Investigation performed at Massachusetts General Hospital, Boston, Massachusetts, and Sanatorio Allende, Cordoba, Argentina

Transcription

1 2440 COPYRIGHT 2004 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED Ununited Diaphyseal Forearm Fractures with Segmental Defects: Plate Fixation and Autogenous Cancellous Bone-Grafting BY DAVID RING, MD, CHRISTIAN ALLENDE, MD, KOROUSH JAFARNIA, MD, BARTOLOME T. ALLENDE, PHD, AND JESSE B. JUPITER, MD Investigation performed at Massachusetts General Hospital, Boston, Massachusetts, and Sanatorio Allende, Cordoba, Argentina Background: With current techniques of plate-and-screw fixation, diaphyseal nonunions of the radius and ulna are unusual. The few reports that have been published have discussed the use of structural corticocancellous bone grafts for the treatment of atrophic nonunions that are associated with osseous defects. We reviewed the rate of union and the functional results in association with the use of plate-and-screw fixation and autogenous cancellous (nonstructural) bone grafts. Methods: Thirty-five patients with an atrophic ununited diaphyseal fracture of the forearm were treated with 3.5-mm plate-and-screw fixation and autogenous cancellous bone-grafting. A segmental osseous defect with an average size of 2.2 cm (range, 1 to 6 cm) was present in each patient. Twenty of the original fractures had been open. Eleven patients had had treatment of a deep infection before referral to us. The nonunion involved both forearm bones in eight patients, the radius alone in sixteen patients, and the ulna alone in eleven patients. Results: The atrophic nonunion was associated with an open fracture in twenty patients, suboptimal fixation in twenty-two, a fracture-dislocation of the forearm in nine, and infection in eleven. All fractures healed without additional intervention within six months. Two patients had a subsequent Darrach resection of the distal part of the ulna for the treatment of arthrosis of the distal radioulnar joint. After an average duration of follow-up of forty-three months, the final arc of motion averaged 121 in the forearm, 131 at the elbow, and 137 at the wrist, with an average grip strength of 83% compared with that of the contralateral limb. According to the system of Anderson and colleagues, five patients had an excellent result, eighteen had a satisfactory result, eleven had an unsatisfactory result (because of elbow stiffness related to associated elbow injuries in three and because of wrist stiffness in eight), and one had a poor result (because of malunion). Conclusions: When the soft-tissue envelope is compliant, has limited scar, and consists largely of healthy muscle with a good vascular supply, autogenous cancellous bone-grafting and stable internal plate fixation results in a high rate of union and improved upper limb function in patients with diaphyseal nonunion of the radius and/or ulna. Level of Evidence: Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence. With current techniques of plate-and-screw fixation, the failure of a diaphyseal fracture of the forearm to heal is uncommon 1-3. As a consequence, few reports have been published to help guide the treatment of diaphyseal forearm nonunions Nonunion of a diaphyseal forearm fracture is usually associated with either a complex injury, a complication such as infection, or inadequate internal fixation 1-3. As a result, the majority of nonunions are atrophic and result in a defined bone defect 4,5,8,9,11. The treatment of these nonunions and associated bone defects must include restoration of length and alignment in order to restore functional forearm motion 3. For the most part, treatment has been based on stable plate fixation combined with either intercalary nonvascularized structural (corticocancellous) bone grafts 4,5,7-11 or vascularized grafts 6,12,13, the latter of which are used in conjunction with soft-tissue transfers when a nonunion with an osseous defect is complicated by inadequate or noncompliant soft-tissue coverage 13. To our knowledge, bridge-plating and

2 2441 autogenous cancellous bone-grafting has been used infrequently in the forearm 14. Given the documented success following the use of plate fixation and nonstructural, autogenous cancellous bone to bridge osseous defects in the tibia 14-19, femur 20-22, and humerus 23, we reviewed our experience with the use of similar techniques for the treatment of atrophic nonunions of the forearm that were associated with osseous defects measuring between 1 and 6 cm in length in order to document the rate of union and the functional result. Materials and Methods uring the eighteen-year period between 1983 and 2001, Dtwo surgeons (B.T.A. and J.B.J.) performed plate-andscrew fixation in fifty-four patients who had a diaphyseal nonunion of the forearm. The criteria for inclusion in the present study were (1) an atrophic nonunion with a segmental defect measuring between 1 and 6 cm in length, (2) treatment with autogenous cancellous bone-grafting, and (3) a minimum of twelve months of follow-up. For the purposes of this series, an atrophic nonunion was defined as an unstable fracture with no signs of healing at a minimum of four months after the injury. Nineteen patients were excluded, including five patients with a hypertrophic nonunion, four patients who had been treated earlier in the study period with a structural (corticocancellous) bone graft, four patients with an unstable or noncompliant soft-tissue envelope who received a vascularized bone and soft-tissue transfer 13, and six patients who had less than twelve months of follow-up and could not be contacted. The remaining thirty-five patients formed the study cohort. The human research committee approved a protocol for the retrospective review of medical records and selective invitations to return for a free clinical and radiographic examination. The study group included eighteen men and seventeen women with an average age of forty years (range, twenty-one to sixty-six years). Eighteen fractures involved the right arm, and seventeen involved the left arm; nineteen fractures (including all eighteen fractures involving the right arm and one of the seventeen fractures involving the left arm) involved the dominant limb. The mechanism of injury was a motor-vehicle or motorcycle accident for thirteen patients, a fall for ten, a work-related injury for nine, an assault for two, and a gunshot wound for one. The pattern of injury was a diaphyseal fracture of both forearm bones in twenty-two patients, a fracture of the radius with dislocation of the distal radioulnar joint (a Galeazzi fracture-dislocation of the forearm) in eight patients, an isolated fracture of the ulnar diaphysis in four patients, and a fracture of the proximal part of the ulna with anterior dislocation of the proximal radioulnar joint (an anterior Monteggia fracture) in one patient. Twenty fractures were associated with an open wound; according to the system of Gustilo and Anderson 24,25, there were five type-1, eight type-2, and seven type-3 fractures. Three patients sustained an injury of the ipsilateral upper extremity, including a fracture-dislocation of the elbow, a fracture of the distal part of the humerus, and a perilunate dislocation of the wrist. Four patients had associated neurovascular injury, including an injury of the ulnar nerve in three (with injury of the ulnar artery in one) and injury of the radial nerve in one. The initial treatment of the fracture consisted of plateand-screw fixation in twenty-six patients, intramedullary rod fixation in one, external fixation in four, and cast immobilization in four (after débridement of an open wound in two). Eleven patients had development of a deep infection, which was treated with serial débridement and parenteral antibiotics (Figs. 1-A through 1-D). All of the infections were quiescent at the time of the index procedure for the treatment of nonunion. Suppression of the infection was achieved by means of serial débridement until all infected and devitalized tissue had been removed, followed by a course of organism-specific parenteral antibiotics. At the time of the index procedure, thirty-one of the thirty-five patients had had at least one previous operative procedure, but only two patients had had two attempts to achieve union. The previous implant was thought to be of inadequate size in five patients (all of whom had received a onethird tubular plate) and of inadequate length in eight patients (all of whom had received only two screws on one side of the fracture). Including the nine patients who initially had been managed with a cast, an intramedullary device, or an external fixator, a total of twenty-two patients (63%) were considered to have had suboptimal fracture fixation. The nonunion involved both forearm bones in eight patients, the radius alone in sixteen patients, and the ulna alone in eleven patients. On the radial side, three fractures involved the proximal third of the diaphysis, seven involved the middle part of the diaphysis, and fourteen involved the distal third of the diaphysis. On the ulnar side, two fractures occurred proximally, eight occurred in the middle part of the diaphysis, and nine occurred distally. In thirty-four patients, the interval between the injury and the index procedure for the treatment of nonunion averaged thirteen months (range, four to forty-six months). The remaining patient had a nonunion of 252 months duration. After removal of loose implants, sclerotic or dysvascular bone, and inflammatory and fibrous tissues and restoration of the length and alignment of the bone, all thirty-five patients had a segmental osseous defect with an average length of 2.2 cm (range, 1 to 6 cm) as measured in the operative wound. Five patients had a defect measuring between 4 and 6 cm in length. Autogenous cancellous bone graft from the iliac crest (thirty-one patients), the resected distal part of the ulna (two patients), or both (two patients) was applied to the fracture site so that it entirely filled the defect. No bone-graft substitutes were used. The twenty-four radial nonunions were secured with a 3.5-mm plate that averaged between nine and ten holes (range, seven to fourteen holes) in length. A volar Henry exposure was used in eighteen patients, and a dorsal Thompson exposure was used in six. In four patients with a distal nonunion of both forearm bones and one patient with a longstanding radial nonunion after an open Galeazzi fracture-

3 2442 dislocation, a Darrach resection of the distal part of the ulna was performed. Thus, of the nineteen ulnar nonunions, four were excised and fifteen were repaired with a 3.5-mm plate that averaged nine holes (range, six to twelve holes) in length. A dynamic compression plate was used in twenty patients, and a limited-contact dynamic compression plate was used in fifteen (Synthes, Paoli, Pennsylvania). In three patients with a radial nonunion, the plate was contoured to stand away from the bone near the fracture site (the so-called wave-plate osteosynthesis method 21,22 ). Complications and Additional Procedures Two patients had a subsequent Darrach resection of the ulna for the treatment of pain and limited motion related to arthrosis of the distal radioulnar joint. Two patients had swelling, stiffness, and pain, findings that were suggestive of a chronic regional pain syndrome. The pain resolved in both patients, but the fingers remained stiff. There were no recurrent infections, wound problems, or major complications at the site from which the bone graft had been obtained. None of the plates were removed. Fig. 1-A Figs. 1-A through 1-D Radiographs of the forearm of a forty-three-year-old man who had Gustilo and Anderson type-3 open diaphyseal fractures of both the radius and ulna. Fig. 1-A A deep infection of the radius developed, and the plate and infected bone were removed. The radius was stabilized with an external fixator while the infection was treated with serial débridements and parenteral antibiotics. Evaluation The final functional result was rated at the time of the most recent follow-up with use of the system of Anderson and colleagues 2. According to this system, an excellent result is defined as a united fracture with <10 loss of elbow or wrist motion and <25% loss of forearm rotation, a satisfactory result is defined as a healed fracture with <20 loss of elbow or wrist motion and <50% loss of forearm rotation, an unsatisfactory result is defined as a healed fracture with >30 loss of elbow or wrist motion and >50% loss of forearm rotation, and failure is defined as malunion, nonunion, or unresolved chronic osteomyelitis. Results he patients were followed for an average of forty-three T months (range, twelve months to nineteen years). All Fig. 1-B Intraoperative distraction with an adjustable external fixator (a distractor) facilitated restoration of alignment and provided provisional stabilization.

4 THE JOUR NAL OF BONE & JOINT SURGER Y JBJS.ORG VO L U M E 86-A N U M B E R 11 N O VE M B E R 2004 U N U N I T E D D I A P HY S E A L F O R E A R M F R A C T U RE S : P L A T E F I X A T I O N A N D A U T O G E N O U S C A N C E L L O U S B O N E -G R A F T I N G Discussion ontemporary reports on plate-and-screw fixation of forearm fractures have demonstrated nonunion rates of well below 5%1-3,26,27. The present study represents one of the largest series of forearm nonunions that has been reported in the English-language literature. When forearm fractures fail to heal, hypertrophic nonunion is uncommon; this finding was noted in only five (9%) of the fifty-four patients who were treated by us. Nonunion of the forearm is related to (1) complex injuries, including open fracture, comminution, and fracturedislocation; (2) inadequate fixation; (3) fracture-dislocation; and (4) infection1-4,8,13,26. It is notable that in the present series, all of the atrophic forearm nonunions also were associated with a segmental osseous defect. This finding was directly related to C Fig. 1-C Early radiographs made after bridge-plating and autogenous cancellous bone-grafting. fractures healed within six months. The ulna healed with 15 of angulation in one patient and with <10 of angular deformity in the other patients. The final ranges of motion averaged 59 (range, 30 to 80 ) of pronation, 62 (range, 40 to 80 ) of supination, 65 (range, 40 to 80 ) of wrist extension, 72 (range, 40 to 90 ) of wrist flexion, 3 (range, 0 to 20 ) of elbow flexion contracture, and 134 (range, 100 to 145 ) of elbow flexion. The grip strength averaged 83% (range, 65% to 100%) of that on the contralateral side. According to the system of Anderson and colleagues2, five patients had an excellent result, eighteen had a satisfactory result, eleven had an unsatisfactory result (because of elbow stiffness related to associated elbow injuries in three and because of wrist stiffness in eight), and one had a poor result (because of malunion). Fig. 1-D The graft consolidated, and the fracture healed within six months. Satisfactory function was restored.

5 2444 bone loss at the time of débridement of an open wound or an infection, devascularization of bone in relation to implant application, an inflammatory response resulting from loose implants, and mobility at the site of the nonunion with resultant bone loss. The presence of a segmental osseous defect may have been accentuated in patients in whom one forearm bone was intact, thereby limiting the ability of the bones to shorten and to achieve apposition of the fragments. Optimal functioning of the radioulnar articulations depends on the maintenance or restoration of the alignment of the radius and ulna 3. In some patients with long-standing malalignment or dislocation of the distal radioulnar joint, realignment of the radioulnar relationship will result in painful distal radioulnar joint arthrosis after the abnormal joint is again brought into alignment. This finding was observed in two patients in our series, both of whom had a second procedure for resection of the distal part of the ulna. The use of nonvascularized, autogenous, corticocancellous grafts to treat forearm nonunions that are associated with defects has been reported in several small series 4,5,8-11. The disadvantages of this technique include morbidity at the donor site (usually the iliac crest 28 ), slow incorporation of the graft 7, and susceptibility to infection 7. While these disadvantages are not avoided by the use of an autogenous cancellous bone graft, it is our impression that they are diminished because the process of obtaining a nonstructural graft does not seem to be as painful or disfiguring and the cancellous graft is quickly vascularized and incorporated within a few weeks (although complete healing can take longer). Bridging of osseous defects with a purely cancellous bone graft requires a compliant, well-vascularized soft-tissue envelope 14, Christian et al. 15 and others 16,18,19 have reported healing after the treatment of extremely large tibial defects with use of cancellous graft alone when the soft-tissue envelope was either adequate or reconstructed with a latissimus dorsi flap. A scarred, noncompliant envelope with much of the muscle lost, devitalized, or scarred is much less likely to support the incorporation of autogenous cancellous grafts. In this situation, a vascularized bone transfer may be preferable. Several investigators have reported successful results in association with the use of a free fibular graft 6,12,13. This type of graft can be transferred as an osteoseptocutaneous flap, thereby reconstructing the soft tissues as well as the bone 13. The use of bridge-plating and nonstructural, autogenous cancellous bone-grafting for the treatment of atrophic nonunions associated with osseous defects has been used successfully in the femur and the humerus 23, again with the requisite that a supportive soft-tissue envelope is present. We achieved a high rate of union in association with the use of similar techniques for the treatment of atrophic forearm nonunions associated with segmental osseous defects. The functional results were diminished by residual stiffness related to the original trauma, previous operations, and prolonged immobilization and disuse of the limb. Nonetheless, all of our patients noted substantial functional improvement in comparison with the marked preoperative functional disability associated with an atrophic forearm nonunion. David Ring, MD Jesse B. Jupiter, MD Department of Orthopaedic Surgery, Massachusetts General Hospital, ACC 525 (D.R.) and ACC 527 (J.B.J.), 15 Parkman Street, Boston, MA address for D. Ring: dring@partners.org Christian Allende, MD Bartolome T. Allende, PhD Department of Orthopaedic Surgery and Rehabilitation, Sanatorio Allende, Hipolito Yrioyen 384, Cordoba 5000, Argentina Koroush Jafarnia, MD Department of Orthopaedics, Baylor College of Medicine, Red Oak Drive, Suite 200, Houston, TX In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from the AO Foundation. None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated. References 1. Chapman MW, Gordon JE, Zissimos AG. Compression-plate fixation of acute fractures of the diaphyses of the radius and ulna. 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