55-year-old woman with persistent nonunion in an upper extremity
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A 55-year-old woman initially sustained a closed, right distal third humeral shaft fracture in 2005 after a motor vehicle crash and underwent open reduction and internal fixation while she was living in the Dominican Republic.
She subsequently did well for a number of years with minimal complaints. In 2016, she sustained a foot fracture that required her to remain non-weight-bearing and use crutches for an extended period of time. During this period, she developed worsening right arm pain. X-rays of her humerus were obtained, demonstrating hardware failure and a nonunion of her previous fracture site (Figure 1). She presented to our orthopedic team in late 2017 for further management of her nonunion.
Source: Erick Heiman, DO
A thorough workup for infectious and metabolic etiology was done, which was normal aside from a slightly elevated C-reactive protein of 1.4 and an erythrocyte sedimentation rate (ESR) of 43. After weighing the risks, benefits and alternatives, the patient elected to proceed with surgical management of her nonunion. In November 2017, she underwent removal of hardware, intraoperative biopsy of her nonunion site to rule out infectious etiology and iliac crest bone marrow aspirate with revision open reduction and internal fixation (ORIF). All biopsy cultures were negative. Postoperatively, she did well until approximately 1 year later when she started developing worsening elbow pain. X-rays demonstrated incomplete union of her fracture, which was further confirmed with CT scan (Figure 2).
Further workup at that time revealed elevated inflammatory markers, with a CRP of 14.7 and ESR of 51. In April 2019, she underwent removal of hardware and saucerization of her humerus with insertion of antibiotic-coated plate (Figure 3). Her intraoperative cultures, again, did not grow any organisms; however, due to clinical concerns, infectious disease was consulted, and she was treated for presumed infectious nonunion with 6 weeks of IV vancomycin and cefepime.
In January 2020, she underwent removal of the antibiotic-coated plate and revision ORIF with dual plating and iliac crest bone marrow aspirate without any acute complications. Approximately 1 year later, the patient again presented with continued pain. Imaging at this time revealed broken hardware and evidence of nonunion (Figure 4).
What are the best next steps in management of this patient?
See answer below.
Advanced imaging, scans for infection and revision ORIF of humerus nonunion
Advanced imaging was obtained and a CT scan confirmed a persistent nonunion (Figure 5).
Given the patient's history of a previous infection, a tagged white blood cell scan and inflammatory markers were obtained, which showed no evidence of infection or osteomyelitis. After an extensive conversation discussing risks, benefits and alternatives, the patient elected to undergo revision surgery.
Surgical procedure
The patient was indicated for a revision ORIF of her right humerus nonunion, biopsy, bone marrow aspirate and free fibula autograft. The plastic surgery team was consulted regarding the harvesting of the free fibula graft and anastomosis.
The patient was initially positioned supine on a radiolucent table. Prior to final positioning, bone marrow aspirate from the right ilium was obtained under fluoroscopic guidance. The patient was then placed in the left lateral decubitus position with a beanbag, utilizing a radiolucent total knee positioner to support the arm. Both the right arm and right leg were prepped into the sterile field.
The previous posterior approach to the arm was reopened with excision of the superficial scar. The ulnar nerve was identified and found to be subluxated from the groove. Careful dissection and neurolysis was performed and the nerve was mobilized and protected down to the first motor branch to the flexor carpi ulnaris. Attention was turned to the radial nerve, which was identified two finger-breadths proximal to the confluence of the triceps and carefully dissected out. Neurolysis was also performed after identification of a previously placed nerve wrap. Once both nerves were sufficiently mobilized and protected, attention was turned to the humerus nonunion. A paratricipital (triceps sparing) deep interval was used to access the humerus. The previous failed hardware was removed. All fibrous tissue was debrided from the nonunion site and sent for biopsy and culture. The atrophic bone was identified and resected to the level of punctate bleeding bone with the aid of a high speed bur. The defect was measured to be 9 cm.
The plastic surgery team simultaneously dissected out the right fibula. A 13-cm vascularized free fibular graft was harvested to allow adequate coverage of the bone defect with additional overlap in the distal and proximal segments of humerus. Flexible reamers were used to reconstitute the intramedullary canal in the proximal and distal humeral shaft segments and allow for placement of the fibula autograft within the canal. The graft was then positioned, and a posterolateral J-plate and a medially based 3.5-mm custom-contoured reconstruction plate were used to stabilize the proximal and distal aspect of the native humerus that contained the fibula autograft. Once the graft was stabilized, the end-to-side anastomosis to the brachial artery was performed. Triphasic audible flow was confirmed throughout the flap and pedicle. The wound was then copiously irrigated and a bone graft composite that contained demineralized bone matrix, a platelet-rich fibrin gel, bone marrow aspirate and vancomycin powder was placed in and around the areas of desired fusion. A hemovac drain was placed and the wound was closed primarily. The patient was placed in a soft dressing and made non-weight-bearing after surgery (Figure 6).
Discussion
A nonunion is defined by the FDA as an unhealed fracture that is at least 9 months out from occurrence without progression of healing in the past 3 months. Nonunions are characterized by the appearance of callus in one of the following three ways: hypertrophic, oligotrophic or atrophic. When evaluating a nonunion, it is important to look at the patient as a whole and assess host factors, fixation strategies and the potential for infection. The etiology of the nonunion can be one or a combination of the following four factors: motion (too little or too much), avascularity, gap or infection. Determining the cause or combination of causes that are contributing to the nonunion is essential for developing a successful surgical plan when performing revision ORIF.
In this case, after addressing any infectious etiology, the patient was found to have an atrophic nonunion, which was likely caused by a lack of biology at the fracture site secondary to multiple surgeries. Appropriate management of the nonunion required excision of avascular bone, leaving the patient with a large bone defect and challenging problem to address. There are several options in the upper extremity to address segmental bone defects. Modern techniques include bone transport, induced membrane technique (Masquelet technique) and structural autograft.
Bone transport was typically used after osteomyelitis and done using an external fixator system. This method showed the highest complication rate of all techniques, although most (61%) were superficial pin site infections. The induced membrane technique was the most common technique applied using plate stabilization and was primarily used after osteomyelitis. The number of surgeries needed to obtain union was higher than with the other modalities (2.6). Structural autograft included a majority of vascularized free fibula grafts, as well as non-vascularized fibula grafts. This modality demonstrated the shortest time to union with the fewest number of surgeries to obtain union.
Vascularized free fibula graft is a viable option for bone defects in the upper extremity in both infected and non-infected cases. While harvesting an autograft has the added morbidity of an additional surgical site, it has the potential benefit of the revision nonunion treatment being able to be performed in a single operation. A study of 16 patients with an average defect size of 8 cm and 85-month follow-up showed that 15 patients of the 16 patients achieved union at an average of 3.5 months. Donor site morbidity is a consideration as one prospective study showed a short-term donor-site complication rate of 31.2%, in which most of the complications were due to skin graft failure or wound complications. Long-term morbidity was observed in 17% with most complications being limited ankle motion and weakness. However, 96% of patients returned to their preoperative ambulatory status.
Large bone defects secondary to nonunions are complicated problems to address. These require thorough preoperative evaluation and a carefully executed surgical plan to achieve the best outcome and, ultimately, bony union and a functional upper extremity.
At the most recent 4-month follow-up visit, our patient was satisfied with her outcome and demonstrated both clinical and radiographic evidence of union (Figure 7). She was completely nontender on exam and has nearly full painless range of motion that lacks about 10° extension with full pronation and supination.
Key points
- When undergoing a revision ORIF for a nonunion, identification of the etiology of the nonunion is essential to developing a successful surgical plan that addresses the issue.
- Utilization of a free fibular graft in the setting of nonunion can provide the necessary vasculature to address atrophic nonunions due to avascularity.
- Using a free fibula as a structural autograft can be a successful way to address segmental bone defects in the upper extremity.
- References:
- Browner BD, editor. Skeletal Trauma: Fractures, Dislocations, Ligamentous Injuries. Philadelphia: W. B. Saunders; 1992.
- Ferreira N, et al. Eur J Orthop Surg Traumatol. 2021;doi:10.1007/s00590-021-02887-4.
- Momoh AO, et al. Plast Reconstr Surg. 2011;doi:10.1097/PRS.0b013e318221dc2a.
- Noaman HH. Ann Plast Surg. 2013;doi:10.1097/SAP.0b013e3182a1aff0.
- Seigerman DA, et al. J Orthop Trauma. 2012;doi:10.1097/BOT.0b013e31821d0200.
- Thomas JD, Kehoe JL. Bone Nonunion. [Updated 2022 May 8]. In: StatPearls [Internet]. Treasure Island, Florida: StatPearls Publishing; 2022 Jan.
- For more information:
- Andrea Attenasio, DO; Erick Heiman, DO; Jibran A. Khan, DO; and Frank A. Liporace, MD, can be reached at the division of orthopaedic trauma & adult reconstruction, department of orthopaedic surgery, Jersey City Medical Center in Jersey City, New Jersey. Attenasio’s email: andrea.attenasio@gmail.com. Heiman’s email: heiman.erick@gmail.com. Khan’s email: jibranakhando@gmail.com. Liporace’s email: liporace33@gmail.com.
- Edited by Mark E. Cinque, MD, MS, and Filippo F. Romanelli, DO, MBA. Cinque is a chief resident in the department of orthopedic surgery at Stanford. He will pursue a fellowship in sports medicine at The Steadman Clinic/Steadman Philippon Research Institute following residency completion. His interest is in complex knee surgery and multiligament reconstruction. Romanelli is a chief orthopedic resident at Rutgers – Jersey City Medical Center with an interest in adult reconstruction. He will be at New York University for his fellowship. For information on submitting Orthopedics Today Grand Rounds cases, please email: orthopedics@healio.com.
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