Treatment of scaphoid nonunions: quantitative meta-analysis of the literature.

We conducted a systematic quantitative meta-review of the literature to provide evidence-based suggestions for the treatment of scaphoid nonunion. This search identified 1,121 articles of which 36 met eligibility requirements. In unstable nonunions, screw fixation with grafting at 94% union was superior to K-wires and wedge grafting (77% union). Immediate mobilization versus 6 weeks or more of casting showed the same union rate of 74%. For avascular necrosis of the proximal fragment, union was achieved in 88% of those patients with a vascularized graft versus 47% with screw and wedge fixation. These results suggest that established unstable nonunions should be treated with screw fixation and wedge grafting. There is not evidence supporting the need for postoperative immobilization in patients with solid screw fixation. A vascularized graft may be preferable for patients with avascular necrosis of the proximal fragment or with a previously failed surgery.