Role of Locked Compression Plate in Osteoporotic Humeral Shaft Nonunions: A Clinical Study

Vol 32 | Issue 2 | July – Sep 2017 | page:24-27 | Javed Jameel, Sandeep Kumar, Rizwan Khan, Shishir Rastogi.


Authors: Javed Jameel [1], Sandeep Kumar [1], Rizwan Khan [1], Shishir Rastogi [1].

[1] Department of Orthopaedics, Hamdard Institute of Medical Science and Research, Jamia Hamdard, New Delhi, India.

Address of Correspondence

Javed Jameel,
Hamdard Institute of Medical Science and Research, Jamia Hamdard,
New Delhi, India.
E-mail: drrizwan85@gmail.com


Abstract

Background: Osteoporotic humeral shaft nonunion is a challenge to modern implant design because of inadequate screw purchase in the bone. Locked compression plating (LCP) is the answer to this difficult condition. In this prospective study, we have tried to evaluate the role of LCP in management of osteoporotic humeral shaft nonunion in patients above 18 years of age.
Materials and Methods: We treated 14 such cases with mean age of 48 years. Open reduction and fixation with LCP along with cancellous bone grafting were done, and the cases were evaluated clinically and radiologically till union.
Results: All the fracture went on to the satisfactory union after an average of 21 weeks (14-32 weeks). Two patients had delayed union and required bone marrow injections. All the patients after union were able to perform their pre-injury work. Pain and limitation of motion improved remarkably.
Conclusion: LCP is a very effective procedure to achieve union in osteoporotic humeral shaft fractures in adult patients. We propose fixation with LCP as it provides additional stability at fracture site, led to high rate of union, with few complications.
Keywords: Osteoporosis, humeral shaft nonunion, locked compression plating.


Introduction:

Humeral shaft fractures result from direct and indirect violence. Common mechanisms for humeral shaft fractures include fall on the outstretched hand, motor vehicle accidents, and direct load to the arm. Most of these fractures heal by conservative means or by surgical intervention. Few fractures fail to unite by 6 months time and they are labeled as nonunion. Humerus shaft nonunion is invariably associated with osteoporosis which further complicates the fracture. The major technical problem faced by the surgeon is the difficulty in obtaining secure fixation of an implant to osteoporotic bone. There is less cortical and cancellous bone for the screw threads to gain purchase so that the pullout strength of the implant is significantly reduced. Bone mineral density correlates linearly with the holding power of screws.1 The load transmitted at the bone implant interface can often exceed the reduced strain tolerance of osteoporotic bone. This may result in microfracture, resorption of the bone, and loosening of the implant, with secondary failure of fixation Although several surgical methods for the management of humeral shaft nonunion have been examined in the literature such as compression plating with bone grafting2 intramedullary nailing3 Illizarov fixator4,non-vascularised intramedullary fibular graft5 but no single technique has proved its superiority over the other. Very few studies have been published about the use of locking compression plate (LCP) in the management of a nonunion of humeral fractures6,7,8 We conducted a prospective study at our institution to evaluate the clinical and radiographical results of locked compression plate in the treatment of osteoporotic humeral shaft nonunion.

Materials and method
This prospective study was conducted at Jawaharlal Nehru medical College, AMU Aligarh from January 2006-July 2008. The tool for data collection was a predesigned data sheet to collect information on the cases. The questionnaire contained information on age, sex, residence, side involved, co-morbid conditions, mechanism of injury, fracture location, initial treatment of the fracture, time from injury to definitive treatment, definitive treatment, time taken to unite, function and complications. In this study, nonunion was defined as absence of radiographic signs of union and persistent pain on clinical examination six months after injury.

Inclusion criteria
(a) patients more than 18 years of age
(b) patients with osteoporotic humerus shaft non-union
Exclusion criteria
(a) patients less than 18 years of age
(b) patients with fresh fracture of humerus shaft
(c) patients with infected/pathological humeral shaft fractures

Surgical technique
Treatment consisted of a standard Henry’s anterolateral approach for proximal and middle third humeral fractures while posterior triceps splitting approach for lower third fractures. The radial nerve to be identified and protected for the duration of the procedure. Removal of any preexisting implant followed by freshening of bone ends, reaming of medullary canal, reduction followed by stabilization of fracture by 4.5/5mm locking compression plate and autogenous cancellous bone grafting. A minimum of eight cortices of fixation above and below the fracture site were obtained in most fractures. Postoperatively, anteroposterior and lateral radiographs were done to assess alignment, loosening of devices, and later presence of bridging callus across the nonunion site. Patients were placed in an arm sling primarily for comfort for two weeks. Gentle pendulum and active assisted shoulder and elbow range of motion were started at 2 weeks post surgery followed by strengthening and passive range of motion exercises. Patients were reviewed at 2, 6, 12 and 16 weeks. The primary outcomes measured were time to union, function and complications. Union was determined by radiographic evidence of cortical bone bridging at the nonunion site, stable hardware position on radiographs, as well as absence of pain with manual palpation of the nonunion site. Function was assessed using the Disability of the Arm, Shoulder and Hand (DASH) Score for 30 activities of daily living requiring full shoulder and elbow movement. Score range from 0 (no disability) to 100.

Results
We performed open reduction and internal fixation with locking compression plate and iliac crest bone grafting in osteoporotic humeral shaft nonunions in 14 consecutive patients with mean age of 48 years (range 20–60 years, (Table 1).
There were 10 males and 4 females with an equal number of right and left arm affected (7 each). Mean age was 48 years (range 24-65 years). Delay in presentation ranged from 24 to 76 weeks (mean 35 weeks). The mechanism of injury was road-traffic accident in 7 patients, slipping onto ground in 6 and fall from height in one patient. All patients were in good health before the fracture and were doing their routine work. Fracture types included 10 transverse, three short oblique, and one long oblique. None of the fractures was comminuted. All of the fractures were close. There were six proximal third, three middle-third, and five extra-articular distal-third humeral fractures. All the patients had osteoporosis as assessed by cortical index9 (Cortical index is the combined medial and lateral cortical thickness divided by the total width of the bone at that level). No preop complication like radial nerve palsy was reported prior to management in any of the patients. None of the patients had undergone previous surgery. Nine patients had taken local treatment from quacks, five patients were treated in plaster splints for inadequate period. Preoperatively all the patients complained of limitation of shoulder and elbow motion and were unable to use the affected limb properly. Average preop DASH score was 89 (range 65-95). All the patients were followed for an average 12 months (range 6-18 months). There were two cases of superficial skin infection which healed with a course of antibiotics. There was no radial nerve palsy and hardware loosening. Twelve patients showed evidence of complete healing as defined by radiographic evidence of at least three out of four bridging cortices within 24 weeks of the procedure (range 14-32 weeks)(Figure 1 to 3).Two patients required additional bone marrow injections for delayed union with stable hardware position. Postop mean range of movement was 1290 (range 1000-1500). At final follow-up, the average DASH score was 24 (range 10-30).

Discussion 

Nonunion shaft of humerus was managed successfully by several authors using dynamic compression plates2 however osteoporotic humerus shaft nonunion is difficult to manage because of presence of inadequate purchase of implant. Various methods have been employed to achieve union including double plating10,Plating with nonvascularised intramedullary fibula5 but double plating entail extensive periosteal stripping of humerus and nonvascularised fibula has low healing rate. Intramedullary rush pin with plating11 and structural allograft with BMP-7 and mesenchymal stem cells12 was advocated by few authors. Intramedullary implants has high complication rate including rotator cuff injury and shoulder stiffness. Illizarov external fixators4 has been used by several authors in management of humerus nonunion specially in presence of infection, but they are associated with numerous complications like pin tract infection, risk of neurovascular impalement by wires. Additionally the assembly is quite bulky and has high discomfort rate for the patient. Ring et al used LCP in 24 patients with osteoporotic humerus shaft nonunion and achieved successful union in all the cases6 The average duration of nonunion of 9 months in our series (range: 6-19 months) was comparable to that of Ring et al. who had reported an average duration of 28 months (5‑192 months).The mean age of our patients was 48 years in comparison with the mean age of 72 years in the study by Ring et al. Laboratory studies have also shown that locking plate constructs were superior to unlocked plate and screw constructs in osteoporotic diaphyseal humeral fracture models tested in vitro using cyclical torsional loading13. Within the present series, fourteen patients of humeral shaft nonunion with osteoporosis underwent successful salvage with a standard protocol that included fixation with a Locking compression plate, application of autogeneous bone graft, and optimization of associated patient co-morbidities in the perioperative period. All fourteen patients achieved clinical and radiographic union with good functional result.. The strength of our study is that it was a prospective study that allowed comparison between the functional status in the preoperative and postoperative periods. The drawbacks of the present study are the absence of a control group for comparison with the treatment group.

Clinical relevance
Locked compression plating is a very effective procedure to achieve union in osteoporotic humeral nonunion in adult patients. We propose fixation with locked compression plate and autologous bone grafting as it provides additional stability at fracture site, led to predictable high rate of union, and with fewer complications.


References

1. Thiele OC,Eckhardt C,Linke B,Schneider E, Lill CA. Factors affecting the stability of screws in human cortical osteoporotic bone a cadaver study. The Bone & Joint Journal 2007;89(5):701-5
2. Kumar A, Sadiq SA. Non-union of the humeral shaft treated by internal fixation. Int Orthop 2002;26:214–6.
3. Kui LX Giang WH Yong WY, Xiang WZ. Treatment of nonunions of humeral fractures with interlocking intramedullary nailing. Chinese Journal of Traumatology 2008; 11(6):335-340.
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5. Vidyadhara S, Vamsi K, Rao SK, Gnanadoss JJ, Pandian S. Use of intramedullary fibular strut graft: A novel adjunct to plating in the treatment of osteoporotic humeral shaft nonunion. Int Orthop 2009;33:1009‑14.
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9. Bloom RA, Laws JW Humeral cortical thickness as an index of osteoporosis in women, Br. J. Radiol 1970, 43, 522-527
10. Martinez AA, Cuenca J, Herrera A. Two-plate fixation for humeral shaft nonunions Journal of Orthopaedic Surgery 2009;17(2):135-8
11. Sitati FC, Kingori J. Outcome of Management of Humerus Diaphysis Non-union East Cent. Afr. j. surg 2009;14(2): 13-17
12. Murena L, Canton G, Vulcano E, Surace MF, Cherubino P. Treatment of Humeral Shaft Aseptic Nonunions in Elderly Patients With Opposite Structural Allograft, BMP-7, and Mesenchymal Stem Cells. Orthopedics 2014;37(2):201-6
13. Gardner MJ, Griffith MH, Demetrakopoulos D, Brophy RH, Grose A, Helfet DL, et al. Hybrid locked plating of osteoporotic fractures of the humerus. J Bone Joint Surg Am 2006;88:1962‑7.


How to Cite this Article: Jameel J, Kumar S, Khan R, Rastogi S. Role of Locked Compression Plate in Osteoporotic Humeral Shaft Nonunions: A Clinical Study. Journal of Bone and Joint Diseases Jul-Sep 2017;32(2):24-27.

 

 


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