[Bipartition of the scaphoid as posttraumatic pseudarthrosis].
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Longstanding unstable scaphoid nonunions inevitably lead to carpal collapse and symptomatic secondary arthrotic changes, ruling out reconstructive procedures to the scaphoid itself. Partial mediocarpal fusion, however, can preserve some wrist motion and markedly reduce or even eliminate wrist pain. By correcting the malalignment of the lunate and capitate, carpal height is restored. By excision of the scaphoid, its destroyed articular surfaces are removed. In 26 of 31 patients undergoing mediocarpal fusion, complete or at least significant reduction of wrist pain was observed. Average grip strength increased by 23%, whereas wrist mobility decreased by 33 to 40% with a relatively short follow-up of 14 months. Total wrist fusion remains the last line of defense.
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Nonunion after a calcaneus fracture is rare. A forty-two-year-old man presented with complaints of extreme left heel pain on weight-bearing, that required him to use crutches. Clinical and radiological studies yielded a diagnosis of calcaneal nonunion. He had a history of an open calcaneal fracture that occurred in a traffic accident eight months before, for which he received cast treatment. He underwent surgical treatment (curettage, bone graft, and internal fixation) for the nonunion of the calcaneus. Eight months after the operation, no problem was observed at the union site, and the patient returned to his normal activity levels. He had a slight heel pain appearing only after walking long distances, which was attributed to the subtalar joint.
In scaphoid nonunion, Russe's modification of the Matti procedure with cancellous bone grafting, using a cortico-cancellous graft is very useful. In small proximal scaphoid fragments with avascular necrosis, resection and interspacing of bone graft of the iliac crest leads to good results. In old cases of nonunion and avascular necrosis of proximal fragment, the use of a bone block from the iliac crest with microvascular anastomosis of the vessels leads to better results.
Twenty eight patients with fourteen acute scaphoid fractures and fourteen with scaphoid non-union were examined with standard X-rays in two planes, special scaphoid projections and computed tomography. Nine scaphoid fractures were revealed by both standard X-rays and CT, whereas four fractures could only be detected by CT. Computed tomography should be used when there is clinical suspicion of scaphoid fracture but standard radiographs remain negative. All carpal bones should be examined. Fourteen patients with suspected scaphoid non-union were examined. In twelve patients, scaphoid non-union seemed to be complete in standard X-rays, whereas CT showed a bony bridge between the proximal and distal fragment. Another patient showed bony union. Two patients showed no non-union in standard X-rays. One was confirmed after a Matti-Russe procedure, but the bone graft was dislocated, causing restricted wrist motion. One scaphoid non-union was demonstrated by CT. Two patients showed signs of additional carpal fractures. Diagnostic applications of CT for scaphoid non-union include the determination of the exact location of the fragments and the evaluation of post-traumatic cysts, thus simplifying pre-operative planning.
107 of 604 cases with scaphoid non-union had secondary arthrosis of the wrist before surgical treatment by the Matti-Russe technique. In contrast to earlier opinions the results of this retrospective study show that this procedure is indicated more frequently.