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PubMed2005

Revision surgery for nonunion after early failure of fixation of fractures of the distal humerus.

Sixteen patients who underwent a revision operation for nonunion of fractures of the distal humerus following previous internal fixation were reviewed at a mean follow-up of 39 months (8 to 69). The Mayo elbow performance score was excellent in 11, good in two, fair in two and poor in one. In 15 patients union was achieved and in one with an infected nonunion a subsequent bone graft was necessary in order to obtain union.Age, gender, a history of smoking, mechanism of the injury and the AO classification of the initial fracture did not correlate with the development of nonunion. In 12 patients (75%), the initial fixation was assessed as being suboptimal. The primary surgery was regarded as adequate in only three patients. Our findings suggest that the most important determinant of nonunion of a distal humeral fracture after surgery is the adequacy of fixation.

Adult↗
PubMed1994

The relationship of angulation to translation in fracture deformities.

We measured both angulation and translation on anteroposterior and lateral roentgenograms of 100 fixed post-traumatic deformities (either malunions or stiff [hypertrophic] non-unions) of long bones. We used trigonometric formulae to calculate the true planes and actual magnitude of both the angulation and the transverse translation of each deformity. We found that the planes of angulation and translation for each osseous deformity were rotated 43 +/- 25 degrees (mean and standard deviation) with respect to each other; in fact, we found almost as many instances in which the planes of angulation and translation of the fragments were within 10 degrees of perpendicular to each other as we did instances in which the angulation and translation were within 10 degrees of being in the same plane. Only seven angular deformities and six translational deformities occurred along either the sagittal or the coronal plane; the remaining deformities were in planes that were oblique to the standard reference planes.

Biomechanical Phenomena↗
PubMed1997

Osteosynthesis for the treatment of non-union of the lateral humeral condyle in children.

We reviewed the results of osteosynthesis for the treatment of an established non-union of the lateral humeral condyle in sixteen children whose average age was nine years (range, four to thirteen years) at the time of the operation. The average interval between the injury and the operation was five years (range, five months to ten years). The presenting symptoms were pain in the elbow in seven patients, apprehension in nine, a cubitus valgus deformity in six, limitation of motion in three, and dysfunction of the ulnar nerve in four. The average duration of follow-up was eleven years (range, four to thirty-two years). Osseous union was achieved after the initial operation in thirteen patients. Of the three patients who had a persistent non-union, two had a second operation and the third, who was asymptomatic, refused additional operative intervention. The result was rated excellent in eight patients, good in seven, and poor in one, with use of a modification of the functional rating index of Broberg and Morrey. The patient who had a poor result had evidence of avascular necrosis of the fragment.

Adolescent↗
PubMed2002

Expression and activation of the BMP-signaling components in human fracture nonunions.

BACKGROUND: The potential use of bone morphogenetic proteins (BMPs) to promote bone-healing is of great interest to orthopaedic surgeons. Although the complex mechanism leading from the local presence of BMP (whether endogenous or exogenous) to bone formation is increasingly understood, limited information is available as to whether endogenous BMPs, their receptors, or other molecules involved in their signal transduction, such as Smad1, are present or disappear during the development of fracture nonunions. The purpose of the present study was to determine, by immunohistochemical analysis, whether BMPs, BMP receptors, or Smad1 disappear from tissues during the development of a fracture nonunion. METHODS: Twenty-one patients (average age, sixty-one years; range, thirty to eighty-five years) with a delayed union (four patients) or a nonunion (seventeen patients) were included. The average duration of the delayed union or nonunion was twenty-two months (range, 3.5 to 120 months). With use of immunohistochemical analysis, we studied the localization of BMP-2, BMP-4, and BMP-7 and their receptors BMPR-IA, BMPR-IB, and BMPR-II as well as pSmad1. With use of a pSmad1 antibody, we also studied whether the BMP receptors that were expressed were activated. RESULTS: The immunohistochemical localization of all seven BMP-signaling components was demonstrated in seventeen (81%) of the twenty-one patients. The remaining four patients lacked one or more of the components. Areas of newly formed bone had the highest percentage of positively staining cells, with the staining generally decreasing in areas remote from bone formation. However, even in areas of dense fibrous tissue and in specimens that lacked newly formed bone, immunostaining was still present. The staining patterns showed co-localization of the BMP-2, BMP-4, and BMP-7 proteins with the BMP receptors. The presence of pSmad1 signified the activated state of the BMP receptors, which implies that the BMP signal is transduced inside the cell.

Adult↗
PubMed2003

Open reduction and internal fixation of delayed unions and nonunions of fractures of the distal part of the humerus.

BACKGROUND: The purpose of the present retrospective study was to evaluate the results of open reduction and internal fixation of delayed unions and nonunions of fractures of the distal part of the humerus. METHODS: Between 1976 and 2001, fifty-two patients with a delayed union (thirteen patients) or nonunion (thirty-nine patients) of the distal part of the humerus were treated with open reduction and internal fixation along with selective elbow joint arthrolysis and bone-grafting. The average time to presentation was eighteen months (range, two to 192 months) after the injury. Thirty-nine of the fifty-two patients had undergone an average of 1.6 previous operations. There were twenty-seven supracondylar, six transcondylar, thirteen intercondylar, two lateral condylar, and four medial condylar delayed unions or nonunions. The average duration of follow-up was thirty-three months (range, three to 198 months). RESULTS: Fifty-one of the fifty-two patients had healing of the delayed union or nonunion after the index operation; the average time to union was six months (range, two to twenty-four months). The average range of elbow motion increased from 71 degrees preoperatively to 94 degrees postoperatively. Complications included two superficial infections, two deep infections, and five cases of ulnar neuropathy. Fifteen patients (29%) needed additional surgery after the index procedure. Specifically, seven patients underwent removal of prominent hardware; six underwent hardware removal along with excision of heterotopic bone, ulnar neurolysis, and/or manipulation under anesthesia; one underwent irrigation and débridement; and one underwent compartment release. CONCLUSIONS: Open reduction through an extensile exposure and rigid internal fixation consistently results in healing of a delayed union or nonunion of the distal part of the humerus. An improved range of motion of the elbow can be achieved by securing the site of the nonunion and performing aggressive elbow joint arthrolysis and soft-tissue releases in patients with severe contractures. LEVEL OF EVIDENCE: Therapeutic study, Level IV (case series [no, or historical, control group]). See p. 2 for complete description of levels of evidence.

Adolescent↗
PubMed2003

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.

Adult↗
PubMed2003

Intramedullary nailing of humeral shaft fractures with a locking flexible nail.

BACKGROUND: Studies on intramedullary nailing of humeral shaft fractures in the orthopaedic literature have shown mixed results. The purpose of this investigation was to document the clinical outcome and complications associated with the use of a new flexible, locking intramedullary nail that can be implanted in the humerus in either a retrograde or an antegrade manner without violating the rotator cuff mechanism or damaging the articular surface of the humeral head. METHODS: Fifty consecutive patients with fifty-one humeral shaft fractures were entered into our prospective clinical outcome study. The fracture was classified on the basis of the anatomic location and pattern. Implant positioning and fracture alignment were assessed postoperatively. Complications were recorded, and the time to union was measured. Shoulder function was evaluated with use of a combination of the Constant shoulder score, Short Form-36 (SF-36) clinical outcome data, range-of-motion measurements, and a subjective pain-rating scale. RESULTS: Forty-one patients with forty-two fractures had an adequate duration of clinical follow-up (a mean of twenty-two months) for analysis. Thirty-nine fractures healed, with a mean time to clinical union of twelve weeks (range, four to fifty weeks). Thirty-eight of the forty-two shoulders had minimal or no pain. Thirty-six shoulders had a full range of motion. The mean Constant shoulder score was 90 points. Four patients had five complications, which included two nonunions, two hardware failures, and one wound infection. All four patients had been managed with a 7.5-mm nail. A multivariate analysis demonstrated that an age of more than fifty years was associated with a lower Constant score and that the occurrence of a complication was associated with a lower physical component score on the SF-36. CONCLUSIONS: The flexible humeral nail allows both retrograde and antegrade implantation and static locking. Nail insertion can be accomplished without violating the rotator cuff or damaging the articular surface of the humeral head. Although the nail functioned well in most of our patients, the use of a small-diameter (7.5-mm) nail was associated with a higher complication rate. This implant should be used with caution in any patient with a medullary canal diameter of <or=8 mm.

Adolescent↗
PubMed2004

ORIF of delayed unions and nonunions of distal humeral fractures. Surgical technique.

BACKGROUND: The purpose of the present retrospective study was to evaluate the results of open reduction and internal fixation of delayed unions and nonunions of fractures of the distal part of the humerus. METHODS: Between 1976 and 2001, fifty-two patients with a delayed union (thirteen patients) or nonunion (thirty-nine patients) of the distal part of the humerus were treated with open reduction and internal fixation along with selective elbow joint arthrolysis and bone-grafting. The average time to presentation was eighteen months (range, two to 192 months) after the injury. Thirty-nine of the fifty-two patients had undergone an average of 1.6 previous operations. There were twenty-seven supracondylar, six transcondylar, thirteen intercondylar, two lateral condylar, and four medial condylar delayed unions or nonunions. The average duration of follow-up was thirty-three months (range, three to 198 months). RESULTS: Fifty-one of the fifty-two patients had healing of the delayed union or nonunion after the index operation; the average time to union was six months (range, two to twenty-four months). The average range of elbow motion increased from 71 degrees preoperatively to 94 degrees postoperatively. Complications included two superficial infections, two deep infections, and five cases of ulnar neuropathy. Fifteen patients (29%) needed additional surgery after the index procedure. Specifically, seven patients underwent removal of prominent hardware; six underwent hardware removal along with excision of heterotopic bone, ulnar neurolysis, and/or manipulation under anesthesia; one underwent irrigation and débridement; and one underwent compartment release. CONCLUSIONS: Open reduction through an extensile exposure and rigid internal fixation consistently results in healing of a delayed union or nonunion of the distal part of the humerus. An improved range of motion of the elbow can be achieved by securing the site of the nonunion and performing aggressive elbow joint arthrolysis and soft-tissue releases in patients with severe contractures.

Fracture Fixation, Internal↗
PubMed2005

Supracondylar dome osteotomy for cubitus valgus deformity associated with a lateral condylar nonunion in children.

BACKGROUND: Open reduction, autogenous bone-grafting, and internal fixation for the treatment of established nonunion of the lateral condyle associated with a cubitus valgus deformity has a high rate of complications. As a consequence, we developed a new technique that includes in situ compression fixation of the lateral condylar nonunion and a dome-shaped supracondylar osteotomy of the distal aspect of the humerus through a single posterior incision. METHODS: Eight consecutive patients were treated with the new surgical technique between 1994 and 2000. The mean age at the time of surgery was 8.6 years. The mean interval between the lateral condylar fracture and surgery was 4.9 years. The mean preoperative radiographic humerus-ulna angle was 31 degrees of valgus. The postoperative results were classified with a modification of the scoring system described by Dhillon et al., which assesses pain, weakness, range of motion, the humerus-ulna angle, and prominence of the medial epicondyle on a 12-point scale. RESULTS: All eight lateral condylar nonunions achieved union within three months postoperatively. The mean postoperative humerus-ulna angle was 5.5 degrees of valgus. All of the supracondylar dome osteotomies healed uneventfully, and there was no loss of correction postoperatively. The mean duration of follow-up was 4.5 years. The overall results were excellent in two patients, good in four patients, and fair in two patients. CONCLUSIONS: With better exposure of the lateral condylar nonunion through a posterior approach, we can effectively stabilize the lateral condylar nonunion and avoid postoperative loss of motion and osteonecrosis of the condyle. With a dome-shaped supracondylar osteotomy, we can correct the cubitus valgus deformity and avoid the development of a medial epicondylar prominence. With careful selection of patients, this new technique can be an effective method to treat this clinically challenging problem.

Child↗
PubMed2006

Supracondylar dome osteotomy for cubitus valgus deformity associated with a lateral condylar nonunion in children. Surgical technique.

BACKGROUND: Open reduction, autogenous bone-grafting, and internal fixation for the treatment of established nonunion of the lateral condyle associated with a cubitus valgus deformity has a high rate of complications. As a consequence, we developed a new technique that includes in situ compression fixation of the lateral condylar nonunion and a dome-shaped supracondylar osteotomy of the distal aspect of the humerus through a single posterior incision. METHODS: Eight consecutive patients were treated with the new surgical technique between 1994 and 2000. The mean age at the time of surgery was 8.6 years. The mean interval between the lateral condylar fracture and surgery was 4.9 years. The mean preoperative radiographic humerus-ulna angle was 31 degrees of valgus. The postoperative results were classified with a modification of the scoring system described by Dhillon et al., which assesses pain, weakness, range of motion, the humerus-ulna angle, and prominence of the medial epicondyle on a 12-point scale. RESULTS: All eight lateral condylar nonunions achieved union within three months postoperatively. The mean postoperative humerus-ulna angle was 5.5 degrees of valgus. All of the supracondylar dome osteotomies healed uneventfully, and there was no loss of correction postoperatively. The mean duration of follow-up was 4.5 years. The overall results were excellent in two patients, good in four patients, and fair in two patients. CONCLUSIONS: With better exposure of the lateral condylar nonunion through a posterior approach, we can effectively stabilize the lateral condylar nonunion and avoid postoperative loss of motion and osteonecrosis of the condyle. With a dome-shaped supracondylar osteotomy, we can correct the cubitus valgus deformity and avoid the development of a medial epicondylar prominence. With careful selection of patients, this new technique can be an effective method to treat this clinically challenging problem.

Child↗
PubMed1984

Electrical treatment of non-united fractures.

The semi-invasive technique for electrical stimulation of bone healing developed by Brighton et al. (1977) was used in 23 patients with nonunited fractures of the tibia (14 cases), humerus (4 cases), scaphoid, femur and fibula as well as one failed arthrodesis of the ankle. The fractures were clinically not healed and not operated on within a minimum of 6 months. The mean period from fracture to treatment was 18 months. Electrical stimulation led to solid bone healing in 10 cases. Two deep infections occurred during the treatment. Of 13 cases that did not unite, a great range of motion in the nonunion area was an obvious cause of failure in seven cases. The results in this series cannot compete with those of bone graft surgery for nonunions.

Adult↗
PubMed1991

Treatment of humeral shaft fractures related to associated injuries. A retrospective study of 237 patients.

The results of treatment in 237 patients with humeral shaft fractures in relation to the severity of associated injuries were reviewed. Three groups were defined with the Injury Severity Score: multiply injured (ISS greater than or equal to 18; n 58), moderately injured (4 less than ISS less than 18; n 52), and singly injured patients (ISS = 4; n 127). Three basic forms of therapy were evaluated: operative stabilization, traction, and bracing. In singly injured patients the best results were obtained by bracing, and no cases of delayed union were observed. In multiply injured patients, the incidence of delayed union was low after operative stabilization. In moderately injured patients who had to remain in bed, traction therapy was warranted. The majority of 21 primary and 19 secondary radial nerve injuries showed good recovery, independent of surgical exploration.

Adolescent↗