,.ase). ~ammatory.; ’72, Lea& traosseous loint Sur~ y of the;. A technique for anterior wedge-shaped grafts for scaphoid nonunions with carpal instability Thisarticle presents a brief description of the following modifications of the original Fiskproce- durefor navicular nonunions with carpal instability: (1) preoperative calculation of exact scaphoid lengthandform based on comparative roentgenograms of the opposite wrist, (2) the use of a palmar approach, (3) the insertion of a wedge-shaped corticocancellous graft from the lilac crest after resection of the pseudarthrosis, and(4) the use of internal fixation. Preoperative planning is considered essential to restore the anatomic length, analyze the angular deformity, evaluate the pathologic scapholunate angle, andcalc~alate the resection and size of the graft needed. The palmar approach reduces the danger of ialtrogenic damage of the vascularsupply of the scaphoid and accidental lesions of the superficialbranches of the radial nerve. Furthermore it provides a better exposure of the scapholunate joint to correct lunate rotation. Iliac bone is preferred to the radial styloid graft, as proposed by Fisk, because of its better ability to resist compression forces. Internalfixation adds rotational stability so that continued postoperative plaster immobilization can be reduced to a minimum of 8 weeks.(J HAND SURG 9A:733-7, 1984.) Diego L. Fernandez, M.D., Aarau, Switzerland he association of fractures or nonunions the scaphoid with dorsal carpal instability patterns is recognized entity and has been extensively analyzed various authors. 1-7 In these cases a pathologic dor- rotation of the lunate with increased scapholunate angle is invariably seen in the lateral wrist x-ray Fisk 6 has stressed the point that, in established with carpal instability, correction of the flex- deformity and restoration of normalscaphoid length normal tension in the palmar radiocarpal which in turn corrects the pathologic rota- of the lunate. Heproposedradial wedge grafting of navicular to achieve union and overcome instabil- In his technique,8 a radial exposure with osteotomy the radial styloid is used, and after reduction of the of the carpus, the palmar radial wedge- defect of the navicular is filled in with a graft from the osteotomizedstytoid process. Nointer- fixation material is used. ,gy Section, Department of Surgery, Kantonsspi- tal, Aarau, Switzerland. Received for publication Oct. 14, 1983; accepted in revised form Dec. 14, 1983. Reprint requests: Diego L. Fernandez, M.D., Department of Sur- gery, Kantonsspital, CH-5001 Aarau, Switzerland. Onthe other hand, the Russe 9’ 10 palmarinlay graft- ing procedure is a reliable and universally accepted methodfor achievement of union of the scaphoid, even in the presence of avascular necrosis of the proximal fragment. Russe has reported a 100% union rate in a seIies of 40 cases treated operatively during 1973 and 1979.1° In our department, this is the preferred method of treatment for scaphoid waist nonunions without car- pail instability. - However, in cases with severe scaphoid shortening, cystic nonunions with bone resorption, and important flexion deformity, wehave foundit difficult to restore accurate scaphoid length with .inlay grafting tech- niques. Insertion of a longer graft usually distracts the nonunion site, creating a ring-like bone defect that ren- ders the nonunionunstable, therefore increasing the failure rate because of recurrence of the flexion de- formity. In six consecutive cases, resection of the nonunion si~!e and insertion of a tight-fitting wedge-shaped cor- ticocancetlous graft has renderedsatisfactory results in terms of union and correction of the dorsal instability pattern (Table I). In a recent report, Linscheid et al. 11 presented six cases of palmar wedgegrafting combined with cancel- lc,us bone grafting of the proximal and distal fragments. THE JOURNAL OF HAND SURGERY 733