A meta-analysis of plate fixation versus intramedullary nailing for humeral shaft fractures

Background

There is a lack of consensus on whether intramedullary nailing (IMN) or plating is superior for humeral shaft fractures.

Methods

In this meta-analysis, we combined data from PubMed, the Excerpta Medica Database (Embase), the Cochrane Library, and the Chinese National Knowledge Infrastructure (CNKI) (all to Dec 31, 2011). Six randomized controlled trials (RCTs) and two quasi-RCTs including 384 participants were selected and assessed by use of an 11-item scale. Heterogeneity was assessed by use of the standard chi-squared test and the I ² statistic.

Results and conclusions

The results indicated that two primary outcomes (total number of complications and functional measurement) were significantly better for plate fixation. Significantly lower risk of delayed-union, restriction, impingement of the shoulder, shoulder pain, and re-operation were found for the plating group, which suggested that plating is superior to IMN for humeral shaft fractures.

Level of evidence

Level II; meta-analysis of RCTs and quasi-RCTs; treatment study.     

Antegrade locked intramedullary nailing in humeral shaft fractures

Thirty-three humeral nailings were carried out using the Russell-Taylor nail. Twenty-two acute fractures and one non-union united, gave an overall union rate of 70%.Eighteen patients (56%) experienced pain in the shoulder or at the fracture site. Thirteen patients (41%) had poor shoulder function. Only 17 (51%) of the patients were satisfied with the outcome. Fourteen patients (42%) needed further surgery.We conclude that antegrade intamedullary nailing of humeral shaft fractures leads to a substantial risk of non-union and impairment of shoulder function. There was no significant correlation between fracture comminution and fracture healing in our study.     

顺行锁定髓内钉和动力加压钢板治疗肱骨干骨折的系统评价

[目的]对比顺行锁定髓内钉和动力加压钢板治疗肱骨干骨折的临床结果,并为以后此类骨折的治疗提供更可信的证据。[方法]计算机检索Cochrane library、Medline、Embase、CNKI等数据库网站,检索2016年12月以前有关顺行锁定髓内钉和动力加压钢板治疗肱骨干骨折的文献,筛选文献后采用Revman 5.0软件进行分析,获得两种方法治疗肱骨干骨折的临床结果。[结果]最初搜索文献472篇,经过筛选后最终有8篇纳入研究,共计完成随访患者373例,其中顺行髓内钉治疗者187例,动力加压钢板治疗者186例。Meta分析表明,顺行锁定髓内钉组患者术后感染率明显低于动力加压钢板组[OR=0.34,95%CI(0.12,0.98),P=0.05],但前者肩部撞击征与再次手术率明显高于后者[OR=7.81,95%CI(2.51,24.33),P<0.001;OR=2.61,95%CI(1.19,5.72),P=0.02],术后桡神经损伤与骨折不愈合率,两者之间差异无统计学意义。[结论]与顺行锁定髓内钉相比,动力加压钢板治疗肱骨干骨折可以降低肩部撞击征与再次手术发生率,但却增加了术后感染的发生率;术后桡神经损伤及骨折不愈合方面,两者差异无统计学意义。     

Slotted versus non-slotted locked intramedullary nailing for femoral shaft fractures

Summary Experimentally, two slotted nails, the Grosse-Kempf nail and the AO/ASIF universal femoral nail, were compared to the non-slotted Grosse-Kempf nail and control bone using a cadaver femoral osteotomy. The stiffnesses and strengths of the osteotomies fixed with slotted nails in 10–30° torsion were 6–8% and the values of non-slotted nails 40% of control bone. The maximal moments were 14–18% and 48%, respectively. In the clinical range of torsion, the implant-bone construct never failed or was deformed. Clinically, 46 femoral shaft fractures were randomized to treatment with Grosse-Kempf nails, 24 with slotted nails and 22 with non-slotted nails. Four complications in the slotted nail group and three in the non-slotted nail group were considered to be independent of the choice of nail and did not affect the end result. Three splinterings of the distal fragment, one resulting in a change of the osteosynthesis implant to a condylar plate, were considered to result from the high stiffness of the non-slotted nail. Osteosynthesis of femoral shaft fractures using slotted nails has not resulted in healing disturbances, which could be accounted for by the high torsional elasticity of the nail; there seems to be no indication for high-stiffness nails in femoral fractures.     

Antegrade locked nailing for humeral shaft fractures

Treatment results of antegrade locked nailing of acute humeral shaft fractures, including union rate and recovery of shoulder function, have been inconsistent. This led the current authors to hypothesize that implant design and surgical techniques might account for this inconsistency. In the current study, 47 fractures (38 acute; nine pathologic) in 47 patients achieved union with the techniques of closed nailing, short to long segment nailing, and fracture compression. Satisfactory recovery of shoulder function occurred because of minimal surgical trauma, prevention of impingement by the nail or locking screws, and prevention of axillary nerve injury or comminution of the humeral head. Forty-seven patients with 38 acute fractures and nine pathologic fractures were treated with humeral locked nails. Mean followup time was 21.4 months. With a single operation, all 38 acute fractures proceeded to eventual union; the average time to union was 7.8 weeks. Thirty-five patients had excellent or satisfactory recovery of shoulder function. Complications included slipout of the proximal screw, nail breakage, fragment displacement, and transient postoperative radial nerve palsy. All nine patients with pathologic fractures had substantial pain relief and increased arm function after surgery. The current study shows the reliability of antegrade locked nailing for proximal and middle third fractures of the humeral shaft.     

交锁髓内钉固定治疗肱骨干骨折术后并发症分析

目的 目前对于肱骨交锁髓内钉固定治疗肱骨干骨折的文献报告较多,但对其术后并发症的研究较少.对交锁髓内钉固定治疗肱骨干骨折的术后并发症进行分析研究.方法 2000年1月至2004年1月,对73例肱骨干骨折（1例为双侧）及16例肱骨骨不连的患者行肱骨交锁髓内钉固定术治疗,术后随访12～34个月,平均25.4个月.男56例,女33例,平均39.3岁.74侧肱骨干骨折中62侧为闭合性骨折,余12侧为开放性骨折,其中Gustilo Ⅰ型7侧,Ⅱ型3侧,Ⅲa型2侧.12例骨不连患者有手术史.骨折病例采用闭合复位髓内钉固定,骨不连病例采用切开复位髓内钉内固定及异体骨植入.53侧采用顺行髓内钉固定,37侧采用逆行髓内钉固定.结果 17例患者中出现了18例明显并发症,发生率为20%.其中骨不连5例,顺行与逆行髓内钉之间差异无统计学意义（P=0.33）;肩关节撞击征2例,骨折端分离3例,肩关节损伤3例,肘关节损伤3例,医原性骨折2例,成角畸形2例,一过性桡神经损伤3例,深部感染1例.骨折端存在明显间隙者有较高的骨不连发生率（P=0.012）.结论 交锁髓内钉固定治疗肱骨干骨折有较高的并发症发生率,逆行髓内钉内固定有较高的医原性骨折的可能性,但只要选用合适的内置物、提高手术操作技巧,就能把并发症发生率降至最低.     

Complications of locked nailing in humeral shaft fractures

BACKGROUND: The purpose of this study was to investigate the complications of humeral locked nailing. METHODS: Between 1994 and 2000, 161 humeral shaft fractures (98 acute fractures and 63 delayed unions or nonunions) in 159 patients treated with humeral locked nails were followed up for an average of 25.4 months. There were 89 men and 70 women, with an average age of 53.5 years. Acute fractures included 68 closed, 18 type I, 8 type II, 3 type IIIA, and 1 type IIIB open fractures. Thirty-six nonunions had previous operations. In general, acute fractures were treated with closed nailing and nonunions were treated with open nailing with bone grafting. Since 1998, interfragmentary wiring has been added in nonunions to compress the fracture. RESULTS: In total, 30 patients had 31 significant complications. Nine of them were persistent nonunions, six from acute fractures and three from nonunions. Fracture gap was associated with a significantly higher risk of nonunion. The risk of operative comminution was significantly higher in retrograde nailing, and operative comminution resulted in a significantly higher risk of nonunion. Seven of the nine nonunions underwent revisional nailing and achieved eventual union. Removal of the protruded screws was performed in two cases. Other complications included shoulder impairment, elbow impairment, angular malunion, and post-nailing radial nerve palsy. CONCLUSION: Many complications of humeral locked nailing can be prevented by improving the implant design or surgical techniques. The patients with persistent nonunion can be reliably treated by revisional nailing and bone grafting.     

Antegrade locked nailing of open humeral shaft fractures

This retrospective study of 21 patients evaluates the effectiveness of primary antegrade locked intramedullary nailing for open humeral shaft fractures. Study participants were culled from the patient database of Harborview Medical Center, an urban level-1 trauma center in Seattle, Wash. Patients were evaluated for infection, nerve injury, shoulder function, range of motion, union, and healing. All 21 fractures united. Nineteen united in an average of 9.5 weeks. Two complications united in an average of 42 weeks. Seven patients had preoperative nerve palsies with complete recovery in 4 and incomplete recovery in 2 weeks. At final follow-up, 4 patients had clinically significant shoulder pain.     

钢板内固定和髓内钉固定治疗肱骨干骨折的系统评价

[目的]对钢板内固定与髓内钉固定治疗成人肱骨干骨折的疗效进行系统评价.[方法]在Pubmed、Co-chrane Library、EMBASE、Science Direct以及CNKI、CBM、中国医学学术会议论文数据库等网站进行检索.文献检索起止时间为1995年1月～2010年9月.再对入选文献的参考文献进行手工检索.系统收集钢板内固定和髓内钉固定治疗肱骨干骨折的相关文献,并按临床科研方法的国际通用原则进行阅读和评价.采用Cochrane协作网提供的软件Revman 4.2进行Meta-分析,以获得钢板内固定和髓内钉固定治疗肱骨干骨折的疗效及其安全性指标的相关证据.[结果]共检索到192篇原始文献,有6篇符合最终的入选标准,总计随访患者335例.Meta分析结果表明,钢板内固定与髓内钉固定比较,可显著降低再次手术发生率但是增加术后感染率.[结论]钢板内固定可显著降低再次手术发生率但是增加术后感染率.在骨折不愈合率、医源性神经损伤等方面,两者差异无统计学意义.因本次系统评价纳入病例数较少,尚需要更多设计严谨的大样本随机对照研究来增加证据的论证强度.     

Locked antegrade intramedullary nailing of humeral shaft fractures

This paper reports the results of treating 35 humeral shaft fractures with antegrade nailing in patients between the ages of 25 and 92 (mean 64.5): 14 patients were aged between 25 and 59, and 21 between 66 and 92. The nail was set in place proximally with a spiral blade and distally with 1 or 2 screws. In the first 14 cases, uncannulated humeral nailing (UHN) was carried out, and in the next 21 cannulated humeral nailing (CHN). The latter technique uses a guide wire which, in cases of an error in the length of the nail, is useful in that it allows another nail to be set in place. Main outcome parameters were fracture healing, shoulder discomfort, and radial nerve recovery. The DASH functional scoring system, modified according to Beaton et al. for subjective assessment was used, and range of motion was checked with the constant score. X-rays were used to assess fracture healing time and cases of malunion. Two patients developed non-union, one caused by a UHN which was too short, and the other by a nail blocked distally by a single screw. In 7 patients, consolidation was achieved, but with varus between 3 and 8 degrees (mean 5 degrees), without aesthetic or functional damage. In 33 out of 35 patients, shoulder functionality had mean DASH score results of 21.9, whereas shoulder range of motion reached a mean constant score (CS) of 26.5 (78.8%) with respect to the opposite shoulder. In 5 cases of stiffness, the UHN turned out to be insufficiently buried. Results improved with the CHN. Much better results were seen in the group of patients aged between 25 and 59 (mean age 43), but worse in older ones (66–92 years, mean age 78). Radial nerve palsy after surgery occurred in 2 cases, and the nerve was immediately examined. It did not appear to be trapped in the fracture in either case, and recovery was complete 6 months later. CHN appears to be a valid solution, both in younger patients, thanks to excellent results, and in older ones, who have fewer functional requirements.     

Dynamic compression plating versus locked intramedullary nailing for humeral shaft fractures: a meta-analysis of RCTs and nonrandomized studies

Purpose

There is no consensus regarding treatment of humeral shaft fracture. In this meta-analysis, we pooled studies to compare dynamic compression plate with locked intramedullary nail for this injury.

Methods

PubMed, MEDLINE, and Embase databases were searched for relevant studies published between January 1995 and July 2012. Evaluated endpoints were method-related complications and revision. Study quality was assessed, and meta-analyses were analyzed using the Cochrane Collaboration’s REVMAN 5.0 software.

Results

Fourteen randomized controlled (RCTs) and nonrandomized studies with 727 patients were analyzed. There was a significantly higher risk of total method-related complications and shoulder impairment resulting from locked intramedullary nailing compared with dynamic compression plating. Plating was significantly associated with a higher risk of infection and postoperative nerve palsy. There was no significant difference with respect to nonunion and revision rate.

Conclusions

Nailing may cause more method-related complications and shoulder impartment than plating, although it may lead to a lower risk of infection and postoperative nerve palsy. In the future, more high-quality RCTs are required to enhance these conclusions.     

Complications of Marchetti locked nailing for humeral shaft fractures

---

R é sum é  Le but de ce travail est de déterminer les risques et les complications du clou fasciculé (Marchetti) dans le traitement des fractures de la diapyse humérale. Cette série rétrospective de 50 cas comporte 36 fractures récentes, 8 pseudarthroses et 6 fractures pathologiques. Aucune complication per-opératoire n’est à déplorer. Parmi les complications post-opératoires 7 pseudarthroses (4 parmi les 36 fractures récentes, 3 parmi les 8 pseudarthroses opérées) et 2 effractions articulaires sans conséquences sont survenues. Cinq fractures supracondyliennes sont survenues à la suite de l’ablation de l’implant.

---

---

Accepted: 20 October 1999     

External fixation versus locked intramedullary nailing in tibial shaft fractures: a prospective,randomised study of 78 patients

Introduction We performed a prospective, randomised study to compare the Ex-fi-re external fixator (EF) with locked intramedullary (IM) nailing in tibial fractures. Only fractures without soft-tissue problems of importance were included.Materials and methods Ex-fi-re is a unilateral, dynamic axial fixator with fracture reduction capabilities. The Grosse-Kempf nail was used for nailing. A total of 78 patients with 79 fractures were entered in the study (41 Ex-fi-re, 38 IM nails).Results Time to radiographic union and full weight-bearing did not differ significantly, but unprotected weight-bearing was achieved earlier in the IM group (12 vs 20 weeks; p<0.001). There were more reoperations due to secondary dislocation in the EF group. There were no differences in final angulation or shortening. After 6 months and 1 year there were no differences in knee motion, ankle motion, fracture site pain or ankle pain. Some 64% of the nailed patients complained of anterior knee pain after 1 year.Conclusion The results were comparable in most respects. Unprotected weight-bearing was achieved earlier after IM nailing. Anterior knee pain was frequent after nailing.     

逆行穿带锁髓内针治疗新鲜肱骨干骨折

目的 总结使用逆行穿带锁髓内针治疗肱骨干骨折的临床经验以提高肱骨干骨折的治疗水平。方法 1999年2月－2000年6月使用逆行穿带锁髓内针的方法治疗肱骨干新鲜骨折32例,骨折均为闭合型,手术采用从鹰嘴窝上向近端逆行穿针法。结果 32例3个月时全部骨性愈合,肩肘关节活动恢复95％以上。1例出现术后桡神经麻痹。结论 逆行穿针避免了对肩袖的干扰,髓内针能有效地稳定骨折,软组织进一步破坏小,肩肘关节功能恢复快。     

Fixation of humeral head fractures with antegrade intramedullary nailing

The new method of antegrade intramedullary fixation of humeral head fractures is based on a straight proximal humeral nail with special head fixation screws and conventional interlocking screws at the proximal end of the shaft fragment leaving an axillary nerve shelter space in between. The nail acts as a central load carrier. The head fixation screws run through threaded holes in the proximal end of the nail thus being held in a stiff angle and without gliding. The entry points of these screws correspond to the anatomical main portions of the lesser and greater tubercle. They allow a three-dimensional screw grip to the subchondral bony layer of the head fragment. The purpose of this intramedullary construct is to keep the fracture stable at a grade which allows instant postoperative active exercise and which corresponds to the needs of mechanical tranquility in a predominantly endosteal healing area. In a prospective clinical study 45 patients could be followed up after 3, 6 and 12 months. We found an ongoing improvement of the postoperative results up to an average Constant Score of 85.7 pts after one year. The complication rate was 16 %. The main complication was the screw protrusion into the joint.     

Antegrade locked intramedullary nailing versus dynamic compression plating for humeral shaft fractures in adults: a meta-analysis of randomized controlled trials

There are two generally accepted techniques, antegrade locked intramedullary nailing and dynamic compression plating, for the treatment of humeral shaft fractures in adults. However, which technique is superior remains controversial. The aim of this meta-analysis is to compare the clinical outcomes of the two techniques and to present the best evidence currently available. We conducted an electronic search of using databases including the Cochrane registry of clinical trials, Medline, and Embase. Studies were selected, and data were extracted independently by two investigators. Four trials were found, which matched the inclusion criteria. Statistical heterogeneity was not detected among these included trials. The available evidence demonstrated that dynamic compression plating may lead to fewer complications and shoulder impairments but may cause higher risk of infection than antegrade locked intramedullary nailing. Incidences of nerve palsy and nonunion were comparable between the two methods. Future high-quality trials are required to overcome the limitation of mall population size currently presented.