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Bulstra AEJ, Vidovic AJ, Doornberg JN, Jaarsma RL, Buijze GA. Scaphoid Length Loss Following Nonunion Is Associated with Dorsal Intercalated Segment Instability. J Wrist Surg 2023; 12:407-412. [PMID: 37841362 PMCID: PMC10569863 DOI: 10.1055/s-0043-1760753] [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: 05/07/2022] [Accepted: 12/19/2022] [Indexed: 10/17/2023]
Abstract
Background Dorsal intercalated segment instability (DISI) in scaphoid nonunions is frequently attributed to fracture location relative to ligamentous attachments onto the scaphoid apex. We hypothesize scaphoid length loss to have a stronger correlation with DISI deformity than fracture location in patients with scaphoid nonunion. Questions/Purposes To investigate the correlation between (1) scaphoid length loss, (2) fracture location relative to the scaphoid apex, and (3) type of nonunion (Herbert classification) and DISI deformity in skeletally mature patients with scaphoid nonunion. Patients and Methods Twenty-seven cases of computed tomography (CT)-confirmed scaphoid nonunion (>6 months) were retrospectively included. Our primary outcome was the degree of DISI as measured by the radiolunate (RL) angle on CT. Scaphoid length loss was expressed as height-to-length (H/L) ratio. Fracture location was classified as proximal or distal to the scaphoid apex. Nonunions were classified as fibrous unions (type D1) or pseudoarthrosis (type D2). The correlation between RL angle, H/L ratio, fracture location, and nonunion type was evaluated. Results H/L ratio was the only factor associated with the degree of DISI as measured by RL angle. As scaphoid length loss increased (increasing H/L ratio), the RL angle increased. There was no significant difference in RL angle between fractures located proximal (30 degrees) or distal (28 degrees) to the scaphoid apex, or type D1 (31 degrees) versus type D2 (28 degrees) nonunions. There was no correlation between patient age, sex, or wrist side affected and RL angle. Conclusions Scaphoid length loss, rather than fracture location, is correlated to the degree of DISI deformity in patients with scaphoid nonunion. This highlights the importance of restoring scaphoid height when planning scaphoid nonunion reconstruction. Level of Evidence Level III, diagnostic study.
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Affiliation(s)
- Anne Eva J. Bulstra
- Department of Orthopaedic and Trauma Surgery, Flinders Medical Centre, Flinders University, Bedford Park, South Australia
- Department of Orthopaedic Surgery, Amsterdam UMC, Location Academic Medical Center, Amsterdam, The Netherlands
| | - Alex Jug Vidovic
- Department of Orthopaedic and Trauma Surgery, Flinders Medical Centre, Flinders University, Bedford Park, South Australia
| | - Job N. Doornberg
- Department of Orthopaedic and Trauma Surgery, Flinders Medical Centre, Flinders University, Bedford Park, South Australia
- Department of Orthopaedic Surgery, Amsterdam UMC, Location Academic Medical Center, Amsterdam, The Netherlands
| | - Ruurd L. Jaarsma
- Department of Orthopaedic and Trauma Surgery, Flinders Medical Centre, Flinders University, Bedford Park, South Australia
| | - Geert Alexander Buijze
- Department of Orthopaedic Surgery, Amsterdam UMC, Location Academic Medical Center, Amsterdam, The Netherlands
- Department of Hand and Upper Limb Surgery, Clinique Générale d'Annecy, Annecy, France
- Department of Orthopedic Surgery, Montpellier University Medical Center, Lapeyronie Hospital, Montpellier, France
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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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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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Rancy SK, Wolfe SW, Jerome JTJ. Predictors of Failure for Vascularized and Nonvascularized Bone Grafting of Scaphoid Nonunions: A Systematic Review. J Hand Microsurg 2021; 14:322-335. [DOI: 10.1055/s-0041-1735349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Abstract
Objective This article compares predictors of failure for vascularized (VBG) and nonvascularized bone grafting (NVBG) of scaphoid nonunions.
Methods We conducted a systematic literature review of outcomes after VBG and NVBG of scaphoid nonunion. Fifty-one VBG studies (N = 1,419 patients) and 81 NVBG studies (N = 3,019 patients) met the inclusion criteria. Data were collected on surgical technique, type of fixation, time from injury to surgery, fracture location, abnormal carpal posture (humpback deformity and/or dorsal intercalated segmental instability [DISI]), radiographic parameters of carpal alignment, prior failed surgery, smoking status, and avascular necrosis (AVN) as defined by punctate bleeding, magnetic resonance imaging (MRI) with contrast, MRI without contrast, X-ray, and histology. Meta-analysis of proportions was conducted with Freeman–Tukey double arcsine transformation. Multilevel mixed-effects analyses were performed with univariable and multivariable Poisson regression to identify confounders and evaluate predictors of failure.
Results The pooled failure incidence effect size was comparable between VBG and NVBG (0.09 [95% confidence interval [CI] 0.05–0.13] and 0.08 [95% CI 0.06–0.11], respectively). Humpback deformity and/or DISI (incidence-rate radios [IRRs] 1.57, CI: 1.04–2.36) and lateral intrascaphoid angle (IRR 1.21, CI: 1.08–1.37) were significantly associated with an increased VBG failure incidence. Time from injury to surgery (IRR 1.09, CI: 1.06–1.12) and height-to-length (H/L) ratio (IRR 53.98, CI: 1.16–2,504.24) were significantly associated with an increased NVBG failure incidence, though H/L ratio demonstrated a wide CI. Decreased proximal fragment contrast uptake on MRI was a statistically significant predictor of increased failure incidence for both VBG (IRR 2.03 CI: 1.13–3.66) and NVBG (IRR 1.39, CI: 1.16–1.66). Punctate bleeding or radiographic AVN, scapholunate angle, radiolunate angle, and prior failed surgery were not associated with failure incidence for either bone graft type (p > 0.05).
Conclusion Humpback deformity and/or DISI and increasing lateral intrascaphoid angle may be predictors of VBG failure. Time from injury to surgery may be a predictor of NVBG failure. AVN as defined by decreased contrast uptake on MRI may be a marker of increased failure risk for both bone graft types.
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Affiliation(s)
- Schneider K. Rancy
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, United States
| | - Scott W. Wolfe
- Division of Hand and Upper Extremity, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, United States
| | - J. Terrence Jose Jerome
- Department of Orthopedics, Hand & Reconstructive Microsurgery, Olympia Hospital & Research Centre, Trichy, Tamil Nadu, India
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Nagura N, Naito K, Sugiyama Y, Obata H, Goto K, Kaneko A, Tomita Y, Iwase Y, Kaneko K, Ishijima M. Correction of humpback and DISI deformities by vascularized bone grafting in patients with scaphoid nonunion. SICOT J 2021; 7:13. [PMID: 33704058 PMCID: PMC7949886 DOI: 10.1051/sicotj/2021011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 02/20/2021] [Indexed: 11/20/2022] Open
Abstract
Introduction: Although vascularized bone grafting (VBG) using 1, 2 intercompartmental supraretinacular artery (1, 2 ICSRA) is effective for scaphoid nonunion, dorsal intercalated segment instability (DISI) deformity persists even after correction of humpback deformity (HD). The purpose of this retrospective study was to evaluate the correction of HD and DISI deformity after 1, 2 ICSRA VBG for scaphoid nonunion. Methods: We treated 18 patients (mean age: 25.8, 16 males and 2 females) with scaphoid nonunion using a 1, 2-ICSRA VBG between January 2010 and December 2018. The average time from injury to surgery was 20.0 (3–120) months. The nonunions were located at the waist in all patients. The correction of HD and DISI deformity was investigated on the preoperative images and images at the last examination. Results: In all patients, the correction of HD was positively correlated with that of DISI deformity. Moreover, we focused on the time from injury to surgery and evaluated changes in HD and DISI deformity according to the time to surgery. As a result, changes in HD and DISI deformity were positively correlated in patients with a shorter time to surgery but were not correlated when the time to surgery exceeded 5 months. Conclusions: These results suggest that DISI deformity can be corrected by correcting HD when the time from injury to surgery is short, but that correction is difficult if the time to surgery is prolonged.
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Affiliation(s)
- Nana Nagura
- Department of Orthopaedics, Juntendo University Faculty of Medicine, 2-1-1 Hongo, Bunkyo-ku, 113-8421 Tokyo, Japan
| | - Kiyohito Naito
- Department of Orthopaedics, Juntendo University Faculty of Medicine, 2-1-1 Hongo, Bunkyo-ku, 113-8421 Tokyo, Japan
| | - Yoichi Sugiyama
- Department of Orthopaedics, Juntendo University Faculty of Medicine, 2-1-1 Hongo, Bunkyo-ku, 113-8421 Tokyo, Japan - Department of Orthopeadic Surgery, Juntendo Tokyo Koto Geriatric Medical Center, 3-3-20 Shisuna, Koto-ku, 136-0075 Tokyo, Japan
| | - Hiroyuki Obata
- Department of Orthopaedics, Juntendo University Faculty of Medicine, 2-1-1 Hongo, Bunkyo-ku, 113-8421 Tokyo, Japan - Department of Medicine for Orthopaedics and Motor Organ, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, 113-8421 Tokyo, Japan
| | - Kenji Goto
- Department of Orthopaedics, Juntendo University Faculty of Medicine, 2-1-1 Hongo, Bunkyo-ku, 113-8421 Tokyo, Japan
| | - Ayaka Kaneko
- Department of Orthopaedics, Juntendo University Faculty of Medicine, 2-1-1 Hongo, Bunkyo-ku, 113-8421 Tokyo, Japan - Department of Medicine for Orthopaedics and Motor Organ, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, 113-8421 Tokyo, Japan
| | - Yoshimasa Tomita
- Department of Orthopaedic Surgery, Japan Labour Health and Safety Organization Tokyo Rosai Hospital, 4-13-21 Omori-Minami, Ota-ku, 143-0013 Tokyo, Japan
| | - Yoshiyuki Iwase
- Department of Orthopeadic Surgery, Juntendo Tokyo Koto Geriatric Medical Center, 3-3-20 Shisuna, Koto-ku, 136-0075 Tokyo, Japan
| | - Kazuo Kaneko
- Department of Orthopaedics, Juntendo University Faculty of Medicine, 2-1-1 Hongo, Bunkyo-ku, 113-8421 Tokyo, Japan
| | - Muneaki Ishijima
- Department of Orthopaedics, Juntendo University Faculty of Medicine, 2-1-1 Hongo, Bunkyo-ku, 113-8421 Tokyo, Japan - Department of Medicine for Orthopaedics and Motor Organ, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, 113-8421 Tokyo, Japan
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Oki S, Matsuo T, Furuhata R, Iwabu S. Scaphoid non-union with pre-existing screws treated by 3D preoperative planning. BMJ Case Rep 2021; 14:14/1/e239548. [PMID: 33431475 PMCID: PMC7802672 DOI: 10.1136/bcr-2020-239548] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Scaphoid fractures, if deemed operative, can often be treated successfully by headless compression screw fixation. Unfortunately, some patients go on to develop a scaphoid fracture non-union with screw loosening, bone resorption, bone deformity and carpal malalignment. To assist surgeons in managing these difficult cases, specifically designed scaphoid fracture plates have recently been introduced. We present a case of a scaphoid fracture non-union with retained screws and bone loss that was effectively treated by volar plate fixation using a three-dimensional (3D) printed model to assist with restoration of scaphoid morphology and implant positioning. Before surgery, 3D preoperative planning using a surface registration technique and a 3D printer was performed. Referring to the 3D-printed reduced model facilitated the prediction of gaps after reduction and helped decide the implant position and screw directions. Carpal alignment parameters gradually improved by 1 year postoperatively.
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Affiliation(s)
- Satoshi Oki
- Department of Orthopedic Surgery, Saiseikai Utsunomiya Hospital, Utsunomiya, Tochigi, Japan
| | - Tomoki Matsuo
- Department of Orthopedic Surgery, Saiseikai Utsunomiya Hospital, Utsunomiya, Tochigi, Japan
| | - Ryogo Furuhata
- Department of Orthopedic Surgery, Saiseikai Utsunomiya Hospital, Utsunomiya, Tochigi, Japan
| | - Shohei Iwabu
- Department of Orthopedic Surgery, Saiseikai Utsunomiya Hospital, Utsunomiya, Tochigi, Japan
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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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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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Mathoulin CL, Arianni M. Treatment of the scaphoid humpback deformity - is correction of the dorsal intercalated segment instability deformity critical? J Hand Surg Eur Vol 2018; 43:13-23. [PMID: 29105591 DOI: 10.1177/1753193417739526] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Treatment of scaphoid fractures has been focused mainly on achieving union, with less attention to restoring normal scaphoid shape and orientation. Malalignment of one carpal bone will disrupt the kinetics of the entire wrist. The dorsal intercalated segment instability deformity associated with scaphoid waist nonunion is a nondissociative form of carpal instability. It has to be reduced in the treatment of scaphoid waist nonunions to avoid kinetic problems that will lead to arthritic changes. Computerized tomography scanning has become indispensable to visualize the humpback deformity clearly. Different techniques may be used to restore the normal anatomy of scaphoid, from non-vascularized graft to arthroscopic bone grafting, and also the option of vascularized bone grafting.
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