The functional outcome of operative treatment of ununited fractures of thehumeral diaphysis in older patients

Twenty-two elderly patients (average age, seventy-two years) who had an atr ophic, unstable, ununited fracture of the humeral diaphysis were managed wi th plate-and-screw fixation and application of an autogenous bone graft fro m the iliac crest. Fifteen of the patients had had at least one previous op eration in an attempt to obtain union of the fracture. One patient had an a ctive infection and two had a quiescent infection, an with Staphylococcus e pidermidis. The average duration of nonunion before the patients were first seen by us was two years and four months (range, five months to sixteen ye ars). Fifteen of the nonunions were synovial. In each patient, at least one modification of the standard technique of plate-and-screw fixation was nee ded as a result of osteopenia. In order to enhance fixation, the standard p rotocol incorporated the use of a long plate (with an average of eleven hol es and an average length that was 76 percent of that of the bone), a plate, vith a blade (used in thirteen patients), and replacement of loose, 4.5-mil limeter cortical-bone screws with 6.5-millimeter cancellous-bone screws (tw elve patients). Spiked nuts (Schuhli nut; Synthes, Paoli, Pennsylvania) tha t lock the screws to the plate, creating a solid point of fixation analogou s to a blade, were incorporated into the protocol when they became availabl e (used in six patients). In five limbs, the nonunion was associated with a n osseous defect that could not be addressed by shortening of the bone alon e. Three of these limbs were stabilized with a bridge plate that had been c ontoured to stand away from the bone at the site of nonunion (so-called wav e-plate osteosynthesis), and the remaining two limbs were stabilized with a combination of intramedullary and extramedullary plates. In one of these t wo limbs, the extramedullary plate was contoured (that is, a wave plate). The fracture united in twenty (91 percent) of the patients. There was no pr ogressive loosening or breakage of a fixation device, even in two patients who had radiographs that were suggestive of an incomplete union. Five of th e patients were followed for a limited duration (average, one year and six months) as a result of death or illness. They had two excellent results, tw o good results, and one poor result according to a modification of the rati ng system of Constant and Murley. The remaining seventeen patients, includi ng the two who had a persistent nonunion, were followed for an average of t hree years and one month (range, two years to five years and ten months). T hey had significant improvements in all of the functional scores at the mos t recent follow-up evaluation: the average score according to the modified system of Constant and Murley increased from 9 to 72 points (p < 0.001), th e average score according to the Enforced Social Dependency Scale decreased from 39 to 9 points (p < 0.001), and the average score based on the Disabi lities of the Arm, Shoulder, and Hand Questionnaire decreased from 77 to 24 points (p < 0.001). According to the scores based on the Disabilities of t he Arm, Shoulder, and Hand Questionnaire, nine of the seventeen patients wh o had been followed for more than two years had an excellent result, four h ad a good result, two had a fair result, and the two who had a persistent n onunion had a poor result. Complications included postoperative delirium, a stitch abscess, transient radial nerve palsy, a fracture distal to the pla te, and the need for a blood transfusion, in one patient each. Two patients had a fibrous union. There were no major medical complications. An unstable, united fracture of the humeral diaphysis can be extremely disa bling and may threaten the ability of an elderly patient to function indepe ndently. Operative treatment can be very successful when the techniques of plate-and-screw fixation are modified to address osteopenia and relative or absolute loss of bone. Healing of the fracture substantially improves func tion and the degree of independence.