Scaphoid Non-union Arthroscopic Treatment without Bone Graft: Is it Possible?

Scaphoid fractures are the most frequent fractures of carpal bones, accounting for 70 to 80% of all carpal fractures. Appropriate and early diagnosis of scaphoid fractures is imperative. To relieve symptoms and prevent degenerative changes, scaphoid non-union surgery should aim at healing and restoration of the normal anatomy, and correction of carpal deformities. Since the scaphoid non-unions are a heterogeneous group, and categorization is not easy, the management remains controversial with a reported failure rate as high as 40% and the absence of a "gold standard" treatment. Based on (a) Qu and Von Schroeder's new concepts on the osteogenic ability of the non-union cells stimulated by osteoinductive bone factors; (b) the encouraging results obtained by Illarramedi et al on decompression of the distal radius and ulna in Kiënbock disease treatment; and (c) along with the minimal surgical trauma of percutaneous and arthroscopic techniques, the authors have begun treating scaphoid non-unions without bone graft by using arthroscopic-assisted reduction and internal fixation with metaphyseal core decompression of the distal radius. The technique has also been used in advanced cases with "humpback" deformity and long-standing non-unions. Resting on the observations of CT scans and arthroscopic findings, we have introduced a new comprehensive classification of scaphoid non-union for better categorization and typification and provide an improved treatment approach. We recommend arthroscopic-assisted treatment in young and middle-aged non-smoking patients with scaphoid non-unions. Percutaneous fixation alone is sufficient for stable stages I and II, whereas additional core decompression of the distal radius can be used for unstable stages, for bone defects greater than 10 mm, and for the proximal pole non-unions. This method is not suggested in non-unions with significant sclerosis, with a complete absence of punctate bleeding of the proximal pole, and in those with a very small proximal fragment.