Vascularized Medial Femoral Condyle Bone Grafting as a Salvage Strategy for Recalcitrant Atypical Ulnar Shaft Nonunion After Long-Term Bisphosphonate Therapy

Atypical ulnar shaft fractures related to prolonged bisphosphonate therapy carry a considerable risk of nonunion due to compromised bone biology. A 70-year-old woman developed a persistent ulnar shaft nonunion with impaired biological healing after sustaining a low-energy injury following more than 10 years of bisphosphonate use. Conservative management was unsuccessful, and she was referred 8 months after injury with ongoing pain and radiographic evidence of an atypical ulnar fracture. Given the high risk of failure with conventional fixation and nonvascularized bone grafting, biological salvage was undertaken using a vascularized medial femoral condyle bone graft in combination with plate fixation. Radiographic bone union was achieved without complications, and satisfactory function was maintained at 1.5-year follow-up. This case demonstrates that vascularized bone grafting can serve as an effective salvage strategy for recalcitrant atypical ulnar shaft nonunion in patients with prolonged bisphosphonate exposure.