title: Comparison of two percutaneous volar approaches for screw fixation of scaphoid waist fractures: radiographic and biomechanical study of an osteotomy-simulated model.
abstract: BACKGROUND
  When a surgeon uses a percutaneous volar approach to treat scaphoid waist fractures, central screw placement is complicated by the shape of the scaphoid and by obstruction by the trapezium. In this study, we used radiographs and biomechanical tests to compare the standard volar percutaneous approach with the transtrapezial approach, with regard to central screw placement at the distal pole of the scaphoid.
  
  
  METHODS
  Fourteen matched pairs of cadaveric wrists were randomly assigned to two treatment groups. Under fluoroscopic control, a guidewire was drilled into the scaphoid, either through a transtrapezial approach or through a standard volar approach that avoided the trapezium. Guidewire position was measured in the coronal and sagittal planes. A transverse osteotomy was performed along the scaphoid waist, and this was followed by the insertion of the longest possible cannulated headless bone screw. Each specimen was placed into a fixture with a pneumatically driven plunger resting on the surface of the distal pole. Load was applied by using a load-controlled test protocol in a hydraulic testing machine.
  
  
  RESULTS
  All guidewires were inside the central one-third of the proximal pole. The guidewire positions at the distal pole differed significantly between the transtrapezial and standard volar approach groups (p < 0.001). The load to 2 mm of displacement and the load to failure averaged, respectively, 324.4 N (standard error of the mean [SEM] = 73.5 N) and 386.4 N (SEM = 65.6 N) for the transtrapezial approach group compared with 125.7 N (SEM = 22.6 N) (p = 0.002) and 191.4 N (SEM = 36.30 N) (p = 0.005) for the standard volar approach group.
  
  
  CONCLUSIONS
  The data suggest that, in a cadaveric osteotomy-simulated scaphoid waist fracture model, the transtrapezial approach reliably achieves central positioning of a screw in the proximal and distal poles. This position offers a biomechanical advantage compared with central placement in only the proximal pole.
authors.affiliation: Department of Orthopaedics, Lievensberg Hospital, Boerhaaveplein 1, 4624VT Bergen op Zoom, The Netherlands. E-mail address: geertmeermans@hotmail.com.
authors.forename: Geert
authors.initials: G
authors.lastname: Meermans
authors.affiliation: Department of Anatomy and Embryology (F.V.G. and G.H.) and Laboratory of Dental Materials (M.J.B.), University of Antwerp, Groenenborgerlaan 171, 2020 Antwerp, Belgium.
authors.forename: Francis
authors.initials: F
authors.lastname: Van Glabbeek
authors.affiliation: Department of Anatomy and Embryology (F.V.G. and G.H.) and Laboratory of Dental Materials (M.J.B.), University of Antwerp, Groenenborgerlaan 171, 2020 Antwerp, Belgium.
authors.forename: Marc J
authors.initials: MJ
authors.lastname: Braem
authors.affiliation: Department of Orthopaedics, AZ Monica Hospital, Stevenslei 20, 2100 Deurne, Belgium.
authors.forename: Roger P
authors.initials: RP
authors.lastname: van Riet
authors.affiliation: Department of Anatomy and Embryology (F.V.G. and G.H.) and Laboratory of Dental Materials (M.J.B.), University of Antwerp, Groenenborgerlaan 171, 2020 Antwerp, Belgium.
authors.forename: Guy
authors.initials: G
authors.lastname: Hubens
authors.affiliation: Department of Orthopaedics, AZ Monica Hospital, Stevenslei 20, 2100 Deurne, Belgium.
authors.forename: Frederik
authors.initials: F
authors.lastname: Verstreken
mesh_terms: D000368:Aged; D001696:Biomechanical Phenomena / Q000502:physiology; D001863:Bone Screws; D002102:Cadaver; D005593:Fracture Fixation, Internal / Q000295:instrumentation / Q000379:methods; D050723:Fractures, Bone / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D006801:Humans; D010027:Osteotomy / Q000295:instrumentation / Q000379:methods*; D011859:Radiography; D021361:Scaphoid Bone / Q000000981:diagnostic imaging / Q000293:injuries* / Q000601:surgery