Due to the unique morphology and tenuous vascularity, proximal pole fractures of the scaphoid are prone to nonunion if neglected. The vascular anatomy and the understanding that the blood flow to the proximal pole is retrograde in nature, has supported the concept of disruption of blood flow to the proximal pole with the possibility of avascular necrosis in a non-united proximal pole.
Historically, surgical management at this stage has favored the use of a vascularized bone graft over a non-vascularized bone graft to achieve union and good outcomes.
But the current literature seems to deviate from the long-standing understanding of proximal pole nonunion and its relationship to avascular necrosis. Not only does it state that avascular necrosis is evidently extremely rare, but it also advocates arthroscopic bone grafting of proximal pole non unions using morselized non vascularized bone
During the period of 2021 to 2023, we came across 4 unique cases of proximal pole nonunion, each of them noteworthy in their presentation and subsequent management. These cases were subsequently treated arthroscopically with using non vascularized bone graft from the iliac crest successfully.
All our four unique and difficult proximal pole nonunion cases successfully with variations of techniques - A failed screw fixation treated successfully with arthroscopic bone grafting negating the need of an open procedure of vascularized bone graft. A very old proximal pole nonunion which shows the absence of avascular necrosis and turns out amenable to the procedure in question. Surgery on small proximal pole non-union which is difficult using open techniques with extensive soft tissue dissection and possible disruption of blood supply and stabilizing structures of the wrist done successfully using arthroscopic technique ensuring the integrity of these structures giving the nonunion a higher chance of healing
Arthroscopic bone graft of non-united fracture of the proximal pole of the scaphoid is a reliable safe technique once the surgical technique has mastered. The technique should only be used on nonunions where there is an intact proximal pole. Our experience clearly shows that even difficult proximal pole nonunions can be treated arthroscopically using non-vascularized bone grafts with good bone healing, cosmetically favorable scars, lesser postoperative pain and faster wound healing.
