DOI: 10.1016/j.jcot.2019.02.007
A recent study published in the Journal of Clinical Orthopaedics and Trauma highlights a novel approach for the treatment of proximal humerus fractures—a condition often associated with significant morbidity, particularly in the elderly population. The research focused on intramedullary nail fixation via the Neviaser portal, a technique that has not been extensively reported in the literature so far.
The Study at a Glance
A team led by Dr. Yoshitaka Tanaka of the Department of Orthopaedic Hand and Microsurgery Center at Osaka Ekisaikai Hospital assessed the feasibility and outcomes of this minimally invasive technique. The retrospective study involved four female patients with an average age of 78.8 years who sustained 2-part proximal humerus fractures and underwent the intramedullary nail fixation procedure using the Neviaser portal. Over a mean follow-up period of 12 months, all patients achieved bone union without severe complications, such as deep wound infections or neurological deficits.
Clinical Outcomes
The study reported satisfactory clinical outcomes, with mean shoulder flexion, abduction, and external rotation at the final follow-up being 123.5°, 118°, and 36°, respectively. Pain, assessed using the mean visual analog scale (VAS) score, was at 21/100 at the final follow-up, indicating a relatively low pain level post-operation.
Complications to Consider
Nevertheless, the investigation did reveal some implant-related complications in two patients. One patient experienced a proximal nail protrusion that led to secondary subacromial impingement, whereas another faced a postoperative fixation failure due to an inability to insert the end-cap from the Neviaser portal.
Advancements in Proximal Humeral Fractures Treatment
Proximal humeral fractures, most common among the elderly due to osteoporosis and fall risk, have long posed challenges to orthopedic surgeons. The delicate balance between stable fixation and preserving the vascularity of bone fragments often dictates the success of the treatment.
Classically, treatment options have ranged from conservative management with slings and physiotherapy to more invasive procedures such as open reduction and internal fixation with plates and screws. However, intramedullary nailing has gained traction as it may offer less invasive fixation with comparable, if not superior, outcomes.
Introducing the Neviaser Portal: An Anatomical Advantage
The Neviaser portal is traditionally known within the context of shoulder arthroscopy, described by Neviaser in 1987. Its utility in intramedullary nailing of proximal humerus fractures is an innovative adaptation. The portal’s location allows for a more direct approach to the top of the humeral head, potentially reducing the damage to surrounding soft tissues.
Discussion and Perspectives
The study by Tanaka and colleagues adds to the pool of evidence supporting intramedullary nailing for proximal humeral fractures. Previous studies have often focused on traditional antegrade or retrograde methods of nailing, with varying results. This novel approach through the Neviaser portal may offer an alternative path that minimizes complications associated with other methods, given the direct visualization and application it allows.
Some earlier studies have noted issues with proximal humeral nailing such as nail protrusion, nonunion, and rotator cuff damage. The employment of the Neviaser portal has the potential to mitigate such issues due to its anatomical proximity to the humeral head and the reduced need for extensive soft tissue dissection.
Limitations and Future Directions
It is important to note that the study had limitations, such as the small sample size and the retrospective nature of the analysis, which might introduce a degree of selection bias. Furthermore, there was no control group for comparison with traditional treatment methods.
Future research efforts should include a larger cohort and ideally be designed as a randomized controlled trial to accurately validate the technique’s efficacy and comparability to other established methods. Also, the development and refinement of specific instruments tailored for the Neviaser portal could further optimize the procedure and minimize complications related to hardware.
Conclusion
In summary, the innovative use of intramedullary nail fixation via the Neviaser portal for proximal humerus fractures offers another option for surgeons aiming to optimize patient outcomes. The recent study suggests a successful bone union without severe complications, a promising aspect for a demographic often plagued by these injuries.
While this study provides an encouraging outlook on this procedure, continued innovation, along with more extensive clinical trials, is needed to affirm its position within the orthopedic armamentarium.
References:
1. Murray I.R., Amin A.K., White T.O., “Proximal humeral fractures: current concepts in classification, treatment and outcomes,” J Bone Joint Surg Br, 2011.
2. Bernard J., Charalambides C., Aderinto J., “Early failure of intramedullary nailing for proximal humeral fractures,” Injury, 2000.
3. Lin J., Hou S.M., “Locked-nail treatment of humeral surgical neck nonunion,” J Trauma, 2003.
4. Stedtfeld H.W., Mittlmeier T., “Fixation of proximal humeral fractures with an intramedullary nail: tips and tricks,” Eur J Trauma Emerg Surg, 2007.
5. Knierim A.E., Bollinger A.J., Wirth M.A., “Short, locked humeral nailing via Neviaser portal: an anatomic study,” J Orthop Trauma, 2013.
Keywords
1. Proximal Humerus Fracture Treatment
2. Intramedullary Nail Fixation
3. Neviaser Portal Technique
4. Minimally Invasive Humeral Nailing
5. Orthopedic Innovations in Shoulder Surgery
