Five years' clinical experience with the unreamed humeral nail in the treatment of humeral shaft fractures

Humeral shaft fracture: systematic review of non-operative and operative treatment

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.

Are the unreamed nails indicated in diaphyseal fractures of the lower extremity? A biomechanical study

INTRODUCTION

Intramedullary nailing is generally accepted as the first choice for the treatment of diaphyseal fractures of femur and tibia, with a gradual incease in the use of unreamed nails. Different studies during last years show controversial outcomes. Some authors strongly favor unreamed nailing, but most of the authors conclude that reamed nailing have proved to be more successful.

MATERIAL AND METHODS

This study simulates unreamed intramedullary nailing of four femoral and three tibial fracture types by means of Finite Element (FE) models, at early postoperative stages with a fraction of physiological loads, in order to determine whether sufficient stability is achieved, and if the extent of movements and strains at the fracture site may preclude proper consolidation.

RESULTS

The behavior observed in the different fracture models is very diverse. In the new biomechanical situation, loads are only transmitted through the intramedullary nail. Mean relative displacement values of fractures in the femoral bone range from 0.30 mm to 0.82 mm, depending on the fracture type. Mean relative displacement values of the tibial fractures lie between 0.18 and 0.62 mm, depending on the type of fracture. Concerning mean strains, for femoral fractures the maximum strains ranged between 12.7% and 42.3%. For tibial fractures the maximum strains ranged between 10.9% and 40.8%.

CONCLUSIONS

The results showed that unreamed nailing provides a very limited mechanical stability, taking into account that analyzed fracture patterns correspond to simple fracture without comminution. Therefore, unreamed nailing is not a correct indication in femoral fractures and should be an exceptional indication in open tibial fractures produced by high-energy mechanism.

TREATMENT OF HUMERAL SHAFT FRACTURES: ANTEGRADE INTERLOCKING INTRAMEDULLARY NAILING WITH ADDITIONAL INTERLOCKING NEUTRALIZATION SCREWS THROUGH FRACTURE SITE

The aim of this study was to compare union time between two different nail designs for the treatment of humeral shaft fracture, i.e. antegrade interlocking intramedullary nail with and without additional interlocking neutralization screws. The retrospective study included 51 patients treated with antegrade humeral intramedullary nailing between January 2015 and December 2017. The inclusion criteria of the study were proximal and middle third humeral shaft fractures. Fifty-one patients met the inclusion criteria; 23 patients were treated with antegrade intramedullary nail with additional interlocking neutralization screws through fracture site (group A) and 28 patients were treated with antegrade intramedullary nail without additional interlocking neutralization screws (group B). Medical documentation and radiographic images taken preoperatively and postoperatively were reviewed. Radiological union was defined as cortical bridging of at least three of four cortices in two-plane radiographs, with disappearance of the fracture gap. There were no significant differences in union time between the groups (p>0.05). To our knowledge, this is the first report of antegrade interlocking humeral nailing with additional interlocking neutralization screws through fracture site. Hypothetical advantages of fracture gap reduction by additional interlocking neutralization screws to promote union were not confirmed by this first clinical trial.

Internal fixation of shaft humerus fractures by dynamic compression plate or interlocking intramedullary nail: a prospective, randomised study

Compare the results of internal fixation of shaft of humerus fractures using dynamic compression plating (DCP) or antegrade interlocking intramedullary nail (IMN). Fifty patients with diaphyseal fracture of the shaft of the humerus and fulfilling the inclusion criterion were randomly assigned to one of the two groups. Twenty-five patients were managed with closed antegrade interlocking intramedullary nail, and 25 underwent open reduction and internal fixation using dynamic compression plating. The mean age of patients with IMN fixation was 37.28 years (SD 12.26) and 37.72 years (SD 12.70) for those who underwent plating. Road traffic accident was the most common mode of injury in both groups. There was a statistically significant difference between the two groups with respect to duration of hospital stay, operative time and blood loss. There was no significant difference between the two groups in terms of union or complications. The functional assessment at the end of 1 year between the two groups did not show any significant difference in outcome. Antegrade interlocking IMN and DCP fixation are comparable when managing diaphyseal shaft of humerus fractures with respect to union rates and complications. Although shoulder related complications are more in the IMN group, however, it is associated with shorter hospital stay, lesser operative time and less blood loss. This makes interlocking IMN an effective option in managing these fractures.

Complications after interlocking intramedullary nailing of humeral shaft fractures

INTRODUCTION

IM nails have gained popularity for stabilization of humeral shaft fractures (HSF). The initial enthusiasm was tempered by a number of specific complications and thus indications need to be re-evaluated.

PATIENTS AND METHODS

This retrospective study includes 111 patients with HSF subjected to a treatment protocol of IM fixation with first and second generation of humeral nails. Antegrade approach was used in 105 (94.5%) and retrograde in 6 (5.5%) patients. Reaming was performed in 51 (45.9%) fractures. The study covers a period of 10 years. Mean follow-up time was 3.5 (1-6) years. This investigation is directed at technical errors and complications, especially those corrected by secondary surgery.

RESULTS

We registered 52 (46.85%) intra-operative complications in 40 (36.04%) patients, on average 1.3 per patient. The most common were: distraction n=5 (4.5%), long proximal locking screws n=9 (8.1%), additional diaphyseal fracture n=7 (6.3%) and countersinking of the nail in the humeral head n=8 (7.2%). The number of postoperative complications was 40 (36.0%) related to 19 (17.1%) patients. Technical errors, such as distraction, longer nail and additional fractures have affected time to union and resulted in chronic shoulder pain. 36 (32.5%) secondary surgeries were needed to address these problems. When first generation nails are used, the intra-operative complication related risk increases 1.58 times, and the postoperative complication related risk is 1.67 times higher compared to second generation nails. According to Constant-Murley score excellent and very good functional results were achieved in 93 (83.78%) patients. While reaming did not influence the clinical results for both nail generations, overall better results were achieved with second generation nails. Postoperative shoulder pain has been registered in 18 (16.2%) patients.

CONCLUSION

We registered a number of technical errors and complications, which we consider technique specific. The analysis and avoidance of these complications, related only to IM nailing of the humerus, will allow IM nails to successfully bridge the gap between functional bracing and plating.

Minimally invasive plating osteosynthesis for mid-distal third humeral shaft fractures

Mid-distal third humeral shaft fractures can be effectively treated with minimally invasive plating osteosynthesis and intramedullary nailing (IMN). However, these 2 treatments have not been adequately compared. Forty-seven patients (47 fractures) with mid-distal third humeral shaft fractures were randomly allocated to undergo either minimally invasive plating osteosynthesis (n=24) or IMN (n=23). The 2 groups were similar in terms of fracture patterns, fracture location, age, and associated injuries. Intraoperative measurements included blood loss and operative time. Clinical outcome measurements included fracture healing, radial nerve recovery, and elbow and shoulder discomfort. Radiographic measurements included fracture alignment, time to healing, delayed union, and nonunion. Functional outcome was satisfactory in both groups. Mean American Shoulder and Elbow Surgeons score and Mayo score were both better for the minimally invasive plating osteosynthesis group than for the IMN group (98.2 vs 97.6, respectively, and 93.5 vs 94.1, respectively; P<.001). Operative time was shorter and less intraoperative blood loss occurred in the minimally invasive plating osteosynthesis group than in the IMN group. Average time to union was similar in both groups. Primary union was achieved in 23 of 24 patients in the minimally invasive plating osteosynthesis group and in 22 of 23 in the IMN group. Minimally invasive plating osteosynthesis may have outcomes comparable with IMN for the management of mid-distal third humeral shaft fractures. Minimally invasive plating osteosynthesis is more suitable for complex fractures, especially for radial protection and motion recovery of adjacent joints, compared with IMN for simple fractures.

An innovative technique of rear entry creation for retrograde humeral nailing: how to avoid iatrogenic comminution

BACKGROUND

Antegrade and retrograde nails are widely used for intramedullary fixation of humeral shaft fractures. Creating the rear entry is the crucial step for retrograde nailing. The common manual technique is associated with considerable risks of additional iatrogenic comminution of the distal humerus.

DESCRIPTION OF THE TECHNIQUE

A specific device for the creation of a rear entry hole has been developed as part of the instruments for humeral shaft nailing (Targon H) and made commercially available (BBraun Aesculap, Germany). After standard triceps-splitting approach, a guide instrument is firmly applied to the distal humerus with one screw. The screw hole is later used for distal interlocking. The oval rear entry hole is then performed by frontal cutter along the guide.

PATIENTS AND METHODS

We have been performing a retrospective evaluation of all unreamed humeral nailings (Targon H) since 2000. Operation time, use of the guide instrument and intra-operative problems were analysed. X-rays were checked for iatrogenic humeral comminution directly after the operation and after physiotherapy. Cases of infection and nonunion were noted.

RESULTS

We identified 87 cases of intramedullary fracture fixation with an interlocking nail (46 antegrade, 41 retrograde). In all retrograde cases a guide instrument and an access reamer were used for the creation of an entry hole. No iatrogenic comminutions were observed during the operation or on postoperative X-rays. Active postoperative exercises were generally allowed in every patient. Mean operative time was shorter for retrograde than for antegrade nailing (90 min vs. 108 min; p = 0.012). We saw two nonunions (2%) and no infections.

CONCLUSIONS

Use of access reamer and guide instrument is a safe and reproducible way of creating a rear entry hole for retrograde humeral nailing. The risk of additional comminution seems to be eliminated.

Plating osteosynthesis of mid-distal humeral shaft fractures: minimally invasive versus conventional open reduction technique

Results of two methods, conventional open reduction-internal plating and minimally invasive plating osteosynthesis (MIPO), in the treatment of mid-distal humeral shaft fractures were compared. Thirty-three patients were retrospectively analysed and divided into two groups. Group A (n = 17) patients were treated by MIPO and group B (n = 16) by conventional plating. The mean operation time in group A was 92.35 +/- 57.68 minutes and 103.12 +/- 31.08 minutes in group B (P = 0.513). Iatrogenic radial nerve palsy in group A was 0% (0/17) and 31.3% in group B (5/16 (P = 0.012). The mean fracture union time in group A was 15.29 +/- 4.01 weeks (range 8-24 weeks), and 21.25 +/- 13.67 weeks (range 10-58 weeks) in group B (P = 0.095). The mean UCLA end-result score in group A was 34.76 +/- 0.56 points (range 33-35), and 34.38 +/- 1.41 points (range 30-35) in group B (P = 0.299). The mean MEPI in group A was 99.41 +/- 2.43 points (range 90-100) and 99.69 +/- 1.25 points (range 95-100) in group B ( P = 0.687). When compared to the conventional plating techniques, MIPO offers advantages in terms of reduced incidence of iatrogenic radial nerve palsies and accelerated fracture union and a similar functional outcome with respect to shoulder and elbow function.

Humeral nailing revisited

Unreamed interlocked humeral nailing for stabilisation of acute humeral fractures was introduced a decade ago. Antegrade and retrograde nail insertion are equally popular. The role of nailing as opposed to plating of humeral fractures is the subject of continuous debate. Between 1997 and 2005, 99 acute fractures of the humeral shaft were treated operatively with the unreamed humeral nail (UHN, Synthes) in our Level I Trauma Centre. The mean age of the patients was 63 years. Only eight patients (8.1%) were polytraumatised, nine patients had an open fracture (9.1%), five had a primary radial nerve palsy (5.1%). There were 54 antegrade and 45 retrograde nailings. The procedures were performed by 19 different surgeons, who carefully followed a detailed operation protocol. There were 6 adverse events: 3 secondary radial nerve palsies (3%), 2 fissures at the insertion point (2%) and one false placement of a locking screw (1%). Three patients developed pseudarthrosis (3%). Eight further operation were necessary (8.1%): 3 exploration of the radial nerve, 3 for treatment of pseudarthrosis, one replacement of a locking screw and one wound revision for superficial wound infection. Ninety patients (92 fractures) were evaluated after bone healing. Shoulder function was assessed using the Constant Score, elbow function with the Mayo Elbow Score. 91.3% and 5.4% of patients had an excellent or good shoulder function, 81.5% and 14.1% had an excellent or good elbow function. All patients with a functional deficit of the shoulder joint had antegrade, all patients with a deficit at the elbow joint retrograde nailing. Motor function recovered in all radial nerve palsies. 93.5% of patients had an excellent or good functional end result. Unreamed humeral nailing is a valid therapeutic option for stabilisation of acute humeral shaft fractures. Antegrade and retrograde nailing are associated with specific but different complications. By strictly adhering to the operation technique, the number and severity of complications can be reduced. When good fracture alignment and stability are obtained, uneventful bone healing with good functional outcome is the rule.

Minimally invasive plating osteosynthesis (MIPO) of middle and distal third humeral shaft fractures

OBJECTIVE

To evaluate the clinical, radiographic, and functional outcomes of middle and distal third humeral shaft fractures treated with the minimally invasive percutaneous osteosynthesis (MIPO).

DESIGN

Prospective, single-center, nonconsecutive clinical series study.

SETTING

: Skeletal trauma center of a university teaching hospital.

PATIENTS

Thirteen patients who were seen from May 2004 to October 2005 with an average age of 38.1 years (range, 25 to 60 years) form the basis of this study. Patients were obtained from a surgical database of 1 surgeon.

INTERVENTION

The middle and the distal third humeral shaft fractures were reduced by closed means and fixed with long narrow 4.5-mm dynamic compression plates introduced through 2 small incisions away from the fracture sites and placed on the anterior aspect of the humerus.

MAIN OUTCOME MEASUREMENTS

Time to fracture healing and functional assessments were assessed at an average follow-up of 12.5 months (range, 7 to 19 months) for the affected shoulders and elbows using the UCLA and Mayo elbow performance scoring systems, respectively.

RESULTS

All fractures united with a mean healing time of 16.2 weeks (range, 12 to 32 years). There were no nonunions, radial nerve palsies, or implant failures. The UCLA scoring system showed excellent results in 7 cases (53.8%) and good results in 6 cases (46.2%). Thirteen patients had excellent results of their elbow function when assessed with the Mayo elbow performance scoring system.

CONCLUSION

Closed reduction and internal fixation of middle or distal third humeral shaft fractures using MIPO is a safe and effective surgical treatment method and an alternative option to open techniques.

Accessory radial collateral vascular bone graft for the management of nonunion of humeral shaft fracture after intramedullary nailing

SUMMARY

An easy pedicle vascular bone graft technique for the management of nonunion of humeral shaft fracture is described. The distal and lateral part of the humerus, including the lateral epicondyle, is transferred to the nonunion site of the humerus. This vascular bone graft is based on the accessory radial collateral artery. It promotes healing of the nonunion.

Humeral shaft fractures treated by dynamic compression plates, Ender nails and interlocking nails

Between January 1991 and December 2002, we treated 92 acute, displaced, closed humeral shaft fractures (AO classification type A). We used three fixation methods: dynamic compression plates (DCP) in 36 patients, Ender nails (EN) in 32 patients and interlocking nails (ILN) in 24 patients. The patients were followed for a minimum of 24 months. At one year, all fractures except two (one DCP/one ILN) had united. Patients treated with EN had shorter mean operation time, 51 (35-110) min; less mean blood loss, 70 (30-170) ml and shorter mean hospital stay, 5.8 (3-12) days. There were three iatrogenic radial nerve palsies: two in the DCP group and one in the ILN group. There was one wound infection. There were three cases with impingement of the shoulder but range of motion was restored after nail removal. For patients with multiple trauma or high operative risk, EN fixation served as a safer and faster procedure. ILN fixation offered a stable fixation via a smaller incision but more fracture comminution might happen.

Marchetti nailing of closed fresh humeral shaft fractures

INTRODUCTION

The purpose of this study was to analyse the results of Marchetti nailing.

METHOD

Between 1995 and 2003, 143 patients with closed fresh humeral shaft fractures were treated with the Marchetti-Vicenzi nail. The fractures were classified according to the AO classification: 37 A1, 24 A2, 25 A3, 22 B1, 15 B2, 7 B3, 7 C1, 4 C2 and 2 C3.

RESULTS

Fracture healing was obtained in 136 cases. The mean healing time was 11 weeks. There were seven non-unions. The range of motion of the shoulder was excellent in 95 patients (66.4%), moderate in 43 (30%) and poor in five (4.2%). The elbow had an excellent range of motion in 89 patients (62.2%), moderate in 48 (33.5%) and poor in six (4.2%). The functional result was excellent in 56 patients (39.1%), good in 62 (43.3%), fair in 18 (12.6%) and poor in seven (4.9%).

CONCLUSION

Marchetti-Vicenzi nailing appears to be a good method for the treatment of humeral shaft fractures. It is technically easy and its results are satisfactory.