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.

Peri-Trapezium Peri-Trapezoid Trans-scaphoid Open Fracture Dislocation of the Carpus: A Case Report.

The axial fracture dislocation of the carpal bones is a poorly understood injury. These injuries are often associated with nerve injuries, soft tissue injuries, and amputations. An optimal treatment is not yet known. We present a rare case of an open trans-scaphoid axial fracture dislocation of the carpus, characterized by a unique mechanism of injury. The patient received timely treatment, including irrigation and debridement, as well as reduction and fixation of the carpal fracture dislocation. It is essential to understand that these injuries tend to result in poor clinical outcomes, even with optimal treatment. Therefore, engaging in meaningful discussions and setting realistic expectations with patients is imperative.

A variant of perilunate dislocation: A case report and literature review.

Perilunate dislocation is a rare carpal dislocation, which are predominantly trans-styloid and trans-scaphoid. This type of fracture dislocation is seen due to axial loading of a hyperextended ulnar-deviated wrist. This can result in the disruption of the scapholunate, lunocapitate, and lunotriquetral ligaments. The lunate may dislocate volar or dorsal to the other carpal bones. Herein, we have reported a case of trans-styloid, trans-scaphoid perilunate fracture dislocation with carpal tunnel syndrome, which has never been reported in the literature. A 38-year-old construction worker presented with a swollen hand and signs of carpal tunnel syndrome. The patient was diagnosed with perilunate fracture dislocation after a through clinical and radiological assessment. The scaphoid had invaginated into the radial styloid and demonstrated a comminuted fracture pattern. Volar lunate displacement was identified, and the patient demonstrated signs of carpal tunnel syndrome, which is not a common presentation. Open reduction with ligament repair was performed to minimize jeopardizing the hand function. Spelt tea cup sign is a diagnostic for perilunate dislocation. Operative exploration and reduction is imperative for failed closed lunate dislocation reduction to minimizes ongoing soft tissue jeopardy. Moreover, carpal tunnel release is indicated in the present of symptomatic carpal tunnel syndrome. To our knowledge, only a few cases of trans-styloid, trans-scaphoid perilunate dislocation with neurological deficit have been reported.

Preiser's disease in teenage female: A rare case report.

Preiser's disease or idiopathic avascular necrosis of the scaphoid is a rare condition where ischemia and necrosis of the scaphoid bone occurs without previous fracture. It is thought to be caused by repetitive micro trauma or side effects of drugs (e.g., steroids or chemotherapy) in conjunction with existing defective vascular supply to the proximal pole of the scaphoid. Wrist radiography or CT coupled with MRI is the imaging modality of choice in the diagnosis of this rare entity. Here, we report a case of Preiser's disease of the left wrist in a 17-year-old female patient who presented with left wrist pain of 2 years duration in the absence of trauma history or causative drug use. The diagnosis was made by wrist X-ray and MRI. She was managed by Physiotherapy and wrist immobilization using wrist and forearm support as well as NSAIDS (Meloxicam).

Accuracy of wrist fracture detection on radiographs by artificial intelligence compared to human clinicians. A systematic review and meta-analysis.

PURPOSE: The aim of the study is to perform a systematic review and meta-analysis comparing the diagnostic performance of artificial intelligence (AI) and human readers in the detection of wrist fractures. METHOD: This study conducted a systematic review following PRISMA guidelines. Medline and Embase databases were searched for relevant articles published up to August 14, 2023. All included studies reported the diagnostic performance of AI to detect wrist fractures, with or without comparison to human readers. A meta-analysis was performed to calculate the pooled sensitivity and specificity of AI and human experts in detecting distal radius, and scaphoid fractures respectively. RESULTS: Of 213 identified records, 20 studies were included after abstract screening and full-text review. Nine articles examined distal radius fractures, while eight studies examined scaphoid fractures. One study included distal radius and scaphoid fractures, and two studies examined paediatric distal radius fractures. The pooled sensitivity and specificity for AI in detecting distal radius fractures were 0.92 (95% CI 0.88-0.95) and 0.89 (0.84-0.92), respectively. The corresponding values for human readers were 0.95 (0.91-0.97) and 0.94 (0.91-0.96). For scaphoid fractures, pooled sensitivity and specificity for AI were 0.85 (0.73-0.92) and 0.83 (0.76-0.89), while human experts exhibited 0.71 (0.66-0.76) and 0.93 (0.90-0.95), respectively. CONCLUSION: The results indicate comparable diagnostic accuracy between AI and human readers, especially for distal radius fractures. For the detection of scaphoid fractures, the human readers were similarly sensitive but more specific. These findings underscore the potential of AI to enhance fracture detection accuracy and improve clinical workflow, rather than to replace human intelligence.

An Umbrella Review and Updated Meta-Analysis of Imaging Modalities in Occult Scaphoid and Hip and Femoral Fractures.

Background: Occult fractures may cause multiple morbidities. If occult fractures were detected earlier, complications may be preventable. This umbrella review and updated meta-analysis will aim to evaluate the use of imaging modalities in detecting occult scaphoid and hip fractures. Methods: The protocol for this study is available in the International Prospective Register of Systematic Reviews (PROSPERO) database (CRD42024525388). The literature search started and ended on 17 March 2024. We searched seven academic databases: MEDLINE, Cochrane Library, Pubmed, Science Direct, Google Scholar, WHO International Clinical Trials Registry Platform, and The Joanna Briggs Institute (JBI) database. The meta-analysis was conducted with the STATA program using the "midas" command. Results: There are four systematic reviews evaluating occult hip and femoral fractures with 6174 patients and two reviews evaluating occult scaphoid fractures with 1355 patients. The prevalence of occult scaphoid fracture and occult hip and femoral fractures is 23.87% (95% CI 18.25-29.49) and 44.8% (95% CI 39.38-51.4), respectively. Magnetic resonance imaging (MRI) had the best posterior probability of positive likelihood ratio (LR+) with 95% and 96% and negative likelihood ratio (LR-) with 0.15% and 1% for both occult scaphoid and hip fractures, respectively, assuming a 25% baseline. MRI could both confirm and exclude occult hip fractures while it can only confirm occult scaphoid fractures. Bone scans are inappropriate for either type of occult fractures The level of evidence for occult scaphoid fracture is weak while it is suggestive for occult hip fractures. Conclusion: The findings strengthen the use of MRI after an initially negative radiograph fracture for occult hip and femoral fractures, with a CT scan as a viable second option.

Idiopathic avascular necrosis of the scaphoid (Preiser's disease): a case report and review of the literature.

Idiopathic avascular necrosis of the scaphoid bone, Preiser's disease, was originally described as a deteriorative pathology whereby the osseous structure necroses due to loss of blood supply. It may present with multifactorial etiology, which is still largely not well understood. We describe a case of Preiser's disease in a 70-year-old female, with worsening pain and loss of range of motion in her right wrist over a two-year period. Past medical history was significant for Sjogren's disease, fibromyalgia, and dystonia. Pain began several months following traumatic right dorsal wrist injury. Diagnosis of traumatic scaphoid fracture was originally suspected. Conservative treatment was unsuccessful. Radiographs did not demonstrate evidence of primary fracture. CT scan and MRI demonstrated osteonecrosis of the proximal pole of the scaphoid, but no evidence of fracture, either residual or healing, was found. Proximal row carpectomy was performed for avascular necrosis of the scaphoid. Histology confirmed diagnosis and verified absence of fracture. Postoperatively, the patient's pain and range of motion improved. This report combines histological findings of Preiser's disease with radiographic images which may ameliorate understanding of the clinical pathophysiology. We describe an unusual manifestation of Preiser's disease whereby a single traumatic event, in the absence of fracture, led to idiopathic scaphoid avascular necrosis, which may have been associated with Sjogren's syndrome and fibromyalgia. These conditions may have negatively impacted microvasculature and decreased bone mineral density, inversely correlated with the production of fatty marrow, facilitating the onset of osteonecrosis in the scaphoid.

Inter-Rater and Intrarater Reliability of Radiographs in the Diagnosis of Pediatric Scaphoid Fractures.

BACKGROUND: Pediatric scaphoid fractures can be challenging to diagnose on plain radiograph. Rates of missed scaphoid fractures can be as high as 30% to 37% on initial imaging and overall sensitivity ranging from 21% to 97%. Few studies, however, have examined the reliability of radiographs in the diagnosis of scaphoid fractures, and none are specific to the pediatric population. Reliability, both between different specialists and for individual raters, may elucidate some of the diagnostic challenges. METHODS: We conducted a 2-iteration survey of pediatric orthopedic surgeons, plastic surgeons, radiologists, and emergency physicians at a tertiary children's hospital. Participants were asked to assess 10 series of pediatric wrist radiographs for evidence of scaphoid fracture. Inter-rater and intrarater reliability was calculated using the intraclass correlation coefficient of 2.1. RESULTS: Forty-two respondents were included in the first iteration analysis. Inter-rater reliability between surgeons (0.66; 95% confidence interval, 0.43-0.87), radiologists (0.76; 0.55-0.92), and emergency physicians (0.65; 0.46-0.86) was "good" to "excellent." Twenty-six respondents participated in the second iteration for intrarater reliability (0.73; 0.67-0.78). Sensitivity (0.75; 0.69-0.81) and specificity (0.78; 0.71-0.83) of wrist radiographs for diagnosing scaphoid fractures were consistent with results in other studies. CONCLUSIONS: Both inter-rater and intrarater reliability for diagnosing pediatric scaphoid fractures on radiographs was good to excellent. No significant difference was found between specialists. Plain radiographs, while useful for obvious scaphoid fractures, are unable to reliably rule out subtle fractures routinely. Our study demonstrates that poor sensitivity stems from the test itself, and not rater variability.

A Comparison of Rib Osteochondral Graft to Medial Femoral Trochlear Osteocartilaginous Graft for the Salvage of the Fragmented Scaphoid Proximal Pole: A Single-Center Experience with Minimum 2-Year Follow-Up.

Purpose Fragmented fractures of the proximal pole of the scaphoid that cannot be internally fixed may be salvaged by four-corner arthrodesis or proximal row carpectomy. Replacement of the proximal scaphoid with costal-osteochondral graft (COG) or the medial femoral trochlea (MFT) graft are two alternative solutions for this clinical presentation. The purpose of this study was to compare the clinical and radiographic results of the COG and the MFT graft with a minimum 2-year follow-up from a single centre. Methods A retrospective study was performed to investigate the outcome of COG and MFT with a minimum 2 year follow up. Demographic data and clinical assessment including wrist range of motion and grip strength measurements and Oxford Knee score were collected. Patients completed the outcome measures of Disabilities of Arm, Shoulder, and Hand (DASH), the Patient-Rated Wrist Evaluation (PRWE), and a ten-point visual analogue score for pain (VAS). Radiological examination was performed on all wrists at follow-up. Results The visual analogue score, DASH and PRWE were similar between the two groups. There was radiographic evidence of arthritis between the radial styloid and distal scaphoid in all patients that underwent COG but no evidence in those that underwent MFT graft reconstruction. There were different complications in each group. Thirty percent of patients that underwent MFT reconstruction had persistent knee pain at follow up. Conclusion Though there are notable differences in the follow-up period, patients undergoing MFT risk developing knee pain, while those undergoing COG risk radiographic progression of wrist arthritis. Level of Evidence III - Comparative study.

Arthroscopic Debridement for Treatment of Chronic Dynamic Scaphoid Instability.

Background There is a paucity of information on minimal surgical intervention for the treatment of chronic dynamic scaphoid instability (CDSI) that will achieve an acceptable mid-term result. Purpose We hypothesize that by following a debride-first-then-wait protocol, some patients with CDSI can be treated with arthroscopic debridement alone and avoid a reconstructive procedure. Patients and Methods We performed a retrospective, longitudinal study from January 2008 to December 2018 of all patients diagnosed with CDSI and treated with arthroscopic debridement of the scapholunate interosseous ligament. In all cases, a debride-first-then-wait protocol was followed that included a predetermined wait period after arthroscopic debridement, giving the patient a chance to experience possible symptom improvement. This approach integrated the patient's perceived wellness into the decision-making process. All wrists that remained symptomatic or experienced recurrence of symptoms were treated with a reconstructive procedure. The wrists were divided into two groups: arthroscopic debridement only (ADO) and reconstructive procedure (RP). Results Seventy-nine wrists (72 patients) of 191 consecutive wrist arthroscopies met the inclusion criteria. The ADO group consisted of 43 wrists (54%). An average of 6.3 years later (range: 2-11 years), these patients remained satisfied with the results of the arthroscopic debridement and did not want further treatment. The RP group included 36 wrists (46%) with 91.7% of reconstructive surgeries occurring within 6 months of the arthroscopy. With a mid-term follow-up, 75% of Geissler grade II ligament tears, 48% of grade III tears, and 39% of grade IV tears were successfully treated with arthroscopic debridement alone and avoided a reconstructive surgery. Conclusion By adopting a debride-first-then-wait protocol, some patients with CDSI can be treated with a more limited intervention, arthroscopic debridement. In this series, 54% of wrists with CDSI avoided a reconstructive surgery for an average of 6.3 years. Type of Study / Level of Evidence Case Series, Level IV.

Pure traumatic unstable radiocarpal dislocation over pre-existing ulnar impingement syndrome, extensively arched carpus and medially rotated scaphoid: An exceptional and complex case report.

Introduction and importance: Radiocarpal dislocation is a rare and severe injury that demands urgent diagnosis and treatment. In this case report, we present the unique scenario of a 32-year-old male who suffered a traumatic pure unstable radiocarpal dislocation. This dislocation was associated with ulnar impingement syndrome, an extensively arched carpus, and a medially rotated scaphoid. The complexity of this injury underscores the importance of timely intervention and comprehensive management. Case presentation: The patient had a pre-existing short ulnar head with radial-sided deformity, radioulnar convergence, negative ulnar variance, erosive scalloping of the distal radius, subchondral sclerosis of the ulnar head, scapholunate diastasis, and distal radioulnar joint (DRUJ) diastasis. Following a high-velocity motor vehicle accident, the initial treatment involved closed reduction and radio-metacarpal external fixation. Additionally, surgical intervention was required for an open dislocation of the metatarsophalangeal (MTP) joint of the left hallux. Clinical discussion: The subsequent management of this complex case included the Sauvé-Kapandji procedure, ulnolunate and ulnotriquetral ligamentoplasty using the palmaris longus tendon, and scapholunate fusion. The patient reported no prior wrist instability or injury upon awakening, but mild mechanical wrist pain persisted after exertion. Follow-up assessments revealed residual pain during prono-supination, along with slightly limited radial inclination. This exceptional case highlights the biomechanical challenges and the need for a multidisciplinary approach in treating such injuries. Conclusion: To the best of our knowledge, this is the first documented instance of a traumatic pure unstable radiocarpal dislocation associated with ulnar impingement syndrome, an extensively arched carpus, and a medially rotated scaphoid. Despite the complexity, proper bone healing and favorable functional outcomes were achieved through meticulous surgical management. This case underscores the importance of individualized treatment strategies for rare and challenging wrist injuries.

Managing Kienbock Disease's Surgical Treatment and Outcome Analysis: A Case Report and Review of Literature.

A 38-year-old man without a severe traumatic history reported to the outpatient department (OPD) with wrist pain at the dorsal aspect, mild swelling, stiffness, and restricted mobility at the left wrist joint. The patient had been experiencing these symptoms for a year. There was sharp tenderness, graded as 4 above the lunate bone, on examination of the left wrist joint. Advanced imaging, which is magnetic resonance imaging (MRI), and radiographs suggested that the patient had Kienbock's illness. Typically, the surgical approach for Kienbock's used is wrist fusion or proximal row carpectomy. However, in this case, a novel strategy of bone grafting, scaphoid-capitate fusion, and lunate excision was adopted. This case report explains the outcome of our scaphoid-capitate arthrodesis, which was done to maintain functional mobility and relieve discomfort by halting the progression of carpal collapse and carpal-ulnar translation.

Three-corner arthrodesis for scapholunate and scaphoid nonunion advanced collapsed wrists: outcomes at long term follow-ups.

OBJECTIVES: This study aimed to assess clinical, functional and radiological outcomes after three-corner arthrodesis in patients suffering from symptomatic scapholunate or scaphoid non-union advanced collapsed wrists. We hypothesised that three-corner arthrodesis provided satisfactory clinical and radiological results in the long term. MATERIAL AND METHODS: This was a retrospective study of 13 patients (14 wrists) who underwent a three-corner arthrodesis between March 2004 and January 2019 with a mean follow-up of 6,7 years. Clinical assessment consisted of wrist motion, grip strength, pain and functional scores (Quick-DASH, PRWE, MWS). All complications and surgical revisions were investigated. Radiographic assessment searched for union, evaluated carpal height and ulnar translation, lunate tilt and occurrence of radio-lunate arthritis. RESULTS: At the last follow-up Quick-DASH and PRWE scores were 24,87(± 17.2) and 47.4 (± 26.9) respectively and were significantly improved. Wrist motion was 35°, 32°, 10° et 24° of flexion, extension, radial and ulnar deviation respectively. Union was obtained for 13 (92,9%) wrists. The mean radiolunate angle was 11° (-17°-34°). Three patients needed reintervention, which 2 consisted of total wrist arthrodesis due to persisting pain. Mild signs of radio-lunate arthritis were found in three patients. CONCLUSION: Three-corner arthrodesis seemed to provide satisfactory long-term functional outcomes. The union rate was high and even patients with signs of radio-lunate arthritis still had improved outcomes at the last follow-up. It could be a part of surgical options in wrists with radio- and midcarpal arthritis, among other procedures.

Isolated Osseous Excision in the Adult Carpus: A Narrative Review.

Various pathologies of the adult carpus result in clinical scenarios where excision can be considered and even recommended. In the appropriate patient population, isolated carpal excision can alleviate pain and improve mobility. Excisions of the pisiform, trapezium, and trapezoid have abundant literature evidence to support positive long-term functional outcomes. In contrast, isolated excision of the capitate, hamate, and triquetrum has limited support in the literature secondary to compromise of carpal mechanics and lead to recurrent pain. Additionally, isolated scaphoid and lunate excision are best avoided secondary to carpal collapse and should be paired with concomitant stabilizing procedures in the carpus. This article provides a comprehensive literature review of isolated excision of each osseous carpal bone, their indications, and previously assessed outcomes.

Scaphoid Fractures Requiring Bone Graft: Does Graft Source Matter?

Background: Treatment of scaphoid fractures often requires bone grafting. In such cases, bone graft is traditionally harvested from the iliac crest, but utilizing the distal radius carries less morbidity and is becoming more popular. The purpose of this study is to compare the outcomes of treatment of scaphoid waist fractures with the use of distal radius and iliac crest bone grafts. Methods: A retrospective chart review of patients undergoing repair of a scaphoid waist fracture with bone graft at our institution between 2010 and 2020 was completed. Bone graft was used in patients with nonunion, humpback deformity, or for correction of scaphoid alignment. The primary outcome was rate of union as determined by postoperative X-ray or computed tomography scan. Fisher exact tests, Student t tests, and Mann-Whitney U tests were used as appropriate. Results: Thirty-nine patients were included in the study. Twenty-nine patients were treated with distal radius bone graft, and 10 were treated with an iliac crest graft. There was no statistical difference in union rate between the distal radius and iliac crest cohorts (97% vs 80%, P = .16). There was no significant difference for complication rates, rate of unplanned secondary surgery, time to union, postoperative scapholunate angle, or duration of immobilization. Conclusions: In the fixation of scaphoid waist fractures with bone graft, there is no significant difference in union rate between distal radius and iliac crest grafts. With the well-documented morbidity associated with iliac crest grafts, surgeons should consider using distal radius grafts instead of iliac crest grafts.

[Trans-scapho-perilunar fracture-dislocation: a case report]. / Fractura-luxación transescafo-perilunar: reporte de un caso clínico.

Trans-scaphoid perilunate fractures-dislocations are rare injuries caused by high-energy trauma of the wrist. Diagnosis is based on medical history, physical examination, and tools such as radiographs, computed tomography scan, and magnetic resonance imaging. Early treatment consists of closed reduction and casting to stabilize the limb. Definitive treatment is surgical and includes bone and soft tissue repair. A case of trans-scaphoid perilunate fracture-dislocation is presented, along with diagnosis, management and outcome.

Las fracturas-luxaciones transescafo-perilunares son lesiones infrecuentes causadas por impactos de alta energía hacia la muñeca. El diagnóstico se basa en la historia clínica, exploración física y herramientas como la radiografía, la tomografía computarizada y la resonancia magnética. El manejo inmediato consiste en una reducción cerrada e inmovilización para estabilizar la extremidad. El tratamiento definitivo es de carácter quirúrgico e incluye la reparación ósea y de tejidos blandos. Se presenta un caso de fractura-luxación transescafo-perilunar, su diagnóstico, manejo y evolución.

An anatomical feasibility study using the first metatarsal head as a vascularized bone graft for proximal pole of scaphoid reconstruction.

A cadaveric study showed that vascularized transfer of the articular surface of the ipsilateral first metatarsal head with the lateral collateral ligament could be suitable for reconstruction of the proximal pole of scaphoid and scapholunate ligament. Further study of the technique is recommended.

Arthroscopy-assisted Procedures in Hand and Wrist Surgery: An Update. Where Are We So Far?

Wrist and hand arthroscopy, despite being an old tool, has gained popularity and advanced in assisting in the treatment of various injuries and conditions in the region in recent years. Dorsal, volar, ulnar, and radial accessory portals are used to reach all points of the carpal and hand joints. The minimal tissue damage, lesser injury to the capsule and its mechanoreceptors, the assessment of injuries associated with the reason for surgery, and aesthetically more favorable scars have attracted many doctors and their patients. As a result, there has been an increase in publications and diversifications of arthroscopic techniques. The aim of this update article is to present the advances and the evidence available in the literature to assist readers in their decision on which technique to use in the treatment of wrist and hand conditions.

Rare Case of Open Comminuted Scaphoid Fracture Dislocation: Treatment With Free Bone Graft and Locking Plate.

To the best of our knowledge, there are no reports in the literature of an open comminuted scaphoid fracture dislocation. We present such a rare case. The case report illustrates the case of a 58-year-old right-handed press operator who injured his left wrist when his hand got caught in a press machine. He received initial treatment at another hospital and was subsequently referred to our hospital. Eight days after the injury, surgery was performed under the brachial plexus block. Successful bone fusion was achieved through volar locking plate fixation, primary free bone grafting from the radius, and Kirschner wire fixation. Our case report may be a valuable resource for the treatment of similar injuries.