Pseudarthrosis following proximal humeral fractures: a possible mechanism

Does double distal locking reduce non-union rates in intramedullary nailing for humeral shaft fracture?

INTRODUCTION

Intramedullary nailing is one of the surgical treatments for humeral shaft fracture. Non-union is a common complication, with rates of 10-20%. The objective of this study was to compare non-union in humeral shaft fractures treated by intramedullary nailing with double distal locking, single distal locking or no locking.

HYPOTHESIS

Nailing with double distal locking decreases non-union rates compared to single or no locking.

MATERIAL AND METHODS

This single-center retrospective comparative study included 87 patients with closed humeral shaft fracture without neurologic deficit treated by anterograde intramedullary nailing: group 1 (double locking): 15 fractures; group 2 (single locking): 63 fractures; group 3 (no locking): 9 fractures. Non-union was defined as absence of radiographic callus at 6 months without clinical pain. The primary endpoint was non-union rate per group. The secondary endpoints were Constant score at 6 months, and postoperative use of non-steroidal anti-inflammatory drugs (NSAIDs).

RESULTS

There were no significant differences in non-union rate: 20.0% in group 1, 20.3% in group 2, and 0% in group 3 (p=0.32). Constant score at 6 months was significantly different between the 3 groups (p=0.01). Group 2 used more NSAIDs than the other groups (39.1% vs. 20.0% in group 1 and 33.3% in group 3; p=0.37).

DISCUSSION

Non-union rates were similar regardless of distal locking for closed humeral shaft fractures without neurologic deficit treated by intramedullary nailing. Nevertheless, patients in the double locking group had higher Constant scores at 6 months, probably related to greater stability of fixation, allowing more efficient rehabilitation.

LEVEL OF EVIDENCE

III; retrospective comparative study.

Factors associated with humeral shaft nonunion

BACKGROUND

The primary aim was to identify patient and injury factors independently associated with humeral diaphyseal fracture nonunion after nonoperative management. The secondary aim was to determine the effect of management (operative/nonoperative) on nonunion.

METHODS

From 2008-2017, a total of 734 humeral shaft fractures (732 consecutive skeletally mature patients) were retrospectively identified from a trauma database. Follow-up was available for 663 fractures (662 patients, 90%) that formed the study cohort. Patient and injury characteristics were recorded. There were 523 patients (79%) managed nonoperatively and 139 (21%) managed operatively. Outcome (union/nonunion) was determined from medical records and radiographs.

RESULTS

The median age at injury was 57 (range 16-96) years and 54% (n = 359/662) were female. Median follow-up was 5 (1.2-74) months. Nonunion occurred in 22.7% (n = 119/524) of nonoperatively managed injuries. Multivariate analysis demonstrated preinjury nonsteroidal anti-inflammatory drugs (NSAIDs; odds ratio [OR] 20.58, 95% confidence interval [CI] 2.12-199.48; P = .009) and glenohumeral arthritis (OR 2.44, 95% CI 1.03-5.77; P = .043) were independently associated with an increased risk of nonunion. Operative fixation was independently associated with a lower risk of nonunion (2.9%, n = 4/139) compared with nonoperative management (OR for nonoperative/operative management 9.91, 95% CI 3.25-30.23; P < .001). Based on these findings, 5 patients would need to undergo primary operative fixation in order to avoid 1 nonunion.

CONCLUSIONS

Preinjury NSAIDs and glenohumeral arthritis were independently associated with nonunion following nonoperative management of a humeral diaphyseal fracture. Operative fixation was the independent factor most strongly associated with a lower risk of nonunion. Targeting early operative fixation to at-risk patients may reduce the rate of nonunion and the morbidity associated with delayed definitive management.

Proximal humeral fractures: a review of current concepts

The majority of proximal humerus fractures are sustained via low energy falls in the elderly population. These patients can attain an acceptable level of function via non-operative treatment. There is yet to be a clear consensus on treatment options suitable for those that fall outside of this majority group. Open reduction internal fixation, intra medullary nailing and arthroplasty surgery have all been used to varying effects. Good results are achievable if complications such as mal-union, non-union and avascular necrosis can be avoided. This review aims to clarify the options available to the current day trauma surgeon.

Proximal humeral fractures: current concepts in classification, treatment and outcomes

Most proximal humeral fractures are stable injuries of the ageing population, and can be successfully treated non-operatively. The management of the smaller number of more complex displaced fractures is more controversial and new fixation techniques have greatly increased the range of fractures that may benefit from surgery. This article explores current concepts in the classification and clinical aspects of these injuries, reviewing the indications, innovations and outcomes for the most common methods of treatment.

Proximal humeral nonunions treated with fixed-angle locked plating and an intramedullary strut allograft

OBJECTIVE

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.

DESIGN

Retrospective clinical analysis of patients' medical charts and radiographs.

SETTING

Clinical practice of senior authors.

PATIENTS/PARTICIPANTS

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.

INTERVENTION

All patients with a symptomatic viable nonunion of the proximal humerus were treated with a fixed-angle locked plate and an intramedullary cortical allograft.

MAIN OUTCOME MEASUREMENT

Patients were followed until radiographic union was achieved, with this being the principle determinant of a successful outcome.

RESULTS

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.

CONCLUSION

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.

Komplikationsmanagement nach winkelstabiler Plattenosteosynthese am proximalen Humerus

PURPOSE

In this prospective study, complications observed after angularly stable proximal humerus plate fixation (locking proximal humerus plate) were analysed by deriving specific therapies.

PATIENTS

Fifty patients (median age 65 years, range 25-84 years, 39 female, 11 male) with displaced proximal humerus fractures (seven single, 36 double, and seven triple fractures) were evaluated 3, 6, and 12 months after angularly stable plate fixation using a standard protocol.

RESULTS

Age- and gender-matched median constant scores 12 months postoperatively showed for the three fracture types 86, 87, and 55 points and complication rates of 14, 19, and 100%, respectively. There were seven primary and seven secondary implant displacements, five humeral head necroses, four osseous malalignments, two nonunions, two deep infections, and one heterotopic ossification. Nine reoperations were required in six patients: implant removal (n=3), reosteosynthesis (n=2), revision because of nonunion (n=2), and deep infection (n=2).

CONCLUSIONS

Differentiated analysis of complications and the development of specific prevention and therapeutic strategies considering surgical technique, implant, fracture morphology, and humeral head perfusion minimize the rate of complications observed after angularly stable locking proximal humerus plate fixation.

Complications of operative fixation of proximal humeral fractures in patients with rheumatoid arthritis

Currently, there is no information in the literature on operative treatment of proximal humeral fractures in patients with rheumatoid arthritis. Eleven patients underwent osteosynthesis of the proximal humerus from December 1987 to December 2002. Nine patients were treated for acute fractures, and two were treated for nonunions. Four had loss of initial anatomic reduction, two were treated nonoperatively with resultant malunion, and two required revision fixation. Two patients with symptomatic pseudarthrosis were treated with internal fixation and bone grafting. Both had complications (1 requiring hemiarthroplasty after painful nonunion and 1 with chondrolysis). All patients with acute fractures achieved fracture union. One patient had an excellent result, four had satisfactory results, and six had an unsatisfactory result. Patients and treating physicians should be aware of the high rate of complications and unsatisfactory results in patients with rheumatoid arthritis who undergo operative treatment of proximal humeral fractures.

Management of surgical neck nonunions

A surgical neck nonunion is a seriously debilitating complication of a proximal humerus fracture. Patients have virtually no functional use of their shoulders and experience pain. Successful treatment is reliable in relief of pain and potentially can restore function. The diagnosis is not difficult, however, a CT scan may be necessary to identify tuberosity or head-splitting fractures. Successful treatment for these nonunions is difficult but gratifying because the percent improvement is immense.