Sub-muscular plating of the humerus: an emerging technique

Humeral shaft fracture: systematic review of non-operative and operative treatment

INTRODUCTION

Humeral shaft fractures can be treated non-operatively or operatively. The optimal management is subject to debate. The aim was to compare non-operative and operative treatment of a humeral shaft fracture in terms of fracture healing, complications, and functional outcome.

METHODS

Databases of Embase, Medline ALL, Web-of-Science Core Collection, and the Cochrane Central Register of Controlled Trials (CENTRAL) were systematically searched for publications reporting clinical and functional outcomes of humeral shaft fractures after non-operative treatment with a functional brace or operative treatment by intramedullary nailing (IMN; antegrade or retrograde) or plate osteosynthesis (open plating or minimally invasive). A pooled analysis of the results was performed using MedCalc.

RESULTS

A total of 173 studies, describing 11,868 patients, were included. The fracture healing rate for the non-operative group was 89% (95% confidence interval (CI) 84-92%), 94% (95% CI 92-95%) for the IMN group and 96% (95% CI 95-97%) for the plating group. The rate of secondary radial nerve palsies was 1% in patients treated non-operatively, 3% in the IMN, and 6% in the plating group. Intraoperative complications and implant failures occurred more frequently in the IMN group than in the plating group. The DASH score was the lowest (7/100; 95% CI 1-13) in the minimally invasive plate osteosynthesis group. The Constant-Murley and UCLA shoulder score were the highest [93/100 (95% CI 92-95) and 33/35 (95% CI 32-33), respectively] in the plating group.

CONCLUSION

This study suggests that even though all treatment modalities result in satisfactory outcomes, operative treatment is associated with the most favorable results. Disregarding secondary radial nerve palsy, specifically plate osteosynthesis seems to result in the highest fracture healing rates, least complications, and best functional outcomes compared with the other treatment modalities.

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

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

Submuscular double bridge plating for complex distal fractures of the humerus: an alternative, safe, and efficient treatment method

PURPOSE

The aim of our study is to show the functional outcomes and complication rates of humeral complex fractures in adults, using osteosynthesis with two bridging orthogonal submuscular plates.

METHODS

The study consists of a prospective case series of 13 patients with isolated humeral complex fractures treated with two bridging orthogonal submuscular plates. Functional assessment was performed using disabilities of the arm, shoulder, and hand (DASH) score with 30 items. The age ranged from 22 to 68 years, with a mean age of 39 years. Functional assessment with DASH score was performed at the twelfth postoperative week.

RESULTS

All patients presented fracture healing in the fourth postoperative month. Of the 13 patients, five (38%) had a DASH score of zero (best function possible). One patient developed neuropraxis and presented with a score of 100 (worst possible). One case developed superficial infection, which was treated with oral antibiotics and local debridement.

CONCLUSIONS

This study demonstrated satisfactory functional outcome in patients with distal-third diaphyseal humeral complex fractures treated with two locked submuscular plates. The authors consider it as a safe method and an efficient alternative, especially in younger patients who require early functional recovery.

Comparison of the effect on bone healing process of different implants used in minimally invasive plate osteosynthesis: limited contact dynamic compression plate versus locking compression plate

Minimally invasive plate osteosynthesis (MIPO) has been widely accepted because of its satisfactory clinical outcomes. However, the implant construct that works best for MIPO remains controversial. Different plate designs result in different influence mechanisms to blood flow. In this study, we created ulnar fractures in 42 beagle dogs and fixed the fractures using MIPO. The dogs were randomly divided into two groups and were fixed with a limited contact dynamic compression plate (LC-DCP) or a locking compression plate (LCP). Our study showed that with MIPO, there was no significant difference between the LCP and the LC-DCP in terms of fracture fixation, bone formation, or mineralization. Combined with the previous literature, we inferred that the healing process is affected by the quality of fracture reduction more than plate selection.

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

OBJECTIVES

To compare the risk of major complications after either minimally invasive plate osteosynthesis (MIPO) or intramedullary nailing (IMN) of humeral shaft fractures.

DESIGN

Retrospective, case-match controlled study.

SETTING

A major metropolitan tertiary referral trauma center in Australia.

PATIENTS

Thirty patients with fractures of the humeral shaft.

INTERVENTION

Either MIPO or IMN were performed on 15 patients each with traumatic humeral shaft fractures.

PRIMARY OUTCOME MEASURE

The cumulative risk of 3 major complications associated with these procedures: nonunion, infection, and iatrogenic radial nerve injury.

RESULTS

An overall major complication rate of 53% was observed in the patients treated with IMN; one complication (7%) was identified in those managed with humeral MIPO, a nonunion. Complications after IMN included 4 patients (27%) with nonunion, 3 patients (20%) with iatrogenic radial nerve injuries, and 1 patient (7%) with a wound infection. Statistical analysis revealed a significant between-group difference (P = 0.01) in the cumulative rate of major complications. When each of these complications was considered independently, no statistically significant difference was demonstrated.

CONCLUSIONS

This study suggests that humeral MIPO results in a significantly lower pooled major complication rate than that of IMN, and it should therefore be considered an attractive alternative to IMN in those patients requiring surgical stabilization of a traumatic humeral shaft fracture.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

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

HYPOTHESIS

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

METHODS

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

RESULTS

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

CONCLUSION

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