Treatment of Humeral Nonunions with Allograft, Demineralized Bone Matrix, and Plate Fixation

Objective: Due to the risks inherent in autologous iliac crest bone graft harvest, the results of patients with humeral nonunions who were treated with allograft, demineralized bone matrix, and plate fixation were evaluated. Design: Retrospective review of patients who underwent operative treatment of humeral nonunions with allograft, demineralized bone matrix, and plate fixation. Setting: University medical center. Patients: Ten patients with nonunions of the humerus who were treated with open reduction and internal fixation with bone graft with a minimum of 2 years follow-up were included. The mean duration of the nonunion preoperatively was 24 months (range, 4-120 months). The patients had undergone an average of one (range, 0-3) previous surgery on the humerus. Intervention: Open reduction and internal fixation with plate and screw fixation and bone graft. All ten patients had bone grafting with cancellous allograft and demineralized bone matrix, while four of the ten also had intramedullary fibular allograft supplementing the fixation in cases of osteopenia or bone loss. Main Outcome Measures: Clinical and radiographic evidence of bone union. Medical records, operative reports, physical examination, and preoperative, postoperative, and follow-up radiographs were reviewed. Outcomes were assessed with the Disabilities of the Arm, Shoulder, and Hand Questionnaire (DASH) to evaluate subjective outcome. Results: At a mean follow-up of 33 months (range, 25-42 months; minimum, 2 years) 9 of the 10 nonunions (90 %) had healed. One patient required a second operation to gain union. The nonunion that failed to heal, in a patient with severe coronary artery disease and congestive heart failure, initially healed at 3 months but at 40 months postoperatively had refractured through the old nonunion site with loss of internal fixation after a fall at home. Patient outcomes evaluated with the DASH questionnaire demonstrated 3 excellent, 4 good, 2 fair, and 1 poor result at follow-up. All patients with healed fractures at follow-up had functional shoulder and elbow range of motion. Conclusions: These results show that allograft and demineralized bone matrix can be a useful adjunct to plate fixation in the treatment of humeral nonunions, even in patients who have had previous surgery.