Management of forearm nonunions: current concepts

Exposed Intramedullary Fixation Produces Similar Outcomes to Buried Fixation for Acute Pediatric Monteggia Fractures

BACKGROUND

Treatment of acute pediatric Monteggia fractures requires ulnar length stability to maintain reduction of the radiocapitellar joint. When operative care is indicated, intramedullary ulna fixation can be buried or left temporarily exposed through the skin while under a cast. The authors hypothesized that treatment with exposed fixation yields equivalent results to buried fixation for Monteggia fractures while avoiding secondary surgery for hardware removal.

METHODS

A retrospective review of children with acute Monteggia fractures at our Level 1 pediatric trauma center was performed. Patient charts and radiographs were evaluated for age, fracture type, fracture location, Bado classification, type of treatment, complications, cast duration, time to fracture union, time to hardware removal, and range of motion.

RESULTS

Out of 59 acute Monteggia fractures surgically treated (average age 6 y, range 2 to 14), 15 (25%) patients were fixed with buried intramedullary fixation and 44 (75%) with exposed intramedullary fixation under a cast. There were no significant differences between buried and exposed intramedullary fixation in cast time after surgery (39 vs. 37 d; P =0.55), time to fracture union (37 vs. 35 d; P =0.67), pronation/supination (137 vs. 134 degrees; P =0.68) or flexion/extension (115 vs. 114 degrees; P =0.81) range of motion. The exposed fixation had a return to OR of 4.5% (2 out of 44), and the buried fixation returned to the OR for removal on all patients.

CONCLUSION

Exposed intramedullary fixation yielded equivalent clinical outcomes to buried devices in the treatment of acute pediatric Monteggia fractures while eliminating the need for a second surgery to remove hardware, reducing the associated risks and costs of surgery and anesthesia, but had a higher complication rate. Open Monteggia fractures or patterns with a known risk of delayed union may benefit from buried instead of exposed intramedullary fixation for earlier mobilization.

LEVEL OF EVIDENCE

III.

Vascularized Ulnar Periosteal Pedicled Flap for Upper Extremity Reconstruction in Adults: A Prospective Case Series of 11 Patients

PURPOSE

We hypothesized that a vascularized ulnar periosteal pedicled flap (VUPPF) is a versatile graft applicable in adult patients that yields good outcomes and is a reliable alternative to other vascularized bone grafts to reduce both the technical demands and donor site morbidity of other options.

METHODS

We reviewed 11 adult patients who underwent surgical treatment of forearm atrophic nonunion with a VUPPF. Patients' demographics, outcomes (measured by pain on the visual analog scale; Quick Disabilities of the Arm, Shoulder, and Hand score; range of motion; and grip strength), and associated complications were reported.

RESULTS

Of the 11 patients, 5 had previous surgery in an attempt to treat the nonunion with an autologous cancellous bone graft from the iliac crest or olecranon. The average time from nonunion until the VUPPF was 9 months (SD, ±3 months; range, 6-14 months). The mean visual analog scale score improved considerably after surgery (8.7 vs 0.6), and considerable improvement was also noted in the Quick Disabilities of the Arm, Shoulder, and Hand score (50 vs 6). A notable improvement was seen in grip strength after surgery. Pronation/supination also improved considerably between the preoperative assessment and the final postoperative follow-up.

CONCLUSIONS

A vascularized ulnar periosteal pedicled flap seems to be a useful and versatile option for a variety of bone union failures of the upper extremity in adults, either at initial presentation or as a salvage technique.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Forearm segmental bone defect: Successful management using the Masquelet Technique with the aid of 3D printing technology

The management of forearm nonunion is challenging for orthopaedic surgeons because the forearm is a unique anatomical segment in which all the bones and structures involved embody a complex functional unit. Therefore, when treating such a complex condition, the surgeon must focus not only on bone healing but also on the restoration of the native anatomy in order to replicate the normal relationship between the bones and all the surrounding structures and thus the full function of the forearm, the elbow and the wrist.

Here we report the case of a 53-year-old patient with a left forearm deformity due to an atrophic nonunion of the ulna and a malunion of the radius, which was successfully managed with the use of the Masquelet technique associated with a corrective osteotomy of the radius, performed with the aid of a 3D model.

Biodegradable Zn-Sr alloy for bone regeneration in rat femoral condyle defect model: In vitro and in vivo studies

Bone defects are commonly caused by severe trauma, malignant tumors, or congenital diseases and remain among the toughest clinical problems faced by orthopedic surgeons, especially when of critical size. Biodegradable zinc-based metals have recently gained popularity for their desirable biocompatibility, suitable degradation rate, and favorable osteogenesis-promoting properties. The biphasic activity of Sr promotes osteogenesis and inhibits osteoclastogenesis, which imparts Zn-Sr alloys with the ideal theoretical osteogenic properties. Herein, a biodegradable Zn-Sr binary alloy system was fabricated. The cytocompatibility and osteogenesis of the Zn-Sr alloys were significantly better than those of pure Zn in MC3T3-E1 cells. RNA-sequencing illustrated that the Zn-0.8Sr alloy promoted osteogenesis by activating the wnt/β-catenin, PI3K/Akt, and MAPK/Erk signaling pathways. Furthermore, rat femoral condyle defects were repaired using Zn-0.8Sr alloy scaffolds, with pure Ti as a control. The scaffold-bone integration and bone ingrowth confirmed the favorable in vivo repair properties of the Zn-Sr alloy, which was verified to offer satisfactory biosafety based on the hematoxylin-eosin (H&E) staining and ion concentration testing of important organs. The Zn-0.8Sr alloy was identified as an ideal bone repair material candidate, especially for application in critical-sized defects on load-bearing sites due to its favorable biocompatibility and osteogenic properties in vitro and in vivo.

Characteristics, Treatments, and Outcomes of Tibial Plateau Nonunions: A Systematic Review

BACKGROUND

Due to the rare incidence of tibial plateau nonunions, current studies are limited to small sample sizes and patient demographics. The aim of this systematic review is to quantify and report patient and fracture traits, possible risk factors, and treatment outcomes of tibial plateau nonunions.

METHODS

PubMed, Clinical Key, and MEDLINE were searched for articles published prior to August 2020 in accordance to the preferred reporting items for systematic reviews and meta-analyses (PRISMA). The authors used varying combinations of the following terms to identify relevant articles: "tibial," "plateau," "nonunion," "non-union." Studies were assessed for patient demographics, pre-revision nonunion characteristics, treatment, and post-revision outcomes.

RESULTS

Eight studies were included, yielding 31 tibial plateau nonunions (21 males, 10 females). The majority of nonunions were associated with high energy trauma (52.2%) and were Schatzker class VI (54.8%). Schatzker class I and II nonunions were not attributed to neglect, contradicting previous suggestions. Time to union was 4.0 months, the most common treatments being autologous bone grafting (76.7%) and revision plating (63.3%).

CONCLUSION

This study demonstrates the effectiveness of autologous bone grafts and revision plating for tibial plateau nonunions. Physicians may use these findings to guide decision making in the event of high energy plateau nonunions. Lastly, various limitations exist within the current literature, emphasizing the need for standardized reporting measures.

Percutaneous injection of platelet-rich plasma to treat atrophic nonunion after internal fixation of ulnar fracture: a case report

Non-union is a serious postoperative complication of fracture. Early detection and intervention can avoid revision surgery. Platelet-rich plasma releases many active tissue factors and has potential to promote fracture healing. Percutaneous injection of platelet-rich plasma at the fracture site may avoid surgical treatment when non-union occurs. We present a case of atrophic non-union of an ulna fracture treated conservatively with percutaneous injection of platelet-rich plasma.

A novel technique of ulna strut grafting for post-septic radial clubhand deformity: Case series of 4 patients with review of literature

BACKGROUND

Though distal end radius fractures are one of the commonest fractures to occur, their nonunions are extremely uncommon. Out of these, post-septic defect nonunions with acquired radial clubhand deformity are even more rare and pose unique problems in management. We present a case series of 4 patients of post-septic radius nonunion with acquired radial clubhand deformity successfully treated with a novel technique of using Ulna Strut grafting for radius defect after ulnar shortening. All 4 patients have a good functional and cosmetic outcomes with radiological union at the cost of minimal limb length discrepancy of the forearm.

METHODS

This is a case series of 4 patients with a retrospective study design and study duration of 3 years from August 2016 till March 2019.4 patients presenting to us with post-septic defect nonunions of radius with an acquired radial clubhand deformity were selected with a mean age of 19.75 years which included 2 males and 2 females.

RESULTS

The mean time for radiological union was 3.125 months. The average range of motion at the wrist joint was 35° of flexion and 50° of extension with average protonation being 47.5° and supination being 75°.There were no subsequent complications reported in these patients except for a minimal limb length discrepancy with satisfactory functional outcomes in all the patients.

CONCLUSION

The use of Ulnar shortening and Ulna strut grafting for the treatment of defect nonunions of radius with acquired clubhand deformity yielded predictable results. It is a simple procedure that does not require additional training, with no additional morbidity of iliac crest or fibula bone grafting and had a minimum complication rate. The technique looks promising in the future, though a study on a larger population would further strengthen the predictability of this unique technique.

Both Bone Forearm Infected Nonunion: Report of a One-Bone Free Fibula Flap Salvage and Literature Review

Background: Both bone forearm infective nonunions represent a rare but functionally limb threatening condition. Method: We report a successful salvage of a severe near total both bone diaphysial osteomyelitis by conversion to a one-bone forearm with free fibula flap. A literature review on forearm salvage addressing both bone defects was performed. Results: Bony union was achieved at 4 months with a highly functional extremity salvage in our case. Conclusion: While very little prior experience has been reported for long segmental both bone forearm infected nonunions, we report of this highly satisfactory salvage using one-bone free tissue transfer strategy. We also provided our literature review with history, indication and evolution of individualized treatment options for this difficult surgical condition.

Non-union: Indications for external fixation

External fixation is currently used as the definitive mode of fracture stabilisation in the management of ˜50% of long-bone non-unions. Distinction between non-union and delayed union is a diagnostic dilemma especially in fractures healing by primary bone repair. This distinction is important, as non-unions are not necessarily part of the same spectrum as delayed unions. The aetiology of a fracture non-union is usually multifactorial and the factors can be broadly categorized into mechanical factors, biological (local and systemic) factors, and infection. Infection is present in ˜40% of fracture non-unions, often after open fractures or impaired wound healing, but in 5% of all non-unions infection is present without any clinical or serological suspicion. General indications for external fixation include clinical scenarios where; 1) percutaneous correction of alignment, or mechanical stimulation of the non-union site is required; 2) fixation of juxta-articular or 'emmental' bone fragments is necessary; and 3) staged bone or soft tissue reconstruction is anticipated. Specific anatomical indications include infected non-unions of the tibia, humerus, and juxta-articular bone. External fixation is an essential tool in the management of fracture non-unions. However, with greater understanding of the outcomes associated with both external and internal fixation the relative indications are now being refined.

Wnt Pathway in Bone Repair and Regeneration - What Do We Know So Far

Wnt signaling plays a central regulatory role across a remarkably diverse range of functions during embryonic development, including those involved in the formation of bone and cartilage. Wnt signaling continues to play a critical role in adult osteogenic differentiation of mesenchymal stem cells. Disruptions in this highly-conserved and complex system leads to various pathological conditions, including impaired bone healing, autoimmune diseases and malignant degeneration. For reconstructive surgeons, critically sized skeletal defects represent a major challenge. These are frequently associated with significant morbidity in both the recipient and donor sites. The Wnt pathway is an attractive therapeutic target with the potential to directly modulate stem cells responsible for skeletal tissue regeneration and promote bone growth, suggesting that Wnt factors could be used to promote bone healing after trauma. This review summarizes our current understanding of the essential role of the Wnt pathway in bone regeneration and repair.

Management of Infected Nonunion of the Forearm by the Masquelet Technique

Purpose

Infected nonunion of the forearm bones is a challenge for the orthopedic surgeon on several fronts. The forearm itself is unique as the difficulties include the relation between restoration of shaft length with the anatomy and long-term functional outcome of adjacent joints, and the risk of elbow and wrist stiffness related to prolonged immobilization. The problem of infection is complex due to the presence of bone necrosis, segmental bone loss, sinus tract formation, fracture instability, and scar adhesion of the soft tissues. The ideal management method for these situations is still debated.

Materials and methods

We used the two-stage-induced membrane technique devised by Alain Masquelet for the management of these infected nonunion of 12 forearm bones.

Results

All 12 bones united uneventfully. The bones united in a period ranging from 6 to 12 months with a mean of 7.8 months.

Conclusion

Our results show that this technique addresses several of the challenges pertinent to the forearm nonunion simultaneously and results are uniformly predictable.

How to cite this article

Dhar SA, Dar TA, Mir NA. Management of Infected Nonunion of the Forearm by the Masquelet Technique. Strategies Trauma Limb Reconstr 2019;14(1):1–5.

Novel use of a trabecular metal spacer in the treatment of a long-standing ulnar fracture non-union

The use of trabecular metal (TM) implants in spine and joint surgery is well documented. However, their use has yet to be reported as an alternative to either allograft or autograft in the management of fracture non-unions. We present our experience in using a TM implant for treating a patient with a long-standing ulnar fracture non-union. Excision of devitalised bone resulted in a 17 mm defect which the TM implant was used to infill. The defect was then bridged with a locking plate. At 2-year clinical and radiographic review, bony union and a pain-free return to full function was noted. In this case, the use of a TM implant avoided the morbidity associated with an iliac crest autograft.

Treatment of Radial Nonunion with Corticocancellous Bone Graft and Fascia of Anterolateral Thigh Free Flap: The Wrap Technique

Supplemental Digital Content is available in the text.

The management of nonunion of the forearm bones is a challenging task. Multiple factors have been associated with the establishment of forearm nonunion, such as the fracture position and complexity, general condition of the patient, and the previously utilized surgical technique. The optimal surgical treatment of a bone gap remains a subject of discussion. Autogenous corticocancellous bone grafts and vascularized bone flaps have been used with differing results. The authors describe a technique for the treatment of posttraumatic nonunion of the radius with a 5-cm bone gap using the free anterolateral thigh fascial flap wrapped around a tricortical iliac bone graft. The fracture healed after 5 weeks. The use of a vascularized tissue wrapped around the bone graft resulted in a well-healed bone and no signs of resorption after 2 years of follow-up. A bone graft wrapped by a fascial flap could magnify the restorative effect on the bone defect because of its dual role of constructing vascularization and inducing tissue regeneration.

The missing effect of human recombinant Bone Morphogenetic Proteins BMP-2 and BMP-7 in surgical treatment of aseptic forearm nonunion

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.

Infected Gap Non Union of Radius Treated with Modified Nicoll's Technique-A Case Report

Management of atrophic non union of forearm bones is a challenging task. 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). We here report a case of infected non union of radius managed with modified Nicoll's method. Here, intra medullary nailing is preferred over plating which was originally described by Nicoll. At two years follow up, the patient is symptom free and is able to carry out his daily activities with ease.

Surgical treatment of aseptic forearm nonunion with plate and opposite bone graft strut. Autograft or allograft?

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.