Avascular Necrosis Of Proximal Pole Research Articles

A case report on non-union in scaphoid fracture using bone graft

Scaphoid is the most common carpal bone to get fractured in the wrist. Scaphoid fracture is very challenging to treat since it has a tenuous vascular pattern.Non unions and degenerative arthritis can occur due to diagnostic delay and treatment inadequacy. Surgical management with newer techniques have emerged for the treatment of non-union in scaphoid fractures. Despite the advancement of the newly developed fixation techniques, including open and percutaneous fixation, the non-union rate of scaphoid remain as high as 10% after surgical management. Scaphoid non union can present with or without avascular necrosis of proximal pole, and may show a humpback deformity on the radiograph. Surgical treatment is directed at correcting the deformity with open reduction with internal fixation with bone grafting.

The role of vascularized flaps in the treatment of proximal pole avascular necrosis in scaphoid non-unions.

Objectives: The purpose of this study is to evaluate the clinical and radiological outcomes of scaphoid non unions surgically treated with bone graft versus medial condyle corticoperiosteal free flaps. Materials and Methods: 32 patients were divided in 2 groups. Group A (17 patients 12male, 5 females, mean age 35 years old) treated with bone grafts; Group B (15patients 11 male, 4 females, mean age 33 years old) treated with medial condyle cortico periosteal free flap. A radiological follow up was performed about every 30 days after surgery until the complete healing and at 12-month follow-up. The clinical follow up was performed at 6 and 12 months from surgery. Functional assessment was provided by Mayo wrist score and Visual Analogic Scale (VAS). Results: The average length of follow up was 12.52 months ± 1.36. In group A 60% of patients healed in 4.4 ± 1months with a reduction of 28.4% of healing times in group B (p<0.05). In Group B all nonunion sites healed primarily at an average time period of 3.2 ± 1 months. Statistical analysis showed a significant difference (p<0.001) about the preoperative and the postoperative VAS and Mayo Wrist Score evaluation in both groups at 6 and 12-month follow-up, moreover we recorded a statistical difference between groups at the 6-month and 12-month follow-up (p<0.05). Conclusion: The present study showed that the free flaps showed better clinical and radiographic results for the surgical treatment of scaphoid nonunions. In fact, despite the good results of the bone graft, the flaps seems to be preferable in the treatment of these nonunions. (www.actabiomedica.it)

MR angiogram confirms sustained blood flow in 1,2 ICSR artery of vascularized bone grafting in scaphoid nonunion treatment.

To evaluate the functioning of 1,2 intercompartmental supraretinacular artery (ICSRA) in vascularized bone grafting (VBG) of scaphoid nonunions with avascular necrosis of proximal pole. Fourteen patients with scaphoid nonunion were treated operatively with 1,2 ICSRA VBG. Viability of the pedicle artery was evaluated by MR angiography with intravenous contrast agent. In 13 out of 14 patients, the 1,2 ICSR artery was found to be patent and functional. Revascularization of scaphoid proximal pole was revealed in all cases, and nonunion healing was confirmed as well. 1,2 ICSRA VBG in scaphoid nonunion is an effective surgical technique. It combines the advantages of bone grafting and vascular supply via the transferred pedicle artery which seems to be functional postoperatively if a meticulous operative technique is used.

Dual-energy contrast-enhanced CT to evaluate scaphoid osteonecrosis with surgical correlation.

To evaluate the validity of contrast enhanced dual energy CT using a lung perfusion algorithm in assessing for post-traumatic scaphoid proximal pole avascular necrosis. From Aug 2013 to Aug 2016, 18 patients (19 wrists, 16 males, 2 females, mean age 28years) were assessed as high-risk for proximal pole scaphoid avascular necrosis by a single surgeon following a scaphoid fracture and were referred for contrast-enhanced dual energy CT. 8 wrists had specimens sent for correlative histological analysis and 11 were correlated with operative notes. Eight surgical specimens were sent to histology and showed a 100% correlation (8/8) with the DECT findings. The remaining 11 wrists that did not have a specimen sent had in-surgery findings that also correlated with DECT. A single case was discrepant (1/11) due to presence of an intra-osseous ganglion, which was reported as osteonecrosis on CT, but considered viable at surgery. No case was called viable on CT that proved to be necrotic at either surgery or histologically. Contrast-enhanced dual energy CT using a perfusion algorithm is an innovative and promising method in evaluating viability of the post-trauma proximal pole of scaphoid.

LOCAL EXPERIENCE IN TREATMENT OF SCAPHOID NONUNION WITH AND WITHOUT AVASCULAR NECROSIS

Early _&#x0D; detection and_ proper adequate treatment of scaphoid fractures are essential to avoid complications of ma lunion1 delayed union, nonunion and the avascular necrosis, with their disabling &#x0D; sequelae The aim of this study is to assess prospectively the clinical and radiological results using &#x0D; the modified Matt1:Russe technique , for the treatment of scaphoid nonunion with and without &#x0D; questionable viability of the proximal fragment. With our experience of the numerous procedures &#x0D; and techniques proposed for the treatment of this complex problem, we are reporting our results in &#x0D; 23 cases, 8 of which were associated with avascular necrosis of their proximal fragments. Although &#x0D; the data were hm11ed for cases of nonunion scaphoid fracture, with proximal pole avascular necrosis, we noticed that mcreased bone density is a reliable sign of a vascularity. Our success rate in &#x0D; cases without avascular necrosis was (93%) , while it was (75%) in the presence of avascular necrosis. Hence the conclusion was: The modified free bone grafting technique of Matti-Russe, which was &#x0D; normally recommended for the treatment of scaphoid nonunion, is yet effective even in presence &#x0D; of avascular necrosis; and with this technique fixation seems unnecessary.

Primary medial femoral condyle vascularized bone graft for scaphoid nonunions with carpal collapse and proximal pole avascular necrosis.

This study aimed to determine the outcome of free vascularized medial femoral condyle bone grafts in the primary treatment of scaphoid nonunions with scaphoid foreshortening or carpal collapse and intraoperatively documented avascular necrosis. Thirty-two patients (28 male, four female) met the inclusion criteria. Median time from injury to surgery was 70 weeks. Thirty of 32 patients healed at a median of 12 weeks. There was significant improvement from preoperative to postoperative lateral intrascaphoid angle, scapholunate angle, and radiolunate angle. Two scaphoids failed to unite; one patient underwent scaphoidectomy and four-corner fusion 15 months postoperatively after suffering a subsequent injury. Another patient underwent 1,2-intercompartmental supraretinacular artery-based vascularized bone grafting at 4 months postoperatively and then scaphoid excision with four-corner fusion 4 years later. The free vascularized medial femoral condyle bone graft restores scaphoid vascularity and architecture while promoting union in a subset of scaphoid nonunions that has historically been a clinical challenge. Level of evidence: IV.

The Role of Medial Femoral Condyle Free Vascularized Bone Graft for the Treatment of Failed Scaphoid Nonunion Surgery associated with Proximal Pole Avascular Necrosis

There is no financial information to disclose. Revision surgery for scaphoid nonunions with proximal pole avascular necrosis is a challenge. We hypothesize that the use of free-vascularized medial femoral condyle bone grafts can heal the bone, revascularize the proximal pole, and restore scaphoid architecture, resulting in acceptable functional outcomes. We retrospectively reviewed patients who had failed prior operative treatment for a scaphoid nonunion and proximal pole avascular necrosis. Between May of 2005 and September of 2016, 49 patients were identified with this preoperative diagnosis and subsequent treatment with a medial femoral condylar free vascularized bone flap. Mean time from injury to revision surgery was 24 months, and a mean 15 months following the initial surgery. Of the 49 patients, 36 had a prior bone graft procedure and 6 patients had two previous surgeries. Initial internal fixation was with a scaphoid screw in 43 patients and K-wires alone in 3. All patients had documented avascular necrosis of the proximal pole at the time of our surgery, defined by complete absence of punctate bleeding of the proximal pole with the tourniquet deflated. Carpal indices, time to union, functional outcomes and complications were recorded. Forty-one of 49 previously operated on scaphoid nonunions healed (84%) at a mean of 16 weeks (range, 9 to 31 weeks) based upon CT scan imaging. Radiographs demonstrated significant improvement in carpal alignment following surgery, as determined by the lateral scaphoid angle, scapholunate angle, radiolunate angle, scaphoid height to length ratio and carpal height ratio. There was a trend towards improved grip strength and no significant change in total wrist range of motion pre- and postoperatively. Twenty-nine patients underwent 21 subsequent planned procedures (removal of buried K wires). There were two superficial postoperative donor site infections, however no patients complained of medial thigh pain at final follow-up. Age, smoking status, BMI, time to surgery, or preoperative radiographic findings were not found to be statistically significant predictors of failure. •We present the largest series to date of patients who have undergone revision scaphoid nonunion surgery with documented avascular necrosis of the proximal pole.•84% of patients who had failed prior scaphoid nonunion surgery healed at a mean of 16 weeks after treatment with free-vascularized medial femoral condyle grafts.

Ulnar hemimelia in deformed left forearm treated with ilizarov fixator

Pedicle bone graft as primary procedure for treatment of scaphoid nonunion. Pedicle bone graft use in delayed and nonunion of fractures and avascular necrosis scaphoid fracture. The most common indications for Pedicle bone graft have been for scaphoid nonunion, lunatomalacia (Kienbock's disease), and osteonecrosis of the scaphoid (Preiser's disease). Advantages over non vascularized bone graft have been established. Pedicle bone graft provide improved blood flow, osteocyte preservation, and accelerated healing rates. Local pedicle VBGs are the most commonly used methods. They are technically less demanding than are free VBGs and are associated with less morbidity. In managing osteonecrosis, most surgeons would agree that VBG should be reserved for scaphoid nonunion with an intact cartilaginous shell and no collapse. In treating scaphoid pathology, indications for pedicle bone graft include fractures/nonunions with proximal pole avascular necrosis and/or small proximal pole fragments.

Results of pronator quadratus pedicle bone graft as primary procedure for treatment of scaphoid nonunion

Pedicle bone graft as primary procedure for treatment of scaphoid nonunion. Pedicle bone graft use in delayed and nonunion of fractures and avascular necrosis scaphoid fracture. The most common indications for Pedicle bone graft have been for scaphoid nonunion, lunatomalacia (Kienbock's disease), and osteonecrosis of the scaphoid (Preiser's disease). Advantages over non vascularized bone graft have been established. Pedicle bone graft provide improved blood flow, osteocyte preservation, and accelerated healing rates. Local pedicle VBGs are the most commonly used methods. They are technically less demanding than are free VBGs and are associated with less morbidity. In managing osteonecrosis, most surgeons would agree that VBG should be reserved for scaphoid nonunion with an intact cartilaginous shell and no collapse. In treating scaphoid pathology, indications for pedicle bone graft include fractures/nonunions with proximal pole avascular necrosis and/or small proximal pole fragments.

The Vascular Anatomy of the Capitate: New Discoveries Using Micro-Computed Tomography Imaging

To study the intraosseous 3-dimensional microvasculature of the capitate bone using a novel high-resolution micro-computed tomography (μCT) imaging technology, and to examine the blood supply as it relates to the most common fracture types. Ten cadaveric wrists were injected with a lead-based contrast agent. The capitates were harvested and imaged using a μCT scanner. The intraosseous vascularity was incorporated into a 3-dimensional image. We measured the vascular pattern as well as the vessels' cross-sectional area, number, and distribution. An average capitate fracture line was calculated using clinical data from 22 patients with capitate fractures. The fracture line was projected on the representative capitate to assess its relation with the nutrient vessels' entry points. The capitate is a well-vascularized carpal supplied by dorsal and volar vascular systems that anastomose in 30% of cases. There was no predominance of one vascular system over the other. Most vessels enter the capitate at the distal half and supply the proximal pole in a retrograde fashion. In addition, most specimens (70%) also had at least one vessel entering the proximal pole through the volar capitate ligaments and supplying the proximal pole directly. The average fracture line had an oblique orientation, and 90% of the specimens had a blood vessel entering proximal to that line. This μCT vascular study further verifies that the capitate receives most of its vasculature in a retrograde fashion, but the study also shows that most capitates have vessels supplying the proximal pole directly. These findings might explain why most capitate waist fractures do not progress to proximal pole avascular necrosis. This study characterizes the microvasculature of the capitate and might shedlight on processes involved in bone healing and the etiology of capitate avascular necrosis.

Proximal scaphoid hemiarthroplasty for the treatment of post-fracture avascular necrosis of the proximal pole

Introduction The scaphoid is the most frequently fractured carpal bone. Most of its surface is covered by articular cartilage, which limits the space for the entrance of nutritious vessels. This leads to a precarious irrigation, especially at its proximal pole. A fracture further impairs bloodflow, which may lead to delayed union, nonunion, or even avascular necrosis of the proximal fragment. The proximal scaphoid hemiarthroplasty is one of the techniques available to treat the scaphoid proximal pole osteonecrosis. This part of the bone is substituted by a pyrocarbon implant that aims to maintain proximal carpal row kinematics and prevent carpal collapse, minimizing the risk for symptomatic osteoarthrosis. The goal of our study was to evaluate the long-term results of proximal scaphoid hemiarthroplasty for posttraumatic avascular necrosis of the scaphoid's proximal pole. Materials and methods Twelve patients who underwent this procedure were identified, and the average follow-up time was 6.5 years (range 5–8 years). All patients were male, with a mean age of 39 years (ranging from 28 to 55). In 8 patients the non-dominant limb was the one affected. The procedure was carried out through a dorsal approach and all patients were subjected to the same rehabilitation protocol. Functional results were determined using the QuickDASH and Mayo Wrist Score. Results There were no immediate postoperative complications such as infection or dislocation of the implant. All patients presented with peri-implant osteolysis at follow-up. None of the patients was forced to abandon their previous professional activity, even though 50% required some type of adaptation necessary at their workplace. The average functional capacity was, according to the Mayo Wrist Score, of 67.5 points (range 50–80), corresponding to a “Satisfactory” degree of function. From the application of the QuickDASH resulted an average disability of 25 (range 3–47.7). Discussion All patients mentioned as having the biggest disability with working with, or carrying, heavy objects. The results of this series are in line with previously published studies about this technique. Conclusion Hemiarthroplasty with a pyrocarbon implant is a safe technique for the treatment of post-fracture avascular necrosis of the scaphoid pole. This technique allowed for a satisfactory functional result at a mean follow-up of 6.5 years.

Factors Associated with Re-operation after Surgery for Scaphoid Nonunion: Level 4 Evidence

Hypothesis: To determine the rate of unplanned reoperation after surgery for scaphoid nonunion, the reasons for unplanned reoperation, and factors associated with unplanned reoperation. Methods: Using an institutional database, we identified 190 patients that had surgery for a scaphoid non-union from 2000 to 2013. There were 172men and 18 women with an average age of 26 11 years (Range, 16 to 84 years). The result of the surgerywas categorized as follows: no unplanned reoperation and healed fracture; unplanned reoperation for any reason; unplanned repeat surgery recommended but not done; and unknown status. We tested age, sex, affected side, interval between injury and operation, operation duration, fracture location, dorsal intercalated segment instability, surgeonperception of avascular necrosis of proximal pole, fixation device, type of bone graft, surgeon, and operative approach for association with unplanned repeat surgery. Results: After the index operation to treat scaphoid non-union in 190 wrists, 100 (53%) had no unplanned reoperation and healed; 39 (21%) had an unplanned reoperation; in 34 (18%) unplanned repeat surgery was recommended but not done; and in 17 the status was unknown (9%). After all subsequent surgeries, 110 patients (58%) healed (10 after one or more subsequent surgeries), 49 (26%) had persistent nonunion, 5 (3%) had a salvage procedure (e.g. excision of the distal pole of the scaphoid), and the status of 26 patients was unknown (14%). The indication for surgery in all 73 patients who had unplanned reoperation or recommended unplanned reoperation was persistent nonunion. In bivariate and multivariable analysis, the only factor related to reoperation was Kirschner wire rather than compression screw fixation of the scaphoid. Summary Points: Persistent nonunion is common after surgery for scaphoid non-union. Surgeries for persistent nonunion is even less successful.

Accuracy of enhanced and unenhanced MRI in diagnosing scaphoid proximal pole avascular necrosis and predicting surgical outcome.

Determine the sensitivity, specificity and accuracy of unenhanced and enhanced MRI in diagnosing scaphoid proximal pole (PP) avascular necrosis (AVN) and correlate whether MRI can help guide the selection of a vascularized or nonvascularized bone graft. The study was approved by the IRB. Two MSK radiologists independently performed a retrospective review of unenhanced and enhanced MRIs from 18 patients (16 males, 2 females; median age, 17.5 years) with scaphoid nonunions and surgery performed within 65 days of the MRI. AVN was diagnosed on the unenhanced MRI when a diffusely decreased T1-W signal was present in the PP and on the enhanced MRI when PP enhancement was less than distal pole enhancement. Surgical absence of PP bleeding was diagnostic of PP AVN. Postoperative osseous union (OU) was assessed with computed tomography and/or radiographs. Sensitivity, specificity and accuracy for PP AVN were 71, 82 and 78% for unenhanced and 43, 82 and 67% for enhanced MRI. Patients with PP AVN on unenhanced MRI had 86% (6/7) OU; 100% (5/5) OU with vascularized bone grafts and 50% (1/2) OU with nonvascularized grafts. Patients with PP AVN on enhanced MRI had 80% (4/5) OU; 100% (3/3) OU with vascularized bone grafts and 50% (1/2) OU with nonvascularized grafts. Patients with viable PP on unenhanced and enhanced MRI had 91% (10/11) and 92% (12/13) OU, respectively, all but one with nonvascularized graft. When PP AVN is evident on MRI, OU is best achieved with vascularized grafts. If PP AVN is absent, OU is successful with nonvascularized grafts.

The use of the free vascularised bone graft for nonunion of the scaphoid: a systematic review

BackgroundFractures of the scaphoid are well known to be problematic especially when complicated by avascular necrosis, nonunion and carpal collapse. Fixation techniques have involved nonvascularised bone grafting; however, in the presence of avascular necrosis, generally poor union rates (47%) occur as identified by a meta-analysis performed by Merrell et al. The introduction of pedicled vascularised bone grafts showed further improvement; however, in the presence of carpal collapse, union rates as low as 50% have been reported by Chang et al. amongst others using the 1,2-intercompartmental supraretinacular artery pedicled graft. The difficulty lies in having a short pedicle with limited manoeuvrability to correct a humpback deformity and insert into the scaphoid cavity. Prior trauma to the soft tissues or distal radius may prohibit the use of pedicled grafts. The aim of this systematic review is to examine the published evidence for the use of free vascularised bone grafts in cases of scaphoid nonunion.MethodsA systematic review was performed with the following defined search strategy on MEDLINE and Google Scholar: ((scaphoid nonunion) OR scaphoid pseudarthrosis) AND bone graft. Articles were reviewed and data compiled into tables for analysis. Statistical analysis was performed with determination of descriptive statistics, and differences between the groups were calculated using categorical variables and chi-square test. A p value of 0.05 or less was considered to be statistically significant.ResultsTwo hundred and sixty-three articles were identified with a total of 12 articles meeting the inclusion criteria. Two hundred and forty-five cases of scaphoid nonunion were identified through the articles included in this systematic review. Fifty-six patients underwent free vascularised bone grafts from the medial femoral condyle with a 100% union rate and correction of humpback deformity, and 188 patients underwent free vascularised bone grafting from the iliac crest with an 87.7% union rate. The difference between the two similar groups was statistically significant (p = 0.006).ConclusionsThe promising data suggests that the medial femoral condylar free graft based on the descending genicular vessels can be considered in cases of proximal pole avascular necrosis and humpback deformity or in situations where other flaps are precluded or deemed unlikely to cause union.

Free Medial Femoral Condyle Vascularized Bone Grafting for Scaphoid Nonunions with Proximal Pole Avascular Necrosis and Carpal Collapse

Treating scaphoid nonunions complicated by avascular necrosis and collapse with humpback deformity has proven challenging. Conventional nonvascularized interposition grafts restore the structural architecture, but fail to restore the vascular supply to the scaphoid. Pedicled inlay grafts restore blood flow, but fail to correct the humpback deformity or restore scaphoid length. Restoration of both vascularity and geometry is critical for promoting bony union. The free vascularized medial femoral condyle bone graft provides both and has proven successful in treating this problematic subset of scaphoid nonunions. The rationale, indications, contraindications, anatomical basis, and technique of scaphoid preparation, bone graft harvest, insetting, fixation, and microvascular anastomosis are presented for the treatment of scaphoid nonunions with avascular necrosis and carpal collapse.

Role of Vascularized Bone Grafts in the Treatment of Scaphoid Nonunions Associated With Proximal Pole Avascular Necrosis and Carpal Collapse

I a r n e THE INCIDENCE OF scaphoid nonunion has been estimated to be approximately 15% and can be related to a delay in diagnosis and treatment, roximal location of the fracture, displacement greater han 1 mm, and carpal instability. Left untreated, these wrists often undergo progressive, predictable degenerative changes also known as scaphoid nonunion advanced collapse. Avascular necrosis (AVN) of the scaphoid ocurs in an estimated 3% of all scaphoid fractures. Predominantly seen within the proximal pole, the etiology has been attributed to the retrograde intraosseous blood supply of the scaphoid. Plain radiographic signs of AVN include sclerosis of the proximal pole with occasional fragmentation and collapse. Computed tomography scans can effectively demonstrate collapse and bony characteristics of the nonunion, including resorptive findings, sclerosis, narrowing of joint spaces, and fragmentation. Magnetic resonance imaging (MRI) has been recommended to assess the vascularity of the proximal pole. Standard MRI has been shown to have an accuracy of 68%, which increases to 83% when gadolinium-enhanced MRI is used. Despite this, many surgeons rely solely on this modality, which only measures edema within the bone, not the actual blood flow. Currently, the only definitive method to determine vascularity of the proximal pole is direct intraoperative assessment to determine absence or presence of punctate bleeding of the proximal fragment, as was described by Green in 1985.

Medial femoral condyle vascularized bone grafts for scaphoid nonunions

Free vascularized bone grafts from the medial femoral condyle provide both structural support and blood supply to promote union in the difficult subset of scaphoid nonunions complicated by humpback deformity and proximal pole avascular necrosis. These nonunions have not consistently achieved union when treated with grafts which fail to restore scaphoid geometry or vascularity. The rationale, indications, contraindications, technique and results of bone grafting scaphoid nonunions with grafts harvested from the medial femoral condyle are presented.

A New Volar Vascularization Technique Using the Superficial Palmar Branch of the Radial Artery for the Collapsed Scaphoid Nonunion

Achieving union to prevent scaphoid nonunion advanced collapse wrist in the scaphoid nonunion is a challenging clinical problem. Much of the difficulty relates to the tenuous blood supply to the scaphoid. One unsolved reconstructive problem is the collapsed scaphoid that requires an intercalated wedge graft with proximal pole avascular necrosis. We offer a simple technique that only requires preservation of the superficial palmar branch of the radial artery that is typically ligated during the volar approach to the scaphoid. This technique can also be used during any open volar approach to the scaphoid to increase vascularity and healing.

Vascularized Bone Grafting of Scaphoid Nonunions

Scaphoid fractures represent the most common carpal fracture and must always be included in the differential diagnosis for wrist pain in the athlete. In the short-term, nonunions may result in mild discomfort; however, the long-term sequelae of nonunions result in a predictable descent into wrist arthrosis. Athletes with excellent compensatory ability and multiple incentives to continue in sport may neglect these injuries until significant disruption of the scaphoid blood supply or arthritic changes have already occurred. The restoration and evaluation of scaphoid vascularity represent a challenging and important area of hand surgery. Magnetic resonance imaging and computed tomography (CT) scans have important roles in evaluating these injuries before and after surgery. Stable fixation and the use of local pedicled bone grafting or free vascularized grafts are the mainstays of treatment. Although technically more complex, better results have been reported with vascularized bone grafting and fixation compared with fixation and nonvascularized grafting alone, especially in cases of proximal pole avascular necrosis.

Outcome After Vascularized Bone Grafting of Scaphoid Nonunions With Avascular Necrosis

Vascularized bone grafting has been proposed as a treatment for scaphoid nonunions with avascular necrosis of the proximal pole. The purpose of this investigation is to report the results of vascularized bone graft and internal fixation for established scaphoid nonunions with proximal pole avascular necrosis as measured by validated outcome instruments. From 1996 to 2004, 30 consecutive patients with established scaphoid nonunion, proximal pole avascular necrosis, and no prior surgery were treated with open reduction and internal fixation in addition to a vascularized bone graft based on 1,2 intercompartmental supraretinacular artery. A total of 19 patients had nonunions of the scaphoid waist and 11 had nonunions of the proximal pole of the scaphoid. Preoperative and postoperative evaluation included measurement of clinical (grip strength and range of motion), radiographic (scapholunate angle, scaphoid height-to-length ratio, and radioscaphoid arthritis), function (Disabilities of the Arm, Shoulder, and Hand questionnaire) and satisfaction parameters. We recorded union and return to activity and analyzed data both in the aggregate and stratified by nonunion location. Union rate was 28 of 30 (93%) and time to union was 5.1 months (+/-2.4). Significant improvements were found for grip strength, Disabilities of the Arm, Shoulder, and Hand score, satisfaction score, and scaphoid height-to-length ratio (p < .01). No significant difference was found for composite wrist range of motion. Two patients experienced complications and required a second procedure to achieve union. A total of 28 of 30 (93%) of patients returned to work or sports activity at their preinjury level. The results of this investigation support the use of a vascularized bone graft for the treatment of scaphoid nonunions with avascular necrosis of the proximal pole.