Distal Scaphoid Research Articles

Resection arthroplasty for treatment of nonunion and avascular necrosis of the distal scaphoid

Background Posttraumatic osteonecrosis of distal pole of scaphoid is extremely rare, with only few reported cases so far. The purpose of this study was to evaluate the clinical and radiographic results of treatment of distal scaphoid nonunion and avascular necrosis with resection arthroplasty in adult patients. Patients and methods From 2008 to 2013, seven patients presented to the authors for treatment of nonunion and avascular necrosis of the distal part of the scaphoid following distal pole fracture. Pain was evaluated by means of the visual analog scale. The time to return to previous activities and work status were documented. Wrist function was measured according to the Mayo Modified Wrist Score. Carpal height index (Nattrass modification) and radiolunate angle were recorded. Results Follow-up period ranged from 24 to 60 months. Three patients had an excellent result (43%), and four had a good result (57%). There is significant postoperative improvement of pain, range of wrist motion, and Mayo Modified Wrist Score. All patients returned to their previous occupations within 2 months. There were statistically significant increases in the radiolunate angle and no significant decrease in Nattrass carpal height. Conclusion Resection of the distal scaphoid appears to be a valid technique and to constitute an alternative to vascularized bone graft or limited intercarpal arthrodesis for the treatment of scaphoid nonunion with avascular necrosis of distal pole. Level of evidence: level IV, case series.

Classifications in Brief: Watson and Ballet Classification of Scapholunate Advanced Collapse Wrist Arthritis.

Classifications in Brief: Watson and Ballet Classification of Scapholunate Advanced Collapse Wrist Arthritis.

A CT-based approach with 3D modeling to determine optimal radiographic views of the scaphotrapezial and scaphotrapezoid joints

PurposeTo use a CT-based approach with 3D modeling to determine novel radiographic views of the scaphotrapezial (STl) and scaphotrapezoid (STd) joints. Materials and methodsConsecutive wrist CT scans excluding those with pathology of the distal radius, scaphoid, trapezium, or trapezoid of subjects between ages 18 and 60 years were retrospectively reviewed. Three-dimensional reconstructions of CT scans were created and best-fit planes of the STl and STd joints were generated. Angles of these planes relative to a distal radial coordinate system were calculated to determine tilt of the wrist and the X-ray beam for novel radiographic views of these joints. ResultsFifty eligible wrist CT scans were identified. The mean age was 38 years (range, 18 to 59). For the novel STl PA view, the wrist is supinated 17° from the standard PA view and the X-ray beam is canted 6° caudad. In the STl lateral view, the wrist is pronated 17° from the standard lateral view, and the X-ray beam is canted 20° caudad. In the STd PA tilt view, the wrist is supinated 28° from the standard PA view, and the X-ray beam is canted 13° caudad. In the STd joint lateral tilt view, the wrist is pronated 28° from the standard lateral view, and the X-ray beam is canted 29° caudad. ConclusionWe describe novel radiographic views of the STl and STd joints based on 3D modeling of wrist CT scans. Further studies are required to assess the efficacy of these views in detecting joint pathology.

Simultaneous Fractures of the Ipsilateral Scaphoid and Distal Radius.

Background Ipsilateral fractures of the distal radius and scaphoid are rare, with few reports describing mechanisms of injury, fracture patterns, and treatment approaches. Purpose This article describes the clinical and radiographic features of ipsilateral distal radius and scaphoid fractures occurring simultaneously. Materials and Methods Electronic databases from 2007 to 2017 at a single Level 1 trauma center were reviewed for patients with concurrent fractures of the distal radius and scaphoid. Patient demographics, injury mechanism, scaphoid and distal radius fracture pattern, treatment approach, and radiographic healing were studied. Results Twenty-three patients were identified. Nineteen of the 23 (83%) were males, and 19 of 23 (83%) of the injury mechanisms were considered high energy. Twenty-two of the 23 (96%) scaphoid fractures were nondisplaced, all treated with screw fixation. Most distal radius fractures were displaced and comminuted, 17 of 23 (74%) were intra-articular. All distal radius fractures were treated surgically with internal and/or external fixation. Three patients were lost to follow-up. Average follow-up of the remaining 20 was to 19.8 weeks. Nineteen of the 20 (95%) scaphoids healed, one scaphoid went on to nonunion with avascular necrosis. All 20 radius fractures healed, 16 of 20 (80%) in anatomic alignment. Conclusion Ipsilateral fractures of the distal radius and scaphoid are rare and are usually result of high-energy mechanisms. The scaphoid fracture is usually a nondisplaced fracture at the waist. The distal radius fracture pattern varies but most are displaced and comminuted. The union rate of the scaphoid is high, even if subjected to radiocarpal distraction required for distal radius management. Level of Evidence Therapeutic level IV study.

Distal Scaphoid Excision in Treatment of Symptomatic Scaphoid Nonunion: Systematic Review and Meta-analysis.

Background: Current treatment options for persistent scaphoid nonunion are limited to salvage procedures such as proximal row carpectomy (PRC) or 4-corner fusion (4CF). Several small studies have demonstrated that distal scaphoid excision may provide a simpler alternative with faster recovery. The purpose of this study was to determine the efficacy of distal scaphoid excision as a treatment option for symptomatic scaphoid nonunion. Methods: The MEDLINE and PubMed databases were searched for the use of distal scaphoid excision in scaphoid nonunions. Studies included reported on either the functional or patient-centered outcomes following distal scaphoid excision for symptomatic scaphoid nonunion. Results: Six articles described the outcomes of 70 patients with an average of 11.7 patients per study. Functional outcomes including flexion-extension arc, radial-ulnar deviation, and grip strength improved by an average of 98.95%, 58.96%, and 131.08%, respectively. Patient-derived outcomes included the Modified Mayo Wrist Score, which improved by 92.6%, and the Disabilities of the Arm, Shoulder and Hand, which improved by 137.17%. An average of 68.75% of patients experience complete relief of pain with 20.83% of patients experiencing pain with strenuous activity. The average postoperative visual analog scale (0-10) was 0.71. On average, 93.33% of patients returned to work with an average time of return being 6.89 weeks. Complete satisfaction was reported by 87.80% of patients. Complications included progression into 4CF or PRC and newly developed midcarpal arthritis. Conclusions: Given favorable outcomes, our analysis suggests that distal scaphoid excision may be a favorable, low-risk treatment for scaphoid nonunion without eliminating more extensive options such as 4CF and wrist arthrodesis.

Autologous iliac bone flap graft with cross Kirschner wire fixation for treatment of scaphoid waist fracture nonunion in young adults

Objective To explore the autologous iliac flap graft without blood flow combined with cross Kirschner wire and splint fixation in the treatment of scaphoid waist fracture nonunion in young adults. Methods From January 2010 and August 2015, 18 cases of scaphoid waist fracture nonunion were treated in our department. According to preoperative MRI evaluation, ischemic necrosis of proximal or distal pole scaphoid was not seen. The incision was made at dorsal radial wrist. Autologous iliac flap grafting and packing combined with cross Kirschner wire and splint fixation were conducted after cleaning up the dead bone of scaphoid nonunion. Postoperatively, injured limb was continuously fixed by splint for 6 weeks. Removal of Kirschner wire was conducted when fracture line blurred showed by wrist X-ray photograph. The patients were guided to gradually strengthen the wrist joint function exercise. Results Postoperative follow-up ranged from 6 to 24 months, with an average of 13 months. All the cases of scaphoid waist fracture nonunion were healed with 2 cases of delayed union. No scaphoid necrosis occurred. Wrist joint stability was achieved. Wrist joint pain disappeared in 16 cases. Two cases still had slightly pain and significantly alleviated compared with preoperative condition. Postoperatively the angle of wrist extension was 38° to 60° (average, 52°), of wrist flexion 36° to 60° (average, 48°). The wrist range of motion obviously improved. Hand grip strength was 42.5 to 55.5 kg (average, 50.6 kg) for male patients and 28.5 to 35.4 kg (average, 32.6 kg) for female patients. Grip strength increased postoperatively and the patients returned to original work. Conclusion Autologous iliac flap graft without blood flow combined with cross Kirschner wire and splint fixation is a good method for treating scaphoid waist fracture nonunion in young adults, because of the simple technique, minor local injuries of wrist, and satisfactory curative effects. Key words: Scaphoid bone; Fractures,bone; Nonunion; Iliac bone flap

Analysis of instability patterns in acute scaphoid fractures by 4-dimensional computed tomographic imaging – A prospective cohort pilot study protocol

IntroductionA scaphoid fracture is the most common carpal fracture. When healing of the fracture fails (nonunion), a specific pattern of osteoarthrosis occurs, resulting in pain, restricted wrist motion and disability. Scaphoid fracture classification systems recognize fragment displacement as an important cause of nonunion. The fracture is considered unstable if the fragments are displaced. However, whether and how displaced bone fragments move with respect to one another has not yet been investigated in vivo. With a four-dimensional (4D) computed tomographic (CT) imaging technique we aim to analyze the interfragmentary motion patterns of displaced and non-displaced scaphoid fragments. Furthermore, the correlation between fragment motion and the development of a scaphoid nonunion is investigated. We hypothesize that fragment displacement is not correlated to fragment instability; and concurrent nonunion is related to fragment instability and not to interfragmentary displacement. MethodsIn a prospective single-center cohort pilot study, patients with a one-sided acute scaphoid fracture and no history of trauma to the contralateral wrist are illegible for inclusion. Twelve patients with a non-displaced scaphoid fracture and 12 patients with a displaced scaphoid fracture are evaluated. Both wrists are scanned with 4D-CT imaging during active flexion–extension and radio-ulnar deviation motion. The contralateral wrist serves as kinematic reference. Relative displacement of the distal scaphoid fragment with respect to the proximal scaphoid fragment, is described by translations and rotations (the kinematic parameters), as a function of the position of the capitate. Non-displaced scaphoid fractures are treated conservatively, displaced scaphoid fractures receive intraoperative screw fixation. Follow-up with CT scans is conducted until consolidation at 1½, 3 and 6 months. This trial is registered in the Dutch Toetsingonline trial registration system, number: NL60680.018.17. EthicsThis study is approved by the Medical Ethics Committee of the Academic Medical Center, Amsterdam.

Operative Treatment for Nonunion of the Distal Scaphoid

Operative Treatment for Nonunion of the Distal Scaphoid

Variable Bone Density of Scaphoid: Importance of Subchondral Screw Placement.

Background Ideal internal fixation of the scaphoid relies on adequate bone stock for screw purchase; so, knowledge of regional bone density of the scaphoid is crucial. Questions/Purpose The purpose of this study was to evaluate regional variations in scaphoid bone density. Materials and Methods Three-dimensional CT models of fractured scaphoids were created and sectioned into proximal/distal segments and then into quadrants (volar/dorsal/radial/ulnar). Concentric shells in the proximal and distal pole were constructed in 2-mm increments moving from exterior to interior. Bone density was measured in Hounsfield units (HU). Results Bone density of the distal scaphoid (453.2 ± 70.8 HU) was less than the proximal scaphoid (619.8 ± 124.2 HU). There was no difference in bone density between the four quadrants in either pole. In both the poles, the first subchondral shell was the densest. In both the proximal and distal poles, bone density decreased significantly in all three deeper shells. Conclusion The proximal scaphoid had a greater density than the distal scaphoid. Within the poles, there was no difference in bone density between the quadrants. The subchondral 2-mm shell had the greatest density. Bone density dropped off significantly between the first and second shell in both the proximal and distal scaphoids. Clinical Relevance In scaphoid fracture ORIF, optimal screw placement engages the subchondral 2-mm shell, especially in the distal pole, which has an overall lower bone density, and the second shell has only two-third the density of the first shell.

Dorsal ligamentoplasty for posttraumatic scapholunate dissociation

Scapholunate dissociation in stages 2 and 3 may lead to posttraumatic damage if left untreated. Different types of treatment have been described, including capsulodesis, tenodesis, and others. The purpose of all procedures is to avoid palmar shift of the distal scaphoid resulting in secondary arthritis (SLAC wrist). This study aimed to evaluate a modified dorsal ligamentoplasty in second- and third-degree scapholunate dissociation in a prospective study design. Furthermore, the study aimed to find out if there is a correlation between radiological and clinical parameters at follow-up and whether or not a SLAC wrist can be avoided. From 2007 to 2011 we performed 29 dorsal ligamentoplasties in our hospital in patients with second- and third-degree scapholunate dissociation. In a prospective study design, 25 patients were followed up after an average period of 18 months. Parameters recorded preoperatively included ROM, the radiological parameters SL diastasis, SL diastasis in power grip and SL angle, the DASH score, and the VAS score. The postoperative evaluation additionally included power grip, the Mayo wrist score, and patients' subjective satisfaction. The average subjective satisfaction after surgery was good. The average postoperative ROM was 83.8 % of the ROM of the healthy wrist and decreased by 11 % compared with the preoperative level. The average postoperative grip strength was 85.7 % of the strength of the healthy hand. The VAS score was 2.7 with a significant reduction from 6.7 preoperatively. The average DASH score decreased significantly from 60 preoperatively to 22.5 postoperatively. The average Mayo wrist score after surgery was 73. All radiological parameters at follow-up were significantly better than preoperatively, although they remained in a pathological range. The Pearson correlation analysis showed no relevant correlation between clinical and radiological scores. Three cases (12 %) required revision surgery. The described modified dorsal ligamentoplasty at the carpus can be recommended in second- and third-degree scapholunate dissociation. Clinical results are comparable to other techniques, but there is only a single approach required and the complication rate is very low. The short average follow-up of 18 months must be viewed critically as the rate of SLAC wrists might be higher during longer follow-up periods.

Long-Term Outcomes After Distal Scaphoid Fractures: A 10-Year Follow-Up

The aim of this study was to evaluate the functional, clinical, and radiological outcome 10 years after distal scaphoid fractures. From a prospective epidemiological study on posttraumatic radial-sided wrist pain, we evaluated 41 cases of distal scaphoid fractures. All cases had been treated nonsurgically in a thumb spica cast. Patients were examined using radiographs, magnetic resonance imaging andcomputed tomography at the time of injury and with computed tomography after a median of 10 years (range, 8-11 years). Fractures were classified according to a modified Prosser classification system. The primary outcome was assessment of self-reported function using Disabilities of the Arm, Shoulder, and Hand (DASH) and Patient-Reported Wrist Evaluation (PRWE). Secondary outcomes were clinical status (range of motion and grip and pinch strength) and to evaluate fracture healing and arthritis in the scaphotrapezium-trapezoid (STT)joint. Functional impairment and pain scores at follow-up were low: median DASH score 2, median PRWE 0, and median visual analog scale (VAS) pain score 0. We found no impairment in range of motion or strength. We found 26 type I fractures, 12 type IIA, 1 type IIC, and 2 type IV. There was 1 asymptomatic nonunion in a type I fracture. Computed tomography revealed arthritis in the STT joint in 7 out of 41 wrists, none of which caused clinical symptoms. From an 8- to 11-year perspective, patients with distal scaphoid fractures report normal self-assessed hand function as well as good wrist motion and strength. The risk for development of posttraumatic STT arthritis was low. Prognostic II.

Operative Treatment of Ipsilateral Fracture Distal Radius And Scaphoid

Operative Treatment of Ipsilateral Fracture Distal Radius And Scaphoid

Combined Fractures of the Scaphoid and Distal Radius: Evaluation of Early Surgical Fixation (21 Patients with 22 Wrists).

Introduction The purpose of this retrospective study, is to evaluate the clinical and functional results of early surgical fixation of the ipsilateral distal radius and scaphoid fractures in 22 of 21 patients. Patients and Methods Overall, 22 combined ipsilateral scaphoid, and distal radius fracture treatments between 2002 and 2015 were evaluated. The mean age was 34.9 (range: 19-82) years. One patient had bilateral injuries. In 17 patients the injury was due to a fall from a height, and in 4 patients due to a motorcycle accident. According to the AO classification, there were 2 type B and 20 type C fractures of the distal radius. The volar locking plate fixation technique was applied in 14 wrists, screw fixation technique in 1, external fixation combined with Kirschner wires (K-wire) stabilization technique was used in 3 wrists, and only K-wire pinning technique was used in 4 wrists. All scaphoid fractures were type B (21 type B2, 1 type B1) according to the Herbert-Fischer classification. K-wire fixation was applied in 2 and cannulated screw fixation was performed in 20 fractures. Clinical evaluation was performed with measuring the pinch power, grip power, and range of motions. Functional evaluation was performed using patient-rated wrist evaluation score (PRWE). Results The average follow-up period was 25 (range: 12-97) months. All radius and scaphoid fractures healed. The mean active wrist motions were found to be 45 degrees of flexion, 48.5 degrees of extension, 20 degrees of radial deviation, and 43 degrees ulnar deviation. Mean grip/pinch strengths were 31/8.5 kg. Mean PRWE score was 5.5 (range: 0-8.5). All patients returned to preoperative activity level and can do preinjury jobs. Conclusion Combined ipsilateral fractures of distal radius and scaphoid are complex and rare injuries due to high energy traumas. Stable early primary fracture fixation in these injuries can be expected with good functional results. Level of Evidence Level IV.

Scaphotrapeziotrapezoidal Joint Osteoarthritis: A Systematic Review of Surgical Treatment.

The management of scaphotrapeziotrapezoidal (STT) joint osteoarthritis (OA) remains controversial. This systematic review aims to review the evidence for surgical interventions specific to STT OA. Medline and Embase libraries were searched using a pre-defined search strategy in October 2014. All study designs and languages were included and evaluated by two reviewers (VMD and LM) against the inclusion/exclusion criteria. The study eligibility criteria included papers discussing surgical treatment of STT OA, and the review was conducted using the PRISMA guidelines. 295 unique results were identified from the search strategy after duplicates were filtered. 21 articles met the eligibility criteria. Trapezial excision and partial trapezoidal excision is an effective treatment with low morbidity and complications, although can lead to weakness of the thumb. Distal scaphoid excision remains an effective pain relief treatment with improved grip and pinch strengths post-operatively. The procedure is technically less demanding than arthrodesis, does not carry the risks of non-union and complication rate of STT joint arthrodesis, and has a shorter immobilisation requirement. It produces reliable results, but is contraindicated if there is either scapholunocapitate pathology or midcarpal instability. STT joint fusion has a place, typically producing 75% range of movement of the non-operated wrist. However it has a higher associated complication rate, and simultaneous radial styloidectomy is recommended to reduce ongoing pain from impingement. Implant arthroplasty using a graphite-coated pyrocarbon implant has been used more recently. The patients gained significant pain relief, although there have been reports of implant dislocation secondary to surgical errors. A reduction in post-operative wrist extension and radial deviation has been noted. From this systematic review, we have composed a treatment algorithm for the surgical management of STT joint OA.

Assessment of Forearm Rotational Control Using 4 Upper Extremity Immobilization Constructs.

Forearm immobilization techniques are commonly used to manage distal radius, scaphoid, and metacarpal fractures. The purpose of our study was to compare the degree of rotational immobilization provided by a sugar-tong splint (STS), short arm cast (SAC), Munster cast (MC), and long arm cast (LAC) at the level of the distal radioulnar joint (DRUJ), carpus, and metacarpals. Seven cadaveric upper extremity specimens were mounted to a custom jig with the ulnohumeral joint fixated in 90° of flexion. Supination and pronation were unrestricted. K-wires were placed in the distal radius, scaphoid, and metacarpals using fluoroscopic guidance to measure the total arc of rotation referenced to the ulnar ex-fix pin. Baseline measurements followed by sequential immobilization with well-molded STS, SAC, MC, and LAC were obtained with 1.25, 2.5, and 3.75 ft-lb of supination and pronation force directed through the metacarpal K-wire. Each condition was tested 3 times. Digital photographs were taken perpendicular to the ulnar axis to analyze the total arc of motion. The most effective constructs from least to greatest allowed rotational arcs were LAC, MC, SAC, and STS. Above-elbow constructs (MC, LAC) demonstrated superior immobilization compared with below-elbow constructs (SAC) ( P < .001). Circumferential constructs (SAC, MC, LAC) were superior to the noncircumferential construct (STS) ( P < .001). There were no significant differences between the MC and LAC in all conditions tested. Both circumferential and proximally extended immobilization independently improved rotational control of the wrist. However, extending immobilization proximal to the epicondyles did not confer additional stability.

Three-Dimensional Analysis of Acute Scaphoid Fracture Displacement: Proximal Extension Deformity of the Scaphoid.

Our goal was to analyze the movement of acute scaphoid waist fracture fragments and adjacent bones in a common coordinate system. Our hypothesis was that the distal scaphoid fragment flexes and pronates and the proximal fragment extends. Computed tomography (CT) scans of patients diagnosed with an acute scaphoid waist fracture were evaluated using a 3-dimensional (3D) model. The scans of 57 nondisplaced and 23 displaced fractures were compared with a control group of 27 scans showing no pathological involvement of the wrist. Three anatomical landmarks were labeled on the distal and proximal fragments of the scaphoid, the lunate, and the trapezium. Each set of labels formed a triangle representing the bone or fragment. Four landmarks were labeled on the distal radial articular surface and used to create a common coordinate system. The position of each bone or fragment was calculated in reference to these coordinates. The displaced fracture group showed significant extension, supination, and volar translation of the proximal scaphoid fragment when compared with the other groups. The lunate tended toward a supinated position, which was not statistically significant. The distal scaphoid fragment and the trapezium showed no movement. In acute displaced scaphoid fractures, it is the proximal fragment that displaces and should be reduced. The typical "humpback" deformity is actually a "proximal extension" deformity, the consequence of displacement of the proximal fragment of the scaphoid (with the lunate). Manipulating only the proximal fragment (with the lunate) may be technically easier and more effective than manipulating both fragments.

ECRL Suspension as a Revision Procedure in Failed Resection Arthroplasty of the First Carpometacarpal (CMC-I) Joint

Objective: Resection arthroplasty (RSA) is the standard procedure for first carpometacarpal (CMC-I) joint arthritis and gives excellent results in 95% of patients. There are several reasons explaining the 5% unsatisfying results. To the best of our knowledge, there is no report in the literature concerning revision procedures in failed RSA. The purpose of this retrospective study was to investigate the outcome after extensor carpi radialis longus (ECRL) suspension as a revision procedure in patients with persistent pain due to proximalization and bony impingement of the base of the first metacarpal and the base of the second metacarpal bone and/or the distal scaphoid. Methods: Between 2002 and 2013, 3429 patients with CMC-I arthritis underwent an RSA using the abductor pollicis longus (APL) tendon in our clinic. In the same period of time, we performed 128 revision procedures due to persistent pain following an RSA. Twenty-one of these patients with a mean age of 59 years (range, 51-70 years) demonstrated a proximalization and bony impingement. In these cases, we performed a revision suspension using half of the ECRL tendon. After an average follow-up of 4 years, 15 patients (13 female, 2 male) were available for a clinical and radiological follow-up examination, including range of motion (Kapandji-Score), grip and pinch strength, as well as several clinical tests (eg, grind test). Mayo Wrist Score (MWS) as well as DASH score and patient’s pain (visual analogue scale [VAS], 0-10) were evaluated. Standard radiographs of the wrist and the thumb in two planes were obtained. One of the 6 patients who could not be included in the follow up died, another refused follow-up due to total well-being and 4 patients moved and could not be located. Results: The time between RSA and revision averaged 2 years (range, 1-7 years). Clinical examination showed a positive grind test in 4 patients, and 11 patients remained free of pain. Eleven patients showed full opposition, and 4 patients showed mild restriction of opposition. The Kapandji score averaged 9.4 (range, 8-10), pinch strength averaged 76% of the opposite side. Postoperative MWS was 67, and DASH score was 39 points, whereas MWS was 37 preoperatively. Postoperative pain on VAS was 3 at rest and 5 with activity, whereas it was 8 at rest and 9 with activity previous to revision. Thirteen patients reported major improvement and 2 reported unchanged pain postoperatively. Fourteen patients were satisfied with the final result and would have the same procedure. Radiological evaluation showed a significant improvement in proximalization postoperatively. Twelve patients resumed the original employment, 10 of them performing heavy manual labor. Conclusion: These findings show that ECRL tendon suspension after previous RSA leads to a significant clinical improvement. The operation appears to be an effective revision procedure for patients with persistent pain due to proximalization of the first metacarpal bone and bony impingement following RSA.

Percutaneous Fixation for Scaphoid Nonunion With Bone Grafting Through the Distal Insertion Hole of a Fully Threaded Headless Screw

Objective: Percutaneous scaphoid screw fixation is a popular treatment for acute scaphoid fractures with no or minimal displacement. For treating scaphoid nonunions, however, open reduction and internal fixation with bone grafting is still the most popular treatment. Percutaneous fixation with bone grafting through the screw insertion hole has received little attention, although it minimizes damage to the surrounding tissues. We report excellent results of 10 scaphoid nonunions treated by retrograde percutaneous fixation with curettage and bone grafting through the distal insertion hole of a fully threaded headless screw. Materials and Methods: Ten scaphoid nonunions with substantial bone loss were treated, including 1 revision case. All nonunions were located at the middle third of the scaphoid. The mean patient age at operation was 24.7 years, and the mean interval between fracture and surgery was 8.8 months. In the revision case, the interval between the primary and revision surgery was 6 months. Surgery was performed under general anesthesia or an axillary brachial plexus block with local anesthesia at the iliac crest donor site. A 1.1-mm guidewire was percutaneously inserted into the scaphoid tuberosity and advanced to the proximal pole of the scaphoid with the wrist in an extended and ulnar-deviated position. A 1.2-mm second derotation wire was also inserted radial or ulnar to the original guidewire. A 2.0-mm cannulated drill was passed over the guidewire, stopping at the distal end of the cystic lesion. The guidewire was then removed. The 1.2-mm second derotation wire maintained the reduction of the scaphoid. Curettage inside the cystic lesion was performed using a small curette inserted through the distal insertion hole. Bone graft was harvested percutaneously from the iliac crest with an 11-gauge bone biopsy needle and inserted into the cystic lesion through the drill hole of the distal scaphoid fragment. The removed guidewire was reinserted into the previously drilled hole followed by insertion of a selected fully threaded headless screw (Acutrak 2 mini; Acumed, Hillsboro, OR, USA). After the operation, the wrist was immobilized in a thumb spica cast for the initial 6 weeks, followed by splinting until bone union was confirmed. In one case, curettage alone was performed before retrograde insertion of the headless screw. In the other cases including the revision, curettage and bone grafting with a bone biopsy needle was required through a distal insertion hole. Results: The mean follow-up was 12.1 months. Radiologically, union was achieved at averaged 12 weeks postoperatively. At the final follow-up, there was significant improvement in the wrist extension range of movement (from 65.8° to 80.8°) and grip strength (from 65.5% to 87.8% of the unaffected side). Nine patients were free of pain, and 1 experienced mild pain only during heavy manual labor. The mean visual analogue scale (VAS), Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), and Cooney wrist scores were 0.1, 1.75, and 98.5, respectively. All patients returned to their work or athletic activities. Conclusions: Retrograde percutaneous fixation with bone grafting through the distal insertion hole of a fully threaded headless screw is a promising option for surgical treatment of scaphoid nonunions.

Distal Scaphoid Resection and Prosthetic Semireplacement Arthroplasty for a Scaphoid Nonunion with Degenerative Changes.

Distal Scaphoid Resection and Prosthetic Semireplacement Arthroplasty for a Scaphoid Nonunion with Degenerative Changes.

Arthroscopic Proximal Trapeziotrapezoid Resection for STT Osteoarthritis

Background: The most common treatment for scaphotrapeziotrapezoid joint (STTj) osteoarthritis (OA) is resection arthroplasty of the distal scaphoid, with or without prosthetic interposition. However, this procedure shows a considerable amount of unsatisfactory results related to the progression of dorsal intercalated segment instability (DISI) carpal malalignment. Similar complications result even when an arthroscopic approach is used, which is also a technically demanding procedure. To overcome these drawbacks and reduce ligamentous damage around the STTj, we developed an arthroscopic technique that consists of resection of the proximal aspect of trapezium and trapezoid: distal STTj resection arthroplasty (dSTT/RA)