We report the use of a free vascularised iliac bone graft in the treatment of 21 patients (19 men and 2 women) with an avascular nonunion of the scaphoid in which conventional bone grafting had previously failed. The mean age of the patients was 32 years (23 to 46) and the dominant wrist was affected in 14. The mean interval from fracture to the vascularised bone grafting was 39 months (9 to 62). Pre-operative MRI showed no contrast enhancement in the proximal fragment in any patient. Fracture

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... nion was assessed radiologically or with CT scans if the radiological appearances were inconclusive. At a mean follow-up of 5.6 years (2 to 11) union was obtained in 16 patients. The remaining five patients with a persistent nonunion continued to experience pain, reduced grip strength and limited range of wrist movement. In the successfully treated patients the grip strength and range of movement did not recover to match the uninjured side. Prevention of progressive carpal collapse, the absence of donor site morbidity, good subjective results and pain relief, justifies this procedure in the treatment of recalcitrant nonunion of the scaphoid. Scaphoid fractures are sometimes unrecognised, but even when primarily recognised and treated appropriately, nonunion may occur in 5% to 15%. 1 Pseudarthrosis of a scaphoid fracture usually results from a combination of a long-standing nonunion, previous failed surgery, avascularity of the proximal fragment or in certain fractures of the proximal third of the scaphoid. 2 Observations on the natural history of scaphoid nonunion reveal that osteoarthritis is time dependent and may become progressively worse in association with long-standing nonunion. Therefore, most hand surgeons would recommend surgical treatment of symptomatic nonunion. 3 In scaphoid fractures with a long-standing nonunion and in those where previous surgery has failed, the results of conventional bone grafting are generally poor, 4 although good results have been reported following rib graft arthroplasty. 5 Recently vascularised bone grafts have been recommended for persisting scaphoid nonunions after failed earlier surgery and for nonunions with evidence of avascular necrosis (AVN). 6 A vascularised periosteal graft may also give good results. 7 We evaluated the use of a free vascularised iliac crest bone graft and internal fixation with a Kirschner (K)-wire to treat patients who had recalcitrant scaphoid nonunions with evidence of AVN after at least two previous failed operations. In particular, we examined the rate of union and the functional outcome from this extensive procedure. Patients and Methods Patients were selected for this study from a population of 94 patients undergoing reconstructive surgery for nonunion of scaphoid fractures treated at our institution between 1994 and 2003. Inclusion criteria and the indication for free vascularised iliac crest bone grafting were limited to patients with recalcitrant nonunion. This was defined as persistence of a fracture gap at least nine months after a second attempt at non-vascularised bone grafting, with associated resorption of bone and cystic changes at the fracture site, 8 which itself followed failed initial internal screw fixation and failure of subsequent attempted conventional bone grafting. In all, patients were identified who had two previous failed surgical attempts at achieving union. Patients with advanced collapse were excluded, as were patients who had established radioscaphoid arthritis for which a four-corner arthrodesis 9 was performed (n = 9), and patients with arthritis throughout the carpus who had an arthrodesis of the wrist (n = 7). The remaining 26 patients who had no signs of arthritis were treated by free vascularised iliac bone grafting and internal fixation with a