Revision of failed bone grafting for nonunion of the scaphoid. Treatment options and results.

Failure of bone grafting in scaphoid nonunion presents the hand surgeon a perplexing set of problems. Controversy remains as to the best course of treatment in this difficult situation. The authors have retrospectively reviewed during a 5-year period the patients treated at the Mayo Clinic who have gone on to a second nonunion after a failed initial bone grafting procedure. Twenty-five patients were identified, 19 of whom had a second bone grafting procedure. Depending on the preoperative evaluation, 4 types of bone grafting procedures were performed: conventional Russe procedure, 4; Maltese cross bone graft procedure, 6; interpositional wedge graft, 5; and vascularized pedicle bone graft, 4. Twenty-two of 25 united (88%). Average followup at 57 months (range, 25-90 months), shows satisfactory results (16% very satisfied and 8% moderately satisfied), but varying degrees of pain. Results using a modification of the Mayo Wrist Score are somewhat disappointing with 3 excellent, 5 good, 10 fair, and 7 poor. It must be remembered, however, these wrists have had at least 2 surgeries, multiple long periods of immobilization, and often a delay in treatment with a prolonged period of abnormal carpal mechanics. It is thought that a second bone grafting attempt should be strongly considered. The key to success is matching the type of bone graft procedure to the specific unique features of scaphoid shortening, carpal instability, and proximal pole vascularity that each patient's wrist displays. A treatment algorithm is presented to help decision making in this difficult problem.