The effect of comorbidity and duration of nonunion on outcome after surgical treatment for nonunion of the humerus

Plate fixation with autogenous bone grafting for longstanding humeral shaft nonunion: A retrospective study of 6 cases

Longstanding humeral shaft nonunion is uncommon because humeral shaft fractures often respond well to conservative and surgical treatments. However, when it occurs, the treatment of longstanding humeral shaft nonunion is challenging. This study is a retrospective analysis of the clinical and radiographic findings in a consecutive series of patients with longstanding humeral shaft nonunions who underwent locking compression plate (LCP) fixation and autogenous iliac crest bone grafting.Six patients were surgically treated at Xi'an Hong Hui Hospital for longstanding humeral shaft nonunions between February 2011 and June 2015. Four patients were of synovial pseudarthrosis, 1 was atrophic, and 1 was hypertrophic. Follow-up was for at least 12 months after intervention. Standardized treatment included a thorough debridement, LCP and screw fixation, and autogenous iliac crest bone grafting. In 3 patients, a single plate was applied, and in the other 3 patients, double plates were used. The main outcome measurements were shoulder and elbow function (Constant and Murley scale, and Mayo elbow performance index [MEPI]) and the visual analog scale (VAS) for pain. In addition, all complications were documented.Our series included 6 male patients with an average age of 56.3 years and an average nonunion duration of 19.5 years. All patients had previously undergone at least 1 operation. At a mean of 26 months follow-up, all fractures had achieved solid union and none of the implants had evidence of loosening or breakage. Postoperative alignment was within 10° of anatomic in 4 patients, 1 patient had 23° of valgus angulation, and 1 patient had a posterior angulation of 12°. Mean humeral shortening was 2.8 cm. The mean Constant and Murley joint function score was 88.3 points, the mean MEPI was 96.7 points, and the mean VAS was 0.7. All patients reported significant improvement in shoulder and elbow function, and each patient was able to resume work and was satisfied with the treatment.Plate fixation combined with autogenous iliac crest bone grafting is an excellent option for the treatment of longstanding humeral shaft nonunion.

Plating, nailing, external fixation, and fibular strut grafting for non-union of humeral shaft fractures

PURPOSE

To compare various treatment modalities (plating, Ilizarov external fixation, and non-vascular fibular cortical strut grafting) for non-union of humeral shaft fractures.

METHODS

Records of 9 women and 26 men aged 24 to 71 (mean, 42) years who presented with non-union of humeral shaft fractures were reviewed. The humeral shaft fractures were secondary to low-energy trauma (n=22) or vehicular accidents (n=13) and involved the proximal (n=9), middle (n=15), and distal (n=11) regions. 13 of the fractures were open. Infection was evident in 8 of the non-unions. For non-unions with infection (n=8), a 2-stage procedure entailing temporary Ilizarov fixation followed by plating was used. For non-unions without infection (n=23), one-stage plating and cancellous bone grafting was used. For non-unions of osteoporotic bone (n=4), one-stage non-vascularised fibular strut grafting was used. Outcome was measured using the Disabilities of the Arm, Shoulder and Hand (DASH) scoring system.

RESULTS

The 35 patients were followed up for a mean of 16 (range, 6-60) months. All achieved bone union except for one (who had persistent infection). Respectively for non-unions with infection, nonunions without infection, and non-unions of osteoporotic bone, the mean times to bone union were 6.5 (range, 4-10), 5 (range, 4-8), and 10 (range, 6-14) months, the mean improvement in DASH score was 30, 43, and 18, and malalignment was noted in 5, 2, and one patient. Three patients had a preoperative radial nerve palsy for which standard tendon transfer was performed 6 weeks after treatment for non-union.

CONCLUSION

Compression plating achieved the best results. An external fixator may be used temporarily for infected non-unions. Fibular strut grafting may be used when non-unions warrant additional stability.

Fixed intramedullary nailing and percutaneous autologous concentrated bone-marrow grafting can promote bone healing in humeral-shaft fractures with delayed union

Treatment of humeral diaphyseal nonunion can be difficult and usually requires an extensive approach to the humerus with bone grafting, a procedure that could result in a lengthy operation with significant morbidity for the patient. The purpose of the present study is to describe a novel minimally invasive technique for the treatment of humeral-shaft fractures that do not demonstrate union progress within 16-24 weeks of injury. Fixed intramedullary nailing with percutaneously harvested and introduced autologous concentrated bone-marrow cells (mixed with demineralised bone matrix putty) was successfully used to treat five patients who had delayed union of a humeral-shaft fracture. The procedure was minimally invasive with no complications and resulted in sound union of all cases within 20 weeks.

Uninfected nonunion of the humeral diaphyses: review of 21 patients treated with shingling, compression plate, and autologous bone graft

INTRODUCTION

Controversy continues around selecting the best strategy for managing nonunions of the humeral diaphysis. The objective of this retrospective study was to analyse the results of management of this complication using a uniform surgical technique.

HYPOTHESIS

The rate of union obtained in the present series is comparable to the results reported in the literature.

PATIENTS AND METHODS

Twenty-one patients were surgically treated at the Geneva University Hospital for nonunion of the humeral diaphysis between 1995 and 2005 with a mean follow up of 50 months. Open reduction and internal fixation in compression using plates and screws with autologous bone graft enhancement was used. Eight cases were revisions of nonunions following a closed orthopaedic treatment and 13 cases were revisions following a failed surgical treatment.

RESULTS

All the patients obtained union within a mean 4.5 months. The functional scores for the shoulder (Constant) and the elbow (Mayo) were 77 and 97 points (mean), respectively.Two patients developed transient paresis related to radial nerve and musculocutaneous nerve injuries and one had a recurring fracture. A single patient required a second intervention for delayed union.

DISCUSSION

Of the surgical techniques for managing nonunion of the humerus, plate osteosynthesis is the most widely used. This simultaneously allows anatomic reduction, fracture compression, and osteogenesis stimulation. However, it can lead to infectious complications(although absent in our series) and neurological complications (10% transitory paresis in our patients).We report 95% rapid union in our series. Other techniques such as intramedullary nailing and external fixation do not provide equivalent results, and this is in agreement with the data found in the literature. We therefore recommend using compression plate fixation associated with autologous bone graft for the treatment of established nonunion of the humeral shaft.

Treatment of osteopenic humeral shaft nonunion with compression plating, humeral cortical allograft struts, and bone grafting

Surgical stabilization of humeral shaft nonunions can be difficult to achieve if severe osteopenia or loss of bone stock is present. We present a technique whereby a 4.5-mm standard dynamic compression plate is used in conjunction with a humeral cortical allograft strut and bone grafting to stabilize humeral shaft nonunions complicated by severe bone loss. Six patients with established nonunion of the humeral shaft underwent this technique. Union was achieved at an average of 3.4 months (range 2-6 months). Our method using onlay allograft struts can provide an effective alternative in the management of humeral shaft nonunion complicated by severe osteopenia of various etiologies.

Functional outcome of AO type C distal humeral fractures

PURPOSE

To review the functional outcome of AO type C distal humeral fractures (bicondylar fractures) managed with dual orthogonal plate fixation.

METHOD

Twenty-three patients were reviewed retrospectively at a mean of 45.1 months. Patient-rated outcomes (Disabilities of the Arm Shoulder and Hand [DASH], Patient Rated Ulnar Nerve Evaluation [PRUNE], American Shoulder and Elbow Surgeons Elbow form [ASES-e], and Short Form-36 [SF-36]), clinical, radiographic, and objective evaluations were used to assess outcomes.

RESULTS

Almost 40% of patients required a third plate for adequate fixation. Patients identified minimal subjective deficits (10%) with a mean satisfaction of 93%. The arc of motion was decreased in the flexion-extension plane (122 degrees relative to 138 degrees, p <.01), whereas strength was lower for both elbow flexion-extension and forearm rotation (p <.05). The overall complication rate was 48%, however, most were minor and resolved without further surgery. No ulnar neuropathies were identified at follow-up after routine ulnar nerve transposition.

CONCLUSIONS

Outcomes of AO type C distal humeral fractures were good with dual orthogonal plating, ulnar nerve transposition, and early motion. Additional plating may be required with distal fracture patterns or osteopenic bone.

Advances in the management of humeral nonunion

Approximately 10% of all long-bone fractures occur in the humerus. Although primary treatment usually is successful, humeral nonunion can lead to marked morbidity and functional limitation. Complications include joint contractures of the shoulder and elbow, especially with periarticular pseudarthrosis. Marked osteopenia or bone loss, or both, often occur after fracture and after failure to achieve union. Retained implants often break, impeding fixation and requiring removal. Soft-tissue deficits and incisions from the original injury or prior surgeries also may complicate reconstruction, as can intra-articular fractures and associated nerve palsies. Successful surgical management of humeral nonunion requires stable internal fixation that allows early joint motion and uses autogenous bone graft to promote healing. Contracture release and early joint motion are necessary to optimize function. Shoulder hemiarthroplasty and semiconstrained total elbow arthroplasty are viable options for irreversible joint damage. Advances in preoperative evaluation and surgical reconstruction have improved functional outcomes.

Factors associated with Short Form-36 outcomes in nonoperative treatment for ipsilateral fractures of the clavicle and scapula

Twenty consecutive patients with ipsilateral fractures of the clavicle and scapula were treated nonoperatively with immobilization and physical therapy. Results were evaluated using the Herscovici, Rowe, and Constant scoring systems and the Short Form-36 (SF-36) questionnaire. The average comprehensive SF-36 score was lower than the scores obtained using the other scoring systems. In the SF-36 questionnaire, physical scores were strongly associated with nonphysical scores (P<.001). No association was found between SF-36 physical scores and age (P=.37), fracture pattern (clavicle, P=.81; scapula, P=.18), fracture displacement (P=.18), or injury severity score (P=.52). Outcomes were found to relate more to nonphysical factors than to the physical injury.

Treatment of non-union of the humerus using the Orthofix external fixator

An Orthofix monolateral axial external fixator was used to treat 31 patients with non-union of the humeral shaft, 30 of whom had been previously treated surgically. In seven cases the non-union was hypertrophic and one of these cases had been treated by simple fixation anol compression, the others by fixation, bone grafting and decortication; in 20 cases the non-union was hypotrophic and had been treated by fixation and decortication with bone grafting. The remaining four cases had septic non-union, treated by debridement of the focus of infection and fixation, followed in three cases by a bone graft and osteomuscular decortication once the infection had been eradicated. The fracture site consolidated in all patients in a mean time of 4.9 months. Five patients required further surgery: three in the group with infected non-union and two who had had a new bone graft and application of the external fixator, one because of a refracture (the patient was receiving chronic treatment with antimitotic agents) and one because of persistent non-union. There were no major complications (e.g. radial nerve palsy, joint stiffness, deep infection), and only six cases of pin track infection (5% of the screws implanted). The authors believe that this method is reliable, effective and low risk provided that the patient is cooperative; furthermore, the monolateral axial external fixator is tolerated well and allows movement of the shoulder and elbow throughout the period of treatment.

Functional outcome following surgical treatment of intra-articular distal humeral fractures through a posterior approach

BACKGROUND

While surgical repair is considered the standard of care of displaced intra-articular distal humeral fractures, most investigators have assessed its results with use of surgeon-based and/or radiograph-based outcome measures. The purpose of our study was to determine the functional outcome of fixation of displaced intra-articular distal humeral fractures with use of a standardized evaluation methodology consisting of objective testing of muscle strength and use of patient-based questionnaires (both limb-specific and general health-status questionnaires).

METHODS

We identified twenty-five patients (fourteen male and eleven female), with a mean age of forty-seven years, who had an isolated, closed, displaced, intercondylar, intra-articular fracture of the distal part of the humerus repaired operatively through a posterior approach and fixed with plates on both the medial and the lateral column. All patients returned for follow-up that included recording of a complete history, physical examination, radiographic examination, completion of both a limb-specific questionnaire (Disabilities of the Arm, Shoulder and Hand [DASH]) and a general health-status questionnaire (Short Form-36 [SF-36]), and objective muscle-strength testing.

RESULTS

The mean duration of follow-up was thirty-seven months (range, eighteen to seventy-five months). The mean flexion contracture was 25 degrees (range, 5 to 65 degrees), and the mean arc of flexion-extension was 108 degrees (range, 55 to 140 degrees). Significant decreases in mean muscle strength compared with that on the normal side were seen in both elbow flexion measured at 90 degrees (74 percent of normal, p = 0.01) and elbow extension measured at 45 degrees (76 percent of normal, p = 0.01), 90 degrees (74 percent of normal, p = 0.01), and 120 degrees (75 percent of normal, p = 0.01). The mean DASH score was 20 points, indicating mild residual impairment. The SF-36 scores revealed minor but significant decreases in the role-physical and physical function scores (p = 0.01 and 0.03, respectively) but no alteration of the mental component or mean scores. Six patients (24 percent) had a reoperation; three of them had removal of prominent hardware used to fix the site of an olecranon osteotomy.

CONCLUSIONS

The surgical repair of an intra-articular distal humeral fracture is an effective procedure that reliably maintains general health status as measured by patient-based questionnaires. Our study quantified a decrease in the range of motion and muscle strength of these patients, which may help to explain the mild residual physical impairment detected by the limb-specific outcome measures and physical function components of the general health-status measures.

The effect of surgery for rotator cuff disease on general health status. Results of a prospective trial

BACKGROUND

Previous studies of the effect of rotator cuff surgery have concentrated on limb-specific or surgeon-based outcome criteria. We conducted a prospective trial to determine the effect of surgery for rotator cuff disease on general health status.

METHODS

Seventy-one patients (fifty of whom were men and twenty-one of whom were women) with a mean age of 56.1 years were enrolled in the study. In addition to routine clinical and radiographic evaluation, all patients completed the Short Form-36 (SF-36) health-status questionnaire and five limb-specific questionnaires preoperatively and at six, twelve, eighteen, and twenty-four months postoperatively. All patients had a standard open acromioplasty and resection of the subacromial bursa. Thirty-one patients had repair of an associated rotator cuff tear. Sixty-seven patients (94 percent) completed the study; the remaining four patients were lost to follow-up.

RESULTS

The preoperative SF-36 scores for physical function (60.6, p = 0.02), role function-physical (20.8, p = 0.001), pain (38.6, p = 0.003), physical component summary (37.0, p = 0.001), and mental component summary (45.6, p = 0.02) were significantly decreased compared with normative data. The preoperative limb-specific scores also were low. At the time of the most recent follow-up evaluation, there was improvement that approached or reached significance both in the limb-specific scores (p < or = 0.0026) and in the general-health-status scores for pain (p = 0.0001), role function-physical (p = 0.06), vitality (p = 0.01), and physical component summary (p = 0.01). The presence of a rotator cuff tear had a significant negative effect on limb-specific scores both preoperatively (p = 0.04) and postoperatively (p = 0.05). Although operative treatment of rotator cuff disease led to improved scores, patients who had filed a Workers' Compensation claim had lower limb-specific and SF-36 scores both preoperatively (p = 0.02 and p = 0.01, respectively) and postoperatively (p = 0.01 and p = 0.005, respectively).

CONCLUSIONS

Surgery for chronic rotator cuff disease reliably and significantly improves general health status.

Displaced tibial shaft fractures: a prospective randomized study of closed intramedullary nailing versus cast treatment in 53 patients

Of 53 patients with unilateral, displaced and closed or grade 1 open tibial shaft fractures, 27 patients (group I) were randomized to treatment with an intramedullary nail and 26 patients (group II) to treatment with a plaster cast. 12 fractures in the latter group were considered stable enough for treatment with only a cast (group IIa), while 14 fractures in group II showed redisplacement during reduction under anesthesia or at 1 week follow-up. Therefore, these fractures were stabilized with cerclage or screws (group IIb), which was a prerequisite for continuing cast treatment. The mean time-to-union was 19 weeks for group I, and 25 weeks for group II. 6 patients in group I and 16 in group II had delayed union. The Nottingham Health Profile index scores on physical mobility, social isolation, work ability, and sexual life were significantly better in group I than in group II at 3 months after injury. Delayed union, malunion, and restricted range of motion at the ankle joint were common complications when these fractures were treated with a cast. We recommend intramedullary nailing for these fractures.