Scaphoid morphology and clinical outcomes in scaphoid reconstructions

doi:10.1016/j.injury.2011.08.015

Injury

Volume 43, Issue 3, March 2012, Pages 306-310

https://doi.org/10.1016/j.injury.2011.08.015 Get rights and content

Abstract

Scaphoid malunion and carpal malalignment can result after scaphoid reconstruction, if the two fragments are not properly reduced before fixation. However, currently there is no information about which degree of deformity or malalignment can be tolerated without impairing clinical function.

The purpose of this study was to investigate the influence of the scaphoid morphology and carpal alignment on clinical outcomes after scaphoid reconstruction.

A total of 65 patients with an average age of 29 years were followed-up after a mean period of 45 months. In all patients, osseous union after a first-time scaphoid reconstruction in the middle third had been confirmed. Scapholunate (SL) and radiolunate (RL) angles were obtained on plain radiographs as were intrascaphoid (ISA) and dorsal cortical (DCA) angles and the height/length (H/L) ratio of the reconstructed scaphoid on computed tomography (CT) scans. These parameters were correlated with clinical outcome measures. RL angles correlated significantly with wrist range of motion, grip strength and pain levels, whilst SL angles, ISA, DCA and H/L ratio failed to show significant correlations.

Our data suggest that clinical outcome is correlated with correct restoration of bone morphology and carpal alignment. After reconstruction, the RL angle should not exceed 10°.

Section snippets

Inclusion and exclusion criteria

A protocol for the retrospective review of medical records and selective invitation for a follow-up examination with informed consent was approved by our institutional review boards.

The inclusion criteria of this study were (1) first-time treatment of an established nonunion of the middle third of the scaphoid by bone grafting and internal fixation with a Herbert screw between 1998 and 2005, (2) intra-operative classification of the nonunion as D2 according to Filan and Herbert,¹⁶ (3) osseous

Results

Clinical and radiographic outcomes are summarised in Table 1. The total range of motion averaged 119° (range, 70–155°) for extension/flexion movements. Grip strength averaged 89% (range, 35–115%) of the contralateral side. The average DASH score was 10.6 (range, 0–65). According to the Mayo score, the majority of outcomes were good or excellent; there were only 10 fair or poor outcomes (Fig. 3). All but four patients returned to their original occupation.

On average, the lunate was slightly

Discussion

We conducted this study to investigate the influence of different radiographic parameters on clinical outcomes in successfully reconstructed scaphoids. Our data demonstrate a strong influence of the RL angle on all objective and subjective outcome measures. ISA, DCA but not H/L ratio correlated well with outcomes scores.

Dorsal extension of the lunate, as indicated by an increased RL angle, was the strongest predictor for poor clinical outcomes. This configuration of the carpus is commonly

Conflict of interest statement

There are no conflicts of interest.

References (30)

P.C. Amadio et al.
Scaphoid malunion
J Hand Surg [Am]
(1989)
W.P. Cooney et al.
Scaphoid nonunion: role of anterior interpositional bone grafts
J Hand Surg [Am]
(1988)
K. Oka et al.
Patterns of carpal deformity in scaphoid nonunion: a 3-dimensional and quantitative analysis
J Hand Surg Am
(2005)
R.C. Burgess
The effect of a simulated scaphoid malunion on wrist motion
J Hand Surg [Am]
(1987)
D.K. Smith et al.
The effects of simulated unstable scaphoid fractures on carpal motion
J Hand Surg [Am]
(1989)
D. Birchard et al.
Experimental corrective scaphoid osteotomy for scaphoid malunion with abnormal wrist mechanics
J Hand Surg [Am]
(1990)
G.I. Bain et al.
Measurement of the scaphoid humpback deformity using longitudinal computed tomography: intra- and interobserver variability using various measurement techniques
J Hand Surg [Am]
(1998)
D. Ring et al.
Both scanning plane and observer affect measurements of scaphoid deformity
J Hand Surg [Am]
(2005)
M. Garcia-Elias et al.
Reliability of carpal angle determinations
J Hand Surg Am
(1989)
R. Nakamura et al.
Scaphoid non-union with D.I.S.I. deformity. A survey of clinical cases with special reference to ligamentous injury
J Hand Surg [Br]
(1991)

H. Moritomo et al.

Scaphoid nonunions: a 3-dimensional analysis of patterns of deformity

J Hand Surg Am

(2000)

Y. Tsuyuguchi et al.

Anterior wedge-shaped bone graft for old scaphoid fractures or non-unions. An analysis of relevant carpal alignment

J Hand Surg Br

(1995)

R. Nakamura et al.

Scaphoid non-union: factors affecting the functional outcome of open reduction and wedge grafting with Herbert screw fixation

J Hand Surg Br

(1993)

G.R. Sennwald et al.

X-ray analysis after repair of scaphoid non-union through a dorsal approach

J Hand Surg Br

(1995)

S. Eggli et al.

Unstable scaphoid fracture nonunion: a medium-term study of anterior wedge grafting procedures

J Hand Surg Br

(2002)

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Scaphoid Malunion Clinical and Radiographic Outcomes at a Minimum of 4 Years Follow-Up
2020, Journal of Hand Surgery
Citation Excerpt :
Similarly, Forward et al18 found that patient-reported outcomes did not correlate with any measure of scaphoid deformity, including H/L, LISA, or dorsal cortical angle. Megerle et al7 expanded on this concept by attempting to correlate patient-reported outcomes with a larger set of radiographic measurements including scapholunate angle, radiolunate angle (RLA), H/L, LISA, and dorsal cortical angle. Only RLA demonstrated a significant association with outcome measures.
To evaluate the radiographic and clinical outcomes of patients with scaphoid malunion after acute fracture at a mean of 7 years after injury.
Patients with scaphoid malunion were identified from a departmental database of acute scaphoid fractures. Patients with a scaphoid height-to-length ratio greater than 0.6 on final follow-up computed tomography (CT) scan were considered malunited. These patients were contacted to return for CT imaging and clinical assessment. A total of 22 patients were included (4 females and 18 males). Average age of the group was 41 years (range, 16–64 years) and average length of follow-up was 7.4 years (range, 4.4–11.8 years) after injury.
Ten patients who underwent CT imaging demonstrated arthritic changes at the radial styloid, scaphoid fossa, or scaphotrapeziotrapezoid joint(s). Despite this, patients had good clinical function that was not significantly different compared with the uninjured side. Patients reported minimal pain and disability based on patient-reported outcome measures, and there was a moderate correlation between passive range of motion and height-to-length ratio.
Nearly half of all patients with malunited acute scaphoid fractures demonstrated radiographic findings of early arthritis on CT imaging but overall good clinical results on midterm follow-up.
Prognostic IV.
The Impact of Scaphoid Malunion on Radioscaphoid Joint Contact: A Computational Analysis
2020, Journal of Hand Surgery
The clinical relevance of scaphoid malunion is controversial because the biomechanical sequelae remain poorly understood. In this computational study, the effect of increasing scaphoid malunion on radioscaphoid joint contact was assessed.
Six computational wrist models of active wrist flexion-extension were used to examine 6 scaphoid malunions of varying severities. The malunions were computationally created using 3-dimensional imaging software. Each scaphoid was shortened at the waist by 2 mm to simulate fracture comminution and the distal pole was angulated volarly from 15° to 55° in 10° intervals to create a total of 6 scaphoid malunion models per specimen. Each malunion model was then assessed at 3 wrist positions: neutral, 40° flexion, and 40° extension. The radioscaphoid contact area, as well as the contact centroid, was calculated.
There was a statistically significant association between malunion severity and a wider area of contact at the radiocar: pal joint. The centroid of this radioscaphoid contact area also moved in an ulnar direction for all tested wrist positions. In the extended wrist position, the centroid also moved volarly.
In this computational model, the amount of radioscaphoid joint contact was significantly increased with progressive scaphoid malunion severity. Furthermore, the position of the contact centroid had a significant change in position in the ulnar direction in all wrist positions with increasing scaphoid malunion. The clinical importance of this contact is yet to be elucidated, but this computational model serves as a basis for understanding the biomechanical consequences of scaphoid humpback deformities.
This study provides a computational analysis examining changes at the radioscaphoid joint that may occur within the wrist with the scaphoid malunited.
Imaging for Acute and Chronic Scaphoid Fractures
2019, Hand Clinics
Citation Excerpt :
Contrast-enhanced DECT has been used experimentally to assess scaphoid proximal pole vascularity in a group of high-risk subjects in a small study but the results cannot be broadly applied without additional study.45 CT has significant value for assessing deformity that may indicate a malunion, especially when 3-D imaging can be performed and the carpal bones virtually disarticulated.46–48 This can be done unilaterally but is best when the noninjured wrist can be imaged to determine asymmetry and plan for surgery to restore normal morphology and function.49
The Management of the Healed Scaphoid Malunion: What to Do?
2019, Hand Clinics
Retrospective Comparative Outcomes Analysis of Arthroscopic Versus Open Bone Graft and Fixation for Unstable Scaphoid Nonunions
2018, Arthroscopy - Journal of Arthroscopic and Related Surgery
Citation Excerpt :
Some authors claim that residual deformity has an impact on the clinical outcomes of surgically treated scaphoid injuries,26,28,29 whereas others have found no relation between residual deformity and clinical outcomes.17,22,30 In their retrospective study of 65 patients who had a scaphoid reconstruction, Megerle et al.26 demonstrated that the RLA correlated significantly with wrist range of motion, grip strength and pain levels, whereas the SLA, intrascaphoid angle, dorsal cortical angles, and HLR failed to show significant correlations.26 In contrast, Kim et al.17 showed that radiographic parameters of 36 unstable scaphoid nonunions, who were treated with arthroscopic osteosynthesis, showed no correlation with wrist function or DASH and Patient Rated Wrist Evaluation scores at minimum follow-up of 24 months.
To compare union rates and clinical and radiologic outcomes after arthroscopic and open bone grafting and internal fixation for unstable scaphoid nonunions.
Between March 2009 and November 2014, patients with unstable scaphoid nonunion underwent arthroscopic (group A) or open (group O) bone grafting and internal fixation. One senior surgeon alternatively performed either arthroscopic or open osteosynthesis for the same surgical indications. Visual analog scale score, grip strength, active range of motion, Mayo wrist score (MWS), and Disabilities of Arm, Shoulder, and Hand score were assessed preoperatively and postoperatively. Union was determined by computed tomography 8 to 10 weeks postoperatively with bridging trabecula at the nonunion site. Scapholunate angle (SLA), radiolunate angle (RLA), and lateral intrascaphoid angle (LISA), plus height/length ratio (HLR) served to gauge carpal bone alignment in preoperative and postoperative radiographs. Those outcomes of patients with carpal collapse deformities, who met following conditions; (1) LISA of >45° or HLR of >0.65 on computed tomography images or (2) SLA of >60° or RLA of >10° on plain radiographs, were also compared.
Overall, 62 patients qualified for study (group A, 28; group O, 34). Union rates did not differ by patient subset (group A, 96.4%; group O, 97.1%; P ≒ 1); and visual analog scale score, grip strength, range of motion, Mayo Wrist Score, and Disabilities of Arm, Shoulder, and Hand scores were similar at last follow-up. In radiographic assessments, SLA, RLA, and LISA were similar, whereas scaphoid HLR excelled through open technique (group A, 0.59 ± 0.07; group O, 0.55 ± 0.05; P = .002). Subgroup analysis of patients with carpal collapse deformities (group A, 9; group O, 14) showed that all radiographic measures in group A (vs group O) reflected lesser correction (SLA, 56.7° ± 7.3° vs 49.2°±9.1° [P = .049]; RLA, 9.2° ± 2.0° vs 5.7° ± 3.0° [P = .005]; LISA, 34.8° ± 4.8° vs 25.6° ± 13.0° [P = .028]; HLR, 0.66 ± 0.04 vs 0.54 ± 0.07 [P < .001]).
Arthroscopic and open bone grafting and internal fixation in treating unstable scaphoid nonunions, did not show any significant differences in clinical and radiologic outcomes at the minimum of 2 years after operation. In scaphoid nonunions with carpal collapse deformities, open bone grafting restored better carpal alignment than arthroscopic bone grafting, although there were no differences in clinical outcomes between the 2 techniques.
Level III, retrospective comparative study.
Diagnosing the Malunited Scaphoid
2018, Scaphoid Fractures: Evidence-Based Management

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Scaphoid morphology and clinical outcomes in scaphoid reconstructions

Abstract

Section snippets

Inclusion and exclusion criteria

Results

Discussion

Conflict of interest statement

J Hand Surg [Am]

J Hand Surg [Am]

J Hand Surg Am

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J Hand Surg [Br]

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J Hand Surg Br