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Incidence of osteoarthritis in the scapho-trapezial joint after herbert screw fixation of the scaphoid
INCIDENCE OF OSTEOARTHRITIS IN THE SCAPHO-TRAPEZIAL JOINT AFTER HERBERT SCREW FIXATION OF THE SCAPHOID N. J. S. KEHOEn, R. G. HACKNEY and N. J. BARTON From the Department of Hand Surgery, University Hospital, Queen’s Medical Centre, Nottingham, UK
Twenty patients treated with a Herbert screw for scaphoid fractures (acute or non-union) were reviewed and X-rayed 5–10 years later to assess whether there were degenerative changes in the scapho-trapezial joint due to insertion of the screw. Six had some irregularity in the lateral part of that joint, three of which followed backing-out of the screw. Two others were described as showing irregularity all round the scaphoid but, apart from these, no radiological abnormalities were seen in the central or ulnar part of the scapho-trapezial joint, or on the proximal tip of the scaphoid. Journal of Hand Surgery (British and European Volume, 2003) 28B: 5: 496–499 Keywords: osteoarthritis; scaphoid fracture; Herbert screw; scapho-trapezial joint
INTRODUCTION The Herbert screw has been shown to be a good method of fixation for the fractured scaphoid, with or without a bone graft. The standard Herbert screw, which is used in most cases, is introduced through the articular cartilage on the distal end of the scaphoid. It has no head but a flat end which is sunk until it is deep to the joint surface. Nevertheless, the screw itself or the procedures required to insert it, could damage the cartilage surfaces of the scapho-trapezial joint, and lead to later degenerative changes (Fig 1). PATIENTS AND METHOD Thirty-six patients, all of whom had a fractured scaphoid treated by open reduction and fixation with a Herbert screw, using the palmar approach, were invited to attend a follow-up clinic. Twenty of these responded and attended, of whom six had been treated with the screw alone for a displaced fracture, a trans-scaphoid perilunate dislocation, or a late presentation. The other 14 had undergone surgery for non-union, in which a bone graft was used in addition to the Herbert screw. The average age at operation was 24 years, those for non-union occurring an average of 42 months after the original fracture. The follow-up period was from 5 to 10 years. Assessment was by out-patient review, recording symptoms, signs and radiographic changes. Scaphoid series X-rays, including Ziter and Gedda views, were taken of both wrists, to give the best views for assessment of
Fig 1 Early degenerative change in the scapho-trapezial joint. This patient was not included in the series because his follow-up was only for 2 years.
changes in the scapho-trapezial and radio-scaphoid joints.
RESULTS
n Nick Kehoe was a Hand Fellow in Nottingham in 1993, when this work was started. He became a Consultant at the Royal Hallamshire Hospital in Sheffield, but tragically died in a climbing accident on 14 May 1998. His records of this study were not available for some years but it has now been completed and is presented in his memory.
Details of each patient are shown in Table 1. Twelve patients had no pain, five had intermittent pain with exercise and three had some pain at rest. They remained 496
INCIDENCE OF OSTEOARTHRITIS
497
Table 1—Clinical details and outcome Pt
Timings Delay (m)
Clinical signs
Age at op
F-up (m)
DF loss
PF loss
Radiology Grip loss kg
Union?
Abnormality in joint?
ABr ABt LB ABx GC
1.2 12 5 0 60
24.7 25.3 26.9 21.5 25.5
90 100 55 103 70
25 30 0 0 60
20 20 0 20 45
7 10 5 3 5
Yes Yes Yes Yes Yes
No No No No Screw removed. ‘‘Joints irregular all round scaphoid’’. No
GD
60
25.9
100
15
15
0
No
CH
120
31.1
74
20
0
7
No
Screw sunk into scaphoid. S/T irregular radially.
MI EJ
22 16
19.1 18.0
97 126
20 35
10 35
9 10
Yes Yes
No Ulnar rim of screw possibly in S/T joint; depression round it.
KL DL EL PM
6 6 16 120
28.0 20.6 22.3 28.9
94 96 92 126
30 20 N/A 15
0 10 N/A 15
29 10 N/A 2
Yes Yes Yes Yes
No No No Screw protruding distally. Cavity in trapezium.
CM
36
22
105
25
5
–
Yes
S/T slightly narrow near end of screw.
AP PS
3 24
23.7 31
87 133
0 0
0 0
12 0
No Yes
No Irregular distal scaphoid but joint not narrowed.
SS
6
20.1
126
30
15
27
Yes
‘‘Irregular all round scaphoid’’.
BS WW
1 18
34.3 17.5
114 100
10 Fused
0
9 *
Yes No
No Screw backed out – removed. S/T irregular radially with depression where screw was.
MW
22
19.5
84
0
0
0
No
No
Delay: Time in months from injury to operation for non-union. (Delays of less than 6 months were in patients with trans-scaphoid, peri-lunate fracture dislocations (A Br) (A Bx) displaced fractures of the scaphoid (BS) or delayed presentation). DF loss and PF loss: reduction in ranges, dorsi-flexion (DF) and palmar-flexion (PF) compared with uninjured side. Grip loss: reduction in grip strength (kg) compared with the uninjured side. Negative figures indicate that the operated side was stronger.
in the same or very similar employment as preoperatively, and only two of 18 had reduced their sporting activities. Fifteen patients (75%) achieved union and five did not. Three of the persisting non-unions were pain-free, four had not changed their occupation and four had maintained their sporting activities. One patient progressed from non-union via styloidectomy, further grafting and limited fusion, to arthrodesis of the wrist. Eight patients were considered to have radiological abnormalities in the scapho-trapezial joint and these are summarized in Table 1. All had been treated for nonunion with a bone graft and Herbert screw introduced through the scapho-trapezial joint. In four this was combined with radial styloidectomy, which supplied the graft (Fisk 1970); in the other four the graft came from the iliac crest. In two cases non-union had persisted, one requiring further surgery.
In one patient the distal end of the screw was protruding into the scapho-trapezial joint and in two others it had been protruding but had been removed. In contrast, two screws appeared to have sunk further into the scaphoid, leaving a depression above their distal end, though one was still protruding slightly on the ulnar side. There was no instance of definite osteoarthritis in the scapho-trapezial joint and the irregularities seen were all confined to the radial margin of the scapho-trapezial joint, close to the point of insertion of the screw. The hypothesis that pushing the bone levers right across the joint would damage its surface was not confirmed, although two patients (whose X-rays have unfortunately been destroyed) were described as having irregularity all round the scaphoid. There were no changes localized to the proximal tip of the scaphoid where the point of the Herbert jig would have punctured the articular cartilage.
498
THE JOURNAL OF HAND SURGERY VOL. 28B No. 5 OCTOBER 2003
DISCUSSION
Unfortunately neither of these papers specified the scapho-trapezial joint, in which an obvious possible cause of osteoarthritis is the use of internal fixation, especially a screw. However, Callanan et al. (1996) studied 30 patients treated by Herbert screw fixation for fractures sustained 5–7 years earlier. In 20 the fracture had been operated upon at an early stage and in only four were bone grafts introduced. They used the semipronated oblique radiographs and also Bett’s views which are claimed to show the scapho-trapezial joint better. They found no evidence of degenerative changes in any patient. The Herbert screw has no head and its rear end is sunk beneath the surface of the articular cartilage on the distal pole of the scaphoid, but the manoeuvres required to insert it could damage the joint surface. First, the scapho-trapezial joint is opened and the distal pole of the scaphoid levered up so that one can get at it. The tips of the levers have to be pushed in through the joint and might scratch it. Moreover, a case has been reported (Sicre et al., 1997) of scapho-trapezio-trapezoid arthritis following injury to the scapho-trapezial ligament, across which one cuts during this operation. The jig is then inserted; this has a sharp tip which pierces the articular cartilage at the proximal end of the scaphoid, and the barrel which is pushed down onto the distal pole has two small spikes to keep it in place. Thus it damages the articular cartilage over both poles of the scaphoid, but only over a tiny area: no more than that damaged by a temporary Kirschner wire, which is usually regarded as harmless. Finally, the screw itself is inserted. If misdirected, it may emerge from the far surface of the scaphoid; this should not happen but even Herbert’s own series (Filan and Herbert, 1996) includes 14 cases with ‘‘some protrusion of the screw’’. This shows that it can happen even in the best-regulated families, though it was 14 out of 431 operations which is a very small proportion. In theory, any of these manoeuvres might injure the articular surface. In practice, our study, with rather longer follow-up than that of Callanan et al. (1996) and a higher proportion of bone grafts, found little evidence of such damage. Those changes which were seen were, in six patients, confined to the most radial part of the scapho-trapezial joint where the screw was inserted (Fig 2). In three of these six the screw had backed out and in another one it had sunk further into the scaphoid leaving a defect over its end; the fifth had both depression (on the radial side) and protrusion (on the ulnar side). Herbert (personal communication) has very rarely found the screw backing out and it may be that, for fear of stripping the thread, we did not put in the screw tightly enough. No case showed frank osteoarthritis, though admittedly the follow-up is only medium term and these young men still had 20 or 30 years of vigorous activity in front of them. In our hands (Barton, 1997) the Herbert screw and bone graft has been the most successful way of treating
It is na.ıve to suppose that bone grafting can eliminate the subsequent development of osteoarthritis, because there is no way one can open up the scaphoid and insert a bone graft where there would normally be articular cartilage without leaving a very abnormal surface. Long-term follow-up of patients successfully treated by conventional Russe grafts (Martini and Schiltenwolf, 1995; Steiger and Sennwald, 1990; Hooning Van Duyvenbode et al., 1991) found signs of arthrosis in many of them. Jiranek et al. (1992) studied 26 wrists 7–18 years after Russe grafts: some by the original procedure (Russe, 1960) and some by the modified technique (Green, 1985). All had CT scans which showed that 24 of the 26 had evidence of carpal arthritis at the latest follow-up: kissing osteophytes on the dorso-radial aspect of the scaphoid and the dorsal aspect of the radial styloid. In addition, ten patients (40%) had osteoarthritis of the scapho-trapezial joint and seven of the scapho-lunate joint. This is of interest because it shows that scaphotrapezial osteoarthritis may develop after a bone grafting to the scaphoid in which neither a Herbert screw nor Kirschner wires were used. This was confirmed by the work of Saede! n et al. (2001) who studied 62 acute fractures, of which 30 had been treated in a cast and 32 by a Herbert screw inserted through the scapho-trapezial joint. The patients were reviewed after 10–12 years, when CT scans, as well as plain radiographs, were carried out on both wrists of many of the patients. These showed scapho-trapezial osteoarthritis in 14 of 23 treated with the screw but also, surprisingly, in four of 16 treated in plaster. In addition, radiocarpal osteoarthritis was present in two patients in each group. Presumably this is attributable to malunion (which was the particular focus of Jiranek’s study); this could not only alter the relationship between the distal scaphoid and radial styloid but also the relationship between the scaphoid and trapezium. Nicholl and Buckland-Wright (2000) found no difference in the incidence of osteoarthritis in the scapho-trapezial joint between 23 scaphoid fractures treated conservatively and 18 treated by bone graft and Herbert screw fixation, but the screw cases were more likely to have osteophytes on the distal scaphoid. The method of study was macroradiography and the mean follow-up period was 5 years in the conservative cases and 6 years in the operative ones. Filan and Herbert (1996) and Rajagopalan et al. (1999) reported some patients as developing osteoarthritis after successful bone grafting and Herbert screw fixation, but the latter noted that some of these had ‘‘osteoarthritic symptoms before the operation, which suggests that the degenerative changes were caused by the non-union and not by the operation.’’ However, their patient’s symptoms (pain or stiffness or both) might equally well have been caused by the non-union.
INCIDENCE OF OSTEOARTHRITIS
Fig 2 The screw is not protruding but, 8 years after it was inserted in patient CM, there is narrowing of the radial part of the scaphotrapezial joint, near the point of insertion of the screw.
non-union and, although the study now reported did find some radiological abnormalities, it provides no evidence that the insertion of the screw will lead to later osteoarthritis in the medium term.
499 Callanan I, Lahoti O, McElwain JP (1996). Herbert screw insertion in the scaphotrapezial joint. A cause of degenerative change? Journal of Hand Surgery, 21B: 775–777. Filan SL, Herbert TJ (1996). Herbert screw fixation of scaphoid fractures. Journal of Bone and Joint Surgery, 78B: 519–529. Fisk GR (1970). Carpal instability and the fractured scaphoid. Annals of the Royal College of Surgeons of England, 46: 63–76. Green DP (1985). The effect of avascular necrosis on Russe bone grafting for scaphoid non-union. Journal of Hand Surgery, 70A: 597–605. Hooning Van Duyvenbode JFF, Keijser LCM, Hauet EJ, Obermann WR, Rozing PM (1991). Pseudarthrosis of the scaphoid treated by the MattiRusse operation. A long-term review of 77 cases. Journal of Bone and Joint Surgery, 73B: 603–606. Jiranek WA, Ruby LK, Millender LB, Bankoff MS, Newburg AH (1992). Longterm results after Russe bone-grafting: the effect of malunion of the scaphoid. Journal of Bone and Joint Surgery, 74A: 1217–1228. Martini AK, Schiltenwolf M (1995). Das Schicksal des Handgelenkes beim spontanen Verlauf der Kahnbeinpseudarthrose. Handchirurgie, Mikrochirugie, Plastische Chirurgie, 27: 201–207 (in German, with English summary). Nicholl JE, Buckland-Wright JC (2000). Degenerative changes at the scaphotrapezial joint following Herbert screw insertion: a radiographic study comparing patients with scaphoid fracture and primary hand arthrosis. Journal of Hand Surgery, 25B: 422–426. Rajagopalan BM, Squire DS, Samuels LO (1999). Results of Herbert-screw fixation with bone-grafting for the treatment of nonunion of the scaphoid. Journal of Bone and Joint Surgery, 81A: 48–52. Russe O (1960). Fracture of the carpal navicular. Diagnosis, non-operative treatment, and operative treatment. Journal of Bone and Joint Surgery, 42A: 759–768. . . Saede´n B, Tornkvist H, Ponzer S, Hoglund M (2001). Fracture of the carpal scaphoid. A prospective, randomised 12-year follow-up comparing operative and conservative treatment. Journal of Bone and Joint Surgery, 83B: 230–234. Sicre G, Laulan J, Rouleau B (1997). Scaphotrapeziotrapezoid osteoarthritis after scaphotrapezial ligament injury. Journal of Hand Surgery, 22B: 189–190. Steiger R, Sennwald G (1990). Sp.atresultate opersierter skaphoidpseudarthrosen. Handchirurgie, Mikrochirurgie, Plastische Chirurgie, 22: 152–155 (in German, with English summary).
Received: 23 September 2002 Accepted after revision: 3 March 2003 Mr N.J. Barton, 2 Church Farm Barn, Point Road, Avening, Tetbury, Gloucester GL8 8ND, UK.
References Barton NJ (1997). Experience with scaphoid grafting. Journal of Hand Surgery, 22B: 153–160.
r 2003 The British Society for Surgery of the Hand. Published by Elsevier Ltd. All rights reserved. doi:10.1016/S0266-7681(03)00098-6 available online at http://www.sciencedirect.com
Twenty patients treated with a Herbert screw for scaphoid fractures (acute or non-union) were reviewed and X-rayed 5–10 years later to assess whether there were degenerative changes in the scapho-trapezial joint due to insertion of the screw. Six had some irregularity in the lateral part of that joint, three of which followed backing-out of the screw. Two others were described as showing irregularity all round the scaphoid but, apart from these, no radiological abnormalities were seen in the central or ulnar part of the scapho-trapezial joint, or on the proximal tip of the scaphoid. Journal of Hand Surgery (British and European Volume, 2003) 28B: 5: 496–499 Keywords: osteoarthritis; scaphoid fracture; Herbert screw; scapho-trapezial joint
INTRODUCTION The Herbert screw has been shown to be a good method of fixation for the fractured scaphoid, with or without a bone graft. The standard Herbert screw, which is used in most cases, is introduced through the articular cartilage on the distal end of the scaphoid. It has no head but a flat end which is sunk until it is deep to the joint surface. Nevertheless, the screw itself or the procedures required to insert it, could damage the cartilage surfaces of the scapho-trapezial joint, and lead to later degenerative changes (Fig 1). PATIENTS AND METHOD Thirty-six patients, all of whom had a fractured scaphoid treated by open reduction and fixation with a Herbert screw, using the palmar approach, were invited to attend a follow-up clinic. Twenty of these responded and attended, of whom six had been treated with the screw alone for a displaced fracture, a trans-scaphoid perilunate dislocation, or a late presentation. The other 14 had undergone surgery for non-union, in which a bone graft was used in addition to the Herbert screw. The average age at operation was 24 years, those for non-union occurring an average of 42 months after the original fracture. The follow-up period was from 5 to 10 years. Assessment was by out-patient review, recording symptoms, signs and radiographic changes. Scaphoid series X-rays, including Ziter and Gedda views, were taken of both wrists, to give the best views for assessment of
Fig 1 Early degenerative change in the scapho-trapezial joint. This patient was not included in the series because his follow-up was only for 2 years.
changes in the scapho-trapezial and radio-scaphoid joints.
RESULTS
n Nick Kehoe was a Hand Fellow in Nottingham in 1993, when this work was started. He became a Consultant at the Royal Hallamshire Hospital in Sheffield, but tragically died in a climbing accident on 14 May 1998. His records of this study were not available for some years but it has now been completed and is presented in his memory.
Details of each patient are shown in Table 1. Twelve patients had no pain, five had intermittent pain with exercise and three had some pain at rest. They remained 496
INCIDENCE OF OSTEOARTHRITIS
497
Table 1—Clinical details and outcome Pt
Timings Delay (m)
Clinical signs
Age at op
F-up (m)
DF loss
PF loss
Radiology Grip loss kg
Union?
Abnormality in joint?
ABr ABt LB ABx GC
1.2 12 5 0 60
24.7 25.3 26.9 21.5 25.5
90 100 55 103 70
25 30 0 0 60
20 20 0 20 45
7 10 5 3 5
Yes Yes Yes Yes Yes
No No No No Screw removed. ‘‘Joints irregular all round scaphoid’’. No
GD
60
25.9
100
15
15
0
No
CH
120
31.1
74
20
0
7
No
Screw sunk into scaphoid. S/T irregular radially.
MI EJ
22 16
19.1 18.0
97 126
20 35
10 35
9 10
Yes Yes
No Ulnar rim of screw possibly in S/T joint; depression round it.
KL DL EL PM
6 6 16 120
28.0 20.6 22.3 28.9
94 96 92 126
30 20 N/A 15
0 10 N/A 15
29 10 N/A 2
Yes Yes Yes Yes
No No No Screw protruding distally. Cavity in trapezium.
CM
36
22
105
25
5
–
Yes
S/T slightly narrow near end of screw.
AP PS
3 24
23.7 31
87 133
0 0
0 0
12 0
No Yes
No Irregular distal scaphoid but joint not narrowed.
SS
6
20.1
126
30
15
27
Yes
‘‘Irregular all round scaphoid’’.
BS WW
1 18
34.3 17.5
114 100
10 Fused
0
9 *
Yes No
No Screw backed out – removed. S/T irregular radially with depression where screw was.
MW
22
19.5
84
0
0
0
No
No
Delay: Time in months from injury to operation for non-union. (Delays of less than 6 months were in patients with trans-scaphoid, peri-lunate fracture dislocations (A Br) (A Bx) displaced fractures of the scaphoid (BS) or delayed presentation). DF loss and PF loss: reduction in ranges, dorsi-flexion (DF) and palmar-flexion (PF) compared with uninjured side. Grip loss: reduction in grip strength (kg) compared with the uninjured side. Negative figures indicate that the operated side was stronger.
in the same or very similar employment as preoperatively, and only two of 18 had reduced their sporting activities. Fifteen patients (75%) achieved union and five did not. Three of the persisting non-unions were pain-free, four had not changed their occupation and four had maintained their sporting activities. One patient progressed from non-union via styloidectomy, further grafting and limited fusion, to arthrodesis of the wrist. Eight patients were considered to have radiological abnormalities in the scapho-trapezial joint and these are summarized in Table 1. All had been treated for nonunion with a bone graft and Herbert screw introduced through the scapho-trapezial joint. In four this was combined with radial styloidectomy, which supplied the graft (Fisk 1970); in the other four the graft came from the iliac crest. In two cases non-union had persisted, one requiring further surgery.
In one patient the distal end of the screw was protruding into the scapho-trapezial joint and in two others it had been protruding but had been removed. In contrast, two screws appeared to have sunk further into the scaphoid, leaving a depression above their distal end, though one was still protruding slightly on the ulnar side. There was no instance of definite osteoarthritis in the scapho-trapezial joint and the irregularities seen were all confined to the radial margin of the scapho-trapezial joint, close to the point of insertion of the screw. The hypothesis that pushing the bone levers right across the joint would damage its surface was not confirmed, although two patients (whose X-rays have unfortunately been destroyed) were described as having irregularity all round the scaphoid. There were no changes localized to the proximal tip of the scaphoid where the point of the Herbert jig would have punctured the articular cartilage.
498
THE JOURNAL OF HAND SURGERY VOL. 28B No. 5 OCTOBER 2003
DISCUSSION
Unfortunately neither of these papers specified the scapho-trapezial joint, in which an obvious possible cause of osteoarthritis is the use of internal fixation, especially a screw. However, Callanan et al. (1996) studied 30 patients treated by Herbert screw fixation for fractures sustained 5–7 years earlier. In 20 the fracture had been operated upon at an early stage and in only four were bone grafts introduced. They used the semipronated oblique radiographs and also Bett’s views which are claimed to show the scapho-trapezial joint better. They found no evidence of degenerative changes in any patient. The Herbert screw has no head and its rear end is sunk beneath the surface of the articular cartilage on the distal pole of the scaphoid, but the manoeuvres required to insert it could damage the joint surface. First, the scapho-trapezial joint is opened and the distal pole of the scaphoid levered up so that one can get at it. The tips of the levers have to be pushed in through the joint and might scratch it. Moreover, a case has been reported (Sicre et al., 1997) of scapho-trapezio-trapezoid arthritis following injury to the scapho-trapezial ligament, across which one cuts during this operation. The jig is then inserted; this has a sharp tip which pierces the articular cartilage at the proximal end of the scaphoid, and the barrel which is pushed down onto the distal pole has two small spikes to keep it in place. Thus it damages the articular cartilage over both poles of the scaphoid, but only over a tiny area: no more than that damaged by a temporary Kirschner wire, which is usually regarded as harmless. Finally, the screw itself is inserted. If misdirected, it may emerge from the far surface of the scaphoid; this should not happen but even Herbert’s own series (Filan and Herbert, 1996) includes 14 cases with ‘‘some protrusion of the screw’’. This shows that it can happen even in the best-regulated families, though it was 14 out of 431 operations which is a very small proportion. In theory, any of these manoeuvres might injure the articular surface. In practice, our study, with rather longer follow-up than that of Callanan et al. (1996) and a higher proportion of bone grafts, found little evidence of such damage. Those changes which were seen were, in six patients, confined to the most radial part of the scapho-trapezial joint where the screw was inserted (Fig 2). In three of these six the screw had backed out and in another one it had sunk further into the scaphoid leaving a defect over its end; the fifth had both depression (on the radial side) and protrusion (on the ulnar side). Herbert (personal communication) has very rarely found the screw backing out and it may be that, for fear of stripping the thread, we did not put in the screw tightly enough. No case showed frank osteoarthritis, though admittedly the follow-up is only medium term and these young men still had 20 or 30 years of vigorous activity in front of them. In our hands (Barton, 1997) the Herbert screw and bone graft has been the most successful way of treating
It is na.ıve to suppose that bone grafting can eliminate the subsequent development of osteoarthritis, because there is no way one can open up the scaphoid and insert a bone graft where there would normally be articular cartilage without leaving a very abnormal surface. Long-term follow-up of patients successfully treated by conventional Russe grafts (Martini and Schiltenwolf, 1995; Steiger and Sennwald, 1990; Hooning Van Duyvenbode et al., 1991) found signs of arthrosis in many of them. Jiranek et al. (1992) studied 26 wrists 7–18 years after Russe grafts: some by the original procedure (Russe, 1960) and some by the modified technique (Green, 1985). All had CT scans which showed that 24 of the 26 had evidence of carpal arthritis at the latest follow-up: kissing osteophytes on the dorso-radial aspect of the scaphoid and the dorsal aspect of the radial styloid. In addition, ten patients (40%) had osteoarthritis of the scapho-trapezial joint and seven of the scapho-lunate joint. This is of interest because it shows that scaphotrapezial osteoarthritis may develop after a bone grafting to the scaphoid in which neither a Herbert screw nor Kirschner wires were used. This was confirmed by the work of Saede! n et al. (2001) who studied 62 acute fractures, of which 30 had been treated in a cast and 32 by a Herbert screw inserted through the scapho-trapezial joint. The patients were reviewed after 10–12 years, when CT scans, as well as plain radiographs, were carried out on both wrists of many of the patients. These showed scapho-trapezial osteoarthritis in 14 of 23 treated with the screw but also, surprisingly, in four of 16 treated in plaster. In addition, radiocarpal osteoarthritis was present in two patients in each group. Presumably this is attributable to malunion (which was the particular focus of Jiranek’s study); this could not only alter the relationship between the distal scaphoid and radial styloid but also the relationship between the scaphoid and trapezium. Nicholl and Buckland-Wright (2000) found no difference in the incidence of osteoarthritis in the scapho-trapezial joint between 23 scaphoid fractures treated conservatively and 18 treated by bone graft and Herbert screw fixation, but the screw cases were more likely to have osteophytes on the distal scaphoid. The method of study was macroradiography and the mean follow-up period was 5 years in the conservative cases and 6 years in the operative ones. Filan and Herbert (1996) and Rajagopalan et al. (1999) reported some patients as developing osteoarthritis after successful bone grafting and Herbert screw fixation, but the latter noted that some of these had ‘‘osteoarthritic symptoms before the operation, which suggests that the degenerative changes were caused by the non-union and not by the operation.’’ However, their patient’s symptoms (pain or stiffness or both) might equally well have been caused by the non-union.
INCIDENCE OF OSTEOARTHRITIS
Fig 2 The screw is not protruding but, 8 years after it was inserted in patient CM, there is narrowing of the radial part of the scaphotrapezial joint, near the point of insertion of the screw.
non-union and, although the study now reported did find some radiological abnormalities, it provides no evidence that the insertion of the screw will lead to later osteoarthritis in the medium term.
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Received: 23 September 2002 Accepted after revision: 3 March 2003 Mr N.J. Barton, 2 Church Farm Barn, Point Road, Avening, Tetbury, Gloucester GL8 8ND, UK.
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r 2003 The British Society for Surgery of the Hand. Published by Elsevier Ltd. All rights reserved. doi:10.1016/S0266-7681(03)00098-6 available online at http://www.sciencedirect.com