PREPRINT

  • 1. Introduction
  • 2. Surgical Approach
  • 3. Incision and Exposure
  • 4. Prepare Fracture Fusion Site
  • 5. Harvest Bone Graft from Iliac Crest
  • 6. Bone Graft Inset
  • 7. Review of Anatomy
  • 8. Closure
  • 9. Post-op Remarks
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Bone Graft for Non-Union of Right Thumb Proximal Phalanx Fracture

Sudhir B. Rao, MD1; Mark N. Perlmutter, MS, MD, FICS, FAANOS2; Arya S. Rao3; Grant Darner4

1Big Rapids Orthopaedics
2Carolina Regional Orthopaedics
3Undergraduate Student, Deparment of Biological Sciences, Columbia University
4Duke University School of Medicine

Transcription

CHAPTER 1

Hi, good afternoon. I'm Dr. Rao from orthopaedics and I want to talk to you about a case that we are about to do. This is an 11-year-old female, who injured her thumb about a year ago, the fracture probably got infected, and she ended up with an established non-union of the head of the proximal phalanx, of her dominant right thumb. When we saw her a few days ago she had a completely unstable thumb with a well-established non-union, at the very distal end of the proximal phalanx. This non-union would never heal by itself under any circumstances. She had a dysfunctional thumb, and we decided to operate on this patient. Dr. Perlmutter and I decided to go ahead with the bone grafting and internal fixation of this non-union. We decided to use iliac crest bone graft because it is a round bone, it is osteogenic, and it has the best potential to facilitate healing of this non-union. The basic surgical steps of this procedure as follows: the patient is anesthetized, we use a tourniquet on her upper arm to exsanguinate the limb and have a bloodless surgery. We will make a dorsal longitudinal incision, split the extensor mechanism, and dissect down to the non-union site. We will then remove all fibrous tissue and non-viable bone from the non-union. We will establish a gap at the non-union site. Once we establish the dimensions of this gap, we will proceed to a harvest a bone graft from the opposite iliac crest. The bone graft will be bicortical in nature, which means it has cortex on the inside and outside. This will also facilitate stability of the bone graft. Once the bone graft is harvested, it will be trimmed to size and placed in the defect. We will try and make the graft as tight as possible so that it has an inference fit inside the non-union site. The entire construct will then be fixed with a single K-wire inserted from the tip of the terminal phalanx to engage the proximal phalanx. Once this is done, we will close the incision anatomically, we will immobilize the digit in a splint and cast for several weeks until healing is established. Once healing is demonstrated, the K-wire will be pulled out, and the patient will be allowed to resume normal activity. We expect once healing is complete, and the patient is allowed to resume her usual activities, she will eventually regain full function in that thumb. This can take between 3 to 6 months.

CHAPTER 2

Today we're operating on a little girl, that had fractured, sometime ago, perhaps a year, the distal end of the first bone in her thumb. It's her right thumb, her dominant right thumb. Her thumb is tilted over the edge. It's not functional, she can't hold anything with it. The joint is functionally dislocated. So the plan for today is to take a segment of bone from her pelvis, and move that up- a little small square of bone that we'll strategically fit right where it needs to be, very tightly, very snugly, to get the fracture fragments to heal. I'll direct your attention to the X-rays. The X-rays show that the distal fragment of bone that is attached to the distal phalanx, and they together have dislocated off of the fractured end of the bone. The end of the bone is very white because it's dead. And we'll end up resecting that because it won't have a good blood flow. And so we're going to create a little block of bone that will be about that big- between my fingers- we'll take that block of bone and fit it very square, as we center the end of the bone on the end of this shaft. The fragment of bone will sit there, so we'll have: her phalanx, distal phalanx, which that's the tip of her finger, then there will be the end of that fracture, then a block of bone, and then her native bones. And a single pin will go down through the end of this, through the distal end of the fracture fragment, into the graft that we're gonna harvest from the pelvis, and then into the shaft of this bone, and for stability, the pin will go into this bone, down here. The pin will stay in for 2 months. By then this child will certainly heal the fracture- hopefully heal the fracture. And then we'll start her on a play program, which will hopefully give her some function. The typical function of this joint is 90 degrees. If she gets stiff and she bends 45 degrees, that's a functional range of motion. If you look at a hand making a fist, that's about how much we need to- to function, and she'll certainly have that. It's rare that somebody has to bend 90 degrees to function normally. So we anticipate that the dominant hand is going to have perfectly normal functioning when we're done.

CHAPTER 3

This is the beginning of our procedure. This is a little girl who had a fracture to her thumb through the growth plate of the distal phalanx, and the middle- and the proximal phalanx, I'm sorry. So- so there's a fracture, at the growth plate, of the end of the proximal phalanx, or the first of the two bones in the thumb. And- what we're doing is taking the- an incision through the skin, and then through the extensor tendon. Our intent is to fuse that joint. It won't move. It's a floppy joint now. And there's no way to get that fracture to unite. So our intent is to fuse the joint. Is that your physis there? No, the physis is here. It's proximal. I mean the fracture. Yeah. Sorry. Yeah. Okay, Rongeur please? Her extensor tendon, yeah, it's kind of short. I mean that's the distal joint right there. That's the distal joint. Uh huh.

CHAPTER 4

Okay. So, this is a tool that's a biter, it's called a Rongeur, and it's taking out all the fibrous tissue that grew between the fracture fragments. The goal is to expose bleeding bone here. It's very sclerotic. Yeah, it's just- I don't want to take off too much, I'm going to just… John, if you don't mind, can you look at the room temperature please? If we're getting iliac crest graft, we might as well… Get a lot- clean it out. Yeah, it's all sclerotic bone. Yeah. Lose it all. So the bone at the end of the fragment is very hard, we call it sclerotic bone, it's very, very solid, it's marble like in its consistency. It has decreased blood flow, accordingly. So our intent is to go to her iliac crest of her pelvis… Flex that- bone site. So I can get to the… So I just bent the tip of the bone down to expose the fracture site. He's going to cut away some soft tissue now that may get stuck in our intended fusion site. Those are the origins of the collateral ligaments, and other soft tissues. Now, lets see if she has anything I can use to open up the medullary canal. Do you have- how about a K-wire? Yeah. Uh- the K- the wire, the K-wire. The pins- the metal pins for the drill. So he's going to use this tool to bite it- all the non-living bone off. I want to go to the distal fragment too soon. And now we're going to the distal fragment to clean off the base of it, which is covered in fibrous tissue. That fibrous tissue is scar tissue, and it will not let us- will not let the fractures heal to themselves. We have to expose raw bone to raw bone, as if it was a fresh fracture for it to heal together. Are you trying to make a cup? I'm just trying to get bone without destroying that small fragment. I think I've got bone exposed. I think you did. I'm going to have you make a big chunk, let's see how much defect you… A centimeter. Yeah, you can always take more. Oh, I'm going to take more. Okay. A centimeter by how deep? A centimeter by centimeter, just get a centimeter. If you can- what I'm looking for- cortex volar, cortex dorsal, and cancellous on either side. Yeah, yeah. Yeah, yeah. Yeah, yeah.

So here's her iliac crest bone. It was prepped out a head of time, and these little red dots are where we injected it with numbing medicine before we get started.

CHAPTER 5

Do you need my help? No, I think I'm good. I'll take the Weitlaner in front of you. I don't have a Weitlaner. I'm only kidding (laughing), do you have Army-Navy's? Yeah. They have Weitlaners. Here. They do? Yeah. Do you want another one? One will do. Okay, so here's the iliac crest, and- Bovie. Do you have a cobb elevator? I'll take a Cobb, and I don't want to use this these Ray-Tec's. If I could- another sponge would be perfect. Sponge? Something bigger than this, so I can pack it a little bit. Sponge. So this is the top of the crest. Can you tell them we need a big sponge, like this- like this? Her periosteum is like shoe leather. Can we turn the coag up? At 11, how thick is her cartilage cap? We should be able to do this without any power. Are you on the inner table? I can't see from here. This is the inner table. Can I have another sponge, please? Can I show you a neat trick? Sure, I'll learn anything from you. Alright, let's have that osteome and mallet.

Mallet. Take it off. (Hammering) She has some Hohmanns there, let's get those ones. Leave it there. Do you leave it in, put it back? Yeah. So Hohmann- Hohmann retractor. So, what you're looking at is the growth plate, cartilage cap here, and then the raw pelvic bone there. We're going to put that cartilage cap back on, so it continues to grow. Alright. Alright, I'll take that. Let go of that. (Hammering) Alright, hold that. It just pulls out. Mallet. (Hammering) Number 1 Vicryl, numero one Vicryl. How do you say Vicryl? Vicryl. Vicryl? Okay. Okay, get me another one. Hohmann. Mallet. (Hammering) Alright, now with your osteotome, just take a chunk of bone. (Hammering) Hold that. (Hammering) Kocher? (Hammering) This will free the whole thing now. (Hammering) I don't want to crush it, so go ahead and knock it out. (Hammering) This- it's out.

So what I'm doing now is I'm trimming the bone graft to size. He has the piece of graft that we just harvested from the iliac crest. Now he's trimming to size to fit the gap that we created when we cleaned out that bone. We have a specific space. Now we're trying to get that space to match perfectly, and so we're going to make a little block of bone that will fill that space where the fracture was broken, and un-unite it. And we'll put a pin through the end of the finger, through that fracture- including the fragment of iliac crest that we just moved there. And then that will heal- hopefully. And her body will heal it as if it was a freshly broken bone, and unite the distal end of that proximal phalanx, and preserve the joint motion. She'll certainly have some stiff motion, but as she develops, she may actually have a normal functional range of motion- or near normal, but certainly functional range of motion. I think we should point out that we are using her own bone, with like cells that will supply all the- the nutrients and the growth factors that facilitate union. Great point. Choices of bone graft, or bone filler, include artificial bone- that's commercially available, donor bone from people who've donated their hearts, and lungs, and kidneys for people who need them, also donate bone- that's called cadaver or allograft. And- then there's autograft, where people donate their own tissues to themselves for surgery. In this case, when you donate your own tissues, they are rich in the stem cells and the other growth factors that allow tissues to heal back to themselves. So using one's own tissue to patch a gap in that tissue, has a distinct advantage. The disadvantages of it are that you have to make an incision some place to harvest that tissue. In this case, it's a minimal- intervention- to treat a very significant problem- the dominant thumb in a child. Her pelvic bone will continue to develop normally, she will have no deficits from this whatsoever. The scar is in line with her skin folds, and once this is closed cosmetically, she may never have a scar that's visible out of her underwear line. If visible at all. So he's retracting the tissue there now, and sizing the graft. That will take a few moments, if he hasn't completed that already. I have just closed the fascia completely over- the pelvic bone. And all that remains is skin. The deep subcutaneous tissues first. If you close one layer, I'm going to have you come over and help here. Sounds like a deal. That's more pressing. One more throw, and I'm there. No more here. 3-0 Monocryl. I almost have the right size here. So he's plugging the hole with a cube of her bone. He wants it to be very, very tight. He's taking time to take little bits away at a time- because he wants the tension of the tissues to hold that, which is why we're not retracting it open for him, because it changes the tension of the tissues. He's going to snip away a little bit at a time- at a time- making it a little bit smaller.

CHAPTER 6

What you can see- what he's done already is put a pin at the end of the finger. Not right this minute. We're going to put the pin across the frag- the fragments in a moment. Do you want me to drive it while you hold it? No, I just want to position it well before we try it. Yeah, I'm just saying. Yeah, okay, let's get the- K-wire driver and properly position it. That's the graft. That's the bone, and the pin is- you can see the pin- right there- before you grab it. Yeah. Let me extend. Okay, grab it.

You're not centered, so... I figured, I just want to close it a little bit. You're centered. I'm going to have you drill slowly so you're through the graft, but not into… Tell me when. Lift up your- a little bit. And go slow. Keep going. (Drilling) Stop. Now we're into the graft. Go. Stop. Go. Are you feeling bone? I am. Keep Going. Keep Going. 1, 3- do you see there? Yeah, keep going. Keep going. Do we need more bone? You might hit the base of the proximal phalanx. Yeah, but I think I'm there. Okay, then let's take this out. We're going to test it now to see the- challenge our fixation. Looks good. So there's no big gap- it's pretty stable. Do you want to drive it across? I do. Okay. So we're putting the pin into the next bone to give it greater stability. I'm touching the end of the other bone. Tell me when. (Drilling) Right there. Okay it's not going to get any better than that. No.

The most time I do is put a little cencellous chips around it. I saved these right here as a matter of face. What he had said off the mic was that those little cancellous chips around- cancellous is the spongy bone on the inside. Those bone chips that we removed- see if she has them. And we're going to pack them- these in there to augment our healing capability. Trying to get it at the interface.

CHAPTER 7

Now what we're going to do now- we have our natural bone, the longst bone- that's- we borrowed from her pelvis, was replaced from her pelvis. The end of that natural bone- so, that should all fuse as one bone. Under my pickups, is the distal phalanx of the thumb- the fragment that was broken that has the articular surface, our graft, and the remaining proximal part of the proximal phalanx. You want more in there? I can close her, if you want to take him and help. Yes. We're going to close the pelvis, okay? So, our host is going to close the remainder of the pelvic wound. 3-0 please.

CHAPTER 8

So, we're going to try to hide the stitching, okay? So we're going to come under here, start- if I start deep like this, I'm going to just come through the edge of the skin, right? I don't want the fat because the fat doesn't hold anything, right? I don't want to come through the skin like that, I want to just grab that white. Okay. Then I'm going to go straight across, and we're going to- and I'm going to go into the white that I just exited before, right? I'm going to go- 90 degrees at it. I don't want to do this because I'll just skive a little piece. I want to catch a lot of it. See how I'm under the skin? And then I'm going to follow the curve, just by rotating it. See? You'll pull it together. So, go around twice to start. Grab the end. Only leave about 3 cm. And then- see the- it's all in line. And then- where did it go? Oh, there it is. Other way, and then go into it. So, you cross your hands, then go into it. And cross your hands, and then we can cut it. Now what he sewing now is the extensor tendon. He split it to get exposure to the bone. He's sewing it together. Once the fracture heals, the extensor tendon will have healed well before then. Two months from now, we'll take out the pin. And once the pin is out, the fracture will be healed. Okay now, pull it through. Leave about 3 cm. The fracture will be healed, the extensor tendon will be healed, hopefully there will be little scar tissue binding everything together, and she'll start moving her thumb. And as she grows, she should have a straight thumb that's functional. She won't bend 90 degrees like mine is bending now on the video, probably, but if she bends just 45 degrees, and it's straight, and its strong, she'll be extremely functional. Could I show you one more? You did an excellent job with that. Let's put one right next to where you put yours. They opened up on their own. See how I could see through the skin? Now I'm just gonna rotate my- I'm just going to rotate my wrist, and it shows up. Doesn't mean I can retrieve it with these- clamps. Now, here's what I want to show you. It's important that they're both on the same side. See how I put them on opposite sides? So we want- we want to get them- both strings on the same side- like that. Oh, okay. But see how that comes together nice? So, you go around twice, right? Keep- see how I keep the needle in my hand? And- and then I can- still keeping that pinched, I can use my middle finger now to pinch. And then we- see how I can just pull it in? Oh, okay. But I'm not- I'm not doing this, right? With the big thing. So after the tendon is closed, he's going to close the skin in a few layers. Then we're going to cut the pin. That's a big pin to bend, I bet we just cut it. Maybe he can bend it. We'll put a nice, padded dressing on her, and the dressing will include a plaster splint to give it extra support. We'll keep it immobilized, as I said, for 6 to 8 weeks- probably 8. It'll definitely be stiff, but with growth she might- get a- and I anticipation she will get a functional range of motion- she won't do this, but she'll do this. Now, let me show you how to close the sub-Q. Where's the needle? In your hand? Okay, I want to start it, and then you finish it, okay? Good. These open up on their own, don't they? Mm hmm. Yeah. A little springy. You come into the corner. Let me steal those from you. So this is only in that white layer, okay? Note- nothing in fat. Only in the white. So look- just get a visualization, come straight across, right? Right where I came- cut across. You go horizontal and out the white layer. Okay? And you follow that- see how it closes pretty? Yeah. That's what you wanna do, no- you don't have to get big ones. It's tedious, but just walk it all the way down. Right before the corners. Nothing to grab, so just guess- guess- guess well though. You can see the tip- good, good, you got it! Yay! Follow the curve of the needle, but you gotta pull- pull out, yeah. Okay, now see? Now- if you just- if you ended it there, you'd have a gap, right? Now go into the corner on the other side- and then come out- yeah, come out here. So, the premise of a Steri-Strip, or tapes like this, is if you take the- if you take the tension off of this suture line, and spread it out from here to here, the scar has less tension on it and it will heal prettier. It'll stay together more. See how I'm pulling it like this? I want to lay that down, and that takes tension off the suture. Okay. We'll put this down- a non-stick dressing because if it bleeds through, the cotton will stick to it, and then it pulls this off. Okay, drapes down. Tape. Tape.

CHAPTER 9

So, I'm just done with the operation. You just saw the procedure where we- exposed the non-union of the proximal phalanx, of the right thumb, and inserted a bicortical piece of iliac crest- autogenous graft, fixed with a single K-wire. The critical steps of the operation, again, are to establish the site on non-union, thoroughly debride the site of all fibrous tissue and non-viable bone, and then use the patient's own iliac crest as a bone graft with a tight interference fit. The bone graft should be shaped so that it fits in that space without any bone voids as such. The fixation with a K-wire is really supplemental and aids in the healing of the non-union. We do an anatomic closure, as you saw. The thumb will be immobilized in a splint or a cast for about 6 to 8 weeks at least, until healing is evident. I expect with the surgery that you just saw, that the patient will have an excellent outcome once she has completely healed and rehabilitated.