Endosteal Fibular Strut Graft with Proximal Humeral Locking Plate in Delayed and Neglected Fractures of the Proximal Humerus

Purpose: The purpose of this study was to define a treatment protocol in which a non-vascularized endosteal fibular strut graft, a corticocancellous grafts and a locking plate construct are used for stabilization of the delayed and neglected proximal humerus fractures and to report its outcome. Patients & Methods: Eleven patients (6 females and 5 males) with delayed, neglected proximal humerus fractures were included in this study, conducted between March 2015 and December 2019. Average age of the patients was 57 years (range: 41 to 67 yrs). All patients were treated with the debridement, decortication and shingling of the bone at the site of the fracture followed by using an endosteal fibular strut graft, corticocancellous bone grafts and stabilization with locking plate. The patients were followed up for a mean time of 16.3 months (range: 13 to 40 months). The patient outcomes were evaluated using the Disabilities of the Arm, Shoulder, and Hand Questionnaire, and the modified scoring system of Constant and Murley. Results: Union at the fracture site was achieved in all patients at a mean of 8.5 months (range: 6 to 11 months). The DASH score improved from an average pre-operative score of 71.1 (range: 64 to 78) to an average post-operative score of 25.2 (range: 21 to 35) at the final follow-up. Albeit with a small sample size of n = 11, this difference was found to be statistically significant (p < 0.05). The CM score improved from an average pre-operative score of 33.2 (range: 20 to 48) to an average post-operative score of 66.8 (range: 59 to 72) at the final follow-up. This difference was also found to be statistically significant in this patient cohort (p < 0.05). The results were excellent in 3 patients, good in 6 and moderate in 2. Conclusions: An endosteal fibular strut, subperiosteally placed cortico-cancellous grafts with a locking plate fixation helps in biological healing of neglected fractures of proximal humerus. How to cite this paper: Gadegone, P.W., Gadegone, W. and Lokhande, V. (2020) Endosteal Fibular Strut Graft with Proximal Humeral Locking Plate in Delayed and Neglected Fractures of the Proximal Humerus. Open Journal of Orthopedics, 10, 359-370. https://doi.org/10.4236/ojo.2020.1012034 Received: September 18, 2020 Accepted: December 7, 2020 Published: December 10, 2020 Copyright © 2020 by author(s) and Scientific Research Publishing Inc. This work is licensed under the Creative Commons Attribution International License (CC BY 4.0). http://creativecommons.org/licenses/by/4.0/ Open Access P. W. Gadegone et al. DOI: 10.4236/ojo.2020.1012034 360 Open Journal of Orthopedics


Introduction
The incidence of proximal humeral fractures accounts for 5% to 8% of all fractures [1]. In developing countries, ignorance and lack of accurate diagnosis lead to fractures being neglected for a long period of time. The proximal humerus fractures, after initial neglect, are extremely challenging to treat because they are often associated with shoulder and elbow joint stiffness, marked osteopenia and metaphyseal or diaphyseal bone defects [2]. To date, there is no consensus on a standardized treatment or management protocol of neglected fractures of the humerus. Many surgeons agree that in neglected and nonunited fracture cases in young adults, salvage is possible and an attempt should be made to preserve the humeral head and native shoulder joint be means of novel fixation techniques [3]. Various methods of bone grafting are described in the literature. The fibula is a long bone that can be useful as vascularized or non-vascularized graft in reconstruction of bony defects [4]. Non-vascularized fibula should be considered a valuable alternative treatment option for patients with bone defects or segmental reconstructions. The use of fibular strut bone graft, the stability of fixation, stiffness of the plate and screw constructs are markedly improved [5]. Patient outcomes i.e. safety and effectiveness of the procedure in allowing a patient to regain the ability to function and perform activities of daily living in a near pain-free state similar to their pre-fracture state, depend highly on the integrity and quality of the fracture union [6]. The locking plate with autogenous grafting is accepted as the gold standard method which has yielded satisfactory results in nonunited fractures.
The goals of this article were: 1) to define an open reduction treatment protocol in which a non-vascularized endosteal fibular strut graft, a supplementary cortico-cancellous iliac crest graft and a locking plate construct are used for stabilization and osteosynthesis of the neglected proximal humerus fracture, and 2) to report on patient outcomes, i.e. safety and effectiveness data, following this treatment protocol.

Patients and Methods
This study was conducted at a multispecialty orthopaedic hospital and government medical college following receipt of approval from the hospital's human research ethics committee. A written informed consent was obtained from all patients who agreed to participate in this study. A total of 11 patients (six female and five male) were included in this study that was conducted between March 2015 and December 2019 at a multispecialty orthopaedic hospital and govern- Six patients received initial treatment from a village Hakim (i.e. a local practitioner "specializing" in traditional medicine). Five patients were considered as being negligent or ignorant as they received either no care or were taken to local "bone-setters". The average time of neglect from initial injury for all 11 patients in this study was 7 weeks (range: 4 to 12 weeks). All patients presented with closed fractures, and upon further evaluation revealed radiological findings like an atrophic type of non-union. The patients reported mild pain, displayed tenderness and abnormal mobility at the site of fracture, and complained of difficulty in performing basic activities of daily living.

Pre-Operative Evaluation & Fracture Classification
Pre-operative radiographic evaluation was conducted in all patients. For all patients, anterior posterior (AP) radiographic views were taken with both internal and external rotation of the shoulder joint, however a radiograph in the axillary view position was not possible in some patients because of shoulder stiffness. All patients were observed to have stiffness of their shoulder and elbow joints to varying degrees. All the necessary investigations were completed to rule out the possibility of an infection.
With regards to treatment options for fractures of the proximal humerus, various classification schemes have been proposed, however, there is no classification scheme described for neglected fracture of humerus. Using the existing classification scheme presented by Checcia and colleagues [7] based on the criteria of nonunion and the characteristic of fracture pattern, five patients in our study were classified to be in Group 1, four patients in Group 2 and two patients in Group 3.

Surgical Technique
All the patients agreed to the written consent after explaining them about the procedure.
A delto-pectoral approach was used to expose the fracture site. Excision of the fibrous and devitalized bone was done. The medullary canal was opened with straight and curved bone awl and if needed canal was opened with appropriate reamer to accommodate the fibular strut graft. Shingling of proximal and distal part of fracture site was done for cortico-cancellous grafts. Under Tourniquet control the midshaft of the fibula was harvested with care taken to protect the superficial peroneal nerve. We resorted to harvest a slightly lengthy fibula so that it could be trimmed as necessary to telescope snugly into the fragments across the fracture site and proximally into hollow cavity of proximal humerus [ Figure  1(a), Figure 1  The Shoulder and elbow exercises were initiated a day after the operation depending upon the patient comfort. The sutures were removed after 10 days.
Three patients had superficial infection. They were controlled in five days with dressing and antibiotics. The patients were guided by the physiotherapy protocols to be followed. After hospital discharge, the patients were observed on a monthly basis until healing of the fracture clinically and radiologically. The presence of bridging callus, as well as any loosening or failure of the fixation was noted. The fracture union was considered, if on X-ray, the callus formation was seen in three of four cortices on AP and lateral views.

Clinical Scores and Statistics
Data was collected in this study retrospectively. Two well established and frequently used clinical scoring methods were used i.e. DASH Questionnaire (Dis-

abilities of the Arm, Shoulder and Hand) and the CMS (Constant & Murley
Score) [8]. DASH provides data on grip strength, range of motion, radiographic parameters and functional outcomes whereas CMS objectively evaluates shoulder outcomes. Statistical analyses were conducted on the data collected to test the null hypothesis at an α of 0.05, the null hypothesis being that there would be no statistically significant difference between the preoperative and post-operative DASH and CMS (Table 1).

Results
Complete union of the fracture was successfully achieved in all patients at a mean follow-up time of 8.5 months (range: 6 to 11 months). This was confirmed upon clinical evaluation as well as radiographic determination of bridging calluses observed between the fractured bone segments. There was detection of a statistically significant difference between the means of the preoperative and post-operative data groups. Post-operatively, the average CMS more than doubled, i.e. an increase of >100%, which too met the criteria of a clinically significant difference ( Table 2 and Table 3).  This bar graph shows a comparison between the average preoperative and postoperative DASH scores and CMS (chart).
Objective functional outcomes, i.e. range of motion and basic tasks when conducting activities of daily living, using a patient satisfaction rating were also recorded and reported for all patients. These were observed to be excellent in three patients, good in six patients and moderate in two patients. None of the patients reported as having poor functional outcomes following this procedure.
There were no perioperative complications noted for any of the patients.

Discussion
The term neglected, in the context of seeking medical treatment, is generally defined as the passage of a time period of at least three weeks since the occurrence of an injury for which there is either no treatment sought or a lack of appropriate and adequate treatment administered. Neglected proximal humerus fractures pose a challenging problem to the treating orthopaedic surgeon as there is a dearth of published literature that provides a preferred treatment protocol or procedure option that has been successful in patients such cases [9]. Successful surgical management of any humeral nonunion or malunion case requires a stable internal fixation that enables early joint motion. An autologous bone graft is also advocated to promote the natural bone healing process in such cases [12] [13]. Due to the continual advent of newer operative techniques and implant designs in the management of complex fracture cases, a stable internal fixation is now easily achievable even in the most complex of cases.
In this research study we followed the general principles of achieving a stable such published data to some extent. In one such study, a union rate of 96% was achieved with plate fixation in combination with intramedullary bone peg insertion and cancellous bone grafting [13]. The rate of complications reported in that study was also low. A union rate of 100% was reported in another article on nonunion fracture cases [12]. The neglected fractures mimics like nonunited fractures hence it requires the procedure which will produce early union of atrophic nonunited bone and to restore the strength of functionless limb. Our procedure helps in salvaging the fracture by achieving early union. It has profound effect on the overall compliance of the patient, reduces the repeated morbidity from the lengthy and costly treatment of prosthetic replacement. We did not see any complication like the postoperative infection; implant cut through and even fracture of the fibula graft in any case. Transient radial nerve palsy was noted in one patient which might be during the tissue handling at the time of fixation, and it recovered fully after six months of follow up. Two patients had donor site discomfort and peroneal compartment weakness resolved after physiotherapy in three months.
Hertel et al. [14] in their follow up study observed that initial predictors of humeral head ischemia do not necessarily preclude development of avascular necrosis and therefore, fixation is worth considering in such cases even if signs of ischemia are present [15]. noted that if such a reconstruction is not possible or is tried and fails, performing a traditional or reverse shoulder arthroplasty still remains available as the next in line viable option for these patients [16].
This study isn't without its limitations. Our patient cohort was very small in size comprising of only 11 patients. The follow-up duration was also less than 24 months, which is short-term. As a result, we are unaware of the long-term implications of this treatment protocol and if it will continue to allow the patients to live a close to normal and pain free lifestyle as it relates to their shoulder joint mobility. Lastly, we could not locate any other peer reviewed published articles that report on patient outcomes in specific cases of neglected fractures of the proximal humerus, therefore, we could not adequately compare the findings of our study to similarly published data. Longer term studies including a greater number of patients are required to corroborate the findings of our study, and we encourage the orthopaedic surgeon community to implement the treatment protocol we recommend and publish their findings in-line with the data we report.

Conclusion
An endosteal fibular strut graft provides added stability of fixation with a locking plate for treatment of delayed and neglected fractures of the proximal humerus.
Additionally, subperiosteally placed corticocancellous grafts at the fracture fixation site provide for a quick response time the biological healing of the bone.
The treatment procedure defined in this study can be universally adopted for a successful outcome in cases of delayed and neglected fractures of the long bones.