Massive bone defects due to infection at the surgical site associated with a distal humeral fracture that was treated using fibula autograft: a case report

Introduction and importance:

Distal humerus fractures comprise between 2 and 5% of all fractures, and approximately one-third of all humerus fractures are of this type. In the present report, the authors described the massive bone defects due to infection at the surgical site associated with a distal humeral fracture that was treated using fibula autograft.

Case presentation:

A 28-year-old female patient experienced a fall from a height of 4 m and was referred to Poursina Educational and Medical Center. Clinical examinations and radiological imaging showed an open fracture of the right distal humerus. In the postoperative 50-day follow-up, the complication of infection at the surgical site causes bone loss of up to 8 cm. The posterior triceps-split approach (Campbell) to the distal humerus was used in this surgery. To evaluate the quality of surgery, standard radiographs of anteroposterior and lateral of the elbow joint and humeral shaft were performed after surgery.

Clinical discussion:

At 5 months postoperatively, the patient’s initial results are good, and the range of motion of the elbow joint is ~10–120°.

Conclusion:

Based on the results of the present study, fibular transplantation in distal humerus fractures is considered one of the bone treatment options for repair.

Introduction

Highlights

• In postoperative 50 days follow-up, the complication of infection at the surgical site causes bone loss of up to 8 cm.

• At 5 months postoperatively, the patient’s initial results are good, and the range of motion of the elbow joint is ~10–120°.

• Fibular transplantation in distal humerus fracture is considered one of the bone repair treatment options.

Distal humerus fractures (DHFs) comprise between 2 and 5% of all fractures, and approximately one-third of all humerus fractures are of this type1,2. Following the global increase in the elderly population, the incidence of DHF is also increasing3. The highest incidence of this injury is seen in older women, and the most common cause is falling from a standing height4. DHF is more likely to occur when the elbow is in more than 110° flexion compared to 90° or less extended elbow, which leads to fractures of the olecranon, radial head, or coronoid5. This type of the fracture causes severe loss of function due to disruption to the individual in daily activities including eating and personal hygiene6. therefore, the main goal of DHF treatment is to restore early mobilization7.

Meanwhile, open reduction internal fixation (ORIF) is known as the gold standard treatment for DHF in patients with healthy bones2,5. Although the use of ORIF in DHF has had satisfactory results. According to reports, the incidence of complications has been up to 50%, which includes: joint contracture, nerve palsy, infection, nonunion, malunion, painful implants, heterotopic ossification, and post-traumatic arthritis1. The results of a review by Yetter et al.4 showed that infections accounted for 8.24% of ORIF in articular distal humeral fracture complications. These complications can lead to a failure to achieve satisfactory reconstruction due to bone defects2.

There are various techniques for repairing distal humerus defects, such as autograft prosthesis composite, which, despite being able to provide good potential for bone healing, is not widely used due to concerns about donor site complications and low removable mass8. In the present report, we describe the massive bone defects due to infection at the surgical site associated with a distal humeral fracture that was treated using a fibula autograft.

This case report has been reported in line with the SCARE criteria 20209 (Supplementary Table S1, http://links.lww.com/MS9/A54).

Case report

A 28-year-old female patient experienced a fall from a height of 4 m and was referred to Poursina Educational and Medical Center. Clinical examinations and radiological imaging including standard radiographs of anteroposterior, lateral of the elbow joint, and spiral computed tomography scan with three-dimensional reconstruction showed an open fracture of the right distal humerus. Based on the Working Group on Osteosynthesis Questions/American Orthopaedic Trauma Association fracture classification, the patient had a C2 fracture. The patient has not experienced any neurovascular or other associated injuries. After primary care, the patient underwent ORIF surgical treatment with a good radiographic result. In postoperative 50 days follow-up, the complication of infection at the surgical site causes bone loss of up to 8 cm. Following bone loss as well as to treat infection in the area, screws and plates located at the fracture site were removed. Then, an external fixator was used for the patient. Two treatment approaches, including arthrodesis or arthroplasty of the elbow joint, were considered for this patient. Due to the patient’s age and subsequent problems performing daily tasks, arthrodesis was not performed. In addition, due to the lack of joint prosthesis in Iran, arthroplasty was not possible. Based on the above conditions, the treatment team decided to reconstruct the distal humerus bone with a fibula autograft (Fig. 1). The surgical procedure is described in Table 1. At 5 months postoperatively and 10 sessions of physiotherapy, the patient’s initial results are good, and the range of motion (ROM) of the elbow joint is ~10–120° in flexion and extension, as well as complete supination and pronation (Fig. 2). In addition, the patient was able to perform his daily tasks completely and without restrictions. She has no complaints about pain and is completely satisfied with her surgery. At 5 months postoperatively, the patient’s initial results are good and the ROM of the elbow joint is ~10–120°.

Figure 1.

Right humerus (A) and fibular graft taking (B) during operation.

Table 1.

Surgical procedure

Surgical procedure

The patient was placed in the lateral position with elbow flexion and forearm crossing the chest after induction of general anesthesia. The posterior triceps-split approach (Campbell) to the distal humerus was used in this surgery. In the midline of the posterior aspect of the elbow and the olecranon tip, a longitudinal incision was made. Fasciocutaneous flaps were raised to protect the cutaneous nerves, and subcutaneous tissue was removed from the deep fascia. The triceps tendon was incised longitudinally in the midline from the tip to the upper limit of the olecranon fossa. After the separation of the radial nerve, this nerve was protected by a rubber strip. To release the elbow, the fibrous scar and the anterior and posterior capsules were removed. In addition, dead bones and redundant calli were debrided. The main articular cartilage was protected, and to facilitate reconstruction, fracture fragments, and adhesive fibrous tissue were removed. At the distal humerus, the trochlear and capitellar joint surfaces were aligned with the olecranon and radial head articular surfaces. Then, the width of the distal humerus defect was measured, and using a fibula bone, a cylindrical autograft with a suitable shape and size of 8 cm was taken from the fibula shaft and placed inside the bone defect. Distal bone fragments were inserted using Kirschner wires for temporary fixation. Finally, the distal humerus bone structure was stabilized using anatomical locking compression plates in a parallel configuration. To prevent direct stimulation of the hardware, the ulnar nerve was displaced using a soft tissue sling. The deep muscles and fascia of the transplant site as well as the donor site were carefully sutured. The triceps cleft was also repaired with an absorbable suture. To evaluate the quality of surgery, standard radiographs of the anteroposterior and lateral views of the elbow joint and humeral shaft were performed after surgery.

Figure 2.

Postoperative lateral (A) and anteroposterior (B) views of radiographies after 5 months.

Discussion

One of the most important factors in the process of ossification is the location of the graft. Replacement and ossification occur faster in long bones than in broad bones10,11. In this report, the patient underwent reoperation after an extensive bone defect, and an external fixator was placed for him. After controlling the infection at the operation site, the patient was a candidate for arthroplasty, but due to the lack of necessary equipment in Iran, bone reconstruction was performed by transplantation from the patient’s fibula. Due to its size and shape, the fibula bone allows for satisfactory stabilization and reconstruction of the humerus. It is also not difficult to remove the fibula bone and the risk of complications is very low during transplantation less than 20 cm12,13. Another bone used for autograft is the iliac bone, which uses the cancellous and cortical surfaces of the bone for transplantation. To heal bone fractures based on the fracture site, the iliac bone can be shaped and used in different shapes and sizes during surgery. This autograft can improve the reconstruction of the triangular structure of the distal humerus14.

The results of a case report on the reconstruction of a severe fracture of the distal humerus using a fibula bone graft in the United Kingdom show that there were no complications in the patient after surgery and that both bones were healing. Also, after a 26-month follow-up, the patient’s elbow function was stable and showed that the results of the operation were successful15. Another case report study was performed on the reconstruction of severe distal humerus open fracture and fracture between the condyles using free vascular fibular transplantation in a 46-year-old man. The results of this case report show that vascular bone grafting is more effective in treating fractures of long bones (>6 cm) than conventional corticocancellous transplantation16. In another study, the patient had a DHF, and her lateral trochlear lip was completely lost. A corticocancellous bone graft from the iliac crest was used for bone regeneration in this patient. The results of treatment after 24 months of follow-up showed that there was a 25–115° ROM in the elbow joint, which was a good result. The patient herself was satisfied with the outcome of the treatment and was able to perform her daily tasks17. In a study in China, a 26-year-old male patient underwent surgery to reconstruct the triangular structure of the humerus using a structural iliac crest autograft after 45 days due to an accident involving an open fracture of the distal humerus with a large bone defect. Internal reconstruction was also performed through a parallel double-plate configuration. The results showed that during a 3-year follow-up period, the patient’s ROM was completely increased without significant complications14. In another study, similar in condition to the present case report, a distal humerus osteoporotic fracture case underwent dual plating surgery, which failed due to a lack of bone screws. A fibular strut allograft was then used to compensate for this fracture. The results of this operation showed that the patient was able to work without pain after three months, and after 6 months, the fracture completely healed through radiographic diagnosis18.

The results of a retrospective case series study aimed at evaluating the success of open reduction and internal fixation using double plating with biological and artificial bone grafting on 16 patients with aseptic nonunions of the distal humerus showed that after hardware failure or biological constraints, the use of two locking plates and bone graft augmentation using autografts or allografts with artificial bone grafts is an effective treatment for intra-articular distal humeral nonunions19. Another study investigated the plate-and-bone-strut-allograft method with bone chip augmentation in third humeral shaft aseptic nonunions. According to the findings, all 26 participants in the study had healed completely after 106 days, had good ROM, and had no complications20. Another case series study was conducted to assess the outcomes of an on-lay bone graft strut construction with bone chips as grafting augmentation in the management of aseptic nonunions of the humeral shaft. The outcomes demonstrated that the patients had optimal ROM in the elbow region 12 months after the procedure and did not exhibit any radial nerve palsies21. Also, another study in Italy compared strut graft and traditional plating methods in fractures around the humerus prosthesis. The results of this study on 30 patients in two groups showed that there was no significant difference in ROM and daily activities of patients in the humerus between the two surgical methods after 12 months22.

A study examined proximal humeral aseptic nonunion grafting and fixation. According to the findings of this study, the bone has generally improved after 126 days based on the radiography. After a year of follow-up, the patient’s performance and quality of life both improved significantly23. A cohort study investigated the two-stage bone-and-strut method for treating septic nonunions in the upper limb. Following the findings, the patient’s hand’s capacity to move improved and their pain subsided after 24 months. Additionally, with few adverse complications, the majority of patients have resumed their regular lifestyles24.

The patient present in this case report has acceptable initial treatment results after 5 months of bone grafting and the ROM of her elbow joint is about 10–120°. It is expected that in the future, the patient’s condition will improve with the help of adjuvant treatment and physiotherapy procedures.

Conclusion

In general, the surgeon should consider the appropriate method of bone reconstruction and repair, taking into account the severity of the injury to the humerus and elbow joint. Treatment and repair of DHF become more difficult as the fracture becomes more complex. According to the results of the present study, fibular transplantation in DHF is considered one of the treatment options for bone repair.

Ethical approval

The authors declare that this study is exempt from any ethical approval in our institution.

Consent

Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Sources of funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Authors’ contributions

Study concept and design, data acquisition, data interpretation, drafting of the manuscript, revision of the manuscript, and the final version of the manuscript are all approved by all authors.

Conflicts of interest disclosure

All of the authors declare that they have no competing interests.

Registration of research studies

1. Name of the registry: NA.

2. Unique identifying number or registration ID: NA.

3. Hyperlink to your specific registration (must be publicly accessible and will be checked): NA.

Guarantor

Amir Salari and Arash Aris.

Data availability

The data sets generated and analyzed during the current study are available from the corresponding author on reasonable request.

Provenance and peer review

Not commissioned, externally peer reviewed.

Acknowledgments

None.

Supplementary Material

ms9-85-0955-s001.docx ^{(16.7KB, docx)}