We present the case of a 22 y.o. male patient suffering from scaphoid non-union with avascular necrosis of the proximal pole and initial degenerative arthritis

Adani, Roberto

De Santis, Giorgio

Faldini, Cesare

Marcuzzi, Augusto

Sapino, Gianluca

Vita, Fabio

English

PubMed

Archivio istituzionale della ricerca - Università di Modena e Reggio Emilia

Adaptive Proximal Scaphoid Implant stability despite a perilunate dislocation: a case reportAugusto Marcuzzi1, Fabio Vita1,2, Gianluca Sapino1,3, Giorgio De Santis3, Roberto Adani1, Cesare Faldini21Department of Hand Surgery and Microsurgery, University Hospital of Modena, Modena, Italy; 2Department of Orthopedic and Traumatological Surgery, Istituto Ortopedico Rizzoli, Bologna, Italy; 3Department of Plastic and Reconstructive Surgery, University Hospital of Modena, Modena, ItalySummary. Background: We present the case of a 22 y.o. male patient suffering from scaphoid non-union with avascular necrosis of the proximal pole and initial degenerative arthritis. Case report: He referred to our institution with functional impairment and persistent pain (VAS 8\10). The patient underwent the positioning of the small size Adaptive Proximal Scaphoid Implant (APSI), without fixation, through an open dorsal approach and radial styloidectomy. The post-operative course was uneventful, and the patient could resume his daily routine without limitations. 5 years later the patient returned to our department referring a dorsal perilunate dislocation on the same hand. Unexpectedly no implant dislocation occurred and we were able to reduce the perilunate dislocation maintaining the same implant. At 30-month follow-up the patient was pain free (VAS 0\10) with almost completely recovered function of the hand and wrist. Conclusion: In order to minimize implant dislocation, both an adequate scaphoid resection and the choice of the right implant size (which should be lightly downsized compared to the scaphoid resection) are of paramount importance. At the same time, the capsuloplasty should be carefully performed at the right tension, providing adequate stability to the implant. This technique provided satisfactory functional results in a long-term follow-up, even in a young and active patient. Moreover, it does not preclude or complicate the possibility of resorting to different surgical procedures in case of necessity, whilst maintaining the same implant. (www.actabiomedica.it)Keyword: APSI, scaphoid non-union, perilunate dislocation, implant dislocationActa Biomed 2021; Vol. 92, Supplement 3: e2021001  DOI: 10.23750/abm.v92iS3.9470 © Mattioli 1885C a s e  r e p o r tIntroductionScaphoid fractures are among the most common occurring fractures to the carpal bones, accounting for almost 70% of all carpal fractures (1). Non-union is a well-known complication, particularly when the proximal pole of the scaphoid is involved, with an in-cidence rate ranging from 10% to 15% of scaphoid fractures. The high non-union rate is primarily due to the reduced retrograde bloody supply to the bone from the radial artery, but its incidence can rise depend-ing on patient comorbidities, reduced immobilization time and delayed diagnosis\treatment (2, 3). A surgical treatment is required especially in unstable non-union. Key objectives should be preserving the length and alignment of the scaphoid, in order to restore carpal stability and prevent the onset of degenerative radio-carpal arthritis, according to the scaphoid non-union advanced collapse (SNAC) pattern (4).  Various surgical strategies have been proposed in order to stop the progression of the degenerative process and to regain the wrist function, ranging from bone autograft (eventually vascularized) with internal fixation, in milder cases, to partial or total wrist arthro-desis, in the most severe (5-7).Despite being less commonly reported, the Adap-tive Proximal Scaphoid Implant (APSI) represents a valuable surgical alternative in selected patients, par-Acta Biomed 2021; Vol. 92, Supplement 3: e2021001284ticularly in case of small avascular proximal pole frag-ments (8). Its efficacy relies on the replacement of the proximal scaphoid pole, maintaining the carpal height and wrist kinematics. Implant instability and disloca-tion are among the most frightening complications, and the reported incidence of these has probably dis-couraged authors from using this technique (9, 10). We describe a case of scaphoid non-union with avascular necrosis of the proximal pole treated using an APSI, which remained stable and well positioned, de-spite the patient experiencing a perilunate dislocation 5 years after the surgery. Surgical tips and indications are discussed together with general and functional out-comes. Case ReportIn February 2012, a 22 y.o. male patient came to our institution one year after a proximal pole scaphoid fracture of the non-dominant left hand, treated else-where with an internal screw fixation, referring func-tional impairment and persistent pain (VAS 8\10). The clinical examination showed a reduced range of motion (ROM, measured with a goniometer) of the wrist: 25° flexion (30% of contralateral), 20° extension (23% of contralateral), 5° radial deviation (50% of con-tralateral), 10° ulnar deviation (25% of contralateral) and 50° prono-supination (32% of contralateral). The grip strength tested using a hand-held dynamometer (Baseline1→, White Plains, NY, 10602, USA) was re-duced to 21 Kg\N (contralateral 28 kg\N), while the key pinch strength test measured 8 Kg\N (contralat-eral 12 Kg\N). The DASH (Disability of the Arm, Shoulder and Hand) score and PRWE (Patient Rated Wrist Evaluation) score assessed a reduced functional-ity of the wrist (70 and 88 points, respectively) (11, 12) (Table 1). The X-Ray showed a scaphoid non-un-ion together with a mild arthritis at the radial styloid (SNAC I). At the MRI, the proximal pole appeared avascular and necrotic (stage IV according to Herbert Classification) (Figure 1).Using regional anesthesia and under fluoroscopic imaging control during the surgery, the patient under-went the positioning of the small size APSI spacer, without fixation, through an open dorsal approach and radial styloidectomy, according to previously de-scribed technique; beside the ablation of the internal Figure 1. A) X-Ray antero-posterior view showing a scaphoid non-union together with a mild arthritis at the radial styloid (SNAC I); B) At the MRI, coronal view, the proximal pole of the scaphoid appears avascular and necrotic (stage IV according to Herbert Classification).Table 1.  Contralateral Pre-OP Post-OP 1 Post-OP 2Flexion° 80 25 65 64Extension° 85 20 70 73Radial Dev.° 10 5 15 15Ulnar Dev.° 40 10 25 20Prono-sup.° 160 50 75 60Grip strength, Kg\N 28 21 24 23Pinch strength, Kg\N 12 8 10 9DASH, points 0 70 7 8.3PRWE, points 0 88 8.5 9Abb.: prono-sup, prono-supination; dev., deviation; DASH, Disability of Arm, Shoulder and Hand; PRWEActa Biomed 2021; Vol. 92, Supplement 3: e2021001 285fixation screw (8). A double layered capsuloplasty was performed using 4-0 PDS sutures, re-tensioning care-fully the capsular ligaments. A splint cast was kept for 3 weeks, afterwards the patient begun a specific physi-otherapy rehabilitation protocol for 3 months. At his 6 month follow-up, no complications had occurred, the patient was very satisfied with the treatment and he had resumed his daily routine. No residual pain was described (VAS 0\10) and there was great improve-ment of all functional measured outcomes (refer to Ta-ble1 for all details) (Figure 2). 5 years later, following a high energy motorbike accident, the patient returned to our department referring a dorsal perilunate dislo-cation (stage II according to Taleisnik classification) on the same hand, unexpectedly without dislocation of the implant (13). In the O.R., the implant was tempo-rary removed through the same dorsal access, the peri-lunate dislocation was reduced and fixed with 3 Kir-shner wires (2 between triquetrum and lunate, and 1 between capitate and triquetrum), and finally the same implant reinserted. The wrist was then immobilized for 45 days before starting physiotherapy for 6 months. At the 30 months follow-up, the patient was pain free (VAS 0\10) with almost completely recovered function of the hand and wrist. The ROM values were as follow: 64° flexion, 73° extension, 15° radial deviation, 20° ul-nar deviation and 60° prono-supination.  Grip strength was improved to 19 Kg\N and the key pinch strength test to 9 Kg\N, while functional outcomes were greatly enhanced according to the DASH and PRWE scores (8.3 and 9 points, respectively) (Table 1). The antero-posterior and lateral X-ray projection performed at that time did not detect any sign of implant dislocation or osteoarthritis progression, while the carpal height was maintained (Figure 3). The patient was able to re-turn to his daily activities and sports.DiscussionScaphoid nonunion represents a disabling disease, causing wrist pain and functional impairment of the hand and reducing the patient’s quality of life. The sur-gical management of this pathology, especially when is associated to the necrosis of the proximal pole of the scaphoid, pose unique challenges to the hand sur-geons, and there is a lack of consensus in literature (1). The use of autologous non-vascularized bone graft with internal fixation is widely accepted as the standard treatment for scaphoid non-union, eventually combined with the radial styloidectomy in presence of mild osteoarthritis degeneration (SNAC I) (14). However, when the proximal fragment is avascular, a high incidence of failure is expected (15). In such cases, the use of vascularized bone graft either pedicled Figure 3. A-B) X-Ray antero-posterior and lateral view show-ing a dorsal perilunate dislocation (stage II according to Ta-leisnik classification) without dislocation of the implant; C-D) The perilunate dislocation is reduced and fixed with 3 Kirshner wires (2 between triquetrum and lunate, and 1 between capitate and triquetrum), the APSI is reinserted; E-F) X-Ray antero-posterior and lateral view at 30 months follow-up, showing good implant positioning without arthritis progression.Figure 2. A-B) X-Ray antero-posterior and lateral view show-ing the good positioning of the APSI at 6 months post-op.Acta Biomed 2021; Vol. 92, Supplement 3: e2021001286(from the distal radius) or free (i.e. free medial condyle flap or iliac crest free flap) is advisable (16). Neverthe-less, the bone graft from the distal radius is limited in size and has a thin cortex which may be insufficient for severe deformities, while performing a free flap from the medial condyle is time consuming, requires micro-surgical expertise and is related to increased donor site morbidity (7, 17). More invasive procedure, such as the proximal row carpectomy (PRC), the 4-corner fusion (4CF) or the total wrist arthrodesis, are considered as salvage procedures and are reserved for symptomatic SNAC III-IV (5). The use of the APSI has been documented with promising results in SNAC earlier stages (I-II), even in young and demanding patients (8). The ovoid-shape implant replaces the degenerated proximal pole of the scaphoid, and thanks to the preservation of the bone length, the distribution forces at the proximal carpal row are restored (9). The APSI is made of pyrocar-bon, an inert and resistant material, characterized by an elasticity and density modulus very similar to that of the cortical bone, thus reducing the risk of stress shielding (18). Pequignot et al., first described in 2000 the use of this implant in 25 patients with a satisfacto-ry functional outcome and no progression towards the osteoarthritis degeneration on a 6 years follow-up (19). In 2007, Grandis and Berzero reported their experi-ence in 98 patients (age range 22-68), who described pain relief and resumption of previous jobs and daily activities. Similarly, thanks to a 10 years follow-up on 39 SNAC I-II wrist patients, Aribert et al. suggested that the APSI outcomes were similar to those reported with more traditional procedures (PRC and 4CF), be-ing less invasive (9). Poumellac et al. state that an evo-lution towards a carpal collapse with reduced carpal height is seen in longer follow-ups but it is generally well-tolerated (8).Implant infection, dislocation (dorsal or volar), peri-implant osteolysis and progression of arthritis degeneration are among the most commonly reported complications in implant surgery (20). In our patient, the proximal pole of the scaphoid was avascular and fractured in several small pieces. Ac-cording to the first author preference and to literature, an interposition hemiarthroplasty of the scaphoid us-ing the APSI was performed (9, 18, 19). In our opin-ion, in order to minimize implant dislocation, both an adequate scaphoid resection and the choice of the right implant size (which should be lightly downsized com-pared to the scaphoid resection) are of paramount im-portance. At the same time, the capsuloplasty should be carefully performed at the right tension, providing adequate stability to the implant. In the presented case, thanks to this surgical shrewdness and despite a high energy trauma (result-ing in perilunate dislocation), the implant remained in position, maintaining the carpal height and avoid-ing the need for more complex procedure (e.g. PRC). Consistent with the previous literature, the APSI guar-anteed satisfactory results in a long-term follow-up, allowing the maintenance of the wrist function with good ROM and strength recuperation. Moreover, the technique does not preclude or complicate the possi-bility of resorting to different surgical procedures in case of necessity, whilst maintaining the same implant.Conflict of interest: Each author declares that he or she has no commercial associations (e.g. consultancies, stock ownership, equity interest, patent/licensing arrangement etc.) that might pose a con-flict of interest in connection with the submitted articleReferences  1.  Borges CS, Ruschel PH, Pignataro MB. Scaphoid Recon-struction. Orthop Clin North Am. 2020;51(1):65-76.  2.  Nacif GC, Pedro FMJ, de Moraes VY, Fernandes M, Bel-lot JC. How Scaphoid Fractures Are Treated in Brazil. Acta Ortop Bras. 2018;26(5):290-3.  3.  Yeo JH, Kim JY. Surgical Strategy for Scaphoid Nonunion Treatment. J Hand Surg Asian Pac Vol. 2018;23(4):450-62.  4.  Vender MI, Watson HK, Wiener BD, Black DM. Degen-erative change in symptomatic scaphoid nonunion. J Hand Surg Am. 1987;12(4):514-9.  5.  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Adaptive Proximal Scaphoid Implant (APSI): 10-year outcomes in patients with SNAC wrists. Hand Surg Rehabil. 2019;38(1):34-43.10.  Gras M, Wahegaonkar AL, Mathoulin C. Treatment of Avascular Necrosis of the Proximal Pole of the Scaphoid by Arthroscopic Resection and Prosthetic Semireplacement Arthroplasty Using the Pyrocarbon Adaptive Proximal Scaphoid Implant (APSI): Long-Term Functional Out-comes. J Wrist Surg. 2012;1(2):159-64.11.  MacDermid JC, Turgeon T, Richards RS, Beadle M, Roth JH. Patient rating of wrist pain and disability: a reliable and valid measurement tool. J Orthop Trauma. 1998;12(8):577-86.12.  Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH (disabili-ties of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG). Am J Ind Med. 1996;29(6):602-8.13.  Taleisnik J. Classification of carpal instability. Bull Hosp Jt Dis Orthop Inst. 1984;44(2):511-31.14.  Reigstad O, Thorkildsen R, Grimsgaard C, Reigstad A, Rokkum M. Is revision bone grafting worthwhile after failed surgery for scaphoid nonunion? Minimum 8 year follow-up of 18 patients. J Hand Surg Eur Vol. 2009;34(6):772-7.15.  Green DP. The effect of avascular necrosis on Russe bone grafting for scaphoid nonunion. J Hand Surg Am. 1985;10(5):597-605.16.  Merrell GA, Wolfe SW, Slade JF, 3rd. Treatment of scaph-oid nonunions: quantitative meta-analysis of the literature. J Hand Surg Am. 2002;27(4):685-91.17.  Zaidemberg C, Siebert JW, Angrigiani C. A new vascular-ized bone graft for scaphoid nonunion. J Hand Surg Am. 1991;16(3):474-8.18.  Daruwalla ZJ, Davies K, Shafighian A, Gillham NR. An al-ternative treatment option for scaphoid nonunion advanced collapse (SNAC) and radioscaphoid osteoarthritis: early results of a prospective study on the pyrocarbon adaptive proximal scaphoid implant (APSI). Ann Acad Med Singa-pore. 2013;42(6):278-84.19.  Pequignot JP, Lussiez B, Allieu Y. [A adaptive proximal scaphoid implant]. Chir Main. 2000;19(5):276-85.20.  Marcuzzi A, Ozben H, Russomando A. The use of a pyro-carbon capitate resurfacing implant in chronic wrist disor-ders. J Hand Surg Eur Vol. 2014;39(6):611-8.Received: 10 April 2020Accepted: 10 May 2020Correspondence:Gianluca Sapino, M.D.Department of Plastic and Reconstructive SurgeryUniversity Hospital of ModenaLargo del Pozzo 71, 41124Modena, ItalyFax: +39-0594222454Tel: +39-0594225286Gianluca.sapino@gmail.com

Adaptive Proximal Scaphoid Implant stability despite a perilunate dislocation: a case report

http://dx.doi.org/10.23750/abm.v92iS3.9470

Adaptive Proximal Scaphoid Implant stability despite a perilunate dislocation: a case report

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