Outcome of diaphyseal forearm fracture-nonunions treated by autologous bone grafting and compression plating
© dos Reis et al; licensee BioMed Central Ltd. 2009
Received: 18 December 2008
Accepted: 18 May 2009
Published: 18 May 2009
The treatment of forearm fracture-nonunions continues to represent a therapeutic challenge, and reported outcomes are moderate at best. Limiting aspects of this particular anatomic location include the relation between restoration of shaft length with the anatomy and long-term functional outcome of adjacent joints, as well as the risk of elbow and wrist stiffness related to prolonged immobilization. The present study was designed to assess the outcome of autologous bone grafting with compression plating and early functional rehabilitation in patients with forearm fracture non-unions.
Prospective follow-up study in 31 consecutive patients presenting with non-unions of the forearm diaphysis (radius, n = 11; ulna, n = 9; both bones, n = 11). Surgical revision was performed by restoring anatomic forearm length by autologous bone grafting of the resected non-union from the iliac crest and compression plating using a 3.5 mm dynamic compression plate (DCP) or limited-contact DCP (LC-DCP). The main outcome parameters consisted of radiographic bony union and functional outcome, as determined by the criteria defined by Harald Tscherne in 1978. Patients were routinely followed on a short term between 6 weeks to 6 months, with an average long-term follow-up of 3.6 years (range 2 to 6 years).
Radiographically, a bony union was achieved in 30/31 patients within a mean time of 3.5 months of revision surgery (range 2 to 5 months). Clinically, 29/31 patients showed a good functional outcome, according to the Tscherne criteria, and 26/31 patients were able to resume their previous work. Two postoperative infections occurred, and one patient developed a persistent infected nonunion. No case of postoperative failure of fixation was seen in the entire cohort.
Revision osteosynthesis of forearm nonunions by autologous iliac crest bone grafting and compression plating represents a safe and efficacious modality for the treatment of these challenging conditions.
The surgical treatment of diaphyseal forearm fracture-nonunions remains a therapeutic challenge for orthopaedic trauma surgeons. Key to success in the management of these demanding conditions is to develop a comprehensive treatment concept which considers the forearm and its adjacent joints, the elbow and wrist, as a complex functional unit [1, 2]. Nonunions of the radius and ulna shaft cause a severe anatomic and functional impairment, related to disturbance of the interosseous membrane and dysfunction of the adjacent joints, elbow and wrist [3–6]. These demanding nonunions require the surgical correction to restore the anatomy of the forearm and to improve function [1, 7]. New techniques have been recently postulated for the treatment of forearm nonunions, including distraction-compression osteogenesis, locked plating, and locked intramedullary nailing [8–10]. In addition, free fibula transfer flaps have been advocated as a means to restore anatomic length and ensure bony union [11, 12].
In the present study, we evaluated the long-term radiological and clinical outcome of 31 consecutive patients treated by autologous bone grafting and compression plating for fracture-nonunions of the forearm. We hypothesized that this "classic" treatment concept would result in excellent clinical outcome and a low incidence of long-term functional impairment.
Results and discussion
Clinical and radiological residual deformities in 13 patients following revision surgery for forearm fracture-nonunions
Number of patients (total n = 13)
Positive ulnar variant: 1 mm
Positive ulnar variant: 2 mm
Negative ulnar variant: 1 mm
Ulnar head prominence
Ulnar head absence
Loss of radial bow
Functional outcome in 30 patients with radiologically healed forearm fracture nonunions, assessed 6 months after revision surgery
Number of patients
Normal (identical to contralateral side)
Limited ulnar shift
Number of patients
Normal (identical to contralateral side)
Number of patients
Normal (identical to contralateral side)
This study demonstrates the efficacy and safety for the treatment concept of autologous bone grafting and compression plating for forearm fracture-nonunions, leading to excellent radiological and functional long-term outcome. Reconstruction of the anatomy of both forearm bones is of crucial importance in the management of the diaphyseal forearm nonunions [1–6]. The concept of corticocancellous iliac crest bone grafting and compression plating for, was previously postulated as an early treatment strategy for traumatic segmental defects of the upper extremity, including forearm fractures . Despite open wounds in some patients which healed by secondary intention, the exposed cortical bone graft was not shown to be prone to infection . More recently, a retrospective analysis of 41 patients with comminuted both bone forearm fractures treated by compression plating with or without primary bone grafting determine a nonunion rate of 12%, and no benefit was revealed for early bone grafting with regard to the rate of union . Barbieri and colleagues reported their experience in a case series of 12 patients treated by iliac crest bone block grafting and compression plating for diaphyseal defects of the forearm, secondary to infection and bone loss . The authors demonstrated a successful union in 10/12 patients, within a mean time period of 17 weeks after the surgical revision . However, a high rate of 30% recurrent infections of was reported in this cohort, which questions the safety of autologous bone grafting in the setting of posttraumatic infection and chronic osteomyelitis. Similarly, Moroni and colleagues reported a high incidence of infection of 12.5% after intercalary bone graft fixation in patients with isolated forearm nonunions . In the present study, the incidence of postoperative infection was much lower (2/31 patients). One case resulted in failure by developing a chronic infected nonunion, while the other case was successfully managed by surgical debridement and antibiotic therapy, resulting in a healed union and a good functional long-term outcome. Bony union were achieved in 96.7% of all cases (30/31) on average time of 3.5 months. The functional outcome measured by the Tscherne's criteria showed good results in 26/31 patients. Based on these findings, our data confirm the safety and efficacy of autologous bone grafting and compression plate fixation of fracture nonunions of the forearm .
Autogenous cortical bone grafts were historically described as a successful modality for the reconstruction of traumatic segmental skeletal defects [20–23]. While the plate fixation of forearm fractures remains the gold standard, complications have been shown to occur in up to 28% of all patients . One of the major challenges of long-term complications are forearm nonunions with bone loss and segmental defects. In the present study, we demonstrate the safety and efficacy of corticocancellous iliac crest bone grafting and compression plating for revision fixation of forearm fracture-nonunions, leading to excellent radiological and functional long-term outcomes.
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