A Focused Technical Case Series Highlighting the Role of Double Plating in Revision Surgery for Humeral Shaft Nonunion With Metabolic Optimization

Introduction: Humeral shaft nonunion remains a significant clinical challenge, particularly after failed fixation attempts. Recent biomechanical and clinical studies suggest that double plate fixation may offer superior mechanical stability in revision surgery. Moreover, addressing underlying metabolic and nutritional deficiencies may enhance bone healing in complex nonunion cases. Methods: We present a focused technical case series of 3 patients with hypertrophic humeral shaft nonunions (AO 1.2.A.3) who had undergone at least 2 prior failed surgeries. All patients presented with painless progressive deformity and functional limitation. Comprehensive metabolic evaluation revealed previously undiagnosed vitamin D deficiency, hypoalbuminemia, and hypothyroidism. All cases were managed with open resection of the nonunion site, autologous iliac crest bone grafting, and double locked plate fixation (anterior 10-hole LCP and lateral 5-hole LCP, in either parallel or orthogonal configuration). A tailored metabolic correction protocol was implemented preoperatively and postoperatively. Results: All 3 patients achieved radiographic union within 8 weeks. Functional outcomes improved progressively, with DASH scores decreasing from a mean of 45.0 to 5.0, and Constant and MEPS scores reaching >90 by 12 months. No complications or reoperations were recorded. All patients returned to unrestricted manual labor. Conclusion: Double plate fixation, combined with metabolic and nutritional optimization, is a safe and effective strategy for complex humeral shaft nonunion with prior failed fixation. A multidisciplinary approach that integrates biomechanical stability with systemic metabolic correction may accelerate healing and improve long-term functional outcomes. Level of Evidence: Level IV.