Martin Caloia

Incidence of Ligamentous and Other Injuries Associated With Scaphoid Fractures During Arthroscopically Assisted Reduction and Percutaneous Fixation

PURPOSE The purpose of this study was to describe chondral/osteochondral and ligamentous injuries associated with scaphoid fractures treated with arthroscopically assisted reduction and percutaneous fixation. METHODS The study consisted of 8 patients with stable scaphoid fractures and 16 with unstable scaphoid fractures. The mean age was 32 +/- 14 years (range, 17 to 75 years). The arthroscopic findings were recorded, including intrinsic and extrinsic ligamentous injuries as well as osteochondral injuries. Percutaneous screw fixation through a dorsal approach was performed. In all patients with associated soft-tissue injuries, a short-arm thumb spica cast was used for a 3- to 6-week period. Follow-up included clinical evaluation with the Mayo Modified Wrist Score and plain radiographs. The mean follow-up time was 27 +/- 16 months, with a minimum of 1 year. The mean healing time was 7 +/- 4 weeks (range, 6 to 24 weeks). RESULTS Associated soft-tissue and/or chondral/osteochondral injuries were diagnosed arthroscopically in 15 of 24 cases in this series. The result was scored as good or excellent in 23 patients and poor in 1. Complications included 1 case with partial necrosis of the proximal scaphoid pole and 2 patients with loss of wrist flexion and grip strength that improved after hardware removal. CONCLUSIONS In this series, 15 of 24 patients with acute scaphoid fractures presented with associated ligamentous and/or chondral/osteochondral injuries. LEVEL OF EVIDENCE Level IV, therapeutic case series.

Arthroscopic Treatment of Scaphoid Nonunion Without Bone Graft and Distal Radius Core Decompression A New Approach to an Old Problem—Preliminary Report

Introduction: The scaphoid bone is the most commonly broken carpal bone and an untoward characteristic of this bone is its unpredictable union. The management of scaphoid nonunion still remains controversial with a reported failure rate up to 40% and absence of a “gold standard” of treatment. Based on the new concepts of the potential osteogenic capacity of the nonunion cells with the ability to heal, the encouraging results generated by increasing vascularization within the metaphyseal radius, and ulna decompression used in the treatment of Kienböck disease as well as the advantages of minimal surgical trauma using percutaneous and arthroscopic techniques, we propose to treat scaphoid nonunions with (a) arthroscopic-assisted reduction and internal fixation (AASSIF) and adding (b) metaphyseal core decompression of the distal radius (MCDDR) in advanced stages, without bone graft. Material and Methods: We evaluated retrospectively 48 patients with scaphoid nonunions treated prospectively by (AASSIF) with (MCDDR) in 48 cases. The average age was 30.63 years. The right side was affected in 31 patients, and 79.7% corresponded to the dominant extremity. The mean time from injury to surgery was 22.93 months. The nonunions were grouped according to the Slade-Dodds classification. Results: Scaphoid union was obtained in 44 patients, 4 patients failed to obtain healing. One patient decided to not be operated again, because of the lack of symptoms. Three required a new surgical procedure 9 months later. In 2 patients, the failures were by improper placement of the screw, although these patients had no symptoms. In cystic and/or magnitude bone nonunion defects with large zones of necrosis, defect filling was observed, even in those cases in which the loss of bone stock exceeded 10 mm. The biological effect of the metaphyseal decompression characterized by an increased hyperemia over the radial column was demonstrated with SPECT studies. The visual analogue scale showed an average of 1.04 (0-2) postoperative pain. The average postoperative range of function was 65.3° extension (range, 46° to 88°), 69.2° flexion (range, 55° to 88°), 10.7° radial deviation (range, 5° to 20°), and 26° ulnar deviation (range, 20° to 37°). The average Mayo score was 95 ± 6. Conclusion: We recommend arthroscopic-assisted internal fixation without bone grafting and core decompression of the distal radius for young or middle-aged nonsmoking patients with scaphoid nonunions including cystic and deformed types, typical of advanced stages. The method is not recommended for nonunions with significant sclerosis or in those with a very small proximal fragment in which solid screw fixation would be questionable.

Surgical Versus Nonsurgical Treatment of Ulnar Styloid Fractures in the Context of Distal Radius Fractures

Objective: The objective of this study was to compare surgical versus nonsurgical treatment of ulnar styloid fractures occurring in the context of distal radius fractures treated by open reduction and internal fixation (ORIF) with volar locked plates. Methods: A multicenter retrospective study, including four different level I trauma centers, was carried out. Patients operated on between 2009 and 2012, with ulnar styloid fractures, in the context of an unstable displaced distal radius fracture that had ORIF with a volar locked plate were included; they were divided into two groups according to whether the ulnar styloid fracture was treated nonsurgically (group I) or surgically (group II). Only patients in which distal radius fracture reduction after ORIF was considered anatomical were included. Ulnar styloid fractures were classified according to Rotella’s classification. Results: Fifty-seven patients were included in the study (group I: 29, group II: 28). Follow-up averaged 55.98 months and was different between groups (group I: 63.14 months SD, 1.95, and group II: 48.43 months SD, 3.74), averaging 14.5 months (SD, 4.5) less in group II (P = .001). Patient’s age averaged 49.5 years (SD, 1.82) and was similar (P = .225) between both groups. Women were more frequent in group II (P = .0435). In 35% of patients, the dominant extremity was operated; dominance was different (P = .0501) between groups (28% in group I and 42% in group II). According to Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification in group I, there were 10 type A, 1 type B, and 18 type C fractures, whereas in group II, there were 7 type A, 5 type B, and 16 type C fractures. Ulnar styloid fractures were located at its base in 28 patients, middle third in 19 patients, and tip in 10 patients. Ulnar styloid classification distribution evidenced differences between groups (P = .020); while in group I, there was homogeneous frequency of proximal and tip fractures, and most fractures in group II were proximal. Styloid fracture union chance was statistically significantly different (P = .054; styloid fracture united in 14 of the 29 cases of group I and in 19 of the 28 cases of group II); patients in group II had 2.76 (95% confidence interval [CI], 1.086-8.80) more chances of uniting than those in group I. Disability of the Arm, Shoulder and Hand (DASH) score and Visual Analog Scale (VAS) pain score (at rest and during activities) did not show significant differences between groups (DASH, P = .276; VAS at rest, P = .877; and VAS during activities, P = .681). Ulnar deviation and strength at last follow-up evidenced better results in group I (P = .0389 and P = .024, respectively). Postoperative immobilization, performed using long-arm or short-arm, casts or braces, was different in the groups (P < .001); 41% of patients in group I had a long-arm cast and the rest a short-arm brace, whereas 95% of patients in group II had braces. There were no significant differences in time of postoperative immobilization (P = .469). Conclusion: In this multicenter study, no significant differences between surgical and nonsurgical treatment of ulnar styloid fractures occurring in the context of distal radius fractures treated by ORIF with volar locked plates were evidenced. Anatomical reduction of distal radius fractures remains the most important objective in treating these lesions.