- Jaime Morales MD#15449jmc at comb dot catOrthopaedic Surgery Service, Hospital del Vendrell (Tarragona), Spain
- Jordi Canosa MDOrthopaedic Surgery Service, Hospital del Vendrell (Tarragona), Spain
The lack of consolidation of humeral diaphysis fractures following surgery is described with an incidence of 2.5 - 13%    . Pseudoarthrosis may give rise to significant morbidity by limiting activities of daily life due to pain and loss of function. Literature abounds in studies on different methods for treating pseudoarthrosis of the humerus after the first treatment has failed, with a success rate of almost 100%            . Despite this success, there are no studies on the treatment of refractory pseudoarthrosis after failure of more than one surgical procedure. Our study report the case of a patient with refractory pseudoarthrosis after the failure of several treatment attempts, which was solved thanks to osteosynthesis and the implantation of a cortical allograft strut in internal osteosynthesis based on the sandwich technique, similar to that used in periprosthetic fractures of the femur.
A 40-year old female patient with no relevant past medical history, who was thrown from a horse. She was taken to the emergency room of another hospital where she was diagnosed for a comminuted fracture of the distal third of the right humerus (type C3 of the AO classification) (Fig 1). The examination showed that there was no vascular-nervous damage. A surgical procedure was performed and an internal osteosynthesis applied, by placing a strut on the external face, connected to several wire cerclages. The postoperative radiological examination evidenced reduction and adequate alignment. Despite this, the synthesis was unstable, due to insufficient cortical screws in the proximal area. The fracture progressed to gradual decoaptation of the top screws, with pseudoarthrosis of the fracture. For this reason, the patient was again subjected to surgery and a new osteosynthesis was performed on the anterior face of the humerus. This osteosynthesis also failed to consolidate the fracture and the pseudoarthrosis persisted (Fig.2).
In view of these failed attempts, the patient visited our hospital for a new procedure. All the material was removed, and a decortication was performed, with filling from an autologous graft taken from the iliac crest and a new synthesis, which resulted in stable fixation. The postoperative radiological examination evidenced the adequate alignment of the bone, stable synthesis and plenty of autologous graft. Successive radiological controls led us to think that the fracture was consolidated. Despite the radiological image, a new injury caused the rupture of the synthesis material and the radiological examination showed a clear non-union of the bone (Fig.3). At this point, we were faced with a patient with a rupture of the material, as a consequence of humeral pseudoarthrosis, who had undergone several surgical procedures.
To solve this problem we planned a fourth operation consisting of removing all the material, implanting a cortical allograft on the inner face of the humerus shaft and synthesis of the bone fragments and allograft with a moulded plate on the outer face (Fig.4). In radiological terms, the whole assembly was shown to evolve towards bone consolidation and complete integration of the allograft (Fig.5). From the clinical standpoint, the patient was completely mobile and had no pain in her shoulder or elbow. Her muscular strength was normal and there was no evidence of sepsis or any effect on the radial nerve (Fig.6).
The most common cause of failed primary surgical treatment in diaphyseal fractures of the humerus is insufficient internal fixation     . The current guidelines for the adequate fixation of an osteosynthesis recommend both in primary fixation and in cases of pseudoarthrosis the insertion of six to ten cortical screws      . The necessary surgical techniques for successfully treating humeral pseudoarthrosis have been well described. These techniques generally include changing the osteosynthesis, making an open reduction and internal fixation with a dynamic compression plate and autogenic bone      . This is considered as the gold standard and the reported success rate with compression plates, screws of 4.5 mm and autogenic bone graft is 90%     . Although several investigators have reported the treatment of pseudoarthrosis in primary humeral diaphysis, few studies have focused solely on the review procedures for recovering refractory pseudoarthrosis with persistent non-consolidation after several procedures. Some studies have focused on complex surgical techniques for treating persistent pseudoarthrosis after two or more surgical procedures. Patel used a circular external Ilizarov fixing device in 16 patients , Martí recently reported a series of 51 patients with humeral diaphyseal pseudoarthrosis, of whom 10 had undergone at least two surgical procedures before the authors' intervention . Hornicek was the first author to describe the successful use of cortical grafts with struts to reinforce the osteosynthesis in persistent pseudoarthrosis of the humerus .
The aetiology of humeral pseudoarthrosis is due to many factors. Systemic factors (metabolic diseases, medicines ,...) and toxic habits (smoking) have been reported. Also, poor bone quality with osteopenia or osteoporosis may be a factor enhancing the non-consolidation of these fractures . Despite this, local factors and those caused by treatment are much more important. In the first group, the severity and seriousness of the injury, the opening of the focus, the comminuting of the fracture and the vascular bone filling lesion are to be highlighted. There are variable aetiological agents related to treatment, depending on whether that treatment is conservative or surgical. In the latter case, the scant contact between the bone fragments, the diastasis of the focus, the lack of stability of the synthesis and the lack of vascularisation of the fragments are the most common predisposing factors.
If we consider the disease as a conjunction of biomechanics, limited bone vitality and adverse biological environment, we can also ascertain how to plan the rescue to achieve the consolidation with the best possible clinical outcome.
Weber explains the objectives of treatment of humeral pseudoarthrosis: consolidation of the focus through bone filling and stable synthesis, and fast mobilisation of the affected segment, in order to achieve maximum functionality of the affected segment. In our case, the third procedure completed was based on the guidelines given by Weber , but even so we were unable to achieve the consolidation objective. This leads us to think that, in some cases, pseudoarthrosis fails to respond to treatment and thus new treatment techniques must be applied.
In recent years, different studies have been published describing new types of treatment. New indications are microvascular grafts , autologous or allograft of the fibula implanted in the bone marrow cavity or fixed "onlay" with a plate and screws , structural allografts of the bone shaft   , and the use of bone marrow concentrates or BMP  .
The use of the cortical allograft as a strut, in accordance with the so-called sandwich technique, was originally used to treat periprosthetic fractures of the femur, in cases of severe osteopenia or osteoporosis. The allograft acts as a biological plate, either alone or in combination with other internal fixation devices, stabilising the fracture  . In addition to bringing mechanical stability, which can improve the healing of the fractures, it also increases bone density. Provided they are duly selected and prepared. The cortical allograft can be customised to adapt to practically any femur or humerus. Several studies show its efficacy with consolidation rates ranging from 89 to 99% when used in treating periprosthetic fractures of the femur        , and good results in periprosthetic fractures of the humerus following total elbow arthroplasty .
There is a dynamic change in the graft biomechanics during the incorporation and the remodelling process. The mechanics and histological response have been well studied in the canine model   . A highly vascularised area forms mesenchymal tissue at the graft-host union. Subsequently, the osteoclasts create cut-off cones in the graft, which is then invaded by vascular shoots. As the graft remodelling takes place, it becomes weaker and more susceptible to a mechanical failure, unless the fracture is consolidated. Therefore, the construction must be sufficiently safe during the incorporation period, 4-6 months, to ensure the fracture consolidates before the cortical allograft weakens. This is the rationale for the use of a rigid internal fixation in our case. Thus, stable fixation, with as many screws as possible. This is facilitated by the good apposition of the struts in the bone. On the other hand, the use of spongy graft may improve both fracture consolidation and union of the cortical allograft   .
In our opinion, the allograft offers many advantages. In the case reported, it allows us to restore the internal humeral shaft and what we could call the shoe. As a natural consequence, we reconstructed the Pauwels’ principle of distractive and compressive forces. The result of all this is the achievement of very favourable biomechanics for consolidating the focus. It also prevents new bone capital losses, with all the screws together creating a plate-humerus-allograft. Therefore, the screws can be secured to the strut formed by the cortical allograft, increasing fracture stability. Consequently, this is a highly stable "construction" that makes it possible to improve the local setting, the biology and the biomechanics    .
The potential disadvantages of this technique are based on the extensive de-periostisation required to insert the plate and the allograft as of a strut. In theory, this could compromise the blood supply to the receiving axis, but in our case this has not been shown to be clinically important.
It is admitted that allograft procedures entail many factors which increase the risk of infection, including large surgical incisions, extensive soft tissue resection, long exposure time and an increase in blood loss. Therefore, the risk of infection associated with the use of allografts is likely related to other graft contamination factors  , but even so utmost care must be exerted in using these surgical procedures.
Other types of treatment for use in refractory pseudoarthrosis of the humerus, such as the use microvascularised bone grafts , require a specialised department that is not always available at all hospitals. In addition, there is a not a wide experience in the use of morphogenetic bone proteins alone or in combination with conventional autografts .
In conclusion, we can assure that the use of a cortical allograft as a strut, using the sandwich technique associated with internal osteosynthesis is a good method for solving cases of refractory humeral pseudoarthrosis. The main advantages of this method include the reduction of morbidity, rigid stabilisation and a rapid return to autonomy. The risk of iatrogenic lesions of the radial nerve must be considered during the procedure.
Jaime Morales: The author, their immediate family, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
Jordi Canosa: The author, their immediate family, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
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