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Upper Limb: A. Ali, H. Douglas, and D. Stanley Revision surgery for nonunion after early failure of fixation of fractures of the distal humerus J Bone Joint Surg Br 2005; 87-B: 1107-1110 [Abstract] [Full text] [PDF]

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Letter from Mr Joshy

Suraj Joshy, Tharian K   (18 August 2005)

The role of biological augmentation in nonunion

Anil Agarwal, Rachna Agarwal   (17 August 2005)

Letter from Mr Joshy 18 August 2005
Suraj Joshy, Research Fellow, Orthopaedics City Hospital, Birmingham, Tharian K Send letter to journal: Re: Letter from Mr Joshy surajjoshy{at}yahoo.co.uk Suraj Joshy, et al.	Sir, I read this paper with great interest. The most important determinant of nonunion of fracture of the distal humerus after surgery is the adequacy of the initial fixation. One of the aims of the study was to evaluate the factors which may predispose to nonunion of the distal humerus. There are critical methodological issues that need to be considered when interpreting the results. The authors state that age and a history of smoking were not important factors in the development of nonunion. It is proven beyond doubt that both these factors have a significant impact on the incidence of nonunion. This study did not show any such correlation because of the small number of cases. Similarly, the authors also state that the mechanism of the injury is not relevant. The explanation for this conclusion is that the same number of patients developed nonunion after simple falls as compared with high energy trauma. For these conclusions to be validated there should be a well-defined control group or the data of all the patients with distal humeral fractures treated by surgery must be available. The aim of the paper is valuable and relevant but without sound methodology results should be interpreted with caution. S. JOSHY City Hospital, Birmingham, UK.
The role of biological augmentation in nonunion 17 August 2005
Anil Agarwal, Consultant Delhi, India, Rachna Agarwal Send letter to journal: Re: The role of biological augmentation in nonunion rachna_anila{at}yahoo.co.in Anil Agarwal, et al.	Sir, We read this article with interest. Many of the cases were only one to three months after injury (cases 2, 8, 13 and 15). An essential criterion for nonunion is a lack of progression of healing for several months.1 With a follow-up as short as one to three months, we believe that several cases represent failure of the implant rather than nonunion. Furthermore, drawing from a series of 16 cases where age, severity of injury or fracture pattern have no bearing on nonunion seems premature. Any fracture which is inadequately fixed and is mobile (12 out of 16 cases in this series) tends to progress to nonunion. Ali, Douglas and Stanley mainly emphasised the role of mechanical factors (rigid fixation) in their cases of nonunion. However, they augmented their fixation with bonegrafting. The fracture probably healed because of better bony continuity and a better mechanical and biological environment. Hence the role of biological augmentation should also be given due consideration. A. AGARWAL R. AGARWAL New Delhi, India. 1. Canale ST. Campell's Operative Orthopaedics. Vol.3, Ninth ed. Mosby; Missouri, 1998:2580.