Intramedullary nailing for non-union of the humeral diaphysis: a review

The role of Platelet Rich Plasma and other orthobiologics in bone healing and fracture management: A systematic review

BACKGROUND

Treatment of large bone defects and fracture healing complications (delayed and non-union) presents a substantial challenge for orthopaedic surgeons. Given that bone healing requires mechanical stability as well as a favourable biological microenvironment, orthobiologics such as Platelet-Rich Plasma (PRP) may have a significant clinical role to play.

AIMS

To perform a systematic review of the available literature to assess the clinical effect of PRP, with or without other orthobiologics, on bone healing.

METHOD

Two independent reviewers performed the literature search based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Clinical studies of any evidence, assessing effect of PRP with or without other orthobiologics on bone healing, were included. A qualitative analysis was carried out on the clinical and radiological outcomes reported.

RESULT

27 articles with 1631 patients (mean age = 43.56, 57.1% male, mean follow-up = 17.27 months) were included in the qualitative. Of the 27 studies, 13 dealt with fracture complications (delayed or non-unions), 7 with acute fracture healing, 4 with tibial osteotomies and lengthening procedures and 3 with lumbar spine pathology. 18/27 studies showed a clinical benefit of PRP, 8/27 showed no significant effect, and 1/27 showed a worse outcome with PRP.

CONCLUSION

Our review suggests PRP may play a clinical role in bone healing but further randomised controlled trials (RCTs) using standardised outcomes should be performed to establish its efficacy.

Surgical management of humeral shaft nonunions. Success of a consistent protocol over 17 years

INTRODUCTION

Surgical treatment of humeral shaft nonunions is characterized by variability of fixation methods, graft choices, and rates of union and iatrogenic radial nerve palsy. The aim of the current study is to evaluate the union rate of humeral shaft aseptic nonunions and the rate of postoperative complications following a consistent management protocol.

PATIENTS AND METHODS

This is a retrospective review of 41 consecutive adult patients (23 female and 18 male with a mean age of 42 years) with aseptic nonunions of the humeral shaft treated by the senior author in our institution over a 17-year period. Nonunions were located in the middle third of the diaphysis in 33 patients, in the distal third in 6, and in the proximal third in 2 patients. Comorbidities were present in 49% of patients and the most common were smoking in 27% and diabetes mellitus in 17% of patients. Patients were treated at an average of 24 months after their injury. Surgical protocol consisted of careful dissection of the radial nerve, debridement of the nonunion site, stable plate fixation and augmentation of local biology.

RESULTS

Thirty-eight patients had mean clinical and radiographic follow-up of 9.4 months. All 38 nonunions healed at a mean time of 3.5 months. There were no persistent nonunions and no failures of fixation. None of the 40 patients with an intact radial nerve preoperatively developed any signs of radial nerve compromise after surgery. Complications consisted of one superficial infection (2%) that resolved with oral antibiotics and one deep infection (2%) that required implant removal and debridement. The mean pain score on the visual analog scale was 0.7. Mean elbow range of motion was 125 degrees with a mean extension deficit of 5 degrees and mean flexion of 130 degrees.

CONCLUSIONS

Our surgical protocol achieved consistent healing of nonunions of the humeral shaft with a low complication rate and no iatrogenic radial nerve palsy, even in long-standing nonunions in patients with comorbidities.

Use of Masquelet technique in treatment of septic and atrophic fracture nonunion

BACKGROUND

Treatment of atrophic non-unions and large bone defects or infections remains a challenging task for the treating surgeon. In the herein study, we present our experience of the 'Masquelet technique' according to the 'diamond concept' for the treatment of complex long bone reconstruction procedures.

METHODS

Between February 2010 and March 2015, 150 patients (mean age 51.4) with atrophic and- /or infected non-unions were included in this prospective study. All patients received autologous bone graft, a graft expander (TCP (tricalcium phosphate)) and BMP (bone morphogenic protein). Clinical and radiological parameters were assessed at 6 weeks, and at 3, 6 and 12 months. The SF-12 questionnaire was used to evaluate the subjective health of patients.

RESULTS

A successful bony consolidation of the non-unions was observed in 120 (80%) cases with a median healing time of 12.1 months. The mean defect gap was 4.4cm. Initial infection was documented in 54 cases. The most frequently identified pathogen was staphylococcus epidermidis and staphylococcus aureus. A successful removal of microorganisms with subsequent healing was achieved in 39 cases (72%). The SF-12 scores of subjective physical and mental health increased from PCS 31.5 preoperatively to 36.7 one year postoperatively, while MCS increased from 45.5 to 48.7.

CONCLUSIONS

Our study showed that the Masquelet technique according to the 'diamond concept' is a valid method to treat complex atrophic non-unions with large bone defects and associated infection. Following the principles of the 'diamond concept' (targeted optimization of tissue engineering and bone regeneration) a high rate of success can be expected in these difficult reconstruction cases.

A Case Report of Humeral Nail Breakage after 11 Years Secondary to Shaft Nonunion: Treatment with Autogenous Iliac Crest Bone Graft and Compression Plate

Introduction

The rate of nonunion of operatively treated fractures of humeral shaft is low. Increased incidence of nonunion is associated with different conditions such as open fractures, bone loss, or fracture gapping. Nonunions after prior intramedullary nailing can be difficult to address, even more with hardware failure. We present the case of a humeral nail breakage 11 years after implantation, secondary to nonunion.

Case Report

A 33-year-old man referred to our hospital with oligotrophic nonunion of the middle humeral diaphysis and nail breakage after 11 years from the first fracture. We decided then to schedule a one-stage surgical procedure of nail removal and new osteosynthesis with autogenous iliac crest bone graft.

Conclusions

The patient presented good clinical evolution, without functional limitation or pain. Bone graft union was radiologically confirmed at final follow-up. To the best of our knowledge, this is the first case of non-traumatic nail breakage in a humeral shaft nonunion after such a long period of time. In this case, we found that a one-stage surgical procedure with nail removal and locking compression plate fixation associated with tricortical autogenous iliac crest bone grafting after long-standing humeral shaft nonunion is favorable.

Humeral shaft non-union after intramedullary nailing

BACKGROUND

The humerus shaft is one of the sites with the largest probability of developing pseudoarthrosis after fracture. We present the results of nine patients with atrophic pseudoarthrosis of humeral shaft treated with angular stability plate associated with allograft and platelet-rich plasma (PRP), after a first treatment with intramedullary nail to correct the fracture.

MATERIAL AND METHODS

From January 2012 to December 2014, nine patients were treated for atrophic pseudoarthrosis (PSA) of humeral shaft treated previously using intramedullary nail; seven humeral diaphysis fractures were located in the middle-proximal third and two in the middle third. In one case, a reverse shoulder prosthesis implant was associated to treat a co-existent rotator cuff massive lesion. The mean time between injury and treatment of non-union was 32 weeks (min 16-max 180); all patients were evaluated with Constant, DASH and UCLA score.

RESULTS

At the final follow-up (23.7 months), the mean Dash score was 22.25 pt, the Constant score was 64 pt, and the UCLA score value was 27 pt. The average pain value was 2 for the arm interested and 0 into PSA focus. Radiographic healing was obtained at 7 months.

CONCLUSIONS

The humeral shaft non-union is an invalidating problem which affects the daily living. Our treatment with plate, cortical bone graft, and PRP can build a high-stability structure that can help healing and graft integration.

Anterior augmentation plating of aseptic humeral shaft nonunions after intramedullary nailing

INTRODUCTION

Humeral shaft nonunion after intramedullary nailing is a rare but serious complication. Treatment options include implant removal, open plating, exchange nailing and external fixation. The objective of this retrospective study was to determine whether augmentation plating without nail removal is feasible for treating a humeral shaft nonunion.

MATERIALS AND METHODS

Between 2002 and 2014, 37 patients (mean age 51, range 20-84 years) with aseptic humeral shaft nonunions prior to intramedullary nailing were treated with augmentation plating. The initial fractures had been fixed with retrograde nails (10 cases) or anterograde nails (27 cases). There were 34 atrophic nonunions and 3 hypertrophic nonunions. Nonunion treatment of all patients consisted of local debridement through an anterior approach to the humerus and anterior placement of the augmentation plates. Supplemental bone grafting was performed in all atrophic nonunion cases. All patients were followed until union was radiologically confirmed.

RESULTS

Union was achieved in 36 patients (97 %) after a mean of 6 months (range 3-24 months). There was one case of iatrogenic median nerve palsy that showed complete spontaneous recovery 6 weeks postoperatively. One patient sustained a peri-implant stress fracture that was treated successfully by exchanging the augmentation plate to bridge the nonunion and the fracture. No infections or wound healing complications developed. At a mean follow-up of 14 months, all patients showed free shoulder and elbow motion and no restrictions in daily or working life.

CONCLUSIONS

The results indicate that augmentation plating using an anterior approach is a safe and reliable option for humeral shaft nonunions after failed nailing, and the treatment has no substantial complications. Because the healing rates are similar to the standard technique of nail removal and fixation by compression or locking plates, we consider this technique to be an alternative choice for treatment.

Treatment of nonunions in fractures of the humeral shaft according to the Diamond Concept

Methods

Between 2005 and 2012, 50 patients (23 female, 27 male) with nonunion of the humeral shaft were included in this retrospective study. The mean age was 51.3 years (14 to 88). The patients had a mean of 1.5 prior operations (sd 1.2;1 to 8). All patients were assessed according to a specific risk score in order to devise an optimal and individual therapy plan consistent with the Diamond Concept. In 32 cases (64%), a change in the osteosynthesis to an angular stable locking compression plate was performed. According to the individual risk an additional bone graft and/or bone morphogenetic protein-7 (BMP-7) were applied.

Results

A successful consolidation of the nonunion was observed in 37 cases (80.4%) with a median healing time of six months (IQR 6). Younger patients showed significantly better consolidation. Four patients were lost to follow-up. Revision was necessary in a total of eight (16%) cases. In the initial treatment, intramedullary nailing was most common.

Discussion

The use of locking compression plates in combination with autologous cancellous bone graft has been shown to be a safe and effective treatment. In more complex cases, the use of the Masquelet technique and BMP-7 may be indicated at the first revision operation. Take home message: Our results suggest the Diamond Concept is a successful treatment strategy for nonunions of the humeral shaft. Cite this article: Bone Joint J 2016;98-B:81–7.

Treatment of aseptic nonunion after intramedullary nailing fixation with locking plate

OBJECTIVE

To evaluate the safety and efficacy of locking plate combined with bone grafting in the treatment of aseptic nonunion following intramedullary nailing fixation of fractures of the long bones.

METHODS

Thirty-eight consecutive patients treated in our hospital between January 2004 and December 2006 were included in this retrospective study. The nonunions included 20 femurs, 15 tibias, and 3 humeri. The duration of non-union ranged from 6 to 84 months and 21 (55.3%) of them were located around the metaphysis of the affected long bones. There were 12 women and 26 men with a mean age of 39.2 years (range, 9-70 years). Locking plate combined with bone grafting was the procedure chosen to treat every case of nonunion in this series. The clinical outcomes were evaluated.

RESULTS

All patients were followed up for 6-20 months (average 11.6 months). After locking plate fixation combined with bone grafting, union was achieved in all cases, the average healing time being 5.3 months (range, 4-8 months). Infection of the superficial incision occurred in three cases (7.9%) and delayed healing of the incision in one case, all of which healed with no further complications. The function of the adjacent joints was excellent to good in 30 patients (78.9%), fair in 7 (18.4%) and poor in 1 (2.6%) after follow-up.

CONCLUSION

Locking plate fixation combined with bone grafting is a highly effective treatment for aseptic nonunions of the long bones after intramedullary nailing fixation, especially in the case of metaphyseal nonunion.

Management of non-union of humeral fractures with the Stryker T2 compression nail

INTRODUCTION

Fractures of the humeral shaft are relatively common injuries and the majority achieve union uneventfully; however, non-union rates of up to 13% are reported when managed either conservatively or operatively. Despite the many surgical techniques described for the management of non-unions, including plate fixation, intramedullary nailing or external fixation, some cases remain resistant to treatment with ongoing problems achieving union.

METHOD

We describe a technique using the Stryker T2 humeral nail which incorporates a compression system allowing closure of the non-union fracture gap. Twelve patients underwent compression nailing for established humeral fracture non-union. All achieved radiological union at an average of 4.5 months (range 3-12 months).

RESULTS

All patients reported a return to their normal pre-injury level of activities.

CONCLUSION

We conclude that this technique of intramedullary nailing with a novel compression technique is effective in the treatment of humeral shaft fracture non-union.

Application of rhBMP-7 and platelet-rich plasma in the treatment of long bone non-unions: a prospective randomised clinical study on 120 patients

The purpose of this prospective randomised clinical study was to compare the efficacy of recombinant bone morphogenetic protein 7 (rhBMP-7) and platelet-rich plasma (PRP) as bone-stimulating agents in the treatment of persistent fracture non-unions. One hundred and twenty patients were randomised into two treatment groups (group rhBMP-7 vs. group PRP). Sixty patients with sixty fracture non-unions were assigned to each group (median age: 44 years, range 19-65, for the rhBMP-7 group and 41 years, range 21-62, for the PRP group, respectively). In the rhBMP-7 group, there were 15 tibial non-unions, 10 femoral, 15 humeral, 12 ulnar, and 8 radial non-unions. In the PRP group, there were 19 tibial non-unions, 8 femoral, 16 humeral, 8 ulnar, and 9 radial non-unions. The median number of operations performed prior to our intervention was 2 (range 1-5) and 2 (range 1-5) with autologous bone graft being used in 23 and 21 cases for the rhBMP-7 and PRP groups, respectively. Both clinical and radiological union occurred in 52 (86.7%) cases of the rhBMP-7 group compared to 41 (68.3%) cases of the PRP group, with a lower median clinical and radiographic healing time observed in the rhBMP-7 group (3.5 months vs. 4 months and 8 months vs. 9 months, respectively). This study supports the view that in the treatment of persistent long bone non-unions, the application of rhBMP-7 as a bone-stimulating agent is superior compared to that of PRP with regard to their clinical and radiological efficacy.

Humeral diaphyseal aseptic non-unions: an Algorithm of management

Successful operative treatment of a humeral shaft non-union may be a challenge for the surgeon. Several treatment options have been reported over the years. A systematic review of the literature was performed. Twenty-three retrieved articles (level of evidence IV) fulfilled our inclusion criteria and dealt with aseptic diaphyseal humeral non-union managed by plating, intramedullary nailing and external fixation based on Ilizarov's principles. Despite an obvious superiority of plating in the treatment of humeral shaft non-unions, there is no doubt that intramedullary nailing as well as external fixation devices have a role. An algorithm of management of the humeral shaft non-unions following a rational approach is suggested.