One-bone Forearm Research Articles

Correction of Forearm Deformities in Congenital Ulnar Club Hand: One-Bone Forearm

To describe our experience in the correction of congenital ulnar club hand, using the one-bone forearm procedure. Fifteen cases of congenital ulnar club hand treated at Gaslini Children's Hospital of Genoa, Italy, from 1996 to 2008 were evaluated retrospectively. The one-bone forearm procedure was proposed for all 9 cases of type 2 (following the Bayne classification) and then performed in 8 patients with an average age of 5.5 years (range, 3-12 y). At surgery, the patients presented paradoxical hyperextension of the elbow (up to 45° of extension). Average follow-up was 5.3 years (range, 1 to 13 y). Union of the osteotomy was obtained in all cases. In 7 cases, union occurred in an average of 65 days (range, 45-90 d); in 1 case (surgery at 12 y of age), union was delayed, with recovery 5.5 months after surgery and no need for further surgical procedures. All treated cases showed improvement of forearm function and of grasping ability of the hand (generally tridactyl). In addition, the paradoxical hyperextension movement that was present before surgery disappeared in all patients. Long-term radiographic follow-up showed in all cases the formation of a structure that was morphologically similar to that of the previously resected radial head. The one-bone forearm procedure improves malformed forearm functions, thus increasing the possibility of carrying out daily life activities. The creation of the one-bone forearm should be preceded by the release of the distal ulnar anlage, which maintains fixed wrist deformity; this procedure should be performed within the first year of life.

One-Bone Forearm Procedure for Acquired Pseudoarthrosis of the Ulna Combined with Radial Head Dislocation in a Child: A Case with 20 Years Follow-Up

This report describes a 6 year-old boy who was treated with one-bone forearm procedure for acquired pseudoarthrosis of the ulna combined with radial head dislocation after radical ulna debridement for osteomyelitis. At more than 20 years of follow-up, the patient had a nearly full range of elbow movements with a few additional surgical procedures. Pronation and supination was restricted by 45°, but the patient had near-normal elbow and hand functions without the restriction of any daily living activity. This case shows that one-bone forearm formation is a reasonable option for forearm stability in longstanding pseudoarthrosis of the ulna with radial head dislocation in a child.

Infected nonunions of diaphyseal fractures of the forearm

There are no reported series that specifically deal with repair of infected nonunions of the diaphysis of the forearm bones. We sought to determine whether a standardized treatment protocol we have utilized for 15 patients from 1989 to 2005 results in a high union rate, resolution of infection, and a good functional outcome. The study cohort included nine male and six female patients who presented to a University hospital setting with an infected nonunion of the diaphysis of the radius or ulna. Every patient had a minimum of 2-year follow-up. The average patient age was 45 years (range 17-79). Eight of the patients had fractures involving their dominant arm. Thirteen patients had initially fractured both the radius and ulna, but two of these patients had subsequently healed one of the bones. One patient had an isolated radius fractures, and one patient fractured the ulna alone. All patients underwent a protocol that combines aggressive surgical debridements as necessary, definitive fixation after 7-14 days, tricortical iliac crest bone grafting for segmental defects, leaving wounds open to heal by secondary intention, 6 weeks of culture-specific intravenous antibiotics, and early active range of motion (ROM) exercises. We sought to report our success rate of nonunion repair, number of re-interventions, complication rate, final ROM, and the ability to eradicate the infection using this treatment regimen. At most recent follow-up (average 5 years, range 2-15 years), all patients had united and resolved their infections. One case was considered a failure, although he did go on to unite a one-bone forearm and was free of infection at most recent follow-up. All but three patients, including the one failure, had at least 50 degrees of supination/pronation and 30-130 degrees of flexion/extension arc. Excluding the one failure that united his one-bone forearm at 46 months, the average time to union was 13.2 weeks (range 10-15 weeks). The results of this study indicate that our standard protocol for treatment of infected nonunion of the shafts of the radius and ulna is reliable at obtaining fracture union with a good functional result, while also resolving the infection.

The ulnius: a one-bone forearm in children

Surgical creation of a one-bone forearm is appropriately utilized for a variety of underlying conditions. It functions best when the proximal ulna and distal radius are available for use. A variety of surgical techniques have been utilized. This report reviews the pediatric literature and presents four personal cases, each with a different underlying abnormality. The rotational position of forearm fusion is discussed.

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 …

Wide excision of the distal ulna: Biomechanical testing of a salvage procedure

Purpose: To study changes in the relationship of the distal radius and ulna after progressive resection of the distal ulna. Method: Six-degree-of-freedom motion sensors were used to determine relative motion and a displacement transducer was used to determine strain changes in the interosseous membrane (IOM). These were applied in cadaveric specimens loaded to simulate wrist motion and axial compressive forces. Results: Strain in the IOM decreased with increasing resection of the distal ulna. The distance between the radius and ulna decreased with increasing resection up to 20% of ulna length. Conclusions: The decreased strain in the IOM and stabilization of the distance between the radius and ulna at 20% resection level provides biomechanical support for the satisfactory clinical results seen after wide ulnar resection. Wide excision of the distal ulna may be a viable salvage alternative to creation of a one-bone forearm. (J Hand Surg 2003:28A:105–110. Copyright © 2003 by the American Society for Surgery of the Hand.)

OPTIMAL POSITION FOR THE ONE-BONE FOREARM: An analysis using a hinged brace in normal subjects

The purpose of the present study was to determine whether there is an optimal position for fixation of the one-bone forearm. Eight normal individuals were fitted with a hinged brace which fixed the position of pronation and supination and underwent functional hand testing using the tests of Jebsen et al. Our results indicate that a one-bone forearm in a position of 30° of pronation will provide the best function for writing and working with small objects using the dominant arm.

THE MANAGEMENT OF BONE DEFECTS OF THE FOREARM AFTER TRAUMA

In summary, the authors believe that traumatic bone defects of the diaphyseal forearm, fewer than 6 cm in length, can be well managed with corticocancellous bone grafting, provided the patient has an adequate soft-tissue envelope. In cases of soft-tissue compromise, primary bone grafting is still the treatment of choice, combined with simultaneous soft-tissue coverage. This does not exclude the use of immediate primary shortening. Traumatic bone defects larger than 6 cm can best be managed with osteoseptocutaneous free fibular graft with excellent functional and cosmetic results. The creation of a one-bone forearm is rarely necessary, but remains a treatment option for an otherwise unsalvageable extremity. Osteo-articular defects can be more difficult to manage. Proximal osteo-articular defects of the radial head can be treated with excision or placement of a titanium radial head prosthesis. Distal osteo-articular defects may be better addressed in the case of radial bone loss by primary wrist fusion and, in the ulna, by a primary Darrach or Suave-Kapandji procedure.

Revision of the ununited one-bone forearm

Between 1975 and 1995, 7 patients were surgically treated for persistent forearm pain following previously unsuccessful attempts of constructing a radioulnar synostosis using interosseous bone grafting with either cross screw or pin fixation. These prior reconstructive procedures were salvage operations to address symptomatic radioulnar instability. The time interval between index operation and revision surgery was a mean of 12.6 months (range, 4-36 months). The postoperative follow-up period averaged 29.7 months (range, 11-61 months). To address these failed radioulnar arthrodeses, plate osteosynthesis and aggressive bone grafting were used in 5 of 7 patients (group 1) (4 with autologous graft and 1 with demineralized bone matrix). Union was achieved in all 5 patients after a single revision operation. Radiographic evidence of solid union was seen at approximately 4 months. In the remaining 2 patients (group 2), revision synostosis procedures were performed; these involved local bone grafting and repeat transverse screw fixation in 1 patient and iliac crest bone grafting alone in the other. One of these 2 patients progressed to union; the other had a persistent symptomatic fibrous union. The 5 patients in group 1 reported symptomatic relief, while the 2 patients in group 2 were dissatisfied. There were no postoperative complications in our series. Based on our findings, we advocate abundant bone grafting and plating for rigid internal fixation in failed radioulnar synostosis procedures.

Lengthening of a one-bone forearm: A sequel of neonatal osteomyelitis

An 8-year-old girl presented with marked shortening of the right forearm due to destruction of both the radius and ulna secondary to neonatal osteomyelitis. A one-bone forearm operation was performed to achieve a stable forearm. Two years later, the one-bone forearm was lengthened for 6 months by callus distraction (callotasis) achieving 12 cm of extra length. The patient was last followed up at the age of 16. The appearance and functional outcome of the right upper limb had been improved and she was independent in all activities of daily living.

SALVAGE PROCEDURES AFTER FAILED SURGERY ABOUT THE DISTAL ULNA

This article discusses four types of salvage procedures that may offer a successful means of treating patients after failed distal ulnar surgery. The procedures include distal radio-ulnar joint fusion, the Sauvé-Kapandji procedure, creation of a one-bone forearm, and massive resection of the distal ulna.

Wide excision of the distal ulna: A multicenter case study

Excision of the distal ulna to treat degenerative disease or instability has fallen into disfavor following reports of radioulnar impingement, carpal instability, and distal ulnar instability. Alternative procedures for reconstruction of the painful distal ulna have been developed to address these problems; the results have been generally favorable. When faced with distal ulnar reconstruction that has failed after multiple surgical procedures, or a distal ulnar neoplasm, the surgeon is left with few treatment options. Creation of a one-bone forearm, free fibular transfer, and allograft replacement have been attempted, with mixed outcomes. We report the results of 5 men and 7 women who underwent wide excision of the distal ulna, defined as surgical excision of 25% to 50% of the ulnar length. The diagnosis was failed distal radioulnar reconstruction or excision in 8 patients, osteomyelitis in 1, congenital pseudoarthrosis of the radius in 1, and neoplasm in 2. No soft tissue reconstruction was performed. Patients were examined at an average of 22 months after surgery for radiocarpal and radioulnar instability, functional outcome, pain relief, grip strength, and range of motion. Nine of the 12 procedures resulted in good or excellent results; 1 patient had a fair result after resection for osteosarcoma, and the procedure in 2 patients failed, requiring conversion to a one-bone forearm. Grip strength was restored to 75% of the normal side and range of motion was restored to 86% of the normal side. Wide excision of the distal ulna without soft tissue reconstruction is a simple and durable treatment of neoplasms of the distal ulna or salvage of the failed reconstruction of the distal radioulnar joint. We do not recommend its use in patients with incompetency or disruption of the interosseous membrane.

Clinical results of the one-bone forearm

Between 1973 and 1991, 19 patients underwent creation of a one-bone forearm at our institution as treatment for radioulnar instability secondary to trauma ("type 1" patients) or tumor resection or congenital deformity ("type 2" patients). Seventeen had failed previous reconstruction attempts. Ten one-bone forearms were constructed in neutral rotation, and nine in varying pronation (mean, 24 degrees). The distal ulna was absent or excised at the time of surgery in nine patients, partially excised in two, and shortened in one. At a mean follow-up interval of 42 months, the primary union rate was 68%, and the secondary rate was 74%. Using a rating scale devised for this study, 37% excellent, 32% good, 26% fair, and 5% poor results were noted. Poor results were statistically associated with previous trauma (type 1 patients), infection, severe nerve injury, and multiple previous surgical procedures. This is a retrospective study, and because of the limitations of such studies, no correlation of results with forearm rotational position, preoperative wrist or elbow dysfunction, fusion location, distal ulna excision or synostosis union was noted. Significant complications were noted in 10 patients, with a higher rate in type 1 patients. Although one-bone forearm construction remains a viable salvage option for forearm instability in selected patients, results may be less predictable than previously reported.

Preliminary soft tissue distraction in congenital forearm deficiency

Four patients (five limbs) were treated with preliminary soft tissue distraction using an Orthofix external distractor. The patient's ages ranged from 6 months to 14 years. Forearm deficiencies treated included partial absence of the radius (one patient), radial aplasia (two patients, three limbs), and partial absence of the ulna (one patient). Soft tissue distraction (mean, 55 days) was continued in radial deficiency until the hand could be passively centralized without residual radial deviation, allowing centralization to be accomplished through a single mid-dorsal incision. Mean measurement of distraction for the radial deficiencies was 1 cm. In the ulnar deficiency, soft tissue distraction was carried out until the cut radius was distal to the partially absent ulna (98 days) allowing for the creation of a one-bone forearm using the entire radius. Distraction (1 mm/day) was done by the children's parents with no distractor removed because of patient intolerance. All radial deficiency limbs remained centralized at a mean followup period of 14 months.

Congenital pseudarthrosis of the ulna

Congenital ulnar pseudarthrosis is a very rare condition. Two cases are reported in addition to 36 already reported in the English literature. One of the cases reported had a “one-bone forearm” procedure done, with a satisfactory result after 6 years. The second case had a free vascularized fibula graft procedure with restoration of the bony alignment and union after 8 months of follow-up.

One-Bone Forearm as a Salvage Procedure for Recalcitrant Forearm Deformity in Hereditary Multiple Exostoses

Hereditary multiple exostoses commonly affect the forearm and cause significant deformity. The response of this disease to operative intervention is usually gratifying, but in recalcitrant cases salvage procedures may be necessary. We report two patients treated with radial-ulnar fusion, review the technical aspects of the creation of the so-called "one-bone forearm," and discuss the classification and treatment alternatives available to surgeons treating patients with forearm exostoses. Treatment of both forearms resulted in functional, painless extremities at 3- and 14-year follow-up.

One-Bone Forearm as a Salvage Procedure for Recalcitrant Forearm Deformity in Hereditary Multiple Exostoses

One-Bone Forearm as a Salvage Procedure for Recalcitrant Forearm Deformity in Hereditary Multiple Exostoses

Pseudoarthrosis of the ulna in neurofibromatosis

Four children suffering from neurofibromatosis with ulnar pseudarthrosis and progressive reabsorption of the middle and distal thirds of the ulna are reported. None had any pain or sensory loss, but all had progressive deformity of the forearm. Instability of the elbow and wrist were present in three cases, while one case showed good stability and function. A cross-union of the ulna with the radius to produce a one-bone forearm was accomplished using screw fixation and iliac bone grafting, and a one-bone forearm was achieved in three cases. Non-operative management was decided on in the patient with slow ulna reabsorption. The creation of a one-bone forearm is more likely to produce sound union, thus avoiding the need for further operations, while conservative management should be reserved for patients with a slowly progressive condition.

乳児尺骨骨髄炎による広範な欠損に対する法の一例

A 3 years and 5 months old child, who had lost distal shaft of the ulna after osteomyelits at the age of 6 months, had deformity of the left forearm and dislocation of the radio-humeral joint. She was treated by production of a one-bone forearm. The functional results were good.

Vascularized bone grafts in the treatment of infected forearm nonunions

Infected nonunions of both-bone forearm fractures may not respond to conventional treatment. Four patients with infected nonunions were successfully treated with vascularized fibular grafts and conversion to a one-bone forearm after failure of as many as six procedures. The fibula was fixed to the ulna proximally and the radius distally with internal fixation, and this was supplemented with an external fixator in three of the four patients. All wounds healed and all bone junctures healed primarily with the exception of one that required supplemental cancellous grafting. Free vascularized fibular grafts should be considered for infected nonunions that are unresponsive to properly executed conventional surgical and antibiotic treatment.