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Introduction
The use of the medial femoral condyle free flap (MFCF) is a
versatile option for the treatment of upper and lower extremity
nonunions and reconstructive procedures associated with
bone loss or avascular necrosis.1,2 The benefit of this type of
flap is the viability of the bone which favors primary ossifica-
tion and increases bone density.1,3 Atrophic nonunions are
associated with poor bone vascularity at the fracture site.
Effective treatments provide not only bone, but also restore
healthy blood flow to the area. The sites where vascularized
bone grafts can be harvested are the fibula, radius, scapula,
iliac crest and the medial aspect of the knee.4 Vascularized free
bone flaps are especially useful for the treatment of nonunions
and recalcitrant nonunions, meaning nonunions that have
failed three or more treatments to obtain consolidation.5,6 If
the recipient site is irregular, the MFCF is indicated due to the
versatile anatomy of this flap.7
In 1991, Doi and Sakai8 demonstrated the use of the vas-
cularized supracondylar region of the femur with vascular
supply through the descending genicular artery (DGA), a
branch of the superficial femoral artery and the superomedial
genicular artery (SMGA).9 The SMGA offers the greatest
vascularity of the medial condyle of the femur.4,10 This versa-
tile flap can be used as an osteocutaneous flap if a skin paddle
is needed and can be incorporated to address a tendon, muscle
and chondral defect as well.2,6,11–13 Donor site morbidity is
limited and primarily relates to sensory disturbances in the
distribution of the saphenous nerve.14–16 The purpose of this
case series is to demonstrate the versatility of the MFCF in
the management of different types of nonunion for various
anatomical levels of the upper extremity.
Case section
Subjects
Three patients were treated with MFCF. Case 1 is a supracon-
dylar humerus fracture initially treated with open reduction
internal fixation (ORIF) and autologous non-vascularized bone
graft which presented with an infected nonunion requiring
hardware removal. Case 2 is a patient who failed to heal after
The medial femoral condyle free flap:
An excellent option for difficult cases:
case series
Jorge I Quintero1,2 , Dylan Childs1,2 and Rodrigo Moreno1,2
Abstract
The use of the medial femoral condyle free flap is a versatile option for the treatment of upper extremity non unions and
reconstructive procedures associated with bone loss or osteonecrosis. The benefit of this type of flap is the viability of the
bone which favors primary ossification and increases bone density. Vascularized free bone flaps are especially useful for
the treatment of recalcitrant nonunions, or nonunions that have failed three or more treatments to obtain consolidation.
We present a case series of three patients treated with medial femoral condyle free flap for reconstruction of the upper
extremity of different etiologies at the level of the distal humerus, distal radius and distal phalanx of the thumb.
Keywords
Medial femoral condyle free flap, recalcitrant nonunion, thumb reconstruction, knee, upper extremity reconstruction
Date received: 29 August 2019; accepted: 20 May 2020
1 Christine M. Kleinert Institute for Hand and Microsurgery, Louisville, KY,
USA
2 Division of Hand Surgery, Department of Surgery, School of Medicine,
University of Louisville, Louisville, KY, USA
Corresponding Author:
Jorge I Quintero, Christine M. Kleinert Institute for Hand and
Microsurgery, 225 Abraham Flexner Way, Suite 850, Louisville, KY 40202,
USA.
Email: jorgekin82@hotmail.com
933763SCO0010.1177/2050313X20933763SAGE Open Medical Case ReportsQuintero et al.
case-report2020
Case Report
2 SAGE Open Medical Case Reports
of the management of a distal metaphyseal giant cell tumor
treated with excision, autologous bone grafting and a wrist
fusion. Case 3 involves a reconstructive option for the distal
phalanx of the thumb in a patient suffering a crush injury.
All patients were treated with the same surgical tech-
nique, by the same senior author and the approach to the
knee was ipsilateral to the affected upper limb. The disabili-
ties of the arm, shoulder and hand (DASH)17 score is a vali-
dated upper extremity outcome questionnaire used to assess
functional outcomes which was performed in the three
patients presented.
Surgical technique
The patient is placed in supine position, the ipsilateral leg to
the affected upper extremity is prepped circumferentially from
the ankle to the groin. A sterile tourniquet is applied high at the
thigh and the lower extremity is then externally rotated and
flexed at the hip and knee to assume a frog-leg position.
A curvilinear incision of approximately 12 cm is made
from the level of the adductor hiatus to the midpoint of the
medial patella. Dissection is performed through the subcuta-
neous tissue until the fascia of the vastus medialis is identi-
fied. The vastus medialis is retracted anteriorly and the
adductor tendon is identified and retracted posteriorly. The
medial femoral condyle is then exposed and the transverse
and longitudinal branches of the DGA are visualized. The
periosteum was incised leaving the central pedicle attached.
Attention was then directed to harvesting the graft in a rec-
tangular manner with small, posterior and anterior segments.
The proximal and posterior portions were isolated with a key
elevator leaving the central pedicle with periosteum still
adherent. At this point, an osteotomy through the cancellous
portion under the pedicle was performed. The graft was then
released with an osteotome on all four sides and elevated.
After this was done, the tourniquet was deflated to confirm
the graft had adequate blood supply. Ligation of the graft
pedicle was performed 5 cm proximally using ligaclips. The
graft was then transferred to the repair site. Suture repair of
the fascia was performed with absorbable 2–0 suture, subcu-
taneous tissue was closed with interrupted absorbable 4–0
and the skin was closed with subcuticular 4–0 absorbable
suture.
Case 1. A 58-year-old female with a past medical history of
hypertension presented after a fall where she sustained a
supracondylar fracture of the left elbow. Initial surgery con-
sisted of ORIF of the medial and lateral columns through a
chevron osteotomy of the ulna. She failed to show signs of
union at 5 months postoperatively and underwent bone stimu-
lator therapy for 4 months. Radiographs showed loosening of
hardware and a persistent nonunion. The patient then under-
went removal of hardware, repeat fixation with 90/90 plating
and iliac crest bone graft (ICBG). Unfortunately, she devel-
oped a deep surgical site infection 4 weeks postoperatively
necessitating debridement, removal of hardware and 6 weeks
of antibiotic therapy followed by repeat ORIF with contralat-
eral ICBG. Six months postoperatively she fails to demon-
strate union and to avoid yet another failure of fixation the
decision was made to use a MFCF.
A para-tricipital and anteromedial approach was per-
formed, with dissection and exposure of the brachial artery,
median nerve and ulnar nerve. The fracture site at the medial
column was debrided and cancellous graft was placed with-
out removing the plate. After harvest of the MFCF as
described above, the graft was placed in the medial column
crossing the fracture site and secured with two 2.0 mm corti-
cal screws after elevating the periosteum about 5 mm at both
ends of the graft. The pedicle was anastomosed to the bra-
chial artery in end-to-side fashion. Five months after surgery,
there was no pain, elbow flexion of 110 degrees and her
elbow extension lag of 30 degrees. Her left-hand strength
was 30 pounds compared with the right side that was
40 pounds. Subsequent radiographs demonstrated signs of
consolidation with bone bridging at the medial column and
residual radiolucency at the lateral column. The patient
reported no complaints, with flexion of 110 degrees, exten-
sion lag of 30 degrees and complete prono-supination at the
time of her final follow-up visit. The result of a DASH score
performed 2 years after her last surgery was 0.8 (Figure 1).
Case 2. A 59-year-old male patient, with a history of diabetes,
hypertension and hypercholesterolemia, presented with pain
in the left wrist. He reported no history of trauma and a De
Quervain’s release done by another surgeon 3 months prior
without improvement of his pain after this procedure. The
patient complained of pain at the radial and dorsal aspect of
the wrist with mild edema and severe tenderness at the level of
the distal radius and radial styloid. anteroposterior (AP) and
lateral x-rays of the wrist revealed a large area of radiolucency
at the metaphysis of the radius suggestive of a giant cell tumor
with cortical breakthrough of the lesion. The patient was
treated surgically with en bloc excision of the tumor, tricorti-
cal bone grafting of 4 cm and wrist fusion with a 3.5/2.7 meta-
physeal Synthes plate (West Chester, PA, USA). A giant cell
tumor of the radius was confirmed by pathology. Nine months
after surgery, x-rays show clear radiolucency at the interval of
the graft and proximal aspect of the radius shaft. The decision
was made to perform an MFCF without removal of hardware
as this appeared to be intact.
A rectangular cortico-cancellous graft from the medial
femoral condyle was harvested and it was carved in a “C”
shape carrying out two controlled fractures of the cortical
graft, but maintaining the periosteum intact. The nonunion site
at the shaft of the radius was debrided and excision of fibrous
tissue was done. The site was packed with cancellous graft
taken from the medial femoral condyle area and the flap was
placed circumferentially around the radial, volar and ulnar
cortices of the radius at the proximal segment of the fusion.
The pedicle was sutured end-to-side to the radial artery and to
Quintero et al. 3
the venae comitantes. Monthly evaluation was performed
after the surgery, with slow bone bridging observed on x-rays.
Twelve months after the MFCF was done, complete consoli-
dation of the radius was observed. At this time, the patient
demonstrated grip strength in the right hand of 100 and 75 lbs
in the affected hand. Supination was 70 degrees with pronation
of 80 degrees. A DASH questionnaire, 2 years after the surgi-
cal intervention, showed a score of 36.7 (Figure 2).
Case 3. A 31-year-old healthy male presented with a crush
injury to the right thumb. On physical examination the inter-
phalangeal joint and pulp of the thumb were exposed with
complete loss of the distal phalanx. Through the wound, we
were able to see the volar surface of the nailbed was intact.
The wound was primarily at the volar aspect of the distal pha-
lanx with ragged edges and questionable blood supply of the
skin flaps.
Initial debridement of the thumb was performed, and a
cement spacer replicating the distal phalanx was placed to
build an induction membrane, applying the principals of the
Masquelet technique for the management of long segmental
defects. The spacer also supported the nailbed which avoids
a progressive hook nail deformity. Stabilization of the bone
cement spacer was done. The severely mangled skin was
monitored with evidence of partial epidermal skin necrosis,
but at 10 weeks, the pulp of the thumb was completely healed
with no soft tissue defects.
Reconstruction of the distal phalanx was accomplished
with a rectangular 3 × 1 cm MFCF.
Exposure of the thumb was performed through a Brunner
incision and fixation was performed using a 90/90 technique
with #0 malleable wires to fuse this to the interphalangeal
joint of the thumb. Examination of the digital arteries of the
thumb revealed both arteries were severed at the interphalan-
geal joint level. The digital arteries were identified at the
level of the palm and after tourniquet was deflated the blood
flow of both digital arteries was poor. The pedicle of the graft
was anastomosed to the radial artery at the snuffbox with a
vein graft harvested from the volar forearm. The vein graft
was anastomosed with the radial artery in an end-to-side
fashion. The vein was sutured to the venae comitantes of the
radial artery. The upper limb was immobilized in a thumb
spica splint. At the 2-month postoperative visit, the patient
complains of mild knee discomfort while playing soccer or
after prolonged standing. Five months after surgery, radio-
graphs showed stable fusion. The patient reported no pain
and demonstrated grip strength of 85lbs in the affected right
hand with a left-hand grip strength of 100 lbs. DASH score
was 12.5 (Figure 3).
Postoperative treatment included 81 mg of aspirin daily
for 30 days. The flap was assessed using Doppler 2 weeks
after surgery, and the donor site was examined as well. All
patients were allowed to bear weight and ambulate as toler-
ated after surgery.
Three patients were included in this case series: a recalci-
trant nonunion of the distal humerus, nonunion of a wrist
fusion secondary to a distal radius giant cell tumor en bloc
excision and a thumb distal phalanx reconstruction due to
complete distal phalanx loss. Average age was 49 years old
(31–59), one female, two males, one right upper limb and
two left upper limbs, one right knee donor site and two left
knee donor sites (see Table 1). None were smokers, two were
Figure 1. (a) Supracondylar fracture, (b) ORIF, (c) nonunion 5 months, (d) hardware removal, (e) ORIF and iliac bone graft, and (f) final
consolidation after MFCF. Red: bone graft MFCF.
4 SAGE Open Medical Case Reports
diabetic and one patient had hypertension. All patients
underwent prior surgery before the MFCF (Table 2). Two
patients were admitted overnight for pain control.
Patients were evaluated for flexion, extension and grip
strength of the recipient site and compared with the con-
tralateral extremity (Table 3). Donor site was evaluated for
flexion and extension of the knee as well as occult fracture or
sensory loss. Average time to consolidation after the MFCF
was 7.3 months (5–12 months). No final pain at the donor
site was reported, all patients had full range of motion of the
knee and no complications were identified with a mean fol-
low-up of 8.6 months (5–12 months; Table 4).
Discussion
The cases detailed above illustrate the broad utility of the
MFCF where moderate size cortico-cancellous bone is
required. In a hostile wound bed that requires free tissue
transfer due to inadequate vascularity, the MFCF provides
versatility and reliability with acceptable donor site morbid-
ity. Overall, a 100% consolidation was achieved. Recent lit-
erature reports eight thumb reconstructions using the MFCF
demonstrating the versatility and reliability of this flap.18 On
the distal humerus fracture, final DASH score of 0.8 demon-
strates good outcomes compared with the literature (27.8),
however, we are aware that this is only one case and further
patients would need to be evaluated to confirm this result.
Our time for consolidation after the MFCF was similar to
previously published averages.19
Bakri et al.20 performed a revision reconstruction with the
MFCF in 46 cases of nonunion in the upper and lower limbs.
In 87% (n = 40), consolidation was achieved with a mean
time of 3.5 months, while three fractures consolidated in
12 months, two fractures failed and one flap died. Cavadas
and Landín21 demonstrated the final consolidation in recalci-
trant nonunion of the tibia in a time-lapse of 3.1 months. In
Figure 2. (a) Distal radius x-ray giant cell tumor, (b) wrist fusion iliac bone graft, (c) nonunion, and (d) final result after MFCF. Red:
bone graft MFCF.
Quintero et al. 5
our cases, we defined definitive healing as consolidation in
four cortexes confirmed by x-ray.
In our case of radius nonunion, we identified atheroscle-
rosis on the intima of both the donor and recipient vessels.
Henry22 demonstrated nonunion of the distal radius with
100% consolidation in a time of 6.1 weeks with the MFCF;
this report also concluded that the benefits of this graft are a
greater layer of cancellous and cortical bone, molding the
graft for length and width and robust blood supply.
The DGA was used in all of our cases. Iorio et al.23
reported 100% presence of the DGA in 12 fresh cadavers.
Literature supports the evidence that the SMGA is seen in
Table 1. Demographics.
Patient Age Gender Diagnosis Treated site Knee
1 58 Female Recalcitrant nonunion distal humerus Left distal humerus Left
2 59 Male Distal radius giant cell tumor Left distal radius Left
3 31 Male Right thumb distal phalanx bone defect Right thumb Right
Table 2. Associated risk factors.
Patient Prior surgery Surgery Smoking Diabetes Hypertension
1 Yes ORIF/ICBG No Yes Yes
2 Yes Arthrodesis/ICBG No Yes No
3 Yes Irrigation and debridement No Yes No
ORIF: open reduction internal fixation; ICBG: iliac crest bone graft.
Figure 3. (a) Thumb with bone cement spacer, (b) MFCF, and (c) final x-ray. Red: bone graft MFCF.
6 SAGE Open Medical Case Reports
the majority of the cases, the DGA can be absent in 10%–
15% cases.11,10,24 Anatomic variability should be accounted
for and alterations to flap harvest should be included in pre-
operative planning.
During the reconstruction of the phalanx, the size of the
graft that can be used is about 5 × 7 cm and for forearm non-
union up to 5 cm.2
Although the vascularized free fibular graft25 is an accepta-
ble option, it comes with complications, such as instability of
the ankle joint, pain due to the vast anatomic dissection and
neurological injury of the common peroneal nerve, venous
thromboembolism, muscle weakness indicated also in defects
more than 5 cm which makes it a less desirable option when
compared with the MFCF in the three cases that we presented.
Regarding the medical advances, until this date, we do
not know how to assess the integrity of the vascularized flap
and the healing process besides the clinical and radiological
follow-up. Further studies should be done to have the correct
interpretation of the bone healing after a free vascularized
bone graft.
No complications were identified at the donor site at final
follow-up. Windhofer et al.26 evaluated postoperative knee
x-ray and magnetic resonance imaging without osteochon-
dral pathology and normal patella alignment. Other compli-
cations that have been reported when using the MFCF graft
include pain of the donor site, seroma, saphenous nerve par-
aesthesia and distal femur fracture.2 Minimal bone regenera-
tion has been observed in the donor area of the medial
condyle after harvesting the graft, leading some to advocate
for the use of allograft bone grafting to promote regeneration
of bone in the donor site.27
Some disadvantages of the procedure include the longer
operative time required for the harvest and fixation of the
flap, and the requirement for microsurgical skills for the har-
vest and anastomosis of the flap.5 While the vascularity of
the SMGA and DGA is consistent, individual variability can
exist and requires a learning curve for flap elevation.11
In most studies where incomplete consolidation or fail-
ure of the graft was found, the patients were smokers,
confirming the observation that smoking interferes with the
consolidation process.28
Conclusion
In conclusion, the MFCF graft can be used to manage large
bone defects, small bone defects, recalcitrant nonunion
and osseous reconstructions secondary to bone loss. It is a
versatile option for irregular defects and the anatomical
structure of the donor site allows to use cortical, cancel-
lous or periosteal flap for bone reconstruction. The con-
sistent anatomy in the knee makes the MFCF easily
identifiable, resulting in low morbidity at the donor site.
For these reasons, the authors consider the MFCF an excel-
lent treatment option for a wide array of nonunion and
reconstructive procedures.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship and/or publication of this article.
Ethics approval
Our institution does not require ethical approval for reporting
individual cases or case series. All procedures were in accordance
with the ethical standards of the responsible committee on human
experimentation and with the Helsinki Declaration on 1975, as
revised in 2008.
Funding
The author(s) received no financial support for the research, author-
ship and/or publication of this article.
Informed consent
Written informed consent was obtained from the patient(s) for their
anonymized information to be published in this article.
ORCID iD
Jorge I Quintero https://orcid.org/0000-0001-8413-8119
Table 3. Final range of motion and grip strength.
Patient Flexion Extension Jamar right (lbs) Jamar left (lbs) DASH
1 110º 30ºlag 40 30 0.8
2 None ( full pronation) None ( full supination) 100 75 36.7
3 Full MCP range of motion Full MCP range of motion 80 100 12.5
DASH: disabilities of the arm, shoulder and hand score; MCP: metacarpophalangeal.
Table 4. Final follow-up, consolidation, knee function and complication.
Patient Consolidation Month Knee fracture Knee pain Knee flexion Knee extension Complication
1 Yes 9 No No Full Full No
2 Yes 12 No No Full Full No
3 Yes 5 No No Full Full No
Quintero et al. 7
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