Factors Associated with Patient-Reported Outcomes Following a Humeral Shaft Fracture: Nonunion Results in a Poorer Outcome Despite Union after Surgical Fixation

Oliver, William W.; Searle, Henry Kelvin Christopher; Molyneux, Samuel G; White, Timothy O.; Clement, Nicholas D.; Duckworth, Andrew D.

doi:10.1097/bot.0000000000002315

Cited by 10 publications

(10 citation statements)

References 61 publications

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“…Complete details regarding humeral shaft fracture management in our centre have been published previously. 9 union outcome was determined through review of medical records and radiographs. union was determined using established criteria, and was defined clinically as reduced/absent pain at the fracture site, and radiologically as bridging callus across all fracture cortices prior to clinic discharge.…”

Section: Methodsmentioning

confidence: 99%

“…This study formed part of a larger audit of 291 humeral shaft fractures managed in the study centre. 9 Of this larger study, as well as patients initially managed operatively (n = 64), patients who developed a recalcitrant nonunion following nonunion surgery (n = 4) and patients who declined operative management of their nonunion (n = 6) were excluded. Those with a delayed union following nonoperative management, defined as nonunion at six months with spontaneous union thereafter, without further surgical intervention (n = 2), were also excluded.…”

Section: Methodsmentioning

confidence: 99%

“…Complete details regarding humeral shaft fracture management in our centre have been published previously. 9 …”

Section: Methodsmentioning

confidence: 99%

“…recalcitrant nonunion rate negligible); initial operative management involving plate and screw fixation would generate fracture union (i.e. nonunion rate after initial fixation negligible); longer-term HRQoL (according to the EQ-5D-3L) would be equivalent after initial nonoperative and initial operative management, provided union had been achieved; 3 , 4 , 8 , 9 and any difference in longer-term HRQoL (according to the EQ-5D-3L) resulting from nonunion after nonoperative management would be present throughout the preceding five years.…”

Section: Methodsmentioning

confidence: 99%

“…One of the principal differences between these two management strategies is the rate of nonunion, which is reported to be less than 3% after open reduction and compression plating, 5 and 15% to 17% after nonoperative management. 6 , 7 Given the potential impact of humeral shaft nonunion upon longer-term patient-reported outcomes, 8 , 9 one of the most compelling arguments for offering fixation to more patients may lie in mitigating the detrimental effects of this complication upon patient function and health-related quality of life (HRQoL). Health economic analyses have been recommended as essential in rationalizing humeral shaft fracture management.…”

Section: Introductionmentioning

confidence: 99%

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Routine fixation of humeral shaft fractures is cost-effective

et al. 2022

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Aims The primary aim was to estimate the cost-effectiveness of routine operative fixation for all patients with humeral shaft fractures. The secondary aim was to estimate the health economic implications of using a Radiographic Union Score for HUmeral fractures (RUSHU) of < 8 to facilitate selective fixation for patients at risk of nonunion. Methods From 2008 to 2017, 215 patients (mean age 57 yrs (17 to 18), 61% female (n = 130/215)) with a nonoperatively managed humeral diaphyseal fracture were retrospectively identified. Union was achieved in 77% (n = 165/215) after initial nonoperative management, with 23% (n = 50/215) uniting after surgery for nonunion. The EuroQol five-dimension three-level health index (EQ-5D-3L) was obtained via postal survey. Multiple regression was used to determine the independent influence of patient, injury, and management factors upon the EQ-5D-3L. An incremental cost-effectiveness ratio (ICER) of < £20,000 per quality-adjusted life-year (QALY) gained was considered cost-effective. Results At a mean of 5.4 yrs (1.2 to 11.0), the mean EQ-5D-3L was 0.736 (95% confidence interval (CI) 0.697 to 0.775). Adjusted analysis demonstrated the EQ-5D-3L was inferior among patients who united after nonunion surgery (β = 0.103; p = 0.032). Offering routine fixation to all patients to reduce the rate of nonunion would be associated with increased treatment costs of £1,542/patient, but would confer a potential EQ-5D-3L benefit of 0.120/patient over the study period. The ICER of routine fixation was £12,850/QALY gained. Selective fixation based on a RUSHU < 8 at six weeks post-injury would be associated with reduced treatment costs (£415/patient), and would confer a potential EQ-5D-3L benefit of 0.335 per ‘at-risk patient’. Conclusion Routine fixation for patients with humeral shaft fractures to reduce the rate of nonunion observed after nonoperative management appears to be a cost-effective intervention at five years post-injury. Selective fixation for patients at risk of nonunion based on their RUSHU may confer even greater cost-effectiveness, given the potential savings and improvement in health-related quality of life. Cite this article: Bone Jt Open 2022;3(7):566–572.

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Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

“…Complete details regarding humeral shaft fracture management in our centre have been published previously. 9 …”

Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Routine fixation of humeral shaft fractures is cost-effective

et al. 2022

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Ultrasound assessment of humeral shaft nonunion risk: a feasibility and proof of concept study

Oliver,

Nicholson,

Bell

et al. 2023

Eur J Orthop Surg Traumatol

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Purpose To determine the feasibility and reliability of ultrasound in the assessment of humeral shaft fracture healing and estimate the accuracy of 6wk ultrasound in predicting nonunion. Methods Twelve adults with a non-operatively managed humeral shaft fracture were prospectively recruited and underwent ultrasound scanning at 6wks and 12wks post-injury. Seven blinded observers evaluated sonographic callus appearance to determine intra- and inter-observer reliability. Nonunion prediction accuracy was estimated by comparing images for patients that united (n = 10/12) with those that developed a nonunion (n = 2/12). Results The mean scan duration was 8 min (5–12) and all patients tolerated the procedure. At 6wks and 12wks, sonographic callus (SC) was present in 11 patients (10 united, one nonunion) and sonographic bridging callus (SBC) in seven (all united). Ultrasound had substantial intra- (weighted kappa: 6wk 0.75; 12wk 0.75) and inter-observer reliability (intraclass correlation coefficient: 6wk 0.60; 12wk 0.76). At 6wks, the absence of SC demonstrated sensitivity 50%, specificity 100%, positive predictive value (PPV) 100% and negative predictive value (NPV) 91% in nonunion prediction (overall accuracy 92%). The absence of SBC demonstrated sensitivity 100%, specificity 70%, PPV 40% and NPV 100% in nonunion prediction (overall accuracy 75%). Of three patients at risk of nonunion (Radiographic Union Score for HUmeral fractures < 8), one had SBC on 6wk ultrasound (that subsequently united) and the others had non-bridging/absent SC (both developed nonunion). Conclusions Ultrasound assessment of humeral shaft fracture healing was feasible, reliable and may predict nonunion. Ultrasound could be useful in defining nonunion risk among patients with reduced radiographic callus formation.

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