Case-Match Controlled Comparison of Minimally Invasive Plate Osteosynthesis and Intramedullary Nailing for the Stabilization of Humeral Shaft Fractures

Effect of cerclage wiring on humeral shaft fracture associated with the third fragment

INTRODUCTION

In humeral shaft fractures, the presence of a free bone fragment, called the third fragment or butterfly fragment, is thought to induce non-union. We hypothesised that non-union and subsequent reoperations could be reduced by performing cerclage wiring for fragments, in addition to intramedullary nailing for fractures with the third fragment. This study aimed to examine the effectiveness of cerclage wiring for the third fragments associated with humeral shaft fractures.

MATERIALS AND METHODS

This study included patients with humeral shaft fractures involving the third fragment, who underwent osteosynthesis with intramedullary nailing at our institution between April 2013 and June 2024. The patients were divided into two groups: those who underwent osteosynthesis using an intramedullary nail alone (Group1) and those who underwent osteosynthesis using an intramedullary nail with cerclage wiring (Group2). Patient and injury characteristics, surgical time, intraoperative blood loss, postoperative complications, fracture healing, time to bone union, and reoperation were investigated and compared between the two groups.

RESULTS

Sixteen patients were included in Group1 and 27 patients were included in Group2. There were no significant differences in patient characteristics or injuries. Surgical time was significantly longer (p = 0.01) and intraoperative blood loss was significantly greater (p = 0.01) in Group2. There were no significant differences in the rates of infection and postoperative nerve paralysis (p = 1, 0.522). The rates in non-union was significantly higher in Group1 (p = 0.05). There were no significant differences in reoperation rate (p = 0.137). In cases where fracture healing was achieved, the time to bone union was significantly longer in Group1 (p < 0.001).

CONCLUSION

Cerclage wiring, in addition to intramedullary nailing for fractures with a third fragment, may prevent non-union. Although the addition of cerclage wiring significantly increased the surgical time and intraoperative blood loss, there was no increase in postoperative complications.

Outcomes of Intramedullary Nailing Versus Plate Fixation in the Management of Humeral Shaft Fractures: A Systematic Review and Meta-Analysis

This systematic review and meta-analysis aimed to compare the outcomes of intramedullary nailing (IMN) and open reduction with internal fixation (ORIF) in treating traumatic humeral shaft fractures in adults (18 years and above). A comprehensive literature search was conducted in databases including PubMed, Google Scholar, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL). The primary outcome was time to union, while secondary outcomes included non-union rates, incidences of iatrogenic radial nerve palsy, surgical site infections, and intra-operative comminution. Twenty-six studies, encompassing 1,674 patients (867 IMN, 807 ORIF), were included. IMN demonstrated a shorter time to union compared to ORIF (mean difference -1.06 (95% CI, -1.88 to -0.23)), with significant statistical heterogeneity (I² = 70%), and a mean difference of -2.14 (95% CI, -3.16 to -1.12) in the randomized controlled trial (RCT) subgroup analysis, which had no significant statistical heterogeneity. Both techniques had comparable non-union rates (risk ratio 0.34 (95% CI, 0.94 to 1.93)). IMN was associated with lower incidences of iatrogenic radial nerve palsy (risk ratio 0.48 (95% CI, 0.27 to 0.87)) and surgical site infections (risk ratio 0.44 (95% CI, 0.25 to 0.76)), but had a higher risk of intra-operative comminution (risk ratio 3.04 (95% CI, 1.24 to 7.44)). The studies exhibited significant heterogeneity and varying outcome measures, highlighting the need for cautious interpretation. IMN offers rapid fracture stabilization and minimal additional physiological insult, while ORIF remains preferable for achieving precise anatomical reduction. These findings highlight the importance of considering patient-specific factors and surgical expertise in selecting the appropriate fixation technique.

Shoulder problems after percutaneous antegrade intramedullary nailing in humeral diaphyseal fractures using contemporary straight third-generation nail

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.

Percutaneous Intramedullary Nailing of Complex Humeral Shaft Fractures: A Retrospective Case Series

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.

Prevalence and risk factors for pseudarthrosis in humeral shaft fractures treated by minimally invasive plate osteosynthesis: A 10-year review

Introduction

Fractures of the humeral shaft account for about 3% to 5% of all fractures. Although conservative treatment remains the first choice, there are a number of surgical indications. Minimally invasive plate osteosynthesis shows good functional results. However, complications have been reported, such as non-union.

Objective

To assess the prevalence and risk factors for non-union after treatment of humeral shaft fractures using minimally invasive plate osteosynthesis.

Materials and methods

This retrospective study was carried out in patients treated by minimally invasive plate osteosynthesis between 2009 and 2019. Demographic data and variables related to the fracture that could influence bone healing were analysed. The unpaired t-test and Mann-Whitney test were used for the statistical analyses. Categorical variables were analysed using the chi-square test or Fisher's exact test.

Results

The study population showed a male predominance (53 of 75, 70.7%). The average time for fracture healing was 19.8 ± 15.3 weeks. Seven patients developed non-union. Only the presence of an open fracture increased the likelihood of non-union.

Conclusions

The prevalence of non-union in patients treated by minimally invasive plate osteosynthesis was 9.3%. Patients with open fractures were six times more likely to progress to non-union. Fracture characteristics (Arbeitsgemeinschaft für Osteosynthesefragen classification, fracture location and plate working length) did not influence progression to non-union.

Treating multifocal humerus fractures: A comparison between the mipo technique and intramedullary nailing

INTRODUCTION AND OBJECTIVE

Proximal humerus fractures with metaphysodiaphyseal extension represent a challenge for the orthopedic surgeon due to their reduced incidence and the difficulty in the treatment decision. These can be treated with an intramedullary nail or using the MIPO technique, associating different advantages and complications depending on the procedure. The objective of this study was to compare metaphyseal-diaphyseal fractures of the humerus treated with antegrade intramedullary nailing and those operated using the MIPO technique to see if there were significant differences in terms of functional, clinical, and radiological results.

MATERIAL AND METHODS

retrospective, analytical and unicentric review of 29 patients with proximal fracture with metaphyseal-diaphyseal extension treated by MIPO technique and 33 patients surgically treated by antegrade intramedullary nailing (IMN) in our hospital from 2014 to 2020. Demographic, functional, radiographic and clinical data were obtained..

RESULTS

No significant differences were observed between both groups in terms of fracture mechanism (p=0.34), fracture type (p=0.13) or Maresca classification (p=0.32). Surgical time was significantly shorter in the IMN group compared to the MIPO technique (p=0.014). No significant difference was observed regarding the need for blood transfusion (p=0.32). The mean consolidation in the MIPO group was 21 weeks compared to 21 weeks in the IMN, with no significant differences between both groups (p= 0.88). No significant differences were observed between CONSTANT test at one year in the MIPO group versus the IMN group (p=0.79), nor in radial nerve palsies (p=0.28).

CONCLUSIONS

Proximal fractures with metaphyseal-diaphyseal extension are a challenge for the orthopedic surgeon due to the infrequency, the complexity of these fractures and the fact that there is no established consensus on the ideal treatment for this type of injury. Both the MIPO technique with the Philos plate and the intramedullary nail are valid options for the treatment of these fractures, with no differences observed in terms of fracture consolidation time or in terms of functional results.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

WHICH SURGICAL TREATMENT IS PREFERABLE IN HUMERAL DIAPHYSEAL FRACTURES? A SYSTEMATIC REVIEW

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.

Assessment of Shoulder Function after Internal Fixation of Humeral Diaphyseal Fractures in Young Adults: A Prospective Comparative Study

BACKGROUND

Humeral shaft fractures are commonly encountered in casualties. There are different methods of operative internal fixation with no consensus on the best technique. The objective of this study was to assess shoulder function and rate of complications among two different options of fixation, intramedullary nailing, and minimal invasive plate osteosynthesis (MIPO) in young adults.

METHODS

Forty-two patients with humeral shaft fractures were included in the study and divided into two equal groups: group A treated with antegrade intramedullary locked nails (IMN) and group B with MIPO. Fracture union was evaluated with serial X-rays, and shoulder function was assessed in both groups using the scale of the American Shoulder and Elbow Surgeons (ASES), University of California at Los Angeles Shoulder Scale (UCLA), and visual analog score (VAS). The mean differences between groups were recorded and considered significant if the P value was ˂0.05.

RESULTS

The results were reported prospectively with no significant differences in mean age, sex, side of injury, type of fracture, mechanism of injury, and the follow-up period between the groups studied. Group A had shorter operative time and minimal blood loss than group B. Regarding shoulder function scores (ASES, UCLA, and VAS), the results in the MIPO group were better than the IMN group with shorter time of union and fewer complications.

CONCLUSION

Despite a shorter operative time and lower blood loss during locked intramedullary nail fixation in the management of humeral shaft fractures, MIPO enables more superior shoulder function with better fracture healing and lower morbidities.

Anterior Minimally Invasive Plate Osteosynthesis for Humeral Shaft Fractures Is Safer Than Open Reduction Internal Fixation: A Matched Case-Controlled Comparison

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.

MIPO versus nailing for humeral shaft fractures: a meta-analysis and systematic review of randomised clinical trials and observational studies

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.

Comparison between osteosynthesis with interlocking nail and minimally invasive plating for proximal- and middle-thirds of humeral shaft fractures

PURPOSE

Options for the treatment of proximal- and middle-thirds of humeral shaft fractures include intramedullary interlocking nail (IMN) and minimally invasive plate osteosynthesis (MIPO). However, whether IMN provides better clinical outcomes than MIPO surgical technique still remains unclear. This study was designed to compare clinical outcomes of the IMN with MIPO technique for the treatment of proximal- and middle-thirds of humeral shaft fractures.

METHOD

A retrospective cohort analysis of 55 proximal- and middle-thirds of humeral shaft fractures surgically treated using IMN (n = 25) or MIPO (n = 30) from January 2012 to January 2016. Peri-operative and follow-up data (a minimum of 1 year) of the patients (aged from 18 to 56 years) were collected. Operative time, union time, VAS scores, surgery-related complications, and implant removal rate were compared between the two groups in this study. Besides, the functional outcomes were evaluated using the Rating Scale of American Shoulder and Elbow Surgeons' Form (ASES) and Mayo Elbow Performance Score System (MEPS).

RESULT

We found significantly shorter operative time and much less blood loss in IMN group, and lower VAS scores in the IMN group after surgery at first and third months but not at the sixth month. Complication rate was found to be relatively higher in the MIPO group when compared to the IMN group. No significant difference was observed between these two groups regarding ASES and MEPS scores. Three patients in the MIPO group suffered iatrogenic radial nerve injury and recovered after four to five months later. No implant failures occurred in either group.

CONCLUSION

Intramedullary interlocking nail seemed to be superior to minimally invasive plate osteosynthesis in the treatment of proximal- and middle-thirds of humeral shaft fractures due to shorter operative time and union time, less early post-operative pain, and fewer complications. The intramedullary interlocking nail could be considered a better surgical option for the management of proximal middle humeral fractures, though it may also depend on the surgeons' skills and learning curve. Further in-depth prospective studies are in great need to verify our conclusion.

Intramedullary Nailing and Minimally Invasive Percutaneous Plate Osteosynthesis in Treatment of Displaced Clavicular Mid-shaft Fractures: A Prospective Study

OBJECTIVE

To compare the difference between MIPO and IMN methods in the treatment of displaced clavicular mid-shaft fractures.

METHODS

A total 163 patients were consecutively enrolled and randomly divided into the MIPO group or the IMN group. Clinical characteristics and outcomes including age, gender, causes of fractures, and AO/OTA type as well as hospitalization time, healing time, and postoperative complications were analyzed. Constant-Murley scores and DASH scores were used for assessment of shoulder joint and upper extremity function, respectively.

RESULTS

In this study, 82 cases received MIPO and 81 cases received IMN. The mean operation time, mean bleeding volume, mean hospitalization time, and mean healing time showed no significant difference between the MIPO and IMN groups. At 3 months after surgery, Constant-Murley scores were significantly higher and DASH scores were significantly lower in the MIPO group than the IMN group. No significant difference was observed for both indexes at 6 months. The fracture nonunion rate was significantly lower in the MIPO group. No significant difference was found in other complications.

CONCLUSION

Both methods were effective for the treatment of displaced clavicular mid-shaft fractures. However, the MIPO method might be better for recovery of shoulder and upper extremity function in the short term and might have a lower nonunion rate.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Non-hip/non-vertebral fractures - How to treat best?

Fractures of the extremities in the elderly constitute more than two-thirds of all fragility fractures befalling frail, osteoporotic and sarcopenic patients. Although treatment controversies abound, consensus exists. Upper extremity fractures hinder activities of daily living and are debilitating. Open fractures or displaced fractures will need surgical intervention. Wrist fractures treated operatively allow early use of the hand. Most pelvic fractures are treated conservatively. In the lower extremities, fractures of the long bones, tibia and femur need surgical intervention. Non-displaced fractures around the foot may be treated with immobilisation and avoidance of full weight-bearing. As a rule, fractures take four months for consolidation. Individually tailored solutions are needed for frail patients with comorbidities. Maintaining joint mobility and muscle strength preserves mobility and autonomy. Caring for extremities trauma is team work, involving family and health care providers. Prevention efforts are mandatory.

Minimally Invasive Plate Osteosynthesis of Humeral Shaft Fractures: Current State of the Art

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.

Lateral Subcutaneous Locking Compression Plate and Small Incision Reduction for Distal-third Diaphyseal Humerus Fractures

Objective

Iatrogenic radial nerve injury is a great challenge for orthopaedic surgeons who deal with distal‐third diaphyseal humerus fractures. Conventional open reduction and internal fixation (ORIF) remains the gold standard, but complications such as nonunion and iatrogenic radial nerve injury still occur. We fixed the fractures with a lateral locking compression plate (LCP) subcutaneously after small incision reduction to protect the radial nerve. This study reports the clinical and radiographic outcomes of our modified method.

Methods

Thirty‐eight patients with distal‐third diaphyseal humerus fractures were treated with lateral subcutaneous LCP and small incision reduction at our department between September 2013 and August 2016. There were 33 males and 5 females, with an average age of 30.3 years (range, 17 to 49 years). All the cases were types A or B (AO/OTA classification, type A, 24 cases; type B, 14 cases). Among them, 6 cases were combined with preoperative radial nerve palsy. All patients were diagnosed with closed humeral fractures after X‐ray examination, and had typical upper limb pain, swelling, and movement disorders. The operations were performed by a single surgeons’ team. Union time, range of motion (ROM), University of California, Los Angeles (UCLA) shoulder rating scale, and Mayo Elbow Performance Index (MEPI) scores were assessed to evaluate the postoperative results.

Results

All patients were followed up for an average of 11.4 months (range, 3 to 36 months). The average operation time was 75.5 min (range, 60 to 150 min) and average intraoperative radiation exposure was 10.5 s (range, 8 to 18 s). Bony union was achieved in all cases after an average of 16.2 weeks (range, 12 to 25 weeks). No complications such as infection or screw and plate fracture occurred, and no iatrogenic radial nerve injury was observed. According to the UCLA shoulder rating scale, the average score was 33.7 (range, 31 to 35), with 33 excellent (86.8%) and 5 good cases (13.2%). They were all excellent according to their MEPI scores (ranging, 94 to 100, with an average of 97.4). The average operation time for secondary removal of the plate was 15.2 min (range, 10 to 20 min), and no complications such as infection or secondary radial nerve injury occurred.

Conclusions

Lateral subcutaneous LCP and small incision reduction may reduce the risk of iatrogenic radial nerve injury significantly in the treatment of distal‐third diaphyseal humerus fractures. It also leads to solid fixation, good postoperative function, and convenient removal of the plate without injuring the radial nerve.

Interventions for humeral shaft fractures: mixed treatment comparisons of clinical trials

We designed a study to compare the efficacy of five main therapeutic options, including external fixation, open reduction and plate osteosynthesis (ORPO), minimally invasive plate osteosynthesis (MIPO), dynamic compression plate (DCP), and intramedullary nail (IMN) in treating humeral shaft fractures. Our results indicated that MIPO and IMN were recommended as the optimal treatments for clinical use.

PURPOSE

Nowadays, five main therapeutic options are used in treating humeral shaft fractures: external fixation, open reduction and plate osteosynthesis (ORPO), minimally invasive plate osteosynthesis (MIPO), dynamic compression plate (DCP), and intramedullary nail (IMN). Aiming to provide reliable evidence for clinical selection, we designed a network meta-analysis (NMA) to evaluate the efficacy of these treatments.

METHODS

NMA was conducted on Bayesian framework with software R 3.3.2 and STATA 13.0. Nonunion rate, radial nerve palsy rate, union time, complication rate, and infection rate were considered as primary outcomes. Mean operation time was the secondary outcome. The outcomes were measured by odds ratio (OR) value and corresponding 95% credible intervals (CrIs) or mean difference (MD) with 95% CrIs. Surface under cumulative ranking curve (SUCRA) was calculated to show the ranking probability of each treatment.

RESULTS

Our results indicated that ORPO had a higher risk of radial nerve palsy than MIPO (OR = 2.83, 95% CrIs = 1.28-6.23), and DCP had a better performance in preventing complications than IMN (OR = 0.31, 95% CrIs = 0.11-0.84); no other significant difference were observed. According to the SUCRA results, MIPO had a high-ranking probability in almost all outcomes, while external fixation had lowest values in the majority of outcomes.

CONCLUSIONS

We recommended MIPO as the optimal treatment for humeral shaft fractures after taking all outcomes into consideration; IMN was also recommended for its relatively good performance, but its complication still needed to be noticed.

Comparison between antegrade intramedullary nailing (IMN), open reduction plate osteosynthesis (ORPO) and minimally invasive plate osteosynthesis (MIPO) in treatment of humerus diaphyseal fractures

INTRODUCTION

The three currently used methods of treatment: namely open reduction plate osteosynthesis (ORPO), Minimally invasive plate osteosynthesis (MIPO), antegrade intramedullary nailing(IMN) are all reported as satisfactory procedures for treatment of humeral shaft fractures. However none of the published reports have a comparison of superiority of one procedure over the other. We evaluated the clinical, radiological and functional outcome of the three procedures.

MATERIALS AND METHODS

We studied adult patients with humerus shaft fractures over a period of 2 years from May 2014 to May 2016 in a level 1 trauma center. Forty-four were treated with IMN, 34 treated with ORPO, and 34 with MIPO. The null hypothesis tested in this study is that there is no difference between IMN, ORPO, MIPO with respect to union time, surgical time, complication rate, non-union rate and functional outcome. Functional outcome was studied by comparing the UCLA shoulder and MEP scores in the three groups.

RESULTS

112 patients were studied consisting of 83 males and 29 females with mean age of 39 years (range 18-70). IMN group showed early union with mean of 12.73 weeks compared to MIPO (14.45 weeks) and ORPO(13.58 weeks), (p<0.05). MIPO had no events of non-union, as compared to ORPO (5 non-unions) and IMN (10 non-unions), (p=0.04). The range of movement at the shoulder with the UCLA score was significantly better with a score of 32.26 in MIPO as compared to 27.54 in IMN and 28.82 in ORPO (p<0.05). The difference in MEPS score in the three groups was not significant (p=0.31). IMN required a mean of 117.95 minutes intraoperatively as compared to 131 and 150.58 mins in MIPO, ORPO respectively.

CONCLUSION

MIPO is overall better with respect to non-union, functional outcome and complications rate. The surgical time depends on the surgeons' skill and learning curve. Thus considering the advantages and risks involved in the various procedure and surgical acumen, each case should be individualized to have a good outcome. We advocate that MIPO can be safely used as an alternative in treating these fractures.