A comparative study of volar locking-plate fixation with corticocancellous and pure cancellous bone grafts for scaphoid nonunion with dorsal intercalated segmental instability secondary to scaphoid humpback deformity.

INTRODUCTION: Bone grafts for scaphoid nonunion with deformity include cortcicocancellous or pure cancellous bone grafts. This study compared the outcomes between two types of bone grafts when employing a volar locking-plate in patients with scaphoid nonunion with dorsal intercalated segmental instability (DISI). PATIENTS AND METHODS: This retrospective study included 34 patients with scaphoid nonunion and DISI due to humpback deformity treated between March 2017 and January 2022. Two types of bone grafts were obtained from iliac crest. Twenty of the corticocancellous (CC) group underwent a wedge-shaped graft, while 14 patients of the pure cancellous (C-only) group received graft chips. In both groups, a 1.5-mm anatomically pre-contoured locking plate was used for fixation. Radiographic evaluations included the union rate and carpal alignment including scapholunate angle (SLA), radiolunate angle (RLA), intrascaphoid angle (ISA) and scaphoid height to length ratio (HLR). Clinical assessments encompassed wrist range-of-motion, grip strength, and patient-reported outcomes. RESULTS: Nineteen of the 20 patients in the CC group and 12 of the 14 patients in the C-only group respectively, achieving osseous union. The mean follow-up period in CC group was 14.7 (range, 12 ∼ 24) months and that in C-only group was 12.6 (range, 12 ∼ 15) months. Postoperatively, there were no significant intergroup differences of radiographic parameters including SLA (CC; 49.9° ± 6.7° vs. C-only; 48.9° ± 3.5°, P = 0.676), RLA (1.7° ± 6.4° vs. 2.4° ± 3.3°, P = 0.74), ISA (36° ± 7.5° vs. 36.6° ± 12.2°, P = 0.881), and HLR (0.54 ± 0.09 vs. 0.53 ± 0.05, P = 0.587). Clinical outcomes, including the flexion-extension arc (137° ± 30° vs. 158° ± 33°, P = 0.122), grip strength (93.4 % ± 15.4% vs. 99.5 % ± 16.7 %, P = 0.39), Quick Disabilities of the Arm, Shoulder, and Hand scores (11.2 ± 8.3 vs. 12.5 ± 7.7, P = 0.74) and Mayo Wrist Scores (81.2 ± 13.1 vs. 89 ± 11.4, P = 0.242) also showed no significant intergroup differences. CONCLUSIONS: Volar locking-plate fixation with pure cancellous bone grafts achieved outcomes comparable to those achieved with corticocancellous bone grafts in scaphoid nonunion with deformity, possibly due to the biomechanical advantages of the volar plate to provide structural supports.

Carpal Collapse After Scaphoid Nonunion: A Novel Combined Approach to the 1,2 Intercompartmental Supraretinacular Artery Radial Flap.

Purpose: Scaphoid nonunion remains a major problem in hand surgery. The 1,2 intercompartmental supraretinacular artery flap (1,2 ICSRA), as first described by Zaidemberg et al, is widely used with reported union rates of approximately 80%. However, its use is limited in the case of associated carpal collapse as in dorsal intercalated segmental instability (DISI) and humpback deformity. In this study, we present a novel approach to this flap enabling the correction of associated carpal collapse. Methods: Between 2006 and 2015, 9 patients with scaphoid nonunion or delayed union with carpal collapse were treated with a vascularized bone flap based on the 1,2 ICSRA using a combined volar and dorsal approach. Immobilization in a short-arm cast was applied for 8 weeks. Union rates, correction of DISI and humpback deformity, as well as clinical end points were noted. In addition, scapholunate (SL) angles were measured using 2 accepted radiological techniques, employing either the scaphoid midline axis or its proximal radiological landmarks as a reference. Results: All cases united and a median time to bone consolidation of 4 months (range, 2-5 months) was observed. Preoperative DISI deformities (n = 4) were corrected in all patients. Humpback deformities (n = 5) were also corrected. Two patients had repeat surgery: one for K-wire removal after bony consolidation and the other for neuropathic pain. Conclusions: The 1,2 ICSRA bone flap is a reliable treatment for scaphoid nonunion associated with carpal collapse. This combined volar and dorsal approach permits the correction of DISI and humpback deformity without compromising the scaphoid vascular supply, which eliminates the need to use free bone flaps from other sites. In this series, we observed a 100% union rate. Two patients required reoperation for symptomatic hardware and dorsal wrist pain linked to superficial neuritis. Type of study/level of evidence: Therapeutic IV.

Scaphoid specific volar locking plate and non-vascularised iliac crest bone graft in scaphoid non-union. A comparative cohort study.

Scaphoid non-union develops in 10% of scaphoid fractures. There is sparse literature on fixation methods other than screws. We compared union rates following fixation of scaphoid non-union using screw fixation and a novel method of plate fixation. Retrospective study. Union rates were assessed at 3 months post-operatively by a musculoskeletal radiologist. 15 patients underwent screw fixation and 15 underwent plate fixation. 86% union rate with screw fixation and 72% plate fixation united. There was no significant difference. Screw fixation and plate fixation in our institution both provide union rates that are consistent with the literature.

Closing Radial Wedge Osteotomy for Preiser Disease: Clinical Outcomes.

PURPOSE: To determine clinical outcomes of Preiser disease treated with closing radial wedge osteotomy (CRWO). METHODS: Seven patients with Preiser disease underwent CRWO. Two wrists had stage 2 disease, 3 had stage 3, 2 had stage 4 (Herbert-Lanzetta classification). Magnetic resonance imaging (MRI) showed that 4 wrists had stage 1 and 3 had stage 2 indicating complete and incomplete necrosis, respectively (Kalainov criteria), before surgery. Two wrists had concomitant Kienböck disease. The range of motion (ROM) of the wrists was restricted owing to pain, and median Modified Mayo Wrist Score (MMWS) was 15 points. Patients were followed after surgery with radiography, MRI, and clinical evaluation (ROM, grip strength, MMWS). Radiolunate and scapholunate angles were calculated on lateral radiographs. RESULTS: Although there were no usual postoperative complications (eg, infection, neuropathy, distal radius nonunion), 1 patient had an extensor pollicis longus tendon rupture, and another experienced osteoarthritis with deterioration of the distal radioulnar joint. Final follow-up radiography showed that 2 wrists were stage 3, 5 were stage 5 (Herbert-Lanzetta classification). At 1 year after surgery, T1-weighted MRI showed that 2 of 6 wrists had improved from stage 1 to stage 2 (Kalainov criteria). At the final evaluation, 5 wrists had no pain, and 2 had only mild pain. Compared with the contralateral wrist, the median ROM was 80% in extension, 73% in flexion. Median grip strength was 71%, median MMWS was 75 points, and clinical results were good in 1 patient, fair in 5, and poor in 1. CONCLUSIONS: Although follow-up radiography showed that the disease stage had progressed in 4 of 7 patients, wrist pain alleviation, retention of ROM, and improvement of grip strength were obtained. The CRWO may be an option for reducing wrist pain and retaining ROM of the wrist owing to Preiser disease. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Dorsal intercalated segmental instability associated with malunion of a reconstructed scaphoid.

We analysed scaphoid deformity as a result of surgical treatment of scaphoid fracture nonunion and assessed the deformity associated with a dorsal intercalated segmental instability pattern of carpal malalignment. A total of 45 patients who were treated for scaphoid fracture nonunion were included in the study. The height-to-length ratio of the scaphoid was measured on computed tomographic images and used to assess scaphoid deformity. Carpal malalignment was quantified based on the radio-lunate angle. A correlation analysis between the height-to-length ratio and the radio-lunate angle was performed. Dorsal intercalated segmental instability was defined as a radio-lunate angle >15°, and a receiver operating curve analysis was used to calculate the cutoff height-to-length ratio that can be accompanied with dorsal intercalated segmental instability. Extension of the lunate increases in proportion to the flexion deformity of the scaphoid; dorsal intercalated segmental instability can occur if the height-to-length ratio of the scaphoid is >0.73. LEVEL OF EVIDENCE: IV.

The Role of Lunate Morphology on Scapholunate Instability and Fracture Location in Patients Treated for Scaphoid Nonunion.

BACKGROUND: To determine the association between lunate morphology and the scapholunate instability using radiographic images, and investigate the association between lunate morphology and scaphoid fracture location. METHODS: Between January 2003 and December 2011, we retrospectively evaluated the plain radiographs and computed tomography (CT) images of 70 patients who underwent surgical intervention for a scaphoid nonunion, in order to determine the association between lunate type (I or II) and scapholunate instability or scaphoid fracture location. We determined the scaphoid fracture location using the fragment ratio and measured the radiolunate angle and capitate-triquetrum (C-T) distance. RESULTS: A type II lunate was present in 68.6% (48 of 70 cases). Mean fragment ratio of fracture location was 50.6% in the type II lunate group and 56.2% in the type I lunate group (p = 0.032). Sixteen of the 70 patients had dorsal intercalated segmental instability (DISI) deformities. Nine of 22 cases showed DISI deformity in type I lunate and 7 of 48 cases showed DISI deformity in type II lunate (p = 0.029). However, there were no significant differences between the presence of DISI deformity and fracture location (p = 0.15). Morphologic comparisons by both plain radiography and CT indicated a mean C-T distance in the type I lunate group (22 cases) of 2.3 mm and 5.0 mm in the type II lunate group (48 cases). The C-T distances were significantly correlated with lunate morphology (p = 0.001). CONCLUSIONS: A type II lunate was associated with low incidence of DISI deformity and proximal location of fracture in patients presenting with a scaphoid nonunion.

The Role of Lunate Morphology on Scapholunate Instability and Fracture Location in Patients Treated for Scaphoid Nonunion

BACKGROUND: To determine the association between lunate morphology and the scapholunate instability using radiographic images, and investigate the association between lunate morphology and scaphoid fracture location. METHODS: Between January 2003 and December 2011, we retrospectively evaluated the plain radiographs and computed tomography (CT) images of 70 patients who underwent surgical intervention for a scaphoid nonunion, in order to determine the association between lunate type (I or II) and scapholunate instability or scaphoid fracture location. We determined the scaphoid fracture location using the fragment ratio and measured the radiolunate angle and capitate-triquetrum (C-T) distance. RESULTS: A type II lunate was present in 68.6% (48 of 70 cases). Mean fragment ratio of fracture location was 50.6% in the type II lunate group and 56.2% in the type I lunate group (p = 0.032). Sixteen of the 70 patients had dorsal intercalated segmental instability (DISI) deformities. Nine of 22 cases showed DISI deformity in type I lunate and 7 of 48 cases showed DISI deformity in type II lunate (p = 0.029). However, there were no significant differences between the presence of DISI deformity and fracture location (p = 0.15). Morphologic comparisons by both plain radiography and CT indicated a mean C-T distance in the type I lunate group (22 cases) of 2.3 mm and 5.0 mm in the type II lunate group (48 cases). The C-T distances were significantly correlated with lunate morphology (p = 0.001). CONCLUSIONS: A type II lunate was associated with low incidence of DISI deformity and proximal location of fracture in patients presenting with a scaphoid nonunion.

The Role of Lunate Morphology on Scapholunate Instability and Fracture Location in Patients Treated for Scaphoid Nonunion

BACKGROUND: To determine the association between lunate morphology and the scapholunate instability using radiographic images, and investigate the association between lunate morphology and scaphoid fracture location. METHODS: Between January 2003 and December 2011, we retrospectively evaluated the plain radiographs and computed tomography (CT) images of 70 patients who underwent surgical intervention for a scaphoid nonunion, in order to determine the association between lunate type (I or II) and scapholunate instability or scaphoid fracture location. We determined the scaphoid fracture location using the fragment ratio and measured the radiolunate angle and capitate-triquetrum (C-T) distance. RESULTS: A type II lunate was present in 68.6% (48 of 70 cases). Mean fragment ratio of fracture location was 50.6% in the type II lunate group and 56.2% in the type I lunate group (p = 0.032). Sixteen of the 70 patients had dorsal intercalated segmental instability (DISI) deformities. Nine of 22 cases showed DISI deformity in type I lunate and 7 of 48 cases showed DISI deformity in type II lunate (p = 0.029). However, there were no significant differences between the presence of DISI deformity and fracture location (p = 0.15). Morphologic comparisons by both plain radiography and CT indicated a mean C-T distance in the type I lunate group (22 cases) of 2.3 mm and 5.0 mm in the type II lunate group (48 cases). The C-T distances were significantly correlated with lunate morphology (p = 0.001). CONCLUSIONS: A type II lunate was associated with low incidence of DISI deformity and proximal location of fracture in patients presenting with a scaphoid nonunion.

Scaphoid overstuffing: the effects of the dimensions of scaphoid reconstruction on scapholunate alignment.

PURPOSE: Osteochondral replacement of the proximal scaphoid has been reported using a vascularized flap from the medial femoral trochlea. A concern with this technique is the loss of stability of the scapholunate relationship with resection of the scaphoid proximal pole. Overexpansion of the scaphoid dimensions (overstuffing) during scaphoid reconstruction with the osteochondral flap may play a role in maintaining scapholunate alignment. Our purpose was to determine if overstuffing the scaphoid can correct rotatory carpal instability in a cadaveric model studied radiographically. METHODS: The radiolunate angle and scapholunate interval were measured for 5 fresh cadaver wrists. We completely incised the scapholunate interosseous ligament and performed an osteotomy to excise the proximal third of the scaphoid to simulate a proximal pole deficiency nonunion and create a dorsal intercalated segmental instability deformity. Radiographic measurements were repeated. The proximal pole of the scaphoid was replaced with its original piece of bone; radiographic measurements were repeated without scapholunate ligament repair. The osteotomy site was overstuffed with a 4-mm sawbone spacer without scapholunate ligament repair, and radiographs were obtained. RESULTS: Sectioning of scapholunate ligaments and proximal pole excision successfully created carpal instability demonstrated by abnormal radiolunate angles. Without ligament repair, proximal pole replacement did not restore normal radiolunate angles. Expansion of the scaphoid dimensions corrected radiolunate angles on lateral unloaded radiographs and improved scapholunate intervals on clenched fist radiographs. These findings were statistically significant compared with the unexpanded (replaced) scaphoid. CONCLUSIONS: These findings suggest that scaphoid reconstruction that results in expansion of the scaphoid's normal dimensions will restore carpal alignment without scapholunate ligament reconstruction. CLINICAL RELEVANCE: Osteochondral reconstruction of difficult proximal pole nonunions may not require any preservation or reconstruction of scapholunate integrity if the reconstruction expands the normal dimensions of the native scaphoid. Scapholunate interval and carpal alignment may be restored by scaphoid over stuffing. The effects on increased contact pressure and range of motion require further investigation.