1
|
Boadi PJ, Da Silva A, Mizels J, Joyce CD, Anakwenze OA, Klifto CS, Chalmers PN. Intramedullary versus locking plate fixation for proximal humerus fractures: indications and technical considerations. JSES REVIEWS, REPORTS, AND TECHNIQUES 2024; 4:615-624. [PMID: 39157214 PMCID: PMC11329022 DOI: 10.1016/j.xrrt.2024.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/20/2024]
Abstract
Background The incidence of proximal humerus fractures (PHFs) continues to increase with an aging population, and intramedullary nailing (IMN) and locking plate fixation are two commonly employed techniques for the surgical management of PHF. However, the optimal fixation method can be a source of ongoing controversy. Some influencing factors include the extent of humeral head involvement, fracture complexity, patient age, and surgeon preference. There are many studies that provide a mix of data either when comparing the two techniques or analyzing them in isolation. The aim of this review is to further elucidate the indications and technical considerations involved specifically in IMN vs. locking plate fixation for PHF to further aid orthopedic surgeons when choosing surgical management. Methods A narrative approach was chosen for this review allowing for a comprehensive review of literature, including recent findings pertaining to the comparison of management options for PHF. A comprehensive literature search was conducted using the PubMed, Embase, and Cochrane Library databases. The inclusion criteria involved studies that discussed "proximal humerus fracture" and either "intramedullary nail" or "locking plate fixation." Results Complications such as avascular necrosis, hardware failure, additional surgical interventions, infection, fracture redisplacement, rotator cuff rupture, and nonunion did not show significant differences between the two groups. Newer generation humeral nails have minimized early complications. As both techniques undergo further refinement and utilization when specifically indicated, functional outcomes, potential complications, and postoperative pain continue to be improved. Conclusion The available evidence suggests that both intramedullary nails and locking plates can effectively restore shoulder function in the treatment of displaced proximal humeral fractures, with unclear superiority of either method. The choice of technique should be tailored to patient factors such as fracture type, age, bone quality, and functional expectations. Surgeon experience also plays a role. While certain presentations may exhibit trends that favor one fixation, no specific technique can be universally recommended. Both IMN and LP have shown comparable and satisfactory outcomes, and the final fixation method chosen should take into account the unique characteristics of each patient.
Collapse
Affiliation(s)
| | - Adrik Da Silva
- University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Josh Mizels
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | | | - Oke A. Anakwenze
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Christopher S. Klifto
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Peter N. Chalmers
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| |
Collapse
|
2
|
Hurley ET, Wickman J, Crook BS, Cabell G, Rodriguez K, Boadi P, DeBaun MR, Pean C, Klifto C. Intramedullary nailing vs. open reduction-internal fixation for humeral shaft fractures: a meta-analysis of randomized controlled trials. J Shoulder Elbow Surg 2023; 32:2567-2574. [PMID: 37579941 DOI: 10.1016/j.jse.2023.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 06/23/2023] [Accepted: 07/10/2023] [Indexed: 08/16/2023]
Abstract
BACKGROUND The purpose of this study was to perform a meta-analysis of randomized controlled trials (RCTs) to compare outcomes following intramedullary nailing (IMN) vs. open reduction-internal fixation (ORIF) for humeral shaft fractures. METHODS A literature search of 3 databases was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. RCTs comparing IMN and ORIF for humeral shaft fractures were included. Clinical outcomes were compared using RevMan. P < .05 was considered statistically significant. RESULTS Ten RCTs with 512 patients were included. Overall, 8.4% of patients treated with IMN and 6.4% of patients treated with ORIF had nonunion (P = .57, I2 = 0%), with a significantly faster time to union with IMN (10 weeks vs. 11.9 weeks, P < .05). There was no significant difference in the rate of reoperation (11.6% in IMN group vs. 7.6% in ORIF group, P = .26) or radial nerve palsy (2.8% in IMN group vs. 4.2% in ORIF group, P = .58). A lower rate of infection was noted with IMN (1.2% vs. 5.3%, P < .05). Additionally, there was a lower operative time with IMN (61 minutes vs. 88 minutes, P < .05). CONCLUSIONS The Level I evidence in the literature does not show a significant difference in rates of union, reoperation, or radial nerve palsy between IMN and ORIF for humeral shaft fractures. Overall, treatment with IMN results in a lower infection rate, less operative time, and a modestly quicker time to union. The optimal treatment strategy for humeral shaft fractures may be best informed by fracture pattern and surgeon preference.
Collapse
Affiliation(s)
- Eoghan T Hurley
- Department of Orthopedic Surgery, Duke University School of Medicine, Durham, NC, USA.
| | - John Wickman
- Department of Orthopedic Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Bryan S Crook
- Department of Orthopedic Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Grant Cabell
- Department of Orthopedic Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Kaitlyn Rodriguez
- Department of Orthopedic Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Prince Boadi
- Department of Orthopedic Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Malcolm R DeBaun
- Department of Orthopedic Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Christian Pean
- Department of Orthopedic Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Christopher Klifto
- Department of Orthopedic Surgery, Duke University School of Medicine, Durham, NC, USA
| |
Collapse
|
3
|
Gerich T, Mouton C, Jabbarian L, Weydert JP, Hoffmann A, Pape D, Seil R. The portal of Neviaser: a valid option for antegrade nailing of humerus fractures. J Exp Orthop 2020; 7:8. [PMID: 32114683 PMCID: PMC7049297 DOI: 10.1186/s40634-020-00222-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 01/31/2020] [Indexed: 11/10/2022] Open
Abstract
Introduction The objective of this retrospective non-randomized study was to evaluate the portal of Neviaser (PN) as an alternative approach in antegrade humeral nailing. Methods The surgical approach for the straight antegrade intramedullary nail (SAIN) was either the anterolateral delta-split (group 2, n = 79) or the portal of Neviaser (group 3, n = 27). Length of surgery and time of radiation were extracted from charts. Patients stabilized using the PN were followed for a clinical and radiological exam. At follow-up we evaluated the DASH (Disability of the Arm, Shoulder and Hand) and CMS (Constant-Murley Score). Results Between 10.2015 and 12.2018 191 proximal and diaphyseal humeral fractures were operated using either an angular stable extramedullary device (group 1, PHILOS®, n = 85) or a straight humeral nail (MultiLoc®, n = 106). Time of radiation and intervention followed a normal distribution. The mean length of surgery was 172.9 min (SD 91.5) in group 1, 121.5 min (SD 54.1) in group 2 and 96.4 min (SD 33.7) in group 3 (p < 0.01). Time of radiation was significantly different with 1.1 min (SD 0.6: group 1), 3.1 min (SD 1.6: group 2) and 2.9 min (SD 1.7: group 3) (p < 0.01). After a mean interval of 21.5 months (range 6–43 months) 14 / 27 patients of group 3 were available for a clinical and radiological follow-up. The mean DASH in group 3 was 25, the CMS reached 70. The age and sex weighted CMS mean value was 96%. Forward flexion was 131°, abduction 125°. The ratio of strength affected versus non-affected side was 4.4: 6.2 kg. Conclusions The portal of Neviaser is a feasible and safe approach and is an alternative to the anterolateral delta-split. Length of surgery and time of radiation were significantly shorter. Level of evidence IV
Collapse
Affiliation(s)
- Torsten Gerich
- Department of Orthopaedic Trauma, Centre Hospitalier de Luxembourg, 4, rue Barble, L-1210, Luxembourg, Luxembourg.
| | - Caroline Mouton
- Department of Orthopaedic Surgery, Centre Hospitalier de Luxembourg, 76 rue d'Eich, L-1460, Luxembourg, Luxembourg
| | - Lea Jabbarian
- Department of Public Health, Erasmus MC, P.O. Box 2040, Rotterdam, 3000, CA, Netherlands
| | - Jean-Paul Weydert
- Department of Physiotherapy, Centre Hospitalier de Luxembourg, 4, rue Barble, L-1210, Luxembourg, Luxembourg
| | - Alexander Hoffmann
- Department of Orthopaedic Surgery, Centre Hospitalier de Luxembourg, 76 rue d'Eich, L-1460, Luxembourg, Luxembourg
| | - Dietrich Pape
- Department of Orthopaedic Surgery, Centre Hospitalier de Luxembourg, 76 rue d'Eich, L-1460, Luxembourg, Luxembourg
| | - Romain Seil
- Department of Orthopaedic Surgery, Centre Hospitalier de Luxembourg, 76 rue d'Eich, L-1460, Luxembourg, Luxembourg
| |
Collapse
|
4
|
Tanaka Y, Gotani H, Sasaki K, Yoshimura T, Yagi H. Evaluation of intramedullary nail fixation via the Neviaser portal for proximal humerus fracture. J Clin Orthop Trauma 2019; 10:474-479. [PMID: 31061572 PMCID: PMC6491907 DOI: 10.1016/j.jcot.2019.02.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Revised: 01/08/2019] [Accepted: 02/07/2019] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES To our knowledge, no cases have been reported so far regarding the treatment of proximal humerus fracture with intramedullary nail fixation via the Neviaser portal. This study aimed at evaluating the results of intramedullary nail fixation via the Neviaser portal for proximal humerus fracture. METHODS Four patients with 2-part proximal humerus fracture, who underwent the intramedullary nail fixation via the Neviaser portal, were included in this study. All the patients were females, and the mean age was 78.8 years. We evaluated their clinical and radiographic findings retrospectively. RESULTS The mean follow-up period was 12 months. All the patients achieved a bone-union without severe complications, such as deep wound infections or any neurological deficits. At the final follow-up, mean shoulder flexion, abduction, and external rotation were 123.5°, 118°, and 36°, respectively. Mean visual analog pain scale (VAS) score at the final follow-up was 21/100. Complications related to the implants were observed in two patients. In one patient, protrusion of the proximal tip of the nail occurred from the entry point, and this caused secondary subacromial impingement. In the other patient, insertion of the end-cap from the Neviaser portal was not possible, and this resulted in the failure of fixation postoperatively. CONCLUSION The Neviaser portal may be suitable for the insertion of an intramedullary nail, because it facilitates to make an entry-point at the top of the humeral head. However, the problems related to the use of the present instruments still remain and need to be improved.
Collapse
|
5
|
Abstract
BACKGROUND Deformity and growth arrest of the humerus in children may result as sequelae of proximal humerus fractures and unicameral bone cysts, or as complications of their treatment. As approximately 80% of the growth of the humerus arises from the proximal physis, the resultant upper limb-length discrepancy can be substantial. Benefits to lengthening the shortened arm have been previously demonstrated with the use of external fixation devices. To our knowledge, no reports have been published on the use of intramedullary implants for this purpose. METHODS A 15-year-old girl with humeral shortening secondary to proximal humeral growth disturbance following treatment for a unicameral bone cyst was treated with humeral osteoplasty and gradual lengthening with an off-label use of a fully implantable motorized intramedullary lengthening nail. A varus proximal humeral deformity and lateral starting point allowed for avoidance of the rotator cuff insertion. RESULTS Humeral lengthening (5 cm) was achieved at 9 weeks, with bony union at 7 months, and hardware removal at 9½ months. Shoulder and elbow motion was maintained during and after treatment. CONCLUSIONS This is the first case report of humeral lengthening using a fully implantable motorized intramedullary lengthening nail. Although some technical limitations remain when compared with other methods, the procedure was well tolerated throughout the course of treatment. LEVEL OF EVIDENCE Level IV-case report.
Collapse
|
6
|
Dilisio MF, Nowinski RJ, Hatzidakis AM, Fehringer EV. Intramedullary nailing of the proximal humerus: evolution, technique, and results. J Shoulder Elbow Surg 2016; 25:e130-8. [PMID: 26895601 DOI: 10.1016/j.jse.2015.11.016] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Revised: 11/05/2015] [Accepted: 11/10/2015] [Indexed: 02/01/2023]
Abstract
Proximal humerus fractures are the third most common fracture in the elderly. Although most fractures can be treated conservatively with acceptable outcomes, certain fracture patterns are at high risk for progression to humeral malunions, nonunions, stiffness, and post-traumatic arthrosis. The goal of antegrade humeral nailing of proximal humerus fractures is to provide stability to a reduced fracture that allows early motion to optimize patient outcomes. Certain technical pearls are pivotal in managing these difficult fractures with nails; these include rotator cuff management, respect of the soft tissues, anatomic tuberosity position, blood supply maintenance, knowledge of the deforming forces on the proximal humerus, fracture reduction, and rehabilitation strategies. Modern proximal humeral nail designs and techniques assist the surgeon in adhering to these principles and have demonstrated promising outcomes. Humeral nail designs have undergone significant innovation during the past 40 years and now can provide stable fixation in the humeral shaft distally as well as improved stability in the head and tuberosity fragments, which were the common site of fixation failure with earlier generation implants. Compared with other fixation strategies, such as locking plate fixation, no compelling evidence exists to suggest one technique over another. The purpose of this review is to describe the history, results, new designs, and techniques that make modern intramedullary nailing of proximal humerus fractures a viable treatment option.
Collapse
Affiliation(s)
- Matthew F Dilisio
- Creighton University Orthopaedics, CHI Health Alegent Creighton Clinic, Omaha, NE, USA.
| | | | | | - Edward V Fehringer
- Columbus Community Hospital Orthopaedics and Sports Medicine, Columbus, NE, USA
| |
Collapse
|