Treatment Of Humeral Shaft Nonunion Research Articles

COMPARISON OF SINGLE- AND DOUBLE-PLATE FIXATION TECHNIQUES IN THE TREATMENT OF NONUNIONS OF THE HUMERAL SHAFT.

ABSTRACTIntroduction Humerus shaft fractures may be treated conservatively or surgically. In 2.5% to 13% of cases, nonunion is observed, and it leads to severe pain and morbidity. Plate osteosynthesis has become popular in the treatment of nonunion of the humeral shaft. In this study, we compared the clinical outcomes of patients with humerus shaft nonunion whom we treated with single- or double-plate fixation.Materials and Methods Fifty-three patients diagnosed with aseptic humeral shaft nonunion and treated with plate fixation were included in the study. Patients were evaluated according to the number of plates (single vs. double plates). The two groups were subjected to statistical evaluation according to their clinical and radiographical results.Results The average age of the patients was 53 years (range: 1-86); 28 (52.8%) were female and 25 (47.2%) were male. The union rate was 90.32% for single plate and 90.91% for double plate fixation. There was no statistically significant difference between single and double plates in the clinical and radiographical results (union time, union rate, Q-DASH score) (p > 0.05). There was a significant correlation between age and union times / Q-DASH scores according to the Spearman correlation test (p < 0.05). Transient radial nerve neuropraxia developed in 2 patients and 1 patient suffered from an infection that was treated with debridement and antibiotic therapy.Conclusion In our study, similar good results were obtained with single and double plates. In treatment of humeral shaft nonunions, a second plate is not needed if enough stability is provided with single plate fixation. Level of evidence III, Retrospective comparative study.

Approach to Humeral Shaft Nonunion: Evaluation and Surgical Techniques.

Humeral shaft fractures account for 1% to 3% of all fractures. Traditional nonsurgical treatment with a functional brace is still the standard treatment of these fractures; however, modern studies have reported that nonunion rates may be as high as 33%. Recent information suggests that the development of nonunion after nonsurgical treatment may be identified as early as 6 to 8 weeks postinjury. Even with surgical treatment, nonunion rates as high as 10% have been reported. Regardless of the original treatment method, nonunion results in poor quality of life for the patient and therefore should be addressed. A thorough preoperative evaluation is important to identify any metabolic or infectious factors that may contribute to the nonunion. In most cases, surgical intervention should consist of compression plating with or without bone graft. Although most patients will achieve union with standard surgical intervention, some patients may require specialized techniques such as cortical struts or vascularized fibular grafts. Successful treatment of humeral shaft nonunion improves function, reduces disability, and improves the quality of life for patients. In this article, we outline our approach to the treatment of humeral shaft nonunion in a variety of clinical settings.

Surgical management of humeral shaft nonunions. Success of a consistent protocol over 17 years

IntroductionSurgical treatment of humeral shaft nonunions is characterized by variability of fixation methods, graft choices, and rates of union and iatrogenic radial nerve palsy. The aim of the current study is to evaluate the union rate of humeral shaft aseptic nonunions and the rate of postoperative complications following a consistent management protocol. Patients and methodsThis is a retrospective review of 41 consecutive adult patients (23 female and 18 male with a mean age of 42 years) with aseptic nonunions of the humeral shaft treated by the senior author in our institution over a 17-year period. Nonunions were located in the middle third of the diaphysis in 33 patients, in the distal third in 6, and in the proximal third in 2 patients. Comorbidities were present in 49% of patients and the most common were smoking in 27% and diabetes mellitus in 17% of patients. Patients were treated at an average of 24 months after their injury. Surgical protocol consisted of careful dissection of the radial nerve, debridement of the nonunion site, stable plate fixation and augmentation of local biology. ResultsThirty-eight patients had mean clinical and radiographic follow-up of 9.4 months. All 38 nonunions healed at a mean time of 3.5 months. There were no persistent nonunions and no failures of fixation. None of the 40 patients with an intact radial nerve preoperatively developed any signs of radial nerve compromise after surgery. Complications consisted of one superficial infection (2%) that resolved with oral antibiotics and one deep infection (2%) that required implant removal and debridement. The mean pain score on the visual analog scale was 0.7. Mean elbow range of motion was 125 degrees with a mean extension deficit of 5 degrees and mean flexion of 130 degrees. ConclusionsOur surgical protocol achieved consistent healing of nonunions of the humeral shaft with a low complication rate and no iatrogenic radial nerve palsy, even in long-standing nonunions in patients with comorbidities.

The comparison of single plate and double plate fixation methods for treatment of humeral shaft nonunions.

Objectives This study aims to evaluate the early- and mid-term shoulder and elbow functions and compare the union rates after the application of single plate and double plate for the treatment of humerus shaft nonunions.Patients and methods This retrospective study included 56 patients (36 males, 20 females; mean age 53.8±9.5; range, 28 to 68 years) treated with double plate (n=25) and single plate (n=31) osteosynthesis between October 2012 and January 2016. Surgical treatment of the nonunion was applied in the fourth month after the fracture at the earliest. Autograft taken from the iliac bone was applied during the surgery in all patients. Evaluation was performed using The University of California at Los Angeles (UCLA) Shoulder Score, Mayo Elbow Performance Score (MEPS), Visual Analog Scale (VAS), Constant Shoulder Score, and Disabilities of the Arm Shoulder and Hand (DASH) questionnaire.Results The mean postoperative follow-up time was 40.7±9.6 (range, 25 to 58) months. No statistically significant difference was determined in respect of time to union, follow-up time, DASH questionnaire score, UCLA Shoulder Score, VAS, MEPS and Constant Shoulder Score after union in the comparison of the two groups (p>0.05). In the examination of postoperative early (three months) recovery phase of shoulder and elbow functions, statistically significant superior scores were obtained in the double plate group for MEPS (double plate median=85 [min 75-max 90], single plate median=75 [min 70-max 85]) and Constant Shoulder Score (double plate median=89 [min 85-max 92], single plate median=81 [min 75-max 90]) (p<0.001).Conclusion There was no statistically significant difference in terms of time to union and union rates between single plate and double plate fixations for surgical treatment of humeral shaft nonunions. However, superior clinical results were obtained in the early recovery phase of shoulder and elbow functions with double plate fixation.

Healing the Index Humeral Shaft Nonunion: Risk Factors for Development of a Recalcitrant Nonunion in 125 Patients.

Humeral shaft nonunions are challenging to treat, and those that require >1 surgical procedure in order for a nonunion to heal are termed recalcitrant. Most studies on nonunion have evaluated the union rate independent of the number of procedures required to achieve union. The aims of the present study were (1) to compare the healing rates after the index operation for the treatment of a nonunion with conventional versus locked plating with or without graft augmentation, (2) to report the prevalence of recalcitrant nonunion, and (3) to identify risk factors that predict a recalcitrant nonunion. We performed a retrospective analysis of a prospectively collected database of 125 humeral shaft nonunions treated with open reduction and plate fixation by a single surgeon over 25 years. Univariate and multivariate regression analyses were performed to compare healing rates by type of plate fixation and biological augmentation and to identify demographic, injury, and treatment-related risk factors for the development of a recalcitrant nonunion. One hundred and five patients (84%) had healing after the index procedure for the treatment of nonunion. Twenty patients (16.0%) required secondary procedures and were defined as having a recalcitrant nonunion. Eight of these patients (6.4% of the overall group) healed after the secondary interventions, and 12 (9.6% of the overall group) had a failure to unite. There were no significant differences in healing rates between conventional and locked plates or between the types of bone graft (autogenous or recombinant human bone morphogenetic protein). Risk factors for the development of a recalcitrant nonunion were plate fixation of the acute humeral fracture, a history of deep infection, and ≥2 prior procedures. Plate fixation with bone graft augmentation remains a successful method for the treatment of humeral shaft nonunions. Neither plate type nor graft type reduced the risk of a recalcitrant nonunion. Factors that predicted a recalcitrant nonunion were operative fixation of the acute fracture with a plate, a history of deep infection, and ≥2 surgical procedures. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Humeral shaft non-union in the elderly: Results with cortical graft plus stem cells

Introduction: Humeral shaft is a common site of fracture non-union. Biology and bone quality represent some of the problems that the orthopaedic surgeon has to face up in the elderly. The goals of treatment of humeral shaft non-union are the achievement of mechanical stability and creation of a favourable biologic environment. Bone graft and stem cells are some of the augmentation techniques available to reach these goals.Purpose: Evaluation of the outcomes of humeral shaft non-union in elderly population treated with cortical allograft and stem cells.Material and methods: A cohort of 21 patients with humeral shaft non-union was reviewed. Inclusion criteria were patients aged more than 65 years, with a diagnosis of humeral shaft non-union treated with cortical allograft and stem cells. Primary endpoints were ‘bone healing’ and ‘time-to-union’. Secondary endpoints were shoulder and elbow function and patients’ quality of life with Oxford Shoulder Score (OSS), Constant score and EuroQol-5D (EQ-5D).Results: 6 patients met the inclusion criteria. In 5 of them, the cortical allograft was opposite to a plate, whereas in the other one a “Sandwich” technique was chosen because of large osteolysis. ‘Bone healing’ occurred in all patients after a mean of 3.3 months (range 2–5). In all but two patients, the elbow range of motion was in almost normal range (15–130). The mean OSS was 35.8 (+/− 6.4), whereas the mean Constant was 53.3 (+/− 2.2). The mean EQ-5D index was 0.451 (+/− 0.21).Discussion: Bone healing occurred in all patients, with a time-to-union comparable or even better compared with other series. The use of cortical bone graft provide both stability and biological benefit, whereas stem cells improve the non-union environmental biology. Functional outcomes were lower than other series and patients’ quality of life was similar to Italian elderly women. Conclusion: The use cortical allograft with stem cells is a viable strategy to treat humeral shaft non-union in the elderly.

Intramedullary nail fixation combined with autogenous bone graft and augmentation plate for treatment of humeral shaft nonunion in a patient with rheumatoid arthritis

Intramedullary nail fixation combined with autogenous bone graft and augmentation plate for treatment of humeral shaft nonunion in a patient with rheumatoid arthritis

Union rate after operative treatment of humeral shaft nonunion--A systematic review.

Humeral shaft nonunions can lead to morbidity from subsequent operations, complications and impaired function. Currently there is no evidenced-based consensus for treatment of humeral shaft nonunions. We aimed to summarize and analyze union rates and complications after operative treatment for humeral shaft nonunion. Studies investigating operative treatment strategies for humeral shaft nonunion were identified by searching: EMBASE, MEDLINE, Ovid SP, Web of Science, Cochrane Central, PubMed and Google Scolar up to October 24, 2014. Studies were eligible if: (1) outcome of operative treatment for humeral shaft nonunion was reported; (2) at least ten adult patients with humeral shaft nonunion included; (3) full text article available; (4) written in English, German or Dutch; and (5) nonunion was defined as no bone-bridging between the fracture ends after 6 months. Thirty-six studies were included. A union rate of 98% was found in patients (n=672) who underwent plate fixation with autologous bone grafting (ABG), 95% in plate fixation without ABG (n=19), 88% in intramedullary nailing with ABG (n=164), 66% in intramedullary nailing without ABG (n=78), 92% in bone strut fixation (n=91) and 98% in external fixation (n=152). A total complication rate of 12% was found in patients treated with plate fixation combined with ABG, 15% in intramedullary nail with ABG and 8% intramedullary nailing without ABG, 20% in bone strut fixation and 22% in external fixation. Plate fixation with ABG was recommended for humeral shaft nonunion, since the union rate is highest and the complication rate is relatively low. Level IV.

Locking plate fixation with or without auto-iliac graft for humeral shaft nonunion

Objective To evaluate the clinical outcomes of open reduction and locking plate fixation with or without auto-iliac graft for humeral shaft nonunion.Methods Between January 2008 and May 2012,65 cases of humeral shaft nonunion were treated in our department.They were 48 men and 17 women,24 to 54 years of age (39.8 years).Of them,43 were atrophic and 22 hypertrophic.The radial nerve was exposed and protected during operation.After the nonunion portion was debrided,the humeral length was recovered.Next the fracture sites were fixated by a locking plate.The defected area was filled with auto-iliac graft if necessary.The visual analogue scale (VAS) scores and The Short Form-36 (SF-36) scores were documented after operation; the functional recovery was evaluated using Constant scoring at the last follow-up.Results The patients obtained a mean follow-up of 13.8 months (from 10 to 32 months).Of them,50 achieved clinical bone union after an average of 3.8 months (from 3 to 7 months).The remaining 6 cases showed no sign of union 9 months postoperatively.Of the 50 patients with union,the mean VAS score was decreased significantly from the preoperative 5.1 ± 3.2 points to the postoperative 1.4 ± 0.8 points,and the mean SF-36 score was increased significantly from the preoperative 45.7 ± 16.9 points to the postoperative 72.9 ± 18.5 points (P ＜ 0.05).The function was scored at the last follow-up as excellent in 34 cases,good in 12,fair in 2 and poor in 2,giving an excellent to good rate of 92.0％.The radical nerve injury was repaired within 3 months postoperation in 3 patients.Rotation deformity occurred in 3 cases without obvious functional limitation.No implant complications such as plate breakage and screw loosening were observed.Conclusion Open reduction and locking plate fixation with or without auto-iliac graft is one effective treatment of humeral shaft nonunion,but damage to the radial nerve should be avoided and fixation of 6 layers of cortex should be maintained at both fracture ends during operation Key words: Humerus; Fractures, ununited; Bone plates

Treatment of Humeral Shaft Aseptic Nonunions in Elderly Patients With Opposite Structural Allograft, BMP-7, and Mesenchymal Stem Cells

Humeral shaft aseptic nonunions occur in 2% to 10% of patients managed conservatively and 10% to 15% of patients treated surgically. The complex muscular and neurovascular anatomy of the upper limb makes the surgical approach to the fracture site demanding and risky, especially when previous surgeries have been attempted. The clinical consequence of atrophic humeral shaft nonunions is a severe functional limitation that may significantly affect activities of daily living, especially in the elderly. The surgical treatment of humeral shaft nonunions is challenging for orthopedic surgeons. Patients with atrophic nonunions require both a stable fixation and enhancement of the biologic response because of the weak biologic reaction observed at the fracture site. The gold standard of treatment in elderly patients has not been described. Nonetheless, older age and comorbidities are associated with potentially malignant nonunions. This study reports the authors' experience using opposite cortical allograft combined with bone morphogenetic protein 7 and mesenchymal stem cells to treat humeral shaft atrophic nonunions in 2 elderly patients. The nonunion site healed at 4 months (patient 1) and 8 months (patient 2) postoperatively, with full return to activities of daily living and no pain. Neither patient reported complications of the radial nerve, which is at high risk of injury during this type of surgery. The only reported complication (patient 2) was an intraoperative longitudinal partial distal humeral fracture, probably caused by compression screw overtightening. The use of a locking plate and opposite cortical allograft, combined with BMP-7 and mesenchymal stem cells, represents a safe and effective treatment for malignant nonunions in older patients.

Treatment of humeral shaft nonunion

Treatment of humeral shaft nonunion

Anterior minimally invasive bridge-plate technique for treatment of humeral shaft nonunion

BackgroundThe present study introduces a new surgical technique and the results of a case series of patients with humeral shaft nonunion.Materials and methodsFifteen patients with diagnosis of diaphyseal nonunion of humerus were operated by a bridge-plate technique. A 4.5-mm plate is slid on the anterior surface of the humerus, submuscular to the brachial muscle. With the plate over the anterior surface of the humerus, screws are inserted from anterior to posterior on the ends of the plate. When there is a small bone gap, an iliac autologous graft is inserted. Minimum follow-up was 1 year.ResultsBone healing was obtained in all patients: 1.5 months postoperatively in 11 patients, 2 months in 3 patients, and 3 months in 1 patient. There were no postoperative infections, there was one case with loosening of the screws and plate, and there were no nerve injuries.ConclusionsThe present technique avoids wide dissection, radial nerve isolation, and periosteum stripping. The anterior minimally invasive bridge-plate technique for treatment of humeral shaft nonunion is a safe procedure and obtained bone healing in all patients in this series.

A82 Treatment of humeral shaft non-unions after intramedullary nailing

A82 Treatment of humeral shaft non-unions after intramedullary nailing

Ilizarov treatment of humeral shaft nonunion in an antiepileptic drug patient with uncontrolled generalized tonic-clonic seizure activity

Nonunion of the humeral shaft in patients with antiepileptic drug associated metabolic bone disorder constitute a challenging surgical problem difficult to treat due to seizure activity, osteoporosis, and poor stabilization options. We report a case of nonunion of the humeral shaft in an antiepileptic drug patient with uncontrolled generalized tonic-clonic seizure activity successfully treated with Ilizarov external fixator and a follow-up of 4 years.

Comment on: Shape memory Ni-Ti alloy swan-like bone connector for treatment of humeral shaft nonunion

Dear Editor, We read with interest the article on “Shape memory Ni-Ti alloy swan-like bone connector for treatment of humeral shaft nonunion” [1].We would like to congratulate the authors for the original and outstanding work and would like to raise some querries. How was the implant sterilised? Does routine autoclaving have any effect on the material properties of the implant? In our experience, while reducing nonunions, the bone adjacent to the fracture is often denuded of soft tissues (as is also seen in Fig. 2e of this article [1]) and the radial nerve is at risk. The authors have themselves in another study reported neuropraxia in 4:105 cases operated with shape memory connector [2].Moreover, the implant embraces the bone, and the radial nerve is further at risk. We would like to know how often the radial nerve was explored? A circumferentially placed implant is more likely to cause damage to vascularity. How was the implant size to be placed decided? Were the patients given any postoperative supplementary stabilisation? The authors state that implant removal was easy. If bone graft was placed around the implant, then at the time of removal, the implant should have been surrounded by bone, making the removal difficult. Nitinol implants have been used in spine [3], noncemented hip replacement, and in staples for osteosynthesis [4]. What is the authors view on use of these implants in femur and forearm nonunions? Do they suggest shape memory connectors (SMC) to treat fresh fractures? Corrossion resistance properties of Ni-Ti shape memory alloys have been questioned [5] and their in vitro behavior studied [6].The alloy has been stated to be comparable or inferior to steel. Biocompatability needs to be time tested.

Authors’ reply to comments by Sharma et al. on the article by Su JC et al.: Shape memory Ni-Ti alloy swan-like bone connector for treatment of humeral shaft nonunion

Thank you very much for your questions concerning the article entitled “Shape memory Ni-Ti alloy swan-like bone connector for treatment of humeral shaft nonunion” [1]. These questions, are very interesting thoughtful and represent concerns of many researchers. I want to thank the editor for providing this platform, through which scholars can learn about the design and application of medical appliances based on shape memory alloy. Our response to your queries is as follows:

Shape memory Ni-Ti alloy swan-like bone connector for treatment of humeral shaft nonunion

From August 1990 to December 2007, 156 patients with humeral shaft nonunion were treated with our patented Ni-Ti shape memory alloy swan-like memory pressure connector (SMC). The SMC device cooled with ice before implantation was warmed to 40-50 degrees C after implantation to produce balanced axial and compression forces to stabilise the fracture three-dimensionally. This combined with autologous bone grafting achieved bone tissue regeneration in the fracture and promoted smooth recovery of joint function, with a nonunion healing rate of 98.7% after a single SMC implantation. Failure of nonunion healing occurred in only two cases but was successfully managed by a further operation. Complications were not found in any of these patients apart from four with pre-existing radial nerve injuries. These results demonstrate the effectiveness of the SMC device for the management of humeral shaft nonunion. The device provides continuous compression of the fracture with minimal trauma to the local blood supply.

Comparison of Three Different Treatment Modalities in the Management of Humeral Shaft Nonunions (Plates, Unilateral, and Circular External Fixators)

To compare 3 different fixation methods for the treatment of humeral shaft nonunions in terms of union time, functional outcome, and complications. Retrospective case series. University hospital. Between 1996 and 2004, 80 patients (mean age, 49; range, 15 to 86; 30 women and 50 men) with nonunions of the humeral shaft were treated surgically in our institution. Circular external fixators (CEF) were used in 35 patients, unilateral limb reconstruction system (LRS) fixators in 24 patients and fixation with plates in 21 patients. Surgical procedure included hardware removal in previously operated patients, autogenous grafting in all patients in the plate group and in those patients with atrophic nonunions in the external fixator groups, compression of the nonunion site in all patients. Radiological union time, complications, shortening, and disabilities of the arm, shoulder, and hand (DASH) score. Mean follow-up period was 48.1 months (range, 12 to 121). Mean radiological union time was 5.5 months (range, 1.5 to 12) in the CEF group, 5.2 months (range, 3 to 10) in the LRS group, and 5.7 months (range, 3 to 12) in the plate group. Mean DASH score was 23.7 in the CEF group, 18.6 in the LRS group, and 26 in the plate group. There were no statistical differences in terms of union time and the DASH score among the 3 groups. Successful union was achieved in 77 (96.3%) patients. Both external fixation and plate fixation produce excellent results in humeral shaft nonunions if applied properly. The procedure can be tailored to the surgeon's experience, keeping in mind that plate fixation demonstrates a longer healing time in those cases that had previous surgeries.

Humeral diaphyseal aseptic non-unions: An algorithm of management

Successful operative treatment of a humeral shaft non-union may be a challenge for the surgeon. Several treatment options have been reported over the years. A systematic review of the literature was performed. Twenty-three retrieved articles (level of evidence IV) fulfilled our inclusion criteria and dealt with aseptic diaphyseal humeral non-union managed by plating, intramedullary nailing and external fixation based on Ilizarov's principles. Despite an obvious superiority of plating in the treatment of humeral shaft non-unions, there is no doubt that intramedullary nailing as well as external fixation devices have a role. An algorithm of management of the humeral shaft non-unions following a rational approach is suggested.

Treatment of the humeral shaft nonunion after surgical failure using the Selfdynamisable internal fixator

A nonunion of the humeral shaft is not a rare condition and is a complication of both nonoperative and operative treatment of the fracture. Several fixation options were used in the nonunion treatment, including various plate techniques, intramedullary nails and external fixator. We applied our Selfdynamisable internal fixator for the treatment of humeral shaft nonunion after surgical failure and evaluated its clinical outcome. Six patients with persistent atrophic nonunion of the humeral shaft were treated with Selfdynamisable internal fixator. The inclusion criteria were mobile, unstable resistant nonunion of the humeral diaphysis which persisted after surgical treatment for nonunion. All patients were men with a mean age of 32 (27-39) years. The initial fracture treatment was external fixator in two patients and plaster cast for four patients. All cases failed to unite after primary treatment. Plate fixation was resorted for fracture union but failed. The revision surgery consisted of removal of hardware, freshening of bone ends and bone grafting, and internal fixation with a Selfdynamisable internal fixator. The average follow-up was 33 months. All the nonunions healed after indexed operation. The average time for union was 5.5 months (range 4-9 months). There was no loosening or breakage of the fixation device. The functional results, according to the scale of Constant and Murlay modified by Ring, were excellent in five and good in one patient. There were no complications of nerve injuries or infections related to the operation. Selfdynamisable internal fixator with bone graft for the treatment of recalcitrant humeral shaft nonunion provided successful clinical outcome with minimal complications.