Scientific Article   |    
Unstable Nonunions of the Distal Part of the Humerus
David Ring, MD; Lawrence Gulotta, BA; Jesse B. Jupiter, MD
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Investigation performed at the Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts

David Ring, MD
Lawrence Gulotta, BA
Jesse B. Jupiter, MD
Department of Orthopaedic Surgery, Massachusetts General Hospital, Hand and Upper Extremity Service, ACC 525 (D.R. and L.G.) and ACC 527 (J.B.J.), 15 Parkman Street, Boston, MA 02114. E-mail address for D. Ring: dring@partners.org.

In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from the AO Foundation. None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

J Bone Joint Surg Am, 2003 Jun 01;85(6):1040-1046
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Background: Some nonunions of the distal part of the humerus are so unstable that the hand and the forelimb cannot be supported against gravity. The purpose of the present retrospective study was to analyze the results of open reduction and internal fixation, joint contracture release, and autogenous bone-grafting in the treatment of these unstable nonunions of the distal part of the humerus.

Methods: Fifteen patients (average age, sixty years) with an unstable nonunion of the distal part of the humerus were treated with excision of fibrous and synovial tissues, opening of sclerotic fracture surfaces, internal fixation with multiple plates and screws, and autogenous bone-grafting. The average time from the original fracture to the index treatment of the nonunion was eleven months. Vascularized fibular grafts and supplemental external fixation were necessary in two patients with large bone defects after débridement at the site of a previous infection.

Results: Three nonunions failed to heal and were treated with total elbow arthroplasty. Twelve nonunions healed, but six of the twelve required additional surgery because of painful implants, ulnar neuropathy, or elbow contracture. After an average duration of follow-up of fifty-one months (range, twenty-four to 130 months), the twelve patients in whom the nonunion healed had an average arc of ulnohumeral motion of 95°, with an average flexion of 117° and an average flexion contracture of 22°. According to the Mayo Elbow Performance Index, the functional result was rated as excellent in two patients, good in nine, and fair in one.

Conclusions: Unstable nonunions of the distal part of the humerus can be treated successfully in most active, healthy patients with use of rigid internal fixation, joint contracture release, and bone-grafting.

Level of Evidence: Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    David Ring
    Posted on August 19, 2003
    Dr. Ring responds to, "Would author recommend a different approch"?
    Massachusetts General Hospital

    We agree that impacted articular and metaphyseal fragments often go unrecognized. For a discussion of this with regards to complex articular fractures see our article published earlier this year in JBJS.

    Regarding the use of triceps reflecting approaches for exposure of the distal humerus we have not encountered as many problems as others have reported with an olecranon osteotomy. Olecranon osteotomy gives the best exposure and may be the best way to handle the triceps as the anatomy of the insertion is least disturbed with this method—it returns to near normal once the osteotomy is healed. If one pays attention to the technique of the osteotomy creation and repair, problems will be uncommon. A report of Dr. Jupiter’s experience with olecranon ostetomy will be published shortly in the Journal of Orthopaedic Trauma. The keys of the technique are a chevron shaped osteotomy (Dr. Jupiter prefers apex distal, but I have adopted an apex proximal osteotomy by suggestion of Dr. David Helfet), cracking of the articular surface to create an interdigitating surface, oblique drilling of the K-wires so that the wires engage the anterior ulnar cortex distal to the coronoid process, and a 180-degree bend proximally with impaction of the bent ends beneath the triceps and into the olecranon. The results of olecranon osteotomy are technique- dependent. A carefully created and repaired osteotomy will serve the elbow surgeon well.

    A recent paper in JBJS based on mechanical testing of cadavers suggests that small wires do not provide adequate fixation. We believe that study is flawed and does not reflect the clinical situation. We use 0.045-inch Kirschner wires and two 22 gauge stainless steel figure of eight tension wires for repair of an olecranon osteotomy. We have very rarely had broken or loose wires. This is in spite of immediate active elbow exercises. This is a reflection of the power of the tension band concept--a basic engineering fact applied successfully in orthopaedics.

    Several triceps reflecting techniques including the Bryan/Morrey exposure, the TRAP, and a modification of Campell’s triceps split used and reported by Michael McKee and his colleagues are alternatives to olecranon osteotomy. We have not found these as useful as an olecranon osteotomy.

    Prof. Ram Chander Siwach
    Posted on August 16, 2003
    Would author recommendDifferent approach ?

    Sir, the authors experience and expertise is obvious with the results obtained in the cases. The authors have rightly emphasized the importance of age, sex , demands , dominance of the hand in the article as this is very important for us; where requirements of the patients are different.

    We have observed in the fresh cases of intraarticular fractures that there is displacement in the articular fragments that gets compressed in the metaphyseal regions of the humerus and therefore while assembling the articular fragments intraoperatively; the ‘fragment’ is missing. This leads to unstable reduction of the fracture which is a preventable cause of instability and can be avoided if the radiographs are studied carefully preoperatively.

    What are the recommendations of the authors in using triceps reflecting anconeus pedicle approach which avoids hardware, non-union complications of the osteotomy of the olecranon and ostearthrosis of the joint thereby easy arthroplasty in case the need arises.

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