天鹅形状记忆接骨器治疗30例肱骨干骨不连

目的 探讨天鹅形状记忆加压接骨器（SMC）治疗肱骨干骨不连的临床疗效。方法30例肱骨骨不连患者全部采用SMC进行治疗。术后根据正侧位X线片复查骨不连愈合情况,应用Neer—Morrey评分分别对患者肩、肘关节功能进行评价。结果30例均获随访,时间2～6年,29例术后平均（3．8±1．1）个月骨不连处为类骨板样骨替代,1例因跌伤再次骨折后拒绝治疗。21例6个月-2年去除SMC,未发生再骨折、感染等并发症。余者因年龄〉65岁未取出。除4例在接受SMC治疗前已存在桡神经损伤症状外,余均未引起桡神经损伤。肩关节功能：优28例,良1例,差1例。肘关节功能：优29例,差1例。结论SMC由于其独特的设计及材料优势,中远期随访证实其应用于治疗肱骨干骨不连时具有良好的临床疗效。     

Treatment of the humeral shaft nonunion after surgical failure using the Selfdynamisable internal fixator

Introduction A nonunion of the humeral shaft is not a rare condition and is a complication of both nonoperative and operative treatment of the fracture. Several fixation options were used in the nonunion treatment, including various plate techniques, intramedullary nails and external fixator. We applied our Selfdynamisable internal fixator for the treatment of humeral shaft nonunion after surgical failure and evaluated its clinical outcome. Materials and methods Six patients with persistent atrophic nonunion of the humeral shaft were treated with Selfdynamisable internal fixator. The inclusion criteria were mobile, unstable resistant nonunion of the humeral diaphysis which persisted after surgical treatment for nonunion. All patients were men with a mean age of 32 (27–39) years. The initial fracture treatment was external fixator in two patients and plaster cast for four patients. All cases failed to unite after primary treatment. Plate fixation was resorted for fracture union but failed. The revision surgery consisted of removal of hardware, freshening of bone ends and bone grafting, and internal fixation with a Selfdynamisable internal fixator. Results The average follow-up was 33 months. All the nonunions healed after indexed operation. The average time for union was 5.5 months (range 4–9 months). There was no loosening or breakage of the fixation device. The functional results, according to the scale of Constant and Murlay modified by Ring, were excellent in five and good in one patient. There were no complications of nerve injuries or infections related to the operation. Conclusion Selfdynamisable internal fixator with bone graft for the treatment of recalcitrant humeral shaft nonunion provided successful clinical outcome with minimal complications.     

上肢骨干骨折内固定实验动物模型的建立

目的：建屯内固定术治疗上肢骨干骨折的实验动物模型，为研究不同内固定下骨折愈合的机制提供实验对象。方法：新西兰大白兔25只，随机选择一侧前肢上臂，取外侧切口显露肱骨，以线锯在其中段截骨，复位后植入天鹅记忆接骨器(SMC组)；同法在对侧植入4孔动力加压接骨板(DCP组)。分别在术后l、2、48、12周摄片观察骨折愈合情况，并处死5只动物取材，HE染色，行病理学观察。结果：术后动物全部成活，前肢负重明显低于后肢。X线片显示：SMC组在术后8周骨折愈合，愈合过程中未见明显外骨痂及板下皮质骨疏松；DCP组骨折愈合速度较慢，术后12周时骨折端仍有骨痂，伴局部皮质骨疏松。，病理学观察：术后8周，SMC组骨折端直接由板层骨替代；术后12周，DCP组形成骨性连接，处于改建塑形期。结论：SMC固定下实验性兔肱骨干骨折愈合过程与临床相似，愈合速度和质量优于DCP固定。兔肱骨干骨折内固定模型是一种较为理想的上肢骨干骨折内固定实验模型。     

Treatment of humeral shaft nonunion with interlocking nail and percutaneous injection of bone marrow

OBJECTIVE: To investigate the effect of treatment of humeral shaft nonunion with interlocking nail and percutaneous injection of bone marrow after operation. METHODS: Twenty-five adult patients with humeral shaft nonunion, initially treated with plates, intramedullary nails, or external fixators changed to use RussellTaylor reamed antegrade intramedullary nails with autologous bone grafting and percutaneously bone marrow injection into the fracture sites ten days after the operation to promote union. RESULTS: All patients achieved a solid union with good function. The union period was a median of 4.5 months. CONCLUSION: We believe that the procedure may provide firm internal fixation and improve activity of osteoblasts in fracture sites for accelerating fracture healing.     

带锁髓内钉内固定加经皮注射红骨髓治疗肱骨骨不连

目的 探讨采用Ｒｕｓｓｅｌｌ－Ｔａｙｌｏｒ扩髓型带锁髓内钉顺得内固定与植骨、术后注射红骨髓治疗肱骨骨不连。方法 肱骨骨不连患者２５例,以往平均手术次数２次,骨折后时间１０个月～４年,平均１年１０个月。用带锁髓内钉顺行静力型固定骨折端,取自体髂骨植骨缺损。术后１０ｄ于骨折区注射自体红骨髓。术后早期功能锻炼。平均随访时间１６个月。结果 所有病例均达到骨性愈合,平均愈合时间４．５个月,关节功能恢复很好。     

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.     

交锁髓内钉治疗肱骨干骨折后骨不愈合原因分析

背景：作为治疗肱骨干骨折的一种选择,髓内钉并没有降低骨折不愈合的风险。现有临床资料的研究有助于推测其发生的原因。 目的：探讨交锁髓内钉治疗肱骨干骨折后骨不愈合的原因。 方法：回顾分析2005年1月至2010年1月行交锁髓内钉固定治疗的52例肱骨干骨折患者。观察术后骨折愈合情况,分析术后骨折不愈合的原因,探讨防治方法。运用Rodriquez-Merchan评分评价功能恢复情况。 结果：52例患者获得平均15个月（12-20个月）随访。47例患者骨折愈合（其中延迟愈合5例）,愈合时间3-6个月,平均4．1个月。5例患者骨折不愈合,均为肱骨干中下段骨折,4例二次手术治疗,1例保守治疗。Rodriquez．Merchan评分：优33例,良12例,中2例,差5例,优良率86．6％。 结论：交锁髓内钉固定肱骨干骨折术后发生的骨折不愈合,与损伤情况、手术操作、感染的控制、患者术后配合情况等多种因素相关。     

Komprimierte Marknagelung bei Oberarmschaftfrakturen

Since there is low fragment impaction in the case of transverse and short oblique fractures of the humerus, these involve an especially high risk of nonunion. The body weight exerts hardly any axial load on the human humerus, which in daily life is exposed much more to tension and rotational forces, requiring a high stabilization potency. This can be achieved by intramedullary nailing; interfragmentary compression, if appropriate, can augment its effects. A special compression device shifts the dynamic bolt at the nail base together with its bone fragment in the direction of the fracture gap, bringing about fragment adaptation followed by fragment compression and locking of the bolt. The result is then consolidated by means of an additional, static, bolt. Biomechanical studies have shown significantly higher stiffness values for compressed intramedullary nailing than for conventional nailing in cadaver humeri. Clinical results in 21 cases of compression nailing of the humeral shaft show complete bone healing in a median of 3.4 months with no necessity for revision surgery. There were no complications in these patients. In transverse fractures of the humeral shaft the use of interlocking nails with interfragmentary compression yields greater stability and thus a higher probability of undisturbed and fast bony healing.     

Salvage of humeral nonunions with onlay bone plate allograft augmentation

Eight women and one man were treated for 10 established diaphyseal humeral nonunions. Six patients sustained fractures in motor vehicle accidents and two patients sustained fractures in a fall. Two of the fractures were open. One patient with multiple myeloma originally was treated conservatively and received local radiation, followed by open reduction and internal plate fixation. The other patients previously were treated with fracture braces, intramedullary nails, dynamic compression plates, or a combination of these techniques. After removal of the surgical hardware and fibrous tissue at the nonunion site, stable fixation was accomplished using a cortical long bone plate allograft (femoral and tibial) or fibular shaft allograft and a dynamic compression plate. All humeral nonunions had united at an average of 2.9 months. Radiographic incorporation of the allograft cortical bone plate and fibular shaft into the host cortex occurred in all but one patient by 3 months. Graft to host junction healing was accomplished by incorporation of the cortical allograft plate into the host cortex, resulting in an increased diameter of the bone. Cortical allograft bone plates and fibular grafts provide structural and probably osteoinductive support to enhance healing of these nonunions.     

Anterior plating as a surgical alternative in the treatment of humeral shaft non-union

This study included 15 patients with humeral shaft fractures who had no clinical, radiological or bone scan signs of healing after eight months. The patients were followed for a mean of 35.8 months. No patient was lost to follow-up. Anterior plating of humeral shaft nonunion via an anterior approach was performed using a straight plate and compression for well-vascularised non-unions and wave plating with a tricortical graft for poorly vascularised non-unions. All non-unions healed within 6–18 weeks (mean, nine weeks) without local complication. One patient had a mild decrease in elbow and shoulder range of motion. No neurovascular injury was observed. Anterior plating is a simple, safe and effective treatment for humeral shaft non-union. As this approach avoids the need for radial nerve visualisation and extensive soft-tissue dissection, and the healing time is similar to that of other methods, we suggest this treatment as an alternative option.     

肱骨干骨折术后不愈合的原因分析及治疗

目的探讨肱骨干骨折术后不愈合的原因及治疗方法。方法回顾分析21例肱骨干骨折术后不愈合患者,采用锁定加压钢板内固定加自体髂骨植骨治疗。结果随访6～18个月,平均11个月,骨折经二次手术后均达骨性愈合。结论肱骨骨折术后不愈合的常见原因为创伤重、术中操作及内植物选择不当、功能锻炼不规范。锁定加压钢板加自体松质骨植骨是治疗肱骨骨折术后骨不愈合的有效方法。     

The spiral compression plate for proximal humeral shaft nonunion: a case report and description of a new technique

We present a case of humeral nonunion managed with a dynamic compression plate (DCP) contoured in a spiral fashion to preserve the deltoid muscle insertion. A forty-one-year-old woman sustained a closed proximal third humeral shaft fracture with an associated supraclavicular brachial plexus injury. She presented five months later with an atrophic nonunion of the proximal humeral shaft, inferior subluxation of the humeral head, and a resolving brachial plexopathy. Autogenous cancellous bone grafting and open reduction and internal fixation with a narrow DCP was performed. The deltoid muscle insertion was preserved by contouring the plate to fix the proximal humerus laterally over the greater tuberosity and anteriorly over the mid-humeral shaft. During the postoperative period, the humeral head reduced spontaneously. Five months after surgery, the fracture healed, and an excellent clinical result was achieved. We recommend the use of the spiral DCP for proximal shaft fractures and nonunions when preservation of the deltoid insertion is desirable.     

Isolated interfragmentary compression for nonunion of humeral shaft fractures initially treated by nailing: A preliminary report of seven cases

Introduction

Plating with bone grafting is considered the gold standard treatment for nonunion of humeral shaft fractures. However, this complex procedure involves multiple risks. The aim of this study is to evaluate an alternative treatment using isolated axial interfragmentary compression for the dynamisation of humeral shaft nonunion after retrograde locked nailing.

Materials and methods

Between January 2000 and May 2009, 124 humeral shaft fractures were treated in our trauma department with retrograde locked nailing using the unreamed humeral nail (UHN^®, Synthes, Paoli, PA, USA). Nonunion occurred in seven patients (5.6%) – five females and two males, mean age 44 years (range: 17–73 years). The nonunion was treated by applying isolated secondary interfragmentary compression. Mean follow-up was 43 months (range: 8–74 months). The Rommens score and the disabilities of the arm, shoulder and hand (DASH) score were used to evaluate the global functioning of the upper limb.

Results

The compression procedure was successful in all seven cases. In each case, the union occurred without any complications in 3–5 months. The mean DASH score was 25/100 (range: 8.3–60.8/100). The Rommens score was judged excellent for five of the seven patients but two were rated moderate. One of these suffered from complex regional pain syndrome type II since the fracture, and another developed a stiff shoulder 6 months after trauma.

Conclusion

Isolated secondary interfragmentary compression appears to be a simple and successful procedure in cases of humeral nonunion.     

Nonunion of the humeral shaft

Retrospective review of records of 26 patients with nonunion of the humeral shaft revealed several factors frequently associated with the development of nonunion. The fractures were transverse and short oblique and treated per primam with hanging casts or open reduction. Surgical fixation was unstable. The types of nonunion were atrophic in 19 patients, hypertrophic in five patients, and synovial pseudarthrosis in two patients. Twenty-four of 26 nonunions (92%) treated with bone grafts and rigid internal fixation healed in an average of 5.6 months. Overall, 47 surgical procedures, including prior procedures, were performed on these 26 nonunions. The average number of operations per patient was 1.8. Successful platings produced immobilization, consisting of an average of 6.8 points of cortical fixation above the nonunion and 7.1 cortices below. Rigid fixation was not obtained in the unsuccessful procedures. Unsuccessful platings were noted to have unstable fixation, with an average of 2.7 points of cortical fixation above the nonunion and 3.0 cortices below. Bone grafting was performed in only 55% of the unsuccessful platings. Optimal treatment of nonunions of the humeral shaft consists of resecting atrophic nonunions, shortening the bones, drilling sclerotic areas, and apposing bleeding diaphyseal surfaces; open reduction with internal fixation with a broad compression plate, including at least six points of cortical fixation above and below the nonunion; compression of the nonunion by means of interfragmentary lag screws, prestressing of the plate, dynamic compression by the plate, or direct compression by the external compression device; and autogeneic cancellous iliac bone grafts.     

Radial nerve transposition with humeral fracture fixation: preliminary results

Humeral shaft fractures traditionally have been managed with closed treatment. In patients with polytrauma, open fractures, and patients at risk for nonunion, open reduction and internal fixation and intramedullary nailing have been advocated. The current study describes a technique used in humeral shaft fractures that reduces the risk of iatrogenic radial nerve injury during plate osteosynthesis in fracture patterns at high risk of nonunion (highly comminuted, transverse fractures). Ten patients who had radial nerve transposition were reviewed retrospectively using the electronic records database at the authors' institution. The average age of the patients was 27 years and average followup was 25 months. All had humeral shaft fractures, AO class A3.2 in four patients, B3.2 in five patients, and C2.2 in one patient. All fractures were deemed to be at high risk for nonunion. There were no iatrogenic nerve palsies as a result of the transposition, and no infections. Two patients had delayed or nonunion, who achieved healing after a second intervention. Transposition of the radial nerve is a useful adjunct to plating of humeral shaft fractures in patients at high risk for nonunion. The technique is safe, does not cause iatrogenic injury, and protects the radial nerve during all subsequent approaches to the fracture site.     

AO非扩髓肱骨交锁髓内钉在肱骨干骨折不愈合中的应用

目的 探讨AO非扩髓(AO—UHN)肱骨交锁髓内钉加自体松质骨植骨在肱骨干骨折不愈合中的应用。方法 20例患者手术取出原内固定，行正向或逆向插入AO—UHN肱骨交锁髓内钉，在不愈合部位行丰富的自体松质骨植骨。术后进行影像学观察和疗效评定。结果 20例患者有15例得到随访，随访时间为9～23个月(平均13．8个月)，愈合时间4～10个月(平均6．2个月)。除1例在12个月时仍未愈合予再次植骨后6个月获得愈合外，其余均在一次手术后获得愈合，优良率为90％。结论 AO—UHN肱骨交锁髓内钉加自体松质骨植骨是治疗肱骨干骨折不愈合的一种有效方法。     

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.     

股骨干骨折骨不连的治疗

目的 对近５年收治的５１例股骨干骨折骨不连进行总结,探讨股骨干骨折骨不连的治疗方法。方法 分别采用调整内固定物加植骨治疗８例,更换不同钢板加植骨治疗１４例,外固定架加植骨治疗２９例。结果 ５１例中４８例在平均６．３个月达到临床愈合,１３人出现膝关节活动障碍。其中９例再次行膝关节松解术。结论 预防骨不连的关键在于术中无创操作,尽量少剥离骨膜并在术后尽可能将其复位。肌折尽可能解剖复位。骨缺损尤其是压力     

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.