Christian Allende

Ununited Diaphyseal Forearm Fractures with Segmental Defects: Plate Fixation and Autogenous Cancellous Bone-Grafting

BACKGROUND With current techniques of plate-and-screw fixation, diaphyseal nonunions of the radius and ulna are unusual. The few reports that have been published have discussed the use of structural corticocancellous bone grafts for the treatment of atrophic nonunions that are associated with osseous defects. We reviewed the rate of union and the functional results in association with the use of plate-and-screw fixation and autogenous cancellous (nonstructural) bone grafts. METHODS Thirty-five patients with an atrophic ununited diaphyseal fracture of the forearm were treated with 3.5-mm plate-and-screw fixation and autogenous cancellous bone-grafting. A segmental osseous defect with an average size of 2.2 cm (range, 1 to 6 cm) was present in each patient. Twenty of the original fractures had been open. Eleven patients had had treatment of a deep infection before referral to us. The nonunion involved both forearm bones in eight patients, the radius alone in sixteen patients, and the ulna alone in eleven patients. RESULTS The atrophic nonunion was associated with an open fracture in twenty patients, suboptimal fixation in twenty-two, a fracture-dislocation of the forearm in nine, and infection in eleven. All fractures healed without additional intervention within six months. Two patients had a subsequent Darrach resection of the distal part of the ulna for the treatment of arthrosis of the distal radioulnar joint. After an average duration of follow-up of forty-three months, the final arc of motion averaged 121 degrees in the forearm, 131 degrees at the elbow, and 137 degrees at the wrist, with an average grip strength of 83% compared with that of the contralateral limb. According to the system of Anderson and colleagues, five patients had an excellent result, eighteen had a satisfactory result, eleven had an unsatisfactory result (because of elbow stiffness related to associated elbow injuries in three and because of wrist stiffness in eight), and one had a poor result (because of malunion). CONCLUSIONS When the soft-tissue envelope is compliant, has limited scar, and consists largely of healthy muscle with a good vascular supply, autogenous cancellous bone-grafting and stable internal plate fixation results in a high rate of union and improved upper limb function in patients with diaphyseal nonunion of the radius and/or ulna.

Posttraumatic one-bone forearm reconstruction. A report of seven cases.

Hey Groves1 first described the one-bone forearm in 1921, and subsequently several other studies on the topic have been published2-11. The indications for one-bone forearm reconstruction include atraumatic instability, previous bone tumor resection or congenital deformity (type-2 cases according to the system of Peterson et al.3), or posttraumatic lesions (type-1 cases). When chosen for the correct indication, this reconstructive technique can provide a stable forearm with good functional and cosmetic results as well as patient satisfaction4. Despite multiple published series, there is no clear agreement regarding the indications for, best operative technique for, or the long-term results of the creation of a one-bone forearm following injury. We report seven cases of complex combined skeletal and soft-tissue posttraumatic lesions of the forearm, each of which was successfully treated by conversion to a one-bone forearm with use of intramedullary fixation and autogenous bone graft. We retrospectively reviewed the results of seven patients who had been treated, between 1985 and 1997, by the creation of a one-bone forearm to address severe combined posttraumatic osseous and soft-tissue lesions of the forearm (Table I). They were informed verbally that data concerning their cases would be submitted for publication. The mean age of the patients at the time of the procedure was twenty-nine years (range, sixteen to thirty-eight years), and the dominant side was reconstructed in four patients. Five patients were manual laborers and had a work-related injury. One was an architect who was injured in an airplane accident, and one was a sixteen-year-old patient who had sequelae of an injury sustained in a farm machine accident at the age of three years. Both bones were affected in six patients, and only the radius was affected in one. View this table: TABLE I Patient Data All fractures were initially open and secondary to …

Defectos óseos diafisarios postraumáticos en la extremidad superior de niños. [Post-traumatic diaphyseal bone defects in the upper extremity of children].

Introduction The aim of this study was to evaluate the results achieved in children presenting chronic segmentary bone defects at the humerus or forearm. Methods We retrospectively evaluated nine children, treated between 2005 and 2015, presenting long bone upper extremity fractures that got infected and resulted in segmentary bone defects; all lesions had six or more months from trauma. Seven patients were male and two female. Patient’s age averaged 9.9 years. Four defects were located at the humerus, three at the ulna, and two at the radius. All patients had had previous surgical interventions, averaging 3.7; originating bony defects that averaged 4.5 centimeters. Time between initial trauma and definitive surgery averaged 21.8 months. Results Follow-up averaged 2.2years. Union was achieved in all patients. A cement spacer was used in one case, in another case a free fibular bone graft was used. Two patients with humerus defects had significant shortening. All patients returned to their recreational and sports activities without limitations. Discussion Posttraumatic bone defects are rare in children. We present nine cases with segmentary diaphyseal bone defects localized in humerus, ulna or radius; in eight cases the reconstruction was done combining autogenous bone grafts and plates bridging the defects; achieving union and stability without pain in all cases. Conclusions The combination of different types of bone autograft, various plaques placed bypassing the lesion and the use of the induced membrane technique allowed us to obtain consolidation and return to normal activity in the nine children with segmental bone defects in hummers, ulna or radius.

Surgical Versus Nonsurgical Treatment of Ulnar Styloid Fractures in the Context of Distal Radius Fractures

Objective: The objective of this study was to compare surgical versus nonsurgical treatment of ulnar styloid fractures occurring in the context of distal radius fractures treated by open reduction and internal fixation (ORIF) with volar locked plates. Methods: A multicenter retrospective study, including four different level I trauma centers, was carried out. Patients operated on between 2009 and 2012, with ulnar styloid fractures, in the context of an unstable displaced distal radius fracture that had ORIF with a volar locked plate were included; they were divided into two groups according to whether the ulnar styloid fracture was treated nonsurgically (group I) or surgically (group II). Only patients in which distal radius fracture reduction after ORIF was considered anatomical were included. Ulnar styloid fractures were classified according to Rotella’s classification. Results: Fifty-seven patients were included in the study (group I: 29, group II: 28). Follow-up averaged 55.98 months and was different between groups (group I: 63.14 months SD, 1.95, and group II: 48.43 months SD, 3.74), averaging 14.5 months (SD, 4.5) less in group II (P = .001). Patient’s age averaged 49.5 years (SD, 1.82) and was similar (P = .225) between both groups. Women were more frequent in group II (P = .0435). In 35% of patients, the dominant extremity was operated; dominance was different (P = .0501) between groups (28% in group I and 42% in group II). According to Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification in group I, there were 10 type A, 1 type B, and 18 type C fractures, whereas in group II, there were 7 type A, 5 type B, and 16 type C fractures. Ulnar styloid fractures were located at its base in 28 patients, middle third in 19 patients, and tip in 10 patients. Ulnar styloid classification distribution evidenced differences between groups (P = .020); while in group I, there was homogeneous frequency of proximal and tip fractures, and most fractures in group II were proximal. Styloid fracture union chance was statistically significantly different (P = .054; styloid fracture united in 14 of the 29 cases of group I and in 19 of the 28 cases of group II); patients in group II had 2.76 (95% confidence interval [CI], 1.086-8.80) more chances of uniting than those in group I. Disability of the Arm, Shoulder and Hand (DASH) score and Visual Analog Scale (VAS) pain score (at rest and during activities) did not show significant differences between groups (DASH, P = .276; VAS at rest, P = .877; and VAS during activities, P = .681). Ulnar deviation and strength at last follow-up evidenced better results in group I (P = .0389 and P = .024, respectively). Postoperative immobilization, performed using long-arm or short-arm, casts or braces, was different in the groups (P < .001); 41% of patients in group I had a long-arm cast and the rest a short-arm brace, whereas 95% of patients in group II had braces. There were no significant differences in time of postoperative immobilization (P = .469). Conclusion: In this multicenter study, no significant differences between surgical and nonsurgical treatment of ulnar styloid fractures occurring in the context of distal radius fractures treated by ORIF with volar locked plates were evidenced. Anatomical reduction of distal radius fractures remains the most important objective in treating these lesions.

Resultados de la Utilización de Aloinjerto Criopreservado en Fracturas y No-consolidaciones de Huesos Largos. [Outcomes of cryopreserved allograft in long bones fractures and nonunions.]

Background The aim of this study was to evaluate the indications and incorporation of cryopreserved allograft in long bone fractures and nonunions. Methods Retrospective study of 20 patients treated between 2005 and 2011, with 7 fractures and 14 long bones nonunions in which cryopreserved allograft bone was used (one patient had bilateral femoral involvement), associated with autograft in 11 cases. Average age 45.2 years (range 19 to 74). Ten women and ten men. Bone defects were classified according to whether they were circumferential or not. Results Bony union after using morcellized allograft was achieved in 14 cases, after an average of 8 months (range 4 to 18), among the remaining 7 cases union was achieved after revision surgery in 5 cases, another case did not achieve consolidation, and an amputation was performed in another patient. Conclusions Bone autograft remains the gold standard in bone defect reconstructions. Using new extraction systems for autografts, such as reamed irrigation/aspiration (RIA, Synthes) has made the use of allograft in fractures infrequent. In our patients with multiple surgeries, bone defects or severe psychiatric disorders, the use of isolated cryopreserved allograft or associated with bone autograft obtained good results (18 cases with consolidation), although 5 patients required revision surgeries.

Osteointegración del aloinjerto crioconservado asociado a plasma enriquecido en plaquetas, en defectos óseos infectados. Estudio experimental. [Osseointegration of cryopreserved allograft associated with platelet-rich plasma, in infected bone defects. Experimental study.

espanolIntroduccionEl objetivo de este trabajo experimental es determinar si el agregado de plasma rico en plaquetas influye en la osteointegracion del aloinjerto crioconservado con antibioticos, en fracturas infectadas, con perdida osea, en huesos largos de conejos.Material y metodosSe evaluaron cuatro grupos de 7 conejos cada uno, a los cuales se les genero una fractura infectada del femur derecho. En los cuatro grupos, se coloco aloinjerto molido con antibiotico local, en el grupo II y en el grupo IV, se agrego tambien plasma rico en plaquetas. Se sacrifico a los grupos I y II, a los 30 dias, y a los grupos III y IV, a los 90 dias. Se realizo una evaluacion histologica y tomografica.ResultadosNueve conejos murieron en el periodo de estudio. No hubo diferencias estadisticamente significativas entre los grupos evaluados. En el grupo IV, con plasma rico en plaquetas, se observo neoformacion osea en tres de las cuatro muestras; se advirtieron sectores de acoplamiento entre el tejido receptor y el injertado, con consolidacion en las imagenes tomograficas.ConclusionesEn este trabajo, hubo correlacion entre los resultados histologicos y tomograficos. Pese a que no se hallaron diferencias estadisticamente significativas, el agregado de plasma rico en plaquetas, ademas de estimular la generacion de nuevos tejidos, disminuyo la reabsorcion del tejido injertado al analisis anatomopatologico, y mostro mayor neoformacion osea y consolidacion en el grupo IV (75%) tratado con plasma rico en plaque- tas que en el grupo III (25%) al que no se asocio plasma rico en plaquetas al aloinjerto oseo. EnglishBackgroundThe objective of this experimental work was to determine whether the addition of platelet-rich plasma influences the osseointegraton of cryopreserved allograft with antibiotics in infected fractures with bone loss, in long bones of rabbits.MethodsFour groups of 7 rabbits with generated infected fracture of the right femur. Milled allograft with local antibiotic was placed in the four groups; groups II and IV also received platelet-rich plasma. Rabbits in groups I and II were sacrificed at 30 days, and those of groups III and IV at 90 days. Histological and CT evaluation was performed.ResultsNine rabbits died during the study period. There were no statistically significant differences between groups. In group IV with platelet-rich plasma, bone formation was observed in three of the four samples, with noticeable areas of coupling between the receiver and the grafted tissue with consolidation in CT.ConclusionsIn our study, there was no correlation between the histological and tomographic findings. Although we found no statistically significant differences, the addition of platelet-rich plasma stimulated the generation of new tissue, and also decreased reabsorption of the grafted tissue according to the pathologic analysis. Besides increased bone formation and consolidation was detected in group IV (75%) treated with platelet-rich plasma, compared to group III (25%) without platelet-rich plasma bone allograft.

Two-team simultaneous open surgical treatment in bilateral shoulder fracture dislocation.

UNLABELLED Different surgical options have been described for the treatment of bilateral shoulder fracture dislocations. We report 2 cases of bilateral shoulder fracture dislocation treated simultaneously by 2 surgical teams. One case had bilateral hemiarthroplasty performed, and the second case had 1 hemiarthroplasty and McLaughlin procedure on the other shoulder. A device to allow holding the patient in a bend chair position, with both shoulders hanging outside the operative table, allowing their free movement, was designed. At 1-year follow-up, neither of the patients had complications and both are pleased with their early result. Simultaneous treatment of both the shoulders by 2 different surgical teams in bilateral shoulder fracture dislocations that need surgical treatment has the advantages of reduced overall hospitalization time, reduced anesthetic risk, faster return to work, and reduced overall cost of care. The decision for simultaneous bilateral shoulder surgery must be made in concert with the patient, medical consultant, and anesthesiologist. LEVEL OF EVIDENCE Level IV-case series.

Trombosis de la arteria axilar en el posquirúrgico de una fractura del húmero proximal Tratamiento con stent autoexpansible

Una paciente de 76 años, con antecedentes de hipertensión e hipotiroidismo, consultó por dolor e impotencia funcional después de una caída desde su propia altura e impacto del hombro izquierdo contra el suelo, en ocasión de un asalto. En el examen físico no se evidenció compromiso neurovascular del miembro (pulsos periféricos presentes, sensibilidad conservada, relleno capilar conservado). La radiografía de hombro (frente, perfil transtorácico y Lammy) mostró una fractura-luxación del húmero proximal multifragmentaria (AO 11–C3) (Fig. 1). Los estudios de laboratorio y la valoración prequirúrgica estaban dentro de los parámetros normales. La paciente fue intervenida quirúrgicamente cinco días después de ocurrida la fractura (durante ese período no se evidenció alteración neurovascular alguna); se le realizó un reemplazo parcial de hombro cementado por abordaje deltopectoral; la remoción de la cabeza humeral, en estrecho contacto con las estructuras neurovasculares, se realizó luego de la desinserción del tendón del músculo subescapular mediante maniobras digitales suaves. En el intraoperatorio se le administró una unidad de glóbulos rojos sedimentados. En el posoperatorio inmediato se evidenció palidez en el miembro superior operado y pulsos presentes pero débiles, por lo que se efectuó una ecografía Doppler que registró ausencia de flujo en la arteria humeral, arteria subclavia con flujo francamente disminuido y signos a favor de una obstrucción en la arteria subclavia distal, unión subclavioaxilar izquierda, en el sitio donde la cabeza humeral luxada se había posicionado después del accidente. Se realizó una angiografía del miembro superior izquierdo con un catéter diagnóstico JR 3.5 6F, en la que se visualizó una obstrucción total de la arteria axilar izquierda, con flujo distal TIMI 0 (TIMI: trombólisis en infarto de miocardio. Sistema de puntaje de 0 a 3, haciendo referencia a niveles de flujo sanguíneo durante la angiografía percutánea. TIMI 0: sin perfusión, TIMI I: penetración sin perfusión, TIMI II: reperfusión parcial, TIMI III: perfusión completa). Se avanzó un catéter guía JR 8 French a través del cual se introdujo un microcatéter rapid transit sobre una guía 0.014 BMW y se logró transponer la lesión obstructiva de la arteria axilar (Fig. 2). La imagen angiográfica, luego de transponer la obstrucción, mostró una disección localizada de la