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Is there a trend in CT scanning scaphoid nonunions for deformity assessment?—A systematic review
Accepted Manuscript Title: Is there a trend in CT scanning scaphoid nonunions for deformity assessment?—A systematic review Authors: Paul W.L. ten Berg, Marieke G.A. de Roo, Mario Maas, Simon D. Strackee PII: DOI: Reference:
S0720-048X(17)30137-7 http://dx.doi.org/doi:10.1016/j.ejrad.2017.03.023 EURR 7789
To appear in:
European Journal of Radiology
Received date: Revised date: Accepted date:
17-11-2016 16-3-2017 29-3-2017
Please cite this article as: ten Berg Paul WL, de Roo Marieke GA, Maas Mario, Strackee Simon D.Is there a trend in CT scanning scaphoid nonunions for deformity assessment?—A systematic review.European Journal of Radiology http://dx.doi.org/10.1016/j.ejrad.2017.03.023 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Is There a Trend in CT Scanning Scaphoid Nonunions for Deformity Assessment? – A systematic review Running title: CT Scanning Scaphoid Nonunions Paul W. L. ten Berga, MD; Marieke G.A. de Rooa, MD; Mario Maasb, MD PhD; Simon D. Strackeea, MD PhD Affiliations: a Department of Plastic, Reconstructive, and Hand Surgery, Academic Medical Center, University of Amsterdam, Room G4-226, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands. b Department of Radiology, Academic Medical Center, University of Amsterdam, Room G1-211, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands. Corresponding author: Paul W.L. ten Berg, MD Department of Plastic, Reconstructive, and Hand Surgery Academic Medical Center, University of Amsterdam, Room G4-226 Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands E-mail: [email protected] Tel.: 0031 20 5662572 Fax: 0031 206917549 Conflict of interest: None Funding statement: PWLtB received a PhD grant (2014) from the Academic Medical Center (Amsterdam, Netherlands) supporting this research. Authorship: All authors have made substantial contributions to the following: (1) the conception and design of the study, or acquisition of data, or analysis and interpretation of data, (2) drafting the article or revising it critically for important intellectual content, (3) final approval of the version to be submitted. Highlights (for review)
Article: Is There a Trend in CT Scanning Scaphoid Nonunions for Deformity Assessment? – A systematic review The effect of scaphoid nonunion deformity on wrist function is uncertain. Most articles use standard, unreliable 2-D measures to assess scaphoid deformity. There is a clear trend in the use of CT scans in the workup of scaphoid nonunions. CT enables creating 3-D images, which may improve assessing scaphoid deformity. With this trend, assessing deformity with 3-D CT will be increasingly accessible.
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ABSTRACT Purpose: The effect of scaphoid nonunion deformity on wrist function is uncertain due to the lack of reliable imaging tools. Advanced three-dimensional (3-D) computed tomography (CT)-based imaging techniques may improve deformity assessment by using a mirrored image of the contralateral intact wrist as anatomic reference. The implementation of such techniques depends on the extent to which conventional CT is currently used in standard practice. The purpose of this systematic review of medical literature was to analyze the trend in CT scanning scaphoid nonunions, either unilaterally or bilaterally. Materials and methods: Using Medline and Embase databases, two independent reviewers searched for original full-length clinical articles describing series with at least five patients focusing on reconstructive surgery of scaphoid nonunions with bone grafting and/or fixation, from the years 2000 to 2015. We excluded reports focusing on only nonunions suspected for avascular necrosis and/or treated with vascularized bone grafting, as their workup often includes magnetic resonance imaging. For data analysis, we evaluated the use of CT scans and distinguished between uni- and bilateral, and pre- and postoperative scans. Results: Seventy-seven articles were included of which 16 were published between 2000‒2005, 19 between 2006‒2010, and 42 between 2011‒2015. For these consecutive intervals, the rates of articles describing the use of pre- and postoperative CT scans increased from 13%, to 16%, to 31%, and from 25%, to 32%, to 52%, respectively. Hereof, only two (3%) articles described the use of bilateral CT scans. Conclusion: There is an evident trend in performing unilateral CT scans before and after reconstructive surgery of a scaphoid nonunion. To improve assessment of scaphoid nonunion deformity using 3-D CT-based imaging techniques, we recommend scanning the contralateral wrist as well.
Keywords: Scaphoid; CT; three-dimensional; deformity; morphology; reconstruction
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1. Introduction A scaphoid nonunion is the result of a failed healing of the bone once fractured. A nonunion through the body of the scaphoid is associated with a flexion deformity in which the distal fragment rotates to the palmar side—a so-called humpback deformity [1]. It is also associated with a dorsal intercalated segment instability (DISI) deformity in which the lunate together with the proximal scaphoid fragment rotates in a pathological extended stance. Scaphoid nonunion patients with no or only limited carpal osteoarthritis are usually treated with reconstructive surgery directed at achieving both union and carpal realignment, to improve clinical outcome [2]. A common technique to realign the midcarpal joint is the use of an interpositional structural bone graft in addition to scaphoid screw fixation. This graft is usually harvested from the iliac crest and inserted between the scaphoid fragments through an open volar approach [1]. It is currently unclear how close the restored scaphoid anatomy must be to the original intact anatomy to yield a good clinical outcome [3]. Some clinical articles suggested an association of scaphoid malalignment, with pain, loss of motion and weakness after fracture healing [4-6]; while others failed to show an association between radiologic measurements of the intrinsic scaphoid morphology and outcome [3, 7]. A factor contributing to this uncertainty is the unreliable way of measuring scaphoid deformity on both pre- and postoperative images, for which there is currently no consensus about the optimal measuring method [8-10]. On standard radiographs the projection of overlapping bones may hamper obtaining good visualization of the intrinsic scaphoid morphology [10]. Additional computed tomography (CT) provides more detailed information about the bony architecture [11]. Still, standard CT measures of scaphoid deformity only provide two-dimensional (2D) information (Fig. 1), while the displacement pattern and fracture line morphology in scaphoid nonunions are three-dimensional (3-D) problems [12-15]. Moreover, these CT measures have shown to have limited reproducibility [16-18]. Therefore, surgeons stress the need for new imaging methods to more accurately and reproducibly measure scaphoid deformity [3, 18].Recent advances in imaging techniques enable synthesizing the information from a standard CT into virtual 3-D models of the scaphoid nonunion fragments Reconstruction of a 3-D model is often based on a 3-D polygon created from a sequence of segmented 2-D CT images. Currently, many image segmentation and 3-D
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reconstruction methods exist which can be applied in (semi-)automated fashion [19]. To assess the level of fragment displacement objectively, a mirrored model of the contralateral intact scaphoid may serve as anatomic template, requiring a bilateral CT scan. Using dedicated planning software, the proximal and distal fragments can be virtually matched with the proximal and distal intact poles by image registration [12-15]. Subsequently, fragment displacement can be defined as the difference in position between the distal fragment and the intact distal pole relatively to the proximal fragment. To express displacement in 3-D space, an anatomical coordinate system can be defined based on the principal axes of the virtual model of the contralateral intact scaphoid using its inertial properties (Fig. 2) [20]. The contralateral scaphoid is considered an accurate template because of the reported high level of bilateral shape symmetry in scaphoid pairs [21]. These advanced imaging techniques may improve characterizing scaphoid nonunions as well as investigating the relation between the level of scaphoid deformity and clinical outcome. The clinical implementation of advanced 3-D CT-based imaging techniques is influenced by the extent to which conventional CT is currently used in standard practice. Numbers about the exact rate of using CT in the management of scaphoid nonunions are lacking. The purpose of this systematic review was to analyze the use of CT as reported in clinical series on reconstructive surgery of scaphoid nonunions, with special interest in the ability of CT to generate 3-D CT-based images. We addressed the following questions: 1. Is there a trend in CT scanning scaphoid nonunions, either unilaterally or bilaterally? 2. Is there a difference between the pre-operative and postoperative use of CT? 3. Which CT measures of scaphoid humpback deformity are most commonly applied? 2. Material and methods We conducted an online literature search in Medline and Embase from 2000 to 2015. The search and data extraction were performed by two independent reviewers, according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines [22]. Disagreements between reviewers were discussed until consensus was reached. 2.1 Eligibility criteria systematic review
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All reports on the reconstructive surgery of scaphoid nonunions not suspected for avascular necrosis (AVN) were eligible for inclusion. We excluded reports focusing only on scaphoid nonunions with or suspected for AVN, proximal nonunions and/or scaphoid nonunions treated with vascularized bone grafting, as their workup often includes magnetic resonance imaging (MRI). To increase power, studies comparing both non-vascularized and vascularized bone grafting were included, with special attention to the non-vascularized treatment group. Inclusion criteria were: (1) original full-length clinical articles focusing on reconstructive surgery with non-vascularized bone grafting and/or fixation for scaphoid nonunions; (2) series of at least five adult patients; (3) publication date between 01.01.2000 and 31.12.2015; (4) English language. Exclusion criteria were: (1) non-clinical studies; (2) series focusing only on vascularized or osteocartilaginous bone grafting; (3) series including only proximal nonunions; (4) diagnostic studies focusing on MRI; (5) non original full-length articles; (6) follow-up studies based on series already described in previous included articles from the same institution. 2.2 Literature search, study selection and data extraction We used Medical Subject Headings (MeSH) (= scaphoid bone), using free search terms in title and abstract with (=scaphoid*), and using free search terms in all fields with truncation. The full search strategy is addressed in Figure 3. We retrieved all titles and abstracts for eligibility assessment, after removing duplicates in Endnote X7 (Thomas Reuter, London, UK). If eligibility criteria were met, articles were obtained and reviewed. After final selection, all articles were reviewed with special attention to the described imaging modality and applied CT deformity measures. 2.3 Quality assessment We did not assess the quality of the articles as we focused on the descriptions of applied imaging modalities only, independent to other methodologic parameters, such as blinding and randomization. This makes the use of general quality assessment tools to appreciate overall outcome of a study redundant. 3. Results Seventy-seven articles met our inclusion criteria (Fig. 3; see also appendix for full reference list of included articles), of which 16 were published between 2000‒2005, 19 between 2006‒2010, and
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42 between 2011‒2015. In these consecutive year periods, the rates of articles describing pre- and postoperative CT scans increased from 13%, to 16%, to 31%, and from 25%, to 32%, to 52%, respectively (Fig. 4). Overall, 18 (23%) and 32 (42%) articles described the use of pre- and postoperative CT scans, respectively. In respectively 9 (12%) and 14 (18%) of these articles, CT scans were routinely performed. In total, two (3%) articles described the use of bilateral CT scans. Of the articles describing the use of CT scans, eight articles described standard CT measures of the humpback deformity based on the ISA, four on the H/L ratio, and two on the DCA (Fig. 1). Only one clinical article of Murase et al. [23] used 3-D CT-based image techniques to evaluate the level of angulation and displacement in scaphoid nonunion in their workup prior to surgery.
4. Discussion This systematic review demonstrated a clear trend from the year 2000 in performing unilateral CT scans in the workup of scaphoid nonunions treated reconstructively, with a more widespread use of postoperative scans. The use of bilateral CT scans is uncommon. A reason of the unpopularity of scanning both wrists could be the increased associated radiation dose. However, radiation to the skeletal system has relatively little impact on the patient, especially when both wrists are imaged simultaneously; moreover, scaphoid imaging requires only a small scanning volume. A more obvious explanation could be the limited diagnostic value of the contralateral scan as currently used in standard practice. As standard measures of scaphoid morphology and deformity are unreliable [3, 16-18], evaluation of the contralateral wrist remains to a large degree subjective. Contralateral scanning becomes more relevant when automated 3-D CT-based imaging techniques are implemented, integrating the contralateral side as anatomic template. Only then, we could establish a reliable benchmark of how close the restored scaphoid anatomy must be to the original intact anatomy to yield a good outcome. The difference in rates between the use of pre- and postoperative CT scans could be explained by the difference in purpose of performing the scan. Post-operative scans are often primarily performed to assess trabecular bridging as measure for bony union, which is considered an adequate overall measure of surgical success [24]. Previous studies have shown that inter-observer agreement for radiologic assessment of union was substantially higher on postoperative CT [8, 25] than on
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radiography [26]. Additionally, the reconstructed scaphoid morphology can be measured to assess whether the nonunion fragments were adequately reduced. Pre-operative scans can be used to plan the reconstruction. However, there is debate about the value of surgical planning as there are many factors influencing the surgical strategy that are difficult to determine pre-operatively. For example, the exact amount of sclerotic margin at the nonunion fracture sites that has to be removed is often determined intra-operatively, which hampers planning the exact graft size and the level of fragment reduction [27]. On the other hand, there is relative consensus about the use of preoperative CT scans for selecting nonunions suitable for percutaneous fixation. To this end, Slade [28] developed a progressive classification for scaphoid nonunions, ranging from early nonunions with minimal sclerosis and without substantial cystic bone resorption, to pseudarhtrosis with profound bone resorption and deformity. The latter author [29] stated that well-aligned nonunions with no or only limited sclerosis are an indication for percutaneous fixation. Based on the current review, the ISA is the most commonly applied standard CT measure of humpback deformity (Fig. 1). However, the H/L ratio is considered a more reproducible measure, although still leading to unsatisfactory observer agreement [16-18]. One factor contributing to observer variation is the scanning position of the wrist and the selection of the central slice to perform measurements on [3]. Nowadays, many radiologic workstations allow obtaining sagittal- and coronal multiplanar reconstructions in the central longitudinal axis of the scaphoid to evaluate angulation and displacement, independent to the configuration of the carpal bones during scanning [25, 30]. Despite the improvements of scaphoid imaging protocols, the manual standard CT measures themselves remain prone for observer variations. We therefore recommend using the H/L ratio only if no other techniques are available than standard CT measurement techniques. One study of Murase et al. [23] used 3-D CT-based imaging techniques to assess fragment displacement in scaphoid nonunions in 3-D space. To this end, virtual 3-D models of the proximal and distal fragments were matched with the proximal and distal parts of the mirrored contralateral intact scaphoid, similar to the technique described in Figure 1. To guide fragment reduction during surgical reconstruction, real-sized stereolithographic models of the scaphoid nonunions fragments and of the intact side were created. The authors [23] reported good clinical outcome. A more recent scaphoid
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study also showed the surgical benefits of using a real-sized 3-D printed model as intraoperative guide to plan an osteotomy and determine the size and shape of the bone graft [31]. In addition, two other recent clinical series [27, 32] published in 2016 described 3-D CT-based imaging techniques using the contralateral intact scaphoid as template to assess the level of scaphoid deformity as well. Based on these techniques, 3-D printed patient-specific reduction guides were created to improve scaphoid fragment reduction. Using 3-D displacement analysis postoperatively, average residual displacement was respectively 7° and less than 1.5mm, based on comparison with the contralateral intact scaphoid. Both studies [27, 32] showed satisfactory clinical outcome. Still, larger studies with long term followup are required to evaluate the consequences of the level of 3-D scaphoid reconstruction on wrist function and osteoarthritic development, before one could recommend one surgical procedure over another. The use of 3-D imaging techniques to evaluate the reconstructed scaphoid morphology may also help us in reaching consensus on the advisability of an osteotomy in case of a malunited scaphoid, when taken in addition to the clinical aspects. The strength of the current review is the inclusion of a large number of articles, providing a robust measure of the trend in CT scanning scaphoid nonunions. A limitation is the inclusion of clinical series published in English language only, producing a language bias. However, the number of non-English articles was relatively low, which, in case of inclusion, would probably not have led to a difference in main outcome. Another limitation is the omission of a quality assessment of the included articles. To our knowledge, no specific quality guidelines have yet been developed for our purposes. A general quality assessment of the articles would not have been relevant because we focused on the descriptions of a single radiologic imaging modality, rather than on overall outcome. In conclusion, there is an evident trend in performing unilateral CT scans before and after scaphoid nonunion reconstructions. With this trend and the continuing software development efforts, we foresee that 3-D CT-based imaging techniques to assess scaphoid nonunion deformity in 3-D space will be increasingly accessible for a broader clinical practice. To further enhance effectively implementing these techniques, we recommend scanning the contralateral wrist as well. With these techniques, we may improve characterizing scaphoid nonunions and subsequent surgical management,
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as well as investigating the relation between the level of reconstructed scaphoid morphology and clinical outcome, which is currently to a large degree speculative. Conflicts of interest None Authorship APPENDIX Is There a Trend in CT Scanning Scaphoid Nonunions for Deformity Assessment? – A systematic review Reference list of included articles for systematic review [1] N. Maruthainar, V.J. Rasquinha, P. Gallagher, The treatment of scaphoid nonunion: A review of a novel technique using precision bone grafting compared with Herbert screw fixation and bone graft, Journal of Hand Surgery 25 B(5) (2000) 427-430. [2] K. Ritter, A.A. Giachino, The treatment of pseudoarthrosis of the scaphoid by bone grafting and three methods of internal fixation, Canadian Journal of Surgery 43(2) (2000) 118-124. [3] H. Takami, S. Takahashi, M. Ando, Scaphoid nonunion treated by open reduction, anterior inlay bone grafting, and Kirschner-wire fixation, Archives of orthopaedic and trauma surgery 120(3-4) (2000) 134-138. [4] M.M. Tomaino, J. King, M. Pizillo, Correction of lunate malalignment when bone grafting scaphoid nonunion with humpback deformity: Rationale and results of a technique revisited, Journal of Hand Surgery 25(2) (2000) 322-329. [5] A.J.H. Trezies, T.R.C. Davis, N.J. Barton, Factors influencing the outcome of bone grafting surgery for scaphoid fracture non-union, Injury 31(8) (2000) 605-607. [6] T.M. Abuzakuk, A. Mofidi, M. O'Sullivan, Internal fixation of scaphoid fractures. Review of 25 cases, European Journal of Orthopaedic Surgery and Traumatology 11(1) (2001) 25-28. [7] L.S. Christodoulou, C.K. Kitsis, S.T. Chamberlain, Internal fixation of scaphoid non-union: A comparative study of three methods, Injury 32(8) (2001) 625-630. [8] Y.F. Leung, S.P.S. Ip, C. Cheuk, K.T. Sheung, Y.L. Wai, Trephine bone grafting technique for the treatment of scaphoid nonunion, Journal of Hand Surgery 26(5) (2001) 893-900. [9] S. Eggli, D.L. Fernandez, T. Beck, Unstable scaphoid fracture nonunion: A medium-term study of anterior wedge grafting procedures, Journal of Hand Surgery 27 B(1) (2002) 36-41. [10] S. Kujala, T. Raatikainen, J. Ryhanen, O. Kaarela, P. Jalovaara, Composite implant of native bovine bone morphogenetic protein (BMP) and biocoral in the treatment of scaphoid nonunions - A preliminary study, Scandinavian Journal of Surgery 91(2) (2002) 186-190. [11] G.H. Prosser, E.S. Isbister, The presentation of scaphoid non-union, Injury 34(1) (2003) 65-67.
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[12] I.J.F. Slade, W.B. Geissler, A.P. Gutow, G.A. Merrell, Percutaneous internal fixation of selected scaphoid nonunions with an arthroscopically assisted dorsal approach, Journal of Bone and Joint Surgery - Series A 85(SUPPL. 4) (2003) 20-32. [13] I. Akmaz, A. Kiral, O. Pehlivan, M. Mahirogullari, C. Solakoglu, O. Rodop, Biodegradable implants in the treatment of scaphoid nonunions, International Orthopaedics 28(5) (2004) 261-266. [14] P.H.J. Bullens, M. Driesprong, H. Lacroix, J. Vegter, Treatment of scaphoid non-union with a percutaneous corticocancellous bone graft, Journal of Hand Surgery 30(4) (2005) 365-368. [15] W. Daecke, P. Wieloch, P. Vergetis, M. Jung, A.K. Martini, Occurrence of carpal osteoarthritis after treatment of scaphoid nonunion with bone graft and herbert screw: A long-term follow-up study, Journal of Hand Surgery 30(5) (2005) 923-931. [16] T. Murase, H. Moritomo, A. Goto, K. Sugamoto, H. Yoshikawa, Does three-dimensional computer simulation improve results of scaphoid nonunion surgery?, Clinical orthopaedics and related research (434) (2005) 143-150. [17] V. Finsen, M. Hofstad, H. Haugan, Most scaphoid non-unions heal with bone chip grafting and Kirschner-wire fixation. Thirty-nine patients reviewed 10 years after operation, Injury 37(9) (2006) 854-859. [18] C.P. Little, B.J. Burston, J. Hopkinson-Woolley, P. Burge, Failure of surgery for scaphoid nonunion is associated with smoking, Journal of Hand Surgery 31(3) (2006) 252-255. [19] A.D. Tambe, L. Cutler, S.R. Murali, I.A. Trail, J.K. Stanley, In scaphoid non-union, does the source of graft affect outcome? Iliac crest versus distal end of radius bone graft, Journal of Hand Surgery 31(1) (2006) 47-51. [20] A.F. Dinah, R.H. Vickers, Smoking increases failure rate of operation for established non-union of the scaphoid bone, International Orthopaedics 31(4) (2007) 503-505. [21] C. Ramamurthy, L. Cutler, D. Nuttall, A.J. Simison, I.A. Trail, J.K. Stanley, The factors affecting outcome after non-vascular bone grafting and internal fixation for nonunion of the scaphoid, The Journal of bone and joint surgery. British volume 89(5) (2007) 627-32. [22] M. Yasuda, Y. Ando, K. Masada, Treatment of scaphoid nonunion using volar biconcave cancellous bone grafting, Hand surgery : an international journal devoted to hand and upper limb surgery and related research : journal of the Asia-Pacific Federation of Societies for Surgery of the Hand 12(2) (2007) 135-140. [23] J. Braga-Silva, F.M. Peruchi, G.M. Moschen, D. Gehlen, A.V. Padoin, 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, Journal of Hand Surgery: European Volume 33(5) (2008) 636-640. [24] J.J. Gregory, R.S. Mohil, A.B. Ng, J.G. Warner, S.P. Hodgson, Comparison of Herbert and Acutrak screws in the treatment of scaphoid non-union and delayed union, Acta orthopaedica Belgica 74(6) (2008) 761-765.
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[25] K. Ikeda, N. Osamura, K. Tomita, Percutaneous screw fixation without bone graft for cystic-type scaphoid fractures, Journal of Trauma - Injury, Infection and Critical Care 65(6) (2008) 1453-1458. [26] P.K. Inaparthy, J.E. Nicholl, Treatment of delayed/nonunion of scaphoid waist with Synthes cannulated scaphoid screw and bone graft, Hand (New York, N.Y.) 3(4) (2008) 292-6. [27] M. Schreuder, I. Degreef, L. De Smet, Treatment of scaphoid non-unions with a corticocancellous graft and Herbert screw fixation: Results at five years follow-up, Acta orthopaedica Belgica 74(1) (2008) 24-28. [28] F. Yassaee, S.S. Yang, Mini-Incision Fixation of Nondisplaced Scaphoid Fracture Nonunions, Journal of Hand Surgery 33(7) (2008) 1116-1120. [29] Y.C. Huang, Y. Liu, T.H. Chen, Long-term results of scaphoid nonunion treated by intercalated bone grafting and Herbert's screw fixation-a study of 49 patients for at least five years, International Orthopaedics 33(5) (2009) 1295-1300. [30] O. Reigstad, R. Thorkildsen, C. Grimsgaard, A. Reigstad, M. Rokkum, Is revision bone grafting worthwhile after failed surgery for scaphoid nonunion? Minimum 8 year follow-up of 18 patients, The Journal of hand surgery, European volume 34(6) (2009) 772-777. [31] R. Grewal, K.U. Boyd, J. Macdermid, R.Y. McMurtry, A qualitative evaluation of scaphoid remodeling in bone-grafted scaphoid nonunions, Hand (New York, N.Y.) 5(4) (2010) 430-3. [32] J.K. Kim, J.O. Kim, S.Y. Lee, Volar percutaneous screw fixation for scaphoid waist delayed union, Clinical orthopaedics and related research 468(4) (2010) 1066-1071. [33] A. Notarnicola, L. Moretti, S. Tafuri, S. Gigliotti, S. Russo, L. Musci, B. Moretti, Extracorporeal shockwaves versus surgery in the treatment of pseudoarthrosis of the carpal scaphoid, Ultrasound in Medicine and Biology 36(8) (2010) 1306-1313. [34] O. Reigstad, R. Thorkildsen, C. Grimsgaard, A. Reigstad, M. Rokkum, Healing of ununited scaphoid fractures by Kirschner wires and autologous structural bone grafts, Journal of Plastic Surgery and Hand Surgery 44(2) (2010) 106-111. [35] S. Ribak, C.E.G. Medina, R. Mattar Jr, H.J.R. Ulson, M.R. De Resende, M. Etchebehere, Treatment of scaphoid nonunion with vascularised and nonvascularised dorsal bone grafting from the distal radius, International Orthopaedics 34(5) (2010) 683-688. [36] M. Bumbasirevic, S. Tomic, A. Lesic, V. Bumbasirevic, Z. Rakocevic, H.D. Atkinson, The treatment of scaphoid nonunion using the Ilizarov fixator without bone graft, a study of 18 cases, Journal of orthopaedic surgery and research 6 (2011) 57. [37] H. Chim, F. Malkoc, S.C. Tay, A. Yam, L.C. Teoh, Technique of olecranon bone grafting for surgical fixation of scaphoid fractures, Journal of Hand Surgery 36(7) (2011) 1220-1223. [38] P.J. Chu, J.T. Shih, Arthroscopically assisted use of injectable bone graft substitutes for management of scaphoid nonunions, Arthroscopy - Journal of Arthroscopic and Related Surgery 27(1) (2011) 31-37.
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[39] A. Ghoneim, The unstable nonunited scaphoid waist fracture: Results of treatment by open reduction, anterior wedge grafting, and internal fixation by volar buttress plate, Journal of Hand Surgery 36(1) (2011) 17-24. [40] A. Kilic, S. Sokucu, A.S. Parmaksizoglu, M. Gul, Y.S. Kabukcuoglu, Comparative evaluation of radiographic and functional outcomes in the surgical treatment of scaphoid non-unions, Acta orthopaedica et traumatologica turcica 45(6) (2011) 399-405. [41] M. Leixnering, C. Pezzei, P. Weninger, M. Mayer, R. Bogner, S. Lederer, J. Schauer, M. Figl, First experiences with a new adjustable plate for osteosynthesis of scaphoid nonunions, Journal of Trauma - Injury, Infection and Critical Care 71(4) (2011) 933-938. [42] M. Mahmoud, W. Koptan, Percutaneous screw fixation without bone grafting for established scaphoid nonunion with substantial bone loss, Journal of Bone and Joint Surgery - Series B 93 B(7) (2011) 932-936. [43] P.K. Raju, S.G. Kini, Fixation techniques for non-union of the scaphoid, Journal of orthopaedic surgery (Hong Kong) 19(1) (2011) 80-84. [44] M. Saint-Cyr, G. Oni, C. Wong, M.K. Sen, A.S. LaJoie, A. Gupta, Dorsal percutaneous cannulated screw fixation for delayed union and nonunion of the scaphoid, Plastic and reconstructive surgery 128(2) (2011) 467-473. [45] K. Watanabe, Analysis of carpal malalignment caused by scaphoid nonunion and evaluation of corrective bone graft on carpal alignment, Journal of Hand Surgery 36(1) (2011) 10-16. [46] A.B. Zoubos, I.K. Triantafyllopoulos, G.C. Babis, P.N. Soucacos, A modified matti-russe technique for the treatment of scaphoid waist non-union and pseudarthrosis, Medical Science Monitor 17(2) (2011) MT7-MT12. [47] J.T. Capo, B. Shamian, M. Rizzo, Percutaneous screw fixation without bone grafting of scaphoid non-union, Israel Medical Association Journal 14(12) (2012) 729-732. [48] M.E. Kent, N.N. Rehmatullah, L. Young, A.J. Chojnowski, Scaphoid nonunion in the presence of a degenerate carpus: don't rush to salvage surgery, The Journal of hand surgery, European volume 37(1) (2012) 56-60. [49] S.G. Kirkham, M.J. Millar, Cancellous bone graft and Kirschner wire fixation as a treatment for cavitary-type scaphoid nonunions exhibiting DISI, Hand (New York, N.Y.) 7(1) (2012) 86-93. [50] K. Megerle, P.S. Harenberg, G. Germann, S. Hellmich, Scaphoid morphology and clinical outcomes in scaphoid reconstructions, Injury 43(3) (2012) 306-310. [51] K.O. Oduwole, B. Cichy, J.P. Dillon, J. Wilson, J. O'Beirne, Acutrak versus Herbert screw fixation for scaphoid non-union and delayed union, Journal of orthopaedic surgery (Hong Kong) 20(1) (2012) 61-65. [52] Y. Bao, H. Kang, Z.Y. Zhang, M.B. Nie, F.J. Guo, Treatment of scaphoid nonunion: Pedicled vascularized bone graft vs. traditional bone graft, Journal of Huazhong University of Science and Technology - Medical Science 33(5) (2013) 713-716.
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[53] M.S. Cohen, J.B. Jupiter, K. Fallahi, S.K. Shukla, Scaphoid waist nonunion with humpback deformity treated without structural bone graft, Journal of Hand Surgery 38(4) (2013) 701-705. [54] M. Corsten, C. Heffinger, L. Kolios, M. Lehnhardt, B. Bickert, C. Hirche, Functional results and quality of life after bilateral scaphoid reconstruction: A case series, Archives of orthopaedic and trauma surgery 133(2) (2013) 283-286. [55] S. El-Sallakh, W. Mousa, T. Aly, Intercalated bone PEG in the treatment of non-united scaphoid fractures, Hand surgery : an international journal devoted to hand and upper limb surgery and related research : journal of the Asia-Pacific Federation of Societies for Surgery of the Hand 18(1) (2013) 2733. [56] T. Goyal, S.R. Sankineani, S.K. Tripathy, Local distal radius bone graft versus iliac crest bone graft for scaphoid nonunion: a comparative study, Musculoskelet Surg 97(2) (2013) 109-14. [57] A. Oron, A. Gupta, S. Thirkannad, Nonunion of the scaphoid distal pole, Hand surgery : an international journal devoted to hand and upper limb surgery and related research : journal of the AsiaPacific Federation of Societies for Surgery of the Hand 18(1) (2013) 35-39. [58] H.Y. Park, J.O. Yoon, I.H. Jeon, H.W. Chung, J.S. Kim, A comparison of the rates of union after cancellous iliac crest bone graft and Kirschner-wire fixation in the treatment of stable and unstable scaphoid nonunion, Bone and Joint Journal 95 B(6) (2013) 809-814. [59] F. Ya'ish, C.A. Bailey, C.P. Kelly, M.A. Craigen, Bioabsorbable fixation of scaphoid fractures and non-unions; analysis of early clinical outcomes, Hand surgery : an international journal devoted to hand and upper limb surgery and related research : journal of the Asia-Pacific Federation of Societies for Surgery of the Hand 18(3) (2013) 343-349. [60] F.A. Caporrino, J.B.G. Dos Santos, F.T. Penteado, V.Y. De Moraes, J.C. Belloti, F. Faloppa, Dorsal vascularized grafting for scaphoid nonunion: A comparison of two surgical techniques, Journal of orthopaedic trauma 28(3) (2014) e44-e48. [61] S. Euler, S. Erhart, C. Deml, T. Kastenberger, M. Gabl, R. Arora, The effect of delayed treatment on clinical and radiological effects of anterior wedge grafting for non-union of scaphoid fractures, Archives of orthopaedic and trauma surgery 134(7) (2014) 1023-1030. [62] R.M. Garcia, F.J. Leversedge, J.M. Aldridge, M.J. Richard, D.S. Ruch, Scaphoid nonunions treated with 2 headless compression screws and bone grafting, Journal of Hand Surgery 39(7) (2014) 1301-1307. [63] M. Maniglio, A. Schweizer, L. Nagy, Scaphoid waist nonunions treated with illiac crest or vascularized bone grafts, Swiss Medical Weekly 144 (2014) 15S. [64] A. Afshar, A. Mohammadi, K. Zohrabi, N. Navaeifar, S.H. Sami, H. Taleb, Correlation of Reconstructed Scaphoid Morphology with Clinical Outcomes, The archives of bone and joint surgery 3(4) (2015) 244-9. [65] U. Ahmed, S. Malik, M. David, C. Simpson, S. Tan, D. Power, The Headless Compression Screw - Technical challenges in scaphoid fracture fixation, Journal of Orthopaedics 12 (2015) S211-S216.
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[66] C. Eder, N. Schwab, A. Scheller, B.D. Krapohl, A new variant of scaphoid reconstruction: Treatment of scaphoid non-union with avascular bone interponate and high compression screw (Synthes((R))), GMS Interdisciplinary plastic and reconstructive surgery DGPW 4 (2015) Doc07. [67] P. Farsetti, R. Caterini, V. Potenza, M. Dragoni, E. Ippolito, Modified murray technique for carpal navicular nonunion, Orthopedics 38(9) (2015) e766-e772. [68] G. Hegazy, Percutaneous Screw Fixation of Scaphoid Waist Fracture Non-Union Without Bone Grafting, Journal of hand and microsurgery 7(2) (2015) 250-5. [69] J.P. Kim, J.B. Seo, J.Y. Yoo, J.Y. Lee, Arthroscopic management of chronic unstable scaphoid nonunions: Effects on restoration of carpal alignment and recovery of wrist function, Arthroscopy Journal of Arthroscopic and Related Surgery 31(3) (2015) 460-469. [70] C.H. Lee, K.H. Lee, B.G. Lee, D.Y. Kim, W.S. Choi, Clinical outcome of scaphoid malunion as a result of scaphoid fracture nonunion surgical treatment: A 5-year minimum follow-up study, Orthopaedics and Traumatology: Surgery and Research 101(3) (2015) 359-363. [71] S.K. Lee, D.J. Byun, J.L. Roman-Deynes, Z. Model, S.W. Wolfe, Hybrid russe procedure for scaphoid waist fracture nonunion with deformity, Journal of Hand Surgery 40(11) (2015) 2198-2205. [72] C.W. McInnes, J.L. Giuffre, Fixation and Grafting after Limited Debridement of Scaphoid Nonunions, Journal of Hand Surgery 40(9) (2015) 1791-1796. [73] A. Poggetti, M. Rosati, I. Castellini, G. Evangelisti, P. Battistini, P. Parchi, M. Lisanti, Treatment of Scaphoid Waist Nonunion Using Olecranon Bone Graft and Stryker Asnis Micro Cannulated Screw: A Retrospective Study-80 Case Studies and 6 Years of Follow-Up, Journal of Wrist Surgery 4(3) (2015) 194-199. [74] J.S. Somerson, D.J. Fletcher, R.C. Srinivasan, D.P. Green, Compression screw fixation without bone grafting for scaphoid fibrous nonunion, Hand (New York, N.Y.) 10(3) (2015) 450-3. [75] C. Taleb, F. Bodin, S. Collon, A. Gay, S. Facca, P. Liverneaux, Retrograde percutaneous screw fixation for scaphoid type II non-union in Schernberg zones 2 to 4: A series of 38 cases, Chirurgie de la main 34(1) (2015) 32-38. [76] J. Wu, S.C. Tay, A.Y. Shin, The Effect of Screw Design on Union Rates in Scaphoid Nonunions, Hand surgery : an international journal devoted to hand and upper limb surgery and related research : journal of the Asia-Pacific Federation of Societies for Surgery of the Hand 20(2) (2015) 273-9. [77] L. Xiong, L. Harhaus, C. Heffinger, B. Bickert, T. Kremer, U. Kneser, C. Hirche, A comparative study on autologous bone grafting combined with or without posterior interosseous nerve neurectomy for scaphoid nonunion treatment, Journal of Plastic, Reconstructive and Aesthetic Surgery 68(8) (2015) 1138-1144. All authors have made substantial contributions to the following: (1) the conception and design of the study, or acquisition of data, or analysis and interpretation of data, (2) drafting the article or revising it critically for important intellectual content, (3) final approval of the version to be submitted.
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[16] G.I. Bain, J.D. Bennett, J.C. MacDermid, G.P. Slethaug, R.S. Richards, J.H. Roth, Measurement of the scaphoid humpback deformity using longitudinal computed tomography: intra- and interobserver variability using various measurement techniques, J Hand Surg Am 23(1) (1998) 76-81. [17] M. Bhat, M. McCarthy, T.R. Davis, J.A. Oni, S. Dawson, MRI and plain radiography in the assessment of displaced fractures of the waist of the carpal scaphoid, J Bone Joint Surg Br 86(5) (2004) 705-13. [18] D. Ring, J.D. Patterson, S. Levitz, C. Wang, J.B. Jupiter, Both scanning plane and observer affect measurements of scaphoid deformity, J Hand Surg Am 30(4) (2005) 696-701. [19] R. Yanagisawa, Y. Sugaya, S. Kasahara, S. Omachi, Tooth shape reconstruction from dental CT images with the region-growing method, Dentomaxillofac Radiol 43(6) (2014) 20140080. [20] E.L. Leventhal, S.W. Wolfe, E.F. Walsh, J.J. Crisco, A computational approach to the "optimal" screw axis location and orientation in the scaphoid bone, J Hand Surg Am 34(4) (2009) 677-84. [21] P.W. ten Berg, J.G. Dobbe, S.D. Strackee, G.J. Streekstra, Three-Dimensional Assessment of Bilateral Symmetry of the Scaphoid: An Anatomic Study, Biomed Res Int 2015 (2015) 547250. [22] D. Moher, A. Liberati, J. Tetzlaff, D.G. Altman, P. Group, Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement, Int J Surg 8(5) (2010) 336-41. [23] T. Murase, H. Moritomo, A. Goto, K. Sugamoto, H. Yoshikawa, Does three-dimensional computer simulation improve results of scaphoid nonunion surgery?, Clin Orthop Relat Res (434) (2005) 143-50. [24] G.A. Merrell, S.W. Wolfe, J.F. Slade, 3rd, Treatment of scaphoid nonunions: quantitative metaanalysis of the literature, J Hand Surg Am 27(4) (2002) 685-91. [25] P.F. Hannemann, L. Brouwers, D. van der Zee, A. Stadler, K.W. Gottgens, R. Weijers, M. Poeze, P.R. Brink, Multiplanar reconstruction computed tomography for diagnosis of scaphoid waist fracture union: a prospective cohort analysis of accuracy and precision, Skeletal Radiol 42(10) (2013) 1377-82. [26] J.J. Dias, M. Taylor, J. Thompson, I.J. Brenkel, P.J. Gregg, Radiographic signs of union of scaphoid fractures. An analysis of inter-observer agreement and reproducibility, J Bone Joint Surg Br 70(2) (1988) 299-301. [27] M. Haefeli, D.J. Schaefer, R. Schumacher, M. Muller-Gerbl, P. Honigmann, Titanium template for scaphoid reconstruction, J Hand Surg Eur Vol 40(5) (2015) 526-33. [28] J.F. Slade, 3rd, S.D. Dodds, Minimally invasive management of scaphoid nonunions, Clin Orthop Relat Res 445 (2006) 108-19. [29] J.F. Slade, 3rd, W.B. Geissler, A.P. Gutow, G.A. Merrell, Percutaneous internal fixation of selected scaphoid nonunions with an arthroscopically assisted dorsal approach, J Bone Joint Surg Am 85-A Suppl 4 (2003) 20-32. [30] W.H. Mallee, J.N. Doornberg, D. Ring, M. Maas, M. Muhl, C.N. van Dijk, J.C. Goslings, 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) 9(1) (2014) 117-21.
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Figure Legends Fig. 1. Sagittal CT slices of both wrists of a patient with a unilateral scaphoid waist nonunion (a) healthy intact scaphoid. (b),(c), and (d) scaphoid nonunion showing a typical humpback deformity as evaluated with standard CT measures [12], including (b) Intrascaphoid angle (ISA); the angle between the two lines perpendicular to the proximal and distal articular surface of the scaphoid nonunion, (c) Height-to-length (H/L) ratio; the ratio between the height of the scaphoid as measured from a palmar baseline to the dorsal humpback, and the length along the palmar baseline limited by the most proximal and distal aspects of the scaphoid, and (d) Dorsal cortical angle (DCA); the angle between two lines along the dorsal cortex of the proximal and distal fragments. Fig. 2. Virtual 3-D CT-based images of a scaphoid nonunion (orange model) and the mirrored contralateral intact scaphoid (transparent white model) from the same patients as in Figure 1. By using the contralateral scaphoid model as template, after superimposing the proximal fragment and the intact proximal pole, the level of displacement of the distal fragment can be quantified based on the difference with the position of the intact distal pole in 3-D space using a local anatomic coordinate system (X,Y,Z). Fig. 3. Flow chart of the systematic review. OC: osteocartilaginous; †See online appendix for full reference list of the included articles. Fig. 4. Column chart showing a trend in the use of CT scans, including scans that were acquired routinely or only in selected cases. The light grey columns represent the use of preoperative CT scans; the dark grey columns the use of postoperative CT scans.
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S0720-048X(17)30137-7 http://dx.doi.org/doi:10.1016/j.ejrad.2017.03.023 EURR 7789
To appear in:
European Journal of Radiology
Received date: Revised date: Accepted date:
17-11-2016 16-3-2017 29-3-2017
Please cite this article as: ten Berg Paul WL, de Roo Marieke GA, Maas Mario, Strackee Simon D.Is there a trend in CT scanning scaphoid nonunions for deformity assessment?—A systematic review.European Journal of Radiology http://dx.doi.org/10.1016/j.ejrad.2017.03.023 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Is There a Trend in CT Scanning Scaphoid Nonunions for Deformity Assessment? – A systematic review Running title: CT Scanning Scaphoid Nonunions Paul W. L. ten Berga, MD; Marieke G.A. de Rooa, MD; Mario Maasb, MD PhD; Simon D. Strackeea, MD PhD Affiliations: a Department of Plastic, Reconstructive, and Hand Surgery, Academic Medical Center, University of Amsterdam, Room G4-226, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands. b Department of Radiology, Academic Medical Center, University of Amsterdam, Room G1-211, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands. Corresponding author: Paul W.L. ten Berg, MD Department of Plastic, Reconstructive, and Hand Surgery Academic Medical Center, University of Amsterdam, Room G4-226 Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands E-mail: [email protected] Tel.: 0031 20 5662572 Fax: 0031 206917549 Conflict of interest: None Funding statement: PWLtB received a PhD grant (2014) from the Academic Medical Center (Amsterdam, Netherlands) supporting this research. Authorship: All authors have made substantial contributions to the following: (1) the conception and design of the study, or acquisition of data, or analysis and interpretation of data, (2) drafting the article or revising it critically for important intellectual content, (3) final approval of the version to be submitted. Highlights (for review)
Article: Is There a Trend in CT Scanning Scaphoid Nonunions for Deformity Assessment? – A systematic review The effect of scaphoid nonunion deformity on wrist function is uncertain. Most articles use standard, unreliable 2-D measures to assess scaphoid deformity. There is a clear trend in the use of CT scans in the workup of scaphoid nonunions. CT enables creating 3-D images, which may improve assessing scaphoid deformity. With this trend, assessing deformity with 3-D CT will be increasingly accessible.
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ABSTRACT Purpose: The effect of scaphoid nonunion deformity on wrist function is uncertain due to the lack of reliable imaging tools. Advanced three-dimensional (3-D) computed tomography (CT)-based imaging techniques may improve deformity assessment by using a mirrored image of the contralateral intact wrist as anatomic reference. The implementation of such techniques depends on the extent to which conventional CT is currently used in standard practice. The purpose of this systematic review of medical literature was to analyze the trend in CT scanning scaphoid nonunions, either unilaterally or bilaterally. Materials and methods: Using Medline and Embase databases, two independent reviewers searched for original full-length clinical articles describing series with at least five patients focusing on reconstructive surgery of scaphoid nonunions with bone grafting and/or fixation, from the years 2000 to 2015. We excluded reports focusing on only nonunions suspected for avascular necrosis and/or treated with vascularized bone grafting, as their workup often includes magnetic resonance imaging. For data analysis, we evaluated the use of CT scans and distinguished between uni- and bilateral, and pre- and postoperative scans. Results: Seventy-seven articles were included of which 16 were published between 2000‒2005, 19 between 2006‒2010, and 42 between 2011‒2015. For these consecutive intervals, the rates of articles describing the use of pre- and postoperative CT scans increased from 13%, to 16%, to 31%, and from 25%, to 32%, to 52%, respectively. Hereof, only two (3%) articles described the use of bilateral CT scans. Conclusion: There is an evident trend in performing unilateral CT scans before and after reconstructive surgery of a scaphoid nonunion. To improve assessment of scaphoid nonunion deformity using 3-D CT-based imaging techniques, we recommend scanning the contralateral wrist as well.
Keywords: Scaphoid; CT; three-dimensional; deformity; morphology; reconstruction
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1. Introduction A scaphoid nonunion is the result of a failed healing of the bone once fractured. A nonunion through the body of the scaphoid is associated with a flexion deformity in which the distal fragment rotates to the palmar side—a so-called humpback deformity [1]. It is also associated with a dorsal intercalated segment instability (DISI) deformity in which the lunate together with the proximal scaphoid fragment rotates in a pathological extended stance. Scaphoid nonunion patients with no or only limited carpal osteoarthritis are usually treated with reconstructive surgery directed at achieving both union and carpal realignment, to improve clinical outcome [2]. A common technique to realign the midcarpal joint is the use of an interpositional structural bone graft in addition to scaphoid screw fixation. This graft is usually harvested from the iliac crest and inserted between the scaphoid fragments through an open volar approach [1]. It is currently unclear how close the restored scaphoid anatomy must be to the original intact anatomy to yield a good clinical outcome [3]. Some clinical articles suggested an association of scaphoid malalignment, with pain, loss of motion and weakness after fracture healing [4-6]; while others failed to show an association between radiologic measurements of the intrinsic scaphoid morphology and outcome [3, 7]. A factor contributing to this uncertainty is the unreliable way of measuring scaphoid deformity on both pre- and postoperative images, for which there is currently no consensus about the optimal measuring method [8-10]. On standard radiographs the projection of overlapping bones may hamper obtaining good visualization of the intrinsic scaphoid morphology [10]. Additional computed tomography (CT) provides more detailed information about the bony architecture [11]. Still, standard CT measures of scaphoid deformity only provide two-dimensional (2D) information (Fig. 1), while the displacement pattern and fracture line morphology in scaphoid nonunions are three-dimensional (3-D) problems [12-15]. Moreover, these CT measures have shown to have limited reproducibility [16-18]. Therefore, surgeons stress the need for new imaging methods to more accurately and reproducibly measure scaphoid deformity [3, 18].Recent advances in imaging techniques enable synthesizing the information from a standard CT into virtual 3-D models of the scaphoid nonunion fragments Reconstruction of a 3-D model is often based on a 3-D polygon created from a sequence of segmented 2-D CT images. Currently, many image segmentation and 3-D
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reconstruction methods exist which can be applied in (semi-)automated fashion [19]. To assess the level of fragment displacement objectively, a mirrored model of the contralateral intact scaphoid may serve as anatomic template, requiring a bilateral CT scan. Using dedicated planning software, the proximal and distal fragments can be virtually matched with the proximal and distal intact poles by image registration [12-15]. Subsequently, fragment displacement can be defined as the difference in position between the distal fragment and the intact distal pole relatively to the proximal fragment. To express displacement in 3-D space, an anatomical coordinate system can be defined based on the principal axes of the virtual model of the contralateral intact scaphoid using its inertial properties (Fig. 2) [20]. The contralateral scaphoid is considered an accurate template because of the reported high level of bilateral shape symmetry in scaphoid pairs [21]. These advanced imaging techniques may improve characterizing scaphoid nonunions as well as investigating the relation between the level of scaphoid deformity and clinical outcome. The clinical implementation of advanced 3-D CT-based imaging techniques is influenced by the extent to which conventional CT is currently used in standard practice. Numbers about the exact rate of using CT in the management of scaphoid nonunions are lacking. The purpose of this systematic review was to analyze the use of CT as reported in clinical series on reconstructive surgery of scaphoid nonunions, with special interest in the ability of CT to generate 3-D CT-based images. We addressed the following questions: 1. Is there a trend in CT scanning scaphoid nonunions, either unilaterally or bilaterally? 2. Is there a difference between the pre-operative and postoperative use of CT? 3. Which CT measures of scaphoid humpback deformity are most commonly applied? 2. Material and methods We conducted an online literature search in Medline and Embase from 2000 to 2015. The search and data extraction were performed by two independent reviewers, according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines [22]. Disagreements between reviewers were discussed until consensus was reached. 2.1 Eligibility criteria systematic review
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All reports on the reconstructive surgery of scaphoid nonunions not suspected for avascular necrosis (AVN) were eligible for inclusion. We excluded reports focusing only on scaphoid nonunions with or suspected for AVN, proximal nonunions and/or scaphoid nonunions treated with vascularized bone grafting, as their workup often includes magnetic resonance imaging (MRI). To increase power, studies comparing both non-vascularized and vascularized bone grafting were included, with special attention to the non-vascularized treatment group. Inclusion criteria were: (1) original full-length clinical articles focusing on reconstructive surgery with non-vascularized bone grafting and/or fixation for scaphoid nonunions; (2) series of at least five adult patients; (3) publication date between 01.01.2000 and 31.12.2015; (4) English language. Exclusion criteria were: (1) non-clinical studies; (2) series focusing only on vascularized or osteocartilaginous bone grafting; (3) series including only proximal nonunions; (4) diagnostic studies focusing on MRI; (5) non original full-length articles; (6) follow-up studies based on series already described in previous included articles from the same institution. 2.2 Literature search, study selection and data extraction We used Medical Subject Headings (MeSH) (= scaphoid bone), using free search terms in title and abstract with (=scaphoid*), and using free search terms in all fields with truncation. The full search strategy is addressed in Figure 3. We retrieved all titles and abstracts for eligibility assessment, after removing duplicates in Endnote X7 (Thomas Reuter, London, UK). If eligibility criteria were met, articles were obtained and reviewed. After final selection, all articles were reviewed with special attention to the described imaging modality and applied CT deformity measures. 2.3 Quality assessment We did not assess the quality of the articles as we focused on the descriptions of applied imaging modalities only, independent to other methodologic parameters, such as blinding and randomization. This makes the use of general quality assessment tools to appreciate overall outcome of a study redundant. 3. Results Seventy-seven articles met our inclusion criteria (Fig. 3; see also appendix for full reference list of included articles), of which 16 were published between 2000‒2005, 19 between 2006‒2010, and
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42 between 2011‒2015. In these consecutive year periods, the rates of articles describing pre- and postoperative CT scans increased from 13%, to 16%, to 31%, and from 25%, to 32%, to 52%, respectively (Fig. 4). Overall, 18 (23%) and 32 (42%) articles described the use of pre- and postoperative CT scans, respectively. In respectively 9 (12%) and 14 (18%) of these articles, CT scans were routinely performed. In total, two (3%) articles described the use of bilateral CT scans. Of the articles describing the use of CT scans, eight articles described standard CT measures of the humpback deformity based on the ISA, four on the H/L ratio, and two on the DCA (Fig. 1). Only one clinical article of Murase et al. [23] used 3-D CT-based image techniques to evaluate the level of angulation and displacement in scaphoid nonunion in their workup prior to surgery.
4. Discussion This systematic review demonstrated a clear trend from the year 2000 in performing unilateral CT scans in the workup of scaphoid nonunions treated reconstructively, with a more widespread use of postoperative scans. The use of bilateral CT scans is uncommon. A reason of the unpopularity of scanning both wrists could be the increased associated radiation dose. However, radiation to the skeletal system has relatively little impact on the patient, especially when both wrists are imaged simultaneously; moreover, scaphoid imaging requires only a small scanning volume. A more obvious explanation could be the limited diagnostic value of the contralateral scan as currently used in standard practice. As standard measures of scaphoid morphology and deformity are unreliable [3, 16-18], evaluation of the contralateral wrist remains to a large degree subjective. Contralateral scanning becomes more relevant when automated 3-D CT-based imaging techniques are implemented, integrating the contralateral side as anatomic template. Only then, we could establish a reliable benchmark of how close the restored scaphoid anatomy must be to the original intact anatomy to yield a good outcome. The difference in rates between the use of pre- and postoperative CT scans could be explained by the difference in purpose of performing the scan. Post-operative scans are often primarily performed to assess trabecular bridging as measure for bony union, which is considered an adequate overall measure of surgical success [24]. Previous studies have shown that inter-observer agreement for radiologic assessment of union was substantially higher on postoperative CT [8, 25] than on
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radiography [26]. Additionally, the reconstructed scaphoid morphology can be measured to assess whether the nonunion fragments were adequately reduced. Pre-operative scans can be used to plan the reconstruction. However, there is debate about the value of surgical planning as there are many factors influencing the surgical strategy that are difficult to determine pre-operatively. For example, the exact amount of sclerotic margin at the nonunion fracture sites that has to be removed is often determined intra-operatively, which hampers planning the exact graft size and the level of fragment reduction [27]. On the other hand, there is relative consensus about the use of preoperative CT scans for selecting nonunions suitable for percutaneous fixation. To this end, Slade [28] developed a progressive classification for scaphoid nonunions, ranging from early nonunions with minimal sclerosis and without substantial cystic bone resorption, to pseudarhtrosis with profound bone resorption and deformity. The latter author [29] stated that well-aligned nonunions with no or only limited sclerosis are an indication for percutaneous fixation. Based on the current review, the ISA is the most commonly applied standard CT measure of humpback deformity (Fig. 1). However, the H/L ratio is considered a more reproducible measure, although still leading to unsatisfactory observer agreement [16-18]. One factor contributing to observer variation is the scanning position of the wrist and the selection of the central slice to perform measurements on [3]. Nowadays, many radiologic workstations allow obtaining sagittal- and coronal multiplanar reconstructions in the central longitudinal axis of the scaphoid to evaluate angulation and displacement, independent to the configuration of the carpal bones during scanning [25, 30]. Despite the improvements of scaphoid imaging protocols, the manual standard CT measures themselves remain prone for observer variations. We therefore recommend using the H/L ratio only if no other techniques are available than standard CT measurement techniques. One study of Murase et al. [23] used 3-D CT-based imaging techniques to assess fragment displacement in scaphoid nonunions in 3-D space. To this end, virtual 3-D models of the proximal and distal fragments were matched with the proximal and distal parts of the mirrored contralateral intact scaphoid, similar to the technique described in Figure 1. To guide fragment reduction during surgical reconstruction, real-sized stereolithographic models of the scaphoid nonunions fragments and of the intact side were created. The authors [23] reported good clinical outcome. A more recent scaphoid
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study also showed the surgical benefits of using a real-sized 3-D printed model as intraoperative guide to plan an osteotomy and determine the size and shape of the bone graft [31]. In addition, two other recent clinical series [27, 32] published in 2016 described 3-D CT-based imaging techniques using the contralateral intact scaphoid as template to assess the level of scaphoid deformity as well. Based on these techniques, 3-D printed patient-specific reduction guides were created to improve scaphoid fragment reduction. Using 3-D displacement analysis postoperatively, average residual displacement was respectively 7° and less than 1.5mm, based on comparison with the contralateral intact scaphoid. Both studies [27, 32] showed satisfactory clinical outcome. Still, larger studies with long term followup are required to evaluate the consequences of the level of 3-D scaphoid reconstruction on wrist function and osteoarthritic development, before one could recommend one surgical procedure over another. The use of 3-D imaging techniques to evaluate the reconstructed scaphoid morphology may also help us in reaching consensus on the advisability of an osteotomy in case of a malunited scaphoid, when taken in addition to the clinical aspects. The strength of the current review is the inclusion of a large number of articles, providing a robust measure of the trend in CT scanning scaphoid nonunions. A limitation is the inclusion of clinical series published in English language only, producing a language bias. However, the number of non-English articles was relatively low, which, in case of inclusion, would probably not have led to a difference in main outcome. Another limitation is the omission of a quality assessment of the included articles. To our knowledge, no specific quality guidelines have yet been developed for our purposes. A general quality assessment of the articles would not have been relevant because we focused on the descriptions of a single radiologic imaging modality, rather than on overall outcome. In conclusion, there is an evident trend in performing unilateral CT scans before and after scaphoid nonunion reconstructions. With this trend and the continuing software development efforts, we foresee that 3-D CT-based imaging techniques to assess scaphoid nonunion deformity in 3-D space will be increasingly accessible for a broader clinical practice. To further enhance effectively implementing these techniques, we recommend scanning the contralateral wrist as well. With these techniques, we may improve characterizing scaphoid nonunions and subsequent surgical management,
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as well as investigating the relation between the level of reconstructed scaphoid morphology and clinical outcome, which is currently to a large degree speculative. Conflicts of interest None Authorship APPENDIX Is There a Trend in CT Scanning Scaphoid Nonunions for Deformity Assessment? – A systematic review Reference list of included articles for systematic review [1] N. Maruthainar, V.J. Rasquinha, P. Gallagher, The treatment of scaphoid nonunion: A review of a novel technique using precision bone grafting compared with Herbert screw fixation and bone graft, Journal of Hand Surgery 25 B(5) (2000) 427-430. [2] K. Ritter, A.A. Giachino, The treatment of pseudoarthrosis of the scaphoid by bone grafting and three methods of internal fixation, Canadian Journal of Surgery 43(2) (2000) 118-124. [3] H. Takami, S. Takahashi, M. Ando, Scaphoid nonunion treated by open reduction, anterior inlay bone grafting, and Kirschner-wire fixation, Archives of orthopaedic and trauma surgery 120(3-4) (2000) 134-138. [4] M.M. Tomaino, J. King, M. Pizillo, Correction of lunate malalignment when bone grafting scaphoid nonunion with humpback deformity: Rationale and results of a technique revisited, Journal of Hand Surgery 25(2) (2000) 322-329. [5] A.J.H. Trezies, T.R.C. Davis, N.J. Barton, Factors influencing the outcome of bone grafting surgery for scaphoid fracture non-union, Injury 31(8) (2000) 605-607. [6] T.M. Abuzakuk, A. Mofidi, M. O'Sullivan, Internal fixation of scaphoid fractures. Review of 25 cases, European Journal of Orthopaedic Surgery and Traumatology 11(1) (2001) 25-28. [7] L.S. Christodoulou, C.K. Kitsis, S.T. Chamberlain, Internal fixation of scaphoid non-union: A comparative study of three methods, Injury 32(8) (2001) 625-630. [8] Y.F. Leung, S.P.S. Ip, C. Cheuk, K.T. Sheung, Y.L. Wai, Trephine bone grafting technique for the treatment of scaphoid nonunion, Journal of Hand Surgery 26(5) (2001) 893-900. [9] S. Eggli, D.L. Fernandez, T. Beck, Unstable scaphoid fracture nonunion: A medium-term study of anterior wedge grafting procedures, Journal of Hand Surgery 27 B(1) (2002) 36-41. [10] S. Kujala, T. Raatikainen, J. Ryhanen, O. Kaarela, P. Jalovaara, Composite implant of native bovine bone morphogenetic protein (BMP) and biocoral in the treatment of scaphoid nonunions - A preliminary study, Scandinavian Journal of Surgery 91(2) (2002) 186-190. [11] G.H. Prosser, E.S. Isbister, The presentation of scaphoid non-union, Injury 34(1) (2003) 65-67.
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[12] I.J.F. Slade, W.B. Geissler, A.P. Gutow, G.A. Merrell, Percutaneous internal fixation of selected scaphoid nonunions with an arthroscopically assisted dorsal approach, Journal of Bone and Joint Surgery - Series A 85(SUPPL. 4) (2003) 20-32. [13] I. Akmaz, A. Kiral, O. Pehlivan, M. Mahirogullari, C. Solakoglu, O. Rodop, Biodegradable implants in the treatment of scaphoid nonunions, International Orthopaedics 28(5) (2004) 261-266. [14] P.H.J. Bullens, M. Driesprong, H. Lacroix, J. Vegter, Treatment of scaphoid non-union with a percutaneous corticocancellous bone graft, Journal of Hand Surgery 30(4) (2005) 365-368. [15] W. Daecke, P. Wieloch, P. Vergetis, M. Jung, A.K. Martini, Occurrence of carpal osteoarthritis after treatment of scaphoid nonunion with bone graft and herbert screw: A long-term follow-up study, Journal of Hand Surgery 30(5) (2005) 923-931. [16] T. Murase, H. Moritomo, A. Goto, K. Sugamoto, H. Yoshikawa, Does three-dimensional computer simulation improve results of scaphoid nonunion surgery?, Clinical orthopaedics and related research (434) (2005) 143-150. [17] V. Finsen, M. Hofstad, H. Haugan, Most scaphoid non-unions heal with bone chip grafting and Kirschner-wire fixation. Thirty-nine patients reviewed 10 years after operation, Injury 37(9) (2006) 854-859. [18] C.P. Little, B.J. Burston, J. Hopkinson-Woolley, P. Burge, Failure of surgery for scaphoid nonunion is associated with smoking, Journal of Hand Surgery 31(3) (2006) 252-255. [19] A.D. Tambe, L. Cutler, S.R. Murali, I.A. Trail, J.K. Stanley, In scaphoid non-union, does the source of graft affect outcome? Iliac crest versus distal end of radius bone graft, Journal of Hand Surgery 31(1) (2006) 47-51. [20] A.F. Dinah, R.H. Vickers, Smoking increases failure rate of operation for established non-union of the scaphoid bone, International Orthopaedics 31(4) (2007) 503-505. [21] C. Ramamurthy, L. Cutler, D. Nuttall, A.J. Simison, I.A. Trail, J.K. Stanley, The factors affecting outcome after non-vascular bone grafting and internal fixation for nonunion of the scaphoid, The Journal of bone and joint surgery. British volume 89(5) (2007) 627-32. [22] M. Yasuda, Y. Ando, K. Masada, Treatment of scaphoid nonunion using volar biconcave cancellous bone grafting, Hand surgery : an international journal devoted to hand and upper limb surgery and related research : journal of the Asia-Pacific Federation of Societies for Surgery of the Hand 12(2) (2007) 135-140. [23] J. Braga-Silva, F.M. Peruchi, G.M. Moschen, D. Gehlen, A.V. Padoin, 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, Journal of Hand Surgery: European Volume 33(5) (2008) 636-640. [24] J.J. Gregory, R.S. Mohil, A.B. Ng, J.G. Warner, S.P. Hodgson, Comparison of Herbert and Acutrak screws in the treatment of scaphoid non-union and delayed union, Acta orthopaedica Belgica 74(6) (2008) 761-765.
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[25] K. Ikeda, N. Osamura, K. Tomita, Percutaneous screw fixation without bone graft for cystic-type scaphoid fractures, Journal of Trauma - Injury, Infection and Critical Care 65(6) (2008) 1453-1458. [26] P.K. Inaparthy, J.E. Nicholl, Treatment of delayed/nonunion of scaphoid waist with Synthes cannulated scaphoid screw and bone graft, Hand (New York, N.Y.) 3(4) (2008) 292-6. [27] M. Schreuder, I. Degreef, L. De Smet, Treatment of scaphoid non-unions with a corticocancellous graft and Herbert screw fixation: Results at five years follow-up, Acta orthopaedica Belgica 74(1) (2008) 24-28. [28] F. Yassaee, S.S. Yang, Mini-Incision Fixation of Nondisplaced Scaphoid Fracture Nonunions, Journal of Hand Surgery 33(7) (2008) 1116-1120. [29] Y.C. Huang, Y. Liu, T.H. Chen, Long-term results of scaphoid nonunion treated by intercalated bone grafting and Herbert's screw fixation-a study of 49 patients for at least five years, International Orthopaedics 33(5) (2009) 1295-1300. [30] O. Reigstad, R. Thorkildsen, C. Grimsgaard, A. Reigstad, M. Rokkum, Is revision bone grafting worthwhile after failed surgery for scaphoid nonunion? Minimum 8 year follow-up of 18 patients, The Journal of hand surgery, European volume 34(6) (2009) 772-777. [31] R. Grewal, K.U. Boyd, J. Macdermid, R.Y. McMurtry, A qualitative evaluation of scaphoid remodeling in bone-grafted scaphoid nonunions, Hand (New York, N.Y.) 5(4) (2010) 430-3. [32] J.K. Kim, J.O. Kim, S.Y. Lee, Volar percutaneous screw fixation for scaphoid waist delayed union, Clinical orthopaedics and related research 468(4) (2010) 1066-1071. [33] A. Notarnicola, L. Moretti, S. Tafuri, S. Gigliotti, S. Russo, L. Musci, B. Moretti, Extracorporeal shockwaves versus surgery in the treatment of pseudoarthrosis of the carpal scaphoid, Ultrasound in Medicine and Biology 36(8) (2010) 1306-1313. [34] O. Reigstad, R. Thorkildsen, C. Grimsgaard, A. Reigstad, M. Rokkum, Healing of ununited scaphoid fractures by Kirschner wires and autologous structural bone grafts, Journal of Plastic Surgery and Hand Surgery 44(2) (2010) 106-111. [35] S. Ribak, C.E.G. Medina, R. Mattar Jr, H.J.R. Ulson, M.R. De Resende, M. Etchebehere, Treatment of scaphoid nonunion with vascularised and nonvascularised dorsal bone grafting from the distal radius, International Orthopaedics 34(5) (2010) 683-688. [36] M. Bumbasirevic, S. Tomic, A. Lesic, V. Bumbasirevic, Z. Rakocevic, H.D. Atkinson, The treatment of scaphoid nonunion using the Ilizarov fixator without bone graft, a study of 18 cases, Journal of orthopaedic surgery and research 6 (2011) 57. [37] H. Chim, F. Malkoc, S.C. Tay, A. Yam, L.C. Teoh, Technique of olecranon bone grafting for surgical fixation of scaphoid fractures, Journal of Hand Surgery 36(7) (2011) 1220-1223. [38] P.J. Chu, J.T. Shih, Arthroscopically assisted use of injectable bone graft substitutes for management of scaphoid nonunions, Arthroscopy - Journal of Arthroscopic and Related Surgery 27(1) (2011) 31-37.
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[39] A. Ghoneim, The unstable nonunited scaphoid waist fracture: Results of treatment by open reduction, anterior wedge grafting, and internal fixation by volar buttress plate, Journal of Hand Surgery 36(1) (2011) 17-24. [40] A. Kilic, S. Sokucu, A.S. Parmaksizoglu, M. Gul, Y.S. Kabukcuoglu, Comparative evaluation of radiographic and functional outcomes in the surgical treatment of scaphoid non-unions, Acta orthopaedica et traumatologica turcica 45(6) (2011) 399-405. [41] M. Leixnering, C. Pezzei, P. Weninger, M. Mayer, R. Bogner, S. Lederer, J. Schauer, M. Figl, First experiences with a new adjustable plate for osteosynthesis of scaphoid nonunions, Journal of Trauma - Injury, Infection and Critical Care 71(4) (2011) 933-938. [42] M. Mahmoud, W. Koptan, Percutaneous screw fixation without bone grafting for established scaphoid nonunion with substantial bone loss, Journal of Bone and Joint Surgery - Series B 93 B(7) (2011) 932-936. [43] P.K. Raju, S.G. Kini, Fixation techniques for non-union of the scaphoid, Journal of orthopaedic surgery (Hong Kong) 19(1) (2011) 80-84. [44] M. Saint-Cyr, G. Oni, C. Wong, M.K. Sen, A.S. LaJoie, A. Gupta, Dorsal percutaneous cannulated screw fixation for delayed union and nonunion of the scaphoid, Plastic and reconstructive surgery 128(2) (2011) 467-473. [45] K. Watanabe, Analysis of carpal malalignment caused by scaphoid nonunion and evaluation of corrective bone graft on carpal alignment, Journal of Hand Surgery 36(1) (2011) 10-16. [46] A.B. Zoubos, I.K. Triantafyllopoulos, G.C. Babis, P.N. Soucacos, A modified matti-russe technique for the treatment of scaphoid waist non-union and pseudarthrosis, Medical Science Monitor 17(2) (2011) MT7-MT12. [47] J.T. Capo, B. Shamian, M. Rizzo, Percutaneous screw fixation without bone grafting of scaphoid non-union, Israel Medical Association Journal 14(12) (2012) 729-732. [48] M.E. Kent, N.N. Rehmatullah, L. Young, A.J. Chojnowski, Scaphoid nonunion in the presence of a degenerate carpus: don't rush to salvage surgery, The Journal of hand surgery, European volume 37(1) (2012) 56-60. [49] S.G. Kirkham, M.J. Millar, Cancellous bone graft and Kirschner wire fixation as a treatment for cavitary-type scaphoid nonunions exhibiting DISI, Hand (New York, N.Y.) 7(1) (2012) 86-93. [50] K. Megerle, P.S. Harenberg, G. Germann, S. Hellmich, Scaphoid morphology and clinical outcomes in scaphoid reconstructions, Injury 43(3) (2012) 306-310. [51] K.O. Oduwole, B. Cichy, J.P. Dillon, J. Wilson, J. O'Beirne, Acutrak versus Herbert screw fixation for scaphoid non-union and delayed union, Journal of orthopaedic surgery (Hong Kong) 20(1) (2012) 61-65. [52] Y. Bao, H. Kang, Z.Y. Zhang, M.B. Nie, F.J. Guo, Treatment of scaphoid nonunion: Pedicled vascularized bone graft vs. traditional bone graft, Journal of Huazhong University of Science and Technology - Medical Science 33(5) (2013) 713-716.
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[53] M.S. Cohen, J.B. Jupiter, K. Fallahi, S.K. Shukla, Scaphoid waist nonunion with humpback deformity treated without structural bone graft, Journal of Hand Surgery 38(4) (2013) 701-705. [54] M. Corsten, C. Heffinger, L. Kolios, M. Lehnhardt, B. Bickert, C. Hirche, Functional results and quality of life after bilateral scaphoid reconstruction: A case series, Archives of orthopaedic and trauma surgery 133(2) (2013) 283-286. [55] S. El-Sallakh, W. Mousa, T. Aly, Intercalated bone PEG in the treatment of non-united scaphoid fractures, Hand surgery : an international journal devoted to hand and upper limb surgery and related research : journal of the Asia-Pacific Federation of Societies for Surgery of the Hand 18(1) (2013) 2733. [56] T. Goyal, S.R. Sankineani, S.K. Tripathy, Local distal radius bone graft versus iliac crest bone graft for scaphoid nonunion: a comparative study, Musculoskelet Surg 97(2) (2013) 109-14. [57] A. Oron, A. Gupta, S. Thirkannad, Nonunion of the scaphoid distal pole, Hand surgery : an international journal devoted to hand and upper limb surgery and related research : journal of the AsiaPacific Federation of Societies for Surgery of the Hand 18(1) (2013) 35-39. [58] H.Y. Park, J.O. Yoon, I.H. Jeon, H.W. Chung, J.S. Kim, A comparison of the rates of union after cancellous iliac crest bone graft and Kirschner-wire fixation in the treatment of stable and unstable scaphoid nonunion, Bone and Joint Journal 95 B(6) (2013) 809-814. [59] F. Ya'ish, C.A. Bailey, C.P. Kelly, M.A. Craigen, Bioabsorbable fixation of scaphoid fractures and non-unions; analysis of early clinical outcomes, Hand surgery : an international journal devoted to hand and upper limb surgery and related research : journal of the Asia-Pacific Federation of Societies for Surgery of the Hand 18(3) (2013) 343-349. [60] F.A. Caporrino, J.B.G. Dos Santos, F.T. Penteado, V.Y. De Moraes, J.C. Belloti, F. Faloppa, Dorsal vascularized grafting for scaphoid nonunion: A comparison of two surgical techniques, Journal of orthopaedic trauma 28(3) (2014) e44-e48. [61] S. Euler, S. Erhart, C. Deml, T. Kastenberger, M. Gabl, R. Arora, The effect of delayed treatment on clinical and radiological effects of anterior wedge grafting for non-union of scaphoid fractures, Archives of orthopaedic and trauma surgery 134(7) (2014) 1023-1030. [62] R.M. Garcia, F.J. Leversedge, J.M. Aldridge, M.J. Richard, D.S. Ruch, Scaphoid nonunions treated with 2 headless compression screws and bone grafting, Journal of Hand Surgery 39(7) (2014) 1301-1307. [63] M. Maniglio, A. Schweizer, L. Nagy, Scaphoid waist nonunions treated with illiac crest or vascularized bone grafts, Swiss Medical Weekly 144 (2014) 15S. [64] A. Afshar, A. Mohammadi, K. Zohrabi, N. Navaeifar, S.H. Sami, H. Taleb, Correlation of Reconstructed Scaphoid Morphology with Clinical Outcomes, The archives of bone and joint surgery 3(4) (2015) 244-9. [65] U. Ahmed, S. Malik, M. David, C. Simpson, S. Tan, D. Power, The Headless Compression Screw - Technical challenges in scaphoid fracture fixation, Journal of Orthopaedics 12 (2015) S211-S216.
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[66] C. Eder, N. Schwab, A. Scheller, B.D. Krapohl, A new variant of scaphoid reconstruction: Treatment of scaphoid non-union with avascular bone interponate and high compression screw (Synthes((R))), GMS Interdisciplinary plastic and reconstructive surgery DGPW 4 (2015) Doc07. [67] P. Farsetti, R. Caterini, V. Potenza, M. Dragoni, E. Ippolito, Modified murray technique for carpal navicular nonunion, Orthopedics 38(9) (2015) e766-e772. [68] G. Hegazy, Percutaneous Screw Fixation of Scaphoid Waist Fracture Non-Union Without Bone Grafting, Journal of hand and microsurgery 7(2) (2015) 250-5. [69] J.P. Kim, J.B. Seo, J.Y. Yoo, J.Y. Lee, Arthroscopic management of chronic unstable scaphoid nonunions: Effects on restoration of carpal alignment and recovery of wrist function, Arthroscopy Journal of Arthroscopic and Related Surgery 31(3) (2015) 460-469. [70] C.H. Lee, K.H. Lee, B.G. Lee, D.Y. Kim, W.S. Choi, Clinical outcome of scaphoid malunion as a result of scaphoid fracture nonunion surgical treatment: A 5-year minimum follow-up study, Orthopaedics and Traumatology: Surgery and Research 101(3) (2015) 359-363. [71] S.K. Lee, D.J. Byun, J.L. Roman-Deynes, Z. Model, S.W. Wolfe, Hybrid russe procedure for scaphoid waist fracture nonunion with deformity, Journal of Hand Surgery 40(11) (2015) 2198-2205. [72] C.W. McInnes, J.L. Giuffre, Fixation and Grafting after Limited Debridement of Scaphoid Nonunions, Journal of Hand Surgery 40(9) (2015) 1791-1796. [73] A. Poggetti, M. Rosati, I. Castellini, G. Evangelisti, P. Battistini, P. Parchi, M. Lisanti, Treatment of Scaphoid Waist Nonunion Using Olecranon Bone Graft and Stryker Asnis Micro Cannulated Screw: A Retrospective Study-80 Case Studies and 6 Years of Follow-Up, Journal of Wrist Surgery 4(3) (2015) 194-199. [74] J.S. Somerson, D.J. Fletcher, R.C. Srinivasan, D.P. Green, Compression screw fixation without bone grafting for scaphoid fibrous nonunion, Hand (New York, N.Y.) 10(3) (2015) 450-3. [75] C. Taleb, F. Bodin, S. Collon, A. Gay, S. Facca, P. Liverneaux, Retrograde percutaneous screw fixation for scaphoid type II non-union in Schernberg zones 2 to 4: A series of 38 cases, Chirurgie de la main 34(1) (2015) 32-38. [76] J. Wu, S.C. Tay, A.Y. Shin, The Effect of Screw Design on Union Rates in Scaphoid Nonunions, Hand surgery : an international journal devoted to hand and upper limb surgery and related research : journal of the Asia-Pacific Federation of Societies for Surgery of the Hand 20(2) (2015) 273-9. [77] L. Xiong, L. Harhaus, C. Heffinger, B. Bickert, T. Kremer, U. Kneser, C. Hirche, A comparative study on autologous bone grafting combined with or without posterior interosseous nerve neurectomy for scaphoid nonunion treatment, Journal of Plastic, Reconstructive and Aesthetic Surgery 68(8) (2015) 1138-1144. All authors have made substantial contributions to the following: (1) the conception and design of the study, or acquisition of data, or analysis and interpretation of data, (2) drafting the article or revising it critically for important intellectual content, (3) final approval of the version to be submitted.
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Figure Legends Fig. 1. Sagittal CT slices of both wrists of a patient with a unilateral scaphoid waist nonunion (a) healthy intact scaphoid. (b),(c), and (d) scaphoid nonunion showing a typical humpback deformity as evaluated with standard CT measures [12], including (b) Intrascaphoid angle (ISA); the angle between the two lines perpendicular to the proximal and distal articular surface of the scaphoid nonunion, (c) Height-to-length (H/L) ratio; the ratio between the height of the scaphoid as measured from a palmar baseline to the dorsal humpback, and the length along the palmar baseline limited by the most proximal and distal aspects of the scaphoid, and (d) Dorsal cortical angle (DCA); the angle between two lines along the dorsal cortex of the proximal and distal fragments. Fig. 2. Virtual 3-D CT-based images of a scaphoid nonunion (orange model) and the mirrored contralateral intact scaphoid (transparent white model) from the same patients as in Figure 1. By using the contralateral scaphoid model as template, after superimposing the proximal fragment and the intact proximal pole, the level of displacement of the distal fragment can be quantified based on the difference with the position of the intact distal pole in 3-D space using a local anatomic coordinate system (X,Y,Z). Fig. 3. Flow chart of the systematic review. OC: osteocartilaginous; †See online appendix for full reference list of the included articles. Fig. 4. Column chart showing a trend in the use of CT scans, including scans that were acquired routinely or only in selected cases. The light grey columns represent the use of preoperative CT scans; the dark grey columns the use of postoperative CT scans.
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