Chronic nonunions of the humerus are a challenging problem. This report presents 13 cases of chronic humerus nonunion resulting from trauma or osteomyelitis treated with vascularized fibula transfer after failure of conventional management.
On average, patients were 35 years of age and had 4.2 prior operations. Average graft length was 12.5 cm and osseous healing was obtained in 92% patients with an average healing time of 18 weeks. Ninety one percent of patients who united had good to excellent range of motion of their shoulder and elbow. There were eight complications in 7 of 13 patients (54%). Two patients developed fractures of the graft, and three had superficial infections at the harvest site requiring operative debridement. Two patients had median neurapraxia that resolved by 4 months. Two patients complained of intermittent pain at the donor site.
Although uncommon, humeral non-unions that fail conventional treatment means to achieve union pose a daunting challenge. This is in part due to unfavorable soft-tissue envelopes and frequent osseous defects that arise from nonunion or osteomyelitis debridement. In this situation, vascularized fibular transfer may provide the best reconstructive option given its exceptional strength, availability of adequate bone length, and the ability to incorporate a skin paddle to provide healthy soft-tissue coverage. Although technically demanding with potential donor site morbidity liabilities and a risk for complications, this procedure offers hope of union to patients who have > 6 cm osseous defect and have failed other therapies.