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Ununited Diaphyseal Forearm Fractures with Segmental Defects: Plate Fixation and Autogenous Cancellous Bone-Grafting
David Ring, MD1; Christian Allende, MD2; Koroush Jafarnia, MD3; Bartolome T. Allende, PhD2; Jesse B. Jupiter, MD1
1 Department of Orthopaedic Surgery, Massachusetts General Hospital, ACC 525 (D.R.) and ACC 527 (J.B.J.), 15 Parkman Street, Boston, MA 02114. E-mail address for D. Ring: dring@partners.org
2 Department of Orthopaedic Surgery and Rehabilitation, Sanatorio Allende, Hipolito Yrioyen 384, Cordoba 5000, Argentina
3 Department of Orthopaedics, Baylor College of Medicine, 17270 Red Oak Drive, Suite 200, Houston, TX 77090.
View Disclosures and Other Information
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.
Investigation performed at Massachusetts General Hospital, Boston, Massachusetts, and Sanatorio Allende, Cordoba, Argentina

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2004 Nov 01;86(11):2440-2445
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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.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    David Ring
    Posted on December 09, 2004
    Dr. Ring responds to Dr. Calif
    Massachusetts General Hospital

    To the Editor:

    Bone transport using distraction histogenesis (the Ilizarov concept) is certainly one alternative in the treatment of ununited fractures associated with bone defects; however, the appeal of the technique has been limited by the cumbersome nature of the frame, the challenge to the patient who must operate the frame correctly and deal with pin track infections and other problems, and the frequent docking site nonunions that require secondary open procedures.

    Dr. Calif describes the need for a “limited open exposure for surgical debridement, and removal of hardware” and expresses concern regarding “the surgical invasiveness and the resultant devascularization”. Our data demonstrate that these concerns may be overstated. The difference between a “limited open exposure” and a larger exposure for plate and screw application is limited in terms of bone vascularity if the surgeon takes care to keep the periosteum and muscle attachments intact as much as possible. When it is described that “large deficits are subsequently addressed by bone grafting after full restoration of bone length” this sounds as if techniques similar to the ones we described are being used—large cancellous bone grafts bridging defects and protected by fixation devices (in this case an external frame?).

    We have used the techniques of Ilizarov(1, 2), but prefer plate and screw fixation and bridging bone grafts(3, 4) because they are easier for the patient and the surgeon and the results may be superior(1).


    1. Ring D, Jupiter JB, Gan BS, Israeli R, Yaremchuk M. Infected nonunion of the tibia. Clin Orthop 1999;369:302-311.

    2. Ring D, Jupiter JB, Labropoulous PA, Guggenheim JJ, Stanitski DF, Spencer DM. Limb deformity in osteogenesis imperfecta treated by the method of distraction histogenesis. J Bone Joint Surg 1996;78A:220-225.

    3. Ring D, Jupiter JB, Quintero J, Sanders RA, Marti RK. Atrophic ununited diaphyseal fractures of the humerus with a bony defect: treatment by wave-plate osteosynthesis. J Bone Joint Surg [Br] 2000;82B:867-871.

    4. Ring D, Jupiter JB, Sanders RA, Quintero J, Santoro VM, Ganz R, et al. Complex nonunion of fractures of the femoral shaft treated by wave- plate osteosynthesis. J Bone Joint Surg 1997;79B:289-294.

    Edward Calif
    Posted on November 23, 2004
    Ununited diaphyseal forearm fractures with segmental defects
    Rambam Medical Center, Haifa, Israel

    To The Editor:

    We wish to congratulate Dr. Ring and colleagues for their contribution, "Ununited diaphyseal forearm fractures with segmental defects: plate fixation and autogenous cancellous bone-grafting" (2004;86:2440-5); one of the largest reported series of forearm nonunions, which will certainly help guide the management of this intricate problem.

    Concomitant compounding factors including active infection, failed previous fixation, bone deficit, or inadequate soft tissue coverage further complicate the problem of nonunion and constitute a surgical challenge. In our practice, we refrain from employing the plating technique in such cases. We have, however, a rewarding experience in utilizing the hybrid external fixation, based on the Ilizarov's concept, as an efficient therapeutic modality. Following limited exposure for surgical debridement, and removal of hardware, if any, the bones are fixated with a hybrid Ilizarov-AO frame. An isolated external fixation frame is applied to each bone, thus sparing the mobility of radio-ulnar joints. Each frame is transfixed to the bone with threaded mini-Schanz pins and Kirschner wires. Restoration of length is crucial, but is not always readily attainable long after injury. This is achieved postoperatively by gradual distraction through the fracture site at a rate of 1mm/day. Small bone deficits are usually bridged by bony tissue through distraction osteogenesis, while large deficits are subsequently addressed by bone grafting after full restoration of bone length. Early mobilization of the elbow, forearm, and wrist is encouraged postoperatively, thus achieving complete osseous union and good functional outcome.

    The hybrid frame offers favorable conditions for healing of both the bony and soft tissues by providing stable fixation, while still allowing axial micro-movements at the fracture site. Furthermore, this configuration minimizes the surgical invasiveness and the resultant devascularization. The transfixing pins and wires are inserted extra- focally, obviating the need for embedding hardware and nonvascularized bone in a dysvascular and potentially septic location.

    This promising modality poses a surgical alternative to plating and bone grafting. However, it requires patient's compliance and may be technically demanding.

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