Replacement of the proximal portion of the scaphoid with spherical implant for post-traumatic carporadial arthritis

Replacement of The Proximal Portion of The Scaphoid with S pherical Implant for Post-Traumatic Ca rporadial Arthritis KENNETH G. JONES From Little Rock, Arkansas, U.S.A. Nineteen spherical prosthetic replacements have been performed in eighteen non service patients for osteonecrosis of the proximal scaphoid-with carporadial arthritis. One period of observation postoperative was for seven weeks only. Two procedures failed in the same patient. The patient with Preiser’s disease is too recent to permit definitive conclusions on follow-up. Each of the other fifteen patients followed for an acceptable period are considered to have a good or satisfactory result. Surgeons who attend patients with painful wrists, even though they routinely and diligently exercise those methods advocated by Stewart (1954), Russe (1951), and Linscheid (1972), as applicable to their problems, will still find it necessary to manage an occasional patient with post-traumatic carporadial arthritis, a complication of a nonunion or a malunion of the scaphoid, advanced carpal instability or Preiser’s osteonecrosis. Few of these patients will come from the most will come from own practice; surgeon’s “elsewhere”. In some instances, prior management may have been adequate though unsuccessful. Many patients will have never presented their “chronically sprained wrist” to any physician for treatment. In 1955, Smith (1956), when advocating styloidectomy of the radius alone as an acceptable method of management for this problem, when seen as a complication of a scaphoid fracture, found that the ‘‘highly recommended” been following had earlier:“excision of one or both fragments, excision of the proximal carpal row, prolonged immobilization, internal screw fixation, insertion of a prosthesis, drilling of fragments, intercarpal arthrodesis or radiocarpal arthrodesis, bone-grafting, and bone-grafting with styloidectomy of the radius.” They also observed “ . . . all are found wanting in some degree by various other authors”. That may be so, since, at this stage, the normal anatomy has been irretrievably lost. To hope for restoration of totally normal function would seem to be more idealistic than realistic. We are obligated, therefore, to continue to search for means to restore maximum function for these cases. Surgical procedures that sacrifice the least amount of normal anatomy while retaining structural integrity through substitution of non-viable implants for destroyed segments have usually provided the most satisfactory approach to that goal. Allografting, as a routine procedure, has yet to be established. Received Kenneth

VOL.

for publication February 1984. G. Jones, Orthopaedic Clinic, 9500 Lile Drive,

10-B No.

2 JUNE

1985

Little Rock 72215, Arkansas

U.S.A.

The spherical vitallium implant designed by Fett (Metcalfe, 1954) and as used by Legge (1951) and those physicians participating in a study by the Scientific and Research Committee of the Pennysylvania Orthopedic Society (1962), the contoured vitallium spacer of Waugh and Reuling (1945), the acrylic prosthesis considered by Agner (1963) and the resilient contoured silastic prosthesis described by Swanson (1968) were presented as replacements for the entire scaphoid. In most instances, this will require a sacrifice of some normal bone and some normal joints. Because the writer considers that requirement as undesirable and unnecessary, he has further expanded the concept on which the techniques of management reported earlier are based by insisting “that all, or almost all, relatively normal bone and articulations be retained”. Only osteonecrotic unsalvageable bone requires removal. The spacer to be used to fill the created void should be designed and constructed so that the recipient cavity can be shaped by the surgeon with ease to secure proper can be readily congruity. This requirement accomplished by contouring the surfaces forming the cavity to accept a spherical implant. The series under consideration was developed on this basis. The conditions responsible for the carporadial arthritis in these patients are: nonunion of the scaphoid, twelve; post-traumatic carpal instability, five; and Preiser’s osteonecrosis, one. Fourteen males and four females make up the group of patients under study. Ages ranged between twenty-one years and seventy-three years, with the average being 39.3 years at the time of surgery. The mean age was thirty-five years. Prior to the surgery, the shortest history, belonging to the patient who presented with cystic changes and collapse of the proximal portion of the scaphoid, was three months. All other histories were two years or longer with an extreme of thirty-four years. The average duration of symptoms was 8.5 years. The left hand was affected twelve times, the right six. The dominant hand was affected in only five patients. Pain aggravated by motion and by loading, limited motion, 217

KENNETH G. JONES

Fig. 1

Line of incision.

Fig. 2

swelling, and reduced capacity complaints common to all.

for

Preparation of space for spherical implant.

work

were

Seven of the eighteen patients had worn a plaster mould or moulds applied by their surgeon. Three of them had undergone surgery earlier. One had had a bone graft of the scaphoid; one underwent dual screw fixation of the scaphoid; and the third received a carpal tunnel release. Eleven patients had never been attended earlier for this problem by any physician. The one patient with minimal arthritic changes, whose symptoms began with an injury two years earlier, demonstrated nonunion of the scaphoid with avascular necrosis of its proximal segment notwithstanding an earlier bone graft. He refused a second bone graft procedure. The patient who had undergone an open reduction and screw fixation of the scaphoid presented himself with a gross nonunion and aseptic necrosis of the proximal fragment.

Fig. 3

Prepared space.

The lesion in seven patients was exposed through a volar incision placed radial to the flexor carpi radialis tendon as is often used for a Russe bone graft procedure. While this approach is adequate, a straight dorsal incision between the tendons of the extensor carpi radialis longus and brevis muscles and ulnarward to the ulnar border of the tendon of the extensor pollicis longus muscle where it passes beyond the radius provides a better exposure for the procedure (Figure 1). The volar approach was chosen initially for these patients because it permitted visualization of the pathology before abandoning a bone graft to the scaphoid. Since now it is fully appreciated that the process being considered is too advanced to be treated effectively by that means, the dorsal approach is preferred.

Lateral

Distal Scaphoid

Fig. 6 Fig. 5 Routine closure of capsule.

218

Fig. 4a & b Spherical implant in place.

Capsule closure augmented by strip of Extensor carpi radialis brevis. THE JOURNAL OF HAND SURGERY

REPLACEMENT OF THE PROXIMAL PORTION OF THE SCAPHOID

All serviceable capsule is retained for closure. Hypertrophic and necrotic fragments of the scaphoid are removed along with the reactive synovium. Any exostosis arising from the radial styloid process is usually removed. The proximal end of the retained distal scaphoid is shaped with a high-speed burr to present a shallow concavity (Figure 2). The same instrument is used to convert the radial proximal corner of the capitate to a very shallow concavity if it protrudes into the hemispherical void. The scaphoid surfaces of the lunate and distal radius are left contoured as encountered (Figure 3). A spherical silicone rubber prosthesis (neither vitallium nor pyrolitic carbon are currently available. See note page 222) is selected, introduced into the cavity and checked for size and position by x-ray. The proper sphere is considered to be one which has a diameter sufficiently small that the surface it presents to the radial fossa, as seen in the posteroanterior plane (Figure 4a), will not extend beyond the normal sweep of the proximal carpal row. As seen on a lateral projection (Figure 4b), a sphere of that diameter will not fill the cup of the distal radius. Experience with the one failure in the series, the patient who suffered a fracture-dislocation of his first prosthesis (18 mm.) and dislocation of a second prosthesis (20 mm.), suggests, since all the other spheres implanted were 11 mm. to 14 mm. in diameter and none fractured or dislocated, that a small prosthesis would be preferable to one that is too large. However, a longstanding dorsal tilt of the distal articular surface of the radius, early resumption of activities, and a stressful occupation were additional factors contributing to those failures. If the size of the prosthesis and its bed are properly mated, volar flexion of the wrist of at least 30” prior to wound closure should be possible without allowing dorsal dislocation of the implant. Routinely, the capsule is imbricated and sutured with the wrist in 10-15” of dorsal flexion (Figure 5). If the repaired capsule is considered to be deficient on closure, it can be augmented by a 10 cm. strip of tendon turned down from the radial half of the extensor carpi radialis brevis. The developed strip of tendon, which is left attached to the base of the second and third metacarpals, is passed across the capsule, through a transverse canal in the dorsal surface of the radius and then once again across the wrist joint to be sutured to the capsule and to itself (Figure 6). The ulnar half of the extensor carpi radialis longus could be selected for capsule reinforcement if the surgeon prefers. Augmentation has been used in only five of the eighteen patients. Immobilization is continued four to six weeks postoperatively. Instructions are then given to the patient in home exercise. The post-traumatic carporadial arthritis, common to all patients in this series, was precipitated by three separate VOL. 10-B No. 2 JUNE 1985

pathological processes. Circumstances singular to each of the pathological entities warrant consideration of the patients under those categories.

Scaphoid Fractures Complicated by Non-union: Twelve Cases. Subsequent to 1967, the osteonecrotic proximal segment of the scaphoid has been removed from twelve patients with a fractured scaphoid followed by contouring of the void to mate with a spherical implant. A localized joint debridement has been performed in each instance. Also, when indicated, an exostectomy of the radial styloid process, in contradistinction to a styloidectomy of the radius, has been done. Two vitallium prostheses were used. Figures 7 and 8 depict a patient who has now worked twelve years as a labourer. Eleven silastic spheres were used in these cases. The one failure in the series received two silastic implants.

Though this group is small, it is comparable to others dealing with carporadial arthritis as a complication of a fracture of the scaphoid. Results as disclosed through the follow-up study are most encouraging. The advantages of this approach to the problem, considered by the author as established, are:

1. Surgical violation of tissues is limited; the procedure is simple. 2. Mating of the prosthesis to the space should present few technical difficulties even though most surgeons will be infrequently confronted with this problem. 3. The restoration sought closely resembles normal anatomy. 4. In the event of failure, all the salvage procedures remain available to the surgeon. In addition, should removal of the sphere become indicated the palmaris longus tendon can be used, in the manner described by Carroll (1977) for Kienbock’s disease, to fill the scaphoid defect.

In retrospect, one may wonder why the spherical implant was originally designed as a substitute for the entire scaphoid. Following fracture of the scaphoid, only the proximal portion of the bone with its precarious blood supply is subsequently destroyed in most nonunions. When the surgical defect is kept small, contouring can be accomplished with ease. Entrapment of the implant should be more certain. Also, a 12-14 mm. spherical implant offers a smaller foreign surface to be accommodated by the host than one which more anatomically duplicates the scaphoid. 219

KENNETH G.

Fig. 7a & b Patient CB. Preoperative(implant): Failedbonegraft, right scaphoid. Patient refused a scond bone graft, elected implant procedure.

At the time of the surgery under consideration, these twelve patients collectively demonstrated the following: in one instance, the degenerative process was early and limited; in three patients it was moderate in degree; while deterioration of the carporadial articulation was extensive in eight. Avascular necrosis of the proximal segment is regarded to have occurred in each of these patients in the course of their disease. In all twelve, nonunion of the fracture was confirmed at surgery. Osteonecrosis with cystic changes of the proximal segment appeared to have preceded fracture in one patient. A detritus cyst was present in the retained distal scaphoid segment of two patients. These defects were curetted and filled with a cancellous bone graft taken from the radius before insertion of the implant. They subsequently healed without apparent compromise of the results. Four fracture cases which demonstrated advanced arthritic changes had an exostectomy (4-8 mm.) to remove hyperostotic bone arising from the radial styloid process (Figures 9 and 10) which could impinge against the retained distal scaphoid fragment on full radial deviation. The radial styloid process was never sacrificed. To do so might create an escape corridor for the sphere on motion of the wrist. Even so, one implant was positioned in the presence of an earlier limited radial styloidectomy without subsequent dislocation of the prosthesis (Figures 11 and 12). The redundant synovium present in all patients was excised. One of these twelve patients underwent two implant procedures. Both operations failed. implant, placed through a volar approach, (Figures 13 to 16) and dislocated volarward 220

spherical The first fractured six weeks

JONES

Fig. 8

Postoperative (implant, vitallium-12

mm.).

following surgery. The second, placed through a dorsal approach nine months after the first surgery, without capsule reinforcement, subluxated dorsalward. It was removed at the end of four weeks. Patient management was salvaged by implantation of a coiled palmaris longus tendon. Four years later this patient continues to be employed as a machinist. Wrist function is considered to be good although ulnar translocation is evident. The first patient of the group, who was fifty-two years of age in 1967, disappeared from follow-up seven weeks after surgery at which time the vitallium prosthesis was stable and the patient relatively pain free, but with no more than ten degrees of motion in all directions. The average follow-up for the ten remaining patients is 168 weeks. Each of the ten demonstrates a stable prosthesis with ranges of motion between 60-90% of their opposite wrist. The patient shown in Figures 17 and 18 demonstrates motion at seven months post surgery. The patient shown in Figures 19 to 21 represents a six and a half year follow-up. In each instance, the restriction of motion shown was evident prior to implant surgery. All are aware that the wrist is not normal. Two have moderate discomfort on extension. Swelling has been absent or minimal subsequent to surgery. The average period for these patients to return to their former work and activities, usually with some limitation, was nine weeks. Grip strength, as evaluated by the Jamar Dynamometer, in five of the twelve demonstrates the abnormal side to average 55% of the normal side. Grip strength of their operated wrist, as judged by all patients, is regarded to be improved following surgery. Overall results are considered, by these ten patients and their surgeon, to be good. THE JOURNAL

OF HAND SURGERY

REPLACEMENT

Fig. 9

Patient LSJ. Preoperative (implant): exostosis of left scaphoid and radius.

OF THE PROXIMAL

Detritus

cysts,

Fig 1la & b Patient JFG. Preoperative (implant): Failed dual screw fixation of right scaphoid and limited styloidectomy of radius. VOL. 10-B No. 2 JUNE 1985

PORTION OF THE SCAPHOID

Fig. lOa& bPostoperative (implant, silastic-ll mm.): Detritus cysts removed or bone grafted, exostectomy of scaphoid and radius.

Fig. lZa& bPostoperative

(implant, silastic-

mm.): Stable,

221

KENNETH

Fig. 13a & bPatient RH. Preoperative (implant): Establishednonunion of right scaphoid with compaction of proximal segment. Note: Dorsal tilt of lower radius.

Fig. 15a & bPostoperative subluxation.

(implant, second, silastic-

mm.): Dorsal

G. JONES

Fig. 14a & bPostoperative (implant, silasticsubluxation and fracture of prosthesis.

mm.):

Fig. 16a & bPostoperative (implant, coiled palmaris longus tendon): Third procedure.

NOTE Recently Howmedica (Mr. George Coursi) has agreed to once again make vitallium spheres available in 10, 12 and 14mm sizes-Silastic lo-15 mm’s are available from Sutter Biomedical. Mastic: Sutter Biomedical, Inc. 3940 Ruffin Road, Suite A San Diego, California 92123. l-800-854-2216. l-619-569-8148. VitaNium: Howmedica, Inc. Orthopaedics Division, 359 Veterans Boulevard, Rutherford, New Jersey 07070. l-201-935-2100. Pyrolite (Pyrolitic Carbon): Intermedics Orthopedics, Inc. 6968 Sierra Court, Dublin, California 94566. l-800-227-2544.

222

Volar

THE JOURNAL

OF HAND

spheres,

SURGERY

REPLACEMENT OF THE PROXIMAL PORTION OF THE SCAPHOID

Fig. 17a& bPatient CF. Preoperative (implant): nonunion of left scaphoid with avascular necrosis of proximal segment.

Fig. 19

Patient MLB. Preoperative (implant): Collapse absorption of the proximal pole of the left scaphoid.

and

Post-traumatic Carporadial Instability: Five Cases Management of these five patients with advanced radiocarpal degenerative changes due to carpal instability has been similar to the fracture patients, but more extensive in three. In two patients, the process was regarded to be symptomatic primarily because of the advanced carporadial arthritis (Figures 22 and 23). At the late date these two patients were seen, the instability which existed early was not regarded to be sufficiently marked to require extended efforts toward stabilization. VOL. 10-B No.

2 JUNE 1985

Fig. 18a & bPostoperative (implant, silasticnormal wrist.

mm.): Compared to

Fig. 20

Postoperative (implant, silastic-

Fig. 21

Postoperative (implant). X-ray after six years.

mm.).

For that reason, the surgical procedure performed was the same as for those scaphoids with a nonunion. In the other three patients, because of the marked residual carpal instability, additional surgery was needed (Watson and Hempton, 1980; Watson, 1980). In one patient, in addition to placement of the implant and a radial exostectomy, a distal fragment scaphocapitate fusion, and a lunocapitate fusion were performed. Both areas of fusion were stabilized with K-wires and a bone graft from the radius (Figures 24 and 25). A second case 223

KENNETH G. JONES

Fig. 22a & bPatient WW. Preoperative advanced collapse.

(implant): Left scapholunate

Fig. 23a &

bPostoperative (implant, silastic-14mm.): Exostectomy of radius but no additional surgery for stabilization.

with carpal instability and marked volar displacement of the lunate, presented with a severe carpal tunnel syndrome that required release. Under the same anaesthetic through a second incision placed on the dorsum of the wrist, the lunate was rolled up and stabilized with two K-wires to obtain a lunocapitate fusion. Then the proximal segment of the scaphoid was resected and used as a bone graft across the area of fusion. An 11 mm. silastic sphere was placed in the defect. Capsule closure was supplemented by a 10cm. strip of tendon derived from the radial half of the extensor carpi radialis brevis. The fifth patient in this

group demonstrated a totally unstable proximal carpal row which required stabilization in addition to resection of the carporadial arthritis (Figures 26 and 27). The scaphoid was rolled down and its distal half fused to the capitate. A mini screw and a bone graft from the radius provided initial stability. The lunotriquetral unit was rolled up and stabilized to the distal carpal bones with mini screws and a bone graft between the triquetrum and the hamate and the lunate and the capitate. The proximal half of the scaphoid was then resected and replaced with a 12 mm. silastic sphere. Closure was routine.

Fig. 24a & bPatient AMD. Preoperative (implant): Right scapholunate advanced collapse.

Fig. 25

224

Postoperative (implant, siiastic-12 mm.): Exostectomy of scaphoid, arthrodesis of distal scaphoid to capitate and lunate to capitate (not solidly united but apparently stable). THE JOURNAL OF HAND SURGERY

REPLACEMENT

OF THE PROXIMAL

PORTION OF THE SCAPHOID

Fig. 26a & bPatient JM. Preoperative (implant): Left wrist instability of entire proximal carpal row with absorption of proximal half of scaphoid.

Fig. 27a & bPostoperative (implant, silastic-12mm.): In addition, stabilization of proximal carpal now with mini screws and bone graft from radius.

The two patients with carpal instability who did not require added surgery were followed 214 and 64 weeks. The first returned to work nine weeks postoperatively as a baker, an occupation he had been forced to forego prior to surgery and continued employed for four years until his demise from metastatic prostatic carcinoma (Figures 28 and 29). The second requested he be permitted to return to work eleven weeks following surgery. He has continued to be employed as a labourer without pain, swelling or complaints, for over twenty months. Motion is judged to be 25’70 of a normal range. Strength is estimated at two-thirds of normal. The third patient, whose added surgery consisted of a distal scaphocapitate and a lunocapitate fusion, returned to work fourteen weeks following surgery as an insect exterminator. He has continued to be employed during

forty-two weeks. He does experience some discomfort on stress. The patient who underwent a carpal tunnel release and a lunocapitate fusion was a seventy-three year old nursing home resident at the time of surgery. She has had an excellent result from the carpal tunnel release and a satisfactory result from her carpal surgery even though some absorption of the lunate has occurred with loss of carpal height. Her residual discomfort is primarily, if not totally, in the distal radioulnar joint as demonstrated by injection of that articulation with a local anaesthetic. Resection of the distal ulna in the future may provide additional improvement. The last patient of this group with the triple fusion returned to limited work as a sheet metal worker at fourteen weeks. Though motion is good and strength fair, follow-up is short.

Fig. 28a & bPatient FR. Preoperative implant: Left wrist scapholunate advanced collapse. VOL. 10-B No.

2 JUNE 1985

Fig. 29

Postoperative (implant, surgery for stabilization.

silastic-

mm.): No added

225

KENNETH G. JONES

disease left

Fig. 31a & bPostoperative (implant, silasticmm.): Drilling of retained distal half of bone. At four months collapse has not occurred.

Osteonecrosis of Scaphoid (Preiser’s Disease): One Case If one believes this process to be a consequence of trauma, then management of the carporadial arthritis seen in one patient with that diagnosis may be included in this study.

The superiority of silicone rubber, vitallium or pyrolitic carbon as a material out of which to construct a spherical carpal implant is yet to be determined.

Fig. 30a& bpatient SM. Preoperative (implant): Preiser’s scaphoid with collapse of proximal half.

References A housewife had had symptoms for two years when first seen (Figures 30 and 31). The collapsed proximal segment of the avascular scaphoid was subsequently resected and replaced with a 12 mm. silastic sphere after the retained distal avascular segment had been drilled several times. Closure was without augmentation. The wrist was immobilized for three weeks. The patient had suffered severe pain and loss of motion before surgery. Four months after surgery, she experiences only slight pain on motion and demonstrates 30” of dorsal flexion, 20” of volar flexion and 10” of both radial and ulnar deviation. It is hoped that the retained distal fragment of the scaphoid is becoming revascularized. Conclusion The clinical evidence suggests that prosthetic replacement of only the osteonecrotic collapsed portion of the scaphoid (usually the proximal half) should produce results superior to sacrifice and replacement of the entire bone for traumatic carporadial arthritis. Further evaluation of that concept is indicated. Since a spherical implant, when properly fitted, can be constrained in the wrist and has the added advantage of within its fibro-osseous being omnirotational confinement, it is thought to constitute the most ideal shape. 226

AGNER, 0. (1963). Treatment of Non-united Navicular Fractures by Total Excision of the Bone and the Insertion of Acrylic Prostheses. Acta Orthopaedica Scandinavica, 33: 235-245. CARROLL, R. E. (1977). Fascial Arthroplasty in the Treatment of Kienbiick’s Disease. Orthopaedic Transactions, 1:36. LEGGE, R. F. (1951). Vitallium Prosthesis in the Treatment of Fracture of the Caroal Navicular. Western Journal of Sureerv. 59: 468-471. LINSCHEID, R. L., DOBYNS, J. H., BEABOUT; J: iy. and BRYAN, R. S. (1972). Traumatic Instability of the Wrist. Diagnosis, Classification and Pathomechanics. The Journal of Bone and Joint Surgery, 54: 1612-1632. METCALFE, J. W. (1954). The Vitallium Sphere Prosthesis for Nonunion of the Navicular Bone. The Journal of the International College of Surgeons, 22: 459-462. PENNSYLVANIA ORTHOPEDIC SOCIETY (1962). Evaluation of Treatment for Non-union of the Carpal Navicular, A Report Made by the Scientific Research Committee of the Pennysylvania Orthopedic Society. The Journal of Bone and Joint Surgery, 44A: 169-174. RUSSE, 0. (1951). Behandlungsergebnisse der Spongiosaauffiillung bei Kahnbeinpseudarthrosen. Zeitschrift fur Orthopiidie Und Ihre Grenzgebiete, 81: 466-473. SMITH, L and FRIEDMAN, B. (1956). Treatment of Ununited Fracture of the Carpal Navicular by Styloidectomy of the Radius. The Journal of Bone and Joint Surgery, 38A: 368-376. STEWART, M. J. (1954). Fractures of the Carpal Navicular (Scaphoid): A Report of 436 Cases. The Journal of Bone and Joint Surgery, 36A: 9981006. SWANSON, A. B. (1968): Silicone Rubber Implants for Replacement of Arthritic or Destroyed Joints in the Hand. The Surgical Clinics of North America, 48: 1113-1127. WATSON, H. K. and HEMPTON, R. F. (1980): Limited wrist arthrodeses 1. The triscaphoid joint. The Journal of Hand Surgery, 5: 320-327. WATSON, H. K. (1980). Limited Wrist Arthrodesis. Clinical Orthopaedics and Related Research, 149: 126-136. WAUGH, R. L. and REULING, L. (1945). Ununited Fractures of the Carpal Scaphoid. Preliminary Report On The Use Of Vitallium Replicas As Replacements After Excision. The American Journal of Surgery, 67: 184-200. THE JOURNAL OF HAND SURGERY