What type of bone graft is best for achieving union in a humerus non-union?

Autologous Iliac Crest Bone Graft Is Best for Achieving Union in Humeral Non-union

Autologous iliac crest bone graft is the optimal choice for achieving union in humeral shaft non-union cases requiring open reduction and plating, due to its superior fusion rates and biological properties. 1

Comparison of Bone Graft Options

Autologous Iliac Crest Bone Graft

• Provides the highest union rates (100%) in humeral shaft non-unions when combined with plate fixation 1
• Offers ideal graft characteristics including osteoconduction, osteoinduction, and osteogenesis 2
• Average time to union is approximately 4.5 months 1
• Considered the "gold standard" due to its biological properties 2
• Contains viable osteoprogenitor cells that directly contribute to new bone formation 2

Demineralized Bone Matrix (DBM)

• Achieves 97% union rate in humeral shaft non-unions when combined with plate fixation 1
• Average time to union is approximately 4.2 months 1
• Can be used as a bone graft extender for instrumented fusions 2
• Lacks the osteogenic properties of autologous bone but retains some osteoinductive potential 2

Allograft Bone

• Associated with higher non-union rates compared to autograft in multiple-level procedures 2
• Shows significantly increased graft collapse (30%) compared to autograft (5%) 2
• May be acceptable for single-level fusions but has higher failure rates in more complex cases 2
• Smoking has a more significant negative impact on fusion success with allograft compared to autograft 2

Vascularized Fibular Graft

• Can be effective for recalcitrant non-unions where other methods have failed 3
• More technically challenging and associated with donor site morbidity 2
• Indicated primarily for cases with significant bone loss or after multiple failed attempts at union 4

Clinical Decision Algorithm

1. First-line treatment: Autologous iliac crest bone graft with plate fixation 1, 5

   • Provides highest union rates (100%)
   • Offers optimal biological environment for healing

2. Alternative if donor site morbidity is a significant concern: Demineralized bone matrix with plate fixation 1

   • Nearly equivalent union rates (97%)
   • Avoids donor site complications

3. For cases with significant bone loss or multiple failed attempts: Consider autologous non-vascularized fibula graft with supplemental iliac crest bone graft 4

   • Provides structural support and biological factors
   • Mean time to union approximately 17 weeks

4. For recalcitrant distal humeral non-unions: Consider pedicled vascularized bone graft from distal radius 3

   • Reserved for cases with at least 3 previous failed surgical interventions

Important Considerations and Potential Complications

Donor Site Morbidity with Iliac Crest Harvest

• Approximately 44% of patients experience donor site morbidity 1
• Most common issue is prolonged pain at the harvest site 1
• Rare complications include superficial infection requiring debridement 1
• Must be weighed against the superior union rates when making decisions 1

Factors Contributing to Failed Union

• Unstable fixation is a common cause of persistent non-union 5
• Lack of osteogenic supply can lead to failure of healing 5
• Unrecognized surgical site infection may be present in some persistent non-unions 5
• Smoking negatively impacts fusion rates, especially with allograft 2

Technical Considerations

• Proper debridement of the non-union site is essential regardless of graft choice 5, 6
• Direct compression of the fracture site using plate osteosynthesis improves outcomes 6
• Single-stage procedures are preferred when possible 5
• Two-stage procedures may be necessary in cases of infection 5

By following this evidence-based approach and selecting autologous iliac crest bone graft as the primary option, surgeons can maximize the likelihood of achieving union in humeral shaft non-unions while being prepared with appropriate alternatives when specific patient factors necessitate a different approach.