Ángel Antonio Martínez, Antonio Herrera, José María Pérez, Jorge Cuenca, and Jesús Martínez. Service of Orthopaedic and Trauma Surgery, Miguel Servet ...
J Orthop Sci (2001) 6:238–241
Treatment of humeral shaft nonunion by external fixation: a valuable option Ángel Antonio Martínez, Antonio Herrera, José María Pérez, Jorge Cuenca, and Jesús Martínez Service of Orthopaedic and Trauma Surgery, Miguel Servet University Hospital, C/Calamita, s/n, Zaragoza 50009, Spain
Abstract We report the treatment of six patients with nonunion of the humerus, using a unilateral fixator and bone grafting. Union was obtained in all patients, with an average time to union of 4.5 months. Superficial pin tract infection was seen in five patients, but resolved uneventfully. One patient had transient radial nerve palsy. The results, according to the Stewart and Hundley criteria, were excellent in one patient, good in three, fair in one, and poor in one. The main cause of the fair and poor results was marked limitation of shoulder and elbow motion. This method, however, seems to be therapeutically effective.
treatment of gunshot fractures of the humeral shaft,11 but we know of no previous study evaluating the use of a unilateral external fixator for the treatment of humeral shaft nonunions. This article describes the authors´ experience in treating a group of six patients with humeral diaphyseal nonunion with a unilateral fixator.
Key words Humeral shaft · Nonunion · External fixation
Between 1990 and 1996, six patients (four men and two women) were operated on for nonunion of the humeral shaft, using a unilateral external fixator. Their average age at the time of this surgery was 42 years (range, 28– 70 years). The time that had elapsed from fracture until this treatment was more than 6 months in all patients average, 18 months; range, 9–22 months). There were no delayed unions in this series. Primary treatment at the time of initial fracture had included closed methods in four patients, plating fixation in one, and flexible intramedullary nailing in one patient. Two patients had a history of septic pseudoarthrosis as a result of type 2 open fractures according to the classification of Gustilo. The drainage did not continue when an external fixator was employed. The nonunion was located in the middle third of the humeral shaft in four patients and in the upper third in two. There were only two hypertrophic nonunions. The remaining four were atrophic nonunions. The fracture line was transverse in two patients, spiral in two, and comminuted the other two. We used a unilateral fixator: the Hoffman external fixator (Howmedica International, Rutherford, NJ, USA). At least three pins were inserted proximally to the fracture and three distally. Decortication and cancellous bone grafting harvested from the iliac crest was performed through a limited anterolateral approach. Slight compression over the nonunion was initiated on the seventh day, with 0.25 mm every 2 days. The
Introduction Several operative methods have been used in the treatment of humeral shaft nonunions. Good results have been reported with plate fixation and bone grafting.2,6 Plate fixation requires considerable soft-tissue dissection, with a risk of secondary radial nerve damage. In contrast, some authors have reported the successful treatment of humeral shaft nonunion by intramedullary nailing,9,12 although these and other authors have observed that intramedullary locking nailing does not provide sufficient rotational stability; in particular the Seidel nail sometimes requires an added staple or plate across the fracture site over the nail to improve rotational stability.4,13,14 Successful results have been reported with the Ilizarov external fixator.3,7,10 This method requires little tissue dissection, achieves stable fixation, and allows secondary corrections and gradual compression. Unilateral fixators have been used in the Offprint requests to: Á.A. Martínez, C/Princesa, 11-13, 1°C, Zaragoza 50005, Spain Received: August 21, 2000 / Accepted: December 22, 2000
Patients and methods
Á.A. Martínez et al.: Treatment of humeral nonunion by external fixation
compression was continued for 2 months. The median length of follow-up was 19 months (range, 12–30 months). The functional results were expressed according to the Stewart and Hundley criteria7 as follows: excellent, no pain, no limitation of mobility, and good alignment; good, no pain, limitation of adjacent joint mobility less than 20°, and angulation less than 10°; fair, pain after effort or fatigue, limitation of mobility ranging from 20° to 40°, and angulation greater than 10°; and poor, permanent pain, limitation of mobility greater than 40°, and nonunion or radial nerve palsy (Table 1).
Results Union was obtained in all patients (representative results are shown in Fig. 1a–c), with the average time to
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union being 4. months (range, 3.5–6 months). Superficial pin tract infections occurred in five patients, but were treated successfully with oral antibiotics. Iatrogenic radial nerve palsy was observed in one patient after the fixator was applied, but complete spontaneous nerve recovery occurred in 5 months. One patient had an excellent result, with no limitation of elbow or shoulder motion, three had a good outcome, with only minimal limitation of elbow or shoulder movement, one had a fair result, and one patient had a poor result, with marked limitation of elbow and shoulder mobility (Table 2). The alignment obtained was good in four patients. There were two patients with angulation, one of them with 12° varus malunion and the other with 10° valgus malunion. Only two patients had pain after effort. The main cause of the fair and poor results was shoulder and elbow stiffness.
Table 1. Functional results according to the Stewart and Hundley criteria7 Number of patients 1 3 1 1
Score
Pain
Limitation of elbow or shoulder mobility
Excellent Good Fair Poor
None Occasional After effort Permanent
None ,20° 20°–40° .40°
Angulation Good alignment ,10° .10° Nonunion or radial nerve palsy
a,b
c Fig. 1. a Initial appearance of the fracture. b Application of unilateral fixator and bone grafting 14 months after initial treatment. c Follow-up radiograph of the humerus 1 year after treatment with the unilateral fixator. Union was achieved 6
months after application of the fixator. A focal bone defect occurred because of bone graft remodelling and reabsorption. The final functional result was poor
Good Good Poor Orthopedic (4 months) Nails Orthopedic (6 months) 17 30 13 20 22 14 T/M C/M C/P 32 40 70 4 5 6
T, Transverse; S, spiral; C, comminuted; P, proximal; M, middle; Ext, extension; Fle, flexion; Abd, abduction; ExtRo, external rotation
No Abd 210° Abd 240° ExtRo 245°
None None Abd 220°
None Ext 210° Ext 220° Fle 210° Ext 210° No Ext 220° Orthopedic (3 months) Plate Orthopedic (5 months) 16 12 26 T/P S/M S/M 1 2 3
36 28 46
9 21 22
Shoulder mobility Limitation Elbow mobility limitation Previous treatment Follow-up (months) Fracture type/level
Interval between fracture and our tract. (months)
Discussion
Age (years) Patient no.
Table 2. Details of the six patients
Excellent Good Fair
Á.A. Martínez et al.: Treatment of humeral nonunion by external fixation Result
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Nonunions of the humeral shaft are most often managed by cancellous bone grafting and plate fixation. Plate fixation is associated with more extensive softtissue dissection and a higher incidence of radial nerve palsy than nailing.5,12 There is also difficulty in obtaining sufficient screw purchase in osteoporotic bone. The Ilizarov fixator has proved sufficient stability in patients with severe osteoporosis.8,10 The Hoffmann external fixation system uses U-shaped threaded pins. The helical flute pin design and the U-shaped thread profile increases the surface area in contact with the bone, thus improving bone anchorage. Intramedullary nailing has been used by some authors.9,12 Wu and Shih12 compared 19 humeral shaft nonunions treated by plate fixation and bone grafting with 16 treated by Seidel interlocking nailing and bone grafting. The union rate and time to union were comparable, but plating was associated with more complications, such as new fracture and iatrogenic radial nerve palsy. External fixation is a good alternative to these other treatment modalities, and is particularly indicated in septic nonunions or in severe osteoporosis, where sufficient stability can be achieved with the fixator. The unilateral fixator has been used successfully in spinal cord injury patients, who usually have marked osteoporosis, to treat femoral shaft fractures.1 We used at least three pins proximally and three distally to improve stability, and we added bone grafting to stimulate bone union. The considerable limitation of shoulder and elbow motion observed in two patients could have been caused by the long period of immobilization prior to our treatment. The advantage of the Ilizarov external fixator over the unilateral fixator is the possibility for progressive reduction in case of malalignment. In addition bone grafting rarely is performed with the Ilizarov fixator.3,7,10 The advantage of the unilateral fixator over the Ilizarov fixator is that is easier to apply. We think that the Ilizarov fixator provides better fixation than the unilateral fixator, but the stability achieved with the unilateral fixator is good enough to achieve union. Major disadvantages of the external fixators are the length of time required and pin tract infections, resulting in a significant reduction of patient comfort. This is why this method should be reserved for selected complicated cases.
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