Management of Scaphoid Nonunion With Iliac Crest Graft and K-wire Fixation: An Economically Viable Option.

Purpose This study details the functional results, patient satisfaction, and cost-effectiveness of patients treated with Fisk-Fernandez surgery using iliac crest graft and K-wire for scaphoid nonunion. Materials and methods This study involved a retrospective analysis conducted between November 2022 and August 2024. Forty-two patients diagnosed with scaphoid nonunion were treated using a surgical approach that included autologous bone grafting combined with K-wire fixation to promote bone healing and stability. To enable comparison, the QuickDASH-9 score, visual analog scale (VAS), and patient-rated wrist evaluation (PRWE) score were used for both preoperative and postoperative evaluations at the final follow-up. Results Our study group received treatment for an average of 16 months post-injury, ranging from 6 to 28 months. The average time of union was six months, ranging from four to 18 months. The study significantly improved QuickDASH-9 scores, grip strength, PRWE scores, and VAS for pain. The study reported no complications, and all patients returned to their basic activities of daily living. Conclusion Results of this study show that displaced scaphoid nonunions can be successfully treated with K-wire fixation combined with iliac crest bone grafting utilizing the Fisk-Fernandez approach.

Ultrasound-based Measurement of the Intra-scaphoid angle.

INTRODUCTION: Ultrasound is gaining popularity for diagnosing scaphoid fractures. However, it hasn't been used to assess fracture displacement, such as humpback deformity. We propose a sonographic method to measure the intra-scaphoid angle, potentially serving as an alternative to CT scans for detecting fragment malposition after a scaphoid fracture. METHODS: We recruited 11 healthy adult volunteers without wrist pathology and performed bilateral wrist ultrasounds, totaling 22 examinations. Each wrist was splinted at 50 ° extension and fully supinated. Two hand surgeons independently performed the ultrasounds. All images were then evaluated separately by two evaluators. The following measurements were taken: 1. Inter-poles distance (IPD): Distance between the summits of the two scaphoid poles on the palmar cortex. 2. Palmar cortical intra-scaphoid angle (PCISA): Angle between the two summits and the deepest point of the waist on the palmar cortex. Measurements were compared for inter-investigator and inter-evaluator reliability using the intraclass correlation coefficient (ICC). RESULTS: The study included four males and seven females, with an average age of 35 years (range 21-56). The mean PCISA was 142 ° (SD 10 °) and the mean IPD was 16.3 mm (SD 2.1 mm). Differences in IPD measurements averaged 0.3 mm (range 0-5.2 mm) among investigators and 1.0 mm (range 0.1-3.8 mm) among evaluators. For PCISA, the differences averaged 4 ° (range 0-17 °) among investigators and 6 ° (range 0-15 °) among evaluators. The ICC for IPD was 0.804 (investigators) and 0.572 (evaluators); for PCISA, it was 0.704 (investigators) and 0.602 (evaluators). CONCLUSION: This study presents a cost-effective and accessible sonographic technique to measure the intra-scaphoid angle. Further research is required to assess its effectiveness in scaphoid fractures and compare it to CT-based measurements like the H/L ratio, LISA, and DCA.

Surgical Treatment of Scaphoid Fractures: Recommendations for Management.

Background: Several operative treatments exist for scaphoid fractures, varying by approach (e.g., ercutaneous, volar, or dorsal), implant type (e.g., screw or Kirschner wire), and bone raft choice (e.g., none, nonvascularized, or vascularized). Many previous systematic eviews and meta-analyses have investigated outcomes following different surgicalÚpproaches, the use of vascularized versus nonvascularized bone graft for scaphoidßracture nonunions, and treatment for specific fracture patterns. However, given the advancements n scaphoid fracture treatment in recent years, there is a need for updated treatment recommendations hat would be beneficial to hand surgeons. Purpose: We present a comprehensive review of the operative treatment of scaphoid fractures based on recent literature and propose a unified treatment algorithm for managing these fractures. Methods: The English-language literature was searched from 2002 to 2023 for high evidence level (e.g., randomized trials), review, and meta-analysis articles with the following search terms: "scaphoid, "u8220"scaphoid" AND "nonunion, " and "scaphoid" AND "malunion. " Each article was creened by the authors to determine the scaphoid fracture scenario addressed and ubsequent treatment recommendations. The findings from article reviews were then rganized by scaphoid fracture types in this manuscript. Results: A total of 95 pertinent articles were ultimately selected and used as the basis for reviewing different scaphoid fracture scenarios. A treatment algorithm was then proposed based on literature review. Conclusion: This summary of the recent literature can guide hand surgeons in addressing scaphoidßractures. Future research in scaphoid fracture treatment, particularly for nonunions, would be most beneficial n the form of systematic review, meta-analysis, or multicenter prospective randomized clinical trials. Level of Evidence: IV.

A comparative study of volar locking-plate fixation with corticocancellous and pure cancellous bone grafts for scaphoid nonunion with dorsal intercalated segmental instability secondary to scaphoid humpback deformity.

INTRODUCTION: Bone grafts for scaphoid nonunion with deformity include cortcicocancellous or pure cancellous bone grafts. This study compared the outcomes between two types of bone grafts when employing a volar locking-plate in patients with scaphoid nonunion with dorsal intercalated segmental instability (DISI). PATIENTS AND METHODS: This retrospective study included 34 patients with scaphoid nonunion and DISI due to humpback deformity treated between March 2017 and January 2022. Two types of bone grafts were obtained from iliac crest. Twenty of the corticocancellous (CC) group underwent a wedge-shaped graft, while 14 patients of the pure cancellous (C-only) group received graft chips. In both groups, a 1.5-mm anatomically pre-contoured locking plate was used for fixation. Radiographic evaluations included the union rate and carpal alignment including scapholunate angle (SLA), radiolunate angle (RLA), intrascaphoid angle (ISA) and scaphoid height to length ratio (HLR). Clinical assessments encompassed wrist range-of-motion, grip strength, and patient-reported outcomes. RESULTS: Nineteen of the 20 patients in the CC group and 12 of the 14 patients in the C-only group respectively, achieving osseous union. The mean follow-up period in CC group was 14.7 (range, 12 ∼ 24) months and that in C-only group was 12.6 (range, 12 ∼ 15) months. Postoperatively, there were no significant intergroup differences of radiographic parameters including SLA (CC; 49.9° ± 6.7° vs. C-only; 48.9° ± 3.5°, P = 0.676), RLA (1.7° ± 6.4° vs. 2.4° ± 3.3°, P = 0.74), ISA (36° ± 7.5° vs. 36.6° ± 12.2°, P = 0.881), and HLR (0.54 ± 0.09 vs. 0.53 ± 0.05, P = 0.587). Clinical outcomes, including the flexion-extension arc (137° ± 30° vs. 158° ± 33°, P = 0.122), grip strength (93.4 % ± 15.4% vs. 99.5 % ± 16.7 %, P = 0.39), Quick Disabilities of the Arm, Shoulder, and Hand scores (11.2 ± 8.3 vs. 12.5 ± 7.7, P = 0.74) and Mayo Wrist Scores (81.2 ± 13.1 vs. 89 ± 11.4, P = 0.242) also showed no significant intergroup differences. CONCLUSIONS: Volar locking-plate fixation with pure cancellous bone grafts achieved outcomes comparable to those achieved with corticocancellous bone grafts in scaphoid nonunion with deformity, possibly due to the biomechanical advantages of the volar plate to provide structural supports.

The role of vascularized bone grafting for scaphoid nonunions in adolescents.

A total of 26 adolescent patients were treated for scaphoid nonunion with a vascularized bone graft from either the medial femoral condyle or dorsal distal radius. There was an 85% union incidence, improved carpal alignment and a low incidence of complications.

Clinical outcomes of double-screw fixation with bone grafting for displaced scaphoid nonunions: A series of 21 cases.

Purpose: This study reports the clinical outcomes of double-screw fixation with bone grafting for displaced scaphoid nonunions. Patients and methods: This study was a retrospective survey. From January 2018 to December 2019, 21 patients with displaced scaphoid fractures underwent open debridement and two headless compression screw fixation with bone grafting. The preoperative and postoperative lateral intrascaphoid angle (LISA) and scapholunate angle (SLA) were recorded. Preoperative and postoperative grip strength (% of the healthy side), active range of motion (AROM), visual analogue scale (VAS), and patient-rated wrist evaluation (PRWE) scores at the final follow-up were obtained for all patients for comparison. Results: Patients were treated for an average of 38.3 months (range 12-250) after the injury. The average time of postoperative follow-up was 30.5 months (range 24-48). All fractures achieved union at a mean of 2.7 months (range 2-4) after surgery, and 14 scaphoids of 21 patients (66.7%) healed by 8 weeks. CT scans showed no evidence of cortical penetration of either screw in all patients. There was a statistically significant improvement in AROM, grip strength, and PRWE. No complications occurred in this study, and all patients returned to work. Conclusion: This study indicates that double-screw fixation with bone grafting is an effective technique for treating displaced scaphoid nonunions.

Mechanism of scaphoid waist fracture: finite element analysis.

The mechanism of scaphoid waist fracture is not completely understood. We used finite element analysis to study the formation of scaphoid waist fractures. Clinical computed tomography scans of 12 wrists were used to create models for finite element analysis. The points of application of load were at different sites along the scaphotrapeziotrapezoid joint distally, and the scaphoid fossa plus the area underlying the radioscaphocapitate ligament was regarded as the fixed proximal support. A fracture was produced at the scaphoid waist in all cases. The location of failure of bone at its anterior or dorsal cortex, either in tension or in compression, was determined by the site of application of the load. The anterior cortex failed in compression when the point of impact was located along the trapezium facet or the entire distal pole, whereas it failed in tension when the point of impact was along the trapezoid facet.

Residual flexion deformity after scaphoid nonunion surgery: 7-year follow-up study.

The clinical implication of a residual flexion deformity following surgery for scaphoid nonunion is unclear. Sixty-three patients who underwent scaphoid nonunion surgery were assessed after a mean of 7 years (range 5-10) to analyse the outcomes based on the presence of residual scaphoid deformity. Primary outcome was Disabilities of the Arm, Shoulder and Hand score. Secondary outcomes were Patient-Rated Wrist Evaluation score, wrist range of motion and strength. Patients were dichotomized to residual deformity or no deformity. Scaphoid deformity was calculated from CT scans based on the median difference between the height-length ratio of the operated versus the uninjured scaphoid. There were no differences between residual deformity (n = 33) and no deformity (n = 30) in any outcome variables, except for wrist extension which was slightly worse in the deformity group. The deformity group had a greater number of radiographic osteoarthritis, but all cases were mild, and osteoarthritis did not correlate to a worse outcome. We conclude that residual scaphoid deformity has no relevant negative impact on mid-term wrist function.Level of evidence: IV.

Predictors of Failure for Vascularized and Nonvascularized Bone Grafting of Scaphoid Nonunions: A Systematic Review.

Objective This article compares predictors of failure for vascularized (VBG) and nonvascularized bone grafting (NVBG) of scaphoid nonunions. Methods We conducted a systematic literature review of outcomes after VBG and NVBG of scaphoid nonunion. Fifty-one VBG studies ( N = 1,419 patients) and 81 NVBG studies ( N = 3,019 patients) met the inclusion criteria. Data were collected on surgical technique, type of fixation, time from injury to surgery, fracture location, abnormal carpal posture (humpback deformity and/or dorsal intercalated segmental instability [DISI]), radiographic parameters of carpal alignment, prior failed surgery, smoking status, and avascular necrosis (AVN) as defined by punctate bleeding, magnetic resonance imaging (MRI) with contrast, MRI without contrast, X-ray, and histology. Meta-analysis of proportions was conducted with Freeman-Tukey double arcsine transformation. Multilevel mixed-effects analyses were performed with univariable and multivariable Poisson regression to identify confounders and evaluate predictors of failure. Results The pooled failure incidence effect size was comparable between VBG and NVBG (0.09 [95% confidence interval [CI] 0.05-0.13] and 0.08 [95% CI 0.06-0.11], respectively). Humpback deformity and/or DISI (incidence-rate radios [IRRs] 1.57, CI: 1.04-2.36) and lateral intrascaphoid angle (IRR 1.21, CI: 1.08-1.37) were significantly associated with an increased VBG failure incidence. Time from injury to surgery (IRR 1.09, CI: 1.06-1.12) and height-to-length (H/L) ratio (IRR 53.98, CI: 1.16-2,504.24) were significantly associated with an increased NVBG failure incidence, though H/L ratio demonstrated a wide CI. Decreased proximal fragment contrast uptake on MRI was a statistically significant predictor of increased failure incidence for both VBG (IRR 2.03 CI: 1.13-3.66) and NVBG (IRR 1.39, CI: 1.16-1.66). Punctate bleeding or radiographic AVN, scapholunate angle, radiolunate angle, and prior failed surgery were not associated with failure incidence for either bone graft type ( p > 0.05). Conclusion Humpback deformity and/or DISI and increasing lateral intrascaphoid angle may be predictors of VBG failure. Time from injury to surgery may be a predictor of NVBG failure. AVN as defined by decreased contrast uptake on MRI may be a marker of increased failure risk for both bone graft types.

Correction of residual humpback deformity after arthroscopic treatment of scaphoid non-union.

BACKGROUND: The aim of this study was to assess residual humpback deformity after arthroscopic treatment of scaphoid non-union. MATERIAL AND METHOD: We reviewed the medical records of 47 patients with scaphoid non-union who underwent arthroscopic treatment between 2012 and 2018. Patients who did not receive an intraoperative bone graft were excluded (10 patients), as were those who did not achieve bone union (three patients). The radiographic assessment consisted of pre- and postoperative radiographs and CT-scans. RESULTS: The radiolunate angle, scapholunate angle and Youm index were measured. At the final follow-up, the scapholunate angle was 54±8̊ (36-80̊) and the radiolunate angle was 11±7̊ (2-45̊). The scapholunate angle was significantly different between the preoperative measurement and the last follow-up; however, the radiolunate angle and Youm index did not change significantly. CONCLUSION: Our study found that arthroscopic treatment of scaphoid non-union with a cancellous bone graft taken from the distal radius results corrects the humpback deformity. LEVEL OF EVIDENCE: IV.

Can CT-Scan Measurements of Humpback Deformity, Dislocation, and the Size of Bony Cysts Predict Union after Surgery for Scaphoid Nonunion?

Objective Scaphoid fractures are associated with high rates of late- or nonunion after conservative treatment. Nonunion is reported to occur in approximately 10% of all scaphoid fractures. It is known that the union of scaphoid fractures is affected by factors such as location at proximal pole, tobacco smoking, and the time from injury to treatment. Same factors seem to affect the healing after surgery for scaphoid nonunion. While the impact of preoperative humpback deformity on the functional outcome after surgery has been previously reported, the impact of humpback deformity, displacement, and the presence of bony cysts on union rate and time to healing after surgery has not been studied. Purpose The primary purpose of this study is to assess the association of humpback deformity, fragment displacement, and the size of cysts along the fracture line with the union rate and union time, following surgery of scaphoid nonunion. The second purpose of the study is to investigate the interobserver reliability in the evaluation of computed tomography (CT) scans of scaphoid nonunion. Patients and Methods From January 2008 to December 2018, 178 patients were surgically treated in our institution. After exclusion criteria were met, 63 patients with scaphoid delayed- or established nonunion, and preoperative CT scans of high quality (<2mm./ slice), were retrospectively analyzed. There was 58 men and 5 women with a mean age of 30 years (range: 16-72 years). Four orthopaedic surgeons and one radiologist independently analyzed the CT scans. The dorsal cortical angle (DCA), lateral intrascaphoid angle (LISA), the height-to-length ratio, the size of the cysts, and displacement of the fragments were measured. Healing was defined by CT scan, or by conventional X-ray, and status of no pain at clinical examination. Thirty-two of the patients had developed nonunion (>6 months postinjury), while 31 were in a stage of delayed union (3-6 months postinjury). Results Open surgery with cancellous or structural bone graft was the treatment of choice in 49 patients, 8 patients were treated with arthroscopic bone grafting, and 6 patients with delayed union were operated with percutaneous screw fixation, without bone graft. Overall union rate was 86% (54/63) and was achieved after 84 days (12 weeks) (mean). The failure rate and time to healing were not associated with the degree of the humpback deformity, size of the cysts, or displacement of the nonunion in general. However, greater dislocation, and the localization of the nonunion at the scaphoid waist, showed significant influence on the union rate. Dislocation at nonunion site, in the group of the patients who united after surgery, was 2.7 mm (95% confidence interval [CI]: 1.5-3.7), and in the group who did not unite was 4.2 mm (95% CI: 2.9-5.7); p = 0.048). Time from injury to surgery was significantly correlated with time to union ( p < 0.05), but not associated with the union rate ( p < 0.4). Patients treated arthroscopically achieved faster healing (42 days), (standard deviation [SD]: 22.27) as compared with patients treated by open techniques (92 days; SD: 70.86). Agreement among five observers calculated as intraclass correlation coefficient was for LISA: 0.92; for height-to-length ratio: 0.73; for DCA: 0.65; for size of cysts: 0.61; and for displacement in millimeters: 0.24, respectively. Conclusions The degree of humpback deformity and the size of cysts along the fracture line of scaphoid nonunion have no predictive value for the result, neither for the union rate nor the union time after surgery for the scaphoid nonunion. However, larger dislocation of the fragments measured at the scaphoid waist showed lower union rate. Time to healing following surgery is mainly influenced by the time from injury to the surgical treatment and may be influenced by the choice of the surgical technique. Interrater reliability calculation was best with LISA measurements, and worse with the measurements of the dislocation. Level of Evidence This is a Level III, observational, case-control study.

The effect of reformatting axis of computed tomography scans on the measurement of deformities in scaphoid waist nonunion.

BACKGROUND: Computed tomography (CT) has been used to understand the deformity of scaphoid nonunion, but no standard protocol for the reformatting of scaphoid CT imaging exists. The purpose of this study was to compare the reliability of measurements of the deformity of scaphoid waist nonunion between CT-scans reformatted in line with the scaphoid long axis and CT-scans reformatted in line with the wrist axis. HYPOTHESIS: We hypothesized that CT-scan which was reformatted along the scaphoid long axis is more reliable for understanding the deformity of scaphoid waist nonunion. PATIENTS AND METHODS: CT-scans of 28 wrists with a scaphoid waist nonunion were reformatted along both the long axis of the scaphoid and of the wrist. For each set of CT-scans, the nonunion gap in axial, coronal and sagittal series, the intrascaphoid angle, and the height to length ratio were measured. All scans were reviewed twice by three observers and intraclass correlation coefficients (ICCs) for inter- and intraobserver reliability were assessed. RESULTS: For the measurement of nonunion gaps and height to length ratio, neither inter- nor intraobserver reliability showed significant differences between the two reformatting scans. However, for the intrascaphoid angle, both inter- (ICC: 0.202 vs. 0.419, p<0.001) and intraobserver (ICC: 0.614 vs. 0.790, p<0.001) reliability were significantly higher on scaphoid axis CT-scan than on wrist axis CT-scan. DISCUSSION: In the assessment of deformity in patients with scaphoid waist nonunion, scaphoid axis reformatting CT-scans showed superior reliability for the measurement of intrascaphoid angle than did wrist axis reformatting CT-scans. Although there are several limitations for the correct assessment of all three-dimensional deformity, scaphoid axis reformatting CT-scans could help in assessing the extent of humpback deformity in patients with scaphoid waist nonunion. LEVEL OF EVIDENCE: IV; diagnostic.

Correction of humpback and DISI deformities by vascularized bone grafting in patients with scaphoid nonunion.

INTRODUCTION: Although vascularized bone grafting (VBG) using 1, 2 intercompartmental supraretinacular artery (1, 2 ICSRA) is effective for scaphoid nonunion, dorsal intercalated segment instability (DISI) deformity persists even after correction of humpback deformity (HD). The purpose of this retrospective study was to evaluate the correction of HD and DISI deformity after 1, 2 ICSRA VBG for scaphoid nonunion. METHODS: We treated 18 patients (mean age: 25.8, 16 males and 2 females) with scaphoid nonunion using a 1, 2-ICSRA VBG between January 2010 and December 2018. The average time from injury to surgery was 20.0 (3-120) months. The nonunions were located at the waist in all patients. The correction of HD and DISI deformity was investigated on the preoperative images and images at the last examination. RESULTS: In all patients, the correction of HD was positively correlated with that of DISI deformity. Moreover, we focused on the time from injury to surgery and evaluated changes in HD and DISI deformity according to the time to surgery. As a result, changes in HD and DISI deformity were positively correlated in patients with a shorter time to surgery but were not correlated when the time to surgery exceeded 5 months. CONCLUSIONS: These results suggest that DISI deformity can be corrected by correcting HD when the time from injury to surgery is short, but that correction is difficult if the time to surgery is prolonged.

[Osteophyte-induced impingement reduces range of motion in humpback deformity of incorrectly healed scaphoid reconstruction]. / Osteophytenbedingtes Impingement verringert die Beweglichkeit bei in "Humpback"-Deformität fehlverheilter Skaphoidrekonstruktion.

BACKGROUND: The gold standard in the treatment of scaphoid pseudarthrosis is reduction, interposition of an iliac crest graft and stabilization with a headless bone (Herbert) screw, aiming to reduce the frequently observed humpback deformity. This study correlated the extent of humpback deformity after scaphoid reconstruction to clinical and radiological postoperative parameters. MATERIAL AND METHODS: Between 2008 and 2010 a total of 56 patients with scaphoid pseudarthrosis were surgically treated. Of the patients 34 could be included in this retrospective study. The average follow-up period was 7.3 months. The humpback deformity was evaluated by computed tomography (CT) scan performed along the long axis of the scaphoid. The disability of the arm, shoulder and hand (DASH) score, grip strength (Jamar), range of motion (RoM), Mayo wrist score (MWS) and other parameters were used to determine the clinical outcome. The patients were divided into two groups: 1) no or only slight humpback deformity (<25°), 2) severe humpback deformity (>45°). RESULTS: The RoM and DASH scores were slightly better for the first group. The second group had a significantly increased incidence of osteophyte formation (p < 0.05) and decreased RoM (-16°). CONCLUSION: It is postulated that the main disadvantage of an nonreduced humpback deformity is the increased occurrence of osteophyte formation in the dorsal aspect of the scaphoid. This can cause an impingement during extension and leads to a significant restriction of movement of the wrist. LEVEL OF EVIDENCE: III.

Vascularized Bone Grafting for Scaphoid Nonunion with Humpback Deformity: The Surgical Technique.

Background Scaphoid nonunion with humpback deformity and avascular necrosis (AVN) is a challenging problem. Correction of dorsal intercalated segment instability (DISI) requires grafting of a large and hard vascularized bone segment onto the volar side of the scaphoid. Purposes We have been treating the patients with one-incision vascularized bone grafting technique for scaphoid nonunion to improve blood supply and correct humpback deformity. We evaluated these cases retrospectively to the surgical efficacy of our procedure. Methods We harvested vascularized bone from the dorsal side of the radius using the method by Zaidemberg et al and inserted the cortical aspect into the scaphoid volar side using a direct lateral approach. Totally, 11 patients (nine males andtwo females) with a mean age of 40 years were recruited for this study. The mean time from fracture to treatment was 6 years and 3 months. The mean preoperative radiolunate angle was 25 degrees. All the patients showed AVN of the proximal scaphoid on T1-weighted images. An averaged follow-up period was 2 years and 3 months. Results Postoperative computed tomography revealed bony union in 10 patients (91% of union rate) with a mean modified Mayo'swrist score of 88 points (range, 75-100 points) and a mean disabilities of arm, shoulder, and hand (DASH) score of 4 points (range, 0-20 points). The mean radiolunate angle was corrected from 25 to 5 degrees. No adverse events were observed, except temporary mild paresthesia of the radial nerve territory in two patients. Conclusion This technique effectively corrected DISI in patients with scaphoid nonunion accompanied by humpback deformity and AVN.

Postoperative Outcomes of Volar Plate Fixation in Cases of Scaphoid Deformity or Nonunion: A Case Series.

Background Fractures through the waist of scaphoid are a common injury, resulting in deformity or nonunion. Recently, a locking plate has been shown to fix deformity or nonunion of scaphoid, with limited observation of functional postoperative outcomes. Objectives We present a case series of 16 patients, with the disabilities of the arm, shoulder, and hand (DASH) score evaluation in primary fixation of scaphoid fractures with humpback deformity ( n = 11) and revision open reduction internal fixation (ORIF) for nonunion ( n = 5), using the Medartis TriLock 1.5 scaphoid plate and bone grafting. Patients and Methods DASH scores were obtained preoperatively and postoperatively at 3, 6, and 12 (if required) months. Patient demographics, smoking status, employment type, and grip strengths were recorded. Results Thirteen patients attended follow-up. Union was clinically and radiologically assessed with 13 achieving union. The mean preoperative DASH score was 34.0 ( n = 16) and at treatment completion (discharge or DNA) was 11.5 ( n = 13), with mean reduction of 18.5 ( p = 0.03). At treatment completion, mean reduction in DASH score of revision ORIF was 13.7 ( p = 0.27; n = 4), compared with 20.7 ( p < 0.01; n = 9) in primary fixation with plate. Conclusions Deformity correction, reduction in DASH score, and rate of union make the plate system useful in the management of scaphoid fractures with humpback deformity and revision for nonunion. Level of Evidence This is a Level IV study.

Scaphoid Malunion Clinical and Radiographic Outcomes at a Minimum of 4 Years Follow-Up.

PURPOSE: To evaluate the radiographic and clinical outcomes of patients with scaphoid malunion after acute fracture at a mean of 7 years after injury. METHODS: Patients with scaphoid malunion were identified from a departmental database of acute scaphoid fractures. Patients with a scaphoid height-to-length ratio greater than 0.6 on final follow-up computed tomography (CT) scan were considered malunited. These patients were contacted to return for CT imaging and clinical assessment. A total of 22 patients were included (4 females and 18 males). Average age of the group was 41 years (range, 16-64 years) and average length of follow-up was 7.4 years (range, 4.4-11.8 years) after injury. RESULTS: Ten patients who underwent CT imaging demonstrated arthritic changes at the radial styloid, scaphoid fossa, or scaphotrapeziotrapezoid joint(s). Despite this, patients had good clinical function that was not significantly different compared with the uninjured side. Patients reported minimal pain and disability based on patient-reported outcome measures, and there was a moderate correlation between passive range of motion and height-to-length ratio. CONCLUSIONS: Nearly half of all patients with malunited acute scaphoid fractures demonstrated radiographic findings of early arthritis on CT imaging but overall good clinical results on midterm follow-up. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Modified Matti-Russe technique using a "butterfly bone graft" for treatment of scaphoid non-union.

INTRODUCTION: Autologous bone grafts are used to treat scaphoid non-union with shortening and humpback deformity. The superiority of internally fixed bone graft to embedded bone graft has not been clearly proven. METHODS: Retrospectively analyzed 42 cases of scaphoid waist non-union treated using the "butterfly bone graft" (modified Matti-Russe technique). RESULTS: Complete healing was reached by all patients, with an average time of 4.4 (SD ± 0.7) months. Mayo Wrist Score improved from and QuickDASH score significantly improved in all patients after treatment. CONCLUSIONS: Butterfly bone graft is effective and reliable in treating scaphoid non-union with shortening and humpback deformity.

Correction of Humpback Deformities in Patients With Scaphoid Nonunion Using 1,2-Intercompartmental Supraretinacular Artery Pedicled Vascularized Bone Grafting With a Dorsoradial Approach.

PURPOSE: Although 1,2-intercompartmental supraretinacular artery (1,2-ICSRA)-based vascularized bone grafting (VBG) has gained popularity in the treatment of scaphoid nonunion, correcting humpback deformities with this technique remains challenging. The purpose of this retrospective study was to determine the possibility of correcting humpback deformities using a 1,2-ICSRA VBG with a dorsoradial approach. METHODS: We treated 25 patients with scaphoid nonunion using a 1,2-ICSRA VBG between January 2007 and December 2017. For those with a humpback deformity, we performed vascularized wedge grafting from the dorsoradial side, instead of inlay bone grafting from the dorsal or volar side of the scaphoid. After excluding patients with scaphoid nonunion without a humpback deformity and those followed up for less than 6 months, we reviewed the imaging results and union rate in the remaining 19 patients (18 men and 1 woman). The nonunion sites and patient distribution were as follows: proximal one-third, 2; waist, 16; and distal one-third, 1. RESULTS: The union rate at the last follow-up performed a minimum of 6 months after the intervention was 94.7%. The correction was adequate in 17 patients and inadequate in 2 patients. The lateral intrascaphoid, radiolunate, and scapholunate angles were improved. CONCLUSIONS: Humpback and dorsal intercalated segmental instability deformities can be corrected adequately using a 1,2-ICSRA VBG with a dorsoradial approach. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Carpal Collapse After Scaphoid Nonunion: A Novel Combined Approach to the 1,2 Intercompartmental Supraretinacular Artery Radial Flap.

Purpose: Scaphoid nonunion remains a major problem in hand surgery. The 1,2 intercompartmental supraretinacular artery flap (1,2 ICSRA), as first described by Zaidemberg et al, is widely used with reported union rates of approximately 80%. However, its use is limited in the case of associated carpal collapse as in dorsal intercalated segmental instability (DISI) and humpback deformity. In this study, we present a novel approach to this flap enabling the correction of associated carpal collapse. Methods: Between 2006 and 2015, 9 patients with scaphoid nonunion or delayed union with carpal collapse were treated with a vascularized bone flap based on the 1,2 ICSRA using a combined volar and dorsal approach. Immobilization in a short-arm cast was applied for 8 weeks. Union rates, correction of DISI and humpback deformity, as well as clinical end points were noted. In addition, scapholunate (SL) angles were measured using 2 accepted radiological techniques, employing either the scaphoid midline axis or its proximal radiological landmarks as a reference. Results: All cases united and a median time to bone consolidation of 4 months (range, 2-5 months) was observed. Preoperative DISI deformities (n = 4) were corrected in all patients. Humpback deformities (n = 5) were also corrected. Two patients had repeat surgery: one for K-wire removal after bony consolidation and the other for neuropathic pain. Conclusions: The 1,2 ICSRA bone flap is a reliable treatment for scaphoid nonunion associated with carpal collapse. This combined volar and dorsal approach permits the correction of DISI and humpback deformity without compromising the scaphoid vascular supply, which eliminates the need to use free bone flaps from other sites. In this series, we observed a 100% union rate. Two patients required reoperation for symptomatic hardware and dorsal wrist pain linked to superficial neuritis. Type of study/level of evidence: Therapeutic IV.