Kashayi-Chowdojirao Sreekanth, Vallurupalli Aashish, Chilakamarri Vijay Krishna, Patnala Chandrasekhar, Chodavarapu Lalith Mohan, Kancherla Nageswara Rao, Khazi Syed Asif Hussain
Department of Orthopaedics, Nizam's Institute of Medical Sciences, Panjagutta, Hyderabad 500082, Telangana State, India.
J Clin Orthop Trauma. 2017 Nov;8(Suppl 2):S21-S30. doi: 10.1016/j.jcot.2016.12.006. Epub 2016 Dec 22.
Non-union humeral shaft fractures are seen frequently in clinical practice at about 2-10% in conservative management and 30% in surgically operated patients. Osteosynthesis using dynamic compression plate (DCP), intramedullary nailing, locking compression plate (LCP), Ilizarov technique along with bone grafting have been reported previously. In cases of prior failed plate-screw osteosynthesis the resultant osteopenia, cortical defect, bone loss, scalloping around screws and metallosis, make the management of non-union more complicated. Fibular graft as an intramedullary strut is useful in these conditions by increasing screw purchase, union and mechanical stability. This study is a retrospective and prospective follow up of revision plating along with autologous non-vascularised intramedullary fibular strut graft (ANVFG) for humeral non-unions following failed plate osteosynthesis.
Seventy eight cases of nonunion humeral shaft fractures were managed in our institute between 2008 and 2015. Of these, 57 cases were failed plate osteosynthesis, in which 15 cases were infected and 42 cases were noninfected. Out of the 78 cases, bone grafting was done in 55 cases. Fibular strut graft was used in 22 patients, of which 4 cases were of primary nonunion with osteoporotic bone. Applying the exclusion criteria of infection and inclusion criteria of failed plate osteosynthesis managed with revision plating using either LCP or DCP and ANVFG, 17 cases were studied. The mean age of the patients was 40.11 yrs (range: 26-57 yrs). The mean duration of non-union was 4.43 yrs (range: 0.5-14 yrs). The mean follow-up period was 33.41 months (range: 12-94 months). The average length of fibula was 10.7 cm (range: 6-15 cm). Main outcome measurements included bony union by radiographic assessment and pre- and postoperative functional evaluation using the DASH (Disabilities of the Arm, Shoulder and Hand) score. Results: Sixteen out of 17 fractures united following revision plating and fibular strut grafting. Average time taken for union was 3.5 months (range: 3-5 months). Complications included one each of implant failure with bending, transient radial nerve palsy and transient ulnar nerve palsy. No case had infection, graft site morbidity or peroneal nerve palsy. Functional assessment by DASH score improved from 59.14 (range: 43.6-73.21) preoperatively to 23.39 (range: 8.03-34.2) postoperatively (p = 0.0003). Conclusion: The results of our study indicate that revision plating along with ANVFG is a reliable option in humeral diaphyseal non-unions with failed plate-screw osteosynthesis providing adequate screw purchase, mechanical stability and high chances of union with good functional outcome.
肱骨干骨折不愈合在临床实践中较为常见，保守治疗时发生率约为2%-10%，手术治疗患者中发生率为30%。以往曾报道过使用动力加压钢板（DCP）、髓内钉、锁定加压钢板（LCP）、伊里扎洛夫技术以及植骨进行骨固定。对于先前钢板螺钉骨固定失败的病例，由此导致的骨质减少、皮质缺损、骨丢失、螺钉周围骨吸收和金属沉着症，使得骨折不愈合的治疗更加复杂。腓骨移植作为髓内支撑物，通过增加螺钉把持力、促进愈合和提高机械稳定性，在这些情况下是有用的。本研究是对钢板固定失败后采用翻修钢板联合自体非血管化髓内腓骨支撑移植（ANVFG）治疗肱骨干骨折不愈合进行的回顾性和前瞻性随访。
2008年至2015年间，我院共治疗78例肱骨干骨折不愈合患者。其中，57例为钢板固定失败，其中15例感染，42例未感染。78例患者中，55例行植骨术。22例患者使用了腓骨支撑移植，其中4例为原发性骨质疏松性骨不愈合。应用感染排除标准以及采用LCP或DCP和ANVFG进行翻修钢板固定治疗钢板固定失败的纳入标准，对17例患者进行了研究。患者平均年龄为40.11岁（范围：26-57岁）。骨折不愈合的平均持续时间为4.43年（范围：0.5-14年）。平均随访时间为33.41个月（范围：12-94个月）。腓骨平均长度为10.7 cm（范围：6-15 cm）。主要观察指标包括通过影像学评估判断骨愈合情况，以及使用上肢、肩部和手部功能障碍（DASH）评分进行术前和术后功能评估。结果：17例骨折患者中，16例在翻修钢板和腓骨支撑移植后愈合。愈合平均时间为3.5个月（范围：3-5个月）。并发症包括1例植入物弯曲失败、1例短暂性桡神经麻痹和1例短暂性尺神经麻痹。无感染、移植部位并发症或腓总神经麻痹病例。DASH评分的功能评估从术前的59.14（范围：43.6-73.21）改善至术后的23.39（范围：8.03-34.2）（p = 0.0003）。结论：我们的研究结果表明，翻修钢板联合ANVFG是治疗钢板螺钉固定失败的肱骨干骨折不愈合的可靠选择，可提供足够的螺钉把持力、机械稳定性，且愈合机会高，功能预后良好。
