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PubMed2004

Olecranon osteotomy for exposure of fractures and nonunions of the distal humerus.

Although olecranon osteotomy provides excellent exposure of the distal humerus, enthusiasm for this approach has been limited by reports suggesting numerous complications. It has been suggested that specific techniques for creating and repairing an olecranon osteotomy may help limit complications. This paper describes a technique for olecranon osteotomy using an apex, distal, chevron-shaped osteotomy, Kirschner wires directed out the anterior ulnar cortex distal to the coronoid process and bent 180degrees and impacted into the olecranon proximally, and two 22- gauge, figure-of-eight, stainless steel tension wires. A single surgeon used this technique for exposure of a fracture (16 patients) or nonunion (29 patients) of the distal humerus in 45 consecutive patients. One patient returned to activity too soon, had loosening of the wire fixation, and required a second operation for plate fixation of the ulna. The remaining 44 osteotomies (98%) healed with good alignment within 6 months. There were no broken or migrated wires prior to healing. Twelve patients (27%) had removal of the wires used to repair the olecranon: in 6 patients, this was for symptoms related to the wires (13%); 1 for septic olecranon bursitis, and 5 at the time of another procedure (elbow capsular release in 4 patients and submuscular ulnar nerve transposition in 1). Olecranon osteotomy can be used for exposure of the distal humerus with a low rate of complications when specific techniques are used.

Adolescent↗
PubMed2005

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.

Aged↗
PubMed1982

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.

Adult↗
PubMed1989

A combined therapeutic protocol for aseptic nonunion of the humeral shaft: a report of 25 cases.

Twenty-five patients with aseptic nonunion of the humeral shaft, treated by a combined therapeutic procedure, are reported. The initial treatment of these 21 closed and four open fractures had been nonoperative in 21 patients and surgical in four. Seven further open procedures had been performed in four of these patients, also undergoing failure. The time period between the fracture and our treatment averaged 13 months (range, 6-46 months). A uniform therapeutic protocol, consisting of decortication, internal fixation with a broad, straight DCP ASIF plate and autologous cancellous bone grafting, was performed in all cases, supplemented with the use of surgical cement in one. Radiologic healing was achieved primarily in 24 patients in periods averaging 6 months and after renewal of the protocol in one patient. Followup averaged 35 months (range, 8-69 months): results were good in 21 patients.

Adolescent↗
PubMed1995

Metaphyseal nonunion: a diagnostic dilemma.

Twenty-eight patients with metaphyseal nonunion were evaluated retrospectively. Initially, all patients were thought to have healing of their fractures. Mild pain and/or instability with weightbearing or discomfort localized around the hardware were common symptoms of this nonunion; however, substantial pain was not a predominant feature. In the majority of cases, routine roentgenograms were not helpful in establishing the diagnosis. Overlapping hardware made visualization difficult; furthermore, the presence of a callus gave a false impression of fracture healing. Tomograms were done in 13 patients, but were not helpful in four patients. Stress views and examination under fluoroscopy were reliable means of making this diagnosis, particularly around the knee region. It was done, however, only in a few patients. Subtle changes in the position of hardware or the position of the fragments are also an indication of failure of union. The average time from the initial injury to the diagnosis of nonunion was 36 weeks. Five patients whose pain was attributed to the hardware were found to have a nonunion intraoperatively at time of attempted hardware removal. In one patient, the nonunion was diagnosed during a quadricepsplasty. In two patients, the diagnosis was missed a second time following revision of fixation and bone grafting. Diagnosis of metaphyseal nonunion requires a high index of suspicion, because it occurs among all age groups. It is not as rare as previously described and poses many difficulties. The authors recommend the use of additional studies, including tomograms or stress views, oblique to establish difficult diagrams.

Adolescent↗
PubMed1997

Staged management of infected humeral nonunion.

Fourteen patients with infected humeral nonunion complicated by sinus discharge were treated with a staged protocol consisting of (1) radical debridement with local antibiotic beads implantation, and (2) external skeletal fixation with autologous bone grafting. In the first stage, a thorough debridement and sequestrectomy were done. Antibiotic beads were used to obliterate the bone defect, and the wound was then directly closed. In the second stage, the bead chains were replaced with autogenous cancellous bone graft. Unilateral Hoffman external skeletal fixators were applied simultaneously. The mean follow-up period was 73.6 months (range, 29 months to 9 years). The length of time to achieve bony union ranged from 3.5 to 8 months (average, 4.3 months). Hoffman pin complication was found in two cases, which were then shifted to plate internal fixation. All the infections were eradicated, and the wounds healed without further skin graft or flap coverage. All the fractures achieved bony union except for one in a patient who died. Most patients acquired satisfactory function of elbow motion after removal of external fixation and physical therapy. The method of two-stage management was effective for infected humeral nonunion. Not only was the infection eradicated and osseous union achieved, but also the limb function and joint motion were preserved.

Adult↗
PubMed2000

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.

Adult↗
PubMed2001

Nonunion after intramedullary nailing of humeral shaft fractures.

OBJECTIVE: To assess results of exchange nailing in nonunion after intramedullary (IM) nailing of humeral shaft fractures. METHODS: This was a retrospective study; 24 patients with nonunion after IM nailing of humeral shaft fractures were reviewed. In 13 cases, nonunion was treated using exchange nailing, and 11 patients were treated nonoperatively. Union was assessed from radiographs. Shoulder joint symptoms and function were assessed after a mean 4.7 years' follow-up using Constant-Murley scoring and self-administered questionnaires devised by L'Insalata et al. RESULTS: Single or repeated exchange nailing resulted in union in 6 of 13 patients. Shoulder joint function was satisfactory (mean Constant-Murley score of 72) for those patients whose fracture eventually united and poor (mean Constant-Murley score of 39) for those left with nonunion. CONCLUSION: Exchange nailing results in a poor union rate in nonunion after IM nailing of humeral shaft fractures. Permanent nonunion of the humeral shaft leaves the patient with severe disability.

Adult↗
PubMed2002

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.

Adult↗
PubMed1991

Free vascularized thin corticoperiosteal graft.

This paper describes a new thin corticoperiosteal graft harvested from the medial condylar and supracondylar areas of the femur. It is based on the articular branch of the descending genicular artery and vein and consists of periosteum with a thin (0.5 to 1.0 mm) layer of outer cortical bone. By retaining the cortex, the cambium layer is preserved, and this is thought to have a better osteogenic capacity than vascularized periosteal grafts. This graft was used to treat six patients with fracture nonunion of the upper extremity in which conventional treatment had failed. Uneventful bony union was achieved in all patients within 10 weeks.

Adult↗
PubMed1977

Nonunion of fractures of the proximal humerus: a method of treatment using a modified Moe plate.

Treatment of nonunion of fractures of the proximal or middle third of the humerus by use of a modified Moe plate is described. We have found this treatment to produce more favorable results than other methods using either internal or external immobilization. Simple modification of an existing mechanically sound device has led to a very useful instrument for the internal fixation of this type of fracture.

Aged↗
PubMed2003

Locked nailing of severely comminuted or segmental humeral fractures.

Some comminuted or segmental humeral fractures have been well-treated by functional bracing, but some also have been reported to have a bad outcome. If surgery is required, unlocked nailing has the disadvantage of unstable fixation, and plating has the disadvantage of extensive soft tissue injury. In the current study, closed locked nailing was used to treat 23 Orthopaedic Trauma Association Type C humeral fractures (C1, five; C2, three; C3, 15). The patients were 12 men and 11 women with a mean age of 42.4 years. There were 16 closed fractures and four Type I, two Type II, and one Type IIIA open fractures. Eight fractures were in the proximal third, seven in the middle third, and eight in the distal third. With one nailing, 21 of 23 (91%) fractures achieved solid union in an average of 13.2 weeks. The two nonunions eventually united after another revision nailing and bone grafting. No patients had significant impairment of elbow function. Excellent or satisfactory shoulder function was obtained in 20 patients. Closed locked nailing showed reliable treatment results for severely comminuted or segmental humeral fractures. The keys to success include compression of the fractures, static locking, postoperative external support, and experienced surgical technique.

Adult↗
PubMed2003

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.

Adult↗
PubMed2005

Nonunion of the diaphysis of long bones.

The treatment of diaphyseal nonunion of long bones is difficult and controversial. We retrospectively reviewed 113 patients with diaphyseal nonunion treated by various modalities, during 15 years at one institution. There were 36 cases of nonunion of the tibia, 23 nonunions of the femur, 21 nonunions of the humerus, 13 nonunions of the radius, 18 nonunions of the ulna and two nonunions of the clavicle. The minimum followup was 24 months (average, 40 months, range 2-15 years). The nonunions were classified as aseptic (84) and septic (29) and additionally classified as hypertrophic (61) and atrophic (52) in order to determine the treatment. The treatment was individualized based on the stability at the nonunion site, need for bone grafting, and control of infection. All fractures healed and every patient in the study regained functional use of the limb without pain or instability and functional range of movements that they had at the time of presentation with nonunion. Residual problems seen in some patients were joint stiffness, limb length discrepancy, and angular deformity. Twenty-six patients required repeat surgery using bone grafting because no satisfactory progress of fracture healing was seen in 4 months. Complications were related to the iliac crest donor site and persistent infection at the nonunion site.

Debridement↗