Virtual morphological comparison of three intramedullary nailing systems for the treatment of proximal humeral fractures

[An integrated approach for early recovery of function in patients after fractures of the humerus in its proximal section]

The frequency of fractures of the proximal humerus (PH) is 4-5% of fractures of all human bones and can reach 80% of all bone injuries of the humerus. An analysis of the long-term results of the methods used to treat fractures of the proximal humerus showed the absence of a generally accepted universal method that provides consistently good results for all variants of fractures of the PH.

PURPOSE OF THE STUDY

Creation of a complex highly effective system for the treatment of PH fractures, which includes a minimally invasive method of surgical treatment using the method of cephalomedullary osteosynthesis with direct locking pins and a highly specialized program of rehabilitation measures using a biofeedback (BFB) device, which will reduce the duration of treatment and improve the results of functional recovery injured limb.

MATERIAL AND METHODS

The results of treatment of 214 patients with fractures of the proximal humerus were analyzed. Of these, in 122 (57%) patients (the main group) osteosynthesis was used with a direct cephalomedullary fixator with the possibility of blocking the screws in the nail in different planes. The comparison group included 92 (43.0%) patients treated using other surgical techniques. Rehabilitation measures were started in the early postoperative period (from the 2nd day) in both groups and included a complex of physiotherapeutic treatment, physical exercises in different modes, in addition in the main group of the study, training was performed using a device with biofeedback.

RESULTS

It is shown that the used treatment approach allows to increase the frequency of achieving good and excellent (52.4% in the main group and 27.2% in the comparison group) results and reduce the frequency of unsatisfactory results of treatment (9.8% in the main group and 21.7% in the comparison group) on the Constant score.

CONCLUSION

The data obtained prove the high efficiency of the developed complex method for the treatment of proximal humerus fractures and restoration of the function of the upper limb.

Straight proximal humeral nailing: Risk of iatrogenic tendon injuries with respect to different entry points in anatomical specimens

BACKGROUND

The purpose of the study was to evaluate the relationship of implant-related injuries to the adjacent anatomical structures in a newer generation straight proximal humeral nail (PHN) regarding different entry points. The proximity of the proximal lateral locking-screws of the MultiLoc proximal humeral nail (ML PHN) may cause iatrogenic tendon injuries to the lateral edge of the bicipital humeral groove (BG) as reference point for the tendon of the long head of biceps brachii (LBT) as well as the lateral insertion of the infraspinatus tendon (IST).

MATERIALS AND METHODS

The study comprised n = 40 upper extremities. Nail application was performed through a deltoid approach and supraspinatus tendon (SSP) split with a ML PHN. All tests were performed in three different entry points. First nail (N1) - standard position in line with the humeral shaft axis; second nail (N2) - a more lateral entry point; third alternative (N3) - medial position, centre of the humeral head. After nail placement, each specimen was screened for potential implant-related injuries or worded differently hit rates (HR) to the BG and the IST. The distances to the anatomical structures were measured and statistically interpreted.

RESULTS

The observed iatrogenic IST injury rate was 17.5% (n = 7/40) for N1, 5% (n = 2/40) for N2 and 62.5% (n = 25/40) for N3, which was statistically significantly higher (p < 0.001). Regarding the BG, the evaluated HR was 7.5% (n = 3/40) for both N1 and N2. Only the nail placed in the head centre (N3) showed an iatrogenic injury rate of 20% (n = 8/40) (p < 0.062). No statistically significant association between humeral head size and the HR could be observed (head diameter: IST: p = 0.323, BG: p = 0.621; head circumference: IST: p = 0.167; BG: p = 0.940). For the IST and BG, all distances in nail positions N1 and N2 as well as N2 and N3 differ statistically significant (p < 0.001).

CONCLUSIONS

An entry point for nail placement in line or slightly laterally to the humeral shaft axis - but still at the cartilage - should be advocated.

Is it safe to assist proximal humeral nailing to residents? An analysis of 1134 cases

INTRODUCTION

Intramedullary nailing is a common procedure for the treatment of proximal humeral fractures. In practical resident training this standardized operation plays an important role in the introduction to osteosynthesis. Our aim was to investigate whether assisting this operation to residents influences the surgical complication rate both in-house and on re-admission.

METHODS

All 1134 patients who received a proximal humeral Targon PH nail (Aesculap) for proximal humeral fractures were included between 2000 and 2013. Several age groups (≤60 years, 61-70 years, 71-80 years, 80-90 years, and over 90 years) were analyzed separately. Complications including screw/nail protrusion, displacement, infection, humeral head necrosis, nonunion, stiffness, hematoma, impingement, screw loosening, implant failure, dislocation were recorded. 803 (70.7%) of the patients were female. Mean patient age was 71.7 years (standard deviation: 14.0 years). For detection of significantly different complication frequencies between operations performed by residents or attending physicians, we used the χ² test in cases with all expected values greater than five, otherwise we used the two-sided Fisher's exact test.

RESULTS

Supervised residents performed 204 operations. Overall complication rate was 12.6% (95% CI: 10.7-14.5%). The complication rate of the attending operations was 13.2% while it was 9.8% for resident operations. The difference was not significant. No statistically significant relation between age group and complication rate was found. In all patients older than 80 years the complication rate was higher when operated by residents compared to those operated by consultants, whereas in younger patients it was lower. Whereas the difference was not significant in patients younger than 60 and older than 80, we found significantly less complications in the group of patients between 61 and 80 years of age. On the other hand patients between 81 and 90 years displayed a 1.46 fold higher risk after training operations. No significant differences in the frequency of the different complications were found.

CONCLUSION

We conclude that proximal humeral nailing is an operation suitable for teaching purposes. However, patients between 81 and 90 years of age seem to be at an increased risk for complications if operated by a resident.

Long endomedullary nail in proximal third humeral shaft fractures

INTRODUCTION

Proximal humeral fractures with a spiral line of fracture extending from the humeral head to the diaphyseal region are increasing. Treatment for these fractures is comparable to that for shaft fractures. The purpose of this study was to evaluate the use of a new "Long" humeral nail for this type of lesion and identify the best distal locking.

MATERIALS AND METHODS

Forty-three patients treated with a Long Diphos Nail^® were selected for this study: main exclusion criteria were poor cognitive and responsive ability to physical therapy, four-part fracture requiring humeral head replacement, an isolated greater or lesser tubercle fracture and a head-splitting fracture. All patients were divided into two groups according to the distal locking (single or double) and clinically evaluated at 1, 3, 6 and 12 months after surgery. The following parameters were evaluated: fracture healing on radiographic images every month; level of pain with Visual Analogue Scale (VAS); recovery of shoulder function or ability to resume normal daily activities according to the Constant Scoring System (CSS); patient satisfaction; and complications, like fracture consolidation defect or delay. A statistical analysis was performed.

RESULTS

Improvements in pain, satisfaction and shoulder functional recovery were recorded. Patients reached fracture healing in two to six months. The mean healing time was better for double distal locking (p=0.04).There was a clinically greater difference (p=0.006) between the groups for the mean Constant score at 3 months follow-up, with better results for the double distal locking group. Complications were: one patient with a consolidation delay with a single distal locking screw breakage; it was necessary to remove the nail and perform a second treatment.

CONCLUSIONS

The results of the study indicate the efficacy of Long Diphos Nail^® in the treatment of fractures with a line of fracture extending to the proximal diaphyseal region. The features of a multiplane stabilisation above the fracture and a distal double locking may represent the key for a good fixation for 11-A2, A3 or B2 fractures with a long spiral line. A double distal locking reduces fracture micro-instability and so patients recover function and strength quicker because of less pain at the fracture site.

STUDY DESIGN

retrospective, cohort of cases.

LEVEL OF EVIDENCE

IV.