Bone grafting without a vascularized tip has been used for many years to treat navicular osteonecrosis. The results of various types of treatment with a variety of techniques have been widely reported. These techniques include chiseling cancellous bone or cancellous bone with osteocortex from various sites, usually the distal radius or the iliac crest. The bone graft may be fixed in different ways. From simple compression fixation such as kerf pins to screw fixation. Additional factors affecting fracture healing include blood supply to the fracture site, fracture site, patient’s age, smoking, previous surgical history, and others. The methods and criteria for evaluating navicular fracture healing need to be considered when determining predictive factors, which may change at follow-up. The only reliable method to induce bone healing is the use of bone grafting. Internal fixation alone can control symptoms for many years, but bone healing is achieved in only a minority of cases. Bone grafting can be: 1. Longitudinal bone plugs, which are implanted axially for fixation, acting as if they were screws. 2. an onlay graft, from the dorsal side or, more commonly, from the palmar side as recommended by Russe. In general, this type of graft is inserted from the palmar side because it protects the vascularity of the dorsal aspect of the navicular bone and also corrects the flexion deformity at the site of the nonunion. This is probably the most widely used technique. As for the source of the graft. Various biologic graft substitutes are being tried, but the traditional bone block graft is primarily taken from the distal radius or the iliac crest. The latter is generally more effective, but there are still no studies to confirm this. Most studies have shown equal fracture healing rates with various bone grafts, and Tamble and colleagues compared two groups of patients with similar fracture sites, duration of bone discontinuity, and types of internal fixation implants. Fracture healing rates were not affected by the source of the bone graft. Fixation methods included kerf pins and various types of screws. Herbert’s pioneering tailless navicular nail allows the screw to be placed across the site of the osteonecrosis and pressurized, with or without a bone graft, into the navicular bone. The success of the Herbert nail led to further development of caudeless screws, both in terms of their ability to be compressed and their ease of use, especially with percutaneous insertion. Evidence on whether one method of fixation is superior to another is still lacking. However, most surgeons prefer to use some type of screw. Only in emergencies are kerf pins used. If screws are not technically possible, then a kerf pin may be the only option. Many other factors affecting bone healing have been reported. Schuind and colleagues reported on a multicenter clinical study of 138 patients with navicular osteonecrosis. Clinicians attempted to assess predictors of bone healing or failure in this group of patients. They reported a healing rate of 75%. Detailed statistical analysis showed that heavy physical work, duration of osteonecrosis longer than 5 years, radial stem resection, and postoperative braking significantly reduced the likelihood of fracture healing. In multivariate analysis, it was found that delays in diagnosis and treatment after initial trauma, especially if the disease duration was more than 5 years, reduced fracture healing rates. Ischemic osteonecrosis, especially when located proximally, is generally considered a poor predictor. Although the diagnosis is sometimes controversial, there is no doubt that fractures are difficult to heal. It is not surprising that reported healing rates vary widely. A systematic review by Munk and Larsen of 5246 patients with navicular nonunion reported in 147 publications showed that the healing rate for bone grafts without a vascular tip and without internal fixation was 80%, while the healing rate with internal fixation was 84%. Two final difficulties are the assessment of fracture healing and how long after bone grafting can failure be determined. For the latter, there is no definitive conclusion, but most authors give 12 months for this type of surgery because beyond this time fracture healing is no longer likely to occur. Regarding the assessment of fracture healing, many publications have used the criteria proposed by Dias in 2001. That is, the presence of trabeculae across the fracture site or, conversely, the presence of sclerotic trabeculae at the fracture margin. There is no doubt that these criteria will help the surgeon to quantify bone healing. There is no doubt that MRI or CT are more accurate than X-rays. But they are more expensive. They are time consuming and may not be readily available for use. The rate of healing is affected by the site of the fracture, and the rate of healing for each site is shown in the figure. The closer the fracture is to the proximal end, the lower the healing rate. Surgical manipulation plays a major role in the successful healing of the fracture.