Prognostic factors in the treatment of carpal scaphoid nonunions

Scaphoid Nonunions Treated with Nonvascularized Bone Grafting and Screw Fixation

Background  Vascularized bone grafting with screw fixation is currently considered the treatment of choice for scaphoid nonunions with avascular necrosis (AVN) of the proximal pole. A viable alternative to using vascularized bone grafts for scaphoid nonunions with AVN is nonvascularized bone grafting with screw fixation. Question  What are the functional outcomes of patients with scaphoid nonunions and associated proximal pole AVN who are treated with nonvascularized distal radius bone grafting and screw fixation? Patients and Methods  Eight scaphoid nonunions with AVN, which received nonvascularized distal radius bone graft and screw fixation, underwent a retrospective review. Range of motion, strength, and Disabilities of the Arm, Shoulder, and Hand (DASH) scores were obtained. Follow-up X-rays were compared with immediate postoperative X-rays. Results  At a mean follow-up of 88.9 months, thumb palmar abduction and radial abduction were significantly higher on the operative side ( p  = 0.28 and 0.49, respectively). Extension/flexion arc was significantly lower in the operative wrist ( p  = 0.148). There was no significant difference between the operative and nonoperative sides with regard to strength. The median postoperative DASH score was 2.9 (interquartile range [IQR]: 8.3). There was no progression of osteoarthritis when immediate postoperative and follow-up X-rays were compared. Radiographic union was observed in six of the seven (85.7%) patients who were able to return to the office for follow-up radiographs. The mean scapholunate and radioscaphoid angles measured on X-rays were within normal anatomic range postoperatively. Conclusions  Using nonvascularized distal radius bone graft and screw fixation in the treatment of scaphoid nonunions with associated AVN has favorable radiologic and functional outcomes and should be considered a viable treatment option for this difficult problem.

Treatment of scaphoid nonunion by arthroscopic cancellous bone grafting

INTRODUCTION

In order to avoid Scaphoid Nonunion Advanced Collapse (SNAC) type osteoarthritis, which progressively affects the radial and midcarpal joints, several vascularized and non-vascularized grafting techniques have been described. Over the past decade, there has been growing interest in arthroscopic cancellous bone grafts for scaphoid nonunion. The aim of this novel prospective study was to assess the healing rate of scaphoid grafts under arthroscopy, and the prognostic factors for healing.

MATERIAL AND METHODS

This prospective study was carried out across 10 centers between September 2019 and April 2021, in patients aged 16 to 65. Scaphoid nonunion grafting was performed arthroscopically. Union was assessed on CT scans and displacement correction angles were measured preoperatively and then at 3 and 6months. We assessed mobility, Jamar wrist strength, functional results as per the Patient Related Wrist Score (PRWE) and the Quick Disabilities of the Arm, Shoulder and Hand (Quick DASH) score. Risk factors for nonunion were assessed.

RESULTS

We included 77 patients with a mean age of 24years (18 to 55years) with a mean time between trauma and treatment of nonunion of 34.8months (6 to 180months). The population was represented by 46 manual workers and 20 were smokers. In 42 cases, the nonunion was proximal, in Schernberg zone I or II. At the last follow-up of 12.9months on average (Standard Deviation: 8.7months), union was achieved in 72 patients (93.5%). The average duration of union was 3.4months (Standard Deviation 1.6). Among the 5 patients who did not heal, grafting was performed in addition to the fixation. We did not identify any contributory factors for nonunion.

CONCLUSION

This study demonstrated the effectiveness of arthroscopic treatment of scaphoid nonunion with a union rate at least equivalent to pedicled vascularized grafts. Smoking and delayed treatment were no longer considered unfavorable prognostic factors in the context of arthroscopic treatment.

LEVEL OF EVIDENCE

III.

Results of arthroscopic cancellous bone grafting for treatment of scaphoid nonunion in comparison with open cancellous bone grafting

This study primarily aimed to report the outcome of the arthroscopic cancellous bone grafting technique for treating scaphoid nonunion. The secondary aim was to compare the bone union rate and time, and the ability to correct the angulation of the scaphoid, between arthroscopically treated patients (n = 27), and patients treated with open cancellous bone grafting (n = 27). Nine surgeons (two in the arthroscopic and seven in the open group) with Level III experience operated on the patients. The pain score, grip strength and Quick Disability of the Arm, Shoulder and Hand score improved significantly after the arthroscopic treatment (p = 0.0001). Arthroscopic cancellous bone grafting achieved union in 25 out of 27 patients. A retrospective comparison with open cancellous bone grafting showed four nonunions. Arthroscopically treated patients healed 5.4 weeks faster compared with the open group (p = 0.033). Patients treated with open grafting had a higher risk of failure (odds ratio = 2.17), although this was not found significant (p = 0.39). The open method corrected the angulation deformity better (dorsal cortical angle correction of 4°) than the arthroscopic method (dorsal cortical angle correction of 1°), but this was not statistically significant neither within the groups (p = 0.55, p = 0.87) nor postoperatively between the groups (p = 0.98). The height-to-length ratio was not different before and after the surgery for the arthroscopic group (p = 0.44) and the open group (p = 0.27), or postoperatively between the groups (p = 0.44).Level of evidence: III.

Arthroscopic treatment of stable nonunion, unstable nonunion, or nonunion of the scaphoid with early degenerative radioscaphoid arthritis

BACKGROUND

This study was designed to analyze the clinical follow-up results (minimum of 2 years) in patients with stable nonunion, unstable nonunion, or nonunion of the scaphoid with early degenerative radioscaphoid arthritis (Lichtman classification stage I-III) treated with arthroscopic osteosynthesis with autogenous bone graft.

METHODS

We retrospectively recruited 44 consecutive patients with scaphoid fracture nonunion treated with arthroscopy-assisted percutaneous internal fixation with autogenous bone grafts from January 2010 to November 2019. We recorded union and return to activity and analyzed data with regular clinical follow-up at a mean duration of 33 months (range 24-46 months). Clinical (i.e., visual analog scale pain score, grip strength, and range of motion), radiographic, and functional (Mayo Modified Wrist Score (MMWS)) outcomes at the final follow-up were compared with the preoperative assessments and analyzed in patients with different stages.

RESULTS

We confirmed union in 39 of the 44 patients (88.6%) after a mean 15.4 weeks post-operatively according to clinical examinations and standard radiography. All clinical parameters improved significantly. For the MMWS, there were 25 excellent and 14 good results. Of the 44 patients, 40 (90.9%) returned to work or sports activities at their preinjury levels. Comparisons of the outcomes between patients in different stages of scaphoid nonunion revealed no significant difference in the aspect of union rate, VAS pain score, and functional score improvement.

CONCLUSIONS

Arthroscopic osteosynthesis with autogenous bone grafts is a reliable and minimally invasive method for achieving nonunion healing and improving clinical outcomes in stage I-III scaphoid nonunion.

LEVEL OF EVIDENCE

Level IV, case series.

Scaphoid nonunion with DISI deformity treated in a two-stage operation with the Ilizarov mini fixator: A case report

Scaphoid nonunion causes humpback deformity and dorsal intercalated segment instability (DISI) deformity due to dorsal rotation of the proximal scaphoid fragment. In the treatment of scaphoid nonunion, it is important to not only achieve bone union, but also to improve DISI deformity and carpal bone alignment in order to attenuate pain, increase the range of motion, and prevent the development of osteoarthritis.

We encountered a case of DISI deformity caused by the long-term neglect of scaphoid nonunion that was treated in a two-stage operation with the Ilizarov mini fixator. A 28-year-old male had been injured during a soccer game 10 years ago. Although he had wrist pain, he did not visit a hospital. This led to chronic scaphoid nonunion with DISI deformity. Since 10 years had passed from the initial injury, DISI deformity was considered to be difficult to correct using a single stage procedure. Therefore, a two-stage operation was performed. The Ilizarov mini fixator was used to gradually correct DISI deformity in the first stage, and screw fixation with bone grafting was performed in the second stage.

Difficulties are associated with achieving good clinical results in cases of long-term scaphoid nonunion. In cases of DISI deformity, it is important to correct the alignment of lunate dorsiflexion and the distal carpal row as well as achieve bone union. Although the Ilizarov external fixator has been used for scaphoid nonunion, it has not yet been applied to scaphoid nonunion with DISI deformity. The Ilizarov mini fixator may be useful to correct long-term deformities, and good results were obtained in the present case. It represents an option for the treatment of scaphoid nonunion with DISI deformity.

Bone Morphogenic Protein 2 Use for the Surgical Treatment of Acute Scaphoid Fractures and Scaphoid Non-unions

BACKGROUND

Bone morphogenic protein 2 (BMP-2) has demonstrated promise as an adjunct to surgically treating fractures. Its reported use in the upper extremity is limited. Questions/purpose: This study reports union rates, outcomes, and complications of scaphoid fractures treated with adjunctive BMP-2 to further characterize BMP-2 use in the hand and wrist.

METHODS

Retrospective review of scaphoid fractures treated surgically in one region of the military health system from 2009 to 2019 was conducted to identify cases employing BMP-2. Fracture healing was determined by computed tomography. Primary outcomes were union rate, time to union, and complications. Secondary outcomes included union rates for prior non-unions, union rates at 4 & 6 weeks, and functional outcomes.

RESULTS

Fourteen patients met inclusion criteria. Non-unions accounted for 50% of included fractures. The total union rate was 93%. Mean time to union was 6.2 weeks. All acute fractures healed with mean time to union of 4.8 weeks. Non-unions had a union rate of 86% with mean time to union of 7.7 weeks. Four patients (29%) developed radiographic heterotopic ossification (HO); however, there was no significant decrease in motion was appreciated. Thirteen patients (93%) resumed the push-ups portion of the military fitness test. No major complications were identified during follow up.

CONCLUSIONS

Adjunctive use of BMP-2 in operative fixation of scaphoid fractures resulted in desirable union rates without major complications. Larger, prospective studies are needed to assess if adjunctive BMP-2 use in scaphoid fractures provides significant benefit versus other treatments.

Arthroscopic Treatment of Scaphoid Nonunion With Olecranon Bone Graft and Screw Fixation Leads to Union and Improved Outcomes

PURPOSE

To evaluate the outcomes of arthroscopic treatment of scaphoid nonunion using olecranon bone graft and screw fixation and to analyze the outcomes in accordance with variations in the chronicity, location, and severity of nonunion.

METHODS

Between March 2012 and December 2020, patients with diagnoses of scaphoid delayed nonunion and nonunion with substantial bone resorption (Slade and Dodds grade IV-VI) underwent arthroscopic-assisted olecranon bone graft and screw fixation. Preoperative and postoperative measurements included the visual analog scale score for pain; range of motion; grip strength; the Modified Mayo Wrist Score; the Disabilities of the Arm, Shoulder and Hand (DASH) score; and the minimal clinically important difference for the DASH score. Union rate and duration were also evaluated. The outcomes between groups of patients with different conditions were analyzed.

RESULTS

Twenty-two patients were included. The average follow-up period was 32.5 months. The visual analog scale pain score, range of motion, grip strength, Modified Mayo Wrist Score, and DASH score were significantly improved after surgery (P < .001). The minimal clinically important difference threshold for the DASH score was reached by 100% of patients. At final follow-up, all patients had united scaphoid with no complications. The average time to union was 15.3 weeks. Group analysis showed significant improvements in mean grip strength between patients with delayed union (3-6 months) and those with chronic nonunion (> 1 year) (17.75 kg vs 12.25 kg, P = .032), between grade IV nonunion and grade V nonunion (14.86 kg vs 10.43 kg, P = .035), and between grade V nonunion and grade VI nonunion (10.43 kg vs 15.63 kg, P = .013). Patients with grade VI nonunion achieved union at 17.8 weeks postoperatively, a significantly longer period than that for patients with grade IV nonunion (11.4 weeks, P = .014).

CONCLUSIONS

Arthroscopic treatment of scaphoid nonunion using olecranon bone graft and screw fixation provided satisfactory outcomes regardless of the chronicity, location, and severity of nonunion.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Scaphoid Nonunion Vascularized Bone Grafting in 2021: Is Avascular Necrosis the Sole Determinant?

The decision regarding the use of vascularized bone grafting (VBG) or nonvascularized bone grafting for the treatment of scaphoid nonunion (SNU) needs guidelines based on patient- and fracture-specific risk factors. Historically, the presence of avascular necrosis was viewed as the primary indication for VBG; however, avascular necrosis is not the only indicator to determine whether VBG can improve our treatment of difficult SNU cases. The methods of detecting scaphoid avascular necrosis lack consensus and accuracy, limiting their use as decision-making tools. Additionally, many other preoperative risk factors for SNU surgery failure have been reported and require careful and standardized study, including the location of nonunion in the scaphoid proximal pole, the duration of nonunion, previous failed nonunion surgery, smoking, and fracture nonunion displacement or collapse. An appropriate study size and design are needed to determine the factors that guide the use of VBG or nonvascularized bone grafting to optimize the outcomes of SNU surgery.

Fixação percutânea sem enxerto ósseo para pseudartrose do escafóide

Objective  To describe the clinical and radiographic outcomes of patients submitted to percutaneous fixation without bone graft for scaphoid nonunion, with a minimum follow-up of six months.

Methods  A case series study of a convenience sample of hand surgeons with prospective evaluation. Patients with scaphoid (waist or proximal pole) nonunion and the following features were included: more than six months of history; X-rays showing sclerosis of the edges of the nonunion, with resorption of the nonunion focus measuring less than 4 mm (Slade & Gleissler I, II, III and IV) and no angular deformity; and no proximal pole necrosis on magnetic resonance imaging (MRI).

Results  After six months of follow-up, all nonunion were consolidated, with no major complications. The functional outcomes revealed good scores on the disabilities of the arm, shoulder and hand (DASH; n = 12; mean: 6.9; standard deviation [SD]: 2.1) and patient-rated wrist evaluation (PRWE; n = 12; mean: 7.97, SD: 1.5) questionnaires. The results of the visual analog scale (VAS) showed little residual pain (n = 12; mean: 0.71; SD: 0.2). Slight decreases in flexion (69 versus 59.1; p  = 0.007), extension (62.4 versus 48.7; p  = 0.001) and radial deviation (29.6 versus 24.6; p  = 0.014) were detected in comparison to the contralateral side.

Conclusions  All cases in the series presented consolidation and good functional scores at the six-month evaluation. This is a promising option (with lower technical demand and morbidity) for the treatment of scaphoid nonunion. Comparative studies are required to assess the effectiveness of this technique in comparison with other options.

Are Vascularized Periosteal Flaps Useful for the Treatment of Difficult Scaphoid Nonunion in Adults? A Prospective Cohort Study of 32 Patients

PURPOSE

To evaluate clinical and radiological outcomes after surgical treatment of difficult scaphoid nonunion in adults with a vascularized thumb metacarpal periosteal pedicled flap (VTMPF).

MATERIALS AND METHODS

Thirty-two patients at least 18 years old, with scaphoid nonunion and characteristics associated with a poor prognosis, who underwent a VTMPF procedure, were included in this retrospective cohort study with a mean follow-up of 17 months. Factors associated with a poor prognosis were a delay in presentation of over 5 years, the presence of avascular necrosis, and previous nonunion surgery. All patients had at least 1 poor prognostic factor and 25% had 2 or more.

RESULTS

In 30 men and 2 women, the mean age was 36 years (range, 19-56 years). There were 11 type D3 nonunions (Herbert classification) and 15 type D4. Five patients had delayed presentation of over 5 years. Fourteen patients had previously undergone an unsuccessful surgical attempt to treat their nonunion. The patients experienced no postoperative complications. Overall union rate was 97% (31 of 32 patients), with 72% cross-sectional trabecular percentage bridging at 12 weeks. Pain subsided after surgery and patients experienced improvements in both their Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and Modified Mayo Wrist Score (MMWS). Overall 41% and 42% gains in strength and wrist motion, relative to the contralateral normal side, were observed. At final follow-up, there were no differences between the treated and the untreated (healthy) hands, in terms of wrist range of motion, grip, or pinch strength.

CONCLUSIONS

In this study, the use of VTMPF for difficult scaphoid nonunion in adults was associated with good general outcomes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

[Treatment of scaphoid non-union: vascularised iliac crest graft or medial femur condyle graft?]

Treatment of scaphoid non-unions is still challenging for responsible hand surgeons, especially in cases of avascular proximal pole non-unions or failed prior surgeries. Several surgical procedures treating scaphoid non-unions have been established. These aim to restore correct anatomy to provide stability and adequate blood flow. Treatment options range from avascular to free, vascularized bone grafts. The two most used free vascularized bone grafts derive from the iliac crest and the medial femoral condyle. The vascular anatomy of the medial femoral condyle graft is more constant, the donor site morbidity lower and the healing rate higher in comparison to the iliac crest graft. It is easier to harvest the femoral condyle graft and additionally, it can be harvested as a cortico-cancellous or osteochondral graft. Looking at all advantage, we come to the conclusion that the free vascularized medial femoral condyle graft is our method of choice for the treatment of a avascular proximal pole non-union of the scaphoid.

Study of Anatomical Variations of 1,2 Intercompartmental Supraretinacular Artery-Based Vascularized Bone Graft in Cadavers

BACKGROUND

The aim of this study is to describe the anatomy of the 1,2 intercompartmental supraretinacular artery (1,2 ICSRA), including the location of the perforators, number of perforators, and proximal and distal origins of the artery.

MATERIALS AND METHODS

The study was done by dissecting both wrists of 11 fresh-frozen cadavers. In each specimen, skin incision and dissections were done in the forearm by the Henry approach. Radial artery was identified and cannulated and dye was injected. The dye consisted of the mixture of polyvinyl chloride and acetone in the ratio of 1:4, to which red-colored resin was added. The artery of interest 1,2 ICSRA was dissected and its anatomical characteristics such as distal origin, proximal origin, number of perforators, and largest perforator were measured.

RESULTS

Of the 22 wrists dissected, only in 19 wrists we were able to recognize the perforators. Average number of perforators seen was 3.05 (range 1-5). Average distance of the largest perforator from the radial styloid was 11.79 mm (range 6-19 mm). The average distance of the distal origin of 1,2 ICSRA from the radial styloid was 6.71 mm distal to radial styloid. It ranged from 16 mm distal to styloid process to 6 mm proximal to the styloid process. The average distance of proximal origin of 1,2 ICSRA from the radial styloid was 40.52 mm proximal to the radial styloid (range 25-66 mm). The maximum density of perforators of 2.84 was noticed to be in the region of 6-18 mm from the distal articular margin.

CONCLUSION

The distal origin of 1,2 ICSRA in our study was much more distal in comparison to the western population. The detailed anatomy of the 1,2 ICSRA presented in this study may guide in planning and dissection to maximize the vascularity of a pedicled bone graft based on this vessel for the management of scaphoid nonunions and other carpal pathologies.

Comparison of Shape Memory Staple and Gelled Platelet-Rich Plasma versus Shape Memory Staple alone for the Treatment of Waist Scaphoid Nonunion: A Single-Center Experience

Purpose  The aim of this study was to analyze the results of two different methods of surgical treatment of waist scaphoid nonunions (SNUs). We retrospectively analyzed data from 87 patients referred to our department from January 2010 to December 2017 who were surgically treated for waist SNU.

Methods  The mean period of time passed from trauma was 11.2 (±5.6) months. Patients were divided into two groups based on surgical treatment received: volar exposure osteosynthesis with shape memory staple (SMS) (group A) and volar exposure osteosynthesis with SMS and gelled platelet-rich plasma (GPRP) application at the bone defect level (group B). A cast (thumb excluded) was maintained for 4 weeks. Healing was checked clinically (pain, QuickDASH [Disabilities of the Arm, Shoulder, and Hand] score, Mayo Wrist Score) and radiologically (standard X-ray).

Results  Union was achieved in 40 patients in group A (95.2%) and in all patients in group B (45 patients; 100%). A statistically significant difference was observed in the improvement of the Mayo Wrist Score, QuickDASH score, and pain (measured through the visual analog scale) after 3 months from surgery ( p  = 0.02).

Conclusion  SMS is effective in treating waist SNU at more than 6 months from trauma. GPRP application can improve bone healing and upper limb function.

Level of Evidence  This is a retrospective observational Level III study.

Factors Associated with Scaphoid Nonunion following Early Open Reduction and Internal Fixation

Background  Nonunion after open reduction and internal fixation (ORIF) of scaphoid fractures is reported in 5 to 30% of cases; however, predictors of nonunion are not clearly defined. Objective  The purpose of this study is to determine fracture characteristics and surgical factors which may influence progression to nonunion after scaphoid fracture ORIF. Patients and Methods  We performed a retrospective case-control study of scaphoid fractures treated by early ORIF between 2003 and 2017. Inclusion criteria were surgical fixation within 6 months from date of injury and postoperative CT with minimum clinical follow-up of 6 months to evaluate healing. Forty-eight patients were included in this study. Nonunion cases were matched by age, sex, and fracture location to patients who progressed to fracture union in the 1:2 ratio. Results  This series of 48 patients matched 16 nonunion cases with 32 cases that progressed to union. Fracture location was proximal pole in 15% (7/48) and waist in 85% (41/48). Multivariate regression demonstrated that shorter length of time from injury to initial ORIF and smaller percent of proximal fracture fragment volume were significantly associated with scaphoid nonunion after ORIF (63 vs. 27 days and 34 vs. 40%, respectively). Receiver operating curve analysis revealed that fracture volume below 38% and time from injury to surgery greater than 31 days were associated with nonunion. Conclusion  Increased likelihood for nonunion was found when the fracture was treated greater than 31 days from injury and when fracture volume was less than 38% of the entire scaphoid. Level of Evidence  This is a Level III, therapeutic study.

Drill and Fill Technique for the Treatment of Scaphoid Delayed Unions and Nonunions

Background  This article reviews the results of a surgical technique using three iterations of drilling , autologous cancellous bone grafting ( filling ), and use of an intraosseous compression screw for the treatment of nondisplaced or minimally displaced scaphoid delayed unions or nonunions. Methods  Part 1-Cadaveric study: Three cadaveric scaphoids underwent stained cancellous bone graft packing and headless cannulated compression screw placement using a single iteration of drilling and graft packing. Three additional scaphoids were allocated to the triple "drill and fill" group, and underwent three iterations of drilling and graft packing before screw insertion. Graft particle distribution on mid-sagittal sections was assessed under fluorescence microscopy. Comparison of normalized areas between the single and triple "drill and fill" groups was performed using repeated measures ANOVA and Tukey's post hoc test. Part 2-Clinical study: Twelve patients with minimally displaced scaphoid delayed unions and nonunions treated between April 2007 and December 2013 with the triple "drill and fill" technique were included. The average follow-up was 60.4 weeks. Two fellowship-trained musculoskeletal radiologists independently reviewed images for fracture healing. Results  By the histomorphometric analysis, there was improved autograft distribution along the screw tract, particularly within the proximal pole, with three iterations of drilling and filling. Clinically, 11 of 12 delayed unions and nonunions had healed. Conclusion  Our results support the use of the "drill and fill" technique as an option for the treatment of select nondisplaced or minimally displaced scaphoid nonunions and delayed unions at the waist without avascular necrosis of the proximal pole. Level of Evidence  This is a Level IV study.

Scaphoid Reconstruction

Surgical strategies for scaphoid nonunions become more complex based on time from injury to treatment. The decision-making process, however, can follow a logical sequence. Scaphoid nonunions less than 1 year after trauma and no carpal malalignment can be treated with percutaneous screw fixation under fluoroscopic and/or arthroscopic guidance. Reinterventions or patients with avascular proximal poles that do not need substantial grafts are reliably treated with pedicle vascularized bone grafts. Resection of the distal pole of the scaphoid is a good option in old nonunions or after a failed scaphoid procedures. When there are radioscaphoid degenerative changes, salvage procedures such as proximal row carpectomy (PRC) should be considered.

The outcome of bone graft surgery for nonunion of fractures of the scaphoid

Data on 806 patients undergoing bone graft surgery for a scaphoid fracture nonunion were retrospectively collected at 19 centres in the United Kingdom. Each centre contributed at least 30 cases. Sufficient data were available in 462 cases to study factors that influenced the outcome of surgery. Overall union occurred in at least 69%, and nonunion in at least 22%, with 9% of cases having 'uncertain union status'. Union appeared to be adversely influenced by smoking and the time between acute scaphoid fracture and nonunion surgery, with adjusted odds ratios of 1.8 and 2.4, respectively, but neither achieved the pre-determined significance level of 0.003. The type of bone graft (vascular vs non-vascular; iliac crest vs distal radius) did not appear to influence outcome. Further large multicentre prospective studies with clear definitions of 'union' and other factors are needed to clarify whether modification of surgical technique can influence union. Level of evidence: IV.

The Authors' Technique for Volar Plating of Scaphoid Nonunion

Internal fixation of the scaphoid using a plate has been reported in the literature as far back as 1977. Recently, a specific plate designed for scaphoids has been developed, which provides considerably more buttress support than intramedullary headless screws, and offers a reliable method of rigid internal fixation for complex fractures. Indications to use such a plate include complex acute fractures, such as those with significant waist comminution or steep reverse oblique fractures, and complex nonunions with central bone loss resulting from failed previous headless screw fixation. This is now the authors' preferred treatment for these injuries.

Bony anatomy of the third metacarpal and relationship with the capitate: a computed tomography study

PURPOSE

The purpose of this study was to accurately establish the anatomical variability of the third metacarpal, its medullary canal, and the relationship with the capitate in the context of high rates of component loosening still seen in total wrist arthroplasty.

METHODS

CT scans of a 100 hands (age: 41 ± 14 years (range: 16-71 years); male/female ratio: 53/47) were studied to establish the detailed anatomy of the third metacarpal and the capitate.

RESULTS

Although the shape of the third metacarpal and the angles formed with the capitate were highly variable, the third metacarpal length was longer in males (p < 0.001), the proximal cortical bone was thicker (p < 0.001) and the sagittal metacarpal-capitate axis offset was greater (p = 0.01). A relationship was found between the total length of the metacarpal and the distance to the isthmus from the base (r = 0.63; p < 0.0001) which was unaffected by gender. No age-related relationships were significant.

CONCLUSION

The anatomy of the third metacarpal and capitate varies considerably more than has been alluded to in current wrist arthroplasty literature. Differences between males and females can likely be attributed to hand size. The distance of the isthmus from the base can be predicted from the total length of the metacarpal with a standard error of 1.9 mm.

Scaphoid specific volar locking plate and non-vascularised iliac crest bone graft in scaphoid non-union. A comparative cohort study

Scaphoid non-union develops in 10% of scaphoid fractures. There is sparse literature on fixation methods other than screws. We compared union rates following fixation of scaphoid non-union using screw fixation and a novel method of plate fixation. Retrospective study. Union rates were assessed at 3 months post-operatively by a musculoskeletal radiologist. 15 patients underwent screw fixation and 15 underwent plate fixation. 86% union rate with screw fixation and 72% plate fixation united. There was no significant difference. Screw fixation and plate fixation in our institution both provide union rates that are consistent with the literature.

An Epidemiologic Perspective on Scaphoid Fracture Treatment and Frequency of Nonunion Surgery in the USA

BACKGROUND

Scaphoid fractures treated non-operatively and operatively may be complicated by nonunion.

QUESTIONS/PURPOSES

We sought to test the primary hypothesis that the incidence density of scaphoid fracture treatment is higher than previously estimated, to determine the frequency and risk factors for nonunion treatment, and to determine whether the frequency of surgical treatment increased over time.

METHODS

The MarketScan^® database was queried for all records of treatment (casting and surgery) for closed scaphoid fractures over a 6-year period. We examined subsequent claims to determine frequency of additional procedures for nonunion treatment (revision fixation or vascularized grafting occurring 28 days or more after initial treatment). Trend analyses were used to determine whether changes in frequency of surgical treatment or revision procedure occurred.

RESULTS

The estimated incidence density of scaphoid fracture is 10.6 per 100,000 person-years in a commercially insured population of less than 65 years of age. Of 8923 closed scaphoid fractures, 29 and 71% were treated with surgery and casting, respectively. The frequency of surgical treatment rose significantly, from 22.1% in 2006 to 34.1% in 2012. The frequency of nonunion treatment was 10.8% after surgery and 3% after casting; neither changed over time. Younger age, male sex, and surgical treatment are associated with a higher risk of nonunion treatment.

CONCLUSIONS

Our estimated incidence of scaphoid fracture is higher than previously reported. The increased enthusiasm in the USA to surgically treat scaphoid fractures is reflected by our trend analysis. The frequency of surgical treatment for presumed nonunion after initial surgical management for closed scaphoid fractures exceeded 10%. Given the increased utilization of surgery, surgeons and patients should be aware of the frequency of nonunion treatment to inform treatment decisions.

Screw Fixation Alone for Scaphoid Fracture Nonunion

Scaphoid fracture nonunion can often lead to pain, arthrosis, and disability. While typically the result of delayed diagnosis or inadequate treatment, it can sometimes occur even if the initial care was timely and appropriate. Whereas early recognition of acute fractures allows for nonoperative management, nonunions frequently require surgical treatment. Traditionally, this has involved open debridement and bone grafting. However, some publications suggest that certain stable nonunions may be amenable to percutaneous debridement and fixation without formal bone grafting. Although certain characteristics appear to be appropriate indications for such management, well-designed clinical studies are needed to better define them.

Time-dependent changes in bone healing capacity of scaphoid fractures and non-unions

The scaphoid is the most frequently fractured carpal bone and prone to non‐union due to mechanical and biological factors. Whereas the importance of stability is well documented, the evaluation of biological activity is mostly limited to the assessment of vascularity. The purpose of this study was to select histological and immunocytochemical parameters that could be used to assess healing potential after scaphoid fractures and to correlate these findings with time intervals after fracture for the three parts of the scaphoid (distal, gap and proximal). Samples were taken during operative intervention in 33 patients with delayed or non‐union of the scaphoid. Haematoxylin and Eosin (HE), Azan, Toluidine, von Kossa and Tartrate‐resistant acid phosphatase (TRAP) staining were used to characterise the samples histologically. We determined distribution of collagen 1 and 2 by immunocytochemistry, and scanning electron microscopy (SEM) was used to investigate the ultrastructure. To analyse the samples, parameters for biological healing status were defined and grouped according to healing capacity in parameters with high, partial and little biological activity. These findings allowed scoring of biological healing capacity, and the ensuing results were correlated with different time intervals after fracture. The results showed reduced healing capacity over time, but not all parts of the scaphoid were affected in the same way. For the distal fragment, regression analysis showed a statistically significant correlation between summarised healing activity scores and time from initial fracture (r = −0.427, P = 0.026) and decreasing healing activity for the gap region (r = −0.339, P = 0.090). In contrast, the analyses of the proximal parts for all patients did not show a correlation (r = 0.008, P = 0.969) or a decrease in healing capacity, with reduced healing capacity already at early stages. The histological and immunocytochemical characterisation of scaphoid non‐unions (SNUs) and the scoring of healing parameters make it possible to analyse the healing capacity of SNUs at certain time points. This information is important as it can assist the surgeon in the selection of the most appropriate SNU treatment.

Scaphoid Fracture Fixation in a Nonunion Model: A Biomechanical Study Comparing 3 Types of Fixation

PURPOSE

Union of a scaphoid fracture after fixation is influenced by various factors, one of which is fracture stability. This study aims to compare the biomechanical stability of 3 different types of scaphoid fracture fixation in a scaphoid nonunion model.

METHODS

Thirty cadaveric scaphoid specimens were assigned to one of 3 different fixation groups: (1) single 3.0-mm compression screw, (2) two 2.2-mm screws, and (3) scaphoid plate. A 3-mm volar wedge osteotomy was created at the scaphoid waist to simulate a nonunion model. The primary outcome measure was load to failure, whereas secondary outcome measures were load to 2-mm displacement, energy absorbed, stiffness, and mode of failure, recorded by video and retrieval analysis.

RESULTS

There was a significantly lower load to failure in the single screw construct compared with that in the double screw (mean difference 187.2 N) and plate fixation constructs (mean difference 150.7 N). The mean load to 2-mm displacement in the single screw construct (91.5 N) was also significantly lower than that in the double screw (181.8 N) and plate fixation constructs (197.2 N). There was a significantly lower stiffness with the single screw fixation compared with that of the double screws (mean difference 85.4 N/mm), and lower energy absorbed with single screws when compared with that of double screws (mean difference 386.5 mJ) and when compared with plate fixation (mean difference 270.8 mJ).

CONCLUSIONS

In this biomechanical study comparing fixation methods using a model of scaphoid nonunion with bone loss, we found that double screws or plate fixation demonstrated significantly greater stability, stiffness, and energy absorption when compared with a single compression screw. We found no discernible differences between double screw fixation and the plate groups.

CLINICAL RELEVANCE

The use of double screws or plate fixation in a nonunion setting may allow accelerated rehabilitation without compromise to fracture stability.

The clinical result of arthroscopic bone grafting and percutaneous K-wires fixation for management of scaphoid nonunions

The purpose of this study is to analyze the clinical results of patients with scaphoid nonunion treated with arthroscopic bone grafting and K (Kirschner)-wires fixation.We retrospectively reviewed the records of 27 patients with scaphoid nonunion who had been treated with arthroscopic bone grafting and K-wires fixation method from November 2008 to February 2014. The average patient age was 35 years. The time from injury to treatment averaged 45 months. The average follow-up period was 18 months. Bone union was assessed using serial plain radiographs. The functional outcome was evaluated by comparing the modified Mayo wrist score with the visual analog scale (VAS) for pain, which were measured at the time of preoperation and at final follow-up.Union was achieved in 26 of the 27 nonunions (96.29%). The average radiologic union time was 10 weeks. The average VAS score decreased from 6.38 (range, 3-10) preoperatively to 1.59 (range, 0-3) at the final follow-up. The average modified Mayo wrist score improved from 60.19 preoperatively to 83.46 at the final follow-up. According to this score, there were 12 excellent, 6 good, and 9 fair results at the final follow-up.Arthroscopic bone grafting and percutaneous K-wires fixation is an effective treatment method for a scaphoid nonunion and has the advantages of allowing thorough assessment, enabling a comprehensive management approach for scaphoid nonunion in a minimally invasive manner, and this method can also be used for the scaphoid nonunion with SNAC stage I.

Cylinder-Shaped Bone Graft for Scaphoid Nonunion

BACKGROUND

Wedge-shaped bone grafts that are internally fixed by a Herbert-type screw are a well-established surgical treatment for scaphoid nonunion. A procedure using cylinder-shaped bone grafts was also reported, but preoperative wrist functions were not assessed. In addition, it was not reported whether the humpback deformity of the scaphoid nonunion was corrected. The purpose of the current study was to compare preoperative wrist functions in cases of scaphoid nonunion with those observed at final follow-up, using cylinder-shaped bone grafts The humpback deformity of the scaphoid nonunion was also evaluated.

METHODS

We conducted a retrospective study to examine operative outcomes from 2008 to 2015. Twelve wrists in 12 patients (average age, 41 years; range, 17-67), with a mean follow-up of 19 months, were included in the current study. Cylinder-shaped bone grafts were obtained from the iliac crest with a newly designed trephine and fixed with a Herbert-type screw. We reviewed both the preoperative wrist functions and those obtained at final follow-up.

RESULTS

Union was achieved in 11 of 12 nonunion cases. Preoperative wrist functions, except for the range of wrist motion, significantly improved by final follow-up.

CONCLUSIONS

We conclude that the use of cylinder-shaped bone grafts improves preoperative wrist functions in cases of scaphoid nonunion.

Correlation of CT imaging and histology to guide bone graft selection in scaphoid non-union surgery

INTRODUCTION

For the treatment of scaphoid non-unions (SNU), different surgical techniques, including vascularized and non-vascularized bone grafts, are applied. Besides stability, vascularity, and the biological situation at the non-union site are important for healing and the appropriate choice of treatment. We assessed the healing potential of SNUs by histological parameters and compared it to CT parameters of bone structure and fracture location. Based on the results, we developed a CT classification and a treatment algorithm to impact graft selection in SNU surgery.

PATIENTS AND METHODS

Preoperative 2D-CT reformations of 29 patients were analyzed for trabecular structure, sclerosis, and fragmentation of the proximal fragment. The fracture location was assessed on 3D-CT reconstructions and grouped in three zones depending on the potential blood supply. Samples were taken during surgery for histological evaluation. Histological parameters of bone healing were defined and a bone healing capacity score (BHC), reflecting histological bone viability, was calculated. CT findings were compared to BHC, age of SNU, and time to union.

RESULTS

Cases with trabecular structure and without fragmentation showed a statistically significant higher BHC. Time to union was significantly faster if trabecular structure was present and sclerosis was absent. In intraarticular proximal pole non-unions, where no blood supply is assumed, the BHC was statistically significantly lower and time to union was longer compared to SNUs of the other locations. A statistically significant correlation between BHC and time to union was found in the proximal and distal fragment with higher BHC associated with faster healing.

CONCLUSIONS

CT parameters of bone structure and fracture location can reflect histological healing capacity of SNUs. This can guide bone graft selection in SNU surgery.

Factors Influencing Outcome in the Management of Scaphoid Non-union and Comparison of Matti Russe and Interpositional Grafting Techniques

BACKGROUND

Scaphoid non-union is often caused due to missed fractures, inadequate or inappropriate management. Matti-Russe and interpositional grafting techniques are used in the treatment of non-union. There are very few studies in literature that compare the outcomes of these techniques. The aim of our study was to analyse the factors influencing outcome in the management of scaphoid non-union and to compare the results of the Matti Russe procedure with interpositional grafting techniques.

METHODS

Fifty scaphoid non-unions with a mean follow-up of 39.9 ± 5.5 months were included in this retrospective study. Demographic parameters, treatment, functional and radiological outcomes were recorded. The influence of demographic and treatment factors on union in this cohort was statistically analysed.

RESULTS

Union was achieved in 76% of cases. Good to excellent results were achieved in 84% of patients. There was no significant difference in union rates, deformity correction achieved and period of immobilisation between the MR and IG techniques. The occurrence of arthritic changes correlated with the time interval between injury and surgery (p = 0.002).

CONCLUSIONS

The most important factor that influences the outcome is the time period between the occurrence of the fracture and surgery for non-union. The Matti-Russe procedure can achieve comparable results to interpositional grafting techniques with a shorter period of immobilisation than previously thought to be required. We believe that the presence of a deformity is not a contraindication for the procedure.

Ilizarov fixation for the treatment of scaphoid nonunion: a novel approach

OBJECTIVES

To evaluate the safety and efficacy of the Ilizarov fine-wire compression/distraction technique in the treatment of scaphoid nonunion (SNU), without the use of bone graft.

DESIGN

This is a prospective study of 20 consecutive patients in one center.

PATIENTS AND METHODS

This study included 20 patients (19 males) with a mean SNU duration of 14.5 months. Four patients had proximal pole, 15 had waist, and 1 had a distal SNU. Patients with carpal instability, humpback deformities, carpal collapse, avascular necrosis, and marked degenerative change were excluded. Following frame application, the treatment comprises three stages: The frame is distracted by 1 mm per day until the radiographs show a 2-3 mm opening at the SNU site (mean 10 days); the SNU site is compressed for 5 days, at a rate of 1 mm per day, with the wrist in 15 degrees of flexion and 15 degrees of radial deviation; the wrist is then immobilized in the Ilizarov fixator for 8 weeks.

RESULTS

Radiographic (radiography and CT scan) and clinical bony union was achieved in all 20 patients after a mean of 90.3 days (70-130 days). All patients returned to their pre-injury occupations. Thirteen patients had excellent results, four good, and three fair, according to the Mayo wrist score.

CONCLUSIONS

In these selected patients, this technique safely achieved bony union without the need to open the SNU site and without the requirement of bone graft.

Estimating Scaphoid Lengths Using Anatomical Measurements in the Wrist

PURPOSE

In reconstructive surgery of scaphoid nonunions with humpback deformity, some surgeons recommend restoration of the normal scaphoid length whereas others overexpand the normal length to ensure carpal realignment and prevent late collapse. To be able to define overexpansion and investigate which levels of overexpansion yield optimal clinical results, a precise method for estimating the original scaphoid length is required. The purpose of this anatomic study was to investigate the precision of estimating normal scaphoid lengths based on intact adjacent bone dimensions, compared with using the contralateral scaphoid length.

METHODS

From bilateral computed tomographic scans of 28 healthy wrist pairs, 3-dimensional virtual bone models were created. The left and right scaphoid lengths were determined at the central axis. The capitate length at the central axis and the distal radius width served to derive an ipsilateral scaphoid length estimate. Estimation precision for individual cases was based on the 95% range (±1.96 × SD) of the observed differences between the actual and estimated lengths.

RESULTS

On average, the capitate length was 10% smaller than the scaphoid length; the radius width was 9% larger. Consequently, we averaged the capitate length and radius width for ipsilateral estimations. The average difference between the scaphoid length and the latter ipsilateral estimate was 0.1 mm. The average contralateral scaphoid length difference was also 0.1 mm. Estimation precisions, however, were ±2.2 and ±1.4 mm, respectively.

CONCLUSIONS

Scaphoid length estimation based on the contralateral scaphoid is more precise than the estimating scaphoid length using the ipsilateral radius and capitate.

CLINICAL RELEVANCE

Scaphoid overexpansion can be ensured if the restored length is at least 1.4 mm longer than the contralateral length. This may be valuable information when establishing a target length for reconstruction and investigating the consequences of scaphoid overexpansion on clinical function, such as range of motion, which are currently unknown.

Scaphoid fracture non-union: a systematic review of surgical treatment using bone graft

This systematic review assesses the quality and outcomes of published articles concerning bone graft surgery for scaphoid fracture non-union. Searches of the CENTRAL, MEDLINE, EMBASE, CINAHL and AMED databases captured 2710 articles. Each article was screened and 144 met our inclusion criteria. Data regarding source, study design, population, intervention, comparator and outcomes were extracted. There were 5464 scaphoid non-union outcomes within the 144 studies. Mean reported union rates for vascularized and non-vascularized bone graft were 84% and 80%, respectively. Avascular necrosis was diagnosed in several ways and, when present, the vascularized bone graft union rate was 74% compared with 62% with non-vascularized bone graft. Reported union rates vary considerably. These differences may be due to patient factors, fracture factors, treatment factors or study design failures or bias. We recommend that future researchers take into account the deficiencies of previous studies and use the suggested minimum data set in future studies.

LEVEL OF EVIDENCE

II.

Hybrid Russe Procedure for Scaphoid Waist Fracture Nonunion With Deformity

PURPOSE

To assess the results of a hybrid Russe procedure using a corticocancellous strut, cancellous autologous nonvascularized bone graft, and cannulated headless compression screw to reduce the deformity reliably from a collapsed scaphoid nonunion, provide osteoinductive stimulus, and stabilize the fracture for predictable union.

METHODS

A hybrid Russe procedure was performed for scaphoid waist fracture nonunions with humpback deformity and no evidence of avascular necrosis. A volar distal radius autologous bone graft was harvested and a strut of cortical bone was fashioned and placed into the nonunion site to restore length and alignment. We packed cancellous bone graft in the remainder of the nonunion site and fixed the scaphoid was with a headless compression screw. Union was determined by radiographs or computed tomography, and intrascaphoid, scapholunate, and radiolunate angles were calculated on final radiographs. We recorded wrist range of motion, grip strength, pinch strength, pain, and complications.

RESULTS

Fourteen male and 3 female patients (average age, 32 years; range, 16-78 years), with a mean follow-up of 32 months, were examined clinically and radiographically. All 17 scaphoids united with a mean time for union of 3.6 months. The mean postoperative intrascaphoid angle was significantly reduced from 65° preoperatively to 35° postoperatively. The mean radiolunate angle was significantly improved from 20° from neutral (lunate tilted dorsally) preoperatively to 0° postoperatively. The scapholunate angle also demonstrated significant improvement from 70° preoperatively to 56° postoperatively. Grip strength improved from 70% of the contralateral hand to 89% after the procedure. All patients were satisfied with the functional outcome and no donor site morbidity or hardware issues were identified.

CONCLUSIONS

This straightforward hybrid Russe technique predictably restored radiolunate, scapholunate, and intrascaphoid angles with a 100% union incidence. The technique provides excellent functional results in patients with a challenging clinical problem, and we recommend it for scaphoid fracture waist nonunions with dorsal intercalated segment instability deformity.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Treatment of Scaphoid Nonunion: A Systematic Review of the Existing Evidence

PURPOSE

To determine by systematic review the optimal treatment of scaphoid nonunion.

METHODS

We conducted a systematic review of the literature with a meta-analysis of proportions to investigate the comparative effectiveness of different surgical techniques.

RESULTS

A total of 48 publications (1,602 patients) met the eligibility criteria. Vascularized and nonvascularized bone grafts had an estimated union incidence of 92% and 88%, respectively. Distal radius and iliac crest bone grafts had similar union rates (89% and 87%, respectively) but harvesting of iliac crest bone grafts had more complications. Both screw and K-wire fixation had a higher incidence of union (88% and 91%, respectively) than no fixation (79%). No approach was statistically different. Patients fixed with screws were mobilized earlier than those with K-wire fixation.

CONCLUSIONS

Current evidence does not demonstrate a significantly superior method for the treatment of scaphoid nonunion. A multicenter randomized trial would be ideal but the large numbers that would be required may make this unrealistic. We recommend the continued reporting of series with specific assessments and outcome measures to optimize future comparisons in an attempt to determine the best management of scaphoid nonunion.

CLINICAL RELEVANCE

The use of bone grafts and the methods of their fixation for scaphoid nonunion are debated issues in hand and wrist surgery, with multiple methods employed. There is no current consensus on optimal treatment. A meta-analysis of proportions of available data from recent studies was deemed the most appropriate way to assimilate the available evidence with the view to inform surgeons of the optimal treatment according to the evidence base.

Treatment of Scaphoid Waist Nonunion Using Olecranon Bone Graft and Stryker Asnis Micro Cannulated Screw: A Retrospective Study-80 Case Studies and 6 Years of Follow-Up

Background Screw fixation and bone grafting are the gold standard for scaphoid waist nonunion without avascular necrosis. Question/Purpose Assesses the scaphoid waist nonunion healing rate with use of an uncommon cancellous bone graft (olecranon) and an unusual fixation system (Asnis Micro Cannulated Screw System; Stryker Inc., Kalamazoo, MI, USA). Material and Methods A series of 102 consecutive patients were treated for scaphoid waist nonunion (without deformity). Of these, 80 patients subjected to clinical (Modified Mayo Wrist Score (MMWS), Jamar hydraulic dynamometer) and radiographic examination before and after surgery were evaluated. Ipsilateral olecranon cancellous bone graft and the ASNIS Micro 3.0-mm diameter screw, were used. The average follow up was 6 years (min 3; max 10). Results Radiographic consolidation was achieved in 90% of patients; dorsal intercalated segment instability (DISI) deformities were corrected in 71.4% of cases. Ninety percent improved the range of motion of the wrist and grip strength. All patients showed a significant reduction of peak force in the operated hand. In 6.25% we observed clinical and radiographic screw head-trapezium impingement. Twenty-six patients developed a degenerative wrist sign. The MMWS yielded 68 optimal, 8 good, and 4 bad results. Conclusions To treat scaphoid waist nonunions without misalignment, low-profile headed screw and olecranon bone graft allowed a high consolidation rate with positive results to long-term follow-up. The Asnis Micro 3.0 mm diameter screw may be a suitable option for treating scaphoid waist nonunion. Level of Evidence IV.

Arthroscopic Management of Scaphoid Nonunions

The difficulty in healing scaphoid nonunions is challenged further by the dynamic, unstable nature of the fracture-fragment interface. Recently, several investigators have introduced a minimally invasive technique for scaphoid nonunion repair, which has the advantages of minimal morbidity and accurate articular reduction, resulting in less postoperative stiffness and increased functional outcomes. However, failure to recognize the critical steps during minimally invasive surgery can result in incorrect treatment or limit any chances for successful bone repair. We reviewed the selected literature pertinent to arthroscopic techniques in the treatment of scaphoid nonunions. Furthermore, we presented a new arthroscopic approach that can be used in place of traditional formal open exposures in challenging cases of nonunion.

Clinical outcome of scaphoid malunion as a result of scaphoid fracture nonunion surgical treatment: A 5-year minimum follow-up study

BACKGROUND

Although malunion resulting from reconstruction for scaphoid fracture nonunion is a typical complication, there has been little consideration regarding its clinical outcomes.

HYPOTHESIS

The quality of restoration of the scaphoid anatomy may have little effect on clinical outcomes.

MATERIALS AND METHODS

Twenty-five patients with scaphoid fracture nonunion underwent curettage and internal fixation with bone grafting performed by a single surgeon, and they were followed up for a minimum of 5 years. Some of these patients comprised the malunion group if the height/length ratio (H/L ratio) in the most central longitudinal computed tomographic image was more than 0.6. We compared the clinical outcomes of the malunion group with a well-union group based on various clinical scores (Patient Evaluation Measure, Disabilities of the Arm, Shoulder and Hand, modified Mayo wrist scoring system).

RESULTS

The average follow-up period was 81 months (range: 65-110), and 15 cases among the 25 patients were included in the malunion group. There were no statistical differences in the clinical scores between malunions (15 cases) and well unions (10 cases), and there was no correlation between the H/L ratios and the clinical outcomes.

CONCLUSION

The clinical outcomes of malunited scaphoids after reconstruction for scaphoid fractures nonunion did not differ significantly from well-united scaphoids at a minimum 5-year follow-up.

Retrograde percutaneous screw fixation for scaphoid type II non-union in Schernberg zones 2 to 4: a series of 38 cases

Regardless of the treatment used, 25 to 45% of scaphoid fractures do not heal. Open surgery compromises vascularization and destabilizes ligament attachments. The aim of this retrospective study was to assess the value of retrograde percutaneous screw fixation of Alnot stage IIA and IIB scaphoid non-union in Schernberg zones 2 to 4. This series included 38 patients with a mean age of 31 years. Based on the Alnot classification, there were 16 stage IIA non-unions (12 in zone 3 and 4 in zone 2 according to the Schernberg classification) and 22 stage IIB non-unions (9 in zone 3 and 13 in zone 2). The time elapsed between the initial trauma and the surgical treatment was 10 months on average. Percutaneous retrograde fixation was performed with a cannulated 2.7mm compression screw. At 25 months follow-up, 31 of the non-union cases had healed (81.6%), of which 14 were stage IIA (87.5%) and 17 were stage IIB (77.3%), after an average 6.3 months. Average pain was 1.6. The average Quick DASH was 17.3/100. Compared to the opposite side, the average range of motion was 84.8% in flexion, 84.7% in extension, 98.9% in pronation, 96.5% in supination, 96.8% in ulnar deviation and 86.4% in radial deviation. The grip strength was 80.4% of the contralateral side. Seven patients did not heal after screw fixation; four of them healed after additional electromagnetic stimulation and three after addition of a vascularized bone graft. Based on this study's results, stage IIA non-unions can heal with simple retrograde percutaneous screw fixation. The same procedure could be enough for stage IIB non-union cases, however we recommend adding a cancellous bone graft by arthroscopy. Open surgery procedures are preferred when percutaneous procedures have failed.

Scaphoid fracture nonunion: correlation of radiographic imaging, proximal fragment histologic viability evaluation, and estimation of viability at surgery: diagnosis of scaphoid pseudarthrosis

PURPOSE

The purpose of this study was to correlate the pre-operative imaging, vascularity of the proximal pole, and histology of the proximal pole bone of established scaphoid fracture non-union.

METHODS

This was a prospective non-controlled experimental study. Patients were evaluated pre-operatively for necrosis of the proximal scaphoid fragment by radiography, computed tomography (CT) and magnetic resonance imaging (MRI). Vascular status of the proximal scaphoid was determined intra-operatively, demonstrating the presence or absence of puncate bone bleeding. Samples were harvested from the proximal scaphoid fragment and sent for pathological examination. We determined the association between the imaging and intra-operative examination and histological findings.

RESULTS

We evaluated 19 male patients diagnosed with scaphoid nonunion. CT evaluation showed no correlation to scaphoid proximal fragment necrosis. MRI showed marked low signal intensity on T1-weighted images that confirmed the histological diagnosis of necrosis in the proximal scaphoid fragment in all patients. Intra-operative assessment showed that 90% of bones had absence of intra-operative puncate bone bleeding, which was confirmed necrosis by microscopic examination.

CONCLUSIONS

In scaphoid nonunion MRI images with marked low signal intensity on T1-weighted images and the absence of intra-operative puncate bone bleeding are strong indicatives of osteonecrosis of the proximal fragment.

Osteoarthritis of the wrist

This article reviews pathogenesis and treatment of wrist osteoarthritis. Because there is no cure for osteoarthritis, treatment is directed at symptomatic relief. Surgical treatment is reserved for patients who have failed nonoperative modalities. This article reviews the surgical treatment of wrist osteoarthritis with an emphasis on selection of the appropriate procedure. Literature guiding surgical treatment with patient outcomes is reviewed.

Quantification of contralateral differences of the scaphoid: a comparison of bone geometry in three dimensions

The purpose of this study was to accurately quantify contralateral differences of the scaphoid in three-dimensional space to evaluate the feasibility of using the healthy contralateral bone as a reconstruction template in the preoperative planning of complex mal- or nonunions. Three-dimensional surface models of the left and right scaphoids were reconstructed from computed tomography images and compared in 26 individuals. Left-right differences were quantified with respect to volume, surface area, length, and surface-to-surface deviation. The average left-right differences in volume, surface area, and length were 95.4 mm(3) (SD 66.2 mm(3)), 32.7 mm(2) (SD 22.9 mm(32)), and 0.28 mm (SD 0.4 mm), respectively. The average surface-to-surface deviation between the sides was 0.26 mm (SD 0.2 mm). High statistical correlation (Pearson) between the left and the right side was found in all evaluated measures.

Comparative study of the diagnostic value of panoramic and conventional radiography of the wrist in scaphoid fractures

Background

Scaphoid fractures are the most common type of carpal fractures.

Objectives

The aim of the study was to compare the diagnostic value of panoramic and conventional radiographs of the wrist in scaphoid fractures.

Patients and Methods

The panoramic and conventional radiographs of 122 patients with acute and chronic wrist trauma were studied. The radiographs were analyzed and examined by two independent radiologist observers; one physician radiologist and one maxillofacial radiologist. The final diagnosis was made by an orthopedic specialist. Kappa test was used for statistical calculations, inter- and intra-observer agreement and correlation between the two techniques.

Results

Wrist panoramic radiography was more accurate than conventional radiography for ruling out scaphoid fractures. There was an agreement in 85% or more of the cases. Agreement values were higher with better inter and intra observer agreement for panoramic examinations than conventional radiographic examinations.

Conclusion

The panoramic examination of the wrist is a useful technique for the diagnosis and follow-up of scaphoid fractures. Its use is recommended as a complement to conventional radiography in cases with inconclusive findings.

Ilizarov treatment of scaphoid nonunion

INTRODUCTION

This is single centre retrospective review of a consecutive series of patients with scaphoid nonunion (SNU) treated using the Ilizarov technique without bone graft. Fifteen of the original 18 patients were available for clinical and radiological examination at a minimum follow-up of 5 years (range 5-10 years). An evaluation was made of the late functional results, satisfaction scores, residual symptoms, grip strength and the presence of radiocarpal and scaphoid degenerative changes.

METHODS

The series consisted of 15 patients; 14 males; 1 female, with a mean SNU duration of 15.7 months, and a mean age of 23.6 years. Patients with carpal instability, humpback deformity, carpal collapse, avascular necrosis or marked degenerative change, were excluded from this treatment method. Following frame application the treatment consisted of three stages: distraction, compression and immobilisation. The technique is detailed herein.

RESULTS

Radiographic (CT) and clinical bony union was achieved in all 15 patients after a mean of 88 days (70-130 days). Mean modified Mayo wrist scores initially improved from 21 preoperatively to 86 at previous review, and were 96 at a mean follow-up of 81 months (62-120 months), with excellent results in 10, and good results seen in 5 patients. At latest review the mean grip strengths had returned to 96% of the uninjured hand, and 7 patients had regained full strength; mean wrist flexion/extension arc of motion had also continued to improve to 136° from 131°. All patients returned to their pre-injury occupations and levels of activity at a mean of 117 days. Three patients suffered superficial K-wire infections, which resolved with oral antibiotics. One patient continues to suffer intermittent mild aching in the wrist. No patient suffered loss of scaphoid height, humpback deformity, DISI instability or collapse of the regenerate bone.

CONCLUSION

In these selected patients this technique safely achieved bony union without the need to open the SNU site and without the need for bone graft. These patients also had the capacity to continually improve their wrist function beyond 3 years following their treatment.

Vascularized bone grafts for the treatment of carpal bone pathology

Primary bone healing fails to occur in 5-15 % of scaphoid bones that undergo fracture fixation. Untreated, occult fractures result in nonunion up to 12 % of the time. Conventional bone grafting is the accepted management in the treatment algorithm of scaphoid nonunion if the proximal pole is vascularized. Osteonecrosis of the proximal scaphoid pole intuitively suggests a need for transfer of the vascularized bone to the nonunion site. Scaphoid nonunion treatment aims to prevent biological and mechanical subsidence of the involved bone, destabilization of the carpus, and early degenerative changes associated with scaphoid nonunion advanced collapse. Pedicled distal radius and free vascularized bone grafts (VBGs) offer hand surgeons an alternative treatment option in the management of carpal bone nonunion. VBGs are also indicated in the treatment of avascular necrosis of the scaphoid (Preiser's disease), lunate (Kienböck's disease), and capitate. Relative contraindications to pedicled dorsal radius vascularized bone grafting include humpback deformity, carpal instability, or collapse. The free medial femoral condyle bone graft has offered a novel treatment option for the humpback deformity to restore geometry of the carpus, otherwise not provided by pedicled grafts. In general, VBGs are contraindicated in the setting of a carpal bone without an intact cartilaginous shell, in advanced carpal collapse with degenerative changes, and in attempts to salvage small or collapsed bone fragments. Wrist salvage procedures are generally accepted as the more definitive treatment option under such circumstances. This manuscript offers a current review of the techniques and outcomes of VBGs to the carpal bones.