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Consistent Protocol-Based Management of Humerus Shaft Nonunion: An Analysis of 100 Cases

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Abstract

Introduction

Humerus shaft nonunions are very disabling and challenging to treat. The current study aims to analyse the rate of union and the incidence of complications following a consistent protocol in treating humerus shaft nonunion.

Methodology

We did a retrospective analysis of 100 patients with humerus shaft nonunion treated over an eight-year period from 2014 to 2021. The mean age was 42 years (range 18–75 years). There were 53 male and 47 female patients. The average time interval from injury to nonunion surgery was 23 months (range 3 months to 23 years). The series included 12 recalcitrant nonunions and 12 patients with septic nonunion. All patients underwent freshening of fracture edges to increase the contact surface area, stable fixation with a locking plate and intramedullary iliac crest bone grafting. Infective nonunions were treated in a staged manner, following a similar treatment protocol after the elimination of infection in the first stage.

Results

Complete union was achieved in 97% of the patients with a single procedure. One patient achieved union after an additional procedure, while two patients were lost to further follow-up. The mean time to union was 5.7 months (range 3–10 months). Three patients (3%) had postoperative radial nerve palsy, which recovered completely within 6 months. Three patients (3%) had a superficial surgical site infection, while one patient (1%) developed a deep infection.

Conclusion

Intramedullary cancellous autologous grafts combined with stable fixation by compression plating achieve a high union rate with minimal complications.

Level of Evidence

III.

Level of Clinical Care

Level I Tertiary trauma centre.

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References

  1. Papasoulis, E., Drosos, G. I., Ververidis, A. N., & Verettas, D. A. (2010). Functional Bracing of humerus shaft f fractures. A review of clinical studies. Injury, 41, e21–e27.

    Article  PubMed  Google Scholar 

  2. Chapman, J. R., Henley, M. B., Agel, J., & Benca, P. J. (2000). Randomized prospective study of humeral shaft fracture fixation: Intramedullary nail versus plates. Journal of Orthopaedic Trauma, 14(3), 162–166.

    Article  CAS  PubMed  Google Scholar 

  3. McCormack, R. G., Brien, D., Buckley, R. E., McKee, M. D., Powell, J., & Schemitsch, E. H. (2000). Fixation of fractures of the shaft of the humerus by dynamic compression plate or intramedullary nail. A prospective, randomised trial. Journal of Bone and Joint Surgery, 82(3), 336–339.

    Article  CAS  Google Scholar 

  4. Peters, R. M., Claessen, F. M., Doornberg, J. N., Kolovich, G. P., Diercks, R. L., & van den Bekerom, M. P. (2015). Union rate after operative treatment of humeral shaft non-union—A systematic review. Injury, 46, 2314–2324.

    Article  PubMed  Google Scholar 

  5. Brinker, M. R., Loftis, C. M., Khoriaty, J. D., & Dunn, W. R. (2022). The devastating effects of humeral nonunion on health-related quality of life. Journal of Shoulder and Elbow Surgery S1058-2746(22)00504-3.

  6. Oliver, W. M., Molyneux, S. G., White, T. O., Clement, N. D., Duckworth, A. D., & Keating, J. F. (2021). Open reduction and internal fixation for humeral shaft nonunion: Bone grafting is not routinely required and avoids donor site morbidity. Journal of Orthopaedic Trauma, 35(8), 414–423.

    Article  PubMed  Google Scholar 

  7. Kumar, M. N., Ravindranath, V. P., & Ravishankar, M. R. (2013). Outcome of locking compression plates in humeral shaft nonunions. Indian Journal of Orthopaedics, 47(2), 150–155.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Abalo, A., Dosseh, E. D., Adabra, K., Walla, A., James, Y. E., & Dossim, A. (2011). Open reduction and internal fixation of humeral nonunions: Radiological and functional results. Acta Orthopaedica Belgica, 77, 299–303.

    PubMed  Google Scholar 

  9. Marti, R. K., Verheyen, C. C., & Besselaar, P. P. (2002). Humeral shaft nonunion: Evaluation of uniform surgical repair in fifty-one patients. Journal of Orthopaedic Trauma, 16(2), 108–115.

    Article  CAS  PubMed  Google Scholar 

  10. Lin, C. L., Fang, C. K., Chiu, F. Y., Chen, C. M., & Chen, T. H. (2009). Revision with Dynamic compression plate and cancellous bone graft for aseptic nonunion after surgical treatment of humeral shaft fracture. Journal of Trauma, 67, 1393–1396.

    PubMed  Google Scholar 

  11. Martinez, A. A., Cuenca, J., & Herrera, A. (2004). Treatment of humeral shaft nonunions: Nailing versus plating. Archives of Orthopaedic and Trauma Surgery, 124(2), 92–95.

    Article  PubMed  Google Scholar 

  12. Ilyas, I., & Younge, D. A. (2003). Locked intramedullary nailing for difficult nonunions of the humeral diaphysis. International Orthopaedics, 27, 278–281.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  13. Tomic, S., Bumbasirevic, M., Lesic, A., Mitkovic, M., & Atkinson, H. D. E. (2007). Ilizarov frame fixation without bone graft for atrophic humeral shaft nonunion: 28 patients with a minimum 2-year follow-up. Journal of Orthopaedic Trauma, 21, 549–555.

    Article  PubMed  Google Scholar 

  14. Atalar, A. C., Kocaoglu, M., Demirhan, M., Bilsel, K., & Eralp, L. (2008). Comparison of three different treatment modalities in the management of humeral shaft nonunion (plates, unilateral and circular external fixators. Journal of Orthopaedic Trauma, 22(4), 248–257.

    Article  PubMed  Google Scholar 

  15. Fayaz, H. C., Giannoudis, P. V., Vrahas, M. S., Smith, R. M., Moran, C., Pape, H. C., Krettek, C., & Jupiter, J. B. (2011). The role of stem cells in fracture healing and nonunion. International Orthopaedics, 35(11), 1587–1597.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Ring, D., Kloen, P., Kadzielski, J., Helfet, D., & Jupiter, J. B. (2004). Locking compression plates for osteoporotic nonunions of the diaphyseal humerus. Clinical Orthopaedics and Related Research, 425, 50–54.

    Article  Google Scholar 

  17. Nicholson, J. A., Makaram, N., Simpson, A., & Keating, J. F. (2021). Fracture nonunion in long bones: A literature review of risk factors and surgical management. Injury, 52(Suppl 2), S3–S11.

    Article  PubMed  Google Scholar 

  18. Driesman, A. S., Fisher, N., Karia, R., Konda, S., & Egol, K. A. (2017). Fracture site mobility at 6 weeks after humeral shaft fracture predicts nonunion without surgery. Journal of Orthopaedic Trauma, 31(12), 657–662.

    Article  PubMed  Google Scholar 

  19. Rutgers, M., & Ring, D. (2006). Treatment of diaphyseal fractures of the humerus using a functional brace. Journal of Orthopaedic Trauma, 20(9), 597–601.

    Article  PubMed  Google Scholar 

  20. Chloros, G. D., Kanakaris, N. K., Vun, J. S. H., Howard, A., & Giannoudis, P. V. (2021). Scoring systems for early prediction of tibial fracture non-union: An update. International Orthopaedics, 45(8), 2081–2091.

    Article  PubMed  Google Scholar 

  21. Giannoudis, P. V., Einhorn, T. A., & Marsh, D. (2007). Fracture healing: The diamond concept. Injury, 38(Suppl 4), S3–S6.

    Article  PubMed  Google Scholar 

  22. Wiss, D. A., & Garlich, J. M. (2020). Healing the index humeral shaft nonunion: Risk factors for the development of a recalcitrant nonunion in 125 patients. Journal of Bone and Joint Surgery. American Volume, 102(5), 375–380.

    Article  PubMed  Google Scholar 

  23. Hsu, T. L., Chiu, F. Y., Chen, C. M., & Chen, T. H. (2005). Treatment of nonunion of humeral shaft fracture with dynamic compression plate and cancellous bone graft. Journal of the Chinese Medical Association, 68, 73–76.

    Article  PubMed  Google Scholar 

  24. Zalavras, C. G., Yasmeh, S., & Bougioukli, S. (2021). Surgical management of humeral shaft nonunions. Success of a consistent protocol over 17 years. Injury, 52(12), 3580–3587.

    Article  PubMed  Google Scholar 

  25. Ozdemir, G., Bingol, O., Inci, F., Ceyhan, E., Karahan, N., & Deveci, A. (2022). Treatment of the refractory atrophic humeral nonunion with autogenous block iliac crest graft and spongioplasty: A retrospective study. Acta Chirurgiae Orthopaedicae et Traumatologiae Cechoslovaca, 89(3), 208–212.

    CAS  PubMed  Google Scholar 

  26. Feng, D., Wang, X., Sun, L., Cai, X., Zhang, K., Wang, Z., & Zhu, Y. (2020). Double plating with autogenous bone grafting as a salvage procedure for recalcitrant humeral shaft nonunion. BMC Musculoskeletal Disorders, 21(1), 769.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Pollon, T., Reina, N., Delclaux, S., Bonnevialle, P., Mansat, P., & Bonnevialle, N. (2017). Persistent non-union of the humeral shaft treated by plating and autologous bone grafting. International Orthopaedics, 41(2), 367–373.

    Article  PubMed  Google Scholar 

  28. Rollo, G., Prkić, A., Pichierri, P., Eygendaal, D., Bisaccia, M., Filipponi, M., Giaracuni, M., Hitov, P., Tanovski, K., & Meccariello, L. (2019). Plate-and-bone-strut fixation of distal third humeral shaft aseptic non-unions: A consecutive case series. J Clin Orthop Trauma., 10(Suppl 1), S127–S132.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Babhulkar, S., Babhulkar, S., & Vasudev, A. (2017). Recalcitrant aseptic atrophic non-union of the shaft of the humerus after failure of surgical treatment: Management by excision of non-union, bone grafting and stabilization by LCP in different modes. Injury, 48(Suppl 2), S33–S43.

    Article  PubMed  Google Scholar 

  30. Muller, M. E., Allgower, M., & Willenegger, H. (1965). Compression fixation with plates: Technique of internal fixation of fractures (pp. 47–51). Springer.

    Book  Google Scholar 

  31. Rubel, I. F., Kloen, P., Campbell, D., Schwartz, M., Liew, A., Myers, E., et al. (2002). Open reduction and internal fixation of humeral nonunions: A biomechanical and clinical study. Journal of Bone and Joint Surgery, 84-A(8), 1315–1322. https://doi.org/10.2106/00004623-200208000-00004

    Article  Google Scholar 

  32. Karakasli, A., Basci, O., Ertem, F., Sekik, E., & Havitcioglu, H. (2016). Dual plating for fixation of humeral shaft fractures: A mechanical comparison of various combinations of plate lengths. Acta Orthopaedica et Traumatologica Turcica, 50(4), 432–436.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Roberts, T. T., & Rosenbaum, A. J. (2012). Bone grafts, bone substitutes and orthobiologics: The bridge between basic science and clinical advancements in fracture healing. Organogenesis, 8(4), 114–124.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Brennan, M. L., Taitsman, L. A., Barei, D. P., Puttler, E., & Nork, S. E. (2008). Shortening osteotomy and compression plating for atrophic humeral nonunions: Surgical technique. Journal of Orthopaedic Trauma, 22(9), 643–647.

    Article  PubMed  Google Scholar 

  35. Taylor, C. (2008). Delayed union and non-union of fractures. In A. H. Crenshaw (Ed.), Campbell’s operative orthopaedics (8th ed., pp. 3529–3574). Elsevier.

    Google Scholar 

  36. Kusnezov, N., Dunn, J. C., Stewart, J., Mitchell, J. S., & Pirela-Cruz, M. (2015). Acute limb shortening for major near and complete upper extremity amputations with associated neurovascular injury: A review of the literature. Orthopaedic Surgery, 7(4), 306–316.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Konda, S. R., Davidovitch, R. I., & Egol, K. A. (2016). Initial surgical treatment of humeral shaft fracture predicts difficulty healing when humeral shaft nonunion occurs. HSS Journal, 12(1), 13–17.

    Article  PubMed  Google Scholar 

  38. Bassiony, A. A., Almoatasem, A. M., Abdelhady, A. M., Assal, M. K., & Fayad, T. A. (2009). Infected nonunion of the humerus after failure of surgical treatment: Management using the orthofix external fixator. Annals of the Academy of Medicine, Singapore, 38(12), 1090–1094.

    Article  PubMed  Google Scholar 

  39. Xiao, C., Tang, F., Zhou, Y., Zhang, W., Luo, Y., Duan, H., & Tu, C. (2016). A locking compression plate as an external fixator for treating infected nonunion of the humeral diaphysis. BMC Surgery, 16, 53.

    Article  PubMed  PubMed Central  Google Scholar 

  40. Haidukewych, G. J., & Sperling, J. W. (2003). Results of treatment of infected humeral nonunions: The Mayo Clinic experience. Clinical Orthopaedics and Related Research, 414, 25–30. https://doi.org/10.1097/01.blo.0000084399.53464.4e

    Article  Google Scholar 

  41. Claessen, F. M., Peters, R. M., Verbeek, D. O., Helfet, D. L., & Ring, D. (2015). Factors associated with radial nerve palsy after operative treatment of diaphyseal humeral shaft fractures. Journal of Shoulder and Elbow Surgery, 24(11), e307-311.

    Article  PubMed  Google Scholar 

  42. Gottschalk, M. B., Carpenter, W., Hiza, E., Reisman, W., & Roberson, J. (2016). Humeral shaft fracture fixation: Incidence rates and complications as reported by American board of orthopaedic surgery part II candidates. Journal of Bone and Joint Surgery. American Volume, 98(17), e71.

    Article  PubMed  Google Scholar 

  43. Koh, J., Tornetta, P., 3rd., Walker, B., Jones, C., Sharmaa, T., Sems, S., et al. (2020). What is the real rate of radial nerve injury after humeral nonunion surgery? Journal of Orthopaedic Trauma, 34(8), 441–446.

    Article  PubMed  Google Scholar 

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Funding

No funding was received for conducting this study. The authors have no relevant financial or non-financial interests to disclose.

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Authors and Affiliations

  1. Department of Orthopaedics and Trauma, Ganga Medical Centre and Hospitals Pvt. Ltd, 313, Mettupalayam Road, Coimbatore, Tamil Nadu, India

    Jayaramaraju Dheenadhayalan, Kavinkumar Vembanan, Agraharam Devendra, Ramesh Perumal, Vasudeva Nagashree, Aditya H. Kumar & Shanmuganathan Rajasekaran

  2. No.3, Gandhinagar, Behind Cheran Nagar, GN Mills Post, Coimbatore, 641029, Tamil Nadu, India

    Jayaramaraju Dheenadhayalan

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Jayaramaraju Dheenadhayalan, Kavinkumar Vembanan, Agraharam Devendra, Ramesh Perumal, Vasudeva Nagashree, Aditya H Kumar, and Shanmuganathan Rajasekaran declare that they have no conflicts of interest.

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All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (Institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008. Approval was obtained from the Institutional Ethics Committee.

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Dheenadhayalan, J., Vembanan, K., Devendra, A. et al. Consistent Protocol-Based Management of Humerus Shaft Nonunion: An Analysis of 100 Cases. JOIO 57, 552–564 (2023). https://doi.org/10.1007/s43465-023-00819-4

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