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1、Humeral NonunionsPeter M Bonutti, MD, FACS Assistant Clinical Professor, University of Arkansas Bonutti Research Effingham, IllinoisFirst, I would like to talk a little bit about proximal humeral nonunions and how to treat them, sometimes nonsurgically and other times surgically. Then we will work d
2、own toward the humeral shaft. We will avoid the distal humerus because that will fall into a different scope.There are problems with proximal humeral nonunions. There are certain patients that are significantly at risk, including the noncompliant patients and psychiatric patients. There are signific
3、ant medical problems. Patients with diabetes or patients who smoke, always check on them. If there is a significant amount of comminution or if there is soft tissue interposition, we want to watch out. If you get patients like this coming into your practice, Nonoperative treatment is a possibility i
4、n certain patients, especially older patients. Looking at their age, pain, activity level, and if they have the mental status. If they have problems with Alzheimers or low-demand patients, nonoperative treatment is a viable option. Think about that.Surgical treatment, basically the gold standard, is
5、 open reduction internal fixation with either some type of tension band or figure of eight wire, plus an intramedullary (IM) nail indicated for displaced tuberosities. There is a reasonable union result more than 90% can work well. Sometimes metallic cables can be used. I use Mersilene tape now, and
6、 progress to that. It had good fixation.However, the function can be variable in these nonunion patients. In these patients, if you do a tension band type technique, then be aware that it does not release the intra-articular contracture. So be aware of that because they do end up very stiff.Plate fi
7、xation can also be considered. There are several plates including, blade plates, compression plates, and condylar plates. Unfortunately, they have poor purchase on the proximal humeral head, especially in older patients who are osteoporotic. There is significant bulk with these devices, so you will
8、lose range of motion just from the bulk of the devices with impingement. Again, there is no capsular release. If they are stiff preoperatively, it will stay stiff postoperatively but will decrease.IM nails for proximal nonunions have been considered, but there are not a whole lot of data. A number o
9、f devices are available with their interlocks. Again, the proximal interlocks are fairly weak. A number of devices, and there is no significant data for treatment for proximal nonunions.There are data for proximal humeral fractures. Published, good results, such as Ray in the Journal of Shoulder and
10、 Elbow Surgery. If you look at these published results, there is asignificant amount of nail impingement and hardware migration as these fractures heal. They almost all require secondary surgical procedures. So IM nails, especially in antegrade approach, may have some difficulty in nonunions.Hemiart
11、hroplasty can be considered, but there are a number of patients in a couple of studies that show fairly poor results. Flatow showed 45% of his patients were unsatisfied, and Norris found 95% pain relief, which is fairly good, but only 53% of patients were able to obtain overhead activity. You need t
12、o be aware of that.Also, we have these surgical problems when these things show up in your office cemented and wired together. These are real disasters. You want to avoid that.In a recent paper on hemiarthroplasty, Bouileus looked for proximal humeral problems, 71 patients with either avascular necr
13、osis, nonunion, or malunion. Good to excellent was only 42%. Fifty-eight percent of them had poor results, and there was a 27% complication rate. In these challenging patients, be aware that these can be very difficult. There was a big problem if you had a greater tuberosity osteotomy. If you had to
14、 osteotomize the greater tuberosity, then the results are markedly worse.My personal approach, the gold standard in these treatments, is usually a figure of eight plus some type of IM device. The indications are displaced tuberosity, plus neck nonunion. We are going to have reasonable pain relief an
15、d union. In my practice, more than 90% reasonable elevation but it is limited because you do not perform any intraoperative capsular release. We try to stretch them and gain motion preoperatively, but caution the patients postoperatively.IM nails, basically the indications are very limited for nonun
16、ions. You have to have a nonunion with intact tuberosities, which is fairly uncommon. You can use them, they do work. It is a simpler technique, and I think it does have results, however, cup impingement is a real problem and high incidence of secondary surgery, basically 100% in my series.Hemiathroplasty can be used. We talked previously about problems such as displaced tuberosities, avascular necrosis, etc. They do work fairly well. The thing I like about t
