Humeral non-union is a rare complication following diaphyseal fractures, with an incidence reported to vary between 1% and 10% in different studies [1-3]. Surgical management typically involves open reduction, refreshing of fracture edges, and stabilization through various methods, such as plate and screw fixation, interlocking nails, or external fixators [4-5, 7-9]. The addition of cancellous bone grafts has been shown to significantly improve union rates. Osteoporosis is a frequent challenge in chronic humeral non-union cases, often resulting from disuse, advanced age, or prior surgeries. Achieving stable fixation with plates in osteoporotic bones can be particularly difficult [10-11]. To address this, techniques such as using polymethyl methacrylate with screws [12] and locking compression plates (LCPs) have been developed. Although LCPs are advantageous in managing these cases, their high cost and limited availability present challenges in resource-constrained settings. Interlocking nails or external fixators may not be suitable for elderly patients due to preexisting stiffness in adjacent joints at the time of treatment. This study presents the successful management of twelve cases of humeral non-union in osteoporotic patients using a combination of an intramedullary fibular strut graft and a dynamic compression plate with screws. The findings are based on experiences from a tertiary care hospital in SCB Medical College and hospital, Odisha.

A total of twelve patients with osteoporotic humeral shaft non-union were treated at tertiary care centres between 2021 and 2023 using a combination of an intramedullary fibular strut graft and dynamic compression plate (DCP). The inclusion criteria were diaphyseal fractures of the humerus that had failed to unite for a minimum of four months and were associated with severe osteoporosis and thin cortices. Patients with significant soft-tissue scarring or compromised vascularity were excluded and instead treated with vascularized fibular grafts, which are not included in this study. Due to the rarity and complexity of this condition, a control group could not be included.

The patients’ mean age was 67.75 years (range 53–85 years), consisting of seven females and five males (Table 1). Nine cases involved the left humerus, while three involved the right. Six fractures occurred at the mid-shaft, and the other six at the junction of the middle and proximal thirds. Eight were closed fractures, and four open fracture had progressed to atrophic non-union.

All patients reported mild pain, tenderness, restricted mobility at the non-union site, and limitations in daily activities. Stiffness of the shoulder and elbow was noted in all cases to varying degrees. The mean time between injury and presentation was 12.22 months (range 6–27 months). The average preoperative DASH score was 83±6 (range 76–98). Four patients each had comorbidities of diabetes and ischemic heart disease, while six had hypertension. None were smokers. Of the Eight closed fractures, nonunion followed conservative management.

Surgical intervention was performed under general anesthesia with prophylactic antibiotics administered preoperatively. A posterior approach was used for mid-shaft and distal fractures, while proximal fractures were addressed via an anterolateral approach. Fracture sites were cleared of devitalized bone and fibrous tissue, and medullary canals were reopened using a drill. The fibular strut graft was harvested under tourniquet control, with care to protect the superficial peroneal nerve. The graft was shaped to fit snugly into the fracture fragments. Excess fibular length was removed, and the graft ends were beveled as needed to ensure proper fit across the fracture site.

The fractures were stabilized using a dynamic compression plate and screws in compression mode. A minimum of three screws on each side of the fracture, engaging three or four cortices, was used. Any remaining fibular graft was packed longitudinally across the fracture site. Iliac crest bone grafting was not performed in any of the cases. Post-surgery, patients with stiff joints underwent passive joint mobilization. Arm slings were used for three weeks, after which elbow and shoulder mobilization exercises were initiated. Weight-bearing activities were delayed for three months or until radiographic evidence of fracture healing was observed.

At follow-up, an independent observer evaluated clinical and radiological outcomes. Pain, instability, joint mobility, and complications were recorded. Radiographs were reviewed for signs of fracture union, defined as bridging trabeculae in at least three cortices, as well as for any evidence of implant loosening or failure.

All fractures had solid clinico-radiologically evident frac- ture union by the three-month follow-up, and patients were very satisfied with the treatment

There were no wound problems. The average arm shortening was 1.61±1.2 cm (range, 0.6–2.7 cm). The patient with radial nerve injury required a tendon transfer surgery six months after nonunion surgery.

Patients were followed-up for an average of 16.02 months (range, 7– 26 months). None had pain over the fracture site and the DASH score at the last follow-up averaged 29±14 (range, 8–44). Although three patients had some discomfort over

the fibular graft harvest site, none had any pain or problems at the last follow-up.

There was an average loss of ten degrees abduction and fifteen degrees flexion of the shoulder. There was no change in shoulder rotations following surgery. All patients with preoperative fixed flexion deformity of elbow to varying degrees had persistence of similar deformity at the last follow-up. Range of motion of the elbow had improved by fifteen degrees following surgery. All patients had gone back to their near normal pre-injury activity levels at the last follow-up.

One of the patients had intraoperative splintering of the distal fracture fragment at the tip of the plate which healed in the ‘U’ plaster slab over a period of six weeks without affecting the outcome. None of the implants had loosening or breakage at the last follow-up. Two patients had developed superficial wound infections postoperatively, but delayed suture removal and oral antibiotics were sufficient to resolve these problems. One patient had transient common peroneal nerve palsy which recovered spontaneously at six-week follow-up. At the last follow- up, none of the patients had any morbidity due to fibular graft harvest.

The occurrence of nonunion following humeral shaft fractures is generally uncommon, owing to the typically positive outcomes of both nonoperative management and carefully selected surgical interventions. Consequently, there is limited research available on the outcomes of surgical repair for humeral shaft nonunion [3, 11]. Factors contributing to nonunion may include the severity of the initial trauma, transverse fracture patterns, or the presence of interposed soft tissue. Nonunion after surgical treatment can result from poor bone contact, inadequate stabilization, compromised bone vitality, osteoporosis, or bone defects. Additionally, variables such as obesity, alcohol use, and the chosen treatment method can also influence outcomes.

In patients with osteoporosis, whether due to disuse or systemic metabolic conditions, surgical treatment becomes particularly challenging. Reduced screw pullout strength in osteoporotic bone increases the risk of implant failure. Addressing humeral nonunion in such cases presents a complex problem for orthopedic surgeons [1, 10]. While various strategies for managing atrophic nonunion exist, each has limitations. Commonly used options include interlocking nails, Ilizarov external fixators, locking compression plates (LCPs), and vascularized or cancellous bone grafts from the iliac crest [9].

Interlocking nails offer stable fixation, even in osteoporotic bones, and function as load-sharing devices. However, their use requires fluoroscopic guidance, involves technical challenges, and can limit shoulder mobility in the short term, although long-term outcomes are generally comparable to plating. Nonunion patients frequently present with joint stiffness, and nailing may exacerbate this issue. Bone transport using the Ilizarov technique can be effective for complex post-traumatic conditions, but the method is resource-intensive, technically demanding, and associated with potential complications such as infection and soft tissue problems [4, 6, 8].

LCPs are a promising option, particularly in osteoporotic cases, as they provide angular stability and minimize screw backout. However, the high cost and limited availability of LCPs restrict their widespread use. Dynamic compression plates (DCPs) are more accessible and familiar to surgeons, offering a cost-effective alternative. Plate fixation for humeral nonunion has been well-documented, with common complications including screw loosening, radial nerve injury, and infection. For adequate stabilization, DCPs typically require screws with six or eight cortices of purchase on each side of the fracture, provided the bone quality is sufficient [7]. In some cases, methyl methacrylate bone cement has been used to enhance screw pullout strength, but this adds to costs and carries potential cardiotoxicity risks.

Although cancellous bone grafting from the iliac crest can promote union, it lacks the mechanical strength needed to withstand stresses before fracture healing and is associated with significant donor site morbidity. The fibula, on the other hand, provides a mechanically robust graft option. Capable of supporting approximately one-eighth of the body’s weight, the fibula can serve as a vascularized or nonvascularized graft for reconstructing bony defects. While vascularized grafting is effective, it requires specialized surgical skills and equipment that may not be accessible in all healthcare facilities. Nonvascularized fibular grafts are easier to harvest with minimal trauma. A portion of the epiphyseal region is typically preserved during harvest to avoid joint interference, resulting in a primarily cortical graft. This cortical structure provides immediate structural integrity and stability at the fracture site while offering some osteogenic potential.

The fibula’s unique characteristics—length, geometric configuration, and mechanical strength—make it particularly suitable for addressing long-bone defects. Although cortical grafts revascularize more slowly and may face risks such as infection, delayed union, or graft fracture, these complications can be minimized with careful surgical technique. Contrary to concerns about poor vascular support leading to graft resorption or failure, no such issues were observed in this study. While fibular graft harvest carries a risk of peroneal nerve injury, proper identification and protection of the nerve during surgery can effectively prevent this complication.

In this study, dynamic compression plate fixation with screws engaging six or eight cortices on each side of the nonunion, combined with an intramedullary fibular strut graft, yielded excellent outcomes with minimal complications. The fibular graft served as a medullary filler, enhancing stability and preventing abnormal movement. None of the screws loosened or backed out during follow-up. The use of Muller’s compression device facilitated compression at the fracture site, further promoting union. Although polymethyl methacrylate has been suggested to enhance screw stability in osteoporotic bone, we consider it a non-biological solution that increases surgical costs and time [2, 12].

Based on the favorable results in this series, this technique offers a reliable and straightforward option for treating humeral shaft nonunion in osteoporotic patients. It combines cost-effectiveness with biological benefits, avoiding the drawbacks associated with other methods.

Using an intramedullary fibular strut graft across the fracture site, combined with compression plating, effectively achieves fracture union in osteoporotic atrophic nonunion of the humerus without necessitating additional cancellous bone grafting from the iliac crest. This technique is straightforward, widely familiar to surgeons, cost-effective, and associated with lower donor site morbidity.

The fibular graft functions as an internal splint, providing mechanical stability at the fracture site and enhancing the fixation construct by increasing cortical screw purchase. This improvement in screw engagement significantly enhances their pullout strength. The intramedullary placement of the graft contributes to load sharing, promotes bone ongrowth, and facilitates osseointegration.

Additionally, shaping the fibular graft with beveled ends and retaining full-thickness fibular segments at the nonunion site not only adds mechanical stability but also helps preserve limb length. Given its success in the humerus, this technique holds potential for broader application in managing nonunion of long bones in the lower limbs.

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