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UOEH 38（ 4 ）: 297－304（2016）

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［Case Report］

Troubleshooting in the Treatment of Pseudoarthrosis After a Humeral Diaphyseal Fracture: A Case Report Naoaki Kurinomaru1*, Yukichi Zenke1, Kayoko Furukawa2, Yoshiaki Yamanaka1 and Akinori Sakai2 1

Department of Orthopaedic Surgery, University Hospital of Occupational and Environmental Health, Japan. Yahatanishiku, Kitakyushu 807-8555, Japan 2 Department of Orthopaedic surgery, School of Medicine, University of Occupational and Environmental Health, Japan. Yahatanishi-ku, Kitakyushu 807-8555, Japan

Abstract : We report a case of a patient with a history of surgery for insufficient pseudoarthrosis after a humeral diaphyseal fracture. Although most humeral nonunions are successfully treated with a single procedure, some humeral nonunions are more difficult to heal and require multiple procedures. A-61-year-old man presented at our hospital with pain and deformity in his left upper arm. The humeral diaphyseal fracture had been previously treated elsewhere with open reduction and internal fixation. Some days prior to his visit at our hospital, he had had pain in his left upper arm, without a particular cause, and was admitted to our hospital for initial evaluation. After a complete physical examination, symptoms of infection and any neurovascular deficit were ruled out. Radiographic examination revealed atrophic nonunion of the middle third of the humeral shaft associated with disuse osteopenia. Anterograde intramedullary nailing and bone grafting were performed for the resistant atrophic nonunion of the humeral diaphysis. In addition to the intramedullary nailing, additional fixation was performed for residual rotational instability. A postoperative evaluation revealed a periprosthetic fracture in the distal part of the humerus. Poor bone quality or a deficient plate technique might have lead to the facture. We performed open reduction and internal fixation (ORIF): he underwent fixation with a 2-plate construct for the nonunion of the humeral diaphyseal fracture, together with decortication, debridement, and bone grafting. Eight months after surgery, the patient’s bone had healed and he had recovered flexion (110°) and extension (−30°) without complications. An orthopedic surgeon should be aware of these complications when choosing open reduction and internal fixation for the treatment of a history of insufficient pseudoarthrosis. Patients should be closely followed up for evidence of any complications such as infections and malunions. Fracture fixation in patients with pseudoarthrosis requires strategies to overcome the technical difficulties faced during the procedure. Keywords : nonunion, humeral diaphyseal fracture, intrameduallary nail, complication. （Received August 17, 2016, accepted October 31, 2016）

Introduction 　Humeral diaphyseal fracture is a common injury, accounting for 3-5% of all fractures [1]. The nonunion rates of humeral diaphyseal fractures treated nonoper-

atively range from 0% to 13%, with the incidence increasing to 15-30% for operatively treated fractures [2]. 　Numerous techniques and fixation constructs have been described to treat humeral diaphyseal nonunions with mostly good to excellent rates of fracture heal-

*Corresponding Author: Naoaki Kurinomaru, Department of Orthopaedic Surgery, University Hospital of Occupational and Environmental Health, Japan. Yahatanishi-ku, Kitakyushu 807-8555, Japan Tel: +81-93-691-7444, Fax: +81-93-692-0184, E-mail: [email protected]

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ing. Of humeral diaphyseal fractures treated conservatively, 90-95% attain union with good functional outcomes [3]. The reported nonunion rate after conservative or surgical treatment of humeral diaphyseal fractures is 8-13% [4]. Although most humeral nonunions are successfully treated with a single procedure, some are more difficult to heal and require multiple procedures. Thus, treatment is challenging for the surgeon when nonunion occurs. Nonunion of humeral diaphyseal fractures often results in pain with prolonged disability, resulting in reoperation, long absence from work, and impaired quality of life. Several surgical methods have been used for treating nonunions of the humeral diaphysis, including compression plating and autologous bone grafting, the Ilizarov external fixator , and intramedullary nailing. Plate fixation with bone grafting achieves union in more than 90% of cases [4]. However, the main problem with plate fixation is that it requires a wide dissection that entails high risk of damage to the radial nerve. Radial nerve injury has been reported in around 5% of patients treated with this method. On the other hand, successful results have been reported with the Ilizarov external fixator, which led to union in 94% of cases [4]. The major disadvantages of external fixators are the length of operation time required, pin-tract infections, and the large size of the frame, resulting in significant discomfort for the patient. Intramedullary nailing, which has been used by many surgeons in the treatment of humeral nonunions [4, 5], is an accepted technique for the treatment of humeral diaphyseal nonunion, and is also an established method for the treatment of highenergy long bone fractures, especially in a polytrauma setting and in osteoporotic, impending and pathological fractures. The technical errors and complications after intramedullary nailing of humeral diaphyseal nonunion have been recorded and discussed in only a limited number of studies [5]. Therefore we present our experience with extreme complications in the treatment of humeral diaphyseal nonunion of the long bones with the application of intramedullary nailing.

few years prior, from a fall. At that time, he underwent treatment with open reduction and internal fixation for a humeral diaphyseal fracture at another hospital. 　He did not seek further medical treatment, because of the absence of clinical symptoms. However, some days prior to his visit at our hospital, he had pain in his left upper arm, without a particular cause, so he consulted us for the pain, left upper limb deformity and functional limitation. The range of motion in his elbow was unremarkable, as opposed to having a stiff shoulder joint (Fig. 1). He was admitted to the hospital for initial evaluation. After a complete physical examination and after neurovascular deficit was ruled out, radiographic examination revealed an atrophic nonunion of the middle third of the humeral shaft associated with severe nonuse osteopenia (Fig. 2). In addition, we found evidence of a fracture in the base of the

Case report 　A 61-year-old man presented at our hospital with pain in his left upper arm. He had fractured his left arm a

Fig. 1. Clinical photographs showing disability over past fracture aspect of the left upper arm.

Troubleshooting in the Treatment of Pseudoarthrosis After Humeral Diaphyseal Fracture

coronoid process, which was later corroborated by a computed tomographic scan (Fig. 3). Accordingly, we diagnosed a pseudoarthrosis occurring after a humeral diaphyseal fracture. Following this diagnosis, our preoperative planning included the following: first, three screws were removed, then anterograde intramedullary nailing and bone grafting were performed for the resistant atrophic nonunion of the humeral diaphysis. The patient was admitted for surgery for the treatment of pseudoarthrosis from a humera diaphyseal fracture. 　First, the nonunion site was exposed through an extensile posterior approach to the hu-meral diaphysis, and then three screws were removed. The fracture site was exposed through a lateral approach for the midshaft fracture and by using the same approach as in the previous surgery as necessary. The radial nerve was found and protected. 　The fracture site was cleared of fibrous tissue so that the nonunion site was debrided, 3cm of necrotic stump was resected, and a locked antegrade intramedullary nailing was then performed. Humeral intramedullary nailing was inserted by the anterograde approach. 　Fixation consisted of a self-compressive screw plate for the humerus, radius and ulna.

　We found an articular defect that was filled with bone graft. Additional fixation was performed for the residual rotational instability after locking with the intramedullary nail. 　Sufficient rotational stability could be achieved with a smaller implant. We took an X-ray after the operation, and fixed the patientʼs arm with a cast (Fig. 4).

Fig. 3. Preoperative 3D-CT.

Fig. 2. Preoperative X-ray after internal fixation.

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Fig. 4. Postoperative X-rays after the first operation.

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　On the next day, a postoperative evaluation revealed a periprosthetic fracture in the distal part of the humerus (Fig. 5). Poor bone quality or a deficient plate technique might have lead to the fracture. On the 10th day after our first operation, the additional plate was removed and the pseudoarthrosis from the humeral diaphyseal fracture was again debrided of devitalized and inflammatory tissue. The same approach as in our previous surgery was used for the upper third, fractures and extended distally as needed, with the radial and ulna nerve protected. First, we exposed the additional plate and screws and removed them. After that, the large bone defect was exposed. The medial portion of the brachialis was then placed between the plate and the radial nerve (Fig. 6). For the nonunion of the humeral shaft, he underwent fixation with a Mayo congruent elbow plate construct in addition to three locking screws (Fig. 7). In the same way, a Mayo congruent elbow plate with a Synthes cable system was used in the lateral portion (Fig. 8). For the above-mentioned reasons, he underwent fixation with a 2-plate construct, together with decortication, debridement, and bone grafting, for the nonunion of the humeral shaft (Fig. 9). After the surgery, a cast was applied for initial stabilization and was

Fig. 6. The lateral portion of the brachialis was placed between the plate and the radial nerve.

Fig. 7. When the plate and screws were removed, we could see a large bone defect.

Fig. 5. An iatrogenic fracture was caused during primary anterograde nailing. Plate osteosynthesis was performed as a secondary procedure.

Fig. 8. The medial portion of the brachialis was placed between the plate and the radial nerve. The patient underwent fixation for nonunion of the humeral shaft, using a Mayo congruent elbow plate construct in addition to three locking screws.

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removed 1 week later. Thereafter, a functional brace was retained for 3 months, after which time physical therapy was started and radiography was performed to evaluate the clinical and radiographic improvements. He was permitted to use the arm for daily life and light work in the short term. Heavy lifting was avoided until radiographic evidence of healing was found. Healing was defined as the presence of a bridging callus in at least 3 cortices on 2 radiographic views. Thus the time for union was 8 months (Fig.10). No signs of infection were observed, and cultures produced no bacterial, mycobacterial, or fungal growth. Eight months after the surgery, the patientʼs fracture has healed with no associated complications, and he also recovered flexion (110°) and extension (−10°)(Fig.11). The patient is now almost fully functional and has returned to his daily activities with no limitations. Fig. 11. Clinical photo of the same patient with good range of elbow extension and flexion.

Discussion

Fig. 9. Postoperative X-rays after second operation.

Fig. 10. Following up X-rays showing full union of the fracture site.

　The most important finding of our study is that fractures below or at the tip of the implant are a clinical concern. Orthopedic surgeons should be aware of this possible complication when choosing to use interlocking humeral nails for the treatment of humeral shaft fractures. 　Fracture fixation in patients with pseudoarthrosis requires strategies to overcome the technical difficulties faced during the procedure. The complex anatomy, the nonuse osteopenia, and the joint stiffness resulting from prolonged immobilization all contribute to making treatment of humeral shaft nonunions challenging. It has been postulated that locked humeral nailing can provide a secure fixation of the entire humeral shaft, especially when performed for pathological lesions. In our first operation, additional fixation was performed for the residual rotational instability after locking with the intramedullary nail because of the lack of preparation of the locking compression plates, with the result that the next day, the rational instability could not be restricted and the patient suffered a fracture. Poor bone quality or a deficient plate technique may lead to

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fracture. Many factors associated with compromised fracture healing have been described, including smoking, alcohol abuse, anti-inflammatory drug use, unstable fixation, poor patient compliance, devitalization of soft tissues, inadequate immobilization and infection. 　Before an operation for pseudoarthrosis, we must consider not only the implant choice but also the quality of the bone. Similar case studies have been reported. Metsemarkers reported 5 patients (4%) who had early technical failures that required revision surgery[5]. In one case, the patient incurred an iatrogenic fracture during retrograde nailing. The clinical consequences of atrophic humeral diaphyseal nonunions are a severe functional limitation that may significantly affect activities of daily living. Operative treatment to achieve adequate fixation in ununited fractures is often complicated by the coexistence of suboptimal surgical conditions, such as prior surgical attempts or significant bone loss. Various treatment strategies for nonunion of humeral diaphyseal fractures have been reported, ranging from (double) plating augmented with autologous bone graft or intramedullary fixation with bone to treatment with an external fixator [6], but an evidence-based consensus regarding the optimal treatment of humeral diaphyseal nonunions has not been reached yet. Hypertrophic nonunions may heal if a stable fixation is achieved, but patients with atrophic nonunions require both a stable fixation and enhancement of the biological response because of the weak biological reaction observed at the fracture site. Compression plating fixation has the advantages of high union rate and good functional recovery, but for humeral diaphyseal fractures or nonunions, the use of long and broad steel plates of 4.5 mm in thickness is recommended by the Arbeitsge-meinscheft for Osteosyntheses Fragen/Association for the Study of International Fixation (AO/ASIF) group. For nonunions with osteoporosis, placement of 10- or 11-hole plates with 5 or more screws proximal or distal to the nonunions is recommended [7]. 　Even though the use of locking compression plates and screws may fix the bone with osteoporosis and has been reported in the treatment of humeral nonunions with osteoporosis, this still requires a long skin incision and extensive soft-tissue stripping that may in-

terfere with fracture healing [8]. Thus, intramedullary nailing has advantages over the use of steel plates in that it is associated with fewer tissue traumas, fewer circulatory impairements, and lower risk of radial nerve injury during the removal of nails. Intrameduallary nailing has been widely used in the treatment of acute humeral fractures, pathologic fractures and nonunions [8]. In addition, reliable results have been reported for augmentation plating after intramedullary nailing for nonunions in the lower extremities. The technique takes advantage of the high axial stiffness resulting from in situ nails and uses short plates to minimize adverse rotational micromovements without compressing the nonunion site[9]. 　Placement of a second plate on a 90° plane or, alternatively, a strong on lay cortical bone graft or an intramedullary fibular allografts has been reported to enhance stability at the nonunion site. It is often said that humeral intramedullary nailing is an effective alternative treatment for humeral nonunion, but use of a locked intramedullary nailing system in the humerus is associated with some serious problems, such as shoulder dysfunction, migration of nails despite adequate locking in osteoporotic patients, radial nerve palsy, ossification in the olecranon fossa that causes elbow dysfunction, creation of an additional comminution at the fracture site, and a fracture below the locking humeral nail [10]. 　In conclusion, we emphasize that orthopedic surgeons should be aware of the possibility of a fracture below or at the tip of the implant when choosing to use interlocking humeral nails for the treatment of humeral shaft fractures. We stress the importance of good surgical technique with respect to the final outcome.

Conflict of interest 　No potential conflicts of interest are disclosed.

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108–115 3 . Foster RJ Dixon GL Bach AW Appleyard RW & Green

273−276 7 . Rosen H (1990): The treatment of nonunions and

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multi-center study. J Bone Joint Surg Am 67-A: 857– 864 4 . Hornicek FJ, Zych GA, Hutson JJ & Malinin TI (2001): Salvage of humeral nonunions with onlay bone plate allograft augmentation. Clin Orthop 386: 203–209 5 . Metsemarkers WJ, Wijnen V, Sermon A & Vanderschot P

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8 . Lin J, Hou SM & Hang YS (2000): Treatment of humeral shaft delayed unions and nonunions with humeral locked nails. J Trauma 48: 695–703 9 . Choi YS & Kim KS (2005): Plate augmentation leaving the nail in situ and bone grafting for non-union of femoral shaft fractures. Int Orthop 29: 287–290

(2015): Intermeduallary nailing of humeral shaft frac-

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上腕骨骨幹部骨折後の偽関節手術に対し術後合併症を回避し得た1例

栗之丸　直朗1，善家　雄吉1，古川　佳世子2，山中　芳亮1，酒井　昭典2 1 2

産業医科大学病院　整形外科 産業医科大学　医学部　整形外科

要　　　旨：脆弱性の強い上腕骨骨幹部骨折後の偽関節に対して手術を施行した 1 例を報告する．上腕骨骨幹部骨 折はほとんどの場合，初期治療で問題のないことが多いが，一部の症例では治療が困難であることがある． 症例は 61 歳，男性．左上腕骨骨幹部骨折を受傷した．他院にて骨接合術を施行され，術後，疼痛なく日常生活も仕事もでき ていた．特に誘因なく左上腕部に疼痛および不安定感を自覚した．近医を受診して左上腕骨偽関節を指摘され，保 存療法を行うも症状の改善はなく，当院へ紹介受診となった．初診時は，左上腕中央部に肘関節屈曲で前方に大きく 突出する可動性の骨性隆起を触れた．しかし，明らかな感染，神経麻痺や血行障害は認めなかった．左上腕骨骨幹部 骨折遅発性偽関節と診断し，偽関節手術を施行した．残存スクリューを抜釘後，近位より髄内釘を挿入した．骨接合 術終了直後に髄内釘遠位端での骨折が生じた．二期的手術として，上腕骨遠位端骨折に対して骨折部のデブリード マンを行った後，骨移植と両側プレートによる骨接合術を施行した．術後 8ヶ月が経過し骨癒合および可動域は良好 であり，合併は認めていない．偽関節発症後に長期間が経過している症例は，骨折部の骨硬化が強いものの骨脆弱性 を有しており，骨接合に難渋することが予想される．骨脆弱性の強い偽関節手術施行の際は，術中骨折の可能性も考 慮し， 十分な術前計画を練った上でインプラントを準備しなければならない． キーワード：偽関節， 上腕骨骨幹部骨折，髄内釘，合併症． J UOEH（産業医大誌）38 （4） ：297 － 304（2016）