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.     

Treatment of humeral shaft delayed unions and nonunions with humeral locked nails

OBJECTIVE: To report experience with use of humeral locked nails in treating humeral delayed unions and nonunions. The following techniques yielded encouragingly good results: static locking, short-to-long segment nailing, bone grafting, fracture compression, and minimal surgical trauma. DESIGN AND METHODS: A total of 41 consecutive patients with 13 delayed unions and 28 nonunions were treated with humeral locked nails. Delay from trauma to surgery averaged 4.2 months for delayed union and 15.5 months for nonunion. The average age of patients was 50.2 years; average follow-up time was 23.2 months. There were 7 proximal-third fractures, 21 middle-third fractures, and 13 distal-third fractures. The antegrade approach was used for 13 fractures and retrograde for 28. Open nailing was performed in 39 fractures and closed nailing in 2. If the fracture motion was still present after nail insertion, axial compression of the fracture site was specially applied. Bone grafting was performed in the fractures with open nailing. Thirty-four fractures were nailed with 8-mm nails, and 7 fractures were nailed with 7-mm nails. RESULTS: With a single operation, all but two patients achieved osseous union in, on average, 5.6 months. One of these two patients eventually gained union after another surgery with fracture compression along the original nail and concurrent bone grafting. The second patient, undergoing hemodialysis for chronic renal failure, had persistent nonunion. At follow-up, for patients with antegrade nailing, all but four patients had less than 20 degrees limitation of shoulder abduction. For patients with retrograde nailing, all but two had less than 10 degrees limitation of elbow motion. Only the patient with persistent nonunion had continual pain and significant impairment of arm function. CONCLUSIONS: Humeral locked nailing seems to be effective for humeral delayed unions or nonunions. It may be an acceptable alternative for fractures unsuited for plate fixation, such as those with comminution, osteoporosis, or a severely adhered radial nerve.     

Seidel intramedullary nailing of humeral diaphyseal fractures: a preliminary report

Forty-two humeral diaphyseal fractures in 41 patients were treated at three centers between April 1988 and November 1989. There were 28 acute fractures; four were open. Average time to union was 8 weeks. There were no infections. Six patients with seven pathologic fractures due to metastatic disease died during the course of this study, but the nail had allowed them to be functional with minimal surgical dissection. Five of six nonunions united with one procedure. There was one residual nonunion in a patient with a wide canal and an arthrodesed shoulder above the nonunion. There were three preoperative radial and two preoperative axillary nerve palsies, and no iatrogenic nerve palsies. In all patients with anterior deltoid incisions, shoulder motion returned reliably, but took as long as 6 months. Four rods were left prominent in the rotator cuff and the patients had symptoms of impingement until rod removal. Six patients had restricted shoulder function, one due to a fracture of the humeral head and five from a lateral deltoid incision. This incision was used in 12 cases. There were no stiff shoulders when using an anterior deltoid incision.     

肱骨交锁髓内钉治疗肱骨骨折术后骨不连

目的介绍应用肱骨交锁髓内钉治疗肱骨骨折术后骨不连的经验。方法1997年10月～2001年7月,应用肱骨交锁髓内钉治疗12例肱骨骨折术后骨不连患者,其中肥大型5例,萎缩型2例,假关节形成5例。受伤至骨不连手术的时间平均为10．5个月(5～33个月)。手术采用开放复位顺行置入髓内钉,锁入远端交锁钉后向近端打拔以使断端加压,自体髂骨及RBX植骨。结果所有患者获平均21个月(9～51个月)随访。12例患者骨不连均获得愈合,平均愈合时间为5．8个月(3．5～8．0个月)。其中1例去除髓内钉后1年于原骨不连部位发生再骨折,重新植骨内固定而获得愈合。11例肩关节及上肢功能恢复良好。所有患者未遗留神经损伤症状。结论肱骨交锁髓内钉为治疗肱骨骨折术后骨不连的有效方法。     

Antegrade locked intramedullary nailing in humeral shaft fractures

Thirty-three humeral nailings were carried out using the Russell-Taylor nail. Twenty-two acute fractures and one non-union united, gave an overall union rate of 70%.Eighteen patients (56%) experienced pain in the shoulder or at the fracture site. Thirteen patients (41%) had poor shoulder function. Only 17 (51%) of the patients were satisfied with the outcome. Fourteen patients (42%) needed further surgery.We conclude that antegrade intamedullary nailing of humeral shaft fractures leads to a substantial risk of non-union and impairment of shoulder function. There was no significant correlation between fracture comminution and fracture healing in our study.     

Augmentative Ilizarov external fixation after failure of diaphyseal union with intramedullary nailing

OBJECTIVE: To investigate the use of the Ilizarov circular fixator and nail retention in treating diaphyseal nonunion following previous intramedullary nailing. DESIGN: Retrospectively reviewed, consecutive series. Mean duration of follow-up after achieving bone union: 19.2 months (range 6 to 33 months). SETTING: A tertiary referral center for nonunion surgery. PATIENTS: Nine patients (two femoral, three tibial, and four humeral nonunions) were included in the study. All patients were referred from other centers after failure to achieve union with intramedullary nailing. Patients who had nonunion with other fixation devices in situ, those with active infection and nonunion following nonoperative treatment, were excluded from the study. The patients had undergone an average of 2.4 operations (range 1 to 5 operations) before application of the Ilizarov fixator. All patients completed the study. INTERVENTION: The circular fixator was used to compress the nonunion site from without, retaining the intramedullary nail in each case. We excluded a patient who had his nonunion site explored followed by bone excision and transport. The mean duration of fixator treatment was 6.2 months (3 to 11 months). MAIN OUTCOME MEASUREMENTS: Clinical and x-ray evidence of bone union, infection, residual deformity, shortening, and assessment of functional outcome. RESULTS: Bone union was achieved in all nine patients using the circular fixator over the nail. The bone results were graded as six excellent, one good, and two fair. All patients reported a reduction in pain and satisfaction with their final outcome. CONCLUSIONS: There is a role for the use of the Ilizarov fixator with nail retention in resistant long bone diaphyseal nonunion in carefully selected patients. This method can achieve high union rates where other treatment methods have failed.     

Treatment of nonunions of humeral fractures with inter-locking intramedullary nailing

Objective： To introduce the experience of treating nonunions of humeral fractures with interlocking intramedullary nailing.
Methods： Twelve patients with humeral nonunions were treated with interlocking intramedullary nailing. The time interval between trauma and surgery was 10.5 months on average. Open reduction with anterograde approach was performed. Axial compression was specially applied to the fracture site with humeral nail holder after insertion of distal locked screws. Iliac bone grafting was added.
Results： The average follow-up period was 21 months （ranging 9-51 months）. All patients achieved osseous union 5.8 months after treatment on average. Eleven patients hadgood functions of the shoulder joints and the upper extremities. No patient experienced any permanent neurological deficit. Refracture of the original ununited region occurred in one patient after removal of the internal fixator one year later, but union was achieved after closed re-intramedullary nailing fixation.
Conclusion： Humeral interlocking intramedullary nailing is an effective alternative treatment for humeral nonunion.     

HUCKSTEP INTRAMEDULLARY NAILING FOR NON-UNION OF HUMERAL SHAFT FRACTURES

Background : Various techniques of internal fixation for non-union of humeral shaft fractures have been attempted, leading to union rates of between 50 and 90% with persisting non-union causing pain and disability. Some of these techniques have led to shoulder and elbow dysfunction. Methods : Eight patients treated with Huckstep nail fixation for humeral shaft non-union were reviewed and the rate of union was determined. Elbow and shoulder function were assessed as well as the presence of pain or disability. Results : Union was achieved in seven of the eight patients (87.5%). Four patients had occasional mild pain after union. All patients achieved good arm function. Average shoulder abduction was 157° and flexion 151° excluding one patient with antecedent advanced osteoarthrosis of the gleno-humeral joint. No patient experienced any permanent neurological deficit. Conclusions : Huckstep nail fixation achieved union rates comparable to or higher than the other techniques of internal fixation for non-union of humeral shaft fractures. Unlike the various methods of closed nailing, Huckstep nail fixation is not associated with shoulder and elbow dysfunction. It should be considered as a therapeutic option in humeral shaft fracture and non-union, especially where the fracture site needs to be opened.     

Locked nailing with interfragmentary wiring for humeral nonunions

OBJECTIVE: Locked nailing for humeral nonunions is threatened by residual fracture gap and fracture motion. This article describes the clinical experience of using interfragmentary wiring to solve these problems. METHODS: Interfragmentary wiring was used in 21 consecutive humeral nonunions treated with humeral locked nails. The average age of patients was 49.5 years, with an average nonunion duration of 14.4 months. Eighteen patients had previous operations. Nonunions were located at the proximal third in 4, the middle third in 10, and the distal third in 7. Antegrade nailing was used in 11 and retrograde nailing in 10. Sixteen nonunions were nailed with 8-mm nails and five with 7-mm nails. Interfragmentary wiring was applied to either the posterior or the lateral cortex of humeri in a figure-of-eight configuration. Bone grafting was performed in all and average follow-up time was 22 months. RESULTS: With a single operation, all patients achieved osseous union in, on average, 18.3 weeks. One patient with segmental nonunion suffered acute renal failure 4 months after operation, but fracture healing was not affected. Wire infection occurred in one patient with preoperative infection at the nail entry site and was treated by implant removal. Other complications including two transient radial nerve palsies and one brachial artery injury did not affect the final outcome. At follow-up, all but four patients had complete recovery of shoulder flexion and abduction. The average postoperative Neer score (91.1 points) was significantly better than the average preoperative score (65.5 points). All but three patients had complete recovery of elbow motion. CONCLUSION: Interfragmentary wiring, a safe procedure if properly performed, could effectively decrease the residual fracture gap and fracture motion in locked nailing of humeral nonunions. Further biomechanical studies and prospective, randomized, controlled studies are warranted.     

Locking flexible nails for diaphyseal humeral fractures in the multiply injured patient: a preliminary study

Multiply injured patients are sometimes treated with standard intramedullary nails for diaphyseal humeral fractures. We evaluated the use of the Synthes titanium locked flexible nail in 43 multiply injured patients (average injury severity score, 35.2) assessing time to union, nonunion rate, shoulder and elbow pain, and range of motion. Twenty-seven patients underwent antegrade insertion, and 16 underwent retrograde insertion. An increase in union rate was noted with antegrade (93%) versus retrograde (69%) insertion, without statistically significant difference in shoulder and elbow pain or range of motion. We recommend the locking flexible humeral nail with antegrade insertion for multiply injured patients with large soft-tissue damage or severe comminution that renders plate fixation difficult.     

TREATMENT OF HUMERAL SHAFT FRACTURES WITH THE SEIDEL INTRAMEDULLARY NAIL

Background: The use of intramedullary nails for the management of humeral shaft fractures has been controversial. Recently, the Seidel nail has become available. The purpose of this study was to review our initial experience with the Seidel nail. Methods: A retrospective clinical and radiographic review of 25 consecutive patients treated with Seidel intramedullary humeral nail was performed. The nail was used for non-union in 10 patients, delayed union in four, acute fracture in eight and pathological fracture in three. Eighteen of the 19 survivors were clinically reviewed at an average of 15 months (range 8–25). Pain, function, satisfaction, shoulder power, range of motion and clinical outcome were graded using the UCLA shoulder score. Results: Pain was present at the shoulder in four patients and at the fracture site in nine. Average shoulder abduction was 99° and nine patients could not abduct the shoulder past 90°. Sixty-six per cent of patients reviewed were graded as only fair or poor using the UCLA shoulder score. In three patients rotational control was not achieved with the distal locking device at the time of surgery. Complications included non-union in 10 patients and three intra-operative fractures. Conclusions: Non-union was more likely to occur if rotational control was not obtained, or if the patient had the nail inserted for a previous non-union. Use of the Seidel nail frequently leads to shoulder pain and dysfunction. The distal locking device is unreliable and predisposes to non-union. We do not recommend the continued use of the Seidel nail.     

Closed retrograde Hackethal nail stabilization of humeral shaft fractures.

We retrospectively reviewed 48 consecutive humeral shaft fractures treated with Hackethal stacked, flexible, intramedullary (IM) nails. The indications for fixation were polytrauma or fracture patterns not amenable to bracing. The average age of patients was 40 years. Eight had associated primary nerve injuries. All fractures were reduced closed, and the nails were inserted retrograde through a distal posterior cortical window. Follow-up was possible in 33 patients. Ninety-seven percent (32 of 33) had healed at 1 year. There were no iatrogenic nerve palsies. There was one delayed union, one nonunion, one deep infection, and three occurrences of heterotopic ossification at the entry portal. Two patients with distal nail migration required second operations. Clinical examination showed normal range of motion at the shoulder and an average of 5 degrees loss of extension at the elbow. Hackethal's bundled IM nailing was shown to be a reliable, inexpensive, and relatively atraumatic method for stabilization of simple and comminuted humeral shaft fractures.     

脱钙骨基质治疗长骨骨折延迟愈合及骨不连

目的探讨脱钙骨基质(decalcifiedbonematrix,DBM)治疗长骨骨折延迟愈合和骨不连的疗效。方法长骨延迟愈合、骨不连共57例,男45例,女12例;年龄21~65岁,平均42岁。开放性骨折17例,闭合骨折40例。骨折延迟愈合32例中,肱骨4例,股骨10例,胫骨18例;骨不连25例中,肱骨5例,股骨4例,胫骨16例。全部采用DBM于骨断端处和骨缺损区植入治疗。结果57例患者均获随访,随访时间4~37个月,平均7.8个月。骨折延迟愈合32例中骨折愈合31例,1例胫骨骨折未愈合;骨不连25例中骨折愈合23例,2例未愈合,其中胫骨1例、肱骨1例。愈合时间3~6.6个月,平均4.7个月。结论DBM治疗长骨骨折延迟愈合及骨不连,其疗效满意、并发症少。     

Russell-Taylor交锁髓内钉治疗肱骨干骨折

目的 总结Ｒｕｓｓｅｌｌ－Ｔａｙｌｏｒ交锁髓内钉（ＲＴ钉）治疗肱骨干骨折的效果。方法 用非扩髓的ＲＴ钉治疗１６例肱骨干骨折,其中新鲜骨折１２例,病理骨折３例,骨折不愈合１例。２例新鲜骨折伴有桡神经挫伤。结果 平均随访１４．５个月,１５例骨折愈合,平均愈合时间为１６．５周,２例肩部疼痛。结论 ＲＴ钉可有效治疗肱骨干骨折,尤其适用于病理性骨折、骨折不愈合、多段骨折及粉碎性骨折。     

Treatment of post-traumatic humeral diaphyseal nonunion with bone loss

Four patients with post-traumatic nonunion and shortening of the humeral diaphysis were treated with a hybrid advanced Ilizarov technique. The mean age of the patients was 32 years, and the mean total amount of humeral shortening was 6.63 cm. Three nonunions were atrophic and infected, and one was hypertrophic. All patients obtained union of the humeral fracture with resolution of infection at a mean external fixation time of 8 months. Restoration of normal humeral length was achieved in two patients, with a third having a residual discrepancy of 1 cm. The final patient, who had an infected nonunion with 11 cm of total humeral shortening, had a residual limb length discrepancy of 3 cm. All had improvement in shoulder and elbow motion after treatment. Superficial pin tract infections were seen in all patients, but all responded to pin-site care and oral antibiotics. Two patients had three refractures after removal of the fixator, two of which were treated by a second application of an Ilizarov frame and one by a cast. All patients had reduced pain and improved function at completion of the treatment. The Ilizarov method, though not a panacea for all humeral nonunions with extensive bone loss, does offer a viable salvage procedure in this unusual and often complex clinical problem.     

Orange city tapping nail: An innovative implant for humeral diaphyseal fractures

BackgroundWe have conducted this study to evaluate the effectiveness of Orange City tapping nail in humeral diaphyseal fractures in terms of radiological union, shoulder function and complications. It’s a pilot study with the new implant “Orange City tapping nail” developed at our institute.Materials and methodsThirty patients with humeral diaphyseal fractures were treated with Orange City tapping nail through antegrade nailing procedure. The cases were followed up prospectively for a period of minimum six months. Outcome of the procedure were assessed according to American Shoulder and Elbow Surgeons (ASES) score, radiological union, complications and secondary procedures required.ResultsTwenty eight (93.33%) fractures united with an average consolidation time of 15.75 weeks. Two patients had nonunion. Functional outcome was excellent to good in 24 (80%) patients. One (3.33%) case had infection with Orange City tapping nail.ConclusionResults of Orange City tapping nail were excellent to good for humeral diaphyseal fractures in terms of union, shoulder function and complications. It is a safe, easy and reliable method for the treatment of humeral diaphyseal fractures. Postoperative shoulder stiffness and impingement depends on operative technique and postoperative rehabilitation. We need a larger comparative study with conventional antegrade nail to evaluate the effectiveness of the implant.     

Fractures adjacent to humeral prostheses.

In a review of records and radiographs from 1974 through 1988, we identified seven patients who had a humeral fracture after either a total shoulder replacement or a shoulder hemiarthroplasty. All seven patients had complications after the fracture, and five fractures did not unite until an operation was done. All of the fractures that were treated operatively healed without sequelae. Four patients who were managed operatively had satisfactory relief of pain and one had fair relief. One patient who had a non-union refused further treatment for medical reasons. The one fracture that united without operative treatment healed with the tip of the prosthesis outside of the humeral shaft, but persistent pain led to a revision total shoulder replacement. The average time to union after the operation was approximately five months (range, four to seven months). There was a permanent decrease in the motion of the shoulder from preinjury levels in five of the six patients who had union of the fracture.     

Open exchange locked nailing in humeral nonunions after intramedullary nailing

Humeral nonunions after cannulated intramedullary nailing have been difficult to reconstruct. In the current study, 23 consecutive patients were treated by open exchange locked nailing with bone grafting. There were 16 men and seven women with a mean age of 46.2 years. The nonunions followed humeral locked nailing in eight patients, Seidel nailing in 13, and Küntscher nailing in two. The average nonunion time was 14.7 months. The nonunions, located at the proximal (1/3) in four humeri, middle (1/3) in 15, and distal (1/3) in four, were antegrade nailed in 10 and retrograde nailed in 13. Nineteen had 8-mm nails and four had 7-mm nails. Supplementary wiring was used in 19 patients. The average followup was 21.4 months. With one surgery, all but one patient (96%) achieved osseous union in, on average, 16.3 weeks. One patient with chronic renal dialysis had persistent nonunion and an osteolytic supracondylar fracture. Other complications included one postoperative radial nerve palsy, one brachial artery injury, and one wire infection. At followup, all patients with solid union had excellent or satisfactory recovery of shoulder function. The average postoperative Neer score (90.7) was significantly better than the average preoperative score (68.5). Two patients had losses of elbow motion of 10 degrees and 20 degrees, respectively. This study shows that humeral nonunion after cannulated intramedullary nailing can be treated effectively by open exchange locked nailing with bone grafting. Supplementary wiring can compress the nonunion and facilitate bone healing.     

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。     

交锁髓内钉治疗肱骨干骨折的疗效分析(附58例回顾性分析)

目的评价采用交锁髓内钉治疗肱骨干骨折的临床效果。方法对58例肱骨干骨折采用闭合复位或有限切开复位交锁髓内钉固定并随访10～16个月。结果58例中57例骨折愈合,有1例骨折延迟愈合经取除远端锁钉动力化后骨折愈合,平均愈合时间为12周。肩关节功能按Neer评分,优38例,良15例,可5例,优良率为91.4%。结论肱骨交锁髓内钉对骨折端的血运影响较小、固定牢靠,是治疗肱骨干骨折的有效方法。