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Necessity of grafting in scaphoid nonunion fixation: A comparative outcome analysis
Amr Elshahhat1, Moheib Ahmed2, Ahmed Saleh2
1Department of Orthopedic Surgery, Mansoura University, Mansoura 33516, Dakahlia, Egypt. amrelshahat@mans.edu.eg.
Background:
Scaphoid nonunion (SNU) presents substantial functional limitations, frequently necessitating surgical intervention to restore wrist mobility and prevent degenerative changes. While the traditional approach to managing SNUs has relied on open fixation combined with bone grafting, the universal necessity of grafting, especially in stable nonunion (NU), is increasingly questioned. Emerging evidence indicates that graft-less fixation can deliver favorable outcomes, with notable healing observed in such cases.
Aim:
To compare the outcomes of graft-less vs graft-augmented fixation in stable SNU, focusing on union rates (URs), healing time (HT), and functional recovery.
Methods:
A retrospective analysis of 44 patients with stable SNUs (Slade grades I-V) managed by either graft-less (n = 21) or graft-augmented (n = 23) fixation. Subgroup analysis included non-vascularized (n = 12) and vascularized grafts (n = 11). Clinical and radiological outcomes were assessed over a minimum 24-month follow-up. HT and UR were compared across groups concerning NU type, bone resorption, duration, and anatomical location.
Results:
Overall UR was 81.8%. URs did not differ significantly between groups (P > 0.05), whereas HT was significantly shorter with graft augmentation (P < 0.001). Graft-less fixation yielded superior grip strength (P < 0.001), radial/ulnar tilt (P = 0.004, < 0.001), and Mayo modified wrist scores (P = 0.01). Graft augmentation particularly improved outcomes in cystic SNUs, those with ≥ 5 mm bone loss, and NUs ≥ 1 year. Non-vascularized and vascularized grafts demonstrated comparable outcomes (UR: 91.7% vs 81.8%, P = 0.5). Smoking showed a significant association with delayed healing in graft-augmented fixation (P = 0.04), whereas no such relationship was observed in graft-less fixation.
Conclusion:
Fixation without grafting is viable in selected stable SNUs, offering comparable union and superior function, albeit with longer HT. Bone grafting remains advantageous in cystic, long-standing, or biologically compromised NUs. Treatment should be tailored based on NU characteristics and patient factors.
