JSES - 2026-08-01 - Journal Article; Multicenter Study
Quality of surgical technique in patients with a humeral shaft fracture in the HUMMER study (HUMMER-Survey): an international survey among expert surgeons.
Den Hartog D, Nugteren LHT, Adolfsson LE, Aguado HJ, Derksen RJ, Giannoudis PV, Mahabier KC, Meylaerts SAG, Obremskey WT, O'Driscoll SW, Van Bergen SH, Wijffels MME, Verhofstad MHJ, Van Lieshout EMM, HUMMER Expert panel, HUMMER Investigators
Topics
Key Takeaway
Expert-rated good surgical technique in humeral shaft fracture fixation was associated with nonunion rates of 3% versus 26% for poor technique, and complication rates of 16% versus 35% compared to nonoperative treatment.
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Summary
This substudy of the HUMMER trial asked whether expert-rated surgical technique quality (good/sufficient vs. poor, per AO principles) in operatively treated humeral shaft fractures correlates with functional outcomes and complications. Sixteen orthopedic trauma surgeons from 7 countries independently rated radiographs of 245 operative cases. Good technique was associated with superior Constant-Murley Score (P=.003), faster DASH improvement (P=.014), better shoulder and forearm ROM, and a nonunion rate of 3% vs. 26% in poorly performed cases; however, no significant difference in overall complication rates or reoperations was found between good and poor technique groups in direct comparison.
Key Limitation
The study does not define or quantify what specific technical errors constituted 'poor' technique, preventing surgeons from identifying correctable intraoperative factors that drive the outcome differences.
Original Abstract
BACKGROUND
It is undetermined whether the quality of surgical technique in a humeral shaft fracture (reduction and fixation) affects outcomes. The aim of this study was to score the quality of surgical technique performed in patients with humeral shaft fractures and to assess whether the quality of surgical technique was associated with complications and (functional) outcomes.
METHOD
A panel of expert orthopedic trauma surgeons, experienced in upper extremity surgery, assessed the quality of surgical technique (good, sufficient, or poor) in patients who participated in the HUMMER study on plain radiographs. The surgical technique was well performed if the experts considered that it (at least) adhered to the Arbeitsgemeinschaft für Osteosynthesefragen principles. Quality was evaluated by 2 experts independently. In case they disagreed, consensus was reached after an expert panel discussion. The quality of surgical technique was examined for its association with functional outcomes, complications, and reoperations. Outcomes included Disabilities of the Arm, Shoulder and Hand score, Constant-Murley Score, pain (visual analog scale), quality of life (Short Form-36, EuroQoL-5D), and range of motion.
RESULTS
Among 245 surgically treated patients, an expert panel of 16 orthopedic trauma surgeons from 7 countries classified surgical technique of 82% of plate cases and 60% of intramedullary nailing cases as good or sufficiently performed. Good-performed surgery was associated with a better Constant-Murley Score (P treatment = .003) and faster improvement of the Disabilities of the Arm, Shoulder and Hand score (P interaction = .014) and pain level (P interaction = .034). Good-performed surgical technique showed better abduction, forward flexion, external rotation of the shoulder, and pronation-supination of the forearm (P treatment between <.001 and .038) than poorly performed surgical technique. No significant differences were found in overall complication rates, reoperations, or nonunion between good-performed surgical technique and poorly performed surgical technique. Operative treatment with well-performed surgical technique had superior functional outcomes, and fewer complication (16% vs. 35%, P < .019) and nonunion rates (3% vs. 26%, P < .001) than nonoperative treatment. These differences did not reach statistical significance for poorly performed surgeries. Analyzing the outcomes of the well-performed surgery group still resulted in the conclusion that operative treatment is superior to nonoperative treatment, and that plate fixation is superior to intramedullary nailing.
CONCLUSION
Good-performed surgical technique was associated with faster functional recovery, improvement of range of motion, and fewer complications than poor surgical technique. Although operative treatment is superior to nonoperative treatment, this is particularly demonstrated when the surgery is performed well as assessed by expert upper extremity surgeons. In cases of poorly performed surgical technique, the benefits of operative treatment over nonoperative treatment were restricted to the earliest follow-up moments.