Surgical Discussion

Patient positioning:  The patient was positioned supine on the operating table with the affected arm draped free to allow for manipulation and access during the procedure.

Anatomical surgical approach:  A deltopectoral approach was utilized, involving an incision made along the deltopectoral groove. The cephalic vein was identified and preserved. Subperiosteal dissection was performed to expose the proximal humerus. Complete debridement of the pseudarthrosis was carried out, followed by re-canalization and freshening of the bone ends.

The surgeon noted that closed nailing and compression plating without debridement would not be effective in this case due to the nature of synovial pseudarthrosis. A fibular graft was used to restore the medial column, and proximal tibial autograft along with an osteogenic/osteoinductive graft substitute was applied to enhance biological healing. Orthogonal plating provided structural stability. The patient exhibited decent on-table motion after a gentle examination under anesthesia, despite expectations of stiffness due to prior movement through the pseudoarthrosis.

Postoperative protocol:   Postoperative rehabilitation included immobilization followed by gradual mobilization exercises. The patient may require manipulation under anesthesia (MUA) or open lysis of adhesions if significant stiffness persists.

Follow up:   Not specified.

Orthopaedic implants used:   Orthogonal plating system, fibular graft, proximal tibial autograft, osteogenic/osteoinductive graft substitute.