Vascularized bone graft pedicled on the volar carpal artery from the volar distal radius as primary procedure for scaphoid non-union

Transcription

1 Orthopaedics & Traumatology: Surgery & Research (2011) 97, Available online at ORIGINAL ARTICLE Vascularized bone graft pedicled on the volar carpal artery from the volar distal radius as primary procedure for scaphoid non-union M. Gras a,, C. Mathoulin b a Nollet Locomotor System Institut, 23, rue Brochant, Paris, France b Hand Institute, Jouvenet Clinic, Paris, France Accepted: 23 August 2011 KEYWORDS Scaphoid non-union; Vascularized bone graft Summary Introduction: The treatment of scaphoid non-union with non-vascularized bone graft leads to non-union in 10 to 20% of cases and up to 50% in case of proximal pole necrosis. Vascularized bone graft improves consolidation rates, but is generally restricted to secondary scaphoid non-union. Hypothesis: This study assessed the value of a primary vascularized bone graft pedicled on the transverse volar carpal artery from the volar aspect of the distal radius as donor site. Patients and methods: This retrospective study included 111 cases of vascularized bone graft for scaphoid non-union as primary procedure in 73 cases and secondarily in 38. The procedures were performed through a single incision. Results: Mean delay before surgery was 25.5 and 33 months respectively, with union rates of 96% and 89.5%. Results showed improvement in both groups, but were better in primary surgery in terms of range of motion, strength, pain, function, satisfaction and return to work. There were more complications with secondary surgery. Discussion: All reports agree that union is better with vascularized bone graft. This technique performed as a day of admission surgery through a single incision under locoregional anesthesia seems feasible as a primary intervention. Level of evidence: IV retrospective study Elsevier Masson SAS. All rights reserved. Introduction Five to 30% of scaphoid fractures evolve towards non-union [1,2]. Without treatment, this leads to periscaphoid arthritis Corresponding author. address: drmathildegras@gmail.com (M. Gras). and carpal collapse with dorsal intercalated segment instability (DISI) deformity of the lunatum [3]. Non-vascularized bone graft gives non-union in up to 20% of cases [4 6], and in more than 50% in case of proximal pole necrosis [7]. Vascularized bone graft seems to be associated with a better rate of consolidation, but is generally restricted to secondary intervention or proximal pole necrosis [5,8] /$ see front matter 2011 Elsevier Masson SAS. All rights reserved. doi: /j.otsr

2 Vascularized bone graft for scaphoid non-union 801 Table 1 Grade Alnot classification of scaphoid non-union. Description Figure 1 Cadaver dissection showing the volar carpal artery following the distal edge of the pronator quadratus before anastomosing with the anterior interosseous artery and a branch of the ulnar artery (R: radial artery; U: ulnar artery). Several vascularized grafts have been described [9 18], including graft pedicled on the palmar carpal artery [19]. Mathoulin [14,19] adopted Kuhlmann s graft harvested from the volar radius [16], vascularized by the volar carpal artery with anastomosis between the radial and ulnar arteries [20], following a cadaver study [19] (Fig. 1). This retrospective study compared results of vascularized bone graft from the volar radius for scaphoid non-union as a primary intervention in 73 cases and secondarily in 38 cases. I IIA IIB III IV Linear non-union without altered scaphoid form, instability or intracarpal malalignment Stable non-union with incipient bone resorption at fracture line, without instability or malalignment More or less mobile non-union with anterior defect and proximal pole flexion on distal tubercle inducing DISI More or less mobile displacement non-union with instability or reducible malalignment with IIIA: isolated styloscaphoid arthritis IIIB: radial and/or intracarpal arthritis Proximal fragment necrosis with IVA: malalignment IVB: radioscaphoid and/or intracarpal arthritis screw in 21 cases (55%); and staples in three cases (8%). Non-union was grade 2A, 2B, or 3A, with associated styloidectomy. Table 2 shows data for the two groups. Surgical technique [14,21] Surgery was performed as a day case procedure under locoregional anesthesia, through a single incision: the Henry approach was extended by a distal lateral limb towards the scaphoid tubercle (Fig. 2). Patients and method Inclusion and exclusion criteria This retrospective single-surgeon series included patients operated on for scaphoid non-union between January 1994 and September Non-unions of grade 1 or 3B or grade 4 with necrosis were excluded. Homogeneous patient groups Two homogeneous groups of vascularized bone graft from the volar radius were identified. Group 1 comprised 73 patients with primary vascularized graft for non-union. Thirty-three were initially managed conservatively by 1 24 weeks immobilization (mean 10.3 weeks). Non-union was classified using the Alnot classification (Table 1), as grade 2A, 2B, or 3A. Associated radial styloidectomy was performed in the same sitting. Group 2 comprised 38 patients with secondary vascularized graft. The primary treatment was non-vascularized iliac crest bone graft in 14 cases (37%), revised in two cases; a Figure 2 Surgical approach for treatment of scaphoid nonunion: Henry approach extended by a lateral limb toward the scaphoid tubercle.

3 802 M. Gras, C. Mathoulin Table 2 Patient characteristics. Primary treatment patients (n = 73) Secondary treatment patients (n = 38) Sex 89% (65), 11% (8) 87% (33), 13% (5) Mean age (years) ± 11.2 (15 to 61 yrs) ± 8.6 (19 to 47 yrs) Dominant involvement 64% (47) 66% (25) Occupation 26% manual workers (19) 71% manual workers (27) 74% sedentary (54) 29% sedentary (11) Fracture-surgery interval (months) (4 to 120) (10 to 72) Initial treatment 55% non-diagnosed 45% (33) conservative treatment 92% (35) immobilization (15.4 weeks) (10.3 weeks immobilization) Type of fracture 26% proximal pole (19) 13% proximal pole (5) 74% waist (54) 87% waist (33) Type of non-union (Alnot classification) 2A: 67% (49) 2A: 39.5% (15) 2B: 30% (22) 2B: 52.5% (20) 3A: 3% (2) 3A: 8% (3) Figure 3 Dissection of the volar carpal artery. In some cases where the scaphoid showed a humpback deformity, reduction was performed using a chisel and maintained by temporary pins. The volar carpal artery lies between the palmar periosteum of the radius and the distal part of the superficial aponeurosis of the pronator quadratus, the last distal centimeter of which was opened; then the periosteum was sectioned using a knife for about 1 cm on either side of the pedicle. The lateral half of the pedicle was released subperiosteally up to the radial artery (Fig. 3). The graft was harvested from the radius using a chisel. The pedicle was then dissected up to the origin of the volar carpal artery (Fig. 4). The scaphoid was screwed from distal to proximal. The bone graft was fitted to fill the defect on the volar aspect of the scaphoid (Fig. 5), and stabilized by tightening the screw (Fig. 6) or using a temporary pin (Fig. 7). The capsule was sutured without compressing the pedicle, and the radioscaphocapitate ligament was repaired. A palmar splint with the wrist in 40 extension was kept until consolidation was achieved. The pin was removed at 3 weeks. Figure 4 Harvesting pyramidal graft and exposure of scaphoid bone defect. Drawing and photograph.

4 Vascularized bone graft for scaphoid non-union 803 force was measured in kilogram using a Jamar dynamometer. Consolidation time was determined using control X-rays. Complications, return to work, functional recovery on the Mayo Wrist Score and overall patient satisfaction were recorded. All data were collected by a single observer (C.M.). Results were evaluated using descriptive statistical analysis. Results Figure 5 Positioning graft with respect to defect. None of the patients were lost to follow-up. Mean followup (FU) was 25.5 months (10 65 months) in group 1 and 33 months (10 63 months) in group 2. Table 3 shows data for the two groups. Complications There were six complications (8%) in group 1. Three patients (4%) showed non-union; two had proximal pole (PP) fractures (10.5% of PPs) initially and the third a waist fracture (W) (1.8% of Ws). Three patients (4%) showed stiffness requiring tenoarthrolysis; they had proximal pole fracture (15.8% of PPs). There were 10 complications (26%) in group 2. Four patients (10.5%) showed non-union; one PP (20% of PPs) and three Ws (9% of Ws). Two underwent secondary four-corner arthrodesis and scaphoidectomy, and were not satisfied by their operations. The other two refused further surgery. One patient (2.5%) with waist fracture initially (3% of Ws) showed stiffness requiring tenoarthrolysis. Three patients (8%) had complex regional pain syndrome. Subjective and functional results Figure 6 Evaluation methods Stabilization of graft by tightening screw. Range of motion, force and pain were measured preoperatively and at last follow-up. Motion was measured in flexion, extension and radial and ulnar inclination. Muscle Figure 7 Stabilization of graft by temporary pin, taking care not to damage the pedicle. There was significant pain relief. In group 1 with PP, pain passed from severe in 10.5% of cases and moderate in 89.5% initially, to 10.5% moderate and 89.5% pain-free. In W, pain passed from severe in 7.4% of cases and moderate in 92.6% initially, to 1.8% moderate and 98.2% pain-free. In group 2, pain levels were markedly higher, both preand postoperatively. In PP, pain was initially severe in 60% of cases and moderate in 40%, and decreased to 60% moderate and 40% pain-free. In W, pain was initially severe in 60.6% of cases and moderate in 39.4%, and decreased to 3% severe, 39.4% moderate and 57.6% pain-free. Although there was clear improvement in pain, these results were less satisfactory than for first-line treatment. In group 1, the functional results on the Mayo Wrist Score were excellent or good in 94.5% of cases; 98.5% of patients were completely satisfied or had only minor reservations. One patient with initial PP fracture was dissatisfied. He had a poor functional score, showed non-union, and was the only one who would not have the operation again. In group 2, the functional results were 73.2% excellent or good and 26.5% moderate or poor (PP: 40% excellent, 40% good, 20% poor; W: 42.5% excellent, 30.3% good, 18.2% moderate and 9% poor). Overall, functional results were worse than in group 1. Seventy-six percent of patients were completely satisfied or had only minor reservations, 16% had

5 804 M. Gras, C. Mathoulin Table 3 Clinical and radiological results per group. Primary treatment patients (n = 73) Secondary treatment patients (n = 38) Follow-up (months) 25.5 ± 14.5 (10 to 65) 33 ± 18.3 (10 to 63) Radiologic consolidation 96% 89.5% Mean time to consolidation (weeks) 9.7 ± 4.9 (6 to 24) 10.8 ± 4.2 (6 to 24) Flexion (degrees) ± 13.7 ( 30 to 40) ± 12.2 ( 10 to 40) Extension (degrees) +7.8 ± 10.4 ( 5 to 40) ± 14.6 (0 to 50) Radial deviation (degrees) +5.3 ± 5.5 ( 8 to 20) +6.3 ± 6.3 ( 5 to15) Ulnar deviation (degrees) +5.6 ± 5.9 ( 5 to 20) +7.4 ± 6.8 (0 to 20) Muscle force (Kg) ± 9.5 (0 to 35) ± 12 ( 6 to45) Preoperative Postoperative Preoperative Postoperative Pain Severe 8% (6) 0% 60.5% (23) 2.5% (1) Moderate 92% (67) 4% (3) 39.5% (15) 42% (16) None 0% 96% (70) 0% 55.5% (21) Complications Non-union 4% 10.5% Stiffness 4% 2.5% CRPS 0% 8% Functional results (Mayo Wrist score) Excellent 83.5% (61) 42% (16) Good 11% (8) 31.5% (12) Moderate 4% (3) 16% (6) Poor 1.5% (1) 10.5% (4) Overall satisfaction Completely satisfied 85% (62) 44.5% (17) Minor reservations 13.5% (10) 31.5% (12) Major reservations 0% 16% (6) Dissatisfied 1.5% (1) 8% (3) major reservations and 8% were dissatisfied. The three dissatisfied patients had poor functional results and non-union on X-ray, and were the only patients to say they would not have the operation again; two had had W fractures (6% of Ws) and one PP (20% of PPs). In group 1, patients returned to work at a mean 9.7 ± 5.7 weeks, except for one patient who never returned and remained on disability benefit for work accident. Three patients (4%) had to change jobs (5.3% of PPs and 3.7% of Ws). In group 2, patients returned to work at a mean of 17.5 ± 12 weeks (PP, 14.6 weeks; W, 18 weeks), except for one patient who never returned and who was one of the four showing non-union.. Six patients (16%) had to change jobs; two PPs (40% of PPs); four W (12.1% of Ws). Clinical results Range of motion and force improved, with greater gain in the primary group. In group 1, mean flexion rose from 51.4 to 62, gain = 10.6 (PP, 11.3 ;W,0.4 ), extension from 61.2 to 69.3, gain = 7.8 (PP, 10 ;W,7.4 ), radial deviation from 15.5 to 20.2, gain = 5.3 (PP, 4.5 ;W,4.8 ), and ulnar deviation from 24.6 to 30, gain = 5.6 (PP, 5.8 ;W,5.3 ). There was clear improvement in force on the Jamar, from a mean 26.8 to 42.3 kg (compared to the contralateral control values which remained stable at a mean 46.3 and 45.4 kg, respectively): i.e. a gain of 16.4 kg (PP, 15.4 kg; W, 16 kg). Results for motion and force showed similar improvement in secondary grafting, but at lower levels. Mean flexion rose from 35 to 46.3, gain = 11.3 (PP, 8 ; W, 11.9 ), extension from 41.6 to 58.5, gain = 16.3 (PP, 22 ; W, 16.2 ), radial deviation from 13.3 to 19.8, gain = 6.3 (PP, 1.7 ;W,6.9 ), and ulnar deviation from 14.8 to 22, gain = 7.4 (PP, 5 ;W, 7.4 ). There was clear improvement in force on the Jamar, although less than in group 1, from 20.4 kg to 39.5 kg (compared to the contralateral control values which remained stable at a mean 45.3 and 45 kg, respectively, similar to in group 1): i.e., a gain of 18.2 kg (PP, 18.7 kg; W, 19.5 kg). Radiology results In group 1, radiologic consolidation was achieved in 70 cases i.e., 96% (PP, 89.5%, W, 98.2%) at a mean of 9.7 weeks (PP 11.3 weeks; W 9.2 weeks). In group 2, radiologic consolidation was achieved in 34 cases i.e., 89.5% (PP, 80%, W, 91%) at a mean of 10.8 weeks (PP, 17 weeks, W, 10 weeks). Discussion Bone graft from the volar radius vascularized by the volar carpal artery is a good treatment for moderate scaphoid

6 Vascularized bone graft for scaphoid non-union 805 defects (Alnot grades IIA, IIB or IIIA). The anterior approach allows graft harvesting and treatment of the non-union to be performed as a single procedure. Although harvesting may seem difficult at first, it is in fact a simple technique that provides excellent results. The surgery is performed under locoregional anesthesia through a single incision with reduced surgery time as a day case, thus reducing hospital stay and overall costs. It was first described for failure of classical techniques. However, given the quality of the functional results and the speed of consolidation, we recommend it as primary treatment of scaphoid non-union. The present study is the first to report results of vascularized grafts as a primary treatment for scaphoid non-union. It shows improvement for all evaluation criteria in these cases. Various factors seem to affect consolidation. The mean age of patients who failed to show union after primary non-union treatment was 40 years, versus 30 in case of successful union. Age has been identified as a factor of poor prognosis by other authors [7,22]. Likewise, the greater the delay between fracture and surgery the poorer is the consolidation. The mean delay in patients without consolidation was 48.3 months, versus 19 months in case of consolidation. Several studies [22,23] correlated smoking and non-consolidation. A study conducted in 2008 [24] reported a lower consolidation rate (73%) with vascularized grafts from the volar radius; these findings highlight the difficulties encountered in harvesting and osteosynthesis, especially for less experienced surgeons. There was notably a risk of perioperative articular fracture of the radius [24,25], which seemed greatest at the beginning of the learning curve. Although the conventional Matti-Russe graft remains an excellent option, many studies reported better consolidation rates using vascularized bone graft: union was achieved in 70% to 90% of non-vascularized grafts [26,27] and more than 90% of vascularized grafts [2,16,19,28 34]. Munk and Larsen [35] confirmed these findings in a metaanalysis of 5,246 cases of scaphoid non-union, with an 80% consolidation rate (78 82) for non-vascularized bone graft without osteosynthesis, 84% (82 85) with osteosynthesis, and 91% (87 94) for vascularized graft. In non-union with avascular necrosis of the proximal pole, however, surgeons seem to agree that a primary vascularized graft is the best conservative management [7,36 38], due to the very poor consolidation rate obtained with nonvascularized grafts (< 50%). Dailiana [39] reported that union on MRI was achieved faster with a vascularized graft. Some authors recommend other vascularized free grafts, from the supracondylar region of the femur [40,41], base of the third metatarsal [42], iliac crest [43], rib [44], etc. Primary treatment by vascularized graft depending on the series showed equally good or better consolidation, recovery of motion and pain relief compared to secondary treatment or non-vascularized graft. Vascularized graft from the volar radius is thus a good alternative for primary treatment of scaphoid non-union. The present retrospective findings should be confirmed with longer follow-up. A larger trial is required to validate the use of vascularized graft for primary treatment of scaphoid non-union. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. References [1] Kawamura K, Chung KC. Treatment of scaphoid fractures and nonunions. J Hand Surg [Am] 2008;33(6): [2] Larson AN, Bishop AT, Shin AY. Dorsal distal radius vascularized pedicled bone grafts for scaphoid nonunions. Tech Hand Up Extrem Surg 2006;10(4): [3] LK, Ruby JS, Belsky MR. The natural history of scaphoid nonunion. A review of fifty-five cases. J Bone Joint Surg Am 1985;67(3): [4] Megerle KX, Müller M, Germann G, Sauerbier M. Treatment of scaphoid nonunions of the proximal third with conventional bone grafting and mini-herbert screws: an analysis of clinical and radiological results. J Hand Surg Eur Vol 2008;33(2): [5] GA, Merrell SW, Slade JF. Treatment of scaphoid nonunions: quantitative meta-analysis of the literature. J Hand Surg [Am] 2002;27(4): [6] Alnot J, Le Bellec Y. Traitement des pseudarthrose du scaphoïde carpien par greffe corticospongieuse non vascularisée : étude rétrospective de 47 cas. Chir Main 2008;27(4): [7] Merrell GA, Wolfe SW, Slade 3rd JF. Treatment of scaphoid nonunions: quantitative meta-analysis of the literature. J Hand Surg [Am] 2002;27(4): [8] Waitayawinyu T, Pfaeffle J, McCallister W, Nemechek N, Trumble T. Management of scaphoid nonunions. Hand Clin 2010;26(1): [9] Roy-Camille R. Fractures et pseudarthroses du scaphoïde carpien. Utilisation d un greffon pédiculé. Actua Chir Orthop 1965;4: [10] Kawai HKY. Pronator quadratus pedicled bone graft for old scaphoid fractures. J Bone Joint Surg 1988;70B: [11] JN, Kuhlmann MM, Boabighi A, Baux S. Vascularized bone graft pedicled on the volar carpal artery for nonunion of the scaphoid. J Hand Surg [Am] 1987;12B: [12] JC, Guimberteau BP. Recalcitrant nonunion of the scaphoid treated with a vascularized bone graft based on the ulnar artery. J Bone Joint Surg 1990;72A: [13] C, Zeidemberg JS, Angrigiani C. A new vascularized bone graft for scaphoid nonunion. J Hand Surg [Am] 1991;16A: [14] C, Mathoulin MH, Vandeputte G. Greffon osseux vascularisé dans la reconstruction des os du carpe. Ann Chir Plast Esthet 2005;50(1):43 8. [15] A, Yuceturk ZI, Tuncay C, Tangodan R. Treatment of scaphoid nonunions with a vascularized bone graft based on the first dorsal metacarpal artery. J Hand Surg [Am] 1997;22B: [16] F, Brunelli CM, Saffar P. Description d un greffon osseux vascularisé prélevé au niveau de la tête du deuxième métacarpien. Ann Chir Main 1992;11:40 5. [17] Pistré V, Réau AF, Pélissier P, Martin D, Baudet J. Les greffons osseux vascularisés pédiculés prélevés sur la main et le poignet : revue de la littérature et nouveau site donneur. Chir Main 2001;20(4): [18] Arora R, Lutz M, Zimmermann R, Pechlaner S, Gabl M. Free vascularised iliac bone graft for avascular scaphoid non-unions and Kienböck s disease. J Hand Surg Eur Vol 2007;32(Supplement 1):75. [19] C, Mathoulin MH. Vascularized bone graft from the palmar carpal artery for treatment of scaphoid non-union. J Hand Surg [Am] 1998;23B:

7 806 M. Gras, C. Mathoulin [20] Haerle M, Schaller HE, Mathoulin C. Vascular anatomy of the palmar surfaces of distal radius and ulna: its relevance to pedicled bone grafts at the distal palmar forearm. J Hand Surg 2003;28(B): [21] Mathoulin C. Technique: vascularized bone grafts from the volar distal radius to treat scaphoid nonunion. J Am Soc Surg Hand 2004;4(1). [22] Chang MA, Bishop AT, Moran SL, Shin AY. The outcomes and complications of 1,2-intercompartmental supraretinacular artery pedicled vascularized bone grafting of scaphoid nonunions. J Hand Surg [Am] 2006;31(3): [23] Little CP, Burston BJ, Hopkinson-Woolley J, Burge P. Failure of surgery for scaphoid non-union is associated with smoking. J Hand Surg [Br] 2006;31(3): [24] Jessu M, Wavreille G, Strouk G, Fontaine C, Chantelot C. Pseudarthroses du scaphoïde traitées par greffon vascularisé de Kuhlmann : résultats radiographiques et complications. Chir Main 2008;27(2 3): [25] Levadoux MPJ, Samson P. Complications spécifiques après réalisation de greffons pédiculés du radius distal : à propos d une série de 36 greffons réalisés. Chir Main 2004;23(6):326. [26] Filan SL, Herbert TJ. Herbert screw fixation of scaphoid fractures. J Bone Joint Surg Br 1996;78(4): [27] Chantelot C, Frebault C, Limousin M, Robert G, Migaud H, Fontaine C. Long-term outcome of non-vascularized grafts for carpal scaphoid nonunion: 58 cases with 8.8-year follow-up. Rev Chir Orthop Reparatrice Appar Mot 2005;91(8): [28] Le Bellec Y, Alnot JY. Traitement des pseudarthroses du scaphoïde carpien par greffe corticospongieuse non vascularisée : étude rétrospective de 47 cas. Chir Main 2008;27(4): [29] Kuhlmann JN, Mimoun M, Boabighi A, Baux S. Vascularized bone graft pedicled on the volar carpal artery for non-union of the scaphoid. J Hand Surg [Br] 1987;12(2): [30] Mathoulin C, Haerle M, Vandeputte G. Vascularized bone graft in carpal bone reconstruction. Ann Chir Plast Esthet 2005;50(1):43 8. [31] Chen AC, Chao EK, Tu YK, Ueng SW. Scaphoid nonunion treated with vascular bone grafts pedicled on the dorsal supra-retinacular artery of the distal radius. J Trauma 2006;61(5): [32] Dailiana ZH, Malizos KN, Zachos V, Varitimidis SE, Hantes M, Karantanas A. Vascularized bone grafts from the palmar radius for the treatment of waist nonunions of the scaphoid. J Hand Surg 2006;31(3): [33] Guimberteau JC, Panconi B. Recalcitrant non-union of the scaphoid treated with a vascularized bone graft based on the ulnar artery. J Bone Joint Surg Am 1990;72(1): [34] Malizos KN, Zachos V, Dailiana ZH, Zalavras C, Varitimidis S, Hantes M, et al. Scaphoid nonunions: management with vascularized bone grafts from the distal radius: a clinical and functional outcome study. Plast Reconstr Surg 2007;119(5): [35] Munk B, Larsen CF. Bone grafting the scaphoid nonunion: a systematic review of 147 publications including 5,246 cases of scaphoid nonunion. Acta Orthop Scand 2004;75(5): [36] Chantelot C, Frebault C, Limousin M, Robert G, Migaud H, Fontaine C. Long-term outcome of non-vascularized grafts for carpal scaphoid nonunion: 58 cases with 8.8-year follow-up. Rev Chir Orthop 2005;91(8): [37] Waitayawinyu T, McCallister WV, Katolik LI, Schlenker JD, Trumble TE. Outcome after vascularized bone grafting of scaphoid nonunions with avascular necrosis. J Hand Surg 2009;34(3): [38] Jones Jr DB, Burger H, Bishop AT, Shin AY. Treatment of scaphoid waist nonunions with an avascular proximal pole and carpal collapse. A comparison of two vascularized bone grafts. J Bone Joint Surg Am 2008;90(12): [39] Dailiana ZH, Zachos V, Varitimidis S, Papanagiotou P, Karantanas A, Malizos KN. Scaphoid nonunions treated with vascularised bone grafts: MRI assessment. Eur J Radiol 2004;50(3): [40] Jones Jr DB, Moran SL, Bishop AT, Shin AY. Free-vascularized medial femoral condyle bone transfer in the treatment of scaphoid nonunions. Plast Reconstr Surg 2010;125(4): [41] Doi K, Hattori Y. Vascularized bone graft from the supracondylar region of the femur. Microsurgery 2009;29(5): [42] Del Pinal F, Garcia-Bernal FJ, Delgado J, Sanmartin M, Regalado J. Reconstruction of the distal radius facet by a free vascularized osteochondral autograft: anatomic study and report of a patient. J Hand Surg [Am] 2005;30(6): [43] Gabl M, Pechlaner S, Zimmermann R. Free vascularized iliac bone graft for the treatment of scaphoid nonunion with avascular proximal fragment. Oper Orthop Traumatol 2009;21(4 5): [44] Lanzetta M. Scaphoid reconstruction by a free vascularized osteochondral graft from the rib: a case report. Microsurgery 2009;29(5):420 4.