Osteosynthesis of a scaphoid neck fracture with a cannulated compression screw: evaluation of 52 patients / Osteossíntese de fratura no colo do escafoide com parafuso canulado de compressão: avaliação de 52 pacientes

ABSTRACT Objective: To evaluate the effectiveness of the dorsal fixation technique with a cannulated compression screw (CCS) for transverse scaphoid neck fractures. Methods: A case series study was carried out with patients treated with a CSS between April 2014 and May 2021. The main outcome was the healing of the fracture, verified by radiographic evaluation that used images of the wrist in anteroposterior, lateral, radial deviation, ulnar deviation and oblique views, obtained in the postoperative period. Results: Fifty-two patients aged between 15 and 65 years were analyzed, of which 43 (83%) were male. Of the 52 patients, 19 (36.53%) had a right-hand injury and 33 (63.46%) had a left-hand injury. Results were excellent in 47 patients (90.38%); good in 4 patients (7.69%), with reduced mobility compared to contralateral and poor in 1 patient (1.92%), with failure of consolidation and breakage of the synthesis material. In 51 cases (99%) there was bone consolidation at the end of six months. Conclusion: Osteosynthesis with a cannulated compression screw is a safe, effective and promising method for the treatment of scaphoid neck fractures. Level of Evidence IV, Case Series.

RESUMO Objetivo: Avaliar a eficácia da técnica de fixação dorsal com parafuso canulado de compressão (CCS) para fraturas transversas do colo do escafoide. Métodos: Foi realizado um estudo de série de casos com pacientes tratados com CSS entre abril de 2014 e maio de 2021. O desfecho principal foi a consolidação da fratura, verificada por meio da avaliação radiográfica das imagens do punho em anteroposterior, perfil, desvio radial, desvio ulnar e oblíquo obtidas no pós-operatório. Resultados: Foram analisados 52 pacientes com idade entre 15 e 65 anos, sendo 43 (83%) do sexo masculino. Dos 52 pacientes, 19 (36,53%) tinham lesão na mão direita e 33(63,46%) na mão esquerda. Os resultados foram excelentes em 47 dos pacientes (90,38%); bons em quatro (7,69%), com mobilidade reduzida comparada ao membro contralateral; e ruim em um (1,92%), com falha da consolidação e quebra do material de síntese. Em 51 casos (99%) houve consolidação óssea ao final de seis meses. Conclusão: A osteossíntese com parafuso canulado de compressão é um método seguro, eficaz e promissor para o tratamento das fraturas no colo do escafoide. Nível de Evidência IV, Série de Casos.

Treatment of acute non-displaced scaphoid fracture of wrist with syringe needle-guided percutaneous cannulated headless hollow compression screw internal fixation / 中国骨伤

OBJECTIVE@#To investigate the clinical efficacy of needle-guided percutaneous cannulated compression screw fixation in the treatment of acute non-displaced scaphoid fracture of wrist.@*METHODS@#The clinic data of twenty-eight patients with acute non-displaced scaphoid fracture from January 2014 to January 2019 were analyzed retrospectively. According to the intraoperative method of placement of cannulated screw, they were divided into Guide group(16 patients)and Conventional group(12 patients). There were 13 males and 3 females in Guide group, aged from 20 to 60 years old with an average of(31.42±9.71)years old;5 patients were classified as type A2, 3 patients were classified as type B1 and 8 patients were classified as type B2 according to Herbert classification;they were treated with percutaneous cannulated compression screw fixation under the guidance of needle. There were 11 males and 1 female in Conventional group, aged from 23 to 61 years old with an average of(30.51±7.52)years old;5 patients were classified as type A2, 2 patients were classified as type B1 and 5 patients were classified as type B2 according to Herbert classification;they were treated with conventional percutaneous cannulated compression screw fixation. The operation time, screw angle relative to the longitudinal axis of the scaphoid and wrist function score were assessed and compared between the two groups.@*RESULTS@#A total of 28 patients were followed up from 20 to 45 months with an average of (33.00±8.72) months. None of patients had intraoperative complication and incision infection. These patients returned to work gradually 2 weeks after operation, and all fractures healed within 12 weeks. The operation time in the Guide group was significantly less than that in the Conventinal group(P<0.05). Screw angle relative to the longitudinal axis of the scaphoid in the Guide group was significantly smaller than that in the Conventional group(P<0.05). There was no significant difference in Mayo wrist function scores at the last follow-up between the two groups(P>0.05). During the follow-up period, none of the 28 patients showed internal fixation displacement, arthritis, scaphoid necrosis and other complications.@*CONCLUSION@#In the treatment of acute non-displaced scaphoid fractures, the operation time of needle-guided percutaneous cannulated headless compression screw fixation is significantly shorter than that of conventional percutaneous screw fixation, and the screw axis is easier to be parallel to the longitudinal axis of the scaphoid.

Arthroscopic treatment of scaphoid fracture nonunion with bone graft and Kirschner wire combined with screw fixation / 中国修复重建外科杂志

OBJECTIVE@#To explore the effectiveness of arthroscopic treatment of scaphoid fracture nonunion with bone graft and Kirschner wire combined with screw fixation.@*METHODS@#The clinical data of 14 patients with scaphoid fracture nonunion who met the selection criteria between February 2021 and September 2022 were retrospectively analyzed. There were 13 males and 1 female with an average age of 32 years ranging from 17 to 54 years. The time from injury to operation ranged from 6 to 15 months, with an average of 9.6 months. According to the Slade-Geissler classification of scaphoid fracture nonunion, there were 3 cases of grade Ⅲ, 8 cases of grade Ⅳ, and 3 cases of grade Ⅴ. The preoperative visual analogue scale (VAS) score was 5.9±1.0, and the modified Mayo wrist score was 53.2±9.1. There were 2 cases of scaphoid nonunion advanced collapse, both of which were stage Ⅰ. All patients were treated with arthroscopic bone graft and Kirschner wire combined with screw fixation, and the fracture healing was observed by X-ray film monthly after operation, and the effectiveness was evaluated by VAS score and modified Mayo wrist score before and after operation.@*RESULTS@#All patients were followed up 6-14 months, with an average of 8.4 months. All fractures healed in 4-8 months, with an average of 6.3 months. The postoperative pain symptoms and wrist function of the patients significantly improved when compared with those before operation, and the VAS score at last follow-up was 2.4±1.3, and the modified Mayo wrist score was 87.1±6.7, which were significantly different from those before operation ( t=12.851, P<0.001; t=-14.410, P<0.001). According to the modified Mayo wrist evaluation, 9 cases were excellent, 3 cases were good, and 2 cases were fair.@*CONCLUSION@#Arthroscopic bone graft and Kirschner wire combined with screw fixation is an effective surgical method for the treatment of scaphoid fracture nonunion.

WALANT Technique in Percutaneous Scaphoid Osteosynthesis / WALANT na osteossíntese percutânea do escafoide

Abstract Scaphoid fractures account for 50 to 70% of all carpal bone fractures. Percutaneous scaphoid osteosynthesis can use the dorsal or volar approach, both with good results, and is most commonly performed under general anesthesia or regional nerve block. The wide-awake local anesthesia no tourniquet (WALANT) technique is already considered a safe and cost-effective technique in hand surgery around the world. Local anesthesia with epinephrine causes vasoconstriction, which obviates the need for tourniquet and, consequently, the need to use patient sedation. Thus, the possibility of testing fixation stability under physiological forces is another great advantage of using local anesthesia. In the technique described in the present paper, active wrist and hand motion can be tested immediately after scaphoid fixation. Wide-awake local anesthesia no tourniquet has been increasingly used in soft-tissue hand surgery and in the fixation of metacarpal and phalangeal fractures. However, to date, there is no published literature addressing the use of this technique in percutaneous scaphoid osteosynthesis. The purpose of the present technical note is to describe the use of WALANT for both the dorsal and volar approaches in percutaneous scaphoid osteosynthesis.

Resumo As fraturas do escafoide representam entre 50 e 70% de todas as fraturas dos ossos do carpo. A osteossíntese percutânea do escafoide pode usar a abordagem dorsal ou volar, ambas com bons resultados. É mais comumente realizada sob anestesia geral ou bloqueio nervoso regional. A técnica de anestesia local com o paciente totalmente acordado e sem torniquete (WALANT, na sigla em inglês) já é considerada uma técnica segura e eficaz na cirurgia da mão. A anestesia local com epinefrina causa vasoconstrição, o que evita o uso de torniquete e, consequentemente, a necessidade de sedação do paciente. Assim, a possibilidade de testar a estabilidade da fixação sob forças fisiológicas é outra grande vantagem do uso da anestesia local. Na técnica descrita aqui, o movimento ativo do punho e da mão pode ser testado imediatamente após a fixação escafoide. A técnica WALANT tem sido cada vez mais utilizada na cirurgia da mão em partes moles e na fixação de fraturas de metacarpo e falanges. No entanto, até o momento, não há literatura publicada abordando o uso dessa técnica na osteossíntese percutânea do escafoide. O objetivo desta nota técnica é descrever o uso de WALANT tanto para a abordagem dorsal quanto volar na osteossíntese percutânea do escafoide.

Tratamiento de no unión de fractura de escafoides con tornillos canulados sin cabeza e injerto autólogo esponjoso de radio distal / Treatment for non-union scaphoid fractures with headless cannulated screws and distal radius cancellous autograft

Resumen: Introducción: las fracturas de escafoides representan 50-80% de las fracturas de los huesos del carpo. De las fracturas de escafoides 10% evolucionan a no unión con tratamiento conservador y presentan cambios degenerativos en el carpo en 75-97% a cinco años y en 100% a 10 años. El objetivo de este trabajo fue evaluar la tasa y tiempo de consolidación en pacientes con diagnóstico de no unión de fractura de escafoides, sin fragmentación del polo proximal, tras tratamiento con dos tornillos canulados sin cabeza e injerto autólogo esponjoso de radio distal. Material y métodos: serie de casos de cuatro pacientes con diagnóstico de no unión de fractura de escafoides sin fragmentación del polo proximal, tratados mediante reducción abierta y fijación interna utilizando dos tornillos canulados sin cabeza y toma más aplicación de autoinjerto esponjoso de radio distal. Todos recibieron el mismo tratamiento postoperatorio y se tomó control radiográfico para evidenciar consolidación una vez que el paciente experimentó resolución clínica. Resultados: la tasa de consolidación radiográfica fue de 100% con un tiempo de consolidación promedio de 11.25 ± 3.4 semanas. No presentaron complicaciones y no fue necesaria una cirugía de revisión. Conclusión: el resultado del uso de dos tornillos canulados sin cabeza y toma más aplicación de autoinjerto óseo esponjoso de radio distal avala la técnica como una opción efectiva y segura para el tratamiento de no unión de fracturas de escafoides sin fragmentación del polo proximal.

Abstract: Introduction: scaphoid fractures comprise 50-80% of the fractures of the carpal bones. Ten percent of the scaphoid fractures evolve to non-union and show degenerative changes in the carpus in 75-97% at five years and in 100% at 10 years. The objective of this work was to evaluate the rate and time to union in patients with diagnosis of scaphoid non-union without fragmentation of the proximal pole after treatment with two cannulated headless screws and distal radius cancellous autograft. Material and methods: case series with short-term follow-up of four patients with scaphoid non-union without fragmentation of the proximal pole treated by internal fixation using two cannulated headless screws and distal radius cancellous bone autograft. All received the same postoperative treatment and radiographic control was taken as soon as the patient experienced clinical resolution. Results: the radiographic union rate was 100% with an average time to union of 11.25 ± 3.4 weeks. There were no complications and revision surgery was not necessary. Conclusion: the results of the use of two cannulated headless screws and distal radius cancellous bone autograft endorses the technique as an effective and safe option for the treatment of scaphoid non-union without fragmentation of the proximal pole.

Percutaneous Grafting and Screw Fixation in Patients with Scaphoid Nonunion / Enxerto percutâneo e fixação de parafusos em pacientes com não consolidação do escafoide

Abstract Objective The aim of the present study was to analyze the clinical and radiological results of patients with type-V cystic scaphoid nonunion who were treated with percutaneous grafting and screw. Methods A total of 11 patients were treated with a percutaneous bone graft with screw fixation. The criteria for inclusion in the study were a type-V scaphoid nonunion and age > 18 years old. Those with humpback deformity, arthritis, ligament damage determined on magnetic resonance imaging, or avascular necrosis (AVN) in the nonunion fragment were excluded from the study. Results The mean follow-up time was 36 months (range: 15-53 months). At the final follow-up examination, the mean visual analogue scale score was 1.06 (range: 0-2.3). Postoperatively, the mean extension was 61.6° (44-80°), flexion 66° (60-80°), radial deviation 12° (7-20°), and ulnar deviation 25° (20-34°). The mean grip strength of the operated hand was found to be 94%, compared with the healthy side. The results obtained in the Mayo Modified Wrist Score were poor in 2 patients, good in 2 and excellent in 7 (64%). With the exception of 2 patients, union was obtained radiologically in 9 patients, with a mean of 12.6 weeks (range, 8-16 weeks). Conclusion Percutaneous grafting and screw fixation cannot replace open surgery in cases with deformity, shortening, humpbacking, or in long term nonunions; however, it is a reliable and effective treatment method in selected cases, such as Slade & Dodds type-V cystic nonunion.

Resumo Objetivo O objetivo do presente estudo foi analisar os resultados clínicos e radiológicos de pacientes com não consolidação do escafoide que foram tratados com enxerto percutâneo e parafuso. Métodos Um total de 11 pacientes foram tratados com enxerto ósseo percutâneo com fixação de parafuso. Os critérios de inclusão no estudo foram não consolidação do escafoide do tipo 5 e idade > 18 anos. Foram excluídos do estudo aqueles com deformidade corcunda, artrite, dano ligamentar determinado por ressonância magné- tica ou necrose avascular (NAV) no fragmento de não consolidação. Resultados O tempo médio de seguimento foi de 36 meses (intervalo: 15-53 meses). No exame final de seguimento, o escore médio de escala visual analógica foi de 1,06 (intervalo: 0-2,3). No pós-operatório, a extensão média foi de 61,6° (44-80°), flexão 66° (60-80°), desvio radial 12° (7--20°) e desvio ulnar 25° (20-34°). A força média de aderência da mão operada foi de 94% em comparação com o lado saudável. Os resultados obtidos no Mayo Modified Wrist Score foram ruins em 2 pacientes, bons em 2 e excelentes em 7 (64%). Com exceção de 2 pacientes, a consolidação foi confirmada radiologicamente em 9 pacientes com média de 12,6 semanas (intervalo: 8-16 semanas). Conclusão Enxerto percutâneoe fixação de parafusos não podem substituir a cirurgia aberta em casos de deformidade, encurtamento ou acorcundamento ou em não consolidação a longo prazo; no entanto, é um método de tratamento confiável e eficaz em casos selecionados, tais como a não consolidação do tipo V de Slade e Dodds.

The functional outcomes of scaphoid nonunion with deformity treated with anterior wedge bone grafting: A case series

INTRODUCTION@#Scaphoid nonunion is one of the most difficult fractures to treat. Restoration of carpal alignment and fracture stability can provide good outcomes in the management of scaphoid nonunion.@*OBJECTIVE@#The purpose of this study was to determine the functional outcomes of scaphoid nonunion associated with humpback deformity treated with anterior wedge bone grafting and internal fixation.@*METHODS@#A retrospective review of all patients with scaphoid nonunion treated with anterior wedge bone grafting from January 1, 2014 to December 31, 2019 was done. Outcome measurements were time to union, pre- and postoperative FIL-DASH scores, grip, pinch, and scapholunate angle improvement. The other outcome measures were pain and complications.@*RESULTS@#A total of 12 patients were included in the study. All were males with an average age of 27.4 years (SD, 9.6). The average delay to surgery was 9.5 months (SD, 10). All fractures were at the waist, except for three proximal pole fractures, none had established avascular necrosis. Eleven out of 12 scaphoids healed at an average of 11.5 weeks (SD, 3.2). There was a significant improvement in the FIL-DASH score and scapholunate angle after surgical reconstruction. Grip strength averaged 83% of the contralateral side. All returned to previous normal activities. One patient with persistent proximal pole nonunion was managed with a 4-corner arthrodesis.@*CONCLUSION@#Anterior wedge bone grafting for scaphoid nonunion restored the scapholunate angle and was able to establish union in 11 of 12 scaphoid nonunions with good outcomes.

Treatment of Chondral Knee Lesions with Autologous Chondrocytes Embedded in a Fibrin Scaffold. Clinical and Functional Assessment / Tratamento de lesões condrais no joelho com condrócitos autólogos embebidos em arcabouço de fibrina. Avaliação clínica e funcional

Abstract Objective The aim of our study is to analyze the clinical and functional results obtained using autologous chondrocytes embedded in a fibrin scaffold in knee joint injuries. Methods We included 56 patients, 36 men and 20 women, with a mean age 36 years. Six of the patients were professional athletes, with single knee injuries that were either chondral or osteochondral (43 chondral, 9 osteochondral, 2 cases of osteochondritis dissecans and 2 osteochondral fractures), 2 to 10 cm2 in size and ≤ 10 mm deep, with no signs of osteoarthritis. The location of the injury was in the patella (8), the medial femoral condyle (40) and lateral femoral condyle (7) and one in the trochlea. The mean follow-up was 3 (range: 1-6) years. The clinical course was assessed using the Cincinnati and Knee Injury and Osteoarthritis Outcome (KOOS) scores, 6 and 12 months after surgery. The paired Student t-test was used to compare pre-and postoperative results. Results Six months after the implant, patients resumed their everyday activities. On the assessment scores, their condition was improving in comparison with their presurgical state (p < 0.05). They were also able to carry out their sporting activities more easily than prior to surgery (p < 0.05). Conclusion The seeding of chondrocytes in fibrin may provide a favorable microenvironment for the synthesis of extracellular matrix and improved the clinical condition and activity of the patients 1 year after surgery.

Resumo Objetivo O objetivo do nosso estudo é analisar os resultados clínicos e funcionais do tratamento de lesões nas articulações do joelho com condrócitos autólogos embebidos em arcabouço de fibrina. Métodos O estudo foi realizado com 56 pacientes (36 homens e 20 mulheres) com idade média de 36 anos; 6 indivíduos eram atletas profissionais. Os pacientes apresentavam lesões únicas, condrais ou osteocondrais (43 condrais, nove osteocondrais, 2 casos de osteocondrite dissecante e duas fraturas osteocondrais) no joelho, com 2 a 10 cm2 de tamanho e ≤ 10 mm de profundidade, sem sinais de osteoartrite. As lesões estavam localizadas na patela (8), no côndilo femoral medial (40), no côndilo femoral lateral (7) e na tróclea (1). O período médio de acompanhamento foi de 3 anos (faixa de 1-6 anos). A evolução clínica foi avaliada pelos escores de Cincinnati e Knee Injury and Osteoarthritis Outcome (KOOS), 6 e 12 meses após a cirurgia. O teste t de Student pareado foi utilizado para comparação dos achados pré e pós-operatórios. Resultados Os pacientes retomaram suas atividades diárias 6 meses após o implante. Os escores avaliados demonstraram a melhora em comparação ao estado pré-cirúrgico (p < 0,05). Além disso, os pacientes conseguiram realizar suas atividades esportivas com mais facilidade do que antes da cirurgia (p < 0,05). Conclusão A cultura de condrócitos em fibrina pode proporcionar um microambiente favorável para a síntese de matriz extracelular e melhorar a condição clínica e a atividade dos pacientes 1 ano após a cirurgia

Detección de tornillos prominentes en la articulación radiocarpiana mediante la proyección tangencial del escafoides dorsal / Detection of protruding screws in the radiocarpal joint using the "scaphoid skyline view"

INTRODUCCIÓN: Una de las complicaciones de la osteosíntesis retrógrada del escafoides es la protrusión del tornillo en la articulación radiocarpiana, dada la limitada visualización intraoperatoria del polo proximal del escafoides con las proyecciones tradicionales. OBJETIVO: Evaluar la capacidad de una nueva proyección radiológica, la proyección "tangencial del escafoides dorsal", o TED, para identificar tornillos prominentes radiocarpianos durante la osteosíntesis retrógrada del escafoides con tornillos canulados. MATERIALES Y MÉTODOS: Estudio cadavérico en muñecas frescas congeladas. Se introdujo en el escafoides un tornillo canulado con técnica retrógrada estándar. La proyección TED fue evaluada en 5 muñecas, con angulaciones del antebrazo de 15°, 30° y 45° para definir la mejor visualización del polo proximal del escafoides y del tornillo. Se comparó la capacidad para identificar la prominencia del tornillo en el polo proximal de la proyección TED de 30° con 5 proyecciones tradicionales de escafoides en 9 muñecas. El tornillo se posicionó a nivel de la superficie del escafoides, y luego se avanzó a intervalos de 0,5 mm bajo visualización directa por artrotomía dorsal. Tras cada intervalo, se repitieron todas las proyecciones para determinar su capacidad de detectar tornillos prominentes en el escafoides. RESULTADOS: La mejor visualización del polo proximal del escafoides se logró con la proyección TED de 30°. Al comparar la proyección TED de 30° y las tradicionales, con la TED se logró identificar tornillos prominentes a 0,8 mm promedio, seguida por la proyección posteroanterior con cubitalización y extensión a 1.3 mm (p » 0.014), con una alta precisión y correlación interobservador de estas proyecciones. CONCLUSIÓN: La proyección TED demostró ser la más sensible para detectar tornillos prominentes en la articulación radiocarpiana. Su uso rutinario podría evitar complicaciones durante la osteosíntesis.

INTRODUCTION: One of the complications of the retrograde percutaneous scaphoid fixation is the protrusion of the screw in the radiocarpal joint due to the limited intraoperative visualization of the proximal pole of the scaphoid with the traditional radiographic views. OBJETIVE: To evaluate the sensitivity of a novel radiographic view (the skyline scaphoid view, SSV) to detect screws protruding in the radiocarpal joint during the retrograde fixation of the scaphoid. MATERIALS AND METHODS: We studied nine cadaverous fresh frozen wrists. A retrograde cannulated screw was inserted in the scaphoid. To validate the SSV, 5 wrists were studied, comparing 3 forearm angulations (15°, 30° and 45°) to get the best visualization of the proximal pole and screw. We compared the ability to identify the protrusion of the screw in the proximal pole of the 30° SSV with that of 5 standard scaphoid radiographic views in 9 wrists. The screw was positioned at the level of the surface of the scaphoid, and was sequentially protruded in 0.5 mm increments, with direct visualization of its tip through a dorsal capsulotomy. After each increment, all views were repeated to determine if they were able to detect screws projecting from the scaphoid. RESULTS: The best visualization of the proximal pole of the scaphoid was found with the 30° SSV. In the comparison of the 30° SSV and the standard views, with the SSV we were able to identify the protrusion of the screws at an average of 0.8 mm, followed by the posterior-anterior view with ulnar deviation and extension at 1.3 mm (p » 0.014), with high precision and interobserver agreement regarding these views. CONCLUSION: The SSV was the most sensitive view to detect protruding screws in the proximal pole of the scaphoid. Its routine use could avoid complications during osteosynthesis.

Treatment of fresh undisplaced scaphoid lumbar fractures with robotic navigation and percutaneous internal fixation / 中华创伤骨科杂志

Objective:To investigate the clinical efficacy of robotic navigation and percutaneous internal fixation in the treatment of fresh undisplaced scaphoid lumbar fractures.Methods:From November 2019 to October 2020, 8 patients were treated at Department of Hand Surgery, Xuzhou Renci Hospital for fresh undisplaced scaphoid lumbar fractures. There were 7 males and one female with an average age of 27.5 years (from 18 to 42 years), and 5 left and 3 right cases. Navigation by a Tianji orthopedic robot was conducted to decide the positions for implantation of percutaneous Herbert screws to fixate the fractures. The bone healing was followed up by regular X-ray and CT examinations. The functional recovery was evaluated by Mayo wrist score, grip strength, pinch strength and wrist range of motion, and the wrist pain was evaluated by visual analogue scale (VAS).Results:All the 8 patients were followed up for a mean time of 12.8 months (from 6 to 19 months). All the wounds healed by the first intention without any inflammation or infection. CT examination at 3 months postoperation found that all the fracture ends got united. At the final follow-up, the average active motions of the injured wrist were: 67.9° in flexion, 64.1° in extension, 21.2° in radial deviation and 52.2° in unlar deviation, respectively. The average grip strength was recovered to 31.3 kg, reaching up to 85.2% (from 66.7% to 100.0%) of the contralateral wrist; the average pinch force was recovered to 19.5 kg, reaching up to 89.3% (from 77.8% to 100.0%) of the contralateral wrist. At the last follow-up, the Mayo wrist function scores averaged 97.5 (from 95 to 100) and all the 8 cases were excellent. The VAS pain score of the wrist averaged 0.88 (from 0 to 2).Conclusion:In the treatment of fresh undisplaced scaphoid lumbar fractures, navigation with a Tianji orthopedic robot can be used to visualize percutaneous minimally invasive screw fixation so that accurate positioning and precise screw placement are ensured, leading to rapid rehabilitation.

Transfer of vascular pedicled free medial femoral condyle bone flap in treatment of scaphoid nonunion / 中华显微外科杂志

Objective:To investigate the clinical effect of the free medial femoral condylar bone flap in treatment of scaphoid nonunion.Methods:From May, 2012 to May, 2016, 15 patients, which were 10 males and 5 females and aged from 18 to 63 (mean 43.5±15.5) years, with scaphoid nonunion were treated with transfer of free medial femoral condyle bone flaps. After debridement of the fractural segment in surgery, the bone flap was transferred to scaphoid and had the bone defect filled. The artery of the bone flap was end-to-side or end-to-end anastomosed to the radial artery. The concomitant vein of the bone flap was end-to-end anastomosed to the concomitant vein of the radial artery. Thirteen patients were treated with the free osteoperiosteal medial femoral condylar graft, and 2 were treated with the free osteochondral medial femoral condylar graft. Fracture healing was evaluated based on X-ray evidence. The clinical effect was evaluated by visual analogue scale (VAS), strength of grip and modified Mayo wrist score. The t-test was used to compare the function between before and after surgery. Results:All patients were entered into a followed-up for an average of 32.5 (8-60) months, 11 of them took the follow-up reviews at the outpatient clinic and 4 via WeChat distanced interviews. All fractures of the 15 patients healed with an average healing time at 12.5 (10-16) weeks. The VAS score decreased from (3.5±1.5) before the surgery to (1.0±1.0) after the surgery. The strength of grip increased from (16.5±4.3) kg before the surgery to (31.5±3.5) kg at the last follow-up review. The modified Mayo wrist score increased from (46.2 ±11.4) before the surgery to (68.5 ±10.8) at the last follow-up review. The wrist function was excellent in 8 patients, good in 6 and fair in 1. There was significant difference in functional evaluation ( P<0.05). Conclusion:The transfer of free medial femoral condylar bone flap is effective in the treatment of scaphoid nonunion. This technique provides both of sufficient blood supply and a structural support for defected scaphoid bone and promotes the healing of fracture. Osteochondral flap transfer may be used as an alternative measure to prevent wrist osteoarthritis and collapse, in the case that there is an avascular necrosis of the proximal pole of the scaphoid. It has an advantage in the treatment of refractory scaphoid nonunion.

Percutaneous Fixation without Bone Graft for Scaphoid Nonunion / Fixação percutânea sem enxerto ósseo para pseudartrose do escafóide

Abstract Objective To describe the clinical and radiographic outcomes of patients submitted to percutaneous fixation without bone graft for scaphoid nonunion, with a minimum follow-up of six months. Methods A case series study of a convenience sample of hand surgeons with prospective evaluation. Patients with scaphoid (waist or proximal pole) nonunion and the following features were included: more than six months of history; X-rays showing sclerosis of the edges of the nonunion, with resorption of the nonunion focus measuring less than 4 mm (Slade & Gleissler I, II, III and IV) and no angular deformity; and no proximal pole necrosis on magnetic resonance imaging (MRI). Results After six months of follow-up, all nonunion were consolidated, with no major complications. The functional outcomes revealed good scores on the disabilities of the arm, shoulder and hand (DASH; n = 12; mean: 6.9; standard deviation [SD]: 2.1) and patient-rated wrist evaluation (PRWE; n = 12; mean: 7.97, SD: 1.5) questionnaires. The results of the visual analog scale (VAS) showed little residual pain (n = 12; mean: 0.71; SD: 0.2). Slight decreases in flexion (69 versus 59.1; p = 0.007), extension (62.4 versus 48.7; p = 0.001) and radial deviation (29.6 versus 24.6; p = 0.014) were detected in comparison to the contralateral side. Conclusions All cases in the series presented consolidation and good functional scores at the six-month evaluation. This is a promising option (with lower technical demand and morbidity) for the treatment of scaphoid nonunion. Comparative studies are required to assess the effectiveness of this technique in comparison with other options.

Resumo Objetivo Descrever os resultados clínico-radiográficos de pacientes tratados por meio de fixação percutânea sem enxerto ósseo para pseudartrose do escafóide, com seguimento mínimo de seis meses. Métodos Série de casos de uma amostra de conveniência de grupo de cirurgiões de mão com avaliação prospectiva.. Foram incluídos pacientes com diagnóstico de pseudartrose do escafóide (cintura ou polo proximal) com as seguintes características: mais de seis meses de histórico; radiografias demonstrando esclerose das bordas da pseudartrose, com reabsorção do foco de pseudartrose menor do que 4 mm (Slade & Gleissler I, II, III e IV), sem deformidade angular; e sem necrose do polo proximal pela ressonância magnética (RM). Resultados Na avaliação com mais de seis meses, todas as pseudartroses estavam consolidadas e sem maiores complicações. Os resultados funcionais demonstraram boas pontuações nos questionários de disfunções do braço, ombro e mão (disabilities of the arm, shoulder and hand, DASH; n = 12; média: 6,9; desvio padrão [DP]: 2,1) e de avaliação do punho pelo paciente (patient-rated wrist evaluation, PRWE; n = 12; média: 7,97; DP: 1,5). Observou-se pouca dor residual de acordo com a escala visual analógica (EVA; n = 12; média: 0,71; DP: 0,2). Houve discreta diminuição da flexão (69 versus 59,1; p = 0,007), da extensão (62,4 versus 48,7; p = 0,001) e do desvio radial (29,6 versus 24.6; p = 0,014) em comparação ao lado contralateral. Conclusões Nesta série, todos os casos estavam consolidados ao sexto mês de avaliação, com bom status funcional. Trata-se de uma opção promissora (menor demanda técnica e morbidade) para o tratamento da pseudartrose do escafóide. Estudos comparativos serão úteis para avaliar a efetividade da técnica com relação a outras opções.

Pronator quadratus pedicled bone graft for scaphoid non-unions

Scaphoid fractures frequently present with nonunion and proximal pole necrosis, the treatment of which is bone grafting. Pronator quadratus pedicled vascularized bone graft is an option especially in the setting of proximal pole necrosis. We describe our experience of managing such scaphoid non-unions using pronator quadratus pedicled vascularized bone graft. Six patients were managed using pronator quadratus pedicled vascularized bone graft following scaphoid fracture nonunion with proximal pole necrosis. All patients had good fracture healing and symptom resolution. Mild deficit in wrist extension was noted in all patients. Pronator quadratus pedicled vascularized bone graft is an attractive option for managing scaphoid nonunion. Lying adjacent to the fracture site, bone can be harvested and transferred without making any other incisions. This procedure introduces another source of blood supply to the fracture site and hence improves fracture healing.

Correlation between Global Wrist Laxity and Movement of the Scaphoid and the Lunate in Various Places During Radio Ulnar Deviation of the Wrist

Introduction: In the intact wrist, three dimensional motionsof the carpal bones has been reported as a screw displacementaxis representation of the motion as the angular motion ofthe bones or as translations between the bones, however thelatter has frequently been quantified as a displacement in thedirection of the screw axis. Current research aimed to establishcorrelation between global wrist laxity and movement of thescaphoid and the lunate in various places during radio ulnardeviation of the wrist.Material and methods: The proposed study was a prospectivestudy conducted in the Department of Orthopedics, RMCH,Bareilly, UP, comprising 100 healthy volunteers with equal sexration who never had any symptoms pertaining to their wristjoint. An informed written consent was obtained. Standardposterolateral and true lateral radiograph of wrist were madeto exclude any radiological abnormality. PA and lateralradiograph were obtained in full radial and ulnar deviation.A custom-made positioning device was used to ensure properplacement of the hand and wrist during the examination.Results: We observed that the age varied from 21 years to 40years. Radial deviation varied from 10 to 25 degree with meanof 18.06 degree. Ulnar deviation varied from 25 to 60 degreewith mean of 36.51 degree. Laxity score varied from 31 to 100with mean of 64.20.Conclusion: Within the limitations of the present study,it can be concluded that the ulnar deviation of the wrist isseen to cause radial translation ad dorsal rotation of theproximal carpal row. Similarly, the radial deviation was seento cause ulnar translation and volar rotation of the proximalcarpal row.

Luxación palmar divergente del escafoides y semilunar: reporte de caso / Palmar divergent dislocation of the scaphoid and lunate: case report

Reportamos el caso de un hombre de 61 años de edad quien presentó una luxación palmar divergente del escafoides y semilunar de la muñeca derecha secundario a trauma por caída de una escalera en su casa, quien fue atendido a las 24 horas del accidente, se le realizó una resección de los dos huesos (desvascularizados completamente), y se redujo el hueso grande en la fosa semilunar del radio más reparación de la cápsula articular y los ligamentos palmares radiocarpales. Al control del primer año el resultado ha sido satisfactorio, con un buen desempeño de su actividad laboral, y con una congruencia de la articulacion radio hueso grande y estabilidad completa de la muñeca. Nivel de Evidencia: IV

We report the case of a 61-year-old man who presented a Palmar divergent dislocation of the scaphoid and lunate of the right wrist secondary to trauma due to the fall of a ladder in his house, who was seen 24hours after the accident, he underwent a resection of the two bones (completely devascularized), and the Capitate bone was reduced in the lunate fossa of the radius by adding a repair of the joint capsule and the radiocarpal palmar ligaments. After the first year of follow up the result has been broadly satisfactory, with good performance of his working activity, and with a congruence of the Radial-Capitate joint with complete stability of the wrist. Evidence Level: IV

The Effect of Intra-carpal Kirschner Wire Augmentation in Screw Fixation of Scaphoid – A Retrospective Cohort Study

@#Introduction: Scaphoid fractures are most often treated with a single headless compression screw. However, intercarpal Kirschner wire (K-wire) might be added to improve stability and fracture outcomes. This study will determine if there is a difference in treatment outcome (union rate and time to union) between scaphoid fracture fixations using a single headless compression screw with and without augmentation using a intracarpal intramedullary K-wire. Material and Methods: We conducted a retrospective review of patients who underwent surgery for isolated scaphoid fractures over a 15 years period from December 2000 to December 2015. Only patients who underwent open surgery with bone grafting were included. They were divided into a group treated with a single screw fixation, and another group treated with screw and K-wire fixations. Results: Forty-four (58.7%) patients had single screw fixation and 31 (41.3%) had screw augmented with K-wire fixation. The overall union rate was 88.0%, with an overall mean time to union of 5.3 months. There was no difference in union rate (p=0.84) and time to union (p=0.66) between the single screw group and combined screw and K-wire group. Univariate analysis found that older age (t=-2.11, p=0.04) had a significant effect on union rate. Regression model showed that age had a significant effect on months to union. Conclusion: In open fixation of scaphoid fractures with compression screw and bone grafting, union rate and time to union is comparable whether or not screw fixation was augmented with an intracarpal K-wire. There was no increased risk of complications associated with augmented screw. Age of patient affected time to union and union rate.

Nitinol memory alloy two foot fixator with autologous cancellous bone grafting for old scaphoid fracture and nonunion / 中国修复重建外科杂志

Objective: To summarize the effectiveness of nitinol memory alloy two foot fixator with autologous cancellous bone grafting in treating old scaphoid fracture and nonunion. Methods: Between January 2013 and January 2017, 11 patients of old scaphoid fracture and nonunion were treated with nitinol memory alloy two foot fixator and autologous cancellous bone grafting. All patients were male with an average age of 26.1 years (range, 18-42 years). The fractures were caused by sport in 3 cases, falling in 7 cases, and a crashing object in 1 case. The interval between injury and operation was 6-18 months (mean, 8.9 months). Postoperative outcome measures included operation time, fracture healing time, grip strength, range of motion (ROM) of flexion, extension, ulnar deviation, and radial deviation, Mayo score, visual analogue scale (VAS) score, and the Disabilities of the Arm, Shoulder, and Hand (DASH) score. Results: The operation time was 35-63 minutes (mean, 48 minutes). All incisions had primary healing with no infection and loosening or breakage of internal fixator. All patients were followed up 12-30 months (mean, 20.7 months). X-ray films showed that fracture healing was achieved in all patients with an average time of 15 weeks (range, 12-25 weeks). All internal fixators were removed after 10-12 months of operation (mean, 11.2 months). At last follow-up, the grip strength, ROMs of flexion, ulnar deviation, and radial deviation were superior to those before operation ( P<0.05), no significant difference was found in ROM of extension between pre- and post-operation ( t=0.229, P=0.824). There were significant differences in above indexes between affected and normal sides ( P<0.05). At last follow-up, the Mayo, VAS, DASH scores were also significantly superior to those before operation ( P<0.05). Conclusion: For the old scaphoid fracture and nonunion, Ni-Ti arched shape-memory alloy fixator and autologous cancellous bone grafting can obtain good effectiveness, which is an effective treatment.

Clinical application of nitinol memory alloy two foot fixator combined with Kirschner wire in treatment of trans-scaphoid perilunate dislocation / 中国修复重建外科杂志

Objective: To evaluate the effectiveness of nitinol memory alloy two foot fixator combined with Kirschner wire in the treatment of trans-scaphoid perilunate dislocation. Methods: Between September 2011 and October 2018, 17 patients with trans-scaphoid perilunate dislocation were treated with nitinol memory alloy two foot fixator and Kirschner wire. There were 12 males and 5 females, with an average age of 32.6 years (range, 23-52 years). The disease duration was 8 hours to 9 days, with an average of 6.5 days. The causes of injury included 6 cases of falling injury, 4 cases of traffic accident injury, 3 cases of stress injury of wrist caused by sports, 2 cases of violent injury of wrist caused by machine impact, 1 case of military training injury, and 1 case of other injury. One case was complicated with nerve injury. According to Herbert's classification, all the fractures were type B4. At 1 week before operation, 3 months, 6 months after operation and last follow-up, the wrist function was evaluated according to the Krimmer scale score. Results: All the 17 patients were followed up 10.5-48 months, with an average of 18.6 months. There was no loosening or infection of the internal fixator, no necrosis of the scaphoid and lunate. The periosteal dislocations of the patients were well reduced and the scaphoid fractures all healed. The healing time was 4-18 months, with an average of 11.3 months. The Krimmer wrist scores were 37.5±4.4, 61.3±7.2, 83.3±9.3, 87.3±8.2 at 1 week before operation, 3 months, 6 months after operation and last follow-up, respectively. The Krimmer wrist score at each time point after operation was significantly improved when compared with that before operation ( P0.05). At last follow-up, the Krimmer wrist function was excellent in 13 cases, good in 2 cases, fair in 1 case, poor in 1 case, and the excellent and good rate was 88.23%. Conclusion: Nitinol memory alloy two foot fixator combined with Kirschner wire in the treatment of trans-scaphoid periosteal dislocation has definite effectiveness, simple operation, and good recovery of wrist function after operation.

High resolution 3D intraosseous vascular model of the scaphoid bone reconstructed by micro CT / 解剖学报

[Abstract] Objective The purpose of this study is to construct a high-resolution model focusing on the vascular pattern of the scaphoid by using micro CT and to provide anatomical reference for the daily clinical use. Methods The lead-based contrast was perfused from the brachial artery and then the scaphoid bone was harvested. 3D models of the scaphoid bones were constructed by using micro CT to show how arteries distributed in and on the bones. Results The arteries on the surface stretched from the distal radius covered with scaphoid fossa to the radial side of the waist and then head back to the distal ulna along the dorsoradial ridge, formed like a letter “Ⅴ”. The arteries gathered at the inflection point of the letter “Ⅴ” and the dorsal region. The tubercle region was anastomosed extensively with 3 to 5 major intraosseous vessels originated from the extraosseous vessels covering the waist and the tubercle. There are only 1 to 2 major intraosseous vessels entering the bone via a long route from the ulnar side. The vessels running in the scapholunate ligament didn’t spilt into any intraosseous branches. Conclusion The superficial vascularity formes a “Ⅴ”-like pattern. The inflection point of the letter “Ⅴ” and the dorsal region display a dense vascularization and these vessels contributed a lot to the intraosseous vascularity.

Fractura metafisaria de radio distal asociada a una fractura de escafoides, en un adolescente de 14 años / Distal radius fracture combined with scaphoid fracture, in a 14-year-old teenager / Fratura metafisária do rádio distal associada a uma fratura escafóide em adolescente de 14 anos

La asociación entre fractura de radio distal y fractura de escafoides es una asociación infrecuente, en la presentación inicial, pasa inadvertida muchas veces la fractura a nivel de escafoides. El diagnóstico precoz nos permite un correcto tratamiento evitando posibles complicaciones en la evolución. Se presenta el caso de un adolescente de 14 años con dicha asociación lesional. Se le realizó reducción cerrada y fijación percutánea con alambres de Kirschner a nivel del radio distal y se trató la fractura de escafoides, de forma ortopédica, con yeso antebraquipalmar con inclusión del primer dedo. Se obtuvo la consolidación de ambos focos con excelentes resultados clínicos.

The association between distal radius fracture and scaphoid fracture is a rare association, in many cases the scaphoid fracture can be overlooked at the initial presentation. The early diagnosis allows a correct treatment avoiding possible complications in the follow-up. The case of a 14-year-old teenager with this association is presented. Closed reduction and percutaneous fixation was performed with Kirschner Wires at distal radius fracture, the scaphoid fracture was treated orthopedically with short-arm thumb spica cast. Consolidation of both fractures was obtained with excellent clinical results.

A associação entre fratura do rádio distal e fratura do escafoide é uma associação pouco freqüente; na apresentação inicial, a fratura do escafóide geralmente passa despercebida. O diagnóstico precoce nos permite um tratamento correto, evitando possíveis complicações na evolução. É apresentado o caso de um adolescente de 14 anos com essa associação lesional. Ele foi submetido a redução fechada e fixação percutânea com fios de Kirschner no raio distal, e a fratura do escafóide foi tratada ortopedicamente com um molde de antebraço incluindo o primeiro dedo. A consolidação de ambos os focos foi obtida com excelentes resultados clínicos.