Gap nonunion of forearm bones treated by modified Nicoll's technique

Abstract

Background: The management of an atrophic nonunion with a gap following a fracture of the radius and/or ulna is a challenging problem. Various methods of treatment available in the literature are cortical tibial graft (Boyd), ulnar segment graft (Miller and Phalen), iliac crest graft (Spira), cancellous insert graft (Nicoll), vascularized fibular graft (Jupiter), and bone transport by ring fixator (Tesworth). The present study reports the results of tricorticocancellous bone block grafts using modified Nicoll's technique, in diaphyseal defects of forearm bones.

Materials and methods: A total of 38 forearm bones (either radius or ulna or both) in 23 patients with a gap of 1.5-7.5 cm were treated by debridement and tricorticocancellous bone block graft under compression with intramedullary nail fixation between June 1985 and June 2005. There were 15 male and 8 female patients. Sixteen patients had open and seven patients had closed fractures initially. Time of presentation since the original injury varied from 9 months to 84 months. Eighteen patients had already undergone one to three operations.

Results: Thirty-six bones showed union at both host graft junctions. The mean duration of union was 17.5 weeks (range, 14-60 weeks). Two bones had union only at one host graft junction and did not show any evidence of callus formation up to 9 months on the other end, hence requiring subsequent procedure in the form of phemister bone grafting. Patients were followed for a minimum period of 2 years (range, 2-7 years). Results were based on the status of union and range of motion (ROM) for elbow/wrist and grip strength at the final follow-up. Complications observed were the reactivation of infection (n = 1) and herniation of the muscles at the donor site (n = 1).

Conclusion: The tricorticocancellous strut bone grafting under optimal compression, augmented with intramedullary fixation, provides a promising solution to difficult problem of an atrophic nonunion of forearms bones with gap.

Keywords: Gap nonunion of radius/ulna; intramedullary fixation; tricorticocancellous strut bone graft.

Figure 1

X-ray of right forearm lateral (a) and anteroposterior (AP) view (b) of a case of 10-month old ununited fracture both bones of the forearm with implant in situ (plate). AP view (c) shows fracture fixation with intramedullary nail and interposed tricorticocancellous strut bone graft. 20 weeks follow-up AP X-rays (d) shows fracture union with incorporation of bone graft

Figure 2

X-ray of left forearm with elbow lateral (a) and anteroposterior view (b) of a case of 2-year-old neglected Monteggia fracture dislocation with ununited ulna and broken implant in situ (intramedullary nail). Lateral view (c) shows radial head excision and fracture fixation with intramedullary nail and interposed tricorticocancellous strut bone graft incorporation at 24 weeks follow-up