Salvage of an intra-articular distal humerus recalcitrant nonunion using a pedicled vascularized bone graft

Distal humerus fractures are relatively uncommon, constituting nearly 2% of all fractures and one-third of humeral fractures in adults.1Amir S. Jannis S. Daniel R. Distal humerus fractures: a review of current therapy concepts.Curr Rev Musculoskelet Med. 2016 Jun; 9: 199-206https://doi.org/10.1007/s12178-016-9341-zCrossref PubMed Scopus (45) Google Scholar However, intraarticular fractures of the distal humerus are even rarer to a general orthopedist.2Bégué T. Articular fractures of the distal humerus.Orthop Traumatol Surg Res. 2014 Feb; 100 (S55-63)https://doi.org/10.1016/j.otsr.2013.11.002Abstract Full Text Full Text PDF Scopus (44) Google Scholar Optimal treatment involves intraarticular anatomical reduction and stable fixation.1Amir S. Jannis S. Daniel R. Distal humerus fractures: a review of current therapy concepts.Curr Rev Musculoskelet Med. 2016 Jun; 9: 199-206https://doi.org/10.1007/s12178-016-9341-zCrossref PubMed Scopus (45) Google Scholar,14Nauth A. McKee M.D. Ristevski B. Hall J. Schemitsch E.H. Distal humeral fractures in adults.J Bone Joint Surg Am. 2011 Apr 06; 93: 686-700https://doi.org/10.2106/JBJS.J.00845Crossref PubMed Scopus (180) Google Scholar Total elbow arthroplasty (TEA) is indicated for inflammatory arthritis, primarily rheumatoid arthritis, primary osteoarthritis, posttraumatic elbow arthritis and severe acute comminuted distal humerus fractures, in patients older than 65 years of age.1Amir S. Jannis S. Daniel R. Distal humerus fractures: a review of current therapy concepts.Curr Rev Musculoskelet Med. 2016 Jun; 9: 199-206https://doi.org/10.1007/s12178-016-9341-zCrossref PubMed Scopus (45) Google Scholar,6Frankle M.A. Herscovici Jr., D. DiPasquale T.G. Vasey M.B. Sanders R.W. A comparison of open reduction and internal fixation and primary total elbow arthroplasty in the treatment of intraarticular distal humerus fractures in women older than age 65.J Orthop Trauma. 2003; 17: 473-480https://doi.org/10.1097/00005131-200308000-00001Crossref PubMed Scopus (286) Google Scholar However, the scope of TEA indications has expanded to include trauma and posttraumatic conditions, in up to 69% of patients over 60 years of age.3Celli A. Paroni C. Bonucci P. Celli L. Total elbow arthroplasty for acute distal humeral fractures with humeral condyle resection or retention: a long-term follow-up study.JSES Int. 2021 Apr 22; 5: 797-803https://doi.org/10.1016/j.jseint.2021.03.006Abstract Full Text Full Text PDF Scopus (1) Google Scholar,7Gerow D.E. Tan E.H. Bamberger H.B. Cue Ball Arthroplasty With Humeroradial Total Elbow Arthroplasty (TEA) Revision: An Approach to Managing Infection and Severe Ulnar Bone Loss in TEA.J Shoulder Elb Arthroplast. 2020 Sep 29; 42471549220961592https://doi.org/10.1177/2471549220961592Crossref Google Scholar An alternative to TEA and fixation for young adults with distal humerus fractures is the use of distal humerus hemiarthroplasty (DHH).11Luciani A.M. Baylor J. Akoon A. Grandizio L.C. Controversies in the Management of Bicolumnar Fractures of the Distal Humerus.J Hand Surg Am. 2023 Feb; 48: 177-186https://doi.org/10.1016/j.jhsa.2022.10.006Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar Nevertheless, concerns persist regarding the high revision rates associated with TEA procedures in young and active patients.1Amir S. Jannis S. Daniel R. Distal humerus fractures: a review of current therapy concepts.Curr Rev Musculoskelet Med. 2016 Jun; 9: 199-206https://doi.org/10.1007/s12178-016-9341-zCrossref PubMed Scopus (45) Google Scholar,3Celli A. Paroni C. Bonucci P. Celli L. Total elbow arthroplasty for acute distal humeral fractures with humeral condyle resection or retention: a long-term follow-up study.JSES Int. 2021 Apr 22; 5: 797-803https://doi.org/10.1016/j.jseint.2021.03.006Abstract Full Text Full Text PDF Scopus (1) Google Scholar,7Gerow D.E. Tan E.H. Bamberger H.B. Cue Ball Arthroplasty With Humeroradial Total Elbow Arthroplasty (TEA) Revision: An Approach to Managing Infection and Severe Ulnar Bone Loss in TEA.J Shoulder Elb Arthroplast. 2020 Sep 29; 42471549220961592https://doi.org/10.1177/2471549220961592Crossref Google Scholar,11Luciani A.M. Baylor J. Akoon A. Grandizio L.C. Controversies in the Management of Bicolumnar Fractures of the Distal Humerus.J Hand Surg Am. 2023 Feb; 48: 177-186https://doi.org/10.1016/j.jhsa.2022.10.006Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar Conversely, in cases of avascular nonunion due to initial trauma and multiple previous surgeries, conventional non-vascularized graft may prove insufficient for achieving bone healing, even when coupled with stable fixation.13Mullett H. Hausman M. Zaidemberg C. Recalcitrant distal humeral and proximal forearm nonunion: salvage using an extended pedicled radial forearm osseous flap.J Trauma. 2008 Apr; 64: E60-E64https://doi.org/10.1097/01.ta.0000229713.56091.5bCrossref PubMed Scopus (14) Google Scholar Existing literature demonstrates the reliability of vascularized bone graft in addressing nonunion in multiple operated extraarticular distal humerus fractures. 13Mullett H. Hausman M. Zaidemberg C. Recalcitrant distal humeral and proximal forearm nonunion: salvage using an extended pedicled radial forearm osseous flap.J Trauma. 2008 Apr; 64: E60-E64https://doi.org/10.1097/01.ta.0000229713.56091.5bCrossref PubMed Scopus (14) Google Scholar,17Zaidenberg E.E. Juarez Cesca F. Pastrana M.J. Zaidenberg C.R. Pedicled Vascularized Bone Graft of the Distal Radius for Recalcitrant Nonunion of the Distal Humerus.J Orthop Trauma. 2018 Oct; 32: e394-e399https://doi.org/10.1097/BOT.0000000000001255Crossref Scopus (5) Google Scholar However, to our knowledge, there have been no reports of treating intraarticular nonunion in this manner. This case study presents the application of a pedicled vascularized bone graft from the distal radius in the treatment of a patient with aseptic intraarticular malunion-nonunion of the distal humerus, previously managed through multiple open reduction and internal fixation (ORIF) procedures. The objective is to preserve the elbow joint and obtain bone healing. A healthy 49-year-old female sustained 33 month prior an intercondylar and supracondylar humeral fracture. [Figure 1] The patient was treated initially with two insufficient osteosynthesis and one implant removal in a situation with an unhealed fracture. This led thirty-three months later to the situation at referral with a pain visual analog scale (VAS) 10/10 and with functional impairment. [Figure 2, Figure 3, Figure 4, Figure 5]Figure 2Immediate initial x-rays showing the insufficient internal fixation of the distal humerus with medial and lateral plates.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Follow-up X-rays showing implant loosening mainly in the supracondylar area of the distal humerus.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 4X-rays that show the left distal humerus nonunion after hardware removal.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 5Left elbow X-rays that show the distal humerus fixation using a pre-contoured dorsolateral reconstruction 3.5 plate, and a long screw to address the medial column. The olecranon osteotomy was fixed with wires and cerclage.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Physical examination revealed a left upper extremity in an antalgic position. Eutrophic skin showed two scars around the elbow, one medial and one lateral. ROM: Flexion axis 80- 100 and full forearm rotation with severe crepitus. The patient had diminished strength of the triceps brachii (3+/5) and brachialis anterior (4/5 in the Daniels Strength Scale). The extensor mechanism was competent. Crepitation at the distal third of the arm was elicited and felt with elbow flexion and extension. [Figure 5, Figure 6] Fracture related infection was ruled out with absence of fistula, sinus, wound breakdown, purulent drainage. Laboratory serum markers were within normal values (including ESR, WBC and C-reactive protein), moreover deep tissue samples were obtained at the beginning of the surgery and a negative polymorphonuclear neutrophils trans-op high-power field histopathology for was reported. Diagnostic imaging, including bilateral plain orthogonal x-rays, and a CT scan with 3-D reconstruction of the elbow, revealed hardware material in the lateral column of the distal humerus with healed bone, peri implant loosening in the medial column around a screw, associated with bone loss proximal to the trochlea, and a malunion of the capitellum and a congruent ulnohumeral joint. [Figure 6] A comprehensive single surgical procedure was undertaken with the patient placed on supine position under regional anesthesia. A posterior elbow approach was performed, radial and ulnar nerves were identified and dissected, and the ulnar nerve was transposed anteriorly. The hardware was removed. Furthermore, we performed an olecranon osteotomy to expose the articular fragments. Débridement was carried out removing all the pseudoarthrosis tissue, along with the fibrotic tissue in the radio capitellar joint, and anterior contracture release. Then, a rotational osteotomy of the capitellum was performed. A temporary fixation with 2.7/3.5 variable angle medial and lateral anatomical plates (DePuy Synthes, Raynham, MA, USA) using bridging plate technique was placed. Attention was placed on the volar aspect of the forearm, a Henry approach is performed to raise the flap from distal to proximal paying attention to the periosteal perforators nourishing the bone harvested, radial artery (RA) and vena comitantes were elevated up to the middle of the forearm, with the necessary length to reach the defect in the distal humerus. [Figure 7, Video 1] Good hemostasis of the muscular branches of the RA was done using a bipolar cautery to prevent hematoma formation. Skeletonizing the artery should be avoided as well, maintaining the soft tissue around the artery will prevent vasospasm. The flap can be transferred to the elbow defect making a subcutaneous tunnel or by incising the skin to the defect avoiding any pressure over the pedicle. Careful attention should be placed to avoid twisting or kinking the flap pedicle. In this case, the graft was rotated 180° and tunneled subcutaneously, the osseous block was placed on the medial column with bone loss and held with a screw fixed to the most distal hole of the medial plate. [Figure 8]Figure 8Intraoperative images that show the location of the vascularized graft (rectangle) filling the medial column previous defect, the slim arrows show the precise location of the graft held in place with a variable angle locking screw fixed to the medial plate. The wide arrow shows the site of the derotational osteotomy performed in the lateral column.View Large Image Figure ViewerDownload Hi-res image Download (PPT) The donor area of the distal radius was reinforced with autogenous bone graft from the iliac crest obtained by a second surgical team simultaneously and fixed with two 3.5 screws. [Figure 7] The patient was placed on a cushioned soft dressing and immediate mobilization was allowed. The postoperative regime included a COX-2 anti-inflammatory twice a day for three weeks plus acetaminophen as needed for pain. Isometric elbow flexion and extension. At the beginning of the fourth week physical therapy was prescribed, including overhead motion protocol. At 3-month follow-up the patient was painless with radiological findings of partial bone healing in the distal humerus, olecranon was completely healed. Complete bone healing was observed at the 6-month follow-up. At the two-year postoperative evaluation Disabilities of Arm, Shoulder, and Hand (DASH) score was 0.8, Mayo Elbow Performance Score (MEPS) 100, and Oxford Elbow Score 95.8. Elbow ROM showed 55° of flexion and -20° of extension. Supination was measured on 90° and pronation in 90°, pain VAS was 0/10. Triceps muscle strength was 5/5, biceps 5/5, hand intrinsic muscles 5/5, in the Daniels Strength Scale. Skin scars were eutrophic. [Figure 9, Video 2] The patient resumed her regular activities of daily living and swimming. X-rays show complete bone healing, in both surgical sites, no hardware failure or loosening. [Figure 10]Figure 10Two-year follow-up AP and lateral x-ray views of the left elbow (Right) that show integration of the flap and complete bone healing, along with a congruent joint elbow joint. Left: AP and lateral wrist x-rays that show integration of the iliac crest bone autograft at the donor site.View Large Image Figure ViewerDownload Hi-res image Download (PPT) There is scarce evidence of the use of bone pediculated flaps to treat hypotrophic distal humerus nonunion, and the reports are solely for extraarticular involvement of the elbow.13Mullett H. Hausman M. Zaidemberg C. Recalcitrant distal humeral and proximal forearm nonunion: salvage using an extended pedicled radial forearm osseous flap.J Trauma. 2008 Apr; 64: E60-E64https://doi.org/10.1097/01.ta.0000229713.56091.5bCrossref PubMed Scopus (14) Google Scholar,17Zaidenberg E.E. Juarez Cesca F. Pastrana M.J. Zaidenberg C.R. Pedicled Vascularized Bone Graft of the Distal Radius for Recalcitrant Nonunion of the Distal Humerus.J Orthop Trauma. 2018 Oct; 32: e394-e399https://doi.org/10.1097/BOT.0000000000001255Crossref Scopus (5) Google Scholar The current case to the best of our knowledge reports the first use of this technique to treat an intra-articular malunion-nonunion of the distal humerus that combine corrective derotation osteotomy along with pedicled vascularized bone graft to salvage the joint instead of performing to a TEA replacement. Consolidation was achieved six months after surgery, more importantly, clinical recovery was nearly to preoperative normal function, sparing the joint from an implant procedure in a patient younger than 65 years old. The patient reported in this study has a follow-up of two years to date. Open reduction and internal fixation (ORIF) is the gold standard for the operative treatment of intra-articular distal humeral fractures. However, high complication rates up to 35% have been reported, even in young patients. Infection, soft tissue problems, malunion, nonunion, and stiffness are common complications.16Savvidou O.D. Zampeli F. Koutsouradis P. Chloros G.D. Kaspiris A. Sourmelis S. et al.Complications of open reduction and internal fixation of distal humerus fractures.EFORT Open Rev. 2018 Oct 24; 3: 558-567https://doi.org/10.1302/2058-5241.3.180009Crossref PubMed Scopus (27) Google Scholar According to Choo and Ramsey4Choo A. Ramsey M.L. Total Elbow Arthroplasty: Current Options.J Am Acad Orthop Surg. 2013; 21: 427-437https://doi.org/10.5435/JAAOS-21-07-427Crossref PubMed Scopus (28) Google Scholar elbow arthroplasty provides predictable results in carefully selected patients. However, as Morrey et al have reported, during the decision-making process age, functional status and functional demands must be addressed before choosing the treatment for a failed ORIF of the distal humerus.12Morrey M.E. Morrey B.F. Sanchez-Sotelo J. Barlow J.D. O'Driscoll S. A review of the surgical management of distal humerus fractures and nonunions: From fixation to arthroplasty.J Clin Orthop Trauma. 2021 Jun 12; 20101477https://doi.org/10.1016/j.jcot.2021.101477Abstract Full Text Full Text PDF Scopus (7) Google Scholar There are arguments for early TEA in patients older than 65 years, with clinical outcomes and reoperation rates similar to those patients treated with ORIF.5Dehghan N. Furey M. Schemitsch L. Ristevski B. Goetz T. Schemitsch E.H. McKee M. Canadian Orthopaedic Trauma Society (COTS)Long-term outcomes of total elbow arthroplasty for distal humeral fracture: results from a prior randomized clinical trial.J Shoulder Elbow Surg. 2019 Nov; 28: 2198-2204https://doi.org/10.1016/j.jse.2019.06.004Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar,10Logli A.L. Shannon S.F. Boe C.C. Morrey M.E. O'Driscoll S.W. Sanchez-Sotelo J. Total Elbow Arthroplasty for Distal Humerus Fractures Provided Similar Outcomes When Performed as a Primary Procedure or After Failed Internal Fixation.J Orthop Trauma. 2020 Feb; 34: 95-101https://doi.org/10.1097/BOT.0000000000001631Crossref PubMed Scopus (16) Google Scholar Complications of TEA are also frequent and difficult to treat and include periprosthetic infection (2-4%), periprosthetic fracture, implant loosening (2%), ulnar neuropathy (5%), triceps insufficiency (3%), and implant failure.9Kim J.M. Mudgal C.S. Konopka J.F. Jupiter J.B. Complications of total elbow arthroplasty.J Am Acad Orthop Surg. 2011; 19: 328-339https://doi.org/10.5435/00124635-201106000-00003Crossref PubMed Scopus (102) Google Scholar,15Russo R, Guastafierro A and Della Rotonda G. Total elbow linked arthroplasty in distal humeral fractures and distal humeral nonunion: Peculiarities of surgical technique and expected results. In: Castoldi F, Giannicola G and Rotini R (eds) Elbow Arthroplasty. Cham: Springer Nature Switzerland AG, 2020, ISBN-10: 3030144577. ISBN-13: 978-3030144579. pp 103-113.Google Scholar To avoid such complications, algorithms have been proposed in the treatment of acute distal humerus fractures, as well as for the treatment of nonunion and malunion.8Hackl M. Müller L.P. Leschinger T. Wegmann K. Ellenbogentotalendoprothetik bei traumatischen und posttraumatischen Knochendefekten [Total elbow arthroplasty in traumatic and post-traumatic bone defects].Orthopade. 2017 Dec; 46 (German): 990-1000https://doi.org/10.1007/s00132-017-3493-4Crossref Scopus (12) Google Scholar,12Morrey M.E. Morrey B.F. Sanchez-Sotelo J. Barlow J.D. O'Driscoll S. A review of the surgical management of distal humerus fractures and nonunions: From fixation to arthroplasty.J Clin Orthop Trauma. 2021 Jun 12; 20101477https://doi.org/10.1016/j.jcot.2021.101477Abstract Full Text Full Text PDF Scopus (7) Google Scholar However, mainly due to the scarcity of cases in this second group of patients, decision making is more difficult. The current opinion is to address joint surface condition, joint congruity, and viability of the fragments. If the condition of the joint surface is poor an immediate TEA is suggested;12Morrey M.E. Morrey B.F. Sanchez-Sotelo J. Barlow J.D. O'Driscoll S. A review of the surgical management of distal humerus fractures and nonunions: From fixation to arthroplasty.J Clin Orthop Trauma. 2021 Jun 12; 20101477https://doi.org/10.1016/j.jcot.2021.101477Abstract Full Text Full Text PDF Scopus (7) Google Scholar however, in the setting of young patients, we believe that efforts should be made to avoid TEA. Moreover, the nonunions and malunions are typically located in the supracondylar area, and the standardized treatment of compression through parallel plating is usually enough to address those problems.12Morrey M.E. Morrey B.F. Sanchez-Sotelo J. Barlow J.D. O'Driscoll S. A review of the surgical management of distal humerus fractures and nonunions: From fixation to arthroplasty.J Clin Orthop Trauma. 2021 Jun 12; 20101477https://doi.org/10.1016/j.jcot.2021.101477Abstract Full Text Full Text PDF Scopus (7) Google Scholar In the case of multiple surgical interventions, bone loss, hypovascularity, and poor soft tissue bed are usually present, even in young patients.13Mullett H. Hausman M. Zaidemberg C. Recalcitrant distal humeral and proximal forearm nonunion: salvage using an extended pedicled radial forearm osseous flap.J Trauma. 2008 Apr; 64: E60-E64https://doi.org/10.1097/01.ta.0000229713.56091.5bCrossref PubMed Scopus (14) Google Scholar,17Zaidenberg E.E. Juarez Cesca F. Pastrana M.J. Zaidenberg C.R. Pedicled Vascularized Bone Graft of the Distal Radius for Recalcitrant Nonunion of the Distal Humerus.J Orthop Trauma. 2018 Oct; 32: e394-e399https://doi.org/10.1097/BOT.0000000000001255Crossref Scopus (5) Google Scholar Our patient presented severe elbow disability due to a medial column nonunion with bone loss and a lateral column malunion with humeroradial fibrosis and without infection, markedly limiting her activities of daily living. Since the patient was a young adult, with severe limiting elbow nonunion and pain, and with desire to regain mobility in her elbow, she was offered an option to save the joint, and reserve a TEA as an alternative option in case of treatment failure or the development of painful posttraumatic arthritis. Distal humeral fractures treatment is technically difficult, and when it is not done correctly, it leads to severe complications, including non-union with severe bone loss. However, when such complications happen, the present technique could be a valuable option to solve the situation, that provides structural and osteogenic supply. This approach represents an alternative to the use of hemi- or total elbow replacement in younger patients who have undergone multiple prior surgeries.

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