Proximal Scaphoid Pole Reconstruction Utilizing Ipsilateral Proximal Hamate Autograft

Proximal pole scaphoid fractures complicated by nonunion and osteonecrosis present a challenging scenario with few good reconstructive options, especially when the proximal fragment is small or fragmented^1-4. The use of an ipsilateral proximal hamate osteochondral autograft has emerged as a promising technique for reconstructing the proximal scaphoid pole, with the potential to restore carpal mechanics while avoiding the morbidity associated with free vascularized bone grafts or distant autograft sites.

The procedure involves replacing the diseased proximal scaphoid with a structurally matched osteochondral graft from the ipsilateral proximal hamate. After excising the necrotic or fragmented scaphoid pole, a size-matched graft-harvested with its attached volar capitohamate ligament-is rotated 180° on its longitudinal axis to replicate normal scaphoid anatomy. The defect is measured in 3 planes using the scapholunate joint (proximal) and viable distal scaphoid surface as boundaries. On the hamate, an osteotomy is marked 8 to 10 mm distal to its proximal tip, parallel to the articular surface. The volar capitohamate ligament is preserved to guide graft orientation and maintain stability. These measurements align with recent anatomic and biomechanical studies that have confirmed 6 to 10-mm grafts accurately reproduce scaphoid morphology without compromising carpal kinematics. The graft is then inserted into the defect and secured with rigid internal fixation (headless compression screws or Kirschner wires). Residual gaps may be filled with cancellous bone graft. Scapholunate interosseous ligament (SLIL) reconstruction is typically performed by suturing the hamate's volar capitohamate ligament to the dorsal SLIL remnant on the lunate with a 2-0 nonabsorbable suture. In patients with a partially intact SLIL, such as after failed fixation, the hamate graft alone may provide adequate stability, making formal reconstruction unnecessary. If intraoperative findings reveal dorsal scapholunate instability or an attenuated SLIL, reconstruction is indicated. Healthy, tensionable ligament remnants are repaired directly or reinforced with suture anchors. When dorsal fibers are deficient but volar remnants remain, the attached volar capitohamate ligament is used for reinforcement. For small defects, a micro-interference screw may be employed for fixation. Postoperatively, the wrist is immobilized in a cast. When radiographic evidence of union is observed, the cast is removed and the patient begins a structured hand therapy program.

Alternatives include vascularized and nonvascularized bone grafts (e.g., iliac crest), a vascularized medial femoral trochlear osteochondral flap, costochondral rib graft, proximal row carpectomy, and wrist arthrodesis^1,2. These may be limited by donor-site morbidity, complexity, or suboptimal restoration of wrist biomechanics.

The articular surface of the proximal hamate closely matches the curvature and size of the proximal pole of the scaphoid, making it an ideal structural substitute. The use of an articular autograft from the same wrist avoids the need for distant donor sites and microsurgical anastomoses, reducing overall morbidity. Additionally, because the graft is harvested with its volar ligament attached, it enables a simultaneous SLIL reconstruction, addressing carpal instability in a way that standard bone grafts cannot. This technique is relatively straightforward and reproducible, and it is especially beneficial in young, active patients with an irreparable proximal scaphoid, offering a chance to heal the nonunion and preserve near-normal wrist function without resorting to salvage procedures.

Radiographic union is expected in the majority of cases within 8 to 12 weeks. Published series have demonstrated union rates of >90%, improved pain, restoration of near-normal wrist kinematics, and substantial improvements in range of motion and grip strength, although not always to the level of the contralateral wrist. Complications are rare but include nonunion, donor-site pain, and persistent stiffness.

Limit proximal hamate resection to approximately 10 mm distal to its tip in order to replicate the scaphoid defect size while maintaining carpal stability.Ensure preservation of the triquetrohamate and volar capitohamate ligaments, as their integrity prevents instability.Rotate the graft 180° on its longitudinal axis in order to correctly orient the articular surfaces.Fixation should be rigid but not violate adjacent cartilage.Supplement with a distal radial bone graft if a distal scaphoid defect is present.Early controlled motion prevents stiffness.

ON = osteonecrosisVAS = visual analog scaleROM = range of motionQuickDASH = abbreviated version of the Disabilities of the Arm, Shoulder and HandCT = computed tomographyMRI = magnetic resonance imagingECRL = extensor carpi radialis longusEPL = extensor pollicis longusK-wire = Kirschner wireAP = anteroposteriorDISI = dorsal intercalated segment instabilityNA = not applicable.