Nickel Brian T, Klement Mitchell R, Richard Marc J, Zura Robert, Garrigues Grant E
Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, United States.
Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, United States.
Injury. 2016 Dec;47 Suppl 7:S40-S43. doi: 10.1016/S0020-1383(16)30853-1.
Nonunion following closed treatment of humeral shaft fracture is estimated to be 5.5%. Many surgical techniques have been described to address humeral shaft nonunion including: open reduction, internal fixation (ORIF) with compression plating and bone graft, dual plating, cortical strut allograft and autograft, and adding biologic augmentation (BMP). The current standard of care includes ORIF with compression plating and bone grafting, but even this technique has an approximated 10% failure rate. We describe a novel surgical technique using cup and cone reamers, which were originally designed for metatarsophalangeal or metacarpalphalangeal arthrodesis. Cup and cone reamers are the appropriate size for mid-shaft, transverse humeral nonunions to ensure ideal apposition of healthy, bleeding bone.
We retrospectively reviewed 3 patients with nonunion of the midshaft humerus which were treated with the cup and cone technique and a large fragment LCDC plate. An anterolateral approach was used in 2 cases and a posterior in the other. After exposure of fracture ends, 24-mm hemispherical convex and concave reamers were then used to ream the proximal and distal ends in order to create a "cup and cone" articulation of the fracture ends. All patients were followed for a minimum of 6 months with a mean follow-up of 12 months.
All patients treated with this technique achieved union, reported zero pain and full functional outcome. Specifically, patients had a mean age of 36.3 and the mean interval between injury and time to surgery was 11.5 months. Two of the patients presented with nonunions after attempted closed treatment and the other patient had 3 prior surgeries for infected nonunion. Union was achieved at a mean of 12 weeks.
To our knowledge, the use of cup and cone reamers for nonunion of the humerus has never been described. We describe a simple and effective technique for humeral shaft nonunions which has been successful in both septic and hypertrophic nonunions, as well as from multiple approaches-both anterolateral and posterior.
肱骨干骨折闭合治疗后骨不连的发生率估计为5.5%。已有多种手术技术用于治疗肱骨干骨不连，包括：切开复位、加压钢板内固定（ORIF）联合植骨、双钢板固定、皮质支撑异体骨和自体骨移植，以及添加生物增强材料（骨形态发生蛋白）。目前的标准治疗方法包括ORIF联合加压钢板固定和植骨，但即使是这种技术也有大约10%的失败率。我们描述了一种使用杯状和锥状扩孔钻的新型手术技术，这种扩孔钻最初是为跖趾或掌指关节融合术设计的。杯状和锥状扩孔钻的尺寸适合肱骨干中段横行骨不连，以确保健康、有出血的骨块理想对合。
我们回顾性分析了3例采用杯状和锥状技术及大骨折块锁定加压接骨板（LCDC）治疗的肱骨干中段骨不连患者。2例采用前外侧入路，另1例采用后外侧入路。暴露骨折端后，使用24毫米半球形凸凹扩孔钻对近端和远端进行扩孔，以形成骨折端的“杯状和锥状”关节。所有患者至少随访6个月，平均随访12个月。
所有采用该技术治疗的患者均实现了骨愈合，报告无痛且功能完全恢复。具体而言，患者的平均年龄为36.3岁，受伤至手术的平均间隔时间为11.5个月。其中2例患者在尝试闭合治疗后出现骨不连，另1例患者此前因感染性骨不连接受了3次手术。平均在12周时实现了骨愈合。
据我们所知，从未有过使用杯状和锥状扩孔钻治疗肱骨干骨不连的报道。我们描述了一种治疗肱骨干骨不连的简单有效技术，该技术在感染性和肥大性骨不连以及前外侧和后外侧等多种入路的治疗中均取得了成功。
