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Chen S, Zhang C, Jiang B, Mi Y, Zhu Y, Jia X. Comparison of Conservative Treatment and Surgery Treatment for Acute Scaphoid Fracture: A Meta-Analysis of Randomized Controlled Trials. World J Surg 2023; 47:611-620. [PMID: 36484804 DOI: 10.1007/s00268-022-06833-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE This meta-analysis aimed to investigate the effectiveness of conservative and surgical treatments of scaphoid fracture. METHODS The literature databases of Pubmed, Cochrane library, and Embase were searched in March 2022. This work extracted the data based on healing time, grip strength, range of wrist motion, nonunion, time before returning to work, and complications (including persistent pain, malunion of the fracture, wound infection, scar sensitivity, hypertrophic scar, and implant-related complications). Stata 14.0 software was used for statistical analysis. RESULTS Twelve RCTs studies met our inclusion criteria. The surgical group had a shorter healing-time and time before returning to work than the conservative group. In addition, the surgical group had significantly better grip strength and range of wrist motion than the conservative group (P < 0.01). However, there was no significant difference between nonunion (P = 0.538) and complications (P = 0.661) between the two groups. CONCLUSION This meta-analysis showed that surgical treatment of scaphoid fracture achieved better grip strength and range of wrist motion, and had a lower healing time and time before returning to work than the conservative treatment. The two treatments had similar results in nonunion and complications. Further RCTs were required for the research.
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Affiliation(s)
- Shao Chen
- Department of Orthopedics, Ningbo First Hospital, 59 Liuting Street, Ningbo, Zhejiang, China
| | - Caihua Zhang
- Department of Orthopedics, Ningbo First Hospital, 59 Liuting Street, Ningbo, Zhejiang, China
| | - Bo Jiang
- Department of Orthopedics, Ningbo First Hospital, 59 Liuting Street, Ningbo, Zhejiang, China
| | - Yunfeng Mi
- Department of Orthopedics, Ningbo First Hospital, 59 Liuting Street, Ningbo, Zhejiang, China
| | - Yingchun Zhu
- Department of Orthopedics, Ningbo First Hospital, 59 Liuting Street, Ningbo, Zhejiang, China.
| | - Xuewen Jia
- Department of Orthopedics, Ningbo First Hospital, 59 Liuting Street, Ningbo, Zhejiang, China
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2
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Siotos C, Asif M, Lee J, Horen SR, Seal SM, Derman GH, Hasan JS, Grevious MA, Doscher ME. Cast selection and non-union rates for acute scaphoid fractures treated conservatively: a systematic review and meta-analysis. J Plast Surg Hand Surg 2023; 57:16-21. [PMID: 35034563 DOI: 10.1080/2000656x.2021.2024439] [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: 10/19/2022]
Abstract
Cast selection for conservatively treated acute scaphoid fractures remains controversial. Cast options include short arm versus long arm, and those that include the thumb or leave it free. We sought to investigate the role of how cast choice affects nonunion rates after conservative management of scaphoid fractures. We searched PubMed, Embase, and Google Scholar from inception through July 14, 2020, according to the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. We extracted information of interest, including cast type, and non-union rates at the end of the treatment period. We then performed a meta-analysis using the random-effects model. We identified seven relevant studies. Non-union was observed in 15 out of 156 (9.6%) with short-arm cast and 13 out of the 124 (10.5%) with long-arm cast (OR = 0.79, 95% CI [0.19, 3.26], p = 0.74). Non-union was observed in 18 out of 174 (10.3%) with thumb immobilization cast and 18 out of the 179 (10.1%) without thumb immobilization (OR = 0.97, 95% CI [0.49, 1.94], p = 0.69). In our study, short arm casting was proven non-inferior to long arm casting. Similarly, casts without thumb immobilization were equally as effective as casts with thumb immobilization in terms of non-union rates for acute scaphoid fractures treated non-operatively.
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Affiliation(s)
- Charalampos Siotos
- Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, IL, USA.,Division of Plastic and Reconstructive Surgery, Cook County Health, Chicago, IL, USA
| | - Mohammed Asif
- Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Jugyeong Lee
- Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Sydney R Horen
- Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Stella M Seal
- Welch Medical Library, Johns Hopkins University, Baltimore, MD, USA
| | - Gordon H Derman
- Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Jafar S Hasan
- Division of Plastic and Reconstructive Surgery, Cook County Health, Chicago, IL, USA
| | - Mark A Grevious
- Division of Plastic and Reconstructive Surgery, Cook County Health, Chicago, IL, USA
| | - Matthew E Doscher
- Division of Plastic and Reconstructive Surgery, Cook County Health, Chicago, IL, USA
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3
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Lake NH, Khan R, Mombell KW, Fergus M, Gomez-Leonardelli D. Scaphoid Nonunion Is a Disabling Problem in a Military Population. Hand (N Y) 2023; 18:122-125. [PMID: 33829892 PMCID: PMC9806531 DOI: 10.1177/15589447211003177] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Scaphoid nonunion can occur in up to 55% of displaced scaphoid fractures. Long-term functional outcomes of this injury are lacking. In addition, no study has published rate of return to active military service after this injury. Our goal was to educate providers and patients on expected functional outcomes and return to duty after treatment of scaphoid nonunion. METHODS We conducted a retrospective review of patients who underwent scaphoid nonunion repair at our institution from 2008 to 2017. The primary outcome measures were union rates, return to duty rates, and functional outcome scores obtained by telephone call. A total of 144 patients were included and 40 responded to our call for long-term follow-up. RESULTS A total of 72% of patients achieved union after surgery, 18% required revision surgery, and 74% of patients were able to return to full duty after surgery. However, this number progressively decreased at 1, 2, and 5 years after surgery. At an average of 5.9 years after surgery, the mean Quick Disabilities of the Arm, Shoulder, and Hand (qDASH) score was 23.9. The mean qDASH for patients who achieved union (21.9) was significantly lower than those with persistent nonunion (29.2) (P = .0115). CONCLUSION Scaphoid nonunion is a difficult problem in the military. We found a high rate of persistent nonunion often requiring revision to partial or full wrist arthrodesis. In addition, our long-term functional outcome scores demonstrate significant disability after this injury, even when union is achieved. This information can help us better counsel our patients and set expectations after treatment of this injury.
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Hu H, Teng X, Li X, Li M, Chang S. Comparison of Two Different Percutaneous Screw Fixations for Treating Herbert B2-Type Acute Scaphoid Fractures. Orthop Surg 2022; 14:3187-3194. [PMID: 36254105 PMCID: PMC9732583 DOI: 10.1111/os.13517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 08/12/2022] [Accepted: 08/31/2022] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE Scaphoid fracture was the most common carpal fracture and the most challenging. The purpose of this study was to investigate and compare the clinical effects of closed reduction and percutaneous cannulated screw internal fixation under fluoroscopy and arthroscopy-assisted percutaneous cannulated screw internal fixation in the treatment of Herbert B2-type of acute scaphoid fractures. METHODS A retrospective controlled study was conducted on 29 patients with Herbert B2-type acute scaphoid fracture with a displacement of >1 mm admitted to our hospital from January 2017 to June 2021. Patients were divided into two groups, 11 patients were treated with closed reduction percutaneous cannulated screw internal fixation under fluoroscopy and 18 patients were treated with percutaneous cannulated screw internal fixation assisted by arthroscopy. The operative time, intraoperative fluoroscopy times, fracture healing time, complications, and postoperative wrist function score of the two groups were compared. RESULTS All patients were followed up for 6-18 months (mean follow-up duration: 10.38 ± 2.69 months). The respective operation times in the arthroscopy group and fluoroscopy group was 51.50 ± 6.69 min and 56.73 ± 11.48 min, respectively (p > 0.05). The number of fluoroscopies performed in the arthroscopy group was (6.83 ± 1.30), which was less than that in the fluoroscopy group (10.91 ± 2.62) (p < 0.05). All fractures in the arthroscopy group healed after the operation, and the fracture healing time was 11.44 ± 1.25W. Ten patients in the fluoroscopy group healed. The fracture healing time was 13.60 ± 2.32 W. The fracture healing time in arthroscopy group was less than that in the fluoroscopy group (p < 0.05). One patient in the fluoroscopy group had nonunion and healed after bone grafting and internal fixation. At the postoperative 6-month follow-up, the modified Mayo wrist function score was used to evaluate the clinical results. The wrist function score of patients in the arthroscopy group was 90 (85, 95), which was >80 (80, 90) in the fluoroscopy group (z = 2.74, p < 0.05). CONCLUSION For Herbert B2-type acute scaphoid fracture with fracture displacement > 1 mm, the arthroscopy-assisted percutaneous cannulated screw internal fixation has less fluoroscopy times, short fracture healing time, and good recovery effect of wrist function compared to the fluoroscopy.
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Affiliation(s)
- Haoliang Hu
- Department of Orthopaedic SurgeryYangpu Hospital, School of Medicine, Tongji UniversityShanghaiChina,Department of Hand SurgeryNingbo No. 6 HospitalNingboChina
| | - Xiaofeng Teng
- Department of Hand SurgeryNingbo No. 6 HospitalNingboChina
| | - Xueyuan Li
- Department of Hand SurgeryNingbo No. 6 HospitalNingboChina
| | - Miaozhong Li
- Department of Hand SurgeryNingbo No. 6 HospitalNingboChina
| | - Shimin Chang
- Department of Orthopaedic SurgeryYangpu Hospital, School of Medicine, Tongji UniversityShanghaiChina
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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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Abstract
In recent decades, there has been a trend toward increased use of operative treatment of hand fractures. However, internal stabilization with wires or open reduction and internal fixation of the phalanges and the metacarpals carries a risk of surgical complications that can be avoided by using appropriate conservative treatment. In this article, some hand fractures that can be managed safely without surgery are discussed. In conclusion, when facing a fracture in the hand, the first consideration is whether the fracture can be treated nonoperatively and not which operative treatment is most appropriate. This applies to both displaced and undisplaced fractures.
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7
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Li C, Peng Z, Zhou Y, Ruan M, Su YY, Liu S, Meng XH, Xu YQ. The progress in the classification and treatment of scaphoid nonunion. Surgeon 2022; 20:e231-e235. [PMID: 35750549 DOI: 10.1016/j.surge.2022.05.006] [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: 07/29/2020] [Accepted: 05/26/2022] [Indexed: 10/17/2022]
Abstract
Scaphoid fracture is the most common carpal fracture, accounting for 50%-80% of all carpal fractures in the Youngers and manual workers. The nonunion rate of scaphoid fractures was approximately 10-15%. Scaphoid nonunion can lead to wrist deformity, wrist collapse, ischemic necrosis, and traumatic osteoarthritis resulting in the loss of wrist function and seriously influence the patients' lives. Achieving bony union is essential for the treatment of scaphoid nonunion. Although many surgical procedures including various forms of bone grafting have been developed to improve bony union, there is no conclusion about which method is the most effective and optimal. In this review, we provide an overview of the diagnostic, classification and progress in the treatments of scaphoid nonunion fractures.
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Affiliation(s)
- Chuan Li
- Department of Orthopaedic, Kunming Medical University, Kunming 650500, China; Department of Orthopaedic, 920th Hospital of Joint Logistics Support Force, Kunming 650032, China
| | - Zhi Peng
- Department of Orthopaedic, Kunming Medical University, Kunming 650500, China
| | - You Zhou
- Department of Orthopaedic, Children's Hospital of Kunming Medical University, Yunnan 650228, China
| | - Mo Ruan
- Department of Orthopaedic, 920th Hospital of Joint Logistics Support Force, Kunming 650032, China
| | - Yong-Yue Su
- Department of Orthopaedic, 920th Hospital of Joint Logistics Support Force, Kunming 650032, China
| | - Shuai Liu
- Department of Orthopaedic Surgery, Sheng-Jing Hospital, China Medical University, Shenyang 110004, China
| | - Xu-Han Meng
- Department of Orthopaedic, 920th Hospital of Joint Logistics Support Force, Kunming 650032, China
| | - Yong-Qing Xu
- Department of Orthopaedic, 920th Hospital of Joint Logistics Support Force, Kunming 650032, China.
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8
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Dittman LE, Kakar S. CMC Mimickers: Differential Diagnosis and Work-Up for Radial-Sided Wrist Pain. Hand Clin 2022; 38:149-160. [PMID: 35465933 DOI: 10.1016/j.hcl.2022.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
In patients with radial-sided wrist pain, a myriad of possible etiologies exists and as such, a detailed history, examination, and, where indicated, imaging is obtained to try and aid with its diagnosis. The purpose of this article is to provide an overview of radial-sided wrist pain, diagnostic modalities and discuss current treatment options. More detailed information is out-of-scope for this article and if needed, we would guide the reader to seek out other selected texts, as indicated.
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Affiliation(s)
| | - Sanjeev Kakar
- Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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9
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Surucu S, Kehribar L. Non-Displaced Scaphoid Waist Fractures: Percutaneous Screw Fixation Versus Cast Immobilization. Cureus 2022; 14:e22684. [PMID: 35242486 PMCID: PMC8885762 DOI: 10.7759/cureus.22684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2022] [Indexed: 11/19/2022] Open
Abstract
Background Scaphoid waist fractures make up 66% of scaphoid fractures and are mostly non-displaced. The purpose of this study was to demonstrate that percutaneous screw fixation is preferable to cast immobilization in the treatment of non-displaced or minimally displaced scaphoid waist fractures. Methodology Between 2017 and 2019, we conducted a retrospective review of patients aged 17-65 years who underwent treatment for acute non-displaced scaphoid waist fractures. In total, 52 patients with scaphoid waist fractures were included in the analysis, 25 of whom underwent percutaneous screw treatment and 27 were treated with a short plaster cast. Patient satisfaction, pain, range of motion, and grip strength were evaluated using the Mayo Modified Wrist Score (MMWS). In addition, the time to return to work/sports, union time, complications, and non-union status were evaluated. Results A total of 52 (35 male, 15 female) patients were enrolled in this study. The average follow-up time was 24.9 months (range, 24-29 months). The mean age was 28.12 years (range, 17-45 months). Group 1 consisted of 25 patients who underwent percutaneous screw fixation, and group 2 consisted of 27 patients who were treated with a short plaster cast. There were significant differences in return to work, return to sports, and union time between the two groups (p < 0.001). The sixth-month MMWS was significantly different between the two groups (p < 0.001), but the first-year MMWS was not significantly different between the two groups (p = 0.864). There were no complications in both groups. Conclusions With percutaneous screw fixation, acute non-displaced or minimally displaced scaphoid waist fractures demonstrated a high rate of union and early return to work/sports.
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10
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Ansari SA, Hirst JT, Younis F. Management of acute scaphoid fractures: a pragmatic approach for the non-specialist. Br J Hosp Med (Lond) 2021; 82:1-7. [PMID: 34601925 DOI: 10.12968/hmed.2021.0227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Scaphoid fractures are common and can cause significant morbidity if treated incorrectly. Thus, a working knowledge of the initial assessment and management of scaphoid fractures by non-specialists is crucial to allow quick diagnosis and avoid potentially catastrophic complications of scaphoid fracture. This article summarises the anatomy of the scaphoid, discusses methods to assess for scaphoid fractures and delineates management plans (conservative or operative) for fractures of the scaphoid based on location of vascular compromise. This article can also help the clinician predict which fractures may not unite with conservative management and therefore need referral to a specialist orthopaedic surgeon for possible surgery.
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Affiliation(s)
- Saif A Ansari
- Department of Surgery, St Helens and Knowsley Hospitals NHS Trust, Prescot, UK
| | - John T Hirst
- Department of Surgery, East Lancashire Hospitals NHS Trust, Blackburn, UK
| | - Fizan Younis
- Department of Surgery, East Lancashire Hospitals NHS Trust, Blackburn, UK
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11
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Zhang D, Blazar P, Earp BE. Factors Associated With Surgical Treatment of Nondisplaced or Minimally Displaced Scaphoid Waist Fractures. J Hand Surg Am 2021; 46:209-214.e1. [PMID: 33288391 DOI: 10.1016/j.jhsa.2020.10.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 08/14/2020] [Accepted: 10/22/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine whether there are identifiable factors associated with the surgical treatment of nondisplaced or minimally displaced scaphoid waist fractures. METHODS We identified 50 patients who underwent nonsurgical treatment and 67 patients who underwent surgical treatment of nondisplaced or minimally displaced scaphoid waist fractures at 2 tertiary care referral centers in a single metropolitan area in the United States between January 2010 and March 2019. Bivariate analysis was used to screen for factors associated with surgical treatment. Multivariable stepwise logistic regression was used to determine factors associated with surgical treatment of a nondisplaced or minimally displaced scaphoid fracture. RESULTS Multivariable logistic regression analysis showed that male sex (odds ratio = 2.80; 95% confidence interval, 1.20-6.52) and employed status (odds ratio = 3.12, 95% confidence interval, 1.24-7.85) were associated with surgical treatment of nondisplaced or minimally displaced scaphoid waist fractures. CONCLUSIONS Male and employed patients have increased odds of undergoing scaphoid surgery for nondisplaced or minimally displaced waist fractures compared with female and unemployed patients. These differences may represent patient preference, surgeon counseling, or a combination. Further study is needed to understand the etiology of this sex difference. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Dafang Zhang
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA.
| | - Philip Blazar
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Brandon E Earp
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA
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12
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Stirling PHC, Broll RD, Molyneux SG, Oliver CW, McQueen MM, Duckworth AD. Percutaneous fixation of acute scaphoid waist fractures: Long-term patient-reported functional outcomes and satisfaction at a mean of 11 years following surgery. HAND SURGERY & REHABILITATION 2021; 40:293-298. [PMID: 33652139 DOI: 10.1016/j.hansur.2021.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 02/14/2021] [Accepted: 02/23/2021] [Indexed: 10/22/2022]
Abstract
The aim of this study was to report the long-term functional outcomes and complication rates following early percutaneous fixation of acute fractures of the scaphoid. A trauma database was searched to identify all skeletally-mature patients with an undisplaced or minimally-displaced scaphoid waist fracture managed with early percutaneous retrograde screw fixation over a thirteen-year period from 1997-2010. Medical records were retrospectively reviewed, and complications documented. Long-term follow-up was by a questionnaire-based review. The Patient-Rated Wrist Evaluation (PRWE) was the primary outcome measure. Secondary outcomes included the Quick version of the Disability of the Arm, Shoulder and Hand score (QuickDASH), the EuroQol 5-dimensions score (EQ-5D-5L), and complications. During the study period 114 patients underwent this procedure. The mean age was 28 years (range 17-62) and 97 patients (85%) were male. The median time from injury to surgery was nine days (range 1-27). Twelve patients (11%) reported a complication, all of whom required repeat surgical intervention (six revision ORIF for non-union, five elective removal of hardware, one early revision fixation due to screw impingement). Long-term outcome data was available for 77 patients (68%) at mean follow-up of 11.4 years (range 6.4-19.8). The median PRWE was 0 (IQR 0-7.5), median QuickDASH 0 (IQR 0-4.5) and median EQ-5D-5L 1.0 (IQR 0.837-1.0). There were 97% (n = 74) patients satisfied with their outcome. Early percutaneous fixation of acute non-displaced or minimally displaced scaphoid fractures results in good long-term patient reported outcomes and health-related quality of life. Although comparable with previous studies, the overall surgical reintervention rate is notable and can result in inferior outcomes. LEVEL OF EVIDENCE: Therapeutic level III (Retrospective Cohort Study).
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Affiliation(s)
- P H C Stirling
- Edinburgh Orthopaedics - Trauma, Royal Infirmary of Edinburgh, 51 Little France Cres, Edinburgh EH16 4SA, United Kingdom
| | - R D Broll
- Edinburgh Orthopaedics - Trauma, Royal Infirmary of Edinburgh, 51 Little France Cres, Edinburgh EH16 4SA, United Kingdom
| | - S G Molyneux
- Edinburgh Orthopaedics - Trauma, Royal Infirmary of Edinburgh, 51 Little France Cres, Edinburgh EH16 4SA, United Kingdom
| | - C W Oliver
- Edinburgh Orthopaedics - Trauma, Royal Infirmary of Edinburgh, 51 Little France Cres, Edinburgh EH16 4SA, United Kingdom
| | - M M McQueen
- Edinburgh Orthopaedics - Trauma, Royal Infirmary of Edinburgh, 51 Little France Cres, Edinburgh EH16 4SA, United Kingdom
| | - A D Duckworth
- Edinburgh Orthopaedics - Trauma, Royal Infirmary of Edinburgh, 51 Little France Cres, Edinburgh EH16 4SA, United Kingdom; Usher Institute, University of Edinburgh, NINE Edinburgh BioQuarter, Edinburgh.
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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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Dias J, Brealey S, Cook L, Fairhurst C, Hinde S, Leighton P, Choudhary S, Costa M, Hewitt C, Hodgson S, Jefferson L, Jeyapalan K, Keding A, Northgraves M, Palmer J, Rangan A, Richardson G, Taub N, Tew G, Thompson J, Torgerson D. Surgical fixation compared with cast immobilisation for adults with a bicortical fracture of the scaphoid waist: the SWIFFT RCT. Health Technol Assess 2020; 24:1-234. [PMID: 33109331 PMCID: PMC7681317 DOI: 10.3310/hta24520] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Scaphoid fractures account for 90% of carpal fractures and occur predominantly in young men. Immediate surgical fixation of this fracture has increased. OBJECTIVE To compare the clinical effectiveness and cost-effectiveness of surgical fixation with cast treatment and early fixation in adults with scaphoid waist fractures that fail to unite. DESIGN Multicentre, pragmatic, open-label, parallel two-arm randomised controlled trial with an economic evaluation and a nested qualitative study. SETTING Orthopaedic departments of 31 hospitals in England and Wales recruited from July 2013, with final follow-up in September 2017. PARTICIPANTS Adults (aged ≥ 16 years) presenting within 2 weeks of injury with a clear, bicortical fracture of the scaphoid waist on plain radiographs. INTERVENTIONS Early surgical fixation using Conformité Européenne-marked headless compression screws. Below-elbow cast immobilisation for 6-10 weeks and urgent fixation of confirmed non-union. MAIN OUTCOME MEASURES The primary outcome and end point was the Patient-Rated Wrist Evaluation total score at 52 weeks, with a clinically relevant difference of 6 points. Secondary outcomes included Patient-Rated Wrist Evaluation pain and function subscales, Short Form questionnaire 12-items, bone union, range of movement, grip strength, complications and return to work. RESULTS The mean age of 439 participants was 33 years; 363 participants were male (83%) and 269 participants had an undisplaced fracture (61%). The primary analysis was on 408 participants with valid Patient-Rated Wrist Evaluation outcome data for at least one post-randomisation time point (surgery, n = 203 of 219; cast, n = 205 of 220). There was no clinically relevant difference in the Patient-Rated Wrist Evaluation total score at 52 weeks: the mean score in the cast group was 14.0 (95% confidence interval 11.3 to 16.6) and in the surgery group was 11.9 (95% confidence interval 9.2 to 14.5), with an adjusted mean difference of -2.1 in favour of surgery (95% confidence interval -5.8 to 1.6; p = 0.27). The non-union rate was low (surgery group, n = 1; cast group, n = 4). Eight participants in the surgery group had a total of 11 reoperations and one participant in the cast group required a reoperation for non-union. The base-case economic analysis at 52 weeks found that surgery cost £1295 per patient more (95% confidence interval £1084 to £1504) than cast treatment. The base-case analysis of a lifetime-extrapolated model confirmed that the cast treatment pathway was more cost-effective. The nested qualitative study identified patients' desire to have a 'sense of recovering', which surgeons should address at the outset. LIMITATION There were 17 participants who had initial cast treatment and surgery for confirmed non-union, which in 14 cases was within 6 months from randomisation and in three cases was after 6 months. Three of the four participants in the cast group who had a non-union at 52 weeks were not offered surgery. CONCLUSIONS Adult patients with an undisplaced or minimally displaced scaphoid waist fracture should have cast immobilisation and suspected non-unions immediately confirmed and urgently fixed. Patients should be followed up at 5 years to investigate the effect of partial union, degenerative arthritis, malunion and screw problems on their quality of life. TRIAL REGISTRATION Current Controlled Trials ISRCTN67901257. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 52. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Joseph Dias
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Stephen Brealey
- Alcuin Research Resource Centre Building, Department of Health Sciences, University of York, York, UK
| | - Liz Cook
- Alcuin Research Resource Centre Building, Department of Health Sciences, University of York, York, UK
| | - Caroline Fairhurst
- Alcuin Research Resource Centre Building, Department of Health Sciences, University of York, York, UK
| | | | - Paul Leighton
- School of Medicine, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Surabhi Choudhary
- Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Matthew Costa
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Kadoorie Centre, John Radcliffe Hospital, Oxford, UK
| | - Catherine Hewitt
- Alcuin Research Resource Centre Building, Department of Health Sciences, University of York, York, UK
| | - Stephen Hodgson
- Department of Orthopaedic Surgery, Bolton NHS Foundation Trust, Royal Bolton Hospital, Bolton, UK
| | - Laura Jefferson
- Alcuin Research Resource Centre Building, Department of Health Sciences, University of York, York, UK
- Department of Health Sciences, University of York, York, UK
| | | | - Ada Keding
- Alcuin Research Resource Centre Building, Department of Health Sciences, University of York, York, UK
| | - Matthew Northgraves
- Alcuin Research Resource Centre Building, Department of Health Sciences, University of York, York, UK
| | - Jared Palmer
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Amar Rangan
- Alcuin Research Resource Centre Building, Department of Health Sciences, University of York, York, UK
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | | | - Nicholas Taub
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Garry Tew
- Alcuin Research Resource Centre Building, Department of Health Sciences, University of York, York, UK
- Department of Sport, Exercise and Rehabilitation, Northumbria University, Newcastle upon Tyne, UK
| | - John Thompson
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - David Torgerson
- Alcuin Research Resource Centre Building, Department of Health Sciences, University of York, York, UK
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15
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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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16
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Luria S. Understanding the Patterns of Deformity of Wrist Fractures Using Computer Analysis. Curr Rheumatol Rev 2020; 16:194-200. [PMID: 32967607 DOI: 10.2174/1573397115666190429144944] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 11/14/2018] [Accepted: 04/11/2019] [Indexed: 11/22/2022]
Abstract
Computer modeling of the wrist has followed other fields in the search for descriptive methods to understand the biomechanics of injury. Using patient-specific 3D computer models, we may better understand the biomechanics of wrist fractures in order to plan better care. We may better estimate fracture morphology and stability and evaluate surgical indications, design more adequate or effective surgical approaches and develop novel methods of therapy. The purpose of this review is to question the actual advances made in the understanding of wrist fractures using computer models.
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Affiliation(s)
- Shai Luria
- Department of Orthopaedic Surgery, Hadassah Hebrew-University Medical Center, Kiryat Hadassah, POB 12000, Jerusalem 91120, Israel
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17
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Skou ST, Juhl CB, Hare KB, Lohmander LS, Roos EM. Surgical or non-surgical treatment of traumatic skeletal fractures in adults: systematic review and meta-analysis of benefits and harms. Syst Rev 2020; 9:179. [PMID: 32792014 PMCID: PMC7425058 DOI: 10.1186/s13643-020-01424-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 07/10/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND A comprehensive overview of treatments of common fractures is missing, although it would be important for shared decision-making in clinical practice. The aim was to determine benefits and harms of surgical compared to non-surgical treatments for traumatic skeletal fractures. METHODS We searched Medline, Embase, CINAHL, Web of Science, and CENTRAL until November 2018, for randomized trials of surgical treatment in comparison with or in addition to non-surgical treatment of fractures in adults. For harms, only trials with patient enrollment in 2000 or later were included, while no time restriction was applied to benefits. Two reviewers independently assessed studies for inclusion, extracted data from full-text trials, and performed risk of bias assessment. Outcomes were self-reported pain, function, and quality of life, and serious adverse events (SAEs). Random effects model (Hedges' g) was used. RESULTS Out of 28375 records screened, we included 61 trials and performed meta-analysis on 12 fracture types in 11 sites: calcaneus, clavicula, femur, humerus, malleolus, metacarpus, metatarsus, radius, rib, scaphoideum, and thoraco-lumbar spine. Seven other fracture types only had one trial available. For distal radius fractures, the standardized mean difference (SMD) was 0.31 (95% CI 0.10 to 0.53, n = 378 participants) for function, favoring surgery, however, with greater risk of SAEs (RR = 3.10 (1.42 to 6.77), n = 436). For displaced intra-articular calcaneus fractures, SMD was 0.64 (0.13 to 1.16) for function (n = 244) and 0.19 (0.01 to 0.36) for quality of life (n = 506) favoring surgery. Surgery was associated with a smaller risk of SAE than non-surgical treatment for displaced midshaft clavicular fractures (RR = 0.62 (0.42 to 0.92), n = 1394). None of the other comparisons showed statistical significance differences and insufficient data existed for most of the common fracture types. CONCLUSIONS Of 12 fracture types with more than one trial, only two demonstrated a difference in favor of surgery (distal radius fractures and displaced intra-articular calcaneus fractures), one of which demonstrated a greater risk of harms in the surgical group (distal radius fractures). Our results highlight the current paucity of high-quality randomized trials for common fracture types and a considerable heterogeneity and risk of bias in several of the available trials. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42015020805.
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Affiliation(s)
- Søren T Skou
- Research Unit for Musculoskeletal Function and Physiotherapy, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark. .,Department of Physiotherapy and Occupational Therapy, Næstved-Slagelse-Ringsted Hospitals, Region Zealand, Slagelse, Denmark.
| | - Carsten B Juhl
- Research Unit for Musculoskeletal Function and Physiotherapy, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.,Department of Rehabilitation, Copenhagen University Hospital, Herlev and Gentofte, Denmark
| | - Kristoffer B Hare
- Department of Physiotherapy and Occupational Therapy, Næstved-Slagelse-Ringsted Hospitals, Region Zealand, Slagelse, Denmark.,Department of Orthopedics, Næstved-Slagelse-Ringsted Hospitals, Region Zealand, Slagelse, Denmark.,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - L Stefan Lohmander
- Department of Clinical Sciences Lund, Orthopedics, Lund University, Lund, Sweden
| | - Ewa M Roos
- Research Unit for Musculoskeletal Function and Physiotherapy, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
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18
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Dias JJ, Brealey SD, Fairhurst C, Amirfeyz R, Bhowal B, Blewitt N, Brewster M, Brown D, Choudhary S, Coapes C, Cook L, Costa M, Davis T, Di Mascio L, Giddins G, Hedley H, Hewitt C, Hinde S, Hobby J, Hodgson S, Jefferson L, Jeyapalan K, Johnston P, Jones J, Keding A, Leighton P, Logan A, Mason W, McAndrew A, McNab I, Muir L, Nicholl J, Northgraves M, Palmer J, Poulter R, Rahimtoola Z, Rangan A, Richards S, Richardson G, Stuart P, Taub N, Tavakkolizadeh A, Tew G, Thompson J, Torgerson D, Warwick D. Surgery versus cast immobilisation for adults with a bicortical fracture of the scaphoid waist (SWIFFT): a pragmatic, multicentre, open-label, randomised superiority trial. Lancet 2020; 396:390-401. [PMID: 32771106 DOI: 10.1016/s0140-6736(20)30931-4] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 04/02/2020] [Accepted: 04/16/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Scaphoid fractures account for 90% of carpal fractures and occur predominantly in young men. The use of immediate surgical fixation to manage this type of fracture has increased, despite insufficient evidence of improved outcomes over non-surgical management. The SWIFFT trial compared the clinical effectiveness of surgical fixation with cast immobilisation and early fixation of fractures that fail to unite in adults with scaphoid waist fractures displaced by 2 mm or less. METHODS This pragmatic, parallel-group, multicentre, open-label, two-arm, randomised superiority trial included adults (aged 16 years or older) who presented to orthopaedic departments of 31 hospitals in England and Wales with a clear bicortical fracture of the scaphoid waist on radiographs. An independent remote randomisation service used a computer-generated allocation sequence with randomly varying block sizes to randomly assign participants (1:1) to receive either early surgical fixation (surgery group) or below-elbow cast immobilisation followed by immediate fixation if non-union of the fracture was confirmed (cast immobilisation group). Randomisation was stratified by whether or not there was displacement of either a step or a gap of 1-2 mm inclusive on any radiographic view. The primary outcome was the total patient-rated wrist evaluation (PRWE) score at 52 weeks after randomisation, and it was analysed on an available case intention-to-treat basis. This trial is registered with the ISRCTN registry, ISRCTN67901257, and is no longer recruiting, but long-term follow-up is ongoing. FINDINGS Between July 23, 2013, and July 26, 2016, 439 (42%) of 1047 assessed patients (mean age 33 years; 363 [83%] men) were randomly assigned to the surgery group (n=219) or to the cast immobilisation group (n=220). Of these, 408 (93%) participants were included in the primary analysis (203 participants in the surgery group and 205 participants in the cast immobilisation group). 16 participants in the surgery group and 15 participants in the cast immobilisation group were excluded because of either withdrawal, no response, or no follow-up data at 6, 12, 26, or 52 weeks. There was no significant difference in mean PRWE scores at 52 weeks between the surgery group (adjusted mean 11·9 [95% CI 9·2-14·5]) and the cast immobilisation group (14·0 [11·3 to 16·6]; adjusted mean difference -2·1 [95% CI -5·8 to 1·6], p=0·27). More participants in the surgery group (31 [14%] of 219 participants) had a potentially serious complication from surgery than in the cast immobilisation group (three [1%] of 220 participants), but fewer participants in the surgery group (five [2%]) had cast-related complications than in the cast immobilisation group (40 [18%]). The number of participants who had a medical complication was similar between the two groups (four [2%] in the surgery group and five [2%] in the cast immobilisation group). INTERPRETATION Adult patients with scaphoid waist fractures displaced by 2 mm or less should have initial cast immobilisation, and any suspected non-unions should be confirmed and immediately fixed with surgery. This treatment strategy will help to avoid the risks of surgery and mostly limit the use of surgery to fixing fractures that fail to unite. FUNDING National Institute for Health Research Health Technology Assessment Programme.
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Affiliation(s)
- Joseph J Dias
- Leicester General Hospital, University Hospitals of Leicester National Health Service (NHS) Trust, Leicester, UK.
| | - Stephen D Brealey
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Caroline Fairhurst
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Rouin Amirfeyz
- University Hospitals Bristol NHS Foundation Trust, Bristol Royal Infirmary, Bristol, UK
| | - Bhaskar Bhowal
- Leicester General Hospital, University Hospitals of Leicester National Health Service (NHS) Trust, Leicester, UK
| | - Neil Blewitt
- North Bristol NHS Trust, Southmead Hospital, Bristol, UK
| | - Mark Brewster
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | - Daniel Brown
- The Royal Liverpool and Broadgreen University Hospitals NHS Trust, Royal Liverpool University Hospital, Liverpool, UK
| | - Surabhi Choudhary
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | - Christopher Coapes
- South Tees Hospitals NHS Foundation Trust, The James Cook University Hospital, Middlesbrough, UK
| | - Liz Cook
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Matthew Costa
- The Kadoorie Centre, John Radcliffe Hospital, Oxford, UK; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Nuffield Orthopaedic Centre, Oxford, UK
| | - Tim Davis
- Nottingham University Hospitals NHS Trust, Queen's Medical Centre Campus, Nottingham, UK
| | - Livio Di Mascio
- Barts Health NHS Trust, The Royal London Hospital, London, UK
| | - Grey Giddins
- Royal United Hospital Bath NHS Trust, Royal United Hospital, Bath, UK
| | - Helen Hedley
- University Hospitals Coventry and Warwickshire NHS Trust, University Hospital, Coventry, UK
| | - Catherine Hewitt
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | | | - Jonathan Hobby
- Hampshire Hospitals NHS Foundation Trust, Basingstoke and North Hampshire Hospital, Basingstoke, UK
| | - Stephen Hodgson
- Bolton NHS Foundation Trust, Royal Bolton Hospital, Bolton, UK
| | | | - Kanagaratnam Jeyapalan
- Leicester General Hospital, University Hospitals of Leicester National Health Service (NHS) Trust, Leicester, UK
| | - Phillip Johnston
- Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Jonathon Jones
- Peterborough and Stamford Hospitals NHS Foundation Trust, Peterborough City Hospital, Peterborough, UK
| | - Ada Keding
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Paul Leighton
- School of Medicine, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Andrew Logan
- Cardiff and Vale University of Health Board, University Hospital of Wales, Cardiff, UK
| | - Will Mason
- Gloucestershire Hospitals NHS Foundation Trust, Gloucestershire Royal Hospital, Gloucester, UK
| | - Andrew McAndrew
- Royal Berkshire NHS Foundation Trust, Royal Berkshire Hospital, Reading, UK
| | - Ian McNab
- Oxford University Hospitals NHS Trust, Nuffield Orthopaedic Centre, Oxford, UK
| | - Lindsay Muir
- Salford Royal Hospital NHS Foundation Trust, Salford, UK
| | - James Nicholl
- Maidstone and Tunbridge Wells NHS Trust, Tunbridge Wells, Kent, UK
| | | | - Jared Palmer
- Leicester General Hospital, University Hospitals of Leicester National Health Service (NHS) Trust, Leicester, UK
| | - Rob Poulter
- Royal Cornwall Hospitals NHS Trust, Royal Cornwall Hospital, Truro, Cornwall, UK
| | - Zulfi Rahimtoola
- Royal Berkshire NHS Foundation Trust, Royal Berkshire Hospital, Reading, UK
| | - Amar Rangan
- York Trials Unit, Department of Health Sciences, University of York, York, UK; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Nuffield Orthopaedic Centre, Oxford, UK
| | | | | | - Paul Stuart
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Nicholas Taub
- Department of Health Sciences, University of Leicester, George Davies Centre, Leicester, UK
| | - Adel Tavakkolizadeh
- King's College Hospital NHS Foundation Trust, King's College Hospital, Brixton, London, UK
| | - Garry Tew
- Department of Sport, Exercise and Rehabilitation, Northumbria University, Newcastle upon Tyne, UK
| | - John Thompson
- Department of Health Sciences, University of Leicester, George Davies Centre, Leicester, UK
| | - David Torgerson
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - David Warwick
- University Hospital Southampton NHS Foundation Trust, Southampton General Hospital, Southampton, UK
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Rocchi L, Merendi G, Cazzato G, Caviglia D, Donsante S, Tulli A, Fanfani F. Scaphoid waist fractures fixation with staple. Retrospective study of a not widespread procedure. Injury 2020; 51 Suppl 3:S2-S8. [PMID: 31902574 DOI: 10.1016/j.injury.2019.12.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Revised: 12/09/2019] [Accepted: 12/16/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION In carpal scaphoid fractures, the surgical treatment with screw is considered the gold standard; shape memory staple however presents substantial advantages. The authors report a study on unstable fractures of the scaphoid waist (type B1, B2, B5, according to Herbert classification) treated with shape memory staple on a large sample of patients, with the aim to confirm the usefulness of this method, the quality of reduction and fixation, the functional results, the time of union and the possible complications. MATERIALS AND METHODS A retrospective analysis of 131 patients with scaphoid waist fractures with minimum follow-up 1 year was performed. Staples were used in all cases; technical details are discussed. Outcome measures were: postoperative pain, flexion-extension wrist range, hand grip strength, radiographic consolidation, work absence. Herbert and Fisher Grading System was used to assess subjective, objective and radiographic results. RESULTS Consolidation was achieved in all cases of primary fractures (0-30 days) within three months after surgery, and within eight months in all but two cases of delayed unions (operated within 6 months of the injury). Pain was absent at follow-up in 79% of cases, never severe or unbearable, the average flexion-extension range achieved was 112°. Handgrip strength values were comparable to those of contralateral wrist in 75% of cases. Mean time lost at work was 7.4 weeks. No algo-distrophy or malunion were observed. Discussion CONCLUSIONS: Scaphoid waist fractures' treatment with shape memory staple should be considered as an excellent alternative to screw fixation.
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Affiliation(s)
- L Rocchi
- Orthopaedics & Hand Surgery Unit, Department of Orthopaedics, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Roma, Italy
| | - G Merendi
- Orthopaedics & Hand Surgery Unit, Department of Orthopaedics, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Roma, Italy
| | - G Cazzato
- Orthopaedics & Hand Surgery Unit, Department of Orthopaedics, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Roma, Italy.
| | - D Caviglia
- Orthopaedics & Hand Surgery Unit, Department of Orthopaedics, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Roma, Italy
| | - S Donsante
- Orthopaedics & Hand Surgery Unit, Department of Orthopaedics, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Roma, Italy
| | - A Tulli
- Orthopaedics & Hand Surgery Unit, Department of Orthopaedics, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Roma, Italy
| | - F Fanfani
- Orthopaedics & Hand Surgery Unit, Department of Orthopaedics, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Roma, Italy
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20
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O’Hara NN, Isaac M, Slobogean GP, Klazinga NS. The socioeconomic impact of orthopaedic trauma: A systematic review and meta-analysis. PLoS One 2020; 15:e0227907. [PMID: 31940334 PMCID: PMC6961943 DOI: 10.1371/journal.pone.0227907] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 01/02/2020] [Indexed: 02/06/2023] Open
Abstract
The overall objective of this study was to determine the patient-level socioeconomic impact resulting from orthopaedic trauma in the available literature. The MEDLINE, Embase, and Scopus databases were searched in December 2019. Studies were eligible for inclusion if more than 75% of the study population sustained an appendicular fracture due to an acute trauma, the mean age was 18 through 65 years, and the study included a socioeconomic outcome, defined as a measure of income, employment status, or educational status. Two independent reviewers performed data extraction and quality assessment. Pooled estimates of the socioeconomic outcome measures were calculated using random-effects models with inverse variance weighting. Two-hundred-five studies met the eligibility criteria. These studies utilized five different socioeconomic outcomes, including return to work (n = 119), absenteeism days from work (n = 104), productivity loss (n = 11), income loss (n = 11), and new unemployment (n = 10). Pooled estimates for return to work remained relatively consistent across the 6-, 12-, and 24-month timepoint estimates of 58.7%, 67.7%, and 60.9%, respectively. The pooled estimate for mean days absent from work was 102.3 days (95% CI: 94.8-109.8). Thirteen-percent had lost employment at one-year post-injury (95% CI: 4.8-30.7). Tremendous heterogeneity (I2>89%) was observed for all pooled socioeconomic outcomes. These results suggest that orthopaedic injury can have a substantial impact on the patient's socioeconomic well-being, which may negatively affect a person's psychological wellbeing and happiness. However, socioeconomic recovery following injury can be very nuanced, and using only a single socioeconomic outcome yields inherent bias. Informative and accurate socioeconomic outcome assessment requires a multifaceted approach and further standardization.
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Affiliation(s)
- Nathan N. O’Hara
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
- Department of Public Health, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Marckenley Isaac
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Gerard P. Slobogean
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Niek S. Klazinga
- Department of Public Health, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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21
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The Fragility Index in Hand Surgery Randomized Controlled Trials. J Hand Surg Am 2019; 44:698.e1-698.e7. [PMID: 30420197 DOI: 10.1016/j.jhsa.2018.10.005] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 08/13/2018] [Accepted: 10/03/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE Randomized controlled trials (RCTs) are the gold standard for comparing clinical interventions. Statistical significance as reported via a P value has been used to determine if a difference between clinical interventions exists in an RCT. However, P values do not clearly convey information about the robustness of a study's conclusions. An emerging metric, called the fragility index (the number of subjects who would need to change outcome category to raise the P value above the .05 threshold), is an indirect measure of how likely a repeat of the trial would reach the same conclusions. This study addressed the fragility of RCTs using dichotomous outcomes in hand surgery. METHODS Using systematic searching of the MEDLINE database, we identified hand surgery RCTs published in 11 high-impact journals published in the last decade (2007-2017). Studies were identified that involved 2 parallel arms, allocated patients to treatment and control in a 1:1 ratio, and reported statistical significance for a dichotomous variable. The fragility index was calculated using Fisher's exact test, using previously published methods. RESULTS Five hand surgery RCTs were identified for inclusion reporting a range of fragility indices from 0 to 26. Two of the trials (40%) had a fragility index of 2 or less. Two of the trials (40%) reported that the number of patients lost to follow-up exceeded the fragility index, meaning that results of the patients lost to follow-up could theoretically completely reverse the study conclusions. CONCLUSIONS The range of fragility indices reported in the recent hand surgery literature is consistent with previous reporting within orthopedic surgery. CLINICAL RELEVANCE The fragility index is a useful metric to analyze the robustness of the study conclusions that should complement other methods of critical evaluation including the P value or effect sizes. Our results emphasize the need for future efforts to strengthen the robustness of RCT conclusions.
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Scaphoid Fracture Repair Does Not Significantly Diminish Short-Term Participation in the National Football League. HSS J 2019; 15:137-142. [PMID: 31327944 PMCID: PMC6609658 DOI: 10.1007/s11420-018-9640-6] [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: 07/04/2018] [Accepted: 09/19/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Fixation of scaphoid fractures is recommended in elite athletes to hasten healing and return-to-sport times. Complications such as nonunion negatively affect athletic performance. QUESTIONS/PURPOSES The purpose of this study was to examine the prevalence and impact of scaphoid repair on National Football League (NFL) participation during athletes' first season in the NFL, while identifying significant predictors for development of carpal arthritis and scaphoid nonunion. METHODS A total of 1311 football athletes invited to the NFL Scouting Combine from 2012 to 2015 were evaluated for history of scaphoid fracture repair. Athlete demographics, surgical history, and imaging and physical examination findings were recorded. Future NFL participation based on draft status, games played, and games started during athletes' first season were gathered using publicly available databases. RESULTS Nineteen (1.4%) athletes underwent 24 operations for scaphoid repair. Limitations in wrist range of motion or strength were present in 47.4% of athletes with a history of repair. Arthritic changes were present in 32% of wrists, while radiographic nonunion was present in two athletes following scaphoid fracture. Defensive backs were observed to have a higher incidence for arthritic changes following repair compared to other positions. No significant difference in prospective NFL participation was found in athletes with a history of scaphoid repair than in those without. CONCLUSIONS Athletes with a history of scaphoid repair are not at significant risk for diminished participation during their first season in the NFL.
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Garala K, Dias J. Scaphoid fracture geometrics: an assessment of location and orientation. J Plast Surg Hand Surg 2019; 53:180-187. [DOI: 10.1080/2000656x.2019.1581789] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Kanai Garala
- University Hospitals of Coventry and Warwickshire, Coventry, UK
| | - Joseph Dias
- Academic Team of Musculoskeletal Surgery (AToMS), Undercroft, Leicester General Hospital, Leicester, UK
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Li H, Guo W, Guo S, Zhao S, Li R. Surgical versus nonsurgical treatment for scaphoid waist fracture with slight or no displacement: A meta-analysis and systematic review. Medicine (Baltimore) 2018; 97:e13266. [PMID: 30508914 PMCID: PMC6283056 DOI: 10.1097/md.0000000000013266] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Surgical or nonsurgical treatment for scaphoid waist fracture with slight or no displacement is still controversial. This study compared the efficacy of the 2 methods through meta-analysis to provide a reference for the choice of clinical treatment options. METHODS Two individuals independently searched for relevant RCTs and cohort studies from PubMed (1946-February 2018), Embase (1946-February 2018), and Cochrane library (1997-February 2018). After quality assessment and data extraction, Stata 14 software was used for combining the effect size, testing heterogeneity, and studying bias. GRADEpro was used to rate the level of evidence. RESULTS Ten RCTs and 4 cohort studies with 765 patients were included. No statistical difference in satisfaction, pain, and Disability of the Arm, Shoulder, and Hand score was found after surgical and nonsurgical treatments. Compared with nonsurgical treatment, surgical treatment shortened the time to union (SMD = -5.01, 95% CI: -7.47 to -2.58, P = .000), decreased the convalescence (SMD = -2.09, 95% CI: -3.08 to -1.11, P = .000), and reduced the incidence of nonunion (RR = 0.47, 95% CI: 0.24-0.90), P = .023). Subgroup analyses showed that the percutaneous fixation treatment can shorten the time to union [SMD = -1.82, 95%CI (-2.22 to -1.42), P = = .000] and the convalescence (SMD = -4.26, 95%CI: -6.16 to -2.35, P = = .054), and open reduction fixation treatment can reduce the incidence of nonunion (RR = 0.20, 95%CI: 0.06-0.69, P = = .01). CONCLUSION For scaphoid waist fractures with slight or no displacement, there was no statistical difference in patient satisfaction, pain, and The Disability of the Arm, Shoulder, and Hand scores between surgical treatment and nonsurgical treatment. Closed surgical treatment can shorten the time to union and convalescence, and open reduction can reduce the incidence of nonunion. On the basis of this conclusion, chief physicians can consider which treatment to use according to the patient's clinical situation and their subjective intention.
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Affiliation(s)
- Hangyu Li
- Center for Applied Statistical Research and College of Mathematics, Jilin University
| | - Wenlai Guo
- Hand & Foot Surgery and Reparative & Reconstruction Surgery Center, The Second, Hospital of Jilin University, Changchun, China
| | - Shanshan Guo
- Center for Applied Statistical Research and College of Mathematics, Jilin University
| | - Shishun Zhao
- Center for Applied Statistical Research and College of Mathematics, Jilin University
| | - Rui Li
- Hand & Foot Surgery and Reparative & Reconstruction Surgery Center, The Second, Hospital of Jilin University, Changchun, China
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Fowler TP, Fitzpatrick E. Simultaneous Fractures of the Ipsilateral Scaphoid and Distal Radius. J Wrist Surg 2018; 7:303-311. [PMID: 30174987 PMCID: PMC6117171 DOI: 10.1055/s-0038-1641719] [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: 10/06/2017] [Accepted: 03/06/2018] [Indexed: 10/17/2022]
Abstract
Background Ipsilateral fractures of the distal radius and scaphoid are rare, with few reports describing mechanisms of injury, fracture patterns, and treatment approaches. Purpose This article describes the clinical and radiographic features of ipsilateral distal radius and scaphoid fractures occurring simultaneously. Materials and Methods Electronic databases from 2007 to 2017 at a single Level 1 trauma center were reviewed for patients with concurrent fractures of the distal radius and scaphoid. Patient demographics, injury mechanism, scaphoid and distal radius fracture pattern, treatment approach, and radiographic healing were studied. Results Twenty-three patients were identified. Nineteen of the 23 (83%) were males, and 19 of 23 (83%) of the injury mechanisms were considered high energy. Twenty-two of the 23 (96%) scaphoid fractures were nondisplaced, all treated with screw fixation. Most distal radius fractures were displaced and comminuted, 17 of 23 (74%) were intra-articular. All distal radius fractures were treated surgically with internal and/or external fixation. Three patients were lost to follow-up. Average follow-up of the remaining 20 was to 19.8 weeks. Nineteen of the 20 (95%) scaphoids healed, one scaphoid went on to nonunion with avascular necrosis. All 20 radius fractures healed, 16 of 20 (80%) in anatomic alignment. Conclusion Ipsilateral fractures of the distal radius and scaphoid are rare and are usually result of high-energy mechanisms. The scaphoid fracture is usually a nondisplaced fracture at the waist. The distal radius fracture pattern varies but most are displaced and comminuted. The union rate of the scaphoid is high, even if subjected to radiocarpal distraction required for distal radius management. Level of Evidence Therapeutic level IV study.
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Affiliation(s)
- Timothy P. Fowler
- Department of Orthopaedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Elizabeth Fitzpatrick
- Department of Orthopaedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa
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Walker ME, Chuang C, Moores CR, Webb ML, Buonocore SD, Grant Thomson J. The Hand Surgeon Consultation Improves Patient Knowledge in a Hand Surgery Mission to Honduras. J Hand Surg Asian Pac Vol 2018; 23:11-17. [PMID: 29409417 DOI: 10.1142/s2424835518500017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND The purpose of this study was to assess impact of the surgeon consultation and informed consent process on patient education in an international hand surgery mission compared with a US academic hand surgery practice. These two groups were selected to evaluate communication difficulties in a surgical mission setting compared with standard of care in a high-income country. METHODS A multi-part survey was administered to patients presenting to a hand surgery mission during March 2012 and new patients of a university hand center in a 3-month period during 2011. Surveys were administered prior to and following surgeon consultation with one fellowship-trained hand surgeon. The survey assessed knowledge of basic hand anatomy, physiology, disease, individual diagnosis, and surgical risks. RESULTS 71 patients participated in the study (university n=36, mission n=35). Pre-consultation quiz score averaged 58% in the university group versus 27% in the mission group. Post-consultation quiz scores averaged 62% in the university group versus 40% in the mission group. Only the mission group's quiz score increase was statistically significant. 93% of the university group reported learning about their condition and diagnosis, but only 40% demonstrated correct insight into their diagnosis. In the mission group, 73% reported learning about their condition and diagnosis while 53% demonstrated correct insight into their diagnosis. Although all consultations involved discussion of surgical risks, only 62% of the university group and 52% of the mission group recalled discussing surgical risks. CONCLUSIONS The hand surgeon consultation was more effective in improving hand knowledge in the surgery mission group compared to in a university hand practice. This suggests that the surgeon consultation should be pursued despite communication barriers in surgical missions. However, the discrepancy between patient perception of knowledge gains and correct insight into diagnosis, and the deficit of patient retention of surgical risks need to be improved.
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Affiliation(s)
- Marc E Walker
- * Section of Plastic Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Carolyn Chuang
- * Section of Plastic Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Craig R Moores
- * Section of Plastic Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Matthew L Webb
- * Section of Plastic Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Samuel D Buonocore
- * Section of Plastic Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - J Grant Thomson
- * Section of Plastic Surgery, Yale University School of Medicine, New Haven, CT, USA
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Shammas RL, Mela N, Wallace S, Tong BC, Huber J, Mithani SK. Conjoint Analysis of Treatment Preferences for Nondisplaced Scaphoid Fractures. J Hand Surg Am 2018; 43:678.e1-678.e9. [PMID: 29456053 DOI: 10.1016/j.jhsa.2017.12.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 11/23/2017] [Accepted: 12/20/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE We used conjoint analysis to assess the relative importance of factors that influence a patient's decision between surgical or nonsurgical management of a nondisplaced scaphoid fracture. Our hypothesis was that out-of-pocket costs will have a greater influence on decision making than the time spent in a cast or brace, degree of soreness, or the risk of treatment failure. METHODS Two-hundred and fifty participants were recruited using Amazon Mechanical Turk and asked to assume that they had experienced a nondisplaced scaphoid waist fracture. They then indicated their relative preferences among 13 pairs of alternatives with variations in the following attributes: time in a cast, time in a brace, duration of ongoing soreness, risk of treatment failure (by which we meant scaphoid nonunion), out-of-pocket costs based on estimates of direct costs ($500-2,500), and apprehension about surgery. A conjoint analysis was used to determine the relative importance of these factors when choosing between surgical or nonsurgical management. RESULTS The factor with the greatest influence on treatment choice was the cost of the procedure. After assessing the respondent's apprehension to undergo surgery, a sensitivity analysis showed the proportion of respondents who would choose surgery given different outcomes. To make the predicted share of those who are "not worried" about surgery equal to those who are "somewhat worried" or "a little worried" would require that the cost of surgery increase by $2,700. In addition, 2 weeks in a cast, 3 weeks in a brace, 2 months of soreness, or a 2% increase in the risk of fracture nonunion generates the same surgical choice probability as a $2,000 increase in the out-of-pocket cost of surgery. CONCLUSIONS As conceptualized in this conjoint analysis, out-of-pocket costs and apprehension about surgery seem to have a greater impact on a decision for surgery than the time spent in a brace or cast and the risk of treatment failure. TYPE OF STUDY/LEVEL OF EVIDENCE Economic and decision analysis III.
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Affiliation(s)
| | - Nathan Mela
- Fuqua School of Business, Duke University, Durham, NC
| | - Scott Wallace
- Fuqua School of Business, Duke University, Durham, NC
| | - Betty C Tong
- Division of Thoracic and Cardiovascular Surgery, Duke University Medical Center, Durham, NC
| | - Joel Huber
- Fuqua School of Business, Duke University, Durham, NC
| | - Suhail K Mithani
- Division of Plastic, Maxillofacial, and Oral Surgery, Duke University Medical Center, Durham, NC.
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Zhao H, Tian S, Kong L, Bai J, Lu J, Zhang B, Tian D. Factors associated with union time of acute middle-third scaphoid fractures: an observational study. Ther Clin Risk Manag 2018; 14:1127-1131. [PMID: 29950849 PMCID: PMC6016271 DOI: 10.2147/tcrm.s169310] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background The aim of this study was to investigate the union time of acute middle-third scaphoid fractures following treatments and to analyze the effect of different factors on late union. Patients and methods We retrospectively reviewed patients with acute middle-third scaphoid fracture at our institution between January 2013 and December 2017. Patient demographics, fracture characteristics, and treatment strategy, such as age, gender, body mass index, habit of smoking, sides of injury, dominant hand, ulnar variance, multiple fractures, and treatment methods, were investigated. Univariate and multivariate analyses were used to identify possible predictive factors. Results A total of 132 patients with scaphoid fracture were included in our study. Operation was performed in 67 patients (50.8%), and conservative treatment was performed in the other 65 patients (49.2%). The union time was 7.2±0.5 weeks. In the multivariate logistic regression analysis, late diagnosis (odds ratio, 1.247; 95% CI, 1.022–1.521) and conservative treatment method (odds ratio, 1.615; 95% CI, 1.031–2.528) were identified as 2 independent predictors of late union in scaphoid fractures patients. Other parameters were not demonstrated to be predictive factors. Conclusion Late diagnosis and conservative treatment were two factors associated with late union. Long time of follow-up is necessary for patient with these factors.
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Affiliation(s)
- Hongfang Zhao
- Department of Orthopedics, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei 050051, People's Republic of China
| | - Siyu Tian
- Department of Orthopedics, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei 050051, People's Republic of China
| | - Lingde Kong
- Department of Orthopedics, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei 050051, People's Republic of China
| | - Jiangbo Bai
- Department of Orthopedics, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei 050051, People's Republic of China
| | - Jian Lu
- Department of Orthopedics, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei 050051, People's Republic of China
| | - Bing Zhang
- Department of Orthopedics, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei 050051, People's Republic of China
| | - Dehu Tian
- Department of Orthopedics, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei 050051, People's Republic of China
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Severo AL, Cattani R, Schmid FN, Cavalheiro HL, Castro Neto DND, Lemos MBD. Percutaneous treatment for waist and proximal pole scaphoid fractures. Rev Bras Ortop 2018; 53:267-275. [PMID: 29892575 PMCID: PMC5993880 DOI: 10.1016/j.rboe.2018.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Accepted: 09/22/2016] [Indexed: 12/02/2022] Open
Abstract
Objective Analyze the percutaneous fixation technique for scaphoid fractures in the waist of the scaphoid and the proximal pole, and demonstrate its result. Methods A retrospective cross-cohort study conducted from January 2005 to April 2015, aiming at the consolidation time, epidemiological profile, level of function, return to work, and complications. Results Twenty-eight patients were selected, with a mean of eight weeks of follow-up. They presented a mean age of 30.5 years, male prevalence (25 patients; 89.2%), and no differences between dominant and non-dominant sides. The mean time from diagnosis was 4.16 weeks, but in three cases of fibrous union, the pre-operative period was over one year. The most frequent mechanism of injury was a fall on the outstretched hand, in 22 cases (78.5%). Of all fractures, 24 cases were in the waist (85.8%) and four were of the proximal pole (14.2%); seven patients had displacement (25%). There was consolidation in 26 cases (92.8%) with a mean of 7.5 weeks after surgery. In cases of non-union, radiological follow-up was up to 24 weeks, requiring a new surgical intervention. Conclusions Percutaneous fixation is an excellent, reproducible technique that allows early active mobility of the wrist with a low complication rate, although it requires a learning curve.
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Affiliation(s)
- Antônio Lourenço Severo
- Instituto de Ortopedia e Traumatologia, Hospital São Vicente de Paulo (HSVP), Universidade Federal da Fronteira Sul (UFFS), Passo Fundo, RS, Brazil
| | - Rodrigo Cattani
- Instituto de Ortopedia e Traumatologia, Hospital São Vicente de Paulo (HSVP), Universidade Federal da Fronteira Sul (UFFS), Passo Fundo, RS, Brazil
| | - Filipe Nogueira Schmid
- Instituto de Ortopedia e Traumatologia, Hospital São Vicente de Paulo (HSVP), Universidade Federal da Fronteira Sul (UFFS), Passo Fundo, RS, Brazil
| | - Haiana Lopes Cavalheiro
- Instituto de Ortopedia e Traumatologia, Hospital São Vicente de Paulo (HSVP), Universidade Federal da Fronteira Sul (UFFS), Passo Fundo, RS, Brazil
| | - Deodato Narciso de Castro Neto
- Instituto de Ortopedia e Traumatologia, Hospital São Vicente de Paulo (HSVP), Universidade Federal da Fronteira Sul (UFFS), Passo Fundo, RS, Brazil
| | - Marcelo Barreto de Lemos
- Instituto de Ortopedia e Traumatologia, Hospital São Vicente de Paulo (HSVP), Universidade Federal da Fronteira Sul (UFFS), Passo Fundo, RS, Brazil
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Severo AL, Cattani R, Schmid FN, Cavalheiro HL, Castro Neto DND, Lemos MBD. Tratamento percutâneo para fraturas do terço médio e proximal do escafoide. Rev Bras Ortop 2018. [DOI: 10.1016/j.rbo.2016.09.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Raittio LT, Jokihaara J, Huttunen TT, Leppänen OV, Launonen AP, Mattila VM. Rising incidence of scaphoid fracture surgery in Finland. J Hand Surg Eur Vol 2018; 43:402-406. [PMID: 28825372 DOI: 10.1177/1753193417726051] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
UNLABELLED The aim of the present study was to investigate the incidence of scaphoid fracture surgery by obtaining data from the national discharge register in Finland, a country of 5 million inhabitants, for the period from 1997 to 2014. A total of 1380 patients with scaphoid fracture were treated surgically. Half of the patients were aged under 28 years and 84% were men. The surgical treatment of scaphoid fractures was classified into two groups. There were 640 (46%) primary fracture fixations and 740 (54%) treatments of fracture nonunion. The overall incidence of all scaphoid fixations increased twofold (from 14.8 to 30.1 per 1,000,000 person-years) and threefold in the primary fixation group (from 5.5 to 17.8 per 1,000,000 person-years) during the study period. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Lauri T Raittio
- 1 Department of Orthopaedics and Trauma Surgery, Tampere University Hospital, Tampere, Finland.,2 Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
| | - Jarkko Jokihaara
- 3 Department of Hand- and Microsurgery, Tampere University Hospital, Tampere, Finland
| | - Tuomas T Huttunen
- 2 Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland.,4 Department of Anaesthesia, Tampere University Hospital, Tampere, Finland
| | - Olli V Leppänen
- 2 Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland.,3 Department of Hand- and Microsurgery, Tampere University Hospital, Tampere, Finland
| | - Antti P Launonen
- 1 Department of Orthopaedics and Trauma Surgery, Tampere University Hospital, Tampere, Finland
| | - Ville M Mattila
- 1 Department of Orthopaedics and Trauma Surgery, Tampere University Hospital, Tampere, Finland.,2 Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
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Al-Ajmi TA, Al-Faryan KH, Al-Kanaan NF, Al-Khodair AA, Al-Faryan TH, Al-Oraini MI, Bassas AF. A Systematic Review and Meta-analysis of Randomized Controlled Trials Comparing Surgical versus Conservative Treatments for Acute Undisplaced or Minimally-Displaced Scaphoid Fractures. Clin Orthop Surg 2018; 10:64-73. [PMID: 29564049 PMCID: PMC5851856 DOI: 10.4055/cios.2018.10.1.64] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 10/17/2017] [Indexed: 11/15/2022] Open
Abstract
Background Surgical and conservative methods have been reported by various studies for high rates of fracture union and subsequent regain of function among patients with undisplaced or minimally-displaced scaphoid fractures. Hence, this study aims to analyze the best available evidence to comprehend the relative benefits and risks of these therapeutic options. Methods A systematic search of the literature from different databases and search engines was performed with strict eligibility criteria to obtain the highest quality of evidence. All randomized controlled trials delineating the outcomes of surgical versus conservative treatments for acute undisplaced or minimally-displaced scaphoid fractures were included and then evaluated using scoring tools: Cochrane risk of bias tool and PEDro scale. Data were pooled using random-effects models with standard mean differences for continuous outcomes and risk ratios for dichotomous variables. Results The search yielded 339 potentially related articles, further trimmed down to eight studies based on the eligibility criteria. The meta-analysis revealed that surgical treatment resulted in significantly better functional outcomes than conservative treatment. Furthermore, surgery resulted in the prevention of delayed union of fractures and reduction of time needed to return to work. Conclusions While four studies reported advantages of surgical treatment, evidence was insufficient to provide a definitive conclusion that surgery is a better option. Due to the significant limitations with respect to certain variables, the superiority of one method to the other could not be established.
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Affiliation(s)
- Turki A Al-Ajmi
- Imam Muhammad Ibn Saud Islamic University, College of Medicine, Riyadh, Saudi Arabia
| | - Khalid H Al-Faryan
- Imam Muhammad Ibn Saud Islamic University, College of Medicine, Riyadh, Saudi Arabia
| | - Naif F Al-Kanaan
- Imam Muhammad Ibn Saud Islamic University, College of Medicine, Riyadh, Saudi Arabia
| | | | | | - Maher I Al-Oraini
- California State University, College of Science, Los Angeles, CA, USA
| | - Abdulelah F Bassas
- Department of Plastic and Reconstructive Surgery, Security Forces Hospital, Riyadh, Saudi Arabia
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Bhat AK, Acharya AM, Manoh S, Kamble V. A Prospective Study of Acute Undisplaced and Minimally Displaced Scaphoid Fractures Managed by Aggressive Conservative Approach. J Hand Surg Asian Pac Vol 2018; 23:18-25. [PMID: 29409429 DOI: 10.1142/s2424835518500029] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND To identify acute un-displaced and minimally displaced scaphoid fractures which are unlikely to unite with non-operative treatment at six weeks with CT scan and stabilize them with percutaneous screw fixation with the aim of preventing non-union. METHODS A scaphoid series radiographs of wrist were obtained for patients with undisplaced or minimally displaced fractures and were immobilized in a thumb spica cast for six weeks. At six weeks, CT scan was done for patients showing doubtful signs of clinical and radiographic union. Patients with a gap less than 2 mm were continued on cast for an additional two to four weeks. Those with gap more than 2 mm underwent percutaneous screw fixation. In both cases the immobilisation was discontinued when the fracture was considered to be united and mobilization was initiated. RESULTS 21 out of 39 patients managed initially with cast for six weeks showed clinical and radiological evidence of union. 18 patients showed persistent tenderness of which eight showed a clear gap in radiographs and 10 patients had doubtful union. Eight of these 10 patients on CT scan showed fracture gap of more than 2 mm while two patients showed fracture gap of less than 2 mm. Hence, 16 patients underwent percutaneous fixation. Repeat radiographs showed progression to union at an average of 3.8 weeks from surgery. Remaining two eventually united on continuing the cast. All patients showed confirmed union at one year on follow up. CONCLUSIONS An objective measurement of fracture gap by CT scan at six weeks is useful in predicting cases with tendency for delayed union. Early percutaneous fixation of fractures would not further jeopardize the blood supply of fracture site. This aggressive conservative management also avoids unnecessary surgery in all acute scaphoid fractures.
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Affiliation(s)
- Anil K Bhat
- * Unit of Hand and Microsurgery, Department of Orthopaedics, Kasturba Medical College Hospital, Manipal Academy of Higher Education, Manipal, India
| | - Ashwath M Acharya
- * Unit of Hand and Microsurgery, Department of Orthopaedics, Kasturba Medical College Hospital, Manipal Academy of Higher Education, Manipal, India
| | - S Manoh
- * Unit of Hand and Microsurgery, Department of Orthopaedics, Kasturba Medical College Hospital, Manipal Academy of Higher Education, Manipal, India
| | - Vinay Kamble
- * Unit of Hand and Microsurgery, Department of Orthopaedics, Kasturba Medical College Hospital, Manipal Academy of Higher Education, Manipal, India
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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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Abstract
LEARNING OBJECTIVES After reading this article, the participant should be able to: 1. Understand the epidemiology, classification, and anatomy pertinent to the scaphoid. 2. Appropriately evaluate a patient with suspected scaphoid fracture, including appropriate imaging. 3. Understand the indications for operative treatment of scaphoid fractures, and be familiar with the various surgical approaches. 4. Describe the treatment options for scaphoid nonunion and avascular necrosis of the proximal pole. SUMMARY The goal of this continuing medical education module is to present the preoperative assessment and the formation and execution of a surgical treatment plan for acute fractures of the scaphoid. In addition, secondary surgical options for treatment of scaphoid nonunion and avascular necrosis are discussed.
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37
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Vanhees M, van Riet RR, van Haver A, Kebrle R, Meermans G, Verstreken F. Percutaneous, Transtrapezial Fixation without Bone Graft Leads to Consolidation in Selected Cases of Delayed Union of the Scaphoid Waist. J Wrist Surg 2017; 6:183-187. [PMID: 28725498 PMCID: PMC5515604 DOI: 10.1055/s-0036-1597681] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 11/19/2016] [Indexed: 01/08/2023]
Abstract
Purpose We evaluated clinical and radiographic outcome of percutaneous transtrapezial fixation of the scaphoid delayed union or nonunion using a headless bone screw without bone grafting. Methods Sixteen patients with delayed union or nonunion of the scaphoid were included in this retrospective study between 2006 and 2011. All patients had a delayed presentation of scaphoid fracture, and none of them was treated conservatively elsewhere. Patients with bone graft, sclerotic bone debridement, or displacement of the fragment at the nonunion site were excluded. A percutaneous transtrapezial fixation technique was used in all cases. Patients were reviewed until clinical and radiographic union was observed. At the final follow-up, DASH (Disabilities of the Arm, Shoulder and Hand) and PRWHE (Patient-Rated Wrist and Hand Evaluation) outcome scores were completed. Results Radiographic union was obtained in 15 out of 16 patients (94%) at an average follow-up of 36 months (range: 12-98 months). No complications from the percutaneous technique were noted. The average DASH score was 6 (range: 0-39) and the average PRWHE score was 10 (range: 0-56). No statistical significant difference in range of motion and grip strength was found between the operated side and the contralateral side. Conclusion Percutaneous transtrapezial screw fixation for delayed or nonunion of selected scaphoid fractures without bone grafting is promising. At a mean of 4 months, 94% union was obtained with good functional results when there was no sclerosis, minimal osteolysis, and no displacement at the scaphoid nonunion site. Type of Study Therapeutic study. Level of Evidence IV.
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Affiliation(s)
- Matthias Vanhees
- Department of Orthopedic Surgery, Monica Hospital, Antwerp, Belgium
- Department of Orthopedic Surgery, Antwerp University Hospital, Antwerp, Belgium
| | - Roger R.P. van Riet
- Department of Orthopedic Surgery, Monica Hospital, Antwerp, Belgium
- Department of Orthopedic Surgery, Antwerp University Hospital, Antwerp, Belgium
| | - Annemieke van Haver
- Monica Orthopedic Research (MoRe) Foundation, Monica Hospital, Antwerp, Belgium
| | - Radek Kebrle
- Department of Orthopedic Surgery, Ustav Plasticke Chirurgie a Chirurgie Ruky, Vysoke nad Jizerou, Czech Republic
| | - Geert Meermans
- Department of Orthopedic Surgery, Lievensberg Ziekenhuis, Bergen op Zoom, The Netherlands
| | - Frederik Verstreken
- Department of Orthopedic Surgery, Monica Hospital, Antwerp, Belgium
- Department of Orthopedic Surgery, Antwerp University Hospital, Antwerp, Belgium
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Abstract
BACKGROUND The purpose of this systematic review is to analyze the indications, outcomes, and complications of scaphoid fixation with a staple. METHODS The literature was reviewed for all cases of the scaphoid staple. Five articles including 188 patients, of 77 primary scaphoid fractures and 111 other indications that included delayed union, nonunion, and avascular necrosis, were reviewed. Demographic data, outcomes, and complications were recorded. RESULTS The union rate of the scaphoid staple is 94.7%, and 95.7% of patients return to work after an average of 9.8 weeks after a 4.7-week period of immobilization. The complication rate was 9.0%, and 7.5% required hardware removal. Clinical and radiographic healing was higher in primary fractures as compared with other indications. Other indications, as compared with primary fracture, had a higher rate of hardware removal. CONCLUSIONS For all indications, the scaphoid staple has a high union rate and a low complication rate. In the authors' experience, the procedure is fast, not technically challenging, and may be considered for primary fracture, delayed union, nonunion, and avascular necrosis of the scaphoid.
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Affiliation(s)
- John Dunn
- William Beaumont Army Medical Center, Fort Bliss, TX, USA
| | | | - Austin Fares
- Creighton University School of Medicine, Omaha, NE, USA,Austin Fares, Creighton University School of Medicine, 2500 California Plaza, Omaha, NE 68102, USA.
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Weinstock-Zlotnick G, Mehta SP. A structured literature synthesis of wrist outcome measures: An evidence-based approach to determine use among common wrist diagnoses. J Hand Ther 2017; 29:98-110. [PMID: 27264897 DOI: 10.1016/j.jht.2016.03.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Revised: 03/11/2016] [Accepted: 03/14/2016] [Indexed: 02/03/2023]
Abstract
STUDY DESIGN Structured literature synthesis. INTRODUCTION Hand therapists and researchers have numerous options when selecting outcome measures for patients with wrist pathologies. An evidence-based approach to determining which measures are used most often can inform choices. PURPOSE OF THE STUDY To describe how frequently outcome measures are used in recent randomized controlled trials of patients with wrist diagnoses. Identifying assessment design and related International Classification of Functioning, Disability and Health (ICF) domains provides additional consideration for selection. METHODS Systematic PubMed and Cumulative Index to Nursing and Allied Health Literature searches for the time frame between January 2005 and March 2015 captured measures used in randomized controlled trials researching wrist-specific fractures, ligament injuries, nerve injuries, arthritis/arthroplasty, or stress injuries/wrist pain. RESULTS Three most frequent measures used within each diagnostic category are detailed with assessment design described and ICF domain identified. Across diagnoses, grip/pinch strength and Disabilities of Arm, Shoulder and Hand were the most frequently used physical and patient-reported outcome measures, respectively. The Jebsen-Taylor Hand Function Test was the most frequently used performance measure. DISCUSSION AND CONCLUSIONS Consideration of the evidence, ICF domains, wrist diagnoses, and assessment design can help hand therapists select the measure most appropriate for use. LEVEL OF EVIDENCE 2a.
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Affiliation(s)
| | - Saurabh P Mehta
- School of Physical Therapy, Marshall University, Huntington, WV, USA; Department of Orthopedic Surgery, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV, USA
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de Boer BNP, Doornberg JN, Mallee WH, Buijze GA. Surgical treatment of non- and minimally-displaced acute scaphoid fractures favours over-conservative treatment but only in the short term: an updated meta-analysis. J ISAKOS 2016. [DOI: 10.1136/jisakos-2015-000024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Ilizarov fixation for the treatment of scaphoid nonunion: a novel approach. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2016; 27:41-51. [PMID: 27766431 DOI: 10.1007/s00590-016-1871-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 10/12/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVES To evaluate the safety and efficacy of the Ilizarov fine-wire compression/distraction technique in the treatment of scaphoid nonunion (SNU), without the use of bone graft. DESIGN This is a prospective study of 20 consecutive patients in one center. PATIENTS AND METHODS This study included 20 patients (19 males) with a mean SNU duration of 14.5 months. Four patients had proximal pole, 15 had waist, and 1 had a distal SNU. Patients with carpal instability, humpback deformities, carpal collapse, avascular necrosis, and marked degenerative change were excluded. Following frame application, the treatment comprises three stages: The frame is distracted by 1 mm per day until the radiographs show a 2-3 mm opening at the SNU site (mean 10 days); the SNU site is compressed for 5 days, at a rate of 1 mm per day, with the wrist in 15 degrees of flexion and 15 degrees of radial deviation; the wrist is then immobilized in the Ilizarov fixator for 8 weeks. RESULTS Radiographic (radiography and CT scan) and clinical bony union was achieved in all 20 patients after a mean of 90.3 days (70-130 days). All patients returned to their pre-injury occupations. Thirteen patients had excellent results, four good, and three fair, according to the Mayo wrist score. CONCLUSIONS In these selected patients, this technique safely achieved bony union without the need to open the SNU site and without the requirement of bone graft.
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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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Grewal R, Suh N, MacDermid JC. Is Casting for Non-Displaced Simple Scaphoid Waist Fracture Effective? A CT Based Assessment of Union. Open Orthop J 2016; 10:431-438. [PMID: 27708739 PMCID: PMC5034027 DOI: 10.2174/1874325001610010431] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2016] [Revised: 08/10/2016] [Accepted: 08/16/2016] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE The purpose of this study is to report the union rate and time to union for acute non-displaced scaphoid waist fractures treated with a short arm thumb spica cast. METHODS A database was searched (2006-2013) to identify acute undisplaced scaphoid waist fractures. Cases that were not given a trial of casting were excluded (n=33). X-rays, CT scans and health records for each patient were reviewed to extract data. RESULTS 172 patients met inclusion criteria. There were 138 males, 34 females, the mean age was 30 ± 16 years. The union rate was 99.4% (1 nonunion/172 subjects). The mean time to union was approximately 7.5 weeks (53 ± 37 days). Energy of injury, age or gender did not affect union rates or time to union. Cysts did not affect the union rate (p=0.73) but patients with cystic resorption along the fracture line required approximately 10 weeks for union (69 ± 60 days) compared to 7 weeks (51 ± 34 days) for those without cysts (p=0.05). Diabetes did not affect the union rate (p=0.81) but was found to increase the risk of delayed union (p=0.05). There was a weak, but statistically significant correlation between the number of days before the fracture was casted and the length of time needed to achieve union (r=0.27, p=0.001). CONCLUSION Non-displaced scaphoid waist fractures have a high healing rate with appropriate identification and immobilization. Follow-up CT scans to assess healing can identify union within a shorter time frame (~7 weeks) than previously reported in the literature.
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Affiliation(s)
- Ruby Grewal
- Division of Orthopedic Surgery University of Western Ontario, Roth
- McFarlane Hand and Upper Limb Center, St Joseph's Health Care, London, England
| | - Nina Suh
- Division of Orthopedic Surgery University of Western Ontario, Roth
- McFarlane Hand and Upper Limb Center, St Joseph's Health Care, London, England
| | - Joy C MacDermid
- Division of Orthopedic Surgery University of Western Ontario, Roth
- McFarlane Hand and Upper Limb Center, St Joseph's Health Care, London, England
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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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Rambau GM, Rhee PC. Evaluation and Management of Nondisplaced Scaphoid Waist Fractures in the Athlete. OPER TECHN SPORT MED 2016. [DOI: 10.1053/j.otsm.2016.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Ten Berg PW, Drijkoningen T, Strackee SD, Buijze GA. Classifications of Acute Scaphoid Fractures: A Systematic Literature Review. J Wrist Surg 2016; 5:152-159. [PMID: 27104083 PMCID: PMC4838473 DOI: 10.1055/s-0036-1571280] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Accepted: 12/11/2015] [Indexed: 01/02/2023]
Abstract
Background In the lack of consensus, surgeon-based preference determines how acute scaphoid fractures are classified. There is a great variety of classification systems with considerable controversies. Purposes The purpose of this study was to provide an overview of the different classification systems, clarifying their subgroups and analyzing their popularity by comparing citation indexes. The intention was to improve data comparison between studies using heterogeneous fracture descriptions. Methods We performed a systematic review of the literature based on a search of medical literature from 1950 to 2015, and a manual search using the reference lists in relevant book chapters. Only original descriptions of classifications of acute scaphoid fractures in adults were included. Popularity was based on citation index as reported in the databases of Web of Science (WoS) and Google Scholar. Articles that were cited <10 times in WoS were excluded. Results Our literature search resulted in 308 potentially eligible descriptive reports of which 12 reports met the inclusion criteria. We distinguished 13 different (sub) classification systems based on (1) fracture location, (2) fracture plane orientation, and (3) fracture stability/displacement. Based on citations numbers, the Herbert classification was most popular, followed by the Russe and Mayo classifications. All classification systems were based on plain radiography. Conclusions Most classification systems were based on fracture location, displacement, or stability. Based on the controversy and limited reliability of current classification systems, suggested research areas for an updated classification include three-dimensional fracture pattern etiology and fracture fragment mobility assessed by dynamic imaging.
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Affiliation(s)
- Paul W. Ten Berg
- Department of Plastic, Reconstructive, and Hand Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Tessa Drijkoningen
- Department of Plastic, Reconstructive, and Hand Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Simon D. Strackee
- Department of Plastic, Reconstructive, and Hand Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Geert A. Buijze
- Department of Orthopaedic Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Rancy SK, Zelken JA, Lipman JD, Wolfe SW. Scaphoid Proximal Pole Fracture Following Headless Screw Fixation. J Wrist Surg 2016; 5:71-76. [PMID: 26855840 PMCID: PMC4742264 DOI: 10.1055/s-0035-1565928] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 09/26/2015] [Indexed: 10/22/2022]
Abstract
Background Headless screw fixation of scaphoid fractures and nonunions yields predictably excellent outcomes with a relatively low complication profile. However, intramedullary implants affect the load to failure and stress distribution within bone and may be implicated in subsequent fracture. Case Description We describe a posttraumatic fracture pattern of the scaphoid proximal pole originating at the previous headless screw insertion site in three young male patients with healed scaphoid nonunions. Each fracture was remarkably similar in shape and size, comprised the volar proximal pole, and was contiguous with the screw entry point. Treatment was challenging but successful in all cases. Literature Review Previous reports have posited that stress-raisers secondary to screw orientation may be implicated in subsequent peri-implant fracture of the femoral neck. Repeat scaphoid fracture after screw fixation has also been reported. However, the shape and locality of secondary fracture have not been described, nor has the potential role of screw fixation in the production of distinct fracture patterns. Clinical Relevance Hand surgeons must be aware of this difficult complication that may follow antegrade headless screw fixation of scaphoid fracture nonunion, and of available treatment strategies.
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Affiliation(s)
- Schneider K. Rancy
- Department of Hand and Upper Extremity Surgery, Hospital for Special Surgery, New York, New York
| | - Jonathan A. Zelken
- Department of Hand and Upper Extremity Surgery, Hospital for Special Surgery, New York, New York
| | - Joseph D. Lipman
- Department of Biomechanics, Hospital for Special Surgery, New York, New York
| | - Scott W. Wolfe
- Department of Hand and Upper Extremity Surgery, Hospital for Special Surgery, New York, New York
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Dacombe PJ, Amirfeyz R, Davis T. Patient-Reported Outcome Measures for Hand and Wrist Trauma: Is There Sufficient Evidence of Reliability, Validity, and Responsiveness? Hand (N Y) 2016; 11:11-21. [PMID: 27418884 PMCID: PMC4920509 DOI: 10.1177/1558944715614855] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Patient-reported outcome measures (PROMs) are important tools for assessing outcomes following injuries to the hand and wrist. Many commonly used PROMs have no evidence of reliability, validity, and responsiveness in a hand and wrist trauma population. This systematic review examines the PROMs used in the assessment of hand and wrist trauma patients, and the evidence for reliability, validity, and responsiveness of each measure in this population. METHODS A systematic review of Pubmed, Medline, and CINAHL searching for randomized controlled trials of patients with traumatic injuries to the hand and wrist was carried out to identify the PROMs. For each identified PROM, evidence of reliability, validity, and responsiveness was identified using a further systematic review of the Pubmed, Medline, CINAHL, and reverse citation trail audit procedure. RESULTS The PROM used most often was the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire; the Patient-Rated Wrist Evaluation (PRWE), Gartland and Werley score, Michigan Hand Outcomes score, Mayo Wrist Score, and Short Form 36 were also commonly used. Only the DASH and PRWE have evidence of reliability, validity, and responsiveness in patients with traumatic injuries to the hand and wrist; other measures either have incomplete evidence or evidence gathered in a nontraumatic population. CONCLUSIONS The DASH and PRWE both have evidence of reliability, validity, and responsiveness in a hand and wrist trauma population. Other PROMs used to assess hand and wrist trauma patients do not. This should be considered when selecting a PROM for patients with traumatic hand and wrist pathology.
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Affiliation(s)
- Peter Jonathan Dacombe
- University Hospitals Bristol, Bristol Royal Infirmary, Bristol, England,Peter Jonathan Dacombe, University Hospitals Bristol, Bristol Royal Infirmary, Bristol BS2 8HW, England.
| | - Rouin Amirfeyz
- University Hospitals Bristol, Bristol Royal Infirmary, Bristol, England
| | - Tim Davis
- Queen’s Medical Centre, Nottingham, England
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Gruszka D, Herr R, Hely H, Hofmann P, Klitscher D, Hofmann A, Rommens PM. Impact of Different Screw Designs on Durability of Fracture Fixation: In Vitro Study with Cyclic Loading of Scaphoid Bones. PLoS One 2016; 11:e0145949. [PMID: 26741807 PMCID: PMC4704798 DOI: 10.1371/journal.pone.0145949] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 12/10/2015] [Indexed: 11/28/2022] Open
Abstract
PURPOSE The use of new headless compression screws (HCSs) for scaphoid fixation is growing, but the nonunion rate has remained constant. The aim of this study was to compare the stability of fixation resulting from four modern HCSs using a simulated fracture model to determine the optimal screw design(s). METHODS We tested 40 fresh-frozen cadaver scaphoids treated with the Acumed Acutrak 2 mini (AA), the KLS Martin HBS2 midi (MH), the Stryker TwinFix (ST) and the Synthes HCS 3.0 with a long thread (SH). The bones with simulated fractures and implanted screws were loaded uniaxially into flexion for 2000 cycles with a constant bending moment of 800 Nmm. The angulation of the fracture fragments was measured continuously. Data were assessed statistically using the univariate ANOVA test and linear regression analysis, and the significance level was set at p < 0.05. RESULTS The median angulation of bone fragments φ allowed by each screw was 0.89° for AA, 1.12° for ST, 1.44° for SH and 2.36° for MH. With regards to linear regression, the most reliable curve was achieved by MH, with a coefficient of determination of R2 = 0.827. This was followed by AA (R2 = 0.354), SH (R2 = 0.247) and ST (R2 = 0.019). Data assessed using an adapted ANOVA model showed no statistically significant difference (p = 0.291) between the screws. CONCLUSIONS The continuous development of HCSs has resulted in very comparable implants, and thus, at this time, other factors, such as surgeons' experience, ease of handling and price, should be taken into consideration.
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Affiliation(s)
- Dominik Gruszka
- Department of Orthopaedics and Traumatology, University Medical Center of Johannes Gutenberg University, Mainz, Germany
| | - Robert Herr
- Department of Orthopaedics and Traumatology, University Medical Center of Johannes Gutenberg University, Mainz, Germany
| | - Hans Hely
- Physics Division, RheinMain University of Applied Sciences, Wiesbaden, Germany
| | - Peer Hofmann
- Physics Division, RheinMain University of Applied Sciences, Wiesbaden, Germany
| | - Daniela Klitscher
- Department of Orthopaedics and Traumatology, University Medical Center of Johannes Gutenberg University, Mainz, Germany
| | - Alexander Hofmann
- Department of Orthopaedics and Traumatology, University Medical Center of Johannes Gutenberg University, Mainz, Germany
| | - Pol Maria Rommens
- Department of Orthopaedics and Traumatology, University Medical Center of Johannes Gutenberg University, Mainz, Germany
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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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