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Heitzmann LG, de Souza Aquino I, Tenor Junior AC, da Costa MP, Nogueira MP. Anatomical study of the safety corridor for bridge plating positioned on the lateral border of the humerus. Surg Radiol Anat 2024; 46:1439-1445. [PMID: 38858314 DOI: 10.1007/s00276-024-03405-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 05/30/2024] [Indexed: 06/12/2024]
Abstract
PURPOSE This study shows the danger zone and the safety corridor in the lateral approach with bridge plating by measuring the distance between the lateral side of the plate positioned on the lateral aspect of the humerus and the radial nerve after it pierces the lateral intermuscular septum, in the different forearm positions. METHODS Forty arms of 20 human cadavers were used, the radial nerve was identified and marked on the lateral surface the radial nerve at the exit of the lateral intermuscular septum and anteriorisation of the nerve in relation to the humeral shaft and the lateral epicondyle was also marked. The distances were measured with a digital caliper. A submuscular extraperiosteal corridor was created, proximally between the biceps brachialis and deltoid muscle and distally between the triceps and brachioradialis muscle, followed by the positioning of the low contact large fragments contoured plate with 14 combined holes (fixed and cortical angle), inserted from distal to proximal. Measurements were performed in four positions (elbow flexion with forearm pronation, elbow flexion with forearm supination, elbow extension with forearm pronation and elbow extension with forearm supination). RESULTS Significant statistical differences occurred with the different positions, and the elbow flexion with forearm supination was shown to be the position that provides the safest submuscular extraperiosteal corridor in a lateral approach of the humerus. CONCLUSION The danger zone of radial nerve is an area that extends from 15 cm to 5 cm proximal to the lateral epicondyle and the safest way to create a submuscular and extraperiosteal corridor in the lateral region of the humerus is with the elbow in flexion and the forearm in supination.
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Affiliation(s)
| | - Igel de Souza Aquino
- Instituto de Assistência Médica ao Servidor Público Estadual (IAMSPE), São Paulo, SP, Brazil
| | | | - Miguel Pereira da Costa
- Instituto de Assistência Médica ao Servidor Público Estadual (IAMSPE), São Paulo, SP, Brazil
| | - Monica Paschoal Nogueira
- Instituto de Assistência Médica ao Servidor Público Estadual (IAMSPE), São Paulo, SP, Brazil.
- Rua Pedro de Toledo, Vila Clementino, 1800, 04039-004, Sao Paulo, Brazil.
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Liu D, Liang J, Yang H, Zhang Y, Lu Z. Medial minimally invasive percutaneous plate osteosynthesis for humeral shaft fractures: a case series and novel technique description. Arch Orthop Trauma Surg 2023; 143:6657-6664. [PMID: 37530845 DOI: 10.1007/s00402-023-04992-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 07/10/2023] [Indexed: 08/03/2023]
Abstract
INTRODUCTION Minimally Invasive Percutaneous Plate Osteosynthesis (MIPPO) is increasingly favored for treating humeral shaft fractures (HSFs). However, conventional MIPPO techniques pose challenges in fixing fractures near fossa olecranon and carry a risk of iatrogenic radial nerve palsy. A novel technique using a medial MIPPO for treating humeral shaft fractures (HSFs) is described. Results of clinical follow-up are presented. MATERIALS AND METHODS This study is a retrospective case series study. Twenty-one patients (mean age 43.9 ± 17.66 [22‒81] years) with HSFs were treated with the novel MIPPO fixation method. Clinical outcomes including time for radiographic consolidation, Disabilities of the Arm, Shoulder, and Hand (DASH) score, and complications were assessed at the last follow-up. The mean follow-up was 26 ± 17.12 (range 12-67) months. RESULTS All patients had a bony union at a mean of 15.76 ± 6.74 (range 8-40) weeks based on X-ray with an early and aggressive range of motion. The complication rate was 0. The mean DASH score was3.29 ± 4.09 (range 0-14.17) at the time of the last follow-up. The mean screw density was 0.49 ± 0.1 (range 0.2-0.65). CONCLUSION This novel surgical technique for HSFs is a viable alternative to previously described methods with the advantage of being less prone to nerve injury and easy to fix distal extra-articular HSFs. The learning curve is short. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Dapeng Liu
- Department of Orthopedics, The Fifth Affiliated Hospital of Xinjiang Medical University, No. 118, West Henan Road, Urumqi, China.
| | - Jinghao Liang
- Department of Orthopedics, Xinjiang Cardiovascular and Cerebrovascular Disease Hospital, Urumqi, China
| | - Hongju Yang
- Department of Surgical Anesthesiology, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Ying Zhang
- Department of Orthopedics, The Fifth Affiliated Hospital of Xinjiang Medical University, No. 118, West Henan Road, Urumqi, China
| | - Zhanxin Lu
- Department of Orthopedics, The Fifth Affiliated Hospital of Xinjiang Medical University, No. 118, West Henan Road, Urumqi, China
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Boretto JG, Arroyo Sánchez C, Abril Gaona C, Donndorff AG, de Carli P, Gallucci GL, Rellán I. [Translated article] The use of an anatomical implant compared to a straight LCP decreases extraction in posterior humeral MIPO. Rev Esp Cir Ortop Traumatol (Engl Ed) 2023; 67:T394-T400. [PMID: 37315919 DOI: 10.1016/j.recot.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 02/14/2023] [Indexed: 06/16/2023] Open
Abstract
PURPOSE Posterior MIPO approach in the humerus has been described by using a 4.5mm LCP plate. Although straight plates have shown good results, they have not been designed to adapt to the distal humeral metaphysis. The goal of the study was to test the null hypothesis that there is no difference in hardware removal after posterior MIPO with either a straight or a pre-contoured plate. METHODS Patients older than 18 years, who had suffered mid-distal humeral shaft fracture, were treated by a posterior MIPO technique with a locking plate and had a minimum of 12-month follow-up were retrospectively included. Patients were separated into: group 1 (LCP 4.5mm straight plate); and group 2 (3.5mm anatomically shaped plate). Clinical and radiological evaluations were performed in the postoperative period. Patient-reported outcomes and the need of hardware removal because of pain were assessed. RESULTS Sixty-seven patients fulfilled the inclusion criteria. Twenty-seven patients in group 1 and 40 in group 2. No patient was lost to follow-up. There were no statistical differences between in patient reported outcomes measures. All the fractures healed. Within group 1, 18% (95%CI: 6-38%) of the patients required implant removal while in group 2 this incidence was 0% (95%CI: 0-9%) (P 0.009). CONCLUSION These results suggest that the use of a 4.5mm LCP compared to an anatomical 3.5mm LCP in posterior MIPO of the humerus generates greater discomfort and therefore leads to a 18% increase in the risk of implant removal.
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Affiliation(s)
- J G Boretto
- Servicio de Ortopedia y Traumatología, Hospital Italiano de Buenos Aires, Instituto de Ortopedia y Traumatología «Carlos E. Ottolenghi», Potosí, Buenos Aires, Argentina.
| | - C Arroyo Sánchez
- Servicio de Ortopedia y Traumatología, Clínica Foscal, Bucaramanga, Colombia
| | - C Abril Gaona
- Servicio de Ortopedia y Traumatología, Clínica Foscal, Bucaramanga, Colombia
| | - A G Donndorff
- Servicio de Ortopedia y Traumatología, Hospital Italiano de Buenos Aires, Instituto de Ortopedia y Traumatología «Carlos E. Ottolenghi», Potosí, Buenos Aires, Argentina
| | - P de Carli
- Servicio de Ortopedia y Traumatología, Hospital Italiano de Buenos Aires, Instituto de Ortopedia y Traumatología «Carlos E. Ottolenghi», Potosí, Buenos Aires, Argentina
| | - G L Gallucci
- Servicio de Ortopedia y Traumatología, Hospital Italiano de Buenos Aires, Instituto de Ortopedia y Traumatología «Carlos E. Ottolenghi», Potosí, Buenos Aires, Argentina
| | - I Rellán
- Servicio de Ortopedia y Traumatología, Hospital Italiano de Buenos Aires, Instituto de Ortopedia y Traumatología «Carlos E. Ottolenghi», Potosí, Buenos Aires, Argentina
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Boretto JG, Arroyo Sánchez C, Abril Gaona C, Donndorff AG, de Carli P, Gallucci GL, Rellán I. The use of an anatomical implant compared to a straight LCP decreases extraction in posterior humeral MIPO. Rev Esp Cir Ortop Traumatol (Engl Ed) 2023; 67:394-400. [PMID: 36842670 DOI: 10.1016/j.recot.2023.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 02/12/2023] [Accepted: 02/14/2023] [Indexed: 02/28/2023] Open
Abstract
PURPOSE Posterior MIPO approach in the humerus has been described by using a 4.5mm LCP plate. Although straight plates have shown good results, they have not been designed to adapt to the distal humeral metaphysis. The goal of the study was to test the null hypothesis that there is no difference in hardware removal after posterior MIPO with either a straight or a pre-contoured plate. METHODS Patients older than 18 years, who had suffered mid-distal humeral shaft fracture, were treated by a posterior MIPO technique with a locking plate and had a minimum of 12-month follow-up were retrospectively included. Patients were separated into: group 1 (LCP 4.5mm straight plate); and group 2 (3.5mm anatomically shaped plate). Clinical and radiological evaluation were performed in the postoperative period. Patient-reported outcomes and the need of hardware removal because of pain were assessed. RESULTS Sixty-seven patients fulfilled the inclusion criteria. Twenty-seven patients in group 1 and 40 in group 2. No patient was lost to follow-up. There were no statistical differences between in patient reported outcomes measures. All the fractures healed. Within group 1, 18% (95%CI: 6-38%) of the patients required implant removal while in group 2 this incidence was 0% (95%CI: 0-9%) (P 0.009). CONCLUSION These results suggest that the use of a 4.5mm LCP compared to an anatomical 3.5mm LCP in posterior MIPO of the humerus generates greater discomfort and therefore leads to a 18% increase in the risk of implant removal.
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Affiliation(s)
- J G Boretto
- Servicio de Ortopedia y Traumatología, Hospital Italiano de Buenos Aires, Instituto de Ortopedia y Traumatología «Carlos E. Ottolenghi», Potosí, Buenos Aires, Argentina.
| | - C Arroyo Sánchez
- Servicio de Ortopedia y Traumatología, Clínica Foscal, Bucaramanga, Colombia
| | - C Abril Gaona
- Servicio de Ortopedia y Traumatología, Clínica Foscal, Bucaramanga, Colombia
| | - A G Donndorff
- Servicio de Ortopedia y Traumatología, Hospital Italiano de Buenos Aires, Instituto de Ortopedia y Traumatología «Carlos E. Ottolenghi», Potosí, Buenos Aires, Argentina
| | - P de Carli
- Servicio de Ortopedia y Traumatología, Hospital Italiano de Buenos Aires, Instituto de Ortopedia y Traumatología «Carlos E. Ottolenghi», Potosí, Buenos Aires, Argentina
| | - G L Gallucci
- Servicio de Ortopedia y Traumatología, Hospital Italiano de Buenos Aires, Instituto de Ortopedia y Traumatología «Carlos E. Ottolenghi», Potosí, Buenos Aires, Argentina
| | - I Rellán
- Servicio de Ortopedia y Traumatología, Hospital Italiano de Buenos Aires, Instituto de Ortopedia y Traumatología «Carlos E. Ottolenghi», Potosí, Buenos Aires, Argentina
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Van Bergen SH, Mahabier KC, Van Lieshout EMM, Van der Torre T, Notenboom CAW, Jawahier PA, Verhofstad MHJ, Den Hartog D. Humeral shaft fracture: systematic review of non-operative and operative treatment. Arch Orthop Trauma Surg 2023:10.1007/s00402-023-04836-8. [PMID: 37093269 PMCID: PMC10374687 DOI: 10.1007/s00402-023-04836-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 03/01/2023] [Indexed: 04/25/2023]
Abstract
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.
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Affiliation(s)
- Saskia H Van Bergen
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Kiran C Mahabier
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Esther M M Van Lieshout
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Tim Van der Torre
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Cornelia A W Notenboom
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Priscilla A Jawahier
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Michael H J Verhofstad
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Dennis Den Hartog
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.
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Treating multifocal humerus fractures: A comparison between the mipo technique and intramedullary nailing. Injury 2022; 53:3332-3338. [PMID: 35970638 DOI: 10.1016/j.injury.2022.07.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 07/19/2022] [Accepted: 07/29/2022] [Indexed: 02/02/2023]
Abstract
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.
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Jitprapaikulsarn S, Gromprasit A, Sukha K, Patamamongkonchai C, Jiamton C. Minimally invasive plate osteosynthesis via posterior approach for type B and C fractures of distal humeral shaft: surgical tactics and a clinical series. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2022; 33:1431-1437. [PMID: 35377077 DOI: 10.1007/s00590-022-03255-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 03/15/2022] [Indexed: 11/26/2022]
Abstract
The optimal technique and implant for fixation of multifragmentary fractures of the distal humeral shaft remain inconclusive. We describe the use of minimally invasive plate osteosynthesis (MIPO) via posterior approach and extra-articular distal humerus locking compression plate (LCP-EADH) fixation for 18 such fractures. All fractures were united with a mean union time of 17.6 weeks (range 12-20). Transient radial nerve palsy was demonstrated in 2 patients. Six patients had 5° varus angulation and 1 had 5° valgus angulation. Triceps power was Grade 5 in all patients. The mean arc of elbow motion was 127.5 degrees (range 115-140). Six patients had an excellent MEP score and 12 had a good MEP score. As the results, posterior MIPO and LCP-EADH fixation could be an alternative for multifragmentary fractures of the distal humeral shaft, particularly for fractures with a very short distal fragment.
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Affiliation(s)
- Surasak Jitprapaikulsarn
- Department of Orthopedics, Buddhachinaraj Hospital, 90 Srithamtraipidok Road, Phitsanulok, 65000, Thailand.
| | - Arthit Gromprasit
- Department of Orthopedics, Buddhachinaraj Hospital, 90 Srithamtraipidok Road, Phitsanulok, 65000, Thailand
| | - Kritsada Sukha
- Department of Orthopedics, Buddhachinaraj Hospital, 90 Srithamtraipidok Road, Phitsanulok, 65000, Thailand
| | - Chawanan Patamamongkonchai
- Department of Orthopedics, Buddhachinaraj Hospital, 90 Srithamtraipidok Road, Phitsanulok, 65000, Thailand
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Yang J, Liu D, Zhang L, Lu Z, Liu T, Tao C. Treatment of humeral shaft fractures: a new minimally-invasive plate osteosynthesis versus open reduction and internal fixation: a case control study. BMC Surg 2021; 21:349. [PMID: 34551734 PMCID: PMC8459486 DOI: 10.1186/s12893-021-01347-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 09/13/2021] [Indexed: 11/24/2022] Open
Abstract
Background To evaluate the feasibility and safety of a new minimally-invasive surgical approach–anteromedial minimally-invasive plate osteosynthesis (MIPO)–in the treatment of middle and distal humeral shaft fractures. Methods Fourteen patients with humeral shaft fracture treated with anteromedial MIPO from November 2016 to March 2020 (MIPO Group) were selected as the study subjects. Open reduction and internal fixation (ORIF) were used to treat 14 patients with humeral shaft fractures as the control group (ORIF group). The two groups were fixed with a locking compression plate (LCP) or LCP + multi-directional locking screw system (MDLS). The incision length, intraoperative blood loss, intraoperative fluoroscopy time, operation time, length of hospital stay, fracture healing time, QuickDASH score and Constant score were observed and compared between the two groups. Results Fourteen patients were enrolled in each group. The incision length (7.79 ± 2.39 cm), intraoperative blood loss (96.07 ± 14.96 mL), operative time (110.57 ± 21.90 min), hospital stay (6.29 ± 1.49 days) and fracture healing time (14.94 ± 0.99 weeks) in the MIPO group were all lower than those in the ORIF group, and the difference was statistically significant for each parameter (P < 0.05). The intraoperative fluoroscopy time (20.07 ± 3.22) in the MIPO group was significantly higher than that in the ORIF group (P < 0.05). There were no significant differences in age (P = 0.078), QuickDASH score (P = 0.074) or Constant score (P = 0.293) between the two groups and no postoperative complications occurred in any of the patients. Conclusion The anteromedial approach MIPO technique has the advantages of less trauma, less bleeding, low risk of nerve injury and high rate of fracture healing. It is one of the most effective methods for the treatment of middle and middle–distal humeral shaft fractures.
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Affiliation(s)
- Jing Yang
- Department of Orthopedics, The Second Xiangya Hospital, Central South University, Changsha, 410000, Hunan, China.,Department of Orthopedics, The Fifth Affiliated Hospital of Xinjiang Medical University, Urumqi, 830000, Xinjiang, China
| | - Dapeng Liu
- Department of Orthopedics, The Fifth Affiliated Hospital of Xinjiang Medical University, Urumqi, 830000, Xinjiang, China
| | - Lina Zhang
- Department of Mental Health Institute, The Second Xiangya Hospital, Central South University, Changsha, 410000, Hunan, China
| | - Zhanxin Lu
- Department of Orthopedics, The Fifth Affiliated Hospital of Xinjiang Medical University, Urumqi, 830000, Xinjiang, China
| | - Tang Liu
- Department of Orthopedics, The Second Xiangya Hospital, Central South University, Changsha, 410000, Hunan, China.
| | - Cheng Tao
- Department of Orthopedics, The Second Xiangya Hospital, Central South University, Changsha, 410000, Hunan, China.
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Patino JM, Ramella JC, Michelini AE, Abdon IM, Rodriguez EF, Corna AFR. Plates vs. nails in humeral shaft fractures: Do plates lead to a better shoulder function? JSES Int 2021; 5:765-768. [PMID: 34223427 PMCID: PMC8245902 DOI: 10.1016/j.jseint.2021.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
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.
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Affiliation(s)
- Juan M Patino
- Departamento de Ortopedia y Traumatologia, Servicio de cirugía de la mano y miembro superior, Unidad de Hombro y Codo, Hospital Militar Central "Cosme Argerich", Buenos Aires, Argentina
| | - Juan C Ramella
- Departamento de Ortopedia y Traumatologia, Servicio de cirugía de la mano y miembro superior, Unidad de Hombro y Codo, Hospital Militar Central "Cosme Argerich", Buenos Aires, Argentina
| | - Alejandro E Michelini
- Departamento de Ortopedia y Traumatologia, Servicio de cirugía de la mano y miembro superior, Unidad de Hombro y Codo, Hospital Militar Central "Cosme Argerich", Buenos Aires, Argentina
| | - Ignacio M Abdon
- Departamento de Ortopedia y Traumatologia, Servicio de cirugía de la mano y miembro superior, Unidad de Hombro y Codo, Hospital Militar Central "Cosme Argerich", Buenos Aires, Argentina
| | - Emanuel Fedum Rodriguez
- Departamento de Ortopedia y Traumatologia, Servicio de cirugía de la mano y miembro superior, Unidad de Hombro y Codo, Hospital Militar Central "Cosme Argerich", Buenos Aires, Argentina
| | - Alejandro F Rullan Corna
- Departamento de Ortopedia y Traumatologia, Servicio de cirugía de la mano y miembro superior, Unidad de Hombro y Codo, Hospital Militar Central "Cosme Argerich", Buenos Aires, Argentina
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Keshav K, Baghel A, Kumar V, Neradi D, Kaustubh K, Mishra P. Is Minimally Invasive Plating Osteosynthesis Better Than Conventional Open Plating for Humeral Shaft Fractures? A Systematic Review and Meta-Analysis of Comparative Studies. Indian J Orthop 2021; 55:283-303. [PMID: 34306542 PMCID: PMC8275817 DOI: 10.1007/s43465-021-00413-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 04/26/2021] [Indexed: 02/04/2023]
Abstract
INTRODUCTION The aim of systematic review and meta-analysis was to find out whether minimally invasive plate osteosynthesis (MIPO) is better than open reduction and internal plate fixation (ORIF) in terms of functional outcome, achieving union (union time and incidence of non-union), intraoperative parameters (surgical duration, blood loss, and radiation exposure), and complications (iatrogenic radial nerve palsy and infection) for humeral shaft fractures. MATERIALS AND METHODS We searched online databases (Pubmed, Embase, Scopus, and The Cochrane Library) from inception till 3rd September 2020 for articles comparing MIPO with ORIF for humeral shaft fractures. The methodological quality of randomized controlled trials (RCTs) was done by Cochrane Risk of Bias assessment tool 2 (RoB2) and of non-randomized studies (case-control and cohort studies) by Methodological Index for non-randomized studies (MINORS). Meta-analysis was performed using Review Manager 5.4 software. RESULTS 11 studies (5 RCTs and 6 non-randomized comparative studies) involving a total of 582 patients (MIPO-290, ORIF-292) meeting our inclusion criteria were included in the study. There was no statistically significant difference in pooled analysis of functional outcome scores between MIPO and ORIF. Union time was significantly lesser (mean difference = 3.12 weeks) and incidence of non-union lower (odd's ratio = 0.27) in MIPO group. Surgical duration and intraoperative blood loss were significantly lesser in MIPO group. Iatrogenic radial nerve palsy and infection were higher in ORIF group. CONCLUSIONS This study showed that MIPO gives similar functional outcomes as compared to ORIF but causes significantly lesser blood loss, requires lesser operative duration and has a lesser incidence of major complications. TRIAL REGISTRATION International prospective register of systematic reviews (PROSPERO)-CRD42020208346, Date of registration 09/10/2020. SUPPLEMENTARY INFORMATION The online version contains supplementary material available at 10.1007/s43465-021-00413-6.
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Affiliation(s)
- Kumar Keshav
- Department of Orthopaedics, Apex Trauma Centre, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh 226029 India
| | - Anurag Baghel
- Department of Orthopaedics, Apex Trauma Centre, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh 226029 India
| | - Vishal Kumar
- Spine Surgery, Department of Orthopaedics, PGIMER, Chandigarh, 160012 India
| | - Deepak Neradi
- Spine Surgery, Department of Orthopaedics, PGIMER, Chandigarh, 160012 India
| | | | - Prabhaker Mishra
- Department of Biostatistics and Health Informatics, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh 226029 India
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Beeres FJ, Diwersi N, Houwert MR, Link BC, Heng M, Knobe M, Groenwold RH, Frima H, Babst R, Jm van de Wall B. ORIF versus MIPO for humeral shaft fractures: a meta-analysis and systematic review of randomized clinical trials and observational studies. Injury 2021; 52:653-663. [PMID: 33223254 DOI: 10.1016/j.injury.2020.11.016] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 11/03/2020] [Accepted: 11/05/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND There is no consensus on the optimal operative technique for humeral shaft fractures. This meta-analysis aims to compare minimal-invasive plate osteosynthesis (MIPO) with open reduction internal fixation (ORIF) for humeral shaft fractures regarding non-union, re-intervention, radial nerve palsy, time to union, operation duration and functional outcomes. METHODS PubMed/Medline/Embase/CENTRAL/CINAHL were searched for both randomized clinical trials (RCT) and observational studies comparing MIPO with ORIF for humeral shaft fractures. Effect estimates were pooled across studies using random effects models and presented as weighted odds ratio (OR), risk difference (RD), mean difference (MD) and standardized mean difference (SMD) with corresponding 95% confidence interval (95%CI). Subgroup analysis was performed stratified by study design (RCTs and observational studies). RESULTS A total of two RCT's (98 patients) and seven observational studies (263 patients) were included. The effect estimates obtained from observational studies and RCT's were similar in direction and magnitude. MIPO carries a lower risk for non-union (RD: 5%; OR 0.3, 95% CI 0.1-0.9) and secondary radial nerve palsy (RD 5%; OR 0.3, 95%CI 0.1- 0.9). Nerve function eventually restored spontaneously in all patients in both groups. Results were inconclusive regarding re-intervention (RD 7%; OR: 0.7, 95%CI 0.2-1.9), infection (RD 4%; OR 0.4, 95%CI 0.1-1.5), time to union (MD -1 week, 95%CI -3 - 1) and operation duration (MD -13 minutes, 95%CI -38.9 - 11.9). Functional shoulder scores (SMD 0.01, 95%CI -0.3 - 0.3) and elbow scores (SMD 0.01, 95%CI -0.3 - 0.3) were similar for the different operative techniques. CONCLUSION MIPO has a lower risk for non-union than ORIF for the treatment of humeral shaft fractures. Radial nerve palsy secondary to operation is a temporary issue resolving in all patients in both treatment groups. Although both treatment options are viable, the general balance leans towards MIPO having more favorable outcomes.
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Affiliation(s)
- Frank Jp Beeres
- Lucerne Cantonal Hospital, Department of Orthopedic and Trauma Surgery, Spitalstrasse 16, 6000 Luzern, Switzerland
| | - Nadine Diwersi
- Lucerne Cantonal Hospital, Department of Orthopedic and Trauma Surgery, Spitalstrasse 16, 6000 Luzern, Switzerland
| | - Marijn R Houwert
- University Medical Center Utrecht, Department of Trauma Surgery, Heidelberglaan 100, 3584CX, Utrecht, the Netherlands
| | - Björn C Link
- Lucerne Cantonal Hospital, Department of Orthopedic and Trauma Surgery, Spitalstrasse 16, 6000 Luzern, Switzerland
| | - Marilyn Heng
- Harvard Medical School Orthopedic Trauma Initiative, Massachusetts General Hospital Boston, Department of Orthopedic Surgery, Boston, USA
| | - Matthias Knobe
- Lucerne Cantonal Hospital, Department of Orthopedic and Trauma Surgery, Spitalstrasse 16, 6000 Luzern, Switzerland
| | - Rolf Hh Groenwold
- Leiden University Medical Center, Department of Clinical Epidemiology, Leiden, the Netherlands
| | - Herman Frima
- Northwest Hospital group, Department of Trauma Surgery, Wendelaarstraat 58, 1814 GS Alkmaar, the Netherlands
| | - Reto Babst
- Lucerne Cantonal Hospital, Department of Orthopedic and Trauma Surgery, Spitalstrasse 16, 6000 Luzern, Switzerland
| | - Bryan Jm van de Wall
- Lucerne Cantonal Hospital, Department of Orthopedic and Trauma Surgery, Spitalstrasse 16, 6000 Luzern, Switzerland.
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Rellán I, Gallucci GL, Donndorff AG, De Carli P, Zaidenberg EE, Richard MJ, Boretto JG. Time until union in absolute vs. relative stability MIPO plating in simple humeral shaft fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:191-197. [PMID: 33778903 DOI: 10.1007/s00590-021-02920-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 02/17/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE The objective of this study is to evaluate the effect of absolute stability (AS) versus relative stability (RS) performed through a minimally invasive plate osteosynthesis (MIPO) in AO/OTA 12A1 and 12A2 fractures on healing and the time to radiographic union. METHODS This was a retrospective cohort study of all patients treated with plate fixation for AO/OTA type 12A1-A2 fractures at a single institution. Patients were grouped according to the type of stability used in their surgery. Time until radiographic union was estimated using the Kaplan-Meier method, which was compared by long-rank test between both types of surgical techniques. RESULTS A total of 70 patients were included in this study with 35 patients in each group. The median follow-up was 9 (IQR 6-14) months. The median time to radiographic union was significantly lower in the AS group than in the RS group: 12 (interquartile range (IQR) 10-14) weeks versus 18 (IQR 16-19) weeks, respectively (p < 0.001). Non-union was seen in two cases (7%) in the relative stability group. Three patients in the RS group developed a post-operative radial nerve palsy. CONCLUSION The main finding of this study is that the median time to radiographic union was significantly shorter in the patients treated with AS compared to those with a RS technique. These findings support the recommendations of the AO foundation in that simple metaphyseal fractures (type A) that require surgical treatment should be treated with an AS construct. RS techniques should be reserved to multifragmentary fractures where fragment preservation of blood supply is paramount.
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Affiliation(s)
- Ignacio Rellán
- Department of Orthopaedics, Instituto de Ortopedia y Traumatología "Carlos E. Ottolenghi", Hospital Italiano de Buenos Aires, Buenos Aires, Argentina, Potosí 4215 (C1199ACK), Buenos Aires, Argentina.
| | - Gerardo Luis Gallucci
- Department of Orthopaedics, Instituto de Ortopedia y Traumatología "Carlos E. Ottolenghi", Hospital Italiano de Buenos Aires, Buenos Aires, Argentina, Potosí 4215 (C1199ACK), Buenos Aires, Argentina
| | - Agustin Guillermo Donndorff
- Department of Orthopaedics, Instituto de Ortopedia y Traumatología "Carlos E. Ottolenghi", Hospital Italiano de Buenos Aires, Buenos Aires, Argentina, Potosí 4215 (C1199ACK), Buenos Aires, Argentina
| | - Pablo De Carli
- Department of Orthopaedics, Instituto de Ortopedia y Traumatología "Carlos E. Ottolenghi", Hospital Italiano de Buenos Aires, Buenos Aires, Argentina, Potosí 4215 (C1199ACK), Buenos Aires, Argentina
| | - Ezequiel Ernesto Zaidenberg
- Department of Orthopaedics, Instituto de Ortopedia y Traumatología "Carlos E. Ottolenghi", Hospital Italiano de Buenos Aires, Buenos Aires, Argentina, Potosí 4215 (C1199ACK), Buenos Aires, Argentina
| | - Marc Joseph Richard
- Department of Orthopaedic Surgery, Division of Hand, Upper Extremity, and Microvascular Surgery, Duke University Medical Center, 4709 Creekstone Drive , Suite 200, Durham, NC, 27703, USA
| | - Jorge Guillermo Boretto
- Department of Orthopaedics, Instituto de Ortopedia y Traumatología "Carlos E. Ottolenghi", Hospital Italiano de Buenos Aires, Buenos Aires, Argentina, Potosí 4215 (C1199ACK), Buenos Aires, Argentina
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Chamseddine AH, El-Hajj OM, Haidar IM, Rahal MJH, Farhat HS, Hellani AA, Asfour AH, Zeyneddin MM. Minimally invasive percutaneous plate osteosynthesis for treatment of proximal humeral shaft fractures. INTERNATIONAL ORTHOPAEDICS 2020; 45:253-263. [PMID: 33094402 DOI: 10.1007/s00264-020-04858-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 10/15/2020] [Indexed: 12/28/2022]
Abstract
PURPOSE The objective of this study was to evaluate the feasibility and safety of a minimally invasive percutaneous plate osteosynthesis (MIPPO) procedure for proximal humeral shaft fractures using lateral minimal proximal and distal approaches and lateral bridge plating with primary radial nerve control, and to assess its clinical and radiographic outcomes. METHODS A retrospective review was done for the medical records of adult patients admitted for fracture of the proximal humeral shaft without associated injury to the ipsilateral upper limb and who consented to undergo a novel MIPPO technique herein reported. Patients were reviewed at regular follow-up periods and assessed at a final follow-up for evaluation of Constant, normalized Constant, and QuickDASH scores. RESULTS There were 21 adult patients with mean age of 56 years. Three patients were lost from early follow-up; one of them had post-operative radial nerve paralysis. Eighteen patients were reviewed for the purpose of this study at a mean of 20 months of final follow-up; among them, one patient developed post-operative radial nerve paralysis with complete recovery after three months. Bone healing was achieved without any malalignment in 17 patients at a mean of 15 weeks, and one patient developed nonunion. At final assessment (mean, 20 months), the mean values of Constant, normalized Constant, and QuickDASH scores were 84 (range, 59 to 100), 95 (range, 73 to 100), and 5 (range, 0 to 18.2) respectively. CONCLUSION Compared to pre-reported methods of MIPPO, this technique of lateral proximal and distal mini-approaches with lateral bridge plating after primary control of the radial nerve seems safe and feasible for proximal humeral shaft fractures. It gives good clinical and radiographic results with excellent restoration of upper limb function, very low incidence of post-operative radial nerve injury, and high rate of bone union in good alignment.
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Affiliation(s)
- Ali Hassan Chamseddine
- Division of Orthopaedic and Trauma Surgery, Sahel General Hospital, University Medical Centre, PO Box: 99/25, Airport Road, Ghoubeiry, Beirut, Lebanon.
| | - Oussama M El-Hajj
- Division of Orthopaedic and Trauma Surgery, Sahel General Hospital, University Medical Centre, PO Box: 99/25, Airport Road, Ghoubeiry, Beirut, Lebanon
| | - Ibrahim M Haidar
- Division of Orthopaedic and Trauma Surgery, Sahel General Hospital, University Medical Centre, PO Box: 99/25, Airport Road, Ghoubeiry, Beirut, Lebanon
| | - Mohammad Jawad H Rahal
- Division of Orthopaedic and Trauma Surgery, Sahel General Hospital, University Medical Centre, PO Box: 99/25, Airport Road, Ghoubeiry, Beirut, Lebanon
| | - Hussein S Farhat
- Division of Orthopaedic and Trauma Surgery, Sahel General Hospital, University Medical Centre, PO Box: 99/25, Airport Road, Ghoubeiry, Beirut, Lebanon
| | - Ali A Hellani
- Division of Orthopaedic and Trauma Surgery, Sahel General Hospital, University Medical Centre, PO Box: 99/25, Airport Road, Ghoubeiry, Beirut, Lebanon
| | - Ali H Asfour
- Division of Orthopaedic and Trauma Surgery, Sahel General Hospital, University Medical Centre, PO Box: 99/25, Airport Road, Ghoubeiry, Beirut, Lebanon
| | - Mariam M Zeyneddin
- Division of Orthopaedic and Trauma Surgery, Sahel General Hospital, University Medical Centre, PO Box: 99/25, Airport Road, Ghoubeiry, Beirut, Lebanon
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Anterior minimally invasive plating osteosynthesis using reversed proximal humeral internal locking system plate for distal humeral shaft fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2020; 30:1515-1521. [PMID: 32468266 DOI: 10.1007/s00590-020-02708-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 05/22/2020] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To describe the surgical application of anterior minimally invasive plating osteosynthesis (MIPO) using reversed proximal humerus internal locking system (PHILOS) plate for multifragmentary distal humeral shaft fractures. METHODS Twelve patients with distal humeral shaft fractures (type 12B, n = 6 and type 12C, n = 6) were operated on by anterior MIPO and reversed PHILOS plate fixation. The amount of intact bone in the distal fragment was measured by fracture-to-coronoid distance (FCD). Data of the postoperative alignment, complications, union time, and clinical outcomes were collected. RESULTS The mean time for fractures to unite in all patients was 14.8 weeks (range 12-22). There was no perioperative complication. The mean FCD was 4.8 cm (range 2.1-8.1). The mean coronal angulation was 3.4° (range 0-9), and the mean sagittal angulation was 1° (range 0-5). All patients had excellent UCLA shoulder score and MEP score results, and the mean range of elbow motion was 140° (range 130-145). CONCLUSION Anterior MIPO using reversed PHILOS plate is safe and effective for multifragmentary fractures of the distal humeral shaft even in a fracture with a length of intact bone above the coronoid fossa of only 2 cm.
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Negrillo-Cárdenas J, Jiménez-Pérez JR, Cañada-Oya H, Feito FR, Delgado-Martínez AD. Automatic detection of landmarks for the analysis of a reduction of supracondylar fractures of the humerus. Med Image Anal 2020; 64:101729. [PMID: 32622119 DOI: 10.1016/j.media.2020.101729] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 05/13/2020] [Accepted: 05/18/2020] [Indexed: 02/07/2023]
Abstract
An accurate identification of bone features is required by modern orthopedics to improve patient recovery. The analysis of landmarks enables the planning of a fracture reduction surgery, designing prostheses or fixation devices, and showing deformities accurately. The recognition of these features was previously performed manually. However, this long and tedious process provided insufficient accuracy. In this paper, we propose a geometrically-based algorithm that automatically detects the most significant landmarks of a humerus. By employing contralateral images of the upper limb, a side-to-side study of the landmarks is also conducted to analyze the goodness of supracondylar fracture reductions. We conclude that a reduction can be classified by only considering the detected landmarks. In addition, our technique does not require a prior training, thus becoming a reliable alternative to treat this kind of fractures.
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Affiliation(s)
| | | | | | - Francisco R Feito
- Graphics and Geomatics Group of Jaén, University of Jaén, Jaén, Spain
| | - Alberto D Delgado-Martínez
- Department of Orthopedic Surgery, Complejo Hospitalario de Jaén, Jaén, Spain; Department of Health Sciences, University of Jaén, Jaén, Spain
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Cañada-Oya H, Cañada-Oya S, Zarzuela-Jiménez C, Delgado-Martinez AD. New, Minimally Invasive, Anteromedial-Distal Approach for Plate Osteosynthesis of Distal-Third Humeral Shaft Fractures: An Anatomical Study. JB JS Open Access 2020; 5:e0056. [PMID: 32309762 PMCID: PMC7147638 DOI: 10.2106/jbjs.oa.19.00056] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background: Fractures of the distal third of the humeral shaft remain a challenge today. Plate osteosynthesis is the most commonly used method of treatment. Current minimally invasive plate osteosynthesis (MIPO) techniques applied to the distal part of the humerus have shown a high risk of radial nerve injury, and they are unable to adequately fix distal-most fractures. Our hypothesis was that using a new MIPO approach, distal humeral shaft fractures can be safely fixed. The aim of this study was to develop this new anteromedial-distal MIPO approach. Methods: We conducted a laboratory descriptive study using 16 arms from adult human specimens. A new anteromedial-distal MIPO approach, starting distally through a small window in the pronator teres muscle, was developed. A premolded plate was introduced in the anterior side of the medial epicondylar area, through the anterior face of the humerus, up to the proximal part of the humeral shaft. Several anatomical parameters were measured on dissection to define the distances of the plate and screws to the neurovascular structures that could be at risk. Results: The radial nerve was not at risk because of its pathway through the posterior and lateral aspects of the arm. The mean distance from the most distal border of the medial epicondyle to the proximal border of the coronoid fossa was 3.36 cm (95% confidence interval [CI], 3.23 to 3.50 cm). At least 3 screws could be inserted in all specimens in this area and up to 5 when the fixation area was extended 2 cm proximally. The mean width of the medial epicondylar area was 2.19 cm (95% CI, 2.03 to 2.33 cm), space enough for the distal fixation of the plate. The ulnar nerve was at risk only from the tip of the most distal screw (mean distance of 2.50 mm; 95% CI, 1.60 to 3.40 mm) in specimens with a very narrow medial epicondylar area. Conclusions: This approach provides adequate fixation for distal humeral shaft fractures, but proper clinical studies must be undertaken. Clinical Relevance: This new approach avoids the risk of radial nerve injury.
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Affiliation(s)
| | - Sabina Cañada-Oya
- Department of Orthopaedic Surgery, Hospital Virgen de la Victoria, Málaga, Spain
| | | | - Alberto D Delgado-Martinez
- Department of Orthopaedic Surgery, Complejo Hospitalario de Jaén, Jaén, Spain.,Department of Surgery, University of Jaen, Jaen, Spain
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Wen H, Zhu S, Li C, Chen Z, Yang H, Xu Y. Antegrade intramedullary nail versus plate fixation in the treatment of humeral shaft fractures: An update meta-analysis. Medicine (Baltimore) 2019; 98:e17952. [PMID: 31725653 PMCID: PMC6867742 DOI: 10.1097/md.0000000000017952] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
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.
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Affiliation(s)
- Hongjie Wen
- Department of Orthopaedic Surgery, The Fourth Affiliated Hospital of Kunming Medical University
| | - Shouyan Zhu
- Department of Radiology, The Second People's Hospital of Yunnan
| | - Canzhang Li
- Department of Orthopaedic Surgery, The Fourth Affiliated Hospital of Kunming Medical University
| | - Zhong Chen
- Department of Orthopaedic Surgery, The Fourth Affiliated Hospital of Kunming Medical University
| | - Huagang Yang
- Department of Orthopaedic Surgery, The Fourth Affiliated Hospital of Kunming Medical University
| | - Yongqing Xu
- Department of Orthopaedic Surgery, 920th Hospital of Joint Logistics Support Force, Kunming Medical University, Kunming, China
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Buranaphatthana T, Apivatthakakul T, Apivatthakakul V. Anteromedial minimally invasive plate osteosynthesis (MIPO) for distal third humeral shaft fractures - Is it possible?: A cadaveric study. Injury 2019; 50:1166-1174. [PMID: 31072594 DOI: 10.1016/j.injury.2019.04.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 04/08/2019] [Accepted: 04/28/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The purpose of this study was to evaluate the feasibility of the anteromedial minimally invasive plate osteosynthesis (MIPO) approach for distal third humeral shaft fractures and identify neurovascular structures at risk with this approach. METHODS Twenty cadaveric arms were fixed with 12-hole precontoured narrow locking compression plates (LCP) with the anteromedial approach using MIPO technique. The proximal approach was done between the biceps and deltoid muscle directly to the bone. The distal approach involved elevating the brachialis from medial intermuscular septum. The plate was inserted beneath the brachialis tunnel from distal to proximal. Three locking screws were fixed at each end through incisions and the rest of screws were inserted percutaneously. The arms were then dissected to identify damage to or direct contact between the screws and brachial artery (BA), median nerve (MN), musculocutaneous nerve (MCN), and radial nerve (RN). The distances from the screws to structures at risk, humeral length, and length of three distal screws in mediolateral (ML) direction were measured. RESULTS The average humeral length was 28.97 cm. The average danger zone for the BA and MN were 20.47%-62.66% of the humeral length from the lateral epicondyle, and 20.47%-75.02% for the MCN. The ulnar nerve was not endangered by this approach as it lies posteromedially to the humerus. The danger zone for the RN averaged 27.07%-43.74%, and the most dangerous screw that either penetrated or touched the nerve was at the fifth hole, which lay at 33.14% of the humeral length. The average length of three distal screws in ML direction were 41.4, 25.0 and 22.5 mm. CONCLUSIONS The anteromedial MIPO approach can be performed through the internervous plane beneath the brachialis muscle without exposing any nerves or causing any muscle splitting with a 12-hole plate. Both proximal and distal screw insertion must be done with direct exposure. Insertion of percutaneous screws in the middle part of the plate between the two incisions is not possible. This approach could be an alternative for extra-articular distal third humeral shaft fractures which provides less invasive surgical dissection, allows the use of longer distal screws, and achieves better cosmesis.
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Affiliation(s)
- T Buranaphatthana
- Department of Orthopaedics, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
| | - T Apivatthakakul
- Department of Orthopaedics, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand; Musculoskeletal Science and Translational Research Center (MSTR), Chiang Mai University, Chiang Mai, 50200, Thailand.
| | - V Apivatthakakul
- Department of Orthopaedics, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
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Kulkarni VS, Kulkarni MS, Kulkarni GS, Goyal V, Kulkarni MG. Comparison between antegrade intramedullary nailing (IMN), open reduction plate osteosynthesis (ORPO) and minimally invasive plate osteosynthesis (MIPO) in treatment of humerus diaphyseal fractures. Injury 2017; 48 Suppl 2:S8-S13. [PMID: 28802426 DOI: 10.1016/s0020-1383(17)30487-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The three currently used methods of treatment: namely open reduction plate osteosynthesis (ORPO), Minimally invasive plate osteosynthesis (MIPO), antegrade intramedullary nailing(IMN) are all reported as satisfactory procedures for treatment of humeral shaft fractures. However none of the published reports have a comparison of superiority of one procedure over the other. We evaluated the clinical, radiological and functional outcome of the three procedures. MATERIALS AND METHODS We studied adult patients with humerus shaft fractures over a period of 2 years from May 2014 to May 2016 in a level 1 trauma center. Forty-four were treated with IMN, 34 treated with ORPO, and 34 with MIPO. The null hypothesis tested in this study is that there is no difference between IMN, ORPO, MIPO with respect to union time, surgical time, complication rate, non-union rate and functional outcome. Functional outcome was studied by comparing the UCLA shoulder and MEP scores in the three groups. RESULTS 112 patients were studied consisting of 83 males and 29 females with mean age of 39 years (range 18-70). IMN group showed early union with mean of 12.73 weeks compared to MIPO (14.45 weeks) and ORPO(13.58 weeks), (p<0.05). MIPO had no events of non-union, as compared to ORPO (5 non-unions) and IMN (10 non-unions), (p=0.04). The range of movement at the shoulder with the UCLA score was significantly better with a score of 32.26 in MIPO as compared to 27.54 in IMN and 28.82 in ORPO (p<0.05). The difference in MEPS score in the three groups was not significant (p=0.31). IMN required a mean of 117.95 minutes intraoperatively as compared to 131 and 150.58 mins in MIPO, ORPO respectively. CONCLUSION MIPO is overall better with respect to non-union, functional outcome and complications rate. The surgical time depends on the surgeons' skill and learning curve. Thus considering the advantages and risks involved in the various procedure and surgical acumen, each case should be individualized to have a good outcome. We advocate that MIPO can be safely used as an alternative in treating these fractures.
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Affiliation(s)
- Vidisha Sunil Kulkarni
- Department of Orthopaedics and Trauma, Swasthiyog Pratishthan Fracture and Orthopaedic Hospital, Miraj 416410, India
| | - Madhura Sujay Kulkarni
- Department of Orthopaedics and Trauma, Swasthiyog Pratishthan Fracture and Orthopaedic Hospital, Miraj 416410, India.
| | - Govind Shivram Kulkarni
- Department of Orthopaedics and Trauma, Swasthiyog Pratishthan Fracture and Orthopaedic Hospital, Miraj 416410, India
| | - Vaibhav Goyal
- Department of Orthopaedics and Trauma, Swasthiyog Pratishthan Fracture and Orthopaedic Hospital, Miraj 416410, India
| | - Milind Govind Kulkarni
- Department of Orthopaedics and Trauma, Swasthiyog Pratishthan Fracture and Orthopaedic Hospital, Miraj 416410, India
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Zhang Q, Sun N, Huang Q, Zhu S, Wu X. Minimally Invasive Plating Osteosynthesis in the Treatment of Humeral Shaft Fractures: A Meta-Analysis. J INVEST SURG 2016; 30:133-142. [PMID: 27612003 DOI: 10.1080/08941939.2016.1215581] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Whether minimally invasive plating osteosynthesis (MIPO) or other operative interventions is superior in the treatment of humeral shaft fractures remains controversial. Therefore, we conducted a meta-analysis to quantitatively compare the clinical outcomes of MIPO and other operative interventions in the treatment of humeral shaft fractures. METHODS Pubmed, Embase, and Web of Science were systematically searched to identify all available studies comparing clinical outcomes between patients receiving MIPO and other operative interventions. The weight mean difference (WMD) was pooled to compare the operative time, union time, University of California, Los Angeles (UCLA) score, and Mayo elbow performance index (MEPI).The risk ratio (RR) was pooled to compare the union rate, and incidence of complications. Pooled estimates were calculated by using a fixed-effects model or a randomized-effects model, according to the heterogeneity among studies. RESULTS Nine studies were included in this meta-analysis. Our results suggest that both MIPO and other operative interventions can achieve similar union time, UCLA score, MEPI, and union rate. However, MIPO is associated with better outcomes including shorter operation time, and lower incidence of radial nerve injury. CONCLUSION Evidence from this meta-analysis demonstrated that, MIPO is effective but safer than other operative interventions in the treatment of humeral shaft fracture. However, due to the potential limitations in this meta-analysis, randomized controlled trials with larger sample sizes using appropriate blinding methods are needed to confirm these findings.
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Affiliation(s)
- Quan Zhang
- a Department of Orthopedic Traumatology , Beijing Jishuitan Hospital , China
| | - Ning Sun
- a Department of Orthopedic Traumatology , Beijing Jishuitan Hospital , China
| | - Qiang Huang
- a Department of Orthopedic Traumatology , Beijing Jishuitan Hospital , China
| | - Shiwen Zhu
- a Department of Orthopedic Traumatology , Beijing Jishuitan Hospital , China
| | - Xinbao Wu
- a Department of Orthopedic Traumatology , Beijing Jishuitan Hospital , China
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