Les fractures de l’humérus répondent bien au traitement conservateur avec une bonne consolidation. Concernant les pseudarthroses, la littérature est assez controversée et ceci reste un traitement difficile pour les chirurgiens orthopédistes, notamment en ce qui concerne l’ostéoporose et la raideur des articulations adjacentes. Le fixateur externe d’Ilizarov, les plaques en compression, les greffes vascularisées sont des possibilités techniques et thérapeutiques. Nous avons utilisé des fragments de péroné pontant le foyer de fractures associés à une plaque dynamique en compression. Les patients dans cette étude ont eu un bon résultat avec consolidation de la fracture au dernier suivi. Le péroné est un site intéressant pour le prélèvement des greffons, avec peu de morbidité. Aucun patient n’a nécessité un complément de greffes iliaques. Cette étude est la plus importante concernant une série de patients présentant une pseudarthrose athrophique avec ostéoporose au niveau de l’humérus traités avec succès par l’utilisation combinée de greffes de péroné intra médullaire et d’une plaque dynamique en compression.

Average age of the patients was 65.33 years (range, 54–84). There were four females and two males (Table 1). Five patients had involvement of left humerus and only one on the right side. Three patients each had fractures of mid-shaft and junction of middle and proximal thirds. Five were closed fractures and one open fracture had eventual atrophic nonunion upon presentation. All patients had mild pain, tenderness and gross abnormal mobility at the nonunion site, and limitation of activities of daily living. All patients had stiffness of shoulder and elbow to varying degrees. Average delay at presentation from the time of injury was 13.33 months (range, 7–26 months). Preoperative DASH score averaged 84±5 (range, 77–97). Two patients each had diabetes mellitus and ischemic heart disease and three had hypertension. None of the patients were smokers. Five patients with closed fractures had nonunion following conservative treatment.

All patients underwent surgery under general anaesthesia after administration of prophylactic antibiotics. Mid-shaft fractures and fractures at the junction of middle and lower thirds were exposed through a posterior approach with care taken to identify and protect the radial nerves. Fractures at the junction of proximal and middle thirds were treated through an anterolateral approach. Fracture fragments were freshened off the devitalised bone and fibrous tissue up to the point of bleeding bone ends, and the medullary canal was opened using a drill. Both fragments were then reamed progressively using serial hand reamers up to the point of reaching the fairly healthy cortical bone.

The mid-shaft of fibula was then harvested under tourniquet control with care taken to identify and protect the superficial peroneal nerve. Fibular shaft of excess length was harvested so that it could be trimmed as necessary. Three sides of the fibula were trimmed so as to enable it to snugly telescope into the fracture fragments across the fracture site. If the thickness did not permit its use, it was conversely bevelled at two ends leaving behind the full thickness shaft in the middle which later would bridge the nonunion site or bone defect more effectively. The strut was pushed into one of the fracture fragments and the exact length of graft that needed trimming was assessed. Once the final shaping of the graft was done, the fracture was reduced with the intramedullary fibular graft spanning the fracture site.

Osteosynthesis across the fracture site was achieved using a dynamic compression plate and screws in compression mode. An additional Muller’s compression device was used at one end of the plate to achieve intraoperative compression at the fracture site in all patients. At least three screws on each side of the fracture with three or four cortical purchase for each of the screws were attempted. The remaining excess pieces of fibular graft were packed longitudinally bridging the fracture site. None of the patients had iliac crest bone grafting. Patients with elbow and shoulder stiffness underwent passive joint manipulation at the end of surgery. All patients were protected in an arm sling for a period of three weeks after the surgery. Elbow and shoulder mobilisation was initiated aggressively after three weeks. Lifting of weights using the operated limb was deferred for a period of three months or until osseointegration of the fibular ends or fracture healing.

There was an average loss of ten degrees abduction and 15 degrees flexion of the shoulder. There was no change in shoulder rotations following surgery. All patients with preoperative fixed flexion deformity of elbow to varying degrees had persistence of similar deformity at the last follow-up. Range of motion of the elbow had improved by 15 degrees following surgery. All patients had gone back to their near normal pre-injury activity levels at the last follow-up.

Osteoporosis, either as a result of disuse or due to generalised metabolic causes, compounds the choice of surgical treatment in these patients. It significantly reduces the pullout strength of the screws thus increasing the chance of implant failure. Humeral nonunion in osteoporotic bone presents a reconstructive challenge for the treating orthopaedic surgeon [1, 10]. While a number of methods of managing atrophic fracture nonunion have been suggested, each has its drawbacks. Most surgeons favour the use of an interlocking nail, Ilizarov external fixator, or LCP for stabilisation and vascularised fibular graft or cancellous iliac crest bone graft for enhancement of fracture union [9].

Interlocking nails require an image intensifier and are technically demanding. Their use is also known to hinder the shoulder movements in the short term, although the long term results are comparable with that of plating. Patients with nonunion of the humerus usually present with some stiffness of the adjacent joints and nailing may in fact worsen it. But, nailing has the advantages of being a load sharing device and affords stable fixation of the nonunion site even in osteoporotic bones. Bone transport using distraction histogenesis in the treatment of complex post-traumatic problems has a certain appeal, but enthusiasm for the Ilizarov technique has been tempered by its complexity and technical difficulty, the commitment of time and resources required for a good result, and the potential for numerous complications [4, 6, 8].

Locking compression plates are very promising, especially in this clinical scenario, but their use is limited due to problems with cost and availability. The dynamic compression plate is a familiar implant and easy to use by all surgeons. It is also more economical for patients. Plate fixation for nonunion humerus has been widely described in the literature. The main complications with this method include screw back-outs, radial paralysis, and infection. Dynamic compression plates fixed with screws having six or eight cortical purchases on either side of the fracture are often sufficient provided the bone quality is adequate to hold the plate and screws in place until fracture union [7]. Some authors have tried the use of methyl methacrylate bone cement along with the cortical screws to enhance the pull-out strength successfully; but it adds to the cost and has the potential for cardio toxicity.

Iliac crest cancellous bone graft has no mechanical strength to withstand stresses prior to solid union of the fracture site and also is associated with quite significant graft harvest site morbidity. The fibula transmits one eighth of body weight and can be as useful as vascularised or nonvascularised graft in reconstruction of bony defects. Vascularised bone grafting requires surgical experience and equipment not readily available in every hospital. The technique is demanding of time and resources, and vascular thrombosis may compromise the result [5]. Nonvascularised fibula is easy bone to harvest with the least possible tissue trauma. When harvesting the fibula transplant, a few centimetres of the epiphyseal portions have to be left in place so as not to interfere with the joints involved. The portion harvested is therefore almost completely cortical in character. The cortical bone affords immediate structural continuity and stability at the fracture site. It also has some osteogenic potential in addition to acting like a strut across the fracture site when used as an intramedullary bone graft. Fibula is probably the most suitable donor bone for reconstruction of defects in a long bone because of its length, geometrical shape, and mechanical strength. Grafts of cortical bone revascularise slowly and incompletely. There is a substantial risk of infection, delayed union and nonunion, and fractures through the graft are common. Although it is believed that skeletal reconstruction with bone grafts frequently fails because the surrounding soft tissue cannot provide adequate vascularity for graft incorporation and, even if successful, only results in slow revascularisation of the dead graft by creeping substitution, we did not find any graft being resorbed or failing. The fibular graft harvest has also been reported to have a high potential for peroneal nerve paralysis but if adequate care is taken to identify and protect the nerve during exposure, this complication can well be prevented. There is a moderate cost of fibular harvest regarding operating time, hospital stay, nursing cost, walking problems, crutches, etc.