Prospective randomized comparative study of antegrade and retrograde locked nailing for middle humeral shaft fracture

Background: Humeral shaft fractures can be effectively treated by either antegrade or retrograde locked intramedullary nailing, but these two methods have not been adequately compared. The present study compared the effectiveness and potential risks of these two approaches on middle humeral shaft fractures using the same locked nails. Methods: In this prospective comparative study, 92 fractures in 92 patients with middle humeral shaft fractures were randomly allocated to receive either antegrade or retrograde locked nailing by sealed-envelope technique. The clinical outcomes of fracture healing, time to healing, complications, elbow and shoulder functional recovery, and time for functional recovery were compared. Results: Retrograde nailing required significantly longer time than antegrade nailing (64.8 vs. 51.3 minutes; p < 0.01) Except for three patients lost to follow-up, the average follow-up time was 18.6 months for 44 fractures in the antegrade group and 19.8 months for 45 fractures in the retrograde group. The fracture healed in 42 fractures (95%) in the antegrade group versus 42 fractures (93%) in the retrograde group, and this difference was not significant. After exclusion of two patients with brachial plexus injury and three with head injury, functional recovery was compared between 41 patients with antegrade and 43 with retrograde nailing. For shoulder joints, the difference in the average Neer shoulder score between the two groups was statistically significant (90.8 vs. 93.5; p = 0.03). However, if four elderly patients were excluded, the average score in the antegrade group was 91.9, and the difference became insignificant (p = 0.1). Still, the antegrade group needed significantly longer time for shoulder functional recovery (16.4 vs. 8.3 weeks; p < 0.01). For elbow joints, the average postoperative Mayo elbow performance score (96.3 vs. 94.8; p = 0.16) did not differ significantly between these two approaches, but the retrograde approach needed significantly longer time for elbow functional recovery (3.9 vs. 8.8 weeks; p < 0.01). All patients, except those with associated injuries, resumed their pretrauma occupations or activities. Conclusion: With proper patient selection, antegrade and retrograde nailing have similar treatment results, including healing rate and eventual functional recovery for middle humeral fractures. It is recommended that retrograde nailing be used in patients with a wide medullary canal or preexisting shoulder problems and antegrade nailing be used in patients with young age or a small medullary canal. In critically ill patients, antegrade nailing is preferred because of shorter operation time.