OBJECTIVE: To Investigate the value of 3D printed guide-assisted percutaneous management of minimally displaced scaphoid waist fractures(Herbert\'s B2) with delayed diagnosis or presentation.
METHODS: From October 2018 to February 2022, 10 patients with established delayed diagnoses and presentation of minimally displaced scaphoid waist fractures were treated with 3D printed guides assisted with percutaneous internal fixation without bone grafting. This technique was based on the patient\'s preoperative CT and imported into the software. Based on Boolean subtraction, the most centralized screw placement position was identified and a customized guide was produced. Intraoperative percutaneous insertion of the guide wire was assisted by the custom guide.
RESULTS: All 10 patients were successful in one attempt. The fractures healed at a mean of 7.7 weeks postoperatively (range 6-10 weeks). At a mean follow-up of 7.7 months (6-13 months), patients had excellent recovery of wrist function with minimal pain reduction. There were no major postoperative complications and the patients all returned to their previous activities before the injury.
CONCLUSIONS: Percutaneous internal fixation based on 3D printed guides is a safe and effective technique for delayed diagnosis or presentation of patients with minimally displaced fractures of the scaphoid waist. This method allows for easy insertion of screws and avoids multiple attempts.

OBJECTIVE: To compare the robotic-assisted and the traditional freehand percutaneous scaphoid fixation in number of guidewire attempts, duration of fluoroscopy time, amount of radiation dose, and screw centrality.
METHODS: Twenty cadaveric specimens were randomized into either the robotic or freehand group. The scaphoids in both groups were fixed by either the same attending or resident from our hand surgery department. The operation duration, amount of radiation from intraoperative fluoroscopy, total fluoroscopy time, and the number of guidewire attempts were documented and compared. Postoperatively, all the specimens had a computed tomography (CT) scan performed, and the difference in the final position of the screw and the central axis of the scaphoid was examined.
RESULTS: In the robotic group, all the guide wires were satisfactorily positioned within a single attempt, while the median number of attempts in the traditional freehand group was 18 (quaternion 14-65). This also meant that the surgeon in the robotic group experienced significantly lower radiation exposure dose and time as compared to the freehand group. There were no significant differences in the final screw position as compared to the central axis of the scaphoid in both groups. Although there was no difference in surgeon performance in the robotic group, the operative time for the attending was significantly lower as compared to the resident in the freehand group.
CONCLUSIONS: Robotic-assisted surgery for scaphoid fracture fixation is superior to the traditional freehand method as it facilitates accurate screw placement with lower radiation exposure and fewer guide wire attempts.

BACKGROUND: The treatment of unstable scaphoid fracture and nonunion remains a challenging problem for hand surgeons. Minimally invasive treatment has become the preferred method of treatment.
OBJECTIVE: This study introduces the arthroscopic technique with two headless compression screws (HCS) fixation and distal radius bone grafting for the treatment of unstable scaphoid fracture and nonunion, aiming to evaluate its clinical and radiological outcomes.
METHODS: It was a retrospective study. From January 2019 to February 2021, a total of 23 patients were included in the current study. Among them, 13 patients with unstable scaphoid fracture underwent arthroscopic treatment with two HCS; 10 patients with scaphoid nonunion underwent arthroscopic treatment with two HCS and a distal radius bone graft. The range of motion of the wrist, visual analog scale (VAS), grip strength, the Modified Mayo Wrist Score (MMWS), the Patient-Rated Wrist Evaluation (PRWE) score, and the Disability of the Arm, Shoulder and Hand (DASH) score were collected at preoperatively and the final follow-up. A computed tomography scan of the wrist was performed on each patient to analyze for union and postoperative osteoarthritis during the follow-up period.
RESULTS: Significant improvement was only observed in wrist extension. Clinical outcomes including grip strength, VAS pain score, MMWS, PRWE score, and DASH score were significantly improved at the final follow-up. In the subgroup analysis, both patients stabilized with either two HCS or a distal radius bone graft and two HCS have improved clinical outcomes after surgery, respectively. All patients achieved union. No screw fixation failure occurred, and no other postoperative complication was observed in any of the patients.
CONCLUSIONS: The arthroscopic technique with two-HCS fixation and distal radius bone grafting is a reliable and effective technique for the treatment of unstable scaphoid fracture and nonunion, providing satisfactory union rates and clinical outcomes.

This study aimed to explore the feasibility and efficacy of percutaneous fixation of minimally displaced scaphoid waist fractures using a 3-dimensional-printed guide in 10 cases.
Fractures were examined using preoperative computed tomography. The skin interface and bone models were reconstructed using computed tomography data. Guidewire insertion was assisted by a guide. Computed tomography was performed 4-6 weeks after surgery until healing of the fracture was confirmed. The mean follow-up period was 7 months (range, 6-9 months). The fracture healing time, grip strength, flexion-extension arc, patient-rated wrist evaluation, and Mayo wrist score were recorded.
A total of 6 hands were in the dominant limb. The mean operation time was 41 minutes (range, 32-70 minutes). Three (30%) scaphoids healed at 6 weeks after surgery, 8 (80%) scaphoids healed at 8 weeks after surgery, and 100% scaphoids healed at 12 weeks after surgery. After correcting for hand dominance, the mean grip strength was 84% (range, 71% to 95%) of that of the contralateral side. The flexion-extension arc was 97% (range, 82% to 100%) of that of the contralateral side. The mean Mayo wrist score was 95 (range, 85-100), and pain decreased to minimal levels. All patients returned to their preinjury activities.
Three-dimensional printing is an effective and feasible technology that can help guide intraoperative processes.
Therapeutic V.

OBJECTIVE: Scaphoid fracture was the most common carpal fracture and the most challenging. The purpose of this study was to investigate and compare the clinical effects of closed reduction and percutaneous cannulated screw internal fixation under fluoroscopy and arthroscopy-assisted percutaneous cannulated screw internal fixation in the treatment of Herbert B2-type of acute scaphoid fractures.
METHODS: A retrospective controlled study was conducted on 29 patients with Herbert B2-type acute scaphoid fracture with a displacement of >1 mm admitted to our hospital from January 2017 to June 2021. Patients were divided into two groups, 11 patients were treated with closed reduction percutaneous cannulated screw internal fixation under fluoroscopy and 18 patients were treated with percutaneous cannulated screw internal fixation assisted by arthroscopy. The operative time, intraoperative fluoroscopy times, fracture healing time, complications, and postoperative wrist function score of the two groups were compared.
RESULTS: All patients were followed up for 6-18 months (mean follow-up duration: 10.38 ± 2.69 months). The respective operation times in the arthroscopy group and fluoroscopy group was 51.50 ± 6.69 min and 56.73 ± 11.48 min, respectively (p > 0.05). The number of fluoroscopies performed in the arthroscopy group was (6.83 ± 1.30), which was less than that in the fluoroscopy group (10.91 ± 2.62) (p < 0.05). All fractures in the arthroscopy group healed after the operation, and the fracture healing time was 11.44 ± 1.25W. Ten patients in the fluoroscopy group healed. The fracture healing time was 13.60 ± 2.32 W. The fracture healing time in arthroscopy group was less than that in the fluoroscopy group (p < 0.05). One patient in the fluoroscopy group had nonunion and healed after bone grafting and internal fixation. At the postoperative 6-month follow-up, the modified Mayo wrist function score was used to evaluate the clinical results. The wrist function score of patients in the arthroscopy group was 90 (85, 95), which was >80 (80, 90) in the fluoroscopy group (z = 2.74, p < 0.05).
CONCLUSIONS: For Herbert B2-type acute scaphoid fracture with fracture displacement > 1 mm, the arthroscopy-assisted percutaneous cannulated screw internal fixation has less fluoroscopy times, short fracture healing time, and good recovery effect of wrist function compared to the fluoroscopy.

We compared robotic-assisted scaphoid screw fixation to conventional technique in terms of accuracy, surgical times, radiation exposure, and clinical outcomes, including range of motion, grip strength, functional score, and complications.
This study was a registered, prospective, randomized, controlled trial. From May 2019 to December 2019, 1 surgeon performed 18 robotic-assisted and 18 conventional scaphoid screw fixations and these patients were eligible for participation in this study. Surgical time, including the time of the overall procedure, set-up time, and time for ideal guidewire placement, was recorded. The number of guidewire attempts also was recorded. All patients were evaluated clinically and radiographically at follow-up with respect to the severity of pain, wrist motion, grip strength, complications, and Mayo modified wrist score.
The average set-up time and overall time of the procedure were longer in the robotic-assisted than in the conventional groups, while the mean guidewire insertion time and the mean guidewire attempts was less in the robotic-assisted group than that of the conventional group. The overall radiation exposure was lower in the robotic group.
Robotic-assisted technique provided a useful tool to improve implantation accuracy and shorten radiation exposure. Additional cost and prolonged duration of surgery without evidence of improved clinical scores may limit widespread acceptance of this technique.
Therapeutic II.

This study aimed to develop and evaluate a convolutional neural network for identifying scaphoid fractures on radiographs. A dataset of 1918 wrist radiographs (600 patients) was taken from an orthopaedic referral centre between 2010 to 2020. A YOLOv3 and a MobileNetV3 convolutional neural network were trained for scaphoid detection and fracture classification, respectively. The diagnostic performance of the convolutional neural network was compared with the majority decision of four hand surgeons. The convolutional neural network achieved a sensitivity of 82% and specificity of 94%, with an area under the receiver operating characteristic of 92%, whereas the surgeons achieved a sensitivity of 76% and specificity of 96%. The comparison indicated that the convolutional neural network\'s performance was similar to the majority vote of surgeons. It further revealed that convolutional neural network could be used in identifying scaphoid fractures on radiographs reliably, and has potential to achieve the expert-level performance.Level of evidence: III.

OBJECTIVE: Studies exploring the epidemiological characteristics of scaphoid fracture nonunion are important to understand the causes and lead to effective prevention strategy. However, such knowledge is limited especially in China. This study aims to reveal the clinical and epidemiological features of scaphoid fracture nonunion in Chinese patients.
METHODS: This was a retrospective study, which was based on patients with scaphoid fracture nonunion treated in a Chinese national orthopedic referral center from 1 August 2009 to 1 August 2020. The basic demographic and clinical characteristics, including gender, age at diagnosis of scaphoid fracture nonunion, dominant hand, the location of fracture, the side, the causes of the injury, age of the injury, age of the treatment for scaphoid fracture nonunion, and the delay period, were retrieved from the medical records. The patients were divided into a non-delay group and a delay group based on whether they had visited the doctor within 1 month after the injury. Scaphoid fracture was classified into the proximal, waist, and distal fractures according to the location. The t-test or Mann-Whitney U test was used to compare the difference between groups when the dependent variable is continuous, while a chi-square test was used when the dependent variable is categorical.
RESULTS: A total of 363 patients were included in this study. The mean age at the diagnosis of scaphoid fracture nonunion was 32 (ranging from 14 to 78). Waist fracture nonunion (76.5%) was most common. Among the 169 patients who sought medical care within 1 month after the injury (non-delay group), more than half (90 cases) were misdiagnosed. 23 cases could not recall the injury, so the time of delay could not be determined. Among the 171 patients who did not seek medical care for acute injury (delay group), the average time was 52 months between the initial injury and the treatment. The proportion of waist nonunions was higher among patients in the delay group than that in the non-delay group.
CONCLUSIONS: Nonunion of scaphoid fracture is caused mainly by delayed treatment and misdiagnosis in China, suggesting that timely treatment and improved diagnosis could lower the prevalence. The fracture location may be a factor contributing to the delaying of seeking medical care.

The purpose of this study was to assess the efficiency, safety, and accuracy of cannulated screw fixation using a robot-assisted method compared with a traditional percutaneous freehand method.
This retrospective clinical study included 18 patients with scaphoid fracture who underwent cannulated screw fixation by robot-assisted technique or traditional percutaneous freehand technique from June 2018 to June 2020. All patients were divided into the robot-assisted group (9 patients) or the traditional surgery group (9 patients). The operation time, blood loss, number of intra-operative fluoroscopies, fracture healing time, Mayo wrist function score, and screw implantation accuracy were recorded in the two groups.
The average age of the robot-assisted group was 37.9 ± 10.6 years (with a range of 30 to 52 years), there were eight males and one female, and there were six cases of scaphoid fracture on the right side and three on the left side. The average pre-operative time was 2.8 ± 0.7 days (ranging from 1 to 3 days). The average age of the traditional surgery group was 31.6 ± 6.8 years (with a range of 20 to 45 years), there were eight males and one female, and there were five cases of scaphoid fracture on the right side and four on the left side. The average pre-operative time was 2.1 ± 0.8 days (with a range of 2 to 4 days). The number of intra-operative fluoroscopies was 24.4 ± 3.5 in the traditional surgery group, whereas it was only 10.1 ± 1.9 in the robot-assisted group, which was significantly lower (P < 0.05). The average operation time of the traditional operation group was 48.4 ± 12.2 min, and that of the robot-assisted group was 32.6 ± 4.2 minutes, which was significantly shorter (P < 0.05). The angles between the actual screw position and the central axis of the scaphoid on both the coronal and sagittal post-operative CT images were 8.3° ± 2.3° and 8.8° ± 1.6° for the traditional operation group and 3.8° ± 0.8° and 4.3° ± 1.2° for the robot-assisted group, so the accuracy of the robot-assisted group was significantly higher (P < 0.05). There were no significant differences between the two groups in wrist function recovery or fracture healing time.
Robot-assisted treatment of scaphoid fracture is more accurate than traditional freehand technology, with shorter operation time and fewer intra-operative fluoroscopies. There is no difference between the two surgical techniques in intra-operative bleeding, post-operative fracture healing, or functional recovery. Robot-assisted surgery is a safe, effective, and accurate method for treating scaphoid fracture.

Seven aspects of the management of acute scaphoid fractures are open to debate: Diagnosis of true fractures among suspected fractures, assessment of fracture displacement, cast immobilization strategies, the role of surgical fixation, proximal pole fractures, assessment of union, and the underlying objective of treatment. We reviewed current evidence, and our varied interpretations of it, to highlight areas of uncertainty where more evidence might be helpful.