Bridging of bone defects in the forearm with iliac graft combined with intramedullary nailing.

The successful treatment of an established pseudarthrosis in a forearm bone is always difficult, especially when the skin or soft tissues have been damaged by previous injury or infection. The usual technique is by the use of massive onlay grafts, as advised by Henderson (1938), Campbell (1939) and Speed (1942). In my experience this method, using a tibial graft, has had only moderate success in cases of pseudarthrosis. When there is actual loss of bone and a gap needs to be bridged, the problem becomes even more complicated. The use of twin onlay grafts, as recommended by Boyd (1943), has definite advantages : the two cortical grafts screwed together give firm mechanical fixation, while bone chips, which fill the defect between the bones, supply an osteogenetic element. But the dual onlay graft has the disadvantage of considerably increasing the diameter of the bone, thus increasing the difficulties sometimes encountered in skin closure. Moreover granulation tissue may intrude into the bone at the site of screw fixation, leading to local absorption of the graft around the screw. Boyd stated that twin grafting in the forearm was advisable only when the bone defect was close to a joint. For defects in the shaft proper he advised full thickness fibular grafts, which fit the diameter of the bones and thus facilitate skin closure. There is less functional incapacity after the removal of a graft from the fibula than there is when the tibia is used. However, it is recognised that fibular grafts have poor osteogenetic power ; their incorporation into the forearm bones is a prolonged and often uncertain process. Tavernier (1946) bridged bone defects in the forearm by tibial grafts secured together with catgut and a Kirschner wire through the medullary canal of the hone, with success in two cases. Palmer (1952) described experiments in dogs, and claimed successfully bridged bone defects in long bones with cylindrical homotransplants with cancellous chips, using a V-nail for fixation. With the same technique clinically he bridged a defect in a humerus. Disappointed with my results after twin onlay grafting, I have developed a method of bridging bone defects by inserting a full-thickness iliac graft and ensuring rigidity by intramedullary nailing. OPERATIVE TECHNIQUE