Surgical lengthening of the humerus: case report and review

This article reviews 12 cases of humeral lengthening accomplished by transverse midshaft osteotomy and gradual distraction by an external fixator attached to two half pins in the proximal and two half pins in the distal humeral fragments. Six cases were treated by second-stage (application plate, screws, and bone graft with removal of apparatus) and third-stage (removal of plate and screws) procedures. In the other six cases, the external apparatus was allowed to remain in place until the humerus united. There were few complications. There were no nonunions, delayed unions, malunions, or late fractures.     

Correction of tibial malunion and nonunion with six-axis analysis deformity correction using the Taylor Spatial Frame

OBJECTIVE: To determine the effectiveness of six-axis analysis deformity correction using the Taylor Spatial Frame for the treatment of posttraumatic tibial malunions and nonunions. DESIGN: Retrospectively reviewed, consecutive series. Mean duration of follow-up was 3.2 years (range 2-4.2 years). SETTING: Tertiary referral center for deformity correction. PATIENTS/PARTICIPANTS: Eighteen patients were included in the study (11 malunions and 7 nonunions). All deformities were posttraumatic in nature. The mean number of operations before the application of the spatial frame was 2.6 (range 1-6 operations). All patients completed the study. INTERVENTION: Six-axis analysis deformity correction using the Taylor Spatial Frame (Smith & Nephew, Memphis, TN) was used for correction of posttraumatic tibial malunion or nonunion. Nine patients had bone grafting at the time of frame application. One patient with a tibial plafond fracture simultaneously had deformity correction and an ankle fusion for a mobile atrophic nonunion. Two patients had infected tibial nonunions that were treated with multiple débridements, antibiotic beads, and bone grafting at the time of spatial frame application. A rotational gastrocnemius flap was used to cover a proximal third tibial defect in one patient. The average length of time the spatial frame was worn, time to healing, was 18.5 weeks (range 12-32 weeks). MAIN OUTCOME MEASUREMENTS: Assessment of deformity correction in six axes, knee and ankle range of motion, incidence of infection, and return to preinjury activities. RESULTS: Of the 18 patients treated with the Taylor Spatial Frame, with adjunctive bone graft as necessary, 17 achieved union and significant correction of their deformities in six axes (ie, coronal angulation and translation, sagittal angulation and translation, rotation, and shortening). Fifteen patients returned to their preinjury activities at last follow-up. CONCLUSION: Six-axis analysis deformity correction using the Taylor Spatial Frame is an effective technique to treat posttraumatic malunions and nonunions of the tibia, with several advantages over previously used devices.     

Humeral shaft nonunions treated with fibular allograft and compression plating

The present study is a retrospective review of the treatment of 12 humeral shaft nonunions by using an intramedullary allograft with compression plating. The average age of the patients was 61 years (range, 36-82 years). Eight cases involved the proximal shaft, 3 cases were at the mid-diaphyseal level, and 1 case was at the distal one third. Follow-up averaged 30 months (range, 12-96 months). Ten patients (83%) went on to uneventful healing at an average of 3 months after surgery. Two failures involving patients with multiple medical conditions occurred secondary to reinjury. Two cases of postoperative radial nerve neuropraxia involved the posterior approach to the humerus. Each resolved with no long-term residual morbidity. One patient developed postoperative adhesive capsulitis of the shoulder that resolved with nonoperative treatment. We feel that a fibular allograft, along with compression plating, can give satisfactory results for humeral shaft nonunions. This technique can be especially helpful in proximal humeral nonunions and in nonunions involving osteoporotic bone. Patients with multiple medical problems at risk for refalls should be protected until complete healing has occurred.     

顺行交锁髓内治疗肱骨干骨折不愈合

目的 评价顺行交锁髓内钉治疗肱骨干骨折不愈合的临床效果。方法 对13例肱骨干骨折不愈合采用自体髂骨移植,顺行Russell-Rayler交锁髓内钉治疗。术后行X线片检查和肩关节功能评估。结果 平均随访18个月（14－25个月）,13例均获骨愈合,平均愈合时间4．3个月（3－7个月）。肩关节功能：优9例,良3例,一般1例。肩关节功能完全恢复9例,3例有来自近端交锁螺钉的肩关节撞击症状。结论 对肱骨干骨折不愈合可采用顺行交锁髓内钉治疗;为促进骨愈合,骨端加压和骨移植是必要的。     

Shoulder arthroplasty for late sequelae of proximal humeral fractures

Twenty-eight patients with sequelae of proximal humeral fractures were treated with shoulder arthroplasty and were reviewed with a mean follow-up of 47 months. There were 8 malunions, 7 osteonecrosis, and 2 nonunions of the proximal humerus. Degenerative joint disease without any distortion of the tuberosities had developed in 11. We performed 8 total shoulder arthroplasties and 20 hemiarthroplasties. On the basis of the Neer criteria, the results were satisfactory in only 64%. Fifteen patients had superior migration of the implant. One patient had to be reoperated on because of deep infection. The prognosis was influenced positively by the integrity of the rotator cuff at surgery, whereas the need for greater tuberosity osteotomy worsened the final result. The data suggest that malunion of the greater tuberosity can be tolerated if it does not compromise acceptable positioning of the humeral component. However, if there is a malunion of the greater tuberosity with major displacement, an osteotomy must be performed, with unpredictable results.     

Management of nonunions of the proximal humeral diaphysis

It has been reported that the majority of nonunions of the humeral shaft evaluated are within the proximal one-third of the diaphysis. We are not aware of any reported series of humeral nonunions dealing specifically with the proximal diaphysis. We therefore sought to identify patients with a humeral shaft nonunion from an orthopaedic trauma service database, determine the frequency of those within the proximal one-third and review our treatment strategy and resulting clinical outcomes for these difficult fractures. Clinical and radiographical follow-up was available for 19 patients with a mean age of 70 years (range 29–94 years). This represented 46% of all humeral shaft nonunions treated during the study period. Dual plating was used in 11 cases to get adequate fixation in the proximal segment. Post-operative alignment was within 5° of anatomic in all cases. All nonunions healed at an average of 15.2 weeks (range 8–36 weeks). The mean length of follow-up was 12.5 months (range 6–122 months). All patients reported significant improvement in pain. The mean range of motion following fracture union was forward flexion 137°, external rotation 41° and internal rotation 30°. There were two minor complications and neither required a secondary surgery. The surgical technique we have used emphasising a thorough debridement of the nonunion site, correction of the deformity, fracture site compression with a rigid construct and bone grafting provides excellent rates of union and clinical outcomes.     

Interlocking intramedullary nailing for nonunion of the proximal humerus with the Straight Nail System

Nonunion of the proximal humerus is a challenging problem. Since 1996, we have performed interlocking intramedullary nailing for the treatment of proximal humeral nonunions with the Straight Nail System and bone grafting. The objective of this study was to investigate the clinical outcomes of this procedure in patients with proximal humeral nonunion. We investigated 14 consecutive patients (mean age, 74.3 +/- 8.7 years). One patient was excluded because of associated brachial plexus palsy. All but 2 were initially treated conservatively. Range-of-motion exercises were started 1 week after the operation. The mean follow-up period was 37.8 months. Union was achieved in all cases without any evidence of malunion. All patients had improved range of motion of the shoulder and were satisfied with the surgical results. Mean flexion of the shoulder was 122 degrees +/- 14 degrees, and mean external rotation was 35 degrees +/- 10 degrees. Interlocking intramedullary nailing with the Straight Nail System and bone grafting offered a successful method of stable internal fixation in these complex proximal humeral nonunion cases.     

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

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

Osteogenic protein-1 (bone morphogenic protein-7) combined with various adjuncts in the treatment of humeral diaphyseal nonunions

A prospective study was conducted to determine the efficacy of using recombinant BMP-7 (rhOP-1) as an adjuvant in the treatment of diaphyseal humeral nonunions. Twenty-three consecutive patients with atrophic humeral diaphyseal nonunions were treated at seven separate institutions. All nonunions were fixed with either a compression plate or an intramedullary nail in conjunction with various bone grafting techniques. Recombinant OP-1 was delivered to the fracture site in a Type I collagen carrier at the time of fixation. All fractures went on to eventual union. There were no serious complications and no adverse reactions to the rhOP-I implant. Our study suggests that rhOP-1 may be a safe and effective adjuvant for the treatment of humeral diaphyseal nonunions.     

Diaphysäre Humeruspseudarthrosen

The development of humerus nonunion is dependent on the type of fracture, the extent of soft tissue stripping during surgery, the stability of the osteosynthesis, and multiple patient-dependent factors. Treatment should focus on nonunion pathogenesis. The gold standard for the treatment of oligotrophic, atrophic and infected nonunions is radical resection of the nonunion tissue, bone grafting and plate fixation, preferentially using locking plates. Reaming bone graft and stabilization with intramedullary (i.m.) nailing is utilized in hypertrophic nonunion. Since 1993, we have followed-up 51 patients after surgical treatment for humeral shaft nonunion. In eight of 35 cases (22.8%) treated with i.m. nailing, bone healing was not achieved, whereas in all 14 cases of nonunion treated with plate osteosynthesis bone healing occurred. Evaluation of failure in healing humeral shaft nonunion using the i.m. nailing technique revealed that the i.m. nail specifically designed to treat humeral shaft fractures showed several biomechanical and biological deficits for the treatment of nonunions. The major reason for failure in bone healing was a lack of bone grafting that is essential for osteoinduction in oligotrophic nonunions, loosening of locking screws, and unstable small implants.     

Diaphysäre Oberarmpseudarthrosen – operative und konservative Behandlung

Operative treatment of acute humeral shaft fractures represents a major source of nonunions. The analysis of the biomechanical and biological causes of diaphyseal nonunions of the humerus is a prerequisite for the successful treatment of ununited humeral shaft fractures. Biologically active nonunions heal after debridement and correction of deformities with an improvement of mechanical stability, preferably by fixation with a compression plate. In atrophic nonunions, the restoration of the biologic capacity to restore osteogenesis by bone grafting is additionally necessary. The treatment of synovial pseudarthrosis and infected nonunion requires removal of bone and debridement of synovial and infected avascular tissues, respectively. Intramedullary nails to improve mechanical stability and nonoperative treatment with extracorporeal shock waves should only be used in a few special cases which do not have any severe deformities.     

Temporary fixation with the Agee-Wristjack during correctional osteotomies for malunions and nonunions of the distal radius

Upper extremity surgeons are often responsible for managing complex malunions and nonunions of distal radius fractures. Studies have demonstrated that corrective osteotomies of the malunited distal radius with placement of sculpted bone grafts produce the best functional and cosmetic results in patients. We describe a technique for providing provisional stabilization of the osteotomy site for treatment of distal radius malunions and nonunions using the Agee-Wristjack external fixator device. The Agee-Wristjack has several features that make it superior to other available small external fixators. Its gear mechanisms confer stable distraction of the distal radius following osteotomy and greatly facilitate appropriate positioning of the distal fragment. Iliac crest bone graft may be harvested and shaped precisely to fit the osteotomy defect. Placement of the Agee-Wristjack's distal fixator pins into the index metacarpal instead of the distal radius fragment facilitates application of a plate, with minimal interference from the distal pins. Finally, the Agee-Wristjack may be maintained following surgery to supplement the internal fixation.     

Shoulder arthroplasty for the treatment of the sequelae of fractures of the proximal humerus

The purpose of this multicenter study was to analyze the results of shoulder arthroplasty for the treatment of the sequelae of proximal humerus fractures and establish an updated classification system and treatment guidelines for these complex situations. Seventy-one sequelae of proximal humerus fractures were treated with shoulder replacement with the use of the same nonconstrained, modular, and adaptable prosthesis: the Aequalis prosthesis (Tornier Inc, St Ismier, France). The average time between initial fracture and shoulder arthroplasty was 5 years and 5 months. On the basis of anatomic classification schemes, sequelae were divided into 4 types: type 1, humeral head collapse or necrosis with minimal tuberosity malunion (40 cases); type 2, locked dislocations or fracture-dislocations (9 cases); type 3, nonunions of the surgical neck (6 cases); and type 4, severe malunions of the tuberosities (16 cases). The mean postoperative follow-up was 19 months (range, 12 to 48 months). Overall, the postoperative Constant score was excellent in 11 cases (16%), good in 19 cases (26%), fair in 18 cases (25%), and poor in 23 cases (33%). There were 18 complications (27%). Fifty-nine of 70 patients (81%) stated that they were satisfied with the result. The most significant factor affecting functional outcome was greater tuberosity osteotomy (P <.005). Regarding both surgical treatment and postoperative prognosis, we identify 2 categories of proximal humerus fracture sequelae: category 1, intracapsular/impacted fractures sequelae (associated with both cephalic collapse or necrosis [type 1] and chronic dislocation or fracture-dislocation [type 2]), in which an articulating joint can be reconstructed without a greater tuberosity osteotomy; and category 2, extracapsular/disimpacted fractures sequelae (associated with both surgical neck nonunions [type 3] and severe tuberosity malunions [type 4]) where the proximal humerus cannot be reconstructed without a greater tuberosity osteotomy. All of the excellent and good postoperative Constant scores were obtained in type 1 and 2, in which osteotomy of the greater tuberosity was not required. All patients in type 3 and 4, who underwent a greater tuberosity osteotomy, had either fair or poor results and did not regain active elevation above 90 degrees. We conclude that a greater tuberosity osteotomy is the most likely reason for poor and unpredictable results after shoulder replacement arthroplasty for the treatment of the complex sequelae of proximal humerus fractures. Shoulder arthroplasty for the treatment of the sequelae of fractures of the proximal humerus should be performed without an osteotomy of the greater tuberosity when possible. If prosthetic replacement is possible without an osteotomy, surgeons should accept the distorted anatomy of the proximal humerus and adapt the prosthesis and their technique to the modified anatomy. A modular and adaptable prosthesis with both adjustable offsets and inclination may allow surgeons to adapt to a large number of malunions and may help to avoid the troublesome greater tuberosity osteotomy in a higher proportion of cases.     

Results of treatment of infected humeral nonunions: the Mayo Clinic experience

Between 1987 and 2001, 15 infected humeral nonunions were treated of which nine were distal, four were proximal, and two were midshaft. One patient was lost to followup. The remaining 14 patients were followed up for a mean of 37 months (range, 8-156 months). All patients were treated with debridement and intravenous antibiotics. Ten patients had surgical attempts at achieving bony union: external fixation (four patients), plating (two patients), external fixation and plating (two patients), tension band wiring (one patient), and bone grafting with shoulder spica casting (one patient). Three patients were treated definitively with a functional brace because of low functional demands and one patient had resection arthroplasty followed by delayed total elbow arthroplasty. Of the 10 nonunions treated with surgical attempts at achieving bony union, only seven healed. None of those nonunions in patients treated with a functional brace healed. At final followup, 12 of 14 patients had minimal or no pain and two patients had moderate pain, both with ununited fractures. Complications included one seroma and two cases of posttraumatic elbow stiffness for which the patients required capsular release. This study documents the challenges in achieving bony union in the infected humeral nonunion in contradistinction to the predictable union rates reported for aseptic humeral nonunions. Although pain relief was predictable in most patients, functional results generally were poor and bony union was difficult to obtain.     

Reconstruction of posttraumatic bone defects of the humerus with vascularized fibular graft

Humeral nonunions still present a challenge to the orthopedic surgeon. Many methods of treating recalcitrant, posttraumatic humeral shaft nonunions have been described, with varying degrees of success. The present report reviews our experience with the use of vascularized fibular grafting for the treatment of large humeral defects. We treated 13 patients, with an average length of the humeral defect of 10.5 cm. Nine patients healed primarily, 3 required additional bone grafting, and 1 had a second fibular transplant. The mean period to radiographic bone union was 6 months. Only 5 patients regained full range of motion of the shoulder and elbow. The vascularized fibular graft is a reliable reconstructive procedure for recalcitrant pseudoarthrosis of the humerus in which the bony gap is greater than 6 to 7 cm, especially when traditional procedures have not provided the expected result.     

Treatment of osteopenic humeral shaft nonunion with compression plating, humeral cortical allograft struts, and bone grafting

Surgical stabilization of humeral shaft nonunions can be difficult to achieve if severe osteopenia or loss of bone stock is present. We present a technique whereby a 4.5-mm standard dynamic compression plate is used in conjunction with a humeral cortical allograft strut and bone grafting to stabilize humeral shaft nonunions complicated by severe bone loss. Six patients with established nonunion of the humeral shaft underwent this technique. Union was achieved at an average of 3.4 months (range 2-6 months). Our method using onlay allograft struts can provide an effective alternative in the management of humeral shaft nonunion complicated by severe osteopenia of various etiologies.     

Operative treatment of scaphoid nonunions]

43 reconstructive procedures were performed in nonunions and malunions of the scaphoid waist. In 8 cases of proximal pole nonunions the Chacha operation was carried out. Before surgical treatment SL angles and scaphoid length were measure on radiograms, taken with both hands in neutral position. Reconstruction procedures of the scaphoid waist were implemented basing on the carpal stretch test. Five different types of scaphoid nonunions were noted, basing on the localisation of the pathology. Operative procedures were selected in close correlation to nonunion localisation: simple reconstruction, reconstruction and revascularisation on the proximal part of the waist and rerevascularisation of the proximal pole. Additionally 3 revision procedures were performed in cases of nonunion after scaphoid reconstruction. Bone healing was observed in 49 cases, including the revision procedures.     

Vascularized medial femoral condyle corticoperiosteal flaps for the treatment of recalcitrant humeral nonunions

Background: Several methods have been used in the management of humeral nonunions. With the advent of modern microsurgical techniques, vascularized bone grafting is becoming increasingly used to improve local biology. We report our experience in the use of a vascularized corticoperiosteal bone flap from the medial femoral supracondylar region in the treatment of recalcitrant humeral nonunions. Methods: A retrospective review was performed of all patients treated with this technique over a 4‐year period within our institution. Patient demographics, nonunion characteristics, complications, and long‐term outcomes were analyzed. Results: Six patients underwent vascularized periosteal graft reconstruction. Prior to this, all had failed an average of three procedures with the length of nonunion ranging from 6 to 68 months. All six nonunions healed by an average of 6.8 months (range 2–12 months). Two patients required additional secondary procedures. Functional outcome improved in all patients as adjudged by disabilities of the arm, shoulder, and hand, Mayo elbow performance, and Constant Murley scores. Conclusions: The vascularized medial femoral condyle corticoperiosteal flap provides an additional treatment option for the management of humeral nonunions. © 2011 Wiley‐Liss, Inc. Microsurgery, 2011.     

Shoulder hemi-arthroplasty in proximal humeral fractures

Most fractures of the proximal humerus with significant displacement are best treated surgically. The range of surgical treatment varies from closed reduction and pinning to hemiarthroplasty depending on the degree of displacement, age of the patient, and bone quality. Determining whether or not the individual fractured bone segments are displaced to a significant degree requires high quality x-rays which can be difficult to obtain from acutely injured patients. Indications for replacement of the humeral head in acute fractures include: head splitting fractures in elderly patients, Neer 4-part fracture dislocations, selected 3 part fractures and fracture dislocations in elderly patients with poor bone quality and a very small head fragment, selected severe impression fractures in elderly patients that involve more than 40% to 50% of the articular surface and selected anatomical neck fractures in which internal fixation is not possible. If a prosthetic replacement of the humeral head is chosen, secure repair of the tuberosities is essential to avoid tuberosity migration and malunion. The clinical results of prosthetic replacement of the proximal humerus for acute fractures are superior to those for late arthroplasty. This treatment modality has been proven to relieve pain. However, even for patients treated with primary arthroplasty, a restricted range of motion has to be expected postoperatively. Furthermore, several studies indicate that a significant number of complications can occur following early and late prosthetic replacement. Humeral head replacement as a salvage procedure after malunions or failed open reduction and internal fixation is technically demanding with a relatively high rate of complications. Newer implant designs and instruments may improve the clinical results.