Recalcitrant Humeral Nonunion: Biological Reconstruction Technique
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Published:
Aug 17, 2023
Keywords:
Nonunion, recalcitrant, allograft, humeral fractures
Main Article Content
Abstract
Introduction: Nonunion of the humeral shaft occurs in between 2% and 10% of non-surgically treated fractures and up to 15% of fractures treated with initial open reduction and internal fixation. The definition of recalcitrant nonunion is still under debate. The purpose of this study is to present the outcomes of a series of patients with recalcitrant pseudarthrosis of the humerus who were treated with stable osteosynthesis combined with biological reconstruction using allograft utilizing a novel surgical approach.
Materials and Methods: The series included 33 patients treated between 2012 and 2021. 20 women and 13 men, with a mean age of 65.4 years. The evolution time of recalcitrant pseudarthrosis was 33.3 months. The mean follow-up was 33.2 months.
Results: Out of a total of 33 patients treated with this technique, 32 (97%) achieved a complete consolidation and one patient had a partial consolidation. The average consolidation period was 4.6 months and the complete osseointegration of the allograft was 8.1 months. For the functional evaluation, the visual analog scale (VAS), ASES score, Constant score and elbow motion arcs were taken into account.
Conclusions: Even among experienced surgeons, the treatment of recalcitrant pseudarthrosis of the humerus remains an obstacle and an unsolved challenge. The use of a specialized osteosynthesis material added to a bone allograft fixed with screws significantly increases mechanical stability, allowing early range of motion, and works as an osteoinductive and osteoconductive scaffold, all of which are essential for consolidation.
Materials and Methods: The series included 33 patients treated between 2012 and 2021. 20 women and 13 men, with a mean age of 65.4 years. The evolution time of recalcitrant pseudarthrosis was 33.3 months. The mean follow-up was 33.2 months.
Results: Out of a total of 33 patients treated with this technique, 32 (97%) achieved a complete consolidation and one patient had a partial consolidation. The average consolidation period was 4.6 months and the complete osseointegration of the allograft was 8.1 months. For the functional evaluation, the visual analog scale (VAS), ASES score, Constant score and elbow motion arcs were taken into account.
Conclusions: Even among experienced surgeons, the treatment of recalcitrant pseudarthrosis of the humerus remains an obstacle and an unsolved challenge. The use of a specialized osteosynthesis material added to a bone allograft fixed with screws significantly increases mechanical stability, allowing early range of motion, and works as an osteoinductive and osteoconductive scaffold, all of which are essential for consolidation.
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How to Cite
Caloia, M., Meritano, A., González Scotti, D., Ronconi, S., Serur, M. E., Caloia, H., Chamorro, G., Guevara Herrera, G., & Laboranti, A. (2023). Recalcitrant Humeral Nonunion: Biological Reconstruction Technique. Revista De La Asociación Argentina De Ortopedia Y Traumatología, 88(4), 392-408. https://doi.org/10.15417/issn.1852-7434.2023.88.4.1556
Section
Clinical Research
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https://www.aaot.org.ar/revista/2008/n1_vol73/art02.pdf
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https://doi.org/10.2106/JBJS.19.01115
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20. Lin CL, Fang CK, Chiu FY, Chen CM, Chen TH. Revision with dynamic compression plate and cancellous bone
graft for aseptic nonunion after surgical treatment of humeral shaft fracture. J Trauma 2009;67(6):1393-6.
https://doi.org/10.1097/TA.0b013e31818c1595
21. Hierholzer C, Sama D, Toro JB, Peterson M, Helfet DL. Plate fixation of ununited humeral shaft fractures: effect of type of bone graft on healing. J Bone Joint Surg Am 2006;88(7):1442-7. https://doi.org/10.2106/JBJS.E.00332
22. Garbayo Marturet AJ, Tejero Ibáñez A, Repáraz Padrós FJ, Castaño Serrano A. Tratamiento de la pseudoartrosis recalcitrante de húmero en pacientes de edad avanzada. Anales Sis San Navarra 2014;37(2):257-64. https://doi.org/10.4321/S1137-66272014000200009
23. Campochiaro G, Baudi P, Gialdini M, Corradini A, Duca V, Rebuzzi M, et al. Humeral shaft non-union after
intramedullary nailing. Musculoskeletal Surg 2017;101(2):189-93. https://doi.org/10.1007/s12306-017-0468-x
24. Gogus A, Ozturk C, Tezer M, Camurdan K, Hamzaoglu A. “Sandwich technique” in the surgical treatment of
primary complex fractures of the femur and humerus. Int Orthop 2007;31(1):87-92. https://doi.org/10.1007/s00264-006-0134-7
25. Hornicek FJ, Zych GA, Hutson JJ, Malinin TI. Salvage of humeral nonunions with onlay bone plate allograft
augmentation. Clin Orthop Relat Res 2001;(386):203-9. https://doi.org/10.1097/00003086-200105000-00026
26. Marinelli A, Antonioli D, Guerra E, Bettelli G, Zaccarelli L, Rotini R. Humeral shaft aseptic nonunion: treatment
with opposite cortical allograft struts. Chir Organi Mov 2009;93(Suppl 1):21-8. https://doi.org/10.1007/s12306-009-0007-5
https://doi.org/10.1016/j.injury.2006.04.130
2. Brinker MR, O’Connor DP. The incidence of fractures and dislocations referred for orthopaedic services in a
capitated population. J Bone Joint Surg Am 2004;86(2):290-7. PMID: 14960673
3. Ekholm R, Adami J, Tidermark J, Hansson K, Törnkvist H, Ponzer S. Fractures of the shaft of the humerus: An
epidemiological study of 401 fractures. J Bone Joint Surg Br 2006;88(11):1469-73. https://doi.org/10.1302/0301-620X.88B11.17634
4. Tsai C-H, Fong Y-C, Chen Y-H, Hsu CJ, Chang CH, Hsu HC. The epidemiology of traumatic humeral shaft
fractures in Taiwan. Int Orthop 2009;33(2):463-7. https://doi.org/10.1007/s00264-008-0537-8
5. Kim SH, Szabo RM, Marder RA. Epidemiology of humerus fractures in the United States: nationwide emergency department sample, 2008. Arthritis Care Res (Hoboken) 2012;64(3):407-14. https://doi.org/10.1002/acr.21563
6. Bergdahl C, Ekholm C, Wennergren D, Nilsson F, Möller M. Epidemiology and patho-anatomical pattern of 2,011 humeral fractures: data from the Swedish fracture register. BMC Musculoskelet Disord 2016;17(1):1-10.
https://doi.org/10.1186/s12891-016-1009-8
7. Jupiter JB, von Deck M. Ununited humeral diaphyses. J Shoulder Elbow Surg 1998;7:644-53. https://doi.org/10.1016/s1058-2746(98)90016-7
8. Sarmiento A, Zagorski JB, Zych GA, Latta LL, Cappset CA. Functional bracing for the treatment of fractures of the humeral diaphysis. J Bone Joint Surg Am 2000;82:478-86. https://doi.org/10.2106/00004623-200004000-00003
9. Van Houwelingen AP, McKee MD. Treatment of osteopenic humeral shaft nonunion with compression plating,
humeral cortical allograft struts, and bone grafting. J Orthop Trauma 2005;19(1):36-42. https://doi.org/10.1097/00005131-200501000-00007
10. Murlimanju BV, Prashanth KU, Prabhu LV, Saralaya VV, Pai MM, Rai R. Morphological and topographical
anatomy of nutrient foramina in human upper limb long bones and their surgical importance. Rom J Morphol
Embryol 2011;52(3):859-82. PMID: 21892530
11. Patake SM, Mysorekar VR. Diaphysial nutrient foramina in human metacarpals and metatarsals. J Anat 1977;124(Pt 2):299-304. PMID: 591428
12. Giannoudis PV, Einhorn TA, Marsh D. Fracture healing: the diamond concept. Injury 2007;38(Suppl 4):S3-S6.
https://doi.org/10.1016/S0020-1383(08)70003-2
13. Bhandari M, Fong K, Sprague S, Williams D, Petrisor B. Variability in the definition and perceived causes of
delayed unions and non-unions: a cross-sectional, multinational survey of orthopaedic surgeons. J Bone Joint Surg Am 2012;94(15):e1091-e1096. https://doi.org/10.2106/JBJS.K.01344
14. Fayaz HC, Giannoudis PV, Vrahas MS, Smith RM, Moran C, Pape HC, et al. The role of stem cells in fracture
healing and non-union. Int Orthop 2011;35(11):1587-97. https://doi.org/10.1007/s00264-011-1338-z
15. Zaidenberg C. Seudoartrosis recalcitrante del húmero distal: injerto óseo vascularizado del radio distal Nueva
técnica quirúrgica. Rev Asoc Argent Ortop Traumatol 2008;73(1):6-12. Disponible en:
https://www.aaot.org.ar/revista/2008/n1_vol73/art02.pdf
16. Wiss DA, Garlich, JM. Healing the index humeral shaft nonunion. J Bone Joint Surg Am 2020;102(5):375-80.
https://doi.org/10.2106/JBJS.19.01115
17. Tang JB, Giddins G. Why and how to report surgeons’ levels of expertise. J Hand Surg Eur Vol 2016;41(4):365-6. https://doi.org/10.1177/1753193416641590
18. Andrzejowski P, Giannoudis PV. The diamond concept for long bone non-union management. J Orthop Traumatol 2019;20(1):1-13. https://doi.org/10.1186/s10195-019-0528-0
19. Giannoudis PV, Einhorn TA, Schmidmaier G, Marsh D. The diamond concept–open questions. Injury 2008;39(Supp 2):S5-S8. https://doi.org/10.1016/S0020-1383(08)70010-X
20. Lin CL, Fang CK, Chiu FY, Chen CM, Chen TH. Revision with dynamic compression plate and cancellous bone
graft for aseptic nonunion after surgical treatment of humeral shaft fracture. J Trauma 2009;67(6):1393-6.
https://doi.org/10.1097/TA.0b013e31818c1595
21. Hierholzer C, Sama D, Toro JB, Peterson M, Helfet DL. Plate fixation of ununited humeral shaft fractures: effect of type of bone graft on healing. J Bone Joint Surg Am 2006;88(7):1442-7. https://doi.org/10.2106/JBJS.E.00332
22. Garbayo Marturet AJ, Tejero Ibáñez A, Repáraz Padrós FJ, Castaño Serrano A. Tratamiento de la pseudoartrosis recalcitrante de húmero en pacientes de edad avanzada. Anales Sis San Navarra 2014;37(2):257-64. https://doi.org/10.4321/S1137-66272014000200009
23. Campochiaro G, Baudi P, Gialdini M, Corradini A, Duca V, Rebuzzi M, et al. Humeral shaft non-union after
intramedullary nailing. Musculoskeletal Surg 2017;101(2):189-93. https://doi.org/10.1007/s12306-017-0468-x
24. Gogus A, Ozturk C, Tezer M, Camurdan K, Hamzaoglu A. “Sandwich technique” in the surgical treatment of
primary complex fractures of the femur and humerus. Int Orthop 2007;31(1):87-92. https://doi.org/10.1007/s00264-006-0134-7
25. Hornicek FJ, Zych GA, Hutson JJ, Malinin TI. Salvage of humeral nonunions with onlay bone plate allograft
augmentation. Clin Orthop Relat Res 2001;(386):203-9. https://doi.org/10.1097/00003086-200105000-00026
26. Marinelli A, Antonioli D, Guerra E, Bettelli G, Zaccarelli L, Rotini R. Humeral shaft aseptic nonunion: treatment
with opposite cortical allograft struts. Chir Organi Mov 2009;93(Suppl 1):21-8. https://doi.org/10.1007/s12306-009-0007-5