Closing the gap- a novel technique for humeral shaft nonunions using cup and cone reamers

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Injury, Int. J. Care Injured 47S7 (2016) S40–S43

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Closing the gap: a novel technique for humeral shaft nonunions using cup and cone reamers Brian T. Nickel*, Mitchell R. Klement, Marc J. Richard, Robert Zura, Grant E. Garrigues Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, United States

K E Y W O R D S

A B S T R A C T

nonunion

Introduction: Nonunion following closed treatment of humeral shaft fracture is estimated to be 5.5%. Many surgical techniques have been described to address humeral shaft nonunion including: open reduction, internal fixation (ORIF) with compression plating and bone graft, dual plating, cortical strut allograft and autograft, and adding biologic augmentation (BMP). The current standard of care includes ORIF with compression plating and bone grafting, but even this technique has an approximated 10% failure rate. We describe a novel surgical technique using cup and cone reamers, which were originally designed for metatarsophalangeal or metacarpalphalangeal arthrodesis. Cup and cone reamers are the appropriate size for mid-shaft, transverse humeral nonunions to ensure ideal apposition of healthy, bleeding bone. Methods and patients: We retrospectively reviewed 3 patients with nonunion of the midshaft humerus which were treated with the cup and cone technique and a large fragment LCDC plate. An anterolateral approach was used in 2 cases and a posterior in the other. After exposure of fracture ends, 24-mm hemispherical convex and concave reamers were then used to ream the proximal and distal ends in order to create a “cup and cone” articulation of the fracture ends. All patients were followed for a minimum of 6 months with a mean follow-up of 12 months. Results: All patients treated with this technique achieved union, reported zero pain and full functional outcome. Specifically, patients had a mean age of 36.3 and the mean interval between injury and time to surgery was 11.5 months. Two of the patients presented with nonunions after attempted closed treatment and the other patient had 3 prior surgeries for infected nonunion. Union was achieved at a mean of 12 weeks. Conclusion: To our knowledge, the use of cup and cone reamers for nonunion of the humerus has never been described. We describe a simple and effective technique for humeral shaft nonunions which has been successful in both septic and hypertrophic nonunions, as well as from multiple approaches-both anterolateral and posterior. © 2016 Elsevier Ltd. All rights reserved.

humerus technique reamer humeral shaft orthopaedic fracture trauma

Introduction Humeral shaft fractures are commonly injuries representing 5–8% of all fractures [1]. The vast majority of these fractures heal uneventfully with functional bracing and serial radiographic evaluation. However, recent literature quotes the nonunion rate at 5.5% [2,3] which is significantly greater than the historical 0–2% rate initially reported by Sarmiento [4]. Controversy continues to exist around selecting the best surgical strategy to treat humeral shaft nonunions with debate between closed and open techniques [2,5,6]. Closed surgical techniques. including intramedullary nailing [7,8] or external fixation [9], reduce the risk of sepsis and radial nerve

* Corresponding author at: Brian T. Nickel, Department of Orthopaedic Surgery, Box DUMC 3000, Durham, NC 27710, United States. Fax: (919) 681-7672 E-mail address: [email protected] (B.T. Nickel).

0020-1383 / © 2016 Elsevier Ltd. All rights reserved.

paralysis. Open reduction techniques [10–12] allow for more precise correction of deformity and the ability to obtain absolute stability. Open techniques include open reduction, internal fixation (ORIF) with compression plating and bone graft, dual plating, cortical strut allograft and autograft. This also allows the option of biologic augmentation. Despite the previously mentioned advantages to ORIF, the nonunion rate of open plating has been reported to be 4.3–12.5% [13–15]. This high rate of nonunion perhaps is related to nonstandardized bone preparation which varies between osteotomy [16], decortication, bone grafting with autograft or allograft, and limited fibrous callus removal [15]. Nevertheless, the reported optimal open treatment is resection of atrophic nonunions, shortening the bones, and drilling sclerotic areas to create apposing bleeding diaphyseal surfaces [5]. The authors aim to describe a novel surgical technique to achieve congruent bleeding diaphyseal surfaces for humeral shaft nonunions using cup and cone reamers originally designed for MTP arthrodesis.

B.T. Nickel et al. / Injury, Int. J. Care Injured 47S7 (2016) S40–S43

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The authors also will describe early success in a limited case series using this technique. Methods and patients Surgical technique Surgical approach is dependent upon both surgeon preference and location of the fracture. Generally, the posterior approach is sufficient for most midshaft nonunions, but proximal and distal fractures may require an anterolateral approach. Regardless of approach, care should be taken to protect and/or explore the radial nerve if indicated. First, the surgeon must expose the nonunion site, debride fibrous, avascular tissue and identify the bony fracture edges (Figure 1). The intramedullary canal must be re-opened with a curette to allow egress of marrow elements. Often, the use of a serrated bone clamp will assist in delivering the fracture site and stabilizing the humeral shaft from the reamer rotational forces. Next, the surgeon will ream both fracture ends (Figure 2a and 2b), reduce the fracture (Figure 2c), and apply a compression plate of their choice (Figure 2d). In detail, the reamer should be a 24 mm reamer, which comes standard in most cup and cone reamer trays; displayed is the Wright Medical Charlotte MTP Reamers used at the author’s institution. This should be done at a low speed initially, approximately 50% max reamer trigger speed, in order to protect from fracture propagation and to gently contour the fracture edges. Care should be taken to not shorten the fracture edges by more than 1 cm each or 2 cm combined. Once this is complete, the concave reamer will create the “cone” surface and the convex reamer creates a “cup” surface. The new bony surfaces are concentric and can be manipulated in all three planes to facilitate reduction and correct malalignment. Lastly, standard AO principals are used to apply a compression plate. Clinical Experience Retrospectively, three patients were reviewed that underwent this technique. The mean interval between injury and time to surgery was 11.5 months, range 7–18. There was a mean age of 36.3, range 30–48. Two of the patients presented with nonunions after a fall having failed attempted closed treatment and the other patient had 3 prior surgeries for infected nonunion after a motor vehicle collision. All patients treated with this technique achieved union (mean 12 weeks) and deformity correction (Figures 3–5). Moreover, all patients reported zero pain and full functional outcome.

Fig. 2. a) One fracture end is shaped into a “cup” with the convex reamer. b) The other fracture end is shaped into a “cone” with the concave reamer. c) Newly concentric surfaces are reduced. d) Compression plate applied.

mechanical and biological environment of the nonunion area [17–22]. Convex to concave reamers are widely cited in the orthopaedic literature to achieve arthrodesis in various joints including the knee [23], tibiotalocalcaneal [24], small joints of the hand [25], and first metatarsophalangeal [26]. Alternatives to cup and cone reamers involve osteotomes, curettes, motorized burrs/saws, and rounguers to fashion the bony ends, but this is a tedious process and can result

Discussion Diagnostic and treatment modalities of long bone nonunions have been evolving with a specific objective to optimize both the

Fig. 1. Debride nonunion and expose fracture edges.

Fig. 3. Aseptic nonunion after 8 months of failed function bracing; union at 11 weeks postop.

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studies would help determine the true efficacy of this technique. Future studies will evaluate combining this technique in septic nonunion cases with a methylmethacrylate antibiotic intramedullary nail when implanting hardware would be contraindicated. Conclusions The use of 24 mm cup and cone reamers for open surgical treatment of humeral shaft nonunions has never been described. We describe a fast, simple, and effective technique to correct alignment in any plane and maximize bony surface contact for humeral shaft nonunions. Clinically, it has been successful in both septic and hypertrophic nonunions, as well as from multiple approaches-both anterolateral and posterior. This technique is an excellent option for fractures which are neither amendable to closed treatment or have failed previous closed or open surgical fixation. Conflict of interest None References Fig. 4. Aseptic nonunion after 6 months of failed function bracing; union at 12 weeks postop.

Fig. 5. Deformed septic nonunion failed original ORIF, two irrigation and debridement with removal of hardware; union at 13 weeks postop.

in imperfect apposition of the contiguously prepared surfaces [25]. Therefore, advantages of cup and cone reamers include their ability simply and easily maximize bone to bone surface area contact at the fusion site [24], while allowing correction of deformity in any plane due to the adjacent concentric surfaces. There are limitations to this technique. As with shortening osteotomies, any reduction in bone length may lead to a secondary loss of triceps muscle tensioning. Previous literature reported that shortening the humerus by two or more centimeters may cause significant reduction in triceps force with particularly negative implications in patients requiring terminal extension strength for weight bearing [27]. For this reason, we recommend as minimal shortening as necessary at the fracture ends to create cup/cone surfaces-one should attempt not to trim greater than two centimeters in total. Secondly, care should be taken to minimize reamer speed upon initial contact of the fracture sites to avoid rotational forces. Lastly, our small cohort of patients is underpowered and larger, prospective

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