Scaphoid fracture: Arthroscopic assisted grafting of non-union and fixation using Acutrak screw
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This procedure is designed to follow on from the Diagnostic Wrist Arthroscopy technique published in OrthoOracle.
This is a detailed step by step instruction through the procedure of an arthroscopic graft and mini-open screw fixation of a scaphoid non-union using the Acumed TM ARC Tower traction system and Mini Acutrak TM screw.
Scaphoid non-unions are best diagnosed and morphology assessed on a CT scan if subtle, although they are usually clearly seen in a scaphoid series of radiographs. An MRI can be used to try to assess the vascularity of the proximal fragment in proximal pole fractures however MRI scans (with or without Gadolinium) are far from infallible and the gold standard test for vascularity remains punctate bleeding from the bone intra-operatively.
When an non-union is established, in the absence of associated arthritis, and is symptomatic it usually requires treatment for which there are a number of options available.
Treatment options will often vary depending on the amount of collapse of the scaphoid, sclerosis or cyst formation around the non-union, location of the non-union within the scaphoid and the skill and preferences of the surgeon.
Options include – simple screw or k-wire fixation with or without graft. Grafting open or arthroscopic and can be vascularised or non-vascularised, cancellous or cortico-canecellous with the most common donor sites being distal radius and iliac crest.
Arthroscopic scaphoid grafting is an evolving technique and is best attempted once the surgeon is already confident and adept in more routine arthroscopic procedures such as joint debridements and Triangular fibro-cartilage complex (TFCC) repairs.
When embarking on this procedure for the first time it is best to attempt a non-union with minimal bony deformity which does not need correcting and located in the waist of the scaphoid. This means the fracture site can be easily accessed, there are large fragments with good vascularity proximally and distally to hold a screw and no manipulation of the fragments is required intra-operatively.
The main theoretical advantage of this technique is the preservation of vascularity by minimal soft tissue dissection which as there is no clear evidence proving the benefit of vascular over non-vascularised grafting techniques then it is a very attractive option. It also aims to reduce scarring around the joint and try to preserve mobility post-operatively.
Following an arthroscopic scaphoid grafting and mini open screw fixation patients are usually placed in plaster cast for 6-8 weeks with physio therapy of the fingers and thumb followed by cast removal and physiotherapy of the wrist once union is confirmed radiologically and clinically.
Complications in this procedure include non-union, metalwork issues, infection, iatrogenic cartilage injuries and tendon and nerve injuries.
Author: Mr Mark Brewster FRCS (Tr & Orth)
Institution: The Queen Elizabeth Hospital, Birmingham, UK.
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