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Noori A, Persitz J, Khan S, Chan A, Paul R. Arthroscopic assisted versus open non-vascularized bone grafting in delayed union and nonunion of the scaphoid: a systematic review and meta-analysis. BMC Musculoskelet Disord 2024; 25:611. [PMID: 39090587 PMCID: PMC11293166 DOI: 10.1186/s12891-024-07723-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 07/22/2024] [Indexed: 08/04/2024] Open
Abstract
BACKGROUND Delayed union and nonunion of the scaphoid is a common complication often requiring surgical reconstruction and bone grafting. Our goal was to systematically assess the healing time and clinical outcomes following arthroscopic-assisted versus open non-vascularized bone grafting of the scaphoid. METHODS A comprehensive search of the MEDLINE, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Cochrane Central databases was completed from inception to September 2023. We included randomized trials and observational studies that reported outcomes following scaphoid delayed union/nonunion comparing arthroscopic-assisted vs. open non-vascularized bone grafting. Two reviewers independently extracted data and assessed the risk of bias. One investigator assessed certainty of evidence and a senior investigator confirmed the assessment. We pooled effects using random-effects models, when possible, for all outcomes reported by more than 1 study. RESULTS Overall, 26 studies and 822 patients were included in the study. Very low certainty evidence demonstrated that arthroscopic-assisted surgery may decrease healing time compared to open surgery (weighted mean difference [WMD] -7.8 weeks; 95%CI -12.8 to -2.8). Arthroscopic bone grafting did not result in an improvement in union rate (relative risk 1.01; 95%CI 0.9 to 1.09). The pooled data in arthroscopic graft group showed mean time to union of 11.4 weeks (95%CI: 10.4 to 12.5) with union rate of 95% (95%CI 91-98%). A single comparative study reported very low certainty evidence that arthroscopy-assisted vs. open surgery may not have an effect on pain relief (MD 0 cm, 95%CI -0.4 to 0.5 on VAS 10 cm for pain) or improving function (MD -1.2, 95% CI -4.8 to 2.3 on 100 points DASH). CONCLUSION AND FUTURE DIRECTIONS Our results suggest that arthroscopic-assisted non-vascularized bone grafting may be associated with improved average weeks to heal in comparison with open surgery for scaphoid delayed union/nonunion reconstruction with overall comparable union rates. There is insufficient evidence to assess the effects of arthroscopic-assisted reconstruction on union rate, time to union, and patient-reported outcomes in patients with other important nonunion characteristics such as established humpback deformity.
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Affiliation(s)
- Atefeh Noori
- Hand Program, Division of Plastic, Reconstructive and Aesthetic Surgery, University Health Network, Toronto Western Hospital, Affiliated with University of Toronto, East Wing, 2nd Floor, Rm. 400, Toronto, Canada
| | - Jonathan Persitz
- Hand Program, Division of Plastic, Reconstructive and Aesthetic Surgery, University Health Network, Toronto Western Hospital, Affiliated with University of Toronto, East Wing, 2nd Floor, Rm. 400, Toronto, Canada
| | - Shawn Khan
- Hand Program, Division of Plastic, Reconstructive and Aesthetic Surgery, University Health Network, Toronto Western Hospital, Affiliated with University of Toronto, East Wing, 2nd Floor, Rm. 400, Toronto, Canada
| | - Andrea Chan
- Hand Program, Division of Plastic, Reconstructive and Aesthetic Surgery, University Health Network, Toronto Western Hospital, Affiliated with University of Toronto, East Wing, 2nd Floor, Rm. 400, Toronto, Canada.
- Division of Orthopaedic Surgery, The Hospital for Sick Children, Toronto, Canada.
| | - Ryan Paul
- Hand Program, Division of Plastic, Reconstructive and Aesthetic Surgery, University Health Network, Toronto Western Hospital, Affiliated with University of Toronto, East Wing, 2nd Floor, Rm. 400, Toronto, Canada.
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Rinaldi A, Pilla F, Chiaramonte I, Pederiva D, Vita F, Schilardi F, Gennaro A, Faldini C. Arthroscopic surgery for scaphoid nonunion: a 10-year systematic literature review. Musculoskelet Surg 2024; 108:125-132. [PMID: 38340306 PMCID: PMC11133090 DOI: 10.1007/s12306-023-00805-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 11/21/2023] [Indexed: 02/12/2024]
Abstract
The purpose of the study was to investigate whether arthroscopic treatment of carpal scaphoid nonunions by osteosynthesis with bone grafting represents a successful surgical technique. This systematic literature review, conducted following the PRISMA guidelines, explores the past 10 years of clinical studies concerning the arthroscopic treatment of scaphoid nonunions. The most relevant keywords were used to search the databases, and the Downs and Black 27-item checklist has been used as quality assessment tool. Twelve papers that meet the premised eligibility criteria have been identified. These studies demonstrate the efficacy of this surgical solution, achieving a postoperative union rate of 96% in the average time of 13.5 weeks. Regardless of the method of synthesis and the origin of the graft used, excellent results were obtained. Patients who underwent this procedure reported a pain reduction of almost 80% compared to the preoperative level, improvement in grip strength close to 40%, and recovery in wrist function during daily activities. Arthroscopy has numerous advantages compared to the open approach. These are technically recognized by the surgeon and by the patient. Some disadvantages include a longer intraoperative time and considerable significant technical difficulty. Arthroscopic treatment of scaphoid nonunion by osteosynthesis with bone graft achieves a 96% union rate of the treated scaphoid with satisfying clinical results.
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Affiliation(s)
- Alberto Rinaldi
- 1St Orthopaedics and Traumatology Clinic, IRCCS Istituto Ortopedico Rizzoli, via Giulio Cesare Pupilli, 1, 40136, Bologna, Italy.
| | - Federico Pilla
- 1St Orthopaedics and Traumatology Clinic, IRCCS Istituto Ortopedico Rizzoli, via Giulio Cesare Pupilli, 1, 40136, Bologna, Italy
| | - Ilaria Chiaramonte
- 1St Orthopaedics and Traumatology Clinic, IRCCS Istituto Ortopedico Rizzoli, via Giulio Cesare Pupilli, 1, 40136, Bologna, Italy
| | - Davide Pederiva
- 1St Orthopaedics and Traumatology Clinic, IRCCS Istituto Ortopedico Rizzoli, via Giulio Cesare Pupilli, 1, 40136, Bologna, Italy
| | - Fabio Vita
- 1St Orthopaedics and Traumatology Clinic, IRCCS Istituto Ortopedico Rizzoli, via Giulio Cesare Pupilli, 1, 40136, Bologna, Italy
| | - Francesco Schilardi
- 1St Orthopaedics and Traumatology Clinic, IRCCS Istituto Ortopedico Rizzoli, via Giulio Cesare Pupilli, 1, 40136, Bologna, Italy
| | - Andrea Gennaro
- 1St Orthopaedics and Traumatology Clinic, IRCCS Istituto Ortopedico Rizzoli, via Giulio Cesare Pupilli, 1, 40136, Bologna, Italy
| | - Cesare Faldini
- 1St Orthopaedics and Traumatology Clinic, IRCCS Istituto Ortopedico Rizzoli, via Giulio Cesare Pupilli, 1, 40136, Bologna, Italy
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Rong C, Zhang Q, Zhu S, Zhang G, Zeng J, Han Q, Guo Y. 3D printed guide-assisted percutaneous screw fixation for minimally displaced scaphoid waist fractures with delayed diagnosis or presentation. BMC Musculoskelet Disord 2024; 25:127. [PMID: 38341564 PMCID: PMC10858476 DOI: 10.1186/s12891-024-07243-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 01/30/2024] [Indexed: 02/12/2024] Open
Abstract
OBJECTIVES To Investigate the value of 3D printed guide-assisted percutaneous management of minimally displaced scaphoid waist fractures(Herbert's B2) with delayed diagnosis or presentation. METHODS From October 2018 to February 2022, 10 patients with established delayed diagnoses and presentation of minimally displaced scaphoid waist fractures were treated with 3D printed guides assisted with percutaneous internal fixation without bone grafting. This technique was based on the patient's preoperative CT and imported into the software. Based on Boolean subtraction, the most centralized screw placement position was identified and a customized guide was produced. Intraoperative percutaneous insertion of the guide wire was assisted by the custom guide. RESULTS All 10 patients were successful in one attempt. The fractures healed at a mean of 7.7 weeks postoperatively (range 6-10 weeks). At a mean follow-up of 7.7 months (6-13 months), patients had excellent recovery of wrist function with minimal pain reduction. There were no major postoperative complications and the patients all returned to their previous activities before the injury. CONCLUSIONS Percutaneous internal fixation based on 3D printed guides is a safe and effective technique for delayed diagnosis or presentation of patients with minimally displaced fractures of the scaphoid waist. This method allows for easy insertion of screws and avoids multiple attempts.
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Affiliation(s)
- Cunmin Rong
- Department of Hand and Foot Surgery, The Affiliated Hospital of Jining Medical University, Jining, 272029, Shandong, China.
| | - Qinglin Zhang
- Department of Hand and Foot Surgery, The Affiliated Hospital of Jining Medical University, Jining, 272029, Shandong, China
| | - Shaobo Zhu
- Department of Hand and Foot Surgery, The Affiliated Hospital of Jining Medical University, Jining, 272029, Shandong, China
| | - Guanghui Zhang
- Department of Hand and Foot Surgery, The Affiliated Hospital of Jining Medical University, Jining, 272029, Shandong, China
| | - Junhao Zeng
- Department of Hand and Foot Surgery, The Affiliated Hospital of Jining Medical University, Jining, 272029, Shandong, China
| | - Qingluan Han
- Department of Hand and Foot Surgery, The Affiliated Hospital of Jining Medical University, Jining, 272029, Shandong, China
| | - Yang Guo
- Department of Hand Surgery, Beijing Jishuitan Hospital, Beijing, 100035, China
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Burnier M, Loisel F, Ardouin L, Beauthier V, Durand A, Erhard L, Gay A, Gras M, Mares O, Cognet JM. Treatment of scaphoid nonunion by arthroscopic cancellous bone grafting. Orthop Traumatol Surg Res 2023; 109:103665. [PMID: 37499747 DOI: 10.1016/j.otsr.2023.103665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 01/16/2023] [Accepted: 03/28/2023] [Indexed: 07/29/2023]
Abstract
INTRODUCTION In order to avoid Scaphoid Nonunion Advanced Collapse (SNAC) type osteoarthritis, which progressively affects the radial and midcarpal joints, several vascularized and non-vascularized grafting techniques have been described. Over the past decade, there has been growing interest in arthroscopic cancellous bone grafts for scaphoid nonunion. The aim of this novel prospective study was to assess the healing rate of scaphoid grafts under arthroscopy, and the prognostic factors for healing. MATERIAL AND METHODS This prospective study was carried out across 10 centers between September 2019 and April 2021, in patients aged 16 to 65. Scaphoid nonunion grafting was performed arthroscopically. Union was assessed on CT scans and displacement correction angles were measured preoperatively and then at 3 and 6months. We assessed mobility, Jamar wrist strength, functional results as per the Patient Related Wrist Score (PRWE) and the Quick Disabilities of the Arm, Shoulder and Hand (Quick DASH) score. Risk factors for nonunion were assessed. RESULTS We included 77 patients with a mean age of 24years (18 to 55years) with a mean time between trauma and treatment of nonunion of 34.8months (6 to 180months). The population was represented by 46 manual workers and 20 were smokers. In 42 cases, the nonunion was proximal, in Schernberg zone I or II. At the last follow-up of 12.9months on average (Standard Deviation: 8.7months), union was achieved in 72 patients (93.5%). The average duration of union was 3.4months (Standard Deviation 1.6). Among the 5 patients who did not heal, grafting was performed in addition to the fixation. We did not identify any contributory factors for nonunion. CONCLUSION This study demonstrated the effectiveness of arthroscopic treatment of scaphoid nonunion with a union rate at least equivalent to pedicled vascularized grafts. Smoking and delayed treatment were no longer considered unfavorable prognostic factors in the context of arthroscopic treatment. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Marion Burnier
- Hôpital privé Jean-Mermoz, 55, avenue Jean-Mermoz, 69008 Lyon, France.
| | - François Loisel
- Service d'orthopédie, de traumatologie, de chirurgie plastique, reconstructrice et assistance main, CHU J.-Minjoz, 3, boulevard A.-Fleming, 25030 Besançon, France
| | - Ludovic Ardouin
- Institut de la main Nantes Atlantique, Elsan Santé Atlantique, boulevard Charles-Gautier, 44800 Saint-Herblain, France
| | - Violaine Beauthier
- Service de chirurgie orthopédique, CHU Saint-Antoine, 184, rue du Faubourg-Saint-Antoine, 75012 Paris, France
| | - Alexandre Durand
- Institut européen de la main, 13, rue Blaise-Pascal, 54320 Maxéville, France
| | - Lionel Erhard
- Clinique du Médipôle, 158, rue Léon-Blum, 69100 Villeurbanne, France
| | - André Gay
- 383, avenue du Prado, 13008 Marseille, France
| | - Mathilde Gras
- Institut de la Main, Clinique Bizet, 22 bis, rue Georges-Bizet, 75116 Paris, France
| | - Olivier Mares
- Chu de Nîmes, avenue du Pr-Debré, 30000 Nîmes, France
| | - Jean-Michel Cognet
- Chirurgie de la main et du membre supérieur, Médipôle, 1, rue Jules-Méline, 51430 Bezannes, France
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Kaempf de Oliveira R, Brunelli JP, Aita M, Delgado PJ. 360-degree Arthroscopic Management of Scaphoid Pseudarthrosis: Description of Technique and Indications. Tech Hand Up Extrem Surg 2023; 27:230-238. [PMID: 37529866 DOI: 10.1097/bth.0000000000000448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2023]
Abstract
Nonunion remains one of the main complications of scaphoid fractures, with no consensus being reached as to the best surgical technique for scaphoid pseudoarthrosis. Thus, different types of procedures for bone stability and biological stimulus for consolidation have been described. The use of arthroscopy for scaphoid pseudoarthrosis has advantages as it allows for treating associated injuries, preserving wrist proprioception by minimizing damage to the joint capsule and ligaments and not deteriorating the already fragile scaphoid vasculature, leading to a quick recovery. Arthroscopy was initially indicated for stable scaphoid pseudoarthroses, being used in all patterns of this condition, including unstable ones and those with flexion collapse. However, most scientific articles describe the use of arthroscopy only through the dorsal portals, creating technical difficulty in complete debridement of the site of pseudarthrosis and in placing bone graft. This study describes the 360-degree technique, which standardizes arthroscopy in scaphoid pseudoarthrosis treatment, allowing, with the use of dorsal, volar, and radial portals, direct approach to the entire circumference of the nonunion site, facilitating the debridement of the injury site, the correction of the scaphoid deformity, and the placement of a graft directly on the site of the defect, mainly in its volar region after correction of the flexion deformity. The 360-degree technique aims to help and standardize the arthroscopic procedure for scaphoid pseudarthrosis, creating a routine with defined surgery stages. Additional portals allow complete access to the entire nonunion site and better positioning of the bone graft under direct view.
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Affiliation(s)
| | - João Pedro Brunelli
- Hand Surgeon at Hospital Santa Casa de Misericórdia of Porto Alegre, Porto Alegre, Brazil
| | - Márcio Aita
- Hand Surgeon at Faculdade de Medicina do ABC, Santo André, Brazil
| | - Pedro J Delgado
- Coordinating Physician of the Hand Surgery Unit, Hospital Universitário Madrid Monteprincipe, Universidade CEU San Pablo, Boadilla del Monte, Madrid, Spain
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Gvozdenovic R, Kongensgaard TB. Results of arthroscopic cancellous bone grafting for treatment of scaphoid nonunion in comparison with open cancellous bone grafting. J Hand Surg Eur Vol 2023; 48:903-910. [PMID: 37066665 DOI: 10.1177/17531934231166343] [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] [Indexed: 04/18/2023]
Abstract
This study primarily aimed to report the outcome of the arthroscopic cancellous bone grafting technique for treating scaphoid nonunion. The secondary aim was to compare the bone union rate and time, and the ability to correct the angulation of the scaphoid, between arthroscopically treated patients (n = 27), and patients treated with open cancellous bone grafting (n = 27). Nine surgeons (two in the arthroscopic and seven in the open group) with Level III experience operated on the patients. The pain score, grip strength and Quick Disability of the Arm, Shoulder and Hand score improved significantly after the arthroscopic treatment (p = 0.0001). Arthroscopic cancellous bone grafting achieved union in 25 out of 27 patients. A retrospective comparison with open cancellous bone grafting showed four nonunions. Arthroscopically treated patients healed 5.4 weeks faster compared with the open group (p = 0.033). Patients treated with open grafting had a higher risk of failure (odds ratio = 2.17), although this was not found significant (p = 0.39). The open method corrected the angulation deformity better (dorsal cortical angle correction of 4°) than the arthroscopic method (dorsal cortical angle correction of 1°), but this was not statistically significant neither within the groups (p = 0.55, p = 0.87) nor postoperatively between the groups (p = 0.98). The height-to-length ratio was not different before and after the surgery for the arthroscopic group (p = 0.44) and the open group (p = 0.27), or postoperatively between the groups (p = 0.44).Level of evidence: III.
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Affiliation(s)
- Robert Gvozdenovic
- Department of Hand Surgery, Herlev and Gentofte University Hospital of Copenhagen, Hellerup, Denmark
- University of Copenhagen, Faculty of Health and Medical Sciences, Institute of Clinical Medicine, Copenhagen N, Denmark
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Seth I, Lim B, Xie Y, Hunter-Smith DJ, Rozen WM. Exploring the role of artificial intelligence chatbot on the management of scaphoid fractures. J Hand Surg Eur Vol 2023; 48:814-818. [PMID: 37177798 DOI: 10.1177/17531934231169858] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Affiliation(s)
- Ishith Seth
- Department of Plastic Surgery, Peninsula Health, Melbourne, Victoria, 3004, Australia
| | - Bryan Lim
- Department of Plastic Surgery, Peninsula Health, Melbourne, Victoria, 3004, Australia
- Faculty of Medicine, Monash University, Melbourne, Victoria, 3002, Australia
| | - Yi Xie
- Department of Plastic Surgery, Peninsula Health, Melbourne, Victoria, 3004, Australia
| | - David J Hunter-Smith
- Department of Plastic Surgery, Peninsula Health, Melbourne, Victoria, 3004, Australia
| | - Warren M Rozen
- Department of Plastic Surgery, Peninsula Health, Melbourne, Victoria, 3004, Australia
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Lin TY, Fu CW, Tsai PS, Huang CH, Wei SH, Chuang MY. Outcomes after arthroscopic treatment for scaphoid nonunion using ipsilateral radius bone graft and a headless compression screw: a comparison between the patients with and without avascular necrosis. INTERNATIONAL ORTHOPAEDICS 2023; 47:1041-1049. [PMID: 36680634 DOI: 10.1007/s00264-023-05700-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Accepted: 01/10/2023] [Indexed: 01/22/2023]
Abstract
PURPOSE To determine whether avascular necrosis can affect clinical outcomes or the union incidence after arthroscopic bone grafting for the treatment of scaphoid nonunion. METHODS This retrospective comparative study included thirty-four patients with scaphoid nonunion that underwent arthroscopic bone graft from the ipsilateral radius and internal fixation. The patients were divided into two cohorts (group A, with avascular necrosis, n = 15; group B, without avascular necrosis, n = 19) based on pre-operative magnetic resonance imaging findings. Additionally, the patients were grouped in accordance with the location of nonunion (waist, n = 27; proximal pole, n = 7). The mean follow-up was 20.7 months (range 12.0-40.0 months). Clinical outcomes, including the visual analog scale (VAS) pain score, grip strength, range of motion (ROM), Mayo Wrist Score (MWS), and Disabilities of the Arm, Shoulder, and Hand (DASH) score, were evaluated. Radiographic measurements for carpal bone alignment were assessed as well. RESULTS Union rates did not differ between groups (group A, 93.3%; group B, 94.7%: p = 0.863), and the post-operative VAS pain score, ROM, and MWS were similar at follow-up for a minimum of one year. DASH and grip strength were significantly better in group B, but the intergroup differences were minimal (mean DASH 11.9 versus 9.6; mean grip strength 77.5% versus 95.4% of contralateral side). There was no significant intergroup difference in mean time to achieving union (group A, 14.9 weeks; group B, 14.6 weeks; p = 0.900). In post-operative radiographic assessments, no significant intergroup differences were noted in any of the parameters. Subgroup analysis regarding the location of nonunion showed there were no significant intergroup differences in union rates, mean time to achieving union, and clinical outcome measures at the last post-operative follow-up. CONCLUSIONS Arthroscopic bone grafting and internal fixation in the treatment of scaphoid nonunion provided good union rates and satisfactory outcomes regardless of vascularity status.
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Affiliation(s)
- Ting-Yi Lin
- Department of Orthopaedic Surgery, MacKay Memorial Hospital, No. 92, Sec. 2, Zhongshan N. Rd., Taipei, 10449, Taiwan
| | - Chun-Wei Fu
- Department of Orthopaedic Surgery, MacKay Memorial Hospital, No. 92, Sec. 2, Zhongshan N. Rd., Taipei, 10449, Taiwan
| | - Pei-Shan Tsai
- Department of Radiology, MacKay Memorial Hospital, Taipei, 10449, Taiwan
- Department of Biomedical Imaging and Radiological Sciences, National Yang Ming Chiao Tung University, Taipei, 11221, Taiwan
- Department of Medicine, Mackay Medical College, New Taipei City, 25245, Taiwan
- Mackay Junior College of Medicine, Nursing and Management, New Taipei City, 25245, Taiwan
| | - Chang-Hung Huang
- Department of Orthopaedic Surgery, MacKay Memorial Hospital, No. 92, Sec. 2, Zhongshan N. Rd., Taipei, 10449, Taiwan
- Department of Medical Research, MacKay Memorial Hospital, New Taipei City, 25160, Taiwan
- School of Dentistry, National Yang Ming Chiao Tung University, Taipei, 11221, Taiwan
- Institute of Geriatric Welfare Technology and Science, MacKay Medical College, New Taipei City, 25245, Taiwan
| | - Shun-Hua Wei
- Department of Physical Therapy and Assistive Technology, National Yang Ming Chiao Tung University, Taipei, 11221, Taiwan
| | - Min-Yao Chuang
- Department of Orthopaedic Surgery, MacKay Memorial Hospital, No. 92, Sec. 2, Zhongshan N. Rd., Taipei, 10449, Taiwan.
- Department of Medicine, Mackay Medical College, New Taipei City, 25245, Taiwan.
- Mackay Junior College of Medicine, Nursing and Management, New Taipei City, 25245, Taiwan.
- Department of Medical Research, MacKay Memorial Hospital, New Taipei City, 25160, Taiwan.
- Department of Physical Therapy and Assistive Technology, National Yang Ming Chiao Tung University, Taipei, 11221, Taiwan.
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Hendrix N, Hendrix W, van Dijke K, Maresch B, Maas M, Bollen S, Scholtens A, de Jonge M, Ong LLS, van Ginneken B, Rutten M. Musculoskeletal radiologist-level performance by using deep learning for detection of scaphoid fractures on conventional multi-view radiographs of hand and wrist. Eur Radiol 2023; 33:1575-1588. [PMID: 36380195 PMCID: PMC9935716 DOI: 10.1007/s00330-022-09205-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 09/19/2022] [Accepted: 09/25/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To assess how an artificial intelligence (AI) algorithm performs against five experienced musculoskeletal radiologists in diagnosing scaphoid fractures and whether it aids their diagnosis on conventional multi-view radiographs. METHODS Four datasets of conventional hand, wrist, and scaphoid radiographs were retrospectively acquired at two hospitals (hospitals A and B). Dataset 1 (12,990 radiographs from 3353 patients, hospital A) and dataset 2 (1117 radiographs from 394 patients, hospital B) were used for training and testing a scaphoid localization and laterality classification component. Dataset 3 (4316 radiographs from 840 patients, hospital A) and dataset 4 (688 radiographs from 209 patients, hospital B) were used for training and testing the fracture detector. The algorithm was compared with the radiologists in an observer study. Evaluation metrics included sensitivity, specificity, positive predictive value (PPV), area under the characteristic operating curve (AUC), Cohen's kappa coefficient (κ), fracture localization precision, and reading time. RESULTS The algorithm detected scaphoid fractures with a sensitivity of 72%, specificity of 93%, PPV of 81%, and AUC of 0.88. The AUC of the algorithm did not differ from each radiologist (0.87 [radiologists' mean], p ≥ .05). AI assistance improved five out of ten pairs of inter-observer Cohen's κ agreements (p < .05) and reduced reading time in four radiologists (p < .001), but did not improve other metrics in the majority of radiologists (p ≥ .05). CONCLUSIONS The AI algorithm detects scaphoid fractures on conventional multi-view radiographs at the level of five experienced musculoskeletal radiologists and could significantly shorten their reading time. KEY POINTS • An artificial intelligence algorithm automatically detects scaphoid fractures on conventional multi-view radiographs at the same level of five experienced musculoskeletal radiologists. • There is preliminary evidence that automated scaphoid fracture detection can significantly shorten the reading time of musculoskeletal radiologists.
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Affiliation(s)
- Nils Hendrix
- Radiology Department, Jeroen Bosch Ziekenhuis, Henri Dunantstraat 1, 5223 GZ, 's-Hertogenbosch, the Netherlands.
- Jheronimus Academy of Data Science, Sint Janssingel 92, 5211 DA, 's-Hertogenbosch, the Netherlands.
- Department of Medical Imaging, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, the Netherlands.
| | - Ward Hendrix
- Radiology Department, Jeroen Bosch Ziekenhuis, Henri Dunantstraat 1, 5223 GZ, 's-Hertogenbosch, the Netherlands
- Department of Medical Imaging, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, the Netherlands
| | - Kees van Dijke
- Radiology Department, Noordwest Ziekenhuisgroep, Wilhelminalaan 12, 1815JD, Alkmaar, the Netherlands
| | - Bas Maresch
- Radiology Department, Ziekenhuis Gelderse Vallei, Willy Brandtlaan 10, 6717 RP, Ede, the Netherlands
| | - Mario Maas
- Radiology and Nuclear Medicine Department, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Stijn Bollen
- Radiology Department, Groene Hart Ziekenhuis, Bleulandweg 10, 2803 HH, Gouda, the Netherlands
| | - Alexander Scholtens
- Radiology and Nuclear Medicine Department, Tergooi, Van Riebeeckweg 212, 1213 XZ, Hilversum, the Netherlands
| | - Milko de Jonge
- Radiology Department, St. Antonius Ziekenhuis, Soestwetering 1, 3543 AZ, Utrecht, the Netherlands
| | - Lee-Ling Sharon Ong
- Jheronimus Academy of Data Science, Sint Janssingel 92, 5211 DA, 's-Hertogenbosch, the Netherlands
- Cognitive Science and Artificial Intelligence Department, Tilburg University, Warandelaan 2, 5037 AB, Tilburg, the Netherlands
| | - Bram van Ginneken
- Department of Medical Imaging, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, the Netherlands
| | - Matthieu Rutten
- Radiology Department, Jeroen Bosch Ziekenhuis, Henri Dunantstraat 1, 5223 GZ, 's-Hertogenbosch, the Netherlands
- Department of Medical Imaging, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, the Netherlands
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10
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De Bie A, Louis P, Cognet JM. Correction of residual humpback deformity after arthroscopic treatment of scaphoid non-union. Orthop Traumatol Surg Res 2022; 108:103294. [PMID: 35487429 DOI: 10.1016/j.otsr.2022.103294] [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: 06/14/2021] [Revised: 11/15/2021] [Accepted: 12/07/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND The aim of this study was to assess residual humpback deformity after arthroscopic treatment of scaphoid non-union. MATERIAL AND METHOD We reviewed the medical records of 47 patients with scaphoid non-union who underwent arthroscopic treatment between 2012 and 2018. Patients who did not receive an intraoperative bone graft were excluded (10 patients), as were those who did not achieve bone union (three patients). The radiographic assessment consisted of pre- and postoperative radiographs and CT-scans. RESULTS The radiolunate angle, scapholunate angle and Youm index were measured. At the final follow-up, the scapholunate angle was 54±8̊ (36-80̊) and the radiolunate angle was 11±7̊ (2-45̊). The scapholunate angle was significantly different between the preoperative measurement and the last follow-up; however, the radiolunate angle and Youm index did not change significantly. CONCLUSION Our study found that arthroscopic treatment of scaphoid non-union with a cancellous bone graft taken from the distal radius results corrects the humpback deformity. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Anaïs De Bie
- SOS Mains Champagne Ardenne, Clinique Courlancy, 38b, rue de Courlancy, 51100 Reims, France
| | - Pascal Louis
- SOS Mains Champagne Ardenne, Clinique Courlancy, 38b, rue de Courlancy, 51100 Reims, France
| | - Jean Michel Cognet
- SOS Mains Champagne Ardenne, Clinique Courlancy, 38b, rue de Courlancy, 51100 Reims, France.
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Hu H, Teng X, Li X, Li M, Chang S. Comparison of Two Different Percutaneous Screw Fixations for Treating Herbert B2-Type Acute Scaphoid Fractures. Orthop Surg 2022; 14:3187-3194. [PMID: 36254105 PMCID: PMC9732583 DOI: 10.1111/os.13517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 08/12/2022] [Accepted: 08/31/2022] [Indexed: 12/14/2022] Open
Abstract
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.
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Affiliation(s)
- Haoliang Hu
- Department of Orthopaedic SurgeryYangpu Hospital, School of Medicine, Tongji UniversityShanghaiChina,Department of Hand SurgeryNingbo No. 6 HospitalNingboChina
| | - Xiaofeng Teng
- Department of Hand SurgeryNingbo No. 6 HospitalNingboChina
| | - Xueyuan Li
- Department of Hand SurgeryNingbo No. 6 HospitalNingboChina
| | - Miaozhong Li
- Department of Hand SurgeryNingbo No. 6 HospitalNingboChina
| | - Shimin Chang
- Department of Orthopaedic SurgeryYangpu Hospital, School of Medicine, Tongji UniversityShanghaiChina
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12
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Huwae TECJ, Dradjat RS, Refa AA. Asymptomatic Nonunion Scaphoid Fracture After Kirschner Wire Fixation of Trans-Scaphoid Lunate Dislocation: A Case Report with 3 Years of Follow-up. Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2022.10805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background: Trans-scaphoid lunate dislocation is an orthopaedic injury, mostly because of high energy trauma. Due to subtle clinical and radiological findings, it might be easily left undiagnosed, with estimated 25% cases are missed at initial assessment in emergency department. Non-union scaphoid, which accounts for 5-10% of all scaphoid fractures treated with K-wires fixation, mostly occurs in young and active individual.
Case Presentation: Thirty-seven-years-old right-handed man complained pain, and restricted range of motion (ROM) on his right wrist after fell from 2m height. Loss of symmetry and parallelism of joint space in Gilula's line shown in X-ray, possible for a trans-scaphoid lunate dislocation. We performed dorsal approach and internal fixation using Kirschner wire (1.0). The patient had a short arm cast for 4 weeks. The K-wires were removed 5 weeks postoperatively. We achieved good result clinically in 3, 9, and 36 months of follow up (Mayo Wrist Score of 70, 80, 90, respectively). The ROM of wrist is preferable than pre-surgery (RD 20o, UD 20o, and WF-WE 60o) with avascular necrosis of scaphoid in 9th month follow up (in 2019). Unfortunately, at 3 years of follow up, X-ray showed non-union scaphoid, avascular necrosis, and osteophytes between scaphoid and radius.
Discussion: Unless it is asymptomatic, surgery is the recommended treatment for scaphoid non-union in order to limit further morbidity from pain, weakness, and stiffness of the wrist joint. However, in this case, the patient has been doing any activities with his right hand normally and never felt any pain in the last 2 years, eventhough the X-ray shows fracture line at distal of scaphoid. Thus, we choose not to do any treatment for it.
Conclusion: In the case of trans-scaphoid lunate dislocation, the use of K-wire fixation shows excellent clinical outcome, but radiological finding shows non-union scaphoid with osteophytes, thus it has possibility to develop degenerative disease in the future.
Keywords: Trans-scaphoid Lunate dislocation; Non-union; K-wire Fixation
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13
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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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14
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Le Mapihan M, Dahan E, Bourcheix LM, Hardy A. Arthroscopic preservation of the scaphoid's blood supply during nonunion treatment. J Hand Surg Eur Vol 2022; 47:420-422. [PMID: 34647498 DOI: 10.1177/17531934211049920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Marie Le Mapihan
- Department of Orthopedic Surgery, Ambroise Paré Hospital, Boulogne, France
| | - Emmanuel Dahan
- Department of Orthopedic Surgery, Ambroise Paré Hospital, Boulogne, France.,IRCOS, Ambroise Paré hospital, Clinique Jouvenet, Paris, France
| | - Laurent-Marie Bourcheix
- Laboratory of Anatomy, Assistance Publique Hôpitaux de Paris, Paris, France.,IFCM-Institut Francais de Chirurgie de la Main, Paris, France
| | - Alexandre Hardy
- Department of Orthopedic Surgery, Ambroise Paré Hospital, Boulogne, France.,Clinique du Sport, Paris, France
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15
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Bain GI, Baker A, Whipple TL, Poehling GG, Mathoulin C, Ho PC. History of Wrist Arthroscopy. J Wrist Surg 2022; 11:96-119. [PMID: 35478952 PMCID: PMC9038311 DOI: 10.1055/s-0041-1740304] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 09/01/2021] [Indexed: 12/31/2022]
Abstract
Wrist arthroscopy has a rich history, drawing on contributions from around the world. Its foundation was laid in Japan with Kenji Takagi and Masaki Watanabe, who developed the arthroscope and the techniques for arthroscopy. Across several decades they advanced the optic and lighting technology, allowing the miniaturization which made wrist arthroscopy technologically feasible. A safe and standardized technique for wrist arthroscopy was evolved by Terry Whipple, Gary Poehling, and James Roth in the 1980s, and they shared this with their fellow surgeons through courses and publications. The techniques then spread across the world, leading to widespread uptake and exploration of new therapeutic possibilities. The worldwide spread of wrist arthroscopy was accelerated by the European Wrist Arthroscopy Society (EWAS), founded in 2005 by Christophe Mathoulin. The Asia Pacific Wrist Association (APWA), founded by PC Ho in 2015, also extended the progression of wrist arthroscopy. This article brings together this history and tells the global story of its development through the recollections of those involved. The manuscript includes some amazing videos of the early historical arthroscopy. There are also videos of Gary and Terry describing some of their special memories of the early politics, developments, and evolution of wrist arthroscopy.
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Affiliation(s)
- Gregory I Bain
- Department of Orthopaedic Surgery, Flinders University and Flinders Medical Centre, Adelaide, Australia
| | - Andrew Baker
- Faculty of Health and Medical Sciences, School of Medicine, The University of Adelaide, Adelaide, Australia
| | - Terry L Whipple
- Hillelson-Whipple Clinic, Richmond, Virginia
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, Virginia
| | - Gary G Poehling
- Department of Orthopaedic Surgery, Wake Forest, Baptist Medical Center, Winston-Salem, North Carolina
| | | | - Pak-Cheong Ho
- Department of Orthopaedic & Traumatology, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong SAR
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16
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Waitayawinyu T, Lertcheewanan W, Boonyasirikool C, Niempoog S. Arthroscopic Treatment of Scaphoid Nonunion With Olecranon Bone Graft and Screw Fixation Leads to Union and Improved Outcomes. Arthroscopy 2022; 38:761-772. [PMID: 34571185 DOI: 10.1016/j.arthro.2021.09.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 09/08/2021] [Accepted: 09/13/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the outcomes of arthroscopic treatment of scaphoid nonunion using olecranon bone graft and screw fixation and to analyze the outcomes in accordance with variations in the chronicity, location, and severity of nonunion. METHODS Between March 2012 and December 2020, patients with diagnoses of scaphoid delayed nonunion and nonunion with substantial bone resorption (Slade and Dodds grade IV-VI) underwent arthroscopic-assisted olecranon bone graft and screw fixation. Preoperative and postoperative measurements included the visual analog scale score for pain; range of motion; grip strength; the Modified Mayo Wrist Score; the Disabilities of the Arm, Shoulder and Hand (DASH) score; and the minimal clinically important difference for the DASH score. Union rate and duration were also evaluated. The outcomes between groups of patients with different conditions were analyzed. RESULTS Twenty-two patients were included. The average follow-up period was 32.5 months. The visual analog scale pain score, range of motion, grip strength, Modified Mayo Wrist Score, and DASH score were significantly improved after surgery (P < .001). The minimal clinically important difference threshold for the DASH score was reached by 100% of patients. At final follow-up, all patients had united scaphoid with no complications. The average time to union was 15.3 weeks. Group analysis showed significant improvements in mean grip strength between patients with delayed union (3-6 months) and those with chronic nonunion (> 1 year) (17.75 kg vs 12.25 kg, P = .032), between grade IV nonunion and grade V nonunion (14.86 kg vs 10.43 kg, P = .035), and between grade V nonunion and grade VI nonunion (10.43 kg vs 15.63 kg, P = .013). Patients with grade VI nonunion achieved union at 17.8 weeks postoperatively, a significantly longer period than that for patients with grade IV nonunion (11.4 weeks, P = .014). CONCLUSIONS Arthroscopic treatment of scaphoid nonunion using olecranon bone graft and screw fixation provided satisfactory outcomes regardless of the chronicity, location, and severity of nonunion. LEVEL OF EVIDENCE Level IV, therapeutic case series.
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Affiliation(s)
- Thanapong Waitayawinyu
- Department of Orthopaedics, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand.
| | - Warisara Lertcheewanan
- Department of Orthopaedics, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand
| | | | - Sunyarn Niempoog
- Department of Orthopaedics, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand
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17
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Nakamura T, Cheong Ho P, Atzei A, Corella F, Haugstvedt JR. Revolutions in arthroscopic wrist surgeries. J Hand Surg Eur Vol 2022; 47:52-64. [PMID: 34293945 DOI: 10.1177/17531934211030861] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Recent technical and technological developments in wrist arthroscopic surgery allow for advanced treatments of difficult wrist disorders. In this review, world leaders of wrist arthroscopy describe bone graft for scaphoid nonunion, transosseous repair for triangular fibrocartilage fovea avulsion, palmaris longus reconstruction of the triangular fibrocartilage, and arthroscopic reconstruction of the scapholunate and lunotriquetral ligaments.
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Affiliation(s)
- Toshiyasu Nakamura
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, Tokyo, Japan
| | - Pak Cheong Ho
- Department of Orthopaedic & Traumatology, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong SAR, China
| | - Andrea Atzei
- Pro-Mano, Hand Surgery and Rehabilitation, Treviso, Italy
| | - Fernando Corella
- Hand Surgery Unit, Orthopadic and Trauma Department, Hospital Universitario Infanta Leonor, Madrid, Spain
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18
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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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19
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Chong HH, Kulkarni K, Shah R, Hau MYT, Athanatos L, Singh HP. A meta-analysis of union rate after proximal scaphoid fractures: terminology matters. J Plast Surg Hand Surg 2021; 56:298-309. [PMID: 34550858 DOI: 10.1080/2000656x.2021.1979016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Heterogeneity in the anatomical definition of 'proximal' affects the comparison of outcomes of these scaphoid fractures. This study aims to review published outcomes of all variants to determine both, differences in terminology, and union rate based upon definition. A literature search was conducted to identify articles that reported descriptions and union rate of all acute (<8 weeks of injury) proximal scaphoid fractures in adult patients (>16 years old). Proximal fractures were grouped as reported ('third', 'pole', 'fifth' or 'undefined'). The data were pooled using a fixed-effects method, and a meta-analysis was conducted to compare relative risk (RR) of non-union against non-proximal fractures. Qualitative analysis of 12 articles included three main definitions: 'proximal' (1 article), 'proximal third' (3 articles), and 'proximal pole' (8 articles). Only 6 articles adopted a specific anatomical or ratio description. In a pooled meta-analysis of union rates (15 articles), 'proximal third' and 'proximal pole' fractures demonstrated a relative risk (RR) of non-union of 2.3 and 3.4 in comparison to non-proximal fractures, respectively. Operative management yielded lower non-union rates than non-operative for all fracture types (6% vs. 18%). In conclusion, non-union risk varies depending on definition, with non-standardised classifications adding heterogeneity to reported outcomes. We recommend an approach utilizing fixed anatomical landmarks on plain radiographs (referencing scaphoid length and scapho-capitate joint) to standardise reporting of proximal fracture union in future studies. Abbreviations: CI: confidence intervals; CT: computer tomography; Df: degrees of freedom; DL: dersimonian and laird estimator; MRI: magnetic resonance imaging; NICE: national institute for health and care excellence; OTA: orthopaedic trauma association; PA: posterior-anterior; PRISMA: preferred reporting items for systematic reviews and meta analyses; RCT: randomised controlled trial; RR: relative risk; SNAC: scaphoid non-union advanced collapse; UK: United Kingdom.
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Affiliation(s)
- Han Hong Chong
- University Hospital of Leicester NHS Trust, Leicester, United Kingdom
| | - Kunal Kulkarni
- Pulvertaft Hand Centre, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Rohi Shah
- University Hospital of Leicester NHS Trust, Leicester, United Kingdom
| | - Melinda Y T Hau
- University Hospital of Leicester NHS Trust, Leicester, United Kingdom
| | - Lambros Athanatos
- University Hospital of Leicester NHS Trust, Leicester, United Kingdom
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Tsujii M, Odake K, Nishimura A, Nishimura M, Sudo A. Endoscopic resection of scar tissues and bone graft with an intramedullary nail left in situ for distal femoral nonunion after nailing: A case report. J Orthop Surg (Hong Kong) 2021; 28:2309499020958203. [PMID: 32969313 DOI: 10.1177/2309499020958203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Femoral shaft nonunion after the intramedullary nailing has been successfully treated with advances in surgical technique. Nonetheless, the techniques cause morbidity to periosteum at the fracture site. We report the case of a 67-year-old man who underwent endoscopic surgery for refractory nonunion following the fracture of the distal femoral shaft, despite two fixations using an interlocking nail. In addition, the patient had uncontrolled diabetic mellitus. Endoscopy allowed us to acquire a clear view of the nonunion site, in which the resection of scar tissues and the packing of the cancellous bone were performed. At the final follow-up, bone healing was observed, and the patient was able to return to normal daily and social activity.
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Affiliation(s)
- Masaya Tsujii
- Department of Orthopaedic Surgery, Graduate School of Medicine, 12946Mie University, Tsu, Japan
| | - Kazuya Odake
- Department of Orthopaedic Surgery, Graduate School of Medicine, 12946Mie University, Tsu, Japan
| | - Akinobu Nishimura
- Department of Orthopaedic Surgery, Graduate School of Medicine, 12946Mie University, Tsu, Japan
| | - Makoto Nishimura
- Department of Orthopaedic Surgery, Graduate School of Medicine, 12946Mie University, Tsu, Japan
| | - Akihiro Sudo
- Department of Orthopaedic Surgery, Graduate School of Medicine, 12946Mie University, Tsu, Japan
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21
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Yeh CW, Hsu CE, Wang WC, Chiu YC. Wrist function recovery course in patients with scaphoid nonunion treated with combined volar bone grafting and a dorsal antegrade headless screw. J Orthop Surg Res 2020; 15:519. [PMID: 33168036 PMCID: PMC7653748 DOI: 10.1186/s13018-020-02055-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 10/28/2020] [Indexed: 11/23/2022] Open
Abstract
Background Surgical treatment is necessary for scaphoid nonunion. Open surgery with a combined volar and dorsal approach is thought to have poor functional outcomes and a prolonged recovery course. However, the detailed recovery course for this approach is rarely reported. The aim of this study was to investigate the recovery course and radiographic outcome for patients with scaphoid nonunion who underwent a combined volar bone grafting and dorsal antegrade headless screw approach. Material and methods Eighteen patients with scaphoid nonunion who underwent combined volar bone grafting and dorsal antegrade headless screw fixation were enrolled in this retrospective study. Preoperative and serial postoperative wrist functional and radiographic outcomes were collected and analysed. Results All 18 patients achieved bone union at a mean time of 14.3 weeks. Compared to the preoperative status, the grip strength, wrist motion arc, and Mayo Wrist score were improved significantly 6 months after surgery, whilst the Disabilities of the Arm, Shoulder, and Hand (DASH) score did not recover until 12 months after surgery. Significant improvements were found in all scaphoid radiographic parameters. Conclusion The surgical outcomes for scaphoid nonunion treated with a combined volar bone grafting and dorsal antegrade headless screw achieved a high union rate, with great wrist functional and radiographic outcomes. The earliest recovered wrist functional parameters were grip strength, motion arc, Mayo Wrist score and finally the DASH score at postoperative 6 months and 12 months, respectively.
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Affiliation(s)
- Chen-Wei Yeh
- School of Medicine, China Medical University, Taichung, 40447, Taiwan.,Department of Education, China Medical University Hospital, Taichung, 40447, Taiwan
| | - Cheng-En Hsu
- Sports Recreation and Health Management Continuing Studies-Bachelor's Degree Completion Program, Tunghai University, Taichung, 407, Taiwan.,Department of Orthopedics, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Wei-Chih Wang
- Department of Orthopedic Surgery, China Medical University Hospital, China Medical University, No. 2, Xueshi Rd., North Dist, Taichung City, 40454, Taiwan
| | - Yung-Cheng Chiu
- School of Medicine, China Medical University, Taichung, 40447, Taiwan. .,Department of Orthopedic Surgery, China Medical University Hospital, China Medical University, No. 2, Xueshi Rd., North Dist, Taichung City, 40454, Taiwan.
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22
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Leow M, Chung SR, Tay SC. The Effect of Intra-carpal Kirschner Wire Augmentation in Screw Fixation of Scaphoid - A Retrospective Cohort Study. Malays Orthop J 2020; 14:104-109. [PMID: 33403069 PMCID: PMC7751989 DOI: 10.5704/moj.2011.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Introduction: Scaphoid fractures are most often treated with a single headless compression screw. However, intercarpal Kirschner wire (K-wire) might be added to improve stability and fracture outcomes. This study will determine if there is a difference in treatment outcome (union rate and time to union) between scaphoid fracture fixations using a single headless compression screw with and without augmentation using a intracarpal intramedullary K-wire. Material and Methods: We conducted a retrospective review of patients who underwent surgery for isolated scaphoid fractures over a 15 years period from December 2000 to December 2015. Only patients who underwent open surgery with bone grafting were included. They were divided into a group treated with a single screw fixation, and another group treated with screw and K-wire fixations. Results: Forty-four (58.7%) patients had single screw fixation and 31 (41.3%) had screw augmented with K-wire fixation. The overall union rate was 88.0%, with an overall mean time to union of 5.3 months. There was no difference in union rate (p=0.84) and time to union (p=0.66) between the single screw group and combined screw and K-wire group. Univariate analysis found that older age (t=-2.11, p=0.04) had a significant effect on union rate. Regression model showed that age had a significant effect on months to union. Conclusion: In open fixation of scaphoid fractures with compression screw and bone grafting, union rate and time to union is comparable whether or not screw fixation was augmented with an intracarpal K-wire. There was no increased risk of complications associated with augmented screw. Age of patient affected time to union and union rate.
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Affiliation(s)
- Mqh Leow
- Biomechanics Laboratory, Singapore General Hospital, Singapore
| | - S R Chung
- Department of Hand and Reconstructive Microsurgery, Singapore General Hospital, Singapore
| | - S C Tay
- Biomechanics Laboratory, Singapore General Hospital, Singapore
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23
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Hsiung W, Huang HK, Wang JP, Chang MC, Huang YC. Arthroscopic realignment and osteosynthesis of unstable scaphoid nonunion with cancellous bone graft from the ipsilateral radius. INTERNATIONAL ORTHOPAEDICS 2020; 45:191-197. [PMID: 33048201 DOI: 10.1007/s00264-020-04840-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 09/29/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE The treatment of delayed union and established nonunion of the scaphoid using a volar approach with impaction of bone graft, either a cancellous or cortico-cancellous wedge graft, for osteosynthesis and maintenance of reduction. With the advancement of instruments and techniques of wrist arthroscopy, wider indications for wrist problems can be solved by this minimally invasive technique. We report our results of arthroscopic reduction, cancellous bone grafting to the regional distal radius, and headless screw fixation for the treatment of scaphoid nonunion, even with humpback deformity. METHODS Between August 2014 and February 2018, 41 patients (42 wrists) with unstable scaphoid nonunion received arthroscopic surgery. The mean follow-up was 38.1 months (range 24-70 months). We evaluated the results with a function questionnaire and clinical outcomes based on the visual analog scale (VAS) pain score, range of motion and grip strength, and radiologic measurements. RESULTS The union rate was 92.6% (38/41 patients) and union time was 4.6 months. Patients regained almost a full range of motion compared with the contralateral wrist. The post-op Quick DASH, Mayo wrist score, and VAS pain score all had significant improvement, with p < 0.05. The scapholunate angle showed significant correction from pre-op 68.0° to post-op 58.3°. The average VAS satisfaction score at final follow-up was 8.7. CONCLUSION Arthroscopic realignment and osteosynthesis for the treatment of unstable scaphoid nonunion with ipsilateral radius bone graft, even with humpback deformity, can achieve a high union rate, good radiological correction, and good functional recovery.
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Affiliation(s)
- Wei Hsiung
- Department of Surgery, School of Medicine, National Yang-Ming University, No.155, Sec.2, Linong Street, Taipei, Taiwan
- Department of Orthopaedics & Traumatology, Taipei Veterans General Hospital, No.201, Sec. 2, Shipai Rd., Beitou District, Taipei City, Taiwan
| | - Hui-Kuang Huang
- Department of Surgery, School of Medicine, National Yang-Ming University, No.155, Sec.2, Linong Street, Taipei, Taiwan
- Department of Orthopaedics & Traumatology, Taipei Veterans General Hospital, No.201, Sec. 2, Shipai Rd., Beitou District, Taipei City, Taiwan
- Department of Orthopaedics, Chiayi Christian Hospital, No.539, Zhongxiao Rd., East Dist., Chiayi City, Taiwan
- Chung Hwa University of Medical Technology, No.89, Wenhua 1st St., Rende Dist., Tainan City, Taiwan
| | - Jung-Pan Wang
- Department of Surgery, School of Medicine, National Yang-Ming University, No.155, Sec.2, Linong Street, Taipei, Taiwan
- Department of Orthopaedics & Traumatology, Taipei Veterans General Hospital, No.201, Sec. 2, Shipai Rd., Beitou District, Taipei City, Taiwan
| | - Ming-Chau Chang
- Department of Surgery, School of Medicine, National Yang-Ming University, No.155, Sec.2, Linong Street, Taipei, Taiwan
- Department of Orthopaedics & Traumatology, Taipei Veterans General Hospital, No.201, Sec. 2, Shipai Rd., Beitou District, Taipei City, Taiwan
| | - Yi-Chao Huang
- Department of Surgery, School of Medicine, National Yang-Ming University, No.155, Sec.2, Linong Street, Taipei, Taiwan.
- Department of Orthopaedics & Traumatology, Taipei Veterans General Hospital, No.201, Sec. 2, Shipai Rd., Beitou District, Taipei City, Taiwan.
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24
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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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25
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Eng K, Gill S, Hoy S, Shridar V, Van Zyl N, Page R. Volar Scaphoid Plating for Nonunion: A Multicenter Case Series Study. J Wrist Surg 2020; 9:225-229. [PMID: 32509427 PMCID: PMC7263855 DOI: 10.1055/s-0040-1702199] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 01/07/2020] [Indexed: 10/24/2022]
Abstract
Background The volar scaphoid plate from Medartis (Medartis AG, Austrasse, Basel, Switzerland) is a variable angle titanium locking plate, preformed for the volar aspect of the scaphoid. It does not have compressive capability, and may act as a bridging device. It may provide an advantage over a compression screw where the pathoanatomy is less favorable to such a device with increased rotational stability. It may act as a buttress plate for correction of humpback deformity for example. It has been used in nonunions and with vascularized grafts. Questions Our study aims to assess the results of our patients with scaphoid nonunion treated with scaphoid volar plating over a larger number of patients. We aim to identify techniques to increase the success of plating. Methods Patients from our cohort were retrospectively reviewed. Operations were performed by three hand fellowship trained surgeons and in two centers. Inclusion involved a scaphoid plate procedure for a nonunion of the scaphoid with a minimum of 6 months of follow-up. Exclusions were those who had less than 6 months of follow-up. Data included demographics, patient-rated wrist evaluation (PRWE), a quick disabilities of the arm, shoulder, and hand (qDASH), visual analogue score, and range and grip. Radiology was reviewed. Results Thirty-two eligible patients were assessed. The mean age was 25 years (range 13-46), 2 were female and 15 were smokers. Mean follow-up postsurgery was 18 months. Twenty-nine of 32 patients united (90.6%) on computed tomography scan. Clinical assessment was performed in the 25 patients. The mean qDASH score was 12.5 (range 0-42) and mean PRWE was 11 (range 0-54). The mean arc of motion was 115 degrees. The mean grip strength was 39 kg compared with 41 kg on the nonoperated side. Conclusion We postulate that the plate acts like an internal bridging device, acting over a small distance, and inherent stability of the construct with structural graft and accurate reduction prior to plating is advantageous. Potential problems include plate impingement on the volar lip of the radius, particularly when trying to plate more proximal fractures. Ideally, it is utilized for mid to distal waist fractures.
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Affiliation(s)
- Kevin Eng
- Department of Orthopaedic Surgery, Barwon Health, Geelong, Australia
- Deakin University, Waurn Ponds, Australia
| | - Stephen Gill
- Department of Orthopaedic Surgery, Barwon Health, Geelong, Australia
- Deakin University, Waurn Ponds, Australia
| | - Simon Hoy
- Department of Orthopaedic Surgery, Barwon Health, Geelong, Australia
- Deakin University, Waurn Ponds, Australia
| | - Vivek Shridar
- Department of Orthopaedic Surgery, Toowoomba Hospital, South Toowoomba, QLD, Australia
| | - Natasha Van Zyl
- Department of Orthopaedic Surgery, Toowoomba Hospital, South Toowoomba, QLD, Australia
| | - Richard Page
- Department of Orthopaedic Surgery, Barwon Health, Geelong, Australia
- Deakin University, Waurn Ponds, Australia
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26
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Kakar S, Burnier M, Atzei A, Ho PC, Herzberg G, Del Piñal F. Dry Wrist Arthroscopy for Radial-Sided Wrist Disorders. J Hand Surg Am 2020; 45:341-353. [PMID: 32122689 DOI: 10.1016/j.jhsa.2020.01.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 01/20/2020] [Accepted: 01/24/2020] [Indexed: 02/02/2023]
Abstract
The development of wrist arthroscopy has been useful in diagnosis, prognosis, and treatment of both ligament and osseous injuries. As the treatment indications and techniques become more refined, this article explores the role of dry arthroscopy to treat radial-sided disorders of the wrist.
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Affiliation(s)
- Sanjeev Kakar
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN.
| | - Marion Burnier
- Service Chirurgie Orthopédique Membre Supérieur, Hôpital Edouard Herriot, Lyon, France
| | - Andrea Atzei
- Hand Surgery Unit, Policlinico G.B. Rossi, Verona, Italy
| | - P C Ho
- Department of Orthopaedics and Traumatology, The Chinese University of Hong Kong, Hong Kong, China
| | - Guillaume Herzberg
- Service Chirurgie Orthopédique Membre Supérieur, Hôpital Edouard Herriot, Lyon, France
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27
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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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28
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Combined Pedicled Vascularized and Wedge Nonvascularized Bone Graft for Treating Scaphoid Waist Nonunion With Humpback Deformity. Tech Hand Up Extrem Surg 2020; 23:155-159. [PMID: 31738737 DOI: 10.1097/bth.0000000000000244] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Pedicled vascularized bone graft (VBG) is a useful method in treating the scaphoid fracture nonunion, especially when the avascular necrosis exists. Humpback deformity is an important issue that we have to correct it during the treatment. We describe a method by using combined wedge non-VBG to correct the nonunion deformity when treating scaphoid nonunion with pedicled VBG. The wedge bone graft was harvested just proximal to the 2,3 intercompartmental supraretinacular artery VBG and was used as an inlay at the volar site to correct the humpback deformity, whereas the VBG was set at the dorsal site for bone bridging and blood supply. We also present our results of 10 patients with scaphoid fracture nonunion and humpback deformity treated with this method. Bone healing was achieved and the lateral intrascaphoid angles could be improved in all the 10 patients. Functional outcomes, including the Visual Analog Pain Scale for pain during activity, grip strength, the shortened Disabilities of the Arm, Shoulder, and Hand questionnaire (QuickDASH), and the modified Mayo Wrist Scores, were significantly improved.
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29
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Arthroscopic treatment of scaphoid nonunion with humpback deformity and DISI with corticocancellous bone grafting: Technical note. HAND SURGERY & REHABILITATION 2019; 38:280-285. [PMID: 31394281 DOI: 10.1016/j.hansur.2019.07.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 06/17/2019] [Accepted: 07/29/2019] [Indexed: 11/23/2022]
Abstract
For two decades, scaphoid nonunion has been treated arthroscopically. However, compressed cancellous bone graft does not have the same mechanical properties as corticocancellous bone graft for reducing the scaphoid humpback deformity and DISI tilt. Here, we describe an arthroscopic technique to treat Alnot stage IIB scaphoid nonunion. We treated a 27-year-old male patient for scaphoid waist nonunion with humpback deformity and DISI. A 8×8×10 mm cylindrical corticocancellous bone graft was harvested from the dorsal aspect of the radius using a single-use osteochondral autograft transfer system (OATS®, Arthrex Inc., Naples, USA). It was inserted in the nonunion site through an arthroscopic volar approach. Bone union was obtained at 3 months with lasting correction of the scaphoid humpback deformity and DISI. The functional result at 6 months was excellent. There were no complications. Scaphoid nonunion with humpback deformity and DISI may be treated arthroscopically with a corticocancellous bone graft.
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30
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Abstract
Arthroscopic bone grafting (ABG) in difficult scaphoid delayed union and nonunion allows thorough assessment and comprehensive management for scaphoid fracture and its sequelae. It provides a favorable biological environment for bony healing and produces minimal trauma to the soft tissues, aiding in rehabilitation. With adequate training and experience, high union rates and satisfactory clinical outcomes can be achieved. Poor blood supply of the scaphoid is not a contraindication to bone grafting; union rates over 80% have been reported, comparable to other existing surgical methods. This article discusses the rationale, surgical techniques, and results of ABG.
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31
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Liu B, Wu F, Ng CY. Wrist arthroscopy for the treatment of scaphoid delayed or nonunions and judging the need for bone grafting. J Hand Surg Eur Vol 2019; 44:594-599. [PMID: 30987500 DOI: 10.1177/1753193419841253] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
This study reports outcomes of arthroscopy in the treatment of delayed or nonunions of 25 scaphoids (25 patients). The surgery was performed between 8 and 43 weeks after injury. Intraoperatively, 11 fractures were deemed stable to probing and underwent percutaneous screw fixation only; 14 were unstable and received arthroscopic bone grafting with percutaneous screw fixation. All fractures united. At a mean follow-up of 21 months (range 12-48), the mean Mayo wrist score was 96, and patient-rated wrist evaluation was 4, and the flexion-extension arc was 90% of the contralateral wrist. We conclude that arthroscopy is valuable in the treatment of scaphoid delayed or nonunions and in judging the need for bone grafting. Our data indicate that regardless of cystic formation in the scaphoid, bone grafting is not always necessary. Percutaneous fixation alone is sufficient when scaphoid delayed or nonunions are between 8 weeks and 1 year following injury, without scaphoid nonunion advanced collapse or dorsal intercalated segment instability, and when forceful probing confirms stability of the scaphoid arthroscopically. Level of evidence: IV.
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Affiliation(s)
- Bo Liu
- 1 Department of Hand Surgery, The Fourth Clinical College of Peking University, Beijing, China
| | - Feiran Wu
- 2 Upper Limb Unit, Wrightington Hospital, Wigan, UK
| | - Chye Yew Ng
- 2 Upper Limb Unit, Wrightington Hospital, Wigan, UK
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32
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Zemirline A, Taleb C, Naito K, Vernet P, Liverneaux P, Lebailly F. Distal radius fracture fixation with a volar locking plate and endoscopic carpal tunnel release using a single 15mm approach: Feasibility study. HAND SURGERY & REHABILITATION 2018; 37:S2468-1229(18)30068-9. [PMID: 29779839 DOI: 10.1016/j.hansur.2018.03.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 03/09/2018] [Accepted: 03/13/2018] [Indexed: 12/31/2022]
Abstract
Distal radius fractures (DRF) may trigger, reveal or decompensate acute carpal tunnel syndrome (CTS) in 0.5-21% of cases. Internal fixation and median nerve release must then be carried out urgently. Less invasive approaches have been described for both the median nerve release using an endoscopic device and for the DRF fixation using a volar locking plate. We assessed the feasibility of DRF fixation and median nerve release through a single, minimally-invasive 15mm approach on a series of 10 cases. We reviewed retrospectively 10 consecutive cases of DRF associated with symptomatic CTS in 8 women and 2 men, aged 57 years on average. CTS was diagnosed clinically. All patients were treated during outpatient surgery with a volar locking plate and endoscopic carpal tunnel release using a single 15mm minimally-invasive approach. In one case, arthroscopic scapholunate repair was also required. Six months after the procedure, all patients were reviewed with a clinical examination and a radiological evaluation. The average values for the clinical and radiological outcomes were as follows: pain on VAS 1.5/10; QuickDASH 14.3/100; flexion 90%; extension 90.6%; pronation 95.6%; supination 87.9%; grip strength 90.1%; 2PD test 5.2mm (4-8mm). Five complications occurred: two cases of temporary dysesthesia in the territory of the median nerve and one case of temporary hypoesthesia of the palmar branch of the median nerve, which had all completely recovered; two cases of complex regional pain syndrome type I, which were still active at 6 months. Despite its methodological weaknesses, our study is the only one to describe the technical feasibility of a single 15mm minimally-invasive approach for both internal fixation using a volar locking plate and endoscopic nerve release, with no serious complications. This technique should be added to the surgical toolbox of minimally-invasive procedures for the hand and wrist.
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Affiliation(s)
- A Zemirline
- Hand Center of Brittany, Saint-Grégoire Private Hospital Center, 6, boulevard de la Boutière, 35760 Saint-Grégoire, France.
| | - C Taleb
- Department of Orthopaedic Surgery, Mulhouse Hospital Center, 20, avenue Docteur René-Laennec, 68100 Mulhouse, France
| | - K Naito
- Department of Orthopaedics, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, 113-8421 Tokyo, Japan
| | - P Vernet
- Department of Hand Surgery, Strasbourg University Hospital, 10, avenue Achille-Baumann, 67400 Illkirch, France
| | - P Liverneaux
- Department of Hand Surgery, Strasbourg University Hospital, 10, avenue Achille-Baumann, 67400 Illkirch, France
| | - F Lebailly
- Clinique Saint-Paul, 3, rue des Hibiscus, 97200 Fort-De-France, France
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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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Donald SM, Niu R, Jones CW, Smith BJ, Clarke EC, Lawson RD. Effects of Removal and Reinsertion of Headless Compression Screws. J Hand Surg Am 2018; 43:139-145. [PMID: 29137829 DOI: 10.1016/j.jhsa.2017.10.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 08/30/2017] [Accepted: 10/02/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE This study investigates the loss of compression when 3 commonly used headless compression screws are backed out (reversed), and assesses the ability to re-establish compression with screws of greater diameter. METHODS Two investigators tested 3 screw designs (Acutrak 2, Synthes HCS, Medartis SpeedTip CCS) in 2 diameters and lengths. Each design had 10 test cycles in a polyurethane foam bone model with compression recorded using a washer load cell. A 28-mm screw of the narrower diameter was inserted until 2 mm recessed and then reversed 30°, 60°, 90°, 180°, 270°, 360°, and 720°. After this the screw was removed completely and a 24-mm screw of greater diameter inserted until recessed 2 mm with the compressive force again recorded. RESULTS All screws showed an immediate, statistically significant loss of compression at 30° of reversing. The Acutrak 2 Micro screw demonstrated not only the greatest mean compressive force, but also the fastest compressive loss. Insertion of the shorter screw of greater diameter was associated with re-establishment of compression to levels comparable with the original screw. CONCLUSIONS This study reaffirms the importance of establishing the correct screw length before insertion due to the immediate loss of compression with reversal of these devices. CLINICAL RELEVANCE If a headless compression screw penetrates the far joint surface, the screw should be completely removed and replaced with a shorter screw of greater diameter.
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Affiliation(s)
- Simon M Donald
- Department of Hand Surgery and Peripheral Nerve Surgery, Royal North Shore Hospital, University of Sydney, Sydney, Australia
| | - Rui Niu
- Department of Hand Surgery and Peripheral Nerve Surgery, Royal North Shore Hospital, University of Sydney, Sydney, Australia
| | - Christopher W Jones
- Department of Hand Surgery and Peripheral Nerve Surgery, Royal North Shore Hospital, University of Sydney, Sydney, Australia
| | - Belinda J Smith
- Department of Hand Surgery and Peripheral Nerve Surgery, Royal North Shore Hospital, University of Sydney, Sydney, Australia
| | - Elizabeth C Clarke
- Murray Maxwell Biomechanics Laboratory, Kolling Institute, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Richard D Lawson
- Department of Hand Surgery and Peripheral Nerve Surgery, Royal North Shore Hospital, University of Sydney, Sydney, Australia.
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Mathoulin CL, Arianni M. Treatment of the scaphoid humpback deformity - is correction of the dorsal intercalated segment instability deformity critical? J Hand Surg Eur Vol 2018; 43:13-23. [PMID: 29105591 DOI: 10.1177/1753193417739526] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Treatment of scaphoid fractures has been focused mainly on achieving union, with less attention to restoring normal scaphoid shape and orientation. Malalignment of one carpal bone will disrupt the kinetics of the entire wrist. The dorsal intercalated segment instability deformity associated with scaphoid waist nonunion is a nondissociative form of carpal instability. It has to be reduced in the treatment of scaphoid waist nonunions to avoid kinetic problems that will lead to arthritic changes. Computerized tomography scanning has become indispensable to visualize the humpback deformity clearly. Different techniques may be used to restore the normal anatomy of scaphoid, from non-vascularized graft to arthroscopic bone grafting, and also the option of vascularized bone grafting.
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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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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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Cognet JM, Louis P, Martinache X, Schernberg F. Arthroscopic grafting of scaphoid nonunion – surgical technique and preliminary findings from 23 cases. HAND SURGERY & REHABILITATION 2017; 36:17-23. [DOI: 10.1016/j.hansur.2016.11.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Revised: 11/16/2016] [Accepted: 11/18/2016] [Indexed: 10/20/2022]
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Schuind F, Moungondo F, El Kazzi W. Prognostic factors in the treatment of carpal scaphoid non-unions. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2016; 27:3-9. [DOI: 10.1007/s00590-016-1886-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Accepted: 10/24/2016] [Indexed: 01/22/2023]
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Bumbaširević M. Scaphoid nonunion: special edition. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2016; 27:1-2. [PMID: 27848020 DOI: 10.1007/s00590-016-1872-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 10/17/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Marko Bumbaširević
- Clinic of Orthopedic Surgery and Traumatology, Clinical Centre of Serbia, School of Medicine, University of Belgrade, 26 Visegradska Street, Belgrade, 11 000, Serbia.
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Asmus A, Lautenbach M, Schacher B, Kim S, Eisenschenk A. [Scaphoid pseudarthrosis : Indications for avascular iliac crest or radius bone grafts]. DER ORTHOPADE 2016; 45:951-965. [PMID: 27637546 DOI: 10.1007/s00132-016-3337-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Operative treatment of the scaphoid nonunion includes avascular corticocancellous and cancellous bone grafts and increasingly the use of vascular pedicled and free vascular corticocancellous grafts. Especially the latter require a fair amount of operative expertise and experience in microsurgical techniques. OBJECTIVE Which criteria lead to the decision for or against an avascular graft used for reconstruction of scaphoid nonunion? Is our current classification system of a scaphoid pseudarthrosis able to illustrate our diagnostic potential in a way that makes us refer to operative procedures? METHODS Evaluation of current literature and expert opinions RESULTS: Avascular bone grafts show a high union rate as long as a sufficient vascularisation of the remaining fragments is present. In general, patients benefit from a very good functional outcome. Even revisions of failed scaphoid union may be successfully treated with an avascular bone graft. Failures of union are repeatedly experienced in treating proximal pole fractures with critical vascularisation or extensive bone loss, especially including avascular necrosis of the proximal pole (AVN). Current classification systems do not allow description and correlation of morphologic findings so as to compare results profoundly and to recommend specific procedures. CONCLUSIONS As long as sufficient vascularisation of remaining fragments is seen, the avascular bone graft is eligible for reconstructing scaphoid nonunion. Classification systems do not seem to reflect the status quo of diagnostic possibilities and make it difficult to provide guidelines for state-of-the-art operative procedures.
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Affiliation(s)
- A Asmus
- Abt. Hand-, Replantations- und Mikrochirurgie, Unfallkrankenhaus Berlin, Warener Str. 7, 12683, Berlin, Deutschland.
| | - M Lautenbach
- Handchirurgie, obere Extremität und Fußchirurgie, Zentrum für Orthopädie und Unfallchirurgie, Krankenhaus Waldfriede e.V., Argentinische Allee 40, 14163, Berlin, Deutschland
| | - B Schacher
- Abt. Hand-, Replantations- und Mikrochirurgie, Unfallkrankenhaus Berlin, Warener Str. 7, 12683, Berlin, Deutschland
| | - S Kim
- Abt. Hand- und funktionelle Mikrochirurgie, Universitätsmedizin Greifswald, Ferdinand-Sauerbruchstr, 17475, Greifswald, Deutschland
| | - A Eisenschenk
- Abt. Hand-, Replantations- und Mikrochirurgie, Unfallkrankenhaus Berlin, Warener Str. 7, 12683, Berlin, Deutschland.,Abt. Hand- und funktionelle Mikrochirurgie, Universitätsmedizin Greifswald, Ferdinand-Sauerbruchstr, 17475, Greifswald, Deutschland
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Uesato R, Toh S, Hayashi Y, Maniwa K, Ishibashi Y. Non-vascularized bone grafting in scaphoid nonunion: principles and type of fixation. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2016; 27:11-21. [PMID: 27761662 DOI: 10.1007/s00590-016-1868-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 10/09/2016] [Indexed: 12/21/2022]
Abstract
In scaphoid fractures, delayed diagnosis and nonunion are fairly common as a result of several factors, including the difficulty of radiographic diagnosis of non-displaced fractures and underestimation of the injury by the patient. Main factors to consider when deciding treatment are the type of fracture and fracture stability. In the stable nonunion (Type D1 according to the Filan and Herbert classification, or linear type of Ikeda's classification), percutaneous screw fixation without bone graft is recommended. The indications of non-vascularized bone grafting are as follows: (1) arthroscopic cancellous bone graft in type D1 and cystic type of Ikeda's classification. (2) tricortical bone graft from the iliac crest in type D2 or D3 if the possibility of avascular necrosis of the proximal fragment is excluded. In this paper, our non-vascularized bone grafting for scaphoid nonunion would like to be described mainly about principles and type of fixation.
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Affiliation(s)
- Ryoko Uesato
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Satoshi Toh
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan. .,Department of Orthopaedic Surgery, Hirosaki National Hospital, National Hospital Organization, Hirosaki, Japan.
| | - Yoshimitsu Hayashi
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Keiichiro Maniwa
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yasuyuki Ishibashi
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
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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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Wu J, Tay SC, Shin AY. The Effect of Screw Design on Union Rates in Scaphoid Nonunions. ACTA ACUST UNITED AC 2016; 20:273-9. [PMID: 26051768 DOI: 10.1142/s0218810415500239] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND The purpose of this study is to compare the outcome of the conical fully threaded headless screw to that of a smooth shaft headless screw in a series of scaphoid nonunions requiring screw fixation to determine if screw design had an influence on union rates. METHODS We retrospectively reviewed 104 cases of surgically treated scaphoid nonunions. After eliminating cases with our exclusion criteria, the study cohort had 40 cases for analysis. A comparison and analysis of union rates was undertaken between the fully threaded Acutrak 2 mini screw and the smooth shaft Herbert screw. RESULTS Overall union rate for screw fixation was 88%. The fully threaded conical screw fixation had a significantly lower union rate of 50% compared to 97% for the smooth shaft screws. CONCLUSIONS Our data revealed that the fully threaded conical screws were associated with significantly lower union rate compared to the smooth shaft Herbert type screws.
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Affiliation(s)
- Jiwei Wu
- † Department of Hand Surgery, Singapore General Hospital, Singapore
| | - Shian Chao Tay
- † Department of Hand Surgery, Singapore General Hospital, Singapore
| | - Alexander Y Shin
- * Division of Hand Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Karl JW, Swart E, Strauch RJ. Diagnosis of Occult Scaphoid Fractures: A Cost-Effectiveness Analysis. J Bone Joint Surg Am 2015; 97:1860-8. [PMID: 26582616 DOI: 10.2106/jbjs.o.00099] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Scaphoid fractures are common but may be missed on initial radiographs. Advanced imaging modalities such as computed tomography (CT) and magnetic resonance imaging (MRI) have improved diagnostic accuracy, but at an increased initial cost. The purpose of this study was to evaluate the cost-effectiveness of immediate advanced imaging for suspected occult scaphoid fractures. METHODS A decision analysis model was created to evaluate three diagnostic strategies for patients with concerning history and examination but negative radiographs: (1) empiric cast immobilization with orthopaedic follow-up and repeat radiography at two weeks post-injury, (2) immediate CT scanning, or (3) immediate MRI. Prevalence of occult scaphoid fracture, sensitivity and specificity of CT and MRI, and risks and outcomes of a missed fracture were derived from published clinical trials. Costs of imaging, lost worker productivity, and surgical costs of nonunion surgery were estimated on the basis of the literature. RESULTS Advanced imaging was dominant over empiric cast immobilization; advanced imaging had lower costs and its health outcomes were projected to be better than those of empiric cast immobilization. MRI was slightly more cost-effective than CT on the basis of the mean published diagnostic performance, but was highly sensitive to test performance characteristics. Advanced imaging would have to increase in cost to more than $2000 or decrease in sensitivity to <25% for CT or <32% for MRI for empiric cast immobilization to be cost-effective. CONCLUSIONS Given its relatively low cost and high diagnostic accuracy, advanced imaging for suspected scaphoid fractures in the setting of negative radiographs represents a cost-effective strategy for reducing both costs and morbidity. The decision to use CT compared with MRI is a function of individual institutional costs and local test performance characteristics.
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Affiliation(s)
- John W Karl
- Columbia University Medical Center, 622 West 168th Street, PH-1130, New York, NY 10032. E-mail address for R.J. Strauch:
| | - Eric Swart
- Columbia University Medical Center, 622 West 168th Street, PH-1130, New York, NY 10032. E-mail address for R.J. Strauch:
| | - Robert J Strauch
- Columbia University Medical Center, 622 West 168th Street, PH-1130, New York, NY 10032. E-mail address for R.J. Strauch:
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Abstract
The treatment for giant cell tumors of the tendon sheath is surgical therapy, but surgical recurrence rates were reported to be as high as 50% in some cases. Therefore, complete radical excision of the lesion is the treatment of choice. If the tumor originates from the joint, it is important to perform capsulotomy. Here, the authors report the first case of successful treatment of a localized intra-articular giant cell tumor in the wrist by arthroscopic resection.A 28-year-old right-handed woman visited the clinic because of left wrist ulnar-side pain, which had been aggravated during the previous 15 days. Vague ulnar-side wrist pain had begun 2 years ago. When the authors examined the patient, the wrist showed mild swelling on the volo-ulnar aspect and the distal radioulnar joint, as well as volar joint line tenderness. She showed a positive result on the ulnocarpal stress test and displayed limited range of motion. Magnetic resonance imaging revealed an intra-articular mass with synovitis in the ulnocarpal joint. Wrist arthroscopy was performed using standard portals under regional anesthesia. The arthroscopic findings revealed a large, well-encapsulated, yellow lobulated soft-tissue mass that was attached to the volar side of the ulnocarpal ligament and connected to the extra-articular side. The mass was completely excised piece by piece with a grasping forceps. Histopathologic examination revealed that the lesion was an intra-articular localized form of a tenosynovial giant cell tumor.At 24-month follow-up, the patient was completely asymptomatic and had full range of motion in her left wrist, and no recurrence was found in magnetic resonance imaging follow-up evaluations.The authors suggest that the arthroscopic excision of intra-articular giant cell tumors, as in this case, may be an alternative method to open excisions, with many advantages.
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Affiliation(s)
- Young-Keun Lee
- From the Department of Orthopedic Surgery, Chonbuk National University Hospital, Jeonju (Y-KL); Department of Computer Engineering, Sungkyul University, Anyang (YH); and Research Center for Advanced Image and Information Technology, School of Electronics and Information Engineering, Chonbuk National University, Jeonju, South Korea (ML)
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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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