Management of Scaphoid Nonunion (SNU) With Ilizarov Ring Fixator Using Two Olive Wire Compression Without Bone Grafting: A Case Series

Background: The scaphoid is the most commonly fractured bone among the carpal bones seen in orthopedic practice. The majority have good favorable prognosis, but some develop nonunion of fracture despite optimal treatment, which can lead to further complications if left untreated. It is recommended that displaced scaphoid nonunions (SNUs) should be reduced and fixed to prevent degenerative changes from occurring, even if they are asymptomatic. Many treatments have been described, from a percutaneous fixation with a k-wire or screw to open reduction and internal fixation with or without bone grafting, but none of them is the gold standard. Aim: To evaluate the outcome of an SNU treated with an Ilizarov fixator using two olive wires without bone graft. Methods: Eleven cases of non-union scaphoid fractures were considered in the study which was presented to the Department of Orthopedics of Kalinga Institute of Medical Sciences during the period of March 2015 to March 2018. This study has been approved by the scientific and ethical committees. The anatomical location of the fracture was graded according to the MAYO classification. An Ilizarov frame was applied with two cross olive wires for achieving compression at the fracture area and maintained for six weeks. A final outcome was assessed using the scaphoid outcome score. Results: One out of 11 patients operated on during the study period was lost in follow-up, so 10 patients were considered for analysis of the results. There were nine male patients and one female patient. The majority were right-sided and dominant-handed, with varied occupations. The average duration of nonunion, when presented, was 10.7 months (a range of 6-20 months). The average follow-up was 43.6 months (range 27-60 months). Union was achieved in an average of 12.9 weeks (range 10-18 weeks). All the patients returned to their pre-injury activity level in a mean of 17.1 weeks (range 13-23 weeks). Grip strength improved from a mean of 29.5 kg preoperatively to 39.4 kg postoperatively. At the final follow-up, the mean scaphoid outcome score was 9.1. An excellent outcome was obtained in five cases (50%), a good outcome in three cases (30%), a fair outcome in one case (10%), and in one case (10%), a poor outcome. Conclusion: With our technique of Ilizarov fixation and compression with two cross olive wires, SNU can be treated safely even without opening the non-union site and even without bone grafting. Since we excluded SNU patients with humpback deformity, carpal instability, carpal collapse, or avascular necrosis (AVN), our results might not be directly comparable to those of other SNU series in the literature. These would have predisposed to a poor outcome. Since we did not assign the patients at random, it is challenging to compare the Ilizarov technique to other widely used SNU treatments and determine whether it is more effective. However, the study's results are encouraging and show that the Ilizarov method using two olive wires for compression.