Intrascaphoid Angle Research Articles

Ultrasound-based Measurement of the Intra-scaphoid angle

IntroductionUltrasound is gaining popularity for diagnosing scaphoid fractures. However, it hasn't been used to assess fracture displacement, such as humpback deformity. We propose a sonographic method to measure the intra-scaphoid angle, potentially serving as an alternative to CT scans for detecting fragment malposition after a scaphoid fracture. MethodsWe recruited 11 healthy adult volunteers without wrist pathology and performed bilateral wrist ultrasounds, totaling 22 examinations. Each wrist was splinted at 50 ° extension and fully supinated. Two hand surgeons independently performed the ultrasounds. All images were then evaluated separately by two evaluators. The following measurements were taken: 1. Inter-poles distance (IPD): Distance between the summits of the two scaphoid poles on the palmar cortex. 2. Palmar cortical intra-scaphoid angle (PCISA): Angle between the two summits and the deepest point of the waist on the palmar cortex. Measurements were compared for inter-investigator and inter-evaluator reliability using the intraclass correlation coefficient (ICC). ResultsThe study included four males and seven females, with an average age of 35 years (range 21–56). The mean PCISA was 142 ° (SD 10 °) and the mean IPD was 16.3 mm (SD 2.1 mm). Differences in IPD measurements averaged 0.3 mm (range 0–5.2 mm) among investigators and 1.0 mm (range 0.1–3.8 mm) among evaluators. For PCISA, the differences averaged 4 ° (range 0–17 °) among investigators and 6 ° (range 0–15 °) among evaluators. The ICC for IPD was 0.804 (investigators) and 0.572 (evaluators); for PCISA, it was 0.704 (investigators) and 0.602 (evaluators). ConclusionThis study presents a cost-effective and accessible sonographic technique to measure the intra-scaphoid angle. Further research is required to assess its effectiveness in scaphoid fractures and compare it to CT-based measurements like the H/L ratio, LISA, and DCA.

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

IntroductionBone 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 MethodsThis 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. ResultsNineteen 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. ConclusionsVolar 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.

Comparison of corticocancellous bone graft from the anterolateral metaphysis of the distal radius versus iliac crest for the treatment of unstable scaphoid nonunion with humpback deformity

BackgroundCorticocancellous bone grafting from the iliac crest is acceptable treatment for unstable scaphoid nonunion with a viable proximal pole. However, harvesting graft from the iliac crest is associated with donor site morbidity and the requirement of general anesthesia. Thus, bone grafting from the anterolateral metaphysis of the distal radius (DR) can be a treatment option. However, no study has compared the clinical effect between the two grafting techniques.MethodsFrom 2014 to 2019, patients with unstable scaphoid nonunion with humpback deformity underwent corticocancellous bone grafting from the anterolateral metaphysis of the DR (group DR) or iliac crest (group IC). Humpback deformity was determined by evaluating the scapholunate angle (SLA) ≥ 60°, intrascaphoid angle (ISA) ≥ 45°, and radiolunate angle (RLA) ≥ 15° from preoperative radiographs and computed tomography scans. The SLA, ISA, and RLA served to gauge carpal alignment. The operative time, grip strength, active range of motion (ROM), the Modified Mayo Wrist score (MMWS), and Disabilities of Arm, Shoulder, and Hand (DASH) score were assessed postoperatively.ResultsThirty-eight patients qualified for the study (group DR, 15; group IC, 23). Union rates did not differ by patient subset (group DR, 100%; group IC, 95.7%; P = .827), and grip strength, ROM, MWS, and DASH score were similar between groups at the last follow-up. The operative time (minutes) was significantly shorter in group DR (median, 98; quartiles, 80, 114) than in group IC (median, 125; quartiles, 105, 150, P < .001). The ISA, RLA, and SLA improved postoperatively in both groups (P < 0.001). The degree of restoring carpal alignment, as evaluated by SLA, showed superior correction capability in group DR (median, 25.3% quartiles, 21.1, 35.3, P < 0.05). Donor site complications were not significantly different between the groups.ConclusionsCorticocancellous bone graft from the anterolateral metaphysis of the DR for unstable scaphoid nonunion is associated with a shorter operation time and comparable results with that from the iliac crest in regard to union, restoration of carpal alignment, and wrist function.Level of EvidenceLevel III.

Carpal Tunnel Syndrome as a Complication of Surgical Scaphoid Reconstruction in Nonunion and Secondary Fracture Dislocation

AbstractThe purpose of this study was to identify risk factors for postoperative carpal tunnel syndrome (CTS) in operative management for scaphoid nonunion and secondary fracture dislocation, treated surgically with takedown and bone grafting. We reviewed medical records of all our patients that underwent carpal tunnel release after scaphoid reconstruction surgery from August 2002 to December 2020. We identified a total of 7 out of 191 patients (3.7%). We investigated surgical parameters, pre- to postoperative changes, in three-dimensional measurements of the scaphoid and carpal tunnel morphometry. We found the preoperative intrascaphoid angle (ISA) and the postoperative change in ISA to correlate with an increased risk of postoperative CTS. Patients undergoing operative scaphoid reconstruction that require a high degree of geometric correction can be at risk to develop postoperative CTS, hence they should be subject to a lower threshold decision for prophylactic carpal tunnel release. Level of Evidence Level III.

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

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

Comparative analysis of cancellous graft and cortico-cancellous graft in osteosynthesis of scaphoid pseudoarthrosis with plate.

Scaphoid is the most fractured carpal bone, with a 5-10% nonunion rate. Treatment challenges include choosing the implant and graft that best corrects humpback deformity and carpal malalignment with higher chances of bony healing. Compare cortico-cancellous and cancellous grafts between two groups of patients treating scaphoid nonunion with locking plates using autologous bone graft and evaluate bone healing rates and radiographic, tomographic, and functional parameters before and after surgery. Non-randomized prospective study including 20 cases of scaphoid nonunion. Groups were divided into Group A (ten patients treated with cortico-cancellous iliac graft) and Group B (ten patients treated with cancellous iliac graft). Patients underwent pre- and postoperative radiographs, computed tomography, and functional evaluation. In postoperative analysis, Group A showed a statistically significant difference in intrascaphoid angle (p = 0.002) and scapholunate angle (p = 0.011) correction when comparing the pre- and postoperative periods. Group B showed a statistically significant difference in intrascaphoid angle (p = 0.002) and scapholunate angle correction (p = 0.0018), grip strength (p = 0.002), and tip pinch strength (p = 0.001) when comparing the pre- and postoperative periods. By comparing both groups, Group B showed a statistically significant difference in intrascaphoid angle correction (p = 0.002), grip strength (p = 0.002), tip pinch strength (p = 0.002), and radial deviation (p = 0.0003). There was no statistical difference when comparing bony healing between groups. Scaphoid nonunion treatment with a locking plate was effective, showing a high bony healing rate and improved carpal alignment in imaging tests for both graft types. However, results for intrascaphoid angle correction, grip strength, tip pinch strength, and radial deviation were better in Group B. IV, case series.

Clinical outcomes of double-screw fixation with bone grafting for displaced scaphoid nonunions: Aseries of 21 cases.

This study reports the clinical outcomes of double-screw fixation with bone grafting for displaced scaphoid nonunions. This study was a retrospective survey. From January 2018 to December 2019, 21 patients with displaced scaphoid fractures underwent open debridement and two headless compression screw fixation with bone grafting. The preoperative and postoperative lateral intrascaphoid angle (LISA) and scapholunate angle (SLA) were recorded. Preoperative and postoperative grip strength (% of the healthy side), active range of motion (AROM), visual analogue scale (VAS), and patient-rated wrist evaluation (PRWE) scores at the final follow-up were obtained for all patients for comparison. Patients were treated for an average of 38.3 months (range 12-250) after the injury. The average time of postoperative follow-up was 30.5 months (range 24-48). All fractures achieved union at a mean of 2.7 months (range 2-4) after surgery, and 14 scaphoids of 21 patients (66.7%) healed by 8 weeks. CT scans showed no evidence of cortical penetration of either screw in all patients. There was a statistically significant improvement in AROM, grip strength, and PRWE. No complications occurred in this study, and all patients returned to work. This study indicates that double-screw fixation with bone grafting is an effective technique for treating displaced scaphoid nonunions.

Comparative analysis of scaphoid nonunion treatment with screw fixation and angular stable plate.

Scaphoid fractures represent 5-10% of nonunion rate and the treatment options consist of an open reduction with correction of deformity, restoration of the scaphoid length with autologous wedge grafting and fixation. However, there is still no consensus in the literature on the best fixation method. Therefore, the purpose of the study is to compare plate fixation and screw fixation in treating scaphoid nonunion with humpback deformity and carpal instability. Prospective, non-randomised study comparing the treatment of two groups of patients with scaphoid nonunion. A total of 19 patients were included in the study, the first ten patients were included in group 1 (plate fixation), subsequently nine patients were included in group 2 (screw fixation). The nonunion duration was longer than 6months and patients did not present type III Scaphoid Nonunion Advanced Collapse (SNAC). Clinical evaluations included pain intensity, range of motion, grip strength, pinch test and functional scales Disabilities of the Arm, Shoulder and Hand (DASH) and Mayo Wrist Score. Radiographic evaluations consisted of radiographs of both wrists in AP, AP with ulnar deviation, lateral and oblique views. Patients further underwent a tomography of the affected wrist for bone deformity, carpal collapse and later consolidation evaluation. According to post-operative measurements, group 1 showed a significant improvement in the scapholunate angle (p = 0.011) and in the intrascaphoid angle (p = 0.002). Group 2 only showed an improvement in the scapholunate angle (p = 0.011). All patients in group 1 achieved consolidation in 8weeks, while group 2 patients had a slower consolidation, with a mean of 14weeks and standard deviation (SD) of 4.2, with statistical significance (p = 0.006). Our prospective study, despite the limitations, contributes to the literature for demonstrating a better fixation using plate, with a better correction of humpback deformity and Dorsal Intercalated Segment Instability (DISI) and a faster consolidation. II, therapeutics studies; prospective comparative study.

Scaphoid Malunion: Incidence, Predictors, and Outcomes.

Background Scaphoid malunion is rarely reported. Previous literature has attributed loss of carpal height and degenerative changes to scaphoid malunion, but the percentage of asymptomatic malunions remains unknown. Purpose The authors of this study aim to define predictors of malunion and outcomes associated with scaphoid malunion. Methods Institutional board review was obtained prior to evaluating medical records of patients 18 years and older who were treated for scaphoid fractures and/or nonunion between 2000 and 2020. The following data were collected for each patient: age, gender, fracture location, surgical technique, time to union, and whether malunion resulted. Malunion was defined using a lateral intrascaphoid angle (LISA) >45 degrees and height-to-length ratio (HLR) >60. Pain scores, range of motion (ROM), and secondary surgery were also evaluated. Results Overall, 355 scaphoid injuries, including 196 acute fractures and 159 nonunions, were evaluated in this analysis. Of these, 55 scaphoids (15%) met the definition of malunion. Of these patients, 23% were female. The mean age at the time of injury was 29 years. Nonunion cases were more likely than acute cases to be associated with malunion. Proximal pole fractures were more likely to associated with malunion than waist fractures. When controlling for nonunion and fracture location, malunited scaphoids were not associated with any significant difference in pain score, ROM, or secondary surgery, compared with nonmalunion cases. A total of 10 patients (3.3%) without malunion and 2 patients (3.6%) with malunion went on to a secondary surgery. Final extension/flexion was 67/67 degrees and 56/59 degrees in nonmalunion and malunion groups, respectively, but these differences were not significant. Conclusion Compared with scaphoid injuries that do not result in malunion, scaphoid injuries that heal into malunion have similar outcomes. While scaphoid malunion in a single case or series may be associated with poor outcomes, this study suggests that scaphoid malunions do not have worse functional outcomes. Level of Evidence This is a Level IV study.

Comparison of the functional and radiological outcomes of vascularized and non-vascularized bone graft options in the treatment of scaphoid nonunion.

Objectives This study aims to compare the functional and radiological outcomes of the patients with scaphoid waist nonunion treated with non-vascularized bone graft and vascularized bone graft options.Patients and methods Between January 2016 and February 2020, a total of 24 patients (22 males, 2 females; mean age: 30.6±9.4 years; range, 18 to 66 years) with scaphoid waist nonunion who were treated with vascularized or non-vascularized bone graft were retrospectively analyzed. Of these patients, eight were treated with iliac crest non-vascularized bone graft (IC-NBG), seven with vascularized free medial femoral condyle (MFC) graft, and nine with 1,2-intercompartmental supraretinacular artery pedicled vascularized bone graft (1,2-ICSRA-VBG). The grip strength, flexion, extension, radial deviation, ulnar deviation angles were measured and compared to the contralateral hand for functional outcomes. Union rates, the scaphoid height-to-length ratio, the lateral intrascaphoid angle (LISA) were evaluated for radiological outcomes. The Mayo Wrist Score, Visual Analog Scale (VAS) score, and Quick Disability of the Arm, Shoulder and Hand (Q-DASH) Questionnaire score were calculated.Results Union was observed in seven (87.5%) patients after IC-NBG, in six (85.7%) patients after MFC bone graft and nine (100%) patients in the treatment group with 1,2-ICSRA-VBG. There were no statistically significant differences among the IC-NBG, MFC and 1,2-ICSRA-VBG groups in terms of the union rates, the scaphoid height-to-length ratio, VAS score, Q-DASH score, grip strength and flexion, ulnar deviation, radial deviation angles after surgery (p>0.05). However, extension was statistically lower in the MFC group than IC-NBG and 1,2-ICSRA-VBG groups after surgery. The Mayo score was better in the IC-NBG group than MFC and 1,2-ICSRA-VBG, indicating a statistically significant difference (p<0.05).Conclusion Based on our study results, we suggest to use IC-NBG for scaphoid waist nonunion as the primary procedure, as the union rates are comparable with the MFC and 1,2-ICSRA-VBG techniques and it has advantages such as shorter operation time, easier technique, no special experience requirement, and better functional outcomes.

Predictors of Failure for Vascularized and Nonvascularized Bone Grafting of Scaphoid Nonunions: A Systematic Review

Objective This article compares predictors of failure for vascularized (VBG) and nonvascularized bone grafting (NVBG) of scaphoid nonunions.Methods We conducted a systematic literature review of outcomes after VBG and NVBG of scaphoid nonunion. Fifty-one VBG studies (N = 1,419 patients) and 81 NVBG studies (N = 3,019 patients) met the inclusion criteria. Data were collected on surgical technique, type of fixation, time from injury to surgery, fracture location, abnormal carpal posture (humpback deformity and/or dorsal intercalated segmental instability [DISI]), radiographic parameters of carpal alignment, prior failed surgery, smoking status, and avascular necrosis (AVN) as defined by punctate bleeding, magnetic resonance imaging (MRI) with contrast, MRI without contrast, X-ray, and histology. Meta-analysis of proportions was conducted with Freeman–Tukey double arcsine transformation. Multilevel mixed-effects analyses were performed with univariable and multivariable Poisson regression to identify confounders and evaluate predictors of failure.Results The pooled failure incidence effect size was comparable between VBG and NVBG (0.09 [95% confidence interval [CI] 0.05–0.13] and 0.08 [95% CI 0.06–0.11], respectively). Humpback deformity and/or DISI (incidence-rate radios [IRRs] 1.57, CI: 1.04–2.36) and lateral intrascaphoid angle (IRR 1.21, CI: 1.08–1.37) were significantly associated with an increased VBG failure incidence. Time from injury to surgery (IRR 1.09, CI: 1.06–1.12) and height-to-length (H/L) ratio (IRR 53.98, CI: 1.16–2,504.24) were significantly associated with an increased NVBG failure incidence, though H/L ratio demonstrated a wide CI. Decreased proximal fragment contrast uptake on MRI was a statistically significant predictor of increased failure incidence for both VBG (IRR 2.03 CI: 1.13–3.66) and NVBG (IRR 1.39, CI: 1.16–1.66). Punctate bleeding or radiographic AVN, scapholunate angle, radiolunate angle, and prior failed surgery were not associated with failure incidence for either bone graft type (p > 0.05).Conclusion Humpback deformity and/or DISI and increasing lateral intrascaphoid angle may be predictors of VBG failure. Time from injury to surgery may be a predictor of NVBG failure. AVN as defined by decreased contrast uptake on MRI may be a marker of increased failure risk for both bone graft types.

Quel est l’effet de l’axe de reformatage des coupes tomodensitométriques sur la mesure des déformations de taille au cours des pseudarthroses du scaphoïde carpien

BackgroundComputed tomography (CT) has been used to understand the deformity of scaphoid nonunion, but no standard protocol for the reformatting of scaphoid CT imaging exists. The purpose of this study was to compare the reliability of measurements of the deformity of scaphoid waist nonunion between CT scans reformatted in line with the scaphoid long axis and CT scans reformatted in line with the wrist axis. HypothesisWe hypothesized that CT scan which was reformatted along the scaphoid long axis is more reliable for understanding the deformity of scaphoid waist nonunion. Patients and methodsCT scans of 28 wrists with a scaphoid waist nonunion were reformatted along both the long axis of the scaphoid and of the wrist. For each set of CT scans, the nonunion gap in axial, coronal and sagittal series, the intra-scaphoid angle, and the height to length ratio were measured. All scans were reviewed twice by three observers and intraclass correlation coefficients (ICCs) for inter- and intra-observer reliability were assessed. ResultsFor the measurement of nonunion gaps and height to length ratio, neither inter- nor intra-observer reliability showed significant differences between the two reformatting scans. However, for the intra-scaphoid angle, both inter- (ICC: 0.202 vs. 0.419, p<0.001) and intra-observer (ICC: 0.614 vs. 0.790, p<0.001) reliability were significantly higher on scaphoid axis CT scan than on wrist axis CT scan. DiscussionIn the assessment of deformity in patients with scaphoid waist nonunion, scaphoid axis reformatting CT scans showed superior reliability for the measurement of intra-scaphoid angle than did wrist axis reformatting CT scans. Although there are several limitations for the correct assessment of all three-dimensional deformity, scaphoid axis reformatting CT scans could help in assessing the extent of humpback deformity in patients with scaphoid waist nonunion. Level of evidenceIV; diagnostic.

Can CT-Scan Measurements of Humpback Deformity, Dislocation, and the Size of Bony Cysts Predict Union after Surgery for Scaphoid Nonunion?

Objective Scaphoid fractures are associated with high rates of late- or nonunion after conservative treatment. Nonunion is reported to occur in approximately 10% of all scaphoid fractures. It is known that the union of scaphoid fractures is affected by factors such as location at proximal pole, tobacco smoking, and the time from injury to treatment. Same factors seem to affect the healing after surgery for scaphoid nonunion. While the impact of preoperative humpback deformity on the functional outcome after surgery has been previously reported, the impact of humpback deformity, displacement, and the presence of bony cysts on union rate and time to healing after surgery has not been studied. Purpose The primary purpose of this study is to assess the association of humpback deformity, fragment displacement, and the size of cysts along the fracture line with the union rate and union time, following surgery of scaphoid nonunion. The second purpose of the study is to investigate the interobserver reliability in the evaluation of computed tomography (CT) scans of scaphoid nonunion. Patients and Methods From January 2008 to December 2018, 178 patients were surgically treated in our institution. After exclusion criteria were met, 63 patients with scaphoid delayed- or established nonunion, and preoperative CT scans of high quality (<2mm./ slice), were retrospectively analyzed. There was 58 men and 5 women with a mean age of 30 years (range: 16-72 years). Four orthopaedic surgeons and one radiologist independently analyzed the CT scans. The dorsal cortical angle (DCA), lateral intrascaphoid angle (LISA), the height-to-length ratio, the size of the cysts, and displacement of the fragments were measured. Healing was defined by CT scan, or by conventional X-ray, and status of no pain at clinical examination. Thirty-two of the patients had developed nonunion (>6 months postinjury), while 31 were in a stage of delayed union (3-6 months postinjury). Results Open surgery with cancellous or structural bone graft was the treatment of choice in 49 patients, 8 patients were treated with arthroscopic bone grafting, and 6 patients with delayed union were operated with percutaneous screw fixation, without bone graft. Overall union rate was 86% (54/63) and was achieved after 84 days (12 weeks) (mean). The failure rate and time to healing were not associated with the degree of the humpback deformity, size of the cysts, or displacement of the nonunion in general. However, greater dislocation, and the localization of the nonunion at the scaphoid waist, showed significant influence on the union rate. Dislocation at nonunion site, in the group of the patients who united after surgery, was 2.7 mm (95% confidence interval [CI]: 1.5-3.7), and in the group who did not unite was 4.2 mm (95% CI: 2.9-5.7); p = 0.048). Time from injury to surgery was significantly correlated with time to union ( p < 0.05), but not associated with the union rate ( p < 0.4). Patients treated arthroscopically achieved faster healing (42 days), (standard deviation [SD]: 22.27) as compared with patients treated by open techniques (92 days; SD: 70.86). Agreement among five observers calculated as intraclass correlation coefficient was for LISA: 0.92; for height-to-length ratio: 0.73; for DCA: 0.65; for size of cysts: 0.61; and for displacement in millimeters: 0.24, respectively. Conclusions The degree of humpback deformity and the size of cysts along the fracture line of scaphoid nonunion have no predictive value for the result, neither for the union rate nor the union time after surgery for the scaphoid nonunion. However, larger dislocation of the fragments measured at the scaphoid waist showed lower union rate. Time to healing following surgery is mainly influenced by the time from injury to the surgical treatment and may be influenced by the choice of the surgical technique. Interrater reliability calculation was best with LISA measurements, and worse with the measurements of the dislocation. Level of Evidence This is a Level III, observational, case-control study.

The effect of reformatting axis of computed tomography scans on the measurement of deformities in scaphoid waist nonunion

BackgroundComputed tomography (CT) has been used to understand the deformity of scaphoid nonunion, but no standard protocol for the reformatting of scaphoid CT imaging exists. The purpose of this study was to compare the reliability of measurements of the deformity of scaphoid waist nonunion between CT-scans reformatted in line with the scaphoid long axis and CT-scans reformatted in line with the wrist axis. HypothesisWe hypothesized that CT-scan which was reformatted along the scaphoid long axis is more reliable for understanding the deformity of scaphoid waist nonunion. Patients and methodsCT-scans of 28 wrists with a scaphoid waist nonunion were reformatted along both the long axis of the scaphoid and of the wrist. For each set of CT-scans, the nonunion gap in axial, coronal and sagittal series, the intrascaphoid angle, and the height to length ratio were measured. All scans were reviewed twice by three observers and intraclass correlation coefficients (ICCs) for inter- and intraobserver reliability were assessed. ResultsFor the measurement of nonunion gaps and height to length ratio, neither inter- nor intraobserver reliability showed significant differences between the two reformatting scans. However, for the intrascaphoid angle, both inter- (ICC: 0.202 vs. 0.419, p<0.001) and intraobserver (ICC: 0.614 vs. 0.790, p<0.001) reliability were significantly higher on scaphoid axis CT-scan than on wrist axis CT-scan. DiscussionIn the assessment of deformity in patients with scaphoid waist nonunion, scaphoid axis reformatting CT-scans showed superior reliability for the measurement of intrascaphoid angle than did wrist axis reformatting CT-scans. Although there are several limitations for the correct assessment of all three-dimensional deformity, scaphoid axis reformatting CT-scans could help in assessing the extent of humpback deformity in patients with scaphoid waist nonunion. Level of evidenceIV; diagnostic.

Structural Versus Nonstructural Bone Grafting for the Treatment of Unstable Scaphoid Waist Nonunion Without Avascular Necrosis: A Randomized Clinical Trial

We evaluated the impact of structural versus nonstructural bone grafting on the time to union, scaphoid deformity correction, and clinical outcomes in adults with unstable scaphoid waist nonunion without avascular necrosis. We hypothesized that nonstructural grafting would provide earlier time to union, restoration of scaphoid anatomy, and equivalent clinical outcomes compared with structural grafting. We prospectively randomized 98 patients to undergo open reduction, iliac crest bone grafting with either corticocancellous (CC group) or cancellous bone only (C-only), and internal fixation using a Herbert screw. The lateral intrascaphoid angle (LISA) and scaphoid height length ratio (HLR) were measured on wrist computed tomography scans along the scaphoid longitudinal axis before surgery and an average of 84 weeks afterward. Pain, range of motion, grip strength, and Quick-Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score were measured before surgery and an average 84 weeks afterward. The trajectory of scaphoid union showed a higher union rate of the C-only group at 12, 14, and 16 weeks after surgery. However, at 24 weeks after surgery, there was no difference between the groups, The union rate was 94% in patients treated with C-only and 90% with CC grafting. In patients with preoperative LISA less than 70° and/or HLR less than 0.80 (n= 53), there were no differences between the CC and C-only grafting techniques for radiographic and clinical outcomes, QuickDASH scores, and malunion rate. In patients who had preoperative LISA greater than 70° and/or HLR greater than 0.80 (n= 45), radiographic outcome measures, range of motion, and QuickDASH scores were significantly better in the CC than in the C-only group. Scaphoid malunion was observed in 9 of 22 of C-only patients (41%) and 4 of 23 of CC patients (18%). The severity of the scaphoid deformity may be a factor in determining the best graft type, because this may affect the rate of successful deformity correction. Corticocancellous grafting in patients who had a high degree of scaphoid deformity provided consistent deformity correction and superior QuickDASH scores. Otherwise, C-only grafting provides earlier time to union and equivalent clinical and radiographic outcomes compared with CC grafting. Therapeutic I.

Normal ranges for measurements of the scaphoid bone from sagittal computed tomography images.

This study aimed to determine normal values of three parameters commonly used to determine malunion by investigating intact scaphoids on sagittal computed tomography images from healthy individuals. We analysed 62 normal scaphoids and found the mean height–length ratio, lateral intrascaphoid angle and dorsal cortical angle to be 0.58, 27° and 128°, respectively. These measurements had good-to-excellent, poor-to-moderate and moderate-to-good inter- and intra-rater reliabilities, respectively. This study provides information on normal parameters of the scaphoid that may inform clinical decision making when assessing malunion. We suggest that the lateral intrascaphoid angle should be used with great caution as a measure of deformity.Level of evidence: III

1,2 Intercompartmental Supraretinacular Artery-Based Vascularized Graft for Scaphoid Nonunion With Avascular Necrosis.

BackgroundThe treatment for scaphoid nonunion with avascular necrosis is vascularized and non-vascularized bone grafts. A vascularized bone graft promotes biological healing and revascularizes ischemic bone. The purpose of this retrospective study is to analyze the outcome of 1,2 intercompartmental supraretinacular artery (1,2-ICSRA)-based vascularized graft in scaphoid nonunion with avascular necrosis.Materials and methodsWe treated 11 patients with scaphoid nonunion with avascular necrosis using a (1,2-ICSRA)-based vascular graft and Herbert screw fixation between 2013 and 2017. Plain radiographs, computed tomography (CT) scan, magnetic resonance imaging (MRI) confirmed the avascular necrosis in all patients. We noted the age, delay in treatment, time for bone union, preoperative range of movements, grip strength, scapholunate, intrascaphoid angle, and radiolunate angles. We confirmed the bone union by CT scan and measured the functional outcome with pain score, modified Mayo wrist score, grip strength, range of movement, and Disabilities of the Arm, Shoulder, and Hand (DASH) score.ResultsThe mean age of the patients was 29 years (range 20-42 years). The mean follow-up was 31 months (range, 26-36 months). All patients achieved good radiological union and revascularization of the proximal pole necrosis at an average of 14 weeks (range, 12-18 weeks). There was a significant postoperative improvement in grip strength, visual analog scale VAS score, intrascaphoid angle, scapholunate angle, and radiolunate angle (p<.05). The mean range of wrist flexion was 88%, extension 70%, radial deviation 80%, and ulnar deviation 85% of the opposite side.ConclusionsScaphoid nonunion with avascular necrosis can be treated with a 1,2-ICSRA-based vascularized bone graft. Vascularized bone grafts promote biological healing and revascularization of the ischemic bone.

Clinical and Patient-Reported Outcomes After Hybrid Russe Procedure for Scaphoid Nonunion.

Background: Hybrid Russe technique for the treatment of scaphoid nonunion with humpback deformity has been described with a reported 100% union rate. We sought to evaluate the reproducibility of this technique. Methods: We completed a retrospective chart review of patients with a scaphoid waist nonunion and humpback deformity treated with the hybrid Russe technique from 2015 to 2019 with a minimum of 3-month follow-up. Twenty patients with 21 nonunions were included (mean follow-up: 7.0 months). Scapholunate angle was the primary outcome measure. Secondary outcomes included: intrascaphoid angle, radiolunate angle, pain on the visual analog scale (VAS), and Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score. Other variables included: time to computed tomography (CT) union, range of motion, and complications. Descriptive statistics were presented. Pre- and postoperative angles, VAS, and QuickDASH scores were evaluated with Wilcoxon signed rank tests. Results: The mean scapholunate angle improved -17.6° ± 6.4°. The mean intrascaphoid angle improved 28.2° ± 6.3°. The mean radiolunate angle improved 12.8° ± 8.8°. Of the 21 scaphoids, 20 (95%) demonstrated union on a CT scan. One patient was diagnosed with a nonunion. In total, 90% of patients noted symmetric range of motion compared with the contralateral side. The mean VAS pain score improved 6 ± 3 points. The mean QuickDASH score improved 10 ± 8 points. Complications (aside from nonunion) included 1 patient with persistent wrist pain that resolved with removal of hardware. Conclusions: The hybrid Russe technique for the treatment of scaphoid nonunions with humpback deformity demonstrates a 95% union rate. This technique is effective, reproducible, and may serve as an alternative to techniques that include structural grafts from distant sites.

Palmar Radiocarpal Artery Vascularized Bone Graft for the Unstable Humpbacked Scaphoid Nonunion With an Avascular Proximal Pole

The most challenging scaphoid nonunion is the unstable nonunion with humpbacked collapse coupled with an avascular proximal pole. Dorsal distal radius pedicled vascularized bone grafts (VBGs) are contraindicated in cases of humpback deformity. The free medial femoral condyle VBG is an excellent option but it is an extensive microsurgical procedure with lengthy operative times and dual-limb incisions. In search of a local, volar, vascularized source of bone to treat this challenging subset of scaphoid nonunions, we analyzed our results with a volar distal radius bone graft based on the pedicled palmar radiocarpal artery (PRCA). A prospective cohort of 15 unstable nonunions with avascular proximal pole fragments was treated with the PRCA graft and open reduction internal fixation. Preoperative carpal indices revealed a high degree of instability. All 15 lacked punctate bleeding from the proximal pole. All 15 patients were treated with the PRCA VBG technique and scanned with computed tomography at approximately 6 and 12 weeks to assess for interval healing. All nonunions healed with an average cross-sectional trabeculation score of 70% at week 6and 84% at week 12. Sagittal intrascaphoid angles improved from 50° to 27°, radiolunate angle improved from -20° to -7°, scapholunate angle improved from 86° to 64°, and revised carpal height ratio improved from 1.45 to 1.53, indicating correction of the humpback collapse deformity. Patients were observed an average of 22 months to have no sign of further avascular necrosis. Pedicled PRCA-VBG successfully addresses the dual needs of the humpbacked scaphoid nonunion with an avascular proximal pole while simultaneously limiting dissection to one limb and avoiding the additional complexities of free tissue transfer. Therapeutic II.

Combined Pedicled Vascularized and Wedge Nonvascularized Bone Graft for Treating Scaphoid Waist Nonunion With Humpback Deformity.

Pedicled vascularized bone graft (VBG) is a useful method in treating the scaphoid fracture nonunion, especially when the avascular necrosis exists. Humpback deformity is an important issue that we have to correct it during the treatment. We describe a method by using combined wedge non-VBG to correct the nonunion deformity when treating scaphoid nonunion with pedicled VBG. The wedge bone graft was harvested just proximal to the 2,3 intercompartmental supraretinacular artery VBG and was used as an inlay at the volar site to correct the humpback deformity, whereas the VBG was set at the dorsal site for bone bridging and blood supply. We also present our results of 10 patients with scaphoid fracture nonunion and humpback deformity treated with this method. Bone healing was achieved and the lateral intrascaphoid angles could be improved in all the 10 patients. Functional outcomes, including the Visual Analog Pain Scale for pain during activity, grip strength, the shortened Disabilities of the Arm, Shoulder, and Hand questionnaire (QuickDASH), and the modified Mayo Wrist Scores, were significantly improved.