The inflatable intramedullary nail for humeral shaft fractures

Complications following intramedullary nailing of proximal humerus and humeral shaft fractures: a systematic review

HYPOTHESIS

The purpose of this study was to systematically review complications arising from intramedullary nailing (IMN) of proximal and humeral shaft fractures. This study hypothesized that there would be a low rate of complications and revision among patients treated with IMN for humerus fractures.

METHODS

Two independent reviewers performed a literature search in the PubMed database based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies were included if they reported on outcomes following the use of intramedullary nails for proximal humerus fractures or humeral shaft fractures. Variables that were collected included complications, visual analog scale pain scores and revision operations.

RESULTS

Overall, 179 studies met the inclusion criteria, with 7984 shoulders. The average age of patients in this study was 55.2 years and 60.7% of patients were female. The mean follow-up was 16.6 months. The overall complication rate for all fractures treated with intramedullary nails was 18.9%, and the overall revision rate was 6.8%. Among the complications were fracture complications (7.5%), hardware complications (7.2%), soft tissue complications (1.8%), neurovascular complications (1.6%), and infection (0.8%). Four-part proximal humerus fractures (52.9%) and open fractures (36.7%) had the highest rates of complication. Among the reasons for revision were hardware removal or replacement (5.0%), conversion to arthroplasty (0.6%), and other (1.2%). The mean visual analog scale pain score at last follow-up was 1.6.

CONCLUSION

Overall, there was a moderate rate of complications but low rate of revision following IMN of humerus fractures. Open fractures and 4-part proximal humerus fractures had the highest complication rates.

Humeral shaft fractures: a cost-effectiveness analysis of operative versus nonoperative management

BACKGROUND

Humeral shaft fractures can be managed operatively or nonoperatively with functional bracing in the absence of neurovascular injury, open fracture, or polytrauma. A consensus on optimal management has not been reached, nor has the cost-effectiveness perspective been investigated.

METHODS

A decision tree was constructed describing the management of humeral shaft fractures with open reduction-internal fixation (ORIF), intramedullary nailing (IMN), and functional bracing in a non-elderly population. Probabilities were defined using weighted averages determined from systematic review of the literature. Cost-effectiveness was evaluated with incremental cost-effectiveness ratios, measured in cost per quality-adjusted life-year (QALY). Willingness-to-pay thresholds of $50,000/QALY and $100,000/QALY were evaluated.

RESULTS

Eighty-six studies were included. Using bracing as the referent in the health care model, we observed that bracing was the preferred strategy at both incremental cost-effectiveness ratio thresholds. ORIF and IMN had higher overall effectiveness (0.917 QALYs and 0.913 QALYs, respectively) compared with bracing (0.877 QALYs). The cost-effectiveness of bracing was driven by a substantially lower overall cost. In the societal model-accounting for both health care and societal costs-the cost difference narrowed between bracing, ORIF, and IMN. Bracing remained the preferred strategy at the $50,000/QALY threshold; ORIF was preferred at the $100,000/QALY threshold. ORIF and IMN were comparable strategies across a range of probability values in sensitivity analyses.

CONCLUSIONS

Functional bracing, with its low cost and satisfactory clinical outcomes, is often the most cost-effective strategy for humeral shaft fracture management. ORIF becomes preferable at the higher willingness-to-pay threshold when societal burden is considered. QALY values for ORIF and IMN were comparable.

Efficacy and Safety Evaluation of Intramedullary Nail and Locking Compression Plate in the Treatment of Humeral Shaft Fractures: A Systematic Review and Meta-analysis

Objective

The surgical treatment scheme of humeral shaft fracture is still controversial with no consensus reached. This meta-analysis was aimed at comparing the efficacy and safety of intramedullary nail (IMN) and locking compression plate (LCP) in the treatment of humeral shaft fractures.

Methods

PubMed, Medline, Embase, Ovid, Cochrane Library, ISI Web of Science, Clinical Trials, and Chinese databases, including China National Knowledge Infrastructure Project, Wanfang database, and China biomedical abstracts database, were used to search the literature. Review Manager software was employed for statistical analysis and establishing forest and funnel maps. Categorical variables were measured by relative risk (RR), and standardized mean difference (SMD) was used to measure continuous variables. 95% confidence intervals were used for each variable. The modified Jadad scale, Newcastle-Ottawa scale, and Cochrane's bias risk tools were used to evaluate the bias and risk of eligible studies.

Results

A total of 14 studies were included in the analysis with a total of 903 patients with humeral shaft fracture. Significant differences with regard to operation time (Std = -1.18, 95% CI: -2.14, -0.22, Z = 2.41, P = 0.02), blood loss (Std = -2.97, 95% CI: -4.32, -1.63, Z = 4.34, P < 0.001), and postoperative infection rate (RR = 0.32, 95% CI: -0.15, 0.68, Z = 2.98, P = 0.003) were noted between the IMN group and LCP group. In addition, the American Shoulder and Elbow Surgeon (ASES) score (Std = -0.22, 95% CI: -0.44, 0.01, Z = 2.08, P = 0.04) and the rate of shoulder and elbow function limitation (RR = 1.88, 95% CI: 1.06, 3.33, Z = 2.17, P = 0.03) between the 2 groups were also statistically significant. There were no significant differences in the rate of radial nerve injury, nonunion, delayed healing, and secondary operation between the two groups.

Conclusion

IMN is superior than the LCP in terms of the operation time, intraoperative bleeding, and postoperative infection, suggesting its superiority in the humeral shaft fracture fixation. However, IMN is inferior to LCP in ASES score and shoulder elbow function limitation rate, indicating poor early postoperative functional recovery. More studies are required to evaluate and analyze the clinical efficacy between IMN and LCP regarding long-term function after artificial graft removal.

Comparison of Expandable and Locked Intramedullary Nailing for Humeral Shaft Fractures

Introduction In this study, we clinically and radiologically investigated whether the application of expandable nails for surgical treatment of humeral shaft fractures has an advantage over locked intramedullary nails. Methods Patients treated with intramedullary fixation due to humeral shaft fractures in our clinic were investigated retrospectively. Patients with fractures of type 12A and 12B according to the AO classification in the middle 1/3 shaft region of the humerus were divided into two groups as those receiving fixation with expandable nails and with locked intramedullary nails. The union rate, union time, Q-DASH scores, duration of surgery, and complication rates were statistically compared between the two groups. Results The study included 38 patients with clinical follow-up from among 47 patients; 20 patients received fixation with locked intramedullary nails and 18 with expandable nails. The mean age of the patients was 56.92 (19-91) years and 53% (n=20) were men while 47% (n=18) were women. During statistical evaluation, a statistically significant difference was found between the groups for union (100% and 72.2%) and complication rates (6% and 13%). More union and lower complication rates were found in patients treated with locked intramedullary nails. In comparing the mean of surgical times (71.1 and 30.2 min), expandable nails had a shorter surgical time. However, there was no statistically significant difference between the union time and Q-DASH scores between the two groups. Conclusion Locked intramedullary nails are a better fixation method than expandable nails due to the low complication rate and high rate of union. However, due to shorter surgery time, expandable nailing is an alternative method in limited cases.

Antegrade intramedullary nail versus plate fixation in the treatment of humeral shaft fractures: An update meta-analysis

BACKGROUND

There is no consensus regarding the surgical treatment of humeral shaft fracture. The present meta-analysis was performed to compare the efficacy and safety between antegrade intramedullary nailing (IMN) and plating for humeral shaft fracture.

METHODS

PubMed, MEDLINE, Cochrane Library, EMBASE, Clinical Trails, Ovid, ISI Web of Science, and Chinese databases including WanFang Data, China National Knowledge Infrastructure were searched through March 10, 2019. The Review Manager software was adapted to perform statistical analysis and relative risk (RR) were used for the binary variables, and weighted mean difference and standardized mean difference (SMD) were used to measure the continuous variables. Each variable included its 95% confidence interval (CI).

RESULTS

A total of 15 trials with 839 patients were included in the analysis. There was significant difference between IMN group and plate group in blood loss (SMD = 3.49, 95% CI: 1.19, 5.79, P = .003) and postoperative infections (RR = 3.04, 95% CI: 1.49, 6.24, P = .002). Additionally, significant difference was observed between minimally invasive plate osteosynthesis (MIPO) group and IMN group in nonunion rate (RR = 3.20, 95% CI: 0.12, 0.84, P = .02). Statistical significance was also observed between the open reduction plate fixation group and IMN group in restriction of shoulder and elbow joints results (RR = 0.49, 95% CI: 0.26, 0.96, P < .05). No significant difference was observed for the operation time, American Shoulder and Elbow Surgeons score, nerve injury, delayed union, reoperation in either group.

CONCLUSION

IMN may be superior to plate in reducing blood loss and postoperative infections for the treatment of humeral shaft fracture. However, MIPO was superior to IMN group in nonunion and equal to IMN in other parameters. Further research is required and future studies should include analysis of assessments at different stages and follow-up after removal of the implants.

[Photodynamic intramedullary bone stabilization of pathological fractures]

Pathological fractures of long tubular bones are stabilized with conventional implants. Essentially, plates and intramedullary nails are used for stabilization and are two different techniques, which compete with each other with respect to the surgical treatment. A large number of such means of osteosynthesis are commercially available but are primarily focused on acute fractures in otherwise biologically healthy bones. The pathological fracture or the treatment of impending pathological fractures due to metastatic osteolysis differs from the treatment of healthy bones in some fundamental aspects. The characteristics of pathological fractures make the development of new technologies that meet the specific needs of both the patient and the surgeon desirable. A new approach in treatment is stabilization of internal long bone fractures by the use of a cylindrical balloon implant, which is introduced into the bone via a small proximal or distal hole and then filled and expanded to a much larger diameter with a liquid monomer. The curing process is initiated with the application of blue light forming a rigid implant by polymerization (IlluminOss™). Many of the well-known disadvantages of conventional implants can be eliminated with this technology. Specifically, with respect to the irregular shape of the natural medullary canal it is possible to completely fill the medullary canal of the tubular bone. The filling of the canal provides torsional stability without the use of interlocking screws. Similarly, the use of the balloon technique enables minimally invasive surgery and furthermore permits the additive use of conventional metallic plates whenever necessary. The new balloon techniques show high primary stability in the treatment of pathological shaft fractures. In particular cases, the addition of a supplemental plate osteosynthesis is recommended.

[Osteoporotic bone fractures: intramedullary augmentation and hybrid osteosynthesis]

The increasing number of people who are living longer and have a far more active lifestyle is inevitably associated with greater numbers of fractures. Stabilization of these fractures in older patients with plates and screws is complicated by fragile bone substance, especially in osteoporotic bone, since osteosynthesis with a conventional plate depends exclusively on the holding power of the screws. Therefore, treatment requires new stabilization technologies designed for these specific tasks. A small diameter polyethylene terephthalate (PET, Dacron®) balloon is delivered in a minimally invasive fashion and placed within the canal, transversing the fracture. Once positioned, the balloon is expanded with a liquid monomer to fill the medullary canal. The liquid monomer is then rapidly cured using visible blue light, forming a patient-customized intramedullary implant that stabilizes the entire length of the bone in contact with the implant. The described intramedullary implant can be easily drilled in any position or location, providing a substantial increase in screw holding power. Thus, a major advantage of the technique is the possibility to augment the newly formed balloon "nail" with a conventional plate and screws at the primary stabilization or at any later time.