I'll be talking about vascularized bone grafting and the different options. Again, no disclosures relative into this talk. I can't seem to forward though. Good. Nope. All right, maybe just forward for me. That's not going. All right. So background first, I'll talk about what some of the science behind it and then the different types. So most of our vascularized bone grafting stems from the work of Hori. Basically using a dog model, he found that placing new vessels, putting a vessel into the bone will cause neovascularization. So as you see here in the picture, A is one of the vessels they implanted into the bone and then B is all the new vessels that form. So dorsal grafts. So probably one of the most well-known one is the 1,2-intercompartmental supraretinacular one. It originates five centimeters proximal to radial carpal joint, runs beneath the brachioradialis muscle, distantly enters the snuff box, and anastomosis with the radial artery and or radial carpal arch. It's ideally suited for dorsal scaphoid bone grafting, though it has been described for volar grafting. And you do that with the radial styloidectomy so you can pass it over to the volar side. It has a short pedicle. There's a 2,3-intercompartmental supraretinacular one. It originates from the anterior interosseous artery or the posterior division of the anterior interosseous artery. It's superficial to the extensor retinaculum directly on the listers and anastomosis with the dorsal intercarpal arch or the fourth extensor compartmental artery. The arc of motion is greater than the 1,2 and it may be used for a keen box or scaphoid nonunion. There's a capsular-based one described by Dr. Sotirianos. It's based on the fourth extensor compartmental artery and runs along the four of the fourth compartment. And basically, it's a no-pedicle dissection. And basically, you isolate the capsule and its insertion as you see in that middle picture. And this is the vessel anastomosis with the dorsal intercarpal arch and other compartmental arteries. There's an index dorsal metacarpal artery. It could be used volar or dorsal. And one study showed that it had a union rate at 10 weeks in all 14 of their scaphoid nonunion cases. Now, let's move on to the volar graphs. So, there's one that's described by Coleman and further reported by Metholin. It's based on the volar carpal artery and it lies between the palmar periosteum of the radius and the distal part of the superficial aponeurosis of the peroneal quadratus. So, if you see in these pictures, there's an injection study that second picture on the left basically shows the artery. A picture on the bottom right shows the exposure. And basically, you take the pedicle and the piece of bone and the bone is on the distal ulnar aspect of the volar distal radius. You take it with a 5-millimeter strip of fascia and periosteum and it can be used for humpback deformity correction. Its relative contraindications include prior volar wrist surgery or trauma. There's another one described on the pronator. You basically take the distal third of the pronator along the fibers of the muscle and you take its insertion on the distal radial aspect of the distal radius. And you can make a counter incision on the ulnar side where you release the origin of the pronator to allow more arc of motion to reach the scaphoid. And I've done this before. You need a little bit of wrist flexion to get the muscle pedicle down to the scaphoid. There has been some question of the vascularity of this bone graft. There's a thumb metacarpal one based on the first dorsal metacarpal artery. It originates 5 to 10 millimeters proximal to the trapezoid metacarpal joint. And the graft can be harvested from the metacarpal head, which would give you a pedicle about 15 millimeters or at its base. I described a technique why every time I expose the volar scaphoid, I would see the superficial palmar branch. And I basically dissected out the sleeve and ligated. And at the end of my non-union surgery, I'll try to plug it back in into the non-union site. And you can use it all the time to supplement any other procedure like the procedure for that metholon described. And the picture on the right is after the tourniquet's down. And you basically cut the end of the artery so there's a little bit of bleeding but not too much. Who knows what that means? But I've used it a number of times. And it's always there when you're exposing it. So why not preserve the artery? So free grafts is one described of the iliac crest. In one study, 80% of the patients achieved scaphoid non-union. Achieved union when they had scaphoid non-union. And the artery's based off from the deep circumflex iliac bundle. And one that's been more recently described or described more in literature is the supracondylar femur one. The blood supply can be based on the descending genicular vessel or the superior medial genicular vessel. And here's some pictures of the vascularized graft and the implantation on the bottom right. Thank you.

vascularized bone grafting

neovascularization

supraretinacular graft

free grafts

implantation