Revisiting the role of bone grafting in scaphoid fixation with volar plates: a multivariable analysis

Purpose: To evaluate the radiographic and functional outcomes of scaphoid fractures and nonunions treated with volar locked plate fixation, with or without autologous bone grafting, and to explore whether graft use was associated with improved consolidation or function. Methods: This retrospective cohort study included 19 adult patients who underwent surgical treatment with volar anatomical plates for scaphoid fractures or nonunions. Radiographic union was assessed at 3, 6, and 12 months. Functional outcomes were measured using the QuickDASH score preoperatively and at 12 months postoperatively. Graft use was determined intraoperatively based on defect characteristics. Statistical analyses included non-parametric tests and multivariable models. Results: The mean patient age was 24.5 ± 5.4 years, and 94.7% were male. Scaphoid nonunion was present in 11 patients (57.9%), and autologous bone grafting was performed in 15 (78.9%). Radiographic consolidation was achieved in 94.7% of cases at 12 months. QuickDASH scores improved significantly (mean change: 20.6 points; p < 0.001). There were no significant differences in union or functional outcomes between grafted and non-grafted patients (p = 1.000 and p = 0.115, respectively). Interestingly, patients with nonunions demonstrated significantly better postoperative function than those with acute fractures (p = 0.034), although this did not exceed the minimal clinically important difference. Multivariable analysis failed to identify predictors of union or function, explaining only 37% of the variance. Conclusion: Volar locked plate fixation provides high union rates and significant functional improvement in scaphoid fractures and nonunions. Bone grafting did not confer additional benefit, supporting selective rather than routine use. Further studies are warranted to clarify prognostic factors and optimize treatment strategies.