Treatment of diaphyseal forearm atrophic nonunions with intramedullary nails and modified Nicoll’s technique in adults

Öz

Objective:The aim of this study was to evaluate the outcome of tricorticocancellous autologous bone grafting with intramedullary forearm nails in the treatment of radius or ulna aseptic nonunion.

Methods: The study included 8 patients (mean age: 39 years; range: 19 to 55 years) who underwent plate-screw osteosynthesis for the treatment of nonunion (6 ulna, 2 radius) following forearm fracture. In all cases, the length of the applied tricortical graft was below 3 cm. Patients were evaluated using the visual analog scale, Grace and Eversmann scale and DASH score. Wrist flexion and extension and postoperative hand and forearm grip strength were assessed.

Results: Graft incorporation and union was completed at a mean of 22 (range: 18 to 28) weeks. No patient had nonunion, deep infection or radioulnar synostosis. Follow-up ranged from 18 to 52 months. Radiographic union was achieved in all patients. Mean visual analog scale pain score was 1 (range: 0 to 3). Grace and Eversmann ratings were excellent in 5 and good in 3 patients. Mean DASH score was 10.7 (range: 1.7 to 21.7) points.

Conclusion: Intramedullary nailing and tricorticocancellous iliac bone block grafting appears to be a technically easy and reliable procedure that enables early postoperative rehabilitation in the treatment of nonunion of the forearm.

Anahtar Kelimeler

• Forearm
• intramedullary nail
• nonunion
• tricorticocancellous bone graft

Yetişkinlerde ön kol diyafizer atrofik kaynamamalarının intramedüller çivi ve modifiye Nicoll tekniği ile tedavisi

Öz

Amaç:Bu çalışmanın amacı radius veya ulnada aseptik kaynamama gelişen olguların intramedüller ön kol çivileri ve trikortikokansellöz otolog kemik grefti ile tedavisinin sonuçlarını değerlendirmekti.

Çalışma planı: Çalışmaya ön kol kırığı sonrası kaynamama (6 ulna, 2 radius) nedeniyle plak-vida ile osteosentez uygulanan 8 hasta (ortalama yaş: 39, dağılım: 19-55) alındı. Uygulanan trikortikal greftin uzunluğu tüm olgularda 3 cm’nin altında idi. Hastalar görsel analog skala, Grace ve Eversmann skalası ve DASH skoru ile değerlendirildiler. Bilek fleksiyon ve ekstansiyonu ile ameliyat sonrası el ve ön kol kavrama kuvvetleri incelendi.

Bulgular: Greft inkorporasyonu ve kaynamanın 22 (dağılım: 18-28) haftada tamamlandığı görüldü. Hastaların hiçbirinde kaynamama, derin enfeksiyon veya radyoulnar sinostoz bulgusu yoktu. Takip süresi 18 ile 52 ay arasındaydı. Kaynama tüm hastalarda radyografilerle doğrulandı. Ortalama görsel analog skala ağrı puanı 1 (dağılım: 0-3) olarak belirlendi. Grace ve Eversmann skorları 5 hastada mükemmel, 3 hastada iyi idi. Ortalama DASH skoru ise 10.7 (dağılım: 1.7-21.7) olarak kaydedildi.

Çıkarımlar: Ön kol kaynamamalarının intramedüller çivi ve trikortikokansellöz iliak kemik blok greftlemesi ile tedavisi teknik açıdan basit, ameliyat sonrası erken dönemde rehabilitasyona olanak sağlayan, güvenilir bir yöntemdir.

Anahtar Kelimeler

• İntramedüller çivi; kaynamama; ön kol; trikortikokansellöz kemik grefti

Kaynakça

1. Richard MJ, Ruch DS, Aldridge JM 3rd. Malunions and nonunions of the forearm. Hand Clin 2007;23:235-43.
2. Langkamer VG, Ackroyd CE. Internal fixation of fore- arm fractures in the 1980s: lessons to be learnt. Injury 1991;22:97-102. CrossRef
3. Hadden WA, Reschauer R, Seggl W. Results of AO plate fixation of forearm shaft fractures in adults. Injury 1983;15:44-52. CrossRef
4. Schemitsch EH, Richards RR. The effect of malunion on functional outcome after plate fixation of fractures of both bones of the forearm in adults. J Bone Joint Surg Am 1992;74:1068-78.
5. Tarr RR, Garfinkel AI, Sarmiento A. The effects of angu- lar and rotational deformities of both bones of the fore- arm. An in vitro study. J Bone Joint Surg Am 1984;66:65- 70.
6. Kloen P, Buijze GA, Ring D. Management of forearm nonunions: current concepts. Strategies Trauma Limb Reconstr 2012;7:1-11. CrossRef
7. Kloen P, Wiggers JK, Buijze GA. Treatment of diaphyseal non-unions of the ulna and radius. Arch Orthop Trauma Surg 2010;130:1439-45. CrossRef
8. Moroni A, Caja VL, Sabato C, Rollo G, Zinghi G. Com- posite bone grafting and plate fixation for the treatment of nonunions of the forearm with segmental bone loss: a report of eight cases. J Orthop Trauma 1995;9:419-26.

9. Moroni A, Rollo G, Guzzardella M, Zinghi G. Surgical treatment of isolated forearm non-union with segmental bone loss. Injury 1997;28:497-504. CrossRef
10. 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 Joint Surg Am 2004;86-A:2440-5.
11. Faldini C, Miscione MT, Acri F, Chehrassan M, Bonomo M, Giannini S. Use of homologous bone graft in the treat- ment of aseptic forearm nonunion. Musculoskelet Surg 2011;95:31-5. CrossRef
12. Gupta DK, Kumar G. Gap nonunion of forearm bones treated by modified Nicoll’s technique. Indian J Orthop 2010;44(1):84-8.
13. Lloyd-Roberts GC. Experiences with boilded cadaveric bone. J Bone Joint Surg Br 1952;34-B:428-32.
14. Boyd HB. The treatment of difficult and unusual non- union. J Bone Joint Surg 1943;25:535.
15. Miller RC, Phalen GS. The repair of defects of the ra- dius with fibular bone grafts. J Bone Joint Surg Am 1947;29:629-36.
16. Spira E. Bridging of bone defects in the forearm with iliac graft combined with intramedullary nailing. J Bone Joint Surg Br 1954;36-B:642-6.
17. Nicoll EA. The treatment of gaps in long bones by cancel- lous insert grafts. J Bone Joint Surg Br 1956;38-B:70-82.
18. Tetsworth K, Krome J, Paley D. Lengthening and defor- mity correction of the upper extremity by the Ilizarov technique. Orthop Clin North Am 1991;22:689-713.
19. Jupiter JB, Gerhard HJ, Guerrero J, Nunley JA, Levin LS. Treatment of segmental defects of the radius with use of the vascularized osteoseptocutaneous fibular autogenous graft. J Bone Joint Surg Am 1997;79:542-50.
20. Johnson EE, Marder RA. Open intramedullary nailing and bone-grafting for non-union of tibial diaphyseal frac- ture. J Bone Joint Surg Am 1987;69:375-80.
21. Martínez AA, Herrera A, Cuenca J. Good results with unreamed nail and bone grafting for humeral nonunion: a retrospective study of 21 patients. Acta Orthop Scand 2002;73:273-6. CrossRef
22. Wiss DA, Stetson WB. Nonunion of the tibia treated with a reamed intramedullary nail. J Orthop Trauma 1994;8:189-94. CrossRef
23. Hong G, Cong-Feng L, Hui-Peng S, Cun-Yi F, Bing-Fang Z. Treatment of diaphyseal forearm nonunions with in- terlocking intramedullary nails. Clin Orthop Relat Res 2006;450:186-92. CrossRef
24. Scott J, Huskisson EC. Graphic representation of pain. Pain 1976;2:175-84. CrossRef
25. Grace TG, Eversmann WW Jr. Forearm fractures: treat- ment by rigid fixation with early motion. J Bone Joint Surg Am 1980;62:433-8.
26. Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH (dis- abilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG) Am J Ind Med 1996;29:602-8. CrossRef
27. Watanabe T, Owashi K, Kanauchi Y, Mura N, Takahara M, Ogino T. The short-term reliability of grip strength measurement and the effects of posture and grip span. J Hand Surg Am 2005;30:603-9. CrossRef
28. Faldini C, Pagkrati S, Nanni M, Menachem S, Giannini S. Aseptic forearm nonunions treated by plate and op- posite fibular autograft strut. Clin Orthop Relat Res 2009;467:2125-34. CrossRef
29. Babhulkar S, Pande K, Babhulkar S. Nonunion of the diaphysis of long bones. Clin Orthop Relat Res 2005;431:50-6. CrossRef
30. Krzykawski R, Król R, Kamiński A. The results of locked intramedullary nailing for non-union of forearm bones. Ortop Traumatol Rehabil 2008;10:35-43.
31. Johnson KD. Management of malunion and nonunion of the tibia. Orthop Clin North Am 1987;18:157-71.
32. Rodriguez-Merchan EC, Gomez-Castresana F. In
33. ternal fixation of nonunions. Clin Orthop Relat Res 2004;419:13-20. CrossRef
34. Ring D, Jupiter JB, Sanders RA, Quintero J, Santoro VM, Ganz R, et al. Complex nonunion of fractures of the femo- ral shaft treated by wave-plate osteosynthesis. J Bone Joint Surg Br 1997;79:289-94. CrossRef
35. Rand JA, An KN, Chao EY, Kelly PJ. A comparison of the effect of open intramedullary nailing and compres- sion-plate fixation on fracture-site blood flow and fracture union. J Bone Joint Surg Am 1981;63:427-42.
36. Davey PA, Simonis RB. Modification of the Nicoll bone- grafting technique for nonunion of the radius and/or ulna. J Bone Joint Surg Br 2002;84:30-3. CrossRef
37. Marti RK, Schüller HM, van Steijn MJ. Superolateral bone grafting for acetabular deficiency in primary to- tal hip replacement and revision. J Bone Joint Surg Br 1994;76:728-34.
38. Dabezies EJ, Stewart WE, Goodman FG, Deffer PA. Management of segmental defects of the radius and ulna. J Trauma 1971;11:778-88. CrossRef
39. Ilizarov GA, Kaplunov AG, Degtiarev VE, Lediaev VI. Treatment of pseudarthroses and ununited fractures, complicated by purulent infection, by the method of com- pression-distraction osteosynthesis. [Article in Russian] Ortop Travmatol Protez 1972;33:10-4. [Abstract]
40. Müller ME, Allgöwer M, Schneider R, Willenegger H. Manual of Internal Fixation. Techniques Recommended by the AO Group. 2nd edition. New York, NY: Springer; 1979. CrossRef
41. Williamson DM, Copeland SA, Landi A. Pseudarthro- sis of the radius treated by free vascularised bone graft. J Hand Surg Br 1989;14:221-5. CrossRef
42. Kamrani RS, Mehrpour SR, Sorbi R, Aghamirsalim M, Farhadi L. Treatment of nonunion of the forearm bones with posterior interosseous bone flap. J Orthop Sci 2013;18:563-8. CrossRef