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2

SCIENTIFIC ARTICLE

PercutaneousScrewFixation forScaphoidFracture:A

ComparisonBetween theDorsal and theVolarApproaches

In-Ho Jeon, MD, Ivan D. Micic, MD, Chang-Wug Oh, MD, Byung-Chul Park, MD, Poong-Taek Kim, MD

Purpose To evaluate the position of the screws and find the difference of clinical andradiologic outcome between the volar approach and the dorsal approach groups in percuta-neous screw fixation for acute scaphoid fractures.

Methods Forty-one consecutive patients with an acute scaphoid fracture, who had percutaneousfixation via either the volar approach or the dorsal approach, were evaluated at an average of 30months after the surgery. The volar approach was used in 19 patients and the dorsal approach in22 patients. By using a computerized digital image program, angles between the Herbert screwwith respect to the long axis of the scaphoid and the fracture line were measured with plainradiographs in the posteroanterior, lateral, and the 45° semipronated oblique views.

Results The screws showed no significant difference between the 2 groups in posteroanterior andlateral views; however, screws in the dorsal approach group were observed to be placed moreparallel to the long axis of the scaphoid in the semipronated oblique view. The screws in thedorsal approach group were positioned more perpendicular to the fracture lines of the scaphoidcompared with those of the volar approach group for all 3 different radiographic views. There wasno statistically significant difference between the 2 treatment groups regarding fracture healing.According to the Mayo wrist score system, excellent results were recorded in 18 patients in thedorsal approach group and 15 patients in the volar approach group.

Conclusions This study suggests that screws are placed more parallel to the long axis of thescaphoid and perpendicular to the fracture line via the dorsal approach; however, there wasno significant difference with regard to functional outcome and bone union. (J Hand Surg2009;34A:228–236. © 2009 Published by Elsevier Inc. on behalf of the American Society forSurgery of the Hand.)

Type of study/level of evidence Therapeutic IV.

Key words Acute scaphoid fracture, dorsal approach, percutaneous fixation, volar approach.

fsps

HE COMPLEX THREE-DIMENSIONAL anatomies andtenuous blood supply of carpal scaphoid bonesmake fracture management challenging. Open

urgical treatment is well established in the manage-ent of acute unstable scaphoid fractures for early

From the Department of Orthopedic Surgery, College of Medicine, Kyungpook National University Hospi-tal, Daegu, Korea; and the Department of Orthopaedic Surgery and Traumatology, Clinical Center, Fac-ulty of Medicine, Nis, Serbia.

Received for publication April 10, 2008; accepted in revised form October 16, 2008.

No benefits in any form have been received or will be received related directly or indirectly to the

subject of this article.

28 � © Published by Elsevier, Inc. on behalf of the ASSH.

unctional recovery by adequate reduction.1–17 Earlyurgical intervention with fixation enabled young activeatients to return to previous activities of daily living orports as soon as possible.1

Previous reports on percutaneous screw fixation in

orresponding author: In-Ho Jeon, MD, Department of Orthopaedic Surgery, Kyung-ook National University Hospital, 50, 2-Ga, Samduk, Chung-Gu, Taegu, 700-721, Korea;-mail: jeonchoi@chollian.net.

363-5023/09/34A02-0004$36.00/0oi:10.1016/j.jhsa.2008.10.016

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PERCUTANEOUS SCREW FIXATION FOR SCAPHOID FRACTURE 229

the management of scaphoid fractures have describedthis technique, and this approach has been advocatedover the past few years. Since Streli’s first report on thepercutaneous technique in 1970,2 many reports havedescribed the percutaneous fixation of scaphoid frac-tures. Both the volar approach3–17 and the dorsal ap-proach18–21 have appeared in the literature with rela-tively low complication rates. Slade et al.18 stressed thatusing the dorsal approach, the screw is introduced fromthe narrow proximal pole to the wide distal fragment,and therefore, it is easier to place the screw in thecentral portion of the scaphoid. Chan et al.22 conducteda cadaveric comparison between the proximal and distaltechniques of percutaneous screw placement in thescaphoid and concluded that the proximal-dorsal ap-proach allowed more central screw placement. Al-though good clinical results from the volar and thedorsal percutaneous screw fixation techniques havebeen reported, there has been no clinical comparativestudy done between the dorsal and the volar approachesin the literature.

The purpose of this study is to evaluate the positionof the screws and find the difference of clinical andradiologic outcome between the volar approach and thedorsal approach groups in percutaneous screw fixationfor acute scaphoid fractures.

MATERIALS AND METHODS

From January 1999 to December 2005, we prospec-tively followed up 53 patients with an acute scaphoidfracture. All fractures were classified according to themodified classification of Herbert and Fisher.23 Allfractures were classified as type B2 unstable acute frac-tures (22 fractures in the dorsal group and 19 fracturesin the volar group). Mild comminution in the palmarside was noted in 4 patients. All patients were managedwith percutaneous screw fixation by 1 hand surgeon atthe university hospital.

Forty-one patients treated by percutaneous fixationwith noncannulated Herbert screw fulfilled the inclu-sion criteria: (1) type B2 acute displaced fractures ofscaphoids, (2) a surgery within 2 weeks after initialinjury, and (3) minimum follow-up of 2 years.

Exclusion criteria were patients with (1) a proximalpole fracture, (2) a complicated fracture like transcaph-oid perilunar dislocations, or (3) an associated fracturein the distal radius or other carpal bones.

Initially, all surgeries were performed using thevolar approach from January 1999 to June 2001,and subsequently the dorsal approach was used in

all patients beginning July 2001. A total of 19

JHS �Vol A, Fe

fractures were fixed via the volar approach and 22by the dorsal approach.

The study group included 39 male and 2 femalepatients with an average age (of overall patients in thedorsal or volar group) of 28 years (range, 14–52 years).Thirty-six right hands (34 dominant) were involved.Nineteen patients were students at the time of surgery.The remaining 22 patients included 9 manual workers,7 office workers, 3 farmers, and 3 drivers.

Diagnosis of the fracture was based on physicalexamination, plain radiographs, and computed tomog-raphy (CT). Standard posteroanterior, lateral, and 45°semipronated oblique view and thin-section CT scanalong the long axis of the thumb were taken in allpatients before the surgery to confirm fracture site dis-placement, comminution, or angulation.

At the time of surgery, details of the fracture patternswere recorded. The average age (of each group) of thepatients was 30 years (range, 14–52 years) in the dorsalgroup and 27 years (range, 16–52 years) in the volargroup. Overall, fractures were most common in patientsin their twenties and thirties (32 patients). Patient detailsare summarized in Table 1. The most common injurywas a minor fall on an outstretched hand in 33 patients,and among them 15 fractures occurred during sportsactivities. Five fractures were caused by a direct blowsuch as a punch, and 1 fracture was due to a road trafficaccident.

Surgical technique

The volar approach: Under general or brachial plexus an-esthesia, patients were placed supine on the operatingtable and the scaphotrapezial joint was identified andmarked on the volar side of the skin. A trial manualreduction of the fractures was facilitated under an imageintensifier if necessary. A transverse stab incision wasmade at about 1 cm distal to the scaphotrapezial jointunder image intensifier control. After blunt dissection tothe distal end of the scaphoid, a 1.4-mm (0.045-in)K-wire was used temporarily to facilitate fracture sta-bilization along the long axis of the scaphoid directedtoward the center of the proximal pole. A semipronatedoblique view was required in addition to anteroposteriorand lateral views, because lateral radiograph did notshow the entire proximal outline of the scaphoid. Thelength of the guide wire within the scaphoid was deter-mined. The drill was inserted, parallel to the guide wireunder fluoroscopy. After tapping, a Herbert screw ofappropriate length was introduced under image intensi-fier control. Compression was confirmed by an image

intensifier, and the end of the screw was buried beneath

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230 PERCUTANEOUS SCREW FIXATION FOR SCAPHOID FRACTURE

the distal surface of the scaphoid to avoid any furtherdamage to the scaphotrapezial joint.

The dorsal approach: Under appropriate anesthesia withthe patient in a supine position, the dorsal scapholunatejoint was marked. The wrist was pronated and flexeduntil the scaphoid was seen as a circle on fluoroscopy.The center of the circle was chosen as the target pointfor the insertion of the guide wire into the proximal poleof the scaphoid. After stab incision over the center ofthe circle (usually over the scapholunate joint), theguide wire was driven dorsal to volar so that it exited atthe radial base of the thumb. The reduction and place-ment of the guide wire was confirmed under an imageintensifier. A pilot hole was drilled parallel to the guideK-wire. After tapping, a Herbert screw was insertedunder an image intensifier in a freehand manner. Afterfixation, the position of the screw could be verifiedusing an image intensifier.

Postoperative management

The wrist was supported in a volar splint for 3 weeks.Active assisted finger exercises were encouraged im-mediately after surgery. The splint was removed andwrist exercises were initiated 3 weeks after the surgery.Resisted or weight-bearing exercise was allowed afterhealing was established. Clinical and radiographic con-trols were performed at 4, 8, and 12 weeks and at theend of follow-up.

Evaluation

Clinical evaluations as well as the pain scale, range ofmotion, grip strength, and functional outcome based onthe Mayo wrist score system24 were performed at the

TABLE 1. Comparison of Details Between the Dorsa

Variables

Dorsal (n � 22)

MedianRange

(Minimum–Maximum)

Gender (F:M), n (%) 2 (9.1):22 (90.1)

Age (y) 27 38 (14–52) 3

Time from injury tooperation (days)

10 10 (4–14) 1

Follow-up time (mo) 29 18 (24–42) 3

Statistically significant at p � .05.*The result of the Mann-Whitney U test.†The result of the chi-square test.

end of follow-up.

JHS �Vol A, Fe

Plain radiographs of posteroanterior, lateral, and 45°semipronated oblique views standardized by 2 radiog-raphers were acquired via digital radiography and savedusing a picture archiving and communications system(PACS) (Mediface; Infinitt, Seoul, Republic of Korea).The axes and angles were measured using the softwaretool in the PACS. The long axis of the scaphoid in theposteroanterior and semipronated oblique views wasdetermined as a line between the center of the distaltuberosity and the most convex point of the proximalpole of the scaphoid, and the long axis of the scaphoidwas determined as the volar outline in the lateral view

FIGURE 1: Technique for measuring scaphoid long axis inplain radiographs of A posteroanterior view and B lateral view.The long axis of the scaphoid in the posteroanterior andsemipronated oblique views was determined as a line betweenthe center of the distal tuberosity and the most convex point ofthe proximal pole of the scaphoid, and it was determined asthe volar outline in the lateral view.

pproach and the Volar Approach Groups

Group

p Value*

Volar (n � 19)

n) Median

Range(Minimum–Maximum)

Mean(SD)

0 (0.0):9 (100) .178†

2) 24 36 (16–52) 27 (9) .425

) 10 8 (6–14) 10 (2) .766

) 28 14 (24–38) 30 (5) .958

l A

Mea(SD

0 (1

0 (3

0 (6

(Fig. 1). The relationship between (1) the long axis of

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PERCUTANEOUS SCREW FIXATION FOR SCAPHOID FRACTURE 231

the Herbert screw with respect to the long axis of thescaphoid and (2) the fracture line with respect to theangle of the long axis of the scaphoid was measuredon the posteroanterior, lateral, and semipronatedoblique views. This measurement was conductedby 1 hand surgeon who was not involved in thetreatment and 1 musculoskeletal radiologist, twiceby both practicioners. When there were any dis-agreements between the measurements, the measure-ments were repeated until agreement was reached.Radiologic union was defined as cross-trabeculationon all radiographic views, and radiographic signs ofarthrosis were checked.

Statistical analyses

Statistical analyses were performed for comparisonsbetween age, gender, and all clinical factors between thevolar and the dorsal groups. All variables in each groupwere described as mean, SD, median, range for quantita-tive variables, and frequency with a percentage for quali-tative variables. To compare the 2 groups for all variables(except gender), a Mann-Whitney U test was used, be-cause a normality test was not appropriate. A chi-squaretest was performed for gender. Statistical software(SPSS, ver. 12.0; SPSS Inc., Chicago, IL) was used,and a p value �.05 was considered significant.

RESULTS

Clinical results

The demographics of the 2 groups were very similaraccording to age, gender, time between injury and sur-

TABLE 2. Clinical Results of the Dorsal Approach a

Dorsal (n � 22)

Variables MedianRange

(Minimum–Maximum) Mea

Pain 25 10 (15–25) 23.18

Flexion (°) 65 15 (60–75) 66

Extension (°) 63 20 (50–70) 61

Radial deviation (°) 25 11 (20–31) 25

Ulnar deviation (°) 34 10 (26–36) 32

Modified Mayo wristscore (points)

100 80–100 96

Statistically significant at p � .05.*The result of the Mann-Whitney U test.

gery, and follow-up time (Table 1). Most subjective

JHS �Vol A, Fe

pain was reduced by internal fixation of the scaphoid 2or 3 days postoperatively. The outcome measurementsof pain, tenderness, range of motion, grip strength, andMayo wrist score are shown in Table 2. The 2 groupswere similar at the baseline for all outcome measure-ments and the mean follow-up period (Table 1). Over-all, the final range of motion of the wrist in both groupsaveraged 66° (range, 60° to 80°) of flexion, 61° (range,50° to 65°) of extension, 25° (range, 20° to 31°) ofradial deviation, and 33° (range, 28° to 38°) of ulnardeviation. In the dorsal approach group, averages of 66°of flexion and 61° of extension were recorded, and inthe volar approach group, averages of 67° of flexionand 60° of extension were recorded.

Although the volar group demonstrated slightlygreater flexion and less extension, there was no statis-tically significant difference between the 2 groups (p �.05) (Table 2).

According to the more stringent modified Mayowrist score system,24 the functional results in the dorsalapproach group were excellent for 18 patients, good for3 patients, and fair for 1 patient; however, in the volarapproach group, 15 patients had excellent results and 4patients showed good results. There was no statisticallysignificant difference between the 2 groups (p � .446).

The fracture union was diagnosed in all but 1 patienton the visit at 12 weeks. This delayed union in the volargroup required additional splint immobilization, andcomplete radiographic union was achieved 20 weeksafter surgery. There was no statistically significant dif-ference between the 2 groups regarding the fracture

the Volar Approach Groups

Group

Volar (n � 19)

) MedianRange

(Minimum–Maximum) Mean (SD) p Value*

1) 25 5 (20–25) 23.42 (2.39) .910

65 20 (60–80) 67 (6) .989

60 15 (50–65) 60 (5) .300

24 5 (22–27) 24 (1) .380

33 7 (31–38) 34 (2) .414

95 85–100 95 (6) .446

nd

n (SD

(2.9

(4)

(5)

(2)

(3)

(6)

union (p � .683).

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232 PERCUTANEOUS SCREW FIXATION FOR SCAPHOID FRACTURE

Radiographic result

Radiographs made at the time of the surgery wereused for axis measurements. The analysis of theinclination of the fracture line showed there was nostatistically significant difference between the 2groups at 3 different radiographic views. The meaninclination angle in the dorsal approach group was81°, and it was 82° in the volar approach group (p� .788). Radiographs at the time of the mostrecent follow-up revealed that all fractures hadhealed.

The angle between the screw and the scaphoid long axis at 3 differentviews: The position of the screw in the dorsal

FIGURE 2: A, B. The angle between the long axis of thepostoperative radiograph. The long axis of the scaphoid is markis marked with a dotted red line. The Herbert screw in A thscaphoid than in B the volar approach. C, D. The angle betmeasured in the standard postoperative radiograph. The fracturlong axis of the Herbert screw is marked with a dotted redvertical to the horizontal fracture line of the scaphoid than in D

approach group was more parallel to the long axis

JHS �Vol A, Fe

of the scaphoid than that in the volar approachgroup (Fig. 2A, B). The average angle between thescrew and the scaphoid in the dorsal approachgroup was 11° at posteroanterior view, 8° at lateralview, and 8° at semipronated oblique view. On theother hand, in the volar approach group, the aver-age angle between the screw and scaphoid was 13°at posteroanterior view, 13° at lateral view, and16° at semipronated oblique view. Although thescrews showed no significant difference betweenthe 2 groups in posteroanterior and lateral views,screws in the dorsal approach group were observedto be placed more parallel to the long axis of thescaphoid in the semipronated oblique view (p �

hoid and the Herbert screw is measured using the standardith a dotted black line, and the long axis of the Herbert screw

rsal approach is placed more parallel to the long axis of thethe fracture site and the long axis of the Herbert screw is

e of the scaphoid is marked with a dotted black line, and theThe Herbert screw in C the dorsal approach is placed more

volar approach.

scaped we doweene linline.

.019) (Table 3).

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PERCUTANEOUS SCREW FIXATION FOR SCAPHOID FRACTURE 233

The angle between the screw and vertical to the fracture line at 3 differentviews: The screws in the dorsal approach group werepositioned more perpendicular to the fracture lines ofthe scaphoid compared with those of the volar approachgroup (Fig. 2C, D). The average angle between the 2axes in the dorsal approach group was 80° at posteroan-terior view, 83° at lateral view, and 80° at semipronatedoblique view. In the volar approach group, the averageangle between the 2 axes was 74° at posteroanteriorview, 72° at lateral view, and 73° at semipronatedoblique view. There was a statistically significant dif-ference between the dorsal approach group and thevolar approach group for all 3 different radiographicviews (p � .05) (Table 3).

Complications

There were no perioperative complications. None of thepatients showed radiographic signs of arthrosis duringthe study period. One patient sustained an injury of thesuperficial branch of the radial artery during the volarapproach, and there was 1 instance of a delayed union,which required additional splint immobilization. Onepatient in the dorsal approach group complained of apainful hypertrophic scar on the dorsum of the wrist; noadditional procedures were necessary. There were nocomplications related to Herbert screw (ie, migration orloosening). None of the patients showed stiffness of thefingers or thumb, nor did they develop complex re-

TABLE 3. Comparison of Radiographic Results BetGroups

Variables

Dorsal (n � 22)

MedianRange

(Minimum–Maximum

Long axis–screwposteroanterior (°)

10 33 (0–33)

Long axis–screw lateral (°) 6 30 (0–30)

Long axis–screw oblique (°)‡ 40 (0–40)

Fracture line–screwposteroanterior (°)

81 30 (60–90)

Fracture line–screw lateral (°) 85 20 (70–90)

Fracture line–screwoblique (°)‡

82 23 (65–88)

*The result of the Mann-Whitney U test.†Statistically significant at p � .05.‡Oblique: 45° inclined semipronated oblique view.

gional pain syndrome.

JHS �Vol A, Fe

DISCUSSIONNondisplaced fractures of the scaphoid waist were man-aged with immobilization as the standard treatment;however, unstable and displaced scaphoid fractures whentreated with plaster immobilization are at the greatest riskof nonunion.25 Reports on open internal fixation of scaph-oid fractures have documented a high rate of union,26,27

but there are risks of violating intact volar ligaments and,subsequently, carpal instability.28,29 In addition, surgicaltrauma of the soft tissue around the scaphoid, whichhas tenuous vascular supply, shows a risk of delayedhealing or nonunion.30 Thus, recently, there has beenan increased trend toward percutaneous fixation fordisplaced scaphoid fractures. This procedure bearsthe inherent advantages of limited soft tissue dissec-tion and it hastens fracture healing.5

Many authors have reported good or excellent func-tional outcome with percutaneous screw fixation (Ap-pendix; this appendix may be viewed at the Journal’sWeb site, www.jhandsurg.org). Use of cannulated AOscrews,14,15,17 cannulated Acutrak screws,8,20,31,32 ornon-cannulated Herbert screws6,10,13,16 have been re-ported in previous studies. Although cannulatedscrews have resulted in a higher rate of centralplacement in the scaphoid with better resistanceand compressive forces,33 in our experience wefound that a non-cannulated Herbert screw, using thefreehand method, is also reliable for acute scaphoid

the Dorsal Approach and the Volar Approach

Group

Volar (n � 19)

eanD) Median

Range(Minimum–Maximum) Mean (SD) p Value*

(10) 14 26 (2–28) 13 (9) .416

(8) 14 36 (0–36) 13 (10) .148

(9) 9 19 (3–22) 10 (5) .019†

(8) 72 30 (59–89) 74 (10) .039†

(6) 72 28 (58–86) 72 (8) .000†

(6) 77 39 (50–89) 73 (12) .023†

ween

)M(S

11

8

8

80

83

80

fractures.

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234 PERCUTANEOUS SCREW FIXATION FOR SCAPHOID FRACTURE

Both the volar approach and the dorsal approach foracute fractures have been reported in the literature.Streli2 in 1970 first reported a detailed surgical tech-nique of percutaneous screw fixation for scaphoid frac-ture; this was followed by Wozasek and Moser16 in1991. Since then, the majority of series have beenoperated via the volar distal approach with successfuloutcome; however, the dorsal approach became popularafter the method was introduced by Slade et al.18 in2001. The reported union time in the volar approachvaried from 6 to 18 weeks with different screw fixationmethods.3–17 The union time in the dorsal approach wasreported as being between 8 to 12 weeks.21,31,32 Theunion rate was 89% to 100%. On the other hand,complications were also reported related to both meth-ods of fixation.32 Complex regional pain syndrome,superficial skin infection, and nonunion3,4,15 have beenreported in the volar approach. In the dorsal approach,only 1 extensor pollicis longus rupture and one non-union (3%)31 have been reported (Appendix; this ap-pendix may be viewed at the Journal’s Web site, www.jhandsurg.org).

Slade et al. used an arthroscopic-assisted approach inall patients, and it allowed confirmation of fracturereduction and screw implantation as well as an evalu-ation of concurrent ligament injuries that could not bedetected with standard imaging.

The advantages of the dorsal approach were theexact targeting of the central axis of the scaphoid, moreprecise placement of the screw within the scaphoid, andavoiding injury to the volar carpal ligament.18 On theother hand, the volar approach has easier access to theentry because the guide wire does not cross the radio-carpal joint, there are less technically demanding,and it is easy to maintain fracture reduction withwrist extension, so there is no risk of injuring theextensor tendons.

It has been shown that the technical aspects of screwinsertion are important for the clinical outcome afterfixation of acute fractures of the scaphoid waist.14,34

The study of Trumble et al.14 concluded that centralplacement of the screw in the proximal fragment of thescaphoid with either the cannulated or Herbert screw isassociated with a significant reduction in the times tounion (p � .05). In addition, there is evidence that thepostoperative range of motion is associated with thedegree of scaphoid alignment achieved by internal fix-ation; however, their study was carried out in a non-union series that had been present for more than 4months and not in the acute fractures. The biomechani-cal study of McCallister et al.35 in the cadaveric model

confirmed that the central placement of a screw in the

JHS �Vol A, Fe

proximal fragment had superior results of stiffness, loadat displacement, and load at failure compared withthose after eccentric positioning of the screw. The com-parative study by Chan and McAdams22 on 12 cadav-eric models demonstrated that the proximal/dorsal ap-proach to percutaneous screw fixation of scaphoid waistfractures allowed for a more central placement in thedistal pole, but there was no marked difference when itwas used in the proximal or waist regions.

Radiographic analysis of the 2 groups in our studyconfirmed that screws were inserted in a more favorableposition (ie, perpendicular to the fracture line) throughthe dorsal approach than through the volar approach.This might have biomechanical advantages in terms offracture healing; however, this was not confirmed in ourstudy. In addition, 45° semipronated oblique view con-firmed that the screws were placed more parallel to thelong axis of the scaphoid through the dorsal approach.In the volar approach, the guide wire tends to lead thescrew to volar placement in the distal pole.

Our study demonstrated that union was achieved inall but 1 case, with similar time to union in the volar andthe dorsal groups. The clinical results of this studysuggest that both the volar and the dorsal approachesoffered reliable results. There was no significant differ-ence between the 2 groups in terms of union time andfunctional outcome, which included pain, range of mo-tion, return to work, and grip strength. Functional resultat last follow-up demonstrated that 82% of patients inthe volar group and 79% in the dorsal group weregraded as excellent according to the Mayo wrist scoresystem.24 There was 1 delayed union in the volar ap-proach group and 1 painful hypertrophic scar in thedorsal approach group. No hardware-related problemsas reported by Bushnell et al.32 were observed in ourstudy. These results were comparable with those ofother reports (Appendix; this appendix may be viewedat the Journal’s Web site, www.jhandsurg.org).

In our practice, we used exclusively the volar ap-proach influenced by excellent results reported byWozasek and Moser16 and Inoue and Shionoya9 from1999 to 2001. Since 2001, we learned that the dorsalapproach introduced by Slade et al.18 provided bettertargeting and more precise placement. Thus, wechanged our policy to the dorsal approach since then.This study is one of the largest series analyzing theoutcome of percutaneous scaphoid fixation.

The subjects in our study are relatively uniform withregard to age, interval between injury and surgery, andfollow-up time. The analysis of the fracture pattern andcharacteristics are crucial in this study. In this retrospec-

tive study, we excluded any fracture in the distal one

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PERCUTANEOUS SCREW FIXATION FOR SCAPHOID FRACTURE 235

third or proximal one third of the scaphoid, and thecollection was relatively homogenous. There was novertical fracture in the waist. Analysis of the inclinationof the fracture line at 3 different radiographic viewsshowed there was no statistically significant differencebetween the 2 groups. All surgeries were performed bythe same surgeon at the single institute. The patientswere evaluated by an independent doctor who was notinvolved in the treatment.

This study has the limitation of lack of assessment ofintraobserver and interobserver variability for reproduc-ible and reliable studies. The geometry of the scaphoidlacks symmetry in any single plane, thus, its true centralaxis is inherently a 3-dimensional entity. Thus, thisstudy has a limitation in identification of the true longaxis of the scaphoid, because this is based on an inter-pretation of single planar imaging in 3 different planes.Thus, a 3-dimensional imaging technique of screwplacement (such as with 3-dimensional CT reconstruc-tion) is warranted to compare the volar and the dorsaltechniques in the future. This measurement was con-ducted independently by 1 hand surgeon who was notinvolved in the treatment and by 1 musculoskeletal radi-ologist. In addition, this study contains the inherent weak-ness of the retrospective study, a small sample size, andabsence of power analysis. None of the outcomes differedsignificantly between the 2 groups, but this conclusionmust be evaluated carefully given the potential of lowpower to detect clinically important differences. We didcollect all patients who satisfied the inclusion criteriaduring the time, so all available patients were used.Further, the size of the difference between the 2 groupswas small for each outcome variable, and good out-comes were observed in both groups, so we do notbelieve clinically important differences were misseddue to sample size limitations. Nevertheless, a prospec-tive controlled study with appropriate power analysis inadvance is required in the future.

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JHS �Vol A, Fe

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PERCUTANEOUS SCREW FIXATION FOR SCAPHOID FRACTURE 236.e1

APPENDIX. Review of the Literature on Percutane

Authors YearNumber of

Patients Approach Instrum

Wozasek and Moser16 1991 130 Volar Conventionwith was

Ledoux et al.11 1995 23 Volar Herbert scrInoue and Shionoya9 1997 40 Volar Herbert scr

Haddad and Goddard8 1998 15 Volar Acutrak scrTaras et al.13 1999 5 Volar Herbert scrAdolfsson et al.3 2001 25 Volar Acutrak staBond et al.5 2001 11 Volar Acutrak scrSlade et al.21 2002 27 Dorsal Acutrak scr

(arthroscassisted)

Brutus et al.6 2002 30 Volar Herbert scr

Yip et al.17 2002 49 Volar AO/ASIFcannulat

Jeon et al.10 2003 13 Volar Herbert scr

Chen et al.7 2005 11 Volar Cannulated

Shih et al.12 2005 15 Volar Cannulated

Wong et al.15 2005 52 Volar AO/ASIFcannulatAcutrak

Arora et al.4 2007 21 Volar CannulatedBedi et al.32 2007 18 Dorsal Acutrak scrBushnell et al.32 2007 24 Dorsal Acutrak orMcQueen et al.36 2008 30 Volar Acutrak

Author 2007 22 Volar Herbert scr

Author 2007 19 Dorsal Herbert scr

AO/ASIF, Arbeitsgemeinschaft fuer Osteosynthesefragen–Associationsefragen–Association for the Study of Internal Fixation; ND, not descrmotion; Mayo score, Mayo wrist score system.24

Note: We searched Medline, PubMed, and Web of Science databa“fracture” in combination with “percutaneous scaphoid” and “percutaretrieved articles. We limited the publications to acute scaphoid fracturedealing with nonunion, or no description on union rate. Thus, we incjournals and (2) publications with data of union (or union time) and f

ous Fixation for Acute Scaphoid Fracture

ent Union (%)Union Time

(Mean, Weeks) Functional Outcome

al screwher

89 ND Full functional restoration

ew 100 ND 95% of unaffected sideew 100 6 � 2.1 Satisfactory wrist function in 37

of 40ew 100 8 13 excellent, 2 goodew 100 8.2 NDndard 92 �16 12 of 23: 6% ROM lossew 100 7 Overall satisfiedewopic

100 12 90% to 95% of ROM

ew 90 ND 86.6% screw perpendicular tofracture line

ed screw100 12 All: excellent (no criteria)

ew 100 9.2 93%: no or minimal loss offunction (Herbert score)

screw 100 10.6 6 of 11: excellent 5 of 11: good(Mayo score)

screw 100 ND 11 of 15: excellent (Mayoscore)

ed andscrew

96 11 Mean 90; 75% excellent (Mayoscore)

screw 95 6 NDew 94 8 DASH score 6 of 100Twinfix 96 ND 29% complication rate

97 9.2 100% excellent/good (Green/O’Brien score)

ew 100 9.36 18 of 22: excellent 4 of 22:good (Mayo score)

ew 100 9.50 15 of 19: excellent 4 of 19:good (Mayo score)

for the Study of Internal Fixation; Arbeitsgemeinschaft fuer Osteosynthe-ibed; DASH, Disabilities of the Arm, Shoulder, and Hand; ROM, range of

ses from 1990 to 2007 using key words “percutaneous” or “scaphoid” orneous scaphoid fixation” and we also examined the references lists of theand also excluded the review articles, technical reports, and any publicationsluded only (1) English language full-length publications in peer-reviewedunctional outcome.

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