Injury 54 (2023) 110727

Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

Clinical outcomes in patients with scaphoid non-union treated with the

vascularized medial femoral condyle technique a case series
Luis Alejandro García-González 1, *, Francisco Javier Aguilar-Sierra 2, Daniel Gómez-Cadavid 2,
María Cristina Rodriguez-Ricardo 3, Barbara Gomez-Eslava 4
Service of hand surgery, Department of Orthopedic Surgery, San Ignacio University Hospital, Pontificia Universidad Javeriana, Bogotá, Colombia

A R T I C L E I N F O A B S T R A C T

Keywords: Introduction: Non-union is a prevalent complication of scaphoid fractures. Late diagnosis is common and has a
Vascularized clinical impact due to functional limitations for the patient. Multiple treatments have been proposed to manage
Medial this complication, ranging from conservative (i.e., orthopedic) to surgical treatment. The vascularized medial
Femoral
femoral condyle technique has shown satisfactory clinical and paraclinical results, mainly in presence of avas­
Scaphoid
Nonunion
cular necrosis of the proximal pole but data regarding functional outcomes and patient satisfaction is scarce.
Case series This case series aims to describe the clinical and patient-reported outcomes in a consecutive series of patients
Technique with non-union of the proximal third of the scaphoid treated with vascularized medial femoral condyle
technique.
Methods: Case series reporting results for a consecutive – initial cohort of patients who presented with a non
united fracture of the proximal pole of the scaphoid, avascular necrosis of the proximal pole was documented by
CT od MRI imaging preoperatively in all patients. Measurement instruments include the q-DASH and PRWE
questionnaires, radiographic images, goniometry, and assessment of grip strength.
Results: Twelve consecutive patients are included and they represent the initial cases for all surgeons involved;
bone union was obtained in 10 patients (83%) after a mean follow-up time of 31 months (6–72), successful
improvement in the range of motion and grip strength was documented. A high rate of satisfaction expressed by
the patient was obtained, with an average score in Q-DASH of 17.3 and 20.1 in PRWE.
Conclusions: The vascularized medial condyle technique in cases of nonunion of scaphoid fracture is a repro­
ducible treatment in clinical terms, both in imaging and functional terms, and in patient satisfaction. The
learning curve is flat for a dedicated multi surgeon team.

Introduction burden for the health system and impacts the productivity of this pop­
ulation [5]. One of the main characteristics of this fracture is the subtlety
The incidence of fractures of the hand and wrist is increasing. The of the symptoms, associated with the difficulty of imaging diagnosis
increase is in part due to more active lifestyles and sports practice in the through conventional radiographs, which explains why 10 and 25% of
general population [1]. The scaphoid is the most frequently fractured of these fractures are not diagnosed at the time of the injury and remain
the carpal bones in the adult and pediatric population [2,3], corre­ unrecognized until non-union symptoms appear [6]. The primary
sponding to approximately 60 to 90% of all carpal fractures in the complications of scaphoid fractures are non-union, osteonecrosis, carpal
working age [4]. This fracture also represents a considerable economic instability, and arthritis [7].

This paper is part of a supplement supported by AO Trauma Latin America.

* Corresponding author at: Carrera 7◦ # 40-62, Departamento de Ortopedia, Bogotá, Colombia.
E-mail address: lagarcia@javeriana.edu.co (L.A. García-González).
1
Hand and Upper Extremity Surgeon. Assistant Professor. Pontificia Universidad Javeriana and San Ignacio University Hospital, Bogotá, Colombia.
2
Hand and Upper Extremity Surgeon, Pontificia Universidad Javeriana, Bogotá, Colombia.
3
Hand Surgeon. Centro Hospitalario Serena del Mar, Cartagena, Colombia.
4
Hand Surgeon. Graduate Student at the Master of Medical Science in Clinical Investigation-Translational Investigation Track, Harvard Medical School, Boston,
Massachusetts.

https://doi.org/10.1016/j.injury.2023.04.014
Accepted 12 April 2023
Available online 14 April 2023
0020-1383/© 2023 Published by Elsevier Ltd.
L.A. García-González et al. Injury 54 (2023) 110727

Regarding non-union, its incidence is 2/100,000 and 0.4/100,000 with an unstable nonunion, absent or minimal arthrosis and avascular
for men and women, respectively, corresponding to 10–15% of all necrosis of the proximal pole.
scaphoid fractures. These numbers place scaphoid non-union as the most The protocol was presented to and authorized by the institutional
frequent complication after a fracture [8]. Any fracture that persists for Research and Ethics Committee. All patients signed a specific informed
more than six months is considered non-union [9]; in this anatomical consent for this study.
scenario, non-union is a relevant complication due to secondary func­ First, a review of the clinical records was conducted to establish the
tional limitation. Risk factors for the development of scaphoid reason for consultation and mechanism of trauma. Patients were con­
non-union have been identified, such as the no use of a splint, tacted by phone, and then interviewed and examined at the clinic.
anatomical location (i.e., proximal fractures), soft tissue interposition, Sociodemographic characteristics and the variables to measure the
fracture comminution, and proximal pole fracture displacement with clinical and functional outcomes were collected.
associated instability and/or avascular necrosis [10]. Proximal pole As instruments for measuring the clinical variables, radiographs
fractures are related to vascular supply interruption of the scaphoid and taken at the time of the follow-up indicated for the present study were
secondary avascular necrosis [8]. used, with the aim of assessing graft integration according to Hanne­
The use of bone grafts has been proposed as a therapeutic option mann criteria, [24] using the institutional radiographic imaging com­
since 1920 with satisfactory results [11]. This treatment modality in­ puter program: Kanteron Systems S.L.U.
cludes non-vascularized bone grafts (NVBGs), which in presence of In addition, motion arcs and grip strength were measured on patients
avascular necrosis have a union rate as low as 47% [12]. Therefore, available for in-person follow-up.
vascularized bone grafts (VGB) have gained traction because of their Patients’ satisfaction was assessed by two questions during the
biological properties to provide vascular flow [13,14]. Vascularized interview: “If necessary, would you have this surgery done on you
bone grafts can be pedunculated or free. Pedunculated bone grafts again?” and “Are you overall satisfied with the function of your hand for
consist of a bone segment of an adjacent bone (i.e., radius) that is rotated work and daily life duties?”; functional outcomes were collected through
to fill the scaphoid bone defect, maintaining vascular supply to the the disabilities of the arm, shoulder and hand questionnaire – shortened
transferred bone. However, in cases of carpal collapse or humpback version (Q-DASH) [25,26] and the patient-rated wrist evaluation ques­
deformity, pedunculated bone graft has lower union rates (50%) [15]. tionnaire (PRWE) [20,27]. The Q-DASH includes 11 items, 8 aimed at
Additional challenges related to pedicle length, graft handling in case of reintroduction to daily, social and work life, and 3 assessing symptoms.
scaphoid deformity, and the association of soft tissue or distal radius The second questionnaire has 15 questions, of which 5 questions
trauma may preclude the use of local bone graft. correspond to pain measures and 10 questions evaluate wrist function in
Free bone grafts can overcome these difficulties by using a bone daily activities. Out of the two questionnaires, the score of 0 was the best
segment that receives vascular supply when anastomosed [16]. Among and 100 was the worst. Both questionnaires have been validated for
the surgical techniques, the vascularized medial femoral condyle tech­ Spanish language application in previous studies. Post-operative com­
nique described by Doi et al. represents one of the most used methods to plications were also explored and reported.
treat this condition. The technique fits a vascularized bone segment into The data obtained were entered into an Excel database (Microsoft®
the scaphoid bone defect, providing vascular supply by the radial artery Excel® for Microsoft 365 MSO version 2110 compilation
microvascular anastomoses. It represents one of the most used methods 16.0.14527.20234), means and standard deviation were calculated
to treat this condition [17].This technique has been evaluated in several where applicable.
publications regarding its ability to consolidate, showing percentages of
effectiveness close to 90% [18–20], and mean consolidation times be­ Surgical technique
tween 12 and 22 weeks [20]. However, the scientific literature sup­
porting the technique in terms of function and patients’ satisfaction is With the patient under general anesthesia, in supine position, the
lacking. No clinical trials compare the vascularized bone graft surgical wrist is approached through a volar incision following the Flexor Carpi
techniques in this scenario. radialis (FCR) tendon (Fig. 1A). At this point, the lunate bone is evalu­
After non-union, avascular necrosis and progressive degenerative ated by fluoroscopy and it is determined if there is extension deformity,
changes might occur. Radio carpal osteoarthritis is reported in up 100% correcting it if necessary. The scaphoid is exposed via a volar capsu­
of cases [21,22] with cyst formation, bone resorption, and scaphoid lotomy, fragments are debrided and final shape and size of the defect is
humpback deformity [16] leading to articular wrist collapse (SNAC: determined (Fig. 1B). The vascularized medial femoral condyle harvest
scaphoid nonunion advanced collapse) and dorsal intercalated segment technique in avascular necrosis of scaphoid fractures begins with a
instability (DISI) secondary to the scaphoid proximal pole extension longitudinal medial incision centered on the distal portion of the vastus
with the lunate bone [16]. The pathological mechanisms above have
functional implications for the patient regarding wrist mobility, grip
strength and interference with daily activities [23]. Thus, the treatment
[7] and the scientific evidence supporting the different surgical tech­
niques are crucial to improving overall treatment success.
This study aims to describe the clinical and patient-reported out­
comes of patients with scaphoid non-union and avascular necrosis,
treated with the vascularized medial femoral condyle technique by a
team of four different hand surgeons and to document the involved
learning curve process.

Materials and methods

An observational study was carried out, including a consecutive se­

ries of 12 patients, all with a diagnosis of non-union of scaphoid frac­
tures treated with the vascularized medial femoral condyle technique by
the authors between 2015 and 2022. Inclusion criteria was having had a
free femoral condyle graft for treatment of a scaphoid nonunion. This Fig. 1. A: Surgical approach to the wrist. B: Proximal pole of scaphoid after
technique is indicated at the authors’ institution for patients presenting debridement.

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L.A. García-González et al. Injury 54 (2023) 110727

medialis that extends from the knee joint line proximally 20 cm (the
ipsilateral femur was chosen for use of a crutch or cane in the opposite
hand if necessary after surgery) (Fig. 2A). The vastus medialis muscle is
identified at its medial border and elevated from the fascia of its
compartment, then the descending genicular and medial genicular
vessels are identified, to subsequently select the larger of the two that
supplies the periosteum and the bone of the medial femoral condyle.
Next a vascularized cortico-cancellous bone graft is extracted based on
this pedicle and of sufficient size to fill the scaphoid defect (Fig. 2b and
C).
The graft is contoured to fit the scaphoid defect, correcting the
humpback deformity (if any) and restoring normal scaphoid length.
Positioning is confirmed by fluoroscopy examination and fixation is
carried out with a headless compression screw (2,3 to 3,0 mm in
diameter) (Fig. 3A to D) . Following this, the radial artery and
concomitant veins are exposed proximally and end-to-side artery repair
is performed on the radial artery, and end-to-end venous repair is per­
formed on the concomitant veins (Fig. 4). Finally, blood flow through
the anastomosis to the graft is confirmed. The operated upper limb is left
immobilized for 6 to 10 weeks. [17,20,28,29]. Antithrombotic therapy
was instated with low molecular weight heparin for 1 week after surgery
and then discontinued.

Results

Twelve patients were treated with the medial vascularized condyle

technique after a diagnosis of non-union of the proximal pole of the
scaphoid between 2015 and 2022 and all conform this series . All pa­
tients consulted for pain and functional limitation of the affected wrist, Fig. 3. A: Fluoroscopic images of the scaphoid: A: After fragments’ preparation.
B: Lunate temporary stabilization with Radio-lunate K wire and graft implan­
and referring to trauma with the extended wrist as the mechanism
tation. C and D: lateral and PA views after headless screw fixation.
causing the fracture in all of them. Two patients had a fracture in the
dominant wrist.
Of 12 patients operated on by the hand surgery team, contact was patient that we could not contact but during previous follow ups we
made with 11 patients (91%), one patient (#1) could not be reached but confirmed consolidation (Fig. 6).
her clinical records allowed for results reporting. The mean follow-up - Clinical: Mean global wrist motion was 70% and grip strength was
time was 31.3 (6 - 72) months. The average age was 31 years at the 80% of the contralateral hand. Final Q-Dash and PRWE scores were
time of diagnosis. Ten patients were male and two females. Patients’ 17 and 20 points respectively. Full function and subjective measures
occupations were: 1 student, 3 salespeople, 1 security guard, 1 cook, 1 are presented in Table 1.
electrician, 1 teacher, 2 analysts, 1 engineer, and 1 construction worker.
Eleven patients were treated initially with a cast and 1 patient Patient satisfaction
received surgical treatment. In all cases, non-union was confirmed
clinically and radiographically, and avascular necrosis of the scaphoid All the patients stated that they were satisfied with their surgery once
was evidenced by MRI or CT (Fig. 5), which was confirmed at the time of this question was asked, and 100% reported that they would undergo
medial vascularized condyle surgery by absence of bleeding of the the surgery again if they had the same diagnosis in the contralateral
proximal pole after debridement . However, in no case was there hand. Ninety-two percent of the patients (11/12) reported not present­
osteoarthritis. ing pain at the moment and one patient manifested pain when kneeling.
After surgery, the patients presented pain in the operated knee for an
Outcome variables average of 3.5 months.

- Radiographic: The percentage of consolidation according to Hanne­ Complications

mann criteria was 83% (10/12) at final follow-up time, including the
None of the patients presented postoperative infection. One of the
patients required reintervention to remove the osteosynthesis material

Fig. 2. A: Surgical approach to medial condyle of the femur. B and C: Deep dissection and graft isolation.

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L.A. García-González et al. Injury 54 (2023) 110727

excellent clinical and imaging results demonstrated by several studies,

although to date there is no clinical trial that compares all surgical
techniques of vascularized bone grafts in this stage. Specifically with
regard to the vascularized medial femoral condyle bone graft technique,
the state of the art is less robust, but the studies support its use due to the
results obtained objectively in the postoperative period; however, few
studies have assessed the functionality and patient satisfaction with this
technique, so this study aims to describe the clinical and reported out­
comes of patients with nonunion of scaphoid fractures managed with the
medial femoral condyle technique.
Current study’s results show a consolidation percentage of 83% in
the mean follow-up time with the medial femoral condyle bone graft
technique. Clinical and subjective measures obtained were comparable
to those reported by other series, as stated below; Regarding the
objective outcomes of the intervention with the medial femoral condyle
bone graft technique, the study by Keller et al. In 2020 the study showed
radiographic evidence of bone union in 95%, slightly higher than that
evidenced in our study, with a mean union time of 16 weeks in osteo­
periosteal grafts, in addition to postoperative improvement in hump­
back deformity and associated DISI. [20] Clinically, the results of grip
strength and range of motion were assessed in the study by Jones et al.
The study by Keller et al. assessed active range of motion and grip
strength in a standardized manner with digital analysis systems,
reporting an average extension of 50◦ preoperatively and no changes
Fig. 4. Arterial end to side anastomosis under microscope magnification.
postoperatively, which corresponded at 73% of the extension angle of
the contralateral, and an average flexion of 49◦ preoperatively and 44◦
due to pain with mobilization and imaging evidence of an intra-articular
at the end of the 16-month follow-up, which corresponded to 68% of the
screw; this patient never achieved consolidation. One patient developed
contralateral; grip strength was 34 kg preoperatively and 44 kg post­
a surgical site hematoma in the knee wound that required exploration
operatively, the latter being 89% of the contralateral. [20] Both studies
and debridement.
In patients 2 and 3 bone union was not achieved, both patients were
available for follow up and neither accepted further treatment, both
were employed and mostly symptom free (Q-Dash: 39 and 25; PRWE: 25
and 31 respectively).

Discussion

Fractures of the hand and wrist have a continually increasing inci­

dence due in large part to more active lifestyles in the general popula­
tion. Of these, the scaphoid bone is the carpal bone that fractures most
frequently, with the particularity of difficulty in diagnosis due to the
subtlety of symptoms and the low sensitivity reported for its diagnosis
with radiography, between 43 and 70%. [30] This tendency to late
diagnosis and its complex three-dimensional anatomy makes this frac­
ture susceptible to complications, within these, the most frequent is
non-union in up to 10 to 15% of all cases, [8], with high relevance due to
the functional limitation it poses for the patient. [23] Surgical man­
agement of scaphoid non-union with vascularized bone grafts has shown
Fig. 6. Final follow up X ray images of case #1 showing full consolidation.

Fig. 5. T2 images in MRI depicting avascular necrosis of the proximal pole of the scaphoid.

4
L.A. García-González et al. Injury 54 (2023) 110727

present results that are comparable to the results reported in our study. [6] Reigstad O, Grimsgaard C, Thorkildsen R, Reigstad A, Røkkum M. Scaphoid non-
unions, where do they come from? The epidemiology and initial presentation of
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score of 59 points was reported in this same intervention, which vascularized bone grafts. JBJS 2008;90(12):2616–25.
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