Open vs. closed reduction combined with minimally invasive plate osteosynthesis in humeral fractures

MRI evaluation of axillary neurovascular bundle: Implications for minimally invasive proximal humerus fracture fixation

Background

Percutaneous fixation of proximal humeral fractures places the axillary nerve and posterior humeral circumflex artery at risk for injury. Safe operative zones for the axillary nerve are described based on external measurements from anatomic landmarks, but no study to date has incorporated advanced imaging to help guide surgical procedures in the region of the axillary neurovascular bundle (ANVB). We sought to define the location and trajectory of the ANVB in relation to osseous landmarks using magnetic resonance imaging (MRI) measurements.

Methods

Retrospective review of 750 consecutive MRI studies was performed with 55 imaging studies meeting inclusion criteria for patient positioning, image alignment, and quality. Five measurements were performed including the distance from mid-lateral acromion to lateral ANVB, mid-lateral acromion to medial ANVB, greater tuberosity to lateral ANVB, vertical distance between inferior anatomic neck and lateral ANVB, and angle the ANVB crosses the humerus. Height, gender, and age were recorded. Analysis was performed using ANOVA and Pearson correlation tests.

Results

The lateral ANVB was below the inferior articular margin of the humeral head by an average of 12.9 ± 3.9 mm and within a 22 mm window. It was an average of 57.4 ± 5.1 mm from the lateral mid-acromion, and 34.7 ± 4.3 mm below the greater tuberosity. The angle formed by the ANVB crossing the humerus averaged 19.5 ± 3.9 degrees upward from medial to lateral. Height and gender directly impacted measurements.

Conclusions

The use of the inferior humeral head articular margin provides a radiographic landmark to aid intraoperative lateral ANVB assessment which may be helpful during percutaneous fracture fixation.

Comparison between minimally invasive plate osteosynthesis and open reduction-internal fixation for proximal humeral fractures: a meta-analysis based on 1050 individuals

BACKGROUND

This meta-analysis aimed to compare the clinical outcomes and complications of minimally invasive plate osteosynthesis (MIPO) and open reduction-internal fixation (ORIF) in patients with proximal humeral fractures.

METHODS

We searched PubMed, EMBASE, Ovid, and the Cochrane Library to identify all relevant studies from inception to April 2019. Cochrane Collaboration's Review Manage 5.3 was used for meta-analysis.

RESULTS

Sixteen studies involving 1050 patients (464 patients in the MIPO group and 586 patients in the ORIF group) were finally included. According to the meta-analysis, MIPO was superior to ORIF in operation time, blood loss, postoperative pain, fracture union time, and constant score. However, MIPO was associated with more exposure to radiation and axillary nerve injury. No significant differences were found in length of hospital stays and complication except for axillary nerve injury.

CONCLUSION

The present evidence indicates that compared to ORIF, MIPO had advantages in functional outcomes, operation time, blood loss, postoperative pain, and fracture union time for the treatment of PHFs. However, the MIPO technique had a higher rate of axillary nerve injury and longer radiation time compared to ORIF.

Comparison between minimally invasive plate osteosynthesis and open plating for proximal humeral fractures: a meta-analysis

AIM

We conducted this meta-analysis for comparing the efficacy and safety in proximal humeral fractures by treatment minimally invasive plate osteosynthesis and open plating.

METHODS

The potential academic literature were identified from the Cochrane Library, Springer, PubMed, Embase and ScienceDirect. Pooled data were analyzed by RevMan 5.1.

RESULTS

Seven studies marched with the inclusion criteria. Meta-analysis showed the significant differences in terms of blood loss, operative time, length of hospital stays and constant score between two groups. No significant differences were found in time to union, the union rate and complications.

CONCLUSION

Minimally invasive plate osteosynthesis in proximal humeral fractures provided significantly shorter operative times, length of hospital stays, less blood loss and better clinical outcomes without increasing complications.

Minimally invasive treatment of displaced femoral shaft fractures with a teleoperated robot-assisted surgical system

BACKGROUND

Minimally invasive surgical operation of intramedullary (IM) nailing is a standard technique for treating diaphyseal fractures. However, in addition to its advantages, there are some drawbacks such as the frequent occurrence of malalignment, physical fatigue and high radiation exposure to medical staff. The use of robotic and navigation techniques is promising treatments for femoral fractures.

MATERIALS AND METHODS

This paper presents a novel robot-assisted manipulator for femoral shaft fracture reduction with indirect contact with the femur. An alternative clinical testing model was proposed for orthopedic surgeons to practice femoral fracture reduction. This model imitates the human musculoskeletal system in shape and functional performance. The rubber tube simulate muscles providing contraction forces, and the silicone simulates passive elasticity of muscles. Two-group experiments were performed for studying feasibility of the teleoperated manipulator.

RESULTS

The average operative time was about 7min. In the first group experiments, the femur axial, antero-posterior (AP) and lateral views mean errors were 2.2mm, 0.7mm and 1.1mm, respectively, and their maximums were 3.0mm, 0.9mm and 1.5mm; the mean errors of rotation were 0.8° around x-axis, 1.6° around y-axis, 2.0° around z-axis, and their maximums were 1.1°, 2.2°, 2.9°, respectively. For the second group experiments, the femur axial, AP and lateral views mean errors were 1.8mm, 0.4mm and 0.8mm, respectively, and their maximums were 2.2mm, 0.7mm and 1.1mm; the mean errors of rotation were 1.2° around x-axis, 1.6° around y-axis, 1.9° around z-axis, and their maximums were 2.4°, 1.8°, 2.7°, respectively. Reduction for AP view displacement is easier than lateral (p<0.05) because of the tube-shaped anatomy and the muscle contraction forces. Errors around x-axis are smaller than those around y-, and z- axes (p<0.05), i.e., electro-mechanical actuator is easier to control than pneumatic.

CONCLUSION

An experimental model for simulating human femoral characteristics was proposed. Experiments conducted on the artificial lower limb model demonstrated high reduction accuracy, safety, sufficient working space, and low radiation exposure of the proposed robot-assisted system. Thus, the minimally invasive teleoperated manipulator would have greater development prospect.

Surgical interventions to treat humerus shaft fractures: A network meta-analysis of randomized controlled trials

BACKGROUND

There are three main surgical techniques to treat humeral shaft fractures: open reduction and plate fixation (ORPF), intramedullary nail (IMN) fixation, and minimally invasive percutaneous osteosynthesis (MIPO). We performed a network meta-analysis to compare three surgical procedures, including ORPF, IMN fixation, and MIPO, to provide the optimum treatment for humerus shaft fractures.

METHODS

MEDLINE, EMBASE, Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, and Cochrane library were researched for reports published up to May 2016. We only included randomized controlled trials (RCTs) comparing two or more of the three surgical procedures, including the ORPF, IMN, and MIPO techniques, for humeral shaft fractures in adults. The methodological quality was evaluated based on the Cochrane risk of bias tool. We used WinBUGS1.4 to conduct this Bayesian network meta-analysis. We used the odd ratios (ORs) with 95% confidence intervals (CIs) to calculate the dichotomous outcomes and analyzed the percentages of the surface under the cumulative ranking curve.

RESULTS

Seventeen eligible publications reporting 16 RCTs were included in this study. Eight hundred and thirty-two participants were randomized to receive one of three surgical procedures. The results showed that shoulder impingement occurred more commonly in the IMN group than with either ORPF (OR, 0.13; 95% CI, 0.03-0.37) or MIPO fixation (OR, 0.08; 95% CI, 0.00-0.69). Iatrogenic radial nerve injury occurred more commonly in the ORPF group than in the MIPO group (OR, 11.09; 95% CI, 1.80-124.20). There were no significant differences among the three procedures in nonunion, delayed union, and infection.

CONCLUSION

Compared with IMN and ORPF, MIPO technique is the preferred treatment method for humeral shaft fractures.