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Introduction: Untreated ununited scaphoid fractures will almost inevitably progress to radiographic and symptomatic osteoarthritis of the wrist. This may lead to subsequent morbidity and lifelong disability especially in young males in which the fracture scaphoid is more common. Patients and methods: Twenty-one patients presenting non-united fracture scaphoid were operated upon by using disto-proximal bone peg technique with average time between injury and operation as 11 months (6–18 months). All of them male with average age of 26 years (17–35 years). There were 17 patients with fracture waist (80.9%) and four patients with fracture proximal pole (19.1%). Results: Anatomy of the wrist was restored and radiological healing confirmed in 17/21, partial healing in 3/21 and non-union in 3/21 patients. Eighteen patients (85.7%) were graded as satisfactory, 5 patients (23.8%) were graded as excellent, ten patients (47.6%) were graded as good, and three patients (14.3%) were graded as fair. The remaining three patients (14.3%) were graded as unsatisfactory. Conclusion: We conclude that the disto-proximal bone peg technique of taking the graft from the ipsilateral ulna without using any metal work for fixing scaphoid non-union fracture is a reliable, easy, and inexpensive alternative method. However, we would not recommend it for the non-union of the scaphoid proximal pole fracture. Also we find the time lag before operation is one of the most important factors to achieve union in non-united fractures of the scaphoid. Level of evidence: Therapeutic case series, level 1V.

This study was undertaken to determine the incidence of and assess factors affecting nonunion of scaphoid distal pole fractures. A total of 193 established scaphoid nonunions were treated in our clinics between the years 1999 and 2004; of which, eight cases involved the distal pole of the scaphoid. These were further analyzed to determine factors that may have contributed to the development of nonunion. This study reveals that distal pole nonunions account for 4.1% of all scaphoid nonunions. We found inadequate initial treatment to be the cause for nonunion in 63% of patients. Type IIC fracture pattern according to Posser's classification was seen in 100% of patients and a persistent Dorsal Intercalated Segmental Instability (DISI) pattern in 100% patients. In addition, 100% of fractures occurred at the watershed zone between the two vascular networks of the scaphoid. We believe the key features leading to the likelihood of nonunion at the distal pole include a Type IIC fracture pattern associated with a continued deforming force that eventually leads to a DISI deformity. The watershed area between the proximal vascular network supplying the waist and the distal one supplying the distal pole is especially vulnerable to poor healing.

The difficulty in healing scaphoid nonunions is challenged further by the dynamic, unstable nature of the fracture-fragment interface. Recently, several investigators have introduced a minimally invasive technique for scaphoid nonunion repair, which has the advantages of minimal morbidity and accurate articular reduction, resulting in less postoperative stiffness and increased functional outcomes. However, failure to recognize the critical steps during minimally invasive surgery can result in incorrect treatment or limit any chances for successful bone repair. We reviewed the selected literature pertinent to arthroscopic techniques in the treatment of scaphoid nonunions. Furthermore, we presented a new arthroscopic approach that can be used in place of traditional formal open exposures in challenging cases of nonunion.

Background: The purpose of this study is to compare the outcome of the conical fully threaded headless screw to that of a smooth shaft headless screw in a series of scaphoid nonunions requiring screw fixation to determine if screw design had an influence on union rates.

Methods: We retrospectively reviewed 104 cases of surgically treated scaphoid nonunions. After eliminating cases with our exclusion criteria, the study cohort had 40 cases for analysis. A comparison and analysis of union rates was undertaken between the fully threaded Acutrak 2 mini screw and the smooth shaft Herbert screw.

Results: Overall union rate for screw fixation was 88%. The fully threaded conical screw fixation had a significantly lower union rate of 50% compared to 97% for the smooth shaft screws.

Conclusions: Our data revealed that the fully threaded conical screws were associated with significantly lower union rate compared to the smooth shaft Herbert type screws.

Background: Nonunion involving the metaphyseal region of the distal radius is exceedingly rare, usually involving co-morbidity. Patients that have failed multiple prior conventional surgical interventions represent an even more difficult subset to treat; this investigation examined the utility of a specially designed free vascularized medial femoral condyle flap consisting of a central structural block graft with an extended corticoperiosteal sleeve to wrap around the junctions.

Methods: Six patients (5 males, 1 female) with a mean age of 52 years had failed to achieve union involving the distal radius metaphysis after a mean of 3.7 prior surgeries occurring over a mean period of 24 months. Comorbidities included smoking, alcoholism, chronic nutritional deficiency, and prior osteomyelitis. The unique descending genicular artery medial femoral condyle flap designed to address these patients consisted of a central structural block graft in continuity with an extended corticoperiosteal sleeve. The structural block filled the bone defect, and the corticoperiosteal sleeve wrapped around the bone junctions and the neighboring bone margins. The mean flap size was 5.3 (+/- 1.3) cm long by 4.5 (+/- 0.9) cm wide. Pre-operative to post-operative DASH scores were compared using the paired student’ s t-test, with p < 0.05.

Results: All flaps achieved union at a mean of 6.8 (+/- 2.1) weeks following surgery, using the criteria of bridging trabeculae on all 3 radiographs: coronal, sagittal, and oblique. The mean pre-operative DASH score of 63 (+/- 10) was statistically significantly different compared to the mean post-operative DASH score of 18 (+/- 8).

Conclusions: With few alternative solutions able to address this unique and difficult problem, the structural block of vascularized bone with the extended corticoperiosteal sleeve proved able to achieve a union that had failed multiple previous attempts and able to resist reactivation of infection, in a challenging group of patients with comorbidities.

This study was carried out to assess the effect of bone marrow transplant into the 47 ununited fracture sites of the long bones of the extremities in 46 patients on bone healing. Among 46 cases, there were 43 pure fractures; a case of simultaneous ipsilateral femoral and tibial osteotomies for leg lengthening; a case of ununited repositioned cryo-treated proximal half of tibia as a limb salvage; and a case of internal transport of proximal tibia.

Among the 43 pure fractures, there were 11 hypertrophic, 30 oligotrophic, and 2 gap nonunions. Bone marrow transplant was performed for any type of the delayed union and nonunion, and was also indicated in the distraction callotasis site of poor osteogenesis.

Overall union rate in 43 fractures was 55.8% (24 cases). In two gap nonunions, no callus was formed. Union was obtained in all the 11 hypertrophic nonunions and 13 (46.4%) of the 30 oligotrophic nonunions. The oligotrophic and gap nonunions responded poorly to the marrow transplant. One of the two tibial osteotomy gaps healed with good evidence of endosteal callus formation. In a femoral osteotomy site for lengthening and in an ununited repositioned site of the cryo-treated tibia, there were no visible callus at all. The average time for clinical and radiological unions in the fracture cases were 5 and 7 months on average. In our series, there were no complications, including infection.

The results in this series suggest that bone marrow transplant is a good source of callus formation or stimulant in treating the delayed union and hyper- and oligotrophic nonunions of any origin, and also enhances the callus formation at the gap of the early stage of the internal transport.

Background: Wedge-shaped bone grafts that are internally fixed by a Herbert-type screw are a well-established surgical treatment for scaphoid nonunion. A procedure using cylinder-shaped bone grafts was also reported, but preoperative wrist functions were not assessed. In addition, it was not reported whether the humpback deformity of the scaphoid nonunion was corrected. The purpose of the current study was to compare preoperative wrist functions in cases of scaphoid nonunion with those observed at final follow-up, using cylinder-shaped bone grafts The humpback deformity of the scaphoid nonunion was also evaluated.

Methods: We conducted a retrospective study to examine operative outcomes from 2008 to 2015. Twelve wrists in 12 patients (average age, 41 years; range, 17–67), with a mean follow-up of 19 months, were included in the current study. Cylinder-shaped bone grafts were obtained from the iliac crest with a newly designed trephine and fixed with a Herbert-type screw. We reviewed both the preoperative wrist functions and those obtained at final follow-up.

Results: Union was achieved in 11 of 12 nonunion cases. Preoperative wrist functions, except for the range of wrist motion, significantly improved by final follow-up.

Conclusions: We conclude that the use of cylinder-shaped bone grafts improves preoperative wrist functions in cases of scaphoid nonunion.

Background: The purpose of this retrospective study was to report outcomes of arthroscopic bone grafting and K-wire fixation to treat scaphoid non-union.

Methods: We included in at two healthcare facilities, 42 consecutive patients (34 men, 8 women) with a mean age of 25 years (range 15–56 years) with scaphoid non-union of the proximal and middle third without intracarpal deformity or SNAC osteoarthritis. All patients were evaluated (pain, range of motion, strength, function, X-rays) by an independent examiner.

Results: At the mean follow-up of 18 months (range 12–56), pain was significantly reduced from 7 to 1 on a visual analogue scale (out of 10). The scores on the Quick Disabilities of the Arm, Shoulder and Hand questionnaire and Patient Rated Wrist Evaluation were improved significantly. At the last review, grip strength was 83% of the contralateral side, the average wrist flexion-extension was 125° and the radioulnar deviation was 58°. Bone union was achieved in 37 cases (88%). The mean time of checking the bone union was 3 months (range, 2–8). Four patients required revision surgery because of failed union.

Conclusions: Based on our findings, we found that this procedure can be used as a surgical treatment for scaphoid non-union of the proximal and middle third without intracarpal deformity or osteoarthritis. The arthroscopic bone grafting is a reliable, effective, and minimally invasive procedure.

Wrist arthrodesis has been used successfully for the management of severe wrist flexion deformity when soft tissue procedures would not provide adequate correction. However, in athetoid type cerebral palsy which has a component of involuntary movement, the outcome of wrist arthrodesis has not been discussed much. We present our experience in 2 athetoid type cerebral palsy patients who underwent wrist arthrodesis due to severe involuntary movement of the wrist. One patient had a nonunion and both patients had unexpected aggravation of involuntary movement in the adjacent joints. Secure fixation using a pre-contoured plate is necessary and preparation for iliac bone grafting should be considered as proximal row carpectomy is usually not necessary in these patients. In addition, although single-event, multi-level surgery is advocated for patients with cerebral palsy, potential additional procedures for the adjacent joints should be discussed preoperatively because unexpected aggravation of involuntary movement of adjacent joints can occur after stabilization of the wrist.

We report a case of trapezoid nonunion diagnosed 3 months post injury. A 25-year-old male patient felt continuous wrist pain after being injured. His radiograph showed non-union with sclerotic change and bone resorption. He was planned for surgery, and this was done using a minimally invasive technique. Via a dorsal approach, we percutaneously drilled to the nonunion site and freshened the fracture ends. Bone plugs were harvested from the iliac crest using a bone marrow biopsy needle and packed into the nonunion site. The fracture was then fixed with a cannulated headless compression screw. This procedure could be performed without injuring the ligaments around the trapezoid. The patient was immobilised for 4 weeks, and bone union was achieved 6 months after surgery. He had full range of finger and wrist motion and no pain at the final follow-up.

Level of Evidence: Level V (Therapeutic)

Nonunion of fracture has presented an overall therapeutic challenge in clinical practice. Selection of an adequate nonunion model is the basis for testing effective prevention or treatment of nonunion by new intervention techniques. This chapter describes two atrophic nonunion models in rabbits for simulating the clinical conditions that cause nonunion: by the creation of a critical-sized bony defect, and by the interposition of soft tissue. Both nonunion models are evaluated radiographically and histomorphologically at the end of the experiment. Atrophic nonunion characteristics are clearly present in all animals in the defect and interposition of soft tissue models 12 weeks after operation, and persist until 22 weeks. Both the critical-size defect and the tissue interposition techniques are therefore regarded as effective methods to develop atrophic nonunion models.