. The Herbert screw was inserted according to the original description using an elevator for the scaphotrapezial joint and a jig.1 The wrist was immobilized in a palmar splint. The dorsal approach was used for small proximal fragments (classifications I and II according to Schernberg et al15) with placement of the Herbert screw in a free-hand technique16. A combination of both approaches was used for complicated nonunion with humpback deformity.25 In 6 cases styloidectomy additionally was performed. In both approaches a forearm cast was applied after swelling had decreased. The forearm was immobilized until radiologic evidence showed union, or for a maximum of 12 weeks, with an average time of 5.9 ⫾ 1.9 weeks (range, 3–12 wk). Physiotherapy was started after removal of the cast and was continued for approximately 2 months.
Statistical Methods Means and SDs were calculated for the continuous parameters: age, time, ROM, scores, and radiologic indexes and angles. The association between 2 continuous variables was tested by the unpaired Student t test. The paired t test was applied to compare intraindividual continuous parameters and the Pearson chi-square test was used to compare discrete variables. A logistic regression analysis was applied to estimate the influence of incorrect anatomic reconstruction of the scaphoid, persistent nonunion, or necrosis of the proximal fragment on occurrence of OA. A 2-tailed p value less than or equal to .05 was considered significant. All tests were without alpha
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Table 1. Severity of OA Before Surgery and at Follow-Up Evaluation for all 50 Patients
Severity of OA
Before Surgery: All Patients (n ⴝ 50)
At Follow-Up Evaluation: All Patients (n ⴝ 50)
At Follow-Up Evaluation: of Patients Without Preoperative OA (n ⴝ 35)
35 9 4 1 1
27 14 3 3 3
27 8 0 0 0
No OA Grade 1 Grade 2 Grade 3 Grade 4
NOTE. Additionally radiologic outcome for patients without radiologic evidence of OA before surgery is shown.
adjustment. Data analysis was performed with statistical software (SPSS for Windows 11.0.1; SPSS Inc. Chicago, IL)26.
Results Evidence of Osteoarthritis Before surgery 35 of 50 patients had no radiologic evidence of OA but at follow-up evaluation this number had decreased to 27 of 50 patients. For all patients the incidence of OA increased significantly between preoperative and follow-up x-rays (p ⱕ .001). The severity of OA before surgery and at follow-up evaluation is shown in Table 1. The grade of OA at the time of surgery compared with that at follow-up evaluation persisted in 36 patients. Patients with incorrect reconstruction of the scaphoid, persistent nonunion, or necrosis of the proximal fragment had a significantly increased risk for OA (odds ratio, 5.4; p ⫽ .007). Patients with OA at the time of surgery (n ⫽ 15) tended to have an increase in the grade of OA at follow-up evaluation (p ⫽ .084). Nine of these patients remained unchanged but in 6 patients an increase in severity was observed. Two of the 6 patients with progressive OA had persistent nonunion (with radiolucent line around the screw). Another
patient had malalignment of the scaphoid and in 2 others the time interval between fracture and surgery was long (15 and 16 y). In the remaining patient no reason for the increase in severity could be found. Of the 35 patients who had no degenerative changes at the time of surgery 27 had no evidence of OA at follow-up evaluation. The 8 patients who developed radiologic signs of OA had low grade changes (grade I, n ⫽ 8) (Table 1). Two of these 8 patients had a concomitant injury (transscaphoid perilunate dislocation, second metacarpal fracture) and in 2 other patients nonunion persisted. In 1 patient the screw was too long; in 1 of 2 other patients with preoperatively increased SLA the DISI deformity persisted. The remaining patient from this group was 43 years old. For all patients progression of degenerative changes between preoperative and follow-up x-rays was significant for the radial styloid–scaphoid, radial-scaphoid, scaphocapitate, and lunocapitate joints (Table 2). Patients with OA of the scaphotrapezium-trapezoid (STT) joint had no significant difference in age compared with the remaining patients (41.1 vs. 40.1 y; p ⫽ .80). They experienced very few symptoms (3 were free of pain, 2 experienced pain only during heavy manual labor; subjective assessment of surgical outcome was rated as excellent in all
Table 2. Number of Patients With Radiologic Evidence of OA by Joint for All Patients Before Surgery and at Follow-Up Evaluation
Evidence of OA
Before Surgery: All Patients (n ⴝ 50)
At Follow-Up Evaluation: All Patients (n ⴝ 50)
2 (n ⴝ 50)
At Follow-Up Evaluation: of Patients Without Preoperative OA (n ⴝ 35)
Radial styloid–scaphoid joint Radial scaphoid joint Scaphocapitate joint STT joint Lunocapitate joint
12 6 1 0 1
18 16 8 5 3
0.001 0.001 0.021 — 0.001
4 5 1 2 0
NOTE. Additionally radiologic outcome for patients without radiologic evidence of OA before surgery is shown. All 6 patients who had additional styloidectomy were classified as having OA at the radial styloid-scaphoid joint.
At follow-up evaluation the mean Disabilities of the Arm, Shoulder, and Hand questionnaire score (range, 0 –100) was 9.2 ⫾ 12.7 points for all patients. The average subjective and objective Jiranek scores (range, 0 –100) were 75.6 ⫾ 18.8 and 85.7 ⫾ 10.9,
9.2 9.2 1.8 3.5 3.7 8.7 ⫾ ⫾ ⫾ ⫾ ⫾ ⫾ 71 67 25 33 88 85 .180 .065 .005 .430 — — 12.9 12.0 3.8 4.3 4.0 6.2 ⫾ ⫾ ⫾ ⫾ ⫾ ⫾ 59 60 23 31 88 86 ⫾ 9.5 ⫾ 9.3 ⫾ 4.7 ⫾ 3.5 — — 57 56 21 30
NOTE. Preoperative ROM was documented in 45 patients. One patient was excluded for ROM of opposite wrist at follow-up evaluation because of an acute fracture.
Combined Results
Flexion Extension Radial deviation Ulna deviation Supination Pronation
Except for radial deviation no significant differences in ROM before surgery and at follow-up evaluation were noted (Table 3). At follow-up evaluation ROM for flexion (p ⱕ .001), extension (p ⱕ .001), and radial (p ⱕ .001) and ulnar (p ⫽ .001) deviation of the wrist was decreased significantly compared with the opposite healthy wrist (Table 3). Flexion/extension and radial/ulnar deviation were reduced compared with the opposite arm (mean, 19° and 5°, respectively). No differences in supination (p ⫽ .811) or pronation (p ⫽ .579) of the forearm were found between both arms. The exact ROM of both forearms and wrists is shown in Table 3. Grip strength of the affected arm was 28.7 ⫾ 6.2 kg versus 30.6 ⫾ 6.5 kg for the opposite arm. Differences in grip strength between both arms were significant (p ⱕ .001).
ROM ⴞ SD (deg) of Injured Wrist at Follow-Up Evaluation (n ⴝ 50)
Clinical Assessment
ROM ⴞ SD (deg) of Injured Wrist Before Surgery (n ⴝ 45)
At follow-up evaluation 20 patients were free of pain and 23 experienced pain only during heavy manual labor. Pain during daily activity was reported in 6 patients and 1 patient reported pain at rest. Subjective assessment of the surgical outcome was rated as excellent in 24 patients, improved in 25, and worse in 1. In terms of function 34 patients reported having no limitation on stress at the affected site. A further 15 patients stated that they were careful not to overexert their arm and experienced restrictions during sports. One patient had to change jobs.
Table 3. Range of Motion of Injured Wrist Before Surgery and of Both Wrists at Follow-Up Evaluation
Pain, Subjective Assessment, and Function
t test Before Surgery vs Follow-Up Evaluation p Value (n ⴝ 45)
ROM ⴞ SD (deg) of Opposite Wrist (n ⴝ 49)
t Test Injured vs Opposite Wrist p Value (n ⴝ 49)
5 patients). None of the 5 patients with the dorsal approach experienced OA at the STT joint. The interval between fracture and surgery was significantly longer for patients with preoperative (p ⱕ .001) and follow-up (p ⫽ .005) evidence of carpal OA. In 15 patients the interval between the fracture and surgery exceeded 5 years. Within an average period of 8.6 years from trauma to surgery 14 of 50 patients developed carpal OA; however, only 8 of 35 patients without OA at time of surgery developed early degenerative changes within the following 12.1 years.
ⱕ.001 ⱕ.001 ⱕ.001 .001 .811 .579
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Table 4. Distribution of Patients According to the Subjective and Objective Jiranek, Cooney, and Martini Scores Score
Excellent
Good
Fair
Poor
Subjective Jiranek (n ⫽ 50) Objective Jiranek (n ⫽ 49) Cooney (n ⫽ 49) Martini (n ⫽ 49)
16 29 13 23
10 14 19 21
5 4 14 5
19 2 3 0
NOTE. One patient was excluded from objective scores (Jiranek, Cooney, Martini) because of an acute fracture of the opposite hand.
respectively. The mean Cooney score (range, 0 –100) was 79.6 ⫾ 10.0 and the average Martini score (range, 0 –29) was 23.5 ⫾ 4.4. The distribution of different scores is shown in Table 4.
Radiologic Assessment of the Scaphoid According to the postoperative x-rays of the 50 patients 47 screws were placed correctly. For 1 patient no postoperative x-ray was available. The Herbert screw was too short in 1 wrist and too long (or even penetrating the adjacent joint) in 2 wrists. Those 2 patients had subsequent removal of the screw. Reconstruction of the scaphoid was classified as correct in 44 of 50 patients based on postoperative x-rays. Malrotation of the scaphoid was found in 1 patient and malalignment (with step) between both fragments was seen in 2 patients. A further 3 scaphoids appeared to be fused in a humpback deformity. Compared with normal distribution the humpback deformity was associated with decreased Youm carpal height ratio (0.521) and an increased SLA (68°). On follow-up x-ray scaphoid nonunion fused in 42 of the 50 patients in this study. Definite radiologic signs of persistent pseudarthrosis were observed in 6 patients. A further 2 patients showed possible signs of nonunion. In 2 patients displacement of the Herbert screw occurred because of persistent nonunion. In 4 patients with possible or definite nonunion, however, no radiolucent line around the Herbert screw was noted. The grade of OA persisted in 3 of the 4 patients and progressed in 1 patient from grade 1 to grade 3. At follow-up evaluation 46 scaphoid proximal poles had a normal appearance, 2 had possible avascularity (Schernberg classification II/III), and a further 2 had definite avascularity (sclerosis, fragmentation) (Schernberg classification II/III). Nonunion persisted in 3 of those 4 patients with possible or definite necrosis of the proximal pole.
Radiologic Assessment of the Carpus For all patients the SLA and radiolunate angle decreased significantly from 55° ⫾ 13° to 51° ⫾ 11° (p
⫽ .035) and from 11° ⫾ 10 to 8° ⫾ 9 (p ⫽ .047), respectively. Dorsal intercalated segment instability deformity was found in 6 patients before surgery and in 1 patient at follow-up evaluation. The Youm carpal height ratio was not influenced by surgery (normal, 0.54 ⫾ 0.03; before surgery, 0.54 ⫾ 0.04; at follow-up evaluation, 0.54 ⫾ 0.04; p ⫽ .20).
Further Surgery and Complications Eight patients in this analysis had possible or definite nonunion at follow-up evaluation. In none of these 8 patients was a second surgical attempt performed to achieve union. Five patients had a secondary surgery other than scaphoid reconstruction: removal of a malpositioned Herbert screw (2 patients), arthroscopic resection of loose bodies (2 patients), and denervation (1 patient).
Discussion Although there are many inherent limitations to such a retrospective analysis, we have used it to report long-term results after bone graft and Herbert screw fixation for scaphoid nonunion. According to our analysis this procedure can prevent the occurrence of OA in most patients (27 of 35) who had no degenerative changes at the time of surgery. None of those patients developed midcarpal (lunocapitate) OA. In 8 of 14 patients with early preoperative changes, the arthritic progression seemed to persist. Early forms of radiocarpal OA, especially at the radial styloid– scaphoid and radial scaphoid joints, were typical findings in patients who had arthritic progress. Of all patients analyzed, only 12% (6 of 50) had moderate or severe forms of degeneration with 6% (3 of 50) including the midcarpal joint. Thirty percent of our patients already showed minor degenerative changes before surgery, a result that in part was caused by the high number of patients with a long interval between fracture and surgery. In the Matti-Russe procedure 10 to 12 years after surgery, carpal osteoarthrosis has been reported to develop in 41% to 69% of patients.10 –13 Osteoarthri-
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tis between the scaphoid and radial styloid process was described in 58% to 100% and severe forms with midcarpal involvement were found in 26% of patients.10 –12 According to Martini and Otto12 radiocarpal OA exists in 28% of all patients without preoperative degeneration 12.1 years after the MattiRusse procedure. More than 10 years after Herbert screw fixation we found an OA rate of 11% (4 of 35) at the radial styloid–scaphoid joint and 14% (5 of 35) at the radiocarpal joint for patients without evidence of OA before surgery (Table 2). According to these data Herbert screw fixation shows superior results in terms of OA compared with the Matti-Russe procedure. As shown by Jiranek et al,11 carpal reconstruction by the Matti-Russe procedure is limited. In 62% of the patients from the study byJiranek et al11 carpal collapse was present at follow-up evaluation and was associated with progression of OA. According to Hooning van Duyvenbode et al13 a DISI deformity after the Matti-Russe procedure can be seen in 32% of patients. For humpback deformity of the scaphoid Amadio et al27 found an increase in the progression of OA when compared with normal scaphoid anatomy. After an average follow-up period of 45 months 54% of their patients with malunion had OA of the wrist but only 22% had a correct scaphoid union. As a result corrective osteotomy for scaphoid malunion has been proposed.17 In the case of scaphoid angulation and shortening, consistent with an increased SLA after Herbert screw fixation, the clinical results also were found to be inferior.28,29 Therefore the question arises as to whether bone graft with Herbert screw fixation is a reliable procedure for preventing scaphoid malunion and the associated progression of carpal OA. Several researchers have pointed out the predictable reconstruction of scaphoid angulation and carpal alignment by bone graft and Herbert screw. According to Inoue et al30 only 26 of 144 patients and 10 of 105 patients in a study by Preisser et al31 showed a persistent DISI deformity after surgery. Carpal alignment was achieved in 32 of 38 cases with DISI deformity in a study by Nakamura et al.28 In our analysis, 5 of 6 preoperative DISI deformities were corrected. The SLA and carpal height ratio were corrected, respectively, from 65° and 0.51 before surgery to 54° and 0.54 after surgery, as reported by Cooney et al.32 A decrease in the SLA was described by Richards and Regan33 (from 73° to 61°) and by Tsuyuguchi et al29 (from 65° to 55°) and also was seen in our study (from 55° to 51°). The reliable
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stabilization of a correctly reconstructed scaphoid by insertion of an adequate bone graft can be considered the chief advantage of the Herbert screw fixation in scaphoid nonunion. According to our data incorrect scaphoid reconstruction, failure to achieve union, or occurrence of necrosis of the proximal fragment resulted in a nearly 6-fold increased risk for OA. The alignment of the carpus by Herbert screw fixation must be considered the main reason for the decreased rate of OA compared with untreated nonunion or even after the Matti-Russe procedure. Other factors, however, such as the duration of postoperative immobilization also are prognostic factors for the progression of OA.34,35 Successful alignment of the carpus and short immobilization of the wrist are in conformity with the low rate of severe OA after 10 years in our study. One third of patients without preoperative carpal OA, however, have at least slow arthritic progression despite surgery. Progression was related mostly to failed anatomic reconstruction of the scaphoid or initial concomitant injury. In contrast to Callanan et al36 and in agreement with Preisser et al,31 Nicholl and Buckland-Wright,37 and Kehoe et al38 we found a high percentage of OA at the STT joint. In all of these patients the elevator was used to pry open the STT joint to gain access for the jig, which could explain the comparably high number of arthroses.37 On the other hand, mild STT arthrosis might have been present because of the process of aging, an effect we were not able to exclude in our study. Most patients, however, were young (mean age, 40.2 ⫾ 8.6 y; range, 27.9 – 65.3 y) and patients with STT OA were of the same age as the remaining patients. Our long-term results (145 mo), in conformity with other studies28 –33,39 – 43 with short or intermediate follow-up periods (14 – 48 mo), indicate that healing of scaphoid nonunion by Herbert screw fixation leads to good and excellent subjective and clinical results in most patients. Concerning postoperative pain the vast majority of patients in our study (86%) (43 of 50) and in others (80%–92%)31,43 had excellent or good results after Herbert screw reconstruction. A high average subjective Jiranek score confirms our good subjective result, although a reasonable number of patients were rated with poor outcomes in the last score. Healing of scaphoid nonunion by Herbert screw fixation is achieved at the cost of wrist motion (flexion/extension), which was decreased to 76% to 86% that of the opposite wrist.31,33,40 Similar to ROM the grip strength of the injured wrist cannot be restored totally by this pro-
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cedure, remaining at 75% to 97% that of the ipsilateral hand.28,32,33,40 We also observed a significant decrease of flexion (to 88%) and radial deviation (to 91%) similar to decreased grip strength (to 94%) compared with the opposite hand. Compared with preoperative values the ROM remained unchanged after surgery, except for radial deviation. The Cooney score was rated as excellent or good in 67% by Inoue et al,30 in 58% by Nakamura et al,28 and in 67% (32 of 49) in our study with a high average level of 79.7 points. Most of the nonunions healed after bone graft in combination with Herbert screw fixation in our study (84%; 42 of 50). Again the union rate was comparable with that of Inoue et al30 (90%), Preisser et al31 (89%), Cooney et al32 (71%), Shah and Jones43 (80%), Rajagopalan et al42 (86%), Daly et al40 (95%), Richards and Regan33 (90%), and Nakamura et al28 (94%). Most patients with persistent nonunion but a firmly affixed and stabilizing Herbert screw had a low pain level and good function, resulting in high score levels. This was in contrast to patients who presented with a radiolucent line around the Herbert screw and who had poor clinical results. Different devices presently used for fixation and use of vascularized bone transplants in cases of avascularity of the proximal pole could increase the union rate.2,4,44 Reconstruction of the scaphoid by screw fixation, however, is a technically demanding procedure with multiple pitfalls.34,45 We also experienced a considerable number of complications and failures in our study (ie, incorrect screw length, improper reconstruction of the scaphoid); this mainly was because we assessed all consecutive patients from the time of the introduction of this procedure in the late 1980s. Furthermore ours is a teaching hospital and we included the learning curve of this procedure in our cohort. With sufficient experience we expect the complication rate to be notably lower and the outcome better. The authors thank Leonard Bodell PhD, MD, for his critical review and helpful suggestions and Sven Schneider DPhil, MA, for statistical support.
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