Objective: The purpose of this study was to evaluate the results of open reduction and internal fixation of nonunions of the surgical neck of the humerus.
Design: Retrospective review of patients who underwent operative treatment of a surgical neck of the humerus nonunion.
Setting: Shoulder and elbow service at two university centers.
Patients: Thirteen patients with a two-part nonunion of the surgical neck of the humerus who were treated with open reduction and internal fixation with bone graft with a minimum of 12 months' follow-up were included. Patients with avascular necrosis, posttraumatic arthritis, severe humeral head bone loss, or a nonunion of one of the two tuberosities were excluded.
Intervention: Open reduction and internal fixation with either a blade plate or a T-plate and autogenous bone graft.
Main Outcome Measures: Medical records, operative reports, physical examination, and preoperative and postoperative radiographs were reviewed. Outcome was assessed using Neer's criteria for the evaluation of total shoulder arthroplasty, visual analogue pain scale, range of motion, and ability to perform activities of daily living.
Results: The results were excellent in 11 patients, satisfactory in 1 patient, and poor in 1 patient. The 11 nonunions in patients with excellent results healed within 6 months. The patient with the poor result initially had a persistent nonunion and required revision, open reduction and internal fixation, and bone grafting. This patient healed and went on to have an excellent result at final follow-up. All fractures were healed at the time of this study. Pain scores decreased from an average of 4.2 preoperatively to 1.2 postoperatively on a 5-point pain scale. Forward elevation in the scapular plane improved from 24° preoperatively to 144° postoperatively. All patients but one were able to attain overhead elevation. All patients were able to perform activities of daily living, such as dressing, bathing, combing hair, and performing perineal care, at final follow-up. Overall satisfaction increased from an average of 1.0 to 9.4 on a 10-point visual analogue scale.
Conclusions: Open reduction and internal fixation with autogenous bone graft results in excellent outcomes even in patients >65 years old and patients with significant medical problems. This treatment method offers predictable fracture healing and has a low complication rate.
Established nonunions of the surgical neck following proximal humerus fractures pose a significant disability to the patient and a treatment challenge to the physician. Surgical neck nonunions often require surgical treatment, with the exception of the most medically ill or debilitated patients. 1 Reconstructive procedures are technically difficult. The results vary widely, 1–12 and reports often contain several different methods of fixation, including hemiarthroplasty, with only a few patients in each treatment group. Although this literature gives an overall picture of the results of operative treatment of proximal humerus nonunions, retrospective studies containing multiple treatment methods are confusing and may fail to identify procedures with better results and factors influencing the outcome.
Many approaches to the treatment of proximal humerus nonunions have been described, including intramedullary rods, rods with tension bands, open reduction and internal fixation (ORIF), prosthetic replacement, and use of intramedullary cortical bone grafts. 4–8,10–13 In most situations, prosthetic replacement is reserved for older, sicker patients, introducing a significant selection bias when included in many reports. 4,5,8,13 The use of intramedullary nails may cause mechanical impingement, necessitating a second procedure for hardware removal. 8 The effect of these factors on the outcome is difficult to determine. The purpose of this study is to evaluate the clinical and radiographic results of osteosynthesis using either a blade plate or a T-plate with bone grafting.
From the *Department of Orthopaedic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri; †Penn Orthopaedic Institute, Philadelphia, Pennsylvania; ‡Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania; §Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH.
Accepted for publication September 17, 2003.
No funds were received in support of this study.
The devices described in this article are FDA approved.
Reprints: Leesa M. Galatz, MD, Department of Orthopaedic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, One Barnes–Jewish Hospital Plaza, #11300WP, St. Louis, MO 63110 (e-mail: firstname.lastname@example.org).