1. Introduction
Treatment of humeral shaft fractures has come a long way from its initial conception of non-operative methods like coaptation splint, Functional bracing to operative interventions like plate osteosynthesis and intramedullary nailing.1, 2, 3, 4 Although non-operative modalities have varied results, they are associated with disadvantages like, prolonged immobilization, non-anatomical union, and decrease in activities of daily living. Plate osteosynthesis has been considered as the gold standard but has associated problems like extensive soft tissue dissection, radial nerve palsy, non-union, and infection.5,6 With the advent of intramedullary nailing for humerus shaft fractures, the benefits of closed reduction, preservation of fracture hematoma and minimally invasive techniques can be achieved. These nails can be inserted into an ante or retrograde fashion depending upon the fracture geometry, bone quality, underlying pathology, presence of co-morbid conditions and surgeon's preference.
The aim of the present study was to compare the functional and radiological outcome in patients with humerus shaft fractures treated with antegrade or retrograde nailing technique.
2. Material and methods
A Prospective randomized study was conducted at a Tertiary care hospital between May 2014 and June 2016 on 43 patients with diaphyseal humerus fractures treated by antegrade or retrograde nailing technique. The inclusion criteria were closed fractures, compound grade 1 and grade 2 fractures and segmental fractures. Patients with prior radial nerve palsy, compound grade 3 fractures, patients with a narrow medullary canal (<6 mm at the isthmus) and with severe medical co-morbidities like cardio-pulmonary dysfunction were excluded from the study. Randomization was done using the closed envelope technique. The patients were asked to open a sealed opaque envelope just prior to the surgery, depending on which the procedure was decided and the patients were divided into two groups. Patients who were operated using the antegrade nailing technique were included in group A (n = 24) while the patients with retrograde nailing were in group B (n = 19). A total of 47 patients who had humerus shaft fracture were screened amongst which, 4 patients refused to participate in the study and were thus excluded from the study. All the necessary pre-operative work-up was done in form x-rays and hematological investigations. Prior well written informed consent was taken from all the patients. Ethical committee approval was obtained before the commencement of the study. Similar post-operative pain control and mobilization were followed for all the patients. Regular follow-up was done at 3,6,12 and 24 months respectively.
The primary endpoints were functional recovery, radiological and clinical union and the rate of complications with both the techniques. The secondary endpoints were surgical time, intra-operative bleeding and duration of the hospital stay. The Final outcome was determined using the modified criteria of Stewart and Hundley1 at the end of 24 months. This criterion comprises of three components namely pain, mobility and limb alignment. The final results are interpreted as excellent-no pain, no loss of mobility and proper alignment, good-no pain, limitation of adjacent joint and mobility less than 20°/angulation less than 10°, fair-pain after effort or fatigue, limitation of mobility between 20 and 40°/angulation greater than 10°, poor-permanent pain, limitation of mobility greater than 40°/non-union or radial nerve palsy.
2.1. Surgical technique
General anaesthesia combined with a regional block was used in all the cases. Standard surgical steps were followed. A total of three doses of second-generation cephalosporin was administered in the peri-operative period.
2.2. Antegrade nailing technique-
In the supine position, an anterolateral approach for proximal humerus was used. A 5 cm incision was made starting distal to the lateral aspect of the acromion. Deltoid muscle was split carefully along its anterior and middle fibres, and the sub-deltoid bursa was excised. The supraspinatus tendon was split along the line of its fibres and the cut ends were tagged for future closure. Entry was made with the curved awl just lateral to the articular cartilage and around 0.5 cm posterior to the bicipital groove. Following that, the guide wire was passed and a closed reduction was done by gentle traction and manipulation under C arm image intensifier. Reaming of the canal was done till the level of the isthmus. Appropriate size nail was then inserted. Proximal locking was done with the help of zig. Distal locking was done under visualization by a mini-open incision using freehand technique (Fig. 1 and Fig. 2). The proximal tip of the nail was buried about 5 mm below the articular surface to safeguard the rotator cuff.
Fig. 1.
pre-operative app and lateral radiograph.
Fig. 2.
post-operative radiograph antegrade nailing.
2.3. Retrograde nailing technique
In lateral position, the affected limb was prepared and kept in 90° abduction at theshoulder and 90° flexion at the elbow joint. A posterior approach was used. Triceps muscle was split in the line of its fibres and entry point was made just above the level of olecranon fossa with the help of 3.2 mm drill bit. Reaming was performed only at the entry point to avoid iatrogenic shaft fracture at the time of nail insertion. Appropriate size nail was then inserted. Proximal locking of the nail was done with the help of zig and freehand technique was used for distal locking (Fig. 3 and Fig. 4).
Fig. 3.
pre-operative app and Lateral radiograph.
Fig. 4.
post-operative radiograph retrograde nailing.
Similar post-operative pain management and physiotherapy protocol were used for all the cases. Mobilization was started from Post-operative day 1 in the form of shoulder and elbow movements. All the patients were asked to use an arm pouch for a period of 3 weeks. Assisted passive mobilization at the shoulder (forward elevation and abduction) and elbow (flexion and extension) were started from second post-operative day within the limits of pain tolerance.
3. Results
The mean age of the patients was 42.4 ± 1.8 and 44.1 ± 2.4 in group A and B respectively. There were 19 (44.18%) females and 24 (55.9%) males in the present study. Dominant side was involved 27 (62.7%) cases. The commonest mechanism of injury was road traffic accident accounting for 24 (55.8%) cases. Thirty-seven (86%) cases had closed fracture humerus. As per the AO-OTA classification system and there were 21 (48.9%) cases of type 12-A, 10 (23.2%) cases of type 12-B and 12 (27.9%) cases of type 12-C. Majority of the cases 24 (55.8%) had middle third shaft fracture, which was followed by lower third 12 (27.9%) and proximal third 7 (16.3%) fractures respectively. Five (11.6%) patients had associated head injury, and 3 (6.9%) patients had either a chest or abdominal injury while 12 (27.9%) patients had multiple fractures among both the groups. There were 17 (39.5%) patients with transverse fracture pattern, 21 (48.9%) patients with spiral and 5 (11.6%) patients with segmental fracture observed in the present study (Table 1). The average surgical time was 80 ± 8.4 min in group A and 95 ± 5.3 min in group B which was statistically significant (p = 0.0001*). The radiological union was seen at 15 ± 2.4 and 16 ± 4.1 in group A and B respectively. The average intra-operative bleeding was 43 ± 8.6 ml in group A and 41 ± 7.1 ml in group B. There were 2 (4.6%) cases of superficial infection in each group (group A and group B respectively) which responded well to oral antibiotics. There was 1 (5.2%) case of iatrogenic fracture of the posterior cortex in a patient in group B. There was 1 (2.3%) case of radial nerve neuropraxia in group A which recovered completely within 2 months after the surgery. There was 1 (2.3%) case of grade II compound fracture with a delayed union which had to be revised later with plating and bone grafting. There were 3 (12.5%) cases in group A which had post-operative shoulder stiffness. No case of elbow stiffness was seen in both of the groups (Table 2). As per the modified criteria of Stewart and Hundley1, 8 (18.6%) cases had excellent, 27 (62.8%) cases had good, 6 (13%) cases had fair and 2 (4.65%) cases had poor results respectively.
Table 1.
Demographics.
| Characteristics | Group A n = 24 (%) | Group B n = 19 (%) | Test of Significance | P value |
|---|---|---|---|---|
| Age | 42.4 ± 1.8 | 44.1 ± 2.4 | Two sample Independent t-test | 0.0112 |
| Side involved | ||||
| Dominant | 15 (62.5) | 12 (63.2) | Chi square test | 0.9646 |
| Non-dominant | 09 (37.5) | 07 (36.8) | ||
| Mechanism of Injury | ||||
| Road Traffic accident | 13 (54.2) | 11 (57.8) | Chi square test | 0.8465 |
| Fall | 09 (29.1) | 06 (31.6) | ||
| Assault | 04 (16.7) | 02 (10.6) | ||
| Nature of Injury | ||||
| Closed | 22 (91.6) | 15 (79) | Fishers Exact | 0.4514 |
| Open | 02 (8.4) | 04 (21) | ||
| Fracture Type | ||||
| 12-A | 12 (50) | 09 (47.4) | Chi square test | 0.4488 |
| 12-B | 04 (16.7) | 06 (31.6) | ||
| 12-C | 08 (33.3) | 04 (21) | ||
| Fracture Level | ||||
| Upper third | 06 (25) | 01 (5.2) | Chi square test | 0.1705 |
| Middle third | 13 (54.1) | 11 (57.8) | ||
| Lower third | 05 (20.9) | 07 (36.8) | ||
| Associated injuries | ||||
| Head injury | 03 (12.5) | 02 (10.5) | Chi square | 0.9659 |
| Chest/Abdominal trauma | 02 (8.4) | 1 (5.2) | ||
| Polytrauma (Multiple fractures) | 07 (29.1) | 05 (26.3) | ||
| Fracture Pattern | ||||
| Transverse | 10 (41.6) | 07 (36.8) | Chi square test | 0.7466 |
| Spiral | 12 (50) | 09 (47.4) | ||
| Segmental | 02 (8.4) | 03 (15.8) | ||
Table 2.
Results.
| Variable | Group A n = 24 (%) | Group B n = 19 (%) | Test of significance | P Value |
|---|---|---|---|---|
| Surgical time (Mins) | 80 ± 8.4 | 95 ± 5.3 | Two sample Independent t-test | 0.0001∗ |
| Time for Radiological Union (Weeks) |
15 ± 2.4 | 16 ± 4.1 | Two sample Independent t-test | 0.3233 |
| Duration of Hospital Stay (Weeks) | 5.2 ± 1.4 | 6.1 ± 2.8 | Two sample Independent t-test | 0.1765 |
| Intra-operative bleeding (ml) | 43 ± 8.6 | 41 ± 7.1 | Two sample Independent t-test | 0.4189 |
| Complications | ||||
| Superficial | 1 (4.1) | 1 (5.2) | Fisher's Exact | 1 |
| Infection | ||||
| Iatrogenic | – | 1 (5.2) | Fisher's Exact | 0.4546 |
| Fracture | ||||
| Radial Nerve | 1 (4.1) | – | Fisher's Exact | 1 |
| Neuropraxia | ||||
| Delayed Union | 1 (4.1) | – | Fisher's Exact | 1 |
| Shoulder | 3 (12.5) | – | Fisher's Exact | 0.2565 |
| Stiffness |
*- Statistically significant.
3.1. Statistics
Chi-square test was used for demographics such as side involved, mechanism of injury, fracture type, fracture level, fracture pattern. Fisher's exact test was used for parameters such as nature of injury and complications such as superficial infection, iatrogenic fracture, radial nerve palsy, delayed union and shoulder stiffness. Two sample independent t-test was used for variables like age, surgical time, time for radiological union and duration of the hospital stay. The results were expressed as mean with standard deviation and p < 0.05 was considered to be statistically significant. The analysis was done using the Epi-Info software (version 3.4.3) and Microsoft excel 2013 (Microsoft office v15.0).
4. Discussion
Intramedullary nailing has been the preferred modality of treatment for lower limb bones like femur and tibia owing to its load sharing principle. However, the implications of the same have been popularised only since the past few decades for humerus7. The initial first-generation nails like Kuntscher nail, Rush nail, Enders nail or J nail gave a three-point fixation but lacked rotational stability which was the primary reason for their failure. With the advent of interlocking nailing technique, these issues were minimized to a large extent.8,9
The first antegrade nailing was described by Derweduwen in 1979 with a limited experience However, the Seidel nail with two proximal locking screws and three distal flanges changed the concept of intramedullary nailing for shaft humerus fractures.10 The recent generation of antegrade nailing with screws at both the ends has been popular because of its technical ease, superiority in terms of position, better stability and decreased the duration of surgery especially in poly-trauma patients. Proper patient selection, proper arm position, choice of the nail and technique familiarity, correct entry portal preparation and adequate reduction are the pre-requisites for executing successful nailing. Nevertheless, there have been associated concerns like shoulder impairment due to rotator cuff violation, cartilage damage, proximal nail migration or adhesive capsulitis with the use of this technique.11, 12, 13 Also, the distal locking involves insertion of the antero-posterior screw at the transition zone of the lower third humerus which is difficult and carries a risk of neurovascular injury. Latero-medial locking, on the other hand, can cause injury to the radial or lateral cutaneous nerve.14,15
Retrograde nailing was introduced in order to elude these aforementioned complications and technical difficulties. However, apart from being technically demanding procedure, this technique has pitfalls like posterior cortex comminution due to high nail resistance (due to the triangular geometry of distal the humerus providing less space for the nail insertion), stiffness at the elbow joint due to the violation of triceps muscle.5,11,16
Tsai EH et al.13 in their retrospective study observed that these injuries had a male predominance with road traffic accident as the most common mechanism of injury. Similar findings were seen in the present study with a male predominance and RTA as the most common mechanism of injury involving 55.8% patients.
Ajmal et al.17 and Cox et al.18 in their series, found shoulder impairment of 41% and 16% respectively. In contrast to the mentioned studies, there were 12.5% cases in the present study who had shoulder impingement. Careful exposure and meticulous repair of the cuff along with embedding the nail tip below the subchondral bone avoids the chances of rotator cuff injury.15 There is a risk of injury to the long head of biceps and axillary nerve which can be avoided by the use of an antero-posterior screw. A meta-analysis by Bhandari et al.,19 showed that the rate of impingement and penetration rate is low with plate osteosynthesis as compared with intramedullary nailing. However, the final outcome in terms of union was similar in both groups.
Shoulder impingement has been one of the pivotal reasons for the introduction of the retrograde humerus nailing techniques. The entry for the retrograde nail is not in the line of the humerus owing to the presence of olecranon. Thus, the nail is directed towards the anterior cortex making it prone for a fracture at the supracondylar level which can be as high as 20%.7,14,20,21 Various attempts have been made to alleviate this problem which includes creating small drill holes in a rhomboid configuration and connecting them or a specialized device for the same.21 Lin et al.,22 Marchetti et al.23 and Sanzana et al.24 studied retrograde nailing technique and concluded that this technique involves violation of the elbow joint and also increases the chances of an iatrogenic fracture of the posterior cortex at the entry site. One case had an oblique fracture of the posterior cortex of the distal humerus, just proximal to the entry point due to the hammering of the nail during its retrograde insertion. Since it was an undisplaced oblique fracture, the patient was treated with prolong immobilization for a period of 3 weeks following which gentle passive mobilization was began. The patient, however, did well in the follow-up period.
Baltov et al.25 in their study, encountered an infection rate of 0.9% using different generation nails. In the present study, there was one case of superficial infection in both the groups which resolved completely with oral antibiotics. There was one case of radial nerve neuropraxia in the present study in a patient with middle third fracture with Thurston Holland fragment. The cause of the neuropraxia might be the number of attempts for closed reduction using the guide wire. The patient recovered completely within 3 months of surgery.
Cheng et al.26 in their series of 92 fractures observed that the retrograde nailing is associated with longer operative duration as compared to the antegrade nailing technique which was statistically significant. Similar findings were seen in the present study. Longer duration for retrograde nailing might be related to the difficulty encountered in the entry along with the free hand distal locking.
We believe that with due precautions, both the nailing techniques can be used at a different level of humeral shaft fractures. Fixation stability can be increased when the nail is inserted from the shorter to the longer fragment.19 The antegrade technique is favorable in cases with proximal fractures while retrograde nailing gives better outcome and stability in distal fractures.10,11 In the middle third fractures, there has been no significant difference noted in terms of fracture union and functional outcome.
In the present study, No statistically significant difference was noted in terms of functional outcome in either of the techniques.
5. Limitations
The small number of sample size and short duration of follow-up are the limitations of the present study.
6. Conclusion
Antegrade and retrograde nailing have favorable outcomes in humeral shaft fractures at different levels. Selection of the technique as per the fracture geometry, patient comorbidities is of paramount importance. In our opinion, antegrade nailing can be done in more proximal fractures at the meta-diaphyseal junction especially in a younger population with smaller medullary canal and polytrauma, whereas retrograde nailing can be opted for patients with wider medullary canal and more distal fractures due to the ease of its insertion and better stability. The middle third fractures can be operated using either of the two techniques. Multi-centric randomized control trials will help further to develop proper guidelines and consensus for this particular type of fracture.
Conflicts of interest
NIL.
Funding
NONE.
References
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