Background: Delayed union or nonunion of a fracture of the humerus
is an infrequent but debilitating complication. Open reduction and internal
fixation combined with autologous bone-grafting can result in reliable healing
of the fracture; however, there is morbidity associated with the bone-graft
donor site. This study was designed to evaluate healing of ununited fractures
of the humeral shaft treated by one surgeon at one institution with a strict
and consistent surgical protocol but with the use of two different types of
bone graft: autologous iliac crest bone graft and demineralized bone
Methods: A consecutive retrospective cohort series was analyzed.
From 1992 to 1999, forty-five patients with an aseptic, atrophic delayed union
or nonunion of a humeral shaft fracture were treated with open reduction and
internal fixation with a plate and autologous iliac crest bone graft. The mean
time from the fracture to the surgery was 14.0 months, and the mean duration
of follow-up was 32.8 months. From 2000 to 2003, thirty-three patients with
the same condition were treated with the same protocol with the exception that
demineralized bone matrix was used instead of autologous iliac crest bone
graft. The mean time from the fracture to the surgery in that group was 22.6
months, and the mean duration of follow-up was 20.4 months. All patients in
both groups were assessed clinically and radiographically.
Results: Osseous union was noted clinically and radiographically
following the index surgery in 100% of the forty-five patients treated with
autologous bone graft and 97% (thirty-two) of the thirty-three patients
treated with demineralized bone matrix. The mean time to union was 4.5 months
in the group treated with autologous bone graft and 4.2 months in the group
treated with demineralized bone matrix. The overall functional outcome did not
differ between the groups; however, twenty (44%) of the autologous bone-graft
recipients had donor site morbidity, including a prolonged pain in the
majority and a superficial infection requiring irrigation and
débridement in one patient.
Conclusions: Healing of an ununited humeral shaft fracture can be
achieved consistently with rigid plate fixation and lag-screw compression
augmented with either autologous cancellous bone graft or commercially
available demineralized bone matrix. The harvest of the autologous bone graft
is frequently associated with complications.
Level of Evidence: Therapeutic Level III. See
Instructions to Authors for a complete description of levels of evidence.