Session V - Post Traumatic Reconstruction

Surgical Treatment of Diaphyseal Forearm Bone Nonunions

Charalampos G. Zalavras, MD; Michalis Handes, MD; Theodoros Xenakis, MD; Alexandros Beris, MD; Konstantinos N. Malizos, MD; Panayotis N. Soucacos, MD, University of Thessaly, Larissa, Greece; University of Iannina, Greece

Purpose: Forearm bone nonunions have markedly decreased since the introduction of the AO devices and principles of internal fixation. Nevertheless, they may still constitute a challenging problem, especially when accompanied by infection or bone loss. We present our experience with surgical management of diaphyseal forearm bone nonunions.

Methods: A consecutive series of 38 nonunions in 28 patients after diaphyseal forearm bone fractures (AO/OTA type 22 fractures) was retrospectively evaluated. The mean patient age was 33 years. Twenty-three nonunions complicated a closed and 15 an open fracture, involving the radius in 22 and the ulna in 16 cases. Fourteen nonunions were accompanied by infection, and nine of these were accompanied by bone loss ranging from 4 to 8 cm. All nonunions were treated with bone grafting and stable plate fixation with use of 4.5-mm plates. However, a two-stage protocol was used for infected nonunions. The first stage included hardware removal, debridement, and administration of systemic and local antibiotics. Subsequently, stable plate fixation was applied while the existing bone defects were bridged by free vascularized fibular grafts in four patients, cancellous bone graft in three, and avascular fibular grafts in two patients.

Results: Follow-up ranged from 1 to 13 years (mean, 4 years) and union was initially achieved in 28 (74%) of 38 nonunions. Five successful reoperations with new osteosynthesis and bone grafting were performed for three persistent nonunions and two implant failures. Thus, union was eventually achieved in 33 (84%) of the nonunions. A difference in the rate of healing was observed between aseptic and infected cases. Twenty-three (96%) of 24 aseptic nonunions went on to heal, whereas only 10 (71%) of 14 infected forearms healed.

Discussion: Stable osteosynthesis and bone grafting improve both the biomechanical and biological environment at the nonunion site and have proven in our experience to be a useful method for the treatment of diaphyseal forearm bone nonunions. The presence of infection and bone loss adversely affects the outcome. The vascularized fibular graft may provide a solution in defects larger than 5 cm, especially when the vascularity of the soft tissue envelope is compromised.

Conclusion: Diaphyseal forearm bone nonunions can be successfully treated with stable osteosynthesis and bone grafting, even in the presence of infection and bone loss.