Management of humeral impending or pathological fractures with intramedullary nailing: reaming versus non reaming technique-a retrospective comparative study

PURPOSE

To compare reamed intramedullary nailing (RIM) versus un-reamed intramedullary nailing (URIM) for the treatment of impending and pathological fractures of the humeral shaft in terms of 24-h postoperative pain, blood transfusion requirements, surgical time, surgical complications, medical complications, length of stay and consolidation rates.

METHODS

A retrospective comparative study between January 2013 and December 2018 was conducted. Student's t test, Mann-Whitney U and Chi-square tests were used to detect differences within the two study groups. Multiple linear regression was done to adjust for possible confounders.

RESULTS

A total of 53 patients (33 RIM vs. 20 URIM) underwent humeral nailing. Fifteen (28%) were impending fractures (7 RIM vs. 8 URIM). Multiple myeloma (49%) and metastatic carcinoma (39.6%) were the most common etiologies. Pain score (5.13 ± 0.68 RIM vs. 6.78 ± 0.62 URIM; p = 0.082) and total dose of opioids (33.125 ± 27.6 RIM vs. 33.3 ± 22.28 URIM; p = 0.462) showed similar results. Blood transfusion was more prevalent within RIM group (34.48% RIM vs. 20% URIM; p = 0.044) with a clinical tendency of higher blood loss (207.86 ± 150.83RIM vs. 127.00 ± 179.98 URIM; p = 0.092). There was a consolidation rate of 71.05% (27/38) with no statistical difference (73.08% (19/26) RIM vs. 66.67% (8/12) URIM; p = 0.685).

CONCLUSION

Our study suggests possible benefit of URIM in terms of less blood transfusions with no difference in consolidation rates. Even though without significance, a tendency to less blood loss, less events of systemic complication and lower length of stay was observed with URIM. Despite its limitations, this study can be used to design future prospective ventures that quantify patient-reported outcomes and provide more clear evidence.

Reduced Surgical Time and Higher Accuracy of Distal Locking with the Electromagnetic Targeting System in Humeral Shaft Intramedullary Nailing

Objective

To evaluate the efficacy of the electromagnetic distal targeting system in the treatment of humeral shaft fractures.

Methods

From January 2012 to December 2018, we retrospectively reviewed 60 patients with humeral shaft fractures treated by intramedullary nailing. Among 60 cases, 41 were men and 19 were women. The average age at surgery was 48.5 years (range, 21–81 years). We performed the same surgical procedure for all patients. According to the different distal locking technique used, all patients were divided into two groups. The standard fluoroscopic freehand technique was used for Group FH, while the electromagnetic real‐time targeting technique was used for Group EM. All procedures were performed by two senior surgeons. Overall surgical time, cases of complications, failure of distal locking, union time, and shoulder function assessment were recorded intraoperatively and during follow‐up.

Results

Twenty‐seven patients in Group FH and 33 patients in Group EM met the inclusion criteria. No significant difference was found in the demographic data of the two groups. The mean surgical time was 76.48 ± 10.73 min in Group FH and 65.61 ± 8.91 min in Group EM (P < 0.05), showing significant difference. Seven failures occurred in Group FH and two failures occurred in Group EM (P < 0.05). No relevant complications were noted. The average union time was 3.37 ± 0.49 months in Group FH and 3.39 ± 0.50 months in Group EM (P = 0.855). The mean follow‐up was 14.30 ± 2.28 months in Group FH and 15.27 ± 2.83 months in Group EM (P = 0.153). The disabilities of the arm, shoulder and hand score (DASH) score, the range of motion (checked with the constant score), and the degree of functionality were, respectively, 21.52 ± 3.23, 27.04 ± 1.84, and 81.31% ± 3.88% in Group FH and 19.09 ± 2.40, 26.18 ± 1.70, and 77.97% ± 3.91% in Group EM (P = 0.233, 0.971, and 0.607).

Conclusion

The electromagnetic real‐time targeting system reduced surgical time and improved accuracy, and there was no radiation exposure in the distal locking procedure for humeral shaft fractures.

Complications after interlocking intramedullary nailing of humeral shaft fractures

INTRODUCTION

IM nails have gained popularity for stabilization of humeral shaft fractures (HSF). The initial enthusiasm was tempered by a number of specific complications and thus indications need to be re-evaluated.

PATIENTS AND METHODS

This retrospective study includes 111 patients with HSF subjected to a treatment protocol of IM fixation with first and second generation of humeral nails. Antegrade approach was used in 105 (94.5%) and retrograde in 6 (5.5%) patients. Reaming was performed in 51 (45.9%) fractures. The study covers a period of 10 years. Mean follow-up time was 3.5 (1-6) years. This investigation is directed at technical errors and complications, especially those corrected by secondary surgery.

RESULTS

We registered 52 (46.85%) intra-operative complications in 40 (36.04%) patients, on average 1.3 per patient. The most common were: distraction n=5 (4.5%), long proximal locking screws n=9 (8.1%), additional diaphyseal fracture n=7 (6.3%) and countersinking of the nail in the humeral head n=8 (7.2%). The number of postoperative complications was 40 (36.0%) related to 19 (17.1%) patients. Technical errors, such as distraction, longer nail and additional fractures have affected time to union and resulted in chronic shoulder pain. 36 (32.5%) secondary surgeries were needed to address these problems. When first generation nails are used, the intra-operative complication related risk increases 1.58 times, and the postoperative complication related risk is 1.67 times higher compared to second generation nails. According to Constant-Murley score excellent and very good functional results were achieved in 93 (83.78%) patients. While reaming did not influence the clinical results for both nail generations, overall better results were achieved with second generation nails. Postoperative shoulder pain has been registered in 18 (16.2%) patients.

CONCLUSION

We registered a number of technical errors and complications, which we consider technique specific. The analysis and avoidance of these complications, related only to IM nailing of the humerus, will allow IM nails to successfully bridge the gap between functional bracing and plating.

Diaphyseal humeral fractures and intramedullary nailing: Can we improve outcomes?

While intramedullary nailing has been established as the treatment of choice for diaphyseal fractures of the femur and tibia, its role in the management of diaphyseal humeral fractures remains controversial. The reasons include not only the complicated anatomy and unique biomechanical characteristics of the arm but also the fact that surgical technique and nail designs devised for the treatment of femoral and tibial fractures are being transposed to the humerus. As a result there is no consensus on many aspects of the humeral nailing procedure, e.g., the basic nail design, nail selection criteria, timing of the procedure, and the fundamental principles of the surgical technique (e.g., antegrade/retrograde, reamed/unreamed, and static/dynamic). These issues will be analyzed and discussed in the present article. Proposals aiming to improve outcomes include the categorization of humeral nails in two distinct groups: "fixed" and "bio", avoidance of reaming for the antegrade technique and utilization of "semi-reaming" for the retrograde technique, guidelines for reducing complications, setting the best "timing" for nailing and criteria for selecting the most appropriate surgical technique (antegrade or retrograde). Finally, suggestions are made on proper planning and conducting clinical and biomechanical studies regarding the use of intramedullary nailing in the management of humeral shaft fractures.

Fixed intramedullary nailing and percutaneous autologous concentrated bone-marrow grafting can promote bone healing in humeral-shaft fractures with delayed union

Treatment of humeral diaphyseal nonunion can be difficult and usually requires an extensive approach to the humerus with bone grafting, a procedure that could result in a lengthy operation with significant morbidity for the patient. The purpose of the present study is to describe a novel minimally invasive technique for the treatment of humeral-shaft fractures that do not demonstrate union progress within 16-24 weeks of injury. Fixed intramedullary nailing with percutaneously harvested and introduced autologous concentrated bone-marrow cells (mixed with demineralised bone matrix putty) was successfully used to treat five patients who had delayed union of a humeral-shaft fracture. The procedure was minimally invasive with no complications and resulted in sound union of all cases within 20 weeks.

Intramedullary nailing of combined/extended fractures of the humeral head and shaft

OBJECTIVES

To evaluate the use of intramedullary nailing in the management of both "combined" and "extended" fractures of the humeral head and shaft.

DESIGN

Retrospective case series study.

SETTING

Level I trauma center.

PATIENTS AND INTERVENTION

Twenty-one consecutive patients who underwent intramedullary nail insertion for "extended" or "combined," closed, nonpathologic fractures of the humeral head and shaft between October 1999 and December 2006 were included in the study. Two patients were lost to follow up and one died before fracture healing.

MAIN OUTCOME MEASUREMENTS

Evaluation of outcomes was assessed with the use of the Constant score.

RESULTS

There were no neurovascular problems or infections. Eighteen fractures united from 4 to 7 months postoperatively. One case of avascular necrosis of the humeral head, one case of acromion impingement, and one case of unacceptable loss of reduction occurred. Shoulder range of motion was not regained fully in any case and mild shoulder discomfort remained in eight patients. The mean Constant score for all 18 patients was 74.4 (range, 20-95) for the affected side and 89.17 points for the uninjured side. The percentage created from the mean affected/unaffected side scores was 83.4%.

CONCLUSIONS

Intramedullary nailing for proximal humeral fractures associated with shaft extension or segmental involvement appears to offer a reliable treatment option.

A new modular nail for the diaphyseal fractures of the humerus

Over a period of 5 years, 63 traumatic and eight pathological diaphyseal humeral fractures were treated with a new modular humeral nail. The nail is cannulated, square in shape--with concave sides--and has two different extensions that can be used with either the antegrade or the retrograde approach. Adequate rotational and axial stability is provided without the need for distal locking screws in the majority of fractures, while the need for proximal locking screws during the antegrade procedure is abolished. This study aims to present the 'Garnavos' nail and the results of its use, along with proposals and guidelines that should be considered whenever intramedullary nailing is selected for the treatment of diaphyseal humeral fractures.

Arthroscopic removal of an intramedullary nail in the humerus

The most frequent criticism of antegrade humeral nailing is its potentially deleterious effect on shoulder function owing to the trauma to the rotator cuff at the insertion point. This problem may also occur when removing an intramedullary nail from the humerus. In an effort to decrease the trauma to the rotator cuff at the nail insertion site during removal of an intramedullary nail from the humerus and to allow recovery of shoulder function as soon as possible after removal, we performed arthroscopic removal of the intramedullary nail and arthroscopic rotator cuff repair. The advantages of this method include the fact that it is a less invasive approach, which causes minimal disruption of the rotator cuff, requires fewer days in hospital, and allows simultaneous arthroscopic correction of the accompanying lesion.

Antegrade interlocking nailing of humeral shaft fractures

The results of 39 humeral shaft fractures (37 patients) treated with antegrade locked nailing using a Russell-Taylor nail were reviewed. There were 30 acute fractures, 6 fractures malaligned in a hanging cast or brace, and 3 pathological fractures. Patient age ranged from 26 to 80 years (average, 59.7 years) and average follow-up was 25.7 months (range, 6-48 months). Fracture union was achieved in 92.3% of our cases, while shoulder function was excellent or good in 87.2% of cases. Antegrade locked nailing offers a dependable solution for the treatment of humeral shaft fractures, especially in polytrauma patients and cases of segmental or pathological fractures. Far less satisfactory results were obtained in comminuted fractures of the proximal third in the humerus, especially in osteoporotic patients, and we therefore advocate caution with the use of intramedullary nailing in this type of fracture. Certain technical aspects such as avoiding nailing the fracture in distraction, properly countersinking the tip of the nail, and achieving adequate fixation stability have been found to be of paramount importance to reduce the incidence of delayed union/non-union rate and to obtain better functional results from the shoulder joint.