The Herbert screw for the treatment of scaphoid fractures

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

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

LEVEL OF EVIDENCE

II.

Treatment of acute scaphoid fractures: a systematic review and meta-analysis

BACKGROUND/METHODS

The purpose of this review was to assess the current evidence supporting operative fixation versus casting for acute scaphoid fractures through a systematic review and meta-analysis of the literature.

RESULTS

Our search yielded 59 articles that met our inclusion criteria with five studies achieving high, 22 moderate, and 32 low Structured Effectiveness Quality Evaluation Scale scores. Pooled results of the four Sackett level 1 evidence studies showed no significant difference between the operative (114/115, 99%) versus non-operative group (106/112, 95%) (p = 0.07) when the definition of nonunion was based on more definitive criterion versus plain radiographs that may be insufficient to assess bony union. Similar results were found for the Sackett level 2 and 4 articles.

CONCLUSIONS

This systematic review reveals that significant weaknesses exist in the literature with respect to the level of evidence and quality of published studies on this topic. Currently, there is insufficient evidence to support the most effective treatment for acute scaphoid fractures.

Nonoperative compared with operative treatment of acute scaphoid fractures. A randomized clinical trial

BACKGROUND

Traditionally, acute nondisplaced scaphoid fractures have been treated nonoperatively in a cast, and the expected union rate approaches 90%. Internal fixation of nondisplaced scaphoid fractures has increased in popularity, and a union rate of 100% has been reported. The growing trend is to recommend internal fixation for the majority of acute scaphoid fractures. The true long-term benefits of this more complicated treatment modality have not yet been determined in randomized controlled trials. The purpose of this study was to compare the long-term results of operative fixation of acute scaphoid fractures with those of nonoperative treatment.

METHODS

During the period between 1992 and 1997, eighty-three patients with an acute nondisplaced or minimally displaced scaphoid fracture were randomly allocated to, and received, either nonoperative treatment with a cast or internal fixation with a Herbert screw. At a median of ten years after the injury, seventy-five (93%) of the eighty-one patients who were still alive were assessed clinically and radiographically.

RESULTS

All fractures united. A significant increase in the prevalence of osteoarthritis in the scaphotrapezial joint was found in the operatively treated group. No differences in subjective symptoms, as measured with limb-specific outcome scores, were found between the two groups. The range of motion and grip strength were greater, but not significantly greater, in the nonoperatively treated group.

CONCLUSIONS

This study did not demonstrate a true long-term benefit of internal fixation, compared with nonoperative treatment, for acute nondisplaced or minimally displaced scaphoid fractures. The long-term risks of surgery should be considered when recommending operative treatment.

Treatment of scaphoid nonunions: quantitative meta-analysis of the literature

We conducted a systematic quantitative meta-review of the literature to provide evidence-based suggestions for the treatment of scaphoid nonunion. This search identified 1,121 articles of which 36 met eligibility requirements. In unstable nonunions, screw fixation with grafting at 94% union was superior to K-wires and wedge grafting (77% union). Immediate mobilization versus 6 weeks or more of casting showed the same union rate of 74%. For avascular necrosis of the proximal fragment, union was achieved in 88% of those patients with a vascularized graft versus 47% with screw and wedge fixation. These results suggest that established unstable nonunions should be treated with screw fixation and wedge grafting. There is not evidence supporting the need for postoperative immobilization in patients with solid screw fixation. A vascularized graft may be preferable for patients with avascular necrosis of the proximal fragment or with a previously failed surgery.