Vascularized Medial Femoral Trochlea Osteocartilaginous Flap Reconstruction of Proximal Pole Scaphoid Nonunions

SCIENTIFIC ARTICLE

Vascularized Medial Femoral Trochlea Osteocartilaginous Flap Reconstruction of Proximal Pole Scaphoid Nonunions Heinz K. Bürger, MD, Christian Windhofer, MD, Alexander J. Gaggl, MD, James P. Higgins, MD Purpose The descending geniculate artery’s branching pattern includes periosteal vessels supplying the cartilage-bearing trochlea of the medial patellofemoral joint. Previous cadaveric studies described anatomic similarities between the greater curvature of the proximal scaphoid and the convex surface of the medial femoral trochlea (MFT). We describe the technique and report our first 16 consecutive cases of vascularized osteocartilaginous arthroplasty for chronic scaphoid proximal pole nonunions using the MFT, with a minimum of 6 months of follow-up. Methods Chart reviews of 16 consecutive cases of osteocartilaginous MFT flap transfers for scaphoid reconstruction were performed at 2 institutions. Follow-up data were recorded at a minimum of 6 months, with an average of 14 months (range, 6 –72 mo). Patient age and sex, duration of nonunion, number of previous surgical procedures, surgical technique, achievement of osseous union, preoperative and postoperative scapholunate angles, preoperative and postoperative range of motion, and pain relief were recorded. Results Computed tomography imaging confirmed healing in 15 of 16 reconstructed scaphoids. Mean patient age was 30 years (range, 18 – 47 y). The average number of previous surgical procedures was 1 (range, 0 –3). All patients experienced some wrist pain improvement (12/16 complete relief, 4/16 incomplete relief). Wrist range of motion at follow-up averaged 46° extension (range, 28° to 80°) and 44° flexion (range, 10° to 80°), which was similar to preoperative measurements (average 46° extension and 43° flexion). Scapholunate relationship remained unchanged with average scapholunate angles of 52° before surgery and 49° after surgery. Conclusions Osteochondral vascularized MFT flaps provide a reliable means of achieving resolution of difficult proximal pole scaphoid nonunions. These flaps allow resection of the proximal portion of the unhealed scaphoid and reconstruction with an anatomically analogous convex segment of cartilage-bearing bone. This technique provides the advantages of vascularized bone and ease of fixation. Early follow-up demonstrates a high rate of union with acceptable motion and pain relief. Clinical relevance Early follow-up suggests that the vascularized MFT osteocartilaginous flap is a valuable tool for treating challenging proximal pole scaphoid nonunions. (J Hand Surg 2013;38A:690–700. Copyright © 2013 by the American Society for Surgery of the Hand. All rights reserved.) Key words Medial femoral trochlea flap, medial femoral condyle, osteocartilaginous autograft, scaphoid nonunion, vascularized bone.

From the Privat Hospital Maria Hilf, Klagenfurt, Austria; Trauma Department, Unfallkrankenhaus, Salzburg, Austria; Department of Oral and Maxillofacial Surgery, University Hospital, Salzburg, Austria; The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD.

Corresponding author: James P. Higgins, MD, c/o Anne Mattson, The Curtis National Hand Center, MedStar Union Memorial Hospital; 3333 North Calvert Street, Mezzanine, Baltimore, MD 21218; e-mail: [email protected].

The authors thank Anne Mattson for editorial assistance.

0363-5023/13/38A04-0009$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2013.01.036

Received for publication September 25, 2012; accepted in revised form January 17, 2013. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article.

690 䉬 ©  ASSH 䉬 Published by Elsevier, Inc. All rights reserved.

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condyle (MFC) corticoperiosteal flap has been used in numerous anatomic locations to address challenging cases of nonunion or bone loss. It has been successfully used in the clavicle,1,2 humerus,2– 6 radius,2,5,7–9 ulna,3,5,7,9,10 metacarpal,6,9,11 femur,2 tibia,2,3,12,13 phalanx,9,14 carpals and tarsals,6,12,15–19 orbit,20 maxilla/ mandible,9,21–23 and skull.9,24 Because of its malleable quality as a thin corticoperiosteal flap, particular focus has been given to its application for scaphoid nonunion reconstruction as an alternative to pedicled vascularized bone flap from the distal radius.17,25–27 In these studies, the segment of cortical bone harvested was at the distal aspect of the MFC supplied by the longitudinal branch of the descending geniculate artery (DGA). Anatomic studies to date have focused on defining the arterial anatomy of the MFC flap, with an emphasis on aiding the surgeon with dissection of the pedicle and locating the region of greatest density of corticoperiosteal perforators to the bone over the medial condyle,22,28 the extent of periosteal perfusion provided by the DGA pedicle,29 the vascular supply to the skin component,9,30 and the branching pattern of the vessels about the distal femur.29,31 The vascular pattern of this system includes periosteal vessels supplying the cartilage-bearing trochlea of the medial patellofemoral joint via the transverse branch of the DGA. The utility of harvesting this convex cartilaginous surface as a vascularized flap was described by the senior author (H.K.B.) in a case report of scaphoid reconstruction of a recalcitrant proximal pole nonunion in 2008.32 Subsequent cadaveric studies have described the pertinent vascular arcade supplying this bone and cartilage29,31 and the anatomic similarities between the greater curvature of the proximal scaphoid and the convex surface of the medial femoral trochlea (MFT).31 We have performed or collaborated on more than 30 cases of vascularized osteocartilaginous arthroplasty for chronic scaphoid proximal pole nonunions using the MFT. This report describes the technique and provides early results of our first 16 consecutive cases using this procedure.

T

691

HE FREE MEDIAL FEMORAL

MATERIALS AND METHODS Clinical series Chart reviews of our original 16 consecutive cases of osteocartilaginous MFT flap transfers for scaphoid reconstruction were performed in 2 centers. Patients were deemed candidates for MFT osteocartilaginous reconstruction in the setting of proximal pole nonunions with inadequate proximal fragment bone

FIGURE 1: Radiograph of a 20-year-old patient (patient #1 in Table 1) with a longstanding (36 mo) scaphoid nonunion of the proximal pole. Because of the poor quality and small size of the proximal fragment bone and cartilage shell, this patient was exemplary of the 5 patients that had MFT reconstruction as their first surgical treatment.

quality for conventional (proximal pole–preserving) reconstruction. In these cases, the proximal pole demonstrated extremely poor bone quality and small size of the cartilage shell due to previous surgical attempts at fixation and/or cavitation and bone loss from longstanding nonunions of proximal fractures (Fig. 1). All cases were performed by the authors between January 2006 and February 2012. All patients had established (at least 6 months’ duration) proximal pole nonunions without evidence of wrist arthritis. Six patients had previous failed attempts at reconstruction with vascularized pedicled bone grafting procedures, either as their sole previous surgical procedure (n ⫽ 2) or as one of multiple previous surgical procedures (n ⫽ 4). Four patients had a single previous procedure with screw fixation without bone grafting. One patient had a single previous procedure using nonvascularized bone grafting. Five patients had no previous surgical intervention. These 5 patients had extremely thin proximal pole fragments with magnetic resonance imaging evidence of avascular necrosis. Although the majority of the cohort (12/16) had preoperative magnetic resonance

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FIGURE 2: Drawing of planned curvilinear incision for MFT flap if skin paddle is anticipated. If no skin paddle is planned, a straight incision is created from the point midway between the medial condyle and the patella, extending proximally toward the Hunter canal (dotted superimposed line).

imaging evidence of proximal pole avascular necrosis, this was not considered a prerequisite for MFT reconstruction. The MedStar Health Research Institute’s institutional review board in the United States and the Ethikkommission für das Bundesland Salzburg in Austria reviewed and approved this study. Data recorded included age and sex of patient, duration of nonunion, number of previous surgical procedures, surgical approach (volar/dorsal), type of fixation, location of anastomosis, achievement of osseous union, preoperative and postoperative scapholunate angles, preoperative and postoperative range of motion, and relief of pain. Osteocartilaginous medial femoral trochlea harvest technique We used the methodology previously described by Iorio et al.9 The planned incision is determined by the required length of pedicle and the plan for postoperative monitoring. If a skin paddle is desired to monitor the bone flap, a sweeping curvilinear incision is created, starting at the Hunter canal and moving distally and anteriorly to the midpoint between the medial border of the patella and the MFC, where it continues distal and posterior, stopping 2 to 3 cm below the joint line and just posterior to the mid-axis of the leg (Fig. 2). If no skin paddle is planned, a straight incision is created from the point midway between the medial condyle and the patella, extending proximally toward the Hunter canal.

FIGURE 3: Descending geniculate artery pedicle (indicated by black arrow; knee is to the right); close-up view of anteromedial distal femur demonstrating transverse branch (indicated by red arrow) coursing toward medial trochlea; marking indicates the area of typical osteocartilaginous harvest from proximal trochlea.

This skin incision is continued to the subfascial plane of the vastus medialis, which allows the skin paddle to be rapidly elevated and retracted posteriorly as the vastus medialis is dissected anteriorly. The DGA can then be identified as the medial column of the femur is exposed. Dissecting subfascially ensures protection of all skin vessels that may branch off the distal DGA into the reflected skin. Branches to the vastus medialis course anteriorly (penetrating the fascial plane) and are ligated. If a skin segment is desired (for ease of closure or postoperative monitoring) a decision is made regarding the approach for the skin paddle, selecting the saphenous artery branch or distal cutaneous branch. The details of the skin paddle harvest technique have been described previously.9 The DGA yields 2 major periosteal branches at the level of the condylar flare. The longitudinal branch is the commonly used branch for scaphoid nonunions or corticocancellous bone flaps. The transverse branch courses anteriorly toward the medial trochlea and is invested intimately with the proximal margin of the cartilage of the trochlea. This relationship must be preserved and marks the target area for harvest (Fig. 3). To minimize the amount of harvested cartilage, we used intraoperative modeling to determine the 3-dimensional requirements of the resected scaphoid (Fig. 4). After lining the carpal defect with a thin layer of surgical glove latex material, we used saline-cooled methyl methacrylate cement to fill the defect and solidify into a surgical model. The hardened model is placed over the medial trochlea to guide the resection margins of the

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FIGURE 4: Creating, sculpting, and insetting a model of the MFT. A Defect created after generous resection of nonunited proximal scaphoid (radius is to the right; hand is to the left) via volar approach. The mold is created by inserting malleable material into defect lined with latex surgical glove material. B Elevated and bleeding bone and cartilage segment on intact pedicle. C Resultant model and the adjacent, harvested MFT cartilage-bearing segment.

flap. This technique has enabled us to harvest only the amount of cartilage needed for reconstruction of the scaphoid. It has also allowed us to achieve congruent insetting of the flap with minimal revisions of osseous sculpting before final inset. The proximal-to-distal arc of curvature of this cartilage is harvested to reproduce the desired radial-toulnar arc of curvature of the osteocartilaginous segment required for scaphoid reconstruction. In all cases, the cartilage-bearing surface is used to recreate the convex proximal surface of the scaphoid to provide a congruent surface for radiocarpal articulation (Fig. 5). Usually, the scaphoid is generously resected proximally to enable the MFT cartilage to provide complete coverage of the scaphoid fossa. Radial styloidectomies were not performed. The distally directed surface is cancellous bone and is thus fashioned to contact the thin remaining cartilage surface of the native scaphoid (after careful resection of the scaphoid proximal pole). In this manner, a distal

native cartilage-bearing surface is preserved for midcarpal articulation (Fig. 6). The width, length, and depth of osteocartilaginous segment required is harvested on the transverse branch and common DGA origin vessel. Vessel harvest can be continued to the DGA origin off the superficial femoral artery in the Hunter canal if such length and vessel caliber is desired. This can yield 8 cm length with 1.2-mm arterial diameter. The length of vascular pedicle available is more than is required to reach the radial artery recipient sites. The excess pedicle length can be problematic in a small field of dissection in the wrist. We have successfully managed the pedicle length with 2 techniques. One option is to preserve the length and caliber of the DGA pedicle and perform an endto-side anastomosis in the radial artery proximally via a subcutaneous tunnel to a proximal counterincision. More commonly, we have resected the additional pedicle length and performed the anas-

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FIGURE 5: Representation of MFT and the planned portion of reconstructed proximal scaphoid. Portion of MFT harvested to provide vascularized osteocartilaginous reconstruction of the proximal scaphoid. A, descending geniculate artery. B, transverse branch. C, longitudinal branch. D, superiomedial geniculate artery.

tomosis in the same volar surgical field as the scaphoid dissection. In the latter situation, the smaller-caliber pedicle was usually anastomosed end-to-end into the palmar branch of the radial artery. We achieve fixation with cannulated screws, miniplate fixation, or K-wire through a volar or dorsal approach. The approach is by surgeon preference and consideration for the need to remove previously failed hardware. The majority of cases were treated with screws placed via the volar approach. The ability to resect the proximal pole fragment and a generous portion of the proximal scaphoid distal to the fracture line enables the resultant large osseous segment to be readily fixed by volar screw fixation (Fig. 7). Furthermore, the availability of the palmar branch of the radial artery in the volar dissection field made this the most common approach used in this series. The cartilage-bearing segment of the MFT provides a good contour match with the radial scaphoid fossa. It carries a much thicker cartilage shell than the native

FIGURE 6: Intraoperative C-arm image demonstrating the resection of the proximal scaphoid to prepare for the MFT flap. Note the preservation of the convex midcarpal cartilage wedge effacing the capitate.

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scaphoid and adjacent lunate. The surgeon can achieve a satisfying congruency of the curvatures of the proximal lunate adjacent to the new proximal scaphoid. Despite this, the cartilage thickness of the MFT segment will provide the appearance of a stepoff radiographically. In addition, the surgeon must anticipate the potential appearance of screw prominence proximally, despite generous countersinking technique, if a dorsal approach is used (Fig. 8). After surgery, the patients were immobilized in a short arm cast for 8 weeks, followed by a removable splint for 4 weeks. Osseous union was detected radiographically and ultimately confirmed with computed tomography scan between weeks 12 and 16. Computed tomography scans were obtained as soon as possible after the 12-week postoperative date. Some were obtained later for patient convenience. RESULTS We reviewed a cohort of 16 cases of consecutive MFT osteocartilaginous proximal scaphoid reconstructions performed between 2006 and 2012 (Table 1). Follow-up data were recorded at a minimum of 6 months, with an average of 14 months (range, 6 –72 mo). The mean age of the patents was 30 years (range,18 – 47 y). There were 13 men and 3 women. Seven of the 16 patients were smokers. The average number of previous surgical procedures was 1 (range, 0 –3). Approaches to the scaphoid were more often volar (13/16) than dorsal. Many different fixation techniques were used: cannulated screw (6 cases), mini-plate with cannulated screw (4 cases), mini-plate with additional K-wire (3 cases), K-wires alone (2 cases), and mini-plate alone (1 case). The arterial anastomosis was most commonly end-toend into the palmar branch of the radial artery (12/16 radial artery; end-to-side in the others). All patients had end-to-end anastomosis of either 2 veins (10 patients) or 1 vein (6 patients), using the superficial veins or venae comitantes of the radial artery system. Computed tomography scans confirmed healing in 15 of 16 reconstructed scaphoids. The patient who failed to achieve union was a smoker and continued to have wrist pain, although it was somewhat diminished. She subsequently had additional surgery with placement of a revision screw and bone graft. All patients experienced at least some improvement in wrist pain (12/16 complete relief; 4/16 incomplete relief). Wrist range of motion at follow-up averaged 46° extension (range, 28° to 80°) and 44° flexion (range, 10° to 80°), which was similar to preoperative (average, 46° extension and 43° flexion). Pronosupination and digital range of motion were unaffected. Scapholunate

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relationships in the reconstructed wrists remained unchanged, with average SL angles of 52° before surgery and 49° at the latest postoperative follow-up. DISCUSSION The medial condyle of the femur has become a versatile and increasingly used surgical donor site. The accessibility of the periosteal vascular filigree of the descending genicular and superomedial genicular arteries provides a wealth of options for the reconstructive surgeon. The MFC’s many favorable characteristics and osteogenic capabilities have led to its application in long bone nonunions,1– 8,12,13 metacarpal and phalangeal nonunions,6,11,14 carpal and tarsal nonunions and avascular necrosis,6,12,15–19 and skull,24 orbital,20 and maxillary/mandibular defects.21–23 It is conventionally viewed as a pliable, corticoperiosteal, vascularized flap that can be molded and contoured around or within nonunion sites with small or no bone deficits. This is among the reasons that this flap has gained great attention in the treatment of recalcitrant scaphoid nonunions. However, in recent years, the literature has demonstrated a progressive expansion of the type of tissue capable of being transferred on this pedicle. Rather than being used solely as a corticoperiosteal layer, clinical series now demonstrate its use as a corticocancellous semistructural flap,5,11,12,14,21,23,33 a myotendinous flap,34 and a skin-bearing flap.5,6,9,10,12,20 –22,34 Anatomic studies have detailed the branching pattern of the vessels about the distal femur, indicating that the upper transverse branch of the periosteal filigree courses directly to the proximal aspect of the cartilage-bearing medial trochlea of the patellofemoral joint.29,31 The presence of a cartilage-bearing portion of this vascular axis suggests great opportunity for the treatment of unsolved intra-articular challenges in which other solutions do not exist or are ineffective. Uses of nonvascularized osteochondral autografts in the upper extremity are numerous. This concept has been used to reconstruct the proximal35,36 and distal37–39 portions of the proximal interphalangeal joint, the sigmoid fossa of the distal radial ulnar joint,40 the thumb carpometacarpal joint,41 the coronoid,42 and the radiocarpal43 and midcarpal joints.44,45 These reconstructions rely on the assumption that synovial nutrition is adequate to ensure the survival of the cartilage. Experimentally, subchondral bone/cartilage interface has been demonstrated to be important for the survival of the deep layers of cartilage.46,47 The importance of vascular supply to the nutrition of cartilage has also been suggested clinically.

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Vascularized osteochondral flaps have been described as a component of toe transfer reconstructions, of vascularized joint transfers, and in an elegant de-

scription of scaphoid fossa reconstruction using the base of the third metatarsal.48 Toe joint transfers have been demonstrated to maintain joint space in longer

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FIGURE 8: Postoperative x-rays on reconstructed proximal pole nonunions; A Patient #15, and B patient #10 in Table 1. Reconstructions were performed via a dorsal approach. Note the radiographic appearance of stepoff between the lunate and the reconstructed scaphoid due to the thickness of the trochlea cartilage layer.

term follow-up if the vascular supply to the joint is maintained,49 –51 whereas collapse is seen in nonvascularized joint grafts.52 These data suggest that use of osteochondral flaps may lead to superior survival compared with their nonvascularized graft counterparts when transferred to an intrasynovial environment. Further study on this important issue is warranted. In the setting of proximal nonunions of the scaphoid, conventional treatment has known limitations. Bone grafting is technically challenging to perform while sparing the scaphoid cartilage shell, and vascularized bone procedures appear to better address the vascularity of the proximal pole segment.53

Vascularized corticocancellous bone grafts from the distal radius, MFC, or iliac crest provide the same challenges of preservation of the scaphoid cartilage shell during excavation of the nonunion site and insertion of the bone flap. In addition, the often extremely small proximal pole segment and fragile, contoured vascularized bone flap make rigid screw fixation difficult and may require use of less satisfactory K-wire fixation.25 In this series, patients were deemed candidates for MFT osteocartilaginous reconstruction in the setting of proximal pole nonunions with inadequate proximal fragment bone quality for conventional (proximal pole–

FIGURE 7: Preoperative and postoperative x-rays of 4 cases of scaphoid nonunion MFT reconstructions. A Patient #13 (as described in Table 1) demonstrates use of a volar approach showing preoperative and immediate postoperative result. B Patient #10 demonstrates use of a dorsal approach showing preoperative (left) and 1-year postoperative x-ray (center and right). Note that the dorsal approach will commonly result in x-rays having the appearance of prominence of trailing screw threads due to extremely thick cartilage of medial trochlea. C Patient #2 demonstrates use of a volar approach showing preoperative magnetic resonance imaging and 1-year postoperative x-ray. This patient had 2 previous attempts at repair 5 years before. D Use of volar approach showing preoperative x-ray (left) and 3-month postoperative anteroposterior and lateral x-ray (center). Computed tomography scan on coronal plane (right) demonstrates congruity of joint surfaces. The resection of the scaphoid included the proximal pole, nonunion site, and additional distal bone to permit ease of inset and fixation of large osteochondral MFT segments.

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TABLE 1.

Details of Scaphoid Nonunions Treated With MFT Reconstruction First Surgery (Volar/Dorsal, Bone Graft, Vascularized)

Third Surgery (Volar/Dorsal, Bone Graft, Vascularized)

Months From Injury to MFT

Approach Used for MFT

Union Achieved

Preoperative SL Angle

Postoperative SL Angle

Patient #

Age/Sex

No. of Surgeries Before MFT

1

20/M

0

N/A

N/A

N/A

36

Volar

Yes

52

49

Complete

2

28/M

2

Dorsal 1,2 ICSRA VBG

Volar Iliac crest BG

N/A

61

Volar

Yes

65

62

Complete

3

18/F

3

Dorsal No BG

Revision dorsal screw 1,2 ICSRA BG

BG

31

Volar

Yes

48

40

Complete

4

21/M

0

N/A

N/A

N/A

21

Volar

Yes

52

50

Complete

Second Surgery (Volar/Dorsal, Bone Graft, Vascularized)

Pain Relief

47/M

2

1,2 ICSRA VBG

BG augmentation

N/A

Unknown

Volar

Yes

60

55

Complete

42/M

2

Dorsal 1,2 ICSRA VBG

Proximal pole excision

N/A

Unknown

Volar

Yes

60

54

Complete

7

41/M

1

Volar BG

N/A

N/A

36

Volar

Yes

60

52

Incomplete

8

30/M

0

N/A

N/A

N/A

Unknown

Volar

Yes

60

50

Complete

9

23/M

1

Volar No BG

N/A

N/A

86

Volar

Yes

54

50

Complete

10

43/M

1

Dorsal 1,2 ICSRA VBG

N/A

N/A

Unknown

Dorsal

Yes

44

36

Complete

11

23/M

1

Dorsal 1,2 ICSRA VBG

N/A

N/A

Unknown

Volar

Yes

59

35

Incomplete

12

23/M

1

Volar No BG

N/A

N/A

27

Volar

Yes

76

69

Incomplete

13

36/M

0

N/A

N/A

N/A

96

Volar

Yes

46

48

Complete

14

28/F

1

Volar No BG

N/A

N/A

78

Volar

No

60

41

Incomplete

15

36/F

0

N/A

N/A

N/A

19

Dorsal

Yes

55

46

Complete

16

24/M

1

Volar No BG

N/A

N/A

14

Dorsal

Yes

35

40

Complete

SL, scapholunate; BG, bone graft; VBG, vascularized bone graft; ICSRA, intercompartmental supraretinacular artery; N/A, not applicable.

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preserving) reconstruction. In these cases, the proximal pole demonstrated extremely poor bone quality and small size of the cartilage shell due to previous surgical attempts at fixation and/or cavitation and bone loss from longstanding nonunions of proximal fractures. The availability of vascularized osteocartilaginous bone provides the surgeon with the freedom to aggressively resect the avascular and fragile proximal pole and further resect distal to the fracture line to accommodate a reconstructed segment that is generous enough to use rigid screw fixation while confidently preserving the vascular pedicle connections to the flap. It can, therefore, address the problem with both improved biology and stability. The similarity in size and contour of the medial trochlea of the femur to that of the greater arc of curvature of the proximal scaphoid31 ensures a near-anatomic reconstruction of the scaphoid, even after substantial resection of the avascular proximal pole. The most obvious problem is that of the stability imparted by the scapholunate ligament. Were this not preserved, one would expect disruptions of carpal relationships despite a successfully reconstructed and united scaphoid. We have attempted to address this by carefully preserving the distalmost portions of the scapholunate ligament while excavating the diseased segment of the scaphoid. This technique maintains both the valuable linkage of the proximal row and the concave cartilage surfaces effacing the midcarpal joint. Although the proximal aspect of the volar and dorsal scapholunate ligaments are not preserved, our clinical results in intermediate follow-up in this study have not demonstrated evidence of scapholunate instability. Preoperative scapholunate angles averaged 55°, whereas in the latest postoperative x-rays, they averaged 49°. The majority of the patients demonstrated a slight decrease of the scapholunate angles. This suggests that the preservation of this distal-most scapholunate linkage may be adequate to maintain intercarpal relationships. Longer-term follow-up would help to further ensure that scapholunate dissociation does not develop. Although the initial results are promising, there are many limitations and unanswered questions. Intermediate and long-term radiographic and subjective outcomes will provide us with a better understanding of how successful osteocartilaginous flaps can preserve joint dynamics and prevent the course of arthritic changes associated with the natural history of scaphoid nonunion advanced collapse wrist. In addition, the long-

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term behavior of autogenous vascularized cartilage in an intrasynovial environment over time would help us predict the ultimate benefit of these reconstructions. Any new vascularized bone flap procedure requires a careful analysis of the donor site morbidity to evaluate the overall benefit of the procedure. Although these patients reported minimal or no pain at the knee donor site at this early postoperative interval, we plan to reassess these patients at greater than 1-year follow-up to assess subjective and radiographic changes at the donor site. Early follow-up suggests that the vascularized MFT osteocartilaginous flap provides a valuable tool for the treatment of challenging proximal pole scaphoid nonunions. REFERENCES 1. Fuchs B, Steinmann SP, Bishop AT. Free vascularized corticoperiosteal bone graft for the treatment of persistent nonunion of the clavicle. J Shoulder Elbow Surg. 2005;14(3):264 –268. 2. Choudry UH, Bakri K, Moran SL, et al. The vascularized medial femoral condyle periosteal bone flap for the treatment of recalcitrant bony nonunions. Ann Plast Surg. 2008;60(2):174 –180. 3. Kaminski A, Burger H, Muller EJ. Free vascularised corticoperiosteal bone flaps in the treatment of non-union of long bones: an ignored opportunity? Acta Orthop Belg. 2008;74(2):235–239. 4. Muramatsu K, Doi K, Ihara K, et al. Recalcitrant posttraumatic nonunion of the humerus: 23 patients reconstructed with vascularized bone graft. Acta Orthop Scand. 2003;74(1):95–97. 5. del Pinal F, Garcia-Bernal FJ, Regalado J, et al. Vascularised corticoperiosteal grafts from the medial femoral condyle for difficult non-unions of the upper limb. J Hand Surg Eur Vol. 2007;32(2): 135–142. 6. Doi K, Sakai K. Vascularized periosteal bone graft from the supracondylar region of the femur. Microsurgery. 1994;15(5):305–315. 7. De Smet L. Treatment of non-union of forearm bones with a free vascularised corticoperiosteal flap from the medial femoral condyle. Acta Orthop Belg. 2009;75(5):611– 615. 8. Henry M. Genicular corticoperiosteal flap salvage of resistant atrophic non-union of the distal radius metaphysis. Hand Surg. 2007; 12(3):211–215. 9. Iorio ML, Masden DL, Higgins JP. Cutaneous angiosome territory of the medial femoral condyle osteocutaneous flap. J Hand Surg Am. 2012;37(5):1033–1041. 10. Sakai K, Doi K, Kawai S. Free vascularized thin corticoperiosteal graft. Plast Reconstr Surg. 1991;87(2):290 –298. 11. Sammer DM, Bishop AT, Shin AY. Vascularized medial femoral condyle graft for thumb metacarpal reconstruction: case report. J Hand Surg Am. 2009;34(4):715–718. 12. Pelzer M, Reichenberger M, Germann G. Osteo-periosteal-cutaneous flaps of the medial femoral condyle: a valuable modification for selected clinical situations. J Reconstr Microsurg. 2010;26(5):291– 294. 13. Cavadas PC, Landin L. Treatment of recalcitrant distal tibial nonunion using the descending genicular corticoperiosteal free flap. J Trauma. 2008;64(1):144 –150. 14. Grant I, Berger AC, Ireland DC. A vascularised bone graft from the medial femoral condyle for recurrent failed arthrodesis of the distal interphalangeal joint. Br J Plast Surg. 2005;58(7):1011–1013. 15. Larson AN, Bishop AT, Shin AY. Free medial femoral condyle bone grafting for scaphoid nonunions with humpback deformity and proximal pole avascular necrosis. Tech Hand Up Extrem Surg. 2007; 11(4):246 –258.

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