Aseptic Humeral Nonunion: What Went Wrong? What to Do? A Retrospective Analysis of 20 Cases

Abstract

Purpose: Due to recent advances in internal fixation techniques, instrumentation and orthopedic implants there is an increasing number of humeral shaft fracture treated operatively. As a consequence, an increased number nonunion after operative fixation are being referred to our center. The aim of this study is to report the common error during osteosynthesis that may have led to nonunion and present a systematic analytical approach for the management of aseptic humeral shaft nonunion.Methods: In between January 2007 to December 2013, 20 patients with humeral shaft nonunion after operative procedure were treated according to our treatment algorithm. We could analysis x-rays of 12 patients from initial treatment to nonunion. In a subgroup of 12 patients the initial operative procedure were analyzed to determine the error that may have caused nonunion. The following questions were used to examine the cases: 1) Was the fracture biology preserved during the procedure? 2) Does the implant construct have enough stability to allow fracture healing?Results: In 19 out of 20 patients have showed radiographic evidence of union on follow up. One patient has to undergo reoperation because of the technical error with bone graft placement but eventually healed. There were 2 cases wherein the treatment algorithm was not followed. All patients had problems with mechanical stability, and in 13 patients had biologic problems. In the analysis of the initial operative fixation, only one of 12 patients had biologic problems.Conclusion: In our analysis, the common preventable error made during operative fixation of humeral shaft fracture is failure to provide adequate stability for bony union to occur. And with these cases we have demonstrated a systematic analytic management approach that may be used to prevent surgeons from reproducing the same fault and reduce the need for bone grafting. [ J Trauma Inj 2016; 29: 129-138 ]

Grafting and fixation after aseptic non-union of the humeral shaft: A case series

“…6, 17e20 However, we believe in concordance to Kim et al, humeral shaft non-unions require two questions; what went wrong, and what to do?. 2 For the first question, the technical failures in reaching adequate stability and acceptable strain for fracture healing are the foremost reason. 2 Since the humerus is a non-weight bearing bone, there is a lack of axial loading what promotes fracture distraction and straining which makes compression plating seem favourable.…”

“…2 For the first question, the technical failures in reaching adequate stability and acceptable strain for fracture healing are the foremost reason. 2 Since the humerus is a non-weight bearing bone, there is a lack of axial loading what promotes fracture distraction and straining which makes compression plating seem favourable. 2 Concerning the second question, each case should be evaluated whether union is suspected to be reached without further biological stimulation (i.e., atrophic non-union) and when necessary, how this biological stimulus can be promoted with minimal patient morbidity.…”

“…2 Since the humerus is a non-weight bearing bone, there is a lack of axial loading what promotes fracture distraction and straining which makes compression plating seem favourable. 2 Concerning the second question, each case should be evaluated whether union is suspected to be reached without further biological stimulation (i.e., atrophic non-union) and when necessary, how this biological stimulus can be promoted with minimal patient morbidity. 2 Healy et al agree on the principles of improving the suboptimal biologic response and achieving mechanical stability by rigid fixation in treating atrophic humeral shaft non-unions.…”

Plate-and-bone-strut fixation of distal third humeral shaft aseptic non-unions: A consecutive case series

“…1). To successfully treat humeral shaft fractures with internal fixation, it is important to recognize that torsion is the predominant form of mechanical stress at the fracture site and because it is a non-weight bearing bone the lack of axial loading promotes fracture distraction 2,13,15 . Other common treatments of intra-articular or distal humeral atrophic non-union include elbow arthrodesis, arthroplasty 16 , allografts 17e20 , open reduction and internal fixation 21 , prosthesis 22 or the Ilizarov technique 23 .…”

“…From these options, we have chosen the posterior plate to reduce the distracting forces and used the opposing anterior bone splint to further increase stability at the fracture site 17e19, 24 . Besides stability, the osteo-inductive and osteo-formative abilities of the bone strut, bone chips and bone paste, provided a second mechanism to increase fracture healing and addition of mechanical load transfer 2,5,6,20,25 . This extramedullary fixation does not impede the intramedullary bone marrow, which was only reamed up to vital tissue.…”