Humeral nails: When to choose what and how to use

Reduced Surgical Time and Higher Accuracy of Distal Locking with the Electromagnetic Targeting System in Humeral Shaft Intramedullary Nailing

Objective

To evaluate the efficacy of the electromagnetic distal targeting system in the treatment of humeral shaft fractures.

Methods

From January 2012 to December 2018, we retrospectively reviewed 60 patients with humeral shaft fractures treated by intramedullary nailing. Among 60 cases, 41 were men and 19 were women. The average age at surgery was 48.5 years (range, 21–81 years). We performed the same surgical procedure for all patients. According to the different distal locking technique used, all patients were divided into two groups. The standard fluoroscopic freehand technique was used for Group FH, while the electromagnetic real‐time targeting technique was used for Group EM. All procedures were performed by two senior surgeons. Overall surgical time, cases of complications, failure of distal locking, union time, and shoulder function assessment were recorded intraoperatively and during follow‐up.

Results

Twenty‐seven patients in Group FH and 33 patients in Group EM met the inclusion criteria. No significant difference was found in the demographic data of the two groups. The mean surgical time was 76.48 ± 10.73 min in Group FH and 65.61 ± 8.91 min in Group EM (P < 0.05), showing significant difference. Seven failures occurred in Group FH and two failures occurred in Group EM (P < 0.05). No relevant complications were noted. The average union time was 3.37 ± 0.49 months in Group FH and 3.39 ± 0.50 months in Group EM (P = 0.855). The mean follow‐up was 14.30 ± 2.28 months in Group FH and 15.27 ± 2.83 months in Group EM (P = 0.153). The disabilities of the arm, shoulder and hand score (DASH) score, the range of motion (checked with the constant score), and the degree of functionality were, respectively, 21.52 ± 3.23, 27.04 ± 1.84, and 81.31% ± 3.88% in Group FH and 19.09 ± 2.40, 26.18 ± 1.70, and 77.97% ± 3.91% in Group EM (P = 0.233, 0.971, and 0.607).

Conclusion

The electromagnetic real‐time targeting system reduced surgical time and improved accuracy, and there was no radiation exposure in the distal locking procedure for humeral shaft fractures.

New trends in fixation of proximal humeral fractures: a review

Surgical treatment of proximal humeral fractures continues to be a challenge especially in osteoporotic patients. Locking plates and intramedullary nails have been used with satisfactory results but the previous reported complications have not been substantially reduced. Most of the existing studies involve a small number of patients followed up for a rather short period of time. Since proximal humeral fractures constitute a heterogenous group of complex fractures in an even more heterogenous population, no single fixation method is a panacea. Choice of implant and method of fixation should be selected according to individual patient and fracture pattern characteristics based on clearly defined indications and contraindications. Based on the findings of the existing clinical studies the authors propose a treatment algorithm.

Diaphyseal humeral fractures and intramedullary nailing: Can we improve outcomes?

While intramedullary nailing has been established as the treatment of choice for diaphyseal fractures of the femur and tibia, its role in the management of diaphyseal humeral fractures remains controversial. The reasons include not only the complicated anatomy and unique biomechanical characteristics of the arm but also the fact that surgical technique and nail designs devised for the treatment of femoral and tibial fractures are being transposed to the humerus. As a result there is no consensus on many aspects of the humeral nailing procedure, e.g., the basic nail design, nail selection criteria, timing of the procedure, and the fundamental principles of the surgical technique (e.g., antegrade/retrograde, reamed/unreamed, and static/dynamic). These issues will be analyzed and discussed in the present article. Proposals aiming to improve outcomes include the categorization of humeral nails in two distinct groups: "fixed" and "bio", avoidance of reaming for the antegrade technique and utilization of "semi-reaming" for the retrograde technique, guidelines for reducing complications, setting the best "timing" for nailing and criteria for selecting the most appropriate surgical technique (antegrade or retrograde). Finally, suggestions are made on proper planning and conducting clinical and biomechanical studies regarding the use of intramedullary nailing in the management of humeral shaft fractures.

Fixed intramedullary nailing and percutaneous autologous concentrated bone-marrow grafting can promote bone healing in humeral-shaft fractures with delayed union

Treatment of humeral diaphyseal nonunion can be difficult and usually requires an extensive approach to the humerus with bone grafting, a procedure that could result in a lengthy operation with significant morbidity for the patient. The purpose of the present study is to describe a novel minimally invasive technique for the treatment of humeral-shaft fractures that do not demonstrate union progress within 16-24 weeks of injury. Fixed intramedullary nailing with percutaneously harvested and introduced autologous concentrated bone-marrow cells (mixed with demineralised bone matrix putty) was successfully used to treat five patients who had delayed union of a humeral-shaft fracture. The procedure was minimally invasive with no complications and resulted in sound union of all cases within 20 weeks.

Intramedullary nailing of combined/extended fractures of the humeral head and shaft

OBJECTIVES

To evaluate the use of intramedullary nailing in the management of both "combined" and "extended" fractures of the humeral head and shaft.

DESIGN

Retrospective case series study.

SETTING

Level I trauma center.

PATIENTS AND INTERVENTION

Twenty-one consecutive patients who underwent intramedullary nail insertion for "extended" or "combined," closed, nonpathologic fractures of the humeral head and shaft between October 1999 and December 2006 were included in the study. Two patients were lost to follow up and one died before fracture healing.

MAIN OUTCOME MEASUREMENTS

Evaluation of outcomes was assessed with the use of the Constant score.

RESULTS

There were no neurovascular problems or infections. Eighteen fractures united from 4 to 7 months postoperatively. One case of avascular necrosis of the humeral head, one case of acromion impingement, and one case of unacceptable loss of reduction occurred. Shoulder range of motion was not regained fully in any case and mild shoulder discomfort remained in eight patients. The mean Constant score for all 18 patients was 74.4 (range, 20-95) for the affected side and 89.17 points for the uninjured side. The percentage created from the mean affected/unaffected side scores was 83.4%.

CONCLUSIONS

Intramedullary nailing for proximal humeral fractures associated with shaft extension or segmental involvement appears to offer a reliable treatment option.

A new modular nail for the diaphyseal fractures of the humerus

Over a period of 5 years, 63 traumatic and eight pathological diaphyseal humeral fractures were treated with a new modular humeral nail. The nail is cannulated, square in shape--with concave sides--and has two different extensions that can be used with either the antegrade or the retrograde approach. Adequate rotational and axial stability is provided without the need for distal locking screws in the majority of fractures, while the need for proximal locking screws during the antegrade procedure is abolished. This study aims to present the 'Garnavos' nail and the results of its use, along with proposals and guidelines that should be considered whenever intramedullary nailing is selected for the treatment of diaphyseal humeral fractures.