Management of Humeral Shaft Fractures With Intramedullary Interlocking Nail Versus Locking Compression Plate

Compression nailing versus compression plating for management of diaphyseal fractures of the humerus: A prospective cohort study

Background

Compression plate osteosynthesis is the preferred treatment for diaphyseal humerus fractures. In contrast, intramedullary interlocking nailing offers many advantages but lacks in providing compression across the fracture site. We aimed to do a prospective cohort study to compare the compression plating (CP) technique with the novel compression nailing (CN) technique for diaphyseal humeral fractures.

Methods

The study was performed with a total of 32 patients included in the study, who were further divided into two groups: Group CN (n = 16) and Group CP (n = 16). An external compression device was used along with a standard antegrade humeral nailing system to achieve compression across the fracture site. The Rodriguez-Merchan criteria and the American Shoulder and Elbow Surgeons (ASES) score at six months were used for the functional evaluation in these patients.

Results

In this study cohort, the mean age was 35 ± 12.02 years. The total mean operative time was 85.86 ± 10.62 min for Group CN and 87.69 ± 3.82 min for Group CP (p value = 0.48, student 't' test), and the total mean blood loss during surgery was 81.25 ± 9.21 ml for Group CN and 202.88 ± 16.86 ml for Group CP (p value = 0.001, student 't' test). The mean duration of follow-up in Group CN was 31.31 ± 7.99 weeks, while in Group CP it was 31.56 ± 7.30 weeks. According to Rodriguez-Merchan criteria, 12 had (75 %) excellent, three (18.75 %) had moderate, and one (6.25 %) had poor results. Whereas in Group CP, there were 13 (81.25 %) excellent results, two (12.5 %) moderate results, and one (6.25 %) poor result (p-value = 0.887, chi-square test).

Conclusion

The compression nailing group was found to have an upper hand in terms of significantly less blood loss and less soft tissue dissection required as compared to compression plating. With compression nailing, we were able to achieve controlled compression across the fracture site.

Mechanical study of the safe distance between humerus shaft fracture and distal locking screws in antegrade nailing

BACKGROUND

Optimal positioning of distal locking screws in intramedullary humeral nailing remains uncertain, particularly the influence of the distance between the fracture plane and the proximal distal locking screw on construct stability. This study aims to evaluate the mechanical stability of humeral nailing under different fracture-to-screw distances and numbers of distal locking screws using finite element analysis and mechanical testing on bone models.

METHODS

A finite element model and mechanical testing on six sawbones models were performed under traction (500 N), compression (500 N), and torsion (3 Nm). Models were tested with two osteotomy distances from the proximal distal locking screw (2 cm and 5 cm) and with either one or two distal locking screws. Axial and torsional stiffness and fracture displacement were recorded and analyzed statistically.

RESULTS

Finite element analysis showed higher stress concentrations near the distal fracture fragment. Mechanical testing demonstrated that traction and torsional stability were significantly affected by fracture-to-screw distance (p = 0.006 and p = 0.015), while compression stability was influenced by the number of distal screws (p = 0.035).

CONCLUSION

A fracture-to-screw distance of 5 cm was associated with improved axial and torsional stability, while double distal screws enhanced compressive stiffness. These biomechanical results, although very promising, should be confirmed with clinical studies.

Mechanical evaluation for the finite element analysis of intramedullary nailing and plate screw system used in humerus transverse fractures

Aim

This study aims to examine the commonly used plate screw system and intramedullary nailing method in osteosynthesis in humeral shaft fractures in terms of stress shielding using finite element analysis.

Material and methods

Images were obtained by computerized tomography (CT) to create a 3D model of the humerus bone. After the CT images were transferred to the ANSYS 2021 R2 program (ANSYS, Inc., Canons-burg, PA), a transverse fracture model was created from the shaft region of the humeral bone meshed to the humerus bone and modeled in the 3D environment.

Results

The tetrahedron mesh structure was used for the finite element models in our study. The element size was chosen as 3.5 mm for the bone model and 2 mm for the plate and intramedullary nail models. The node numbers of bone, intramedullary nail, and plate were 91230, 462578, and 581352, respectively. The element numbers of bone, intramedullary nail, and plate were 61350, 311285, and 370350, respectively. Maximum stress values of 260 MPa on the nail and 280 MPa on the plate were detected in this study.

Conclusion

Fewer stress values were obtained and stress concentrations were not formed on the implant in osteosynthesis performed by intramedullary nailing. It can be concluded that this study may guide further studies for those focusing on it and may contribute to the development of a more comprehensive understanding of the topic.

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

HYPOTHESIS

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

METHODS

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

RESULTS

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

CONCLUSION

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

Different treatment for humeral shaft fractures: A network meta-analysis

BACKGROUND

The main treatment methods for humeral shaft fractures include minimally invasive plate osteosynthesis (MIPO), intramedullary nailing (IMN), open reduction and internal fixation (ORF), and non-operative treatment (NonOP). However, the optimal treatment plan remains unclear. This article utilizes a network meta-analysis to compare the therapeutic effects of MIPO, IMN, ORF, and NonOP for the treatment of humeral shaft fractures.

METHODS

We searched electronic databases, including the PubMed, Embase, The Cochrane Library, and the Web of Science Databases, from inception to June 1, 2024. The "Risk of Bias Assessment" tool recommended by the Cochrane Collaboration was used to evaluate the quality of the included literature. RevMan 5.4 software and R software with gemtc package was used for the graphical representation and data analysis of the network meta-analysis.

RESULTS

A total of 23 randomized controlled trials were finally included. The results indicated that the efficacy of disabilities of the arm, shoulder and hand score was significantly higher in the MIPO group than in the open reduction and internal fixation (ORIF) group (weighted mean difference = 4.7, 95% confidence intervals, 1.8-7.75). IMN was associated with a decrease of the constant-Murley scores score than NonOP (weighted mean difference = -4.4, 95% confidence intervals, -8.7 to -0.068). IMN, MIPO, and ORIF was associated with a decrease of the fracture healing time than NonOP. The difference for nonunion rate and iatrogenic radial nerve injuries between any 2 groups was not statistically significant (P > .05).

CONCLUSION

The evidence from current meta-analysis indicated that ORIF provides the best recovery effects for upper limb and shoulder joint function after the treatment of humeral shaft fractures, with the drawback of a relatively higher incidence of complications. To ensure the reliability of this study's results, more high-quality randomized controlled trials are needed in the future to verify these findings.

IlluminOss photodynamic bone stabilization system improves pain and function in the treatment of humeral metastatic disease

Aims

The aim of the LightFix Trial was to evaluate the clinical outcomes for one year after the treatment of impending and completed pathological fractures of the humerus using the IlluminOss System (IS), and to analyze the performance of this device.

Methods

A total of 81 patients with an impending or completed pathological fracture were enrolled in a multicentre, open label single cohort study and treated with IS. Inclusion criteria were visual analogue scale (VAS) Pain Scores > 60 mm/100 mm and Mirels' Score ≥ 8. VAS pain, Musculoskeletal Tumor Society (MSTS) Upper Limb Function, and The European Organization for Research and Treatment of Cancer QoL Group Bone Metastases Module (QLQ-BM22) scores were all normalized to 100, and radiographs were obtained at baseline and at 14, 30, 90, 180, and 360 days postoperatively.

Results

The mean VAS pain score decreased significantly from 84 (SD 15) to 50 (SD 29), 38 (SD 30), 31 (SD 29), 31 (SD 29), and 21 (SD 23) between the baseline and follow-up times (p < 0.001). The mean MSTS function scores significantly increased from 27 (SD 19) to 52 (SD 22), 60 (23), 67 (SD 23), 72 (SD 26), and 83 (SD 14) (p < 0.001). The pain and functional subscales of the QLQ-BM22 also significantly improved at most times. A total of 12 devices broke, giving an unadjusted device fracture rate of 15%.

Conclusion

Stabilization with the IS decreased pain and improved function with consistent results during the first postoperative year. IS is a new, minimally invasive type of internal fixation. The use of the IS alone may be better for impending rather than completed pathological fractures, and may be better in completed fractures if an added plate or more than the usual number of locking screws is required. Caution is warranted regarding its use alone in patients with a completed pathological fracture due to the rate of breakage of the device.

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.

Management of Humeral Shaft Fracture: A Network Meta-Analysis of Individual Treatment Modalities

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.

Displaced humeral shaft fractures: Assessment of fracture union and complications following dual plate fixation using an anterior approach

The humeral bone is subject to torsional forces. In case of displaced shaft fractures, internal fixation remains the standard of care. This retrospective two-center study assessed the fracture union rate and complications after dual 3.5 mm locking compression plate (LCP) fixation using an anterolateral approach. Over a 9-year period, 38 patients underwent surgery in two centers. They had a mean age of 53.7 years (15-97, ± standard deviation (SD) 26) and there were three open fracture cases (7.9 %). The dominant side was affected in 21 cases (55.3 %) and there were 11 polytrauma patients (29 %). Mean operative time was 78 min (40-124, ± 19.8 SD). Patients were treated with dual 3.5 mm LCP fixation (6 screws on either side of the fracture line, anterolateral approach without a tourniquet). The first two orthogonal views showing at least 3 cortical bridges out of 4 determined fracture healing, as assessed by two independent raters. Pre- and postoperative complications were tabulated. Clinical outcomes included range of motion (ROM) and return to activities, while functional outcomes were assessed with the Disability of the Arm Shoulder and Hand (DASH), the Constant score, the Subjective Shoulder Score (SSV) and the Mayo Elbow Performance Score (MEPS). Minimum follow-up was 1 year. Four patients were given a shoulder immobilizer to wear for 3 weeks; immediate mobilization was the standard of care for the other patients. Fracture union was achieved in all cases within a mean of 11.7 weeks (6-28 ± 7.1 SD) without any heterotopic ossification of the brachialis muscle. There were eight patients with preoperative radial nerve palsy and two cases of postoperative palsy. There was one surgical site infection (2.6 %). Return to work for active patients was possible in 87 % of cases within a mean of 23 weeks (6-72 ± 11 SD). The Constant score was 84.6 (35-100, ± 13.4 SD), the SSV score was 80.7 (60-100, ± 8.2 SD), the DASH score was 13.5 (0-38.3, ± 8.8 SD) and the MEPS score was 85 (55-100, ± 11.9 SD). Traditional fixation methods provide little control over torsional forces, leading to non-union rates between 3 % and 12 % and delayed union (12 to 20 weeks). The simplicity of the technique described here, and the short operative time, may help explain the low infection rate. Dual plate fixation makes it possible to use more screws and allows nerve exploration and decompression in case of preoperative nerve palsy. Dual plate fixation to treat humeral shaft fractures is a simple and reliable technique.

Dynamic Compression Plating Versus Antegrade Intramedullary Nailing for the Treatment of OTA/AO 12-A Fractures: A Retrospective Cohort Study

BACKGROUND

Fractures of the humerus diaphysis are common and often result from motor vehicle accidents (MVAs). Treatment methods range from nonoperative approaches to various operative techniques, including antegrade intramedullary nailing (AIMN) and dynamic compression plate (DCP) fixation. This study aimed to compare the cost effectiveness and outcomes of plating and nailing for humerus diaphyseal fractures.

METHODS

 A retrospective cohort study involving 59 cases of humerus diaphyseal OTA/AO 12-A fractures was conducted at King Saud Medical City (KSMC), a level I trauma center located in the center region in Riyadh, Saudi Arabia. Patients treated with AIMN, anterolateral plating, or posterior plating were included. Data on demographics, clinical parameters, radiographic healing, and costs were collected and analyzed.

RESULTS

The average surgical duration was shorter in the AIMN group compared to the anterolateral and posterior plating groups but with no statistical significance (P > 0.05). The average length of stay (LOS) was shorter, and the change in hemoglobin levels was lower in the AIMN group when compared to other groups but without a statistically significant difference (P > 0.05). The average cost of AIMN was significantly higher than that of anterolateral and posterior plating groups (P < 0.0001).

CONCLUSION

 While both nailing and plating procedures are options for treating OTA/AO 12-A fractures, AIMN carries a higher overall procedural cost. The practice of drain placement in our study population is likely the cause of the increased LOS in the plating groups. Relative additional analgesic requirements were associated with AIMN. Surgeons should consider meticulous hemostasis to avoid drain placement, which can decrease LOS, thus possibly decreasing unnecessary treatment costs of humerus shaft fractures.

Intramedullary nailing vs. open reduction-internal fixation for humeral shaft fractures: a meta-analysis of randomized controlled trials

BACKGROUND

The purpose of this study was to perform a meta-analysis of randomized controlled trials (RCTs) to compare outcomes following intramedullary nailing (IMN) vs. open reduction-internal fixation (ORIF) for humeral shaft fractures.

METHODS

A literature search of 3 databases was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. RCTs comparing IMN and ORIF for humeral shaft fractures were included. Clinical outcomes were compared using RevMan. P < .05 was considered statistically significant.

RESULTS

Ten RCTs with 512 patients were included. Overall, 8.4% of patients treated with IMN and 6.4% of patients treated with ORIF had nonunion (P = .57, I2 = 0%), with a significantly faster time to union with IMN (10 weeks vs. 11.9 weeks, P < .05). There was no significant difference in the rate of reoperation (11.6% in IMN group vs. 7.6% in ORIF group, P = .26) or radial nerve palsy (2.8% in IMN group vs. 4.2% in ORIF group, P = .58). A lower rate of infection was noted with IMN (1.2% vs. 5.3%, P < .05). Additionally, there was a lower operative time with IMN (61 minutes vs. 88 minutes, P < .05).

CONCLUSIONS

The Level I evidence in the literature does not show a significant difference in rates of union, reoperation, or radial nerve palsy between IMN and ORIF for humeral shaft fractures. Overall, treatment with IMN results in a lower infection rate, less operative time, and a modestly quicker time to union. The optimal treatment strategy for humeral shaft fractures may be best informed by fracture pattern and surgeon preference.

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.

Conservative Management with Functional Brace Versus Various Surgical Fixation Techniques for Humeral Shaft Fractures: A Network Meta-Analysis

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.

Treatment of humeral shaft fractures with different treatment methods: a network meta-analysis of randomized controlled trials

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.

Evaluation of Humeral Shaft Fracture Outcomes by Treatment Method: A Systematic Review and Meta-analysis Based on Comparison Studies

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.

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.

The standardized exploration of the radial nerve during humeral shaft fixation reduces the incidence of iatrogenic palsy

BACKGROUND

The purpose of this study is to determine if a standardized protocol for radial nerve handling during humeral shaft repair reduces the incidence of iatrogenic nerve palsy post operatively.

METHODS

Seventy-three patients were identified who underwent acute or reconstructive humeral shaft repair with radial nerve exploration as part of the primary procedure for either humeral shaft fracture or nonunion. All patients exhibited intact radial nerve function pre-operatively. A retrospective chart review and analysis identified patients who developed a secondary radial nerve palsy post-operatively. In each case, the radial nerve was identified and mobilized for protection, regardless of whether the implant necessitated the extensile exposure.

RESULTS

Fractures were classified according to AO/OTA guidelines and included 23 Type 12A, 11 Type 12B, and 3 Type 12C. Eight patients had periprosthetic fractures and 28 fractures could not be classified. All patients in the cohort were fixed with locking plates. Surgery was indicated for 36 patients with humeral nonunions and 37 patients with acute humeral shaft fractures. Of the 73 patients, 2 (2.7%) developed radial nerve palsy following surgery, one from the posterior approach and one from the anterolateral approach. Both patients exhibited complete recovery of radial nerve function by 6-month follow-up. No significant differences (p > 0.05) were found in any demographic or surgical details between those with and without radial nerve injury.

CONCLUSIONS

Nerve exploration identification and protection leads to a low incidence of transient radial nerve palsy compared to the rate reported in the current literature (2.7% compared to 6-24%). Thus, radial nerve exploration and mobilization should be considered when approaching the humeral shaft for acute fracture and nonunion repairs.

LEVEL OF EVIDENCE

Level III.

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.

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.

Fragility of statistically significant findings from randomized clinical trials of surgical treatment of humeral shaft fractures: A systematic review

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.

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.

Surgical Anatomy of the Radial Nerve at the Dorsal Region of the Humerus: A Cadaveric Study

BACKGROUND

Surgery for humeral shaft fractures is associated with a high risk of iatrogenic radial nerve palsy (RNP). Plausible causes are difficult anatomical conditions and variants.

METHODS

We performed a cadaveric study with 23 specimens (13 female and 10 male Caucasian donors) to assess the course and anatomy of the radial nerve (RN) with its branches alongside the humeral shaft. The accuracy of identification of the RN in the surgical field was analyzed by measuring the location, course, diameter, and form of each nerve and vessel of interest.

RESULTS

The RN is not a single structure running alongside the humeral shaft; at least 4 parallel structures crossed the dorsal humerus in all subjects. The RN was accompanied by 2 vessels and at least 1 other nerve, which we named the musculocutaneous branch (MCB). With an oval profile and an average diameter of 3.1 mm (range, 2.6 to 3.8 mm), the MCB was thinner but, in some cases, close to the average diameter of 4.7 mm (range, 4.0 to 5.2 mm) of the RN, which had a round profile. Both accompanying vessels had similar diameters: 3.5 mm (range, 2.6 to 4.2 mm) for the radial collateral artery and 4.0 mm (range, 2.9 to 4.4 mm) for the medial collateral artery. In 20 (87%) of the cases, the RN ran proximal to and in 3 (13%) of the cases, distal to the MCB. Furthermore, a distal safe zone of at least 110 mm (range, 110 to 160 mm) was found, measured from the radial (lateral) epicondyle proximally.

CONCLUSIONS

The RN does not cross the dorsal humerus alone, as often stated in anatomical textbooks, but runs parallel to vessels and at least 1 nerve branch with a similar appearance. Thus, for reliable preservation of the RN, we recommend identification and protection of all crossing structures in posterior humeral surgeries 110 mm proximal to the radial epicondyle.

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

Objective

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

Methods

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

Results

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

Conclusion

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

Antegrade intramedullary locking nail in the management of proximal and middle thirds of humeral diaphyseal fractures

PURPOSE

The aim of the study was to evaluate the antegrade intramedullary locking nail osteosynthesis for the treatment of the proximal and middle thirds of humeral shaft fractures.

METHODS

A retrospective study was made on 218 patients diagnosed with humeral diaphysis fractures who undergo surgery with antegrade intramedullary locking nail between January 2017 and December 2021. The clinical follow-up started two days after surgery and continued at one month, three months, six months and one year. The functional recovery evaluation was performed using visual analogue scale (VAS) score, Rating Scale of American Shoulder and Elbow Surgeons Form (ASES), Mayo Elbow Performance Score System (MEPS) and rate of complications.

RESULTS

Low intra-operative blood loss, short operation time, short hospitalisation, early mobilisation of the patient and high union rate imposed intramedullary nailing as a standard procedure for the treatment of proximal and middle thirds of humeral diaphyseal fractures in the past years, and the union rate was 99.5%. VAS score evaluated at one month, three months and six months indicated a very good overall post-operative experience. The ASES and MEPS score were evaluated at six months and one year and showed excellent results. All the patients (except 1 case) were able to return to their previous jobs within six months.

CONCLUSION

Humeral nailing is associated with early return to function of the upper limb, with very good clinical and functional outcomes of the shoulder and elbow. This method could be considered the best surgical option for the management of proximal middle humeral fractures.

The management of displaced humeral shaft fractures - A survey of UK shoulder and elbow surgeons

Introduction

Indications for surgical management of displaced humeral shaft fractures are not clearly established, leading to variations in practice. The aim of this study was to determine the scale of these variations in the UK practice to help design a future national trial.

Methods

An online survey was sent to all surgeon members of British Elbow and Shoulder Society to help define humeral shaft fractures, fracture displacement as well as indications for operative and non-operative management. Patient and injury related factors considered important when managing humeral shaft fractures were investigated.

Results

The survey achieved a response rate of 32% (104/327). There was a lack of consensus on definitions for humeral shaft fractures and fracture displacement. A functional brace was the most common form of non-operative treatment (63%). Majority immobilise humeral shaft fractures for 4-8 weeks or until callus are visible (62%) with a similar number considering operative treatment if adequate signs of healing are not present at around 12-16 weeks. Around half of our respondents exclusively use plates with variations in preference of approach and a minority (2%) exclusively use intra-medullary nails.

Conclusion

The significant variation in management of displaced humeral shaft fractures in the UK suggests a clear need to evaluate clinical and cost effectiveness through a multi-centre randomised trial.

Humeral Shaft Fractures: A Literature Review on Current Treatment Methods

In this review, we aim to provide a concise yet comprehensive summation of the assessment and management of humeral shaft fractures. These are uncommon but prevalent enough that they are part of any trauma surgeon's scope of practice. They have historically been treated using non-operative methods, including braces and casts, supported by published excellent results in the rate of the bone union. However, recently published studies challenge these results and suggest the outcomes might be better with surgery, but the complications of an operation such as infection and nerve injury can not be overlooked. In summary, non-surgical treatment is still the gold standard in the treatment of these fractures, but the indications for surgical management are now clearer and include early signs of delayed union and patients who are unable to have a brace fitted or are uncompliant. It is likely that these new developments will start to change practice, and therefore the treatment of humeral shaft fractures should be a topic of interest of any clinician who deals with them.

New ways of treatment of fractures of the humeral shaft: does the combination of intramedullary nail osteosynthesis and cerclage improve the healing process?

Introduction

The humeral shaft fracture is a rare fracture of the long bones with various treatment options. Dreaded complications such as lesions of the radial nerve or non-unions make the decision for what kind of therapy option more difficult. Biomechanically the upper arm is mostly exposed to rotational forces, which affect intramedullary nail osteosynthesis. Additive cerclage may compensate for these in spiral fractures. The aim of this study is to investigate what effect a combination of intramedullary nail osteosynthesis and limited invasive cerclage has on the rate of healing. In addition, this study addresses the question if complications arise as a result of cerclage.

Methods

In this retrospective study, 109 patients were evaluated, who, during a period of 6 years, underwent operative treatment of a humerus shaft fracture with a combination of intramedullary nail osteosynthesis and additive cerclage. The primary end point was to establish the rate of healing. A secondary end point was to evaluate complications such as infections and damage to the nerve. This was followed by an examination of patient files and X-ray images and a statistical analysis with SPSS.

Results and conclusion

The healing process shows a non-union rate of 2.6%, and complications such as secondary radial nerve lesions of 4.6%. The antegrade intramedullary nail osteosynthesis with limited invasive, additive cerclage reduces the risk of non-union and does not lead to an increased risk of iatrogenic damage to the radial nerve. Wound healing was not impaired and there were no infections through the cerclage in our patient cohort.

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.

Plates vs. nails in humeral shaft fractures: Do plates lead to a better shoulder function?

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.

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

PURPOSE

This meta-analysis compares open reduction and internal fixation with a plate (ORIF) versus nailing for humeral shaft fractures with regard to union, complications, general quality of life and shoulder/elbow function.

METHODS

PubMed/Medline/Embase/CENTRAL/CINAHL was searched for observational studies and randomised clinical trials (RCT). Effect estimates were pooled across studies using random effects models. Results were presented as weighted odds ratio (OR) or risk difference (RD) with corresponding 95% confidence interval (95% CI). Subgroup analysis was performed stratified for study design (RCTs and observational studies).

RESULTS

Eighteen observational studies (4906 patients) and ten RCT's (525 patients) were included. The pooled effect estimates of observational studies were similar to those obtained from RCT's. More patients treated with nailing required re-intervention (RD 2%; OR 2.0, 95% CI 1.0-3.8) with shoulder impingement being the most predominant indication (17%). Temporary radial nerve palsy secondary to operation occurred less frequently in the nailing group (RD 2%; OR 0.4, 95% CI 0.3-0.6). Notably, all but one of the radial nerve palsies resolved spontaneously in each groups. Nailing leads to a faster time to union (mean difference - 1.9 weeks, 95% CI - 2.9 to - 0.9), lower infection rate (RD 2%; OR 0.5, 95% CI 0.3-0.7) and shorter operation duration (mean difference - 26 min, 95% CI - 37 to - 14). No differences were found regarding non-union, general quality of life, functional shoulder scores, and total upper extremity scores.

CONCLUSION

Nailing carries a lower risk of infection, postoperative radial nerve palsy, has a shorter operation duration and possibly a shorter time to union. Shoulder impingement requiring re-intervention, however, is an inherent disadvantage of nail fixation. Notably, absolute differences are small and almost all patients with radial nerve palsy recovered spontaneously. Satisfactory results can be achieved with both treatment modalities.

[Antegrade and retrograde nailing of humeral shaft fractures]

OBJECTIVE

Restoring humeral shaft alignment using direct or indirect reduction techniques with subsequent intramedullary stabilisation with an antegrade or retrograde inserted humeral nail. Achieving osseous union and restoration of painfree upper arm function.

INDICATIONS

Antegrade: Humerus shaft fractures located in the proximal 2/3 of the humerus. Combined fractures of the ipsilateral proximal humerus and humerus shaft. Segmental fractures of the humerus shaft. Pathological fractures or osteolysis (palliative indication). Retrograde: Humerus shaft fractures located in the middle and distal part of the humerus diaphysis.

CONTRAINDICATIONS

Acute infection in the area of the surgical approach; polytrauma with acute life-threatening haemodynamic instability.

SURGICAL TECHNIQUE

In the antegrade technique: anterolateral acromial approach. Determination of the correct nail entry point on the humeral head. Incision of the rotator cuff with longitudinal split of the fibres. Closed or semi-open fracture reduction. Insertion of an intramedullary nail with an appropriate length and diameter. Interfragmentary compression when required. Proximal and distal static interlocking with at least 2 bolts on each side. In the retrograde technique, the nail is inserted after opening of the medullary cavity directly proximal to the olecranon fossa.

POSTOPERATIVE MANAGEMENT

Functional aftertreatment with passive and active-assisted exercises during the first 3 weeks. Subsequent active exercises avoiding forced rotation of the arm. Sports activities and severe stress are avoided for 3 months. Postoperative radiographs as well as after 2, 6 and 12 weeks.

RESULTS

Very good healing results with excellent clinical and radiological healing are achieved in more than 90% of cases after both antegrade and retrograde nailing. Intraoperative problems that have been reported in up to 40% of cases occurred mainly with former generation nails or were attributable to technical errors. Correspondingly, with the closed reduction technique postoperative infections are rare (< 3%). Undesirable distraction at the fracture site is successfully corrected by intraoperative interfragmentary compression. Success and complication rates after intramedullary nailing and plate fixation are not significantly different. Functional shoulder-related problems may occur after antegrade nailing, whereas elbow problems may occur after retrograde nailing.

Evaluation of the accuracy of the Sureshot® electromagnetic targeting system in distal locking of long-nailed humeral diaphyseal fractures

INTRODUCTION

Osteosynthesis of humeral diaphyseal fractures by long intramedullary nailing is a widespread practice. Distal interlocking is a delicate and uncertain step in the procedure, and the free-hand method is adopted by most surgeons. We evaluated the accuracy of a magnetic field-guided system for distal interlocking of long intramedullary nailed humeral diaphyseal fractures.

HYPOTHESIS

The field magnetic method to interlock distal screws procured satisfying success rates at first attempt in each hole.

STUDY DESIGN

Single center, retrospective, descriptive and continuous.

MATERIAL AND METHODS

We used the Sureshot® Distal Targeting System (DTS) and the Trigen® (Smith & Nephew) nail. All patients who presented to our center for osteosynthesis of a fracture of the humeral diaphysis by long intramedullary nailing between April 1, 2016 and June 30, 2018 were retrospectively included.

RESULTS

The analyses included 32 of the 34 patients who presented during this period (mean age, 64 years). There were 51 attempts to install distal interlocking screws. The screws were interlocked successfully in 40 cases (78.4%), and there were 11 failures (21.6%). There was an average of 29 fluoroscopic views and an average cumulative dose area product of 36.90 cGcm².

DISCUSSION

We found a lower success rate than that found in the literature for the accuracy of Sureshot® DTS in long humeral nailing. We found also a lower success rate than for tibial and femoral centromedullary nailing with this system. Our study showed a success rate of only 78.4% at the first attempt for distal interlocking of Trigen® humeral long nails.

LEVEL OF EVIDENCE

IV; retrospective study without control group.

Operation time effect on rates of perioperative complications after operative treatment of distal radius fractures

Purpose

The purpose is to identify the impact of operation time length on complications for patients undergoing operative treatment of distal radius fracture.

Methods

Patients who underwent operative treatments for distal radius fractures were identified in a national database. Data collected include patient demographic information, comorbidities, and complications.

Results

Operation time was found to be an independent predictor for return to the operating room. Operation time was not found to be a predictor of other postoperative complications.

Conclusion

Surgeons should work to shorten procedure duration whenever possible to minimize the risks that longer operative times can have on patient outcomes.

Radial nerve palsy associated with closed humeral shaft fractures: a systematic review of 1758 patients

BACKGROUND AND PURPOSE

Humeral shaft fractures are often associated with radial nerve palsy (RNP) (8-16%). The primary aim of this systematic review was to assess the incidence of primary and secondary RNP in closed humeral shaft fractures. The secondary aim was to compare the recovery rate of primary RNP and the incidence of secondary RNP between operative and non-operative treatment.

METHODS

A systematic literature search was performed in 'Trip Database', 'Embase' and 'PubMed' to identify original studies reporting on RNP in closed humeral shaft fractures. The Coleman Methodology Score was used to grade the quality of the studies. The incidence and recovery of RNP, fracture characteristics and treatment characteristics were extracted. Chi-square and Fisher exact tests were used to compare operative versus non-operative treatment.

RESULTS

Forty studies reporting on 1758 patients with closed humeral shaft fractures were included. The incidence of primary RNP was 10%. There was no difference in the recovery rate of primary RNP when comparing operative treatment with radial nerve exploration (98%) versus non-operative treatment (91%) (p = 0.29). The incidence of secondary RNP after operative and non-operative treatment was 4% and 0.4%, respectively (p < 0.01).

INTERPRETATION

One-in-ten patients with a closed humeral shaft fracture has an associated primary RNP, of which > 90% recovers without the need of (re-)intervention. No beneficial effect of early exploration on the recovery of primary RNP could be demonstrated when comparing patients managed non-operatively with those explored early. Patients managed operatively for closed humeral shaft fractures have a higher risk of developing secondary RNP.

LEVEL OF EVIDENCE

Level IV; Systematic Review.

Comparison of locking plates and intramedullary nails in treatment of three-part or four-part proximal humeral neck fractures in elderly population: A randomized trial protocol

BACKGROUND

Locking plate and intramedullary nail are two commonly applied methods to fix proximal humeral fractures. There are limited randomized studies that specifically evaluate the results of proximal humeral neck fractures with three-part or four-part treated by locking plates or intramedullary nails. Our goal was to compare functional outcomes, complications, and imaging features between the two groups.

METHODS

This single-center, prospective, randomized controlled test will be conducted in Tengzhou Central People's Hospital. Patients with these conditions will be included: age between 55 and 80 years; are able to communicate normally and agree to participate in our study; with the radiological evidence of proximal humeral fractures with three-part or four-part; surgical treatment was performed within twenty-one days after the acute fracture. Consecutive patients with proximal humeral fractures will be stochastic to be dealt with a locking plate or a bone nail. The informed consent will be acquired in each patients. Two groups will use the same postoperative rehabilitation protocol. Clinical outcomes include Intraoperative blood loss, operation time, Constant-Murley score, Disability, Arm, Shoulder and Hand score, shoulder range of motion (such as external rotation), and postoperative complications. The significance level was defaulted as P < .05.

RESULTS

This study will provide a solid theoretical basis for exploring which technique is better in treatment of 3-part or 4-part proximal humeral neck fractures in elderly population.

TRIAL REGISTRATION

This study protocol was registered in Research Registry (number: researchregistry6047).

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 versus a locking compression plate for humeral shaft fracture (AO/OTA 12-A and B): A retrospective study

INTRODUCTION

There has been great progress in surgical techniques for treating humeral shaft fractures over the past few decades. The purpose of this study was to compare the therapeutic effects of intramedullary nailing (IMN) and locking compression plate (LCP) for humeral shaft fractures (AO/OTA 12-A and B).

HYPOTHESIS

Compared with LCP, better therapeutic effects could be obtained with less invasive IMN.

MATERIALS AND METHODS

Patients with a humeral shaft fracture who received anterograde IMN or LCP fixation in our institution from December 2011 to June 2016 were reviewed in this study. They were divided into two groups according to the different fixation methods: Group A (IMN) and Group B (LCP). The surgical time, intraoperative blood loss, and complications of the patients were reviewed. Fracture healing was evaluated by radiographs performed at each follow-up. The functional outcome was assessed by the DASH (Disabilities of the Arm, Shoulder and Hand) scoring system at the final follow-up.

RESULTS

Thirty-four patients in Group A and forty-six patients in Group B were included in this study. Mean incision length and blood loss in Group B were greater than those in Group A (p<0.001). The average surgical times were 118.53minutes in Group A and 128.91minutes in Group B (p=0.114). The mean DASH scores were 23.76±16.78 in Group A and 22.37±15.18 in Group B (p=0.609). The complication rates were 8/34 in Group A and 7/46 in Group B, respectively (p=0.887).

DISCUSSION

The study hypothesis was partially confirmed. Although IMN was a less invasive technique, similar therapeutic results were obtained for humeral shaft fractures (AO/OTA 12-A and B) fixed with two surgical methods.

LEVELS OF EVIDENCE

III, retrospective comparative study.

Locking compression plate fixation versus intramedullary nailing of humeral shaft fractures: which one is better? A single-centre prospective randomized study

PURPOSE

To compare the radiological and clinical outcomes of interlocking nail (ILN) and locking plate fixation (LCP) for humeral shaft fractures.

METHODS

A total of 63 patients with displaced humeral shaft fractures between October 2014 and January 2017 were evaluated prospectively. They were divided randomly into two as LCP fixation (group 1) and interlocking nail (ILN) (group 2). Functional outcomes were evaluated using the Disabilities of the Arm, Shoulder, and Hand (DASH), American Shoulder and Elbow Surgeons (ASES), the University of California at Los Angeles (UCLA) shoulder scores, and Short Form-36 (SF-36) questionnaires, and pain was assessed with visual analogue scale (VAS).

RESULTS

After fracture callus was radiologically observed, DASH, ASES, and UCLA scores as well as SF-36 questionnaires and VAS results were noted to have no significant difference between the two groups (p = 0.109, p = 0.082, p = 0.146, p = 0.322, and p = 0.175, respectively). At the last follow-up (post-operative 24 months), the UCLA score was significantly better in group 1 (p = 0.034), whereas VAS result was significantly worse in group 2 (p = 0.017). DASH, ASES scores, and SF-36 questionnaires had no difference (p = 0.193, p = 0.088, p = 0.289). Other parameters revealed no significant differences. Fracture consolidation was observed at a mean of four months in both groups (3 to 7 months in group 1 and 3 to 8 months in group 2) (p = 0.189). Four patients in group 1 and five patients in group 2 underwent surgery for nonunion (p = 0.725). Post-operative radial nerve palsy was seen in one patient in group 2. Two patients in group 1 with superficial infection were treated with antibiotics, and they recovered.

CONCLUSIONS

Regarding our results, the LCP group had significantly better shoulder function than the ILN group, whereas the ILN group had significantly less pain, with similar complication rates. Therefore, both procedures are favourable surgical options for patients with humeral shaft fractures.

Plate fixation versus intramedullary nailing of proximal humerus fractures: an ACS NSQIP-based comparative analysis over 8 years

PURPOSE

The primary goal of this study was to compare the utilization of plate versus intramedullary nail (IMN) in the treatment of humerus fractures. Secondarily, we sought to examine whether any differences in demographics and clinical course of patients who receive a nail versus plate affect the procedure selection process.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was queried for patients surgically treated for a humeral shaft fracture from the years 2007-2015, using current procedural terminology (CPT) code. Patients with overlapping procedures, nonunion, polytrauma, and malignancy were excluded. The Charlson Comorbidity Index (CCI) was calculated to compare preoperative comorbidities. A two-sample Wilcoxon rank-sum (Mann-Whitney U) test was used to compare numerical values, whereas the Fisher exact and Chi-squared analyses were performed to compare categorical variables. A p value < 0.05 was considered significant. Preoperative variables with a p value < 0.05 and a clinical prevalence > 1%, indicating statistical and clinical significance, were included in a logistic regression for multivariate analysis to identify any independent predictors for procedure selection (IMN versus PF) based on preoperative patient characteristics.

RESULTS

During the study period plate fixation increased from 7 cases per year to 272 cases per year, while IMN increased from 8 cases per year to 80 cases per year. IMNs were mostly in older patients (63.85 vs 56.19 years, p < 0.001), and patients with a higher Charlson Comorbidity Index (CCI) (4.64 vs 2.79, p < 0.001). IMN was associated with shorter operation times (104 min vs 128 min, p < 0.001) and longer lengths of hospital stay (3.43d vs 2.78d, p < 0.001). No significant differences in overall complication rates were seen between patients who received IMN versus PF. However, the postoperative mortality rate was higher in patients who received IMN compared to PF (2.19% vs 0.40%, p < 0.01). Based on the regression analysis, patient age was the only independent patient factor demonstrated to predict the utilization of IMN over PF in older patients with humeral shaft fractures p = 0.043).

CONCLUSION

According to this NSQIP-based analysis, the rate of PF and IMN utilization increased in the treatment of humeral shaft fractures over a period of 8 years, but PF was performed at an overall a higher rate than IMN. Intramedullary nailing was preferred over PF in older patients with more comorbidities. The last possibly contributed to the higher 30-day mortality rate observed in patients who received IMN compared to PF.

LEVEL OF EVIDENCE III

Retrospective comparative study.

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.

Early post-operative outcomes of plate versus nail fixation for humeral shaft fractures

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.

Humeral shaft non-union in the elderly: Results with cortical graft plus stem cells

INTRODUCTION

Humeral shaft is a common site of fracture non-union. Biology and bone quality represent some of the problems that the orthopaedic surgeon has to face up in the elderly. The goals of treatment of humeral shaft non-union are the achievement of mechanical stability and creation of a favourable biologic environment. Bone graft and stem cells are some of the augmentation techniques available to reach these goals.

PURPOSE

Evaluation of the outcomes of humeral shaft non-union in elderly population treated with cortical allograft and stem cells.

MATERIAL AND METHODS

A cohort of 21 patients with humeral shaft non-union was reviewed. Inclusion criteria were patients aged more than 65 years, with a diagnosis of humeral shaft non-union treated with cortical allograft and stem cells. Primary endpoints were 'bone healing' and 'time-to-union'. Secondary endpoints were shoulder and elbow function and patients' quality of life with Oxford Shoulder Score (OSS), Constant score and EuroQol-5D (EQ-5D).

RESULTS

6 patients met the inclusion criteria. In 5 of them, the cortical allograft was opposite to a plate, whereas in the other one a "Sandwich" technique was chosen because of large osteolysis. 'Bone healing' occurred in all patients after a mean of 3.3 months (range 2-5). In all but two patients, the elbow range of motion was in almost normal range (15-130). The mean OSS was 35.8 (+/- 6.4), whereas the mean Constant was 53.3 (+/- 2.2). The mean EQ-5D index was 0.451 (+/- 0.21).

DISCUSSION

Bone healing occurred in all patients, with a time-to-union comparable or even better compared with other series. The use of cortical bone graft provide both stability and biological benefit, whereas stem cells improve the non-union environmental biology. Functional outcomes were lower than other series and patients' quality of life was similar to Italian elderly women.

CONCLUSION

The use cortical allograft with stem cells is a viable strategy to treat humeral shaft non-union in the elderly.

Outcome Assessment of Z-shaped Osteotomy in the Management of Humeral Shaft Nonunion Secondary to Failed Plate Osteosynthesis

Restoration of fracture alignment by osteotomy is crucial for the management of humeral nonunion. In the present study, we introduced a new way of osteotomy (Z-shaped) in treating humeral shaft nonunion secondary to failed plate osteosynthesis. Clinical data of 24 patients with humeral shaft nonunion following implant failure (from 2010 to 2014) were retrospectively evaluated. These patients underwent Z-shaped osteotomy in revision surgery after the initial surgery, plate osteosynthesis, was failed. Outcomes were evaluated using visual analogue scale (VAS) and Constant and Murley score. Repeated analysis of variance (ANOVA) was used for statistical analysis. Patients were followed up for a minimum of 24 months (26.83±4.33 months). The operative time was 102.33±10.16 min, and hospital stay averaged 9.75±2.13 days. All patients achieved clinical union at the latest follow-up. Complications included radial palsy (n=1) and superficial wound infection (n=1). The postoperative VAS scores decreased significantly compared to preoperative score (F=257.99, P<0.01). Constant and Murley score increased and reached 81.33±0.95 at 24 months' follow-up (F=247.35, P<0.01). Among all the cases, 15 cases were graded as "excellent", and 9 as "good". In conclusion, Z-shaped osteotomy was easy to perform, and it provided additional medial support with more bone contact areas. Revision surgery using locking plate and Z-shaped osteotomy achieved high union rate and improved functional outcome. It was a reasonable and safe option for treating humeral nonunion following implant failure.

Six-year experience with antegrade intramedullary nail for the treatment of proximal and diaphyseal humeral fractures

BACKGROUND

Proximal and shaft humeral fractures are very common worldwide; surgical treatment can be a viable option to reduce limb immobilization and to allow the patient an earlier return to daily activities. The aim of our study was to evaluate the outcomes of patients treated with intramedullary nail in our Institute from January 2010 to December 2016.

MATERIALS AND METHODS

This is an observational cohort study. Inclusion criteria were: traumatic proximal and diaphyseal humeral fractures treated with antegrade nail; a minimum follow-up of 6 months. We evaluated the fracture healing time, the functional recovery (using the Constant score) and postoperative complications (need of blood transfusion, infections and need of re-intervention). The t test was used for statistical analysis.

RESULTS

Ninety-five patients were included (20 proximal and 75 diaphyseal fractures). Bone callus formation was evident a mean of 57 days after surgery. In all patients, there was an improvement in the functional recovery over time, but those younger than 65 years had better outcomes. The type of fracture and patients' gender did not affect these results at one and 6 months of follow-up. In 18 cases, blood transfusions were needed; infections never occurred; finally, revision surgery was performed in 10 cases (two reverse total shoulder arthroplasties, one open reduction and internal fixation with plate and screws and seven nail removals for intolerance).

CONCLUSION

In our study, intramedullary nail proved to be a minimally invasive technique with a rapid improvement in range of motion, an earlier rehabilitation and acceptable pain.

Arthroscopy-assisted versus standard intramedullary nail fixation in diaphyseal fractures of the humerus

PURPOSE

The aim of this study was to assess applicability of arthroscopic technique in intramedullary nail fixation of humerus shaft fractures and to compare with conventional nailing in terms of its effects on perioperative and postoperative intra-articular complication rates as well as on clinical and functional outcomes.

METHODS

This prospective randomized controlled clinical trial included 40 patients (12 females and 28 males) indicated for surgery between either undergo arthroscopy-assisted (Arthroscopy-assisted intramedullary nailing [AIMN]; n = 20) or conventional (Intramedullary nailing [IMN]; n = 20) anterograde intramedullary nailing. Two groups were compared in terms of mean number of fluoroscopic shootings until the guide wire was inserted, time for union, length of hospital stay, and complication rates. Shoulder functions were assessed by Constant and American Shoulder and Elbow Surgeons (ASES) score.

RESULTS

Groups did not significantly differ in terms of age, gender, and mechanism of injury, length of hospital stay, union rate, and mean union time ( p > 0.05). Mean ASES and Constant scores were found to be statistically significantly higher in AIMN group than that in IMN group ( p = 0.000 and p = 0.002, respectively). Mean number of fluoroscopic shootings until the guide wire was inserted was 2.15 in AIMN group, which was significantly lower compared to 4.2 of IMN group ( p = 0.000).

CONCLUSIONS

Arthroscopy-assisted technique may be an applicable and safe method owing to its cosmetic advantages and more satisfactory postoperative shoulder functions subsequent to less injury to deltoid, rotator cuff, and other soft tissue, as compared to conventional anterograde approach.

Surgical interventions to treat humerus shaft fractures: A network meta-analysis of randomized controlled trials

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.

Reliability, validity, responsiveness, and minimal important change of the Disabilities of the Arm, Shoulder and Hand and Constant-Murley scores in patients with a humeral shaft fracture

BACKGROUND

The Disabilities of the Arm, Shoulder and Hand (DASH) and Constant-Murley scores are commonly used instruments. The DASH is patient-reported, and the Constant-Murley combines a clinician-reported and a patient-reported part. For patients with a humeral shaft fracture, their validity, reliability, responsiveness, and minimal important change (MIC) have not been published. This study evaluated the measurement properties of these instruments in patients who sustained a humeral shaft fracture.

METHODS

The DASH and Constant-Murley instruments were completed 5 times until 1 year after trauma. Pain score, Short Form 36, and EuroQol-5D were completed for comparison. Internal consistency was determined by the Cronbach α. Construct and longitudinal validity were evaluated by assessing hypotheses about expected Spearman rank correlations in scores and change scores, respectively, between patient-reported outcome measures (sub)scales. The smallest detectable change (SDC) was calculated. The MIC was determined using an anchor-based approach. The presence of floor and ceiling effects was determined.

RESULTS

A total of 140 patients were included. Internal consistency was sufficient for DASH (Cronbach α = 0.96) but was insufficient for Constant-Murley (α = 0.61). Construct and longitudinal validity were sufficient for both patient-reported outcome measures (>75% of correlations hypothesized correctly). The MIC and SDC were 6.7 (95% confidence interval, 5.0-15.8) and 19.0 (standard error of measurement, 6.9), respectively, for DASH and 6.1 (95% CI -6.8 to 17.4) and 17.7 (standard error of measurement, 6.4), respectively, for Constant-Murley.

CONCLUSIONS

The DASH and Constant-Murley are valid instruments for evaluating outcome in patients with a humeral shaft fracture. Reliability was only shown for the DASH, making this the preferred instrument. The observed MIC and SDC values provide a basis for sample size calculations for future research.

A Bayesian network meta-analysis of three different surgical procedures for the treatment of humeral shaft fractures

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.

Causes of Secondary Radial Nerve Palsy and Results of Treatment

Background

The aim of this study was to analyze the causes that lead to secondary damage of the radial nerve and to discuss the results of reconstructive treatment.

Material/Methods

The study group consisted of 33 patients treated for radial nerve palsy after humeral fractures. Patients were diagnosed based on clinical examinations, ultrasonography, electromyography, or nerve conduction velocity. During each operation, the location and type of nerve damage were analyzed. During the reconstructive treatment, neurolysis, direct neurorrhaphy, or reconstruction with a sural nerve graft was used. The outcomes were evaluated using the Medical Research Council (MRC) scales and the quick DASH score.

Results

Secondary radial nerve palsy occurs after open reduction and internal fixation (ORIF) by plate, as well as by closed reduction and internal fixation (CRIF) by nail. In the case of ORIF, it most often occurs when the lateral approach is used, as in the case of CRIF with an insertion interlocking screws. The results of the surgical treatment were statistically significant and depended on the time between nerve injury and revision (reconstruction) surgery, type of damage to the radial nerve, surgery treatment, and type of fixation. Treatment results were not statistically significant, depending on the type of fracture or location of the nerve injury.

Conclusions

The potential risk of radial nerve neurotmesis justifies an operative intervention to treat neurological complications after a humeral fracture. Adequate surgical treatment in many of these cases allows for functional recovery of the radial nerve.