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Ghijsen SC, Heeg E, Teunis T, den Hollander VEC, Schuurman AH. Symptomatic Heterotopic Bone Formation after 1,2 ICSRA in Scaphoid Nonunions. J Wrist Surg 2024; 13:208-214. [PMID: 38808192 PMCID: PMC11129891 DOI: 10.1055/s-0043-1771339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 06/28/2023] [Indexed: 05/30/2024]
Abstract
Background We observed several cases of heterotopic bone formation after a 1,2 intercompartmental supraretinacular artery (1,2 ICSRA) distal radius vascularized bone graft (VBG) for the treatment of scaphoid nonunion. This adverse event seems underreported. Knowledge about factors associated with the formation of heterotopic bone after VBGs might help reduce this adverse event. Purpose What factors are associated with resected heterotopic bone formation after 1,2 ICSRA distal radius graft for the treatment of scaphoid nonunion? Patients and Methods We retrospectively reviewed all patients with a scaphoid nonunion treated with a 1,2 ICSRA distal radius graft between 2008 and 2019 in an urban level 1 trauma center in the Netherlands. We included 42 scaphoid nonunions in 41 people treated with the 1,2 ICSRA graft. We assessed potential correlation with patient, fracture, and treatment demographics. Results Heterotopic bone developed in 23 VBGs (55% [23/42]), of which 5 (12% [5/42]) were resected. Heterotopic bone was located radially (at the pedicle side) in all participants. Except a longer follow-up time ( p = 0.028), we found no variables associated with the development of heterotopic bone formation. Conclusion The location of the heterotopic bone at the pedicle site in all cases suggests a potential association with the periosteal strip. Surgeons might consider not to oversize the periosteal strip as a potential method to prevent heterotopic ossification after VBG. Level of Evidence Level II, prognostic study.
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Affiliation(s)
- S. C. Ghijsen
- Department of Plastic, Reconstructive, and Hand Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - E. Heeg
- Department of Plastic, Reconstructive, and Hand Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - T. Teunis
- Department of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - V. E. C. den Hollander
- Department of Plastic, Reconstructive, and Hand Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - A. H. Schuurman
- Department of Plastic, Reconstructive, and Hand Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Plastic, Reconstructive, and Hand Surgery, Central Military Hospital (CMH), Utrecht, The Netherlands
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Duncumb JW, Robinson PG, Williamson TR, Murray IR, Campbell D, Molyneux SG, Duckworth AD. Bone grafting for scaphoid nonunion surgery : a systematic review and meta-analysis. Bone Joint J 2022; 104-B:549-558. [PMID: 35491585 DOI: 10.1302/0301-620x.104b5.bjj-2021-1114.r1] [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: 11/05/2022]
Abstract
AIMS The purpose of this systematic review was to determine the rates of union for vascularized versus non-vascularized grafting techniques in the operative management of scaphoid nonunion. Secondary aims were to determine the effect of the fixation techniques used, the source of grafting, as well as the influence of fracture location (proximal pole) and avascular necrosis (AVN). METHODS A search of PubMed, MEDLINE, and Embase was performed in June 2021 using the Preferred Reporting Items for Systematic Review and Meta-Analyses statement and registered using the PROSPERO International prospective register of systematic reviews. The primary outcome was union rate. RESULTS There were 78 studies that met the inclusion criteria with a total of 7,671 patients (87.8% male, 12.2% female). The mean age was 27.9 years (SD 3.8) and the mean follow-up was 30.9 months (SD 25.9). The mean union rate was 88.7% (95% confidence interval (CI) 85.0 to 92.5) for non-vascularized grafts versus 87.5% (95% CI 82.8 to 92.2) for vascularized grafts (p = 0.685). Pooled analysis of trial data alone found a mean union rate of 82.4% (95% CI 66.9% to 97.9%) for non-vascularized grafts and 89.4% (95% CI 84.1% to 94.7%) for vascularized grafts (p = 0.780). No significant difference was observed in union rates between any of the fixation techniques used in the studies (p = 0.502). Distal radius and iliac crest graft source had comparable mean union rates (86.9% (95% CI 83.1 to 90.7) vs 87.6% (95% CI 82.2 to 92.9); p = 0.841). Studies that excluded patients with both proximal pole fractures and AVN (n = 14) had a mean union rate of 96.5% (95% CI 94.2 to 98.9) that was significantly greater than the mean union rate of 86.8% (95% CI 83.2 to 90.4) observed in the remaining studies (p < 0.001). CONCLUSION Current evidence suggests vascularized bone grafting does not yield significantly superior results to non-vascularized grafting in scaphoid nonunion management. However, potential selection bias lessens the certainty of these findings. The fixation type or source of the graft used was not found to influence union rates either. Sufficiently designed and powered prospective randomized controlled trials in this area are needed. Cite this article: Bone Joint J 2022;104-B(5):549-558.
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Affiliation(s)
- Joseph W Duncumb
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - Tom R Williamson
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Iain R Murray
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | | | - Andrew D Duckworth
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK.,Usher Institute, University of Edinburgh, Edinburgh, UK
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Pinder RM, Brkljac M, Rix L, Muir L, Brewster M. Treatment of Scaphoid Nonunion: A Systematic Review of the Existing Evidence. J Hand Surg Am 2015; 40:1797-1805.e3. [PMID: 26116095 DOI: 10.1016/j.jhsa.2015.05.003] [Citation(s) in RCA: 136] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 04/30/2015] [Accepted: 05/01/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine by systematic review the optimal treatment of scaphoid nonunion. METHODS We conducted a systematic review of the literature with a meta-analysis of proportions to investigate the comparative effectiveness of different surgical techniques. RESULTS A total of 48 publications (1,602 patients) met the eligibility criteria. Vascularized and nonvascularized bone grafts had an estimated union incidence of 92% and 88%, respectively. Distal radius and iliac crest bone grafts had similar union rates (89% and 87%, respectively) but harvesting of iliac crest bone grafts had more complications. Both screw and K-wire fixation had a higher incidence of union (88% and 91%, respectively) than no fixation (79%). No approach was statistically different. Patients fixed with screws were mobilized earlier than those with K-wire fixation. CONCLUSIONS Current evidence does not demonstrate a significantly superior method for the treatment of scaphoid nonunion. A multicenter randomized trial would be ideal but the large numbers that would be required may make this unrealistic. We recommend the continued reporting of series with specific assessments and outcome measures to optimize future comparisons in an attempt to determine the best management of scaphoid nonunion. CLINICAL RELEVANCE The use of bone grafts and the methods of their fixation for scaphoid nonunion are debated issues in hand and wrist surgery, with multiple methods employed. There is no current consensus on optimal treatment. A meta-analysis of proportions of available data from recent studies was deemed the most appropriate way to assimilate the available evidence with the view to inform surgeons of the optimal treatment according to the evidence base.
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Affiliation(s)
- Richard M Pinder
- Department of Plastic Surgery, Castle Hill Hospital, Cottingham, United Kingdom.
| | - Milos Brkljac
- University of Manchester Medical School, Greater Manchester, United Kingdom
| | - Louise Rix
- University of Manchester Medical School, Greater Manchester, United Kingdom
| | - Lindsay Muir
- Department of Orthopaedics, Salford Royal NHS Foundation Trust, Salford, United Kingdom
| | - Mark Brewster
- The Birmingham Hand Centre, Royal Orthopaedic Hospital, Northfield, Birmingham, United Kingdom
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Jaminet P, Werdin F, Pfau M, Götz M, Manoli T, Rahmanian-Schwarz A, Schaller HE. [Treatment algorithm for scaphoid nonunion : retrospective case-control study of 208 patients]. Unfallchirurg 2011; 115:994-9. [PMID: 21465239 DOI: 10.1007/s00113-011-1956-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
INTRODUCTION We present a retrospective study on different treatment options for scaphoid nonunion. The results are compared to the literature and a treatment algorithm is proposed. MATERIALS AND METHODS Based on a retrospective case-control study, 208 patients suffering from scaphoid nonunion were treated between 2000 and 2006. The patients were grouped depending on the localization of the nonunion: proximal (n=10), middle (n=105), or distal (n=93) third. In the presence of a small avascular proximal fragment, a vascularized bone graft from the distal radius was added (n=53). The determination of scaphoid healing was achieved by conventional radiographs or CT scans. RESULTS Overall scaphoid healing occurred in 89.9% (n=187). For small proximal scaphoid fragments (n=93), we could show healing rates up to 83% (n=77). Using a vascularized bone graft from the distal radius, scaphoid consolidation was achieved in 81% for avascular proximal fragments and recurrent scaphoid nonunion (n=53). CONCLUSION Using sophisticated treatment options, the prognosis of scaphoid nonunions is very good.
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Affiliation(s)
- P Jaminet
- Klinik für Hand-, Plastische, Rekonstruktive und Verbrennungschirurgie, Berufsgenossenschaftliche Unfallklinik, Eberhard-Karl-Universität Tübingen, Schnarrenbergstraße 95, 72076, Tübingen, Deutschland.
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Arora R, Lutz M, Zimmermann R, Krappinger D, Niederwanger C, Gabl M. Free vascularised iliac bone graft for recalcitrant avascular nonunion of the scaphoid. ACTA ACUST UNITED AC 2010; 92:224-9. [DOI: 10.1302/0301-620x.92b2.22367] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
We report the use of a free vascularised iliac bone graft in the treatment of 21 patients (19 men and 2 women) with an avascular nonunion of the scaphoid in which conventional bone grafting had previously failed. The mean age of the patients was 32 years (23 to 46) and the dominant wrist was affected in 14. The mean interval from fracture to the vascularised bone grafting was 39 months (9 to 62). Pre-operative MRI showed no contrast enhancement in the proximal fragment in any patient. Fracture union was assessed radiologically or with CT scans if the radiological appearances were inconclusive. At a mean follow-up of 5.6 years (2 to 11) union was obtained in 16 patients. The remaining five patients with a persistent nonunion continued to experience pain, reduced grip strength and limited range of wrist movement. In the successfully treated patients the grip strength and range of movement did not recover to match the uninjured side. Prevention of progressive carpal collapse, the absence of donor site morbidity, good subjective results and pain relief, justifies this procedure in the treatment of recalcitrant nonunion of the scaphoid.
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Affiliation(s)
- R. Arora
- Department of Trauma Surgery Medical University Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Tyrol, Austria
| | - M. Lutz
- Department of Trauma Surgery Medical University Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Tyrol, Austria
| | - R. Zimmermann
- Department of Trauma Surgery Medical University Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Tyrol, Austria
| | - D. Krappinger
- Department of Trauma Surgery Medical University Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Tyrol, Austria
| | - C. Niederwanger
- Department of Trauma Surgery Medical University Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Tyrol, Austria
| | - M. Gabl
- Department of Trauma Surgery Medical University Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Tyrol, Austria
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Weber DM, Fricker R, Ramseier LE. Conservative treatment of scaphoid nonunion in children and adolescents. ACTA ACUST UNITED AC 2009; 91:1213-6. [DOI: 10.1302/0301-620x.91b9.21906] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
This is a retrospective study of six children with ununited scaphoid fractures treated conservatively. Their mean age was 12.8 years (9.7 to 16.3). Five had no early treatment. Radiological signs of nonunion were found at a mean of 4.6 months (3 to 7) after injury. Treatment consisted of cast immobilisation until clinical and radiological union. The mean clinical and radiological follow-up was for 67 months (17 to 90). We assessed the symptoms, the range of movement of the wrist and the grip strength to calculate the Modified Mayo Wrist score. The fracture united in all patients after a mean period of immobilisation of 5.3 months (3 to 7). Five patients were pain free; one had mild pain. All returned to regular activities, and had a range of movement and grip strength within 25% of normal, resulting in an excellent Modified Mayo Wrist score. Prolonged treatment with cast immobilisation resulted in union of the fracture and an excellent Modified Wrist Score in all patients.
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Affiliation(s)
- D. M. Weber
- Department of Hand Surgery, Orthopaedic Department, Children’s University Hospital, Steinwiesstrasse 75, CH-8032 Zurich, Switzerland
| | - R. Fricker
- Department of Surgery, Kantonsspital Bruderholz, CH, 4101 Bruderholz, Switzerland
| | - L. E. Ramseier
- Balgrist Orthopaedic University Hospital, Zurich Forchstrasse 340, CH 8008, Zurich, Switzerland
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