Treatment Of Scaphoid Nonunion Research Articles

Greffe cortico-spongieuse ou greffe spongieuse pure dans les pseudarthroses instables du scaphoïde

IntroductionThis study was undertaken to determine whether corticocancellous bone grafting and cancellous bone grafting differ in terms of bone union rate, restoration of scaphoid anatomy, and wrist function when unstable scaphoid nonunion are concomitantly treated by screw fixation. Materials and methodsThis is retrospective cohort study. In group A (17 patients), unstable scaphoid nonunion was treated with corticocancellous graft harvested from the iliac crest and headless compression screw using volar approach. In group B (18 patients), unstable scaphoid nonunion was treated with cancellous graft harvested from the distal radius or iliac crest and headless compression screw using volar approach. Mean time to union was measured using CT image. Scaphoid deformity was also measured using lateral intrascaphoid angle and height to length ratio using CT images. Wrist functional status was assessed by measuring grip strength, wrist range of motion and DASH score at 1 year postoperatively. ResultsMean time to union was significantly greater in group A (15 weeks vs. 11 weeks). No significant intergroup difference was observed for lateral intrascaphoid angle and height to length ratio after treatment of scaphoid nonunion. No significant intergroup difference was observed for grip strength, wrist range of motion, or DASH scores at 1 year postoperatively. ConclusionsCancellous bone grafting was found to lead to earlier bone union than corticocancellous bone grafting and to similar restorations of scaphoid deformity and wrist function when scaphoid nonunion was treated by headless compression screw fixation and bone grafting. Level of EvidencePrognostic III.

The Vascularity and Osteogenesis of a Vascularized Flap for the Treatment of Scaphoid Nonunion: The Pedicle Volar Distal Radial Periosteal Flap.

Background: Vascularized periosteal flaps from the distal radius have been previously proposed. The purpose of this study was to investigate the vascularity and osteogenic potential of a vascularized volar distal radial periosteal flap for the treatment of scaphoid nonunion. Methods: In 5 fresh frozen cadavers, a rectangular periosteal flap was elevated from the distal radius with the pedicle just proximal to the watershed line. Latex dye was injected into the radial artery proximally and the vascularity of the flap characterized by microscopic evaluation. Patients with scaphoid nonunion were then treated with open reduction, internal fixation, and distal radius cancellous bone graft. Two groups of patients with midwaist nonunion scaphoid were then evaluated. The first group received the vascularized periosteal flap and the second group received a nonvascularized periosteal flap. A third group of proximal pole nonunions also received the vascularized flap. Results: Cadaveric dissections revealed that all of the injected flaps demonstrated vascularity to the distal edge of the flap. Vascularized flaps formed visible bone on imaging in 55% of cases. None of the nonvascularized flaps formed visible bone. In group 1, 12/12 midwaist nonunions united. In group 2, union was achieved in 6/6 of patients who completed the follow-up. In group 3, 6/7 proximal pole fractures united. Conclusions: Previously proposed vascularized periosteal flaps from the distal radius appear to possess notable osteogenic potential that may be of interest to surgeons treating scaphoid nonunion.

Vascularized Bone Grafts for the Treatment of Scaphoid Nonunion

Scaphoid nonunion without treatment can progress to carpal collapse and a predictable pattern of radiocarpal arthrosis. Surgical intervention is indicated to prevent progressive carpal instability and arthritis. In proximal pole nonunion and occasionally in scaphoid waist fracture with osteonecrosis, or when traditional bone grafting has failed to achieve union, vascularized bone grafts are used because they improve the biology of bone healing. This review describes the most common vascularized bone grafts used to treat scaphoid nonunion, either pedicled or free.

Scaphoid nonunion: what is the role of the Zaidemberg 1,2 intercompartmental supraretinacular arterial flap?

The reported results for the treatment of scaphoid nonunions with non-vascularized grafts are based on observational studies with a high variability in union rates from 38%-100% and time to union from 6-18 weeks, and there is also a lack of a standard classification. Meta-analyses and systematic reviews have been presented to better support conclusions from large pools of data (604 to 5246 cases), but their interpretation remains limited because of lack of uniformity in the studies analysed. Several authors have presented results from the Zaidemburg flap, with highly variable outcomes despite using the same technique; union rates have ranged from 27%-100% achieved between 6.5-19 weeks. Technical details that may be responsible for the discrepancies are discussed. There is a need for a validated prognostic classification system for scaphoid nonunions that can allow comparisons between outcome studies.

Outcomes of Scaphoid Nonunion with Segmental Defect Treated with Plate Fixation and Autogenous Cancellous Graft: First Clinical Report

There is no financial information to disclose. Treatment of scaphoid nonunion with segmental defect presents a challenging clinical problem. Various techniques have been proposed, usually involving vascularized bone grafting with or without structural bone. Outcomes of these complex procedures have been inconsistent in the medical literature. The authors hypothesize that similar or perhaps better clinical and radiographic outcomes are possible with a relatively simplified technique of volar plate fixation augmented with autogenous pure cancellous graft. The authors performed a retrospective chart review of 49 consecutive patients with scaphoid nonunion with segmental defect treated with plate fixation and pure cancellous bone grafting. Surgical management included a single volar incision, reduction, insertion of bone graft from ipsilateral olecranon and/or distal radius, and application of a volar locking plate. Post-operative outcome measures included time to union based on computerized tomography (CT), return to work, patient-reported pain and disability scores, grip strength, and range of motion (ROM). The average patient was 31 years old and treated an average of 28 months after initial injury. Twenty-nine patients (59.0%) were treated for nonunion at the scaphoid waist, 19 (38.8%) at the proximal pole, and 1 (2.0%) at the distal pole. 13 patients (26.5%) were treated specifically for avascular necrosis confirmed with magnetic resonance imaging (MRI). Mean follow-up was 18.9 months (range, 12-34). Union was achieved in all patients and average time to union was 78 +/- 18.4 days post-operatively. Complications included symptomatic hardware that required plate removal for 1 patient. Mean DASH score improved from 13.4 +/- 0.5 pre-operatively to 41.4 +/- 3.7 post-operatively. Mean visual analogue scale (VAS) improved from 7.0 +/- 0.7 pre-operatively to 2.1 +/- 0.7 post-operatively. All employed patients returned to work, although 5 (13.9%) did not return to full capacity. Grip strength improved from 79.9% of the non-operative side pre-operatively, to 93.5% post-operatively. At final follow-up, ROM including wrist flexion, extension, ulnar deviation, and radial deviation improved 128%, 173%, 112%, and 164%, respectively, compared to pre-operative ROM. •The combination of scaphoid plate fixation and pure cancellous bone grafting for scaphoid nonunions with segmental defects yields reliable union rates and good patient outcomes.•Autogenous cancellous bone grafting is a reliable alternative to more technically demanding or morbid grafting procedures for the treatment of scaphoid nonunions with segmental bone defects.•In cases of avascular necrosis, outcomes of volar locked plating with pure cancellous grafting appear to be similar, if not superior, to those reported for vascularized bone grafting techniques.

Scaphoid nonunion: does open reduction, bone grafting and Herbert screw fixation justify the treatment?

Conventional bone grafting and Herbert screw fixation give satisfactory results for scaphoid nonunion; however, vascularized bone grafting has superior results, especially in the case of avascular necrosis of proximal fragment. Vascularized bone grafting is technically more demanding with small error of margin, problems of getting the appropriate graft, fixation and incorporation, and requires longer duration for wrist immobilization. Forty-five patients of scaphoid nonunion were treated by cancellous bone grafting, cortex containing graft if required and Herbert screw fixation. Functional outcomes were assessed at the latest follow up after surgery (minimum oneyear after surgery). The average pre-operative and post-operative scapho-lunate angle, grip strength, flexion-extension movement, radio-ulnar movement, scaphoid index and modified mayo score were improved from 49.60±6.40° (37-66) to 36.26±4.73° (range 28-46), 20.66±3.17kg (15-27) to 31.11±3.29kg (range 25-40), 78.57±14.22° (45-110) to 132.86±13.90° (100-165), 30.06±6.06° (20-44) to 44.95±6.37°(range 35-59), 0.66±0.076 (0.55-0.79) to 0.60±0.065 (range 0.49-0.73) and 58.66±5.24 (50-70) to 84.37±5.01 (range 75-95), respectively, with P value <0.001. Based on modified mayo score, 21 (46.7%) patients had excellent results, 19 (42.2%) had good results, 4 (8.9%) had fair results and one patient (2.2%) had poor results. Bone grafting and Herbert screw fixation provides a good option for treatment of scaphoid nonunion, especially in the absence of avascular necrosis of proximal fragment. More importantly, vascularized bone grafting in all scaphoid nonunion may not be necessary and could otherwise have been united uneventfully by this technique. However, avascular necrosis of proximal fragment must be ruled out pre-operatively as well as intra-operatively.

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.

Low-Intensity Pulsed Ultrasound for Nonoperative Treatment of Scaphoid Nonunions: A Meta-Analysis.

Background: Scaphoid fractures progress to nonunion rates of up to 15% when non-displaced, and are even more frequent when the fracture is displaced. Standard treatment in these cases is surgery; however, individuals unable to undergo this operation, or for those who wish to try more conservative measures, there may be benefit from nonoperative options. Of these, low-intensity pulsed ultrasound (LIPUS) has been shown to improve fracture nonunion healing. The purpose of this study was to perform a comprehensive meta-analysis of relevant literature to determine success of the use of LIPUS for treatment of scaphoid nonunion. Methods: Utilizing PubMed, Embase, and Ovid databases, we performed a literature search using key terms for scaphoid nonunions. A total of 686 studies met initial search criteria. Studies reporting fewer than 5 cases, those not published in English, those not related to LIPUS nonoperative scaphoid nonunion treatment, and those without sufficient data were excluded. Five studies met these criteria, and statistical analysis was performed to determine overall union rates. Results: The use of LIPUS on 166 nonunions reported a mean healing index of 78.6%. The average time to union following LIPUS treatment was 4.2 months. Conclusions: While surgical intervention is still the standard, our results show that LIPUS may serve as a nonoperative alternative to scaphoid nonunion in certain cases. The results are encouraging in which these challenging fracture a nonunions can heal without further surgical intervention in the majority of patients.

Internal Bone Grafting for the Treatment of Scaphoid Nonunions.

Scaphoid fracture is the most common carpal fracture of the upper extremity and a significant proportion of these can eventually progress to nonunion. Excision of pseudoarthrosis and fibrous scar tissue at the nonunion site is regarded as one of the important steps in management of scaphoid nonunions. We describe a technique of internal bone grafting, where curettage of the nonunion site was performed through a drill hole in the scaphoid and bone graft was packed through this same hole before fixation with a headless compression screw. We have been able to achieve a union rate of 86% using this technique. The advantage of the technique is that it does not disturb the external fibrocartilaginous shell that would have formed around the nonunion site, thus leaving the articular surface undisturbed.

Management of nonunion following surgery of scaphoid fracture

Treatment of scaphoid nonunion after failed surgery for acute scaphoid fracture presents a unique challenge. Prior surgery complicates evaluation of the patient and increases the technical difficulty of future procedures. Healing of nonunion is crucial to prevention of carpal collapse and progressive arthritis. It is required to identify whether the technical factors or treatment methods led to the failure of primary surgery. CT is important for confirming nonunion and planning revision surgery. Several studies have described the use of bone grafts and fixation devices for scaphoid nonunion repair, including nonvascularized and vascularized bone grafts, screws, pins, and plates. Satisfactory healing rates have been achieved using nonvascularized bone grafts supplemented with screw or wire fixation, especially in the absence of bone necrosis. Although vascularized grafts require high demanding surgical skills, they improve the odds of union in the setting of osteonecrosis. Key words: Carpal joints; Scaphoid bone; Fractures, ununited; Surgical treatment

Vascularized versus non-vascularized bone grafts in the treatment of scaphoid non-union

Conventional non-vascularized bone grafts as well as vascularized bone grafts are used to treat scaphoid non-union (SN). Due to limited available studies, the field of application using both grafts for SN still remains controversial. The aim of this study was to evaluate a treatment algorithm for the use of both vascularized versus non-vascularized bone grafts based on clinical outcomes and quality of life (QoL) to improve the level of evidence. Based on a retrospective cohort study, including 28 patients with vascularized and 45 patients with conventional bone grafts, functional parameters, radiological outcome, Mayo-wrist-score, and QoL by SF-36 were applied to statistically compare the outcome of these two techniques. Time between last procedure or trauma and study group scaphoid reconstruction was almost double in the vascularized bone grafting group. Comparable union rates were achieved with vascularized as well as non-vascularized bone grafts. Significant differences were observed between both groups for grip strength and radial-ulnar active range of motion. Further functional outcomes, radiological outcomes as well as QoL were found similar for both techniques in patients with surgical union. In order to achieve comparable and appropriate treatment results, vascularized bone grafts are recommended for patients with delayed treatment, impaired scaphoid vascularity, and revision surgery. Even in preselected, complex cases, the results are comparable to conventional grafts, which are the basis for further patient education and approve the powerful role of surgical angiogenesis of vascularized bone grafts.

A Critical Appraisal of Vascularized Bone Grafting for Scaphoid Nonunion.

Background Vascularized bone grafting (VBG) has the potential to yield reliable results in scaphoid nonunion; however, results across studies have been highly variable. This study critically evaluates surgical techniques, fracture location, and patient selection in relation to radiographic, clinical, and patient-centered outcomes after VBG for scaphoid nonunion. Methods We conducted a systematic review of the literature for the use of VBG in scaphoid nonunion. Physical examination, radiographic, and patient-centered outcomes were assessed. Four substratifications were performed: the location of scaphoid nonunion, pedicled versus free technique, Kirschner wire (K-wire) versus screw fixation, and VBG done as a primary versus revision procedure. Results A total of 41 publications were included in final analysis. VBG had an 84.7% union rate at 13 weeks after surgery. On an average, 89% of patients returned to preinjury activity levels by 18 weeks after surgery and 91% of patients reported satisfaction with the procedure. Proximal pole nonunions demonstrated similar union rates but lower functionality scores compared with nonunions across all regions of the scaphoid. Pedicled techniques demonstrated slightly improved range of motion compared with free technique. K-wire versus screw fixation demonstrated significantly higher union rates and faster union times. There were no differences in outcomes for VBG done as a primary versus revision procedure. Conclusion VBG serves as a viable option for the treatment of scaphoid nonunion, with consistent union rates in addition to significantly improved postoperative patient functionality. The fixation of these vascularized bone grafts with K-wires versus screw fixation may result in superior radiologic outcomes. Level of Evidence Therapeutic, Level III, systematic review.

Intramedullary Screw and Kirschner Wire Fixation for Unstable Scaphoid Nonunion.

Surgical treatment of scaphoid nonunion is not always successful, often requiring stabilization and bone grafting to achieve healing. Even after intramedullary screw fixation, residual instability may still hinder union. The purpose of this study was to describe the addition of Kirschner wires (KWs) through the capitate and the lunate to supplement an intramedullary screw for temporary enhanced stability, possibly improving healing of unstable fractures. A case-control study reviewing 25 cases with addition of KWs and 19 controls was performed. Demographic and fracture information, time to diagnosis, and healing time were documented. We found no differences in population characteristics, fracture characteristics, or outcome measures between patients treated with this method and those treated with a screw alone. We had no complications related to the addition of KWs. Preoperative lunate type and scapholunate gapping was suggestive but not significantly associated with KW insertion. Addition of KWs is safe and may be considered in scaphoid nonunion in the presence of intraoperative suboptimal stability. Intraoperative stability may possibly be inferred by reviewing preoperative radiographs for signs of instability.

Prognostic factors in the treatment of carpal scaphoid non-unions.

In this literature review, the authors analyse the prognostic factors in the curative treatment of scaphoid non-unions. The main negative prognostic factors are smoking, the time elapsed since the fracture, and avascular necrosis of the proximal fragment. If the latter is present, the revascularization by a pedicle or microsurgical bone autograft is probably the treatment of choice. In non-unions without evidence of osteonecrosis, vascularized bone grafts are probably not superior to conventional bone grafts, which can presently be performed under arthroscopic control, with minimal morbidity.

Management of scaphoid nonunions with vascularized bone grafts from the distal radius: mid- to long-term follow-up.

Scaphoid nonunion represents a challenging problem that leads to disability if neglected. Vascularized bone grafts are proposed to augment the local biology and increase the likelihood of union but long-term outcomes are sparse. In this work, we present the mid- to long-term outcome of 140 scaphoid nonunions managed with vascularized bone grafts from the distal radius. Sixteen patients underwent concomitant closed wedge osteotomy of the distal radius because of arthritic changes. There were 130 males and ten females, with mean time from injury to surgery 3.3years. Delayed presentation was associated with arthritic changes. Forty-two patients had avascular necrosis of the proximal pole and sixteen had more severe arthritic changes. The mean follow-up was 10years. Pain decreased postoperatively but range of motion did not improve but only in early reconstructions. Grip strength reached 79% of the non-injured hand. Mayo modified wrist score improved from 56 to 84 (p<0.001). Except one, all the rest 139 nonunions healed in a mean time of 9weeks. MRI evaluation in 77 patients revealed healing at a mean of 3months postoperatively even in cases of avascular necrosis. Scaphoid length, carpal height, and scapholunate angle increased, but capitolunate did not change significantly. The presence of arthritis preoperatively was associated with progression of arthritic changes after 10years. Treatment of scaphoid nonunions with vascularized bone grafts from distal radius reliably led to highest rate of bone healing with good mid- to long-term outcomes. Enhancement of the local biology and reconstitution of scaphoid and carpal height resulted in improved function mostly in early interventions.

Percutaneous Fixation for Scaphoid Nonunion with Bone Grafting Through the Distal Insertion Hole of a Fully Threaded Headless Screw.

Percutaneous scaphoid screw fixation is a popular treatment for acute scaphoid fractures with no or minimal displacement. For treating scaphoid nonunions, however, open reduction and internal fixation with bone grafting is still the most popular treatment. Percutaneous fixation with bone grafting through the screw insertion hole has received little attention, although it minimizes damage to the surrounding tissues. We report excellent results of six scaphoid nonunions treated by retrograde percutaneous fixation with curettage and bone grafting through the distal insertion hole of a fully threaded headless screw. Six scaphoid nonunions with substantial bone loss were treated, including one revision case. All nonunions were located at the middle third of the scaphoid. The mean patient age at operation was 26 years, and the mean interval between fracture and surgery was 7 months. In the revision case, the interval between the primary and revision surgery was 6 months. In one case, curettage alone was performed before retrograde insertion of the headless screw. In the other cases including the revision, curettage and bone grafting with a bone biopsy needle was required through a distal insertion hole. The mean follow-up was 11.3 months. Radiologically, union was achieved at averaged 12 weeks postoperatively. At the final follow-up, there was significant improvement in the wrist extension range of movement (from 65.8° to 80.8°) and grip strength (from 69.5% to 93.0% of the unaffected side). Five patients were free of pain, and one experienced mild pain only during heavy manual labor. The mean VAS, DASH, and Cooney wrist scores were 0.3, 1 and 99, respectively. All patients returned to their work or athletic activities. Retrograde percutaneous fixation with bone grafting through the distal insertion hole of a fully threaded headless screw is a promising option for surgical treatment of scaphoid nonunions.

Scaphoid reconstruction with vascularized bone grafts from the distal radius

The aim of the present technical report is to describe the alternative solutions for the reconstruction of scaphoid nonunions with pedicled vascularized bone grafts from the distal radius. The surgical technique for the reconstruction A. of proximal scaphoid nonunions with pedicled bone grafts (based on the 1,2 or on the 2,3 intercomparmtental arteries) or with capsular bone grafts from the dorsal distal radius and B. of waist nonunions of the scaphoid with grafts from the palmar distal radius, pedicled on the palmar carpal arch, is presented. Vascularized bone grafts from the adjacent radius are used for the treatment of scaphoid nonunions to enhance union and to revascularize a nonviable proximal pole. The most suitable graft is selected according to the location of the nonunion (at the waist or the proximal pole of the scaphoid) and to the previous procedures/scars at the wrist level.

Treatment of Scaphoid Nonunion by Surgery and Extracorporeal Shockwave Therapy

Objective/Hypothesis: Nonunion of the scaphoid is even today a challenge for the treating hand surgeon. Main cause of a scaphoid nonunion is the missed fracture, an inadequate immobilization or a fracture in the proximal third. As a consequence, scaphoid nonunion led to an osteosclerosis at the fracture surfaces and tilting of the fracture (“humpback deformity”). These changes consequently result in the end in a carpal collapse, the so-called scaphoid nonunion advanced collapse (SNAC) wrist. Several methods for treating scaphoid nonunion are available, like sole bone graft in the technique according to Matti-Russe, with or without additional stabilization by a headless bone screw or plate. In the last decades, Extracorporeal Shockwave Therapy (ESWT) has become an established procedure for nonunion treatment. However, the mechanism of shockwave therapy is poorly understood, but it is considered verified, that it leads to angiogenesis and vasculogenesis in the treated tissue, which causes a persisting increase of blood supply. Main aim of this study was to investigate union rate and clinical outcome of a combined treatment of scaphoid nonunion by surgery and ESWT. Material and Methods: Twenty-three patients with scaphoid nonunion treated by nonvascularized bone graft from the iliac crest, followed by ESWT within 2 weeks postsurgery, were investigated. A scaphoid plate was used in 11 patients, a double cannulated compression screw (CCS) in 9 patients, and 1 CCS in 3 patients. Age, gender, range of motion (ROM), date of surgery, the last follow-up examination, and surgical technique were included in the statistical analysis. Disabilities of the Arm, Shoulder and Hand (DASH) scores, Patient Rated Wrist Evaluation (PRWE), the Green O’Brien Score, and the Michigan Hand Questionnaire score were determined for all patients. A computed tomography (CT) was performed to analyze union and signs of osteoarthritis. An existing dorsal intercalated segment instability (DISI) deformity, a SNAC wrist, or a humpback deformity were registered. Results: The mean duration of follow-up was 20 ± 10 months. In the last CT, 87% of scaphoid nonunions healed. All scaphoid nonunions treated by plate showed union at follow-up. The mean DASH score was 12 ± 13 points, PRWE 12 ± 12 points, and Michigan Hand Questionnaire score 86%. The mean Green O’Brien was 87, which indicates a good clinical outcome. The mean ROM in the sagittal plane was 88 ± 18% while forearm rotation was 98 ± 5% compared with the healthy side. Two patients had a humpback deformity and 5 a mild DISI deformity. No patient had a SNAC wrist. Conclusion: The results of this case series suggest that a combination of surgery and extracorporeal shockwave is suitable for treating scaphoid nonunion with a good functional outcome. An additional finding was that all nonunions treated by a scaphoid plate healed at follow-up.

Failed Scaphoid Surgery With Nonunion, Bone Defect, and Loose Headless Screw Treated by Nonunion Resection, Bone Grafting, and Scaphoid Plating

Objectives: Failed scaphoid osteosynthesis or failed scaphoid nonunion treatment with headless screw lead to a persistent scaphoid nonunion with loose screw, bone defect that is not just between proximal and distal fragment but also around loose screw within these fragments. Stable intramedullary screw fixation is seldom possible. In these cases, stable fixation maybe performed by using scaphoid plate and angular stable screws. Patient and Methods: Ten consecutive patients with persistent scaphoid nonunion after primary osteosynthesis for fracture treatment or after secondary treatment for scaphoid nonunion were within the group. Size of the fragments and bone defect within proximal and distal fragments did not allow operating surgeon to use headless screw for stabilization. All patients were treated by screw removal, nonunion resection, bone grafting by autograft from iliac crest, and stabilization by 1.5 mm scaphoid plate with angular stable screws through volar approach. Surgery was followed by 6 weeks of casting and 6 weeks of protected mobilization. All patients were followed clinically and radiologically at 2, 6, 12, and 24 weeks after surgery until clear signs of healing or nonhealing of the scaphoid. In case of doubts about the healing process, computed tomography (CT) scan was used for confirmation and patients were followed up to 18 months after surgery. In 2 patients with screw inserted from proximal pole, second approach was used with stabilization through volar approach. In 2 patients, removal of the screw was impossible so it was decided to leave the screw within the bone with grafting around it and applying adjacent plate stabilization on top. Results: Eight patients healed the scaphoid. Wrist synovitis disappeared with scaphoid stabilization. Pain subsided to 0 in 6 with return of full wrist motion and function. In 2 cases, residual motion limitation of 20° and 30° with residual pain at the end of motion arc in heavy load persisted. Two patients that failed to heal have persistent wrist synovitis, motion limitation, and pain with function restriction. One of the persistent nonunions was 9 years old nonunion and second had small proximal fragment with difficulty to fix proximal fragment with screws. In 4 patients, plate was removed in second setting. Discussion: Persistent scaphoid nonunion after previous attempts to heal it with loose headless screw within the bone mean structural problem for operating surgeon due to necessity to reconstruct shape of the bone and stabilize it by osteosynthesis. Intramedullary screws cannot be used in this occasion. Extramedullary stabilization by scaphoid plate and angular stable screws owes reliable stabilization necessary for scaphoid healing and maybe treatment of choice as we have shown in this presentation.