Treatment of Nonunion of the Humerus Using Ilizarov External Fixator

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Acta Orthopædica Belgica, Vol. 86 e-Supplement - 2 - 2020
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Acta Orthop. Belg., 2020, 86 e-supplement 2, 000-000
Role of Ilizarov external xator in treatment of humeral non-union
Mohammed Anter Meselhy, Emad Sanad, Mamdoh Elkaramany
From the Benha Faculty Of Medicine, Orthopedic Surgery, Egypt
ORIGINAL STUDY
n Mohammed Anter Meselhy,
n Emad Sanad,
n Mamdoh Elkaramany
Benha Faculty Of Medicine, Orthopedic Surgery, Egypt.
Correspondence : Mohammed Anter Meselhy, MD ortho-
pedics, Associated professor of orthopedic surgery, Benha
University, Orthopedic department, Benha University, Kafer el
gazar, Banha, Qalyubia 13511 Egypt, Phone : +20 1007550217,
Fax : +20 (13) 3227518.
E-mail : m.anteroof@yahoo.com
© 2020, Acta Orthopaedica Belgica.
The Ilizarov external xator has proven its
superiority in the treatment of different types
of fracture non- union ; it offers rigid stability,
possibility for bone transport and cyclic compression
distraction which promotes bone healing at the
fracture site (14).
In this study, we offer the ring xator as a
solution for both septic and aseptic types of humeral
non–union ; we also discuss the technique and the
outcome of this method in the treatment of humeral
non-union.
MATERIALS AND METHODS
Between
November
2011 and June 2015, 20
patients
with 20 humeral shaft nonunions were
treated by the Ilizarov method. The inclusion
criteria were non-united humeral shaft fractures
whether infected or not and including patients with
severe nerve damage ; elderly and non-co-operative
patients were excluded.
Treatment of non-union of the bone is a challenge,
especially when the fracture is complicated by
infection, angulation and translation, which is difcult
to be managed by conventional methods.
Here, we discuss the technique and the results of
treatment of humeral non- union by the Ilizarov
method.
20 patients with 20 humeral shaft nonunions were
treated by debridement and xation following the
Ilizarov method. The mean age of the patients was
35.05±11.48 years, there were 13 males and 7 females.
The mean follow up period was 16.2 months. The
mean time in the frame was 8.1 months. Bony union
was achieved in all patients.
According to the A.S.A.M.I. Scale results were
excellent in 13 patients (65%), good in 4 (20%), fair
in 3 (15%). There were no poor results.
The Ilizarov method is effective in various types of
humeral non-union, provided a good understanding
of the fracture requirements.
Level of evidence : IV.
Keywords : Ilizarov ; humerus ; non-union.
INTRODUCTION
Non-union is considered as one of the major com-
plications of fracture treatment : in spite of major
advancement in methods of fracture xation, mana-
gement of fracture non-union, especially when
com-plicated by infection is still a challenging and
difcult situation (13).

2 m.a. meselhy, e. sanad, m. elkaramany
Acta Orthopædica Belgica, Vol. 86 e-Supplement - 2 - 2020
In this multicentric study, all patients were trea-
ted by the same surgeon, using the same technique.
All patients had a diaphyseal fracture of the hume-
rus ; the mean age of the patients was 35.05±11.48
years,
range (19 to 58) years. There were 13
males
and 7 females. The initial fracture was open in 5
patients, and closed in 15.
The mean duration of
fracture nonunion was 10.4 months
(range from
7 to 20 months). The nonunion was complicated
by infection in 14 patients. Sixteen had undergone
previous surgery in an attempt to heal the nonunion,
(1-3 previous surgeries). The right humerus was
affected in 12 patients (the dominant side in 11) and
the left in 8 (the dominant side in 1).
16 patients out of 20 were initially treated
surgically by either plate and screws, an interlocking
nail or a monoplaner external xator, while 4
patients were managed conservatively by a hanging
cast and u- shape slab (Table I).
Nonunion was found in the
middle third of the
humerus in 12 patients, in the proximal third in 5
and in the distal third in three. 8 patients had an
angulation deformity at the non- union site while 3
patients had limb shortening range (1-2) cm .
Preoperative assessment
All patients were carefully assessed preopera-
tively both
clinically and radiologically, Associated
problems like
infection, deformity and joint stiffness
were documented.
Preoperative
shoulder stiffness was found in
5 cases and elbow stiffness in 9.
Sympathetic
dystrophy was present in 10 cases.
The radiological assessment of the site of non
-union and nearby joints included plain X-rays
(Antero-posterior and lateral views), computed
tomography (C.T.), magnetic resonance image
(M.R.I.) and a technetium-99m bone scan.
Laboratory investigations were done for all
patients, including infection and culture and sen-
sitivity tests for patients with an infected non -union.
According to the classication advocated by
Ilizarov in 1998 (7), we had 15 patients with a hyper-
trophic non -union and 5 cases with an atrophic
non -union. Six patients had an aseptic non- union
while 14 were complicated by infection, of whom
3 presented with an actively draining sinus and 11
were closed.
Surgical technique
Patients were operated under general anesthesia.
The patient was installed in the supine position,
the affected limb resting on the operating table,
allowing complete visualization of the whole arm
with the image intensier.
The whole affected upper limb was draped,
including the hand, to allow visualization of nger
movement during half pin and wire application.
Internal xation hardware was removed through
the previous incision, in both septic and aseptic
non-union. Any necrotic bone proximal and distal
to the fracture site was removed using a power
saw until bleeding healthy surfaces were obtained
and. The medullary canal was opened using a drill
bit ; bone cortices were refreshed using a thin
osteotome. Reduction of fracture wad obtained by
acute shortening and the fracture was provisionally
held with K-wires.
The Ilizarov external xator assembly was
done from proximal to distal, arches and complete
Value (20)
N(%)
Initial fracture
15(75.0)
Closed
Open 5(25.0)
Initial ttt
4(20.0)
Conser vative
Ex Fix 3(15.0)
ILN 5(25.0)
Plate 8(40.0)
No of previous surgeries
4(20.0)
0
1 7(35.0)
2 6(30.0)
3 3(15.0)
Table I. — Distribution of the study group, according to
type of
initial fracture, method of initial treatment and
number of previous
surgeries

Acta Orthopædica Belgica, Vol. 86 e-Supplement - 2 - 2020
role of ilizarov external fixator in treatment of humeral non-union 3
Ilizarov rings were used ; the rst arch was xed
to the humerus proximal to the deltoid muscle
insertion using 5mm and 6mm half pins, the
direction of half pins was from lateral to medial
and from anterolateral and posterolateral to medial,
engaging both cortices.
The 2nd level of xation was below the level of
the deltoid muscle insertion ; an arch or a complete
Ilizarov ring was used with a sufcient clear zone at
the medial and posterior aspect of the arm ; it was
xed to the humerus, above the fracture site, with 5
and 6 mm half pins from posterior to anterior and
from posterolateral to anteromedial, away from the
radial nerve.
The pins of the 3rd and 4th levels were inserted
below the fracture site : complete one and half rings
or complete one and 5/8th rings, open anteriorly,
were used for xation of the distal fragment.
Half pins of 5mm were inserted from lateral
to medial and from posterior to anterior with the
elbow in exion during introduction of these pins
in the distal 1/3 of the humerus.the K-wires for
premenalary xation of the fracture were removed
(Fig. 1 A, B, C.).
1.8 mm wires were used in the distal construct
especially in the intercondylar and supracondylar
regions : at the lateral surface of the lateral condyle
with the elbow exed, one wire was inserted from
posterolateral to anteromedial on the medial condyle,
while the other wire was inserted transversely from
the medial to the lateral epicondyle, with particular
attention to eventual nger movement.
After tensioning of the wires, the proximal and
distal constructs were connected using connecting
rods. The wound was closed in layers with a drain
(Table.II).
Postoperative treatment
On day 2, plain x-rays with anteroposterior and
lateral views of the whole arm were taken to control
the alignment and the nonunion site.
On day 3, the drain was removed, dressings were
changed and an acute compression of the nonunion
was done, if needed. Instructions for proper pin care
and limb elevation were given.
The patient was discharged from the hospital on
the 4th to the 6th postoperative day. IV antibiotics
Fig. 1. — Intraoperative clinical photos showing the
technique of debridement and Ilizarov application. A : bone
after removal of hardware and debridement. B : bone with
temporary xation by K-wires. C : application of Ilizarov
apparatus from proximal to distal.
Value (20)
N(%)
Nonunion type
5(25.0)
Mobile
Stiff 15(75.0)
Infective organism
6(30.0)
None
Gm –ve bacilli 1(5.0)
MRSA 5(25.0)
Pseudomonas 1(5.0)
Staph 7(35.0)
Site of nonunion
3(15.0)
Distal 1/3 diaphysis
Middle 1/3 diaphysis 12(60.0)
Proximal 1/3 diaphysis 5(25.0)
Treatment method with Ilizarov
10(50.0)
Acute compression
Compression-distraction 8(40.0)
Gradual compression 2(10.0)
Table II. — Distribution of the study group, according to
nonunion
type, site, presence of infective organism, number
o f previous
operations and method of treatment by Ilizarov

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Acta Orthopædica Belgica, Vol. 86 e-Supplement - 2 - 2020
and analgesics were administered during the
hospital stay. The patient was discharged with oral
antibiotics, according to cultures and sensitivity
tests, oral non steroidal anti inammatory drugs,
anti oedema drugs like alpha chemotrypsin and
neurotonics for two weeks.
The patients were followed in the out patient clinic
on a two week basis to control the frame stability
and pin sites and the radiographic progression of the
bone union (Fig. 2A, B, 3A, B).
In some cases, cyclic compression distraction
technique was applied as the patient moved the
nuts for distraction and for compression by rate of
half a turn each 12 hours, we began by distraction
for 4 days, then compression for next 4 days then
this cycle of repeated compression distraction was
repeated for 5 cycles followed by acute compression
at the nonunion site (Table.II).
After fracture consolidation, dynamization of
the frame was done by loosening the nuts, then by
decreasing the number of connecting rods between
the proximal and distal constructs and nally
by removal of all connecting rods to be sure of
complete union.
Removal of the apparatus was done in the
operation theatre under general anesthesia.
Physiotherapy and rehabilitation
Post-operative phases
Phase 1 (Inpatient ; postoperative day 1-7)
Independent mobilization and transfers.
Range of motion exercises of the joints above
and below the frame within normal
ranges or at
least to the ranges measured in the operating room
after
application of the Ilizarov frame.
Stretching exercises and functional loading
activities for home program.
Phase 2 (Outpatient).
Maintenance of range of motion of joints above
and below the xator.
Functional loading activities advanced to incor-
porate closed kinematic
chain strengthening .
Fig. 2. — X-rays showing : A: pre-operative X-rays of infected non united fracture mid-shaft humerus xed with a plate and screws.
B : X-rays after removal of internal xation, sequestrectomy and Ilizarov application with acute compression. C & D : follow-up
X-rays after Ilizarov removal.

Acta Orthopædica Belgica, Vol. 86 e-Supplement - 2 - 2020
role of ilizarov external fixator in treatment of humeral non-union 5
and non-parametric tests respectively. Inter-group
comparison of categorical data was performed using
McNemar test.
A P value <0.05 was considered statistically
signicant (*) and >0.05 statistically insignicant ;
P value <0.01 was considered highly
signicant
(**) in all analyses.
The mean time between injury and the appli-
cation of the frame was 12.65 (SD 3.91-range 7-20)
months. The mean follow up period was 16.2 (SD
4.35-range 10-24)
months. The mean time in the
frame was 8.1 (SD 2.34-range, 5-12)
months. Bony
union was achieved in all patients.(Fig. 2C,2D,3C).
The ASAMI (Association for the Study and
Application of the Method of Ilizarov) protocol,
1991”1” was used
to standardize the side effects
and complications.(Table III)
According to this scale, the bone results were
excellent in 13 patients (65%), good in 4 (20%), fair
in 3 (15%) and poor in none. (Table IV)
Residual deformity was found in 5 cases (25%),
the deformity being less than 7 degrees of the
normal anatomical axis. 3 patients (15%) had a
signicant shortening > 2.5
cm. Supercial type pin
tract, infection around wires or pins was
present in
all 20 patients.
Phase 3 (Outpatient ; xator removed)
(1) Mobility of any joints incorporated into the
xator restored to within
normal limits.
(2) Strengthening increased to a normal level
with closed kinematic chain
activities.
RESULTS
Data management
The clinical data were recorded on a report form.
These data were
tabulated and analyzed using the
computer program SPSS (Statistical
package for
social science) version 20 to obtain :
Descriptive data
Descriptive statistics were calculated from the
data in the form of :
mean and standard deviation (
±
SD)
for quantitative data and f
requency and distribution for
qualitative data
Analytic statistics
In the statistical comparison between the different
groups the signicance of difference was tested
using one of the following tests :
Paired t test and Willcoxon test (Ztest) : Used
to compare the mean of
variables in different
time periods of quantitative data of
parametric
Fig. 3. — X-rays showing :A : non united fracture mid-shaft
humerus xed by double plating with xation failure. B :
Ilizarov application after removal of plates and screws. C :
follow-up X-rays after apparatus removal.
Value (20)
Mean ±SD (range)
Time before Ilizaro v 12.65±3.91 (7-20)
Ilizarov duration 8.1±2.34 (5-12)
Duration of follow up 16.2±4.35 (10-24)
Table III. — Distribution of the study group, according to time
before
Ilizaov, Ilizarov duration and duration of follow-up
Bone results Number Percentage
Excellent 13 65%
Good 420%
Fair 3 15%
Poor 0 0%
Table IV. — Bone results

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Acta Orthopædica Belgica, Vol. 86 e-Supplement - 2 - 2020
Frame adjustment was needed in one patient.
Psychological troubles were observed in 5 patients
in the form of depression and anxiety treated with
psychotropic medication.
The functional results were
excellent in 12
patients (60%), good in 4 (20%), fair in 2 (10%)
and poor in 2 patients (10%) (Table V & VI).
The result obtained Number Percentage
Excellent 12 60%
Good 420%
Fair 2 10%
Poor 2 10%
Table V. — Functional results
Pre op
Mean ±SD
Post op
Mean ±SD Te st P value
Elbow ROM arc 97.0±31.68 106.75±30.49 Paired t= 1.93 0.068
Shoulder abduction 127.25±36.47 123.5±22.07 Paired t= 0.60 0.55
DASH 29.27±11.52 7.54±13.69 Z= 3.92 0.001**
VA S 7.15±1.46 1.9±2.1 Z= 3.94 0.001**
Table VI. — Comparison of elbow ROM arc, shoulder abduction,
DASH score and VAS score preoperative and postoperative
Manish et
al 2010 (9)
Das et al
2005 (4)
Patel et al
2000 (12) Our series
Age (mean) years 39.4 (18-57) 24-65 36-65 35.05 (19-58)
No. of patients 19 11 16 20
No. of previous
operations
(mean) 1.7 3 2.6 1.95
Follow up (Mean) Months 24-126 9-22 31 16.2
Time to Ilizarov (Mean) months 10.4 9.65 9.5 12.65
Ilizarov duration 6.4 7.2 48.1
Union 100 % 100% 98% 100%
Eradication of Infection 100 % 100% 95% 70%
Complications 87 68 71 65 complications
Bone results Excellent 94.73% 90.9% 92% 65%
Good 5.26% 9.09% 4% 20%
Fair 0% 0% 4% 15%
Poor 0% 0% 0% 0%
Functional results
73.68% 63.63% 15% 60%
Exce llent
Good 21.05% 0% 45% 20%
Fair 5.26% 9.09% 15% 10%
Poor 0% 0% 20% 10
Table VII. — the comparison between the current study and other similar studies.

Acta Orthopædica Belgica, Vol. 86 e-Supplement - 2 - 2020
role of ilizarov external fixator in treatment of humeral non-union 7
xator ; the anatomical and functional results were
compared with the results of other similar studies ;
our results were satisfactory.(Table.VII)
CONCLUSION
We hypothesized that the Ilizarov technique is
effective in the treatment of
humeral nonunion, as
regards bone healing and eradication of infection
with an acceptable rate of complications.
The study was approaved by ethical committee
of Benha university and were in accordance with
the ethical standards of the institutional and national
research committee and with the 1964 Helsinki
declaration and its later amendments or comparable
ethical standards.
Acknowledgement
To our professor Gammal Ahmed Hosny, who
had helped us to perform this work.
and professor Emad eldin Essmat for his support.
Ethical approval.
Informed consent
All patients signed an informed consent after
clear explanation of the surgical procedure.
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DISCUSSION
One of the most important factors in fracture
union is the preservation of local blood supply of
the bone fragments : in the humerus wide surgical
exposure can destroy the nutrient vessels between
the middle and lower thirds of the bone (11,15).
Revision surgeries by conventional methods of
internal xation are technically difcult ; most of
humeral nonunions are displaced and angulated
with or without bone loss. Moreover, these methods
are contraindicated when the fracture is complicated
by infection (3).
The Ilizarov external xator offers two antagonist
mechanisms in enhancement of fracture union :
rigid static xation as a scaffold and dynamic
xation when compression distraction is needed at
the fracture site.
Circular xation carries many advantages :
the ability to correct angulation, the possibility
of acute or gradual bone translation, the ability
to restore bone length through distraction osteo-
genesis, enhancement of local blood supply by
distraction and increasing the osteogenesis through
compression ; moreover insertion of transosseous
wires, especially in osteoporotic bone, allows rigid
stability (7,8,11,16).
In case of infected non- union, the Ilizarov
external xator proved to be superior, offering rigid
xation, preservation of local blood supply, ability
for bone transport after corticotomy and the ability
to perform repeated compression distraction cycles
at the nonunion site (2,5,6).
Ring et,al. have documented loss of humeral
length of an average of 2.4cm (range1-3.5)cm, in
their study group of humeral nonunion treated by a
bridging plate and autogenous iliac bone graft (13).
Lammens et al. have reported bone consolidation
in 28 out of 30 patients with humeral nonunion
after an average of 4.5 months, they had however 4
patients with a refracture after frame removal. In our
series union was achieved after an average period
of 5 months and there was no refractures following
frame removal (10).
In the current study we discuss the outcome and
the technique of treatment of 20 cases of different
types of humeral nonunion with the Ilizarov external

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