Proximal Pole Scaphoid Fracture Nonunion Treated With Ipsilateral Hamate Transfer: A Case Series.

Purpose: The scaphoid's retrograde blood flow renders it vulnerable to fracture nonunion proximally. As proximal fragmentation occurs, reconstructive options become challenging with little consensus regarding treatment. Proposed surgical techniques include vascularized or nonvascularized grafts and fragment excision with scapholunate (SL) ligament advancement. We hypothesized that ipsilateral proximal hamate with volar capitohamate ligament autograft would provide a viable treatment for proximal pole scaphoid nonunion in a sample drawn from a military population.

Methods: Eleven patients with fragmented proximal pole scaphoid nonunion underwent open fragment excision and internal fixation with ipsilateral proximal hamate transfer by a single surgeon at a tertiary-referral military hospital. Patient demographics, clinical parameters, return-to-duty rates, and Quick Disabilities of the Arm, Shoulder, and Hand questionnaire scores were obtained. Radiographs and computed tomography scans were evaluated to determine preoperative lunate height and proximal pole fragmentation and postoperative SL widening, carpal alignment, and bony healing. Descriptive statistics were used for analysis.

Results: The 11 patients were male active-duty service members, with an average age of 24.3 years (range: 18-29 years) and an average follow-up of 96 weeks. The average preoperative lunate height was 7.2 mm. The harvested hamate graft length was equal to the lunate height. The average final postoperative SL widening was 1.5 mm, a reduction of 23.3% from initial postoperative radiographs. One patient was excluded, and one patient required reoperation for arthrofibrosis. At the last follow-up, 10 patients demonstrated radiographic evidence of union, and 6 returned to unrestricted military service. The average Quick Disabilities of the Arm, Shoulder, and Hand Questionnaire score for 10 patients was 15.7 at the final follow-up.

Conclusions: In the short-term follow-up, treating proximal pole scaphoid nonunion with ipsilateral proximal hamate autograft transfer results in reliable bony union, stable radiographic SL alignment, and low levels of disability while avoiding risks and morbidity associated with other options.

Type of study/level of evidence: Therapeutic V.