Preiser's Disease-Current Concepts of Etiology and Management.

The term Preiser's disease typically is used to describe idiopathic avascular necrosis of the scaphoid, but there have been a number of putative etiologies considered. It is rare and the natural history is not fully understood. Management of the condition should be based on patient factors as well as the stage of disease with regard to the scaphoid and the surrounding wrist. This chapter appraises the available evidence and aims to provide the reader with a framework to manage this rare condition.

Blood Flow in the Scaphoid Is Improved by Focused Extracorporeal Shock Wave Therapy.

BACKGROUND: Extracorporeal shock wave therapy (ESWT) has shown benefits in patients with nonunion or delayed bone healing, pseudarthrosis, and avascular necrosis of bone. Until now, these effects were explained by the release of growth factors, activation of cells, and microfractures occurring after ESWT. Microcirculation is an important factor in bone healing and may be compromised in fractured scaphoids because its blood supply comes from the distal end. Due to this perfusion pattern, the scaphoid bone is prone to nonunion after fracture. The ability of ESWT to enhance microcirculation parameters in soft tissue was of interest to determine if it improves microcirculation in the scaphoid. QUESTIONS/PURPOSES: (1) Does capillary blood flow increase after a single session of ESWT in the scaphoid? (2) Do oxygen saturation in the bone and postcapillary venous filling pressure increase after a single session of ESWT in the scaphoid? METHODS: ESWT (0.3 mJ/mm, 8Hz, 1000 impulses) was applied to the intact scaphoid of 20 volunteers who were without wrist pain and without any important metabolic disorders. Mean age was 43 ± 14 years, 12 men and eight women (40% of total). Volunteers were recruited from January 2017 to May 2017. No anesthetic was given before application of ESWT. An innovative probe designed for measurements in bone by compressing soft tissue and combining laser-Doppler flowmetry and spectrophotometry was used to noninvasively measure parameters of microcirculation in the scaphoid. Blood flow, oxygenation, and venous filling pressure were assessed before and at 1, 2, 3, 5, 10, 15, 20, 25, and 30 minutes after ESWT application. Room temperature, humidity, ambient light and measuring sequences were kept consistent. A paired t-test was performed to compare experimental data with baseline (p < 0.05 taken as significant). RESULTS: At baseline, capillary blood flow of the bone was 108 ± 46 arbitrary units (AUs) (86 to 130). After treatment with ESWT, it was 129 ± 44 AUs (106 to 150; p = 0.011, percentage change of 19 %) at 1 minute, 138 ± 46 AUs (116 to 160; p = 0.002, percentage change of 28%) at 2 minutes, 146 ± 54 AUs (121 to 171; p = 0.002, percentage change of 35%) at 3 minutes and 150 ± 52 AUs (126 to 174; p < 0.001, percentage change of 39%) at 5 minutes. It remained elevated until the end of the measuring period at 30 minutes after treatment at 141 ± 42 AUs (121 to 161; p = 0.002) versus baseline). Oxygen saturation and postcapillary venous filling pressure in bone showed no change, with the numbers available. CONCLUSIONS: A single session of ESWT increased capillary blood flow in the scaphoid during measuring time of 30 minutes. Bone oxygenation and postcapillary venous filling pressure, however, did not change. Because increased oxygenation is needed for improved bone healing, it remains unclear if a sole increase in capillary blood flow can have clinical benefits. As the measuring period was limited to only 30 minutes, bone oxygenation and postcapillary filling pressure may subsequently show change only after the measuring-period ended. CLINICAL RELEVANCE: Further studies need to evaluate if increased capillary blood flow can be sustained for longer periods and if bone oxygenation and postcapillary venous filling pressure remain unchanged even after prolonged or repetitive ESWT applications. Moreover, clinical studies must validate if increased microcirculation has a positive impact on bone healing and to determine if ESWT can be therapeutically useful on scaphoid fractures and nonunions.

Scaphoid Reconstruction.

Surgical strategies for scaphoid nonunions become more complex based on time from injury to treatment. The decision-making process, however, can follow a logical sequence. Scaphoid nonunions less than 1 year after trauma and no carpal malalignment can be treated with percutaneous screw fixation under fluoroscopic and/or arthroscopic guidance. Reinterventions or patients with avascular proximal poles that do not need substantial grafts are reliably treated with pedicle vascularized bone grafts. Resection of the distal pole of the scaphoid is a good option in old nonunions or after a failed scaphoid procedures. When there are radioscaphoid degenerative changes, salvage procedures such as proximal row carpectomy (PRC) should be considered.

The Vascular Anatomy of the Scaphoid: New Discoveries Using Micro-Computed Tomography Imaging.

PURPOSE: The purpose of this study was to investigate the intraosseous vascular anatomy of the scaphoid using recent advances in micro-computed tomography (micro-CT) imaging and 3-dimensional reconstruction. We also studied the effect of scaphoid shape and screw position on the intraosseous vascular structure. METHODS: Thirteen upper extremities were injected with a contrast agent. The scaphoid bones were extracted and scanned using a micro-CT scanner. The vascular impact of screw insertion at various axes through the scaphoid was calculated and compared using the generated 3-dimensional models. The specimens were 3-dimensionally-printed and the morphology was assessed according to bone dimensions. A relationship between the internal vascular patterns and these morphological features was determined. RESULTS: All specimens received vascular inflow from the dorsal ridge forming a vascular network that supplied an average of 83% of the bone's volume. This network was supplemented in 4 specimens with volar vessels entering at the waist. Another network was identified, created by vessels entering volarly at the tubercle, which supplied the remainder of the scaphoid. One specimen did not receive any vessels at the tubercle. With regards to screw placement, screws placed in the central axis were the least disruptive to the internal vascularity, followed by the antegrade (dorsal) insertion axis. Two morphological bone types were identified: type I or full scaphoids and type II or slender scaphoids. Type I possessed a more robust internal vascular network than type II scaphoids. CONCLUSIONS: This study identifies 2 distinct types of scaphoid morphology with 1 of them having a less robust blood supply, which may prove to be related to development of nonunion, avascular necrosis, or Preiser disease. Central axis and antegrade (dorsal) screw fixation may be least disruptive to the internal blood supply. CLINICAL RELEVANCE: Safer fixation of the scaphoid bone may be achieved by knowledge of intraosseous vascular patterns.

Diagnosis and Management of Acute Scaphoid Fractures.

The scaphoid is the most commonly fractured carpal bone; despite its frequent injury, the diagnosis of fracture can be complicated by the presence of normal radiographs at the time of presentation. Clinical intuition can be increased by physical examination and immediately available modalities such as ultrasound within the emergency department. Definitive diagnosis should be made with computed tomography and magnetic resonance to verify the presence of displacement. This article provides an overview of the incidence and presentation of acute scaphoid fractures with a surgical focus on percutaneous dorsal screw fixation.

Posttraumatic Avascular Necrosis After Proximal Femur, Proximal Humerus, Talar Neck, and Scaphoid Fractures.

Posttraumatic avascular necrosis (AVN) is osteonecrosis from vascular disruption, commonly encountered after fractures of the femoral neck, proximal humerus, talar neck, and scaphoid. These locations have a tenuous vascular supply; the diagnosis, risk factors, natural history, and treatment are reviewed. Fracture nonunion only correlates with AVN in the scaphoid. In the femoral head, the risk is increased for displaced fractures, but the time to surgery and open versus closed treatment do not seem to influence the risk. Patients with collapse are frequently symptomatic, and total hip arthroplasty is the most reliable treatment. In the humeral head, certain fracture patterns correlate with avascularity at the time of injury, but most do not go on to develop AVN due to head revascularization. Additionally, newer surgical approaches and improved construct stability appear to lessen the risk of AVN. The likelihood of AVN of the talar body rises with increased severity of talar injury. The development of AVN corresponds with a worse prognosis and increases the likelihood of secondary procedures. In proximal pole scaphoid fractures, delays in diagnosis and treatment elevate the risk of AVN, which is often seen in cases of nonunion. The need for vascularized versus nonvascularized bone grafting when repairing scaphoid nonunions with AVN remains unclear.

Treatment for proximal pole scaphoid nonunion with capsular-based vascularized distal radius graft.

PURPOSE: We retrospectively reviewed the results of 89 patients with proximal pole scaphoid nonunion, 58 with avascular necrosis, treated with a capsular-based vascularized distal radius graft. METHODS: Seventy-one male and eighteen female patients with symptomatic nonunion at the proximal pole of the scaphoid were included in this study. No patient had a humpback deformity. In all patients, the vascularized bone graft was harvested from the dorsum of the distal radius and was attached to a capsular flap of the dorsal wrist capsule. After fixation of the scaphoid with a small cannulated screw, the graft was inserted press-fit into the scaphoid trough in the nonunion site. Supplementary fixation of the graft with a microsuture anchor into the scaphoid was used in 66 patients. RESULTS: At a mean time of 12.3 weeks (range 6-24) after surgery, solid union was achieved in 76 of 89 patients (49 of 58 with avascular necrosis). Eleven patients had persistent nonunion and two fibrous union as determined by CT scan. Sixty-six of the patients with solid bone union were completely pain free, and ten complained of slight pain with strenuous activities. No donor site morbidity was observed. CONCLUSIONS: The capsular-based vascularized bone graft from the distal radius is a reliable alternative technique for scaphoid nonunions. It is a simple and expedient harvesting technique without the need for a microsurgical anastomoses. The supplemental fixation with a microsuture anchor eliminates the risk of graft displacement.

MR angiogram confirms sustained blood flow in 1,2 ICSR artery of vascularized bone grafting in scaphoid nonunion treatment.

PURPOSE: To evaluate the functioning of 1,2 intercompartmental supraretinacular artery (ICSRA) in vascularized bone grafting (VBG) of scaphoid nonunions with avascular necrosis of proximal pole. MATERIALS AND METHODS: Fourteen patients with scaphoid nonunion were treated operatively with 1,2 ICSRA VBG. Viability of the pedicle artery was evaluated by MR angiography with intravenous contrast agent. RESULTS: In 13 out of 14 patients, the 1,2 ICSR artery was found to be patent and functional. Revascularization of scaphoid proximal pole was revealed in all cases, and nonunion healing was confirmed as well. CONCLUSION: 1,2 ICSRA VBG in scaphoid nonunion is an effective surgical technique. It combines the advantages of bone grafting and vascular supply via the transferred pedicle artery which seems to be functional postoperatively if a meticulous operative technique is used.

Preiser disease after repeated local glucocorticoid injections: A case report.

RATIONALE: Preiser disease or avascular necrosis (AVN) of the scaphoid causes intolerable wrist pain and malalignment of the carpal bones. In previously reported cases, patients have had a history of steroid use for systemic illness such as autoimmune hemolytic anemia, systemic lupus erythematosus, or renal transplantation, or have had other risk factors, such as smoking, alcoholism, or infection. In particular, systemic glucocorticoid therapy has been most commonly associated with the disease. Although there are reports of AVN of the scaphoid induced by systemic glucocorticoids, no prior report has associated AVN of the carpal bones with repeated local injections of glucocorticoids. PATIENT CONCERNS: We present a case in which it was strongly suspected that AVN of the scaphoid was induced by repeated local glucocorticoid injections. The patient had no history of excessive alcohol use, smoking, or trauma, except for local repeated steroid injections. DIAGNOSES: Initially, she had diagnosed with de Quervain's disease and was treated by repeated local glucocorticoid injections followed by surgery for de Quervain's disease. Five years after surgery for de Quervain's disease, the patient presented at our hospital with sudden onset of intolerable pain in her right wrist without a history of trauma. In spite of nonsurgical treatment with rest, immobilization, analgesia, and surgery, her wrist pain was not improved. After further repeated local steroid injections in her wrist, radiographs, and magnetic resonance imaging of her wrist showed the AVN of the scaphoid. INTERVENTIONS: Surgery was performed and the fragmented proximal scaphoid and the entire lunate were resected. OUTCOMES: The diagnosis was confirmed according to the histopathological examination of the proximal scaphoid bone, which showed the characteristic of AVN of the scaphoid. At follow-up evaluation, radiographs of the right wrist showed no progression of osteoarthritis. The patient had no tenderness or residual pain at the wrist and had no desire to pursue additional surgery. LESSONS: We have presented a case with AVN of the scaphoid, which was strongly suspected to be associated with the repeated local steroid injections. Further studies are required to more fully elucidate the association between AVN of the scaphoid and repeated local steroid injections.

New findings about the intrascaphoid arterial system.

We investigated the intraosseous arteries of six normal cadaveric scaphoids using red lead injection and three-dimensional reconstruction with micro-computed tomography. The arterial entrances were generally located around the dorsal ridge, the insertion of the scaphocapitate ligament and the radial part of the radioscaphocapitate ligament. Two to three trunk arteries entered the scaphoid on dorsal ridge at the level of the waist. The distal part of the scaphoid was mainly supplied by arteries from the waist. The blood supply of about 40% of proximal part of the scaphoid was poor. The blood supply from the scaphoid dorsal ridge plays an important role, not only for the proximal part of the scaphoid, but also for the waist and even the distal pole. The intrascaphoid arterial pattern may be contributory to nonunion, especially in proximal pole fractures.

Success of scaphoid nonunion surgery is independent of proximal pole vascularity.

We followed 35 consecutive patients with scaphoid nonunions in a prospective longitudinal registry. All nonunions were treated with curettage, non-vascularized autogenous grafting and headless screw fixation. Preoperative magnetic resonance imaging, intraoperative bleeding points and histopathological analysis of cancellous bone in the proximal pole were recorded as measures of viability. Healing was categorized as ≥50% bony bridging on computed tomographic images in the plane of the scaphoid. Nine of 23 proximal poles demonstrated ischaemia on magnetic resonance imaging but none were interpreted as infarcted. Twenty-eight of 33 were found to have impaired vascularity as assessed by intraoperative bleeding. Fourteen of 32 demonstrated ≥50% trabecular necrosis and four of 33 demonstrated ≥50% tissue necrosis on histopathological analysis. Thirty of 33 demonstrated focal or robust remodelling activity. Despite pathological evidence of impaired vascularity in over half of the patients, 33 of the 35 scaphoids had healed by 12 weeks. We conclude that proximal pole infarction is decidedly rare and that vascularized bone grafting is seldom required. LEVEL OF EVIDENCE: IV.

[Diagnosis of the scaphoid bone : Fractures, nonunion, circulation, perfusion]. / Diagnostik des Skaphoids : Fraktur, Pseudarthrose, Durchblutung, Perfusion.

The clinical relevance of scaphoid bone fractures is reflected by their high incidence, accounting for approximately 60 % among carpal fractures and for 2-3 % of all fractures. With adequate therapy most scaphoid bone fractures heal completely without complications. Insufficient immobilization or undiagnosed fractures increase the risk of nonunion and the development of pseudarthrosis.X-ray examination enables initial diagnosis of scaphoid fracture in 70-80 % of cases. Positive clinical symptoms by negative x­ray results require further diagnostics by multi-slice spiral CT (MSCT) or MRI to exclude or confirm a fracture. In addition to the diagnosis and description of fractures MSCT is helpful for determining the stage of nonunion. Contrast enhanced MRI is the best method to assess the vitality of scaphoid fragments.

[Application of bone flap pedicled on retrograde branch of radial artery for treatment of old scaphoid bone fractures of type AO-B].

OBJECTIVE: To investigate application of the bone flap pedicled on the retrograde branch of radial artery for treatment of old scaphoid bone fractures of type AO-B. METHODS: From October 2007 to October 2011,41 patients with old scaphoid bone fractures of type AO-B were treated by transplantation of the bone flap pedicled on the retrograde branch of radial artery including 26 males and 15 females with an average of (27.3±4.5) years old ranging from 16 to 43 years old. The courses before operation ranged from 6 to 22 months with an average of 11 months. All fractures belonged to the type B of AO classification, that is old wrist fracture of scaphoid bone. All patients' wrist function (pain, function, motion, grip strength) were evaluated by Cooney's modifiedwrist scoring system before and 6 months after operation,and the conditions of bone healing were observed during the follow-up time. RESULTS: Among them, 36 patients were followed up from 4 to 15 months with an average of 8.3 months. The wounds were healed well without other complications as infection appearing. X-rays or CT confirmed that all fractures were healed completely. The Cooney wrist score was improved from preoperative 53.61±13.97 to postoperative 81.81±8.71 (P<0.01). CONCLUSION: The operation of transplantation of the bone flap pedicled on the retrograde branch of radial artery is an effective method to treat old scaphoid bone fractures,which is scientific and has curative effects, and valuable for clinical application.

Scaphoid fracture nonunion: correlation of radiographic imaging, proximal fragment histologic viability evaluation, and estimation of viability at surgery: diagnosis of scaphoid pseudarthrosis.

PURPOSE: The purpose of this study was to correlate the pre-operative imaging, vascularity of the proximal pole, and histology of the proximal pole bone of established scaphoid fracture non-union. METHODS: This was a prospective non-controlled experimental study. Patients were evaluated pre-operatively for necrosis of the proximal scaphoid fragment by radiography, computed tomography (CT) and magnetic resonance imaging (MRI). Vascular status of the proximal scaphoid was determined intra-operatively, demonstrating the presence or absence of puncate bone bleeding. Samples were harvested from the proximal scaphoid fragment and sent for pathological examination. We determined the association between the imaging and intra-operative examination and histological findings. RESULTS: We evaluated 19 male patients diagnosed with scaphoid nonunion. CT evaluation showed no correlation to scaphoid proximal fragment necrosis. MRI showed marked low signal intensity on T1-weighted images that confirmed the histological diagnosis of necrosis in the proximal scaphoid fragment in all patients. Intra-operative assessment showed that 90% of bones had absence of intra-operative puncate bone bleeding, which was confirmed necrosis by microscopic examination. CONCLUSIONS: In scaphoid nonunion MRI images with marked low signal intensity on T1-weighted images and the absence of intra-operative puncate bone bleeding are strong indicatives of osteonecrosis of the proximal fragment.

On the history and definition of Preiser's disease.

In 1910, Georg Preiser (1876-1913) described five cases of rarifying osteitis. Based on his imaging studies, he diagnosed post-traumatic avascular necrosis (AVN) of the scaphoid without any sign of primary fracture. This was followed by an article in 1911 in which Preiser related his findings to Kienböck's disease and Köhler's disease of the tarsal navicular. Upon searching the literature, we found descriptions and discussions of Preiser's imaging; however, the original images have never been published. We reproduce Preiser's original imaging in this current review. All of these appear to show a fracture and no signs of AVN, suggesting that Georg Preiser misinterpreted his findings. There is no apparent uniformity in the literature regarding the definition, description, or aetiology of Preiser's disease, and it is for this reason that we find the use of eponyms to be confusing.

Treatment of scaphoid nonunion: pedicled vascularized bone graft vs. traditional bone graft.

The clinical results of the application of pedicled vascularized bone graft (VBG) from Lister's tubercle vs. traditional bone graft (TBG) were evaluated and compared. Thirteen cases of symptomatic scaphoid nonunion were treated between January 2011 and December 2012, including 7 cases subject to VBG and the rest 6 cases to TBG, respectively. Outcomes were assessed by modified Mayo wrist score system. All cases were followed up for an average period of 3.5 months after operation. The results showed that total scores in VBG group were 86.4±9.4 after operation with excellent result in 4 cases, good in 2 and acceptable in one, and those in TBG group were 71.7±9.3 after operation with good result in 2 cases, acceptable in 3 and disappointing in one. Total score of wrist function was significantly improved in VBG group as compared with TBG group (P<0.05). Our study suggests that VBG method is more effective for treating scaphoid nonunion than TBG method.

Is dynamic contrast-enhanced MRI useful for assessing proximal fragment vascularity in scaphoid fracture delayed and non-union?

OBJECTIVE: To assess dynamic contrast-enhanced magnetic resonance imaging (DCE MRI) as a measure of vascularity in scaphoid delayed-union or non-union. MATERIALS AND METHODS: Thirty-five patients (34 male, one female; mean age, 27.4 ± 9.4 years; range, 16-51 years) with scaphoid delayed-union and non-union who underwent DCE MRI of the scaphoid between September 2002 and October 2012 were retrospectively reviewed. Proximal fragment vascularity was classified as good, fair, or poor on unenhanced MRI, contrast-enhanced MRI, and DCE MRI. For DCE MRI, enhancement slope, Eslope comparison of proximal and distal fragments was used to classify the proximal fragment as good, fair, or poor vascularity. Proximal fragment vascularity was similarly graded at surgery in all patients. Paired t test and McNemar test were used for data comparison. Kappa value was used to assess level of agreement between MRI findings and surgical findings. RESULTS: Twenty-five (71 %) of 35 patients had good vascularity, four (11 %) had fair vascularity, and six (17 %) had poor vascularity of the proximal scaphoid fragment at surgery. DCE MRI parameters had the highest correlation with surgical findings (kappa = 0.57). Proximal scaphoid fragments with surgical poor vascularity had a significantly lower Emax and Eslope than those with good vascularity (p = 0.0043 and 0.027). The sensitivity, specificity, positive and negative predictive value and accuracy of DCE MRI in predicting impaired vascularity was 67, 86, 67, 86, and 80 %, respectively, which was better than that seen with unenhanced and post-contrast MRI. Flattened time intensity curves in both proximal and distal fragments were a feature of protracted non-union with a mean time interval of 101.6 ± 95.5 months between injury and MRI. CONCLUSIONS: DCE MRI has a higher diagnostic accuracy than either non-enhanced MRI or contrast enhanced MRI for assessing proximal fragment vascularity in scaphoid delayed-union and non-union. For proper interpretation of contrast-enhanced studies in scaphoid vascularity, one needs to incorporate the time frame between injury and MRI.