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Treatment of nonunited scaphoid fractures by pulsed electromagnetic field and cast
The Journal of HAND SURGERY
Wei et ai.
metacarpophalangeal joint and reconstruction in great toe-to-hand free tissue transfers. J HAND SURG [Am] 9:645-9 , 1984 13. Lister GO, Kalismen M, Tsai TM: Reconstruction of the
hand with free microneurovascular toe-to-hand transfer: experience with 54 toe transfers. Plast Reconstr Surg 71 :372-84, 1983
Treatment of nonunited scaphoid fractures by pulsed electromagnetic field and cast Thirty-five of 44 nonunited scaphoid fractures that were at least 6 months old healed in a mean time of 4.3 months during pulsed electromagnetic field (PEMF) treatment using external coils and a thumb spica cast. The mean time from the onset of the fracture to treatment was 40 months. No concurrent operation was performed. Follow-up time averaged 8.4 months. Eight of nine fractures with avascular necrosis healed. Five of eight fractures in the proximal third healed. Twelve (75%) of 16 patients treated in short-arm thumb spica casts and PEMF healed versus 22 (92%) of 24 patients treated initially in long-arm thumb spica casts and PEMF. We have found PEMF to be a reliable alternative method of treating nonunited scaphoid fractures. Because of the low risk, simplicity of use, and reliability, we recommend its consideration in the treatment of undisplaced, nonunited fractures without carpal instability less than 5 years after the injury. Treatment should initially begin with a long-arm cast. (J HAND SURG llA:344-9, 1986.)
Gary K. Frykman, M.D., Julio Taleisnik, M.D., Gregory Peters, M.D., Richard Kaufman, M.D., Basil Belal, M.B., M.Ch., Virchel E. Wood, M.D., and Robert S. Unsell, M.D., Lorna Linda and Irvine, Calif., Grand Rapids, Mich., Cleveland Heights, Ohio, and London, England
Nonunion of the scaphoid continues to represent a challenge to the surgeon who treats hand injuries . There are many treatment modalities advocated, including benign neglect, 1 casting, I. 2 wrist denervation / bone grafting,4. 5 internal fixation with compression screw, 6. 7 radial styloidectomy, B excision of proximal pole,2, 9. 10 proximal row carpectomy,9. 11 scaphoid replacement arthroplasty, 12wrist arthrodesis, 13 or combined scaphoid replacement arthroplasty and From the Hand Surgery Service , Department of Orthopedic Surgery, Lorna Linda University School of Medicine, Lorna Linda, Calif., University of California, Irvine, Irvine College of Medicine, Irvine, Calif. , and London Hospital, Whitechapel, London, England. Received for publication Nov. 16, 1982; accepted in revised form July 4, 1985. Reprint requests: Gary K . Frykman, M.D., Lorna Linda University School of Medicine, Lorna Linda, CA 92350.
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limited carpal arthrodesis . 14 No one method is suitable for treatment of all nonunited scaphoid fractures; therefore, a variety of methods must be included in the surgeon's armamentarium, IS , 16 Better results are achieved if union can be obtained before the development of carpal collapse and posttraumatic arthrosis.' 6 Although the mechanisms of action on tissues are not fully understood, 17 electrical treatment of nonunited fractures of long bones has been successful in about 80% of patients. 'B -23 The rate for successful union of tibias has been as high as 87%.24 There are two widely used but different concepts for electrical treatment of nonunions. One concept has a constant, direct 20 microampere current delivered to one or more cathodes, which are implanted directly at the fracture site, from either an "invasive" (the cathode, anode, and battery are implanted through a surgical procedure)2o, 22 or "semi-invasive" system (cathodes
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Fig. 1. This method places inductive electromagnetic coils on opposite sides of the fracture site. These coils supply a 15 Hz pulsed quasirectangular electrical signal.
are drilled percutaneously across the fracture site, and the anode is a pad on the skin surface). 18. 21 The second concept uses a totally noninvasive system that involves placement of two electromagnetic coils outside the cast with an alignment block incorporated into the cast to center the coils over the fracture site l9 , 23 (Figs. 1 and 2). Although an equivalent success rate has been reported for treatment of non united fractures by each of the three methods, a distinct advantage of the pulsed electromagnetic field (PEMF) is that it requires no surgical procedure, it can be performed in the office, and there is no danger of introducing infection. 19,23 The first report of treatment of scaphoid non unions with an electrical field used an AO compression screw and a parallel Kirschner wire inserted into the scaphoid; both were connected to a transformer, which generated an electrical alternating current field. 25 A 79% union rate was reported with this method, and a 60% union rate with the screw-only method. Bora et aJ.26 reported healing of 12 (71%) of 17 using the semi-invasive method on nonunited scaphoid fractures. He stated that avascular necrosis was a contraindication, but that a previous bone grafting procedure was not a contraindication. This article presents a retrospective study designed to evaluate the efficacy of noninvasive PEMF in the treatment of nonunited fractures of the scaphoid.
Materials and methods We reviewed all of the cases of non united scaphoid fractures that we treated with the PEMF system* from 1979 through 1984. Wy examined patients' records and information was obtained by means of a standardized protocol. To be included in this study, the scaphoid *Bi-osteogen, System Electro-biology Inc., Fairfield, N,J,
Fig. 2. The electromagnetic coils are attached by a Velcro
strap over a thumb spica cast and applied to a patient with a scaphoid nonunion. The box transforms 110 volt AC line current to the proper pulsed signal. The patient wears the apparatus 8 to 10 hours a day. fracture had to be nonunited and at least 6 months old, regardless of previous treatment methods, with no surgical procedures having been performed during or just before initiation of PEMF treatment. None of our patients had collapse of the scaphoid or degeneration of the peri scaphoid joints. Three patients showed loss of carpal alignment. This series represents consecutive cases treated by us following a standardized protocol. 27 PEMF coils were centered over the scaphoid (Fig. 2) and attached to either a long-arm thumb spica cast or a short-arm thumb spica cast. There were 50 patients initially treated. Three patients failed to return for follow-up examination after immobilization was stopped and the electrical treatment coils were removed. Although their fractures had healed these patients were excluded from our final study. There were three additional patients who received inadequate treatment of 2 months or less (this did not conform to our protocol), and they were also excluded from the study. All of the remaining 44 patients were followed until their fractures healed, or until this method of treatment failed. There were 41 male and 3 female patients in this group. Their ages ranged from 14 to 46 years,
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Fig. 3. Uncomplicated healing of nonunited scaphoid with PEMF. A, Unhealed proximal third fracture 6 months after injury. B, Eight months after fracture when PEMF began. C, Appearance 3 months after beginning PEMF. D, Eight months later.
with a mean age of 25 years. In 8 patients the fracture was localized to the proximal third of the scaphoid, in 33 patients to the middle third, and in 3 patients to the distal third. Nine patients had had one previous bone graft and two patients had two bone-grafting procedures before PEMF treatment was initiated. Nine patients had x-ray evidence of avascular changes of the proximal fragment. The length of time from injury to PEMF treatment ranged from 6 to 241 months with a mean of 40 months. All of the patients who were included in our final study were examined from 1 to 33 months, with a mean of 8.4 months, after immobilization and electrical treatment was stopped.
Results The fractures healed in 35 (80%) of the 44 patients, as shown in Fig. 3. Five (62.5%) of the eight fractures in the proximal third of the scaphoid healed and 30 (83%) of the 36 fractures in the middle and distal thirds healed with electrical treatment. Fractures of eight (89%) of the nine patients who had avascular necrosis before treatment healed. Eight (73%) of the eleven patients who had undergone previous bone-grafting procedures healed. The mean duration of electrical treatment and casting was 4.3 months, with a range of 2.5 to 9 months. Only four patients had PEMF treatment for longer than 6 months.
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Fig. 4. A, Scaphoid nonunion of 96 months' duration in distal third. B, Synovial pseudarthrosis, proved by arthrograms , after fracture did not heal by PEMF. Synovial pseudarthrosis is a contraindication to PEMF treatment .
In four patients, records failed to indicate whether above-elbow or below-elbow immobilization was used. Of the remaining 40 patients, healing occurred in 12 (75%) of the 16 who were treated in a short-arm thumb spica cast and in 22 (92%) of the 24 patients who were treated initially in a long-arm thumb spica cast. The duration of long-arm cast immobilization ranged from 4 to 20 weeks, with a median of 6 weeks and was followed by below-elbow immobilization for the balance of the PEMF treatment. Of the 35 patients with healed fractures, 33 returned to their pre-injury work, 11 to heavy labor, 13 to moderately strenuous work, and 9 to light work. One patient who performed heavy labor was not able to resume his previous occupation, and in one patient this information was unknown. At follow-up on the patients with healed fractures, wrist t
HEALING OF SCAPHOID FRACTURES WITH PEMF VS. TIME SINCE FRACTURE
... .... .. ..
Healed
.
::
..
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c •• • • =.~~.~-=.-.~~.~~~--~.~ • ~r---.~.~.=.=.-.~-= 1ii 00 0 00 0 0
Not Healed
6
12
4860 24 Time in Months
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192 240
Fig. 5. The effect of pretreatment duration of scaphoid fracture on healing with PEMF.
poor cooperation and removed their own casts more than once during treatment. There were only three failures among the patients who conformed to the criteria for inclusion in this study. The fractures that failed to unite with PEMF had a mean duration of fracture of 81 months (range 6 to 241 months) versus a mean of 27 months for the fractures that healed. Fig. 5 shows that in fractures that were more than 60 months old, only 2 (29%) of 7 healed, but 27 (90%) of 30 of fractures that were less than 60 months old healed. This difference is statistically significant (p < 0.(01). Discussion Although there is some controversy in the literature regarding the need to treat asymptomatic non unions of the scaphoid,4. 16 recent reports indicate that the longer
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Frykman et ai.
the duration of the nonunion, the greater the degenerative changes about the scaphoid. 28 . 29 Mack et al. 28 suggest that "asymptomatic patients with an undisplaced stable nonunion should be advised of the possibility of late degenerative changes." This study of PEMF treatment was designed for this type of patient. We believe that the main problem in objectively evaluating the efficacy of PEMF treatment is the lack of a reliable double-blind study between like series of patients treated with immobilization alone, and those treated with immobilization and PEMF. However, there are too many other variables for such a study to be accurate. Instead, in our opinion, the patients in these studies themselves provided the comparison for the efficacy of PEMF since in many cases, immobilization alone was used unsuccessfully. In our series, with PEMF and casting, healing occurred in an average of 4.3 months. In addition, a meaningful comparison may be made between our patients and a reported series of patients with nonunited scaphoid fractures that were treated with immobilization alone. Stewart2 reported such a series. Ninety scaphoid fractures, which were more than 1 month old, were treated with casting alone; they had a healing rate of 57% and a "probable" healing rate (i.e., lost to follow-up) of 73%. The average length of immobilization was 20 weeks. Some patients were treated with immobilization for as long as 59 weeks. Immobilization of the fracture began an average of 5 months after the injury. Although Stewart's series and our series were not strictly comparable, the union rate of our patients' fractures was considerably greater (80% versus 57%). This becomes significant because of the longer time from injury to treatment in our series, 40 months versus 5 months. Finally, union occurred slightly faster in our series, a mean of 4.3 months versus 4.7 months. Our results with PEMF are comparable to bone grafting where union rates of 50% to 100% have been reported. 4 • 5. 15.30 However, PEMF may not be quite as effective as the Russe bone graft technique; a recent review of the literature reported it to lead to union on an average of 90% of patients. 31 Our results are better than those reported following open reduction and internal fixation with compression screw osteosynthesis; the latter technique has a reported success rate of 17 to 73%.7.15 The above-elbow immobilization clearly seems to enhance the succe~s rate of PEMF treatment. This is confirmed by Beckenbaugh,32 who reported that healing occurred in only 7 of lO patients who were treated in
short-arm casts versus 12 (87%) of 14 of patients treated in long-arm immobilization with the addition of PEMF. Final grip strength in our patients (83% of normal) is comparable to that obtained following direct electrical current treatment (76%)26 or bone grafting (85% )31. The overall mean range of motion of the wrist in our patients was 89% of normal. This was much greater than that reported using the semi invasive method (50% of wrist dorsiflexion and 42% of wrist palmar flexion).26 Thus, preservation of motion with noninvasive techniques seems to provide a distinct advantage over the semiinvasive method. From our experience, PEMF treatment is contraindicated for displaced fractures, for synovial pseudarthrosis,23 in the presence of periscaphoid osteoarthritis, and for wrists that exhibit a loss of normal radiocarpal alignment. Adherence to these contraindications would have eliminated four out of the nine patients in our failure group. Our results also suggest that non united scaphoid fractures that are older than 5 years are much less likely to unite with PEMF. Other techniques are recommended for these fractures. Finally, patient selection is important, because this method requires the patient's cooperation in order to be successful. A newer portable, battery-operated unit is now available* and should allow for easier patient compliance. The advantages of PEMF treatment are evident: no pain, no anesthetic, no surgical risk, and no known complications. The cost of this treatment is less than the combined cost of hospitalization, anesthetic, and surgical fees. The length of treatment is comparable to that following bone grafting procedures. We believe that PEMF treatment should be specifically considered as an alternative method for treatment when previous surgery has failed, for problem fractures in the proximal third of the scaphoid, and whenever surgery is not safe or is rejected by the patient. *EBI Bone Healing System Model 420, EBI Medical Systems, Fairfield, N.J.
REFERENCES 1. London PS: The broken scaphoid bone. The case against pessimism. J Bone Joint Surg [Am] 43:237-44, 1961 2. Stewart MJ: Fractures of the carpal navicular (scaphoid). A report of 436 cases. J Bone Joint Surg [Am] 36:9981006, 1954 3. Buck-Gramcko D: Denervation of the wrist. J HAND SURG 2:54-61, 1977
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4. Russo 0: Fracture of the carpal navicular. Diagnosis, non-operative treatment, and operative treatment. J Bone Joint Surg [Am] 42:759-68, 1960 5. Herness D, Posner MA: Some aspects of bone grafting for nonunion of the carpal navicular. Acta Orthop Scand 48:373-8, 1977 6. Maudsley RH, Chen SC: Screw fixation in the management of the fractured carpal scaphoid. J Bone Joint Surg [Br] 54:432-41, 1972 7. Herbert TJ, Fisher WE: Management of the fractured scaphoid using a new bone screw. J Bone Joint Surg [Br] 66: 114-23, 1984 8. Mazet R, Hohl M: Fractures of the carpal navicular. J Bone Joint Surg [Am] 45:82-112, 1963 9. Taleisnik J: Fractures of the carpal bones. In Green DP, editor: Operative hand surgery, New York, 1982, Churchill Livingstone, pp 669-702 10. Zemel NP, Stark HH, Ashworth CR, Rickard TA, Anderson DR: Treatment of selected patients with an ununited fracture of the proximal part of the scaphoid by excision of the fragment and insertion of a carved silicone - rubber spacer. J Bone Joint Surg [Am] 66:510-7,1984 11. Inglis AE, Jones EC: Proximal-row carpectomy for diseases of the proximal row. J Bone Joint Surg [Am] 59:460-3, 1977 12. Swanson AB: Silicone rubber implants for the 'replacement of the carpal scaphoid and lunate bones. Orthop Clin North Am 1:299, 1970 13. Gordon LH, King D: Partial wrist arthrodesis for old ununited fractures of the carpal navicular. Am J Surg 102:460-4, 1961 14. Watson HK, Goodman ML, Johnson TR: Limited wrist arthrodesis. Part II: Intercarpal and radiocarpal combinations. J HAND SURG 6:223-33, 1981 15. Cooney WP, Dobyns JH, Linscheid RL: Nonunion of the scaphoid: Analysis of the results from bone grafting. J HAND SURG 5:343-53, 1980 16. Kleinert JM, Zenni EJ: Nonunion of the scaphoid. Review of the literature and current treatment. Orthopaedic Review 13: 125-40, 1984 17. Black J: Tissue response to exogenous electromagnetic signals. Orthop Clin North Am 15: 15-31, 1984 18. Brighton CT, Black J, Friedenberg ZB, Esterhai JL, Day LJ, Connolly JF: A multicenter study of the treatment of non-union with constant direct current. J Bone Joint Surg [Am] 63:2-13, 1981
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19. Bassett CAL, Mitchell SN, Gaston SR: Pulsing electro" magnetic field treatment in ununited fractures and failed arthrodeses. JAMA 247:623-8, 1982 20. Paterson D, Lewis GN, Cass CA: Clinical experience in Australia with an implanted bone growth stimulator (1976-1978). Orthop Trans 3:288, 1979 21. Brighton CT: The semi-invasive method of treating nonunion with direct current. Orthop Clin North Am 15:3345, 1984 22. Paterson D: Treatment of nonunion with a constant direct current: A totally implantable system. Orthop Clin North Am 15:47-59, 1984 23. Bassett CAL: The development and application of pulsed electromagnetic fields (PEMFs) for ununited fractures and arthrodeses. Orthop Clin North Am 15:61-87, 1984 24. Bassett CAL, Mitchell SN, Gaston SR: Treatment of ununited tibial fractures with pulsing electromagnetic fields. J Bone Joint Surg [Am] 63:511-23,1981 25. Wilhelm K: Die ergebnisse der behandlund der naviculare-pseudarthrose mit magnetischen und elektrischen potentaIien. Medizinische Orthopadische Technik 2:67-70, 1978 26. Bora FW, Osterman AL, Woodbury DF, Brighton CT: Treatment of nonunion of the scaphoid by direct current. Orthop Clin North Am 15:107-12, 1984 27. Electro-Biology, Inc., Fairfield, N.J.: Procedure manual for the prescribing, application, and management of the EBI Bi-Osteogen System 204, May, 1979. 28. Mack GR, Bosse MJ, Gelberrnan RH, Yu E: The natural history of scaphoid nonunions. J Bone Joint Surg [Am] 66:504-9, 1984 29. Ruby LK, Stinson J, Belsky MR: The natural history of scaphoid nonunion. A review of fifty-five cases. J Bone Joint Surg [Am] 67:428-32, 1985 30. Schneider LH, Aulicino P: Nonunion of the carpal scaphoid: The Russe procedure. J Trauma 22:315-9, 1982 31. Rasmussen P, Schwab JP, Johnson PR: Symptomatic scaphoid nonunions treated by Russe bone grafting. Orthopaedic Review 14:41-7, 1985 32. Beckenbaugh RD: Noninvasive pulsed electromagnetic stimulation in the treatment of scaphoid nonunions. Presented at the American Society for Surgery of the Hand Annual Meeting, Las Vegas, Nev. Jan. 21,1985
Wei et ai.
metacarpophalangeal joint and reconstruction in great toe-to-hand free tissue transfers. J HAND SURG [Am] 9:645-9 , 1984 13. Lister GO, Kalismen M, Tsai TM: Reconstruction of the
hand with free microneurovascular toe-to-hand transfer: experience with 54 toe transfers. Plast Reconstr Surg 71 :372-84, 1983
Treatment of nonunited scaphoid fractures by pulsed electromagnetic field and cast Thirty-five of 44 nonunited scaphoid fractures that were at least 6 months old healed in a mean time of 4.3 months during pulsed electromagnetic field (PEMF) treatment using external coils and a thumb spica cast. The mean time from the onset of the fracture to treatment was 40 months. No concurrent operation was performed. Follow-up time averaged 8.4 months. Eight of nine fractures with avascular necrosis healed. Five of eight fractures in the proximal third healed. Twelve (75%) of 16 patients treated in short-arm thumb spica casts and PEMF healed versus 22 (92%) of 24 patients treated initially in long-arm thumb spica casts and PEMF. We have found PEMF to be a reliable alternative method of treating nonunited scaphoid fractures. Because of the low risk, simplicity of use, and reliability, we recommend its consideration in the treatment of undisplaced, nonunited fractures without carpal instability less than 5 years after the injury. Treatment should initially begin with a long-arm cast. (J HAND SURG llA:344-9, 1986.)
Gary K. Frykman, M.D., Julio Taleisnik, M.D., Gregory Peters, M.D., Richard Kaufman, M.D., Basil Belal, M.B., M.Ch., Virchel E. Wood, M.D., and Robert S. Unsell, M.D., Lorna Linda and Irvine, Calif., Grand Rapids, Mich., Cleveland Heights, Ohio, and London, England
Nonunion of the scaphoid continues to represent a challenge to the surgeon who treats hand injuries . There are many treatment modalities advocated, including benign neglect, 1 casting, I. 2 wrist denervation / bone grafting,4. 5 internal fixation with compression screw, 6. 7 radial styloidectomy, B excision of proximal pole,2, 9. 10 proximal row carpectomy,9. 11 scaphoid replacement arthroplasty, 12wrist arthrodesis, 13 or combined scaphoid replacement arthroplasty and From the Hand Surgery Service , Department of Orthopedic Surgery, Lorna Linda University School of Medicine, Lorna Linda, Calif., University of California, Irvine, Irvine College of Medicine, Irvine, Calif. , and London Hospital, Whitechapel, London, England. Received for publication Nov. 16, 1982; accepted in revised form July 4, 1985. Reprint requests: Gary K . Frykman, M.D., Lorna Linda University School of Medicine, Lorna Linda, CA 92350.
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limited carpal arthrodesis . 14 No one method is suitable for treatment of all nonunited scaphoid fractures; therefore, a variety of methods must be included in the surgeon's armamentarium, IS , 16 Better results are achieved if union can be obtained before the development of carpal collapse and posttraumatic arthrosis.' 6 Although the mechanisms of action on tissues are not fully understood, 17 electrical treatment of nonunited fractures of long bones has been successful in about 80% of patients. 'B -23 The rate for successful union of tibias has been as high as 87%.24 There are two widely used but different concepts for electrical treatment of nonunions. One concept has a constant, direct 20 microampere current delivered to one or more cathodes, which are implanted directly at the fracture site, from either an "invasive" (the cathode, anode, and battery are implanted through a surgical procedure)2o, 22 or "semi-invasive" system (cathodes
Vol. l1A, No.3 May 1986
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Fig. 1. This method places inductive electromagnetic coils on opposite sides of the fracture site. These coils supply a 15 Hz pulsed quasirectangular electrical signal.
are drilled percutaneously across the fracture site, and the anode is a pad on the skin surface). 18. 21 The second concept uses a totally noninvasive system that involves placement of two electromagnetic coils outside the cast with an alignment block incorporated into the cast to center the coils over the fracture site l9 , 23 (Figs. 1 and 2). Although an equivalent success rate has been reported for treatment of non united fractures by each of the three methods, a distinct advantage of the pulsed electromagnetic field (PEMF) is that it requires no surgical procedure, it can be performed in the office, and there is no danger of introducing infection. 19,23 The first report of treatment of scaphoid non unions with an electrical field used an AO compression screw and a parallel Kirschner wire inserted into the scaphoid; both were connected to a transformer, which generated an electrical alternating current field. 25 A 79% union rate was reported with this method, and a 60% union rate with the screw-only method. Bora et aJ.26 reported healing of 12 (71%) of 17 using the semi-invasive method on nonunited scaphoid fractures. He stated that avascular necrosis was a contraindication, but that a previous bone grafting procedure was not a contraindication. This article presents a retrospective study designed to evaluate the efficacy of noninvasive PEMF in the treatment of nonunited fractures of the scaphoid.
Materials and methods We reviewed all of the cases of non united scaphoid fractures that we treated with the PEMF system* from 1979 through 1984. Wy examined patients' records and information was obtained by means of a standardized protocol. To be included in this study, the scaphoid *Bi-osteogen, System Electro-biology Inc., Fairfield, N,J,
Fig. 2. The electromagnetic coils are attached by a Velcro
strap over a thumb spica cast and applied to a patient with a scaphoid nonunion. The box transforms 110 volt AC line current to the proper pulsed signal. The patient wears the apparatus 8 to 10 hours a day. fracture had to be nonunited and at least 6 months old, regardless of previous treatment methods, with no surgical procedures having been performed during or just before initiation of PEMF treatment. None of our patients had collapse of the scaphoid or degeneration of the peri scaphoid joints. Three patients showed loss of carpal alignment. This series represents consecutive cases treated by us following a standardized protocol. 27 PEMF coils were centered over the scaphoid (Fig. 2) and attached to either a long-arm thumb spica cast or a short-arm thumb spica cast. There were 50 patients initially treated. Three patients failed to return for follow-up examination after immobilization was stopped and the electrical treatment coils were removed. Although their fractures had healed these patients were excluded from our final study. There were three additional patients who received inadequate treatment of 2 months or less (this did not conform to our protocol), and they were also excluded from the study. All of the remaining 44 patients were followed until their fractures healed, or until this method of treatment failed. There were 41 male and 3 female patients in this group. Their ages ranged from 14 to 46 years,
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Fig. 3. Uncomplicated healing of nonunited scaphoid with PEMF. A, Unhealed proximal third fracture 6 months after injury. B, Eight months after fracture when PEMF began. C, Appearance 3 months after beginning PEMF. D, Eight months later.
with a mean age of 25 years. In 8 patients the fracture was localized to the proximal third of the scaphoid, in 33 patients to the middle third, and in 3 patients to the distal third. Nine patients had had one previous bone graft and two patients had two bone-grafting procedures before PEMF treatment was initiated. Nine patients had x-ray evidence of avascular changes of the proximal fragment. The length of time from injury to PEMF treatment ranged from 6 to 241 months with a mean of 40 months. All of the patients who were included in our final study were examined from 1 to 33 months, with a mean of 8.4 months, after immobilization and electrical treatment was stopped.
Results The fractures healed in 35 (80%) of the 44 patients, as shown in Fig. 3. Five (62.5%) of the eight fractures in the proximal third of the scaphoid healed and 30 (83%) of the 36 fractures in the middle and distal thirds healed with electrical treatment. Fractures of eight (89%) of the nine patients who had avascular necrosis before treatment healed. Eight (73%) of the eleven patients who had undergone previous bone-grafting procedures healed. The mean duration of electrical treatment and casting was 4.3 months, with a range of 2.5 to 9 months. Only four patients had PEMF treatment for longer than 6 months.
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Fig. 4. A, Scaphoid nonunion of 96 months' duration in distal third. B, Synovial pseudarthrosis, proved by arthrograms , after fracture did not heal by PEMF. Synovial pseudarthrosis is a contraindication to PEMF treatment .
In four patients, records failed to indicate whether above-elbow or below-elbow immobilization was used. Of the remaining 40 patients, healing occurred in 12 (75%) of the 16 who were treated in a short-arm thumb spica cast and in 22 (92%) of the 24 patients who were treated initially in a long-arm thumb spica cast. The duration of long-arm cast immobilization ranged from 4 to 20 weeks, with a median of 6 weeks and was followed by below-elbow immobilization for the balance of the PEMF treatment. Of the 35 patients with healed fractures, 33 returned to their pre-injury work, 11 to heavy labor, 13 to moderately strenuous work, and 9 to light work. One patient who performed heavy labor was not able to resume his previous occupation, and in one patient this information was unknown. At follow-up on the patients with healed fractures, wrist t
HEALING OF SCAPHOID FRACTURES WITH PEMF VS. TIME SINCE FRACTURE
... .... .. ..
Healed
.
::
..
0
c •• • • =.~~.~-=.-.~~.~~~--~.~ • ~r---.~.~.=.=.-.~-= 1ii 00 0 00 0 0
Not Healed
6
12
4860 24 Time in Months
96
192 240
Fig. 5. The effect of pretreatment duration of scaphoid fracture on healing with PEMF.
poor cooperation and removed their own casts more than once during treatment. There were only three failures among the patients who conformed to the criteria for inclusion in this study. The fractures that failed to unite with PEMF had a mean duration of fracture of 81 months (range 6 to 241 months) versus a mean of 27 months for the fractures that healed. Fig. 5 shows that in fractures that were more than 60 months old, only 2 (29%) of 7 healed, but 27 (90%) of 30 of fractures that were less than 60 months old healed. This difference is statistically significant (p < 0.(01). Discussion Although there is some controversy in the literature regarding the need to treat asymptomatic non unions of the scaphoid,4. 16 recent reports indicate that the longer
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Frykman et ai.
the duration of the nonunion, the greater the degenerative changes about the scaphoid. 28 . 29 Mack et al. 28 suggest that "asymptomatic patients with an undisplaced stable nonunion should be advised of the possibility of late degenerative changes." This study of PEMF treatment was designed for this type of patient. We believe that the main problem in objectively evaluating the efficacy of PEMF treatment is the lack of a reliable double-blind study between like series of patients treated with immobilization alone, and those treated with immobilization and PEMF. However, there are too many other variables for such a study to be accurate. Instead, in our opinion, the patients in these studies themselves provided the comparison for the efficacy of PEMF since in many cases, immobilization alone was used unsuccessfully. In our series, with PEMF and casting, healing occurred in an average of 4.3 months. In addition, a meaningful comparison may be made between our patients and a reported series of patients with nonunited scaphoid fractures that were treated with immobilization alone. Stewart2 reported such a series. Ninety scaphoid fractures, which were more than 1 month old, were treated with casting alone; they had a healing rate of 57% and a "probable" healing rate (i.e., lost to follow-up) of 73%. The average length of immobilization was 20 weeks. Some patients were treated with immobilization for as long as 59 weeks. Immobilization of the fracture began an average of 5 months after the injury. Although Stewart's series and our series were not strictly comparable, the union rate of our patients' fractures was considerably greater (80% versus 57%). This becomes significant because of the longer time from injury to treatment in our series, 40 months versus 5 months. Finally, union occurred slightly faster in our series, a mean of 4.3 months versus 4.7 months. Our results with PEMF are comparable to bone grafting where union rates of 50% to 100% have been reported. 4 • 5. 15.30 However, PEMF may not be quite as effective as the Russe bone graft technique; a recent review of the literature reported it to lead to union on an average of 90% of patients. 31 Our results are better than those reported following open reduction and internal fixation with compression screw osteosynthesis; the latter technique has a reported success rate of 17 to 73%.7.15 The above-elbow immobilization clearly seems to enhance the succe~s rate of PEMF treatment. This is confirmed by Beckenbaugh,32 who reported that healing occurred in only 7 of lO patients who were treated in
short-arm casts versus 12 (87%) of 14 of patients treated in long-arm immobilization with the addition of PEMF. Final grip strength in our patients (83% of normal) is comparable to that obtained following direct electrical current treatment (76%)26 or bone grafting (85% )31. The overall mean range of motion of the wrist in our patients was 89% of normal. This was much greater than that reported using the semi invasive method (50% of wrist dorsiflexion and 42% of wrist palmar flexion).26 Thus, preservation of motion with noninvasive techniques seems to provide a distinct advantage over the semiinvasive method. From our experience, PEMF treatment is contraindicated for displaced fractures, for synovial pseudarthrosis,23 in the presence of periscaphoid osteoarthritis, and for wrists that exhibit a loss of normal radiocarpal alignment. Adherence to these contraindications would have eliminated four out of the nine patients in our failure group. Our results also suggest that non united scaphoid fractures that are older than 5 years are much less likely to unite with PEMF. Other techniques are recommended for these fractures. Finally, patient selection is important, because this method requires the patient's cooperation in order to be successful. A newer portable, battery-operated unit is now available* and should allow for easier patient compliance. The advantages of PEMF treatment are evident: no pain, no anesthetic, no surgical risk, and no known complications. The cost of this treatment is less than the combined cost of hospitalization, anesthetic, and surgical fees. The length of treatment is comparable to that following bone grafting procedures. We believe that PEMF treatment should be specifically considered as an alternative method for treatment when previous surgery has failed, for problem fractures in the proximal third of the scaphoid, and whenever surgery is not safe or is rejected by the patient. *EBI Bone Healing System Model 420, EBI Medical Systems, Fairfield, N.J.
REFERENCES 1. London PS: The broken scaphoid bone. The case against pessimism. J Bone Joint Surg [Am] 43:237-44, 1961 2. Stewart MJ: Fractures of the carpal navicular (scaphoid). A report of 436 cases. J Bone Joint Surg [Am] 36:9981006, 1954 3. Buck-Gramcko D: Denervation of the wrist. J HAND SURG 2:54-61, 1977
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4. Russo 0: Fracture of the carpal navicular. Diagnosis, non-operative treatment, and operative treatment. J Bone Joint Surg [Am] 42:759-68, 1960 5. Herness D, Posner MA: Some aspects of bone grafting for nonunion of the carpal navicular. Acta Orthop Scand 48:373-8, 1977 6. Maudsley RH, Chen SC: Screw fixation in the management of the fractured carpal scaphoid. J Bone Joint Surg [Br] 54:432-41, 1972 7. Herbert TJ, Fisher WE: Management of the fractured scaphoid using a new bone screw. J Bone Joint Surg [Br] 66: 114-23, 1984 8. Mazet R, Hohl M: Fractures of the carpal navicular. J Bone Joint Surg [Am] 45:82-112, 1963 9. Taleisnik J: Fractures of the carpal bones. In Green DP, editor: Operative hand surgery, New York, 1982, Churchill Livingstone, pp 669-702 10. Zemel NP, Stark HH, Ashworth CR, Rickard TA, Anderson DR: Treatment of selected patients with an ununited fracture of the proximal part of the scaphoid by excision of the fragment and insertion of a carved silicone - rubber spacer. J Bone Joint Surg [Am] 66:510-7,1984 11. Inglis AE, Jones EC: Proximal-row carpectomy for diseases of the proximal row. J Bone Joint Surg [Am] 59:460-3, 1977 12. Swanson AB: Silicone rubber implants for the 'replacement of the carpal scaphoid and lunate bones. Orthop Clin North Am 1:299, 1970 13. Gordon LH, King D: Partial wrist arthrodesis for old ununited fractures of the carpal navicular. Am J Surg 102:460-4, 1961 14. Watson HK, Goodman ML, Johnson TR: Limited wrist arthrodesis. Part II: Intercarpal and radiocarpal combinations. J HAND SURG 6:223-33, 1981 15. Cooney WP, Dobyns JH, Linscheid RL: Nonunion of the scaphoid: Analysis of the results from bone grafting. J HAND SURG 5:343-53, 1980 16. Kleinert JM, Zenni EJ: Nonunion of the scaphoid. Review of the literature and current treatment. Orthopaedic Review 13: 125-40, 1984 17. Black J: Tissue response to exogenous electromagnetic signals. Orthop Clin North Am 15: 15-31, 1984 18. Brighton CT, Black J, Friedenberg ZB, Esterhai JL, Day LJ, Connolly JF: A multicenter study of the treatment of non-union with constant direct current. J Bone Joint Surg [Am] 63:2-13, 1981
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19. Bassett CAL, Mitchell SN, Gaston SR: Pulsing electro" magnetic field treatment in ununited fractures and failed arthrodeses. JAMA 247:623-8, 1982 20. Paterson D, Lewis GN, Cass CA: Clinical experience in Australia with an implanted bone growth stimulator (1976-1978). Orthop Trans 3:288, 1979 21. Brighton CT: The semi-invasive method of treating nonunion with direct current. Orthop Clin North Am 15:3345, 1984 22. Paterson D: Treatment of nonunion with a constant direct current: A totally implantable system. Orthop Clin North Am 15:47-59, 1984 23. Bassett CAL: The development and application of pulsed electromagnetic fields (PEMFs) for ununited fractures and arthrodeses. Orthop Clin North Am 15:61-87, 1984 24. Bassett CAL, Mitchell SN, Gaston SR: Treatment of ununited tibial fractures with pulsing electromagnetic fields. J Bone Joint Surg [Am] 63:511-23,1981 25. Wilhelm K: Die ergebnisse der behandlund der naviculare-pseudarthrose mit magnetischen und elektrischen potentaIien. Medizinische Orthopadische Technik 2:67-70, 1978 26. Bora FW, Osterman AL, Woodbury DF, Brighton CT: Treatment of nonunion of the scaphoid by direct current. Orthop Clin North Am 15:107-12, 1984 27. Electro-Biology, Inc., Fairfield, N.J.: Procedure manual for the prescribing, application, and management of the EBI Bi-Osteogen System 204, May, 1979. 28. Mack GR, Bosse MJ, Gelberrnan RH, Yu E: The natural history of scaphoid nonunions. J Bone Joint Surg [Am] 66:504-9, 1984 29. Ruby LK, Stinson J, Belsky MR: The natural history of scaphoid nonunion. A review of fifty-five cases. J Bone Joint Surg [Am] 67:428-32, 1985 30. Schneider LH, Aulicino P: Nonunion of the carpal scaphoid: The Russe procedure. J Trauma 22:315-9, 1982 31. Rasmussen P, Schwab JP, Johnson PR: Symptomatic scaphoid nonunions treated by Russe bone grafting. Orthopaedic Review 14:41-7, 1985 32. Beckenbaugh RD: Noninvasive pulsed electromagnetic stimulation in the treatment of scaphoid nonunions. Presented at the American Society for Surgery of the Hand Annual Meeting, Las Vegas, Nev. Jan. 21,1985