There is no question that a segmental bone defect of this size will not heal on it's own. Observation alone would result in fatigue failure of the implant. This case raises two questions:
1. When to reconstruct the bone defect?
2. What is the best method for reconstruction of a short bone defect in the
forearm?
The question of timing of the reconstruction is more straight forward. This patient had a significant soft tissue injury as well as the fracture. A plate was placed initially to function as an internal external fixator (few screws, longer plate) to stabilize the skeleton thus providing the optimal environment for healing of the soft tissues. Healing of the soft tissue environment before bone grafting is critical. A bone graft placed into an acute inflammatory response has a very little chance of incorporating and healing a segmental defect. Acute bone grafting before stabilization of the soft tissue envelope in this patient is not the best option.
The vascularized fibula or the fibular allograft would provide cortical bone for a stable fragment-graft-implant construct. The tricortical iliac crest does not have the same quality cortical bone and a less stable fragment-graft-implant construct is achieved. The more stable the construct the earlier motion can be started and the less external immobilization required. The cortical bone of the fibula does not incorporate as well as the mostly cancellous bone of the iliac crest. The advantage of the vascularized fibular autograft is stability and better incorporation. The disadvantage of the vascularized fibula is the complexity of the free tissue transfer.
The entry and exit wounds in this patient were allowed to heal by secondary intention and did so in four weeks. The forearm soft tissue swelling decreased dramatically around the same time. The initial dysasthesias also resolved. Treatment options (3, 4, & 5) for reconstruction of the defect were discussed with the patient. Because the defect was short (3-5cm) a tricortical iliac crest autograft was offered as the best option. The risk of donor site morbidity was explained to the patient. The patient wanted to resume his employment as soon as possible without the risks of autograft even when the risk of infectious disease transmission was discussed.
The patient choose the fibular allograft reconstruction technique as the option that offered him the most benefit with the least risk. The procedure was scheduled about six weeks after the injury. A pre-operative plan was drawn. The reconstruction would include a step cut interface proximally and a transverse interface distally. Rotation of the radius would be fined tuned through the distal transverse interface. The proximal interface was a step cut for stability and a larger surface area for healing.