Fixation and Grafting After Limited Debridement of Scaphoid Nonunions

Purpose To evaluate a surgical technique of treating nondisplaced waist and proximal pole scaphoid nonunions without avascular necrosis (AVN). Methods We performed a retrospective review of all patients with nondisplaced, scaphoid waist or proximal pole nonunions without AVN treated with the following technique. Two K-wires are positioned along the scaphoid axis to stabilize the proximal and distal poles. Debridement with a curette or burr is performed parallel to the nonunion site until the K-wires are visualized and punctate bleeding of the proximal and distal fragments is encountered. The volar, radial fibrous union is left intact. Distal radius cancellous bone graft is packed into the nonunion site. A headless screw is placed perpendicular to the fracture and the K-wires are removed. Results Between 2012 and 2014, 12 patients (ages 13-29 y) with clinical and radiographic evidence (10 had computed tomography or magnetic resonance imaging; 2 had radiographs only) of scaphoid nonunion were identified (10 transverse waist and 2 proximal pole fractures). Median interval from injury to surgery was 38 weeks (range, 3 mo to 9 y). Four patients were active smokers and 2 had failed previous iliac crest bone grafting. All patients healed as confirmed by computed tomography. Average time to union was 14 weeks (range, 6-31 wk). Four patients had delayed union requiring a bone stimulator. All patients had resolution of pain and there were no complications. Conclusions The technique described is an effective and efficient method of treating nondisplaced scaphoid nonunions without AVN. We suggest that complete debridement of the nonunion is not essential to achieve union. In addition, pinning the proximal and distal scaphoid poles initially and maintaining the volar fibrous union of the scaphoid nonunion stabilizes the fracture fragments, increasing the technical ease of grafting and fixation. Copyright (C) 2015 by the American Society for Surgery of the Hand. All rights reserved.