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Mickley JP, Lynch DJ, Gordon AM, Roebke AJ, Goyal KS. Fracture Gap Closure and Reduction Are Affected by the Orientation of the Headless Compression Screw. Hand (N Y) 2024; 19:656-663. [PMID: 36692082 PMCID: PMC11141410 DOI: 10.1177/15589447221150504] [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] [Indexed: 01/25/2023]
Abstract
BACKGROUND We evaluated the impact of a variable-pitch headless screw's angle of insertion relative to the fracture plane on fracture gap closure and reduction. METHODS Variable-pitch, fully threaded headless screws were inserted into polyurethane blocks of "normal" bone model density using a custom jig. Separate trials were completed with a 28-mm screw placed perpendicular and oblique/longitudinal to varying fracture planes (0°, 15°, 30°, 45°, and 60°). Fluoroscopic images were taken after each turn during screw insertion and analyzed. Initial screw push-off, residual fracture gap at optimal fracture gap reduction, and malreduction were determined in each trial. Statistical analysis was performed via a 1-way analysis of variance followed by Student t tests. RESULTS Malreduction was found to be significantly different between the perpendicular (1.88 mm ± 1.38) and the oblique/longitudinal (0.58 mm ± 0.23) screws. The malreduction increased for the perpendicular screw as the fracture angle increased (60° > 45°=30° > 15° > 0°). Residual fracture gap at optimal fracture gap reduction was also found to be significantly different between the perpendicular (0.97 ± 0.42) and oblique/longitudinal (1.43 ± 1.14) screws. The residual fracture gap increased for the oblique/longitudinal screw as the fracture angle increased, although the oblique/longitudinal screw with a 60° fracture angle was the only configuration significantly larger than all the other configurations. Screw push-off was not found to be significantly different between the oblique/longitudinal screw and perpendicular screw trials. CONCLUSIONS The perpendicular screw had a larger malreduction that increased with fracture angle, whereas the oblique/longitudinal screw had a larger residual fracture gap that increased with fracture angle.
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Affiliation(s)
- John P. Mickley
- The Ohio State University College of Medicine, Columbus, USA
| | - Daniel J. Lynch
- The Ohio State University College of Medicine, Columbus, USA
| | - Adam M. Gordon
- The Ohio State University Wexner Medical Center, Columbus, USA
| | | | - Kanu S. Goyal
- The Ohio State University Wexner Medical Center, Columbus, USA
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Rogers MJ, Ohlsen SM, Huang JI. Fixation Techniques for Scaphoid Nonunion. J Am Acad Orthop Surg 2023; 31:783-792. [PMID: 37307573 DOI: 10.5435/jaaos-d-23-00287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 04/18/2023] [Indexed: 06/14/2023] Open
Abstract
Scaphoid fractures are common injuries with high risk of nonunion. Various fixation techniques exist for managing scaphoid nonunions, including Kirschner wires, single or dual headless compression screws, combination fixation techniques, volar plating, and compressive staple fixation. The indication for each fixation technique varies depending on the patient, type of nonunion, and clinical scenario.
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Affiliation(s)
- Miranda J Rogers
- From the Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA
- None of the following authors or any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Rogers, Ohlsen, and Huang
| | - Suzanna M Ohlsen
- From the Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA
- None of the following authors or any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Rogers, Ohlsen, and Huang
| | - Jerry I Huang
- From the Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA
- None of the following authors or any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Rogers, Ohlsen, and Huang
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Surke C, Huntington LS, Zhang X, Ek ETH, Ackland D, Tham SK. Double-Screw Osteosynthesis in an Unstable Scaphoid Fracture Model: A Biomechanical Comparison of Two Screw Configurations. J Hand Surg Am 2022; 47:1118.e1-1118.e8. [PMID: 34690014 DOI: 10.1016/j.jhsa.2021.08.019] [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: 09/25/2020] [Revised: 06/28/2021] [Accepted: 08/25/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE Although there is evidence that a single headless compression screw is sufficient for fixation of most scaphoid fractures, double-screw osteosynthesis has been shown to result in higher failure strength and stiffness than a single screw. However, the biomechanical effect of different screw configurations has not been determined. METHODS A standardized unstable fracture model was produced in 28 cadaveric scaphoids. Specimens were randomly allocated to 1 of 2 fixation groups using 2 internal compression screws positioned in either the sagittal or coronal plane. A specimen-specific 3-dimensionally-printed customized screw placement and osteotomy device was developed using computer-aided design-generated models derived from computed tomography scan data of each individual scaphoid. Load to failure and stiffness of the repair constructs were evaluated using a mechanical testing system. RESULTS There were no significant differences in size, weight, and density between the scaphoid specimens. The average distance between screws was significantly greater in the sagittal group than in the coronal group. There were no significant differences between the coronal and sagittal aligned double screws in load to 2 mm displacement (mean coronal 180.9 ± 109.7 N; mean sagittal 156.0 ± 85.8 N), load to failure (mean coronal 275.9 ± 150.6 N; mean sagittal 248.0 ± 109.5 N), stiffness (mean coronal 111.7 ± 67.3 N/mm; mean sagittal 101.2 ± 45.1 N/mm), and energy absorption (mean coronal 472.6 ± 261.4 mJ; mean sagittal 443.5 ± 272.7 mJ). CONCLUSIONS There are no significant biomechanical differences between the sagittal or coronal aligned double headless compression screws in a scaphoid fracture model with bone loss. CLINICAL RELEVANCE In cases where double-screw fixation of the scaphoid is being considered, the placement of double screws can be at the discretion of the surgeon, and can be dictated by ease of access, surgical preference, and fracture orientation.
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Affiliation(s)
- Carsten Surke
- Department of Plastic and Hand Surgery, Inselspital, University Hospital Bern, University of Bern, Switzerland; Hand and Wrist Biomechanics Laboratory, O'Brien Institute, Fitzroy, Victoria, Australia
| | - Lachlan S Huntington
- Hand and Wrist Biomechanics Laboratory, O'Brien Institute, Fitzroy, Victoria, Australia; Department of Biomedical Engineering, University of Melbourne, Parkville, Victoria, Australia
| | - Xin Zhang
- Department of Biomedical Engineering, University of Melbourne, Parkville, Victoria, Australia
| | - Eugene T H Ek
- Hand and Wrist Biomechanics Laboratory, O'Brien Institute, Fitzroy, Victoria, Australia; Division of Hand Surgery, Department of Orthopaedic Surgery, Monash University, Dandenong Hospital, Dandenong, Australia
| | - David Ackland
- Department of Biomedical Engineering, University of Melbourne, Parkville, Victoria, Australia
| | - Stephen K Tham
- Hand and Wrist Biomechanics Laboratory, O'Brien Institute, Fitzroy, Victoria, Australia; Division of Hand Surgery, Department of Orthopaedic Surgery, Monash University, Dandenong Hospital, Dandenong, Australia; Department of Plastic and Hand Surgery, St Vincent's Hospital, Fitzroy, Victoria, Australia.
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Kılıç B, Çalışkan M, Agar A, Uzun B, Ertem F, Gülabi D, Ertürk C. Comparison of two different screw trajectories in the treatment of oblique scaphoid fractures: A mechanical study on composite bone models. Jt Dis Relat Surg 2021; 32:377-382. [PMID: 34145814 PMCID: PMC8343848 DOI: 10.52312/jdrs.2021.15] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 05/17/2021] [Indexed: 11/22/2022] Open
Abstract
Objectives
In this mechanical study, we aimed to compare two different screw trajectories in terms of durability against axial loads on oblique scaphoid fractures using composite bone models. Materials and methods
Oblique osteotomies were made along the dorsal sulcus of 14 composite scaphoid bone models. Following this, all bone models were randomly classified. One group of bones were fixed with a screw placed perpendicular to the osteotomy line and the other group was fixed with a screw placed centrally down the long axis of the scaphoid bone. Each scaphoid bone model was positioned on a mechanical testing machine. Subsequently, axial loading tests were applied on each bone model to measure the amount of loading required to cause 2-mm displacement and failure on the osteotomy side and maximum displacement at the time of failure on scaphoid bone models. Results
There was no statistically significant difference in load to 2-mm displacement and failure between the two groups (p>0.05). Also, there was no statistically significant difference between the two groups in terms of maximum displacement seen on failure (p>0.05). Conclusion
In our study, we found that the stability of the screws which laid perpendicular to the fracture line and parallel to the long axis of the scaphoid was the same in fixing oblique scaphoid fractures.
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Affiliation(s)
- Bülent Kılıç
- SBÜ, Kanuni Sultan Süleyman Eğitim ve Araştırma Hastanesi, Ortopedi ve Travmatoloji Kliniği, 34303 Küçükçekmece, İstanbul, Türkiye.
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Ramos-Marques N, Ferrão A, Morais B, Barreira M, Teixeira F. Percutaneous Scaphoid Fixation: Experience Value among Different Approaches. J Wrist Surg 2021; 10:23-26. [PMID: 33552690 PMCID: PMC7850804 DOI: 10.1055/s-0040-1716352] [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] [Received: 05/25/2020] [Accepted: 07/14/2020] [Indexed: 10/23/2022]
Abstract
Background Percutaneous scaphoid osteosynthesis is an attractive and increasingly popular option, as a treatment for acute scaphoid fractures in selected cases, and as an alternative to conservative treatment. The purpose of this study is to assess the radiographic positioning of the screw in percutaneous scaphoid fixation, taking into consideration the surgeons' experience, and the difference between volar and dorsal approaches. Methods We retrospectively assessed patients undergoing percutaneous scaphoid fixation from 2013 to 2019. Inclusion criteria are as follows: (1) scaphoid waist fractures (Herbert's B2), (2) a minimum of 18 years of age and a maximum of 55 years of age, (3) dominant hand, (4) manual work, (5) minimum follow-up time of 6 months, and (6) without associated lesions. Criteria for correct positioning are as follows: (1) on the axis or parallel to the scaphoid axis with a maximum deviation of 1.5 mm volar/dorsal, (2) without proximal/dorsal prominence, (3) correct scaphoid alignment/reduction, and (4) absence of threads in the fracture site. Radiographs were evaluated separately by a hand surgeon, a general orthopaedic surgeon, and an orthopaedic resident. Results With a total of 39 patients, a dorsal approach was performed in 10 patients and a palmar approach in 29 patients. We verified a very good interobserver reliability. The hand surgeon's team correctly positioned 15 (83.3%, 15/18), while the other team did 9 correctly (42.9%, 9/21). Comparing teams according to the approach used, the dorsal approach did not show a statistical difference, while the same was not true for the volar approach ( p < 0.05). Conclusion This points to a positive impact on the team's experience in the positioning of the screws, and therefore in the benefit of treatment by teams dedicated to the area, while daring to suggest that less-experienced surgeons should utilize the dorsal approach.
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Affiliation(s)
- Nuno Ramos-Marques
- Deparment of Orthopedic Surgery, Hospital Curry Cabral, Centro Hospitalar Universitário Lisboa Central, EPE, Lisboa, Portugal
| | - Ana Ferrão
- Deparment of Orthopedic Surgery, Hospital Curry Cabral, Centro Hospitalar Universitário Lisboa Central, EPE, Lisboa, Portugal
| | - Bruno Morais
- Deparment of Orthopedic Surgery, Hospital Curry Cabral, Centro Hospitalar Universitário Lisboa Central, EPE, Lisboa, Portugal
| | - Mariana Barreira
- Deparment of Orthopedic Surgery, Hospital Curry Cabral, Centro Hospitalar Universitário Lisboa Central, EPE, Lisboa, Portugal
| | - Frederico Teixeira
- Deparment of Orthopedic Surgery, Hospital Curry Cabral, Centro Hospitalar Universitário Lisboa Central, EPE, Lisboa, Portugal
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Graul I, Lindner R, Schettler N, Friedel R, Hofmann GO. Deviations in positioning variable pitch screws- scaphoid waist fractures. Orthop Traumatol Surg Res 2020; 106:347-351. [PMID: 31899116 DOI: 10.1016/j.otsr.2019.10.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 09/10/2019] [Accepted: 10/07/2019] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Operative therapy using a headless cannulated variable pitch compression screw is the gold standard for the treatment of instable scaphoid fractures. HYPOTHESIS Deviation from the central placement is associated with a loss of stability and stiffness. MATERIAL AND METHODS An artificial bone model was manufactured and different screw positions (central, 10° and 20° to the long axis) were assessed. A shearing test with axial force on the 45° flexed scaphoid was applied. RESULTS The inserted variable pitch screw showed the highest stiffness and failure force in a position in the long axis. At 10 degrees, a slight decrease in stiffness (32.7N/mm±9.3N/mm) and failure force (41.6N±13.2N) was observed, while a significant reduction in stiffness (29.3N/mm±4.6N/mm) and failure force (50.3N±19.5N) was measured at 20 degrees. DISCUSSION Deviations in the angle of insertion of the compression screw cause loss in failure force, thus deviations from the central placement is associated with less stability and stiffness. LEVEL OF PROOF Controlled laboratory study (basic science study, biomechanical testing).
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Affiliation(s)
- Isabel Graul
- Department of Trauma-, Hand- and Reconstructive Surgery, University Jena, Germany.
| | - Robert Lindner
- Department of Trauma-, Hand- and Reconstructive Surgery, University Jena, Germany
| | - Nicky Schettler
- Department of Trauma, Orthopedics and hand surgery, Helios Erfurt, Germany
| | - Reinhard Friedel
- Department of Trauma-, Hand- and Reconstructive Surgery, University Jena, Germany
| | - Gunther O Hofmann
- Department of Trauma-, Hand- and Reconstructive Surgery, University Jena, Germany; Department of Trauma, BG Bergmanstrost, Halle, Germany
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Abstract
In cases of suspected scaphoid fracture where the initial radiographs are negative, a supplementary MRI, or alternatively CT, should be carried out within three to five days. Fracture classification, assessment of dislocation as well as evaluation of fracture healing is best done on CT with reconstructions in the coronal and sagittal planes, following the longitudinal axis of the scaphoid. After adequate conservative management, union is achieved at six weeks for approximately 90% of non-displaced or minimally displaced (≤ 0.5 mm) scaphoid waist fractures. Scaphoid waist fractures with moderate displacement (0.5–1.5 mm) can be treated conservatively, but require prolonged cast immobilization for approximately eight to ten weeks. Internal fixation is recommended for all scaphoid waist fractures with dislocation ≥ 1.5 mm. Distal scaphoid fractures can be treated conservatively. The majority heal uneventfully after four to six weeks of immobilization, depending on fracture type. In general, proximal scaphoid fractures should be treated with internal fixation.
Cite this article: EFORT Open Rev 2020;5:96-103. DOI: 10.1302/2058-5241.5.190025
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Affiliation(s)
- Martin Clementson
- Department of Hand Surgery, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Anders Björkman
- Department of Hand Surgery, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Niels O B Thomsen
- Department of Hand Surgery, Skåne University Hospital, Lund University, Malmö, Sweden
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Lucenti L, Lutsky KF, Jones C, Kazarian E, Fletcher D, Beredjiklian PK. Antegrade Versus Retrograde Technique for Fixation of Scaphoid Waist Fractures: A Comparison of Screw Placement. J Wrist Surg 2020; 9:34-38. [PMID: 32025352 PMCID: PMC7000263 DOI: 10.1055/s-0039-1698745] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 09/05/2019] [Indexed: 10/25/2022]
Abstract
Background Scaphoid waist fractures are often treated using headless compression screws using dorsal or volar approaches. Objectives The purpose of this study is to compare differences in screw position using a volar (retrograde) or dorsal (antegrade) approach. Patients and Methods A total of 82 patients were retrospectively evaluated: 41 treated with a volar and 41 with a dorsal approach were selected. Postoperative radiographs were reviewed by three observers who rated screw location in the proximal pole, waist, and distal pole. Results Thirty-four patients (83%) in the antegrade group had central screw placement in the waist of the scaphoid in posteroanterior and lateral planes compared with 14 (34.9%) in the retrograde group ( p < 0.05). For the antegrade group, the screw was central in 217 of 246 zones (88.2%) compared with 127 of 246 (51.6%) in the retrograde group ( p < 0.05). Conclusions The dorsal antegrade approach appears to allow the surgeon to achieve central screw placement along all three scaphoid regions. Level of Evidence This is Level III study.
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Affiliation(s)
- Ludovico Lucenti
- Department of Orthopaedic Surgery, University Hospital Policlinico-Vittorio Emanuele, University of Catania, Italy
| | - Kevin F. Lutsky
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
- Division of Hand Surgery, Rothman Institute, Philadelphia, Pennsylvania
| | - Christopher Jones
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
- Division of Hand Surgery, Rothman Institute, Philadelphia, Pennsylvania
| | | | - Daniel Fletcher
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
- Division of Hand Surgery, Rothman Institute, Philadelphia, Pennsylvania
| | - Pedro K. Beredjiklian
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
- Division of Hand Surgery, Rothman Institute, Philadelphia, Pennsylvania
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Experimental Study and Preliminary Clinical Application of Mini-invasive Percutaneous Internal Screw Fixation for Scaphoid Fracture under the Guidance of a 3D-printed Guide Plate. Curr Med Sci 2019; 39:990-996. [DOI: 10.1007/s11596-019-2133-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 11/05/2019] [Indexed: 11/26/2022]
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Patel S, Giugale J, Tiedeken N, Debski RE, Fowler JR. Impact of Screw Length on Proximal Scaphoid Fracture Biomechanics. J Wrist Surg 2019; 8:360-365. [PMID: 31579543 PMCID: PMC6773614 DOI: 10.1055/s-0039-1685514] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 03/04/2019] [Indexed: 10/27/2022]
Abstract
Background Proximal scaphoid fractures display high nonunion rates and increased revision cases. Waist fracture fixation involves maximizing screw length within the cortex; however, the optimal screw length for proximal scaphoid fractures remains unknown. Purpose The main purpose of this article is to compare stiffness and ultimate load for proximal scaphoid fracture fixation of various headless compression screw lengths. Methods Eighteen scaphoids underwent an osteotomy simulating a 7 mm oblique proximal fracture. Screws of three lengths (10, 18, and 24 mm) were randomly assigned for fixation. Each specimen underwent cyclic loading with stiffness calculated during the last loading cycle. Specimens that withstood cyclic loading were loaded to failure. Results No significant difference in stiffness between screw lengths was found. Ultimate load was significantly impacted by the screw length. A significant difference in ultimate load between a 10 and 24 mm screw was found; however, no significant difference occurred in ultimate load between an 18 and 24 mm screw. Conclusions No significant difference in stiffness between all groups could be due to similarities in purchase in the proximal aspect. The 10 mm screw withstanding less ultimate load compared to the 24 mm screw could be due to the 10 mm screw gaining less purchase on either side of the fracture site compared to the 24 mm screw. Lack of significant difference in ultimate load between the 18 and 24 mm screw could be occurring because the fracture site is closer to the 18 mm screw midpoint, as distal threads are engaged closer to the fracture. Clinical Relevance Maximizing screw length may not provide superior fixation biomechanically compared with fixation utilizing a 6 mm shorter screw for proximal scaphoid fractures.
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Affiliation(s)
- Samik Patel
- Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania
- Orthopaedic Robotics Laboratory, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Juan Giugale
- Orthopaedic Robotics Laboratory, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Nathan Tiedeken
- Orthopaedic Robotics Laboratory, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Richard E. Debski
- Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania
- Orthopaedic Robotics Laboratory, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - John R. Fowler
- Orthopaedic Robotics Laboratory, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
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Salabi V, Rigoulot G, Sautet A, Cambon-Binder A. Three-dimensional-printed patient-specific Kirschner-wire guide for percutaneous fixation of undisplaced scaphoid fractures: a cadaveric study. J Hand Surg Eur Vol 2019; 44:692-696. [PMID: 31156020 DOI: 10.1177/1753193419851525] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Undisplaced scaphoid waist fractures can be managed by percutaneous fixation. The purpose of this study is to compare percutaneous fixation using a three-dimensional (3-D)-printed guide with the conventional method in a cadaveric study. Twelve wrists were divided into two groups: standard fluroscopic technique group, and a patient-specific 3-D-printed guide group. In the patient-specific group, using high resolution CT scans, we manufactured a mould-guide including a wire guide sleeve aligned with the planned ideal path, and 3-D printed it. On postoperative CT scans we measured the angular deviation of the screw axis from the ideal axis, and compared the two groups. The angular deviation was significantly lower in the patient-specific guide group. We concluded that a 3-D-printed guide for scaphoid percutaneous fixation allows a more accurate placement of the screw than a fluoroscopy guide in our cadaveric model.
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Affiliation(s)
- Vincent Salabi
- 1 Orthopaedic and Traumatology Department, Saint-Antoine Hospital, Paris, France
| | | | - Alain Sautet
- 1 Orthopaedic and Traumatology Department, Saint-Antoine Hospital, Paris, France
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Abstract
Most minimally displaced scaphoid fractures and all displaced scaphoid fractures in elite athletes are treated with early fixation to maximally expedite the return to full function. Computed tomographic (CT) scans are recommended in all scaphoid fractures to facilitate a complete understanding of fracture anatomy and to allow for optimal screw placement. Screw placement is important to maximize healing capacity of the fracture and allow for return to sport. Postoperative CT scans can be helpful to evaluate the extent of healing and may allow patients to return to play sooner.
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Affiliation(s)
- Edward W Jernigan
- Division of Hand and Upper Extremity Surgery, Hospital for Special Surgery, 523 East 72nd Street, FL 4, New York, NY 10021, USA
| | - Kyle W Morse
- Division of Hand and Upper Extremity Surgery, Hospital for Special Surgery, 523 East 72nd Street, FL 4, New York, NY 10021, USA.
| | - Michelle G Carlson
- Division of Hand and Upper Extremity Surgery, Hospital for Special Surgery, 523 East 72nd Street, FL 4, New York, NY 10021, USA
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Brekke AC, Snoddy MC, Lee DH, Richard MJ, Desai MJ. Biomechanical Strength of Scaphoid Partial Unions. J Wrist Surg 2018; 7:399-403. [PMID: 30349753 PMCID: PMC6196095 DOI: 10.1055/s-0038-1661362] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Accepted: 05/21/2018] [Indexed: 10/28/2022]
Abstract
Background It remains unknown how much force a partially united scaphoid can sustain without refracturing. This is critical in determining when to discontinue immobilization in active individuals. Purpose The purpose of this study was to test the biomechanical strength of simulated partially united scaphoids. We hypothesized that no difference would exist in load-to-failure or failure mechanism in scaphoids with 50% or more bone at the waist versus intact scaphoids. Materials and Methods Forty-one cadaver scaphoids were divided into four groups, three experimental osteotomy groups (25, 50, and 75% of the scaphoid waist) and one control group. Each was subjected to a physiologic cantilever force of 80 to 120 N for 4,000 cycles, followed by load to failure. Permanent deformation during physiologic testing and stiffness, max force, work-to-failure, and failure mechanism during load to failure were recorded. Results All scaphoids survived subfailure conditioning with no significant difference in permanent deformation. Intact scaphoids endured an average maximum load to failure of 334 versus 321, 297, and 342 N for 25, 50, and 75% groups, respectively, with no significant variance. There were no significant differences in stiffness or work to failure between intact, 25, 50, and 75% groups. One specimen from each osteotomy group failed by fracturing through the osteotomy; all others failed near the distal pole loading site. Conclusion All groups behaved similarly under physiologic and load-to-failure testing, suggesting that inherent stability is maintained with at least 25% of the scaphoid waist intact. Clinical Relevance The data provide valuable information regarding partial scaphoid union and supports mobilization once 25% union is achieved.
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Affiliation(s)
- Adam C. Brekke
- Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mark C. Snoddy
- Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Donald H. Lee
- Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Marc J. Richard
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | - Mihir J. Desai
- Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee
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Ideal Starting Point and Trajectory of a Screw for the Dorsal Approach to Scaphoid Fractures. J Hand Surg Am 2018; 43:993-999. [PMID: 29779707 DOI: 10.1016/j.jhsa.2018.03.044] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 01/24/2018] [Accepted: 03/26/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine the screw starting point and trajectory for the dorsal approach to scaphoid fractures that provides a combination of length and compression at the fracture site. METHODS Computed tomography scans were obtained of 10 scaphoid fractures for 3 common fracture types. A computerized model was generated for each scaphoid. Screw starting point, length, and angle to the fracture plane were analyzed for starting points and trajectories within a safe zone that protected against cortical penetration. A novel analysis was developed to assess a combination of screw length and angle to fracture plane, termed "effective compression length" (ECL). ECL assessed the screw working distance perpendicular to the fracture. Results were analyzed to determine optimal screw starting point and trajectory. RESULTS For proximal pole fractures, a screw perpendicular to the fracture was 9.7 mm from the longitudinal axis starting point (LASP). The screw with the largest ECL was 6.8 mm from the LASP, crossing the fracture at a 67° obliquity. For waist fractures, a perpendicular screw was 7.8 mm from the LASP. The screw with the largest ECL was 6.0 mm away, crossing the fracture at 74°. For distal oblique fractures, a perpendicular screw was 10.2 mm from the LASP. The screw with the largest ECL was 6.4 mm away, crossing the fracture at 70°. A screw with the classic starting point and trajectory crossed the fracture at obliquities of 48°, 51°, and 45° for proximal, waist, and distal fractures, respectively. CONCLUSIONS Scaphoid screws placed with the classic starting point and trajectory cross the fracture at an obliquity. By altering the screw starting point and trajectory, screws with adequate length will be more perpendicular to the fracture plane. CLINICAL RELEVANCE Screw starting point and trajectory for scaphoid fractures may be altered based on fracture type to obtain a long screw that is closer to perpendicular to the fracture.
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Guss MS, Mitgang JT, Sapienza A. Scaphoid Healing Required for Unrestricted Activity: A Biomechanical Cadaver Model. J Hand Surg Am 2018; 43:134-138. [PMID: 29122424 DOI: 10.1016/j.jhsa.2017.09.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Revised: 09/12/2017] [Accepted: 09/27/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine if scaphoid fractures with bridging bone of 50% of their width treated with a centrally placed screw will restore biomechanical integrity equivalent to that of the intact scaphoid. METHODS Twenty-four fresh cadaver scaphoids were used. Six were left intact to serve as the control group. Six were osteotomized 50% of their width and made up the osteotomy without screw group. Six were included in the 50% osteotomy plus compression screw group. The remaining 6 were to be treated with an osteotomy of 25% or 75% with a screw, based upon the results of the 50% osteotomy with screw group. Biomechanical testing was performed using an Instron testing machine, with a load applied to the scaphoid's distal pole. Load to failure and stiffness were measured. RESULTS Intact scaphoids had an average load to failure of 610.0 N. The average load to failure of the 50% osteotomy group without a screw was 272.0 N and with a screw was 666.3 N. There was no significant difference in load to failure between the 50% osteotomy plus screw and the intact scaphoid. The 75% osteotomy plus screw was found to have a load to failure of 174.0 N, significantly lower than the intact scaphoid. The 50% osteotomy plus screw had a significantly higher stiffness than the intact scaphoid control. CONCLUSIONS A 50% intact scaphoid with a centrally placed screw showed similar load to failure and significantly higher stiffness than the intact scaphoid when tested in cantilever bending. CLINICAL RELEVANCE This study demonstrates that patients with scaphoid waist fractures who undergo surgery with a compression screw may be able to return to unrestricted activity with 50% partial healing.
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Affiliation(s)
- Michael S Guss
- Department of Orthopaedic Surgery, Division of Hand Surgery, NYU Hospital for Joint Diseases, New York, NY
| | - Joshua T Mitgang
- Department of Orthopaedic Surgery, Division of Hand Surgery, NYU Hospital for Joint Diseases, New York, NY
| | - Anthony Sapienza
- Department of Orthopaedic Surgery, Division of Hand Surgery, NYU Hospital for Joint Diseases, New York, NY.
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Ten Berg PWL, Dobbe JGG, Brinkhorst ME, Meermans G, Strackee SD, Verstreken F, Streekstra GJ. Scaphoid screw fixation perpendicular to the fracture plane: Comparing volar and dorsal approaches. Orthop Traumatol Surg Res 2018; 104:109-113. [PMID: 29253617 DOI: 10.1016/j.otsr.2017.11.013] [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: 05/17/2017] [Revised: 11/02/2017] [Accepted: 11/08/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION To percutaneously fixate a midwaist scaphoid fracture, both volar and dorsal approaches are considered valid options although they may have different screw insertion angles relative to the scaphoid fracture plane influencing fixation stability. In this virtual simulation study, we investigated the accessibility of placing a screw perpendicularly to the fracture plane in transverse and horizontal oblique scaphoid midwaist fracture models and compared standard volar and dorsal approaches. MATERIAL AND METHODS Computed tomography scans of 38 healthy wrists were used to obtain virtual 3-dimensional wrist models in flexion and extension. In case the trapezium in volar approach or the distal radius in dorsal approach obstructed the screw axis perpendicular to the fracture plane, an alternative non-obstructed screw axis was chosen as close as possible to the perpendicular axis. The deviation angle between the best possible non-obstructed screw placement and true perpendicular screw placement was quantified. RESULTS For transverse fractures, the average deviation angle (±standard deviation) was 8° (±5°) in volar approach, and 0° (±0°) in dorsal approach. For horizontal oblique fractures, these angles were 40° (±6°) and 14° (±8°), respectively. DISCUSSION In our simulations, compared to the volar approach, the dorsal approach provided the most precise screw placement perpendicular to the fracture plane, with the largest differences for horizontal oblique fractures. When taken in addition to screw purchase, thread engagement and protrusion risk, information about screw orientation may help surgeons in deciding between percutaneous approaches in scaphoid surgery on which there is currently no consensus. LEVEL OF EVIDENCE N/A.
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Affiliation(s)
- P W L Ten Berg
- Department of Plastic, Reconstructive, and Hand Surgery, Academic Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands.
| | - J G G Dobbe
- Department of Biomedical Engineering and Physics, Academic Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - M E Brinkhorst
- Department of Plastic, Reconstructive, and Hand Surgery, Erasmus Medical Center, University Medical Center Rotterdam, 3015 CE Rotterdam, The Netherlands
| | - G Meermans
- Department of Orthopaedics, Lievensberg Hospital, 4624 VT Bergen Op Zoom, The Netherlands
| | - S D Strackee
- Department of Plastic, Reconstructive, and Hand Surgery, Academic Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - F Verstreken
- Department of Orthopaedics, Monica Hospital, 2018 Antwerp, Belgium
| | - G J Streekstra
- Department of Biomedical Engineering and Physics, Academic Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; Department of Radiology, Academic Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
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Swanstrom MM, Morse KW, Lipman JD, Hearns KA, Carlson MG. Effect of Screw Perpendicularity on Compression in Scaphoid Waist Fractures. J Wrist Surg 2017; 6:178-182. [PMID: 28725497 PMCID: PMC5515612 DOI: 10.1055/s-0036-1596059] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 10/25/2016] [Indexed: 10/20/2022]
Abstract
Background Central and perpendicular (PERP) screw orientations have each been described for scaphoid fracture fixation. It is unclear, however, which orientation produces greater compression. Questions/Purposes This study compares compression in scaphoid waist fractures with screw fixation in both PERP and pole-to-pole (PTP) configurations. PERP orientation was hypothesized to produce greater compression than PTP orientation. Methods Ten preoperative computed tomography scans of scaphoid waist fractures were classified by fracture type and orientation in the coronal and sagittal planes. Three-dimensional models of each scaphoid and fracture plane were created. Simulated Acutrak 2 (Acumed, Hillsboro, OR) screws were placed into the models in both PERP and PTP orientations. Engagement length and screw angle relative to the fracture were measured. Compression strength was calculated from the shear area, average density, and angle acuity. Results The PTP angle between screw and fracture ranged from 36 to 84 degrees. By definition, the PERP screw-to-fracture angle was 90 degrees. Perpendicularity of the PTP screw to the fracture was positively correlated to compression strength. PERP screws had greater compression than PTP screws when the PTP screw-to-fracture angle was < 80 degrees (106 vs. 80 N), but there was no difference in compression when the PTP screw-to-fracture angle was > 80 degrees, approximating the PERP screw. Conclusion Increasing screw perpendicularity resulted in higher compression when the screw-to-fracture angle of the PTP screw was < 80 degrees. Maximum compression was obtained with a screw PERP to the fracture. The increased compression gained from PERP screw placement offsets the decreased engagement length. Clinical Relevance These results provide guidelines for optimal screw placement in scaphoid waist fractures.
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Affiliation(s)
- Morgan M. Swanstrom
- Division of Hand and Upper Extremity Surgery, Hospital for Special Surgery, New York, New York
| | - Kyle W. Morse
- Division of Hand and Upper Extremity Surgery, Hospital for Special Surgery, New York, New York
| | - Joseph D. Lipman
- Department of Biomechanics, Hospital for Special Surgery, New York, New York
| | - Krystle A. Hearns
- Division of Hand and Upper Extremity Surgery, Hospital for Special Surgery, New York, New York
| | - Michelle G. Carlson
- Division of Hand and Upper Extremity Surgery, Hospital for Special Surgery, New York, New York
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Volk I, Gal J, Peleg E, Almog G, Luria S. Three-dimensional comparison of alternative screw positions versus actual fixation of scaphoid fractures. Injury 2017; 48:1183-1189. [PMID: 28351546 DOI: 10.1016/j.injury.2017.03.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 02/23/2017] [Accepted: 03/12/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE The recommended technique for the fixation of a scaphoid waist fracture involves a headless compression screw placed in the proximal fragment center. This is usually accomplished by placing a longitudinal axis screw as visualized by fluoroscopy. The screw length has been shown to have a biomechanical advantage. An alternative to these options, which has been debated in the literature, is a screw placed perpendicular to the fracture plane and in its center. The perpendicular screw may have a biomechanical advantage despite the fact that it may be shorter. This study examined the differences in location and length in actual patients between a screw in the center of the proximal fragment with a longitudinal axis screw, and the actual fixating screw. These were then compared to a perpendicular axis screw. METHODS Pre- and post-operative CT scans of 10 patients with scaphoid waist fractures were evaluated using a 3D computer model. Comparisons were made between the length, location and angle of actual and virtual screw alternatives; namely, a screw along the central third of the proximal fragment (central screw axis) where the scaphoid longitudinal axis was calculated mathematically (longitudinal screw axis) and a screw placed at 90° to the fracture plane and in its center (perpendicular screw axis). RESULTS The longitudinal axis screw was found to be significantly longer than the other axes (28.3mm). There was a significant difference between the perpendicular axis screw and the location and angle of the other screw axis, but it was only shorter than the longitudinal screw (23.6mm versus 25.5mm for the actual screw; ns.). CONCLUSIONS A computed longitudinal axis screw is longer than a central or actual screw placed longitudinally by visual inspection by the surgeon. Although it needs to be placed using computer assisted (CAS) techniques, it may have the biomechanical advantages of a longer screw in a similar trajectory. The perpendicular screw was found to be significantly different in position and angle but not shorter than the actually placed screw. It has biomechanical advantages and does not require visualization with CAS methods, making it the more attractive alternative.
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Affiliation(s)
- Ido Volk
- Dept. of Orthopedic Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Jonathan Gal
- Dept. of Orthopedic Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Eran Peleg
- Dept. of Orthopedic Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Gil Almog
- Dept. of Orthopedic Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Shai Luria
- Dept. of Orthopedic Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
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Tait MA, Bracey JW, Gaston RG. Acute Scaphoid Fractures: A Critical Analysis Review. JBJS Rev 2016; 4:01874474-201609000-00003. [PMID: 27760075 DOI: 10.2106/jbjs.rvw.15.00073] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Nondisplaced scaphoid fractures can be effectively treated nonoperatively, with union rates approaching or, in some series, exceeding the rates attained with operative intervention. The evidence supports equal outcomes when using a short arm or long arm cast for the closed treatment of nondisplaced scaphoid fractures. Also, equivalent outcomes have been demonstrated with or without a thumb spica component to the cast. Operative intervention is the recommended treatment for displaced scaphoid fractures. Advanced imaging should be obtained if clinical suspicion is present for a scaphoid fracture with negative radiographs more than 2 weeks after the injury. In some settings, it may even be more cost-effective to obtain advanced imaging sooner.
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Affiliation(s)
- Mark A Tait
- OrthoCarolina Hand Center, Charlotte, North Carolina
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20
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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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21
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Slutsky DJ, Herzberg G, Shin AY, Buijze GA, Ring DC, Mudgal CS, Leung YF, Dumontier C. Coronal Fractures of the Scaphoid: A Review. J Wrist Surg 2016; 5:194-201. [PMID: 27574573 PMCID: PMC5001190 DOI: 10.1055/s-0036-1585414] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2016] [Accepted: 05/30/2016] [Indexed: 10/21/2022]
Abstract
Coronal (or frontal plane) fractures of the scaphoid are distinctly uncommon. There are few published reports of coronal fractures of the scaphoid. This fracture is often missed on the initial X-ray films. A high index of suspicion should exist when there is a double contour of the proximal scaphoid pole on the anteroposterior X-ray view. A computed tomography scan is integral in making the diagnosis. Early recognition is key in salvaging the scaphoid fracture and in preventing articular damage. Level of Evidence IV. Retrospective case series.
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Affiliation(s)
- David J. Slutsky
- The Hand and Wrist Institute, Torrance, California; Department of Orthopedics,
Harbor-UCLA Medical Center, Los Angeles, California
| | - Guillaume Herzberg
- Department of Orthopaedic Surgery, Orthopaedic Upper Limb Surgery Unit, Edouard
Herriot Hospital Claude, Lyon, France
| | - Alexander Y. Shin
- Division of Hand and Microvascular Surgery, Department of Orthopedic Surgery,
Mayo Clinic, Rochester, Minnesota
| | - Geert A. Buijze
- Department of Orthopedic Surgery, Academic Medical Center, University of
Amsterdam, Amsterdam, The Netherlands
| | - David C. Ring
- Department of Orthopedic Surgery, Dell Medical School, University of Texas,
Austin, Texas
| | - Chaitanya S. Mudgal
- Department of Orthopedic Surgery, Harvard Medical School, Boston,
Massachusetts
| | - Yuen-Fai Leung
- Department of Orthopaedics and Traumatology, Tseung Kwan O Hospital, Hong
Kong
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22
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Beutel BG, Melamed E, Hinds RM, Gottschalk MB, Capo JT. Mechanical Evaluation of Four Internal Fixation Constructs for Scaphoid Fractures. Hand (N Y) 2016; 11:72-7. [PMID: 27418893 PMCID: PMC4920514 DOI: 10.1177/1558944715614889] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The objective of this study was to compare the mechanical performance of 4 different constructs for fixation of oblique scaphoid fractures. METHODS Twenty-eight synthetic scaphoids underwent an oblique osteotomy along the dorsal sulcus. Each was randomly assigned to fixation by 1 of 4 methods: two 1.5-mm headless compression screws, one 2.2-mm screw, one 3-mm screw, or a 1.5-mm volar variable-angle plate. After fixation, scaphoids were potted at a 45° angle and loaded at the distal pole by a hydraulically driven mechanical testing system plunger until the fixation failed. Excursion and load were measured with a differential transformer and load cell, respectively. From these data, the stiffness, load-to-failure, and maximum displacement of each construct were calculated. RESULTS The 2.2-mm screw demonstrated the highest stiffness and the two 1.5-mm screws had the lowest. However, there were no significant differences among the fixation methods in terms of stiffness. Both 2.2- and 3-mm screw constructs had significantly higher loads-to-failure than two 1.5-mm screws. The maximum load for the plate approached, but did not achieve, statistical significance compared with the 1.5-mm screws. There was no significant difference among constructs in displacement. CONCLUSIONS All constructs demonstrated similar mechanical properties that may provide sufficient stability for effective clinical use. Given their significantly higher loads-to-failure, a 2.2- or 3-mm screw may be superior to two 1.5-mm screws for fixation of unstable scaphoid fractures. The volar plate did not have superior mechanical characteristics to the compression screws.
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Affiliation(s)
- Bryan G. Beutel
- NYU Hospital for Joint Diseases, New York, NY, USA,Bryan G. Beutel, Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, 301 East 17th Street, Suite 1402, New York, NY 10003, USA.
| | | | | | | | - John T. Capo
- NYU Hospital for Joint Diseases, New York, NY, USA
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23
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Bain GI, Turow A, Phadnis J. Dorsal Plating of Unstable Scaphoid Fractures and Nonunions. Tech Hand Up Extrem Surg 2015; 19:95-100. [PMID: 26053203 DOI: 10.1097/bth.0000000000000087] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Achieving stable fixation of displaced acute and chronic nonunited scaphoid fractures continues to be a challenge for the treating surgeon. The threaded compression screw has been the mainstay of treatment of these fractures for the last 3 decades; however, persistent nonunion after screw fixation has prompted development of new techniques. Recent results of volar buttress plating have been promising. We describe a novel technique of dorsal scaphoid plating. In contrast to volar plating, the dorsal plate is biomechanically more favorable as it utilizes the tension side of the scaphoid bone for dynamic compression. Dorsal scaphoid plating provides a more stable construct than the traditional Herbert screw and mitigates the need for vascular or corticocancellous bone grafting in most cases.
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Affiliation(s)
- Gregory I Bain
- *Flinders University, Adelaide †Department of Orthopaedic Surgery, Flinders Medical Centre, Bedford Park, South Australia, Australia
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24
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Kang L. Operative Treatment of Acute Scaphoid Fractures. HAND SURGERY : AN INTERNATIONAL JOURNAL DEVOTED TO HAND AND UPPER LIMB SURGERY AND RELATED RESEARCH : JOURNAL OF THE ASIA-PACIFIC FEDERATION OF SOCIETIES FOR SURGERY OF THE HAND 2015; 20:210-4. [PMID: 26051762 DOI: 10.1142/s021881041540002x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Optimal treatment of acute scaphoid fractures is a necessary goal for many reasons. One is that the scaphoid is the most commonly fractured carpal bone. Another is that a missed diagnosis of an acute scaphoid fracture leads to the more challenging situation of a delayed union, non-union and risk for premature radiocarpal arthrosis. Because the scaphoid has an inherent risk for nonunion due to its the tenuous blood supply, timely diagnosis and appropriate treatment are considered critical to achieving acceptable results and to avoiding the consequences of failed union.
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Affiliation(s)
- Lana Kang
- 1 Hospital for Special Surgery, Weill Cornell Medical College & New York Presbyterian Hospital, New York, USA
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25
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Abstract
This article reviews the most common complications associated with the management of carpal fractures. Discussion focuses on the recognition of commonly "missed" fractures and fracture patterns and the negative sequelae that can result from these delayed diagnoses. The pitfalls of conservative treatment of specific carpal fractures are reviewed, and the most common complications resulting from the operative management of carpal injuries are described.
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Affiliation(s)
- R Glenn Gaston
- OrthoCarolina, 1915 Randolph Road, Charlotte, NC 28207, USA.
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26
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Meermans G, Van Glabbeek F, Braem MJ, van Riet RP, Hubens G, Verstreken F. Comparison of two percutaneous volar approaches for screw fixation of scaphoid waist fractures: radiographic and biomechanical study of an osteotomy-simulated model. J Bone Joint Surg Am 2014; 96:1369-76. [PMID: 25143497 DOI: 10.2106/jbjs.l.01729] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND When a surgeon uses a percutaneous volar approach to treat scaphoid waist fractures, central screw placement is complicated by the shape of the scaphoid and by obstruction by the trapezium. In this study, we used radiographs and biomechanical tests to compare the standard volar percutaneous approach with the transtrapezial approach, with regard to central screw placement at the distal pole of the scaphoid. METHODS Fourteen matched pairs of cadaveric wrists were randomly assigned to two treatment groups. Under fluoroscopic control, a guidewire was drilled into the scaphoid, either through a transtrapezial approach or through a standard volar approach that avoided the trapezium. Guidewire position was measured in the coronal and sagittal planes. A transverse osteotomy was performed along the scaphoid waist, and this was followed by the insertion of the longest possible cannulated headless bone screw. Each specimen was placed into a fixture with a pneumatically driven plunger resting on the surface of the distal pole. Load was applied by using a load-controlled test protocol in a hydraulic testing machine. RESULTS All guidewires were inside the central one-third of the proximal pole. The guidewire positions at the distal pole differed significantly between the transtrapezial and standard volar approach groups (p < 0.001). The load to 2 mm of displacement and the load to failure averaged, respectively, 324.4 N (standard error of the mean [SEM] = 73.5 N) and 386.4 N (SEM = 65.6 N) for the transtrapezial approach group compared with 125.7 N (SEM = 22.6 N) (p = 0.002) and 191.4 N (SEM = 36.30 N) (p = 0.005) for the standard volar approach group. CONCLUSIONS The data suggest that, in a cadaveric osteotomy-simulated scaphoid waist fracture model, the transtrapezial approach reliably achieves central positioning of a screw in the proximal and distal poles. This position offers a biomechanical advantage compared with central placement in only the proximal pole.
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Affiliation(s)
- Geert Meermans
- Department of Orthopaedics, Lievensberg Hospital, Boerhaaveplein 1, 4624VT Bergen op Zoom, The Netherlands. E-mail address:
| | - Francis Van Glabbeek
- Department of Anatomy and Embryology (F.V.G. and G.H.) and Laboratory of Dental Materials (M.J.B.), University of Antwerp, Groenenborgerlaan 171, 2020 Antwerp, Belgium
| | - Marc J Braem
- Department of Anatomy and Embryology (F.V.G. and G.H.) and Laboratory of Dental Materials (M.J.B.), University of Antwerp, Groenenborgerlaan 171, 2020 Antwerp, Belgium
| | - Roger P van Riet
- Department of Orthopaedics, AZ Monica Hospital, Stevenslei 20, 2100 Deurne, Belgium
| | - Guy Hubens
- Department of Anatomy and Embryology (F.V.G. and G.H.) and Laboratory of Dental Materials (M.J.B.), University of Antwerp, Groenenborgerlaan 171, 2020 Antwerp, Belgium
| | - Frederik Verstreken
- Department of Orthopaedics, AZ Monica Hospital, Stevenslei 20, 2100 Deurne, Belgium
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Faucher GK, Golden ML, Sweeney KR, Hutton WC, Jarrett CD. Comparison of screw trajectory on stability of oblique scaphoid fractures: a mechanical study. J Hand Surg Am 2014; 39:430-5. [PMID: 24559623 DOI: 10.1016/j.jhsa.2013.12.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Revised: 12/08/2013] [Accepted: 12/11/2013] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine whether a screw placed perpendicular to the fracture line in an oblique scaphoid fracture will provide fixation strength that is comparable with that of a centrally placed screw. METHODS Oblique osteotomies were made along the dorsal sulcus of 8 matched pairs of cadaveric scaphoids. One scaphoid from each pair was randomized to receive a screw placed centrally down the long axis. In the other scaphoid, a screw was placed perpendicular to the osteotomy. Each scaphoid underwent cyclic loading from 80 N to 120 N at 1 Hz. Cyclic loading was carried out until 2 mm of fracture displacement occurred or 4,000 cycles was reached. The specimens that reached the 4,000-cycle limit were then loaded to failure. Screw length, number of cycles, and load to failure were compared between the groups. RESULTS We found no difference in number of cycles or load to failure between the 2 groups. Screws placed perpendicular to the fracture line were significantly shorter than screws placed down the central axis. CONCLUSIONS A perpendicularly placed screw provides equivalent strength to one placed along the central axis. CLINICAL RELEVANCE Compared with a screw placed centrally in an oblique scaphoid fracture, a screw placed perpendicular to the fracture line allows the use of a shorter screw without sacrificing strength of fixation.
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Affiliation(s)
- Gregory K Faucher
- Hand and Upper Extremity Surgery, The Emory Orthopaedic Center, Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA
| | - M Leslie Golden
- Hand and Upper Extremity Surgery, The Emory Orthopaedic Center, Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA
| | - Kyle R Sweeney
- Hand and Upper Extremity Surgery, The Emory Orthopaedic Center, Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA
| | - William C Hutton
- Hand and Upper Extremity Surgery, The Emory Orthopaedic Center, Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA
| | - Claudius D Jarrett
- Hand and Upper Extremity Surgery, The Emory Orthopaedic Center, Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA.
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28
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Meermans G, Verstreken F. Letter regarding "Optimal fixation of oblique scaphoid fractures: a cadaver model". J Hand Surg Am 2012; 37:1957-8; author reply 1958. [PMID: 22916872 DOI: 10.1016/j.jhsa.2012.06.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2012] [Accepted: 06/07/2012] [Indexed: 02/02/2023]
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