A typical hockey-stick incision is made along the course of the flexor carpi radialis (FCR) tendon and extended distally along the border of the glabrous skin of the thenar eminence to the STT joint. Splitting the sheath of the FCR allows the FCR to be retracted ulnarly. The floor of the FCR sheath is incised longitudinally to expose the wrist capsule and extrinsic ligaments. The superficial branch of the radial artery to the superficial arch is typically divided between sutures. The distal and proximal poles of the scaphoid are exposed with a capsular incision in line with the scaphoid axis, and the extrinsic capsular ligaments are carefully tagged with nonabsorbable suture for later repair. The wrist is extended over a rolled towel, and the nonunion is gapped open using skin hooks in the proximal and distal fragments (Fig. 11.5). All fibrous tissue at the nonunion site is removed and bone is curretted to remove sclerotic bone and fibrous tissue down to bleeding cancellous bone. The prepared cavity is measured to judge the size of the cortical strut, which is generally 12–18 mm.

In cases of humpback deformity and DISI, the lunate must be reduced. This may be done with a wrist flexion maneuver to reduce the extended lunate and proximal scaphoid pole, followed by the placement of a percutaneous radiolunate 0.062 in K-wire. The wire may be placed from a dorsal or a radial insertion site across the radius and into the reduced lunate. The wire is either buried below the skin or left out of the skin depending on surgeon preference, and left in place for 4 weeks, providing additional stability to the scaphoid construct. The wrist is then extended to reduce the distal scaphoid pole and restore alignment.

After preparation and cavitation of the scaphoid, proximal dissection is performed to expose the bone graft site in the metaphysis of the radius. The pronator quadratus is reflected ulnarwards off the radial metaphysis. A 20 × 5 mm rounded cortical window is then made from the volar cortex of the distal radius using osteotomes or K-wires, and the cortical fragment is set aside for later use (Fig. 11.6). Abundant cancellous bone graft is harvested from the radius. A “matchstick” is fabricated from the volar cortical window of the radius and sized to act as an intramedullary cortical strut to restore the length and alignment of the scaphoid (Figs. 11.7, 11.8). Using bone hooks to extend the prepared proximal and distal poles, the cortical strut is inserted into the defect and tamped into position. Cancellous bone graft is then packed tightly in the remainder of the nonunion site, and this is followed with fixation with a headless scaphoid screw (Figs. 11.9, 11.10), generally inserted from distal to proximal. Intraoperative fluoroscopy is used to confirm adequate reduction and fixation. The volar capsule and radiocarpal ligaments are repaired with interrupted nonabsorbable sutures. In the case of previous surgery, this technique may still be used, but the new and/or larger diameter screw should be placed in a different track if technically feasible. The cortical strut may be inserted down the previous screw tract. Also, if there is difficulty getting the screw guidewire in the optimal position in the scaphoid from the volar approach , a mini incision is made dorsally and the screw is placed from the dorsal approach .