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Maniglio M, Moutinot B, Durand S. Ultrasound-based Measurement of the Intra-scaphoid angle. HAND SURGERY & REHABILITATION 2024:101755. [PMID: 39117061 DOI: 10.1016/j.hansur.2024.101755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2024] [Revised: 07/22/2024] [Accepted: 07/23/2024] [Indexed: 08/10/2024]
Abstract
INTRODUCTION Ultrasound is gaining popularity for diagnosing scaphoid fractures. However, it hasn't been used to assess fracture displacement, such as humpback deformity. We propose a sonographic method to measure the intra-scaphoid angle, potentially serving as an alternative to CT scans for detecting fragment malposition after a scaphoid fracture. METHODS We recruited 11 healthy adult volunteers without wrist pathology and performed bilateral wrist ultrasounds, totaling 22 examinations. Each wrist was splinted at 50 ° extension and fully supinated. Two hand surgeons independently performed the ultrasounds. All images were then evaluated separately by two evaluators. The following measurements were taken: 1. Inter-poles distance (IPD): Distance between the summits of the two scaphoid poles on the palmar cortex. 2. Palmar cortical intra-scaphoid angle (PCISA): Angle between the two summits and the deepest point of the waist on the palmar cortex. Measurements were compared for inter-investigator and inter-evaluator reliability using the intraclass correlation coefficient (ICC). RESULTS The study included four males and seven females, with an average age of 35 years (range 21-56). The mean PCISA was 142 ° (SD 10 °) and the mean IPD was 16.3 mm (SD 2.1 mm). Differences in IPD measurements averaged 0.3 mm (range 0-5.2 mm) among investigators and 1.0 mm (range 0.1-3.8 mm) among evaluators. For PCISA, the differences averaged 4 ° (range 0-17 °) among investigators and 6 ° (range 0-15 °) among evaluators. The ICC for IPD was 0.804 (investigators) and 0.572 (evaluators); for PCISA, it was 0.704 (investigators) and 0.602 (evaluators). CONCLUSION This study presents a cost-effective and accessible sonographic technique to measure the intra-scaphoid angle. Further research is required to assess its effectiveness in scaphoid fractures and compare it to CT-based measurements like the H/L ratio, LISA, and DCA.
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Affiliation(s)
- Mauro Maniglio
- Department of Hand Surgery, Balgrist University Clinic, Zürich, Switzerland; Department of Hand and Plastic Surgery, CHUV Centre Hospitalier Universitaire Vaudois, University Hospital, Lausanne, Switzerland.
| | - Bérénice Moutinot
- Department of Hand Surgery, HUG Hôpitaux Universitaires de Genève, Geneva, Switzerland; Department of Hand and Plastic Surgery, CHUV Centre Hospitalier Universitaire Vaudois, University Hospital, Lausanne, Switzerland.
| | - Sébastien Durand
- Department of Hand and Plastic Surgery, CHUV Centre Hospitalier Universitaire Vaudois, University Hospital, Lausanne, Switzerland.
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Rinaldi A, Pilla F, Chiaramonte I, Pederiva D, Vita F, Schilardi F, Gennaro A, Faldini C. Arthroscopic surgery for scaphoid nonunion: a 10-year systematic literature review. Musculoskelet Surg 2024; 108:125-132. [PMID: 38340306 PMCID: PMC11133090 DOI: 10.1007/s12306-023-00805-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 11/21/2023] [Indexed: 02/12/2024]
Abstract
The purpose of the study was to investigate whether arthroscopic treatment of carpal scaphoid nonunions by osteosynthesis with bone grafting represents a successful surgical technique. This systematic literature review, conducted following the PRISMA guidelines, explores the past 10 years of clinical studies concerning the arthroscopic treatment of scaphoid nonunions. The most relevant keywords were used to search the databases, and the Downs and Black 27-item checklist has been used as quality assessment tool. Twelve papers that meet the premised eligibility criteria have been identified. These studies demonstrate the efficacy of this surgical solution, achieving a postoperative union rate of 96% in the average time of 13.5 weeks. Regardless of the method of synthesis and the origin of the graft used, excellent results were obtained. Patients who underwent this procedure reported a pain reduction of almost 80% compared to the preoperative level, improvement in grip strength close to 40%, and recovery in wrist function during daily activities. Arthroscopy has numerous advantages compared to the open approach. These are technically recognized by the surgeon and by the patient. Some disadvantages include a longer intraoperative time and considerable significant technical difficulty. Arthroscopic treatment of scaphoid nonunion by osteosynthesis with bone graft achieves a 96% union rate of the treated scaphoid with satisfying clinical results.
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Affiliation(s)
- Alberto Rinaldi
- 1St Orthopaedics and Traumatology Clinic, IRCCS Istituto Ortopedico Rizzoli, via Giulio Cesare Pupilli, 1, 40136, Bologna, Italy.
| | - Federico Pilla
- 1St Orthopaedics and Traumatology Clinic, IRCCS Istituto Ortopedico Rizzoli, via Giulio Cesare Pupilli, 1, 40136, Bologna, Italy
| | - Ilaria Chiaramonte
- 1St Orthopaedics and Traumatology Clinic, IRCCS Istituto Ortopedico Rizzoli, via Giulio Cesare Pupilli, 1, 40136, Bologna, Italy
| | - Davide Pederiva
- 1St Orthopaedics and Traumatology Clinic, IRCCS Istituto Ortopedico Rizzoli, via Giulio Cesare Pupilli, 1, 40136, Bologna, Italy
| | - Fabio Vita
- 1St Orthopaedics and Traumatology Clinic, IRCCS Istituto Ortopedico Rizzoli, via Giulio Cesare Pupilli, 1, 40136, Bologna, Italy
| | - Francesco Schilardi
- 1St Orthopaedics and Traumatology Clinic, IRCCS Istituto Ortopedico Rizzoli, via Giulio Cesare Pupilli, 1, 40136, Bologna, Italy
| | - Andrea Gennaro
- 1St Orthopaedics and Traumatology Clinic, IRCCS Istituto Ortopedico Rizzoli, via Giulio Cesare Pupilli, 1, 40136, Bologna, Italy
| | - Cesare Faldini
- 1St Orthopaedics and Traumatology Clinic, IRCCS Istituto Ortopedico Rizzoli, via Giulio Cesare Pupilli, 1, 40136, Bologna, Italy
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McLaughlin K, Jabbar FAA, Kelly LJ, Jovanovic I, Gray MP, Charalambous CP, Harrison JWK. Does correction of carpal malalignment influence the union rate of scaphoid nonunion surgery? J Hand Surg Eur Vol 2024; 49:564-569. [PMID: 37987674 DOI: 10.1177/17531934231212979] [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: 11/22/2023]
Abstract
The aim of this retrospective study was to assess the relation between carpal malalignment correction and radiological union rates in surgery for scaphoid nonunions. A total of 59 scaphoid waist fracture nonunions treated with open reduction and palmar tricortical autograft were divided according to their pre- and postoperative scapholunate (SL) and radiolunate (RL) angles. We found that carpal malalignment failed to correct in 32 of 59 (54.2%) patients despite meticulous surgical technique and placement of an appropriately sized wedge-shaped graft. In total, 43 (72.9%) fractures united at a mean of 4.47 months (range 3-11). Of the 27 fractures with postoperative SL and RL angles within the normal range, 21 united, whereas 22 of the 32 remaining fractures that failed to achieve postoperative angles within the normal range went on to union. The postoperative SL and RL angles were not related to union. Our findings suggest that in scaphoid fracture nonunion surgery, carpal malalignment may not be corrected in a substantial proportion of patients, but such correction may not be essential for bony union. Our findings also show that there is no marked collapse of the scaphoid graft in the early postoperative period. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Kealan McLaughlin
- Gateshead NHS Foundation Trust, Gateshead, UK
- Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | | | - Luke J Kelly
- School of Mathematical Sciences, University College Cork, Cork, Ireland
| | - Iva Jovanovic
- Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | | | - Charalambos P Charalambous
- Blackpool teaching Hospitals NHS Foundation Trust, Blackpool, UK
- School of Medicine, University of Central Lancashire, Preston, UK
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Xiao M, Welch JM, Cohen SA, Kamal RN, Shapiro LM. How Is Scaphoid Malunion Defined: A Systematic Review. Hand (N Y) 2023; 18:38S-45S. [PMID: 34486427 PMCID: PMC10052615 DOI: 10.1177/15589447211038678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Abnormal scaphoid alignment after fracture is used as an indication for fixation. Acceptable alignment after reduction and fixation of scaphoid fractures is not well defined. We systematically reviewed the literature to identify how scaphoid malunion is currently defined and by what parameters. METHODS A systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Multiple databases were searched for studies published in the English language that reported on outcomes after scaphoid malunion and included measurements to define malunions. Radiographic scaphoid measurement parameters were collected. Clinical outcome measures recorded included grip strength, wrist range of motion, and patient-reported outcome measures. Study quality was analyzed using the Methodological Index for Non-Randomized Studies (MINORS) criteria. Descriptive summaries of the studies are presented. RESULTS The initial search yielded 1600 articles. Ten articles (161 participants, 93% males, mean age = 28.3 + 6.3 years, mean MINORS score = 10.2 + 1.6) were included and analyzed. Scaphoid malunion was defined if the lateral intrascaphoid angle (LISA) was >45° (3 articles), LISA >35° (1 article), and height to length ratio >0.6 (3 articles). Four out of 5 studies found no significant associations between patient outcomes and degree of scaphoid malunion measured on imaging. CONCLUSIONS There is a lack of consensus for defining scaphoid malunion on imaging and absence of correlation between findings on imaging and patient outcomes. Future studies defining scaphoid malunion should be appropriately powered, incorporate measures of intrarater and interrater reliabilities for all reported imaging measurements, and utilize validated patient-reported outcome measures to reflect that malunion is associated with inferior outcomes meaningful to patients.
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Affiliation(s)
| | | | | | | | - Lauren M. Shapiro
- Stanford University, Redwood City, CA, USA
- Duke University, Durham, NC, USA
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Putnam J, Pfaff K, Yao J. Scaphoid Malunion: Incidence, Predictors, and Outcomes. J Wrist Surg 2023; 12:40-45. [PMID: 36644719 PMCID: PMC9836771 DOI: 10.1055/s-0042-1751016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 05/17/2022] [Indexed: 01/18/2023]
Abstract
Background Scaphoid malunion is rarely reported. Previous literature has attributed loss of carpal height and degenerative changes to scaphoid malunion, but the percentage of asymptomatic malunions remains unknown. Purpose The authors of this study aim to define predictors of malunion and outcomes associated with scaphoid malunion. Methods Institutional board review was obtained prior to evaluating medical records of patients 18 years and older who were treated for scaphoid fractures and/or nonunion between 2000 and 2020. The following data were collected for each patient: age, gender, fracture location, surgical technique, time to union, and whether malunion resulted. Malunion was defined using a lateral intrascaphoid angle (LISA) >45 degrees and height-to-length ratio (HLR) >60. Pain scores, range of motion (ROM), and secondary surgery were also evaluated. Results Overall, 355 scaphoid injuries, including 196 acute fractures and 159 nonunions, were evaluated in this analysis. Of these, 55 scaphoids (15%) met the definition of malunion. Of these patients, 23% were female. The mean age at the time of injury was 29 years. Nonunion cases were more likely than acute cases to be associated with malunion. Proximal pole fractures were more likely to associated with malunion than waist fractures. When controlling for nonunion and fracture location, malunited scaphoids were not associated with any significant difference in pain score, ROM, or secondary surgery, compared with nonmalunion cases. A total of 10 patients (3.3%) without malunion and 2 patients (3.6%) with malunion went on to a secondary surgery. Final extension/flexion was 67/67 degrees and 56/59 degrees in nonmalunion and malunion groups, respectively, but these differences were not significant. Conclusion Compared with scaphoid injuries that do not result in malunion, scaphoid injuries that heal into malunion have similar outcomes. While scaphoid malunion in a single case or series may be associated with poor outcomes, this study suggests that scaphoid malunions do not have worse functional outcomes. Level of Evidence This is a Level IV study.
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Affiliation(s)
- Jill Putnam
- Stanford University School of Medicine, Redwood City, California
| | - Kayla Pfaff
- Heritage College of Osteopathic Medicine, Ohio University, Athens, Ohio
| | - Jeffrey Yao
- Stanford University School of Medicine, Redwood City, California
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Schriever T, Wilcke M. Residual flexion deformity after scaphoid nonunion surgery: 7-year follow-up study. J Hand Surg Eur Vol 2023; 48:20-26. [PMID: 36165430 DOI: 10.1177/17531934221125355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The clinical implication of a residual flexion deformity following surgery for scaphoid nonunion is unclear. Sixty-three patients who underwent scaphoid nonunion surgery were assessed after a mean of 7 years (range 5-10) to analyse the outcomes based on the presence of residual scaphoid deformity. Primary outcome was Disabilities of the Arm, Shoulder and Hand score. Secondary outcomes were Patient-Rated Wrist Evaluation score, wrist range of motion and strength. Patients were dichotomized to residual deformity or no deformity. Scaphoid deformity was calculated from CT scans based on the median difference between the height-length ratio of the operated versus the uninjured scaphoid. There were no differences between residual deformity (n = 33) and no deformity (n = 30) in any outcome variables, except for wrist extension which was slightly worse in the deformity group. The deformity group had a greater number of radiographic osteoarthritis, but all cases were mild, and osteoarthritis did not correlate to a worse outcome. We conclude that residual scaphoid deformity has no relevant negative impact on mid-term wrist function.Level of evidence: IV.
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Affiliation(s)
- Thorsten Schriever
- Karolinska Institute, Department of Clinical Science and Education, Södersjukhuset, Stockholm, Sweden.,Department of Hand Surgery Södersjukhuset, Stockholm, Sweden
| | - Maria Wilcke
- Karolinska Institute, Department of Clinical Science and Education, Södersjukhuset, Stockholm, Sweden.,Department of Hand Surgery Södersjukhuset, Stockholm, Sweden
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De Bie A, Louis P, Cognet JM. Correction of residual humpback deformity after arthroscopic treatment of scaphoid non-union. Orthop Traumatol Surg Res 2022; 108:103294. [PMID: 35487429 DOI: 10.1016/j.otsr.2022.103294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 11/15/2021] [Accepted: 12/07/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND The aim of this study was to assess residual humpback deformity after arthroscopic treatment of scaphoid non-union. MATERIAL AND METHOD We reviewed the medical records of 47 patients with scaphoid non-union who underwent arthroscopic treatment between 2012 and 2018. Patients who did not receive an intraoperative bone graft were excluded (10 patients), as were those who did not achieve bone union (three patients). The radiographic assessment consisted of pre- and postoperative radiographs and CT-scans. RESULTS The radiolunate angle, scapholunate angle and Youm index were measured. At the final follow-up, the scapholunate angle was 54±8̊ (36-80̊) and the radiolunate angle was 11±7̊ (2-45̊). The scapholunate angle was significantly different between the preoperative measurement and the last follow-up; however, the radiolunate angle and Youm index did not change significantly. CONCLUSION Our study found that arthroscopic treatment of scaphoid non-union with a cancellous bone graft taken from the distal radius results corrects the humpback deformity. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Anaïs De Bie
- SOS Mains Champagne Ardenne, Clinique Courlancy, 38b, rue de Courlancy, 51100 Reims, France
| | - Pascal Louis
- SOS Mains Champagne Ardenne, Clinique Courlancy, 38b, rue de Courlancy, 51100 Reims, France
| | - Jean Michel Cognet
- SOS Mains Champagne Ardenne, Clinique Courlancy, 38b, rue de Courlancy, 51100 Reims, France.
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Gvozdenovic R, Presman B, Larsen MB, Radev DI, Joerring S, Jensen CH. Can CT-Scan Measurements of Humpback Deformity, Dislocation, and the Size of Bony Cysts Predict Union after Surgery for Scaphoid Nonunion? J Wrist Surg 2021; 10:418-429. [PMID: 34631295 PMCID: PMC8490000 DOI: 10.1055/s-0041-1730342] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 04/13/2021] [Indexed: 10/21/2022]
Abstract
Objective Scaphoid fractures are associated with high rates of late- or nonunion after conservative treatment. Nonunion is reported to occur in approximately 10% of all scaphoid fractures. It is known that the union of scaphoid fractures is affected by factors such as location at proximal pole, tobacco smoking, and the time from injury to treatment. Same factors seem to affect the healing after surgery for scaphoid nonunion. While the impact of preoperative humpback deformity on the functional outcome after surgery has been previously reported, the impact of humpback deformity, displacement, and the presence of bony cysts on union rate and time to healing after surgery has not been studied. Purpose The primary purpose of this study is to assess the association of humpback deformity, fragment displacement, and the size of cysts along the fracture line with the union rate and union time, following surgery of scaphoid nonunion. The second purpose of the study is to investigate the interobserver reliability in the evaluation of computed tomography (CT) scans of scaphoid nonunion. Patients and Methods From January 2008 to December 2018, 178 patients were surgically treated in our institution. After exclusion criteria were met, 63 patients with scaphoid delayed- or established nonunion, and preoperative CT scans of high quality (<2mm./ slice), were retrospectively analyzed. There was 58 men and 5 women with a mean age of 30 years (range: 16-72 years). Four orthopaedic surgeons and one radiologist independently analyzed the CT scans. The dorsal cortical angle (DCA), lateral intrascaphoid angle (LISA), the height-to-length ratio, the size of the cysts, and displacement of the fragments were measured. Healing was defined by CT scan, or by conventional X-ray, and status of no pain at clinical examination. Thirty-two of the patients had developed nonunion (>6 months postinjury), while 31 were in a stage of delayed union (3-6 months postinjury). Results Open surgery with cancellous or structural bone graft was the treatment of choice in 49 patients, 8 patients were treated with arthroscopic bone grafting, and 6 patients with delayed union were operated with percutaneous screw fixation, without bone graft. Overall union rate was 86% (54/63) and was achieved after 84 days (12 weeks) (mean). The failure rate and time to healing were not associated with the degree of the humpback deformity, size of the cysts, or displacement of the nonunion in general. However, greater dislocation, and the localization of the nonunion at the scaphoid waist, showed significant influence on the union rate. Dislocation at nonunion site, in the group of the patients who united after surgery, was 2.7 mm (95% confidence interval [CI]: 1.5-3.7), and in the group who did not unite was 4.2 mm (95% CI: 2.9-5.7); p = 0.048). Time from injury to surgery was significantly correlated with time to union ( p < 0.05), but not associated with the union rate ( p < 0.4). Patients treated arthroscopically achieved faster healing (42 days), (standard deviation [SD]: 22.27) as compared with patients treated by open techniques (92 days; SD: 70.86). Agreement among five observers calculated as intraclass correlation coefficient was for LISA: 0.92; for height-to-length ratio: 0.73; for DCA: 0.65; for size of cysts: 0.61; and for displacement in millimeters: 0.24, respectively. Conclusions The degree of humpback deformity and the size of cysts along the fracture line of scaphoid nonunion have no predictive value for the result, neither for the union rate nor the union time after surgery for the scaphoid nonunion. However, larger dislocation of the fragments measured at the scaphoid waist showed lower union rate. Time to healing following surgery is mainly influenced by the time from injury to the surgical treatment and may be influenced by the choice of the surgical technique. Interrater reliability calculation was best with LISA measurements, and worse with the measurements of the dislocation. Level of Evidence This is a Level III, observational, case-control study.
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Affiliation(s)
- Robert Gvozdenovic
- Department of Orthopedics, Hand Surgery Unit, Herlev/Gentofte Copenhagen University Hospital, Hellerup, Denmark
| | - Benjamin Presman
- Department of Orthopedics, Hvidovre Copenhagen University Hospital, Hvidovre, Denmark
| | - Morten Bo Larsen
- Department of Orthopedics, Hand Surgery Unit, Herlev/Gentofte Copenhagen University Hospital, Hellerup, Denmark
| | - Dimitar Ivanov Radev
- Department of Radiology, Bispebjerg/Frederiksberg Copenhagen University Hospital, Copenhagen NV, Denmark
| | - Stig Joerring
- Department of Orthopedics, Hand Surgery Unit, Herlev/Gentofte Copenhagen University Hospital, Hellerup, Denmark
| | - Claus Hjorth Jensen
- Department of Orthopedics, Hand Surgery Unit, Herlev/Gentofte Copenhagen University Hospital, Hellerup, Denmark
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Lee GB, Kim JK, Shin YH. The effect of reformatting axis of computed tomography scans on the measurement of deformities in scaphoid waist nonunion. Orthop Traumatol Surg Res 2021; 107:102980. [PMID: 34102335 DOI: 10.1016/j.otsr.2021.102980] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 09/21/2020] [Accepted: 10/05/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Computed tomography (CT) has been used to understand the deformity of scaphoid nonunion, but no standard protocol for the reformatting of scaphoid CT imaging exists. The purpose of this study was to compare the reliability of measurements of the deformity of scaphoid waist nonunion between CT-scans reformatted in line with the scaphoid long axis and CT-scans reformatted in line with the wrist axis. HYPOTHESIS We hypothesized that CT-scan which was reformatted along the scaphoid long axis is more reliable for understanding the deformity of scaphoid waist nonunion. PATIENTS AND METHODS CT-scans of 28 wrists with a scaphoid waist nonunion were reformatted along both the long axis of the scaphoid and of the wrist. For each set of CT-scans, the nonunion gap in axial, coronal and sagittal series, the intrascaphoid angle, and the height to length ratio were measured. All scans were reviewed twice by three observers and intraclass correlation coefficients (ICCs) for inter- and intraobserver reliability were assessed. RESULTS For the measurement of nonunion gaps and height to length ratio, neither inter- nor intraobserver reliability showed significant differences between the two reformatting scans. However, for the intrascaphoid angle, both inter- (ICC: 0.202 vs. 0.419, p<0.001) and intraobserver (ICC: 0.614 vs. 0.790, p<0.001) reliability were significantly higher on scaphoid axis CT-scan than on wrist axis CT-scan. DISCUSSION In the assessment of deformity in patients with scaphoid waist nonunion, scaphoid axis reformatting CT-scans showed superior reliability for the measurement of intrascaphoid angle than did wrist axis reformatting CT-scans. Although there are several limitations for the correct assessment of all three-dimensional deformity, scaphoid axis reformatting CT-scans could help in assessing the extent of humpback deformity in patients with scaphoid waist nonunion. LEVEL OF EVIDENCE IV; diagnostic.
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Affiliation(s)
- Gwan Bum Lee
- Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jae Kwang Kim
- Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Young Ho Shin
- Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.
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Aruse O, Immerman I, Badir O, Haj ME, Volk I, Luria S. Scaphoid fracture displacement is not correlated with the fracture angle. J Hand Surg Eur Vol 2021; 46:607-615. [PMID: 33794693 DOI: 10.1177/17531934211004434] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Classifications of scaphoid fractures associate the angle of the fracture with its stability. To examine this assumption, we measured acute scaphoid fracture angles and inclinations in relation to different scaphoid axes, using fracture displacement as an indicator of instability. We examined the effect of using different axes on the measurements of angles. CT scans of 133 scaphoid fractures were classified according to the location of the fractures. Using a three-dimensional computer model, we computed four scaphoid axes. For each fracture, we then measured the fracture angle and the direction of the fracture inclination in relation to each one of the axes. We found a correlation between displacement and the angles of proximal fractures using one of these axes (the surface principal component analysis axis). No such correlations were found for waist fractures, which were the majority of fractures. There were significant differences between the measurements made with different axes. The findings indicate that the angle of the fracture and the direction of the fracture inclination are minor factors in the displacement of most scaphoid fractures.Level of evidence: III.
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Affiliation(s)
- Ophir Aruse
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,The Orthopedic Surgery Department, Hadassah Medical Center, Jerusalem, Israel
| | - Igor Immerman
- Department of Orthopaedic Surgery, University of California San Francisco, CA, USA
| | - Omar Badir
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,The Orthopedic Surgery Department, Hadassah Medical Center, Jerusalem, Israel
| | - Madi El Haj
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,The Orthopedic Surgery Department, Hadassah Medical Center, Jerusalem, Israel
| | - Ido Volk
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,The Orthopedic Surgery Department, Hadassah Medical Center, Jerusalem, Israel
| | - Shai Luria
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,The Orthopedic Surgery Department, Hadassah Medical Center, Jerusalem, Israel
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11
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Guldbrandsen CW, Radev DI, Gvozdenovic R. Normal ranges for measurements of the scaphoid bone from sagittal computed tomography images. J Hand Surg Eur Vol 2021; 46:594-599. [PMID: 33459143 PMCID: PMC8226418 DOI: 10.1177/1753193420987522] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
This study aimed to determine normal values of three parameters commonly used to determine malunion by investigating intact scaphoids on sagittal computed tomography images from healthy individuals. We analysed 62 normal scaphoids and found the mean height-length ratio, lateral intrascaphoid angle and dorsal cortical angle to be 0.58, 27° and 128°, respectively. These measurements had good-to-excellent, poor-to-moderate and moderate-to-good inter- and intra-rater reliabilities, respectively. This study provides information on normal parameters of the scaphoid that may inform clinical decision making when assessing malunion. We suggest that the lateral intrascaphoid angle should be used with great caution as a measure of deformity.Level of evidence: III.
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Affiliation(s)
- Cæcilie W. Guldbrandsen
- Department of Hand Surgery, Herlev/Gentofte
University Hospital of Copenhagen, Hellerup, Denmark,Cæcilie W. Guldbrandsen, Department of Orthopedic
Surgery, Hand Surgery Unit, Herlev/Gentofte University Hospital, Gentofte Hospitalsvej 17,
st., 2900 Hellerup, Denmark.
| | - Dimitar I. Radev
- Department of Radiology, Bispebjerg and
Frederiksberg Hospital, Copenhagen, Denmark
| | - Robert Gvozdenovic
- Department of Hand Surgery, Herlev/Gentofte
University Hospital of Copenhagen, Hellerup, Denmark
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Dias J, Brealey S, Cook L, Fairhurst C, Hinde S, Leighton P, Choudhary S, Costa M, Hewitt C, Hodgson S, Jefferson L, Jeyapalan K, Keding A, Northgraves M, Palmer J, Rangan A, Richardson G, Taub N, Tew G, Thompson J, Torgerson D. Surgical fixation compared with cast immobilisation for adults with a bicortical fracture of the scaphoid waist: the SWIFFT RCT. Health Technol Assess 2020; 24:1-234. [PMID: 33109331 PMCID: PMC7681317 DOI: 10.3310/hta24520] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Scaphoid fractures account for 90% of carpal fractures and occur predominantly in young men. Immediate surgical fixation of this fracture has increased. OBJECTIVE To compare the clinical effectiveness and cost-effectiveness of surgical fixation with cast treatment and early fixation in adults with scaphoid waist fractures that fail to unite. DESIGN Multicentre, pragmatic, open-label, parallel two-arm randomised controlled trial with an economic evaluation and a nested qualitative study. SETTING Orthopaedic departments of 31 hospitals in England and Wales recruited from July 2013, with final follow-up in September 2017. PARTICIPANTS Adults (aged ≥ 16 years) presenting within 2 weeks of injury with a clear, bicortical fracture of the scaphoid waist on plain radiographs. INTERVENTIONS Early surgical fixation using Conformité Européenne-marked headless compression screws. Below-elbow cast immobilisation for 6-10 weeks and urgent fixation of confirmed non-union. MAIN OUTCOME MEASURES The primary outcome and end point was the Patient-Rated Wrist Evaluation total score at 52 weeks, with a clinically relevant difference of 6 points. Secondary outcomes included Patient-Rated Wrist Evaluation pain and function subscales, Short Form questionnaire 12-items, bone union, range of movement, grip strength, complications and return to work. RESULTS The mean age of 439 participants was 33 years; 363 participants were male (83%) and 269 participants had an undisplaced fracture (61%). The primary analysis was on 408 participants with valid Patient-Rated Wrist Evaluation outcome data for at least one post-randomisation time point (surgery, n = 203 of 219; cast, n = 205 of 220). There was no clinically relevant difference in the Patient-Rated Wrist Evaluation total score at 52 weeks: the mean score in the cast group was 14.0 (95% confidence interval 11.3 to 16.6) and in the surgery group was 11.9 (95% confidence interval 9.2 to 14.5), with an adjusted mean difference of -2.1 in favour of surgery (95% confidence interval -5.8 to 1.6; p = 0.27). The non-union rate was low (surgery group, n = 1; cast group, n = 4). Eight participants in the surgery group had a total of 11 reoperations and one participant in the cast group required a reoperation for non-union. The base-case economic analysis at 52 weeks found that surgery cost £1295 per patient more (95% confidence interval £1084 to £1504) than cast treatment. The base-case analysis of a lifetime-extrapolated model confirmed that the cast treatment pathway was more cost-effective. The nested qualitative study identified patients' desire to have a 'sense of recovering', which surgeons should address at the outset. LIMITATION There were 17 participants who had initial cast treatment and surgery for confirmed non-union, which in 14 cases was within 6 months from randomisation and in three cases was after 6 months. Three of the four participants in the cast group who had a non-union at 52 weeks were not offered surgery. CONCLUSIONS Adult patients with an undisplaced or minimally displaced scaphoid waist fracture should have cast immobilisation and suspected non-unions immediately confirmed and urgently fixed. Patients should be followed up at 5 years to investigate the effect of partial union, degenerative arthritis, malunion and screw problems on their quality of life. TRIAL REGISTRATION Current Controlled Trials ISRCTN67901257. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 52. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Joseph Dias
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Stephen Brealey
- Alcuin Research Resource Centre Building, Department of Health Sciences, University of York, York, UK
| | - Liz Cook
- Alcuin Research Resource Centre Building, Department of Health Sciences, University of York, York, UK
| | - Caroline Fairhurst
- Alcuin Research Resource Centre Building, Department of Health Sciences, University of York, York, UK
| | | | - Paul Leighton
- School of Medicine, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Surabhi Choudhary
- Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Matthew Costa
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Kadoorie Centre, John Radcliffe Hospital, Oxford, UK
| | - Catherine Hewitt
- Alcuin Research Resource Centre Building, Department of Health Sciences, University of York, York, UK
| | - Stephen Hodgson
- Department of Orthopaedic Surgery, Bolton NHS Foundation Trust, Royal Bolton Hospital, Bolton, UK
| | - Laura Jefferson
- Alcuin Research Resource Centre Building, Department of Health Sciences, University of York, York, UK
- Department of Health Sciences, University of York, York, UK
| | | | - Ada Keding
- Alcuin Research Resource Centre Building, Department of Health Sciences, University of York, York, UK
| | - Matthew Northgraves
- Alcuin Research Resource Centre Building, Department of Health Sciences, University of York, York, UK
| | - Jared Palmer
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Amar Rangan
- Alcuin Research Resource Centre Building, Department of Health Sciences, University of York, York, UK
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | | | - Nicholas Taub
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Garry Tew
- Alcuin Research Resource Centre Building, Department of Health Sciences, University of York, York, UK
- Department of Sport, Exercise and Rehabilitation, Northumbria University, Newcastle upon Tyne, UK
| | - John Thompson
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - David Torgerson
- Alcuin Research Resource Centre Building, Department of Health Sciences, University of York, York, UK
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Seltser A, Suh N, Chambers SB, MacDermid JC, Grewal R. Scaphoid Malunion Clinical and Radiographic Outcomes at a Minimum of 4 Years Follow-Up. J Hand Surg Am 2020; 45:883.e1-883.e7. [PMID: 32534723 DOI: 10.1016/j.jhsa.2020.04.002] [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: 04/06/2019] [Revised: 02/28/2020] [Accepted: 04/02/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the radiographic and clinical outcomes of patients with scaphoid malunion after acute fracture at a mean of 7 years after injury. METHODS Patients with scaphoid malunion were identified from a departmental database of acute scaphoid fractures. Patients with a scaphoid height-to-length ratio greater than 0.6 on final follow-up computed tomography (CT) scan were considered malunited. These patients were contacted to return for CT imaging and clinical assessment. A total of 22 patients were included (4 females and 18 males). Average age of the group was 41 years (range, 16-64 years) and average length of follow-up was 7.4 years (range, 4.4-11.8 years) after injury. RESULTS Ten patients who underwent CT imaging demonstrated arthritic changes at the radial styloid, scaphoid fossa, or scaphotrapeziotrapezoid joint(s). Despite this, patients had good clinical function that was not significantly different compared with the uninjured side. Patients reported minimal pain and disability based on patient-reported outcome measures, and there was a moderate correlation between passive range of motion and height-to-length ratio. CONCLUSIONS Nearly half of all patients with malunited acute scaphoid fractures demonstrated radiographic findings of early arthritis on CT imaging but overall good clinical results on midterm follow-up. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic IV.
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Affiliation(s)
- Anna Seltser
- Department of Surgery, London, Ontario, Canada; Roth-McFarlane Hand and Upper Limb Centre, St Joseph's Health Care, London, Ontario, Canada
| | - Nina Suh
- Department of Surgery, London, Ontario, Canada.
| | - Spencer B Chambers
- Department of Plastic and Reconstructive Surgery, London, Ontario, Canada
| | - Joy C MacDermid
- School of Physical Therapy, University of Western Ontario, London, Ontario, Canada; Roth-McFarlane Hand and Upper Limb Centre, St Joseph's Health Care, London, Ontario, Canada
| | - Ruby Grewal
- Department of Surgery, London, Ontario, Canada
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The Impact of Scaphoid Malunion on Radioscaphoid Joint Contact: A Computational Analysis. J Hand Surg Am 2020; 45:610-618.e1. [PMID: 32220491 DOI: 10.1016/j.jhsa.2020.01.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 12/02/2019] [Accepted: 01/24/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE The clinical relevance of scaphoid malunion is controversial because the biomechanical sequelae remain poorly understood. In this computational study, the effect of increasing scaphoid malunion on radioscaphoid joint contact was assessed. METHODS Six computational wrist models of active wrist flexion-extension were used to examine 6 scaphoid malunions of varying severities. The malunions were computationally created using 3-dimensional imaging software. Each scaphoid was shortened at the waist by 2 mm to simulate fracture comminution and the distal pole was angulated volarly from 15° to 55° in 10° intervals to create a total of 6 scaphoid malunion models per specimen. Each malunion model was then assessed at 3 wrist positions: neutral, 40° flexion, and 40° extension. The radioscaphoid contact area, as well as the contact centroid, was calculated. RESULTS There was a statistically significant association between malunion severity and a wider area of contact at the radiocar: pal joint. The centroid of this radioscaphoid contact area also moved in an ulnar direction for all tested wrist positions. In the extended wrist position, the centroid also moved volarly. CONCLUSIONS In this computational model, the amount of radioscaphoid joint contact was significantly increased with progressive scaphoid malunion severity. Furthermore, the position of the contact centroid had a significant change in position in the ulnar direction in all wrist positions with increasing scaphoid malunion. The clinical importance of this contact is yet to be elucidated, but this computational model serves as a basis for understanding the biomechanical consequences of scaphoid humpback deformities. CLINICAL RELEVANCE This study provides a computational analysis examining changes at the radioscaphoid joint that may occur within the wrist with the scaphoid malunited.
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Seltser A, Suh N, MacDermid JC, Grewal R. The Natural History of Scaphoid Fracture Malunion: A Scoping Review. J Wrist Surg 2020; 9:170-176. [PMID: 32257621 PMCID: PMC7113010 DOI: 10.1055/s-0039-1693658] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Accepted: 06/06/2019] [Indexed: 10/26/2022]
Abstract
Background A scaphoid malunion occurs when a scaphoid fracture heals in a nonanatomic position or when the fracture is fixed without correction of the sagittal angular deformity. Although altered carpal mechanics and early osteoarthritis have been suggested as natural sequelae, the natural history and clinical outcomes are debatable. Purposes The purpose of this study is to review and summarize the available literature regarding clinical, functional, and radiographic outcomes of patients with scaphoid malunion. Methods A systematic search of the MEDLINE/PubMed, EMBASE, Cochrane Library, and Web of Science was performed to identify published studies concerning the clinical and radiological results of scaphoid malunion following either acute scaphoid fracture or surgically treated nonunions. Results Five publications with a total of 83 malunions were included in the final synthesis. The diagnosis of malunion was based on computed tomography by calculating the lateral intrascaphoid angle (threshold of 35 or 45 degrees) or height/length ratio (threshold of 0.6). Self-reported and clinical evaluation techniques varied between the studies and direct comparison was not possible between the different outcome measures. Most patients demonstrated arthritic changes; however, correlation with pain and functional results was not always present. Conclusions This scoping review confirmed that patients with malunited scaphoids seem to have higher likelihood of post traumatic arthritis. However, clinical implications remain uncertain and better methods for assessing and defining scaphoid deformity are required.
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Affiliation(s)
- Anna Seltser
- Department of Surgery, University of Western Ontario, London, Ontario, Canada
- Roth-McFarlane Hand and Upper Limb Center, St. Joseph's Hospital, London, Ontario, Canada
| | - Nina Suh
- Department of Surgery, University of Western Ontario, London, Ontario, Canada
- Roth-McFarlane Hand and Upper Limb Center, St. Joseph's Hospital, London, Ontario, Canada
| | - Joy C. MacDermid
- School of Physical Therapy, University of Western Ontario, London, Ontario, Canada
- Clinical Research Lab, Roth-McFarlane Hand and Upper Limb Centre, St Joseph's Health Centre, London, Ontario, Canada
| | - Ruby Grewal
- Department of Surgery, University of Western Ontario, London, Ontario, Canada
- Roth-McFarlane Hand and Upper Limb Center, St. Joseph's Hospital, London, Ontario, Canada
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16
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Schormans PMJ, Schots JPM, Weijers RE, Loeffen DV, Poeze M, Hannemann PFW. Multiplanar reformation computed tomography for carpal malalignment. J Hand Surg Eur Vol 2019; 44:1049-1055. [PMID: 31426709 DOI: 10.1177/1753193419869193] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Correct interpretation of scaphoid axial length and carpal malalignment is difficult owing to the complex geometry of the scaphoid. Traditional measurements, such as the scapholunate angle and radiolunate angle, have shown limited reproducibility. To improve the assessment of these measurements, we used multiplanar reformation computed tomography with added average intensity projection. Four measurements for scaphoid morphology and carpal alignment were independently measured by four observers on computed tomography scans of 39 consecutive patients who were treated conservatively for scaphoid fracture. Fleiss's kappa for categorical results showed substantial agreement for the measurements of the scapholunate and radiolunate angles. Intraclass correlation coefficients were significant for measurements of the axial length, scapholunate angle and radiolunate angle. Our results suggest that multiplanar reformation computed tomography with added average intensity projection is a reliable technique for assessment of scaphoid morphology and carpal alignment. Level of evidence: II.
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Affiliation(s)
- Philip M J Schormans
- Department of Trauma Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Judith P M Schots
- Department of Trauma Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - René E Weijers
- Department of Radiology, Maastricht University Medical Centre, Maastricht The Netherlands
| | - Daan V Loeffen
- Department of Radiology, Maastricht University Medical Centre, Maastricht The Netherlands
| | - Martijn Poeze
- Department of Trauma Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Pascal F W Hannemann
- Department of Trauma Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
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Abstract
Successful bone union is only a portion of scaphoid fracture management. Malunion is possible and can alter wrist kinematics, potentially causing wrist pain and accelerated degeneration. Evaluation of scaphoid malunion begins with adequate imaging and understanding of deformity. Treatment includes nonoperative management, reconstruction, or salvage options. Correction of malunion can be obtained with an osteotomy and the use of structural graft to recreate anatomy and restore normal carpal motion. Clinical improvement of symptomatic scaphoid malunion can be reliably obtained with reconstruction, although the natural history and role for intervention in asymptomatic malunions remains unclear.
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18
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Kim JP, Seo JB. Editorial Commentary: The Practical Goal of Arthroscopic Osteosynthesis for the Treatment of Unstable Scaphoid Nonunion. Arthroscopy 2018; 34:2819-2820. [PMID: 30286881 DOI: 10.1016/j.arthro.2018.07.040] [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: 07/26/2018] [Accepted: 07/30/2018] [Indexed: 02/02/2023]
Abstract
Arthroscopic reduction with osteosynthesis using bone grafting has become a successful alternative to open techniques for the treatment of chronically unstable scaphoid nonunions. Several studies have demonstrated that arthroscopic techniques are safe and reproducible in addition to causing less soft tissue damage and providing promising short- and mid-term results. However, these techniques have limitations in restoring normal carpal alignment, especially in patients with unstable scaphoid nonunion and carpal collapse deformities, although this does not affect the recovery of clinical function. Therefore, the practical goal of arthroscopic technique should be kept in mind when treating unstable scaphoid nonunions.
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Oh WT, Kang HJ, Chun YM, Koh IH, Lee YJ, Choi YR. Retrospective Comparative Outcomes Analysis of Arthroscopic Versus Open Bone Graft and Fixation for Unstable Scaphoid Nonunions. Arthroscopy 2018; 34:2810-2818. [PMID: 30173911 DOI: 10.1016/j.arthro.2018.04.024] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 04/23/2018] [Accepted: 04/25/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare union rates and clinical and radiologic outcomes after arthroscopic and open bone grafting and internal fixation for unstable scaphoid nonunions. METHODS Between March 2009 and November 2014, patients with unstable scaphoid nonunion underwent arthroscopic (group A) or open (group O) bone grafting and internal fixation. One senior surgeon alternatively performed either arthroscopic or open osteosynthesis for the same surgical indications. Visual analog scale score, grip strength, active range of motion, Mayo wrist score (MWS), and Disabilities of Arm, Shoulder, and Hand score were assessed preoperatively and postoperatively. Union was determined by computed tomography 8 to 10 weeks postoperatively with bridging trabecula at the nonunion site. Scapholunate angle (SLA), radiolunate angle (RLA), and lateral intrascaphoid angle (LISA), plus height/length ratio (HLR) served to gauge carpal bone alignment in preoperative and postoperative radiographs. Those outcomes of patients with carpal collapse deformities, who met following conditions; (1) LISA of >45° or HLR of >0.65 on computed tomography images or (2) SLA of >60° or RLA of >10° on plain radiographs, were also compared. RESULTS Overall, 62 patients qualified for study (group A, 28; group O, 34). Union rates did not differ by patient subset (group A, 96.4%; group O, 97.1%; P ≒ 1); and visual analog scale score, grip strength, range of motion, Mayo Wrist Score, and Disabilities of Arm, Shoulder, and Hand scores were similar at last follow-up. In radiographic assessments, SLA, RLA, and LISA were similar, whereas scaphoid HLR excelled through open technique (group A, 0.59 ± 0.07; group O, 0.55 ± 0.05; P = .002). Subgroup analysis of patients with carpal collapse deformities (group A, 9; group O, 14) showed that all radiographic measures in group A (vs group O) reflected lesser correction (SLA, 56.7° ± 7.3° vs 49.2°±9.1° [P = .049]; RLA, 9.2° ± 2.0° vs 5.7° ± 3.0° [P = .005]; LISA, 34.8° ± 4.8° vs 25.6° ± 13.0° [P = .028]; HLR, 0.66 ± 0.04 vs 0.54 ± 0.07 [P < .001]). CONCLUSIONS Arthroscopic and open bone grafting and internal fixation in treating unstable scaphoid nonunions, did not show any significant differences in clinical and radiologic outcomes at the minimum of 2 years after operation. In scaphoid nonunions with carpal collapse deformities, open bone grafting restored better carpal alignment than arthroscopic bone grafting, although there were no differences in clinical outcomes between the 2 techniques. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Won-Taek Oh
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Ho-Jung Kang
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Yong-Min Chun
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Il-Hyun Koh
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Yong-Jun Lee
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Yun-Rak Choi
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea.
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Ten Berg PWL, de Roo MGA, Maas M, Strackee SD. Is there a trend in CT scanning scaphoid nonunions for deformity assessment?-A systematic review. Eur J Radiol 2017. [PMID: 28629558 DOI: 10.1016/j.ejrad.2017.03.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE The effect of scaphoid nonunion deformity on wrist function is uncertain due to the lack of reliable imaging tools. Advanced three-dimensional (3-D) computed tomography (CT)-based imaging techniques may improve deformity assessment by using a mirrored image of the contralateral intact wrist as anatomic reference. The implementation of such techniques depends on the extent to which conventional CT is currently used in standard practice. The purpose of this systematic review of medical literature was to analyze the trend in CT scanning scaphoid nonunions, either unilaterally or bilaterally. MATERIALS AND METHODS Using Medline and Embase databases, two independent reviewers searched for original full-length clinical articles describing series with at least five patients focusing on reconstructive surgery of scaphoid nonunions with bone grafting and/or fixation, from the years 2000-2015. We excluded reports focusing on only nonunions suspected for avascular necrosis and/or treated with vascularized bone grafting, as their workup often includes magnetic resonance imaging. For data analysis, we evaluated the use of CT scans and distinguished between uni- and bilateral, and pre- and postoperative scans. RESULTS Seventy-seven articles were included of which 16 were published between 2000 and 2005, 19 between 2006 and 2010, and 42 between 2011 and 2015. For these consecutive intervals, the rates of articles describing the use of pre- and postoperative CT scans increased from 13%, to 16%, to 31%, and from 25%, to 32%, to 52%, respectively. Hereof, only two (3%) articles described the use of bilateral CT scans. CONCLUSION There is an evident trend in performing unilateral CT scans before and after reconstructive surgery of a scaphoid nonunion. To improve assessment of scaphoid nonunion deformity using 3-D CT-based imaging techniques, we recommend scanning the contralateral wrist as well.
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Affiliation(s)
- Paul W L Ten Berg
- Department of Plastic, Reconstructive, and Hand Surgery, Academic Medical Center, University of Amsterdam, Room G4-226, Meibergdreef 9, 1105, Amsterdam, AZ, The Netherlands
| | - Marieke G A de Roo
- Department of Plastic, Reconstructive, and Hand Surgery, Academic Medical Center, University of Amsterdam, Room G4-226, Meibergdreef 9, 1105, Amsterdam, AZ, The Netherlands
| | - Mario Maas
- Department of Radiology, Academic Medical Center, University of Amsterdam, Room G1-211, Meibergdreef 9, 1105 Amsterdam, AZ, The Netherlands
| | - Simon D Strackee
- Department of Plastic, Reconstructive, and Hand Surgery, Academic Medical Center, University of Amsterdam, Room G4-226, Meibergdreef 9, 1105, Amsterdam, AZ, The Netherlands
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Kim JH, Lee KH, Lee BG, Lee CH, Kim SJ, Choi WS. Dorsal intercalated segmental instability associated with malunion of a reconstructed scaphoid. J Hand Surg Eur Vol 2017; 42:240-245. [PMID: 27920391 DOI: 10.1177/1753193416680133] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
UNLABELLED We analysed scaphoid deformity as a result of surgical treatment of scaphoid fracture nonunion and assessed the deformity associated with a dorsal intercalated segmental instability pattern of carpal malalignment. A total of 45 patients who were treated for scaphoid fracture nonunion were included in the study. The height-to-length ratio of the scaphoid was measured on computed tomographic images and used to assess scaphoid deformity. Carpal malalignment was quantified based on the radio-lunate angle. A correlation analysis between the height-to-length ratio and the radio-lunate angle was performed. Dorsal intercalated segmental instability was defined as a radio-lunate angle >15°, and a receiver operating curve analysis was used to calculate the cutoff height-to-length ratio that can be accompanied with dorsal intercalated segmental instability. Extension of the lunate increases in proportion to the flexion deformity of the scaphoid; dorsal intercalated segmental instability can occur if the height-to-length ratio of the scaphoid is >0.73. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- J-H Kim
- 1 Department of Orthopaedic Surgery, Seonam University College of Medicine, Goyang, Korea
| | - K-H Lee
- 2 Department of Orthopaedic Surgery, Hanyang University College of Medicine, Seoul, Korea
| | - B G Lee
- 2 Department of Orthopaedic Surgery, Hanyang University College of Medicine, Seoul, Korea
| | - C-H Lee
- 3 Department of Orthopaedic Surgery, Eulji University College of Medicine, Seoul, Korea
| | - S-J Kim
- 4 Department of Orthopaedic Surgery, Hanil General Hospital, Seoul, Korea
| | - W-S Choi
- 5 Department of Orthopaedic Surgery, Ajou University School of Medicine, Suwon, Korea
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Cognet JM, Louis P, Martinache X, Schernberg F. Arthroscopic grafting of scaphoid nonunion – surgical technique and preliminary findings from 23 cases. HAND SURGERY & REHABILITATION 2017; 36:17-23. [DOI: 10.1016/j.hansur.2016.11.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Revised: 11/16/2016] [Accepted: 11/18/2016] [Indexed: 10/20/2022]
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Tait MA, Bracey JW, Gaston RG. Acute Scaphoid Fractures: A Critical Analysis Review. JBJS Rev 2016; 4:01874474-201609000-00003. [PMID: 27760075 DOI: 10.2106/jbjs.rvw.15.00073] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Nondisplaced scaphoid fractures can be effectively treated nonoperatively, with union rates approaching or, in some series, exceeding the rates attained with operative intervention. The evidence supports equal outcomes when using a short arm or long arm cast for the closed treatment of nondisplaced scaphoid fractures. Also, equivalent outcomes have been demonstrated with or without a thumb spica component to the cast. Operative intervention is the recommended treatment for displaced scaphoid fractures. Advanced imaging should be obtained if clinical suspicion is present for a scaphoid fracture with negative radiographs more than 2 weeks after the injury. In some settings, it may even be more cost-effective to obtain advanced imaging sooner.
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Affiliation(s)
- Mark A Tait
- OrthoCarolina Hand Center, Charlotte, North Carolina
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Dias J, Brealey S, Choudhary S, Cook L, Costa M, Fairhurst C, Hewitt C, Hodgson S, Jefferson L, Jeyapalan K, Keding A, Leighton P, Rangan A, Richardson G, Rothery C, Taub N, Thompson J, Torgerson D. Scaphoid Waist Internal Fixation for Fractures Trial (SWIFFT) protocol: a pragmatic multi-centre randomised controlled trial of cast treatment versus surgical fixation for the treatment of bi-cortical, minimally displaced fractures of the scaphoid waist in adults. BMC Musculoskelet Disord 2016; 17:248. [PMID: 27260639 PMCID: PMC4893284 DOI: 10.1186/s12891-016-1107-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 05/28/2016] [Indexed: 12/22/2022] Open
Abstract
Background A scaphoid fracture is the most common type of carpal fracture affecting young active people. The optimal management of this fracture is uncertain. When treated with a cast, 88 to 90 % of these fractures unite; however, for the remaining 10-12 % the non-union almost invariably leads to arthritis. The alternative is surgery to fix the scaphoid with a screw at the outset. Methods/Design We will conduct a randomised controlled trial (RCT) of 438 adult patients with a “clear” and “bicortical” scaphoid waist fracture on plain radiographs to evaluate the clinical effectiveness and cost-effectiveness of plaster cast treatment (with fixation of those that fail to unite) versus early surgical fixation. The plaster cast treatment will be immobilisation in a below elbow cast for 6 to 10 weeks followed by mobilisation. If non-union is confirmed on plain radiographs and/or Computerised Tomogram at 6 to 12 weeks, then urgent surgical fixation will be performed. This is being compared with immediate surgical fixation with surgeons using their preferred technique and implant. These treatments will be undertaken in trauma units across the United Kingdom. The primary outcome and end-point will be the Patient Rated Wrist Evaluation (a patient self-reported assessment of wrist pain and function) at 52 weeks and also measured at 6, 12, 26 weeks and 5 years. Secondary outcomes include an assessment of radiological union of the fracture; quality of life; recovery of wrist range and strength; and complications. We will also qualitatively investigate patient experiences of their treatment. Discussion Scaphoid fractures are an important public health problem as they predominantly affect young active individuals in the more productive working years of their lives. Non-union, if untreated, can lead to arthritis which can disable patients at a very young age. There is a rapidly increasing trend for immediate surgical fixation of these fractures but there is insufficient evidence from existing RCTs to support this. The SWIFFT Trial is a rigorously designed and adequately powered study which aims to contribute to the evidence-base to inform clinical decisions for the treatment of this common fracture in adults. Trial registration The trial is registered with the International Standard Randomised Controlled Trial Register (ISRCTN67901257). Date registration assigned was 13/02/2013.
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Affiliation(s)
- Joseph Dias
- AToMS - Academic Team of Musculoskeletal Surgery, Undercroft (nr Ward 28), University Hospitals of Leicester NHS Trust, Leicester General Hospital, Gwendolen Road, Leicester, LE5 4PW, UK.
| | - Stephen Brealey
- York Trials Unit, Department of Health Sciences, University of York, Heslington, York, YO10 5DD, UK
| | - Surabhi Choudhary
- Department of Radiology, University Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham, B15 2WB, UK
| | - Liz Cook
- York Trials Unit, Department of Health Sciences, University of York, Heslington, York, YO10 5DD, UK
| | - Matthew Costa
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, The Kadoorie Centre, John Radcliffe Hospital, Oxford, OX3 9DU, UK
| | - Caroline Fairhurst
- York Trials Unit, Department of Health Sciences, University of York, Heslington, York, YO10 5DD, UK
| | - Catherine Hewitt
- York Trials Unit and NIHR RDS YH, Department of Health Sciences, Faculty of Science, University of York, ARRC Building, Heslington, York, YO10 5DD, UK
| | - Stephen Hodgson
- Bolton NHS Foundation Trust, Trust HQ, Royal Bolton Hospital, 1st Floor, Minerva Road, Farnworth, Bolton, BL4 0JR, UK
| | - Laura Jefferson
- York Trials Unit, Department of Health Sciences, University of York, Heslington, York, YO10 5DD, UK
| | - Kanagaratnam Jeyapalan
- Department of Diagnostic Radiology, University Hospitals of Leicester, The Glenfield Hospital, Groby Road, Leicester, LE3 9QP, UK
| | - Ada Keding
- York Trials Unit, Department of Health Sciences, University of York, Heslington, York, YO10 5DD, UK
| | - Paul Leighton
- School of Medicine, University of Nottingham, Nottingham Health Science Partners, C-Floor South Block, Queens Medical Centre, Nottingham, NG7 2UH, UK
| | - Amar Rangan
- South Tees Hospitals NHS Foundation Trust, The James Cook University Hospital, Marton Road, Middlesbrough, TS4 3BW, UK
| | - Gerry Richardson
- Centre for Health Economics, University of York, Heslington, York, YO10 5DD, UK
| | - Claire Rothery
- Centre for Health Economics, University of York, Heslington, York, YO10 5DD, UK
| | - Nicholas Taub
- Department of Health Sciences & NIHR Research Design Service for the East Midlands, University of Leicester, Centre for Medicine, University Road, Leicester, LE1 7RH, UK
| | - John Thompson
- Department of Health Sciences, College of Medicine, Biological Sciences and Psychology, University of Leicester, Centre for Medicine, University Road, Leicester, LE1 7RH, UK
| | - David Torgerson
- York Trials Unit and NIHR RDS YH, Department of Health Sciences, Faculty of Science, University of York, ARRC Building, Heslington, York, YO10 5DD, UK
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Three-Dimensional Assessment of Bilateral Symmetry of the Scaphoid: An Anatomic Study. BIOMED RESEARCH INTERNATIONAL 2015; 2015:547250. [PMID: 26413532 PMCID: PMC4564638 DOI: 10.1155/2015/547250] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Revised: 03/20/2015] [Accepted: 03/20/2015] [Indexed: 11/20/2022]
Abstract
Preoperative 3D CT imaging techniques provide displacement analysis of the distal scaphoid fragment in 3D space, using the matched opposite scaphoid as reference. Its accuracy depends on the presence of anatomical bilateral symmetry, which has not been investigated yet using similar techniques. Our purpose was to investigate symmetry by comparing the relative positions of distal and proximal poles between sides. We used bilateral CT scans of 19 adult healthy volunteers to obtain 3D scaphoid models. Left proximal and distal poles were matched to corresponding mirrored right sides. The left-to-right positional differences between poles were quantified in terms of three translational and three rotational parameters. The mean (SD) of ulnar, dorsal, and distal translational differences of distal poles relative to proximal poles was 0.1 (0.6); 0.4 (1.2); 0.2 (0.6) mm and that of palmar rotation, ulnar deviation, and pronation differences was −1.1 (4.9); −1.5 (3.3); 1.0 (3.7)°, respectively. These differences did not significantly differ from zero and thus were not biased to left or right side. We proved that, on average, the articular surfaces of scaphoid poles were symmetrically aligned in 3D space. This suggests that the contralateral scaphoid can serve as reference in corrective surgery. No level of evidence is available.
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26
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Abstract
This article reviews the most common complications associated with the management of carpal fractures. Discussion focuses on the recognition of commonly "missed" fractures and fracture patterns and the negative sequelae that can result from these delayed diagnoses. The pitfalls of conservative treatment of specific carpal fractures are reviewed, and the most common complications resulting from the operative management of carpal injuries are described.
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Affiliation(s)
- R Glenn Gaston
- OrthoCarolina, 1915 Randolph Road, Charlotte, NC 28207, USA.
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27
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Lee CH, Lee KH, Lee BG, Kim DY, Choi WS. Clinical outcome of scaphoid malunion as a result of scaphoid fracture nonunion surgical treatment: A 5-year minimum follow-up study. Orthop Traumatol Surg Res 2015; 101:359-63. [PMID: 25769874 DOI: 10.1016/j.otsr.2014.09.026] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Revised: 05/19/2014] [Accepted: 09/01/2014] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- C-H Lee
- Department of Orthopaedic Surgery, Eulji Hospital, Eulji University, College of Medicine, Seoul, Korea
| | - K-H Lee
- Department of Orthopaedic Surgery, Hanyang University College of Medicine, Seoul, Korea
| | - B-G Lee
- Department of Orthopaedic Surgery, Hanyang University College of Medicine, Seoul, Korea
| | - D-Y Kim
- Department of Orthopaedic Surgery, Hanyang University College of Medicine, Seoul, Korea
| | - W-S Choi
- Department of Trauma Surgery, Ajou University Hospital, 164, World cup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do, Korea.
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28
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Kim JP, Seo JB, Yoo JY, Lee JY. Arthroscopic management of chronic unstable scaphoid nonunions: effects on restoration of carpal alignment and recovery of wrist function. Arthroscopy 2015; 31:460-9. [PMID: 25442643 DOI: 10.1016/j.arthro.2014.08.035] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Revised: 08/21/2014] [Accepted: 08/28/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to assess the effects of arthroscopically assisted reduction and osteosynthesis on restoration of carpal alignment and recovery of clinical wrist function in patients with unstable scaphoid nonunion. METHODS Thirty-six patients who underwent arthroscopically assisted osteosynthesis with or without bone grafting for unstable scaphoid nonunion between July 2006 and January 2012 were enrolled. The average time from injury to surgery was 51 ± 78.3 months. Radiographic and clinical evaluations were assessed on preoperative and postoperative days, and follow-up evaluation took place at a minimum of 24 months. RESULTS Union was achieved in 86% (31 of 36) of patients at a mean of 11 ± 2.7 weeks. Scaphoid axial length (SAL), lateral intrascaphoid angle (ISA), scapholunate angle (SLA), and reversed carpal height ratio (CHR) was significantly improved after surgery, and those correction ratios averaged 66% ± 46.8%, 74% ± 58.2%, 81% ± 59.8%%, and 94% ± 46%, respectively. The range of wrist motion was unchanged after surgery, but the grip strength improved from 74% ± 22.1% preoperatively to 89% ± 13.7% postoperatively compared with the contralateral side (P = .042). Mean Disabilities of the Arm, Shoulder, and Hand (DASH) and Patient-Related Wrist Evaluation (PRWE) scores improved significantly (P < .001) from 44 and 51 preoperatively to 13 and 23 postoperatively, respectively. The radiological parameters of the scaphoid and carpal alignment in patients who achieved bony union did not correlate with clinical wrist function. CONCLUSIONS Arthroscopic reduction and osteosynthesis of chronic unstable scaphoid nonunion is limited for restoration of normal carpal alignment but has positive effects on the recovery of clinical wrist function. LEVEL OF EVIDENCE Level IV, therapeutic case series.
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Affiliation(s)
- Jong Pil Kim
- Departments of Orthopedic Surgery and Department of Kinesiology and Medical Science, Dankook University College of Medicine, Cheonan, Republic of Korea.
| | - Joong Bae Seo
- Departments of Orthopedic Surgery and Department of Kinesiology and Medical Science, Dankook University College of Medicine, Cheonan, Republic of Korea
| | - Jun Young Yoo
- Departments of Orthopedic Surgery and Department of Kinesiology and Medical Science, Dankook University College of Medicine, Cheonan, Republic of Korea
| | - Jee Young Lee
- Department of Diagnostic Radiology, Dankook University College of Medicine, Cheonan, Republic of Korea
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29
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ten Berg PWL, Dobbe JGG, Strackee SD, Streekstra GJ. Quantifying scaphoid malalignment based upon height-to-length ratios obtained by 3-dimensional computed tomography. J Hand Surg Am 2015; 40:67-73. [PMID: 25534836 DOI: 10.1016/j.jhsa.2014.10.037] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Revised: 10/14/2014] [Accepted: 10/14/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine if 3-dimensional height-to-length (H/L) measurements including coronal plane assessment will improve malalignment detection of scaphoid fractures and to determine if more waist than proximal pole nonunions are malaligned. METHODS Computed tomography scans of uninjured wrists (n = 74) were used to obtain 3-dimensional models of healthy scaphoids. These models were used to determine 95% normal ranges of the H/L ratio in standard sagittal and coronal planes in an automated fashion. Subsequently, the H/L ratios of fibrous nonunions (n = 26) were compared with these normal ranges and were classified as either aligned or malaligned. RESULTS The mean normal H/L ratio in the sagittal plane was 0.61 (range, 0.54-0.69) and in the coronal plane 0.42 (range, 0.36-0.48). The mean H/L ratios of the nonunions differed from those of the healthy scaphoids in these planes: 0.65 and 0.48, respectively. Based on sagittal plane evaluation of all nonunions, 46% exceeded the normal H/L range versus 54% based on combining sagittal and coronal plane measurements. More waist nonunions (71%) than proximal pole nonunions (22%) exceed the normal H/L range. CONCLUSIONS Evaluation of the H/L ratio in the coronal plane provided valuable additional information for the detection of scaphoid deformities. More malaligned cases were found for waist nonunions than for proximal pole nonunions. CLINICAL RELEVANCE This method may be a helpful diagnostic tool to detect malalignment and to choose between in situ fixation or reconstruction.
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Affiliation(s)
- Paul W L ten Berg
- Department of Plastic, Reconstructive, and Hand Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Department of Biomedical Engineering and Physics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Department of Radiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
| | - Johannes G G Dobbe
- Department of Plastic, Reconstructive, and Hand Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Department of Biomedical Engineering and Physics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Department of Radiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Simon D Strackee
- Department of Plastic, Reconstructive, and Hand Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Department of Biomedical Engineering and Physics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Department of Radiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Geert J Streekstra
- Department of Plastic, Reconstructive, and Hand Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Department of Biomedical Engineering and Physics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Department of Radiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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30
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Megerle K, Harenberg PS, Germann G, Hellmich S. Scaphoid morphology and clinical outcomes in scaphoid reconstructions. Injury 2012; 43:306-10. [PMID: 21903213 DOI: 10.1016/j.injury.2011.08.015] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2011] [Revised: 07/28/2011] [Accepted: 08/09/2011] [Indexed: 02/02/2023]
Abstract
Scaphoid malunion and carpal malalignment can result after scaphoid reconstruction, if the two fragments are not properly reduced before fixation. However, currently there is no information about which degree of deformity or malalignment can be tolerated without impairing clinical function. The purpose of this study was to investigate the influence of the scaphoid morphology and carpal alignment on clinical outcomes after scaphoid reconstruction. A total of 65 patients with an average age of 29 years were followed-up after a mean period of 45 months. In all patients, osseous union after a first-time scaphoid reconstruction in the middle third had been confirmed. Scapholunate (SL) and radiolunate (RL) angles were obtained on plain radiographs as were intrascaphoid (ISA) and dorsal cortical (DCA) angles and the height/length (H/L) ratio of the reconstructed scaphoid on computed tomography (CT) scans. These parameters were correlated with clinical outcome measures. RL angles correlated significantly with wrist range of motion, grip strength and pain levels, whilst SL angles, ISA, DCA and H/L ratio failed to show significant correlations. Our data suggest that clinical outcome is correlated with correct restoration of bone morphology and carpal alignment. After reconstruction, the RL angle should not exceed 10°.
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Affiliation(s)
- K Megerle
- Department for Hand, Plastic and Reconstructive Surgery, Burn Center - BG Trauma Center Ludwigshafen, Plastic and Hand Surgery of the University of Heidelberg, Ludwig-Guttmannstr. 13, 67071 Ludwigshafen, Germany.
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31
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Abstract
A displaced fracture of the scaphoid is one in which the fragments have moved from their anatomical position or there is movement between them when stressed by physiological loads. Displacement is seen in about 20% of fractures of the waist of the scaphoid, as shown by translation, a gap, angulation or rotation. A CT scan in the true longitudinal axis of the scaphoid demonstrates the shape of the bone and displacement of the fracture more accurately than do plain radiographs. Displaced fractures can be treated in a plaster cast, accepting the risk of malunion and nonunion. Surgically the displacement can be reduced, checked radiologically, arthroscopically or visually, and stabilised with headless screws or wires. However, rates of union and deformity are unknown. Mild malunion is well tolerated, but the long-term outcome of a displaced fracture that healed in malalignment has not been established. This paper summarises aspects of the assessment, treatment and outcome of displaced fractures of the waist of the scaphoid.
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Affiliation(s)
- J. J. Dias
- The Glenfield Hospital, Department of Orthopaedic Surgery, University Hospitals of Leicester NHS Trust, Groby Road, Leicester LE3 9QP, UK
| | - H. P. Singh
- The Glenfield Hospital, Department of Orthopaedic Surgery, University Hospitals of Leicester NHS Trust, Groby Road, Leicester LE3 9QP, UK
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32
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Amirfeyz R, Bebbington A, Downing ND, Oni JA, Davis TRC. Displaced scaphoid waist fractures: the use of a week 4 CT scan to predict the likelihood of union with nonoperative treatment. J Hand Surg Eur Vol 2011; 36:498-502. [PMID: 21467089 DOI: 10.1177/1753193411403092] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
This study assessed whether nonunion of displaced scaphoid waist fractures with nonoperative treatment could be predicted from 4 week CT scans. Thirty-one patients with unilateral displaced scaphoid waist fractures and adequate follow-up were included. CT scans in the longitudinal axis of the scaphoid with sagittal and coronal slices were done 4 weeks after the index injury. The effects of fracture gap, sclerosis and bone resorption on union were assessed. Fracture union was observed in all 13 displaced fractures with a < 2 mm gap, four of the seven with a gap of 2-3 mm and only four of the 11 with a gap > 3 mm (p = 0.01). Bone resorption involving more than 50% of the fracture cross-section was also associated with nonunion, but sclerosis was not.
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Affiliation(s)
- R Amirfeyz
- Department of Trauma and Orthopaedic Surgery, Queens Medical Centre, University Hospital, Nottingham, UK
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