Abstract
Scaphoid nonunion with proximal pole avascular necrosis (AVN) presents a significant surgical challenge due to compromised vascularity and limited healing potential. Bone grafting has emerged as an effective strategy, with donor site selection, distal radius versus iliac crest, being crucial to clinical outcomes. This systematic review evaluated five studies, including 262 patients (distal radius vascularized bone grafting (DR-VBG): 53; iliac crest grafts: 209), comparing DR-VBG and iliac crest grafts in scaphoid nonunion with AVN. DR-VBG consistently demonstrated faster union (7.9-8.6 months), superior anatomical restoration, and lower donor-site morbidity compared with iliac crest grafts, which, despite providing robust structural support, were associated with higher pain, gait disturbances, nerve injury, and scarring. Functional outcomes were comparable when union was achieved; however, DR-VBG showed subtle advantages in carpal alignment and long-term wrist biomechanics. These findings support DR-VBG as the preferred donor site in AVN-complicated scaphoid nonunion, while iliac crest grafts remain a viable option when greater structural volume is required.