J Wrist Surg 2021; 10(05): 418-429
DOI: 10.1055/s-0041-1730342
Scientific Article

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

1   Department of Orthopedics, Hand Surgery Unit, Herlev/Gentofte Copenhagen University Hospital, Hellerup, Denmark
,
Benjamin Presman
2   Department of Orthopedics, Hvidovre Copenhagen University Hospital, Hvidovre, Denmark
,
Morten Bo Larsen
1   Department of Orthopedics, Hand Surgery Unit, Herlev/Gentofte Copenhagen University Hospital, Hellerup, Denmark
,
Dimitar Ivanov Radev
3   Department of Radiology, Bispebjerg/Frederiksberg Copenhagen University Hospital, Copenhagen NV, Denmark
,
Stig Joerring
1   Department of Orthopedics, Hand Surgery Unit, Herlev/Gentofte Copenhagen University Hospital, Hellerup, Denmark
,
Claus Hjorth Jensen
1   Department of Orthopedics, Hand Surgery Unit, Herlev/Gentofte Copenhagen University Hospital, Hellerup, Denmark
› Institutsangaben

Abstract

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.

Note

This study was performed at Herlev/Gentofte Copenhagen University Hospital, Hand Surgery Unit.


Ethical Approval

Ethical committee approval for retrospective studies is not necessary in Denmark. This study acquired necessary approval by the Danish Patient Safety Authority, case number 3–3013–2815/1.




Publikationsverlauf

Eingereicht: 10. Januar 2021

Angenommen: 13. April 2021

Artikel online veröffentlicht:
02. Juli 2021

© 2021. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 
  • References

  • 1 Larsen CF, Brøndum V, Skov O. Epidemiology of scaphoid fractures in Odense, Denmark. Acta Orthop Scand 1992; 63 (02) 216-218
  • 2 Hove LM. Epidemiology of scaphoid fractures in Bergen, Norway. Scand J Plast Reconstr Surg Hand Surg 1999; 33 (04) 423-426
  • 3 Jørgsholm P, Ossowski D, Thomsen N, Björkman A. Epidemiology of scaphoid fractures and non-unions: a systematic review. Handchir Mikrochir Plast Chir 2020; 52 (05) 374-381
  • 4 Szabo RM, Manske D. Displaced fractures of the scaphoid. Clin Orthop Relat Res 1988; (230) 30-38
  • 5 Grewal R, Suh N, Macdermid JC. Use of computed tomography to predict union and time to union in acute scaphoid fractures treated nonoperatively. J Hand Surg Am 2013; 38 (05) 872-877
  • 6 Clay NR, Dias JJ, Costigan PS, Gregg PJ, Barton NJ. Need the thumb be immobilised in scaphoid fractures? A randomised prospective trial. J Bone Joint Surg Br 1991; 73 (05) 828-832
  • 7 Ruby LK, Stinson J, Belsky MR. The natural history of scaphoid non-union. A review of fifty-five cases. J Bone Joint Surg Am 1985; 67 (03) 428-432
  • 8 Lindström G, Nyström A. Incidence of post-traumatic arthrosis after primary healing of scaphoid fractures: a clinical and radiological study. J Hand Surg [Br] 1990; 15 (01) 11-13
  • 9 Inoue G, Sakuma M. The natural history of scaphoid non-union. Radiographical and clinical analysis in 102 cases. Arch Orthop Trauma Surg 1996; 115 (01) 1-4
  • 10 Russe O. Fracture of the carpal navicular. Diagnosis, non-operative treatment, and operative treatment. J Bone Joint Surg Am 1960; 42-A: 759-768
  • 11 Tambe AD, Cutler L, Murali SR, Trail IA, Stanley JK. In scaphoid non-union, does the source of graft affect outcome? Iliac crest versus distal end of radius bone graft. J Hand Surg [Br] 2006; 31 (01) 47-51
  • 12 Zaidemberg C, Siebert JW, Angrigiani C. A new vascularized bone graft for scaphoid nonunion. J Hand Surg Am 1991; 16 (03) 474-478
  • 13 Steinmann SP, Bishop AT, Berger RA. Use of the 1,2 intercompartmental supraretinacular artery as a vascularized pedicle bone graft for difficult scaphoid nonunion. J Hand Surg Am 2002; 27 (03) 391-401
  • 14 Straw RG, Davis TR, Dias JJ. Scaphoid nonunion: treatment with a pedicled vascularized bone graft based on the 1,2 intercompartmental supraretinacular branch of the radial artery. J Hand Surg [Br] 2002; 27 (05) 413
  • 15 Chang MA, Bishop AT, Moran SL, Shin AY. The outcomes and complications of 1,2-intercompartmental supraretinacular artery pedicled vascularized bone grafting of scaphoid nonunions. J Hand Surg Am 2006; 31 (03) 387-396
  • 16 Braga-Silva J, Peruchi FM, Moschen GM, Gehlen D, Padoin AV. A comparison of the use of distal radius vascularised bone graft and non-vascularised iliac crest bone graft in the treatment of non-union of scaphoid fractures. J Hand Surg Eur Vol 2008; 33 (05) 636-640
  • 17 Chu PJ, Shih JT. Arthroscopically assisted use of injectable bone graft substitutes for management of scaphoid nonunions. Arthroscopy 2011; 27 (01) 31-37
  • 18 Wong WY, Ho PC. Minimal invasive management of scaphoid fractures: from fresh to nonunion. Hand Clin 2011; 27 (03) 291-307
  • 19 Kim JP, Seo JB, Yoo JY, Lee JY. Arthroscopic management of chronic unstable scaphoid nonunions: effects on restoration of carpal alignment and recovery of wrist function. Arthroscopy 2015; 31 (03) 460-469
  • 20 Kang HJ, Chun YM, Koh IH, Park JH, Choi YR. Is arthroscopic bone graft and fixation for scaphoid nonunions effective?. Clin Orthop Relat Res 2016; 474 (01) 204-212
  • 21 Cognet JM, Louis P, Martinache X, Schernberg F. Arthroscopic grafting of scaphoid nonunion - surgical technique and preliminary findings from 23 cases. Hand Surg Rehabil 2017; 36 (01) 17-23
  • 22 Slade III JF, Dodds SD. Minimally invasive management of scaphoid nonunions. Clin Orthop Relat Res 2006; 445 (445) 108-119
  • 23 Slade III JF, Gillon T. Retrospective review of 234 scaphoid fractures and nonunions treated with arthroscopy for union and complications. Scand J Surg 2008; 97 (04) 280-289
  • 24 Mahmoud M, Koptan W. Percutaneous screw fixation without bone grafting for established scaphoid nonunion with substantial bone loss. J Bone Joint Surg Br 2011; 93 (07) 932-936
  • 25 Saint-Cyr M, Oni G, Wong C, Sen MK, LaJoie AS, Gupta A. Dorsal percutaneous cannulated screw fixation for delayed union and nonunion of the scaphoid. Plast Reconstr Surg 2011; 128 (02) 467-473
  • 26 Altay T, Gunal I, Kayali C, Sener M. Dorsal percutaneous screw fixation of delayed or nonunion of scaphoid fractures: decision making with MRI. Int Orthop 2014; 38 (05) 1007-1010
  • 27 Ohta S, Ikeguchi R, Noguchi T. et al. Percutaneous fixation for scaphoid nonunion with bone grafting through the distal insertion hole of a fully threaded headless screw. J Hand Surg Asian Pac Vol 2016; 21 (03) 357-363
  • 28 Vanhees M, van Riet RRP, van Haver A, Kebrle R, Meermans G, Verstreken F. Percutaneous, transtrapezial fixation without bone graft leads to consolidation in selected cases of delayed union of the scaphoid waist. J Wrist Surg 2017; 6 (03) 183-187
  • 29 Ramamurthy C, Cutler L, Nuttall D, Simison AJ, Trail IA, Stanley JK. The factors affecting outcome after non-vascular bone grafting and internal fixation for nonunion of the scaphoid. J Bone Joint Surg Br 2007; 89 (05) 627-632
  • 30 Weber ER. Biomechanical implications of scaphoid waist fractures. Clin Orthop Relat Res 1980; (149) 83-89
  • 31 Schweizer A, Fürnstahl P, Nagy L. Three-dimensional computed tomographic analysis of 11 scaphoid waist nonunions. J Hand Surg Am 2012; 37 (06) 1151-1158
  • 32 Schwarcz Y, Schwarcz Y, Peleg E, Joskowicz L, Wollstein R, Luria S. Three-dimensional analysis of acute scaphoid fracture displacement: proximal extension deformity of the scaphoid. J Bone Joint Surg Am 2017; 99 (02) 141-149
  • 33 Amadio PC, Berquist TH, Smith DK, Ilstrup DM, Cooney III WP, Linscheid RL. Scaphoid malunion. J Hand Surg Am 1989; 14 (04) 679-687
  • 34 Nakamura P, Imaeda T, Miura T. Scaphoid malunion. J Bone Joint Surg Br 1991; 73 (01) 134-137
  • 35 Burgess RC. The effect of a simulated scaphoid malunion on wrist motion. J Hand Surg Am 1987; 12 (5 Pt 1): 774-776
  • 36 Gillette BP, Amadio PC, Kakar S. Long-term outcomes of scaphoid malunion. Hand (N Y) 2017; 12 (01) 26-30
  • 37 Bhat M, McCarthy M, Davis TR, Oni JA, Dawson S. MRI and plain radiography in the assessment of displaced fractures of the waist of the carpal scaphoid. J Bone Joint Surg Br 2004; 86 (05) 705-713
  • 38 Mallee WH, Doornberg JN, Ring D. et al. Computed tomography for suspected scaphoid fractures: comparison of reformations in the plane of the wrist versus the long axis of the scaphoid. Hand (N Y) 2014; 9 (01) 117-121
  • 39 Cheema AN, Niziolek PJ, Steinberg D, Kneeland B, Kazmers NH, Bozentka D. The effect of computed tomography scans oriented along the longitudinal scaphoid axis on measurements of deformity and displacement in scaphoid fractures. J Hand Surg Am 2018; 43 (12) 1092-1097
  • 40 Bain GI, Bennett JD, MacDermid JC, Slethaug GP, Richards RS, Roth JH. Measurement of the scaphoid humpback deformity using longitudinal computed tomography: intra- and interobserver variability using various measurement techniques. J Hand Surg Am 1998; 23 (01) 76-81
  • 41 Singh HP, Forward D, Davis TRC, Dawson JS, Oni JA, Downing ND. Partial union of acute scaphoid fractures. J Hand Surg [Br] 2005; 30 (05) 440-445
  • 42 Koo TK, Li MY. A guideline of selecting and reporting intraclass correlation coefficients for reliability research. J Chiropr Med 2016; 15 (02) 155-163
  • 43 Buijze GA, Jørgsholm P, Thomsen NOB, Björkman A, Besjakov J, Ring D. Diagnostic performance of radiographs and computed tomography for displacement and instability of acute scaphoid waist fractures. J Bone Jt Surg - Ser A 2012; DOI: 10.2106/JBJS.K.00993.
  • 44 Afshar A, Mohammadi A, Zohrabi K, Navaeifar N, Sami SH, Taleb H. Correlation of reconstructed scaphoid morphology with clinical outcomes. Arch Bone Jt Surg 2015; 3 (04) 244-249
  • 45 Jiranek WA, Ruby LK, Millender LB, Bankoff MS, Newberg AH. Long-term results after Russe bone-grafting: the effect of malunion of the scaphoid. J Bone Jt Surg - Ser A 1992; DOI: 10.2106/00004623-199274080-00012.
  • 46 Forward DP, Singh HP, Dawson S, Davis TRC. The clinical outcome of scaphoid fracture malunion at 1 year. J Hand Surg Eur Vol 2009; 34 (01) 40-46
  • 47 Schuind F, Moungondo F, El Kazzi W. Prognostic factors in the treatment of carpal scaphoid non-unions. Eur J Orthop Surg Traumatol 2017; 27 (01) 3-9
  • 48 Lee CH, Lee KH, Lee BG, Kim DY, Choi WS. Clinical outcome of scaphoid malunion as a result of scaphoid fracture nonunion surgical treatment: a 5-year minimum follow-up study. Orthop Traumatol Surg Res 2015; 101 (03) 359-363
  • 49 ten Berg PWL, Dobbe JGG, Strackee SD, Streekstra GJ. Quantifying scaphoid malalignment based upon height-to-length ratios obtained by 3-dimensional computed tomography. J Hand Surg Am 2015; 40 (01) 67-73
  • 50 Ring D, Patterson JD, Levitz S, Wang C, Jupiter JB. Both scanning plane and observer affect measurements of scaphoid deformity. J Hand Surg Am 2005; 30 (04) 696-701
  • 51 Megerle K, Harenberg PS, Germann G, Hellmich S. Scaphoid morphology and clinical outcomes in scaphoid reconstructions. Injury 2012; 43 (03) 306-310
  • 52 Mathoulin CL, Arianni M. Treatment of the scaphoid humpback deformity - is correction of the dorsal intercalated segment instability deformity critical?. J Hand Surg Eur Vol 2018; 43 (01) 13-23
  • 53 Aibinder WR, Wagner ER, Bishop AT, Shin AY. Bone grafting for scaphoid nonunions: is free vascularized bone grafting superior for scaphoid nonunion?. Hand (N Y) 2019; 14 (02) 217-222
  • 54 Oh WT, Kang HJ, Chun YM, Koh IH, Lee YJ, Choi YR. Retrospective comparative outcomes analysis of arthroscopic versus open bone graft and fixation for unstable scaphoid nonunions. Arthroscopy 2018; 34 (10) 2810-2818
  • 55 Guldbrandsen CW, Gvozdenovic R. Normal ranges for measurements of the scaphoid bone from sagittal computed tomography images. J Hand Surg 2021; 46 (06) 594-599