We're going to have Greg come on back up here. I'm glad you enjoyed your talk. It's always amazing when a primary plastic surgery trained surgeon says, well, I'll do the bone graft talk. So Jim took a hit for us there. It's not an exciting subject, but it is evolving and it is being used and we need to know about it. So this next section is on a little in-house scoring system we use. You know, back in the days when the CAT scans came in those big paper folders and you had to put up 10 sheets on the view boxes and you'd, all right, six weeks post-op and it looks like it's healing a little bit. Then you put all those films back in the jacket and then you'd either mobilize them or you'd cast them again. And you'd see them back at 12 weeks, you get another CAT scan. And you put those images up and you go, well, it looks like it's healing, maybe a little bit more. Where's the six-week scan? And then nurses would run for that jacket. We found it to be such a waste of time, we came up with this little in-house scoring system of just determining percentage tract reculations across the fracture site on good quality sagittal and coronal CT cuts and then we just gave it a number. It's very arbitrary, but it is reproducible and it does kind of help you monitor your progress along the road to healing. So DS taught us in the late 80s that plain x-rays pretty much are useless. He shuffled up 20 sets of x-rays, gave them to hand surgeons, orthopedic surgeons, and radiologists, and they were all blinded and he asked them, is it united or not? And not only did he find high inter-observer variability, but just to rub salt in the wound, he took the same sets of x-rays, relabeled them, and two months later gave them back to the same radiologists, orthopedists, and hand surgeons. And you guessed it, they didn't agree with themselves two months later. So not only high inter-observer, but high inter-observer variability over time, radiographs are unreliable in assessing union. Tim Davis further expanded on this and he kind of went ahead and introduced, not only introduced, but he at least got into the literature, the topic of partial union. And you know, these things don't go from fracture, cast versus screw, to union in one day. It's a continuum, it's a highway. And he took 60 scaphoids, CT'd them at three to four months, found 30 had completely united, 14 had completely ununited, and then there were 22 fence-sitters. So about a third of them were kind of tweeners. And they were distributed amongst quarter to half-heeled, half to three-quarter, three-quarter to whole-heeled. And then you heard Dave Ring earlier talk about this, but he took this and expanded on it with 30 sagittal images only. He validated the high inter-observer agreement and CT was reliable for diagnosis of union and a positive predictive value. Now the time to union he discourages just like Diaz does. The manuscripts would come in and say, well, it was 3.65 months to union. Well, it's, you know, that's not the way to do it. We want to start thinking more about how much of the cross-sectional surface area of that peanut is actually linked back together, or the proximal pole and the distal pole linking together. So, and I'll kind of blow through this because we used it earlier as a case example, but if you're going to do this, you have to have proper images because if you don't have proper images, you're blind. Again, for those of you that were still sleeping in the earlier part of the session or weren't here, the CT of the wrist is on the left, the CT of the scaphoid is on the right, and you have to insist on images in the longitudinal oblique axis of the scaphoid or you get these crummy, depressing views on the left that make the proximal pole look unsalvageable when actually it is salvageable. Okay? So if you're going to read your percentage of union, you have to have high-quality images. And again, just to illustrate, it's still a problem because manuscripts are being published and all the work is based on subpar images. I don't know how they draw valid conclusions. So what we do with this is, just to illustrate how we use the technique, it's a 21-year-old triple-A pitcher in the American League, falls down the dugout steps after a bench-clearing brawl in late August, sustains a hyperextension injury, and then he gets called up to the bigs two days later like they all do in early September. And throughout the month of September, his pitching coach watches his control become wildly erratic and his speed drop, and down in the low 80s. So they finally force him to go get an exam and x-rays, and here he is five weeks out, proximal third, already possibly a little cystic resorption. That's what a CT looks like. So our protocol is on the bottom there, half-millimeter slice thicknesses with about 50% overlap, ultra-high resolution, and you can get good reformatted images in the—giving you good coronal and sagittal images. So he gets stabilized, and now he's in the office six weeks later and he wants to know, has he healed? So we put all the cuts up and we go, oh, that doesn't look all that good. We assign a score of zero if there's no trabeculations on that cut, versus 0.5 if we see it on half the cut, or 1.0 if we see it completely across from east to west coast. And as you can see, he doesn't score all that well, about 10% coronal at week six. Same thing with the sagittals. We try and strive for about 10 cuts, but if it's a smaller scaphoid, if it's a female, petite bone, it's only eight millimeters wide, versus 12 in a bigger guy, sometimes you only get eight with that sequence. And here he's doing a little better on the sagittal cuts, and we see the trabeculations always occur in a peri-implant configuration. Not surprising, that's where you kicked up the bone dust, the sawdust, as you drilled, possibly reamed, and put the screw across. And that's also where the fracture's probably the most stable, is right around the shaft of the implant. So it starts there, and then it kind of—just like you throw a pebble in a pond and the waves ripple outward, that's how we see the trabeculations occur. It starts peri-implant, and it kind of centripetally radiates outward from the shaft of the implant. So he's doing a little better on the sagittal, he's up to about 30%. So a blended average at six weeks would say, hey, you're about 20% of the way home. We've at least got linkage. So at 12 weeks, he gets repeated. This is anticipation of heading off to spring training, and the pitchers and catchers have to report early, and the agent and the club want to know, and he's 40% on the coronal cuts, and he's even better on the sagittal cuts. We see maturing bone across the majority of the images. So we tell him he's about halfway home, and we put a—we send him down to Bionic Glove at Louisville, a division of Louisville Slugger that Jimmy Kleinert runs, Harold's son, and they make him a custom insert in his glove. He's an American League pitcher, so he's not going to hit anyway, and he can catch with that hand. He can still pitch with the other hand. So he makes it back for spring training, and they start to get into contract negotiations, and the agent and the club want to know, all right, is it healing the rest of the way, or is the proximal pole succumbing to late segmental collapse? And so we said, well, we can CT it. MR is going to be artifactual. So we CT it, and sure enough, now he's up to 65% on the coronal, 65% on the sagittals. And then likewise, this thing bore on and bore on, and finally, when they came down to brass tacks at the start of the following season, they wanted to know, is the proximal pole viable? So we scanned it again, and it afforded us these wonderful images showing the sequence now over a one-year span from fracture treatment to one year later. You can just see how the images progress. Nowhere along there can you say it united, or I have union. You can say that the mooring line was thrown to the dock at the bow, and now we've got to throw a mooring line, you know, at the stern, and each time you see them, they're gradually throwing down more bone. And, you know, some of these, they're fresh fractures. You CT them, like I showed you, at four weeks. If they're pushing to get back in the game, a simple, stable fracture, non-displaced, and they're all united 100% at four to six weeks, but these more difficult proximal poles, late presentation, definitely take longer. Okay. So that's it. We're going to save those cases for later.

scoring system

bone healing

fractures

CT scans

union