Seudoartrosis de la diáfisis humeral tratada mediante impactación intramedular Translated title: Pseudoarthrosis of the humeral shaft treated by intramedullary impaction

To evaluate the outcomes of patients with atrophic humeral shaft nonunion (HSNU) treated by Ilizarov frame fixation without the use of bone graft. A retrospective review of 28 consecutive patients treated in 1 center between 1996 and 2002. Tertiary referral center. We studied 28 consecutive patients: 12 male and 16 female. Of the patients, 21 had been previously operated (15 by internal fixation using compression plates, 3 by intramedullary nailing, and 3 by external fixation), and 9 of those 21 patients also had failed revision procedures; 7 patients had been treated nonoperatively from the time of injury to the time of the index procedure for HSNU. Mean age at the time of the index operation was 44 years (16-73 years). Removal of the previous fixation device, excision of fibrous tissue at the HSNU site, opening of the intramedullary canal, excision of avascular bony ends, and stabilization fixation and compression of the humerus with an Ilizarov circular frame (proximal semicircular ring) using smooth 1.8-mm K-wires. No bone graft was used. The mean postoperative follow-up was 76 months (24-174 months). Radiologic union using plain radiographs. Clinical and functional outcome using the Lammens system, which evaluates pain, range of shoulder and elbow movements (and their limitations), and humeral alignment and union. Patient subjective outcomes were assessed using a 4-point patient satisfaction questionnaire. Bony union was achieved in all 28 cases after a mean of 4.1 months (3.4-5.7 months). There were 6 superficial pin tract infections (which resolved with antibiotics) and 1 transient radial nerve palsy (which resolved at 2.5 months). One patient refractured his humeral shaft following a fall, but the fracture successfully united 5.7 months later after a further Ilizarov frame application. All patients had good or excellent functional outcomes and range of shoulder and elbow movements as rated by the Lammens scoring system. Ilizarov circular frame fixation without bone graft is a reliable method for the treatment of atrophic nonunion of the humerus, even after failed previous surgery.

Humeral shaft fractures respond well to conservative treatment and unite without much problem. Since it is uncommon, there is not much discussion regarding the management of nonunion in the literature, and hence this is a challenge to the treating orthopaedic surgeon. Osteoporosis of the fractured bone and stiffness of the surrounding joints compounds the situation further. The Ilizarov fixator, locking compression plate, and vascularised fibular graft are viable options in this scenario but are technically demanding. We used a fibular strut graft for bridging the fracture site in order to enhance the pull-out strength of the screws of the dynamic compression plate. Six patients in the study had successful uneventful union of the fracture at the last follow-up. The fibula is easy to harvest and produces less graft site morbidity. None of the study patients needed additional iliac crest bone grafting. This is the largest reported series of patients with osteoporotic atrophic nonunion of humerus successfully treated solely using the combination of an intramedullary fibular strut graft and dynamic compression plate.

Background: Nonunion in diaphyseal fractures of the humerus can be treated by various modalities like plating and bone grafting, exchange nailing, fibular strut grafting and Ilizarov’s method of ring fixation. To achieve union in infected nonunion in which multiple surgeries have already been done is further challenging. We conducted a prospective study wherein the outcome of the treatment of nonunion of diaphyseal fractures of the humerus by Ilizarov’s method was analyzed. Materials and Methods: Nineteen patients with diaphyseal nonunion of the humerus were treated by Ilizarov’s external fixator. These included nonunion after plating (n=11), intramedullary nailing (n=1) or conservative methods (n=7). In post-surgical infected nonunion (n=6), the implants were removed, debridement done, bone fragments were docked followed by application of ring fixator and compression. In aseptic nonunion (n=13), distraction for three weeks followed by compression was the protocol. Early shoulder and elbow physiotherapy was instituted. The apparatus was removed after clinical and radiological union and the results were assessed for bone healing and functional status. Results: Fracture union was achieved in all the 19 cases. Pin site infection was seen in 2 cases (10.52%). The bone healing results were excellent in eighteen cases (94.73%) and good in one case (5.26%).The functional results were found to be excellent in fourteen cases (73.68%), good in four (21.05%) and fair in one case (5.26%). Conclusion: Ilizarov’s method is an excellent option for treatment of septic and aseptic non union of diaphyseal fractures of the humerus as it addresses all the problems associated with non union of the humerus like infection, deformity and joint stiffness.