Major bone defects in the forearm caused by severe trauma is often with combined with composite soft tissue defects, and even blood supply disorders. Ischemic time is the main criterion to decide whether to preserve or amputate limbs. For severe open forearm injuries, limb preservation is superior than amputation. Daoutis et al. [16] have reported the functional outcomes of 47 patients with replantation and evaluated the outcomes using Chen criteria [15], concluding satisfactory functional outcomes in 37 of the 42 patients. In 2007, Sabapathy et al. [17] have shown the functional outcomes of 22 patients with replantation and concluded that replantation is a valuable procedure, and radical debridement, appropriate bone shortening and reduction of ischemic time are of great significance for the successful replantation. In 2017, Mattiassich et al. [18] have reported long-term results of upper limb replantation and concluded that long-term effects are possible. In this study, according to the criteria of Chen, 3 patients had a grade-I functional outcome, 14 patients had a grade-II functional outcome, and 1 patient had a grade-III functional outcome. Apart from the time of injury, segmental comminuted fractures during debridement can lead to bone loss in the radius and ulna. In consideration of the two factors, rescue is a major challenge [17] [19], and requires highly personalized therapeutic approaches.
OBF procedure has been used as a rescue option for complex forearm instability due to various causes. There is no consensus on the indications for this operation. According to previous studies, this operation is used to treat forearm bone loss caused by congenital abnormalities, tumors and infections [5-9].To our knowledge, the study by Peterson et al. [6] had the largest sample size among previous studies. In total, 19 patients received OBF reconstruction between 1973 and 1991 (only 1 case was caused by acute trauma, the rest cases were due to tumor resection / congenital abnormalities, etc.). According to the Peterson scoring system designed by Peterson et al. (the Peterson scoring system is also used in our study) (Table 4), 37% cases were excellent, 32% cases were good, 26% cases were fair and 5% cases were poor. Allende et al. [8] reported a mean clinical score of 7.7 (the Peterson scoring system [6]), without cases of infection, nonunion or re-fracture. In our case series, except for 1 patient was somewhat satisfactory, the remaining 17 patients were subjectively satisfied with limb reconstruction, and no one was willing to accept amputation, even if the limb was short and disfigured. Based on the Peterson scoring system, the outcome was excellent for 3 patients, good for 13 patients, fair for 1 patient, and poor for 1 patient. Except for 1 patient who failed to resume their original physical work and could only performed daily activities, the rest 17 patients can resume their original physical work. Therefore, OBF reconstruction combined with DRUJF is an alternative method to preserve severe acute forearm injuries and provides therapeutic ideas.
Sauvé-Kapandji procedure refers to the DRUJF and distal ulnar segment osteotomy pseudoarthrosis to treat forearm rotation dysfunction caused by changes in the distal radioulnar joint (DRUJ). Sauvé-Kapandji procedure can relieve inferior ulnar radial arthritis or mismatch by fusing the DRUJ, resolve ulnar variability through segmental resection of the distal ulna, and restores the forearm rotation function through the formed pseudo joint [20]. Simple OBF reconstruction can generally cause wrist longitudinal instability, DRUJ instability and chronic pain [10]. Ota et al. [21] also consider that the wrist width loss after Sauvé-Kapandji procedure is associated with the aggravated carpal ulnar deviation, therefore, attention should be paid to maintaining the original wrist width to prevent progressive ulnar deviation of the wrist. OBF reconstruction was generally used alone. And we also found cases of distal radioulnar dislocation after simple OBF reconstruction (Figure 1). We later performed DURJF as a salvage procedure. In this study, the OBF reconstruction combined with DURJF was simultaneously performed, which can theoretically maintain the line of force in the wrist for a long time, prevent the ulnar deviation and palmar subluxation of the wrist, and decrease the number of operations.
There are certain limitations in this study. Although all data were prospectively collected, this study was a retrospective one. A prospective study involving a large population and long-term follow-up is required to confirm our results. In addition, a lack of a control group and statistical analysis in this study is correlated with the retrospective nature of this rare surgical procedure. The strengths of this study include a relatively homogeneous group of patients who suffered traumatic major bone loss in the forearm, and OBF reconstructions consist of the proximal ulna and the distal radius. Compared with other studies using telephone follow-up, face-to-face survey follow-up is used in our study, which avoids inconsistency between clinical results and patient evaluation as much as possible. Moreover, all the surgical procedures are performed by the same senior surgeon. Another advantage is the long-term follow-up, especially regarding the results of patient evaluations, which ranges from 2 to 16 years. To the best of our knowledge, it is the first case report with the largest sample size of the emergency treatment using OBF reconstruction combined with DRUJF to treat major bone defects in the forearm caused by severe trauma.