RECONSTRUCTION OF LARGE POSTTRAUMATIC SKELETAL
DEFECTS OF THE FOREARM BY VASCULARIZED FREE
ROBERTO ADANI, M.D.,1* LUCA DELCROIX, M.D.,2MARCO INNOCENTI, M.D.,2IGNAZIO MARCOCCIO, M.D.,1
LUIGI TARALLO, M.D.,1ANDREA CELLI, M.D.,1and MASSIMO CERUSO, M.D.2
Vascularized bone graft is most commonly applied for reconstruction of the lower extremity; indications for its use in the reconstruction of the
upper extremity have expanded in recent years. Between 1993?2000, 12 patients with segmental bone defects following forearm trauma
were managed with vascularized fibular grafts: 6 males and 6 females, aged 39 years on average (range, 16?65 years). The reconstructed
site was the radius in 8 patients and the ulna in 4. The length of bone defect ranged from 6?13 cm. In 4 cases, the fibular graft was harvested
and used as a vascularized fibula osteoseptocutaneous flap. To achieve fixation of the grafted fibula, plates were used in 10 cases, and
screws and Kirschner wires in 2. In the latter 2 cases, an external skeletal fixator was applied to ensure immobilization of the extremity. The
follow-up period ranged from 10?93 months. Eleven grafts were successful. The mean period to obtain radiographic bone union was 4.8
months (range, 2.5?8 months). Fibular grafts allow the use of a segment of diaphyseal bone which is structurally similar to the radius and ulna
and of sufficient length to reconstruct most skeletal defects of the forearm. The vascularized fibular graft is indicated in patients with
intractable nonunions where conventional bone grafting has failed or large bone defects, exceeding 6 cm, are observed in the radius or ulna.
ª 2004 Wiley-Liss, Inc. Microsurgery 24:423–429, 2004.
Almost 30 years have elapsed since the vascularized
fibula graft was first mentioned in the literature,1and
this technique is now commonly used in clinical practice.
Use of the vascularized fibular graft (VFG) in recon-
structive surgery of the upper extremity was introduced
at the end of the 1970s,2and for a long time its appli-
cation in posttraumatic reconstruction of the forearm
was limited to a small number of isolated clinical
cases.3?8In 1984, Dell and Sheppard9described its use in
the treatment of infected pseudoarthrosis of the forearm,
and reported on 4 cases. It was not until 1991 that a
significant series was reported in the literature;10some
other papers were recently published on this subject.11?15
The purpose of this study was to report on our
experience acquired in the treatment of posttraumatic
bone losses of the forearm with the use of a vascularized
MATERIALS AND METHODS
Between 1993?2000, 12 patients (6 males and 6 fe-
males) underwent surgery to reconstruct large post-
traumatic bone defects of the forearm with the use of
vascularized fibular grafts. Their mean age was 39 years,
and ranged between 16?65 years.
The indication for surgery (Table 1) was an isolated
fracture of the radius in 2 cases (one of which was an
open fracture), an isolated fracture of the ulna in 1, and
a fracture involving two bones of the forearm in 8 (5 of
which were open fractures). The remaining patient re-
quired surgery after failure of a previous surgical cor-
rection of Madelung’s deformity.
Initial fixation was performed using plates in 8 pa-
tients, Kirschner wires in 2 (one of which was associated
with a plaster cast), and external fixator in 1. Finally,
case 4 required a radius osteotomy for Madelung’s dis-
ease, followed by internal fixation with screws and
All patients had previously undergone repeated
surgeries to achieve union or to treat the site of infec-
tion; the mean number of surgeries ranged from 3?6,
and averaged 4 per patient.
During these stages of treatment, osteomyelitis
developed in most cases, i.e., in 10 out of 12.
The time elapsed between initial trauma and recon-
structive surgery ranged from 5?96 months, and aver-
aged 39 months.
The radius was reconstructed in 8 cases, and the ulna
in 4. The length of bone defect ranged from 6?13 cm,
and averaged 8.4 cm (Table 2).
In 3 cases, the fibular graft was harvested and used
as an osteocutaneous flap to reconstruct the normal
aspect of the forearm; in one patient (case 11), the flap
was used as a monitor flap. Fibular fixation was
achieved using plates in most patients (10 cases), in 4
1Department of Orthopaedic Surgery, University of Modena and Reggio
Emilia Policlinico, Modena, Italy
2Hand and Microsurgery Unit Centro Trautiatologico Ortoredico, Florence,
This paper was presented at the Annual Meeting of the American Society for
Reconstructive Microsurgery (Cancun, Mexico, January 11?15, 2002), and at
the Second Congress of the World Society for Reconstructive Microsurgery
(Heidelberg, Germany, June 11?14, 2003).
*Correspondence to: Roberto Adani, M.D., Department of Orthopaedic Sur-
gery, University of Modena and Reggio Emilia Policlinico, Largo del Pozzo n.
71, 41100 Modena, Italy. E-mail: email@example.com
Received 15 December 2003; Accepted 28 January 2004
Published online 17 September 2004 in Wiley InterScience (www.interscience.
wiley.com). DOI: 10.1002/micr.20067
ª 2004 Wiley-Liss, Inc.
cases a long plate was used, in 5 cases two separate
plates were employed, and in case 12, the plate was used
only for proximal graft fixation (Table 2); pin staple and
screws associated with external fixation systems, such as
that of Ilizarov, were employed for the remaining 2
Vascular end-to-end and end-to-side anastomoses
were performed both on the radial and ulnar artery; in 2
cases, the peroneal artery was used to reconstruct the
radial artery by performing vascular anastomoses both
proximally and distally.
Eleven patients with successful outcomes (Table 3)
were reviewed at a follow-up ranging between 10?93
months from initial surgery.
Two cases required additional bone-grafting to
Distal screw loosening was seen in case 4, who re-
quired a second operation to remove the previous plate
and replace it with a new plate associated with the bone
Table 1. Peroperative evaluation*
Case Age (years)Sex Type of injury Initial treatment Previous operationsInfection
Closed fracture, radius
Closed fractures, radius and ulna
Open fractures, radius and ulna
Closed fractures, radius and ulna
Closed fracture, ulna
Open fractures, radius and ulna
Closed fractures, radius and ulna
Open fractures, radius,
(with bone loss) and ulna
Open fractures, radius and ulna
Open fracture, radius
Open fractures, radius and ulna
Kirschner wires and plaster
*ORIF, open reduction internal fixation.
Table 2. Operative Evaluation*
Site of bone
proceduresCaselength (cm) ProximalDistal
graft and new
97R 13.0yesPin, staple, and external
Insertion of fibula into
and pin fixation
*R, radius; U, ulna.
424Adani et al.
Case 8 showed distal bone consolidation 4 months
after reconstructive surgery. However, further surgery
was deemed necessary and was performed to insert a
cancellous bone graft at the proximal level and enhance
A similar situation was observed for case 2, who
showed distal bone consolidation 4.5 months after sur-
gery but no proximal bone consolidation. The patient,
however, refused any further operations, since the limb
was painless and could be used almost normally in
activities common to daily life. No changes occurred
over time (Fig. 1).
In the remaining patients, consolidation of the fibula
was seen proximally and distally after a mean interval of
4.8 months (range, 2.5?8 months).
All patients were reviewed and classified according
to the Tang system,4which is based on two assessment
criteria: the clinical and radiological findings. Clinical
results were rated excellent, good, fair, or poor:
Excellent: Ability to carry out normal work or study;
Good: Ability to carry out everyday activities with no
difficulties related to the reconstructed part;
Fair: Limited ability to perform everyday activities,
sometimes with difficulty; or
Poor: Inability to perform everyday activities, with ei-
ther a significant limb shortening or pain at the sur-
Similarly, radiographic results were rated excellent,
good, fair, or poor:
Excellent: Healing within 6 months with no reinterven-
Good: Healing within 1 year with no reintervention;
Fair: Healing after 1 year or reinterventions; or
Poor: Nonunion after repeated surgery.
According to the Tang system, the following results
were obtained: excellent clinical evaluation in 6 patients,
good in 4, fair in 1, and poor in none; and excellent
radiographic evaluation in 7 patients, good in 1, fair in
2, and poor in 1.
At final evaluation, elbow and wrist movements, as
well as forearm rotation, were measured (Table 3). The
elbow movement was complete in all cases. The average
pronation of the reconstructed forearm was 52? (range,
20?80?). The average extension of the wrist was 30?
(range, 10?45?), and the average flexion was 28? (range,
Extensive bone loss involving the radius and/or ulna2
may be managed with various different surgical tech-
niques. A method of restoring normal length and gain-
ing union of the affected bone or bones is desiderable.
A bone graft, which is usually corticocancellous and
harvested from the iliac crest, is generally used to treat
bone defects not exceeding 5 cm, when tissue vascular-
ization is good and, above all, when there is no infection
risk.16?18Also, the Nicoll technique is recommended
only in the absence of infection and if the bony gap does
not exceed 50 mm.19,20
The use of nonvascularized fibular grafts has pro-
vided interesting results.21,22However, this technique
requires prolonged immobilization and a consolidation
time ranging between 6?11 months.18
In addition, its use is contraindicated when there is
some evidence of existing or recurring infection,11,12as
happens with conventional bone grafts.
At present, the use of allografts in bone reconstruc-
tion of the forearm is confined to oncologic surgery,23,24
and has found no clinical applications in poorly vascu-
larized or infected areas.
Table 3. Postoperative evaluation
ROM (degrees) Wrist ROM (degrees)
PronationSupination Extension Flexion
Forearm Reconstruction by VFG 425
The creation of a ‘‘one-bone forearm,’’ which can be
obtained by transferring the distal radius onto the
proximal ulna, involves complete loss of the pronosup-
ination. Its use is therefore indicated for severe forearm
traumas involving both the radius and the ulna, asso-
ciated with severe damage or functional loss of the distal
Finally, the use of external fixators according to the
Ilizarov technique, combining distraction osteogenesis
with bone transfer,27,28has found wide application in
the treatment of bone losses affecting the lower
extremity. As far as the upper extremity is concerned,
these fixators are currently confined to the treatment of
some congenital deformities and specific posttraumatic
events associated with radial and ulnar bone loss.29In
addition, the length of bone defect should not exceed 3
cm on average, and the external fixator should be left in
situ for about 4 months to achieve a mean lengthening
of 4 cm. Both the radius and ulna are poor producers of
new bone by callotasis,19and thus the frame may be
required for many months, even when bridging a small
gap. Rotation of the forearm may be very limited after
successful bone transport.
The treatment of extensive posttraumatic bone
losses of the forearm is therefore not easy, above all if
infected pseudoarthrosis and skeletal instability are
Further confirmation was found in the current series,
where most patients had already undergone an average
of 4 surgeries during the 39 months prior to treatment
The vascularized fibular graft was used, as suggested
by other authors,10?12,15,19
exceeding 6 cm and averaging 8.4 cm. When possible,
stable internal fixation with plates (Fig. 2) was preferred
to ‘‘minimal synthesis.’’ It is difficult to establish the
relationship between consolidation time and type of
fixation used, on account of the number of cases avail-
able. The synthesis performed in case 8, in fact, required
a long consolidation time and also a second bone graft.
However, in case 9, the same type of synthesis ensured
consolidation after 3 months, i.e., a lower time interval
to treat bone defects
Figure 1. Case 2. A: Severe infection of ulna. B:
Reconstruction using VFG, employing a bridging
plate. C: Radiographic evaluation: marked non-
union at proximal site.
426 Adani et al.
than the average time recorded in the series (Fig. 3).
Stable fixation with plates allows for a possible margin
of partial failure, as happened with case 2, where
proximal consolidation did not occur: such a situation
would have been very difficult to manage in the presence
of ‘‘minimal synthesis.’’ Moreover, the use of a com-
Figure 2. Case 3. A: Open fractures
involving radius and ulna, associated
with compartmental syndrome initially
treated elsewhere with internal fixation,
subsequently removed. B: After serial
reconstruct ulna. C: Radiographic re-
was used to
Figure 3. Case 9. A: Subamputation of hand, with extensive bone loss of radius. B: Reconstruction with fibular osteocutaneous flap. C:
Forearm Reconstruction by VFG427
pression plate provided such a solid assembly that early
mobilization was possible, and this certainly accounted
for a quicker and more complete recovery.
Mean consolidation time was 4.8 months, an interval
of time comparable to those reported in other case series
The only failure (case 10) was ascribable to a con-
comitant vein and artery thrombosis of the anastomosed
vessels, which led to complete loss of the osteocutaneous
flap in spite of the repeated revision surgeries and the
salvage attempt with venous grafts. In all remaining
cases where the fibular graft was harvested together with
the fibular flap, no skin necrosis was observed. The
procedure selected30?32allowed a one-stage surgical
reconstruction of the skeletal defect and skin surface of
the forearm under precarious conditions. The validity of
this technique is confirmed by the results obtained
(Table 3): 10 patients out of 11 returned to everyday
routine activities. The possibility of preserving prono-
supination activity, even if partially (Fig. 4),33together
with the restored skeletal stability, undoubtedly en-
Figure 4. Case 11. A: Open fracture involving radius, after repeated surgeries, with nearly complete resorption of ‘‘conventional’’ bone graft.
B: Reconstruction using VFG. C: Radiographic evaluation. D, E: Clinical evaluation: pronosupination is maintained.
428 Adani et al.
No secondary fractures were found in any patients of Download full-text
the current series, thus confirming that secondary frac-
tures are more likely to occur in the lower extremity or
when a stable synthesis is not performed.34
Various techniques and donor sites may be chosen to
reconstruct bone losses of the forearm.14However, the
specific features of the vascularized fibular graft make it
suitable for an excellent bone reconstruction of this
anatomical region: the fibular shape and diameter are
similar to those of the forearm bones; morbidity at the
donor site is limited; and the available length is signifi-
cant for every bone.
In addition, VFG allows a one-stage surgical
reconstruction, as do other vascularized bone grafts, and
is a highly infection-resistant graft on account of its
autonomous vascularization. Furthermore, it allows the
reconstruction of soft-tissue losses, since it can be har-
vested as an osteocutaneous flap.
This study confirms that this technique is a valuable
option in the treatment of bone losses of the forearm in
the presence of a bone gap exceeding 6 cm, especially
when the ‘‘traditional’’ procedures available have not
ensured the expected results.
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Forearm Reconstruction by VFG429