Editor's Picks

This month's picks come from section editor is Sanjeev Kakar, MD from the Mayo Clinic in Rochester, MN.   

Find even more on these topics and many more in the Curriculum of Hand Surgery, Course Recordings, and Annual Meeting Archives

To view previous Editor Picks selections, visit the archive.

 

 

 

Arthroscopic Bone Grafting for Scaphoid Nonunion

By Geert A. Buijze, MD By Geert Buijze

Case Overview Case Overview We present a case of a 38-year-old male with a symptomatic nonunion at the proximal third of the scaphoid, 10 years after screw fixation of an acute scaphoid waist fracture. Diagnostic wrist arthroscopy under portal site local anesthesia showed that the proximal pole was split in a small volar fragment and a larger dorsal fragment. The screw could be visualized in the nonunion gap and did not purchase to either proximal fragment. The nonunion site was highly unstable on probing with dense scar tissue over the dorsal side. There were 2 grade 4 chondral lesions in the volar aspect of the scaphoid fossa and most of the cartilage of the scaphoid was still preserved. After elaborate informed consent, the patient chose to undergo arthroscopic bone grafting and revision fixation of the nonunion. Due to patient delay, this procedure was performed 9 months later. And because of the risk of a progressing SNAC wrist, it was preceded by a second diagnostic wrist arthroscopy under local anesthesia without tourniquet at the same setting. Method/Technique Arthroscopic Bone Grafting including take down of the nonunion site with a 2.0mm shaver and a 2.9 mm burr, removing the sclerotic bone at the nonunion site and leaving some fibrosis at the radiocarpal side to prevent graft spilling. Reduction, percutaneous fixation with K-wires and arthroscopic bone grafting using iliac crest bone graft. Results Our case at 6 months follow up, he performed well clinically with good ROM and no pain on grinding and stress. Radiographs showed progressive consolidation and satisfactory alignment. Our prospective series included 58 established symptomatic nonunion and 11 delayed union cases treated during April 1997 to November 2009. At final clinical follow-up, there was no pain in 53 patients (78.2%) while the average pain score according to a 10-points visual analog scale in the remaining 15 patients was 1.8. There was significant improvement of ADL performance score increase from 33.4 to 39.0 on a 40-points scale, ADL pain score (decrease from 5.4 to 1.0 on a 20-points scale), exertion pain (decrease from 5.0 to 1.8 on a 10-points scale) and grip power (increase from 65.2% to 77.8% of the opposite hand)(p<0.05). The average combined range of motion of the affected wrist adding extension, flexion, radial and ulnar deviation range decreased from 82.2% to 74.4% of the opposite side (P=0.05). All patients had inconspicuous scars left. Carpal alignment was evaluated radiologically compared to non-affected side. The average scapho-lunate angle was 62.3? (range 49 76?) and the average AP intra-scaphoid angle was 34.5? (range 27-50?). Summary Arthroscopic approach can reduce potential morbidity associated with an open arthrotomy such as pain and stiffness, maximally preserve blood supply to carpal bone for improved healing and create minimal disturbance to the ligamentous structures. Based on these sound surgical principles and the potential advantages, the authors have developed a novel technique of arthroscopic bone grafting and percutaneous fixation of the fracture since 1997. It has become the authors standard primary treatment in all scaphoid delayed union and nonunion. The presented case is a perfect example showing both the surgical technique and its effectiveness in even the most challenging cases.

Duration: 14:44
Arthroscopic management of perilunate fracture dislocations

By Francisco Del Pinal, MD By Francisco Del Pinal

role of arthroscopy for distal radius fractures

Duration: 8:54