Patients and Methods
Patients
It was a prospective and continuous study from January 2008 to July 2015. All patients with non-union of the humerus were included
Criteria for non-inclusion concerned septic non-union, patients lost to follow-up and incomplete records. The data were collected on the history of the patients (which included the patient’s civil status, history and habit, initial treatment), clinical examination, radiography status, treatment and progression after treatment.
Thus 22 cases of non-union of the humeral diaphysis were collected in 22 patients. They were 14 men and 8 women with an average age of 52.7 years (23-85 years).
The reason for the consultation was the deformation of the arm during the execution of the gestures and the absolute functional impotence of the limb. All patients were right-handed and the dominant side was reached 7 times. Pain was present in 7 of them.Patients were in various occupations (6 housewives, 2 drivers, 5 without profession, 2 retired patients, 1 plumber, 1 pompist, 2 merchants, 1 fisherman, 1 receptionist and 1 transporter).
According to the radiological aspect we have found several anatopathological forms. The classification of Weber and Cech [6] allowed us to find 15 eutrophic, 5 atrophic and 2 hypertrophic forms.
Surgical technique
The antero external way was used in all our patients. After dissection and isolation of the radial nerve on the string we carried out an osteomuscular decortication according to Judet followed by permeabilization of the medullary canal, curettage, and hew again the bone banks until bleeding.
The osteosynthesis used a wide AO plate in 18 cases and a narrow plate of Lecestre® type in 4 cases. The cortical intake on both sides of the non-union focus is summarized in (Figure 1)
Figure 1 : Number of screws per synthesis.
Cortico-spongy grafting was performed in 17 patients. For all, the closure was done on a drain of Redon® aspirator which was removed on D2 postoperative. A plaster brachio-ante-brachial splint was set up for 2 months in 14 of them.
The average duration of hospital stay was 5 days (extremes 2 and 7 days). The rehabilitation process was undertaken during the hospital stay by the mobilization of the fingers in all and of the elbow in the non immobilized patients. It was active and passive when the splint was removed. Secondarily, it was actively assisted and then active. The evaluation was based on the criteria of Stewart and Hundley [11,16] for pain, mobility and quality of consolidation. The analysis of the data was carried out on EPI info software and the results are significant if p˂0,001.
Results
Etiological Factors
The mean age of the patients was 52.7 years with extremes of 23 years and 85 years
The circumstances of occurrence of the initial fracture were various with a greater incidence of road traffic accidents in 15 cases, work in 2 cases, domestic accidents in 3 cases, particular accidents and public roads 1 case each (Figure 2).
Figure 2: Evaluation of the treatment of humeral shaft pseudarthrosis
Two of our patients were fat and none were smokers or alcohol addicts.
The initial fracture was closed in 21 cases and opened in 1 case; the gravity having not been specified. Radial nerve damage prior to surgery was found in 2 patients. According to the OA classification [28], the humeral shaft fractures were the most listed (18 cases): cross-sectional (11 cases) and oblique (7 cases) fractures; followed by distal third humeral fractures (4 cases). The initial treatment was surgical in 14 patients, orthopedic in 4 others and traditional for the remaining 4. In patients treated with intramedullary fixation/nailing, diastasis greater than 3mm was observed in all patients. Two pins of variable diameter (22 / 10th and 25 / 10th) have been installed in all. For patients treated with screwed plates, the latter was narrow in 2 of the cases and wide in 4 of the cases. The average number of screws was 5 per patient (extremes 3 and 8) (Figure 3).
Figure 3: Pseudarthrosis on a spindle treated by screwed plate.
Depending on the nature of the initial treatment instituted, the types of non-union are summarized in Table 1.
Table 1: Distribution of pseudarthroses according to the initial treatment.
|
Initial Treatment
|
PSD hyper
|
PSD eutro
|
PSD oligo
|
Total
|
|
Orthopedic
|
|
4
|
|
4
|
|
Traditional
|
|
2
|
2
|
4
|
|
Surgical
|
|
|
|
14
|
|
Pins
|
2
|
5
|
1
|
8
|
|
Plate
|
|
4
|
2
|
6
|
|
Total
|
2
|
15
|
5
|
22
|
Two of the patients were already undergoing a non-union of the humeral shaft and showed a dismantling of the osteosynthesis equipment with persistence of the non-union.
The mean duration of management of non-union was 5 months with extremes of 2 months and 10 months (Figure 4)
Figure 4: Armed pseudarthrosis on plate treated by screwed plate.
Therapeutic evaluation
At the average follow-up of 18 months we obtained consolidation in all our patients in an average delay of 5 months (extreme: 3 months and 10 months). A shortening of the arm was noted in 22.72% of patients. The study of the strength showed a reduction of it to 10% in 4 patients (This is what justifies our good, average and bad results).
We have not noticed elbows or fingers stiffness in all our patients.
Six cases of radial nerve paralysis were observed after surgical treatment, 4 of which were regressed and 2 remained permanent. In the latter, this paralysis was present before the cure and a section of the nerve was observed at first. We carried out a tendinous transfer in one of the patients with a recovery of the extension of the wrist and the fingers. The latter did not accept the intervention.
According to the criteria of Stewart and Hundley [11,16], we obtained over 80% very good and good results
Favoring Factors
The occurrence of shaft non-union is common to all fracture sites and is related to the initial lesion, patient and / or treatment and its follow-up.
In our series, non-union occurs mainly in adults with an average age of less than 50 years according to the literature [1,3,8,9,12,40]. These are young patients in full activity who are more exposed to trauma and therefore to their complications. This is a disabling pathology considering the important constraints exerted on the humerus during the movements of the upper limb.
A number of factors are regularly implicated for their role in the evolution towards the non-union of humeral shaft fractures. The elements related to the patient’s condition are accepted by the majority of the authors and confirmed by the various studies [2,5,9,12]. These include obesity, smoking, alcoholism and osteoporosis [1,2,10,15,39]; which our study did not find because only obesity is found in 2 patients. Non-union of the humerus complicates above all a fracture with a single transverse or oblique line located at the middle third or distal third [8,9,10,12,15,24,32,33] because of their small contact surface, and hence a lower osteogenic potential [2,9,10]. According to Caroll’s anatomical study [7], the main alimentary artery of the humerus is located at its medial edge at the middle third. The trauma can then injure this artery and compromise the vascularization necessary for a good consolidation. The open fracture is not a determining factor in the genesis of the non-union because in our 22 patients, only one had an open fracture. On the other hand, it constitutes an aggravating circumstance in the same way as the comminuted fracture site [9,37,39]. One of the most incriminating factors in the genesis of non-union is the type of treatment of the initial fracture. In this series, 3 types of initial treatment are performed. In addition to the surgical treatment that involved more than half of the cases, we had orthopedic treatment and as a recurrent and frequent occurrence in Africa, the treatment made by bone-setters. Whatever the initial treatment, non-union remains an indirect and formidable complication [4,5,16,29,32,33]. Indeed orthopedic treatment, whether by plaster or by directional splint well conducted gives more than 90% consolidation [2,4,5,9,29]. On the other hand, surgical methods, either by ascending fasciculated insertion or by centromedullary nailing or by screwed plate, are considered to be the largest providers of non-union of the humerus [4,5,9,11,12,29]. The occurrence of non-union in our serie is related to a fault in the treatment. A relationship was found between the number of spindles and the type of non-union. The latter is interrelated with the mobility of the fracture focus. Thus, the more the focus moves, the more the non-union becomes hypertrophic as evidenced by our results. The hypertrophic forms are essentially found after a nailing badly filling the medullary canal while the synthesis by plate gives more eutrophic non-union and no hypertrophic form. However, it does not allow us to assert with certainty this interpretation because our sample is small. For plaque synthesis, the number of screws and the type of plate used played an important role in the occurrence of non-union. The average of the screws was 5 per patient with a narrow plate use unsuited to the constraints of the humerus.
Thus, we can say that the non-union of the humeral shaft is not the direct consequence of the choice of the treatment initially used (whether surgical or orthopedic), but rather it is related to the way in which this treatment is applied. It may be either persistent diastasis, poor supervision of orthopedic treatment with manipulation of a poorly warned radiologist, short or narrow plate, insufficient number of screws or a nailing which does not filling the medullary canal of the shaft with often a short lever arm.
Evaluation of Treatment
If the factors predicting the evolution towards non-union are relatively consensual, the debates concerning its management remain more controversial.
Several techniques have been described in their management
Self-compressive plate fixation combined with corticospongy auto-graft after open reduction is the method of choice in our study. We have approached the humerus by the antero-external route, the most commonly used pathway, which permits a perfect exposure of all the 1/3 middle of the shaft with the possibility of extension [2,10,17,25]. However, this route imposes isolation and dissection of the radial nerve, especially if there is an initial lesion of this nerve. Excision of the non-union focus was an essential step in our case. On the other hand, BRILHAULT and FAVAR [2,6] consider that this gesture, intended to excise all the fibrous tissue of non-union, is not always necessary. In our series, this gesture allowed us to correct and to control the axial deviations and to obtain an excellent confrontation of the banks which are re-cut in order to exert a good compression. The osteomuscular decortication represented a basic gesture in our treatment of non-union. Its principle was clearly stated by Judet [2,19,41] father of the technique. The permeabilization again of the medullary canal was practiced for all our patients in order to restart the vascularization of the focus of non-union.
In our series autologous bone grafting was performed in 18 of 22 cases according to the condition of the banks and bone fragments on site. The role of these grafts is double: to induce consolidation and to fill partial or segmental bone defects. In the literature and in the cures of non-union using a screwed plate, the graft seems to play a primordial role and several authors have reported it [1,2,8,10,12,16,18,21,35]. Thus the osteosynthesis by screwed plate is mainly used. It is the only technique allowing, in the same gesture, to ensure a good stabilization of the non-union focus, to control the radial nerve, while providing an osteogenic complement indispensable for consolidation. Moreover, it protects against exposure to X-rays. The constraints to which the humerus is subjected are important, it is therefore essential to have a solid fixation ensured by a large and thick plate of at least 3 mm with at least 8 cortical takes, ie, 3 to 4 screws of type 4.5 bi cortical on each side of the non-union focus ensuring inter-fragmentary compression [3,9,12,14,16,18,29,34,36] .
The pre-molded plates of Lecestre® type were used for the non union of the 1/3 distal union 1/3 medium to ensure a sufficient lever arm for a good distribution of the screws. Since compression is not possible in this case, a longer consolidation period (10 months) is observed in one of the patients. Despite this delay in this patient, our overall consolidation rate, which is 100% for 22 patients, shows that the screw plate technique is reliable even if our sample is reduced. This rate is around 95% for external fixators as well as screwed plates with less consolidation time than the latter [2,9,12,16,29,32,33,36]. To all these arguments are added the duration of hospitalization which is on average one week [4,26,32]. But the wide opening of the non union, the possibility of traction on a neurological element, the high infectious risk and, above all, the poor performance of the screws in the case of osteoporosis, constitute the reproaches of this technique [1,2,8,9].
The external fixator is also a type of treatment regularly used in the non-union of the humerus especially in the management of septic forms. . But some authors use it systematically in this pathology [3,8,9,13,22,26,30]. The principle is to obtain a stable osteosynthesis by a non-invasive method making it possible to compress the focus of non-union according to the technique of Ilizarov. This method allows a gradual reduction of the focus with consolidation rates greater than 90% comparable to those of the plate [3,9,20,30]. But it is often responsible for discomfort for the patient because the material is bulky and is the source of neurological complications associated with infection of the orifices of the plugs or pins [3,9,22].
As for the centromedullary nailing which is more indicated in case of aseptic non-union without loss of bone substance [3,10,23,31] and without radial paralysis, its indications are much more controversial. Numerous studies have highlighted the failures of this technique [9,27,31], namely insufficiency of primary stability, the need for a shine enhancer, rotator cuff lesions during the approach and attack of the endomedullary vascularization of the humerus. However, this technique has the advantage of not opening the focus of non-union which would decrease the risk of iatrogenic lesions of the radial nerve and infection of the focus.
From the point of view of functional evaluation, the method of treatment with plate is accompanied by an excellent score according to the criteria of Stewart and Huntley because the rotator cuff is respected in the same way elbow and functional rehabilitation is possible in post immediate surgery [3,32,36,38,40,41].
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