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Massin V, Laumonerie P, Bonnevialle N, Le Baron M, Ollivier M, Flecher X, Argenson JN, Lami D. What treatment for humeral shaft non-union? Case-series assessment of a strategy. Orthop Traumatol Surg Res 2023; 109:103532. [PMID: 36572380 DOI: 10.1016/j.otsr.2022.103532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 08/05/2022] [Accepted: 09/27/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Humeral shaft non-union is frequent, with severe clinical impact. Management, however, is poorly codified and there is no clear decision-tree. HYPOTHESIS Analyzing our experience over the last 15years could enable a reproducible strategy to be drawn up, with a decision-tree based on the 2 main causes: failure of internal fixation, and infection. MATERIAL AND METHOD Sixty-one patients were included in a retrospective cohort, with a mean 94 months' follow-p. The treatment strategy was based on screening first for infection then for mechanical stability deficit in case of prior internal fixation. Any fixation revision was associated to cancellous autograft. In case of suspected or proven infection, 2-stage treatment was implemented. In case of primary non-operative treatment, the strategy was based on the non-union risk on the Non-Union Scoring System (NUSS), with internal fixation and possible graft. RESULTS There were 6 failures, for a consolidation rate of 90%; excluding patients not managed according to the study protocol, the consolidation rate was 95%. There was 1 case of spontaneously resolving postoperative radial palsy, and 3 patients required surgical revision. DISCUSSION The present strategy achieved consolidation in most cases, providing the surgeon with a decision-tree for these patients. Infectious etiologies are often overlooked and should be a focus of screening. LEVEL OF EVIDENCE IV, retrospective or historical series.
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Affiliation(s)
- Valentin Massin
- Service de chirurgie orthopédique, Hôpital Nord, Pôle Locomoteur, Assistance Publique-Hôpitaux de Marseille, Marseille, France; Institut du Mouvement et de l'Appareil Locomoteur, Assistance Publique-Hôpitaux de Marseille, Marseille, France.
| | - Pierre Laumonerie
- Service de chirurgie orthopédique, Hôpital Pellegrin, CHU de Bordeaux, Bordeaux, France
| | - Nicolas Bonnevialle
- Service de chirurgie orthopédique, Hôpital Pierre Paul Riquet, CHU de Toulouse, Toulouse, France
| | - Marie Le Baron
- Service de chirurgie orthopédique, Hôpital Nord, Pôle Locomoteur, Assistance Publique-Hôpitaux de Marseille, Marseille, France; Institut du Mouvement et de l'Appareil Locomoteur, Assistance Publique-Hôpitaux de Marseille, Marseille, France
| | - Matthieu Ollivier
- Institut du Mouvement et de l'Appareil Locomoteur, Assistance Publique-Hôpitaux de Marseille, Marseille, France; Service de chirurgie orthopédique, Hôpital Sainte-Marguerite, Pôle Locomoteur, Assistance-Publique Hôpitaux de Marseille, Marseille, France
| | - Xavier Flecher
- Service de chirurgie orthopédique, Hôpital Nord, Pôle Locomoteur, Assistance Publique-Hôpitaux de Marseille, Marseille, France; Institut du Mouvement et de l'Appareil Locomoteur, Assistance Publique-Hôpitaux de Marseille, Marseille, France
| | - Jean-Noël Argenson
- Institut du Mouvement et de l'Appareil Locomoteur, Assistance Publique-Hôpitaux de Marseille, Marseille, France; Service de chirurgie orthopédique, Hôpital Sainte-Marguerite, Pôle Locomoteur, Assistance-Publique Hôpitaux de Marseille, Marseille, France
| | - Damien Lami
- Institut du Mouvement et de l'Appareil Locomoteur, Assistance Publique-Hôpitaux de Marseille, Marseille, France; Service de chirurgie orthopédique, Hôpital Sainte-Marguerite, Pôle Locomoteur, Assistance-Publique Hôpitaux de Marseille, Marseille, France
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Bégué T, Mouchantaf M, Aurégan JC. Aseptic humeral shaft nonunion. Orthop Traumatol Surg Res 2023; 109:103462. [PMID: 36942794 DOI: 10.1016/j.otsr.2022.103462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 05/25/2022] [Indexed: 12/24/2022]
Abstract
Aseptic humeral shaft nonunions are rare lesions, with less than 700 cases per year in France. This low frequency explains why they are difficult to manage. They can be hypertrophic or atrophic, with or without a defect. The diagnosis is made based on radiographs and/or CT scan images. Nonunion is suspected early on when a patient presents with abnormal motion at the fracture site 6 weeks after the initial injury event in the context of conservative treatment or has large residual displacement after initial treatment or an open fracture. The treatment for hypertrophic nonunion consists in applying stable, rigid fixation, most often using a large-fragment plate with 4.5 mm screws, combined with cancellous autograft. When combined with the osteoperiosteal decortication first described by Judet, it produces union in 98% of cases. Intramedullary (IM) nail fixation with an autograft is another possibility. In atrophic nonunions, resecting the ends and ensuring the soft tissues have good vitality will generally lead to fracture union. Nonunions with critical size defects (larger than 5 cm), which have a high risk of infection, are a treatment challenge that requires stable fixation and recourse to more complex treatments like the two-step induced membrane technique or vascularized fibular graft. In all cases, to avoid complex repeat revision, internal fixation with plate or IM nail must be combined with a bone graft in situ to maximize the chances of union.
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Affiliation(s)
- Thierry Bégué
- Service de chirurgie orthopédique et traumatologique, hôpital Antoine Béclère, université Paris-Saclay, AP-HP, 157, rue de la Porte de Trivaux, 92140 Clamart, France.
| | - Mark Mouchantaf
- Service de chirurgie orthopédique et traumatologique, hôpital Antoine Béclère, université Paris-Saclay, AP-HP, 157, rue de la Porte de Trivaux, 92140 Clamart, France
| | - Jean-Charles Aurégan
- Service de chirurgie orthopédique et traumatologique, hôpital Antoine Béclère, université Paris-Saclay, AP-HP, 157, rue de la Porte de Trivaux, 92140 Clamart, France
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Anterior augmentation plating of aseptic humeral shaft nonunions after intramedullary nailing. Arch Orthop Trauma Surg 2016; 136:631-8. [PMID: 26852379 DOI: 10.1007/s00402-016-2418-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Indexed: 10/22/2022]
Abstract
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.
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HUMeral shaft fractures: measuring recovery after operative versus non-operative treatment (HUMMER): a multicenter comparative observational study. BMC Musculoskelet Disord 2014; 15:39. [PMID: 24517194 PMCID: PMC3922994 DOI: 10.1186/1471-2474-15-39] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Accepted: 02/06/2014] [Indexed: 02/08/2023] Open
Abstract
Background Fractures of the humeral shaft are associated with a profound temporary (and in the elderly sometimes even permanent) impairment of independence and quality of life. These fractures can be treated operatively or non-operatively, but the optimal tailored treatment is an unresolved problem. As no high-quality comparative randomized or observational studies are available, a recent Cochrane review concluded there is no evidence of sufficient scientific quality available to inform the decision to operate or not. Since randomized controlled trials for this injury have shown feasibility issues, this study is designed to provide the best achievable evidence to answer this unresolved problem. The primary aim of this study is to evaluate functional recovery after operative versus non-operative treatment in adult patients who sustained a humeral shaft fracture. Secondary aims include the effect of treatment on pain, complications, generic health-related quality of life, time to resumption of activities of daily living and work, and cost-effectiveness. The main hypothesis is that operative treatment will result in faster recovery. Methods/design The design of the study will be a multicenter prospective observational study of 400 patients who have sustained a humeral shaft fracture, AO type 12A or 12B. Treatment decision (i.e., operative or non-operative) will be left to the discretion of the treating surgeon. Critical elements of treatment will be registered and outcome will be monitored at regular intervals over the subsequent 12 months. The primary outcome measure is the Disabilities of the Arm, Shoulder, and Hand score. Secondary outcome measures are the Constant score, pain level at both sides, range of motion of the elbow and shoulder joint at both sides, radiographic healing, rate of complications and (secondary) interventions, health-related quality of life (Short-Form 36 and EuroQol-5D), time to resumption of ADL/work, and cost-effectiveness. Data will be analyzed using univariate and multivariable analyses (including mixed effects regression analysis). The cost-effectiveness analysis will be performed from a societal perspective. Discussion Successful completion of this trial will provide evidence on the effectiveness of operative versus non-operative treatment of patients with a humeral shaft fracture. Trial registration The trial is registered at the Netherlands Trial Register (NTR3617).
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Steffner RJ, Lee MA. Emerging concepts in upper extremity trauma: humeral shaft fractures. Orthop Clin North Am 2013; 44:21-33. [PMID: 23174323 DOI: 10.1016/j.ocl.2012.08.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Fractures of the humeral shaft are common in low-energy and high-energy trauma, and optimal clinical management remains controversial. Nonsurgical management has been supported as the preferred treatment based on high union rates and minimal functional deficit due to a rich vascular supply from overlying muscle and the wide motion available at the glenohumeral joint. Recent studies of nonoperative management have challenged surgeons' understanding of these fractures and the perception of favorable outcomes. Current considerations support expanded operative indications with traditional open-plate fixation and with the use of minimally invasive techniques, implants, and a reconsideration of intramedullary nailing.
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Affiliation(s)
- Robert J Steffner
- Department of Orthopaedic Surgery, Ellison ACC, University of California-Davis, Sacramento, CA 95817, USA.
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