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Bone transport for the treatment of infected forearm nonunion
Injury, Int. J. Care Injured 45 (2014) 1880–1884
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Bone transport for the treatment of infected forearm nonunion Qun Zhang a,1, Peng Yin a,b,1, Ming Hao a, Jia Li a, Houchen Lv a, Tongtong Li a,b, Hao Zhang a, Guoqi Wang a, Lihai Zhang a,*, Peifu Tang a,* a b
Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing 100853, PR China Medical College, Nankai University, No. 94 Weijin Road, Tianjin 300071, PR China
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 25 July 2014
Objective: The objective of this study was to evaluate the effectiveness of the treatment of infected forearm nonunion by bone transport. Materials and methods: We retrospectively reviewed 16 patients with infected forearm nonunion treated by bone transport. Our study included 10 males and 6 females with a mean of age 38.25 years. The site of bone defects involved 9 radius and 7 ulna. The average length of the bone defects after radical debridement was 3.81 cm (range 2.2–7.5 cm). Results: The mean follow-up after removal of the frame was 39.63 months (range 26–55 months). No patient was lost to follow-up. All the patients had bone union and no recurrence of infection was observed. The mean external fixation time was 6.19 months (range 3–10 months), and the mean external fixation index was 1.63 months/cm (range 1.14–2.00 months/cm). The mean degrees of wrist flexion were 49.698 (range 45–558), and the mean degrees of wrist extension were 50.638 (range 40–608). The mean degrees of elbow flexion were 143.128 (range 135–1508), and the mean degrees of elbow extension were 4.698 (range 0–208). The mean degrees of forearm pronation were 82.508 (range 70–908), and the mean degrees of forearm supination were 83.758 (range 75–908). Conclusion: Our study suggested that bone transport in the treatment of infected forearm nonunion acquired satisfied functional results. Radical debridement is the key step to control bone infection. ß 2014 Elsevier Ltd. All rights reserved.
Keywords: Infected nonunion Forearm Bone transport Bone defects
Introduction Infected forearm nonunion is rare in clinical practice, but the problem is usually very complex on account of the presence of segmental bone loss, bone necrosis, fracture instability, sinus tract formation, and scar adhesion of the soft tissue [1–3]. To date, the treatment of infected forearm nonunion has still been a challenge for orthopaedic surgeons [1–7]. Some different modalities of treatment have been described, but the results of the treatment are not completely satisfying. Corticocancellous bone grafting or a non-vascularized fibular graft has a limitation of the size of bone defects, which is only suitable for the treatment of bone defects <6 cm [8,9]. Although massive bone defects >6 cm can be managed with a vascularized fibular graft, the treatment is often
* Corresponding authors. Tel.: +86 10 01066938101; fax: +86 10 6816 1218. E-mail addresses: [email protected] (L. Zhang), [email protected], [email protected] (P. Tang). 1 These authors are both co-first authors. http://dx.doi.org/10.1016/j.injury.2014.07.029 0020–1383/ß 2014 Elsevier Ltd. All rights reserved.
complicated by a low rate of primary union and a high rate of infection and thrombosis [10,11]. Bone transport has been successfully used in lower limbs, being less invasive and more versatile compared to other methods, and it can treat infected nonunion with bone defects of any length. However, there are seldom reports about infected forearm nonunion treated by bone transport. Therefore, we describe our successful experience in the treatment of infected forearm nonunion by bone transport. Patients and methods Between January 2004 and January 2011, 22 patients with infected forearm nonunion were treated in our institution. Our eligible criteria were: (1) patients treated by bone transport, (2) patients 18 years of age, and (3) patients without an associated neurological impairment of the ipsilateral upper extremity. Sixteen patients were included in our study. Our study included 10 males and six females with an average age of 38.25 years (range 19–62 years). The mechanisms of initial injury included traffic accident in 10 patients, falling in four
Q. Zhang et al. / Injury, Int. J. Care Injured 45 (2014) 1880–1884
patients, and injuries by machines in two patients. The site of bone defects involved nine radii and seven ulnae. Infected forearm nonunion existed at the time of surgery and the mean number of previous operations was 2.38 (range 1–5 operations). The mean length of bone defects was 3.81 cm (range 2.2–7.5 cm), which was measured in the operation. Infecting samples that were obtained from purulent drainage or deep bone at the site of infected nonunion were cultured and the outcomes were 11 patients with infecting organism of Staphylococcus aureus, three patients with Pseudomonas, one patient with Escherichia coli, and one patient with Klebsiella. Further details were listed in Table 1. Surgical technique The patients were positioned laterally on a radiolucent table. The operative incisions were performed in accordance with previous surgical incisions when possible. Then the infected scarred soft tissue and necrotic bone were debrided radically. Cortical bone bleeding, described as the so-called paprika sign, was accepted as an indication of vital tissue [12]. Representative tissue cultures were obtained from infected tissue for the sake of finding out the infectious bacterium to choose sensitive antibiotics. Two pins were inserted about 2–3 cm above and below the preselected osteotomy site under an image intensifier control. A 1–2-cm incision was made in order to expose the preselected osteotomy site, and then a subperiosteally transverse osteotomy was performed. The periosteum was sutured and the incisions were closed with drainage tubes. If the infected site had large soft tissue defects, open dressing changing or vacuum sealing drainage (VSD) were performed to close the wound. Postoperative protocol All patients received a course of sensitive antibiotics for 2–4 weeks intravenously and were encouraged to perform isometric muscle motions such as pushing a wall and joint range-of-motion exercises on the second day after the operation. Distraction was performed at the rate of 0.25 mm per 6 h after the latency period of 7–10 days. If the regeneration quality were poor, the speed of distraction would slow down. When bone transport was completed, the radius or ulna docked ends were compressed by 0.25 mm per day in order to provide full contact until the patient felt pain at the docking site. Radiographs were reviewed every 2 weeks during the distraction period and monthly during the consolidation period. The
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monolateral external fixator was removed when the radiographs showed solid docking-site union and the regenerated area had a minimum of three complete cortices. The flexion and extension of the wrist and elbow joint and the pronation and supination of forearm were evaluated at the end of follow-up. Results The mean follow-up after removal of the frame was 39.63 months (range 26–55 months). No patient was lost to follow-up. All the patients had bone union and no recurrence of infection was observed. The mean external fixation time was 6.19 months (range 3–10 months), and the mean external fixation index was 1.63 months/cm (range 1.14–2.00 months/cm). The mean degrees of wrist flexion were 49.698 (range 45–558), and the mean degrees of wrist extension were 50.638 (range 40–608). The mean degrees of elbow flexion were 143.128 (range 135–1508), and the mean degrees of elbow extension were 4.698 (range 0–208). The mean degrees of forearm pronation were 82.508 (range 70–908), and the mean degrees of forearm supination were 83.758 (range 75–908). Further details are listed in Table 2 (Fig. 1). Complications All the patients experienced pain during the distraction period and required oral analgesics. Ten patients had a pin-track infection (case 1, cases 3 and 4, case 6, case 9, cases 11–13, and case 16), and these patients presented with only local inflammation, which was treated by pin care and oral administration of empirical broadspectrum antibiotics. Three patients required bone grafting at the docking site to obtain union (case 1, case 9, and case 15). Poor regenerated bone formation occurred in two patients (case 4 and case 11), who also required bone grafting to obtain union at last. One patient (case 2) had dislocation of the radial head, which was treated by reduction of the radial head and reapplication of an external fixator, and the patients had bone union at last (Fig. 2). There were no neurovascular complications or a compartment syndrome. Discussion This is a retrospective study of bone transport for the treatment of infected forearm nonunion. The present study showed that the infected forearm nonunion treated by bone transport acquired satisfying functional results. The motion ranges of the wrist, elbow,
Table 1 Characteristics of 16 patients with infected forearm nonunion. Case number
Sex
Age (years)
Mechanisms of initial injury
Site of bone defect
Bone defect (cm)
Number of previous operations
Infecting organism
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Male Female Male Male Female Male Male Male Male Female Female Female Male Male Male Female
62 38 40 28 30 24 19 43 41 54 32 29 38 50 45 39
TA TA F TA TA HM TA F TA F HM TA TA TA F TA
Radius Ulna Radius Radius Radius Ulna Ulna Radius Radius Ulna Radius Ulna Ulna Ulna Radius Radius
7.5 4.4 3.7 3.5 2.4 5 2.2 2.6 4.7 2.8 3.7 3.5 4 3.3 3.5 4.2
5 2 2 3 1 2 1 2 3 2 3 2 4 1 2 3
Staph. aureus Staph. aureus Pseudomonas Staph. aureus E. coli Staph. aureus Staph. aureus Pseudomonas Staph. aureus Staph. aureus Staph. aureus Pseudomonas Staph. aureus Staph. aureus Klebsiella Staph. aureus
F, falling; TA, traffic accident; HM, hurting by machine.
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Fig. 1. (A) Radiograph of a 62-year-old man (case 1) who had an infected nonunion of the right forearm with internal fixation. (B) Debridement of the site of infected nonunion with 7.5 cm bone defect in radius and corticotomy of radius (red arrow) after application of the fixator. (C) Two weeks after operation with bone transport. (D) Two months after operation with bone transport. (E) Eight months after operation with transport, it showed good consolidation of the regenerate, and bone union at the docking site was obtained by bone grafting. (F) After ten months of the surgery, it showed complete bone union and the external fixators were removed. (For interpretation of the references to colour in figure legend, the reader is referred to the web version of the article.)
Fig. 2. (A) Radiograph of a 38-year-old women (case 2) who had a dislocation of radial head (red arrow) at six weeks after operation with bone transport. (B) The patient was treated by reduction of radial head and re-applying an external fixator. (C) It showed bone union at four months of surgery. (D) After five months of the operation, the external fixator was removed, and it showed complete bone union. (For interpretation of the references to colour in figure legend, the reader is referred to the web version of the article.)
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Table 2 Results of treatment in the 16 patients. Case number
External fixation time (months)
External fixation index (months/cm)
Follow-up (months)
Wrist flexion/ extension (8)
Elbow extension/ flexion (8)
Forearm pronation (8)
Forearm supination (8)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
10 5 6 7 4 9 3 5 9 4 6 6 7 5 6 7
1.33 1.14 1.62 2 1.66 1.8 1.36 1.92 1.91 1.43 1.62 1.71 1.75 1.52 1.71 1.67
55 36 40 44 28 38 26 44 48 36 40 45 40 36 42 36
50–0–50 55–0–45 45–0–40 50–0–55 50–0–55 50–0–50 55–0–60 50–0–40 45–0–50 50–0–60 50–0–40 50–0–55 45–0–55 50–0–50 50–0–50 50–0–55
0–145 5–140 0–135 10–140 0–150 5–140 0–150 20–135 10–140 0–145 10–140 0–145 5–140 0–150 10–145 0–150
85 80 75 70 90 85 90 85 75 85 80 80 80 85 90 85
85 75 80 85 85 80 90 80 85 85 90 85 80 85 85 85
and forearm were nearly normal levels. All the patients achieved bone union and no recurrence of infection was observed. The main goals in the treatment of infected forearm nonunion are to debride all infectious tissues radically, regain proper length and relationship between forearm bones, achieve bone union, and recover an optimal function of forearm results. Various methods have been used for the treatment of infected forearm nonunion including bone grafting, non-vascularized fibular graft, vascularized fibular graft, and bone transport. Bone grafting is the most common treatment for forearm bone defects. Prasarn et al. reported 15 patients with infected forearm nonunion were treated by the protocol that combines aggressive debridement, definitive fixation following 7–14 days, tricortical iliac crest bone grafting as necessary, leaving wounds open to heal by secondary intention, antibiotic treatment for 6 weeks, and early function exercise [1]. All patients eventually had infection-free union, and the average length of bone defects was 2.1 cm. In another study, 35 patients (including 11 infected forearm nonunion) were treated by cancellous autograft, but the authors did not provide a detailed treatment protocol for the infected patients, and the mean length of bone defects was 2.2 cm. Although bone grafting is an effective treatment for forearm bone defects, it is difficult to treat the patient with massive bone defects >6 cm [13]. In addition, the grafted bone may be absorbed [14]. The use of non-vascularized fibular graft has been successful in the treatment of bone defects, but the method relies on revascularization, and it may take many months to be incorporated during which time they lose much of their strength and are susceptible to fracture [10]. Vascularized fibular graft has been introduced in the treatment of massive bone defects. Its advantage is that it does not rely on revascularization and therefore should become fully incorporated sooner. Nevertheless, it is a technically demanding procedure with a high rate of infection and thrombosis of the graft vessels [11,15,16]. Donor-site morbidity is also common. Gore et al. reported that most patients had mild muscle weakness after removal of a portion of the fibula [17]. Gonzalez et al. reported that excision of a segment of the fibula was statistically linked with valgus deformity [18]. Bone transport is suitable for the treatment of infected nonunion with bone defects of any length. It can treat infection and bone nonunion simultaneously. Hence, bone transport has gradually been a major treatment for infected nonunion, particularly in the lower extremity [19–22]. However, reports on the treatment of infected forearm nonunion by bone transport were rare [3,4]. Therefore, we conducted this study of bone transport for the treatment of infected forearm nonunion. In our study, the mean degrees of forearm pronation and supination were better than the 68.38 and 70.78 reported by Liu
et al. [3] and the mean degrees of wrist flexion and extension were similar to the 50.78 and 51.08 reported by Liu et al. [3] The external fixation index was higher than the 42.5 days/cm reported by Liu et al. [3] and the reason may be a larger size of bone defects in our study. The mean complications of every patient was 1 (16/16), which was lower than the 1.86 (39/21) reported by Liu et al. [3]. The pin-track infection rate was 62.5% (10/16), but the degree of pin-track infection was slight. We thought that meticulous pin care was the key to avoiding the complication. There was a dislocation of the radial head in our study. We believed that good mechanical stability of the monolateral external fixator could prevent the complication; meanwhile, we also should pay more attention to meticulously adjust the external fixator during the distraction period. In our experience, some important aspects of bone transport should be paid attention: (1) we should choose a monolateral external fixator with good mechanical stability based on specific conditions of the patient. (2) We should perform a subperiosteally transverse osteotomy and try our best to protect the blood supply of periosteum. (3) Debridement should be performed radically in order to avoid the recurrence of infection. This is the key step to control bone infection. (4) Distraction usually begins between 7 and 10 days after the operation at a rate of 0.25 mm per 6 h. If the regeneration quality is poor, the speed of distraction will slow down. We described a successful alternative technique for the treatment of the challenging problem of infected forearm nonunion. The main strength of our study is that all the operations were performed by the same orthopaedic surgeon, which can avoid the differences caused by different surgeons’ preference and experience. A number of data on the characteristics of patients, treatment results, and complications were reported in our study. However, our study has its limitations. It is retrospective in nature and the number of patients is relatively small, and there is no control group to compare our results with. More prospective randomized controlled trials are needed to overcome the limitations of our study. In conclusion, our study suggested that bone transport in the treatment of infected forearm nonunion acquired satisfying functional results. Radical debridement is the key step to control bone infection.
Conflict of interest statement Each author certifies that he has no commercial associations that might pose a conflict of interest with the submitted article.
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References [1] Prasarn ML, Ouellette EA, Miller DR. Infected nonunions of diaphyseal fractures of the forearm. Arch Orthop Trauma Surg 2010;130:867–73. [2] Ring D, Allende C, Jafarnia K, Allende BT, Jupiter JB. Ununited diaphyseal forearm fractures with segmental defects: plate fixation and autogenous cancellous bone-grafting. J Bone Jt Surg 2004;86:2440–5. [3] Liu T, Liu Z, Ling L, Zhang X. Infected forearm nonunion treated by bone transport after debridement. BMC Musculoskelet Disord 2013;14:273. [4] Hani E-M, Elalfi B, Wasfi K. Functional outcome following treatment of segmental skeletal defects of the forearm bones by Ilizarov application. Acta Orthop Belg 2005;71:157–62. [5] dos Reis FB, Faloppa F, Fernandes HJA, Albertoni WM, Stahel PF. Outcome of diaphyseal forearm fracture-nonunions treated by autologous bone grafting and compression plating. Ann Surg Innov Res 2009;3:5. [6] Noaman HH. Management of upper limb bone defects using free vascularized osteoseptocutaneous fibular bone graft. Ann Plast Surg 2013;71:503–9. [7] Malki A, Wong-Chung J, Hariharan V. Centralization of ulna for infected nonunion of radius with extensive bone loss. A modified Hey–Groves procedure. Injury 2000;31:345–9. [8] Omololu B, Ogunlade S, Alonge T. Limb conservation using non vascularised fibular grafts. W Afr J Med 2002;21:347–9. [9] Stevanovic M, Gutow AP, Sharpe F. The management of bone defects of the forearm after trauma. Hand Clin 1999;15:299–318. [10] Steinlechner C, Mkandawire N. Non-vascularised fibular transfer in the management of defects of long bones after sequestrectomy in children. J Bone Jt Surg B Vol 2005;87:1259–63. [11] Han C, Wood M, Bishop A, Cooney W. Vascularized bone transfer. J Bone Jt Surg 1992;74:1441–9.
[12] Eralp L, Kocaoglu M, Rashid H. Reconstruction of segmental bone defects due to chronic osteomyelitis with use of an external fixator and an intramedullary nail. Surgical technique. J Bone Jt Surg Am Vol 2007;89(Suppl. 2 Pt 2):183–95. [13] Arai K, Toh S, Yasumura M, Okamoto Y, Harata S. One-bone forearm formation using vascularized fibula graft for massive bone defect of the forearm with infection: case report. J Reconstr Microsurg 2001;17:151–6. [14] Zhang X, Liu T, Li Z, Peng W. Reconstruction with callus distraction for nonunion with bone loss and leg shortening caused by suppurative osteomyelitis of the femur. J Bone Jt Surg B Vol 2007;89:1509–14. [15] Yajima H, Tamai S, Mizumoto S, Inada Y. Vascularized fibular grafts in the treatment of osteomyelitis and infected nonunion. Clin Orthop Relat Res 1993;256–64. [16] Minami ATK, Iwasaki N, Kato H, Kaneda K. Vascularised fibular grafts. J Bone Jt Surg [Br] 2000;82-B:1022–5. [17] Gore DR, Gardner GM, Sepic SB, Mollinger LA, Murray MP. Function following partial fibulectomy. Clin Orthop Relat Res 1987;220:206–10. [18] Gonza´lez-Herranz P, del Rı´o A, Burgos J, Lo´pez-Mondejar JA, Rapariz JM. Valgus deformity after fibular resection in children. J Pediatr Orthop 2003;23:55–9. [19] Maini L, Chadha M, Vishwanath J, Kapoor S, Mehtani A, Dhaon BK. The Ilizarov method in infected nonunion of fractures. Injury 2000;31:509–17. [20] Sala F, Thabet AM, Castelli F, Miller AN, Capitani D, Lovisetti G, et al. Bone transport for postinfectious segmental tibial bone defects with a combined Ilizarov/Taylor Spatial Frame technique. J Orthop Trauma 2011;25:162–8. [21] Megas P, Saridis A, Kouzelis A, Kallivokas A, Mylonas S, Tyllianakis M. The treatment of infected nonunion of the tibia following intramedullary nailing by the Ilizarov method. Injury 2010;41:294–9. [22] Krishnan A, Pamecha C, Patwa JJ. Modified Ilizarov technique for infected nonunion of the femur: the principle of distraction-compression osteogenesis. J Orthop Surg (Hong Kong) 2006;14:265–72.
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Bone transport for the treatment of infected forearm nonunion Qun Zhang a,1, Peng Yin a,b,1, Ming Hao a, Jia Li a, Houchen Lv a, Tongtong Li a,b, Hao Zhang a, Guoqi Wang a, Lihai Zhang a,*, Peifu Tang a,* a b
Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxin Road, Beijing 100853, PR China Medical College, Nankai University, No. 94 Weijin Road, Tianjin 300071, PR China
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 25 July 2014
Objective: The objective of this study was to evaluate the effectiveness of the treatment of infected forearm nonunion by bone transport. Materials and methods: We retrospectively reviewed 16 patients with infected forearm nonunion treated by bone transport. Our study included 10 males and 6 females with a mean of age 38.25 years. The site of bone defects involved 9 radius and 7 ulna. The average length of the bone defects after radical debridement was 3.81 cm (range 2.2–7.5 cm). Results: The mean follow-up after removal of the frame was 39.63 months (range 26–55 months). No patient was lost to follow-up. All the patients had bone union and no recurrence of infection was observed. The mean external fixation time was 6.19 months (range 3–10 months), and the mean external fixation index was 1.63 months/cm (range 1.14–2.00 months/cm). The mean degrees of wrist flexion were 49.698 (range 45–558), and the mean degrees of wrist extension were 50.638 (range 40–608). The mean degrees of elbow flexion were 143.128 (range 135–1508), and the mean degrees of elbow extension were 4.698 (range 0–208). The mean degrees of forearm pronation were 82.508 (range 70–908), and the mean degrees of forearm supination were 83.758 (range 75–908). Conclusion: Our study suggested that bone transport in the treatment of infected forearm nonunion acquired satisfied functional results. Radical debridement is the key step to control bone infection. ß 2014 Elsevier Ltd. All rights reserved.
Keywords: Infected nonunion Forearm Bone transport Bone defects
Introduction Infected forearm nonunion is rare in clinical practice, but the problem is usually very complex on account of the presence of segmental bone loss, bone necrosis, fracture instability, sinus tract formation, and scar adhesion of the soft tissue [1–3]. To date, the treatment of infected forearm nonunion has still been a challenge for orthopaedic surgeons [1–7]. Some different modalities of treatment have been described, but the results of the treatment are not completely satisfying. Corticocancellous bone grafting or a non-vascularized fibular graft has a limitation of the size of bone defects, which is only suitable for the treatment of bone defects <6 cm [8,9]. Although massive bone defects >6 cm can be managed with a vascularized fibular graft, the treatment is often
* Corresponding authors. Tel.: +86 10 01066938101; fax: +86 10 6816 1218. E-mail addresses: [email protected] (L. Zhang), [email protected], [email protected] (P. Tang). 1 These authors are both co-first authors. http://dx.doi.org/10.1016/j.injury.2014.07.029 0020–1383/ß 2014 Elsevier Ltd. All rights reserved.
complicated by a low rate of primary union and a high rate of infection and thrombosis [10,11]. Bone transport has been successfully used in lower limbs, being less invasive and more versatile compared to other methods, and it can treat infected nonunion with bone defects of any length. However, there are seldom reports about infected forearm nonunion treated by bone transport. Therefore, we describe our successful experience in the treatment of infected forearm nonunion by bone transport. Patients and methods Between January 2004 and January 2011, 22 patients with infected forearm nonunion were treated in our institution. Our eligible criteria were: (1) patients treated by bone transport, (2) patients 18 years of age, and (3) patients without an associated neurological impairment of the ipsilateral upper extremity. Sixteen patients were included in our study. Our study included 10 males and six females with an average age of 38.25 years (range 19–62 years). The mechanisms of initial injury included traffic accident in 10 patients, falling in four
Q. Zhang et al. / Injury, Int. J. Care Injured 45 (2014) 1880–1884
patients, and injuries by machines in two patients. The site of bone defects involved nine radii and seven ulnae. Infected forearm nonunion existed at the time of surgery and the mean number of previous operations was 2.38 (range 1–5 operations). The mean length of bone defects was 3.81 cm (range 2.2–7.5 cm), which was measured in the operation. Infecting samples that were obtained from purulent drainage or deep bone at the site of infected nonunion were cultured and the outcomes were 11 patients with infecting organism of Staphylococcus aureus, three patients with Pseudomonas, one patient with Escherichia coli, and one patient with Klebsiella. Further details were listed in Table 1. Surgical technique The patients were positioned laterally on a radiolucent table. The operative incisions were performed in accordance with previous surgical incisions when possible. Then the infected scarred soft tissue and necrotic bone were debrided radically. Cortical bone bleeding, described as the so-called paprika sign, was accepted as an indication of vital tissue [12]. Representative tissue cultures were obtained from infected tissue for the sake of finding out the infectious bacterium to choose sensitive antibiotics. Two pins were inserted about 2–3 cm above and below the preselected osteotomy site under an image intensifier control. A 1–2-cm incision was made in order to expose the preselected osteotomy site, and then a subperiosteally transverse osteotomy was performed. The periosteum was sutured and the incisions were closed with drainage tubes. If the infected site had large soft tissue defects, open dressing changing or vacuum sealing drainage (VSD) were performed to close the wound. Postoperative protocol All patients received a course of sensitive antibiotics for 2–4 weeks intravenously and were encouraged to perform isometric muscle motions such as pushing a wall and joint range-of-motion exercises on the second day after the operation. Distraction was performed at the rate of 0.25 mm per 6 h after the latency period of 7–10 days. If the regeneration quality were poor, the speed of distraction would slow down. When bone transport was completed, the radius or ulna docked ends were compressed by 0.25 mm per day in order to provide full contact until the patient felt pain at the docking site. Radiographs were reviewed every 2 weeks during the distraction period and monthly during the consolidation period. The
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monolateral external fixator was removed when the radiographs showed solid docking-site union and the regenerated area had a minimum of three complete cortices. The flexion and extension of the wrist and elbow joint and the pronation and supination of forearm were evaluated at the end of follow-up. Results The mean follow-up after removal of the frame was 39.63 months (range 26–55 months). No patient was lost to follow-up. All the patients had bone union and no recurrence of infection was observed. The mean external fixation time was 6.19 months (range 3–10 months), and the mean external fixation index was 1.63 months/cm (range 1.14–2.00 months/cm). The mean degrees of wrist flexion were 49.698 (range 45–558), and the mean degrees of wrist extension were 50.638 (range 40–608). The mean degrees of elbow flexion were 143.128 (range 135–1508), and the mean degrees of elbow extension were 4.698 (range 0–208). The mean degrees of forearm pronation were 82.508 (range 70–908), and the mean degrees of forearm supination were 83.758 (range 75–908). Further details are listed in Table 2 (Fig. 1). Complications All the patients experienced pain during the distraction period and required oral analgesics. Ten patients had a pin-track infection (case 1, cases 3 and 4, case 6, case 9, cases 11–13, and case 16), and these patients presented with only local inflammation, which was treated by pin care and oral administration of empirical broadspectrum antibiotics. Three patients required bone grafting at the docking site to obtain union (case 1, case 9, and case 15). Poor regenerated bone formation occurred in two patients (case 4 and case 11), who also required bone grafting to obtain union at last. One patient (case 2) had dislocation of the radial head, which was treated by reduction of the radial head and reapplication of an external fixator, and the patients had bone union at last (Fig. 2). There were no neurovascular complications or a compartment syndrome. Discussion This is a retrospective study of bone transport for the treatment of infected forearm nonunion. The present study showed that the infected forearm nonunion treated by bone transport acquired satisfying functional results. The motion ranges of the wrist, elbow,
Table 1 Characteristics of 16 patients with infected forearm nonunion. Case number
Sex
Age (years)
Mechanisms of initial injury
Site of bone defect
Bone defect (cm)
Number of previous operations
Infecting organism
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Male Female Male Male Female Male Male Male Male Female Female Female Male Male Male Female
62 38 40 28 30 24 19 43 41 54 32 29 38 50 45 39
TA TA F TA TA HM TA F TA F HM TA TA TA F TA
Radius Ulna Radius Radius Radius Ulna Ulna Radius Radius Ulna Radius Ulna Ulna Ulna Radius Radius
7.5 4.4 3.7 3.5 2.4 5 2.2 2.6 4.7 2.8 3.7 3.5 4 3.3 3.5 4.2
5 2 2 3 1 2 1 2 3 2 3 2 4 1 2 3
Staph. aureus Staph. aureus Pseudomonas Staph. aureus E. coli Staph. aureus Staph. aureus Pseudomonas Staph. aureus Staph. aureus Staph. aureus Pseudomonas Staph. aureus Staph. aureus Klebsiella Staph. aureus
F, falling; TA, traffic accident; HM, hurting by machine.
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Fig. 1. (A) Radiograph of a 62-year-old man (case 1) who had an infected nonunion of the right forearm with internal fixation. (B) Debridement of the site of infected nonunion with 7.5 cm bone defect in radius and corticotomy of radius (red arrow) after application of the fixator. (C) Two weeks after operation with bone transport. (D) Two months after operation with bone transport. (E) Eight months after operation with transport, it showed good consolidation of the regenerate, and bone union at the docking site was obtained by bone grafting. (F) After ten months of the surgery, it showed complete bone union and the external fixators were removed. (For interpretation of the references to colour in figure legend, the reader is referred to the web version of the article.)
Fig. 2. (A) Radiograph of a 38-year-old women (case 2) who had a dislocation of radial head (red arrow) at six weeks after operation with bone transport. (B) The patient was treated by reduction of radial head and re-applying an external fixator. (C) It showed bone union at four months of surgery. (D) After five months of the operation, the external fixator was removed, and it showed complete bone union. (For interpretation of the references to colour in figure legend, the reader is referred to the web version of the article.)
Q. Zhang et al. / Injury, Int. J. Care Injured 45 (2014) 1880–1884
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Table 2 Results of treatment in the 16 patients. Case number
External fixation time (months)
External fixation index (months/cm)
Follow-up (months)
Wrist flexion/ extension (8)
Elbow extension/ flexion (8)
Forearm pronation (8)
Forearm supination (8)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
10 5 6 7 4 9 3 5 9 4 6 6 7 5 6 7
1.33 1.14 1.62 2 1.66 1.8 1.36 1.92 1.91 1.43 1.62 1.71 1.75 1.52 1.71 1.67
55 36 40 44 28 38 26 44 48 36 40 45 40 36 42 36
50–0–50 55–0–45 45–0–40 50–0–55 50–0–55 50–0–50 55–0–60 50–0–40 45–0–50 50–0–60 50–0–40 50–0–55 45–0–55 50–0–50 50–0–50 50–0–55
0–145 5–140 0–135 10–140 0–150 5–140 0–150 20–135 10–140 0–145 10–140 0–145 5–140 0–150 10–145 0–150
85 80 75 70 90 85 90 85 75 85 80 80 80 85 90 85
85 75 80 85 85 80 90 80 85 85 90 85 80 85 85 85
and forearm were nearly normal levels. All the patients achieved bone union and no recurrence of infection was observed. The main goals in the treatment of infected forearm nonunion are to debride all infectious tissues radically, regain proper length and relationship between forearm bones, achieve bone union, and recover an optimal function of forearm results. Various methods have been used for the treatment of infected forearm nonunion including bone grafting, non-vascularized fibular graft, vascularized fibular graft, and bone transport. Bone grafting is the most common treatment for forearm bone defects. Prasarn et al. reported 15 patients with infected forearm nonunion were treated by the protocol that combines aggressive debridement, definitive fixation following 7–14 days, tricortical iliac crest bone grafting as necessary, leaving wounds open to heal by secondary intention, antibiotic treatment for 6 weeks, and early function exercise [1]. All patients eventually had infection-free union, and the average length of bone defects was 2.1 cm. In another study, 35 patients (including 11 infected forearm nonunion) were treated by cancellous autograft, but the authors did not provide a detailed treatment protocol for the infected patients, and the mean length of bone defects was 2.2 cm. Although bone grafting is an effective treatment for forearm bone defects, it is difficult to treat the patient with massive bone defects >6 cm [13]. In addition, the grafted bone may be absorbed [14]. The use of non-vascularized fibular graft has been successful in the treatment of bone defects, but the method relies on revascularization, and it may take many months to be incorporated during which time they lose much of their strength and are susceptible to fracture [10]. Vascularized fibular graft has been introduced in the treatment of massive bone defects. Its advantage is that it does not rely on revascularization and therefore should become fully incorporated sooner. Nevertheless, it is a technically demanding procedure with a high rate of infection and thrombosis of the graft vessels [11,15,16]. Donor-site morbidity is also common. Gore et al. reported that most patients had mild muscle weakness after removal of a portion of the fibula [17]. Gonzalez et al. reported that excision of a segment of the fibula was statistically linked with valgus deformity [18]. Bone transport is suitable for the treatment of infected nonunion with bone defects of any length. It can treat infection and bone nonunion simultaneously. Hence, bone transport has gradually been a major treatment for infected nonunion, particularly in the lower extremity [19–22]. However, reports on the treatment of infected forearm nonunion by bone transport were rare [3,4]. Therefore, we conducted this study of bone transport for the treatment of infected forearm nonunion. In our study, the mean degrees of forearm pronation and supination were better than the 68.38 and 70.78 reported by Liu
et al. [3] and the mean degrees of wrist flexion and extension were similar to the 50.78 and 51.08 reported by Liu et al. [3] The external fixation index was higher than the 42.5 days/cm reported by Liu et al. [3] and the reason may be a larger size of bone defects in our study. The mean complications of every patient was 1 (16/16), which was lower than the 1.86 (39/21) reported by Liu et al. [3]. The pin-track infection rate was 62.5% (10/16), but the degree of pin-track infection was slight. We thought that meticulous pin care was the key to avoiding the complication. There was a dislocation of the radial head in our study. We believed that good mechanical stability of the monolateral external fixator could prevent the complication; meanwhile, we also should pay more attention to meticulously adjust the external fixator during the distraction period. In our experience, some important aspects of bone transport should be paid attention: (1) we should choose a monolateral external fixator with good mechanical stability based on specific conditions of the patient. (2) We should perform a subperiosteally transverse osteotomy and try our best to protect the blood supply of periosteum. (3) Debridement should be performed radically in order to avoid the recurrence of infection. This is the key step to control bone infection. (4) Distraction usually begins between 7 and 10 days after the operation at a rate of 0.25 mm per 6 h. If the regeneration quality is poor, the speed of distraction will slow down. We described a successful alternative technique for the treatment of the challenging problem of infected forearm nonunion. The main strength of our study is that all the operations were performed by the same orthopaedic surgeon, which can avoid the differences caused by different surgeons’ preference and experience. A number of data on the characteristics of patients, treatment results, and complications were reported in our study. However, our study has its limitations. It is retrospective in nature and the number of patients is relatively small, and there is no control group to compare our results with. More prospective randomized controlled trials are needed to overcome the limitations of our study. In conclusion, our study suggested that bone transport in the treatment of infected forearm nonunion acquired satisfying functional results. Radical debridement is the key step to control bone infection.
Conflict of interest statement Each author certifies that he has no commercial associations that might pose a conflict of interest with the submitted article.
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