Management of Humeral Nonunion After the Failure of Locking Intramedullary Nails

Abstract

We reviewed 21 cases of humeral nonunion following the failure of "locking" humeral nails. The nails had been inserted as the primary operative procedure following humeral fracture in fifteen cases or after the failure of closed treatment in six cases. Reconstruction after the failure of these implants was complicated by poor bone stock and difficulty in achieving union. Although technically difficult, open reduction and internal fixation with plating and bone grafting (successful in nine of nine cases) was more consistent than exchange nailing (successful in four of 10 cases) in achieving union (p = 0.01). Two patients refused further surgical intervention. The degree of bone loss associated with a loose nail, the lack of success of exchange nailing, and the insertion site morbidity associated with humeral nail removal differentiate these nonunions from similar lower extremity problems. The degree of bone loss following failed locking nailing of the humerus is a major concern, and exchange nailing alone may not be an acceptable option to deal with this problem.

Nonunion of the humerus after failure of surgical treatment

“…15,[17][18][19] The purpose of our study was specifically to assess its effectiveness in treating nonunion which per- sisted despite surgical stabilisation, since such cases are notoriously difficult to treat. [10][11][12] Further surgery can put vital structures such as the radial nerve at risk. Internal fixation can be difficult because of disuse osteopenia or other bone defects.…”

“…21,22 Exchange nailing after reaming, although successful in treating nonunion of the tibia after intramedullary nailing, 23,24 has not proved successful in the humerus. 10,22,25 five. In the ten patients who had an intramedullary nail in situ, six fractures had previously failed to unite, despite exchange nailing.…”

“…3,8 Failure to unite after surgical treatment may be due to poor contact between the bone ends, inadequate stabilisation, 9 devitalisation of bone, osteopenia and bone defects. 10 When there are the additional complications of poor soft tissue 11 or infection, treatment by conventional methods of internal fixation becomes very difficult. We describe our experience using the Ilizarov circular external fixator or 'frame' to treat nonunion of the humerus which persisted after surgical stabilisation.…”

Shape memory Ni-Ti alloy swan-like bone connector for treatment of humeral shaft nonunion

“…According to some reports, the incidence of radial nerve injury in nonunion management may reach 8% with open reduction and plate fixation [10,15,18,22]. In the nine cases treated by McKnee et al [15], radial nerve injury was found in two cases. In our study, radial nerve injuries were observed in none of these cases except for the four cases with pre-existing injuries.…”

Reconstruction of Post-Traumatic Bone Defect of the Upper-Limb with Vascularized Fibular Graft

“…1,2,3,4,5,6,7 Obesity, smoking, abuse of alcohol or drugs, osteoporosis and immunodepression are additional factors that prevent bone healing. 1,4,6 Based on characteristic of the bone ends, non-unions may be atrophic, oligotrophic, and hypertrophic.…”