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Putnam J. Rethinking Scaphoid Fixation. Hand Clin 2023; 39:597-604. [PMID: 37827612 DOI: 10.1016/j.hcl.2023.05.007] [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: 10/14/2023]
Abstract
Scaphoid fixation, whether for acute injuries or nonunion, is made challenging by the small and intra-articular nature of the most commonly fractured carpal bone. The purpose of this article is to review the techniques to simplify scaphoid fixation and to optimize healing and early return to activity.
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Affiliation(s)
- Jill Putnam
- The Hand and Upper Extremity Center, The Ohio State University, 915 Olentangy River Road, Suite 3200, Columbus, OH 43212, USA.
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Wataya EY, Meneghel GH, Mores V, Nakamoto JC, Xavier RM, Junior RM. Comparative analysis of cancellous graft and cortico-cancellous graft in osteosynthesis of scaphoid pseudoarthrosis with plate. Arch Orthop Trauma Surg 2023; 143:6955-6963. [PMID: 37526738 DOI: 10.1007/s00402-023-05003-9] [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: 01/23/2023] [Accepted: 07/20/2023] [Indexed: 08/02/2023]
Abstract
INTRODUCTION Scaphoid is the most fractured carpal bone, with a 5-10% nonunion rate. Treatment challenges include choosing the implant and graft that best corrects humpback deformity and carpal malalignment with higher chances of bony healing. OBJECTIVE Compare cortico-cancellous and cancellous grafts between two groups of patients treating scaphoid nonunion with locking plates using autologous bone graft and evaluate bone healing rates and radiographic, tomographic, and functional parameters before and after surgery. METHODS Non-randomized prospective study including 20 cases of scaphoid nonunion. Groups were divided into Group A (ten patients treated with cortico-cancellous iliac graft) and Group B (ten patients treated with cancellous iliac graft). Patients underwent pre- and postoperative radiographs, computed tomography, and functional evaluation. RESULTS In postoperative analysis, Group A showed a statistically significant difference in intrascaphoid angle (p = 0.002) and scapholunate angle (p = 0.011) correction when comparing the pre- and postoperative periods. Group B showed a statistically significant difference in intrascaphoid angle (p = 0.002) and scapholunate angle correction (p = 0.0018), grip strength (p = 0.002), and tip pinch strength (p = 0.001) when comparing the pre- and postoperative periods. By comparing both groups, Group B showed a statistically significant difference in intrascaphoid angle correction (p = 0.002), grip strength (p = 0.002), tip pinch strength (p = 0.002), and radial deviation (p = 0.0003). There was no statistical difference when comparing bony healing between groups. CONCLUSION Scaphoid nonunion treatment with a locking plate was effective, showing a high bony healing rate and improved carpal alignment in imaging tests for both graft types. However, results for intrascaphoid angle correction, grip strength, tip pinch strength, and radial deviation were better in Group B. LEVEL OF EVIDENCE IV, case series.
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Affiliation(s)
- Erick Yoshio Wataya
- Hand Surgery Service, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de Sao Paulo, HCFMUSP, 333 Ovídio Pires de Campos St., Cerqueira César, São Paulo, SP, 05403-010, Brazil
| | - Guilherme Henrique Meneghel
- Hand Surgery Service, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de Sao Paulo, HCFMUSP, 333 Ovídio Pires de Campos St., Cerqueira César, São Paulo, SP, 05403-010, Brazil.
| | - Victor Mores
- Hand Surgery Service, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de Sao Paulo, HCFMUSP, 333 Ovídio Pires de Campos St., Cerqueira César, São Paulo, SP, 05403-010, Brazil
| | | | - Renato Martins Xavier
- Hand Surgery Service, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de Sao Paulo, HCFMUSP, 333 Ovídio Pires de Campos St., Cerqueira César, São Paulo, SP, 05403-010, Brazil
| | - Rames Mattar Junior
- Hand Surgery Service, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de Sao Paulo, HCFMUSP, 333 Ovídio Pires de Campos St., Cerqueira César, São Paulo, SP, 05403-010, Brazil
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Liau CJ, Liew SK, Arsad SR, Muhammad Nawawi RF, Silvanathan JP. Scaphoid Plate Osteosynthesis in Complex Fractures and Wrist Trauma: A Case Series. Cureus 2023; 15:e45067. [PMID: 37842372 PMCID: PMC10568241 DOI: 10.7759/cureus.45067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/11/2023] [Indexed: 10/17/2023] Open
Abstract
Introduction Treatment of scaphoid fracture is challenging due to its unique blood supply and geometry. Traditionally, a headless compression screw is the standard treatment for unstable scaphoid fracture. Some fractures are complex, for example, comminution with bone loss. A scaphoid plate is an option in these difficult fractures providing adequate rotational stability. Aim To share our experience in using scaphoid plates in complex wrist trauma and comminuted fractures. Method and material Complex wrist trauma involving scaphoid fractures that were comminuted and multi-fragmentary fractures treated with plate osteosynthesis were retrospectively reviewed between July 2019 and September 2021. Patient demographic data, preoperative radiographs, CT scans, pain, wrist range of motion, and fracture union rate to union were reviewed. Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH®) score was recorded at 1-year postoperative follow-up. Results Nine patients associated with complex wrist trauma were included in this case series. The mean follow-up was 2.5 years (13-30 months). The union rate was 100%. The mean arc of motion was 105° (95-110°). QuickDASH® score was 19.96 at 1-year postoperative follow-up. Four patients had good outcomes, four satisfactory, and one poor outcome. One hardware complication was observed which was the impingement of the plate proximally over the articular surface of the distal radius. Conclusion A scaphoid plate is a reliable option for treating complex and difficult fractures. It provides adequate stability, especially in comminution, bone loss, or multi-fragmentary fractures which are not amendable using other fixation methods. We recommend the expansion of plate osteosynthesis beyond scaphoid nonunion into complex wrist trauma.
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Affiliation(s)
- Chai Jiun Liau
- Hand & Microsurgery Unit, Orthopedics Department, Hospital Selayang, Selangor, MYS
- Hand & Microsurgery Unit, Orthopedics Department, Hospital Kuala Lumpur, Kuala Lumpur, MYS
| | - Siew Khei Liew
- Hand & Microsurgery Unit, Orthopedics Department, University Putra Malaysia, Selangor, MYS
| | - Syahril Rizal Arsad
- Hand & Microsurgery Unit, Orthopedics Department, Hospital Selayang, Selangor, MYS
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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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Lemke KA, Mannambeth RV, Carman CJ, Csongvay S. Volar Plating of Scaphoid Fractures: A Retrospective Case Series. Hand (N Y) 2023; 18:46S-51S. [PMID: 35227110 PMCID: PMC10052624 DOI: 10.1177/15589447221075674] [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: 02/10/2023]
Abstract
BACKGROUND The purpose of this study was to evaluate the rate of union of scaphoid fractures managed with volar plating and assess postoperative complications. METHODS Retrospective consecutive case series of 28 patients with scaphoid fractures, 9 acute and 19 chronic nonunions, undergoing surgical fixation with volar scaphoid plating by a single surgeon between 2013 and 2019. Patients were followed up for a minimum of 3 months with scaphoid bony union being confirmed on radiograph or computed tomography. Postoperative complications and need for plate removal were recorded. RESULTS Overall union rate of 96% with all 19 chronic nonunions demonstrating radiological union and 1 of 9 acute fractures not uniting and requiring revision surgery. The only postoperative complication identified was symptomatic plate impingement which necessitated plate removal in 57% of cases. CONCLUSIONS This case series demonstrates volar plating of scaphoid fractures can be used as an alternative technique to achieve union.
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Affiliation(s)
| | | | | | - Steve Csongvay
- The Alfred Hospital, Melbourne, Victoria, Australia
- Cabrini Hospital - Malvern, Melbourne, Victoria, Australia
- St John of God Ballarat Hospital, Victoria, Australia
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Quadlbauer S, Pezzei C, Jurkowitsch J, Beer T, Moser V, Rosenauer R, Salminger S, Hausner T, Leixnering M. Double screw versus angular stable plate fixation of scaphoid waist nonunions in combination with intraoperative extracorporeal shockwave therapy (ESWT). Arch Orthop Trauma Surg 2023:10.1007/s00402-023-04806-0. [PMID: 36808564 DOI: 10.1007/s00402-023-04806-0] [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: 12/04/2022] [Accepted: 01/29/2023] [Indexed: 02/23/2023]
Abstract
INTRODUCTION Over the past years, different fixation techniques focused on rotational stability in order to increase stability and stimulate union rates. Additionally, extracorporeal shockwave therapy (ESWT) has gained importance in the treatment of delayed and nonunions. Purpose of this study was to compare the radiological and clinical outcome of two headless compression screws (HCS) and plate fixation in scaphoid nonunions, in combination with intraoperative high energy ESWT. MATERIALS AND METHODS Thirty-eight patients with scaphoid nonunions were treated by using a nonvascularized bone graft from the iliac crest and stabilization with either two HCS or a volar angular stable scaphoid plate. All patients received one ESWT session with 3000 impulses and energy flux per pulse of 0.41 mJ/mm2 intraoperatively. Clinical assessment included range of motion (ROM), pain according to the Visual Analog Scale (VAS), grip strength, disability of the Arm Shoulder and Hand Score, Patient-Rated Wrist Evaluation Score, Michigan Hand Outcomes Questionnaire and modified Green O'Brien (Mayo) Wrist Score. To confirm union, a CT scan of the wrist was performed. RESULTS Thirty-two patients returned for clinical and radiological examination. Out of these, 29 (91%) showed bony union. All patients treated with two HCS compared to 16 out of 19 (84%) patients treated by plate showed bony union on the CT scans. The difference was not statistically significant. However, at a mean follow-up interval of 34 months, no significant differences could be found in ROM, pain, grip strength and patient-reported outcome measurements between the two HCS and plate group. Height-to-length ratio and capitolunate angle improved significantly in both groups compared to preoperative. CONCLUSIONS Scaphoid nonunion stabilization by using two HCS or angular stable volar plate fixation and intraoperative ESWT results in comparable high union rates and good functional outcome. Due to the higher rate for a secondary intervention (plate removal), HCS might be preferable as first choice, whereas the scaphoid plate fixation should be reserved for recalcitrant (substantial bone loss, humpback deformity or failed prior surgical intervention) scaphoid nonunions.
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Affiliation(s)
- S Quadlbauer
- AUVA Trauma Hospital Lorenz Böhler - European Hand Trauma and Replantation Center, Donaueschingenstrasse 13, 1200, Vienna, Austria. .,Ludwig Boltzmann Institute for Experimental Und Clinical Traumatology, AUVA Research Center, 1200, Vienna, Austria. .,Austrian Cluster for Tissue Regeneration, Vienna, Austria.
| | - Ch Pezzei
- AUVA Trauma Hospital Lorenz Böhler - European Hand Trauma and Replantation Center, Donaueschingenstrasse 13, 1200, Vienna, Austria
| | - J Jurkowitsch
- AUVA Trauma Hospital Lorenz Böhler - European Hand Trauma and Replantation Center, Donaueschingenstrasse 13, 1200, Vienna, Austria
| | - T Beer
- AUVA Trauma Hospital Lorenz Böhler - European Hand Trauma and Replantation Center, Donaueschingenstrasse 13, 1200, Vienna, Austria
| | - V Moser
- AUVA Trauma Hospital Lorenz Böhler - European Hand Trauma and Replantation Center, Donaueschingenstrasse 13, 1200, Vienna, Austria
| | - R Rosenauer
- AUVA Trauma Hospital Lorenz Böhler - European Hand Trauma and Replantation Center, Donaueschingenstrasse 13, 1200, Vienna, Austria.,Ludwig Boltzmann Institute for Experimental Und Clinical Traumatology, AUVA Research Center, 1200, Vienna, Austria.,Austrian Cluster for Tissue Regeneration, Vienna, Austria
| | - S Salminger
- AUVA Trauma Hospital Lorenz Böhler - European Hand Trauma and Replantation Center, Donaueschingenstrasse 13, 1200, Vienna, Austria
| | - T Hausner
- AUVA Trauma Hospital Lorenz Böhler - European Hand Trauma and Replantation Center, Donaueschingenstrasse 13, 1200, Vienna, Austria.,Ludwig Boltzmann Institute for Experimental Und Clinical Traumatology, AUVA Research Center, 1200, Vienna, Austria.,Austrian Cluster for Tissue Regeneration, Vienna, Austria.,Department for Orthopedic Surgery and Traumatology, Paracelsus Medical University, 5020, Salzburg, Austria
| | - M Leixnering
- AUVA Trauma Hospital Lorenz Böhler - European Hand Trauma and Replantation Center, Donaueschingenstrasse 13, 1200, Vienna, Austria
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Cheng C, Jiang Z, Sun H, Hu J, Ouyang Y. Arthroscopic treatment of unstable scaphoid fracture and nonunion with two headless compression screws and distal radius bone graft. J Orthop Surg Res 2023; 18:52. [PMID: 36653796 PMCID: PMC9847075 DOI: 10.1186/s13018-023-03529-7] [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: 10/17/2022] [Accepted: 01/10/2023] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The treatment of unstable scaphoid fracture and nonunion remains a challenging problem for hand surgeons. Minimally invasive treatment has become the preferred method of treatment. PURPOSE This study introduces the arthroscopic technique with two headless compression screws (HCS) fixation and distal radius bone grafting for the treatment of unstable scaphoid fracture and nonunion, aiming to evaluate its clinical and radiological outcomes. METHODS It was a retrospective study. From January 2019 to February 2021, a total of 23 patients were included in the current study. Among them, 13 patients with unstable scaphoid fracture underwent arthroscopic treatment with two HCS; 10 patients with scaphoid nonunion underwent arthroscopic treatment with two HCS and a distal radius bone graft. The range of motion of the wrist, visual analog scale (VAS), grip strength, the Modified Mayo Wrist Score (MMWS), the Patient-Rated Wrist Evaluation (PRWE) score, and the Disability of the Arm, Shoulder and Hand (DASH) score were collected at preoperatively and the final follow-up. A computed tomography scan of the wrist was performed on each patient to analyze for union and postoperative osteoarthritis during the follow-up period. RESULTS Significant improvement was only observed in wrist extension. Clinical outcomes including grip strength, VAS pain score, MMWS, PRWE score, and DASH score were significantly improved at the final follow-up. In the subgroup analysis, both patients stabilized with either two HCS or a distal radius bone graft and two HCS have improved clinical outcomes after surgery, respectively. All patients achieved union. No screw fixation failure occurred, and no other postoperative complication was observed in any of the patients. CONCLUSIONS The arthroscopic technique with two-HCS fixation and distal radius bone grafting is a reliable and effective technique for the treatment of unstable scaphoid fracture and nonunion, providing satisfactory union rates and clinical outcomes.
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Affiliation(s)
- Cong Cheng
- grid.284723.80000 0000 8877 7471Department of Hand Surgery, Affiliated Longhua People’s Hospital, Southern Medical University, Shenzhen, 518000 China
| | - Zongyuan Jiang
- grid.284723.80000 0000 8877 7471Department of Hand Surgery, Affiliated Longhua People’s Hospital, Southern Medical University, Shenzhen, 518000 China
| | - Haoran Sun
- grid.284723.80000 0000 8877 7471Department of Hand Surgery, Affiliated Longhua People’s Hospital, Southern Medical University, Shenzhen, 518000 China
| | - Jiaping Hu
- grid.284723.80000 0000 8877 7471Department of Hand Surgery, Affiliated Longhua People’s Hospital, Southern Medical University, Shenzhen, 518000 China
| | - Yanggang Ouyang
- grid.284723.80000 0000 8877 7471Department of Hand Surgery, Affiliated Longhua People’s Hospital, Southern Medical University, Shenzhen, 518000 China
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Abstract
The scaphoid is predisposed to nonunion after fracture because of its tenuous blood supply and propensity for delayed diagnosis. Many surgical techniques exist and continue to be developed to treat scaphoid non-unions. However, with variability in patient presentation, differences in nonunion location and type, and multiple bone graft sources and fixation options, selecting a surgical strategy proves a difficult task. The goal of this article is to provide an updated review of surgical strategies used to treat scaphoid nonunions. Particular attention is paid to methods of fixation as well as the ongoing debate over indications for structural and vascularized bone grafting. [Orthopedics. 2022;45(5):e235-e242.].
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Welle K, Taeger S, Prangenberg C, Hackenberg RK, Kieback JD, Kabir K. Locking plate osteosynthesis of scaphoid nonunion with severe bone defects: a case series. Sci Rep 2022; 12:8379. [PMID: 35589911 PMCID: PMC9120041 DOI: 10.1038/s41598-022-12305-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 12/24/2021] [Indexed: 11/21/2022] Open
Abstract
The treatment of scaphoid nonunion can be challenging with increasing defect size. We evaluated the outcome of scaphoid nonunion with a substantial bone defect treated with a multidirectional locking plate combined with cancellous bone grafting only. Thirteen patients with significant osseous defects measuring 6 mm or more suffering from primary nonunion without treatment (n = 6) or recalcitrant nonunion following Herbert screw osteosynthesis (n = 7) were treated and reviewed retrospectively. The stabilization was performed after debridement, autologous cancellous bone grafting and volar locking plate osteosynthesis. After a mean follow-up period of 12 months, 12 of the 13 patients achieved successful unions with a free range of motion and complete remittance of pain in everyday activity. The mean scapholunate angle decreased from 59.7° ± 11 to 43.9° ± 5 (effect strength d:1.7, p < 0.00001), scaphoid humpback deformity angle from 58.9° ± 8 to 45.1° ± 8 (d:1.8, p < 0.0001), whereas strength of the injured hand increased from 36.4 kg ± 10 to 42.4 kg ± 9 (d:1.4, p < 0.0001). One nonunion persisted without fragment dislocation receiving revision after 1 year. Thus, locking plate osteosynthesis with cancellous bone grafting is a valid alternative in scaphoid nonunions with extensive bone defects. Additionally, stable retention of the fragments prevents dislocation even in delayed or persistent nonunion. Further prospective studies are required to confirm these findings.
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Affiliation(s)
- Kristian Welle
- Department of Orthopedics and Trauma Surgery, University Hospital of Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.
| | - Stefan Taeger
- Department of Orthopedics and Trauma Surgery, Hopitaux Robert Schuman, 9, rue Edward Steichen, 2540, Luxembourg, Luxembourg
| | - Christian Prangenberg
- Department of Orthopedics and Trauma Surgery, University Hospital of Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Roslind Karolina Hackenberg
- Department of Orthopedics and Trauma Surgery, University Hospital of Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Jan-Dirk Kieback
- Department of Orthopedics and Trauma Surgery, University Hospital of Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Koroush Kabir
- Department of Orthopedics and Trauma Surgery, University Hospital of Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
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Rancy SK, Wolfe SW, Jerome JTJ. Predictors of Failure for Vascularized and Nonvascularized Bone Grafting of Scaphoid Nonunions: A Systematic Review. J Hand Microsurg 2021; 14:322-335. [DOI: 10.1055/s-0041-1735349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Abstract
Objective This article compares predictors of failure for vascularized (VBG) and nonvascularized bone grafting (NVBG) of scaphoid nonunions.
Methods We conducted a systematic literature review of outcomes after VBG and NVBG of scaphoid nonunion. Fifty-one VBG studies (N = 1,419 patients) and 81 NVBG studies (N = 3,019 patients) met the inclusion criteria. Data were collected on surgical technique, type of fixation, time from injury to surgery, fracture location, abnormal carpal posture (humpback deformity and/or dorsal intercalated segmental instability [DISI]), radiographic parameters of carpal alignment, prior failed surgery, smoking status, and avascular necrosis (AVN) as defined by punctate bleeding, magnetic resonance imaging (MRI) with contrast, MRI without contrast, X-ray, and histology. Meta-analysis of proportions was conducted with Freeman–Tukey double arcsine transformation. Multilevel mixed-effects analyses were performed with univariable and multivariable Poisson regression to identify confounders and evaluate predictors of failure.
Results The pooled failure incidence effect size was comparable between VBG and NVBG (0.09 [95% confidence interval [CI] 0.05–0.13] and 0.08 [95% CI 0.06–0.11], respectively). Humpback deformity and/or DISI (incidence-rate radios [IRRs] 1.57, CI: 1.04–2.36) and lateral intrascaphoid angle (IRR 1.21, CI: 1.08–1.37) were significantly associated with an increased VBG failure incidence. Time from injury to surgery (IRR 1.09, CI: 1.06–1.12) and height-to-length (H/L) ratio (IRR 53.98, CI: 1.16–2,504.24) were significantly associated with an increased NVBG failure incidence, though H/L ratio demonstrated a wide CI. Decreased proximal fragment contrast uptake on MRI was a statistically significant predictor of increased failure incidence for both VBG (IRR 2.03 CI: 1.13–3.66) and NVBG (IRR 1.39, CI: 1.16–1.66). Punctate bleeding or radiographic AVN, scapholunate angle, radiolunate angle, and prior failed surgery were not associated with failure incidence for either bone graft type (p > 0.05).
Conclusion Humpback deformity and/or DISI and increasing lateral intrascaphoid angle may be predictors of VBG failure. Time from injury to surgery may be a predictor of NVBG failure. AVN as defined by decreased contrast uptake on MRI may be a marker of increased failure risk for both bone graft types.
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Affiliation(s)
- Schneider K. Rancy
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, United States
| | - Scott W. Wolfe
- Division of Hand and Upper Extremity, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, United States
| | - J. Terrence Jose Jerome
- Department of Orthopedics, Hand & Reconstructive Microsurgery, Olympia Hospital & Research Centre, Trichy, Tamil Nadu, India
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Morgan SDJ, Sivakumar BS, Graham DJ. Scaphoid plating for recalcitrant scaphoid fractures: a systematic review. J Hand Surg Eur Vol 2021; 46:616-620. [PMID: 33861659 DOI: 10.1177/17531934211005637] [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: 02/03/2023]
Abstract
We conducted a systematic review of scaphoid plating for recalcitrant scaphoid fractures using EMBASE, Pubmed, Cochrane and MEDLINE. Thirteen studies were included. Ninety-three per cent of cases reported were male with a mean age of 27 years. Bony union was reported in eleven studies and achieved in 72% to 100% of cases. Scaphoid plates showed no significant difference in union incidence compared with headless compression screws. Mean removal incidence of plates was 21%. Postoperative flexion-extension arc was 119°. Grip strength improved by 14% postoperatively over that before surgery. There was a general improvement in patient-reported outcome measures. Eighty-six per cent of reported participants returned to their previous work. In these clinical reports, plates frequently required removal more frequently than headless compression screws.
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Affiliation(s)
| | - Brahman S Sivakumar
- Australian Research Collaboration on the Hand (ARCH), Australia.,Royal North Shore Hospital, St Leonards, NSW, Australia.,Hornsby Ku-Ring-Gai Hospital, Sydney, NSW, Australia
| | - David J Graham
- Gold Coast University Hospital, Southport, QLD, Australia.,Australian Research Collaboration on the Hand (ARCH), Australia
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Van Nest DS, Reynolds M, Warnick E, Sherman M, Ilyas AM. Volar Plating versus Headless Compression Screw Fixation of Scaphoid Nonunions: A Meta-analysis of Outcomes. J Wrist Surg 2021; 10:255-261. [PMID: 34109071 PMCID: PMC8169164 DOI: 10.1055/s-0040-1721405] [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: 09/08/2020] [Accepted: 10/19/2020] [Indexed: 10/22/2022]
Abstract
Background Headless compression screw fixation with bone grafting has been the mainstay of treatment for scaphoid nonunion for the past several decades. Recently, locked volar plate fixation has gained popularity as a technique for scaphoid fixation, especially for recalcitrant or secondary nonunions. Purpose The purpose of this meta-analysis was to compare union rates and clinical outcomes between locked volar plate fixation and headless compression screw fixation for the treatment of scaphoid nonunions. Methods A literature search was performed for studies documenting treatment outcomes for scaphoid nonunions from 2000 to 2020. Inclusion criteria consisted of (1) average age > 18 years, (2) primary study using screw fixation, plate fixation, or both, with discrete data reported for each procedure, and (3) average follow-up of at least 3 months. Exclusion criteria consisted of studies with incomplete or missing data on union rates. Data from each study was weighted, combined within treatment groups, and compared across treatment groups using a generalized linear model or binomial distribution. Results Following title and full-text review, 23 articles were included for analysis. Preoperatively, patients treated with plate fixation had significantly longer time from injury to surgery and were more likely to have failed prior surgical intervention. There was no significant difference between union rates at 92 and 94% for screw and plate fixation, respectively. However, plate fixation resulted in longer time to union and lower modified Mayo wrist scores. Conclusion Patients treated with locked volar plate fixation were more likely to be used for recalcitrant or secondary nonunions. There was no statistically significant difference in union rates between screw and plate fixation. The results from this meta-analysis support the select use of locked volar plate fixation for scaphoid nonunion, especially recalcitrant nonunions and those that have failed prior surgical repair.
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Affiliation(s)
- Duncan S. Van Nest
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Michael Reynolds
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Eugene Warnick
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Matthew Sherman
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Asif M. Ilyas
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Tavakolian PA, Adams NS, Edwards SG. Scaphoid Nonunion Volar Plating with Pure Nonvascularized Cancellous Autograft. JBJS Essent Surg Tech 2021; 11:ST-D-20-00029. [PMID: 34277132 DOI: 10.2106/jbjs.st.20.00029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background Surgical treatment of scaphoid nonunion has evolved over the years to include a variety of procedures and techniques involving a number of vascularized and nonvascularized bone grafting options and fixation strategies. Volar plating of scaphoid nonunions with use of pure cancellous nonvascularized autograft is a safe and effective treatment method with good functional outcomes and union rates1. Description Volar plating of the scaphoid nonunion is performed via a volar approach, with debridement and reduction of the nonunion site. A nonvascularized pure cancellous bone autograft is then harvested and impacted from the distal aspect of the ipsilateral radius or the olecranon. Finally, a low-profile volar locking plate is applied for fixation2. Alternatives There is no consensus regarding the optimal treatment of scaphoid nonunion. Headless compression screws are currently popular, and advances have been made over time to include various nonvascularized and vascularized corticocancellous grafts. The advent of plate fixation of the scaphoid has enabled the surgical treatment of nonunion to better replicate scaphoid morphology, allowing for improved biomechanical stability and optimizing the biologic milieu for healing. Rationale Headless compression screws, although a reasonable option for most acute scaphoid fractures, may not be the most appropriate application for nonunions. Compression, in itself, is not required for the surgical treatment of scaphoid nonunion, and can even prove detrimental by forcing the reduction into a malunion. The stability of headless compression screws must rely on a structural graft to resist the compression and create friction. The more structural the graft, however, the less biologically active it tends to be. Further, the simple placement of a metallic screw within the fracture site is counter to orthopaedic principles because it dramatically lowers the surface area available for union. Volar locking plates address the shortcoming of headless compression screws by (1) directly buttressing the deforming forces superior to headless screws3-6; (2) utilizing the most accessible, biologically active nonvascularized bone graft, which is pure cancellous graft; (3) allowing for maximal surface area contact for union; and (4) preserving the intraosseous vascular network within the scaphoid and its vascular supply at its dorsal ridge. Expected Outcomes Volar scaphoid plating with cancellous bone grafting is a reliable technique with excellent union rates and favorable functional outcomes. A review of 34 patients with scaphoid nonunions with segmental defects treated with volar plates and pure cancellous autograft demonstrated 100% union as verified by computed tomography scans postoperatively1. Average Disabilities of the Arm, Shoulder and Hand scores and grip strengths improved by final follow-up. Another series of 13 scaphoid nonunions with osteonecrosis treated with volar plating and pure cancellous autograft showed 100% union and good patient-reported and functional outcomes, despite smokers, proximal poles, and previous failed surgical procedures in the cohort2. These favorable results are consistent with earlier reports of the modern plating systems; however, concerns for hardware-related complications have been elucidated over the years, including symptomatic hardware impingement7. This risk can be mitigated by proper surgical technique and plate placement. Important Tips Clear visualization of the entire volar surface of the scaphoid is crucial. Take care not to reflect too much capsule, so as to cause ulnar translation of the carpus.Thorough debridement of nonviable bone is paramount. Using a 2.0 or 3.0-mm low-speed burr with continuous irrigation can be helpful. We have had successful unions even in cases in which the remaining proximal pole was just a cortical shell and essentially a hollow vessel for graft.Err on the side of verticalization of the scaphoid, overextending and supinating the distal pole. Overstuffing the nonunion site with cancellous autograft aids in reduction and maximizes the osteoinductive and osteoconductive properties of the graft.Impaction of the graft is crucial, and the surgeon should harvest more autograft than one might initially anticipate.Secure the plate to the proximal portion of the scaphoid first. There is less room for error on the proximal portion where plate positioning is more critical.Do not cross the scaphoid "line in the sand"; to do so will result in plate impingement on the radius. Proper placement of the plate is just distal to the point at which the convex surface of the proximal pole transitions to become the concave surface of the scaphoid waist, as viewed from a volar approach.Plate modification for proximal pole fractures and nonunions: removal of the most proximal hole in the plate allows for improved fixation despite the plate itself remaining behind the scaphoid "line in the sand." In these cases, the locking screws must be directed so that they buttress the subchondral bone of each pole, especially the proximal pole.
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Affiliation(s)
- Paul A Tavakolian
- Department of Orthopaedic Surgery, University of Arizona College of Medicine-Phoenix, Phoenix, Arizona
| | - Nicholas S Adams
- Department of Orthopaedic Surgery, University of Arizona College of Medicine-Phoenix, Phoenix, Arizona
| | - Scott G Edwards
- Department of Orthopaedic Surgery, University of Arizona College of Medicine-Phoenix, Phoenix, Arizona
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Wagner ER, Spencer CC, Dawes AM, Gottschalk MB, Daly CA. Management of Proximal Pole Scaphoid Nonunions: A Critical Analysis Review. JBJS Rev 2021; 9:01874474-202104000-00001. [PMID: 33819205 DOI: 10.2106/jbjs.rvw.19.00181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» Optimal management of nonunions of the proximal pole of the scaphoid is controversial and dependent on many patient and pathophysiologic considerations. » If the proximal pole subchondral bone support is sufficient, options include open reduction and internal fixation, either alone or in combination with autologous nonvascularized or vascularized bone graft. » If the proximal pole is not salvageable, replacement with osteochondral autografts or osteochondral flaps is the only option for reconstruction of the native anatomy.
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Affiliation(s)
- Eric R Wagner
- Emory University School of Medicine, Atlanta, Georgia
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Ek ET, Johnson PR, Bohan CM, Padmasekara G. Clinical Outcomes of Double-Screw Fixation with Autologous Bone Grafting for Unstable Scaphoid Delayed or Nonunions with Cavitary Bone Loss. J Wrist Surg 2021; 10:9-16. [PMID: 33552688 PMCID: PMC7850798 DOI: 10.1055/s-0040-1714252] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 06/03/2020] [Indexed: 10/23/2022]
Abstract
Objective This study reports on the clinical outcomes of double screw fixation with autologous cancellous bone grafting and early active range of motion for delayed and nonunited scaphoid waist fractures with cavitary segmental bone loss. Patients and Methods Twenty-one consecutive patients underwent fixation using two 2.2 mm antegrade headless compression screws with autologous distal radius cancellous bone graft. Postoperatively, patients were allowed early active motion with a resting splint until union was achieved. Patients were reviewed radiologically and clinically to assess for fracture union, complications, residual pain, wrist function, and return to work and recreational activities. Results All but one patient was male, and the mean age was 23 years (range, 15-38 years). The average time from initial injury was 16 months (range, 3-144 months). Nineteen of 21 (90.5%) patients achieved union at a mean of 2.8 months (range, 1.4-9.2 months). Of the patients who failed, one underwent revision surgery with vascularized bone grafting at 10.6 months. The other patient refused further intervention as he was asymptomatic. Conclusion Double-screw fixation with bone grafting and early active range of motion is a safe and effective technique for management of delayed and nonunited unstable scaphoid fractures with cavitary bone loss. This potentially allows for earlier return to function, without compromise to union rates. Level of Evidence This is a Level IV, retrospective case series study.
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Affiliation(s)
- Eugene T. Ek
- Melbourne Orthopaedic Group, Windsor, Melbourne, Victoria, Australia
- Division of Hand Surgery, Department of Orthopaedic Surgery, Monash University, Dandenong Hospital, Dandenong, Melbourne, Victoria, Australia
- Department of Surgery, Monash University, Monash Medical Centre, Clayton, Melbourne, Victoria, Australia
| | - Paul R. Johnson
- Melbourne Orthopaedic Group, Windsor, Melbourne, Victoria, Australia
| | - Carmel M. Bohan
- Melbourne Orthopaedic Group, Windsor, Melbourne, Victoria, Australia
| | - Gayan Padmasekara
- Melbourne Orthopaedic Group, Windsor, Melbourne, Victoria, Australia
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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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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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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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Electrical stimulation-based bone fracture treatment, if it works so well why do not more surgeons use it? Eur J Trauma Emerg Surg 2019; 46:245-264. [PMID: 30955053 DOI: 10.1007/s00068-019-01127-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Accepted: 03/29/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Electrical stimulation (EStim) has been proven to promote bone healing in experimental settings and has been used clinically for many years and yet it has not become a mainstream clinical treatment. METHODS To better understand this discrepancy we reviewed 72 animal and 69 clinical studies published between 1978 and 2017, and separately asked 161 orthopedic surgeons worldwide about their awareness, experience, and acceptance of EStim for treating fracture patients. RESULTS Of the 72 animal studies, 77% reported positive outcomes, and the most common model, bone, fracture type, and method of administering EStim were dog, tibia, large bone defects, and DC, respectively. Of the 69 clinical studies, 73% reported positive outcomes, and the most common bone treated, fracture type, and method of administration were tibia, delayed/non-unions, and PEMF, respectively. Of the 161 survey respondents, most (73%) were aware of the positive outcomes reported in the literature, yet only 32% used EStim in their patients. The most common fracture they treated was delayed/non-unions, and the greatest problems with EStim were high costs and inconsistent results. CONCLUSION Despite their awareness of EStim's pro-fracture healing effects few orthopedic surgeons use it in their patients. Our review of the literature and survey indicate that this is due to confusion in the literature due to the great variation in methods reported, and the inconsistent results associated with this treatment approach. In spite of this surgeons seem to be open to using this treatment if advancements in the technology were able to provide an easy to use, cost-effective method to deliver EStim in their fracture patients.
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