Closed interlocking nailing of humeral shaft fractures with the Russell-Taylor nail

Risk factors of poor mid-term shoulder functional outcomes of osteosynthesis using antegrade intramedullary nailing for humeral shaft fractures: a retrospective study with a minimum 5-year follow-up

BACKGROUND

Osteosynthesis using antegrade intramedullary nailing for humeral shaft fractures yields satisfactory bone union rates; however, it may adversely affect postoperative shoulder function. To date, factors affecting mid- or long-term shoulder functional outcomes following intramedullary nail fixation have not been clarified. In this study, we aimed to identify the risk factors for poor mid-term functional outcomes over 5 years postoperatively following antegrade intramedullary nail osteosynthesis for humeral shaft fractures.

METHODS

We retrospectively identified 33 patients who underwent surgery using an antegrade intramedullary nail for acute traumatic humeral shaft fractures and were followed up for at least 5 years postoperatively. We divided the patients into clinical failure and no clinical failure groups using an age- and sex-adjusted Constant score of 55 at the final follow-up as the cutoff value. We compared preoperative, perioperative, and postoperative factors between the two groups.

RESULTS

Five of the 33 patients had poor shoulder functional outcomes (adjusted Constant score < 55) at a mean follow-up of 7.5 years postoperatively. Proximal protrusion of the nail at the time of bone union (P = 0.004) and older age (P = 0.009) were significantly associated with clinical failure in the univariate analyses. Multivariate analysis showed that proximal protrusion of the nail (P = 0.031) was a risk factor for poor outcomes.

CONCLUSIONS

The findings of this study provide new information on predictive factors affecting mid-term outcomes following osteosynthesis using antegrade nails. Our results demonstrated that proximal protrusion of the nail was significantly associated with poor mid-term functional shoulder outcomes. Therefore, particularly in older adults, it is essential to place the proximal end of the intramedullary nail below the level of the articular cartilage.

Antegrade intramedullary locking nail in the management of proximal and middle thirds of humeral diaphyseal fractures

PURPOSE

The aim of the study was to evaluate the antegrade intramedullary locking nail osteosynthesis for the treatment of the proximal and middle thirds of humeral shaft fractures.

METHODS

A retrospective study was made on 218 patients diagnosed with humeral diaphysis fractures who undergo surgery with antegrade intramedullary locking nail between January 2017 and December 2021. The clinical follow-up started two days after surgery and continued at one month, three months, six months and one year. The functional recovery evaluation was performed using visual analogue scale (VAS) score, Rating Scale of American Shoulder and Elbow Surgeons Form (ASES), Mayo Elbow Performance Score System (MEPS) and rate of complications.

RESULTS

Low intra-operative blood loss, short operation time, short hospitalisation, early mobilisation of the patient and high union rate imposed intramedullary nailing as a standard procedure for the treatment of proximal and middle thirds of humeral diaphyseal fractures in the past years, and the union rate was 99.5%. VAS score evaluated at one month, three months and six months indicated a very good overall post-operative experience. The ASES and MEPS score were evaluated at six months and one year and showed excellent results. All the patients (except 1 case) were able to return to their previous jobs within six months.

CONCLUSION

Humeral nailing is associated with early return to function of the upper limb, with very good clinical and functional outcomes of the shoulder and elbow. This method could be considered the best surgical option for the management of proximal middle humeral fractures.

Factors associated with humeral shaft nonunion

BACKGROUND

The primary aim was to identify patient and injury factors independently associated with humeral diaphyseal fracture nonunion after nonoperative management. The secondary aim was to determine the effect of management (operative/nonoperative) on nonunion.

METHODS

From 2008-2017, a total of 734 humeral shaft fractures (732 consecutive skeletally mature patients) were retrospectively identified from a trauma database. Follow-up was available for 663 fractures (662 patients, 90%) that formed the study cohort. Patient and injury characteristics were recorded. There were 523 patients (79%) managed nonoperatively and 139 (21%) managed operatively. Outcome (union/nonunion) was determined from medical records and radiographs.

RESULTS

The median age at injury was 57 (range 16-96) years and 54% (n = 359/662) were female. Median follow-up was 5 (1.2-74) months. Nonunion occurred in 22.7% (n = 119/524) of nonoperatively managed injuries. Multivariate analysis demonstrated preinjury nonsteroidal anti-inflammatory drugs (NSAIDs; odds ratio [OR] 20.58, 95% confidence interval [CI] 2.12-199.48; P = .009) and glenohumeral arthritis (OR 2.44, 95% CI 1.03-5.77; P = .043) were independently associated with an increased risk of nonunion. Operative fixation was independently associated with a lower risk of nonunion (2.9%, n = 4/139) compared with nonoperative management (OR for nonoperative/operative management 9.91, 95% CI 3.25-30.23; P < .001). Based on these findings, 5 patients would need to undergo primary operative fixation in order to avoid 1 nonunion.

CONCLUSIONS

Preinjury NSAIDs and glenohumeral arthritis were independently associated with nonunion following nonoperative management of a humeral diaphyseal fracture. Operative fixation was the independent factor most strongly associated with a lower risk of nonunion. Targeting early operative fixation to at-risk patients may reduce the rate of nonunion and the morbidity associated with delayed definitive management.

Fractures of the proximal- and middle-thirds of the humeral shaft should be considered as fragility fractures

Aims

The aim of this study was to determine the current incidence and epidemiology of humeral diaphyseal fractures. The secondary aim was to explore variation in patient and injury characteristics by fracture location within the humeral diaphysis.

Methods

Over ten years (2008 to 2017), all adult patients (aged ≥ 16 years) sustaining an acute fracture of the humeral diaphysis managed at the study centre were retrospectively identified from a trauma database. Patient age, sex, medical/social background, injury mechanism, fracture classification, and associated injuries were recorded and analyzed.

Results

A total of 900 fractures (typical 88.9%, n = 800/900; pathological 8.3%, n = 75/900; periprosthetic 2.8%, n = 25/900) were identified in 898 patients (mean age 57 years (16 to 97), 55.5% (n = 498/898) female). Overall fracture incidence was 12.6/100,000/year. For patients with a typical fracture (n = 798, mean age 56 years (16 to 96), 55.1% (n = 440/798) female), there was a bimodal distribution in men and unimodal distribution in older women (Type G). A fall from standing was the most common injury mechanism (72.6%, n = 581/800). The majority of fractures involved the middle-third of the diaphysis (47.6%, n = 381/800) followed by the proximal- (30.5%, n = 244/800) and distal-thirds (n = 175/800, 21.9%). In all, 18 injuries (2.3%) were open and a radial nerve palsy occurred in 6.7% (n = 53/795). Fractures involving the proximal- and middle-thirds were more likely to occur in older (p < 0.001), female patients (p < 0.001) with comorbidities (p < 0.001) after a fall from standing (p < 0.001). Proximal-third fractures were also more likely to occur in patients with alcohol excess (p = 0.003) and to be classified as AO-Orthopaedic Trauma Association type B or C injuries (p < 0.001).

Conclusion

This study updates the incidence and epidemiology of humeral diaphyseal fractures. Important differences in patient and injury characteristics were observed based upon fracture location. Injuries involving the proximal- and middle-thirds of the humeral diaphysis should be considered as fragility fractures. Cite this article: Bone Joint J 2020;102-B(11):1475–1483.

Intramedullary nailing versus a locking compression plate for humeral shaft fracture (AO/OTA 12-A and B): A retrospective study

INTRODUCTION

There has been great progress in surgical techniques for treating humeral shaft fractures over the past few decades. The purpose of this study was to compare the therapeutic effects of intramedullary nailing (IMN) and locking compression plate (LCP) for humeral shaft fractures (AO/OTA 12-A and B).

HYPOTHESIS

Compared with LCP, better therapeutic effects could be obtained with less invasive IMN.

MATERIALS AND METHODS

Patients with a humeral shaft fracture who received anterograde IMN or LCP fixation in our institution from December 2011 to June 2016 were reviewed in this study. They were divided into two groups according to the different fixation methods: Group A (IMN) and Group B (LCP). The surgical time, intraoperative blood loss, and complications of the patients were reviewed. Fracture healing was evaluated by radiographs performed at each follow-up. The functional outcome was assessed by the DASH (Disabilities of the Arm, Shoulder and Hand) scoring system at the final follow-up.

RESULTS

Thirty-four patients in Group A and forty-six patients in Group B were included in this study. Mean incision length and blood loss in Group B were greater than those in Group A (p<0.001). The average surgical times were 118.53minutes in Group A and 128.91minutes in Group B (p=0.114). The mean DASH scores were 23.76±16.78 in Group A and 22.37±15.18 in Group B (p=0.609). The complication rates were 8/34 in Group A and 7/46 in Group B, respectively (p=0.887).

DISCUSSION

The study hypothesis was partially confirmed. Although IMN was a less invasive technique, similar therapeutic results were obtained for humeral shaft fractures (AO/OTA 12-A and B) fixed with two surgical methods.

LEVELS OF EVIDENCE

III, retrospective comparative study.

Arthroscopy-assisted versus standard intramedullary nail fixation in diaphyseal fractures of the humerus

PURPOSE

The aim of this study was to assess applicability of arthroscopic technique in intramedullary nail fixation of humerus shaft fractures and to compare with conventional nailing in terms of its effects on perioperative and postoperative intra-articular complication rates as well as on clinical and functional outcomes.

METHODS

This prospective randomized controlled clinical trial included 40 patients (12 females and 28 males) indicated for surgery between either undergo arthroscopy-assisted (Arthroscopy-assisted intramedullary nailing [AIMN]; n = 20) or conventional (Intramedullary nailing [IMN]; n = 20) anterograde intramedullary nailing. Two groups were compared in terms of mean number of fluoroscopic shootings until the guide wire was inserted, time for union, length of hospital stay, and complication rates. Shoulder functions were assessed by Constant and American Shoulder and Elbow Surgeons (ASES) score.

RESULTS

Groups did not significantly differ in terms of age, gender, and mechanism of injury, length of hospital stay, union rate, and mean union time ( p > 0.05). Mean ASES and Constant scores were found to be statistically significantly higher in AIMN group than that in IMN group ( p = 0.000 and p = 0.002, respectively). Mean number of fluoroscopic shootings until the guide wire was inserted was 2.15 in AIMN group, which was significantly lower compared to 4.2 of IMN group ( p = 0.000).

CONCLUSIONS

Arthroscopy-assisted technique may be an applicable and safe method owing to its cosmetic advantages and more satisfactory postoperative shoulder functions subsequent to less injury to deltoid, rotator cuff, and other soft tissue, as compared to conventional anterograde approach.

Segmented interlocking nail: An in vivo evaluation of a novel humeral osteotomy fixation device in a caprine model

Objectives: To describe a novel humeral fixation device, the insertion technique, healing of humeral osteotomies, and clinical outcomes in a caprine model over a six month period.

Methods: Fourteen mature female Boer/Nubian cross goats with a mean body weight of 50.7 kg were implanted with a proprietary segmented interlocking nail (SILN) in both humeri. Each goat had one humerus randomly selected for mid-diaphyseal osteotomy.

Results: Immediately after surgery all but one goat was able to stand, although none of the goats were weight bearing on the osteotomy limb. During the six month study, clinical lameness was always associated with the osteotomy limb. One month after surgery, lameness for twelve of the goats was grade 2/5 or better. At three months, 11 of the 14 did not exhibit any signs of lameness. On radio-graphic images, notable malalignment of the osteotomy was observed, although all osteotomies went to bone union.

Clinical significance: The results of this study suggest that despite misalignment, the SILN maintained adequate osteotomy fixation to achieve bone union in the research model studied, with reduced morbidity and early return to function with bilateral implantation. The SILN used in this study allowed intramedullary fixation of humeral diaphyseal osteotomies with a limited and safe surgical approach.

Insertion-related pain with intramedullary nailing

The use of intramedullary nails for the treatment of long bone fractures has become increasingly frequent over the last decade with gradually expanding indications and technological advances. Improved biomechanics relative to plates and less direct fracture exposure are some of the potential benefits of intramedullary nails. However, persistent insertion-related pain is common and may limit satisfactory long term outcomes. The etiologies of this phenomenon remain unclear. Proposed theories for which there is a growing body of supporting evidence include hardware prominence, suboptimal nail entry points leading to soft tissue irritation and structural compromise, local heterotrophic ossification, implant instability with persistent fracture micromotion, and poorly defined insertional strain. Many factors that lead to insertion-related pain are iatrogenic, and careful attention to detail and refined surgical techniques will optimize outcomes.

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.

Displaced proximal humeral fractures: when is surgery necessary?

BACKGROUND

Several therapeutic methods have been traditionally used in the treatment of displaced proximal humeral fractures; however, the indication of these treatments is still controversial. The purpose of this study was to compare the medium-term functional results of four methods commonly used in the treatment of proximal humeral fractures [conservative treatment, proximal humeral nails (PHN), percutaneous K-wiring (PKW), and locking-plates (LP)] taking into consideration the type of fracture and the age of the patients.

METHODS

We conducted a retrospective cohort study on patients with proximal humeral fractures treated with one of the following methods: conservative treatment, PHN, PKW, or LP. Functional results were assessed using the absolute Constant score and the disabilities of the arm shoulder and hand score (DASH). The functional outcome was analysed according to age (≥65 years and <65 years) and fracture type (displaced 2-fragment and 3-4-fragment fractures).

RESULTS

A total of 113 patients were included in the study, with a mean age of 65.3 SD 15.2 years and average follow-up time of 26.2 SD 12.6 months. Patients under 65 years had higher Constant scores when treated with PHN and PKW than those treated conservatively (77.2 vs. 54.7, p=0.01 and 74.0 vs. 54.7, p=0.03, respectively). Patients above 65 years had higher Constant scores when treated with PKW compared to PHN and conservative treatment (68.7 vs. 51.9, p=0.02 and 68.7 vs. 55.9, p=0.029, respectively). In 2-fragment fractures, PKW resulted in higher Constant scores than conservative treatment (70.4 vs. 53.9, p=0.048). No differences were found in the final outcome between patients treated with LP and those treated conservatively regardless of age, and fracture type. There were also no differences between any of the evaluated methods in the treatment of 3-4-fragment fractures.

CONCLUSION

The use of PKW was associated with better functional results than conservative treatment in individuals of all ages, especially in patients with 2-fragment fractures; PKW also achieved better functional results than PHN in elderly patients. PHN was superior to conservative treatment in young individuals. No significant differences were found between LP and conservative treatment in any of the analysed categories.

Optimizing intramedullary entry location on the proximal humerus based on variations of neck-shaft angle

BACKGROUND

The purpose of this study was to define the relationship between the humeral neck-shaft angle (NSA) and variations in the ideal entry portal aligned with the long axis of the intramedullary canal of the proximal humerus.

METHODS

Three-dimensional images of 36 cadaveric humeri with various NSAs were reconstructed by a computerized surgical simulation program. The anteroposterior, mediolateral, and linear distances between a line from the center of the proximal medullary canal to the bicipital groove were measured. Differences among humeri with various NSAs were analyzed.

RESULTS

The intramedullary axis line was located a mean of 9 ± 2 mm posteriorly and 11 ± 3 mm medially from the bicipital groove. The axis line was 9 ± 2 mm posterior and 11 ± 2 mm medial with a standard NSA. The axis line in humeri with a varus NSA was 8 ± 2 mm posteriorly and 9 ± 2 mm medially, whereas the axis line was 10 ± 3 mm posteriorly and 14 ± 3 mm medially with a valgus NSA. The differences in the mediolateral distances between the groups were significant (P < .00009).

CONCLUSION

Care should be taken in choosing the entry portal position in humeri with various NSAs as the entry portal position differs according to the NSA. It is recommended that the location of the entry portal be moved toward the center of the humeral head to align with the centerline of the intramedullary canal in humeri with a valgus NSA in particular.

Fracture union in closed interlocking nail in humeral shaft fractures

Background:

Fracture shaft humerus is a major cause of morbidity in patients with upper extremity injuries. The aim of this study was to evaluate the outcome of interlocking nail in humeral shaft fractures.

Methods:

This study was conducted in the Department of Orthopedic Surgery in SMS and R Sharda University from January 2010 to November 2013. Seventy-eight patients were recruited from emergency and out-patient department having a close fracture of humerus shaft. All patients were operated under general anesthesia and closed reamed interlocking nailing was done. All patients were followed for 9 months.

Results:

Out of 78 patients, 69 patients underwent union in 90–150 days with a mean of 110.68 days. Complications found in four patients who had nonunion, and five patients had delayed union, which was treated with bone grafting. All the patients were assessed clinically and radiologically for fracture healing, joint movements and implant failure. The results were excellent in 88.46% and good in 6.41% patients. Complete subjective, functional, and clinical recovery had occurred in almost 100% of the patients.

Conclusions:

The results of the present study indicates that in the presence of proper indications, reamed antegrade intramedullary interlocked nailing appears to be a method of choice for internal fixation of osteoporotic and pathologic fractures.

A cohort study of 4,190 patients treated with low-intensity pulsed ultrasound (LIPUS): findings in the elderly versus all patients

BACKGROUND

Patient age is one of many potential risk factors for fracture nonunion. Our hypothesis is that older patients (≥ 60) with fracture risk factors treated with low-intensity pulsed ultrasound (LIPUS) have similar heal rate (HR) to the population as a whole. We evaluate the impact of age in conjunction with other risk factors on HR in LIPUS-treated patients with fresh fracture (≤ 90 days old).

METHODS

The Exogen Bone Healing System is a LIPUS device approved in 1994 to accelerate healing of fresh fracture. After approval, the FDA required a Post-Market Registry to assess performance. Patient data collected from October 1994 until October 1998 were individually reviewed and validated by a registered nurse. Four distinct data elements were required to report a patient: date fracture occurred; date treatment began; date treatment ended; and a dichotomous outcome of healed v. failed, by clinical and radiological criteria. Data were used to calculate two derived variables; days to treatment (DTT) and days on treatment (DOT). Every validated fresh fracture patient with DTT, DOT, and outcome is reported.

RESULTS

The validated registry had 5,765 patients with fresh fracture; 73% (N = 4,190) are reported, while 13% of patients were lost to follow-up, 11% withdrew or were non-compliant, and 3% died or are missing outcome. Among treatment-compliant patients, HR was 96.2%. Logistic estimates of the odds ratio for healing are equivalent for patients age 30 to 79 years and all age cohorts had a HR > 94%. Open fracture, current smoking, diabetes, vascular insufficiency, osteoporosis, cancer, rheumatoid arthritis, and prescription NSAIDs all reduced HR, but older patients (≥ 60) had similar HRs to the population as a whole. DTT was significantly shorter for patients who healed (p < 0.0001).

CONCLUSIONS

Comorbid conditions in conjunction with aging can reduce fracture HR. Patients with fracture who used LIPUS had a 96% HR, whereas the expected HR averages 93%. Time to treatment was significantly shorter among patients who healed (p < 0.0001), suggesting that it is beneficial to begin LIPUS treatment early. Older patients (≥ 60) with fracture risk factors treated with LIPUS exhibit similar heal rates to the population as a whole.

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.

Meta-analysis of the outcomes of intramedullary nailing and plate fixation of humeral shaft fractures

OBJECTIVE

The purpose of this study is to compare the outcomes of intramedullary nailing and plate fixation in the treatment of humeral shaft fractures using meta-analysis.

METHODS

PubMed, MEDLINE, EMBASE, the Cochrane Controlled Clinical Trials Register (CCTR) databases were searched for studies that investigated the efficacy of intramedullary nailing and plate fixation in the management of humeral shaft fractures. Delayed healing rate, nonunion, postoperative infection and radial nerve paralysis were key outcomes of interest. Data were searched within the time period of July 1990 through September 2012. The statistical software RevMan 5.0 was used to analyze the statistical significance of the results.

RESULTS

Total 459 cases of patients in 10 literature, including 231 cases of plate group and 228 cases of the intramedullary nailing groups were collected. The results of meta-analysis showed that delayed healing rate of humeral shaft fractures was lower in plate fixation compared with intramedullary nailing (RR = 2.64, 95% CI (1.08, 6.49), P < 0.05). No statistically significant difference in nonunion, postoperative infections, radial nerve paralysis and other complications was identified between nailing and plate fixation groups (P > 0.05).

CONCLUSIONS

In general, the effect size of intramedullary nailing may be comparable to that of plate fixation in the terms of nonunion, postoperative infections, radial nerve paralysis. The only slightly difference was identified in the event of delayed healing rate.

The function and muscle strength recovery of shoulder after humeral diaphysis fracture following plating and intramedullary nailing

OBJECTIVE

To evaluate the shoulder function and shoulder girdle muscle strength of humeral diaphysis fractures postoperatively following intramedullary nailing (IMN) and open reduction internal fixation (ORIF).

METHODS

Fifty cases of humeral diaphysis fractures were randomly allocated into two groups. Antegrade IMN and ORIF were, respectively, performed in group I and II. Union status, functional scoring, range of motion, muscle strength of shoulder girdle including external/internal rotation and abduction/adduction strength were recorded at 18 months after surgery. Statistical package for social sciences 13.0 was used for analysis.

RESULTS

Group I had lower functional score than group II (P < 0.05). Both groups had approximately 50 % of muscle strength loss on injured side. In group II, the internal rotation strength loss was significantly greater compared to group I (P < 0.01). The total side to side (internal plus external) range of rotation (ROR) lack and external ROR lack of involved shoulder was significantly greater in group I (P = 0.005 and 0.049). The range of abduction lack was also significantly greater in group I.

CONCLUSIONS

Both surgically treated groups had significant loss of muscle strength of shoulder girdle when measured at 18 months postoperatively. There was greater loss of rotation strength in ORIF group than the IMN group. However, IMN had lower functional scores and a decreased range of motion postoperatively. The assumption that rotator cuff damage caused by nailing leads to weaker abduction strength than plating was not supported.

Short, locked humeral nailing via Neviaser portal: an anatomic study

OBJECTIVE

Supraspinatus tendon trauma may contribute to residual shoulder pain after nail fixation for proximal humeral fractures. Some have proposed a more medial starting point for humeral nail insertion to avoid cuff tendon footprint damage. We hypothesized that percutaneous nail insertion via Neviaser portal would not only be possible, but would avoid tendon trauma, while sacrificing articular cartilage.

MATERIALS AND METHODS

Under c-arm guidance and in percutaneous fashion, we nailed 16 consecutive complete (head and neck, etc, intact) specimen right proximal humeri with locked short humeral nails (Aequalis) via Neviaser portal. Each shoulder was dissected to study the damage to the rotator cuff and long head of the biceps tendons as well as to the articular surfaces. We measured the humeral-thoracic abduction arc before the damaged articular surface contacted the superior glenoid. There were 5 male specimens and 11 female specimens with a mean age of 83 years at the time of death.

RESULTS

We successfully inserted 15 of 16 humeral nails through this percutaneous approach. No supraspinatus tendon or long head of the biceps tendon was damaged. All nails passed entirely through supraspinatus muscle belly. Thirteen of 15 starting points were entirely on articular surface. Mean arc of abduction before superior glenoid contact was 76 degrees (range, 50 degrees-130 degrees). Mean distance from the edge of the articular surface to the most lateral part of the nail insertion was 11 mm (0-25 mm).

CONCLUSIONS

Short, locked humeral nail insertion is possible in percutaneous fashion via Neviaser portal without tendon injury. However, successful insertion comes at the cost of articular cartilage damage.

Locked antegrade intramedullary nailing of humeral shaft fractures

This paper reports the results of treating 35 humeral shaft fractures with antegrade nailing in patients between the ages of 25 and 92 (mean 64.5): 14 patients were aged between 25 and 59, and 21 between 66 and 92. The nail was set in place proximally with a spiral blade and distally with 1 or 2 screws. In the first 14 cases, uncannulated humeral nailing (UHN) was carried out, and in the next 21 cannulated humeral nailing (CHN). The latter technique uses a guide wire which, in cases of an error in the length of the nail, is useful in that it allows another nail to be set in place. Main outcome parameters were fracture healing, shoulder discomfort, and radial nerve recovery. The DASH functional scoring system, modified according to Beaton et al. for subjective assessment was used, and range of motion was checked with the constant score. X-rays were used to assess fracture healing time and cases of malunion. Two patients developed non-union, one caused by a UHN which was too short, and the other by a nail blocked distally by a single screw. In 7 patients, consolidation was achieved, but with varus between 3 and 8 degrees (mean 5 degrees), without aesthetic or functional damage. In 33 out of 35 patients, shoulder functionality had mean DASH score results of 21.9, whereas shoulder range of motion reached a mean constant score (CS) of 26.5 (78.8%) with respect to the opposite shoulder. In 5 cases of stiffness, the UHN turned out to be insufficiently buried. Results improved with the CHN. Much better results were seen in the group of patients aged between 25 and 59 (mean age 43), but worse in older ones (66-92 years, mean age 78). Radial nerve palsy after surgery occurred in 2 cases, and the nerve was immediately examined. It did not appear to be trapped in the fracture in either case, and recovery was complete 6 months later. CHN appears to be a valid solution, both in younger patients, thanks to excellent results, and in older ones, who have fewer functional requirements.

Mismatch analysis of humeral nailing: antegrade versus retrograde insertion

BACKGROUND

Closed humeral nailing is now considered an alternative treatment for humeral-shaft fracture. The nail can be inserted with either the antegrade or retrograde method. We investigated and compared the problem of geometric mismatch of the humeral nail to the humerus between the two methods of insertion.

METHODS

The study was performed using virtual simulation based on computed tomography (CT) data of 76 Thai cadaveric humeri and the commonly used Russell-Taylor humeral nail 8 mm in diameter and 220 mm long. Mismatch of the nail to the intact humerus was analyzed and compared between the antegrade and retrograde nailing approaches.

RESULTS

The results showed: (1) the diameter of the medullary canal averaged 7.9-13.8 mm; (2) the minimal reaming diameter to accommodate virtual nail insertion averaged 8.8-14.8 mm for the antegrade and 8.8-29.3 mm for the retrograde approach; (3) the minimal reaming thickness of the inner cortex averaged 0.1-1.5 mm for the antegrade and 0.1-9.9 mm for the retrograde approach; (4) the percentages of cortical bone removed prior to nail insertion were 3.8-107.1% and 3.8-1,287.6% for the antegrade and retrograde approaches, respectively; (5) the eccentricity of the nail-medullary canal center were 0.4-3.4 and 0.4-10.6 mm for the antegrade and retrograde approaches, respectively.

CONCLUSIONS

Less mismatching occurred with antegrade nailing than with the retrograde approach. Retrograde nailing requires excessive reaming at the distal part of the humerus to accommodate nail insertion. This may create bone weakness and the risk of supracondylar fracture.

Postoperative malrotation of humeral shaft fracture after plating compared with intramedullary nailing

OBJECTIVE

We supposed difference of rotation alignment of postoperative humeral shaft fracutres between open reduction and internal fixation (ORIF) and intramedullay nailing (IMN) could be identified and the difference might influence the involved shoulder. This study evaluated and compared the extent of malrotation and shoulder function after humeral shaft fractures treated operatively with IMN or ORIF.

MATERIALS AND METHODS

Fifty humeral shaft fractures were randomly allocated into 2 groups. Group I underwent antegrade IMN and group II underwent ORIF. Malrotation was measured postoperatively by computed tomography scan (CT). Fracture union and functional outcomes were recorded at 12 months.

RESULTS

The final analysis comprised 45 patients. Group I had lower functional scores than group II (P < .05). Internal malrotation of 20° or more (humeral head internally rotated) was found in 27.2% of group I patients, but there was no malrotation in group II. The internal and external range of motion of the involved shoulder was significantly correlated with the degree of malrotation (P < .01).

DISCUSSION

This study comprehensively evaluated the degree of malrotation using CT scanning for every patient. These data bring to light some unexpected results about poor shoulder function and degeneration after humeral shaft fracture. The study can provide baseline data for larger series and longer follow-up periods.

CONCLUSIONS

Patients who underwent IMN had lower functional scores and a decreased range of motion postoperatively and also had a greater degree of malrotation than the ORIF group, which had none. The degree of malrotation correlated with a decreased range of motion and may possibly be a reason for degenerative arthritis at long-term follow-up.

UPPER LIMB TRACTION DEVICE FOR ANTEROGRADE INTRAMEDULLARY LOCKED NAIL OF HUMERAL SHAFT FRACTURES

Diaphyseal fractures of the femur and tibia in adults are mostly treated surgically, usually by means of intramedullary locked-nail osteosynthesis. Some comminuted and/or highly deviated shaft fractures may present a veritable technical challenge. Fracture (or orthopedic) tables, which enable vertical, horizontal and rotational instrumental stabilization of the limb, greatly facilitate reduction and implant placement maneuvers and are widely used by orthopedic surgeons. Humeral shaft fractures are mostly treated nonsurgically. However, some cases with indications that are well defined in the literature require surgical treatment. They can be fixed by means of plates or intramedullary nails, using anterograde or retrograde routes. In the humerus, fracture reduction and limb stabilization maneuvers for implantation of intramedullary nails are done manually, usually by two assistants. Because muscle fatigue may occur, this option may be less efficient. The aim of this paper is to present an external upper-limb traction device for use in anterograde intramedullary locked-nail osteosynthesis of humeral shaft fractures that enables vertical, horizontal and rotational stabilization of the upper limb, in a manner similar to the device used for the lower limbs. The device is portable, of simple construction, and can be installed on any operating table equipped with side rails. It was used for surgical treatment of 29 humeral shaft fractures using an anterograde locked intramedullary nail. Our experience was extremely positive. We did not have any complications relating to its use and we believe that it notably facilitated the surgical procedures.

Telegraph antegrade nailing in the treatment of humeral fractures with rotator interval split technique

Twenty-four proximal humeral fractures were treated by surgical internal fixation with a locked antegrade intramedullary nail. The purpose of this paper was to assess the clinical outcomes of proximal epiphyseal and diaphyseal humeral fractures treated with an antegrade humeral nail implanted after an interval rotator split. We treated six proximal epiphyseal fractures and seven bifocal fractures of the epiphysis and shaft and eleven diaphyseal fractures. The mean follow-up was 23 months (range 12 to 34 months). Twenty patients were available for follow-up. All but two fractures progressed to healing. The Mean Constant score was 80%, Relative Constant score was 95.5%. We divided the clinical outcomes by fracture pattern to define the best surgical indication. There were good clinical outcomes in all three groups, but the clinical score was highest in the shaft fracture group. An intramedullary antegrade nail inserted through the interval rotator without penetrating the rotator cuff had a good clinical outcome and with certain fracture types can be an effective and satisfactory device.

Humeral nailing revisited

Unreamed interlocked humeral nailing for stabilisation of acute humeral fractures was introduced a decade ago. Antegrade and retrograde nail insertion are equally popular. The role of nailing as opposed to plating of humeral fractures is the subject of continuous debate. Between 1997 and 2005, 99 acute fractures of the humeral shaft were treated operatively with the unreamed humeral nail (UHN, Synthes) in our Level I Trauma Centre. The mean age of the patients was 63 years. Only eight patients (8.1%) were polytraumatised, nine patients had an open fracture (9.1%), five had a primary radial nerve palsy (5.1%). There were 54 antegrade and 45 retrograde nailings. The procedures were performed by 19 different surgeons, who carefully followed a detailed operation protocol. There were 6 adverse events: 3 secondary radial nerve palsies (3%), 2 fissures at the insertion point (2%) and one false placement of a locking screw (1%). Three patients developed pseudarthrosis (3%). Eight further operation were necessary (8.1%): 3 exploration of the radial nerve, 3 for treatment of pseudarthrosis, one replacement of a locking screw and one wound revision for superficial wound infection. Ninety patients (92 fractures) were evaluated after bone healing. Shoulder function was assessed using the Constant Score, elbow function with the Mayo Elbow Score. 91.3% and 5.4% of patients had an excellent or good shoulder function, 81.5% and 14.1% had an excellent or good elbow function. All patients with a functional deficit of the shoulder joint had antegrade, all patients with a deficit at the elbow joint retrograde nailing. Motor function recovered in all radial nerve palsies. 93.5% of patients had an excellent or good functional end result. Unreamed humeral nailing is a valid therapeutic option for stabilisation of acute humeral shaft fractures. Antegrade and retrograde nailing are associated with specific but different complications. By strictly adhering to the operation technique, the number and severity of complications can be reduced. When good fracture alignment and stability are obtained, uneventful bone healing with good functional outcome is the rule.

Antegrade humeral nailing through the rotator cuff interval: a new entry portal

The conventional approach for antegrade intramedullary nailing (AIN) of humerus fractures is associated with persistent pain and compromised shoulder function. Damage to the critical hypovascular zone of the rotator cuff near its insertion on the humerus and/or irritation of the subacromial space by prominent hardware are the factors believed to be responsible for poor shoulder function after AIN of the humerus. This study describes a new entry portal through the rotator interval that minimizes iatrogenic damage to the rotator cuff at its insertion. This approach offers a solution for the disappointing postoperative shoulder function and pain scores associated with conventional antegrade nailing techniques. This study consisted of 33 patients with 34 humeral fractures followed for an average of 34 months. The overall satisfaction rate was more than 90%, according to the ASES (American Shoulder and Elbow Society) score. The mean Constant Score was 84 (SD, 14; range, 17 to 98), and primary bone union was achieved in 32 of the 34 cases.

Concomitant injuries to the ipsilateral shoulder in patients with a fracture of the diaphysis of the humerus

Antegrade intramedullary nailing of fractures of the shaft of the humerus is reported to cause impairment of the shoulder joint. We have reviewed 33 patients with such fractures to assess how many had injuries to the ipsilateral shoulder. All had an MR scan of the shoulder within 11 days of injury. The unaffected shoulder was also scanned as a control. There was evidence of abnormality in 21 of the shoulders (63.6%) on the injured side; ten had bursitis of the subacromial space, five evidence of a partial tear of the rotator cuff, one a complete rupture of the supraspinatus tendon, four inflammatory changes in the acromioclavicular joint and one a fracture of the coracoid process. These injuries may contribute to pain and dysfunction of the shoulder following treatment, and their presence indicates that antegrade nailing is only partly, if at all, responsible for these symptoms.

Minimally invasive plating osteosynthesis (MIPO) of middle and distal third humeral shaft fractures

OBJECTIVE

To evaluate the clinical, radiographic, and functional outcomes of middle and distal third humeral shaft fractures treated with the minimally invasive percutaneous osteosynthesis (MIPO).

DESIGN

Prospective, single-center, nonconsecutive clinical series study.

SETTING

: Skeletal trauma center of a university teaching hospital.

PATIENTS

Thirteen patients who were seen from May 2004 to October 2005 with an average age of 38.1 years (range, 25 to 60 years) form the basis of this study. Patients were obtained from a surgical database of 1 surgeon.

INTERVENTION

The middle and the distal third humeral shaft fractures were reduced by closed means and fixed with long narrow 4.5-mm dynamic compression plates introduced through 2 small incisions away from the fracture sites and placed on the anterior aspect of the humerus.

MAIN OUTCOME MEASUREMENTS

Time to fracture healing and functional assessments were assessed at an average follow-up of 12.5 months (range, 7 to 19 months) for the affected shoulders and elbows using the UCLA and Mayo elbow performance scoring systems, respectively.

RESULTS

All fractures united with a mean healing time of 16.2 weeks (range, 12 to 32 years). There were no nonunions, radial nerve palsies, or implant failures. The UCLA scoring system showed excellent results in 7 cases (53.8%) and good results in 6 cases (46.2%). Thirteen patients had excellent results of their elbow function when assessed with the Mayo elbow performance scoring system.

CONCLUSION

Closed reduction and internal fixation of middle or distal third humeral shaft fractures using MIPO is a safe and effective surgical treatment method and an alternative option to open techniques.

Humeral fractures in the elderly: treatment with a reamed intramedullary locking nail

In the elderly person, comorbidities combined with lower functional demands tend to indicate non-operative treatment; however, fast functional recovery is mandatory to prevent loss of independency and social ability. This retrospective follow-up study included 40 people with a mean age of 75 (range 60-87) years. They had all received treatment with a reamed intramedullary nail for humeral fracture; 21 were operated after a mean of 6 (range 0-16) days, and 19 after a mean of 28 (range 9-63) days after a primary decision for non-operative treatment. In all, 5 cases (12.5%) were lost to follow-up. The primary healing rate was 94% (33/35) after a mean of 17 (range 6-61) weeks; 14% (5/35) needed re-operation, in 2 cases because of healing problems. Functional results could be assessed in 18 cases: the median Neer score was 90 (range 45-97) points and the median Morrey score 98 (range 74-100) points. The relative functional scores were 94 (range 89-101) and 100 (range 97-100) points, respectively. All functional scores were independent of introduction site and time to treatment. On the basis of these results we conclude that treatment of humeral fractures in the elderly with an intramedullary nail leads to good healing and functional results, and an acceptable re-operation rate.

[The AO/ASIF Flexnail : A flexible intramedullary nail for the treatment of humeral shaft fractures]

BACKGROUND

The use of conventional implants for intramedullary nailing of humeral shaft fractures is associated with specific difficulties. During antegrade implantation structures of the rotator cuff can be affected leading to a reduced functional result of the shoulder. If the nail is implanted in a retrograde manner problems arise due to a relatively large hole close to or within the olecranon fossa, which is necessary for insertion of the nail. Supracondylar fractures as well as persistent elbow pain and loss of function are reported in the literature. To overcome these disadvantages a flexible nail has been developed that can be stiffened and locked after implantation.

METHOD

Between October 2000 and February 2002, 34 patients were treated with the flexible nail at our institution; 29 were available for follow-up. Fracture healing was documented on radiographs and clinical outcome was evaluated with use of the Constant as well as the Kwasny score.

RESULTS

Median duration until fracture consolidation was 10 weeks. In two patients fracture union was not achieved within the follow-up period. The median outcome measured with the Constant score was 93 points and 2.5 with the Kwasny score. Both values correspond to a very good functional outcome.

CONCLUSION

We conclude that the flexible humeral nail is an excellent treatment option for humeral shaft fractures. Damage to the rotator cuff and the distal humerus can be avoided due to its unique flexible construction, improving the functional outcome of intramedullary nailing for the treatment of humeral shaft fractures.

Open intramedullary nailing with tension band and locking sutures for proximal humeral fracture: hot air balloon technique

To reduce complications and increase fixation after the internal fixation of proximal humeral fractures, interlocking intramedullary nailing and tension-band and locking sutures were used simultaneously, and their results are reviewed. Twenty-six consecutive patients who underwent open intramedullary nailing with tension-band and locking sutures for proximal humeral fractures were selected. The mean follow-up period was 39 months. With regard to the functional evaluation, the mean Neer score was 90 points and the mean American Shoulder and Elbow Surgeons score was 85. When patients were divided into those aged less than 65 years and those aged 65 years or greater and into those with 2-part fractures and those with 3-part fractures, postoperative pain, the American Shoulder and Elbow Surgeons score, and the Neer score showed no difference between the 2 groups. Open intramedullary nailing accompanied by tension-band and locking sutures for proximal humeral fractures shows sufficient fixation in older patients, and therefore, good postoperative shoulder function can be expected.

Failure of reamed nailing in humeral non-union: an analysis of 26 patients

The use of an intramedullary nail in the treatment of humeral non-unions remains controversial. This study evaluated the treatment of humeral delayed and non-unions with reamed nailing and compression. In a retrospective analysis of prospectively gathered data from 26 cases all treated with the Telescopic Locking Nail (TLN), the healing rate after the first intervention for non-union was 58%. After one or more re-interventions combined with an external cancellous bone graft at some time during follow-up, 90% of the 21 patients with complete follow-up eventually healed after a mean of 22 months. A total of 49 procedures with a mean of 1.9 per patient were needed. After a mean follow-up of 65 (range 24-88) months, we conducted a study to assess the functional results in the shoulder and elbow. Twelve patients were suitable for inclusion. We used the Neer and Morrey score for shoulder and elbow function, respectively. For the Neer score the median was 91 points and for the Morrey score 94 points. The outcome suggests that simple reamed nailing of humeral non-union is insufficient. Reamed interlocked nailing is feasible, provided that the primary intervention for non-union is combined with an external cancellous bone graft.

Modified extra rotator-cuff entry point in antegrade humeral nailing

INTRODUCTION

We describe an extra-articular, extra-rotator cuff entry point for antegrade humeral nailing, which preserves the articular surface and rotator cuff integrity.

MATERIAL AND METHODS

Thirty-two patients with humeral shaft fractures underwent antegrade intramedullary nailing using a modified insertion point located 1 cm below the crest of the greater tuberosity, in a region outside the articular surface and rotator cuff area.

RESULTS

In all cases, nailing was done successfully, without any perforation of the humeral inner cortex by the nail. Extension of the fracture line to the distal metaphysis happened intraoperatively in one case of a distal diaphysis fracture. In the remainder of the patients, postoperative reduction of the fracture was successful, with no sign of an iatrogenic incident of fracture comminution. Excellent active shoulder function and full early functional recovery of the shoulder joint (to 16th week postoperatively) were established in 98% of the patients. All fractures were united in a mean period of 14 weeks.

CONCLUSION

We suggest an extra-articular, extra-rotator cuff entry point for antegrade humeral nailing as a possible and safe technique with beneficial results for the shoulder's postoperative function.

Recovery of shoulder joint function after humeral shaft fracture: a comparative study between antegrade intramedullary nailing and plate fixation

INTRODUCTION

Antegrade intramedullary (IM) nailing of humeral shaft fractures is reported to cause shoulder joint impairment. This retrospective study compared shoulder joint symptoms, range of motion (ROM), and isometric strength after antegrade IM nailing and dynamic compression (DC) plating of humeral shaft fractures.

MATERIALS AND METHODS

We compared 29 patients with DC plating and 44 with antegrade IM nailing of their humeral shaft fractures. Shoulder pain, L'Insalata and Constant scores, shoulder joint ROM and isometric shoulder strengths were measured after mean follow-up of 6.2 (1-15) years (DC plating) and 5.5 (2-10) years (IM nailing).

RESULTS

Patients had nonsignificantly more shoulder pain after IM nailing than after DC plating. Shoulder scores and isometric strength measurements showed no difference between the groups. Flexion was significantly better after DC plating, but none of the other ROM parameters differed between the groups. The shoulder scores and all ROM and strength parameters of the injured side were significantly lower than on the uninjured side in both groups.

CONCLUSIONS

Shoulder joint ROM and strength does not recover to normal after humeral shaft fracture. Antegrade IM nailing if performed properly is not responsible for shoulder joint impairment.

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.

Plating of humeral shaft fractures--has the pendulum swung back?

We reviewed 49 patients following plate osteosynthesis of humeral shaft fractures. There were no complications as a result of surgery. Union occurred in 47 patients (96%) at a mean of 9 weeks. Two patients required secondary procedures to achieve union. All patients had full range of motion in the elbow and shoulder joints following union. In the light of the popularisation of intramedullary nailing techniques in the last decade, with recognised complications of iatrogenic radial nerve injury, inadequate rotational stabilisation, non-union and shoulder impingement, we advocate plating of humeral shaft fractures as the surgical treatment of choice.

Intramedullary nailing of humeral shaft fractures with a locking flexible nail

BACKGROUND

Studies on intramedullary nailing of humeral shaft fractures in the orthopaedic literature have shown mixed results. The purpose of this investigation was to document the clinical outcome and complications associated with the use of a new flexible, locking intramedullary nail that can be implanted in the humerus in either a retrograde or an antegrade manner without violating the rotator cuff mechanism or damaging the articular surface of the humeral head.

METHODS

Fifty consecutive patients with fifty-one humeral shaft fractures were entered into our prospective clinical outcome study. The fracture was classified on the basis of the anatomic location and pattern. Implant positioning and fracture alignment were assessed postoperatively. Complications were recorded, and the time to union was measured. Shoulder function was evaluated with use of a combination of the Constant shoulder score, Short Form-36 (SF-36) clinical outcome data, range-of-motion measurements, and a subjective pain-rating scale.

RESULTS

Forty-one patients with forty-two fractures had an adequate duration of clinical follow-up (a mean of twenty-two months) for analysis. Thirty-nine fractures healed, with a mean time to clinical union of twelve weeks (range, four to fifty weeks). Thirty-eight of the forty-two shoulders had minimal or no pain. Thirty-six shoulders had a full range of motion. The mean Constant shoulder score was 90 points. Four patients had five complications, which included two nonunions, two hardware failures, and one wound infection. All four patients had been managed with a 7.5-mm nail. A multivariate analysis demonstrated that an age of more than fifty years was associated with a lower Constant score and that the occurrence of a complication was associated with a lower physical component score on the SF-36.

CONCLUSIONS

The flexible humeral nail allows both retrograde and antegrade implantation and static locking. Nail insertion can be accomplished without violating the rotator cuff or damaging the articular surface of the humeral head. Although the nail functioned well in most of our patients, the use of a small-diameter (7.5-mm) nail was associated with a higher complication rate. This implant should be used with caution in any patient with a medullary canal diameter of <or=8 mm.