Artroscopia de pseudoartrosis del escafoides
P.Croutzet, C. De Cheveigné, A. Gaston, B. Ferreira
Sociedad Española de cirurgía otopédica y traumatología - Octubre 2014
Arthroscopic surgery was an improvement for scaphoid fractures; besides, bone-inducing proteins (BMP) were a major improvement in diaphyseal nonunions. However, scaphoid nonunion treatments are still surgical challenges.
This preliminary series wants to improve recovery and outcomes of scaphoid nonunion treatments by associating an arthroscopic debridement and double screw fixation on the one hand with a bone inducing protein on the other hand.
Over a period of one year, 4 recent (<1year) scaphoid nonunions, without osteonecrosis, were operated on with an arthroscopic debridement and double screw fixation associated with a bone inducing protein.
We used two cannulated (Ø 2 mm) compression screws, a 1,9mm arthroscope with four portals, a midcarpal radial and three radiocarpal portals (3-4, 2 et 1-2), a wrist shaver and burr for debridement, a bone morphogenetic protein (eptotermine alpha) was injected into the nonunion site through a 18 gauge needle before full screws’ compression.
A splint was kept for 4 weeks followed by active/passive physiotherapy.
Physical examination and X-ray were performed after 3 and 6 weeks then CT-scan after 3 and 6 months.
Analysis criteria were:
- perioperative: presence of arthritis, sclerotic or fibrous tissue type, duration of surgery
- postoperative: pain, wrist motion (F/E° ; Inclinations ; P/S°), grasp strength, time off work and sports, radiographic analysis (reduction, CT-scan consolidation, secondary displacement).
All patients were reviewed 4 times Duration of surgery was 60 minutes (50-90), we noticed none scapho-lunate ligament injury, beginning of arthritis in 3 cases and fibrous tissue in 2 cases. About strength and mobility:
- After 6 weeks: F/E: 50/45°, I°R/I°C 5°/10°, P/S 70°/75°, Grasp 30%
- After 3 months: F/E: 70/60°, I°R/I°C 10°/20°, P/S 75°/80°, Grasp 55%
- After 6 months: F/E: 85/75°, I°R/I°C 10°/25, P/S 75°/80°, Grasp 85%
We noticed 3 anatomic reductions. 2 patients got consolidation after 3 months, 1 after 6 months and one didn’t obtained consolidation after 6 months without secondary displacement.
One patient was still experiencing pain in full extension after 6 months but was still able to play rugby.
Time off work was 6 weeks (4-10).
This is a preliminary series and more cases will come to precise outcomes.
However, it seems possible to treat successfully scaphoid nonunion, without bone grafting, by using an arthroscopic procedure associating a double screw fixation with a bone inducing protein.
In the future, improvement of surgical skills on the one hand and drug development focused on scaphoid nonunion on the other hand should improve results and enlarge indications.
Voir la présentation en Espagnol