Displaced humeral surgical neck fractures: classification and results of third-generation percutaneous intramedullary nailing

Abstract

Background: The high rates of complications and reoperations observed with the early designs of firstgeneration (unlocked) and second-generation (bent design) humeral intramedullary nail (IMNs) have discouraged their use by most surgeons. The purpose of this study was to report the results of a thirdgeneration (straight, locking, low-profile, tuberosity-based fixation) IMN, inserted through a percutaneous approach, for the treatment of displaced 2-part surgical neck fractures. Methods: We performed a retrospective review of 41 patients who underwent placement of a thirdgeneration IMN to treat a displaced 2-part surgical neck fracture (AO/OTA type 11A3). The mean age at surgery was 57 years (range, 17-84 years). After percutaneous insertion through the humeral head, the IMN was used as a reduction tool. Static locking fixation was achieved after axial fracture compression ("back-slap" hammering technique). Patients were reviewed and underwent radiography with a minimum of 1 year of follow-up; the mean follow-up period was 26 months (range, 12-53 months). Results: Preoperatively, 3 types of surgical neck fractures were observed: with valgus head deformity (Type A = 8 cases), shaft translation without head deformity (Type B = 19 cases), or with varus head deformity (Type C = 14 cases). At final follow-up, all fractures went on to union, and the mean humeral neck-shaft angle was 132°± 5°. We observed 2 malunions and 1 case of partial humeral head avascular necrosis. No cases underwent screw migration or intra-articular penetration. At last review, mean active forward elevation was 146°(range, 90°-180°) and mean external rotation was 50°(range, 20°-80°). The mean Constant-Murley score and Subjective Shoulder Value were 71 (range, 43-95) and 80% (range, 50%-100%), respectively. Conclusions: Antegrade insertion of a third-generation IMN through a percutaneous approach provides a high rate of fracture healing, excellent clinical outcome scores, and a low rate of complications. No morbidity related to the passage of the nail through the supraspinatus muscle and the cartilage was observed. The proposed A, B, and C classification allows choosing the optimal entry point for intramedullary nailing. The study was approved by the Institutional Review Board of Institut Universitaire Locomoteur et du Sport (No. 2016-02).

Locking Intramedullary Nails Versus Locking Plates in the Treatment of 2-part and 3-part Proximal Humeral Surgical Neck Fractures in Elderly Patients: A Prospective Cohort Study

“…Furthermore, there were no cases of iatrogenic rotator cuff tear due to the use of 3 rd generation intramedullary nails with an improved entry point, which is identical to Boileau's study [18]. In the plate group, a decrease in the screw holding strength decreasing and the loosening of internal xation might have been the result of the loss of reduction of the greater tuberosity.…”

“…In addition, these nails were not recommended for patients with comminuted tuberosity fractures. The newly developed 3 rd generation locking intramedullary nails (straight, multilocking, low-pro le nails allowing tuberosity-based xation) overcome these problems [18].…”

“…Treatment with locking intramedullary nails is more consistent with the principle of minimally invasive surgery [13,14]; however, this approach also has several disadvantages, such as the potential for screw displacement and iatrogenic rotator cuff tears [15,16]. The improved 3 rd generation locking intramedullary nails show better biomechanical advantages and a signi cantly reduced risk of rotator cuff tear because the nail entry point is in the muscle portion of the supraspinatus [17][18][19].…”

In vitro evaluation of the tension band suture method for proximal humerus fracture treatment

“…Open reduction and internal fixation (ORIF), using either angular or sliding stable antegrade locking intramedullary nails (IMN) or anatomically designed proximal humeral angular stable plates, is one standard surgical treatment option for proximal humeral fractures [ 7 ]. These modern implants offer high primary stability, which can allow early functional exercises and provide good to excellent results in the majority of patients, with an acceptable complication rate [ 8 , 9 ]. However, considerable issues exist after surgery, especially for the elderly due to their poor bone quality, and no single approach is considered to be the standard of care [ 5 ].…”

Cross-elements to enhance fixation in osteoporotic bone with application to proximal humeral locking plates: a biomechanical study

“…1 Surgical treatments include open reduction and internal fixation (ORIF) with proximal humeral locking plates, closed reduction and percutaneous pinning (CRPP), intramedullary nailing, hemiarthroplasty (HA), and reverse total shoulder arthroplasty (RSA). 7,22,29 Proximal humeral locking plates are the gold standard. 30 Long-term clinical results are excellent and good in approximately two-thirds of patients with moderate and poor results reported in one-third.…”