Outcomes of Scaphoid Nonunion with Segmental Defect Treated with Plate Fixation and Autogenous Cancellous Graft: First Clinical Report: Level 4 Evidence

There is no financial information to disclose. Treatment of scaphoid nonunion with segmental defect presents a challenging clinical problem. Various techniques have been proposed, usually involving vascularized bone grafting with or without structural bone. Outcomes of these complex procedures have been inconsistent in the medical literature. The authors hypothesize that similar or perhaps better clinical and radiographic outcomes are possible with a relatively simplified technique of volar plate fixation augmented with autogenous pure cancellous graft. The authors performed a retrospective chart review of 49 consecutive patients with scaphoid nonunion with segmental defect treated with plate fixation and pure cancellous bone grafting. Surgical management included a single volar incision, reduction, insertion of bone graft from ipsilateral olecranon and/or distal radius, and application of a volar locking plate. Post-operative outcome measures included time to union based on computerized tomography (CT), return to work, patient-reported pain and disability scores, grip strength, and range of motion (ROM). The average patient was 31 years old and treated an average of 28 months after initial injury. Twenty-nine patients (59.0%) were treated for nonunion at the scaphoid waist, 19 (38.8%) at the proximal pole, and 1 (2.0%) at the distal pole. 13 patients (26.5%) were treated specifically for avascular necrosis confirmed with magnetic resonance imaging (MRI). Mean follow-up was 18.9 months (range, 12-34). Union was achieved in all patients and average time to union was 78 +/- 18.4 days post-operatively. Complications included symptomatic hardware that required plate removal for 1 patient. Mean DASH score improved from 13.4 +/- 0.5 pre-operatively to 41.4 +/- 3.7 post-operatively. Mean visual analogue scale (VAS) improved from 7.0 +/- 0.7 pre-operatively to 2.1 +/- 0.7 post-operatively. All employed patients returned to work, although 5 (13.9%) did not return to full capacity. Grip strength improved from 79.9% of the non-operative side pre-operatively, to 93.5% post-operatively. At final follow-up, ROM including wrist flexion, extension, ulnar deviation, and radial deviation improved 128%, 173%, 112%, and 164%, respectively, compared to pre-operative ROM. •The combination of scaphoid plate fixation and pure cancellous bone grafting for scaphoid nonunions with segmental defects yields reliable union rates and good patient outcomes.•Autogenous cancellous bone grafting is a reliable alternative to more technically demanding or morbid grafting procedures for the treatment of scaphoid nonunions with segmental bone defects.•In cases of avascular necrosis, outcomes of volar locked plating with pure cancellous grafting appear to be similar, if not superior, to those reported for vascularized bone grafting techniques.