Anterior augmentation plating of aseptic humeral shaft nonunions after intramedullary nailing

Functional Outcomes in Aseptic Humeral Shaft Nonunion Treated With Plate Osteosynthesis: A Retrospective Cohort Study

Introduction

Aseptic nonunion is prevalent in orthopedic practice, causing persistent pain and functional impairment. Humeral shaft fractures, accounting for 3-5% of all fractures, have nonunion rates of 2-33% in nonoperative and 5-10% in surgical management. This study, the largest case series on operative management of aseptic humeral shaft nonunion (AHSN), treated with plate osteosynthesis.

Materials and methods

This retrospective study, conducted at a referral center in eastern India, included 132 patients with aseptic humeral shaft nonunion from May 2002 to April 2012 and May 2015 to December 2020. Patients aged 20-70 years with nonunion more than 6 months post-trauma were included. Exclusions were open fractures, infections, gap nonunions, pathologic fractures, and concomitant upper limb injuries. Surgical techniques involved excising fibrous and unhealthy tissue, compressing the nonunion site, decorticating, shingling, autologous bone grafting, and stable fixation with dynamic or locking compression plates. Outcomes were assessed using Quick DASH, VAS, Constant Shoulder score at a minimum follow-up of 24 months.

Results

The study included 132 patients, 84 males and 48 females, with a mean age of 42.3 years. Fractures were due to high-energy trauma in 78 cases and low-energy trauma in 54 cases. All patients with atrophic type of AHSN received autologous bone grafts and plating techniques. Quick DASH scores improved from 77 to 5 on average. Constant Shoulder score improved from 22 to 88 and VAS score improved from 6.7 to 1.3. Union was achieved in 21 weeks on an average, with minimal complications. Despite variations in time intervals, treatments, and follow-up durations, consistent management strategies emphasize stable fixation, bone grafts, and careful management of complications to achieve high union rates and satisfactory outcomes. Complications included seven infections, one failure needed refixation and two case of transient radial nerve palsy.

Conclusion

Absolute stability using plate with or without autologous bone grafting for aseptic humeral shaft nonunion results in high union rates and satisfactory radiologic and functional outcome.

Operative Management of Aseptic Humeral Shaft Nonunion: A Retrospective Study from Eastern India

Aseptic nonunion is prevalent in orthopedic practice, causing persistent pain and functional impairment. Humeral shaft fractures, accounting for 3-5% of all fractures, have nonunion rates of 2-33% in nonoperative and 5-10% in surgical management. This study, the largest case series on operative management of humeral shaft nonunion, examines surgical techniques and outcomes. This retrospective study, conducted at a referral center in eastern India, included 132 patients with aseptic humeral shaft nonunion from 2002 to 2020. Cases were from May 2002 to April 2012 and May 2015 to December 2020. Patients aged 20-70 years with nonunion more than 6 months post-trauma were included. Exclusions were open fractures, infections, gap nonunions, pathological fractures, and concomitant upper limb injuries. Surgical techniques involved excising fibrous and unhealthy tissue, compressing the nonunion site, decorticating, shingling, autologous bone grafting, and stable fixation with dynamic or locking compression plates. Outcomes were assessed using DASH, VAS, and constant shoulder score scores at a minimum follow-up of 24 months. The study included 132 patients, 84 males and 48 females, with a mean age of 42.3 years. Fractures were due to high-energy trauma in 78 cases and low-energy trauma in 54 cases. All patients received autologous bone grafts and plating techniques. Quick DASH scores improved from 77 to 5 on average. Union was achieved in 21 weeks on average, with minimal complications. Despite variations in time intervals, treatments, and follow-up durations, consistent management strategies emphasize stable fixation, bone grafts, and careful complication management to achieve high union rates and satisfactory outcomes. Complications included seven infections, one failure needed refixation and one case of transient radial nerve palsy. Absolute stability using a plate with or without autologous bone grafting for aseptic humeral shaft nonunion results in high union rates and satisfactory radiological and functional outcome.

Prognostic factors of extracorporeal shockwave therapy in the treatment of nonunion in long bones: a retrospective study

BACKGROUND

Nonunion of long bone fractures is a significant complication following surgical fixation, with an incidence ranging from 5 to 10%. Surgical intervention is the standard treatment for nonunions, but it may come with potential complications. Nonoperative approaches, such as Extracorporeal Shockwave Therapy (ESWT), have been advocated as alternatives.

METHODS

In the retrospective study conducted between January 2004 and January 2018, 91 patients who underwent ESWT for tibia or femur nonunions were included. Nonunion was defined based on radiographic criteria and clinical symptoms. The nonunion morphology was categorized as hypertrophic, oligotrophic, or atrophic. ESWT was administered using the OssaTron device in a single treatment session. Bony union was defined as the presence of a bridging callus over the fracture site with more than three-fourths of the circumference in both planes within the 12-month postoperative period.

RESULTS

The study included 91 patients, with an overall union rate of 62.6%. A higher healing rate was observed in trophic nonunion(69.9%) than in atrophic nonunion(33.3%). Multivariate analysis identified the number of surgeries, maximum fracture gap, and atrophic nonunion as independent factors influencing the risk of fracture nonunion after ESWT. The receiver operating characteristic curves were generated for these factors, providing more than one surgical intervention, and fracture gap greater than 3.94 mm as negative predictors of ESWT for long bone nonunions.

CONCLUSION

The study's primary findings suggest that ESWT is effective in achieving bony union for nonunions in long bones(62.6%). Despite the overall positive results, the study highlights that atrophic nonunions, larger fracture gaps of more than 3.94 mm, and multiple surgeries are associated with poorer outcomes.

[Non-unions of the upper extremities]

The diagnosis and treatment of non-unions still represents an interdisciplinary challenge. Therefore, prevention, early detection and specific treatment are of great importance. Non-unions of the upper extremities, although less common than that of the lower extremities, requires special attention for successful treatment due to the central role of the shoulder girdle and arm in day to day activities. Successful treatment of non-unions requires a comprehensive evaluation of the patient's medical history, a thorough clinical examination and in particular radiological imaging. In order to effectively treat the pseudarthrosis it is crucial to distinguish between pseudarthroses that are suspected to be due to infections and those that are not. This article presents a treatment algorithm for managing both pseudarthrosis due to infection and pseudarthrosis without infection in the upper extremities.

Treatment of presumed aseptic non-union of the humeral shaft by osteosynthesis combining intramedullary nailing and screw plate

In 2020, the most common treatment for presumed aseptic non-union of the humeral shaft seems to be decortication, often associated with bone autografting, and stabilized by a screw plate. We propose to evaluate an original technique of rigid osteosynthesis combining intramedullary nailing and screw plate. Between January 2004 and January 2020, 45 patients underwent treatment of presumed aseptic non-union of the humeral shaft by osteosynthesis combining intramedullary nailing and a screw plate. The minimum radio-clinical follow-up was one year postoperatively. The series included 19 men and 26 women with a mean age of 53 years (range 19-84 years). Bone consolidation was achieved in 43 patients, a rate of 95.5%. Comparing patients who achieved bone consolidation with the two failed consolidations did not reveal any statistically significant factor. Interobserver agreement was almost perfect (k=0.93) for the use of the RUST for humeral shaft fractures treated with intramedullary nailing and screw plate. In our study, the treatment of presumed aseptic non- union of the humeral shaft with an osteosynthesis combining intramedullary nailing and screw plate gives, with 95.5% of bone consolidation, results equal to or even superior to the different treatments currently described in the literature.

Single versus double plate fixation of humeral shaft nonunion

INTRODUCTION

Humeral shaft fractures are common fractures of the diaphysis of the humerus. The aim of this study was to evaluate factors affecting the clinical outcomes of humeral nonunions surgically treated with open reduction and single- versus double-plate fixation with grafting.

MATERIALS AND METHODS

A total of 31 patients with nonunion treated with single- or double-plate screw fixation with bone grafting were retrospectively analysed. The patients were divided into two groups according to the treatment method as Group 1 (single-plate, n = 14) and Group 2 (double-plate, n = 17). Data including demographic and clinical characteristics of the patients, initial and final treatment, type of nonunion and localisation, graft use, shortening, follow-up, time to union, Quick Disabilities of the Arm, Shoulder and Hand (Quick-DASH) scores, and patient-reported cosmetic outcomes were recorded.

RESULTS

Of the patients, eight were males, and 23 were females, with a mean age of 47.6 ± 15.8 (range, 20-86) years. Initial treatment was conservative treatment (Sarmiento brace) in seven patients, plate fixation in 22 patients, and intramedullary nailing in two patients. The mean follow-up was 31.0 ± 16.9 months in Group 1 and 25.4 ± 15.6 months in Group 2. There was one nonunion in Group 1 and three in Group 2. There were no significant differences in the union rate and time to union (p = 0.378 and p = 0.262, respectively). The mean Quick-DASH scores and cosmetic results were similar between the groups (p = 0.423 and p = 0.165, respectively). Radial nerve palsy developed in three patients in Group 2, and all these patients recovered completely during follow-up.

CONCLUSIONS

Although the double-plate fixation technique has similar clinical, radiological, and functional results to single-plate fixation, it is a more invasive and expensive technique with a longer operation time. Therefore, it should not be used as the first-line treatment option for all humeral shaft nonunion. Nevertheless, the double-plate technique may be preferred to achieve in cases requiring high stability, such as hypertrophic nonunion, osteopenia and comminuted fractures.

Medial augmentation plating of aseptic distal femoral nonunions

BACKGROUND

Distal femur nonunions are well-recognized contributors to persistent functional disability, with limited data regarding their treatment options. In the current study, we asked whether additional medial augmentation plating is a feasible treatment option for patients with aseptic distal femoral nonunion and intact lateral implants.

METHODS

We conducted a single-center, retrospective study including 20 patients treated for aseptic distal femoral nonunion between 2002 and 2017. The treatment procedure included a medial approach to the distal femur, debridement of the nonunion site, bone grafting and medial augmentation plating utilizing a large-fragment titanium plate. Outcome measures were bone-related and functional results, measured by the Hospital for Special Surgery Knee Rating Scale (HSS) and the German Short Musculoskeletal Function Assessment questionnaire (SMFA-D).

RESULTS

Eighteen of 20 nonunions showed osseous healing at 8.16 ± 5.23 (range: 3-21) months after augmentation plating. Regarding functional results, the mean HSS score was 74.17 ± 11.12 (range: 57-87). The mean SMFA-D functional index was 47.38 ± 16.78 (range 25.74-71.32) at the last follow-up. Index procedure-associated complications included two cases of persistent nonunion and one case of infection.

CONCLUSIONS

According to the assessed outcome measures, augmentation plating is a feasible treatment option, with a high proportion of patients achieving bony union and good functional outcomes and a few patients experiencing complications.

Management of humeral nonunions following failed surgical fixation

INTRODUCTION

Management of humerus nonunions with previously failed fixation presents a complex problem. There are multiple revision fixation strategies, of which compression plating is a mainstay. The aim of this study was to assess the results of open reduction and direct compression plating without the need for autograft or allograft in the setting of revision humerus open reduction internal fixation.

METHODS

This study is a retrospective analysis of 19 patients treated between 2008 and 2017 for humerus nonunions following failed fixation who were treated by a single surgeon using direct compression plating with bone graft substitutes. Patients were treated with neurolysis of the radial nerve, hardware removal, debridement of the nonunion site with shortening osteotomies, compression plating, and augmentation with bone graft substitutes. All patients were followed until radiographic and clinical union.

RESULTS

Nineteen patients were identified for the study and 17 had adequate follow-up for final analysis. Humeral union was achieved in 16/17 (94.1%) patients with a mean time to union of 23 weeks. Two patients required a repeat compression plating with bone graft substitute to achieve union. The one patient with a nonunion radiographically reported minimal clinical symptoms and opted for no revision surgery. An association with the index procedure was seen, as three out of four of the patients who experienced radial nerve palsies after their index procedure subsequently experienced a radial nerve palsy after the procedure to repair their nonunion. All patient's all experienced a return of function in their radial nerve either back to baseline or improved from before the revision nonunion surgery.

CONCLUSION

The use of humeral shortening osteotomy and compression plating without autograft or allograft is a viable option for management of humeral nonunions which avoids the morbidity associated with autograft harvest. The patients with radial nerve palsy after the index procedure are likely to have a transient radial nerve palsy as well after the revision surgery necessitating proper informed consent prior to the operation.

Approach to Humeral Shaft Nonunion: Evaluation and Surgical Techniques

Humeral shaft fractures account for 1% to 3% of all fractures. Traditional nonsurgical treatment with a functional brace is still the standard treatment of these fractures; however, modern studies have reported that nonunion rates may be as high as 33%. Recent information suggests that the development of nonunion after nonsurgical treatment may be identified as early as 6 to 8 weeks postinjury. Even with surgical treatment, nonunion rates as high as 10% have been reported. Regardless of the original treatment method, nonunion results in poor quality of life for the patient and therefore should be addressed. A thorough preoperative evaluation is important to identify any metabolic or infectious factors that may contribute to the nonunion. In most cases, surgical intervention should consist of compression plating with or without bone graft. Although most patients will achieve union with standard surgical intervention, some patients may require specialized techniques such as cortical struts or vascularized fibular grafts. Successful treatment of humeral shaft nonunion improves function, reduces disability, and improves the quality of life for patients. In this article, we outline our approach to the treatment of humeral shaft nonunion in a variety of clinical settings.

High-energy extracorporeal shockwave therapy in humeral delayed and non-unions

INTRODUCTION

Within the last few decades, focused high-energy extracorporeal shockwave therapy (ESWT) has proven to be an effective alternative to standard of care revision surgery in delayed healing fractures or manifest non-unions in various anatomical regions.

MATERIALS AND METHODS

A retrospective multi-variant analysis of an open prospective, single-armed clinical study was conducted. Patients receiving focused high-energy ESWT for a delayed healing or an apparent non-union of a humeral fracture between January 1999 and December 2015 at a single trauma center were included in the study. Bony healing was defined as cortical continuity in three of four cortices and pain-free force loading and evaluated using CT scans and clinical examination at three- and six-month follow-ups after ESWT.

RESULTS

A total of 236 patients were included. N = 93 (43.8%) showed bony consolidation three months after ESWT and n = 105 (52.5%) after six months. Sub-group analysis showed significantly better healing for the proximal metaphyseal humerus (66.7% after six months, n = 42) compared to the diaphyseal region (48.1%, n = 133) and distal metaphyseal humerus (48.1%, n = 25). Regression analysis indicated significantly increased healing rates for patients of younger ages (p = 0.001) and a fracture diastasis of less than 5 mm (p = 0.002).

CONCLUSION

The findings of this study indicate that ESWT can be considered as a treatment option for a well-selected patient population despite the lower healing rates compared to other anatomical regions.

Closed Compression Nailing Using a New-Generation Intramedullary Nail without Autologous Bone Grafting for Humeral Shaft Nonunion

Introduction

Although the recommended treatment for humeral shaft nonunion is compression plating with autologous bone grafting, we treated a case of humeral shaft nonunion with an intramedullary nail (IMN) without bone grafting. Presentation of Case. Osteosynthesis with IMN was performed on a 24-year-old man with a humeral shaft fracture at another hospital. However, bony union was not obtained 1 year after the first surgery, and he was referred to our institution. We treated the nonunion with exchange nailing without autologous bone grafting using compression function of the nail, leading to bony union at 7 months postoperatively. At the final follow-up 2 years and 4 months postoperatively, the patient had full range of motion in the left shoulder and elbow joints. Discussion. Compression plating with autologous bone grafting is reported to be the gold standard for the treatment of humeral shaft nonunion. IMN is advantageous for minimal invasion; however, the conventional type of IMN cannot apply compression force between fragments and does not have sufficient stability against rotational force. In this case, we used an IMN that could apply compression between the fragments and which had rotational stability via many screws. We did not perform bone grafting because the current nonunion was adjudged to be biologically active, and we achieved good functional results.

Conclusion

We treated humeral shaft nonunion using IMN with compression, but without bone grafting, leading to successful clinical outcomes. This strategy might be an appropriate choice for the treatment of humeral shaft nonunion with biological activity.

[Antegrade and retrograde nailing of humeral shaft fractures]

OBJECTIVE

Restoring humeral shaft alignment using direct or indirect reduction techniques with subsequent intramedullary stabilisation with an antegrade or retrograde inserted humeral nail. Achieving osseous union and restoration of painfree upper arm function.

INDICATIONS

Antegrade: Humerus shaft fractures located in the proximal 2/3 of the humerus. Combined fractures of the ipsilateral proximal humerus and humerus shaft. Segmental fractures of the humerus shaft. Pathological fractures or osteolysis (palliative indication). Retrograde: Humerus shaft fractures located in the middle and distal part of the humerus diaphysis.

CONTRAINDICATIONS

Acute infection in the area of the surgical approach; polytrauma with acute life-threatening haemodynamic instability.

SURGICAL TECHNIQUE

In the antegrade technique: anterolateral acromial approach. Determination of the correct nail entry point on the humeral head. Incision of the rotator cuff with longitudinal split of the fibres. Closed or semi-open fracture reduction. Insertion of an intramedullary nail with an appropriate length and diameter. Interfragmentary compression when required. Proximal and distal static interlocking with at least 2 bolts on each side. In the retrograde technique, the nail is inserted after opening of the medullary cavity directly proximal to the olecranon fossa.

POSTOPERATIVE MANAGEMENT

Functional aftertreatment with passive and active-assisted exercises during the first 3 weeks. Subsequent active exercises avoiding forced rotation of the arm. Sports activities and severe stress are avoided for 3 months. Postoperative radiographs as well as after 2, 6 and 12 weeks.

RESULTS

Very good healing results with excellent clinical and radiological healing are achieved in more than 90% of cases after both antegrade and retrograde nailing. Intraoperative problems that have been reported in up to 40% of cases occurred mainly with former generation nails or were attributable to technical errors. Correspondingly, with the closed reduction technique postoperative infections are rare (< 3%). Undesirable distraction at the fracture site is successfully corrected by intraoperative interfragmentary compression. Success and complication rates after intramedullary nailing and plate fixation are not significantly different. Functional shoulder-related problems may occur after antegrade nailing, whereas elbow problems may occur after retrograde nailing.

Double plating with autogenous bone grafting as a salvage procedure for recalcitrant humeral shaft nonunion

Background

Although most cases of humeral shaft nonunion respond well to surgical intervention, surgeons still encounter patients with humeral shaft nonunion who have already undergone repeated surgeries for nonunion. This study retrospectively analyzed the efficacy of double locking compression plate (LCP) fixation in combination with autogenous iliac crest bone grafting for recalcitrant humeral shaft nonunion.

Methods

A consecutive series of patients with aseptic recalcitrant humeral shaft nonunion underwent surgical treatment between May 2010 and August 2017 in our institution. Standardized treatment included thorough debridement, double LCP and screw fixation, and autogenous iliac bone grafting. The injury type and the duration of nonunion were recorded for all patients. The main outcome measurements were the Constant and Murley scale for shoulder function, Mayo elbow performance index (MEPI) for elbow function, and visual analog scale (VAS) for pain. In addition, all complications were documented.

Results

The study cohort comprised six females and nine males with a mean age of 45.3 ± 13.1 years. Each patient had already undergone at least one failed surgery for humeral shaft nonunion. The average duration of nonunion before the index intervention was 126.8 ± 124.2 months. All patients achieved bone union without implant failure. At final follow-up, the mean Constant and Murley score and mean MEPI were significantly improved, and the mean VAS score was significantly decreased. Each patient was very satisfied with the treatment. Four patients had complications, including one with a superficial wound infection, one with radial nerve palsy, one with ulnar nerve palsy, and one with discomfort at the iliac crest.

Conclusion

Double plate fixation combined with autogenous iliac crest bone grafting results in successful salvage of humeral shaft nonunion after prior failed surgical interventions.

Early outcomes of magnetic intramedullary compression nailing for humeral fractures

PURPOSE

The optimal treatment protocol for humeral shaft fractures at risk for nonunions is controversial. Here, we aim to describe magnetic intramedullary compression nailing as an option for these challenging scenarios and to evaluate its clinical and radiographic outcomes.

METHODS

This retrospective case series was performed at an urban university-based level-1 trauma center. Patients aged 18-65 who underwent fixation of their at-risk humerus shaft fracture using the PRECICE nail were included in this investigation. These fractures are characterized by a persistent distraction gap, minimal callous formation, or malalignment greater than 20 degrees. The study data were collected through a retrospective chart review and review of the radiographic studies. Primary outcome measure was radiographic union. Secondary outcome measures included mechanical failure, nonunion, malunion, medical, and surgical complications. Functional outcome was determined by range of motion and restoration of rotator cuff strength.

RESULTS

A total of six patients were included who underwent treatment of their humeral shaft fracture with a NuVasive PRECICE nail after failure of conservative management. After nail placement along with our compression protocol, all patients achieved bony union and experienced favorable outcomes with return to their previous working status. Two complications included a superficial incisional infection treated with antibiotics and a backing out of proximal screw which did not cause discomfort. No other mechanical failures, surgical complications, or medical complications occurred.

CONCLUSIONS

Early results of controlled compression nailing for humeral shaft fracture demonstrated favorable clinical outcomes. This technique may be utilized for these challenging situations.

The biology and treatment of acute long-bones diaphyseal fractures: Overview of the current options for bone healing enhancement

Diaphyseal fractures represent a complex biological entity that could often end into impaired bone-healing, with delayed union and non-union occurring up to 10% of cases. The role of the modern orthopaedic surgeon is to optimize the fracture healing environment, recognize and eliminate possible interfering factors, and choose the best suited surgical fixation technique. The impaired reparative process after surgical intervention can be modulated with different surgical techniques, such as dynamization or exchange nailing after failed intramedullary nailing. Moreover, the mechanical stability of a nail can be improved through augmentation plating, bone grafting or external fixation techniques with satisfactory results. According to the "diamond concept", local therapies, such as osteoconductive scaffolds, bone growth factors, and osteogenic cells can be successfully applied in "polytherapy" for the enhancement of delayed union and non-union of long bones diaphyseal fractures. Moreover, systemic anti-osteoporosis anabolic drugs, such as teriparatide, have been proposed as off-label treatment for bone healing enhancement both in fresh complex shaft fractures and impaired unions, especially for fragility fractures. The article aims to review the biological and mechanical principles of failed reparative osteogenesis of diaphyseal fractures after surgical treatment. Moreover, the evidence about the modern non-surgical and pharmacological options for bone healing enhancement will discussed.

Miniplate osteosynthesis in fracture surgeries: Case series with review of concepts

PURPOSE

Miniplates were initially developed as targets for foot and hand fractures, but they have been used in the treatment of fixation of small bone fragments, reduction of long bone fractures and non-union treatment, which have been difficult to treat. In this study, the authors used miniplates to treat fractures of the upper extremities, lower extremities, and pelvis obtained good outcomes. Herein, the authors report these good outcomes and review the current concept of miniplates.

PATIENTS AND METHODS

Forty-two patients treated with miniplates between March 2012 and March 2017 who attended follow-up for > 1 year were included in this retrospective study. Miniplates were selected according to purpose, which was classified into three categories: fixation, reduction, and stability enhancement. For fixation, miniplates were used to fix distal fibular fractures occurring distal to the syndesmosis and treat patellar and olecranon fractures with severe comminution. For reduction, miniplates were used to reduce the tibia during intramedullary nailing in tibiofibular shaft fractures, while reduction was performed in advance of definitive plating fixation in patients with humeral and pelvic fractures. To enhance stability, the miniplate was inserted after autobone graft for atrophic nonunion at the humeral shaft following nail insertion. The validity of a miniplate was analyzed by reviewing the published literature on the use of miniplates in orthopedic fracture surgeries.

RESULTS

Bony union was achieved in all cases. No specific postoperative complications were observed; however, mild pain and limited range of motion observed in two patients were resolved after implant removal. Sixteen studies on fracture treatment using miniplates reported clinically fair outcomes.

CONCLUSION

Miniplates are not just small metal plates. Depending on the location and treatment of the fracture, the miniplate can effectively fix small bone fragments, help the main plate to maintain the reduction of large bone fragments, and increase the fixation force for nonunion treatment.

Open reduction and internal fixation of humeral midshaft fractures: anterior versus posterior plate fixation

Background

Fractures of the humeral shaft represent 2–4% of all fractures. Fractures of the humerus have traditionally been approached posteriorly for open reduction and internal fixation. Reports of treating midshaft fractures with an open anterolateral approach and anterior plating are limited. The purpose of this study was to evaluate a series of humeral shaft fractures treated with plate osteosynthesis regarding the effect of the approach and plate location on the healing rate and occurrence of complications.

Methods

We conducted a retrospective chart review of patients aged over 18 years with humeral midshaft fractures treated with anterior or posterior plate fixation. Selection of the approach to the humerus was based on the particular pattern of injury and soft tissue involvement. The minimum follow-up duration was set at six months. The outcomes included the rate of union, primary nerve palsy recovery, secondary nerve damage, infection and revision surgery.

Results

Between 2006 and 2014, 58 patients (mean age, 59.9; range, 19–97 years) with humeral midshaft fractures were treated with anterior (n = 33) or posterior (n = 25) plate fixation. After a mean follow-up duration of 34 months, 57 of 58 fractures achieved union after index procedure. Twelve fractures were associated with primary radial nerve palsy. Ten of the twelve patients with primary radial palsy recovered completely within six months after the index surgery. In total, one patient developed secondary palsy after anterior plating, and three patients developed secondary palsy after posterior plating. No significant difference in the healing rate (p = 0.4), primary nerve palsy recovery rate (p = 0.6) or prevalence of secondary nerve palsy (p = 0.4) was found between the two clinical groups. No cases of infection after plate fixation were documented.

Conclusions

Open reduction and internal fixation using an anterior approach with plate fixation provides a safe alternative to posterior plating in the treatment of humeral shaft fractures. An anterior approach allows supine positioning of the patient and yields union and complication rates comparable to those of a posterior approach with plate fixation for the treatment of humeral shaft fractures.

Minimally invasive plate osteosynthesis in humerus nonunion after intramedullary nailing

INTRODUCTION

The purpose of this study was to evaluate the results achieved after the use of lateral minimally invasive plate osteosynthesis (MIPO) in oligotrophic humerus nonunions resulting from failed intramedullary nailing (IM).

METHOD

We evaluated nine patients with humerus nonunion after failed locked intramedullary nailing, all treated using 3.5-mm locked compression plates (LCP) placed through lateral minimally invasive approaches, between 2010 and 2016. Patient's age averaged 39.7 years. All nonunions were diaphyseal and oligotrophic. All nonunions had previous surgical treatment with static locked nails (seven antegrade and two retrograde). The IM nails were all well inserted in the humerus (none of them protruded or had rotator cuff lesions associated). Pre-operative Disabilities of the Arm, Shoulder and Hand (DASH) score averaged 25.5 points. Pre-operative Constant's score averaged 80.2. Pre-operative visual analog scale of pain averaged 2.4 points.

RESULTS

Follow-up averaged 17.7 months. Time between initial surgery and revision procedure averaged 11.7 months. Union was achieved in all cases, after an average of 4.8 months. DASH score at last follow-up averaged 5.1 points, and final Constant's score averaged 93.7 points. The analog scale of pain averaged 0.7 points. Time from definitive surgery to work return averaged 3.9 months. Long 3.5-mm LCPs were used (plate length averaged 16.9 screw holes). In two cases, a third 4-cm incision at the nonunion site was performed and cancellous autologous iliac crest bone graft was associated.

CONCLUSION

In our series of nine patients, we achieved union and good objective and subjective results, with high patient satisfaction, using a lateral MIPO technique and placing long 3.5-mm LCPs in selected oligotrophic humerus nonunions after failed IM nailing.

Diaphyseal long bone nonunions - types, aetiology, economics, and treatment recommendations

The intention of the current article is to review the epidemiology with related socioeconomic costs, pathophysiology, and treatment options for diaphyseal long bone delayed unions and nonunions. Diaphyseal nonunions in the tibia and in the femur are estimated to occur 4.6-8% after modern intramedullary nailing of closed fractures with an even much higher risk in open fractures. There is a high socioeconomic burden for long bone nonunions mainly driven by indirect costs, such as productivity losses due to long treatment duration. The classic classification of Weber and Cech of the 1970s is based on the underlying biological aspect of the nonunion differentiating between "vital" (hypertrophic) and "avital" (hypo-/atrophic) nonunions, and can still be considered to represent the basis for basic evaluation of nonunions. The "diamond concept" units biomechanical and biological aspects and provides the pre-requisites for successful bone healing in nonunions. For humeral diaphyseal shaft nonunions, excellent results for augmentation plating were reported. In atrophic humeral shaft nonunions, compression plating with stimulation of bone healing by bone grafting or BMPs seem to be the best option. For femoral and tibial diaphyseal shaft fractures, dynamization of the nail is an atraumatic, effective, and cheap surgical possibility to achieve bony consolidation, particularly in delayed nonunions before 24 weeks after initial surgery. In established hypertrophic nonunions in the tibia and femur, biomechanical stability should be addressed by augmentation plating or exchange nailing. Hypotrophic or atrophic nonunions require additional biological stimulation of bone healing for augmentation plating.

Controlled Compression Nailing for At Risk Humeral Shaft Fractures

Compression techniques seem to be the primary factor in determining the success of both plating and nailing techniques for the management of acute fractures and for delayed and nonunion management of these fractures. An intramedullary nail that can provide continual compression (like a plate) and mechanical manipulation of the callous throughout the course of treatment is an ideal device that provides all the advantages of plating and nailing and avoids the noted limitations of both. The UNYTE compression humeral nail is based on the PRECICE intramedullary limb lengthening system. This nail provides the ability to intraoperatively compress a humeral fracture immediately and continue compression in the outpatient setting with the external remote controller. This compression nail allows the surgeon to continually modulate stability through controlled compression and the ability to relengthen if necessary. The capacity to achieve constant compression at the fracture site has demonstrated rapid healing of the "at risk" humerus fracture in this series. We review the current indications for use of this device after its early introduction. In most cases, this was the failure of conservative brace management that presented with a progressive distraction gap and minimal callous formation or those fractures that could not be adequately controlled in the brace with malalignment greater than 20 degrees. The protocol for intraoperative compression using the external remote controller is detailed, as is the outpatient protocol for follow-up. The compression algorithm for progression to full fracture healing is also reviewed.

Treatment of aseptic non-union after intramedullary nailing without removal of the nail

Failure of bone healing after intramedullary nailing of a diaphyseal long bone fracture is a severe complication that requires an effective management to ensure the best chances for successful bone-union and termination of a long period of incapacity and morbidity for the sufferers. Traditional procedures require removal of the existing nail and re-fixation with wider nail, plate or external fixation constructs. The concept that bone union can be obtained with the existing nail in situ is gaining popularity as its removal adds trauma and potential complications and prolongs the operating time. This article reviews all techniques that have been proposed for the management of aseptic diaphyseal long bone non-unions that stimulate bone healing without removing the existing nail.