Management for locking compression plate/ dynamic

compression plate implant failure in non union osteoporotic

humerus shaft bone fracture

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Original Article

Management for locking compression plate/dynamic compression plate implant failure in nonunion osteoporotic humerus shaft bone fracture

Mohammed Iftekar Ali

Apollo Reach Hospital, Karimnagar, India

a r t i c l e i n f o

Article history:

Received 30 October 2014

Accepted 9 April 2015

Available online xxx

Keywords:

Humerus

Nonunion

Interlocking

Nail

Osteoporosis

E-mail address: drayeshaosman@yahoo.chttp://dx.doi.org/10.1016/j.apme.2015.04.0010976-0016/Copyright © 2015, Indraprastha M

Please cite this article in press as: Ali Mfailure in non union osteoporotic hj.apme.2015.04.001

a b s t r a c t

Introduction: To introduce the experience of treating nonunion osteoporotic of humeral

fractures with interlocking nailing for failed surgical treatment by plating. Etiology for non-

union after failed surgical management of humeral shaft fractures is multi-factorial.

Following factors may play a role in nonunion e inadequate fracture fixation with poor

contact between the fracture segments, osteomalacia, osteoporosis, infection, devitaliza-

tion of bone and many more.

Materials and methods: A retrospective comparative study of twenty four patients who

had locking compression plate failure in osteoporotic humerus shaft fractures treated with

interlocking nail and iliac crest bone graft at Gandhi Hospital from 2007 to 2010.

Results: Twenty extremities had a return to nearly normal function within twelve weeks

after nailing. According to Rommens criteria excellent results seen in 79.2%, moderate

16.7%, poor 4.1%. The mean Constant-Murley score improved from pre operative 45.9 ± 17.6

to 79.1 ± 12.6 (p < 0.001) post operative.

Conclusion: Interlocking intramedullary nailing of the humerus provides immediate sta-

bility and can be accomplished with a closed technique, brief operative time, and mini-

mum morbidity, with a resultant early return of function to the extremity.

LEVEL OF EVIDENCE: iii retrospective cohort study.

Copyright © 2015, Indraprastha Medical Corporation Ltd. All rights reserved.

1. Introduction

Osteoporotic humeral nonunion resulting after operative

intervention of plate fixation presents a different set of prob-

lems like broken or loosened implants, scarred tissues, avas-

cular bone ends and sometimes deep seated infection.1,2

Loosened screws cause osteolysis at the hole sites and loss

of local bone substance. The cortex underneath the plate

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edical Corporation Ltd. A

I, Management for lockumerus shaft bone fr

becomes sclerotic and avascular. In such a complicated con-

dition replating becomes even more difficult and enough

stability may not be achieved. In addition, dissection and

periosteal damage further decreases the viability of the bone

ends and puts radial nerve at a high risk of injury. The major

technical problem the surgeon faces is the difficulty to pro-

duce secure fixation of the implant to the bone. The common

mode of failure of internal fixation in osteoporotic bone is

ll rights reserved.

ing compression plate/dynamic compression plate implantacture, Apollo Medicine (2015), http://dx.doi.org/10.1016/

Table 2 e Final results According to Rommen's criteria.

Result No. of cases %

Excellent 19 79.2

Moderate 4 16.7

Poor 1 4.1

a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) 1e42

bone failure rather than implant breakage. Rosen has defined

a delay of 3e4months inbony healing as a delayed union and a

delay of 6e8 months as a non-union.3

The high rate of complications has encouraged extensive

research into the development of implants that improve the

bone-implant interface by preventing high bone strain and

distributing the force to the bone in a load-sharing rather than

load-bearing configuration. Intramedullary nails are load

sharing and provide relative stability. They seem to be the

most efficient method of reducing strain at the bone-implant

interface. Cancellous or corticocancellous bone autografts to

assist fracture healing are probably still the best.

2. Materials & methods

A retrospective study of Twenty four cases of failure fixation

in non union osteoporotic fracture shaft humerus, were sta-

bilised with the interlocking nail and iliac crest bone

graft.1,2,4e7 Therewere 10male {41.66%) and 14 female (58.33%)

patients. All patients (Table 2) had atrophic nonunion of the

humerus except two. The right side was affected in 14 cases

[58.3%], and left 10 cases [41.7%]. The nonunion was in the

upper third of the humerus diaphysis in four cases (16.6%),

middle third in 18 cases [75%), and lower third in two cases

(8.3%). The original fracture was close in 20 cases (83.3% and

open in 4 cases (16.7%). In 4 cases (16.7%), there was history of

infection after the index surgery, however, active infection

was controlled by debridement and antibiotics. Autogenous

Iliac crest bone graft (ICBG) was performed in all cases. Our

inclusion criteria are all patient older than 50 year with failed

surgical fixation. Our exclusion criteria are fresh fracture and

young patient. All surgery were performed by single surgeon.

Average duration of surgery is one hour. All women and men

older than 50 years with low energy fracture were subjected to

BMD testing. The gold standard method is DEXA scan {dual

energy X-ray absorptiometry}.In our study hip, spine, forearm

were evaluated. In our study average mean T-score is �2.5,

serum vitaminD3 level is <50 nmol/L (<20 ng/mL) at 1st sur-

gery (Table 3).

2.1. Operative procedure: interlocking nail

The previous operative scar was used to approach the fracture

site. Implant removal is done. Debridement of non union site

is done followed by trimming and decortications of bone ends

were done.1,2,4 A longitudinal skin incision is made from the

most lateral point of the acromion. Using the small curved

Table 1 e Postoperative complications.

Complication No. of cases % (in comparison to all cases)

Immediate

Superficial

Infection 1 4.1

Delayed

Shoulder 4 16.6

Dysfunction

Non Union 1 4.1

Please cite this article in press as: Ali MI, Management for lockfailure in non union osteoporotic humerus shaft bone frj.apme.2015.04.001

awl, the entry portal is established, Interloking nail is inserted,

proximal and distal lockingwas done. Anterior iliac crest bone

grafts were used in all cases.

Post Operative Care.

� Antibiotics i.v for 3 days

� Universal shoulder immobiliser is given

� Suture removal on 10th day

� Assisted active ROM exercises for wrist & hand from 1st

post operative day

� Active assisted shoulder & elbow exercises started after 2

weeks

� 5 mg Zoledronic acid infusion was given two weeks after

surgery followed by yearly once for three years with

maintenance calcium citrate 500 mg once a day. It should

be given two weeks after surgery because delay dosing

would potentially increase the quantity of zoledronic acid

binding to the target area, leading to a greater anti catabolic

effect with the same dose. Second delayed administration

would allow the initial endogenous anabolic and catabolic

response to establish themselves before dose administra-

tion. Zoledronic acid administered as a 5 mg intravenous

infusion annually increases bone mineral density in the

lumbar spine and femoral neck by 6.7% and 5.1% respec-

tively and reduces the incidence of new vertebral and hip

fractures by 70% and 41%. Most common side effects are

post-dose fever, flu-like symptoms, myalgia, arthralgia,

and headache which usually occur in the first 3 days after

infusion and are self-limited. Rare adverse effects include

renal dysfunction, hypocalcemia, atrial fibrillation, and

osteonecrosis of the jaw.

3. Results

There were 24 cases with mean age of 63.29 years.

The mean time of radiological bone healing was 4.2

months (range three to seven months). Sound bone healing

was achieved in all cases except one (4.1%). Result of case1

was shown in Fig. 1a, b, c.The number of cases available for

follow up is twenty four and duration of follow up is eighteen

months. According to the to Rommen's Criteria, the functional

outcome was excellent in 19cases (79.2%), moderate in four

cases (16.7%), poor in one case [4.1%] which was treated by

Ilizarov ring fixator. Therewere no cases of iatrogenic nerve or

vascular injury due to surgery. There was good relief of pain

within two weeks after nailing procedures and excellent relief

after five weeks. All patients had improvement in the func-

tional use of the extremity after fixation. No patient noted any

limitation of motion of the elbow. The range of motion of the

shoulder was documented numerically for eleven patients,

who had a mean of 101� (range, 55e180�) of abduction and 98�

ing compression plate/dynamic compression plate implantacture, Apollo Medicine (2015), http://dx.doi.org/10.1016/

Table 3 e Criteria for assessment of results.

Rommen et al criteria

� Excellent

e Good clinical & radiological union

e Less than 10% loss of range of motion

e No significant subjective complaints

� Moderate

e Good clinical & radiological union

e 10e30% loss of range of motion

e Minimum subjective symptoms

� Poor

e No signs of clinical & radiological union

e Greater than 30% loss of range of motion

_ Moderate subjective symptoms

a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) 1e4 3

(range, 45e170�) of forward flexion. Nine other patients had a

full range of motion of the shoulder, four patients had

shoulder dysfunction. Complications were infrequent. Post

operative complications are shown in Table 1. There was one

superficial infections, treated by regular dressings. Two pa-

tients had removal of a proximal locking screw because of

local tenderness. The mean duration of follow-up for the

twenty four patients was ten months (range, nine to fifteen

months). The mean Constant-Murley score improved from

pre operative 45.9 ± 17.6 to 79.1 ± 12.6 (p < 0.001) post

operatively.

The results are shown in Table 2.

4. Discussion

Osteoporotic humeral nonunions are notoriously difficult to

treat.6 The clinical situation can be complicated by previous

surgical attempts and comorbidities such as obesity and

osteopenia. Rate of nonunion ranges from 0 to 8 % with

nonoperative treatment and 0e13% with operative treat-

ment.8 The goal of treatment of any nonunion is restoration of

Fig. 1 e a: Case No. 1a:6 months old non union fracture left hum

implant loosening taken in antero posterior view, b: Case No. 1b

operative X-ray left humerus taken in antero posterior view with

X-ray of left humerus 8 months taken in antero posterior view.

Please cite this article in press as: Ali MI, Management for lockfailure in non union osteoporotic humerus shaft bone frj.apme.2015.04.001

function, achieving stable fixation, acceptable alignment, and

a functional range of motion.9 Nonunion is treated by various

operative procedure including plating, intramedullary nailing,

external fixation with Ilizarov device.1,5,6

Nonunion after plate fixation may be associated with

extensive fibrosis, enlarged screw holes, sclerotic avascular

bone ends.1,4,7,10e15 In plate osteo-synthesis of long bones, the

stability of the fracture depends on friction between the

cortical bone surface and the plate, generated by the hold of

the screws. The stress in the implantebone construct in

fragile bones is high, and the holding power of the screws is

low and cut-out with subsequent implant loosening is likely.5

Because of the decreased holding power of plate-and-screw

fixation in osteoporotic bone fractures, internal fixation can

have a high failure rate, ranging from 10% to 25%.The inci-

dence of nerve injury in plate fixation is 0e5.6% (9), and there

is a risk of refracture both because of the potential for failure

and because of stress concentration at the extremity of the

plate.1 Another disadvantage is that it requires exposure,

which is associated with increased rates of infection and

nonunion.1

Circular external fixators have advantages such as not

requiring a postoperative plaster cast immobilization, but

they have disadvantages as well, such as difficulty of appli-

cation, the technical difficulty, the possibility of injury to

blood vessels and nerves, restricted movement, pin-tract in-

fections, and septic arthritis.16,17

Treatment with intramedullary nailing has advantages

such as requiring less soft tissue dissection, a small area of

exposure, a low rate of infection, relative ease of use, and a

low rate of radial nerve paralysis. Intramedullary fixation of-

fers an advantage compared with plate fixation in that the

implant is load-sharing rather than load bearing.1,5,8,18e23

However, it also has disadvantages, such as inapplicability

in cases where the distal fragment is short, or where there is

rotational instability, or lack of compression. Traditional non

erus, treated with locking compression plate humerus with

: In continuation with figure no. 1a Immediate second post

autogenous iliae crest bone graft, c: Case No. 1c: Follow up

X-ray showing good union of fracture.

ing compression plate/dynamic compression plate implantacture, Apollo Medicine (2015), http://dx.doi.org/10.1016/

a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) 1e44

reamed nails, such as Ender and Rush nails, and reamed

Kuntscher nails do not achieve sufficient stability, particularly

in rotation. Stability, rotational stability in particular, can be

achieved with locked intramedullary nails if the distal and

proximal screws are correctly inserted.24,25 Gupta et al ob-

tained good rotational stability with intramedullary nails,

with a functional improvement rate of 89%.26 Successful

outcome rates of 87.5e100% have been reported in non unions

treated with locked intramedullary nails.1,13 In our patients,

nails appropriate to the width of the medulla were locked at

the distal and proximal ends; rotational stability was achieved

in all patients, and complete consolidation in 96%.It is claimed

in the literature that compression is not achievedwhen locked

intramedullary nails are used in nonunions or primary frac-

tures, and hence that treatment may be unsuccessful.1

Nonetheless, 100% successful results have been reported

with the achievement of rotational stability.26 The rate of

nonunions caused by lack of compression may be reduced by

achieving sufficient contact between fracture fragments intra

operatively.

In conclusion, intramedullary nailing and autogenous bone

grafting increases the union rate provided that a nail with a

diameter appropriate to the width of the medulla is used and

that distal and proximal locking are performed correctly. In

addition, that the low infection rate, low risk of radial nerve

injury, and the need for only limited surgical exposure make

this a suitable choice in the treatment of nonunions.

Conflict of interest statement

The author has none to declare.

Ethical statement

The ethical statement as (1) the patients gave the informed

consent prior being included into the study; (2) the study was

authorized by the local ethical committee and was performed

in accordance with the Ethical standards of the 1964 Decla-

ration of Helsinki as revised in 2000.

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ing compression plate/dynamic compression plate implantacture, Apollo Medicine (2015), http://dx.doi.org/10.1016/

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