DOI QR코드

DOI QR Code

Aseptic Humeral Nonunion: What Went Wrong? What to Do? A Retrospective Analysis of 20 Cases

  • Kim, Jinil (Department of Orthopaedic Surgery, Korea University Guro Hospital) ;
  • Cho, Jae-Woo (Department of Orthopaedic Surgery, Korea University Guro Hospital) ;
  • Cho, Won-Tae (Department of Orthopaedic Surgery, Korea University Guro Hospital) ;
  • Cho, Jun-Min (Department of General Surgery, Korea University Guro Hospital) ;
  • Kim, Namryeol (Department of Orthopaedic Surgery, Korea University Guro Hospital) ;
  • Kim, Hak Jun (Department of Orthopaedic Surgery, Korea University Guro Hospital) ;
  • Oh, Jong-Keon (Department of Orthopaedic Surgery, Korea University Guro Hospital) ;
  • Kim, Jin-Kak (Department of Orthopaedic Surgery, Korea University Guro Hospital)
  • Received : 2016.10.12
  • Accepted : 2016.12.07
  • Published : 2016.12.31

Abstract

Purpose: Due to recent advances in internal fixation techniques, instrumentation and orthopedic implants there is an increasing number of humeral shaft fracture treated operatively. As a consequence, an increased number nonunion after operative fixation are being referred to our center. The aim of this study is to report the common error during osteosynthesis that may have led to nonunion and present a systematic analytical approach for the management of aseptic humeral shaft nonunion. Methods: In between January 2007 to December 2013, 20 patients with humeral shaft nonunion after operative procedure were treated according to our treatment algorithm. We could analysis x-rays of 12 patients from initial treatment to nonunion. In a subgroup of 12 patients the initial operative procedure were analyzed to determine the error that may have caused nonunion. The following questions were used to examine the cases: 1) Was the fracture biology preserved during the procedure? 2) Does the implant construct have enough stability to allow fracture healing? Results: In 19 out of 20 patients have showed radiographic evidence of union on follow up. One patient has to undergo reoperation because of the technical error with bone graft placement but eventually healed. There were 2 cases wherein the treatment algorithm was not followed. All patients had problems with mechanical stability, and in 13 patients had biologic problems. In the analysis of the initial operative fixation, only one of 12 patients had biologic problems. Conclusion: In our analysis, the common preventable error made during operative fixation of humeral shaft fracture is failure to provide adequate stability for bony union to occur. And with these cases we have demonstrated a systematic analytic management approach that may be used to prevent surgeons from reproducing the same fault and reduce the need for bone grafting.

Keywords

References

  1. Bohler L. Conservative treatment of fresh closed fractures of the shaft of the humerus. Journal of Trauma-Injury, Infection, and Critical Care 1965; 5: 464-8. https://doi.org/10.1097/00005373-196507000-00003
  2. Mast JW, Spiegel PG, HARVEY JP, Harrison C. Fractures of the Humeral Shaft A Retrospective Study of 240 Adult Fractures. Clinical orthopaedics and related research 1975; 112: 254-62.
  3. Balfour G, Mooney V, Ashby M. Diaphyseal fractures of the humerus treated with a ready-made fracture. J Bone Joint Surg Am 1982; 64: 11-3. https://doi.org/10.2106/00004623-198264010-00002
  4. Edward AP. Chapter 57: Fractures of the Humeral Shaft. In: Canale ST, Beaty JH. Campbell's operative orthopaedics. Vol. 3. 12th ed. Philadelphia: Mosby 2013: 2852-69.
  5. Sarmiento A, Waddell JP, Latta LL. Diaphyseal humeral fractures: treatment options. The Journal of Bone & Joint Surgery 2001; 83: 1566-79.
  6. Court-Brown CM, Heckman JD, McQueen MM, Ricci WM, Tornetta PI. Humerus Shaft Fractures. In: McKee MD. Rockwood and Green's fractures in adults. Vol. 1. 8th ed. Philadelphia: Wolters Kluwer Health 2015: 1298-1301.
  7. Robinson C, Bell K, McQueen M. Locked nailing of humeral shaft fractures. Experience in Edinburgh over a two-year period. Journal of Bone & Joint Surgery, British Volume 1992; 74: 558-62.
  8. Mulier T, Seligson D, Sioen W, Van Den Bergh J, Reynaert P. Operative treatment of humeral shaft fractures. Acta Orthop Belg 1997; 63: 170-7.
  9. Marti RK, Kloen P. Concepts and cases in nonunion treatment. 1st ed. New York: Thieme, 2011.
  10. Swanson EA, Garrard EC, O'Connor DP, Brinker MR. Results of a systematic approach to exchange nailing for the treatment of aseptic tibial nonunions. J Orthop Trauma 2015; 29: 28-35. https://doi.org/10.1097/BOT.0000000000000151
  11. Park S-H, O'CONNOR K, McKellop H, Sarmiento A. The Influence of Active Shear or Compressive Motion on Fracture-Healing*. The Journal of Bone & Joint Surgery 1998; 80: 868-78. https://doi.org/10.2106/00004623-199806000-00011
  12. Augat P, Burger J, Schorlemmer S, Henke T, Peraus M, Claes L. Shear movement at the fracture site delays healing in a diaphyseal fracture model. Journal of orthopaedic research 2003; 21: 1011-7. https://doi.org/10.1016/S0736-0266(03)00098-6
  13. Bishop N, Van Rhijn M, Tami I, Corveleijn R, Schneider E, Ito K. Shear does not necessarily inhibit bone healing. Clinical orthopaedics and related research 2006; 443: 307-14. https://doi.org/10.1097/01.blo.0000191272.34786.09
  14. Steiner M, Claes L, Ignatius A, Simon U, Wehner T. Disadvantages of interfragmentary shear on fracture healingmechanical insights through numerical simulation. Journal of Orthopaedic Research 2014; 32: 865-72. https://doi.org/10.1002/jor.22617
  15. Schopfer A, Hearn T, Malisano L, Powell J, Kellam J. Comparison of torsional strength of humeral intramedullary nailing: a cadaveric study. Journal of orthopaedic trauma 1994; 8: 414-21. https://doi.org/10.1097/00005131-199410000-00008
  16. Dalton JE, Salkeld SL, Satterwhite YE, Cook SD. A biomechanical comparison of intramedullary nailing systems for the humerus. Journal of orthopaedic trauma 1993; 7: 367-74. https://doi.org/10.1097/00005131-199308000-00014
  17. Blum J, Machemer H, Hogner M, Baumgart F, Schlegel U, Wahl D, et al. [Biomechanics of interlocked nailing in humeral shaft fractures. Comparison of 2 nail systems and the effect of interfragmentary compression with the unreamed humeral nail]. Der Unfallchirurg 2000; 103: 183-90. https://doi.org/10.1007/s001130050520
  18. Molster A, Gjerdet NR, Strand RM, Hole RM, Hove LM. Intramedullary nailing in humeral shaft fractures. Archives of orthopaedic and trauma surgery 2001; 121: 554-6. https://doi.org/10.1007/s004020100304
  19. Garnavos C. Diaphyseal humeral fractures and intramedullary nailing: Can we improve outcomes? Indian journal of orthopaedics 2011; 45: 208. https://doi.org/10.4103/0019-5413.67117
  20. Ruedi TP, Murphy WM. AO principles of fracture management: Ao Publishing; 2007.
  21. Stoffel K, Dieter U, Stachowiak G, Gachter A, Kuster MS. Biomechanical testing of the LCP-how can stability in locked internal fixators be controlled? Injury 2003; 34: 11-9. https://doi.org/10.1016/j.injury.2003.09.021
  22. Flinkkila T, Ristiniemi J, Hamalainen M. Nonunion after intramedullary nailing of humeral shaft fractures. Journal of Trauma and Acute Care Surgery 2001; 50: 540-4. https://doi.org/10.1097/00005373-200103000-00021
  23. Devnani A. Simple approach to the management of aseptic non-union of the shaft of long bones. Singapore medical journal 2001; 42: 20-5.
  24. Khan MS, Sahibzada AS, Khan MA, Sultan S, Younas M, Khan AZ. Outcome of plating, bone grafting and shortening of non-union humeral diaphyseal fracture. J Ayub Med Coll Abbottabad 2005; 17: 44-6.
  25. Hsu T-L, Chiu F-Y, Chen C-M, Chen T-H. Treatment of nonunion of humeral shaft fracture with dynamic compression plate and cancellous bone graft. Journal of the Chinese Medical Association 2005; 68: 73-6. https://doi.org/10.1016/S1726-4901(09)70138-8
  26. Lin C-L, Fang C-K, Chiu F-Y, Chen C-M, Chen T-H. Revision with dynamic compression plate and cancellous bone graft for aseptic nonunion after surgical treatment of humeral shaft fracture. Journal of Trauma and Acute Care Surgery 2009; 67: 1393-6. https://doi.org/10.1097/TA.0b013e31818c1595
  27. 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. The Journal of Bone & Joint Surgery 2006; 88: 1442-7.