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Colasanti CA, Anil U, Cerasani MN, Li ZI, Morgan AM, Simovitch RW, Leucht P, Zuckerman JD. Management of Humeral Shaft Fracture: A Network Meta-Analysis of Individual Treatment Modalities. J Orthop Trauma 2024; 38:e257-e266. [PMID: 38578605 DOI: 10.1097/bot.0000000000002808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 03/11/2024] [Indexed: 04/06/2024]
Abstract
OBJECTIVE The purpose of this study was to perform a network meta-analysis of level I and II evidence comparing different management techniques to define the optimum treatment method for humeral shaft fractures (HSFs). METHODS DATA SOURCES A systematic review of the literature using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines of MEDLINE, Embase, and Cochrane Library was screened from 2010 to 2023. STUDY SELECTION Inclusion criteria were evidence level I or II studies comparing nonoperative and/or operative repair techniques including open reduction internal fixation plate osteosynthesis (ORIF-Plate), minimally invasive percutaneous plating (MIPO), and intramedullary nail (IMN) fixation for the management of HSFs (OTA/AO 12A, B, C). DATA EXTRACTION The risk of bias and methodologic quality of evidence were assessed according to the guidelines designed by the Cochrane Statistical Methods Group and Cochrane Methods Bias Group. DATA SYNTHESIS Network meta-analysis was conducted with a frequentist approach with a random-effects model using the netmeta package version 0.9-6 in R. RESULTS A total of 25 studies (1908 patients) were included. MIPO resulted in the lowest complication rate (2.1%) when compared with ORIF-Plate (16.1%) [odds ratio (OR), 0.13; 95% confidence interval (CI), 0.04-0.49]. MIPO resulted in the lowest nonunion rate (0.65%) compared with all management techniques (OR, 0.28; 95% CI, 0.08-0.98), whereas Non-Op resulted in the highest (15.87%) (OR, 3.48; 95% CI, 1.98-6.11). MIPO demonstrated the lowest rate of postoperative radial nerve palsy overall (2.2%) and demonstrated a significantly lower rate compared with ORIF-Plate (OR, 0.22; 95% CI, 0.07-0.71, P = 0.02). IMN resulted in the lowest rate of deep infection (1.1%) when compared with ORIF-Plate (8.6%; P = 0.013). MIPO resulted in a significantly lower Disabilities of the Arm, Shoulder, and Hand score (3.86 ± 5.2) and higher American Shoulder and Elbow Surgeons score (98.2 ± 1.4) than ORIF-Plate (19.5 ± 9.0 and 60.0 ± 5.4, P < 0.05). CONCLUSION The results from this study support that surgical management results in better postoperative functional outcomes, leads to higher union rates, reduces fracture healing time, reduces revision rate, and decreases malunion rates in patients with HSFs. In addition, MIPO resulted in statistically higher union rates, lowest complication rate, lowest rate of postoperative radial nerve palsy, and lower intraoperative time while resulting in better postoperative Disabilities of the Arm, Shoulder, and Hand and American Shoulder and Elbow Surgeons scores when compared with nonoperative and operative (ORIF and IMN) treatment modalities. LEVEL OF EVIDENCE Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
| | - Utkarsh Anil
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY; and
| | - Michele N Cerasani
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY; and
| | - Zachary I Li
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY; and
| | - Allison M Morgan
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY; and
| | - Ryan W Simovitch
- Department of Orthopaedic Surgery, Hospital for Special Surgery, FL
| | - Philipp Leucht
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY; and
| | - Joseph D Zuckerman
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY; and
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Furuhata R, Tanji A, Nakamura S. Risk factors of poor mid-term shoulder functional outcomes of osteosynthesis using antegrade intramedullary nailing for humeral shaft fractures: a retrospective study with a minimum 5-year follow-up. BMC Musculoskelet Disord 2024; 25:456. [PMID: 38851687 PMCID: PMC11162049 DOI: 10.1186/s12891-024-07572-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 06/06/2024] [Indexed: 06/10/2024] Open
Abstract
BACKGROUND Osteosynthesis using antegrade intramedullary nailing for humeral shaft fractures yields satisfactory bone union rates; however, it may adversely affect postoperative shoulder function. To date, factors affecting mid- or long-term shoulder functional outcomes following intramedullary nail fixation have not been clarified. In this study, we aimed to identify the risk factors for poor mid-term functional outcomes over 5 years postoperatively following antegrade intramedullary nail osteosynthesis for humeral shaft fractures. METHODS We retrospectively identified 33 patients who underwent surgery using an antegrade intramedullary nail for acute traumatic humeral shaft fractures and were followed up for at least 5 years postoperatively. We divided the patients into clinical failure and no clinical failure groups using an age- and sex-adjusted Constant score of 55 at the final follow-up as the cutoff value. We compared preoperative, perioperative, and postoperative factors between the two groups. RESULTS Five of the 33 patients had poor shoulder functional outcomes (adjusted Constant score < 55) at a mean follow-up of 7.5 years postoperatively. Proximal protrusion of the nail at the time of bone union (P = 0.004) and older age (P = 0.009) were significantly associated with clinical failure in the univariate analyses. Multivariate analysis showed that proximal protrusion of the nail (P = 0.031) was a risk factor for poor outcomes. CONCLUSIONS The findings of this study provide new information on predictive factors affecting mid-term outcomes following osteosynthesis using antegrade nails. Our results demonstrated that proximal protrusion of the nail was significantly associated with poor mid-term functional shoulder outcomes. Therefore, particularly in older adults, it is essential to place the proximal end of the intramedullary nail below the level of the articular cartilage.
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Affiliation(s)
- Ryogo Furuhata
- Department of Orthopaedic Surgery, Ashikaga Red Cross Hospital, 284-1 Yobe-cho, Ashikaga, 326-0843, Tochigi, Japan.
| | - Atsushi Tanji
- Department of Orthopaedic Surgery, Ashikaga Red Cross Hospital, 284-1 Yobe-cho, Ashikaga, 326-0843, Tochigi, Japan
| | - Soichiro Nakamura
- Department of Orthopaedic Surgery, Ashikaga Red Cross Hospital, 284-1 Yobe-cho, Ashikaga, 326-0843, Tochigi, Japan
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Lopiz Y, Garriguez-Pérez D, Román-Gómez J, Scarano-Pereira JP, Ponz-Lueza V, García-Fernandez C, Marco F. Shoulder problems after percutaneous antegrade intramedullary nailing in humeral diaphyseal fractures using contemporary straight third-generation nail. J Shoulder Elbow Surg 2023; 32:2317-2324. [PMID: 37245620 DOI: 10.1016/j.jse.2023.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 03/28/2023] [Accepted: 04/05/2023] [Indexed: 05/30/2023]
Abstract
BACKGROUND Antegrade intramedullary nailing in humeral shaft fracture has been abandoned by certain orthopedic surgeons because of rotator cuff injury caused by first- and second-generation intramedullary nails (IMNs). However, only a few studies have specifically addressed the results of antegrade nailing for the treatment of humeral shaft fractures with a straight third-generation IMN; thus, complications need to be re-evaluated. We hypothesized that fixation of displaced humeral shaft fractures with a straight third-generation antegrade IMN with the percutaneous technique avoid shoulder problems (stiffness and pain) incurred by first- and second-generation IMNs. METHODS This was a retrospective, single-center, nonrandomized study of 110 patients with a displaced humeral shaft fracture between 2012 and 2019 treated surgically with a long third-generation straight IMN. Mean follow-up was 35.6 months (range, 15-44 months). RESULTS There were 73 women and 37 men with a mean age of 64.7 ± 19 years. All fractures were closed (37.3% 12A1, 13.6% 12B2, and 13.6% 12B3 AO/OTA classification). Mean Constant score was 82 ± 19, Mayo Elbow Performance Score 96 ± 11 and the mean EQ-5D visual analog scale score was 69.7 ± 21.5. Mean forward elevation 150° ± 40°, abduction 148° ± 45°, and external rotation 38° ± 15°. Symptoms associated with rotator cuff disease were present in 6.4%. Evidence of radiographic fracture healing was detected in all but 1 case. One postoperative nerve injury and 1 adhesive capsulitis were present. Overall, 6.3% underwent second surgeries (4.5% were minor surgeries like hardware removal). CONCLUSION Percutaneous antegrade intramedullary nailing of humeral shaft fractures with a straight third-generation nail considerably reduced complications related to shoulder problems and achieved good functional results.
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Affiliation(s)
- Yaiza Lopiz
- Shoulder and Elbow Unit, Department of Traumatology and Orthopaedic Surgery, Clínico San Carlos Hospital, Madrid, Spain; Department of Surgery, Complutense University, Madrid, Spain.
| | - Daniel Garriguez-Pérez
- Shoulder and Elbow Unit, Department of Traumatology and Orthopaedic Surgery, Clínico San Carlos Hospital, Madrid, Spain
| | - Julia Román-Gómez
- Shoulder and Elbow Unit, Department of Traumatology and Orthopaedic Surgery, Clínico San Carlos Hospital, Madrid, Spain
| | - Juan Pablo Scarano-Pereira
- Shoulder and Elbow Unit, Department of Traumatology and Orthopaedic Surgery, Clínico San Carlos Hospital, Madrid, Spain
| | - Virginia Ponz-Lueza
- Shoulder and Elbow Unit, Department of Traumatology and Orthopaedic Surgery, Clínico San Carlos Hospital, Madrid, Spain
| | - Carlos García-Fernandez
- Shoulder and Elbow Unit, Department of Traumatology and Orthopaedic Surgery, Clínico San Carlos Hospital, Madrid, Spain
| | - Fernando Marco
- Shoulder and Elbow Unit, Department of Traumatology and Orthopaedic Surgery, Clínico San Carlos Hospital, Madrid, Spain; Department of Surgery, Complutense University, Madrid, Spain
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Bi C, Wu J, Wu X. Clinical Application of Nail-Plate Fixation in the Treatment of Complex Proximal Third Humeral Fracture: A Case Report and Literature Review. Orthop Surg 2023; 15:2187-2192. [PMID: 36056587 PMCID: PMC10432451 DOI: 10.1111/os.13445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 07/22/2022] [Accepted: 07/23/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Proximal humeral fractures with increasing incidence are common over the past decades. Among them, the complicated and displaced ones, especially combined with the proximal third humeral shaft fractures, need to be treated surgically. Humeral intramedullary nail and locking plate are the most frequently used options. However, few studies address the application of nail-plate combination for management. CASE PRESENTATION A 49-year-old man struck by a car was referred to our emergency trauma center. The X-ray and three-dimensional computed tomography (CT) showed a complex proximal humeral fracture with proximal third shaft fracture. No evidence of other associated injuries and neurovascular symptom of the injured left upper limb was shown by physical examination. Nail-plate fixation was performed to restore the anatomic integrity of proximal humerus. The injured arm was maintained in a broad arm sling for 14 days after surgery. The active as well as positive movements under the instruction were encouraged as long as the pain could be tolerated from postoperative day 2. One year after the surgery, the fracture was healed, and the patient regained normal shoulder motion. The good clinical outcomes were obtained by application of nail-plate fixation to treat complex proximal third humeral shaft fractures. Thus, this surgical intervention could be performed as an alternative.
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Affiliation(s)
- Chun Bi
- Department of Orthopaedics Trauma, Trauma Center, Shanghai General Hospital, School of MedicineShanghai Jiao Tong UniversityShanghaiChina
| | - Jianhong Wu
- Department of Orthopaedics Trauma, Trauma Center, Shanghai General Hospital, School of MedicineShanghai Jiao Tong UniversityShanghaiChina
| | - Xiaoming Wu
- Department of Orthopaedics Trauma, Trauma Center, Shanghai General Hospital, School of MedicineShanghai Jiao Tong UniversityShanghaiChina
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Zavras AG, Monahan KT, Winek NC, Pan T, Altman GT, Altman DT, Westrick ER. Conservative Management with Functional Brace Versus Various Surgical Fixation Techniques for Humeral Shaft Fractures: A Network Meta-Analysis. J Bone Joint Surg Am 2023; 105:1112-1122. [PMID: 37224234 DOI: 10.2106/jbjs.22.01374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
BACKGROUND Historically, humeral shaft fractures have been successfully treated with nonoperative management and functional bracing; however, various surgical options are also available. In the present study, we compared the outcomes of nonoperative versus operative interventions for the treatment of extra-articular humeral shaft fractures. METHODS This study was a network meta-analysis of prospective randomized controlled trials (RCTs) in which functional bracing was compared with surgical techniques (including open reduction and internal fixation [ORIF], minimally invasive plate osteosynthesis [MIPO], and intramedullary nailing in both antegrade [aIMN] and retrograde [rIMN] directions) for the treatment of humeral shaft fractures. The outcomes that were assessed included time to union and the rates of nonunion, malunion, delayed union, secondary surgical intervention, iatrogenic radial nerve palsy, and infection. Mean differences and log odds ratios (ORs) were used to analyze continuous and categorical data, respectively. RESULTS Twenty-one RCTs evaluating the outcomes for 1,203 patients who had been treated with functional bracing (n = 190), ORIF (n = 479), MIPO (n = 177), aIMN (n = 312), or rIMN (n = 45) were included. Functional bracing yielded significantly higher odds of nonunion and significantly longer time to union than ORIF, MIPO, and aIMN (p < 0.05). Comparison of surgical fixation techniques demonstrated significantly faster time to union with MIPO than with ORIF (p = 0.043). Significantly higher odds of malunion were observed with functional bracing than with ORIF (p = 0.047). Significantly higher odds of delayed union were observed with aIMN than with ORIF (p = 0.036). Significantly higher odds of secondary surgical intervention were observed with functional bracing than with ORIF (p = 0.001), MIPO (p = 0.007), and aIMN (p = 0.004). However, ORIF was associated with significantly higher odds of iatrogenic radial nerve injury and superficial infection than both functional bracing and MIPO (p < 0.05). CONCLUSIONS Compared with functional bracing, most operative interventions demonstrated lower rates of reoperation. MIPO demonstrated significantly faster time to union while limiting periosteal stripping, whereas ORIF was associated with significantly higher rates of radial nerve palsy. Nonoperative management with functional bracing demonstrated higher nonunion rates than most surgical techniques, often requiring conversion to surgical fixation. LEVEL OF EVIDENCE Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Athan G Zavras
- Department of Orthopaedic Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania
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Den Hartog D, Mahabier KC, Van Bergen SH, Verhofstad MHJ, Van Lieshout EMM. Functional and Clinical Outcomes After Plate Osteosynthesis Versus Intramedullary Nailing of a Humeral Shaft Fracture: The Results of the HUMMER Multicenter, Prospective Cohort Study. J Bone Joint Surg Am 2023; 105:1101-1111. [PMID: 37220192 DOI: 10.2106/jbjs.22.00647] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
BACKGROUND Plate osteosynthesis (referred to throughout as plating) and intramedullary nailing (referred to throughout as nailing) are the most common operative strategies for humeral shaft fractures. However, it is undecided which treatment is more effective. This study aimed to compare functional and clinical outcomes of these treatment strategies. We hypothesized that plating would result in an earlier recovery of shoulder function and fewer complications. METHODS From October 23, 2012, to October 3, 2018, adults with a humeral shaft fracture, OTA/AO type 12A or 12B, were enrolled in a multicenter, prospective cohort study. Patients were treated with plating or nailing. Outcome measures included the Disabilities of the Arm, Shoulder and Hand (DASH) score, Constant-Murley score, ranges of motion of the shoulder and elbow, radiographic healing, and complications until 1 year. Repeated-measure analysis was done with correction for age, sex, and fracture type. RESULTS Of the 245 included patients, 76 were treated with plating and 169 were treated with nailing. Patients in the plating group were younger, with a median age of 43 years compared with 57 years for the nailing group (p < 0.001). The mean DASH score after plating improved faster over time, but did not differ significantly from the score after nailing at 12 months (11.7 points [95% confidence interval (CI), 7.6 to 15.7 points]) for plating and 11.2 points [95% CI, 8.3 to 14.0 points] for nailing). The Constant-Murley score and shoulder abduction, flexion, external rotation, and internal rotation displayed a significant treatment effect (p treatment ≤ 0.001), in favor of plating. The plating group had 2 implant-related complications, whereas the nailing group had 24, including 13 nail protrusions and 8 screw protrusions. Plating resulted in more postoperative temporary radial nerve palsy (8 patients [10.5%] compared with 1 patient [0.6%]; p < 0.001) and a trend toward fewer nonunions (3 patients [5.7%] compared with 16 patients [11.9%]; p = 0.285) than nailing. CONCLUSIONS Plating of a humeral shaft fracture in adults results in faster recovery, especially of shoulder function. Plating was associated with more temporary nerve palsies, but fewer implant-related complications and surgical reinterventions, than nailing. Despite heterogeneity in implants and surgical approach, plating seems to be the preferred treatment option for these fractures. LEVEL OF EVIDENCE Therapeutic Level II . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Dennis Den Hartog
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Qiu H, Liu Y, Chen Y, Weng Z, Liu D, Dong J, Lu M. Treatment of humeral shaft fractures with different treatment methods: a network meta-analysis of randomized controlled trials. BMC Musculoskelet Disord 2023; 24:583. [PMID: 37460932 DOI: 10.1186/s12891-023-06626-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 06/12/2023] [Indexed: 07/20/2023] Open
Abstract
PURPOSE Humeral shaft fractures (HSFs) can be treated non-operatively (Non-OP), with open reduction and plate osteosynthesis (ORPO), minimally invasive plate osteosynthesis (MIPO), or with intramedullary nails (IMN). However, the best treatment for HSFs still remains controversial.We performed a network meta-analysis to explore which should be the best method for HSFs. METHODS The computerized search had been conducted on electronic databases PubMed, EMBASE, Cochrane Library, and Medline from the establishment of the database to the end of December 2022. The quality evaluation of the included literature had been completed by Review Manager (version 5.4.1). Stata 17.0 software (Stata Corporation, College Station, Texas, USA)was used for network meta-analysis.We included randomized controlled trials (RCTs) comparing different treatments to treating HSFs. RESULTS The pairwise comparison results demonstrated that there was no statistical difference between IMN, MIPO, Non-OP, and ORPO in terms of radial nerve injury and infection, and Non-OP presented significantly more nonunion than ORPO, IMN, and MIPO. However, no statistically significant difference between ORPO, IMN, and MIPO was discovered. The results of the network meta-analysis displayed that surface under the cumulative ranking curve (SUCRA) probabilities of IMN, MIPO, Non-OP, and ORPO in radial nerve injury were 46.5%, 66.9%, 77.3%, and 9.3%, respectively, in contrast, that in infection were 68.6%, 53.3%, 62.4%, and 15.4%, respectively, and that in nonunion were 51.7%, 93.1%, 0.7%, and 54.5%, respectively. CONCLUSION We came to the conclusion that MIPO is currently the most effective way to treat HSFs. TRIAL REGISTRATION Name of the registry: Prospero, 2. Unique Identifying number or registration ID: CRD42023411293.
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Affiliation(s)
- Hao Qiu
- Trauma Orthopedics and Hand Foot Ankle Surgery, The Ninth People's Hospital of Chongqing, Chongqing, 400700, China
| | - Yuting Liu
- Department of Endocrinology, The Ninth People's Hospital of Chongqing, Chongqing, 400700, China
| | - Yu Chen
- Trauma Orthopedics and Hand Foot Ankle Surgery, The Ninth People's Hospital of Chongqing, Chongqing, 400700, China
| | - Zheng Weng
- Trauma Orthopedics and Hand Foot Ankle Surgery, The Ninth People's Hospital of Chongqing, Chongqing, 400700, China
| | - Dun Liu
- Trauma Orthopedics and Hand Foot Ankle Surgery, The Ninth People's Hospital of Chongqing, Chongqing, 400700, China
| | - Jing Dong
- Department of Clinical Medicine, Chongqing Medical and Pharmaceutical College, Chongqing, 401331, China.
| | - Minpeng Lu
- Department of Pain Medicine, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.
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Beyer J, Rao B, Liu J, Skie M. Evaluation of Humeral Shaft Fracture Outcomes by Treatment Method: A Systematic Review and Meta-analysis Based on Comparison Studies. JBJS Rev 2023; 11:01874474-202307000-00004. [PMID: 37459427 DOI: 10.2106/jbjs.rvw.23.00037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
BACKGROUND The purpose of this systematic review and meta-analysis was to evaluate various outcomes of humeral shaft fractures treated with different treatment methods, which included functional bracing, open reduction and internal fixation, intramedullary nailing, and locked compression plate. METHODS A systematic review was performed using research databases including PubMed, EMBASE, and Google Scholar. Keywords relating to treatment of humeral shaft fractures were used, and comparison studies that reported patient characteristics and outcomes, including nonunion, malunion, function scores, and complications, were included. One hundred fourteen records were screened, with 18 studies ultimately included in the meta-analysis. Treatment groups were consolidated into brace or surgery and then further categorized into subgroups based on surgical technique used. Postoperative events, complications, and functional scores were compared among the treatment groups. Statistical analysis for this study was conducted using Review Manager 5.3, with a standard p-value of ≤0.05 for statistical significance. RESULTS Eighteen studies were included in this review with a total of 706 patients. Z-tests showed that risks of revision, nonunion, and malunion were higher in the brace treatment group compared with the surgical treatment group (p < 0.0001, <0.0001, 0.004, respectively). Risk of infection was expectedly higher in the surgical group compared with the brace group (p = 0.04). Radial nerve injury rates were also higher in the unspecified surgical group compared with the brace group (p = 0.01). In the surgical group, the mean Constant shoulder score was also significantly higher than that in the brace group (p = 0.004). When comparing the nail and plate groups, Z-tests revealed higher risks of delayed unions and other complications in the nail group (p = 0.04 and 0.001, respectively) but higher risk of infection in the plate group (p = 0.05). CONCLUSION The conservative treatment of humeral shaft fractures with functional braces may be associated with a lower incidence of infection and nerve injury when compared with operative treatment methods. However, nonoperative treatment may also come with higher risks of revision, nonunion, and malunion than the many available surgical modalities. Operative management with either intramedullary nail or plate has shown to be a reliable method of management with reasonable outcomes for humeral shaft fractures. While the nail group had higher risk of delayed unions and other complications, the plate group had higher risk of infections. Both nail and plate surgical treatments have shown to result in high union rates and should be considered by the surgeon on a case-by-case basis when treating humeral shaft fractures. LEVEL OF EVIDENCE Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Julia Beyer
- Department of Orthopedic Surgery, University of Toledo Medical Center, Toledo, Ohio
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Van Bergen SH, Mahabier KC, Van Lieshout EMM, Van der Torre T, Notenboom CAW, Jawahier PA, Verhofstad MHJ, Den Hartog D. Humeral shaft fracture: systematic review of non-operative and operative treatment. Arch Orthop Trauma Surg 2023:10.1007/s00402-023-04836-8. [PMID: 37093269 PMCID: PMC10374687 DOI: 10.1007/s00402-023-04836-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 03/01/2023] [Indexed: 04/25/2023]
Abstract
INTRODUCTION Humeral shaft fractures can be treated non-operatively or operatively. The optimal management is subject to debate. The aim was to compare non-operative and operative treatment of a humeral shaft fracture in terms of fracture healing, complications, and functional outcome. METHODS Databases of Embase, Medline ALL, Web-of-Science Core Collection, and the Cochrane Central Register of Controlled Trials (CENTRAL) were systematically searched for publications reporting clinical and functional outcomes of humeral shaft fractures after non-operative treatment with a functional brace or operative treatment by intramedullary nailing (IMN; antegrade or retrograde) or plate osteosynthesis (open plating or minimally invasive). A pooled analysis of the results was performed using MedCalc. RESULTS A total of 173 studies, describing 11,868 patients, were included. The fracture healing rate for the non-operative group was 89% (95% confidence interval (CI) 84-92%), 94% (95% CI 92-95%) for the IMN group and 96% (95% CI 95-97%) for the plating group. The rate of secondary radial nerve palsies was 1% in patients treated non-operatively, 3% in the IMN, and 6% in the plating group. Intraoperative complications and implant failures occurred more frequently in the IMN group than in the plating group. The DASH score was the lowest (7/100; 95% CI 1-13) in the minimally invasive plate osteosynthesis group. The Constant-Murley and UCLA shoulder score were the highest [93/100 (95% CI 92-95) and 33/35 (95% CI 32-33), respectively] in the plating group. CONCLUSION This study suggests that even though all treatment modalities result in satisfactory outcomes, operative treatment is associated with the most favorable results. Disregarding secondary radial nerve palsy, specifically plate osteosynthesis seems to result in the highest fracture healing rates, least complications, and best functional outcomes compared with the other treatment modalities.
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Affiliation(s)
- Saskia H Van Bergen
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Kiran C Mahabier
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Esther M M Van Lieshout
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Tim Van der Torre
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Cornelia A W Notenboom
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Priscilla A Jawahier
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Michael H J Verhofstad
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Dennis Den Hartog
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.
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Muacevic A, Adler JR, Liu JN, Ponce BA, Phipatanakul WP. Percutaneous Intramedullary Nailing of Complex Humeral Shaft Fractures: A Retrospective Case Series. Cureus 2022; 14:e32999. [PMID: 36712726 PMCID: PMC9879284 DOI: 10.7759/cureus.32999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/24/2022] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Humeral diaphyseal fractures have been traditionally stabilized with plates and screws. However, surgical morbidity can be quite extensive, particularly in more complex segmental and comminuted fracture patterns. An intramedullary nail (IMN) has the biomechanical advantage of being a load-sharing device and can be placed with a more minimally invasive technique. The purpose of this study was to evaluate the clinical and radiographic outcomes of complex humeral shaft fractures treated with an IMN utilizing a percutaneous surgical technique. METHODS A retrospective review was performed on a consecutive series of patients who underwent treatment of a complex humeral shaft fracture with an IMN placed with a percutaneous technique. Clinical outcome scores and radiographic analysis were performed at a minimum one-year follow-up. RESULTS Of the 14 patients included, 12 had clinical and radiographic follow-ups at one year. The majority (64%) were obese and involved polytrauma (50%), and 79% were AO Foundation/Orthopaedic Trauma Association (AO/OTA) type C fractures. Union after the index procedure was 93%, with one nonunion requiring a secondary operation. The average operative time was 103 minutes. There were no other complications or additional procedures. The mean clinical outcome scores included American Shoulder and Elbow Society (ASES): 78.2, Constant Score: 72.1, Single Assessment Numerical Evaluation (SANE): 81.9, and Penn Shoulder Score: 82.7. CONCLUSION This study demonstrates complex comminuted and segmental humeral shaft fractures in a higher-risk patient population can be effectively managed with IMN. Percutaneous placement of an IMN should be considered as a treatment option in complex humeral shaft fractures, particularly in patients with secondary comorbidities such as obesity and polytrauma.
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11
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Morris SC, Gowd AK, Agarwalla A, Phipatanakul WP, Amin NH, Liu JN. Fragility of statistically significant findings from randomized clinical trials of surgical treatment of humeral shaft fractures: A systematic review. World J Orthop 2022; 13:825-836. [PMID: 36189338 PMCID: PMC9516622 DOI: 10.5312/wjo.v13.i9.825] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 02/28/2022] [Accepted: 08/17/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Despite recent meta-analyses of randomized controlled trials (RCTs), there remains no consensus regarding the preferred surgical treatment for humeral shaft fractures. The fragility index (FI) is an emerging tool used to evaluate the robustness of RCTs by quantifying the number of participants in a study group that would need to switch outcomes in order to reverse the study conclusions.
AIM To investigate the fragility index of randomized control trials assessing outcomes of operative fixation in proximal humerus fractures.
METHODS We completed a systematic review of RCTs evaluating the surgical treatment of humeral shaft fractures. Inclusion criteria included: articles published in English; patients randomized and allotted in 1:1 ratio to 2 parallel arms; and dichotomous outcome variables. The FI was calculated for total complications, each complication individually, and secondary surgeries using the Fisher exact test, as previously published.
RESULTS Fifteen RCTs were included in the analysis comparing open reduction plate osteosynthesis with dynamic compression plate or locking compression plate, intramedullary nail, and minimally invasive plate osteosynthesis. The median FI was 0 for all parameters analyzed. Regarding individual outcomes, the FI was 0 for 81/91 (89%) of outcomes. The FI exceeded the number lost to follow up in only 2/91 (2%) outcomes.
CONCLUSION The FI shows that data from RCTs regarding operative treatment of humeral shaft fractures are fragile and does not demonstrate superiority of any particular surgical technique.
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Affiliation(s)
- Stephen Craig Morris
- Department of Orthopaedic Surgery, Loma Linda University, Loma Linda, CA 92354, United States
| | - Anirudh K Gowd
- Department of Orthopaedic Surgery, Wake Forest University Baptist Medical Center, Winston-Salem, NC 27157, United States
| | - Avinesh Agarwalla
- Department of Orthopaedic Surgery, Westchester Medical Center, Valhalla, NY 10595, United States
| | - Wesley P Phipatanakul
- Department of Orthopaedic Surgery, Loma Linda University, Loma Linda, CA 92354, United States
| | - Nirav H Amin
- Department of Orthopaedic Surgery, Premier Orthopaedic and Trauma Specialists, Pomona, CA 91767, United States
| | - Joseph N Liu
- Department of Orthopedic Surgery, USC Epstein Family Center for Sports Medicine, Los Angeles, CA 90089, United States
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Fox HM, Hsue LJ, Thompson AR, Ramsey DC, Hadden RW, Mirarchi AJ, Nazir OF. Humeral shaft fractures: a cost-effectiveness analysis of operative versus nonoperative management. J Shoulder Elbow Surg 2022; 31:1969-1981. [PMID: 35398163 DOI: 10.1016/j.jse.2022.02.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 02/12/2022] [Accepted: 02/24/2022] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Henry M Fox
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, OR, USA
| | - Lauren J Hsue
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, OR, USA
| | - Austin R Thompson
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, OR, USA
| | - Duncan C Ramsey
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, OR, USA
| | - Ryan W Hadden
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, OR, USA
| | - Adam J Mirarchi
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, OR, USA
| | - Omar F Nazir
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, OR, USA.
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Saracco M, Fulchignoni C, Fusco F, Logroscino G. WHICH SURGICAL TREATMENT IS PREFERABLE IN HUMERAL DIAPHYSEAL FRACTURES? A SYSTEMATIC REVIEW. Orthop Rev (Pavia) 2022; 14:37575. [PMID: 36034729 PMCID: PMC9404283 DOI: 10.52965/001c.37575] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
Abstract
INTRODUCTION Humeral diaphyseal fractures are very common. Many treatments have been proposed but the choice of the best one is often complex. OBJECTIVE The aim of the proposed study is to analyze the data in the literature in order to define the risks, advantages and disadvantages of the alternative surgical treatments (anterograde/retrograde intramedullary nailing, ORIF, MIPO). METHODS PubMed / Medline and Google Scholar were searched for prospective randomized or case-control retrospective studies about surgical treatment of humeral diaphyseal fractures with nailing, ORIF and MIPO, according to PRISMA guidelines. The primary outcome considered was the fracture healing time by comparing nailing-ORIF, nailing-MIPO and ORIF-MIPO. Differences in the rate of post-operative complications, patient satisfaction, intra-operative blood loss and surgical time were considered secondary outcomes. RESULTS 506 studies were identified, but only 10 studies were valid for the systematic review. No differences between nailing, ORIF and MIPO were recorded in terms of healing and surgical times. Intra-operative blood loss was significantly higher during ORIF (p 0.024). No differences were found in the restoration of function evaluated using clinical scales. The rate of complications was 27.4% for nailing, 21.2% for ORIF and 13.8% for MIPO. The difference was statistically significant only by comparing nailing with MIPO (p 0.012), probably because anterograde nailing is more often correlated to shoulder impairment. ORIF was at higher risk of infection compared to nailing (p 0.007). CONCLUSION Humeral diaphyseal fractures require careful pre-operative planning, ensuring reduced healing time, less soft tissue damage and low rate of complications. The lower exposure of the fracture allows for excellent results with reduced bleeding and lower risk of complications.
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Affiliation(s)
- Michela Saracco
- Department of Orthopaedics, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma - Università Cattolica del Sacro Cuore, Rome, Italy
| | - Camillo Fulchignoni
- Department of Orthopaedics, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma - Università Cattolica del Sacro Cuore, Rome, Italy
| | - Fabrizio Fusco
- Department of Orthopaedics and Trauma, Osp. "San Giovanni di Dio" - ASL Napoli 2 Nord, Napoli, Italy
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KUNDAKÇI B, BİÇER Ö, HURİ G, TEKİN M, BAĞIR M, DEVECİ MA, MİRİOĞLU A. Minimal invasive percutaneous plate osteosynthesis (MIPPO) in humeral shaft fractures. CUKUROVA MEDICAL JOURNAL 2022. [DOI: 10.17826/cumj.1030704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Purpose: We aimed to evaluate the radiological and functional results of humeral shaft fractures treated with minimally invasive percutaneous plate osteosynthesis (MIPPO) in our clinic.
Materials and Methods: Data of 21 humeral shaft fractures of 20 patients treated with MIPPO were evaluated retrospectively. Demographic data, type of injury, fracture classification according to AO classification and fracture location, smoking, radial nerve injury were recorded. Radiographically, the union at 6th month and alignment were evaluated. Objective results were evaluated in terms of shoulder and elbow range of motion. Subjective results were assessed by the American Shoulder and Elbow Society Score (ASES), University of California, Los Angles (UCLA) score, Mayo Elbow Performance Index (MEPI), the Disability of The Arm, Shoulder and Hand (DASH) Score and Constant Shoulder Score.
Results: The average elbow motion was 131.4° ± 19.8°. The mean ASES and UCLA scores were 88.5 ± 16.4 and 32.1 ± 5.2, respectively. The mean MEPI and DASH scores were 93.1 ± 11.3 and 11.8 ± 20.0, respectively, and the Constant score was mean 9.1 ± 15.3. Nonunion was observed in two patient at 6th month.
Conclusion: We believe that MIPPO is a successful technique for the treatment of humeral shaft fractures with minimal soft tissue damage, intact shoulder and elbow motion function.
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Results of the keyhole interlocked nailing for humeral diaphyseal fractures in adults. INTERNATIONAL ORTHOPAEDICS 2021; 45:3155-3161. [PMID: 34494134 DOI: 10.1007/s00264-021-05202-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 08/25/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE To evaluate the effectiveness of interlocked humerus nail through a keyhole incision for the management of humeral diaphyseal fractures in terms of radiological union, shoulder function, and complications. MATERIALS AND METHODS In this prospective study of sixty-two patients with humeral diaphyseal fractures in our institute (51 men, 11 women; mean age 42 years; range 20 to 73 years), fifty-nine fractures were closed and three were grade I open fractures. Three patients had a preoperative radial nerve palsy. Key hole surgery was performed by closed technique (n = 56) and limited open technique (n = 6) with reamed humerus interlocked nail through an antegrade nailing procedure. The cases were followed up prospectively for union and function. The mean follow-up was 12.3 months (range 12 months to 18 months). The outcome of the procedure was assessed according to American Shoulder and Elbow Surgeons (ASES) score, radiological union, complications, and secondary procedures required. RESULTS Fifty-eight (93.33%) fractures united with an average consolidation time of 12.75 weeks. Two patients had delayed union. Two patients had nonunion which required plating and bone grafting. No cases of infection were encountered. Neuropraxia which was detected preoperatively recovered fully in all three cases between three and six weeks. The ASES scores were excellent-to-good in fifty-six (90.32%) patients, fairly functional outcome was noted in four patients(6.5%), and two patients (3.2%) continued to have poor function at the time of final follow-up. CONCLUSION The results of keyhole interlocked humerus nail with proximal multi-locking options were excellent-to-good for humeral diaphyseal fractures in terms of union, shoulder function, and complications. It is a safe, easy, and reliable method for the treatment of humeral diaphyseal fractures.
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Anterior Minimally Invasive Plate Osteosynthesis for Humeral Shaft Fractures Is Safer Than Open Reduction Internal Fixation: A Matched Case-Controlled Comparison. J Orthop Trauma 2021; 35:424-429. [PMID: 33252449 DOI: 10.1097/bot.0000000000002021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/11/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Compare anterior minimally invasive plate osteosynthesis (MIPO) to open reduction/internal fixation (ORIF) for humeral shaft fractures, assessing complications and clinical outcomes. DESIGN Retrospective matched case-controlled cohort. SETTING Tertiary referral trauma centre. PATIENTS/PARTICIPANTS Humeral shaft fractures identified retrospectively over 5 years; 31 were treated by MIPO and 54 by ORIF. Matched-case cohort assembled according to fracture pattern, sex, age, and comorbidities, with 56 total patients (28 per group). INTERVENTIONS MIPO and ORIF. MAIN OUTCOME MEASURES Complication rate was the primary outcome (radial nerve injury, nonunion, infection, and reoperation). Radiographic alignment and the Disabilities of the Arm, Shoulder and Hand Score were secondary outcomes. RESULTS Cumulative complication rates were 3.6% after anterior MIPO and 35.7% after ORIF (P = 0.0004). The only complication after anterior MIPO was a nonunion, managed with revision ORIF and bone graft. The ORIF group had 10 complications, including 5 superficial infections, 4 iatrogenic radial nerve injuries, and 1 nonunion. The mean Disabilities of the Arm, Shoulder and Hand score after MIPO was 17.0 ± 18.0 and after ORIF was 24.9 ± 19.5. The mean coronal plane angulation after MIPO was 1.8 ± 1.3 degrees and after ORIF was 1.0 ± 1.2 degrees. The mean sagittal plane angulation after MIPO was 3.0 ± 2.9 degrees and after ORIF was 1.0 ± 1.2 degrees. CONCLUSIONS The cumulative complication rate was 10 times higher after ORIF of humeral shaft fractures compared with the MIPO technique. MIPO achieved nearly equivalent radiographic alignment, with no clinically meaningful differences observed. MIPO is the safer option and should be considered for patients with humeral shaft fractures that would benefit from surgical intervention. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Patino JM, Ramella JC, Michelini AE, Abdon IM, Rodriguez EF, Corna AFR. Plates vs. nails in humeral shaft fractures: Do plates lead to a better shoulder function? JSES Int 2021; 5:765-768. [PMID: 34223427 PMCID: PMC8245902 DOI: 10.1016/j.jseint.2021.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
Background The purpose of this study was to compare shoulder outcomes and function after humeral shaft fractures treated with plates and screws vs. antegrade nailing. Methods A group of 27 patients treated with plates and a group of 30 patients (previously published) who had undergone antegrade locked intramedullary nailing, all with acute humeral shaft fractures, were retrospectively compared. Final shoulder range of motion (ROM), full shoulder ROM recovery rate, functional outcomes, residual pain, complications, and elbow flexion-extension range were also analyzed. Results There were a total of 57 patients: 27 cases in the plate (P) group and 30 in the nail (N) group (average age, 41.9 years).There were 66.7% men in group N and 63.0% in group P. The average age was 38 years (interquartile range [IQR] 28) in group N and 37 years (IQR 55) in group P. There were no differences in follow-up between groups, which averaged 28 months (IQR 7) in group P and 30 months (IQR 2) in group N (P = .385). There was no difference in both groups in elbow flexion-extension. Group P had a full shoulder ROM (66.6% vs. 40.0%; P = .02) and excellent Rodríguez-Merchán scoring (66% vs. 40.0%; P < .01), which was significantly higher than in group N. In group P, the Constant score was 95 (IQR 9). Conclusions Treatment with plates in this comparative study led to a better ROM in the shoulder and fewer complications. Loss of shoulder motion may be expected after humeral shaft osteosynthesis. However, the functional scores and the healing index can be good and excellent with both techniques.
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Affiliation(s)
- Juan M Patino
- Departamento de Ortopedia y Traumatologia, Servicio de cirugía de la mano y miembro superior, Unidad de Hombro y Codo, Hospital Militar Central "Cosme Argerich", Buenos Aires, Argentina
| | - Juan C Ramella
- Departamento de Ortopedia y Traumatologia, Servicio de cirugía de la mano y miembro superior, Unidad de Hombro y Codo, Hospital Militar Central "Cosme Argerich", Buenos Aires, Argentina
| | - Alejandro E Michelini
- Departamento de Ortopedia y Traumatologia, Servicio de cirugía de la mano y miembro superior, Unidad de Hombro y Codo, Hospital Militar Central "Cosme Argerich", Buenos Aires, Argentina
| | - Ignacio M Abdon
- Departamento de Ortopedia y Traumatologia, Servicio de cirugía de la mano y miembro superior, Unidad de Hombro y Codo, Hospital Militar Central "Cosme Argerich", Buenos Aires, Argentina
| | - Emanuel Fedum Rodriguez
- Departamento de Ortopedia y Traumatologia, Servicio de cirugía de la mano y miembro superior, Unidad de Hombro y Codo, Hospital Militar Central "Cosme Argerich", Buenos Aires, Argentina
| | - Alejandro F Rullan Corna
- Departamento de Ortopedia y Traumatologia, Servicio de cirugía de la mano y miembro superior, Unidad de Hombro y Codo, Hospital Militar Central "Cosme Argerich", Buenos Aires, Argentina
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Rellán I, Gallucci GL, Donndorff AG, De Carli P, Zaidenberg EE, Richard MJ, Boretto JG. Time until union in absolute vs. relative stability MIPO plating in simple humeral shaft fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:191-197. [PMID: 33778903 DOI: 10.1007/s00590-021-02920-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 02/17/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE The objective of this study is to evaluate the effect of absolute stability (AS) versus relative stability (RS) performed through a minimally invasive plate osteosynthesis (MIPO) in AO/OTA 12A1 and 12A2 fractures on healing and the time to radiographic union. METHODS This was a retrospective cohort study of all patients treated with plate fixation for AO/OTA type 12A1-A2 fractures at a single institution. Patients were grouped according to the type of stability used in their surgery. Time until radiographic union was estimated using the Kaplan-Meier method, which was compared by long-rank test between both types of surgical techniques. RESULTS A total of 70 patients were included in this study with 35 patients in each group. The median follow-up was 9 (IQR 6-14) months. The median time to radiographic union was significantly lower in the AS group than in the RS group: 12 (interquartile range (IQR) 10-14) weeks versus 18 (IQR 16-19) weeks, respectively (p < 0.001). Non-union was seen in two cases (7%) in the relative stability group. Three patients in the RS group developed a post-operative radial nerve palsy. CONCLUSION The main finding of this study is that the median time to radiographic union was significantly shorter in the patients treated with AS compared to those with a RS technique. These findings support the recommendations of the AO foundation in that simple metaphyseal fractures (type A) that require surgical treatment should be treated with an AS construct. RS techniques should be reserved to multifragmentary fractures where fragment preservation of blood supply is paramount.
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Affiliation(s)
- Ignacio Rellán
- Department of Orthopaedics, Instituto de Ortopedia y Traumatología "Carlos E. Ottolenghi", Hospital Italiano de Buenos Aires, Buenos Aires, Argentina, Potosí 4215 (C1199ACK), Buenos Aires, Argentina.
| | - Gerardo Luis Gallucci
- Department of Orthopaedics, Instituto de Ortopedia y Traumatología "Carlos E. Ottolenghi", Hospital Italiano de Buenos Aires, Buenos Aires, Argentina, Potosí 4215 (C1199ACK), Buenos Aires, Argentina
| | - Agustin Guillermo Donndorff
- Department of Orthopaedics, Instituto de Ortopedia y Traumatología "Carlos E. Ottolenghi", Hospital Italiano de Buenos Aires, Buenos Aires, Argentina, Potosí 4215 (C1199ACK), Buenos Aires, Argentina
| | - Pablo De Carli
- Department of Orthopaedics, Instituto de Ortopedia y Traumatología "Carlos E. Ottolenghi", Hospital Italiano de Buenos Aires, Buenos Aires, Argentina, Potosí 4215 (C1199ACK), Buenos Aires, Argentina
| | - Ezequiel Ernesto Zaidenberg
- Department of Orthopaedics, Instituto de Ortopedia y Traumatología "Carlos E. Ottolenghi", Hospital Italiano de Buenos Aires, Buenos Aires, Argentina, Potosí 4215 (C1199ACK), Buenos Aires, Argentina
| | - Marc Joseph Richard
- Department of Orthopaedic Surgery, Division of Hand, Upper Extremity, and Microvascular Surgery, Duke University Medical Center, 4709 Creekstone Drive , Suite 200, Durham, NC, 27703, USA
| | - Jorge Guillermo Boretto
- Department of Orthopaedics, Instituto de Ortopedia y Traumatología "Carlos E. Ottolenghi", Hospital Italiano de Buenos Aires, Buenos Aires, Argentina, Potosí 4215 (C1199ACK), Buenos Aires, Argentina
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van de Wall BJM, Baumgärtner R, Houwert RM, Link BC, Heng M, Knobe M, Groenwold RHH, Babst R, Beeres FJP. MIPO versus nailing for humeral shaft fractures: a meta-analysis and systematic review of randomised clinical trials and observational studies. Eur J Trauma Emerg Surg 2021; 48:47-59. [PMID: 33452548 DOI: 10.1007/s00068-020-01585-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 12/27/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE There is no consensus on the optimal operative technique for humeral shaft fractures. This meta-analysis aims to compare minimal-invasive plate osteosynthesis (MIPO) with nail fixation for humeral shaft fractures regarding healing, complications and functional results. METHODS PubMed/Medline/Embase/CENTRAL/CINAHL were searched for randomized clinical trials (RCT) and observational studies comparing MIPO with nailing for humeral shaft fractures. Effect estimates were pooled across studies using random effects models and presented as weighted odds ratio (OR), risk difference (RD), mean difference (MD) and standardized mean difference (SMD) with corresponding 95% confidence interval (95%CI). Analyses were repeated stratified by study design (RCTs and observational studies). RESULTS A total of 2 RCTs (87 patients) and 5 observational studies (595 patients) were included. The effects estimated in observational studies and RCTs were similar in direction and magnitude for all outcomes except operation duration. MIPO has a lower risk for non-union (RD 7%; OR 0.2, 95% CI 0.1-0.5) and re-intervention (RD 13%; OR 0.3, 95% CI 0.1-0.8). Functional shoulder (SMD 1.0, 95% CI 0.2-1.8) and elbow scores (SMD 0.4, 95% CI 0-0.8) were better among patients treated with MIPO. The risk for radial nerve palsy following surgery was equal (RD 2%; OR 0.6, 95% CI 0.3-1.2) and nerve function recovered spontaneously in all patients in both groups. No difference was detected with regard to infection, time to union and operation duration. CONCLUSION MIPO has a considerable lower risk for non-union and re-intervention, leads to better shoulder function and, to a lesser extent, better elbow function compared to nailing. Although nailing appears to be a viable option, the evidence suggests that MIPO should be the preferred treatment of choice. The learning curve of minimal-invasive plating should, however, be taken into account when interpreting these results.
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Affiliation(s)
- Bryan J M van de Wall
- Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Spitalstrasse 16, 6000, Luzern, Switzerland.
| | - Ralf Baumgärtner
- Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Spitalstrasse 16, 6000, Luzern, Switzerland
| | - R Marijn Houwert
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Björn C Link
- Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Spitalstrasse 16, 6000, Luzern, Switzerland
| | - Marilyn Heng
- Department of Orthopaedic Surgery, Harvard Medical School Orthopaedic Trauma Initiative, Massachusetts General Hospital Boston, Boston, USA
| | - Matthias Knobe
- Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Spitalstrasse 16, 6000, Luzern, Switzerland
| | - Rolf H H Groenwold
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Reto Babst
- Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Spitalstrasse 16, 6000, Luzern, Switzerland
| | - Frank J P Beeres
- Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Spitalstrasse 16, 6000, Luzern, Switzerland
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Abstract
Humeral shaft fractures are relatively common, representing approximately 1% to 5% of all fractures. Conservative management is the treatment of choice for most humeral shaft fractures and offers functional results and union rates that are not inferior to surgical management. Age and oblique fractures of the proximal third are risk factors for nonunion. Surgical indication threshold should be lower in patients older than 55 years presenting with this type of fracture. Functional outcomes and union rates after plating and intramedullary nailing are comparable, but the likelihood of shoulder complications is higher with intramedullary nailing. There is no advantage to early exploration of the radial nerve even in secondary radial nerve palsy.
Cite this article: EFORT Open Rev 2021;6:24-34. DOI: 10.1302/2058-5241.6.200033
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Affiliation(s)
- Nicolas Gallusser
- Department of Orthopaedics and Traumatology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Bardia Barimani
- Division of Orthopedic Surgery, McGill University, Montreal, Canada
| | - Frédéric Vauclair
- Department of Orthopaedics and Traumatology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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Ferrara F, Biancardi E, Touloupakis G, Bibiano L, Ghirardelli S, Antonini G, Crippa C. Residual interfragmentary gap after intramedullary nailing of fragility fractures of the humeral diaphysis: short and midterm term results. ACTA BIO-MEDICA : ATENEI PARMENSIS 2019; 90:432-438. [PMID: 31910167 PMCID: PMC7233757 DOI: 10.23750/abm.v90i4.7315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 09/14/2018] [Indexed: 11/23/2022]
Abstract
The purpose of this retrospective study was to evaluate the short and midterm radiological outcome with regards to bone healing, correlated with humeral shaft fractures treated with anterograde intramedullary nailing, when interfragmentary gap was significant. Here, we critically review our experience of short and midterm term results in over 65 year-old patients. Inclusion criteria in the study were: (1) patients over 65 years old (2) patients with displaced humeral mid shaft fractures (AO/OTA 12 A B C type fractures); (3) patients treated with closed reduction and internal fixation with intramedullary nail (Trigen Humeral Nail® Smith and Nephew) with at least two screws for proximal locking and one screw for distal locking; (4) residual interfragmentary gap, being considered significant any gap >6 mm (being 7 mm the minimum nail diameter available in our facility). Various factors were considered in our analysis: the size of the interfragmentary gap in both projections (also the mean of the measured gaps was calculated), the relationship between the greater and the mean interfragmentary gap and the second diameter measurement of the nail in the half distal part, the number of the screws in distal locking procedure, the use of a reaming procedure or not, the AO classification, the actual age at the time of surgery, the operating time, the nail second diameter as described before and its ratio with the measured residual gap. At 3 months follow-up, 4 patients showed radiographic healing (26,67%), 9 patients showed a visible callus (60%), with a total of 13 patients (86,67%) showing signs of normal recovery, the remaining 2 patient had insufficient callus formation (13,3%). At 6 months follow-up, 1 patient was missing (6,67%), although radiographic healing was already evident during the previous follow-up check, another one showed incomplete callus formation, the remaining 13 patients showed radiographic healing (86,67%), with a total of 14 patient considered healed at 6 months follow-up (93,33%). In conclusion, osteosynthesis with anterograde nail in geriatric patients appears to be a quite safe approach despite a great interfragmentary gap. After 6 months of treatment, callus formation and the overall clinical outcome were proven to be above satisfaction. (www.actabiomedica.it).
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Affiliation(s)
- Fabrizio Ferrara
- Department of Orthopedics and Traumatology, San Carlo Borromeo Hospital (Milan, Italy).
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22
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Copay AG, Chung AS, Eyberg B, Olmscheid N, Chutkan N, Spangehl MJ. Minimum Clinically Important Difference: Current Trends in the Orthopaedic Literature, Part I: Upper Extremity: A Systematic Review. JBJS Rev 2019; 6:e1. [PMID: 30179897 DOI: 10.2106/jbjs.rvw.17.00159] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND The minimum clinically important difference (MCID) attempts to define the patient's experience of treatment outcomes. Efforts at calculating the MCID have yielded multiple and inconsistent MCID values. The purposes of this review were to describe the usage of the MCID in the most recent orthopaedic literature, to explain the limitations of its current uses, and to clarify the underpinnings of MCID calculation. Subsequently, we hope that the information presented here will help practitioners to better understand the MCID and to serve as a guide for future efforts to calculate the MCID. The first part of this review focuses on the upper-extremity orthopaedic literature. Part II will focus on the lower-extremity orthopaedic literature. METHODS A review was conducted of the 2014 to 2016 publications in The Journal of Arthroplasty, The Journal of Bone & Joint Surgery, The American Journal of Sports Medicine, Foot & Ankle International, Journal of Orthopaedic Trauma, Journal of Pediatric Orthopaedics, and Journal of Shoulder and Elbow Surgery. Only clinical science articles utilizing patient-reported outcome measure (PROM) scores were included in the analysis. A keyword search was then performed to identify articles that calculated or referenced the MCID. Articles were then further categorized into upper-extremity and lower-extremity publications. MCID utilization in the selected articles was subsequently characterized and recorded. RESULTS The MCID was referenced in 129 (7.5%) of 1,709 clinical science articles that utilized PROMs: 52 (40.3%) of 129 were related to the upper extremity, 5 (9.6%) of 52 independently calculated MCID values, and 47 (90.4%) of 52 used previously published MCID values as a gauge of their own results. MCID values were considered or calculated for 16 PROMs; 12 of these were specific to the upper extremity. Six different methods were used to calculate the MCID. Calculated MCIDs had a wide range of values for the same PROM (e.g., 8 to 36 points for Constant-Murley scores and 6.4 to 17 points for American Shoulder and Elbow Surgeons [ASES] scores). CONCLUSIONS Determining useful MCID values remains elusive and is compounded by the proliferation of PROMs in the field of orthopaedics. The fundamentals of MCID calculation methods should be critically evaluated. If necessary, these methods should be corrected or abandoned. Furthermore, the type of change intended to be measured should be clarified: beneficial, detrimental, or small or large changes. There should also be assurance that the calculation method actually measures the intended change. Finally, the measurement error should consistently be reported. CLINICAL RELEVANCE The MCID is increasingly used as a measure of patients' improvement. However, the MCID does not yet adequately capture the clinical importance of patients' improvement.
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Affiliation(s)
| | - Andrew S Chung
- Department of Orthopaedics, Mayo Clinic-Arizona, Phoenix, Arizona
| | - Blake Eyberg
- Orthopaedic Surgery Residency, University of Arizona College of Medicine, Phoenix, Arizona
| | - Neil Olmscheid
- Orthopedic Surgery Residency, McLaren Greater Lansing, Michigan State University, Lansing, Michigan
| | - Norman Chutkan
- Orthopaedic Surgery Residency, University of Arizona College of Medicine, Phoenix, Arizona
| | - Mark J Spangehl
- Department of Orthopaedics, Mayo Clinic-Arizona, Phoenix, Arizona
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23
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Erden T, Kapicioglu M, Demirtas A, Bilsel K, Akpinar F, Kuduz H. Biomechanical comparison of humeral nails with different distal locking mechanisms: Insafelock nails versus conventional locking nails. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2019; 53:490-496. [PMID: 31562026 PMCID: PMC6938903 DOI: 10.1016/j.aott.2019.08.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 05/23/2019] [Accepted: 08/22/2019] [Indexed: 11/25/2022]
Abstract
Objective The aim of this study was to compare the biomechanical resistance to rotational and axial forces of a conventional locking nail with a newly designed intramedullary humeral nail developed for humeral shaft fractures with a secure locking mechanism through the distal part of the nail. Methods InSafeLOCK humeral nail system (group 1, TST, Istanbul, Turkey) and Expert humeral nail system (group 2, DePuy Synthes, Bettlach, Switzerland) of the same size (9 × 300 mm) were examined. In total, 24 fourth-generation humerus sawbones were used in the experiment. Osteotomy was performed at the humerus shaft, and a defect was created by removing 1 cm of bone. After pre-loading 5000 cycles at a frequency of 2 Hz and a force of 50–250 N for axial loading and 5000 torsion torques between 0.5 Nm and 6.5 Nm at a 2 Hz frequency for torsional loading, the failure load values of each load were recorded. Distal interlocking was performed with an endopin in group 1, while a double cortex screw was used in group 2. Results All samples successfully passed the cyclic loading. The initial and final stiffness values were similar between the groups after axial loading (p = 0.873 and p = 0.522, respectively). The mean axial failure load values in groups 1 and 2 were 2627 ± 164 N and 7141 ± 1491 N, respectively. A significant difference was found in the axial failure load values (p = 0.004). Significant differences were observed between the initial and final torsional stiffness between the two groups (p = 0.004 and p = 0.004, respectively). No significant difference was found in the failure load values after torsional loading (11791 ± 2055 N.mm and 16997 ± 5440 N.mm) (p = 0.055). Conclusion These results provide a biomechanical demonstration of the adequate stability of both nails after axial and rotational loading. The reliability of the newly developed InSafeLOCK humeral nail system, which does not require fluoroscopic control and an additional incision for distal locking, supports its use in the clinic.
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Wen H, Zhu S, Li C, Chen Z, Yang H, Xu Y. Antegrade intramedullary nail versus plate fixation in the treatment of humeral shaft fractures: An update meta-analysis. Medicine (Baltimore) 2019; 98:e17952. [PMID: 31725653 PMCID: PMC6867742 DOI: 10.1097/md.0000000000017952] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
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.
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Affiliation(s)
- Hongjie Wen
- Department of Orthopaedic Surgery, The Fourth Affiliated Hospital of Kunming Medical University
| | - Shouyan Zhu
- Department of Radiology, The Second People's Hospital of Yunnan
| | - Canzhang Li
- Department of Orthopaedic Surgery, The Fourth Affiliated Hospital of Kunming Medical University
| | - Zhong Chen
- Department of Orthopaedic Surgery, The Fourth Affiliated Hospital of Kunming Medical University
| | - Huagang Yang
- Department of Orthopaedic Surgery, The Fourth Affiliated Hospital of Kunming Medical University
| | - Yongqing Xu
- Department of Orthopaedic Surgery, 920th Hospital of Joint Logistics Support Force, Kunming Medical University, Kunming, China
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Putnam JG, Nowak L, Sanders D, MacNevin M, Lawendy AR, Jones C, McKee M, Schemitsch E. Early post-operative outcomes of plate versus nail fixation for humeral shaft fractures. Injury 2019; 50:1460-1463. [PMID: 31221428 DOI: 10.1016/j.injury.2019.06.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 06/14/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION This study was designed to measure early postoperative outcomes of plate vs. nail fixation for humeral shaft fractures. PATIENTS AND METHODS Patients ≥18 years who underwent plate or nail fixation for low-energy humeral shaft fractures between 2005-2016 were identified from the National Surgical Quality Improvement Program (NSQIP). Multivariable regression was used to compare postoperative outcomes using propensity score adjustment to account for differences between fixation groups. Variables included in the propensity score were age, American Society of Anesthesiologists (ASA) class, hypertension, steroid use, cancer, functional status, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and sex. RESULTS Plate fixation was used in 1418 patients (70.6%), while nail fixation was used in 591 (29.4%). Patients undergoing nail fixation were more likely to be older, have a higher American Society of Anesthesiologists (ASA) class, and have comorbidities. Mean operative time was statistically longer in the plate fixation group (130 +/-62 min vs. 102 +/-54 min). After propensity score adjustment, type of fixation was not a significant predictor of major or minor complications, length of stay, or readmission. However, nail fixation was a significant predictor of mortality following propensity score adjustment (OR 3.15, 95% Confidence interval 1.26-7.85). CONCLUSION Patients undergoing intramedullary nail fixation tended to be older patients with more comorbidities, suggesting that surgeons are selecting nail fixation in patients who may not be ideal surgical candidates. Although LOS, complications, and readmission rates were higher in the nail group, this difference was not statistically significant following propensity score adjustment. However, nail fixation remained an independent predictor of 30-day mortality following adjustment. This suggests that nail fixation may not be a safer surgical option in patients with multiple medical co-morbidities and low-energy humeral shaft fractures.
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Affiliation(s)
- Jill G Putnam
- Department of Orthopaedic Surgery, University of Arizona College of Medicine-Phoenix, 1320 N 10th Street, Suite A, Phoenix, AZ, 85006, United States.
| | - Lauren Nowak
- University of Toronto, Toronto, Ontario, Canada.
| | - David Sanders
- London Health Sciences Centre, London, Ontario, Canada.
| | - Melanie MacNevin
- Department of Orthopaedic Surgery, University of Arizona College of Medicine-Phoenix, 1320 N 10th Street, Suite A, Phoenix, AZ, 85006, United States; London Health Sciences Centre, London, Ontario, Canada.
| | | | - Clifford Jones
- Department of Orthopaedic Surgery, University of Arizona College of Medicine-Phoenix, 1320 N 10th Street, Suite A, Phoenix, AZ, 85006, United States.
| | - Michael McKee
- Department of Orthopaedic Surgery, University of Arizona College of Medicine-Phoenix, 1320 N 10th Street, Suite A, Phoenix, AZ, 85006, United States.
| | - Emil Schemitsch
- London Health Sciences Centre, London, Ontario, Canada; Western University, London, Ontario, Canada.
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Minimally Invasive Plate Osteosynthesis of Humeral Shaft Fractures: Current State of the Art. J Am Acad Orthop Surg 2018; 26:652-661. [PMID: 30113346 DOI: 10.5435/jaaos-d-17-00238] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Most closed humeral shaft fractures can be successfully managed nonsurgically. However, fractures for which closed treatment is unsuccessful are stabilized using either plates or intramedullary nails. There are shortcomings associated with each technique, including the potential complications of nonunion, infection, shoulder pain, and radial nerve injury. Minimally invasive plate osteosynthesis (MIPO), an innovative alternative treatment, is gaining in popularity. This technique is based on the anterior humeral shaft providing a relatively safe surface for plate application, and limited open exposures proximally and distally allow percutaneous insertion of the necessary implant. More than 40 articles have been published regarding MIPO, and it compares favorably to other available forms of treatment with excellent functional outcomes and a lower rate of iatrogenic radial nerve injury. Larger randomized controlled trials comparing this method with other accepted techniques, including nonsurgical management, are necessary to better define the role of MIPO in the management of humeral shaft fractures.
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Toogood P, Huang A, Siebuhr K, Miclau T. Minimally invasive plate osteosynthesis versus conventional open insertion techniques for osteosynthesis. Injury 2018; 49 Suppl 1:S19-S23. [PMID: 29929686 DOI: 10.1016/s0020-1383(18)30297-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Osteosynthesis has evolved theoretically and practically throughout its evolution. Similar to trends in other surgical fields, surgical techniques in fracture fixation, such as minimally invasive plate osteosynthesis (MIPO), have moved from large dissections to more tissue sparing methods. These plating techniques have been developed for a variety of bones, but more universal clinical adoption will rely upon improved clinical outcomes. The current review will describe minimally invasive techniques, evaluate their rationale, and summarize evidence for their efficacy.
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Affiliation(s)
- Paul Toogood
- University of California, San Francisco (UCSF), Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, Mark Zuckerberg and Priscilla Chan San Francisco General Hospital and Trauma Center, San Francisco, California, USA.
| | - Adrian Huang
- University of California, San Francisco (UCSF), Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, Mark Zuckerberg and Priscilla Chan San Francisco General Hospital and Trauma Center, San Francisco, California, USA
| | - Karl Siebuhr
- University of California, San Francisco (UCSF), Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, Mark Zuckerberg and Priscilla Chan San Francisco General Hospital and Trauma Center, San Francisco, California, USA
| | - Theodore Miclau
- University of California, San Francisco (UCSF), Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, Mark Zuckerberg and Priscilla Chan San Francisco General Hospital and Trauma Center, San Francisco, California, USA
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28
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Metsemakers WJ, Kortram K, Morgenstern M, Moriarty TF, Meex I, Kuehl R, Nijs S, Richards RG, Raschke M, Borens O, Kates SL, Zalavras C, Giannoudis PV, Verhofstad MHJ. Definition of infection after fracture fixation: A systematic review of randomized controlled trials to evaluate current practice. Injury 2018; 49:497-504. [PMID: 28245906 DOI: 10.1016/j.injury.2017.02.010] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2016] [Revised: 02/08/2017] [Accepted: 02/17/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION One of the most challenging musculoskeletal complications in modern trauma surgery is infection after fracture fixation (IAFF). Although infections are clinically obvious in many cases, a clear definition of the term IAFF is crucial, not only for the evaluation of published research data but also for the establishment of uniform treatment concepts. The aim of this systematic review was to identify the definitions used in the scientific literature to describe infectious complications after internal fixation of fractures. The hypothesis of this study was that the majority of fracture-related literature do not define IAFF. MATERIAL AND METHODS A comprehensive search was performed in Embase, Cochrane, Google Scholar, Medline (OvidSP), PubMed publisher and Web-of-Science for randomized controlled trials (RCTs) on fracture fixation. Data were collected on the definition of infectious complications after fracture fixation used in each study. Study selection was accomplished through two phases. During the first phase, titles and abstracts were reviewed for relevance, and the full texts of relevant articles were obtained. During the second phase, full-text articles were reviewed. All definitions were literally extracted and collected in a database. Then, a classification was designed to rate the quality of the description of IAFF. RESULTS A total of 100 RCT's were identified in the search. Of 100 studies, only two (2%) cited a validated definition to describe IAFF. In 28 (28%) RCTs, the authors used a self-designed definition. In the other 70 RCTs, (70%) there was no description of a definition in the Methods section, although all of the articles described infections as an outcome parameter in the Results section. CONCLUSION This systematic review shows that IAFF is not defined in a large majority of the fracture-related literature. To our knowledge, this is the first study conducted with the objective to explore this important issue. The lack of a consensus definition remains a problem in current orthopedic trauma research and treatment and this void should be addressed in the near future.
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Affiliation(s)
- W J Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Belgium.
| | - K Kortram
- Department of Trauma Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - M Morgenstern
- Department of Orthopaedic and Trauma Surgery, University Hospital of Basel, Switzerland
| | | | - I Meex
- Department of Trauma Surgery, University Hospitals Leuven, Belgium
| | - R Kuehl
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital of Basel, Switzerland
| | - S Nijs
- Department of Trauma Surgery, University Hospitals Leuven, Belgium
| | | | - M Raschke
- Department of Orthopaedic and Trauma Surgery, University Hospital of Münster, Germany
| | - O Borens
- Orthopedic Septic Surgical Unit, Department of the Locomotor Apparatus and Department of Surgery and Anaesthesiology, Lausanne University Hospital, Lausanne, Switzerland
| | - S L Kates
- Department of Orthopaedic Surgery, Virginia Commonwealth University, USA
| | - C Zalavras
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, USA
| | - P V Giannoudis
- Department of Trauma and Orthopaedic Surgery, University Hospital of Leeds, United Kingdom and NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, Leeds, UK
| | - M H J Verhofstad
- Department of Trauma Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
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29
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Zhao JG, Wang J, Meng XH, Zeng XT, Kan SL. Surgical interventions to treat humerus shaft fractures: A network meta-analysis of randomized controlled trials. PLoS One 2017; 12:e0173634. [PMID: 28333947 PMCID: PMC5363833 DOI: 10.1371/journal.pone.0173634] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2016] [Accepted: 02/22/2017] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND There are three main surgical techniques to treat humeral shaft fractures: open reduction and plate fixation (ORPF), intramedullary nail (IMN) fixation, and minimally invasive percutaneous osteosynthesis (MIPO). We performed a network meta-analysis to compare three surgical procedures, including ORPF, IMN fixation, and MIPO, to provide the optimum treatment for humerus shaft fractures. METHODS MEDLINE, EMBASE, Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, and Cochrane library were researched for reports published up to May 2016. We only included randomized controlled trials (RCTs) comparing two or more of the three surgical procedures, including the ORPF, IMN, and MIPO techniques, for humeral shaft fractures in adults. The methodological quality was evaluated based on the Cochrane risk of bias tool. We used WinBUGS1.4 to conduct this Bayesian network meta-analysis. We used the odd ratios (ORs) with 95% confidence intervals (CIs) to calculate the dichotomous outcomes and analyzed the percentages of the surface under the cumulative ranking curve. RESULTS Seventeen eligible publications reporting 16 RCTs were included in this study. Eight hundred and thirty-two participants were randomized to receive one of three surgical procedures. The results showed that shoulder impingement occurred more commonly in the IMN group than with either ORPF (OR, 0.13; 95% CI, 0.03-0.37) or MIPO fixation (OR, 0.08; 95% CI, 0.00-0.69). Iatrogenic radial nerve injury occurred more commonly in the ORPF group than in the MIPO group (OR, 11.09; 95% CI, 1.80-124.20). There were no significant differences among the three procedures in nonunion, delayed union, and infection. CONCLUSION Compared with IMN and ORPF, MIPO technique is the preferred treatment method for humeral shaft fractures.
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Affiliation(s)
- Jia-Guo Zhao
- Departments of Orthopaedic Surgery, Clinical College of Orthopaedic Surgery, Tianjin Medical University, Tianjin, China
- Department of Orthopaedic Surgery, Tianjin Hospital, Tianjin, China
| | - Jia Wang
- Department of Orthopaedic Surgery, Tianjin Hospital, Tianjin, China
| | - Xiao-Hui Meng
- Department of Orthopaedic Surgery, Yixing Traditional Chinese Medicine Hospital, Yixing, Jiangsu Province, China
| | - Xian-Tie Zeng
- Department of Orthopaedic Surgery, Tianjin Hospital, Tianjin, China
| | - Shi-Lian Kan
- Department of Orthopaedic Surgery, Tianjin Hospital, Tianjin, China
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30
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Rotator Cuff-Sparing Approach for Antegrade Humeral Nailing With Biceps Tenodesis: A Technical Trick With Clinical Implications. J Orthop Trauma 2017; 31:e60-e65. [PMID: 27580320 DOI: 10.1097/bot.0000000000000684] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Antegrade intramedullary nails are an established, effective method of fixation for humeral shaft fractures. One significant limitation of this technique is chronic postoperative shoulder pain, which is likely related to the standard approach that involves splitting the rotator cuff to gain access to the nail starting point. Furthermore, mounting evidence suggests that both the intra-articular portion of the biceps tendon and the extra-articular portion in the bicipital groove can scar down after trauma, causing pain and limiting shoulder range of motion. We describe an approach through the rotator interval with tenodesis of the biceps tendon and resection of the intra-articular portion. Using a rotator cuff interval instead of a rotator cuff insertion approach allows access to the optimal humeral nail starting point while avoiding damage to intra-articular structures of the shoulder, potentially decreasing sources of postoperative shoulder pain.
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Qiu H, Wei Z, Liu Y, Dong J, Zhou X, Yin L, Zhang M, Lu M. A Bayesian network meta-analysis of three different surgical procedures for the treatment of humeral shaft fractures. Medicine (Baltimore) 2016; 95:e5464. [PMID: 28002327 PMCID: PMC5181811 DOI: 10.1097/md.0000000000005464] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND The optimal surgical procedure for humeral shaft fractures remains a matter of debate. We aimed to establish the optimum procedure by performing a Bayesian network meta-analysis. METHODS PubMed, EMBASE, the Cochrane Library, and Medline were searched for both randomized controlled trials and prospective studies of surgical treatment for humeral shaft fractures. The quality of the included studies was assessed according to the Cochrane Collaboration's "Risk of bias". RESULTS Seventeen RCTs or prospective studies were included in the meta-analysis. The pooled results showed that the occurrence rate of radial nerve injury was lowest for minimally invasive plate osteosynthesis (MIPO; SUCRA probability, 95.1%), followed by open reduction and plate osteosynthesis (ORPO; SUCRA probability, 29.5%), and was highest for intramedullary nailing (IMN; SUCRA probability, 25.4%). The aggregated results of pairwise meta-analysis showed no significant difference in radial nerve injury rate when comparing ORPO versus IMN (OR, 1.92; 95% CI, 0.96 to 3.86), ORPO versus MIPO (OR, 3.38; 95% CI, 0.80 to 14.31), or IMN versus MIPO (OR, 3.19; 95% CI, 0.48 to 21.28). Regarding the nonunion, SUCRA probabilities were 90.5%, 40.2%, and 19.3% for MIPO, ORPO, and IMN, respectively. The aggregated results of a pairwise meta-analysis also showed no significant difference for ORPO versus IMN (OR, 0.83; 95% CI, 0.41 to 1.69), ORPO versus MIPO (OR, 2.42; 95% CI, 0.45 to 12.95), or IMN versus MIPO (OR, 2.49; 95% CI, 0.35 to 17.64). CONCLUSION The current evidence indicates that MIPO is the optimum choice in the treatment of humeral shaft fractures and that ORPO is superior to IMN.
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Affiliation(s)
- Hao Qiu
- Department of Orthopaedic Surgery, Yongchuan Hospital of Chongqing Medical University
- Department of Orthopaedic Surgery, The Children's Hospital of Chongqing Medical University
| | - Zhihui Wei
- Department of Orthopaedic Surgery, Yongchuan Hospital of Chongqing Medical University
| | - Yuting Liu
- Department of Endocrinology, The Second Affiliated Hospital of Chongqing Medical University
| | - Jing Dong
- Department of Endocrinology, Yongchuan Hospital of Chongqing Medical University
| | - Xin Zhou
- Department of Orthopaedic Surgery, Yongchuan Hospital of Chongqing Medical University
| | - Liangjun Yin
- Department of Orthopaedic Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Minhua Zhang
- Department of Orthopaedic Surgery, Yongchuan Hospital of Chongqing Medical University
| | - Minpeng Lu
- Department of Orthopaedic Surgery, The Children's Hospital of Chongqing Medical University
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32
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Case-Match Controlled Comparison of Minimally Invasive Plate Osteosynthesis and Intramedullary Nailing for the Stabilization of Humeral Shaft Fractures. J Orthop Trauma 2016; 30:612-617. [PMID: 27768678 DOI: 10.1097/bot.0000000000000643] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To compare the risk of major complications after either minimally invasive plate osteosynthesis (MIPO) or intramedullary nailing (IMN) of humeral shaft fractures. DESIGN Retrospective, case-match controlled study. SETTING A major metropolitan tertiary referral trauma center in Australia. PATIENTS Thirty patients with fractures of the humeral shaft. INTERVENTION Either MIPO or IMN were performed on 15 patients each with traumatic humeral shaft fractures. PRIMARY OUTCOME MEASURE The cumulative risk of 3 major complications associated with these procedures: nonunion, infection, and iatrogenic radial nerve injury. RESULTS An overall major complication rate of 53% was observed in the patients treated with IMN; one complication (7%) was identified in those managed with humeral MIPO, a nonunion. Complications after IMN included 4 patients (27%) with nonunion, 3 patients (20%) with iatrogenic radial nerve injuries, and 1 patient (7%) with a wound infection. Statistical analysis revealed a significant between-group difference (P = 0.01) in the cumulative rate of major complications. When each of these complications was considered independently, no statistically significant difference was demonstrated. CONCLUSIONS This study suggests that humeral MIPO results in a significantly lower pooled major complication rate than that of IMN, and it should therefore be considered an attractive alternative to IMN in those patients requiring surgical stabilization of a traumatic humeral shaft fracture. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Hohmann E, Glatt V, Tetsworth K. Minimally invasive plating versus either open reduction and plate fixation or intramedullary nailing of humeral shaft fractures: a systematic review and meta-analysis of randomized controlled trials. J Shoulder Elbow Surg 2016; 25:1634-42. [PMID: 27522336 DOI: 10.1016/j.jse.2016.05.014] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 05/14/2016] [Accepted: 05/26/2016] [Indexed: 02/01/2023]
Abstract
HYPOTHESIS The purpose of this study was to perform a meta-analysis comparing the clinical outcomes and complications between anterior humeral minimally invasive plate osteosynthesis (MIPO) and the 2 standard techniques, either open reduction and plating or humeral nailing. METHODS We performed a systematic review of Medline, Embase, Scopus, and Google Scholar to identify relevant randomized controlled trials in the English- and German-language literature. Eligibility criteria included randomized controlled trials comparing at least 1 surgical intervention with MIPO and reporting the primary clinical outcome using a validated functional scoring system and description of complications. Publication bias was assessed by funnel plot, and the risk of bias was established using the Cochrane Collaboration's Risk of Bias Tool. Heterogeneity was assessed using χ(2) and I(2) statistics. RESULTS Eight prospective randomized studies (N = 376) met the eligibility criteria and were included in the analysis. The pooled estimate for clinical outcome showed that MIPO resulted in a significantly better outcome (standardized mean difference, 0.366; 95% confidence interval, 0.16 to 0.571; P = .0001; I(2) = 61%). The pooled estimate for all complications showed that the open reduction-internal fixation/nail group had a significantly higher complication rate (odds ratio, 0.507; 95% confidence interval, 0.285 to 0.905; P = .021; I(2) = 97%). CONCLUSION Current evidence indicates the MIPO approach has better clinical outcomes with a lower rate of complications compared with alternative surgical techniques. However, the results of this meta-analysis are limited by problems inherent in the primary studies, including poor reporting of randomization protocols, as well as possible attrition bias and reporting bias, of the primary studies. Future publications may therefore change the trend of the pooled estimate in either direction.
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Affiliation(s)
- Erik Hohmann
- Clinical Medical School, University of Queensland, Brisbane, QLD, Australia.
| | - Vaida Glatt
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia
| | - Kevin Tetsworth
- Department of Orthopaedic Surgery, Royal Brisbane Hospital, Herston, QLD, Australia; Department of Surgery, School of Medicine, University of Queensland, Brisbane, QLD, Australia; Queensland University of Technology, Brisbane, QLD, Australia; Orthopaedic Research Institute of Australia, Brisbane, QLD, Australia
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Zhang Q, Sun N, Huang Q, Zhu S, Wu X. Minimally Invasive Plating Osteosynthesis in the Treatment of Humeral Shaft Fractures: A Meta-Analysis. J INVEST SURG 2016; 30:133-142. [PMID: 27612003 DOI: 10.1080/08941939.2016.1215581] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Whether minimally invasive plating osteosynthesis (MIPO) or other operative interventions is superior in the treatment of humeral shaft fractures remains controversial. Therefore, we conducted a meta-analysis to quantitatively compare the clinical outcomes of MIPO and other operative interventions in the treatment of humeral shaft fractures. METHODS Pubmed, Embase, and Web of Science were systematically searched to identify all available studies comparing clinical outcomes between patients receiving MIPO and other operative interventions. The weight mean difference (WMD) was pooled to compare the operative time, union time, University of California, Los Angeles (UCLA) score, and Mayo elbow performance index (MEPI).The risk ratio (RR) was pooled to compare the union rate, and incidence of complications. Pooled estimates were calculated by using a fixed-effects model or a randomized-effects model, according to the heterogeneity among studies. RESULTS Nine studies were included in this meta-analysis. Our results suggest that both MIPO and other operative interventions can achieve similar union time, UCLA score, MEPI, and union rate. However, MIPO is associated with better outcomes including shorter operation time, and lower incidence of radial nerve injury. CONCLUSION Evidence from this meta-analysis demonstrated that, MIPO is effective but safer than other operative interventions in the treatment of humeral shaft fracture. However, due to the potential limitations in this meta-analysis, randomized controlled trials with larger sample sizes using appropriate blinding methods are needed to confirm these findings.
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Affiliation(s)
- Quan Zhang
- a Department of Orthopedic Traumatology , Beijing Jishuitan Hospital , China
| | - Ning Sun
- a Department of Orthopedic Traumatology , Beijing Jishuitan Hospital , China
| | - Qiang Huang
- a Department of Orthopedic Traumatology , Beijing Jishuitan Hospital , China
| | - Shiwen Zhu
- a Department of Orthopedic Traumatology , Beijing Jishuitan Hospital , China
| | - Xinbao Wu
- a Department of Orthopedic Traumatology , Beijing Jishuitan Hospital , China
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Gottschalk MB, Carpenter W, Hiza E, Reisman W, Roberson J. Humeral Shaft Fracture Fixation: Incidence Rates and Complications as Reported by American Board of Orthopaedic Surgery Part II Candidates. J Bone Joint Surg Am 2016; 98:e71. [PMID: 27605696 DOI: 10.2106/jbjs.15.01049] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Despite extensive research regarding patient outcomes after operative fixation of humeral shaft fractures by means of open reduction and internal fixation (ORIF) or intramedullary nailing (IMN), no current consensus exists regarding the optimal surgical treatment. The objective of this study was to compare IMN and plate fixation (ORIF) of humeral shaft fractures by using the American Board of Orthopaedic Surgery (ABOS) Part II operative database to analyze incidence rates, changes in management trends over time, early complications, and factors affecting the management choice. METHODS The ABOS database is a collection of surgical cases that are self-reported by orthopaedic candidates approved for admission to the ABOS oral examination. The database was searched for records from 2004 to 2013 for humeral shaft surgical cases as indicated by Current Procedural Terminology (CPT) codes 24515 (open reduction internal fixation) and 24516 (insertion of intramedullary nail) pertaining to humeral shaft fractures. The geographic region and fellowship training of the candidates; the year of surgery, diagnosis code, age, and sex of the patients; and the surgeon-reported complications were analyzed. RESULTS The search identified 3,430 surgically treated humeral shaft fractures that were reported to the ABOS database from 2004 to 2013. A significant decline in IMN use was seen from 2004 (42.9%) to 2013 (21.2%, p < 0.001). The IMN cohort had lower complication rates pertaining to both infections (1.5% compared with 3.0% for ORIF, p = 0.007) and nerve palsies (3.1% compared with 7.8%, p < 0.001). No significant difference was seen in the rate of nonunion (1.3% for IMN compared with 1.6% for ORIF, p = 0.63), although follow-up may be too short to demonstrate a difference. The IMN cohort did have significantly higher mortality (4.9% compared with 0.7% for ORIF, p < 0.001). Subset analysis demonstrated that the IMN cohort had significantly more pathologic fractures (26.8% compared with 1.5% of the fractures treated with ORIF, p < 0.001). CONCLUSIONS Although the overall incidence of fixation of humeral shaft fractures was unchanged from 2004 to 2013, there was a significant shift from IMN to ORIF using plate fixation during this time period. Possible reasons for this shift in treatment to ORIF include the potential impact of recent publications highlighting complications of IMN and increased surgeon attention to cost containment. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
| | - William Carpenter
- Department of Orthopaedics, Emory School of Medicine, Atlanta, Georgia
| | - Elise Hiza
- Department of Orthopaedics, Emory School of Medicine, Atlanta, Georgia
| | - William Reisman
- Department of Orthopaedics, Emory School of Medicine, Atlanta, Georgia
| | - James Roberson
- Department of Orthopaedics, Emory School of Medicine, Atlanta, Georgia
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Hu X, Xu S, Lu H, Chen B, Zhou X, He X, Dai J, Zhang Z, Gong S. Minimally invasive plate osteosynthesis vs conventional fixation techniques for surgically treated humeral shaft fractures: a meta-analysis. J Orthop Surg Res 2016; 11:59. [PMID: 27169580 PMCID: PMC4864922 DOI: 10.1186/s13018-016-0394-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 05/04/2016] [Indexed: 01/29/2023] Open
Abstract
Background In this study, we performed a meta-analysis to identify whether minimally invasive plate osteosynthesis (MIPO) was superior to conventional fixation techniques (CFT) for treating humeral shaft fractures. Methods A systematic literature search was conducted up to February 2016 in ScienceDirect, Springer, MEDLINE, and PubMed databases for relevant papers that compared the outcomes of MIPO with CFT, such as open reduction with plate osteosynthesis (ORPO) and intramedullary nail (IMN) for treating humeral shaft fractures. Meta-analysis was performed with Review Manager 5.0 software. Results According to the search strategy, eight studies that covered 391 patients were enrolled, including four randomized controlled trials (RCTs), two prospective cohort trials, and two retrospective cohort trials. Our meta-analysis did not detect any significant difference between MIPO and CFT (IMN and ORPO) in terms of operative time, fracture union rate, and fracture union time. However, MIPO has a less rate of complications and iatrogenic radial nerve palsy than that of ORPO and higher adjacent joint function scores than those of IMN (p < 0.05). Conclusions Based on the present evidence, this meta-analysis suggested that MIPO was a better choice for treating humeral shaft fractures than CFT. However, more high-quality randomized trials are still needed to further confirm this conclusion in the future.
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Affiliation(s)
- Xuqi Hu
- Department of Orthopaedics, the Second Affiliated Hospital of Jiaxing University, 1518 Huancheng North Road, Jiaxing, China
| | - Siqi Xu
- Department of Clinical Laboratory, the Second Affiliated Hospital of Jiaxing University, 1518 Huancheng North Road, Jiaxing, China
| | - Huigen Lu
- Department of Orthopaedics, the Second Affiliated Hospital of Jiaxing University, 1518 Huancheng North Road, Jiaxing, China
| | - Bao Chen
- Department of Orthopaedics, the Second Affiliated Hospital of Jiaxing University, 1518 Huancheng North Road, Jiaxing, China
| | - Xiao Zhou
- Department of Orthopaedics, the Second Affiliated Hospital of Jiaxing University, 1518 Huancheng North Road, Jiaxing, China
| | - Xiaojun He
- Department of Orthopaedics, the Second Affiliated Hospital of Jiaxing University, 1518 Huancheng North Road, Jiaxing, China
| | - Jiaping Dai
- Department of Orthopaedics, the Second Affiliated Hospital of Jiaxing University, 1518 Huancheng North Road, Jiaxing, China
| | - Zhongwei Zhang
- Department of Orthopaedics, the Second Affiliated Hospital of Jiaxing University, 1518 Huancheng North Road, Jiaxing, China
| | - Suiliang Gong
- Department of Orthopaedics, the Second Affiliated Hospital of Jiaxing University, 1518 Huancheng North Road, Jiaxing, China.
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Zhao JG, Wang J, Huang WJ, Zhang P. Surgical interventions for treating humeral shaft fractures in adults. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2016. [DOI: 10.1002/14651858.cd012174] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Jia-Guo Zhao
- Tianjin Hospital; Department of Orthopaedic Surgery; No. 406 Jiefangnan Road Hexi District Tianjin China 300211
| | - Jia Wang
- Tianjin Hospital; Department of Orthopaedic Surgery; No. 406 Jiefangnan Road Hexi District Tianjin China 300211
| | - Wan-Jie Huang
- Shengjing Hospital affiliated to China Medical University; Department of Paediatrics; No.36 Sanhao Street, Heping District Shenyang Liaoning China 110004
| | - Peng Zhang
- The Second Affiliated Hospital of Soochow University; Department of Orthopaedic Surgery; No 1055 Sanxiang Road Suzhou Jiangsu China 215004
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Patino JM. Treatment of humeral shaft fractures using antegrade nailing: functional outcome in the shoulder. J Shoulder Elbow Surg 2015; 24:1302-6. [PMID: 25825135 DOI: 10.1016/j.jse.2015.01.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 01/14/2015] [Accepted: 01/21/2015] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of this study was to evaluate shoulder outcomes and function after humeral shaft fractures treated with antegrade nailing. MATERIALS AND METHODS Thirty patients with acute humeral shaft fractures who underwent antegrade locked intramedullary nailing were retrospectively studied. Range of motion (ROM) of the affected shoulder was evaluated, comparing it with the nonaffected shoulder, radiologic position of the nails, complications, and need for a second surgery. RESULTS The study enrolled 20 men and 10 women (average age, 41.9 years). The average follow-up was 35.8 months. The average shoulder elevation averaged 157°, internal rotation was variable (reaching the sacroiliac joint to T7), and external rotation averaged 75°. Elbow flexion-extension ROM averaged 133° (115°-145°). According to the Rodriguez-Merchan criteria, 12 patients achieved excellent results (40%), 7 good (20%), and 6 fair (23.3%); poor results were found in 5 cases (16.6%). Twelve patients achieved full mobility of the shoulder, whereas 18 had some loss of motion, with significant differences between the affected and nonaffected shoulders (P = .001). CONCLUSION Decreased shoulder ROM is common after antegrade nailing of humeral shaft fractures. Avoidance of nail impingement can improve final outcomes.
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Affiliation(s)
- Juan Martin Patino
- Departamento de Ortopedia y Traumatologia, Servicio de cirugía de miembro superior, Hospital Militar Central "Cosme Argerich", Buenos Aires, Argentina.
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Zhao JG, Wang J, Wang C, Kan SL. Intramedullary nail versus plate fixation for humeral shaft fractures: a systematic review of overlapping meta-analyses. Medicine (Baltimore) 2015; 94:e599. [PMID: 25789949 PMCID: PMC4602489 DOI: 10.1097/md.0000000000000599] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Multiple meta-analyses have been published to compare intramedullary nail and plate for treating humeral shaft fractures; however, results are discordant.The purposes of current study were to perform a systematic review of overlapping meta-analyses comparing intramedullary nail and plate fixation for the treatment of humeral shaft fractures, to appraise the methodological quality and the quality of reporting of meta-analyses, and to propose a guide through the currently discordant available evidence.This systematic review was performed according to the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-analysis. The literature was systematically reviewed to identify meta-analyses comparing intramedullary nail and plate fixation for the treatment of humeral shaft fractures. Only meta-analyses exclusively including randomized clinical trials (RCTs) met eligibility criteria in this systematic review. Methodological quality for each included study was assessed using the Oxford Levels of Evidence and the Assessment of Multiple Systematic Reviews Instrument. We extracted all variables from the included studies and listed the results reported by them. Heterogeneity information of each variable was extracted for the included studies. An I of <60% is accepted in this systematic review. The Jadad algorithm was then applied to determine which meta-analyses provided the best evidence.Seven studies met the inclusion criteria in this study. All studies included RCTs or quasi-RCT and were Level II of evidence. Assessment of Multiple Systematic Reviews scores varied from 6 to 10 with a median of 7.86. Heterogeneity of each outcome was acceptable in those meta-analyses pooled results. The Jadad algorithm suggested that the meta-analyses can be selected based on the search strategies and application of selection. As a result, 2 meta-analyses with more RCTs were selected in this systematic review. The best available evidence suggested that the differences between intramedullary nail and plate fixation were not significant in fracture union, radial nerve injury, and infection. But intramedullary nail significantly increased the risk of shoulder complications (shoulder impingement and restriction of shoulder movement) and reoperation.We concluded that plate fixation is superior to intramedullary nail for the treatment of humeral shaft fractures.
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Affiliation(s)
- Jia-Guo Zhao
- From the Department of Orthopaedic Surgery, Tianjin Hospital, Tianjin (J-GZ, JW); Department of Orthopaedic Surgery, Fourth People's Hospital of Shenyang City, Shenyang (CW); and Department of Hand Surgery, Tianjin Hospital, Tianjin, China (S-LK)
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