This study is a review of 15 patients treated for an unstable nonunion of the distal part of the humerus with internal fixation with multiple plates and screws and autogenous bone grafting. The average time from the original injury to the nonunion surgery was 11 months. The average age of the 13 women and 2 men was 60 years (range, 26-84 years). The initial injury was treated operatively in 14 patients and non-operatively in 1. The surgical approach involved an olecranon osteotomy with subcutaneous ulnar nerve transposition, anterior capsular release, preservation of the collateral ligaments, and open reduction internal fixation with at least 2 orthogonally oriented 3.5mm reconstruction plates. Two patients had an osseous defect greater than 3 cm that was treated with a vascularized fibular bone graft via the brachial artery and vein. Postoperative mobilization began on the first postoperative day with gravity assisted range of motion. Twelve patients healed their nonunion within 4 months after the operative procedure. The average final follow-up was 51 months (range, 24-130) after the index procedure. The arc of elbow motion achieved averaged 95 degrees (range, 60-130 degrees). Forearm rotation was not restricted; strength was felt to be comparable to the contralateral limb. Two patients had no pain and 10 had mild pain. According to the Mayo Elbow Performance Index, 2 patients had an excellent result, 9 good and 1 fair. All olecranon osteotomies healed without breakage or loosening of the implants. However, two patients required removal of painful hardware from the olecranon. Eight patients had radiographic signs of arthrosis, rated grade 2 in 1 patient, and grade 1 in 7. One patient treated with a vascularized fibular graft had a loss of alignment of the articular fragment 2 months after the index procedure that required revision ORIF with canellous bone grafting. Five patients had severe contractures and 4 underwent secondary operative contracture release. Two patients exhibited ulnar nerve dysfunction postoperatively with 1 requiring revision neurolysis. The 3 patients with persistent nonunions were generally older, ranging in age between 64 and 74 years, and were treated with a semi constrained total elbow arthroplasty.
This study reports reasonable success in treating nonunions of the distal humerus with revision plating and autologous bone grafting in 12 of 15 patients. However, 10 of 15 patients underwent further surgical intervention with 2 patients developing subsequent ulnar nerve dysfunction. Four patients had significant elbow contractures despite anterior capsular release at the time of the initial nonunion surgery. Ultimate arc of motion and patient satisfaction, however, were quite high. The authors were unable to identify factors that corresponded with persistent nonunion other than advanced age, inactivity and osteopenia. This study helps us council patients with a persistent distal humeral nonunion with respect to risks and benefits and expected outcomes with surgical intervention. Although surgery may lead to a successful union in a high percent of patients, a number will require more than 1 surgical intervention, either for contracture release, hardware removal or ulnar nerve dysfunction. Further studies are necessary to elucidate patients that may not be candidates for ORIF and may be better treated with total elbow replacement.
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J of Bone and Joint Surg 85A: 1040-1046, 2003.