Artificial intelligence for X-ray scaphoid fracture detection: a systematic review and diagnostic test accuracy meta-analysis.

OBJECTIVES: Scaphoid fractures are usually diagnosed using X-rays, a low-sensitivity modality. Artificial intelligence (AI) using Convolutional Neural Networks (CNNs) has been explored for diagnosing scaphoid fractures in X-rays. The aim of this systematic review and meta-analysis is to evaluate the use of AI for detecting scaphoid fractures on X-rays and analyze its accuracy and usefulness. MATERIALS AND METHODS: This study followed the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) and PRISMA-Diagnostic Test Accuracy. A literature search was conducted in the PubMed database for original articles published until July 2023. The risk of bias and applicability were evaluated using the QUADAS-2 tool. A bivariate diagnostic random-effects meta-analysis was conducted, and the results were analyzed using the Summary Receiver Operating Characteristic (SROC) curve. RESULTS: Ten studies met the inclusion criteria and were all retrospective. The AI's diagnostic performance for detecting scaphoid fractures ranged from AUC 0.77 to 0.96. Seven studies were included in the meta-analysis, with a total of 3373 images. The meta-analysis pooled sensitivity and specificity were 0.80 and 0.89, respectively. The meta-analysis overall AUC was 0.88. The QUADAS-2 tool found high risk of bias and concerns about applicability in 9 out of 10 studies. CONCLUSIONS: The current results of AI's diagnostic performance for detecting scaphoid fractures in X-rays show promise. The results show high overall sensitivity and specificity and a high SROC result. Further research is needed to compare AI's diagnostic performance to human diagnostic performance in a clinical setting. CLINICAL RELEVANCE STATEMENT: Scaphoid fractures are prone to be missed secondary to assessment with a low sensitivity modality and a high occult fracture rate. AI systems can be beneficial for clinicians and radiologists to facilitate early diagnosis, and avoid missed injuries. KEY POINTS: • Scaphoid fractures are common and some can be easily missed in X-rays. • Artificial intelligence (AI) systems demonstrate high diagnostic performance for the diagnosis of scaphoid fractures in X-rays. • AI systems can be beneficial in diagnosing both obvious and occult scaphoid fractures.

Comparison of corticocancellous bone graft from the anterolateral metaphysis of the distal radius versus iliac crest for the treatment of unstable scaphoid nonunion with humpback deformity.

BACKGROUND: Corticocancellous bone grafting from the iliac crest is acceptable treatment for unstable scaphoid nonunion with a viable proximal pole. However, harvesting graft from the iliac crest is associated with donor site morbidity and the requirement of general anesthesia. Thus, bone grafting from the anterolateral metaphysis of the distal radius (DR) can be a treatment option. However, no study has compared the clinical effect between the two grafting techniques. METHODS: From 2014 to 2019, patients with unstable scaphoid nonunion with humpback deformity underwent corticocancellous bone grafting from the anterolateral metaphysis of the DR (group DR) or iliac crest (group IC). Humpback deformity was determined by evaluating the scapholunate angle (SLA) ≥ 60°, intrascaphoid angle (ISA) ≥ 45°, and radiolunate angle (RLA) ≥ 15° from preoperative radiographs and computed tomography scans. The SLA, ISA, and RLA served to gauge carpal alignment. The operative time, grip strength, active range of motion (ROM), the Modified Mayo Wrist score (MMWS), and Disabilities of Arm, Shoulder, and Hand (DASH) score were assessed postoperatively. RESULTS: Thirty-eight patients qualified for the study (group DR, 15; group IC, 23). Union rates did not differ by patient subset (group DR, 100%; group IC, 95.7%; P = .827), and grip strength, ROM, MWS, and DASH score were similar between groups at the last follow-up. The operative time (minutes) was significantly shorter in group DR (median, 98; quartiles, 80, 114) than in group IC (median, 125; quartiles, 105, 150, P < .001). The ISA, RLA, and SLA improved postoperatively in both groups (P < 0.001). The degree of restoring carpal alignment, as evaluated by SLA, showed superior correction capability in group DR (median, 25.3% quartiles, 21.1, 35.3, P < 0.05). Donor site complications were not significantly different between the groups. CONCLUSIONS: Corticocancellous bone graft from the anterolateral metaphysis of the DR for unstable scaphoid nonunion is associated with a shorter operation time and comparable results with that from the iliac crest in regard to union, restoration of carpal alignment, and wrist function. LEVEL OF EVIDENCE: Level III.

In vivo non-contact regions of proximal scaphoid in six extreme wrist positions.

INTRODUCTION: Fractures of the scaphoid are the most common carpal injuries, account for 80-90% of all carpal fractures. 5-15% nonunion of scaphoid fractures were reported even with adequate primary treatment, which probably progresses to osteoarthritic changes several decades later. Researches regarding to scaphoid physiological characteristic in vitro and in vivo and kinds of trials in clinical practice are being kept on going, which contribute much to our clinical practice. With the advancing wrist arthroscopy, 3D-print patient-specific drill guide, and intraoperative fluoroscopic guidance, dorsal approach (mini-invasive and percutaneous technique) is being popular, through which we can implant the screw in good coincidence with biomechanics and with less disturbing tenuous blood supply of the scaphoid. Investigating the noncontact area of the dorsal proximal scaphoid in different wrist positions can facilitate preoperatively estimating insert point of the screw. MATERIALS AND METHODS: Eight volunteers were recruited to accept CT scans in six extreme wrist positions. The images of DICOM mode were imput into the Mimics analytical system, the segmented scaphoid, lunate and radius were exported in mode of ASCII STL and were opened in the software of Geomagic studio. We created four planes based on anatomic markers on the surface of the radius and scaphoid to confine the proximal scaphoid to form the so-called non-contact regions. We measured and compared the areas in six targeted positions. RESULTS: Amidst six extreme wrist positions, area of the non-contact region in extreme dorsal extension (59.81 ± 26.46 mm2) was significantly the smallest, and it in extreme palmar flexion significantly was largest (170.51 ± 30.44 mm2). The non-contact regions increased in order of dorsal extension, supination, ulnar deviation, radial deviation, pronation and palmar flexion. As for two-group comparison, the non-contact region showed significantly larger (p < 0.05) in palmar flexion than the others except for in pronation individually, and in radial deviation (p < 0.05) than in dorsal extension. CONCLUSIONS: Sufficient space was available for the screw started from the dorsal approach despite the wrist positions.

Arthroscopic assisted versus open non-vascularized bone grafting in delayed union and nonunion of the scaphoid: a systematic review and meta-analysis.

BACKGROUND: Delayed union and nonunion of the scaphoid is a common complication often requiring surgical reconstruction and bone grafting. Our goal was to systematically assess the healing time and clinical outcomes following arthroscopic-assisted versus open non-vascularized bone grafting of the scaphoid. METHODS: A comprehensive search of the MEDLINE, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Cochrane Central databases was completed from inception to September 2023. We included randomized trials and observational studies that reported outcomes following scaphoid delayed union/nonunion comparing arthroscopic-assisted vs. open non-vascularized bone grafting. Two reviewers independently extracted data and assessed the risk of bias. One investigator assessed certainty of evidence and a senior investigator confirmed the assessment. We pooled effects using random-effects models, when possible, for all outcomes reported by more than 1 study. RESULTS: Overall, 26 studies and 822 patients were included in the study. Very low certainty evidence demonstrated that arthroscopic-assisted surgery may decrease healing time compared to open surgery (weighted mean difference [WMD] -7.8 weeks; 95%CI -12.8 to -2.8). Arthroscopic bone grafting did not result in an improvement in union rate (relative risk 1.01; 95%CI 0.9 to 1.09). The pooled data in arthroscopic graft group showed mean time to union of 11.4 weeks (95%CI: 10.4 to 12.5) with union rate of 95% (95%CI 91-98%). A single comparative study reported very low certainty evidence that arthroscopy-assisted vs. open surgery may not have an effect on pain relief (MD 0 cm, 95%CI -0.4 to 0.5 on VAS 10 cm for pain) or improving function (MD -1.2, 95% CI -4.8 to 2.3 on 100 points DASH). CONCLUSION AND FUTURE DIRECTIONS: Our results suggest that arthroscopic-assisted non-vascularized bone grafting may be associated with improved average weeks to heal in comparison with open surgery for scaphoid delayed union/nonunion reconstruction with overall comparable union rates. There is insufficient evidence to assess the effects of arthroscopic-assisted reconstruction on union rate, time to union, and patient-reported outcomes in patients with other important nonunion characteristics such as established humpback deformity.

Lunate-capitate arthrodesis for scaphoid nonunion: a comparative study.

BACKGROUND: Scaphoid nonunion advanced collapse (SNAC) injuries are frequently associated with irreversible degenerative wrist arthritic changes that necessitate surgical intervention. Midcarpal fusion remains the mainstay of the management of SNAC II and III injuries. A successful four-corner fusion (4CF) relies on a stable lunate-capitate fusion (LCF). There have been reports of management relying solely on LCF. The outcomes of LC- and 4 C-fusions in SNAC injuries were not widely documented. The objective of this research is to provide valuable insights into the effectiveness of both fusion procedures in the management of SNAC II and III wrist injuries, with a focus on reporting associated complications, functional and radiological outcomes. PATIENTS AND METHODS: This retrospective study encompassed 65 patients diagnosed with SNAC II and III wrist injuries who underwent limited wrist fusion procedures between 2015 and 2024, with a minimum of 2 years of postoperative follow-up. Exclusion criteria encompassed patients with carpal instability, prior wrist surgical interventions, and scapholunate advanced collapse. Following the fusion procedure performed, patients were stratified into two groups: the LCF group consisting of 31 patients, and the 4CF group comprising 34 patients. Preoperative and intraoperative data were retrieved from the patient's medical records. At their final follow-up appointments, patients underwent comprehensive radiographic and clinical evaluations. Clinical outcomes including hand grip strength, range of motion, the Disabilities of the Arm, Shoulder, and Hand Score, and the Mayo Modified Wrist Score, were compared between groups. Any associated complications were reported. RESULTS: The average healing time was 74.7 ± 15.6 and 72.2 ± 13.2 days for the LCF and 4CF groups, respectively. At the final visit, all patients showed functional improvement relative to their preoperative status, with comparable wrist range of motions observed in both groups. The functional wrist scores were slightly better in the LCF patients (P > 0.05). The average grip strength was significantly greater in the LCF group (P = 0.04), with mean strength values of 86.8% and 82.1% of the contralateral side, for the LCF and 4CF groups, respectively. CONCLUSION: The LCF is not less efficient than the 4CF in the treatment of SNAC II and III wrist injuries. Through a less time-consuming procedure, LCF can efficiently provide comparable results to 4CF. LEVEL OF EVIDENCE: level IV evidence.

3D printed guide-assisted percutaneous screw fixation for minimally displaced scaphoid waist fractures with delayed diagnosis or presentation.

OBJECTIVES: To Investigate the value of 3D printed guide-assisted percutaneous management of minimally displaced scaphoid waist fractures(Herbert's B2) with delayed diagnosis or presentation. METHODS: From October 2018 to February 2022, 10 patients with established delayed diagnoses and presentation of minimally displaced scaphoid waist fractures were treated with 3D printed guides assisted with percutaneous internal fixation without bone grafting. This technique was based on the patient's preoperative CT and imported into the software. Based on Boolean subtraction, the most centralized screw placement position was identified and a customized guide was produced. Intraoperative percutaneous insertion of the guide wire was assisted by the custom guide. RESULTS: All 10 patients were successful in one attempt. The fractures healed at a mean of 7.7 weeks postoperatively (range 6-10 weeks). At a mean follow-up of 7.7 months (6-13 months), patients had excellent recovery of wrist function with minimal pain reduction. There were no major postoperative complications and the patients all returned to their previous activities before the injury. CONCLUSIONS: Percutaneous internal fixation based on 3D printed guides is a safe and effective technique for delayed diagnosis or presentation of patients with minimally displaced fractures of the scaphoid waist. This method allows for easy insertion of screws and avoids multiple attempts.

Extremity radiographs derived from low-dose ultra-high-resolution CT: a phantom study.

OBJECTIVE: To demonstrate the potential of low-dose ultra-high-resolution CT (UHRCT) images to generate high-quality radiographic images on extremity phantoms and to estimate the radiation dose required for this. MATERIALS AND METHODS: A hand and knee phantom containing real human bones was imaged on an UHRCT scanner at full-dose, half-dose, and quarter-dose levels using a high-resolution extremity protocol. The raw data was reconstructed using both filtered back projection (FBP) and an iterative reconstruction algorithm (AIDR3D). Using custom designed software, each CT volume data set was converted to attenuation coefficients, and then a synthesized radiograph (synDX) was generated by forward projecting the volume data sets from a point source onto a 2D synthetic detector. The signal-to-noise ratio (SNR) was measured in the synDXs across all dose levels and the root-mean-squared error (RMSE) was computed with the FD synDXs as the reference. RESULTS: The proposed workflow generates high-quality synDXs at any arbitrary angle. For FBP, the SNR largely tracked with the radiation dose levels for both the knee and hand phantoms. For the knee phantom, iterative reconstruction provided a 6.1% higher SNR when compared to FBP. The RMSE was overall higher for the lowest dose levels and monotonically decreased with increasing dose. No substantial differences were observed qualitatively in the visualization of skeletal detail of the phantoms. CONCLUSION: The fine detail provided by UHRCT acquisitions of extremities facilitates the ability to generate quality radiographs, potentially eliminating the need for additional scanning on a conventional digital radiography system.

CT-like images based on T1-weighted gradient echo MRI sequences for the assessment of fractures of the hand and wrist compared to CT.

OBJECTIVE: To evaluate the performance of a 3D T1-weighted gradient-echo (3D T1GRE) computed tomography (CT)-like magnetic resonance imaging (MRI) sequence for detecting and assessing wrist and hand fractures compared to conventional CT. METHODS: Subjects with acute wrist or hand fracture in CT underwent additional 3 T MRI including a CT-like 3D T1GRE sequence and were compared to patients without fractures. Two radiologists assessed fracture morphology on both modalities according to the Arbeitsgemeinschaft Osteosynthese (AO) and graded image quality and diagnostic confidence on a 5-point Likert scale. Besides diagnostic test evaluation, differences in image quality and diagnostic confidence between CT-like MRI and CT were calculated using the Wilcoxon test. Agreement of AO classification between modalities and readers was assessed using Cohen's Kappa. RESULTS: Twenty-eight patients with 43 fractures and 43 controls were included. Image quality (3D T1GRE 1.19 ± 0.37 vs. CT 1.22 ± 0.42; p = 0.65) and diagnostic confidence (3D T1GRE 1.28 ± 0.53 vs. CT 1.28 ± 0.55; p = 1.00) were rated excellent for both modalities. Regarding the AO classification, intra- (rater 1 and rater 2, κ = 0.89; 95% CI 0.80-0.97) and interrater agreement were excellent (3D T1GRE, κ = 0.82; 95% CI, 0.70-0.93; CT, κ = 0.85; 95% CI, 0.75-0.94). CT-like MRI showed excellent sensitivity, specificity and accuracy for fracture detection (reader 1: 1.00, 0.92, 0.96; reader 2: 0.98, 0.94, 0.96). CONCLUSION: CT-like MRI is a comparable alternative to CT for assessing hand and wrist fractures, offering the advantage of avoiding radiation exposure.

Clinically Significant Treatment Delay in Pediatric Scaphoid Fractures.

PURPOSE: Pediatric scaphoid fractures present to treatment in a delayed manner 8% to 29% of the time. The indications for cast immobilization in this population are not clear. The definition of a clinically important treatment delay is based only on anecdotal reports. Successful treatment with a cast may be more desirable than surgical intervention. However, it remains unclear what clinical and radiographic factors may predict success with casting. METHODS: A retrospective analysis of all scaphoid fractures treated at a single pediatric hospital was performed to identify fracture characteristics, the presence of cystic change, treatment method, and healing rate. A cut-point analysis was performed to determine the number of days of treatment delay, predictive of casting failure. Kaplan-Meier assessments were performed to determine the differences in time in cast. Characteristics of the delayed group were described and stratified by treatment success or failure. RESULTS: After review, 254 patients met the inclusion criteria. Cut-point analysis determined that a presentation delay of ≥21 days was associated with failure to unite with casting. The median time in the cast for the acute and delayed groups was not significantly different. The casting union rate of delayed fractures was less than acute fractures (75.0% vs 97.0%). CONCLUSIONS: Delayed presentation of scaphoid fractures 21 days or more after injury predicts a greater risk of casting failure; however, the union rate remains high with comparable time in cast. Cast immobilization for scaphoid fractures presenting 21 days or more after injury is a reasonable option. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognosis IV.

Assessment of Ulnar Carpal Translocation and Carpal Alignment After Volar Plate Fixation With Vascularized Bone Graft for Scaphoid Waist Fracture Nonunions.

PURPOSE: Multiple fixation methods with or without vascularized graft have been described to treat scaphoid nonunions. This study aimed to assess the incidence of carpal malalignment and the degree of ulnar carpal translocation after scaphoid volar plate fixation with pedicled vascularized bone graft in scaphoid waist nonunions with humpback deformity. METHODS: A retrospective cohort study of individuals with recalcitrant scaphoid fracture nonunion treated with volar scaphoid plating and vascularized bone graft was analyzed. All patients had radiographs with the wrist at neutral with clinical follow-up of at least 3 months after surgery. Ulnar subluxation of the carpus was assessed by the change in lunate uncovering and carpal-radial distance before and after surgery. RESULTS: Seventeen patients were included for analysis. Average age was 26 years with an average follow-up interval of 11.0 months. After surgery, 16 patients (94.1%) had fracture union. Between preoperative and initial postoperative imaging, there was an increase in lunate uncovering (mean difference: 8.8%; 95% confidence interval, 4.6% to 13.1%) and carpal-radial distance (mean difference: 3.3% ulnar shift; 95% confidence interval, 1.1% to 5.4%). After surgery, there was minimal change in lunate uncovering and carpal-radial distance from immediately after surgery to final follow-up. CONCLUSIONS: Preoperative lunate uncovering was lower than normal values, suggesting an abnormal radial shift of the carpus with a collapsed scaphoid. Postoperative lunate uncovering was similar to normal values, reflecting an ulnar shift of the carpus after operative intervention. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Diagnostic Performance of Artificial Intelligence for Detection of Scaphoid and Distal Radius Fractures: A Systematic Review.

PURPOSE: To review the existing literature to (1) determine the diagnostic efficacy of artificial intelligence (AI) models for detecting scaphoid and distal radius fractures and (2) compare the efficacy to human clinical experts. METHODS: PubMed, OVID/Medline, and Cochrane libraries were queried for studies investigating the development, validation, and analysis of AI for the detection of scaphoid or distal radius fractures. Data regarding study design, AI model development and architecture, prediction accuracy/area under the receiver operator characteristic curve (AUROC), and imaging modalities were recorded. RESULTS: A total of 21 studies were identified, of which 12 (57.1%) used AI to detect fractures of the distal radius, and nine (42.9%) used AI to detect fractures of the scaphoid. AI models demonstrated good diagnostic performance on average, with AUROC values ranging from 0.77 to 0.96 for scaphoid fractures and from 0.90 to 0.99 for distal radius fractures. Accuracy of AI models ranged between 72.0% to 90.3% and 89.0% to 98.0% for scaphoid and distal radius fractures, respectively. When compared to clinical experts, 13 of 14 (92.9%) studies reported that AI models demonstrated comparable or better performance. The type of fracture influenced model performance, with worse overall performance on occult scaphoid fractures; however, models trained specifically on occult fractures demonstrated substantially improved performance when compared to humans. CONCLUSIONS: AI models demonstrated excellent performance for detecting scaphoid and distal radius fractures, with the majority demonstrating comparable or better performance compared with human experts. Worse performance was demonstrated on occult fractures. However, when trained specifically on difficult fracture patterns, AI models demonstrated improved performance. CLINICAL RELEVANCE: AI models can help detect commonly missed occult fractures while enhancing workflow efficiency for distal radius and scaphoid fracture diagnoses. As performance varies based on fracture type, future studies focused on wrist fracture detection should clearly define whether the goal is to (1) identify difficult-to-detect fractures or (2) improve workflow efficiency by assisting in routine tasks.

Advances in the Treatment of Hand and Wrist Injuries in the Elite Athlete.

Caring for hand and wrist injuries in the elite athlete brings distinct challenges, with case-by-case decisions regarding surgical intervention and return-to-play. Metacarpal fractures, thumb ulnar collateral ligament tears, and scaphoid fractures are common upper-extremity injuries in the elite athlete that can be detrimental to playing time and future participation. Treatment should therefore endure the demand of accelerated rehabilitation and return-to-activity without compromising long-term outcomes. Fortunately, the literature has supported emerging management options that support goals specific to the athlete. This review examined the advances in surgical and perioperative treatment of metacarpal fractures, thumb ulnar collateral ligament injuries, and scaphoid fractures in the elite athlete.

A review of scaphoid fracture, treatment outcomes, and consequences.

PURPOSE: Scaphoid fractures are the most common carpal fracture and can lead to severe complications like carpal collapse and osteoarthritis. This study reviewed scaphoid fracture patterns, outcomes, and consequences in conservative and surgical management. METHODS: Sixty-four patients with scaphoid fracture who attended the hand clinic at King Hussein Medical City from January 2022 to December 2022 were included and reviewed regarding the anatomical fracture site, the associated injury, the treatment modality (conservative versus surgical), the healing time, and fracture sequelae such as nonunion and scaphoid nonunion advanced collapse. RESULTS: Most patients were males (62 patients, 96.9%), and most (47, 73.4%) fell within 25 to 40 years. Scaphoid waist fracture was the most common location (40, 52.5%). Most patients (47, 73.4%) received conservative treatment and 17 (26.6%) were fixed acutely. However, nonunion complicated 53 fractures (82.8%). Notably, there were no differences in the union rate or time between cases of scaphoid nonunion treated with vascularized or nonvascularized grafts. Furthermore, there were no variations in union rates among genders, extremities, age, fracture locations, or among smokers. However, a higher union rate was noted in office workers and those who received conservative treatment. CONCLUSION: Nonunions were higher in our study than in the literature, as our department is a referral center for established nonunion cases. For conservative treatment, we recommend aggressive management and follow-up with a clinical and CT scan at three months and early referral of non-united fractures to the hand clinic to avoid the advanced collapse of the scaphoid.

Cancellous bone graft from the distal radius and headless screw fixation for unstable scaphoid waist nonunion.

PURPOSE: Cancellous bone harvested from the distal radius has been used in various hand surgeries, but studies on its use in scaphoid waist nonunions are insufficient. We investigated the usefulness of cancellous bone graft from the distal radius and headless screw fixation in unstable scaphoid waist nonunion. METHODS: Thirty-one patients who underwent cancellous bone graft from the distal radius and headless screw fixation for unstable scaphoid waist nonunion with follow-up for at least 1 year were included. Bone union time, the number of patients with bone union at six and 12 weeks, total number of patients with bone union at last follow-up, and bone union on the computed tomography (CT) image at postoperative six weeks were evaluated. Further, pre- and postoperative radiological measurements, such as scaphoid length and height, lateral intra-scaphoid angle, and height-to-length ratio, and functional outcomes were compared. Additionally, inter-observer reliability of radiologic parameters was checked. RESULTS: Bone union was achieved in 29 patients. There were two nonunions (6.5%). Bone union time was 10.7 (range, 6-26) weeks. Eighteen (58%) and 25 patients (80.6%) were diagnosed with bone union on the plain radiographs at six and 12 weeks, respectively. Twenty-two patients (71%) were diagnosed with bone union on CT performed at six weeks. Radiological measurements and functional outcomes improved postoperatively. The scaphoid length showed good inter-observer agreement. CONCLUSIONS: In treating unstable scaphoid waist nonunion, cancellous bone graft from the distal radius and headless screw fixation achieved 93.5% union and improved radiological measurements as well as functional outcomes.

A comparative cadaveric study for percutaneous scaphoid fixation: robotic vs freehand.

PURPOSES: To compare the robotic-assisted and the traditional freehand percutaneous scaphoid fixation in number of guidewire attempts, duration of fluoroscopy time, amount of radiation dose, and screw centrality. METHODS: Twenty cadaveric specimens were randomized into either the robotic or freehand group. The scaphoids in both groups were fixed by either the same attending or resident from our hand surgery department. The operation duration, amount of radiation from intraoperative fluoroscopy, total fluoroscopy time, and the number of guidewire attempts were documented and compared. Postoperatively, all the specimens had a computed tomography (CT) scan performed, and the difference in the final position of the screw and the central axis of the scaphoid was examined. RESULTS: In the robotic group, all the guide wires were satisfactorily positioned within a single attempt, while the median number of attempts in the traditional freehand group was 18 (quaternion 14-65). This also meant that the surgeon in the robotic group experienced significantly lower radiation exposure dose and time as compared to the freehand group. There were no significant differences in the final screw position as compared to the central axis of the scaphoid in both groups. Although there was no difference in surgeon performance in the robotic group, the operative time for the attending was significantly lower as compared to the resident in the freehand group. CONCLUSION: Robotic-assisted surgery for scaphoid fracture fixation is superior to the traditional freehand method as it facilitates accurate screw placement with lower radiation exposure and fewer guide wire attempts.

Scaphoid nonunion: a novel modification of Matti-Russe technique with enhanced recovery and full clinical and radiographic union.

BACKGROUND: A scaphoid fracture is a common injury affecting the wrist joint. A fracture of the carpus scaphoid can heal uneventfully or be complicated by non-union. Scaphoid non-union can result in persistent wrist pain, and with functional difficulties affecting all activities of daily living of the patients, this disability is expected to be significant since most of these patients are young active adults. HYPOTHESIS: Extensive removal of the bone from the scaphoid, with the application of a large amount of cancellous bone graft and fixation with two to three wires, could lead to a high union rate and a good functional outcome. METHODS: Eighteen patients with scaphoid fracture non-union were recruited during their visit to the upper limb clinic at our institute. Demographic data were collected, and data regarding comorbidities, smoking, manual work, and others were recorded. Data regarding the interval between injury and surgery, time to radiographic union, and functional wrist scores were reported as well. RESULTS: A cohort of 18 patients was included. The mean age of patients was 30 years; most of our patients were healthy (83.3%), and more than two-thirds were smokers (72.2%). The mean follow-up time was 18 months (1.5 years), 15 patients (83.3%) achieved radiographic unions by 2-3 months, and the remaining 3 patients (16.7%) achieved radiographic unions by (4-5) months, i.e., all patients achieved successful radiographic unions by 5 months at maximum. The mean Mayo score for our series was 83.6 (± 12.4), with 5 patients (27%) achieved ≥ 95% which indicates a significantly high functioning wrist in our cohort. CONCLUSION: Our modified technique with enhanced stability from using three k-wires can achieve full clinical and radiographic unions and result in enhanced recovery postoperatively with cast immobilization limited to 6 weeks total. LEVEL OF EVIDENCE: IV Case series study.

Long-term clinical and radiological results after scaphoid non-union treatment: a retrospective study about 60 cases.

PURPOSE: Scaphoid non-union treatment remains nonconsensual and is based on vascularized or non-vascularized bone grafting. This study aimed to evaluate with a long follow-up the functional, clinical, and radiological outcomes, reported complications and reoperations and studied non-union treatment prognostic factors. METHODS: Patients who had undergone bone graft surgery for scaphoid non-union were retrospectively reviewed. The evaluated outcomes were pain, qDASH, PRWE and MWS scores, active range of motion, grip strength, union rate, scapholunate angle, carpal height, and presence of arthrosis. Complications and reinterventions were also reported. RESULTS: This study included 60 scaphoid non-union treatments with a mean follow-up of 7.7 (1.5-20.3) years. Twenty (33.3%) non-unions were located at the proximal pole, including 6 (10%) with preoperative avascular necrosis (AVN). Union occurred in 51 patients (85%). The functional, clinical, and radiological results were good. The complication rate was 21.3% and the reintervention rate was 16.7%. Subgroup union rate analysis found no difference if the non-union is localized in the proximal pole or if there is AVN. CONCLUSION: With a representative sample of the population and a long follow-up, we have found a good union rate, clinical and functional results regardless of the treatment method chosen. Scaphoid non-union treatment is still controversial and more studies are needed to accurate indications of each graft according to the patient and non-union characteristics. LEVEL OF EVIDENCE IV: Retrospective cohort study.

Outcomes after radioscapholunate arthrodesis for intra-articular malunion of distal radius fractures.

PURPOSE: To study the clinical, radiological, and functional outcomes after of radioscapholunate (RSL) fusion for intra-articular malunion of the distal radius. METHODS: This retrospective study included 26 patients (17 males and 9 females) with intra-articular malunion of distal radius fractures who underwent RSL arthrodesis using locked miniplates (without distal scaphoid excision) between 2012 and 2020. Their mean age was 43 years (range, 32-56). Patients were assessed radiographically for union and clinically for range of motion, grip strength, and pain (assessed by Visual Analogue Scale (VAS) for pain). Functional evaluation was performed by using the Mayo modified wrist score (MMWS) and the Disabilities for the Arm, Shoulder, and Hand (DASH) questionnaire. RESULTS: All patients showed complete healing at the fusion site after a mean of 8.7 weeks (range, 8-12). The mean follow-up period was 72 months (range, 60-84). The pinch strength improved from a mean of 6.2 kg (range, 3-12) to a mean of 9.8 kg (range, 5-18) which represents 80% of the contralateral side. The mean pinch strength was 7 kg (range, 5-18) which presents 80% of the other side. VAS for pain showed a mean improvement of 72.6%. The DASH score improved to a mean of 19.2 (range, 14-24). The MMWS improved to a mean of 68 (range, 45-86). At the final follow-up period, no degenerative changes were detected in the midcarpal joint. CONCLUSION: RSL arthrodesis (using locked miniplates without distal scaphoid excision) is a reliable surgical procedure to manage cases of radiocarpal OA after intra-articular malunion of distal radius fractures with good clinical and radiological outcomes. LEVEL OF EVIDENCE: Level IV- therapeutic.

Musculoskeletal radiologist-level performance by using deep learning for detection of scaphoid fractures on conventional multi-view radiographs of hand and wrist.

OBJECTIVES: To assess how an artificial intelligence (AI) algorithm performs against five experienced musculoskeletal radiologists in diagnosing scaphoid fractures and whether it aids their diagnosis on conventional multi-view radiographs. METHODS: Four datasets of conventional hand, wrist, and scaphoid radiographs were retrospectively acquired at two hospitals (hospitals A and B). Dataset 1 (12,990 radiographs from 3353 patients, hospital A) and dataset 2 (1117 radiographs from 394 patients, hospital B) were used for training and testing a scaphoid localization and laterality classification component. Dataset 3 (4316 radiographs from 840 patients, hospital A) and dataset 4 (688 radiographs from 209 patients, hospital B) were used for training and testing the fracture detector. The algorithm was compared with the radiologists in an observer study. Evaluation metrics included sensitivity, specificity, positive predictive value (PPV), area under the characteristic operating curve (AUC), Cohen's kappa coefficient (κ), fracture localization precision, and reading time. RESULTS: The algorithm detected scaphoid fractures with a sensitivity of 72%, specificity of 93%, PPV of 81%, and AUC of 0.88. The AUC of the algorithm did not differ from each radiologist (0.87 [radiologists' mean], p ≥ .05). AI assistance improved five out of ten pairs of inter-observer Cohen's κ agreements (p < .05) and reduced reading time in four radiologists (p < .001), but did not improve other metrics in the majority of radiologists (p ≥ .05). CONCLUSIONS: The AI algorithm detects scaphoid fractures on conventional multi-view radiographs at the level of five experienced musculoskeletal radiologists and could significantly shorten their reading time. KEY POINTS: • An artificial intelligence algorithm automatically detects scaphoid fractures on conventional multi-view radiographs at the same level of five experienced musculoskeletal radiologists. • There is preliminary evidence that automated scaphoid fracture detection can significantly shorten the reading time of musculoskeletal radiologists.

Prospective comparison of magnetic resonance imaging and computed tomography in diagnosing occult scaphoid fractures.

BACKGROUND: Suspected scaphoid fracture (SF) after a fall on an outstretched hand is a common presentation in the emergency department. Magnetic resonance imaging (MRI) or computed tomography (CT) has been suggested to assist in the diagnosis or exclusion of SF. PURPOSE: To compare MRI and CT at diagnosing occult SFs. MATERIAL AND METHODS: We routinely perform CT scans in patients with clinically suspected occult SF, after 7-10 days of injury following two negative radiographs. All eligible patients with a clinically suspected SF, but negative radiographs and a negative CT, underwent an MRI scan to assess further for evidence of occult fracture. RESULTS: A total of 100 patients were included in our study. MRI showed fractures in 16% of the time (in 15 patients) when plain radiographs and CT did not. Of these fractures, 8% were SFs. In addition to fractures, 10% had bone bruising. A total of 25% of patients with fractures and bone bruising were referred to the hand surgery team for further follow-up. CONCLUSION: The study demonstrated that MRI would identify a radiographically occult SF more often than CT. This supports NICE guidelines which recommend MRI as the best early diagnostic tool for occult SFs.