Proximal Humeral Nonunions Research Articles

Outcome of Osteosynthesis of Late-Presenting Proximal Humerus Non-union: A Case Series.

It can be challenging to treat proximal humeral non-union (PHN). The challenge gets compounded when they are presented either late or after previous surgery. The challenges are far greater due to small proximal fragments, scalloping of the head, medial bone defect, osteoporosis, soft tissue contractures, and problems related to the previous implants. In this retro-prospective study (2007-2020), we report on six cases of PHN which were presented to us more than 5 years after the original injury and managed using an intra-medullary autologous fibular strut graft (FSG) along with fixation with a proximal humeral locking plate and cancellous bone grafting. We quantified shoulder function based on constant score and disabilities of the arm, shoulder and hand (DASH) score. The mean age of patients is found to be 54.3 years (range, 22-74 years) with females dominating our study. The mean pre-operative constant score is 26.33 which improved to 71.83 in the post-operative period. The mean DASH score is 77.98 preoperatively, which improved to 19.5 postoperatively. The paired sample t-test compared the difference in mean of the pre-operative and post-operative scores, which shows significant improvement in outcome. Even in very late PHN in poor-quality bone, the additional use of intramedullary strut grafts provides structural support to the fixation and further enhances the ability to withstand the load-start early motion and have a satisfactory functional outcome. Keywords: Non-union, proximal humerus non-union, proximal humerus fracture, proximal humerus internal locking system, locking plate, autogenous fibular strut graft.

Open reduction and fixation with a locking plate without bone grafting is a reasonable and safe option for treating proximal humerus nonunion.

The aim of this study was to evaluate union rate and clinical outcome in patients with proximal humeral nonunions treated by open reduction and locking plate fixation without bone grafting. From 2011 to 2016, nine patients were treated using open reduction and locking plate stabilization without bone grafting. They were examined both clinically and radiologically, with a mean follow-up period of 31months. Outcome was evaluated using pain and range of motion (ROM) parameters. In addition, self-assessment by patients was registered on the Disability of the Arm, Shoulder and Hand score, Constant-Murley Score, Oxford Shoulder Score, and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form. A CT scan of the shoulder was performed to analyze union. At checkup, all patients showed union in the CT scans, where the mean ROM in abduction was 139° (SD 50°), in adduction 39° (SD 8°), in forward flexion 136° (SD 40°), in extension 44° (SD 11°), in internal rotation 62° (SD 15°), and external rotation 54° (SD 31°). ROM improved significantly in all planes of motion, except for adduction, post-surgery (p < 0.05). Plate removal was necessary in three patients. No complications were reported. Open reduction and locking plate fixation without bone graftingis a reasonable and safe option for treating proximal humerus nonunion. It leads to a high union rate, significant improvement in ROM, and in the majority of the cases to an "excellent" and "good" functional outcome without an increased risk of complications.

Prevalence of non-union and delayed union in proximal humeral fractures.

Little is known about the prevalence of proximal humeral non-union. There is disagreement on what constitutes union, delayed union and non-union. Our aim was to determine the prevalence of these complications in proximal humeral fractures (PHFs) admitted to trauma hospitals. The Victorian Orthopaedic Trauma Outcomes Registry identified 419 cases of PHFs, of which 306 were analysed. Three upper limb orthopaedic surgeons used X-rays to classify fractures according to the Neer classification and determine union. Twelve-item Short Form Health Survey scores were used to assess patient health and wellbeing. Of 306 cases, 49.4% reached union. Median time to union was 100 days (confidence interval 90-121). Of these, 17.0% united by 60 days, 8.5% united by 89 days and 23.9% united after 90 days, demonstrating 'prolonged delayed union'. There were 25 non-unions with a prevalence of 8.2%, most occurring in two-part surgical neck fractures. Our cohort of largely displaced PHFs admitted to trauma hospitals had a non-union prevalence of 8.2% and an overall delayed union prevalence of 32.4%. Consensus is required on definitions of non-union and delayed union timeframes.

The Evaluation of Hemiarthroplasty for Proximal Humeral Nonunion

The Evaluation of Hemiarthroplasty for Proximal Humeral Nonunion

Clinical results of treatment for proximal humeral nonunion with pedicled vascularized scapular bone graft. Two cases report

Clinical results of treatment for proximal humeral nonunion with pedicled vascularized scapular bone graft. Two cases report

Treatment of Proximal Humeral Nonunions With a Locked Plate and an Intramedullary Strut Autograft

Proximal humeral fractures are common and account for 5% of all fractures. As a result of the poor results of conventional plate fixation, a multitude of other operative techniques have been described for the treatment of displaced fractures. The use of locking plates has distinct mechanical advantages over other modes of fixation but does not always adequately hold the head fracture that relies on a medial buttress to prevent its collapse into varus. Nonunions of proximal humeral fractures are not uncommon and represent a significant challenge to the treating surgeon. We describe a technique to treat a proximal humeral nonunion that combines the use of a locked plate with an iliac crest corticocancellous bone peg to augment the mechanical strength of the calcar region and autogenous cancellous bone graft in an attempt to enhance union rates.

Proximal Humeral Nonunion Treated With an Intramedullary Tantalum Cylinder

Nonunion is uncommon after proximal humerus fracture surgery. There is no agreement about preferred method of treatment. Traditional approaches have included laterally based locking plates, autogenous grafting, and endosteal support to provide improved biomechanical stability. Open reduction and internal fixation (ORIF) of proximal humeral nonunion has been performed with various methods, including blade plates and bone grafting, as well as intramedullary support with autologous or allogenic grafts. Both malunion and nonunion have occurred after ORIF with locking plates. Endosteal support in the form of a fibular allograft incorporated into the locking plate construct can increase mechanical stability in selected cases. An ideal implant for proximal humeral nonunion provides medial column mechanical support and osteoconductive and osteoinductive properties. Porous intramedullary tantalum metal may play a role in nonunion surgery as an alternative to fibular allograft because of its versatility of use and salutary biological effects. It offers many material advantages for use in nonunion surgery. Tantalum is extensively porous (75%-80%), has a stiffness close to that of native bone, and offers the possibility of being a carrier for osteoinductive materials. It may also be suitable for patients who refuse allograft material. This article describes a 65-year-old woman with recalcitrant proximal humeral nonunion who was successfully treated with revision ORIF with intramedullary tantalum cylinder augmentation with a lateral-based locking plate and autogenous cancellous bone grafting. At 5-year follow-up, she had excellent motion and clinical and radiographic union.

Unconstrained Shoulder Arthroplasty for Treatment of Proximal Humeral Nonunions: Surgical Technique.

Anatomic unconstrained arthroplasty for the treatment of proximal humeral nonunion is challenging and may require management of rotator cuff tearing or scarring, glenohumeral instability, shoulder capsule fibrosis, poor bone quality and bone defects, and glenohumeral arthritis and may require internal fixation and bone-grafting for stimulation of healing. Obtain anteroposterior, axillary, and lateral scapular Y views of the shoulder to assess the fracture for the size and position of the humeral head, humeral shaft, and greater and lesser tuberosities as well as for fracture nonunion. In cases with substantial contracture or difficult exposure, use an anteromedial approach. For three and four-part fractures, secure the tuberosity fragments with strong sutures and then mobilize them from the articular fragment and the humeral shaft. The tuberosity bone fragment should be reduced to the prosthesis with positioning 6 to 10 mm below the top of the humeral head component. Fixation of the humeral stem usually requires cement, but avoid cement in the area of the tuberosity nonunion to help prevent necrosis of the bone resulting in further nonunion. To achieve tuberosity healing in anatomic alignment, reduce the tuberosities anatomically followed by bone-grafting and rigid fixation. Patients use a shoulder immobilizer for six weeks, begin formal physical therapy at two to four weeks, and initiate a shoulder strengthening program at about ten to twelve weeks. The management of proximal humeral nonunion is challenging and historically results have shown reasonable pain relief with limitations in function. IndicationsContraindicationsPitfalls & Challenges.

Satisfactory Reconstruction Options Still Elusive for Proximal Humeral Nonunions

Satisfactory Reconstruction Options Still Elusive for Proximal Humeral Nonunions

The treatment of proximal humerus nonunions in older patients with reverse shoulder arthroplasty

IntroductionExperience with treating proximal humeral nonunions with reverse total shoulder arthroplasty is limited. We report our results. PatientsEighteen patients with proximal humeral atrophic nonunion were treated with reverse total shoulder prosthesis. There were 12 women and 6 men, with a mean age of 78.8 years (range, 75–84 years). The mean follow up after reverse arthroplasty was 28 months (range, 24–32 months). Extensive proximal humeral bone loss that was found in six cases was treated adding a proximal humeral allograft. A long humeral stem was always used. ResultsThe mean Constant score increased from 26% preoperatively to 55% postoperatively (p <0.0001). The average anterior elevation increased from 35° to 90° (p<0.0001), abduction from 35° to 85° (p<0.0001), external rotation from 15° to 30° (p <0.0001) and internal rotation from 25° to 55° (p <0.0001). The average subjective shoulder score increased from 10% preoperatively to 50% postoperatively (p <0.0001). All but 4 patients would undergo the same procedure again if faced with the same problem. Eight patients were very satisfied, 6 satisfied and 4 unhappy with the operation. We had one case of transitory axillary nerve palsy and two cases of infection. Two prosthetic dislocations occurred; they were successfully treated by revision with a larger polyethylene glenosphere of 44mm. ConclusionsReverse total shoulder arthroplasty improves function and motion in patients with proximal humeral fracture sequelae. However, the rate of dislocation is high.

Shoulder Replacement Surgery

What are the indications for shoulder replacement surgery? The most common indication for shoulder replacement remains primary glenohumeral osteoarthritis. Other indications include complex proximal humeral fractures, rheumatoid arthritis and other inflammatory arthropathies, humeral head osteonecrosis, instability arthropathy, posttraumatic arthritis, chronic fixed glenohumeral dislocation, rotator cuff tear arthropathy, postinfectious arthropathy, glenohumeral chondrolysis, glenohumeral arthritis associated with neurologic pathology such as Parkinson’s disease, glenohumeral arthritis associated with prior radiation therapy, glenohumeral arthritis associated with skeletal dysplasia, certain shoulder girdle tumors, certain proximal humeral malunions, certain proximal humeral nonunions, massive irreparable rotator cuff tears with chronic pseudoparalysis without glenohumeral arthritis, and failure of a previous shoulder arthroplasty.

Unconstrained Shoulder Arthroplasty for Treatment of Proximal Humeral Nonunions

Unconstrained shoulder arthroplasty is one of several methods for treatment of proximal humeral fracture nonunions. The goal of this study was to define the results and complications of this procedure. From 1976 to 2007, sixty-seven patients underwent unconstrained shoulder arthroplasty for proximal humeral nonunion and were followed for more than two years. There were forty-nine women and eighteen men with a mean age of sixty-four years and a mean duration of follow-up of nine years (range, two to thirty years). The fracture type according to the Neer classification was two-part in thirty-six patients, three-part in sixteen, and four-part in fifteen. Hemiarthroplasty was performed in fifty-four patients and total shoulder arthroplasty was done in the remaining thirteen. There were thirty-three excellent or satisfactory results according to the modified Neer rating. Tuberosity healing about the prosthesis occurred in thirty-five shoulders. The mean pain score improved from 8.3 preoperatively to 4.1 at the time of follow-up (p < 0.001). The average active shoulder elevation and external rotation improved from 46° and 26° to 104° and 50° (p < 0.001). Shoulders with anatomic or nearly anatomic healing of the tuberosities had greater active elevation at the time of final follow-up (p = 0.02). There were fourteen complications in twelve patients, with twelve reoperations including five revisions. Kaplan-Meier survivorship with revision as the end point was 97% (95% confidence interval [CI]: 94.3, 100) at one year and 93% (95% CI: 88.0, 99.2) at five, ten, and twenty years. Shoulder arthroplasty decreases pain and improves function in patients with a proximal humeral nonunion. However, the overall results are satisfactory in less than half of the patients. Tuberosity healing is inconsistent and influences the functional outcome.

The treatment of proximal humerus nonunions in older patients with the reverse shoulder arthroplasty

Introduction The experience of the treatment of proximal humeral nonunions with the reverse total shoulder arthroplasty is limited. We report our results. Patients Eighteen patients with proximal humeral atrophic nonunion were treated with the reverse total shoulder prosthesis. There were 12 women and 6 men, with a mean age of 78.8 years (range, 75–84 years). The mean follow-up after the reverse arthorplasty was 28 months (range, 24–32 months). Extensive proximal humeral bone loss that was found in six cases was treated adding a proximal humeral allograft. A long humeral stem was always used. Results The mean constant score increased from 26% preoperatively to 55% postoperatively ( p < 0.0001). The average anterior elevation increased from 35° to 90° ( p < 0.0001), abduction from 35° to 85° ( p < 0.0001), external rotation from 15° to 30° ( p < 0.0001) and internal rotation from 25° to 55° ( p < 0.0001). The average subjective shoulder score increased from 10% preoperatively to 50% postoperatively ( p < 0.0001). All but 4 patients would undergo the same procedure again if faced with the same problem. Eight patients were very satisfied, 6 satisfied and 4 unhappy with the operation. We had one case of transitory axillary nerve palsy and two cases of infection. Two prosthetic dislocations occurred. They were successfully treated by revision with a larger polyethylene glenosphere of 44 mm. Conclusions The reverse total shoulder arthroplasty improves function and motion in patients with proximal humeral fracture sequelae. However, the rate of dislocation is high.

Proximal Humeral Nonunions Treated With Fixed-Angle Locked Plating and an Intramedullary Strut Allograft

Proximal Humeral Nonunions Treated With Fixed-Angle Locked Plating and an Intramedullary Strut Allograft

Subscapularis insufficiency and the risk of shoulder dislocation after reverse shoulder arthroplasty

Dislocation is the most common serious complication after reverse shoulder arthroplasty. One theorized cause is subscapularis insufficiency because the tendon cannot be repaired at the time of surgery. There are no documented risk assessments of reverse total shoulder arthroplasty dislocation related to this cause. The study objective was to quantify the risk of postoperative dislocation after reverse total shoulder arthroplasty in patients with a subscapularis tendon that was irreparable at the time of surgery. A prospective evaluation was done of 138 consecutive reverse arthroplasties performed through a deltopectoral approach by a single surgeon (average follow-up, 36 months). The subscapularis was reparable in 62 patients and irreparable in 76 at the conclusion of the procedure. Seven postoperative dislocations occurred; all dislocations were in patients whose subscapularis was irreparable (P = .012). Dislocations were more likely in patients with complex diagnoses, including proximal humeral nonunion, fixed glenohumeral dislocation, and failed prior arthroplasty. This report documents that an irreparable subscapularis tendon at the time of reverse total shoulder arthroplasty using a deltopectoral approach results in a statistically significant risk for postoperative dislocation. Level IV, Case Series, Treatment Study.

Proximal Humeral Nonunions Treated With Fixed-Angle Locked Plating and an Intramedullary Strut Allograft

To determine if the use of a fixed-angle locked plate plus an intramedullary allograft in the treatment of proximal humeral nonunions resulted in improved union. Retrospective clinical analysis of patients' medical charts and radiographs. Clinical practice of senior authors. Eighteen patients who presented to the senior authors' clinic between 2001 and 2007 with clinical and radiographic evidence of symptomatic proximal humeral nonunions that were treated with the described method were included for analysis. Patients with severe humeral head bone loss, avascular necrosis, evidence of arthrosis, and less than 12-month clinical follow-up were excluded. All patients with a symptomatic viable nonunion of the proximal humerus were treated with a fixed-angle locked plate and an intramedullary cortical allograft. Patients were followed until radiographic union was achieved, with this being the principle determinant of a successful outcome. Radiographic union was achieved in 17 of 18 patients (94%). The average follow-up was 26.5 months (range 12-49 months). The average time from surgery to radiographic union was 5.4 months (range 2.5-8.8 months). There was 1 failure of fixation, and 2 patients developed transient neurologic sequelae. Range of motion measurements obtained from the most recent clinical follow-up were 115 degrees (range 20-180 degrees) active forward elevation, 37 degrees (range 0-70 degrees) passive external rotation, and active internal rotation was to the 10th thoracic vertebrae. American Shoulder and Elbow Surgeon scores improved from a level of 40 preoperatively to 81 postoperatively, and visual analog scale scores improved from 6.7 to 1.5. Intramedullary strut allograft insertion combined with fixed-angle plating is an effective technique for treating viable nonunions of the proximal humerus and was successful in achieving union in 94% of our patients.

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.

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.

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.

The limited-contact dynamic compression plate in the management of proximal humeral non-union

Non-union is an uncommon but troublesome complication of proximal humeral fractures. A number of surgical techniques have been reported. We describe the use of a contoured limited-contact dynamic compression plate in the surgical management of proximal humeral non-union.