PDF(Pubmed)
Abstract：
BACKGROUND: Although isolated fractures of the ulnar shaft are considered common and relatively benign injuries, numerous complications can arise especially in the context of suboptimal care pathways. For pediatric patients, however, there is no single indication of the surgical approach. In the context of the management of these complications, it is known that the vascularized fibular graft has numerous advantages and indications in the treatment of recurrent pseudarthrosis. However, in revision surgery the frequent occurrence of anatomical subversions requires the use of fixation means adapted to the individual patient. We present a clinical case of an adult patient suffering from post-traumatic ulnar pseudarthrosis treated with autologous vascularized fibula grafts and 3D-planned custom-made plate.
METHODS: A 38-year-old Ivorian woman came to our attention with a painful nonunion of the ulnar shaft and significant dysmorphism of the left forearm, with shortening and flexion of the limb as an outcome of unspecified road trauma in childhood. No alterations of the nerve compartment were reported. As far as detectable, she had undergone autologous bone grafting and implantation of questionable synthetic means, without acute treatment. Since we evaluated the patient (2012), we have performed two debridement surgeries, associated with autologous avascular bone graft from the iliac crest and plate fixation (2012 and 2014). In both cases, rupture of the fixation media was observed. In 2021, the pseudarthrosis was treated with a vascularized fibular bone graft. The subverted radius and ulna anatomy and poor bone quality required patient-specific reconstruction of the pseudarthrosic ulna from a 3D scan and the production of custom-made plate and screws, supported by the creation of special guides for drilling and by optimizing the positioning of screws with preoperative digital models. In the postoperative period, regular follow-up visits with X-rays evaluations were performed at 1, 3 and 6 months after surgery. No inflammatory reactions or local rejection were found. The fibula graft healed at the proximal ulnar junction six months after the operation while it took eight months to heal at the distal junction. Functionally, we observed a pain reduction and a range-of-motion preservation.
CONCLUSIONS: The multiple failures of diaphyseal reconstruction with avascular bone grafts have forced the indication to the vascularized fibular flap. This case is a unique experience but we believe that the association between vascularized bone graft and the potential for customization through 3D planning represents a valid surgical potentiality in complex cases of post-traumatic reconstruction.
METHODS: A 38-year-old Ivorian woman came to our attention with a painful nonunion of the ulnar shaft and significant dysmorphism of the left forearm, with shortening and flexion of the limb as an outcome of unspecified road trauma in childhood. No alterations of the nerve compartment were reported. As far as detectable, she had undergone autologous bone grafting and implantation of questionable synthetic means, without acute treatment. Since we evaluated the patient (2012), we have performed two debridement surgeries, associated with autologous avascular bone graft from the iliac crest and plate fixation (2012 and 2014). In both cases, rupture of the fixation media was observed. In 2021, the pseudarthrosis was treated with a vascularized fibular bone graft. The subverted radius and ulna anatomy and poor bone quality required patient-specific reconstruction of the pseudarthrosic ulna from a 3D scan and the production of custom-made plate and screws, supported by the creation of special guides for drilling and by optimizing the positioning of screws with preoperative digital models. In the postoperative period, regular follow-up visits with X-rays evaluations were performed at 1, 3 and 6 months after surgery. No inflammatory reactions or local rejection were found. The fibula graft healed at the proximal ulnar junction six months after the operation while it took eight months to heal at the distal junction. Functionally, we observed a pain reduction and a range-of-motion preservation.
CONCLUSIONS: The multiple failures of diaphyseal reconstruction with avascular bone grafts have forced the indication to the vascularized fibular flap. This case is a unique experience but we believe that the association between vascularized bone graft and the potential for customization through 3D planning represents a valid surgical potentiality in complex cases of post-traumatic reconstruction.
摘要：
背景：尽管尺骨干的孤立性骨折被认为是常见且相对良性的损伤，许多并发症可能会出现，尤其是在护理途径欠佳的情况下。对于儿科患者，然而,没有单一的手术方法的迹象。在处理这些并发症的背景下，众所周知，血管化腓骨移植在治疗复发性假关节方面具有许多优势和适应症。然而,在翻修手术中，解剖颠覆的频繁发生需要使用适合个体患者的固定装置。我们介绍了一例成年患者的临床病例，该患者患有创伤后尺骨假关节，接受了自体血管化腓骨移植物和3D计划的定制钢板治疗。
方法：一名38岁的科特迪瓦妇女引起了我们的注意，尺轴疼痛不愈合，左前臂严重畸形，由于儿童时期未指明的道路创伤，肢体缩短和弯曲。没有报道神经室的改变。至于可检测的，她接受了自体骨移植和植入可疑的合成手段，没有急性治疗。自从我们评估了病人(2012年)，我们做了两次清创手术,与自体无血管骨移植和钢板固定相关（2012年和2014年）。在这两种情况下，观察到固定介质破裂。2021年，假关节接受了血管化腓骨移植治疗。桡骨和尺骨的解剖结构和骨骼质量差需要通过3D扫描和定制板和螺钉的生产来对患者特定的假关节尺骨进行重建，通过创建特殊的钻孔指南和术前数字模型优化螺钉的定位来支持。在术后期间，在术后1,3和6个月进行定期随访,并进行X线评估.未发现炎症反应或局部排斥反应。腓骨移植物在手术后六个月在尺骨近端交界处愈合，而在远端交界处愈合需要八个月。功能上,我们观察到疼痛减轻和运动范围保留。
结论：使用无血管骨移植重建骨干的多次失败迫使血管化腓骨瓣的适应症。这种情况是一种独特的经历，但我们认为，血管化骨移植物与通过3D计划进行定制的潜力之间的关联代表了创伤后重建复杂病例中的有效手术潜力。
方法：一名38岁的科特迪瓦妇女引起了我们的注意，尺轴疼痛不愈合，左前臂严重畸形，由于儿童时期未指明的道路创伤，肢体缩短和弯曲。没有报道神经室的改变。至于可检测的，她接受了自体骨移植和植入可疑的合成手段，没有急性治疗。自从我们评估了病人(2012年)，我们做了两次清创手术,与自体无血管骨移植和钢板固定相关（2012年和2014年）。在这两种情况下，观察到固定介质破裂。2021年，假关节接受了血管化腓骨移植治疗。桡骨和尺骨的解剖结构和骨骼质量差需要通过3D扫描和定制板和螺钉的生产来对患者特定的假关节尺骨进行重建，通过创建特殊的钻孔指南和术前数字模型优化螺钉的定位来支持。在术后期间，在术后1,3和6个月进行定期随访,并进行X线评估.未发现炎症反应或局部排斥反应。腓骨移植物在手术后六个月在尺骨近端交界处愈合，而在远端交界处愈合需要八个月。功能上,我们观察到疼痛减轻和运动范围保留。
结论：使用无血管骨移植重建骨干的多次失败迫使血管化腓骨瓣的适应症。这种情况是一种独特的经历，但我们认为，血管化骨移植物与通过3D计划进行定制的潜力之间的关联代表了创伤后重建复杂病例中的有效手术潜力。
