Secondary Surgery Following Failed Forearm Reconstruction

Abstract

It is not uncommon for longitudinal forearm instability to be recognized quite late after the injury. Frequently, this injury is not appreciated until there have already been changes at both the wrist (ulnar carpal abutment) and the elbow (radiocapitellar abutment). These late cases frequently require an ulnar shortening osteotomy, as well as radial head prosthesis and/or reconstruction of the interosseous ligament. If continued problems result and there are degenerative changes or chronic pain at the radial capitellar joint, a radiocapitellar prosthesis can be considered. The final treatment for some patients may require creation of a one-bone forearm. This prevents any further longitudinal instability of the forearm; however, it obviously results in loss of forearm rotation. These injuries are best treated early and aggressively, as later reconstructive options will usually result in decreased function of the extremity. This chapter goes through the different reconstructive options that are available to the reoperative surgeon.

Appendices

Case 24.1

(a and b) Initial presentation—28-year-old male with flail right arm due to infected nonunion of compound fractures of both radius and ulna (s/p multiple operations including sequestrectomies of the infected nonunions).

(c) Initially underwent segmental bone resection (2.5 cm of radius and 7.5 cm of ulna) and interposition of antibiotic-impregnated bone cement.

(d) Four weeks later, removal of external fixator and open reduction and internal fixation (ORIF) of long bones with iliac crest bone graft (ICBG). Four weeks after ORIF, presented with draining osteomyelitis of ulna and excision of ICBG to ulna, removal of plate, insertion of tobramycin cement, and replating of the large ulnar defect. One week later, bone cement was trimmed leaving a cylinder the same diameter as the ulna plus a bridge of cancellous bone graft from the iliac crest. Two months later, presented again with purulent drainage from ulna. Therefore underwent removal of ulnar plate and second cancellous bone grafting (from iliac crest) to ulna, held in place by the periosteal envelope. The radius was healing.

(e) Despite multiple debridements, antibiotics, and bone grafting, chronic symptomatic osteomyelitis of ulna persisted. Therefore, partial excision of ulna and free vascularized osteocutaneous fibular graft to the ulna was performed.

(f) The cortices of the overlapping ulnar stump and fibular graft are taken down to promote union. However, as good apposition of these surfaces was not achieved with screw fixation, as seen in this radiograph, fibrous nonunion ­persisted. Subsequently, this fibrous nonunion was excised with placement of ICBG and AO plating. Five months later, satisfactory union was achieved, as seen in the radiographs below.

Case 24.2

(a) Initial presentation—68-year-old male presenting with wound over ulna in proximal forearm (h/o soft tissue sarcoma in same region resected, followed by resection of recurrences  ×  2 and intraoperative radiation). Radiographs (X-ray and MRI) showed osteonecrosis and chronic osteomyelitis.

(b) Initial operation—excision of ulceration and 12 cm of infected ulnar bone. Placement of antibiotic-impregnated bone cement and external fixator followed by gracilis myocutaneous flap and split thickness skin graft.

(c) Two months later, external fixator and bone cement were removed. Vascularized osteocutaneous free fibula flap was performed. Because of recent irradiation to forearm, brachial artery and basilic vein outside field of irradiation were ­chosen as recipient vessels. The fibula is measured and its middle third is identified. Fasciocutaneous perforators from the peroneal artery supply the skin at intervals, especially along middle third of the fibula.

(d) Lateral and anterior compartment muscles are freed from fibula, protecting both deep and superficial branches of peroneal nerve. The interosseous membrane is exposed and divided. The distal fibula is exposed and cut 7–8 cm above the lateral malleolus. The proximal fibular cut is also made, protecting the peroneal nerve and vessels.

(e) The peroneal vessels are visualized and ligated distally. The flexor hallucis longus (FHL) muscle is separated from the fibula. Next, the tibialis posterior (TP) muscle is ­separated from the fibula. A cuff of FHL and TP muscle may be left around the vessels, to protect them.

(f) The osteocutaneous fibula flap is left attached by the proximal peroneal vessels, while the tourniquet is let down and the flap is allowed to perfuse for 30 min prior to harvest. Below—the free osteocutaneous fibular flap. Saphenous vein is harvested to be used as vein graft connecting the peroneal artery and vein to the brachial artery and vein, respectively. Below—completed anastomosis. Osteocutaneous fibular graft in place. The fibular graft overlaps the proximal and distal ulnar stumps (see radiographs below). The overlapping apposing cortices are taken down and fixed rigidly with two AO screws each, to promote union.

(g) Immediately postoperative—osteocutaneous fibular flap in place with well-perfused skin paddle. Postoperative day 2—venous congestion and hematoma under the skin paddle was noted. Patient was taken back to operating room, hematoma was evacuated, and a thrombosed venous anastomosis was taken down and repaired. The arterial anastomosis was intact. Postoperative day 3—patient suffered hypotension, was transferred to ICU, and was diagnosed with pneumonia. The flap died.

(h) Postoperative day 4—patient was stabilized and taken to OR. Soft tissue and periosteum beneath the skin paddle were found to be devoid of blood supply. The peroneal vessels were found to be thrombosed and were ligated. All soft tissue was stripped off the fibular graft which was left in situ to be incorporated as a nonvascularized bone graft. The proximal two AO screws were found to be broken. These were removed and interosseous wire times three was used to hold the fibular graft proximally. The skin was easily apposed, even after excision of the skin paddle.

(i) Eight months postoperatively, union has not been achieved. One year postoperatively, radiographs reveal proximal and distal union of the fibular graft.

Case 24.3

(a) Initial presentation—43-year-old female with 1 year of wrist pain. Radiograph—lytic lesion in distal radius. CT—erosion of dorsal cortex of radius by tumor. Biopsy revealed giant cell tumor.

Resection of giant cell tumor of distal radius included:

• Ellipse of skin enclosing biopsy site tract

• Contents of first extensor compartment

• Half of second extensor compartment

• Distal brachioradialis

• 6 cm of distal radius

Intraoperative frozen section of soft tissue margins was negative for tumor. The fibula is measured and its middle third is identified.

Note—radical excision of giant cell tumors as performed above is controversial. Some authors advise less radical operations, such as enucleation of the tumor and cancellous bone grafting.

(b) An osteocutaneous vascularized fibula flap is harvested with peroneal artery and its venae comitantes. Two long toe extensors are harvested to reconstruct the first and second extensor compartments in the wrist. A step cut was made in the proximal radius to accept to accept the fibular bone graft. The dorsal cortices of the scaphoid and lunate were removed in a block fashion to accept the fibula. The ends of the fibula were cut to match the osteotomies of the radius proximally and ­scaphoid and lunate distally. Proximal fixation was with three 2.7-mm AO screws. Distal fixation was with two 0.062-in. Kirschner wires passed across the fibula into the carpal bones. Postoperative X-rays revealed union in 3 months. However, the ulna was subluxed dorsally and was of positive variance. Patient presented with instability of her distal ulna with pain and laxity. Subsequently, a modified Darrach with ECU stabilization was performed, as seen in radiographs below.

(c) Wrist motion at 1 year postoperatively.