Does a Modified Technique to Achieve Arthrodesis of the Wrist After Resection of the Distal Radius and Translocating the Ipsilateral Ulna as a Vascularized Graft to Reconstruct the Defect Improve Grip Strength and Outcomes Scores?

BACKGROUND

Ten years ago, we reported the results of a procedure in which we translocated the ipsilateral ulna as a vascularized autograft to reconstruct defects of the distal radius after tumor resection, with excellent functional results. At that time, wrist arthrodesis was achieved by aligning the translocated ulna with the scapholunate area of the carpus and usually the third metacarpal. This resulted in wrist narrowing. We then wondered if aligning the translocated ulna with the scaphoid and the second metacarpal would result in ulnar deviation and thereby improve grip strength. We believed lateralization would reduce the wrist narrowing that occurs with fusion to the third metacarpal and would make the cosmesis more acceptable. We also modified the incision to dororadial to make the scar less visible and thus improve the cosmesis.

QUESTIONS/PURPOSES

(1) Is there an objective improvement in grip strength and functional scores (Musculoskeletal Tumor Society [MSTS] and Mayo wrist) when the translocated ulna is lateralized and the wrist is fused with the translocated ulna and aligned with the second metacarpal versus when the translocated ulna is aligned with the third metacarpal? (2) Did lateralization caused by the wrist fusion aligned with the second metacarpal minimize wrist narrowing as measured by the circumference compared with the fusion aligned with the third metacarpal?

METHODS

From 2010 and 2018, we treated 40 patients with distal radius tumors at our institution, 30 of whom had a distal radius enbloc resection. Twenty-eight patients had an ipsilateral ulna translocation and wrist arthrodesis in which the radius and translocated ulna were aligned with either the second (n = 15) or the third (n = 13) metacarpals. Two patients in the second metacarpal group and three patients in the third metacarpal group were lost to follow-up before 24 months after surgery and were excluded. A retrospective analysis of 23 patients (20 with giant cell tumors and three with malignant bone tumors) included a review of radiographs and institutional tumor database for surgical and follow-up records to study oncologic (local disease recurrence), reconstruction (union of osteotomy junctions, implant breakage or graft fracture, and wrist circumference), and functional outcomes (MSTS and Mayo wrist scores and objective grip strength assessment compared with the contralateral side). The results were compared for each study group (second metacarpal versus third metacarpal). There was no difference in the incidence of local recurrence or the time to union between the two groups. There were no implant breakages or graft fractures noted in either group.

RESULTS

Patients in the second metacarpal group lost less grip strength compared with the unoperated side in the third metacarpal group (median 12% [range -30% to 35%] versus median 28% [15% to 42%], difference of medians 16%; p = 0.006). There were no between-group differences in terms of MSTS (median 30 [24 to 30] versus median 26.5 [22 to 30], difference of medians 3.5; p = 0.21) or Mayo wrist scores (median 83 [65 to 100] versus median 72 [50 to 90], difference of medians 11; p = 0.10). The second metacarpal group also had less wrist narrowing as seen from the median difference in circumference between the operated and unoperated wrists (median narrowing 10 mm [3 to 35 mm] in the second metacarpal group versus median 30 mm [15 to 35 mm] in the third metacarpal group, difference of medians 20 mm; p = 0.04).

CONCLUSION

Wrist arthrodesis after ulna translocation with alignment of the translocated ulna and the second metacarpal provides a functional position with ulnar deviation that offers some improvement in grip strength but no improvement in the MSTS or Mayo scores. Radialization/lateralization of the translocated ulna achieved from the alignment with the second metacarpal decreases the reduction in the wrist circumference and therefore reduces wrist narrowing.

LEVEL OF EVIDENCE

Level III, therapeutic study.

[Animal experimentation of reimplantation of hypertonic saline-induced devitalized bone]

OBJECTIVE

To observe the healing process and the change of biomechanical properties of hypertonic saline-induced devitalized bone segment, so as to provide fundamental theory for clinical treatment.

METHODS

A model of New Zealand rabbit ulnar segments devitalized by hypertonic saline was established and then reimplanted in situ. The ulnar specimens were taken for examination of X-rays, light microscope and three-point-bend test at the end of 3, 6, 12, and 24 weeks postoperatively.

RESULTS

The devitalized bone healed at the end of 12 weeks in the X-ray film. The histological examination showed that osteoblast multiplied and secreted osteoid gradually. The maximal breaking load of the devitalized bone continuously increased and reached the top at the end of 24 weeks [control group (206.25±16.64) N vs. devitalized group (196.88±8.24) N, P>0.05].

CONCLUSION

The devitalized bone healed through intramembranous and endochondral ossification, and the endochondral ossification predominated; the biomechanical strength of devitalized bone continually increased as time lasted.

[Treatment of the radial shaft loss with pedicled graft from the ulna--a case report]

A case of 68-year-old woman with severe deformation of the left forearm and disability of the hand as a consequence of total dissociation and partial loss of radial shaft, after fracture sustained one year earlier is reported. The restoration of the length and shape of the radius was performed with the use of 4 cm long fragment of the ulna pedicled on the interosseous membrane, fixated with plate. Normal shape of the radius was achieved and the hand was held in the axis of the forearm. Bone healing was achieved at one year, and at the 2.5 years follow-up the patient was free of pain, had full fingers movement, full rotation of the forearm, total grip strength of 16 kG (64% of the power of the healthy hand) and subjective evaluation of the dexterity with DASH scale was 25 points, suggesting a mild loss of function.

Augmentation of the posterior atrophic edentulous maxilla with implants placed in the ulna: a prospective single-blind controlled clinical trial

PURPOSE

To evaluate a new method to treat the posterior atrophic edentulous maxilla: dental implants placed in the ulna and transplanted with their surrounding bone blocks as inlays into the sinus. Conventional sinus augmentation with particulated autogenous bone grafts served as a control procedure.

MATERIALS AND METHODS

Fifty-two implants were placed in the ulnas of 20 patients. After 6 weeks, bone blocks containing 1 to 3 implants were harvested and transplanted into the sinuses protruding 3 to 4 mm. Implants were left to heal for 6 weeks. Twenty patients with similar treatment indications treated with particulated bone grafts from the mental symphysis, tibia, or iliac crest acted as controls. Grafts were allowed to heal for 6 months in the control group. Fifty-two control-group implants were allowed to heal for 4 months. The main outcome measures were prosthetic and implant success. Stability of individual implants was assessed with Osstell and Periotest at baseline and after 6 and 12 months of loading. Independent sample chi-square tests, t tests, and paired t tests were used with a significance level of .05.

RESULTS

No patient dropped out or withdrew; no prosthesis or implant failed. No major surgical complications were occurred. There were no differences between the 2 groups at any time point in implant stability. Both modalities resulted in a significant increase of implant stability at 6 and 12 months. The mean change (SD) from baseline to 1 year in Periotest measurements was 1.44 (0.48) in the test and 1.29 (0.58) in the control (paired t tests; P < .001). For the Osstell, these values were -5.88 (4.18) and -5.48 (3.93) for the test and control groups, respectively (paired t tests: P < .001).

CONCLUSIONS

Ulna implant block grafting represents an alternative to conventional sinus augmentation, particularly when vertical augmentation is desirable or large iliac crest grafts are needed.

Intra-articular radial head fracture in a child with an open physis: a case report

Fractures of the proximal end of the radius in children are uncommon. A case of fracture through the articular surface of the radial head (Salter-Harris type IV) in a 12-year-old boy is presented. Our paper recommends bone peg fixation in the treatment of Salter-Harris (S-H) type III or IV injuries in nearly skeletally mature.

Ipsilateral vascularised ulnar transposition autograft for limb-sparing surgery of the distal radius in 2 dogs with osteosarcoma

Canine osteosarcoma is the most commonly diagnosed primary bone tumour in the dog, affecting mainly large and giant breed dogs with the predilection site being the metaphysis of long bones, specifically the distal radius, proximal humerus, distal femur and proximal tibia and fibula. Treatment options are either palliative or curative intent therapy, the latter limb amputation or limb-sparing surgery together with chemotherapy. This article describes the use of an ipsilateral vascularised ulnar transposition autograft as well as chemotherapy in 2 dogs with osteosarcoma of the distal radius. Both dogs showed minimal complications with the technique and both survived over 381 days following the surgery. Complications seen were loosening of the screws and osteomyelitis. The procedure was well tolerated with excellent limb use. This technique is indicated for use in cases with small tumour size that have not broken through the bone cortex.

Surgical correction of dorsally angulated distal radius malunions with fixed angle volar plating: a case series

PURPOSE

To report our experience using a fixed-angle volar plate in conjunction with a corrective osteotomy and cancellous bone graft for the treatment of distal radius malunions with dorsal angulation in 4 patients.

METHODS

Four consecutive patients had a volarly based opening wedge osteotomy with a fixed angle volar plate and cancellous bone grafting for the treatment of a dorsally angulated distal radius malunion. Data collected retrospectively included a visual analog pain scale, grip strength, range of motion, radiographic parameters, and each patient's subjective functional outcomes as measured by the Disabilities of the Arm, Shoulder, and Hand questionnaire. Motion, strength, and radiographic values were compared with the contralateral arm for each patient.

RESULTS

The average time from initial fracture to corrective osteotomy was 346 days. The average length of follow-up evaluation was 13.5 months. The flexion-extension arc of motion increased an average of 21 degrees to a value of 84% of the contralateral side; the pronation-supination arc of motion increased an average of 20 degrees to a value of 98% of the contralateral side. The average tilt of the radius improved from 26 degrees extension to 2 degrees extension; the average radial inclination improved from 22 degrees to 24 degrees; the average ulnar variance excluding the 1 patient who had a distal ulna resection improved from 5 mm to 1 mm. The average retrospective Disabilities of the Arm, Shoulder, and Hand score improved from 30 to 7; the average retrospective visual analog pain scale score improved from 4.5 to 1. The average grip strength increased from 20 to 29 kg, which corresponded to 73% of the contralateral extremity.

CONCLUSIONS

The rigid characteristics of fixed angle volar plates can provide an alternative to the traditional techniques of distal radius osteotomy including structural bone grafting and dorsal plate fixation or external fixation. In addition these plates are strong enough to allow for early postoperative motion.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic, Level IV.

Structural Allograft Implantation for Thoracic Spinal Impalement

Impalement injury is uncommon, with only occasional reports. Thoracic impalement injuries from falls are rarely seen in the emergency department, because most patients die at the scene of injury. We present an unusual case in which a patient survived a bilateral thoracic impalement injury and was successfully treated for the bleeding thoracic spinal defect with a method that used a structural ulnar allograft implantation.

Total wrist fusion: a study of 115 patients

This retrospective study evaluated the outcome of total wrist fusion, predominantly using the Mannerfelt technique, in patients with rheumatoid arthritis. One hundred and fifteen patients were operated on for painful wrist destruction. The mean pain scores were 3.6 (1-4) pre-operatively, 1.9 (1-4) after 6 weeks and 1.3 (1-4) at 1 year. Although the radiological fusion rate was good, only 40% of the patients were very satisfied with the result. Ability to perform activities of daily living was only very much improved in 30% of the patients. Grip strength significantly improved after surgery.

[Intracystic allograft in management of long bone cyst merging pathologic fracture]

OBJECTIVE

To investigate the efficiency of intracystic allograft fixed with bone plate and steel plate in management of long bone cyst merging pathologic fracture.

METHODS

Twelve cases of long bone cysts with pathologic fractures were treated from January 1996 to April 2002. The median dimension of the cyst on the radiograph was 3. 6 cm x 8.1 cm. We regularly revealed the sites of cysts, cut the anterior wall, got cystic membrane away, implanted allo-bone fibula, ulna or radius shafts which were defatted and deproteined. The auto-bone and the allo-bone of all cases were fixed with bone plate and steel plate; external fixation was managed for 3 weeks after operation.

RESULTS

All incisions achieved primary healing. All cases were followed up 2. 7 years on average. According to Capanna's standard, 9 cases completely healed, 3 cases basically healed, no cases recurred. The function in shoulder joint was slightly limited in 2 cases that cysts were located on the upper humerus, while that of the other 10 cases were recovered completely.

CONCLUSION

Intracystic allograft fixed with bone plate and steel plate is safe and effective in management of long bone cyst merging pathologic fracture.

Osteofasciocutaneous flap based on the dorsal ulnar artery. A new option for reconstruction of composite hand defects

Since the initial description of the dorsal ulnar artery fasciocutaneous flap by Becker and Gilbert in 1988 many modifications have been introduced to allow more versatility to the flap. The authors describe the dissection technique of an osteofasciocutaneous flap based on the dorsal ulnar artery and present a clinical case where this flap has been used to reconstruct a bone defect of the fifth metacarpal. Up to one third of the outer cortex of a long bone is supplied by the periosteal arterioles. This permits the inclusion of a small amount of ulnar cortical bone in the dorsal ulnar flap to reconstruct compound defects of the hand. The essential precaution is not to disrupt the continuity formed by the posterior border of the ulna, the periosteum, bony attachments of the flexor carpi ulnaris and extensor carpi ulnaris muscles, fascia and the skin. This flap allows the transposition of optimal soft tissue coverage to the hand with vascularised bone preserving the main arteries to the hand.

Mandibular Reconstruction: Are Two Flaps Better Than One?

This study compared the combined iliac and ulnar forearm flaps with the osteomusculocutaneous fibular free flap for mandibular reconstruction. A retrospective study of 40 patients who had oromandibular reconstruction was performed, of whom 23 patients had a combined iliac crest without skin and ulnar forearm free flap. Seventeen patients had an osteomusculocutaneous free fibular flap. Ten women and 30 men with a mean age of 57.5 years comprised this study population. Ninety percent of the cases were squamous cell carcinoma (55%, T4), of which 11% were recurrent tumors. Anterolateral mandibular defects constituted 52.9% of the fibular reconstructions and 60.9% accounted for the iliac/ulnar reconstructions. The mean bone gaps were 8.79 cm and 8.95 cm respectively. Functional evaluation was based on the University of Washington Questionnaire through phone calls and personal communication. The mean hospital stay was 15.43 days and 10.09 days for the fibular and iliac/ulnar flaps respectively. The facial artery (64.7%) and facial vein (60%) were the main recipient vessels for the fibular reconstructions whereas the external carotid artery (95.6%) and the internal jugular vein (66.7%) were the main recipient vessels for the iliac/ulnar reconstruction. Overall flap survival was 96.8% (100% of fibular flaps and 95.65% of iliac/ulnar flaps). Two flaps were lost in the iliac/ulnar series because of unsalvageable venous thrombosis. Local complications for the iliac/ulnar flaps were 30.4% but were 5.9% for the fibular reconstructions. Function such as speech, swallowing, and chewing were notably better in the fibular than the iliac/ulnar group in 23 of the patients tested. The cosmetic acceptance of 77.8% of the fibular flaps was judged to be excellent and good, whereas 71.4% of the iliac/ulnar flaps were rated good. It appears that within this study population the free osteomusculocutaneous fibular flap had fewer local complications and a higher flap survival rate than the combined iliac/ulnar forearm flaps. Overall functional outcome was also improved. The use of the double flap may be appropriate in massive oromandibular defects, but may be less appropriate in more modest functional reconstructions of mandibular defects.

[Tumors of the hand bones]

The article is devoted to an actual problem of surgical treatment of hand bone tumors. It presents a classification of hand bone tumors, pathogenesis, clinical course of the most common tumors, methods of surgical treatment. Results of treatment of 108 patients with hand bone tumors are described.

Use of an ipsilateral vascularized ulnar transposition autograft for limb-sparing surgery of the distal radius in dogs: an anatomic and clinical study

OBJECTIVE

To develop a surgical technique for using the distal aspect of the ulna as a transposition autograft in a distal radial defect and to assess patency of vascular supply and viability of the distal ulna in a heterotopic position.

STUDY DESIGN

Cadaveric study and clinical cases.

ANIMALS

Twenty-two normal canine thoracic limbs; 3 dogs with distal radial osteosarcoma.

METHODS

The arteries and veins of 12 limbs were injected with latex. Barium sulfate suspension was injected into the brachial artery of 10 other limbs after removal of the distal radius only (n = 2), ulna transposition (UT) (n = 6), or no procedure (n = 2). The distal ulna grafts were then harvested and decalcified in formic acid. The grafts were cut into 3-5 mm transverse sections and radiographed with a nonscreen film system to determine filling of intramedullary vessels with barium suspension. UT was performed in 3 dogs with distal radial osteosarcoma. Bone scintigraphy was performed 2-7 days after surgery to assess viability of the transposed ulna graft.

RESULTS

Angiography confirmed patency of the caudal interosseous artery in all but 2 limbs in which the UT technique was performed; however, barium-filled vessels were identified in the medullary cavity of all ulnar grafts. Scintigraphy confirmed graft viability in the 3 dogs, all of which had good to excellent limb function.

CONCLUSIONS

The distal aspect of the canine ulna can be used as a vascularized transposition autograft to replace distal radial defects, and viability can be maintained.

CLINICAL RELEVANCE

The UT technique appears to be an acceptable limb-sparing technique for dogs with tumors of the distal aspect of the radius.

Enchondroma of the scaphoid bone

The scaphoid bone is a very rare location for enchondroma. The literature reports eight cases; five of them presented with pathologic fracture, and the youngest patient was 13 years old. This is a report of an 11-year-old patient with scaphoid enchondroma who presented with only mild pain in the left wrist. Magnetic resonance imaging demonstrated the lesion clearly.

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.

[Vascularized bone pedicle grafts of the hand and wrist: literature review and new donor sites]

Some situations in hand surgery require vascularized bone grafts. Good mechanical strength and decreased time for bone healing may explain their use. Although many donor sites have been described, the authors were interested by donor sites with a blood supply provided by an accessory vessel not disturbing the perfusion of the hand. Literature review of the different donor sites demonstrate (a) Three sites at the dorsal aspect of the distal epiphysis and one at the dorsal distal ulna. Only the radialmost site has been regularly used for surgical application. (b) At the palmar aspect of the radial epiphysis, the pronator quadratus vascularised bone graft may be elevated in an antero or retrograde way. (c) Among the carpal bones, the pisiform and part of the capitate has been used as pedickled bone graft. (d) Metacarpals may also be a donor site. Description of sites at the proximal and distal part of the second metacarpal has been used for surgical applications. The authors describe a new site at the first metacarpal at the radiodorsal or uino-dorsal aspect which may be used as a composite bone-skin graft. A clinical application is presented. Clinical use of these pedicles graft is discussed and apply mainly for scaphoid nonunion and some case of Kienbock's disease. Distal stump reconstruction is possible with the new flap.

[The applied anatomy of transposition of the distal dorsal ulna bone flap pedicled with dorsal metacarpal artery]

OBJECTIVE

To investigate the anatomic basis for transposition of the distal dorsal ulna bone flap pedicled with dorsal metacarpal artery to repair the defect of the 3rd or 4th and 5th metacarpal bone head.

METHODS

In 30 adult cadaveric upper limbs, the branches and constitutions of the dorsal carpal arterial networks were observed.

RESULTS

The dorsal carpal arterial networks were consisted of the dorsal carpal branches of ulnar and radial arteries, the terminal branches of posterior interosseous artery and the dorsal carpal branch of anterior interosseous artery, and then the 2nd, 3rd, 4th dorsal metacarpal branches were originated from the networks. The dorsal metacarpal branches were anastomosed with the deep branches of deep palmar arch to constitute the dorsal metacarpal artery.

CONCLUSION

Transposition of the distal dorsal ulna bone flap pedicled with the 3rd, 4th dorsal metacarpal arteries can be used in repairing the defect of 3rd, 4th and 5th metacarpal bone head.

Experimental study of vascularized bone grafts: hypertrophy of the grafted bone

The mechanism underlying hypertrophy of experimentally vascularized bone grafts was studied in 15-week-old rats. The segmental ulna was grafted to the tibial defect with an external fixator. In experiment 1, 24 rats were classified into four groups to evaluate conventional (non-vascularized), cuff (periosteum-encased, non-vascularized), and vascularized bone grafts, and vascularized segmental grafts with fracture. In experiment 2, 12 rats were classified into two groups according to the presence of mechanical loading. This involved vascularized bone grafts with external fixators, and vascularized bone grafts with external fixators removed after bone union. The bone dynamics of the grafts were investigated by several methods, including roentgenographic analysis, histologic studies, and fluorochrome labeling. In experiment 1, a slight bone formation was recognized in the conventional bone graft, while irregular bone formation with creeping substitution was observed in the cuff graft. The vascularized bone graft showed significant hypertrophy; hypertrophy of the vascularized bone with fracture was greater than that without fracture. In experiment 2, markedly circumferential bone formation was observed after removal of the external fixator, while slight new bone formation was observed during the late postoperative period in bone with an external fixator. These results suggest that hypertrophy can be promoted by artificial fracture of the grafted bone, and that mechanical loading is an important factor for remodeling of grafted bone.

Use of a free cortical ulnar autograft following en bloc resection of a mandibular tumor

A dog was presented for the en bloc resection of a previously irradiated mandibular ossifying epulis. A central hemimandibulectomy was performed, and the mandibular defect was stabilized by the use of a free cortical ulnar autograft and rigid internal fixation. The dog had normal mastication and left forelimb function two weeks after surgery. Radiographic evaluation of the surgical site at three and 10 months after surgery showed normal bony healing.

Experimental carpal reverse-flow pedicle vascularized bone grafts. Part II: bone blood flow measurement by radioactive-labeled microspheres in a canine model

Reverse-flow pedicle vascularized bone grafts (VBGs) from the radius, commonly used for carpal nonunion and avascular necrosis, provide superior clinical results. In this experimental study bone blood flow in canine distal radius VBGs was measured to determine the status of the bone circulation immediately after elevation (group 1) and 2 weeks later (group 2). Immediate VBG flow (group 1) was substantial, but significantly less than the contralateral undisturbed distal radius (8.42 mL/min/100 g and 16.53 mL/min/100 g, respectively). At 2 weeks after surgery (group 2) VBG flow was compared with nonvascularized control grafts. Vascularized bone graft flow was significantly higher than group 1 (mean, 33.72 mL/min/100 g). Minimal flow was seen in the conventional graft control (0.62 mL/min/100 g). This study demonstrates that reverse-flow pedicle radius VBG maintain enhanced bone circulation long-term. Given the similarity of human and canine distal radius vascular anatomy, these data support the clinical use of reverse-flow VBG for carpal pathology. (J Hand Surg 2000; 25A:46-54.

Experimental carpal reverse-flow pedicle vascularized bone grafts. Part I: the anatomical basis of vascularized pedicle bone grafts based on the canine distal radius and ulna

We investigated the detailed extraosseous and intraosseous vascular anatomy of the distal radius and ulna in 55 pairs of canine forelimbs. Ten specimens were used for compartment identification. One hundred specimens were investigated after intra-arterial injection with red latex or Batson's compound. The extraosseous vascular network, including the nutrient artery location, was studied by delicate dissection and soft tissue digestion. Two superficial and 4 deep arteries were found on the dorsal aspect, with constant relationships to the retinaculum. On the palmar aspect, bony nutrient vessels rose from the branches of the radial artery (descriptive anatomy). The vascular supply of the canine distal forelimb was very consistent and enabled the design of 5 vascularized pedicle bone grafts similar to those described in humans (applied anatomy). These reverse-flow pedicle grafts may be placed in the carpus, allowing the canine forelimb to serve as an experimental model for the study of vascularized carpal bone grafting. (J Hand Surg 2000; 25A:34-45.

Bone-peg grafting for osteochondritis dissecans of the elbow

In the treatment of osteochondritis dissecans involving the elbow, we have used a bone-peg graft taken from the proximal part of the ulna and inserted into the defect. Thirty-two patients were followed from 2 to 10.5 years. The graft was utilised in 20 elbows, and 6 of these also had concomitant removal of a loose body. Another 6 elbows had removal of a loose body only. Ten elbows were treated conservatively in 5 of these the outcome was unsatisfactory, including 4 in which a bone-peg graft was later necessary. The bone-peg graft gave the best short-term results. Bony union of the dissecans site and reconstitution of subchondral bone required an average of 6.5 months. In 15 patients followed for a minimum of 5 years, the bone-peg graft was effective in limiting the development of osteoarthritis. Bone-peg grafting is a reliable method for treating osteochondritis dissecans of the elbow.

Reconstruction following en bloc resection of a giant cell tumor of the distal radius using a vascularized pedicle graft of the ulna

The surgical procedure described has the advantages of being simple and cost-effective. It provides early bone union and improves stability of the wrist joint. Four cases of giant cell tumor were treated and all 4 cases had satisfactory results.

Transplantation of the canine distal ulna as a free vascularized bone graft

An autogenous free vascular bone graft of the canine distal ulna was evaluated. The vascularity of the graft was based on a musculoperiosteal sheath supplied solely by the caudal interosseous artery and vein. Four autogenous heterotopic (ulna to tibia) vascular transfers were performed. Two avascular transfers were performed to provide baseline criteria from which the success of vascularized transfers could be assessed. Clinical lameness evaluation, serial radiographs, bone scintigraphy, and sequential fluorochrome bone labeling were performed after surgery in both vascular and avascular transfers. All dogs were free of lameness in the donor limb by the 26th postoperative day. Serial radiographs revealed rapid graft incorporation and hypertrophy in all vascularized grafts and severe bone resorption in nonvascularized grafts. Histology, microangiography, and evaluation of fluorochrome bone labels were performed 90 days after surgery to determine graft viability, incorporation and temporal remodeling patterns. Microangiography and fluorochrome assessment complemented the histological findings. Based on these findings the distal ulnar bone graft was determined to be both viable and structurally adequate for selected cases of long bone reconstruction.

Experimental vascularized bone transplantations

The postoperative hypertrophy of the vascularized fibula graft is of particular interest. In order to clarify the etiology of the hypertrophy, we conducted experimental projects on vascularized bone grafts using fluorochrome bone labelings, histomorphometry and measurement of blood flow in rats and rabbits. In the murine vascularized tibio-fibula graft for bone defects of the tibia, where mechanical stress to the graft can be expected, cross-sectional bone growth was maintained with acceleration of new bone formation and an alteration of growth direction at 3 weeks after the transplantation. In vascularized bone grafts where no mechanical stress to the graft is expected, more bone resorption was seen than bone formation. In the murine tail bone graft to a bony defect of the femur, the cancellous bone gradually disappeared, and the trabeculae took on an architecture characteristic of the femur. This process slowly transforms the graft into a femur with the morphologic features of a long bone. These results suggested that remodeling of the graft corresponding with the changes in the dynamic environment was accompanied by adequate resorption. The cross-age transplantation of vascularized tibio-fibula grafts in rats showed that the younger the donor, the faster the hypertrophy. Age is one of the important factors affecting remodeling of the vascularized bone graft. The blood flow of the grafted bone in the rabbits increased immediately after the transplantation as a reaction to surgery. Thereafter the blood flow of the graft may depend on the biological demands for new bone formation in adapting to the biomechanical environment of the recipient site.

The anatomic basis of a free vascularized bone graft based on the canine distal ulna

The anatomy of the canine distal ulna was evaluated to determine its potential as a free vascularized bone graft. Twelve cadavers were studied by gross dissection and nonselective and selective angiography. The caudal interosseous artery consistently served as a source artery to the distal ulnar periosteal vasculature in all dogs. The diameters of the caudal interosseous artery and venae comitantes were large enough to permit microvascular anastomoses. Nonselective perfusions of the brachial artery demonstrated large barium-filled vessels within soft tissues surrounding the ulna with anastomotic connections between medullary and periosteal vasculature. Grafts selectively perfused through the caudal interosseous artery (periosteal circulation only) had barium-filled vessels within the muscular cuff, periosteum, cortical bone, and medullary canal of the ulna. A surgical approach to remove the distal ulna along with an intact musculoperiosteal cuff and its associated vasculature is described.

Total elbow allograft for twice-failed total elbow arthroplasty. A case report

A successful case of total elbow allograft after removal of a twice-failed total elbow prosthesis is reported. The patient, a disabled 63 year old at the time of allograft implantation, can now perform all activities of daily living, including household chores. Both the humeral and ulnar allografts have incorporated, and there is no evidence of degenerative changes or allograft resorption two years nine months postoperatively.

Heterotopic vascularized growth plate transfer in juvenile dogs

Prior animal studies of vascularized epiphyseal transfers placed growth plates in 2 bone systems where the independent growth of epiphyses and their response to altered stresses has been difficult to assess. This study assessed growth of vascularized ulnar epiphyses transferred to the ipsilateral humerus of 12-week-old puppies. Growth was permitted by a specially designed extensible plate. Control groups showed that humeral dissection, osteotomy and ostectomy alone do not stimulate growth. In 4 puppies initial growth of the transferred epiphysis was seen but late collapse and formation of bridging callus occurred so that overall humeral length at maturity was not significantly different from control humeri. Physical forces inherent in heterotopic transfer may preclude long term growth of transferred epiphyses particularly in sites of higher relative load. The extensible plate used here may be a useful device in the fixation of transferred epiphyses with growth potential.

Quantitative histologic study of the influence of anterior spinal instrumentation and biodegradable polymer on lumbar interbody fusion after corpectomy. A canine model

Histomorphometric and microradiographic studies were performed to investigate whether there are different rates of bone remodeling based on the intrinsic stability with anterior spinal instrumentation and to evaluate if biodegradable polymer could be used clinically as the material of choice for anterior spinal instrumentation. Twenty-one coon hounds underwent anterior and posterior spinal destabilizing procedures to produce a reproducible amount of spinal instability: corpectomy of L5, discectomies and partial facetectomies of L4-5 and L5-6, resections of L5 lamina, spinous process, supra- and interspinous ligament, and ligamentum flavum. Group 1 (N = 7) underwent anterior autogenous ulna strut graft alone at L4-6; group 2 (N = 7) underwent anterior biodegradable polymer strut alone at the same level; group 3 (N = 7) underwent same bone graft as in group 1, augmented by anterior Kaneda device. Six months after surgery quantitative histologic study showed that device-related osteopenia occurred in spines treated with Kaneda device. Within the L5 vertebral body the volumetric density of bone (mm3/cm3) was less for the group with Kaneda device (group 3) compared with that without instrumentation (group 1, P less than 0.05). In the spine treated with biodegradable polymer, no adverse host tissue responses were observed histologically. In addition, osteoconductive abilities of the polymer were suggested microscopically. Its mechanical property, however, was not rigid enough to stabilize the corpectomized spine.

The olecranon bone graft for nasal augmentation

The olecranon bone graft offers an alternative to the cranial bone when autogenous material is preferred in the repair of moderate deficiencies of the nasal dorsum. The predictably thick cortex of the olecranon allows the crafting of a customized implant, and minimal donor site morbidity makes it a safe alternative to the cranial graft.

Arthrodesis of the wrist by a new technique

Twenty-eight arthrodeses of the wrist were carried out for various indications using an ulnar graft. The results were evaluated and it was found that the obliquely resected lower end of the ulna gave a longer graft for better fusion between the distal end of radius and the base of the 3rd metacarpal. There was no instability of the inferior radio-ulnar joint, and rotation of the forearm was improved whenever it had been previously limited.

Single stage reconstruction of a large tibial defect using a free vascularised osteomyocutaneous ulnar transfer

We present the case of a young man with 13 cm of bone and soft-tissue loss in the tibia and a severe traction injury of the brachial plexus. A free vascularised composite transfer of the bone and soft tissues of the ulnar side of the forearm was undertaken to reconstruct the defect. Bony union was achieved after a year and was followed by complete functional recovery of the lower limb.

Organization of positional information in the axolotl limb

We have used the phenomenon of position-dependent growth stimulation, brought about by the confrontation of cells with dissimilar positional values, to reveal the organization of positional information in the center of the upper and lower arms of axolotls. When either humerus or radius was transplanted into either dorsal or posterior positions, extra growth leading to the formation of supernumerary digits occurred following amputation through the graft. However, transplants of humerus or radius into anterior or ventral positions did not lead to the formation of any additional digits. The ulna by contrast was capable of stimulating supernumerary digit formation when transplanted into anterior, posterior, dorsal, or ventral positions. We interpret these results to indicate that the humerus and radius are surrounded by symmetrically arranged anterior and ventral positional values, whereas the ulna is surrounded by a complete asymmetrical set of angular positional values. We use our proposed arrangement for the positional information in the limb center to explain a number of previous experimental findings. In addition, we provide an explanation, in terms of the underlying positional information, for the structural and developmental relationships between the different skeletal elements of the vertebrate limb, and in particular for the anatomical pattern known as Gregory's pyramid.

Thumb reconstruction by the posterior interosseous osteocutaneous flap

An island osteo-fasciocutaneous flap, based on the posterior interosseous vessels, is described for thumb reconstruction. The artery supplies the fascial plexus of the posterior forearm as well as the superficial and deep extensor muscles. A vascularised bone segment of the upper third of the ulna can be harvested, including a cuff of the extensor pollicis longus muscle. The flap was used successfully in two clinical cases.

Experimental vascularized bone grafts: histopathologic correlations with postoperative bone scan: the risk of false-positive results

A positive bone scan in an experimental model of bilateral ulna diaphyseal bone grafts demonstrated early bone repair in both vascularized and nonvascularized orthotopic ulna autografts. A positive bone scan did not correlate with the perfusion of the vascularized and nonvascularized grafts as measured by microangiograms done 1 week postoperatively. In this model, if the bone scan is intended to monitor the circulatory status and viability of the bone graft, it must be done earlier than 1 week postoperative prior to the onset of creeping repair in both vascularized and nonvascular ulna autografts.

Modified instruments for wrist fusion

A technique and new instruments for intramedullary fixation of the wrist arthrodesis is described, based on the technique of Clayton, popularized by Nalebuff and Millender. This allows early mobilisation, secure fixation and simplicity of the technique. It also allows other surgical procedures to be performed under the same anaesthetic and tourniquet due to the reduction in operative time.

Canine cortical bone autograft remodeling in two simultaneous skeletal sites

The morphological and physical aspects of cortical bone autografts implanted in dogs for 1-9 months in two differently located skeletal defects are reported with a twofold aim: to provide a reference system for further comparison with various allografts and to delineate a general pattern of cortical bone graft healing. A 3-cm osteoperiosteal gap was created in the diaphyseal segment of the ulna and fibula of mature dogs. The grafts, freed from periosteum and bone marrow, were then inverted and replaced for the autografts in the left limb bone without internal fixation or external splints. On the right side, different allografts were tested. A group of three animals also had an unfilled segmental resection on the right as control. Dogs were observed for 1, 2, 3, 6, and 9 months and were able to bear weight within 3 days. Twenty-eight ulnae and 27 fibulae were available for this autograft study. Fluorochromes were injected at mid-term and at the end of the observation. All the grafts were assessed morphologically by cross-section microradiographs and ultraviolet light microscopy, and a morphometric analysis for porosity and fluorescence was done. To evaluate the physical aspects of graft healing, the recovered ulnar autografts, when available, were submitted to photon absorptiometry and to torsional loading. Morphologically, resorption was found to invade the cortical bone graft transversely through radial tunnels, and in addition to the host-bone-graft junction, the entire transplant surface provided another way for revascularization. The highest porosity level was achieved 2 months after surgery for both ulna and fibula, while new bone formation, as assessed by fluorochromes, was most important at 3 months. At 9 months, porosity remained above the normal range as determined in a set of five nongrafted dogs. While the lack of correlation for porosity between the two grafts suggests that local factors are more important in graft resorption, the observed correlation for fluorescence indicates that new bone deposition is more dependent upon skeletal metabolic activity. Within each graft, porosity and new bone formation were not well correlated. In the ulna, the bone mineral content (BMC) reflected the graft volumetric variations during the remodeling, with the lowest mean value at 3 months. For each graft, BMC was well correlated with the torsional stiffness. When torsionally loaded, the maximal tangential shear stress at failure of the graft was negatively related to its cortical porosity.(ABSTRACT TRUNCATED AT 400 WORDS)

Retinoic acid modifies positional memory in the anteroposterior axis of regenerating axolotl limbs

The effects of retinoic acid (RA) on anteroposterior (AP) positional memory of regenerating axolotl limbs were tested after removing the anterior or posterior half from the zeugopodium (lower arm or leg). RA (150 micrograms/g body wt) was injected into groups of animals bearing the following types of limbs: (1) anterior and posterior half zeugopodia grafted to the eyesocket and amputated distally 7 days later; (2) unamputated anterior and posterior half zeugopodia in situ; (3) double anterior and double posterior half zeugopodia amputated distally 7 days after their construction; (4) sham-operated zeugopodia amputated distally 7 days after operation. Controls consisted of these four groups injected with the retinoid solvent, dimethyl sulfoxide, or not injected. Control half zeugopodia grafted to the eyesocket regenerated no more than one or two digits. Control unamputated half zeugopodia in situ underwent partial or complete regeneration of the missing half from the proximal and midline wound surfaces exposed during construction of the half zeugopodia. Control double anterior and posterior zeugopodia both regenerated symmetrical, hypomorphic regenerates with 1-3 digits in the double anteriors and 1-6 digits in the double posteriors. Sham-operated controls regenerated normally. Regenerating anterior and posterior halves responded differently to RA. RA-treated anterior half zeugopodia in the eyesocket, and anterior half stumps adjacent to the unamputated posterior half zeugopodia in situ both produced regenerates that duplicated stump structures in the proximodistal axis and formed a complete and normal AP pattern. RA-treated double anterior zeugopodia regenerated proximodistal-duplicated pairs of mirror-imaged limbs, each with a complete and normal AP pattern. In contrast, half posterior zeugopodia in the eyesocket, the posterior half stumps of unamputated half anterior zeugopodia in situ, and double posterior zeugopodia all failed to regenerate. These results suggest that RA modifies positional memory in only one direction in the AP axis, posterior.

Cortical bone grafts with muscle pedicles. An experimental study of survival and ability to bridge a bone gap

A cortical bone graft on a muscle pedicle was taken from the ulna and transferred to bridge a complete defect of the radius in 16 dogs. In 14 control dogs a free graft was used, that is, one without a muscle pedicle. Union in the group with pedicle grafts was far superior to that in the group with free grafts, mainly because in those with pedicle grafts there was good subperiosteal new bone formation from active viable periosteum. In six of the pedicle grafts the viability of some osteocytes was retained over a 12-week period and in five the graft was almost completely replaced by new bone.

Fate of vascularized and nonvascularized autografts

Controlled laboratory data demonstrate biologic and mechanical characteristics of orthotopically placed canine ulnar autografts. The pattern of bone repair was similar in vascular and nonvascular ulnar grafts beginning with resorption followed by appositional reactive bone formation. The time intervals in the sequence were accelerated in the vascularized grafts. Both the strength and stiffness of the vascularized grafts were found to be significantly greater in Groups studied from six weeks to six months postoperation. There was no statistical difference between the grafts for mechanical testing performed on dogs either one week or one year postoperation. The vascularized ulnar bone grafts fared better than comparably sized nonvascularized grafts and were more rapidly repaired. The mechanical testing demonstrated superior strength and stiffness of the vascularized grafts throughout the repair process.

Bone grafting: role of histocompatibility in transplantation

The role of histocompatibility matching in bone allografting was studied in two canine bone graft models. In a cancellous ulnar segmental replacement model, frozen bone allografts exchanged between closely matched dogs were significantly better incorporated by radiographic and histologic criteria than were strongly incompatible grafts. Frozen allografts from disparate donors in recipients receiving immunosuppression appeared indistinguishable 6 months later from those in the untreated closely matched groups and from fresh autografts. Fresh vascularized orthotopically placed fibular bone grafts were evaluated by quantitative blood flow assessment, microangiography, and fluorochrome histomorphometry. Revascularized grafts exchanged between untreated closely matched dogs demonstrated preservation of blood flow and a pattern of repair that was delayed but not otherwise different than vascularized autografts. These results suggest that fresh vascularized grafts in the judiciously matched or immunosuppressed recipient offer attractive clinical possibilities.

Closure of a defect of the femur with a compound free forearm transfer including both the radius and the ulna

We report our experience of a patient with a most unusual and unfortunate combination of injuries. We feel that this case demonstrates not only the value of vascularised bone grafts in the treatment of large defects but also the imaginative use of seemingly useless parts in surgical reconstruction.

Osteoinductivity of partially decalcified alloimplants in healing of large osteoperiosteal defects

About 3.5 cm osteoperiosteal circumferential gaps in rabbit ulnae were bridged by partially decalcified (by 0.6 M HCl) allogenic implants, 8-12 weeks after implantation complete bridging of the gap by new bone formation and union at host-graft junctions was observed in 97.2 per cent of the experiments. Instant permeability and the powerful osteo-inductive potential of the implant coupled with some degree of mechanical stability provided by partial decalcification ensured successful bone formation in almost all the experiments. It is suggested that partially decalcified allogenic bone matrix preserved in 70 per cent ethanol may be a reasonably good substitute for autologous bone graft.

Free microvascular epiphyseal transplantation: an experimental study in dogs

Orthopic and heterotopic microvascular epiphyseal transplants based on periosteal blood supply were performed in 2 experiments. Heterotopic transplants averaged 69 per cent of growth of non-operated control bones. Orthopic transplants achieved a better result but the number of dogs available for evaluation was too small to be conclusive. The question is raised whether additional blood supply to the epiphyseal side of the transplant could improve the results.

Growth in revascularized bone grafts in young puppies

The results of microvascular transfers of growing ulnas in puppy forelegs have been studied. These transfers were carried out both heterotopically and orthotopically. The growth in the revascularized bone grafts has been compared to that in heterotopic, nonvascularized ulna transfers and to normal ulnar growth. The growth in the vascularized bone grafts was significantly greater than in the nonvascularized grafts, but significantly less than in normal ulnar growth. A metaphyseal contribution to the blood supply of the growing portion of long bones is suggested.

Compression treatment of long bone pseudarthroses

In 122 cases of non-union and delayed union, rigid fixation with Swiss compression plates without the use of casts, produced 92.6% success with the first operation. Half of the cases, especially in the well aligned fractures with hypertrophic callus, were treated without bone grafts and without resecting the pseudarthrosis. Non-resection did not adversely affect the healing time or rate. There were 9 failures or 7.4% chiefly in the difficult hypovascular atrophic bone-grafted group. Many of these cases were treated with shingling and grafts as well; 4 cases showed signs of healing but refractured secondary to trauma; 4 of 5 failures were replated and eventually healed. About 83% of the 24 infected cases healed with one compression plate operation. All of the fractures that were dry pre- and post-operatively united. In a few with drainage and poor skin coverage or cicatrix, rigid fixation with external fixators and Steinmann pins were applied. Early active exercises with delayed weight-bearing until union, gave remarkable return of function even in the difficult metaphyseal pseudarthroses. The compression method of rigid fixation is an excellent adjuvant to pseudarthrosis therapy.

Prevention and treatment of non-union of slightly displaced fractures of the lateral humeral condyle in children. An end-result study

In a ten-year study of the healing responses of thirty-one children with fresh fractures of the lateral condyle of the humerus with less than four millimeters of displacement, there were three patterns of healing. Forty-nine per cent healed rapidly in six weeks with abundant callus and periosteal new bone. Thirty-eight per cent healed slowly over eight to twelve weeks, mostly by endosteal union with little callus. Thirteen per cent had progressive displacement of the fragment in the plaster cast and required surgery to prevent non-union. Those fractures that healed had two millimeters or less of displacement of the fragment initially. Those that did not heal had an average of three millimeters of initial displacement. Established non-unions in good position that were symptomatic while the elbow was still immature were salvaged by bone-grafting, sparing the physis of the condylar fragment. The fragment united and grew with the elbow to maturity, producing an excellent end result on long-term follow-up. When the physeal plate of the ununited condylar fragment was absent, the fragment could not grow with the elbow and the result of surgery was less satisfactory.