Flattening the learning curve - Early experience of robotic-assisted pedicle screw placement in spine surgery.

Aims and objectives: To determine accuracy of pedicle screws placed by freehand, fluoroscopy-assistance and robotic-assistance with intraoperative image acquisition, and determine the presence of learning curve in robotic spine surgery in a prospective single centre study. Materials and methods: In a prospective study, a total of 1120 pedicle screws were placed in Freehand group (n = 175), 1250 screws were placed in fluoroscopy-assisted group (n = 172), and 1225 screws were inserted in Robotic-assisted group(n = 180). Surgical parameters and screw accuracy were analyzed between the three groups. The preoperative plan was overlapped with post operative O-arm scan to determine if the screws were executed as planned. Results: The frequency of clinically acceptable screw placement (Gertzbein and Robbins grade A, B) in the Freehand, Fluoroscopy-assisted, and Robotic-assisted groups were 97.7 %, 98.6 %, and 99.34 % respectively. Higher pedicle screw accuracy, and lower blood loss were seen with robotic assistance. There was no significant difference in these parameters between surgeries commencing before and after 2 p.m. We found no statistically significant differences between the planned and executed screw trajectories in robotic assisted group irrespective of surgical experience. Conclusion: The third-generation robotic-assisted pedicle screw placement system, used in conjunction with intraoperative 3D O-arm imaging, consistently lowered blood loss and increased accuracy of pedicle screw placement in the thoracolumbar spine. It also has easy adaptability into spine practice with minimal learning curve.

A mysterious case of recurrent fracture: Tumour-induced osteomalacia.

We report a case of tumour-induced osteomalacia in a 59-year-old man who presented with a long-standing history of myalgia, bone pain and pathological fracture of the bilateral femur at different intervals in the past 4 years. A biochemical evaluation revealed hypophosphatemia secondary to phosphaturia. Localization study by Ga-68 DOTANOC PET-CT for adult-onset hypophosphatemic osteomalacia revealed a tumour in the right femoral head. Resection of the tumour resulted in clinical improvement as well as normalization of biochemical parameters.

Thirty-day mortality of patients with hip fracture during COVID-19 pandemic and pre-pandemic periods: A systematic review and meta-analysis.

BACKGROUND: Timely intervention in hip fracture is essential to decrease the risks of perioperative morbidity and mortality. However, limitations of the resources, risk of disease transmission and redirection of medical attention to a more severe infective health problem during coronavirus disease 2019 (COVID-19) pandemic period have affected the quality of care even in a surgical emergency. AIM: To compare the 30-d mortality rate and complications of hip fracture patients treated during COVID-19 pandemic and pre-pandemic times. METHODS: The search of electronic databases on 1st August 2020 revealed 45 studies related to mortality of hip fracture during the COVID-19 pandemic and pre-pandemic times. After careful screening, eight studies were eligible for quantitative and qualitative analysis of data. RESULTS: The pooled data of eight studies (n = 1586) revealed no significant difference in 30-d mortality rate between the hip fracture patients treated during the pandemic and pre-pandemic periods [9.63% vs 6.33%; odds ratio (OR), 0.62; 95%CI, 0.33, 1.17; P = 0.14]. Even the 30-d mortality rate was not different between COVID-19 non-infected patients who were treated during the pandemic time, and all hip fracture patients treated during the pre-pandemic period (OR, 1.03; 95%CI, 0.61, 1.75; P = 0.91). A significant difference in mortality rate was observed between COVID-19 positive and COVID-19 negative patients (OR, 6.99; 95%CI, 3.45, 14.16; P < 0.00001). There was no difference in the duration of hospital stay (OR, -1.52, 95%CI, -3.85, 0.81; P = 0.20), overall complications (OR, 1.62; P = 0.15) and incidence of pulmonary complications (OR, 1.46; P = 0.38) in these two-time frames. Nevertheless, the preoperative morbidity was more severe, and there was less use of general anesthesia during the pandemic time. CONCLUSION: There was no difference in 30-d mortality rate between hip fracture patients treated during the pandemic and pre-pandemic periods. However, the mortality risk was higher in COVID-19 positive patients compared to COVID-19 negative patients. There was no difference in time to surgery, complications and hospitalization time between these two time periods.

Suprapatellar nailing in proximal third tibial fractures - Clinicoradiological outcome.

AIMS AND OBJECTIVES: To evaluate the clinical and radiological outcome of proximal third tibia fractures managed by suprapatellar nailing with a minimum follow-up of 12 months. METHODOLOGY: In our retrospective cohort study of 43 consecutive proximal third tibia fractures from January 2015 to September 2018 treated with intramedullary nailing through suprapatellar approach in semiextended knee position were included. The patients were followed up regularly at 6 weeks, 3 months, 4.5 months, 6 months, 12 months and every 6 months thereafter. At each visit patients were assessed for union, shortening and rotational alignment. The clinical outcome was analysed using Lower Extremity Functional Scale (LEFS) and anterior knee pain. The radiological outcomes are analysed by evaluating the radiographs for progression of fracture union and tibial alignments. RESULTS: After fulfilling the exclusion and inclusion criteria, 43 out of 60 consecutive proximal third tibia fracture were included in the study with an average age of 38.4 years (20-71 years), follow up of 20.4 months (12-45 months) after the index procedure. The radiological union was achieved in 7.3 months (4-13 months). At the end of 1 year follow up, the average LEFS was 89.4% (60%-95%). 4 patients had Malunion - with 1 valgus and 3 anterior angulations, 8 delayed unions and 1 non-union (with bone loss- which required bone grafting). All the fractures united eventually. No incidence of anterior knee pain. CONCLUSION: We recommend suprapatellar nailing in proximal third tibial fractures when meticulously performed using the current surgical principles and techniques with proper implant selection. It results in excellent clinical and radiological outcomes with minimal complications when compared to other modalities of management. Suprapatellar nailing is a viable option for proximal third tibia fractures due to its inherent advantages of positioning, perfect nail entry and placement. Additionally, noteworthy absence of anterior knee pain is an additional benefit of this technique.

CT based measurement of anatomical dimensions of femur and its relevance in nail designs for proximal femoral fractures.

INTRODUCTION: The purpose of this study was to obtain computed tomography (CT) based measurements of femoral dimensions in adults, to identify its relevance with intramedullary nails used in the management of proximal femur fractures and to suggest a best fitting implant dimensions to our population. To best of our knowledge our study would be first to compile different CT based dimension in single study. METHODS: In our retrospective study of 50 femurs, CT based femoral dimensions measured in standardized cuts and compared with previous studies and commonly available proximal femur intramedullary devices. RESULTS: 68.4 was the mean age in our study, neck shaft angle (NSA) was 127.2±5.20, anteversion 11.2±7.40, endosteal isthmus diameter was 11.9 ± 1.7 mm, anterior radius of curvature (ROC) was 116.8 ± 20 mm, horizontal femoral offset 37.5 ± 4.6 mm, medio-lateral angle 7.8±1.60, with good inter and intra observer correlation. Femoral length and neck width was positively correlated to head diameter, horizontal femoral offset with medio-lateral (ML) angle. One of the 50 femur studied had the parameters in the range of available implant and could match appropriately. CONCLUSION: CT based dimensions in our population is different from other population. Based on this study, a design modification of nails used in present day management of proximal femur fractures has been recommended.

Variables affecting functional outcome in floating knee injuries.

BACKGROUND: The surgical outcome of floating knee injuries is difficult to predict. The high-velocity nature of the injury, complex fracture pattern and associated soft tissue/visceral injuries may have some impact on the functional outcome. The present study evaluates the variables affecting the clinical and radiological outcomes of floating knee injuries. MATERIALS AND METHODS: The clinical, radiological and functional outcome (Karlstrom and Olegrud criteria) of 89 patients with 90 floating knee injuries were evaluated at the end of one year who were managed in our level 1 trauma center between January 2013 and December 2016. The details of the injury, fracture pattern, management and complications were collected retrospectively from their records. RESULTS: There were 81 (91.1%) males and 8 (8.9%) females with mean age of 34.34 ±â€¯12.28 years. The mean time for tibia and femur union was 9.52 (±6.6) and 10.5 (±7.37) months. There was significant delay (p < 0.005) in time taken for union in segmental femur fractures (14.3 ±â€¯9.6 months) compared to nonsegmental femur fractures (8.68 ±â€¯5.18 months). Such significant difference in time taken for union was not seen in tibial segmental (10.6 ±â€¯4.62 months) and nonsegmental fractures (9.05 ±â€¯7.27 months). As per the Karlstrom and Olegrud criteria, there were 22 (24.4%) excellent, 26 (28.9%) good, 24 (26.7%) fair and 11 (12.2%) poor outcome. There were 15 patients with malunited tibia, 6 with malunited femur, 10 with limb length discrepancy and 39 with knee stiffness. 28 (33.3%) patients underwent major additional procedures such as bone grafting, re-fixation or bone transport or tendon transfer. It was observed that open tibia fracture, segmental fracture, intra-articular fracture, additional surgical procedures, initial external-fixator (ex-fix) application were significantly associated with development of knee stiffness, limb shortening, malalignment and unsatisfactory (Karlstrom and Olegrud fair to poor) functional outcome. CONCLUSION: Open tibial fractures, segmental fractures, intraarticular involvement, additional surgical procedures and initial external fixator application are the poor prognostic indicators of floating knee injuries.

ACL reconstruction using femoral Rigid-fix and tibial Bio-intrafix devices.

OBJECTIVES: The objective of this study is to report the clinical and functional outcomes of Hamstring graft ACL reconstruction fixed with femoral Rigid-fix and tibial Bio-intrafix devices. METHODS: In a prospective study, the clinical (Lysholm score) and functional outcomes (International Knee Documentation Committee, IKDC) of 44 patients who underwent autologus hamstring graft ACL reconstruction using femoral Rigid-fix and tibial Bio-intrafix devices, were evaluated at the end of one year. Joint laxity was assessed with KT-1000 arthrometer (MEDmetric, San Diego, CA). RESULTS: None of the patients complained of instability, joint swelling or severe pain in the postoperative period. The IKDC score improved from 66.62 + 5.36 to 92.36 + 5.30 (P < 0.001). Lysholm scores in the preoperative and follow up period were 68.28 + 5.54 and 93.87 + 4.75 respectively; the improvement was statistically significant with P value < 0.001. Similarly, the mean anterior translation of tibia improved from 7.45 mm in the preoperative period to 3.89 mm after one year of ACL reconstruction. Associated meniscus injury didn't have significant impact on the overall outcome. No intraoperative or postoperative complications were documented. CONCLUSION: Hamstring graft fixation using femoral Rigid-fix and tibial Bio-intrafix devices provide secure graft fixation and allows aggressive rehabilitation. The clinical and functional outcome of this hybrid fixation technique is rewarding.

Functional outcome of tibial fracture with acute compartment syndrome and correlation to deep posterior compartment pressure.

AIM: To measure single baseline deep posterior compartment pressure in tibial fracture complicated by acute compartment syndrome (ACS) and to correlate it with functional outcome. METHODS: Thirty-two tibial fractures with ACS were evaluated clinically and the deep posterior compartment pressure was measured. Urgent fasciotomy was needed in 30 patients. Definite surgical fixation was performed either primarily or once fasciotomy wound was healthy. The patients were followed up at 3 mo, 6 mo and one year. At one year, the functional outcome [lower extremity functional scale (LEFS)] and complications were assessed. RESULTS: Three limbs were amputated. In remaining 29 patients, the average times for clinical and radiological union were 25.2 ± 10.9 wk (10 to 54 wk) and 23.8 ± 9.2 wk (12 to 52 wk) respectively. Nine patients had delayed union and 2 had nonunion who needed bone grafting to augment healing. Most common complaint at follow up was ankle stiffness (76%) that caused difficulty in walking, running and squatting. Of 21 patients who had paralysis at diagnosis, 13 (62%) did not recover and additional five patients developed paralysis at follow-up. On LEFS evaluation, there were 14 patients (48.3%) with severe disability, 10 patients (34.5%) with moderate disability and 5 patients (17.2%) with minimal disability. The mean pressures in patients with minimal disability, moderate disability and severe disability were 37.8, 48.4 and 58.79 mmHg respectively (P < 0.001). CONCLUSION: ACS in tibial fractures causes severe functional disability in majority of patients. These patients are prone for delayed union and nonunion; however, long term disability is mainly because of severe soft tissue contracture. Intra-compartmental pressure (ICP) correlates with functional disability; patients with relatively high ICP are prone for poor functional outcome.

Arthroscopic Suture Pull-Out Fixation of Displaced Tibial Spine Avulsion Fracture.

The aim of this study is to assess the clinical and radiological outcomes of arthroscopic reduction and fixation of tibial spine avulsion in patients with either open physis or closed physis, using high strength nonabsorbable sutures utilizing intravenous cannula needle as suture passer and retriever. Twenty-six patients of mean age 24.5 years were included in the study with a mean follow-up period of 31 months. Twelve patients had McKeever type III avulsion fracture and 14 had type IV. A follow-up analysis was performed using fracture union time, range of motion assessment, and Lysholm and IKDC (International Knee Documentation Committee) scores with instrumental (KT-1000 arthrometer) laxity assessment. All avulsion fractures showed union at the end of a 3-month follow-up. Mean (± standard deviation [SD]) postoperative Lysholm and IKDC subjective scores were 97.7 (± 3.62, range, 89-100) and 95.55 (± 4.21, 82.8-100), respectively. All patients were graded IKDC grade A except one with grade B. The Lysholm score of open physis group was better than the closed physis group (99.6 vs. 96.5, p < 0.03), whereas IKDC scores of open versus closed physis group (both subjective and objective) and type III and IV McKeever groups did not reveal any statistical difference. KT-1000 assessment revealed mean (± SD) anterior translation of the tibia as 0.85 (±0.9) mm. At the final follow-up, all patients achieved complete range of movement with no symptom of instability. Two patients underwent adhesiolysis for postoperative stiffness in their knee at 4th month postoperatively. Arthroscopic suture pull-out fixation for type III and IV tibial spine avulsion results in excellent clinical and radiological outcomes in patient with open and closed physis without any significant complications. This is a prospective case series with level of evidence IV.

Giant cell rich osteosarcoma of the cuneiforms.

Osteosarcoma is the commonest primary malignant bone tumor in children and adolescents. Giant cell rich osteosarcoma is a rare subtype of conventional osteosarcoma. Osteosarcomas commonly involve the metaphysis and meta-diaphysis of long bones. We report a 19-year-old girl with giant cell rich osteosarcoma of the medial and intermediate cuneiform bones. Even though, giant cell rich osteosarcoma is frequently mistaken for osteoclastoma of the bone; age of onset, location of lesion, radiological features, and histological characteristics on a high power field helps to differentiate the two conditions. Appropriate and early diagnosis of this variant possibly averts severe morbidity and mortality to the patient. Nonmetastatic osteosarcomas in the foot have better prognosis and are amenable to limb salvage surgeries.

Correlation between the forearm plus little finger length and the femoral length.

PURPOSE. To assess the correlation between the forearm plus little finger length and the femoral length in 100 volunteers. METHODS. The forearm plus little finger length and the ipsilateral femoral length of 68 male and 32 female volunteers aged 19 to 55 (mean, 35.8) years were measured using a measuring tape. The forearm plus litter finger length was measured from the tip of the olecranon to the tip of the little finger, whereas the femoral length was measured from the tip of the greater trochanter to the level of proximal pole of the patella over the outer aspect of thigh. Two observers made the measurements on 2 separate occasions. Intra- and inter-observer variations were calculated. A value of 0.75 or greater indicated excellent agreement. RESULTS. The mean forearm plus little finger length and femoral length were 39.87 (SD, 2.73) and 39.85 (SD, 2.44) cm, respectively. The mean difference between these 2 measurements was 0.028 (95% CI, -0.109 to 0.165) cm. The correlation between these 2 measurements was 0.861 (p<0.001). Patient age, sex, and body mass index did not affect this correlation. The intra- and inter-observer reliability was excellent. CONCLUSION. The forearm plus little finger length correlated with the femoral length. This method is simple, radiation-free, and can be applied in day-today practice.

Ulnar buttress arthroplasty after enbloc resection of a giant cell tumor of the distal ulna.

Enbloc resection with or without ulnar stump stabilization is the recommended treatment for giant cell tumors (GCT) of the distal ulna. A few sporadic reports are available where authors have described various procedures to prevent ulnar stump instability and ulnar translation of carpal bones. We report a GCT of the distal ulna in a 43-year-old male which was resected enbloc. The distal radioulnar joint was reconstructed by fixing an iliac crest graft to the distal end of the radius (ulnar buttress arthroplasty) and the ulnar stump was stabilized with extensor carpi ulnaris tenodesis. After a followup at three years, there was no evidence of tumor recurrence or graft resorption; the patient had a normal range of movement of the wrist joint and the functional outcome was excellent as per the score of Ferracini et al.

Clinical and radiological outcome of percutaneous plating in extra-articular proximal tibia fractures: a prospective study.

BACKGROUND: Despite various techniques of fixation, proximal tibia fractures are associated with poor outcome and increased rates of complications. Minimal access and rigid fixation are the keys for optimal outcome in such fractures. Therefore, this study was designed to look for the clinical and radiological outcomes of percutaneous locked plating (PLP) in extra-articular proximal tibia fracture. METHODS: Between April 2008 and September 2010, 47 consecutive patients with 49 proximal third extra-articular tibial fractures (29 closed and 20 open injuries) underwent PLP. The patients were followed up at 6 weeks, 3 months, 6 months and 1 year. The union rate and complications of this fixation were evaluated. The clinico-radiological outcomes were assessed at 1 year of surgery. RESULTS: Four patients had infection in the postoperative period which needed repeated debridement, gentamycin bead application and prolonged antibiotic therapy. Three of these infective cases ended up with nonunion and needed cancellous bone grafting. All the remaining fractures united. The average time for union was 20 weeks in closed and type I open fracture and 25 weeks in type II and III fractures. No neurovascular injury, hardware failure or loss of fixation was documented till the last follow-up. The mean range of knee joint movement was 119°. The average lower extremity functional score (LEFS) was 59 (74%). There were 10 cases of malunion (20.14%), with six varus/valgus and five procurvatum/recurvatum (one having both sagittal and coronal malunion) angulations. There were no statistical differences between patients with malunion and normal alignment with regard to knee range of motion and LEFS. CONCLUSION: Minimally invasive osteosynthesis using PLP in extra-articular proximal tibia fractures showed a promising result with minimal complications.

Bilateral stress fractures of femoral neck in non-athletes: a report of four cases.

Femoral neck stress fractures (FNSFs) are rare, constituting only 5% of all stress fractures in young adults. These fractures are usually seen in athletes, military recruits and patients with underlying metabolic diseases. The treatment of FNSFs is still controversial because of the inherent complications associated with the treatment procedure. We came across 4 cases of bilateral FNSFs in non-athletic individuals who were manual labourers without underlying bony disorders. Two patients with FNSFs and coxa vara deformity on both sides were managed by subtrochanteric valgus osteotomy and dynamic hip screw fixation. One of the remaining two patients was treated by cannulated cancellous screw fixation on one side and subtrochanteric valgus osteotomy on the other side. The fourth patient received subtrochanteric valgus osteotomy on one side and bipolar hemiarthroplasty on the other side after failed cannulated screw fixation. All the fractures healed without any complications. No evidence of avascular necrosis or arthritis was noted in our series. Subtrochanteric valgus osteotomy restores normal neck-shaft angle in patients suffering from FNSFs combined with coxa vara deformity. Moreover, it helps to bring the forces acting around the hip to normal biomechanical levels, leading to fracture union and better results. Replacement arthroplasty is recommended to patients who fail to achieve bony union after fixation.

Ganglion cyst of the posterior cruciate ligament in a child.

Ganglion cysts are more commonly associated with the anterior cruciate ligament than the posterior cruciate ligament (PCL). A literature review showed that all reported cases of ganglion cysts to date involved adults. We report a rare case of ganglion cyst in the PCL of a four-year-old boy, and discuss its aetiology, clinical presentation, imaging features and management. Ganglion cysts of the PCL may be confused with meniscal cysts arising from tears of the posterior horn of the medial meniscus on magnetic resonance (MR) imaging. Hence, the posterior horn of the medial meniscus has to be carefully evaluated to rule out a tear. MR imaging is the method of choice to confirm diagnosis, and arthroscopic resection is a safe treatment modality even in children.

Staged arthroscopic reconstructive surgery for multiple ligament injuries of the knee.

PURPOSE: To review treatment outcome of our staged protocol for multiple ligament injuries of the knee. METHODS: 21 men who were treated for multiple ligament injuries of the knee and had completed at least one year of rehabilitation were evaluated. Patients were examined under anaesthesia and then by diagnostic arthroscopy. Arthroscopic reconstructive procedures for injured cruciate ligaments were performed after a minimum 110º flexion and full extension were regained. Collateral ligaments injuries were treated first, followed by posterior cruciate ligament (PCL) and then anterior cruciate ligament (ACL) tears. Outcome was evaluated using the Lysholm knee score and International Knee Documentation Committee (IKDC) knee ligament evaluation form. RESULTS: 19 patients aged 24 to 55 (mean, 36) years were followed up for a mean of 22 (range, 14-33) months. The mean Lysholm score was 92. The mean scores for patients treated within and after 3 weeks were 93 and 90, respectively. The overall IKDC grading was B in 15 knees and C and D each in 2 knees. For the 2 patients with grade D, one presented 19 months after the injury and had persistent posterior sag (secondary to capsular contracture). His Lysholm score was 82. The second patient developed a deep infection and endured a flexion loss of 30º but had a satisfactory Lysholm score of 94. There was no significant difference between early and delayed treatments and between low- and high-velocity injuries in terms of the Lysholm score, the IKDC grade, the range of movement, and the functional outcome. CONCLUSION: Staged management of multiple ligament injuries of the knee enabled satisfactory restoration of function, stability, and range of movement in most of our patients. By staging the procedures, the need for subsequent ACL reconstruction can be better evaluated, as ACL reconstruction is not necessary in patients not undertaking strenuous activities.

Closing lateral wedge valgus osteotomy with dynamic hip screw for the treatment of varus nonunion of pertrochanteric fracture: can restoration of biomechanics and stabilization alone heal?

INTRODUCTION: Nonunion of pertrochanteric fracture is rare and its occurrence especially without prior surgical intervention has been hardly ever reported. Hence there is not much literature describing the best way to treat them. Nonunion of pertrochanteric fracture collapses in to varus by virtue of deforming action of muscles and thus deranging the biomechanics of the hip and indirectly preventing fracture union further. Hence it is very important to re-orient the abductor lever arm to biomechanically advantageous normal configuration favoring fracture healing. In general, principles of treatment of nonunion like open reduction of the fracture with freshening of fracture fragments, stabilization and bone grafting are very difficult to the surgeon and the patient. METHOD: We herewith describe for the first time in literature a prospective nonrandomized study of closing lateral wedge valgus intertrochanteric osteotomy in addition to dynamic hip screw osteosynthesis in the successful management of seven patients with varus trochanteric nonunion. Average operating time was 63 +/- 13 min (range 39-93 min) and blood loss was 212 +/- 32 ml (range 156-320 ml). Average pre-operative coxa vara of 94 degrees +/- 7 degrees (range 85 degrees -104 degrees ) had improved to a femoral neck shaft angle of 139 degrees +/- 4 degrees (range 134 degrees -145 degrees ) on postoperative radiographs. RESULTS: All fractures and osteotomies had healed uneventfully at the last follow-up with good functional outcome. Harris Hip score had improved from 34 +/- 6 (range 22-47) to 89 +/- 4 (range 83-95) at an average of 11 months (range 7-13 months) follow-up. Valgus osteotomy converts shear forces across the fracture site into compressive forces thus achieving union.

Cephalomedullary nails in the management of ipsilateral neck and shaft fractures of the femur--one or two femoral neck screws?

This was a prospective study of 43 consecutive cases of combined ipsilateral femoral neck and shaft fractures treated with cephalomedullary nails. Sequential clinicoradiological evaluation of all high-energy femoral shaft fractures to detect associated ipsilateral neck fracture improved diagnosis. All but 1 of 35 cases included in the study achieved union of both fractures and excellent or good functional outcome. Mean Harris Hip Score at the last follow-up was 92+/-4 in single-neck screw configurations, and 94+/-3 for two-neck screw cephalomedullary nails which had better tip-apex distance. Mean sliding of the neck screw was 5+/-2mm with single-neck and 3+/-2mm with two-neck screw constructs. In six cases shortening was <1cm; 22 had delayed union of the shaft fracture, but only four of these needed additional surgery. Early aggressive fixation of both fractures using a cephalomedullary nail with the least possible surgical trauma is the key to success in these polytrauma cases.

Use of intramedullary fibular strut graft: a novel adjunct to plating in the treatment of osteoporotic humeral shaft nonunion.

Humeral shaft fractures respond well to conservative treatment and unite without much problem. Since it is uncommon, there is not much discussion regarding the management of nonunion in the literature, and hence this is a challenge to the treating orthopaedic surgeon. Osteoporosis of the fractured bone and stiffness of the surrounding joints compounds the situation further. The Ilizarov fixator, locking compression plate, and vascularised fibular graft are viable options in this scenario but are technically demanding. We used a fibular strut graft for bridging the fracture site in order to enhance the pull-out strength of the screws of the dynamic compression plate. Six patients in the study had successful uneventful union of the fracture at the last follow-up. The fibula is easy to harvest and produces less graft site morbidity. None of the study patients needed additional iliac crest bone grafting. This is the largest reported series of patients with osteoporotic atrophic nonunion of humerus successfully treated solely using the combination of an intramedullary fibular strut graft and dynamic compression plate.