Unstable nonunions of the distal part of the humerus

Nonunion of distal humeral fractures: Current concepts

The incidence of complex articular fractures of the distal humeral in adults has increased and will be growing in the future due to the greater incidence of high energy trauma and to the higher percentage of elderly population. Successful treatment is challenging for the needed balance between a stability of often comminuted fracture and early motion. Nonunion is a common complication after distal humerus fractures that is influenced by a variety of factors such as biology, in particular the blood supply of the metaphysis, the non-anatomical reduction of the fracture, the methods of fixation, and mechanical failure. These can involve the intra-articular or extra-articular areas. Clinical presentation may be mainly with a flail elbow in extra-articular nonunion or mainly with disfunction and stiffness for an intra-articular nonunion. However, the symptoms will depend on the degree of articular surfaces damage and the main localization of nonunion in the intra- and extra-articular region. The surgical treatment is usually required, being the non-operative treatment with a brace a reasonable option just for low-demand patients and with a high risk of complications. Despite a limited range of motion regained, the union rate achieved with internal fixation and bone grafting is substantially high.

Factors Associated With Episode of Care Adverse Events After Humerus Nonunion Repair

BACKGROUND

Humeral nonunions have devastating negative effects on patients' upper extremity function and health-related quality of life. The objective of this study was to identify factors independently associated with 30-day complication, hospital readmission, and reoperation after surgical treatment of humeral nonunions.

MATERIALS AND METHODS

A retrospective case-control study was performed using the American College of Surgeons National Surgical Quality Improvement Program database by querying the Current Procedural Terminology codes for patients who underwent humeral nonunion repair from 2011 to 2020. The study outcomes were 30-day complication, hospital readmission, and reoperation.

RESULTS

Of the 1306 patients in our cohort, 135 patients (10%) developed a complication, 66 patients (5%) were readmitted to the hospital, and 44 patients (3%) underwent reoperation during the 30-day postoperative period. Multivariable logistic regression analysis showed that older age, longer operative time, partially dependent functional status, congestive heart failure, bleeding disorder, and contaminated wound classification were associated with 30-day complication after humeral nonunion repair. Older age and disseminated cancer were associated with 30-day reoperation after humeral nonunion repair. Disseminated cancer was associated with 30-day readmission after humeral nonunion repair.

CONCLUSION

Using a large database over a recent 10-year period, we identified demographic and comorbid factors independently associated with episode of care adverse events after humeral nonunion repair. Patients 50 years or older had approximately three times the incidence of complications, readmissions, and reoperations in the first month after humeral nonunion repair compared with patients younger than 50 years. Our findings are relevant for preoperative risk stratification and counseling. [Orthopedics. 2024;47(4):e181-e187.].

Predictors of Adverse Events in the Surgical Treatment of Adult Distal Humerus Fractures

The purpose of this study was to identify surgical complications after distal humerus fracture fixation as well as correlations between these complications and patient variables. A total of 132 patients underwent open reduction and internal fixation of traumatic distal humerus fractures between October 2011 and June 2018. Included were adult patients who underwent surgical fixation and had more than 6 months of follow-up. Excluded were patients with inadequate radiographic imaging, less than 6 months of follow-up, and previous distal humerus surgery. Multivariate logistic regression models controlling for age and body mass index were used to determine preoperative factors predictive of postoperative complications. A total of 73 patients were included in this analysis. Surgical complications were reported for 17 patients. Reoperation was required for 13 patients. Open injury at presentation was predictive of delayed union. Predictors of subsequent elbow surgery included younger age, polytrauma, open fracture, and ulnar nerve injury at the time of injury. Radial nerve injury at the time of presentation was also a risk factor for postoperative radial nerve symptoms. Predictors of postoperative heterotopic ossification included older age. Thirty-one patients had an olecranon osteotomy during their open reduction and internal fixation and none went on to nonunion. There were 13 patients with ulnar nerve complications. Of these patients, 3 had undergone an ulnar nerve transposition. None of the other studied variables were predictors of complications, malunion, or nonunion at latest follow-up. Although open reduction and internal fixation is effective in treating distal humerus fractures, its complications cannot be overlooked. Open fractures are more likely to go on to delayed union. Ulnar nerve injury, open fracture, and polytrauma were predictive for reoperation. Older patients were less likely to have subsequent surgery but more likely to develop heterotopic ossification. By identifying at-risk patients, managing physicians can better prognosticate and counsel patients on their recovery. [Orthopedics. 2023;46(6):352-357.].

A Novel Hemiarthroplasty Design for Treatment of Post-traumatic Elbow Ankylosis and Distal Humerus Nonunion: A Case Report

CASE

A 26 year old man sustained a blast injury to the right elbow, resulting in chronic distal humerus nonunion and post-traumatic ankylosis. After debridement and flap coverage, a custom distal humerus hemiarthroplasty construct with extramedullary orthogonal plating was used. Satisfaction and functional outcomes were maintained through 6 years of follow-up.

CONCLUSION

This case presents a unique 1-stage surgical solution which demonstrates the potential for uncemented extramedullary hemiarthroplasty fixation with simultaneous compression plate osteosynthesis across a nonunion site. The potential for hemiarthroplasty designs to be linked to orthogonal plates preserves the intramedullary canal for future conversion to total elbow arthroplasty if necessary.

Double Plating in Type C Distal Humerus Fractures: Current Treatment Options and Factors that Affect the Outcome

Purpose

This is a retrospective cohort study of type C distal humeral fractures (AO classification system) aimed at evaluating the effectiveness of current operative treatment options.

Materials and methods

Thirty-seven patients with type C distal humeral fractures, treated operatively from January 2002 to September 2016, were retrospectively studied. Thirty-two were eligible for inclusion. Patients were treated by open reduction using the posterior approach, olecranon osteotomy and parallel-plate two-column internal fixation. Patients were evaluated for fracture healing, functional outcomes and complications (infection, ulnar neuropathy, heterotopic ossification and need for implant removal). Restoration of the normal anatomy was defined by measuring carrying angle, posterior angulation and intercondylar distance of distal humerus.

Results

The mean follow-up time was 8.7 years [range 2–15.5 years, standard deviation (SD) = 3.96]. Mean time to fracture union was 8 weeks for 29 patients (90.6%) (range, 6–10 weeks). In nine cases, there was malunion of varied importance (28.1%). There was one case with postoperative ulnar neuropathy and one case with deep infection. The mean Disabilities of the Arm, Shoulder and Hand (DASH) score and mean Mayo Elbow Performance Score (MEPS) were 20 (range 0–49) and 83.3 (range 25–100), respectively.

Conclusion

In complex distal humerus fractures, the posterior approach with olecranon osteotomy and parallel plating of two columns, after anatomic reconstruction of the articular segment, is a prerequisite for successful elbow function.

How to cite this article

Athanaselis ED, Komnos G, Deligeorgis D, et al. Double Plating in Type C Distal Humerus Fractures: Current Treatment Options and Factors that Affect the Outcome. Strategies Trauma Limb Reconstr 2022;17(1):7–13.

Risk Factors for Non-Union after Open Reduction and Internal Fixation in Patients with Distal Humerus Fractures

BACKGROUND

Only a few studies have reported on the risk factors for non-union after open reduction and internal fixation (ORIF) in distal humerus fractures.

METHODS

We retrospectively reviewed 155 patients who underwent ORIF for distal humerus fractures from January 2008 to June 2020. Various patient factors, including body mass index (BMI), diabetes mellitus (DM), and combined fracture, as well as surgical factors, including fixation methods (e.g., orthogonal plate/parallel plate/single plate/tension bend wiring [TBW]) and combined fracture operations, were evaluated as risk factors for non-unions.

RESULTS

Among the patient factors, BMI (25.0 ± 3.4 vs. 22.7 ± 3.4, p = 0.032), DM (5/13 [38.5%] vs. 20/142 [14.1%], p = 0.038) and combined fracture (5/13 [38.5%] vs. 16/142 [11.3%], p = 0.018) were significantly different between groups with non-union and union. Among the surgical factors, combined fracture operation (5 [38.5%] vs. 9 [6.3%], p = 0.002) and the fixation method (3 [23.1%]/1 [7.7%]/4 [30.8%]/5 [38.5%] vs. 84 [59.2%]/7 [4.9%]/40 [28.2%]/11 [7.7%], p = 0.005) showed a significant difference between groups with non-union and union. Multivariate regression analysis showed that combined fracture operation (OR 10.467; 95% CI 1.880-58.257; p = 0.007) and TBW (OR 9.176; 95% CI 1.474-57.135; p = 0.018) among the fixation methods posed as a significant risk factor for non-union.

CONCLUSIONS

The risk of non-union increased in patients who underwent surgery for another fracture combined with distal humerus fracture and in patients who underwent ORIF with TBW.

Radial Forearm Vascularized Osteomuscular Flap for Proximal Ulnar Deficiency After Revision Total Elbow Arthroplasty: A Case Report

CASE

A 61-year-old woman presented with a failed proximal ulna allograft-prosthetic composite after revision total elbow arthroplasty (TEA). The ulnar deficiency was addressed using an osteomuscular flap from the distal radius pedicled on the radial artery. At final follow-up, she had minimal pain and a flexion-extension arc of 0° to 130°. Radiographs demonstrated graft incorporation and a stable TEA construct.

CONCLUSION

This demonstrates utilization of a vascularized osteomuscular flap from the radius for treatment of proximal ulnar deficiency in the setting of revision TEA. This technique offers an alternative option for the challenge of a failed TEA with ulnar bone loss.

Osteochondral allograft transplantation for complex distal humeral fractures assisted by 3D computer planning and printing technology: technical note

PURPOSE

The surgical treatment of comminuted distal humeral articular fractures (DHF) is challenging and is jeopardized by the high rate of complications. The study aims to describe the application of osteochondral allograft (OCA) transplantation for the treatment of complex DHF assisted with a 3D printed specific instrumentation.

METHODS

Retrospective study. Inclusion criteria were the presence of an articular multi-fragmented DHF treated with frozen OCA. Clinical, self-reported and radiographic outcomes were collected every 6 months. CT were performed at 2 years FU.

RESULTS

Four patients were included. At a mean follow-up of 37.3 months (24-49) MEPS, DASH and VAS were 90 (80-100), 11.8 (0-25) and 1 (0-3) points, respectively. Not significant complication or reoperation was recorded. Graft healing was observed in 3 cases. In all cases, we observed arthritic progression after 2 years of follow-up.

CONCLUSION

OCA transplantation can be considered a reliable and safe procedure in patients affected by a complex DHF.

LEVEL OF EVIDENCE

Level V. Technical Notes.

A review of the surgical management of distal humerus fractures and nonunions: From fixation to arthroplasty

Distal humeral fractures in adults are challenging injuries. They often require surgical intervention in form of internal fixation or total elbow arthroplasty which is being increasingly used in physiologically elderly patients with comminuted fractures. Careful preoperative evaluation including type of fracture, quality of bone, pre-existing conditions and functional demand help in deciding optimal treatment. CT scans including 2D and 3D reconstructions are almost mandatory in proper planning of the surgical treatment. In most cases with a healthy physiologically young patient, ORIF is the treatment of choice. Biomechanical studies have shown that parallel plating resists rotational deformity to a greater degree than 90/90 plating allowing supracondylar union. Accurate realignment of articular fragments and compression at the supracondylar area is key to the success of the internal fixation. Main cause of failure of fixation is the nonunion or malunion in the supracondylar area. The principles described by O'Driscoll et al. allow for rigid fixation of the distal articular fragments and compression at the supracondylar level which is vital to healing and the prevention of hardware failure, and nonunion. Olecranon osteotomy improves the expodure of distal humeral articular surface but has its own share of problems and should be avoided if possible. Irritation of ulnar nerve is a common complication so it should be isolated, kept under vision throughout and if necessary, transposed anteiriorly. Nonunion or malunion of supracondylar fractures can be treated by revision ORIF or total elbow arthroplasty (TEA). Supracondylar shortening, bone grafting and contracture release are important elements of treatment of nonunions. In unreconstructable distal humerus fractures, where open reduction and internal fixation is not possible due to the small size of the fragments, severe comminution and/or poor bone quality, TEA is the treatment of choice. Triceps can be left intact as the excision of fractured fragments usually provide enough space to carry out the operation. Sometimes, the decision to perform TEA is only made after exposing the fracture so the surgeon should be comfortable in performing TEA if ORIF is not possible; and necessary instruments and implants should be available on the shelf. In spite of satisfactory outcome, overall complication rate after TEA remains high and makes surgical efficiency and technical competence of utmost importance.

Reconstruction of infected nonunion of the distal humerus by Ilizarov external fixator

BACKGROUND

Infected nonunion of the distal humerus represents a true challenge as the fragment is usually small and difficult for fixation. The aim of the present study is to assess the results of Ilizarov external fixator in management of infected nonunion of the distal third humerus.

MATERIAL AND METHODS

Twenty-three patients with infected nonunion of the distal humerus were included in this study. The ages ranged from 19 to 58 years with an average of 35 years. Seventeen cases were males and 6 were females. All patients were treated by radical debridement and application of Ilizarov external fixator in one stage surgery.

RESULTS

Bony union was achieved in all cases. Bone graft was required in 12 patients with hypotrophic nonunion. The external fixation time ranged from 4 to 9 months with an average of 5.6 months. Infection was controlled in all cases without recurrence during the period of follow up. The complications included pin tract infection in 7 cases, radial nerve injury in one case, elbow stiffness in 4 cases and refracture after frame removal in one case.

CONCLUSION

Ilizarov external fixator is effective in management of infected nonunion of the distal humerus. The thin tensioned wires produce good grip in the small or osteoporotic bone fragments.

The flail elbow: Every surgeon's nightmare

A flail elbow joint has an excessive or abnormal degree of mobility resulting in loss of function. Such a situation can arise from structural damage or loss of neuromuscular control. Structural damage may be in terms of loss of integrity of bony, ligamentous, or both components, and this is commonly caused by trauma, failed arthroplasty, infections - either in the native joint or associated with the above, or inflammatory arthritides. Arm paralysis from any cause may also leads to a loss of muscle control making the elbow flail. The management of the condition varies according to etiology; and concurrent issues like infection and instability need to be addressed in addition to the structural problems. Treatment can be non-surgical with the use of orthotics to support the elbow, and maybe more appropriate in certain circumstances. Surgical treatment can involve fixation, repair or reconstruction. Often the deficiency is not amenable to these methods and arthroplasty has to be considered. The situation becomes more fraught in case of failure of arthroplasty and/or infection, where reconstruction can be challenging. In this review we have considered diverse clinical scenarios that fall under this broad umbrella, with a focus on those encountered commonly in practice.

Treatment of supracondylar humeral non-union by bone autograft and Hoffmann II external fixation

Supracondylar humeral nonunions are difficult to heal by internal fixation. Prosthetic arthroplasty is a solution in elderly patients. Both therapeutic options are contraindicated in the case of an infection. The article reports bone autografting and Hoffmann humero-humeral and temporary humero-ulnar Hoffmann external fixation. In our series of seven cases, there was only one minor complication, a benign pin-site infection. There were neither neurovascular complication nor loss of reduction. Solid bone healing was obtained in all patients after an average of 5.2 months (range, 2.5 to 6 months). External fixation is a form of "biologic" fixation, as there is no implant apposed on the bone fragments, preventing their revascularization. This easy technique allows to correct the preoperative deformity while providing sufficient stability to allow active mobilization. Temporary elbow bridging does not seem to cause significant stiffening of the joint.

Complications of open reduction and internal fixation of distal humerus fractures

Treatment of distal humerus fractures is demanding. Surgery is the optimal treatment and preoperative planning is based on fracture type and degree of comminution.

Fixation with two precontoured anatomical locking plates at 90^o:90^o orthogonal or 180^o parallel is the optimal treatment.

The main goal of surgical treatment is to obtain stable fixation to allow immediate postoperative elbow mobilization and prevent joint stiffness.

Despite evolution of plates and surgical techniques, complications such as mechanical failure, ulnar neuropathy, stiffness, heterotopic ossification, nonunion, malunion, infection, and complications from olecranon osteotomy are quite common.

Distal humerus fractures still present a significant technical challenge and need meticulous technique and experience to achieve optimal results.

Cite this article: EFORT Open Rev 2018;3:558-567. DOI: 10.1302/2058-5241.3.180009

Screw fixation for supracondylar humerus fractures in children: a report of seventeen cases

PURPOSE

Supracondylar fractures in the pediatric population are common. For years, K-wires have been the preferred method of surgical fixation. However, fixation with K-wires alone may lead to multiple complications. This study reports the results of surgical care of supracondylar humerus fractures using screw fixation with K-wires or screw fixation alone.

METHODS

This study retrospectively reviewed all patients with supracondylar humerus fractures treated with screw fixation between 2007 and 2013. Patients treated only with smooth wires, or having a displaced medial epicondyle, or presenting with lateral condyle fractures were excluded from the study. Flynn's criteria were used to determine the outcome.

RESULTS

Seventeen patients who met inclusion criteria formed the study group. All patients were followed until union, resolution of complications, and return to preinjury activity level. Satisfactory outcome was reported in 70.6% of patients with less than 15° loss of either flexion or extension. Mean time to union was 6.5 weeks (range 3.3-12.1 weeks). Screw fixation alone had a shorter mean time to union (5.5 weeks) than compared screw fixation with K-wires group (6.9 weeks). Full range of motion following surgical invention was associated with Flynn's criteria (p value = 0.044).

CONCLUSION

Screw fixation for pediatric supracondylar fractures is a viable option to achieve healing and early motion in highly unstable fractures as well as fractures which require (1) increased stability, (2) maintenance of stability during wound checks in the immediate postoperative period and after discontinuation of the cast, or (3) if further exploration like associated vascular injury is warranted.

Pedicled Vascularized Bone Graft of the Distal Radius for Recalcitrant Nonunion of the Distal Humerus

OBJECTIVES

To analyze the clinical and radiological outcomes of a series of patients treated with a pedicled vascularized bone graft (VBG) of the distal radius for the treatment of recalcitrant atrophic nonunions of the distal humerus.

DESIGN

Retrospective clinical study.

SETTING

University-affiliated teaching hospital.

PATIENTS

Fifteen patients with supracondylar humeral atrophic nonunions with at least 3 previous failed surgical interventions were included.

INTERVENTION

Debridement of the distal humerus nonunion through a posterior elbow approach with provisional fixation was performed. Then, a pedicled VBG was harvested from the distal radius and tunneled back into the humeral bone defect. Iliac crest was used as needed, both for the nonunion and to stabilize the radius. Finally, definitive fixation with 2 locked plates was performed.

MAIN OUTCOME MEASUREMENTS

Radiological results, complications, elbow range of motion, Mayo elbow performance score, and subjective pain were evaluated.

RESULTS

There were 4 male and 11 female patients, with a mean age of 51 (range, 28-73) years. The mean follow-up period was 46 (range, 37-72) months with a minimum of 3 years. Radiological consolidation was achieved in all patients. Elbow range of motion was >100 degrees in 11 patients and between 50 and 100 degrees in 4 patients. Preoperative Mayo scores were poor in all patients. At final follow-up, Mayo scores were excellent in 3, good in 9, and fair in 3 patients. The mean postoperative visual analog scale score was 1.2 (range 0-3).

CONCLUSIONS

Pedicled VBG of the distal radius was shown to be a reliable and effective alternative for the treatment of recalcitrant atrophic nonunions of the distal humerus, when other methods have failed.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Forearm as a valuable source of vascularized bone graft for the distal humerus

BACKGROUND

The nonunion of a distal humeral fracture is a challenging complication. Our aim was to assess the results of the application of pedicled bone flap to treat this problem.

METHODS

There were 6 men and 3 women with delayed union or nonunion of the distal humerus treated by 10 procedures of rigid fixation plus radial bone forearm or posterior interosseous bone flaps. A locking plate was applied for fixation in 4 patients and a pin and plate for 5 patients. The olecranon osteotomy was performed in 6 elbows.

RESULTS

Patients were a mean age of 49.2 years (range, 31-70 years). The average interval between the trauma and the index operation was 19.2 months (range, 3-49 months). Eight elbows showed union within an average of 3.75 months (range, 3-6 months) in the column where the bony flap was placed. The radial forearm bone flap failed to unite the nonunion of the lateral column of 1 elbow, and additional tension banding was required. Two elbows did not heal at the medial column when the radial forearm bone flap was located on the lateral column. For 1 elbow, another posterior interosseous bone flap was applied on the medial side in another session. By a mean follow-up of 37.3 months (range, 24-79 months), the mean of the visual analog scale demonstrated significant improvement from 6.44 postoperatively to 2.22 (P < .001). The Mayo Elbow Performance Score and 11-Item version of the Disabilities of the Arm, Shoulder and Hand score also showed clinically and statistically significant improvements.

CONCLUSION

Vascularized bone flaps could be considered as an option to facilitate healing of distal humerus delayed union or nonunion.

Open reduction and internal fixation for nonunion of extra-articular distal humeral fractures in patients 70 years and older

HYPOTHESIS

The study purpose was to report the clinical and radiologic outcomes of osteosynthesis by open reduction and internal fixation for nonunion of extra-articular distal humeral fractures in patients aged 70 years or older.

MATERIALS AND METHODS

This retrospective study included 28 patients who received osteosynthesis treatment between March 2010 and December 2015. Primary conservative treatment had failed in all patients. All surgical procedures were performed via the posterior approach without olecranon osteotomy and with the use of double-locking plates for each column.

RESULTS

The mean patient age was 72 years, and surgical procedures were performed a mean of 7.6 months after injury. Preoperatively, extension-flexion was 32° to 101° and forearm pronation-supination was 74° to 47°. The mean visual analog scale score was 4; the mean Mayo Elbow Performance Score was 50; and the mean Disabilities of the Arm, Shoulder and Hand score was 58. All cases showed proper union after a mean of 5.2 months. At the final follow-up examination, the extension-flexion and rotation arcs had improved significantly (to 20° to 124° and to 80° to 66°, respectively; both P < .001), and all clinical scores were satisfactory (visual analog scale score, 1; Mayo Elbow Performance Score, 65; and Disabilities of the Arm, Shoulder and Hand score, 24; all P < .001). Ulnar nerve transposition was performed in 7 patients, and no distinct ulnar nerve symptom was observed in any patient at the final follow-up examination.

CONCLUSIONS

We consider osteosynthesis by open reduction and internal fixation as a recommended option for extra-articular distal humeral fractures in elderly patients aged 70 years or older in whom conservative treatment has failed.

Challenges and Solutions in Management of Distal Humerus Fractures

Background

Management of distal humerus fractures remains a challenge for trauma surgeons and advancements in treatment options continue to be made to achieve the best results for patients presenting with these complex fractures. Our aim in this article is to provide the surgeons with a detailed review of current literature to help them make an evidence based decision when faced with managing such complex injuries in their surgical practice.

Methods

This is a comprehensive review of the current literature that details various aspects of distal distal humerus fractures such as classification, surgical anatomy, surgical approaches, treatment options, choices of devices, outcomes and complications.

Results

With the advancements in techniques and equipment, there has been improvement in patients' outcomes following surgical management of these fractures and a large proportion of these patients are able to achieve pre-injury level of function. The contoured locking plates have enabled successful fixation of many of these fractures that were previously considered unfixable. For those not amenable to surgical fixation, total elbow arthroplasty and elbow hemiarthroplasty are considered as good alternatives.

Conclusion

Since the days where the 'bag of bones' technique was the preferred method of treating these complex injuries, techniques and outcomes have advanced greatly. However, they still present a significant technical challenge and need meticulous technique and experience to achieve optimal results.

Why a surgically treated humeral shaft fracture became a nonunion: review of 11 years in two trauma centers

AIM

The aim of this study was to evaluate nonunion causes of surgically treated humeral shaft fractures in two different trauma centers.

METHODS

A total of 327 cases of humeral shaft fractures were treated in 11 years in two trauma centers. We retrospectively reviewed in detail some factors in order to understand the reasons for nonunion: (1) fracture type, according to the AO classification, (2) grade of open fracture, according to Gustilo-Anderson, (3) timing, (4) reduction and (5) fixation.

RESULTS

We observed 19 nonunions, 10 women and 9 men, with an average age of 57 years. Fractures were 1 A1 case, 2 A2 cases, 4 B2 cases, 6 B3 cases, 2 C1 cases, 1 C2 case and 3 C3 cases. Three cases had a simple fracture with two fragments; all the other were comminuted. Fifteen cases were closed, four open. The major criticalities observed were fracture comminution, exposure, unstable fixation and bone resorption. All 19 patients with nonunion underwent surgical fixation with compression plate and frozen cortical bone graft. A 4.5 LCP plate was used in 17 cases. The remaining 2 cases had an anatomical site-specific proximal humeral 3.5-mm LCP plate (Synthes, Paoli, PA, USA). In 17 patients, the nonunion healed: 15 cases treated with a 4.5 straight plate, and 2 cases with an anatomical site-specific proximal humeral 3.5 mm LCP plate, at a mean of 5 months. In 2 cases, consolidation was not reached.

CONCLUSIONS

We believe that humeral diaphyseal fractures should be treated surgically to avoid many complications. Our retrospective analysis indicates that factors that lead to a fixation failure are fracture comminution, open fracture, unstable fixation. The 19 nonunions treated with compression plating and frozen bone graft demonstrated consolidation in almost 90% of the cases.

Surgical Technique: Treatment of Distal Humerus Nonunions

BACKGROUND

Open reduction and internal fixation of distal humerus fractures is standard of care with good to excellent outcome for most patients. However, nonunions of the distal humerus still occur. These are severely disabling problems for the patient and a challenge for the treating physician. Fortunately, a combination of standard nonunion techniques with new plate designs and fixation methods allow even the most challenging distal humeral nonunion to be treated successfully.

QUESTIONS/PURPOSES

The purpose of this manuscript is to describe our current technique in treating distal humeral nonunion as it has evolved over the last four decades. We have now follow-up on 62 treated patients.

METHODS

A few key steps are essential to obtain bone healing while regaining or preserving elbow motion. These include careful planning, extensile exposure, release of the ulnar nerve, capsular release and mobilization of the distal fragment, debridement, and finally stable fixation after alignment with application of bone graft.

RESULTS

The vast majority of distal humeral nonunions can be treated successfully with open reduction and internal fixation.

CONCLUSION

Important components of the treatment plan are careful preoperative planning, extensile approach, debridement, and solid fixation with-locking-plates and liberal use of bone graft.

Subjective ulnar nerve dysfunction commonly following open reduction, internal fixation (ORIF) of distal humeral fractures and in situ decompression of the ulnar nerve

The aim of this retrospective study was to investigate the frequency of persistent ulnar affection in patients who underwent open reduction and internal fixation (ORIF) of distal humeral fractures without ulnar nerve transposition or mobilisation. Eighty-two patients (53 women), mean age 62 years, were, at a mean of 48 months, reviewed through medical records and a subjective evaluation form concerning ulnar nerve problems. Ulnar nerve affliction, in most cases regarded as mild, was experienced by 22 patients (27%; 14 women) and significantly associated with multiple surgeries. Three patients had been operated with late neurolysis and one with transposition without reported improvement. The proportion of ulnar nerve dysfunction was equally common regardless of medial or lateral plating. ORIF with plate fixation and without ulnar nerve transposition seems to be an acceptable option for patients with distal humeral fractures. The frequency of ulnar nerve affection in our series does not appear higher than previously reported. Subjective ulnar nerve symptoms were, however, relatively common and appear related to the trauma itself, the surgery, or the post-operative management which highlights the need for further analysis of these factors.

Distal humerus fractures nonunion with elbow stiffness in working adults: Can triple tension band technique and Lambda Plate(®) be a standby solution?

BACKGROUND

Distal humerus fracture nonunion and associated elbow stiffness are two intermingled orthopaedic challenges for working adults. This prospective study aimed to evaluate the short-term results of the triple tension band and Lambda plate in managing both problems.

METHODS

The study included fourteen cases. The mean age was 35.7 ± 8.5 years (range 25-49). Eight cases were males. Initial management was conservative in three cases. Three cases had a history of infected nonunion. Eight cases had initially OTA type C injuries and six cases had type A injuries. All cases had olecranon osteotomy, triple tension band, Lambda plating, and autogenous bone grafting. Five cases had ulnar nerve anterior transposition. Evaluation of the cases was objectively via Mayo Elbow Performance (MEP) score and subjectively through Disabilities of the Arm, Shoulder and Hand (DASH) score.

RESULTS

The average follow-up period was 23.7 ± 5.3 months. All cases had a solid bony union in a mean of 16.4 ± 2.1 weeks and the final range of motion averaged 100 ± 19.6°. MEP and DASH scores had significant improvement at the final follow-up periods (P = 0.001). Cases with transposed ulnar nerve had significantly less MEP scores (P = 0.028) and more DASH scores (P = 0.013).

CONCLUSIONS

The prescribed technique could be a good alternative to the known traditional methods with the advantages of: good exposure for arthrolysis; rigid and stable internal fixation even with low bone quality or small-sized distal fragments; and secure early rehabilitation.

Total elbow arthroplasty in distal humeral nonunion: clinical and radiographic evaluation after a minimum follow-up of three years

BACKGROUND

Total elbow arthroplasties (TEAs) are usually indicated in chronic inflammatory arthropathies. This procedure has also recently been used in complex distal humeral fractures and nonunions in selected patients. This study analyzed the clinical and radiographic outcomes in patients treated for nonunions around the elbow region with a minimum follow-up of 3 years.

METHODS

Between May 2002 and June 2012, 20 patients affected with distal humeral nonunions were treated with TEA. All patients were assessed clinically using the Mayo Elbow Performance Score and radiographically to evaluate the positioning of the prosthetic components and signs of loosening. Statistical analyses were performed to investigate the presence of clinical and radiographic variables as predictive factors of poor functional outcomes.

RESULTS

The Mayo Elbow Performance Score of the affected arm improved significantly between the preoperative period and follow-up. Results were good or excellent in 90% of the patients even if a high rate of complications (30%) was encountered. The development of complications after surgery and stages II, III, and IV radiolucency, according to the Morrey criteria, were predictive factors of poor outcomes.

CONCLUSIONS

According to the satisfactory results observed in this study, TEA could be indicated in selected patients aged older than 70 years with low functional demands and affected with distal humeral nonunions in which obtaining a stable fixation is difficult.

Distal Humerus Fractures: Open Reduction Internal Fixation

Distal humerus fractures are challenging injuries for the upper extremity surgeon. However, recent techniques in open reduction internal fixation have been powerful tools in getting positive outcomes. To get such results, the surgeon must be aware of how to properly use these techniques in their respective practices. The method of fixation depends on the fracture, taking the degree of comminution and the restoration of the columns and articular surface into account. This article helps surgeons understand the concepts behind open reduction internal fixation of the distal humerus and makes them aware of pitfalls that may lead to negative results.

Preoperative nerve imaging using computed tomography in patients with heterotopic ossification of the elbow

HYPOTHESIS

This study evaluated the usefulness of computed tomography (CT) imaging for preoperative planning of heterotopic ossification (HO) excision, specifically the spatial relationship between HO and radial and median nerves. Our hypotheses were that CT imaging of the elbow can be used (1) to trace the paths of the radial and median nerves, (2) to distinguish the nerves from the heterotopic bone, and (3) to precisely measure distances from the respective nerve to the most clinically relevant HO.

MATERIALS AND METHODS

Patients who had HO removed from the elbow were reviewed retrospectively. On the basis of preoperative CT scans, 22 were identified as likely having HO along the pathway of the radial or median nerve. These cases were independently evaluated by 4 observers, who answered these questions: (1) Can the location of the nerve be adequately seen on sequential images to permit tracing of its path for surgical planning? (2) Can the nerve be distinguished from the HO accurately enough to permit measurement of its distance from the bone? Each observer also measured the shortest distance between nerves and the HO.

RESULTS

Overall utility of the CT images for visualizing the nerves was high. The radial nerve was more readily distinguished from the HO (21 of 22 cases) than the median nerve (17 of 22 cases). The distance measured from HO was less for the radial nerve (3 mm) than for the median nerve (9 mm).

CONCLUSION

This study demonstrates the usefulness of CT imaging to determine the paths of the radial and median nerves and their spatial relationship to HO at the elbow.

Intra-articular osteotomy for malunited articular fractures of the distal end of the humerus

BACKGROUND

The precarious anatomy of the articular surface of the distal humerus, as well as its meager subchondral bony support and limited soft-tissue attachments, presents enormous challenges for the operative correction of post-traumatic intra-articular deformities. This study presents 8 patients who underwent articular osteotomy with a mean follow-up period of 10.6 years, with an emphasis on functional, patient-rated, and radiographic outcomes.

METHODS

Eight patients (mean age, 39 years; range, 17-60 years) were followed up for a mean period of 10.6 years. The original fracture was a type C variant in 4 patients, a type B unicondylar fracture in 2, and a type B articular shearing fracture in 2. The initial injury was treated operatively in 5 patients and nonoperatively in 3. The osteotomy and reconstruction were performed on average 8 months after injury (range, 6-11 months). The mean preoperative elbow arc of motion was 37°. Two patients had ulnar nerve dysfunction.

RESULTS

All the osteotomies healed after the index procedure without evidence of avascular necrosis. Two patients required a second procedure for stiffness. At follow-up, the mean arc of elbow motion improved to 104° (P = .001), with a mean flexion contracture of 26°. The mean Disabilities of the Arm, Shoulder and Hand score at follow-up was 13 (range, 1-37); the mean patient satisfaction rating on a Likert scale (from 0 to 10) was 9.1; and the mean Mayo Elbow Performance Index score was 83 points (range, 70-100 points). Grade II osteoarthritic changes were seen in 3 patients, grade I in 3, and grade 0 in 2.

CONCLUSIONS

In selected patients with a defined intra-articular malunion, the results of our experience support corrective osteotomy.

[Intra-articular fractures of the distal humerus : aspects of fracture treatment in geriatric patients]

BACKGROUND

In the context of osteoporotic fractures, injuries to the distal humerus are quite uncommon, meaning that each surgeon will have only limited experience.

OBJECTIVE

This leads automatically to the question to what extent treatment recommendations can be transferred to the geriatric population.

METHODS

Looking at the evidence-based literature, recommendations could be limited to three prospective studies. However, this only means that the remaining literature sources do not provide sufficient statistical power to be able to draw conclusions.

RESULTS AND DISCUSSION

For the population of geriatric patients a thorough compilation of the contemporary literature is advisable. This review article on the currently available literature evaluates and individually discusses the relevant aspects of fracture treatment in order to develop recommendations for routine daily practice.

Primary total elbow arthroplasty

BACKGROUND

Primary total elbow arthroplasty (TEA) is a challenging procedure for orthopedic surgeons. It is not performed as frequently as compared to hip or knee arthroplasty. The elbow is a nonweight-bearing joint; however, static loading can create forces up to three times the body weight and dynamic loading up to six times. For elderly patients with deformity and ankylosis of the elbow due to posttraumatic arthritis or rheumatoid arthritis or comminuted fracture distal humerus, arthroplasty is one of the option. The aim of this study is to analyze the role of primary total elbow arthroplasty in cases of crippling deformity of elbow.

MATERIALS AND METHODS

We analyzed 11 cases of TEA, between December 2002 and September 2012. There were 8 females and 3 males. The average age was 40 years (range 30-69 years). The indications for TEA were rheumatoid arthritis, comminuted fracture distal humerus with intraarticular extension, and posttraumatic bony ankylosis of elbow joint. The Baksi sloppy (semi constrained) hinge elbow prosthesis was used. Clinico-radiological followup was done at 1 month, 3 months, 6 months, 1 year, and then yearly basis.

RESULTS

In the present study, average supination was 70° (range 60-80°) and average pronation was 70° (range 60-80°). Average flexion was 135° (range 130-135°). However, in 5 cases, there was loss of 15 to 35° (average 25°) of extension (45°) out of 11 cases. The mean Mayo elbow performance score was 95.4 points (range 70-100). Arm length discrepancy was only in four patients which was 36% out of 11 cases. Clinico-radiologically all the elbows were stable except in one case and no immediate postoperative complication was noted. Radiolucency or loosening of ulnar stem was seen in 2 cases (18%) out of 11 cases, in 1 case it was noted after 5 years and in another after 10 years. In second case, revision arthroplasty was done, in which only ulnar hinge section, hinge screw and lock screw with hexagonal head were replaced.

CONCLUSION

Elbow arthroplasty remains a valuable option for deformed and ankylosed elbows especially in the demanding patients with crippling deformity of the elbow.

Treatment of bone nonunion and bone defects associated with unsuccessful humeral condylar fracture repair with autogenous iliac bone reconstruction

BACKGROUND

Our preliminary study retrospectively assessed outcomes after the use of autogenous iliac bone grafts combined with internal fixation to repair refractory bone nonunions and bone defects associated with supracondylar or intracondylar humeral fractures, or both.

MATERIALS AND METHODS

We identified 22 patients (14 men and 8 women) with a mean age of 33.8 years (range, 17-60 years) with bone nonunion and severe bone defects associated with supracondylar or intercondylar humerus fractures, or both. The humeral condyle in each patient was anatomically reconstructed using autologous iliac bone grafts and internal fixation. Active functional exercise was initiated 3 to 4 weeks after surgery. The following variables were assessed: preoperative and postoperative elbow range of motion, Mayo Elbow Performance Score (MEPS), and postoperative complications.

RESULTS

Mean follow-up was 38.6 months. Mean duration until bone union was 5.6 months. Preoperatively, 16 patients had a fair or poor MEPS (<75). At final follow-up MEPS was excellent (>90) in 8, good (75-90) in 9, fair (60-74) in 4, and poor (<60) in 1 patient. Postoperative heterotopic ossification anterior to the elbow joint occurred in 2 patients.

CONCLUSIONS

Our preliminary results suggest that anatomic reconstruction of the humeral condyle using autogenous iliac bone grafting with internal fixation can improve elbow joint function in patients with bone nonunion and bone defects associated with supracondylar or intracondylar humeral fractures, or both. Larger scale studies are warranted to confirm our findings and compare the efficacy of this vs other surgical approaches.

Fragility fractures of the distal humerus

In light of the growing number of elderly osteopenic patients with distal humeral fractures, we discuss the history of their management and current trends. Under most circumstances operative fixation and early mobilisation is the treatment of choice, as it gives the best results. The relative indications for and results of total elbow replacement versus internal fixation are discussed.

Treatment of post-infection nonunion of the supracondylar humerus with Ilizarov external fixator

BACKGROUND

Nonunion of the supracondylar area of the humerus is a very difficult area to treat. The Ilizarov method has been shown to be effective in the treatment of nonunion of the humeral diaphysis. However, there is little in the literature regarding the treatment of nonunion of the supracondylar area especially in post-infection cases.

METHODS

Eight patients with a mean age of 45.73 ± 11.42 years were treated for post-infection nonunion of the supracondylar area of the humerus with the Ilizarov method and followed up for 3 years. All had undergone at least 2 previous failed operations. The patients were evaluated radiologically and clinically with an outcome survey using the Disabilities of the Arm, Shoulder and Hand (DASH) score.

RESULTS

Solid union was achieved in all patients in a mean time of 6.87 ± 0.99 months. All patients had improvement in shoulder and elbow motion after treatment. The mean DASH score before surgery was 90.66 ± 5.66, whereas that after surgery was 24.62 ± 3.85. There was a significant improvement in the DASH score after surgery; the mean difference was 66.04 ± 1.81, with a t value of 35.88 (P < .001). All patients were satisfied with the treatment and returned to a more normal lifestyle with no pain, as well as complete soft-tissue recovery. None had recurrence of infection.

CONCLUSION

Ilizarov treatment for post-infection nonunion of the supracondylar humerus was shown to be effective, reliable, and tolerated by the patients.

Use of orthogonal or parallel plating techniques to treat distal humerus fractures

Distal humerus fractures continue to be a complex fracture to treat. This article describes two surgical techniques that can be used to tackle these difficult fractures: Parallel plating and orthogonal plating. Both techniques have yielded excellent outcomes after open reduction and internal fixation; yet each has its own set of unique considerations. However, the key to successful treatment of these difficult fractures regardless of technique remains obtaining anatomic reduction with stable fixation and the implementation of early motion.

Linked elbow replacement: a salvage procedure for distal humeral nonunion. Surgical technique

BACKGROUND

Nonunion is a challenging and not uncommon complication of distal humeral fractures. Our long-term experience with linked semiconstrained total elbow arthroplasty as a salvage procedure for patients with distal humeral nonunion not amenable to internal fixation was investigated.

METHODS

Ninety-one consecutive patients (ninety-two elbows) underwent total elbow arthroplasty for the treatment of a distal humeral nonunion, and the results were reviewed at a mean of 6.5 years postoperatively. Patients' charts and anteroposterior and lateral radiographs made prior to and immediately after the joint replacement and at the time of the latest follow-up were reviewed to identify intraoperative and postoperative complications, and radiographic evidence of loosening or bushing wear. The outcome measures consisted of prosthetic survival, with implant removal as the end point for failure, and the Mayo Elbow Performance Score (MEPS).

RESULTS

At the time of the most recent follow-up, joint stability had been initially restored in all patients, including nine who had had a grossly flailed elbow. Sixty-seven (74%) of the patients had no pain or mild pain at the time of the latest follow-up, whereas seventy-nine patients (87%) had had moderate or severe pain prior to the surgery. While 85% (seventy-seven) of the ninety-one patients rated the outcome as better or much better, twenty patients (22%) had a fair or poor MEPS. A total of forty-four complications occurred in forty elbows, and there were thirty-two reoperations, twenty-three of which involved implant revision or removal. Factors that increased the risk of implant failure were a patient age of less than sixty-five years, two or more prior surgical procedures, and a history of infection. The rate of prosthetic survival without removal or revision for any reason was 96% at two years, 82% at five years, and 65% at both ten and fifteen years.

CONCLUSIONS

Linked semiconstrained total elbow arthroplasty is a salvage procedure that can provide pain relief and restore motion and function in patients with a distal humeral nonunion that is not amenable to internal fixation. Substantial risk factors for failure include an age of less than sixty-five years, multiple previous surgical procedures, and any history of infection.

Use of a "hybrid" locking plate for complex metaphyseal fractures and nonunions about the humerus

PURPOSE

To review one surgeon's experience with a novel type of "hybrid" locking plate (which has both 3.5mm and 4.5mm locking holes) for difficult fractures of the meta-diaphyseal humeral shaft.

METHODS

Over a 2-year period, 24 patients who presented with a metaphyseal humeral fracture or nonunion (proximal or distal) were treated surgically by a single surgeon. A "hybrid" locking plate containing 3.5mm locking holes on one end and 4.5mm locking holes on the other end (Metaphyseal plate, Synthes, Paoli, Pa) was used in all patients. The selection of this implant was based on fracture location and bone quality. Fractures were operated on through an anterolateral or direct posterior approach. All fractures were secured with a minimum of three 4.5mm screws on one side of the fracture and three 3.5mm screws on the other side. All patients were treated with a similar post-operative protocol for early range of shoulder and elbow motion.

RESULTS

Three patients were lost to follow-up. The cohort consisted of 15 women and 6 men with a mean age of 49 years (range 18-78). There were 14 acute fractures and 7 nonunions. Twelve fractures involved the distal metaphyseal segment and 9 involved the proximal metaphyseal segment. Twenty-two patients completed a minimum 6-month clinical and radiographic follow-up and form the basis for this report. All 21 patients healed their fractures or nonunions at a mean of 4.5 months. There were no infections or hardware failures. In every case the "hybrid" nature of the plate design was felt to be advantageous.

CONCLUSION

This "second generation" metaphyseal locking plate, which affords the surgeon the ability to place a greater number of smaller calibre screws within a short bone segment, while using traditional large fragment screw fixation in the longer segment, is clearly an improvement in plate design. Meta-diaphyseal upper extremity long bones may serve as the most ideal location for this implant.

The management of nonunion and malunion of the distal humerus--a 30-year experience

This personal series of nonunions of the distal humerus reviews unique features of this problem, categorizes them according to unique anatomic features, and presents pitfalls and pearls in the management of these complex reconstructive problems.

Linked elbow replacement: a salvage procedure for distal humeral nonunion

BACKGROUND

Nonunion is a challenging and not uncommon complication of distal humeral fractures. Our long-term experience with linked semiconstrained total elbow arthroplasty as a salvage procedure for patients with distal humeral nonunion not amenable to internal fixation was investigated.

METHODS

Ninety-one consecutive patients (ninety-two elbows) underwent total elbow arthroplasty for the treatment of a distal humeral nonunion, and the results were reviewed at a mean of 6.5 years postoperatively. Patients' charts and anteroposterior and lateral radiographs made prior to and immediately after the joint replacement and at the time of the latest follow-up were reviewed to identify intraoperative and postoperative complications, and radiographic evidence of loosening or bushing wear. The outcome measures consisted of prosthetic survival, with implant removal as the end point for failure, and the Mayo Elbow Performance Score (MEPS).

RESULTS

At the time of the most recent follow-up, joint stability had been initially restored in all patients, including nine who had had a grossly flailed elbow. Sixty-seven (74%) of the patients had no pain or mild pain at the time of the latest follow-up, whereas seventy-nine patients (87%) had had moderate or severe pain prior to the surgery. While 85% (seventy-seven) of the ninety-one patients rated the outcome as better or much better, twenty patients (22%) had a fair or poor MEPS. A total of forty-four complications occurred in forty elbows, and there were thirty-two reoperations, twenty-three of which involved implant revision or removal. Factors that increased the risk of implant failure were a patient age of less than sixty-five years, two or more prior surgical procedures, and a history of infection. The rate of prosthetic survival without removal or revision for any reason was 96% at two years, 82% at five years, and 65% at both ten and fifteen years.

CONCLUSIONS

Linked semiconstrained total elbow arthroplasty is a salvage procedure that can provide pain relief and restore motion and function in patients with a distal humeral nonunion that is not amenable to internal fixation. Substantial risk factors for failure include an age of less than sixty-five years, multiple previous surgical procedures, and any history of infection.

Post-traumatic distal humerus non-union : Open reduction and internal fixation: long-term results

The objective of this paper is to evaluate the long-term functional results achieved after open reduction and internal fixation of 24 distal humerus non-unions. Non-unions were extra-articular-extracapsular (11 cases), extra-articular-intracapsular (8 cases) and intra-articular (5 cases). Preoperative elbow range of motion averaged 45 degrees. Time between original trauma and revision surgery averaged 14 months. Stabilisation methods varied according to type and location of the non-union. Follow-up averaged 46 months (range: 18-108). Elbow range of motion at last examination averaged 98 degrees . Flexion averaged 110 degrees and extension loss averaged 17 degrees . The disabilities of the arm, shoulder and hand (DASH) score averaged 16 points. Secondary transposition of the ulnar nerve was necessary in three cases. Sixteen patients reported no pain at last examination, seven had mild pain and one had moderate pain. Distal humerus non-unions present different characteristics; consequently, surgical treatment must be individualised for each patient. Even though they are demanding procedures, bony union and good long-term functional results were achieved.

Reconstruction of lateral trochlear defect with radial head autograft

A novel procedure has been developed to address severe fractures of the lateral trochlea and capitellum when open reduction and internal fixation is not practical and patient factors preclude the use of total elbow arthroplasty. We present 3 patients in whom an ipsilateral radial head autograft was used to reconstruct the lateral trochlea, restoring both function and stability of the elbow.

Management of the flail elbow

Flail elbow is a relatively uncommon cause of elbow dysfunction. It is defined as the inability to position the arm in space for useful elbow function because of structural or neurologic inadequacies. Patient function is often severely compromised and treatment options are limited with moderate levels of success depending on etiology. This article reviews the various etiologies of dysfunctional elbow instability, their treatment options, and their expected outcomes.

The posttraumatic stiff elbow: a review of the literature

Loss of motion is a common complication of elbow trauma. Restoration of joint motion in the posttraumatic stiff elbow can be a difficult, time-consuming, and costly challenge. In this review of the literature, the biologic response to trauma and the possible etiologic events that may lead to fibrosis of the capsules and heterotopic ossification will be discussed, as well as nonsurgical and surgical management of stiffness and expected outcomes of treatment.

Humeral nonunion

Humerus fractures comprise 5% to 8% of all fractures. Although uncommon, nonunions can present a frustrating challenge to the orthopedic surgeon. Various risk factors that may predispose patients to nonunion include obesity, osteoporosis, alcoholism, smoking, poor bone quality, and scar tissue. Many methods of treatment have been described with various degrees of success. The rates of healing of humeral nonunions by traditional means of internal fixation with bone graft range from 70% to 92%, although in cases of infection, poorly vascularized beds, and open, segmental, or severely comminuted fractures, secondary bony healing may still be compromised.

Vascularised corticoperiosteal grafts from the medial femoral condyle for difficult non-unions of the upper limb

The vascularised corticoperiosteal graft was introduced by Sakai and Doi, in 1991, as a means to achieve bony union under unfavourable conditions. We present our experience with this vascularised graft, taken from the femoral condyle, in six patients with difficult non-unions (5) or other bony problems (1) in the upper limb. In five cases, a long bone defect--two humeral, two ulnar and one radial--was involved. All had had between three and seven previous operations. Two of the non-unions were secondary to infection. The others had had conventional grafting on two or three previous occasions each. In the sixth case, a corticoperiosteal graft was used to promote healing in a combined carpometacarpal and intercarpal dislocation with a very poor bed. All of the grafts survived without complications and all of the bones healed radiologically in less than three months. Three patients achieved a normal range of motion and two obtained a functional range of motion with only slight limitations. The carpometacarpal arthrodesis was healed soundly at five weeks.