Surgical Treatment of Nonunion of the Humeral Shaft

Abstract

Background. Nonunion of the humerus is formed most often in the middle (52.3%) and the distal (31.6%) thirds of the shaft. Impaired blood supply and persistent microcirculatory disturbances in the injured segment are the key pathogenetic factors of delayed consolidation. The variety of the existing surgical techniques for nonunion and defects of the humeral shaft has so far failed to solve completely the problem of increasing the regenerative potential of bone tissue.
Objective. To improve the outcomes of treatment of patients with nonunion of the humeral shaft on the basis of an analysis of the factors that impaired healing of the preceding fracture, an assessment of the clinical risk factors present in the patient, and refinement of the treatment technology.
Materials and Methods. Seventy-nine patients with nonunion of the humeral shaft who underwent surgical treatment were studied. Depending on the morphological type of the nonunion (hypertrophic, atrophic, normotrophic) and the method of treatment, the patients were allocated to six clinical groups — a main group treated by the refined technique and a comparison group treated by conventional techniques for each type. The refined technique creates optimal conditions for bone regeneration by stimulating microcirculation in the area of the nonunion and enhancing osteogenesis, and includes the use of a collagen haemostatic sponge. All patients underwent radiography, densitometry, measurement of the cortical index, Doppler ultrasonography and electroneuromyography. Outcomes were assessed with the Lyuboshits–Mattis–Schwartzberg (LMS) scale at 12.1 ± 0.5 months and with the QuickDASH and SF-36 instruments at 4.9 ± 0.5 years.
Results. In hypertrophic nonunion the mean time to consolidation was 156.5 ± 7.5 days in the main group versus 181.5 ± 9.4 days in the comparison group (p < 0.05), and good clinical and radiographic results were obtained in 100% versus 70% (p < 0.05). In atrophic nonunion (main group n = 20, comparison group n = 14) consolidation occurred after 177.1 ± 6.59 versus 195.9 ± 8.15 days (p < 0.05) and positive results were achieved in 19 (90%) versus 9 (64.3%) patients (χ² = 16.599; p < 0.021); LMS scores after intramedullary nailing were 29.5 ± 0.703 versus 24.5 ± 0.927 (U = 1.5; p = 0.019), QuickDASH scores were 13.22 ± 1.468 versus 29.15 ± 4.129 (U = 18; p = 0.0023) and SF-36 scores were 75.3 ± 1.633 versus 61.3 ± 1.739 (U = 41.50; p = 0.001). In normotrophic nonunion (main group n = 6, comparison group n = 9) union was achieved after 19.8 ± 1.01 versus 22.3 ± 0.98 weeks (U = 13.00; p = 0.0494), with good results in 100% versus 77.8% of patients. Densitometry in 58 patients showed normal bone mineral density in 10 (17.2%), osteopenia in 23 (39.7%) and osteoporosis in 25 (43.1%).
Conclusion. The refined method of surgical treatment of nonunion of the humeral shaft, based on the use of the tissues of the nonunion itself, autografting and a collagen haemostatic sponge to create an osteogenic environment, shortens the time to union and improves the functional outcomes of the upper limb in hypertrophic, atrophic and normotrophic nonunion alike.