medigraphic.com
ISSN 2992-8036 (Electronic)
ISSN 2306-4102 (Print)
Órgano Oficial del Colegio Mexicano de Ortopedia y Traumatología

2023, Number 2

<< Back Next >>

Acta Ortop Mex 2023; 37 (2)

Diaphyseal osteoporotic nonunion of the humerus in elderly patients. Surgical treatment and long-term results

Paz M, Gutiérrez N, Díaz M, Allende C

Language: Spanish
References: 43
Page: 85-93
PDF size: 248.74 Kb.


ABSTRACT

Introduction: to evaluate the long term radiographic and functional results achieved in adult patients with osteoporotic, atrophic, non-unions of the diaphyseal humerus, treated surgically by open reduction and internal fixation with plates and bone graft. Material and methods: we retrospectively evaluated 22 patients. Patient's age averaged 72 years. Time from initial trauma to definitive surgery averaged 18 months. Eleven patients were smokers, and four had active infection. Pre-operative Constant score and DASH score averaged 23.13 and 81.04, respectively. Pre-operative pain scale averaged 7.45 points. Results: follow-up averaged 69 months. Union was achieved in all cases after an average of 4.68 months. DASH score at last follow-up averaged 20.27 points and Constant score 79.31 points. Analog pain scale averaged 0.77 points. Stabilization was performed using locking blade plates in 12 non-unions, locking compression plates in six cases, and double plating in four non-unions. Patients with active infection were treated in two stages using Masquelet's technique. Bone graft was associated in all cases (cancellous iliac crest autograft in 17, allograft in three, and combined structural allograft and cancellous autograft in two). Two grams of vancomycin powder were associated to the bone graft in all cases. Conclusion: the use of open reduction and internal fixation with plates associated to bone graft with local antibiotics, aloud achieving bony union and good predictable long-term objective and subjective functional results in all cases, without major complications or the need of further surgical intervention.


REFERENCES

  1. Jupiter JB, von Deck M. Ununited humeral diaphyses. J Shoulder Elbow Surg. 1998; 7(6): 644-53.

  2. Rupp M, Biehl C, Budak M, Thormann U, Heiss C, Alt V. Diaphyseal long bone nonunions — types, aetiology, economics, and treatment recommendations. Int Orthop. 2018; 42(2): 247-58.

  3. Launonen AP, Lepola V, Saranko A, Flinkkila T, Laitinen M, Mattila VM. Epidemiology of proximal humerus fractures. Arch Osteoporos. 2015; 10: 209.

  4. Cheung WH, Miclau T, Chow SK, Yang FF, Alt V. Fracture healing in osteoporotic bone. Injury. 2016; 47 Suppl 2: S21-6.

  5. Nandra R, Grover L, Porter K. Fracture non-union epidemiology and treatment. Trauma. 2016; 18(1): 3-11.

  6. Peters RM, Claessen FM, Doornberg JN, Kolovich GP, Diercks RL, van den Bekerom MP. Union rate after operative treatment of humeral shaft nonunion--A systematic review. Injury. 2015; 46(12): 2314-24.

  7. Allende C, Allende BT. The use of a new locking 90 degree blade plate in the treatment of atrophic proximal humerus nonunions. Int Orthop. 2009; 33(6): 1649-54.

  8. Koh J, Tornetta P 3rd, Walker B, Jones C, Sharmaa T, Sems S, et al. What is the real rate of radial nerve injury after humeral nonunion surgery? J Orthop Trauma. 2020; 34(8): 441-6.

  9. Ring D, Perey BH, Jupiter JB. The functional outcome of operative treatment of ununited fractures of the humeral diaphysis in older patients. J Bone Joint Surg Am. 1999; 81(2): 177-90.

  10. Ring D, Kloen P, Kadzielski J, Helfet D, Jupiter JB. Locking compression plates for osteoporotic nonunions of the diaphyseal humerus. Clin Orthop Relat Res. 2004; 425(425): 50-4.

  11. Weber BG, Cech O. Pseudarthrosis: pathophysiology, biomechanics, therapy, results. London, England: Grune & Stratton; 1976.

  12. Spross C, Kaestle N, Benninger E, Fornaro J, Erhardt J, Zdravkovic V, et al. Deltoid tuberosity index: A simple radiographic tool to assess local bone quality in proximal humerus fractures. Clin Orthop Relat Res. 2015; 473(9): 3038-45.

  13. Pelissier P, Masquelet AC, Bareille R, Pelissier SM, Amedee J. Induced membranes secrete growth factors including vascular and osteoinductive factors and could stimulate bone regeneration. J Orthop Res. 2004; 22(1): 73-9.

  14. Alonso-Llames M. Bilaterotricipital approach to the elbow. Its application in the osteosynthesis of supracondylar fractures of the humerus in children. Acta Orthop Scand. 1972; 43(6): 479-90.

  15. Tall M, Bonkoungou D, Sawadogo M, Da SC, Toe MF; Bone and Joint Trauma Study Group (GETRAUM). Treatment of nonunion in neglected long bone shaft fractures by osteoperiosteal decortication. Orthop Traumatol Surg Res. 2014; 100(6 Suppl): S299-303.

  16. McMillan TE, Johnstone AJ. Technical considerations to avoid delayed and non-union. Injury. 2017; 48 Suppl 1: S64-8.

  17. Toro G, Lepore F, Calabro G, Toro G, Rossini M, Vasso M, et al. Humeral shaft non-union in the elderly: Results with cortical graft plus stem cells. Injury. 2019; 50 Suppl 2: S75-9.

  18. Miska M, Findeisen S, Tanner M, Biglari B, Studier-Fischer S, Grützner PA, et al. Treatment of nonunions in fractures of the humeral shaft according to the Diamond Concept. Bone Joint J. 2016; 98-B(1): 81-7.

  19. Lin J, Chiang H, Hou SM. Open exchange locked nailing in humeral nonunions after intramedullary nailing. Clin Orthop Relat Res. 2003; 411(411): 260-8.

  20. McKee MD, Miranda MA, Riemer BL, Blasier RB, Redmond BJ, Sims SH, et al. Management of humeral nonunion after the failure of locking intramedullary nails. J Orthop Trauma. 1996; 10(7): 492-9.

  21. Flinkkila T, Ristiniemi J, Hamalainen M. Nonunion after intramedullary nailing of humeral shaft fractures. J Trauma. 2001; 50(3): 540-4.

  22. Gerber A, Marti R, Jupiter J. Surgical management of diaphyseal humeral nonunion after intramedullary nailing: Wave-plate fixation and autologous bone grafting without nail removal. J Shoulder Elbow Surg. 2003; 12(4): 309-13.

  23. Allende C, Paz A, Altube G, Boccolini H, Malvarez A, Allende B. Revision with plates of humeral nonunions secondary to failed intramedullary nailing. Int Orthop. 2014; 38(4): 899-903.

  24. Reed AA, Joyner CJ, Brownlow HC, Simpson AH. Human atrophic fracture non-unions are not avascular. J Orthop Res. 2002; 20(3): 593-9.

  25. Garcia P, Pieruschka A, Klein M, Tami A, Histing T, Holstein JH, et al. Temporal and spatial vascularization patterns of unions and nonunions: role of vascular endothelial growth factor and bone morphogenetic proteins. J Bone Joint Surg Am. 2012; 94(1): 49-58.

  26. Vidyadhara S, Vamsi K, Rao SK, Gnanadoss JJ, Pandian S. Use of intramedullary fibular strut graft: a novel adjunct to plating in the treatment of osteoporotic humeral shaft nonunion. Int Orthop. 2009; 33(4): 1009-14.

  27. Meier RA, Messmer P, Regazzoni P, Rothfischer W, Gross T. Unexpected high complication rate following internal fixation of unstable proximal humerus fractures with an angled blade plate. J Orthop Trauma. 2006; 20(4): 253-60.

  28. Emara KM, Diab RA, Emara AK. Recent biological trends in management of fracture non-union. World J Orthop. 2015; 6(8): 623-8.

  29. Zaidenberg EE, Juarez Cesca F, Pastrana MJ, Zaidenberg CR. Pedicled vascularized bone graft of the distal radius for recalcitrant nonunion of the distal humerus. J Orthop Trauma. 2018; 32(10): e394-9.

  30. Obremskey WT, Rickert MM, Miller AN, Schemitsch GW, Nauth A, Crist BD, et al. Augmentation of fracture repair: is anything ready for prime time? Instr Course Lect. 2022; 71: 329-344.

  31. 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.

  32. 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: S21-8.

  33. Campochiaro G, Baudi P, Gialdini M, Corradini A, Duca V, Rebuzzi M, et al. Humeral shaft non-union after intramedullary nailing. Musculoskelet Surg. 2017; 101(2): 189-93.

  34. Willis MP, Brooks JP, Badman BL, Gaines RJ, Mighell MA, Sanders RW. Treatment of atrophic diaphyseal humeral nonunions with compressive locked plating and augmented with an intramedullary strut allograft. J Orthop Trauma. 2013; 27(2): 77-81.

  35. Yadav SS. The use of a free fibular strut as a "Biological Intramedullary Nail" for the treatment of complex nonunion of long bones. JB JS Open Access. 2018; 3(2): e0050.

  36. Struijs PA, Poolman RW, Bhandari M. Infected nonunion of the long bones. J Orthop Trauma. 2007; 21(7): 507-11.

  37. Masquelet A, Kanakaris NK, Obert L, Stafford P, Giannoudis PV. Bone repair using the Masquelet technique. J Bone Joint Surg Am. 2019; 101(11): 1024-36.

  38. Alford AI, Nicolaou D, Hake M, McBride-Gagyi S. Masquelet's induced membrane technique: Review of current concepts and future directions. J Orthop Res. 2021; 39(4): 707-18.

  39. Bagliardelli J, Díaz Gallardo P, Flores J, Bustos D, Bruno P, Allende C. Valor de la utilización de espaciadores de cemento y aloinjerto con antibiótico para reconstruir defectos óseos infectados: estudio experimental en conejos. Rev Asoc Argent Ortop Traumatol. 2011; 76(2): 133-40.

  40. Laux CJ, Grubhofer F, Werner CML, Simmen HP, Osterhoff G. Current concepts in locking plate fixation of proximal humerus fractures. J Orthop Surg Res. 2017; 12(1): 137.

  41. Allende C, Mangupli M, Bagliardelli J, Diaz P, Allende BT. Infected nonunions of long bones of the upper extremity: staged reconstruction using polymethylmethacrylate and bone graft impregnated with antibiotics. Chir Organi Mov. 2009; 93(3): 137-42.

  42. Smolle MA, Leitner L, Bohler N, Seibert FJ, Glehr M, Leithner A. Fracture, nonunion and postoperative infection risk in the smoking orthopaedic patient: a systematic review and meta-analysis. EFORT Open Rev. 2021; 6(11): 1006-19.

  43. Zura R, Xiong Z, Einhorn T, Watson JT, Ostrum RF, Prayson MJ, et al. Epidemiology of fracture nonunion in 18 human bones. JAMA Surg. 2016; 151(11): e162775.



EVIDENCE LEVEL

IV




2020     |     www.medigraphic.com