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. 2026 Feb 24;61:101314. doi: 10.1016/j.tcr.2026.101314

Salvage articular reconstruction of the distal radius using a 3D simulation-guided distal clavicle osteochondral autograft after fracture-related infection: A case report

Whee Sung Son 1
PMCID: PMC12969799  PMID: 41810248

Abstract

A male patient developed a severe articular defect of the distal radius following treatment for fracture-related infection caused by methicillin-resistant Staphylococcus aureus. Full functional recovery was achieved with articular reconstruction using a distal clavicular osteochondral autograft guided by three-dimensional (3D) simulation and 3D-printing, with concomitant palmar radiocarpal ligament reconstruction using the acromioclavicular joint capsule.

Keywords: Fracture-related infection, Distal radius articular reconstruction, Distal clavicular osteochondral autografts, Palmar radiocarpal ligament reconstruction

Highlights

  • •

    First case report on articular reconstruction after fracture-related infection.

  • •

    Successful distal radius articular reconstruction using distal clavicle graft.

  • •

    Osteochondral graft using acromioclavicular (AC) joint cartilage.

  • •

    Also used AC joint capsule for palmar radiocarpal ligament reconstruction.

Introduction

The definition and diagnostic criteria of fracture-related infection (FRI) have significantly evolved over recent years, with international consensus efforts focusing on developing standardized approaches [1], [2], [3]. Despite these advancements, the treatment of FRI remains challenging, with bone reconstruction being one of the most difficult aspects, often requiring complex techniques and staged procedures [4], [5].

Recent methods, such as the induced membrane technique and bone transport using intramedullary lengthening nails, serve as valuable tools for managing metaphyseal and diaphyseal bone defects [6], [7], whereas the management of articular defects following FRI remains a critical unresolved issue. Typically, arthrodesis is considered the treatment of choice for articular defects, particularly when joint preservation is not feasible [8], [9], [10]; however, arthrodesis inevitably leads to a substantial loss of joint function, which can be devastating for young and active patients.

So far, no study has addressed the issue of articular surface reconstruction associated with FRI. This study presents a case of successful joint salvage of a distal radius FRI with severe articular loss using a distal clavicular osteochondral autograft and the acromioclavicular joint capsule for radiocarpal ligament reconstruction. The procedure was planned and guided using a three-dimensional (3D) simulation and a 3D-printed model.

Case presentation

Initial presentation

A 36-year-old male sustained multiple trauma following a motorcycle accident. Postinjury imaging revealed a severely comminuted intra-articular fracture of the volar aspect of the left distal radius, accompanied by radiocarpal fracture dislocation (Fig. 1); a concomitant right radial styloid fracture was observed in the contralateral arm. Additionally, the patient sustained a pelvic ring injury, classified as anteroposterior compression type III, along with hypovolemic shock.

Fig. 1.

Fig. 1

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Plain radiographs (A) and computed tomography images (B) of the comminuted intra-articular fracture of the volar aspect of the left distal radius, accompanied by radiocarpal fracture-dislocation.

After initial resuscitation, definitive fixation of the pelvic ring injury was performed on post-injury day 3, along with closed reduction and external fixation of the left distal radius fracture and the associated radiocarpal fracture-dislocation (Fig. 2A). Subsequently, the left distal radius fracture was treated with open reduction and plate fixation with additional Kirschner wire fixation on postinjury day 10 (Fig. 2B, C).

Fig. 2.

Fig. 2

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Plain radiograph (A) showing external fixator application on postinjury day 3, along with definitive fixation of the pelvic ring injury. Plain radiograph (B) and computed tomography image (C) showing open reduction, plate fixation, and additional Kirschner wire fixation in the distal radius on postinjury day 10.

Infection management

Two weeks after surgery, the patient developed signs of infection, including wound discharge and elevated C-reactive protein levels (2.84 mg/dL; normal range: 0–0.5 mg/dL). Immediate surgical exploration was performed, and intraoperative cultures were obtained. One set of cultures was collected during the initial debridement, following which the surgical team changed the gowns and instruments to new sterile sets and obtained an additional post-debridement culture to confirm the appropriateness of the debridement. Each pre- and postdebridement culture set was obtained from at least five different sites [6], [11], [12]. An external fixator was applied, and a vancomycin-loaded polymethylmethacrylate (PMMA) spacer was inserted before concluding the procedure (Fig. 3A, B).

Fig. 3.

Fig. 3

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Photographs and plain radiographs of the two debridement procedures. (A) Intraoperative photograph after pus drainage and plate removal. (B) Plain radiograph after the first debridement procedure showing external fixator application, insertion of vancomycin-loaded polymethylmethacrylate spacer, and fixation with 1.5-mm screws to preserve the lunate facet fragment. (C) Intraoperative photograph of the second debridement procedure. (D) Plain radiograph after the second debridement procedure.

However, the culture results showed that all five pre-debridement specimens grew methicillin-resistant Staphylococcus aureus (MRSA); all five post-debridement specimens also tested positive for MRSA. Consequently, an additional debridement was performed, following which a vancomycin-loaded PMMA spacer and an external fixator were reapplied (Fig. 3C, D). Eventually, all post-debridement cultures from the five sites tested negative, and intravenous vancomycin for 6 weeks, followed by a 2-week drug holiday, was administered in consultation with the hospital's infectious diseases department. After the drug holiday, there was no evidence of infection recurrence, and all infection-related laboratory markers normalized. Therefore, we proceeded with distal radius reconstruction.

Reconstruction of the articular defect

Following infection management, the patient had an articular defect involving approximately one-half to two-thirds of the volar side of the distal radius articular surface (Fig. 4). To plan the defect reconstruction, a mirrored image of the contralateral distal radius was created using computed tomography (CT) data and superimposed onto the defect side to virtually reconstruct a 3D model of the missing articular area (Fig. 5A). This 3D-reconstructed defect was then 3D-printed to facilitate preoperative planning (Fig. 5B). Two potential donor sites—the iliac crest and the distal clavicle—were evaluated, and the 3D simulation and 3D-printed models of these sites were produced and matched to the defect to determine the most suitable harvest site (Fig. 5C–5E).

Fig. 4.

Fig. 4

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Computed tomography image after infection management showing an articular defect involving one-half to two-thirds of the volar aspect of the distal radius articular surface.

Fig. 5.

Fig. 5

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3D-simulated images showing the missing articular area in the distal radius. (A) Image reconstructed using a mirrored image of the contralateral distal radius superimposed onto the injured side. (B) 3D-printed model of the reconstructed missing articular area. (C) 3D-simulated image of the patient's ipsilateral distal clavicle. (D) 3D-printed models of potential donor sites (distal clavicle and iliac crest). (E) 3D-simulated image of the patient's iliac crests. * indicates the reconstructed missing articular area. u: ulnar side; r: radial side; v: volar side; d: dorsal side; and a: articular side.

Ultimately, the distal clavicle was selected because it provided the best match to the concave articular surface required to reconstruct the lunate facet and ensure radiocarpal joint congruity. Additionally, the distal clavicle includes cartilage from the acromioclavicular joint, making osteochondral grafting feasible. The attached acromioclavicular joint capsule was also expected to allow reconstruction of the radiocarpal ligament, which is essential for wrist joint stability. The distal clavicle is commonly resected for treating acromioclavicular joint arthritis, and resections of up to 10 mm are well-tolerated without compromising acromioclavicular joint stability [13], [14], supporting its use as a safe harvest site. The 3D simulation showed that when grafted to the distal radius, the articular surface of the distal clavicle could provide a dorsovolar length of 10.8 mm and a coronal width of 17.7 mm. This dorsovolar length was adequate for reconstructing one-half to two-thirds of the articular defect; although the coronal width was insufficient to extend to the radial styloid, it allowed reconstruction of the lunate and scaphoid facets.

The external fixator was removed, and the previous surgical approach—a modified flexor carpi radialis approach—was used to access the distal radius. The previously inserted PMMA spacer was removed, and light debridement was performed. As before, pre-debridement and post-debridement (after changing to new sterile gowns and instruments) cultures were obtained. The distal clavicle was then harvested using an oscillating saw according to the planned dimensions based on the 3D simulation; the acromioclavicular joint capsule was preserved as much as possible during harvesting (Fig. 6A). The harvested distal clavicle was trimmed to match the 3D-simulated missing articular area as closely as possible (Fig. 6B). The 3D-printed model of the missing articular area was used as an intraoperative reference. During the procedure, the trimmed distal clavicle was directly matched to the defect site for detailed adjustments, while ensuring that there was no intra-articular step-off in any plane by inserting a freer retractor into the joint to palpate and confirm surface congruity (Fig. 7A).

Fig. 6.

Fig. 6

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Photographs of the distal clavicle graft preparation and associated procedures. The harvested distal clavicle (A) was trimmed (B) and prepared for osteochondral grafting. (C) Autogenous bone obtained during trimming was used as additional bone grafting at the interface between the osteochondral graft and the distal radius. (D) The palmar radiocarpal ligament was reconstructed using the acromioclavicular joint capsule.

a: articular side of distal clavicle; and c: acromioclavicular joint capsule.

Fig. 7.

Fig. 7

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Intraoperative and postoperative imaging. (A) Fluoroscopic image showing the assessment of the intra-articular step-off using a freer retractor, with the precisely trimmed distal clavicle graft compressed by a pointed bone clamp and a small colinear clamp. (B) Postoperative plain radiographs of the wrist and shoulder. (C) Postoperative computed tomography images.

The precisely trimmed distal clavicle graft was then positioned at the defect site. A small dorsal incision was made to retract the extensor tendons, and compression was applied using anterior-to-posterior clamping (Fig. 7A). An anatomically long 2.3-mm and 3.5-mm distal radius plate (AcuLoc, Acumed, Hillsboro, OR, USA) was positioned; one proximal cortical screw, followed by distal locking screws, was inserted. Additionally, a proximal locking screw was placed; since the location of the most proximal screw overlapped with the Schanz pin site of the previous external fixator, an additional 2.8-mm plate (ARIX Small Fragment System, Jeil Medical corporation, Seoul, Republic of Korea) was overlapped at this level to prevent a peri-implant fracture (Fig. 7B, C). After plate fixation, the autogenous bone obtained during the distal clavicle trimming was used for additional bone grafting at the interface between the osteochondral graft and the distal radius (Fig. 6C). Finally, the acromioclavicular joint capsule was used to reconstruct the palmar radiocarpal ligament (Fig. 6D).

Postoperative course after joint reconstruction

The patient was monitored closely to observe for any signs of infection recurrence. Notably, one of the cultures was mislabeled, and the pre- or post-debridement status of this culture was not clear. Although all intraoperative cultures initially showed no growth, the mislabeled one grew MRSA. Furthermore, on postoperative day 11, C-reactive protein levels were elevated (0.481–1.539 mg/dL), and There was mild warmth and swelling at the surgical site. Accordingly, immediate surgical exploration was performed, including plate exchange and thorough debridement (Fig. 8). Finally, all cultures confirmed no growth, and no signs of infection recurrence were observed thereafter. Wrist range of motion (ROM) exercises were initiated immediately postoperatively, and from 3 months after surgery, the patient was allowed to resume all activities involving pressure on the wrist. One year after the surgery, the patient had some limitation in wrist flexion (ROM: flexion = 30°, extension = 60°, pronation = 65°, and supination = 75°); however, the patient was able to return to work as a chef without any functional limitations (Fig. 9A, D). Additionally, the donor shoulder (left) showed no ROM limitations or radiographic abnormalities (Fig. 9C). Eventually, the implant was removed, and there were no signs of infection recurrence at the latest follow-up (3 years postoperatively) (Fig. 9B).

Fig. 8.

Fig. 8

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Intraoperative photographs and postoperative imaging. (A) Pre-debridement and (B) post-debridement photographs taken during the second debridement and plate exchange performed for suspected infection recurrence after osteochondral grafting. (C) Postoperative plain radiograph.

Fig. 9.

Fig. 9

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Follow-up plain radiographs and photographs. (A) Plain radiographs at 1-year and (B) 3 years postoperatively; implant removal was performed at 1 year and 3 months postoperatively. (C) Plain radiographs and photographs of the donor side shoulder (left) from which the distal clavicle was harvested, showing no range of motion limitations or radiographic abnormalities. (D) Photographs of the wrist joint at the final follow-up showing no range of motion limitation.

Discussion

This is the first case report demonstrating successful joint salvage of a distal radius articular defect developed following an FRI. Although the patient was at risk of requiring arthrodesis, the joint function was successfully reconstructed using a distal clavicular autogenous osteochondral graft aided by 3D-simulation and 3D printing.

While there are no studies on articular reconstruction following FRI, several oncology-related studies have described articular reconstruction after resection for bone tumor lesions, particularly using proximal fibula autogenous bone grafts [15], [16]. However, the proximal fibula does not provide a cartilage-bearing osteochondral graft, nor does its shape replicate the concave morphology of the lunate facet, limiting its use in wrist reconstruction. Zhang et al. [17] reported wrist joint subluxation following proximal fibula grafting for wrist reconstruction, which may be due to this mismatch in joint shape. Moreover, reconstruction of the distal radius and palmar radiocarpal ligaments is technically challenging in these cases, further contributing to postoperative instability. Conversely, distal radius allografting has been used in the management of bone tumor lesions and can be a good option in certain cases [18], [19]. However, the use of allografts in the case of infection carries a higher risk of recurrence, and their availability may be limited depending on local resources. Other studies on reconstruction for osteochondral injuries and post-traumatic osteochondral defects have utilized tarsal bones as donor sites; for instance, Stougie et al. [20] and del Pinal et al. [21] used non-vascularized and vascularized metatarsal base osteochondral grafts, respectively.

Notably, Feng et al. [22] used CT analysis and cadaveric studies to identify optimal donor sites from the foot for lunate facet reconstruction. Although the second tarsometatarsal joint demonstrated articular dimensions and concavity suitable for lunate facet reconstruction, the authors concluded that it was crucial for maintaining the medial arch and bearing load. Furthermore, the tibialis posterior tendon inserts onto the base of the second metatarsal and the second cuneiform; thus, harvesting from this site may be associated with significant morbidity. Instead, they proposed that the third metatarsal base and third cuneiform, which are similar to the second metatarsal base and second cuneiform in articular dimensions, with appropriate concavity, may represent more suitable donor sites. Therefore, in distal radius articular reconstruction following FRI, the third metatarsal base or third cuneiform may serve as good osteochondral donor sites, offering the essential concavity required for lunate facet reconstruction with limited donor site morbidity. It is noteworthy that the distal clavicle osteochondral graft used in this study offered an additional advantage of allowing simultaneous reconstruction of the palmar radiocarpal ligament.

While this case report demonstrates successful management of FRI, it also highlights persistent concerns in the current treatment strategies for FRI. The first issue is the appropriate extent of debridement. Although additional debridement was required based on positive post-debridement cultures, this culture-based strategy is a valuable tool for guiding complex FRI management [6], [11]. However, there is no clear consensus on whether all post-debridement culture areas testing positive should be excised, and what is the appropriate extent of resection. While removing nonbleeding bone is considered a surgical mainstay, this assessment remains highly subjective. There is a need for more objective intraoperative methods to evaluate devitalized bone, as well as a clearer consensus and guidelines for resection margins. The second issue concerns the timing of surgical exploration when infection recurrence is suspected. Morgenstern et al. [23] noted that early surgical intervention improves the likelihood of successful implant retention or exchange; however, the appropriate waiting period, the cutoff levels for elevated inflammatory laboratory markers, and the characteristic features for FRI recurrence remain subjective. In our case, there was a strong intention to preserve the grafted osteochondral construct; therefore, surgical exploration was performed promptly at the first signs of inflammatory marker elevation and clinical evidence of infection. This approach allowed successful infection management through graft preservation and plate exchange. Nonetheless, some surgeons may consider such early surgical intervention as overly aggressive and choose to observe for a longer period before reoperation. Finally, this case report highlights the importance of precise culture labeling. If the MRSA identified during the final osteochondral graft procedure had been recovered from a properly labeled culture (pre- or post-debridement) or a precise sampling location, it would have been more valuable to guide subsequent treatment.

The primary limitation of this study is that it describes a single case of articular reconstruction following FRI. Additionally, the distal clavicular osteochondral graft may not be suitable for reconstructing the sigmoid notch or extending to the radial styloid process. Moreover, whether the use of the acromioclavicular joint capsule for palmar radiocarpal ligament reconstruction provides a meaningful benefit in wrist stability remains uncertain. Although no wrist instability was observed in this case, comparative analyses with cases using other osteochondral grafts without palmar radiocarpal ligament reconstruction are warranted.

Conclusion

This study demonstrates the successful reconstruction of a distal radius FRI with severe articular loss using a distal clavicular osteochondral autograft and the acromioclavicular joint capsule guided by 3D simulation and a 3D-printed model.

CRediT authorship contribution statement

Whee Sung Son: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing.

Statement of informed consent

The patient provided written informed consent for the publication of this report and the accompanying images.

Statement of funding

This work was supported by the 2025 Yeungnam University Research Grant (grant number: 225A580053).

Declaration of competing interest

The author declares that they have no conflict of interest.

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