Outcome of Osteosynthesis of Late-Presenting Proximal Humerus Non-union: A Case Series

Abstract

Introduction: It can be challenging to treat proximal humeral non-union (PHN). The challenge gets compounded when they are presented either late or after previous surgery. The challenges are far greater due to small proximal fragments, scalloping of the head, medial bone defect, osteoporosis, soft tissue contractures, and problems related to the previous implants.

Material and methods: In this retro-prospective study (2007-2020), we report on six cases of PHN which were presented to us more than 5 years after the original injury and managed using an intra-medullary autologous fibular strut graft (FSG) along with fixation with a proximal humeral locking plate and cancellous bone grafting. We quantified shoulder function based on constant score and disabilities of the arm, shoulder and hand (DASH) score.

Results: The mean age of patients is found to be 54.3 years (range, 22-74 years) with females dominating our study. The mean pre-operative constant score is 26.33 which improved to 71.83 in the post-operative period. The mean DASH score is 77.98 preoperatively, which improved to 19.5 postoperatively. The paired sample t-test compared the difference in mean of the pre-operative and post-operative scores, which shows significant improvement in outcome.

Conclusion: Even in very late PHN in poor-quality bone, the additional use of intramedullary strut grafts provides structural support to the fixation and further enhances the ability to withstand the load-start early motion and have a satisfactory functional outcome. Keywords: Non-union, proximal humerus non-union, proximal humerus fracture, proximal humerus internal locking system, locking plate, autogenous fibular strut graft.

Keywords: Non-union; autogenous fibular strut graft; locking plate; proximal humerus fracture; proximal humerus internal locking system; proximal humerus non-union.

Figure 1

(a and b) X-rays anteroposterior and lateral view showing cavitation effect of long-standing non-union of the proximal humerus in 74-year-old female (c and d) immediate post-operative X-ray showing fixation with proximal humerus internal locking system plate, fibular strut graft supplemented with cortico-cancellous bone graft (e and f), follow-up X-ray at 5 months post-surgery (g and h) follow-up at 35 months post-surgery X-rays (i-l) follow-up at 35 months showing satisfactory range of motion.

Figure 2

65-year-old male with non-union left proximal humerus, (a-d) X-rays and computed tomography scans of shoulder joint showing non-union of proximal humerus with scalloped head in osteoporotic and loss of bone stock (e) showing fibular graft preparation (f) intramedullary fibular graft insertion (g) post-operative X-rays showing fixation with fibular autograft, proximal humerus internal locking system plate, and screws. (h-k) Follow-up X-rays at 6 months and 2 years show union.( l-o): functional outcome at 24 months post-surgery showing satisfactory range of motion.

Figure 3

(a and b) X-rays at presentation showing non-union proximal humerus with broken implant in situ in 56-year-old female (c and d) axillary and anteroposterior views after 66 months (e-g) functional outcome at 66 months post-surgery showing satisfactory range of motion.