Abstract
Background
Impending and complete pathologic fractures of the distal humerus are rare complications of metastatic cancer. Surgical treatment aims to quickly restore function and minimize pain. Plate and screw fixation (PSF) is a common method for addressing these lesions, but unlike in orthopaedic trauma, there are no clear guidelines for best management. While dual PSF theoretically provides better support and reduces the chance of reoperation due to tumor progression, single PSF is currently the more common choice.
Materials and methods
Between March 2008 and September 2021, 35 consecutive patients who underwent PSF for distal humerus metastasis or multiple myeloma were retrospectively reviewed. The proportion of patients who developed various postoperative complications, including infection, nonunion, deep vein thrombosis, tumor progression, and radial nerve palsy, as well as those requiring reoperation, was calculated. Mann-Whitney U test, Pearson's chi-squared, and Fisher's exact test were used to investigate differences between the single and dual PSF groups with statistical significance defined as p ≤ 0.05.
Results
There was no significant difference (p = 0.259) in revision rate, although 3 of 21 (14.3 %) single PSF patients required reoperation compared to 0 of 14 (0.0 %) dual PSF patients. The revisions were performed in one patient due to refracture and in two patients due to tumor progression. Although not statistically significant, a larger percentage of single PSF patients developed a postoperative complication compared to dual PSF patients [odds ratio 0.42 (95 % confidence interval 0.071 to 2.5); p = 0.431]. Single PSF did lead to shorter operative time compared to dual PSF [p < 0.001].
Conclusion
Dual PSF is non-inferior to single PSF and potentially results in fewer reoperations and postoperative complications in distal humerus pathologic lesions, although it leads to longer operative time. The current study is limited by small sample size due to the rarity of distal humerus metastatic lesions.
Keywords: Plate fixation, Distal humerus, Pathologic fracture, Orthopaedic oncology
1. Introduction
The humerus is the second most common site of metastasis in the appendicular skeleton after the femur.1 About 10 % of humeral metastases are located distally.2,3 Patients often undergo surgery for impending or pathologic fracture for the purpose of restoring function and minimizing pain. While dual plate and screw fixation (PSF) is considered the gold standard treatment for distal humerus fractures due to trauma,4,5 there is no consensus on operative management of distal humeral pathologic or impending pathologic fractures. This is likely due to the heterogeneity of pathologies, unique patient circumstances, and limited clinical study. Possible options include conservative management, intramedullary nailing, endoprosthetic elbow replacement, and PSF with either one or two plates.6 PSF is the most commonly performed procedure; however, it is typically performed using a single plate on the medial or lateral column of the distal humerus.2,3,7
Many humeral metastatic cancer studies do not separate treatments for distal lesions.8, 9, 10 Other previous studies have only included subgroup analyses of PSF for distal humeral metastatic lesions. One study concluded that distal humerus pathologic fractures treated with PSF were uncommon and associated with a high reoperation rate of 3/10 (30 %),2 and another study reported that one out of two (50 %) PSF surgeries for distal humeral disease required reoperation.7 Conversely, PSF reoperation rate has also been reported to be as low as 2/29 (6.9 %).3 Interestingly, all PSF procedures for metastatic disease were performed using a single plate in the aforementioned studies, and most reoperations involved implanting a second plate. One study investigated outcomes from 63 PSF surgeries in the humerus for metastatic disease and found an 11.1 % reoperation rate.11 Of these procedures, 71.4 % only used one plate, and 8/63 (12.7 %) were in the distal humerus. However, they did not report how many PSFs in the distal humerus used one versus two plates or which of these required revision.
A biomechanical analysis comparing single and dual PSF for impending pathologic fracture concluded that dual PSF withstood significantly greater peak torque and absorbed more energy than a single plate, indicating that dual PSF may be a more effective initial treatment rather than a salvage option.12 To our knowledge, no previous study has investigated the difference in reoperation rates and postoperative outcomes after single or dual PSF for complete and impending pathologic fractures of the distal humerus. We therefore sought to compare revision rate and postoperative outcomes between single and dual PSF in patients with a distal humerus metastatic lesion.
2. Methods
2.1. Study design and setting
This was a retrospective cohort study performed at a tertiary cancer center. The surgeries were performed by any of four different orthopaedic oncology specialists.
2.2. Participants
All patients who underwent PSF between March 2008 and September 2021 for a distal humerus pathologic fracture or impending fracture due to multiple myeloma, lymphoma, or metastatic disease were identified using CPT codes and included in the study. The patients’ medical records and radiographs were reviewed. Four patients underwent intramedullary nailing for proximal humerus coverage in addition to PSF for distal humerus fixation and these patients were included. All patients meeting the criteria were included regardless of the length of follow-up. Patients treated for metastatic lesions solely of the proximal or midshaft humerus, as well as those treated only with non-PSF fixation methods, were excluded.
2.3. Operative technique
Nerve blocks were sometimes used. Both single and dual PSF began with a standard posterior paratricipital approach, beginning with a midline posterior skin incision followed by mobilization of the triceps while protecting the ulnar and radial nerves. If there was a fracture, soft tissues were curetted and cleaned off the fracture edges. Fractures were sometimes reduced before curettage. A burr was not used for debridement. Peroxide adjuvant was used in some surgeries. One or two plates along with screws were then used for fixation (Fig. 1). When two plates were used, they were always posterolateral and medial condylar plates. Fluoroscopy was used to confirm appropriate reduction and fixation. Cementation with polymethylmethacrylate was then added to the tumor cavity in some patients. Cement was allowed to be at the fracture edges.
Fig. 1.
A-D (A) A 74-year-old man with a history of metastatic renal cell carcinoma who presented with a pathologic fracture in the distal humerus of the left arm. (B) Ten months after surgery the implant appears well seated and well positioned without evidence of loosening. (C) A 66-year-old man with a history of multiple myeloma who presented with an impending pathologic fracture in the distal humerus of the left arm. (D) One year after surgery this radiograph demonstrates stable appearance of the humerus and orthopaedic construct.
2.4. Patient and treatment characteristics
A total of 35 patients (11 women and 24 men) were identified that underwent PSF for a distal humerus lesion. Twenty-one (60 %) patients underwent single plating while 14 (40 %) underwent dual plating. The median age at surgery was 64 years (interquartile range (IQR): 59–69 years). Nineteen (54.3 %) surgeries involved the right humerus, and 16 (45.7 %) involved the left. Twenty-eight (80 %) patients underwent surgery due to a pathologic fracture. The remaining patients underwent surgery prophylactically due to an impending pathologic fracture. Multiple myeloma was the most common malignancy and occurred in 12 (34.3 %) patients. Metastases were due to melanoma, lung adenocarcinoma, lung squamous cell carcinoma, breast cancer, esophageal adenocarcinoma, salivary gland adenocarcinoma, tongue squamous cell carcinoma, hepatocellular carcinoma, renal cell carcinoma, prostate adenocarcinoma, urothelial carcinoma, and follicular thyroid cancer. There were no patients with lymphoma. Thirty-two patients (91.4 %) had lytic lesions while only three (8.6 %) had mixed lytic and blastic lesions. Twenty-seven (77.1 %) patients were previously treated with systemic therapy, including chemotherapy and immunotherapy. Nine (25.7 %) patients were previously treated with radiation. Fourteen (40 %) patients underwent radiation therapy after PSF. Four (11.4 %) patients had prior surgery on their humerus for metastatic disease. Sixteen (45.7 %) received bisphosphonates before and/or after surgery and 9 (25.7 %) received denosumab before and/or after surgery. The median follow-up time was 85 days (IQR: 22–355 days).
2.5. Data sources and measurement
We reviewed clinic notes, operative notes, inpatient progress and discharge notes, radiographs, and radiology reports to identify demographics, surgery data, and postoperative outcomes for patients who underwent single or dual plating of distal humerus metastatic disease. The primary outcome, reoperation, was defined as a subsequent surgery on the distal humerus. Postoperative complications included superficial and deep infection, nonunion, deep vein thrombosis, tumor progression, and radial nerve palsy. Radial nerve palsy was noted as resolved if documented by the surgeon in a subsequent note. Patient follow-up typically occurred every day during the inpatient postoperative period. After discharge, follow-up occurred at two weeks, six weeks, three months, six months, and one year after surgery. Patient date of death was found in the electronic medical records.
Ethical approval
This study was approved by our institution's institutional review board.
2.6. Statistical analysis
We used IBM SPSS Statistics for Windows, Version 28.0 (IBM Corp, Armonk, NY) for all statistical analysis. Mann-Whitney U test was used to analyze continuous variables. Pearson's chi-squared and Fisher's exact test were used to investigate categorical variables. Significance was defined as p ≤ 0.05.
3. Results
Patient demographics were similar between the two groups. Dual PSF patients were more likely to have received bisphosphonate (p = 0.048) or denosumab (p = 0.020) bone-strengthening treatment. Dual PSF patients also had quicker times from lesion diagnosis to consult (p = 0.016) and surgery (p = 0.019) (Table 1).
Table 1.
Patient characteristics.
| Characteristic | Total (n = 35) | 1 Plate (n = 21) | 2+ Plates (n = 14) | p-value |
|---|---|---|---|---|
| Age, years | 64 (59–69) | 63 (58.5–75) | 66 (59–67.5) | 0.686 |
| Gender | ||||
| Female | 11 (31.4 %) | 7 (33.3 %) | 4 (28.6 %) | 1.000 |
| Male | 24 (68.6 %) | 14 (66.7 %) | 10 (71.4 %) | |
| Race | ||||
| Non-white | 10 (28.6 %) | 3 (14.3 %) | 7 (50.0 %) | 0.053 |
| White | 25 (71.4 %) | 18 (85.7 %) | 7 (50.0 %) | |
| BMI, kg/m2 | 28.5 (25.9–30.3) | 28.5 (26.1–30.4) | 28.3 (25.4–30.0) | 0.726 |
| Laterality | ||||
| Left | 16 (45.7 %) | 8 (38.1 %) | 8 (57.1 %) | 0.317 |
| Right | 19 (54.3 %) | 13 (61.9 %) | 6 (42.6 %) | |
| Primary Cancer | ||||
| Multiple Myeloma | 12 (34.3 %) | 6 (28.6 %) | 6 (42.9 %) | 0.477 |
| Metastasis | 23 (65.7 %) | 15 (71.4 %) | 8 (57.1 %) | |
| Lesion Presentation | ||||
| Prophylactic | 12 (34.3 %) | 7 (33.3 %) | 5 (35.7 %) | 1.000 |
| Pathologic fracture | 23 (65.7 %) | 14 (66.7 %) | 9 (64.3 %) | |
| Lesion at Surgery | ||||
| Impending fracture | 7 (20.0 %) | 3 (14.3 %) | 4 (28.6 %) | 0.401 |
| Pathologic fracture | 28 (80.0 %) | 18 (85.7 %) | 10 (71.4 %) | |
| Ortho Consultation | ||||
| Outpatient | 26 (74.3 %) | 18 (85.7 %) | 8 (57.1 %) | 0.112 |
| Inpatient | 9 (25.7 %) | 3 (14.3 %) | 6 (42.9 %) | |
| Soft tissue component | 16 (45.7 %) | 8 (38.1 %) | 8 (57.1 %) | 0.317 |
| Intramedullary Nail | 4 (11.4 %) | 1 (4.8 %) | 3 (21.4 %) | 0.279 |
| Cement fixation | 26 (74.3 %) | 14 (66.7 %) | 12 (85.7 %) | 0.262 |
| Preop chemotherapy | 27 (77.1 %) | 15 (71.4 %) | 12 (85.7 %) | 0.431 |
| Preop radiation | 9 (25.7 %) | 6 (28.6 %) | 3 (21.4 %) | 0.712 |
| Preop surgery | 4 (11.4 %) | 2 (9.5 %) | 2 (14.3 %) | 1.000 |
| Postop radiation | 14 (40.0 %) | 11 (52.4 %) | 3 (21.4 %) | 0.089 |
| Bisphosphonates | ||||
| None | 19 (54.3 %) | 15 (71.4 %) | 4 (28.6 %) | 0.048 |
| Before | 7 (20.0 %) | 2 (9.5 %) | 5 (35.7 %) | |
| After | 3 (8.6 %) | 2 (9.5 %) | 1 (7.1 %) | |
| Before and after | 6 (17.1 %) | 2 (9.5 %) | 4 (28.6 %) | |
| Denosumab | ||||
| None | 26 (74.3 %) | 19 (90.5 %) | 7 (50.0 %) | 0.020 |
| After | 8 (22.9 %) | 2 (9.5 %) | 6 (42.9 %) | |
| Before and after | 1 (2.9 %) | 0 (0.0 %) | 1 (7.1 %) | |
| Time from lesion diagnosis to consult, days | 9 (1–19) | 14 (7–36) | 3 (0–11.5) | 0.016 |
| Time from lesion diagnosis to surgery, days | 23 (10–80) | 28 (14.5–108) | 13 (8.75–20.5) | 0.019 |
Estimated blood loss was similar between single and dual PSF (p = 0.151). Operative time was longer in the dual PSF group. The median operative time for single PSF was 131 min (IQR: 101–164.5 min) compared to 212.5 min (189.75–281.75 min) for dual PSF [p < 0.001] (Table 2).
Table 2.
Outcomes.
| Outcomes | Total (n = 35) | 1 Plate (n = 21) | 2+ Plates (n = 14) | p-value |
|---|---|---|---|---|
| Operative time, mins | 163 (124.5–205) | 131 (101–164.5) | 212.5 (189.75–281.75) | <0.001 |
| Estimated blood loss, mL | 325 (150–575) | 250 (150–400) | 500 (175–700) | 0.151 |
| Service Postop | ||||
| Ortho | 30 (85.7 %) | 20 (95.2 %) | 10 (71.4 %) | |
| Other | 5 (14.3 %) | 1 (4.8 %) | 4 (28.6 %) | 0.134 |
| Postop complication | 8 (22.9 %) | 6 (28.6 %) | 2 (14.3 %) | 0.431 |
| Reoperation | 3 (8.6 %) | 3 (14.3 %) | 0 (0.0 %) | 0.259 |
| Total follow-up, days | 85 (22–355) | 110 (26.5–387) | 60 (20.75–375) | 0.346 |
| Loss of follow-up reason | ||||
| Death | 23 (65.7 %) | 14 (66.7 %) | 9 (64.3 %) | 0.073 |
| Moved | 4 (11.4 %) | 4 (19.0 %) | 0 (0.0 %) | |
| Non-ortho service | 3 (8.6 %) | 0 (0.0 %) | 3 (21.4 %) | |
| Alive | 5 (14.3 %) | 3 (14.3 %) | 2 (14.3 %) | |
| Time from diagnosis to death, days | 1752 (852–4161) | 1146 (513.5–2844.5) | 3930 (1660.25–41159.75) | 0.021 |
| Time from surgery to death, days | 229 (91.25–509.75) | 254 (84.5–499.5) | 156 (86–521) | 0.672 |
The overall reoperation rate was 8.6 %. Three patients out of 21 (14.3 %) underwent revision surgery after single PSF while none of the 14 patients who underwent dual PSF required revision surgery (p = 0.259) (Table 2). The average time to plate failure in these three reoperations was 484 ± 152 days. The reoperation occurred an average of 492 ± 148 days after the initial PSF implantation. (Table 3). One patient developed plate failure because of tumor recurrence and subsequently underwent implantation of a second plate (Fig. 2). A second patient developed a refracture and subsequently underwent distal humerus reconstruction with an endoprosthetic total elbow arthroplasty (Fig. 3). The third patient experienced tumor progression with plate failure and elected to undergo shoulder disarticulation (Fig. 4).
Table 3.
Patients with postoperative complications.
| Patient number | Age (yr) | Sex (M/F) | Primary tumor | Lesion status at surgery | Number of plates | Complication | Reoperation? | Time to reoperation | Time to death |
|---|---|---|---|---|---|---|---|---|---|
| 1 | 68 | F | Multiple myeloma | Pathologic fracture | 1 | Refracture | Yes | 735 | N/A |
| 2 | 51 | M | Squamous cell carcinoma (tongue) | Pathologic fracture | 1 | Tumor progression | Yes | 223 | 523 |
| 3 | 54 | M | Renal cell carcinoma | Pathologic fracture | 1 | Radial nerve palsy, resolved | No | N/A | 2967 |
| 4 | 65 | M | Renal cell carcinoma | Pathologic fracture | 1 | Tumor progression | Yes | 518 | 869 |
| 5 | 67 | M | Prostate cancer | Pathologic fracture | 2 | Radial nerve palsy, resolved | No | N/A | 107 |
| 6 | 61 | F | Renal cell carcinoma | Pathologic fracture | 1 | Radial nerve palsy, death before 6 months | No | N/A | 32 |
| 7 | 74 | M | Renal cell carcinoma | Pathologic fracture | 1 | Radial nerve palsy, resolved | No | N/A | N/A |
| 8 | 66 | M | Multiple myeloma | Pathologic fracture | 2 | Radial nerve palsy, thumb numbness longer than 6 months | No | N/A | N/A |
Fig. 2.
A-D These AP radiographs are from a 65-year-old man with a history of metastatic renal cell carcinoma who presented with (A) a pathologic fracture in the distal part of the right humerus. (B) This radiograph was taken 1 month after single plate screw fixation. (C) Another radiograph was taken 16 months postoperatively and demonstrates plate failure due to tumor recurrence. (D) This radiograph was taken 6 months after reoperation involving implantation of a second plate.
Fig. 3.
A-D These AP radiographs are from a 68-year-old woman with a history of multiple myeloma who presented with (A) an impending pathologic fracture in the distal shaft of the right humerus. (B) This radiograph was taken 26 days after single plate screw fixation. (C) This radiograph was taken 2 years later demonstrating a fracture with varus angulation that required reoperation. (D) This radiograph was taken 15 days after reoperation demonstrating a mid-to-distal humeral resection with metallic prosthesis and elbow arthroplasty.
Fig. 4.
A-D These AP radiographs are from a 51-year-old man with a history of metastatic squamous cell carcinoma of the tongue who presented with (A) a pathologic fracture in the distal part of the right humerus. (B) This radiograph is 19 days after single plate screw fixation. (C) Another radiograph was taken 3 months postoperatively. (D) This radiograph was taken 7 months postoperatively and demonstrates plate failure and disease progression. Continued lesion progression prompted right shoulder disarticulation at the glenohumeral joint.
Overall, eight out of 35 (22.9 %) patients experienced a postoperative complication. Six out of 21 (28.6 %) single PSF patients developed a complication while two out of 14 (14.3 %) dual PSF patients developed a complication [odds ratio 0.42 (95 % confidence interval 0.071 to 2.4); p = 0.431] (Table 2). Complications seen in single PSF patients included one refracture, two tumor progressions, and three radial nerve palsies. The two complications seen in dual PSF patients were both radial nerve palsies (Table 3).
4. Discussion
Unlike for traumatic fractures of the distal humerus, there are no clear guidelines for the management of patients with metastatic lesions of the distal humerus. The distal humerus exhibits triangular anatomy with two columns surrounding the coronoid and olecranon fossa. Adequate fixation of the distal humerus requires restoring the integrity of both columns.13,14 While surgeons have embraced this theory for trauma fractures with dual PSF being the gold standard, they have yet to do so for pathologic lesions. The goal of any surgical intervention in the metastatic bone disease setting is to stabilize the bone and provide pain relief without the need for another procedure for the remainder of the patient's life. PSF is the most frequently performed surgical treatment for distal humerus metastatic impending or pathologic fractures, and a single plate is most common. The theoretical benefits of using a single plate compared to two plates are a lower risk of infection due to shorter operative time, less soft tissue dissection, and a lower risk for nerve injury. Inserting a second plate on the medial side of the humerus presents the risk for ulnar nerve injury in addition to the risk of radial nerve injury that may occur with posterolateral plate placement. However, there is evidence that points toward the benefits of inserting two plates. A biomechanical study on impending fractures of the distal humerus showed dual plates withstand greater peak torque and absorb more energy.12 Furthermore, dual plating is considered the standard of care for distal humerus traumatic fractures.4,5,13,14 To date, analyses of treatment methods for distal humerus metastatic lesions have been relegated to subgroup analyses in larger studies. No study has investigated the clinical outcomes of dual PSF versus single PSF in distal humerus metastatic lesions. We found no significant differences in the reoperation or complication rates between dual and single PSF; however, there was a trend toward a lower rate of implement failure in the dual PSF group and none of the patients in this group required a reoperation. We believe that using two plates may save patients from revision surgery and be worth the potentially increased blood loss and operative time.
While the difference in the reoperation rate between single and dual PSF was not statistically significant, there was an observable difference in that no dual PSF patients required revision. Of the three revisions in the single PSF group, one revision involved inserting a second plate. The insertion of a second plate was commonly seen in several other studies when revision of single PSF was required.2,3,7 If the revision surgery involves converting to a dual PSF, we believe it would be best to start with dual PSF. Multiple surgeries will expose the patient to a greater financial cost and a higher risk of complications than a single initial dual PSF. Furthermore, the concept of dual PSF better adheres to fundamental oncologic principles as it provides complete bone coverage, unlike single PSF.
Regarding the patients that required reoperation, potentially relevant variables are the presence of cement augmentation as well as preoperative and postoperative radiation therapy. One of the reoperations occurred in a single PSF construct that did not have cement augmentation. Cement augmentation provides stability, so this patient's implant failure may have been avoided with cement augmentation. However, cement was used on a per case basis and there was not a significant difference in its use between the two groups. One patient requiring revision received preoperative radiation but no postoperative radiation. The other two revision patients received radiation therapy only after their initial plating surgery. The presence of radiation could have impacted healing and contributed to the need for revision. There was no significant difference in the prevalence of neoadjuvant or adjuvant radiation therapy between the single and dual PSF groups.
In our study, the lack of revisions seen in the dual PSF group could be confounded by the use of bone-strengthening agents and the time from lesion diagnosis to treatment. Bisphosphonate and denosumab use were significantly greater in the dual PSF group. Both are used to reduce the risk of fracture in metastatic bone disease. It is possible that this contributed to dual PSF patients requiring no reoperations, especially since one of the reoperations in the single PSF group was due to a refracture. There was also a significantly shorter time from lesion diagnosis to orthopaedic consultation and surgery in the dual PSF group. These quicker times may have been due to the trend that dual PSF patients were more likely to first be seen by the orthopedics service during an inpatient stay, although this finding was not statistically significant. Whatever the true cause, the quicker times to surgery may have contributed to the lower rate of revisions in the dual PSF group. These issues should be addressed in future studies with larger sample sizes.
The overall postoperative complication rate was 22.9 % in this series. This is difficult to compare to previous studies, as most studies either did not distinguish which humerus PSFs were for distal metastatic lesions, or they only quantified whether the complications were local or systemic. Similar to our study, Casadei et al. found a 22 % complication rate in ten distal metastatic lesions, but this included eight patients treated with intramedullary nail and only two treated with PSF.7 The complication rate in the present study was lower in the dual PSF group compared to the single PSF group (14.3 % vs 28.6 %), although, due to low sample size, this was not a significant difference. The most common complication was radial nerve palsy, in contrast to other studies on distal humerus metastatic lesions in which infection and nonunion were the most common.2,3,7 Two of the three radial nerve palsies in the single PSF group resolved while the third patient died 32 days after surgery. Out of the two radial nerve palsies in the dual PSF group, one resolved completely, and one experienced partial resolution with residual dorsal thumb numbness. Dual PSF could theoretically affect radial nerve palsy due to additional implement and soft tissue exposure, but this was not supported by our data.
We identified one downside to dual PSF. The insertion of a second plate required a greater dissection compared to one plate, leading to longer operative time in patients that underwent dual PSF. This can lead to increased risk of infection and blood loss.15,16
This study had several limitations. The study was retrospective and performed at a tertiary cancer center. Selection bias was likely present, as these patients may present with more advanced disease compared to a community practice. However, a prospective series would take many years to complete, as distal humerus metastatic lesions encompass only a small proportion of humerus metastases. Additionally, dual PSF may have been preferentially employed for more severe lesions or fractures. Our study was underpowered to find statistical significance due to the small sample size. However, it is still a large series of patients with plate fixation for a distal humerus lesion. There was heterogeneity of cancer types in this study, and we were unable to stratify based on these types due to limited sample size. Postoperative complications such as nonunion or refracture could only be identified during follow-up visits, so it is likely that the time to plate failure was overestimated. We also had limited follow-up due to death or follow-up care in facilities besides our own. This limitation is inherent to this patient population, and it means our estimates for reoperation and complication rates are likely low. With longer follow-up, it is possible that more patients would require reoperation.
5. Conclusions
The rate of reoperations and postoperative complications did not differ significantly between dual and single PSF patients; however, both tended to be lower in dual PSF with none of the dual PSF patients requiring revision. Operative time was significantly greater in the dual PSF group. As more surgeons utilize this procedure, future studies may be able to detect significant reductions in the reoperation rate.
Declarations of interest
None.
Ethical approval
This study only involved retrospective review of patient charts. IRB deemed the study exempt.
Please state any sources of funding for your research
None.
Patient's consent
There were no minors requiring Guardian consent. This study was retrospective chart review that did not require patient consent.
CRediT authorship contribution statement
William West: data collection, data analysis, interpretation, Writing – review & editing. Andrew Moore: interpretation, Writing – review & editing. Caroline Gerhardt: data collection. Paul Webb: data collection. Odion Binitie: interpretation, Writing – review & editing. Alexander Lazarides: interpretation, Writing – review & editing. Douglas Letson: interpretation, Writing – review & editing. David Joyce: study concept and design, interpretation, Writing – review & editing.
Acknowledgement
The authors have no acknowledgements for this publication.
References
- 1.Frassica F.J., Frassica D.A. Evaluation and treatment of metastases to the humerus. Clin Orthop Relat Res. Oct 2003;(415 Suppl):S212–S218. doi: 10.1097/01.blo.0000093052.96273.a7. [DOI] [PubMed] [Google Scholar]
- 2.Wedin R., Hansen B.H., Laitinen M., et al. Complications and survival after surgical treatment of 214 metastatic lesions of the humerus. J Shoulder Elbow Surg. Aug 2012;21(8):1049–1055. doi: 10.1016/j.jse.2011.06.019. [DOI] [PubMed] [Google Scholar]
- 3.Janssen S.J., van Dijke M., Lozano-Calderon S.A., et al. Complications after surgery for metastatic humeral lesions. J Shoulder Elbow Surg. Feb 2016;25(2):207–215. doi: 10.1016/j.jse.2015.08.009. [DOI] [PubMed] [Google Scholar]
- 4.Haglin J.M., Kugelman D.N., Lott A., Belayneh R., Konda S.R., Egol K.A. Intra-articular distal humerus fractures: parallel versus orthogonal plating. HSS J. May 2022;18(2):256–263. doi: 10.1177/15563316211009810. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Lee J.K., Choi Y.S., Sim Y.S., Choi D.S., Han S.H. Dual plate fixation on distal third diaphyseal fracture of the humerus. Int Orthop. Aug 2017;41(8):1655–1661. doi: 10.1007/s00264-016-3355-4. [DOI] [PubMed] [Google Scholar]
- 6.Voskuil R.T., Mayerson J.L., Scharschmidt T.J. Management of metastatic disease of the upper extremity. J Am Acad Orthop Surg. Feb 1 2021;29(3):e116–e125. doi: 10.5435/JAAOS-D-20-00819. [DOI] [PubMed] [Google Scholar]
- 7.Casadei R., Drago G., Di Pressa F., Donati D. Humeral metastasis of renal cancer: surgical options and review of literature. Orthop Traumatol Surg Res. Jun 2018;104(4):533–538. doi: 10.1016/j.otsr.2018.03.009. [DOI] [PubMed] [Google Scholar]
- 8.Dijkstra S., Stapert J., Boxma H., Wiggers T. Treatment of pathological fractures of the humeral shaft due to bone metastases: a comparison of intramedullary locking nail and plate osteosynthesis with adjunctive bone cement. Eur J Surg Oncol. Dec 1996;22(6):621–626. doi: 10.1016/s0748-7983(96)92450-6. [DOI] [PubMed] [Google Scholar]
- 9.Sarahrudi K., Wolf H., Funovics P., Pajenda G., Hausmann J.T., Vecsei V. Surgical treatment of pathological fractures of the shaft of the humerus. J Trauma. Mar 2009;66(3):789–794. doi: 10.1097/TA.0b013e3181692132. [DOI] [PubMed] [Google Scholar]
- 10.Janssen S.J., Teunis T., Hornicek F.J., Bramer J.A.M., Schwab J.H. Outcome of operative treatment of metastatic fractures of the humerus: a systematic review of twenty three clinical studies. Int Orthop. 2015;39(4):735–746. doi: 10.1007/s00264-014-2584-7. [DOI] [PubMed] [Google Scholar]
- 11.Weiss K.R., Bhumbra R., Biau D.J., et al. Fixation of pathological humeral fractures by the cemented plate technique. J Bone Joint Surg Br. Aug 2011;93(8):1093–1097. doi: 10.1302/0301-620X.93B8.26194. [DOI] [PubMed] [Google Scholar]
- 12.Damron T.A., Heiner J.P., Freund E.M., Damron L.A., McCabe R., Vanderby R. A biomechanical analysis of prophylactic fixation for pathological fractures of the distal third of the humerus. J Bone Joint Surg Am. Jun 1994;76(6):839–847. doi: 10.2106/00004623-199406000-00007. [DOI] [PubMed] [Google Scholar]
- 13.Li S.-H., Li Z.-H., Cai Z.-D., et al. Bilateral plate fixation for type C distal humerus fractures: experience at a single institution. Int Orthop. 2011;35(3):433–438. doi: 10.1007/s00264-010-1011-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Amir S., Jannis S., Daniel R. Distal humerus fractures: a review of current therapy concepts. Curr Rev Musculoskelet Med. Jun 2016;9(2):199–206. doi: 10.1007/s12178-016-9341-z. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Cheng H., Chen B.P., Soleas I.M., Ferko N.C., Cameron C.G., Hinoul P. Prolonged operative duration increases risk of surgical site infections: a systematic review. Surg Infect. Aug/Sep 2017;18(6):722–735. doi: 10.1089/sur.2017.089. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Manara J., Sandhu H., Wee M., et al. Prolonged operative time increases risk of blood loss and transfusion requirements in revision hip surgery. Eur J Orthop Surg Traumatol. Oct 2020;30(7):1181–1186. doi: 10.1007/s00590-020-02677-4. [DOI] [PubMed] [Google Scholar]