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

Kim, Jinil; Cho, Jae Woo; Cho, Won Tae; Cho, Jun Min; Kim, Namryeol; Kim, Hak Jun; Oh, Jong Keon; Kim, Jin Kak

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.