Transarticular bony defects after trauma and sepsis: arthrodesis using vascularized fibular transfer

Distal Radius Nonunions: A Rare Entity?

Although distal radius fractures are common injuries, nonunion is extremely rare. Nonunion has been associated with increased metaphyseal comminution, concomitant distal ulna fracture, inadequate immobilization, and patient factors. Nonunion should be suspected in patients with persistent pain, limited range of motion, and worsening wrist deformity after wrist remobilization. Treatment selection depends on presence of infection, status of the radiocarpal and distal radioulnar joints, and type of prior surgical interventions. Multiple surgical techniques exist for managing distal radius nonunions including open reduction and internal fixation of the nonunion site with/without bone graft augmentation versus total wrist arthrodesis.

Wrist arthroplasty for treatment of infected distal radius nonunion using free vascularised proximal fibular bone graft

OBJECTIVE

Management of infected distal radius nonunion with a bone defect and radiocarpal and distal radio-ulnar joint arthritis is considered an orthopaedic challenge. Although several methods have been described but none provide a satisfactory solution. Free vascularised fibula bone graft constitutes a good option to eradicate the infection, correct the deformity, compensate for the shortening and maintain motion.

MATERIAL AND METHODS

This study included 15 cases with infected distal radius nonunion associated with bone defects. Nine cases were males and six were females. The average age of the patient was 20 years (range 8 - 60 years). The right wrist was involved in 10 patients and left was affected in 5 patients. Nine cases resulted from a motor vehicle accident, four cases after a firearm injury and two cases due to falling from a height. The average number of previous surgical procedures was three (range 2 -6). The principle of treatment was debridement, excision of distal radius and trimming of the proximal part of radius back to healthy bleeding bone, inserting the free vascularised proximal fibular bone graft to compensate the defect and fixation of the graft.

RESULTS

The procedure was successful in 13 of 15 cases. Bone union was achieved at an average of 4 months. No clinical evidence of osteomyelitis or or infection at final follow-up. Pain was completely relieved in all cases. Wrist joint range of motion averaged flexion 50˚, extension 45˚ and handgrip was the same as the normal site. Twelve cases out of 15 returned to their daily activities.

CONCLUSION

Free vascularised proximal fibula bone graft is a new indication for the treatment of an infected distal radius nonunion with a bone defect.

Traumatic Fibular Loss Managed with a Free Vascularized Fibular Graft: A Case Report

CASE

A 25-year-old man involved in a jet skiing accident experienced a traumatic excision of his distal fibula in conjunction with other lower extremity injuries. He subsequently underwent a reconstruction of his lateral malleolus using an ipsilateral free vascularized fibular graft (FVFG) from his proximal fibular shaft, resulting in a preserved and stabilized ankle joint at 1 year.

CONCLUSION

Traumatic distal fibular excision is a rare injury that can be successfully managed using an FVFG, with fusion of the distal syndesmosis and a symmetric ankle mortise observed at the 1-year follow-up.

The Anterolateral Thigh-Medial Femoral Condyle Chimeric Flow-through Flap for Posttraumatic Wrist Arthrodesis

Wrist arthrodesis in the setting of segmental bone loss can have high failure rates. Therefore, vascularized bone grafting has been advocated for select patients. Patients suffering concomitant large soft tissue loss present even greater challenge. To that end, we describe for the first time successful anterolateral thigh-medial femoral condyle chimeric flow-through flap for posttraumatic wrist arthrodesis and soft tissue coverage. This is a case report of a 19-year-old male laborer who suffered a large blast injury resulting in significant bone and soft tissue injury to the dominant right hand and wrist. After multiple debridements, there was a segmental bone defect from the distal radius and ulna to the metacarpal bases, as well as a 12×8 cm dorsal soft tissue defect. This was reconstructed with a anterolateral thigh-medial femoral condyle chimeric flow-through flap and concomitant wrist arthrodesis in a single stage. Besides a donor site thigh seroma, recovery was uneventful with clinical and radiographic evidence of fusion by >9 weeks postoperation.

Elbow arthrodesis for post-traumatic sequelae: surgical tactics using the Ilizarov frame

BACKGROUND

Surgical arthrodesis of the elbow joint is frequently unsuccessful and rarely performed. It is the purpose of this article to evaluate tactics and different constructs to achieve elbow arthrodesis (EA) using the Ilizarov apparatus in patients with post-traumatic nonreconstructable elbow sequelae.

METHODS

A consecutive series of 4 patients were treated between 2009 and 2013 (3 men and 1 woman; mean age, 46.7 [35-75] years). Two patients had late complications in total elbow replacement and developed nonunion after condylar fractures of the distal humerus. There were 3 ulnohumeral arthrodeses and 1 radiohumeral arthrodesis. The hybrid advanced Ilizarov technique was used in all cases.

RESULTS

Complete union was obtained in 3 EAs (75%) without additional surgery at an average of 23 weeks. Fusion angles ranged from 90° to 120°. One patient required amputation above the elbow because of persistent infection and chronic pain after attempted reconstruction with distraction osteogenesis for infected total elbow replacement with humeral bone loss. The average length of follow-up after EA was 33 months (range, 18-60 months). At final follow-up, the median score of the shortened Disabilities of the Arm, Shoulder, and Hand questionnaire was 42.4 (27.3-52.2). Three patients returned to their working activities.

CONCLUSIONS

EA is not a common orthopedic procedure. Despite its difficulties and need of specific training, the Ilizarov technique provides a reproducible and reliable way of achieving solid fusion with the desired angle. Advantages include infection control, early mobilization, accurate application, convertibility and versatility compared with a monolateral fixator, and improved union rate.

Vascular bone transfer options in the foot and ankle: a retrospective review and update on strategies

BACKGROUND

The foot and ankle area has a tenuous blood supply that can easily be damaged with trauma or open exposures. The navicular and talus are susceptible to avascular necrosis, making arthrodesis difficult. In addition, in this region, large bone gaps occur as a result of avascular necrosis, trauma, or infection. Often, vascularized bone flaps are required for reconstruction or salvage.

METHODS

A retrospective review of all vascularized bone flaps to the foot and ankle performed by the senior surgeon (L.S.L) from July of 2006 to July of 2012 was performed. Twelve cases were identified (seven fibula flaps and five medial femoral condyle flaps). Indications included talus avascular necrosis with tibiotalar and subtalar arthritis (n = 8), talus avascular necrosis with tibiotalar arthritis (n = 1), navicular avascular necrosis (n = 1), talus persistent nonunion (n = 1), and a traumatic bone defect (n = 1).

RESULTS

There were no flap failures or thrombotic events. Ankle stabilization was performed with plates (n = 5), compression screws (n = 2), external fixator (n = 4), and a cast (n = 1). There were three complications requiring return to the operating room. All patients ultimately obtained union, and full weight bearing was allowed at 18.7 ± 13.6 weeks after surgery.

CONCLUSIONS

The authors have successfully used the medial femoral condyle flap and fibula flap for tibiotalar arthrodesis, pantalar arthrodesis, navicular revascularization, and persistent nonunion of the talus. The medial femoral condyle is ideal when a small segment of vascularized bone is required, but when structural support is necessary, the fibula offers a larger cortical surface area, providing more rigidity. Both flaps are valid options for foot and ankle reconstruction and salvage.

Knee joint transplantation combined with surgical angiogenesis in rabbits--a new experimental model

PURPOSE

We have previously described a means to maintain bone allotransplant viability, without long-term immune modulation, replacing allogenic bone vasculature with autogenous vessels. A rabbit model for whole knee joint transplantation was developed and tested using the same methodology, initially as an autotransplant.

MATERIALS/METHODS

Knee joints of eight New Zealand White rabbits were elevated on a popliteal vessel pedicle to evaluate limb viability in a nonsurvival study. Ten additional joints were elevated and replaced orthotopically in a fashion identical to allotransplantation, obviating only microsurgical repairs and immunosuppression. A superficial inferior epigastric facial (SIEF) flap and a saphenous arteriovenous (AV) bundle were introduced into the femur and tibia respectively, generating a neoangiogenic bone circulation. In allogenic transplantation, this step maintains viability after cessation of immunosuppression. Sixteen weeks later, X-rays, microangiography, histology, histomorphometry, and biomechanical analysis were performed.

RESULTS

Limb viability was preserved in the initial eight animals. Both soft tissue and bone healing occurred in 10 orthotopic transplants. Surgical angiogenesis from the SIEF flap and AV bundle was always present. Bone and joint viability was maintained, with demonstrable new bone formation. Bone strength was less than the opposite side. Arthrosis and joint contractures were frequent.

CONCLUSION

We have developed a rabbit knee joint model and evaluation methods suitable for subsequent studies of whole joint allotransplantation.

[Salvage procedures of the elbow. Alternatives to elbow arthroplasty]

Destructive changes of the elbow joint represent a challenge for both patient and surgeon. Resection arthroplasty is associated with postoperative instability and loss of power and is a rarely performed procedure. Interpositional arthroplasty remains a useful option for healthy active patients with severe post-traumatic elbow arthrosis and is one of the oldest methods used to reconstruct the elbow. The principle of interpositional arthroplasty is based on a sparing resection of the destroyed joint surface and on creating a congruent elbow joint with human tissue. Nowadays, autogenous dermis, fascia lata or Achilles allograft are used. A preoperatively stable elbow is required to prevent instability following interpositional arthroplasty. The use of total elbow arthroplasty is limited due to the contraindications and in such cases the only remaining options are salvage procedures of the elbow. In general, arthrodesis should be performed in patients with painful osteoarthritis of the elbow with high demands on the upper extremities. Historically, tuberculosis was the most common indication for elbow arthrodesis and various methods of elbow arthrodesis have been described. However, most attention has been given to the position in which the elbow joint should be fixed and should be decided depending on the individual characteristics of the patient. Sufficient bone stock is crucial for a successful elbow arthrodesis and in cases with massive bone loss reconstruction of the elbow using an allograft can be performed to restore bone quality. However, the high complication rate of this procedure limits the scope of its use. Nevertheless, allograft procedures can restore pain-free joint function for several years.

Arthrodesis of the elbow

Elbow arthrodesis (EA) is a procedure reserved for the salvage of failed elbow reconstruction or elbow injuries that defy reconstruction of a useful joint. Although arthrodesis of some joints is often straightforward and predictable, EA is technically difficult and associated with a high rate of complications. Furthermore, a successful EA does not translate to a gratifying clinical success. The functional limitations to activities of daily living and personal care are significant.

Vascularized fibular graft in infected tibial bone loss

BACKGROUND

The treatment options of bone loss with infections include bone transport with external fixators, vascularized bone grafts, non-vascularized autogenous grafts and vascularized allografts. The research hypothesis was that the graft length and intact ipsilateral fibula influenced hypertrophy and stress fracture. We retrospectively studied the graft hypertrophy in 15 patients, in whom vascularized fibular graft was done for post-traumatic tibial defects with infection.

MATERIALS AND METHODS

15 male patients with mean age 33.7 years (range 18 - 56 years) of post traumatic tibial bone loss were analysed. The mean bony defect was 14.5 cm (range 6.5 - 20 cm). The mean length of the graft was 16.7 cm (range 11.5 - 21 cm). The osteoseptocutaneous flap (bone flap with attached overlying skin flap) from the contralateral side was used in all patients except one. The graft was fixed to the recipient bone at both ends by one or two AO cortical screws, supplemented by a monolateral external fixator. A standard postoperative protocol was followed in all patients. The hypertrophy percentage of the vascularized fibular graft was calculated by a modification of the formula described by El-Gammal. The followup period averaged 46.5 months (range 24 - 164 months). The Pearson correlation coefficient (r) was worked out, to find the relationship between graft length and hypertrophy. The t-test was performed to find out if there was any significant difference in the graft length of those who had a stress fracture and those who did not and to find out whether there was any significant difference in hypertrophy with and without ipsilateral fibula union. The Chi square test was performed to identify whether there was any association between the stress fracture and the fibula union. Given the small sample size we have not used any statistical analysis to determine the relation between the percentage of the graft hypertrophy and stress fracture.

RESULTS

Graft union occurred in all patients in a mean time of 3.3 months, at both ends. At a minimum followup of 24 months the mean hypertrophy noted was 63.6% (30 - 136%) in the vascularized fibular graft. Ten stress fractures occurred in seven patients. The mean duration of the occurrence of a stress fracture in the graft was 11.1 months (2.5 - 18 months) postoperatively. The highest incidence of stress fractures was when the graft hypertrophy was less than 20%. The incidence of stress fractures reduced significantly after the graft hypertrophy exceeded 20%.

CONCLUSION

In most cases hypertrophy of the vascularized fibular graft occurs in response to mechanical loading by protected weight bearing, and the amount of hypertrophy is variable. The presence or absence of an intact fibula has no bearing on the hypertrophy or incidence of stress fracture. The length of the fibular graft has no bearing on the hypertrophy or stress fracture.

Ankle fusion for bone loss around the ankle joint using the Ilizarov technique

We present the results of ankle fusion using the Ilizarov technique for bone loss around the ankle in 20 patients. All except one had sustained post-traumatic bone loss. Infection was present in 17. The mean age was 33.1 years (7 to 71). The mean size of the defect was 3.98 cm (1.5 to 12) and associated limb shortening before the index procedure varied from 1 cm to 5 cm. The mean time in the external fixator was 335 days (42 to 870). Tibiotalar fusion was performed in 19 patients and tibiocalcaneal fusion in one. Associated problems included diabetes in one patient, pelvic and urethral injury in one, visual injury in one patient and ipsilateral tibial fracture in five. At the final mean follow-up of 51.55 months (24 to 121) fusion had been achieved in 19 of 20 patients. A total of 16 patients were able to return to work. The results were graded as good in 11 patients, fair in six and poor in three. The mean external fixation index was 8.8 days/mm (0 to 30). One patient with diabetes developed severe infection which required early removal of the fixator. Refractures occurred in three patients, two of which were at the site of fusion and one at a previous tibial shaft fracture site. Equinus deformity of the ankle fusion occurred after a further fracture in one patient. There were two patients with residual forefoot equinus, and one developed late valgus at the fusion site.

Poor consolidation of the regenerated bone in two patients was treated by bone grafting in one and by bone and fibular strut grafting in the other. Residual soft-tissue infection was still present in two patients.

Extremity war injuries: challenges in definitive reconstruction

The third annual Extremity War Injuries Symposium was held in January 2008 to review challenges related to definitive management of severe injuries sustained primarily as a result of blast injuries associated with military operations in the Global War on Terror. Specifically, the symposium focused on the management of soft-tissue defects, segmental bone defects, open tibial shaft fractures, and challenges associated with massive periarticular reconstructions. Advances in several components of soft-tissue injury management, such as improvement in the use of free-tissue transfer and enhanced approaches to tissue-engineering, may improve overall care for extremity injuries. Use of distraction osteogenesis for treatment of large bone defects has been simplified by the development of computer-aided distraction protocols. For closed tibial fractures, evidence and consensus support initial splinting for transport and aeromedical evacuation, followed by elective reamed, locked intramedullary nail fixation. Management of open tibial shaft fractures sustained as a result of high-energy combat injuries should include serial débridements every 48 hours until definitive wound closure and stabilization are recommended. A low threshold is recommended for early utilization of fasciotomies in the overall treatment of tibial shaft fractures associated with war injuries. For management of open tibial fractures secondary to blast or high-velocity gunshot injuries, good experiences have been reported with the use of ring fixation for definitive treatment. Treatment options in any given case of massive periarticular defects must consider the specific anatomic and physiologic challenges presented as well as the capabilities of the treating surgeon.

The fate of elbow arthrodesis: indications, techniques, and outcome in fourteen patients

Arthrodesis of the elbow remains a salvage procedure. In elbow surgery, it is indicated in cases of painful loss of motion, instability, and infection due to various causes. The literature lacks comprehensive clinical series concerning indications, techniques, and, particularly, outcome in elbow arthrodesis. We retrospectively reviewed our results of elbow arthrodesis in 14 patients. At final follow-up, the chart data of all patients showed favorable results with solid union of the fused elbows, no pain in 8 patients, and moderate pain in 4. In those patients in whom clinical follow-up was possible, after an average 62 months (4-132), noteworthy functional results were observed because of compensatory motion of adjacent joints. The authors outline decisive factors in the decision making process for patients with salvage elbows, as well as the techniques for elbow arthrodesis. Our indications, favorable results, and complications are discussed. A comprehensive review of literature highlights the technical steps necessary for successful elbow arthrodesis.

Unilateral hinged external fixation frame for elbow compression arthrodesis: the stepwise attainment of a stable 90-degree flexion position: a case report

We report a case of an elbow arthrodesis using a modular hinged external fixation device in a patient who sustained a complex high-energy injury. The extensive bone and soft-tissue loss and local infection precluded restoration of the articular anatomy. Other reconstructive options, including total elbow arthroplasty and allograft reconstruction, were not appropriate in this clinical situation. A transelbow hinged external fixator was applied with the elbow in extension. Subsequently, the hinge was brought gradually into 90 degrees of flexion as the elbow fused. Fixation and arthrodesis were successfully achieved by using this modular device, despite severe tissue loss and local septic complications. Furthermore, by gradually flexing the frame from full extension to 90 degrees , the need for flap coverage of the open wound was avoided.

Spontaneous defect remodeling in a distal humerus fracture with extensive osseous loss: a case report of a complex elbow fracture

Sideswipe injuries to the elbow cause complex fracture patterns and remain difficult management problems. The authors report a case of spontaneous bone remodeling of an extensive metaphyseal defect zone.

Ankle and pantalar arthrodeses using vascularized fibular grafts

From 1989 to 1998 ankle and pantalar arthrodeses using vascularized fibular grafts were performed for seven patients. The indications for surgery were chronic nonunion following fracture of the distal tibia in four patients, rheumatoid arthritis in two, and talus necrosis in one. The ankle joint was fused in the two patients with a pilon fracture, and in the other five patients, both the ankle and subtalar joints were fused. In one patient, additional bone grafting was required for delayed union. In the other six patients, the mean period required to obtain radiographic bone union was 6 months (range, 4-9 months). The time until the patients could walk without braces ranged from 6 to 20 months (mean, 12.3 months). Local infection was not encountered in any patients. This procedure represents a viable option for patients in whom a standard, less complicated arthrodesis cannot be performed.

Complications of vascularized fibula graft for reconstruction of long bones

The clinical results and complications of the vascularized fibular graft for the reconstruction of various long bone defects were reviewed in 60 cases. Bony reconstruction was achieved in 57 of the 60 cases; however, various postoperative complications occurred in 54 percent of the cases. One case of arterial thrombosis of an anastomosed vessel and nine cases of venous congestion of the monitoring flap occurred in the early postoperative periods. The authors managed the nine cases of venous congestion of the flap conservatively, and all flaps survived. Partial necrosis of the flap was noted in eight of these nine cases, but additional surgical intervention was required in only four cases. Treatment included a gastrocnemius musculocutaneous flap in one case and a full-thickness skin graft in three cases. The vascularized fibula survived and bony fusion was achieved in all of these cases. The one case of arterial thrombosis resulted in graft failure due to a delay in the decision to perform a thrombectomy. Graft fracture occurred in 13 cases as the mechanical stress to the graft increased. In two cases of femoral reconstruction, graft fracture occurred during dynamization of the graft, despite the use of an Ilizarov external fixator. Correct alignment between the recipient bone and the external fixator is a prerequisite to preventing graft fracture. Vascularized fibular grafting offers the patient a great deal of benefit; however, this graft has a concomitant high risk of complications. Great attention to detail must be paid to prevent postoperative complications.

Reverse segmental pedicled ulna transfer as a salvage procedure in wrist fusion

A new technique for wrist fusion using vascularized bone graft is described. A distally based, pedicled segment of the distal ulna, nourished by the ulnar artery or the distally based palmar-ulnar branch of the anterior interosseus artery was used in three patients to restore carpal height after infection (n=2) or tumour resection (n=1). The forearm is converted to a situation similar to a wide ulnar resection. All three wrist fusions healed uneventfully. This new technique is suitable in cases where a vascularized bone graft is required, but microsurgical techniques are not appropriate or are rejected by the patient.