Medial Femoral Condyle Bone Graft Research Articles

Vascularized medial femoral condyle bone graft for the management of an acute talar neck fracture: A case report

Background Management of talar neck fractures can be challenging due to the high rate of non- or malunion, avascular necrosis and post-traumatic arthritis, which has been attributed to the disruption of the bone’s tenuous blood supply during fracture displacement. Osseous medial femoral condyle (MFC) flaps are increasingly being used in the reconstruction of small bony defects due to recalcitrant non-union and avascular necrosis in the upper and lower limbs. We report a rare case of an MFC flap used in the reconstruction of an acute talar neck fracture. Case Presentation A 38-year-old male presented with multiple injuries following a motor vehicle accident, including an open comminuted talar neck and lateral process fracture, with dislocation of the subtalar and talocrural joints (Hawkins III). Initial exploration and debridement demonstrated a significant defect in the dorsal portion of the talar neck. Temporary stabilisation was achieved with Kirschner wires and the defect was packed with bone cement. Two weeks later, a MFC flap was harvested from the ipsilateral knee and tailored to fit the talar defect. Fixation was achieved with cannulated compression screws. At six weeks post-operative, all wounds had healed, a radiograph demonstrated a positive Hawkins sign and computed tomography showed incorporation of the flap. The patient had no donor site morbidity, and commenced weight bearing at 3 months postoperatively. Conclusion This is the first report demonstrating the viability of MFC flap reconstruction for the management of bony defects in acute talar neck fractures.

Evaluation of grafts fixation techniques for temporomandibular joint reconstruction with medial femoral condyle flap: A numerical study

Reconstruction for large-scale temporomandibular joint (TMJ) defects can be challenging. Previously, we utilized the medial femoral condyle (MFC) flap for TMJ reconstruction. However, the optimal fixation method remains uncertain. In this study, finite element analysis was used to study the effects of three different fixation types of bone graft: overlap type, bevel type, and flush type. Models of different fixation types of MFC flap were reconstructed from CT images. A standard internal fixation model for extracapsular condylar fracture was also included as a control. Displacement of bone graft, deformation of plates and screws, and stress distribution of plates, screws, and cortical and cancellous of the bone graft were analyzed by finite element analysis to investigate their biomechanical features. The displacement of the bone graft and deformation of plates and screws in three different fixation types showed no significant difference. The overlap type and flush type of fixation displayed the lowest and highest stress respectively. All three fixation types could satisfy the mechanical requirement and face no risk of breakage and the major displacement of the MFC bone graft. These results provide insights into the optimal fixation approach for MFC bone grafts, offering valuable guidance and reference for clinical application.

Evaluation of free vascularized medial femoral condyle bone grafts in the treatment of avascular scaphoid waist nonunion.

The aim of this study was to evaluate the medial femoral condyle (MFC) bone graft procedure for scaphoid waist nonunion with avascular necrosis on magnetic resonance imaging or prior surgery failure. Between June 2015 and December 2018, a total of 17 patients (16 males, 1 female; mean age: 29±8.2 years; range, 16 to 40 years) with scaphoid waist nonunion who were treated with vascularized MFC bone grafting were retrospectively analyzed. Pre- and postoperative carpal indices, grip strengths for both hands, range of motion, Visual Analog Scale (VAS) pain score, Quick Disabilities of the Arm, Shoulder, and Hand (QDASH) score, and Mayo Wrist Score (MWS) were evaluated. After vascularized MFC bone graft surgery, 15 patients healed and returned to work without any limitations. Ten patients of left scaphoid nonunion and seven cases of right scaphoid nonunion were treated; for eight of these patients, the operation was on the dominant side. Eight of these patients were smokers. The mean follow-up was 22.4±5.8 months. The mean hand grip strength was increased from 74.5 to 84% on the contralateral side (p<0.05). The average revised carpal height ratio improved from 1.57 to 1.59 (p<0.05) and the scapholunate angle changed from 56.9° to 51.6° (p<0.05). The MFC bone grafting is one of the best surgical procedures for small defects such as scaphoid waist nonunion with high union rates, good functional outcomes, and minimal donor site morbidity.

Does indocyanine green fluorescence angiography impact the intraoperative choice of procedure in free vascularized medial femoral condyle grafting for scaphoid nonunions?

BackgroundFree vascularized medial femoral condyle (MFC) bone grafts can lead to increased vascularity of the proximal pole and restore scaphoid architecture in scaphoid nonunions. The intraoperative perfusion assessment of the bone graft is challenging because the conventional clinical examination is difficult. Indocyanine green (ICG) angiography has previously been shown to provide a real-time intraoperative evaluation of soft tissue perfusion in reconstructive surgery. The present study investigated the utility of ICG angiography in patients treated with a free medial femoral condyle graft for scaphoid nonunions.MethodsWe performed a retrospective analysis of patients with scaphoid nonunions, in which ICG angiography was used intraoperatively for perfusion assessment. The medical records, radiographs, intraoperative imaging, and operative reports of all patients were reviewed. Intraoperative ICG dye was administered intravenously, and laser angiography was performed to assess bone perfusion. The scaphoid union was examined using postoperative CT scans.ResultsTwo patients had documented osteonecrosis of the proximal pole at the time of surgery. Four patients received a nonvascularized prior bone graft procedure, and a prior spongiosa graft procedure was performed in one patient. The mean time from injury to the MFC bone graft surgery was 52.7 months, and the mean time from prior failed surgery was 10.4 months. Perfusion of the vascular pedicle of the MFC and the periosteum could be detected in all patients. In two patients, even perfusion of the cancellous bone could be demonstrated by ICG angiography. Following transplantation of the bone graft, patency of the vascular anastomosis and perfusion of the periost were confirmed by ICG angiography in the assessed cases. No additional surgery regarding a salvage procedure for a scaphoid nonunion advanced collapse was necessary for the further course.ConclusionICG-angiography has shown to be a promising tool in the treatment of scaphoid nonunion with medial femoral condyle bone grafts. It enables intraoperative decision making by assessment of the microvascular blood supply of the periosteum and the vascular pedicle of the MFC bone graft. Further studies need to evaluate the impact on union rates in a long-term follow-up.

Comparison of the functional and radiological outcomes of vascularized and non-vascularized bone graft options in the treatment of scaphoid nonunion.

Objectives This study aims to compare the functional and radiological outcomes of the patients with scaphoid waist nonunion treated with non-vascularized bone graft and vascularized bone graft options.Patients and methods Between January 2016 and February 2020, a total of 24 patients (22 males, 2 females; mean age: 30.6±9.4 years; range, 18 to 66 years) with scaphoid waist nonunion who were treated with vascularized or non-vascularized bone graft were retrospectively analyzed. Of these patients, eight were treated with iliac crest non-vascularized bone graft (IC-NBG), seven with vascularized free medial femoral condyle (MFC) graft, and nine with 1,2-intercompartmental supraretinacular artery pedicled vascularized bone graft (1,2-ICSRA-VBG). The grip strength, flexion, extension, radial deviation, ulnar deviation angles were measured and compared to the contralateral hand for functional outcomes. Union rates, the scaphoid height-to-length ratio, the lateral intrascaphoid angle (LISA) were evaluated for radiological outcomes. The Mayo Wrist Score, Visual Analog Scale (VAS) score, and Quick Disability of the Arm, Shoulder and Hand (Q-DASH) Questionnaire score were calculated.Results Union was observed in seven (87.5%) patients after IC-NBG, in six (85.7%) patients after MFC bone graft and nine (100%) patients in the treatment group with 1,2-ICSRA-VBG. There were no statistically significant differences among the IC-NBG, MFC and 1,2-ICSRA-VBG groups in terms of the union rates, the scaphoid height-to-length ratio, VAS score, Q-DASH score, grip strength and flexion, ulnar deviation, radial deviation angles after surgery (p>0.05). However, extension was statistically lower in the MFC group than IC-NBG and 1,2-ICSRA-VBG groups after surgery. The Mayo score was better in the IC-NBG group than MFC and 1,2-ICSRA-VBG, indicating a statistically significant difference (p<0.05).Conclusion Based on our study results, we suggest to use IC-NBG for scaphoid waist nonunion as the primary procedure, as the union rates are comparable with the MFC and 1,2-ICSRA-VBG techniques and it has advantages such as shorter operation time, easier technique, no special experience requirement, and better functional outcomes.

Free Vascularized Medial Femoral Condyle Bone Graft for Scaphoid Nonunion with Poor Prognosis Factors

Purpose: Authors attempt to evaluate the clinical and radiographic results of the treatment of scaphoid nonunion with poor prognostic factors with the free vascularized medial femoral condyle bone graft. Methods: We operated on eight patients with avascular necrosis or prolonged nonunion of the scaphoid between January 2016 and July 2019. Wrist motion in terms of flexion, extension, and ulnar and radial deviation, a visual analogue scale (VAS), the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, the modified Mayo wrist score, scapholunate angle, and carpal height index were collected in the clinic setting preoperatively and at the latest follow-up in all patients Results: Eight patients with union achieved correction and maintenance of both scapholunate angle and carpal height index. The VAS pain scores significantly improved from 5.1 preoperatively to 3.3 postoperatively. There was a statistically significant improvement in the average DASH score at the final follow-up. Scapholunate relationships in the reconstructed wrists remained almost unchanged, with average scapholunate angles of 49.7° before surgery and 47.0° at the latest postoperative follow-up. There was no statistical significance between the number of poor prognosis factors and the time to union, but there was a positive correlation.Conclusion: It could help surgeons manage the scaphoid nonunion associated with poor prognostic factors such as avascular necrosis, carpal collapse (posttraumatic arthritis), prolonged nonunion, and failed prior scaphoid nonunion surgery.

Overstuffing of Unstable Scaphoid Nonunions: A Radiographic Analysis of Carpal Parameters

The purpose of this study was to radiographically evaluate scaphoid length and carpal parameters before and after reconstruction of nonunions with interposition vascularized medial femoral condyle (MFC) bone graft to determine if the scaphoid was overstuffed or if normal anatomy was restored and to determine the effect on ulnar carpal translocation when the volar radiocarpal ligaments were left unrepaired. Thirty-nine patients with established scaphoid nonunions with carpal collapse were reconstructed by interposition vascularized MFC bone grafts without repair of the volar radiocarpal ligaments. Pre- and postoperative radiographs and computed tomography scans of the 39 patients were reviewed. The scaphoid length, capitate-ulnar distance ratio (CUDR), modified carpal height ratio (MCHR), radiolunate (RL) and scapholunate (SL) angles were measured before and 3 months after surgery. Thirteen of these patients had contralateral wrist radiographs that were used for analysis of scaphoid length restoration. No significant changes were observed for CUDR and MCHR before and after surgery. The length of the scaphoid significantly improved after reconstruction from 21.9 ± 3.3 to 23.7 ± 3.4 mm on posteroanterior x-ray views and from 24.0 ± 2.2 to 27.7 ± 2.8 mm on lateral views. The RL and SL angles also changed significantly after surgery from 19.5° ± 13.5° to 4.1° ± 16.9° and from 67.5° ± 12.5° to 56.0° ± 12.5°, respectively. Regarding the 13 patients with contralateral x-rays, no differences were seen on CUDR, MCHR, or scaphoid length on posteroanterior x-ray views. However, the scaphoid length on lateral x-ray views increased from 23.1 ± 2.40 to 27.6 ± 2.78 mm and was significantly longer than the contralateral side by 9.6%. The RL and SL angles were restored and comparable with the contralateral side. The use of vascularized MFC bone graft increased scaphoid length by 9.6% and restored normal carpal alignment. Despite the increased scaphoid length compared with the contralateral side, the lack of repair of the volar radiocarpal ligaments did not cause ulnar carpaltranslocation in short-term follow-up. Therapeutic IV.

Free Vascularized Medial Femoral Condyle Bone Graft After Failed Scaphoid Nonunion Surgery.

Outcomes following revision surgery for scaphoid nonunions with osteonecrosis are guarded. We hypothesized that use of free vascularized medial femoral condyle (MFC) bone grafts can lead to healing of the nonunion, increase vascularity of the proximal pole, and restore scaphoid architecture, resulting in acceptable functional outcomes. We performed a retrospective review of 49 patients who were treated with an MFC bone graft, between May 2005 and September 2016, after prior failure of operative treatment for scaphoid nonunion. The mean time from the injury to the revision surgery with the MFC bone graft was 24 months, and the mean time from the prior, failed surgery was 15 months. Thirty-six of the 49 patients had had a prior bone graft procedure and 6 patients had had 2 previous surgical procedures for the nonunion. The initial internal fixation of the scaphoid fracture was with a scaphoid screw in 43 patients. All patients had documented osteonecrosis of the proximal pole at the time of our surgery. Carpal indices, time to union, pain scores, functional outcomes, and complications were recorded. Forty-one (84%) of the 49 previously operated on scaphoid nonunions healed at a mean of 16 weeks (range, 9 to 31 weeks) after the MFC bone-grafting as confirmed on computed tomography (CT). Radiographs demonstrated significant improvement in carpal alignment following the surgery with the MFC bone graft. Comparison between preoperative and postoperative values showed a trend toward improved grip strength and no important change in total wrist range of motion. Subsequent procedures were performed in 29 patients, 21 of whom had planned Kirschner wire removal. All 24 patients in whom scaphoid union had been achieved and who were available for follow-up were able to work or attend school full-time, and 88% were satisfied or very satisfied with their wrist function. Age, smoking status, body mass index, time to surgery, and preoperative radiographic findings were not found to be significant predictors of failure. MFC grafts increase vascularity and restore scaphoid architecture, promoting union in most patients with the combination of proximal pole osteonecrosis, carpal collapse, and failed prior scaphoid nonunion surgery. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

MFC Bone Graft for Scaphoid Nonunion, Osteonecrosis, and Failed Prior Surgery: Three Strikes But Not Necessarily Out: Commentary on an article by Nicholas Pulos, MD, et al.: "Free Vascularized Medial Femoral Condyle Bone Graft After Failed Scaphoid Nonunion Surgery".

Commentary Patients with a nonunion of the scaphoid with a proximal fracture line, osteonecrosis of the proximal pole, and a previously unsuccessful attempt at achieving surgical union present the orthopaedic surgeon with a difficult clinical decision. Some surgeons might advocate nonoperative treatment, with the expectation that a salvage procedure (scaphoid excision and 4-corner fusion, proximal row carpectomy, total wrist arthrodesis, or total wrist arthroplasty) might eventually be required to relieve pain and maintain motion. Others might recommend repeat open reduction and internal fixation using either vascularized or nonvascularized local bone, whereas those who are experienced with microsurgical techniques might attempt, on the basis of the data presented in this article, a vascularized medial femoral condyle (MFC) bone graft in order to achieve union and restore vascularity (and therefore mitigate against eventual collapse) of the proximal pole. The authors give us an honest appraisal and have made an important iterative contribution to the care of young patients with this challenging clinical problem. They acknowledged an almost 20% rate of additional surgery (apart from scheduled surgery for the removal of Kirschner wires) and also reported a 1-in-6 rate of persistent nonunion. Even though these results are a reason for reflection and discussion, this surgical procedure is an attempt to restore preinjury anatomy, which is, in my opinion, a worthy goal for these young, physically active patients. Whether the main issue is carpal collapse and humpback deformity in an SNAC (scaphoid nonunion advanced collapse) wrist following scaphoid fracture with proximal pole osteonecrosis (and an initial attempt at achieving surgical union), or pain and tenderness over the proximal pole due to fragmentation and collapse as well as the development of osteoarthritis between the distal scaphoid pole and the radial styloid, remains open to discussion. Also, this article did not address specifically whether the goal of restoration of scaphoid length by means of an MFC graft is directly related to the restoration of carpal alignment. It would seem so; however, this point is really only academic since proximal pole fractures and nonunions do not routinely lead to arthrosis between the proximal pole of the scaphoid and the distal radial articular surface as is seen in chronic SLAC (scapholunate advanced collapse) wrists. Although 1 patient had a subsequent radial styloid excision, the distal pole was not excised, presumably because of the condition of either the proximal pole or the scapholunate ligament, or both. Several caveats outlined in the article bear repetition. First, patients frequently lost wrist motion following this procedure, and this was manifested by several patients’ inability to return to push-up exercises. This is not an unimportant point, especially in patients with specific functional requirements related to their employment. Second, there were some sports-related difficulties as well as persistent discomfort that compromised the outcomes. My mention of this is not meant to denigrate the procedure or the results, but rather to encourage the surgeon to set realistic expectations—i.e., of results that are either similar to or slightly better than those achievable with salvage procedures in terms of pain relief, motion, and strength with (hopefully) longer-term durability. The cases presented in this article are seen infrequently, and the patients often expect a full return to sports and vocational activities. Preoperative counseling and the setting of achievable goals are to be stressed. The surgical results in this retrospective study suggest that, in the infrequent situation where a young patient presents with “3 strikes” (nonunion, osteonecrosis, and prior unsuccessful surgery), he/she might not necessarily be “out.”

Primary medial femoral condyle vascularized bone graft for scaphoid nonunions with carpal collapse and proximal pole avascular necrosis.

This study aimed to determine the outcome of free vascularized medial femoral condyle bone grafts in the primary treatment of scaphoid nonunions with scaphoid foreshortening or carpal collapse and intraoperatively documented avascular necrosis. Thirty-two patients (28 male, four female) met the inclusion criteria. Median time from injury to surgery was 70 weeks. Thirty of 32 patients healed at a median of 12 weeks. There was significant improvement from preoperative to postoperative lateral intrascaphoid angle, scapholunate angle, and radiolunate angle. Two scaphoids failed to unite; one patient underwent scaphoidectomy and four-corner fusion 15 months postoperatively after suffering a subsequent injury. Another patient underwent 1,2-intercompartmental supraretinacular artery-based vascularized bone grafting at 4 months postoperatively and then scaphoid excision with four-corner fusion 4 years later. The free vascularized medial femoral condyle bone graft restores scaphoid vascularity and architecture while promoting union in a subset of scaphoid nonunions that has historically been a clinical challenge. Level of evidence: IV.

Vascularized Medial Femoral Condyle Bone Graft for Resistant Nonunion of the Distal Radius.

Nonunion involving the metaphyseal region of the distal radius is exceedingly rare, usually involving co-morbidity. Patients that have failed multiple prior conventional surgical interventions represent an even more difficult subset to treat; this investigation examined the utility of a specially designed free vascularized medial femoral condyle flap consisting of a central structural block graft with an extended corticoperiosteal sleeve to wrap around the junctions. Six patients (5 males, 1 female) with a mean age of 52 years had failed to achieve union involving the distal radius metaphysis after a mean of 3.7 prior surgeries occurring over a mean period of 24 months. Comorbidities included smoking, alcoholism, chronic nutritional deficiency, and prior osteomyelitis. The unique descending genicular artery medial femoral condyle flap designed to address these patients consisted of a central structural block graft in continuity with an extended corticoperiosteal sleeve. The structural block filled the bone defect, and the corticoperiosteal sleeve wrapped around the bone junctions and the neighboring bone margins. The mean flap size was 5.3 (+/- 1.3) cm long by 4.5 (+/- 0.9) cm wide. Pre-operative to post-operative DASH scores were compared using the paired student' s t-test, with p < 0.05. All flaps achieved union at a mean of 6.8 (+/- 2.1) weeks following surgery, using the criteria of bridging trabeculae on all 3 radiographs: coronal, sagittal, and oblique. The mean pre-operative DASH score of 63 (+/- 10) was statistically significantly different compared to the mean post-operative DASH score of 18 (+/- 8). With few alternative solutions able to address this unique and difficult problem, the structural block of vascularized bone with the extended corticoperiosteal sleeve proved able to achieve a union that had failed multiple previous attempts and able to resist reactivation of infection, in a challenging group of patients with comorbidities.

Free Medial Femoral Condyle Flap for Reconstruction of Scaphoid Pseudarthrosis

Objective/Hypothesis: Nonunions of scaphoid are routinely treated by reconstruction with interposition of cancellous bone grafts from the iliac crest or distal radius. In unfavorable situations as persistent pseudarthrosis following surgical reconstruction or avascular proximal pole, vascularized bone grafts are preferred. Free vascularized bone grafts from the medial femoral condyle were introduced as an additional tool for reconstruction and showed promising results. Material and Methods: In this study, 71 scaphoid nonunions or pseudarthrosis were followed after reconstruction with vascularized bone graft form the medial femur. In 15 cases, an osteocartilaginous graft was used to replace the proximal pole. After a minimum follow-up of 6 months (64 patients), following data were evaluated: consolidation, complications, donor site morbiditiy, pain in rest and stress, range of motion, grip strength, and Krimmer score. Results: Consolidation rate was 88%, in 19.6 % minor complications occurred. Range of motion did not change significantly, 89% grip strength of opposite site could be regained. Pain (VAS) in rest was reduced by 73%, in stress by 51%. Donor site morbiditiy is tolerable: 14.5% had mild symptoms after 3 months, reducing to less than 2% after 6 months. Krimmer Score resulted in very good and good results in 60% of the cases. Conclusion: Reconstruction of scaphoid pseudarthrosis with the free medial femoral condyle bone graft is an adequate technique to reach high consolidation rates in unfavorable situations. Postoperative function improves in terms of grip strength and pain reduction. Range of motion impairment usually persists. The surgical technique is challenging, but the quality of the bone graft is superior to the pediculated bone grafts of the distal radius. In addition, the distal femur offers the possibility of a osteocartilaginous graft to replace the complete proximal pole. Frequently, salvage surgery like 4 corner fusion can be avoided by this technique.

Vascularized medial femoral condyle graft for management of scaphoid non-union.

The purpose of this study was to assess the results of the management of difficult scaphoid non-unions using a vascularized medial femoral condyle graft. We operated on 30 patients with necrosis of the proximal pole or with severe humpback deformity or who presented with persistent non-union despite previous surgery. Twenty-four cases in our series showed full consolidation and six cases showed persistent non-union. The free vascularized medial femoral condyle bone graft can provide not only structural support, but also a consistent and good blood supply that results in excellent rates of union. Level of evidence: IV.

Reconstruction of scaphoid non-union and total scaphoid avascular necrosis in a pediatric patient: a case report.

The medial femoral condyle vascularized bone graft has grown in popularity for treating recalcitrant fracture non-unions and has become particularly useful in treating scaphoid non-union with avascular necrosis of the proximal pole. The medial femoral condyle is an excellent source of dense, well-vascularized bone and results in minimal donor site morbidity. We describe an unusual case of chronic scaphoid non-union and total scaphoid avascular necrosis in a skeletally immature patient. Scaphoid reconstruction was performed with a vascularized medial femoral condyle graft, with successful graft incorporation, and restoration of pain-free wrist motion. Technical considerations for harvest of the medial femoral condyle bone graft in the skeletally immature patient are discussed.

Vascularized Bone Grafts for the Treatment of Carpal Bone Pathology

Primary bone healing fails to occur in 5-15% of scaphoid bones that undergo fracture fixation. Untreated, occult fractures result in nonunion up to 12% of the time. Conventional bone grafting is the accepted management in the treatment algorithm of scaphoid nonunion if the proximal pole is vascularized. Osteonecrosis of the proximal scaphoid pole intuitively suggests a need for transfer of the vascularized bone to the nonunion site. Scaphoid nonunion treatment aims to prevent biological and mechanical subsidence of the involved bone, destabilization of the carpus, and early degenerative changes associated with scaphoid nonunion advanced collapse. Pedicled distal radius and free vascularized bone grafts (VBGs) offer hand surgeons an alternative treatment option in the management of carpal bone nonunion. VBGs are also indicated in the treatment of avascular necrosis of the scaphoid (Preiser's disease), lunate (Kienböck's disease), and capitate. Relative contraindications to pedicled dorsal radius vascularized bone grafting include humpback deformity, carpal instability, or collapse. The free medial femoral condyle bone graft has offered a novel treatment option for the humpback deformity to restore geometry of the carpus, otherwise not provided by pedicled grafts. In general, VBGs are contraindicated in the setting of a carpal bone without an intact cartilaginous shell, in advanced carpal collapse with degenerative changes, and in attempts to salvage small or collapsed bone fragments. Wrist salvage procedures are generally accepted as the more definitive treatment option under such circumstances. This manuscript offers a current review of the techniques and outcomes of VBGs to the carpal bones.

Free Medial Femoral Condyle Vascularized Bone Grafting for Scaphoid Nonunions with Proximal Pole Avascular Necrosis and Carpal Collapse

Treating scaphoid nonunions complicated by avascular necrosis and collapse with humpback deformity has proven challenging. Conventional nonvascularized interposition grafts restore the structural architecture, but fail to restore the vascular supply to the scaphoid. Pedicled inlay grafts restore blood flow, but fail to correct the humpback deformity or restore scaphoid length. Restoration of both vascularity and geometry is critical for promoting bony union. The free vascularized medial femoral condyle bone graft provides both and has proven successful in treating this problematic subset of scaphoid nonunions. The rationale, indications, contraindications, anatomical basis, and technique of scaphoid preparation, bone graft harvest, insetting, fixation, and microvascular anastomosis are presented for the treatment of scaphoid nonunions with avascular necrosis and carpal collapse.

Free-Vascularized Medial Femoral Condyle Bone Transfer in the Treatment of Scaphoid Nonunions

Scaphoid nonunions with associated avascular necrosis and carpal collapse have proven difficult to treat reliably. This study outlines the rationale and approach to the use of a free-vascularized medial femoral condyle bone graft and the authors' experience with it in the treatment of scaphoid nonunions. A retrospective review was conducted to identify all patients with scaphoid nonunions with avascular necrosis and carpal collapse treated with a medial femoral condyle bone graft. Between July of 2004 and August of 2007, 12 such patients (12 men and no women), with a mean age of 25.3 years (range, 18 to 40 years), were identified. Nine of the twelve had failed prior operative treatment. Mean duration of nonunion was 20 months (range, 4 to 36 months). Carpal indices, time to union, early functional outcomes, and complications were recorded. All 12 nonunions healed at a mean of 13 weeks (range, 6 to 26 weeks). Radiographic evaluation demonstrated significant improvement from preoperative to postoperative mean lateral intrascaphoid angle (66 and 28 degrees, respectively; p = 0.00005), scaphoid height-to-length ratio (0.78 and 0.65 respectively; p = 0.006), scapholunate angle (63 and 49 degrees, respectively; p = 0.001), and radiolunate angle (15 and 6 degrees, respectively; p = 0.0005). Five patients underwent subsequent procedures (one radial styloidectomy and four Kirschner wire removals, with one concurrent donor-site stitch abscess débridement). Free-vascularized medial femoral condyle grafts provide both blood supply and structural support to restore scaphoid vascularity and architecture, thereby promoting union. These results suggest that this graft is a promising alternative in the treatment of scaphoid nonunions associated with avascular necrosis and carpal collapse.

Vascularized Medial Femoral Condyle Graft for Thumb Metacarpal Reconstruction: Case Report

The vascularized medial femoral condyle bone graft has many clinical applications. It can be harvested as a thin, pliable, corticoperiosteal graft and wrapped around recalcitrant nonunions in long bones to achieve osseous union. It can also be harvested as a small, structural, corticocancellous graft and used to treat small defects such as scaphoid avascular nonunion. We present a case of thumb metacarpal osteomyelitis resulting in a large segmental osseous defect. Reconstruction was performed using a large, structural, vascularized bone graft from the medial femoral condyle.