Combined radius and ulna reconstruction with a free fibula transfer

Brifish Journal of Plastic Surgery (1996), 49, 178-182 0 1996 The British Association of Plastic Surgeons

Combined radius and ulna reconstruction with a free fibula transfer F. Santanelli, C. Latini, L. Leanza and N. Scuderi Department of Plastic and Reconstructive Surgery, Policlinico Umberto I, University of Rome “La Sapienza”, Rome, Italy SUMMA R Y. A 20-year-old man sustained a high energy injury to his right forearm resulting in comminuted open fractures of the forearm with 6 cm bone loss of the radius and 7 cm bone loss of the ulna. A bone segment was removed from the middle of a free fibula transfer to produce a single flap with two vascularised bone segments to reconstruct both the radius and ulna defects. Step osteotomies were stabilised with a single lag screw for each fracture line and, with a rigid external fixation device on the ulna, two vein grafts were used to anastomose the flap pedicle to the recipient vessels in the forearm. The postoperative period was uneventful. X-rays and scintigrams confirmed good healing of the fractures and normal perfusion of the flap so that the external fixation device could be removed 3 months after surgery. One year after the injury, the patient underwent a functional evaluation showing excellent results with very good preservation of rotation of the forearm.

for the ulna (Fig. 2). An arteriogram showed a normal vascular pattern for the ulnar artery while the flow through the radial artery was interrupted a few centimetres after its origin from the brachial artery.

Microsurgery has expanded the indications for limb reconstruction after tumour surgery or trauma, achieving very good functional and aesthetic results. Bone can be reconstructed with non-vascularised or microsurgically revascularised bone transfers. Some authors have reported successful cases of nonvascularised long autologous fibular grafts; however, the lengths of the grafts were not stated.1-3 In 1974, Ostrup first experimentally performed a free vascularised bone graft.4 In 1975, Taylor et al. successfully demonstrated in two patients the possibility of repair of a large defect of the tibia by a transfer of a free vascularised fibula bone graft from the opposite leg using microvascular techniques.5 Vascularised bone grafts have been advocated in upper limb reconstruction as an alternative to compression-plate fixation and non-vascularised bone graft, when the bone defect is greater than 6 cm and in poorly vascularised wounds.6 We present a case of comminuted open fractures of the forearm, where the large bone loss of both the radius and the ulna was repaired by transfer of a single vascularised fibula flap.

Four days after admission, the patient had a free fibula transfer to reconstruct both the radius and ulna defects. Under tourniquet and via an antero-lateral approach, a 20 cm long fibula graft was harvested. The anterior dissection was carried out by elevating first the peroneal muscles and then the extensor compartment muscles from the anterior shaft of the fibula. The interosseous membrane was sharply divided, the peroneal pedicle was ligated distally and proximal and distal osteotomies of the fibula were made with a Gigli saw to facilitate further dissection of the pedicle from the posterior compartment muscles. The ulna was exposed by an incision along its subcutaneous border, while the volar open wound was used to approach the radius. A wide debridement removing the comminuted bone fragments as much as possible was performed and forearm bone stumps were prepared with step osteotomies (1.5 cm). Before removing the external fixation device, the real length of the bone defects was measured and a 3 cm long segment was removed from the middle of the fibula, in order to make a single flap with two bone segments vascularised by the peroneal vessel pedicle’ (Fig. 3). Step osteotomies (1.5 cm) were made at the ends of the fibula segments (Fig. 3). The fibula was transposed to the forearm, using the distal segment (9 cm) to reconstruct the ulna and the proximal segment (8 cm) for the radius (Fig. 4). The ulna was stabilised first9 and care was taken to re-establish a correct radial bow and rotational alignment to preserve function as much as possible.” Fracture stabilisation was achieved with a single steel lag screw (4.5 x22mm, A-O Sintesys@), for each fracture and with the original ulna rigid external device (Hoffman@), passing the pins through the radius to limit pronation and supinationi with X-ray control. The radial artery and the median forearm vein were dissected at the elbow, where normal vessel wall and adequate flow were present. The long saphenous vein was harvested from the left leg and two vein grafts were used to bridge the gap between the recipient vessels and the

Case report A 20-year-old man sustained a high energy injury to his right forearm in a motor vehicle accident. He was treated primarily by orthopaedic surgeons with an external rigid fixation device on the ulna and several dressings of the open wounds, and then referred to our department 5 days later. On examination, there was massive oedema of the limb, an irregular “L” shaped open wound ( 15 x 7 cm) on the volar aspect of the forearm (Fig. 1) and discontinuity of the radial artery at its distal third. X-rays showed comminuted fractures of the forearm bones, Gustilo type IIIB,7 with multiple fragments and bone loss that was estimated to be approximately 6 cm for the radius and 7 cm 178

Forearm

reconstruction

with free fibula transfer

Fig. 1 Figure

I-Right

Figure

2-Preoperative

Figure

3-Diagram

Figure4-Diagram

forearm

after X-ray

of the bone

primary

treatment.

showing

cornminuted

flap carrying

fractures

two fibula

of the radius

segments

vascularised

and ulna.

by the same peroneal

pedicle.

of the operation, showing the position of the fibula segments in the forearm bones and the vein grafts for flap

revascularisation.

peroneal vessel pedicle; the anastomoses were all made endto-end with 9/O nylon interrupted stitches. The exposed muscle bellies were covered with meshed split-thickness skin grafts. During surgery, prophylaxis against infection and thromboembolism was started: cefuroxime (Curoximm), 1.5 g t.i.d. for three days, dextran 40 (Solplex@, 40mg/ml), 500 ml for the first two days and then every other day for one week, clorichromene HCL (Proendotel@), 30 mg/die

i.v. for the first two days and then 100 mg t.i.d. per OS for the following eight days. Heparin was used only to irrigate the vessel lumens during surgery (1000 i.u./lOO ml). The postoperative period was uneventful. X-rays at 1, 3 and 11 months after surgery showed good bone healing (Fig. 5). Triphasic scintigrams one to three months after surgery also showed normal perfusion and metabolic activity of the bone grafts (Figs 6, 7). The limb was mobilised early, specific physiotherapy was performed from

180

British

Fig. 5

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of Plastic Surgery

Fig. 6

Fig. 7 Figure

5-Eleven

Figure

6-One

Figure

‘I-Three

months month months

postoperative

postoperative

X-ray. scintigram.

postoperative

triphasic

scintigram

the second to the sixth month and the external fixation device was removed 3 months after surgery. Six months after the reconstruction, the patient underwent surgery again, under local anaesthesia, to remove most of the skin graft by means of a skin stretching system (Sure-Closure’@), improving the aesthetic result (Fig. 8A, B). One year after surgery, the patient had a functional evaluation with a Lido Actuator computerised dyna-

Figure

G-Postoperative

results

(A)

before

and (B) after

skin graft

mometer (Loredan Biomedical Inc.@, W. Sacramento, CA, USA). Neutral joint positions, i.e. 0 degrees, were considered to be with the limb in the extended anatomical position; the forearm midway between pronation and supination and the wrist midway between flexion and extension. The examination was performed at a speed of 18O”/s, repeated five times for each movement. Mean values are given in Table 1. The evaluation of the muscular strength, measured in foot-pounds, showed a minor impairment of

reduction

with

a skin stretching

system.

Forearm

reconstruction

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181

transfer

1 One year postoperative functional evaluation of the forearm with a Lido Actuator dynamometer (Loredan

Table

Biomedical

Inc.@, W. Sacramento,

Elbow Isokinetic strength Range of motion Wrist Isokinetic strength Range of motion

(ft-lbs)

(ft-lbs)

Wrist Isokinetic strength Range of motion

(ft-lbs)

Wrist Isokinetic strength Range of motion

(ft-lbs)

CA, USA).

Extension Left 17 144”

Right 16 159”

Flexion Left 16 144

Right 18 159”

Extension Left 5 59”

Right 4 44”

Flexion Left 9 70”

Right 5 70”

Pronation Left Right 6 6 90” 90 Radial dev. Left Right 7 8 51” 38”

Supination Left Right 8 7 88” 75” Ulnar dev. Left Right 11 11 45” 45”

Isokinetic strength: the strength measured during a muscle exercise with a constant speed (measured in degrees per second). Patient’s isokinetic strength evaluated at speed of 180” per second. Range of motion measured during an exercise at 180” per second.

the biceps, brachioradialis and triceps, resulting in a 10% reduction of the flexion strength and 14% reduction of the extension strength of the elbow. ECU, ECRL, ECRB, FCU and FCR were more affected, resulting in a 20% reduction of the dorsiflexion strength and 30% reduction of the palmar flexion strength of the wrist. On the injured limb, the mean range of flexion and extension of the elbow was 159”, i.e. 15” wider compared to 144” on the uninjured limb. Minor impairment was found at the wrist joint, where the palmar flexion mean range was normal (70”), but the dorsiflexion range was 44”, i.e. 15” inferior to the uninjured side (59”) and the mean range of pronation was normal (90”) but supination was 75”, i.e. only 13” inferior to the uninjured side (88”). The mean range of ulnar deviation was also normal while the mean range of radial deviation was 38”, i.e. 13” inferior to the normal value.

Discussion Our patient had combined comminuted fractures of the forearm bones, Gustilo Type IIIB with multiple fragments and a large loss of bone (8 cm of radius and 9 cm of ulna). Due to the length of the bone

Figure

9-Postoperative

result

in (A)

maximum

supination

defects, more than 6 cm, involving both forearm bones, and the poorly vascularised and bacterially contaminated open fracture site, the use of a vascularised bone flap instead of a conventional bone graft was indicated. Other bone graft donor sites such as radius, scapula and iliac crest were considered but excluded because they only provide enough bone to reconstruct the radius, thus creating a one bone forearm, which usually gives poor functional results especially for pronation and supination.” The free fibula transfer, first described for reconstruction of the lower limbs, is equally useful for the upper

limb.

For the forearm,

Jones et al. used a single

double-barrelled free fibula transfer to restore both the radius and the ulna.” They noted that this technique might allow return of motion but this did not happen in their case. By using the same surgical procedures in a similar patient, we achieved excellent preservation of the forearm pronation and supination, compared to other conventional methods of treatment (Fig. 9A, B). There

was a minor

reduction

of the strength

of the

flexor muscles of the injured forearm and wrist, with a wider range of flexion and extension of the elbow because of disuse atrophy of the muscles. Only a minor reduction of the ranges of supination, extension and radial deviation of the wrist joint was found. The reduced ranges of motion were possibly due to fibrosis of the wrist capsule and flexor tendon sheaths. In our case, the rapid healing of the fractures and the triphasic scintigrams performed one and three months after surgery confirmed the survival of both bone struts as vascularised transfers, as has been shown by other authors.’ In conclusion, using this technique it has been possible to achieve several goals: early mobilisation of the limb, rapid bone union within three months, without sign of infection or delayed union or nonunion of the fractures, and an excellent functional result preserving pronation and supination almost completely. The use of a single double-barrelled free fibula transfer is thus suggested in open fractures with massive bone comminution and bone loss more than 6 cm, involving both forearm bones. The use of the skin stretching system to remove the skin graft

and (B) maximum

pronation.

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from the forearm allowed us to raise the fibula without a cutaneous paddle and to achieve a good aesthetic result in both the donor and recipient sites.

9. 10.

Acknowledgement We wish to thank Dr Donatella Trischitta Orthopaedics (Head: Professor M. Pizzetti), “La Sapienza”, for the functional evaluation

from the Institute of University of Rome of the patient.

11.

12.

References 1. Sakellarides HT. Extensive giant-cell tumor of the lower end of the radius: a report of 1 case treated by resection and replacement with the fibula. Clin Orthop 1965; 42: 151-6. 2. Parker SM, Hastings DE, Fornasier VL. Giant cell tumour of distal radius replaced by massive fibular autograft: a case report. Canad J Surg 1974; 17: 26668. 3. Mack GR. Lichtman DM, MacDonald RI. Fibular autografts for distal defects of the radius. J Hand Surg 1979; 4: 576-83. 4. Ostrun LT. Fredrickson JM. Distant transfer of a free living bone graft by microvascular anastomoses. Plast Reconstr Surg 1974; 54: 274485. 5. Taylor GI, Miller GBH, Ham FJ. The free vascularized bone graft: a clinical extension of microvascular techniques. Plast Reconstr Surg 1975; 55: 533344. 6. O’Brien BMcC, Morrison WA. Reconstructive Microsurgery. Edinburgh, London, Melbourne, New York: Churchill Livingstone, 1987. 7. Gustilo RB. Management of open fractures and their complications. Philadelphia: WB Saunders, 1982. 8. Berggren A, Weiland AJ, Ostrup LT, Dorfman H.

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of Plastic Surgery

Microvascular free bone transfer with revascularization of medullary and periosteal circulation or the periosteal circulation alone. J Bone Joint Surg 1982; 64A: 73-87. Miiller ME, Allgbwer M, Willenegger H. Technique of internal fixation of fractures. New York: Springer, 1965. Matthews LS, Kaufer H, Garver DF, Sonstegard DA. The effect on supination-pronation of angular malalignment of fractures of both bones of the forearm. J Bone Joint Surg 1982; 64A: 14-17. Dell PC, Sheppard JE. Vascularized bone grafts in the treatment of infected forearm nonunions. J Hand Surg 1984; 9A: 65338. Jones NF, Swartz WM, Mears DC, Jupiter JB, Grossman A. The “double barrel” free vascularized fibular bone graft. Plast Reconstr Surg 1988; 81: 378885.

The Authors F. C. L. N.

SantaneUi MD, Latini MD Leanza MD Scuderi MD

Cattedra Policlinico,

i

di Chirurgia Plastica 00161 Roma, Italy.

Correspondence Roma, Italy. Presented Florence,

PhD

Universita

to: Dr F. Santanelli,

at the 1994 International 21-24 May 1994.

Paper received 21 March 1995. Accepted 22 August 1995, after

La Sapienza,

Via Archimede

Symposium

revision.

Viale

n.129,

on Plastic

de1

00197

Surgery,