Scaphoid Fractures Requiring Bone Graft: Does Graft Source Matter?

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

The Use of Nitinol Compression Staple Fixation and Bone Graft for Scaphoid Waist Fractures and Nonunion: A Surgical Technique.

In the management of scaphoid fractures, nonunion is an important complication that can lead to carpal instability and early-onset arthritis. Various techniques have been described to treat scaphoid nonunions, yet a clear consensus on the superiority of one method is not yet established. The use of compression staple fixation has been described in the literature and may be a viable alternative to other fixation techniques. Volar Nitinol staple fixation avoids damage to the trapezium during retrograde fixation with a screw. It also avoids damage to the proximal dorsal cartilage, which occurs during anterograde screw fixation. Because of its shape and position on the volar aspect of the scaphoid, staple fixation provides compression, prevents graft extrusion, and avoids taking up space in the medullary canal of the scaphoid. Moreover, it may be technically easier than screw fixation. Despite these advantages, this technique has not been widely adopted. We describe the technique for utilizing Nitinol compression staples and bone grafting in the treatment of scaphoid nonunion.

Mycobacterium marinum tenosynovitis in a patient on etanercept therapy for rheumatoid arthritis.

Opportunistic infections are a theoretical concern with the use of tumor necrosis factor antagonists, as these agents can impair host immunity. A 61-year-old man with rheumatoid arthritis being treated with only etanercept (soluble tumor necrosis factor receptor) and in remission from the rheumatoid arthritis presented with dorsal tenosynovitis of his right wrist. The synovitis was not improved by a local corticosteroid injection. Surgical exploration showed granulomatous inflammation, and cultures were positive for Mycobacterium marinum infection. Etanercept was discontinued 4 months after the hand infection started. The infection resolved completely with surgery and antibiotic therapy with clarithromycin 500 mg twice daily orally for 3 months. Although M. marinum infection was locally invasive, there was no systemic dissemination of the infection despite ongoing etanercept therapy for 4 months before it was discontinued. With more frequent use of this class of agents for rheumatoid arthritis and Crohn's disease, we caution physicians to be alert for the possibility of this kind of local opportunistic infection.