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Colasanti CA, Anil U, Cerasani MN, Li ZI, Morgan AM, Simovitch RW, Leucht P, Zuckerman JD. Management of Humeral Shaft Fracture: A Network Meta-Analysis of Individual Treatment Modalities. J Orthop Trauma 2024; 38:e257-e266. [PMID: 38578605 DOI: 10.1097/bot.0000000000002808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 03/11/2024] [Indexed: 04/06/2024]
Abstract
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.
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Affiliation(s)
| | - Utkarsh Anil
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY; and
| | - Michele N Cerasani
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY; and
| | - Zachary I Li
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY; and
| | - Allison M Morgan
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY; and
| | - Ryan W Simovitch
- Department of Orthopaedic Surgery, Hospital for Special Surgery, FL
| | - Philipp Leucht
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY; and
| | - Joseph D Zuckerman
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY; and
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Hurley ET, Wickman J, Crook BS, Cabell G, Rodriguez K, Boadi P, DeBaun MR, Pean C, Klifto C. Intramedullary nailing vs. open reduction-internal fixation for humeral shaft fractures: a meta-analysis of randomized controlled trials. J Shoulder Elbow Surg 2023; 32:2567-2574. [PMID: 37579941 DOI: 10.1016/j.jse.2023.07.015] [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: 04/12/2023] [Revised: 06/23/2023] [Accepted: 07/10/2023] [Indexed: 08/16/2023]
Abstract
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.
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Affiliation(s)
- Eoghan T Hurley
- Department of Orthopedic Surgery, Duke University School of Medicine, Durham, NC, USA.
| | - John Wickman
- Department of Orthopedic Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Bryan S Crook
- Department of Orthopedic Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Grant Cabell
- Department of Orthopedic Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Kaitlyn Rodriguez
- Department of Orthopedic Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Prince Boadi
- Department of Orthopedic Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Malcolm R DeBaun
- Department of Orthopedic Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Christian Pean
- Department of Orthopedic Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Christopher Klifto
- Department of Orthopedic Surgery, Duke University School of Medicine, Durham, NC, USA
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Lopiz Y, Garriguez-Pérez D, Román-Gómez J, Scarano-Pereira JP, Ponz-Lueza V, García-Fernandez C, Marco F. Shoulder problems after percutaneous antegrade intramedullary nailing in humeral diaphyseal fractures using contemporary straight third-generation nail. J Shoulder Elbow Surg 2023; 32:2317-2324. [PMID: 37245620 DOI: 10.1016/j.jse.2023.04.012] [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: 01/13/2023] [Revised: 03/28/2023] [Accepted: 04/05/2023] [Indexed: 05/30/2023]
Abstract
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.
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Affiliation(s)
- Yaiza Lopiz
- Shoulder and Elbow Unit, Department of Traumatology and Orthopaedic Surgery, Clínico San Carlos Hospital, Madrid, Spain; Department of Surgery, Complutense University, Madrid, Spain.
| | - Daniel Garriguez-Pérez
- Shoulder and Elbow Unit, Department of Traumatology and Orthopaedic Surgery, Clínico San Carlos Hospital, Madrid, Spain
| | - Julia Román-Gómez
- Shoulder and Elbow Unit, Department of Traumatology and Orthopaedic Surgery, Clínico San Carlos Hospital, Madrid, Spain
| | - Juan Pablo Scarano-Pereira
- Shoulder and Elbow Unit, Department of Traumatology and Orthopaedic Surgery, Clínico San Carlos Hospital, Madrid, Spain
| | - Virginia Ponz-Lueza
- Shoulder and Elbow Unit, Department of Traumatology and Orthopaedic Surgery, Clínico San Carlos Hospital, Madrid, Spain
| | - Carlos García-Fernandez
- Shoulder and Elbow Unit, Department of Traumatology and Orthopaedic Surgery, Clínico San Carlos Hospital, Madrid, Spain
| | - Fernando Marco
- Shoulder and Elbow Unit, Department of Traumatology and Orthopaedic Surgery, Clínico San Carlos Hospital, Madrid, Spain; Department of Surgery, Complutense University, Madrid, Spain
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Orapiriyakul W, Apivatthakakul V, Theppariyapol B, Apivatthakakul T. Humerus shaft fractures, approaches and management. J Clin Orthop Trauma 2023; 43:102230. [PMID: 37588079 PMCID: PMC10425411 DOI: 10.1016/j.jcot.2023.102230] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 06/30/2023] [Accepted: 08/03/2023] [Indexed: 08/18/2023] Open
Abstract
Humeral shaft fracture is a common injury which can be treated either conservatively with functional bracing or with surgical fixation. Current evidence shows an increase in the rate of nonunion after conservative treatment, suggesting that indications for conservative treatment may need to be re-examined. This article updates trends in treatment for humeral shaft fracture. Indications for surgery, both for plate osteosynthesis with open reduction and internal fixation (ORIF) as well as for minimally invasive plate osteosynthesis (MIPO) and intramedullary nailing (IMN) are described. Recognition of the advantages and disadvantages of each technique can better define the role of the plate or nail and can aid in the selection of an appropriate surgical approach. ORIF with compression plate continues to have a role in the treatment of simple or AO/OTA type A fractures. The primary goal of minimal invasive osteosynthesis, a surgical technique involving small incisions, closed reduction or mini-open reduction that minimizes soft tissue dissection and helps preserve the periosteal blood supply, is to achieve bone union and the best possible functional outcomes. MIPO of the humerus is now well accepted as being less invasive and providing relative stability to allow indirect (secondary) bone healing with callus formation. MIPO approaches can be performed circumferentially to the humerus, including the proximal, middle and distal shaft. The classic MIPO approach is anterior MIPO, followed by posterior, anterolateral and anteromedial MIPO. IMN is also an option for treating humerus fractures. In the past, IMN was not widely used due to the potential for complications such as shoulder impingement and elbow problems as well as the limited availability of implants and the steep learning curve of this surgical technique. Over the past decade, the launch of a new design of straight antegrade and retrograde IMN with established techniques has encouraged more surgeons to use IMN as an alternative option. Methods of dealing with concomitant and post-treatment radial nerve palsy have also been evolving, including the use of ultrasound for diagnosis of radial nerve conditions. Radial nerves with contusion, entrapment or laceration can be detected using ultrasound with reliability comparable to intraoperative findings. Trends in treatment of radial nerve palsy are described below. Future larger randomized controlled trials comparing conservative and operative management are necessary to further develop appropriate guidelines.
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Affiliation(s)
- Wich Orapiriyakul
- Department of Orthopedics, Faculty of Medicine, Prince of Songkla University, Songkhla, 90110, Thailand
| | - Varat Apivatthakakul
- Department of Orthopaedics, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
| | - Bodin Theppariyapol
- Department of Orthopaedics, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
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Zavras AG, Monahan KT, Winek NC, Pan T, Altman GT, Altman DT, Westrick ER. Conservative Management with Functional Brace Versus Various Surgical Fixation Techniques for Humeral Shaft Fractures: A Network Meta-Analysis. J Bone Joint Surg Am 2023; 105:1112-1122. [PMID: 37224234 DOI: 10.2106/jbjs.22.01374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
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.
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Affiliation(s)
- Athan G Zavras
- Department of Orthopaedic Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania
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Qiu H, Liu Y, Chen Y, Weng Z, Liu D, Dong J, Lu M. Treatment of humeral shaft fractures with different treatment methods: a network meta-analysis of randomized controlled trials. BMC Musculoskelet Disord 2023; 24:583. [PMID: 37460932 DOI: 10.1186/s12891-023-06626-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 06/12/2023] [Indexed: 07/20/2023] Open
Abstract
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.
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Affiliation(s)
- Hao Qiu
- Trauma Orthopedics and Hand Foot Ankle Surgery, The Ninth People's Hospital of Chongqing, Chongqing, 400700, China
| | - Yuting Liu
- Department of Endocrinology, The Ninth People's Hospital of Chongqing, Chongqing, 400700, China
| | - Yu Chen
- Trauma Orthopedics and Hand Foot Ankle Surgery, The Ninth People's Hospital of Chongqing, Chongqing, 400700, China
| | - Zheng Weng
- Trauma Orthopedics and Hand Foot Ankle Surgery, The Ninth People's Hospital of Chongqing, Chongqing, 400700, China
| | - Dun Liu
- Trauma Orthopedics and Hand Foot Ankle Surgery, The Ninth People's Hospital of Chongqing, Chongqing, 400700, China
| | - Jing Dong
- Department of Clinical Medicine, Chongqing Medical and Pharmaceutical College, Chongqing, 401331, China.
| | - Minpeng Lu
- Department of Pain Medicine, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.
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Beyer J, Rao B, Liu J, Skie M. Evaluation of Humeral Shaft Fracture Outcomes by Treatment Method: A Systematic Review and Meta-analysis Based on Comparison Studies. JBJS Rev 2023; 11:01874474-202307000-00004. [PMID: 37459427 DOI: 10.2106/jbjs.rvw.23.00037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
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.
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Affiliation(s)
- Julia Beyer
- Department of Orthopedic Surgery, University of Toledo Medical Center, Toledo, Ohio
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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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Belayneh R, Littlefield CP, Konda SR, Broder K, Kugelman DN, Leucht P, Egol KA. The standardized exploration of the radial nerve during humeral shaft fixation reduces the incidence of iatrogenic palsy. Arch Orthop Trauma Surg 2023; 143:125-131. [PMID: 34191088 DOI: 10.1007/s00402-021-04028-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 06/23/2021] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Rebekah Belayneh
- NYU Langone Orthopedic Hospital, 301 E 17th St, Suite 1402, New York, NY, 10003, USA
| | - Connor P Littlefield
- NYU Langone Orthopedic Hospital, 301 E 17th St, Suite 1402, New York, NY, 10003, USA
| | - Sanjit R Konda
- NYU Langone Orthopedic Hospital, 301 E 17th St, Suite 1402, New York, NY, 10003, USA.,Jamaica Hospital Medical Center, Jamaica, NY, USA
| | - Kari Broder
- NYU Langone Orthopedic Hospital, 301 E 17th St, Suite 1402, New York, NY, 10003, USA
| | - David N Kugelman
- NYU Langone Orthopedic Hospital, 301 E 17th St, Suite 1402, New York, NY, 10003, USA
| | - Philipp Leucht
- NYU Langone Orthopedic Hospital, 301 E 17th St, Suite 1402, New York, NY, 10003, USA
| | - Kenneth A Egol
- NYU Langone Orthopedic Hospital, 301 E 17th St, Suite 1402, New York, NY, 10003, USA. .,Jamaica Hospital Medical Center, Jamaica, NY, USA.
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10
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Saracco M, Fulchignoni C, Fusco F, Logroscino G. WHICH SURGICAL TREATMENT IS PREFERABLE IN HUMERAL DIAPHYSEAL FRACTURES? A SYSTEMATIC REVIEW. Orthop Rev (Pavia) 2022; 14:37575. [PMID: 36034729 PMCID: PMC9404283 DOI: 10.52965/001c.37575] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
Abstract
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.
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Affiliation(s)
- Michela Saracco
- Department of Orthopaedics, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma - Università Cattolica del Sacro Cuore, Rome, Italy
| | - Camillo Fulchignoni
- Department of Orthopaedics, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma - Università Cattolica del Sacro Cuore, Rome, Italy
| | - Fabrizio Fusco
- Department of Orthopaedics and Trauma, Osp. "San Giovanni di Dio" - ASL Napoli 2 Nord, Napoli, Italy
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Hu Y, Wu T, Li B, Huang Y, Huang C, Luo Y. Efficacy and Safety Evaluation of Intramedullary Nail and Locking Compression Plate in the Treatment of Humeral Shaft Fractures: A Systematic Review and Meta-analysis. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:5759233. [PMID: 35799627 PMCID: PMC9256344 DOI: 10.1155/2022/5759233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 06/16/2022] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Yong Hu
- Departments of Orthopedics, Danzhou People's Hospital, Danzhou, 571700 Hainan, China
| | - Tianhui Wu
- Departments of Orthopedics, People's Hospital of Wanning Hainan, Wanning, 571500 Hainan, China
| | - Baolin Li
- Departments of Orthopedics, Danzhou People's Hospital, Danzhou, 571700 Hainan, China
| | - Yongxiang Huang
- Departments of Orthopedics, Danzhou People's Hospital, Danzhou, 571700 Hainan, China
| | - Changqiang Huang
- Departments of Orthopedics, Danzhou People's Hospital, Danzhou, 571700 Hainan, China
| | - Yilin Luo
- Department of Trauma Surgery, Qionghai People's Hospital, Qionghai, 571400 Hainan, China
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12
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Functional and clinical outcome after operative versus nonoperative treatment of a humeral shaft fracture (HUMMER): results of a multicenter prospective cohort study. Eur J Trauma Emerg Surg 2022; 48:3265-3277. [PMID: 35138426 PMCID: PMC9360107 DOI: 10.1007/s00068-022-01890-6] [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: 09/27/2021] [Accepted: 01/21/2022] [Indexed: 11/25/2022]
Abstract
Purpose The best treatment of humeral shaft fractures in adults is still under debate. This study aimed to compare functional and clinical outcome of operative versus nonoperative treatment in adult patients with a humeral shaft fracture. We hypothesized that operative treatment would result in earlier functional recovery. Methods From October 23, 2012 to October 03, 2018, adults with a humeral shaft fracture AO type 12A or 12B were enrolled in a prospective cohort study in 29 hospitals. Patients were treated operatively or nonoperatively. Outcome measures were the Disabilities of the Arm, Shoulder, and Hand score (DASH; primary outcome), Constant–Murley score, pain (Visual Analog Score, VAS), health-related quality of life (Short Form-36 (SF-36) and EuroQoL-5D-3L (EQ-5D)), activity resumption (Numeric Rating Scale, NRS), range of motion (ROM) of the shoulder and elbow joint, radiologic healing, and complications. Patients were followed for one year. Repeated measure analysis was done with correction for age, gender, and fracture type. Results Of the 390 included patients, 245 underwent osteosynthesis and 145 were primarily treated nonoperatively. Patients in the operative group were younger (median 53 versus 62 years; p < 0.001) and less frequently female (54.3% versus 64.8%; p = 0.044). Superior results in favor of the operative group were noted until six months follow-up for the DASH, Constant–Murley, abduction, anteflexion, and external rotation of the shoulder, and flexion and extension of the elbow. The EQ-US, and pronation and supination showed superior results for the operative group until six weeks follow-up. Malalignment occurred only in the nonoperative group (N = 14; 9.7%). In 19 patients with implant-related complications (N = 26; 10.6%) the implant was exchanged or removed. Nonunion occurred more often in the nonoperative group (26.3% versus 10.10% in the operative group; p < 0.001). Conclusion Primary osteosynthesis of a humeral shaft fracture (AO type 12A and 12B) in adults is safe and superior to nonoperative treatment, and should therefore be the treatment of choice. It is associated with a more than twofold reduced risk of nonunion, earlier functional recovery and a better range of motion of the shoulder and elbow joint than nonoperative treatment. Even after including the implant-related complications, the overall rate of complications as well as secondary surgical interventions was highest in the nonoperative group. Trial registration NTR3617 (registration date 18-SEP-2012). Supplementary Information The online version contains supplementary material available at 10.1007/s00068-022-01890-6.
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13
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Beeres FJP, van Veelen N, Houwert RM, Link BC, Heng M, Knobe M, Groenwold RHH, Babst R, van de Wall BJM. Open plate fixation versus nailing for humeral shaft fractures: a meta-analysis and systematic review of randomised clinical trials and observational studies. Eur J Trauma Emerg Surg 2021; 48:2667-2682. [PMID: 34219193 DOI: 10.1007/s00068-021-01728-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 06/08/2021] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Frank Joseph Paulus Beeres
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Spitalstrasse 16, 6000, Luzern, Switzerland
| | - Nicole van Veelen
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Spitalstrasse 16, 6000, Luzern, Switzerland
| | - Roderick Marijn Houwert
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Björn Christian Link
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Spitalstrasse 16, 6000, Luzern, Switzerland
| | - Marilyn Heng
- Department of Orthopedic Surgery, Harvard Medical School Orthopedic Trauma Initiative, Massachusetts General Hospital Boston, Boston, USA
| | - Matthias Knobe
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Spitalstrasse 16, 6000, Luzern, Switzerland
| | | | - Reto Babst
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Spitalstrasse 16, 6000, Luzern, Switzerland.,Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Bryan Joost Marinus van de Wall
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Spitalstrasse 16, 6000, Luzern, Switzerland. .,Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland.
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14
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[Antegrade and retrograde nailing of humeral shaft fractures]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2021; 33:139-159. [PMID: 33825914 DOI: 10.1007/s00064-021-00706-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 11/11/2020] [Accepted: 11/15/2020] [Indexed: 10/21/2022]
Abstract
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.
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Comparison of "Bilboquet" device and locking plate for surgical treatment of proximal humerus complex fractures at two years follow-up. INTERNATIONAL ORTHOPAEDICS 2021; 45:1811-1816. [PMID: 33629174 DOI: 10.1007/s00264-021-04967-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Accepted: 02/02/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE Surgical treatment of three or four part fractures of the proximal humerus is complex. Different conservative techniques have been described. The main goal of this study was to compare the clinical and radiological outcomes of Bilboquet and locking plate at two year follow-up. METHODS This is a retrospective, comparative study, with a continuous series of 41 patients. Bony fixation was achieved with a Bilboquet device in 22 patients or a locking plate in 19 patients. Patient evaluation included clinical data: shoulder range of motion, Constant-Murley shoulder score and DASH (Disabilities of the Arm, Shoulder and Hand) score, and imaging using standard shoulder X-rays. RESULTS Of the 41 patients included, 1 patient was lost to follow-up in the locking plate group. At a mean follow-up of 24 months patients in Bilboquet group showed a Constant score higher than in locking plate (p = 0.02). Range of motion and DASH score were not significantly different between the two groups. avascular necrosis occured in three patients of Bilboquet group (14%) versus in two patients in the locking plate group (11%) (p > 0.5). Complication and reintervention rate were non-significantly higher in the locking plate group than in the Bilboquet group (37 vs 14%). CONCLUSION Bilboquet and locking plate give good functional outcomes in complex proximal humerus fractures. However, the Bilboquet device appears to provide better functional results than locking plate at mid-term follow-up.
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