One bone forearm with vascularized fibular graft. Clinical experience and literature review

The One-Bone Forearm: A Review

The one-bone forearm (OBF) is a salvage technique that may be used to correct global forearm instability secondary to osseous defects. This study aims to provide an overview of the contemporary literature regarding the OBF. A literature review was conducted electronically across MEDLINE, Embase, and PubMed databases in May 2020. Studies were eligible for inclusion if published in the English language; detailed the use of the OBF procedure to correct forearm instability; and were original data studies reporting qualitative or quantitative outcomes. Thirty-four studies, describing a cohort of 210 patients undergoing 211 OBFs, were documented in the literature. The primary etiology necessitating the OBF was trauma, followed by genetic/congenital disorders and infections. Technically, the OBF was most frequently achieved via an end-to-end osteosynthesis with plate fixation. In total, 85.0% (154/182) of OBF were fused in neutral rotation or varying degrees of pronation. Union was achieved in more than 80.0% (174/211) of OBFs. The OBF is a feasible salvage technique that has been used for a wide spectrum of pathology, providing satisfactory outcomes in most cases.

Modified Technique of Single-Bone Forearm in the Treatment of Deformities

The single-bone forearm is a salvage technique for massive loss of bone due to serious trauma, malignant tumors, infections or congenital deformity. It is also described to treat the sequelae of hereditary multiple exostoses disease that affects the distal end of the ulna. We present the case of a 29-year-old patient, operated for sequelae of hereditary multiple exostoses disease of the left forearm by a modified single-bone forearm technique. The patient, right-handed, operated on twice in childhood for a hereditary multiple exostoses disease of the left forearm: incomplete excision of the exostosis of the distal end of the ulna and lengthening of this last on external fixator, without improvement. The patient presented for a deformation of the left forearm with shortening compared to the right side‌. Significant limitation of prono-supination (pronation 15°, supination 20°). Elbow flexion at 110° and extension with deficit of 15°. Wrist flexion at 50° and extension at 50°, radial inclination at 25° and ulnar at 30°. The pain score was 3 according to the Visual Analogue Scale (VAS), especially on effort. Dash score was 31,82/100. We chose the forearm technique with a single bone. The immediate postoperative result found a realignment of the forearm, without neurological or vascular damages. Consolidation was obtained in four months. At five months, the patient recovered elbow flexion at 110° and full extension, wrist flexion at 45° and extension at 50°. Radial inclination at 20° and ulnar at 25°. The single-bone forearm technique has been described, not only for the treatment of hereditary multiple exostoses disease, but also for serious trauma or tumors with massive loss of bone. The technique generally consists of an osteotomy of the radius as well as the ulna, fixing the radius to the ulna creating a synostosis, with or without resection of part of one or both bones of the forearm. The most described complications of single-bone forearm procedure are pain, complications related to soft tissue secondary to the previous injury, and infections. The one-bone forearm remain a salvage technique for massive loss of bone of the forearm, or large deformities due to congenital malformations. This technique could allow the excision of massive bone and keep only a part of the ulna and the radius, with function maintenance and aesthetic forearm preservation.

Treatment of Recalcitrant Nonunion of the Radius With Posterior Interosseous Bone Flap in Children

BACKGROUND

Forearm nonunion is a rare condition in children, and its treatment is usually successful. However, nontraumatic nonunion can be resistant to treatment. Although the vascularized fibular bone graft has been frequently used for complex forearm nonunion, there is no consensus on the best treatment method. In this study, we aimed to investigate the outcome of the antegrade posterior interosseous bone flap (PIBF) in treating children with complex radius nonunion.

METHODS

The participants consisted of 3 girls and 1 boy ranging from 31 months to 9 years of age. They were treated with PIBF surgery, and the nonunion of the radius was fixed with a plate or an external fixator. The nonunion was due to congenital pseudoarthrosis, osteogenesis imperfecta, or infantile osteomyelitis. All patients were evaluated for a clinical and radiologic union.

RESULTS

The radiologic union was achieved 2 to 3 months after the surgery in all cases. The functional recovery of the elbow, forearm, and wrist was satisfactory except for 1 patient who experienced donor site fracture, and finally radioulnar synostosis accompanied by radial head dislocation.

CONCLUSION

Because of the simplicity of its technique and short duration of surgery, PIBF can be a reliable and less-demanding alternative to vascularized fibular bone graft in the treatment of complex forearm nonunion in children.

LEVEL OF EVIDENCE

Level IV.