Non-Vascularized Fibular Autograft for Two-Stage Scapulohumeral Arthrodesis in Ballistic Shoulder Injuries: A Case...

Ballistic trauma to the proximal humerus poses a significant challenge because of extensive bone loss and soft tissue damage, often involving the rotator cuff, deltoid muscle, and axillary nerve. In cases where limb preservation is the priority, scapulohumeral arthrodesis (SHA) remains a viable option, particularly when prosthetic reconstruction is contraindicated because of severe musculotendinous injury. The Masquelet 2-stage induced membrane technique has shown promising results in lower limb reconstruction, yet its application for upper limb arthrodesis in ballistic injuries remains underreported. This study aims to evaluate the outcomes of SHA using a non-vascularized fibular autograft in a 2-stage reconstruction approach following severe ballistic trauma.

This retrospective, multicentric case series included 4 male patients (mean age: 42 years, range: 30-52) treated between 2022 and 2023 for proximal humeral ballistic trauma. Inclusion criteria were significant humeral bone loss (>10.5 cm), rotator cuff and deltoid damage, and axillary nerve dysfunction. Exclusion criteria included scapular involvement and brachial plexus injuries beyond the axillary nerve. The first stage of the Masquelet technique involved radical debridement, resection of necrotic bone, and placement of an antibiotic-laden cement spacer. The second stage, performed 6 weeks later, involved removal of the cement, placement of a perforated non-vascularized fibular autograft, and stabilization with a scapulohumeral plate. Corticocancellous grafting from the iliac crest and femoral head allograft was used to enhance consolidation.

At the 1-year follow-up, all patients demonstrated significant functional improvement. The Constant score showed a substantial increase compared to preoperative values. Pain, assessed by the Visual Analog Scale (VAS), decreased both at rest and during movement. Radiographic analysis confirmed bone consolidation at a mean of 7 months (range: 6-11 months). No cases of recurrent infection or graft failure were observed. One patient required targeted antibiotic therapy because of positive microbiological cultures, but no clinical infection developed. Patient satisfaction was high, with an average rating of 8.5/10.

Two-stage SHA using a non-vascularized fibular autograft may represent a viable treatment option for proximal humeral ballistic trauma with extensive bone and soft tissue damage, particularly in settings where microsurgical expertise is not available. Despite the encouraging early outcomes observed in this small series, further prospective studies with larger cohorts and longer follow-up are needed to validate this approach and assess its long-term efficacy and safety.