Necessity of grafting in scaphoid nonunion fixation: A comparative outcome analysis

Table 5 Comparative studies evaluating graft-less vs graft-augmented fixation in scaphoid nonunion treatment

Ref.	Technique	Fixation device	Follow-up period	UR	HT	Clinical results	Complications
Graft-less vs graft-augmented fixation approaches for scaphoid nonunion
Current study	Mini-open screw fixation vs open curettage-grafting and screw fixation	Screw	27.52 ± 3.1 months	Graft-less fixation: 76.2%; fixation with BG: 87%	Graft-less fixation: 16.2 ± 2 weeks; fixation with BG: 12.5 ± 1.4 weeks (P < 0.001)	Graft-less fixation: Radial and ulnar tilt were greater (P = 0.004, P < 0.001, respectively). The grip strength ratio was also higher (P < 0.001). The MMW score was significantly better (P = 0.01). No relevant difference was noted between both groups regarding all other clinical outcomes	Nonunion: 5 patients (23.8%) after graft-less fixation and 3 patients (13%) with BG utilization. Graft-less group: Superficial wound infection (n = 1). Graft-augmented fixation: Mechanical radial sided wrist pain (n = 1)
Zengin N et al[20], 2023, retrospective	PC screw fixation (n = 16) vs open curettage-grafting and screw fixation (n = 17)	Screw	12 months	CRIF: 12/16 (75%); ORIF: 15/17 (88%) (P = 0.34)	CRIF: 11.8 weeks (8-17 weeks); ORIF: 12.5 weeks (9-17 weeks) (P = 0.41)	No statistically significant difference between both groups regarding postoperative flexion, extension ROMs, grip strength, and DASH score	Nonunion: 4 patients (25%) in the CRIF group and 2 patients (11%) in ORIF group
Zhong et al[28], 2023, retrospective	ORIF (group A) vs PC fixation (group B) vs PC fixation and PRP injection (group C)	Screw	12 months	Grade III SNU: No significant difference among the three groups (P = 0.52). URs were 90.9%, 100%, and 100%, respectively; grade IV SNU: UR was lower in group B than other groups. URs were 90%, 71.4%, and 90.9%, respectively	NR	Grade III SNU: No significant differences in VAS and MMW among the three groups. Grade IV SNU: Groups A and C had significantly lower VAS score and significantly higher MMW score, compared to group B. However, there was no significant difference between groups A and C	Grade III SNU: Nonunion in 9% of patients of group A. Grade IV SNU: Nonunion in 10%, 28.6%, and 9% of groups A, B, and C, respectively
Atilgan et al[19], 2022, retrospective	PC screw fixation (n = 19) vs NVBG and screw fixation (n = 24)	Screw	CRIF: 18.9 ± 1.8 months; ORIF: 16 ± 1.95 months	CRIF: 84.2% (n = 16); ORIF: 87.5% (n = 21)	CRIF: 17.19 ± 2.19 months; ORIF: 14.14 ± 1.82 months (P < 0.001)	MMW score: No statistically significant difference (P = 0.930). VAS score: Statistically significantly higher after CRIF than in ORIF (P = 0.012)	Nonunion: Three patients (15.7%) in the CRIF group, and 3 (12.5%) in the ORIF group
RCTs comparing employment of VBGs vs NVBGs in fixation of scaphoid nonunion
Fan et al[42], 2023	DR pedicled VBG (n = 20) vs IC NVBG (n = 18)	K-wires	One year	VBG: 19/20; NVBG: 16/18	HT was similar (VBG: 16 ± 22 weeks; NVBG: 17 ± 33 weeks)	There were no significant differences between the two groups in ROM, grip strength or functional scores	Nonunion: VBG group (3/20) following K-wire migration, and NVBG group (2/18)
Caporrino et al[41], 2014	DR VBG (n = 35) vs DR NVBG (n = 38)	K-wires	VBG: 29.4 months; NVBG: 28.6 months	No significant difference in UR (88% for VBG vs 80% for NVBG; P = 0.312)	VBG: Bony union was earlier by 12 days compared to NVBG (P = 0.002)	VBG group: Ulnar deviation was lower (P = 0.003), and radial deviation as well (P = 0.064). No significant differences were found for the remaining clinical outcomes	Nonunion rate in VBG group (11%) and NVBG group (20%)
Goyal et al[35], 2013	DR NVBG (n = 42) vs IC NVBG (n = 46)	Herbert screw	Group 1: 4.8 years; group 2: 5.2 years	No significant difference in UR (87.1% vs 86.5%)	Group 1: 4.2 months; group 2: 4.5 months	No significant difference regarding ROM, functional scores. Mean pain VAS scores were significantly different (group 2: 7.1, group 1: 4.2)	Iliac NVBG (local): Local hematoma required drainage (n = 1). Chronic pain for 3 months (n = 6); ASIS avulsion fracture (n = 1); nonunion in group 1 (12.8%), and group 2 (13.5%). Both groups (last visit): Tenderness over anatomical snuffbox in group 1 (n = 5), and group 2 (n = 6); degenerative changes in group 1 (n = 15), and group 2 (n = 14)
Ribak et al[40], 2010	DR VBG (n = 46) vs DR NVBG (n = 40)	Three K-wires	VBG: 24.4 months; NVBG: 21.7 months	Higher UR after VBG (89% vs 72%; P = 0.024). PP nonunion: Slightly higher UR with VBGs (90% vs 69%; P = 0.09)	VBG: Significantly earlier healing compared to NVBG (9.7 weeks vs 12 weeks; P = 0.0001)	VBG: Significantly higher functional outcome scores (P = 0.007)	Nonunion: 5/46 (11%) in VBG group and 11/40 (28%) in NVBG group
Braga-Silva et al[36], 2008	DR VBG (n = 35) vs IC NVBG (n = 45)	K-wires or screws	2.8 ± 1.4 years	Union occurred in all NVBG group and 32/35 of the VBG group (P = 0.135)	NVBG: 8.89 ± 2.26 months; VBG: 7.97 ± 3.06 months	There was no significant difference with respect to ROM or grip strength between the two groups	Nonunion in 3/35 (8.5%) of the VBG group with graft osteonecrosis

UR: Union rate; HT: Healing time; BG: Bone graft; MMW score: Mayo modified wrist score; PC: Percutaneous; CRIF: Closed reduction and internal fixation; ORIF: Open reduction and internal fixation; ROM: Range of motion; DASH score: Disabilities of Arm, Shoulder and Hand score; PRP: Platelet-rich plasma; SNU: Scaphoid nonunion; VAS: Visual analogue score; NVBG: Non-vascularized bone graft; K-wires: Kirschner wires; RCTs: Randomized control trials; VBG: Vascularized bone graft; DR: Distal radius; IC: Iliac crest; ASIS: Anterior superior iliac spine; PP: Proximal pole scaphoid.