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Operative treatment of nonunions of the surgical neck of the humerus
Operative treatment of nonunions of the surgical neck of the humerus Xavier A. Duralde, MD, Evan L Flatow, MD, Roger G. Pollock, MD, Gregory P. Nicholson, MD, Edward B. Self, MD, and Louis U. Bigliani, MD, New York, N. Y.
Twenty patients underwent surgical reconstruction for nonunion of fractures of the surgical neck of the humerus. Average time from injury to surgery was 10 months (range 4 to 14 months). The operation consisted of bone grafting combined with humeral head replacement in 10 cases and open reduction and internal fixation in 10 cases. Results, at an average follow-up of 51 months (range 24 to 124 months), were excellent in five (25%), satisfactory in six (30%), and unsatisfactory in nine (45%). Twelve nonunions resulted from fractures initially treated with closed reduction; repair of these nonunions achieved 67% excellent or satisfactory results. Eight nonunions resulted from fractures initially treated with internal fixation; repair of these nonunions achieved only 38% excellent or satisfactory results. Fifteen complications, 11 of which necessitated reoperation, occurred. Surgical reconstruction for nonunions of the surgical neck of the humerus usually results in significant improvement in pain but much more modest improvement in active motion and function. Surgery should be reserved for patients with significant symptoms and disability. (J SHOULDERELBOWSURG 1996;5:169-80.) Fractures of the proximal humerus are nondisplaced in the vast majority of cases and usually heal uneventfully with closed treatment. ~' 19, 23, 34 Nonunions of proximal humeral fractures are seen infrequently and pose a difficult problem for both patient and surgeon. These nonunions are commonly associated with significant pain and disability,~2, 2~, 2s, 26, 28and technical factors often limit the success of either open reduction and internal fixation or hemiarthroplasty. Poor bone quality caused by shaft resorption, head cavitation, osteoporosis, and communication with synovial fluid from the glenohumeral joint all interfere with successful treatment of nonunions in this area. 2~ Because of the potential for increased morbidity associated with attempted treatment of this problem, conservative management may be indicated for minimally symptomatic patients. 26 Earlier studies on treating proximal humeral nonunions concentrated on operative From The Shoulder Service, New York Orrhopaedic Hospital, Columbia Presbyterian Medical Center. Reprint requests: Louis U. Bigliani, MD, t61 Ft. Washington Ave., New York, N.Y. 10032. Copyright 9 1996 by Journal of Shoulder and Elbow Surgery Board of Trustees. 1058 2746/96/$5.00 + 0 3211169049
technique and contained few patients with relatively short follow-up. 3' 5, ~ Recent larger studies have shown significant improvement in both function and pain but their overall mixed results emphasize the difficulties in treating this problem. ~o, r2, 2~, 2s, 26 The purpose of this study was to review our experience with operative treatment of symptomatic nonunions of the surgical neck of the humerus. MATERIAL A N D METHODS Twenty patients were treated surgically for symptomatic nonunions of the surgical neck of the humerus during the past 11 years at the Shoulder Service of Columbia Presbyterian Medical Center, N. Y., and the Valley Hospital, N. J. Indications for surgery were pain and severe functional limitations. Patients with only mild or moderate complaints were treated conservatively. The study includes 20 patients with 20 nonunions of the surgical neck of the humerus. Nonunions distal to the insertion of the pectoralis major were not included in this study. There were 11 right and nine left shoulders. The dominant arm was affected in 11 cases and the nondominant arm in nine. The average patient age was 64 years (range 23 to 96
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Figure ! Example of inadequate fixation of surgical neck fracture resulting in nonunion.
years). Six patients were older than age 70, and two were older than age 80. All had been functionally independent before their proximal humeral fractures. There were 13 women and seven men. The interval between fracture and surgical treatment for nonunion averaged 10 months (range 4 to 14 months). Surgical neck nonunion developed after a twopart surgical neck fracture in 15 cases, a three-part surgical neck and greater tuberosity fracture in 3 cases, a three-part surgical neck and lesser tuberosity fracture in 1 case, and a four-part fracture in 1 case. All three- and four-part fractures resulted in malunion of the displaced tuberosities. Two patients had associated nerve injuries. All fractures were closed injuries, and there were no cases of polytrauma. In 12 cases, the original fracture had been treated nonoperatively. Causes for the development of nonunion were suggested by the clinical history, radiographic evaluation, and findings at surgery. In the 12 patients whose initial fractures were treated nonoperatively, the causes were multifactorial. Soft tissue interposition was found in eight cases. Poor bone quality was found in five cases and gleno-
Figure 2 Severe head cavitation and osteoporosis in chronic surgical neck nonunion.
humeral ankylosis was found in one. Inappropriately aggressive rehabilitation after fracture appeared to be an important factor in contributing to the nonunion in five cases on review of records. Additionally, two patients were initially treated in a hanging cast. Of the eight patients whose initial fracture was treated operatively, inadequate fixation was an important etiologic factor in creating a nonunion (Figure 1). Fixation techniques included Rush rods in 3, sutures in 2, screws in 1, staples in 1, and a Rush rod with figure-of-eight wires in 1. Both patients whose initial fractures were treated with sutures alone had suture breakage and severe excavation of the humeral head requiring humeral head replacement. Another patient initially treated with a Rush rod alone without a compressive suture or wire had a large hole in the humeral head and significant comminution of the proximal fragment requiring humeral head replacement. Finally, a 73-year-old diabetic patient whose initial fracture was treated with two small screws had loss of
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Table I Pain 0
None
1 2 3
Slight or occasional; no compromise in activity Only after unusual activity but disappears quickly Moderate, interfering with some activities; makes concessions Marked with serious limitations of shoulder activity; occasionally requires medication and interrupts sleep Complete shoulder disability; interrupts sleep
4 5
fixation. This patient also had a preexisting indolent infection not apparent until after nonunion repair with a T-plate, resulting in a deep infection requiring metal removal and head excision. Five patients in the group initially treated operatively were noted to have very poor bone quality at the time of revision surgery, contributing to loss of fixation and development of the nonunion. At examination, patients had pain, loss of motion, and limited function. Sixteen (80%)described their pain as totally disabling, requiring medication and interrupting sleep. All 20 patients had severe restrictions in their ability to perform activities of daily living because of the nonunion. Seven patients had flail shoulders and essentially no active shoulder motion. Preoperative active forward elevation averaged 37 ~ (range 0 ~ to 85~ and preoperative active external rotation averaged 10 ~ (range -30 ~ to 60~ Operative treatment of the nonunion consisted of either open reduction and internal fixation (ORIF) or shoulder arthroplasty depending on the quality of the bone and the status of the glenohumeral joint articular surfaces at the time of surgery. Indications for a humeral head replacement were severe head cavitation or osteoporosis that precluded internal fixation (Figure 2). Coexisting glenohumeral arthritis was also an indication for humeral head replacement. Open reduction and internal fixation was performed in patients with preserved articular surfaces and a proximal bone fragment of adequate quality to hold internal fixation. Bone grafting was used to compensate for proximal shaft bone resorption in all cases. Ten patients underwent ORIF and 10 others underwent shoulder arthroplasty using the Neer II prosthesis, including 9 hemiarthroplasties and 1 total shoulder replacement. Seven cases in the ORIF group received an intramedullary rod and figure-of-8 tension band, two cases received tension band wires alone, and 1 received a T-plate. In the arthroplasty
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Table II Function: Activities of daily living Sleep on that side Reach overhead Comb hair Reach mouth Reach opposite axilla Reach belt buckle Reach back pocket Reach between shoulder blades Carry 10 Ibs Do usual work Do usual sports
group, emphasis was placed on restoring the tension of the myofascial sleeve to compensate for proximal humeral bone loss, and the tuberosities were fixed to the humeral head prosthesis and to the humeral shaft. In one case with severe arthritic changes of the glenoid, a glenoid replacement was performed. The results were rated according to the stringent criteria of Neer for shoulder arthroplasty72 Patients were rated on the basis of pain, function, and range of motion. Pain assessment ranged from 0 (none) to 5 (totally incapacitating) (Table I). Function was assessed by the patient's ability to perform 10 different activities of daily living (Table II). Active elevation in the plane of the scapula and external rotation with the arm at the side were measured preoperatively and at subsequent postoperative visits. Results were rated as either excellent, satisfactory, or unsatisfactory. A patient with an excellent result was enthusiastic about the procedure, had no significant pain, full use of the shoulder, and muscle strength approaching normal. Active elevation was within 35 ~ of normal, and rotation was 90% of the normal side. In a satisfactory result, a patient was satisfied, had occasional pain or weather ache in the shoulder, good use of the arm with activities of daily living, and active forward elevation of at least 90 ~. Additionally, 50% of normal rotation was required for a satisfactory result. An unsatisfactory result failed to achieve these goals. SURGICAL PROCEDURE Surgery was performed in the modified beachchair position under either a general anesthetic (especially when iliac grafting was planned) or a regional anesthetic (interscalene block). The standard deltopectora[ approach was used. The biceps tendon, if present, was a helpful landmark
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Figure 4 Humeral head replacement for surgical neck
nonunion. Long, thin piecesof bone graft shouldbe placed between tuberosityfragment and humeral shaft to promote healing at nonunion site. Figure 3 Open reduction and internal fixation with modified Enders rods and figure-of-eightwire for surgical neck nonunion. Nonunion site is bone grafted.
used to identify the tuberosities and head fragment. Dissection around the nonunion site was often tedious because of distortion of normal anatomy. The axillary nerve was routinely palpated and avoided. The nonunion site commonly consisted of a large area of fibrous tissue or interposed soft tissue. Variable amounts of resorption of the proximal shaft and cavitation of the humeral head were usually present. Soft tissues were carefully dissected from both sides of the nonunion. Fibrous tissue was removed from the undersurface of the cavitated head, and the medullary canal of the distal shaft was opened with an awl. Bone ends were freshened. The distal shaft was generally displaced medially by the pull of the pectoralis tendon, and dissection of this fragment was carefully performed to avoid injury to the musculocutaneous nerve and the medial neurovascular structures. In cases where the proximal fragment was suitable for internal fixation, the bone ends on both sides of the nonunion were meticulously debrided to bleeding bone. Our current preferred technique of internal fixation consists of modified Enders rods
combined with a figure-of-eight tension band with heavy, nonabsorbable suture or wire (Figure 3). ~ The modified Enders rod contains an eye hole proximal to the slot in the rod, thereby reducing prominence and decreasing the chances of impingement. Two Enders rods were then placed through stab wounds in the rotator cuff in the area of the greater tuberosity and were passed through the proximal fragment into the shaft of the distal fragment. Heavy, nonabsorbable suture or wire was then passed through the eyes in these rods and through drill holes in the shaft fragment. Iliac crest bone graft was then wedged into the nonunion site, and additional graft was placed as an onlay type graft over the nonunion site. Nonabsorbable heavy nylon sutures were used circumferentially to hold the graft in place. The combination of the figure-of-8 tension band and intramedullary rods provided predictable longitudinal stability. The additional proximal hole in the Enders rod also avoided proximal displacement of the rods. Drains were placed, and the wound was closed in a routine fashion. Physical therapy, depending on the stability of the fixation, began the day after surgery. In cases where the stability of the construct was in doubt, a shoulder spica cast was used.
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Results: Pain m
%
Severe
Moderate
Minimal
Figure 5 Resultsof nonunion repair regarding pain.
Results: Function (ADL's) BE Pre-op ( ~ Post-op
%
Unsatisfactory
0 ; ~ ~, Satis.
O Satisfactory
Figure 6 ResuJtsof nonunion repair regarding activities of daily living. When the proximal fragment was unsuitable for fixation, a humeral head replacement was used (Figure 4). The biceps tendon was used to help identify the tuberosities. The lesser tuberosity was then osteotomized, taking a relatively small amount of bone with the subscapularis tendon insertion. The humeral head was excised with an osteotome or oscillating saw. If adequate bone stock was present, this often allowed the humeral head prosthesis to be skewered through this "donut"-Iike portion of bone containing the greater tuberosity. The stem of the prosthesis was then placed into the previously prepared medullary canal of the shaft. At this point, tensioning of the
myofascial sleeve was performed with manual longitudinal traction to determine the desired height of the prosthesis in the distal shaft. Typically, resorption of the distal shaft fragment had occurred and required altered placement of the humeral head prosthesis. If this bone loss were not compensated, the normal resting length of the deltoid would not be restored, and shoulder weakness and subluxation of the humeral head component would result. It is important to avoid excessive tightening of the joint with too large a component, because this will lead to glenoid wear and pain. Translation of approximately 50% of the humeral head on the glenoid with a push-pull manual test is
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Figure 7 Example of good resultafter ORIF with Enders rods and figure-of-eight wire for treating surgical neck nonunion (custom Enderswith added proximal hale were not yet available early in study).
Figure 8 Example of good result after humeral head replacement for treating surgical neck nonunion.
optimal for resting tension. After determining humeral head version and height, the humeral component was cemented into the medullary canal. The lesser tuberosity was sutured to the greater tuberosity, and the rotator interval was repaired. Iliac crest bone graft was placed into the surgical neck defect between the head and shaft fragments to reconstitute this bone. The wound was closed over drains. In cases where a small proximal fragment did not allow skewering of the bone with the prosthesis, the tuberosities were divided and the head excised. The tuberosities were then reattached to the fin of the prosthesis as in an acute fracture. Early passive motion within the limits allowed by the security of tuberosity fixation began after surgery.
in 5 (25%), satisfactory in 6 (30%), and unsatisfactory in 9 (45%). Pain relief improved, on average, from a score of 3.9 to 1.4. Before surgery, 16 had severe pain, 1 had moderate pain, and 3 had minimal pain. After surgery, only 3 (15%) patients had severe pain, 4 (20%) had moderate pain, and 13 (65%) had minimal pain. Significant improvement in pain was noted in most of the patients in this study (Figure 5). The majority of patients made substantial functional gains in activities of daily living. Before surgery, all patients were severely restricted in their activities of daily living. After surgery, 11 (55%) could function adequately at or above the horizontal. An additional four (20%) could function satisfactorily below 90 ~. However, five (25%) patients continued to have unsatisfactory function (Figure 6). Improvement in elevation for the entire group averaged 49 ~ from 37 ~ before to 86 ~ after sur-
RESULTS The patients in this study received follow-up treatment for an average of 51 months (range 24 to 124 months). The overall results were excellent
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Table III Results in patients with open reduction and internal fixation Patient 1 2 3 4 5 6 7 8 9 10
Fixation technique Rush rods and wire Painful hardware* Refused further treatment Rush rods and wire Revised to HHR Rush rods and wire Painful hardware Required hardware removal Rush rods and wire Painful hardware Required hardware removal Enders rods and suture Revised with free fibula graft Enders rods and wire Enders rods and wire Painful hardware Required hardware removal Wires Revised to HHR Wires T-plate Hardware and humeral head removed
Result
Final rating
Persistent n o n u n i o n
Unsatisfactory
Persistent n o n u n i o n
Unsatisfactory
Union at 6 months
Satisfactory
Union at 6 months
Satisfactory
Persistent n o n u n i o n
Unsatisfactory
Union at 5.5 mo Union at 9 mo
Excellent Excellent
Persistent n o n u n i o n
Unsatisfactory
Union at 8 mo Deep infection
Satisfactory Unsatisfactory
HHR, Humeral head replacement. *Pain associated with displaced internal fixation devices.
gery (range 0 ~ to 160~ Active external rotation improved 27 ~, from 10 ~ before to 37 ~ after surgery (range 0 ~ to 80~ Of the seven patients with flail extremities before surgery, five regained some function in the arm. However, only five patients overall were able to gain active elevation greater than 145 ~. An additional six patients gained active elevation between 90 ~ and 145 ~ The remaining nine patients could not actively elevate their arms above the horizontal. All nine patients who failed had unsatisfactory motion. Five of these nine patients also had unsatisfactory function in activities of daily living; three had severe pain, and four had moderate pain. There were no patients in the study who obtained satisfactory motion after surgery but were classified as unsatisfactory because of functional limitations or pain. When the results of open reduction and internal fixation were compared with those of humeral head replacement, no significant differences were noted. In the open reduction group, there were 2 excellent, 3 satisfactory, and 5 unsatisfactory resuits. In the humeral head replacement group, there were 3 excellent, 3 satisfactory, and 4 unsatisfactory results. Improvements in pain, motion, and function were similar in both groups. Significant improvements in both pain and function were
noted in both groups. Improvements in active motion, although not great, were similar in both groups. Review of different fixation techniques revealed a higher percentage of good results with the Enders and wire technique (Figure 7 and Table III), although total numbers in each category were small. A review of serial radiographs after surgery was undertaken to determine the time to union in the open reduction and internal fixation group and the rate of tuberosity healing in the prosthetic group. Of the 10 patients who underwent open reduction and internal fixation, only 5 (50%) obtained union at an average of 7 months (Table III). Two patients received humeral head replacements for persistent nonunion, one at 9 months and the other at 31 months after surgery. Both had final unsatisfactory results. One patient developed a deep infection after ORIF with a T-plate and bone grafting, requiring debridement, metal removal, and head excision. This resulted in a flail extremity and an unsatisfactory result. One patient required revision of the ORIF with a free fibular graft to bridge the nonunion site. The surgery was performed 14 months after ORIF. Computed tomographic scan at last follow-up showed a persistent nonunion proximally, although the distal aspect of the fibula graft
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healed to the humeral shaft. This patient also had an unsatisfactory result. The last patient in this group developed a persistent nonunion associated with prominence of the Rush rods and subluxation of the humeral head. This patient refused further surgery and has an unsatisfactory result. Of the 10 patients who underwent prosthetic replacement for surgical neck nonunion, tuberosity healing occurred in seven (70%) (Figure 8). Two tuberosity displacements and one tuberosity fragmentation occurred after surgery. One of the tuberosity displacements was revised at a second operation, but all three of these patients had an unsatisfactory result. A comparison of the initial fracture type was correlated with the results of nonunion surgery, independent of treatment method. Of the 5 patients whose three- or bur-part fractures had resulted in surgical neck nonunion, 1 had an excellent result and 4 had unsatisfactory results. Of the 15 patients who had nonunion after a two-part surgical neck fracture, 4 had excellent results, 6 had satisfactory results, and 5 had unsatisfactory results. Therefore excellent or satisfactory results were seen in 10 of 15 patients with surgical neck fractures compared with 1 of 5 patients whose original fractures were three- or four-part. The effect of initial fracture management on the results of nonunion surgery was evaluated. Of the 12 patients originally treated by closed reduction, excellent results were seen in 3, satisfactory results were seen in 5, and unsatisfactory results were seen in 4. The 8 patients with previous 9 had excellent results in 2, satisfactory results in 1, and unsatisfactory results in 5. Therefore satisfactory or excellent results were seen in 8 of the 12 patients whose initial fractures had been treated nonoperatively, compared with satisfactory or excellent results in 3 of 8 patients whose initial fracture had been treated with open reduction and internal fixation. Nine patients with nonunions of the surgical neck had significant associated medical problems. These included cardiac disease, carcinoma of the colon, peripheral vascular disease, diabetes, and colitis. Overall results in this group included 2 excellent, 3 satisfactory, and 4 unsatisfactory results. This compares favorably with the rest of the treatment group, who had excellent results in 3, satisfactory results in 3, and unsatisfactory results in5. The time interval between fracture and nonunion
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surgery ranged from 4 to 14 months, with an average of 10 months. No deterioration of results was noted with an increased time interval between fracture and nonunion surgery in either ORIF or humeral head replacement groups. The significance of age in relation to outcome was evaluated, and no trends were noted. Fifteen patients were older than age 60; of these, 3 had an excellent result, 6 a satisfactory result, and 6 an unsatisfactory result. There were 5 patients younger than age 60; of these, 2 had an excellent result and 3 an unsatisfactory outcome. Eleven additional operations were required after index surgery for surgical neck nonunion. Nine of these additional operations were required in the group that underwent open reduction and internal fixation. These included four procedures for metal removal for pain and impingement and two conversions to humeral head replacements for persistent nonunion. One of these patients additionally required a subscapularis lengthening after the humeral head replacement for excessive stiffness. One diabetic patient required excision of the humeral head and debridement for a deep infection. An additional patient with persistent nonunion underwent a vascularized fibular grafting. In the humeral head replacement group, two patients required additional surgery. One patient underwent revision surgery for persistent nonunion of the greater tuberosity and a second patient required lysis of adhesions and tuberosity advancement after postoperative fragmentation of the greater tuberosity. Eighteen intraoperative and postoperative complications occurred in this study. Ten of these complications occurred in the ORIF group, and eight occurred in the prosthetic replacement group. One deep infection following ORIF with a T-plate required hardware removal and head excision. Four patients required revision surgery for pain related to position of the internal fixation. Three of these patients had been treated initially with Rush rods and one with Enders rods. One patient, after free fibula grafting for persistent nonunion, fell and sustained a fracture of her fibular graft. This healed uneventfully in a cast. One patient in the ORIF group developed ulnar neuritis after surgery. Three patients in the ORIF group developed impingement symptoms from angular malalignment of the head at time of union. In the prosthetic replacement group, three patients developed tuberosity displacement, and two required revision surgery to
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address this. One patient fell 3 years after surgery and sustained a humeral shaft fracture distal to the prosthesis. This healed uneventfully in a cast. Two patients dislocated their humeral head prostheses after surgery. One of these was revised, and one was left dislocated because of minimal symptoms and advanced patient age. The latter patient, however, did develop ulnar neuritis from the humeral head dislocation. The last patient's complication occurred because the prosthesis was cemented too proximally, resulting in asymmetric wear of the glenoid and pain. DISCUSSION Proximal humeral fractures are common, especially in elderly women, and the frequency of these fractures is increasing. 1' 8, 12, ~4, ~8, 26 Although by no means common, nonunion of these fractures is not rare71 The advanced age and the predominance of women in our series are similar to those in prior studies. Nonunions are most commonly seen after displaced two-part fractures 8 or after cases in which open reduction and internal fixation is the initial treatment. 5 Nonunions occur with various fracture configurations and have been reported to occur with transverse, spiral, and comminuted fractures of the surgical neck. 1~ 18, 2 4 Treatment of established nonunions of the surgical neck is acknowledged to be a difficult reconstructive task, 21 and late reconstructive operations for nonunions have been considered "salvage procedures. ''4 The causes of nonunion of the surgical neck can be divided into factors unique to the area of the fracture site, factors associated with treatment, and systemic factors. As described by Neer, 21 there are multiple local anatomic factors that hinder bone healing. First, the weight of the arm causes distraction of the fracture fragments. Next, the distal fragment primarily consists of cortical bone with poorer healing qualities than the more proximal cancellous fragments. Softening and cavitation of the humeral head characteristically occur, further diminishing healing potential; this was seen in 10 patients in this study. Moreover, soft tissue such as the deltoid, rotator cuff, and biceps tendon can become interposed between the fracture fragments and prevent fracture healing. This was seen in eight of the patients whose initial fractures were treated nonoperatively. Synovial fluid from the adjacent joint can also communicate with the fracture site and limit hematoma formation and fracture
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healing. Displacement of the shaft anteriorly by the pectoralis major and displacement of the humeral head by the attached rotator cuff often limit the stability of the fracture after attempts at reduction. These anatomic factors can be compounded by factors associated with treatment. Distraction by the weight of the arm is worsened by hanging casts, used in two patients before referral. Rangeof-motion exercises begun too soon in the treatment of surgical neck fractures, before healing has occurred, can result in nonunion. This was felt to be a factor in five patients in this series. Five patients were initially treated by closed reduction for three- and four-part fractures, which are usually not amenable to this treatment. Malunion of the tuberosities with surgical neck nonunion occurred in all these cases. Fractures that are treated with ORE can develop nonunions when inadequate fixation techniques are employed and are followed by early postoperative motion of the shoulder. 2~ This was felt to be a significant factor in 5 of the 8 patients in this series whose initial fractures were treated operatively. Finally, systemic disease and polytrauma have also been associated with nonunions of proximal humeral fractures. 12 In this study, systemic disease did not play an important role, and no instances of polytrauma were present in the study group. Few reports in the literature exist concerning results and treatment of surgical neck nonunions. Neer stated in 198321 that only 29 cases had been reported in the literature, and he added an additional 50 cases. Other smaller patient studies with this problem have also been reported. 1~ ~2, 15, 2~, 29 In general, the reported treatment results in these studies are mixed, with approximately 50% of all patients achieving satisfactory results. Healy et al. 12 had good results in 12 of 25 patients, with fair or poor results in the remaining 13. The results were slightly better with open reduction and internal fixation, and they recommended this technique whenever possible rather than humeral head replacement. Kristiansen, 15 using Neer's original grading system, found that 9 of 20 patients had excellent or satisfactory results, while the majority of patients had unsatisfactory or poor results. Tanner and Cofield, 29 in a study of 28 patients whose nonunions were treated with arthroplasty, gave no overall ratings but reported similar results to ours regarding motion, pain, and function after surgery79 A major problem reported in their group was weakness of overhead activity in 40% of their patients.
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Twelve of the patients in their study showed some subluxation after surgery. Norris, 25 in a study of 23 patients, reported reliable improvement in pain, motion, and function, but overall results in each of these categories are very similar to those seen in our study. Frich, lo in his study of 42 patients treated for acute and chronic fractures with arthroplasty, included 1 6 patients with chronic ~o- or three-part fractures. Results in this group were good in only three patients and fair or poor in the other 13. These authors emphasize the difficulty of shoulder reconstruction for nonunions of the surgical neck of the humerus. The decision to treat a nonunion of the surgical neck of the humerus operatively should be weighed carefully in terms of the risks and benefits to the patients. Although nonunion of the surgical neck is often associated with pain and severe restriction in function, 12' 21, 25, 28 nearly 50% of patients may be relatively asymptomatic, 2~ and nonoperative treatment is a viable option for this group. Treatment options for patients with surgical neck nonunions include humeral head replacement, open reduction and internal fixation, or skillful neglect. For any surgical procedure to be undertaken in this group, the deltoid and external rotators of the shoulder should function adequately and the patients should possess a satisfactory general medical condition to tolerate surgery. Healy et al. 12 reported poor results in patients treated nonoperatively at their institution, and others have shown a reliable improvement in pain and strength with treatment of nonunions. ~2 However, as reviewed previously, results of surgical treatment for nonunion have been mixed, with approximately 50% unsatisfactory results. 1~ 12, 15, 25, 29 Although the risk for further cavitation of the head exists with delayed surgery, there was no statistical relationship in our series between the interval from injury to nonunion surgery and outcome. Our data support the view that this problem can be treated expectantly, and that patients should undergo operative intervention only if significantly symptomatic. Asymptomatic or minimally symptomatic patients are encouraged to pursue a course of nonoperative management because the risks of surgery are significant and the benefits are limited in a large percentage of patients. A number of internal fixation techniques have been suggested for treating nonunions of the surgical neck. 2' 11, 12, 1~, 17, 21, 27, sl Our choice of fixation has been the 3.5 mm Enders intramedul-
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lary rods with tension band sutures or wires because this technique specifically addresses problems with fixation unique to this area. ~ 9, 21 The poor quality of bone in the humeral head and osteoporosis noted in the shaft make fixation in this area tenuous. The tension band technique incorporates rotator cuff tendons, which are usually stronger than the soft osteoporotic bone, and converts tension forces at the fracture site to compressive forces, thereby aiding in healing. 6' 9 Recent biomechanic studies by Weinstein and Hawkins 33 have shown that the strength of intramedullary rods combined with tension band techniques is equal to plate and screw fixation for fractures of the proximal humerus in all failure modes, and that this technique is superior with respect to failure against tortional stresses.33 Because of bone loss at the surgical neck of the humerus, angulation of the head is relatively common with both screw-plate fixation or rod fixation. 3~ This angulation may result in painful impingement, leading to inferior results. Impingement from metallic fixation has been reported with both intramedullary rods and plates, often requiring later removal.8, 12, 15, 31 In this study, four patients required fixation removal for impingement symptoms. Custom Enders rods modified with an added hole through the proximal aspect of the rod allow the incorporation of tension band sutures or wires. ~' 7, 32 This technique limits proximal displacement that can cause impingement, as is more often seen with Rush rods. Use of a humeral head prosthesis in treating nonunions of the surgical neck is indicated in cases with severe osteoporosis (where the bone is too soft to hold fixation), glenohumeral arthritis, or severe cavitation of the humeral head. Patients who had very small osteoporotic head fragments had poor results with 9 in other studies. 12' 25 Humeral head replacement is preferable in cases in which osteoporosis, aggravated by disuse, leads to marginal internal fixation not allowing early motion. Humeral head replacement for surgical neck nonunions is demanding, however, and requires meticulous reconstruction of the rotator cuff. Proper tensioning of the myofascial Sleeve around the shoulder is essential in the operative treatment of nonunions of the surgical neck of the humerus.4, 21, 25. 29 Problems with dislocation and subluxation are reported in this and other studies, both after humeral head replacement and after internal fixation and bone grafting. 1~ 12 Results
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depend on reconstitution of anatomic alignment, 4 and poor results have been associated with subluxation. Patients who had failed initial attempts at open reduction and internal fixation of their surgical neck fractures had poorer outcomes after surgical treatment of their nonunions in our study. Whereas 8 of 12 patients whose initial fracture was treated with closure had excellent or satisfactory results, only 3 of 8 patients whose fracture was initially treated with ORIF had an excellent or satisfactory result. Frich et al. 1~ also found poorer results in those patients who had previously undergone ORIF. These results again emphasize the need for judicious selection of patients for ORIF with acute fractures of the surgical neck of the humerus and the necessity of achieving sound fixation on the first attempt. The most striking difference between those patients who underwent open reduction and internal fixation for a surgical neck nonunion and those who underwent humeral head replacement is seen in terms of the number of operations required in their treatment. In the ORIF group, nine additional operations were required for 10 patients, whereas only lwo additional operations were required after humeral head replacement. Neer 21 routinely recommended a second procedure, lysis of adhesions, to improve motion in those patients treated with ORIF for nonunions of the surgical neck of the humerus. Hardware problems were significant in four patients in our study and required hardware removal because of painful impingement. The need for secondary procedures, often required in patients who undergo ORIF, should be kept in mind when discussing surgical options with patients. The rating system chosen in this study is a stringent one used by Neer for evaluating patients after total shoulder arthroplasty7 2 The relatively high percentage of unsatisfactory results with this rating system emphasizes the difficulty in treating these patients and the limited functional results that are often obtained in patients with this complex problem. Earlier studies emphasized time to union and pain reduction in the evaluation of results rather than motion and function, s' lo, 12 Although some patients in our study returned to full function in activities of daily living, a significant proportion of patients had ongoing disability after treatment of their surgical neck nonunion. Eighteen complications were seen during the treatment of this patient group. Cofield 4 has reported displacement of a
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tuberosity as one of the most common problems seen when treating nonunions of the surgical neck with a humeral head prosthesis. This complication was seen in 3 of 10 patients in our series, 2 requiring revision surgery. The relatively high complication rate again demonstrates the difficulties involved in surgically treating these patients. Surgical neck nonunions of the humerus represent a difficult reconstructive problem. The results of surgical treatment can be described as inconsistent, with only 55% of patients in this study obtaining satisfactory or excellent results. However, reliable improvements in pain and low demand function can be obtained, but active motion, especially above the horizontal, is not regained by the majority of patients. Patients who are relatively asymptomatic should be treated expectantly, while surgery should be reserved for those patients with significant pain and functional limitations. Open reduction and internal fixation was performed in this study when the humeral articular surface was preserved and bone quality was adequate for fixation devices. Use of an intramedullary rod combined with a tension band technique is preferred because it provides longitudinal stability and incorporates the strong rotator cuff tendons. Reconstitution of the resting length of the deltoid is an important goal because poor results are noted if proper tensioning of the soft tissues is not obtained. Bone graft is needed at the nonunion site because bone resorption at the proximal end of the humeral shaft is common. Humeral head replacement is indicated in those patients with severe osteoporosis unsuitable for fixation and in those with destruction of the glenohumeral joint surfaces.
REFERENCES
1. Bengner U, Johnell O, Redlund-JohndlI. Changes in the incidenceof fractureof the upperend of the humerusduring a 30-yearperiod. Chn Orthop 1988;231:179-82. 2. Bigliani LU. Treatmentof ~o and three-partfracturesof the proximal humerus.In: BarrJS,jr, editor.The shoulder:instructional courselectures.Philadelphia:W.B. Saunders, 1990; 18:231-44. 3. Bosworlh DM. Blade plate fixation: techniquesuitable for fractures of surgical neck of humerusand similar lesions~ jAMA 1949;14]:1111-3. 4. Cofield RH Comminutedfracturesof the proximal humerus. Gin Orthop 1988;230:49-57. 5. CovenlryMB, LaurnenEL. Ununitedflacluresof the middle and upper humerus.Clin Qrthop 1970;69:192~8 6. CuomoFC, FlatowEL,Miller SR, MadayMG, McllveenSJ, Bigliani LU. Open reductionand internalfixation of 2- and
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10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.
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3-part displaced surgical neck fractures of the proximal humerus, j SHOUtDE~Etsow SuRo 1992;1:287-95. Day L. My technique for closed versus open prosthesis. My technique for 2-part. Presented at Update on Treatment of Displaced Proximal Humeral Fractures Symposium; Fourth Open Meeting, American Shoulder and Elbow Surgeons, 1988, Feb 7~ AtLanta (GAl. DePalma AF, Cautilli RA. Fractures of the upper end of the humerus. Clin Orthop 1961 ;20:73-93. Flatow EL, Cuomo FC, Maday MG, Miller SR, Mcllveen SJ, Bigliani LU. Open reduction and internal fixation of 2-part displaced greater tuberosity fractures of the proximal humerus. J Bone and Joint Surg 1991 ;73A(8): 1213-7. Frich LH, Soejbjerg JO, Sneppen O. Shoulder arthroplasly in complex acute and chronic proximal humeral fractures. Orthopaedics 1991 ; 14(9):949-54. Hawkins RJ, Kiefer GN. Internal fixation techniques for proximal humeral fractures. Clin Orthop 1987;223:77-85. Healy W, Jupiter J, Kristiansen T, White RR. Nonunion of the proximal humerus. J Orthop Trauma 1990;4(4):424-31. Heppenstall RB. Fractures of the proximal humerus. Orthop Clin North Am 1975;6(2):467-75. Horak J, Nilsson BE. Epidemiology of fracture of the upper end of the humerus. Clin Orthop 1975;112:250-3. Kristiansen B, Christensen SW. Plate fixation of proximal humeral fractures. Acta Orthop Scand 1986;57:320-3. Leach RE, Premer RF. Nonunion of the surgical neck of the humerus: method of internal fixation. Minn Med 1965;31822. Lorenzo FT. Osteosynthesis with Blount's staples in fractures of the proximal end of the humerus. J Bone Joint Surg 1955; 37A(1 ):45-8. McCreath SW. Delayed union and nonunion in fractures of the humeral shaft. J Bone Joint Surg 1975;57B:393. Neer CS II. Displaced proximal humeral fractures I. J Bone Joint Surg 1970;52A(6):1077-89. Neer CS Ih Displaced proximal humeral fractures II. J Bone Joint Surg 1970;52A(6): 1090-103.
J. Shoulder Elbow Surg. May/June 1996 21. Neer CS Ih Nonunion of the surgical neck of the humerus. Orthop Trans 1983;7:389. 22. Neer CS II, Watson KC, Stanton FJ. Recent experience in total shoulder replacement. J Bone Joint Surg 1982;64A: 319-32. 23. Nevaiser JS. Complicated fractures and dislocations about the shoulder joint. J Bone Joint Surg 1962;44A(5):984-98. 24. Nissen-Lie SH. Pseudarthrosis humeri. Acta Orthop Scand 1952;21:22. 25. Norris TR, Turner JA, Bovill D. Nonunion of the upper humerus: an analysis of etiology and treatment: 28 cases. In: Post M, Morrey BF, Hawkins RJ, eds. Surgery o~ the shou}der. St Louis: Mosby, 1990. 26. Rockwood CA, Pearce JC. Management of proximal humerus nonunions. Orthop Trans 1989;13:644. 27. Scheck M. Surgical treatment of nonunions of the surgical neck of the humerus. Clin Orthop 1982;167:255-9. 28. Soerensen H. Pseudarthrosis of the surgical neck of the humerus: ~ o cases, one bilateral. Acta Orthop Scand 1964;34:132-8. 29. Tanner MW, Cofield RH. Prosthetic arthroplasty for fractures and fracture dislocations of the proximal humerus. C/in Othop 1983;179:116-28. 30. Vastamaki M. Osteosynthesis in nonunions of the humeral neck. J Bone Joint Surg (BR) 1992;(Suppl I):74B. 31. Wang GL, Reger SI, Stamp WG. Nonunion of fractures of the proximal humerus: a method of treatment using a modified moe plate. South Med J 1977;70(7):818-20. 32. Watson KC. Modifications of Rush pin fixation for fractures of the proximal humerus. Presented at the American Shoulder and Elbow Surgeons Annual Meeting. 1988, Nov, Santa Fe (NM). 33. Weinstein DM, Hawkins RJ. Biomechanica) comparison d tension band wiring versus plating in the fixation of three-part fractures of the proximal humerus. Orthop Trans 1994;18:3. 34. Young TB, Wallace W A Conservative treatment of fractures and fracture dislocations of the upper end of the humerus. J Bone Joint Surg 1985167B(3):373-7.
Twenty patients underwent surgical reconstruction for nonunion of fractures of the surgical neck of the humerus. Average time from injury to surgery was 10 months (range 4 to 14 months). The operation consisted of bone grafting combined with humeral head replacement in 10 cases and open reduction and internal fixation in 10 cases. Results, at an average follow-up of 51 months (range 24 to 124 months), were excellent in five (25%), satisfactory in six (30%), and unsatisfactory in nine (45%). Twelve nonunions resulted from fractures initially treated with closed reduction; repair of these nonunions achieved 67% excellent or satisfactory results. Eight nonunions resulted from fractures initially treated with internal fixation; repair of these nonunions achieved only 38% excellent or satisfactory results. Fifteen complications, 11 of which necessitated reoperation, occurred. Surgical reconstruction for nonunions of the surgical neck of the humerus usually results in significant improvement in pain but much more modest improvement in active motion and function. Surgery should be reserved for patients with significant symptoms and disability. (J SHOULDERELBOWSURG 1996;5:169-80.) Fractures of the proximal humerus are nondisplaced in the vast majority of cases and usually heal uneventfully with closed treatment. ~' 19, 23, 34 Nonunions of proximal humeral fractures are seen infrequently and pose a difficult problem for both patient and surgeon. These nonunions are commonly associated with significant pain and disability,~2, 2~, 2s, 26, 28and technical factors often limit the success of either open reduction and internal fixation or hemiarthroplasty. Poor bone quality caused by shaft resorption, head cavitation, osteoporosis, and communication with synovial fluid from the glenohumeral joint all interfere with successful treatment of nonunions in this area. 2~ Because of the potential for increased morbidity associated with attempted treatment of this problem, conservative management may be indicated for minimally symptomatic patients. 26 Earlier studies on treating proximal humeral nonunions concentrated on operative From The Shoulder Service, New York Orrhopaedic Hospital, Columbia Presbyterian Medical Center. Reprint requests: Louis U. Bigliani, MD, t61 Ft. Washington Ave., New York, N.Y. 10032. Copyright 9 1996 by Journal of Shoulder and Elbow Surgery Board of Trustees. 1058 2746/96/$5.00 + 0 3211169049
technique and contained few patients with relatively short follow-up. 3' 5, ~ Recent larger studies have shown significant improvement in both function and pain but their overall mixed results emphasize the difficulties in treating this problem. ~o, r2, 2~, 2s, 26 The purpose of this study was to review our experience with operative treatment of symptomatic nonunions of the surgical neck of the humerus. MATERIAL A N D METHODS Twenty patients were treated surgically for symptomatic nonunions of the surgical neck of the humerus during the past 11 years at the Shoulder Service of Columbia Presbyterian Medical Center, N. Y., and the Valley Hospital, N. J. Indications for surgery were pain and severe functional limitations. Patients with only mild or moderate complaints were treated conservatively. The study includes 20 patients with 20 nonunions of the surgical neck of the humerus. Nonunions distal to the insertion of the pectoralis major were not included in this study. There were 11 right and nine left shoulders. The dominant arm was affected in 11 cases and the nondominant arm in nine. The average patient age was 64 years (range 23 to 96
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Figure ! Example of inadequate fixation of surgical neck fracture resulting in nonunion.
years). Six patients were older than age 70, and two were older than age 80. All had been functionally independent before their proximal humeral fractures. There were 13 women and seven men. The interval between fracture and surgical treatment for nonunion averaged 10 months (range 4 to 14 months). Surgical neck nonunion developed after a twopart surgical neck fracture in 15 cases, a three-part surgical neck and greater tuberosity fracture in 3 cases, a three-part surgical neck and lesser tuberosity fracture in 1 case, and a four-part fracture in 1 case. All three- and four-part fractures resulted in malunion of the displaced tuberosities. Two patients had associated nerve injuries. All fractures were closed injuries, and there were no cases of polytrauma. In 12 cases, the original fracture had been treated nonoperatively. Causes for the development of nonunion were suggested by the clinical history, radiographic evaluation, and findings at surgery. In the 12 patients whose initial fractures were treated nonoperatively, the causes were multifactorial. Soft tissue interposition was found in eight cases. Poor bone quality was found in five cases and gleno-
Figure 2 Severe head cavitation and osteoporosis in chronic surgical neck nonunion.
humeral ankylosis was found in one. Inappropriately aggressive rehabilitation after fracture appeared to be an important factor in contributing to the nonunion in five cases on review of records. Additionally, two patients were initially treated in a hanging cast. Of the eight patients whose initial fracture was treated operatively, inadequate fixation was an important etiologic factor in creating a nonunion (Figure 1). Fixation techniques included Rush rods in 3, sutures in 2, screws in 1, staples in 1, and a Rush rod with figure-of-eight wires in 1. Both patients whose initial fractures were treated with sutures alone had suture breakage and severe excavation of the humeral head requiring humeral head replacement. Another patient initially treated with a Rush rod alone without a compressive suture or wire had a large hole in the humeral head and significant comminution of the proximal fragment requiring humeral head replacement. Finally, a 73-year-old diabetic patient whose initial fracture was treated with two small screws had loss of
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Table I Pain 0
None
1 2 3
Slight or occasional; no compromise in activity Only after unusual activity but disappears quickly Moderate, interfering with some activities; makes concessions Marked with serious limitations of shoulder activity; occasionally requires medication and interrupts sleep Complete shoulder disability; interrupts sleep
4 5
fixation. This patient also had a preexisting indolent infection not apparent until after nonunion repair with a T-plate, resulting in a deep infection requiring metal removal and head excision. Five patients in the group initially treated operatively were noted to have very poor bone quality at the time of revision surgery, contributing to loss of fixation and development of the nonunion. At examination, patients had pain, loss of motion, and limited function. Sixteen (80%)described their pain as totally disabling, requiring medication and interrupting sleep. All 20 patients had severe restrictions in their ability to perform activities of daily living because of the nonunion. Seven patients had flail shoulders and essentially no active shoulder motion. Preoperative active forward elevation averaged 37 ~ (range 0 ~ to 85~ and preoperative active external rotation averaged 10 ~ (range -30 ~ to 60~ Operative treatment of the nonunion consisted of either open reduction and internal fixation (ORIF) or shoulder arthroplasty depending on the quality of the bone and the status of the glenohumeral joint articular surfaces at the time of surgery. Indications for a humeral head replacement were severe head cavitation or osteoporosis that precluded internal fixation (Figure 2). Coexisting glenohumeral arthritis was also an indication for humeral head replacement. Open reduction and internal fixation was performed in patients with preserved articular surfaces and a proximal bone fragment of adequate quality to hold internal fixation. Bone grafting was used to compensate for proximal shaft bone resorption in all cases. Ten patients underwent ORIF and 10 others underwent shoulder arthroplasty using the Neer II prosthesis, including 9 hemiarthroplasties and 1 total shoulder replacement. Seven cases in the ORIF group received an intramedullary rod and figure-of-8 tension band, two cases received tension band wires alone, and 1 received a T-plate. In the arthroplasty
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Table II Function: Activities of daily living Sleep on that side Reach overhead Comb hair Reach mouth Reach opposite axilla Reach belt buckle Reach back pocket Reach between shoulder blades Carry 10 Ibs Do usual work Do usual sports
group, emphasis was placed on restoring the tension of the myofascial sleeve to compensate for proximal humeral bone loss, and the tuberosities were fixed to the humeral head prosthesis and to the humeral shaft. In one case with severe arthritic changes of the glenoid, a glenoid replacement was performed. The results were rated according to the stringent criteria of Neer for shoulder arthroplasty72 Patients were rated on the basis of pain, function, and range of motion. Pain assessment ranged from 0 (none) to 5 (totally incapacitating) (Table I). Function was assessed by the patient's ability to perform 10 different activities of daily living (Table II). Active elevation in the plane of the scapula and external rotation with the arm at the side were measured preoperatively and at subsequent postoperative visits. Results were rated as either excellent, satisfactory, or unsatisfactory. A patient with an excellent result was enthusiastic about the procedure, had no significant pain, full use of the shoulder, and muscle strength approaching normal. Active elevation was within 35 ~ of normal, and rotation was 90% of the normal side. In a satisfactory result, a patient was satisfied, had occasional pain or weather ache in the shoulder, good use of the arm with activities of daily living, and active forward elevation of at least 90 ~. Additionally, 50% of normal rotation was required for a satisfactory result. An unsatisfactory result failed to achieve these goals. SURGICAL PROCEDURE Surgery was performed in the modified beachchair position under either a general anesthetic (especially when iliac grafting was planned) or a regional anesthetic (interscalene block). The standard deltopectora[ approach was used. The biceps tendon, if present, was a helpful landmark
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Figure 4 Humeral head replacement for surgical neck
nonunion. Long, thin piecesof bone graft shouldbe placed between tuberosityfragment and humeral shaft to promote healing at nonunion site. Figure 3 Open reduction and internal fixation with modified Enders rods and figure-of-eightwire for surgical neck nonunion. Nonunion site is bone grafted.
used to identify the tuberosities and head fragment. Dissection around the nonunion site was often tedious because of distortion of normal anatomy. The axillary nerve was routinely palpated and avoided. The nonunion site commonly consisted of a large area of fibrous tissue or interposed soft tissue. Variable amounts of resorption of the proximal shaft and cavitation of the humeral head were usually present. Soft tissues were carefully dissected from both sides of the nonunion. Fibrous tissue was removed from the undersurface of the cavitated head, and the medullary canal of the distal shaft was opened with an awl. Bone ends were freshened. The distal shaft was generally displaced medially by the pull of the pectoralis tendon, and dissection of this fragment was carefully performed to avoid injury to the musculocutaneous nerve and the medial neurovascular structures. In cases where the proximal fragment was suitable for internal fixation, the bone ends on both sides of the nonunion were meticulously debrided to bleeding bone. Our current preferred technique of internal fixation consists of modified Enders rods
combined with a figure-of-eight tension band with heavy, nonabsorbable suture or wire (Figure 3). ~ The modified Enders rod contains an eye hole proximal to the slot in the rod, thereby reducing prominence and decreasing the chances of impingement. Two Enders rods were then placed through stab wounds in the rotator cuff in the area of the greater tuberosity and were passed through the proximal fragment into the shaft of the distal fragment. Heavy, nonabsorbable suture or wire was then passed through the eyes in these rods and through drill holes in the shaft fragment. Iliac crest bone graft was then wedged into the nonunion site, and additional graft was placed as an onlay type graft over the nonunion site. Nonabsorbable heavy nylon sutures were used circumferentially to hold the graft in place. The combination of the figure-of-8 tension band and intramedullary rods provided predictable longitudinal stability. The additional proximal hole in the Enders rod also avoided proximal displacement of the rods. Drains were placed, and the wound was closed in a routine fashion. Physical therapy, depending on the stability of the fixation, began the day after surgery. In cases where the stability of the construct was in doubt, a shoulder spica cast was used.
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Results: Pain m
%
Severe
Moderate
Minimal
Figure 5 Resultsof nonunion repair regarding pain.
Results: Function (ADL's) BE Pre-op ( ~ Post-op
%
Unsatisfactory
0 ; ~ ~, Satis.
O Satisfactory
Figure 6 ResuJtsof nonunion repair regarding activities of daily living. When the proximal fragment was unsuitable for fixation, a humeral head replacement was used (Figure 4). The biceps tendon was used to help identify the tuberosities. The lesser tuberosity was then osteotomized, taking a relatively small amount of bone with the subscapularis tendon insertion. The humeral head was excised with an osteotome or oscillating saw. If adequate bone stock was present, this often allowed the humeral head prosthesis to be skewered through this "donut"-Iike portion of bone containing the greater tuberosity. The stem of the prosthesis was then placed into the previously prepared medullary canal of the shaft. At this point, tensioning of the
myofascial sleeve was performed with manual longitudinal traction to determine the desired height of the prosthesis in the distal shaft. Typically, resorption of the distal shaft fragment had occurred and required altered placement of the humeral head prosthesis. If this bone loss were not compensated, the normal resting length of the deltoid would not be restored, and shoulder weakness and subluxation of the humeral head component would result. It is important to avoid excessive tightening of the joint with too large a component, because this will lead to glenoid wear and pain. Translation of approximately 50% of the humeral head on the glenoid with a push-pull manual test is
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Figure 7 Example of good resultafter ORIF with Enders rods and figure-of-eight wire for treating surgical neck nonunion (custom Enderswith added proximal hale were not yet available early in study).
Figure 8 Example of good result after humeral head replacement for treating surgical neck nonunion.
optimal for resting tension. After determining humeral head version and height, the humeral component was cemented into the medullary canal. The lesser tuberosity was sutured to the greater tuberosity, and the rotator interval was repaired. Iliac crest bone graft was placed into the surgical neck defect between the head and shaft fragments to reconstitute this bone. The wound was closed over drains. In cases where a small proximal fragment did not allow skewering of the bone with the prosthesis, the tuberosities were divided and the head excised. The tuberosities were then reattached to the fin of the prosthesis as in an acute fracture. Early passive motion within the limits allowed by the security of tuberosity fixation began after surgery.
in 5 (25%), satisfactory in 6 (30%), and unsatisfactory in 9 (45%). Pain relief improved, on average, from a score of 3.9 to 1.4. Before surgery, 16 had severe pain, 1 had moderate pain, and 3 had minimal pain. After surgery, only 3 (15%) patients had severe pain, 4 (20%) had moderate pain, and 13 (65%) had minimal pain. Significant improvement in pain was noted in most of the patients in this study (Figure 5). The majority of patients made substantial functional gains in activities of daily living. Before surgery, all patients were severely restricted in their activities of daily living. After surgery, 11 (55%) could function adequately at or above the horizontal. An additional four (20%) could function satisfactorily below 90 ~. However, five (25%) patients continued to have unsatisfactory function (Figure 6). Improvement in elevation for the entire group averaged 49 ~ from 37 ~ before to 86 ~ after sur-
RESULTS The patients in this study received follow-up treatment for an average of 51 months (range 24 to 124 months). The overall results were excellent
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Table III Results in patients with open reduction and internal fixation Patient 1 2 3 4 5 6 7 8 9 10
Fixation technique Rush rods and wire Painful hardware* Refused further treatment Rush rods and wire Revised to HHR Rush rods and wire Painful hardware Required hardware removal Rush rods and wire Painful hardware Required hardware removal Enders rods and suture Revised with free fibula graft Enders rods and wire Enders rods and wire Painful hardware Required hardware removal Wires Revised to HHR Wires T-plate Hardware and humeral head removed
Result
Final rating
Persistent n o n u n i o n
Unsatisfactory
Persistent n o n u n i o n
Unsatisfactory
Union at 6 months
Satisfactory
Union at 6 months
Satisfactory
Persistent n o n u n i o n
Unsatisfactory
Union at 5.5 mo Union at 9 mo
Excellent Excellent
Persistent n o n u n i o n
Unsatisfactory
Union at 8 mo Deep infection
Satisfactory Unsatisfactory
HHR, Humeral head replacement. *Pain associated with displaced internal fixation devices.
gery (range 0 ~ to 160~ Active external rotation improved 27 ~, from 10 ~ before to 37 ~ after surgery (range 0 ~ to 80~ Of the seven patients with flail extremities before surgery, five regained some function in the arm. However, only five patients overall were able to gain active elevation greater than 145 ~. An additional six patients gained active elevation between 90 ~ and 145 ~ The remaining nine patients could not actively elevate their arms above the horizontal. All nine patients who failed had unsatisfactory motion. Five of these nine patients also had unsatisfactory function in activities of daily living; three had severe pain, and four had moderate pain. There were no patients in the study who obtained satisfactory motion after surgery but were classified as unsatisfactory because of functional limitations or pain. When the results of open reduction and internal fixation were compared with those of humeral head replacement, no significant differences were noted. In the open reduction group, there were 2 excellent, 3 satisfactory, and 5 unsatisfactory resuits. In the humeral head replacement group, there were 3 excellent, 3 satisfactory, and 4 unsatisfactory results. Improvements in pain, motion, and function were similar in both groups. Significant improvements in both pain and function were
noted in both groups. Improvements in active motion, although not great, were similar in both groups. Review of different fixation techniques revealed a higher percentage of good results with the Enders and wire technique (Figure 7 and Table III), although total numbers in each category were small. A review of serial radiographs after surgery was undertaken to determine the time to union in the open reduction and internal fixation group and the rate of tuberosity healing in the prosthetic group. Of the 10 patients who underwent open reduction and internal fixation, only 5 (50%) obtained union at an average of 7 months (Table III). Two patients received humeral head replacements for persistent nonunion, one at 9 months and the other at 31 months after surgery. Both had final unsatisfactory results. One patient developed a deep infection after ORIF with a T-plate and bone grafting, requiring debridement, metal removal, and head excision. This resulted in a flail extremity and an unsatisfactory result. One patient required revision of the ORIF with a free fibular graft to bridge the nonunion site. The surgery was performed 14 months after ORIF. Computed tomographic scan at last follow-up showed a persistent nonunion proximally, although the distal aspect of the fibula graft
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healed to the humeral shaft. This patient also had an unsatisfactory result. The last patient in this group developed a persistent nonunion associated with prominence of the Rush rods and subluxation of the humeral head. This patient refused further surgery and has an unsatisfactory result. Of the 10 patients who underwent prosthetic replacement for surgical neck nonunion, tuberosity healing occurred in seven (70%) (Figure 8). Two tuberosity displacements and one tuberosity fragmentation occurred after surgery. One of the tuberosity displacements was revised at a second operation, but all three of these patients had an unsatisfactory result. A comparison of the initial fracture type was correlated with the results of nonunion surgery, independent of treatment method. Of the 5 patients whose three- or bur-part fractures had resulted in surgical neck nonunion, 1 had an excellent result and 4 had unsatisfactory results. Of the 15 patients who had nonunion after a two-part surgical neck fracture, 4 had excellent results, 6 had satisfactory results, and 5 had unsatisfactory results. Therefore excellent or satisfactory results were seen in 10 of 15 patients with surgical neck fractures compared with 1 of 5 patients whose original fractures were three- or four-part. The effect of initial fracture management on the results of nonunion surgery was evaluated. Of the 12 patients originally treated by closed reduction, excellent results were seen in 3, satisfactory results were seen in 5, and unsatisfactory results were seen in 4. The 8 patients with previous 9 had excellent results in 2, satisfactory results in 1, and unsatisfactory results in 5. Therefore satisfactory or excellent results were seen in 8 of the 12 patients whose initial fractures had been treated nonoperatively, compared with satisfactory or excellent results in 3 of 8 patients whose initial fracture had been treated with open reduction and internal fixation. Nine patients with nonunions of the surgical neck had significant associated medical problems. These included cardiac disease, carcinoma of the colon, peripheral vascular disease, diabetes, and colitis. Overall results in this group included 2 excellent, 3 satisfactory, and 4 unsatisfactory results. This compares favorably with the rest of the treatment group, who had excellent results in 3, satisfactory results in 3, and unsatisfactory results in5. The time interval between fracture and nonunion
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surgery ranged from 4 to 14 months, with an average of 10 months. No deterioration of results was noted with an increased time interval between fracture and nonunion surgery in either ORIF or humeral head replacement groups. The significance of age in relation to outcome was evaluated, and no trends were noted. Fifteen patients were older than age 60; of these, 3 had an excellent result, 6 a satisfactory result, and 6 an unsatisfactory result. There were 5 patients younger than age 60; of these, 2 had an excellent result and 3 an unsatisfactory outcome. Eleven additional operations were required after index surgery for surgical neck nonunion. Nine of these additional operations were required in the group that underwent open reduction and internal fixation. These included four procedures for metal removal for pain and impingement and two conversions to humeral head replacements for persistent nonunion. One of these patients additionally required a subscapularis lengthening after the humeral head replacement for excessive stiffness. One diabetic patient required excision of the humeral head and debridement for a deep infection. An additional patient with persistent nonunion underwent a vascularized fibular grafting. In the humeral head replacement group, two patients required additional surgery. One patient underwent revision surgery for persistent nonunion of the greater tuberosity and a second patient required lysis of adhesions and tuberosity advancement after postoperative fragmentation of the greater tuberosity. Eighteen intraoperative and postoperative complications occurred in this study. Ten of these complications occurred in the ORIF group, and eight occurred in the prosthetic replacement group. One deep infection following ORIF with a T-plate required hardware removal and head excision. Four patients required revision surgery for pain related to position of the internal fixation. Three of these patients had been treated initially with Rush rods and one with Enders rods. One patient, after free fibula grafting for persistent nonunion, fell and sustained a fracture of her fibular graft. This healed uneventfully in a cast. One patient in the ORIF group developed ulnar neuritis after surgery. Three patients in the ORIF group developed impingement symptoms from angular malalignment of the head at time of union. In the prosthetic replacement group, three patients developed tuberosity displacement, and two required revision surgery to
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address this. One patient fell 3 years after surgery and sustained a humeral shaft fracture distal to the prosthesis. This healed uneventfully in a cast. Two patients dislocated their humeral head prostheses after surgery. One of these was revised, and one was left dislocated because of minimal symptoms and advanced patient age. The latter patient, however, did develop ulnar neuritis from the humeral head dislocation. The last patient's complication occurred because the prosthesis was cemented too proximally, resulting in asymmetric wear of the glenoid and pain. DISCUSSION Proximal humeral fractures are common, especially in elderly women, and the frequency of these fractures is increasing. 1' 8, 12, ~4, ~8, 26 Although by no means common, nonunion of these fractures is not rare71 The advanced age and the predominance of women in our series are similar to those in prior studies. Nonunions are most commonly seen after displaced two-part fractures 8 or after cases in which open reduction and internal fixation is the initial treatment. 5 Nonunions occur with various fracture configurations and have been reported to occur with transverse, spiral, and comminuted fractures of the surgical neck. 1~ 18, 2 4 Treatment of established nonunions of the surgical neck is acknowledged to be a difficult reconstructive task, 21 and late reconstructive operations for nonunions have been considered "salvage procedures. ''4 The causes of nonunion of the surgical neck can be divided into factors unique to the area of the fracture site, factors associated with treatment, and systemic factors. As described by Neer, 21 there are multiple local anatomic factors that hinder bone healing. First, the weight of the arm causes distraction of the fracture fragments. Next, the distal fragment primarily consists of cortical bone with poorer healing qualities than the more proximal cancellous fragments. Softening and cavitation of the humeral head characteristically occur, further diminishing healing potential; this was seen in 10 patients in this study. Moreover, soft tissue such as the deltoid, rotator cuff, and biceps tendon can become interposed between the fracture fragments and prevent fracture healing. This was seen in eight of the patients whose initial fractures were treated nonoperatively. Synovial fluid from the adjacent joint can also communicate with the fracture site and limit hematoma formation and fracture
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healing. Displacement of the shaft anteriorly by the pectoralis major and displacement of the humeral head by the attached rotator cuff often limit the stability of the fracture after attempts at reduction. These anatomic factors can be compounded by factors associated with treatment. Distraction by the weight of the arm is worsened by hanging casts, used in two patients before referral. Rangeof-motion exercises begun too soon in the treatment of surgical neck fractures, before healing has occurred, can result in nonunion. This was felt to be a factor in five patients in this series. Five patients were initially treated by closed reduction for three- and four-part fractures, which are usually not amenable to this treatment. Malunion of the tuberosities with surgical neck nonunion occurred in all these cases. Fractures that are treated with ORE can develop nonunions when inadequate fixation techniques are employed and are followed by early postoperative motion of the shoulder. 2~ This was felt to be a significant factor in 5 of the 8 patients in this series whose initial fractures were treated operatively. Finally, systemic disease and polytrauma have also been associated with nonunions of proximal humeral fractures. 12 In this study, systemic disease did not play an important role, and no instances of polytrauma were present in the study group. Few reports in the literature exist concerning results and treatment of surgical neck nonunions. Neer stated in 198321 that only 29 cases had been reported in the literature, and he added an additional 50 cases. Other smaller patient studies with this problem have also been reported. 1~ ~2, 15, 2~, 29 In general, the reported treatment results in these studies are mixed, with approximately 50% of all patients achieving satisfactory results. Healy et al. 12 had good results in 12 of 25 patients, with fair or poor results in the remaining 13. The results were slightly better with open reduction and internal fixation, and they recommended this technique whenever possible rather than humeral head replacement. Kristiansen, 15 using Neer's original grading system, found that 9 of 20 patients had excellent or satisfactory results, while the majority of patients had unsatisfactory or poor results. Tanner and Cofield, 29 in a study of 28 patients whose nonunions were treated with arthroplasty, gave no overall ratings but reported similar results to ours regarding motion, pain, and function after surgery79 A major problem reported in their group was weakness of overhead activity in 40% of their patients.
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Twelve of the patients in their study showed some subluxation after surgery. Norris, 25 in a study of 23 patients, reported reliable improvement in pain, motion, and function, but overall results in each of these categories are very similar to those seen in our study. Frich, lo in his study of 42 patients treated for acute and chronic fractures with arthroplasty, included 1 6 patients with chronic ~o- or three-part fractures. Results in this group were good in only three patients and fair or poor in the other 13. These authors emphasize the difficulty of shoulder reconstruction for nonunions of the surgical neck of the humerus. The decision to treat a nonunion of the surgical neck of the humerus operatively should be weighed carefully in terms of the risks and benefits to the patients. Although nonunion of the surgical neck is often associated with pain and severe restriction in function, 12' 21, 25, 28 nearly 50% of patients may be relatively asymptomatic, 2~ and nonoperative treatment is a viable option for this group. Treatment options for patients with surgical neck nonunions include humeral head replacement, open reduction and internal fixation, or skillful neglect. For any surgical procedure to be undertaken in this group, the deltoid and external rotators of the shoulder should function adequately and the patients should possess a satisfactory general medical condition to tolerate surgery. Healy et al. 12 reported poor results in patients treated nonoperatively at their institution, and others have shown a reliable improvement in pain and strength with treatment of nonunions. ~2 However, as reviewed previously, results of surgical treatment for nonunion have been mixed, with approximately 50% unsatisfactory results. 1~ 12, 15, 25, 29 Although the risk for further cavitation of the head exists with delayed surgery, there was no statistical relationship in our series between the interval from injury to nonunion surgery and outcome. Our data support the view that this problem can be treated expectantly, and that patients should undergo operative intervention only if significantly symptomatic. Asymptomatic or minimally symptomatic patients are encouraged to pursue a course of nonoperative management because the risks of surgery are significant and the benefits are limited in a large percentage of patients. A number of internal fixation techniques have been suggested for treating nonunions of the surgical neck. 2' 11, 12, 1~, 17, 21, 27, sl Our choice of fixation has been the 3.5 mm Enders intramedul-
J. Shoulder Elbow Surg. May/June 1996
lary rods with tension band sutures or wires because this technique specifically addresses problems with fixation unique to this area. ~ 9, 21 The poor quality of bone in the humeral head and osteoporosis noted in the shaft make fixation in this area tenuous. The tension band technique incorporates rotator cuff tendons, which are usually stronger than the soft osteoporotic bone, and converts tension forces at the fracture site to compressive forces, thereby aiding in healing. 6' 9 Recent biomechanic studies by Weinstein and Hawkins 33 have shown that the strength of intramedullary rods combined with tension band techniques is equal to plate and screw fixation for fractures of the proximal humerus in all failure modes, and that this technique is superior with respect to failure against tortional stresses.33 Because of bone loss at the surgical neck of the humerus, angulation of the head is relatively common with both screw-plate fixation or rod fixation. 3~ This angulation may result in painful impingement, leading to inferior results. Impingement from metallic fixation has been reported with both intramedullary rods and plates, often requiring later removal.8, 12, 15, 31 In this study, four patients required fixation removal for impingement symptoms. Custom Enders rods modified with an added hole through the proximal aspect of the rod allow the incorporation of tension band sutures or wires. ~' 7, 32 This technique limits proximal displacement that can cause impingement, as is more often seen with Rush rods. Use of a humeral head prosthesis in treating nonunions of the surgical neck is indicated in cases with severe osteoporosis (where the bone is too soft to hold fixation), glenohumeral arthritis, or severe cavitation of the humeral head. Patients who had very small osteoporotic head fragments had poor results with 9 in other studies. 12' 25 Humeral head replacement is preferable in cases in which osteoporosis, aggravated by disuse, leads to marginal internal fixation not allowing early motion. Humeral head replacement for surgical neck nonunions is demanding, however, and requires meticulous reconstruction of the rotator cuff. Proper tensioning of the myofascial Sleeve around the shoulder is essential in the operative treatment of nonunions of the surgical neck of the humerus.4, 21, 25. 29 Problems with dislocation and subluxation are reported in this and other studies, both after humeral head replacement and after internal fixation and bone grafting. 1~ 12 Results
J. Shoulder Elbow Surg. Volume 5, Number 3
depend on reconstitution of anatomic alignment, 4 and poor results have been associated with subluxation. Patients who had failed initial attempts at open reduction and internal fixation of their surgical neck fractures had poorer outcomes after surgical treatment of their nonunions in our study. Whereas 8 of 12 patients whose initial fracture was treated with closure had excellent or satisfactory results, only 3 of 8 patients whose fracture was initially treated with ORIF had an excellent or satisfactory result. Frich et al. 1~ also found poorer results in those patients who had previously undergone ORIF. These results again emphasize the need for judicious selection of patients for ORIF with acute fractures of the surgical neck of the humerus and the necessity of achieving sound fixation on the first attempt. The most striking difference between those patients who underwent open reduction and internal fixation for a surgical neck nonunion and those who underwent humeral head replacement is seen in terms of the number of operations required in their treatment. In the ORIF group, nine additional operations were required for 10 patients, whereas only lwo additional operations were required after humeral head replacement. Neer 21 routinely recommended a second procedure, lysis of adhesions, to improve motion in those patients treated with ORIF for nonunions of the surgical neck of the humerus. Hardware problems were significant in four patients in our study and required hardware removal because of painful impingement. The need for secondary procedures, often required in patients who undergo ORIF, should be kept in mind when discussing surgical options with patients. The rating system chosen in this study is a stringent one used by Neer for evaluating patients after total shoulder arthroplasty7 2 The relatively high percentage of unsatisfactory results with this rating system emphasizes the difficulty in treating these patients and the limited functional results that are often obtained in patients with this complex problem. Earlier studies emphasized time to union and pain reduction in the evaluation of results rather than motion and function, s' lo, 12 Although some patients in our study returned to full function in activities of daily living, a significant proportion of patients had ongoing disability after treatment of their surgical neck nonunion. Eighteen complications were seen during the treatment of this patient group. Cofield 4 has reported displacement of a
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tuberosity as one of the most common problems seen when treating nonunions of the surgical neck with a humeral head prosthesis. This complication was seen in 3 of 10 patients in our series, 2 requiring revision surgery. The relatively high complication rate again demonstrates the difficulties involved in surgically treating these patients. Surgical neck nonunions of the humerus represent a difficult reconstructive problem. The results of surgical treatment can be described as inconsistent, with only 55% of patients in this study obtaining satisfactory or excellent results. However, reliable improvements in pain and low demand function can be obtained, but active motion, especially above the horizontal, is not regained by the majority of patients. Patients who are relatively asymptomatic should be treated expectantly, while surgery should be reserved for those patients with significant pain and functional limitations. Open reduction and internal fixation was performed in this study when the humeral articular surface was preserved and bone quality was adequate for fixation devices. Use of an intramedullary rod combined with a tension band technique is preferred because it provides longitudinal stability and incorporates the strong rotator cuff tendons. Reconstitution of the resting length of the deltoid is an important goal because poor results are noted if proper tensioning of the soft tissues is not obtained. Bone graft is needed at the nonunion site because bone resorption at the proximal end of the humeral shaft is common. Humeral head replacement is indicated in those patients with severe osteoporosis unsuitable for fixation and in those with destruction of the glenohumeral joint surfaces.
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