Ondemand Precourse 02: the Scaphoid: Little Bone, Big Problems

OnDemand Precourse 02: The Scaphoid:

Little Bone, Big Problems Co-Chairs: David M. Brogan, MD, MSc. and Steve K. Lee, MD

Program Syllabus

75TH VIRTUAL ANNUAL MEETING OF THE ASSH OCTOBER 1 – 3, 2020

822 West Washington Blvd Chicago, IL 60607 Phone: (312) 880-1900 Web: www.assh.org Email: [email protected]

OnDemand Precourse 02: The Scaphoid: Little Bone, Big Problems Please note that in order to receive CME for this session, you will need to view this in the ASSH Learning Management System.

This pre-course is a comprehensive overview of the current controversies and research surrounding scaphoid fracture care. An international group of experts will describe their approach to decision making for scaphoid fractures in the clinic as well as operative tips and techniques. Accomplished microsurgeons will also demonstrate the latest innovative techniques for advanced scaphoid reconstruction.

LEARNING OBJECTIVES At the conclusion of this program, the attendee will:

• Describe indications for operative vs. non-operative treatment of scaphoid fractures in pediatric and adult patients. • Discuss the details of different fixation techniques for primary scaphoid fracture surgery. • Identify the optimal use of pedicled and free vascularized bone flaps for scaphoid reconstruction.

CME CREDIT HOURS

The ASSH designates this live activity for a maximum of 4.00 AMA PRA Category 1 Credits TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

The ASSH is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

PRE/POST EVENT – Learner Assessment The Pre-event Assessment was sent electronically to the email you have on file. The Post-event notification will be sent using the same method. Please check your email 24 hours after this course for a message from ASSH with access instructions and information.

You are encouraged to complete the post-event assessment even if you did not participate in the pre-event assessment. If you experience difficulty completing the post-event assessment online please email [email protected] or call (312) 880-1900.

According to standards established by the Accreditation Council for Continuing Medical Education (ACCME), the ASSH is required to assess learning from participation in Continuing Medical Education events. To address these standards, the Hand Society uses pre-and post-tests

All property rights in the material presented, including common-law copyright, are expressly reserved to the speaker or the ASSH. No statement or presentation made is to be regarded as dedicated to the public domain. for all of its courses. These questions are used to evaluate the knowledge of course participants before attending a program and again after the course to see if improvements were made.

DISCLAIMER The material presented in this continuing medical education program is being made available by the American Society for Surgery of the Hand for educational purposes only. This material is not intended to represent the best or only methods or procedures appropriate for the medical situation discussed; rather the material is intended to present an approach, view, statement or opinion of the authors or presenters, which may be helpful, or of interest to other practitioners.

The attendees agree to participate in this medical education program, sponsored by ASSH with full knowledge and awareness that they waive any claim they may have against ASSH for reliance on any information presented in this educational program. In addition, the attendees also waive any claim they have against the ASSH for injury or other damage that may result in any way from their participation in this program.

All of the proceedings of the 75th Annual Meeting, including the presentation of scientific papers, are intended for limited publication only, and all property rights in the material presented, including common-law copyright, are expressly reserved to the speaker or the ASSH. No statement or presentation made is to be regarded as dedicated to the public domain. Any sound reproduction, transcript or other use of the material presented at this course without the permission of the speaker or the ASSH is prohibited to the full extent of common-law copyright in such material.

The ASSH is not responsible for expenses incurred by an individual who is not confirmed and for whom space is not available at the meeting. Costs incurred by the registrant such as airline or hotel fees or penalties are the responsibility of the registrant.

The approval of the U.S. Food and Drug Administration is required for procedures and drugs that are considered experimental. Instrumentation systems discussed and/or demonstrated in or at ASSH educational programs may not yet have received FDA approval.

Claim your CME hours through www.ASSH.org

How to Claim: By viewing on-demand content in the LMS and completing the test questions when prompted, you will automatically be awarded your CME credit and have the ability to download your certificate immediately. No additional steps are needed.

Physicians should claim only the credit commensurate with the extent of their participation in the activity. *Please note that ASSH does not provide Continuing Education for physical therapists. Visit the APTA website for more information.

Questions? Problems? Contact the American Society for Surgery of the Hand at (312) 880-1900 or by email at [email protected].

Conflict of Interest Disclosures for 2020 Program Committee and Course Faculty

Program Faculty & Disclosures The American Society for Surgery of the Hand gratefully acknowledges those who have generously volunteered considerable time and effort to plan, organize and present this CME course. The ASSH appreciates the faculty’s dedication to teaching, their support of the ASSH mission, and their significant contribution to the educational success of this program. The following is a list of disclosures for all participating faculty and program staff.

CONFLICT OF INTEREST POLICY According to the ASSH conflict of interest policy, individuals involved in continuing medical education activities are required to complete a disclosure statement. The ASSH acknowledges this fact solely for the information of the listener. Non-conflicted reviewers have examined, documented and resolved financial relationship disclosures for this course content.

Financial Disclosure – represented by ● Instructors, planners, content reviewers and managers who affect the content of a CME/CE activity are required to disclose financial relationships they have with commercial interests (i.e. any entity producing, marketing, pre-selling, or distribution health care goods or services consumed by, or used on, patients) associated with this activity.

FDA Disclosure – represented by ▲ Some drugs or medical devices demonstrated at this course may have not been cleared by the FDA or have been cleared by the FDA for specific purposes only. The FDA has stated that it is the responsibility of the physician to determine the FDA clearance status of each drug or medical device he or she wishes to use in clinical practice.

The ASSH policy provides that “off label” uses of a drug or medical device may be described in the ASSH CME activities so long as the “off label” use of the drug or medical device is also specifically disclosed (i.e., it must be disclosed that the FDA has not cleared the drug or device for the described purpose). Any drug or medical device is being used “off label” if the described use is not set forth on the product’s approval label.

Planners 2020 Annual Meeting Program Chairs Dawn M. LaPorte, MD No relevant conflicts of interest to disclose

Ryan P. Calfee, MD, MSc No relevant conflicts of interest to disclose

Session Co-Chairs/Moderators David M. Brogan, MD, MSc. ● Contracted Research: Depuy-Synthes

Steve K. Lee, MD ● Royalty: Arthrex ● Intellectual Property: Arthrex ● Consulting Fee: Synthes, Axogen ● Speakers Bureau: Synthes, Axogen

Faculty Kimberly K. Amrami, MD No relevant conflicts of interest to disclose

Gregory I. Bain, FRACS, PhD ● Consulting Fees: Arthrex ● Speaker Bureau: IBRA Foundation; AO Foundation

Allen T. Bishop, MD No relevant conflicts of interest to disclose

Joseph Joaquim Dias, MD, FRCS No relevant conflicts of interest to disclose

Ryan Garcia, MD ● Non-CME Services: Integra Lifesciences

James P. Higgins, MD No relevant conflicts of interest to disclose

Thomas B. Hughes, MD No relevant conflicts of interest to disclose

Alexandra MacKenzie, OTR/L, CHT No relevant conflicts of interest to disclose

Marc J. Richard, MD ● Royalty: Elsevier ● Consulting Fees: Acumed, Depuy Synthes, DJO, Medartis, Exomed ● Speakers Bureau: Acumed, Depuy Synthes, DJO, Medartis, Exomed, Bioventus

David S. Ruch, MD ● Royalty: Acumed ● Consulting Fees: Acumed ● Speakers Bureau: Acumed

Dean G. Sotereanos, MD ● Consulting Fees: Axogen, Inc Smith & Nephew

Lindley B. Wall, MD No relevant conflicts of interest to disclose

Sudhir Warrier, MD No relevant conflicts of interest to disclose

Mihir J. Desai, MD ● Consulting Fees: Axogen, Acumed ● Speakers Bureau: Axogen, AcumedNon-CME Services: Acumed ● Contracted Research: Axogen

OnDemand Precourse 02: The Scaphoid: Little Bone, Big Problems Co-Chairs: David M. Brogan, MD, MSc. and Steve K. Lee, MD

Description

Please note that in order to receive CME for this session, you will need to view this in the ASSH Learning Management System.

Learning Objectives At the conclusion of this program, the attendee will:

Program

10 Minutes Diagnosis of Occult Scaphoid Fracture: What is Cost Effective? David M. Brogan, MD, MSc.

10 Minutes AMCT vs. MRI to Detect AVN Kimberly K. Amrami, MD

10 Minutes When to Operate and When to Cast Mihir J. Desai, MD

10 Minutes Casting Details: Duration, Length, Inclusion of Thumb Thomas B. Hughes, MD

10 Minutes Pediatric Scaphoid Fractures: Why They are Different Lindley B. Wall, MD

10 Minutes Primary Screw Fixation: Tips for Success Marc J. Richard, MD

10 Minutes Role of Wrist Arthroscopy in Scaphoid Fractures Gregory I. Bain, FRACS, PhD

10 Minutes One vs. Two Screws Ryan Garcia, MD

10 Minutes Regaining Motion After Scaphoid Surgery Alexandra MacKenzie, OTR/L, CHT

10 Minutes Central or Eccentric - The Ideal Starting Point David S. Ruch, MD

10 Minutes Proximal Pole Bleeding: Does it Matter? Steve K. Lee, MD

10 Minutes Role of Pedicled Vascularized Flaps Dean G. Sotereanos, MD

10 Minutes Role of Free Vascularized Bone Flap Allen T. Bishop, MD

10 Minutes Proximal Pole Reconstruction James P. Higgins, MD

10 Minutes SNAC Wrist: Bailout Options Sudhir Warrier, MD

10 Minutes What I tell my patients Joseph Joaquim Dias, MD, FRCS

25 Minutes Scaphoid Hall of Fame: Greatest Disasters and Greatest Saves All Faculty

OnDemand Precourse 02: The Scaphoid: Little Bone, Big Problems

10 Minutes

Diagnosis of Occult Scaphoid Fracture: What is Cost Effective?

David M. Brogan, MD, MSc. ● Contracted Research: Depuy-Synthes

75TH VIRTUAL ANNUAL MEETING OF THE ASSH OCTOBER 1 - 3, 2020

8/14/2020

David M. Brogan, MD, MSc.

Contracted Research: Depuy ‐ Synthes

Diagnosis of Occult Scaphoid Fractures: What is Cost Effective? Pre‐Course 02: The Scaphoid: Little Bone, Big Problems David Brogan Washington University Orthopedics

Washington University Orthopedics | Barnes Jewish Hospital 2

Disclosures

• None

1 8/14/2020

The Problem

• Scaphoid fractures account for 60% of carpal fractures (Hove et al) • Non‐displaced scaphoid fractures are common and difficult to detect • Only 7% of suspected fractures turn out to be true fractures • Meta‐analysis of management of scaphoid waist fractures demonstrated that displaced fractures have a 4x increased risk of non‐union compared to non‐displaced fractures. • Displaced fractures treated surgically have a 2% non‐union rate; displaced fractures treated in a cast have an 18% non‐union rate (Singh et al) • Translation of the fracture, comminution and humpback deformity are independent risk factors for non‐union (Grewal et al)

Consequences of Missed Diagnosis

• Prevalence of true fracture with clinical suspicion of scaphoid fracture is around 18% (Yin 2010) • Late or missed diagnosis of scaphoid fractures can result in substantial pain and morbidity • Failure to immobilize can result in displacement, bone resorption and cyst formation • Chances of non‐union increase with delayed diagnosis

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Goals of the Ideal Imaging Modality

• High sensitivity to detect occult scaphoid fractures • High sensitivity to determine degree of displacement and morphology of fracture characteristics • Low cost / ease of availability in acute fractures

Washington University Orthopedics | Barnes Jewish Hospital 7

Options for Diagnosis

Detection of Occult Fractures

• Varies by modality and by observer, multiple meta‐analyses have examined this • X‐ray • Negative Predictive value of x‐rays – 84% • CT • Sensitivity ranges from 0.36 to 1.0, average of 94% • Specificity from 0.96 to 1.0, average of 89% • MRI • Sensitivity ranges from 0.41 to 1.0, Ring found an average sensitivity of 98% • Specificity from 0.83 to 1.0, average of 99%, • Bone Scan • Sensitivity of 96% • Specificity of 89%

Washington University Orthopedics | Barnes Jewish Hospital 9

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Detection of Fracture Displacement

• Comparison of CT and X‐ray for detection of fracture displacement amongst 6 observers for 30 scaphoid fractures demonstrated improved intra‐observer and inter‐observer reliability with use of CT, or CT and X‐ray compared to X‐ray alone • X‐rays had a sensitivity of 75%, specificity of 64% • CT had a sensitivity of 72%, specificity of 80%, these improved to 80% and 73% respectively when combined • Authors concluded that addition of CT to plain radiographs improves the ability to detect fracture displacement

Lozano‐Calderon 2006.

Washington University Orthopedics | Barnes Jewish Hospital 10

Calculation of Cost Effectiveness

• Depends on a number of assumptions including: • Sensitivity & Specificity of modalities • Pre‐test probability (i.e. clinical suspicion) • Pre‐test probably may differ between ER physicians and hand surgeons • Quality of Life assigned to different health states (wrist arthritis), as well as cost of lost productivity from cast immobilization • Whether or not an intervention is cost effective depends on the cost‐ effectiveness threshold established by the payer ($50k – 100k per QALY)

Washington University Orthopedics | Barnes Jewish Hospital 11

Cost Effectiveness of MRI

• Hansen et al compared the use of immobilization with repeat x‐rays to subacute MRI • 27 patients in each group • MRI increased hospital costs by 151 Euros, but resulted in a decrease in non‐hospital costs of 2869 Euros • Difference was mainly due to lost wages calculated by the time off of work multiplied by the average national wage.

Washington University Orthopedics | Barnes Jewish Hospital 12

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Comparative Cost Effectiveness

• MRI is more incrementally cost effective than CT (base case in this figure) when utility loss of arthritis is > 0.1 for diagnosis of occult fractures • In all cases, the cost of the immobilization, along with the lost wages and potential for worse outcomes make cast immobilization more expensive with worse utility outcomes (Karl et al)

Washington University Orthopedics | Barnes Jewish Hospital 13

Scaphoid Magnetic Resonance Imaging in Trauma (SMaRT) Trial • 132 patients with an exam and history consistent with scaphoid fx but with negative x‐rays were randomized in the ED to a control group (immobilization + follow‐up) vs intervention (immediate MRI, f/u as needed) • Total costs of care to the NHS were calculated for each group as the primary outcome, patients were followed for 6 months by research personnel • Average of 174 pounds saved at 3 months, 266 pounds saved at 6 months with immediate MRI, due to less follow‐up costs • Lost work not included in calculation, satisfaction and pain were similar between groups.

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Case Example: 19 yo M

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Recon along the long axis of the scaphoid

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CT along the long axis of the scaphoid improves detection of fractures • Ring et al performed a prospective trial enrolling 34 patients with a suspected scaphoid fracture within 10 days of injury and compared to radiographs 6 weeks after injury • Comparison of CT scans formatted along the plane of the wrist were compared to reformatted scans along the plane of the scaphoid • PPV was 76% for CT‐scaphoid but only 36% for CT‐wrist, but no significant difference was found

Washington University Orthopedics | Barnes Jewish Hospital 19

2 Weeks Post‐Op

4 months Post‐Op

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Clementson et al 2020 22

Summary

• Cast immobilization and repeat x‐rays may not be cost effective to society • The best modality for early diagnosis of an occult fracture is MRI • The best modality for evaluation of displacement (or healing) is CT scan • Practice patterns may be dependent on the health care system / access to resources and the index of suspicion of the examining practitioner

References

• Clementson et al. “Acute scaphoid fractures: guidelines for diagnosis and treatment” EFFORT Open Reviews 2020, 5(2):96‐103. • Grewal et al. “Use of CT to Predict Union and Time to Union in Acute Scaphoid Fractures Treated Nonoperatively” J Hand Surg Am 2013 38A:872‐877. • Hansen et al. “Cost‐effectiveness of MRI in Managing Suspected Scaphoid Fractures” JHS Eur. 2009, 34(5):627‐630. • Hove, LM. “Epidemiology of scaphoid fractures in Bergen, Norway” Scand J Plast Reconstr Surg Hand Surg 1999, 33(4):423‐426. • Karl et al. “Diagnosis of Occult Scaphoid Fractures: A Cost‐Effectiveness Analysis” JBJS 2015, 97(22):1860‐1868. • Lozano‐Calderon et al. “Diagnosis of Scaphoid Fracture Displacement with Radiography and Computed Tomography” JBJS 2006, 88(12):2695‐2703. • Rua et al. “Clinical and cost implications of using immediate MRI in the management of patients with a suspected scaphoid fracture and negative radiographs results from the SMaRT trial” Bone & Joint Journal 2019, 8:984‐994. • Singh et al. “Management of displaced fractures of the waist of the scaphoid: Meta‐analyses of comparative studies” Injury 2012 43:933‐939. • Yin. “Diagnosing Suspected Scaphoid Fractures” CORR 2010, 468:723‐734.

Washington University Orthopedics | Barnes Jewish Hospital 24

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Thank you

Washington University Orthopedics | Barnes Jewish Hospital 25

David Brogan, MD, MSc Assistant Professor Campus Box 8233 425 S. Euclid Ave. St. Louis, MO 63110 (314) 747-2813

[email protected] Washington University Orthopedics

Washington University Orthopedics | Barnes Jewish Hospital 26

9 OnDemand Precourse 02: The Scaphoid: Little Bone, Big Problems

10 Minutes

AMCT vs. MRI to Detect AVN

Kimberly K. Amrami, MD No relevant conflicts of interest to disclose

75TH VIRTUAL ANNUAL MEETING OF THE ASSH OCTOBER 1 - 3, 2020

8/14/2020

Kimberly K. Amrami, MD

Speaker has no relevant financial relationships with commercial interest to disclose.

CT versus MRI to Detect AVN Precourse 02: The Scaphoid: Little Bone, Big Problems

American Society for Surgery of the Hand Virtual Annual Meeting 2020

Disclosures • No relevant disclosures

1 8/14/2020

CT versus MRI for Imaging the Scaphoid Basic Principles • MRI • Detect radiographically occult scaphoid fractures • Detect associated ligamentous injuries and other soft tissue abnormalities • High sensitivity for bone marrow edema • CT • Characterize radiographically visible fractures • Assess comminution, offset and fragmentation • Determine progression in bony union • Relatively insensitive for bone marrow edema

Two Modalities • CT • Based on density • Hounsfield number, a relatively absolute value

• MRI • Based on hydrogen proton density and environment • Relative measurement of signal intensity, dependent on many factors • Field strength • Sequence type • Repetition time (TR) and Echo time (TE)

Hounsfield Units

Substance HU Air -1000 Lung -700 Fat -84 Water 0 CSF 15 Blood +30 to +45 Muscle +40 HU = 1000x (μX - μwater) / μwater)

Soft Tissue +100 to +300 Water is 0 at standard temp and pressure Cancellous µ is the linear attenuation coefficient +700 Bone Named in honor of Sir Godfrey Hounsfield Dense Bone +3000 First CT images in 1971 Nobel Prize in Medicine and Physiology 1979 Shared with Allen McLeod Cormak

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Bone and Fat – CT and MRI

Bone Fat

• CT • CT • Cortical and trabecular bone • Fat is low in density (-100 HU detail well seen against air, fat and ST compared with 3000 for dense cortical bone) • No artifacts so that bony healing/trabecular bridging is visible at adequate resolution • MRI • MRI • Few mobile protons in cortical • High signal intensity on T1 weighted and trabecular bone using MRI conventional methods • Fat suppression will eliminate signal • Normally low signal on all from fat sequences • Not all FS techniques are created • Susceptibility with bone equal trabeculae causes artifacts

CT Window/Level

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Bone Marrow Edema

• CT • Perceived as increase in density • Normal proximal pole is higher density than distal pole • MRI • Seen on fluid sensitive sequences* • Bright on T2 Increased Radiodensity of the Proximal Pole of the Scaphoid: A Common Finding in Computed Tomography • Low on T1 Imaging of the Wrist.

Cheung y et al. Journal of Computer Assisted Tomography. 30(5):850‐857, September/October 2006. *STIR, T2FS, Dixon, Water Excitation

Pache G, Krauss B, Strohm P, et al. Dual-energy CT virtual noncalcium technique: detecting posttraumatic bone marrow lesions--feasibility study. Radiology. 2010;256(2):617-624.

Why It is So Hard to Diagnose Early AVN • Bone marrow edema is the key feature in early AVN • But it is also present after trauma and during healing • AVN may not be “complete” so that edema pattern may be patchy* • Fluid sensitive MRI will show the edema but can’t differentiate its cause • On CT bone marrow edema increases the relative density in the marrow compared to fat so that reactive change, increased blood flow related to healing and early AVN cannot be differentiated

* Urban MA, Green DP, Aufdemorte TB. The patchy configuration of scaphoid avascular necrosis. J Hand Surg Am. 1993 jul;18(4):669-74.

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Morphologic and Vascular Differences May Explain Variable Vulnerability to AVN

Type A

Type B

Morsy M et al J Hand Surg Am. 2019 Nov;44(11):928-938

Intermediate AVN • MRI • Bone marrow edema may be present with healing and/or developing AVN • Dynamic enhancement may have some value to determine intact arterial supply • Early enhancement needed to distinguish “slow flow” from “no flow” • Delayed enhancement will be present even in the presence of AVN due to diffusion

• CT • Healing response may be difficult to distinguish from sclerosis of AVN • Best use of CT is to evaluate for bony union and deformity

Late Changes of AVN • MRI • Loss of normal marrow fat • May have low signal on all sequences • In some cases bone marrow edema persists

• CT • Sclerosis • Fragmentation • Non-union

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Case Example • 17 year old high school wrestler presents 2/25/2016 after an ankle injury • Also mentioned two prior wrist injuries with inability to full extend the wrist • First wrist injury 11/2015 was a FOOSH • Referred to Dr. Moran for further evaluation after obtaining an x- ray

Initial x-ray – 2/2016

CT – 2/24/2016

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MRI – 2/26/2016

Post Contrast

30 second 2 minutes 4 minutes

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MRI • Low signal on T1 – marrow replaced • Low/no flow in early phase • Delayed enhancement present due to diffusion • Unequivocal diagnosis of AVN

VBG - MFC

3/28/2016 4/18/2016

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9 months post-op – complete osseous union Increased density is healing response

12/2016

Case Example • 53 year old female special needs preschool teacher fell on her non-dominant left hand 5/2017 • Seen locally by Orthopedic Surgery • Persistent pain after two “negative” x-rays • Presented to Mayo 4/2018

FOOSH 5/2017

5/2017 6/2017 8/2017

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6/23/2017 9/12/2017

Developing AVN?

10/23/2017 2/8/2018

2/9/2018 3/14/2018

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Mayo 2cd Opinion

6/23/2017 4/10/2018

3/14/2018

4/10/2018

? AVN

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4/10/2018

11/11/2018 1/10/2019

Final Disposition – Persistent Pain • Delayed union – no AVN • Patient declined surgery/grafting • Additional imaging findings • Ulnar impaction • ECU tendinopathy • TFCC tear • SLIL tear • Ganglion cysts • STT arthritis

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Dynamic Enhancement

Study Contrast Dynamic Delayed Result

Cerezal 2000

Fox 2009 No No No Acceptable

Schmitt 2010 Yes No Not specified Superior

Donati 2011 Yes Yes Yes Inferior

Ng 2012 Yes Yes Yes Dynamic more accurate Larribe 2014 Yes Yes Yes Delayed= Dynamic Fox 2015 Yes No Yes ?

Amrami 2019 – “contradictory results, inconsistent technique”

Virtual Non-Calcium

Virtual Non-Calcium DECT

80 yo FOOSH

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Bottom Line • Complete loss of normal fat signal in the marrow on MRI is the best indicator of AVN • CT is not contributory until AVN is advanced • Helpful to identify non-union or delayed union • In some cases dynamic contrast enhancement may be helpful but evidence in the literature is contradictory • Goal is to identify early arterial flow • May not address slow flow or low flow situations • Some suggestion that enhancement (dynamic and delayed) may be a predictor of success with VBG • CT preferred for follow up after VBG to identify osseous integration of the graft

Thank You for Your Attention • Many thanks to my colleagues and teachers – the hand surgeons at Mayo!

14 OnDemand Precourse 02: The Scaphoid: Little Bone, Big Problems

10 Minutes

When to Operate and When to Cast

Mihir J. Desai, MD No relevant conflicts of interest to disclose

75TH VIRTUAL ANNUAL MEETING OF THE ASSH OCTOBER 1 - 3, 2020

8/14/2020

Mihir J. Desai, MD

Consulting Fees: Axogen, Acumed Speakers Bureau: Axogen, Acumed Non‐CME Services: Acumed Contracted Research: Axogen

Scaphoid Fractures: When to Operate and When to Cast

Mihir J. Desai, MD Assistant Professor of Orthopaedics Vanderbilt University Medical Center ASSH Annual Meeting 2020 Precourse 02

VANDERBILT Orthopaedics 2

Disclosures

• Acumed • Consulting

•Axogen • Consulting/Research Support

VANDERBILT Orthopaedics 3

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Outline

• Classification of fracture as a predictor

• Likelihood of healing will often dictate treatment plan

• The non or minimally displaced waist fracture

• Special consideration of “High Demand” users and athletes

VANDERBILT Orthopaedics 4

Scaphoid Fracture Classification

• Pattern

• Location (Predictive) • Distal • Waist • Proximal

• Herbert (Functional + Predictive)

Herbert Classification

Stable

Unstable

Nonunion

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Acute Scaphoid Fracture Treatment

Nondisplaced, Stable Displaced, Unstable • • distal pole • >1mm displacement (in any area) • pediatrics • >15 degrees LC angle • Tx = cast x 6 weeks + • >45 degrees SL angle • proximal pole Tx = ORIF (Screw fixation)

What about non or minimally displaced waist?

VANDERBILT Orthopaedics 8

• 419 pts – 217 surgical and 212 conservative • Surgery: + Significantly better functional outcomes, satisfaction, grip strength, shorter time to union, and earlier return to work +/‐ No difference in pain, ROM, nonunion rates, infection ‐ More complications and scaphotrapezial arthritis

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• Meta‐analysis of RCT's • Surgical vs. Non‐surgical treatment • Non or minimally displaced scaphoid waist fractures

• 67 articles • 6 studies were analyzed using pairwise methodology • 363 total patients

• Fracture union favored surgical group, not significant

• Surgery associated with significant elevated risk of complications

• ROM, grip strength, OA in STT or radiocarpal did not reach significance VANDERBILT Orthopaedics 10

What's the call?

VANDERBILT Orthopaedics 11

Dias et al (2005) • Early conservative treatment, followed by ORIF +/‐ grafting at 6‐8 weeks of gap persists • No difference in surgery vs. non‐op

• Presence of delayed union at 12 weeks in non‐op group, requiring change of treatment plan

• Prolonged the overall treatment duration

VANDERBILT Orthopaedics 12

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Athlete or High Demand Patients • Earlier return to work/play with surgery (Garcia and Ruch 2014, Rizzo and Shin 2006, and several others)

• Earlier return to work with higher union rate in surgical group (Arora et al. 2006)

VANDERBILT Orthopaedics 13

• 25% intact scaphoid waist is as strong as 100% in withstanding physiological loads

• ~25% bridging trabeculae for return to play

VANDERBILT Orthopaedics 14

Acute Scaphoid Fx Treatment Nondisplaced, Stable Displaced, Unstable • • distal pole • >1mm displacement (in • Pediatrics any area) • ND Waist • >15 degrees LC angle • Low demand • >45 degrees SL angle • proximal pole Tx = cast x 6 weeks + • ND Waist • Athlete, high demand Tx = ORIF (Screw fixation)

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11 y/o male

VANDERBILT Orthopaedics 16

VANDERBILT Orthopaedics 17

VANDERBILT Orthopaedics 18

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VANDERBILT Orthopaedics 19

VANDERBILT Orthopaedics 20

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Thank You

VANDERBILT Orthopaedics 22

8 OnDemand Precourse 02: The Scaphoid: Little Bone, Big Problems

10 Minutes

Casting Details: Duration, Length, Inclusion of Thumb

Thomas B. Hughes, MD No relevant conflicts of interest to disclose

75TH VIRTUAL ANNUAL MEETING OF THE ASSH OCTOBER 1 - 3, 2020

8/14/2020

Thomas B. Hughes, MD

Speaker has no relevant financial relationships with commercial interest to disclose.

The Scaphoid: Little Bone, Big Problems Casting Details: Duration, Length, Inclusion of Thumb

Thomas B. Hughes, M.D.

Clinical Associate Professor of Orthopaedic Surgery University of Pittsburgh School of Medicine Pittsburgh, PA

ASSH Annual Meeting 2020

Disclosures

 My disclosures have been updated on the ASSH website  I have nothing significant to disclose

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Non-operative Treatment of Scaphoid Fractures

 Who do we treat with casting • Stable fractures.  What type of Immobilization • LAC v SAC • Thumb Spica • Removable  What can your patients expect with this treatment

Arthroscopic Assessment

 Buijze et al, JHS, 2012 (Ring) • Factors Associated With Arthroscopically Determined Scaphoid Fracture Displacement and Instability – 58 Patients – 38 unstable – 27 nondisplaced – Therefore, nondisplaced does not equal stable

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Long v. Short

 Gellman, JBJS 1989 • 28 LAC v. 23 SAC • LAC = shorter time to union • Fewer Nonunions

Treatment – Casting

 Doornberg et al, J Trauma, 2011  Meta-analysis of LAC, SAC, TSC, non-TSC  No difference in: • Union rate • Pain • Grip strength • Time to union • Osteonecrosis.

Munster Thumb Spica

 Lawton et al, Orthopedics, 2007 • Prom/Sup – LAC 8º and 9º – Munster 11º and 12º • Elbow TAM – LAC –LAC7º – Munster 52º » P<.0001

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Short cast for 4 weeks

 Geoghegan et al, JHS (Eu), 2009 • 59 patients • 4 weeks in cast • CT at 4 weeks

Short Cast for 4 weeks

 Findings: • 43 were nondisplaced – 16 could possibly have been identified as displaced with injury CT • 37 united – all healed with 8 weeks of casting – 26 out of cast at 4 weeks  Conclusion: undisplaced and united fractures at 4 weeks need not be immobilized further

Thumb inclusion

 Schramm et al, Hand 2008 • Biomechanical study – No difference in fracture angulation or rotation – Difference between casted and uncasted  Conclusion: SAC is fine

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To include the thumb or not…

– Clay et al. JBJS (Br). 1991 Sep;73(5):828-32. – 292 fractures randomized to TSC or SAC » Followed for 6 months – No difference in nonunions.

Thumb Inclusion, or not

 Buijze et al, JHS, 2014 • 62 Patients  There was a significant difference in the average extent of union on CT at 10 weeks (85% vs 70%) favoring treatment with a cast excluding the thumb.  The overall union rate was 98%.

Expectations

 Very reliable treatment for nondisplaced fractures • Grewal et al, Open Orthop J., 2016  1 of 172 went on to nonunion (99.4%)  Looked at time to union and factors affecting union

5 8/14/2020

Timing

 CT obtained at 6-8 weeks  If greater than 50% healed, casting discontinued • Average time to union 53 ± 37 days (7.5 weeks) – Diabetes 77 ± 53, No Diabetes 52 ± 36 – Cystic resorption along fracture line on CT – 69 ± 60 • So, if no DM or Cysts 49 ± 32 – 95%CI 45-55 days

Timing

 Time to Union

Timing

 Length of Treatment Delay in Weeks

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Treatment – Healing???

 Buijze, et al. JHS 2012 • PPV= 0.99 • NPV=0.41 • CT reliable for assessing union, but not for determining nonunion

Treatment – Conclusions

 Consider CT of all nondisplaced scaphoid fractures • Make sure they are truly nondisplaced • Can help stratify those that may take longer to heal  Consider CT at 4-6 weeks to assess healing • May be able to significantly limit the morbidity of casting.

Treatment – Casting

 My Algorithm • Xray diagnosed nondisplaced fracture – CT to confirm displacement (?stability?) – Short arm thumb spica cast • MRI Diagnosed nondisplaced fracture – Short arm cast, no thumb • Pediatric nondisplaced fracture – Long arm thumb spica cast

7 8/14/2020

Thank You

8 OnDemand Precourse 02: The Scaphoid: Little Bone, Big Problems

10 Minutees

Pediatric Scaphoid Fractures: Why They are Different

Lindley B. Wall, MD No relevant conflicts of interest to disclose

75TH VIRTUAL ANNUAL MEETING OF THE ASSH OCTOBER 1 - 3, 2020

8/20/2020

Pediatric Scaphoid Fractures

Lindley B. Wall, MD MSc Washington University

Lindley B. Wall, MD

Speaker has no relevant financial relationships with commercial interest to disclose.

Background

• 0.39% of all pediatric fractures • 2.2% of pediatric hand fractures • Most commonly fractured carpal bone • Most common age 11 to 15 years and typically male (80-95%)

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Anatomy

Males • Ossific nucelus appears 5-6 years of age • Complete ossification by 15 years

Females • Ossific nucelus appears 4-5 years of age • Complete ossification by 13 years

• SL may look wide – just un-ossified scaphoid.

Historical Demographics

• Distal pole scaphoid fractures • 59-87% reported • Very optimistic

• Ahmed et al. JPO 2014 • 56 patients less than 13 years old • Ave age 12yo M and 10yo F • 80% (45/56) distal pole

Demographics

• Change Understanding • Shift in injury pattern over time • Gholson et al. JBJS 2011 • 71% waist fractures; mean age 14.6 years • (Similar to adults) • Attributed to increased BMI and intensity of recreational activities • 1/3 present with non-unions

• 2/3 of pediatric patients are chronic injuries (Toh et al. JPO 2003)

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Classification

Anatomic – similar to Adults: • Distal pole • Waist • Proximal pole

D’Aienzo. JHS Br. 2002 • Chondral – MRI • Osteochondral – 8-11yo • Osseus - >12yo

Imaging

Radiographs initially negative in ~40% • Need for 2 week immobilization • Depending on ossification, may not be apparent for 2 months Role for MRI • Early diagnosis

• Prevent unnecessary immobilize in 58% (Gholson et al JBJS 2011; Johnson et al Ped Rad 2000)

• Additional wrist injuries (distal radius, carpal fractures) – 15% (Nafie. Injury 1987) CT for bony deformity

Non-surgical Treatment

• Non-displaced, acute = Non-surgical • CAST

• Distal pole casted shorter time

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Non-operative Outcomes

Ahmed et al. JPO 2014 • 56 pediatric patients • Mean f/u >5 years • 60% no complaints • 25% with mild or infrequent complaints

Gohlson et al. JBJS 2011 • 222 Acute fractures, 201 casted • 90% Union rate • Time to heal dependent on fracture location, displacement, presence of osteonecrosis

Surgical Treatment

Indications: • Displaced scaphoids • Failed cast treatment • Chronic fractures (>6 weeks) • 65% treated in cast go on to non-union (Gholson JBJS 2011) • Proximal pole? • Proximal pole with AVN

Surgical Treatment

Technique: • Mini-open/percutaneous dorsal or volar screw • Non-union • Screw fixation • Distal radius bone graft • Humpback deformity • Volar approach • Joysticks for reduction • Bone graft

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Surgical Treatment

Vascularized bone flap indications • Failed fixation with bone grafting • Proximal pole fractures with AVN Sources • Vascularized distal radius • Medial femoral condyle

Outcomes

Chronic scaphoids • Bae et al. JPO 2016 • 63 patients; 24 non-unions • 20 of 24 treated surgically • All went on to union • Chronic non-union (and osteonecrosis) was seen as a independent predictor of poorer outcomes (DASH 0 vs 3.75), though most had good clinical outcomes

Outcomes

Chronic scaphoids • Jauregui et al. JPO 2019 – Meta-analysis • 11 studies; 176 non-unions • 157 non-vascularized bone graft • 19 non-grafted • Both had union rate of 95% • Function: ROM and strength improved in both cohorts

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Take Home Points

• Pediatric scaphoids are not all distal pole fractures • Non-surgical treatment for non-displaced do well • Don’t depend on casts for chronic injuries • Surgical treatment for chronic and displaced typically do well – union and functional outcomes

Thank you

6 OnDemand Precourse 02: The Scaphoid: Little Bone, Big Problems

10 Minutes

Primary Screw Fixation: Tips for Success

Marc J. Richard, MD ● Royalty: Elsevier ● Consulting Fees: Acumed, Depuy Synthes, DJO, Medartis, Exomed ● Speakers Bureau: Acumed, Depuy Synthes, DJO, Medartis, Exomed, Bioventus

75TH VIRTUAL ANNUAL MEETING OF THE ASSH OCTOBER 1 - 3, 2020

8/14/2020

Marc J. Richard, MD

Royalty: Elsevier Consulting Fees: Acumed, Depuy Synthes, DJO, Medartis, Exomed Speakers Bureau: Acumed, Depuy Synthes, DJO, Medartis, Exomed, Bioventus

Precourse 02: The Scaphoid: Little Bone, Big Problems Primary Screw Fixation: Tips for Success

Marc J. Richard, MD Associate Professor, Department of Orthopaedic Surgery Director, Hand, Upper Extremity, and Microvascular Surgery Fellowship Duke University Medical Center

Primary Screw Fixation: Tips for Success

• Anatomy • Understanding the Imaging Studies • Pre-Op Planning • Strategies for Execution

1 8/14/2020

Anatomy – Dorsal Blood Supply

• Dorsal branch radial artery- 70-80% of scaphoid (including the proximal pole)

• Majority of the blood supply is from Dorsal ridge vessels

• 93% perforate distal to waist

Anatomy – Volar Blood Supply

• Volar branch radial artery 20-30% of the scaphoid • Distal pole

Imaging

• Plain Radiographs • PA, oblique, lateral • Scaphoid view • CT Scan • In the plane of the scaphoid! • Not a CT of the wrist • MRI

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X-rays

X-rays – After Osteoclasts

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CT Scan

• In the plane of the scaphoid • Consider 3D reconstructions • Thin cuts • Pre-op deformity, post-op union • “For a known scaphoid fx, in order to gain information”

MRI

• Evaluation of an occult fx • 95 – 100% sensitive • T2-weighted fat suppressed incredibly sensitive to bone marrow edema • If bm edema is absent, no fx • Evaluation for vascularity of the proximal pole • BM edema associated with both the healing phase of scaphoid fractures and AVN • Preservation of marrow fat on T1-weighted images thought to be indicative of preserved vascularity

Pre-Op Planning

• Identify the fracture site • Proximal • Waist • Distal • Determine displacement and reducibility • Determine the orientation of the fracture line • Central placement • Perpendicular to the fx line

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Pre-Op Planning

5 8/14/2020

Pre-Op Planning

Volar Percutaneous

19 yo M, Basketball Player

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CT Scan

Distal Pole

Extend, Ulnarly Deviate

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Starting Point…

Advance

Derotation Wire

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Derotation Wire

Measure

Subtract 4 mm…

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Drill

Advance Screw

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Final Xrays

Minimal Incision

Mini-Open Dorsal

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59 yo F, DRFx and scaphoid fx

Fix the Distal Radius

• Small incision ulnar to Lister’s • Retract EPL • Longitudinal capsulotomy (protect SLIL) • Flex wrist to expose starting point

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Starting Point adjacent to SLIL

Advance to Final Depth

Scaphoid Math… subtract 4mm

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• Advance guidewire through the volar skin

• Clamp volarly to avoid cold-welding and removal with drill or for extraction if it breaks

Drill to the distal tip

Advance screw

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Remove the Guidewire

Semi-pronated and Semi-supinated views

Summary - Pearls

• Compared to eccentric placement, central screw placement increases load to failure by 39%, decreases healing time, and increases rigidity by 303% • More likely to get central placement with dorsal screw placement (88% vs. 51%) • Dorsal for waist or proximal pole • Volar for distal pole • If going volar, use a 16g needle to lever trapezium and achieve starting point; if difficulty persists, remove or go through trapezium • Remember scaphoid math; get it right the first time – if exchanging a variable pitch screw (as opposed to a Herbert-Whipple design), will lose purchase with removal and exchange • If a system has an “over” drill for the near cortex, use it; minimizes hoop stresses • Utilize semi-pronated and semi-supinated views to evaluate for prominence

15 8/14/2020

Thank You!

16 OnDemand Precourse 02: The Scaphoid: Little Bone, Big Problems

10 Minutes

Role of Wrist Arthroscopy in Scaphoid Fractures

Gregory I. Bain, FRACS, PhD ● Consulting Fees: Arthrex ● Speaker Bureau: IBRA Foundation; AO Foundation

75TH VIRTUAL ANNUAL MEETING OF THE ASSH OCTOBER 1 - 3, 2020

OnDemand Precourse 02: The Scaphoid: Little Bone, Big Problems

10 Minutes

One vs. Two Screws

Ryan Garcia, MD ● Non-CME Services: Integra Lifesciences

75TH VIRTUAL ANNUAL MEETING OF THE ASSH OCTOBER 1 - 3, 2020

8/14/2020

Ryan Garcia, MD

Non-CME Services: Integra Lifesciences

The Scaphoid: Little Bone, Big Problems

One vs Two Screws

Ryan Garcia, MD Charlotte, NC

Disclosures

•Integra LifeSciences - Consultant

1 8/14/2020

Background

• Scaphoid Fractures

• Non-Operative Treatment • Union Rate – 90-100% • Fracture Displacement (Gap/Translation)

• Operative • Union Rate – 95-100% • Fracture Displacement • Shorter Time to Union and Return to Work and Sports Ibrahim et al. J Hand, 2011

Background

•Basic Orthopedic Fracture Fixation Principles

• Correct any Deformity • Stabilize the Fracture • Early Motion

Fracture Stability in a Small Bone with 3-Dimensional Motion

• Complex Rotational Motion

• Wrist Flexion  Scaphoid Pronation

• Wrist Extension  Scaphoid Supination

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Orthopedic Principles : 101

Orthopedics  Bigger and More is Better

Name 1 Other Orthopedic Fracture Operation (NOT including Pediatrics) Where a Single Screw was EVER the Answer

Background

• Early Published Literature Advocated the Use of a Derotational Wire during Scaphoid Compression Screw Placement

Trumble et al. JBJS, 1996 Manske et al. Orthopedics, 1983

Background

• Cadaveric, Biomechanical Study • Comparison of 1 vs 2 Scaphoid Screws in Torsional Stability / Resistance

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• Heterogenous Population of 19 Patients with Scaphoid Nonunions • All treated with Bone Grafting (vascular and nonvascular) along with 2 Headless Compression Screws

• 100% Union Rate at a Mean of 3.6 Months • No Screw Penetration or Complications

• Concluded that 2 Screws is a Safe and Effective Treatment for Scaphoid Nonunions

Technique

• Use 2 “Micro” Screws

• Separate by a Minimum Distance of the Screw Diameter

• Spread is in the Volar/Dorsal Plane more so than the Radial/Ulnar Plane

Case 1

• 20 Year Old Male

• Referral 9 Months after ORIF Scaphoid Fracture

• Treated with Single Micro Acutrak Screw

• Established Nonunion

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Case 1

• Treated with Nonunion Debridement • Distal Radius Bone Grafting • Upsized Micro to Mini Acutrak • Added a Second Mini Acutrak

Case 1

3.5 Months Postoperative

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Case 1

Long Term Follow-up

Case 2

• 20 Year Old Male

• Motorcycle Crash

Case 2

• Immediate Closed Reduction

• Segmental, Comminuted Scaphoid Waist Fracture

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Case 2

• ORIF Scaphoid with Immediate Distal Radius Bone Grafting • 2 Micro Acutrak Screws for Stable Fixation

Case 2

5 Months Postoperative

Case 2

Long Term Follow-up

7 8/14/2020

Conclusion

•Follow the Basic Principles of Orthopedics • 2 is Always Better than 1

•Consider 2 Scaphoid Compression Screws to Improve Fracture Stability • Nonunions • Severely Displaced/Unstable Fractures

THANK YOU

8 OnDemand Precourse 02: The Scaphoid: Little Bone, Big Problems

10 Minutes

Regaining Motion After Scaphoid Surgery

Alexandra MacKenzie, OTR/L, CHT No relevant conflicts of interest to disclose

75TH VIRTUAL ANNUAL MEETING OF THE ASSH OCTOBER 1 - 3, 2020

8/14/2020

Alexandra MacKenzie, OTR/L, CHT

Speaker has no relevant financial relationships with commercial interest to disclose.

Regaining Motion After Scaphoid Surgery Alexandra MacKenzie OTR/L, CHT

Scaphoid Fractures and Rehab

• Little data/literature on scaphoid fx rehab • Young, male • High velocity injury • Motivated to return to vigorous level of activity/sport/work • Pts of higher socioeconomic status may be more likely to seek earlier tx (Garala 2016)

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Scaphoid Fx Visits

Distal Radius Fx Visits

1 2

Scaphoid Fracture visits made up .39% of therapy visits in 2019

Scaphoid Fractures + Rehab

Scaphoid Fx in Hand Therapy Dept 2019:

Total visits 77

# of patients 18

Percent male 83.3%

Age range male: 13‐48 yo

Age range female: 49‐90+ yo

Mean # of visits 4.3 (1‐8)

Duration of therapy: 1‐8 weeks (mean 4)

Effects of fx management on rehab

• Surgical treatment of scaphoid waist fx: earlier return to work, sport, function, decreased pain with surgical tx • Conservative treatment: fewer complications however, longer immobilization (Schadel‐Hopfner, 2010) • CT can ID scaphoid healing rates earlier and may dictate when to progress activity/rehab (McVeigh 2019)

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Post‐op Orthosis options

• To include or not include the thumb? Duration? • Thumb inclusion in cast is not necessary in non‐displaced stable fx and has not been shown to accelerate rate of union (Sabbagh 2019; Waton 2019; Suh 2019) • Thumb spica casts no more restrictive to wrist motion than Colles’‐type casts; more restrictive than pre‐fabricated splints (Waton 2019) • Delta cast/FCT led to increased pt satisfaction & function without adverse effects on fracture healing (McVeigh 2019)

Orthosis Duration • Duration of cast immobilization after screw insertion ranges widely in literature • No studies to determine if post‐op union rates are affected by the length of immobilization after surgery or type of orthosis used • Level of patient activity, quality of fracture fixation should guide post‐ op immobilization (Suh, 2019) • Wrist immobilization >3.5 weeks associated with increased need for shoulder rehabilitation/shoulder stiffness + pain, likely due to compensatory movement patterns (Cantero‐Tellez 2018)

How soon can a partially united scaphoid fx start to move before re‐fracturing?

Brekke (2018): Guss (2018): • Inherent stability can be • demonstrated 50% scaphoid union maintained as long as 25% of the plus compression screw across waist is intact waist can withstand the same • similar biomechanical strength to forces as an intact scaphoid fully united scaphoid fractures

Studies support early motion, earlier return to unrestricted activity prior to full radiographic healing

3 8/14/2020

2 weeks post‐op: thumb spica orthosis, start AROM wrist

Early Active 4 weeks: AAROM/gentle PROM Motion 8 weeks: Light function/resistance. Splint weaning if healing demonstrated on CT. No contact sports Protocol (Dunn et.al. 2017)

10 study participants, 10 weeks: wall push‐ups, progressing to table no complications, all returned to full active duty 12 weeks: return to push‐ups on knees

16 weeks: unrestricted use

Proprioception

• Sensorimotor control may be impaired after wrist trauma • Inflammation, pain, stiffness, immobilization • Diminished joint position sense (JPS) may lead to decrease in function • SLIL richly innervated with mechanoreceptors • Carpal kinematics may be altered in presence of scaphoid malunion

Karagiannopoulos C, Michlovitz S. 2016 11

Exercises for Proprioception

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Muscles contributing to wrist stability

• Muscles contributing to midcarpal supination: ECRL, FCR, APL, FCU • Isometric contraction contributes to SL stability (Esplugas et al 2016)

Scaphoids and Pushups • Push up with the wrist in extension causes sig increase in pressure in radioscaphoid fossa but not on radiolunate fossa compared with pushups in wrist neutral (Daly 2018) and force is increased on SLIL with wrists in extension (Werner 2019)

This Photo by Unknown Author is licensed under CC BY‐NC‐ND

This Photo by Unknown Author is licensed under CC BY‐NC 14

Return to sport

• Surgical fixation shows increased return rates to sports and earlier return times • Fracture location, conservative or surgical management as well as sport and position all need to be factored into decision for RTP (Jernigan, 2019) • Advocate RTP when there is 50% healing and pt has regained ROM • Mean return to sport times in surgically tx groups was 7.9 weeks (6‐ 11 weeks) (Goffin 2019)

5 8/14/2020

THANK YOU! Alexandra MacKenzie OTR/L, CHT [email protected]

References • Brekke AC et al. Biomechanical strength of scaphoid partial unions. J Wrist Surg 2018; 7(5):399‐405 • Cantero‐Tellez R et al. Duration of wrist immobilization is associated with shoulder pain in patients with after wrist immobilization: an observational study. J Ex Rehab 2018;14(4):694‐698 • Daly BT et al. Effect of push‐up position on wrist joint pressures in the intact wrist and following scapholunate interosseous ligament sectioning. J Hand Surg 2018;43(4):339‐345 • Dunn JC et al. Early active motion protocol following open reduction internal fixation of the scaphoid: a pilot study. Hand Surg Rehab 2017; 36:30‐35 • Esplugas M et al. Role of muscles in the stabilization of ligament‐deficient wrists. J Hand Ther 2016;29:166‐174 • Garala K, Taub NA, Dias JJ. The epidemiology of fractures of the scaphoid: impact of age, gender, deprivation and seasonality. Bone Joint J 2016;98‐B:654–9 • Goffin JS, Liao Q, & Robertson GA. Return to sport following scaphoid fractures: A systematic review and meta‐analysis. World J Orthop 2019; 10(2): 101‐114 • Guss MS, Mirgang JT, Sapienza A. Scaphoid healing required for unrestricted activity: a biomechanical cadaver model. J Hand Surg Am 2018;43(2):134‐138 • Jernigan EW, Morse KW, & Carlson MG. Managing the athlete with a scaphoid fracture. Hand Clin 2019;35:365‐371 • Karagiannopoulos C, Michlovitz S. Rehabilitation strategies for wrist sensorimotor control impairment: From theory to practice. J Hand Ther 2016;29:154‐165 • McVeigh KH et al. An evidence‐based approach to casting and orthosis management of the pediatric, adolescent, and young adult population for injuries of the upper extremity: A review article. Clin J Sport Med 2019;00:1–12 • Sabbagh MD, Morsy M & Moran SL. Diagnosis and management of acute scaphoid fractures. Hand Clin 2019;35:259‐269 • Schadel‐Hopfner M et al. Acute non‐displaced fractures of the scaphoid: earlier return to activities after operative treatment. A controlled multi‐center cohort study. Arch Orthop Trauma Surg 2010;130:1117‐1127 • Suh N & Grewal R. Controversies and best practices for acute scaphoid fracture management. J Hand Surg (Eur) 2018, Vol. 43(1) 4–12 • Waton A, Forrest S, Whatling GM. Optoelectronic measurement of wrist movements in various casts and orthoses used in scaphoid fractures. J Hand Surg (Eur) 2019, Vol. 44(6) 607–613 • Werner FW, Tucci ER, Daly BT, Harley BJ. Changes in scaphoid and lunate position and loading at two wrist pushup positions. Cur Rheum Rev 2019; 15:00‐00

6 OnDemand Precourse 02: The Scaphoid: Little Bone, Big Problems

10 Minutes

Central or Eccentric - The Ideal Starting Point

David S. Ruch, MD ● Royalty: Acumed ● Consulting Fees: Acumed ● Speakers Bureau: Acumed

75TH VIRTUAL ANNUAL MEETING OF THE ASSH OCTOBER 1 - 3, 2020

8/14/2020

David S. Ruch, MD

Royalty: Acumed Consulting Fees: Acumed Speakers Bureau: Acumed

Approach and Starting Point for Scaphoid Fixation: Is There an Exact Answer?

Introductory Case

. 21yo male . Fall on outstretched hand . Proximal pole fracture . Underwent a “percutaneous screw placement”

1 8/14/2020

Told that it was “healed”

Origin of the Debate . Agreement . Proximal Pole fracture line best visualized Dorsal- Fernandez . Distal Pole- stabilize through a volar approach-McQueen . Stability enhanced by central one third axis . Stability correlates to higher clinical union rate- Trumble

JBJS 2003

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3 8/14/2020

Central Screw Placement in Simulated Fractures of the Scaphoid Waist J Bone Joint Surg Am. 2003;85:72-77. Wren V. McCallister, Jeff Knight, Robert Kaliappan and Thomas E. Trumble

For centrally positioned screws, stiffness was 43% greater (p < 0.01) and load at 2 mm of displacement was 113% greater (p <0.01) than those for eccentrically positioned screws.

The Debate: In a B1 Fracture

JHS 2010

B1 Fracture

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B2 Fracture

B3 Fracture

Conclusions

. Higher fixation stability is achieved when the screw is placed perpendicular to the fracture line rather than centrally along the long axis . Higher strains were measured on screws placed perpendicular to the fracture line

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JHS 2013

. Laser scanning technique to create 3D models of 10 scaphoids

. Computed approximate bone apposition areas for both Herbert and Acutrak screws placed perpendicular and along central axis of B1, B2, B3 fractures

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Thoughts

. B1 fractures should be treated with a screw perpendicular to the fracture line to improve stability and maximize area of bone apposition for healing . B2 fractures should be treated along central axis . B3 fractures should be treated perpendicular to the fracture plane

Comparison of Percutaneous Dorsal Versus Volar Fixation of Scaphoid Waist Fractures Using a Computer Model in Cadavers Marc Soubeyrand, MD, David Biau, MD, Cesar Mansour, MD, Sabri Mahjoub, MD, Veronique Molina, MD,Olivier Gagey, MD, PhD Volar Approach

To be in the Center one third of the B1fracture the screw is oblique to the fracture line

7 8/14/2020

B-1 fracture from the dorsal approach-center one third…

Dorsal Screw Placement in flexion

Three-Dimensional Analysis of Acute Scaphoid Fracture Displacement: Proximal Extension Deformity of the Scaphoid Schwarcz Y et al JBJS Am . Extension, supination, and volar translation of the proximal scaphoid fragment . The distal scaphoid fragment and the trapezium showed no movement. . Conclusion: “Manipulating only the proximal fragment (with the lunate) may be technically easier and more effective than manipulating both fragments.

So Volar versus Dorsal Approach? Volar . Allows extension of the fracture . ???Perpendicular on B1 .

8 8/14/2020

So Volar versus Dorsal Approach? Dorsal . Can flex the fracture . Don’t get “blocked” by the trapezium . May be easier to reduce the humpback if the deformity is proximal?? . May be more parallel to the Horizontal oblique pattern

Percutaneous Screw Fixation for Scaphoid Fracture: A Comparison Between the Dorsal and the Volar Approaches In-Ho Jeon, MD, Ivan D. Micic, MD, Chang-Wug Oh, MD, Byung- Chul Park, MD, Poong-Taek Kim, MD

Volar approach

Dorsal approach

Imaging can really help

9 8/14/2020

Document Displacement Helpful in percutaneous technique

Pronated Oblique View in Assessing Proximal Scaphoid Articular Cannulated ScrewPenetration Richard Y. Kim, MD, Emilie C. E. Lijten, Robert J. Strauch, MD

10 8/14/2020

Pronated Oblique View in Assessing Proximal Scaphoid Articular Cannulated ScrewPenetration Richard Y. Kim, MD, Emilie C. E. Lijten, Robert J. Strauch, MD

Pronated oblique

Thank You

11 OnDemand Precourse 02: The Scaphoid: Little Bone, Big Problems

10 Minutes

Proximal Pole Bleeding: Does it Matter?

Steve K. Lee, MD ● Royalty: Arthrex ● Intellectual Property: Arthrex ● Consulting Fee: Synthes, Axogen ● Speakers Bureau: Synthes, Axogen

75TH VIRTUAL ANNUAL MEETING OF THE ASSH OCTOBER 1 - 3, 2020

8/14/2020

Precourse 02: The Scaphoid: Little Bone, Big Problems

Proximal Pole Bleeding – Does it Matter?

Steve K. Lee, MD, Chief of Hand and Upper Extremity Surgery, Hospital for Special Surgery Professor of Orthopaedic Surgery, Weill Medical College of Cornell University New York, NY, USA

Disclosures

• Consultant: Axogen, J&J Depuy Synthes • Speaker’s panel: Axogen, J&J Depuy Synthes • Royalties: Arthrex

1 8/14/2020

2018

PURPOSE

To determine if scaphoid proximal pole vascularity correlates with likelihood of healing or time to union

METHODS

• 35 scaphoid nonunion patients • Vascular assessment: • Pre-op MRI • Intra-op bleeding • Histology

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RESULTS

• Location: 9 proximal, 21 waist, 5 distal • MRI: 0% infarcted, 39% ischemic, 61% normal • Bleeding bone: 15% poor, 58% fair, 27% good • Histology: • 44% proximal poles with >50% trabecular necrosis

RESULTS

• 94% (33/35) healed at avg. 12 weeks (range, 6-22) • 1 healed at 18 weeks after revision for fixation failure • 1 non-compliant patient healed by 38 wks

RESULTS

• ***No significant associations between time to union and MRI, intra op bleeding, histology

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CLINICAL IMPACT

• High incidence of proximal pole ischemia by several measures • Non-vascular graft = 94% rapid healing, even in dysvascular bone • We believe true infarction is decidedly rare • Vascularized bone grafting is rarely necessary *** Vigorous curettage, dense packing with fresh autogenous bone, and rigid fixation leads to healing, regardless of vascular status of the proximal pole

KEYS FOR SUCCESS FOR NON- VASCULARIZED BONE GRAFT

• Preparation of nonunion site is critical • Curette concavity in poles

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• Small cortical intramedullary strut

• High cancellous to cortical bone ratio

• Stability is paramount • Consider supplemental fixation for more stability

5 8/14/2020

Reduce and pin lunate in neutral (out of DISI) 16

Place new screw from opposite direction 17

6 8/14/2020

25 year old professional basketball player, 9 month old scaphoid nonunion

7 8/14/2020

HYBRID RUSSE PROCEDURE

• Palmar approach

• Non-union exposed with the aid of skin hooks

• Fibrous tissue resected

• Bone curetted until cancellous bleeding

•Bone graft harvested from the distal radius

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• A “matchstick “of volar cortex is placed into the nonunion site as a strut

• Cancellous bone graft is packed in the remainder of the nonunion site

• Followed by fixation with a headless screw

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RESULTS

• 100 % union • Average time to union – 3.6 months • DISI 20 deg corrected to 0 deg • Complications: none

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11 8/14/2020

JHS 2015

• 48 studies, 1602 patients • Overall union rate 90% • No evidence for technique superiority • No difference in union: vascular (92%) vs nonvascular graft (88%)

CASE

• 31 year old man, wrist pain with strenuous ADLs and sport • Injury 1.5 years prior

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OPTIONS?•HOW WOULD YOU TREAT THIS?

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14 8/14/2020

CASE

• 28 year old man, wrist pain • Scaphoid ORIF 1 year prior

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OPTIONS?•HOW WOULD YOU TREAT THIS?

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SURGERY

• Removal of previous screw • Non vascularized bone graft • Fixation with 2 small screws

3 months post op

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1 year post op

References

• Lee SK, Byun DJ, Roman-Deynes JL, Model Z, Wolfe SW. Hybrid Russe Procedure for Scaphoid Waist Fracture Nonunion With Deformity. J Hand Surg Am. 2015 Nov;40(11):2198- 205. • Rancy SK, Swanstrom MM, DiCarlo EF, Sneag DB, Lee SK, Wolfe SW. Success of scaphoid nonunion surgery is independent of proximal pole vascularity. J Hand Surg Eur Vol. 2018 Jan;43(1):32-40. • Pinder RM, Brkljac M, Rix L, Muir L, Brewster M. Treatment of Scaphoid Nonunion: A Systematic Review of the Existing Evidence. J Hand Surg Am. 2015 Sep;40(9):1797-1805. • Cohen MS, Jupiter JB, Fallahi K, Shukla SK. Scaphoid waist nonunion with humpback deformity treated without structural bone graft. J Hand Surg Am. 2013;38(4):701e705. • Luchetti TJ, Rao AJ, Fernandez JJ, Cohen MS, Wysocki RW. Fixation of proximal pole scaphoid nonunion with non-vascularized cancellous autograft. J Hand Surg Eur Vol. 2018 Jan;43(1):66-72.

18 8/14/2020

OPTIONS?•DISCUSSION & QUESTIONS

Thank You

19 OnDemand Precourse 02: The Scaphoid: Little Bone, Big Problems

10 Minutes

Role of Pedicled Vascularized Flaps

Dean G. Sotereanos, MD ● Consulting Fees: Axogen, Inc Smith & Nephew

75TH VIRTUAL ANNUAL MEETING OF THE ASSH OCTOBER 1 - 3, 2020

Dean G. Sotereanos, MD Loukia K. Papatheodorou, MD

Role of Pedicled Vascularized Flaps Scaphoid Nonunion

Dean G. Sotereanos Professor of Orthopaedic Surgery

Orthopaedic Specialists - UPMC

University of Pittsburgh Medical Center

Pittsburgh, PA

Disclosures: consultant for Axogen Inc, Smith & Nephew

Scaphoid Nonunions

 5-15% nonunion rate despite treatment – tenuous blood supply

Vascularized Bone Grafts from the Dorsal Radius 1 Dean G. Sotereanos, MD Loukia K. Papatheodorou, MD

Fracture Location an important issue!!!

 Vascular supply enters distal pole and runs retrograde to the proximal scaphoid

 The more proximal the fracture, the more likely are healing complications

Proximal Pole Non-union

Treatment Options:

– Excision of proximal pole

– Retrograde Herbert Screw

– ORIF +/- Conventional Bone Graft

– Vascularized Bone Graft +/- ORIF

Vascularized Bone Grafts

Superior Biologic & Mechanical Properties

preserve live osteocytes and osteoblasts

 Direct bone healing  No creeping apposition  Heal faster and more reliably  Stronger Better Union Rate

Vascularized Bone Grafts from the Dorsal Radius 2 Dean G. Sotereanos, MD Loukia K. Papatheodorou, MD

VBGs from the Dorsal Radius

 1,2 ICSRA Graft

 Capsule-based Vascularized Graft

 4 & 5 ECA Graft

1,2 ICSRA Graft

 Zaidemberg (most common)

- From the dorsal radial aspect of the distal radius

- Nourished by the 1,2 intercompartmental supraretinacular artery (radial artery)

‘A new vascularized bone graft for scaphoid non-union’, J. Hand Surg Am 1991 8

1,2 ICSRA Graft

Vascularized Bone Grafts from the Dorsal Radius 3 Dean G. Sotereanos, MD Loukia K. Papatheodorou, MD

1,2 ICSRA Graft

 Zaidemberg et al, J Hand Surg Am 1991 – Union in 11/11 patients after a mean of 6.2 weeks

 Uerpairojkit et al, J Hand Surg Br 2000 – Union in 10/10 patients after a mean of 6.5 weeks

 Steinmann et al, J Hand Surg Am 2002 – Union in 14/14 patients within 8-16 weeks

 Malizos et al, Plast Reconstr Surg 2007 – Union in 22/22 patients within 6-12 weeks, including 7/7 with documented avascular necrosis

1,2 ICSRA Graft  Boyer et al, J Hand Surg Br 1998 – Union in 6 of 10 patients with nonunion and proximal pole necrosis

 Straw et al, J Hand Surg Br 2002 – Union in only 2 of 16 scaphoid nonunions with associated necrosis

 Chang et al, J Hand Surg Am 2006 – Union rate of 71% (34/48 patients), with only 12 of 24 patients with proximal pole necrosis achieving union

 Hirche et al, J Hand Surg Am 2014 – Union rate of 75% (21/28 patients), 21 patients with proximal pole fracture and 7 nonunions

1,2 ICSRA Graft

 1,2 ICSRA graft is ideally located for transfer to the proximal pole of the scaphoid

 The pedicle has a short arc of rotation and nutrient artery branches are relatively few and small

 The course and characteristics of the pedicle make it vulnerable to impingement, often necessitating radial styloidectomy

Vascularized Bone Grafts from the Dorsal Radius 4 Dean G. Sotereanos, MD Loukia K. Papatheodorou, MD

1,2 ICSRA Graft

 30 pts w/ scaphoid nonunion & proximal pole AVN

 Radial styloidectomy to decrease tension on the vascular pedicle

 Union in 28 of 30 pts (93%) in 5.1 months on average

The Optimum VBG

 Close to the target site

 Provide bone of sufficient quality and quantity

 Vascular supply should be consistent

 Pedicle should have sufficient length

 Dissection should be relatively simple

Capsule-based Vascularized Graft

Vascularized Bone Grafts from the Dorsal Radius 5 Dean G. Sotereanos, MD Loukia K. Papatheodorou, MD

Capsule-based Vascularized Graft

 Develop a new VBG from the distal aspect of the dorsal radius : - that is simple to harvest

 Attached to a wider distally based strip of the dorsal wrist capsule - close to proximal pole nonunion - permits insertion with minimal rotation

CVRBG => axial flap based on 4 ECA

 Latex-injection study => vascularization by the 4th extensor compartment artery (ECA)

 Always present / Mean diameter 0.4 mm

 Runs along the floor of 4th compartment radial to the posterior interosseous nerve (70%) or within the 3,4 intercompartmental septum (30%) Sheetz et al, J Hand Surg [Am] 1995 Dailiana et al, J Trauma 2005 17

CVRBG => axial flap based on 4 ECA

 Provides numerous nutrient arteries to bone and anastomoses distally with the dorsal intercarpal arch with additional anastomoses to the dorsal radiocarpal arch and/or other compartmental arteries

Sheetz et al, J Hand Surg [Am] 1995 Dailiana et al, J Trauma 2005 18

Vascularized Bone Grafts from the Dorsal Radius 6 Dean G. Sotereanos, MD Loukia K. Papatheodorou, MD

Surgical Technique

 Incision: - 4cm straight dorsal - ulnar to Lister’s tub. - centered over the Scapho-Radial joint

 Retinaculum - through the 4th dorsal compartment - EPL retracted radially - EDC ulnarly

Surgical Technique  Capsular flap length: ~ 1.5cm

- outlined with a skin marker on the dorsal wrist capsule

- it widens: from 1cm at the bone block to 1.5 cm at base

- sharply outlined with a scalpel

Surgical Technique

 Bone block for the graft:

- includes the dorsal ridge of the distal radius without extending into the cartilage of the R/C ( 1 cm proximal )

- measures: ~ 1 x 1 cm - depth: ~ 7 mm

- outlined with multiple drill holes (1.0 mm side-cutting drill)

Vascularized Bone Grafts from the Dorsal Radius 7 Dean G. Sotereanos, MD Loukia K. Papatheodorou, MD

Surgical Technique

 Elevation of the bone graft with the capsular flap

(with a thin osteotome)

Surgical Technique

 Debridement and reduction of non-union (if necessary)

 Inspection of R-C joint for arthritis

 Styloidectomy: in cases with early arthritic changes

Surgical Technique  Scaphoid fixation with a small cannulated screw

Vascularized Bone Grafts from the Dorsal Radius 8 Dean G. Sotereanos, MD Loukia K. Papatheodorou, MD

Surgical Technique

 Screw is placed volarly to enable dorsal trough for the VBG

If very small proximal pole : - Mini screw or - 2 K-wires

Surgical Technique  Creation of a trough slightly smaller than the graft to allow impaction (~8X8 mm) (side-cutting burr)

Surgical Technique

 Verification (tourniquet down):

- of the vascularity of the bone graft

and

- vascular status of the pole of the scaphoid

Vascularized Bone Grafts from the Dorsal Radius 9 Dean G. Sotereanos, MD Loukia K. Papatheodorou, MD

Surgical Technique  Secure the VBG with a suture anchor into the trough to avoid dislodgement

Surgical Technique

 Insertion of VBG - press fit - into the dorsal trough across the non-union - with minimal capsular rotation (10 – 30°)

 Graft is tied down loosely

suture anchor

Venouziou AI, Sotereanos DG, J Hand Surg Am 2012 30

Vascularized Bone Grafts from the Dorsal Radius 10 Dean G. Sotereanos, MD Loukia K. Papatheodorou, MD

Post - Op

 Short arm Splint: 2 wks (wrist in slight extension)  Short arm Cast: 4 wks  Orthoplast Splint: in pts with delays in union

Radiographs: 6 w monthly thereafter - to assess progression of union CT scan: if slow union

 After solid union: return to activities as tolerated

Limitations

 Fragmentation or Collapse of Proximal Pole

 Severe Humpback Deformity

 Previous Surgery

 R-C Arthritis

capsular-based distal radius bone graft

2000-2016

89 pts: symptomatic non-union of the proximal pole of the scaphoid 58/89 pts: avascular necrosis

 Age: (mean) 28 yrs (19 – 44)  Time from Injury to Surgery: (mean) 24 m (12 – 51)

Vascularized Bone Grafts from the Dorsal Radius 11 Dean G. Sotereanos, MD Loukia K. Papatheodorou, MD

capsular-based distal radius bone graft

 No previous surgery

Pre – op:

 No fragmentation or collapse of the proximal pole

 Painful – limited ROM

 Grip Strength: (mean) 67% of contralateral wrist

m. F-up: 36 mo Results (24-58 mo)

 76/89 pts: Solid union (85.4%) 12.3 w (6-24) mean time to union 66 pts: pain free completely 10 pts: slight pain with strenuous activities [ 49/58 pts with AVN, 84.5% ]

 13 pts: 11 pts: persistent non-union 2 pt: fibrous union (CT scan)

Sotereanos DG, Darlis NA, Dailiana ZH, Sarris IK, Malizos KN J Hand Surg Am 2006 Papatheodorou LK, Sotereanos DG. Eur J Orthop Surg Traumatol. 2019 35

Results

 No arthritic changes at the dorsal ridge of the radius (harvest site of the graft)

 No donor site morbidity

 No complications

Vascularized Bone Grafts from the Dorsal Radius 12 Dean G. Sotereanos, MD Loukia K. Papatheodorou, MD

Capsule-based Vascularized Graft

 Simple technique

 Eliminates the need for dissection of small caliber pedicle

 No microsurgical anastomoses

 No donor site morbidity

 Results compare favorably to those of other

pedicled or free vascularized grafts 37

Case

 F 51y, with 6 month radial sided L wrist pain

 h/o fall onto outstretched hand

 Minor trauma – mild pain thereafter

 Initial x-rays read as negative

 No previous treatment except cock-up splint prn

X-rays: sclerotic proximal pole of the scaphoid

Vascularized Bone Grafts from the Dorsal Radius 13 Dean G. Sotereanos, MD Loukia K. Papatheodorou, MD

MRI

avascular scaphoid

Differential Diagnosis

 Occult fracture nonunion with AVN

 Preiser’s Disease

Diagnostic Arthroscopy

- SL ligament intact

- Softening of the

proximal pole fracture articular cartilage

- Fracture line visible

Vascularized Bone Grafts from the Dorsal Radius 14 Dean G. Sotereanos, MD Loukia K. Papatheodorou, MD

Capsular-based Vascularized Distal Radius Graft

proximal

distal

Harvesting of VBG

Placement of VBG

Vascularized Bone Grafts from the Dorsal Radius 15 Dean G. Sotereanos, MD Loukia K. Papatheodorou, MD

9 months post-op

Scaphoid Waist Nonunion and Humpback Deformity

 Volar approach

 Vascularized Bone Graft from Volar Radius

VBGs from the Volar Radius

 Volar Radial Carpal Artery graft

 Pronator quadratus pedicled bone graft

Vascularized Bone Grafts from the Dorsal Radius 16 Dean G. Sotereanos, MD Loukia K. Papatheodorou, MD

Volar Radial Carpal Artery Graft

• Volar approach

• Identification of the radial carpal artery

• Exposure of the pedicle

• Elevate the pedicle subperiosteally

Mathoulin and Haerle J Hand Surg Br 1998 49

Volar Radial Carpal Artery Graft • The artery is elevated in a radial direction

• The graft margins are outlined on the ulnar palmar edge of the distal radius

• Elevation of the graft

• Insertion of VBG -press fit - into the nonunion site

• Fixation with compression screw Mathoulin and Haerle J Hand Surg Br 1998 50

Volar Radial Carpal Artery Graft

 Mathoulin et al, J Hand Surg Br 1998, Chir Main 2010 – 102 pts with scaphoid nonunion – Union rate 94% after a mean of 9.5 weeks

 Dailiana et al, J Hand Surg Am 2006 – 9 pts with waist scaphoid nonunion – Union rate 100% within 6-12 weeks

 Jessu et al, Chir Main 2008 – Union rate 73%

Vascularized Bone Grafts from the Dorsal Radius 17 Dean G. Sotereanos, MD Loukia K. Papatheodorou, MD

Pronator Quadratus Pedicled Bone Graft

. Volar approach

. On distal radius: Identification of the pronator quadratus & block of bone graft

. Elevation of the pedicle bone graft (the pronator quadratus is not detached from the harvested bone graft)

. The pronator quadratus is dissected towards the ulna

. Insertion of the graft to nonunion site

. Fixation with screw or KWs Kawai and Yamamoto, JBJS Br 1988

Pronator Quadratus Pedicled Bone Graft

 Kawai and Yamamoto, JBJS Br 1988 – 8 pts with scaphoid nonunion – Union rate 100% after a mean of 8.5 weeks

 Noaman et al, Ann Plast Surg 2011 – 45 pts with scaphoid nonunion – Union rate 96% after a mean of 14 weeks

Summary

 Proximal / mid pole scaphoid nonunion => dorsal radius VBGs

 Waist scaphoid nonunion- Humpback deformity => volar radius VBG / traditional bone grafts

 VBGs => alternative options for Preiser’s and Kienbock’s

Vascularized Bone Grafts from the Dorsal Radius 18 Dean G. Sotereanos, MD Loukia K. Papatheodorou, MD

Thank You

Vascularized Bone Grafts from the Dorsal Radius 19 OnDemand Precourse 02: The Scaphoid: Little Bone, Big Problems

10 Minutes

Role of Free Vascularized Bone Flap

Allen T. Bishop, MD No relevant conflicts of interest to disclose

75TH VIRTUAL ANNUAL MEETING OF THE ASSH OCTOBER 1 - 3, 2020

8/20/2020

Scaphoid nonunion: Free vascularized bone flap reconstruction

Allen T. Bishop MD Mayo Clinic Rochester, MN USA

Allen T. Bishop, MD

Speaker has no relevant financial relationships with commercial interest to disclose.

1 8/20/2020

Vascularity is important!

• Majority comes from dorsal ridge vessels • Proximal pole depends upon retrograde intraosseous flow from dorsal ridge vessels • Some fractures have diminished proximal pole blood flow! Taleisnik & Kelly, JBJS 48A 1966 Gelberman, et al, J Hand 5A, 1980 4

• 48 scaphoid fractures treated with Russe technique • Each examined at surgery for amount of proximal pole bleeding with tourniquet deflated • All treated identically with inlay bone graft: outcome dependent only on prox. pole bleeding *Green DP. J Hand Surg 10A: 597, 1985

Diminished blood flow adversely effects healing

*Green DP. J Hand Surg 10A: 597, 1985 6

2 8/20/2020

Bone grafting in scaphoid nonunion: Role of Vascularized Grafts • 2 problem areas with use of conventional grafts • Avascular necrosis (AVN) • Failed surgery

Vascularized bone grafts provide a solution for poor healing

• Experimental studies provide proof: • Creation of avascular proximal pole • quantify bone blood flow after treatment • study bone histology after treatment

Canine SL bone fracture with AVN • 12 canine bilateral wrist surgeries • Proximal pole removed, frozen in liquid N2 & replaced; 5 mm gap • Distal radius pedicled graft placed across fracture • VBG on one side • Ligated pedicle (NVBG) on the other

*Sunagawa T, Bishop AT. JHS 25A: 849, 2000 9

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Fracture Healing at 8 weeks

• Vascularized graft side • 8 / 11 (73%) healed • 7/7 casted > 3 weeks • Conventional graft side : 0/11 (0%) healed • (p=0.0005)

*Sunagawa T, Bishop AT. JHS 25A: 849, 2000 10

VBG improves proximal pole blood flow 80 • 6 weeks n=6 70 60 • Vascularized graft : 50 71.5± 12.0 40 ml/min/100g 30 • Conventional graft : 20 37.3 ± 29.4 ml/ min/ 10 100g 0 vasc. Graft conv. Graft • P=0.028

vasc. Graft conv. Graft

*Sunagawa T, Bishop AT. JHS 25A: 849, 2000

Experimental carpal VBG Histology: 4 weeks 4 week vascularized 4 week conventional graft: viable marrow, graft: and osteoblasts, necrotic bone and osteoid formation marrow

*Sunagawa T, Bishop AT. JHS 25A: 849, 2000 12

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Experimental carpal VBG Histology: 8 weeks • Vascularized •Conventional bone: no bone: continued osteoid or bone remodeling of formation. Osteoclasts trabeculae active

*Sunagawa T, Bishop AT. JHS 25A: 849, 2000 13

So, why use a free bone flap?

• 50 1,2 ICSRA grafts to scaphoid • 14 grafts failed • 2 major reasons • Persistent DISI, shortened scaphoid • Larger graft needed • Fragmentation of proximal pole • Osteochondral replacement needed 15

5 8/20/2020

1,2 ICSRA conclusions

• Chang study demonstrates the need for both • wedge graft large and strong enough to correct scaphoid length & shape, and • A means to improve the proximal pole blood supply in avascular necrosis

Medial Femoral bone flap • Larger, much stronger graft suitable for use as an interposition/wedge graft • Robust blood supply allows healing and proximal pole revascularization

Medial femoral condyle flap

From medial femoral condyle, based on descending or medial superior genicular vessels

*Hertel R, Masquelet AC. Surg Radiol Anat 11:1989 18

6 8/20/2020

2 Blood vessels supply MFC

*Hertel R, Masquelet AC. Surg Radiol Anat 11:1989

MFC Blood Supply: Descending Genicular Artery*

• present in 89% of anatomic speciments • 1.5mm diameter (1.0-2.0) • Saphenous branch (to skin in 79% • Usually the dominant blood supply

*Yamamoto H, A. T. Bishop A. Y. Shin et al J Hand Surg Eur Vol 2010 35: 569 20

MFC anatomy: Osteoarticular branches

Transverse branch Longitudinal branch

Hugon S et al: Surg Radiol Anat (2010) 32:817–825

7 8/20/2020

Blood supply of the medial femoral condyle Bone nutrient vessels

• Longitudinal branch: • Highest # of nutrient vessels in distal- posterior quadrant- preferred for graft harvest

*Yamamoto H, A. T. Bishop A. Y. Shin et al J Hand Surg Eur Vol 2010 35: 569

• Review of anatomic findings of • 113 consecutive MFC flaps • Dominant vessel (used as pedicle) • Descending genicular : 77% • Superomedial: 23% • Descending genicular absent in 8/113

Oh C Pulos N, Bishop AT, Shin AY. JPRAS 72, 1503-8, 2019 23

Flap Harvest

• Use ipsilateral knee • Medial incision • Elevate vastus medialis to expose condylar surface of femur • Identify genicular vessels on floor of vastus medialis compartment

8 8/20/2020

Exposure of condyle

Exposure of medial condyle,

bone harvest site

Flap elevation

• Proximal to condyle: • select largest genicular artery/vein as pedicle. • Divide any muscular, unused cutaneous branches

9 8/20/2020

Pedicle dissection • On surface of bone: • Bipolor cauterize, divide transverse branch • Elevate longitudinal branch from underlying periosteum and medial collateral ligament • Beaver blade or • Jeweler’s bipolar

Bone flap elevaetion • Bipolar cauterize outside margin of bone flap • Make bone cuts • Add additional wedge resection to elevate graft from deep surface • Donor site filled with bone substitute

MFC flap elevated

Large (1cm3), strong graft Excellent blood flow

10 8/20/2020

Large graft restores normal length, Carpal alignment

MFC VBG

Arterial anastomosis to radial artery e-to-s Venous anastomosis to v. comitans e-to-e

Postoperative care

• Begin knee ROM immediately after surgery • Use of knee immobilizer, cane or crutch in opposite hand if needed • Scaphoid immobilized until CT scan confirms healing

11 8/20/2020

Rapid and reliable healing

Method 1 Method 2 35

Results • January 1994 and September 2006 •252 scaphoid nonunion 10 •AVN 1,2ICSRA •Carpal collapse •Avg. age: 26 12 MFC

*Jones DB, Bürger H, Bishop AT and Shin AY: J. Bone Joint Surg. 90(Am)2616-2625, 2008 36

12 8/20/2020

Union Rates

100 90 80 100% 70 60 MFC 50 N=12 40 40% 30 1,2 20 10 ICSRA N = 10 0 Union Rate p=0.039 37

Time to Union

20 18 16 14 12 19.2 10 weeks 12.7 8 weeks 6 1,2 4 ICSRA MFC 2 0 Time to Union p=0.047 38

• 49 patients with MFC flap for failed operative treatment • Mean 24 months post injury; 15 months post last surgery • All patients with proximal pole AVN • 36/49: prior bone graft; 43/49 with scaphoid screw • 6/49: 2 prior failed surgeries

Pulos N et al.; JBJS 100A (16), 1379-86, 2018 39

13 8/20/2020

MFC for failed prior surgery

• 41/49 (84%) healed in Pulos study • Mean 16 weeks by CT scan (range 9-31) • 88% satisfied/very satisfied • Age, smoking, BMI, time to surgery were not predictive of failure • None had symptoms at donor site at follow-up • 92% reported diminished pain; 79% reported improved wrist function • Most failures converted to SLAC wrist reconstruction successfully

Conclusions

• MFC grafts provide superior results in treating scaphoid nonunions with AVN and humpback deformity • Revascularize necrotic proximal pole • Restore carpal height/alignment • Heal the non-union • Indicated for nonunion with AVN; failed prior scaphoid surgery with AVN • Experimental evidence for superior performance to conventional bone graft for both healing and revitalizing necrotic adjacent bone

14 OnDemand Precourse 02: The Scaphoid: Little Bone, Big Problems

10 Minutes

Proximal Pole Reconstruction

James P. Higgins, MD No relevant conflicts of interest to disclose

75TH VIRTUAL ANNUAL MEETING OF THE ASSH OCTOBER 1 - 3, 2020

8/14/2020

James P. Higgins, MD

Speaker has no relevant financial relationships with commercial interest to disclose.

Proximal Pole Reconstruction: Indications  Non salvageable  “Non salvageable”: proximal pole  Primary surgery with proximal  Age<40, BMI<35: MFT pole <2mm on CT scan  OA changes are very rare sagittal images  Lunate extension is not a contraindication  Secondary surgery with comminution of remaining  Age >40, BMI>34: proximal pole  Salvage procedure  Any tertiary surgery  PRC  MCF  Osteochondral graft  Costochondral  Hamate

1 8/14/2020

Cartilage-bearing convex flaps from the medial femoral trochlea (MFT)

Deficient proximal pole

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3 8/14/2020

4 8/14/2020

4 weeks postop

5 8/14/2020

1 year postop 4 years postop

Bürger H, Windhofer C, Gaggl A, Higgins, JP. Jour Hand Surg (A) April 2013 17

16 y/o s/p ORIF dorsal

kimmett

6 8/14/2020

4 months

24 y/o mechanic 27 months s/p dorsal drbg + screw

Aaron Robinson

7 8/14/2020

intraop

CT at 4 months

8 8/14/2020

8 months postop

18 months

2 years

9 8/14/2020

20 y/o F s/p DRBG with dorsal screw

kuch eruk

2 years postop

DASH score = 1 (0-100) KOOS score =97(100-0) 29

April 2013

 16 consecutive cases  Minimum 6 month, avg 14 month f/u (6-72mo)  Mean age 30. Mean previous procedures 1  15/16 united  12/16 complete pain relief, 4/16 partial  440 flexion, 460 extension  SL preop 520 postop 490

10 8/14/2020

April 2020

Pre-Operative Characteristics of Patients Undergoing Medial Femoral Trochlea Flap for Reconstruction of the Proximal Scaphoid N 41 Male 35 Female 6 Age at Surgery 24.1 (16-40) Dominant Side Injury 19 BMI 27.5 (22-40) Previous Pedicled VBG 7 Prior Failed Scaphoid ORIF Requiring 35 Removal of Hardware 31

Proximal Scaphoid Arthroplasty Follow-Up Summary

Patient Recruitment Follow-Up Duration

 Study Visit – 11  Radiographic Follow-Up  1.5 Years

 Chart Review and  Examination Follow-Up Remote PRO Battery-  2.4 Years 10

 Patient Reported  Chart Review and Otucomes Follow-Up Limited PROs- 20  2.8-2.9 Years

Proximal Scaphoid Arthroplasty Surgical Complications

 Early  Thrombosis and revision arterial anastomosis  Recipient Site dehiscence requiring operative closure

 Late  Removal of migrated headless compression screw

 Recalcitrant scaphoid non-union  Asymptomatic  Patellofemoral pain  Arthroscopic debridement

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Proximal Scaphoid Arthroplasty Radiographic Outcomes

Carpal Height Ratio Radiolunate Angle Carpal Height rd 3 MC Length Normal Range: -15º to +15º Normal Range: 0.51-0.57 34

Proximal Scaphoid Arthroplasty Radiographic Outcomes

Pre-Operative and Post-Operative Radiographic Assessment of the Carpus

n Pre-Operative Post-Operative Difference p

Radiolunate Angle 30 -9.7º 0.7º 10.4º 0.0002 Carpal Height Ratio 30 0.49 0.51 0.02 0.016

Radioscaphoid Arthritis 34 1 3

Mean Radiographic Follow-Up: 1.5 Years Post-Operative

Proximal Scaphoid Arthroplasty

Functional Outcomes Comparing Affected and Unaffected Wrist Function After Proximal Scaphoid Arthroplasty

Unaffected Affected Side Percentage of n Side Post-Operative Unaffected Wrist Flexion (°) 19 64.2 41.6 65% Wrist Extension (°) 19 64.9 43.8 67% Radial Deviation (°) 17 22.6 10.4 46% Ulnar Deviation (°) 17 37.4 27.9 75% Pronation (°) 11 65 61.4 94% Supination (°) 11 60 62.7 105% Key Pinch (kg) 11 9.7 8.6 89% Grip Strength (kg) 20 39.7 33 83% 36

12 8/14/2020

Proximal Scaphoid Arthroplasty

Functional Outcomes

Wrist Flexion/Extension Before and After Proximal Scaphoid Arthroplasty

Affected Side Affected Side n Pre-Operative Post-Operative Difference p

Wrist Flexion (°) 14 46.9 42.8 -4.1 0.42

Wrist Extension (°) 14 48 44.8 -3.2 0.32

Proximal Scaphoid Arthroplasty

Patient Reported Outcomes Battery

 Upper Extremity  Global  DASH  PROMIS Physical Function  PRWE  PROMIS Global Health  PROMIS-Upper Extremity  PROMIS- Pain Intensity  PROMIS-Pain Interference  Lower Extremity  PROMIS- Pain Behavior  KOOS  WOMAC  IKDC  Kujala/AKPS

Results – UE Functional outcomes DASH SCORE: - Mean post-operative DASH score: 10.7  12 (For 27 patients)

- Mean DASH score: 23 (preop)  8 (postop) with more than 10- point for the minimum clinically important difference (MCID). (For the 11 patients with complete data, avg 3.4 year f/u)

PROMIS Upper Extremity SCORE: Mean post-operative PROMIS-UE score: 50 (indicating UE function at general population average).

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Proximal Scaphoid Arthroplasty

Patient Reported Outcomes: Lower Extremity

Post-Operative Patient Reported Outcomes: Lower Extremity Mean Post-Operative n Score Follow-up (y) IKDC 21 82.1 2.9 Kujala/AKPS 21 90.2 2.9 KOOS-Pain 27 91.5 2.8 KOOS-Symptoms 27 86.8 2.8 KOOS-ADL 27 93.9 2.8 KOOS-Sports and Recreation 27 80.2 2.8 KOOS- QOL 27 82.6 2.8 WOMAC 27 93.4 2.8

Zero (Worst)------100 (Best) 40

Proximal Scaphoid Arthroplasty

Patient Reported Outcomes: Lower Extremity Patient Reported Outcomes Before and After Proximal Scaphoid Arthroplasty

Mean Pre- Mean Post- n Follow-up (y) Op Score Op Score Difference p KOOS-Pain 11 3.4 97.7 93.2 -4.5 0.07 KOOS-Symptoms 11 3.4 90.6 91.9 1.3 0.7 KOOS-Activities of Daily Living 11 3.4 98.1 95.9 -2.2 0.059 KOOS-Sports and Recreation 11 3.4 95 84.9 -10.1 0.017 KOOS- Quality of Life 11 3.4 94.9 89.8 -5.1 0.32 WOMAC 11 3.4 98.2 95.2 -3 0.05

KOOS and WOMAC MCID = 10

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-4.5 +1.3 -2.2 -10.1 -5.1 -3.0

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Proximal Scaphoid Arthroplasty

Patient Reported Outcomes: Lower Extremity

Establishing a P.A.S.S. threshold for a PRO can aid in the interpretation of clinical or outcomes research By providing a reference value at which the majority of the population feels “well” .

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-4.5 +1.3 -2.2 -10.1 -5.1 -3.0

Proximal Scaphoid Arthroplasty

Lower Extremity Outcomes in Context: IKDC

15 8/14/2020

2.9 Years Post-Op MFT 47

Results – LE Functional outcomes

PRO – Lower extremity - Clinical improvement and statistically significant decrease of KOOS Sports/Recreation (-10.1 points, p=0.0017) and WOMAC (-3%, p=0.05) scales at 3.4 years.

- KOOS postoperative scores remained well above the Patient Acceptable Symptom State (PASS) thresholds at which the majority of the population “feels well” in a given PRO domain.

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Results – Predictors of PROs Univariate analysis: BMI, sex, age, dominance of the injured side, previous ORIF, and pre-operative RL angle - Male sex predicted superior post-operative PROMIS-UE scores. - Higher BMI predicted worse clinical outcomes with WOMAC, KOOS, IKDC and PROMIS scores.

Multivariate analysis: BMI, sex, and age - BMI was significantly predictive of worse post-operative lower extremity scores when controlled for age and sex

Proximal Scaphoid Arthroplasty

Predictors of Outcome: BMI

BMI Greater than or BMI Less Than 34 Student's T Test Equal to 34 n Mean n Mean Difference p IKDC 16 89 5 60 -29 0.001 Kujala/AKPS 16 93 5 83 -10 0.09 KOOS-Pain 22 95 5 76 -19 <0.001 KOOS-Symptoms 22 91 5 68 -23 <0.001 KOOS-ADL 22 97 5 81 -16 <0.001 KOOS-Sports and Recreation 22 85 5 60 -25 0.009 KOOS- QOL 22 88 5 60 -28 0.001 WOMAC 22 96 5 81 -15 <0.001

BMI <34

MFT BMI >34 51

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Results – BMI and LE PROs

Our heaviest patients had worse reported LE outcomes

Proximal Scaphoid Arthroplasty Alternatives to MFT

4CF PRC MFT Flexion-Extension Arc 54 73 86 Grip Strength 65% 54% 83% DASH 32 19 11 PRWE 27 28 17

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Osteochondral grafts: costochondral rib

• Michael Sandow • Tech Hand and Upper Ext Surg 2001 • 47 patients • Mean folowup 15 months • No patients required further surgery • Green and Obrien function score improvement 65 • preop to 85 (max 100) postop

Osteochondral grafts: hamate autograft

 Case report with promising results  Subsequent studies demonstrating congruity  Low morbidity, same limb, preserves PRC/4CF

Does this hold promise for the future?

 Complexity: is the microsurgery needed?  Durability: Will reconsruction outperform our conventional procedures?

 Prospective collection of salvage and MFT procedures  84 MFT scaphoids  36 MFT lunate

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Thank You James Higgins, MD [email protected] Baltimore, MD

Study purpose

 Compare the histologic characteristics of cartilage of

 osteochondral grafts supported by synovial imbibition alone  osteochondral flaps that have both synovial and vascular pedicle perfusion.

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Adana, Turkey

Ҫukurova University Medical Center

 Mehmet Emre Benlidayi  Sait Polat

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When deprived of subchondral perfusion from underlying bone, osteochondral vascularized flaps in an intrasynovial environment demonstrate superior cartilage quality and survival when compared J Hand Surg Am. 2018, 43: 188.e1-188.e8. to nonvascularized grafts.

24 OnDemand Precourse 02: The Scaphoid: Little Bone, Big Problems

10 Minutes

What I tell my patients

Joseph Joaquim Dias, MD, FRCS No relevant conflicts of interest to disclose

75TH VIRTUAL ANNUAL MEETING OF THE ASSH OCTOBER 1 - 3, 2020

Professor Joe Dias

University Hospitals of Leicester NHS Trust United Kingdom ASSH, USA, 2020

Dias JJ, Brealey SD, Fairhurst C, et al. Surgery versus cast immobilisation for adults with a bicortical fracture of the scaphoid waist (SWIFFT): a pragmatic, multicentre, open-label, randomised superiority trial. Lancet 2020; 396(10248): 390-401. Item Surgery Plaster Cast n % n % Surgical 31 14.2 3 1.4 complications Screw 94 42.9 10 4.6 penetration

Cast problems 6 2.7 45 20.5

Reoperations 8 had 11 re 3.7 1 had 1 0.5 operations reoperation

Dias JJ, Brealey SD, Fairhurst C, et al. Surgery versus cast immobilisation for adults with a bicortical fracture of the scaphoid waist (SWIFFT): a pragmatic, multicentre, open-label, randomised superiority trial. Lancet 2020; 396(10248): 390-401. Dias JJ, Brealey SD, Fairhurst C, et al. Surgery versus cast immobilisation for adults with a bicortical fracture of the scaphoid waist (SWIFFT): a pragmatic, multicentre, open-label, randomised superiority trial. Lancet 2020; 396(10248): 390-401.

6 weeks

Resolve

Cast Fix

• If Scaphoid # does NOT unite • & is untreated

• Almost 100% develop ARTHRITIS • usually within 5 years

• So MUST avoid Non-union

• SMOKING advice

Vender MI, Watson HK, Wiener BD, Black DM. Degenerative change in symptomatic scaphoid nonunion. J Hand Surg [Am] 1987; 12-A:514-9. OnDemand Precourse 02: The Scaphoid: Little Bone, Big Problems

10 Minutes

SNAC Wrist: Bailout Options

Sudhir Warrier, MD No relevant conflicts of interest to disclose

75TH VIRTUAL ANNUAL MEETING OF THE ASSH OCTOBER 1 - 3, 2020

8/20/2020

SNAC wrist

Sudhir Warrier Laud Clinic, Mumbai, India

Sudhir Warrier, MD

Speaker has no relevant financial relationships with commercial interest to disclose.

SNAC wrist

Scaphoid Non-union with Advanced Collapse

Degenerative changes of the wrist following un-united scaphoid fractures

1 8/20/2020

Scaphoid Non-union v/s SNAC

Sypmtoms Scaphoid Non-Union SNAC

Pain Pain

Stiffness Stiffness

Weak Grip Weak Grip

We are trying to identify

A stable non-union from an unstable non-union

Therefore the differentiation is based on the imaging!

(or arthroscopic findings)

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SNAC wrist stages

I Involves only radial styloid

II Radio-carpal involvement

III Mid carpal involvement

IV Global wrist involvement

Watson and Ballet

SNAC wrist I

Styloid changes

SNAC wrist III

Radiocarpal and Midcarpal involvement

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1yr Non-union Cancellous grafts + K wires

7 months post surgery

The asymptomatic scaphoid non‐union!

This unstable non-union may eventually become symptomatic

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Timeline of a SNAC wrist

Cysts Sclerosis Resorption 8 Years

Mack & Gelberman (JBJS Am, 66(4), Apr 1984)

Timeline of a SNAC wrist

Radio-scaphoid arthritis 17 Years

Mack & Gelberman (JBJS Am, 66(4), Apr 1984)

Timeline of a SNAC wrist

Pan-arthritis of the wrist Third decade

Mack & Gelberman (JBJS Am, 66(4), Apr 1984)

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Treatment in early stages

• Splinting in a functional position

• NSAID’s

• Modification of Vocation & Avocation

This may subside acute symptoms for varying periods of time.

Importance of proper pre‐op imaging

Post operative pain and restricted motion Despite union

Unrecognised SNAC I

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Imaging-MRI

• Request for T2 Cartilograms – 3D GRE sequences

No SNAC SNAC II

CT scans

• Sclerosis • Cysts • Loss of joint space • Osteophytes

SNAC I - Treatment

Traditional bone graft of the scaphoid with fixation

Add a radial styloidectomy

…a neurectomy perhaps?

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Radial styloidectomy

7mm on the dorsal aspect

4mm on the volar aspect

Radial Styloidectomy The Radio-scapho-capitate ligament must be preserved

Treatment of SNAC wrist

I Involves only radial styloid (Heal the non-union, styloidectomy) II Radio-carpal involvement (4 corner fusion, Radio-carpal fusion, proximal row carpectomy)

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SNAC II Wrist

2 years post fracture

Styloidectomy and 4 corner fusion

Grip strength is 60%

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SNAC II Wrist

4 corner fusion v/s PRC

• Range 80° 81°

• Radioulnar deviation Better

• Grip Strength 79% 71%

• Pain relief Similar in both groups

Cohen, Kozin 2001 (Procedures were done for SLAC wrists – NOT SNAC wrists )

RCT – PRC v/s 4CF for SNAC II

27 Patients > 5 yr Follow up

Concluded that there was no significant statistical difference in the outcome

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Cost comparison PRC v/s 4CF

• 4CF – Greater facility costs (2 fold to 3 fold increase) • Supply cost 10 fold • Operative time 121 v/s 57 mins • Implant cost only for 4CF

• 4CF costs almost 425% more than a PRC

• Implant cost alone is 130% of entire cost for a PRC ! Kazmers, JWS 2018

10 year follow up of Capito-lunate fusion

• 10 patients (4 SNAC, 4 SLAC)

• No pain • Improved motion ( 20 deg DF/VF, 10 deg UD/RD ) • Returned to manual labour • No degenerative changes noted at the Radio-lunate joint

Dargai, Hand Surg & Rehab, 2019

other procedures ..

• Proximal Row Carpectomy

• Radio-carpal fusion

The proximal capitate surface should be pristine!

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Simply put, Healthy cartilages must oppose each other for pain free function

Else, arthritis will ensue…??

Risk of arthrodesis or reoperation after PRC or 4CF

• 1168 patients, over 24 years! (PRC or 4CF done) • – Chart review

Conclusion: PRC may be preferable to 4CF in stage II SLAC/SNAC wrists

Garcia, JBJS (Am), 2020

Treatment of SNAC wrist

I Involves only radial styloid (styloidectomy) II Radio-carpal involvement (limited fusions, 4 or 3 corner fusion, Radio-carpal fusion, proximal row carpectomy) III Mid carpal involvement ( Wrist fusion, TWA ) IV Global wrist involvement (Wrist fusion, TWA)

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Implant Arthroplasty

Improved ranges Lesser pain Better grip Enhaned functional use

Few (Fewer for SNAC) Short follow up Significant complications Pyrocarbon implant Motec Implant Bellemere, JWS 2012 Giwa et al, JHS‐AP, 2018 ONLY 6 did not return to their occupation (THAT WAS OUT OF 23!!)

Total Wrist Denervation

• Of 39 patients, 5 had a SNAC wrist

• Range of motion retained • Pain- 13 painfree, 19 VAS<3, 5 VAS <6, 2 VAS >6 • DASH scores improved significantly

• Radiological worsening in 31 patients

• NO CHARCOT’S JOINT

Picart, OTSR 2019

Sent to 20 EMINENT SURGEONS who create the EVIDENCE

(at least one publication on the subject/ faculty at a Master Level Course)

1/2 3/4 1/4 4/4

1/1

1/2 0/3

Responses 11/20

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Simple , quick and instinctive – INFORMAL

All cases - hypothetical

• Dominant Hand

• All were given adequate trial of conservative treatment

• All were symptomatic and were on medications

• All were agreeable to submit for surgery

Limitation

• No further investigation reports were shared

• No queries were requested/ answered

• ______

• Responder confidentiality was assured

• (outcome would be shared, if requested!)

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SNAC II analyst SNAC II sportsman

Asia Excise scaphoid PRC+ 4CF styloidectomy USA PRC PRC ?cap flap ?cap flap USA Sc excision Sc excision CL fusion CL fusion USA Prox hamate to scaphoid transfer Prox hamate to scaphoid transfer

Switzerland Total wrist arthrodesis If Rad/Lunate OK 4CF else Total wrist fusion

UK Neurectomy + TWA / CL fusion CL fusion

Austria MFC osteochondral graft MFC osteochondral graft

Canada Scaphoid fusion + 4CF Scaphoid fusion + 4CF

Africa 4CF 4CF

South America Scaphoid excision +Lunocapitate Scaphoid excision +Lunocapitate fusion fusion

Orthopedic resident doctor - 1988

• Sustains a fracture of the scaphoid…. Undiagnosed for a year

• Opinions for surgery, but asymptomatic….

• Fellowship in UK …. Suggested Non-union surgery

• Consultant Orthopedic Surgeon- NHS

• Returns to India 2005 – suggested salvage surgery, to prevent SNAC

15 8/20/2020

TYPE II Lunates

Bain – less incidence of arthritis

12th August 2020

32 YEARS later Asymptomatic

The way I see it (at the present time!)..

• SNAC wrist develops and progresses at an unpredictable pace

• Salvage procedures help in retaining painless function in symptomatic wrists

• The choice of the salvage procedure seems to have little influence over long term outcomes and their ability to prevent arthrosis

• Total wrist denervation remains a less explored option.

• Implant arthroplasty is an emerging and encouraging choice in some instances