Scaphoid nonunion with radioscaphoid arthrosis (SNAC stage I) .

The various management options were discussed with the patient including internal fixation and bone grafting of the scaphoid nonunion ± a limited radial styloidectomy with postoperative immobilization of 3 months or longer versus a distal scaphoid resection and early wrist mobilization .

The patient did not wish to be immobilized for 3 or more months, mostly due to his competitive surfing schedule, and therefore, elected to proceed with a minimally invasive salvage procedure consisting of an arthroscopic resection of the distal fragment of the scaphoid. He understood that he would likely require a more definitive salvage procedure at some point due to the progression of radiocarpal and midcarpal degenerative joint changes.

The patient was positioned supine under general anesthesia with his arm abducted to 90° under tourniquet control. The thumb was suspended by finger traps from a wrist traction tower with 10 pounds of counter traction. Intraoperative fluoroscopy was employed to assess the adequacy of bone resection and for locating the portals as needed. The arthroscopic scaphoidectomy was performed through the midcarpal joint. With the arthroscope introduced in the midcarpal ulnar (MCU) portal, a 2.5-mm shaver was inserted into the midcarpal radial (MCR) portal and used to debride the nonunion site. The scaphotrapeziotrapezoidal ulnar and palmar (STT-U and STT-P) portals are useful for distal 1/3 nonunions. The STT-U portal is located in line with the midshaft axis of the index metacarpal, just ulnar to the extensor pollicus longus (EPL) and radial to the insertion of the extensor carpi radialis tendon into the base of the index metacarpal, at the level of the STT joint (Fig. 18.3). Entry into this portal is facilitated by traction on the index finger. Leaving the EPL to the radial side of the STT-U portal protects the radial artery in the snuffbox from injury. A 2.9-mm and then a 3.5-mm arthroscopic burr were inserted into the MCR or STT-U portal and used to resect the distal scaphoid fragment starting at the nonunion site and moving toward the distal tubercle until the articular surfaces of the trapezoid and trapezium can be seen (Fig. 18.4a, b).

The patient was splinted for 1 week postoperatively then started on a wrist range of motion program, following by progressive strengthening. He returned to competitive surfing at 6th week and unrestricted duty as a carpenter at 8 weeks. At 1-year follow-up, the patient stated that he was able to work as a carpenter with occasional use of a wrist splint. He had no pain at rest, but continued to have mild pain with extremes of radial deviation and wrist extension. On palpation, the patient had mild tenderness over the capitolunate joint but no snuff box tenderness and a negative Watson test. Wrist motion was as follows: flexion 40°, extension 35°, radial deviation 15°, ulnar deviation 20°, pronation 90°, supination 90°. X-rays showed maintenance of a good arthroplasty space with no capitolunate narrowing, but with an increased radiolunate angle of 20°.