The graft was harvested from the lateral radius through a longitudinal incision centered over the radial styloid process. The cutaneous and sensory branches of the radial nerve were protected. Subperiosteal dissection between the first and second extensor compartments was carried out to keep the tendon sheaths intact. A three-sided osteotomy was made on the lateral cortex of the radial styloid; a bone lid was created that had a proximal hinge. The graft was harvested with a curette and about twice the estimated volume of the defect was taken. The bone lid was then repositioned and the first and second compartments were spontaneously repositioned so as to stabilize the harvest site.

Axial traction was placed on the wrist. The arthroscope was inserted into the midcarpal joint through the ulnar midcarpal portal (2 cm distal and 2 cm ulnar to Lister’s tubercle) to explore the distal aspect of the scaphoid. The nonunion was confirmed. Reduction was achieved using simple axial traction on the thumb. Thorough cleaning and curettage of the two scaphoid surfaces was carried out using a curette and shaver through the radial midcarpal portal (2 cm distal to Lister’s tubercle). This step can be done with or without fluid; however, dry arthroscopy is required for graft insertion. The cannula from a 3.0-mm burr was inserted through the radial midcarpal portal up to the defect between the proximal pole and the body of the scaphoid. The graft material was pushed using the head of the burr into the bone defect site, and then compacted using a spatula (Figs. 12.2a, b).

We used a typical percutaneous scapholunate pinning method under arthroscopic and fluoroscopic control. Two pins were driven percutaneously into the radial aspect of the wrist, through the distal body of the scaphoid, so as to bridge the graft area, secure the proximal pole and then was advanced into the lunate (Fig. 12.3)