Surgical Interventions To Treat Humerus Shaft Fractures: An Evidenced-based Study

Objectives: There are three surgical methods and techniques available for the treatment of humeral shaft fractures in adults including open reduction and plate fixation(ORPF),intramedullary nail(IMN)fixation,and minimally invasive percutaneous osteosynthesis(MIPO),but it is presently unclear which of the different surgical options gives the best result.The aim is to assess the effects of different surgical methods for treating humeral shaft fractures in adults.Methods: We searched the Cochrane Bone,Joint and Muscle Trauma Group Specialised Register,the Cochrane Central Register of Controlled Trials,MEDLINE,EMBASE,trial registers and reference lists.Date of search: 29 April 2016.We included randomised and quasi-randomised controlled clinical studies evaluating surgical interventions for treating humeral shaft fractures in adults.Two review authors independently selected trials,assessed risk of bias and extracted data.Where appropriate,results were pooled.We will express treatment effects as risk ratios(RR)and 95% confidence intervals(CI)for dichotomous outcomes.We will express treatment effects of continuous outcomes as mean differences(MD)and 95% CI for single studies or for two or more studies with comparable outcome measures.Standardised mean differences(SMD)will be used when primary studies express the same variable using different instruments and different units of measurement.According to the statistical method described by Chaimani et al.,this Bayesian network meta-analysis was conducted using Win BUGS1.4.We used the odd ratios(ORs)with 95% CIs to calculate the dichotomous outcomes and standardized mean difference(SMD)with 95% CIs to calculate continuous outcomes.We used the funnel plot to detect the presence of small-study effects.The inconsistencies of any available direct and indirect estimates were assessed by comparing statistics for the deviance information criterion.The graphical tools in STATA12 were used to show the network diagram and funnel plot.Results: We included 19 trials involving a total of 1055 participants.Many of the included trials had methodological shortcomings and are at high risk of bias that may affect the validity of their findings.One conference abstract provided very limiteddata on study methodology.Three trials were quasi-randomised based on alternation.The most common shortcoming across trials was the lack of blinding,which is unavoidable due to the nature of surgical treatment.All included trials as at unclear risk of selective reporting bias because of the lack of trial registration details.Fourteen trials,with a total of 692 participants,compared plate with locked IMN in the treatment of humeral shaft fractures in adults.There was no clinically important difference in non-union,malunion,delayed union,iatrogenic radial nerve injury,deep infection,superficial infection,implant failure,intraoperative fracture in insert site,postoperative fracture,return to pre-injury occupation within 6 months,and restriction of elbow range of movement.Locked IMN for is associated with a significantly increased risk of adverse events including shoulder impingement,intraoperative fracture comminution,restriction shoulder range of movement,and need for removal of metalwork.Nine trials with a total of 437 participants,compared DCP with locked IMN.There was no clinically important difference in non-union,iatrogenic radial nerve injury,deep infection,superficial infection,intraoperative fracture in insert site,and implant failure.Locked IMN resulted in more shoulder impingement,intraoperative fracture comminution,restriction shoulder range of movement,and need for removal of metalwork.Two trials,with a total of 110 participants,compared LCP with locked IMN in the treatment of humeral shaft fractures.Locked IMN resulted in less Constant ROM score.There was a similar incidence of participants with adverse events.Three trials compared MIPO versus locked IMN for treating humeral shaft fractures.Locked IMN resulted in more shoulder impingement and less Constant ROM score.There was a similar incidence of participants with other results.One quasi-randomised trial compared DCP with hackethal nail and found that hackethal nail was associated with a significantly higher incidence of symptomatic hardware.One study found that DCP and Ender nail have similar treatment results for humeral shaft fractures.One study found that MIPO is equivalent to ORPF using DCP because of similar treatment results for humeral shaft fractures.One study found MIPO is equivalent to ORPF using LCP because of similar treatment results.One study with found antegrade and retrograde nail have similar treatment results.The results of network meta-analysis showed that shoulderimpingement occurred more commonly in the IMN group than with either ORPF(OR,0.13;95% CI,0.03-0.37)or MIPO fixation(OR,0.08;95% CI,0.00-0.69).Iatrogenic radial nerve injury occurred more commonly in the ORPF group than in the MIPO group(OR,11.09;95% CI,1.80-124.20).There were no significant differences among the three procedures in nonunion,delayed union,and infection.Conclusions: Locked IMN results in a significantly higher risk of shoulder complications than plate fixation.There is a significantly higher occurrence of iatrogenic radial nerve injury in the ORPF group than in the MIPO group.Hence,we concluded that the MIPO technique is the preferred treatment method for humeral shaft fractures.