Internal fixation of proximal humerus fractures using the Polarus intramedullary nail

INTRODUCTION: It has been stated that proximal humeral fractures are the last unsolved fractures in orthopedics. In this study, we evaluate the results of the Polarus nail, in order to constitute to the controversial problem of the treatment of proximal humerus fractures. PATIENTS AND METHODS: Between 2003 and 2005, 27 patients with severely displaced proximal humeral fractures were treated with the Polarus intramedullary system. The fractures were classified according to the Neer classification system. There were 16 2-part fractures and 11 3-part fractures. At the 12-months follow up we graded the clinical outcome of the patients according to the Neer scoring system. RESULTS: The duration from time of injury to operation ranged from 1 to 6 days. The mean operative time was 55 min and no need of blood transfusion was recorded. Bony union was obtained in 27 patients. There were no cases of nonunion and the period from operation to the appearance of sufficient bridging callus on radiographs was 5-11 weeks (mean 6 weeks). In one patient, a backed-out proximal screw was recorded. Stiffness of the shoulder was seen in one patient and avascular necrosis of the head of humerus in another. Related to the clinical outcome, six patients had an excellent result, 15 patients had a satisfactory result, four patients had an unsatisfactory result, and two patients had a poor result. The 77.78% of the patients had an excellent or satisfactory clinical outcome. There was significant difference in the functional outcome between patients younger than 65 years (91.55) and those older than 65 years (80.22) (P < 0.05). No significant difference was recorded in the Neer score between the patients with a 2-part fracture and the patients with a 3-part fracture (80.18) (P > 0.05). CONCLUSION: The Polarus nail is designed to provide stable fixation with a straightforward insertion and targeting procedure. The fact that 77.78% of the patients had an excellent or satisfactory clinical outcome, suggest that Polarus humeral rod system can be a worthy alternative to traditional operative methods for displaced proximal fractures of the humerus.     

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

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

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

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

Multiloc髓内钉治疗肱骨近端骨折的临床疗效分析

目的探讨Multiloc髓内钉治疗肱骨近端骨折的临床疗效。 方法回顾性分析2015年1月至2017年7月在首都医科大学附属北京朝阳医院骨科采用Multiloc髓内钉治疗并获得完整随访资料的33例肱骨近端骨折患者，年龄44~83岁，平均（68.7±15.7）岁；其中Neer分型二部分骨折22例，三部分骨折11例。分别记录手术时间、术中出血量、骨折愈合情况及手术并发症，采用视觉模拟评分（visual analogue scale，VAS）及Constant-Murley评分评价患者术后肩关节功能情况。 结果手术均顺利完成，平均手术时间为93.2 min（70~150 min），术中平均出血量为108.2 ml（30~200 ml）。随访时间最短13个月，最长40个月，平均随访时间为（22.4±7.3）个月。末次随访平均肩关节疼痛评分0.47分（0~2分）。骨折平均愈合时间为（15.7±2.9）周，肩关节活动平均活动范围：前屈140.2°，外展135.9°，内旋36.0°，外旋54.4°。术后平均Constant评分为（85.9±10.8）分，其中优11例、良17例、一般3例，优良率为90.9%。末次随访时无一例发生切口感染、骨折不愈合及肩袖损伤等并发症。 结论Multiloc髓内钉治疗肱骨近端骨折具有手术创伤小、并发症少、内固定物牢固、关节功能恢复优良，对肱骨近端Neer分型二部分和三部分骨折有满意的治疗效果。     

Results of the proximal femoral nail anti-rotation (PFNA) in elderly Chinese patients

A prospective study is presented of 87 unstable intertrochanteric fractures treated with the proximal femoral nail anti-rotation (PFNA) with a follow-up of one year. Of the patients 76% were female. The average age was 75.3 years. The fracture was treated by closed reduction and intramedullary fixation. Pre-injury activity level was recovered in 77% of the patients. Fractures united in all patients. Mechanical failure and cut-out were not observed. A technical problem related to the mismatch of the proximal end of the nail was observed in 11 cases. Nine patients presented with thigh pain due to the redundant proximal end of the nail. The results of the PFNA were satisfactory in most elderly Chinese patients. However, the proximal end of the nail was not matched with the specific anatomy of some short elderly patients. Further modifications of the nail are necessary for the elderly Chinese population.     

Comparative study of the proximal femoral nail antirotation versus the reconstruction nail in the treatment of comminuted proximal femoral fracture

The purpose of our study was to compare the proximal femoral nail antirotation (PFNA; Synthes, Paoli, Pennsylvania) with a reconstruction nail (Recon; Zimmer, Warsaw, Indiana) in the treatment of comminuted proximal femoral fractures. Between 2003 and 2010, twenty-three consecutive patients with AO/Orthopaedic Trauma Association 31-A3 fractures combined with proximal 32 fractures who had a minimum 18-month follow-up were evaluated retrospectively. There were 10 patients (age range, 18-74 years) in the Recon nail group and 13 patients (age range, 22-90 years) in the PFNA nail group. Patients treated with Recon nails experienced a longer operation time (P=.006) and more blood loss (P=.012) than patients treated with the PFNA nail. On postoperative radiographs, the change in the neck-shaft angle was 8.8° in the Recon nail group and 4.7° in the PFNA nail group (P=.048). The fracture union time averaged 31.8 weeks in the Recon nail group and 21.5 weeks in the PFNA nail group (P=.148). More patients in the Recon nail group underwent major or minor reoperation (P=.038) compared with the PFNA nail group. No implant failure occurred in either group. The functional results were similar in the 2 groups. For the treatment of comminuted proximal femoral fractures, use of either the PFNA and Recon nail is clinically effective. However, the PFNA nail provides a shorter operation time, less blood loss, and better realignment ability and reduces the incidence of reoperation. Therefore, the PFNA nail can be considered a better device than the Recon nail.     

MultiLoc髓内钉技术在肱骨近端骨折中的应用和体会

目的 探讨MultiLoc髓内钉治疗肱骨近端Neer分型Ⅱ、Ⅲ、Ⅳ部分骨折中的技术应用以及临床疗效.方法 回顾性分析2017年12月至2019年12月手术治疗的肱骨近端骨折患者共70例,具备完整随访资料者61例,其中男24例、女37例;年龄23～81岁,平均年龄(58.02±13.44)岁;Neer分型:Ⅱ部分骨折17...     

Elastic intramedullary nail for treatment of extremity fractures in children

Objective： To assess the clinical therapeutic effects of elastic intramedullary nail on extremity fractures in children.
Methods： From June 2005 to March 2008, 40 children with extremity fractures were treated by elastic intramedullary nail, in whom femoral shaft fractures occurred in 26 cases, tibiofibular fractures in 8 cases, radial capitular fractures in 4 cases, ulnoradial fractures in 2 cases. All patients were treated by closed reduction and elastic intramedullary nail fixation. Results： All the fractures gained satisfactory reduction and healing. The average duration needed for fracturehealing was 1-2 months. Postoperative follow-up confirmed a sound functional recovery.
Conclusions： The elastic intramedullary nail is a minimally invasive and effective surgical approach for treatment of extremity fractures in children. It allows early functional exercises after operation and secures a satisfactory bone union and functional recovery.     

The Polarus intramedullary nail for proximal humeral fractures: outcome in 28 patients followed for 1 year

Background One of the new treatment options for proximal humeral fractures is the minimally invasive intramedullary nail. In this study, we reviewed the early clinical results after 1 year.

Patients and methods 35 patients with proximal humeral fractures were treated using the Polarus nail. In 14 cases the initial treatment was operative; the other 21 patients were initially treated nonoperatively. 19 patients had a 2-part fracture, 5 had a 3-part fracture and 2 had a 4-part fracture. In 9 patients the fracture extended metaphyseally. The functional outcome was assessed by the Constant score.

Results 28 patients were available for 1-year followup. 17 patients showed excellent functional outcome (with an average Constant score of 81%). 6 patients required revision surgery, 1 because of nonunion and 1 because of an avascular necrosis. 4 others were reoperated because of inadequate position of the osteosynthesis or migration of the screws.

Interpretation The Polarus nail is of value for (displaced) 2-, 3-, and even 4-part proximal humeral fractures and enables early postoperative mobilization with a limited amount of pain.     

The new proximal femoral nail antirotation-Asia: early results

The proximal femoral nail antirotation system was introduced by the Arbeitsgemeinschaft fur Osteosynthesfragen/Association for the Study of Internal Fixation (AO/ASIF) in 2003 and is suitable for treating unstable trochanteric fractures. However, proximal femoral nail antirotation was designed according to the geometric proportions of the White population, and it is known that important differences exist between Asians and Americans with regard to femoral geometry. Reports of serious postoperative complications also exist when used for the elderly Asian population. Therefore, geometrical mismatch between proximal femoral nail antirotation and the femora of Asians has led the AO/ASIF to design a new proximal femoral nail antirotation for Asia with adapted sizes and geometry. This article reports early clinical results of using proximal femoral nail antirotation for Asians in 84 consecutive patients to stabilize unstable trochanteric fractures (AO classification, 31.A2 and A3). Patients were followed up for an average 8 months (range, 4-11 months). Intraoperative and postoperative complications, surgical details, and outcome measurements were evaluated. Fractures were treated by closed reduction and intramedullary fixation. The proximal femoral nail antirotation Asia position was ideal in 80 cases (95%). No patients showed complication related to the mismatch between the nail and femora. The mean time to bone healing was 14 weeks. Functionally, 90% of the patients regained pretrauma mobility. According to the Harris hip scoring system, 63 patients (78%) had an excellent or good outcome. The new proximal femoral nail antirotation Asia yields better results in the treatment of unstable trochanteric fractures in elderly patients by closely matching Asian femoral anatomy and thereby reducing complications related to the implants.     

Internal fixation of proximal humerus fractures with the polarus intramedullary nail

The optimal treatment method for displaced proximal humeral fractures continues to be under debate. There are a variety of fixation techniques, none of which has been proven to be more effective. We retrospectively studied 24 patients with displaced proximal humerus fractures, treated with the Polarus intramedullary nail. All patients were followed radiographically and clinically for one year. Clinical outcome was assessed with the Constant score. All fractures went on to clinical and radiographic union. Mean time to union was 9.2 weeks (range: 9-16). Only one patient with a 3-part fracture had an asymptomatic malunion and one patient had iatrogenic radial nerve palsy, which spontaneously recovered. In total, 83.3% of the patients had an excellent or good clinical outcome. The Polarus nail appeared in this study as an effective device to treat proximal humeral fractures, with good overall functional results and a low complication rate.     

Trochanteric-entry long cephalomedullary nailing of subtrochanteric fractures caused by low-energy trauma

BACKGROUND: Subtrochanteric fractures of the femur that are caused by low-energy trauma are less common than other proximal femoral fractures, but they occur in a similar population of elderly individuals, who are often socially dependent and medically frail. Although a wide range of operative techniques have been used, cephalomedullary nailing theoretically provides the most minimally invasive and biomechanically stable means of treating these complex fractures. The purpose of the present review was to evaluate the functional outcome and perioperative complications associated with the use of a trochanteric-entry cephalomedullary nail to treat all low-energy subtrochanteric fractures that were seen at a single institution. METHODS: Over an eight-year period, we used the long Gamma nail to treat a consecutive series of 302 local patients who had sustained a subtrochanteric fracture during low-energy trauma. The mortality, prevalence of complications, and functional outcome were prospectively assessed during the first year after the injury. Survival analysis was used to assess the rates of reoperation and implant revision during the first year after surgery. RESULTS: At one year, seventy-four (24.5%) of the original 302 patients had died and seventeen (5.6%) had been lost to follow-up. The remaining 211 patients (69.9%) were evaluated with regard to the functional outcome and postoperative complications during the first year after the injury. As with other proximal femoral fractures in the elderly, there was an increased level of social dependence, an increase in the use of walking aids, and a reduction in mobility among survivors. Although eighty-eight (41.7%) of the 211 patients who were evaluated at one year after the injury had some degree of hip discomfort, only two described the pain as severe and disabling. Reoperation for the treatment of implant or fracture-related complications was required in twenty-seven (8.9%) of the 302 patients; however, only eighteen of these patients required nail revision, corresponding with a one-year nail-revision rate of 7.1% (95% confidence interval, 4.0% to 10.2%) on survival analysis. Of the 250 patients who survived for six months after the injury, five (2%) had a nonunion that was confirmed at the time of surgical exploration. Complications related to the proximal lag screw were seen in twelve of the original 302 patients, and a fracture distal to the tip of the nail occurred in five. Although superficial wound infection was relatively common, deep infection occurred in only five of the 302 patients. CONCLUSIONS: Subtrochanteric fractures caused by low-energy trauma are similar to other proximal femoral fractures, with a high mortality rate during the first year after the injury. Trochanteric-entry cephalomedullary nails are associated with an acceptable rate of perioperative complications and favorable functional outcomes. LEVEL OF EVIDENCE: Therapeutic Level IV.     

The Polarus intramedullary nail for proximal humeral fractures Outcome in 28 patients followed for 1 year

Background?One of the new treatment options for proximal humeral fractures is the minimally invasive intramedullary nail. In this study, we reviewed the early clinical results after 1 year.

Patients?and methods 35 patients with proximal humeral fractures were treated using the Polarus nail. In 14 cases the initial treatment was operative; the other 21 patients were initially treated nonoperatively. 19 patients had a 2-part fracture, 5 had a 3-part fracture and 2 had a 4-part fracture. In 9 patients the fracture extended metaphyseally. The functional outcome was assessed by the Constant score.

Results?28 patients were available for 1-year followup. 17 patients showed excellent functional outcome (with an average Constant score of 81%). 6 patients required revision surgery, 1 because of nonunion and 1 because of an avascular necrosis. 4 others were reoperated because of inadequate position of the osteosynthesis or migration of the screws.

Interpretation?The Polarus nail is of value for (displaced) 2-, 3-, and even 4-part proximal humeral fractures and enables early postoperative mobilization with a limited amount of pain.     

Retrograde intramedullary nailing in humeral fractures with new implants. Analyse of 120 consecutive cases

Summary Since 1993, 120 fractures of the humerus were treated by retrograde unreamed nailing. Operations were performed on simple, complex, compound and pathological fractures of the proximal three quarter of the humerus. On the proximal humerus, displaced two-part-fractures and occasionally three- or four-part-fractures were stabilized. In 110 cases a prototype of an unreamed humeral nail with deployable fins for proximal locking was employed. In another ten cases the new solid interlocking nail of the AO/ASIF was used. The operative procedure, rehabilitation program, complications and functional and radiological results are presented. Retrograde nailing offers a high patient comfort and good functional results (Constant-Score on average 87 % of the opposite side). Complications were nail migration (8.3 %), instability (3.8 %), nonunions (5.8 %) and iatrogenic fractures (5.8 %). Patients with high grade osteoporosis, small proximal fragments and poor compliance have an increased rate of complications.      

The Telegraph nail for proximal humeral fractures: a prospective four-year study

Proximal humeral fractures in 67 patients older than 50 years treated with the Telegraph nail (FH Orthopedics, Heimsbrunn, France) were monitored for 4 years to assess the fracture pattern (weighted Constant score), ranges of motion, and patient satisfaction. The outcome was best in patients with extraarticular surgical neck fractures (mean weighted Constant score, 93.5%); scores were 85% and 77.5%, respectively, for valgus impacted fractures and intraarticular displaced or dislocated fractures. Some or all of the hardware was removed in 21 patients (31%). Two required implant removed for mechanical problems related to screw positioning or migration; 8 were revised because proximal migration of the implant resulted in subacromial impingement. Avascular necrosis occurred in 18% of valgus impacted fractures and in 37.5% of displaced articular or dislocated fractures. Secondary migration of the tuberosities occurred in 6 (all 4-part fractures). The Telegraph nail provides a reproducible and satisfactory outcome for surgical neck and valgus impacted fractures in older patients. The outcome was less satisfactory for unstable articular or dislocated fractures.     

A comparison of the Brooker-Wills and Russell-Taylor nails for treatment of patients who have fractures of the femoral shaft

Seventy-three fractures of the femoral shaft (seventy patients) were randomized to treatment with interlocked nailing with either the Brooker-Wills femoral nail (thirty-nine fractures) or the Russell-Taylor femoral nail (thirty-four fractures). Sixty-one patients (sixty-four fractures) were prospectively followed from admission until healing of the fracture. Specific attention was paid to recording operative details, including technical difficulties associated with insertion of the nails. Technical difficulties were encountered in insertion of the proximal screw, distal screw, and nail, and in deployment of the fins. Insertion of the Russell-Taylor nail was associated with less technical difficulty, operative time, and estimated loss of blood. The two nails differ in their biomechanical properties, methods of fixation, and instrumentation. These differences did not affect the clinical outcome; the fractures in both groups of patients healed with excellent functional results.     

Antegrade interlocking nailing of humeral shaft fractures

The results of 39 humeral shaft fractures (37 patients) treated with antegrade locked nailing using a Russell–Taylor nail were reviewed. There were 30 acute fractures, 6 fractures malaligned in a hanging cast or brace, and 3 pathological fractures. Patient age ranged from 26 to 80 years (average, 59.7 years) and average follow-up was 25.7 months (range, 6–48 months). Fracture union was achieved in 92.3% of our cases, while shoulder function was excellent or good in 87.2% of cases. Antegrade locked nailing offers a dependable solution for the treatment of humeral shaft fractures, especially in polytrauma patients and cases of segmental or pathological fractures. Far less satisfactory results were obtained in comminuted fractures of the proximal third in the humerus, especially in osteoporotic patients, and we therefore advocate caution with the use of intramedullary nailing in this type of fracture. Certain technical aspects such as avoiding nailing the fracture in distraction, properly countersinking the tip of the nail, and achieving adequate fixation stability have been found to be of paramount importance to reduce the incidence of delayed union/non-union rate and to obtain better functional results from the shoulder joint.     

髓内钉附加小钢板或阻挡钉治疗胫骨近段骨折比较

[目的]比较传统入路髓内钉附加小钢板或阻挡钉治疗胫骨近段骨折的治疗效果。[方法]2013年1月~2017年1月,36例未累及膝关节的胫骨近段骨折患者纳入本前瞻性研究,采用随机数字表法将患者分为两组。其中,19例采用髓内钉附加小钢板固定,17例采用髓内钉附加阻挡钉治疗。比较两组围手术期、随访和影像资料。[结果]36例患者均顺利完成手术,术中无血管、神经损伤。钢板组在手术时间、术中透视次数显著优于阻挡钉组(P<0.05);但钢板组在手术耗材费用和平均住院时间方面显著不及阻挡钉组(P<0.05)。两组患者随访12~24个月,平均(15.62±4.71)个月。两组患者下地行走时间、完全负重时间的差异无统计学意义(P>0.05)。末次随访时,两组膝关节活动度、Johner-Wruhs术后功能评级的差异无统计学意义(P>0.05),而在膝前痛方面,两组差异无统计学意义(P>0.05)。影像方面,术后钢板组残余侧方移位、前后移位、冠状面成角和矢状面成角均显著小于阻挡钉组(P<0.05)。至末次随访时,两组患者均达到影像学骨性愈合,两组间骨折愈合时间的差异无统计学意义(P>0.05)。所有患者均未见内固定物松动、移位。[结论]无论采用传统入路髓内钉附加小钢板或阻挡钉技术治疗胫骨近段骨折均可取得满意疗效;采用附加钢板虽费用高,但可达到更好的下肢力线恢复。     

Internal fixation of proximal humerus fractures using the T2-proximal humeral nail

Introduction

Surgical management of proximal humerus fractures remains controversial and there is an increasing interest in intramedullary nailing. Created to improve previous designs, the T2-proximal humeral nail (PHN) (Stryker^®) has been recently released, and the English literature lacks a series evaluating its results. We present a clinical prospective study evaluating this implant for proximal humeral fractures.

Method

We evaluated the functional and radiological results and possible complications. Twenty-nine patients with displaced fractures of the proximal humerus were treated with this nail. One patient was lost right after surgery and excluded from the assessment. Eighteen patients were older than 70 years.

Results

There were 21 fractures of the proximal part of the humerus and 7 fractures that also involved the shaft; 15 of the fractures were two-part fractures (surgical neck), 5 were three-part fractures, and 1 was a four-part fracture. All fractures healed in a mean period of 2.7 months. There was one delayed union that healed in 4 months. One case of avascular necrosis of the humeral head was observed (a four-part fracture), but remained asymptomatic and did not require further treatment. In one case a back-out of one proximal screw was observed. A final evaluation with a minimum 1 year follow-up was performed by an independent observer; in 18 patients, the mean Constant score was 65.7 or 76.1% with the adjustment of age and gender; in 19 patients, the mean Oxford Shoulder Score was 21.7. The results obtained with the T2-PHN nail indicate that it represents a safe and reliable method in the treatment of two- and three-part fractures of the proximal humerus. The proximal fixation mechanism diminishes the rate of back-out of the screws, a frequent complication described in the literature. Better functional results were obtained from the patients younger than 70 years, but these were not statistically significant.

     

Antegrade nailing of humeral head fractures with captured interlocking screws

OBJECTIVES/DESIGN: To assess the functional outcome after treatment of proximal humeral fractures with a new antegrade nail that provides angular and sliding stability. INTERVENTION/PATIENTS: Ninety-seven patients were treated during a 4-year period between April 2000 and March 2004. All patients were followed for 6 months, 51 patients (53%) for 12 months, and 31 patients (32%) for 24 months. This study focuses mainly on the patients with a follow up of 1 year. Their mean age was 68 years (range: 33 to 90); 22% were more than 80 years of age. MAIN OUTCOME MEASUREMENTS: All fractures were radiologically graded by the Neer and AO/ASIF classifications. Clinical assessment was performed at all follow-up visits using the Constant-Murley and Neer scores, and complications were recorded. RESULTS: There were 26.8% 2-part, 66% 3-part, and 7.2% 4-part fractures. The relative Constant-Murley score improved significantly (P < 0.001) from 72% at 6 months to 82% at 12 months after operation. No further improvement regarding functional outcome was observed after 24 months. Patients younger than 60 years of age had better results. No significant functional differences were found among 2-, 3- or 4-part fractures. Complications included backing out of the proximal screws (9.8%), secondary dislocation (1.9%), complete osteonecrosis (1.9%), and partial osteonecrosis (5.8%). CONCLUSION: Treatment with this nail provides sufficient fixation of the fragments to allow early mobilization. The good functional results in the majority of the patients indicate that this nail can be used, even in complex fractures and elderly patients.