Although the majority of humeral shaft fractures sustained by elderly adults with osteoporosis can be successfully managed nonoperatively,1-3 at the First Orthopedic Clinic, Medical School, Aristotle University of Thessaloniki, “G. Papanikolaou” Hospital (Thessaloniki, Greece), excellent results have been achieved with the selection of surgical treatment for different types of humeral shaft fractures in a cohort of such individuals. Over a 27-year period (1984–2011), 182 elderly adults with osteoporosis (mean age 66.5, range 57–87; 142 female (mean T-score 3.89), 40 male (mean T-score 3.13); 190 humeral shaft fractures; classification according to Arbeitsgemeinschaft für Osteosynthesefragen Association for the Study of Internal Fixation: AO 12 were treated using internal fixation. Fracture classification was performed according to AO principles.4 The indications were 73 patients with multiple fractures, 51 fractures with coexisting primary radial nerve injury, 12 Goustillo Grade I or II, eight bilateral and 50 insufficient reductions after conservative treatment; 115 fractures were located at the middle third, 32 at the upper third, and 43 at the lower third of the humeral bone; 73 were comminuted (AO 12 C and AO 12 B), 95 transverse (AO 12 A3), eight oblique (AO 12 A2) and 15 spiral (AO 12 A1). A standard anterolateral approach (Thompson and Henry) was performed, and the radial nerve was routinely identified and exposed. Fracture stabilization was mainly performed using a 4-mm self-compressing dynamic compression plate (DCP) (114 cases) and a low-contact (LC) DCP (76 cases) with 4.5-mm cortical screws. In 54 of these cases, compression lag screws were applied. A Y-shaped DCP plate was used in eight cases. Autologous iliac crest grafts were used in 30 cases because of the lack of medial cortex integrity. The addition of cement in the drill holes for extra purchase was selected intraoperatively in 12 cases. All patients received a modification of their osteoporosis treatment by addition of nasal calcitonin in doses of 100 IU per day until fracture union. Patients were asked to attend the outpatient fracture clinic at 4, 8, and 26 weeks; 1 year; and then yearly or on an as-need basis. Patient follow-up in 158 patients was 7 to 24 years (mean 13.6 years). Twenty-four patients did not complete the follow-up and were excluded from the analysis. Fracture healing interval was 3 to 6 months in 153 fractures (92.73%). Nonunion occurred in 12 fractures (7.27%), and new fixation was implemented with more-rigid plating and grafts, with favorable outcome in all cases. Postoperative infection reported in four patients was treated successfully. Cumulative results are reported in Table 1. Two patients developed neurapraxia of the ipsilateral radial nerve after surgical treatment, with nerve functionality restored in a few days without any final functional deficit. Of the 51 patients with preoperative nerve function deficit, two experienced injury to the brachial plexus (no progress noted), whereas the remaining 49 patients experienced radial nerve injury solely. No macroscopic damage of the nerve was observed in 47 patients. A splint for keeping the wrist and fingers in slight extension was suggested postoperatively, and all patients were rehabilitated for a mean of 10 weeks. Full dissection of the radial nerve was observed in one patient, and nerve suturing could not be performed. During the final follow-up, elbow range of motion was very good in 146 patients (153 fractures, 92.7%), whereas an elbow extensor deficit of 10º was recorded in four patients (four fractures, 24.2%). There was no reported motor dysfunction in the ipsilateral shoulder. Nonunion occurred in 12 fractures (7.3%). Thus, results were satisfactory in 146 cases (153 fractures, 92.7%) and unsatisfactory in 12 cases (7.3%). These patients developed mechanical failure of the plate osteosynthesis and fracture pseudarthrosis. The success percentage of functional rehabilitation reaches 92.7% and is similar to the results of other researchers who have used the same technique3, 5 in patients without osteoporosis. Surgical treatment of humeral shaft fractures based on the principles of stable internal fixation has good results in elderly adults with osteoporosis, but it should be chosen only in cases in which there is absolute indication for surgery. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Thomas Pagonis: Study concept and design, acquisition of subjects and data, analysis and interpretation of data, and preparation of manuscript and one of the operating surgeons. Kostantinos Ditisos and Georgios Petsatodis: Acquisition of subjects and data and two of the operating surgeons. Anastasios Christodoulou: Analysis of data and one of the operating surgeons. Sponsor's Role: There was no sponsor for this study.
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May 1, 2015
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