The fate of failed bone graft surgery for scaphoid nonunions

Twenty patients with scaphoid nonunions had bone grafting procedures that failed to achieve union. Nineteen had persistent wrist pain. Electrical stimulation after bone grafting proved useless in obtaining union in five patients. Sixteen patients had additional surgery. Ten had repeat bone grafting. Six scaphoids united after a second grafting and one united after a third graft. However, at follow-up only three of these seven patients had no pain in their wrists. The rate of union was not affected by fracture location, the presence of proximal pole avascular necrosis, or instability. The three patients with nonunion after two bone grafts remain symptomatic. Six patients had salvage procedures; silicone replacement arthroplasty (3), wrist fusion (1), proximal pole excision (1), intercarpal fusion (1). Four were asymptomatic after one of these procedures and two (silicone arthroplasty and intercarpal fusion) became asymptomatic after wrist fusions. Five fractures, believed to be united on the basis of plain radiographs, later demonstrated persistent nonunions. We recommend adequate radiologic follow-up, including tomography, to determine whether or not fracture union has occurred.