Scaphoid Nonunion- Is Arthroscopic Bone Grafting a Panacea?

Scaphoid nonunion can lead to almost 100% of radiographic arthritis between 5 -20 years. Timely surgical intervention is the goal before arthritis sets in. Universal principle of treatment include 1. Correct scaphoid malalignment, 2. Debride necrotic bone, 3. Exposure of healthy, well vascularized cancellous bone , 4. Bone grafting and 5. Stabilization by internal fixation. Cortical autograft was first reported in 1928. Over a century, many grafting methods have been implemented with varied success. Systemic review on 5500 cases showed union rate of 80% with non-vascularised bone graft versus 84% with vascularized bone graft, which dropped to 62% and 74% respectively in the presence of AVN. Current evidence did not show superiority of one method over the others.

In 1998, we first reported the technique of arthroscopic bone grafting (ABG) in repairing carpal defects in 11 cases with 100% union. Potential benefits included: minimal disturbance to ligaments, maximal preservation of vascularity, global assessment of wrist joint, minimal pain and scar, speedy rehabilitation.

The technique can be applied to almost all types of scaphoid delay and nonunion. It fulfills all the golden criteria in achieving successful union but in a minimally invasive manner. Overall union rate of 128 cases in our center was 89.8%. Nonunion location or duration did not affect the outcome. Poor blood supply of scaphoid is not a contraindication as union rate of 78.8% can still be achieved. Humpback and DISI deformity can be corrected with appropriate techniques. Associated SNAC wrist changes can be addressed concomitantly. Revision ABG was applied successfully in 6 consecutive failure primary ABG cases. Recent systemic review on 545 cases of ABG in 18 studies showed union rate of 93.7% at average of 13.6 weeks. There was no difference in using screw or pin fixation. ABG can be considered a universal solution of scaphoid union problems.