Top

Archives of Orthopaedic and Trauma Surgery

Published in:

01-02-2019 | Handsurgery

Treatment of scaphoid waist nonunion by one, two headless compression screws or plate with or without additional extracorporeal shockwave therapy

Authors: S. Quadlbauer, Ch. Pezzei, T. Beer, J. Jurkowitsch, T. Keuchel, C. Schlintner, W. Schaden, T. Hausner, M. Leixnering

Published in: Archives of Orthopaedic and Trauma Surgery | Issue 2/2019

Abstract

Introduction

Scaphoid nonunion remains challenging for hand surgeons. Several treatment options are available such as: non-vascularized or vascularized bone grafting, with or without additional stabilization. In the last few decades, extracorporeal shockwave therapy (ESWT) has become an established procedure for treating delayed and nonunions. Purpose of this retrospective follow-up study was (a) to investigate union rate and clinical outcome of the different implants [either one/two headless compression screws (HCS) or a plate] and (b) union rate and clinical outcome using only surgery, or a combination of surgery and ESWT.

Materials and methods

The study included 42 patients with scaphoid nonunions of the waist with a mean follow-up of 52 months. All patients received a non-vascularized bone graft from the iliac crest and stabilization was achieved by using one, two HCS or a plate. ESWT was performed with 3000 impulses, energy flux density per pulse 0.41 mJ/mm² within 2 weeks after surgery. Clinical assessment included range of motion (ROM), pain according to the Visual Analog Scale (VAS), grip strength, Disability of the Arm Shoulder and Hand Score, Patient-Rated Wrist Evaluation Score, Michigan Hand Outcomes Questionnaire and modified Green O’Brien (Mayo) Wrist Score. In addition, each patient had a CT scan of the wrist.

Results

A total of 33/42 (79%) patients showed union at the follow-up investigation. Patients treated with additional ESWT showed bony healing in 21/26 (81%) and without ESWT in 12/16 (75%). Patients that were stabilized using one HCS showed bony healing in 6/10 (60%), with two HCS 10/12 (83%) and by plate 17/20 (85%). The ESWT group had a significantly lower pain score according to the VAS and better modified Green O’Brien (Mayo) Score. No differences could be found in respect of ROM, grip strength, functional outcome score depending of which stabilization method was used.

Conclusions

Stabilization of scaphoid waist nonunions with two HCS or plate showed higher union rates than a stabilization using only one HCS. In addition, ESWT combined with a nonvascularized bone graft from the iliac crest seems a suitable option for treating scaphoid nonunions.

Duckworth AD, Jenkins PJ, Aitken SA et al (2012) Scaphoid fracture epidemiology. J Trauma Acute Care Surg 72:1. https://doi.org/10.1097/TA.0b013e31822458e8 CrossRef

Hove LM (1999) Epidemiology of scaphoid fractures in Bergen, Norway. Scand J Plast Reconstr Surg Hand Surg 33:423–426. https://doi.org/10.1080/02844319950159145 CrossRefPubMed

Schmidle G, Ebner HL, Klauser AS et al (2018) Correlation of CT imaging and histology to guide bone graft selection in scaphoid non-union surgery. Arch Orthop Trauma Surg. 1–11

Mallee WH, Mellema JJ, Guitton TG et al (2016) 6-week radiographs unsuitable for diagnosis of suspected scaphoid fractures. Arch Orthop Trauma Surg 136:771–778. https://doi.org/10.1007/s00402-016-2438-4 CrossRefPubMedPubMedCentral

Rein S, Hanisch U, Rammelt S et al (2010) Histopathological, radiological and clinical aspects of the temporal assignment of scaphoid non-union. Arch Orthop Trauma Surg 130:1243–1250. https://doi.org/10.1007/s00402-009-1010-x CrossRefPubMed

Kahl T, Razny FK, Benter JP et al (2016) Diagnosis of the scaphoid bone: fractures, nonunion, circulation, perfusion. Orthopade 45:938–944. https://doi.org/10.1007/s00132-016-3333-y CrossRefPubMed

Schädel-Höpfner M, Bickert B, Dumont C et al (2016) Acute scaphoid fractures: Management under consideration of the new S3-level guideline. Orthopade 45:945–950. https://doi.org/10.1007/s00132-016-3336-8 CrossRefPubMed

Cooney WP, Dobyns JH, Linscheid RL (1980) Fractures of the scaphoid: a rational approach to management. Clin Orthop Relat Res 149: 90–97

Dias JJ, Brenkel IJ, Finlay DB (1989) Patterns of union in fractures of the waist of the scaphoid. Bone Joint J 71–B:307–310

10.

Muramatsu K, Doi K, Kuwata N et al (2002) Scaphoid fracture in the young athlete–therapeutic outcome of internal fixation using the Herbert screw. Arch Orthop Trauma Surg 122:510–513. https://doi.org/10.1007/s00402-002-0417-4 CrossRefPubMed

11.

Neshkova IS, Jakubietz RG, Kuk D et al (2015) [Percutaneous screw fixation of non- or minimally displaced scaphoid fractures]. Oper Orthop Traumatol 27:448–454. https://doi.org/10.1007/s00064-014-0325-0 CrossRefPubMed

12.

Langer MF, Oeckenpöhler S, Breiter S et al (2016) Anatomy and biomechanics of the scaphoid. Orthopade 45:926–937. https://doi.org/10.1007/s00132-016-3339-5 CrossRefPubMed

13.

Buijze GA, Ochtman L, Ring D (2012) Management of scaphoid nonunion. J Hand Surg Am 37:1095–1100. https://doi.org/10.1016/j.jhsa.2012.03.002 CrossRefPubMed

14.

Pao VS, Chang J (2003) Scaphoid nonunion: diagnosis and treatment. Plast Reconstr Surg 112:1666–1669CrossRefPubMed

15.

Griffis CE, Olsen C, Nesti L et al (2017) Validity of computed tomography in predicting scaphoid screw prominence: a cadaveric study. Arch Orthop Trauma Surg 137:573–577. https://doi.org/10.1007/s00402-017-2658-2 CrossRefPubMed

16.

Quadlbauer S, Pezzei C, Jurkowitsch J et al (2017) Spontaneous radioscapholunate fusion after septic arthritis of the wrist: a case report. Arch Orthop Trauma Surg 137:579–584. https://doi.org/10.1007/s00402-017-2659-1 CrossRefPubMed

17.

Leixnering M, Pezzei C, Weninger P et al (2011) First experiences with a new adjustable plate for osteosynthesis of scaphoid nonunions. J Trauma Inj Infect Crit Care 71:933–938. https://doi.org/10.1097/TA.0b013e3181f65721 CrossRef

18.

Kawamura K, Chung KC (2008) Treatment of scaphoid fractures and nonunions. J Hand Surg Am 33:988–997CrossRefPubMedPubMedCentral

19.

Hannemann PFW, Brouwers L, Dullaert K et al (2015) Determining scaphoid waist fracture union by conventional radiographic examination: an analysis of reliability and validity. Arch Orthop Trauma Surg 135:291–296. https://doi.org/10.1007/s00402-014-2147-9 CrossRefPubMed

20.

Meszaros T, Vögelin E, Mathys L, Leclère FM (2018) Perilunate fracture-dislocations: clinical and radiological results of 21 cases. Arch Orthop Trauma Surg 138:287–297. https://doi.org/10.1007/s00402-017-2861-1 CrossRefPubMed

21.

Roh YH, Noh JH, Lee BK et al (2014) Reliability and validity of carpal alignment measurements in evaluating deformities of scaphoid fractures. Arch Orthop Trauma Surg 134:887–893. https://doi.org/10.1007/s00402-014-1998-4 CrossRefPubMed

22.

Ender HG (1977) A new method of treating traumatic cysts and pseudoarthrosis of the scaphoid (author’s transl). Unfallheilkunde 80:509–513PubMed

23.

Stankovic P, Burchhardt H (1993) Experience with the Ender hooked plate in the management of 42 scaphoid pseudarthroses. HandchirMikrochir Plast Chir 25:217–222

24.

Huene DR, Huene DS (1991) Treatment of nonunions of the scaphoid with the Ender compression blade plate system. J Hand Surg Am 16:913–922. https://doi.org/10.1016/S0363-5023(10)80160-1 CrossRefPubMed

25.

Birnbaum K, Wirtz DC, Siebert CH, Heller KD (2002) Use of extracorporeal shock-wave therapy (ESWT) in the treatment of non-unions. a review of the literature. Arch Orthop Trauma Surg 122:324–330. https://doi.org/10.1007/s00402-001-0365-4 CrossRefPubMed

26.

Wang CJ (2012) Extracorporeal shockwave therapy in musculoskeletal disorders. J Orthop Surg Res 7:11. https://doi.org/10.1186/1749-799X-7-11 CrossRefPubMedPubMedCentral

27.

Schaden W, Fischer A, Sailler A (2001) Extracorporeal shock wave therapy of nonunion or delayed osseous union. Clin Orthop Relat Res 387:90–94. https://doi.org/10.1097/00003086-200106000-00012 CrossRef

28.

Wang CJ, Liu HC, Fu TH (2007) The effects of extracorporeal shockwave on acute high-energy long bone fractures of the lower extremity. Arch Orthop Trauma Surg 127:137–142. https://doi.org/10.1007/s00402-006-0236-0 CrossRefPubMed

29.

Wang FS, Wang CJ, Sheen-Chen SM et al (2002) Superoxide mediates shock wave induction of ERK-dependent osteogenic transcription factor (CBFA1) and mesenchymal cell differentiation toward osteoprogenitors. J Biol Chem 277:10931–10937. https://doi.org/10.1074/jbc.M104587200 CrossRefPubMed

30.

Wang FS, Yang KD, Chen RF et al (2002) Extracorporeal shock wave promotes growth and differentiation of bone-marrow stromal cells towards osteoprogenitors associated with induction of TGF-β1. J Bone Jt Surg 84:457–461. https://doi.org/10.1302/0301-620X.84B3.11609 CrossRef

31.

Chen YJ, Wurtz T, Wang CJ et al (2004) Recruitment of mesenchymal stem cells and expression of TGF-β1 and VEGF in the early stage of shock wave-promoted bone regeneration of segmental defect in rats. J Orthop Res 22:526–534. https://doi.org/10.1016/j.orthres.2003.10.005 CrossRefPubMed

32.

Wang FS, Wang CJ, Chen YJ et al (2004) Ras induction of superoxide activates ERK-dependent angiogenic transcription factor HIF-1α and VEGF-A expression in shock wave-stimulated osteoblasts. J Biol Chem 279:10331–10337. https://doi.org/10.1074/jbc.M308013200 CrossRefPubMed

33.

Wang FS, Yang KD, Wang CJ et al (2004) Shockwave stimulates oxygen radical-mediated osteogenesis of the mesenchymal cells from human umbilical cord blood. J Bone Miner Res 19:973–982. https://doi.org/10.1359/JBMR.040121 CrossRefPubMed

34.

Wang CJ, Wang FS, Yang KD et al (2003) Shock wave therapy induces neovascularization at the tendon-bone junction. A study in rabbits. J Orthop Res 21:984–989. https://doi.org/10.1016/S0736-0266(03)00104-9 CrossRefPubMed

35.

Low CK, Ang BT (1999) Herbert screw fixation of scaphoid fractures. Hand Surg 04:63–66. https://doi.org/10.1142/S0218810499000022 CrossRef

36.

Herbert TJ, Fisher WE (1984) Management of the fractured scaphoid using a new bone screw. J Bone Joint Surg Br 66:114–123CrossRefPubMed

37.

Quadlbauer S, Beer T, Pezzei C et al (2017) Stabilization of scaphoid type B2 fractures with one or two headless compression screws. Arch Orthop Trauma Surg 137:1587–1595. https://doi.org/10.1007/s00402-017-2786-8 CrossRefPubMed

38.

Dodds SD, Panjabi MM, Slade JF (2006) Screw fixation of scaphoid fractures: a biomechanical assessment of screw length and screw augmentation. J Hand Surg Am 31:405–413. https://doi.org/10.1016/j.jhsa.2005.09.014 CrossRefPubMed

39.

McCallister WV, Knight J, Kaliappan R, Trumble TE (2003) Central placement of the screw in simulated fractures of the scaphoid waist: a biomechanical study. J Bone Jt Surg Ser A 85:72–77. https://doi.org/10.2106/00004623-200301000-00012 CrossRef

40.

Garcia RM, Leversedge FJ, Aldridge JM et al (2014) Scaphoid nonunions treated with 2 headless compression screws and bone grafting. J Hand Surg Am 39:1301–1307. https://doi.org/10.1016/j.jhsa.2014.02.030 CrossRefPubMed

41.

Grewal R, Frakash U, Osman S, McMurtry RY (2013) A quantitative definition of scaphoid union: determining the inter-rater reliability of two techniques. J Orthop Surg Res https://doi.org/10.1186/1749-799X-8-28 CrossRefPubMedPubMedCentral

42.

Krimmer H, Krapohl B, Sauerbier M, Hahn P (1997) Post-traumatic carpal collapse (SLAC- and SNAC-wrist)—stage classification and therapeutic possibilities. Handchir Mikrochir Plast Chir 29:228–233PubMed

43.

Bain GI, Bennett JD, MacDermid JC et al (1998) Measurement of the scaphoid humpback deformity using longitudinal computed tomography: Intra- and interobserver variability using various measurement techniques. J Hand Surg Am 23:76–81. https://doi.org/10.1016/S0363-5023(98)80093-2 CrossRefPubMed

44.

Greenspan A (2011) Orthopedic imaging: a practical approach. Lippincott Williams & Wilkins, Philadelphia

45.

Trumble TE, Gilbert M, Murray LW et al (2000) Displaced scaphoid fractures treated with open reduction and internal fixation with a cannulated screw. J Bone Joint Surg Am 82:633–641CrossRefPubMed

46.

Hudak PL, Amadio PC, Bombardier C (1996) Development of an upper extremity outcome measure: The DASH (disabilities of the arm, shoulder, and head). Am J Ind Med 29:602–608. https://doi.org/10.1002/(SICI)1097-0274(199606)29:6%3C602::AID-AJIM4%3E3.0.CO;2-L CrossRefPubMed

47.

Hemelaers L, Angst F, Drerup S et al (2008) Reliability and validity of the german version of “the patient-rated wrist evaluation (PRWE)” as an outcome measure of wrist pain and disability in patients with acute distal radius fractures. J Hand Ther 21:366–376. https://doi.org/10.1197/j.jht.2008.03.002 CrossRefPubMed

48.

Knobloch K, Kuehn M, Papst S et al (2011) German standardized translation of the michigan hand outcomes questionnaire for patient-related outcome measurement in dupuytren disease. Plast Reconstr Surg 128:39e–40e. https://doi.org/10.1097/PRS.0b013e318218fd70 CrossRefPubMed

49.

Amadio PC, Berquist TH, Smith DK et al (1989) Scaphoid malunion. J Hand Surg Am 14:679–687. https://doi.org/10.1016/0363-5023(89)90191-3 CrossRefPubMed

50.

Inoue G, Sakuma M (1996) The natural history of scaphoid non-union. Arch Orthop Trauma Surg 115:1–4. https://doi.org/10.1007/BF00453208 CrossRefPubMed

51.

Euler S, Erhart S, Deml C et al (2014) The effect of delayed treatment on clinical and radiological effects of anterior wedge grafting for non-union of scaphoid fractures. Arch Orthop Trauma Surg 134:1023–1030. https://doi.org/10.1007/s00402-014-2007-7 CrossRefPubMed

52.

Schädel-Höpfner M, Marent-Huber M, Gazyakan E et al (2010) Acute non-displaced fractures of the scaphoid: earlier return to activities after operative treatment. A controlled multicenter cohort study. Arch Orthop Trauma Surg 130:1117–1127. https://doi.org/10.1007/s00402-009-1004-8 CrossRefPubMed

53.

Arora R, Gschwentner M, Krappinger D et al (2007) Fixation of nondisplaced scaphoid fractures: making treatment cost effective. Prospective controlled trial. Arch Orthop Trauma Surg 127:39–46. https://doi.org/10.1007/s00402-006-0229-z CrossRefPubMed

54.

Spies CK, Hohendorff B, Müller LP et al (2016) Proximal carpal row carpectomy. Oper Orthop Traumatol 28:204–217. https://doi.org/10.1007/s00064-016-0440-1 CrossRefPubMed

55.

Spies C, Unglaub F (2017) (Partial) arthrodesis of the hand and wrist. Oper Orthop Traumatol 29:373. https://doi.org/10.1007/s00064-017-0518-4 CrossRefPubMed

56.

Hernekamp J-F, Kneser U, Kremer T, Bickert B (2017) Mediokarpale teilarthrodese mit winkelstabiler Plattenosteosynthese. Oper Orthop Traumatol 29:409–415. https://doi.org/10.1007/s00064-017-0514-8 CrossRefPubMed

57.

Unglaub F, Langer MF, Unglaub JM et al (2017) (Partial) fusion of the wrist: Indications and surgical procedures. Unfallchirurg 120:513–526. https://doi.org/10.1007/s00113-017-0356-8 CrossRefPubMed

58.

Citak M, O’Loughlin PF, Kendoff D et al (2010) Navigated scaphoid screw placement using customized scaphoid splint: an anatomical study. Arch Orthop Trauma Surg 130:889–895. https://doi.org/10.1007/s00402-010-1044-0 CrossRefPubMed

59.

Pinder RM, Brkljac M, Rix L et al (2015) Treatment of scaphoid nonunion: a systematic review of the existing evidence. J Hand Surg Am 40:1797–1805. https://doi.org/10.1016/j.jhsa.2015.05.003 CrossRefPubMed

60.

Adams JD, Leonard RD (1928) Fracture of the carpal scaphoid. N Engl J Med 198:401–404. https://doi.org/10.1056/NEJM192804121980803 CrossRef

61.

Whipple TL (1995) Stabilization of the fractured scaphoid under arthroscopic control. Orthop Clin North Am 26:749–754PubMed

62.

Inoue G, Shionoya K (1997) Herbert screw fixation by limited access for acute fractures of the scaphoid. J Bone Jt Surg 79:418–421. https://doi.org/10.1302/0301-620X.79B3.7254 CrossRef

63.

Munk B, Larsen CF (2004) Bone grafting the scaphoid nonunion: A systematic review of 147 publications including 5 246 cases of scaphoid nonunion. Acta Orthop Scand 75:618–629CrossRefPubMed

64.

Ghoneim A (2011) The unstable nonunited scaphoid waist fracture: Results of treatment by open reduction, anterior wedge grafting, and internal fixation by volar buttress plate. J Hand Surg Am 36:17–24. https://doi.org/10.1016/j.jhsa.2010.10.003 CrossRefPubMed

65.

Moojen TM, Snel JG, Ritt MJPF et al (2002) Scaphoid kinematics in vivo. J Hand Surg Am 27:1003–1010. https://doi.org/10.1053/jhsu.2002.36519 CrossRefPubMed

66.

Wolfe SW, Neu C, Crisco JJ (2000) In vivo scaphoid, lunate, and capitate kinematics in flexion and in extension. J Hand Surg Am 25:860–869. https://doi.org/10.1053/jhsu.2000.9423 CrossRefPubMed

67.

Jurkowitsch J, Dall’Ara E, Quadlbauer S et al (2016) Rotational stability in screw-fixed scaphoid fractures compared to plate-fixed scaphoid fractures. Arch Orthop Trauma Surg 136:1623–1628. https://doi.org/10.1007/s00402-016-2556-z CrossRefPubMed

68.

Mandaleson A, Tham SK, Lewis C et al (2017) Scaphoid fracture fixation in a nonunion model: a biomechanical study comparing 3 types of fixation. J Hand Surg Am. https://doi.org/10.1016/j.jhsa.2017.10.005 CrossRefPubMed

69.

Goodwin J, Castañeda P, Drace P, Edwards S (2017) A biomechanical comparison of screw and plate fixations for scaphoid fractures. J Wrist Surg. https://doi.org/10.1055/s-0037-1606123 CrossRefPubMedPubMedCentral

70.

Goodwin JA, Castañeda P, Shelhamer RP et al (2017) A Comparison of Plate Versus Screw Fixation for Segmental Scaphoid Fractures: A Biomechanical Study. Hand (NY). https://doi.org/10.1177/1558944717732065 CrossRefPubMedCentral

71.

Trumble TE, Clarke T, Kreder HJ (1996) Non-union of the scaphoid. Treatment with cannulated screws compared with treatment with Herbert screws. J Bone Joint Surg Am 78:1829–1837CrossRefPubMed

72.

Manske PR, McCarthy JA, Strecker WB (1988) Use of the Herbert bone screw for scaphoid nonunions. Orthopedics 11:1653–1661PubMed

73.

Stark A, Brostrom LA, Svartengren G (1987) Scaphoid nonunion treated with the Matti–Russe technique. Long-term results. Clin Orthop Relat Res. 214 175–180

74.

Nakamura R, Horii E, Watanabe K et al (1993) Scaphoid non-union: factors affecting the functional outcome of open reduction and wedge grafting with herbert screw fixation. J Hand Surg (British Eur Vol 18:219–224. https://doi.org/10.1016/0266-7681(93)90114-U CrossRef

75.

Cooney WP, Linscheid RL, Dobyns JH, Wood MB (1988) Scaphoid nonunion: role of anterior interpositional bone grafts. J Hand Surg Am 13:635–650. https://doi.org/10.1016/S0363-5023(88)80116-3 CrossRefPubMed

76.

Braun C, Gross G, Buhren V (1993) Osteosynthesis using a buttress plate-a new principle for stabilizing scaphoid pseudarthroses. Unfallchirurg 96:9–11PubMed

77.

Dodds SD, Halim A (2016) Scaphoid plate fixation and volar carpal artery vascularized bone graft for recalcitrant scaphoid nonunions. J Hand Surg Am 41:e191–e198. https://doi.org/10.1016/j.jhsa.2016.04.021 CrossRefPubMed

78.

Garg B, Goyal T, Kotwal PP et al (2013) Local distal radius bone graft versus iliac crest bone graft for scaphoid nonunion: a comparative study. Musculoskelet Surg 97:109–114. https://doi.org/10.1007/s12306-012-0219-y CrossRefPubMed

79.

Schreuder M, Degreef I, De Smet L (2008) Treatment of scaphoid non-unions with a corticocancellous graft and Herbert screw fixation: results at five years follow-up. Acta Orthop Belg 74:24–28PubMed

80.

Haupt G, Haupt A, Ekkernkamp A et al (1992) Influence of shock waves on fracture healing. Urology 39:529–532. https://doi.org/10.1016/0090-4295(92)90009-L CrossRefPubMed

81.

Wang CJ, Wang FS, Yang KD (2008) Biological effects of extracorporeal shockwave in bone healing: a study in rabbits. Arch Orthop Trauma Surg 128:879–884. https://doi.org/10.1007/s00402-008-0663-1 CrossRefPubMed

82.

Cacchio A, Giordano L, Colafarina O et al (2009) Extracorporeal shock-wave therapy compared with surgery for hypertrophic long-bone nonunions. J Bone Jt Surg Ser A 91:2589–2597. https://doi.org/10.2106/JBJS.H.00841 CrossRef

83.

Notarnicola A, Moretti L, Tafuri S et al (2010) Extracorporeal shockwaves versus surgery in the treatment of pseudoarthrosis of the carpal scaphoid. Ultrasound Med Biol 36:1306–1313. https://doi.org/10.1016/j.ultrasmedbio.2010.05.004 CrossRefPubMed

Title: Treatment of scaphoid waist nonunion by one, two headless compression screws or plate with or without additional extracorporeal shockwave therapy
Authors: S. Quadlbauer
Ch. Pezzei
T. Beer
J. Jurkowitsch
T. Keuchel
C. Schlintner
W. Schaden
T. Hausner
M. Leixnering
Publication date: 01-02-2019
Publisher: Springer Berlin Heidelberg
Published in: Archives of Orthopaedic and Trauma Surgery / Issue 2/2019
Print ISSN: 0936-8051
Electronic ISSN: 1434-3916
DOI: https://doi.org/10.1007/s00402-018-3087-6

Keynote webinar | Spotlight on sleep in brain health

Springer Medicine

Treatment of scaphoid waist nonunion by one, two headless compression screws or plate with or without additional extracorporeal shockwave therapy

Abstract

Introduction

Materials and methods

Results

Conclusions

Keynote webinar | Spotlight on sleep in brain health

Springer Medicine

Abstract

Introduction

Materials and methods

Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 2/2019

Rehabilitation before regenerative cartilage knee surgery: a new prehabilitation guideline based on the best available evidence

Glenoid and rotator interval dimension in patients older than 40 years after traumatic anterior shoulder dislocation

Risk factors associated with non-union after triple pelvic osteotomy (Toennis and Kalchschmidt technique): a case–control study and review of the literature

Factors influencing the accuracy of iliosacral screw insertion using 3D fluoroscopic navigation

A novel method using bone peg fixation for acute osteochondral fracture of the talus: a surgical technique

Risk factors of postoperative valgus malalignment in mobile-bearing medial unicompartmental knee arthroplasty