Galeazzi Fracture Nonunion Treated with a Free Vascularized Corticoperiosteal Graft

Galeazzi fracture is an unstable radial shaft fracture accompanied by injury to the distal radioulnar joint (DRUJ) and interosseous membrane.[1] It accounts for 3 to 7 percent of all forearm fractures.[2] For the treatment of Galeazzi fracture, open reduction and rigid internal fixation have been recommended because most patients treated by closed reduction have an unsatisfactory outcome.[1] [3] However, there have been reports of nonunion of the radius despite rigid internal fixation with a plate.[4] [5] Galeazzi fracture nonunion is an uncommon occurrence, but its management is challenging. Therefore, we have developed a new method for the management of Galeazzi fracture nonunion with a hybrid bone graft consisting of a free vascularized corticoperiosteal graft and a corticocancellous inlay bone graft.

The patient was a 48-year-old man who had suffered a Galeazzi fracture of his left forearm due to a fall 9 months before the present operation. When we first examined him, he had already undergone three operations at other hospitals to treat the injury. These were open reduction and internal fixation with Kirschner wires ×2, followed by open reduction with cancellous bone grafting using a plate. Two months previously, re-fracture had occurred, so he was referred to our hospital. At the time of presentation, there was derangement of the DRUJ, nonunion of the radius, pain, and significant limitation of motion (Fig. [1]).

Figure 1 X-ray films obtained before surgery, immediately after the operation, and 11 months afterwards. In the PA view, the radius appears relatively shortened, compared with the ulna, and there is fracture of the plate. In the lateral view, the fractured radius is angulated dorsally (left). The alignment of the radius has been improved (center). At 11 months after the operation, there is complete union of the radius (right).

A vascularized corticoperiosteal graft, which included the periosteum with a thin layer of the outer cortical bone, was harvested from the medial supracondylar region of the right femur (Fig. [2]). The radial plate was removed and thorough curettage of necrotic bone was done at the recipient site. A corticocancellous strut graft corresponding in size to the defect in the radius was harvested from the iliac crest. The corticocancellous strut graft was positioned so that the cortex of the iliac crest faced sideways. It was used to restore more normal alignment of the radius and was countersunk to prevent displacement (Fig. [3]). The strut graft was attached to the cortex of the radius on both sides using a Kirschner wire and two pins, after which the bone fragments were immobilized using an external fixator (see Fig. [1]). Multiple cancellous bone chips obtained from the iliac crest were inserted into the residual defects around the strut graft. Then, the strut graft and the bone chips were wrapped with the vascularized corticoperiosteal graft, which was fixed to the radius with sutures. Preoperative angiography confirmed that the radial artery was occluded (Fig. [4]). The stump of the radial artery was anastomosed to the descending genicular artery, and the cephalic vein was anastomosed to the vena comitans of the descending genicular artery. The recipient site was closed with a skin graft so that the vascular pedicle was not compressed. The donor site was closed directly in layers.

Figure 2 Intraoperative findings. (A) Donor site of the vascularized, thin corticoperiosteal graft based on the articular branch of the descending genicular vessels is shown (asterisk). It is located between the vastus medialis and adductor magnus. The vastus medialis has been retracted anteriorly. (B) Vascularized corticoperiosteal graft (arrow), supplied by the descending genicular vessels.

Figure 3 Diagram of the surgical method. The corticocancellous strut graft was placed in the defect of the radius so that the cortex of the iliac crest faced sideways.

Figure 4 Preoperative angiography. The radial artery is occluded (arrowhead).

Bony union occurred within 3 months at both ends of the graft. The external fixator was removed 4 months postoperatively. Flexion-extension of the wrist was 20 to 60 degrees, and the range of forearm rotation was slightly limited (supination was 90 degrees and pronation was 60 degrees) (Fig. [5]). The grip power was 33 kg (vs. 42 kg on the right). The patient had no disturbance of hand function during daily activities and there was no distal radioulnar joint instability despite residual prominence of the distal ulna (see Fig. [1]). Accordingly, despite warning about potential problems in the future, the patient elected not to undergo any further treatment to restore normal ulnar variance. The patient returned to his previous employment as a forwarding agent and there was no donor-site morbidity.

Figure 5 Functional outcome.

There were two major problems in this case: one was a poorly vascularized graft bed due to scarring after multiple operations, and the other was poor intrinsic stability because of the Galeazzi fracture.

Nonunion after multiple operations at the same site is commonly associated with a poorly vascularized graft bed. This patient had severe circulatory impairment around the distal forearm, as revealed by preoperative angiography (see Fig. [4]). It was therefore predicted that graft resorption, graft fracture, nonunion, and/or infection were likely to occur if he were treated with an avascular bone graft such as a conventional corticocancellous or cancellous bone graft. In contrast, a vascularized bone graft preserves the nutrient blood supply of the bone, as well as the living bone tissue matrix and osteocytes, and it accelerates healing and promotes resistance to infection.[6]

The free vascularized fibular graft has been the mainstay of vascularized bone grafting for the forearm.[3] A free vascularized corticoperiosteal graft is thin, while a vascularized fibular graft is bulky. A free vascularized fibular graft should be used for large bone defects (>6 cm) and is not indicated for atrophic nonunion without a substantial bone defect, as in this case.[7] [8] The free vascularized corticoperiosteal graft was first described by Sakai et al.[9] in 1991, followed by four clinical reports in the English literature.[7] [8] [9] [10] [11] The free vascularized corticoperiosteal graft is supplied by the articular branch of the descending genicular artery and vein. The graft consists of periosteum with the underlying thin cortical bone and includes the cambium layer, which has superior osteogenic potential.[8] [9] This graft was small, thin, and flexible, so it readily conformed to the recipient bed configuration.[11] There have been no reports about a free vascularized corticoperiosteal graft being used for nonunion of the radius apart from the case of Yajima et al.[11] To our knowledge, there have been no reports on the use of a vascularized bone graft for nonunion of a Galeazzi fracture.

Takami et al.[12] reported that anterior inlay grafting with a corticocancellous strut graft was a reliable method for correcting collapse of the scaphoid, as well as for obtaining bony union in patients with nonunion of a scaphoid fracture. We adopted the idea of anterior bone grafting in the present operation for a Galeazzi fracture. The inlay graft was harvested from the ilium and thus had the thick cortex of the iliac crest and abundant cancellous bone.

If not treated definitively within 10 weeks, dislocation of the DRUJ can lead to limitation of supination and pronation, chronic pain, and weakness in patients with a Galeazzi fracture.[13] At the time of the present operation, 9 months had passed since the initial injury. However, the patient had neither chronic pain nor weakness at 11 months after surgery, although there was limited pronation and flexion of the wrist.

There was poor intrinsic stability, but no substantial bone defects, in this case of Galeazzi fracture nonunion. Because of multiple operations, there was also a poorly vascularized graft bed. We used an inlay strut graft to enhance stability and a vascularized thin corticoperiosteal graft to improve the local blood supply. This method offers several advantages that make it a good choice for treating nonunion of unstable fractures such as the Galeazzi fracture.

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