Minimally Invasive Anterior Plate Osteosynthesis in Humeral Shaft Fractures

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

Most closed humeral shaft fractures can be successfully managed nonsurgically. However, fractures for which closed treatment is unsuccessful are stabilized using either plates or intramedullary nails. There are shortcomings associated with each technique, including the potential complications of nonunion, infection, shoulder pain, and radial nerve injury. Minimally invasive plate osteosynthesis (MIPO), an innovative alternative treatment, is gaining in popularity. This technique is based on the anterior humeral shaft providing a relatively safe surface for plate application, and limited open exposures proximally and distally allow percutaneous insertion of the necessary implant. More than 40 articles have been published regarding MIPO, and it compares favorably to other available forms of treatment with excellent functional outcomes and a lower rate of iatrogenic radial nerve injury. Larger randomized controlled trials comparing this method with other accepted techniques, including nonsurgical management, are necessary to better define the role of MIPO in the management of humeral shaft fractures.

Minimally invasive plating versus either open reduction and plate fixation or intramedullary nailing of humeral shaft fractures: a systematic review and meta-analysis of randomized controlled trials

HYPOTHESIS

The purpose of this study was to perform a meta-analysis comparing the clinical outcomes and complications between anterior humeral minimally invasive plate osteosynthesis (MIPO) and the 2 standard techniques, either open reduction and plating or humeral nailing.

METHODS

We performed a systematic review of Medline, Embase, Scopus, and Google Scholar to identify relevant randomized controlled trials in the English- and German-language literature. Eligibility criteria included randomized controlled trials comparing at least 1 surgical intervention with MIPO and reporting the primary clinical outcome using a validated functional scoring system and description of complications. Publication bias was assessed by funnel plot, and the risk of bias was established using the Cochrane Collaboration's Risk of Bias Tool. Heterogeneity was assessed using χ(2) and I(2) statistics.

RESULTS

Eight prospective randomized studies (N = 376) met the eligibility criteria and were included in the analysis. The pooled estimate for clinical outcome showed that MIPO resulted in a significantly better outcome (standardized mean difference, 0.366; 95% confidence interval, 0.16 to 0.571; P = .0001; I(2) = 61%). The pooled estimate for all complications showed that the open reduction-internal fixation/nail group had a significantly higher complication rate (odds ratio, 0.507; 95% confidence interval, 0.285 to 0.905; P = .021; I(2) = 97%).

CONCLUSION

Current evidence indicates the MIPO approach has better clinical outcomes with a lower rate of complications compared with alternative surgical techniques. However, the results of this meta-analysis are limited by problems inherent in the primary studies, including poor reporting of randomization protocols, as well as possible attrition bias and reporting bias, of the primary studies. Future publications may therefore change the trend of the pooled estimate in either direction.

Clinic research on the treatment for humeral shaft fracture with minimal invasive plate osteosynthesis: a retrospective study of 128 cases

INTRODUCTION

Minimal invasive plate osteosynthesis (MIPO) is one of the most important techniques in the treatment for humeral shaft fractures. This study was performed to evaluate the efficacy of MIPO technique for the treatment for humeral shaft fractures.

MATERIALS AND METHODS

We retrospectively evaluated 128 cases with humeral shaft fractures that were treated with MIPO technique from March 2005 to August 2008. All the patients were followed up by routine radiological imaging and clinical examinations. Constant-Murley score and HSS elbow joint score were used to evaluate the treatment outcome.

RESULTS

The average duration of the surgery was 60 min (range 40-95 min) without blood transfusion. All fractures healed without infection. All cases recovered carrying angle except four cases with 10°-15° cubitus varus. After the average follow-up of 23 (13-38) months, satisfactory function was achieved according to Constant-Murley score and HSS elbow joint score. Constant-Murley score was 80 on average (range 68-91). According to HSS elbow joint score, there were 123 cases of excellent clinical outcome and five cases of effective outcome.

CONCLUSION

It seems to be a safe and effective method for managing humeral shaft fractures with MIPO technique.

Minimal invasive ostheosintesis for treatment of diaphiseal transverse humeral shaft fractures

OBJECTIVE:

To evaluate patients with transverse fractures of the shaft of the humerus treated with indirect reduction and internal fixation with plate and screws through minimally invasive technique.

METHODS:

Inclusion criteria were adult patients with transverse diaphyseal fractures of the humerus closed, isolated or not occurring within 15 days of the initial trauma. Exclusion criteria were patients with compound fractures.

RESULTS:

In two patients, proximal screw loosening occurred, however, the fractures consolidated in the same mean time as the rest of the series. Consolidation with up to 5 degrees of varus occurred in five cases and extension deficit was observed in the patient with olecranon fracture treated with tension band, which was not considered as a complication. There was no recurrence of infection or iatrogenic radial nerve injury.

CONCLUSION:

It can be concluded that minimally invasive osteosynthesis with bridge plate can be considered a safe and effective option for the treatment of transverse fractures of the humeral shaft. Level of Evidence III, Therapeutic Study.

Minimally invasive percutaneous osteosynthesis for proximal humeral shaft fractures with the PHILOS through the deltopectoral approach

PURPOSE

The aim of this study was to evaluate clinical outcomes and complications following minimally invasive plate osteosynthesis (MIPO) with the proximal humeral internal locking system (PHILOS) for treating proximal humeral shaft fracture through the deltopectoral approach.

METHODS

Between November 2008 and March 2010, 74 patients with unilateral proximal humeral shaft fractures were treated using the MIPO technique with the PHILOS through the deltopectoral approach. Patients received an average follow-up of 16.9 (range, 12-24) months, and the final follow-up included anteroposterior and lateral imaging and recording of postoperative complications. The Constant-Murley shoulder score was used to evaluate function.

RESULTS

No intraoperative complications occurred. Postoperative complications included subacromial impingement in four patients. There was no deep infection, neurovascular damage, breakage or implant loosening. All fractures united in an average time of 17.4 (15-25) weeks. In terms of function, the Constant-Murley score was 85.8 points on average (range, 67-100). The range of motion of the involved shoulder was satisfactory, and pain-free in 83.8 % of patients.

CONCLUSIONS

Using the MIPO technique with the PHILOS through the deltopectoral approach is a valid and safe method of treating proximal humeral shaft fractures.

Treatment of proximal and middle one-third humeral fractures with lateral distal tibial helical plate

OBJECTIVE

To evaluate the outcomes of treating patients with proximal and middle one-third humeral fractures treated with lateral distal tibial helical plate.

MATERIALS AND METHODS

From June 2004 to January 2009, 12 patients (8 men, 4 women: average age: 46.8 years, range: 25-63) with proximal and middle one-third humeral fractures were treated with open reduction and internal fixation using lateral distal tibial helical plate. Standard anterior-posterior and lateral radiographs were obtained and evaluated. Shoulder function was assessed according to the Constant-Murley score.

RESULTS

At follow-up (average: 18 months), all fractures had healed (average: 15 weeks, range: 9-23). There were no cases of intraoperative complications, implant failures, infections, or iatrogenic intra- or post-operative nerve lesions. All patients achieved at least 100° of abduction by 3 months post-surgery and full range of movement by 12 months post-surgery, with the exception of one patient who had an impingement symptom with moderate loss of abduction and external rotation. The average Constant-Murley score was 88 points at 12-month follow-up. According to Constant-Murley score, 28% of patients had excellent functional outcome, 64% had good outcome, 8% had moderate outcome, and none had failure. According to self-reporting, all patients had returned to the pre-injury level of activity.

CONCLUSIONS

The lateral distal tibial helical plate promotes bone healing and minimizes the damage to the deltoid muscle insertion region, thereby facilitating rapid and good functional recovery. In addition, the helical plate design avoids affecting sliding of the biceps tendon and maintains good reduction position. The lateral distal tibial helical plate is an effective surgical option for proximal and middle one-third humeral fractures.

Minimal invasive long PHILOS®-plate osteosynthesis in metadiaphyseal fractures of the proximal humerus

Minimal invasive plate osteosynthesis (MIPO) not only meets the criteria of a "biological" osteosynthesis by minimising invasivity as well as iatrogenic soft tissue damage, but can also provide adequate stability for fracture healing and early functional aftertreatment. Up to date, only few publications report on MIPO of humeral shaft fractures mainly using the anterolateral deltopectoral approach for proximal plate insertion. Objective of the present study was to assess the feasibility and clinical outcome of MIPO for metadiaphyseal fractures of the proximal humerus through a lateral approach using angular stable long PHILOS(®)-plates. We retrospectively evaluated 29 patients (mean age 77 years, range 48-95 years) with displaced metadiaphyseal fractures of the proximal humerus treated with MIPO technique. For the first time, an angular stable long PHILOS(®)-plate through a lateral deltoid-split approach proximally and a brachialis/brachioradialis intermuscular approach with exposure of the radial nerve distally, were used. There were no infections and no iatrogenic injuries to the axillary and radial nerve. One patient showed subacromial impingement and one patient had to be reoperated for redislocation of the distal fragment with screw breakage, which was most likely due to incorrect screw placement. This patient was successfully operated using the same method and implant. Besides one patient who refused further follow-up, 28 patients could be followed up to a mean of 8 months (range 3-12 months) each with an entirely healed fracture. Furthermore, patient's quality of life was documented using the SF-36 questionnaire. Comparison with published United States normative data showed no significant deficits in the physical as well as in the mental domains 8 months after MIPO. Minimal invasive long PHILOS(®)-plate osteosynthesis using a combined lateral deltoid-split and brachialis/brachioradialis intermuscular approach proved to be a safe procedure for the treatment of metadiaphyseal fractures of the proximal humerus with low morbidity and full restoration of quality of life in these elderly patients.