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Samade R, Awan HM. Surgical Treatment of Scaphoid Fractures: Recommendations for Management. J Wrist Surg 2024; 13:194-201. [PMID: 38808184 PMCID: PMC11129893 DOI: 10.1055/s-0043-1772689] [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: 02/13/2023] [Accepted: 07/20/2023] [Indexed: 05/30/2024]
Abstract
Background: Several operative treatments exist for scaphoid fractures, varying by approach (e.g., ercutaneous, volar, or dorsal), implant type (e.g., screw or Kirschner wire), and bone raft choice (e.g., none, nonvascularized, or vascularized). Many previous systematic eviews and meta-analyses have investigated outcomes following different surgicalÚpproaches, the use of vascularized versus nonvascularized bone graft for scaphoidßracture nonunions, and treatment for specific fracture patterns. However, given the advancements n scaphoid fracture treatment in recent years, there is a need for updated treatment recommendations hat would be beneficial to hand surgeons. Purpose: We present a comprehensive review of the operative treatment of scaphoid fractures based on recent literature and propose a unified treatment algorithm for managing these fractures. Methods: The English-language literature was searched from 2002 to 2023 for high evidence level (e.g., randomized trials), review, and meta-analysis articles with the following search terms: "scaphoid, "u8220"scaphoid" AND "nonunion, " and "scaphoid" AND "malunion. " Each article was creened by the authors to determine the scaphoid fracture scenario addressed and ubsequent treatment recommendations. The findings from article reviews were then rganized by scaphoid fracture types in this manuscript. Results: A total of 95 pertinent articles were ultimately selected and used as the basis for reviewing different scaphoid fracture scenarios. A treatment algorithm was then proposed based on literature review. Conclusion: This summary of the recent literature can guide hand surgeons in addressing scaphoidßractures. Future research in scaphoid fracture treatment, particularly for nonunions, would be most beneficial n the form of systematic review, meta-analysis, or multicenter prospective randomized clinical trials. Level of Evidence: IV.
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Affiliation(s)
- Richard Samade
- Department of Orthopaedic Surgery, Division of Hand and Upper Extremity Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Hisham M. Awan
- Division of Hand and Upper Extremity Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
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2
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McCarty JC, Hamaguchi R, Eberlin KR. Scaphoid Nonunions: Local Vascularized Bone Flaps. Hand Clin 2024; 40:117-127. [PMID: 37979983 DOI: 10.1016/j.hcl.2023.08.004] [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: 11/20/2023]
Abstract
If untreated, scaphoid nonunions may progress to scaphoid nonunion advanced collapse in a substantial portion of cases and may require salvage procedures. Multiple different techniques have been described to address scaphoid nonunion. Vascularized bone flaps (VBFs) are associated with faster time to union compared with nonvascularized grafts. Because these are local pedicled flaps, they do not require microsurgical anastomoses and should be within the armamentarium of all hand surgeons. Appropriately chosen local VBFs, can achieve union rates up to 90% to 100% in appropriately selected patients.
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Affiliation(s)
- Justin C McCarty
- Division of Plastic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ryoko Hamaguchi
- Division of Plastic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Kyle R Eberlin
- Division of Plastic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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3
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Schädel-Höpfner M, Windolf J, Lögters T, Pillukat T, Jung M, Bickert B. [Scaphoid fractures : Current diagnostic and treatment concepts]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2023; 126:799-811. [PMID: 37707528 DOI: 10.1007/s00113-023-01364-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/01/2023] [Indexed: 09/15/2023]
Abstract
Scaphoid fractures are by far the most frequent fractures of the carpal bones of the hand and often lead to problematic healing processes if the diagnostics and treatment are inadequate. The main complication of a scaphoid fracture is pseudarthrosis, which leads to carpal collapse and degenerative arthritis of the wrist if left untreated. Early diagnosis and individualized differentiated treatment aim to achieve bony healing with restoration of the scaphoid shape and preservation of the function of the wrist. The anatomical and biomechanical characteristics of the scaphoid can impede bony healing after a fracture and, in contrast to the diagnostics and treatment, cannot be influenced. A history of trauma and typical clinical signs of a scaphoid fracture should lead to systematic imaging diagnostics with obligatory computed tomography. Only by determining the exact fracture morphology can an appropriate treatment concept be established. Conservative treatment should be restricted to stable fractures without relevant displacement. Fractures of the proximal scaphoid pole are considered unstable even if they are not displaced. Operative treatment is indicated for all unstable fractures. The favored surgical procedure is osteosynthesis with a cannulated double-threaded screw, which can be used in a retrograde or antegrade manner and in a minimally invasive or open technique, depending on the fracture type. Surgical treatment results in earlier bony healing and quicker restoration of function but can be associated with a higher complication rate. Posttraumatic osteoarthritis after healing in malalignment is usually asymptomatic.
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Affiliation(s)
- Michael Schädel-Höpfner
- Klinik für Unfallchirurgie, Orthopädie und Handchirurgie, Lukaskrankenhaus Neuss, Rheinland Klinikum, Preußenstraße 84, 41464, Neuss, Deutschland.
| | - Joachim Windolf
- Klinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
| | - Tim Lögters
- Klinik für Unfall- und Wiederherstellungschirurgie, Handchirurgie und Orthopädie, St. Vinzenz-Hospital Köln, Köln, Deutschland
| | - Thomas Pillukat
- Klinik für Handchirurgie, Rhönklinikum, Campus Bad Neustadt, Bad Neustadt, Deutschland
| | - Martin Jung
- Orthopädische Chirurgie München, München, Deutschland
| | - Berthold Bickert
- Klinik für Hand‑, Plastische und Rekonstruktive Chirurgie, BG Klinik Ludwigshafen, Ludwigshafen, Deutschland
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4
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Dias JJ, Kheiran A, Ngo DN, Adeleye E, Wildin CJ, Ullah A, Bhowal B, Bindra R. The onset, progress and factors influencing degenerative arthritis of the wrist following scaphoid fracture non-union. Injury 2023; 54:930-939. [PMID: 36621361 DOI: 10.1016/j.injury.2022.12.025] [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: 08/25/2022] [Revised: 12/14/2022] [Accepted: 12/22/2022] [Indexed: 12/25/2022]
Abstract
BACKGROUND/AIMS Scaphoid non-union causes osteoarthritis but factors associated are poorly understood. We investigated the rate of osteoarthritis after scaphoid fracture non-union, and if duration and fracture location influenced arthritis and its severity. METHODS This retrospective cross-sectional observational study of 278 consecutive cases with scaphoid fracture non-union retrieved data on demographics, non-union duration, fracture location, dorsal intercalated segment instability (DISI), severity and distribution of wrist arthritis. Patient Evaluation Measure (PEM) and Quality of Life assessed impact on patients. Regression models investigated prediction of osteoarthritis by different variables. Time-to-event analysis investigated osteoarthritis evolution. Missing (MAR) data for the PEM and QoL was imputed and analysed. RESULTS 278 patients, 246 males, aged 27.9 years (range 11 to 78 years), with a scaphoid fracture non-union confirmed on computed tomography (CT) scans (243) and plain radiographs (35) were reviewed. The interval between injury and imaging was 3.3 years (SD 5.9 years; range 0.1-45). The fracture was proximal to the ridge in 162, distal to the ridge in 83 and in the proximal 20% in 33. DISI (RLA ≥ 10°) occurred in 93.5% (260/278). Osteoarthritis was identified in 62.2% (173/278), and we classified a SNAC pattern in 93.6% (162/173). Of these, 100 (61.7%) had SNAC 1, 22 (13.6%) SNAC 2, 17 (10.5%) SNAC 3, and 23 (14.2%) SNAC 4. The mean duration in years for SNAC 1, 2, 3 and 4 were 2.5, 6.0, 8.2, and 11.3 years respectively. In fractures proximal to the ridge, 50% had arthritis in 2.2 years. Whereas in proximal pole, and distal to the ridge, 50% developed in 3.8 and 6.6 years, respectively. The PEM score was 42.8% (SD 18.9%) in those without arthritis and 48.8% (SD 21.5%) in those with arthritis. The mean QoL was 0.838 in patients without SNAC and 0.792 with SNAC. CONCLUSION Scaphoid fracture non-union caused early carpal collapse, majority had osteoarthritis usually observed within a year following injury and occurred earliest in proximal waist fractures. Distribution of osteoarthritis (SNAC stage) may not always follow a distinctive pattern, as previously described.
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Affiliation(s)
- Joseph J Dias
- AToMS-Academic Team of Musculoskeletal Surgery, Undercroft, University Hospitals of Leicester NHS Trust, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, UK
| | - Amin Kheiran
- AToMS-Academic Team of Musculoskeletal Surgery, Undercroft, University Hospitals of Leicester NHS Trust, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, UK.
| | - Donald N Ngo
- Gold Coast University Hospital, Orthopaedic Surgery, Hospital Blvd, Southport, QLD 4215, Australia
| | - Emmanuel Adeleye
- AToMS-Academic Team of Musculoskeletal Surgery, Undercroft, University Hospitals of Leicester NHS Trust, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, UK
| | - Clare J Wildin
- AToMS-Academic Team of Musculoskeletal Surgery, Undercroft, University Hospitals of Leicester NHS Trust, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, UK
| | - Aamer Ullah
- AToMS-Academic Team of Musculoskeletal Surgery, Undercroft, University Hospitals of Leicester NHS Trust, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, UK
| | - Bhaskar Bhowal
- AToMS-Academic Team of Musculoskeletal Surgery, Undercroft, University Hospitals of Leicester NHS Trust, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, UK
| | - Randy Bindra
- Gold Coast University Hospital, Orthopaedic Surgery, Hospital Blvd, Southport, QLD 4215, Australia
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5
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Manako T, Imade S, Yamagami N, Yamamoto S, Uchio Y. The clinical outcomes of scaphoid nonunion treated with a precisely processed autologous bone screw: a case series. Arch Orthop Trauma Surg 2023; 143:627-635. [PMID: 34347123 DOI: 10.1007/s00402-021-04092-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 07/27/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Metal implants and bioabsorbable implants are frequently used in orthopaedic surgery, but they have some disadvantages. The usefulness of autologous bone has been described, and a method to precisely process autologous bone into implants such as screws and apply the implants clinically has been desired. We created a new system for manufacturing autologous bone screws during surgery and report five cases of scaphoid nonunion treated with precise autologous bone screws made from the tibial cortex using the new system. PATIENTS AND METHODS From 2012 through 2017, seven patients were diagnosed with scaphoid nonunion at our hospital and based on the inclusion/exclusion criteria, five of them were analyzed herein. The surgery was performed according to Zaidemberg's technique. The bone screw in each case was made from autologous tibial cortex using a numerically controlled lathe (model MTS4, Nano Co., Yokohama, Japan) under sterile conditions. The change in each patient's modified Mayo wrist score between the preoperative examination and at the final survey was determined, as were complications. RESULTS The median modified Mayo wrist score improved significantly from 65 to 95 points. All patients who were followed for > 2 years fused at a median duration of 3.5 months. Bone regeneration was confirmed at the donor sites in all cases. One fracture at the donor site occurred as a severe complication. CONCLUSIONS Precisely shaped autologous bone screws manufactured by a computer-assisted machine, together with a vascularized bone graft, may be a useful technique for treating scaphoid nonunions; these screws had good stability and bone replacement. Careful observation of the donor site is required. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Takuya Manako
- Department of Orthopaedic Surgery, Faculty of Medicine, Shimane University, 89-1, Enya, Izumo, Shimane, 693-8501, Japan.
| | - Shinji Imade
- Department of Orthopaedic Surgery, Faculty of Medicine, Shimane University, 89-1, Enya, Izumo, Shimane, 693-8501, Japan
| | - Nobuo Yamagami
- Department of Orthopaedic Surgery, Faculty of Medicine, Shimane University, 89-1, Enya, Izumo, Shimane, 693-8501, Japan
| | - Soichiro Yamamoto
- Department of Orthopaedic Surgery, Faculty of Medicine, Shimane University, 89-1, Enya, Izumo, Shimane, 693-8501, Japan
| | - Yuji Uchio
- Department of Orthopaedic Surgery, Faculty of Medicine, Shimane University, 89-1, Enya, Izumo, Shimane, 693-8501, Japan
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Fujihara Y, Yamamoto M, Hidaka S, Sakai A, Hirata H. Vascularised versus non-vascularised bone graft for scaphoid nonunion: Meta-analysis of randomised controlled trials and comparative studies. JPRAS Open 2022; 35:76-88. [PMID: 36793769 PMCID: PMC9922807 DOI: 10.1016/j.jpra.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 12/07/2022] [Indexed: 12/23/2022] Open
Abstract
Background Numerous studies have investigated surgical techniques for vascularised bone graft (VBG) for scaphoid nonunion; however, their efficacies remain unclear. Thus, to estimate the union rate of VBG for scaphoid nonunion, we performed a meta-analysis of randomised controlled trials (RCTs) and comparative studies. Methods A systematic search was conducted using PubMed, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials. The search formula was as follows: ((scaphoid nonunion) OR (scaphoid pseudarthrosis)) AND (bone graft). Only RCTs were used in the primary analysis, and comparative studies, including RCTs, in the secondary analysis. The primary outcome was nonunion rate. We compared the outcome between VBG and non-vascularised bone graft (NVBG), pedicled VBG and NVBG, and free VBG and NVBG. Results This study included a total of 4 RCTs (263 patients) and 12 observational studies (1411 patients). In the meta-analyses of both RCTs only and RCTs and other comparative studies, no significant difference in nonunion rate was found between VBG and NVBG (summary odds ratio [OR], 0.54; 95% confidence interval [CI], 0.19-1.52 and summary OR, 0.71; 95% CI, 0.45-1.12), respectively. The nonunion rates of pedicled VBG, free VBG, and NVBG were 15.0%, 10.2%, and 17.8%, respectively, and no significant difference was found. Conclusions Our results indicated that the postoperative union rate in NVBG is similar to that in VBG; thus, NVBG could be the first choice of treatment for scaphoid nonunion.
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Affiliation(s)
- Yuki Fujihara
- Department of Orthopaedic and Hand Surgery, Nagoya Ekisaikai Hospital,Address correspondence and requests for reprints to: Yuki Fujihara, M.D., Ph.D. Department of Orthopaedic and Hand Surgery, Nagoya Ekisaikai Hospital, 4-66 Shonen-Cho, Nakagawa-Ku, Nagoya, 454-8502, Japan. Tel: (+81) 90-9944-4925; Fax: (+81) 052-652-7783
| | - Michiro Yamamoto
- Department of Hand Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Satoki Hidaka
- Department of Orthopaedic and Hand Surgery, Nagoya Ekisaikai Hospital
| | - Ai Sakai
- Department of Orthopaedic and Hand Surgery, Nagoya Ekisaikai Hospital
| | - Hitoshi Hirata
- Department of Hand Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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7
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Yin Y, Xu K, Zhang N, Yi Z, Liu B, Chen S. Clinical and Epidemiological Features of Scaphoid Fracture Nonunion: A Hospital-Based Study in Beijing, China. Orthop Surg 2022; 14:2455-2461. [PMID: 36000517 PMCID: PMC9531078 DOI: 10.1111/os.13478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 07/30/2022] [Accepted: 07/30/2022] [Indexed: 11/30/2022] Open
Abstract
Objective Studies exploring the epidemiological characteristics of scaphoid fracture nonunion are important to understand the causes and lead to effective prevention strategy. However, such knowledge is limited especially in China. This study aims to reveal the clinical and epidemiological features of scaphoid fracture nonunion in Chinese patients. Methods This was a retrospective study, which was based on patients with scaphoid fracture nonunion treated in a Chinese national orthopedic referral center from 1 August 2009 to 1 August 2020. The basic demographic and clinical characteristics, including gender, age at diagnosis of scaphoid fracture nonunion, dominant hand, the location of fracture, the side, the causes of the injury, age of the injury, age of the treatment for scaphoid fracture nonunion, and the delay period, were retrieved from the medical records. The patients were divided into a non‐delay group and a delay group based on whether they had visited the doctor within 1 month after the injury. Scaphoid fracture was classified into the proximal, waist, and distal fractures according to the location. The t‐test or Mann–Whitney U test was used to compare the difference between groups when the dependent variable is continuous, while a chi‐square test was used when the dependent variable is categorical. Results A total of 363 patients were included in this study. The mean age at the diagnosis of scaphoid fracture nonunion was 32 (ranging from 14 to 78). Waist fracture nonunion (76.5%) was most common. Among the 169 patients who sought medical care within 1 month after the injury (non‐delay group), more than half (90 cases) were misdiagnosed. 23 cases could not recall the injury, so the time of delay could not be determined. Among the 171 patients who did not seek medical care for acute injury (delay group), the average time was 52 months between the initial injury and the treatment. The proportion of waist nonunions was higher among patients in the delay group than that in the non‐delay group. Conclusions Nonunion of scaphoid fracture is caused mainly by delayed treatment and misdiagnosis in China, suggesting that timely treatment and improved diagnosis could lower the prevalence. The fracture location may be a factor contributing to the delaying of seeking medical care.
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Affiliation(s)
- Yaobin Yin
- Department of Hand Surgery, Beijing Ji Shui Tan Hospital, Beijing, China
| | - Ke Xu
- Department of Hand Surgery, Beijing Ji Shui Tan Hospital, Beijing, China
| | - Nan Zhang
- Department of Hand Surgery, Beijing Ji Shui Tan Hospital, Beijing, China
| | - Zhe Yi
- Department of Hand Surgery, Beijing Ji Shui Tan Hospital, Beijing, China
| | - Bo Liu
- Department of Hand Surgery, Beijing Ji Shui Tan Hospital, Beijing, China
| | - Shanlin Chen
- Department of Hand Surgery, Beijing Ji Shui Tan Hospital, Beijing, China
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8
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Wu F, Zhang Y, Liu B. Arthroscopic bone graft and fixation for proximal scaphoid nonunions. Bone Joint J 2022; 104-B:946-952. [PMID: 35909374 DOI: 10.1302/0301-620x.104b8.bjj-2022-0198.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 This study aims to report the outcomes in the treatment of unstable proximal third scaphoid nonunions with arthroscopic curettage, non-vascularized bone grafting, and percutaneous fixation. METHODS This was a retrospective analysis of 20 patients. All cases were delayed presentations (n = 15) or failed nonoperatively managed scaphoid fractures (n = 5). Surgery was performed at a mean duration of 27 months (7 to 120) following injury with arthroscopic debridement and arthroscopic iliac crest autograft. Fracture fixation was performed percutaneously with Kirschner (K)-wires in 12 wrists, a headless screw in six, and a combination of a headless screw and single K-wire in two. Clinical outcomes were assessed using grip strength, patient-reported outcome measures, and wrist range of motion (ROM) measurements. RESULTS Intraoperatively, established avascular necrosis of the proximal fragment was identified in ten scaphoids. All fractures united within 16 weeks, confirmed by CT. At a mean follow-up of 31 months (12 to 64), there were significant improvements in the Patient-Rated Wrist Evaluation, Mayo Wrist Score, abbreviated Disabilities of the Arm, Shoulder and Hand score, wrist ROM, grip strength, and the patients' subjective pain score. No peri- or postoperative complications were encountered. CONCLUSION Our data indicate that arthroscopic bone grafting and fixation with cancellous autograft is a viable method in the treatment of proximal third scaphoid nonunions, regardless of the vascularity of the proximal fragment. Cite this article: Bone Joint J 2022;104-B(8):946-952.
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Affiliation(s)
- Feiran Wu
- Birmingham Hand Centre, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham, UK
| | - Yuhao Zhang
- Department of Orthopaedic Surgery, Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Bo Liu
- Department of Hand Surgery, Beijing Jishuitan Hospital, the fourth Clinical College of Peking University, Beijing, China
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9
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Johnson NA, Fairhurst C, Brealey SD, Cook E, Stirling E, Costa M, Divall P, Hodgson S, Rangan A, Dias JJ. One-year outcome of surgery compared with immobilization in a cast for adults with an undisplaced or minimally displaced scaphoid fracture : a meta-analysis of randomized controlled trials. Bone Joint J 2022; 104-B:953-962. [PMID: 35909381 DOI: 10.1302/0301-620x.104b8.bjj-2022-0085.r2] [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 There has been an increasing use of early operative fixation for scaphoid fractures, despite uncertain evidence. We conducted a meta-analysis to evaluate up-to-date evidence from randomized controlled trials (RCTs), comparing the effectiveness of the operative and nonoperative treatment of undisplaced and minimally displaced (≤ 2 mm displacement) scaphoid fractures. METHODS A systematic review of seven databases was performed from the dates of their inception until the end of March 2021 to identify eligible RCTs. Reference lists of the included studies were screened. No language restrictions were applied. The primary outcome was the patient-reported outcome measure of wrist function at 12 months after injury. A meta-analysis was performed for function, pain, range of motion, grip strength, and union. Complications were reported narratively. RESULTS Seven RCTs were included. There was no significant difference in function between the groups at 12 months (Hedges' g 0.15 (95% confidence interval -0.02 to 0.32); p = 0.082). The complication rate was higher in the operative group and involved more serious complications. CONCLUSION We found no difference in functional outcome at 12 months for fractures of the waist of the scaphoid with ≤ 2 mm displacement treated operatively or nonoperatively. The complication rate was higher with operative treatment. Cite this article: Bone Joint J 2022;104-B(8):953-962.
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Affiliation(s)
- Nick A Johnson
- University Hospitals of Leicester NHS Trust, Leicester, UK.,Pulvertaft Hand Centre, Royal Derby Hospital, Derby, UK
| | - Caroline Fairhurst
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Stephen D Brealey
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Elizabeth Cook
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Euan Stirling
- Oxford University Hospitals NHS Foundation Trust, Nuffield Orthopaedic Centre, Oxford, UK
| | - Matt Costa
- Oxford Trauma and Emergency Care, NDORMS, University of Oxford, The Kadoorie Centre, John Radcliffe Hospital, Oxford, UK
| | - Pip Divall
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Stephen Hodgson
- Department of Orthopaedic Surgery, Bolton NHS Foundation Trust, Royal Bolton Hospital, Bolton, UK
| | - Amar Rangan
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Joseph J Dias
- University Hospitals of Leicester NHS Trust, Leicester, UK
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10
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Chong HH, Kulkarni K, Shah R, Hau MYT, Athanatos L, Singh HP. A meta-analysis of union rate after proximal scaphoid fractures: terminology matters. J Plast Surg Hand Surg 2021; 56:298-309. [PMID: 34550858 DOI: 10.1080/2000656x.2021.1979016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Heterogeneity in the anatomical definition of 'proximal' affects the comparison of outcomes of these scaphoid fractures. This study aims to review published outcomes of all variants to determine both, differences in terminology, and union rate based upon definition. A literature search was conducted to identify articles that reported descriptions and union rate of all acute (<8 weeks of injury) proximal scaphoid fractures in adult patients (>16 years old). Proximal fractures were grouped as reported ('third', 'pole', 'fifth' or 'undefined'). The data were pooled using a fixed-effects method, and a meta-analysis was conducted to compare relative risk (RR) of non-union against non-proximal fractures. Qualitative analysis of 12 articles included three main definitions: 'proximal' (1 article), 'proximal third' (3 articles), and 'proximal pole' (8 articles). Only 6 articles adopted a specific anatomical or ratio description. In a pooled meta-analysis of union rates (15 articles), 'proximal third' and 'proximal pole' fractures demonstrated a relative risk (RR) of non-union of 2.3 and 3.4 in comparison to non-proximal fractures, respectively. Operative management yielded lower non-union rates than non-operative for all fracture types (6% vs. 18%). In conclusion, non-union risk varies depending on definition, with non-standardised classifications adding heterogeneity to reported outcomes. We recommend an approach utilizing fixed anatomical landmarks on plain radiographs (referencing scaphoid length and scapho-capitate joint) to standardise reporting of proximal fracture union in future studies. Abbreviations: CI: confidence intervals; CT: computer tomography; Df: degrees of freedom; DL: dersimonian and laird estimator; MRI: magnetic resonance imaging; NICE: national institute for health and care excellence; OTA: orthopaedic trauma association; PA: posterior-anterior; PRISMA: preferred reporting items for systematic reviews and meta analyses; RCT: randomised controlled trial; RR: relative risk; SNAC: scaphoid non-union advanced collapse; UK: United Kingdom.
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Affiliation(s)
- Han Hong Chong
- University Hospital of Leicester NHS Trust, Leicester, United Kingdom
| | - Kunal Kulkarni
- Pulvertaft Hand Centre, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Rohi Shah
- University Hospital of Leicester NHS Trust, Leicester, United Kingdom
| | - Melinda Y T Hau
- University Hospital of Leicester NHS Trust, Leicester, United Kingdom
| | - Lambros Athanatos
- University Hospital of Leicester NHS Trust, Leicester, United Kingdom
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11
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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 2021; 24:1-234. [PMID: 33109331 DOI: 10.3310/hta24520] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [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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12
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Keating C, McCombe D, Powell CA, Maloney P, Ek ET, Tham SK. Reconstruction of the Proximal Scaphoid With a Medial Femoral Trochlea Osteochondral Graft: Minimum 2-Year Results. J Hand Surg Am 2021; 46:248.e1-248.e9. [PMID: 33257054 DOI: 10.1016/j.jhsa.2020.10.014] [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: 07/24/2019] [Revised: 07/26/2020] [Accepted: 10/06/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To report the clinical and radiological outcomes after medial femoral trochlear (MFT) osteochondral graft for the salvage of proximal scaphoid fractures with a minimum 2-year follow-up. METHODS A retrospective review was performed of patients with comminuted fractures of the proximal scaphoid treated by excision of the proximal pole and replacement with free vascularized MFT osteochondral graft. Demographic data, objective and radiographic measurements, and patient-reported outcome measures of the upper limb and knee were collected. Pain was assessed by completion of a visual analog scale (VAS). RESULTS Between February 2014 and May 2015, 12 MFT osteochondral grafts were performed. Eight patients were available for follow-up at a mean of 34 months (range, 28-39 months). The mean range of wrist flexion was 31° (range, 15°-60°), extension was 34° (range, 5°-60°), radial deviation was 9° (range, 0°-20°), ulnar deviation was 28° (range, 10°-45°) and grip strength was 42 kg (range, 25-53 kg). The median wrist pain, as measured by VAS, was 0.7 (mean, 1.3; range, 0-6). The average follow-up scapholunate, radiolunate, and radioscaphoid angles were 58.9° (range, 44°-93°), 12.9° (range, 0°-30°), and 46.0° (range, 35°-63°), respectively. The mean Disabilities of the Arm, Shoulder, and Hand (DASH) score was 13.9 (range, 3-43) and Patient Rated Wrist Evaluation (PRWE) score was 22.4 (range, 2-68). The mean postoperative Oxford Knee Score was 42 (range, 14-48). One patient suffered notable knee pain at 37-month follow-up. One patient suffered notable pain on the radial side of the wrist and underwent scaphoid excision and 4-corner arthrodesis. CONCLUSIONS Replacement of the fragmented proximal scaphoid by MFT graft is an alternative to other salvage options and most patients can expect pain relief and acceptable wrist motion. These results need to be balanced against the potential for donor-site morbidity. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic V.
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Affiliation(s)
- Cameron Keating
- Hand Surgery Unit, Department of Plastic Surgery, St. Vincent's Hospital, Melbourne, Australia
| | - David McCombe
- Hand Surgery Unit, Department of Plastic Surgery, St. Vincent's Hospital, Melbourne, Australia; Hand and Wrist Biomechanics Laboratory (HWBL), O'Brien Institute, St. Vincent Institute, Melbourne, Australia
| | - Christopher A Powell
- Hand Surgery Unit, Department of Plastic Surgery, St. Vincent's Hospital, Melbourne, Australia
| | - Peter Maloney
- Division of Hand Surgery, Department of Orthopaedic Surgery, Dandenong Hospital, Monash University, Melbourne, Australia
| | - Eugene T Ek
- Hand and Wrist Biomechanics Laboratory (HWBL), O'Brien Institute, St. Vincent Institute, Melbourne, Australia; Division of Hand Surgery, Department of Orthopaedic Surgery, Dandenong Hospital, Monash University, Melbourne, Australia
| | - Stephen K Tham
- Hand Surgery Unit, Department of Plastic Surgery, St. Vincent's Hospital, Melbourne, Australia; Hand and Wrist Biomechanics Laboratory (HWBL), O'Brien Institute, St. Vincent Institute, Melbourne, Australia; Division of Hand Surgery, Department of Orthopaedic Surgery, Dandenong Hospital, Monash University, Melbourne, Australia.
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13
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Kaiser P, Brueckner G, Kastenberger T, Schmidle G, Stock K, Arora R. Mid-term follow-up of surgically treated and healed scaphoid fractures. HAND SURGERY & REHABILITATION 2021; 40:288-292. [PMID: 33549698 DOI: 10.1016/j.hansur.2020.12.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 12/02/2020] [Accepted: 12/02/2020] [Indexed: 01/16/2023]
Abstract
The aim of this study was to evaluate the mid-term results of surgically treated scaphoid fractures since we were concerned that good results might deteriorate over time due to osteoarthritis or functional impairment. Thirty-three out of 121 surgically treated patients (isolated scaphoid fractures n = 23; scaphoid fractures with concomitant injuries n = 10) were evaluated retrospectively (47-138 months). Five patients (4%) had a non-union after internal fixation and were excluded because of additional treatment. The remaining 83 patients were not available for a follow-up examination. Patients with an isolated scaphoid fracture had a mean extension-flexion of 68°-0°-64°, a radial-ulnar deviation of 27°-0°-41° and a grip strength of 39 kg (corresponding to 87-98% of the uninjured contralateral wrist), while patients with concomitant injuries had a mean extension-flexion of 60°-0°-44°, radial-ulnar deviation of 22°-0°-38° and a grip strength of 42 kg (corresponding to 73-98% of the uninjured contralateral wrist). The Michigan Hand Questionnaire score was 85 and 75 and the Patient-Rated Wrist Evaluation score was 8 and 21, respectively. Fifteen patients had radiological signs of radiocarpal osteoarthritis with a significantly higher occurrence in those who had concomitant injuries compared to those with isolated scaphoid fractures (p < 0.01). There was no significant group difference in scaphotrapeziotrapezoid (STT) osteoarthritis (p = 0.968). One STT osteoarthritis case occurred after plate fixation, one after antegrade screw fixation and 10 after retrograde screw fixation. Surgical treatment of an acute isolated scaphoid fracture has excellent clinical, functional, and radiologic mid-term results, while scaphoid fractures with concomitant wrist injuries have slightly inferior results.
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Affiliation(s)
- P Kaiser
- Department for Orthopaedics and Traumatology, Medical University Innsbruck, Anichstr. 35, 6020 Innsbruck, Austria.
| | - G Brueckner
- Department for Orthopaedics and Traumatology, Medical University Innsbruck, Anichstr. 35, 6020 Innsbruck, Austria.
| | - T Kastenberger
- Department for Orthopaedics and Traumatology, Medical University Innsbruck, Anichstr. 35, 6020 Innsbruck, Austria.
| | - G Schmidle
- Department for Orthopaedics and Traumatology, Medical University Innsbruck, Anichstr. 35, 6020 Innsbruck, Austria.
| | - K Stock
- Department for Orthopaedics and Traumatology, Medical University Innsbruck, Anichstr. 35, 6020 Innsbruck, Austria.
| | - R Arora
- Department for Orthopaedics and Traumatology, Medical University Innsbruck, Anichstr. 35, 6020 Innsbruck, Austria.
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14
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Chang N, Grewal R. Conservative treatment for fractures of the scaphoid. HANDCHIR MIKROCHIR P 2020; 52:399-403. [PMID: 32992397 DOI: 10.1055/a-1242-5345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
This review article aims to discuss the indications, techniques, outcomes, and complications of non-operative management of scaphoid fractures.
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Affiliation(s)
- Nick Chang
- University of Western Ontario Schulich School of Medicine and Dentistry Roth
- McFarlane Hand and Upper Limb Surgery
| | - Ruby Grewal
- University of Western Ontario Roth
- McFarlane Hand and Upper Limb Center
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15
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Crepaldi BE, Keating C, Ek ET, Tham SKY. Medial Femoral Trochlea Graft for Scaphoid Waist Nonunion: A Case Report and Review of the Literature. J Wrist Surg 2020; 9:186-189. [PMID: 32509420 PMCID: PMC7263860 DOI: 10.1055/s-0039-3401015] [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: 11/26/2018] [Accepted: 11/01/2019] [Indexed: 10/25/2022]
Abstract
The medial femoral trochlea (MFT) of the knee is a donor site for convex osteochondral vascularized bone that has been used for the salvage of fractures of the proximal pole of the scaphoid. Chronic nonunited fractures of the scaphoid may lead to a sequence of degenerative change often referred to as scaphoid nonunion advance collapse. The vascularized MFT osteochondral graft has been reported as a salvage procedure for fractures of the proximal pole of the scaphoid, in situations where fixation is not an option. In this "Special review," we describe the technique of free vascularized MFT graft in a case in which the nonunited scaphoid fracture was associated with segmental loss of the articular surface of the scaphoid waist. Given the likely progression of arthritis, if left untreated, we elected to treat this by replacing the lost articular surface using a vascularized intercalary osteochondral MFT graft between the nonunited scaphoid segments.
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Affiliation(s)
- Bruno E. Crepaldi
- St. Vincent's Hand Surgery Unit, Victorian Hand Surgery Associates, Fitzroy, Victoria, Australia
| | - Cameron Keating
- St. Vincent's Hand Surgery Unit, Victorian Hand Surgery Associates, Fitzroy, Victoria, Australia
| | - Eugene T. Ek
- Hand and Wrist Biomechanics Laboratory, O'Brien Institute, Fitzroy, Victoria, Australia
- Dandenong Hospital Hand Unit, Dandenong, Victoria, Australia
| | - Stephen K. Y. Tham
- St. Vincent's Hand Surgery Unit, Victorian Hand Surgery Associates, Fitzroy, Victoria, Australia
- Hand and Wrist Biomechanics Laboratory, O'Brien Institute, Fitzroy, Victoria, Australia
- Dandenong Hospital Hand Unit, Dandenong, Victoria, Australia
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16
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A Mini-Open, Dorsal Approach for Scaphoid Fracture Fixation With a Ligament Sparing Arthrotomy. Tech Hand Up Extrem Surg 2020; 24:32-36. [PMID: 31895249 DOI: 10.1097/bth.0000000000000278] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
There are several surgical approaches that are currently used to address nondisplaced scaphoid waist fractures, including percutaneous fixation, limited exposure fixation, and traditional open techniques through a volar or dorsal approach. Although percutaneous fixation has some theoretical advantages, it is much more difficult to achieve an accurate starting point for a headless compression screw. The purpose of this paper is to describe a simple, dorsal, mini-open approach to the scaphoid that minimizes incision size, extensor tendon dissection, capsular trauma, and vascular disruption, while still allowing for direct visualization of the proximal pole and optimal exposure for accurate screw placement. As a case report, we retrospectively evaluated 80 consecutive patients with closed scaphoid fractures. There were 2 groups, with 44 patients (age: 24±10 y) receiving a percutaneous dorsal approach and 36 patients (age: 30±16 y) treated with a mini-open approach. All scaphoid fractures were acute or fibrous nonunions (<6 mo from injury, except for one) treated with cannulated headless compression screws. Intraoperative and postoperative complications were measured and evaluated for each group to assess for differences between the percutaneous approach and the mini-open technique. We found no significant difference in complication rate with the mini-open dorsal technique compared with the dorsal percutaneous approach (8.3% vs. 4.5%, respectively). Therefore, we suggest consideration of this mini-open dorsal approach for scaphoid fracture fixation as a useful and safe technique.
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17
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The Use of the Proximal Hamate as an Autograft for Proximal Pole Scaphoid Fractures: Clinical Outcomes and Biomechanical Implications. Hand Clin 2019; 35:287-294. [PMID: 31178087 DOI: 10.1016/j.hcl.2019.03.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Scaphoid proximal pole fractures remain a surgical challenge because of high propensity for nonunion, osteonecrosis, and ultimately carpal collapse. Options for management of nonsalvageable proximal pole fractures include non-vascularized bone grafts, vascularized pedicled bone grafts, free vascularized bone flaps, and rib cartilage grafts. The proximal pole of the hamate can also serve as a replacement arthroplasty in the setting of proximal pole scaphoid nonunions with collapse, bone loss, and/or osteonecrosis. This novel graft addresses shortcomings of other graft choices by providing a local structural autograft solution with minimal donor site morbidity, correcting carpal collapse, reconstructing the scapholunate ligament, and mitigating the need for microvascular anastomosis.
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18
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Schreiber JJ, Kang L, Hearns KA, Pickar T, Carlson MG. Micro Screw Fixation for Small Proximal Pole Scaphoid Fractures with Distal Radius Bone Graft. J Wrist Surg 2018; 7:319-323. [PMID: 30174989 PMCID: PMC6117170 DOI: 10.1055/s-0038-1660445] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 04/23/2018] [Indexed: 10/14/2022]
Abstract
Background Achieving adequate fixation and healing of small proximal pole acute scaphoid fractures can be surgically challenging due to both fragment size and tenuous vascularity. Purpose The purpose of this study was to demonstrate that this injury can be managed successfully with osteosynthesis using a "micro" small diameter compression screw with distal radius bone graft with leading and trailing screw threads less than 2.8 mm. Patients and Methods Patients with proximal pole scaphoid fragments comprising less than 20% of the entire scaphoid were included. Fixation was accomplished from a dorsal approach with a micro headless compression screw and distal radius bone graft. Six patients were included. Average follow-up was 44 months (range, 11-92). Results Mean proximal pole fragment size was 14% (range, 9-18%) of the entire scaphoid. The mean immobilization time was 6 weeks, time-to-union of 6 weeks, and final flexion/extension arc of 88°/87°. All patients had a successful union, and no patient had deterioration in range of motion, avascular necrosis, or fragmentation of the proximal pole. Conclusion Small diameter screws with a maximal thread diameter of ≤ 2.8 mm can be used to fix the union of proximal pole acute scaphoid fractures comprising less than 20% of the total area with good success. Level of Evidence Therapeutic case series, Level IV.
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Affiliation(s)
- Joseph J. Schreiber
- Division of Hand and Upper Extremity Surgery, Hospital for Special Surgery, New York, New York
| | - Lana Kang
- Division of Hand and Upper Extremity Surgery, Hospital for Special Surgery, New York, New York
| | - Krystle A. Hearns
- Division of Hand and Upper Extremity Surgery, Hospital for Special Surgery, New York, New York
| | - Tracy Pickar
- Division of Hand and Upper Extremity Surgery, Hospital for Special Surgery, New York, New York
| | - Michelle G. Carlson
- Division of Hand and Upper Extremity Surgery, Hospital for Special Surgery, New York, New York
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19
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Abstract
Scaphoid fracture nonunion can often lead to pain, arthrosis, and disability. While typically the result of delayed diagnosis or inadequate treatment, it can sometimes occur even if the initial care was timely and appropriate. Whereas early recognition of acute fractures allows for nonoperative management, nonunions frequently require surgical treatment. Traditionally, this has involved open debridement and bone grafting. However, some publications suggest that certain stable nonunions may be amenable to percutaneous debridement and fixation without formal bone grafting. Although certain characteristics appear to be appropriate indications for such management, well-designed clinical studies are needed to better define them.
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20
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Proximal Pole Scaphoid Nonunion Reconstruction With 1,2 Intercompartmental Supraretinacular Artery Vascularized Graft and Compression Screw Fixation. J Hand Surg Am 2018; 43:770.e1-770.e8. [PMID: 29426603 DOI: 10.1016/j.jhsa.2018.01.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 12/04/2017] [Accepted: 01/02/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To review the incidence of union of patients with proximal pole scaphoid fracture nonunions treated using a 1,2 intercompartmental supraretinacular artery (1,2 ICSRA) vascularized graft and a small compression screw. METHODS This is a retrospective case series of 12 patients. Calculations of the size of the proximal pole fragment relative to the total scaphoid were performed using posteroanterior view scaphoid radiographs with the wrist in ulnar deviation and flat on the cassette. Analyses were repeated 3 times per subject, and the average ratio of proximal pole fragment relative to the entire scaphoid was calculated. We reviewed medical records, radiographs, and computed tomography (CT) scans of these 12 patients. The CT scans that were performed after an average of 12 weeks were ultimately used to confirm union of the scaphoid fractures. One patient was unable to have a CT so was excluded from the final calculation. RESULTS All 11 (100%) scaphoid fractures that were assessed by CT were found to be healed at the 12-week assessment point. The mean proximal pole fragment size was 18% (range, 7%-27%) of the entire scaphoid. CONCLUSIONS The 1,2 ICSRA vascularized graft and compression screw was an effective treatment for patients with proximal pole scaphoid fractures. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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21
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Luengo Alonso G, Jiménez Díaz V, Garcia Lamas L, Porras Moreno M, Cecilia López D. Scaphoid fractures treated with a volar percutaneous approach. Analysis and results in 92 cases. Rev Esp Cir Ortop Traumatol (Engl Ed) 2018. [DOI: 10.1016/j.recote.2018.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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22
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Abstract
Acute scaphoid fractures are common wrist injuries that continue to elicit debate from surgeons regarding the most appropriate diagnostic and management algorithms. This review will examine the current literature and trends, in an attempt to provide the reader with an evidence-based discussion regarding current controversies of interest to clinicians. In addition, an attempt will be made to provide recommendations for the best treatment practices for acute scaphoid fractures.
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Affiliation(s)
- Nina Suh
- Roth McFarlane Hand and Upper Limb Centre, St. Joseph's Hospital, University of Western Ontario, London, Ontario, Canada
| | - Ruby Grewal
- Roth McFarlane Hand and Upper Limb Centre, St. Joseph's Hospital, University of Western Ontario, London, Ontario, Canada
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23
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Luengo Alonso G, Jiménez Díaz V, Garcia Lamas L, Porras Moreno MA, Cecilia López D. Scaphoid Fractures treated with a volar percutaneous approach. Analysis and results in 92 cases. Rev Esp Cir Ortop Traumatol (Engl Ed) 2017; 62:105-111. [PMID: 29196227 DOI: 10.1016/j.recot.2017.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 10/05/2017] [Accepted: 10/10/2017] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Herbert type B1 and B2 scaphoid fractures can be treated by orthopaedic treatment or surgery. The aim of this study is to analyse results and complications of scaphoid waist fractures treated using the percutaneous volar approach. MATERIAL AND METHOD We present a retrospective study of 92 patients, treated in our institution from 2006 to 2016 using a volar percutaneous fixation. Mean Follow-up was 16 months (range 12-48). Injuries were classified using Hebert's classification, including B1 and B2 fracture types; the other fracture types following this classification system were excluded. Politrauma patients, dorsal approach, fractures associated with distal radius injuries, patients treated using another surgical technique and patients with non follow-up were also excluded. Functional results were evaluated using the DASH questionnaire. Consolidation was established as the presence of bony bridges crossing the fracture site on x-rays, associated with absence of pain. RESULTS The average time to fracture healing was 6.6 weeks (range 5-11). After 12 months of follow-up, the average wrist range of motion was 70° of extension (range 58-75) and 70° of flexion (range 62-80). Regarding functional evaluation, the average DASH questionnaire score was 42. The most frequent complication was non-union in 4 cases (4.44%). Average surgical time was 25min. CONCLUSIONS Volar percutaneous fixation is a simple and quick technique for a specialist surgeon, characterised by low morbidity and complication rates compared to ORIF and orthopaedic treatment, which accelerates the patient's functional recovery.
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Affiliation(s)
- G Luengo Alonso
- Unidad Mano y Codo, Hospital Universitario 12 de Octubre, Madrid, España.
| | - V Jiménez Díaz
- Unidad Mano y Codo, Hospital Universitario 12 de Octubre, Madrid, España
| | - L Garcia Lamas
- Unidad Mano y Codo, Hospital Universitario 12 de Octubre, Madrid, España
| | - M A Porras Moreno
- Unidad Mano y Codo, Hospital Universitario 12 de Octubre, Madrid, España
| | - D Cecilia López
- Unidad Mano y Codo, Hospital Universitario 12 de Octubre, Madrid, España; Universidad Complutense, Departamento de Cirugía, Madrid, España
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24
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Hirche C, Xiong L, Heffinger C, Münzberg M, Fischer S, Kneser U, Kremer T. Vascularized versus non-vascularized bone grafts in the treatment of scaphoid non-union. J Orthop Surg (Hong Kong) 2017; 25:2309499016684291. [PMID: 28125938 DOI: 10.1177/2309499016684291] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Conventional non-vascularized bone grafts as well as vascularized bone grafts are used to treat scaphoid non-union (SN). Due to limited available studies, the field of application using both grafts for SN still remains controversial. The aim of this study was to evaluate a treatment algorithm for the use of both vascularized versus non-vascularized bone grafts based on clinical outcomes and quality of life (QoL) to improve the level of evidence. MATERIALS AND METHODS Based on a retrospective cohort study, including 28 patients with vascularized and 45 patients with conventional bone grafts, functional parameters, radiological outcome, Mayo-wrist-score, and QoL by SF-36 were applied to statistically compare the outcome of these two techniques. RESULTS Time between last procedure or trauma and study group scaphoid reconstruction was almost double in the vascularized bone grafting group. Comparable union rates were achieved with vascularized as well as non-vascularized bone grafts. Significant differences were observed between both groups for grip strength and radial-ulnar active range of motion. Further functional outcomes, radiological outcomes as well as QoL were found similar for both techniques in patients with surgical union. DISCUSSION AND CONCLUSIONS In order to achieve comparable and appropriate treatment results, vascularized bone grafts are recommended for patients with delayed treatment, impaired scaphoid vascularity, and revision surgery. Even in preselected, complex cases, the results are comparable to conventional grafts, which are the basis for further patient education and approve the powerful role of surgical angiogenesis of vascularized bone grafts.
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Affiliation(s)
- Christoph Hirche
- 1 Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Lingyun Xiong
- 1 Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany.,2 Department of Plastic and Reconstructive Surgery, Union Hospital, Huazhong University of Science and Technology, Hubei, China
| | - Christian Heffinger
- 1 Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Matthias Münzberg
- 3 Department of Trauma and Orthopedic Surgery, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Sebastian Fischer
- 1 Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Ulrich Kneser
- 1 Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Thomas Kremer
- 1 Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
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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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Papaloizos MY, Fusetti C, Christen T, Nagy L, Wasserfallen JB. Minimally Invasive Fixation versus Conservative Treatment of Undisplaced Scaphoid Fractures: A Cost-Effectiveness Study. ACTA ACUST UNITED AC 2016; 29:116-9. [PMID: 15010155 DOI: 10.1016/j.jhsb.2003.10.009] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2003] [Accepted: 10/20/2003] [Indexed: 11/16/2022]
Abstract
This study compares the direct and indirect costs of conservative and minimally invasive treatment for undisplaced scaphoid fractures. Costs data concerning groups of non-operated and operated patients were analysed. Direct costs were higher in operated patients. Although highly variable, indirect costs were significantly smaller in operated patients and the total costs were higher in nonoperated patients. In conclusion, operative treatment of scaphoid fractures is initially more expensive than conservative treatment but markedly decreases the work compensation costs.
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Affiliation(s)
- M Y Papaloizos
- Hand Surgery Unit, Geneva University Hospital, Geneva, Switzerland and the Health Technology Assessment Unit, Lausanne University Hospital, Switzerland.
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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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Brannan PS, Gaston RG, Loeffler BJ, Lewis DR. Complications With the Use of BMP-2 in Scaphoid Nonunion Surgery. J Hand Surg Am 2016; 41:602-8. [PMID: 27013317 DOI: 10.1016/j.jhsa.2016.01.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 01/21/2016] [Accepted: 01/22/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE In an effort to improve fracture healing and decrease the need for autologous bone graft, products such as recombinant human bone morphogenetic protein (rhBMP-2) have been developed and used in both spine and nonspine surgery. There is a paucity of literature regarding the use of rhBMP-2 in scaphoid nonunion surgery with very little reporting on the complications associated with its use. The objective of this study was to retrospectively review the complications documented for a case series of patients treated with revision fixation, bone graft, and rhBMP-2 in revision scaphoid nonunion surgery. METHODS We retrospectively reviewed 6 cases of scaphoid nonunion revision surgery comprising open reduction and internal fixation (ORIF). All cases were performed for persistent nonunion after a previous scaphoid ORIF. All patients were treated with revision screw fixation, bone graft, and rhBMP-2. Union was determined by computed tomography in all cases. Complications of nonunion, heterotopic bone formation, delayed wound healing, functional loss of motion, and need for revision surgery are reported. RESULTS Between 2011 and 2014, 6 cases in which rhBMP-2 was used in revision scaphoid nonunion surgery were identified. All patients had failed an initial attempt at ORIF after delayed union or nonunion. The time from injury to index ORIF ranged from 3 months to 4 years (mean, 24 months). Revision surgery with rhBMP-2 was performed at an average of 6 months from the index ORIF. Of the 6 cases, 2 had resultant persistent nonunion. Both underwent scaphoid excision and midcarpal arthrodesis. Four cases developed notable heterotopic ossification (one of which required revision surgery). One patient had a loss of functional motion after the revision surgery. There were no cases of delayed wound healing. Only one of the 6 patients healed without complications. CONCLUSIONS In this case series, the use of rhBMP-2 in scaphoid nonunions was associated with a higher complication rate than reported in previous studies. Surgeons performing off-label use of rhBMP-2 should be aware of the potential for complications including heterotopic ossification. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Park HY, Yoon JO, Kim K, Bae K, Sohn DW, Kim JS. Reliability of semi-pronated ulnar deviation PA view (billiard view) of the wrist in evaluating the scaphoid. J Plast Reconstr Aesthet Surg 2016; 69:977-82. [PMID: 27053512 DOI: 10.1016/j.bjps.2016.02.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 02/15/2016] [Accepted: 02/19/2016] [Indexed: 11/24/2022]
Abstract
Various methods assessing the scaphoid have been reported because of its unique position. In our hospital, pre- and postoperative evaluation of the scaphoid alignment has been carried out in the billiard view, a combination of 45° pronated oblique with ulnar deviation posteroanterior (PA) view, in addition to 3DCT scan and PA and lateral view. This study compared the intra- and inter-observer reliabilities of the lateral intrascaphoid angle and scaphoid length (SL) and scaphoid height (SH) on the billiard view. A total of 60 patients who underwent surgery for scaphoid nonunion were identified and the preoperative and the final follow-up postoperative plain radiographs were used for measurement. Three observers assessed each image. Intra- and inter-observer reliability was determined using intra-class correlation (ICC) coefficients. Intra-observer reliability was all excellent ranging between 0.855 and 0.992. Inter-observer reliability ranged between 0.292 and 0.983. SL and SH demonstrated excellent agreement, while ISA demonstrated poor to moderate agreement. The best method for assessing the scaphoid in simple radiograph remains debatable, but our current data suggest that measuring SL and SH on the billiard view is reproducible and can be used for evaluating restoration of scaphoid alignment.
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Affiliation(s)
- Ho Youn Park
- Department of Orthopedic Surgery, Uijeongbu St. Mary's Hospital, Catholic University, South Korea.
| | - Jun O Yoon
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, South Korea
| | - Keonghwan Kim
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, South Korea
| | - Kunhyung Bae
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, South Korea
| | - Dong Wook Sohn
- Department of Orthopedic Surgery, Myongji Hospital, Goyang, South Korea
| | - Jin Sam Kim
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, South Korea
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Farsetti P, Caterini R, Potenza V, Dragoni M, Ippolito E. Modified Murray Technique for Carpal Navicular Nonunion. Orthopedics 2015; 38:e766-72. [PMID: 26375533 DOI: 10.3928/01477447-20150902-53] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2014] [Accepted: 12/12/2014] [Indexed: 02/03/2023]
Abstract
The authors report the results of long-term follow-up in 29 patients treated for non-union of the carpal navicular with a modified Murray technique performed through a lateral approach. Mean patient age at surgery was 22.5 years. Average time from injury to surgery for nonunion was 18 months. In 5 cases, mild signs of osteoarthritis of the radioscaphoid joint (scaphoid nonunion advanced collapse [SNAC] stage I) were present before surgery, and in 2 cases, radiographic signs of avascular necrosis of the proximal nonunion fragment were evident. In all cases, a corticocancellous nonvascularized bone graft taken from the distal part of the ipsilateral radius was used. Mean follow-up was 11.2 years. Nonunion had healed in 93.1% of cases. At follow-up, the 2 patients in whom nonunion had not healed had severe painful osteoarthritis of the wrist (SNAC stage IV). Twenty patients were asymptomatic, and 5 had occasional pain in the wrist. Wrist range of motion was restricted in all patients compared with the contralateral side. Mild osteoarthritis was observed in 6 patients (SNAC stage I). The average Disabilities of the Arm, Shoulder and Hand score was 8.7 of 100. The modified Murray technique is reliable for treating nonunion of the carpal navicular. The union rate is high, and the incidence of wrist osteoarthritis is low compared with other studies. Early diagnosis and treatment of nonunion (a short interval between fracture and surgery) can minimize the risk of degenerative joint disease. Avascular necrosis of the proximal fragment is not an absolute contraindication to surgery.
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Conservative Treatment Versus Arthroscopic-Assisted Screw Fixation of Scaphoid Waist Fractures--A Randomized Trial With Minimum 4-Year Follow-Up. J Hand Surg Am 2015; 40:1341-8. [PMID: 25913660 DOI: 10.1016/j.jhsa.2015.03.007] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Revised: 03/06/2015] [Accepted: 03/07/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate clinical and radiological outcomes after conservative treatment and arthroscopic-assisted screw fixation of acute non- or minimally displaced scaphoid waist fractures in a randomized controlled trial. METHODS Consecutive patients with acute non- or minimally displaced scaphoid waist fractures were prospectively randomized to conservative or surgical treatment. All patients were screened using radiographs, computed tomography, and magnetic resonance imaging. Conservative treatment consisted of a below-elbow thumb spica cast until radiological signs of union appeared. Surgical treatment consisted of wrist arthroscopy and percutaneous antegrade screw fixation. Clinical examination, radiographs, and computed tomography were used to follow the patients. Twenty-four patients were treated conservatively and 14 patients underwent surgery. The patients were followed at regular intervals for 1 year after surgery. Twenty-one patients treated conservatively and 14 treated surgically were available for follow-up after a median of 6 years (range, 4-8 y). RESULTS At 26 weeks, the conservatively treated group had significantly better range of motion and had reached almost normal value compared with the contralateral wrist. There were no significant differences between the 2 groups concerning grip or pinch strengths at any measure point. At follow-up after a median of 6 years, radiographic signs of arthritis in the radioscaphoid joint were more common in the surgically treated group (3 of 14) than in the conservative group (2 of 21). CONCLUSIONS Non- and minimally displaced scaphoid waist fractures are best treated conservatively. Operative treatment may provide an improved functional outcome in the short term but at the price of a possible increased risk of arthritis in the long term. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic II.
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Reigstad O, Thorkildsen R, Grimsgaard C, Melhuus K, Røkkum M. Undersøkelse og behandling av brudd og pseudartrose i skafoid. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2015; 135:1138-42. [DOI: 10.4045/tidsskr.14.1256] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Affiliation(s)
- Ole Reigstad
- Hand- and Microsurgery section Orthopaedic department OUS-Rikshospitalet Postboks 4950 Nydalen 0424 Oslo Norway
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Hirche C, Heffinger C, Xiong L, Lehnhardt M, Kneser U, Bickert B, Gazyakan E. The 1,2-intercompartmental supraretinacular artery vascularized bone graft for scaphoid nonunion: management and clinical outcome. J Hand Surg Am 2014; 39:423-9. [PMID: 24444804 DOI: 10.1016/j.jhsa.2013.10.028] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Revised: 10/27/2013] [Accepted: 10/28/2013] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the clinical outcome of 1,2-intercompartmental supraretinacular artery pedicled vascularized bone graft for scaphoid nonunion (SN). METHODS A retrospective study was performed to evaluate patients with SN and treated with 1,2-intercompartmental supraretinacular artery pedicled vascularized bone graft between 1997 and 2010. Functional measures, quality of life by Short Form SF-36 questionnaire, and analysis of risk factors were included. RESULTS Out of 39 patients who were eligible for the study, 11 were lost to follow-up. Out of the remaining 28 patients, union was achieved in 21 (75%). The mean length of follow-up was 63 ± 45 months. In hands with scaphoid union, the grip strength and the radioulnar active range of motion were less than the contralateral side but greater compared with patients with nonunion. Active extension-flexion was less compared with the noninjured hand but similar to patients with nonunion. Disabilities of the Arm, Shoulder and Hand (DASH) score decreased from 58 to 23 in dominant hands and from 46 to 13 in nondominant hands. Smoking was found to be a risk factor for nonunion. Patients with scaphoid union tended to higher scores in 8 domains of SF-36-Item Health Survey quality of life without significant difference. CONCLUSIONS Surgical treatment of SN with 1,2-intercompartmental supraretinacular artery pedicled vascularized bone graft provided a union rate comparable with other vascularized bone graft techniques. Previous scaphoid reconstruction with standard iliac crest bone graft was not associated with higher risk for secondary nonunion. There was an upward tendency seen in DASH score and quality of life after scaphoid union. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Christoph Hirche
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, University of Heidelberg, BG Trauma Center Ludwigshafen, Germany.
| | - Christian Heffinger
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, University of Heidelberg, BG Trauma Center Ludwigshafen, Germany
| | - Lingyun Xiong
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, University of Heidelberg, BG Trauma Center Ludwigshafen, Germany
| | - Marcus Lehnhardt
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, University of Heidelberg, BG Trauma Center Ludwigshafen, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, University of Heidelberg, BG Trauma Center Ludwigshafen, Germany
| | - Berthold Bickert
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, University of Heidelberg, BG Trauma Center Ludwigshafen, Germany
| | - Emre Gazyakan
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, University of Heidelberg, BG Trauma Center Ludwigshafen, Germany
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Quantification of contralateral differences of the scaphoid: a comparison of bone geometry in three dimensions. ANATOMY RESEARCH INTERNATIONAL 2014; 2014:904275. [PMID: 24715983 PMCID: PMC3942206 DOI: 10.1155/2014/904275] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Accepted: 12/19/2013] [Indexed: 11/17/2022]
Abstract
The purpose of this study was to accurately quantify contralateral differences of the scaphoid in three-dimensional space to evaluate the feasibility of using the healthy contralateral bone as a reconstruction template in the preoperative planning of complex mal- or nonunions. Three-dimensional surface models of the left and right scaphoids were reconstructed from computed tomography images and compared in 26 individuals. Left-right differences were quantified with respect to volume, surface area, length, and surface-to-surface deviation. The average left-right differences in volume, surface area, and length were 95.4 mm(3) (SD 66.2 mm(3)), 32.7 mm(2) (SD 22.9 mm(32)), and 0.28 mm (SD 0.4 mm), respectively. The average surface-to-surface deviation between the sides was 0.26 mm (SD 0.2 mm). High statistical correlation (Pearson) between the left and the right side was found in all evaluated measures.
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Eastley N, Singh H, Dias JJ, Taub N. Union rates after proximal scaphoid fractures; meta-analyses and review of available evidence. J Hand Surg Eur Vol 2013; 38:888-97. [PMID: 22736744 DOI: 10.1177/1753193412451424] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
We carried out a comprehensive analysis of publications to investigate long term union rates of acute proximal scaphoid fractures. Of 1147 acute scaphoid fractures managed nonoperatively that were available for analysis, 67 (5.8%) were proximal. Amalgamating publications revealed that 34% of acute proximal scaphoid fractures progress to nonunion when managed nonoperatively. A meta-analysis showed that the relative risk of nonunion for these fractures is 7.5 compared with more distal fractures, also managed nonoperatively. More trials are needed to allow direct comparison of acute proximal scaphoid fractures managed operatively and nonoperatively. Power calculations indicate that 76 cases will need to be recruited for such a study. Currently, the proximal scaphoid is defined inconsistently. To avoid misclassification we suggest the region is defined as the proximal fifth of the bone, and computer tomography is used during follow-up.
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Affiliation(s)
- N Eastley
- Department of Orthopaedic Surgery, Glenfield Hospital, Leicester, UK
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Valen B. Treatment of scaphoid fractures in a local hospital. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2013; 133:1079-82. [PMID: 23712172 DOI: 10.4045/tidsskr.12.0191] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Scaphoid fractures are common, but can easily be overlooked clinically. The purpose of this study was to determine the incidence of this injury and the treatment outcome for patients with scaphoid fractures in our department. MATERIAL AND METHOD All patients with scaphoid fractures who were treated in the Orthopaedic Section of Haugesund Hospital from 1987 up to and including 2011 were included in the study. Data was gathered through review of patient records. RESULTS 415 patients were included. 302 (73%) were men, and the average age was 35. The final outcome was known for 385 patients (93%), and only these were included in the analysis of the results. Cast immobilisation resulted in radiographic union in 281 of 308 cases (91%), and 26 follow-up operations brought the number healed up to 302 (98%). Seventeen patients received surgical primary treatment because of extensive displacement. After a maximum of two reoperations, all fractures were healed. Fractures were healed in 319 (98%) of a total of 325 patients who received appropriate primary treatment. 60 patients went without treatment for a long time. Fractures were healed in 41 (68%) of patients who had cast immobilisation followed by surgery in 38 cases. Non-union was found in a total of 66 patients (17%). 50 of the 66 non-union patients underwent surgery; the fractures of 84% of them were healed. The final outcome was healing of 360 of 385 patients (93%). 25 patients (7%) developed persistent non-union. INTERPRETATION The result of plaster casting and surgery was satisfactory. The prognosis for scaphoid fractures that receive appropriate primary treatment is good, but many such fractures are only discovered at a late stage.
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Affiliation(s)
- Birger Valen
- Orthopaedic Section, Haugesund Hospital, Norway.
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Excellent results after bone grafting and K-wire fixation for scaphoid nonunion surgery in skeletally immature patients: a midterm follow-up study of 11 adolescents after 6.9 years. J Orthop Trauma 2013; 27:285-9. [PMID: 22932752 DOI: 10.1097/bot.0b013e31826f8cb9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Scaphoid nonunion is relatively rare in children and adolescents, and no long-term follow-up has been reported. DESIGN Retrospective follow-up study. PATIENTS Eleven patients (10 boys and 1 girl), mean 15.2 (13.9-15.9) years of age, with scaphoid nonunion and open growth plates were operated with bone grafting, Kirschner-wire fixation and 12 weeks of cast immobilization. MAIN OUTCOME MEASUREMENTS Bony union, degenerative wrist changes, and restoration of the carpal architecture were assessed with CT and radiographs. Clinical parameters included active range of motion, grip strength, key pinch strength, and subjective outcome scores (quick disabilities of arm, shoulder and hand (DASH), visual analog scale). RESULTS The patients were followed up after mean 6.9 (3.1-15.1) years; all patients attended. Radiographs and CT confirmed healing of all nonunions, the carpal anatomy was restored, and the wrists were rated as 0 according to the scaphoid nonunion advanced collapse, without degenerative changes. The clinical result was excellent with visual analog scale at rest = 1, at activity = 6, and quick DASH score = 3.3. Active range of motion and grip strength were insignificantly reduced (14 degrees and 2 kg); the key pinch strength remained similar. CONCLUSIONS Healing of a scaphoid nonunion can be expected in adolescents after open reduction, Kirschner-wire fixation, bone grafting, and plaster immobilization, resulting in pain relief and excellent wrist function without degenerative changes after longer term follow-up. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Abstract
INTRODUCTION This is single centre retrospective review of a consecutive series of patients with scaphoid nonunion (SNU) treated using the Ilizarov technique without bone graft. Fifteen of the original 18 patients were available for clinical and radiological examination at a minimum follow-up of 5 years (range 5-10 years). An evaluation was made of the late functional results, satisfaction scores, residual symptoms, grip strength and the presence of radiocarpal and scaphoid degenerative changes. METHODS The series consisted of 15 patients; 14 males; 1 female, with a mean SNU duration of 15.7 months, and a mean age of 23.6 years. Patients with carpal instability, humpback deformity, carpal collapse, avascular necrosis or marked degenerative change, were excluded from this treatment method. Following frame application the treatment consisted of three stages: distraction, compression and immobilisation. The technique is detailed herein. RESULTS Radiographic (CT) and clinical bony union was achieved in all 15 patients after a mean of 88 days (70-130 days). Mean modified Mayo wrist scores initially improved from 21 preoperatively to 86 at previous review, and were 96 at a mean follow-up of 81 months (62-120 months), with excellent results in 10, and good results seen in 5 patients. At latest review the mean grip strengths had returned to 96% of the uninjured hand, and 7 patients had regained full strength; mean wrist flexion/extension arc of motion had also continued to improve to 136° from 131°. All patients returned to their pre-injury occupations and levels of activity at a mean of 117 days. Three patients suffered superficial K-wire infections, which resolved with oral antibiotics. One patient continues to suffer intermittent mild aching in the wrist. No patient suffered loss of scaphoid height, humpback deformity, DISI instability or collapse of the regenerate bone. CONCLUSION In these selected patients this technique safely achieved bony union without the need to open the SNU site and without the need for bone graft. These patients also had the capacity to continually improve their wrist function beyond 3 years following their treatment.
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Affiliation(s)
- Marko Bumbasirevic
- University of Belgrade, School of Medicine, Institute for Orthopaedic Surgery and Traumatology, Clinical Center of Serbia, Belgrade, Serbia.
| | - Henry D Atkinson
- Department of Trauma and Orthopaedics, North Middlesex University Hospital and London Sports Orthopaedics, Sterling Way N18 1QX, UK
| | - Aleksandar Lesic
- University of Belgrade, School of Medicine, Institute for Orthopaedic Surgery and Traumatology, Clinical Center of Serbia, Belgrade, Serbia
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Reigstad O, Grimsgaard C, Thorkildsen R, Reigstad A, Røkkum M. SCAPHOID NON-UNIONS, WHERE DO THEY COME FROM? THE EPIDEMIOLOGY AND INITIAL PRESENTATION OF 270 SCAPHOID NON-UNIONS. ACTA ACUST UNITED AC 2012; 17:331-5. [DOI: 10.1142/s0218810412500268] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Scaphoid injury and subsequent non-union is a well documented and researched subject. This article gives an overview of the epidemiology and results of the patients we have treated for scaphoid non-union at a University Hospital. 283 scaphoid non-unions in 268 patients (83% men) were operated upon, 230 as a primary and 47 as a secondary. The median age at time of surgery was 27 years. One-third of the non-unions were located in the proximal part of the scaphoid and the remaining two-thirds in the middle part. Of the 146 patients (55%) who contacted a doctor at the time of injury, 53 fractures where diagnosed (20%). Fourteen (5%) were operated primarily while 39 (15%) (seven dislocated) were immobilized in plaster casts. Thirty-two (12%) were under the age of 16 at the time of injury. The average time from the injury to the initial non-union surgery was 1.5 years with 2.8 years to the second procedure. The risk of osteoarthritis increased time from injury to surgery (both primary and secondary procedures). The greatest potential for the reduction of scaphoid non-union is an increased awareness amongst younger men. There is also potential for improved accuracy in the diagnosis of scaphoid fractures (better clinical tests, the use of radiographs, CTs and MRIs) in order to identify the fracture and evaluate dislocation at the initial injury. Early diagnosis and treatment of fractures and non-unions will reduce the development of degenerative wrist changes.
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Affiliation(s)
- Ole Reigstad
- Hand and Microsurgery Unit, Orthopedic Department, OUS-Rikshospitalet, Oslo, Norway
| | - Christian Grimsgaard
- Hand and Microsurgery Unit, Orthopedic Department, OUS-Rikshospitalet, Oslo, Norway
| | - Rasmus Thorkildsen
- Hand and Microsurgery Unit, Orthopedic Department, OUS-Rikshospitalet, Oslo, Norway
| | - Astor Reigstad
- Hand and Microsurgery Unit, Orthopedic Department, OUS-Rikshospitalet, Oslo, Norway
| | - Magne Røkkum
- Hand and Microsurgery Unit, Orthopedic Department, OUS-Rikshospitalet, Oslo, Norway
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Three-dimensional computed tomographic analysis of 11 scaphoid waist nonunions. J Hand Surg Am 2012; 37:1151-8. [PMID: 22480499 DOI: 10.1016/j.jhsa.2012.02.020] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2011] [Revised: 02/10/2012] [Accepted: 02/15/2012] [Indexed: 02/02/2023]
Abstract
PURPOSE To virtually assess nonunions of the scaphoid waist using 3-dimensional computed tomography (CT) reconstruction for the amount of displacement of the distal fragment and the postfracture reduction position using the intact opposite scaphoid for reference. METHODS We generated 3-dimensional reconstructions for 11 nonunions of the scaphoid waist and the contralateral intact scaphoids based on CT. The mean age of the patients was 25 years and the time from injury to the CT scan was 2.4 years. We used the mirrored 3-dimensional model of the healthy scaphoid to guide virtual reduction of the nonunion and calculated the amount of displacement of the distal pole fragment from prereduction to postreduction. We compared the results with the intrascaphoid angles calculated using single CT slices. RESULTS The scaphoid nonunions showed a mean flexion deformity of 23°, an ulnar deviation of 5°, and a pronation deformity of 10°. Mean translation was 0.9 mm volarward, 0.2 mm radialward, and 3.3 mm distalward. After reduction, all scaphoids showed a bony overlap on the dorsoradial side; the mean volume of this region was 3% of total bone volume. There was no correlation between the degree of displacement and the intrascaphoid angle measurements. CONCLUSIONS Preoperative planning for scaphoid reconstruction is usually performed using conventional radiographs and single CT slices. However, by synthesizing the information from the CT into a 3-dimensional reconstruction, an exact analysis is possible. This method also allows quantification of prosupination displacement. The postreduction area of dorsal bone overlap may be due to appositional callus formation. CLINICAL RELEVANCE Simple volar opening of the scaphoid allows correction of angulation deformities but results in lengthening of the scaphoid. Correct reduction of the scaphoid fragments is often only possible if the dorsal appositional callus is resected.
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Abstract
OBJECTIVES Untreated scaphoid nonunions are a hazard to the wrist, resulting in deteriorating function and radiologic degenerative changes with increasing time. Long-term results after surgery of scaphoid nonunion reporting clinical, radiologic, and subjective outcomes are scarce. DESIGN Retrospective follow-up study. PATIENTS From 1990 to 1998, 53 patients were operated on for persistent scaphoid nonunion; three patients were excluded from the follow-up (one expelled foreigner, another died of an unrelated cause, one never appeared after surgery), leaving 50 patients eligible for follow-up. INTERVENTION All patients were operated on with open reduction and internal fixation; the majority also received a bone graft. MAIN OUTCOME MEASUREMENTS Radiology and computed tomography verified union, degenerative wrist changes, and final salvage treatment. Range of motion, grip strength, key pinch, and subjective outcome (QuickDASH, visual analog scale). RESULTS Fifty patients were followed up after a mean of 12.2 years (standard deviation [SD], 3.0), 47 by clinical and radiologic examination; three were interviewed by telephone and completed QuickDASH and visual analog scale forms. Union was achieved in 45 of 50 scaphoids and an additional two after a second attempt. Five patients (one persistent and four healed nonunions) underwent salvage procedures. Grip strength (41 vs 45 kg, P = nonsignificant), key pinch (11.5 vs 12.4, P = nonsignificant), and active range of motion (186° vs 214°, P < 0.001) were slightly reduced compared with the uninjured side. The subjective outcome was good (mean visual analog scale = 7, mean QuickDASH = 9.1). Minor degenerative changes were seen in nine wrists at surgery and 22 at follow-up. CONCLUSION Healing of a scaphoid nonunion provides long-term pain relief, excellent wrist function, and halts degenerative changes in the majority of patients. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Kent ME, Rehmatullah NNT, Young L, Chojnowski AJ. Scaphoid nonunion in the presence of a degenerate carpus: don't rush to salvage surgery. J Hand Surg Eur Vol 2012; 37:56-60. [PMID: 21825012 DOI: 10.1177/1753193411413663] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We retrospectively studied 13 patients with degenerative change associated with a scaphoid nonunion treated by internal fixation and bone graft. All patients had radiological signs of radioscaphoid degenerative change (scaphoid nonunion advanced collapse--scaphoid nonunion advanced collapse-- grade II or more) and had surgery more than 2 years after injury. Ten of the 13 patients achieved union at 6 months with all but one of these demonstrating improvement on the Disability of Arm, Shoulder and Hand (DASH) score. Surgeons presented with this difficult patient group might consider reconstruction before salvage procedures.
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Affiliation(s)
- M E Kent
- Department of Orthopaedics and Trauma, Norfolk and Norwich University Hospitals, NHS Foundation Trust, Colney Lane, Norwich, UK
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44
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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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[Operative versus conservative treatment of non-displaced fractures of the scaphoid bone. Results of a controlled multicenter cohort study]. Unfallchirurg 2011; 113:804, 806-13. [PMID: 20827544 DOI: 10.1007/s00113-010-1848-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE Within a prospective, multicenter cohort study we investigated whether operative treatment of scaphoid bone fractures leads to earlier return to previous activity levels. METHODS Only isolated, acute, complete, stable and non-displaced fractures of the mid-third of the scaphoid bone were included. A total of 94 patients with the same number of fractures were recruited. In the operative group, fractures were fixed with a cannulated screw and had postoperative splint immobilization for a maximum of 1 week. In the conservative group a short arm cast was applied until fracture union was achieved. Both groups were followed for 6 months. RESULTS By 15 weeks patients receiving surgical treatment had returned significantly earlier to their full time work and home activities and achieved significantly better results for functional status, pain, and overall satisfaction. However, after screw fixation, complication rates concerning union and secondary operative management were higher. CONCLUSION Operative treatment primarily facilitates earlier return to previous activity levels, as well as better functional status, less pain and higher patient satisfaction, but conservative treatment seems to be safer and associated with a lower complication rate.
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Schädel-Höpfner M, Prommersberger KJ, Eisenschenk A, Windolf J. [Treatment of carpal fractures. Recommendations of the Hand Surgery Group of the German Trauma Society]. Unfallchirurg 2011; 113:741-54; quiz 755. [PMID: 20824422 DOI: 10.1007/s00113-010-1822-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The primary goal in the treatment of carpal fractures is the preservation of a painless wrist function. Scaphoid fractures are the most common carpal fractures and when such a fracture is clinically suspected CT or MRI scans are usually advisable. Only stable and non-displaced scaphoid fractures can be treated conservatively, all other fractures require internal fixation with restoration of normal anatomy. Second most common are fractures of the triquetrum which can occur as chip avulsions of the dorsal rim and are usually treated symptomatically. Fractures of the body of the triquetrum should be treated according to the degree of instability and displacement. This is virtually true for all carpal bones. Perilunate fracture dislocations of the carpus deserve special attention. In these severe injuries a fracture line can run through all carpal bones but the scaphoid is mostly affected. Accurate reduction and internal fixation by screws and K-wires are indicated not only in these cases, but also in carpometacarpal fracture dislocations.
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Affiliation(s)
- M Schädel-Höpfner
- Klinik für Unfall- und Handchirurgie, Universitätsklinikum Düsseldorf, Moorenstrasse 5, 40225, Düsseldorf, Deutschland.
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Abstract
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.
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Rein S, Hanisch U, Rammelt S, Schmidt G, Schaller HE, Zwipp H, Oehmke M, Weindel S. Histopathological, radiological and clinical aspects of the temporal assignment of scaphoid non-union. Arch Orthop Trauma Surg 2010; 130:1243-50. [PMID: 19949806 DOI: 10.1007/s00402-009-1010-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2009] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the correlation between clinical, radiological and histopathological signs of scaphoid non-unions (SNU) with regard to the age of the fracture, primarily because this is relevant for therapy and compensation claims. MATERIALS AND METHODS Thirty-eight patients with SNU underwent clinical and radiological examination of the wrist prior to surgery. Preoperative X-rays of the wrist were analysed using the scores of Herbert and Fisher, Filan and Herbert, Trojan and Jahna, Gupta as well as scaphoid non-union advanced collapse. Sclerotic bone of the SNU was resected during surgery. Resected material was evaluated histologically after staining with hematoxylin-eosin and periodic acid-Schiff reaction. Radiological and histological examinations were performed by independent investigators in a blinded fashion. RESULTS The preoperative range of motion of the injured compared to the contralateral wrist was significantly reduced for the dorsi- and palmar flexion and for the radial and ulnar deviation; however, this reduction was not time dependent. There was no significant correlation between the radiological results and the age of the SNU, while fibrous tissue or fibrocartilage in the fracture gap was present in all cases. Significantly less fibrous or fibrocartilage bone cysts (p = 0.041) and bone remodelling (p = 0.031) were seen in older SNU (at 45 months). Definitive sclerotic bone covering of the fracture edges was significantly more common in older SNU (p = 0.035). CONCLUSION Radiological and most of the conventional histological findings do not correlate with time after initial injury.
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Affiliation(s)
- Susanne Rein
- Department of Trauma and Reconstructive Surgery, University Hospital Carl Gustav Carus, Fetscherstrasse 74, Dresden, Germany.
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49
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Farnell R, Dickson D. The assessment and management of acute scaphoid fractures and non-union. ACTA ACUST UNITED AC 2010. [DOI: 10.1016/j.mporth.2010.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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50
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A new volar vascularization technique using the superficial palmar branch of the radial artery for the collapsed scaphoid nonunion. Tech Hand Up Extrem Surg 2010; 14:160-72. [PMID: 20818218 DOI: 10.1097/bth.0b013e3181d4871f] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Achieving union to prevent scaphoid nonunion advanced collapse wrist in the scaphoid nonunion is a challenging clinical problem. Much of the difficulty relates to the tenuous blood supply to the scaphoid. One unsolved reconstructive problem is the collapsed scaphoid that requires an intercalated wedge graft with proximal pole avascular necrosis. We offer a simple technique that only requires preservation of the superficial palmar branch of the radial artery that is typically ligated during the volar approach to the scaphoid. This technique can also be used during any open volar approach to the scaphoid to increase vascularity and healing.
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