Distal Humerus Nonunion Research Articles

Supracondylar ostectomy and shortening (S.O.S.) for distal humerus nonunions

Many distal humerus nonunions are associated with bone loss, and rigid internal fixation is difficult to obtain, especially for low transcondylar nonunions and those with severe intra-articular comminution. The purpose of this study was to analyze the results of a strategy to address this challenge utilizing internal fixation using the Supracondylar Ostectomy+Shortening (S.O.S.) procedure for distal humerus nonunions. The goals of this procedure are to (1) optimize bony contact and compression through re-shaping the nonunited fragments at the supracondylar level with selective humeral metaphyseal shortening, (2) maximize fixation using parallel-plating, and (3) provide biologic and structural augmentation with bone graft. Between 1995 and 2019, 28 distal humerus nonunions underwent internal fixation using the S.O.S. procedure at a single Institution. There were 14 males and 14 females with mean age of 47 (range 14-78) years at the time of the S.O.S procedure and an average of 1.7 prior surgeries. Medical records and radiographs were reviewed to determine rates of union, reoperations, complications, and Mayo Elbow Performance Scores (MEPS). Patients were also prospectively contacted to update their MEPS and gather additional information on complications and reoperations. Mean clinical exam follow-up was 17months, mean clinical contact follow-up was 19months, and mean radiographic follow-up was 32months. Four patients did not have adequate follow-up to determine union. Of the remaining 24 elbows, 22 achieved union. Two elbows developed collapse of the articular surface and were converted to a total elbow arthroplasty. There were complications in 10 elbows: contracture (5), superficial infection (2), ulnar neuropathy (1), deep infection (1), and hematoma (1). Twelve elbows underwent reoperation: 4 for contracture release, 3 for hardware removal, 2 for total elbow arthroplasty, 1 for bone grafting, 1 for hematoma evacuation, and 1 for ulnar nerve neurolysis. Compared to preoperative data, there was a significant improvement in postoperative flexion, extension and pronation (P<.01). The mean range of motion was 21° of extension, 119° of flexion, 79° of pronation, and 77° of supination. The mean MEPS was 80 points (range, 25-100 points) and 19 elbows (76%) rated as excellent or good. Stable fixation and high union rates are possible in distal humerus nonunions with bone loss using a technique that combines supracondylar humeral shortening, parallel plating, and bone grafting. Secondary procedures are commonly needed to restore function in this challenging patient population.

Postoperative radial nerve palsy in humeral shaft nonunion reconstruction: Can the lateral paratricipital approach prevent this common complication?

BackgroundPostoperative radial nerve palsy (RNP) is a well-known complication of nonunion reconstruction of the humerus. The purpose of the current study is to determine if the surgical approach for nonunion reconstruction of the humerus influences the rate of postoperative radial nerve palsy. MethodsA retrospective case-control study of all humeral shaft and extraarticular distal humerus nonunion reconstructions performed between January 1, 2004, and August 31, 2021, was conducted. Patients included were over 18 years of age, had a non-pathologic humerus fracture nonunion and had intact radial nerve function prior to nonunion reconstruction. Exclusion criteria consisted of nonunions involving the proximal humerus, intraarticular fractures, and reconstructive treatment procedures with either intramedullary nail or external fixation methods. Perioperative variables were recorded and analyzed in regard to the development of postoperative RNP. A subgroup analysis was performed to assess the interaction of significant variables on the development of postoperative RNP. ResultsThe overall rate of postoperative RNP in this series was 6/53 (11%). However, no cases of postoperative radial nerve palsy were observed in patients who underwent nonunion reconstruction with a lateral paratricipital approach. A new RNP was seen in 4/9 (44%) of those patients who underwent a triceps splitting approach, which was significantly higher than those utilizing either an anterolateral approach (2/28, 7%) or a lateral paratricipital approach (0/16, 0%, p = 0.007). Discussion and conclusionOur data suggests that the lateral paratricipital exposure decreases the risk of radial nerve injury with nonunion reconstruction of the humerus. The lateral paratricipital exposure offers the benefit of radial nerve exploration, decompression, neurolysis and protection prior to fracture manipulation and instrumentation. This study shows conventional approaches may predispose patients to a high rate of postoperative RNP, similar to that in the literature.

Treatment of patients with complicated fractures of the distal humerus using the fixators of limited-contact multiplanar osteosynthesis

Treatment of distal humerus fractures is a complex problem in traumatology. The result of treatment depends on the choice of fixator according to the fracture area. Objective. To improve the techno­logy of treatment in patients with complicated distal humerus fractures with fixators of small contact and multiplanar osteosynthesis and to evaluate its efficacy. Methods. 39 patients were treated for the period 2000–2020 with distal humerus nonunion (types 12-B1, 12-C1, 12-C2) and 23 patients with complicated above- and transcondylar humerus fractures (types 13-A2, 13-C1, 13-C2). Fixation of bone fragments of the distal humerus was made with device for fixation (Patent 17502 UA). It is a shaped plate with a groove on which half rings with threaded holes are stabilized. For the osteosynthesis of above- and transcondylar humerus fractures we used V-shaped plate with the possibility to regulate branch spreading width as for the condylar size (Patent 33358 UA). Autografting was performed as for necessity. Results. Plate osteosynthesis was performed mainly through anterior approach with minimal tissues traumatization. Release of radial nerve we made as for necessity. This device provides the stable fixation even in a case of short distal fragment. Device for bone fragments fixation was placed on the posterior condylar surface and lower part of the humerus through olecranon osteotomy. Osteosynthesis with suggested device is one of the options with bone autografting and can be method of choice at repeated surgery. Follow-up period was 1–2 years and later. In 60 patients we obtained good results with completed bone union. Conclusions. Suggested device can be used in cases of distal humerus nonunion. It allows to decrease the damage of surgery, to avoid many complications. Key words. Complicated fractures of the distal humerus, devices for limited-contact multiplanar osteosynthesis.

Distal humerus nonunion: evaluation and management.

Despite recent improvements in surgical implants and techniques, distal humerus nonunion does occur between 8% and 25% of the time.Careful identification and improvement of any modifiable risk factors such as smoking, metabolic disorders, immunosuppressant medications, poor nutritional status and infection is mandatory.A recent computed tomography scan is paramount to determine the nonunion pattern, assess residual bone stock, identify previously placed hardware, and determine whether there is evidence of osteoarthritis or malunion of the articular surface.Internal fixation is the treatment of choice in the majority of patients presenting with reasonable bone stock and preserved articular cartilage; total elbow arthroplasty is an appealing alternative for elbows with severe destruction of the articular cartilage or severe bone loss at the articular segment, especially in older, female patients. Internal fixation requires not only achieving a stable fixation, but also releasing associated elbow contractures and the liberal use of bone graft or substitutes.Although reported union rates after internal fixation of distal humerus nonunions are excellent (over 95%), the complication rate remains very high, and unsatisfactory results do occur.Cite this article: EFORT Open Rev 2020;5:289-298. DOI: 10.1302/2058-5241.5.190050

Autogenous Inlay Bone Graft for Distal Humerus Nonunion with Metaphyseal Bone Defect: A Technical Note

Distal humeral nonunion is one of the most concerned complications in elbow trauma. When bone loss at the fracture site is carried out due to nonunion, metaphyseal bone defect occurs. Therefore positioning of anatomical locking plate becomes difficult owing to abnormal bone contour, and fixation of small nonunion fragment is challenging. We introduce a good method of anatomical locking plate fixation with autogenous inlay strut bone graft for internal fixation. This technique is to insert autogenous inlay bone into the proximal medullary canal and hole of distal bone fragment which will lead to achieve correction of the anatomical alignment, length and rotation deformity. The inlay grafting is reduced to the shaft with two crossed K-wires temporarily. Definitive fixation is performed with locking plates, and autogenous bone graft is added at the defect site.

Primary total elbow arthroplasty for comminuted fracture or nonunion of distal humerus in the elderly

Primary total elbow arthroplasty for comminuted fracture or nonunion of distal humerus in the elderly

Evaluation of surgical treatment of inter-condylar humerus fracture with olecranon osteotomy approach

Background: Inter-condylar fracture distal humerus in adults often pose a challenge to orthopaedic surgeons because of the complex anatomy, fracture pattern and limited bone stock of this region. Adequate exposure of the articular surface of the distal humerus and elbow joint is essential for operative stabilisation of complex distal humerus fracture. Various operative approaches have been recommended to access this difficult region which includes triceps splitting, triceps reflecting and trans-olecranon approaches though each approach has its own advantage & disadvantage. Olecranon osteotomy approach provides better visualization of complex intra-articular fractures, enabling accurate reduction and fixation.Aim of this Study: To assess the functional outcome of intercondylar humerus fracture with olecranon osteotomy approach. Study design: prospective studyMaterial and Methods: Sixty patients of inter-condylar fracture humerus fulfilling the inclusion criteria were treated with internal fixation with various implants with olecranon osteotomy via posterior approach. Preoperative and postoperative radiograph measurements were taken and fractures were classified according to the AO system. All patients were operated through posterior trans-olecranon approach. Elbow exercises were started at third postoperative week. Patients were followed at three weeks and thereafter monthly, with clinical examination and x-rays. Results: The average ROM on follow up after 6 weeks was flexion up to 140o and extension upto 5o of elbow flexion. No cases of olecranon or distal humerus non-union were reported. Conclusions: Posterior surgical approach with olecranon osteotomy provides optimal exposure of the intra articular aspect of distal part of humerus and among them olecranon osteotomy gives the best exposure of the articular surface and there by better reduction and internal fixation which in turn gives better stability and good range of motion as compared to other approaches.

Pedicled Vascularized Bone Graft of the Distal Radius for Recalcitrant Nonunion of the Distal Humerus.

To analyze the clinical and radiological outcomes of a series of patients treated with a pedicled vascularized bone graft (VBG) of the distal radius for the treatment of recalcitrant atrophic nonunions of the distal humerus. Retrospective clinical study. University-affiliated teaching hospital. Fifteen patients with supracondylar humeral atrophic nonunions with at least 3 previous failed surgical interventions were included. Debridement of the distal humerus nonunion through a posterior elbow approach with provisional fixation was performed. Then, a pedicled VBG was harvested from the distal radius and tunneled back into the humeral bone defect. Iliac crest was used as needed, both for the nonunion and to stabilize the radius. Finally, definitive fixation with 2 locked plates was performed. Radiological results, complications, elbow range of motion, Mayo elbow performance score, and subjective pain were evaluated. There were 4 male and 11 female patients, with a mean age of 51 (range, 28-73) years. The mean follow-up period was 46 (range, 37-72) months with a minimum of 3 years. Radiological consolidation was achieved in all patients. Elbow range of motion was >100 degrees in 11 patients and between 50 and 100 degrees in 4 patients. Preoperative Mayo scores were poor in all patients. At final follow-up, Mayo scores were excellent in 3, good in 9, and fair in 3 patients. The mean postoperative visual analog scale score was 1.2 (range 0-3). Pedicled VBG of the distal radius was shown to be a reliable and effective alternative for the treatment of recalcitrant atrophic nonunions of the distal humerus, when other methods have failed. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Distal humerus nonunions after failed internal fixation: Treatment with Ilizarov external fixator

Introduction/Objective. Nonunions of distal humerus after unsuccessful surgical treatment represents challenging surgical problem. The complexity of this condition is increased by bone atrophy, scar tissue, poorly vascularized bone fragment, limited elbow mobility, osteomyelitis and local neurological damage. The advantages of using Ilizarov external fixation method are stable fixation, adequate fracture reduction and fragment compression accompanied by minimal soft tissue trauma, with the possibility of early elbow mobilization. This aim of this paper is to present the treatment results of 19 patients with nonunion of distal humerus after internal osteosynthesis managed by Ilizarov external fixation method. Methods. nineteen consecutive patients were treated with the Ilizarov external fixator. The study group includes 11 male and 8 female patients with an average age of 42 years. Surgical technique consisted of approaching the nonunion, removing loose fixation material, making resection and debridement of bone fragments, after which Ilizarov fixator was placed. Rehabilitation of the elbow started in early postoperative period. The functional status of the arm was evaluated using the DASH score (Disabilities of the Arm, Shoulder and Head). Results. All patients achieved solid bony union after average 7 months from application of external fixator. In 17 patients radiographic analysis indicated the preservation of joint space, while two showed degenerative changes. All patients showed improvement in elbow range of motion and significantly better DASH score with postoperative value of 21. Conclusion. As treatment of distal humerus nonunion, Ilizarov external fixation method provides successful healing and increased range of motion in the elbow.

Surgical Technique: Treatment of Distal Humerus Nonunions

BackgroundOpen reduction and internal fixation of distal humerus fractures is standard of care with good to excellent outcome for most patients. However, nonunions of the distal humerus still occur. These are severely disabling problems for the patient and a challenge for the treating physician. Fortunately, a combination of standard nonunion techniques with new plate designs and fixation methods allow even the most challenging distal humeral nonunion to be treated successfully.Questions/PurposesThe purpose of this manuscript is to describe our current technique in treating distal humeral nonunion as it has evolved over the last four decades. We have now follow-up on 62 treated patients.MethodsA few key steps are essential to obtain bone healing while regaining or preserving elbow motion. These include careful planning, extensile exposure, release of the ulnar nerve, capsular release and mobilization of the distal fragment, debridement, and finally stable fixation after alignment with application of bone graft.ResultsThe vast majority of distal humeral nonunions can be treated successfully with open reduction and internal fixation.ConclusionImportant components of the treatment plan are careful preoperative planning, extensile approach, debridement, and solid fixation with—locking—plates and liberal use of bone graft.

Trends in total elbow arthroplasty in the Medicare population: a nationwide study of records from 2005 to 2012

Utilization of total elbow arthroplasty (TEA) has reportedly increased in recent years. Since the introduction of disease-modifying antirheumatic drugs, there has been a reported decline in its use among rheumatoid patients; yet, the shift in indications for TEA remains unclear. This study evaluated trends in TEA utilization from 2005 to 2012 by analyzing the most common indications within the population of Medicare patients. We performed a retrospective review of a comprehensive Medicare patient population database using the PearlDiver supercomputer (Warsaw, IN, USA) for TEA utilization in rheumatoid arthritis (RA), osteoarthritis (OA), distal humerus fracture (DHF), post-traumatic arthritis (PTA), and distal humerus nonunion (DHNU). Total reported incidence of office visits and TEA utilization for each indication was reviewed. Utilization of TEA remained unchanged (P = .9530) despite a growing Medicare population (P = .0201). There was a significant decline in annual TEA utilization for RA (P = .002) and DHNU (P = .003). No significant change was found in TEA use for DHF, OA, and PTA. A significant increase was noted in total visits coded for OA, RA, and DHNU (P < .001). A significant, strong negative correlation was found for office visit coding and TEA use in RA (r = -0.850; P = .008) and DHNU (r = -0.902; P = .002). From 2005 to 2012, utilization rates of TEA in the Medicare population remained constant. Despite increases in office visits, TEA use for RA and DHNU has declined, likely secondary to improved medical management with disease-modifying antirheumatic drugs and the surgeon's comfort with improved fracture fixation options.

Total Elbow Arthroplasty

Total elbow arthroplasty has continued to evolve over time. Elbow implants may be linked or unlinked. Unlinked implants are attractive for patients with relatively well preserved bone stock and ligaments, but many favor linked implants, since they prevent instability and allow replacement for a wider spectrum of indications. Inflammatory arthropathies such as rheumatoid arthritis represent the classic indication for elbow arthroplasty. Indications have been expanded to include posttraumatic osteoarthritis, acute distal humerus fractures, distal humerus nonunions and reconstruction after tumor resection. Elbow arthroplasty is very successful in terms of pain relief, motion and function. However, its complication rate remains higher than arthroplasty of other joints. The overall success rate is best for patients with inflammatory arthritis and elderly patients with acute distal humerus fractures, worse for patients with posttraumatic osteoarthritis. The most common complications of elbow arthroplasty include infection, loosening, wear, triceps weakness and ulnar neuropathy. When revision surgery becomes necessary, bone augmentation techniques provide a reasonable outcome.

Extensor Mechanism Rupture after Total Elbow Arthroplasty for the Treatment of a Distal Humerus Non-Union

Introduction Total elbow arthroplasty is an available option for the treatment of many pathologies of the elbow. Apart from the classic indication in rheumatoid arthritis, new indications have arisen in fractures and non-unions of the distal part of the humerus. Many complications have been described with the use of this technique. Extensor mechanism rupture is one of them. Case report We present the case of a 61-year-old woman with a nonunited comminuted distal humerus fracture in a severely affected rheumatoid elbow who was treated with a Coonrad-Morrey semiconstrained total elbow arthroplasty. One month after the operation she developed a palpable ossification in distal triceps which was extirpated. Some months later she presented an extensor mechanism rupture which was surgically treated using a direct suture. Conclusions In selected cases, the use of total elbow prosthesis is related to good results. A correct indication and a meticulous surgical technique are essential in order to obtain satisfactory results and to minimise the risk of complications.

Post-traumatic distal humerus non-union

The objective of this paper is to evaluate the long-term functional results achieved after open reduction and internal fixation of 24 distal humerus non-unions. Non-unions were extra-articular-extracapsular (11 cases), extra-articular-intracapsular (8 cases) and intra-articular (5 cases). Preoperative elbow range of motion averaged 45 degrees. Time between original trauma and revision surgery averaged 14 months. Stabilisation methods varied according to type and location of the non-union. Follow-up averaged 46 months (range: 18-108). Elbow range of motion at last examination averaged 98 degrees . Flexion averaged 110 degrees and extension loss averaged 17 degrees . The disabilities of the arm, shoulder and hand (DASH) score averaged 16 points. Secondary transposition of the ulnar nerve was necessary in three cases. Sixteen patients reported no pain at last examination, seven had mild pain and one had moderate pain. Distal humerus non-unions present different characteristics; consequently, surgical treatment must be individualised for each patient. Even though they are demanding procedures, bony union and good long-term functional results were achieved.

Ectopic Ossification of the Triceps Muscle After Application of Bone Morphogenetic Protein-7 to the Distal Humerus for Recalcitrant Nonunion: A Case Report

We report a case of triceps muscle ectopic ossification and resultant elbow stiffness after application of recombinant human bone morphogenetic protein to a distal humerus nonunion site. We recommend caution when using this product in the upper extremity in regions where there is close approximation of soft tissue to bone and where loss of motion would be problematic.

Surgical Approach to the Posttraumatic Stiff Elbow

ABSTRACT Posttraumatic elbow stiffness results from articular and extraarticular sources about the ulnohumeral, radiocapitellar, and proximal radioulnar joints. The underlying pathoanatomy is often complex, making a simple stiff elbow a relatively uncommon entity. Elbow release, or arthrolysis, removes the offending structures while maintaining elbow stability and the integrity of the crossing neurovascular structures. The procedure may be accomplished through deep medial or lateral muscular intervals depending on the anatomy and the location of any concomitant problems such as ulnar nerve dysfunction, heterotopic ossification, distal humerus nonunion, and posttraumatic arthritis, which need to be addressed. Results are generally favorable but do vary depending upon the initial injury, preoperative motion, presence of heterotopic ossification, and etiologic factors such as brain injury. Even attempts to surgically mobilize the completely ankylosed elbow are frequently worthwhile.

The treatment of nonunion of the distal humerus by means of a transcondylar rod: A report of 3 cases

The treatment of nonunion of the distal humerus by means of a transcondylar rod: A report of 3 cases

The management of complex distal humerus nonunion in the elderly by elbow capsulectomy, triple plating, and ulnar nerve neurolysis

Six elderly patients (average age, 68 years) were treated for a complex, low supracondylar nonunion of the humerus. Each nonunion had in common an associated ulnar neuropathy, extensive periarticular fibrosis, a low synovial nonunion, and osteopenic bone. The surgical approach included ulnar nerve neurolysis, complete elbow capsulectomy, three strategically placed plates, and autogenous iliac crest bone graft. All the nonunions healed and all six patients regained ulnar nerve function. The average arc of elbow motion was 102°, with an average flexion of 122° and a flexion contracture of 19°. Radiographic follow-up revealed only one case with a focal area of avascular necrosis involving a previously ununited intraarticular fracture of the trochlea.