title: Scaphoid Plate Fixation and Volar Carpal Artery Vascularized Bone Graft for Recalcitrant Scaphoid Nonunions.
abstract: OBJECTIVE
  We sought to evaluate the clinical and radiographic outcomes after treatment of symptomatic, recalcitrant scaphoid nonunions using a novel combination of volar scaphoid buttress plating with a pedicled vascularized bone graft.
  
  
  METHODS
  We retrospectively followed 9 patients with recalcitrant scaphoid waist nonunions, characterized by failed prior surgery, long duration of nonunion, avascular necrosis of the proximal pole, or considerable bone loss at the nonunion site. We treated these persistent nonunions through a single volar incision with a pedicled vascularized bone graft, based on the volar carpal artery, and a 1.5-mm precontoured, scaphoid-specific, volar buttress plate. Postoperatively, we assessed objective and subjective outcomes as well as radiographs and computed tomography scans.
  
  
  RESULTS
  The median duration of nonunion was 15 months, ranging from 6 to 96 months. Postoperative follow-up ranged from 11 to 19 months. Computed tomography scans demonstrated union in 8 of 9 cases. Complications included 1 minor hematoma that spontaneously resolved. One scaphoid failed to unite, requiring revision surgery. Three patients experienced problems with the plate. One plate was removed from a patient who noted persistent clicking, and 2 plates have caused symptomatic clicking, likely requiring future removal. Eight of nine patients reported satisfaction with the procedure, with QuickDash scores averaging 8.2.
  
  
  CONCLUSIONS
  We present a series of recalcitrant scaphoid nonunions treated with a novel technique of volar buttress plating and vascularized bone graft. In this series, we found a high rate of union, with consistent radiographic improvement and symptomatic relief. This procedure can be performed using a single incision and with minimal donor site morbidity. Volar plating of a scaphoid nonunion comes with the risk of articular prominence, but offers a new alternative to headless screw fixation. Our early results from this series are promising and support this protocol as a viable alternative for challenging nonunions.
  
  
  METHODS
  Therapeutic IV.
authors.affiliation: Yale University Department of Orthopaedics and Rehabilitation, New Haven, CT. Electronic address: sdodds@med.miami.edu.
authors.forename: Seth D
authors.initials: SD
authors.lastname: Dodds
authors.affiliation: Yale University Department of Orthopaedics and Rehabilitation, New Haven, CT.
authors.forename: Andrea
authors.initials: A
authors.lastname: Halim
mesh_terms: D000293:Adolescent; D000368:Aged; D001860:Bone Plates; D004185:Disability Evaluation; D005260:Female; D005593:Fracture Fixation, Internal; D005599:Fractures, Ununited / Q000000981:diagnostic imaging / Q000601:surgery*; D018737:Hand Strength; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D011884:Radius / Q000098:blood supply* / Q000637:transplantation*; D012189:Retrospective Studies; D021361:Scaphoid Bone / Q000000981:diagnostic imaging / Q000601:surgery*; D014057:Tomography, X-Ray Computed; D064232:Visual Analog Scale; D055815:Young Adult
keywords: Avascular necrosis; recalcitrant scaphoid nonunion; scaphoid fracture; vascularized bone graft; volar scaphoid plate