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Vendeville B, Fabbri C, Roche O, Peduzzi L, Sirveaux F. Treatment of presumed aseptic non-union of the humeral shaft by osteosynthesis combining intramedullary nailing and screw plate. Acta Orthop Belg 2024; 90:102-109. [PMID: 38669658 DOI: 10.52628/90.1.11809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024]
Abstract
In 2020, the most common treatment for presumed aseptic non-union of the humeral shaft seems to be decortication, often associated with bone autografting, and stabilized by a screw plate. We propose to evaluate an original technique of rigid osteosynthesis combining intramedullary nailing and screw plate. Between January 2004 and January 2020, 45 patients underwent treatment of presumed aseptic non-union of the humeral shaft by osteosynthesis combining intramedullary nailing and a screw plate. The minimum radio-clinical follow-up was one year postoperatively. The series included 19 men and 26 women with a mean age of 53 years (range 19-84 years). Bone consolidation was achieved in 43 patients, a rate of 95.5%. Comparing patients who achieved bone consolidation with the two failed consolidations did not reveal any statistically significant factor. Interobserver agreement was almost perfect (k=0.93) for the use of the RUST for humeral shaft fractures treated with intramedullary nailing and screw plate. In our study, the treatment of presumed aseptic non- union of the humeral shaft with an osteosynthesis combining intramedullary nailing and screw plate gives, with 95.5% of bone consolidation, results equal to or even superior to the different treatments currently described in the literature.
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Harrison N, Hysong A, Posey S, Yu Z, Chen AT, Pallitto P, Gardner MJ, Dumpe J, Mir H, Babcock S, Natoli RM, Adams JD, Zura RD, Miller AN, Seymour RB, Hsu JR, Obremskey W. Outcomes of Humerus Nonunion Surgery in Patients With Initial Operative Fracture Fixation. J Orthop Trauma 2024; 38:168-175. [PMID: 38158607 DOI: 10.1097/bot.0000000000002740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 12/12/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVES To describe outcomes following humerus aseptic nonunion surgery in patients whose initial fracture was treated operatively and to identify risk factors for nonunion surgery failure in the same population. METHODS DESIGN Retrospective case series. SETTING Eight, academic, level 1 trauma centers. PATIENTS SELECTION CRITERIA Patients with aseptic humerus nonunion (OTA/AO 11 and 12) after the initial operative management between 1998 and 2019. OUTCOME MEASURES AND COMPARISONS Success rate of nonunion surgery. RESULTS Ninety patients were included (56% female; median age 50 years; mean follow-up 21.2 months). Of 90 aseptic humerus nonunions, 71 (78.9%) united following nonunion surgery. Thirty patients (33.3%) experienced 1 or more postoperative complications, including infection, failure of fixation, and readmission. Multivariate analysis found that not performing revision internal fixation during nonunion surgery (n = 8; P = 0.002) and postoperative de novo infection (n = 9; P = 0.005) were associated with an increased risk of recalcitrant nonunion. Patient smoking status and the use of bone graft were not associated with differences in the nonunion repair success rate. CONCLUSIONS This series of previously operated aseptic humerus nonunions found that more than 1 in 5 patients failed nonunion repair. De novo postoperative infection and failure to perform revision internal fixation during nonunion surgery were associated with recalcitrant nonunion. Smoking and use of bone graft did not influence the success rate of nonunion surgery. These findings can be used to give patients a realistic expectation of results and complications following humerus nonunion surgery. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Noah Harrison
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Alexander Hysong
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC
| | - Samuel Posey
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC
| | - Ziqing Yu
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC
| | - Andrew T Chen
- Department of Orthopaedic Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Patrick Pallitto
- Department of Orthopaedic Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Michael J Gardner
- Department of Orthopaedic Surgery, Stanford University, Stanford, CA
| | - Jarrod Dumpe
- Department of Orthopaedic Surgery, Atrium Health Navicent Medical Center, Macon, GA
| | - Hassan Mir
- Department of Orthopaedic Surgery, Florida Orthopedic Institute, Tampa, FL
| | - Sharon Babcock
- Department of Orthopaedic Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, NC
| | - Roman M Natoli
- Department of Orthopaedic Surgery, Indiana University School of Medicine, IU Health Methodist Hospital, Indianapolis, IN
| | - John D Adams
- Department of Orthopaedic Surgery, Prisma Health, Greenville, SC
| | - Robert D Zura
- Department of Orthopaedics, Louisiana State University, New Orleans, LA; and
| | - Anna N Miller
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Rachel B Seymour
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC
| | - Joseph R Hsu
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC
| | - William Obremskey
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN
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Dheenadhayalan J, Vembanan K, Devendra A, Perumal R, Nagashree V, Kumar AH, Rajasekaran S. Consistent Protocol-Based Management of Humerus Shaft Nonunion: An Analysis of 100 Cases. Indian J Orthop 2023; 57:552-564. [PMID: 37006739 PMCID: PMC10050540 DOI: 10.1007/s43465-023-00819-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 01/06/2023] [Indexed: 01/28/2023]
Abstract
Introduction Humerus shaft nonunions are very disabling and challenging to treat. The current study aims to analyse the rate of union and the incidence of complications following a consistent protocol in treating humerus shaft nonunion. Methodology We did a retrospective analysis of 100 patients with humerus shaft nonunion treated over an eight-year period from 2014 to 2021. The mean age was 42 years (range 18-75 years). There were 53 male and 47 female patients. The average time interval from injury to nonunion surgery was 23 months (range 3 months to 23 years). The series included 12 recalcitrant nonunions and 12 patients with septic nonunion. All patients underwent freshening of fracture edges to increase the contact surface area, stable fixation with a locking plate and intramedullary iliac crest bone grafting. Infective nonunions were treated in a staged manner, following a similar treatment protocol after the elimination of infection in the first stage. Results Complete union was achieved in 97% of the patients with a single procedure. One patient achieved union after an additional procedure, while two patients were lost to further follow-up. The mean time to union was 5.7 months (range 3-10 months). Three patients (3%) had postoperative radial nerve palsy, which recovered completely within 6 months. Three patients (3%) had a superficial surgical site infection, while one patient (1%) developed a deep infection. Conclusion Intramedullary cancellous autologous grafts combined with stable fixation by compression plating achieve a high union rate with minimal complications. Level of Evidence III. Level of Clinical Care Level I Tertiary trauma centre.
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Affiliation(s)
- Jayaramaraju Dheenadhayalan
- Department of Orthopaedics and Trauma, Ganga Medical Centre and Hospitals Pvt. Ltd, 313, Mettupalayam Road, Coimbatore, Tamil Nadu India
- No.3, Gandhinagar, Behind Cheran Nagar, GN Mills Post, Coimbatore, 641029 Tamil Nadu India
| | - Kavinkumar Vembanan
- Department of Orthopaedics and Trauma, Ganga Medical Centre and Hospitals Pvt. Ltd, 313, Mettupalayam Road, Coimbatore, Tamil Nadu India
| | - Agraharam Devendra
- Department of Orthopaedics and Trauma, Ganga Medical Centre and Hospitals Pvt. Ltd, 313, Mettupalayam Road, Coimbatore, Tamil Nadu India
| | - Ramesh Perumal
- Department of Orthopaedics and Trauma, Ganga Medical Centre and Hospitals Pvt. Ltd, 313, Mettupalayam Road, Coimbatore, Tamil Nadu India
| | - Vasudeva Nagashree
- Department of Orthopaedics and Trauma, Ganga Medical Centre and Hospitals Pvt. Ltd, 313, Mettupalayam Road, Coimbatore, Tamil Nadu India
| | - Aditya H. Kumar
- Department of Orthopaedics and Trauma, Ganga Medical Centre and Hospitals Pvt. Ltd, 313, Mettupalayam Road, Coimbatore, Tamil Nadu India
| | - Shanmuganathan Rajasekaran
- Department of Orthopaedics and Trauma, Ganga Medical Centre and Hospitals Pvt. Ltd, 313, Mettupalayam Road, Coimbatore, Tamil Nadu India
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Bégué T, Mouchantaf M, Aurégan JC. Aseptic humeral shaft nonunion. Orthop Traumatol Surg Res 2023; 109:103462. [PMID: 36942794 DOI: 10.1016/j.otsr.2022.103462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 05/25/2022] [Indexed: 12/24/2022]
Abstract
Aseptic humeral shaft nonunions are rare lesions, with less than 700 cases per year in France. This low frequency explains why they are difficult to manage. They can be hypertrophic or atrophic, with or without a defect. The diagnosis is made based on radiographs and/or CT scan images. Nonunion is suspected early on when a patient presents with abnormal motion at the fracture site 6 weeks after the initial injury event in the context of conservative treatment or has large residual displacement after initial treatment or an open fracture. The treatment for hypertrophic nonunion consists in applying stable, rigid fixation, most often using a large-fragment plate with 4.5 mm screws, combined with cancellous autograft. When combined with the osteoperiosteal decortication first described by Judet, it produces union in 98% of cases. Intramedullary (IM) nail fixation with an autograft is another possibility. In atrophic nonunions, resecting the ends and ensuring the soft tissues have good vitality will generally lead to fracture union. Nonunions with critical size defects (larger than 5 cm), which have a high risk of infection, are a treatment challenge that requires stable fixation and recourse to more complex treatments like the two-step induced membrane technique or vascularized fibular graft. In all cases, to avoid complex repeat revision, internal fixation with plate or IM nail must be combined with a bone graft in situ to maximize the chances of union.
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Affiliation(s)
- Thierry Bégué
- Service de chirurgie orthopédique et traumatologique, hôpital Antoine Béclère, université Paris-Saclay, AP-HP, 157, rue de la Porte de Trivaux, 92140 Clamart, France.
| | - Mark Mouchantaf
- Service de chirurgie orthopédique et traumatologique, hôpital Antoine Béclère, université Paris-Saclay, AP-HP, 157, rue de la Porte de Trivaux, 92140 Clamart, France
| | - Jean-Charles Aurégan
- Service de chirurgie orthopédique et traumatologique, hôpital Antoine Béclère, université Paris-Saclay, AP-HP, 157, rue de la Porte de Trivaux, 92140 Clamart, France
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Shetty K, Cheppalli N, Kaki D. Autologous Nonvascularized Fibula Graft and Locking Compression Plating for Failed Fixation of Humeral Shaft With Atrophic Gap Nonunion. Cureus 2022; 14:e24293. [PMID: 35602781 PMCID: PMC9119860 DOI: 10.7759/cureus.24293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/18/2022] [Indexed: 11/05/2022] Open
Abstract
Introduction The surgical treatment of humeral shaft atrophic, gap nonunion following failed surgical fixation is challenging. We intended to evaluate the surgical outcome of failed fixation of humeral shaft atrophic, gap nonunions using locking compression plate (LCP) and autologous nonvascularized fibular graft (ANVFG) and autologous iliac crest bone graft (AICBG).
Methods Through our database search between 2015 and 2018, we identified 12 patients with humeral shaft atrophic, gap nonunions with failed surgical fixation underwent open reduction and internal fixation using LCP with autologous fibula graft and iliac crest cancellous bone graft.
Results We have followed all twelve patients for a minimum period of 24 months. All patients had radiological and clinical union with a mean time to union of 17 weeks. In one case superficial surgical site infection was noted and successfully treated with intravenous antibiotics, and in another, transient peroneal nerve palsy was identified and resolved in six months.
Conclusion LCP with ANVFG and AICBG is a reliable option for “complex” diaphyseal humerus atrophic and gap non unions, especially with significant bone loss. This construct provides mechanical stability and supports biological healing in these complex fractures.
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Bridge plating with decortication, autologous bone graft, and tight closure: a “stepwise surgical diamond concept” for treatment of nonunion in a series of fifty five patients. INTERNATIONAL ORTHOPAEDICS 2022; 46:1241-1251. [DOI: 10.1007/s00264-022-05379-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 03/11/2022] [Indexed: 10/18/2022]
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Sadek AF, Fouly EH, Allam AFA, Mahmoud AZ. Non-vascularized fibular autograft for resistant humeral diaphyseal nonunion: Retrospective case series. Orthop Traumatol Surg Res 2021; 107:102843. [PMID: 33548560 DOI: 10.1016/j.otsr.2021.102843] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 10/17/2020] [Accepted: 10/29/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION There is a great surgical challenge when humeral diaphyseal fractures are initially open, complex, or associated with segmental bone loss. The challenge becomes even greater with previous multiple unsuccessful surgeries. The question of this study was: Does combining locked compression plating with non-vascularized fibular autograft in cases of resistant humeral diaphyseal nonunion yield reliable bony union and satisfactory functional outcome? HYPOTHESIS The use of non-vascularized fibular autograft in conjunction with locked compression plating will provide stable construct, enhance bony union and improve functional outcome in cases of resistant humeral diaphyseal nonunion. MATERIALS AND METHODS Thirty-three patients with resistant humeral diaphyseal nonunion who were surgically managed combining non-vascularized fibular autograft fixed with locked compression plating in the period from January 2011 to June 2017, were retrospectively studied. All patients were followed-up for a minimum of 24 months. The time to union, the postoperative disability of arm, shoulder and hand (DASH) score, in addition to the possible complications including infection or nonunion were reported and analyzed. RESULTS Twenty-nine patients have achieved union at the final follow-up with a mean time to radiological union of 7.5±2.6 months (range: 3-12). The mean postoperative DASH score was 7.7±8.9 (range: 0-38.8) which was significantly better than the preoperative value (p<0.001) and superior in the patients of aseptic nonunion (p=0.04). Eight patients showed complications in the form of infection (four), nonunion (two cases), transient radial nerve palsy (one case) and one case of septic nonunion that was managed by two-stage reconstruction using vascularized fibular autograft. There were comparable results in patients with either open or closed fractures. However, patients with septic nonunion experienced more significant complications (p=0.02). DISCUSSION The use of non-vascularized fibula autograft in cases of resistant humeral diaphyseal nonunion provides adequate fracture stability, quadrilateral screw purchase, enhances bony union in addition to promoting satisfactory functional outcome particularly in aseptic nonunion. LEVEL OF EVIDENCE IV; retrospective case series.
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Affiliation(s)
- Ahmed Fathy Sadek
- Orthopaedic Surgery Department, Faculty of Medicine, Minia University, Minia, Egypt.
| | - Ezzat Hassan Fouly
- Orthopaedic Surgery Department, Faculty of Medicine, Minia University, Minia, Egypt
| | | | - Alaa Zenhom Mahmoud
- Orthopaedic Surgery Department, Faculty of Medicine, Minia University, Minia, Egypt
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Dahm F, Feichtinger X, Vallant SM, Haffner N, Schaden W, Fialka C, Mittermayr R. High-energy extracorporeal shockwave therapy in humeral delayed and non-unions. Eur J Trauma Emerg Surg 2021; 48:3043-3049. [PMID: 34515810 DOI: 10.1007/s00068-021-01782-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 08/30/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Within the last few decades, focused high-energy extracorporeal shockwave therapy (ESWT) has proven to be an effective alternative to standard of care revision surgery in delayed healing fractures or manifest non-unions in various anatomical regions. MATERIALS AND METHODS A retrospective multi-variant analysis of an open prospective, single-armed clinical study was conducted. Patients receiving focused high-energy ESWT for a delayed healing or an apparent non-union of a humeral fracture between January 1999 and December 2015 at a single trauma center were included in the study. Bony healing was defined as cortical continuity in three of four cortices and pain-free force loading and evaluated using CT scans and clinical examination at three- and six-month follow-ups after ESWT. RESULTS A total of 236 patients were included. N = 93 (43.8%) showed bony consolidation three months after ESWT and n = 105 (52.5%) after six months. Sub-group analysis showed significantly better healing for the proximal metaphyseal humerus (66.7% after six months, n = 42) compared to the diaphyseal region (48.1%, n = 133) and distal metaphyseal humerus (48.1%, n = 25). Regression analysis indicated significantly increased healing rates for patients of younger ages (p = 0.001) and a fracture diastasis of less than 5 mm (p = 0.002). CONCLUSION The findings of this study indicate that ESWT can be considered as a treatment option for a well-selected patient population despite the lower healing rates compared to other anatomical regions.
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Affiliation(s)
- Falko Dahm
- AUVA Trauma Center Meidling, Kundratstr. 37, 1120, Vienna, Austria. .,Women's College Hospital, University of Toronto Orthopaedics Sports Medicine, Toronto, Canada.
| | - Xaver Feichtinger
- AUVA Trauma Center Meidling, Kundratstr. 37, 1120, Vienna, Austria.,Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Vienna, Austria
| | | | - Nicolas Haffner
- Department for Orthopedics and Trauma Surgery, Krankenhaus Nord-Klinik Floridsdorf, Vienna, Austria
| | - Wolfgang Schaden
- AUVA Trauma Center Meidling, Kundratstr. 37, 1120, Vienna, Austria.,Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Vienna, Austria.,Austrian Cluster for Tissue Regeneration, Vienna, Austria
| | - Christian Fialka
- AUVA Trauma Center Meidling, Kundratstr. 37, 1120, Vienna, Austria.,Medical Faculty, Sigmund Freud University, Vienna, Austria
| | - Rainer Mittermayr
- AUVA Trauma Center Meidling, Kundratstr. 37, 1120, Vienna, Austria.,Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Vienna, Austria.,Austrian Cluster for Tissue Regeneration, Vienna, Austria
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Mavrogenis AF, Quaile A, Pećina M, Scarlat MM. Citations, non-citations and visibility of International Orthopaedics in 2017. INTERNATIONAL ORTHOPAEDICS 2018; 42:2499-2505. [PMID: 30298386 DOI: 10.1007/s00264-018-4198-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Andreas F Mavrogenis
- First Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Marko Pećina
- Department of Orthopaedics, School of Medicine, University of Zagreb, Zagreb, Croatia
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