Palmare winkelstabile Verplattung von Pseudarthrosen und Trümmerfrakturen des Kahnbeins

Rethinking Scaphoid Fixation

Scaphoid fixation, whether for acute injuries or nonunion, is made challenging by the small and intra-articular nature of the most commonly fractured carpal bone. The purpose of this article is to review the techniques to simplify scaphoid fixation and to optimize healing and early return to activity.

Comparative analysis of cancellous graft and cortico-cancellous graft in osteosynthesis of scaphoid pseudoarthrosis with plate

INTRODUCTION

Scaphoid is the most fractured carpal bone, with a 5-10% nonunion rate. Treatment challenges include choosing the implant and graft that best corrects humpback deformity and carpal malalignment with higher chances of bony healing.

OBJECTIVE

Compare cortico-cancellous and cancellous grafts between two groups of patients treating scaphoid nonunion with locking plates using autologous bone graft and evaluate bone healing rates and radiographic, tomographic, and functional parameters before and after surgery.

METHODS

Non-randomized prospective study including 20 cases of scaphoid nonunion. Groups were divided into Group A (ten patients treated with cortico-cancellous iliac graft) and Group B (ten patients treated with cancellous iliac graft). Patients underwent pre- and postoperative radiographs, computed tomography, and functional evaluation.

RESULTS

In postoperative analysis, Group A showed a statistically significant difference in intrascaphoid angle (p = 0.002) and scapholunate angle (p = 0.011) correction when comparing the pre- and postoperative periods. Group B showed a statistically significant difference in intrascaphoid angle (p = 0.002) and scapholunate angle correction (p = 0.0018), grip strength (p = 0.002), and tip pinch strength (p = 0.001) when comparing the pre- and postoperative periods. By comparing both groups, Group B showed a statistically significant difference in intrascaphoid angle correction (p = 0.002), grip strength (p = 0.002), tip pinch strength (p = 0.002), and radial deviation (p = 0.0003). There was no statistical difference when comparing bony healing between groups.

CONCLUSION

Scaphoid nonunion treatment with a locking plate was effective, showing a high bony healing rate and improved carpal alignment in imaging tests for both graft types. However, results for intrascaphoid angle correction, grip strength, tip pinch strength, and radial deviation were better in Group B.

LEVEL OF EVIDENCE

IV, case series.

Scaphoid Plate Osteosynthesis in Complex Fractures and Wrist Trauma: A Case Series

Introduction Treatment of scaphoid fracture is challenging due to its unique blood supply and geometry. Traditionally, a headless compression screw is the standard treatment for unstable scaphoid fracture. Some fractures are complex, for example, comminution with bone loss. A scaphoid plate is an option in these difficult fractures providing adequate rotational stability. Aim To share our experience in using scaphoid plates in complex wrist trauma and comminuted fractures. Method and material Complex wrist trauma involving scaphoid fractures that were comminuted and multi-fragmentary fractures treated with plate osteosynthesis were retrospectively reviewed between July 2019 and September 2021. Patient demographic data, preoperative radiographs, CT scans, pain, wrist range of motion, and fracture union rate to union were reviewed. Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH®) score was recorded at 1-year postoperative follow-up.  Results Nine patients associated with complex wrist trauma were included in this case series. The mean follow-up was 2.5 years (13-30 months). The union rate was 100%. The mean arc of motion was 105° (95-110°). QuickDASH® score was 19.96 at 1-year postoperative follow-up. Four patients had good outcomes, four satisfactory, and one poor outcome. One hardware complication was observed which was the impingement of the plate proximally over the articular surface of the distal radius. Conclusion A scaphoid plate is a reliable option for treating complex and difficult fractures. It provides adequate stability, especially in comminution, bone loss, or multi-fragmentary fractures which are not amendable using other fixation methods. We recommend the expansion of plate osteosynthesis beyond scaphoid nonunion into complex wrist trauma.

Fixation Techniques for Scaphoid Nonunion

Scaphoid fractures are common injuries with high risk of nonunion. Various fixation techniques exist for managing scaphoid nonunions, including Kirschner wires, single or dual headless compression screws, combination fixation techniques, volar plating, and compressive staple fixation. The indication for each fixation technique varies depending on the patient, type of nonunion, and clinical scenario.

Double screw versus angular stable plate fixation of scaphoid waist nonunions in combination with intraoperative extracorporeal shockwave therapy (ESWT)

INTRODUCTION

Over the past years, different fixation techniques focused on rotational stability in order to increase stability and stimulate union rates. Additionally, extracorporeal shockwave therapy (ESWT) has gained importance in the treatment of delayed and nonunions. Purpose of this study was to compare the radiological and clinical outcome of two headless compression screws (HCS) and plate fixation in scaphoid nonunions, in combination with intraoperative high energy ESWT.

MATERIALS AND METHODS

Thirty-eight patients with scaphoid nonunions were treated by using a nonvascularized bone graft from the iliac crest and stabilization with either two HCS or a volar angular stable scaphoid plate. All patients received one ESWT session with 3000 impulses and energy flux per pulse of 0.41 mJ/mm² intraoperatively. Clinical assessment included range of motion (ROM), pain according to the Visual Analog Scale (VAS), grip strength, disability of the Arm Shoulder and Hand Score, Patient-Rated Wrist Evaluation Score, Michigan Hand Outcomes Questionnaire and modified Green O'Brien (Mayo) Wrist Score. To confirm union, a CT scan of the wrist was performed.

RESULTS

Thirty-two patients returned for clinical and radiological examination. Out of these, 29 (91%) showed bony union. All patients treated with two HCS compared to 16 out of 19 (84%) patients treated by plate showed bony union on the CT scans. The difference was not statistically significant. However, at a mean follow-up interval of 34 months, no significant differences could be found in ROM, pain, grip strength and patient-reported outcome measurements between the two HCS and plate group. Height-to-length ratio and capitolunate angle improved significantly in both groups compared to preoperative.

CONCLUSIONS

Scaphoid nonunion stabilization by using two HCS or angular stable volar plate fixation and intraoperative ESWT results in comparable high union rates and good functional outcome. Due to the higher rate for a secondary intervention (plate removal), HCS might be preferable as first choice, whereas the scaphoid plate fixation should be reserved for recalcitrant (substantial bone loss, humpback deformity or failed prior surgical intervention) scaphoid nonunions.

The clinical outcomes of scaphoid nonunion treated with a precisely processed autologous bone screw: a case series

INTRODUCTION

Metal implants and bioabsorbable implants are frequently used in orthopaedic surgery, but they have some disadvantages. The usefulness of autologous bone has been described, and a method to precisely process autologous bone into implants such as screws and apply the implants clinically has been desired. We created a new system for manufacturing autologous bone screws during surgery and report five cases of scaphoid nonunion treated with precise autologous bone screws made from the tibial cortex using the new system.

PATIENTS AND METHODS

From 2012 through 2017, seven patients were diagnosed with scaphoid nonunion at our hospital and based on the inclusion/exclusion criteria, five of them were analyzed herein. The surgery was performed according to Zaidemberg's technique. The bone screw in each case was made from autologous tibial cortex using a numerically controlled lathe (model MTS4, Nano Co., Yokohama, Japan) under sterile conditions. The change in each patient's modified Mayo wrist score between the preoperative examination and at the final survey was determined, as were complications.

RESULTS

The median modified Mayo wrist score improved significantly from 65 to 95 points. All patients who were followed for > 2 years fused at a median duration of 3.5 months. Bone regeneration was confirmed at the donor sites in all cases. One fracture at the donor site occurred as a severe complication.

CONCLUSIONS

Precisely shaped autologous bone screws manufactured by a computer-assisted machine, together with a vascularized bone graft, may be a useful technique for treating scaphoid nonunions; these screws had good stability and bone replacement. Careful observation of the donor site is required.

LEVEL OF EVIDENCE

IV.

Scaphoid Nonunion: A Review of Surgical Strategies

The scaphoid is predisposed to nonunion after fracture because of its tenuous blood supply and propensity for delayed diagnosis. Many surgical techniques exist and continue to be developed to treat scaphoid non-unions. However, with variability in patient presentation, differences in nonunion location and type, and multiple bone graft sources and fixation options, selecting a surgical strategy proves a difficult task. The goal of this article is to provide an updated review of surgical strategies used to treat scaphoid nonunions. Particular attention is paid to methods of fixation as well as the ongoing debate over indications for structural and vascularized bone grafting. [Orthopedics. 2022;45(5):e235-e242.].

[Arthroscopic reconstruction of scaphoid nonunions]

OBJECTIVE

Minimally invasive arthroscopically assisted reconstruction of scaphoid nonunions.

INDICATIONS

Delayed union or nonunion of the scaphoid with sclerosis and with indication for bone transplantation. Limited arthritic changes at the radial styloid.

CONTRAINDICATIONS

Severe humpback deformity with dorsal intercalated segment instability. Midcarpal arthritic changes.

SURGICAL TECHNIQUE

Supine position with the forearm upright and in neutral position, the elbow flexed by 90°, axial traction of 3 to 4 kg. Standard wrist arthroscopy via the 3-4 and the 4-5 portal and the midcarpal joint via the radial and ulnar portal, respectively, with sodium chloride as arthroscopy medium. Change of the optic to the ulnar midcarpal portal and opening of the nonunion with an elevator via the radial midcarpal portal. Resection of the sclerosis with a 3.0 mm burr while irrigating the joint. Harvesting of cancellous bone via the second extensor compartment. On the hand table, closed reduction by joy-stick K‑wires if needed and insertion of K‑wires for the scaphoid screw. Insertion of the screw without entering of the distal thread into the bone. Arthroscopic insertion of the bone transplant by a blunt drill sleeve via the radial portal with steady compression by the obturator. Complete insertion of the screw under arthroscopic control of the compression of the nonunion space with arthroscopic control of stability with the probe.

POSTOPERATIVE MANAGEMENT

Six weeks forearm cast including the thumb metacarpophalangeal joint, radiographic control and non-load bearing movements for two more weeks, CT scan in the oblique sagittal plane after 8 weeks, and increase of load, as well as physiotherapy on demand depending on the radiographic results.

RESULTS

To date, 17 patients with a mean age of the nonunion of 18 months were treated. In 14 patients, bony union was achieved after 8 weeks. In one patient, an extraosseous screw placement was corrected. In another patient with extraosseous screw placement, persisting nonunion was treated with an angular stable plate. One scaphoid demonstrated an asymptomatic tight nonunion after 14 months, while one scaphoid with sclerosis of the proximal pole did not heal.

Intraoperative damage to surgical gloves during various operations on the musculoskeletal system: a multicenter study

INTRODUCTION

Various orthopedic surgical procedures cause mechanical stress for gloves. In some cases, sharp-edged objects impact on the glove surfaces. The systematic description of lesions is still missing.

METHODS

2289 gloves from 409 surgeries [primary hip and knee arthroplasties (PA), revisions arthroplasties (RA) and arthroscopic shoulder, hip and knee surgery (AY)] from 3 clinics were examined for lesions using water tightening test according to the European norm EN 455-1.

RESULTS

Arthroscopies showed the lowest rate of operations with damaged gloves (6.9%). Depending on clinic, 32.7% and 59.2% of PA surgeries generated damaged gloves, while in RA, these numbers rose to 76.0% and 72.8%, respectively. In PA and RA, the most affected finger was the index finger, whereas in arthroscopies, more damage occurred on the middle finger and the thumb. The size of the lesions was rather small with the vast majority being 1 mm or 2 mm in size.

CONCLUSION

All investigated interventions led to glove lesions. With increasing mechanical stress, the number of glove defects increased. EN 455 does not account for the intraoperative tear risk. Stricter requirements for gloves should be introduced. Glove change intervals should be defined and implemented, and new materials should be developed.

Volar Plating versus Headless Compression Screw Fixation of Scaphoid Nonunions: A Meta-analysis of Outcomes

Background  Headless compression screw fixation with bone grafting has been the mainstay of treatment for scaphoid nonunion for the past several decades. Recently, locked volar plate fixation has gained popularity as a technique for scaphoid fixation, especially for recalcitrant or secondary nonunions. Purpose  The purpose of this meta-analysis was to compare union rates and clinical outcomes between locked volar plate fixation and headless compression screw fixation for the treatment of scaphoid nonunions. Methods  A literature search was performed for studies documenting treatment outcomes for scaphoid nonunions from 2000 to 2020. Inclusion criteria consisted of (1) average age > 18 years, (2) primary study using screw fixation, plate fixation, or both, with discrete data reported for each procedure, and (3) average follow-up of at least 3 months. Exclusion criteria consisted of studies with incomplete or missing data on union rates. Data from each study was weighted, combined within treatment groups, and compared across treatment groups using a generalized linear model or binomial distribution. Results  Following title and full-text review, 23 articles were included for analysis. Preoperatively, patients treated with plate fixation had significantly longer time from injury to surgery and were more likely to have failed prior surgical intervention. There was no significant difference between union rates at 92 and 94% for screw and plate fixation, respectively. However, plate fixation resulted in longer time to union and lower modified Mayo wrist scores. Conclusion  Patients treated with locked volar plate fixation were more likely to be used for recalcitrant or secondary nonunions. There was no statistically significant difference in union rates between screw and plate fixation. The results from this meta-analysis support the select use of locked volar plate fixation for scaphoid nonunion, especially recalcitrant nonunions and those that have failed prior surgical repair.

Mid-term follow-up of surgically treated and healed scaphoid fractures

The aim of this study was to evaluate the mid-term results of surgically treated scaphoid fractures since we were concerned that good results might deteriorate over time due to osteoarthritis or functional impairment. Thirty-three out of 121 surgically treated patients (isolated scaphoid fractures n = 23; scaphoid fractures with concomitant injuries n = 10) were evaluated retrospectively (47-138 months). Five patients (4%) had a non-union after internal fixation and were excluded because of additional treatment. The remaining 83 patients were not available for a follow-up examination. Patients with an isolated scaphoid fracture had a mean extension-flexion of 68°-0°-64°, a radial-ulnar deviation of 27°-0°-41° and a grip strength of 39 kg (corresponding to 87-98% of the uninjured contralateral wrist), while patients with concomitant injuries had a mean extension-flexion of 60°-0°-44°, radial-ulnar deviation of 22°-0°-38° and a grip strength of 42 kg (corresponding to 73-98% of the uninjured contralateral wrist). The Michigan Hand Questionnaire score was 85 and 75 and the Patient-Rated Wrist Evaluation score was 8 and 21, respectively. Fifteen patients had radiological signs of radiocarpal osteoarthritis with a significantly higher occurrence in those who had concomitant injuries compared to those with isolated scaphoid fractures (p < 0.01). There was no significant group difference in scaphotrapeziotrapezoid (STT) osteoarthritis (p = 0.968). One STT osteoarthritis case occurred after plate fixation, one after antegrade screw fixation and 10 after retrograde screw fixation. Surgical treatment of an acute isolated scaphoid fracture has excellent clinical, functional, and radiologic mid-term results, while scaphoid fractures with concomitant wrist injuries have slightly inferior results.

Postoperative Outcomes of Volar Plate Fixation in Cases of Scaphoid Deformity or Nonunion: A Case Series

Background  Fractures through the waist of scaphoid are a common injury, resulting in deformity or nonunion. Recently, a locking plate has been shown to fix deformity or nonunion of scaphoid, with limited observation of functional postoperative outcomes. Objectives  We present a case series of 16 patients, with the disabilities of the arm, shoulder, and hand (DASH) score evaluation in primary fixation of scaphoid fractures with humpback deformity ( n  = 11) and revision open reduction internal fixation (ORIF) for nonunion ( n  = 5), using the Medartis TriLock 1.5 scaphoid plate and bone grafting. Patients and Methods  DASH scores were obtained preoperatively and postoperatively at 3, 6, and 12 (if required) months. Patient demographics, smoking status, employment type, and grip strengths were recorded. Results  Thirteen patients attended follow-up. Union was clinically and radiologically assessed with 13 achieving union. The mean preoperative DASH score was 34.0 ( n  = 16) and at treatment completion (discharge or DNA) was 11.5 ( n  = 13), with mean reduction of 18.5 ( p  = 0.03). At treatment completion, mean reduction in DASH score of revision ORIF was 13.7 ( p  = 0.27; n  = 4), compared with 20.7 ( p  < 0.01; n  = 9) in primary fixation with plate. Conclusions  Deformity correction, reduction in DASH score, and rate of union make the plate system useful in the management of scaphoid fractures with humpback deformity and revision for nonunion. Level of Evidence  This is a Level IV study.

Volar Scaphoid Plating for Nonunion: A Multicenter Case Series Study

Background  The volar scaphoid plate from Medartis (Medartis AG, Austrasse, Basel, Switzerland) is a variable angle titanium locking plate, preformed for the volar aspect of the scaphoid. It does not have compressive capability, and may act as a bridging device. It may provide an advantage over a compression screw where the pathoanatomy is less favorable to such a device with increased rotational stability. It may act as a buttress plate for correction of humpback deformity for example. It has been used in nonunions and with vascularized grafts. Questions  Our study aims to assess the results of our patients with scaphoid nonunion treated with scaphoid volar plating over a larger number of patients. We aim to identify techniques to increase the success of plating. Methods  Patients from our cohort were retrospectively reviewed. Operations were performed by three hand fellowship trained surgeons and in two centers. Inclusion involved a scaphoid plate procedure for a nonunion of the scaphoid with a minimum of 6 months of follow-up. Exclusions were those who had less than 6 months of follow-up. Data included demographics, patient-rated wrist evaluation (PRWE), a quick disabilities of the arm, shoulder, and hand (qDASH), visual analogue score, and range and grip. Radiology was reviewed. Results  Thirty-two eligible patients were assessed. The mean age was 25 years (range 13-46), 2 were female and 15 were smokers. Mean follow-up postsurgery was 18 months. Twenty-nine of 32 patients united (90.6%) on computed tomography scan. Clinical assessment was performed in the 25 patients. The mean qDASH score was 12.5 (range 0-42) and mean PRWE was 11 (range 0-54). The mean arc of motion was 115 degrees. The mean grip strength was 39 kg compared with 41 kg on the nonoperated side. Conclusion  We postulate that the plate acts like an internal bridging device, acting over a small distance, and inherent stability of the construct with structural graft and accurate reduction prior to plating is advantageous. Potential problems include plate impingement on the volar lip of the radius, particularly when trying to plate more proximal fractures. Ideally, it is utilized for mid to distal waist fractures.

Clinical and radiological results of the vascularized medial femoral condyle graft for scaphoid non-union

INTRODUCTION

This study evaluated the use of a free vascularized bone graft with and without cartilage from the medial femoral condyle (MFC) in patients with recalcitrant scaphoid non-union, with a special focus on union rates and the osteochondral graft for proximal pole destruction.

MATERIALS AND METHODS

Thirty-eight avascular scaphoid non-unions in 37 patients who were treated with a free osteoperiosteal or osteochondral MFC graft were retrospectively evaluated (mean follow-up 16 months). Bone union, the scapholunate and the radiolunate angles were evaluated on X-ray images. The range of motion, grip strength, VAS, DASH and PRWE scores were evaluated clinically.

RESULTS

The overall union rate was 95%. Bone union was achieved in 27 out of 29 (93%) scaphoids treated with a free osteoperiosteal MFC grafts and in 9 out of 9 (100%) scaphoids treated with a free osteochondral MFC graft. The range of motion remained almost unchanged, while grip strength increased significantly (34 kg vs. 44 kg) and the VAS (22-5), DASH (59-19) and PRWE (62-30) score decreased significantly. The scapholunate (71°-65°) and radiolunate (28°-18°) angle decreased. No major donor site morbidity was observed. Postoperative complications were observed in eight cases (21%).

CONCLUSIONS

The vascularized medial femoral bone graft leads to a good functional outcome in the treatment of scaphoid non-unions. The graft provides adequate blood supply and structural stability to the scaphoid. A proximal pole destruction can be replaced using an osteochondral graft with promising short-term results preventing carpal osteoarthritis and collapse.