Percutaneous screw fixation for scaphoid comparrison between the dorsal and volar approaches
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Percutaneous screw fixation for scaphoid comparrison between the dorsal and volar approaches Document Transcript

  • 1. SCIENTIFIC ARTICLE Percutaneous Screw Fixation for Scaphoid Fracture: A Comparison Between the Dorsal and the Volar Approaches In-Ho Jeon, MD, Ivan D. Micic, MD, Chang-Wug Oh, MD, Byung-Chul Park, MD, Poong-Taek Kim, MD Purpose To evaluate the position of the screws and find the difference of clinical and radiologic outcome between the volar approach and the dorsal approach groups in percuta- neous screw fixation for acute scaphoid fractures. Methods Forty-one consecutive patients with an acute scaphoid fracture, who had percutaneous fixation via either the volar approach or the dorsal approach, were evaluated at an average of 30 months after the surgery. The volar approach was used in 19 patients and the dorsal approach in 22 patients. By using a computerized digital image program, angles between the Herbert screw with respect to the long axis of the scaphoid and the fracture line were measured with plain radiographs in the posteroanterior, lateral, and the 45° semipronated oblique views. Results The screws showed no significant difference between the 2 groups in posteroanterior and lateral views; however, screws in the dorsal approach group were observed to be placed more parallel to the long axis of the scaphoid in the semipronated oblique view. The screws in the dorsal approach group were positioned more perpendicular to the fracture lines of the scaphoid compared with those of the volar approach group for all 3 different radiographic views. There was no statistically significant difference between the 2 treatment groups regarding fracture healing. According to the Mayo wrist score system, excellent results were recorded in 18 patients in the dorsal approach group and 15 patients in the volar approach group. Conclusions This study suggests that screws are placed more parallel to the long axis of the scaphoid and perpendicular to the fracture line via the dorsal approach; however, there was no significant difference with regard to functional outcome and bone union. (J Hand Surg 2009;34A:228–236. © 2009 Published by Elsevier Inc. on behalf of the American Society for Surgery of the Hand.) Type of study/level of evidence Therapeutic IV. Key words Acute scaphoid fracture, dorsal approach, percutaneous fixation, volar approach. HE COMPLEX THREE-DIMENSIONALanatomies and functional recovery by adequate reduction.1–17 Early T tenuous blood supply of carpal scaphoid bones make fracture management challenging. Open surgical treatment is well established in the manage- surgical intervention with fixation enabled young active patients to return to previous activities of daily living or sports as soon as possible.1 ment of acute unstable scaphoid fractures for early Previous reports on percutaneous screw fixation in FromtheDepartmentofOrthopedicSurgery,CollegeofMedicine,KyungpookNationalUniversityHospi- Corresponding author: In-Ho Jeon, MD, Department of Orthopaedic Surgery, Kyung- tal, Daegu, Korea; and the Department of Orthopaedic Surgery and Traumatology, Clinical Center, Fac- pook National University Hospital, 50, 2-Ga, Samduk, Chung-Gu, Taegu, 700-721, Korea; ulty of Medicine, Nis, Serbia. e-mail: jeonchoi@chollian.net. Received for publication April 10, 2008; accepted in revised form October 16, 2008. 0363-5023/09/34A02-0004$36.00/0 doi:10.1016/j.jhsa.2008.10.016 No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. 228 ©  Published by Elsevier, Inc. on behalf of the ASSH.
  • 2. PERCUTANEOUS SCREW FIXATION FOR SCAPHOID FRACTURE 229 the management of scaphoid fractures have described fractures were fixed via the volar approach and 22 this technique, and this approach has been advocated by the dorsal approach. over the past few years. Since Streli’s first report on the The study group included 39 male and 2 female percutaneous technique in 1970,2 many reports have patients with an average age (of overall patients in the described the percutaneous fixation of scaphoid frac- dorsal or volar group) of 28 years (range, 14 –52 years). tures. Both the volar approach3–17 and the dorsal ap- Thirty-six right hands (34 dominant) were involved. proach18 –21 have appeared in the literature with rela- Nineteen patients were students at the time of surgery. tively low complication rates. Slade et al.18 stressed that The remaining 22 patients included 9 manual workers, using the dorsal approach, the screw is introduced from 7 office workers, 3 farmers, and 3 drivers. the narrow proximal pole to the wide distal fragment, Diagnosis of the fracture was based on physical and therefore, it is easier to place the screw in the examination, plain radiographs, and computed tomog- central portion of the scaphoid. Chan et al.22 conducted raphy (CT). Standard posteroanterior, lateral, and 45° a cadaveric comparison between the proximal and distal semipronated oblique view and thin-section CT scan techniques of percutaneous screw placement in the along the long axis of the thumb were taken in all scaphoid and concluded that the proximal-dorsal ap- patients before the surgery to confirm fracture site dis- proach allowed more central screw placement. Al- placement, comminution, or angulation. though good clinical results from the volar and the At the time of surgery, details of the fracture patterns dorsal percutaneous screw fixation techniques have were recorded. The average age (of each group) of the been reported, there has been no clinical comparative patients was 30 years (range, 14 –52 years) in the dorsal study done between the dorsal and the volar approaches group and 27 years (range, 16 –52 years) in the volar in the literature. group. Overall, fractures were most common in patients The purpose of this study is to evaluate the position in their twenties and thirties (32 patients). Patient details of the screws and find the difference of clinical and are summarized in Table 1. The most common injury radiologic outcome between the volar approach and the was a minor fall on an outstretched hand in 33 patients, dorsal approach groups in percutaneous screw fixation and among them 15 fractures occurred during sports for acute scaphoid fractures. activities. Five fractures were caused by a direct blow such as a punch, and 1 fracture was due to a road traffic MATERIALS AND METHODS accident. From January 1999 to December 2005, we prospec- tively followed up 53 patients with an acute scaphoid Surgical technique fracture. All fractures were classified according to the The volar approach: Under general or brachial plexus an- modified classification of Herbert and Fisher.23 All esthesia, patients were placed supine on the operating fractures were classified as type B2 unstable acute frac- table and the scaphotrapezial joint was identified and tures (22 fractures in the dorsal group and 19 fractures marked on the volar side of the skin. A trial manual in the volar group). Mild comminution in the palmar reduction of the fractures was facilitated under an image side was noted in 4 patients. All patients were managed intensifier if necessary. A transverse stab incision was with percutaneous screw fixation by 1 hand surgeon at made at about 1 cm distal to the scaphotrapezial joint the university hospital. under image intensifier control. After blunt dissection to Forty-one patients treated by percutaneous fixation the distal end of the scaphoid, a 1.4-mm (0.045-in) with noncannulated Herbert screw fulfilled the inclu- K-wire was used temporarily to facilitate fracture sta- sion criteria: (1) type B2 acute displaced fractures of bilization along the long axis of the scaphoid directed scaphoids, (2) a surgery within 2 weeks after initial toward the center of the proximal pole. A semipronated injury, and (3) minimum follow-up of 2 years. oblique view was required in addition to anteroposterior Exclusion criteria were patients with (1) a proximal and lateral views, because lateral radiograph did not pole fracture, (2) a complicated fracture like transcaph- show the entire proximal outline of the scaphoid. The oid perilunar dislocations, or (3) an associated fracture length of the guide wire within the scaphoid was deter- in the distal radius or other carpal bones. mined. The drill was inserted, parallel to the guide wire Initially, all surgeries were performed using the under fluoroscopy. After tapping, a Herbert screw of volar approach from January 1999 to June 2001, appropriate length was introduced under image intensi- and subsequently the dorsal approach was used in fier control. Compression was confirmed by an image all patients beginning July 2001. A total of 19 intensifier, and the end of the screw was buried beneath JHS Vol A, February 
  • 3. 230 PERCUTANEOUS SCREW FIXATION FOR SCAPHOID FRACTURE TABLE 1. Comparison of Details Between the Dorsal Approach and the Volar Approach Groups Group Dorsal (n 22) Volar (n 19) Range Mean Range Mean Variables Median (Minimum–Maximum) (SD) Median (Minimum–Maximum) (SD) p Value* Gender (F:M), n (%) 2 (9.1):22 (90.1) 0 (0.0):9 (100) .178† Age (y) 27 38 (14–52) 30 (12) 24 36 (16–52) 27 (9) .425 Time from injury to 10 10 (4–14) 10 (3) 10 8 (6–14) 10 (2) .766 operation (days) Follow-up time (mo) 29 18 (24–42) 30 (6) 28 14 (24–38) 30 (5) .958 Statistically significant at p .05. *The result of the Mann-Whitney U test. †The result of the chi-square test. the distal surface of the scaphoid to avoid any further damage to the scaphotrapezial joint. The dorsal approach: Under appropriate anesthesia with the patient in a supine position, the dorsal scapholunate joint was marked. The wrist was pronated and flexed until the scaphoid was seen as a circle on fluoroscopy. The center of the circle was chosen as the target point for the insertion of the guide wire into the proximal pole of the scaphoid. After stab incision over the center of the circle (usually over the scapholunate joint), the guide wire was driven dorsal to volar so that it exited at the radial base of the thumb. The reduction and place- ment of the guide wire was confirmed under an image FIGURE 1: Technique for measuring scaphoid long axis in intensifier. A pilot hole was drilled parallel to the guide plain radiographs of A posteroanterior view and B lateral view. K-wire. After tapping, a Herbert screw was inserted The long axis of the scaphoid in the posteroanterior and under an image intensifier in a freehand manner. After semipronated oblique views was determined as a line between the center of the distal tuberosity and the most convex point of fixation, the position of the screw could be verified the proximal pole of the scaphoid, and it was determined as using an image intensifier. the volar outline in the lateral view. Postoperative management The wrist was supported in a volar splint for 3 weeks. Active assisted finger exercises were encouraged im- Plain radiographs of posteroanterior, lateral, and 45° mediately after surgery. The splint was removed and semipronated oblique views standardized by 2 radiog- wrist exercises were initiated 3 weeks after the surgery. raphers were acquired via digital radiography and saved Resisted or weight-bearing exercise was allowed after using a picture archiving and communications system healing was established. Clinical and radiographic con- (PACS) (Mediface; Infinitt, Seoul, Republic of Korea). trols were performed at 4, 8, and 12 weeks and at the The axes and angles were measured using the software end of follow-up. tool in the PACS. The long axis of the scaphoid in the posteroanterior and semipronated oblique views was Evaluation determined as a line between the center of the distal Clinical evaluations as well as the pain scale, range of tuberosity and the most convex point of the proximal motion, grip strength, and functional outcome based on pole of the scaphoid, and the long axis of the scaphoid the Mayo wrist score system24 were performed at the was determined as the volar outline in the lateral view end of follow-up. (Fig. 1). The relationship between (1) the long axis of JHS Vol A, February 
  • 4. PERCUTANEOUS SCREW FIXATION FOR SCAPHOID FRACTURE 231 TABLE 2. Clinical Results of the Dorsal Approach and the Volar Approach Groups Group Dorsal (n 22) Volar (n 19) Range Range Variables Median (Minimum–Maximum) Mean (SD) Median (Minimum–Maximum) Mean (SD) p Value* Pain 25 10 (15–25) 23.18 (2.91) 25 5 (20–25) 23.42 (2.39) .910 Flexion (°) 65 15 (60–75) 66 (4) 65 20 (60–80) 67 (6) .989 Extension (°) 63 20 (50–70) 61 (5) 60 15 (50–65) 60 (5) .300 Radial deviation (°) 25 11 (20–31) 25 (2) 24 5 (22–27) 24 (1) .380 Ulnar deviation (°) 34 10 (26–36) 32 (3) 33 7 (31–38) 34 (2) .414 Modified Mayo wrist 100 80–100 96 (6) 95 85–100 95 (6) .446 score (points) Statistically significant at p .05. *The result of the Mann-Whitney U test. the Herbert screw with respect to the long axis of the pain was reduced by internal fixation of the scaphoid 2 scaphoid and (2) the fracture line with respect to the or 3 days postoperatively. The outcome measurements angle of the long axis of the scaphoid was measured of pain, tenderness, range of motion, grip strength, and on the posteroanterior, lateral, and semipronated Mayo wrist score are shown in Table 2. The 2 groups oblique views. This measurement was conducted were similar at the baseline for all outcome measure- by 1 hand surgeon who was not involved in the ments and the mean follow-up period (Table 1). Over- treatment and 1 musculoskeletal radiologist, twice all, the final range of motion of the wrist in both groups by both practicioners. When there were any dis- averaged 66° (range, 60° to 80°) of flexion, 61° (range, agreements between the measurements, the measure- 50° to 65°) of extension, 25° (range, 20° to 31°) of ments were repeated until agreement was reached. radial deviation, and 33° (range, 28° to 38°) of ulnar Radiologic union was defined as cross-trabeculation deviation. In the dorsal approach group, averages of 66° on all radiographic views, and radiographic signs of of flexion and 61° of extension were recorded, and in arthrosis were checked. the volar approach group, averages of 67° of flexion and 60° of extension were recorded. Statistical analyses Although the volar group demonstrated slightly Statistical analyses were performed for comparisons greater flexion and less extension, there was no statis- between age, gender, and all clinical factors between the tically significant difference between the 2 groups (p volar and the dorsal groups. All variables in each group .05) (Table 2). were described as mean, SD, median, range for quantita- According to the more stringent modified Mayo tive variables, and frequency with a percentage for quali- wrist score system,24 the functional results in the dorsal tative variables. To compare the 2 groups for all variables approach group were excellent for 18 patients, good for (except gender), a Mann-Whitney U test was used, be- 3 patients, and fair for 1 patient; however, in the volar cause a normality test was not appropriate. A chi-square approach group, 15 patients had excellent results and 4 test was performed for gender. Statistical software patients showed good results. There was no statistically (SPSS, ver. 12.0; SPSS Inc., Chicago, IL) was used, significant difference between the 2 groups (p .446). and a p value .05 was considered significant. The fracture union was diagnosed in all but 1 patient on the visit at 12 weeks. This delayed union in the volar RESULTS group required additional splint immobilization, and Clinical results complete radiographic union was achieved 20 weeks The demographics of the 2 groups were very similar after surgery. There was no statistically significant dif- according to age, gender, time between injury and sur- ference between the 2 groups regarding the fracture gery, and follow-up time (Table 1). Most subjective union (p .683). JHS Vol A, February 
  • 5. 232 PERCUTANEOUS SCREW FIXATION FOR SCAPHOID FRACTURE FIGURE 2: A, B. The angle between the long axis of the scaphoid and the Herbert screw is measured using the standard postoperative radiograph. The long axis of the scaphoid is marked with a dotted black line, and the long axis of the Herbert screw is marked with a dotted red line. The Herbert screw in A the dorsal approach is placed more parallel to the long axis of the scaphoid than in B the volar approach. C, D. The angle between the fracture site and the long axis of the Herbert screw is measured in the standard postoperative radiograph. The fracture line of the scaphoid is marked with a dotted black line, and the long axis of the Herbert screw is marked with a dotted red line. The Herbert screw in C the dorsal approach is placed more vertical to the horizontal fracture line of the scaphoid than in D the volar approach. Radiographic result of the scaphoid than that in the volar approach group (Fig. 2A, B). The average angle between the Radiographs made at the time of the surgery were screw and the scaphoid in the dorsal approach used for axis measurements. The analysis of the group was 11° at posteroanterior view, 8° at lateral inclination of the fracture line showed there was no view, and 8° at semipronated oblique view. On the statistically significant difference between the 2 other hand, in the volar approach group, the aver- groups at 3 different radiographic views. The mean age angle between the screw and scaphoid was 13° inclination angle in the dorsal approach group was at posteroanterior view, 13° at lateral view, and 81°, and it was 82° in the volar approach group (p 16° at semipronated oblique view. Although the .788). Radiographs at the time of the most screws showed no significant difference between recent follow-up revealed that all fractures had the 2 groups in posteroanterior and lateral views, healed. screws in the dorsal approach group were observed The angle between the screw and the scaphoid long axis at 3 different to be placed more parallel to the long axis of the views: The position of the screw in the dorsal scaphoid in the semipronated oblique view (p approach group was more parallel to the long axis .019) (Table 3). JHS Vol A, February 
  • 6. PERCUTANEOUS SCREW FIXATION FOR SCAPHOID FRACTURE 233 TABLE 3. Comparison of Radiographic Results Between the Dorsal Approach and the Volar Approach Groups Group Dorsal (n 22) Volar (n 19) Range Mean Range Variables Median (Minimum–Maximum) (SD) Median (Minimum–Maximum) Mean (SD) p Value* Long axis–screw 10 33 (0–33) 11 (10) 14 26 (2–28) 13 (9) .416 posteroanterior (°) Long axis–screw lateral (°) 6 30 (0–30) 8 (8) 14 36 (0–36) 13 (10) .148 Long axis–screw oblique (°)‡ 40 (0–40) 8 (9) 9 19 (3–22) 10 (5) .019† Fracture line–screw 81 30 (60–90) 80 (8) 72 30 (59–89) 74 (10) .039† posteroanterior (°) Fracture line–screw lateral (°) 85 20 (70–90) 83 (6) 72 28 (58–86) 72 (8) .000† Fracture line–screw 82 23 (65–88) 80 (6) 77 39 (50–89) 73 (12) .023† oblique (°)‡ *The result of the Mann-Whitney U test. †Statistically significant at p .05. ‡Oblique: 45° inclined semipronated oblique view. The angle between the screw and vertical to the fracture line at 3 different DISCUSSION views: The screws in the dorsal approach group were Nondisplaced fractures of the scaphoid waist were man- positioned more perpendicular to the fracture lines of aged with immobilization as the standard treatment; the scaphoid compared with those of the volar approach however, unstable and displaced scaphoid fractures when group (Fig. 2C, D). The average angle between the 2 treated with plaster immobilization are at the greatest risk axes in the dorsal approach group was 80° at posteroan- of nonunion.25 Reports on open internal fixation of scaph- terior view, 83° at lateral view, and 80° at semipronated oid fractures have documented a high rate of union,26,27 oblique view. In the volar approach group, the average but there are risks of violating intact volar ligaments and, angle between the 2 axes was 74° at posteroanterior subsequently, carpal instability.28,29 In addition, surgical view, 72° at lateral view, and 73° at semipronated trauma of the soft tissue around the scaphoid, which oblique view. There was a statistically significant dif- has tenuous vascular supply, shows a risk of delayed ference between the dorsal approach group and the healing or nonunion.30 Thus, recently, there has been volar approach group for all 3 different radiographic an increased trend toward percutaneous fixation for views (p .05) (Table 3). displaced scaphoid fractures. This procedure bears the inherent advantages of limited soft tissue dissec- Complications tion and it hastens fracture healing.5 There were no perioperative complications. None of the Many authors have reported good or excellent func- patients showed radiographic signs of arthrosis during tional outcome with percutaneous screw fixation (Ap- the study period. One patient sustained an injury of the pendix; this appendix may be viewed at the Journal’s superficial branch of the radial artery during the volar Web site, www.jhandsurg.org). Use of cannulated AO approach, and there was 1 instance of a delayed union, screws,14,15,17 cannulated Acutrak screws,8,20,31,32 or which required additional splint immobilization. One non-cannulated Herbert screws6,10,13,16 have been re- patient in the dorsal approach group complained of a ported in previous studies. Although cannulated painful hypertrophic scar on the dorsum of the wrist; no screws have resulted in a higher rate of central additional procedures were necessary. There were no placement in the scaphoid with better resistance complications related to Herbert screw (ie, migration or and compressive forces,33 in our experience we loosening). None of the patients showed stiffness of the found that a non-cannulated Herbert screw, using the fingers or thumb, nor did they develop complex re- freehand method, is also reliable for acute scaphoid gional pain syndrome. fractures. JHS Vol A, February 
  • 7. 234 PERCUTANEOUS SCREW FIXATION FOR SCAPHOID FRACTURE Both the volar approach and the dorsal approach for proximal fragment had superior results of stiffness, load acute fractures have been reported in the literature. at displacement, and load at failure compared with Streli2 in 1970 first reported a detailed surgical tech- those after eccentric positioning of the screw. The com- nique of percutaneous screw fixation for scaphoid frac- parative study by Chan and McAdams22 on 12 cadav- ture; this was followed by Wozasek and Moser16 in eric models demonstrated that the proximal/dorsal ap- 1991. Since then, the majority of series have been proach to percutaneous screw fixation of scaphoid waist operated via the volar distal approach with successful fractures allowed for a more central placement in the outcome; however, the dorsal approach became popular distal pole, but there was no marked difference when it after the method was introduced by Slade et al.18 in was used in the proximal or waist regions. 2001. The reported union time in the volar approach Radiographic analysis of the 2 groups in our study varied from 6 to 18 weeks with different screw fixation confirmed that screws were inserted in a more favorable methods.3–17 The union time in the dorsal approach was position (ie, perpendicular to the fracture line) through reported as being between 8 to 12 weeks.21,31,32 The the dorsal approach than through the volar approach. union rate was 89% to 100%. On the other hand, This might have biomechanical advantages in terms of complications were also reported related to both meth- fracture healing; however, this was not confirmed in our ods of fixation.32 Complex regional pain syndrome, study. In addition, 45° semipronated oblique view con- superficial skin infection, and nonunion3,4,15 have been firmed that the screws were placed more parallel to the reported in the volar approach. In the dorsal approach, long axis of the scaphoid through the dorsal approach. only 1 extensor pollicis longus rupture and one non- In the volar approach, the guide wire tends to lead the union (3%)31 have been reported (Appendix; this ap- screw to volar placement in the distal pole. pendix may be viewed at the Journal’s Web site, www. Our study demonstrated that union was achieved in jhandsurg.org). all but 1 case, with similar time to union in the volar and Slade et al. used an arthroscopic-assisted approach in the dorsal groups. The clinical results of this study all patients, and it allowed confirmation of fracture suggest that both the volar and the dorsal approaches reduction and screw implantation as well as an evalu- offered reliable results. There was no significant differ- ation of concurrent ligament injuries that could not be ence between the 2 groups in terms of union time and detected with standard imaging. functional outcome, which included pain, range of mo- The advantages of the dorsal approach were the tion, return to work, and grip strength. Functional result exact targeting of the central axis of the scaphoid, more at last follow-up demonstrated that 82% of patients in precise placement of the screw within the scaphoid, and the volar group and 79% in the dorsal group were avoiding injury to the volar carpal ligament.18 On the graded as excellent according to the Mayo wrist score other hand, the volar approach has easier access to the system.24 There was 1 delayed union in the volar ap- entry because the guide wire does not cross the radio- proach group and 1 painful hypertrophic scar in the carpal joint, there are less technically demanding, dorsal approach group. No hardware-related problems and it is easy to maintain fracture reduction with as reported by Bushnell et al.32 were observed in our wrist extension, so there is no risk of injuring the study. These results were comparable with those of extensor tendons. other reports (Appendix; this appendix may be viewed It has been shown that the technical aspects of screw at the Journal’s Web site, www.jhandsurg.org). insertion are important for the clinical outcome after In our practice, we used exclusively the volar ap- fixation of acute fractures of the scaphoid waist.14,34 proach influenced by excellent results reported by The study of Trumble et al.14 concluded that central Wozasek and Moser16 and Inoue and Shionoya9 from placement of the screw in the proximal fragment of the 1999 to 2001. Since 2001, we learned that the dorsal scaphoid with either the cannulated or Herbert screw is approach introduced by Slade et al.18 provided better associated with a significant reduction in the times to targeting and more precise placement. Thus, we union (p .05). In addition, there is evidence that the changed our policy to the dorsal approach since then. postoperative range of motion is associated with the This study is one of the largest series analyzing the degree of scaphoid alignment achieved by internal fix- outcome of percutaneous scaphoid fixation. ation; however, their study was carried out in a non- The subjects in our study are relatively uniform with union series that had been present for more than 4 regard to age, interval between injury and surgery, and months and not in the acute fractures. The biomechani- follow-up time. The analysis of the fracture pattern and cal study of McCallister et al.35 in the cadaveric model characteristics are crucial in this study. In this retrospec- confirmed that the central placement of a screw in the tive study, we excluded any fracture in the distal one JHS Vol A, February 
  • 8. PERCUTANEOUS SCREW FIXATION FOR SCAPHOID FRACTURE 235 third or proximal one third of the scaphoid, and the Percutaneous Herbert screw fixation for fractures of the scaphoid: review of 30 cases. Chir Main 2002;21:350 –354. collection was relatively homogenous. There was no 7. Chen AC, Chao EK, Hung SS, Lee MS, Ueng SW. Percutaneous vertical fracture in the waist. Analysis of the inclination screw fixation for unstable scaphoid fractures. J Trauma 2005;59: of the fracture line at 3 different radiographic views 184 –187. showed there was no statistically significant difference 8. Haddad FS, Goddard NJ. Acute percutaneous scaphoid fixation. A pilot study. J Bone Joint Surg 1998;80B:95–99. between the 2 groups. All surgeries were performed by 9. Inoue G, Shionoya K. Herbert screw fixation by limited acess for the same surgeon at the single institute. The patients acute fractures of the scaphoid. J Bone Joint Surg 1997;79B: were evaluated by an independent doctor who was not 418 – 421. 10. Jeon IH, Oh CW, Park BC, Ihn JC, Kim PT. Minimal invasive involved in the treatment. percutaneous Herbert screw fixation in acute unstable scaphoid frac- This study has the limitation of lack of assessment of ture. Hand Surg 2003;8:213–218. intraobserver and interobserver variability for reproduc- 11. Ledoux P, Chahidi N, Moermans JP, Kinnen L. Percutaneous Her- bert screw osteosynthesis of the scaphoid bone. Acta Orthop Belg ible and reliable studies. The geometry of the scaphoid 1995;61:43– 47. lacks symmetry in any single plane, thus, its true central 12. Shih JT, Lee HM, Hou YT, Tan CM. Results of arthroscopic reduc- axis is inherently a 3-dimensional entity. Thus, this tion and percutaneous fixation for acute displaced scaphoid fractures. study has a limitation in identification of the true long Arthroscopy 2005;21:620 – 626. 13. Taras JS, Sweet S, Shum W, Weiss LE, Bartolozzi A. Percutaneous axis of the scaphoid, because this is based on an inter- and arthroscopic screw fixation of scaphoid fractures in the athlete. pretation of single planar imaging in 3 different planes. Hand Clin 1999;15:467– 473. Thus, a 3-dimensional imaging technique of screw 14. Trumble TE, Clarke T, Kreder HJ. Non-union of the scaphoid. Treatment with cannulated screws compared with treatment with placement (such as with 3-dimensional CT reconstruc- Herbert screws. J Bone Joint Surg 1996;78A:1829 –1837. tion) is warranted to compare the volar and the dorsal 15. Wong TC, Yip TH, Wu WC. Carpal ligament injuries with acute techniques in the future. This measurement was con- scaphoid fractures—a combined wrist injury. J Hand Surg 2005;30B: 415– 418. ducted independently by 1 hand surgeon who was not 16. Wozasek GE, Moser K. Percutaneous screw fixation for fractures of involved in the treatment and by 1 musculoskeletal radi- the scaphoid. J Bone Joint Surg 1991;73B:138 –142. ologist. In addition, this study contains the inherent weak- 17. Yip HS, Wu WC, Chang RY, So TY. Percutaneous cannulated screw ness of the retrospective study, a small sample size, and fixation of acute scaphoid waist fracture. J Hand Surg 2002;27B: 42– 46. absence of power analysis. None of the outcomes differed 18. Slade JF III, Grauer JN, Mahoney JD. Arthroscopic reduction and significantly between the 2 groups, but this conclusion percutaneous fixation of scaphoid fractures with a novel dorsal must be evaluated carefully given the potential of low technique. Orthop Clin North Am 2001;32:247–261. 19. Slade JF III, Jaskwhich D. Percutaneous fixation of scaphoid frac- power to detect clinically important differences. We did tures. Hand Clin 2001;17:553–574. collect all patients who satisfied the inclusion criteria 20. Slade JF III, Taksali S, Safanda J. Combined fractures of the scaphoid during the time, so all available patients were used. and distal radius: a revised treatment rationale using percutaneous and arthroscopic techniques. Hand Clin 2005;21:427– 441. Further, the size of the difference between the 2 groups 21. Slade JF III, Gutow AP, Geissler WB. Percutaneous internal fixation was small for each outcome variable, and good out- of scaphoid fractures via an arthroscopically assisted dorsal ap- comes were observed in both groups, so we do not proach. J Bone Joint Surg 2002;84A:21–36. believe clinically important differences were missed 22. Chan KW, McAdams TR. Central screw placement in percutaneous screw scaphoid fixation. A cadaveric comparison of proximal and due to sample size limitations. Nevertheless, a prospec- distal techniques. J Hand Surg 2004;29A:74 –79. tive controlled study with appropriate power analysis in 23. Herbert TJ, Fisher WE. Management of the fractured scaphoid using advance is required in the future. a new bone screw. J Bone Joint Surg 1984;66B:114 –123. 24. Cooney WP, Dobyns JH, Linscheid RL. Fractures of the scaphoid: a rational approach to management. Clin Orthop 1980;149:90 –97. REFERENCES 25. Gellman H, Caputo RJ, Carter V, Aboulafia A, Mckay M. Com- 1. Hove LM. Epidemiology of scaphoid fractures in Bergen, Norway. parison of short and long thumb-spica casts for non-displaced Scand J Plast Reconstr Surg Hand Surg 1999;33:423– 426. fractures of the carpal scaphoid. J Bone Joint Surg 1989;71B: 2. Streli R. Percutaneous screwing of the navicular bone of the hand 354 –357. with a compression drill screw (a new method). Zentralbl Chir 26. Rettig AC, Kollias SC. Internal fixation of acute stable scaphoid 1970;95:1060 –1078. fractures in the athlete. Am J Sports Med 1996;2:182–186. 3. Adolfsson L, Lindau T, Arner M. Acutrak screw fixation versus cast 27. Rettig ME, Kozin SH, Cooney WP. Open reduction and internal immobilization for undisplaced scaphoid fractures. J Hand Surg fixation of acute displaced scaphoid waist fractures. J Hand Surg 2001;26B:192–195. 2001;26A:271–276. 4. Arora R, Gschwentner M, Krappinger D, Lutz M, Blauth M, Gabl M. 28. Filan SL, Herbert TJ. Herbert screw fixation of scaphoid fractures. Fixation of nondisplaced scaphoid fractures: making treatment cost J Bone Joint Surg 1996;78B:519 –529. effective. Prospective controlled trial. Arch Orthop Trauma Surg 29. Garcia-Elias M, Vall A, Salo JM, Lluch AL. Carpal alignment after 2007;127:39 – 46. different surgical approaches to the scaphoid: a comparative study. 5. Bond CD, Shin AY, McBride MT, Dao KD. Percutaneous screw J Hand Surg 1988;13A:604 – 612. fixation or cast immobilization for nondisplaced scaphoid fractures. 30. Botte MJ, Mortensen WW, Gelberman RH, Rhoades CE, Gellman J Bone Joint Surg 2001;83A:483– 488. H. Internal vascularity of the scaphoid in cadavers after insertion of 6. 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  • 9. 236 PERCUTANEOUS SCREW FIXATION FOR SCAPHOID FRACTURE 31. Bedi A, Jebson PJ, Hayden RJ, Jacobson JA, Martus JE. Internal 34. Adams BD, Blair WF, Reagan DS, Grundberg AB. Technical fixation of acute, nondisplaced scaphoid waist fractures via a limited factors related to Herbert screw fixation. J Hand Surg 1988;13A: dorsal approach: an assessment of radiographic and functional out- 893– 899. comes. J Hand Surg 2007;32A:326 –333. 35. McCallister WV, Knight J, Kaliappan R, Trumble TE. Central 32. Bushnell BD, McWilliams AD, Messer TM. Complications in dorsal placement of the screw in simulated fractures of the scaphoid waist: a percutaneous cannulated screw fixation of nondisplaced scaphoid biomechanical study. J Bone Joint Surg 2003;85A:72–77. waist fractures. J Hand Surg 2007;32A:827– 833. 36. McQueen MM, Gelbke MK, Wakefield A, Will EM, Gaebler C. 33. Toby EB, Butler TE, McCormack TJ, Jayaraman G. A comparison Percutaneous screw fixation versus conservative treatment for frac- of fixation screws for the scaphoid during application of cyclical tures of the waist of the scaphoid: a prospective randomised study. bending loads. J Bone Joint Surg 1997;79A:1190 –1197. J Bone Joint Surg 2008;90B:66 –71. JHS Vol A, February 
  • 10. PERCUTANEOUS SCREW FIXATION FOR SCAPHOID FRACTURE 236.e1 APPENDIX. Review of the Literature on Percutaneous Fixation for Acute Scaphoid Fracture Number of Union Time Authors Year Patients Approach Instrument Union (%) (Mean, Weeks) Functional Outcome 16 Wozasek and Moser 1991 130 Volar Conventional screw 89 ND Full functional restoration with washer Ledoux et al.11 1995 23 Volar Herbert screw 100 ND 95% of unaffected side Inoue and Shionoya9 1997 40 Volar Herbert screw 100 6 2.1 Satisfactory wrist function in 37 of 40 Haddad and Goddard8 1998 15 Volar Acutrak screw 100 8 13 excellent, 2 good Taras et al.13 1999 5 Volar Herbert screw 100 8.2 ND Adolfsson et al.3 2001 25 Volar Acutrak standard 92 16 12 of 23: 6% ROM loss Bond et al.5 2001 11 Volar Acutrak screw 100 7 Overall satisfied Slade et al.21 2002 27 Dorsal Acutrak screw 100 12 90% to 95% of ROM (arthroscopic assisted) Brutus et al.6 2002 30 Volar Herbert screw 90 ND 86.6% screw perpendicular to fracture line Yip et al.17 2002 49 Volar AO/ASIF 100 12 All: excellent (no criteria) cannulated screw Jeon et al.10 2003 13 Volar Herbert screw 100 9.2 93%: no or minimal loss of function (Herbert score) Chen et al.7 2005 11 Volar Cannulated screw 100 10.6 6 of 11: excellent 5 of 11: good (Mayo score) Shih et al.12 2005 15 Volar Cannulated screw 100 ND 11 of 15: excellent (Mayo score) Wong et al.15 2005 52 Volar AO/ASIF 96 11 Mean 90; 75% excellent (Mayo cannulated and score) Acutrak screw Arora et al.4 2007 21 Volar Cannulated screw 95 6 ND Bedi et al.32 2007 18 Dorsal Acutrak screw 94 8 DASH score 6 of 100 Bushnell et al.32 2007 24 Dorsal Acutrak or Twinfix 96 ND 29% complication rate McQueen et al.36 2008 30 Volar Acutrak 97 9.2 100% excellent/good (Green/ O’Brien score) Author 2007 22 Volar Herbert screw 100 9.36 18 of 22: excellent 4 of 22: good (Mayo score) Author 2007 19 Dorsal Herbert screw 100 9.50 15 of 19: excellent 4 of 19: good (Mayo score) AO/ASIF, Arbeitsgemeinschaft fuer Osteosynthesefragen–Association for the Study of Internal Fixation; Arbeitsgemeinschaft fuer Osteosynthe- sefragen–Association for the Study of Internal Fixation; ND, not described; DASH, Disabilities of the Arm, Shoulder, and Hand; ROM, range of motion; Mayo score, Mayo wrist score system.24 Note: We searched Medline, PubMed, and Web of Science databases from 1990 to 2007 using key words “percutaneous” or “scaphoid” or “fracture” in combination with “percutaneous scaphoid” and “percutaneous scaphoid fixation” and we also examined the references lists of the retrieved articles. We limited the publications to acute scaphoid fracture and also excluded the review articles, technical reports, and any publications dealing with nonunion, or no description on union rate. Thus, we included only (1) English language full-length publications in peer-reviewed journals and (2) publications with data of union (or union time) and functional outcome. JHS Vol A, February 