Intramedullary nailing of humeral diaphyseal fractures. Is distal locking really necessary?

Does double distal locking reduce non-union rates in intramedullary nailing for humeral shaft fracture?

INTRODUCTION

Intramedullary nailing is one of the surgical treatments for humeral shaft fracture. Non-union is a common complication, with rates of 10-20%. The objective of this study was to compare non-union in humeral shaft fractures treated by intramedullary nailing with double distal locking, single distal locking or no locking.

HYPOTHESIS

Nailing with double distal locking decreases non-union rates compared to single or no locking.

MATERIAL AND METHODS

This single-center retrospective comparative study included 87 patients with closed humeral shaft fracture without neurologic deficit treated by anterograde intramedullary nailing: group 1 (double locking): 15 fractures; group 2 (single locking): 63 fractures; group 3 (no locking): 9 fractures. Non-union was defined as absence of radiographic callus at 6 months without clinical pain. The primary endpoint was non-union rate per group. The secondary endpoints were Constant score at 6 months, and postoperative use of non-steroidal anti-inflammatory drugs (NSAIDs).

RESULTS

There were no significant differences in non-union rate: 20.0% in group 1, 20.3% in group 2, and 0% in group 3 (p=0.32). Constant score at 6 months was significantly different between the 3 groups (p=0.01). Group 2 used more NSAIDs than the other groups (39.1% vs. 20.0% in group 1 and 33.3% in group 3; p=0.37).

DISCUSSION

Non-union rates were similar regardless of distal locking for closed humeral shaft fractures without neurologic deficit treated by intramedullary nailing. Nevertheless, patients in the double locking group had higher Constant scores at 6 months, probably related to greater stability of fixation, allowing more efficient rehabilitation.

LEVEL OF EVIDENCE

III; retrospective comparative study.

Intramedullary nailing for humeral shaft fractures: Is distal locking necessary?

INTRODUCTION

Intramedullary (IM) nailing of humeral shaft fractures is a reliable means to achieve bone union while allowing early motion. The hypothesis was that distal locking is unnecessary due to good primary stability of the impacted nail in the distal, truncated cone portion of the medullary canal. The primary objective of this study was to confirm the success of the procedure without distal locking by identifying failure criteria. The secondary objectives were to compare the outcomes of IM nailing with and without distal locking.

MATERIAL AND METHODS

This was a retrospective, single-center, non-randomized study of 128 patients with a humeral shaft fracture between 2012 and 2020 treated surgically with a long IM nail. Proximal locking was done in every case, then the rotational stability of the nail was tested. Stable nails were not locked distally (group A), while unstable nails were locked distally through an anterior approach (group B). All patients were reviewed with at least 12 months' follow-up.

RESULTS

Distal locking was performed in 30 patients (mean age 63, 17-91) while the fracture in 98 patients (mean age 65, 20-93) did not require distal locking. The average time to union was 4 months (2-6). The average operative time in group B was 87min (35-185) with 90s fluoroscopy time (33-158) versus 52min (20-127) with 44 s fluoroscopy time (12-143) in group A (p<0.05). Four patients in group B suffered postoperative radial nerve palsy and two others had another fracture at the level of the distal locking screws. The union rate did not differ between groups (Group A 94.6%, group B 86.2%, p=0.217) nor did the functional recovery - SSV of 79.5 (10-100) in group A versus 76 (40-100) in group B (p=0.271) - or the range of motion (p>0.05). There were no instances of rotational malunion.

DISCUSSION

Except for certain distal third fractures, distal locking is not necessary to achieve bone union when the nail is impacted into the medullary canal. This reduces the operative time, fluoroscopy time and risk of neurological damage.

LEVEL OF EVIDENCE

IV.

Humeral shaft fracture: systematic review of non-operative and operative treatment

INTRODUCTION

Humeral shaft fractures can be treated non-operatively or operatively. The optimal management is subject to debate. The aim was to compare non-operative and operative treatment of a humeral shaft fracture in terms of fracture healing, complications, and functional outcome.

METHODS

Databases of Embase, Medline ALL, Web-of-Science Core Collection, and the Cochrane Central Register of Controlled Trials (CENTRAL) were systematically searched for publications reporting clinical and functional outcomes of humeral shaft fractures after non-operative treatment with a functional brace or operative treatment by intramedullary nailing (IMN; antegrade or retrograde) or plate osteosynthesis (open plating or minimally invasive). A pooled analysis of the results was performed using MedCalc.

RESULTS

A total of 173 studies, describing 11,868 patients, were included. The fracture healing rate for the non-operative group was 89% (95% confidence interval (CI) 84-92%), 94% (95% CI 92-95%) for the IMN group and 96% (95% CI 95-97%) for the plating group. The rate of secondary radial nerve palsies was 1% in patients treated non-operatively, 3% in the IMN, and 6% in the plating group. Intraoperative complications and implant failures occurred more frequently in the IMN group than in the plating group. The DASH score was the lowest (7/100; 95% CI 1-13) in the minimally invasive plate osteosynthesis group. The Constant-Murley and UCLA shoulder score were the highest [93/100 (95% CI 92-95) and 33/35 (95% CI 32-33), respectively] in the plating group.

CONCLUSION

This study suggests that even though all treatment modalities result in satisfactory outcomes, operative treatment is associated with the most favorable results. Disregarding secondary radial nerve palsy, specifically plate osteosynthesis seems to result in the highest fracture healing rates, least complications, and best functional outcomes compared with the other treatment modalities.

Humeral shaft fractures: a cost-effectiveness analysis of operative versus nonoperative management

BACKGROUND

Humeral shaft fractures can be managed operatively or nonoperatively with functional bracing in the absence of neurovascular injury, open fracture, or polytrauma. A consensus on optimal management has not been reached, nor has the cost-effectiveness perspective been investigated.

METHODS

A decision tree was constructed describing the management of humeral shaft fractures with open reduction-internal fixation (ORIF), intramedullary nailing (IMN), and functional bracing in a non-elderly population. Probabilities were defined using weighted averages determined from systematic review of the literature. Cost-effectiveness was evaluated with incremental cost-effectiveness ratios, measured in cost per quality-adjusted life-year (QALY). Willingness-to-pay thresholds of $50,000/QALY and $100,000/QALY were evaluated.

RESULTS

Eighty-six studies were included. Using bracing as the referent in the health care model, we observed that bracing was the preferred strategy at both incremental cost-effectiveness ratio thresholds. ORIF and IMN had higher overall effectiveness (0.917 QALYs and 0.913 QALYs, respectively) compared with bracing (0.877 QALYs). The cost-effectiveness of bracing was driven by a substantially lower overall cost. In the societal model-accounting for both health care and societal costs-the cost difference narrowed between bracing, ORIF, and IMN. Bracing remained the preferred strategy at the $50,000/QALY threshold; ORIF was preferred at the $100,000/QALY threshold. ORIF and IMN were comparable strategies across a range of probability values in sensitivity analyses.

CONCLUSIONS

Functional bracing, with its low cost and satisfactory clinical outcomes, is often the most cost-effective strategy for humeral shaft fracture management. ORIF becomes preferable at the higher willingness-to-pay threshold when societal burden is considered. QALY values for ORIF and IMN were comparable.

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.

Are the unreamed nails indicated in diaphyseal fractures of the lower extremity? A biomechanical study

INTRODUCTION

Intramedullary nailing is generally accepted as the first choice for the treatment of diaphyseal fractures of femur and tibia, with a gradual incease in the use of unreamed nails. Different studies during last years show controversial outcomes. Some authors strongly favor unreamed nailing, but most of the authors conclude that reamed nailing have proved to be more successful.

MATERIAL AND METHODS

This study simulates unreamed intramedullary nailing of four femoral and three tibial fracture types by means of Finite Element (FE) models, at early postoperative stages with a fraction of physiological loads, in order to determine whether sufficient stability is achieved, and if the extent of movements and strains at the fracture site may preclude proper consolidation.

RESULTS

The behavior observed in the different fracture models is very diverse. In the new biomechanical situation, loads are only transmitted through the intramedullary nail. Mean relative displacement values of fractures in the femoral bone range from 0.30 mm to 0.82 mm, depending on the fracture type. Mean relative displacement values of the tibial fractures lie between 0.18 and 0.62 mm, depending on the type of fracture. Concerning mean strains, for femoral fractures the maximum strains ranged between 12.7% and 42.3%. For tibial fractures the maximum strains ranged between 10.9% and 40.8%.

CONCLUSIONS

The results showed that unreamed nailing provides a very limited mechanical stability, taking into account that analyzed fracture patterns correspond to simple fracture without comminution. Therefore, unreamed nailing is not a correct indication in femoral fractures and should be an exceptional indication in open tibial fractures produced by high-energy mechanism.

Distally Unlocked Intramedullary Nailing With Cement Fixation for Impending and Actual Pathologic Humerus Fractures: A Retrospective Case Series

The humerus is a common site of metastatic tumor involvement and pathologic fracture. Intramedullary nailing is a treatment option that offers the benefit of protecting a long segment of diseased bone, but it is not without complications. This study aims to examine the survival, functional outcomes, and complications of patients treated with cement-augmented unlocked intramedullary nailing for actual and impending pathologic fractures of the humeral shaft.

TREATMENT OF HUMERAL SHAFT FRACTURES: ANTEGRADE INTERLOCKING INTRAMEDULLARY NAILING WITH ADDITIONAL INTERLOCKING NEUTRALIZATION SCREWS THROUGH FRACTURE SITE

The aim of this study was to compare union time between two different nail designs for the treatment of humeral shaft fracture, i.e. antegrade interlocking intramedullary nail with and without additional interlocking neutralization screws. The retrospective study included 51 patients treated with antegrade humeral intramedullary nailing between January 2015 and December 2017. The inclusion criteria of the study were proximal and middle third humeral shaft fractures. Fifty-one patients met the inclusion criteria; 23 patients were treated with antegrade intramedullary nail with additional interlocking neutralization screws through fracture site (group A) and 28 patients were treated with antegrade intramedullary nail without additional interlocking neutralization screws (group B). Medical documentation and radiographic images taken preoperatively and postoperatively were reviewed. Radiological union was defined as cortical bridging of at least three of four cortices in two-plane radiographs, with disappearance of the fracture gap. There were no significant differences in union time between the groups (p>0.05). To our knowledge, this is the first report of antegrade interlocking humeral nailing with additional interlocking neutralization screws through fracture site. Hypothetical advantages of fracture gap reduction by additional interlocking neutralization screws to promote union were not confirmed by this first clinical trial.

Is distal locking screw necessary for intramedullary nailing in the treatment of humeral shaft fractures? A comparative cohort study

PURPOSE

The gold standard for intramedullary nailing (IMN) in humeral shaft fracture treatment is bipolar interlocking. The aim of this study was to compare clinical and radiographic outcomes in two cohorts of patients treated with IMN with or without distal interlocking. We hypothesized that there was no significant difference between isolated proximal interlocking and bipolar interlocking in terms of consolidation and clinical results.

METHODS

One hundred twenty-one acute humeral shaft fractures were retrospectively included in group WDI (without distal interlocking screw, n = 74) or in group DI (with distal interlocking screw, n = 47). One hundred six patients (87.60%) could be verified by an X-ray, and 63 (52.07%) could be examined clinically. Fracture union at 6 months was the primary outcome, and the second was the final clinical outcome for shoulder and elbow after at least 6 months of follow-up. Pain, operating time, and radiation time were also analyzed.

RESULTS

The two groups were not significantly different for population, fractures, or immobilization duration. No significant difference was found for bone union (WDI 89.06% vs DI 83.33%, p = 0.51), shoulder or elbow functional outcomes, or pain. However, there were significant differences in advantage to the WDI group for operating time (WDI 63.09 ± 21.30 min vs DI 87.96 ± 30.11 min, p < 0.01) and fluoroscopy time (WDI 59.06 ± 30.30 s vs DI 100.36 ± 48.98 s, p < 0.01).

CONCLUSIONS

Thus, it seems that there were no significant differences between proximal unipolar and bipolar interlocking for humeral shaft fractures in terms of consolidation and clinical outcomes. WDI avoided the additional operating time and fluoroscopy time and risks linked to DI.

Long endomedullary nail in proximal third humeral shaft fractures

INTRODUCTION

Proximal humeral fractures with a spiral line of fracture extending from the humeral head to the diaphyseal region are increasing. Treatment for these fractures is comparable to that for shaft fractures. The purpose of this study was to evaluate the use of a new "Long" humeral nail for this type of lesion and identify the best distal locking.

MATERIALS AND METHODS

Forty-three patients treated with a Long Diphos Nail^® were selected for this study: main exclusion criteria were poor cognitive and responsive ability to physical therapy, four-part fracture requiring humeral head replacement, an isolated greater or lesser tubercle fracture and a head-splitting fracture. All patients were divided into two groups according to the distal locking (single or double) and clinically evaluated at 1, 3, 6 and 12 months after surgery. The following parameters were evaluated: fracture healing on radiographic images every month; level of pain with Visual Analogue Scale (VAS); recovery of shoulder function or ability to resume normal daily activities according to the Constant Scoring System (CSS); patient satisfaction; and complications, like fracture consolidation defect or delay. A statistical analysis was performed.

RESULTS

Improvements in pain, satisfaction and shoulder functional recovery were recorded. Patients reached fracture healing in two to six months. The mean healing time was better for double distal locking (p=0.04).There was a clinically greater difference (p=0.006) between the groups for the mean Constant score at 3 months follow-up, with better results for the double distal locking group. Complications were: one patient with a consolidation delay with a single distal locking screw breakage; it was necessary to remove the nail and perform a second treatment.

CONCLUSIONS

The results of the study indicate the efficacy of Long Diphos Nail^® in the treatment of fractures with a line of fracture extending to the proximal diaphyseal region. The features of a multiplane stabilisation above the fracture and a distal double locking may represent the key for a good fixation for 11-A2, A3 or B2 fractures with a long spiral line. A double distal locking reduces fracture micro-instability and so patients recover function and strength quicker because of less pain at the fracture site.

STUDY DESIGN

retrospective, cohort of cases.

LEVEL OF EVIDENCE

IV.

The importance of the supratrochlear foramen of the humerus in humans: an anatomical study

Background

The supratrochlear foramen (STF) is an important and relatively common anatomic variation in the lower end of the humerus in humans. Its structure has received increased attention in recent years. Anatomical knowledge of STF is useful for anatomists, anthropologists, orthopedic surgeons, and radiologists. This aperture is of great interest to anthropologists who claim it as one of the points in establishing a relationship between humans and lower animals. The goal of this study was to describe the features of STF of the humerus in the Turkish population.

Material/Methods

All bones were obtained from the Department of Anatomy, Faculty of Medicine and Department of Antrophology, University of Mustafa Kemal, Hatay. A total of 166 dried humeri (83 right side and 83 left side), of which 78 belonged to males and 88 to females, were examined to determine the presence of supratrochlear foramen. Digital vernier calipers were used to measure the maximum width (transverse) and height (vertical) of the STF.

Results

Out of 166 bones, the foramen was present in 18 humeri (4 right side and 14 left side), showing the incidence as 10.8% with unpaired humeri. We observed 4 types of shape: oval, round, triangular, and sieve-like. The average diameter of the long (transverse) axis was 5.93±1.68 mm and the short (vertical) axis was 4.06±0.89 mm. Some of the bones showed translucency of the bony septum, found in 17 (20.5%) on both sides of the humeri.

Conclusions

There are few studies about STF in the Turkish population. Knowledge of supratrochlear foramen in the distal humerus in humans is important in diagnostic orthopedics, in intramedullary nailing of the humerus, and in possibly increasing the risk of future low-energy fractures. In addition, STF is a radiolucent area in radiographs and may be misinterpreted as an osteolytic or cystic lesion.