Retrospective analysis of scaphoid trapezium pyrocarbon implant intervention in STT arthritis: a 3-year follow-up study.

AIM: The purpose of this study was to evaluate clinical, patient rated and radiological outcome of the scaphoid trapezium pyrocarbon implant (STPI) at a minimum of three years follow-up. METHODS: Consecutive patients operated with the STPI due to scaphotrapeziotrapezoidal (STT) arthritis between 2012 and 2019 were included. Patients were evaluated preoperatively and annually after surgery for range of motion, grip strength, key pinch, quick-DASH, pain, and satisfaction. Radiographs were evaluated for implant position, signs of dorsal intercalated segment instability (DISI), capitolunate (CL) angle, scapholunate (SL) distance, and presence of osteophytes. RESULTS: Twenty-six patients (29 implants) were included. Seven implants were revised during the follow up, mainly due to pain: three implants were removed, four patients received a new STPI of a different size, leaving 22 implants in 20 patients available for follow up, 9 males and 11 females. Median age was 61.7 years (51-78 years). Median follow-up time was 68 months (37-105 months). Comparing preoperative status to the last follow-up, wrist extension and deviation, thumb abduction, and grip strength did not change. Key Pinch, quick DASH, pain, and patient satisfaction improved significantly at last follow-up. Radiographic signs of DISI were seen in six cases preoperatively and in 12 cases at last follow-up. CONLUSION: At a minimum of three years follow-up, the STPI used for STT-arthritis improve pain, quick-DASH result, and patient satisfaction significantly. ROM and grip strength did not change compared to preoperative values. Radiographic signs of carpal instability were common at the follow-up and the revision rate was high.

Capitate Proximal Fragment Migration Compressing the Median Nerve in Scaphocapitate Fracture: A Case Report.

BACKGROUND Scaphocapitate syndrome is a rare clinical entity consisting of a combined scaphoid and capitate fracture along with a 90- or 180-degrees rotation of the proximal capitate fragment. The syndrome is scarcely described in the literature, with proximal migration of the capitate fragment being reported only by Mudgal et al in 1995. Concurrent compression of the median nerve is a highly unfortunate event, suggesting a unique case presented here. CASE REPORT We present a unique case of scaphocapitate fracture-dislocation in a 25-year-old man with volar dislocation of the capitate's fragment deep to the median nerve. X-rays and CT scan were performed and the patient was treated few hours after the injury by a hand specialist, in order to prevent median neuropathy and avascular necrosis of the fragment. Open reduction and internal fixation utilizing a Herbert screw for the scaphoid fracture and 3 additional K-wires was performed. Immediately post-operatively, the acute neurological symptoms had subsided and good reduction was acquired radiologically. One year post-operatively the patient had regained good hand and wrist functionality, with no extension or flexion ROM deficits. CONCLUSIONS Immediate intervention in a specialized center with reduction and fixation utilizing a Herbert screw and K-wires showed favorable 1-year results in our case of scaphocapitate syndrome. The impending complications of median neuropathy and capitate avascular necrosis were avoided despite the high-risk injury pattern.

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.

A comparative study of image quality and diagnostic confidence in diagnosis and follow-up of scaphoid fractures using photon-counting detector CT and energy-integrating detector CT.

PURPOSE: Scaphoid fractures in patients and assessment of healing using PCD-CT have, as far as we know, not yet been studied. Therefore, the aim was to compare photon counting detector CT (PCD-CT) with energy integrating detector CT (EID-CT) in terms of fracture visibility and evaluation of fracture healing. METHOD: Eight patients with scaphoid fracture were examined with EID-CT and PCD-CT within the first week post-trauma, and with additional scans at 4, 6 and 8 weeks. Our clinical protocol for wrist examination with EID-CT was used (CTDIvol 3.1 ± 0.1 mGy, UHR kernel Ur77). For PCD-CT matched radiation dose, reconstruction kernel Br89. Quantitative analyses of noise, CNR, trabecular and cortical sharpness, and bone volume fraction were conducted. Five radiologists evaluated the images for fracture visibility, fracture gap consolidation and image quality, and rated their confidence in the diagnosis. RESULTS: The trabecular and cortical sharpness were superior in images obtained with PCD-CT compared with EID-CT. A successive reduction in trabecular bone volume fraction during the immobilized periods was found with both systems. Despite higher noise and lower CNR with PCD-CT, radiologists rated the image quality of PCD-CT as superior. The visibility of the fracture line within 1-week post-trauma was rated higher with PCD-CT as was diagnostic confidence, but the subsequent assessments of fracture gap consolidation during healing process and the confidence in diagnosis were found equivalent between both systems. CONCLUSION: PCD-CT offers superior visibility of bone microstructure compared with EID-CT. The evaluation of fracture healing and confidence in diagnosis were rated equally with both systems, but the radiologists found primary fracture visibility and overall image quality superior with PCD-CT.

One-Year Outcomes of the Anatomical Front and Back Reconstruction for Scapholunate Dissociation.

PURPOSE: Anatomical front and back (ANAFAB) reconstruction addresses the critical volar and dorsal ligaments associated with scapholunate dissociation. We hypothesized that patients with symptomatic, chronic, late-stage scapholunate dissociation would demonstrate improvements in all radiographic parameters and patient-reported outcomes (PROMs) after ANAFAB reconstruction. METHODS: From 2018 to 2021, 21 ANAFAB reconstructions performed by a single surgeon were followed prospectively, with 20 patients having a minimum follow-up of 12 months. In total, 17 men and four women were included, with an average age of 49 years. Three patients had modified Garcia-Elias stage 3 disease, eight stage 4, seven stage 5, and three stage 7. ANAFAB reconstruction of intrinsic and extrinsic ligament stabilizers was performed using a hybrid synthetic tape/tendon graft in a transosseous reconstruction. Pre- and postoperative radiographic parameters, grip, pinch strength, the Patient-Rated Wrist Evaluation, PROMIS Upper Extremity Function, and PROMIS Pain Interference outcome measures were compared. RESULTS: Mean follow-up was 17.9 months (range: 12-38). Radiographic parameters were improved at follow-up, including the following: scapholunate angle (mean 75.3° preoperatively to 69.2°), scapholunate gap (5.9-4.2 mm), dorsal scaphoid translation (1.2-0.2 mm), and radiolunate angle (13.5° to 1.8°). Mean Patient-Rated Wrist Evaluation scores for pain and function decreased from 40.6 before surgery to 10.4. We were unable to detect a significant difference in grip or pinch strength or radioscaphoid angle with the numbers tested. There were two minor complications, and two complications required re-operations, one patient who was converted to a proximal row carpectomy for failure of fixation, and one who required tenolysis/arthrolysis for arthrofibrosis. CONCLUSIONS: At 17.9-month average follow-up, radiographic and patient-reported outcome parameters improved after reconstruction of the critical dorsal and volar ligament stabilizers of the proximal carpal row with the ANAFAB technique. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Scapholunate Ligament Rupture and Coincident Fracture Proximal Pole Scaphoid Presenting Late with Osteonecrosis: A Rare Case Report with Unique Management.

CASE: A 29-year-old young active man with ununited necrosed proximal fifth of scaphoid with chronic scapholunate ligament disruption was managed by excision of proximal pole fragment and interosseous scapholunate reconstruction using modified Brunelli triple ligament tenodesis technique with satisfying outcome at 6 months and return to sports instructor job by the end of 1 year. CONCLUSION: Meticulous understanding and algorithmic itemwise approach of injury components can lead to optimal management of complex unstable wrist injuries such as scapholunate dissociation. To the best of our knowledge, this is the first report on excision of proximal pole of scaphoid coupled with scapholunate ligament reconstruction.

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.

Ligamentoplasty in scapholunate instability: short-term results of the "all dorsal scapholunate repair" technique.

Injury to the scapholunate complex is the cause of scapholunate instability which can lead to radiocarpal and medio-carpal osteoarthritis. Several ligamentoplasty techniques have been reported for the treatment of chronic scapholunate instability before the osteoarthritis stage. The objective of this study was to assess the short-term results of an "all dorsal scapholunate repair" ligamentoplasty. We report the clinical, radiological and functional results of a retrospective study including 21 patients, operated between June 2019 and December 2020 for a stage 3 or 4 scapholunate instability according to the Garcia Elias classification. With a follow-up of 14.2 months, the pain was 0.1/10 according to the VAS at rest and 4/10 during exercise. Wrist strength was measured at 65% of the opposite side. The flexion-extension range of motion was 105°. Radiologically, there was a reduction of the diastasis and scapholunate angle. Osteolysis areas around the anchors were described in 47% of patients. The mean QuickDASH was 29.2/100, PRWE 24/100 and Mayo wrist score 67.8/100. Eighty-one percent of patients were satisfied. Seventeen patients had returned to work 5.2 months postoperatively. In the case of work-related injury, the functional scores were poorer, with a delayed return to work. This technique provides encouraging results in the short term. Most patients were improved compared to preoperative state. The work-related injury appears to be a poor prognostic factor. A longer-term study is imperative to confirm the maintenance over time of the correction of carpal malalignment and the evolution of the osteolysis areas.Level of evidence: Level IV Retrospective study.

Radiographic evaluation of radial flexion osteotomy effect on static scapholunate instability: a preliminary cadaveric study.

INTRODUCTION: The optimal treatment of chronic scapholunate instability has yet to be established. Scapholunate ligament grafts are still far from being the ideal solution. We conducted an experimental study to evaluate whether flexion-opening wedge osteotomy of the distal radius improves misalignment and avoids rotatory subluxation of the scaphoid in a cadaveric model of static scapholunate dissociative instability. MATERIALS AND METHODS: Radiographic studies were performed on 15 cryopreserved specimens after recreating a model of scapholunate instability by division of the scapholunate interosseous ligament (SLIL) and secondary stabilizers, taking radiographs at baseline, after the instability model, and after distal radius osteotomy. Static and dynamic (under controlled tendon traction) anteroposterior and lateral views were obtained to measure the length (in mm) of the carpal scaphoid and scapholunate interval, scapholunate angle, radio-lunate angle, and palmar tilt of the distal joint surface of the radius and to measure the dorsal scaphoid translation by the concentric circles method. The Wilcoxon test was used for statistical comparisons. RESULTS: The scapholunate interval was significantly decreased after osteotomy in all static anteroposterior views and in all lateral views under tendon traction. Dorsal scaphoid translation was significantly reduced in static lateral view in extension and in dynamic lateral view under 5-pound flexor carpi radialis tendon tension controlled by a digital dynamometer. CONCLUSIONS: Flexion-addition osteotomy of the distal radius appears to improve carpal alignment parameters in a cadaveric model of static scapholunate instability, achieving similar values to those obtained before instability.

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.

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.

Magnetic resonance imaging analysis of the distribution of cartilage damage in scaphoid nonunion.

This study aimed to evaluate the distribution and severity of cartilage damage using magnetic resonance imaging in patients with scaphoid nonunion without advanced wrist arthritis. We retrospectively analysed MRI of patients who underwent osteosynthesis for scaphoid nonunion. Cartilage damage was assessed in eight wrist regions using a modified Whole-Organ Magnetic Resonance Imaging Score. The frequencies of regions affected by any cartilage damage (Score ≥2.5) depicted on MRI were analysed. The study included 32 patients (31 men and one woman), with a mean age of 32 years (SD 11). The distal radioscaphoid (29/32), scaphotrapeziotrapezoid (STT) (22/32), proximal radioscaphoid (14/32) and scaphocapitate (11/32) joints were most commonly affected by degenerative cartilage damage. The STT and proximal radioscaphoid joint were especially likely to be involved in early-stage scaphoid nonunion advanced collapse. We recommend that surgeons should investigate the cartilage status of these joints during decision-making for scaphoid nonunion surgery.Level of evidence: III.

Anatomical front and back reconstruction sustains radiographic alignment: a comparison to three-ligament tenodesis.

Multiple techniques exist to reconstruct the scapholunate interosseous ligament, though none have demonstrated superiority. This study compares 1-year radiographic outcomes of the three-ligament tenodesis and the anatomical front and back reconstruction. All patients who underwent reconstruction of their scapholunate interosseous ligament at one institution with either anatomical front and back reconstruction or three-ligament tenodesis between 2011 and 2020 were retrospectively reviewed. At 52-week follow-up, anatomical front and back reconstruction maintained a statistically significant improvement in scapholunate gap, corrected radiolunate angle and dorsal scaphoid translation, while three-ligament tenodesis demonstrated no sustained improvement in any parameter. The improvement in dorsal scaphoid translation was significantly greater for patients undergoing anatomical front and back reconstruction compared with three-ligament tenodesis at the 16-weeks postoperative timepoint (-1.0 mm, -0.3 mm). Anatomical front and back reconstruction demonstrates sustained improvement in radiographic outcomes at 1 year when compared with three-ligament tenodesis. By addressing both volar and dorsal critical ligament restraints, adoption of anatomical front and back reconstruction for advanced stage scapholunate interosseous ligament injuries should be considered.Level of evidence: IV.

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 Novel Technique of Arthroscopic-Assisted Four-Corner Fusion and Robot-Assisted Fixation for Scaphoid Nonunion Advanced Collapse Wrist: A Single Case Study.

OBJECTIVE: Scaphoid nonunion advanced collapse (SNAC) is a relatively common and debilitating wrist disorder yet its treatment remains challenging and controversial. We aim to describe a novel technique of a dual arthroscopic and robotic assisted four-corner fusion (4CF) in the treatment of SNAC wrist. METHODS: In this study, we describe an original arthroscopic and robotic assisted 4CF, which is novel and currently unpublished in literature. The surgical approach included these predefined steps: arthroscopic resection of the scaphoid, radial styloid and of diseased cartilage between the capitate-lunate joint and triquetrum-hamate joint, correction of Dorsal Intercalated Segment Instability (DISI) deformity of the wrist and robotic assisted 4CF performed percutaneously with screws. Dynamic fluoroscopic imaging with the mini C-arm was performed five times and the 3D scanning machine was used once. RESULTS: Our patient with SNAC II wrist was 57 years old at the time of initial presentation with a history of untreated traumatic wrist injury approximately 20 years ago. Regular wrist X-rays were performed at the outpatient setting and a computed tomography (CT) of the wrist was performed at the third postoperative month to confirm bony union. The patient's wrist range of motion (ROM), grip strength, Visual Analog Scale (VAS) score, Quick Disabilities of Arm, Shoulder, and Hand (QuickDASH) score, Modified Mayo Wrist Score (MMWS), and Patient Rated Wrist Evaluation (PRWE) were also evaluated during short-term follow-up at 6 months. During the patient's review at 6 months, his VAS score was 0 with complete pain relief. His wrist flexion was 20° and wrist extension at 45°. His pronation-supination was normal and comparable to his uninjured contralateral wrist. His operated wrist which was also his dominant hand had a grip strength of 22 kg as compared with 28 kg of the unaffected hand. He also had a Mayo Wrist Score of 85, QuickDASH score of 2.3 and PRWE of 6, and resumed his occupation as a clerk at 3 months. CONCLUSIONS: This dual arthroscopic and robotic assisted 4CF is a novel surgical method worth considering in the treatment of SNAC II wrists. It is minimally invasive and allows for accurate placement of the screws in a single attempt. There was bony union by the third postoperative month as confirmed by CT imaging and excellent resolution of symptoms.

Osteolysis After Augmented Scapholunate Ligament Reconstruction: A Report of 3 Cases.

CASE: Augmented scapholunate ligament reconstruction using polyether ether ketone anchors and ultra-high molecular weight polyethylene synthetic tape has the theoretical advantage of improved stability, avoidance of K-wire fixation, and the potential for earlier mobilization. We present 3 cases of scaphoid and lunate osteolysis/fragmentation, operative and histologic findings at reoperation, and the sequelae of this technique. CONCLUSION: If planning to use suture anchors and synthetic tapes in small carpal bones, we recommend advising patients about the risk of osteolysis and monitoring closely patients who complain of pain with motion after surgery.

Clinical outcomes in patients with scaphoid non-union treated with the vascularized medial femoral condyle technique a case series.

INTRODUCTION: Non-union is a prevalent complication of scaphoid fractures. Late diagnosis is common and has a clinical impact due to functional limitations for the patient. Multiple treatments have been proposed to manage this complication, ranging from conservative (i.e., orthopedic) to surgical treatment. The vascularized medial femoral condyle technique has shown satisfactory clinical and paraclinical results, mainly in presence of avascular necrosis of the proximal pole but data regarding functional outcomes and patient satisfaction is scarce. This case series aims to describe the clinical and patient-reported outcomes in a consecutive series of patients with non-union of the proximal third of the scaphoid treated with vascularized medial femoral condyle technique. METHODS: Case series reporting results for a consecutive - initial cohort of patients who presented with a non united fracture of the proximal pole of the scaphoid, avascular necrosis of the proximal pole was documented by CT od MRI imaging preoperatively in all patients. Measurement instruments include the q-DASH and PRWE questionnaires, radiographic images, goniometry, and assessment of grip strength. RESULTS: Twelve consecutive patients are included and they represent the initial cases for all surgeons involved; bone union was obtained in 10 patients (83%) after a mean follow-up time of 31 months (6-72), successful improvement in the range of motion and grip strength was documented. A high rate of satisfaction expressed by the patient was obtained, with an average score in Q-DASH of 17.3 and 20.1 in PRWE. CONCLUSIONS: The vascularized medial condyle technique in cases of nonunion of scaphoid fracture is a reproducible treatment in clinical terms, both in imaging and functional terms, and in patient satisfaction. The learning curve is flat for a dedicated multi surgeon team.

Standard views do not suffice in assessing distal scaphoid articular cannulated screw penetration.

BACKGROUND: Articular screw penetration is one of the most common hardware-related problems after scaphoid fracture fixation, occurring in up to two-thirds of patients, in particular into the scaphotrapezotrapezoidal (STT) joint. The aim of this study was to investigate whether this clinically important issue could be detected using standard anteroposterior (AP) and lateral, as well as additional nonstandard fluoroscopic views using direct open visualization with magnifying loupes as reference standard. MATERIALS AND METHODS: Ten fresh cadaver wrists were used for this imaging study. A 2.2 mm cannulated compression screws with a length of 24 mm was placed in the scaphoid and incrementally left to protrude at the STT joint up to 2 mm. Eight fluoroscopic views of the wrist were then obtained by rotating the forearm using goniometric measurements, keeping the image beam parallel to the floor: (1) anteroposterior with the wrist in neutral rotation, (2) anteroposterior with the wrist in ulnar deviation, (3) supinated oblique 60° from neutral (60° supinated oblique), (4) supinated oblique 45° from neutral (45° supinated oblique), (5) a true lateral, (6) a true lateral with the wrist in radial deviation, (7) pronated oblique 45° from neutral (45° pronated oblique), and (8) a pronated oblique 60° from neutral (60° pronated oblique). RESULTS: Standard anteroposterior and lateral fluoroscopy views (radiographically calibrated) of a percutaneous cannulated screw fixation of a scaphoid fracture were insufficient to detect distal articular penetration, missing half the amount of screw penetrations in the current study. The 45° pronated oblique view was found as the most sensitive in detecting STT penetration (p < 0.0001). CONCLUSIONS: Standard anteroposterior and lateral fluoroscopy views of a percutaneous cannulated screw fixation of a scaphoid waist fracture are insufficient to detect STT screw penetration. According to the current study, standard views would have missed half the amount of screw penetrations, which seems to reflect the high incidence of this problem in current practice. The most sensitive view was the 45° pronated oblique view, which detected STT screw penetration in all cases. Level of Evidence Not applicable.

Postoperative scaphoid alignment, smoking, and avascular necrosis mostly influence union rate after scaphoid reconstruction: Results from a retrospective single center study involving 370 patients.

Current literature does not definitely demonstrate the superiority of any particular scaphoid reconstruction method. The primary goal of this retrospective single center study was to evaluate the influence of reconstruction techniques and other factors on the union rate after reconstruction of scaphoid nonunions. In the study, 370 patients with nonunions classified as stable (Mayo 1) or unstable (Mayo 2) depending on carpal alignment were included. Minimal radiological follow-up was 3 months. Bone healing after scaphoid reconstruction was evaluated using computer tomography scans in 294 and radiograms in 76 patients. Univariate and multivariate logistic regressions were applied in the analysis. Eight statistically significant factors that influenced the union rate were fixation method, type of previous operations, number of all operations, number of reconstructions, smoking, postoperative pathological lateral intrascaphoid angle (LISA>45°), avascular necrosis (AVN), and stability of nonunion. Smoking and postoperative LISA>45° significantly reduced the probability of bone fusion by approximately 4.4 and 9.5 times, respectively. Patients with reduced vascularity in the nonunion site had a 5.2 times lower chance of bone fusion. Our multivariate logistic regression model can explain 32% of failures after scaphoid reconstruction, including postoperative LISA>45°, patients' present record of smoking, and reduced vascularity in the nonunion site. However, bone graft type does not impact the union rate in general; however, in case of AVN, the tendency toward higher union rates was observed for medial femoral condyle free flaps when compared to other types of graft (non-vascularized and pedicled bone grafts considered as one group, p = 0.09).