S33

Injury, Int. J. Care Injured 48S2 (2017) S33–S43

Volume 48 Issue 6 June 2017 ISSN 0020-1383

Contents lists available at ScienceDirect

Injury
j o u r n a l h o m e p a g e : w w w. e l s e v i e r . c o m / l o c a t e / i n j u r y

Recalcitrant aseptic atrophic non-union of the shaft of the humerus after failure
of surgical treatment: management by excision of non-union, bone grafting and
stabilization by LCP in different modes
Sudhir Babhulkara,*, Sushrut Babhulkara, Aditya Vasudeva
a
Department of Orthopedics, Sushrut Institute of Medical Sciences, Nagpur, India

K E Y W O R D S A B S T R A C T

Non-union humerus shaft Non-union of the humeral shaft is infrequently noticed after surgical fixation. Sixty eight patients whose
Bone grafting osteosynthesis of humeral shaft had failed leading to non-union were identified over a duration of 10 years
Locked compression plating from (January 2006 to December 2015). Clinical and radiographical follow-up was available for 64 patients
Corticocancellous graft
(4 patients were lost for follow-up), with a mean age of 58 years (range 25–78 years). All patients had aseptic
Fibular graft
Bridge plating
atrophic non-union of either: proximal shaft (n=12), mid shaft (n=38), and lower shaft (n=14). All these
patients had failure of primary fixation, with a minimum duration from 36 to 110 weeks. Non-unions were
operated by excision of non-union, autogenous bone grafting and osteosynthesis by locking compression
plating. Adequate fixation of non-union with bone grafting was achieved in all patients. All non-unions
healed well at an average of 16 weeks (range 6-36 weeks). The mean length of follow-up was 120 weeks
(range 60-250 weeks). The mean range of movements following healing of non-union was forward flexion of
140°, external rotation and internal rotation of 30° at shoulder and average fixed flexion deformity of 10° and
flexion of 130° at elbow. Two patients had postoperative radial nerve palsy because of neuropraxia, which
recovered in eight weeks. Three patient developed superficial infections at the iliac crest, which settled with
antibiotics, dressings in 3 weeks time and two patients had some discomfort over the fibular graft harvest
site. In all patients complete clinical and radiological union was achieved with satisfactory outcome in terms
of relief of symptoms and functional improvement in the range of movements. The main points in surgical
treatment were complete excision of non-union, correction of deformity, use of plenty of corticocancellous
graft, furthermore the use of intramedullary fibula and osteosynthesis by long locking compression plating
in different modes of fixation provided good to excellent results and clinical outcome.
© 2017 Elsevier Ltd. All rights reserved.

Introduction inadequate response to healing resulting in non-union. Normally a

certain amount of time is required before fracture healing is expected
Conservative treatment of fractures of the humeral shaft typically to occur. This normal time may vary according to the age, bone
results in a high union rate and an excellent functional result [1–5]. involved, level of fracture, amount of comminution and associated
Reported non-union rates after surgical fixation of fracture can be as soft tissue injury. Non-union is the end result of a delayed union and
high as 8–13% in large series [1,3,4,6]. Commonly the non-union of the fracture union will not occur unless some surgical intervention
the shaft of the humerus is seen in the midshaft. However, obtaining is performed. Sometimes differentiation between delayed union and
fixation of proximal fractures and lower third fractures can be non-union is difficult. Reasons for non-union may be multifold such
difficult due to a short proximal and distal segment (metaphseo- as inadequate reduction and poor fixation, fixation with distraction,
diaphyseal fractures) that prohibits bicortical fixation, and poor loss of blood supply, along with co-morbid condition like Diabetes,
purchase of screws in the metaphyseal bone. An epidemiological malnutrition and immuno-compromised states. Risk factors include
study of diaphyseal humerus fractures reported that 64% involved comminution, high-energy fractures, and technical shortcomings
the midshaft, with only 25% proximal and 11% distal fractures [7]. of surgery. Causes are usually multifactorial [8,9]. Non-union of
In spite of newer methods of fracture fixation cases of non-union humerus and repeated surgeries may cause considerable pain and
of humerus are still encountered. Failure of fixation results in disability because of stiffness in the neighboring joints causing
restriction of shoulder and elbow movements and may result in the
deformity and shortening of arm.
* Corresponding author. Based on the potential of healing, viability, and biomechanics,
E-mail address: sudhirbabhulkar@gmail.com (S. Babhulkar). the non-union is classified as hypertrophic non-union (viable) and

0020-1383/© 2017 Elsevier Ltd. All rights reserved.

S34 S. Babhulkar et al. / Injury, Int. J. Care Injured 48S2 (2017) S33–S43

atrophic non-union (nonviable). However, considering the infection interlocking on 12 occasions. Fourteen patients had two prior
as one of the criterion, non-union is divided in to, aseptic non-union surgeries and the fracture did not unite. In one patient the fracture
and septic non-union [10]. was initially treated by nailing, after its failure it was treated by DCP,
Most humeral shaft non-unions are atrophic and many may have but still the fracture failed to unite. All these patients had aseptic
an associated bony defect. Preoperative evaluation should consist of atrophic non-union without any signs of occult infection. There
a detailed neurovascular examination, locating previous incisions were 36 males and 28 females (Table 2). Forty-nine patients were
and measuring the range of shoulder and elbow motion. After initially managed in other institutions and fifteen patients had
meticulous planning the non-union is assessed, for the level of non- already been unsuccessfully operated primarily at our Institute. In
union, shortening of arm and the deformity. The type of non-union 38 patients, the injury was to their dominant upper limb, 26 patients
should be analyzed, whether the non-union is atrophic, oligotrophic, had on nondominant extremity. Forty-two of the injuries were low-
or hypertrophic which will determine the surgical strategies. The energy fractures (domestic fall) and 22 were high-energy fractures
aim of treatment is to achieve the union of humerus and correct the (twenty one from traffic accidents, one fall from tree). Thirty-eight
deformity and recover with a fully functioning arm. Surgeons should fractures involved the middle third, twelve the proximal third, and
try to achieve full function in terms of flexion-extension of the fourteen the distal third of the humerus. The primary fracture lines
elbow and shoulder movements, and correct the deformity. There is were classified using the AO classification (12): Eight A1 (spiral),
a likelihood of angular and rotational deformity. During correction thirteen A2 (oblique), twenty A3 (transverse), five B1 (spiral wedge),
and excision of non-union all these factors should be considered. six B2 (bending wedge), four B3 (multifragmentary wedge), three
Normal axial relation and correction of rotational deformity is C1 (complex spiral), two C2 (complex segmental), and three C3
essential to achieve good range of functional movements. These (complex irregular).
demanding non-unions require the surgical correction to restore the
anatomy and to improve function. In the literature many surgical Preoperative planning
techniques have been described [10–26]. In patients with humerus
shaft non-union the treatment is surgical with a goals to provide a In all cases the surgery was planned after careful evaluation
stable rigid construct and to create a healthy biological environment of the type of non-union, associated bone loss, condition of soft
which favors fracture healing for early mobilization of arm, shoulder tissues, and stability of earlier fixation. In these non-unions there is
and elbow. Different surgical strategies have been advocated, but likelihood of angular and rotational deformity with shortening of the
standard approach of open reduction and internal fixation with arm. During correction and excision of non-union all these factors
compression plating and addition of autogenous bone grafting is the should be considered, though shortening of humerus and arm does
most acceptable choice of treatment [21–26]. The purpose of this not affect any function. Normal axial relation and correction of
study was to evaluate the results of treatment of patients diagnosed rotational deformity is essential to achieve good range of functional
in our institution with humeral non-union. movements. Broadly the principles of treatment are outlined as
provision of stability, and osteogenic potential to create biological
Materials and methods environment favorable to fracture healing. After achieving stable
mechanical construct and after excising the non-union till the viable
After the approval from the Institutional ethical committee, this bone fragments, addition of adequate autogenous bone grafts, and
study was conducted at the Sushrut Institute of Medical Sciences, bone marrow surrounded by a well vascularized soft tissue envelope
Nagpur, India. All patients with a non-union of humeral shaft, can serve as a reservoir of mesenchymal cells, which are capable
treated in duration of 10 years from 1 January 2006 to 31 December of transforming cartilage and bone forming cells for the success of
2015 were identified. The inclusion criteria were the presence of a union.
non-union of 8–10 months from the date of primary fixation, based Plain X-rays of both the humerus and shoulder, including two
on clinical and radiological findings. All infective and hypertrophic orthogonal views, are adequate for planning. These radiographs
non-unions were excluded. The preoperative diagnosis was based allow visualisation of the fracture configuration and development of
on the patient’s symptoms and signs including pain in the arm at the a strategy for reduction and placement of surgical implants. The level
fracture site which was aggravated by stress, tenderness, doubtful of non-union dictates the surgical exposure, ease of exposure of non-
mobility at the fracture site, and radiological criteria showing union site and internal fixation. An extended deltopectoral approach
absence of bridging bone across the fracture site with no evidence or antero-lateral approach was used for proximal fractures; mid
of progression of healing during the previous 3–4 months and some shaft non-unions were approached by antero-lateral approach or
cases with the evidence of loosening and breakage of implant. by posterior triceps-splitting approach, which is routinely used for
Plain X-ray was sufficient to reach diagnosis of non-union of shaft lower third fractures. When a patient had a distal fracture, the ulnar
humerus. nerve was not routinely released or transposed but was carefully
protected. Whenever the triceps splitting approach was used radial
Epidemiology nerve was always exposed and protected during the entire surgical
procedure. Patient is kept in supine position whenever deltopectoral
A total of 68 patients were identified as having an aseptic non- or anterolateral approach was planned, but was kept in prone or
union of the humeral shaft and were treated by surgery (Table 1). lateral position when posterior triceps splitting approach was used.
Patients were included if fractures were below the surgical neck and
above the junction of the lower third of humerus to supracondylar Operative technique
region – 2 cm above the olecranon fossa (from upper metaphyseo-
diaphyseal region to lower metaphyseo-diaphyseal region) and also During the surgical procedure, previous failed hardware was
if they had adequate radiographical and clinical follow-up until removed followed by debridement of the synovial membranes
fracture union. Clinical and radiographical follow-up was available and inflammatory tissue around the non-union. Atrophic non-
only for 64 patients (4 patients were lost for follow-up), with a mean union requires debridement and excision of interposed fibrous
age of 58 years (range from 25–78 years). All patients had aseptic tissue, necrotic and devitalized areas. Opening the sclerotic bone
atrophic non-union, of proximal shaft (n=12), mid shaft (n=38), ends and roughening the fracture surface stimulates bleeding and
and distal shaft (n=14). All 64 patients had closed fractures and subsequent healing response. The medullary canal is opened on
were stabilized primarily by plating on 52 occasions and nailing both ends of the non-union using a drill, nibbler or curette on either
Table 1
Master chart: nonunion humerus

Time lapse
between
primary Constant and Murley-Shoulder
Age Level of fixation Duration for and Mayo Elbow
(years) fracture and healing of Follow-up Performance Index
Case and and AO non-union Type of treatment for non-union excision, LC plating and non-union period
no. Name sex Side classification-12* (weeks) bone grafting (weeks) (weeks) Complications Shoulder Elbow Results

1 BK 72/M ND M-A3 40 Transverse osteotomy and compression plating, corticocancellous graft 14 76 – 38–84 60–90 Excellent
2 RK 52/M ND M-A3 44 Transverse osteotomy and compression plating, corticocancellous graft 16 68 – 44–90 65–90 Excellent
3 MB 45/F D D-C3 50 Bridge plating-LCP, corticocancellos graft 24 66 Radial nerve- 36–54 55–70 Fair
neuropraxia
4 KS 36/F D P-A2 54 Excision, corticocancellous grafting and Bridge plating 32 86 – 40–76 50–75 Good
5 RH 67/F D M-C2 66 Excision, intra-medullary fibula and corticocancellous, grafting 36 60 – 34–82 45–90 Excellent
with cerclage wiring
6 DB 42/M ND M-C2 64 Excision, corticocancellous grafting and bridge plating 28 64 – 38–76 45–80 Poor
7 PG 70/M D P-C3 68 Excision, corticocancellous grafting and bridge plating 24 84 – 40–58 55–70 Fair
8 RS 45/M D D-C3 72 Excision, corticocancellous grafting and bridge plating 32 114 – 36–54 40–65 Fair
9 LP 63/F D P-C1 52 Excision, corticocancellous grafting and bridge plating 20 120 – 42–58 35–70 Fair
10 MW 54/F D M-C1 56 Excision, corticocancellous grafting and bridge plating 24 96 – 36–74 55–80 Good
11 AL 61/F D D-C1 60 Excision, corticocancellous grafting and bridge plating 20 80 Radial nerve- 30-78 50-85 Good
neuropraxia
12 RZ 57/F D M-A3 36 Excision, intra-medullary fibula and corticocancellous, grafting with LC plating 22 60 – 42–86 65–95 Excellent
13 ST 66/F ND D-A3 44 Transverse osteotomy and compression plating, corticocancellous graft 20 110 – 46–78 60–85 Good
14 CM 53/F ND D-A2 40 Excision, lag screw interfragmentary fixation and neutralization LCP and 32 120 – 38–74 60-75 Good
corticocancellous bone grafting
15 AM 36/M D M-A2 42 Excision, lag screw interfragmentary fixation and neutralization LCP and 22 88 – 36–82 65–90 Excellent
corticocancellous bone grafting
16 SN 56/M D M-A3 40 Transverse osteotomy and compression plating, corticocancellous graft 18 136 – 44–74 55–80 Good
17 NK 39/F ND D-A3 38 Transverse osteotomy and compression plating, corticocancellous graft 16 64 – 46–78 60–85 Good
18 NJ 69/M ND M-B1 45 Excision, intra-medullary Fibula and corticocancellous, grafting with LC plating 24 150 – 30–58 40–70 Fair
19 IK 49/F D M-B2 48 Excision, lag screw interfragmentary fixation and neutralization LCP and 24 180 – 32–60 35–70 Fair
corticocancellous bone grafting
20 JG 55/M D M-B3 60 Excision, corticocancellous grafting and bridge plating 26 220 – 28-62 45-75 Good
21 TT 47/F D D-B3 72 Excision, corticocancellous grafting and bridge plating 28 144 – 24-64 50-80 Good
22 SW 54/F D D-B1 64 Excision, lag screw interfragmentary fixation and neutralization LCP and 30 76 – 22–44 30–65 Fair
S. Babhulkar et al. / Injury, Int. J. Care Injured 48S2 (2017) S33–S43

corticocancellous bone grafting

23 ME 57/M ND M-A1 44 Excision, lag screw interfragmentary fixation and neutralization LCP and 16 88 – 30–62 35–80 Good
corticocancellous bone grafting
24 RP 51/M D M-A2 56 Excision, lag screw interfragmentary fixation and neutralization LCP and 22 96 – 28–66 45–85 Good
corticocancellous bone grafting
25 DC 48/M ND M-A3 44 Excision, intra-medullary fibula and corticocancellous, grafting with LC plating 12 110 Occasional 40–88 65–90 Excellent
discomfort at the
fibular graft
harvest site
26 RL 52/M ND M-B2 76 Excision, lag screw interfragmentary fixation and neutralization LCP and 14 64 – 34–76 25–80 Good
corticocancellous bone grafting
27 VR 53/M D M-A2 88 Excision, lag screw interfragmentary fixation and neutralization LCP and 16 136 – 32–78 30–85 Good
corticocancellous bone grafting
28 SB 55/F D D-B3 96 Excision, corticocancellous grafting and bridge plating 20 84 – 26–56 30–65 Fair
29 SD 50/F D D-B1 72 Excision, lag screw interfragmentary fixation and neutralization LCP and 24 80 – 30–74 40–75 Good
corticocancellous bone grafting
30 MK 62/M ND M-A2 66 Excision, lag screw interfragmentary fixation and neutralization LCP and 22 112 – 34–72 55–75 Good
corticocancellous bone grafting
S35

Continued overleaf
Table 1 (continued)
Master chart: nonunion humerus S36

Time lapse
between
primary Constant and Murley-Shoulder
Age Level of fixation Duration for and Mayo Elbow
(years) fracture and healing of Follow-up Performance Index
Case and and AO non-union Type of treatment for non-union excision, LC plating and non-union period
no. Name sex Side classification-12* (weeks) bone grafting (weeks) (weeks) Complications Shoulder Elbow Results

31 MoK 67/F ND M-A3 36 Excision, intra-medullary fibula and corticocancellous, grafting and LC plating 34 156 – 34–86 60–95 Excellent
32 DP 47/M D P-A2 54 Excision, lag screw interfragmentary fixation and neutralization LCP and 24 76 Superficial 22–58 30–70 Fair
corticocancellous bone grafting infection at the
iliac crest site
33 RM 50/M ND P-A3 60 Transverse osteotomy and compression plating, corticocancellous graft 18 186 – 30–74 45–80 Good
34 PS 48/F ND M-A3 68 Transverse osteotomy and compression plating, corticocancellous graft 16 224 – 26–70 35–85 Good
35 RS 44/M D M-A2 46 Excision, lag screw interfragmentary fixation and neutralization LCP and 22 176 – 24–68 35–85 Good
corticocancellous bone grafting
36 UM 61/M D P-A3 60 Transverse osteotomy and compression plating, corticocancellous graft 20 114 – 40–90 55–90 Excellent
37 VT 56/F D P-B1 40 Excision, lag screw interfragmentary fixation and neutralization LCP and 24 246 – 28–74 30–80 Good
38 BP 39/M D M-A3 40 Transverse osteotomy and compression plating, corticocancellous graft 20 220 – 30–78 25–75 Good
39 SL 41/M ND M-A2 56 Excision, lag screw interfragmentary fixation and neutralization LCP and 20 180 – 30–76 30–75 Good
corticocancellous bone grafting
40 KP 47/M D P-A3 36 Transverse osteotomy and compression plating, corticocancellous graft 18 156 – 46–86 65–90 Excellent
41 SK 30/F D M-B2 84 Excision, lag screw interfragmentary fixation and neutralization LCP and 22 136 – 20–62 35–80 Good
corticocancellous bone grafting
42 AM 40/M ND M-A3 52 Transverse osteotomy and compression plating, corticocancellous graft 20 74 – 24–66 40–85 Good
43 BS 64/M ND M-A3 42 Transverse osteotomy and compression plating, corticocancellous graft 16 88 – 32–84 60–90 Excellent
44 AP 55/M ND P-A2 50 Excision, lag screw interfragmentary fixation and neutralization LCP and 18 110 – 24–68 55–85 Good
corticocancellous bone grafting
45 BS 49/M ND M-A1 54 Excision, lag screw interfragmentary fixation and neutralization LCP and 20 60 – 30–74 50–85 Good
corticocancellous bone grafting
46 BM 51/F D M-A3 44 Transverse osteotomy and compression plating, corticocancellous graft 20 108 – 30–88 50–90 Excellent
47 DG 70/F D P-A1 60 Excision, lag screw interfragmentary fixation and neutralization LCP and 22 90 – 30–62 40–85 Good
corticocancellous bone grafting
48 DM 60/M ND M-A2 72 Excision, lag screw interfragmentary fixation and neutralization LCP and 24 120 – 32–70 45–80 Good
corticocancellous bone grafting
49 PP 78/M D D-B1 76 Excision, intra-medullary fibula and corticocancellous, grafting with LC plating 28 90 Occasional 34–72 35–75 Good
S. Babhulkar et al. / Injury, Int. J. Care Injured 48S2 (2017) S33–S43

discomfort at the
fibular graft
harvest site
50 NS 64/F D M-A1 48 Excision, lag screw interfragmentary fixation and neutralization LCP and 24 84 – 36–78 30–75 Good
corticocancellous bone grafting
51 SS 26/M D M-A2 60 Excision, lag screw interfragmentary fixation and neutralization LCP and 18 104 – 24–66 35–80 Good
corticocancellous bone grafting
52 SP 29/M ND M-A1 62 Excision, lag screw interfragmentary fixation and neutralization LCP and 22 110 – 24–68 45–85 Good
corticocancellous bone grafting
53 SH 59/F ND P-A3 40 Transverse osteotomy and compression plating, corticocancellous graft 20 74 – 34–92 55–90 Excellent
54 SR 73/M D M-A2 92 Excision, lag screw interfragmentary fixation and neutralization LCP and 18 66 – 22–66 30–80 Good
corticocancellous bone grafting
55 ST 38/F ND M-A3 50 Transverse osteotomy and compression plating, corticocancellous graft 16 64 Superficial 44–84 60–90 Excellent
infection at the
iliac crest site
56 NW 71/F ND D-A3 44 Transverse osteotomy and compression plating, corticocancellous graft 20 70 – 24–56 25–0 Fair
57 BT 66/M D M-B2 46 Excision, lag screw interfragmentary fixation and neutralization LCP and 20 96 – 34–66 35–80 Good
corticocancellous bone grafting
Continued overleaf
 Table 1 (continued)
Master chart: nonunion humerus

Time lapse
between
primary Constant and Murley-Shoulder
Age Level of fixation Duration for and Mayo Elbow
(years) fracture and healing of Follow-up Performance Index
Case and and AO non-union Type of treatment for non-union excision, LC plating and non-union period
no. Name sex Side classification-12* (weeks) bone grafting (weeks) (weeks) Complications Shoulder Elbow Results

58 BD 74/F D M-B2 78 Excision, lag screw interfragmentary fixation and neutralization LCP and 22 102 – 38–78 45–85 Good
corticocancellous bone grafting
59 SJ 64/M D D-B3 66 Excision, corticocancellous grafting and bridge plating 30 96 – 30–72 40–80 Good
60 VJ 55/M ND M-A1 96 Excision, lag screw interfragmentary fixation and neutralization LCP and 24 108 – 36–78 35–75 Good
corticocancellous bone grafting
61 GK 69/M D M-A3 40 Transverse osteotomy and compression plating, corticocancellous graft 18 224 – 34–86 60–95 Excellent
62 JP 33/F D M-A1 56 Excision, lag screw interfragmentary fixation and neutralization LCP and 24 88 – 34–76 55–80 Good
corticocancellous bone grafting
63 JS 40/F D D-B2 62 Excision, lag screw interfragmentary fixation and neutralization LCP and 22 96 – 32–78 40–80 Good
corticocancellous bone grafting
64 SS 53/M ND P-A1 44 Excision, lag screw interfragmentary fixation and neutralization LCP and 24 88 Superficial iliac 32–76 55–85 Good
corticocancellous bone grafting infection at the
crest site

Results: Excellent 14, Good 0, Fair 10, Poor 0

*P = proximal; M = middle; D = distal
9
8
7
6
5
4
3
2
1

11

17
18
19
16
14
10

51
15
13

41
31
12

47
21

61
57
37
27

35
33
24

60
50
40
30
20

63
62
59
58
56
55
54
53
52
46
45
43
42
39
38
36
34
32
29
28
26
25
23
22

64
49
48
44
no.
Case
Table 2

JS
SJ

JP
IK

VJ
JG

SL

SS
SS
NJ
LP

ST
ST

SP
PS
RL
TT

PP
BS
BS
SB

SR
RS
RS

AL

BT
BP

SK
RP
RZ
KS

KP

AP
VT
SD
BK

NS
SN
RK

PG

SH
DP
VR
DC

BD
DB

GK
RH

NK

DG
ME

BM
CM
MB

RM
MK
SW

AM
AM

DM
UM

NW
MW

MoK
Name
sex
Age

and

74/F
51/F

71/F
47/F
57/F
61/F

33/F
70/F
67/F
67/F

40/F
38/F
59/F
30/F
56/F
50/F
39/F
53/F

55/F
54/F
54/F
63/F
45/F
36/F

64/F
66/F

48/F
49/F

51/M

41/M
47/M
47/M
57/M

73/M
61/M
72/M

70/M

69/M
60/M
40/M
39/M

53/M
55/M
29/M
26/M
78/M
55/M
50/M
62/M
53/M
56/M
36/M
52/M

52/M
55/M
69/M
45/M
42/M

64/M

64/M
66/M
49/M
44/M
48/M
(years)
S. Babhulkar et al. / Injury, Int. J. Care Injured 48S2 (2017) S33–S43

D
D

D
D
D
D
D
D
D
D

D
D
D
D
D
D
D

D
D
D
D
D
D
D
D
D

D
D
D
D
D
D
D
D
D
D
D
D

*P = proximal; M = middle; D = distal

ND
ND
ND
ND

ND
ND
ND
ND
ND

ND
ND
ND
ND
ND
ND
ND
ND

ND
ND
ND
ND

ND
ND
ND
ND
ND
Side

Results: Excellent 14, Good 0, Fair 10, Poor 0

P-B1
P-C1
P-C3

P-A1
P-A3
P-A1
P-A2
P-A3
P-A3
P-A3
P-A2
P-A2

D-B2
D-B3
D-B1
D-B1
D-B3
D-B1
D-B3
D-C1
D-C3
D-C3

D-A3
D-A3
D-A2
D-A3

M-B2
M-C1

M-B2
M-B2
M-B2
M-B3
M-B2
M-B1
M-C2
M-C2

M-A2

M-A1
M-A3
M-A3
M-A2

M-A1
M-A1
M-A2
M-A1
M-A2
M-A3
M-A3
M-A2
M-A3
M-A3
M-A3
M-A2
M-A2
M-A3
M-A2
M-A1
M-A3
M-A2
M-A3
M-A3
M-A3

M-A1
M-A3
Non-union humerus: age, sex, level and type of fracture

and AO
Level of
fracture

classification-12*

76
76

72
72
72
72

62
96
50

56
40
78
46
50
92
40
60
60
50
36
60
46

42
84
56
40
40
60
60

96
62
54
52
54
36
88
56
45
38
40
42
40
60
56
52
40

36
54

66
66
64
48
66

48
68
68
64

44
44
44
44
44
44
44
(weeks)
non-union
Time lapse

fixation and
between primary
S37
S38 S. Babhulkar et al. / Injury, Int. J. Care Injured 48S2 (2017) S33–S43

side; the bone is decorticated and shingling done on either side of union was achieved; at which point strengthening exercises
the fracture site by using a sharp osteotome over a length of about were begun. Patients were followed up every 6 weeks for wound
2 cm, like petalling. Surgical strategy will differ depending upon complications, painful hardware and radiographic and clinical
the defect in the humerus after excision of non-union. At times evidence of union.
the non-union is excised by performing the transverse osteotomy
by using saw on either side of non-union, causing shortening but Results
achieves perfect cortical opposition (cortex to cortex contact) of the
humeral shaft. The gap created after excision of the non-union is All non-union healed well at an average of 16 weeks (range12–36
closed by opposing both ends even if there is shortening, and the weeks) following the index surgery (Table 4). All fractures had solid
corticocancellous graft are put in and around the non-union site. It clinico-radiologically evident fracture union and patients were very
is important to decorticate and petal both sides (1.5–2 cm) of the satisfied with the treatment (Figures 1–5). There was absence of
non-union and to open the medullary canal to remove the sclerotic pain or tenderness over the previous non-union site and absence
cap using a drill. Autologous bone grafts are procured from the iliac of pain with motion. Out of the 64 patients in two cases there was
crest. The iliac crest is opened by elevating the hinge of periosteum varus deformity of 15 degrees with solid union, but patients had full
medially after stripping the iliacus muscle from the inner table function. The mean length of follow-up was 120 weeks (range 60–
of iliac wing posteriorly as far as possible. This approach helps 250 weeks). None had pain over the fracture site, with useful range
obtain plenty of corticocancellous graft. These corticocancellous of movements at shoulder and elbow in all patients. All 64 patients
grafts are placed in the non-union defect, and osteosynthesis resumed their work of initial nature. No patient required revision
performed under compression, by locking compression plate. surgery for the healing of non-union. Two patients developed
The articulating tensioning device is used whenever possible and neuropraxia of radial nerve, which recovered after 6–8 weeks in
practical. Additionally, a few pieces of cancellous bone are also time. Three patient developed superficial infection at the iliac crest,
placed around the fracture site. The non-union excision was done which settled with antibiotics and dressings after 3 weeks. Two
to create a healthy vascular environment and then the fracture was patients had some discomfort over the fibular graft harvest site.
stabilized by using 4.5/5 mm LCP in different modes of fixation, as Morbidity at the autologous fibular bone graft site was minimal,
far as possible in compression. However sometimes after excising manifested by only occasional discomfort.
the fibrous non-union and adding autogenous corticocancellous An extended deltopectoral approach or antero-lateral approach
grafts, the fracture is stabilized by using long LCP in bridging mode. was used for proximal fractures, mid shaft non-unions were
In six osteoporotic non-union, with wide medullary cavity with approached by antero-lateral approach or by posterior triceps-
thin cortices, intramedullary fibular graft was used to enhance the splitting approach, and triceps splitting approach for all lower
stability of fixation, which increases the screw hold, as advocated by third fractures. All fracture was fixed by locking compression plate
few surgeons [13,14]. in different mode of fixation with autogenous corticocancellous
The following four types of internal fixation were done in 64 graft from iliac crest (intramedullary fibular graft was used in six
patients (Table 3): osteoporotic non-unions).
1) Transverse osteotomy for excision of non-union, achieving The Mayo Elbow Performance Index was calculated for each
cortex-to-cortex contact and Compression plating, and adding patient [29,30]. A score of 100 to 90 points was considered to be
corticocancellous bone grafting in transverse fractures (17 an excellent result; 89 to 75 points, a good result; 74 to 60 points,
patients) (Figure 1A–H). a fair result; and <60 points, a poor result. Shoulder function was
2) Excision, corticocancellous grafting and Bridge plating in evaluated preoperatively and at the most recent follow-up visit with
complex comminuted fractures (12 patients) (Figure 2A–C and the use of a modification of the scale of Constant and Murley [31].
Figure 3A–C). The maximum score on this scale is 100 points: 15 points for pain,
3) Excision of non-union, Intra-medullary Fibular graft and 20 points for activities of daily living, 40 points for range of motion,
corticocancellous grafting and LC plating in osteoporotic fractures and 25 points for power. Between 80 and 100 points was considered
(6 patients) (Figure 4A–C). an excellent objective result; between 60 and 79 points, a good
4) Excision of non-union, Lag screw interfragmentary fixation and result; between 40 and 59 points, a fair result; and between 0 and
neutralization LCP and corticocancellous bone grafting in oblique 39 points, a poor result.
or spiral fractures (29 patients) (Figure 5A–C). Calculating both the functional scores at the time of complete
A plate of sufficient length (at least 9 holes in length and preferably radiological and clinical healing of non-union excellent results were
longer) combined with at least 3–4 screws in each segment was used noted in 14 patients, good results in 40 patients and fair results in
for adequate stabilization. After complete excision of non-union, 10 patients. No patient had poor results (Table 4). The mean range
rigid fixation was performed with full cortex-to-cortex contact by of movements following fracture union was forward flexion of 140°,
using 4.5 or 5 mm LCP. Commonly the fixation was performed in external rotation and internal rotation of 30° at shoulder and on an
compression mode by self-compression plating or with lag screw average fixed flexion deformity of 10° and flexion of 130° at elbow.
and neutralization plating. We did not find the need of double There was an average loss of ten degrees abduction and 15 degrees
plating as advocated by other colleagues [20,27,28]. However, to flexion of the shoulder. There was no change in shoulder rotations
increase the stability we used long LCP in bridging mode, spanning following surgery. All patients with preoperative fixed flexion
the entire diaphysis, especially in complex fractures. deformity of elbow to varying degrees had persistence of similar
deformity at the last follow-up. Range of motion of the elbow had
Post-operative regime improved by 15–40 degrees following surgery. All patients had gone
back to their near normal pre-injury activity levels at the last follow-
Once rigid fixation is achieved no external immobilization was up.
necessary and the patients were given a shoulder-arm pouch.
From the next postoperative day gentle active and active assisted Discussion
range of motion of the elbow and shoulder were begun. To begin
with pendulum exercises to the shoulder-arm and elbow active Long bone non-union with or without bone loss continues to be
movements were started. Aggressive ranges of motion exercises the most common post fracture fixation complication and remains a
were begun after 3–4 weeks and were continued until radiographic subject of great interest to the clinicians [32–42].
 S. Babhulkar et al. / Injury, Int. J. Care Injured 48S2 (2017) S33–S43 S39

Table 3
Non-union humerus: type of surgery

Duration for
healing of Follow-up
Case non-union period
no. Name Type of treatment for non-union excision, LC plating and bone grafting (weeks) (weeks) Complications

1 BK Transverse osteotomy and compression plating, corticocancellous graft 14 76 –

2 RK Transverse osteotomy and compression plating, corticocancellous graft 16 68 –
3 MB Bridge plating-LCP, corticocancellos graft. 24 66 Radial nerve-
neuropraxia
4 KS Excision, corticocancellous grafting and bridge plating 32 86 –
5 RH Excision, intra-medullary fibula and corticocancellous, grafting with cerclage wiring 36 60 –
6 DB Excision, corticocancellous grafting and bridge plating 28 64 –
7 PG Excision, corticocancellous grafting and bridge plating 24 84 –
8 RS Excision, corticocancellous grafting and bridge plating 32 114 –
9 LP Excision, corticocancellous grafting and bridge plating 20 120 –
10 MW Excision, corticocancellous grafting and bridge plating 24 96 –
11 AL Excision, corticocancellous grafting and bridge plating 20 80 Radial nerve-
neuropraxia
12 RZ Excision, intra-medullary fibula and corticocancellous, grafting with LC plating 22 60 –
13 ST Transverse osteotomy and compression plating, corticocancellous graft 20 110 –
14 CM Excision, lag screw interfragmentary fixation and neutralization LCP and corticocancellous bone grafting 32 120 –
15 AM Excision, lag screw interfragmentary fixation and neutralization LCP and corticocancellous bone grafting 22 88 –
16 SN Transverse osteotomy and compression plating, corticocancellous graft s 18 136 –
17 NK Transverse osteotomy and compression plating, corticocancellous graft 16 64 –
18 NJ Excision, intra-medullary fibula and corticocancellous, grafting with LC plating 24 150 –
19 IK Excision, lag screw interfragmentary fixation and neutralization LCP and corticocancellous bone grafting 24 180 –
20 JG Excision, corticocancellous grafting and bridge plating 26 220 –
21 TT Excision, corticocancellous grafting and bridge plating 28 144 –
22 SW Excision, lag screw interfragmentary fixation and neutralization LCP and corticocancellous bone grafting 30 76 –
23 ME Excision, lag screw interfragmentary fixation and neutralization LCP and corticocancellous bone grafting 16 88 –
24 RP Excision, lag screw interfragmentary fixation and neutralization LCP and corticocancellous bone grafting 22 96 –
25 DC Excision, intra-medullary fibula and corticocancellous, grafting with LC plating 12 110 Occasional discomfort
at the fibular graft
harvest site
26 RL Excision, lag screw interfragmentary fixation and neutralization LCP and corticocancellous bone grafting 14 64 –
27 VR Excision, lag screw interfragmentary fixation and neutralization LCP and corticocancellous bone grafting 16 136 –
28 SB Excision, corticocancellous grafting and bridge plating 20 84 –
29 SD Excision, lag screw interfragmentary fixation and neutralization LCP and corticocancellous bone grafting 24 80 –
30 MK Excision, lag screw interfragmentary fixation and neutralization LCP and corticocancellous bone grafting 22 112 –
31 MoK Excision, intra-medullary fibula and corticocancellous, grafting and LC plating 34 156 –
32 DP Excision, lag screw interfragmentary fixation and neutralization LCP and corticocancellous bone grafting 24 76 Superficial infection
at the iliac crest site
33 RM Transverse osteotomy and compression plating, corticocancellous graft 18 186 –
34 PS Transverse osteotomy and compression plating, corticocancellous graft 16 224 –
35 RS Excision, lag screw interfragmentary fixation and neutralization LCP and corticocancellous bone grafting 22 176 –
36 UM Transverse osteotomy and compression plating, corticocancellous graft 20 114 –
37 VT Excision, lag screw interfragmentary fixation and neutralization LCP and corticocancellous bone grafting 24 246 –
38 BP Transverse osteotomy and compression plating, corticocancellous graft 20 220 –
39 SL Excision, lag screw interfragmentary fixation and neutralization LCP and corticocancellous bone grafting 20 180 –
40 KP Transverse osteotomy and compression plating, corticocancellous graft 18 156 –
41 SK Excision, lag screw interfragmentary fixation and neutralization LCP and corticocancellous bone grafting 22 136 –
42 AM Transverse osteotomy and compression plating, corticocancellous graft 20 74 –
43 BS Transverse osteotomy and compression plating, corticocancellous graft 16 88 –
44 AP Excision, lag screw interfragmentary fixation and neutralization LCP and corticocancellous bone grafting 18 110 –
45 BS Excision, lag screw interfragmentary fixation and neutralization LCP and corticocancellous bone grafting 20 60 –
46 BM Transverse osteotomy and compression plating, corticocancellous graft 20 108 –
47 DG Excision, lag screw interfragmentary fixation and neutralization LCP and corticocancellous bone grafting 22 90 –
48 DM Excision, lag screw interfragmentary fixation and neutralization LCP and corticocancellous bone grafting 24 120 –
49 PP Excision, intra-medullary fibula and corticocancellous, grafting with LC plating 28 90 Occasional discomfort
at the fibular graft
harvest site
50 NS Excision, lag screw interfragmentary fixation and neutralization LCP and corticocancellous bone grafting 24 84 –
51 SS Excision, lag screw interfragmentary fixation and neutralization LCP and corticocancellous bone grafting 18 104 –
52 SP Excision, lag screw interfragmentary fixation and neutralization LCP and corticocancellous bone grafting 22 110 –
53 SH Transverse osteotomy and compression plating, corticocancellous graft 20 74 –
54 SR Excision, lag screw interfragmentary fixation and neutralization LCP and corticocancellous bone grafting 18 66 –
55 ST Transverse osteotomy and compression plating, corticocancellous graft 16 64 Superficial infection
at the iliac crest site
56 NW Transverse osteotomy and compression plating, corticocancellous graft 20 70 –
57 BT Excision, lag screw interfragmentary fixation and neutralization LCP and corticocancellous bone grafting 20 96 –
58 BD Excision, lag screw interfragmentary fixation and neutralization LCP and corticocancellous bone grafting 22 102 –
59 SJ Excision, corticocancellous grafting and Bridge plating 30 96 –
60 VJ Excision, lag screw interfragmentary fixation and neutralization LCP and corticocancellous bone grafting 24 108 –
61 GK Transverse osteotomy and compression plating, corticocancellous graft 18 224 –
62 JP Excision, lag screw interfragmentary fixation and neutralization LCP and corticocancellous bone grafting 24 88 –
63 JS Excision, lag screw interfragmentary fixation and neutralization LCP and corticocancellous bone grafting 22 96 –
64 SS Excision, lag screw interfragmentary fixation and neutralization LCP and corticocancellous bone grafting 24 88 Superficial infection
at the iliac crest site

*P = proximal; M = middle; D = distal

S40 S. Babhulkar et al. / Injury, Int. J. Care Injured 48S2 (2017) S33–S43

Fig. 1. (A) X-ray immediate after fracture midshaft humerus. (B) Immediate after closed nailing-interlocking. (C) X-ray 8 months after nailing showing non-union and failing implant,
loosening of locking screw with osteolysis and cutting through of distal end of nail. (D) Nailing was converted to ORIF with DCP which also showing failure. (E) Showing non-union
8 months after DCP fixation. (F) X-ray immediate after Transverse osteotomy and compression plating, corticocancellous graft around the fracture site. (G) X-ray after Transverse
osteotomy and compression plating, corticocancellous graft 4 months showing good radiological healing. (H) X-ray 2 years after index surgery showing excellent remodeling after
healing of non-union.

Fig. 2. (A) Case of non-union with implants failure 8 months after primary fixation in a young 45 years male patient. (B) X-ray immediate after surgery of excision of non-union,
Bridge plating by LCP with plenty of corticocancellous graft. (C) X-ray 6 months after index surgery showing excellent healing of non-union. (D) X-ray 12 months after index surgery
showing excellent healing with bridge plating and bone grafting.
 S. Babhulkar et al. / Injury, Int. J. Care Injured 48S2 (2017) S33–S43 S41

Fig. 3. (A) Case of non-union with implant failure 6 months after primary fixation in a young 36 years female patient. (B) X-ray immediate after surgery of removal of implant
,excision of non-union, revision osteosynthesis with bridge plating by LCP with plenty of corticocancellous graft. (C) X-ray 3 months after index surgery showing fairly good progress
in healing of non-union.

Fig. 4. (A) X-ray showing fracture shaft humerus stabilized by DCP in distraction 4 months after primary surgery in elderly male of 78 years age , showing delayed union. (B) X-ray of
the same elderly female 8 months after primary surgery showing non-union with failure of implant and peri-implant fracture distally with marked osteoporosis. (C) Non-union and
peri-implant fracture treated by excision of non-union, intra-medullary fibular graft, corticocancellous graft and humerus stabilized by long LCP showing good healing of non-union
and peri-implant fracture after 6 months of index surgery.

Fig. 5. (A) Case of non-union humerus with marked osteoporosis in 50 years old lady, initially treated by external fixator which was removed 8 months prior to index surgery. (B)
X-ray immediate after surgery of Excision of non-union, Lag screw interfragmentary fixation and neutralization LCP with plenty of corticocancellous bone grafts. (C) X-ray 3 months
after index surgery showing good attempt towards healing of non-union.

We are reporting the successful outcome of excision of non- is atrophic, oligotrophic, or hypertrophic, which aids in deciding
union, bone grafting and LCP fixation for aseptic atrophic non- the surgical strategy. In general, the strategy is to adhere to the
union of shaft of the humerus. Hypertrophic and septic non-unions principle of “biologic surgical technique” with preservation of soft
were not included in this study. Once non-union of the humerus tissue attachments and simultaneously maintaining the mechanical
shaft is diagnosed, one should analyze whether the non-union stability. Atrophic non-union require thorough excision of interposed
S42 S. Babhulkar et al. / Injury, Int. J. Care Injured 48S2 (2017) S33–S43

Table 4
fibrous tissue and necrotic and devitalized areas. Opening the
Non-union humerus: results of surgery
sclerotic bone ends and roughening the fracture surface stimulates
Constant and Murley-Shoulder bleeding and helps in subsequent healing response. The medullary
and Mayo Elbow Performance Index
canal should be opened at both ends of the non-union using drill
Age (years) Shoulder Elbow and curette on either side. The bony ends should be decorticated
Case no. Name and sex pre–post pre–post Results using a sharp osteotome and nibbler (Shingling). It is important to
1 BK 72/M 38-84 60-90 Excellent raise the petals on both sides of the non-union like the Phemister
2 RK 52/M 44-90 65-90 Excellent decortication before putting the bone grafts and application of
3 MB 45/F 36-54 55-70 Fair the plate. The soft tissues and periosteum are not to be separated
4 KS 36/F 40-76 50-75 Good from the bony petals. It is essential to excise non-union to remove
5 RH 67/F 34-82 45-90 Excellent
all fibrous tissue, but gentle dissection should be performed to
6 DB 42/M 38-76 45-80 Poor
preserve the soft tissue attachment to the bony fragments and not
7 PG 70/M 40-58 55-70 Fair
to damage local vascularity. Careful debridement and excising the
8 RS 45/M 36-54 40-65 Fair
9 LP 63/F 42-58 35-70 Fair non-union by cortical osteotomy so as to achieve perfect cortex-to-
10 MW 54/F 36-74 55-80 Good cortex contact is necessary which facilitates neovascularization and
11 AL 61/F 30-78 50-85 Good migration of osteogenic cells and prepares the host environment for
12 RZ 57/F 42-86 65-95 Excellent successful graft integration [24]. Supplementary use of autogenous
13 ST 66/F 46-78 60-85 Good corticocancellous bone results in graft mediated release of growth
14 CM 53/F 38-74 60-75 Good factors and stimulates differentiation of precursor cells and
15 AM 36/M 36-82 65-90 Excellent osteoblasts. It is advisable to use autologous cancellous bone graft
16 SN 56/M 44-74 55-80 Good
by harvesting the corticocancellous graft from the iliac crest and
17 NK 39/F 46-78 60-85 Good
additional cancellous graft from the inside of the iliac wing [26].
18 NJ 69/M 30-58 40-70 Fair
19 IK 49/F 32-60 35-70 Fair Vascularization of a corticocancellous graft occurs within a few
20 JG 55/M 28-62 45-75 Good weeks if the soft tissue envelope is compliant and well vascularized.
21 TT 47/F 24-64 50-80 Good However, if the autografts are insufficient one can add allografts or
22 SW 54/F 22-44 30-65 Fair bone substitutes.
23 ME 57/M 30-62 35-80 Good Though it is desirable to maintain length, one can sacrifice some
24 RP 51/M 28-66 45-85 Good length of humerus since the shortening in the arm hardly affects
25 DC 48/M 40-88 65-90 Excellent the function. In long standing non-union soft tissue contractures
26 RL 52/M 34-76 25-80 Good
of the arm may complicate dissection, and hence the radial nerve
27 VR 53/M 32-78 30-85 Good
should always be isolated and protected, especially in middle third
28 SB 55/F 26-56 30-65 Fair
29 SD 50/F 30-74 40-75 Good and lower third fractures. Once adequate opposition of fracture ends
30 MK 62/M 34-72 55-75 Good was obtained, cortex-cortex, the Osteosynthesis was performed by
31 MoK 67/F 34-86 60-95 Excellent use of a 4.5-mm locking compression plate [24].
32 DP 47/M 22-58 30-70 Fair Many authors have described different modes of fixation for the
33 RM 50/M 30-74 45-80 Good non-union of humerus shaft, although none have been as successful
34 PS 48/F 26-70 35-85 Good as plate fixation for the treatment of non-unions. It is said that poor
35 RS 44/M 24-68 35-85 Good
technique of fracture fixation is the main cause of failure of fractures
36 UM 61/M 40-90 55-90 Excellent
to heal following operative intervention [1,8,20,21,30,43,44].
37 VT 56/F 28-74 30-80 Good
Obtaining fixation in proximal and distal fractures poses a difficult
38 BP 39/M 30-78 25-75 Good
39 SL 41/M 30-76 30-75 Good problem secondary to a short proximal or distal segment and poor
40 KP 47/M 46-86 65-90 Excellent metaphyseal screw purchase. The excellent results achieved in this
41 SK 30/F 20-62 35-80 Good study were mainly because of method of fracture fixation after
42 AM 40/M 24-66 40-85 Good excision of non-union. A stable construct was performed with rigid
43 BS 64/M 32-84 60-90 Excellent plate fixation with the aim of perfect cortex-to-cortex contact with
44 AP 55/M 24-68 55-85 Good compression, either by using interfragmentary lag screw or with
45 BS 49/M 30-74 50-85 Good
self-compressing LCP [25]. The key factor is to achieve cortex-to-
46 BM 51/F 30-88 50-90 Excellent
cortex apposition with good compression across the non-union after
47 DG 70/F 30-62 40-85 Good
the excision of the non-union through osteotomy at both the fracture
48 DM 60/M 32-70 45-80 Good
49 PP 78/M 34-72 35-75 Good ends [25]. At times the stabilization is achieved by using long LCP in
50 NS 64/F 36-78 30-75 Good bridging mode. Apart from excellent mechanical stability addition
51 SS 26/M 24-66 35-80 Good of corticocancellous bone grafts within the medullary cavity and
52 SP 29/M 24-68 45-85 Good around the fracture site enhanced the local biology of bone. The
53 SH 59/F 34-92 55-90 Excellent problem becomes more complex in the elderly with osteoporotic
54 SR 73/M 22-66 30-80 Good bones. Six of our elderly patients had severe osteoporosis where
55 ST 38/F 44-84 60-90 Excellent
the intramedullary fibula was used to enhance stability of fixation,
56 NW 71/F 24-56 25-70 Fair
to improve the holding capacity of screws and improve the healing
57 BT 66/M 34-66 35-80 Good
potential [13,14]. Whenever osteoporotic non-union were faced
58 BD 74/F 38-78 45-85 Good
59 SJ 64/M 30-72 40-80 Good intramedullary fibular fixation was performed and addition of
60 VJ 55/M 36-78 35-75 Good second plate to improve stability was never required as advocated
61 GK 69/M 34-86 60-95 Excellent by many workers [20,27,28,32].
62 JP 33/F 34-76 55-80 Good The article described the surgical protocol used to treat the
63 JS 40/F 32-78 40-80 Good non-unions of the shaft of humerus from the surgical neck of
64 SS 53/M 32-76 55-85 Good humerus above till the junction of the lower third of humerus to
Results: Excellent 14, Good 0, Fair 10, Poor 0 supracondylar region – 2 cm above the olecranon fossa (from upper
*P = proximal; M = middle; D = distal metaphyseo-diaphyseal region to lower metaphyseo-diaphyseal
 S. Babhulkar et al. / Injury, Int. J. Care Injured 48S2 (2017) S33–S43 S43

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