NON-UNIONS AFTER FIXATION OF HUMERAL FRACTURES USING HACKETHAL'S BUNDLE NAILING TECHNIQUE

Abstract

Objective: The aim of the study was to identify factors contributing to the development of non-union after fixation of diaphyseal humeral fractures using Hackethal's intramedullary nailing technique.

Methods: In the time period from 2001 to 2010 156 patients with diaphyseal humeral fractures were treated surgically using Hackethal's technique. Six of them (3.8%) developed non-union. This group included three women and two men aged 63-69 years and one woman aged 37 years. The following parameters of the patients were recorded: age, gender, comorbidities, substance abuse, mechanism of injury, fracture type and location according to the AO/ASIF classification, and the operative technique.

Results: A non-union developed in six patients treated with Hackethal´s method (3.8%). Five of six non-unions (83%) were observed in patients in their sixties. In the subgroup of sexagenarians, non-union developed in 20.8% of surgically treated patients, as compared to 3.8 % in entire group. In the union group, fractures have been caused by high energy trauma in 52% of patients. In patients who developed non-union, high energy trauma caused 67% of fractures. With correct surgical technique the development of a non-union was observed in 0.7% of patients, with incorrect technique in 35.7% (p<0.001).

Conclusion: Treatment of diaphyseal humeral fractures with Hackethal's intramedullary elastic bundle nailing resulted in an overall high union rate. Factors contributing to the development of non-union were extension of this method to AO type B3 and C fractures and technical imperfection during implantation. Level of Evidence III, Prospective, Case-Control Study.

Keywords: Humeral fractures. Fracture fixation; internal.; intramedullary. Fracture fixation.

Figure 1. (A) Anteroposterior radiograph of a 31 year old female with an AO type 12-A3 mid-diaphyseal fracture of the humerus; (B) Postoperative radiograph showing complete filling of the medullary cavity with the elastic nails; (C) Follow-up at 10 months after surgery shows bony union; (D) Follow-up at one year after implant removal.

Figure 2. (A) Anteroposterior radiograph of a 37 year old female with an AO type 12-C3 mid-diaphyseal fracture of the humerus. (B) A radiograph obtained two days after surgery demonstrates that the medullar cavity is filled incompletely with implants and a slight distraction of the fragments; (C) Follow-up at 6 months after surgery shows no signs of bony consolidation with slight dislocation; (D) Follow-up radiograph at 18 months shows hypertrophic non-union with further dislocation and hardware failure. Non-union was treated surgically with removal of the elastic nails, resection of the pseudoarthrosis and interlocking plate fixation with cancellous bone grafting from the iliac crest; (E) At 21 months (3 months after revision surgery), union was finally obtained.