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Samade R, Awan HM. Surgical Treatment of Scaphoid Fractures: Recommendations for Management. J Wrist Surg 2024; 13:194-201. [PMID: 38808184 PMCID: PMC11129893 DOI: 10.1055/s-0043-1772689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 07/20/2023] [Indexed: 05/30/2024]
Abstract
Background: Several operative treatments exist for scaphoid fractures, varying by approach (e.g., ercutaneous, volar, or dorsal), implant type (e.g., screw or Kirschner wire), and bone raft choice (e.g., none, nonvascularized, or vascularized). Many previous systematic eviews and meta-analyses have investigated outcomes following different surgicalÚpproaches, the use of vascularized versus nonvascularized bone graft for scaphoidßracture nonunions, and treatment for specific fracture patterns. However, given the advancements n scaphoid fracture treatment in recent years, there is a need for updated treatment recommendations hat would be beneficial to hand surgeons. Purpose: We present a comprehensive review of the operative treatment of scaphoid fractures based on recent literature and propose a unified treatment algorithm for managing these fractures. Methods: The English-language literature was searched from 2002 to 2023 for high evidence level (e.g., randomized trials), review, and meta-analysis articles with the following search terms: "scaphoid, "u8220"scaphoid" AND "nonunion, " and "scaphoid" AND "malunion. " Each article was creened by the authors to determine the scaphoid fracture scenario addressed and ubsequent treatment recommendations. The findings from article reviews were then rganized by scaphoid fracture types in this manuscript. Results: A total of 95 pertinent articles were ultimately selected and used as the basis for reviewing different scaphoid fracture scenarios. A treatment algorithm was then proposed based on literature review. Conclusion: This summary of the recent literature can guide hand surgeons in addressing scaphoidßractures. Future research in scaphoid fracture treatment, particularly for nonunions, would be most beneficial n the form of systematic review, meta-analysis, or multicenter prospective randomized clinical trials. Level of Evidence: IV.
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Affiliation(s)
- Richard Samade
- Department of Orthopaedic Surgery, Division of Hand and Upper Extremity Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Hisham M. Awan
- Division of Hand and Upper Extremity Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
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Kjaer M, Rasmussen JV, Gvozdenovic R. Arthroscopic versus open cancellous bone grafting for scaphoid delayed/nonunion in adults (SCOPE-OUT): study protocol for a randomized clinical trial. Trials 2023; 24:273. [PMID: 37060040 PMCID: PMC10103438 DOI: 10.1186/s13063-023-07281-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 03/28/2023] [Indexed: 04/16/2023] Open
Abstract
BACKGROUND Scaphoid non-union results in pain and decreased hand function. Untreated, almost all cases develop degenerative changes. Despite advances in surgical techniques, the treatment is challenging and often results in a long period with a supportive bandage until the union is established. Open, corticocancellous (CC) or cancellous (C) graft reconstruction and internal fixation are often preferred. Arthroscopic assisted reconstruction with C chips and internal fixation provides minimal trauma to the ligament structures, joint capsule, and extrinsic vascularization with similar union rates. Correction of deformity after operative treatment is debated with some studies favouring CC, and others found no difference. No studies have compared time to union and functional outcomes in arthroscopic vs. open C graft reconstruction. We hypothesize that arthroscopic assisted C chips graft reconstruction of scaphoid delayed/non-union provides faster time to union, by at least a mean 3 weeks difference. METHODS Single site, prospective, observer-blinded randomized controlled trial. Eighty-eight patients aged 18-68 years with scaphoid delayed/non-union will be randomized, 1:1, to either open iliac crest C graft reconstruction or arthroscopic assisted distal radius C chips graft reconstruction. Patients are stratified for smoking habits, proximal pole involvement and displacement of > / < 2 mm. The primary outcome is time to union, measured with repeated CT scans at 2-week intervals from 6 to 16 weeks postoperatively. Secondary outcomes are Quick Disabilities of the Arm, Shoulder and Hand (Q-DASH), visual analogue scale (VAS), donor site morbidity, union rate, restoration of scaphoid deformity, range of motion, key-pinch, grip strength, EQ5D-5L, patient satisfaction, complications and revision surgery. DISCUSSION The results of this study will contribute to the treatment algorithm of scaphoid delayed/non-union and assist hand surgeons and patients in making treatment decisions. Eventually, improving time to union will benefit patients in earlier return to normal daily activity and reduce society costs by shortening sick leave. TRIAL REGISTRATION ClinicalTrials.gov NCT05574582. Date first registered: September 30, 2022. Items from the WHO trial registry are found within the protocol.
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Affiliation(s)
- Morten Kjaer
- Gentofte Hospitalsvej 1, Opg. 17 St, 2900, Hellerup, Denmark.
- Department of Orthopedic Surgery, Hand Surgery Unit, Copenhagen University Hospital Herlev/Gentofte, 2900, Hellerup, Denmark.
| | - Jeppe Vejlgaard Rasmussen
- Gentofte Hospitalsvej 1, Opg. 17 St, 2900, Hellerup, Denmark
- Department of Orthopedic Surgery, Shoulder and Elbow Surgery Unit, Copenhagen University Hospital Herlev/Gentofte, 2900, Hellerup, Denmark
| | - Robert Gvozdenovic
- Gentofte Hospitalsvej 1, Opg. 17 St, 2900, Hellerup, Denmark
- Department of Orthopedic Surgery, Hand Surgery Unit, Copenhagen University Hospital Herlev/Gentofte, 2900, Hellerup, Denmark
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Shih YC, Wu CC, Shih JT. Arthroscopic treatment of stable nonunion, unstable nonunion, or nonunion of the scaphoid with early degenerative radioscaphoid arthritis. J Orthop Surg Res 2023; 18:123. [PMID: 36804865 PMCID: PMC9942390 DOI: 10.1186/s13018-023-03609-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 02/13/2023] [Indexed: 02/23/2023] Open
Abstract
BACKGROUND This study was designed to analyze the clinical follow-up results (minimum of 2 years) in patients with stable nonunion, unstable nonunion, or nonunion of the scaphoid with early degenerative radioscaphoid arthritis (Lichtman classification stage I-III) treated with arthroscopic osteosynthesis with autogenous bone graft. METHODS We retrospectively recruited 44 consecutive patients with scaphoid fracture nonunion treated with arthroscopy-assisted percutaneous internal fixation with autogenous bone grafts from January 2010 to November 2019. We recorded union and return to activity and analyzed data with regular clinical follow-up at a mean duration of 33 months (range 24-46 months). Clinical (i.e., visual analog scale pain score, grip strength, and range of motion), radiographic, and functional (Mayo Modified Wrist Score (MMWS)) outcomes at the final follow-up were compared with the preoperative assessments and analyzed in patients with different stages. RESULTS We confirmed union in 39 of the 44 patients (88.6%) after a mean 15.4 weeks post-operatively according to clinical examinations and standard radiography. All clinical parameters improved significantly. For the MMWS, there were 25 excellent and 14 good results. Of the 44 patients, 40 (90.9%) returned to work or sports activities at their preinjury levels. Comparisons of the outcomes between patients in different stages of scaphoid nonunion revealed no significant difference in the aspect of union rate, VAS pain score, and functional score improvement. CONCLUSIONS Arthroscopic osteosynthesis with autogenous bone grafts is a reliable and minimally invasive method for achieving nonunion healing and improving clinical outcomes in stage I-III scaphoid nonunion. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Yin-chuan Shih
- grid.414509.d0000 0004 0572 8535Department of Orthopaedic Surgery, En Chu Kong Hospital, New Taipei City, Taiwan, ROC ,grid.412094.a0000 0004 0572 7815Department of Orthopaedic Surgery, National Taiwan University Hospital, Taipei, Taiwan, ROC ,grid.19188.390000 0004 0546 0241Department of Orthopaedic Surgery, School of Medicine, National Taiwan University, Taipei, Taiwan, ROC ,grid.413051.20000 0004 0444 7352Department of Biomedical Engineering, Yuanpei University of Medical Technology, Hsinchu, Taiwan, ROC
| | - Chang-Chin Wu
- grid.414509.d0000 0004 0572 8535Department of Orthopaedic Surgery, En Chu Kong Hospital, New Taipei City, Taiwan, ROC ,grid.412094.a0000 0004 0572 7815Department of Orthopaedic Surgery, National Taiwan University Hospital, Taipei, Taiwan, ROC ,grid.19188.390000 0004 0546 0241Department of Orthopaedic Surgery, School of Medicine, National Taiwan University, Taipei, Taiwan, ROC ,grid.413051.20000 0004 0444 7352Department of Biomedical Engineering, Yuanpei University of Medical Technology, Hsinchu, Taiwan, ROC
| | - Jui-Tien Shih
- Department of Orthopaedic Surgery, Armed Forces Taoyuan General Hospital, 168, Joing-Hsing R, LongTan County, Taoyuan, Taiwan, ROC.
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Abstract
To report the clinical and radiological outcomes of arthroscopic bone grafting and percutaneous K-wire fixation without radial styloidectomy in patients with scaphoid nonunion advanced collapse (SNAC). We retrospectively analyzed the records of 15 patients with SNAC who were treated with arthroscopic bone grafting and percutaneous K-wire fixation and subsequently followed up for a minimum of 1 year between November 2009 and March 2018. The clinical outcomes were evaluated by comparing the range of motion (ROM), grip strength, the modified Mayo Wrist Score, and visual analog scale (VAS) scores for pain, all of which were measured preoperatively and at the last follow-up. The radiologic outcomes were evaluated by comparing the scapholunate (SL) and radiolunate (RL) angles preoperatively and at the last follow-up. All 15 cases of nonunion were resolved. The average radiologic union time was 9.7 ± 1.2 weeks. The average VAS score increased from 5.7 ± 2.3 (range, 2 - 10) preoperatively to 1.3 ± 1.3 (range, 0 - 3) at the last follow-up (P < .05). The average modified Mayo wrist score increased from 58.3 ± 14.0 preoperatively to 80.0 ± 9.2 at the last follow-up (P < .05). The mean ROM of the wrist improved, but there was no statistical significance. At the last follow-up, the mean flexion and radial deviation on the affected side were significantly decreased, and the mean extension on the affected side was significantly improved compared to the normal side (P < .05). The mean preoperative SL and RL angles were 66 ± 11.9° and 7.2 ± 6.8°, respectively, and were decreased to 50.4 ± 7.5° and 6.4 ± 5.2°, respectively, at the last follow-up. The mean SL angle was significantly corrected (P = .01). Arthroscopic bone grafting and percutaneous Kerschner (K)-wire fixation without radial styloidectomy are considered to be very effective methods for correcting scaphoid deformities to treat SNAC stage I. However, caution may be needed during the surgery to prevent reductions in flexion and the radial deviation of the wrist.
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Affiliation(s)
- Young-Keun Lee
- Department of Orthopedic Surgery, Research Institute of Clinical Medicine of Jeonbuk National University – Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, Jeonbuk, Republic of Korea
- *Correspondence: Young Keun Lee MD, PhD, Department of Orthopedic Surgery, Jeonbuk National University Medical School, 567 Baekje-daero, Deokjin-gu, Jeonju-si, Jeollabuk-do 54896, Republic of Korea (e-mail: )
| | - Young-Ran Jung
- Department of Orthopedic Surgery, Soo Sarang General Hospital, Iksan, Jeonbuk
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Li C, Peng Z, Zhou Y, Ruan M, Su YY, Liu S, Meng XH, Xu YQ. The progress in the classification and treatment of scaphoid nonunion. Surgeon 2022; 20:e231-e235. [PMID: 35750549 DOI: 10.1016/j.surge.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 05/26/2022] [Indexed: 10/17/2022]
Abstract
Scaphoid fracture is the most common carpal fracture, accounting for 50%-80% of all carpal fractures in the Youngers and manual workers. The nonunion rate of scaphoid fractures was approximately 10-15%. Scaphoid nonunion can lead to wrist deformity, wrist collapse, ischemic necrosis, and traumatic osteoarthritis resulting in the loss of wrist function and seriously influence the patients' lives. Achieving bony union is essential for the treatment of scaphoid nonunion. Although many surgical procedures including various forms of bone grafting have been developed to improve bony union, there is no conclusion about which method is the most effective and optimal. In this review, we provide an overview of the diagnostic, classification and progress in the treatments of scaphoid nonunion fractures.
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Affiliation(s)
- Chuan Li
- Department of Orthopaedic, Kunming Medical University, Kunming 650500, China; Department of Orthopaedic, 920th Hospital of Joint Logistics Support Force, Kunming 650032, China
| | - Zhi Peng
- Department of Orthopaedic, Kunming Medical University, Kunming 650500, China
| | - You Zhou
- Department of Orthopaedic, Children's Hospital of Kunming Medical University, Yunnan 650228, China
| | - Mo Ruan
- Department of Orthopaedic, 920th Hospital of Joint Logistics Support Force, Kunming 650032, China
| | - Yong-Yue Su
- Department of Orthopaedic, 920th Hospital of Joint Logistics Support Force, Kunming 650032, China
| | - Shuai Liu
- Department of Orthopaedic Surgery, Sheng-Jing Hospital, China Medical University, Shenyang 110004, China
| | - Xu-Han Meng
- Department of Orthopaedic, 920th Hospital of Joint Logistics Support Force, Kunming 650032, China
| | - Yong-Qing Xu
- Department of Orthopaedic, 920th Hospital of Joint Logistics Support Force, Kunming 650032, China.
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Teng XF, He XK, Chen H, Ruan J. Arthroscopic Treatment of Intraosseous Ganglion Cysts of the Carpus. Front Surg 2022; 9:798432. [PMID: 35747440 PMCID: PMC9209637 DOI: 10.3389/fsurg.2022.798432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 05/11/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveTo investigate the application and the clinical efficacy of wrist arthroscopy in the treatment of carpal intraosseous ganglion cysts (IGCs).MethodsA retrospective case study method was adopted to analyze the clinical data of 28 patients with carpal IGCs admitted to the Sixth Hospital of Ningbo from April 2012 to January 2019. A hypodensity in the bone was shown by X-ray before the operation, with hypodensity and cystic change in the bone being confirmed by computed tomography and magnetic resonance imaging. Arthroscopic open window of the wrist, cystectomy, and autologous iliac bone graft implantation were conducted. Regular postoperative X-ray combined with CT follow-ups were conducted to observe the healing after bone implantation. Patients were followed up regularly and assessed by the Modified Mayo Wrist Score in four aspects of the postoperative pain, wrist mobility, grip, and function to provide an objective overall assessment of the therapeutic outcome.ResultsAll 28 patients were followed up for 8–16 months, with an average follow-up duration of 10 months. After the operation, pain disappeared completely for 25 patients, and 3 cases showed significant improvement. All cases were pathologically confirmed as ganglion cysts and had first-stage bony healing after bone grafting with an average healing time of 10.8 weeks. The grip returned to normal for all patients, and wrist flexion and extension were the same as the healthy wrist for 25 patients, with a Modified Mayo Wrist Score of excellent in 19 cases and good in 9 cases. No recurrence was observed.ConclusionIn patients with symptomatic carpal IGCs, the application of arthroscopic open window, cystectomy, and autologous bone graft implantation could achieve satisfactory clinical therapeutic effects.
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Gvozdenovic R, Presman B, Larsen MB, Radev DI, Joerring S, Jensen CH. Can CT-Scan Measurements of Humpback Deformity, Dislocation, and the Size of Bony Cysts Predict Union after Surgery for Scaphoid Nonunion? J Wrist Surg 2021; 10:418-429. [PMID: 34631295 PMCID: PMC8490000 DOI: 10.1055/s-0041-1730342] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 04/13/2021] [Indexed: 10/21/2022]
Abstract
Objective Scaphoid fractures are associated with high rates of late- or nonunion after conservative treatment. Nonunion is reported to occur in approximately 10% of all scaphoid fractures. It is known that the union of scaphoid fractures is affected by factors such as location at proximal pole, tobacco smoking, and the time from injury to treatment. Same factors seem to affect the healing after surgery for scaphoid nonunion. While the impact of preoperative humpback deformity on the functional outcome after surgery has been previously reported, the impact of humpback deformity, displacement, and the presence of bony cysts on union rate and time to healing after surgery has not been studied. Purpose The primary purpose of this study is to assess the association of humpback deformity, fragment displacement, and the size of cysts along the fracture line with the union rate and union time, following surgery of scaphoid nonunion. The second purpose of the study is to investigate the interobserver reliability in the evaluation of computed tomography (CT) scans of scaphoid nonunion. Patients and Methods From January 2008 to December 2018, 178 patients were surgically treated in our institution. After exclusion criteria were met, 63 patients with scaphoid delayed- or established nonunion, and preoperative CT scans of high quality (<2mm./ slice), were retrospectively analyzed. There was 58 men and 5 women with a mean age of 30 years (range: 16-72 years). Four orthopaedic surgeons and one radiologist independently analyzed the CT scans. The dorsal cortical angle (DCA), lateral intrascaphoid angle (LISA), the height-to-length ratio, the size of the cysts, and displacement of the fragments were measured. Healing was defined by CT scan, or by conventional X-ray, and status of no pain at clinical examination. Thirty-two of the patients had developed nonunion (>6 months postinjury), while 31 were in a stage of delayed union (3-6 months postinjury). Results Open surgery with cancellous or structural bone graft was the treatment of choice in 49 patients, 8 patients were treated with arthroscopic bone grafting, and 6 patients with delayed union were operated with percutaneous screw fixation, without bone graft. Overall union rate was 86% (54/63) and was achieved after 84 days (12 weeks) (mean). The failure rate and time to healing were not associated with the degree of the humpback deformity, size of the cysts, or displacement of the nonunion in general. However, greater dislocation, and the localization of the nonunion at the scaphoid waist, showed significant influence on the union rate. Dislocation at nonunion site, in the group of the patients who united after surgery, was 2.7 mm (95% confidence interval [CI]: 1.5-3.7), and in the group who did not unite was 4.2 mm (95% CI: 2.9-5.7); p = 0.048). Time from injury to surgery was significantly correlated with time to union ( p < 0.05), but not associated with the union rate ( p < 0.4). Patients treated arthroscopically achieved faster healing (42 days), (standard deviation [SD]: 22.27) as compared with patients treated by open techniques (92 days; SD: 70.86). Agreement among five observers calculated as intraclass correlation coefficient was for LISA: 0.92; for height-to-length ratio: 0.73; for DCA: 0.65; for size of cysts: 0.61; and for displacement in millimeters: 0.24, respectively. Conclusions The degree of humpback deformity and the size of cysts along the fracture line of scaphoid nonunion have no predictive value for the result, neither for the union rate nor the union time after surgery for the scaphoid nonunion. However, larger dislocation of the fragments measured at the scaphoid waist showed lower union rate. Time to healing following surgery is mainly influenced by the time from injury to the surgical treatment and may be influenced by the choice of the surgical technique. Interrater reliability calculation was best with LISA measurements, and worse with the measurements of the dislocation. Level of Evidence This is a Level III, observational, case-control study.
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Affiliation(s)
- Robert Gvozdenovic
- Department of Orthopedics, Hand Surgery Unit, Herlev/Gentofte Copenhagen University Hospital, Hellerup, Denmark
| | - Benjamin Presman
- Department of Orthopedics, Hvidovre Copenhagen University Hospital, Hvidovre, Denmark
| | - Morten Bo Larsen
- Department of Orthopedics, Hand Surgery Unit, Herlev/Gentofte Copenhagen University Hospital, Hellerup, Denmark
| | - Dimitar Ivanov Radev
- Department of Radiology, Bispebjerg/Frederiksberg Copenhagen University Hospital, Copenhagen NV, Denmark
| | - Stig Joerring
- Department of Orthopedics, Hand Surgery Unit, Herlev/Gentofte Copenhagen University Hospital, Hellerup, Denmark
| | - Claus Hjorth Jensen
- Department of Orthopedics, Hand Surgery Unit, Herlev/Gentofte Copenhagen University Hospital, Hellerup, Denmark
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Lee YK, Kim KB. Arthroscopic-assisted bone grafting and percutaneous K-wires fixation for the treatment of scaphoid nonunion in the skeletally immature patient: Three cases report. Medicine (Baltimore) 2021; 100:e24095. [PMID: 33546015 PMCID: PMC7837869 DOI: 10.1097/md.0000000000024095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 12/08/2020] [Indexed: 11/26/2022] Open
Abstract
RATIONALE The treatment methods of pediatric scaphoid nonunion are still controversial. To our knowledge, arthroscopic-assisted treatments for pediatric scaphoid nonunion has not been reported in the English-language literature. Therefore, the purpose of this study is to report the use of arthroscopic-assisted bone grafting for scaphoid nonunion fracture in 3 patients and present a literature review. PATIENTS CONCERNS Two 15-year-old patients developed carpal joint injuries over a year, prior to their hospital presentation, since they had not received adequate treatment. The third patient, 12 years of age, was diagnosed with scaphoid fracture after a traffic accident and underwent conservative treatment but presented to the hospital due to issues related with bone union. DIAGNOSIS All 3 patients were diagnosed with scaphoid nonunion at our hospital, using plain wrist radiographs and computed tomography. INTERVENTIONS All the patients underwent arthroscopic debridement; 2 patients received autogenous iliac cancellous bone graft, while the other patient received a bone substitute graft. The internal fixation of the scaphoid was performed with K-wires. OUTCOMES Bone unions were achieved in all patients, and the final follow-up resulted in successful outcomes. LESSONS Arthroscopic-assisted bone grafting and percutaneous K-wire fixation can be considered as a good method for the treatment of pediatric scaphoid nonunion fractures. Therefore, it is a primary treatment option for symptomatic scaphoid nonunion fracture and displaced fractures.
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Simpson CR, Kelly HM, Murphy CM. Synergistic use of biomaterials and licensed therapeutics to manipulate bone remodelling and promote non-union fracture repair. Adv Drug Deliv Rev 2020; 160:212-233. [PMID: 33122088 DOI: 10.1016/j.addr.2020.10.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 10/16/2020] [Accepted: 10/20/2020] [Indexed: 12/16/2022]
Abstract
Disrupted bone metabolism can lead to delayed fracture healing or non-union, often requiring intervention to correct. Although the current clinical gold standard bone graft implants and commercial bone graft substitutes are effective, they possess inherent drawbacks and are limited in their therapeutic capacity for delayed union and non-union repair. Research into advanced biomaterials and therapeutic biomolecules has shown great potential for driving bone regeneration, although few have achieved commercial success or clinical translation. There are a number of therapeutics, which influence bone remodelling, currently licensed for clinical use. Providing an alternative local delivery context for these therapies, can enhance their efficacy and is an emerging trend in bone regenerative therapeutic strategies. This review aims to provide an overview of how biomaterial design has advanced from currently available commercial bone graft substitutes to accommodate previously licensed therapeutics that target local bone restoration and healing in a synergistic manner, and the challenges faced in progressing this research towards clinical reality.
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Affiliation(s)
- Christopher R Simpson
- Tissue Engineering Research Group, Department of Anatomy and Regenerative Medicine, Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
| | - Helena M Kelly
- Tissue Engineering Research Group, Department of Anatomy and Regenerative Medicine, Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland; School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
| | - Ciara M Murphy
- Tissue Engineering Research Group, Department of Anatomy and Regenerative Medicine, Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland; Trinity Centre for Biomedical Engineering, Trinity College Dublin (TCD), Dublin, Ireland; Advanced Materials and Bioengineering Research Centre (AMBER), RCSI and TCD, Dublin, Ireland.
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Haugstvedt JR, Wong CWY. Arthroscopic treatment for nonunion of the scaphoid. HANDCHIR MIKROCHIR P 2020; 52:413-418. [DOI: 10.1055/a-1242-4415] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
AbstractScaphoid nonunion has traditionally been treated by open surgery where the pseudarthrosis has been cleaned while either a structural wedged bone graft, or chips of cancellous bone has been used to fill the defect. K-wires or a screw has been used to stabilize the bone. Using the arthroscopic technique for treatment of nonunion of the scaphoid gives us small exposure to the joint, however with an excellent view of the bones, the articular surfaces and the intraarticular ligaments. The results from arthroscopic treatment for scaphoid nonunion with bone grafting using chips of cancellous bone are as good as from the open technique. The arthroscopic treatment, though, helps us to diagnose and treat concomitant lesions. There is less damage of blood supply, nerves and capsule, which might lead to a faster recovery and rehabilitation. The technique will be described and discussed.
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Affiliation(s)
| | - Clara Wing-yee Wong
- Department of Orthopedics & Traumatology, The Chinese University of Hong Kong
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Gvozdenovic R, Joergensen RW, Joerring S, Jensen CH. Arthroscopically Assisted Bone Grafting Reduces Union Time of Scaphoid Nonunions Compared to Percutaneous Screw Fixation Alone. J Wrist Surg 2020; 9:13-18. [PMID: 32025348 PMCID: PMC7000248 DOI: 10.1055/s-0039-1693146] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Accepted: 05/18/2019] [Indexed: 10/26/2022]
Abstract
Purpose Minimally invasive techniques have been recommended in the treatment of painful but stable scaphoid nonunions. The purpose of this study was to determine if arthroscopically assisted bone grafting provided superior results in healing as compared to percutaneous screw fixation. Materials and Methods One hundred sixty-four consecutive patients with scaphoid nonunions were retrospectively analyzed. One hundred forty-eight patients were treated with the open grafting techniques either with iliac or distal radius bone, leaving 16 patients treated with minimally invasive surgery. In the group treated percutaneously ( n = 8), the time from injury to surgery was 2.5 months (range: 2-4 months) and it was 27.3 months (range: 3-180 months) in the arthroscopic group ( n = 8). The mean age was 39 years (range: 20-66) in the percutaneous group and 22 years (range: 16-32) in the arthroscopic group. In all cases, the Mini Acutrak headless fully threaded compression screw was used. Healing was assessed clinically and radiographically at a minimum follow-up of 12 weeks, mean 7 months (range: 3-12 months). Data were calculated with two-tailed Mann-Whitney U test based on p -value of < 0.05 that was considered statistically significant. Results We recorded no complications in any of the groups. Patients treated arthroscopically received cancellous bone grafting from the distal radius and all patients but one healed at a median of 7.8 weeks (range: 5-18 weeks). Seven patients in the percutaneous group healed at a mean of 10.5 weeks (range: 7-24 weeks), thus leaving one patient from each group without achieving union. Mann-Whitney U test showed the U value of 11, the critical value of U to be 13 ( p < 0.05), thus significantly faster healing was observed in the arthroscopically treated group. Conclusions Arthroscopically treated patients achieved faster healing despite shorter time to surgery in the percutaneous group. Local bone grafting is considered as the main reason for this outcome. Younger population in the arthroscopically treated group may have influenced the result. Level of Evidence This is a Level III comparative study.
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Affiliation(s)
- Robert Gvozdenovic
- Gentofte/Herlev Hospital, University of Copenhagen, Department of Orthopedic Surgery, Hand Surgery Unit, Gentofte Hospital, Kildegårdsvej, Hellerup, Denmark
| | - Rasmus Wejnold Joergensen
- Gentofte/Herlev Hospital, University of Copenhagen, Department of Orthopedic Surgery, Hand Surgery Unit, Gentofte Hospital, Kildegårdsvej, Hellerup, Denmark
| | - Stig Joerring
- Gentofte/Herlev Hospital, University of Copenhagen, Department of Orthopedic Surgery, Hand Surgery Unit, Gentofte Hospital, Kildegårdsvej, Hellerup, Denmark
| | - Claus Hjort Jensen
- Gentofte/Herlev Hospital, University of Copenhagen, Department of Orthopedic Surgery, Hand Surgery Unit, Gentofte Hospital, Kildegårdsvej, Hellerup, Denmark
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Kim JP, Seo JB. Editorial Commentary: The Practical Goal of Arthroscopic Osteosynthesis for the Treatment of Unstable Scaphoid Nonunion. Arthroscopy 2018; 34:2819-2820. [PMID: 30286881 DOI: 10.1016/j.arthro.2018.07.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 07/30/2018] [Indexed: 02/02/2023]
Abstract
Arthroscopic reduction with osteosynthesis using bone grafting has become a successful alternative to open techniques for the treatment of chronically unstable scaphoid nonunions. Several studies have demonstrated that arthroscopic techniques are safe and reproducible in addition to causing less soft tissue damage and providing promising short- and mid-term results. However, these techniques have limitations in restoring normal carpal alignment, especially in patients with unstable scaphoid nonunion and carpal collapse deformities, although this does not affect the recovery of clinical function. Therefore, the practical goal of arthroscopic technique should be kept in mind when treating unstable scaphoid nonunions.
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Oh WT, Kang HJ, Chun YM, Koh IH, Lee YJ, Choi YR. Retrospective Comparative Outcomes Analysis of Arthroscopic Versus Open Bone Graft and Fixation for Unstable Scaphoid Nonunions. Arthroscopy 2018; 34:2810-2818. [PMID: 30173911 DOI: 10.1016/j.arthro.2018.04.024] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 04/23/2018] [Accepted: 04/25/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare union rates and clinical and radiologic outcomes after arthroscopic and open bone grafting and internal fixation for unstable scaphoid nonunions. METHODS Between March 2009 and November 2014, patients with unstable scaphoid nonunion underwent arthroscopic (group A) or open (group O) bone grafting and internal fixation. One senior surgeon alternatively performed either arthroscopic or open osteosynthesis for the same surgical indications. Visual analog scale score, grip strength, active range of motion, Mayo wrist score (MWS), and Disabilities of Arm, Shoulder, and Hand score were assessed preoperatively and postoperatively. Union was determined by computed tomography 8 to 10 weeks postoperatively with bridging trabecula at the nonunion site. Scapholunate angle (SLA), radiolunate angle (RLA), and lateral intrascaphoid angle (LISA), plus height/length ratio (HLR) served to gauge carpal bone alignment in preoperative and postoperative radiographs. Those outcomes of patients with carpal collapse deformities, who met following conditions; (1) LISA of >45° or HLR of >0.65 on computed tomography images or (2) SLA of >60° or RLA of >10° on plain radiographs, were also compared. RESULTS Overall, 62 patients qualified for study (group A, 28; group O, 34). Union rates did not differ by patient subset (group A, 96.4%; group O, 97.1%; P ≒ 1); and visual analog scale score, grip strength, range of motion, Mayo Wrist Score, and Disabilities of Arm, Shoulder, and Hand scores were similar at last follow-up. In radiographic assessments, SLA, RLA, and LISA were similar, whereas scaphoid HLR excelled through open technique (group A, 0.59 ± 0.07; group O, 0.55 ± 0.05; P = .002). Subgroup analysis of patients with carpal collapse deformities (group A, 9; group O, 14) showed that all radiographic measures in group A (vs group O) reflected lesser correction (SLA, 56.7° ± 7.3° vs 49.2°±9.1° [P = .049]; RLA, 9.2° ± 2.0° vs 5.7° ± 3.0° [P = .005]; LISA, 34.8° ± 4.8° vs 25.6° ± 13.0° [P = .028]; HLR, 0.66 ± 0.04 vs 0.54 ± 0.07 [P < .001]). CONCLUSIONS Arthroscopic and open bone grafting and internal fixation in treating unstable scaphoid nonunions, did not show any significant differences in clinical and radiologic outcomes at the minimum of 2 years after operation. In scaphoid nonunions with carpal collapse deformities, open bone grafting restored better carpal alignment than arthroscopic bone grafting, although there were no differences in clinical outcomes between the 2 techniques. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Won-Taek Oh
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Ho-Jung Kang
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Yong-Min Chun
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Il-Hyun Koh
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Yong-Jun Lee
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Yun-Rak Choi
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea.
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Lee YK, Choi KW, Woo SH, Ho PC, Lee M. The clinical result of arthroscopic bone grafting and percutaneous K-wires fixation for management of scaphoid nonunions. Medicine (Baltimore) 2018; 97:e9987. [PMID: 29595703 PMCID: PMC5895373 DOI: 10.1097/md.0000000000009987] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
The purpose of this study is to analyze the clinical results of patients with scaphoid nonunion treated with arthroscopic bone grafting and K (Kirschner)-wires fixation.We retrospectively reviewed the records of 27 patients with scaphoid nonunion who had been treated with arthroscopic bone grafting and K-wires fixation method from November 2008 to February 2014. The average patient age was 35 years. The time from injury to treatment averaged 45 months. The average follow-up period was 18 months. Bone union was assessed using serial plain radiographs. The functional outcome was evaluated by comparing the modified Mayo wrist score with the visual analog scale (VAS) for pain, which were measured at the time of preoperation and at final follow-up.Union was achieved in 26 of the 27 nonunions (96.29%). The average radiologic union time was 10 weeks. The average VAS score decreased from 6.38 (range, 3-10) preoperatively to 1.59 (range, 0-3) at the final follow-up. The average modified Mayo wrist score improved from 60.19 preoperatively to 83.46 at the final follow-up. According to this score, there were 12 excellent, 6 good, and 9 fair results at the final follow-up.Arthroscopic bone grafting and percutaneous K-wires fixation is an effective treatment method for a scaphoid nonunion and has the advantages of allowing thorough assessment, enabling a comprehensive management approach for scaphoid nonunion in a minimally invasive manner, and this method can also be used for the scaphoid nonunion with SNAC stage I.
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Affiliation(s)
- Young-Keun Lee
- Department of Orthopedic Surgery, Research Institute of Clinical Medicine of Chonbuk National University – Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Chonbuk
| | - Kwang-Wook Choi
- Department of Orthopedic Surgery, Research Institute of Clinical Medicine of Chonbuk National University—Biomedical Research Institute of Chonbuk National University Hospital, Jeonju
| | - Sang-Hyun Woo
- W Institute for Hand and Reconstructive Microsurgery, W Hospital, Daegu, Republic of Korea
| | - Pak Cheong Ho
- Department of Orthopaedic and Traumatology, Prince of Wales Hospital, Shatin, N.T., Hong Kong
| | - Malrey Lee
- The Research Center for Advanced Image and Information Technology, School of Electronics & Information Engineering, Chonbuk National University, JeonJu, Chonbuk, Republic of Korea
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15
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Arthroscopic reconstruction for unstable scaphoid non-union. Rev Esp Cir Ortop Traumatol (Engl Ed) 2017. [DOI: 10.1016/j.recote.2017.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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16
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Arthroscopic reconstruction for unstable scaphoid non-union. Rev Esp Cir Ortop Traumatol (Engl Ed) 2017; 61:216-223. [PMID: 28473231 DOI: 10.1016/j.recot.2017.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Revised: 02/27/2017] [Accepted: 03/07/2017] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To evaluate the results of arthroscopic reconstruction for the treatment of unstable scaphoid non-union with cancellous bone autograft. METHODS 13 patients were treated with a mean age of 26 (18-45) years. The average time from injury until surgery was 14 (6-48) months. Preoperative and postoperative clinical and radiological parameters were evaluated. Mean follow-up was 16.8 (12-36) months. RESULTS Consolidation was achieved in all cases at 7 (4-10 weeks), no patient had complications or reoperations. Range of motion, pain, functional assessment (DASH questionnaire) and radiological measurements improved compared to preoperative measurements. The average range of flexion improved: flexion 71.9° (55°-80°) to 81.7° (55°-90°), extension 66.3° (30°-80°) to 84.4° (70° -90°), ulnar deviation 21.5 (10°-25°) to 25.5° (20°-45°) and radial deviation 11.9° (5°-25°) to 13.3° (10th-20th). Pain (VAS 0-10) improved from 6.8 (4-10) to 0.7 (0-3). DASH functional scale improved from 36 (12-78) to 8 (0-10). The Scapho-Lunate Angle improved from 67.7° (62°-88°) to 47° (32°-55°), and the Radio-Lunate Angle improved from 30.8° (10° -45°) to 4(0°-10°). CONCLUSION Treatment of unstable scaphoid non-union with cancellous bone graft assisted by arthroscopy presents good clinical results with a short period of consolidation and recovery.
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Abstract
Scaphoid fracture is the most common carpal fracture of the upper extremity and a significant proportion of these can eventually progress to nonunion. Excision of pseudoarthrosis and fibrous scar tissue at the nonunion site is regarded as one of the important steps in management of scaphoid nonunions. We describe a technique of internal bone grafting, where curettage of the nonunion site was performed through a drill hole in the scaphoid and bone graft was packed through this same hole before fixation with a headless compression screw. We have been able to achieve a union rate of 86% using this technique. The advantage of the technique is that it does not disturb the external fibrocartilaginous shell that would have formed around the nonunion site, thus leaving the articular surface undisturbed.
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Affiliation(s)
- Utkan Aydin
- Christine M. Kleinert Institute for Hand and Microsurgery, Louisville, KY
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18
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Rhee PC, Jones DB, Shin AY, Bishop AT. Evaluation and Treatment of Scaphoid Nonunions: A Critical Analysis Review. JBJS Rev 2016; 2:01874474-201407000-00004. [PMID: 27490062 DOI: 10.2106/jbjs.rvw.m.00074] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Peter C Rhee
- Division of Hand Surgery, Department of Orthopedic Surgery, Mayo Clinic, 200 1st Street SW, Rochester, MN 55905
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Kang HJ, Chun YM, Oh WT, Koh IH, Lee SY, Choi YR. The Effect of Debridement of Coexisting Partial Ligament Injuries on Outcomes Following Arthroscopic Osteosynthesis for Minimally Displaced Scaphoid Nonunions. J Hand Surg Am 2016; 41:e135-42. [PMID: 27137080 DOI: 10.1016/j.jhsa.2016.04.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 03/06/2016] [Accepted: 04/06/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE Partial intercarpal ligament injuries can coexist with scaphoid nonunions. However, whether these injuries should be debrided simultaneously when scaphoid nonunions are treated is unclear. The purpose of this study was to compare union rates and clinical outcomes after arthroscopic management of scaphoid nonunions, in which coexisting partial ligament injuries were, or were not, simultaneously debrided. METHODS This retrospective study included 46 patients with scaphoid nonunions and coexisting partial intercarpal ligament injuries who underwent arthroscopy-guided bone grafting and fixation (K-wires or headless screws) between March 2008 and May 2014 with a minimum follow-up of 1 year. None of the cases had necrosis of the proximal fragment (determined by contrast-enhanced magnetic resonance imaging), severe deformities, or advanced arthritis. The partial intercarpal ligament injuries were either simultaneously debrided (25 patients; group D) or not debrided (21 patients; group ND). Visual analog scale pain scores, grip strength, flexion-extension arc of the wrist, Mayo Wrist Scores, and Disabilities of Arm, Shoulder, and Hand scores were used to compare clinical outcomes between the 2 groups. RESULTS The nonunions united in 93% (43 of 46) of the patients. There were no differences between the 2 groups with regard to patient demographics, preoperative outcome measures, location of scaphoid nonunion, and degree of ligament injury. The overall union rate was similar between group D (92%; 23 of 25) and group ND (95%; 20 of 21). At a median follow-up of 24 months for group D and group ND, the visual analog scale pain score, grip strength, Mayo Wrist Scores, and Disabilities of the Arm, Shoulder, and Hand scores were significantly improved in both groups, compared with preoperative scores. Flexion-extension arc showed no change in both groups compared with preoperative angles. All of the follow-up measurements were similar in the 2 groups. CONCLUSIONS In patients who underwent arthroscopic bone grafting and fixation of scaphoid nonunions, simultaneous debridement of incidentally found partial intercarpal ligament injuries did not result in a better union rate or clinical outcomes than not debriding the partial ligament injuries. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic III.
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Affiliation(s)
- Ho-Jung Kang
- Department of Orthopaedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Yong-Min Chun
- Department of Orthopaedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Won-Taek Oh
- Department of Orthopaedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Il-Hyun Koh
- Department of Orthopaedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Sang-Yun Lee
- Department of Orthopaedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Yun-Rak Choi
- Department of Orthopaedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea.
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Kang HJ, Chun YM, Koh IH, Park JH, Choi YR. Is Arthroscopic Bone Graft and Fixation for Scaphoid Nonunions Effective? Clin Orthop Relat Res 2016; 474:204-12. [PMID: 26250139 PMCID: PMC4686522 DOI: 10.1007/s11999-015-4495-3] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 07/31/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Arthroscopic management of scaphoid nonunions has been advanced as a less invasive technique that allows evaluation of associated intrinsic and extrinsic ligamentous injuries; however, few studies have documented the effectiveness of arthroscopic treatment of scaphoid nonunions and which intraarticular pathologies coexist with scaphoid nonunions. QUESTIONS/PURPOSES (1) What are the outcomes of arthroscopic management of scaphoid nonunions as assessed by the proportion of patients achieving osseous union, visual analog scale (VAS) pain score, grip strength, range of motion, Mayo Wrist Score (MWS), and Disabilities of the Arm, Shoulder and Hand (DASH) score? (2) What complications are associated with arthroscopic scaphoid nonunion management? (3) What forms of intraarticular pathology are associated with scaphoid nonunions? METHODS Between 2008 and 2012, we treated 80 patients surgically for scaphoid nonunions. Of those, 45 (56%) had arthroscopic management. During that time, our general indications for using an arthroscopic approach over an open approach were symptomatic scaphoid nonunions without necrosis of the proximal fragment, severe deformities, or arthritis. Of the patients treated arthroscopically, 33 (73%) were available for followup at least 2 years later. There were five distal third, 19 middle third, and nine proximal third fractures. The mean followup was 33 months (range, 24-60 months). Union was determined by CT taken at 8 to 10 weeks after operation with bridging trabecula at nonunion site. VAS pain scores, grip strength, active flexion-extension angle, MWS, and DASH scores were obtained preoperatively and at each followup visit. The coexisting intraarticular pathologies and complications were also recorded. RESULTS Thirty-two (97%) scaphoid nonunions healed successfully. At the last followup, the mean VAS pain score decreased (preoperative: mean 4.5 [SD 1.8], postoperative: mean 0.6 [SD 0.8], mean difference: 3.9 [95% confidence interval {CI}, 3.2-4.6], p < 0.001) and the mean active flexion-extension angle increased (preoperative: mean 100° [SD 26], postoperative: mean 109° [SD 16], mean difference: 9° [95% CI, 2-16], p = 0.017). The mean grip strength increased (preoperative: mean 35 kg of force [SD 8], postoperative: mean 50 kg of force [SD 10], mean difference: 15 kg of force [95% CI, 11-19], p < 0.001). The mean MWS increased (preoperative: mean 56 [SD 23], postoperative: mean 89 [SD 8], mean difference: 33 [95% CI, 26-41], p < 0.001) and the mean DASH score decreased (preoperative: mean 25 [SD 18], postoperative: mean 4 [SD 3], mean difference: 21 [95% CI, 15-28], p < 0.001). There were no operation-related complications and no progression of arthritis at the last followup. Seventeen patients had coexisting intraarticular pathology, including nine triangular fibrocartilage complex tears (seven traumatic and two degenerative), 17 intrinsic ligament tears (nine scapholunate interosseous ligament tears and eight lunotriquetral interosseous ligament tears), and five mild radioscaphoid degenerative changes. CONCLUSIONS Arthroscopic management of scaphoid nonunions without severe deformities or arthritis was effective in this small series. Although intraarticular pathologies such as triangular fibrocartilage complex tears and intrinsic ligament injuries commonly coexisted with scaphoid nonunions, patients generally achieved good results. LEVEL OF EVIDENCE Level IV, therapeutic study.
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Affiliation(s)
- Ho Jung Kang
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, 50 Yonseiro, Seodaemun-gu, Seoul, 120-752 South Korea
| | - Yong-Min Chun
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, 50 Yonseiro, Seodaemun-gu, Seoul, 120-752 South Korea
| | - Il Hyun Koh
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, 50 Yonseiro, Seodaemun-gu, Seoul, 120-752 South Korea
| | - Jae Han Park
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, 50 Yonseiro, Seodaemun-gu, Seoul, 120-752 South Korea
| | - Yun Rak Choi
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, 50 Yonseiro, Seodaemun-gu, Seoul, 120-752 South Korea
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Pinder RM, Brkljac M, Rix L, Muir L, Brewster M. Treatment of Scaphoid Nonunion: A Systematic Review of the Existing Evidence. J Hand Surg Am 2015; 40:1797-1805.e3. [PMID: 26116095 DOI: 10.1016/j.jhsa.2015.05.003] [Citation(s) in RCA: 141] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 04/30/2015] [Accepted: 05/01/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine by systematic review the optimal treatment of scaphoid nonunion. METHODS We conducted a systematic review of the literature with a meta-analysis of proportions to investigate the comparative effectiveness of different surgical techniques. RESULTS A total of 48 publications (1,602 patients) met the eligibility criteria. Vascularized and nonvascularized bone grafts had an estimated union incidence of 92% and 88%, respectively. Distal radius and iliac crest bone grafts had similar union rates (89% and 87%, respectively) but harvesting of iliac crest bone grafts had more complications. Both screw and K-wire fixation had a higher incidence of union (88% and 91%, respectively) than no fixation (79%). No approach was statistically different. Patients fixed with screws were mobilized earlier than those with K-wire fixation. CONCLUSIONS Current evidence does not demonstrate a significantly superior method for the treatment of scaphoid nonunion. A multicenter randomized trial would be ideal but the large numbers that would be required may make this unrealistic. We recommend the continued reporting of series with specific assessments and outcome measures to optimize future comparisons in an attempt to determine the best management of scaphoid nonunion. CLINICAL RELEVANCE The use of bone grafts and the methods of their fixation for scaphoid nonunion are debated issues in hand and wrist surgery, with multiple methods employed. There is no current consensus on optimal treatment. A meta-analysis of proportions of available data from recent studies was deemed the most appropriate way to assimilate the available evidence with the view to inform surgeons of the optimal treatment according to the evidence base.
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Affiliation(s)
- Richard M Pinder
- Department of Plastic Surgery, Castle Hill Hospital, Cottingham, United Kingdom.
| | - Milos Brkljac
- University of Manchester Medical School, Greater Manchester, United Kingdom
| | - Louise Rix
- University of Manchester Medical School, Greater Manchester, United Kingdom
| | - Lindsay Muir
- Department of Orthopaedics, Salford Royal NHS Foundation Trust, Salford, United Kingdom
| | - Mark Brewster
- The Birmingham Hand Centre, Royal Orthopaedic Hospital, Northfield, Birmingham, United Kingdom
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Abstract
The difficulty in healing scaphoid nonunions is challenged further by the dynamic, unstable nature of the fracture-fragment interface. Recently, several investigators have introduced a minimally invasive technique for scaphoid nonunion repair, which has the advantages of minimal morbidity and accurate articular reduction, resulting in less postoperative stiffness and increased functional outcomes. However, failure to recognize the critical steps during minimally invasive surgery can result in incorrect treatment or limit any chances for successful bone repair. We reviewed the selected literature pertinent to arthroscopic techniques in the treatment of scaphoid nonunions. Furthermore, we presented a new arthroscopic approach that can be used in place of traditional formal open exposures in challenging cases of nonunion.
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Affiliation(s)
- Midum Jegal
- Department of Orthopedic Surgery, College of Medicine, Dankook University, Korea
| | - Jeong Sang Kim
- Department of Orthopedic Surgery, College of Medicine, Dankook University, Korea
| | - Jong Pil Kim
- Department of Orthopedic Surgery, College of Medicine and Department of Kinesiology and Medical Science, Graduate School of Dankook University, Cheonan, Korea
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Kim JP, Seo JB, Yoo JY, Lee JY. Arthroscopic management of chronic unstable scaphoid nonunions: effects on restoration of carpal alignment and recovery of wrist function. Arthroscopy 2015; 31:460-9. [PMID: 25442643 DOI: 10.1016/j.arthro.2014.08.035] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Revised: 08/21/2014] [Accepted: 08/28/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to assess the effects of arthroscopically assisted reduction and osteosynthesis on restoration of carpal alignment and recovery of clinical wrist function in patients with unstable scaphoid nonunion. METHODS Thirty-six patients who underwent arthroscopically assisted osteosynthesis with or without bone grafting for unstable scaphoid nonunion between July 2006 and January 2012 were enrolled. The average time from injury to surgery was 51 ± 78.3 months. Radiographic and clinical evaluations were assessed on preoperative and postoperative days, and follow-up evaluation took place at a minimum of 24 months. RESULTS Union was achieved in 86% (31 of 36) of patients at a mean of 11 ± 2.7 weeks. Scaphoid axial length (SAL), lateral intrascaphoid angle (ISA), scapholunate angle (SLA), and reversed carpal height ratio (CHR) was significantly improved after surgery, and those correction ratios averaged 66% ± 46.8%, 74% ± 58.2%, 81% ± 59.8%%, and 94% ± 46%, respectively. The range of wrist motion was unchanged after surgery, but the grip strength improved from 74% ± 22.1% preoperatively to 89% ± 13.7% postoperatively compared with the contralateral side (P = .042). Mean Disabilities of the Arm, Shoulder, and Hand (DASH) and Patient-Related Wrist Evaluation (PRWE) scores improved significantly (P < .001) from 44 and 51 preoperatively to 13 and 23 postoperatively, respectively. The radiological parameters of the scaphoid and carpal alignment in patients who achieved bony union did not correlate with clinical wrist function. CONCLUSIONS Arthroscopic reduction and osteosynthesis of chronic unstable scaphoid nonunion is limited for restoration of normal carpal alignment but has positive effects on the recovery of clinical wrist function. LEVEL OF EVIDENCE Level IV, therapeutic case series.
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Affiliation(s)
- Jong Pil Kim
- Departments of Orthopedic Surgery and Department of Kinesiology and Medical Science, Dankook University College of Medicine, Cheonan, Republic of Korea.
| | - Joong Bae Seo
- Departments of Orthopedic Surgery and Department of Kinesiology and Medical Science, Dankook University College of Medicine, Cheonan, Republic of Korea
| | - Jun Young Yoo
- Departments of Orthopedic Surgery and Department of Kinesiology and Medical Science, Dankook University College of Medicine, Cheonan, Republic of Korea
| | - Jee Young Lee
- Department of Diagnostic Radiology, Dankook University College of Medicine, Cheonan, Republic of Korea
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Taleb C, Bodin F, Collon S, Gay A, Facca S, Liverneaux P. Retrograde percutaneous screw fixation for scaphoid type II non-union in Schernberg zones 2 to 4: a series of 38 cases. ACTA ACUST UNITED AC 2015; 34:32-8. [PMID: 25579829 DOI: 10.1016/j.main.2014.10.150] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Revised: 09/29/2014] [Accepted: 10/23/2014] [Indexed: 11/25/2022]
Abstract
Regardless of the treatment used, 25 to 45% of scaphoid fractures do not heal. Open surgery compromises vascularization and destabilizes ligament attachments. The aim of this retrospective study was to assess the value of retrograde percutaneous screw fixation of Alnot stage IIA and IIB scaphoid non-union in Schernberg zones 2 to 4. This series included 38 patients with a mean age of 31 years. Based on the Alnot classification, there were 16 stage IIA non-unions (12 in zone 3 and 4 in zone 2 according to the Schernberg classification) and 22 stage IIB non-unions (9 in zone 3 and 13 in zone 2). The time elapsed between the initial trauma and the surgical treatment was 10 months on average. Percutaneous retrograde fixation was performed with a cannulated 2.7mm compression screw. At 25 months follow-up, 31 of the non-union cases had healed (81.6%), of which 14 were stage IIA (87.5%) and 17 were stage IIB (77.3%), after an average 6.3 months. Average pain was 1.6. The average Quick DASH was 17.3/100. Compared to the opposite side, the average range of motion was 84.8% in flexion, 84.7% in extension, 98.9% in pronation, 96.5% in supination, 96.8% in ulnar deviation and 86.4% in radial deviation. The grip strength was 80.4% of the contralateral side. Seven patients did not heal after screw fixation; four of them healed after additional electromagnetic stimulation and three after addition of a vascularized bone graft. Based on this study's results, stage IIA non-unions can heal with simple retrograde percutaneous screw fixation. The same procedure could be enough for stage IIB non-union cases, however we recommend adding a cancellous bone graft by arthroscopy. Open surgery procedures are preferred when percutaneous procedures have failed.
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Affiliation(s)
- C Taleb
- Department of hand surgery, university hospital of Strasbourg, FMTS, university of Strasbourg, 10, avenue Baumann, 67403 Illkirch cedex, France
| | - F Bodin
- Department of plastic surgery, university hospital of Strasbourg, FMTS, university of Strasbourg, 67000 Strasbourg, France
| | - S Collon
- Department of orthopedic surgery, Caen university hospital, 14040 Caen cedex, France
| | - A Gay
- Department of hand surgery, La Timone teaching hospital, Aix Marseille university, 147, boulevard Baille, 14385 Marseille cedex, France
| | - S Facca
- Department of hand surgery, university hospital of Strasbourg, FMTS, university of Strasbourg, 10, avenue Baumann, 67403 Illkirch cedex, France
| | - P Liverneaux
- Department of hand surgery, university hospital of Strasbourg, FMTS, university of Strasbourg, 10, avenue Baumann, 67403 Illkirch cedex, France.
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Abstract
Scaphoid fractures occur commonly in the athlete and should be treated with urgency to avoid undesired late complications. Magnetic resonance imaging may be helpful to make a prompt diagnosis so that an appropriate early treatment plan can be initiated. Cast immobilization in acute, nondisplaced scaphoid fractures seems to have an equivalent union rate to surgical modalities. Despite this, limiting the immobilization and time to union period in the athlete will allow earlier restoration of preinjury level function and eventual return to play. Percutaneous techniques with or without arthroscopy assistance have been advocated as less invasive surgical approaches that may have an added benefit in the athlete. Displaced and unstable fractures should be approached with a volar or dorsal open technique to achieve and confirm an anatomic reduction before screw placement.
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Lui TH. Arthroscopic revision of nonunion of calcaneocuboid distraction arthrodesis. Foot (Edinb) 2013; 23:172-5. [PMID: 24252400 DOI: 10.1016/j.foot.2013.10.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2013] [Revised: 10/27/2013] [Accepted: 10/29/2013] [Indexed: 02/04/2023]
Abstract
Calcaneocuboid distraction arthrodesis is one of the common surgical procedures for correction of flatfoot deformity. Nonunion of the arthrodesis site is a significantly well-known complication of this procedure. Revision arthrodesis is indicated especially if the nonunion is symptomatic. Classically, this is performed openly with removal of the implants, refreshment of the fusion sites, bone grafting and revision fixation. We reported, a case of nonunion of the calcaneocuboid arthrodesis, which was successfully treated with arthroscopic revision arthrodesis. Removal of the implant and revision fixation was not needed.
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Affiliation(s)
- Tun Hing Lui
- Department of Orthopaedics and Traumatology, North District Hospital, 9 Po Kin Road, Sheung Shui, NT, Hong Kong SAR, China.
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Kurien T, Pearson RG, Scammell BE. Bone graft substitutes currently available in orthopaedic practice: the evidence for their use. Bone Joint J 2013; 95-B:583-97. [PMID: 23632666 DOI: 10.1302/0301-620x.95b5.30286] [Citation(s) in RCA: 133] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
We reviewed 59 bone graft substitutes marketed by 17 companies currently available for implantation in the United Kingdom, with the aim of assessing the peer-reviewed literature to facilitate informed decision-making regarding their use in clinical practice. After critical analysis of the literature, only 22 products (37%) had any clinical data. Norian SRS (Synthes), Vitoss (Orthovita), Cortoss (Orthovita) and Alpha-BSM (Etex) had Level I evidence. We question the need for so many different products, especially with limited published clinical evidence for their efficacy, and conclude that there is a considerable need for further prospective randomised trials to facilitate informed decision-making with regard to the use of current and future bone graft substitutes in clinical practice.
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Affiliation(s)
- T Kurien
- Queen’s Medical Centre, University of Nottingham, Nottingham, United Kingdom
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Corsten M, Heffinger C, Kolios L, Lehnhardt M, Bickert B, Hirche C. Functional results and quality of life after bilateral scaphoid reconstruction: a case series. Arch Orthop Trauma Surg 2013; 133:283-6. [PMID: 23124528 DOI: 10.1007/s00402-012-1642-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Indexed: 11/24/2022]
Abstract
Unilateral scaphoid non-union remains a major problem, which can lead to major functional limitations. Until now there is no evidence of outcome of the rare case of bilateral scaphoid non-unions and in how far two-stage bilateral reconstruction affects functional results and the quality of life. Between 1997 and 2010, altogether four bilateral scaphoid non-unions were treated in the centre and retrospectively analyzed. The mean follow-up was performed 36.8 months after reconstruction. The measures included analysis of patient data, analysis of functional measures and quality of life after follow-up. The reconstructions were performed with implantation of a free, non-vascularized iliac crest bone graft (4), osteosynthesis with implantation of a pedicled vascularized bone graft (3) and osteosynthesis with cancellous bone graft (1). The mean range of motion of the wrist was extension/flexion 111.3°. The average grip strength by JAMAR dynamometer showed right versus left sight 32.7 kg (±3.5) versus 33.7 (±2.9). The evaluation of the DASH score resulted in 11.6 (±12.5), the SF36 scale in 87.1 (±9.2) points. The present case series for the first time demonstrated functional mid-term results of the rare event of bilateral scaphoid reconstruction after non-union. With respect to the impact on one affected hand, functional results, DASH score and quality of life are excellent and thus justify good prognosis in patient education after injury.
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Affiliation(s)
- Marcus Corsten
- Department of Hand, Plastic and Reconstructive Surgery, Burn Centre, BG Trauma Centre, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen/Rhine, Germany
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Chatterjea A, Yuan H, Chatterjea S, Garritsen H, Renard A, van Blitterswijk CA, de Boer J. Engineering New Bone via a Minimally Invasive Route Using Human Bone Marrow-Derived Stromal Cell Aggregates, Microceramic Particles, and Human Platelet-Rich Plasma Gel. Tissue Eng Part A 2013; 19:340-9. [DOI: 10.1089/ten.tea.2012.0104] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Affiliation(s)
- Anindita Chatterjea
- Department of Tissue Regeneration, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, The Netherlands
| | - Huipin Yuan
- Department of Tissue Regeneration, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, The Netherlands
| | | | - Henk Garritsen
- Institut für Klinische Transfusionsmedizin, Städtisches Klinikum Braunschweig gGmbH, Braunschweig, Germany
| | - Auke Renard
- Department of Orthopaedics, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Clemens A. van Blitterswijk
- Department of Tissue Regeneration, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, The Netherlands
| | - Jan de Boer
- Department of Tissue Regeneration, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, The Netherlands
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Clinical outcome of rearthrodesis in cases of non-union following four-corner fusion. Arch Orthop Trauma Surg 2011; 131:1567-72. [PMID: 21688144 DOI: 10.1007/s00402-011-1339-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2011] [Indexed: 12/21/2022]
Abstract
PURPOSE Four-corner fusion is a proven treatment option for degenerative arthritis of the wrist (SLAC/SNAC); however, in some cases, non-union occurs. The purpose of this study was to evaluate the clinical outcome of rearthrodesis in cases of non-union following four-corner fusion. Furthermore, the goal was to identify the cause of non-union and the location of pseudarthrosis within the fusion. METHODS Seven patients (5 males, 2 females) who experienced pseudarthrosis following a four-corner fusion procedure and subsequently elected a rearthrodesis procedure were clinically and radiologically examined. The average age was 58 years (range 48-71 years). Average follow-up after rearthrodesis was 27 months (range 4-60 months). All patients experienced persistent wrist pain and non-union was diagnosed via radiography or CT scan. Range of motion, grip strength, the Modified Mayo Wrist score, and the DASH score were evaluated. The level of pain was determined by using a visual analogue scale. Patients were also asked whether they were satisfied with the procedure and if they would elect it again. RESULTS In all patients, the rearthrodesis procedure led to proper bone consolidation, which was verified by radiological examination. Due to persistent wrist pain, one patient required additional procedures (denervation, wrist arthroscopy). In four cases, the location of pseudarthrosis occurred between the triquetrum and hamate. In three cases, the location of pseudoarthrosis was between the capitate and lunate and, additionally, between the triquetrum and hamate. The average DASH score value was 38 and the average Modified Mayo Wrist score was 66. Grip strength was reduced to 85 percent of the contralateral, unaffected side. Three patients indicated that they are dissatisfied with the results and would not elect the procedure again. CONCLUSIONS The most frequent location of pseudarthrosis was between the triquetrum and the hamate, which was caused by incomplete cartilage debridement. Proper bone consolidation could be attained by means of rearthrodesis in cases of non-union following four-corner fusion. However, clinical results remain only moderate.
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