Bone Healing Problems Research Articles

Bringing gene therapy to regenerative medicine

Bringing gene therapy to regenerative medicine

External fixator supplemented with screw fixation versus staged open reduction and internal fixation tibial pilon fracture

Background: The present study aims to compare the results of primary tibial pilon injury . Objective: Our work aims to compare the clinical and radiological outcomes of two different surgical techniques for treatment of tibial pilon fractures. Patients & Methods: Those who matched completely with inclusion criteria were included until fully gaining required sample size. Prospective comparative controlled study using the foot and ankle outcome questionnaire of AAOS. The study was carried on patients with distal tibial fractures that are types 43 (B&C1, C2, C3) OTA classification of distal tibial fractures. patients divided for two groups according to surgical technique: group (A):(30) patients managed with primary external fixator with screws. group (B):(30) patients Managed with staged ORIF. Results: Group B showed a higher AAOS Foot and Ankle Normative score and AAOS foot and ankle core scale standardized mean and shoe comfort standardized mean and shoe comfort normative score and SF36 physical functioning% than Group A. Group A showed a less time interval from injury till fixation than Group B. From statistical point of view the two groups showed no significant difference regarding incidence of acquired complications. Conclusion: The two-stage ORIF gained a reduced risk of postoperative complications related to superficial infections, and bone healing problems. The ORIF 2 stage has several advantages, such as the ability to handle soft tissues including the periosteum, tendons(PTT), and ligaments that may be contained within fragmented fracture .

Bone nonunion management in children with a vascularized tibial periosteal graft

Vascularized periosteal graft have demonstrated a tremendous bone healing capacity in children. The objective is to report outcomes on the use of vascularized tibial periosteal graft (VTPG) during bone reconstruction in a series of children with complex bone healing problems. Cases were collected retrospectively since May 2013 to May 2019, excluding cases of congenital pseudarthrosis of the tibia. Mean age at surgery was 12.8 (range 11-18) years. Indications included treatment of recalcitrant bone nonunion and the prevention of bone allograft-host junction nonunion in seven and three patients, respectively. The periosteal flap, based on the anterior tibial vessels, was harvested as a free flap in six instances and as a pedicled flap in four. Mean follow-up was 25.2 months (range 8-36). The flap showed a 13.6 cm (range 9-16) and mean width 3.4 cm (range 2.7-3.9). Early bone union was achieved, initially through periosteal callus, followed by cortical union at mean times of 2 and 4 months, respectively, in nine cases. The flap was not successful in a patient with severe comorbidities. No donor site complications were registered. VTPG was fast and high effective for the treatment complex bone nonunion or the prevention of allograft nonunion in children.

Complications and subsequent surgery after intra-medullary nailing for tibial shaft fractures: Review of 8110 patients

BackgroundIntramedullary nailing of tibial shaft fractures has been common practice for decades. Nevertheless, complications occur frequently, and subsequent surgery is often required. To improve our understanding on how we may improve trauma care for patients with tibial shaft fractures, this study systematically reviewed all currently available evidence to assess the incidence of complications and rate of re-operations following intramedullary nailing of traumatic tibial fractures. MethodsTrip Database, Medline, Scopus and Cochrane Library were searched on September 7th, 2018. Searches were limited to English studies published after January 1st, 1998. Studies were included if authors included more than 50 patients treated with intramedullary nailing for traumatic tibial fractures. Inclusion of studies and critical appraisal of the evidence was performed by two independent authors. Incidence of complications and rate of re-operations were reported with descriptive statistics. ResultsFifty-one studies involving 8110 patients treated with intramedullary nailing for traumatic tibial fractures were included. Mean age of patients was 37.5 years. The most frequent complication was anterior knee pain (23%), followed by non-union (11%). Eighteen percent of patients required at least one subsequent surgery. The most frequent indication of subsequent surgery was screw removal due to pain or discomfort (9%). Dynamization of the nail to promote union was reported in 8% of the cases. Nail revision and bone-grafting to promote union were applied in 4% and 2% respectively. Discussion & ConclusionPatients treated with intramedullary nailing for tibial fractures need to be consented for high probability of adverse events as anterior knee pain, subsequent surgical procedures and bone healing problems are relatively common. However, based on current data it remains difficult to identify specifiers and determinants of an individual patient with specific fracture characteristics at risk for complications. Future studies should aim to establish patient specific risks models for complications and re-operations, such that clinicians can anticipate them and adjust and individualize treatment strategies.

Treatment of open tibial diaphyseal fractures by external fixation combined with limited internal fixation versus simple external fixation: a retrospective cohort study

BackgroundThe treatment of open tibial shaft fractures is challenging. External fixation (EF) is comparatively safe in treating these open injuries, meanwhile it has the advantages of easy application, minimal additional disruption, and convenient subsequent soft tissue repair. Nevertheless, its application is accompanied by a series of problems in alignment and bone healing. Therefore, limited internal fixation (LIF), such as cortical screws, has been used based on the external fixator for better therapeutic effect. The aim of this study is to compare the outcomes of EF combined with LIF and simple EF in the management of open tibial shaft fractures, evaluating the efficacy and safety of using the combined technique in treating such fractures.MethodsFrom January 2012 to December 2016, patients with open tibial shaft fractures treated with EF with or without LIF augmentation were identified. A total of 152 patients were included in the analysis, and there were 85 patients in the simple external fixation group and 67 patients in the EF-LIF group. General assessment indicators included the direct cost of hospitalization and the times of first surgery, full weight bearing, and complete union. Infections and complications in union or limb alignment were compared as primary outcomes. Additionally, the number of patients who changed the fixation system for various reasons were analysed.ResultsEffective follow-up of all participants for statistical analysis was obtained. The follow-up time averaged 17.15 months (range: 12.00 to 24.00 months) in the EF group and 16.20 months (range: 12.00 to 19.00 months) in the EF-LIF group. Combined fixation provided shortened time to bear full weight and achieve complete bone union, while requiring additional first surgery time. No significant difference was found in infection rates or direct cost of hospitalization. Delayed union and non-union in the EF-LIF group were significantly decreased (20.9% versus 40.0, 1.5% versus 14.1%, p < 0.05). In limb alignment, patients with combined fixation exhibited reduced malreduction, loss of reduction, and malunion. In terms of secondary fixation, the EF-LIF group showed a markedly lower incidence (5.8% versus 34.1%, p < 0.001).ConclusionCompared with simple EF, combined fixation is an effective and safe alternative for management of open tibial diaphyseal fractures. It provides superior initial reduction, better stability and decreases the risk of inferior alignment and delayed union without increasing the risk of infection.

Osteotomies around the Knee

Osteotomies around the knee in unicompartimental osteoarthritis had an impressing revival in the past few years and have to be kept in mind as an alternative to total knee arthroplasty. The most frequent type of osteotomies around the knee is the medial open wedge high tibia osteotomy (MOWHTO). But still also closed wedge high tibia osteotomies (CWHTO) have their relevance in many cases. Distal femur osteotomies (DFO) are used more and more frequently in most cases as closed wedge, the open wedge DFO shows more problems in bone healing. All osteotomies with isolated correction in frontal plane should be done with a biplanar bonecut. In cases of severe varus and valgus malalignment a double-level osteotomy (combined femoral and tibial osteotomy) has to be executed. Severity and frequency of adverse events in osteotomies around the knee are mostly comparable to those in arthroplasty, except non-union which is only related to osteotomies and more often seen in smokers. There are nearly no age limits for osteotomies around the knee. Ten years-survival in HTOs are about 85 to 91% according to literature.

Patients with advanced periodontal disease before intensity-modulated radiation therapy are prone to develop bone healing problems: a 2-year prospective follow-up study

PurposeIntensity-modulated radiation therapy (IMRT) has changed radiation treatment of head and neck cancer (HNC). However, it is still unclear if and how IMRT changes oral morbidity outcomes. In this prospective study, we assessed the outcome of reducing post-IMRT sequelae by means of pre-radiation dental screening and eliminating oral foci.MethodsAll consecutive dentate patients > 18 years, diagnosed with primary oral or oropharyngeal carcinoma, referred for pre-treatment dental screening between May 2011 and May 2013, were included and followed for 2 years. Patients were treated with IMRT or IMRT with chemotherapy (CHIMRT). Dental screening data, demographic data, and data on oral sequelae during follow-up were recorded. Diagnosed oral foci were treated before start of the radiation therapy.ResultsOral foci were found in 44/56 (79%) patients, consisting predominantly of periodontal breakdown. Bone healing problems after radiotherapy occurred more often in patients with periodontal pockets ≥ 6 mm at baseline (19 vs. 4% in patients with pockets < 6 mm). Osteoradionecrosis developed in 4/56 patients (7%) during follow-up. In line with this observation, multiple logistic regression analysis showed that the periodontal inflamed surface area, which is higher in patients with more severe periodontal disease, predicted that a patient has a higher risk on developing osteoradionecrosis or bone healing problems (p = 0.028).ConclusionsPatients with severe periodontal disease before IMRT/CHIMRT are more prone to develop bone healing problems post-radiotherapy.

Management of complex femoral nonunion with monorail external fixator: A prospective study.

To evaluate 30 patients who underwent distraction osteogenesis with monorail external fixator for complex femoral nonunion. Complex femoral nonunion includes infective non-union, gap nonunion, and limb-length discrepancy secondary to traumatic bone loss, which needs specialized treatment to ensure the functional integrity of femoral bone. 30 patients, including 28 male and 2 female (aged 22-62 years) patients, underwent surgical debridement followed by bone transport with monorail fixator. The lengthening index, radiographic consolidation index, functional status, bone healing, and various problems, obstacles, and complications encountered during the treatment were assessed. Patients underwent a mean of 2.2 (range 1-4) surgeries before presentation. The mean bone defect after surgical debridement was 5.83cm (range 2-16cm). The mean treatment duration was 204.7 days (range 113-543 days). The mean lengthening index was 13.06days/cm with range from 12 to 16days/cm. Mean maturation index was 23.51days/cm with range from 17 to 45.5days/cm. In our study, bone result was excellent in 17, good in 9, fair in 3, and poor in 1 patient. In our study functional outcome is excellent in 9 [30%], good in 14 [46.67%], fair in 5, and poor in 2 patients. In our study, we encountered 34 problems, 17 obstacles, and 8 complications. We concluded that monorail external fixator is an effective treatment option for complex nonunion femoral shaft fracture and its functional outcome is comparable with any other treatment options. Lack of complications and its effectiveness makes monorail external fixator the treatment of choice for complex nonunion femoral shaft.

Regulatory authorities and orthopaedic clinical trials on expanded mesenchymal stem cells.

Skeletal injuries requiring bone augmentation techniques are increasing in the context of avoiding or treating difficult cases with bone defects, bone healing problems, and bone regeneration limitations. Musculoskeletal severe trauma, osteoporosis-related fractures, and conditions where bone defect, bone collapse or insufficient bone regeneration occur are prone to disability and serious complications. Bone cell therapy has emerged as a promising technique to augment and promote bone regeneration. Interest in the orthopaedic community is considerable, although many aspects related to the research of this technique in specific indications may be insufficiently recognised by many orthopaedic surgeons. Clinical trials are the ultimate research in real patients that may confirm or refute the value of this new therapy. However, before launching the required trials in bone cell therapy towards bone regeneration, preclinical data is needed with the cell product to be implanted in patients to ensure safety and efficacy. These preclinical studies support the end-points that need to be evaluated in clinical trials. Orthopaedic surgeons are the ultimate players that, through their research, would confirm in clinical trials the benefit of bone cell therapies. To further foster this research, the pathway to eventually obtain authorisation from the National Competent Authorities and Research Ethics Committees under the European regulation is reviewed, and the experience of the REBORNE European project offers information and important clues about the current Voluntary Harmonization Procedure and other opportunities that need to be considered by surgeons and researchers on the topic.

Systematic review of complications after intramedullary fixation for displaced midshaft clavicle fractures

The number of displaced midshaft clavicle fractures treated surgically is increasing, and open reduction and intramedullary fixation is an emerging surgical treatment option. The study quality and scientific levels of published evidence in which possible complications of this treatment are presented vary greatly. We performed systematic computer-based searches of EMBASE and PubMed/MEDLINE. Studies included for review reported complications after intramedullary fixation alone or in comparison to either treatment with plate fixation and/or nonoperative treatment. The Level of Evidence rating and Quality Assessment Tool were used to assess the methodological quality of the studies. Included studies were ranked according to their levels of evidence. Six articles were eligible for inclusion and final quality assessment; 3 studies were graded the highest level of evidence. Major complications like bone-healing problems and deep infections requiring implant removal were reported at a rate no higher than 7%. Reported rates for minor complications, such as wound infection and implant irritation that could be resolved without further surgery, were as high as 31%. The noted rates for major complications requiring additional surgery were low, but implant-related problems that require additional surgery might present with high prevalence. Owing to routine implant removal, treatment with intramedullary fixation often requires an additional surgical procedure.

Distraction Osteogenesis Using a Monolateral External Fixator for Infected Non-Union of the Femur with Bone Loss

To review records of 15 patients who underwent distraction osteogenesis/bone transport using a monolateral external fixator for infected non-union of the femoral shaft. 13 men and 2 women aged 18 to 47 years underwent adequate debridement and resection of nonviable bone, followed by bone transport using a monolateral external fixator for infected non-union of the femoral shaft with bone loss. All patients had a bone defect of >5 cm. The lengthening index, radiographic consolidation index, functional status, bone healing, and various problems, obstacles and complications encountered during the treatment were assessed. The patients had undergone a mean of 2.9 (range, 1-7) surgical procedures before presentation. The mean duration from trauma to presentation was 7.7 (range, 6-18) months. The mean bone defect after adequate resection/debridement was 7.9 (range, 5.5-17) cm. The mean treatment duration was 7.3 (range, 5-15) months. The mean lengthening index was 12.3 (range, 11.5-15) days/cm. The mean treatment index was 27.9 (range, 24-40) days/cm. The mean follow-up duration was 19.3 (range, 15-41) months. Functional outcome was excellent in 5, good in 8, and fair in 2 patients. All patients achieved bone union and eradication of infection. Bone healing was excellent in 12 and good in 3 patients. All the patients were satisfied with the procedure. None had neurovascular complications, joint subluxations, or refracture of the regenerated bone. True complications encountered included knee stiffness (n=6) and knee flexion contracture (n=1). Three patients with an initial bone defect of >10 cm had delayed union and underwent bone grafting. Bone transport using a monolateral external fixator is safe and effective for treating infected non-union of the femoral shaft.

Gene therapy for bone healing

Clinical problems in bone healing include large segmental defects, spinal fusions, and the nonunion and delayed union of fractures. Gene-transfer technologies have the potential to aid healing by permitting the local delivery and sustained expression of osteogenic gene products within osseous lesions. Key questions for such an approach include the choice of transgene, vector and gene-transfer strategy. Most experimental data have been obtained using cDNAs encoding osteogenic growth factors such as bone morphogenetic protein-2 (BMP-2), BMP-4 and BMP-7, in conjunction with both nonviral and viral vectors using in vivo and ex vivo delivery strategies. Proof of principle has been convincingly demonstrated in small-animal models. Relatively few studies have used large animals, but the results so far are encouraging. Once a reliable method has been developed, it will be necessary to perform detailed pharmacological and toxicological studies, as well as satisfy other demands of the regulatory bodies, before human clinical trials can be initiated. Such studies are very expensive and often protracted. Thus, progress in developing a clinically useful gene therapy for bone healing is determined not only by scientific considerations, but also by financial constraints and the ambient regulatory environment.

Pulsed electromagnetic fields stimulation affects BMD and local factor production of rats with disuse osteoporosis

Pulsed electromagnetic fields (PEMF) have been used widely to treat nonunion fractures and related problems in bone healing, as a biological and physical method. With the use of Helmholtz coils and PEMF stimulators to generate uniform time-varying electromagnetic fields, the effects of extremely low frequency electromagnetic fields on bone mineral density (BMD) and local factor production in disuse osteoporosis (DOP) rats were investigated. Eighty 4-month-old female Sprague Dawley (SD) rats were randomly divided into intact (INT) group, DOP group, calcitonin-treated (CT) group, and PEMF stimulation group. The right hindlimbs of all the rats were immobilized by tibia-tail fixation except for those rats in the INT group. Rats in the CT group were injected with calcitonin (2 IU/kg, i.p., once a day) and rats in the PEMF group were irradiated with PEMF immediately postoperative. The BMD, serum transforming growth factor-beta 1 (TGF-beta1), and interleukin-6 (IL-6) concentration of the proximal femur were measured 1, 2, 4, and 8 weeks after treatment. Compared with the CT and DOP groups, the BMD and serum TGF-beta1 concentration in the PEMF group increased significantly after 8 weeks. The IL-6 concentration in the DOP group was elevated significantly after operation. The PEMF group showed significantly lower IL-6 level than the DOP group. The results found demonstrate that PEMF stimulation can efficiently suppress bone mass loss. We, therefore, conclude that PEMF may affect bone remodeling process through promoting TGF-beta1 secretion and inhibiting IL-6 expression.

Tibial Plafond Fractures: Limited Incision Reduction with Percutaneous Fixation

This study was a retrospective review of 18 patients with 19 pilon fractures treated with limited incision reduction and percutaneous plate fixation of the tibia. Patients were treated with either a 1- or 2-stage protocol. The latter consisted of placement of an external fixator followed by definitive reduction. The emphasis of analysis was placed on the identification of complications to the soft tissue envelope or bone-healing problems within the first 6 months after surgery. A major complication was defined as an unplanned operation within the first 6 months. Minor complications were any superficial wound defects that did not require operative intervention to resolve or any malunion or delayed union. With this protocol, no major complications were encountered. Minor complications were identified in 4 patients (4 fractures) of which 2 were minor wound problems. One patient developed a malunion, and the other had a delayed union. Four patients requested removal of prominent hardware. These results indicate that limited incision reduction and percutaneous plate fixation lead to safe methods of stabilization. The authors also provide guidance and strategies for the consistent execution of this technique.

The Effectiveness of Pulsed Electromagnetic Fields Therapy for Treatment of Chronic Pain

Background: Pulsed electromagnetic fields (PEMF) have been widely used to treat nonhealing fractures and related problems in bone healing since their approval by the Food and Drug Administration (FDA) in 1979. Some studies have suggested that electromagnetic fields might be useful in the treatment of chronic illnesses, such as lumbar radiculopathy, whiplash syndrome, posterior neck pain, persistent rotator cuff tendonitis, knee osteoarthritis and post-herpetic neuralgia, etc. Herein, the effectiveness of PEMF therapy for the treatment of chronic pain was assessed. Methods: 40 patients, with chronic back pain, neck pain, post-herpetic neuralgia, complex regional pain syndrome, atypical facial pain, shoulder pain and myofascial pain syndrome were studied. Pulsed electromagnetic fields of 30 and 50 Hz were applied for 20 minutes, 5 times a week. The outcomes were measured using the visual analogue (VAS, 0 - 10) and patient satisfaction scales (good, fair, poor). Data were analyzed using repeated ANOVA measurements for a changes in the VAS (initial VAS final VAS) and by the paired t-test for changes from the baseline VAS to follow-up VAS values. Results: Compared to the mean baseline VAS value before the PEMF therapy (), that after () showed a significant change (P 0.01). The patient satisfaction scales of good and fair were 65.0 and 35.0%, respectively. There were no significant side-effects. Conclusions: The decrease in the VAS score suggests that PEMF therapy has potential as an effective method of improving the symptoms of chronic pain.

Soft-tissue and bone reconstruction in compound fractures of the lower leg.

Open fractures of the lower leg should be treated in co-operation with orthopaedic and plastic surgeons. This is because tibia is largely surrounded with thin soft tissue envelope, which results that compound fractures expose the bone leading easily to soft tissue defect, infection and bone healing problems. When planning the treatment, the mechanism of trauma should be carefully considered; high-energy fractures must be identified. Compound fractures of the lower leg are usually traffic, industrial or farming accidents or gun shot injuries. The amount of bacterial contamination must be considered; usually farming or gun shot injuries are highly contaminated. Also the age and general health (multiple trauma, systemic diseases) of the patient influence the choice of treatment. Local condition of tissue at fracture site, and vascular status of the extremity is important in planning the strategy and timetable of treatment. Also the delay from the injury to trauma unit has an effect on the treatment strategy (1, 2). The open fractures are usually classified using Gustilo system, I, II, IIIA, IIIB and IIIC (3). The treatment of severe compound fractures of the lower leg can be divided into 4 periods. 1) Acute treatment. 2) Soft tissue reconstruction 3) Bone reconstruction and 4) Correction of late problems.

Reconstruction after Bone Healing Problems in Humeral Shaft Fractures

Categorization and therapy of bone healing disturbances of diaphyseal humeral fractures vary in the literature. A consecutive series of 25 revisions for bone healing disturbances was reviewed retrospectively. Timing of revisions, characteristics of delayed healing and nonunions, various operative techniques, duration of bony consolidation, and 1-year functional results were recorded. The indication for revision was delayed healing in 52% of cases and nonunion in 48%. One hypertrophic, 15 normotrophic, seven hypotrophic, and two lytic fracture sites were seen. For stabilization, the operative method used was closed in 28% of cases, open in 40%, and combined in 32%. The rate of bony consolidation amounted to 96%, and the average duration of bone healing was 5.7 months. One of the two septic complications observed healed after metal removal. The second patient died from a preexisting disease. Operative technical complications, iatrogenic radial nerve damage, and metal loosening were not detected. Timing of revision and an adequate operative method form the basis of successful treatment. With the protocol suggested, hospitalization time and financial costs to the patient, muscle and bone atrophy, and contractures of the elbow and shoulder can be lowered significantly. Furthermore, it allows to optimally correct complications of primary treatment and/or earlier revisions.

DNA Strand Gene Transfer and Bone Healing

Continued research is still needed to broaden the understanding of the biology of bone formation, bone repair, and bone remodeling. Preliminary data reviewed in this article confirm that it is possible to use ex vivo and in vivo gene-transfer strategies to transfer genes to bone and express them in the repair site. As work progresses, strategies of gene therapy with osteoinductive-growth factors may provide the orthopedic surgeon with more effective and less-costly treatment options for bone-healing problems.

Retrograde Nailing of Humeral Shaft Fractures

The use of intramedullary nailing in the upper extremity is still controversial. Those who have experience with antegrade nailing have either great enthusiasm or strong criticism for the procedure. Criticism of the procedure is because of the trauma that can occur to the rotator cuff and possible impingement syndrome, which can occur after antegrade nail insertion. The technique of retrograde nail insertion with the unreamed humeral nail is described in detail. In a series of 190 retrograde nailings performed in a prospective multicenter study, the most frequent intraoperative problems were fissure or avulsion at the entry portal (n = 8; 4.2%) and secondary radial nerve palsy (n = 8; 4.2%). All radial nerve palsies recovered spontaneously. Sixty-eight patients were followed up until the fractures healed. There were five (7.4%) bone healing problems. Four of five could be solved with use of the unreamed humeral nail in a second operative procedure, whereas the fifth bone healing problem required plate osteosynthesis. Function of the shoulder and elbow joint was excellent in 89.7% and 88.3% of the patients, respectively. Retrograde humeral nailing is a safe and reliable procedure if done properly. It is a valuable stabilization technique for acute and pathologic fractures and for pseudarthrosis. Bone healing problems after unreamed humeral nailing must be analyzed individually, but they can be treated with the same implant in combination with cancellous bone grafts, reaming, additional hardware, or intrafragmentary compression.

Retrograde Nailing of Fresh and Pathologic Humeral Shaft Fractures With a New Unreamed Humeral Nail (UHN)

Summary Intramedullary nailing of humeral shaft fractures is still a controversial issue. The comments and experience with antegrade nailing vary from enthusiasm to criticism. Main criticisms concern the damage of the rotator cuff and articular cartilage and possible impingement syndrome. The new unreamed humeral nail (UHN) is being used for antegrade and retrograde insertion. We describe the technique of retrograde nail insertion. The nail is 6.7, 7.5, or 9.5 mm. It has one curvature of 4° at the transition proximal to second fourth. There are three interlocking possibilities at the nail base and nail tip. Interfragmentary compression is achieved through a compression device. The entry portal for nail insertion is situated above the olecranon fossa; the elbow capsule is not opened. The occurrence of a supracondylar fissure or fracture and secondary damage to the radial or axillary nerve are the most feared complications. In a series of 190 retrograde nailings, the most frequent intraoperative problems were fissure or avulsion at the entry portal (n = 8; 4.2%) and secondary radial nerve palsy (n = 8; 4.2%). All radial nerve palsies recovered spontaneously. Sixty-eight patients were followed up until fracture healing. There were five (7.4%) bone healing problems. Four of five could be solved with the use of the unreamed humeral nail in a second operative procedure, whereas the fifth required plate osteosynthesis. Function of the shoulder and elbow joint was excellent in 89.7% and 88.3% of the patients, respectively. The UHN is a valuable addition to the implants, available for operative treatment of fresh or pathologic humeral shaft fractures. Retrograde humeral nailing is a safe and reliable procedure if done properly. Bone healing problems after unreamed humeral nailing must be analyzed individually, but they can be treated with the same implant in combination with cancellous bone grafts, reaming, additional hardware, or intrafragmentary compression.