Open reduction-internal fixation versus intramedullary nailing for humeral shaft fractures: an expected value decision analysis

The greater tuberosity version angle: a novel method of acquiring humeral alignment during intramedullary nailing

Aims

This study aims to describe a new method that may be used as a supplement to evaluate humeral rotational alignment during intramedullary nail (IMN) insertion using the profile of the perpendicular peak of the greater tuberosity and its relation to the transepicondylar axis. We called this angle the greater tuberosity version angle (GTVA).

Methods

This study analyzed 506 cadaveric humeri of adult patients. All humeri were CT scanned using 0.625 × 0.625 × 0.625 mm cubic voxels. The images acquired were used to generate 3D surface models of the humerus. Next, 3D landmarks were automatically calculated on each 3D bone using custom-written C++ software. The anatomical landmarks analyzed were the transepicondylar axis, the humerus anatomical axis, and the peak of the perpendicular axis of the greater tuberosity. Lastly, the angle between the transepicondylar axis and the greater tuberosity axis was calculated and defined as the GTVA.

Results

The value of GTVA was 20.9° (SD 4.7°) (95% CI 20.47° to 21.3°). Results of analysis of variance revealed that females had a statistically significant larger angle of 21.95° (SD 4.49°) compared to males, which were found to be 20.49° (SD 4.8°) (p = 0.001).

Conclusion

This study identified a consistent relationship between palpable anatomical landmarks, enhancing IMN accuracy by utilizing 3D CT scans and replicating a 20.9° angle from the greater tuberosity to the transepicondylar axis. Using this angle as a secondary reference may help mitigate the complications associated with malrotation of the humerus following IMN. However, future trials are needed for clinical validation.

Outcome and complication comparison for intramedullary nail versus open reduction internal fixation in humeral diaphyseal fractures for 2800 matched patient pairs utilizing the Nationwide Readmissions Database

INTRODUCTION

Open reduction internal fixation (ORIF) and intramedullary nail fixation (IMN) are the predominant repair methods for operative treatment of humeral diaphyseal fractures; however, the optimal method is not fully elucidated. The purpose of this study was to analyze whether IMN or ORIF humeral diaphyseal surgeries result in a significantly higher prevalence of adverse outcomes and whether these outcomes were age dependent. We hypothesize there is no difference in reoperation rates and complications between IMN and ORIF for humeral diaphyseal fractures.

METHODS

Data collected from 2015 to 2017 from the Nationwide Readmissions Database were evaluated to compare the prevalence of six adverse outcomes: radial nerve palsy, infections, nonunion, malunion, delayed healing, and revisions. Patients treated for a primary humeral diaphyseal fracture with either IMN or ORIF were matched and compared (n = 2,804 pairs). Patients with metastatic cancer were excluded.

RESULTS

Following an ORIF procedure, there was a greater odds of undergoing revision surgery (p = 0.03) or developing at least one of the complications of interest (p = 0.03). In the age-stratified analysis, no significant differences were identified in the prevalence of adverse outcomes between the IMN and ORIF cohorts in the 0-19, 20-39, and 40-59 age groups. Patients who were 60 + had 1.89 times the odds of experiencing at least one complication and 2.04 times the odds of undergoing a revision after an ORIF procedure versus an IMN procedure (p = 0.03 for both).

DISCUSSION

IMN and ORIF for humeral diaphyseal fractures are comparable in regard to complications revision rates in patients under the age of 60. Meanwhile, patients 60 + years show a statistically significant increase in the odds of undergoing revision surgery or experiencing complications following an ORIF. Since IMN appears to be more beneficial to older patients, being 60 + years old should be considered when determining fracture repair techniques for patients presenting with primary humeral diaphyseal fractures.

LEVEL OF EVIDENCE III

Ultrasound-guided preoperative localization of radial nerve in the treatment of extra-articular distal humeral shaft fractures

Background

The aim of this study was to discuss the treatment of extra-articular distal humeral shaft fractures using ultrasound-guided preoperative localization of radial nerve.

Methods

Between May 2010 and December 2019, 56 patients with extra-articular distal humeral shaft fractures were retrospectively reviewed. Twenty eight patients were received examination by using preoperative localization of radial nerve guided by ultrasound-guided preoperative localization (group A) and 28 control patients without ultrasound-guided (group B). All patients were treated surgically for distal humeral shaft fractures by posterior approach techniques. Operative time, radial nerve exposure time, intraoperative bleeding volume, union time and iatrogenic radial nerve palsy rate were compared between the two groups. Elbow function was also evaluated using the Mayo Elbow Performance Score (MEPS).

Results

A significant difference was observed between the two groups, Operative time (113.25 min vs 135.86 min) (P < 0.001), radial nerve exposure time (20.82 min vs 32.53 min) (P < 0.001), intraoperative bleeding volume (246.80 ml vs 335.52 ml) (P < 0.001). However, iatrogenic radial nerve palsy rate (3.6% vs 7.1%) (P = 0.129), the fracture union time (13.52 months vs 12.96 months) (P = 0.796) and the MEPS score (87.56 vs 86.38) (P = 0.594) were no significantly different in both groups.

Conclusions

The study demonstrates that ultrasound-guided preoperative localization is an effective approach in the treatment of extra-articular distal humeral shaft fracture by revealing radial nerve, which may help reduce the operative time, radial nerve exposure time and the intraoperative bleeding volume.

Postoperative malrotation of humerus shaft fracture causes degeneration of rotator cuff and cartilage

We hypothesized that postoperative malrotation of humeral shaft fractures can alter the bio-mechanical environment of the shoulder; thus, rotator cuff and cartilage degeneration could be induced. Therefore, we designed an animal experiment to evaluate the impact of malrotation deformities after minimally invasive surgery for humeral fractures on the rotator cuff and cartilage, which has rarely been described in previous studies. Twenty-four New Zealand white rabbits were randomly divided into the sham control group (A), negative control group (B) and malrotated group (C). A sham operation with surgical exposure alone was performed in group A. Humeral shaft osteotomy was performed in Group B and C. In Group B, the fractures were fixed in situ with plate -screw system. While in Group C, iatrogenic rotational deformity was created after the proximal end of the fracture being internally rotated by 20 degrees and then subsequently fixed. The animals with bone healing were sacrificed for pathological and biochemical examination. In group C, the modified Mankin scale for cartilage pathology evaluation and the modified Movin scale for tendon both showed highest score among groups with statistical significance (P < 0.05); Disordered alignment and proportion of collagen I/III of rotator cuff were confirmed with picrosirius red staining; Transmission electron microscopy also showed ultrastructural tendon damage. Immunohistochemistry showed that both MMP-1 and MMP-13 expression were significantly higher in group C than groups A and B(P < 0.05). Minimally invasive techniques for humerus shaft fracture might be cosmetically advantageous, but the consequent postoperative malrotation could increase the risk of rotator cuff and cartilage degeneration. This conclusion is supported here by primary evidence from animal experiments.

Results of plate fixation for humerus fractures in a large single-center cohort

INTRODUCTION

This study aims to describe the results of plate fixation in one of the largest single-center cohorts that employs plate fixation as the golden standard. Additionally, risk factors related to a negative outcome were identified.

MATERIALS AND METHODS

This was a retrospective cohort study of all patients treated for a humeral shaft fracture in a level-one trauma center between January 2010 and December 2017 with a mean follow-up of 1 year.

RESULTS

Plate fixation was performed in 102 patients with a humeral shaft fracture. The mean age was 50 (SD 20) years with 54.9% (n = 56) being male. Forty-eight percent (n = 48) had an AO type-A, 34.3% (n = 35) type-B, and 18.7% (n = 19) type-C fracture. Deep surgical site infections and non-union occurred in 1% (n = 1) and 3.9% (n = 4) of patients, respectively. Revision of the implant was performed in 15.7% (n = 16) mainly due to implant-related complaints. Only one patient developed radial nerve palsy after surgery. The median duration to radiological fracture healing and full-weight bearing was 18 (range 7-65) weeks and 14 (range 6-56) weeks, respectively. Risk factors for negative outcome included higher age, osteoporosis, open and higher AO class fractures, performing surgery during out-office hours, and the use of LCP 3.5-mm plate and an anterolateral approach.

CONCLUSION

Plate fixation for humeral shaft fractures has low risks of complications. It should be emphasized that the complications can be further minimized with a greater surgical expertise and by refraining from performing a surgery during out-office hours.

Open reduction and internal fixation (ORIF) versus ORIF and primary subtalar arthrodesis for complex displaced intraarticular calcaneus fractures: An expected value decision analysis

Objectives:

To determine the optimal patient-oriented treatment between open reduction and internal fixation (ORIF) with or without primary subtalar arthrodesis (PSTA) for patients with displaced intraarticular calcaneus fractures (DIACFs, OTA 82-C3 and C4).

Design:

Expected value decision analysis.

Setting:

Academic military treatment facility

Participants:

One hundred randomly selected volunteers.

Intervention:

Hypothetical clinical scenario involving ORIF versus ORIF with PSTA.

Main outcome measurements:

Decision analysis was used to elucidate the superior treatment option based on expected patient values, composed of: the product of the average outcome probabilities established by previously published studies and the average ascribed patient utility values for each outcome probability. One-way sensitivity analysis was performed to quantify the amount of change required for the inferior treatment to equal or surpass the superior option.

Results:

Expected values for ORIF and ORIF with PSTA were 8.96 and 18.06, respectively, favoring ORIF with PSTA. One-way sensitivity analysis was performed by artificially decreasing the rate of secondary fusion following isolated ORIF thus increasing its overall expected value. Adjusting the rate of secondary fusion to 0%, the expected value of ORIF with PSTA nearly doubled that of ORIF (18.06 vs 9.45). Similarly, when adjusting the moderate and severe complication rates following ORIF with PSTA to 100%, the expected value of ORIF with PSTA still exceeded that of ORIF (15.45 vs 8.96, and 13.52 vs 8.96, respectively).

Conclusion:

Expected value decision analysis favors ORIF with PSTA as the optimal treatment for complex DIACF.

Comparison between minimally invasive deltoid-split and extended deltoid-split approach for proximal humeral fractures: a case-control study

BACKGROUND

With the rapid aging of the population, the incidence of proximal humeral fracture (PHF) has increased. However, the optimal method for open reduction and internal fixation (ORIF) remains controversial.

METHODS

We performed a retrospective analysis of patients with PHF who underwent locking plate internal fixation at our institution from January 2016 to December 2018. Patients were divided into two groups based on the surgical approach used: an expanded deltoid-split approach group (ORIF group) and minimally invasive deltoid-split approach group (minimally invasive percutaneous plate osteosynthesis, [MIPPO] group). The groups were compared in terms of demographic and perioperative characteristics, and clinical outcomes.

RESULTS

A total of 115 cases of PHF were included in our study, of which 64 cases were treated using the minimally invasive deltoid-split approach and 51 using the extended deltoid-split approach. Fluoroscopy was performed significantly less frequently in the ORIF group and the surgical duration was shorter. However, the postoperative visual analogue scale (VAS) pain score and duration of postoperative hospital stay were significantly higher compared to the MIPPO group. Moreover, secondary loss was significantly less extensive in the ORIF group compared to the MIPPO group, while there was no significant group difference in fracture healing time, Constant shoulder score, or complications at the last follow-up visit.

CONCLUSIONS

The clinical outcomes associated with both the minimally invasive and extended deltoid-split approaches were satisfactory. The data presented here suggest that the extended deltoid-split approach was superior to the minimally invasive deltoid-split approach in terms of operational time, fluoroscopy, and secondary loss of reduction, while the minimally invasive approach was superior in terms of postoperative pain and hospital stay. Accordingly, neither procedure can be considered definitively superior; the optimal surgical procedure for PHF can only be determined after full consideration of the situation and requirements of the individual patient.

Does intramedullary nailing improve the union rate or decrease mechanical complications for patients with extremity sarcoma after biological reconstruction?

INTRODUCTION

This is a retrospective study that evaluate the outcome of patients with extremity sarcoma between extramedullary plate and intramedullary nailing for the biological reconstruction after tumor resection.

METHODS

58 patients (40 treated with plate fixation and 18 with intramedullary nailing, IM group) with sarcomas of the lower and upper extremity who received biological reconstruction at our bone tumor center from November 2003 to November 2015 were reviewed for the study. There were 29 male and 29 female patients with a mean age of 20.8 years (range, 5-72 years). The mean follow-up duration was 90.8 months (range, 12.2-244.4 months). All data were obtained from the clinical, radiograph records and follow-up information. The analysis of outcome, survival, local recurrence, function and complications of patients in the plate group and IM group was performed.

RESULTS

28 cases in the plate group lived at the last follow-up, of which 26 had no evidence of disease, 2 lived with the pulmonary metastasis, whereas 15 in the IM group lived at the last follow-up, of which all had no evidence of disease and no lived with the pulmonary metastasis. There was no significant difference between the two groups for the prognosis. Meanwhile, there was no significant difference of incidence of nonunion, graft fracture and fixation breakage between the two groups, whereas the time to diaphysis union in the plate group (11.6 ± 2.7 months) was shorter than that in IM group (14.7 ± 4.8 months, P = 0.015). It had the tendency that the time to mechanical complications in the intramedullary nailing group (38.1 ± 39.6 months) was longer than that in the plate group (15.7 ± 13.4 months, P = 0.058,95% CI,-45.6-0.8). Furthermore, the infection occurred in 12 cases and five grafts of them developed the deep infection and the mean time to deep infection was 14.8 ± 20.5 months. Furthermore, the incidence of local recurrence for the patients who had plate fixation was similar to the incidence of patients who had nailing fixation. At the last follow-up, the functional evaluation was performed for 39 patients. There was no significant difference in MSTS and VAS functional score for patients between in the plate group (n = 32) and IM group (n = 7).

CONCLUSIONS

The findings of the present study showed that intramedullary nailing does not improve the union rate or decrease the incidence of mechanical complications for patients with extremity sarcoma after biological reconstruction. However, intramedullary nailing may have potential advantages on the service life for the biological reconstruction after extremity sarcoma resection.

Cutaneous paresthesia after internal plate fixation of clavicle fractures and underlying anatomical observations

To assess the clinical and anatomical causes of cutaneous paresthesia after internal fixation of clavicle fractures.This study included 135 patients who underwent internal fixation of clavicle fractures from May 2013 to June 2016 at the First and Second Affiliated Hospital of Guangxi Medical University. The incidence of postoperative supraclavicular nerve injury, the duration of numbness, and improvements after plate removal were retrospectively analyzed. Seven human cadaver specimens were subsequently dissected to analyze the supraclavicular nerve and its relationship to numbness.Of the 135 patients who underwent internal fixation of clavicle fractures, 26 (19.3%) experienced postoperative cutaneous paresthesia, with 22 (16.3%) and 4 (2.8%) experiencing numbness and pain, respectively. The most intense numbness occurred during the first operative month. Of the 22 patients with numbness, 1 (4.5%), 1 (4.5%), and 20 (90.1%) patients reported mild, moderate, and severe numbness, respectively. Two patients described increased awareness of numbness when in contact with clothes, 2 were psychologically affected by numbness, and 20 (90.1%) reported reduced severity of numbness over time. At the last follow-up, numbness was found to persist in 2 (1.5%) patients. None of the patients was bothered by numbness. Cadaver dissection showed that the supraclavicular nerve emerged from the 1/2 posterior edge of the cervical sternocleidomastoid muscle and subsequently divided into 3 branches, with the lateral branch 2.26 ± 1.17 cm from the lateral margin of the acromion, the middle branch near the mid-clavicle, and the medial branch 2.03 ± 0.85 cm from the sternal lateral margin.Cutaneous paresthesia is common following internal fixation of the clavicle. Anatomic analysis showed that the nerve could be easily injured during clavicle operation. Numbness improved in most patients, but persisted for up to 2 years and was even permanent in a few. Most patients considered numbness as an insignificant factor in their daily lives.