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Mukhopadhaya J, Singh NN, Gupta AP, Bhadani JS. Outcome of Osteosynthesis of Late-Presenting Proximal Humerus Non-union: A Case Series. J Orthop Case Rep 2024; 14:165-172. [PMID: 38420251 PMCID: PMC10898685 DOI: 10.13107/jocr.2024.v14.i02.4258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 12/03/2023] [Indexed: 03/02/2024] Open
Abstract
Introduction 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. Material and Methods 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. Results 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. Conclusion 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.
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Affiliation(s)
- John Mukhopadhaya
- Department of Orthopaedics, Paras HMRI Hospital, Patna, Bihar, India
| | - Niraj Narain Singh
- Department of Orthopaedics, ESIC Medical College and Hospital, Bihta, Patna, Bihar, India
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Unal M, Katı YA, Acar B, Turan A, Ozturk S, Yuksel HY. Single versus double plate fixation of humeral shaft nonunion. Arch Orthop Trauma Surg 2024; 144:693-699. [PMID: 37930359 DOI: 10.1007/s00402-023-05111-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 10/12/2023] [Indexed: 11/07/2023]
Abstract
INTRODUCTION Humeral shaft fractures are common fractures of the diaphysis of the humerus. The aim of this study was to evaluate factors affecting the clinical outcomes of humeral nonunions surgically treated with open reduction and single- versus double-plate fixation with grafting. MATERIALS AND METHODS A total of 31 patients with nonunion treated with single- or double-plate screw fixation with bone grafting were retrospectively analysed. The patients were divided into two groups according to the treatment method as Group 1 (single-plate, n = 14) and Group 2 (double-plate, n = 17). Data including demographic and clinical characteristics of the patients, initial and final treatment, type of nonunion and localisation, graft use, shortening, follow-up, time to union, Quick Disabilities of the Arm, Shoulder and Hand (Quick-DASH) scores, and patient-reported cosmetic outcomes were recorded. RESULTS Of the patients, eight were males, and 23 were females, with a mean age of 47.6 ± 15.8 (range, 20-86) years. Initial treatment was conservative treatment (Sarmiento brace) in seven patients, plate fixation in 22 patients, and intramedullary nailing in two patients. The mean follow-up was 31.0 ± 16.9 months in Group 1 and 25.4 ± 15.6 months in Group 2. There was one nonunion in Group 1 and three in Group 2. There were no significant differences in the union rate and time to union (p = 0.378 and p = 0.262, respectively). The mean Quick-DASH scores and cosmetic results were similar between the groups (p = 0.423 and p = 0.165, respectively). Radial nerve palsy developed in three patients in Group 2, and all these patients recovered completely during follow-up. CONCLUSIONS Although the double-plate fixation technique has similar clinical, radiological, and functional results to single-plate fixation, it is a more invasive and expensive technique with a longer operation time. Therefore, it should not be used as the first-line treatment option for all humeral shaft nonunion. Nevertheless, the double-plate technique may be preferred to achieve in cases requiring high stability, such as hypertrophic nonunion, osteopenia and comminuted fractures.
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Affiliation(s)
- Melih Unal
- Department of Orthopedics and Traumatology, Medical Faculty, University of Health Sciences, Antalya Training and Research Hospital, Antalya, Turkey
| | - Yusuf Alper Katı
- Department of Orthopedics and Traumatology, Medical Faculty, University of Health Sciences, Antalya Training and Research Hospital, Antalya, Turkey.
| | - Baver Acar
- Department of Orthopedics and Traumatology, Medical Faculty, University of Health Sciences, Antalya Training and Research Hospital, Antalya, Turkey
| | - Adil Turan
- Department of Orthopedics and Traumatology, Medical Faculty, University of Health Sciences, Antalya Training and Research Hospital, Antalya, Turkey
| | - Serra Ozturk
- Department of Anatomy, Medical Faculty, Akdeniz University, Antalya, Turkey
| | - Halil Yalçın Yuksel
- Department of Orthopedics and Traumatology, Medical Faculty, University of Health Sciences, Antalya Training and Research Hospital, Antalya, Turkey
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Boretto JG, Holc F, Gallucci GL, Donndorff A, Rellán I, De Carli P. Fibula flap in upper extremity segmental/critical size bone defects fixed with locking plates. Single-institution observational cohort. Injury 2023; 54 Suppl 6:110737. [PMID: 37072279 DOI: 10.1016/j.injury.2023.04.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 04/10/2023] [Accepted: 04/12/2023] [Indexed: 04/20/2023]
Abstract
INTRODUCTION Management of bone defects in the upper extremity can vary depending on the size and location of the defect. Large defects may require complex reconstruction techniques. Vascularized bone grafts, mainly free vascularized fibula flap (FVFF), have many advantages in the treatment of bone or osteocutaneous defects. However, complications such as graft fracture are the most common, with a free fibula flap for bone defects in the upper extremity. This study aimed to describe the results and complications associated with the treatment of posttraumatic bone defects in the upper extremity using FVFF. We hypothesized that performing osteosynthesis using locking plates would prevent or reduce the fracture of the fibula flap MATERIALS AND METHODS: This was a retrospective single-centre cohort study. Patients with segmental bone defects caused by trauma who underwent reconstructive surgery with FVFF fixed with locking compression plates (LCP) between January 2014 and 2022 were included. Demographic variables and preoperative data, such as bone defect, location, and time until reconstruction, were collected. Bone defects were classified according to the Testworth classification. Intraoperative variables included the length of the FVFF, type of graft (osteocutaneous or not), type and technique of arterial and venous sutures, number of veins used as output flow, and the osteosynthesis technique used. RESULTS Ten patients were included (six humerus, three ulna, and one radius). All patients had critical-size bone defects, and nine patients had a history of infection. In 9 of 10 patients, bone fixation was performed with a bridge LCP and in one patient with two LCP plates. In eight cases, the FVFF was osteocutaneous. All the patients showed bone healing at the end of the follow-up period. There was one early complication, donor site wound dehiscence, and two long-term complications (proximal radioulnar synostosis and soft-tissue defect). CONCLUSION A high rate of bone union with a low rate of complications can be obtained with an FVFF in upper extremity segmental/critical-size bone defects. Rigid fixation with locking plates avoids stress fractures of the grafts, mainly in humeral reconstruction. However, in these cases, a bridge plate should be used.
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Affiliation(s)
- Jorge G Boretto
- Hand and Upper Extremity Department, Instituto de Ortopedia y Traumatología "Prof. Dr. Carlos Ottolenghi". Hospital Italiano de Buenos Aires, Argentina.
| | - Fernando Holc
- Hand and Upper Extremity Department, Instituto de Ortopedia y Traumatología "Prof. Dr. Carlos Ottolenghi". Hospital Italiano de Buenos Aires, Argentina.
| | - Gerardo L Gallucci
- Hand and Upper Extremity Department, Instituto de Ortopedia y Traumatología "Prof. Dr. Carlos Ottolenghi". Hospital Italiano de Buenos Aires, Argentina.
| | - Agustín Donndorff
- Hand and Upper Extremity Department, Instituto de Ortopedia y Traumatología "Prof. Dr. Carlos Ottolenghi". Hospital Italiano de Buenos Aires, Argentina.
| | - Ignacio Rellán
- Hand and Upper Extremity Department, Instituto de Ortopedia y Traumatología "Prof. Dr. Carlos Ottolenghi". Hospital Italiano de Buenos Aires, Argentina.
| | - Pablo De Carli
- Hand and Upper Extremity Department, Instituto de Ortopedia y Traumatología "Prof. Dr. Carlos Ottolenghi". Hospital Italiano de Buenos Aires, Argentina.
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Delivery Technique for Fibular Strut Bone Grafting to Proximal Humerus Nonunion Fractures. Tech Orthop 2021. [DOI: 10.1097/bto.0000000000000489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Carlock KD, Konda SR, Bianco IR, Zuckerman JD, Egol KA. Repair of proximal humerus fracture nonunions using a standardized treatment algorithm: a case series. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 31:1151-1159. [PMID: 33417051 DOI: 10.1007/s00590-020-02857-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 12/16/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Nonunion of fractures about the proximal humerus represents a rare and complex problem. The purpose of this study was to evaluate the clinical and functional outcomes following proximal humerus fracture (PHF) nonunion repair using a plate and screw construct with a direct comparison to those experienced following operative fixation of acute PHF using a plate and screw construct. METHODS Two separate patient cohorts were included in this study. The first consisted of 16 patients diagnosed with a non-united PHF who underwent operative nonunion repair treated with a standard algorithmic approach. The comparison group consisted of 173 patients who achieved union following initial open reduction and internal fixation of an acute PHF treated with a proximal humerus locking plate construct. All patients had at least 12 months of postoperative follow-up. Outcomes were assessed for both groups using American Shoulder and Elbow Surgeons (ASES) scores, visual analog scale (VAS) pain scores, and postoperative shoulder range of motion (ROM). Statistical analyses were used to compare these outcome measures between the two cohorts. RESULTS The nonunion repair cohort consisted of eleven surgical neck nonunions and five nonunions of both the surgical neck and greater tuberosity. Ten patients had undergone surgical treatment for their original fracture, while six were initially treated non-operatively. All patients had Boileau type 3 sequelae of their proximal humerus fracture. Union was achieved in all patients at a mean of 5.4 months following nonunion repair. Complications included hardware failure requiring revision in two patients (12.5%) and avascular necrosis requiring conversion to anatomic total shoulder arthroplasty following union in one patient (6.3%). The nonunion repair and acute fracture cohorts did not differ with respect to mean ASES scores, VAS pain scores, or active shoulder ROM at any postoperative time point. CONCLUSION Surgical repair of PHF nonunion is a viable treatment strategy that can lead to consistent bony healing with outcomes comparable to those of patients who achieve fracture union following initial surgical repair of an acute proximal humerus fracture. Surgeons should be cognizant of mechanical considerations that may lead to early failure.
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Affiliation(s)
- Kurtis D Carlock
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, 301 E 17th St, Suite 1402, New York, NY, USA
| | - Sanjit R Konda
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, 301 E 17th St, Suite 1402, New York, NY, USA
- Department of Orthopedic Surgery, Jamaica Hospital Medical Center, Jamaica, NY, USA
| | - Isabella R Bianco
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, 301 E 17th St, Suite 1402, New York, NY, USA
| | - Joseph D Zuckerman
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, 301 E 17th St, Suite 1402, New York, NY, USA
| | - Kenneth A Egol
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, 301 E 17th St, Suite 1402, New York, NY, USA.
- Department of Orthopedic Surgery, Jamaica Hospital Medical Center, Jamaica, NY, USA.
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Abstract
OBJECTIVES To characterize the literature on operative interventions for proximal humerus nonunions in adults. Second, to identify prognostic factors associated with outcomes for locked plate open reduction and internal fixation (ORIF). DATA SOURCES PubMed, EMBASE, MEDLINE, Scopus, and Cochrane databases were searched for articles from 1990 to 2020. STUDY SELECTION Studies reporting outcomes of proximal humerus nonunions managed with ORIF, hemiarthroplasty (HA), total shoulder arthroplasty (TSA), or reverse TSA (RTSA) were included. Studies failing to stratify outcomes by treatment or fracture sequelae were excluded. DATA EXTRACTION Two authors independently extracted data and appraised study quality using MINORS score. DATA SYNTHESIS Descriptive statistics were reported. Outcomes for ORIF and arthroplasty groups were not compared due to differing patient populations. CONCLUSIONS Thirty-seven articles were included, representing 508 patients (246 ORIF, 137 HA/TSA, and 125 RTSA). Patients managed by ORIF were younger with simpler fracture patterns than those managed by arthroplasty. Regarding ORIF, locked plates achieved highest union rates (97.0%), but clinical outcomes were comparable with all plate fixation constructs [forward flexion (FF): 123-144°; external rotation: 42-46°; Constant score: 75-84]. Complication and reoperation rates for ORIF were 26.0% and 14.6%, respectively. Furthermore, subgroup analysis of locked plate ORIF demonstrated shorter consolidation time with initial conservative fracture management (4.3 vs. 6.0 months) and autograft use (3.9 vs. 5.5 months). With arthroplasty, RTSA demonstrated greater forward flexion (109.4° vs. 97.2°) but less external rotation (16.5° vs. 36.8°) than HA/TSA. Complication and reoperation rates were 18.2% and 10.9% for HA/TSA and 21.6% and 14.4% for RTSA, respectively. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Ortmaier R, Moroder P, Blocher M, Auffarth A, Wutte C, Freude T, Resch H, Bogner R. Joint-preserving treatment for type 3 sequelae following fracture of the proximal humerus with small head fragments. J Orthop Sci 2019; 24:618-623. [PMID: 30580889 DOI: 10.1016/j.jos.2018.11.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 11/12/2018] [Accepted: 11/29/2018] [Indexed: 01/12/2023]
Abstract
BACKGROUND Although nonunions of the proximal humerus are rare, they cause significant disability to patients. Surgical reconstruction is challenging, especially with small and excavated head fragments. A promising surgical option is open reduction and stabilization using the Humerusblock device along with tension wires. The aim of this retrospective investigation was to evaluate the clinical and radiological results of this procedure. MATERIALS AND METHODS Fifteen patients with symptomatic surgical neck nonunions were treated with open reduction and internal fixation using the Humerusblock device without bone grafting. All patients showed a loss of bone stock, leading to excavated head fragments. The mean interval from injury to the described treatment was 6.2 months (range, 3.4-10.7). At a mean follow-up of 40.5 months, the Constant-Murley score was documented, pain and patient satisfaction were evaluated using a visual analogue scale, and x-rays were taken in two planes. RESULTS The patients' mean age was 69.7 years (range, 52-83). The mean Constant-Murley score improved from 24 points before surgery to 62 points at follow-up, which was an average of 80.8% of the score obtained for the contralateral arm. Radiological examination confirmed bony healing in 14 patients. All but one patient felt satisfied with the results. Three patients required revision surgery because of a hematoma, and early metal removal was performed in one patient because of infection. CONCLUSION Nonunions of humeral surgical neck fractures can be successfully treated by fixation using the Humerusblock device along with tension wires without the need for additional bone grafting. Especially in patients with flat, concave head fragments, this procedure remains a promising reconstructive option to arthroplasty. LEVEL OF EVIDENCE Level IV; Therapeutic retrospective case series.
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Affiliation(s)
- Reinhold Ortmaier
- Department of Orthopaedic Surgery, Ordensklinikum Barmherzige Schwestern Linz, Teaching Hospital of the Paracelsus Medical University Salzburg, Seilerstätte 4, 4020 Linz, Austria; Research Unit for Orthopaedic Sports Medicine and Injury Prevention, ISAG/UMIT, Eduard-Wallhöfer-Zentrum 1, 6060 Hall in Tirol, Austria.
| | - Philipp Moroder
- Center for Musculoskeletal Surgery, Campus Virchow, Charité -Universitaetsmedizin Berlin, 13353 Berlin, Germany.
| | - Martina Blocher
- Department of Orthopaedics and Traumatology, Paracelsus Medical University Salzburg, Muellner Hauptstrasse 48, 5020 Salzburg, Austria.
| | - Alexander Auffarth
- Department of Orthopaedics and Traumatology, Paracelsus Medical University Salzburg, Muellner Hauptstrasse 48, 5020 Salzburg, Austria.
| | - Christof Wutte
- Center for Spinal Cord Injuries, Trauma Center Murnau, Prof.-Küntscher-Str. 8, 82418 Murnau, Germany.
| | - Thomas Freude
- Department of Orthopaedics and Traumatology, Paracelsus Medical University Salzburg, Muellner Hauptstrasse 48, 5020 Salzburg, Austria.
| | - Herbert Resch
- Paracelsus Medical University, Strubergasse 21, 5020 Salzburg, Austria.
| | - Robert Bogner
- AUVA Trauma Center Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, Salzburg, Austria.
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Quadlbauer S, Hofmann GJ, Leixnering M, Rosenauer R, Hausner T, Reichetseder J. Open reduction and fixation with a locking plate without bone grafting is a reasonable and safe option for treating proximal humerus nonunion. INTERNATIONAL ORTHOPAEDICS 2018; 42:2199-2209. [DOI: 10.1007/s00264-018-3820-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Accepted: 01/29/2018] [Indexed: 12/31/2022]
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Matsumae G, Motomiya M, Watanabe N, Iwasaki N. "Half-folded" pedicled scapular bone flap for nonunion after humeral neck fracture: A case report. Microsurgery 2017; 37:689-693. [PMID: 28370473 DOI: 10.1002/micr.30175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 03/03/2017] [Accepted: 03/10/2017] [Indexed: 11/11/2022]
Abstract
Treatment of a nonunion of the proximal humerus remains a challenge because of the small proximal fragment and poor central cancellous bone stock of the humeral head. In this report, we describe our experience using a "half-folded" pedicled scapular bone flap with an anatomical locking plate to treat an atrophic nonunion of the proximal humerus in a 64-year-old right-handed woman. The patient had fallen and experienced a common humeral neck fracture 2.5 years previously. During the operation, we elevated the pedicled scapular bone flap, which measured 8.0 cm long and 1.5 cm wide, with a vascular pedicle about 10 cm long. We modified the bone flap to the half-folded type to fill the massive bone cavity in the humeral head. The proximal tip of the flap was divided into two segments while keeping the ventral soft tissue intact. The grafted bone bridging between the head and shaft of the humerus was rigidly fixed with a plate and screw. The operated shoulder was fixed with a sling and a chest belt for 3 weeks, after which the patient began active motion exercises of the shoulder joint. The flap survived without serious donor site morbidity, and good bone healing was obtained about 3.5 months after surgery. The patient was able to use the shoulder comfortably in daily activity without any serious donor site morbidity at 16 months after the surgery. This procedure may be effective in treating nonunion of the proximal humerus with a massive bone cavity in the humeral head.
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Affiliation(s)
- Gen Matsumae
- Department of Orthopaedic Surgery, Obihiro-Kosei General Hospital, Obihiro, 080-0016, Japan
| | - Makoto Motomiya
- Department of Orthopaedic Surgery, Obihiro-Kosei General Hospital, Obihiro, 080-0016, Japan.,Department of Orthopedic Surgery, Graduate School of Medicine, Hokkaido University, Sapporo, 060-8638, Japan
| | - Naoya Watanabe
- Department of Orthopaedic Surgery, Obihiro-Kosei General Hospital, Obihiro, 080-0016, Japan
| | - Norimasa Iwasaki
- Department of Orthopedic Surgery, Graduate School of Medicine, Hokkaido University, Sapporo, 060-8638, Japan
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Hao C, Wang Y, Shao L, Liu J, Chen L, Zhao Z. Local Injection of Bone Mesenchymal Stem Cells and Fibrin Glue Promotes the Repair of Bone Atrophic Nonunion In Vivo. Adv Ther 2016; 33:824-33. [PMID: 27098172 DOI: 10.1007/s12325-016-0329-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Indexed: 10/21/2022]
Abstract
INTRODUCTION This study aimed to evaluate the efficacy of local injection of bone mesenchymal stem cells (BMSCs) and fibrin glue in the treatment of atrophic nonunion in an animal model. METHODS Thirty-six male Lewis rats were randomly assigned into three groups: Group A (control group), Group B (atrophic nonunion group), and Group C (experimental group). All the rats underwent femoral osteotomy of the right hind limb, and stabilized with a custom-designed external fixator. Atrophic nonunion of the rats in Group B and C was induced by cauterization of the periosteum and bone marrow removal, and repaired by injection of fibrin glue and BMSCs-seeded fibrin glue, respectively. The surgically treated femurs were assessed by radiographic and histological analysis, and biomechanical test. RESULTS During the follow-up period, the external fixator maintained correct placement and all the femurs retained normal positioning. Eight weeks postoperatively, atrophic nonunion was detected in Group B, with the presence of fibrous connective tissue in the osteotomy gap. The femurs in Group C demonstrated complete bony bridging of the osteotomy gap, with the formation of plenty of woven bone. CONCLUSION The repair of bone atrophic nonunion can be promoted through local injection of BMSCs and fibrin glue.
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Meller R, Hawi N, Schmiddem U, Millett P, Petri M, Krettek C. Posttraumatische Fehlstellungen und Pseudarthrosen des proximalen Humerus. Unfallchirurg 2015; 118:577-85. [DOI: 10.1007/s00113-015-0032-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Results of non-union of humerus treated with retrograde humeral nail. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2014; 25:671-6. [DOI: 10.1007/s00590-014-1563-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Accepted: 11/07/2014] [Indexed: 11/27/2022]
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Allende C, Paz A, Altube G, Boccolini H, Malvarez A, Allende B. Revision with plates of humeral nonunions secondary to failed intramedullary nailing. INTERNATIONAL ORTHOPAEDICS 2014; 38:899-903. [PMID: 24258153 PMCID: PMC3971268 DOI: 10.1007/s00264-013-2180-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Accepted: 10/30/2013] [Indexed: 11/26/2022]
Abstract
PURPOSE The objective of this study was to evaluate the results achieved after revision with plates of humeral nonunions secondary to failed intramedullary nailing. METHODS We retrospectively evaluated 32 patients with humeral nonunions secondary to failed intramedullary nailing, treated by internal fixation with plates between 1998 and 2012. Nonunions were diaphyseal in 19 cases, they were located in the proximal humeral metaphysis in nine cases, and in the distal humeral metaphysis in four cases. There were 11 atrophic nonunions and 21 oligotrophic nonunions. Initial treatment was performed with static locked nails in 12 cases, nails with expansive locking systems in 11 cases, and using thin elastic nails in nine cases. The nails were placed antegrade in 18 cases and retrograde in 14 cases. Time between initial surgery and revision surgery averaged 14.5 months. In seven diaphyseal nonunions, the intramedullary nail was left in-situ. Bone graft was added in 25 cases. RESULTS Follow-up averaged 35 months. Union was achieved in all cases, after an average of 3.8 months. Disabilities of the Arm, Shoulder and Hand (DASH) score at last follow-up averaged 14 points, and Constant's score averaged 82 points. The analogue scale of pain averaged 0.8 points. Out of seven patients with radial nerve compromise, six recovered completely and one needed tendon transfers. CONCLUSIONS Revision with plates after failed intramedullary humeral nailing achieved union and good predictable objective and subjective results in all cases. Adequate implant selection and meticulous surgical technique are necessary to achieve successful osteosynthesis and bony union.
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Affiliation(s)
- Christian Allende
- Instituto de Cirugía Reconstructiva de los Miembros, Sanatorio Allende, Córdoba, Argentina,
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Martinez AA, Bejarano C, Carbonel I, Iglesias D, Gil-Albarova J, Herrera A. The treatment of proximal humerus nonunions in older patients with reverse shoulder arthroplasty. Injury 2012; 43 Suppl 2:S3-6. [PMID: 23622989 DOI: 10.1016/s0020-1383(13)70172-4] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Experience with treating proximal humeral nonunions with reverse total shoulder arthroplasty is limited. We report our results. PATIENTS Eighteen 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. 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 Reverse total shoulder arthroplasty improves function and motion in patients with proximal humeral fracture sequelae. However, the rate of dislocation is high.
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Affiliation(s)
- Angel A Martinez
- Department of Orthopaedic and Trauma Surgery, Miguel Servet University Hospital, Zaragoza, Spain
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Martinez AA, Bejarano C, Carbonel I, Iglesias D, Gil-Alvaroba J, Herrera A. WITHDRAWN: The treatment of proximal humerus nonunions in older patients with the reverse shoulder arthroplasty. Injury 2012:S0020-1383(11)00591-2. [PMID: 22222366 DOI: 10.1016/j.injury.2011.12.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
This article has been withdrawn at the request of the editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.
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Affiliation(s)
- Angel A Martinez
- Department of Orthopaedic and Trauma Surgery, Miguel Servet University Hospital, Zaragoza, Spain
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Abstract
OBJECTIVE To evaluate reconstruction surgery without bone grafting in humeral surgical neck nonunions using either a blade plate or the "Humerusblock" implant in small head fragments. DESIGN Retrospective cohort study, Evidence-Based Medicine Level IV. SETTING Paracelsus Medical University Salzburg, Department of Traumatology and Sports Injuries. PATIENTS Fifty-five patients (mean age, 66.2 years) with symptomatic nonunion after humeral surgical neck fractures were subjected to surgical reconstruction. INTERVENTION In 45 patients, open reduction and internal fixation using a blade plate was performed (Group 1). In 10 patients, the Humerusblock device was used (Group 2), because the head fragment of each of these patients was too small for plating. In no patients was bone grafting used. MAIN OUTCOME MEASUREMENTS Shoulder function, level of pain, and bone healing. RESULTS After a mean follow-up time of 74 months, the overall mean Constant score improved from 30.4% preoperatively to 83.2% postoperatively. The improvement was from 30.5% to 85.3% in Group 1 and from 32.2% to 75.4% in Group 2, which represented statistically significant improvements for both groups (P < 0.01). Radiologic bone healing was achieved in 51 patients (93%). The overall complication rate was high, 15%, and complications included plate loosening, avascular head necrosis, persistent nonunion, and infection. CONCLUSIONS Nonunion of humeral surgical neck fractures can be successfully treated by surgical reconstruction without bone grafting using either a blade plate or the Humerusblock for small head fragments. However, an increased complication rate is associated with this challenging posttraumatic pathology.
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Cement Spacers With Antibiotics for the Treatment of Posttraumatic Infected Nonunions and Bone Defects of the Upper Extremity. Tech Hand Up Extrem Surg 2010; 14:241-7. [PMID: 21107224 DOI: 10.1097/bth.0b013e3181f42bd3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Infected nonunions of long bones of the upper extremity: staged reconstruction using polymethylmethacrylate and bone graft impregnated with antibiotics. Musculoskelet Surg 2009; 93:137-42. [PMID: 19876707 DOI: 10.1007/s12306-009-0046-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2009] [Accepted: 10/14/2009] [Indexed: 10/20/2022]
Abstract
This case series evaluates 12 patients presenting posttraumatic infected nonunions affecting long bones of the upper extremity, treated with staged reconstruction using polymethylmethacrylate spacers with antibiotics in the first stage and bone graft impregnated with antibiotics in the definitive surgical procedure. Five nonunions affected the humerus, four the ulna and three the radius. All nonunions were atrophic. Patient's age averaged 35.9 years. The size of the bony defect averaged 2.8 cm. Time between original trauma and revision surgery averaged 9.6 months. Follow-up averaged 19 months. All nonunions healed after an average of 5 months. DASH score at last follow-up averaged 15 points. Although two surgical procedures are needed, one to cure infection and another to achieve bony union, this approach for posttraumatic infected nonunions of long bones of the upper extremities represents a valid treatment alternative.
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