Hand Surgery and Rehabilitation 42 (2023) 455–458

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Case report

Management of capitate avascular necrosis in an adult with a free

medial femoral condyle flap
Petko Shtarbanov a,*, Yazan Ajam b, Onur Berber b, Dariush Nikkhah a,b
a
Division of Surgery and Interventional Science, University College London, London, United Kingdom
b
Department of Plastic and Reconstructive Surgery, Royal Free NHS Foundation Trust Hospital, London, United Kingdom

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

Article history: The treatment of the extremely uncommon avascular necrosis of the capitate with a medial femoral
Received 11 July 2023 condyle corticocancellous free flap has been described previously by one group reporting on
Received in revised form 17 July 2023 outcomes in a paediatric patient. However, no literature to-date has detailed results of this procedure
Accepted 18 July 2023
in an adult. We illustrate the case of a 53-year-old man who sustained capitate avascular necrosis and
Available online 22 July 2023
tendon rupture of traumatic aetiology. He was managed by resection of the necrotic segment,
followed by inset of the medial femoral condyle free flap with the novel applications of indocyanine
Keywords:
green to ensure adequate perfusion and intramedullary cannulated screw fixation of the capitate.
Avascular necrosis
Capitate
Tendon transfer was also performed in the same operative sitting. At 9 months postoperatively, the
Free flap patient displayed full range of motion of the wrist without any pain, and the imaging demonstrated
Medial femoral condyle union. This microsurgical approach may be performed in adult patients with favourable postoperative
Cannulated screw outcomes.
Hand surgery C 2023 SFCM. Published by Elsevier Masson SAS. This is an open access article under the CC BY license

(http://creativecommons.org/licenses/by/4.0/).

Introduction Patient presentation

Avascular necrosis (AVN) of the capitate is an exceedingly
atypical clinical finding of traumatic or idiopathic aetiology.
Nevertheless, it is an important differential diagnosis in patients
presenting with chronic wrist pain and reduced range of motion
[1,2]. Published literature has described a multitude of treatment
approaches including immobilisation [3], pedicled and free
vascularised bone grafting [2,4], prosthetic or interpositional
arthroplasty [2] and carpal arthrodesis [1]. In this case report, we
demonstrated the surgical approach for treating capitate-AVN
using proximal capitate resection and capitate reconstruction with
a medial femoral condyle (MFC) free flap in an adult patient. The
patient also required concurrent index finger tendon transfer. One
other group has reported a microvascular bone transfer from the
medial femoral condyle; however, this was carried out in a
paediatric patient [2], which may partly explain the optimistic
postoperative outcomes described in that case.
* Corresponding author.
E-mail address: petko.shtarbanov.20@ucl.ac.uk (P. Shtarbanov).
The patient was a 53-year-old right-handed man, working as an
art therapist, who had sustained an attritional rupture of the right
flexor digitorum profundus (FDP) tendon to the index finger
2 years prior to presentation when he attempted to grasp an
object; prior to that the patient experienced several weeks of pain
and swelling in the right wrist. This was secondary to a right
capitate body fracture obtained from a fall 4 years prior to
presentation – radiographic imaging was normal at the time. At
presentation, the patient had chronic pain on wrist movement in
all axes. A reduced range of motion was not the main presenting
complaint. The capitate area of non-union and AVN, and
subsequent FDP rupture, were confirmed by x-ray (see Fig. 1),
computed tomography (CT) and magnetic resonance imaging. The
avascular segment was identified as the proximal pole of the
capitate. The patient was managed through the complex hand
multidisciplinary team meeting involving plastic and orthopaedic
hand surgeons and hand therapists. Having discussed different
treatment approaches, the patient underwent a MFC free
vascularised flap to reconstruct the capitate and a flexor digitorum
superficialis (FDS) middle to index flexor digitorum profundus
transfer to manage the FDP rupture in the index finger. It was
explained that the relatively low risks of donor-site morbidity and

https://doi.org/10.1016/j.hansur.2023.07.007
2468-1229/ C 2023 SFCM. Published by Elsevier Masson SAS. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
P. Shtarbanov, Y. Ajam, O. Berber et al.
Fig. 1. X-ray imaging preoperatively (left) and 6 months postoperatively (right).
Fig. 2. The cavity produced following resection of the necrotic capitate (left) was used to create a bone wax impression of the defect through a latex glove (right).
wound complications were outweighed by the imminent possibil-
ity of wrist joint collapse. The patient ceased smoking for 6 weeks
prior to the operation and stopped altogether postoperatively.
Moreover, the patient reported a clinical history of Raynaud’s
disease.
Operative technique
Tourniquets were positioned on the right arm and ipsilateral
thigh. The recipient site was prepared concurrently with the
vascularised MFC corticocancellous flap harvest.
Capitate recipient site preparation
A standard longitudinal dorsal approach was adopted to the
right capitate between the third and fourth extensor compart-
ments, as well as a longitudinal capsulotomy sparing the full dorsal
radioulnar ligament, the radial half of the dorsal radiocarpal
ligament (connecting the distal radius and triquetrum) and entire
dorsal intercarpal ligament (connecting the triquetrum to the
trapezoid and capitate) as described previously by Berger et al.
[5]. The posterior interosseous nerve was identified and neurec-
tomy was performed. Corticotomy was achieved using a burr in the
non-union dorsal surface of the avascular capitate, and the
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Hand Surgery and Rehabilitation 42 (2023) 455–458
proximal necrotic bone, measuring approximately 1 by 1 by
2 cm, was removed. The finding was consistent with the
preoperative diagnosis of AVN. Upon deflation of the tourniquet,
both the distal vascularised and the proximal avascular segments
of the capitate were confirmed through the presence of punctate
bleeding or lack thereof, respectively. In the cavity produced, a
bone wax impression of the defect was created using a latex glove
as described previously by Kazmers et al. [2] (see Fig. 2). The radial
artery and vena comitans at the anatomical snuff box were
prepared for microvascular anastomosis.
Ipsilateral MFC flap harvest and inset
A sharp longitudinal incision, measuring 15 cm in length, was
made proximally from the MFC over the distal half of the medial
thigh at the dorsal border of the vastus medialis (see Fig. 3).
Electrocautery was used to dissect through subcutaneous tissue
and the vastus medialis muscle was reflected back. There was an
anatomical variation in this patient; the descending genicular
artery, which exists in 89% of cases [6], was not present and this
often provides a longer pedicle. The flap was then based on the
superomedial genicular artery (present in 100% of specimens [6]);
the dominant perforator to the MFC was dissected down to the
origin at the popliteal artery. The medial genicular pedicle
P. Shtarbanov, Y. Ajam, O. Berber et al.
Fig. 3. A longitudinal incision was made proximally from the MFC over the distal half of the medial thigh at the dorsal border of the vastus medialis (left). The medial genicular
pedicle containing the artery and vena comitans was isolated (right).
containing the artery and vena comitans was isolated. The piece of
bone, sized 1 by 1 by 2 cm, was carefully harvested with the
associated cuff of periosteum using an osteotome. The bone wax
replica of the necrotic capitate created at the recipient site was
used to template the corticocancellous bone wedge size. The
donor-site void was filled with bone wax and the wound was
closed over a drain.
The free flap was fixed at the recipient site using a 2-millimeter
cannulated screw (DePuy Synthes TM). The screw was inserted
obliquely across the capitate in an antegrade manner. The
microsurgical arterial anastomosis to the radial artery was carried
out end-to-end using 9 0 interrupted sutures. The pedicle of the
vena comitans was anastomosed to that of the radial artery by a 2-
millimeter venous coupler. Satisfactory blood flow through the
anastomoses and bleeding from the bone flap and periosteum were
confirmed on tourniquet release. Indocyanine green was subse-
quently applied to confirm the patency of the anastomoses and the
free tissue bone transplant.
Index FDP tendon reconstruction
The middle finger FDS was harvested from zone II of the right
hand. The carpal tunnel was decompressed and the floor was
inspected for any remaining capitate spur. The carpal tunnel floor
was smooth with no evidence of any bony prominence from the
collapsed capitate. Extensive tenosynovectomy and adhesiolysis
were performed. The middle finger FDS was delivered to the carpal
tunnel wound and tunneled to the index finger FDP. A Pulvertaft
tendon weave was performed [7]. The wrist was protected in a
volar plaster in the wrist and hand position of safety. This was
converted to a forearm-based splint from week 2 postoperatively.
Postoperative follow-up
Following his surgery, the patient was monitored in the
recovery unit by nursing and medical staff. Observations were
stable and his hospital stay was uneventful. The patient was
discharged from hospital on postoperative day 4. For rehabilita-
tion, a plaster of Paris cast was placed in the first postoperative
week, and the patient began active range of motion exercises of the
index finger. The hand and wrist were protected in a fabricated
forearm-based flexor hood splint (Rolyan Ezeform TM 3.0 cm). The
wrist was in neutral, and the metacarpophalangeal joints at
40 degrees flexion, allowing for neutral extension at the
interphalangeal joints. This was worn full-time from week 2 to
week 6 postoperatively. Routine hand therapy followed for soft
tissue scar management and tendon rehabilitation. After 1 month,
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Hand Surgery and Rehabilitation 42 (2023) 455–458
the donor-site and recipient-site wounds had satisfactorily healed,
and the x-ray scan demonstrated some integration of the capitate
fracture. At 3 months postoperatively, wrist range of motion was
40 degrees of extension and 30 degrees of flexion. Following
4 months, the wrist range of motion had improved to 50% of the
normal; the CT imaging showed some bony integration in the distal
end of the MFC flap. The screw head was found to be prominent
over the proximal pole of the capitate, although no pain was
reported on maximal wrist extension which suggested no
impingement. Therefore, no immediate plan was made to remove
this. After 6 months, the x-ray imaging demonstrated improved
union (see Fig. 1). At 9 months of follow-up, the patient displayed a
full range of motion of the wrist without any pain, and further wrist
CT imaging suggested full integration of the bone flap. The range of
motion of the digits and knee joint were also restored to normal
with no residual pain. Scar appearance was satisfactory. Average
grip strength was stable at 35.3 kg and 25.7 kg for the left and right
hand, respectively, after 10 months.
Discussion
The case discussed herein described the management of the
rare capitate-AVN with a free MFC flap in an adult patient, and a
promising postoperative course was demonstrated. This case
example was also complicated by an attritional flexor tendon
rupture in the carpal tunnel which was addressed in the same
operative sitting. The successful use of free MFC flap to treat
capitate-AVN was detailed previously in a paediatric patient
[2]. Our use of intramedullary cannulated screw fixation and
indocyanine green to confirm vessel patency and perfusion to the
bone transplant were novel applications in the field. Cannulated
screw fixation has been shown to be the gold-standard for
scaphoid nonunion [8]. The minimally-invasive intramedullary
cannulated screw fixation was adopted over the traditional
Kirschner-wire method because of evidence, in the context of
unstable phalangeal and metacarpal fractures, it provided signifi-
cantly lower complication rates, including reduced risk of pin-tract
infections, pin loosening and migration, and nonunion [9]. Fur-
thermore, cannulated screw fixation could enable a faster return to
normal daily life and activity due to the lesser need for prolonged
immobilisation [9]. Compared to plate-and-screw methods,
cannulated screw fixation was also associated to less stiffness
and tendon disruption [9]. The challenges and learning points in
this case included the chronicity of the capitate non-union and
collapse. Although an attempt was made to correct the volar
collapse, this was not fully achieved. The soft tissue periosteal cuff
on the medial femoral bone flap impaired visualisation for screw
P. Shtarbanov, Y. Ajam, O. Berber et al.
insertion. This made screw insertion difficult around the bone flap
and hence the screw head prominence was seen on follow-up
imaging. We recommend inserting the guidewire(s) partially in the
desired trajectory prior to graft implantation to ensure satisfactory
placement of the compression screw.
The decision to perform a free MFC flap in this case stemmed
primarily from the defect size, chronicity of the injury and lack of
vascularity on imaging. The large avascular segment was deemed
unsuitable for a non-vascularised bone graft or a pedicled bone
flap. A pedicled flap might not have reached or provided sufficient
bone stock; one group has suggested that a free MFC has several
advantages over pedicled bone flaps including ease of inset and
better union rates in scaphoid nonunion [6]. We believed a free flap
would allow a more accessible manipulation and inset with a
larger bone stock with a robust vascularised periosteum, which
could not be achieved with local options. The limitation of this
operative technique was that a more extensive operation was
required versus a pedicled bone flap. Furthermore, assessment
with indocyanine green was associated with higher cost [10],
thereby reducing the accessibility of this approach to other centres.
In addition, no level-one evidence suggested superiority of this free
flap to other procedures, nevertheless, it was felt this method had
the greatest capability of restoring wrist function and alleviating
pain.
Conflict of interest
Petko Shtarbanov, Yazan Ajam, Onur Berber and Dariush Nikkhah declare that they
have no conflict of interest.
Ethics approval
All procedures performed in studies involving human partici-
pants were in accordance with the ethical standards of the local
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Hand Surgery and Rehabilitation 42 (2023) 455–458
research committee and with the 1964 Helsinki declaration and its
later amendments or comparable ethical standards.
Patient consent
Signed informed consent document was obtained.
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