title: Recalcitrant nonunion of the distal humerus: treatment with free vascularized bone grafting.
abstract: We sought to determine whether open reduction and internal fixation in combination with free vascularized bone grafting and elbow contracture release is an effective treatment for patients with recalcitrant distal humeral nonunions with segmental bone loss. In addition, we wondered whether this treatment strategy has an acceptable complication rate. Five patients, with an average age of 48 years, form the basis of our study. An average of 3.4 surgical procedures were done before the vascularized bone grafting for treatment of nonunion. The average time from injury until the index vascularized graft was 37.2 months. All patients had elbow pain at rest and had severe functional limitations related to the nonunion. There was segmental bone loss averaging 3.2 cm at the time of vascularized grafting. Four of the five patients with nonunions had clinical and radiographic union at the latest followup, and one patient required a total elbow arthroplasty because of articular collapse after the vascularized grafting procedure. The average time from vascularized grafting until bony union was 4.5 months (range, 3-6 months). There were no other complications in this patient group. Free vascularized bone grafting is a treatment alternative for distal humeral fracture nonunion, especially in younger patients who have nonunions with segmental bone loss that are refractory to conventional fixation and bone grafting techniques.
  
  
  METHODS
  Therapeutic study, Level IV (case series--no, or historical, control group). See the Guidelines for Authors for a complete description of levels of evidence.
authors.affiliation: Department of Orthopaedic Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA, USA. pedro.beredjiklian@uphs.upenn.edu
authors.forename: Pedro K
authors.initials: PK
authors.lastname: Beredjiklian
authors.forename: Robert N
authors.initials: RN
authors.lastname: Hotchkiss
authors.forename: Edward A
authors.initials: EA
authors.lastname: Athanasian
authors.forename: Matthew L
authors.initials: ML
authors.lastname: Ramsey
authors.forename: Mark A
authors.initials: MA
authors.lastname: Katz
mesh_terms: D000328:Adult; D000368:Aged; D016025:Bone Transplantation; D004551:Elbow Joint / Q000503:physiopathology / Q000601:surgery*; D005260:Female; D005593:Fracture Fixation, Internal / Q000295:instrumentation / Q000379:methods*; D005599:Fractures, Ununited / Q000503:physiopathology / Q000601:surgery*; D006801:Humans; D006810:Humeral Fractures / Q000503:physiopathology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D016059:Range of Motion, Articular / Q000502:physiology; D016896:Treatment Outcome