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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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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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Li C, Xu X, Su Y, Zhou T, Fan X, Xu Y. Treatment of scaphoid fractures using a memory alloy nail-feet-fixation device. ANZ J Surg 2016; 86:584-8. [PMID: 27323700 DOI: 10.1111/ans.13641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Revised: 03/10/2016] [Accepted: 04/23/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Scaphoid fracture is a common carpal fracture, and its treatment often requires fixation devices. This study aimed to investigate the efficacy and safety of a memory alloy nail-feet-fixation (MANFF) device in treating scaphoid fractures. METHODS Sixty-six patients with closed scaphoid fractures were treated using the MANFF device between August 2011 and November 2013. Surgical outcomes were assessed using the Mayo wrist score, including pain intensity, functional status, range of motion and grip strength. Postoperative radiographic evaluation was performed every month. RESULTS Herbert score of fracture stability was A in 36 patients, B in 20 and C in 10. Forty-five patients were treated using the simple MANFF device, 10 with an auxiliary Kirschner wire and 11 underwent MANFF after autologous bone graft. Patients were followed-up for a mean of 6.5 ± 1.2 months (range, 6-12 months). Bone union was achieved in all patients. There was no infection, non-union, arthritic change, tendon issues or any other complications. At postoperative 6 months, 50 patients achieved excellent outcomes, nine achieved good outcomes, and seven achieved fair outcomes, with a mean score of 89.5 ± 6.3. Therefore, the rate of satisfactory outcomes (excellent and good) was 89.4%. CONCLUSIONS Treatment of scaphoid fractures using the MANFF method has good surgical outcomes in bone union and patient satisfaction.
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Affiliation(s)
- Chuan Li
- Department of Orthopedic Surgery, Kunming General Hospital of Chengdu Military Region, Kunming, China
| | - Xiaoshan Xu
- Department of Orthopedic Surgery, Kunming General Hospital of Chengdu Military Region, Kunming, China
| | - Yongyue Su
- Department of Orthopedic Surgery, Kunming General Hospital of Chengdu Military Region, Kunming, China
| | - Tianhua Zhou
- Department of Orthopedic Surgery, Kunming General Hospital of Chengdu Military Region, Kunming, China
| | - Xinyu Fan
- Department of Orthopedic Surgery, Kunming General Hospital of Chengdu Military Region, Kunming, China
| | - Yongqing Xu
- Department of Orthopedic Surgery, Kunming General Hospital of Chengdu Military Region, Kunming, China
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Ten Berg PW, Drijkoningen T, Strackee SD, Buijze GA. Classifications of Acute Scaphoid Fractures: A Systematic Literature Review. J Wrist Surg 2016; 5:152-159. [PMID: 27104083 PMCID: PMC4838473 DOI: 10.1055/s-0036-1571280] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Accepted: 12/11/2015] [Indexed: 01/02/2023]
Abstract
Background In the lack of consensus, surgeon-based preference determines how acute scaphoid fractures are classified. There is a great variety of classification systems with considerable controversies. Purposes The purpose of this study was to provide an overview of the different classification systems, clarifying their subgroups and analyzing their popularity by comparing citation indexes. The intention was to improve data comparison between studies using heterogeneous fracture descriptions. Methods We performed a systematic review of the literature based on a search of medical literature from 1950 to 2015, and a manual search using the reference lists in relevant book chapters. Only original descriptions of classifications of acute scaphoid fractures in adults were included. Popularity was based on citation index as reported in the databases of Web of Science (WoS) and Google Scholar. Articles that were cited <10 times in WoS were excluded. Results Our literature search resulted in 308 potentially eligible descriptive reports of which 12 reports met the inclusion criteria. We distinguished 13 different (sub) classification systems based on (1) fracture location, (2) fracture plane orientation, and (3) fracture stability/displacement. Based on citations numbers, the Herbert classification was most popular, followed by the Russe and Mayo classifications. All classification systems were based on plain radiography. Conclusions Most classification systems were based on fracture location, displacement, or stability. Based on the controversy and limited reliability of current classification systems, suggested research areas for an updated classification include three-dimensional fracture pattern etiology and fracture fragment mobility assessed by dynamic imaging.
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Affiliation(s)
- Paul W. Ten Berg
- Department of Plastic, Reconstructive, and Hand Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Tessa Drijkoningen
- Department of Plastic, Reconstructive, and Hand Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Simon D. Strackee
- Department of Plastic, Reconstructive, and Hand Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Geert A. Buijze
- Department of Orthopaedic Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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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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Neshkova I, Jakubietz R, Kuk D, Jakubietz M, Meffert R, Schmidt K. Perkutane kanülierte Verschraubung nicht- oder minimal-dislozierter Skaphoidfrakturen. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2015; 27:448-54. [DOI: 10.1007/s00064-014-0325-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Revised: 07/03/2014] [Accepted: 07/20/2014] [Indexed: 12/01/2022]
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Hannemann PFW, Brouwers L, Dullaert K, van der Linden ES, Poeze M, Brink PRG. Determining scaphoid waist fracture union by conventional radiographic examination: an analysis of reliability and validity. Arch Orthop Trauma Surg 2015; 135:291-296. [PMID: 25555379 DOI: 10.1007/s00402-014-2147-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2014] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Conventional radiographic imaging is the first imaging tool of choice in scaphoid fractures. The majority of undisplaced scaphoid waist fractures unite after 6 weeks of cast immobilization. We hypothesized that conventional radiographic imaging at 6 weeks after injury can both accurately and reliably predict union in undisplaced scaphoid waist fractures. MATERIALS AND METHODS Fleiss' kappa statistics were used concerning the opinions of four observers reviewing 47 sets of good-quality scaphoid radiographs of undisplaced scaphoid waist fractures. As reference standard for union, radiographs were taken at a minimum of 6 months after injury to determine validity. RESULTS Overall agreement was defined as moderate. (κ = 0.583) "No consolidation" (κ = 0.816), "full consolidation" (κ = 0.517) and "partial consolidation" (κ = 0.390) were defined as good, moderate and fair agreement, respectively. The average sensitivity and specificity of diagnosing scaphoid waist fracture union on standard scaphoid radiographs were 0.65 and 0.67, respectively. The positive predictive value for diagnosing union was 0.93 and the negative predictive value was 0.22. CONCLUSIONS Conventional radiographic imaging is accurate and moderately reliable in diagnosing union, and reliable but inaccurate in diagnosing nonunion of scaphoid waist fractures at 6 weeks follow-up.
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Affiliation(s)
- P F W Hannemann
- Department of Surgery and Traumasurgery, Maastricht University Medical Centre, PO Box 5800, 6202 AZ, Maastricht, The Netherlands.
| | - L Brouwers
- Department of Surgery and Traumasurgery, Maastricht University Medical Centre, PO Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - K Dullaert
- Department of Radiology, Maastricht University Medical Centre, PO Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - E S van der Linden
- Department of Radiology, Maastricht University Medical Centre, PO Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - M Poeze
- Department of Surgery and Traumasurgery, Maastricht University Medical Centre, PO Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - P R G Brink
- Department of Surgery and Traumasurgery, Maastricht University Medical Centre, PO Box 5800, 6202 AZ, Maastricht, The Netherlands
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