Volume 6, Issue 3 (8-2019)                   J. Res. Orthop. Sci. 2019, 6(3): 7-12 | Back to browse issues page

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Shariatzadeh H, Najd Mazhar F, Dehghani Nazhvani H, Eghbali Jelodar H. Comparison of Computed Tomography Scan and Plain Radiograph for the Assessment of Postoperative Union in Patients Treated for Scaphoid Nonunion. J. Res. Orthop. Sci.. 2019; 6 (3) :7-12
URL: http://jros.iums.ac.ir/article-1-2069-en.html
1- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran.
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1. Introduction
Scaphoid fracture is one of the most common fractures of the upper extremity that accounts for almost (60%) of all fractures of carpal bones [1, 2]. The unusual retrograde blood supply of scaphoid predisposes the non:::union::: event. Scaphoid non:::union::: occurs in (5-10%) of the scaphoid fractures, particularly in the displaced fractures [3, 4]. If inappropriately treated, scaphoid non:::union::: can result in carpal collapse and radiocarpal arthrosis, thereby complicating an already challenging situation [5]. For this reason, the appropriate monitoring of :::union::: following the treatment of scaphoid non:::union::: is essential [6].
The 3-dimensional (3D) anatomy of the scaphoid hampers the accurate assessment of fracture and degree of fragment displacement [7]. For this reason, the evaluation of the :::union::: of scaphoid fractures is difficult on a standard series of radiographs. Even so, plain radiographs continue to be the imaging study of choice for the evaluation of scaphoid :::union::: following the interventional management of scaphoid non:::union::: [8].
Although comparative studies evaluating the :::union::: of the scaphoid are traditionally based on plain radiographs, recent evidence reveals that the monitoring of healing progress of the scaphoid :::union::: to ensure the development of bridging bone across the fracture line is best detected by computed tomography (CT) scanning. CT scans allow for a 3D assessment of the trabecular architecture of the scaphoid with reformatting in multiple planes, and, thus, have proven to be more reliable and accurate in the evaluation of :::union::: [9, 10].
In this study, we aimed at comparing the CT scanning and plain radiograph to assess the scaphoid :::union::: in a series of patients, who underwent the operation for the treatment of scaphoid non:::union:::. The main goal of this study was to find out how CT scanning and plain radiographs are useful in the assessment of scaphoid :::union:::.
2. Methods
This study was approved by the Institutional Review Board of our institute, and the patients provided informed consent for using their medical data for publication. Between 2016 and 2018, the patients, who were referred to our center with a scaphoid non:::union:::, were identified. The patients were included if they were treated with the operation and had both plain radiograph and CT scanning conducted as a part of their follow-up. Those who were treated conservatively and those who had either CT images or plain radiograph were excluded from the study. Also, the patients, who did not have a :::union::: in the plain radiographs, were excluded from the study.
The surgical treatment included open reduction, illiac crest bone graft, and K-wire fixation as previously described (Figure 1) [11]. The clinical and demographic characteristics of the patients were extracted from their medical files. The healing of scaphoid non:::union::: was assessed on both CT images and plain radiographs by two different observers, who were fellowship-trained hand surgeons. The :::union::: was graded as healed or non-healed. In case the grading of two observers did not match, a third observer would be asked to help. The case would be excluded from the study if no consensus was reached regarding the :::union::: on either CT or radiograph. All the radiographs and CT scanning were performed in the same center and with the same machine.

Plain radiographs of the wrist, including anteroposterior and lateral views, were taken conventionally for each patient. The CT assessment was performed on 3D CT images. For this purpose, the :::union::: was investigated in at least three coronal and two sagittal CT sections.
Statistical analysis
The statistical evaluation of the data was performed in SPSS V. 16. The results of descriptive statistics were presented as mean±sd or number and percentage. The :::union::: on CT scans and plain radiographs were compared, using a McNemar’s test. A P-value of less than 0.05 was considered significant.
3. Results
A total of 25 patients, who underwent the operation for the treatment of scaphoid non:::union:::, were included in this study. The Mean±SD age of the patients was 29.1±6.8 years (range: 19-45 years). All the patients were male. The Mean±SD time interval from injury to operation was 36.4±54.3 months (range: 4-240 months). Table 1 presents the clinical and radiographic characteristics of the patients.

The Mean±SD time interval from operation to imaging was 6.5±2.5 months (range: 4-13 months). Based on the plain radiographs, the scaphoid :::union::: was obtained in all patients. Based on the CT evaluation, the scaphoid :::union::: was seen in 23(92%) cases. Accordingly, CT scans and plain radiographs were concordant in 23 cases and discordant in two cases. This difference was not statistically significant (P=0.5). Figure 2 shows the postoperative plain radiograph and CT scan of a case, who was identified with the scaphoid :::union::: in the plain radiograph, whereas :::union::: was not achieved in the corresponding CT image.

4. Discussion
The determination of proper healing is an essential component of the assessment of scaphoid fracture and non:::union:::. The radiographic monitoring of the healing progress of scaphoid is often necessary to prevent subsequent complications. Although plain radiographs are the most commonly used imaging modalities, they are not without pitfalls. Studies have revealed poor reliability of plain radiographs in the assessment of scaphoid fracture :::union::: [10]; thus, other imaging modalities such as CT scan and MRI have been suggested for this purpose [8].
In this study, we aimed to assess the differences between plain radiographs and CT images in checking the scaphoid :::union:::. Based on the results of the present study, a remarkable agreement was observed between plain radiographs and CT images so that in 23 out of 25 cases, both radiographs and CT scans revealed complete scaphoid :::union:::. Even so, in a subset of patients (2 out of 23 cases) the result of plain radiographs and CT scan was inconsistent so that a :::union::: was observed in plain radiographs, but not in CT scans.
Grewal et al. examined the inter-observer reliability of CT scans for quantifying scaphoid :::union:::. For this purpose, four blinded observers reviewed CT scans of 50 scaphoid fractures that were treated conservatively. Each reviewer reported the mean percentage of :::union::: and the weighted mean percentage of the :::union::: and then the inter-observer reliability of scores was assessed. The results revealed high inter-rater reliability among the observers, suggesting CT as a reliable method for the evaluation of scaphoid :::union::: [12].
Hannemann et al. examined the reliability and validity of scaphoid :::union::: assessment, using a multiplanar reconstruction CT scanning randomized at 6, 12, and 24 weeks after injury. For this purpose, three observers reviewed 44 sets of CT scans of 44 non-operatively treated scaphoid waist fractures. The inter-observer agreement was moderate (kappa value =0.576). The average sensitivity and specificity of CT for determining scaphoid :::union::: following fracture were (73%) and (80%), respectively [13].
Buijze et al. aimed at determining the inter-observer agreement CT scans for determining the :::union::: of scaphoid fractures. For this purpose, 59 orthopedic and trauma surgeons rated the :::union::: of a set of 30 sagittal CT scans from 30 scaphoid fractures. A substantial inter-observer agreement was found between the raters. The average sensitivity, specificity, and accuracy of sagittal CT scans for determining the :::union::: of scaphoid fracture were (78%), (96%), and (84%), respectively. The positive and negative predictive values of a diagnosis of the :::union::: were 0.99 and 0.41, respectively. They concluded that CT scans were reliable for determining the :::union::: of scaphoid fracture, but not for ruling out the non:::union::: of scaphoid fractures six to ten weeks after injury [14].
Dias et al. evaluated the inter-observer agreement and reproducibility of plain radiographs in the diagnosis of the :::union::: of scaphoid fractures on films taken 12 weeks after injury. Eight senior observers reviewed 20 sets of radiographs on two occasions with a two month interval. A poor agreement was found regarding the formation of trabeculae and sclerosis, as well as the vascularity of the proximal part of the scaphoid. Moreover, the agreement on :::union::: was poor. They concluded that plain radiographs obtained 12 weeks after the scaphoid fracture was not reliable and reproducible enough for detecting evidence of healing [10].
Reviewing the literature regarding the role of CT scan and plain radiographs in the evaluation of scaphoid :::union::: reveals that CT was more reliable and accurate than plain radiographs in the assessment of scaphoid :::union:::. However, the comparison of CT and plain radiographs in the assessment of scaphoid :::union::: has been less investigated.
Hackney performed an operation to compare CT scans and plain radiographs for the assessment of scaphoid fracture healing after the operation. He retrospectively collected the data of 16 patients with scaphoid fractures, who were treated surgically and had both plain film and CT imaging as a part of their follow-up. Two observers (hand surgeons) assessed the images and graded as healed or non-healed. In 12 cases, the CT and plain radiographs were consistent regarding the healing of scaphoid. In three cases that were treated for the repair of scaphoid non:::union:::, CT could detect the radiographic signs of healing, whereas plain radiographs were unable. They concluded that in cases involving surgical repair of non:::union:::, CT was a superior imaging modality in the detection of subtle radiographic signs of healing before the appearance of such signs on plain film [15].
Following the study of Hackney, the results of the current study suggest the superiority of CT scanning in the detection of the :::union::: in patients, who underwent the operation for the treatment of scaphoid non:::union:::. In contrast to the study of Hackney, we identified two patients, in whom the scaphoid :::union::: was observed in plain radiographs, whereas the CT scans revealed the scaphoid non:::union:::. As this difference was not statistically significant, plain radiographs could still be performed as the primary choice of imaging in the evaluation of scaphoid :::union::: in these patients. However, in the patients, for whom plain radiographs cannot provide a clear-cut answer for the :::union::: status, a complementary CT scanning could be helpful.
The main limitation of this study was the small number of cases that might have adversely affected the power of statistical analysis. Thus, future investigations with a larger sample size are required to understand better the significance of CT scanning in the evaluation of scaphoid :::union:::.
5. Conclusion
In a subset of patients, who undergo the operation for the treatment of scaphoid non:::union:::, a disagreement might exist between CT scans and plain radiographs regarding the healing of scaphoid. In this respect, a :::union::: might be seen in the plain radiographs, but not in the CT scan. As this entails a small number of patients, the plain radiographs could still be used as the imaging modality of choice for the evaluation of scaphoid :::union::: in these patients. However, if :::union::: status is not recognizable on plain radiographs, a complementary CT could be obtained to attain a consensus.

Ethical Considerations
Compliance with ethical guidelines

This study was approved by the Ethics Committee of our institute (Code: 372, 13 may 2019).
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Authors' contributions
All authors contributed in preparing this article.
Conflict of interest
The authors declared no conflict of interests.

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Received: 2019/05/16 | Accepted: 2019/07/13 | Published: 2019/08/1

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