Augmentation plate with bone graft in the management of humeral aseptic nonunion after Intramedullary Nailing: Is nail removal mandatory?

Background
Surgical treatment of aseptic nonunion after intramedullary nail humerus (IMN) offers a wide range of options starting from bone marrow injection to nail removal and usage of alternative fixation methods. There is no consensus regarding nail retaining or nail removal.
Patients and methods
Total 28 patients who had aseptic nonunited fracture humerus after intramedullary nail were treated by a 3.5 locked compression plate using a posterior approach and bone graft with the nail in situ. The study was conducted between January 2019 and December 2022. The age average was 38.6 years old. All nonunions were diaphyseal, with 20 cases having an oligotrophic type while 8 had a hypertrophic type. All nails which were previously used were antegrade with 1 distal locking screw and 2 to 3 proximal locking screws. All nails were seated well without protrusion or encroachment on the supraspinatus tendon. We evaluated pre and post-DASH (Disabilities of arm, shoulder, and hand) scores and visual analog scale (VAS) of pain along with the radiologic union.
Results
The time-lapse between the IMN application and our intervention average was 15.6 months. The patient’s follow-up average was 13.8 months. The final DASH score average was 4.8 (the preop DASH score average was 22). The final VAS pain scale average was 0.6 (the preop VAS pain scale average was 2.8). All cases united after an average of 4.3 months. Two cases had a superficial infection that healed by antibiotics according to culture and sensitivity and repeated dressings.
Conclusion
In this study, surgical treatment obtained excellent clinical and radiological results in aseptic nonunion humerus fractures after IMN failure using 3.5 mm locked compression plate and bone graft with the nail in situ, as long as the conditions of nail retaining are met.