Open plate fixation versus nailing for humeral shaft fractures: a meta-analysis and systematic review of randomised clinical trials and observational studies

Beeres, Frank J.P.; Veelen, Nicole M. van; Houwert, Roderick M.; Link, Bjoern-Christian; Heng, Marilyn; Knobe, Matthias; Groenwold, Rolf H H; Babst, Reto; Wall, Bryan J. M. van de

doi:10.1007/s00068-021-01728-7

Cited by 21 publications

(18 citation statements)

References 44 publications

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“…Regarding different surgical exposures, the risk for nonunion was not significantly different between anterior/ anterolateral and posterior approaches to the humeral shaft. Furthermore, we observed a non-significantly different non-union risk when comparing IM with ORIF, being in line with previous meta-analyses (5,59,60,61). This contradicts common knowledge that open reduction leads to significant exposure of the fracture site, which could potentially -together with required periosteal stripping to allow anatomical reduction -limit blood supply and thus impair fracture healing.…”

Section: :2supporting

confidence: 83%

“…In fact, a nearly two-fold increased risk for postoperative infection was observed for ORIF in comparison to IM. Our observations are in line with a recent metanalysis by Beeres et al (59), albeit contradicting findings in previous ones (5,60,61). Notably, the type of surgical exposure was non-significantly associated with altered risk for post-operative infection in our meta-analysis, although one should bear in mind that the two studies included had been retrospective in nature.…”

Section: :2supporting

confidence: 70%

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Complications in humeral shaft fractures – non-union, iatrogenic radial nerve palsy, and postoperative infection: a systematic review and meta-analysis

et al. 2022

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The aim of this systematic review and meta-analysis was to assess risk for iatrogenic radial nerve palsy (iRNP), non-union, and post-operative infection in humeral shaft fractures. A PubMed search including original articles comparing different treatments for humeral shaft fractures published since January 2000 was performed. Random effect models with relative risks (RR) and 95% CIs were calculated for treatment groups and outcomes. Of the 841 results, 43 studies were included in the meta-analysis (11 level II, 5 level III, 27 level IV). Twenty-seven compared intramedullary nailing (IM) with ORIF, nine conservative with operative treatment, four ORIF with minimally invasive plate osteosynthesis (MIPO), and three anterior/anterolateral with posterior approach. iRNP risk was higher for ORIF vs IM (18 studies; RR: 1.80; P = 0.047), ORIF vs MIPO (4 studies; RR: 5.60; P = 0.011), and posterior vs anterior/anterolateral approach (3 studies; RR: 2.68; P = 0.005). Non-union risk was lower for operative vs conservative therapy (six studies; RR: 0.37; P < 0.001), but not significantly different between ORIF and IM (21 studies; RR: 1.00; P = 0.997), or approaches (two studies; RR: 0.36; P = 0.369). Post-operative infection risk was higher for ORIF vs IM (14 studies; RR: 1.84; P = 0.004) but not different between approaches (2 studies; RR: 0.95; P = 0.960). Surgery appears to be the method of choice when aiming to secure bony union, albeit risk for iRNP has to be considered, particularly in case of ORIF vs IM or MIPO, and posterior approach. Due to the limited number of randomised studies, evidence on the best treatment option remains moderate, though.

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Section: :2supporting

confidence: 83%

Section: :2supporting

confidence: 70%

Complications in humeral shaft fractures – non-union, iatrogenic radial nerve palsy, and postoperative infection: a systematic review and meta-analysis

et al. 2022

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“…In addition, despite our results on fracture union, reoperation, or adverse events suggesting no differences, some meta-analyses synthesizing both RCT and non-randomized studies demonstrated the superiority of intramedullary nail over plate in treating either proximal humeral fractures (Shi et al, 2019) [19] or humeral shaft fractures (Beeres et al, 2021;Wen et al, 2019) [6,8] based on outcomes, such as intraoperative blood loss, operative time, postoperative fracture healing time, and postoperative infections.…”

Section: еNd Of Tablementioning

confidence: 61%

Результати Лікування Переломів Плечової Кістки При Їх Різній Локалізації (Огляд)

Zazirnyi¹,

Savych²,

Levytskyi³

2022

TRAUMA

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The choice of treatment (open reduction and internal fixation) for a humeral fracture with a plate versus an intramedullary nail is highly debated. We compared outcomes (fracture union, reoperation, and adverse events) of intramedullary nailing and plate fixation in patients with proximal humeral, humeral shaft, and distal humeral fractures. No significant differences were found between intramedullary nailing and plate fixation for fracture union, reoperation, or adverse events in patients with proximal humeral or humeral shaft fractures. There is a scarcity of evidence comparing intramedullary nailing and plating for distal humeral fractures. No recommendations can be given from current evidence. Surgeons may have to continue to use discretion based on their personal preference, experience as well as patient’s characteristics and fracture features before more high-quality evidence is available.

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“…1 nonoperative management using a humeral brace remains the default approach for many patients with isolated, closed humeral shaft fractures, 2 partly because the functional benefits associated with operative fixation appear to be transitory with no significant advantage over bracing at one year post-injury. 3,4 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).…”

Section: Introductionmentioning

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).…”

Section: Introductionmentioning

confidence: 99%

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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Open plate fixation versus nailing for humeral shaft fractures: a meta-analysis and systematic review of randomised clinical trials and observational studies

Cited by 21 publications

References 44 publications

Complications in humeral shaft fractures – non-union, iatrogenic radial nerve palsy, and postoperative infection: a systematic review and meta-analysis

Complications in humeral shaft fractures – non-union, iatrogenic radial nerve palsy, and postoperative infection: a systematic review and meta-analysis

Результати Лікування Переломів Плечової Кістки При Їх Різній Локалізації (Огляд)

Routine fixation of humeral shaft fractures is cost-effective

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