Intramedullary nail versus dynamic compression plate fixation in treating humeral shaft fractures: grading the evidence through a meta-analysis

Dynamic Compression Plating Versus Antegrade Intramedullary Nailing for the Treatment of OTA/AO 12-A Fractures: A Retrospective Cohort Study

BACKGROUND

Fractures of the humerus diaphysis are common and often result from motor vehicle accidents (MVAs). Treatment methods range from nonoperative approaches to various operative techniques, including antegrade intramedullary nailing (AIMN) and dynamic compression plate (DCP) fixation. This study aimed to compare the cost effectiveness and outcomes of plating and nailing for humerus diaphyseal fractures.

METHODS

 A retrospective cohort study involving 59 cases of humerus diaphyseal OTA/AO 12-A fractures was conducted at King Saud Medical City (KSMC), a level I trauma center located in the center region in Riyadh, Saudi Arabia. Patients treated with AIMN, anterolateral plating, or posterior plating were included. Data on demographics, clinical parameters, radiographic healing, and costs were collected and analyzed.

RESULTS

The average surgical duration was shorter in the AIMN group compared to the anterolateral and posterior plating groups but with no statistical significance (P > 0.05). The average length of stay (LOS) was shorter, and the change in hemoglobin levels was lower in the AIMN group when compared to other groups but without a statistically significant difference (P > 0.05). The average cost of AIMN was significantly higher than that of anterolateral and posterior plating groups (P < 0.0001).

CONCLUSION

 While both nailing and plating procedures are options for treating OTA/AO 12-A fractures, AIMN carries a higher overall procedural cost. The practice of drain placement in our study population is likely the cause of the increased LOS in the plating groups. Relative additional analgesic requirements were associated with AIMN. Surgeons should consider meticulous hemostasis to avoid drain placement, which can decrease LOS, thus possibly decreasing unnecessary treatment costs of humerus shaft fractures.

A Rare Encounter: Unravelling the Enigma of a Bilateral Humerus Shaft Fracture With a Unique Mode of Injury

Humerus bone fractures make up 4-6% of all adult fractures, of which proximal humerus shaft fracture is only six percent. Simultaneous occurrences of bilateral humerus shaft fractures are infrequently encountered in clinical practice. Precise statistics regarding these injuries are lacking, with scant documentation in the existing literature concerning the subject matter. These fractures may arise due to convulsions triggered by incidents like an electric shock, epilepsy, alcohol withdrawal, and hypoglycemia, which typically give rise to sudden and excessive muscular contractions. Such fractures usually coincide with dislocations of the shoulder joint. However, in our case, the bilateral humerus shaft fractures were caused by physical injuries despite the individual remaining conscious throughout the ordeal. We present a clinical scenario wherein a 28-year-old male sustained fractures in both humerus shafts as a consequence of a road traffic collision with a unique mode of injury, i.e., both the arms of the patient hitting the trolley of a stationary truck. Radiographic investigation revealed a mid-arm shaft fracture on the right side and a fracture of the proximal one-third of the humerus shaft on the left side. He was managed with closed reduction and internal fixation with intramedullary (CRIF) nailing on the right side, and open reduction and internal fixation (ORIF) with plate osteosynthesis for the left side were done. So this is a compelling rare case of bilateral humerus shaft fracture following high-velocity trauma with a unique mode of injury, treated operatively with satisfactory results on follow-up.

Outcome and complication comparison for intramedullary nail versus open reduction internal fixation in humeral diaphyseal fractures for 2800 matched patient pairs utilizing the Nationwide Readmissions Database

INTRODUCTION

Open reduction internal fixation (ORIF) and intramedullary nail fixation (IMN) are the predominant repair methods for operative treatment of humeral diaphyseal fractures; however, the optimal method is not fully elucidated. The purpose of this study was to analyze whether IMN or ORIF humeral diaphyseal surgeries result in a significantly higher prevalence of adverse outcomes and whether these outcomes were age dependent. We hypothesize there is no difference in reoperation rates and complications between IMN and ORIF for humeral diaphyseal fractures.

METHODS

Data collected from 2015 to 2017 from the Nationwide Readmissions Database were evaluated to compare the prevalence of six adverse outcomes: radial nerve palsy, infections, nonunion, malunion, delayed healing, and revisions. Patients treated for a primary humeral diaphyseal fracture with either IMN or ORIF were matched and compared (n = 2,804 pairs). Patients with metastatic cancer were excluded.

RESULTS

Following an ORIF procedure, there was a greater odds of undergoing revision surgery (p = 0.03) or developing at least one of the complications of interest (p = 0.03). In the age-stratified analysis, no significant differences were identified in the prevalence of adverse outcomes between the IMN and ORIF cohorts in the 0-19, 20-39, and 40-59 age groups. Patients who were 60 + had 1.89 times the odds of experiencing at least one complication and 2.04 times the odds of undergoing a revision after an ORIF procedure versus an IMN procedure (p = 0.03 for both).

DISCUSSION

IMN and ORIF for humeral diaphyseal fractures are comparable in regard to complications revision rates in patients under the age of 60. Meanwhile, patients 60 + years show a statistically significant increase in the odds of undergoing revision surgery or experiencing complications following an ORIF. Since IMN appears to be more beneficial to older patients, being 60 + years old should be considered when determining fracture repair techniques for patients presenting with primary humeral diaphyseal fractures.

LEVEL OF EVIDENCE III

Treating multifocal humerus fractures: A comparison between the mipo technique and intramedullary nailing

INTRODUCTION AND OBJECTIVE

Proximal humerus fractures with metaphysodiaphyseal extension represent a challenge for the orthopedic surgeon due to their reduced incidence and the difficulty in the treatment decision. These can be treated with an intramedullary nail or using the MIPO technique, associating different advantages and complications depending on the procedure. The objective of this study was to compare metaphyseal-diaphyseal fractures of the humerus treated with antegrade intramedullary nailing and those operated using the MIPO technique to see if there were significant differences in terms of functional, clinical, and radiological results.

MATERIAL AND METHODS

retrospective, analytical and unicentric review of 29 patients with proximal fracture with metaphyseal-diaphyseal extension treated by MIPO technique and 33 patients surgically treated by antegrade intramedullary nailing (IMN) in our hospital from 2014 to 2020. Demographic, functional, radiographic and clinical data were obtained..

RESULTS

No significant differences were observed between both groups in terms of fracture mechanism (p=0.34), fracture type (p=0.13) or Maresca classification (p=0.32). Surgical time was significantly shorter in the IMN group compared to the MIPO technique (p=0.014). No significant difference was observed regarding the need for blood transfusion (p=0.32). The mean consolidation in the MIPO group was 21 weeks compared to 21 weeks in the IMN, with no significant differences between both groups (p= 0.88). No significant differences were observed between CONSTANT test at one year in the MIPO group versus the IMN group (p=0.79), nor in radial nerve palsies (p=0.28).

CONCLUSIONS

Proximal fractures with metaphyseal-diaphyseal extension are a challenge for the orthopedic surgeon due to the infrequency, the complexity of these fractures and the fact that there is no established consensus on the ideal treatment for this type of injury. Both the MIPO technique with the Philos plate and the intramedullary nail are valid options for the treatment of these fractures, with no differences observed in terms of fracture consolidation time or in terms of functional results.

Humeral shaft fracture: Outcomes of percutaneous antegrade intramedullary nailing using the long Telegraph® nail with dynamic distal locking

INTRODUCTION

Antegrade intramedullary nailing (IMN) in humeral shaft fracture (HSF) has been abandoned by certain orthopedic surgeons due to rotator cuff injury caused by curved nails, and to unreliable anatomical results. The purpose of this study was to report outcomes of straight percutaneous intramedullary nailing with dynamic distal locking in HSF.

HYPOTHESIS

Percutaneous antegrade intramedullary nailing using a long straight nail with dynamic distal locking improves radiological and functional outcome in HSF.

MATERIAL AND METHODS

A retrospective study was carried out, between january 2008 and june 2018, about 76 consecutive patients undergoing straight percutaneous antegrade IMN with dynamic distal locking for isolated closed displaced HSF. Eighteen patients were excluded; 36 were reviewed in June 2018 to assess Constant score.

RESULTS

There were 35 women and 23 men, with a mean age of 53years. All fractures were closed: 36 type A, 16 type B and 6 type C according to the AO/OTA classification. Healing was achieved in 97% of cases, at a mean 13±3weeks. There were no cases of infection or secondary nerve injury. The mean Constant score was 78±13.

DISCUSSION

Surgical treatment of humeral shaft fractures is a subject of discussion, without any consensus. Based on our experience, percutaneous antegrade IMN with dynamic distal locking improves anatomical and functional outcomes, provided that the surgical technique is mastered, which requires a learning curve.

LEVEL OF EVIDENCE

IV, retrospective study.

WHICH SURGICAL TREATMENT IS PREFERABLE IN HUMERAL DIAPHYSEAL FRACTURES? A SYSTEMATIC REVIEW

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.

Intramedullary Nailing Versus Plate Fixation for Humeral Shaft Fractures: A Systematic Review and Meta-Analysis

BACKGROUND

The two techniques most utilized in the surgical treatment of humeral shaft fractures are open reduction internal fixation (ORIF) and intramedullary nailing (IMN). Although there have been multiple comparative clinical studies comparing outcomes for these two treatments, studies have not suggested one approach to be superior to the other. The purpose of this study is to perform a systematic literature review and meta-analysis of studies that evaluated the treatment of humeral shaft fractures with either ORIF or intramedullary nail.

METHODS

We conducted this meta-analysis utilizing stricter inclusion and broader exclusion criteria to examine these two common approaches. We examined those articles which have compared first-time, closed fractures of the humeral diaphysis in adults in fracture patterns that could be treated equivalently by intramedullary nail or plate fixation. The primary outcome of interest was nonunion, and studies that did not report nonunion rates were excluded.

RESULTS

There were a total of 1,926 abstracts reviewed and a total of three articles were included in the final analysis after screening. There was no significant difference in the incidence of nonunion between plating (2/111, 1.8%) and nailing (4/104, 3.9%) (P>0.05). The mean difference in average time to union for plated fractures and nailed fractures was 1.11 weeks (95% CI 0.82 to 1.40) which was statistically significant (P<0.05). There was a significant difference in the incidence of radial nerve palsy (12/111, 10.8%) for plating compared to nailing (0/104, 0%) (P=0.0004). There was no difference in incidence of post-operative infection between the two groups intramedullary nailing (P>0.05).

CONCLUSION

The results of this analysis demonstrate an increased risk of iatrogenic radial nerve injury, and a significantly shorter time to union when treating humeral shaft fractures with plating as compared to intramedullary nailing. There was no difference in the rates of nonunion or delayed union. Based on the evidence, both plating and nailing can achieve a similar treatment effect on humeral shaft fractures.

Efficacy and Safety Evaluation of Intramedullary Nail and Locking Compression Plate in the Treatment of Humeral Shaft Fractures: A Systematic Review and Meta-analysis

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.

Assessment of Shoulder Function after Internal Fixation of Humeral Diaphyseal Fractures in Young Adults: A Prospective Comparative Study

BACKGROUND

Humeral shaft fractures are commonly encountered in casualties. There are different methods of operative internal fixation with no consensus on the best technique. The objective of this study was to assess shoulder function and rate of complications among two different options of fixation, intramedullary nailing, and minimal invasive plate osteosynthesis (MIPO) in young adults.

METHODS

Forty-two patients with humeral shaft fractures were included in the study and divided into two equal groups: group A treated with antegrade intramedullary locked nails (IMN) and group B with MIPO. Fracture union was evaluated with serial X-rays, and shoulder function was assessed in both groups using the scale of the American Shoulder and Elbow Surgeons (ASES), University of California at Los Angeles Shoulder Scale (UCLA), and visual analog score (VAS). The mean differences between groups were recorded and considered significant if the P value was ˂0.05.

RESULTS

The results were reported prospectively with no significant differences in mean age, sex, side of injury, type of fracture, mechanism of injury, and the follow-up period between the groups studied. Group A had shorter operative time and minimal blood loss than group B. Regarding shoulder function scores (ASES, UCLA, and VAS), the results in the MIPO group were better than the IMN group with shorter time of union and fewer complications.

CONCLUSION

Despite a shorter operative time and lower blood loss during locked intramedullary nail fixation in the management of humeral shaft fractures, MIPO enables more superior shoulder function with better fracture healing and lower morbidities.

Open plate fixation versus nailing for humeral shaft fractures: a meta-analysis and systematic review of randomised clinical trials and observational studies

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.

[Antegrade and retrograde nailing of humeral shaft fractures]

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.

Comparison between osteosynthesis with interlocking nail and minimally invasive plating for proximal- and middle-thirds of humeral shaft fractures

PURPOSE

Options for the treatment of proximal- and middle-thirds of humeral shaft fractures include intramedullary interlocking nail (IMN) and minimally invasive plate osteosynthesis (MIPO). However, whether IMN provides better clinical outcomes than MIPO surgical technique still remains unclear. This study was designed to compare clinical outcomes of the IMN with MIPO technique for the treatment of proximal- and middle-thirds of humeral shaft fractures.

METHOD

A retrospective cohort analysis of 55 proximal- and middle-thirds of humeral shaft fractures surgically treated using IMN (n = 25) or MIPO (n = 30) from January 2012 to January 2016. Peri-operative and follow-up data (a minimum of 1 year) of the patients (aged from 18 to 56 years) were collected. Operative time, union time, VAS scores, surgery-related complications, and implant removal rate were compared between the two groups in this study. Besides, the functional outcomes were evaluated using the Rating Scale of American Shoulder and Elbow Surgeons' Form (ASES) and Mayo Elbow Performance Score System (MEPS).

RESULT

We found significantly shorter operative time and much less blood loss in IMN group, and lower VAS scores in the IMN group after surgery at first and third months but not at the sixth month. Complication rate was found to be relatively higher in the MIPO group when compared to the IMN group. No significant difference was observed between these two groups regarding ASES and MEPS scores. Three patients in the MIPO group suffered iatrogenic radial nerve injury and recovered after four to five months later. No implant failures occurred in either group.

CONCLUSION

Intramedullary interlocking nail seemed to be superior to minimally invasive plate osteosynthesis in the treatment of proximal- and middle-thirds of humeral shaft fractures due to shorter operative time and union time, less early post-operative pain, and fewer complications. The intramedullary interlocking nail could be considered a better surgical option for the management of proximal middle humeral fractures, though it may also depend on the surgeons' skills and learning curve. Further in-depth prospective studies are in great need to verify our conclusion.

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.

Risk factors for nonunion after traumatic humeral shaft fractures in adults

Introduction

Humeral shaft fractures account for 3% of adult fractures. Optimal management remains a topic of debate given variable union rates reported in the literature after surgery or functional bracing. The primary aim was to compare these 2 cohorts of patients and their primary fracture union rates. A secondary aim was to identify predictors of nonunion.

Methods

A retrospective cohort study of 164 adult patients with traumatic humeral shaft fractures was performed. Fractures were classified according to the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association classification. Primary outcomes included rate nonunion, including symptomatic fractures requiring conversion to open reduction and internal fixation (ORIF). Secondary outcomes included rates of complications and secondary procedures.

Results

Ninety-four (57%) patients were treated initially with ORIF. Nonoperative patients were older (47.1 vs. 41.5 years, P = .028) and had more medical comorbidity (62% vs. 43%, P = .017), low-energy trauma (62% vs. 34%, P < .0001), and isolated injuries (74% vs. 32%, P < .0001). All patients with open fractures (23%) were treated with débridement and ORIF, and surgical patients had more nerve injuries on presentation (36% vs. 9%, P < .0001). The overall rate of primary fracture union was 88%, similar after ORIF and nonoperative management (92% vs. 83%, P = .095). Multivariate analysis found alcohol abuse (odds ratio [OR]: 3.4, 95% confidence interval [CI]: 1.0-11.0, P = .046) and deep infection (OR: 19.9, 95% CI: 2.6-150.5, P = .004) to be significant predictors of nonunion. Chronic liver disease demonstrated a trend toward increased risk of nonunion (OR: 4.1, 95% CI: 0.8-20.9, P = .088). Seventeen operative patients (18%) developed 17 postoperative complications: iatrogenic nerve palsy (5%), deep infection (5%), and implant failure (3%), the most common. Reoperation rate was 10%, primarily for revision ORIF (4%).

Conclusion

Patients managed nonoperatively were more often older patients with isolated fractures and more medical comorbidity. Surgical candidates were younger, more often with higher energy injuries, and were frequently with concomitant injury. Primary union occurred in 88%, with a trend toward a higher rate after ORIF. Patients with chronic liver disease and/or alcohol abuse are at greater risk for nonunion, irrespective of treatment.

Locking compression plate fixation versus intramedullary nailing of humeral shaft fractures: which one is better? A single-centre prospective randomized study

PURPOSE

To compare the radiological and clinical outcomes of interlocking nail (ILN) and locking plate fixation (LCP) for humeral shaft fractures.

METHODS

A total of 63 patients with displaced humeral shaft fractures between October 2014 and January 2017 were evaluated prospectively. They were divided randomly into two as LCP fixation (group 1) and interlocking nail (ILN) (group 2). Functional outcomes were evaluated using the Disabilities of the Arm, Shoulder, and Hand (DASH), American Shoulder and Elbow Surgeons (ASES), the University of California at Los Angeles (UCLA) shoulder scores, and Short Form-36 (SF-36) questionnaires, and pain was assessed with visual analogue scale (VAS).

RESULTS

After fracture callus was radiologically observed, DASH, ASES, and UCLA scores as well as SF-36 questionnaires and VAS results were noted to have no significant difference between the two groups (p = 0.109, p = 0.082, p = 0.146, p = 0.322, and p = 0.175, respectively). At the last follow-up (post-operative 24 months), the UCLA score was significantly better in group 1 (p = 0.034), whereas VAS result was significantly worse in group 2 (p = 0.017). DASH, ASES scores, and SF-36 questionnaires had no difference (p = 0.193, p = 0.088, p = 0.289). Other parameters revealed no significant differences. Fracture consolidation was observed at a mean of four months in both groups (3 to 7 months in group 1 and 3 to 8 months in group 2) (p = 0.189). Four patients in group 1 and five patients in group 2 underwent surgery for nonunion (p = 0.725). Post-operative radial nerve palsy was seen in one patient in group 2. Two patients in group 1 with superficial infection were treated with antibiotics, and they recovered.

CONCLUSIONS

Regarding our results, the LCP group had significantly better shoulder function than the ILN group, whereas the ILN group had significantly less pain, with similar complication rates. Therefore, both procedures are favourable surgical options for patients with humeral shaft fractures.

Plate fixation versus intramedullary nailing of proximal humerus fractures: an ACS NSQIP-based comparative analysis over 8 years

PURPOSE

The primary goal of this study was to compare the utilization of plate versus intramedullary nail (IMN) in the treatment of humerus fractures. Secondarily, we sought to examine whether any differences in demographics and clinical course of patients who receive a nail versus plate affect the procedure selection process.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was queried for patients surgically treated for a humeral shaft fracture from the years 2007-2015, using current procedural terminology (CPT) code. Patients with overlapping procedures, nonunion, polytrauma, and malignancy were excluded. The Charlson Comorbidity Index (CCI) was calculated to compare preoperative comorbidities. A two-sample Wilcoxon rank-sum (Mann-Whitney U) test was used to compare numerical values, whereas the Fisher exact and Chi-squared analyses were performed to compare categorical variables. A p value < 0.05 was considered significant. Preoperative variables with a p value < 0.05 and a clinical prevalence > 1%, indicating statistical and clinical significance, were included in a logistic regression for multivariate analysis to identify any independent predictors for procedure selection (IMN versus PF) based on preoperative patient characteristics.

RESULTS

During the study period plate fixation increased from 7 cases per year to 272 cases per year, while IMN increased from 8 cases per year to 80 cases per year. IMNs were mostly in older patients (63.85 vs 56.19 years, p < 0.001), and patients with a higher Charlson Comorbidity Index (CCI) (4.64 vs 2.79, p < 0.001). IMN was associated with shorter operation times (104 min vs 128 min, p < 0.001) and longer lengths of hospital stay (3.43d vs 2.78d, p < 0.001). No significant differences in overall complication rates were seen between patients who received IMN versus PF. However, the postoperative mortality rate was higher in patients who received IMN compared to PF (2.19% vs 0.40%, p < 0.01). Based on the regression analysis, patient age was the only independent patient factor demonstrated to predict the utilization of IMN over PF in older patients with humeral shaft fractures p = 0.043).

CONCLUSION

According to this NSQIP-based analysis, the rate of PF and IMN utilization increased in the treatment of humeral shaft fractures over a period of 8 years, but PF was performed at an overall a higher rate than IMN. Intramedullary nailing was preferred over PF in older patients with more comorbidities. The last possibly contributed to the higher 30-day mortality rate observed in patients who received IMN compared to PF.

LEVEL OF EVIDENCE III

Retrospective comparative study.

Length of stay and 30-day readmissions after isolated humeral shaft fracture open reduction and internal fixation compared to intramedullary nailing

INTRODUCTION

Open reduction with internal fixation (ORIF) and intramedullary nailing (IMN) have similar union rates for treating humerus shaft fractures, but IMN leads to increased incidence of shoulder impingement and reoperation. The difference in 30-day readmission rate and length of stay (LOS) between these procedures is unknown. The objective of the study was to compare 30-day unplanned readmissions and length of stay between humeral shaft fractures fixed with either ORIF or IMN.

METHODS

The nationwide readmissions database (NRD) was queried for patients with humeral shaft fractures treated with ORIF or IMN between 2015-2016. IMN cases were propensity matched to ORIF cases based on demographic and co-morbid variables. Multivariable logistic regression determined if treatment modality was an independent risk factor for 30-day readmission or length of stay >3 days.

RESULTS

There were 406 patients treated with IMN matched to 406 patients treated with ORIF. The 30-day readmission rate was 6.4% for IMN and 4.9% for ORIF (p = 0.45), and the median LOS was 3 days for each group (p = 0.45). Congestive heart failure (CHF)(OR=2.7, p = 0.04), depression (OR=3.3, p = 0.0008), and electrolyte abnormality (OR=3.6, p = 0.0003) were independent risk factors for readmission. Older age (OR=1.02, p = 0.03), CHF (OR=2.4, p = 0.03), electrolyte abnormality (OR=2.6, p = 0.0001), obesity (OR=2.8, p<0.0001), Medicaid (OR=2.1, p = 0.04), discharge to a facility (OR = 5.2, p<0.0001), discharge with home health services (OR=2.4, p = 0.0003), and open fracture (OR=2.3, p = 0.01) were independent risk factors for LOS >3 days. Procedure (ORIF vs. IMN) was not a predictor of 30-day readmission or LOS >3 days.

CONCLUSION

Comorbid conditions are risk factors for 30-day readmission and increased LOS. Comorbidity, discharge disposition, and open fractures are risk factors for increased LOS. Treating humeral shaft fractures with either ORIF or IMN did not affect readmission or length of stay.

Fractures of the Humeral Shaft with Primary Radial Nerve Palsy: Do Injury Mechanism, Fracture Type, or Treatment Influence Nerve Recovery?

Adult humeral shaft fractures are associated with primary radial nerve palsy in up to 18% of cases. The purpose of this study was to assess the influence of injury mechanism, fracture type, and treatment on nerve recovery in patients with humeral shaft fractures and primary nerve palsy. Data of fifty patients (age-43.5 ± 21.3; female: male-1:1.8) with humeral shaft fractures and concomitant grade I-II primary radial nerve palsy, who underwent either open reduction and internal fixation (ORIF) or intramedullary nailing at an academic level I trauma center between 1994 and 2013, were evaluated. Factors potentially influencing the time to onset of recovery or full nerve recovery (injury mechanism, fracture type, fracture location and treatment) were analyzed in detail. Thirty patients were treated with ORIF and twenty patients with closed unreamed intramedullary nailing of the humeral shaft, respectively. The mean time to onset of recovery was 10.5 ± 3.4 weeks (2-17 weeks). Twenty-six (52%) patients reported significant clinical improvement within the first 12 weeks. Mean time to full recovery was 26.8 ± 8.9 weeks (4-52 weeks). Twenty-five (50%) patients regained full manual strength within the first six months following the injury. Forty-nine (98%) patients regained full manual strength within the first 52 weeks. Trauma mechanism, fracture type, fracture location, and treatment modality did not influence the time to onset of nerve recovery or time to full recovery following humeral shaft fractures with grade I-II primary radial nerve palsy.

Antegrade intramedullary nail versus plate fixation in the treatment of humeral shaft fractures: An update meta-analysis

BACKGROUND

There is no consensus regarding the surgical treatment of humeral shaft fracture. The present meta-analysis was performed to compare the efficacy and safety between antegrade intramedullary nailing (IMN) and plating for humeral shaft fracture.

METHODS

PubMed, MEDLINE, Cochrane Library, EMBASE, Clinical Trails, Ovid, ISI Web of Science, and Chinese databases including WanFang Data, China National Knowledge Infrastructure were searched through March 10, 2019. The Review Manager software was adapted to perform statistical analysis and relative risk (RR) were used for the binary variables, and weighted mean difference and standardized mean difference (SMD) were used to measure the continuous variables. Each variable included its 95% confidence interval (CI).

RESULTS

A total of 15 trials with 839 patients were included in the analysis. There was significant difference between IMN group and plate group in blood loss (SMD = 3.49, 95% CI: 1.19, 5.79, P = .003) and postoperative infections (RR = 3.04, 95% CI: 1.49, 6.24, P = .002). Additionally, significant difference was observed between minimally invasive plate osteosynthesis (MIPO) group and IMN group in nonunion rate (RR = 3.20, 95% CI: 0.12, 0.84, P = .02). Statistical significance was also observed between the open reduction plate fixation group and IMN group in restriction of shoulder and elbow joints results (RR = 0.49, 95% CI: 0.26, 0.96, P < .05). No significant difference was observed for the operation time, American Shoulder and Elbow Surgeons score, nerve injury, delayed union, reoperation in either group.

CONCLUSION

IMN may be superior to plate in reducing blood loss and postoperative infections for the treatment of humeral shaft fracture. However, MIPO was superior to IMN group in nonunion and equal to IMN in other parameters. Further research is required and future studies should include analysis of assessments at different stages and follow-up after removal of the implants.

Lateral Subcutaneous Locking Compression Plate and Small Incision Reduction for Distal-third Diaphyseal Humerus Fractures

Objective

Iatrogenic radial nerve injury is a great challenge for orthopaedic surgeons who deal with distal‐third diaphyseal humerus fractures. Conventional open reduction and internal fixation (ORIF) remains the gold standard, but complications such as nonunion and iatrogenic radial nerve injury still occur. We fixed the fractures with a lateral locking compression plate (LCP) subcutaneously after small incision reduction to protect the radial nerve. This study reports the clinical and radiographic outcomes of our modified method.

Methods

Thirty‐eight patients with distal‐third diaphyseal humerus fractures were treated with lateral subcutaneous LCP and small incision reduction at our department between September 2013 and August 2016. There were 33 males and 5 females, with an average age of 30.3 years (range, 17 to 49 years). All the cases were types A or B (AO/OTA classification, type A, 24 cases; type B, 14 cases). Among them, 6 cases were combined with preoperative radial nerve palsy. All patients were diagnosed with closed humeral fractures after X‐ray examination, and had typical upper limb pain, swelling, and movement disorders. The operations were performed by a single surgeons’ team. Union time, range of motion (ROM), University of California, Los Angeles (UCLA) shoulder rating scale, and Mayo Elbow Performance Index (MEPI) scores were assessed to evaluate the postoperative results.

Results

All patients were followed up for an average of 11.4 months (range, 3 to 36 months). The average operation time was 75.5 min (range, 60 to 150 min) and average intraoperative radiation exposure was 10.5 s (range, 8 to 18 s). Bony union was achieved in all cases after an average of 16.2 weeks (range, 12 to 25 weeks). No complications such as infection or screw and plate fracture occurred, and no iatrogenic radial nerve injury was observed. According to the UCLA shoulder rating scale, the average score was 33.7 (range, 31 to 35), with 33 excellent (86.8%) and 5 good cases (13.2%). They were all excellent according to their MEPI scores (ranging, 94 to 100, with an average of 97.4). The average operation time for secondary removal of the plate was 15.2 min (range, 10 to 20 min), and no complications such as infection or secondary radial nerve injury occurred.

Conclusions

Lateral subcutaneous LCP and small incision reduction may reduce the risk of iatrogenic radial nerve injury significantly in the treatment of distal‐third diaphyseal humerus fractures. It also leads to solid fixation, good postoperative function, and convenient removal of the plate without injuring the radial nerve.

Humeral shaft fractures

Fractures of the humeral shaft are common injuries with multiple management strategies. Many still regard nonoperative management as the standard of care; however, as the understanding of these injuries increases, treatment recommendations are also evolving. Fracture pattern, fracture location, and identifiable patient risk factors may predict poor outcome with nonoperative management, and earlier operative intervention may be recommended. Operative management includes open reduction and internal fixation through a variety of exposures, intramedullary nail fixation, and external fixation. With increasing rates of shoulder arthroplasty, periprosthetic humeral shaft fractures also deserve special consideration.

Interventions for humeral shaft fractures: mixed treatment comparisons of clinical trials

We designed a study to compare the efficacy of five main therapeutic options, including external fixation, open reduction and plate osteosynthesis (ORPO), minimally invasive plate osteosynthesis (MIPO), dynamic compression plate (DCP), and intramedullary nail (IMN) in treating humeral shaft fractures. Our results indicated that MIPO and IMN were recommended as the optimal treatments for clinical use.

PURPOSE

Nowadays, five main therapeutic options are used in treating humeral shaft fractures: external fixation, open reduction and plate osteosynthesis (ORPO), minimally invasive plate osteosynthesis (MIPO), dynamic compression plate (DCP), and intramedullary nail (IMN). Aiming to provide reliable evidence for clinical selection, we designed a network meta-analysis (NMA) to evaluate the efficacy of these treatments.

METHODS

NMA was conducted on Bayesian framework with software R 3.3.2 and STATA 13.0. Nonunion rate, radial nerve palsy rate, union time, complication rate, and infection rate were considered as primary outcomes. Mean operation time was the secondary outcome. The outcomes were measured by odds ratio (OR) value and corresponding 95% credible intervals (CrIs) or mean difference (MD) with 95% CrIs. Surface under cumulative ranking curve (SUCRA) was calculated to show the ranking probability of each treatment.

RESULTS

Our results indicated that ORPO had a higher risk of radial nerve palsy than MIPO (OR = 2.83, 95% CrIs = 1.28-6.23), and DCP had a better performance in preventing complications than IMN (OR = 0.31, 95% CrIs = 0.11-0.84); no other significant difference were observed. According to the SUCRA results, MIPO had a high-ranking probability in almost all outcomes, while external fixation had lowest values in the majority of outcomes.

CONCLUSIONS

We recommended MIPO as the optimal treatment for humeral shaft fractures after taking all outcomes into consideration; IMN was also recommended for its relatively good performance, but its complication still needed to be noticed.

Comparison between antegrade intramedullary nailing (IMN), open reduction plate osteosynthesis (ORPO) and minimally invasive plate osteosynthesis (MIPO) in treatment of humerus diaphyseal fractures

INTRODUCTION

The three currently used methods of treatment: namely open reduction plate osteosynthesis (ORPO), Minimally invasive plate osteosynthesis (MIPO), antegrade intramedullary nailing(IMN) are all reported as satisfactory procedures for treatment of humeral shaft fractures. However none of the published reports have a comparison of superiority of one procedure over the other. We evaluated the clinical, radiological and functional outcome of the three procedures.

MATERIALS AND METHODS

We studied adult patients with humerus shaft fractures over a period of 2 years from May 2014 to May 2016 in a level 1 trauma center. Forty-four were treated with IMN, 34 treated with ORPO, and 34 with MIPO. The null hypothesis tested in this study is that there is no difference between IMN, ORPO, MIPO with respect to union time, surgical time, complication rate, non-union rate and functional outcome. Functional outcome was studied by comparing the UCLA shoulder and MEP scores in the three groups.

RESULTS

112 patients were studied consisting of 83 males and 29 females with mean age of 39 years (range 18-70). IMN group showed early union with mean of 12.73 weeks compared to MIPO (14.45 weeks) and ORPO(13.58 weeks), (p<0.05). MIPO had no events of non-union, as compared to ORPO (5 non-unions) and IMN (10 non-unions), (p=0.04). The range of movement at the shoulder with the UCLA score was significantly better with a score of 32.26 in MIPO as compared to 27.54 in IMN and 28.82 in ORPO (p<0.05). The difference in MEPS score in the three groups was not significant (p=0.31). IMN required a mean of 117.95 minutes intraoperatively as compared to 131 and 150.58 mins in MIPO, ORPO respectively.

CONCLUSION

MIPO is overall better with respect to non-union, functional outcome and complications rate. The surgical time depends on the surgeons' skill and learning curve. Thus considering the advantages and risks involved in the various procedure and surgical acumen, each case should be individualized to have a good outcome. We advocate that MIPO can be safely used as an alternative in treating these fractures.

Open reduction and internal fixation of humeral shaft fractures versus conservative treatment with a functional brace: a study protocol of a randomised controlled trial embedded in a cohort

INTRODUCTION

Humeral shaft fractures represent 1%-3% of all fractures and 20% of humeral fractures in adults. The treatment of these fractures is mainly conservative and operative treatment is usually reserved for specific circumstances. To date, no randomised controlled trial (RCT) has compared operative treatment of humeral shaft fractures with conservative treatment.

METHODS AND ANALYSIS

We will conduct an RCT to compare the effectiveness and cost-effectiveness of surgical and conservative treatment of humeral shaft fractures. After providing informed consent, 80 patients from 18 years of age with humeral shaft fracture will be randomly assigned to open reduction and internal fixation with locking plate or conservative treatment with functional bracing. We will follow the patients for 10 years and compare the results at different time points. The primary outcome will be Disabilities of Arm, Shoulder and Hand (DASH) at 12 months. The secondary outcomes will include Numerical Rating Scale for pain at rest and in activities, Constant Score and quality of life instrument 15D. Patients not willing to participate in the RCT will be asked to participate in a prospective cohort follow-up study, 'the declined cohort'. This cohort will be followed up at the same time points as the randomised patients to assess the potential effect of participation bias on RCT results and to enhance the external validity of the RCT. In one of the recruiting centres, all cooperative patients with humeral shaft fractures not eligible for randomisation will be asked to participate in a 'non-eligible cohort' study. We will use blinded data interpretation of the randomised cohort to avoid biased interpretation of outcomes. Our null hypothesis is that there is no clinically relevant difference in the primary outcome measure between the two treatment groups. We will consider a difference of a minimum of 10 points in DASH clinically relevant.

ETHICS AND DISSEMINATION

The institutional review board of the Helsinki and Uusimaa Hospital District has approved the protocol. We will disseminate the findings of this study through peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

NCT01719887; pre-results.

Current treatment of infected non-union after intramedullary nailing

Non-union is a devastating consequence of a fracture. Non-unions cause substantial patient morbidity with patients suffering from loss of function of the affected extremity, increased pain, and a substantial decrease in the quality of life. The management is often associated with repeated, unsuccessful operations resulting in prolonged hospital stays, which has social and economic consequences to both the patient and the healthcare system. The rates of non-union following intramedullary (IM) nailing vary according to anatomical location. There is currently no consensus regarding the treatment of infected non-unions following IM nailing, but the most common procedures reported are; exchange IM nail with antibiotic suppression or excision of the non-union, (stabilisation with external fixation or less commonly plate or IM nail) and then reconstruction of the bone defect with distraction osteogenesis or the Masquelet technique. This article explores the general principles of treatment, fixation modalities and proposes a treatment strategy for the management of infected non-unions following intramedullary nailing.

Comparison of Plate, Nail and External Fixation in the Management of Diaphyseal Fractures of the Humerus

INTRODUCTION

Humeral shaft fractures are quite common in orthopedics and represent 1-3% of adult fractures. The surgical treatment is the a better choice in order to obtain a reduction and stable alignment and to prevent the complications. The goal of this study was to compare the three techniques (IMN, LCP and EF) in the treatment of diaphyseal fractures of the humerus in the adult patient.

MATERIALS AND METHODS

We examined 79 patients with diaphyseal fractures of the humerus. 32 were treated with plaque (LCP), 26 with intramedullary nail (IMN) and 21 with eternal fixer (FE) The clinical and radiographic follow-up was done at 1.3, 6 and 12 months. As rating scales we used the ASES and SF-36. We recorded all the complications.

RESULTS

The median follow-up was 11.5 months (9-16). The operative time was significantly smaller in the case of FE (47 ') with a statistically significant difference compared with other techniques. Even the blood loss was lower in the case of FE (60ml), compared to nails (160ml) and LCP (330ml) p <0.05. We had no differences in the duration of hospitalization and the ASES SF-36 score. We had 2 cases of non-union in the LCP group, 1 case in the IMN group and no cases in the FE group. In IMN group we had one case of radial transient paralysis. We did not have any deep infection, in the FE group 8 patients we had superficial secretions from pins.

CONCLUSION

From the results of our study, it is clear that the treatment of humeral shaft fractures guarantee overlapping results with the use of plates, of intramedullary nails, or with the external fixator. Consequently, the choice of which technique to use should be determined based on the experience of the operator and patient compliance.

Rotator Cuff-Sparing Approach for Antegrade Humeral Nailing With Biceps Tenodesis: A Technical Trick With Clinical Implications

Antegrade intramedullary nails are an established, effective method of fixation for humeral shaft fractures. One significant limitation of this technique is chronic postoperative shoulder pain, which is likely related to the standard approach that involves splitting the rotator cuff to gain access to the nail starting point. Furthermore, mounting evidence suggests that both the intra-articular portion of the biceps tendon and the extra-articular portion in the bicipital groove can scar down after trauma, causing pain and limiting shoulder range of motion. We describe an approach through the rotator interval with tenodesis of the biceps tendon and resection of the intra-articular portion. Using a rotator cuff interval instead of a rotator cuff insertion approach allows access to the optimal humeral nail starting point while avoiding damage to intra-articular structures of the shoulder, potentially decreasing sources of postoperative shoulder pain.

A Bayesian network meta-analysis of three different surgical procedures for the treatment of humeral shaft fractures

BACKGROUND

The optimal surgical procedure for humeral shaft fractures remains a matter of debate. We aimed to establish the optimum procedure by performing a Bayesian network meta-analysis.

METHODS

PubMed, EMBASE, the Cochrane Library, and Medline were searched for both randomized controlled trials and prospective studies of surgical treatment for humeral shaft fractures. The quality of the included studies was assessed according to the Cochrane Collaboration's "Risk of bias".

RESULTS

Seventeen RCTs or prospective studies were included in the meta-analysis. The pooled results showed that the occurrence rate of radial nerve injury was lowest for minimally invasive plate osteosynthesis (MIPO; SUCRA probability, 95.1%), followed by open reduction and plate osteosynthesis (ORPO; SUCRA probability, 29.5%), and was highest for intramedullary nailing (IMN; SUCRA probability, 25.4%). The aggregated results of pairwise meta-analysis showed no significant difference in radial nerve injury rate when comparing ORPO versus IMN (OR, 1.92; 95% CI, 0.96 to 3.86), ORPO versus MIPO (OR, 3.38; 95% CI, 0.80 to 14.31), or IMN versus MIPO (OR, 3.19; 95% CI, 0.48 to 21.28). Regarding the nonunion, SUCRA probabilities were 90.5%, 40.2%, and 19.3% for MIPO, ORPO, and IMN, respectively. The aggregated results of a pairwise meta-analysis also showed no significant difference for ORPO versus IMN (OR, 0.83; 95% CI, 0.41 to 1.69), ORPO versus MIPO (OR, 2.42; 95% CI, 0.45 to 12.95), or IMN versus MIPO (OR, 2.49; 95% CI, 0.35 to 17.64).

CONCLUSION

The current evidence indicates that MIPO is the optimum choice in the treatment of humeral shaft fractures and that ORPO is superior to IMN.

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.

Humeral Shaft Fracture Fixation: Incidence Rates and Complications as Reported by American Board of Orthopaedic Surgery Part II Candidates

BACKGROUND

Despite extensive research regarding patient outcomes after operative fixation of humeral shaft fractures by means of open reduction and internal fixation (ORIF) or intramedullary nailing (IMN), no current consensus exists regarding the optimal surgical treatment. The objective of this study was to compare IMN and plate fixation (ORIF) of humeral shaft fractures by using the American Board of Orthopaedic Surgery (ABOS) Part II operative database to analyze incidence rates, changes in management trends over time, early complications, and factors affecting the management choice.

METHODS

The ABOS database is a collection of surgical cases that are self-reported by orthopaedic candidates approved for admission to the ABOS oral examination. The database was searched for records from 2004 to 2013 for humeral shaft surgical cases as indicated by Current Procedural Terminology (CPT) codes 24515 (open reduction internal fixation) and 24516 (insertion of intramedullary nail) pertaining to humeral shaft fractures. The geographic region and fellowship training of the candidates; the year of surgery, diagnosis code, age, and sex of the patients; and the surgeon-reported complications were analyzed.

RESULTS

The search identified 3,430 surgically treated humeral shaft fractures that were reported to the ABOS database from 2004 to 2013. A significant decline in IMN use was seen from 2004 (42.9%) to 2013 (21.2%, p < 0.001). The IMN cohort had lower complication rates pertaining to both infections (1.5% compared with 3.0% for ORIF, p = 0.007) and nerve palsies (3.1% compared with 7.8%, p < 0.001). No significant difference was seen in the rate of nonunion (1.3% for IMN compared with 1.6% for ORIF, p = 0.63), although follow-up may be too short to demonstrate a difference. The IMN cohort did have significantly higher mortality (4.9% compared with 0.7% for ORIF, p < 0.001). Subset analysis demonstrated that the IMN cohort had significantly more pathologic fractures (26.8% compared with 1.5% of the fractures treated with ORIF, p < 0.001).

CONCLUSIONS

Although the overall incidence of fixation of humeral shaft fractures was unchanged from 2004 to 2013, there was a significant shift from IMN to ORIF using plate fixation during this time period. Possible reasons for this shift in treatment to ORIF include the potential impact of recent publications highlighting complications of IMN and increased surgeon attention to cost containment.

LEVEL OF EVIDENCE

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

What Factors are Associated With a Surgical Site Infection After Operative Treatment of an Elbow Fracture?

BACKGROUND

Surgical site infections are one of the more common major complications of elbow fracture surgery and can contribute to other adverse outcomes, prolonged hospital stays, and increased healthcare costs.

QUESTIONS/PURPOSES

We asked: (1) What are the factors associated with a surgical site infection after elbow fracture surgery? (2) When taking the subset of closed elbow fractures only, what are the factors associated with a surgical site infection? (3) What are the common organisms isolated from an elbow infection after open treatment?

METHODS

One thousand three hundred twenty adult patients underwent surgery for an elbow fracture between January 2002 and July 2014 and were included in our study. Forty-eight of 1320 patients (4%) had a surgical site infection develop. Thirty-four of 1113 patients with a closed fracture (3%) had a surgical site infection develop.

RESULTS

For all elbow fractures, use of plate and screw fixation (adjusted odds ratio [OR]= 2.2; 95% CI, 1.0-4.5; p = 0.041) and use of external fixation before surgery (adjusted OR = 4.7; 95% CI, 1.1-21; p = 0.035) were associated with higher infection rates. When subset analysis was performed for closed fractures, only smoking (adjusted OR = 2.2; 95% CI, 1.1-4.5; p = 0.023) was associated with higher infection rates. Staphylococcus aureus was the most common bacteria cultured (59%).

CONCLUSIONS

The only modifiable risk factor for a surgical site infection after open reduction and internal fixation was cigarette smoking. Plate fixation and temporary external fixation are likely surrogates for more complex injuries, therefore no recommendations should be inferred from this association. Surgeons should counsel patients who smoke.

LEVEL OF EVIDENCE

Level IV, prognostic study.

Marchetti Vicenzi elastic retrograde nail in the treatment of humeral shaft fractures: review of the current literature

Shoulder impairment following anterograde intramedullary nailing for humeral shaft fractures represents a challenging problem for the orthopedic surgeon. Traditional retrograde nailing lowers the rates of shoulder impairment although exposing the surgeons to severe technical issues related to the proximal interlocking. The Marchetti Vicenzi nail (MVN) permits a retrograde insertion along with a self-locking mechanism that lowers the risk of iatrogenic damage during proximal interlocking. Aim of this literature review was to evaluate all the case series dealing with MVN and the obtained results in terms of union rates, complications, and functional outcomes in order to evaluate evidence that would substantiate the adoption of MVN in the treatment of humeral shaft fractures. A search was performed using the keywords "humeral shaft fracture nail," "humeral retrograde nail," "humeral elastic nail," "Marchetti Vicenzi nail," "Marchetti nail," "Vicenzi nail." After accurate revision 13 articles found to be relevant with a total of 532 humeral fractures (traumatic and pathologic) and non-unions treated with MVN. The cumulative healing rate reported is 93.7 % with 6.3 % of non-unions. Despite the fact that obtained results compare favorably to the published data on the outcome of anterograde nailing, the evaluated studies presented a huge number of methodological flaws, thus making it difficult to recommend the adoption of MVN in preference of other better-validated forms of treatment.

Intramedullary nailing of humeral shaft fractures: failure analysis of a single centre series

INTRODUCTION

Intramedullary nailing (IMN) is an accepted technique for the treatment of humeral shaft fractures. Previous studies published concerns over whether this technique had higher complication rates such as nonunion and technical failures compared to plate osteosynthesis. We, therefore, conducted a single centre failure analysis to critically evaluate our results regarding IMN of humeral shaft fractures.

MATERIALS AND METHODS

Between January 2000 and January 2013, 246 consecutive patients with humeral shaft fractures were enrolled. Inclusion criteria were skeletal maturity and humeral shaft fractures treated with IMN. Exclusion criteria were skeletal immaturity, primary treatment by plate osteosynthesis, primary treatment outside the University Hospitals Leuven, presence of metaphyseal fractures and the presence of pathological fractures. Negative outcome measures such as infection, nonunion and early technical failure were retrospectively assessed.

RESULTS

During the study period, 149 patients with 149 fractures met the inclusion criteria. Of these, 14 patients were lost to follow-up, two died from trauma-related causes within the first 30 days after the accident, and eight died from other causes (cardiovascular disease and cancer) leaving 125 patients with 125 fractures for a minimum follow-up period of 12 months. Failure analysis showed that six (4.8 %) patients developed a nonunion. One (0.8 %) patient was diagnosed with a deep infection. In total, five (5 %) patients underwent surgical revision due to early technical failures.

CONCLUSIONS

IMN is a valid therapeutic option for humeral shaft fractures. Good surgical technique and soft tissue handling are important for good outcome. Currently, patient demands are receiving greater consideration. In an era where early full range of motion and rapid return to work with minimal scarring is mandatory for most patients, the use of IMN will most likely increase in popularity in the future.

Coffee consumption and risk of endometrial cancer: a dose-response meta-analysis of prospective cohort studies

This is a dose-response (DR) meta-analysis to evaluate the association of coffee consumption on endometrial cancer (EC) risk. A total 1,534,039 participants from 13 published articles were added in this meta-analysis. The RR of total coffee consumption and EC were 0.80 (95% CI: 0.74–0.86). A stronger association between coffee intake and EC incidence was found in patients who were never treated with hormones, 0.60 (95% CI: 0.50–0.72), and subjects with a BMI ≥25 kg/m², 0.57 (95% CI: 0.46–0.71). The overall RRs for caffeinated and decaffeinated coffee were 0.66 (95% CI: 0.52–0.84) and 0.77 (95% CI: 0.63–0.94), respectively. A linear DR relationship was seen in coffee, caffeinated coffee, decaffeinated coffee and caffeine intake. The EC risk decreased by 5% for every 1 cup per day of coffee intake, 7% for every 1 cup per day of caffeinated coffee intake, 4% for every 1 cup per day of decaffeinated intake of coffee, and 4% for every 100 mg of caffeine intake per day. In conclusion, coffee and intake of caffeine might significantly reduce the incidence of EC, and these effects may be modified by BMI and history of hormone therapy.

Intramedullary nail versus plate fixation for humeral shaft fractures: a systematic review of overlapping meta-analyses

Multiple meta-analyses have been published to compare intramedullary nail and plate for treating humeral shaft fractures; however, results are discordant.The purposes of current study were to perform a systematic review of overlapping meta-analyses comparing intramedullary nail and plate fixation for the treatment of humeral shaft fractures, to appraise the methodological quality and the quality of reporting of meta-analyses, and to propose a guide through the currently discordant available evidence.This systematic review was performed according to the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-analysis. The literature was systematically reviewed to identify meta-analyses comparing intramedullary nail and plate fixation for the treatment of humeral shaft fractures. Only meta-analyses exclusively including randomized clinical trials (RCTs) met eligibility criteria in this systematic review. Methodological quality for each included study was assessed using the Oxford Levels of Evidence and the Assessment of Multiple Systematic Reviews Instrument. We extracted all variables from the included studies and listed the results reported by them. Heterogeneity information of each variable was extracted for the included studies. An I of <60% is accepted in this systematic review. The Jadad algorithm was then applied to determine which meta-analyses provided the best evidence.Seven studies met the inclusion criteria in this study. All studies included RCTs or quasi-RCT and were Level II of evidence. Assessment of Multiple Systematic Reviews scores varied from 6 to 10 with a median of 7.86. Heterogeneity of each outcome was acceptable in those meta-analyses pooled results. The Jadad algorithm suggested that the meta-analyses can be selected based on the search strategies and application of selection. As a result, 2 meta-analyses with more RCTs were selected in this systematic review. The best available evidence suggested that the differences between intramedullary nail and plate fixation were not significant in fracture union, radial nerve injury, and infection. But intramedullary nail significantly increased the risk of shoulder complications (shoulder impingement and restriction of shoulder movement) and reoperation.We concluded that plate fixation is superior to intramedullary nail for the treatment of humeral shaft fractures.