El-Rosasy Mahmoud A
Department of Orthopaedic Surgery and Traumatology, Faculty of Medicine, University of Tanta, Egypt.
Indian J Orthop. 2012 Jan;46(1):58-64. doi: 10.4103/0019-5413.91636.
Nonunion of humeral shaft fractures after previously failed surgical treatment presents a challenging therapeutic problem especially in the presence of osteoporosis, bone defect, and joint stiffness. It would be beneficial to combine the use of external fixation technique and intramedullary rod in the treatment of such cases. The present study evaluates the results of using external fixator augmented by intramedullary rod and autogenous iliac crest bone grafting (ICBG) for the treatment of humerus shaft nonunion following previously failed surgical treatment.
Eighteen patients with atrophic nonunion of the humeral shaft following previous implant surgery with no active infection were included in the present study. The procedure included exploration of the nonunion, insertion of intramedullary rod (IM rod), autogenous ICBG and application of external fixator for compression. Ilizarov fixator was used in eight cases and monolateral fixator in ten cases. The monolateral fixator was preferred for females and obese patients to avoid abutment against the breast or chest wall following the use of Ilizarov fixator. The fixator was removed after clinical and radiological healing of the nonunion, but the IM rod was left indefinitely. The evaluation of results included both bone results (union rate, angular deformity and limb shortening) and functional outcome using the University of California, Los Angeles (UCLA) rating scale.
The mean follow-up was 35 months (range 24 to 52 months). Bone union was obtained in all cases. The functional outcome was satisfactory in 15 cases (83%) and unsatisfactory in 3 cases (17%) due to joint stiffness. The time to bone healing averaged 4.2 months (range 3 to 7 months). The external fixator time averaged 4.5 months (range 3.2 to 8 months). Superficial pin tract infection occurred in 39% (28/72) of the pins. No cases of nerve palsy, refracture, or deep infection were encountered.
The proposed technique is effective in treating humeral nonunion especially in the presence of osteoporosis and short bone segments. The inclusion of intramedullary rod as internal splint improves stability of fixation and prevents refracture after fixator removal.
肱骨干骨折在先前手术治疗失败后发生骨不连是一个具有挑战性的治疗难题，尤其是在存在骨质疏松、骨缺损和关节僵硬的情况下。将外固定技术与髓内棒联合用于此类病例的治疗可能会有益处。本研究评估了使用髓内棒增强的外固定器及自体髂骨植骨（ICBG）治疗先前手术治疗失败后的肱骨干骨不连的效果。
本研究纳入了18例先前植入手术失败后出现萎缩性肱骨干骨不连且无活动性感染的患者。手术步骤包括探查骨不连部位、插入髓内棒（IM棒）、自体ICBG植骨以及应用外固定器进行加压。8例使用Ilizarov外固定器，10例使用单侧外固定器。对于女性和肥胖患者，优先选择单侧外固定器，以避免使用Ilizarov外固定器后乳房或胸壁受到挤压。骨不连在临床和影像学愈合后拆除外固定器，但IM棒永久留存。结果评估包括骨结果（愈合率、成角畸形和肢体短缩）以及使用加利福尼亚大学洛杉矶分校（UCLA）评分量表评估的功能结局。
平均随访35个月（范围24至52个月）。所有病例均实现了骨愈合。15例（83%）功能结局满意，3例（17%）因关节僵硬功能结局不满意。骨愈合时间平均为4.2个月（范围3至7个月）。外固定器使用时间平均为4.5个月（范围3.2至8个月）。39%（28/72）的针道发生浅表针道感染。未出现神经麻痹、再骨折或深部感染病例。
所提出的技术在治疗肱骨干骨不连方面有效，尤其是在存在骨质疏松和短骨段的情况下。将髓内棒作为内夹板可提高固定稳定性并防止拆除外固定器后再骨折。
