The Three-Stitch Technique for Antegrade Humerus Nailing: A Minimally Invasive Approach to Improved Functional Outcomes and Reduced Complications in Humerus Shaft Fractures Narrative review
Review Article | Vol 12 | Issue 1 | January-June 2026 | page: 15-20 | Sachin Kale, Abhilash Srivastava, Sandeep Deore, Atul Yadav, Kushdeep, Shivesh Datta
DOI: https://doi.org/10.13107/ti.2026.v12.i01.078 Submitted: 08/02/2026; Reviewed: 03/03/2026; Accepted: 15/03/2026; Published: 10/04/2026Authors: Sachin Kale [1], Abhilash Srivastava [1], Sandeep Deore [1], Atul Yadav [1], Kushdeep [1], Shivesh Datta [1]
[1] Department of Orthopaedics, Dr. D.Y. Patil Medical College, Navi Mumbai, Maharashtra, India. Address of Correspondence Dr. Abhilash Srivastava Assistant Professor, Department of Orthopaedics Dr. D.Y. Patil Medical College, Nerul, Navi Mumbai – 400706, India Email: charlie.srivastava009@gmail.comAbstract
Introduction: Humerus shaft fractures constitute a significant proportion of long bone fractures, presenting challenges in treatment. While plate osteosynthesis and intramedullary nailing are common fixation modalities, traditional approaches often carry substantial risks, including extensive surgical exposure, rotator cuff violation, and neurovascular injury. This article details the three-stitch technique for antegrade humerus nailing, a minimally invasive approach designed to mitigate these perioperative and postoperative complications, particularly for comminuted shaft humerus fractures. Methodology: This report synthesises findings from two prospective studies conducted at Dr. D.Y. Patil Medical College and Hospital, Nerul, Navi Mumbai. The first study (May 2016-May 2018) involved 20 adult patients with diaphyseal humeral shaft fractures. The second study (March 2022-March 2024) included 24 adult patients with posttraumatic comminuted humerus shaft fractures, classified up to type 12C according to AO/OTA. Both studies employed the three-stitch technique for closed antegrade intramedullary interlocking nailing. The surgical technique involved positioning patients in a “beach chair” position, using small stab incisions (approximately 1 cm) for the entry portal (anterior to the anterior rim of the acromion to preserve the rotator cuff), and for proximal and distal locking. Meticulous, blunt soft tissue dissection with a K-wire and the use of soft tissue protection sleeves were critical steps to protect neurovascular structures during drilling and screw insertion, particularly for the antero-posterior distal locking. Patients underwent early mobilisation and were followed up for functional outcomes. Results: In the initial study of 20 diaphyseal fractures, all patients showed good to excellent results at one year, with a mean union time of 8 weeks, and all fractures united by 10 weeks. Crucially, no complications such as rotator cuff violation, shoulder stiffness, or neurovascular injury were reported. For the 24 patients with comminuted fractures, 22 (96%) exhibited excellent functional outcomes and good adherence to rehabilitation. There were only two instances of delayed wound healing, and importantly, no cases of nonunion were observed. Objective assessments using the Mayo Elbow Performance Index (MEPI) and University of California at Los Angeles (UCLA) scores demonstrated significant restoration of function, with MEPI scores improving from 18 to 23 within the excellent outcome group over 6 months, and UCLA scores enhancing from 20 to 23 (exceptional to good ratings). Conclusion: The three-stitch technique for antegrade humerus nailing is a viable and advantageous alternative to conventional methods and other surgical techniques like external fixators and plate osteosynthesis, especially for comminuted injuries. It consistently yields favourable outcomes, significantly reduces complications (including rotator cuff violation and neurovascular injury), and improves cosmetic results. Keywords: Antegrade humerus nailing, three-stitch technique, humerus diaphyseal fractures, MEPI score, UCLA score.References
1. Rose SH, Melton LJ, Morrey BF, Ilstrup DM, Riggs BL. Epidemiological features of humeral fractures. Clin Orthop. 1982;168:24–30. 2. Sarmiento A, Waddellle JP, Latta LL. Diaphyseal humeral fractures: treatment options. Instr Course Lect. 2002;51:257-69. 3. Zuckerman JD, Koval KJ. Fractures of the shaft of the humerus. In: Rockwood and Green Fractures in Adults. 4th ed. Philadelphia, PA: JB Lippincott; 1996. p. 1025-51. 4. Farragos AF, Schemitsch EH, McKee MD. Complications of intramedullary nailing for fractures of the humeral shaft: a review. J Orthop Trauma. 1999;13:258-67. doi:10.1302/0301-620X.90B1.19215. 5. Lögters TT, Wild M, Windolf J, Linhart W. Axillary nerve palsy after retrograde humeral nailing: clinical confirmation of an anatomical fear. Arch Orthop Trauma Surg. 2008;128:1431-5. 6. Cheng HR, Lin J. Prospective randomized comparative study of antegrade and retrograde locked nailing for middle humeral shaft fracture. J Trauma. 2008;65:94-102. 7. Sarmiento A, Kinman P, Galvin E. Functional bracing of fractures of the shaft of the humerus. JBJS (Am). 1977;59-A:596-601. 8. McCormack RG, Brien D, Buckley RE, McKee MD, Powell J, Schemitsch EH. Fixation of fractures of the shaft of the humerus by dynamic compression plate or intramedullary nail. A prospective randomised trial. JBJS (Br). 2000;82-B:336-9. 9. Garnavos C. Diaphyseal humeral fractures and intramedullary nailing: can we improve outcomes. Indian J Orthop. 2011 May;45(3):208-13. 10. Stern PJ, Mattingly DA, Pomeroy DL, Zenni EJ Jr, Kreig JK. Intramedullary fixation of humeral shaft fractures. J Bone Joint Surg Am. 1984;66:639-46. 11. Evans PD, Conboy VB, Evans EJ. The Seidel humeral locking nail: an anatomical study of the complications from locking screws. Injury. 1993;24:175-6. 12. Garnavos C. Intramedullary nailing for humeral shaft fractures: the misunderstood poor relative. Curr Orthop. 2001;15:68-75. 13. Kolonja A, Vecsei N, Mousani M, Marlovits S, Machold W, Vecsei V. Radial nerve injury after anterograde and retrograde locked intramedullary nailing of humerus. A clinical and anatomical study. Osteo Trauma Care. 2002;10:192-6. 14. Barati H, Afzal S. Successful treatment of a multifocal comminuted open fracture of the humerus with severe soft tissue defect: a case report. J Med Case Rep. 2023;17:261. 15. Kumar M, Khatri JP, Singh CM. High-velocity gunshot fractures of humerus: results of primary plate osteosynthesis. Indian J Orthop. 2021;55:714-22. 16. Savvidou OD, Zampeli F, Koutsouradis P, Chloros GD, Kaspiris A, Sourmelis S, et al. Complications of open reduction and internal fixation of distal humerus fractures. EFORT Open Rev. 2018;3:558-67. 17. Shrestha SK, Devkota P, Mainali LP. Minimally invasive plate osteosynthesis in the treatment of isolated ulnar bone fractures. Malays Orthop J. 2012;6:16-9. 18. Bong MR, Kummer FJ, Koval KJ, Egol KA. Intramedullary nailing of the lower extremity: biomechanics and biology. J Am Acad Orthop Surg. 2007;15:97-106. 19. Meriqui RN, Masuda RY, Utino AY, Pierami R, Matsunaga FT, Tamaoki MJS. Intra- and inter-observer agreement in the AO and Garnavos Systems for diaphyseal humerus fracture. Acta Ortop Bras. 2017;25:159-61. 20. Kumar R, Singh P, Chaudhary LJ, Singh S. Humeral shaft fracture management, a prospective study; nailing or plating. J Clin Orthop Trauma. 2012;3:37-42. 21. Hudson PW, Gulbrandsen MT, Liu JN, Ponce BA, Phipatanakul WP. Percutaneous intramedullary nailing of complex humeral shaft fractures: a retrospective case series. Cureus. 2022;14:e32999. 22. Stannard JP, Harris HW, McGwin G Jr, Volgas DA, Alonso JE. Intramedullary nailing of humeral shaft fractures with a locking flexible nail. J Bone Joint Surg Am. 2003;85:2103-10. 23. Scaglione M, Casella F, Ipponi E, Agretti F, Polloni S, Giuntoli M, et al. Multifocal humeral fractures: clinical results, functional outcomes and flowchart of surgical treatment. Strategies Trauma Limb Reconstr. 2022;17:81-7.| How to Cite this article: Kale S, Srivastava A, Deore S, Yadav A, Kushdeep, Datta S | The Three-Stitch Technique for Antegrade Humerus Nailing: A Minimally Invasive Approach to Improved Functional Outcomes and Reduced Complications in Humerus Shaft Fractures Narrative review | January-June 2026; 12(1): 15-20 | https://doi.org/10.13107/ti.2026.v12.i01.78 |
