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.     

A systematic review of ankle fracture treatment modalities in diabetic patients

AimThis systematic review evaluated the surgical outcomes of various ankle fracture treatment modalities in patients with Diabetes Mellitus as well as the methodological quality of the studies.MethodsFor our review, four online databases were searched: PubMed, MEDLINE (Clarivate Analytics), CINAHL (Cumulative Index to Nursing and Allied Health) and Web of Science (Clarivate Analytics). The overall methodological quality of the studies was assessed with the Coleman Methodology Score. Data regarding diabetic ankle fractures were pooled into three outcomes groups for comparison: (1) the standard fixation cohort with management of diabetic ankle fractures using ORIF with small or mini fragment internal fixation techniques following AO principles, (2) the minimally invasive cohort with diabetic ankle fracture management utilizing percutaneous cannulated screws or intramedullary fixation, and (3) the combined construct cohort treated with a combination of ORIF and another construct (transarticular or external fixation).ResultsThe search strategy identified 2228 potential studies from the four databases and 11 were included in the final review. Compared to the standard fixation cohort, the minimally invasive cohort had increased risk of hardware breakage or migration and the combined constructs cohort had increased risk of hardware breakage or migration, surgical site infection and nonunion. Limb salvage rates were similar for the standard fixation and minimally invasive cohorts; however, the combined constructs cohort had a significantly lower limb salvage rate compared to that of the standard fixation cohort. The mean Coleman Methodology Score indicated the quality of the studies in the review was poor and consistent with its limitations.DiscussionThe overall quality of published studies on operative treatment of diabetic ankle fractures is low. Treating diabetic ankle fractures operatively results in a high number of complications regardless of fixation method. However, limb salvage rates remain high overall at 97.9% at a mean follow-up of 21.7 months. To achieve improved limb salvage rates and decrease complications, it is critical is to follow basic AO principles, respect the soft tissue envelope or utilize minimally invasive techniques, and be wary that certain combined constructs may be associated with higher complication rates.Level of evidence2.     

Condylar nonunions of the elbow

Between 1968 and 1978, 32 patients were seen with nonunion of distal humerus fractures in close proximity to the elbow: 25 were treated with open reduction and fixation of the nonunion, and seven patients were treated with excision of the distal fragments and total elbow arthroplasty. Of the 25 patients treated with open reduction and fixation, 22 had union at an average of 7.74 months. However, six of these patients needed secondary procedures for repeat bone grafting or revision of the fixation device. Two of the seven patients with total elbow arthroplasty needed reoperation for loose humeral components.     

Modified use of the proximal humeral internal locking system (PHILOS) plate for distal femoral nonunions

Purpose

Nonunion is a common complication after a distal femoral fracture (DFF). Standard treatment consists of revision plating and/or bone grafting. Single lateral plating for a distal femoral nonunion can be insufficient in case of a persistent medial gap and compromised bone stock. Alternatively, dual plating can be used to treat a distal femoral nonunion, but to date there is no Gold standard. The aim of our study was to report our results after use of a minimally invasively placed proximal humeral internal locking system (Philos) plate as a medial buttress in the treatment of a distal femoral nonunion.

Methods

Fifteen adult patients with a distal femoral nonunion were prospectively entered in a trauma database and retrospectively assessed. All patients underwent a similar operation, which included removal of failed hardware, nonunion debridement, fixation with a lateral plate, and a medial Philos plate combined with bone grafting. Data collected included union rate, time to union, complications and functional outcome.

Results

In twelve out of fifteen patients (80%), the fracture united after our index operation. Median time to union was 4.8 months (range 1.6–15). Three patients (20%) needed additional bone grafting surgery. One patient underwent a Judet quadricepsplasty.

Conclusion

This study suggests that the Philos plate is a safe and effective adjunct as a medial buttress plate for distal femoral nonunions.

     

髓外固定辅助双植骨治疗股骨转子下骨折髓内固定术后骨不连

目的探讨髓外固定股骨近端接骨板(PFP)及锁定加压接骨板(LCP)辅助双植骨头钉孔道内松质骨、异体骨混合打压植骨及骨不连断端结构植骨治疗股骨转子下骨折髓内固定术后骨不连的手术技巧和临床疗效。方法回顾性分析2018年1月至2018年12月期间西安交通大学附属红会医院创伤骨科下肢病区收治且完整随访的21例股骨转子下骨折髓内固定术后骨不连患者资料。男15例,女6例;平均年龄为52.3岁(27~65岁)。骨不连类型:萎缩型18例,缺血型3例。患者骨不连手术与骨折初次手术的时间间隔平均为10.3个月(9~13个月),骨折手术均采用髓内固定(PFNA):闭合复位10例,切开复位11例(其中钢丝捆扎8例)。骨不连均采用髓外固定(PFP+LCP)辅助双植骨(头钉孔道内松质骨、异体骨混合打压植骨+骨不连断端结构植骨)治疗。术后12个月采用Harris评分评估髋关节功能。结果21例患者术后获平均11.4个月(10~12个月)随访。所有患者术后骨不连均获愈合,平均愈合时间为5.2个月(4~6个月)。1例患者术后出现皮下血肿,再次行清创术。术后12个月Harris髋关节评分平均为85.7分(84~92分)。结论PFP接骨板能够有效纠正内翻畸形并坚强固定,LCP接骨板+皮质骨结构植骨能够提供内侧力学支撑,松质骨+异体骨混合打压植骨能够有效增加头钉孔道内骨量,增加近端螺钉的把持力。该方法可以极大地提高骨折愈合率,减少并发症的发生,且能获得较好的髋关节功能。     

附加钢板治疗髓内钉固定后股骨肥大性骨不连

目的:探讨附加钢板治疗髓内钉固定后股骨肥大性骨不连的安全性和有效性。方法:自1998年4月至2008年6月,应用附加钢板治疗9例髓内钉固定后股骨肥大性骨不连,男8例,女1例;年龄21～54岁,平均32岁。1例为股骨上1/3,5例为股骨中1/3,3例为股骨下1/3。采用4～6孔钛合金限制接触性窄动力接骨板,4～6枚皮质骨螺钉固定。6例骨不连间隙大于5mm,4例采用单纯髂骨植骨,2例固骼生和髂骨混合植骨。3例小于5mm,1例植入固骼生,2例将修整的骨痂重新植入。术后保护性负重防止主钉断裂失效,逐渐恢复术前活动水平,术后1、3、6、12个月临床与影像学随诊。结果:6例取髂骨植骨或固骼生混合植骨患者,手术时间60～120min,出血量100～300ml;另3例单纯植入固骼生或骨痂植入患者,手术时间40～100min,出血量60～100ml。供骨区疼痛4例,3例1个月内缓解,1例3个月后缓解,无感染、钢板螺钉松动、断裂等。平均愈合时间8个月,5例术后6～11个月取出髓内钉和钢板。结论:附加钢板有效改善局部旋转不稳定,是治疗髓内钉固定后股骨肥大性骨不连的有效方法之一。     

Unstable nonunions of the distal part of the humerus

BACKGROUND: Some nonunions of the distal part of the humerus are so unstable that the hand and the forelimb cannot be supported against gravity. The purpose of the present retrospective study was to analyze the results of open reduction and internal fixation, joint contracture release, and autogenous bone-grafting in the treatment of these unstable nonunions of the distal part of the humerus. METHODS: Fifteen patients (average age, sixty years) with an unstable nonunion of the distal part of the humerus were treated with excision of fibrous and synovial tissues, opening of sclerotic fracture surfaces, internal fixation with multiple plates and screws, and autogenous bone-grafting. The average time from the original fracture to the index treatment of the nonunion was eleven months. Vascularized fibular grafts and supplemental external fixation were necessary in two patients with large bone defects after débridement at the site of a previous infection. RESULTS: Three nonunions failed to heal and were treated with total elbow arthroplasty. Twelve nonunions healed, but six of the twelve required additional surgery because of painful implants, ulnar neuropathy, or elbow contracture. After an average duration of follow-up of fifty-one months (range, twenty-four to 130 months), the twelve patients in whom the nonunion healed had an average arc of ulnohumeral motion of 95 degrees, with an average flexion of 117 degrees and an average flexion contracture of 22 degrees. According to the Mayo Elbow Performance Index, the functional result was rated as excellent in two patients, good in nine, and fair in one. CONCLUSIONS: Unstable nonunions of the distal part of the humerus can be treated successfully in most active, healthy patients with use of rigid internal fixation, joint contracture release, and bone-grafting.     

“Revision of subtrochanteric femoral nonunions after intramedullary nailing with dynamic condylar screw”

Background

Nonunions of the subtrochanteric region of the femur after previous intramedullary nailing can be difficult to address. Implant failure and bone defects around the implant significantly complicate the therapy, and complex surgical procedures with implant removal, extensive debridement of the nonunion site, bone grafting and reosteosynthesis usually become necessary. The purpose of this study was to evaluate the records of a series of patients with subtrochanteric femoral nonunions who were treated with dynamic condylar screws (DCS) regarding their healing rate, subsequent revision surgeries and implant-related complications.

Methods

We conducted a retrospective chart review of patients with aseptic femoral subtrochanteric nonunions after failed intramedullary nailing. Nonunion treatment consisted of nail removal, debridement of the nonunion, and restoration of the neck shaft angle (CCD), followed by DCS plating. Supplemental bone grafting was performed in all atrophic nonunions. All patients were followed for at least six months after DCS plating.

Results

Between 2002 and 2017, we identified 40 patients with a mean age of 65.4?years (range 34–91?years) who met the inclusion criteria. At a mean follow-up period of 26.3?months (range 6–173), 37 of the 40 (92.5%) nonunions healed successfully (secondary procedures included). The mean healing time of the 37 patients was 11.63?months (± 12.4?months). A total of 13 of the 40 (32.5%) patients needed a secondary revision surgery; one patient had a persistent nonunion, nine patients had persistent nonunions leading to hardware failure, two patients had deep infections requiring revision surgery, and one patient had a peri-implant fracture due to low-energy trauma four days after the index surgery.

Conclusions

The results indicate that revision surgery of subtrochanteric femoral nonunions after intramedullary nailing with dynamic condylar screws is a reliable treatment option overall. However, secondary revision surgery may be indicated before final healing of the nonunion.

     

Treatment of symptomatic medial epicondyle nonunion: Case report and review of the literature

INTRODUCTIONSymptomatic nonunion of humeral medial epicondyle can be problematic and difficult to treat due to high complication rates related to open reduction and internal fixation methods.PRESENTATION OF CASEWe described four patients with symptomatic medial humeral epicondyle nonunion who underwent open reduction and internal fixation.DISCUSSIONSymptomatic nonunion of humeral medial epicondyle is a rare entity. Surgical technique can be difficult because of anatomical and biomechanical factors. In the literature, there are a few cases of humeral medial epicondyle treated by open reduction and internal fixation.CONCLUSIONOpen reduction and internally fixation of the medial epicondyle nonunion with one cannulated screw results with improved elbow function.     

Periprosthetic femoral nonunions treated with internal fixation and bone grafting

IntroductionPeriprosthetic femoral nonunions (PPFN) have a reported incidence of 3–9%. Literature on PPFN management is scarce. The study aim was to review combined results of two academic teaching hospitals using comparable PPFN treatment strategies.Materials and MethodsA retrospective review was conducted of all patients treated for a PPFN between February 2005 and December 2016. All patients treated with internal fixation for a PPFN with complete clinical and radiological follow-up until healing were included. Nineteen patients were identified (mean age 71.2 years, range 49–87). Treatment consisted of failed hardware removal, debridement, reduction, and rigid internal fixation with or without bone graft. For revision PPFN surgery, use of dual-plating and bone graft augmentation was common.ResultsEighteen of 19 patients (94.7%) progressed to osseous union. One patient was converted to a total femoral prosthesis. No patients were lost to follow-up. All were ambulatory at last follow-up and mean follow-up was 39.8 months. Fourteen patients (73.7%) united after our index nonunion surgery at mean 9.8 months. Five patients (26.3%) required revision surgery after our index nonunion treatment and in 4 of these cases union was achieved at mean 18.0 months.ConclusionsOur results suggest debridement, revision of fixation and liberal use of bone grafting can lead to reliable healing in the majority of PPFNs. For those PPFNs that do not heal following initial treatment, good healing potential persists with an additional procedure.Level of EvidencePrognostic Level III.     

Platelet-Rich Plasma,Mesenchymal Stem Cell,and Non-metallic Suture-Based Fixation Technique in a Patellar Fracture Nonunion: A Technical Note and Systematic Review

BackgroudWe performed a systematic review on the management of patellar fracture nonunion and report a novel suture-based non-metallic fixation technique associated with platelet-rich plasma and mesenchymal stem cell injections in the management of this injury.MethodsA systematic search was performed up to August 2020 in PubMed and Scopus electronic databases of scholarly articles evaluating different surgical techniques used for nonunion of patellar fractures, with no restrictions on language or year of publication. Furthermore, we describe our novel non-metallic suture fixation technique and a patient in whom this technique was applied.ResultsA total of 9 articles were included in the systematic review. Tension band wiring was the most commonly used procedure (62.7%). Nonoperative procedures (8.1%) resulted in nonunion in all patients. The most common complication after open reduction and internal fixation was infection (7.8%). Our patient at the latest follow-up reported full functional recovery and full extension and flexion of the affected knee with no pain and subjectively normal strength.ConclusionsThe management of patella nonunions is still a challenge. The technique reported here can be used in patellar fracture nonunion, as well as in primary patellar fractures.     

5种方法治疗髌骨骨折164例

目的:探讨根据髌骨骨折的具体情况采用不同的治疗方法,并对临床结果进行分析。方法:回顾性分析2005年7月至2009年12月收治髌骨骨折164例,男113例,女51例;年龄21～72岁,平均38.5岁。摔伤80例,车祸伤73例,击打伤11例。线性骨折或髌骨分离0.5cm者21例,髌骨分离0.5cm且为单纯横行或纵行骨折者63例,髌骨分离为3块者34例,分离为4块及以上者46例。其中保守治疗21例,钢丝环扎加"8"字内固定术治疗39例,空心钉及张力带钢丝内固定术治疗43例,经皮空心钉内固定术治疗29例,镍钛聚髌器内固定术治疗32例。结果:164例均获随访,时间3～36个月,平均14个月。按Lysholm膝关节评分标准:保守治疗优良19例,钢丝环扎加"8"字内固定优良36例,空心钉及张力带钢丝内固定优良40例,经皮空心钉内固定优良27例,镍钛聚髌器内固定优良30例。结论:能手法整复、固定者,尽量避免手术;需要手术治疗者应根据骨折类型选择不同的术式,可以经皮复位固定的,尽量微创手术;不管保守治疗还是手术内固定,都需要尽早进行合适的功能锻炼。     

Osteosynthese proximaler Tibiafrakturen

From January 1999 until December 2003 we used a plate fixator with multidirectional blocked screws (TiFix) for internal fixation of the proximal tibia in 42 patients. In 23 cases this was used to stabilise fractures: in 11 cases for primary fracture management, in a further 11 after initial management with an external fixator and in 1 after initial fixation with a conventional plate. We also used the TiFix plate in 13 operations for pseudarthrosis and 6 for axis deviation after bone healing. In 34 (80.9%) of the total of 42 cases it was possible to implant the plate in a minimally invasive procedure. At the time of clinical follow up the treatment was complete in 39 (92.9%) cases. Fracture consolidation has been achieved in all cases; no implant failures have been observed. One patient developed a deep wound infection around the plate after revision for pseudarthrosis; in this patient swabs taken intraoperatively had proved positive for staphylococci. Our results underline the high effectiveness of this internal fixator system with multidirectional angular stability in osteosynthesis for proximal tibial fractures. This implant together with the minimally invasive operation technique achieves superior results and low morbidity in the primary treatment of proximal tibial fractures and in treatment of nonunion after such fractures sustained earlier.     

The diaphyseal aseptic tibial nonunions after failed previous treatment options managed with the reamed intramedullary locking nail

BackgroundThe nonunion of open and closed tibial shaft fractures continues to be a common complication of fractures. Tibial nonunions constitute the majority of long bone nonunions seen by orthopaedic surgeons. In this article, we present our approach to the surgical treatment of noninfected tibial shaft nonunions.MethodsBetween 2008 and 2014, 33 patients with aseptic diaphyseal tibial nonunion was treated by reamed intramedullary nailing and were retrospectively reviewed. The initial fracture management consisted of external fixation (27 patients), plate fixation (2 patients) and cast treatment (4 patients). All patients, preoperatively, were evaluated for the signs of the infection, by the same protocol. There were 13 hypertrophic, 16 oligotrophic (atrophic) and 4 defect nonunions registered in our material. The primary goal was to perform a closed intramedullary nailing on antegrade manner. An open procedure was only unavoidable when implants had to be removed or an osteotomy had to be performed to improve the alignment. Functional rehabilitation was encouraged with the assistance of a physiotherapist early postoperative. Patients were examined regularly during followed-up for a minimum of 12 months period for clinical and radiological signs of union, infection, malunion, malalignment, limb shortening, and implant failure.ResultsThe time that elapsed from injury to intramedullary nailing ranged from 9 months to 48 months (mean 17 months).Open intramedullary nailing was unavoidable in 25 cases (75,75%), while closed nailing was performed in 8 patients (24,25%). Osteotomy or resection of the fibula was performed in 78,8% of the cases. All patients were followed up in average period of 2 years postoperative (range 1–4 years), and 31(93,9%) patients achieved a solid union within the first 8 months. Mean union time was 5±0.8 months. Complications included 2 (6,06%) patients, one with deep infection and another case with absence of bone healing. Anatomical alignment has been achieved in the majority of patients, 28 patients (84,8%). The additionally autogenous bone chips were added in 4 patients (12,1%) where cortical defect was greater than 50% of the bone circumference.ConclusionIn conclusion, a reamed intramedullary nail provides optimal conditions for stable fixation, good rotational control, adequate alignment, early weight-bearing and a high union rate of tibial non-unions. Reaming of the medullary canal with preservation of periosteal sleeve create the "breeding ground" for sound healing of tibial shaft nonunions. Additionally cancellous bone grafting is recommended only in the case of defect nonunion.     

Treatment of nonunion of fractures in the epiphyseal-metaphyseal region of long bones

Twenty-four consecutive patients with fracture nonunion in the metaphyseal-epiphyseal areas of long bones were surgically treated. Average time from injury to treatment of the nonunion was 10 months, and average follow-up time after surgical treatment was 29 months. Eight patients with infected nonunions had initial debridement procedures; three of these patients then had placement of external fixators and bone grafting. The remaining five patients and 13 others were then treated by open reduction and internal fixation alone or with the addition of autogenous cancellous bone grafting. Single or double plates and screws were used. Arthrolysis, joint manipulation, and intensive postsurgical exercises were considered necessary to regain joint function. One patient underwent a hemiarthroplasty, and two others underwent arthrodesis as the initial nonunion treatment. Twenty of the 21 patients not treated by arthrodesis or arthroplasty healed their fractures in an average time of 7 months. Fifty-two percent of the patients achieved good or excellent range of motion (ROM) of the contiguous joint, with 70% of the patients reporting no pain in this joint. These fractures have excellent intrinsic healing capability because they occur in anatomical regions with a normally abundant circulation. We recommend stable fixation, with the need for bone grafting only in defect nonunions, together with intra- and postoperative joint mobilization to obtain a satisfactory functional end result.     

Scaphoid nonunions. Pitfalls and pearls.

Our ability to treat scaphoid nonunions has improved dramatically. The degree of collapse and bone loss can be accurately assessed in waist fractures using sagittal images on CT scans. These nonunions require reduction and bone grafting to re-establish the normal geometry of the scaphoid. Magnetic resonance imaging helps evaluate whether or not avascular necrosis is present in the proximal pole. Because of the poor prognosis of conventional bone grafts, a vascularized bone graft is recommended as the primary treatment when AVN is present. The volar collapse of the humpback deformity is best corrected with a volar approach and the proximal pole nonunion is best approached using a dorsal approach. Nearly all proximal pole nonunions require a vascularized bone graft and all acute proximal pole fractures require open reduction and internal fixation. Using specially designed cannulated screws, the nonunions can be stabilized accurately to decrease the time to resolution of the nonunion and minimize the amount of time in a cast. Stable fixation requires that the screw fixation target the central portion of the scaphoid regardless of the type of screw design used. Using these techniques, the hand surgeon should be able to provide a reasonable prognosis for patients presenting with a scaphoid nonunion, and the treatment should result in functional range of motion, grip strength, and relief of pain.     

Pseudoarthrosis of medial tibial plateau fracture-role of alignment procedure

Nonunion in tibial plateau fractures is very rare.Limited literature is available on Pubmed search on intraarticular tibial nonunion.Most of the cases reported have been following failed surgical treat...     

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.     

Salvage technique for treatment of periplafond tibial fractures: the modified fibula-pro-tibia procedure

We describe a technique of fixation for treatment of distal tibia periplafond fractures and nonunions that uses a modification of the principle of the fibula-pro-tibia procedure (fusing the tibia and fibula together to create a one-bone lower leg). The fibula is plated, and the screws are brought across to the medial tibial cortex. The procedure is accomplished with or without a tibial buttress plate and always includes iliac crest bone grafting of the nonunion site and synostosis. We have used this technique in five patients with satisfaction.