The Biomechanical Effect of Torsion on Humeral Shaft Repair Techniques for Completed Pathological Fractures

In the presence of a tumor defect, completed humeral shaft fractures continue to be a major surgical challenge since there is no “gold standard” treatment. This is due, in part, to the fact that only one prior biomechanical study exists on the matter, but which only compared 2 repair methods. The current authors measured the humeral torsional performance of 5 fixation constructs for completed pathological fractures. In 40 artificial humeri, a 2-cm hemi-cylindrical cortical defect with a transverse fracture was created in the lateral cortex. Specimens were divided into 5 different constructs and tested in torsion. Construct A was a broad 10-hole 4.5-mm dynamic compression plate (DCP). Construct B was the same as A except that the screw holes and the tumor defect were filled with bone cement and the screws were inserted into soft cement. Construct C was the same as A except that the canal and tumor defect were filled with bone cement and the screws were inserted into dry cement. Construct D was a locked intramedullary nail inserted in the antegrade direction. Construct E was the same as D except that bone cement filled the defect. For torsional stiffness, construct C (4.45 ± 0.20 Nm/deg) was not different than B or E (p > 0.16), but was higher than A and D (p < 0.001). For failure torque, construct C achieved a higher failure torque (69.65 ± 5.35 Nm) than other groups (p < 0.001). For the failure angle, there were no differences between plating constructs A to C (p ≥ 0.11), except for B versus C (p < 0.05), or between nailing groups D versus E (p = 0.97), however, all plating groups had smaller failure angles than both nailing groups (p < 0.05). For failure energy, construct C (17.97 ± 3.59 J) had a higher value than other groups (p < 0.005), except for A (p = 0.057). Torsional failure always occurred in the bone in the classic “spiral” pattern. Construct C provided the highest torsional stability for a completed pathological humeral shaft fracture.