A Small Ratio of Proximal to Distal Bone Fragments Is a Risk Factor for Scaphoid Nonunion: A Volumetric Analysis of Preoperative CT

Abstract

Background Small proximal bone fragments are a known risk factor for nonunion, but it is not known what ratio of proximal to distal bone fragments actually results in nonunion. Objective We hypothesized that a small proximal ratio of proximal scaphoid fragment volume to distal scaphoid volume as measured by preoperative computed tomography (CT) would be a risk factor for postoperative scaphoid nonunion. Materials and Methods We retrospectively examined the factors that led to postoperative nonunion in 78 patients who underwent surgery using free bone grafts for scaphoid nonunion. Nonunion was defined as no evidence of union on plain radiography or CT more than 3 months after injury. Three-dimensional models of scaphoid fractures were created from the preoperative CT of all cases, and volumes were measured. Other patient characteristics, surgical methods, and imaging were investigated. Results Persistent nonunion was observed in 13 patients after surgery, a rate of 16.7%. A multivariate analysis showed that only the proximal fragment ratio was an independent factor (union group 0.94, persistent nonunion group 0.54, p = 0.03). Receiver operating characteristic analysis showed that a proximal fragment ratio less than 0.66 was associated with persistent nonunion. Conclusion Treatment of scaphoid nonunion with a small proximal fragment ratio should be based on a thorough understanding of the anatomy, blood flow, and carpal kinematics of the scaphoid bone itself. Level of Evidence Level IV, prognostic study.

Keywords: CT; bone volume; nonunion; preoperative; scaphoid bone; scaphoid fracture.

Fig. 1

Scaphoid bone imaging in Mimics. ( A ) Separate proximal fragments. ( B ) Separate distal fragments. ( C ) Three-dimensional model. (Mimics 21.0, Materialise, Leuven, Belgium.)

Fig. 2

Radiographs (anterior–lateral and medial–lateral). ( A ) Union case (preoperative; postoperative, at final follow-up). ( B ) Nonunion case (preoperative; postoperative, at final follow-up).

Fig. 3

Receiver operating characteristic curve of proximal fragment ratio. A proximal fragment ratio less than 0.66 was associated with nonunion (specificity 65%, sensitivity 69%, area under the curve 0.73, 95% confidence interval 0.59–0.88).