Two-part surgical neck fractures, two-part greater tuberosity fractures and three- and four-part fractures of the proximal humerus represent a frequently encountered clinical problem. Many types of conservative treatments have been proposed, with a poor functional outcome, however; when the fracture fragments are displaced, surgery is required. Because the open reduction and the internal fixation disrupts soft tissue and increases the risk of avascular necrosis of the humeral head, closed or minimally open reduction and percutaneous pin fixation should represent an advantage. We report on 31 patients affected by fractures of the proximal humerus (n=6, two-part surgical neck fractures; n=5, with two-part greater tuberosity fractures; n=10, three-part fractures; and n=11, four- part fractures) treated with minimally open reduction and percutaneous fixation. The average age was 57 years. Most of the four-part fractures were of the valgus type with no significant lateral displacement of the articular segment. A small skin incision was performed laterally at the shoulder and a rounded-tipped instrument was introduced to obtain the fracture reduction; this latter was stabilised by percutaneous pins and cannulate screws. A satisfactory reduction was achieved in most cases. The average follow-up was 24 months (range 18–47). Only one patient, with four-part fractures associated with lateral displacement of the humeral head, showed avascular necrosis and received a prosthetic implant. Minimally open reduction and percutaneous fixation is a non-invasive technique with a low risk of avascular necrosis and infection. This surgical technique allows a stable reduction with minimal soft tissue disruption and facilitates postoperative mobilisation

Introduction and Aims:. The surgical treatment of fractures of the scaphoid with delayed presentation or with established non-union pose a formidable challenge with reported failure rates between 15% and 45%. The aim of this study is to report the results of percutaneous versus open fixation with bone grafting of these fractures. Method:. 34 Consecutive patients who underwent surgery between 2009 and 2013 for delayed presentation and established non-union of scaphoid fractures have been reviewed retrospectively. There were 27 males and 7 females with a mean age of 31 years (15 to 66). The mean delay from time of injury to operation was 12 weeks (4 weeks to 11 months) in the percutaneous fixation group and 19 months (5 months to 6 years) in the open fixation group. 19 Patients were treated with percutaneous screw fixation alone and 15 patients underwent open reduction and internal fixation supplemented with autogenous corticocancellous iliac bone graft. The classification of Slade and Dodds (2009) was used as a guide for surgical treatment and the Mini-Acutrak headless compression screw was used as the fixation device in all cases. Results:. Patients underwent final clinical and radiological assessment with plain radiographs 6 months following their surgery. There was one failed union in the percutaneous fixation group and there was one failed union in the open fixation group. One patient in the open fixation group was lost to follow up. No serious complications were recorded in either group. Conclusion:. The success of percutaneous internal fixation for acute fractures of the carpal scaphoid may be extended to include scaphoid fractures with delayed presentation and fractures of the scaphoid with established nonunion. However, appropriate patient selection is necessary to ensure optimal outcomes

Introduction: Scaphoid fractures are the most common carpal fractures, mainly affects young man. The fixation of the displaced fractures is well accepted, but more controversy is seen with the fixation of nondisplaced fractures. Surgery offers less cast time, and faster return to daily and sports activities. MATERIAL AND Methods: We present 20 patiens (17 man- 3 woman), mean age 31 years old, that sustained a nondisplaced scaphoid fracture. Surgical treatment was performed with a volar percutaneous fixation with a Herbert canulated screw. Patients were casted for 1–2 weeks and then rehabilitation was started. Results: 60% of the fractures were produced after low energy trauma. Functional evaluation 2 months postoperative were flexion 60°, extension 55°, radial deviation 21, ulnar deviation 18°. Patients returned to sports activities at 11 weeks and at 13 weeks to their previous work. Time to bone union was 9 weeks. In 5 cases pain in the place of the surgical scar were present, we had one case of sensitive branch lesion. Conclusions: The percutaneous fixation of the nondisplaced scaphoid fractures with a Herbert screw allowed a fast functional recovery, good union rate and few complications

Introduction: Carpal scaphoid fractures can be treated non-operatively in a cast, but the duration of treatment can take up to 12 weeks, with non-union rates of 15%. The hypothesis of this study was: percutaneous fixation of acute scaphoid fractures results in better union rates, faster time to union, and better function. Method: In a prospective study, 48 consecutive acute and subacute scaphoid fractures were treated with percutaneous Acutrak screws. These patients were compared to a case-matched control group treated non-operatively in a cast. Herbert-Fisher type A (‘crack’) and B4 (fracture-dislocations) fractures were excluded from the study. The implant is a cannulated headless titanium screw with conical design and continuous differential pitch for inter-fragmentary compression. The screw was introduced retrograde according to a technique devised by the senior author (MP). In addition to the standard postero-anterior and lateral views, prone and supine oblique views were used to achieve accurate screw placement. Results: There were 16 B1 (oblique), 15 B2 (waist), four B3 (proximal pole) and nine B5 (comminuted) fractures in each group. The average operation time was 19 minutes. The union rate was 97.7% in the operated group, and 81.8% (36/44) in the non-operated group (p< 0.05). The average time to union was significantly quicker in the operated group (seven weeks compared to 12 weeks, p< 0.05). At 12 weeks post-treatment the range of motion as well as the pinch and grip strengths were better in the operated group. After 24 weeks the two groups had comparable functional results. The mean time taken return to work was 2.5 weeks with percutaneous fixation compared to 13 weeks with cast treatment (p< 0.05). The average delay with cast group in return to work was 10.8 weeks with an average loss of income of $8815. The overall cost to the community with the screw treatment was $7640 more with cast treatment. There were no complications in the operated group and seven non-unions in the cast group. Conclusion: Primary percutaneous screw fixation of scaphoid fractures is reliable, fast, cost-efficient and reproducible. The learning curve is moderately steep. It results in improved union rates, decreased time to union, improved early function and early return to work. Prone and supine oblique views are invaluable in assessing accurate screw placement

Introduction: Intraarticular fractures of distal radius are associated with high energy mechanisms, are severe and difficult to obtain a surgical reduction. The aim of our paper is to compare the clinical, radiographically and activity results in workers treated with surgical and conservative procedures. MATERIAL AND METHODS: A prospective study was organized in 43 heavy-labour workers (34 male and 9 female) with unstable fractures of distal radius, treated between 2003 and 2005. The minimal follow-up was of one year. The mean age were 40 years (22–65 years) and dominant limb was involved in 40% of the cases. To treatment groups were established. Group 1, conservative treated with indirect reduction and cast immobilization (n=20) and Group 2 surgically treated with indirect reduction and percutaneous fixation with K-wires and cast immobilization (n=24). Pain, mobility and radiograhs were evaluated and also strength (isokinetics), functionality (DASH score) and, finally, the return to work at 3, 6 and 12 months. RESULTS: Fracture healing was obtained at 7 weeks but the time to return to work were 14 weeks after surgery. Pain score, at 12 months, were 2,3 points for conservative treatment and 2,9 points for the surgically group. The flexion – extension mobility loss, in relation to the contralateral wrist, was lesser in the conservative group at 3 and 6 month but similar (11°) at 12 months in both groups. Radiographs corrections were anatomically in 38% of the cases of group 1 and in 80% of group 2. Functional and strength results were similar in both groups. All the patients return to the same work activity. CONCLUSIONS: Percutaneous fixation of unstable intraarticular distal radius fracture is comparable to the conservative treatment but the percentage of anatomical reductions was higher. It would be of importance in the evolution of the patients

Between June 1996 and April 2002, 56 patients underwent closed reduction and percutaneous fixation of calcaneal fractures. Of the 39 men and 17 woman, five were lost to follow-up. The patients’ mean age was 38 years (17 to 64). Four had bilateral procedures. Using the AOFAS Ankle and Hindfoot Scale (AHS) and Visual Analogue Pain Scale (VAPS), we assessed patients preoperatively and at 6 and 12-monthly intervals. Clinical examination was undertaken preoperatively and postoperatively at 2-week, 6-week, 3-month, 6-month and 12-monthly intervals. Except at two weeks, radiographs included weight-bearing axial and lateral views at all intervals. Follow-up was for a mean period of 42 months (12 to 72). The mean time to union was 10.2 weeks (8 to 14). The AHS improved from 34 preoperatively to 85 at the most recent follow-up. The VAPS improved from 9.1 preoperatively to 2.2 at three years. The satisfaction rate was 86%. Functional results depended on the quality of the reduction of the posterior facet and the severity of the initial injury. Complications included a 5% sural nerve injury and a 3% peroneal tendinopathy. No wound complications were encountered. In selected cases, closed reduction and internal fixation of calcaneal fractures may produce results similar to those of conventional open reduction and internal fixation, with fewer complications. This technique is best performed within 24 to 72 hours of injury

We present the results of a multicentre retrospective study of closed fracture dislocations of the Lisfranc joint treated by closed reduction and percutaneous screw fixation (follow-up: almost 5 years). Forty-two patients that presented between 1994 and 1999 to the authors™ institutions were selected for this study (follow-up AOFAS score 81.0 ± 13.5). A review of the literature shows that opinions differ as to the most appropriate method of treatment, be it closed or open reduction, screws or K-wires fixation, but most of the authors agree that it is imperative to achieve anatomical reduction. In our study, no statistically significant differences could be detected when outcome scores of patients with anatomical reduction were compared with outcome scores of patients with nearly anatomical reduction, in both the combined fracture dislocation and pure dislocation subgroups. The conclusion is that even a nearly anatomical reduction is considered acceptable and predictive of a satisfactory outcome. Furthermore, we found a statistically significant difference in the AOFAS score between patients with combined fracture dislocations and pure dislocations, with the latter having a worse AOFAS score. This suggests that the ligament bone interface cannot heal with sufficient strength to regain stable long-term function

Introduction: Mac Farland fracture is a joint fracture of the ankle in children, which involves the medial malleolus (Salter-Harris type III or IV) and is frequently associated with a fracture of the distal fibula. These injuries have a major risk of resulting in a medial epiphysiodesis bridge which, in turn, can lead to a varus deformity. As of today, recommended treatment for displacements wider than 2mm is open reduction with screw fixation. The aim of this study is to evaluate functional and radiological results of a new less invasive surgical procedure. Materials and Methods: We retrospectively analyzed a case series of patients who suffered from a Mac Farland fracture and underwent percutaneous screw fixation with arthrographic control. Data collected for each child included age at diagnosis, gender, mechanism and side of injury, radiological Salter-Harris classification of medial and lateral malleolus fracture, size of the fracture line gap before and after treatment, and duration of cast immobilization. Results are given according to the classification by Gleizes (2000), based on clinical and radiological criteria: good, fair, and poor. Results: There were twelve patients, five girls and seven boys, with a mean age of twelve years and six months (range: 10–15). Average follow-up was eighteen months (range: 9–57). Medial malleolus fracture was Salter-Harris type III in seven patients and type IV in five. The mean preoperative fracture line gap was 2.7mm (range: 2–4). All the patients underwent closed reduction and ankle arthrography to check for anatomical reposition. The fracture was then percutaneously fixed with two screws in nine patients and one screw in three. Duration of cast immobilization after surgery was forty-five days in average. At the time of last follow-up the functional and radiological results were good for all the patients according to Gleizes’ classification. Conclusion: Closed reduction combined to ankle arthrography followed by percutaneous osteosynthesis is, in our opinion, an interesting less invasive surgical alternative to classic open reduction and internal fixation for displaced Mac Farland fractures

Acute scaphoid fractures are commonly treated with cast for 8–12 weeks. With this prolonged period of immobilisation patients can encounter joint stiffness and muscle wasting requiring extensive physiotherapy. Despite best practice, these fractures also pose a risk of non-union and suboptimal function. Fracture location, duration of time lost from work and impairment in activities of daily living are key factors in scaphoid fracture management. The aim of our study was to compare percutaneous screw fixation of the scaphoid with other operative fixation techniques. Parameters documented were length of conservative treatment, mechanism of injury, post-op complications and patient satisfaction levels with each technique using a standardised questionnaire. Economic benefit was also measured by examining time to return to work, number of x-rays and outpatient visits required per treatment group. In this study, 76 patients requiring operative scaphoid fixation were evaluated. 27 patients underwent percutaneous fixation. Waist fractures accounted for 66% (n= 18), proximal pole fractures 33% (n=8) and distal pole fractures 4% (n=1). There were 16 non-displaced fractures (59%) and 11 displaced fractures (41%). The average length of conservative treatment was 77 days (range: 2–256 days). Within the percutaneous group 2 patients developed non-union. We did not encounter any wound infection or superficial radial nerve damage. Patients treated with early percutaneous fixation had highest satisfaction levels, returned to work earlier and required less follow-up (P< 0.001). In conclusion percutaneous screw fixation provides earlier bone union and avoids the need for prolonged immobilisation when compared to other treatment modalities. The economic benefit of early percutaneous fixation must also be considered when managing patients with scaphoid fractures

Background. Percutaneous K-wire fixation is a well-recognised and often performed method of stabilisation for distal radius fractures. However, there is paucity in the literature regarding the infection rate after percutaneous K-wire fixation for distal radius fractures. Aims. To analyse the rate and severity of infection after percutaneous K-wire fixation for distal radius fractures. Material and methods. Between October 2004 and June 2005, 43 patients with closed distal radius fractures had percutaneous K-wire fixation. The wires were left outside the skin in all the cases for easy removal at the end of six weeks at the clinic. They were followed up in the clinic at 1, 2, 4, and 6 weeks. The pin tracts were examined at 2 weeks and six weeks, or if needed earlier. The severity of pin tract infection was graded using modified Oppenheim classification. Results. Out of 43 patients, the male to female ratio was 13:30. The mean age was 49.1 years (range 5-86 years). There were nine cases of pin tract infection, out of which three were grade I, three were grade II, two were grade III, and one was grade IV. In three cases the K-wires had to be removed earlier. Discussion. The infection rate after percutaneous K-wire fixation for distal radius fractures is high (20.9%), which is equivalent to the infection rate quoted in the literature for hybrid external fixators. As the K-wires are used to fix the fractures, the expected implant infection rate in Trauma and Orthopaedics which is less than 1% should be aimed for. However this is not the case. Hence, burying the K-wires under the skin may be an alternative to reduce the infection rate after percutaneous K-wire fixation of distal radius

The aim of this study was to prospectively assess the outcome of patients with metastatic spinal disease who underwent minimally invasive fixation of the spine for intractable pain or spinal instability.

This is a prospective audit of patients with metastatic spinal cord disease who have undergone minimally invasive fixation of the spine from August 2009 until the present date. This was assessed by pre and post-operative Oswestry Disability Index (ODI), EQ5D and Tokuhashi scores. Intra- and post-operative complications, time to theatre, length of inpatient stay, analgesia requirements, mobility, chest drain requirement and post-operative HDU and ITU stays were also recorded.

So far, 10 patients have met the criteria. There were no intra-operative complications. Post-operatively, there were no complications, chest drains, increase in analgesia or stay on the HDU or ITU. All patients showed an improvement in mobility. The mean post-operative day of mobilisation was 2 days, post-operative days until discharge 5.3 days and length of inpatient stay was shorter than traditional surgery. Blood loss was minimum except one patient with metastatic renal cell carcinoma who needed transfusion intraoperatively.

ODI, VAS and EQ-5D scores were calculated and were significantly improved compared to preoperatively.

This novel approach to management of metastatic spinal disease has resulted in improved mobility, short inpatient stays without the need for chest drains, HDU or ITU and an improved the quality of life in pallliative patients. This is a completely new strategy to treat the pain in these patients without the usual associated risks of surgery and has major advantages over traditional surgical techniques which may preclude this group of patients having any surgical stabilisation procedure at all

Aims: The study was undertaken in order to assess the clinical and radiological results of treatment of comminuted diaphyseal fractures of long bones using the principle of biological fixation, standard implants and minimum access surgery.

Methods: 20 patients operated with this method are subject of this review. All operations were performend on the orthopedic or ordinary translucent table using image intensifier. Fractures were reduced indirectly and fixed with the plate or DCS passed subcutaneously with-our accessing the fracture site.

Results: All fractures united in the average period of 5.9 months.There were no snignificant complications and no infections. Function of adjacent joints was good.

Conclusion: In case of comminuted diaphyseal fractures of long bones biological fixation with minimal access surgery principle using standard implants gives excellent clinical and radiological results and is a valuable alternative to other fixation methods

Background: Treatment of patients with partially or totally unstable pelvic ring disruptions includes primary anterior stabilization with an external fixator and additional posterior internal fixation. Iliosacral screws placed percutaneously under fluoroscopy or navigation guided techniques are widely accepted today to address the posterior lesions. Definite surgery is usually performed on a semi-emergent basis, whereas a delay of more than seven days in definite fixation is accompanied by a high rate of pulmonary complications, malreduction and infections. Purpose: To compare the outcome of patients with type B and C pelvic ring disruptions treated with immediate definite posterior fixation (within 24 hours) as compared to those treated with early fixation (24–96 hours from arrival). Patients and Methods: The medical records of 44 patients with type B and C pelvic ring disruptions were reviewed retrospectively. All posterior lesions were treated with closed reduction and internal fixation with percutaneously placed posterior iliosacral screws. Patients were divided into two groups, based on the time of definite fracture fixation from admittance to the ER. Immediate treatment included patients treated within 24 hrs of arrival (Group A), early intervention was defined as definite fracture fixation between 24–96 hrs from the patient’s arrival (Group B). Post operative radiographs (Pelvis AP, inlet and outlet) were used to assess the quality of final fracture reduction. Patient records were screened for demographic data, injury severity score and early morbidity and mortality. Results: Forty-four patients were treated between the years 1999–2002 due to posterior pelvic ring fractures. 70.5% of the patients were male, the majority of patients (41/44) were injured during motor vehicle accidents, two patients sustained work-related crush injuries and one patient was injured during a suicide attempt. Fracture patterns were classified according to the Tile classification, there were 31 type B and 13 type C fractures. Thirty patients were treated within 24 hrs of admittance to the ER (group A), fourteen were treated between 24 and 96 hrs from arrival (Group B). ISS averaged 19.5 in group A as compared to 17.8 in group B (p=0.74). Overall complication rates were low. Malreduction was noted in one patient (group A), one patient in each group became infected, S1 foraminal penetration occurred in two patients (Group A). Two patients in group A died due to complications not related to the orthopedic intervention. No significant difference was found between the complication rates in both groups (p=0.34). Conclusions: Immediate definite fixation of posterior pelvic lesions can be safely performed with posterior iliosacral screws. Comfortable nursing and early mobilization can be achieved without compromising the quality of fracture reduction and minimizes post-operative complications

Percutaneous fixation is a well recognised technique in the treatment of three-part and four-part fractures of the proximal humerus. Minimal fixation of these fractures do show good functional outcome and may further reduce the incidence of avascular complications. We report a preliminary series of 11 patients who underwent percutaneous minimal fixation of such complex humeral fractures using a new technique. 11 consecutive patients (7 with three-part fractures and 4 with four-part fractures) treated by percutaneous limited fixation in our Hospital were involved in this retrospective study. There were 7 fractures with valgus displacement. Percutaneous technique was employed using small incisions and the fracture was reduced under image guidance. The three-part and the four-part fractures were essentially converted into two part fractures, i.e. only the greater and the lesser tuberosities were re-attached to head with AO cancellous screws after realignment of the fragments. The shaft of the humerus was not fixed to the head in any of the cases. All of these cases had a minimum follow-up of at least 6 months. The results were evaluated using the Constant -Murley Shoulder score. 1 out of 11 cases had to be converted to hemi-arthroplasty due to secondary redisplacement of the fracture. The remaining 10 cases showed good bony union although the greater tuberosity in 2 cases showed a residual superior displacement of 3mm and a residual valgus displacement in 2 out of 7 cases. There were no complications of avascular necrosis in any of the cases. Clinically, compared to the uninjured side the average constant score was 93.7% (range- 68.7% – 100%). 7 patients were very satisfied and 4 were satisfied with the operation. Percutaneous minimal fixation achieves good to very good functional outcome comparable to the conventional methods and theoretically reduces the incidence of infection, avascular necrosis and neurological complications

Many operations have been recommended to treat Pars Interarticularis fractures that have separated and are persistently symptomatic, but little other than conservative treatment has been recommended for symptomatic incomplete fractures. 10 consecutive patients aged 15–28 [mean 21.7 years] were treated operatively between 2010–2014. All but one were either professional athletes [3 cricketers, 2 athletics, 1 soccer] or academy cricketers [3 patients]. 8 patients had unilateral fractures, and two had bilateral fractures at the same level. The duration of pre-operative pain and disability with exercise ranged from 4–24 months [mean 15.4 months]. The operation consists of a percutaneous compression screw inserted through a 1.5cm midline skin incision under fluoroscopic guidance: 6 cases were also checked with the O-arm intra-operatively. Post-operation the patients were mobilised with a simple corset and discharged the following day with a customised rehabilitation program. All 12 fractures in 10 patients healed as demonstrated on post-operative CT scans at between 3–6 months. One patient had the screw revised at 24 hours for an asymptomatic breach, and one patient developed a halo around the fracture site without screw loosening, and had a successful revision operation to remove the screw and graft the pars from the screw channel. All patients achieved a full return to asymptomatic activity, within a timescale of 4–12 months post-surgery, depending on the sport. Athletes that have persistent symptoms from incomplete pars interarticularis fractures should consider percutaneous fixation rather than undergoing prolonged or repeated periods of rest

Background: Tibial plateau fractures are common injuries which often produce major disability. Open reduction and internal fixation of these fractures has a significant complication rate and numerous recent reports have a tendency to avoid open plating in favour of a variety of limited surgical approaches and percutaneous techniques usually in association with external fixation. Patients and Methods: The technique of closed manipulation, indirect reduction and percutaneous screw fixation was attempted in 29 displaced tibial plateau fractures (Schatzker types I – IV) in 29 patients. Closed, indirect reduction was successful in only 25 fractures (86.2%); and the remaining four cases were excluded from the study. Patients` age ranged from 19 – 62 years (average 41 y.). Of the 25 fractures, 4 (16%) were open; type I or II Gustilo Anderson classification. Additional mini incision to raise a depressed articular fragment and to apply a bone graft was needed in 12 fractures (48%). Post operative cast or brace was applied for 3–5 weeks. Full weight bearing was started 8–12 weeks postoperatively. Results: Anatomical reduction was achieved in 20 fractures (80%), and the remaining 5 (20%) were showing grade I residual step or gap formation. Bone healing was achieved in all cases (100 %); and occurred in 8 – 12 weeks (average 9.4 w.) Patients were followed for 24 – 37 months with an average of 30 months. According to the HSS knee score; there were 9 excellent (36%), 13 good (52%), and 3 fair (12%) final end results. According to the Iowa Knee Score there were 14 excellent (56%), 9 good (36%), and 2 fair (8%) final end results. Of these 25 patients, 76% (19 patients) were satisfied; and 24% (6 patients) were not satisfied by the final end result. There were no cases of loss of reduction, wound infection, or cases with poor final clinical outcome. Conclusion: Indirect technique of reduction combined with percutaneous screw fixation could effectively reduce most displaced unicondylar tibial plateau fractures (Schatzker types I – IV) and is associated with good final outcome, with few reported complications

Purpose of the study: Nonunion is a common complication of carpal scaphoid fractures. Incidence is 10% of all fracture types. No one technique has proven totally superior for the treatment of grade IIa and IIb nonunion of the carpal scaphoid (Alnot classification). In this study, we evaluated the contribution of percutaneous screw fixation for the treatment of these nonunions. Material and methods: Our series included 26 patients with grade IIa (n=14) or IIb (n=12) nonunions. Outcome was assessed according to the clinical impact of the screw fixation and globally using the Quick DASH function score for the upper limb. Bone healing was assessed radiographically. Results: Good outcome was good in 81% of the patients (93% for grade IIa and 68% for IIb) with the screw fixation, a healing rate similar to that obtained with classical techniques. Discussion: Percutaneous screw fixation has the advantage of a mini-invasive approach and limits the risk of iatrogenic complications. It should thus be more widely used for the management of carpal scaphoid nonunions

This study of 10 consecutive patients analysed the benefit of percutaneous scaphoid fixation in minimally or non-displaced scaphoid fractures, looking at time to union, range of movement and strength. In all but one patient, who had an associated distal radius fracture, early mobilisation was the goal. Fixation was by canulated compression screw in all cases. Clinical and radiological union took place in a mean time of 7 weeks. Mobilisation was possible from 2 weeks postoperatively in nine of the 10 patients. By the time of union, there was minimal loss of mobility. Patient satisfaction was high. There was no need for prolonged immobilisation in a cast

This study aims to compare the outcomes of Volar locking plating (VLP) versus percutaneous Kirschner wires (K-wire) fixation for surgical management of distal radius fractures.

We systematically searched multiple databases, including MEDLINE for randomized controlled trials (RCTs) comparing outcomes of VLP fixation and K-wire for treatment of distal radius fracture in adults. The methodological quality of each study was assessed by the Cochrane Risk of Bias tool. Patient-reported outcomes, functional outcomes, and complications at 1 year follow up were evaluated. Meta-analysis was performed using random-effects models and results presented as risk ratios (RRs) or mean differences (MDs) with 95% confidence interval (CI).

13 RCTs with 1336 participants met the inclusion criteria. Disabilities of the Arm, Shoulder and Hand (DASH) scores were significantly better for VLP fixation (MD= 2.15; 95% CI, 0.56-3.74; P = 0.01; I2=23%). No significant difference between the two procedures for grip strength measured in kilograms (MD= −3.84; 95% CI,-8.42-0.74; P = 0.10; I2=52%) and Patient-Rated Wrist Evaluation (PRWE) scores (MD= −0.06; 95% CI,-0.87-0.75; P = 0.89; I2=0%). K-wire treatment yielded significantly improved extension (MD= −4.30; P=0.04) but with no differences in flexion, pronation, supination, and radial deviation (P >0.05). The risk of complications and rate of reoperation were similar for the two procedures (P >0.05).

This meta-analysis suggests that VLP fixation improves DASH score at 12 months follow up, however, the difference is small and unlikely to be clinically important. Existing literature does not provide sufficient evidence to demonstrate the superiority of either VLP or K-wire treatment in terms of patient-reported outcomes, functional outcomes, and complications.

Purpose. Primary internal fixation of uncomplicated scaphoid fractures offers many advantages compared to conventional casting. However, ideal fixation placement along the central scaphoid axis can be challenging, especially if the procedure is performed percutaneously. Because of the lack of direct visualization, percutaneous procedures demand liberal use of imaging, thereby increasing exposure to harmful radiation. It has been demonstrated that computer-assisted navigation can improve the accuracy of guidewire placement and reduce X-ray exposure in procedures such as hip fracture fixation. Adapting the conventional computer-assist paradigm, with preoperative imaging and intraoperative registration, to scaphoid fixation is not straightforward, and thus a novel tactic must be conceived. Method. Our navigation procedure made use of a flatpanel C-arm (Innova, GE Healthcare) to obtain a 3D cone-beam CT (CBCT) scan of the wrist from which volumetrically-rendered images were created. The relationship between the Innova imager and an optical tracking system (OptoTrak Certus, Northern Digital Inc.) was calibrated preoperatively so that an intraoperatively-acquired image could be used for real-time navigation. Optical markers fitted to a drill guide were used to track its orientation, which was displayed on a computer monitor relative to the wrist images for navigation. Randomized trials were conducted comparing our 3D navigated technique to two alternatives: one using a standard portable C-arm, and the other using the Innova flatpanel C-arm with 2D views and image intensification. A model forearm with an exchangeable scaphoid was constructed to provide consistency between the trials. The surgical objective was to insert a K-wire along the central axis of a model scaphoid. An exposure meter placed adjacent to the wrist model was used to record X-ray exposure. Procedure time and drill passes were also noted. CT scans of the drilled scaphoids were used to determine the shortest distance from the drill path to the scaphoid surface. Results. The closest distance from the drill path to the scaphoid surface was significantly larger using navigation compared to the 2D Innova method (p<0.05). Fewer drill passes were required using navigation compared to a conventional C-arm (p<0.01). Navigated procedures were significantly longer, although the overall time remained clinically acceptable (∼4min). There was no significant difference in radiation exposure to the patient between the three methods. The 3D CBCT image was acquired remotely in the navigated approach, so conceivably the exposure to the surgeon was much less than the other techniques. Conclusion. Computer-assisted navigation was successfully adapted to percutaneous scaphoid fixation without requiring the tedious preoperative imaging and intraoperative registration that typically plague these procedures. Navigation resulted in superior central screw placement with fewer drilling attempts in comparison to conventional techniques