Free medial femoral condyle bone grafting for scaphoid nonunions with humpback deformity and proximal pole avascular necrosis

Treatment of scaphoid nonunions remains a challenging problem, especially in the setting of proximal pole avascular necrosis or humpback deformity. Conventional bone grafting techniques have demonstrated unpredictable results in the setting of collapse deformities, whereas pedicled dorsal distal radius vascularized bone grafts have recently been reported to have nearly a 50% failure rate when used in scaphoid nonunions with proximal pole nonunion. Free vascularized medial femoral condyle bone grafting is one option for the treatment of scaphoid nonunions with proximal pole avascular necrosis associated with a humpback deformity. The indications, contraindications, and technique of free vascularized medial femoral condyle bone grafting are presented for the treatment of scaphoid nonunions associated with proximal pole avascular necrosis and humpback deformities.     

Vascularized bone transfer for limb salvage and reconstruction after resection of aggressive bone lesions

At our institution from 1980 to 1985, 30 patients underwent resection of malignant or locally aggressive bone tumors, with limb salvage and reconstruction by free vascularized bone grafts. Of the 26 patients followed up for at least four months (average, 21 months), four had complications. In these four, there were three nonunions, two infections, and one stress fracture. The average duration of immobilization was 7.6 months in the lower extremity, five months in the pelvis, and 3.8 months in the upper extremity. The average time to union was 6.3 months in the lower extremity, five months in the pelvis, and five months in the upper extremity. Although the technique of oncologic reconstruction must be individualized, our experience indicates that vascularized bone grafts offer significant advantages over conventional methods in selected patients.     

Ilizarov’s method: a solution for infected bone loss

We report the results of 22 infected nonunions treated by radical resection and bone transport technique according to Ilizarov with a minimal follow-up period of 2 years. This series involves four fractures of the femur diaphysis, ten at tibial level, four defects of the knee and four of the upper limb. The mean length of the bone defect was 7.7 cm. The mean time from the transport procedure to frame removal was 14.5 months. In 15 cases the docking site was reviewed to refresh the bone ends at the end of the transport procedure, of which eight had a bone graft performed. Five refractures were noticed at the docking site in the nonrevised group and one in the other group. Two of them were treated conservatively and four with a new external fixator. Consolidation was achieved in all but two nonunions at the knee level, which means a succesrate of 91%. The infection could be eradicated in all 22 patients. A revision of the docking site at the end of the bone transport procedure with or without bone grafting is recommended.     

Factors associated with functional outcome in patients having limb salvage surgery for primary malignant bone sarcoma using TESS

Introduction: Achieving maximum functional outcome in primary malignant bone sarcoma surgery (PMBS) patients, is challenging for both patients and clinicians. This study, aimed to evaluate different factors that affect postoperative functional outcome of the primary malignant bone sarcoma patients following upper limb (UL) and lower limb (LL) salvage surgery using Toronto Extremity Salvage Score (TESS).Methods: 136 PMBS adult patients were identified and were grouped as lower limb (LL) and upper limb (UL). Each group then sub-grouped to major and minor surgeries. Their functional outcome was compared using TESS by demographic variables(gender and age), neoadjuvant/adjuvant therapy and tumour variables (anatomical sites). In the UL groups, TESS was also compared for major and minor surgery subgroups based on their dominant or non-dominant limb.Results: The result of TESS has revealed that chemotherapy, radiotherapy, and gender have no effect on the functional outcome in PMBS patients. Functional outcome however was significantly affected by age in both LL and UL groups. The TESS was significantly different between major and minor subgroups in UL group with p= 0.0001. In patients with upper LSS on their dominant limb, no significant difference between major/ minor surgery subgroups was observed with p=0.077.Conclusion: Our findings using TESS revealed that factors such as patient’s age, and type of surgery (major or minor) in PMBS patients will affect the patients’ functional outcome after LSS especially in those PMBS patients with upper LSS.     

Cement spacers with antibiotics for the treatment of posttraumatic infected nonunions and bone defects of the upper extremity

Treatment of patients with posttraumatic infected nonunions or highly contaminated open fractures with segmental bone loss of the long bones of the upper extremity is demanding. The use of a 2-stage reconstruction technique, being the first stage characterized by thorough debridement, copious lavage, soft tissue coverage, and placement of a cement spacer with antibiotics at the infected site, and the second stage by cement spacer removal, internal fixation, and placement of bone graft with local antibiotics, is presented. We carried out this technique in 20 cases, in 12 cases the cement was molded to fit the defect and placed as a solid interposition mass, in 3 cases it was placed lateral to the affected bone, and in the remaining 5 cases a Rush nail covered with a cement mantle was used. Follow-up averaged 18 months. All nonunions and fractures healed after an average of 5 months. Disabilities of the arm, shoulder, and hand (DASH) score at last follow-up in nonunions averaged 14 points and 21 points in bone losses. Although generally 2 surgical procedures are needed, 1 to cure or prevent infection and another to achieve bony union, this approach for complex open fractures with segmental bone loss and for infected nonunions of the long bones of the upper extremity represents a valid treatment alternative.     

Upper extremity reconstruction by vascularized bone transfers: results and complications

Twenty-one cases of vascularized fibula transfer for upper limb reconstruction are reviewed. Recipient sites included the humerus in 11 patients, radius in five, ulna in three, and clavicle in two. Overall, primary bone union occurred in 15 patients (71.4%), and eventual union was achieved in 17 patients (81%). Two of the patients in whom there was failure to unite are minimally symptomatic, with stable fibrous nonunions. The most favorable results were achieved in cases of forearm bone reconstruction (100% union) and for long-bone reconstruction after tumor resection (83% union).     

Vascularized bone grafts for scaphoid nonunions

Scaphoid fractures that fail to unite are at risk of developing avascular necrosis and progressive structural collapse, thereby complicating attempts at revision surgical treatment. Vascularized bone grafts have demonstrated utility in promoting consolidation in the treatment of scaphoid nonunions complicated by avascular necrosis. Numerous pedicled and free vascularized grafts have been described with variable, but generally favorable, outcomes. Understanding the indications for different grafts is critical to the successful application of these techniques and grafts in the treatment of challenging scaphoid nonunions.     

Ilizarov treatment of tibial nonunions results in 16 cases

Treatment with the Ilizarov technique was performed in 16 patients with complex tibial nonunions. Two years post treatment the functional stage and patient satisfaction were recorded. There were 4 hypertrophic, 3 atrophic and 9 infected nonunions. Eleven patients had segmental bone loss. Fifteen nonunions united, and limb length discrepancy was reduced within 1.5 cm of the contralateral leg. Average time in the frame was 182 days. Fifteen of the 16 patients were satisfied with the treatment. One patient demanded an amputation after 3 months of treatment, despite good signs of healing. There were no refractures or recurrent infections. In conclusion the Ilizarov technique for complex nonunions has a high rate of success in achieving union and eradicating infection, bone loss and malalignment. The treatment is demanding both to the surgeon and to the patient, but we strongly recommend the Ilizarov treatment for tibial nonunion, especially in cases with chronic infection and severe bone loss.     

Chipping and lengthening technique for delayed unions and nonunions with shortening or bone loss

Autologous bone graft is usually necessary for reconstruction of nonunions with shortening or bone loss. We developed a new technique to reconstruct such nonunions or delayed unions without bone grafting by chipping and lengthening of bone at the original fracture site. Five in six nonunions with shortening or bone loss could be successfully united without bone graft by using our method. The chipping and lengthening technique, which requires neither bone grafting nor change in the anatomy of muscles, is a useful technique for delayed unions and nonunions accompanied by shortening or bone loss.     

Composite implant of native bovine bone morphogenetic protein (BMP), collagen carrier and biocoral in the treatment of resistant ulnar nonunions: report of five preliminary cases

Introduction Bone morphogenetic protein (BMP) has been shown to induce bone formation and union in long bone defects and nonunions. There are, however, no previous reports of BMP being used for ulnar nonunions. We report on five cases of resistant ulnar nonunions treated with a composite implant consisting of a biocoral frame, collagen carrier, and bovine BMP.Materials and methods Four diaphyseal and one olecranon ulnar nonunions were treated using BMP/coral implant combined with internal fixation. Additional autografting was used in three cases. All of the cases were challenging in their own ways: Three of the patients had been operated on earlier for their nonunion without success, one had a 40 mm bone loss, and one had a 9-month-old untreated olecranon fracture. After excision of the sclerotic surfaces of the nonunion, the gap was filled with autograft and a composite implant containing BMP. Fixation was done with a compression plate in the diaphyseal nonunions and with a tension band in the olecranon nonunion.Results Solid union was achieved in all five cases. No infections or other adverse effects were encountered.Conclusion These preliminary results suggest that BMP-containing implants might be a feasible alternative or superior to autografting in the treatment of resistant ulnar nonunions.     

Circular external fixation in tibial nonunions

The Ilizarov method based on compression-distraction and subperiostic corticotomy was used in 82 lower extremities. There were 45 tibial nonunions without a significant bone defect and 37 tibial nonunions with a bone defect that required radical removal of the necrotic bone and bone lengthening or bone transport. Bone healing was obtained in 39 of the 45 tibial nonunions without bone defect (mean bone healing, 5.4 months) and in all patients with bone defect (mean bone healing, 15 months for patients treated with bone transport) although secondary surgeries (autografting and tibial nails) were frequent (23 patients). Infection was eradicated in all patients after necrotic bone removal and bone transport. The final mean limb length discrepancy was 0.7 cm for the patients without a bone defect and 2.03 cm for the patients with a bone defect. In the patients in the bone transport group, residual axial deviation and residual limb shortening were common. Circular external fixation is a useful method to solve complex tibial nonunions in patients in whom internal devices and autografting have failed. Patients must be cooperative, and must understand the length of time the frame needs to be worn, and that complications are a probability.     

Postoperative monitoring of free vascularized bone grafts in reconstruction of bone defects

Vascularized bone transfer is increasingly recognized as a very useful and versatile technique for reconstructing large bone defects. It is especially indicated in patients with challenging conditions, such as nonunions, postoncologic resections, severe trauma, and congenital defects. With increasing experience of reconstructive surgeons, improved microsurgical techniques, and more enhanced flaps, the failure rate of free flaps has been reduced in the last decades. Especially, the early‐postoperative period is decisive in the outcome of surgery. Several techniques have been described for monitoring the postoperative viability of microsurgical free vascularized graft, and their sensitivity and reliability continues to be the object of animal experiments and clinical trials. The qualities of an optimal monitoring device should be objective, continuous, noninvasive, safe, reproducible, easily managed, and interpretable for the nursing staff, inexpensive, and a clear indicator of changes in arterial and venous circulation. Presently, no one neither fulfills all of the criteria completely nor is uniformly accepted. In this article, relative advantages and disadvantages of these various postoperative monitoring techniques are discussed. © 2009 Wiley‐Liss, Inc. Microsurgery 2009.     

Reconstruction with distraction osteogenesis for juxta-articular nonunions with bone loss

BACKGROUND: Nonunions of a juxta-articular lesion with bone loss, which represent a challenging therapeutic problem, were treated using external fixation and distraction osteogenesis. METHODS: Seven juxta-articular nonunions (five septic and two aseptic) were treated. The location of the nonunion was the distal femur in four patients, the proximal tibia in one patient, and the distal tibia in two patients. All of them were located within 5 cm from the affected joints. Preoperative limb shortening was present in six cases, averaging 2.9 cm (range, 1-7 cm). The reconstructive procedure consisted of refreshment of the nonunion site, deformity correction, stabilization by external fixation, and lengthening to eliminate leg length discrepancy or to fill the defect. Shortening-distraction was applied to six patients and bone transport to one patient for reconstruction. Intramedullary nailing to reduce the duration of external fixation was simultaneously performed in two cases. All the patients had at least 1 year of follow-up evaluation. RESULTS: Osseous union without angular deformity or leg length discrepancy greater than 1 cm was achieved in all patients. The mean amount of lengthening was 5.8 cm (range, 2.2-10.0 cm). The mean external fixation period was 219 days (range, 98-317 days), and the mean external fixation index was 34.4 days/cm (range, 24.5-47.6 days/cm). All patients reported excellent pain reduction. There were no recurrences of infection in five patients with prior history of osteomyelitis. The functional results were categorized as excellent in two, good in three, and fair in two. CONCLUSION: Despite the length of postoperative external fixation, distraction osteogenesis can be a valuable alternative for the treatment of juxta-articular nonunions.     

Treatment of nonunions and osseous defects with bone graft and calcium sulfate

The treatment of long bone nonunions and fractures with osseous defects is challenging. The results of 26 patients with either a persistent long bone nonunion or an osseous defect after an open fracture were reviewed. Each patient was treated with debridement of devitalized tissue, open reduction and internal fixation, and bone grafting using a mixture of autogenous iliac crest bone graft and medical grade calcium sulfate. The current study evaluated the union rate and associated complications for treatment of these injuries using this protocol. Each nonunion was confirmed intraoperatively, and healing was determined clinically by the patients' return to full activities without pain and radiographically by the presence of bridging trabeculae. Complications included persistent nonunion (four patients), wound drainage (five patients), wound drainage and cellulitis (one patient) and cellulitis alone (one patient). Using this treatment protocol, 22 patients (85%) achieved healing after one surgery and an additional two patients (92%) achieved healing after a second surgery. Medical grade calcium sulfate increases the volume of graft material, facilitates bone formation, and is safe in the treatment of nonunions and fractures with osseous defects.     

Scaphoid reconstruction with vascularized bone grafts from the distal radius

The aim of the present technical report is to describe the alternative solutions for the reconstruction of scaphoid nonunions with pedicled vascularized bone grafts from the distal radius. The surgical technique for the reconstruction A. of proximal scaphoid nonunions with pedicled bone grafts (based on the 1,2 or on the 2,3 intercomparmtental arteries) or with capsular bone grafts from the dorsal distal radius and B. of waist nonunions of the scaphoid with grafts from the palmar distal radius, pedicled on the palmar carpal arch, is presented. Vascularized bone grafts from the adjacent radius are used for the treatment of scaphoid nonunions to enhance union and to revascularize a nonviable proximal pole. The most suitable graft is selected according to the location of the nonunion (at the waist or the proximal pole of the scaphoid) and to the previous procedures/scars at the wrist level.     

Serratus anterior-rib free flap in limb bone reconstruction

The authors present their experience in surgical reconstruction of bone lesions in posttraumatic bone defects, pseudarthrosis, and osteitis by using the free serratus anterior-rib flap. The flap was used in 12 cases: 7 cases in the upper limb, and 5 cases in the lower limb. The overall immediate success rate in our series was of 91.7%. We had only one failure, due to a venous thrombosis. In all successful cases, the rib showed good integration. This procedure seems to be very useful in the reconstruction of small and medium bone defects, especially in the upper limb.     

Limb reconstruction after traumatic bone loss

A variety of options exist to reconstruct limbs following traumatic bone loss. The management of these injuries is challenging and often requires prolonged and potentially painful treatment. The Ilizarov technique of bone transport using circular external fixators is widely used for limb reconstruction of large bone defects. Other techniques include vascularised fibular grafting, the use of induced pseudosynovial membranes combined with cancellous autologous bone grafts and the use of autologous, allogeneic or synthetic bone grafts on their own for smaller defects. Future directions include further research on bone tissue engineering using stem cell therapy and growth factors such as bone morphogenetic proteins. The purpose of this Continuing Medical Education article is to describe the key limb reconstructive techniques that may be employed to treat traumatic bone loss. In particular, this article is intended to serve as a revision tool for those preparing for postgraduate examinations.     

Vascularized bone graft for scaphoid nonunions

Scaphoid fracture nonunion remains a challenging problem that may persist despite traditional methods of bone grafting and internal fixation. The alteration of wrist mechanics created by nonunion as well as the development of avascular necrosis leads to degenerative change of the radiocarpal joint accompanied by loss of motion and pain. The use of a vascularized bone graft has the theoretical benefit of increased blood flow that exceeds that of nonvascularized grafts. Numerous sources of vascularized bone graft have been described, including those from remote sites as well as from the carpus and distal radius. Knowledge of the blood supply to the distal radius has allowed for development of several vascularized bone graft harvest sites. The results of vascularized bone grafting from the distal radius have been encouraging, with numerous authors reporting the successful treatment of scaphoid nonunions.     

Percutaneous autologous bone marrow transplantation for nonunion of the femur.

Percutaneous bone marrow injections were performed on 7 nonunions of the femur. There were 6 hypervascular nonunions and one avascular nonunion. Two nonunions presented with active infections. One other patient had a history of infection which had subsided. One nonunion received the injection twice. After the site of nonunion was curetted and the bone surface was scored, 150 ml of bone marrow aspirated from the iliac bone was injected. Complete union occurred in 4 patients within 9 months; all of them were uninfected hypervascular nonunions following intramedullary nail fixation. One nonunion with a bone defect united partially leaving a 1 x 1 cm defect. The two infected femoral nonunions failed to unite. The results show that percutaneous autologous bone marrow injection for femoral nonunions can be considered for uninfected hypervascular nonunions following intramedullary nail fixation. In these cases stimulation of healing processes of fracture leading to consolidation can be expected from bone marrow injection. However, femoral nonunion with an active infection and loss of fixation is considered to be a contraindication for this technique.     

Nonunion of the diaphysis of long bones

The treatment of diaphyseal nonunion of long bones is difficult and controversial. We retrospectively reviewed 113 patients with diaphyseal nonunion treated by various modalities, during 15 years at one institution. There were 36 cases of nonunion of the tibia, 23 nonunions of the femur, 21 nonunions of the humerus, 13 nonunions of the radius, 18 nonunions of the ulna and two nonunions of the clavicle. The minimum followup was 24 months (average, 40 months, range 2-15 years). The nonunions were classified as aseptic (84) and septic (29) and additionally classified as hypertrophic (61) and atrophic (52) in order to determine the treatment. The treatment was individualized based on the stability at the nonunion site, need for bone grafting, and control of infection. All fractures healed and every patient in the study regained functional use of the limb without pain or instability and functional range of movements that they had at the time of presentation with nonunion. Residual problems seen in some patients were joint stiffness, limb length discrepancy, and angular deformity. Twenty-six patients required repeat surgery using bone grafting because no satisfactory progress of fracture healing was seen in 4 months. Complications were related to the iliac crest donor site and persistent infection at the nonunion site.