Failed ORIF and Nonunion of Distal Humerus Fractures

Joel Werier, M.D., FRCSC
University of Ottawa
Ottawa, ON

Nonunion is a challenging complication of distal humerus fractures and has a reported incidence of eight to 25% in recent series1-6.The most important factor for hardware failure is poor initial fixation, which can be difficult to achieve in the presence of extensive comminution and osteopenia. Recent advances in surgical techniques and implant fixation, such as pre-contoured locking plates, have lessened the incidence of hardware failure and humeral nonunion7,8.


Other contributing factors to nonunion include smoking, poor soft tissue envelope, medication that inhibits bone formation, immunosuppression, and poor compliance with postoperative rehabilitation protocols.

Most nonunions occur at the supracondylar level and the articular components may be healed in their reduced position (Figure 1). Bone stock may be severely compromised secondary to ongoing bone reabsorption. Loose hardware may further accelerate bone loss by a 'windshield wiper' effect. A synovial pseudarthrosis may develop, characterized by reactive sclerosis on both sides of the nonunion, erosion and bone reabsorption of the distal fragment. Capsular contracture invariably develops in the presence of a nonunion.

WERIERFigure_1a WERIERFigure_1b

Figure 1: Nonunion at supracondylar level

Review of all previous imaging will allow better understanding of the fracture pattern and quality of initial fixation. Standard AP and lateral radiographs help determine whether enough bone stock remains to warrant internal fixation or if total elbow arthroplasty is required. If internal fixation is considered, a CT scan with three-dimensional reconstruction is valuable to assess remaining bone stock, articular congruity and to aid in preoperative planning.

Suspected infection should be further investigated by assessment of white blood count, erythrocyte sedimentation rate, C-reactive protein, and aspiration of the joint and nonunion site.

Open reduction with stable internal fixation is the treatment of choice for most patients with adequate remaining bone stock (Figure 2). Utilizing a previous posterior midline incision will facilitate the revision operation. A posterior midline incision can still be considered in the presence of previous medial and lateral incisions if the soft tissue envelope is adequate.

WERIERFigure_2a WERIERFigure_2b

Figure 2: Post revision ORIF with medial and lateral plating technique. (all images courtesy of Dr. G. King)

Transposition of the ulnar nerve is recommended. Many patients will have had a transposition with their index procedure. If a previously transposed nerve is asymptomatic, further dissection should be avoided unless extended exposure is required to carry out the procedure. However, if the previous ulnar nerve transposition is symptomatic, neurolysis may result in improved outcome9.

There are a number of options for deep surgical exposure, and the choice is influenced by the index surgical approach. An olecranon osteotomy offers excellent exposure10. The olecranon osteotomy should be elevated carefully, as existing fibrosis can tear the trochlear hyaline cartilage off the subchondral bone11. The bilatero-tricipital approach (working on either side of the triceps) can be used for extra articular nonunion12. A triceps reflecting (Bryan-Morrey)13 or TRAP14 (triceps reflecting anconeus pedicle) can be utilized and are useful approaches if one anticipates the possibility of converting from internal fixation to total elbow arthroplasty intra-operatively. Adequate release of the contracture (including the anterior capsule, posterior capsule and posterior bundle of the medial collateral ligament) is essential to regain full motion and decrease stress transmitted to the nonunion site.

Current standard principles for ORIF of acute fractures should also be utilized for non-unions1,8. Bone reabsorption may necessitate metaphyseal shortening, in which case, the distal fragment should be translated anteriorly to allow room for the coronoid and the radial head during elbow flexion. A new olecranon fossa may need to be excavated to facilitate extension1. Parallel plates are applied medially and laterally1,8 and a third posterolateral plate can be considered15. Autogenous cancellous bone graft or osteoinductive bone graft substitute can be placed in the nonunion site. The need for structural graft is dictated by the extent and the location of bone loss.

Careful surgical technique, modern implants, attention to capsular contracture and to the ulnar nerve have resulted in improved outcomes in the recent literature1,7. Helfet et al.7 reported union in 51 of 52 patients with a final arc of motion of 94 degrees. However, 30% of patients required further surgery for hardware removal, contracture, or ulnar nerve symptoms. Suboptimal results have been reported with unstable and osteochondral nonunions16,17.

Total elbow arthroplasty (TEA) is an excellent option for patients with fracture non-unions not amenable to ORIF. Indications include low demand elderly patients with pre-existing cartilage pathology or patients with distal nonunions, severe osteopenia, bone loss, and articular damage. TEA has provided good results in appropriately selected patients18,19,20. Cil et al.20 reviewed 92 consecutive elbow replacements for nonunion with an average follow-up off 6.5 years. 79% of patients reported minimal to no pain, with 85% patient satisfaction. Aseptic loosening was the most frequent implant complication (n=16), followed by implant fracture. Implant survivorship was reported as 96% at two years, 82% at five years, and 65% at ten and 15 years. Risk of failure was increased in patients less than 65 years of age, and those with multiple previous surgeries and history of infection.

Distal humeral nonunions remain a challenging problem and are most often a result of poor initial fixation. Most nonunions can be addressed by stable internal fixation with modern surgical implants, capsular contracture release, and careful evaluation of the ulnar nerve. Total elbow arthroplasty is an effective salvage procedure in select patients.


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