SCIENTIFIC ARTICLE

Suture Anchor Fixation for Scaphoid

Nonunions With Small Proximal Fragments:
Report of 11 Cases
Reza Shahryar Kamrani, MD, Leila Oryadi Zanjani, MD, Mohammad Hossein Nabian, MD

Purpose To describe the use of 2 suture anchors as the fixation devices in the management of
11 patients with scaphoid proximal pole nonunions with small proximal fragments.
Methods In a prospective study, 11 patients with proximal pole scaphoid nonunions (10 with
small proximal fragments and 1 with an oblique nonunion line) were evaluated before surgery
by standard wrist x-rays and functional wrist scores including a visual analog scale (VAS),
Mayo wrist score, and Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH). The
nonunion site was fixed with 2 suture anchors supplemented with autologous cancellous bone
graft. Postoperative evaluations consisting of functional wrist scores and evaluation of
radiological union were performed 9 months after surgery.
Results At the end of the study, we observed union in 10 of the 11 patients. The QuickDASH
and VAS scores showed significant improvement, and 10 patients had satisfactory Mayo
scores.
Conclusions We propose the technique of suture anchor fixation for cases of proximal scaphoid
nonunion in which secure internal fixation with common techniques is challenging because of
the small size of the proximal fragment and the obliquity of the nonunion site. (J Hand Surg
Am. 2014;39(8):1494e1499. Copyright Ó 2014 by the American Society for Surgery of the
Hand. All rights reserved.)
Type of study/level of evidence Therapeutic IV.
Key words Mayo wrist score, proximal pole nonunion, QuickDASH score, scaphoid nonunion,
suture anchor.

inability to achieve secure fixation are explanations

T
HE PROXIMITY OF A FRACTUREline to the prox-
imal pole is one of the major risk factors for
developing scaphoid nonunion and increases
the risk of treatment failure.1e6 Osteonecrosis and an
From the Department of Orthopedic and Trauma Surgery, Shariati Hospital, and the Joint
Reconstruction Research Center, Tehran University of Medical Sciences, Tehran, Iran.
Received for publication November 1, 2013; accepted in revised form May 13, 2014.
No benefits in any form have been received or will be received related directly or
indirectly to the subject of this article.
Corresponding author: Leila Oryadi Zanjani, MD, Department of Orthopedic and
Trauma Surgery, Shariati Hospital, Tehran University of Medical Sciences, PO Box
1411713135, Tehran, Iran; e-mail: leila_zanjani@yahoo.com.
0363-5023/14/3908-0005$36.00/0
http://dx.doi.org/10.1016/j.jhsa.2014.05.020
for scaphoid proximal pole nonunions.2,7
Treatment options for proximal scaphoid non-
union are vascularized or nonvascularized bone graft
with internal fixation.8 Headless screw fixation is the
preferred method for fixation in most scaphoid non-
unions.7,8 In the case of a proximal scaphoid non-
union, it is challenging to fix the small osteochondral
fragment using standard internal fixation techniques.9
Persistent nonunion, even with a small proximal
fragment, leads to late degenerative changes and
persistent pain.10
The purpose of this study was to present a fixation
technique for scaphoid nonunion with a small prox-
imal pole fragment using 2 suture anchors. We report
our results for 11 patients treated with this method.

1494 r Ó 2014 ASSH r Published by Elsevier, Inc. All rights reserved.

 SUTURE ANCHOR FIXATION FOR SCAPHOID NONUNIONS 1495

METHODS
Patient selection and evaluation
We designed a prospective study to assess suture
anchor fixation for proximal pole scaphoid nonunions
unsuitable for a headless compression screw. All
proximal pole scaphoid nonunion cases with a pro-
ximal fragment length 20% or less of overall bone
length and without radiological signs of wrist dege-
neration changes were included in the study (Fig. 1).
We also included cases with small proximal frag-
ments in which the direction of the nonunion line was
close to the long axis of the scaphoid so that fixation
with a headless screw would not produce secure fix-
ation across the nonunion site owing to inadequate
bone stock (Fig. 1). There were no selection limita-
tions for age, sex, etiology, smoking, the time from
injury to presentation, or proximal fragment vascu-
larity. All of the operations were performed by the
senior author (R.S.K). The medical ethics committee
of the orthopedics department of our hospital approved
the study, and informed consent from the patients was
obtained after explanation of the available treatment
options prior to surgery.

Preoperative evaluation
On the preoperative evaluation, the passive wrist flexion
and extension were measured by a goniometer, and
the grip strength was measured in kilograms by a
grip dynamometer (Jamar device, Patterson Medical,
Warrenville, IL) with the forearm in a neutral posi-
tion and the elbow in 90
flexion. The maximal value
of 3 trials was documented. All of the patients were
assessed with a visual analog scale (VAS) for scoring
pain,11 the Quick Disabilities of the Arm, Shoulder,
and Hand (QuickDASH) score, and the Mayo wrist
score12 to document the baseline functional status.
Posteroanterior (PA), lateral, and ulnar-deviated PA
x-ray images were obtained. We evaluated the pres-
ence of dorsal intercalary segment instability (DISI) FIGURE 1: Indications of suture anchor fixation. A Case no. 2,
deformity in lateral radiographs by measuring the small proximal fragment. B Case no. 3, small proximal fragment
radiolunate angle. with oblique fracture line. C Case no. 9, previous percutaneous
The proximal fragment ratio was measured from the headless screw fixation failure with a small proximal fragment.
ulnar-deviated PA view according to the method of
Slutsky and Slade.5 The distances between the midpoint extensor compartments just distal to the Lister tu-
of the nonunion site and the distal and proximal poles bercle. Both extensor compartments were identified
were measured, and the ratio of the length of the and opened longitudinally, and the joint capsule was
proximal fragment to the sum of the proximal and distal opened transversely, resulting in the exposure of the
fragments was expressed as the fragment ratio (Fig. 2). nonunion site. If there was fibrous tissue stabilizing
the nonunion site, a hole was made with a 3-mm bur,
Surgical technique and the nonunion surfaces on the distal and proximal
The scaphoid was exposed dorsally through a 2.5- to fragments were gently freshened through the hole. If
3-cm transverse incision over the third and fourth the nonunion was unstable, the opposing surfaces of

J Hand Surg Am. r Vol. 39, August 2014

1496 SUTURE ANCHOR FIXATION FOR SCAPHOID NONUNIONS
A
FIGURE 2: Calculating fragment ratio. Fragment ratio ¼ AþB  100.
the nonunion were freshened with a bur. Two suture
anchors (FASTak 2.4 mm, Arthrex, Inc., Miami,
FL, or Aim Tec, 3 mm, Textile Hi Tec. Company,
Montpellier, France) were placed in the distal frag-
ment through the nonunion site under fluoroscopic
control. We then made 3 holes in the proximal
fragment with a 1-mm K-wire. Two holes were
placed next to the scapholunate ligament attachment
site. Four strands of the anchor sutures were passed
through the 3 holes in the proximal fragment (1 strand
from each lateral hole and 2 from the middle hole).
We placed autologous cancellous bone graft (iliac
crest, n ¼ 9; distal radius, n ¼ 2) at the nonunion site.
The proximal fragment was pushed to the distal frag-
ment to close the gap. Then, each pair of strands was
tied with 5 throws in the knot. We tried to bury the
knots in the scapholunate ligament attachment site to
avoid later impingement and friction in the radio-
scaphoid joint. Control x-rays were obtained the day
after surgery.
Postoperative evaluations
A short-arm thumb spica cast was applied for 12 weeks.
The patients were reviewed at 12 and 18 weeks after
surgery to assess scaphoid radiographic union, which
we defined as disappearance of a nonunion line or
gap, the presence of bony trabeculae bridging the
nonunion line, and no signs of fixation failure on
standard x-rays.1,9 If union was not seen, a thumb
spica cast was continued for 6 weeks. Computed
J Hand Surg Am.
tomography (CT) was performed in doubtful cases
18 weeks after surgery. Nonunion at 18 weeks was
accepted as treatment failure. Contact sport partici-
pation was restricted for the patients until radio-
graphic union was detected and the preoperative wrist
range of motion was restored. Nine months after
surgery, functional status was evaluated by wrist
motion, VAS score, Mayo wrist score, QuickDASH
score, and grip strength.
Statistical analysis
The data are presented as the mean  SD. The
Wilcoxon test was used for comparing the continuous
variables. A P value less than .05 was considered
statistically significant.
RESULTS
Between December 2010 and March 2013, we treated
11 male patients with small proximal scaphoid non-
union with the anchor suture technique. The mean
age of the patients was 31 years (range, 20e47 y).
The average delay between injury and surgery was
14 months (range, 7e30 mo). One patient (case 6,
Table 1) had had a previous Herbert screw fixation
procedure, which failed, and 10 patients had no his-
tory of surgical intervention. Except for 1 patient with
a fragment ratio of 26% (case 3), who was included in
the study because of nonunion obliquity (Fig. 1), the
proximal fragment ratio in the patients ranged from
9% to 20% (mean, 18%). None of our patients with a
fragment ratio of less than 20% had a DISI deformity
in the radiological evaluations.
The mean wrist flexion-extension arc of motion
pretreatment was 118
 36
(range, 70
e180
), and
at the last follow-up, it was 134
 38
(range,
60
e180
), which was not significantly different
(P ¼ .2).
According to the Mayo functional wrist scores,
there was 1 excellent, 5 good, 4 satisfactory, and
1 poor result at the 9-month follow-up. The average
score increased significantly from 55  10 (range,
35e65) before surgery to 76  13 (range, 50e100) at
the final follow-up (P ¼ .001).
The mean preoperative QuickDASH score of
44  16 (range, 18e70) significantly decreased to
the postoperative mean of 15  16 (range, 0e59)
(P < .001).
The mean preoperative grip strength of the injured
wrists of 39  9 kg (range, 20e50 kg) was statisti-
cally the same as the postoperative grip strength of
39  7 kg (range, 30e70 kg) (P ¼ .9).
The VAS pain score significantly decreased from
the preoperative mean of 6.0 (range, 3e8) to the
r Vol. 39, August 2014
 SUTURE ANCHOR FIXATION FOR SCAPHOID NONUNIONS 1497

postoperative mean of 2.4 (range, 0e9) (P ¼ .002).

Postoperative
The results of the functional scores are summarized in
VAS

2.4
Table 1.

0
3
0
0
1
9
4
4
0
4
1
Radiographic bony union was achieved in 6 pa-
tients after 12 weeks and in 4 more patients after
Preoperative

18 weeks. One patient had not achieved union at the

last follow-up 9 months after surgery.
VAS

8
4
5
7
6
8
7
7
6
3
5
6
DISCUSSION
Postoperative

Secure internal fixation and restoration of alignment

Grip (kg)

32
30
34
46
46
30
50
38
44
34
46
39
comprise the main strategies to achieve union in cases
of scaphoid nonunion.1,8 The preferred fixation de-
vice in scaphoid nonunion is a headless screw.7,8 The
Preoperative

problem arises when the fracture site is close to the

Grip (kg)

proximal end of the bone, producing a small osteo-

20
35
38
30
50
36
50
38
48
44
40
39 chondral fragment that includes minimal bone.9 In
these situations, it might be challenging to achieve
enough purchase in thin bony trabeculae to achieve
Postoperative
ROM (
)

compression without splitting the proximal fragment

160
110
140
170
120
120
160
170
90
60
180
134

using headless screws.9 Salvage procedures such as

radial styloidectomy, distal pole excision, proximal
row carpectomy, and arthrodesis are not indicated in
Preoperative

the absence of arthritic changes.13

ROM (
)

Carter et al14 defined the small proximal fragment

70
120
150
100
70
120
160
130
120
80
180
118

as less than 20% of the overall bone length. They

addressed this condition by using an allograft to
Postoperative

replace the proximal half of the scaphoid, which was

fixed by a Herbert screw to the distal half. They re-
Mayo
Clinical Findings, Before Surgery and at the Last Follow-Up

75
70
80
100
80
50
85
80
75
60
85
76

ported good results in 6 of 8 cases, and their average

union time was between 6 and 12 months after sur-
gery compared with 3 to 4.5 months in our study.
Preoperative

Veitch et al15 and Yao et al7 illustrated the

Mayo

35
60
60
45
55
40
65
55
55
65
65
54

osteochondral rib autograft technique for the treat-

ment of proximal scaphoid nonunion with bone
deficiency or fragmentation in the proximal fragment.
Postoperative

They reported satisfactory results in their patients.

DASH

Yao and Read10 recommended the use of an osteo-

18
16
4
0
7
59
16
9
11
14
9
15

chondral autograft for fragmentation or osteonecrosis

ROM, total wrist range of motion (flexion þ extension).

of the proximal fragment, cases of previous failed

internal fixation and bone grafting, and when the
Preoperative

proximal fragment was too small for internal fixation.

DASH

70
18
54
59
27
61
50
41
45
29
32
44

Veitch et al15 reported improvement in wrist func-

tion in 13 of 14 patients, and none of their patients
experienced nonunion. Although rib osteochondral
Ratio (%)
Fragment

autograft has a wider indication, particularly in cases

9
20
26
16
20
20
17
20
13
19
19
18

of a fragmented proximal fragment, in cases of small

proximal pole nonunion and previous failed surgery,
suture anchor fixation might be technically simpler
(mo)
Age

20
47
27
26
39
40
28
26
32
23
28
30

with less donor site morbidity.

TABLE 1.

A headless screw has been the device of choice for

Patient

Mean
Code

fixation of proximal third scaphoid nonunion mainly

1
2
3
4
5
6
7
8
9
10
11

from a dorsal approach.7,8 However, complications

J Hand Surg Am. r Vol. 39, August 2014

1498 SUTURE ANCHOR FIXATION FOR SCAPHOID NONUNIONS
with headless screw fixation occur. Bushnell et al16
reported 21% major complications in their series of
24 patients. Three patients had hardware problems,
and one postoperative fracture of the proximal pole of
the scaphoid occurred.
The inability to obtain good purchase and stable
fixation in small proximal scaphoid fragments has led
to the use of mini-headless compression screws. Even
with these devices, authors have reported compli-
cations. Krimmer et al17 reported union in 74% of
26 patients using standard Herbert screws or mini-
Herbert screws in addition to bone grafting for
proximal scaphoid nonunions. They believed that the
mini-Herbert screw presented an additional opportu-
nity to fix small proximal fragments. Megerle et al18
achieved 21 unions in 31 patients using mini-Herbert
screws and conventional bone grafts. They did not
mention their indication for the use of mini- rather
than standard Herbert screws and did not clarify the
size of the proximal fragments. They had 1 nonunion
and 3 complications related to protrusion of the
screws, which needed revision surgery. Considering
that most of the patients with scaphoid nonunions are
young people with good bone quality, there is no
need to insert the bone anchors through subcondral
bone for adequate purchase. This reduces the risk of
hardware protrusion compared with screw fixation.
Vascularized bone grafting is an accepted tech-
nique for treating avascular proximal pole nonunion
when the proximal portion is not fragmented.10,19,20
Its superiority has been shown in some studies, but it
has been under question by others.21e23 However, the
problem of the fixation device in scaphoid nonunions
with a small proximal pole remains unsolved with
this technique.
We had concerns about rigid fixation across the
nonunion site using suture anchor fixation. Moritomo
et al24 analyzed the relationship between the fracture
location and the kinematic patterns in the scaphoid.
Their findings illustrated that when the fracture line
passes proximal to the scaphoid apex, there is sig-
nificantly less motion between the bone fragments
during wrist motion, and no DISI deformity is seen.
The authors classified these cases as stable nonunions.
In our study, given the specificities of the nonunion
site, none of the cases had DISI deformity before
treatment. We hypothesized that, with lower deform-
ing forces across the nonunion, 2 suture anchors could
provide enough stability required for bony union. We
did not perform a biomechanical study on the com-
pression force of 2 anchor sutures at the nonunion site.
We had union in 10 of 11 patients using this
method. Union rates from 77% to 94% have been
J Hand Surg Am.
reported in patients treated by internal fixation and
bone graft.23,25 Ramamurthy et al6 showed the size of
the proximal pole and the duration of nonunion time
were the factors that affected the union rate. We sug-
gest that our treatment method resulted in acceptable
union rates considering the small size of proximal pole.
Functional performance represented by the Quick-
DASH score improved after treatment. Ten patients
had satisfactory, good, or excellent outcomes on the
Mayo wrist score. All of our patients, except 1 in
which we failed to achieve union, returned to their
preinjury occupation.
We had concerns about the suture knots in the
radioscaphoid joint. They theoretically could limit
wrist range of motion, and we planned to remove the
knots by arthroscopy after union. Eight of our pa-
tients gained a wrist arc of motion equal to or greater
than their preoperative range of motion. Patients 9
and 10 had limited postoperative wrist range of mo-
tion but declined the option for arthroscopic evalua-
tion and knot removal.
This study had other limitations. The follow-up
time was short. There was no clear definition to the
specific size of the proximal pole nonunion. We
assumed that the Slutsky and Slade5 measurement
was a good score for proximal pole nonunion clas-
sification; however, it has its own deficiency, for
example, in oblique proximal pole nonunions. We
found that the Carter et al classification,14 which
considers 20% as the threshold to divide the proximal
pole nonunions into proximal pole and small prox-
imal pole nonunions, was useful. In our cases, we did
not focus on the vascularity of the proximal pole. We
hypothesized that the union of a small proximal pole
nonunion progresses from distal to proximal, even if
the small proximal fragment was necrotic. We did not
evaluate our patients with wrist magnetic resonance
imaging (MRI); however, 6 patients had received
MRI before referral to us. Three of them showed
avascular necrosis in their proximal segment, 2 of
them did not show signs of avascular necrosis, and
1 showed inconclusive findings. We used plain radio-
graphy to monitor bony consolidation. Although CT
is considered to be more reliable to detect scaphoid
union, plain radiography is used frequently. Megrele
et al18 showed that the main problem of the x-ray was
false-negative results in detection of scaphoid union,
and all of the cases with radiographically confirmed
union had union on CT evaluation. Finally, because
mini-headless screws were not available in our center,
we did not compare suture anchors to screws.
Suture anchor fixation can produce fixation even in
the presence of a thin shell of bone in the proximal
r Vol. 39, August 2014
 SUTURE ANCHOR FIXATION FOR SCAPHOID NONUNIONS
fragment. Because of our results, we propose this
technique for cases of proximal pole scaphoid non-
union with a small proximal fragment or a markedly
oblique fracture line in which rigid fixation with a
screw would be technically difficult.
REFERENCES
1. Slutsky DJ. Principles and Practice of Wrist Surgery. Philadelphia:
Saunders; 2009:233e237.
2. Buijze GA, Ochtman L, Ring D. Management of scaphoid nonunion.
J Hand Surg Am. 2012;37(5):1095e1100.
3. Wong K, von Schroeder HP. Delays and poor management of
scaphoid fractures: factors contributing to nonunion. J Hand Surg
Am. 2011;36(9):1471e1474.
4. Trumble TE, Vo D. Proximal pole scaphoid fractures and nonunion.
J Am Soc Surg Hand. 2001;1(3):155e171.
5. Slutsky DJ, Slade JF. The Scaphoid. New York: Thieme Medical;
2011:44.
6. Ramamurthy C, Cutler L, Nuttall D, Simison AJ, Trail IA,
Stanley JK. The factors affecting outcome after non-vascular bone
grafting and internal fixation for nonunion of the scaphoid. J Bone
Joint Surg Br. 2007;89(5):627e632.
7. Yao J, Read B, Hentz VR. The fragmented proximal pole scaphoid
nonunion treated with rib autograft: case series and review of the
literature. J Hand Surg Am. 2013;38(11):2188e2192.
8. Kawamura K, Chung KC. Treatment of scaphoid fractures and
nonunions. J Hand Surg Am. 2008;33(6):988e997.
9. Gereli A, Nalbantoglu U, Sener IU, Kocaoglu B, Turkmen M.
Comparison of headless screws used in the treatment of proximal
nonunion of scaphoid bone. Int Orthop. 2011;35(7):1031e1035.
10. Yao J, Read B. Osteochondral rib grafts. In: Slutsky DJ, Slade JF,
eds. The Scaphoid. New York: Thieme Medical; 2011:318e324.
11. Jensen MP, Chen C, Brugger AM. Interpretation of visual analog
scale ratings and change scores: a reanalysis of two clinical trials of
postoperative pain. J Pain. 2003;4(7):407e414.
12. Amadio PC, Berquist TH, Smith DK, Ilstrup DM, Cooney WP III,
Linscheid RL. Scaphoid malunion. J Hand Surg Am. 1989;14(4):
679e687.
13. Pao VS, Chang J. Scaphoid nonunion: diagnosis and treatment. Plast
Reconstr Surg. 2003;112(6):1666e1676.
J Hand Surg Am.
1499
14. Carter PR, Malinin TI, Abbey PA, Sommerkamp TG. The scaphoid
allograft: a new operation for treatment of the very proximal scaphoid
nonunion or for the necrotic, fragmented scaphoid proximal pole.
J Hand Surg Am. 1989;14(1):1e12.
15. Veitch S, Blake SM, David H. Proximal scaphoid rib graft arthro-
plasty. J Bone Joint Surg Br. 2007;89(2):196e201.
16. Bushnell BD, McWilliams AD, Messer TM. Complications in dorsal
percutaneous cannulated screw fixation of nondisplaced scaphoid
waist fractures. J Hand Surg Am. 2007;32(6):827e833.
17. Krimmer H, Kremling E, van Schoonhoven J, Prommersberger KJ,
Hahn P. Proximal scaphoid pseudarthrosis—reconstruction by dorsal
bone screw and spongiosa transplantation [in German]. Handchir
Mikrochir Plast Chir. 1999;31(3):174e177.
18. Megerle K, Keutgen X, Muller M, Germann G, Sauerbier M.
Treatment of scaphoid non-unions of the proximal third with con-
ventional bone grafting and mini-Herbert screws: an analysis of
clinical and radiological results. J Hand Surg Eur Vol. 2008;33(2):
179e185.
19. Malizos KN, Dailiana ZH, Kirou M, Vragalas V, Xenakis TA,
Soucacos PN. Longstanding nonunions of scaphoid fractures with
bone loss: successful reconstruction with vascularized bone grafts.
J Hand Surg Br. 2001;26(4):330e334.
20. Steinmann SP, Bishop AT, Berger RA. Use of the 1,2 inter-
compartmental supraretinacular artery as a vascularized pedicle bone
graft for difficult scaphoid nonunion. J Hand Surg Am. 2002;27(3):
391e401.
21. Straw RG, Davis TR, Dias JJ. Scaphoid nonunion: treatment with a
pedicled vascularized bone graft based on the 1,2 intercompartmental
supraretinacular branch of the radial artery. J Hand Surg Br. 2002;
27(5):413.
22. Boyer MI, von Schroeder HP, Axelrod TS. Scaphoid nonunion with
avascular necrosis of the proximal pole. Treatment with a vascular-
ized bone graft from the dorsum of the distal radius. J Hand Surg Br.
1998;23(5):686e690.
23. Merrell GA, Wolfe SW, Slade JF III. Treatment of scaphoid non-
unions: quantitative meta-analysis of the literature. J Hand Surg Am.
2002;27(4):685e691.
24. Moritomo H, Murase T, Oka K, Tanaka H, Yoshikawa H,
Sugamoto K. Relationship between the fracture location and the
kinematic pattern in scaphoid nonunion. J Hand Surg Am.
2008;33(9):1459e1468.
25. Barton NJ. Experience with scaphoid grafting. J Hand Surg Br.
1997;22(2):153e160.
r Vol. 39, August 2014