Failure of reamed nailing in humeral non-union: an analysis of 26 patients

The use of an intramedullary nail in the treatment of humeral non-unions remains controversial. This study evaluated the treatment of humeral delayed and non-unions with reamed nailing and compression. In a retrospective analysis of prospectively gathered data from 26 cases all treated with the Telescopic Locking Nail (TLN), the healing rate after the first intervention for non-union was 58%. After one or more re-interventions combined with an external cancellous bone graft at some time during follow-up, 90% of the 21 patients with complete follow-up eventually healed after a mean of 22 months. A total of 49 procedures with a mean of 1.9 per patient were needed. After a mean follow-up of 65 (range 24-88) months, we conducted a study to assess the functional results in the shoulder and elbow. Twelve patients were suitable for inclusion. We used the Neer and Morrey score for shoulder and elbow function, respectively. For the Neer score the median was 91 points and for the Morrey score 94 points. The outcome suggests that simple reamed nailing of humeral non-union is insufficient. Reamed interlocked nailing is feasible, provided that the primary intervention for non-union is combined with an external cancellous bone graft.     

逆行髓内钉结合植骨治疗肱骨中远段骨折术后不愈合

[目的]探讨肱骨干中远段骨折内固定术后不愈合的原因及对策。[方法]2000年1月～2005年1月治疗肱骨干中远段骨折内固定术后不愈合27例，取出原有内固定后应用逆行髓内钉结合植骨治疗。[结果]随访6～32个月，平均16个月。骨折均愈合，患肢关节功能恢复良好，无伤口感染、髓内钉断裂及肱骨远端骨折等并发症。[结论]逆行髓内钉结合植骨是治疗肱骨干中远段骨折内固定术后不愈合的一种有效方法。     

Treatment of humeral shaft nonunions: nailing versus plating

Introduction The aim of this study was to compare plating and nailing for treating nonunions of the upper two-thirds of the humerus.Materials and methods Fifty nonunions of the upper two-thirds of the humerus were treated by two different methods: 24 of them by unreamed locked nailing and bone graft (group A), and the other 26 by plate fixation and bone grafting (group B).Results All fractures healed in both groups. In group A, the time required for healing was 4.2 months (range 4–6 months), whereas in group B it was 4.7 months (range 4–6 months). This difference was statistically significant (p<0.05). Functional results and the range of motion of the shoulder and elbow were similar with both techniques. In group B there were 3 cases of transient, iatrogenic, radial nerve palsy.Conclusions We feel that both plate fixation and the unreamed humeral locked nail are good alternatives for the treatment of humeral shaft nonunions, although nailing achieves union earlier and has fewer complications.     

Peri-prosthetic humeral non-union: Where biology meets bio-mechanic. A case report

IntroductionThe worldwide incidence of traumatic fractures has been growing over the last years due to the progressive aging of the population. Today, the increase of arthroplasty procedures in orthopaedic surgery is related to a high rate of peri-prosthetic fractures. Healing of the fracture is a multifactorial metabolic process; if these factors are impaired, healing process could be interrupted resulting in non-union.Presentation of caseWe report our experience about a case of a humeral diaphysis non-union secondary to peri-prosthetic fracture (reverse shoulder arthroplasty) treated by conservative approach.DiscussionWe treated this patient using a multilevel approach, consisting of revision surgery and drug therapy.ConclusionWe assume that an aggressive revision surgery done with bone autograft implant and a bone healing therapy administering teriparatide off-label can reduce the convalescence in non-unions and can improve prognosis.     

Locked intramedullary nailing for difficult nonunions of the humeral diaphysis

Antegrade intramedullary nailing and bone grafting was carried out for 27 patients with resistant atrophic nonunion of the humeral diaphysis. The initial fracture was open in 12 cases and closed in 15. There were ten proximal humeral fractures, 13 mid-shaft fractures and four distal humeral shaft fractures. Most had previous attempts at internal fixation with bone grafting. Fifteen cases united, but 12 remained ununited necessitating further surgical treatment. The failures were all in the more complex cases. Lack of rigidity and compression may be the problem.     

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.     

Tibial non-union: a review of current practice

Diaphyseal tibial fractures are common and generally heal well. However, non-union is a frequent consequence, can require prolonged treatment with unpredictable results and lead to chronic disability. This article describes the management of non-unions and provides an algorithm for current management techniques including the challenges of bone loss, deformity and infection and an overview of the role of biological augments in non-union surgery.     

Intramedullary nailing of humeral shaft fractures

From 1996 until 2000 we treated 52 humeral shaft fractures with AO unreamed nailing. Mean patient age was 35.8 years and the average follow-up 29.6 months. There were 31 type A fractures, 15 type B, and 6 type C. Closed retrograde nailing was performed in 46 cases and open nailing in six. Functional results were excellent in 48 cases, moderate in three, and poor in one.     

Intramedullary nailing of humeral shaft fractures

Summary Humeral shaft fractures can be treated either conservatively or operatively. Plating of the humerus is the established operative method, but recently interest has also been focussed on intramedullary nailing. Fifty-nine cases of humeral fractures treated with intramedullary nailing (Seidel/Marchetti-Vicenzi/Prévot) from January 1991 to December 1995 (44 fractures after trauma, 11 pathological fractures, 3 pseudarthroses, 1 re-fracture). Closed reduction in 55/59 cases. One infection (soft tissue); 2/48 pseudarthrosis (indication for nailing: pseudarthrosis!). No iatrogenic palsy of the radial nerve. Functional postoperative treatment in all 44 cases of humeral fractures after adequate trauma. One poor functional result: periarticular ossification after retrograde nailing, possibly connected with long-term respiratory treatment after trauma. Treatment of humeral shaft fractures by intramedullary nailing is favoured in our clinic (low complication rates, excellent or good functional results, limited approaches, small scars). Proximal fractures should be treated by the Seidel nail (stable interlocking of the proximal fragment); very distal fractures need Prévot nailing (reaming of condylar canals). All other fractures of the humeral shaft can be treated by each of the implants used in our clinic. Pathological fractures are an excellent indication for intramedullary stabilization. These patients benefit from stable fixation without intense surgical trauma. Pseudarthrosis, according to our limited experience, seems to require plating plus bone grafting. Plating is also recommended if revision of the radial nerve becomes necessary.      

The limited-contact dynamic compression plate in the management of proximal humeral non-union

Non-union is an uncommon but troublesome complication of proximal humeral fractures. A number of surgical techniques have been reported. We describe the use of a contoured limited-contact dynamic compression plate in the surgical management of proximal humeral non-union.     

Cerclage wiring and intramedullary nailing,a helpful and safe option specially in proximal fractures. A multicentric study

Purpose

Antegrade intramedullary nailing is an alternative for humeral shaft fracture treatment. This surgical technique can be especially demanding in some fracture patterns, leading to problems like malunion and non-union. The purpose of our study is to demonstrate that the use of a nail with cerclage wires could be a safe procedure that facilitate reduction, specially in fractures with abduction of the proximal fragment.

Intramedullary nailing in humeral shaft fractures

The aim of this in vitro study was to compare the mechanical behavior of fixation by the Russell-Taylor nail with the more recent Polarus nail. Fixation with an experimental nail made from polyacetal polymer was also included in the study. Thirty humeri were fractured and randomized to receive one of the three nail types. A four-point nondestructive bending test was performed, as well as torsional testing to failure. The torsional test was designed to record the amount of ‘play’ (uncontrolled rotation) in the bone/implant construct. The Polarus nail gave higher rigidity of the nail/bone construct than the two other types. The Russell-Taylor nailing exhibited a high degree of ‘play’ (uncontrolled rotation). The polyacetal nails allowed a large elastic deformation before failure. Received: 5 December 2000     

Intramedullary nailing with reaming to treat non-union of the tibia

The records of fifty-one patients who were treated by intramedullary nailing with reaming for non-union of the tibia were retrospectively reviewed. The fractures had been treated initially by closed reduction and immobilization in a cast, external fixation followed by immobilization in a cast, fixation by pins incorporated in a plaster cast, minimum internal fixation and immobilization in a cast, dynamic compression plating, or intramedullary nailing with or without reaming. After the initial treatment had failed, intramedullary nailing with reaming was done to gain union. Although closed nailing of the tibia was preferred, in thirty-three patients, the site of the non-union was opened to improve alignment by performing an osteotomy or to remove failed hardware. Bone grafts from the iliac crest were used in ten patients, and a fibular ostectomy or osteotomy was done in thirty-three. Of thirty-four open fractures (fourteen grade I, seven grade II, and thirteen grade III), eight were infected at the time of intramedullary nailing. The average time of the diagnosis of a non-union was 9.6 months; the average length of follow-up after nailing was twenty months. In forty-nine (96 per cent) of the fifty-one patients, tibial union occurred at an average of seven months postoperatively. Complications included persistent infection (three patients), acquired infection after intramedullary nailing with reaming (three patients), fracture of the nail that necessitated an additional operation (two patients), shortening of more than one centimeter (two patients), malrotation of more than 15 degrees (one patient), peroneal palsy (one patient), and amputation (one patient). When used to treat non-union of the tibia, intramedullary nailing with reaming can produce union as effectively as other alternatives, while enabling the patient to function more normally without external immobilization or walking aids.     

Risk factors for humeral head necrosis and non-union after plating in proximal humeral fractures

AimThe aim of this study was to evaluate risk factors for the development of humeral head necrosis and non-union after proximal humeral fractures—in particular, general risk factors that exist independent of fracture type.Materials and methodsThis study included patients (n = 154) treated for proximal humeral fracture by means of open reduction and internal fixation (ORIF) using the Philos^® plate at a single level I trauma centre between January 2005 and December 2013. Follow-up monitoring included radiographic examination before hospital discharge, and again at 6 weeks, 12 weeks, and 6 months after surgery. At a minimum follow-up time of 6 months, radiographs taken in the anteroposterior and axial projection were evaluated in regard to the development of humeral head necrosis, non-union, and secondary screw cut out.ResultsA total of 154 patients (61 males, 93 females) were available for radiological checkup. Mean age was 55.8 years (range: 19–91 years). There were statistically significant correlations between the development of avascular necrosis (AVN) and fracture type, non-union and smoking, and screw cut out – as well as overall complication rate – and age. The time to surgery did not influence the risk for AVN or non-union, independent of fracture type. In this study population, the risk of developing non-union after ORIF was 3.9-fold higher in heavy smokers (i.e., >20 cigarettes per day). The risk for screw cut out was 4.1-fold higher in patients over 60 years of age, and the overall risk for complications was 3.3-fold higher.ConclusionThe older the patient, the more carefully one must consider the decision between conservative and operative treatments. If surgical treatment is performed, screw length should be selected depending on the patient's age. Heavy smokers must be informed preoperatively of the increased risk for bony non-union after ORIF.     

Intramedullary nailing of unstable proximal humeral fractures]

Unstable subcapital fractures and dislocation fractures of the humerus can usually be set by closed reduction. Stabilization of these fractures by intramedullary pins is a method which avoids damage to the soft tissues around the shoulder. Since 1985, elastic steel pins with special features have been in use. The last 20 mm of the tip of the pins is angulated at 15 degrees, and the distal end is curved in a special way for the last 20 mm. According to our experience, the results after using this method in the treatment of unstable fractures of the surgical neck (ASIF type A II/2) and dislocation fractures (ASIF type A III/2) are fair to very good. For unstable fractures (ASIF type C I/2) and other dislocation fractures (ASIF type C III/2), the method is only suitable if good reduction is possible. Between the end of February 1985 and the end of December 1990, 101 fractures of the proximal end of the humerus were treated by closed reduction and fixation with intramedullary pins. Following fractures in the anatomical neck, aseptic necrosis of the fragment of the head leads to unfavorable results. In two patients, pseudarthrosis with poor function developed. Disturbance of wound healing, postoperative hematoma, infection, myositis ossificans, or Sudeck's desease have not been observed.