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Onay T, Akkaya M, Dilek M, Tütüncü MN, Akpınar F. Nonunion of Adult Forearm Fractures: Evaluation of Intramedullary Nailing With Grafting as a Treatment Option. J Orthop Trauma 2025; 39:120-126. [PMID: 39651890 DOI: 10.1097/bot.0000000000002944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/28/2024] [Indexed: 04/29/2025]
Abstract
OBJECTIVES To evaluate the effectiveness of intramedullary nailing combining with iliac or fibular autograft for the treatment of adult forearm nonunions. METHODS DESIGN Retrospective case series. SETTING Two academic trauma referral centers. PATIENT SELECTION CRITERIA Adult patients who sustained surgical treatment for forearm fracture (OTA/AO 2R2-2U2) nonunion with intramedullary nailing and grafting from May 2005 to January 2023 were included. OUTCOME MEASURES AND COMPARISONS The primary outcome was to determine the bone union rates after nonunion surgery with intramedullary nail and grafting. Secondary outcomes were to assess functional scores including The Visual Analog Score; the shortened version of the Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire; Grace-Eversmann evaluation criteria. RESULTS The study included 24 patients comprising 19 men and 5 women (7 radius, 14 ulna, 3 both bones) with an average age at the time of surgery of 40.5 ± 11.2 years (range, 23-61 years) and union was achieved for 24 out of 27 bones (88.8%) in 22 out of 24 patients. The mean (average) preoperative and postoperative QuickDASH scores were found as 64.5 ± 18.2 and 15.3 ± 18.9, respectively. The functional improvement was found statistically significant ( P < 0.001). The mean (average) preoperative and postoperative Visual Analog Score was found to be 7.2 ± 2.1 and 1.52 ± 1.5, respectively. The difference was found statistically significant ( P < 0.001). Two cases of radius nonunion healed with 10 degrees and 15 degrees of angulation and shortening, while nonunion persisted in 2 patients. All remaining cases healed without deformity. Excellent to acceptable results were obtained for 83.3% of patients according to Grace-Eversmann criteria. CONCLUSONS Intramedullary nailing with autologous grafting is a viable option for the treatment of adult forearm nonunions. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Tolga Onay
- Department of Orthopedics and Traumatology, Istanbul Medeniyet University, Istanbul, Turkey
| | - Mesut Akkaya
- Faculty of Medicine, Department of Orthopedics and Traumatology, Health Sciences University, Umraniye Training and Research Hospital, Istanbul, Turkey ; and
| | - Mehmet Dilek
- Department of Orthopedics and Traumatology, Istanbul Medeniyet University, Istanbul, Turkey
| | - Mehmed Nuri Tütüncü
- Department of Orthopedics and Traumatology, Göztepe Süleyman Yalçın City Hospital, Istanbul, Turkey
| | - Fuat Akpınar
- Department of Orthopedics and Traumatology, Istanbul Medeniyet University, Istanbul, Turkey
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Treatment of forearm diaphyseal non-union: Autologous iliac corticocancellous bone graft and locking plate fixation. Orthop Traumatol Surg Res 2021; 107:102833. [PMID: 33524631 DOI: 10.1016/j.otsr.2021.102833] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 07/22/2020] [Accepted: 09/15/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Studies conducted on forearm bone diaphysis non-union are limited due to the rarity of this condition. The present study aimed to evaluate the outcome of our technique using autologous iliac corticocancellous bone graft fixed by locking plate system for the forearm bone diaphyseal non-union without infection. PATIENTS AND METHODS We treated eight patients with non-union of radial or ulnar shaft fracture (four men, four women) aged 38 years (range: 18-52 years) on average. The average follow-up period was 18 months (range: 12-24 months). In our technique, we applied the locking plate to the diaphyseal bone fragment, before grafting the bone block to the non-union site. After excision of sclerotic ununited bone, the autologous iliac corticocancellous bone was grafted to the defect and fixed with single locking screw. Pain, grip strength, and disabilities of the arm, shoulder, and hand (DASH) score were measured and compared before and 12 months after the surgery. Radiographs were taken at each follow-up, and the time of bony union was determined. RESULTS The mean time to radiological union was 4.2 months (range: 3-6 months), and bony union was achieved in all cases within 6 months. All measured values, visual analog scale, DASH score, and grip strength, were significantly improved at 12 months after surgery (p<0.05). No minor/major complications including infection, non-union, or malunion were reported. CONCLUSIONS Locking compression plate fixation and autologous iliac corticocancellous bone grafting with a holding locking screw appears to be a reliable primary procedure for non-union of the forearm diaphyseal fracture without infection. LEVEL OF EVIDENCE IV; therapeutic study.
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Abstract
OBJECTIVES To evaluate a large series of open fractures of the forearm after gunshot wounds (GSWs) to determine complication rates and factors that may lead to infection, nonunion, or compartment syndrome. DESIGN Multicenter retrospective review. SETTING Nine Level 1 Trauma Centers. PATIENTS/PARTICIPANTS One hundred sixty-eight patients had 198 radius and ulna fractures due to firearm injuries. All patients were adults, had a fracture due to a firearm injury, and at least 1-year clinical follow-up or follow-up until union. The average follow-up was 831 days. INTERVENTION Most patients (91%) received antibiotics. Formal irrigation and debridement in the operating room was performed in 75% of cases along with either internal fixation (75%), external fixation (6%), or I&D without fixation (19%). MAIN OUTCOME MEASURES Complications including neurovascular injuries, compartment syndrome, infection, and nonunion. RESULTS Twenty-one percent of patients had arterial injuries, and 40% had nerve injuries. Nine patients (5%) developed compartment syndrome. Seventeen patients (10%) developed infections, all in comminuted or segmental fractures. Antibiotics were not associated with a decreased risk of infection. Infections in the ulna were more common in fractures with retained bullet fragments and bone loss. Twenty patients (12%) developed a nonunion. Nonunions were associated with high velocity firearms and bone defect size. CONCLUSIONS Open fractures of the forearm from GSWs are serious injuries that carry high rates of nonunion and infection. Fractures with significant bone defects are at an increased risk of nonunion and should be treated with stable fixation and proper soft-tissue handling. Ulna fractures are at a particularly high risk for deep infection and septic nonunion and should be treated aggressively. Forearm fractures from GSWs should be followed until union to identify long-term complications. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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De Vitis R, Passiatore M, Cilli V, Maffeis J, Milano G, Taccardo G. Intramedullary nailing for treatment of forearm non-union: Is it useful? - A case series. J Orthop 2020; 20:97-104. [PMID: 32025132 PMCID: PMC6997666 DOI: 10.1016/j.jor.2020.01.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 01/08/2020] [Indexed: 01/23/2023] Open
Abstract
INTRODUCTION Intramedullary osteosynthesis is often considered a second-order method for treatment of forearm non-union. METHODS We evaluated clinical and functional results from 49 patients affected by radio and/or ulna non-union treated using intramedullary nailing, with possible tricortical autologous bone grafting. Healing rate (primary outcome), healing time and functional status have been assessed. RESULTS Healing was observed in 46 cases (93.9%), the average healing time was 6.3 (SD ± 2.5) months. Excellent result (Anderson score) was reached in 38 cases (77.6%), satisfactory in 7 cases (14.3%). CONCLUSIONS Forearm non-unions represent a therapeutic challenge. Intramedullary nailing is a successful option of treatment.
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Affiliation(s)
- Rocco De Vitis
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
- Università Cattolica del Sacro Cuore, Roma, Italy
- Istituto di Clinica Ortopedica, Italy
| | - Marco Passiatore
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
- Istituto di Clinica Ortopedica, Italy
| | - Vitale Cilli
- Centre Hôpitalier de la Haute Senne, Soignies, Belgium
| | | | | | - Giuseppe Taccardo
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
- Università Cattolica del Sacro Cuore, Roma, Italy
- Istituto di Clinica Ortopedica, Italy
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Agarwal A, Raj RY, Gupta S, Shanker M. Osteosynthesis of Postosteomyelitic Forearm Defects in Children Using a Modified Bone Grafting Technique: The Fibular Intramedullary Bridging Bone and Additional Grafting (FIBBAG). J Hand Surg Asian Pac Vol 2020; 25:13-19. [DOI: 10.1142/s2424835520500010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: There are many options to treat post osteomyelitic gaps in forearm bones. We report a pediatric series with postosteomyelitic forearm segmental defects reconstructed with fibular only graft: the non vascular fibular intramedullary bridging bone and additional grafting (FIBBAG) and the results thereof. Methods: Outcomes in 8 patients treated with fibular strut and overlay matchstick grafts were retrospectively assessed. The clinical results were expressed as forearm shortening, range of motion at elbow and wrist joint. The radiological evaluation included time to union, presence of fractures and recurrence of infection, if any. Results: The average patient age was 6 years (range, 3–12 years). The radius was involved in 6 and ulna in 2. Union occurred in all patients. The average intraoperative gap to be spanned was 5.86 cm (range, 3–14 cm). The average time for union was 6.63 months (range, 2–14 months). Two patients required additional bone grafting procedures. No graft fatigues/fractures were noted in available follow up. There was no recurrence of infection in any case. A positive ulnar variance was seen in 3 patients at follow up. Forearm shortening was a major cosmetic limitation following the procedure. Conclusions: Fibular strut and additional bone grafting (FIBBAG) is one of the viable options for reconstruction of post osteomyelitic forearm defects in children with low procedural complication rate.
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Affiliation(s)
- Anil Agarwal
- Department of Paediatric Orthopaedics, Chacha Nehru Bal Chikitsalaya, Geeta Colony, Delhi, India
| | - Rahul Yogendra Raj
- Department of Paediatric Orthopaedics, Chacha Nehru Bal Chikitsalaya, Geeta Colony, Delhi, India
| | - Shobhit Gupta
- Department of Paediatric Orthopaedics, Chacha Nehru Bal Chikitsalaya, Geeta Colony, Delhi, India
| | - Mukesh Shanker
- Department of Paediatric Orthopaedics, Chacha Nehru Bal Chikitsalaya, Geeta Colony, Delhi, India
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Vicenti G, Maruccia M, Carrozzo M, Elia R, Giudice G, Moretti B. Free vascularized osteoseptocutaneous fibular flap for radius shaft nonunion: The final solution when the iliac crest autograft fails. A case report. Injury 2018; 49 Suppl 4:S63-S70. [PMID: 30526951 DOI: 10.1016/j.injury.2018.11.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Revised: 11/14/2018] [Accepted: 11/19/2018] [Indexed: 02/02/2023]
Abstract
Treatment of forearm nonunion associated with bone defects can be challenging. Restoring the correct length and rotation are two main principles for the management of these patients. Herein, we describe a patient with isolated radius nonunion already treated with an iliac crest autograft with no success. A free vascularized osteoseptocutaneous fibular autogenous graft was harvested as the final solution to managed long bone defect after previous multiple surgeries. At the 1- year follow-up, the patient gained full range of motion and was functioning well.
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Affiliation(s)
- Giovanni Vicenti
- School of Medicine, University of Bari "Aldo Moro"- AOU Consorziale "Policlinico", Department of Basic Medical Sciences, Neuroscience and Sense Organs, Orthopaedic and Unit, Bari, Italy
| | - Michele Maruccia
- Division of Plastic and Reconstructive Surgery, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Bari, Italy
| | - Massimiliano Carrozzo
- School of Medicine, University of Bari "Aldo Moro"- AOU Consorziale "Policlinico", Department of Basic Medical Sciences, Neuroscience and Sense Organs, Orthopaedic and Unit, Bari, Italy.
| | - Rossella Elia
- Division of Plastic and Reconstructive Surgery, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Bari, Italy
| | - Giuseppe Giudice
- Division of Plastic and Reconstructive Surgery, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Bari, Italy
| | - Biagio Moretti
- School of Medicine, University of Bari "Aldo Moro"- AOU Consorziale "Policlinico", Department of Basic Medical Sciences, Neuroscience and Sense Organs, Orthopaedic and Unit, Bari, Italy
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Perna F, Pilla F, Nanni M, Berti L, Lullini G, Traina F, Faldini C. Two-stage surgical treatment for septic non-union of the forearm. World J Orthop 2017; 8:471-477. [PMID: 28660139 PMCID: PMC5478490 DOI: 10.5312/wjo.v8.i6.471] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 04/18/2017] [Accepted: 05/15/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the effectiveness of a two-stage surgical procedure for the treatment of septic forearm non-union.
METHODS Septic non-unions are rare complications of forearm fractures. When they occur, they modify the relationship between forearm bones leading to a severe functional impairment. Treatment is challenging and surgery and antibiotic therapy are required to achieve infection resolution. It is even harder to obtain non-union healing with good functional results. The aim of this study is to present a two stages surgical treatment for septic forearm non-union with revision and temporary stabilization of the non-union until infection has cleared and subsequently perform a new synthesis with plate, opposite bone graft strut and intercalary graft. We retrospectively reviewed 18 patients with a mean age at the time of primary injury of 34.5 years (19-57 years) and a mean follow-up of 6 years (2-10 years). All patients presented an atrophic non-union with a mean length of the bone defect of 1.8 cm (1.2-4 cm). Complications and clinical results after surgical treatment were recorded.
RESULTS Mean time to resolution of the infectious process was 8.2 wk (range 4-20 wk) after the first surgery and specific antibiotic therapy. All the non-union healed with an average time of 5 mo (range 2-10 mo) after the second step surgery. Cultures on intraoperative samples were positive in all cases. No major intraoperative complications occurred. Two patients developed minor complications and one needed a second surgical debridement for infection resolution. At the last follow-up functional results were excellent in 5 (27.8%) patients, satisfactory in 10 (55.5%) and unsatisfactory in 3 (16.7%) patients. No activities of daily living (ADLs) limitations were reported by 12 (66.6%) patients, slight by 3 (16.6%) and severe limitation by 3 (16.6%) patients. Mean visual analog scale at the last follow-up was 1 (0-3).
CONCLUSION The two-step technique has proven to be effective to achieve resolution of the infectious process and union with good functional results and low rate of complications.
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Treatment Options for Nonunion With Segmental Bone Defects: Systematic Review and Quantitative Evidence Synthesis. J Orthop Trauma 2017; 31:111-119. [PMID: 27611666 DOI: 10.1097/bot.0000000000000700] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine which reconstruction treatment of long bones nonunion with segmental bone defects (SBDs) is effective to restore bone length and union with good function. DATA SOURCES PubMed was used to identify published literature on treatment of SBD caused by fracture nonunion regardless of infection between January 1975 and December 2014. STUDY SELECTION We included retrospective cohort studies with a minimum sample size of 10 consecutive patients with minimum follow-up of 18 months and available data on radiographic and functional outcomes. DATA EXTRACTION Literature review revealed 24 publications with a sample size of 504 patients (395 males, 109 females). Data on bone union and functional outcome and complications were collected and analyzed based on validated classification systems. DATA SYNTHESIS Two outcome groups were categorized for bone union and functional outcome, success, and failure. We then performed heterogeneity test to examine the variability or differences in the methods used by these studies and based on that we determined whether the fixed effect or random effect method is appropriate in examining the summary or pool estimate. Pool estimate was examined for bone union and functional outcome in each surgical modality and in each anatomic location when data were available. CONCLUSIONS Treatment of SBD can be challenging. This quantitative evidence synthesis shows that bone union was achieved by different procedures with variable bone union and functional outcomes. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Boussakri H, Elibrahimi A, Bachiri M, Elidrissi M, Shimi M, Elmrini A. Nonunion of Fractures of the Ulna and Radius Diaphyses: Clinical and Radiological Results of Surgical Treatment. Malays Orthop J 2016; 10:27-34. [PMID: 28435558 PMCID: PMC5333654 DOI: 10.5704/moj.1607.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Aseptic nonunion of the radius and ulna is a major complication of forearm fractures, accounting for 2% to 10% of all forearm fractures. The aim of our study is to evaluate the functional and radiological results of surgical treatment of diaphyseal aseptic nonunion of the radius and ulna, with autologous bone grafting, decortication and internal plate fixation. A series of 21 patients (26 nonunions) was retrospectively reviewed, the average age was 35 years with a mean of 31,58 years (range 12-44 years). The fractures included isolated radius (n=6) and ulna (n=10), and both radius and ulna (n=5). The Grace and Eversmann score was used to evaluate our results. Fifteen had very good results, five good and one average. Consolidation of the two bones was attained in 6.2 months. Therefore, the functional prognosis of the upper limb imposes the need for an adequate treatment. This management strategy has enabled us to have satisfactory results. However, the best treatment of nonunion remains the preventive treatment with an optimal management and care of the forearm fractures.
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Affiliation(s)
- H Boussakri
- Department of Orthopaedic and Traumatology Surgery, Midelt Hospital, Morocco
| | - A Elibrahimi
- Department of Orthopeadic Surgery B4, Hassan II University Hospital, Fez, Morocco
| | - M Bachiri
- Department of Orthopeadic Surgery B4, Hassan II University Hospital, Fez, Morocco
| | - M Elidrissi
- Department of Orthopeadic Surgery B4, Hassan II University Hospital, Fez, Morocco
| | - M Shimi
- Department of Orthopeadic Surgery B4, Hassan II University Hospital, Fez, Morocco
| | - A Elmrini
- Department of Orthopeadic Surgery B4, Hassan II University Hospital, Fez, Morocco
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von Rüden C, Morgenstern M, Hierholzer C, Hackl S, Gradinger FL, Woltmann A, Bühren V, Friederichs J. The missing effect of human recombinant Bone Morphogenetic Proteins BMP-2 and BMP-7 in surgical treatment of aseptic forearm nonunion. Injury 2016; 47:919-24. [PMID: 26775208 DOI: 10.1016/j.injury.2015.11.038] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 11/08/2015] [Accepted: 11/22/2015] [Indexed: 02/02/2023]
Abstract
INTRODUCTION In this cohort study, the surgical revision concept of open compression plating and autologous bone grafting with and without additional application of BMP for treatment of aseptic ulna and/or radius shaft nonunion was evaluated. The purpose was to evaluate the clinical and radiological outcome, and to determine any difference in osseous healing, range of time between revision surgery and bone healing, and postoperative complications between the cohort groups. PATIENTS AND METHODS Between 01/2005 and 03/2015, a prospective, randomised, controlled cohort study was performed in a Level I Trauma Centre. Forty-nine patients were treated with the diagnosis of aseptic diaphyseal ulnar and/or radial shaft nonunion using compression plating and autologous bone grafting. Additional biological augmentation using BMP-2 or BMP-7 was performed in 24 patients. Clinical and radiological follow-up was performed six weeks, three and six months after revision surgery in accordance to the system by Anderson. RESULTS The study group consisted of 38 men and 11 women with a median age of 44 years (range 19-77). Twenty-four out of 49 patients obtained compression plating either with autologous iliac crest bone grafting (11/24 patients) or cancellous bone grafting (13/24 patients) and additional application of BMP-2 (4/24 patients) or BMP-7 (20/24 patients). The remaining 25 patients did not receive any additional application of BMP, but autologous bone grafting. The median follow-up was 15 months (range 6-54 months). Forty-six out of 49 nonunion healed within 12 months after revision surgery with a median time to union of six months. The clinical outcome, as assessed using the system by Anderson, as well as osseous healing, duration of time interval between revision surgery and bone healing, and postoperative complications did not demonstrate significant differences between the cohort groups. DISCUSSION Atrophic/oligotrophic forearm nonunion healed irrespective of additional application of BMP combined with autologous bone grafting. For successful treatment, radical resection of fibrous nonunion tissue and internal compression plate fixation is required with the aim of achieving high degree of rigid stability. Also, correction of angular deformities, restoration of length, and precise axial alignment of the distal radio-ulnar joint are mandatory prerequisites to successfully achieve bone healing.
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Affiliation(s)
- Christian von Rüden
- Department of Trauma Surgery, Trauma Center, Murnau, Germany; Institute of Biomechanics, Paracelsus Medical University, Salzburg, Austria.
| | | | | | - Simon Hackl
- Department of Trauma Surgery, Trauma Center, Murnau, Germany
| | | | | | - Volker Bühren
- Department of Trauma Surgery, Trauma Center, Murnau, Germany
| | - Jan Friederichs
- Department of Trauma Surgery, Trauma Center, Murnau, Germany
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Application of the Induced Membrane Technique for Forearm Bone Defects. Tech Orthop 2016. [DOI: 10.1097/bto.0000000000000139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Faldini C, Traina F, Perna F, Borghi R, Nanni M, Chehrassan M. Surgical treatment of aseptic forearm nonunion with plate and opposite bone graft strut. Autograft or allograft? INTERNATIONAL ORTHOPAEDICS 2015; 39:1343-9. [PMID: 25776465 DOI: 10.1007/s00264-015-2718-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Accepted: 02/16/2015] [Indexed: 02/07/2023]
Abstract
PURPOSE OF THE STUDY Adequate treatment of forearm nonunion should achieve both biological stimulation of the bone and mechanical stability. The use of bone graft could enhance the healing of a nonunion providing osteogenic, osteoconductive and osteoinductive stimulation and an optimal stability of the fixation. We retrospectively reviewed two cohorts of patients affected by forearm nonunion and treated with plate and opposite bone graft to determine whether the use of autograft versus allograft differs in terms of (1) rate of healing of the nonunion and (2) time of healing. MATERIALS AND METHODS Thirty-four patients were treated for aseptic forearm nonunion with cortical graft strut with opposite plate and intercalary graft in case of segmental bone defect. In 20 patients an autograft harvest from the fibula (group A) and in 14 (group B) an allograft provided by the bone bank of our institution were used. RESULTS All the nonunions healed in a mean of four months in both groups, ranging from two to 12 months in group A and from three to ten months in group B. At the latest follow up forearm function and pain were satisfactory in both groups. CONCLUSION The use of plate and opposite bone graft demonstrated to be effective in promoting the healing of forearm nonunions, without significant differences in terms of rate and time of healing in the two groups. Considering the higher surgical time and the comorbidity of the donor site, if a bone bank is available, we suggest to use homologous cortical bone strut graft with opposite plate and screw fixation for the treatment of aseptic forearm nonunion rather than autograft.
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Abstract
Simultaneous diaphyseal fractures of the radius and ulna, often referred to as both-bone forearm fractures, are frequently encountered by orthopaedic surgeons. Adults with this injury are typically treated with open reduction and internal fixation because of the propensity for malunion of the radius and ulna and the resulting loss of forearm rotation. Large case series support the use of plate and screw fixation for simple fractures. More complex fractures are managed according to strain theory, with the intention of controlling rather than eliminating motion at the fracture site. This can be achieved with flexible plate and screw constructs or intramedullary nails. In general, results of surgical fixation have been good, with only modest losses of forearm strength and rotation. Notable complications include nonunion, malunion, and refracture after device removal.
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Abstract
OBJECTIVE To review the results of a single-stage treatment protocol for presumptive aseptic diaphyseal nonunion with a well-healed wound and no infection history. DESIGN Retrospective comparative study. SETTING Tertiary referral center. PATIENTS AND METHODS We retrospectively reviewed all presumptive aseptic diaphyseal nonunions treated by a single-stage protocol. There were 104 patients who met the inclusion criteria. Eighty-seven patients were available for follow-up through to complete healing (83.7% follow-up rate). INTERVENTION The protocol entails withholding preoperative antibiotics, removing the implant, performing open debridement or canal reaming, taking 5 cultures of the nonunion site or canal reamings, followed by antibiotic administration, and revision open reduction and internal fixation or exchange nailing. If intraoperative cultures are positive, long-term antibiotics are begun specific to organism sensitivities. MAIN OUTCOME MEASUREMENTS To analyze the rate of positive cultures and to compare the rate of secondary surgery to promote healing in positive and negative culture groups. RESULTS Intraoperative cultures were positive in 28.7% (25/87) of patients with complete follow-up. The overall rate of secondary surgery for persistence of nonunion was 12.6% (11/87). In patients with positive intraoperative cultures, rate of secondary surgery was 28% (7/25) versus 6.4% (4/62) in the group without positive intraoperative cultures (P = 0.01). CONCLUSION A single-stage treatment protocol for presumptive aseptic diaphyseal nonunions was effective in obviating further revision surgery in 93.6% of truly aseptic cases and in 72% of positive culture cases and is still employed at our institution.
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Eljabu W, Fabian C, Wissmann K, Reichstein K. Segmental Bone Transport with the Monorail Technique in Reconstructing a Bone Defect in the Forearm: A Case Report. JBJS Case Connect 2013; 3:e87. [PMID: 29252268 DOI: 10.2106/jbjs.cc.l.00298] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- W Eljabu
- Centre of Traumatology, Hand and Reconstructive Surgery, Klinikum Reinkenheide Bremerhaven, Postbrook Strasse 103, 27574 Bremerhaven, Germany.
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Kamrani RS, Mehrpour SR, Sorbi R, Aghamirsalim M, Farhadi L. Treatment of nonunion of the forearm bones with posterior interosseous bone flap. J Orthop Sci 2013; 18:563-8. [PMID: 23604642 DOI: 10.1007/s00776-013-0395-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2012] [Accepted: 04/05/2013] [Indexed: 11/25/2022]
Abstract
BACKGROUND Reconstructions of forearm fracture nonunions are frequently complex. A few studies that help guide the treatment of forearm nonunion have been reported. We offer a novel surgical technique to treat nonunion of the forearm using a regional vascularized bone graft. METHODS Four females and 5 males ranging from 27 to 74 years of age with 7 ulna and 2 radius nonunions were surgically treated by pedicle grafting with a posterior interosseous bone flap (PIBF) and internal fixation with a plate. There were no cases with extensive soft tissue damage or infection. Pre- and postoperatively (mean 21 months), all patients were assessed by radiographs and for function by the Disabilities of the Arm, Shoulder and Hand (DASH) score. RESULTS Function of the upper extremity was improved in all patients. DASH scores improved from 61.2 points pre-operatively to 12 points at final follow-up. All nonunions were united uneventfully. CONCLUSIONS Following debridement of the necrotic tissue, the bone defect can be filled with a vascularized graft from posterior interosseous pedicles. Pedicled PIBF is a safe and useful novel technique in cases of atrophic or hypertrophic nonunion of the middle third of the radius or proximal two-thirds of the ulna.
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Affiliation(s)
- Reza Shahryar Kamrani
- Department of Orthopedic and Trauma Surgery, Shariati Hospital, Tehran University of Medical Sciences, Kargar Shomali Street, Tehran, Iran.
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Calori GM, Colombo M, Mazza E, Ripamonti C, Mazzola S, Marelli N, Mineo GV. Monotherapy vs. polytherapy in the treatment of forearm non-unions and bone defects. Injury 2013; 44 Suppl 1:S63-9. [PMID: 23351875 DOI: 10.1016/s0020-1383(13)70015-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determinate the efficacy of "polytherapy", a surgical technique that utilize all the components of the diamond concept (mesenchymal stem cells, bone morphogenetic proteins and scaffold) versus a "monotherapy", a surgical technique that utilize only one component of the diamond conceptin the treatment of severe forearm non-unions. METHODS We studied a database of 52 patients with 52 forearm non-unions; we classified the patients with the NUSS SCORE and we divided the patients in two group according to the treatment received. So we distinguished a group of patients treated according to the principles of "monotherapy" (33 patients) and a group of patients treated according to the principles of "polytherapy" (19 patients). The minimum follow up was 12 months. RESULTS In the monotherapy group 21/33 non-unions (63.64%) went on to develop a radiographic and clinical healing within a period of 12 months, the calculated DASH SCORE showed a mean value of 55.15 points. In the polytherapy group 17/19 (89.47%) nonunions went on to develop clinical and radiographic healing within 12 months, and the average DASH score showed a mean value of 45.47 points. CONCLUSION The polytherapy technique with the use of recombinant morphogenetic proteins, autologous MSCs and scaffold in the same surgical time appears to be an effective treatment for patients with severe forearm non-unions.
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Affiliation(s)
- G M Calori
- Reparative Orthopaedic Surgery Department, G. Pini Institute, University of Milan, Milan, Italy.
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Capo JT, Marcus MS, Shamian B. Treatment of a segmental defect in open radial and ulnar shaft fractures using rhBMP-2 and iliac crest bone graft: a case report. Hand (N Y) 2011. [PMID: 23204971 PMCID: PMC3213260 DOI: 10.1007/s11552-011-9348-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- John T. Capo
- Division of Hand and Microvascular Surgery, Department of Orthopaedics, UMDNJ-New Jersey Medical School, 90 Bergen Street, DOC 1200, Newark, NJ 07103 USA
| | - Matthew S. Marcus
- Division of Hand and Microvascular Surgery, Department of Orthopaedics, UMDNJ-New Jersey Medical School, 90 Bergen Street, DOC 1200, Newark, NJ 07103 USA
| | - Ben Shamian
- Division of Hand and Microvascular Surgery, Department of Orthopaedics, UMDNJ-New Jersey Medical School, 90 Bergen Street, DOC 1200, Newark, NJ 07103 USA
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Kloen P, Buijze GA, Ring D. Management of forearm nonunions: current concepts. Strategies Trauma Limb Reconstr 2011; 7:1-11. [PMID: 22113538 PMCID: PMC3332319 DOI: 10.1007/s11751-011-0125-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2011] [Accepted: 11/10/2011] [Indexed: 11/24/2022] Open
Abstract
Forearm nonunions are uncommon but severely disabling and challenging to treat. Multiple factors have been associated with the establishment of forearm nonunions such as fracture location and complexity, patient characteristics and surgical technique. Treatment of diaphyseal forearm nonunions differs from that of other type of diaphyseal nonunions because of the intimate relationship between the radius and ulna and their reciprocal movement. There is a wide variation of surgical techniques, and the optimal choice of management remains subject to debate. In this review, we aim to summarize the available evidence in the literature on forearm nonunions and combine it with practical recommendations based on our clinical experience to help guide the management of this complex problem.
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Affiliation(s)
- Peter Kloen
- Department of Orthopaedic Surgery, Academic Medical Center, Meibergdreef 9, 1100 DD, Amsterdam, The Netherlands,
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20
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Faldini C, Miscione MT, Acri F, Chehrassan M, Bonomo M, Giannini S. Use of homologous bone graft in the treatment of aseptic forearm nonunion. Musculoskelet Surg 2011; 95:31-5. [PMID: 21442290 DOI: 10.1007/s12306-011-0117-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2011] [Accepted: 03/14/2011] [Indexed: 12/28/2022]
Abstract
The dyaphyseal nonunion of forearm bones is a complication that changes the normal interaction between radius and ulna, which may lead to forearm malfunction. We reviewed 14 patients treated by surgical technique included a homologous bone graft in combination with a plate. The mean age was 31 years (range, 18-45 years) at the time of surgery. Minimum follow-up was 2 years (mean, 5 years; range, 2-13 years). There were no intraoperative or postoperative complications. At last follow-up, all forearm bones had remodelled. The mean visual analogue pain scale was 1 (range, 0-4). There was a high success rate regarding forearm alignment and functional results; all patients recovered daily and working activities quickly. This surgical technique in treatment of aseptic forearm nonunion by combining homologous bone graft with a plate led to bone healing, improved forearm function, and a durable outcome with long-term follow-up.
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Affiliation(s)
- C Faldini
- Istituto Ortopedico Rizzoli, University of Bologna, Via G.C. Pupilli 1, 40136 Bologna, Italy.
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Abstract
BACKGROUND There are no reported series that specifically deal with repair of infected nonunions of the diaphysis of the forearm bones. We sought to determine whether a standardized treatment protocol we have utilized for 15 patients from 1989 to 2005 results in a high union rate, resolution of infection, and a good functional outcome. METHODS The study cohort included nine male and six female patients who presented to a University hospital setting with an infected nonunion of the diaphysis of the radius or ulna. Every patient had a minimum of 2-year follow-up. The average patient age was 45 years (range 17-79). Eight of the patients had fractures involving their dominant arm. Thirteen patients had initially fractured both the radius and ulna, but two of these patients had subsequently healed one of the bones. One patient had an isolated radius fractures, and one patient fractured the ulna alone. All patients underwent a protocol that combines aggressive surgical debridements as necessary, definitive fixation after 7-14 days, tricortical iliac crest bone grafting for segmental defects, leaving wounds open to heal by secondary intention, 6 weeks of culture-specific intravenous antibiotics, and early active range of motion (ROM) exercises. We sought to report our success rate of nonunion repair, number of re-interventions, complication rate, final ROM, and the ability to eradicate the infection using this treatment regimen. RESULTS At most recent follow-up (average 5 years, range 2-15 years), all patients had united and resolved their infections. One case was considered a failure, although he did go on to unite a one-bone forearm and was free of infection at most recent follow-up. All but three patients, including the one failure, had at least 50 degrees of supination/pronation and 30-130 degrees of flexion/extension arc. Excluding the one failure that united his one-bone forearm at 46 months, the average time to union was 13.2 weeks (range 10-15 weeks). CONCLUSIONS The results of this study indicate that our standard protocol for treatment of infected nonunion of the shafts of the radius and ulna is reliable at obtaining fracture union with a good functional result, while also resolving the infection.
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Abstract
BACKGROUND The management of an atrophic nonunion with a gap following a fracture of the radius and/or ulna is a challenging problem. Various methods of treatment available in the literature are cortical tibial graft (Boyd), ulnar segment graft (Miller and Phalen), iliac crest graft (Spira), cancellous insert graft (Nicoll), vascularized fibular graft (Jupiter), and bone transport by ring fixator (Tesworth). The present study reports the results of tricorticocancellous bone block grafts using modified Nicoll's technique, in diaphyseal defects of forearm bones. MATERIALS AND METHODS A total of 38 forearm bones (either radius or ulna or both) in 23 patients with a gap of 1.5-7.5 cm were treated by debridement and tricorticocancellous bone block graft under compression with intramedullary nail fixation between June 1985 and June 2005. There were 15 male and 8 female patients. Sixteen patients had open and seven patients had closed fractures initially. Time of presentation since the original injury varied from 9 months to 84 months. Eighteen patients had already undergone one to three operations. RESULTS Thirty-six bones showed union at both host graft junctions. The mean duration of union was 17.5 weeks (range, 14-60 weeks). Two bones had union only at one host graft junction and did not show any evidence of callus formation up to 9 months on the other end, hence requiring subsequent procedure in the form of phemister bone grafting. Patients were followed for a minimum period of 2 years (range, 2-7 years). Results were based on the status of union and range of motion (ROM) for elbow/wrist and grip strength at the final follow-up. Complications observed were the reactivation of infection (n = 1) and herniation of the muscles at the donor site (n = 1). CONCLUSION The tricorticocancellous strut bone grafting under optimal compression, augmented with intramedullary fixation, provides a promising solution to difficult problem of an atrophic nonunion of forearms bones with gap.
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Affiliation(s)
- Dinesh K Gupta
- Department of Orthopaedics, MLB Medical College, Jhansi, Uttar Pradesh, India,Address for correspondence: Dr. DK Gupta, H 7/8, Veerangana Nagar, JDA Colony, Kanpur Road, Jhansi, Uttar Pradesh – 284 128, India. E-mail:
| | - Gaurav Kumar
- Department of Orthopaedics, Jhansi Orthopaedic Hospital and Research Centre, Jhansi, Uttar Pradesh, India
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Kloen P, Wiggers JK, Buijze GA. Treatment of diaphyseal non-unions of the ulna and radius. Arch Orthop Trauma Surg 2010; 130:1439-45. [PMID: 20217106 PMCID: PMC2991229 DOI: 10.1007/s00402-010-1071-x] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2009] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Non-unions of the forearm often cause severe dysfunction of the forearm as they affect the interosseus membrane, elbow and wrist. Treatment of these non-unions can be challenging due to poor bone stock, broken hardware, scarring and stiffness due to long-term immobilisation. METHOD We retrospectively reviewed a large cohort of forearm non-unions treated by using a uniform surgical approach during a period of 33 years (1975-2008) in a single trauma centre. All non-unions were managed following the AO-principles of compression plate fixation and autologous bone grafting if needed. PATIENTS The study cohort consisted of 47 patients with 51 non-unions of the radius and/or ulna. The initial injury was a fracture of the diaphyseal radius and ulna in 22 patients, an isolated fracture of the diaphyseal ulna in 13, an isolated fracture of the diaphyseal radius in 5, a Monteggia fracture in 5, and a Galeazzi fracture-dislocation of the forearm in 2 patients. Index surgery for non-union consisted of open reduction and plate fixation in combination with a graft in 30 cases (59%), open reduction and plate fixation alone in 14 cases (27%), and only a graft in 7 cases (14%). The functional result was assessed in accordance to the system used by Anderson and colleagues. RESULTS Average follow-up time was 75 months (range 12-315 months). All non-unions healed within a median of 7 months. According to the system of Anderson and colleagues, 29 patients (62%) had an excellent result, 8 (17%) had a satisfactory result, and 10 (21%) had an unsatisfactory result. Complications were seen in six patients (13%). CONCLUSION Our results show that treatment of diaphyseal forearm non-unions using classic techniques of compression plating osteosynthesis and autologous bone grafting if needed will lead to a high union rate (100% in our series). Despite clinical and radiographic bone healing, however, a substantial subset of patients will have a less than optimal functional outcome.
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Affiliation(s)
- Peter Kloen
- Department of Orthopaedic Surgery, Academic Medical Centre, Meibergdreef 9, 1100 DD Amsterdam, The Netherlands
| | - Jim K. Wiggers
- Department of Orthopaedic Surgery, Academic Medical Centre, Meibergdreef 9, 1100 DD Amsterdam, The Netherlands
| | - Geert A. Buijze
- Department of Orthopaedic Surgery, Academic Medical Centre, Meibergdreef 9, 1100 DD Amsterdam, The Netherlands
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Abstract
With current operative techniques, it is rare that treatment of diaphyseal forearm fractures results in nonunion. Because the rate of nonunion is low, there are only a few published articles that help guide management of forearm nonunions. We describe a new application of wave plate osteosynthesis in the treatment of isolated atrophic nonunions of the ulna. This biologic plating concept restores anatomic alignment without standard rigid fixation and aims to take advantage of the vascularity of the surrounding soft tissues to achieve union by secondary healing. This technique can be most useful in nonunions secondary to segmental bone defects or to large areas of nonviable bone.
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Faldini C, Pagkrati S, Nanni M, Menachem S, Giannini S. Aseptic forearm nonunions treated by plate and opposite fibular autograft strut. Clin Orthop Relat Res 2009; 467:2125-34. [PMID: 19350333 PMCID: PMC2706359 DOI: 10.1007/s11999-009-0827-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2008] [Accepted: 03/23/2009] [Indexed: 01/31/2023]
Abstract
UNLABELLED Forearm nonunion frequently changes the relationship between the radius and ulna and may lead to impairment of forearm function. We propose a new surgical technique for aseptic forearm nonunions combining a fibular cortical autograft strut with a metal plate and a fibular intercalary autograft in cases with a segmental bone defect. We retrospectively reviewed 20 patients with a mean age of 31 years (range, 17-48 years) at the time of surgery. Minimum followup was 12 years (mean, 14 years; range, 12-21 years). There were no intraoperative or postoperative complications. At last followup, all forearm bones had remodeled. The mean visual analog pain scale was 1 (range, 0-3). Forearm function improved; there were no radiographic signs of ankle arthritis at followup. Surgical treatment of aseptic forearm nonunions by combining a massive fibular cortical autograft strut with a plate and associating a fibular intercalary autograft in case of a segmental bone defect led to bone healing, improved forearm function, and a durable outcome with long-term followup. LEVEL OF EVIDENCE Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Cesare Faldini
- Department of Orthopaedic and Trauma Surgery, Istituto Ortopedico Rizzoli, Segreteria Università, University of Bologna, Via GC Pupilli 1, 40136 Bologna, Italy
| | - Stavroula Pagkrati
- Department of Orthopaedic and Trauma Surgery, Istituto Ortopedico Rizzoli, Segreteria Università, University of Bologna, Via GC Pupilli 1, 40136 Bologna, Italy
| | - Matteo Nanni
- Department of Orthopaedic and Trauma Surgery, Istituto Ortopedico Rizzoli, Segreteria Università, University of Bologna, Via GC Pupilli 1, 40136 Bologna, Italy
| | - Shay Menachem
- Department of Orthopaedic and Trauma Surgery, Istituto Ortopedico Rizzoli, Segreteria Università, University of Bologna, Via GC Pupilli 1, 40136 Bologna, Italy
| | - Sandro Giannini
- Department of Orthopaedic and Trauma Surgery, Istituto Ortopedico Rizzoli, Segreteria Università, University of Bologna, Via GC Pupilli 1, 40136 Bologna, Italy
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dos Reis FB, Faloppa F, Fernandes HJA, Albertoni WM, Stahel PF. Outcome of diaphyseal forearm fracture-nonunions treated by autologous bone grafting and compression plating. ANNALS OF SURGICAL INNOVATION AND RESEARCH 2009; 3:5. [PMID: 19450257 PMCID: PMC2694823 DOI: 10.1186/1750-1164-3-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/18/2008] [Accepted: 05/18/2009] [Indexed: 01/14/2023]
Abstract
Background The treatment of forearm fracture-nonunions continues to represent a therapeutic challenge, and reported outcomes are moderate at best. Limiting aspects of this particular anatomic location include the relation between restoration of shaft length with the anatomy and long-term functional outcome of adjacent joints, as well as the risk of elbow and wrist stiffness related to prolonged immobilization. The present study was designed to assess the outcome of autologous bone grafting with compression plating and early functional rehabilitation in patients with forearm fracture non-unions. Methods Prospective follow-up study in 31 consecutive patients presenting with non-unions of the forearm diaphysis (radius, n = 11; ulna, n = 9; both bones, n = 11). Surgical revision was performed by restoring anatomic forearm length by autologous bone grafting of the resected non-union from the iliac crest and compression plating using a 3.5 mm dynamic compression plate (DCP) or limited-contact DCP (LC-DCP). The main outcome parameters consisted of radiographic bony union and functional outcome, as determined by the criteria defined by Harald Tscherne in 1978. Patients were routinely followed on a short term between 6 weeks to 6 months, with an average long-term follow-up of 3.6 years (range 2 to 6 years). Results Radiographically, a bony union was achieved in 30/31 patients within a mean time of 3.5 months of revision surgery (range 2 to 5 months). Clinically, 29/31 patients showed a good functional outcome, according to the Tscherne criteria, and 26/31 patients were able to resume their previous work. Two postoperative infections occurred, and one patient developed a persistent infected nonunion. No case of postoperative failure of fixation was seen in the entire cohort. Conclusion Revision osteosynthesis of forearm nonunions by autologous iliac crest bone grafting and compression plating represents a safe and efficacious modality for the treatment of these challenging conditions.
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Affiliation(s)
- Fernando Baldy dos Reis
- Department of Orthopaedics and Traumatology, Federal University of Sao Paulo (UNIFESP), Sao Paulo, Brazil.
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Nonunion of a Pediatric Distal Radial Metaphyseal Fracture Following Open Reduction and Internal Fixation : A Case Report and Review of the Literature. Eur J Trauma Emerg Surg 2008; 34:173-6. [PMID: 26815625 DOI: 10.1007/s00068-007-6168-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2006] [Accepted: 05/21/2007] [Indexed: 10/23/2022]
Abstract
A boy, age 9, presented with deformation and pain of the left distal forearm, 1 year after a plate osteosynthesis for a distal radial metaphyseal fracture. This case showed a pediatric nonunion of a distal radial metaphyseal fracture which caused strong deformation of the left distal forearm. This is an extremely rare complication in children following an open reduction and internal fixation for a displaced distal forearm fracture. Key points of pediatric fracture healing are discussed and a review of the literature is given.
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Abstract
Modern techniques allow for high rates of union in the treatment of diaphyseal forearm fractures. In the case of nonunion, addressing the biology and stability of the fracture will similarly yield high union rates, but slightly decreased functional outcomes. Malunion of forearm fractures typically results in loss of range of motion and grip strength. Restoration of the anatomical relationships of the forearm yields functional results. Understanding and recreating the anatomy of the forearm is the key to obtaining good functional outcomes.
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Affiliation(s)
- Marc J Richard
- Division of Orthopaedic Surgery, Duke University Medical Center, Durham, NC 27710, USA
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Hong G, Cong-Feng L, Hui-Peng S, Cun-Yi F, Bing-Fang Z. Treatment of diaphyseal forearm nonunions with interlocking intramedullary nails. Clin Orthop Relat Res 2006; 450:186-92. [PMID: 16523119 DOI: 10.1097/01.blo.0000214444.87645.75] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
UNLABELLED Fifteen patients with 26 nonunions of diaphyseal forearm fractures were treated with interlocking intramedullary nails and iliac bone grafts. The purpose of our study was to evaluate the rate of successful healing and complications that developed after using this technique. The mean followup was 31 months (range, 25-38 months). The average length of bone loss after freshening the bone ends was 20 mm (range, 10-30 mm). Radiographic union was achieved in 14 patients (96%). Compared with the uninjured contralateral arm, the mean loss of flexion and extension motion at the wrist was 27 degrees. The mean loss of the arc of motion at the elbow was 18 degrees, and the mean loss of rotation of the forearm was 39 degrees. In seven patients, the amount and location of the maximum radial bow on the injured side were significantly different from those of the contralateral arm. Using the rating system of Anderson et al, two patients (13%) had excellent results, six patients (40%) had satisfactory results, six patients (40%) had unsatisfactory results, and one patient (7%) had a failed result. The mean Disabilities of the Arm and Shoulder Score was 35 points (range, 16-56 points), indicating moderate residual impairment. There were three postoperative complications (an incidence of 12%). Our results showed that interlocking intramedullary nailing of nonunions of the diaphysis of the radius or ulna with an open reaming technique should not be considered an adequate alternative to plate fixation of these injuries. LEVEL OF EVIDENCE Therapeutic study, Level IV (case series no, historical control group).
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Affiliation(s)
- Gao Hong
- Department of Orthopaedic Surgery, Shanghai Sixth People's Hospital, Jiaotong University, 600 Yishan Road, Shanghai 200233, People's Republic of China.
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Ring D, Allende C, Jafarnia K, Allende BT, Jupiter JB. Ununited diaphyseal forearm fractures with segmental defects: plate fixation and autogenous cancellous bone-grafting. J Bone Joint Surg Am 2004. [PMID: 15523016 DOI: 10.2106/00004623-200411000-00013] [Citation(s) in RCA: 90] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND With current techniques of plate-and-screw fixation, diaphyseal nonunions of the radius and ulna are unusual. The few reports that have been published have discussed the use of structural corticocancellous bone grafts for the treatment of atrophic nonunions that are associated with osseous defects. We reviewed the rate of union and the functional results in association with the use of plate-and-screw fixation and autogenous cancellous (nonstructural) bone grafts. METHODS Thirty-five patients with an atrophic ununited diaphyseal fracture of the forearm were treated with 3.5-mm plate-and-screw fixation and autogenous cancellous bone-grafting. A segmental osseous defect with an average size of 2.2 cm (range, 1 to 6 cm) was present in each patient. Twenty of the original fractures had been open. Eleven patients had had treatment of a deep infection before referral to us. The nonunion involved both forearm bones in eight patients, the radius alone in sixteen patients, and the ulna alone in eleven patients. RESULTS The atrophic nonunion was associated with an open fracture in twenty patients, suboptimal fixation in twenty-two, a fracture-dislocation of the forearm in nine, and infection in eleven. All fractures healed without additional intervention within six months. Two patients had a subsequent Darrach resection of the distal part of the ulna for the treatment of arthrosis of the distal radioulnar joint. After an average duration of follow-up of forty-three months, the final arc of motion averaged 121 degrees in the forearm, 131 degrees at the elbow, and 137 degrees at the wrist, with an average grip strength of 83% compared with that of the contralateral limb. According to the system of Anderson and colleagues, five patients had an excellent result, eighteen had a satisfactory result, eleven had an unsatisfactory result (because of elbow stiffness related to associated elbow injuries in three and because of wrist stiffness in eight), and one had a poor result (because of malunion). CONCLUSIONS When the soft-tissue envelope is compliant, has limited scar, and consists largely of healthy muscle with a good vascular supply, autogenous cancellous bone-grafting and stable internal plate fixation results in a high rate of union and improved upper limb function in patients with diaphyseal nonunion of the radius and/or ulna.
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Affiliation(s)
- David Ring
- Department of Orthopaedic Surgery, Massachusetts General Hospital, ACC 525, 15 Parkman Street, Boston, MA 02114, USA.
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Abstract
BACKGROUND The optimal management for ulnar shaft fractures remains debatable. Investigators have advocated nonoperative management as well as internal fixation of these fractures. OBJECTIVE The primary objective of this study was to determine the effect of alternative management strategies of fractures of the ulnar shaft on rates of union, infection, and functional outcomes. A secondary objective was to examine outcomes after alternative strategies in managing patients with bone defects.
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Affiliation(s)
- Mohit Bhandari
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada.
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Adani R, Delcroix L, Innocenti M, Marcoccio I, Tarallo L, Celli A, Ceruso M. Reconstruction of large posttraumatic skeletal defects of the forearm by vascularized free fibular graft. Microsurgery 2004; 24:423-9. [PMID: 15378573 DOI: 10.1002/micr.20067] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Vascularized bone graft is most commonly applied for reconstruction of the lower extremity; indications for its use in the reconstruction of the upper extremity have expanded in recent years. Between 1993-2000, 12 patients with segmental bone defects following forearm trauma were managed with vascularized fibular grafts: 6 males and 6 females, aged 39 years on average (range, 16-65 years). The reconstructed site was the radius in 8 patients and the ulna in 4. The length of bone defect ranged from 6-13 cm. In 4 cases, the fibular graft was harvested and used as a vascularized fibula osteoseptocutaneous flap. To achieve fixation of the grafted fibula, plates were used in 10 cases, and screws and Kirschner wires in 2. In the latter 2 cases, an external skeletal fixator was applied to ensure immobilization of the extremity. The follow-up period ranged from 10-93 months. Eleven grafts were successful. The mean period to obtain radiographic bone union was 4.8 months (range, 2.5-8 months). Fibular grafts allow the use of a segment of diaphyseal bone which is structurally similar to the radius and ulna and of sufficient length to reconstruct most skeletal defects of the forearm. The vascularized fibular graft is indicated in patients with intractable nonunions where conventional bone grafting has failed or large bone defects, exceeding 6 cm, are observed in the radius or ulna.
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Affiliation(s)
- Roberto Adani
- Department of Orthopaedic Surgery, University of Modena and Reggio Emilia Policlinico, Largo del Pozzo n. 71, 41100 Modena, Italy. adani.roberto@ unimo.it
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Baltzer AW, Lattermann C, Whalen JD, Wooley P, Weiss K, Grimm M, Ghivizzani SC, Robbins PD, Evans CH. Genetic enhancement of fracture repair: healing of an experimental segmental defect by adenoviral transfer of the BMP-2 gene. Gene Ther 2000; 7:734-9. [PMID: 10822299 DOI: 10.1038/sj.gt.3301166] [Citation(s) in RCA: 194] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
This study evaluated the ability of gene transfer to enhance bone healing. Segmental defects were created surgically in the femora of New Zealand white rabbits. First generation adenoviruses were used as vectors to introduce into the defects genes encoding either human bone morphogenetic protein-2 (BMP-2) or, as a negative control, firefly luciferase. Representative specimens were evaluated histologically after 8 weeks. Healing of the defects was monitored radiographically for 12 weeks, after which time the repair tissue was evaluated biomechanically. By radiological criteria, animals receiving the BMP-2 gene had healed their osseous lesions after 7 weeks, whereas those receiving the luciferase gene had not. Histologic examination of representative rabbits at 8 weeks confirmed ossification across the entire defect in response to the BMP-2 gene, whereas the control defect was predominantly fibrotic and sparsely ossified. At the end of the 12-week experiment, the control femora still showed no radiological signs of stable healing. The difference in radiologically defined healing between the experimental and control groups was statistically significant (P < 0. 002). Biomechanical testing of the femora at 12 weeks demonstrated statistically significant increases in the mean bending strength (P < 0.005) and bending stiffness (P < 0.05) of the animals treated with the BMP-2 gene. Direct, local adenoviral delivery of an osteogenic gene thus led to the healing of an osseous lesion that otherwise would not do so. These promising data encourage the further development of genetic approaches to enhancing bone healing. Gene Therapy (2000) 7, 734-739.
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Affiliation(s)
- A W Baltzer
- Department of Orthopaedic Surgery, Heinrich Heine University of Düsseldorf, Germany
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