Comparative Outcome Analysis of Arthroscopic-Assisted Versus Open Reduction and Fixation of Trans-scaphoid Perilunate Fracture Dislocations

Surgical Treatment of Scaphoid Fractures: Recommendations for Management

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.

Arthroscopy-assisted Procedures in Hand and Wrist Surgery: An Update. Where Are We So Far?

Wrist and hand arthroscopy, despite being an old tool, has gained popularity and advanced in assisting in the treatment of various injuries and conditions in the region in recent years. Dorsal, volar, ulnar, and radial accessory portals are used to reach all points of the carpal and hand joints. The minimal tissue damage, lesser injury to the capsule and its mechanoreceptors, the assessment of injuries associated with the reason for surgery, and aesthetically more favorable scars have attracted many doctors and their patients. As a result, there has been an increase in publications and diversifications of arthroscopic techniques. The aim of this update article is to present the advances and the evidence available in the literature to assist readers in their decision on which technique to use in the treatment of wrist and hand conditions.

Arthroscopic Volar Capsuloligamentous Reattachment and Reinforcement to Bone

Background:  Injuries of the volar ligaments of the wrist are not uncommon, but their arthroscopic treatment presents a significant challenge. The objective of this paper is to introduce a technique for reattaching (in acute injuries) or reinforcing (in chronic injuries) various volar wrist ligaments to the bone, using standard wrist arthroscopic dorsal and volar portals. Methods:  There are three common steps for all the arthroscopic volar capsuloligamentous reattachments or reinforcements Step 1 - Volar Portal Establishment: volar radial, volar ulnar and volar central portals are used depending on which structure needs to be reattached or reinforced. Step 2 - Anchor Placement: the anchor is positioned at the site where the ligament has been detached. Step 3 - Capsuloligamentous Suture and Knotting: a knot pusher is introduced inside the joint from the dorsal portal and advanced inside the volar portal where the threads of the anchor are located. The knot pusher is loaded with the threads and retrieved to the dorsal portal. A 16G Abbocath, loaded with a loop is used to pierce the volar ligaments. The loop of the Abbocath is captured from the dorsal portal and loaded with the threads. Both threads are taken to the volar portal and knotted after releasing the traction. This way the knot is placed out of the wrist and the ligaments are reattached or reinforced to the bone. Result:  This technique has been used to reinforce and reattach the scapholunate and lunotriquetral ligaments and to reattach the radiocarpal ligaments and the Poirier space. Since this procedure has been performed in various conditions and in conjunction with other ligament treatments (such as perilunate injuries, carpal bone fractures, distal radius fractures, and reinforcement or reattachment of the dorsal portions of intrinsic ligaments), specific results are not presented. Conclusions:  The described technique enables the reattachment and reinforcement of most volar ligaments to the bone using standard wrist arthroscopic portals. It can be performed in conjunction with the treatment of the dorsal portion of intrinsic ligaments or other wrist injuries.

A Comparison of Outcomes in Acute Perilunate Injuries: Systematic Review and Meta-Analysis of Treatment Approaches

BACKGROUND

Perilunate dislocations (PLD) and fracture-dislocations (PLFD) comprise a spectrum of high-energy wrist injuries. The purpose of this review was to review operative strategies for perilunate injuries based on approach and compare outcomes.

METHODS

A systematic review of literature on PLD and fracture-dislocations was carried out according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). PubMed and EMBASE databases were queried for literature. Inclusion criteria included English studies reporting clinical or functional outcomes of acute PLD and PLFD.

RESULTS

Twenty-nine full-text articles (604 PLD and PLFD injuries) were included. The most common method of PLD and PLFD fixation is through an open approach with combined volar and dorsal exposure. There were no differences between approaches with regard to total arc range of motion, grip strength, Mayo Wrist Score, or mean scapholunate angle. Similarly, there was no difference between approaches and postoperative radiographic arthritis or complications. Most patients were able to return to their prior level of function and work. The incidence of postoperative complications ranged from 0% to 22.5%.

CONCLUSION

Current evidence shows no difference in postoperative total wrist arc range of motion, grip strength (as compared to contralateral), or Mayo Wrist Score with regard to surgical approach. The most common method of PLD and PLFD fixation in the literature is through an open approach with combined volar and dorsal exposure. There is a large difference in reported rates of radiographic arthritis, although this finding does not appear to correlate with postoperative pain or disability.

LEVEL OF EVIDENCE

I, Systematic Review.

Arthroscopic-Assisted Fracture Treatment in the Wrist

Wrist arthroscopy in the setting of wrist fracture affords direct visualization of reduction and identification of associated cartilage and soft tissue injuries. Further, mitigating soft tissue insult in the setting of perilunate injuries may decrease postoperative pain and stiffness while attaining outcomes equivalent to open techniques in appropriately selected patients. Technical proficiency of the surgeon continues to be a limitation of the technique. Randomized controlled studies are needed to better understand outcomes.

Outcomes of acute perilunate injuries-a systematic review

PURPOSE

The objective of this systematic review was to perform epidemiological as well as clinical, radiological and patient-reported outcome analysis of surgically treated perilunate dislocations and fracture dislocations (PLDs and PLFDs) based on the so far largest pooled patient population to date.

MATERIAL AND METHODS

This systematic review was written according to the updated guideline for reporting systematic reviews by the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement. A comprehensive literature search of Pubmed, Embase, CENTRAL, and CINAHL databases was performed. All studies reporting on complications, radiological, functional and/or patient-reported outcomes of surgically treated acute PLDs and PLFDs with a minimum follow-up of 12 months were included.

RESULTS

Twenty-six studies encompassing 550 patients with 553 operatively treated acute perilunate injuries (106 PLDs and 447 PLFDs) were included. The overall postoperative complication rate was 15.0% with secondary reduction loss representing the main contributing factor (10.1%). The overall reoperation rate was 10.4% and the incidence of salvage procedures was 2.8%. The risk for secondary reduction loss was higher for PLD than for PLFD injuries (24.2% vs. 7.0%, relative risk [RR] 3.5, 95% confidence interval [CI] 1.6-7.5). There was a higher overall complication rate for the combined dorsopalmar approach when compared to the isolated dorsal approach (17.4% vs. 8.4%, RR 0.5, 95% CI 0.2-1.0, number needed to treat [NNT] 11.2) and for open surgery versus arthroscopic surgery (17.4% vs. 4.8%, RR 0.3, 95% CI 0.1-0.9, NNT 8.0). A significant correlation was found between radiological osteoarthritis (rOA) and follow-up duration of the individual studies, while functional and patient-rated outcomes were comparable.

CONCLUSIONS

Regardless of surgical technique, PLFDs appear to be less susceptible to secondary reduction loss than PLDs. Whenever possible, less invasive (e.g. arthroscopic) surgery should be performed to minimize postoperative complications. The rate of rOA is high and increases significantly with follow-up duration. Interestingly, rOA does not seem to correlate with reduced wrist function nor patient dissatisfaction and the need for salvage surgery is surprisingly rare.

LEVEL OF EVIDENCE

Systematic review of level IV studies.

Carpal dislocations

Carpal dislocations result from sequential disruption of the complex relationship between the bones and ligaments of the wrist. Injuries to the carpus occur via predictable mechanisms, an understanding of which is critical to identify and treat these frequently missed patterns of injury and to avoid the sequela of chronic instability. Lunate dislocations are by far the most common, but isolated dislocation of other carpal bones can also occur. Open reduction and internal fixation still remains the gold standard for treatment regardless of the debate around the specific approaches. These high-energy injuries are associated with significant long-term morbidity even when identified promptly and appropriately treated. This review will focus on the evaluation and management of common forms of carpal dislocations.

A Novel Mini-Invasive Technique of Arthroscopic-Assisted Reduction and Robot-Assisted Fixation for Trans-Scaphoid Perilunate Fracture Dislocations

OBJECTIVE

Perilunate injuries are rare but devastating carpal injuries. The treatment of perilunate injuries remains challenging and contentious. This study aims to describe a novel mini-invasive surgical technique of arthroscopic-assisted reduction and robot-assisted fixation for the treatment of trans-scaphoid perilunate fracture dislocations (PLFDs).

METHODS

We retrospectively reviewed patients with PLFDs after surgical treatment from February 2021 to March 2021. The patients underwent arthroscopic-assisted precise reduction and robot-assisted headless screw fixation. Times of guide wire placement were recorded intraoperatively. Periodic follow-up was performed until union of scaphoid fracture was confirmed. Range of motion of the wrist, grip strength, the Visual Analog Scale (VAS) score, the Mayo Wrist Score, the Quick Disabilities of Arm, Shoulder, and Hand (QuickDASH) score, the Patient-Rated Wrist Evaluation (PRWE), and osteoarthritis were evaluated at the final follow-up.

RESULTS

Two male patients presenting with PLFDs with an average age of 24.5 years old (32 and 17 years) were included in this study. Intraoperatively, anatomic reduction of the scaphoid fracture was achieved under arthroscopic guidance. A robotic-assisted single-attempt guidewire insertion was performed for scaphoid fracture and lunotriquetral interval. The CT scans at 8 and 12 weeks showed the union of the scaphoid fracture. At final mean follow-up of 13.5 months, the extension, radial-ulnar deviation, and pronation-supination were consistent with the contralateral side in both patients. One patient experienced mild limited range of motion with the flexion 46° of the injured wrist compared with 81°of the contralateral wrist. The VAS score was 0 and 2. The grip strength was 32 and 26 kg compared with 24 and 42 kg of the contralateral wrist. The PRWE score was 13 and 10 and the QuickDASH score was 2 and 7. The Mayo Wrist Score was 100 and 65. No sign of osteoarthritis was found at the last follow-up.

CONCLUSIONS

Arthroscopic-assisted reduction and robot-assisted fixation is a viable and promising alternative for the treatment of perilunate fracture dislocations. This technique allows precise reduction and accurate placement of the K-wires/screws into the carpal bones through the optimal biomechanical paths.

Complications and outcomes of operative treatment for acute perilunate injuries: a systematic review

We systematically reviewed the incidence of complications and outcomes of different surgical methods for acute perilunate injury in the MEDLINE, Scopus, Embase and Cochrane Library databases. Forty-three articles with 880 patients were included. The most common complications were arthritis (30%), carpal instability (15%), avascular necrosis of the lunate (12%), complex regional pain syndrome (11%), and nonunion or avascular necrosis of the scaphoid (9%). In the meta-analysis, the mean scapholunate gap was 1.7 mm in the closed surgery group and 2.3 mm in the open surgery group, which was a statistically significant difference. The mean flexion-extension arc of the wrist and modified Mayo wrist score were better in the closed surgery group than in the open surgery group. However, these findings may relate to different cohorts in terms of injury severity. Therefore, the causal relationship between closed surgery and better outcomes may be uncertain as less severe subluxations are more likely to be treated closed.

Comparison of Two Different Percutaneous Screw Fixations for Treating Herbert B2-Type Acute Scaphoid Fractures

OBJECTIVE

Scaphoid fracture was the most common carpal fracture and the most challenging. The purpose of this study was to investigate and compare the clinical effects of closed reduction and percutaneous cannulated screw internal fixation under fluoroscopy and arthroscopy-assisted percutaneous cannulated screw internal fixation in the treatment of Herbert B2-type of acute scaphoid fractures.

METHODS

A retrospective controlled study was conducted on 29 patients with Herbert B2-type acute scaphoid fracture with a displacement of >1 mm admitted to our hospital from January 2017 to June 2021. Patients were divided into two groups, 11 patients were treated with closed reduction percutaneous cannulated screw internal fixation under fluoroscopy and 18 patients were treated with percutaneous cannulated screw internal fixation assisted by arthroscopy. The operative time, intraoperative fluoroscopy times, fracture healing time, complications, and postoperative wrist function score of the two groups were compared.

RESULTS

All patients were followed up for 6-18 months (mean follow-up duration: 10.38 ± 2.69 months). The respective operation times in the arthroscopy group and fluoroscopy group was 51.50 ± 6.69 min and 56.73 ± 11.48 min, respectively (p > 0.05). The number of fluoroscopies performed in the arthroscopy group was (6.83 ± 1.30), which was less than that in the fluoroscopy group (10.91 ± 2.62) (p < 0.05). All fractures in the arthroscopy group healed after the operation, and the fracture healing time was 11.44 ± 1.25W. Ten patients in the fluoroscopy group healed. The fracture healing time was 13.60 ± 2.32 W. The fracture healing time in arthroscopy group was less than that in the fluoroscopy group (p < 0.05). One patient in the fluoroscopy group had nonunion and healed after bone grafting and internal fixation. At the postoperative 6-month follow-up, the modified Mayo wrist function score was used to evaluate the clinical results. The wrist function score of patients in the arthroscopy group was 90 (85, 95), which was >80 (80, 90) in the fluoroscopy group (z = 2.74, p < 0.05).

CONCLUSION

For Herbert B2-type acute scaphoid fracture with fracture displacement > 1 mm, the arthroscopy-assisted percutaneous cannulated screw internal fixation has less fluoroscopy times, short fracture healing time, and good recovery effect of wrist function compared to the fluoroscopy.

Perilunate dislocation and fracture dislocation of the wrist: Outcomes and long-term prognostic factors

INTRODUCTION

Perilunate dislocations and fracture-dislocations are severe injuries that often have serious functional sequelae. Our goal was to evaluate the long-term clinical and radiological results of these perilunate injuries, and to look for prognostic factors of a poor clinical outcome.

HYPOTHESIS

All patients who suffered perilunate injuries in their wrist have functional sequelae and long-term radiographic changes despite optimal treatment with anatomical surgical reduction.

MATERIALS AND METHODS

We did a single-center, retrospective study of 32 patients who had either an isolated perilunate dislocation (n=7) or fracture-dislocation (n=25) in their wrist. Pain, range of motion, strength and functional scores (MWS, PRWE, QuickDASH) were evaluated. Radiographs were analyzed to look for signs of osteoarthritis or carpal instability.

RESULTS

The mean follow-up time was 9.9years (3.5-24). The wrist joint had a mean flexion-extension of 86° (0-140), radioulnar deviation of 38° (0-65) and pronosupination of 153° (120-180). The mean grip strength was 35kg (5-56). The mean MWS, PRWE and QuickDASH scores were 65/100, 32/100 and 29/100, respectively. At the final assessment, 23 patients (79%) had radiographic signs of osteoarthritis while 5 patients (16%) had residual carpal instability. Three patients subsequently underwent palliative treatment. Opening the carpal tunnel and the magnitude of the lunate's displacement are significant predictors of a poor long-term functional outcome (p<0.05). Older age at the time of injury was a predictor for the development of osteoarthritis.

DISCUSSION

Despite optimal treatment, perilunate dislocations and fracture-dislocations at the wrist cause functional sequelae such as pain, stiffness, strength deficit and posttraumatic arthritis in nearly 80% of patients. The functional outcomes are determined by the amount of lunate displacement (stage) and the patient's age. We do not recommend opening the carpal tunnel, even when signs of median nerve compression are present; reducing the dislocation helps to relieve the neurological symptoms.

LEVEL OF EVIDENCE

IV; retrospective observational study.

Long-term results of trans-scaphoid perilunate fracture dislocations treated by open reduction and internal fixation

Purpose

The paper holds the research purpose of confirming the long-term results of trans-scaphoid perilunate fracture dislocations (TSPFD) under the treatment of open reduction and internal fixation.

Methods

Anteroposterial-lateral radiographs of the patient's wrist were taken before and after surgery. We use a dorsal approach for all cases. Postoperative clinical and radiographic assessments were performed routinely. The scapholunate angle (SLA), estradiol angle (RLA), as well as lunotriquetral distance (LTD) assisted in the radiographic assessment. Clinical assessment was performed using the Krimmer score, modified Mayo wrist score (MWS), active flexion extension arc (FEA), radial deviation and ulnar deviation arc (RUDA) and grip strength. A visual analog scale (VAS) assisted in the pain evaluation, the VAS score ranges from 0 to 10.

Results

Twenty-two TSPFD patients due to the wrist trauma received operative treatment and we retrospectively analyzed the surgical results, together with evaluating their clinical and radiological follow-up. These patients held a mean age of 30 years old. Herzberg’s perilunate fracture-dislocation classification was taken into account to find that 19 males and 3 females suffered dorsal dislocation. The fellow-up time lasted 98.3 months on average. All cases obtained sufficient union after open reduction and internal fixation. The last follow-up found the median of grip strength was 20.00 (interquartile range, 20.00–21.25), which was 84.5% of the normal side. The modified Mayo wrist score evaluation scale considered 12 cases as excellent, and 10 good. The median of VAS and Krimmer scores at the final follow-up were 1.50 (interquartile range, 0.75–2.00) and 100.00 (interquartile range, 100.00–100.00), respectively, higher relative to the pre-operation (P < 0.001). No patients showed nerve damage preoperatively or postoperatively, or pin tract infection in any of the patient.

Conclusions

It is necessary to diagnose such complicated biomechanical damage in early stage and adopt the open reduction and stable fixation for treatment; appropriate treatment can contribute to a functionally adequate and anatomically integrated wrist.

Chronic Isolated Dorsal Dislocation of the Lunate. A Rare Presentation of Carpal Instability

Isolated dorsal lunate dislocation is a rare injury. Only one case has been reported previously in which the treatment was performed in the chronic stage. In this report, we present the case of a 49-year-old handworker male who presented a dorsal dislocation of the lunate after a traffic accident. He was referred to our clinic 2.5 months later due to an initial misdiagnosis. Surgical treatment was performed and consisted of an open reduction using a nerve-sparing dorsal approach. A complete rupture of the perilunate ligaments and a marked instability of the lunate were detected. Stabilisation of the scapholunate, lunotriquetral and scaphocapitate spaces with a compression screw and Kirschner wires, respectively, was performed. The persistence of pain and functional limitation after the surgery along with an insufficient reduction of the scapholunate space on the X-ray and the development of a fistula on the ulnar edge of the carpus prompted reintervention. A hardware-free total wrist arthrodesis was preferred over other procedures, such as proximal row carpectomy, owing to the important articular damage. At the 3-month follow-up, he was clinically stable, consolidation of arthrodesis was documented and he had returned to his previous activities. Isolated dorsal dislocation of the lunate is a rare lesion. There is no consensus on the management of isolated chronic dislocations of the lunate. The frequent delay in the diagnosis compromises the final outcome of reconstructive techniques and introduces the risk of residual instability, increasing the incidence of chronic pain associated with post-traumatic osteoarthritis. In the case of chronic lesions, treatment with palliative techniques, such as proximal carpectomy or joint arthrodesis, should be considered.

Perilunate Injury Timing and Treatment Options: A Systematic Review

Introduction  Perilunate injuries are uncommon yet challenging and often missed injuries, representing 7% of all carpal traumas. Two types of injuries can be identified as follows: perilunate dislocations (PLD) and perilunate fracture-dislocations (PLFD). The purpose of this study was to conduct a systematic review and meta-analysis to establish which surgical treatment is superior for patients with perilunate injuries and the significance of delayed treatment. Methods  A total of 2056 articles were screened, and 16 articles were included. Risk of bias for case-control series and case series were assessed through the National Institute of Health study quality assessment tool. Qualitative outcomes of clinical scores for hand function were compared between different time points (acute, < 7 days; delayed 7-45 days; chronic > 45 days), open and closed reduction, and PLD and PLFD. Results  Overall, the clinical outcome scores of patients treated within 7 days are good. The results suggest that closed reduction and internal fixation (CRIF) offers slightly better outcomes than open reduction and internal fixation (ORIF) for PLFD. Patients treated 6 weeks or more after the initial injury seem to have the worst overall outcomes than patients in the acute or delayed setting. The results suggest that patients with chronic PLD have even worse outcomes than patients with chronic PLFD. Conclusions  Timing of surgery is essential for an optimal outcome. When there is a delay of treatment, the outcomes are inferior to those treated acutely. Early referral to centralized treatment units for perilunate injuries would allow for targeted treatment and facilitate research on this difficult wrist injury.

Perilunate Injuries: Current Aspects of Management

Perilunate dislocations (PLD) and perilunate fracture dislocations (PLFD) are high-energy injuries which can result in long-term complications and significant disability. Early identification of these injuries, followed by prompt, appropriate management is key to optimising patient outcomes. Knowledge of the carpal anatomy is essential in order to understand the varied patterns of injury and plan appropriate definitive management. Emergent reduction and close monitoring of the median nerve, followed by prompt stabilisation or repair of the injured structures remain the mainstay of treatment. In this review, we present a summary of the current evidence regarding the identification and management of these complex injuries.

Perilunate fracture-dislocations: Clinical and functional outcomes at a mean follow-up of 3.3 years

INTRODUCTION

Perilunate lesions in the carpus are severe injuries whose functional consequences can limit patients' ability to regain their pre-injury activity levels. The aim of this study was to evaluate the outcomes of a series of patients who suffered a perilunate fracture-dislocation and to assess their ability to resume their social and professional activities.

HYPOTHESIS

After surgical management of this injury, the medium-term functional outcomes will allow patients to return to their pre-injury social and professional activities.

MATERIALS AND METHODS

This was a single center, retrospective study. Included patients were adults who had suffered a perilunate fracture-dislocation that was treated emergently. The clinical and functional assessment consisted of comparing the mobility and grip strength between the injured and contralateral wrists, determining the functional outcome scores and the resumption of social and professional activities. A radiological assessment was done to look for instability of the proximal row of the carpus, nonunion or necrosis of the carpal bones, loss of carpal height, and presence of carpal osteoarthritis.

RESULTS

Ten patients were included with a mean follow-up of 39.4 months. The mean flexion/extension arc decreased significantly to 88° (20°-150) which was 55% of the healthy contralateral side (p=0.0026) while the grip strength decreased but not significantly (40.6 Kg vs. healthy side 62.4 Kg, p=0.063). The mean MWS was 58.75 (40-100), the mean PRWE was 32.9 (4-67.5) and the mean QuickDASH was 30.2 (0-77). Six of the ten patients (60%) were able to return to work, although three required occupational reclassifications. Four patients had signs of proximal row instability. There were seven instances of radiocarpal osteoarthritis, two of which were combined with mid-carpal osteoarthritis.

DISCUSSION

This study found shorter range of motion and worse patient-reported outcomes than other published studies, which may be due to the severity of the perilunate fracture-dislocation injuries and the inclusion of polytrauma patients. Nevertheless, the subjective scores were comparable. These injuries have serious consequences on social and professional activities of manual workers.

LEVEL OF EVIDENCE

IV; retrospective study.

Mid-term clinical and radiographic outcomes of perilunate injuries treated with open reduction and internal fixation

OBJECTIVE

This study aimed to present the mid-term clinical and radiographic outcomes of patients with perilunate injuries treated with open reduction and internal fixation (ORIF).

METHODS

Patients who underwent ORIF due to perilunate injuries from 2004 to 2015 were retrospectively reviewed. Surgery was mostly performed using a standard dorsal approach. Each injury was graded as per Mayfield staging. At the final follow-up, pain intensity was evaluated using a 10-cm visual analog scale (VAS). Wrist and elbow range of motion, handgrip and pinch strength, Modified Mayo Wrist Scores, and the disabilities of the arm, shoulder, and hand (DASH) scores were measured. On plain radiographic examination, the scapholunate (SL) angle, SL interval, carpal height, and continuity of Gilula arcs were evaluated. The presence of arthritis was also assessed using the Herzberg classification.

RESULTS

In total, 26 male patients (27 wrists) who met the inclusion criteria were included in the study. The mean age was 40 years (range: 20-58); the mean follow-up was 45 months (range: 16-96). Most of the injuries were fracture-dislocations (n=20; 71.4%). According to Mayfield staging, 7 wrists were grade 3, and 20 wrists were grade 4. According to Herzberg staging, 11 (40.7%) patients were stage 2a. The mean VAS was 2.3 (range: 0-5) at rest and 3.3 (range: 0-7) during activity. The mean wrist flexion and extension were 50° (range: 21-80°; 73.5% of the unaffected side) and 45.1° (range: 20-74°; 70.9% of the unaffected side), respectively. The mean radial and ulnar deviation were 14.6° (range: 6-25°; 63.6% of the unaffected side) and 22.3° (range: 5-40°; 64.7% of the unaffected side), respectively. Grip and pinch strength were 57.6 kg (range: 15-106; 65.5% of the unaffected side) and 18.6 kg (range: 8-28; 78.2% of the unaffected side), respectively. The mean Mayo score was 63.3 (range: 20-90), and the DASH score was 24.1±25.2. The mean SL angle was 61.6° (range: 40-83). There was 1 wrist with a pathological SL interval, 11 wrists with dorsal intercalated segmental instability, and 3 wrists with fractures of the Gilula arcs. The mean carpal height was within the normal range.

CONCLUSION

In the treatment of perilunate injuries, satisfactory clinical and radiographic outcomes can be expected from ORIF at mid-term follow-up.

LEVEL OF EVIDENCE

Level IV, Therapeutic Study.

[Advances in diagnosis and treatment of acute scaphoid fractures]

OBJECTIVE

To review the advances in diagnosis and treatment of acute scaphoid fractures.

METHODS

The characteristic, classification, diagnosis, and treatment of acute scaphoid fractures were reviewed and summarized.

RESULTS

As one of the common fracture in hand, scaphoid fractures are generally classified as either undisplaced and stable or displaced and unstable. CT and MRI has best diagnostic specificity and sensitivity respectively. Most undisplaced and stable fractures can be treated successfully by plaster immobilization, whereas the displaced and unstable fractures have great prognosis after open reduction and internal fixation.

CONCLUSION

Acute scaphoid fractures should be diagnosed and treated at an early stage, and choose the appropriate treatment according to the location and stability of the fracture.

Retrospective Comparative Outcomes Analysis of Arthroscopic Versus Open Bone Graft and Fixation for Unstable Scaphoid Nonunions

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.