Humeral Nonunion Research Articles

Linked Elbow Replacement: A Salvage Procedure for Distal Humeral Nonunion

Nonunion is a challenging and not uncommon complication of distal humeral fractures. Our long-term experience with linked semiconstrained total elbow arthroplasty as a salvage procedure for patients with distal humeral nonunion not amenable to internal fixation was investigated. Ninety-one consecutive patients (ninety-two elbows) underwent total elbow arthroplasty for the treatment of a distal humeral nonunion, and the results were reviewed at a mean of 6.5 years postoperatively. Patients' charts and anteroposterior and lateral radiographs made prior to and immediately after the joint replacement and at the time of the latest follow-up were reviewed to identify intraoperative and postoperative complications, and radiographic evidence of loosening or bushing wear. The outcome measures consisted of prosthetic survival, with implant removal as the end point for failure, and the Mayo Elbow Performance Score (MEPS). At the time of the most recent follow-up, joint stability had been initially restored in all patients, including nine who had had a grossly flailed elbow. Sixty-seven (74%) of the patients had no pain or mild pain at the time of the latest follow-up, whereas seventy-nine patients (87%) had had moderate or severe pain prior to the surgery. While 85% (seventy-seven) of the ninety-one patients rated the outcome as better or much better, twenty patients (22%) had a fair or poor MEPS. A total of forty-four complications occurred in forty elbows, and there were thirty-two reoperations, twenty-three of which involved implant revision or removal. Factors that increased the risk of implant failure were a patient age of less than sixty-five years, two or more prior surgical procedures, and a history of infection. The rate of prosthetic survival without removal or revision for any reason was 96% at two years, 82% at five years, and 65% at both ten and fifteen years. Linked semiconstrained total elbow arthroplasty is a salvage procedure that can provide pain relief and restore motion and function in patients with a distal humeral nonunion that is not amenable to internal fixation. Substantial risk factors for failure include an age of less than sixty-five years, multiple previous surgical procedures, and any history of infection.

Interlocking intramedullary nailing for nonunion of the proximal humerus with the Straight Nail System

Nonunion of the proximal humerus is a challenging problem. Since 1996, we have performed interlocking intramedullary nailing for the treatment of proximal humeral nonunions with the Straight Nail System and bone grafting. The objective of this study was to investigate the clinical outcomes of this procedure in patients with proximal humeral nonunion. We investigated 14 consecutive patients (mean age, 74.3 +/- 8.7 years). One patient was excluded because of associated brachial plexus palsy. All but 2 were initially treated conservatively. Range-of-motion exercises were started 1 week after the operation. The mean follow-up period was 37.8 months. Union was achieved in all cases without any evidence of malunion. All patients had improved range of motion of the shoulder and were satisfied with the surgical results. Mean flexion of the shoulder was 122 degrees +/- 14 degrees, and mean external rotation was 35 degrees +/- 10 degrees. Interlocking intramedullary nailing with the Straight Nail System and bone grafting offered a successful method of stable internal fixation in these complex proximal humeral nonunion cases.

Callus distraction for humeral nonunion with bone loss and limb shortening caused by chronic osteomyelitis

Nonunion of the humerus with bone loss and shortening due to osteomyelitis is rare but difficult to treat. We describe our experience with a callus distraction technique using a monolateral external fixator for the treatment of this condition. Between October 1994 and January 2004, 11 patients were treated. There were seven males and four females, with a mean age of 14 years (10 to 17). The mean bone loss was 1.9 cm (1 to 2.7) and the mean length discrepancy in the upper limb was 5.6 cm (3.5 to 8.0). The mean follow-up was for 106 months (54 to 166). The mean external fixation index was 34.8 days/cm (29.8 to 40.5). The mean lengthening was 9.5 cm (5.5 to 13.4). There were seven excellent results, three good and one poor. There were nine excellent functional results and two good. The treatment of humeral nonunion with bone loss and shortening due to osteomyelitis by callus distraction is a safe and effective means of improving function and cosmesis.

Reverse Shoulder Arthroplasty for the Treatment of Rotator Cuff Deficiency

Early designs of reverse shoulder arthroplasty components for the treatment of glenohumeral arthritis associated with severe rotator cuff deficiency in some cases have been associated with mechanical failure. The purpose of this study was to perform a prospective outcomes study of reverse shoulder arthroplasty performed with use of 5.0-mm peripheral locking screws for baseplate fixation and a lateralized center of rotation for the treatment of a rotator cuff deficiency. From February 2004 to March 2005, 112 patients (114 shoulders) were treated with a reverse shoulder arthroplasty as part of a United States Food and Drug Administration Investigational Device Exemption study. Ninety-four patients (ninety-six shoulders) were available for a minimum follow-up of two years. Of the ninety-six shoulders, thirty-seven had a primary rotator cuff deficiency, thirty-three had a previous rotator cuff operation, twenty-three had a previous arthroplasty, and three had a proximal humeral nonunion. The patients were prospectively followed clinically (the American Shoulder and Elbow Surgeons [ASES] score, the Simple Shoulder Test [SST], and self-reported satisfaction) and radiographically (mechanical failure, loosening, and notching). Patients were videotaped while performing a standard active range-of-motion protocol before and after treatment. These videos were then analyzed in a blinded fashion by three independent observers using a digital goniometer. At two years, the average total ASES scores had improved from 30 preoperatively to 77.6; the average ASES pain scores, from 15 to 41.6; and the average SST scores, from 1.8 to 6.8 (p < 0.0001 for all). Blinded analysis of range of motion showed that average abduction improved from 61 degrees preoperatively to 109.5 degrees (p < 0.0001); average flexion, from 63.5 degrees to 118 degrees (p < 0.0001); and average external rotation, from 13.4 degrees to 28.2 degrees (p < 0.0001). The patients rated the outcome as excellent in fifty-three shoulders (55%), good in twenty-six (27%), satisfactory in eleven (12%), and unsatisfactory in six (6%). There was no evidence of mechanical failure of the baseplate or scapular notching in any of the patients. Six of the ninety-four patients in this study had a complication. Recent advances in reverse shoulder arthroplasty have allowed for improvement in patient outcomes while minimizing early mechanical failure and scapular notching and decreasing the overall complication rate at short-term follow-up.

Nonunions of the Proximal Humerus: Their Prevalence and Functional Outcome

: We present an analysis of the prevalence of proximal humeral nonunions and an assessment of their functional outcome. : The results of a study of 11 proximal humeral nonunions taken from a previous prospective study of 1,027 consecutive proximal humeral fractures were analyzed to determine the demography of the patient population, the Constant and Neer scores at 6 weeks, 13 weeks, 26 weeks, and 1 year and the functional outcome of the patients. All patients had been followed for 1 year and standard anteroposterior and modified axial X-rays taken at each assessment. The possible factors associated with proximal nonunion were studied. : The prevalence of proximal humeral nonunion is 1.1%, although it rises to about 8% if metaphyseal comminution is present and 10% if there is between 33% and 100% translation of the surgical neck. The effect of nonunion on function is considerable, even as early as 6 weeks after fracture. Our results show a deterioration of overall glenohumeral function after 6 months compared with patients whose fractures unite. Return to routine activities of daily living is markedly slower in the presence of a nonunion. The nonunions occurred in older patients but the age difference was not statistically significant. : Our results show that nonunion after nonoperative treatment of proximal humeral fractures is much less than has previously been reported and they suggest that age, metaphyseal comminution and fracture displacement are all factors in the development of nonunion. They also indicate that if operative treatment is required for proximal humeral nonunion it should not be delayed beyond 6 months after fracture and ideally should be performed as soon as the presence of a nonunion has become established this frequently being about 3 months after fracture.

Reconstruction of posttraumatic bone defects of the humerus with vascularized fibular graft

Humeral nonunions still present a challenge to the orthopedic surgeon. Many methods of treating recalcitrant, posttraumatic humeral shaft nonunions have been described, with varying degrees of success. The present report reviews our experience with the use of vascularized fibular grafting for the treatment of large humeral defects. We treated 13 patients, with an average length of the humeral defect of 10.5 cm. Nine patients healed primarily, 3 required additional bone grafting, and 1 had a second fibular transplant. The mean period to radiographic bone union was 6 months. Only 5 patients regained full range of motion of the shoulder and elbow. The vascularized fibular graft is a reliable reconstructive procedure for recalcitrant pseudoarthrosis of the humerus in which the bony gap is greater than 6 to 7 cm, especially when traditional procedures have not provided the expected result.

Recalcitrant Distal Humeral and Proximal Forearm Nonunion: Salvage Using an Extended Pedicled Radial Forearm Osseous Flap

Recalcitrant Distal Humeral and Proximal Forearm Nonunion: Salvage Using an Extended Pedicled Radial Forearm Osseous Flap

Extracorporeal shock wave treatment of humeral nonunion: a case report

Fracture of the humerus represents a common problem among the young and elderly populations. Although humerus fractures usually heal uneventfully, nonunions can sometimes occur. We present a case of humeral nonunion managed with shock wave therapy in the outpatient setting. A 62-year-old woman with a closed comminuted fracture of the proximal third of the humerus came to our attention 6 months after the trauma with a hypertrophic nonunion. Radiographs showed a hypertrophic callus with a fracture gap of 4 mm. We performed ten shock wave treatments in the outpatient department, with an interval of 60 days between each single treatment. Each session consisted of 2000 impulses at 0.86 mJ/mm2 applied in two planes. No anesthesia was given during the treatment. The patient received a sling to support the treated arm during the first days following each treatment. Follow-up assessment by radiographic and physical examination, performed after 4 weeks and at 3, 6, 12, 18 and 24 months, showed complete bony union and cortical bridging, achieved at the end of the treatment. We believe that this method is a safe and effective alternative to surgery for the treatment of chronic hypertrophic nonunions. Moreover, in case such treatment is unsuccessful, subsequent surgery is not precluded.

Ilizarov Treatment of Infected Nonunions of the Distal Humerus After Failure of Internal Fixation: An Outcomes Study

To report the functional outcomes of Ilizarov treatment of infected nonunion of the distal humerus. Prospective case series. Tertiary referral center. Between July 1998 and August 2003, 6 consecutive patients (age 33 to 73 years) were referred to us with an infected nonunion of the distal humerus following failure of open reduction and internal fixation. The average time from initial injury to presentation with the nonunion was 27 months (range, 6 to 99 months). The average number of prior surgeries was 2.8 (range, 1 to 4). Hardware removal, ulnar nerve neurolysis, 1 stage debridement, autogenous bone grafting, and application of an Ilizarov external fixator with acute compression in the operating room followed by slow gradual compression (0.25-0.50 mm per day) for several weeks postoperatively. Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire; SF-12 Physical Component Scale (PCS); Brief Pain Inventory; quality-adjusted life years. All patients attained bony union. One patient refractured 3 weeks after removal of the external fixator following a fall and ultimately underwent total elbow arthroplasty. At an average follow-up of 4.1 years (range, 2 to 7 years), none of the remaining 5 patients had undergone any additional surgery on their arm and all were free of infection. For these 5 patients, significant improvements were seen in standardized DASH scores (42% initially to 78% at follow-up, P = 0.017), worst pain intensity ratings (5.4 initially to 0.8 at follow-up, P = 0.007), and SF-12 PCS scores (37 initially to 44 at follow-up, P = 0.041). On average, the pretreatment to posttreatment improvement was equivalent to 3.8 quality-adjusted life years. Ilizarov treatment of infected distal humeral nonunions that have failed internal fixation restores function, decreases pain, and improves quality of life. The Ilizarov method should be considered a primary treatment option for this disabling and difficult clinical problem.

The use of recombinant bone morphogenetic protein 7 (OP-1) in the management of humeral non-union

The use of recombinant bone morphogenetic protein 7 (OP-1) in the management of humeral non-union

Exchange Nailing of Ununited Fractures

Exchange nailing is most appropriate for a nonunion without substantial bone loss. There is no clear consensus regarding the use of exchange nailing in the presence of active, purulent infection. The exchange nail should be at least 1 mm larger in diameter than the nail being removed, and it has been recommended that it be up to 4 mm larger when the nail being removed was greatly undersized. Canal reaming should progress until osseous tissue is observed in the reaming flutes. Exchange nailing is an excellent choice for aseptic nonunions of noncomminuted diaphyseal femoral fractures, with union rates reported to range from 72% to 100%. On the basis of the available literature, exchange nailing cannot be recommended for distal femoral nonunions at this time. Exchange nailing is an excellent choice for aseptic nonunions of noncomminuted diaphyseal tibial fractures, with union rates reported to range from 76% to 96%. On the basis of the available literature, exchange nailing is generally not indicated for humeral nonunions.

Surgical treatment of complex humeral nonunion

目的 探讨肱骨骨不连的手术治疗方法及疗效.方法 1998年12月～2005年5月共收治肱骨骨不连患者25例,均为肱骨骨折内固定术后发生骨不连,其中3例并发骨髓炎,6例合并不同程度肱骨骨缺损,骨缺损长度为3～6 cm.骨不连病程8个月～5年.15例行吻合血管游离腓骨移植,10例采用加压交锁髓内针进行肱骨固定并辅以自体骨植骨.结果 术后25例均得到随访,时间6个月～6年2个月.吻合血管游离腓骨移植组中移植的腓骨段均与肱骨干形成骨性愈合,平均骨性愈合时间为3.1个月;交锁髓内针组平均骨愈合时间为3.8个月.按Crates和Whittle肩肘关节功能评价标准,腓骨移植组:优9例,良4例,差2例;交锁髓内针组:优5例,良3例,差2例.结论 应用加压交锁髓内针辅以自体骨移植对硬化性肱骨骨不连是一种有效的外科治疗方法;对合并骨髓炎、大段骨缺损及严重骨质疏松的肱骨骨不连,采用吻合血管游离腓骨移植可一期进行修复与重建。

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

PubMed and Ovid Medline were searched to investigate the role of intramedullary nailing in the treatment of diaphyseal humeral non-union. Of 474 abstracts, 9 retrieved articles fulfilled our inclusion criteria and described management in 166 cases of humeral shaft non-union using several types of intramedullary nails. Union ranged from 40 to 100%; part of the variation could be explained by the quality index of the selected articles. Exchange nailing alone was not effective. Exposure of the fracture site and use of bone grafting were key to successful treatment. The total incidence of severe complications, including radial nerve damage, was very low. Thus, intramedullary nailing in the treatment of humeral shaft non-unions can lead to successful outcomes when associated with autologous bone grafting.

The Olecranon Osteotomy: A Six-year Experience in the Treatment of Intraarticular Fractures of the Distal Humerus

The transolecranon exposure for distal humerus fractures is a suggested technique for improving articular visualization, allowing accurate reduction. Significant osteotomy complications such as nonunion and implant prominence have prompted recommendations for alternate exposures. The purposes of this study are to present the techniques and complications of the olecranon osteotomy for the management of distal humerus fractures, and to evaluate the adequacy of distal humeral and olecranon articular reductions. Retrospective review. Urban level-1 University trauma center. One hundred fourteen skeletally mature AO/OTA type 13-C distal humerus fractures were identified from the orthopedic trauma database and formed the study group. Seventy fractures (61%), including 42 open injuries, were managed using an intraarticular, chevron-shaped olecranon osteotomy. Osteotomy fixations were performed with an intramedullary screw and supplemental dorsal ulnar wiring, or plate stabilization. In the remaining 44 fractures (39%), soft-tissue mobilizing exposures were performed. Patient records and radiographs were reviewed to determine injury and operative characteristics, complications, and adequacy of articular reductions. Patient interviews were conducted by telephone to identify any subsequent surgical procedures. The proportion of osteotomies performed increased as fracture complexity increased (P<0.001). Sixty-seven of 70 patients had adequate follow-up to determine osteotomy union. All osteotomies united. There was 1 delayed union. Sixty-one of 70 patients had adequate follow-up to determine complications associated with ulnar fixations. Five of these patients (8%) underwent elective removal of symptomatic osteotomy fixations. An additional 13 patients had olecranon implants removed in conjunction with other surgical procedures (11 elbow contracture releases, 1 humeral nonunion repair, and 1 chronic draining sinus excision). Symptomatic ulnar fixations in this group could not be reliably ascertained, but may have been present. A total of 18 of 61 patients (29.5%), therefore, had proximal ulna fixations removed. All patients treated using an olecranon osteotomy exposure demonstrated satisfactory radiographic distal humeral articular reductions. Two osteotomies required early revision osteosynthesis secondary to loss of osteotomy reduction. In this study, no osteotomy nonunions were encountered in 67 patients, more than half of which were open injuries. Regardless of which type of fixation is used to secure the osteotomy, secure stabilization must be obtained. Isolated symptomatic olecranon fixation requiring removal occurred in approximately 8% of patients. Although not necessary for all fractures of the distal humerus, the olecranon osteotomy can be useful in the visualization of the complex articular injuries, allowing accurate articular reduction.

Failure of Reamed Nailing in Humeral Non-Union: An Analysis of 26 Patients

Failure of Reamed Nailing in Humeral Non-Union: An Analysis of 26 Patients

Recalcitrant Nonunion of the Distal Humerus

We sought to determine whether open reduction and internal fixation in combination with free vascularized bone grafting and elbow contracture release is an effective treatment for patients with recalcitrant distal humeral nonunions with segmental bone loss. In addition, we wondered whether this treatment strategy has an acceptable complication rate. Five patients, with an average age of 48 years, form the basis of our study. An average of 3.4 surgical procedures were done before the vascularized bone grafting for treatment of nonunion. The average time from injury until the index vascularized graft was 37.2 months. All patients had elbow pain at rest and had severe functional limitations related to the nonunion. There was segmental bone loss averaging 3.2 cm at the time of vascularized grafting. Four of the five patients with nonunions had clinical and radiographic union at the latest followup, and one patient required a total elbow arthroplasty because of articular collapse after the vascularized grafting procedure. The average time from vascularized grafting until bony union was 4.5 months (range, 3-6 months). There were no other complications in this patient group. Free vascularized bone grafting is a treatment alternative for distal humeral fracture nonunion, especially in younger patients who have nonunions with segmental bone loss that are refractory to conventional fixation and bone grafting techniques. Therapeutic study, Level IV (case series--no, or historical, control group). See the Guidelines for Authors for a complete description of levels of evidence.

Treatment of Humeral Nonunions with Allograft, Demineralized Bone Matrix, and Plate Fixation

Objective: Due to the risks inherent in autologous iliac crest bone graft harvest, the results of patients with humeral nonunions who were treated with allograft, demineralized bone matrix, and plate fixation were evaluated. Design: Retrospective review of patients who underwent operative treatment of humeral nonunions with allograft, demineralized bone matrix, and plate fixation. Setting: University medical center. Patients: Ten patients with nonunions of the humerus who were treated with open reduction and internal fixation with bone graft with a minimum of 2 years follow-up were included. The mean duration of the nonunion preoperatively was 24 months (range, 4-120 months). The patients had undergone an average of one (range, 0-3) previous surgery on the humerus. Intervention: Open reduction and internal fixation with plate and screw fixation and bone graft. All ten patients had bone grafting with cancellous allograft and demineralized bone matrix, while four of the ten also had intramedullary fibular allograft supplementing the fixation in cases of osteopenia or bone loss. Main Outcome Measures: Clinical and radiographic evidence of bone union. Medical records, operative reports, physical examination, and preoperative, postoperative, and follow-up radiographs were reviewed. Outcomes were assessed with the Disabilities of the Arm, Shoulder, and Hand Questionnaire (DASH) to evaluate subjective outcome. Results: At a mean follow-up of 33 months (range, 25-42 months; minimum, 2 years) 9 of the 10 nonunions (90 %) had healed. One patient required a second operation to gain union. The nonunion that failed to heal, in a patient with severe coronary artery disease and congestive heart failure, initially healed at 3 months but at 40 months postoperatively had refractured through the old nonunion site with loss of internal fixation after a fall at home. Patient outcomes evaluated with the DASH questionnaire demonstrated 3 excellent, 4 good, 2 fair, and 1 poor result at follow-up. All patients with healed fractures at follow-up had functional shoulder and elbow range of motion. Conclusions: These results show that allograft and demineralized bone matrix can be a useful adjunct to plate fixation in the treatment of humeral nonunions, even in patients who have had previous surgery.

Failure of reamed nailing in humeral non-union: an analysis of 26 patients

The use of an intramedullary nail in the treatment of humeral non-unions remains controversial. This study evaluated the treatment of humeral delayed and non-unions with reamed nailing and compression. In a retrospective analysis of prospectively gathered data from 26 cases all treated with the Telescopic Locking Nail (TLN), the healing rate after the first intervention for non-union was 58%. After one or more re-interventions combined with an external cancellous bone graft at some time during follow-up, 90% of the 21 patients with complete follow-up eventually healed after a mean of 22 months. A total of 49 procedures with a mean of 1.9 per patient were needed. After a mean follow-up of 65 (range 24-88) months, we conducted a study to assess the functional results in the shoulder and elbow. Twelve patients were suitable for inclusion. We used the Neer and Morrey score for shoulder and elbow function, respectively. For the Neer score the median was 91 points and for the Morrey score 94 points. The outcome suggests that simple reamed nailing of humeral non-union is insufficient. Reamed interlocked nailing is feasible, provided that the primary intervention for non-union is combined with an external cancellous bone graft.

Biomechanical and clinical effects of adding interfragmentary wiring to locked nailing for humeral nonunions.

The use of locked nailing for the treatment of humeral nonunions is threatened by the potential of initial instability which may result in residual fracture gap and motion and is detrimental to fracture healing. This study investigated the biomechanical and clinical effects of adding interfragmentary wiring to reduce the initial instability in the treatment of humeral nonunion. The biomechanical study compared the mechanical properties of 3 fixation methods: locked nail alone, with staple, and with interfragmentary wiring. Composite humeri were transected to simulate nonunion and were retrograde nailed. Nail-bone constructs were examined by non-destructive bending tests and destructive torsional tests. The initial instability, fixation stiffness and strength were measured and compared. The clinical study compared 21 nonunions treated by locked nailing alone and 30 nonunions treated by locked nailing with interfragmentary wiring. The indication for wiring was persistent nonunion gap or motion during operation. The union rate, time to union, functional recovery of the adjacent joints and the time for functional recovery were compared between the treatment groups. Biomechanically, in both bending and torsional tests, locked nailing with a staple or wiring resulted in significantly less initial instability than locked nailing alone. Test results for bending stiffness, torsional stiffness, or torsional strength did not differ significantly among the 3 fixation methods. In the clinical study, interfragmentary wiring had the advantage of providing tight nonunion compression, which was beneficial for nonunion healing and promoted early postoperative exercise. Patients treated with locked nailing with interfragmentary wiring had significantly shorter time to union and faster shoulder functional recovery (p < 0.05). Adding interfragmentary wiring was an effective and safe procedure in humeral nonunions treated with locked nailing.

Internal jugular deep venous thrombosis after surgical treatment of a humeral nonunion: a case report and review of the literature

i pper extremity deep venous thrombosis (DVT) is a are entity comprising approximately 1% to 2% of all ases of venous thromboses. Once thought to be a enign process, DVT in the axillary-subclavian system an lead to prolonged pain and swelling in many paients.13 Classically, upper extremity DVT is divided into rimary or effort thrombosis (Paget-Schroetter syndrome) nd secondary thrombosis. Primary causes are those nherent to the anatomic structures in the thoracic outlet r axillary region. Secondary causes include trauma, nfection, neoplasms, central venous catheters, and hyercoagulable states. Whereas primary thrombosis usully occurs in young active individuals, secondary thromosis can occur from any of the etiologic factors escribed above. Although subclavian and axillary vein hrombosis has been reported, we are unaware of a eported case of an internal jugular vein thrombosis after pper extremity fracture surgery.