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.¹ However, intra-articular fractures of the distal humerus are even rarer to a general orthopedist.² Optimal treatment involves intra-articular anatomical reduction and stable fixation.^1,14 Total elbow arthroplasty (TEA) is indicated for inflammatory arthritis, primarily rheumatoid arthritis, primary osteoarthritis, post-traumatic elbow arthritis and severe acute comminuted distal humerus fractures, in patients older than 65 years.^1,6 However, the scope of TEA indications has expanded to include trauma and post-traumatic conditions, in up to 69% of patients over 60 years of age.^3,7 An alternative to TEA and fixation for young adults with distal humerus fractures is the use of distal humerus hemiarthroplasty.¹¹ Nevertheless, concerns persist regarding the high revision rates associated with TEA procedures in young and active patients.^1,3,7,11 Conversely, in cases of avascular nonunion due to initial trauma and multiple previous surgeries, conventional nonvascularized graft may prove insufficient for achieving bone healing, even when coupled with stable fixation.¹³ Existing literature demonstrates the reliability of vascularized bone graft in addressing nonunion in multiple operated extra-articular distal humerus fractures.^13,17 However, to our knowledge, there have been no reports of treating intra-articular 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 intra-articular 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.

Case

A healthy 49-year-old female sustained an intercondylar and supracondylar humeral fracture 33 months prior (Fig. 1). The patient was treated initially with 2 insufficient osteosynthesis and one implant removal in a situation with an unhealed fracture. This led 33 months later to the situation at referral with a pain visual analog scale 10/10 and with functional impairment (Figure 2, Figure 3, Figure 4, Figure 5).

Figure 1.

Initial left elbow X-rays showing a distal humerus fracture with intercondylar and supracondylar involvement.

Figure 2.

Immediate initial X-rays showing the insufficient internal fixation of the distal humerus with medial and lateral plates.

Figure 3.

Follow-up X-rays showing implant loosening mainly in the supracondylar area of the distal humerus.

Figure 4.

X-rays that show the left distal humerus nonunion after hardware removal.

Figure 5.

Left elbow X-rays that show the distal humerus fixation using a precontoured dorsolateral reconstruction 3.5 plate, and a long screw to address the medial column. The olecranon osteotomy was fixed with wires and cerclage.

Physical examination revealed a left upper extremity in an antalgic position. Eutrophic skin showed 2 scars around the elbow, 1 medial, and 1 lateral. Range of motion: 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 (Figs. 5 and 6). Fracture related infection was ruled out with absence of fistula, sinus, wound breakdown, purulent drainage. Laboratory serum markers were within normal values (including erythrocyte sedimentation rate, white blood count, 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 computed tomography scan with 3D 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 (Fig. 6).

Figure 6.

CT scan axial (A to C) views and 3D reconstruction (D and E) that demonstrate a healed but malunited lateral column, the capitellum ulnarly rotated. Medial column with peri-implant loosening around an intercondylar screw, associated with bone loss proximal to the trochlea. CT, computed tomography; 3D, three dimensional.

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 and vena comitantes were elevated up to the middle of the forearm, with the necessary length to reach the defect in the distal humerus (Fig. 7, Video 1). Good hemostasis of the muscular branches of the radial artery 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 (Fig. 8).

Figure 7.

Intraoperative pictures showing at the top the elbow region and the bottom the wrist region. In (A) the bone flap can be seen harvested after identification of the radial artery course in the forearm. At the wrist, the donor area deficit is observed. In (B) the bone flap has been rotated while the pedicle was maintained hydrated and without traction. At the wrist, the iliac crest bone autograft has been temporarily fixed with k-wires and later was replaced with 2 lag screws.

Figure 8.

Intraoperative 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.

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 2 3.5 screws (Fig. 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 3 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 2-year postoperative evaluation, Disabilities of Arm, Shoulder, and Hand score was 0.8, Mayo Elbow Performance Score 100, and Oxford Elbow Score 95.8. Elbow range of motion showed 55° of flexion and −20° of extension. Supination was measured on 90° and pronation in 90°, pain visual analog scale 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 (Fig. 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 (Fig. 10).

Figure 9.

Clinical pictures showing the range of motion achieved 1 year after surgery. The elbow and forearm scars can be seen.

Figure 10.

Two-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. AP, anteroposterior.

Case discussion

There is scarce evidence of the use of bone pediculated flaps to treat hypotrophic distal humerus nonunion, and the reports are solely for extra-articular involvement of the elbow.^13,17 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 6 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 2 years to date.

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.¹⁶ According to Choo and Ramsey⁴ 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.¹² 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.^5,10 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.^9,15

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.^8,12 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 suggested¹²; 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.¹² In the case of multiple surgical interventions, bone loss, hypovascularity, and poor soft tissue bed are usually present, even in young patients.^13,17

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 post-traumatic arthritis.

Conclusion

Distal humeral fractures treatment is technically difficult, and when it is not done correctly, it leads to severe complications, including nonunion with severe bone loss. However, when such complications happen, the present technique could be a valuable option to solve the situation which 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.

Disclaimers:

Funding: No funding was disclosed by the authors.

Conflicts of interest: Efraín Farías-Cisneros declares that he has been a paid consultant from Johnson and Johnson Devices Mexico and International Bone Research Association in occasions not related to this work. The other authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.

Patient consent: Written informed consent was obtained from the patient for publication of this case report and accompanying images.

Supplementary Data

Video 1

Intraoperative video showing the harvesting of the bone vascularized graft from the distal radius.

Video 2

Clinical video two years after the surgery, the patient is showing great functional recovery with good painless range of motion.