Aims. This study aims to report the outcomes in the treatment of unstable proximal third scaphoid nonunions with arthroscopic curettage, non-vascularized bone grafting, and percutaneous fixation. Methods. This was a retrospective analysis of 20 patients. All cases were delayed presentations (n = 15) or failed nonoperatively managed scaphoid fractures (n = 5). Surgery was performed at a mean duration of 27 months (7 to 120) following injury with arthroscopic debridement and arthroscopic iliac crest autograft. Fracture fixation was performed percutaneously with Kirschner (K)-wires in 12 wrists, a headless screw in six, and a combination of a headless screw and single K-wire in two. Clinical outcomes were assessed using grip strength, patient-reported outcome measures, and wrist range of motion (ROM) measurements. Results. Intraoperatively, established avascular necrosis of the proximal fragment was identified in ten scaphoids. All fractures united within 16 weeks, confirmed by CT. At a mean follow-up of 31 months (12 to 64), there were significant improvements in the Patient-Rated Wrist Evaluation, Mayo Wrist Score, abbreviated Disabilities of the Arm, Shoulder and Hand score, wrist ROM, grip strength, and the patients’ subjective pain score. No peri- or postoperative complications were encountered. Conclusion. Our data indicate that arthroscopic bone grafting and fixation with cancellous autograft is a viable method in the treatment of proximal third scaphoid nonunions, regardless of the vascularity of the proximal fragment. Cite this article: Bone Joint J 2022;104-B(8):946–952

Abstract. Background. Scaphoid non-union can result in pain, altered wrist kinematics leading to a Scaphoid Non-union Advance Collapse, ultimately to symptomatic radio-carpal arthritis. Open techniques have their limitations. We describe the rationale, surgical technique and outcomes of our series of arthroscopic bone-grafting (ABG) and fixation of scaphoid non-union. Methods. We performed a prospective single-surgeon series of 22 consecutive patients with clinico-radiologically established scaphoid non-union between March 2015 and April 2019. Data was collected from Electronic Patient Records, Patient Archived Computer system (PACS) and hand therapy assessments. We collected demographic data including age, hand-dominance, occupation and mechanism of injury. The Disabilities of the Arm, Shoulder and Hand Score (Quick DASH), Mayo wrist score, Patient Rated Wrist Evaluation (PRWE) and grip-strength measurements were collected preoperatively and at follow-up appointments. Results. There was an improvement in all outcome measures when comparing preoperative and postoperative results. The Quick DASH score improved by a mean of 24 points, Mayo wrist and PRWE scores improved by 15.1 and 29.7 points, respectively. Grip-strength analysis also improved by 6.1 kgf (Right) and 3.3kgf (Left). Follow-up computerised tomography scans revealed union in 18/22 patients with 2 patients lost to follow-up. One patient required revision ABG procedure to achieve union. Conclusion. Arthroscopic bone grafting and fixation of scaphoid non-union allows a minimally invasive method of managing these injuries. It has advantages of minimal morbidity and accurate articular reduction resulting in less postoperative stiffness and increased functional outcomes. It is an effective alternative to conventional open treatment of established scaphoid non-union

Scaphoid non-union results the typical humpback deformity, pronation of the distal fragment, and a bone defect in the non-union site with shortening. Bone grafting, whether open or arthroscopic, relies on fluoroscopic and direct visual assessment of reduction. However, because of the bone defect and irregular geometry, it is difficult to determine the precise width of the bone gap and restore the original bone length, and to correct interfragmentary rotation. Correction of alignment can be performed by computer-assisted planning and intraoperative guidance. The use of computer navigation in guiding reduction in scaphoid non-unions and displaced fractures has not been reported. Objective. We propose a method of anatomical reconstruction in scaphoid non-union by computer-assisted preoperative planning combined with intraoperative computer navigation. This could be done in conjunction with a minimally invasive, arthroscopic bone grafting technique. Methods. A model consisting of a scaphoid bone with a simulated fracture, a forearm model, and an attached patient tracker was used. 2 titanium K-wires were inserted into the distal scaphoid fragment. 3D images were acquired and matched to those from a computed tomography (CT) scan. In an image processing software, the non-union was reduced and pin tracts were planned into the proximal fragment. The K-wires were driven into the proximal fragment under computer navigation. Reduction was assessed by direct measurement. These steps were repeated in a cadaveric upper limb. A scaphoid fracture was created and a patient tracker was inserted into the radial shaft. A post-fixation CT was obtained to assess reduction. Results and Discussion. In both models, satisfactory alignment was obtained. There were minimal displacement and articular stepping, and scaphoid length was restored with less than 1mm discrepancy. This study demonstrated that an accurate reduction of the scaphoid in non-unions and displaced fractures can be accurately performed using computed navigation and computer-assisted planning. It is the first report on the use of computer navigation in correction of alignment in the wrist

Treatment of tibial plateau fractures Schatzker type V and VI or with soft tissues injuries is still remains under discussion. The purpose of this study is to evaluate the results of treatment with circular frame and closed reduction in 25 patients (15 males and 10 females) with tibial plateau fractures, with a mean age of 42 years old (20 – 76 years). Five fractures were classified as Schatzker type II and III and 20 as type V and VI. Reduction was obtained in 22 cases under foot traction and in 3 arthroscopically. Bone grafts inserted through a hole (• 1 cm) in the inner cortex of the tibia metaphysis under fluoroscopy. Eight unstable knees needed bridging the joint for 4 weeks. In 2 cases a cannulated interfragmentary screw was used. Full weight bearing was allowed 3 months after injury when the device was removed. Follow up ranged from 1 to 10 years (mean 5 years). All fractures were united and there was no infection. Full range of the knee motion was achieved in 23 patients while 2 needed an open arthrolysis. There were 2 malunions which were treated with one valgus osteotomy and one TKR. Asymptomatic arthritis appeared in 6 patients. According to Knee Society Score (KSS) the results were classified as excellent in 12, good in 8, fair in 3 and poor in 2 patients. Circular frames are a satisfactory alternative method for the treatment of tibial plateau fractures either in severe soft tissues injuries or in very complex cases

Autologous chondrocyte implantation (ACI) is a technique used for the treatment of symptomatic osteochondral defects of the knee. A variation of the original periosteum membrane technique is the matrix-induced autologous chondrocyte implantation (MACI) technique. The MACI membrane consists of a porcine type-I/III collagen bilayer seeded with chondrocytes. Osteochondral defects deeper than 8 to 10 mm usually require bone grafting either before or at the time of transplantation of cartilage. We have used a variation of Peterson’s ACI-periosteum sandwich technique using two MACI membranes with bone graft which avoids periosteal harvesting. The procedure is suture-free and requires less operating time and surgical exposure. We performed this MACI-sandwich technique on eight patients, five of whom were assessed at six months and one year post-operatively using the modified Cincinnati knee, the Stanmore functional rating and the visual analogue pain scores.

All patients improved within six months with further improvement at one year. The clinical outcome was good or excellent in four after six months and one year. No significant graft-associated complications were observed. Our early results of the MACI-sandwich technique are encouraging although larger medium-term studies are required before there is widespread adoption of the technique.