Persistent Nonunion Research Articles

The use of recombinant morphogenic protein-2(rhBMP-2) in children undergoing revision surgery for persistent non-union.

The purpose of the study was to evaluate the safety and efficacy with the use of BMP-2 for treating persistent non-unions in children with underlying complex conditions. Between October 2006 and November 2010 in our unit, 15 patients were treated with rhBMP-2 to enhance bone union. There were nine females and six males with a mean age of 9.5 years (range 4–15) at time of surgery. Seventy-five per cent of the patients required revision of internal fixation with insertion of rhBMP-2 to the non-union site, and the reminder had freshening of the non-union site with rhBMP-2 application. Patients had undergone a mean of 2 (1–5) operations prior to implantation of rhBMP-2. All the patients in the study group were available for review with mean follow-up of 44 months (range 21–70). The mean time to union was 16 weeks (range 10–28 weeks). No adverse events related to BMP-2 application were noted in our study group. Healing occurred clinically and radiographically in 16 of the 17 sites. Our study demonstrates that BMP-2 enhances healing of the persistent non-unions without any adverse events

Addition of a Medial Locking Plate to an In Situ Lateral Locking Plate Results in Healing of Distal Femoral Nonunions.

Nonunion of the distal femur after lateral plating is associated with axial malalignment, chronic pain, loss of ambulatory function, and decreased knee ROM. The addition of a medial locking plate with autogenous bone grafting can provide greater stability to allow bone healing and may be used to achieve union in these challenging cases. We wished to determine (1) the proportion of patients who achieve radiographic signs of osseous union for distal femoral nonunions with an in situ lateral plate after treatment with addition of a medial locking plate and autogenous bone grafting, and (2) the frequency and types of complications associated with this treatment. Between 2007 and 2013, we treated 22 patients for 23 distal femoral nonunions, defined as an unhealed fracture with no radiographic signs of osseous union at a mean of 16 months (SD, 13 months) after injury. During that time, we used a treatment algorithm consisting of treatment in one or two stages. The single-stage procedure performed in 16 aseptic nonunions with a stable lateral plate involved addition of a medial locking plate and autogenous bone graft. A two-stage treatment performed in seven nonunions with lateral plate failure involved placement of a new lateral locking plate followed by addition of a medial locking plate with autogenous bone graft at least 2 months after the first procedure. Of the 22 patients treated, 20 had a median followup of 18 months (SD, 6-94 months). We defined osseous union by bridging bone on three of four cortices with absence of a radiolucent line or more than 25% cross-sectional area of bridging bone via CT. Twenty of the 21 nonunions attained radiographic signs of osseous union by 12 months. Six of the 20 patients experienced complications: one patient had a persistent nonunion; four patients underwent removal of symptomatic hardware; and one patient experienced skin breakdown at the bone graft harvest site. A very high proportion of patients achieve union when using medial locking plates to treat distal femoral nonunions after lateral plating of the original injury. Addition of bone graft, staged reconstruction, and revision of the initial lateral plate is indicated when the nonunion is associated with fatigue failure of the initial lateral plate. Level IV, therapeutic study.

The use of a dorsal capsular-based flap graft for scaphoid pseudarthrosis – long-term functional results

Introduction The scaphoid has a very tenuous blood supply that limits its capacity to recover from injury. A fracture of the scaphoid therefore presents an important risk of delayed union, pseudarthrosis and avascular necrosis. The fact that this type of fracture is many times missed on the first observation further increases the risk of pseudarthrosis. The use of pedicle grafts has the ability to fill the nonunion defect with new bone, bringing new osteoblasts and blood supply to the injury site. In 2006, Sotereanos described a capsular-based vascularized distal radius graft for the treatment of scaphoid pseudarthrosis that was readily available, close to the pseudarthrosis, required minimal rotation and did not need the dissection of a pedicle. The goal of our study was to evaluate the long-term results of the treatment of pseudarthrosis of the scaphoid using a capsular-based vascularized distal radius graft (as described by Sotereanos et al., 2006). Materials and methods Ten patients who underwent this procedure were identified, and the average follow-up time was 4,5 years (range 2–6 years). All but one patient were male, with an average age of 30 years (range 18–45). In 8 patients the non-dominant limb was the one affected. A dorsal approach was used, and the technique was according to Sotereanos et al., 2006. Results There were no postoperative complications such as infection or hardware migration. Of the 10 patients, 8 evolved to union, as determined by x ray and clinical examination. None of the patients was forced to abandon their professional activity after surgery, even though 25% required some type of adaptation necessary at their workplace. The average functional capacity was, according to the Mayo Wrist Score, of 82 points (range 65–90), corresponding to a “Good” function. The average disability according to the QuickDASH was 12.6 (range 0–45.5). The two patients with persistent symptomatic nonunions declined further surgical treatment and presented with the worst outcomes. All patients had decreased ROM after surgery. Discussion The union rate after surgery in this series is in line with previously published studies about this technique. No other published studies present long-term functional studies with this technique. Conclusion This technique is safe, easy and reliable for the treatment of scaphoid nonunions. Patients presented a good functional result at a mean follow-up of 4.5 years.

Radiation-associated Fractures

High-dose radiation is injurious to bone and is a known risk factor for the development of late fracture. Management of radiationinduced fractures is generally thought to be difficult, with prolonged healing times and a high nonunion rate. There is a relative paucity of literature to guide treatment. Fractures of the long bones typically should be managed with intramedullary nailing. A low threshold should exist for supplemental bone grafting, and a vascularized fibula graft should be considered for persistent nonunion. To prevent refracture, fixation should be left in situ indefinitely. Resection of the fracture site and reconstruction with an oncologic endoprosthesis is an effective salvage procedure. Periarticular fractures should be treated with joint arthroplasty, which allows early mobilization and avoids prolonged healing times. Fractures of expendable bones, primarily the clavicle, typically should be managed with debridement or resection.

The treatment of atrophic, recalcitrant long-bone nonunion in the upper extremity with human recombinant bone morphogenetic protein-7 (rhBMP-7) and plate fixation: A retrospective review

IntroductionRecombinant Human Bone Morphogenetic Protein-7 (rhBMP-7) has been shown to promote fracture healing in both clinical studies and basic science models, however, there is little information from large-scale studies of its use for human nonunion. The purpose of this study was to determine the safety and efficacy of rhBMP-7 in the treatment of atrophic human long-bone nonunions in the upper extremity. Patients and methodsThis was a single center, retrospective, longitudinal cohort study of patients treated with compression plating and the application of rhBMP-7 in isolation to a long-bone nonunion. Patients over sixteen years of age with an atrophic, aseptic nonunion of a humerus, radius, ulna or clavicle were eligible for inclusion. ResultsWe identified seventy eligible patients who were treated with rhBMP-7 for a long-bone nonunion between July 1997 and April 2012. The mean age of the patients at the time of treatment with rhBMP-7 was 50.7 years (range, 20-92 years). Five patients were lost to follow-up prior to definitive clinical or radiographic union. During the one-year post-operative period fifty-six patients had achieved union and two patients developed a stable fibrous union after the index procedure. Two patients had early implant failure and five patients had persistent nonunion. Thus, the union rate following initial surgery was 89% (58/65) and four of the five nonunion patients went on to heal following revision open reduction and internal fixation. ConclusionWe found that the application of rhBMP-7 for upper extremity nonunion was an effective method (89% union rate) of treating this challenging pathology. Additionally, if not initially successful, further reconstruction was not compromised by rhBMP-7 use.

Mechanobiology in the management of mobile atrophic and oligotrophic tibial nonunions

BackgroundRecent research indicates that atrophic nonunions are biologically active and may heal in the optimal biomechanical environment. MethodsThirty-three patients with mobile atrophic and oligotrophic tibial nonunions were treated with circular external fixation and functional rehabilitation. Seven patients required autogenous bone graft procedures. ResultsBony union was achieved after the initial surgery in 31/33 (93.9%) tibias. Two persistent nonunions were successfully treated with repeat circular external fixation without bone graft. This resulted in final bony union in 33/33 (100%) patients. ConclusionMechanobiological stimulation of tibial nonunions can produce union even if the biological activity appears to be low.

Management of tibial non-unions according to a novel treatment algorithm.

Tibial non-unions represent a spectrum of conditions that are challenging to treat. The optimal management remains unclear despite the frequency with which these diagnoses are encountered. The aim of this study was to determine the outcome of tibial non-unions managed according to a novel tibial non-union treatment algorithm. One hundred and eighteen consecutive patients with 122 uninfected tibial non-unions were treated according to our proposed tibial non-union treatment algorithm. All patients were followed-up clinically and radiologically for a minimum of six months after external fixator removal. Four patients were excluded because they did not complete the intended treatment process. The final study population consisted of 94 men and 24 women with a mean age of 34 years. Sixty-seven non-unions were stiff hypertrophic, 32 mobile atrophic, 16 mobile oligotrophic and one true pseudoarthrosis. Six non-unions were classified as type B1 defect non-unions. Bony union was achieved after the initial surgery in 113/122 (92.6%) tibias. Nine patients had failure of treatment. Seven persistent non-unions were successfully retreated according to the tibial non-union treatment algorithm. This resulted in final bony union in 120/122 (98.3%) tibias. The proposed tibial non-union treatment algorithm appears to produce high union rates across a diverse group of tibial non-unions. Tibial non-unions however, remain difficult to treat and should be referred to specialist units where advanced reconstructive techniques are practiced on a regular basis.

Hexapod external fixator closed distraction in the management of stiff hypertrophic tibial nonunions.

Tibial nonunion represents a spectrum of conditions which are challenging to treat, and optimal management remains unclear despite its high rate of incidence. We present 44 consecutive patients with 46 stiff tibial nonunions, treated with hexapod external fixators and distraction to achieve union and gradual deformity correction. There were 31 men and 13 women with a mean age of 35 years (18 to 68) and a mean follow-up of 12 months (6 to 40). No tibial osteotomies or bone graft procedures were performed. Bony union was achieved after the initial surgery in 41 (89.1%) tibias. Four persistent nonunions united after repeat treatment with closed hexapod distraction, resulting in bony union in 45 (97.8%) patients. The mean time to union was 23 weeks (11 to 49). Leg-length was restored to within 1 cm of the contralateral side in all tibias. Mechanical alignment was restored to within 5° of normal in 42 (91.3%) tibias. Closed distraction of stiff tibial nonunions can predictably lead to union without further surgery or bone graft. In addition to generating the required distraction to achieve union, hexapod circular external fixators can accurately correct concurrent deformities and limb-length discrepancies.

Dorsal Plating of Unstable Scaphoid Fractures and Nonunions.

Achieving stable fixation of displaced acute and chronic nonunited scaphoid fractures continues to be a challenge for the treating surgeon. The threaded compression screw has been the mainstay of treatment of these fractures for the last 3 decades; however, persistent nonunion after screw fixation has prompted development of new techniques. Recent results of volar buttress plating have been promising. We describe a novel technique of dorsal scaphoid plating. In contrast to volar plating, the dorsal plate is biomechanically more favorable as it utilizes the tension side of the scaphoid bone for dynamic compression. Dorsal scaphoid plating provides a more stable construct than the traditional Herbert screw and mitigates the need for vascular or corticocancellous bone grafting in most cases.

Factors Associated with Re-operation after Surgery for Scaphoid Nonunion: Level 4 Evidence

Hypothesis: To determine the rate of unplanned reoperation after surgery for scaphoid nonunion, the reasons for unplanned reoperation, and factors associated with unplanned reoperation. Methods: Using an institutional database, we identified 190 patients that had surgery for a scaphoid non-union from 2000 to 2013. There were 172men and 18 women with an average age of 26 11 years (Range, 16 to 84 years). The result of the surgerywas categorized as follows: no unplanned reoperation and healed fracture; unplanned reoperation for any reason; unplanned repeat surgery recommended but not done; and unknown status. We tested age, sex, affected side, interval between injury and operation, operation duration, fracture location, dorsal intercalated segment instability, surgeonperception of avascular necrosis of proximal pole, fixation device, type of bone graft, surgeon, and operative approach for association with unplanned repeat surgery. Results: After the index operation to treat scaphoid non-union in 190 wrists, 100 (53%) had no unplanned reoperation and healed; 39 (21%) had an unplanned reoperation; in 34 (18%) unplanned repeat surgery was recommended but not done; and in 17 the status was unknown (9%). After all subsequent surgeries, 110 patients (58%) healed (10 after one or more subsequent surgeries), 49 (26%) had persistent nonunion, 5 (3%) had a salvage procedure (e.g. excision of the distal pole of the scaphoid), and the status of 26 patients was unknown (14%). The indication for surgery in all 73 patients who had unplanned reoperation or recommended unplanned reoperation was persistent nonunion. In bivariate and multivariable analysis, the only factor related to reoperation was Kirschner wire rather than compression screw fixation of the scaphoid. Summary Points: Persistent nonunion is common after surgery for scaphoid non-union. Surgeries for persistent nonunion is even less successful.

Salvage of failed osteosynthesis of an intracapsular fracture of the femoral neck using two cannulated compression screws and a vascularised iliac crest bone graft.

We evaluated the outcome of treatment of nonunion of an intracapsular fracture of the femoral neck in young patients using two cannulated screws and a vascularised bone graft. A total of 32 patients (15 women and 17 men, with a mean age of 36.5 years; 20 to 50) with failed internal fixation of an intracapsular fracture were included in the study. Following removal of the primary fixation, two cannulated compression screws were inserted with a vascularised iliac crest bone graft based on the ascending branch of the lateral femoral circumflex artery. At a mean follow-up of 6.8 years (4 to 10), union was achieved in 27 hips (84%). A total of five patients with a mean age of 40.5 years (35 to 50) had a persistent nonunion and underwent total hip arthroplasty as also did two patients whose fracture united but who developed osteonecrosis of the femoral head two years post-operatively. Statistical analysis showed that younger patients achieved earlier and more reliable union (p < 0.001). The functional outcome, as assessed by the Harris Hip score, was better in patients aged < 45 years compared with those aged > 45 years (p < 0.001). These findings suggest that further fixation using two cannulated compression screws and a vascularised iliac crest bone graft is an effective salvage treatment in patients aged < 45 years, in whom osteosynthesis of a displaced intracapsular fractures of the femoral neck has failed.

Bone Marrow Transplantation Followed by Growth Factors Injection in a Patient with Femoral Neck Nonunion: A Case Report

Background: Most fractures of femoral neck typically heal, but a significant proportion of fractures fail to heal, resulting in aseptic bone necrosis, delayed union or persistent nonunion. Specially, nonunion of fractured neck of femur in young adults is a serious problem. Some preclinical evidences show the therapeutic potential of autologous bone marrow for bone fracture healing; however, clinical outcome following of transplantation of bone marrow cells in patients with femoral neck nonunion has never been reported. Case description: We describe a 57-year-old male who had a femoral neck nonunion and received autologous bone marrow transplantation, followed by growth factors injection. The primary endpoint of this study is to achieve radiological fracture healing (union) by evaluating anteroposterior images taken after and on 6th month, following bone marrow therapy and no serious adverse event occurred. Literature review: To our knowledge, this is the first case in the literature of nonunion of femoral neck fracture treated with percutaneous autologous bone marrow transplantation. Clinical relevance: This case suggests that autologous bone marrow transplantation, followed by plasma rich in growth factors (PRGF) could be considered as an exciting option to treat nonunion in femoral neck fracture.

Treatment of nonunited fractures of the proximal humerus using locked plate, synthetic and autogenous bone grafting

BackgroundNonunion following fracture of the proximal humerus is not uncommon, particularly in the elderly. Stable internal fixation is essential to obtain healing of a nonunited fracture of the proximal humerus.AimThis study aimed at evaluation of the results of open reduction and internal fixation of nonunited fractures of the proximal humerus using the locked plate, synthetic and autogenous bone graft.Patients and methodsTwelve patients diagnosed with nonunited fracture of the proximal third of the humerus were included in this study conducted between 2009 and 2011 in Suez Canal University. Eight patients were female and four were male. The mean age of the patients was 72.3 years (range, 65-80 years). The time between injury and surgery ranged from 6 to 12 months (mean 8.7 months). Three patients had undergone previous operations for persistent nonunion. The follow-up period lasted for 7-12 months, with a mean of 9.3 months. Radiographic evaluation was carried out with biplane radiographs taken at the time of the most recent follow-up evaluation, to determine the presence of bridging osseous trabeculae, which is suggestive of healing, as well as any loosening or failure of the fixation. The objective results were assessed on the basis of the modified scoring system of Constant and Murley. The subjective results were assessed on the basis of the score derived from the Disabilities of the Arm, Shoulder, and Hand Questionnaire.ResultsRadiological bone healing was documented in 11 of 12 patients. Objective and subjective assessments documented marked functional improvement in patients with healing fractures. The results were classified as good in 11 of 12 patients, and few complications were encountered.ConclusionLocked plate used in conjunction with synthetic and autogenous bone grafting is an excellent device for the treatment of proximal humerus nonunions with minimal complications.

Vascularized medial femoral condyle graft for management of scaphoid non-union.

The purpose of this study was to assess the results of the management of difficult scaphoid non-unions using a vascularized medial femoral condyle graft. We operated on 30 patients with necrosis of the proximal pole or with severe humpback deformity or who presented with persistent non-union despite previous surgery. Twenty-four cases in our series showed full consolidation and six cases showed persistent non-union. The free vascularized medial femoral condyle bone graft can provide not only structural support, but also a consistent and good blood supply that results in excellent rates of union. Level of evidence: IV.

The Reamer–Irrigator–Aspirator as a Device for Harvesting Bone Graft Compared With Iliac Crest Bone Graft

This study was performed to compare patient outcomes after Reamer-Irrigator-Aspirator (RIA)-harvested bone grafting with the current gold standard, either anterior or posterior iliac crest bone graft (ICBG). Prospective randomized controlled trial. Multicenter study at 3 geographically separate Level 1 trauma centers. One hundred thirty-three patients with nonunion or posttraumatic segmental bone defect requiring operative intervention. Patients were prospectively randomized to receive ICBG or RIA autograft. Supplemental internal fixation was performed per surgeon preference. Operative data included amount of graft, time of harvest, and associated surgical costs. The Short Musculoskeletal Functional Assessment and the Visual Analog Scale were used to document baseline and postoperative function and pain. Clinical and radiographic union was the defined end point; patients considered to have failed treatment if they either developed an infection requiring operative treatment or had a persistent nonunion of the grafted extremity. One hundred thirteen of the 133 enrolled patients were followed until union and included in the final analysis. Intraoperative data showed anterior ICBG to yield 20.7 ± 12.8 (5-60) cm of autograft with an average harvest time of 33.2 ± 16.2 minutes, posterior ICBG yielded 36.1 ± 21.3 (20-100) cm of autograft in 40.6 ± 11.2 minutes, and RIA yielded 37.7 ± 12.9 (5-90) cm in 29.4 ± 15.1 minutes. Anterior ICBG produced significantly less bone graft than either RIA or posterior ICBG (P < 0.001). The RIA harvest was completed in significantly less operative time compared with posterior ICBG (P = 0.005). At $738, the RIA setup was considerably more expensive than the ∼$100 cost of a bone graft tray; however, when compared with posterior ICBG, the longer operative time required for a posterior harvest came at an additional incremental cost of $990-1880, making RIA the less expensive option. Patients were followed for an average of 56.9 ± 42.1 (11-250) weeks. Forty-nine of 57 patients (86.0%) who received ICBG united in an average of 22.5 ± 13.2 weeks; 46 of 56 patients (82.1%) who received RIA healed in an average of 25.8 ± 17.0 weeks. Union rates and time to union were comparable between the 2 procedures. There was no difference in complications requiring reoperation for persistent nonunion or infection at the grafted site, nor there was any difference in donor-site complications. Postoperative follow-up showed that RIA patients had significantly lower donor-site pain scores throughout follow-up. When compared with autograft obtained from the iliac crest, autograft harvested using the RIA technique achieves similar union rates with significantly less donor-site pain. RIA also yields a greater volume of graft compared with anterior ICBG and has a shorter harvest time compared with posterior ICBG. For larger volume harvests, cost analysis favors using RIA. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Indices Affecting Outcome of Neglected Femoral Neck Fractures After Valgus Intertrochanteric Osteotomy

To evaluate preoperative neck resorption and postoperative valgus orientation as predictors of union and functional outcome after valgus intertrochanteric osteotomy for treatment of neglected femoral neck fractures and nonunions. Retrospective cohort study. Tertiary care center. Forty consecutive patients with neglected femoral neck fracture and nonunions were treated with valgus intertrochanteric osteotomy, and follow-up was available in 32 patients (average age, 43 years; range, 14-60 years; average nonunion duration, 6 ± 7 months; range, 1-36 months). Valgus intertrochanteric osteotomy. Clinical outcome was assessed with Harris hip score. Plain radiographs were evaluated for union, avascular necrosis, preoperative bone deficiency (neck resorption ratio), and postoperative femoral head fragment alignment (head-shaft angle). Follow-up at 5 ± 3 years (range, 2-12 years) after surgery showed union in 29 patients (91%), and Harris hip score was 82 ± 13 points (range, 63-100 points). The 3 patients with persistent nonunion at the neck of femur had neck resorption ratio <0.52. Increased postoperative head-shaft angle was associated with lower follow-up Harris hip score; postoperative valgus alignment >15 degrees compared with the contralateral side was associated with poor functional outcome. The presence of avascular necrosis did not affect the outcome. Valgus intertrochanteric osteotomy resulted in union and satisfactory functional outcome in most patients who had neglected femoral neck fractures and nonunions. Preoperative neck resorption ratio <0.5 was a risk factor for nonunion, and excessive valgus alignment was a risk factor for poor functional outcome after osteotomy. Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Neurofibromin deficiency-associated transcriptional dysregulation suggests a novel therapy for tibial pseudoarthrosis in NF1.

Neurofibromatosis type 1 (NF1) is an autosomal dominant disease caused by mutations in NF1. Among the earliest manifestations is tibial pseudoarthrosis and persistent nonunion after fracture. To further understand the pathogenesis of pseudoarthrosis and the underlying bone remodeling defect, pseudoarthrosis tissue and cells cultured from surgically resected pseudoarthrosis tissue from NF1 individuals were analyzed using whole-exome and whole-transcriptome sequencing as well as genomewide microarray analysis. Genomewide analysis identified multiple genetic mechanisms resulting in somatic biallelic NF1 inactivation; no other genes with recurring somatic mutations were identified. Gene expression profiling identified dysregulated pathways associated with neurofibromin deficiency, including phosphoinositide 3-kinase (PI3K) and mitogen-activated protein kinase (MAPK) signaling pathways. Unlike aggressive NF1-associated malignancies, tibial pseudoarthrosis tissue does not harbor a high frequency of somatic mutations in oncogenes or other tumor-suppressor genes, such as p53. However, gene expression profiling indicates that pseudoarthrosis tissue has a tumor-promoting transcriptional pattern, despite lacking tumorigenic somatic mutations. Significant overexpression of specific cancer-associated genes in pseudoarthrosis highlights a potential for receptor tyrosine kinase inhibitors to target neurofibromin-deficient pseudoarthrosis and promote proper bone remodeling and fracture healing.

Local Transplantation of Granulocyte Colony Stimulating Factor-Mobilized CD34+ Cells for Patients With Femoral and Tibial Nonunion: Pilot Clinical Trial

Most bone fractures typically heal, although a significant proportion (5%-10%) of fractures fail to heal, resulting in delayed union or persistent nonunion. Some preclinical evidence shows the therapeutic potential of peripheral blood CD34(+) cells, a hematopoietic/endothelial progenitor cell-enriched population, for bone fracture healing; however, clinical outcome following transplantation of CD34(+) cells in patients with fracture has never been reported. We report a phase I/IIa clinical trial regarding transplantation of autologous, granulocyte colony stimulating factor-mobilized CD34(+) cells with atelocollagen scaffold for patients with femoral or tibial fracture nonunion (n = 7). The primary endpoint of this study is radiological fracture healing (union) by evaluating anteroposterior and lateral views at week 12 following cell therapy. For the safety evaluation, incidence, severity, and outcome of all adverse events were recorded. Radiological fracture healing at week 12 was achieved in five of seven cases (71.4%), which was greater than the threshold (18.1%) predefined by the historical outcome of the standard of care. The interval between cell transplantation and union, the secondary endpoint, was 12.6 ± 5.4 weeks (range, 8-24 weeks) for clinical healing and 16.1 ± 10.2 weeks (range, 8-36 weeks) for radiological healing. Neither deaths nor life-threatening adverse events were observed during the 1-year follow-up after the cell therapy. These results suggest feasibility, safety, and potential effectiveness of CD34(+) cell therapy in patients with nonunion.

Scapulothoracic fusion: outcomes and complications

Scapulothoracic fusion (STF) may be an option to alleviate pain and restore function. The purpose of this study is to report the clinical outcome of patients who underwent STF for the treatment of painful scapular winging. From 1999 through 2008, 10 patients (12 shoulders) underwent an STF for painful winging of the scapula. The mean follow-up period was 41 months (range, 8-72 months). Indications for STF included winging in association with excessive medial and/or lateral clavicular resection and facioscapulohumeral dystrophy, as well as scapular winging related to combined long thoracic and spinal accessory nerve palsy. A retrospective review was performed to evaluate the subjective shoulder value, visual analog scale score, range of motion, unions, and complications. There was a statistically significant improvement in the subjective shoulder value, visual analog scale score, range of motion, and satisfaction postoperatively. The overall complication rate was 50% (6 of 12). There were 2 persistent nonunions (2 of 12, 17%), and 50% (6 of 12) of all fusions required subsequent hardware removal because of discomfort. Complications included pleural effusion (3 of 12, 25%), hemopneumothorax (1 of 12, 8%) pulmonary embolus (1 of 12, 8%), and infection (1 of 12, 8%). With the exception of the revision nonunion, all complications resolved with no negative sequelae. STF results in improved function and pain relief. STF is associated with a high short-term complication rate with limited long-term sequelae.

Outcome of locking compression plates in humeral shaft nonunions

Background: Nonunion of diaphyseal fractures of the humerus are frequently seen in clinical practice (incidence of up to 15% in certain studies) and osteosynthesis using dynamic compression plates, intra medullary nails and Ilizarov fixators have been reported previously. Locking compression plates (LCP) are useful in the presence of disuse osteoporosis, segmental bone loss and cortical defects that preclude strong fixation. We report a prospective followup study of the outcome of the use of LCP for humeral nonunion following failed internal fixation in which implants other than LCP had been used. Materials and Methods: Twenty four patients with nonunion of humeral shaft fractures following failed internal fixation were included in the study. The mean followup period was 3.4 years (range: 2.4 to 5.7 years) and the minimum followup period was 2 years. Mean age of the patients was 41.04 years (range: 24 to 57 years). All 24 patients underwent osteosynthesis using LCP and autologous bone grafting (cortico‑cancellous iliac crest graft combined with or without fibular strut graft). Main outcome measurements included radiographic assessment of fracture union and pre and postoperative functional evaluation using the modified Constant and Murley scoring system. Results: 23 out of 24 fractures united following osteosynthesis. Average time to union was 16 weeks (range: 10 to 28 weeks). Complications included delayed union (n = 2), transient radial nerve palsy (n = 2) and persistent nonunion (n = 1). Functional evaluation using the Constant and Murley score showed excellent results in 11, good in 10, fair in two and poor outcome in one patient. Conclusions: Locking compression plating and cancellous bone grafting is a reliable option for achieving union in humeral diaphyseal nonunion with failed previous internal fixation and results in good functional outcome in patients with higher physiological demands.