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ORIGINAL ARTICLE
Year : 2022  |  Volume : 25  |  Issue : 7  |  Page : 1158-1162

Mid-term radiological results of intra-articular penetration of the screw used in scaphoid surgery


1 Department of Hand Surgery, Sancaktepe Training and Research Hospital, Sancaktepe, Istanbul, Turkey
2 Department of Hand Surgery, Kayseri City Hospital, Kocasinan, Kayseri, Turkey

Date of Submission22-Sep-2021
Date of Acceptance30-May-2022
Date of Web Publication20-Jul-2022

Correspondence Address:
Dr. T Coskun
Sancaktepe Training and Research Hospital, Department of Hand Surgery, Namık Kemal Street No: 7, 34785, Sancaktepe, Istanbul
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_1833_21

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   Abstract 


Background and Aim: Headless cannulated compression screw is often used in scaphoid fracture and nonunion surgery. In the volar and dorsal surgical approach, when adequate fluoroscopic imaging is not performed, the screw may protrude beyond the scaphoid bone and penetrate into the joint. When the length of the screw is too long, and it is noticed intraoperatively, it is replaced with a shorter screw. However, there is no clear consensus in the literature about the way to be followed when screw penetration is noticed in the postoperative period. Materials and Methods: The cases in which cannulated screw penetrated the radioscaphoid, scapholunate, and scaphotrapeziotrapezoid joint on postoperative radiographs were included in this study. Sixteen patients (13 men and 3 women) were included. The mean postoperative follow up time was 35.1 months. There was scaphotrapeziotrapezoid joint penetration in seven cases, scapholunate joint penetration in two cases, and radioscaphoid joint penetration in seven cases. Results: Osteoarthritis developed in the scapholunate joint in two cases and in the radioscaphoid joint in two cases. Early revision surgery or waiting for the fracture to heal and removing the screw, or not performing secondary surgery are among the options. In this study, mid term radiological results of screws penetrating radioscaphoid, scapholunate, and scaphotrapeziotrapezoid joints were examined. It was observed that it may cause osteoarthritis development in radioscaphoid and scapholunate joints, but it did not cause osteoarthritis development in scaphotrapeziotrapezoid joint. Conclusion: In the early postoperative period, revision surgery is recommended to prevent the development of osteoarthritis of screws penetrating the radioscaphoid and scapholunate joint.

Keywords: Joint, osteoarthritis, penetration, scaphoid, screw


How to cite this article:
Coskun T, Arik H O. Mid-term radiological results of intra-articular penetration of the screw used in scaphoid surgery. Niger J Clin Pract 2022;25:1158-62

How to cite this URL:
Coskun T, Arik H O. Mid-term radiological results of intra-articular penetration of the screw used in scaphoid surgery. Niger J Clin Pract [serial online] 2022 [cited 2022 Aug 8];25:1158-62. Available from: https://www.njcponline.com/text.asp?2022/25/7/1158/351461




   Introduction Top


In scaphoid fractures, the cannulated screw in the central axis of the bone is the ideal position, but this may not always be achieved.[1] Penetration of the headless cannulated compression screw into the radioscaphoid (RS), scapholunate (SL), and scaphotrapeziotrapezoid (STT) joints is a rare complication. When it is noticed intraoperatively, the screw size is changed. However, the effect of screw penetration on the joints in the late postoperative period is not clearly stated in the literature.

Central placement of a cannulated screw to the scaphoid fracture is ideal for fracture union. The cannulated screw must not protrude beyond the cartilage of the scaphoid. This is an ideal situation for osteosynthesis. The most common non-ideal placement is the orientation of the volarly inserted screw to the dorsoradial aspect of the scaphoid and chondral penetration.[2] In the open volar approach, the proximal articular surface of the scaphoid is not directly visible. Likewise, in the dorsal open approach, the distal articular surface of the scaphoid is not directly visible. Screw penetration from proximal or distal articular surfaces may cause osteoarthritis in the long term.

Intraoperative fluoroscopy is used to evaluate the screw placement. The complex shape of the scaphoid bone and its anatomical relationship with the other carpal bones prevent the articular surfaces from being fully visualized on X-ray images. Proximal or distal chondral screw penetration may be missed on standard X-ray and fluoroscopy images.[3] Iatrogenic articular screw penetration can cause chondrolysis and osteoarthritis. In this study, we reviewed the postoperative mid-term radiological results of the cases with intra-articular screw penetration.

Treatment of wrist arthritis remains a challenging issue, and the various surgical options need to be carefully evaluated for each patient. Proximal row carpectomy (PRC) and four-corner arthrodesis have proven to be reliable options for reducing pain and restoring adequate function in the majority of patients. In addition, posterior interosseous nerve neurectomy in the dorsal wrist is performed as a single or combined surgery for the treatment of pain associated with wrist arthritis in patients of all ages. Capitolunate arthrodesis, total wrist arthrodesis, radial styloidectomy, total wrist arthroplasty, and wrist hemiarthroplasty procedures have important strengths and weaknesses and require further study in patients.


   Materials and Methods Top


The patients who underwent surgery for scaphoid fractures between January 2016 and January 2021 were reviewed retrospectively by scanning the hospital database. The cases in which cannulated screw penetrated the RS, SL, and STT joints on postoperative radiographs were included in this study. The cases without follow-up radiographs were excluded. All clinical and radiological data were obtained from the hospital's radiology imaging system.

Postoperative standard anteroposterior and lateral radiographs of the patients were examined. In the postoperative follow-up of some patients, oblique radiography and computed tomography were taken. On the radiographs, the parts where the screws protrude from the scaphoid bone near the joint were determined. All follow-up radiographs of the cases with intra-articular screw penetration were examined. The cases that developed secondary joint osteoarthritis and underwent surgery for the second time were recorded.


   Results Top


Sixteen patients (13 men, 3 women) were included in the study. The mean age of the patients was 35.9. The common mechanism in the medical records of the patients was found to be falling on the open hand. The mean postoperative follow-up time was 35.1. When the fracture types of the patients were examined, there were 11 waist fractures and 5 proximal pole fractures. In the surgical technique, 9 cases were performed with the dorsal approach and 7 cases with the volar approach. When the X-rays were examined, there was STT joint penetration in seven cases [Figure 1], SL joint penetration in two cases [Figure 2], and RS joint penetration in seven cases [Figure 3]. In the radiological follow-up of the patients, osteoarthritis was developed in four cases. Osteoarthritis developed in the SL joint in 2 cases and in the RS joint in two cases. PRC was performed as a secondary surgery in only one of the patients who developed osteoarthritis [Table 1].
Figure 1: Scaphotrapeziotrapezoid joint screw penetration

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Figure 2: Scapholunate joint screw penetration (a): Early postoperative X-ray (b): Early postoperative computed tomography image (c): Scapholunate joint osteoarthritis

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Figure 3: Radioscaphoid joint screw penetration (a): Early postoperative AP X-ray (b): Early postoperative lateral X-ray (c): Radioscaphoid joint osteoarthritis AP X-ray (d): Radioscaphoid joint osteoarthritis lateral X-ray

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Table 1: Demographic and clinical information of the patients

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   Discussion Top


Retrograde and antegrade screwing techniques used in scaphoid fractures carry the risk of intra-articular screw penetration due to the three-dimensional (3D) shape of the scaphoid.[4] Especially in the volar approach, it is more likely that the screw extends beyond the scaphoid bone from the dorsoradial side of the radiocarpal joint and extends into the joint. The use of intraoperative fluoroscopy reduces the possibility of screw penetration.[5]

Due to the anatomy of the scaphoid and its relationship with other carpal bones, it can be difficult to determine the screw size. In the anteroposterior view, the proximal convexity of the scaphoid masks the proximal penetration of the screw. Similarly, the proximal part of the lunate bone may hide screw penetration on lateral radiographs. Fluoroscopy with oblique radiography in pronation can determine the penetration of the screw from the proximal part intraoperatively.[6]

The wrist's arc of motion is formed by a combination of complex osseous joints and delicate soft tissue connections. Abnormal friction due to screw penetration within the joint can cause cartilage wear. Degenerative lesions in the cartilage can cause osteoarthritis in the wrist. Osteoarthritis developing in the wrist is well tolerated for years, but functional limitation gradually increases.[7] A surgical treatment plan is made for the involved joint and osteoarthritis.

The complex articular structure of the wrist is formed by the shape of the carpal bones and over 30 ligaments. There is no direct tendon attachment to the carpal bones. The movements of these bones are formed by compression forces. Compression forces on the scaphoid force it to flex.[8] Screws penetrating the joints of the carpal bones cause degenerative cartilage lesions with the effect of compression forces. In particular, the screw tip extending out of the scaphoid bone causes cartilage lesions by flexing the scaphoid with the effect of compression forces.

A screw penetrating the distal and volar part of the scaphoid causes irritation and degeneration in STT joint due to wear-related repetitive compressive movements. In the chronic period, STT joint osteoarthritis may develop. Distal scaphoid excision and STT arthrodesis are two methods described in the literature for STT osteoarthritis.[9] In the cases we examined, it was observed that screws penetrating the STT joint did not cause osteoarthritis. Penetration of the screws into distal and volar part to the scaphoid may be a factor in the absence of osteoarthritis. In the case of symptomatic STT osteoarthritis, screw removal should be planned first. STT arthrodesis or distal scaphoid excision may be planned if symptoms persist despite the termination of screw irritation.

SL dissociation and associated SNAC and radiocarpal joint osteoarthritis are well-defined conditions.[10] However, screw penetration of the SL joint and associated osteoarthritis of the SL joint have not been reported in the literature. In the cases, osteoarthritis developed in the SL joint radiologically, but it did not cause SL ligament rupture. In addition, there is no treatment algorithm for isolated SL joint osteoarthritis in the literature. SL arthrodesis is not a preferred method due to nonunion problems and low patient satisfaction. In case of symptomatic SL osteoarthritis development, RSL arthrodrosis or PRC surgical treatments can be planned.

Degenerative diseases of the radiocarpal joint usually occur after post-traumatic intra-articular injuries. Fractures of the distal radius, scaphoid fracture, or rupture of the SL ligament cause RS joint osteoarthritis if not treated appropriately. Radioscapholunate arthrodesis, wrist arthrodesis, and wrist arthroplasty are defined treatment methods in osteoarthritis due to these injuries in the literature.[11],[12],[13] The position of the scaphoid bone changes with the movements of the wrist. In addition, a significant part of the load transfer between the hand and forearm is on the scaphoid. If there is screw penetration after scaphoid surgery, wrist movements and the load cause wear on the articular cartilage and osteoarthritis in the late period. The more the part of the screw protruding from the bone, the greater the joint cartilage damage will be. We could not find a treatment algorithm for screw penetration noticed postoperatively in the literature. If osteoarthritis develops in the RS joint due to screw penetration, PRC can be performed. However, if osteoarthritis is advanced in this joint, radioscapholunate or total wrist arthrodesis is among the other options. PRC can be preferred to arthrodesis as it preserves the range of motion better.

Scaphoid surgery is difficult due to both the 3D shape of the bone and union problems. There are many publications in the literature about the ideal placement of the screw.[14] The use of fluoroscopy is routinely recommended for the ideal intraoperative screw size.[15] In addition to the standard radiographs, oblique radiographs in pronation and supination are important in determining the ideal screw length.[2] When intraoperative screw penetration is noticed, the screw size should be reduced. When it is noticed in the postoperative period, the direction of penetration and the part extending into the joint are important in decision making. As the screws penetrating the STT joint usually extend into the distal, volar, and radial portion of the scaphoid, joint irritation is usually minimal. In fluoroscopy, the distal scaphoid pole is seen more clearly because other bones are not superimposed. The amount of penetrating screws is usually short and does not cause osteoarthritis. If this situation causes pain in the patient, the screw removal can be planned after the fracture has healed. Screws extending into the SL joint may cause isolated SL joint osteoarthritis due to joint irritation. There is no information in the literature about isolated SL joint osteoarthritis. When it is noticed postoperatively, it is important to remove it before joint movement begins to prevent the development of osteoarthritis. Screws extending to the RS joint cause more cartilage damage when the multiplanar movement of the joint is considered. If intraoperative screw penetration is not noticed, it causes serious cartilage damage in the joint when joint movement begins in the postoperative period.

In scaphoid surgery, it is important to choose the appropriate screw size as well as the ideal screw placement. Screws extending into the STT joint are better tolerated postoperatively. However, screws extending into the SL and RS joints cause osteoarthritis in the long term. Oblique radiographs in pronation and supination are important in preventing this complication. If it is noticed intraoperatively, the screw length should be shortened. When it is noticed postoperatively, screw revision or removal should be considered before joint movements are started.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Guo Y, Tian GL, Chen S, Tapia C. Establishing a central zone in scaphoid surgery: A computational approach. Int Orthop 2014;38:95-9.  Back to cited text no. 1
    
2.
Ahmed U, Malik S, David M, Simpson C, Tan S, Power D. The headless compression screw-technical challenges in scaphoid fracture fixation. J Orthop 2015;12(Suppl 2):S211-6.  Back to cited text no. 2
    
3.
Tumilty JA, Squire DS. Unrecognized chondral penetration by a Herbert screw in the scaphoid. J Hand Surg Am 1996;21:66-8.  Back to cited text no. 3
    
4.
Ahrend MD, Teunis T, Noser H, Schmidutz F, Richards G, Gueorguiev B, et al. 3D computational anatomy of the scaphoid and its waist for use in fracture treatment. J Orthop Surg Res 2021;16:216. doi: 10.1186/s13018-021-02330-8.  Back to cited text no. 4
    
5.
Zlotolow DA, Knutsen E, Yao J. Optimization of volar percutaneous screw fixation for scaphoid waist fractures using traction, positioning, imaging, and an angiocatheter guide. J Hand Surg Am 2011;36:916-21.  Back to cited text no. 5
    
6.
Kim RY, Lijten EC, Strauch RJ. Pronated oblique view in assessing proximal scaphoid articular cannulated screw penetration. J Hand Surg Am 2008;33:1274-7.  Back to cited text no. 6
    
7.
Weiss KE, Rodner CM. Osteoarthritis of the wrist. J Hand Surg Am 2007;32:725-46.  Back to cited text no. 7
    
8.
Kijima Y, Viegas SF. Wrist anatomy and biomechanics. J Hand Surg Am 2009;34:1555-63.  Back to cited text no. 8
    
9.
Jehan S, Javaid Iqbal H, Javaid MM, Mohammed Sharif K. The surgical management for isolated scaphotrapeziotrapezoid (STT) osteoarthritis: A systematic review of the literature. Acta Orthop Belg 2020;86:137-45.  Back to cited text no. 9
    
10.
Shah CM, Stern PJ. Scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) wrist arthritis. Curr Rev Musculoskelet Med 2013;6:9-17.  Back to cited text no. 10
    
11.
Shin EK, Jupiter JB. Radioscapholunate arthrodesis for advanced degenerative radiocarpal osteoarthritis. Tech Hand Up Extrem Surg 2007;11:180-3.  Back to cited text no. 11
    
12.
Hayden RJ, Jebson PJ. Wrist arthrodesis. Hand Clin 2005;21:631-40.  Back to cited text no. 12
    
13.
Srnec JJ, Wagner ER, Rizzo M. Total wrist arthroplasty. JBJS Rev 2018;6:e9.  Back to cited text no. 13
    
14.
Luchetti TJ, Hedroug Y, Fernandez JJ, Cohen MS, Wysocki RW. The morphology of proximal pole scaphoid fractures: Implications for optimal screw placement. J Hand Surg Eur 2018;43:73-9.  Back to cited text no. 14
    
15.
Luria S, Safran O, Zinger G, Mosheiff R, Liebergall M. Intraoperative 3-dimensional imaging of scaphoid fracture reduction and fixation. Orthop Traumatol Surg Res 2015;101:353-7.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1]



 

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