OTA 2008 Posters
Scientific Poster #127 Upper Extremity OTA-2008
Results Using an Intramedullary Allograft with Compression Plating for Aseptic Atrophic Diaphyseal Nonunions of the Humerus
Robert J. Gaines, MD1 (n); Frank A. Liporace, MD2 (e-Stryker); Chad Weber, DO3 (n);
H. Claude Sagi, MD1 (a,b,c,e-Smith + Nephew; b-AO; b,e-Stryker; a,e-Synthes);
Mark A. Mighell, MD1 (a-Synthes, DePuy, A Johnson and Johnson Company);
Roy Sanders, MD1 (a-DJ Orthopaedics, Encor Medical,
Link Orthopaedics, Medtronic Sofamor Danek, Pfizer, Synthes, Tornier, Twin Star Medical,
Zimmer; a,c-DePuy, A Johnson & Johnson Company; a,c-Stryker; a,c,e- Smith + Nephew; c-Linvatec);
1Florida Orthopedic Institute, Tampa, Florida, USA;
2Hospital for Medicine and Dentistry New Jersey, Newark, New Jersey, USA;
3Grandview Medical Center, Dayton, Ohio, USA
Purpose: Our objective was to assess the efficacy of an intramedullary fibula dowel graft as an adjunct to compression plating in aseptic, atrophic nonunions of the humeral diaphysis.
Methods: We performed a retrospective review of 34 aseptic, atrophic diaphyseal humeral nonunions treated between January 1, 1999 and December 31, 2006. All nonunions were defined by the criteria of Brighton (timing) and described as atrophic by the criteria of Weber and Cech. 31 nonunions in 31 patients had complete records and radiographs and were available for clinical follow-up. Five of these patients were subsequently excluded due to the use of iliac crest bone graft and/or bone morphogenetic protein at the time of fibula graft placement. In the 26 nonunions meeting inclusion criteria, the original fracture pattern was oblique in 14 (54%) and transverse in 12 (46%). Six were comminuted and two had segmental bone loss. The initial treatment was nonoperative for 13 fractures (50%) and operative for 13 (50%), including intramedullary nails in 6 fractures and plates in 7. Five patients (19%) underwent two or more surgical attempts to treat the atrophic nonunion before our index procedure. Twelve patients (46%) smoked at least one pack per day. The posterior or deltopectoral approach was used based on the location of the nonunion and/or pre-existing scars. All patients underwent the protocol procedure that included removal of implants (if needed), followed by nonunion takedown, open reaming of the canal, insertion of an intact fibular dowel allograft, and compression plate fixation of the nonunion site. When screws were placed through the graft, the hole was hand-tapped and the screw was inserted without power. Postoperative management included full use of the elbow and shoulder without lifting, pushing, or pulling. Patients were followed monthly for radiographic and clinical evidence of healing.
Results: Minimum follow-up for this study was 12 months (range, 12-54). All 26 nonunions (100%) went on to uneventful union. The mean time to union was 16.5 weeks (range, 10-29 weeks). No graft fractured, and all grafts were incorporated on radiographs as of the last follow-up examination. All patients went on to recover pain-free functional use of their extremity.
Conclusion and Significance: The addition of an intact intramedullary fibula allograft offers the surgeon increased stability when applying a compression plate in the treatment of these avascular and unstable nonunions. This technique appears to be consistent and reliable in the treatment of aseptic, atrophic nonunions of the humeral shaft, and as a result is the treatment of choice at our institution for this otherwise difficult problem.
If noted, the author indicates something of value received. The codes are identified as a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options; e-consultant or employee; n-no conflicts disclosed, and *disclosure not available at time of printing.
• The FDA has not cleared this drug and/or medical device for the use described in this presentation (i.e., the drug or medical device is being discussed for an “off label” use). ◆FDA information not available at time of printing. Δ OTA Grant.