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Posterior minimally invasive plate osteosynthesis (MIPO) of distal third humeral shaft fractures with segmental isolation of the radial nerve
+ Models
CHIMAI-969; No. of Pages 6
Available online at
ScienceDirect www.sciencedirect.com Chirurgie de la main xxx (2015) xxx–xxx
Original article
Posterior minimally invasive plate osteosynthesis (MIPO) of distal third humeral shaft fractures with segmental isolation of the radial nerve Ostéosynthèse mini-invasive par plaque (MIPO) postérieure du tiers distal de la diaphyse humérale avec exposition segmentaire du nerf radial G.L. Gallucci *, J.G. Boretto, V.A. Alfie, A. Donndorff, P. De Carli Servicio de Ortopedia y Traumatología, Hospital Italiano de Buenos Aires, Perón 4190, CC1199ACK CABA Buenos Aires, Argentina Received 11 June 2014; received in revised form 17 June 2015; accepted 30 June 2015
Abstract The aim of this study was to evaluate the clinical, radiographic, and functional outcomes of a cohort of patients with distal third humeral shaft fractures treated using a posterior minimally invasive plate osteosynthesis (MIPO) technique. Twenty-one patients were retrospectively evaluated, 13 men and 8 women with an average age of 37 years. The surgery was performed through two posterior incisions away from the fracture site. The radial nerve was identified and protected. The fracture was fixed with a narrow 4.5/5.0 mm locking compression plate. After an average follow-up of 22 months, flexion–extension of the elbow was 1388 78, with a range of motion of 1318. Shoulder motion was 1608 in forward flexion, 598 in external rotation, and internal rotation was to the spinous process of 9th thoracic vertebra. Pain severity was 0.5 on the VAS. The DASH score was 9. Average Constant score was 84. MEPI was 97. Fracture union was obtained in all patients. One patient developed transient postoperative radial nerve palsy. These results demonstrate that the posterior MIPO technique is a reliable option for treating distal third humeral shaft fractures. Level of evidence. – 4. # 2015 Published by Elsevier Masson SAS. Keywords: MIPO technique; Humerus; Fracture; Minimally invasive osteosynthesis
Résumé Le but de cette étude était d’évaluer les résultats cliniques, radiologiques et fonctionnels d’une cohorte de patients souffrant d’une fracture du tiers distal de la diaphyse humérale, traitée par une technique d’ostéosynthèse mini-invasive postérieure par plaque (MIPO). Dix-neuf patients ont été évalués rétrospectivement, il s’agissait de 13 hommes et 8 femmes avec un âge moyen de 37 ans. L’opération était réalisée par deux petits abords postérieurs distants du site de la fracture. Le nerf radial était individualisé et repéré par l’abord proximal. La fracture était fixée par une plaque verrouillée de 4,5/5,0 mm. Après un recul moyen de 22 mois, les patients avaient obtenu en moyen une mobilité du coude en flexion– extension de 1318 (1388 78). La mobilité de l’épaule a été en moyen de 1608 d’élévation antérieure, 598 de rotation externe et le pouce atteignait le processus épineux de la 9e vertèbre thoracique en rotation interne. La douleur a été de 0,5/10 sur l’échelle visuelle analogique. Le score DASH moyen était de 9. Le score de Constant moyen était de 84. Le score MEPI moyen était de 97. Un patient a développé une paralysie postopératoire transitoire du nerf radial. Toutes les fractures ont consolidé. Les résultats montrent que la technique de MIPO postérieure est une option fiable pour le traitement de fractures du tiers distal de la diaphyse humérale. Niveau de preuve. – 4. # 2015 Publié par Elsevier Masson SAS. Mots clés : Fracture ; Humérus ; Ostéosynthèse mini-invasive
* Corresponding author. E-mail addresses: [email protected] (G.L. Gallucci), [email protected] (J.G. Boretto), [email protected] (V.A. Alfie), [email protected] (A. Donndorff), [email protected] (P. De Carli). http://dx.doi.org/10.1016/j.main.2015.06.007 1297-3203/# 2015 Published by Elsevier Masson SAS.
Please cite this article in press as: Gallucci GL, et al. Posterior minimally invasive plate osteosynthesis (MIPO) of distal third humeral shaft fractures with segmental isolation of the radial nerve. Chir Main (2015), http://dx.doi.org/10.1016/j.main.2015.06.007
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1. Introduction Fractures of the humeral shaft are common, accounting for 3–5% of all fractures [1]. One of the major problems with conventional open plate fixation is that extensive surgical exposure requires significant soft tissue stripping and disrupts the periosteal circulation, resulting in a relatively high rate of nonunion (up to 5.8%) [1]. The rate of postoperative nerve damage has been reported to fall between 5% [2] and 17% [1]. Minimally invasive plate osteosynthesis (MIPO) techniques were developed to achieve biologic fixation while minimizing the likelihood of the complications associated with open reduction. Multiple reports have been published on this technique [3–8], including use of the posterior MIPO technique for treating fractures in the middle and distal thirds of the humeral shaft [9]. In a middle-third humeral shaft fracture, the radial nerve does not need to be identified when using an anterior approach; however, it must always be identified when using a posterior approach. But when the fracture is near the olecranon or coronoid fossa, the anterior approach is not feasible. Because of this, we tested the hypothesis that distal third humeral shaft fractures can be adequately treated with a posterior MIPO approach. The purpose of this retrospective study was to evaluate the functional and radiographic outcomes of a cohort of patients with distal third humeral shaft fractures treated with a posterior MIPO technique. 2. Material and methods From July 2007 to December 2014, 45 cases of fractures involving the distal third of the humeral shaft were operated in our department. Twenty-five of them were treated with a
posterior MIPO procedure and 20 were treated with an open technique. Because this was a retrospective study, no standard parameters were used to decide the technique selected. Included in this study were patients with distal third humeral shaft fractures treated with a posterior MIPO technique, who had a follow-up of more than 1 year. No patients were lost for follow-up. In all, 21 patients were retrospectively evaluated; the remaining four were excluded because less than 1-year followup was available. Thirteen were men and eight were women, with an average age of 37 years (range: 23–73) at the time of the fracture. The right arm was injured in 12 cases and the left in nine. The dominant arm was affected in 12 cases. Preoperative anterior–posterior and lateral radiographs of the humerus were obtained in all patients. Data on the AO/OTA classification, mechanism of injury, additional injuries, and time between trauma and surgery were included in Table 1. All patients stated that they had normal shoulder and elbow range of motion (ROM) before the injury. The surgical technique has been described previously [9]. A proximal incision approximately 5 cm in length was made in the posterior aspect of the arm, 10 cm distal to the acromial angle. The interval between the long and lateral heads of the triceps was developed to expose the radial nerve, which was meticulously protected (Fig. 1). The nerve was released proximally and distally with atraumatic dissection to allow the plate to slide deep to the nerve. A distal incision was made on the posterior aspect of the arm—lateral to the olecranon fossa—that was also about 5 cm long (Fig. 2). The triceps aponeurosis was opened and the bone was exposed. The plate (a narrow 4.5/5.0 mm locking compression plate) was placed on the lateral column, between the olecranon fossa and the lateral edge of the bone. The fracture was indirectly reduced manually, keeping traction on the arm to prevent the bone from
Table 1 Patients’ demographics. Patient
Age
Gender
Affected side
Dominant side
AO
Mechanism of injury
Associated injuries
Time between trauma and surgery (days)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
28 27 37 23 42 43 23 24 73 30 34 28 54 34 24 47 63 45 51 24 34
M F M M M M M M F M F M M F F M F M F M F
R L R R R L R R R L L L R L L R R L L R R
Yes No Yes Yes Yes No Yes Yes Yes No No No Yes No No Yes Yes No Yes No Yes
B1 B3 B1 B3 B1 B3 B3 C3 (open) B3 B3 B3 B1 B3 B1 B1 B3 B3 B3 B1 B3 B1
Fall Fall Fall Fall Car accident Car accident Fall Bicycle accident Fall Fall Fall Car accident Fall Motorcycle accident Car accident Fall Fall Fall Fall Car accident Fall
No No No No Contralateral humeral fracture Acetabular fracture No Open tibia fracture No No No No No No No No No No Femur fracture No No
4 6 4 1 3 5 10 3 5 11 6 5 6 3 5 7 4 12 3 4 9
Please cite this article in press as: Gallucci GL, et al. Posterior minimally invasive plate osteosynthesis (MIPO) of distal third humeral shaft fractures with segmental isolation of the radial nerve. Chir Main (2015), http://dx.doi.org/10.1016/j.main.2015.06.007
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Nonunion was defined as lack of progression in radiographic healing over a three-month period [8]. The humeral axial alignment was assessed at the final evaluation. Complications were recorded, as were any additional procedures performed to resolve them. 3. Results
Fig. 1. The radial nerve is meticulously protected in the proximal incision.
shortening. The plate was inserted along the posterior aspect of the humerus from distal to proximal. The plate had to be slid just over the bone to remain deep to the nerve. Care was taken to avoid damaging the radial nerve. The distal end of the plate was positioned lateral to the olecranon fossa. When the length of the humerus was roughly restored and the plate was in the correct position, the proximal and distal portions of the plate were fixed to the distal and proximal main fragments, respectively. Once the procedure was finished, fluoroscopy was used to check fragment alignment and confirm that no screw had penetrated the olecranon fossa. For the present study, all patients were reassessed and given a clinical and radiological evaluation. For the objective clinical evaluation, elbow and shoulder motion were measured with a goniometer. For the subjective part, pain was measured using the Visual Analog Scale (VAS) on a range from 0 to 10, and disability was measured using the Disabilities of the Arm, Shoulder and Hand (DASH) Scale on a range from 0 to 100. Isolated shoulder function was assessed using the Constant scoring system. Isolated elbow function was assessed by means of the Mayo Elbow Performance Index (MEPI). Radiological evaluation included anterior–posterior (AP) and lateral views of the arm. Union was defined as the absence of pain and the presence of bridging calluses in three of the four cortices seen on the AP and lateral radiographic views.
Fig. 2. Proximal and distal incisions.
The average follow-up was 22 months (range: 12–50). Average elbow motion was 1388 of flexion (range: 125– 1458) and 78 of extension (range: 0–308). The average total range of flexion–extension was 1318 (range: 110–1458), which was 95% of the range of motion on the contralateral side. Average shoulder active motion was 1608 in forward flexion (range: 135–1808), which was 94% of that on the contralateral side; 598 in external rotation (range: 35–908), which was 89% of that on the contralateral side, and internal rotation was to the spinous process of the 9th thoracic vertebra (range: L1–T6), as compared to a contralateral internal rotation of the spinous process of the 7th thoracic vertebra (Table 2). As measured on the VAS, the average postoperative pain level was 0.5 (range: 0–2). The mean postoperative DASH score was 9 (range: 0–21). The average Constant score was 84 (range: 70–95), corresponding to 14 excellent and 7 good results. The average MEPI was 97 (range: 90–100), with all scores in the excellent range. Fracture union was obtained in all patients (Figs. 3 and 4). The postoperative radiological assessment revealed a completely normal alignment of the humerus in the coronal plane in 5 cases, while varus deformity was apparent in 16 cases with an average of 48 varus (range: 2–118). One patient (No. 2) developed postoperative radial nerve palsy, which resolved six weeks after surgery. Ten months later, the implant was removed from this patient due to pain. One plate was removed in another patient due to discomfort. One of the four patients, who had not been included initially because less than 1-year follow-up was available, developed radial nerve palsy with complete recovery at 11 weeks postoperative. 4. Discussion The MIPO technique has gained popularity for treating humeral shaft fractures. However, the risk of radial nerve injury makes it a potentially dangerous surgical technique. Most authors state that the radial nerve does not need to be isolated and protected in the anterior MIPO technique [5–7]. In a cadaveric study, the average distance from the radial nerve to the part of the plate that is nearest the nerve is 3.2 mm when the forearm is supinated [10]. On the other hand, protection of the nerve is essential in the posterior MIPO technique, and the surgeon must be very careful when sliding the plate into place, just anterior to the nerve. In 2014, Balam and Zahrany [11] reported the results of 37 patients treated with the MIPO technique through a posterior approach. They included patients with different types of fractures (B and C in the AO classification). They reported 2 cases of radial palsy and described experiencing intraoperative
Please cite this article in press as: Gallucci GL, et al. Posterior minimally invasive plate osteosynthesis (MIPO) of distal third humeral shaft fractures with segmental isolation of the radial nerve. Chir Main (2015), http://dx.doi.org/10.1016/j.main.2015.06.007
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Table 2 Results for all patients after an average follow-up of 22 months. Patient
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
Shoulder motion (8) injured/contralateral
Elbow motion (8) injured/contralateral
Elevation
External rotation
Internal rotation
Flexion
Extension
170/175 175/175 170/170 180/180 170/175 170/180 175/175 150/175 160/170 170/170 170/175 165/170 150/165 140/170 165/170 150/170 145/160 135/160 160/170 145/160 150/160
70/75 65/70 60/60 75/75 70/75 85/85 90/100 45/60 45/55 80/85 50/50 60/65 55/70 45/55 45/45 55/50 65/70 40/60 35/45 50/60 60/70
T6/T4 T8/T6 T7/T7 T9/T7 T11/T9 T8/T8 T10/T10 T12/T12 L1/T10 T6/T6 T8/T8 T6/T5 T7/T5 T8/T7 T10/T10 T7/T6 L1/T9 T7/T6 T8/T8 T6/T6 L1/T8
145/145 140/140 140/145 140/145 145/140 140/140 145/145 140/140 135/140 145/140 140/140 140/140 135/145 135/140 130/140 125/135 130/135 130/140 130/140 125/135 135/135
0/0 10/0 0/0 10/0 0/0 20/0 0/10 10/0 10/0 10/0 30/0 0/0 10/0 0/0 10/0 15/0 0/0 15/0 0/0 15/0 0/0
Pain on VAS
DASH score
Constant score
MEPI
Angulation (8) varus–valgus
Follow-up (months)
0 0 0 0 0 2 0 2 1 0 0 0 1 0 1 2 0 0 1 2 0
0 1 2 0 0 16 0 21 15 11 5 11 13 16 5 13 11 21 7 18 9
95 90 86 90 95 70 95 70 75 82 72 84 72 86 92 86 78 76 94 86 90
100 100 100 100 100 90 100 90 90 100 100 100 90 100 100 90 100 100 100 90 100
08 08 78 varus 118 varus 38 varus 08 48 varus 108 varus 38 varus 28 varus 08 48 varus 28 varus 08 28 varus 48 varus 38 varus 38 varus 78 varus 68 varus 28 varus
18 21 48 24 50 35 26 24 13 19 12 15 19 21 18 13 15 23 12 14 15
DASH: Disabilities of the Arm, Shoulder and Hand; L: lumbar vertebra; MEPI: Mayo Elbow Performance Index; T: thoracic vertebra; VAS: Visual Analog Scale.
difficulties when preparing the tunnel for the plate and trying to avoid placing tension on the nerve during plate insertion. Due to the required nerve dissection, more cases of radial palsy are to be expected relative to the anterior approach. However, radial nerve palsy has also been described in anterior approach as a transient complication (Table 3).
Our patients presented with fractures in the distal third of the humerus, in some cases extending quite near the olecranon fossa. For this reason, some implants had to be placed almost over the edge of the humeral condyle to ensure three locking screws could be placed in the distal humerus. This positioning can cause local discomfort, and consequently, a high rate of implant removal. Distal placement of the implant in fractures located in the distal third of the humerus is one advantage of the posterior approach over the anterior one. Some authors argue that, when Table 3 Summary of published results for MIPO of distal third humerus fractures.
Fig. 3. Anterior–posterior (A) and lateral (B) preoperative radiographs.
Authors
Number of patients
Approach
Union
Complications
Zhiquan et al. [6] Kobayashi et al. [8] Concha et al. [12] Shetty et al. [13] López-Arévalo et al. [14] Malhan et al. [15] Shin et al. [16]
13 14 35 32 86
Anterior Anterior Anterior Anterior Anterior
13 14 32 32 83
42 21
Anterior Anterior
42 20
Lee et al. [17] Lian et al. [18]
29 24
Anterior Anterior
28 23
Balam and Zahrany [11]
37
Posterior
37
No No 2 infections no 3 RNP 3 nonunions 1 RNP 1 nonunion 2 conversions to open 2 RNP 1 RNP 1 nonunion 1 implant failure 2 RNP
RNP: radial nerve palsy.
Please cite this article in press as: Gallucci GL, et al. Posterior minimally invasive plate osteosynthesis (MIPO) of distal third humeral shaft fractures with segmental isolation of the radial nerve. Chir Main (2015), http://dx.doi.org/10.1016/j.main.2015.06.007
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Fig. 4. Anterior–posterior (A) and lateral (B) final radiographs.
the distance between the fracture line and the upper edge of the olecranon fossa is less than 6 cm, there is not enough space to place three screws in the distal fragment, screws that are needed to achieve stability [8]. As a result, MIPO through the anterior approach becomes impossible. In such cases, conventional plating is recommended. In contrast, we believe that patients with this type of distal humeral shaft fracture are the best candidates for MIPO through the posterior approach, even in cases where the fracture line involves the upper aspect of the olecranon fossa. This is the main difference between the posterior MIPO approach and the other MIPO approaches. However, the posterior MIPO technique is contraindicated in distal humeral fractures with fracture lines distal to the olecranon fossa. In this series, because fracture reduction was achieved and maintained by indirect reduction (manual manipulation), it was not easy to achieve a completely normal varus–valgus alignment. However, completely normal alignment is not necessary for good arm function, as the outcomes of more conservative treatments for such fractures have shown (Figs. 5 and 6). Although union was achieved in all 21 patients, 16 cases had varus angulation, yet no functional deficits of the affected arms were observed. Fig. 5. Anterior–posterior radiograph of a distal third shaft fracture.
Fig. 6. Anterior–posterior (A) and lateral (B) radiographs of the healed fracture.
Please cite this article in press as: Gallucci GL, et al. Posterior minimally invasive plate osteosynthesis (MIPO) of distal third humeral shaft fractures with segmental isolation of the radial nerve. Chir Main (2015), http://dx.doi.org/10.1016/j.main.2015.06.007
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5. Conclusion The results of this study demonstrate that the posterior MIPO technique is a reliable option for treating distal shaft humeral fractures. The radial nerve must be identified and protected in all cases. The posterior MIPO technique is particularly useful when the fracture line is near the olecranon fossa because anterior MIPO is not feasible in this scenario.
[8]
[9]
[10]
Disclosure of interest [11]
The authors declare that they have no conflicts of interest concerning this article.
[12]
References
[13]
[1] Paris H, Tropiano P, Clouet d’Orval B, Chaudet H, Poitout DG. Fractures of the shaft of the humerus: systematic plate fixation. Anatomic and functional results in 156 cases and a review of the literature. Rev Chir Orthop Reparatrice Appar Mot 2000;86:346–59. [2] Volgas DA, Stannard JP, Alonso JE. Nonunions of the humerus. Clin Orthop Relat Res 2004;419:46–50. [3] Farouk O, Krettek C, Miclau T, Schandelmaier P, Guy P, Tscherne H. Minimally invasive plate osteosynthesis and vascularity: preliminary results of a cadaver injection study. Injury )1997;(Suppl. 1):A7–12. [4] Krettek C, Gerich T, Miclau T. A minimal invasive medial approach for proximal tibia fractures. Injury 2001;32(Suppl. 1)SA4–13. [5] Wang ZH, Xiang M, Xie J, Tang HC, Chen H, Liu X. Treatment of humerus shaft fractures using minimally invasive percutaneous plate osteosynthesis through anterior approach. Zhongguo Gu Shang 2009;22(9)681–3. [6] Zhiquan A, Bingfang Z, Yeming W, Chi Z, Peiyan H. Minimally invasive plating osteosynthesis (MIPO) of middle and distal third humeral shaft fractures. J Orthop Trauma 2007;21:628–33. [7] Apivatthakakul T, Arpornchayanon O, Bavornratanavech S. Minimally invasive plate osteosynthesis (MIPO) of the humeral shaft fracture: is it
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possible? A cadaveric study and preliminary report. Injury 2005;36: 530–8. Kobayashi M, Watanabe Y, Matsushita T. Early full range of shoulder and elbow motion is possible after minimally invasive plate osteosynthesis for humeral shaft fractures. J Orthop Trauma 2010;24:212–6. Gallucci GL, Boretto JG, Vujovich A, Alfie V, Donndorff A, De Carli P. Posterior minimally invasive plate osteosynthesis for humeral shaft fractures. Tech Hand Up Extrem Surg 2014;18(1)25–30. Apivatthakakul T, Patiyasikan S, Luevitoonvechkit S. Danger zone for locking screw placement in minimally invasive plate osteosynthesis (MIPO) of humeral shaft fractures: a cadaveric study. Int Orthop 2010;41:169–72. Balam KM, Zahrany AS. Posterior percutaneous plating of the humerus. Eur J Orthop Surg Traumatol 2014;24:763–8. Concha JM, Sandoval A, Streubel PN. Minimally invasive plate osteosynthesis for humeral shaft fractures: are results reproducible? Int Orthop 2010;34:1297–305. Shetty MS, Kumar MA, Sujay K, Kini AR, Kanthi KG. Minimally invasive plate osteosynthesis for humerus diaphyseal fractures. Indian J Orthop 2011;45:520–6. López-Arévalo R, de Llano-Temboury AQ, Serrano-Montilla J, de LlanoGiménez EQ, Fernández-Medina JM. Treatment of diaphyseal humeral fractures with the minimally invasive percutaneous plate (MIPPO) technique: a cadaveric study and clinical results. J Orthop Trauma 2011;25: 294–9. Malhan S, Thomas S, Srivastav S, Agarwal S, Mittal V, et al. Minimally invasive plate osteosynthesis using a locking compression plate for diaphyseal humeral fractures. J Orthop Surg (Hong Kong) 2012;20: 292–6. Shin SJ, Sohn HS, Do NH. Minimally invasive plate osteosynthesis of humeral shaft fracture: a technique to aid fracture reduction and minimize complications. J Orthop Trauma 2012;26:585–90. Lee HJ, Oh CW, Oh JK, Apivatthakakul T, Kim JW, et al. Minimally invasive plate osteosynthesis for humeral shaft fracture: a reproducible technique with the assistance of an external fixator. Arch Orthop Trauma Surg 2013;133:649–57. Lian K, Wang L, Lin D, Chen Z. Minimally invasive plating osteosynthesis for mid-distal third humeral shaft fractures. Orthopedics 2013;36: 1025–32.
Please cite this article in press as: Gallucci GL, et al. Posterior minimally invasive plate osteosynthesis (MIPO) of distal third humeral shaft fractures with segmental isolation of the radial nerve. Chir Main (2015), http://dx.doi.org/10.1016/j.main.2015.06.007
CHIMAI-969; No. of Pages 6
Available online at
ScienceDirect www.sciencedirect.com Chirurgie de la main xxx (2015) xxx–xxx
Original article
Posterior minimally invasive plate osteosynthesis (MIPO) of distal third humeral shaft fractures with segmental isolation of the radial nerve Ostéosynthèse mini-invasive par plaque (MIPO) postérieure du tiers distal de la diaphyse humérale avec exposition segmentaire du nerf radial G.L. Gallucci *, J.G. Boretto, V.A. Alfie, A. Donndorff, P. De Carli Servicio de Ortopedia y Traumatología, Hospital Italiano de Buenos Aires, Perón 4190, CC1199ACK CABA Buenos Aires, Argentina Received 11 June 2014; received in revised form 17 June 2015; accepted 30 June 2015
Abstract The aim of this study was to evaluate the clinical, radiographic, and functional outcomes of a cohort of patients with distal third humeral shaft fractures treated using a posterior minimally invasive plate osteosynthesis (MIPO) technique. Twenty-one patients were retrospectively evaluated, 13 men and 8 women with an average age of 37 years. The surgery was performed through two posterior incisions away from the fracture site. The radial nerve was identified and protected. The fracture was fixed with a narrow 4.5/5.0 mm locking compression plate. After an average follow-up of 22 months, flexion–extension of the elbow was 1388 78, with a range of motion of 1318. Shoulder motion was 1608 in forward flexion, 598 in external rotation, and internal rotation was to the spinous process of 9th thoracic vertebra. Pain severity was 0.5 on the VAS. The DASH score was 9. Average Constant score was 84. MEPI was 97. Fracture union was obtained in all patients. One patient developed transient postoperative radial nerve palsy. These results demonstrate that the posterior MIPO technique is a reliable option for treating distal third humeral shaft fractures. Level of evidence. – 4. # 2015 Published by Elsevier Masson SAS. Keywords: MIPO technique; Humerus; Fracture; Minimally invasive osteosynthesis
Résumé Le but de cette étude était d’évaluer les résultats cliniques, radiologiques et fonctionnels d’une cohorte de patients souffrant d’une fracture du tiers distal de la diaphyse humérale, traitée par une technique d’ostéosynthèse mini-invasive postérieure par plaque (MIPO). Dix-neuf patients ont été évalués rétrospectivement, il s’agissait de 13 hommes et 8 femmes avec un âge moyen de 37 ans. L’opération était réalisée par deux petits abords postérieurs distants du site de la fracture. Le nerf radial était individualisé et repéré par l’abord proximal. La fracture était fixée par une plaque verrouillée de 4,5/5,0 mm. Après un recul moyen de 22 mois, les patients avaient obtenu en moyen une mobilité du coude en flexion– extension de 1318 (1388 78). La mobilité de l’épaule a été en moyen de 1608 d’élévation antérieure, 598 de rotation externe et le pouce atteignait le processus épineux de la 9e vertèbre thoracique en rotation interne. La douleur a été de 0,5/10 sur l’échelle visuelle analogique. Le score DASH moyen était de 9. Le score de Constant moyen était de 84. Le score MEPI moyen était de 97. Un patient a développé une paralysie postopératoire transitoire du nerf radial. Toutes les fractures ont consolidé. Les résultats montrent que la technique de MIPO postérieure est une option fiable pour le traitement de fractures du tiers distal de la diaphyse humérale. Niveau de preuve. – 4. # 2015 Publié par Elsevier Masson SAS. Mots clés : Fracture ; Humérus ; Ostéosynthèse mini-invasive
* Corresponding author. E-mail addresses: [email protected] (G.L. Gallucci), [email protected] (J.G. Boretto), [email protected] (V.A. Alfie), [email protected] (A. Donndorff), [email protected] (P. De Carli). http://dx.doi.org/10.1016/j.main.2015.06.007 1297-3203/# 2015 Published by Elsevier Masson SAS.
Please cite this article in press as: Gallucci GL, et al. Posterior minimally invasive plate osteosynthesis (MIPO) of distal third humeral shaft fractures with segmental isolation of the radial nerve. Chir Main (2015), http://dx.doi.org/10.1016/j.main.2015.06.007
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CHIMAI-969; No. of Pages 6
G.L. Gallucci et al. / Chirurgie de la main xxx (2015) xxx–xxx
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1. Introduction Fractures of the humeral shaft are common, accounting for 3–5% of all fractures [1]. One of the major problems with conventional open plate fixation is that extensive surgical exposure requires significant soft tissue stripping and disrupts the periosteal circulation, resulting in a relatively high rate of nonunion (up to 5.8%) [1]. The rate of postoperative nerve damage has been reported to fall between 5% [2] and 17% [1]. Minimally invasive plate osteosynthesis (MIPO) techniques were developed to achieve biologic fixation while minimizing the likelihood of the complications associated with open reduction. Multiple reports have been published on this technique [3–8], including use of the posterior MIPO technique for treating fractures in the middle and distal thirds of the humeral shaft [9]. In a middle-third humeral shaft fracture, the radial nerve does not need to be identified when using an anterior approach; however, it must always be identified when using a posterior approach. But when the fracture is near the olecranon or coronoid fossa, the anterior approach is not feasible. Because of this, we tested the hypothesis that distal third humeral shaft fractures can be adequately treated with a posterior MIPO approach. The purpose of this retrospective study was to evaluate the functional and radiographic outcomes of a cohort of patients with distal third humeral shaft fractures treated with a posterior MIPO technique. 2. Material and methods From July 2007 to December 2014, 45 cases of fractures involving the distal third of the humeral shaft were operated in our department. Twenty-five of them were treated with a
posterior MIPO procedure and 20 were treated with an open technique. Because this was a retrospective study, no standard parameters were used to decide the technique selected. Included in this study were patients with distal third humeral shaft fractures treated with a posterior MIPO technique, who had a follow-up of more than 1 year. No patients were lost for follow-up. In all, 21 patients were retrospectively evaluated; the remaining four were excluded because less than 1-year followup was available. Thirteen were men and eight were women, with an average age of 37 years (range: 23–73) at the time of the fracture. The right arm was injured in 12 cases and the left in nine. The dominant arm was affected in 12 cases. Preoperative anterior–posterior and lateral radiographs of the humerus were obtained in all patients. Data on the AO/OTA classification, mechanism of injury, additional injuries, and time between trauma and surgery were included in Table 1. All patients stated that they had normal shoulder and elbow range of motion (ROM) before the injury. The surgical technique has been described previously [9]. A proximal incision approximately 5 cm in length was made in the posterior aspect of the arm, 10 cm distal to the acromial angle. The interval between the long and lateral heads of the triceps was developed to expose the radial nerve, which was meticulously protected (Fig. 1). The nerve was released proximally and distally with atraumatic dissection to allow the plate to slide deep to the nerve. A distal incision was made on the posterior aspect of the arm—lateral to the olecranon fossa—that was also about 5 cm long (Fig. 2). The triceps aponeurosis was opened and the bone was exposed. The plate (a narrow 4.5/5.0 mm locking compression plate) was placed on the lateral column, between the olecranon fossa and the lateral edge of the bone. The fracture was indirectly reduced manually, keeping traction on the arm to prevent the bone from
Table 1 Patients’ demographics. Patient
Age
Gender
Affected side
Dominant side
AO
Mechanism of injury
Associated injuries
Time between trauma and surgery (days)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
28 27 37 23 42 43 23 24 73 30 34 28 54 34 24 47 63 45 51 24 34
M F M M M M M M F M F M M F F M F M F M F
R L R R R L R R R L L L R L L R R L L R R
Yes No Yes Yes Yes No Yes Yes Yes No No No Yes No No Yes Yes No Yes No Yes
B1 B3 B1 B3 B1 B3 B3 C3 (open) B3 B3 B3 B1 B3 B1 B1 B3 B3 B3 B1 B3 B1
Fall Fall Fall Fall Car accident Car accident Fall Bicycle accident Fall Fall Fall Car accident Fall Motorcycle accident Car accident Fall Fall Fall Fall Car accident Fall
No No No No Contralateral humeral fracture Acetabular fracture No Open tibia fracture No No No No No No No No No No Femur fracture No No
4 6 4 1 3 5 10 3 5 11 6 5 6 3 5 7 4 12 3 4 9
Please cite this article in press as: Gallucci GL, et al. Posterior minimally invasive plate osteosynthesis (MIPO) of distal third humeral shaft fractures with segmental isolation of the radial nerve. Chir Main (2015), http://dx.doi.org/10.1016/j.main.2015.06.007
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Nonunion was defined as lack of progression in radiographic healing over a three-month period [8]. The humeral axial alignment was assessed at the final evaluation. Complications were recorded, as were any additional procedures performed to resolve them. 3. Results
Fig. 1. The radial nerve is meticulously protected in the proximal incision.
shortening. The plate was inserted along the posterior aspect of the humerus from distal to proximal. The plate had to be slid just over the bone to remain deep to the nerve. Care was taken to avoid damaging the radial nerve. The distal end of the plate was positioned lateral to the olecranon fossa. When the length of the humerus was roughly restored and the plate was in the correct position, the proximal and distal portions of the plate were fixed to the distal and proximal main fragments, respectively. Once the procedure was finished, fluoroscopy was used to check fragment alignment and confirm that no screw had penetrated the olecranon fossa. For the present study, all patients were reassessed and given a clinical and radiological evaluation. For the objective clinical evaluation, elbow and shoulder motion were measured with a goniometer. For the subjective part, pain was measured using the Visual Analog Scale (VAS) on a range from 0 to 10, and disability was measured using the Disabilities of the Arm, Shoulder and Hand (DASH) Scale on a range from 0 to 100. Isolated shoulder function was assessed using the Constant scoring system. Isolated elbow function was assessed by means of the Mayo Elbow Performance Index (MEPI). Radiological evaluation included anterior–posterior (AP) and lateral views of the arm. Union was defined as the absence of pain and the presence of bridging calluses in three of the four cortices seen on the AP and lateral radiographic views.
Fig. 2. Proximal and distal incisions.
The average follow-up was 22 months (range: 12–50). Average elbow motion was 1388 of flexion (range: 125– 1458) and 78 of extension (range: 0–308). The average total range of flexion–extension was 1318 (range: 110–1458), which was 95% of the range of motion on the contralateral side. Average shoulder active motion was 1608 in forward flexion (range: 135–1808), which was 94% of that on the contralateral side; 598 in external rotation (range: 35–908), which was 89% of that on the contralateral side, and internal rotation was to the spinous process of the 9th thoracic vertebra (range: L1–T6), as compared to a contralateral internal rotation of the spinous process of the 7th thoracic vertebra (Table 2). As measured on the VAS, the average postoperative pain level was 0.5 (range: 0–2). The mean postoperative DASH score was 9 (range: 0–21). The average Constant score was 84 (range: 70–95), corresponding to 14 excellent and 7 good results. The average MEPI was 97 (range: 90–100), with all scores in the excellent range. Fracture union was obtained in all patients (Figs. 3 and 4). The postoperative radiological assessment revealed a completely normal alignment of the humerus in the coronal plane in 5 cases, while varus deformity was apparent in 16 cases with an average of 48 varus (range: 2–118). One patient (No. 2) developed postoperative radial nerve palsy, which resolved six weeks after surgery. Ten months later, the implant was removed from this patient due to pain. One plate was removed in another patient due to discomfort. One of the four patients, who had not been included initially because less than 1-year follow-up was available, developed radial nerve palsy with complete recovery at 11 weeks postoperative. 4. Discussion The MIPO technique has gained popularity for treating humeral shaft fractures. However, the risk of radial nerve injury makes it a potentially dangerous surgical technique. Most authors state that the radial nerve does not need to be isolated and protected in the anterior MIPO technique [5–7]. In a cadaveric study, the average distance from the radial nerve to the part of the plate that is nearest the nerve is 3.2 mm when the forearm is supinated [10]. On the other hand, protection of the nerve is essential in the posterior MIPO technique, and the surgeon must be very careful when sliding the plate into place, just anterior to the nerve. In 2014, Balam and Zahrany [11] reported the results of 37 patients treated with the MIPO technique through a posterior approach. They included patients with different types of fractures (B and C in the AO classification). They reported 2 cases of radial palsy and described experiencing intraoperative
Please cite this article in press as: Gallucci GL, et al. Posterior minimally invasive plate osteosynthesis (MIPO) of distal third humeral shaft fractures with segmental isolation of the radial nerve. Chir Main (2015), http://dx.doi.org/10.1016/j.main.2015.06.007
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Table 2 Results for all patients after an average follow-up of 22 months. Patient
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
Shoulder motion (8) injured/contralateral
Elbow motion (8) injured/contralateral
Elevation
External rotation
Internal rotation
Flexion
Extension
170/175 175/175 170/170 180/180 170/175 170/180 175/175 150/175 160/170 170/170 170/175 165/170 150/165 140/170 165/170 150/170 145/160 135/160 160/170 145/160 150/160
70/75 65/70 60/60 75/75 70/75 85/85 90/100 45/60 45/55 80/85 50/50 60/65 55/70 45/55 45/45 55/50 65/70 40/60 35/45 50/60 60/70
T6/T4 T8/T6 T7/T7 T9/T7 T11/T9 T8/T8 T10/T10 T12/T12 L1/T10 T6/T6 T8/T8 T6/T5 T7/T5 T8/T7 T10/T10 T7/T6 L1/T9 T7/T6 T8/T8 T6/T6 L1/T8
145/145 140/140 140/145 140/145 145/140 140/140 145/145 140/140 135/140 145/140 140/140 140/140 135/145 135/140 130/140 125/135 130/135 130/140 130/140 125/135 135/135
0/0 10/0 0/0 10/0 0/0 20/0 0/10 10/0 10/0 10/0 30/0 0/0 10/0 0/0 10/0 15/0 0/0 15/0 0/0 15/0 0/0
Pain on VAS
DASH score
Constant score
MEPI
Angulation (8) varus–valgus
Follow-up (months)
0 0 0 0 0 2 0 2 1 0 0 0 1 0 1 2 0 0 1 2 0
0 1 2 0 0 16 0 21 15 11 5 11 13 16 5 13 11 21 7 18 9
95 90 86 90 95 70 95 70 75 82 72 84 72 86 92 86 78 76 94 86 90
100 100 100 100 100 90 100 90 90 100 100 100 90 100 100 90 100 100 100 90 100
08 08 78 varus 118 varus 38 varus 08 48 varus 108 varus 38 varus 28 varus 08 48 varus 28 varus 08 28 varus 48 varus 38 varus 38 varus 78 varus 68 varus 28 varus
18 21 48 24 50 35 26 24 13 19 12 15 19 21 18 13 15 23 12 14 15
DASH: Disabilities of the Arm, Shoulder and Hand; L: lumbar vertebra; MEPI: Mayo Elbow Performance Index; T: thoracic vertebra; VAS: Visual Analog Scale.
difficulties when preparing the tunnel for the plate and trying to avoid placing tension on the nerve during plate insertion. Due to the required nerve dissection, more cases of radial palsy are to be expected relative to the anterior approach. However, radial nerve palsy has also been described in anterior approach as a transient complication (Table 3).
Our patients presented with fractures in the distal third of the humerus, in some cases extending quite near the olecranon fossa. For this reason, some implants had to be placed almost over the edge of the humeral condyle to ensure three locking screws could be placed in the distal humerus. This positioning can cause local discomfort, and consequently, a high rate of implant removal. Distal placement of the implant in fractures located in the distal third of the humerus is one advantage of the posterior approach over the anterior one. Some authors argue that, when Table 3 Summary of published results for MIPO of distal third humerus fractures.
Fig. 3. Anterior–posterior (A) and lateral (B) preoperative radiographs.
Authors
Number of patients
Approach
Union
Complications
Zhiquan et al. [6] Kobayashi et al. [8] Concha et al. [12] Shetty et al. [13] López-Arévalo et al. [14] Malhan et al. [15] Shin et al. [16]
13 14 35 32 86
Anterior Anterior Anterior Anterior Anterior
13 14 32 32 83
42 21
Anterior Anterior
42 20
Lee et al. [17] Lian et al. [18]
29 24
Anterior Anterior
28 23
Balam and Zahrany [11]
37
Posterior
37
No No 2 infections no 3 RNP 3 nonunions 1 RNP 1 nonunion 2 conversions to open 2 RNP 1 RNP 1 nonunion 1 implant failure 2 RNP
RNP: radial nerve palsy.
Please cite this article in press as: Gallucci GL, et al. Posterior minimally invasive plate osteosynthesis (MIPO) of distal third humeral shaft fractures with segmental isolation of the radial nerve. Chir Main (2015), http://dx.doi.org/10.1016/j.main.2015.06.007
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Fig. 4. Anterior–posterior (A) and lateral (B) final radiographs.
the distance between the fracture line and the upper edge of the olecranon fossa is less than 6 cm, there is not enough space to place three screws in the distal fragment, screws that are needed to achieve stability [8]. As a result, MIPO through the anterior approach becomes impossible. In such cases, conventional plating is recommended. In contrast, we believe that patients with this type of distal humeral shaft fracture are the best candidates for MIPO through the posterior approach, even in cases where the fracture line involves the upper aspect of the olecranon fossa. This is the main difference between the posterior MIPO approach and the other MIPO approaches. However, the posterior MIPO technique is contraindicated in distal humeral fractures with fracture lines distal to the olecranon fossa. In this series, because fracture reduction was achieved and maintained by indirect reduction (manual manipulation), it was not easy to achieve a completely normal varus–valgus alignment. However, completely normal alignment is not necessary for good arm function, as the outcomes of more conservative treatments for such fractures have shown (Figs. 5 and 6). Although union was achieved in all 21 patients, 16 cases had varus angulation, yet no functional deficits of the affected arms were observed. Fig. 5. Anterior–posterior radiograph of a distal third shaft fracture.
Fig. 6. Anterior–posterior (A) and lateral (B) radiographs of the healed fracture.
Please cite this article in press as: Gallucci GL, et al. Posterior minimally invasive plate osteosynthesis (MIPO) of distal third humeral shaft fractures with segmental isolation of the radial nerve. Chir Main (2015), http://dx.doi.org/10.1016/j.main.2015.06.007
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5. Conclusion The results of this study demonstrate that the posterior MIPO technique is a reliable option for treating distal shaft humeral fractures. The radial nerve must be identified and protected in all cases. The posterior MIPO technique is particularly useful when the fracture line is near the olecranon fossa because anterior MIPO is not feasible in this scenario.
[8]
[9]
[10]
Disclosure of interest [11]
The authors declare that they have no conflicts of interest concerning this article.
[12]
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Please cite this article in press as: Gallucci GL, et al. Posterior minimally invasive plate osteosynthesis (MIPO) of distal third humeral shaft fractures with segmental isolation of the radial nerve. Chir Main (2015), http://dx.doi.org/10.1016/j.main.2015.06.007