New ways of treatment of fractures of the humeral shaft: does the combination of intramedullary nail osteosynthesis and cerclage improve the healing process?

Introduction The humeral shaft fracture is a rare fracture of the long bones with various treatment options. Dreaded complications such as lesions of the radial nerve or non-unions make the decision for what kind of therapy option more difficult. Biomechanically the upper arm is mostly exposed to rotational forces, which affect intramedullary nail osteosynthesis. Additive cerclage may compensate for these in spiral fractures. The aim of this study is to investigate what effect a combination of intramedullary nail osteosynthesis and limited invasive cerclage has on the rate of healing. In addition, this study addresses the question if complications arise as a result of cerclage. Methods In this retrospective study, 109 patients were evaluated, who, during a period of 6 years, underwent operative treatment of a humerus shaft fracture with a combination of intramedullary nail osteosynthesis and additive cerclage. The primary end point was to establish the rate of healing. A secondary end point was to evaluate complications such as infections and damage to the nerve. This was followed by an examination of patient files and X-ray images and a statistical analysis with SPSS. Results and conclusion The healing process shows a non-union rate of 2.6%, and complications such as secondary radial nerve lesions of 4.6%. The antegrade intramedullary nail osteosynthesis with limited invasive, additive cerclage reduces the risk of non-union and does not lead to an increased risk of iatrogenic damage to the radial nerve. Wound healing was not impaired and there were no infections through the cerclage in our patient cohort.

Controversial technologies in intramedullary osteosynthesis of rats femur fractures

The aim: to conduct a comparative study of osteoreparative regeneration, namely in the periosteal and intermediate areas of the cortex, during intramedullary osteosynthesis of the femur of rats with and without reaming of the bone marrow canal. Materials and methods. The work is based on the results of an experimental study conducted on 56 white mature laboratory rats, which simulated diaphyseal fracture of the femur and performed stable nail osteosynthesis with reaming of the bone marrow canal in the first series and without reaming in the second series of the experiment. Histological examination of the specimens was performed on the 7th, 14th, 28th and 90th day after surgery. Results. The procedure of reaming the bone marrow canal reduces the potential reparative capacity of bone tissue in the endosteal area and leads to “distorted” activation of the process of the cortex restructuring. There is a significant activation of osteoclastic resorption. Conclusions. Bone fusion is more active with the use of intramedullary fixator without reaming of the bone marrow canal, because its reaming reduces the manifestations of reparative potentials in the endosteal region and leads to excessive activation of the resorptive process of restructuring the cortex of both endosteal and central part

Correction of Torsional Deformity Following Nail Osteosynthesis of a Subtrochanteric Fracture

Torsional deformity is a frequent complication following nail osteosynthesis of a subtrochanteric fracture. This complication is difficult to assess intraoperatively, but can cause major functional restrictions. The authors consider that a clinical assessment should be complemented by a postoperative radiological control standardised with torsion CT. Thus, torsion deformity can be recognised immediately and easily corrected if necessary. This can help to avoid long-term damage that requires considerable surgery. The video shows details of torsion correction after a ca. 5-week old subtrochanteric femoral fracture, which had been initially treated with a femur nail. Before torsion correction, the internal torsion on the right femur was 22° and the external torsion on the left femur was 2°. Thus, the total deformation of the external torsion on the left side was 24°. We note the indication for removal of the nail, torsion correction and reosteosynthesis with long PFNA. The postoperative CT control confirmed that the torsion correction was adequate with internal torsion of 25° on the operated left side.

COMPARISON OF LCP AND INTRAMEDULLARY NAIL OSTEOSYNTHESIS IN CALCANEAL FRACTURES

ABSTRACT Objective: This study compared groups of patients with calcaneal fractures of Sanders types II and III. One group was treated with ORIF using an LCP (plate), while the second was treated with a minimally invasive method using a C-Nail. Methods: The study included 217 patients in the ORIF group and 19 patients in the minimally invasive nail osteosynthesis group. Results: In the LCP group, the outcomes were excellent for 35.7% of the patients; good, 38.9%; satisfactory, 19.7%; and poor, 5.7%. In the C-Nail group, the outcomes were excellent for 36.9% of the patients; good; 31.6%; satisfactory, 21%; and poor, 10.2%. The mean values of the restoration of Böhler's angle from post-injury were 6.8° to 32.3° in the LCP group and 7.1° to 33.3° in the C-Nail group. After 12 months, there was only a minimal decrease in Böhler's angle to 29.2° in both the LCP and C-Nail groups. Conclusion: The outcomes obtained with C-Nail fixation are statistically identical to those obtained with LCP fixation. We conclude that osteosynthesis with a C-Nail is suitable as the first-choice treatment for Sanders types II and III fractures. Level of evidence IV, retrospective observational study.

A Modified Rotator Cuff Sparing Approach to the Proximal Humerus in Antegrade Nail Osteosynthesis with Transosseous Supraspinatus Tendon Refixation

Background Due to the approach within antegrade humerus nail osteosyntheses, lesions of the supraspinatus tendon with a consecutive functional limitation of the rotator cuff (RC), insufficiencies, adhesions and chronic shoulder pain in the long term can result. The evidence respectively the study data situation is limited regarding the evaluation of this issue. Patients/Material and Methods We are the first to present by means of a case report with a geriatric female patient and a dislocated diaphyseal humerus fracture a rotator cuff sparing osseous approach to the proximal humerus in antegrade nail osteosynthesis without harming the vulnerable supraspinatus tendon (SSP). This is possible through a limited osteotomy of the greater tubercle with the preparation of a 10 mm deep and 15 to 20 mm wide osseous SSP base. The medullary cavity is then opened for inserting the nail in an antegrade manner and closed after fracture stabilization through reposition of the attached osteotomy of the greater tubercle by means of a suture anchor, for example. The procedure also includes a biceps tenodesis. Besides the description of the intraoperative approach and procedure, the clinical and functional results were recorded by established scores as well as radiologically respectively sonographically 6 weeks (T1) and 3 months (T2) postoperatively. Results The patient was very satisfied regarding pain and function after the modified operative procedure. The rotator cuff tests were negative and there were no impingement like symptoms or indications for an adhesive capsulitis. Range of motion as well as the Constant and (Quick) DASH-Score showed a very good function in the course. The implant was located regularly in the radiological control and the fracture showed a good osseous consolidation. A bland joint without effusion or periarticular fluid and no adhesion with the delta fascia could be presented by sonography. The RC and especially the SSP showed a normal sonographic separation. The functional results are comparable to the other publications so far. Conclusion The described surgical technique shows a significantly less invasive approach for the implantation of an antegrade humerus nail in the case of a humerus shaft fracture with an excellent function of the affected shoulder in a short-term follow-up. This novel approach should be evaluated by means of prospective studies regarding the functional outcome to justify the establishment of this modified procedure in the long term. Other modified approaches have been depicted but are essentially differing from our described procedure with regards to the invasiveness of the vulnerable tendinous structure of the SSP respectively RC.