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For: Kumar S, Shanmugam N, Kumar S, Ramanusan K. Comparison between operative and non operative treatment of fracture shaft of humerus: an outcome analysis. ACTA ACUST UNITED AC 2017. [DOI: 10.18203/issn.2455-4510.intjresorthop20171537] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]

For:	Kumar S, Shanmugam N, Kumar S, Ramanusan K. Comparison between operative and non operative treatment of fracture shaft of humerus: an outcome analysis. ACTA ACUST UNITED AC 2017. [DOI: 10.18203/issn.2455-4510.intjresorthop20171537] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]

Number

Cited by Other Article(s)

Oliver WM, Bell KR, Carter TH, Graham C, White TO, Clement ND, Duckworth AD, Molyneux SG. Operative vs Nonoperative Management of Fractures of the Humeral Diaphysis: The Humeral Shaft Fracture Fixation Randomized Clinical Trial. JAMA Surg 2025:2832025. [PMID: 40136271 PMCID: PMC11947967 DOI: 10.1001/jamasurg.2025.0301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2024] [Accepted: 01/26/2025] [Indexed: 03/27/2025]

Abstract

Importance

Humeral shaft fractures are routinely managed nonoperatively, but this approach is potentially associated with higher nonunion rates and inferior functional outcomes when compared with operative fixation.

Objective

To assess whether there is any difference in outcome between surgery and functional bracing for adults with an isolated, closed humeral shaft fracture.

Design, Setting, and Participants

This prospective, superiority, parallel-group randomized clinical trial was conducted between September 2018 and October 2023 and took place at an academic major trauma center in the United Kingdom. Patients were reviewed at 2 and 6 weeks and 3, 6, and 12 months postintervention. Patients included 70 adults with an isolated, closed humeral shaft fracture. Exclusion criteria included absolute indications for surgery, pathological/periprosthetic fractures, multiple traumas, significant frailty, and inability to comply with follow-up. Data were analyzed from November 2023 through January 2024.

Interventions

Open reduction and plate fixation (n = 36) or functional bracing (n = 34). Seven patients did not receive their assigned treatment (operative, 5; nonoperative, 2).

Main Outcomes and Measures

The primary outcome measure was the Disabilities of the Arm, Shoulder, and Hand score (DASH) at 3 months postintervention. Secondary outcomes included health-related quality of life (EuroQol 5-Dimension [EQ-5D]/health visual analog scale [EQ-VAS] and Short Form [SF]-12 Physical Component Summary [PCS]/Mental Component Summary [MCS] scores), pain, shoulder/elbow range of motion, and complications. Intention-to-treat analyses were used.

Results

The study included 70 patients (mean [SD] age, 49 [17.1] years; 38 female [54%] and 32 male [46%]). At 3 months, 66 patients (94%) had completed follow-up. The operative group had a significantly better DASH score (difference, 15.0; P = .01). Surgery was also associated with a superior DASH score at 6 weeks (difference, 14.7; P = .01), but not at 6 months (P = .10) or at 12 months (P = .78). Surgery was further associated with a higher EQ-5D score (6 weeks: difference, 0.126, P = .03), EQ-VAS score (6 months: difference, 7; P = .04), and SF-12 MCS score (6 weeks: difference, 9.3; P = .001; 3 months: difference, 6.9; P = .01; and 6 months: difference, 7.1; P = .01). Brace-related dermatitis was significantly more common in the nonoperative group (18% vs operative 3%; P = .05). There were 8 nonunions (11%; operative 6% vs nonoperative 18%, P = .14).

Conclusions and Relevance

For patients with a humeral shaft fracture in this study, surgery conferred early functional advantages over bracing. However, these benefits should be considered in the context of potential operative risks and the absence of any difference in outcomes at 1 year.

Trial Registration

ClinicalTrials.gov Identifier: NCT03689335.

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Guo J, Ma H. Different treatment for humeral shaft fractures: A network meta-analysis. Medicine (Baltimore) 2025;104:e40948. [PMID: 39833039 PMCID: PMC11749579 DOI: 10.1097/md.0000000000040948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2024] [Accepted: 11/25/2024] [Indexed: 01/22/2025] Open

Abstract

BACKGROUND

The main treatment methods for humeral shaft fractures include minimally invasive plate osteosynthesis (MIPO), intramedullary nailing (IMN), open reduction and internal fixation (ORF), and non-operative treatment (NonOP). However, the optimal treatment plan remains unclear. This article utilizes a network meta-analysis to compare the therapeutic effects of MIPO, IMN, ORF, and NonOP for the treatment of humeral shaft fractures.

METHODS

We searched electronic databases, including the PubMed, Embase, The Cochrane Library, and the Web of Science Databases, from inception to June 1, 2024. The "Risk of Bias Assessment" tool recommended by the Cochrane Collaboration was used to evaluate the quality of the included literature. RevMan 5.4 software and R software with gemtc package was used for the graphical representation and data analysis of the network meta-analysis.

RESULTS

A total of 23 randomized controlled trials were finally included. The results indicated that the efficacy of disabilities of the arm, shoulder and hand score was significantly higher in the MIPO group than in the open reduction and internal fixation (ORIF) group (weighted mean difference = 4.7, 95% confidence intervals, 1.8-7.75). IMN was associated with a decrease of the constant-Murley scores score than NonOP (weighted mean difference = -4.4, 95% confidence intervals, -8.7 to -0.068). IMN, MIPO, and ORIF was associated with a decrease of the fracture healing time than NonOP. The difference for nonunion rate and iatrogenic radial nerve injuries between any 2 groups was not statistically significant (P > .05).

CONCLUSION

The evidence from current meta-analysis indicated that ORIF provides the best recovery effects for upper limb and shoulder joint function after the treatment of humeral shaft fractures, with the drawback of a relatively higher incidence of complications. To ensure the reliability of this study's results, more high-quality randomized controlled trials are needed in the future to verify these findings.

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Li Y, Luo Y, Peng J, Fan J, Long XT. Clinical effect of operative vs nonoperative treatment on humeral shaft fractures: Systematic review and meta-analysis of clinical trials. World J Orthop 2024;15:783-795. [PMID: 39165869 PMCID: PMC11331324 DOI: 10.5312/wjo.v15.i8.783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Revised: 06/05/2024] [Accepted: 07/11/2024] [Indexed: 08/13/2024] Open

Abstract

BACKGROUND

Whether operation is superior to non-operation for humeral shaft fracture remains debatable. We hypothesized that operation could decrease the nonunion and reintervention rates and increase the functional outcomes.

AIM

To compare the clinical efficacy between operative and nonoperative approaches for humeral shaft fractures.

METHODS

We searched the PubMed, Web of Science, ScienceDirect, and Cochrane databases from 1990 to December 2023 for clinical trials and cohort studies comparing the effects of operative and conservative methods on humeral shaft fractures. Two investigators independently extracted data from the eligible studies, and the other two assessed the methodological quality of each study. The quality of the included studies was assessed using the Cochrane risk bias or Newcastle-Ottawa Scale. The nonunion, reintervention and the overall complications and functional scores were pooled and analyzed using Review Manager software (version 5.3).

RESULTS

A total of four randomized control trials and 13 cohort studies were included, with 1285 and 1346 patients in the operative and nonoperative groups, respectively. Patients in the operative group were treated with a plate or nail, whereas those in the conservative group were managed with splint or functional bracing. Four studies were assessed as having a high risk of bias, and the other 13 were of a low risk of bias according to the Newcastle-Ottawa Scale or Cochrane risk bias tool. The operative group had a significantly decreased rate of nonunion [odds ratio (OR) 0.30; 95%CI: 0.23 to 0.40), reintervention (OR: 0.33; 95%CI: 0.24 to 0.47), and overall complications (OR: 0.62; 95%CI: 0.49 to 0.78)]. The pooled effect of the Disabilities of Arm, Shoulder, and Hand score showed a significant difference at 3 [mean difference (MD) -8.26; 95%CI: -13.60 to -2.92], 6 (MD: -6.72; 95%CI: -11.34 to -2.10), and 12 months (MD: -2.55; 95%CI: -4.36 to -0.74). The pooled effect of Visual Analog Scale scores and the Constant-Murley score did not significantly differ between the two groups.

CONCLUSION

This systematic review and meta-analysis revealed a trend of rapid functional recovery and decreased rates of nonunion and reintervention after operation for humeral shaft fracture compared to conservative treatment.

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Colasanti CA, Anil U, Cerasani MN, Li ZI, Morgan AM, Simovitch RW, Leucht P, Zuckerman JD. Management of Humeral Shaft Fracture: A Network Meta-Analysis of Individual Treatment Modalities. J Orthop Trauma 2024;38:e257-e266. [PMID: 38578605 DOI: 10.1097/bot.0000000000002808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 03/11/2024] [Indexed: 04/06/2024]

Abstract

OBJECTIVE

The purpose of this study was to perform a network meta-analysis of level I and II evidence comparing different management techniques to define the optimum treatment method for humeral shaft fractures (HSFs).

METHODS

DATA SOURCES

A systematic review of the literature using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines of MEDLINE, Embase, and Cochrane Library was screened from 2010 to 2023.

STUDY SELECTION

Inclusion criteria were evidence level I or II studies comparing nonoperative and/or operative repair techniques including open reduction internal fixation plate osteosynthesis (ORIF-Plate), minimally invasive percutaneous plating (MIPO), and intramedullary nail (IMN) fixation for the management of HSFs (OTA/AO 12A, B, C).

DATA EXTRACTION

The risk of bias and methodologic quality of evidence were assessed according to the guidelines designed by the Cochrane Statistical Methods Group and Cochrane Methods Bias Group.

DATA SYNTHESIS

Network meta-analysis was conducted with a frequentist approach with a random-effects model using the netmeta package version 0.9-6 in R.

RESULTS

A total of 25 studies (1908 patients) were included. MIPO resulted in the lowest complication rate (2.1%) when compared with ORIF-Plate (16.1%) [odds ratio (OR), 0.13; 95% confidence interval (CI), 0.04-0.49]. MIPO resulted in the lowest nonunion rate (0.65%) compared with all management techniques (OR, 0.28; 95% CI, 0.08-0.98), whereas Non-Op resulted in the highest (15.87%) (OR, 3.48; 95% CI, 1.98-6.11). MIPO demonstrated the lowest rate of postoperative radial nerve palsy overall (2.2%) and demonstrated a significantly lower rate compared with ORIF-Plate (OR, 0.22; 95% CI, 0.07-0.71, P = 0.02). IMN resulted in the lowest rate of deep infection (1.1%) when compared with ORIF-Plate (8.6%; P = 0.013). MIPO resulted in a significantly lower Disabilities of the Arm, Shoulder, and Hand score (3.86 ± 5.2) and higher American Shoulder and Elbow Surgeons score (98.2 ± 1.4) than ORIF-Plate (19.5 ± 9.0 and 60.0 ± 5.4, P < 0.05).

CONCLUSION

The results from this study support that surgical management results in better postoperative functional outcomes, leads to higher union rates, reduces fracture healing time, reduces revision rate, and decreases malunion rates in patients with HSFs. In addition, MIPO resulted in statistically higher union rates, lowest complication rate, lowest rate of postoperative radial nerve palsy, and lower intraoperative time while resulting in better postoperative Disabilities of the Arm, Shoulder, and Hand and American Shoulder and Elbow Surgeons scores when compared with nonoperative and operative (ORIF and IMN) treatment modalities.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

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Farid AR, Friend TH, Atarere J, Gustin M, Suneja N, Weaver MJ, Von Keudell AG. Operative and Nonoperative Treatment of Humeral Shaft Fractures: A Cost-Effectiveness Analysis. J Bone Joint Surg Am 2023;105:1420-1429. [PMID: 37478297 DOI: 10.2106/jbjs.22.01386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/23/2023]

Abstract

BACKGROUND

Decision-making with regard to the treatment of humeral shaft fractures remains under debate. The cost-effectiveness of these treatment options has yet to be established. This study aims to compare the cost-effectiveness of operative treatment with that of nonoperative treatment of humeral shaft fractures.

METHODS

We developed a decision tree for treatment options. Surgical costs included the ambulatory surgical fee, physician fee, anesthesia fee, and, in the sensitivity analysis, lost wages during recovery. We used the Current Procedural Terminology codes from the American Board of Orthopaedic Surgery to determine physician fees via the U.S. Centers for Medicare & Medicaid Services database. The anesthesia fee was obtained from the national conversion factor and mean operative time for included procedures. We obtained data on mean wages from the U.S. Bureau of Labor and data on weeks missed from a similar study. We reported functional data via the Disabilities of the Arm, Shoulder and Hand (DASH) scores obtained from existing literature. We used rollback analysis and Monte Carlo simulation to determine the cost-effectiveness of each treatment option, presented in dollars per meaningful change in DASH score, utilizing a $50,000 willingness-to-pay (WTP) threshold.

RESULTS

The cost per meaningful change in DASH score for operative treatment was $18,857.97 at the 6-month follow-up and $25,756.36 at the 1-year follow-up, by Monte Carlo simulation. Wage loss-inclusive models revealed values that fall even farther below the WTP threshold, making operative management the more cost-effective treatment option compared with nonoperative treatment in both settings. With an upward variation of the nonoperative union rate to 84.17% in the wage-exclusive model and 89.43% in the wage-inclusive model, nonoperative treatment instead became more cost-effective.

CONCLUSIONS

Operative management was cost-effective at both 6 months and 1 year, compared with nonoperative treatment, in both models. Operative treatment was found to be even more cost-effective with loss of wages considered, suggesting that an earlier return to baseline function and, thus, return to work are important considerations in making operative treatment the more cost-effective option.

LEVEL OF EVIDENCE

Economic and Decision Analysis Level III . See Instructions for Authors for a complete description of levels of evidence.

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Qiu H, Liu Y, Chen Y, Weng Z, Liu D, Dong J, Lu M. Treatment of humeral shaft fractures with different treatment methods: a network meta-analysis of randomized controlled trials. BMC Musculoskelet Disord 2023;24:583. [PMID: 37460932 DOI: 10.1186/s12891-023-06626-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 06/12/2023] [Indexed: 07/20/2023] Open

Beyer J, Rao B, Liu J, Skie M. Evaluation of Humeral Shaft Fracture Outcomes by Treatment Method: A Systematic Review and Meta-analysis Based on Comparison Studies. JBJS Rev 2023;11:01874474-202307000-00004. [PMID: 37459427 DOI: 10.2106/jbjs.rvw.23.00037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]

Abstract

BACKGROUND

The purpose of this systematic review and meta-analysis was to evaluate various outcomes of humeral shaft fractures treated with different treatment methods, which included functional bracing, open reduction and internal fixation, intramedullary nailing, and locked compression plate.

METHODS

A systematic review was performed using research databases including PubMed, EMBASE, and Google Scholar. Keywords relating to treatment of humeral shaft fractures were used, and comparison studies that reported patient characteristics and outcomes, including nonunion, malunion, function scores, and complications, were included. One hundred fourteen records were screened, with 18 studies ultimately included in the meta-analysis. Treatment groups were consolidated into brace or surgery and then further categorized into subgroups based on surgical technique used. Postoperative events, complications, and functional scores were compared among the treatment groups. Statistical analysis for this study was conducted using Review Manager 5.3, with a standard p-value of ≤0.05 for statistical significance.

RESULTS

Eighteen studies were included in this review with a total of 706 patients. Z-tests showed that risks of revision, nonunion, and malunion were higher in the brace treatment group compared with the surgical treatment group (p < 0.0001, <0.0001, 0.004, respectively). Risk of infection was expectedly higher in the surgical group compared with the brace group (p = 0.04). Radial nerve injury rates were also higher in the unspecified surgical group compared with the brace group (p = 0.01). In the surgical group, the mean Constant shoulder score was also significantly higher than that in the brace group (p = 0.004). When comparing the nail and plate groups, Z-tests revealed higher risks of delayed unions and other complications in the nail group (p = 0.04 and 0.001, respectively) but higher risk of infection in the plate group (p = 0.05).

CONCLUSION

The conservative treatment of humeral shaft fractures with functional braces may be associated with a lower incidence of infection and nerve injury when compared with operative treatment methods. However, nonoperative treatment may also come with higher risks of revision, nonunion, and malunion than the many available surgical modalities. Operative management with either intramedullary nail or plate has shown to be a reliable method of management with reasonable outcomes for humeral shaft fractures. While the nail group had higher risk of delayed unions and other complications, the plate group had higher risk of infections. Both nail and plate surgical treatments have shown to result in high union rates and should be considered by the surgeon on a case-by-case basis when treating humeral shaft fractures.

LEVEL OF EVIDENCE

Level I. See Instructions for Authors for a complete description of levels of evidence.

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Surgical Versus Nonsurgical Management of Humeral Shaft Fractures: A Systematic Review and Meta-Analysis of Randomized Trials. J Am Acad Orthop Surg 2023;31:e82-e93. [PMID: 36580054 DOI: 10.5435/jaaos-d-22-00432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 08/06/2022] [Indexed: 12/30/2022] Open

Abstract

INTRODUCTION

The aim was to compare surgical and nonsurgical management for adults with humeral shaft fractures in terms of patient-reported upper limb function, health-related quality of life, radiographic outcomes, and complications.

METHODS

MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, PubMed, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, International Clinical Trials Registry, and OpenGrey (Repository for Grey Literature in Europe) were searched in September 2021. All published prospective randomized trials comparing surgical and nonsurgical management of humeral shaft fractures in adults were included. Of 715 studies identified, five were included in the systematic review and four in the meta-analysis. Data were extracted by two independent reviewers according to the Preferred Reporting Items for Systematic Review and Meta-Analysis statement. Methodological quality was assessed using the revised Cochrane risk-of-bias tool for randomized trials. Pooled data were analyzed using a random-effects model.

RESULTS

The meta-analysis comprised 292 patients (mean age 41 [18 to 83] years, 67% male). Surgery was associated with superior Disabilities of the Arm, Shoulder and Hand (DASH) and Constant-Murley scores at 6 months (mean DASH difference 7.6, P = 0.01; mean Constant-Murley difference 8.0, P = 0.003), but there was no difference at 1 year (DASH, P = 0.30; Constant-Murley, P = 0.33). No differences in health-related quality of life or pain scores were found. Surgery was associated with a lower risk of nonunion (0.7% versus 15.7%; odds ratio [OR] 0.13, P = 0.004). The number needed to treat with surgery to avoid one nonunion was 7. Surgery was associated with a higher risk of transient radial nerve palsy (17.4% versus 0.7%; OR 8.23, P = 0.01) but not infection (OR 3.57, P = 0.13). Surgery was also associated with a lower risk of reintervention (1.4% versus 19.3%; OR 0.14, P = 0.04).

CONCLUSIONS

Surgery may confer an early functional advantage to adults with humeral shaft fractures, but this is not sustained beyond 6 months. The lower risk of nonunion should be balanced against the higher risk of transient radial nerve palsy.

LEVEL OF EVIDENCE

Level I.

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Karimi D, Brorson S, Midtgaard KS, Fjalestad T, Paulsen A, Olerud P, Ekholm C, Wolf O, Viberg B. Surgical versus non-surgical treatment of humeral SHAFT fractures compared by a patient-reported outcome: the Scandinavian Humeral diAphyseal Fracture Trial (SHAFT)-a study protocol for a pragmatic randomized controlled trial. Trials 2022;23:453. [PMID: 35655280 PMCID: PMC9161482 DOI: 10.1186/s13063-022-06317-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 04/18/2022] [Indexed: 11/10/2022] Open

Abstract

BACKGROUND

The outcome of non-surgical treatment is generally good, but the treatment course can be long and painful with approximately a quarter of the patients acquiring a nonunion. Both surgical and non-surgical treatment can have disabling consequences such as nerve injury, infection, and nonunion. The purpose of the study is to compare patient-reported outcomes after surgical and non-surgical treatment for humeral shaft fractures.

METHODS

A pragmatic randomized controlled trial (RCT) is planned with two study groups (SHAFT-Young and SHAFT-Elderly). A total of 287 eligible acute humeral shaft fractures are scheduled to be recruited and randomly allocated to surgical or non-surgical treatment with the option of early crossover due to delayed union. The surgical method within the allocation is decided by the surgeon. The primary outcome is the Disability of Arm, Shoulder, and Hand (DASH) score at 52 weeks, and is assessor blinded. The secondary outcomes are DASH score, EQ-5D-5L, pain assessed by visual analog score, Constant-Murley score including elbow range of motion, and anchor questions collected at all timepoints throughout the trial. All complications will be reported including; infection, nerve or vascular injury, surgical revisions (implant malpositioning, hardware failure, aseptic loosening, and peri-implant fracture), major adverse cardiovascular events, and mortality.

DISCUSSION

The SHAFT trial is a pragmatic multicenter RCT, that will compare the effectiveness of the main strategies in humeral shaft fracture treatment. This will include a variety of fracture morphologies, while taking the dilemmas within the population into account by splitting the population by age and providing the orthopedic society with an interval for early crossover surgery.

TRIAL REGISTRATION

Clinicaltrials.gov NCT04574336 . Registered on 5 October 2020.

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Functional and clinical outcome after operative versus nonoperative treatment of a humeral shaft fracture (HUMMER): results of a multicenter prospective cohort study. Eur J Trauma Emerg Surg 2022;48:3265-3277. [PMID: 35138426 PMCID: PMC9360107 DOI: 10.1007/s00068-022-01890-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 01/21/2022] [Indexed: 11/25/2022]

Abstract

Purpose

The best treatment of humeral shaft fractures in adults is still under debate. This study aimed to compare functional and clinical outcome of operative versus nonoperative treatment in adult patients with a humeral shaft fracture. We hypothesized that operative treatment would result in earlier functional recovery.

Methods

From October 23, 2012 to October 03, 2018, adults with a humeral shaft fracture AO type 12A or 12B were enrolled in a prospective cohort study in 29 hospitals. Patients were treated operatively or nonoperatively. Outcome measures were the Disabilities of the Arm, Shoulder, and Hand score (DASH; primary outcome), Constant–Murley score, pain (Visual Analog Score, VAS), health-related quality of life (Short Form-36 (SF-36) and EuroQoL-5D-3L (EQ-5D)), activity resumption (Numeric Rating Scale, NRS), range of motion (ROM) of the shoulder and elbow joint, radiologic healing, and complications. Patients were followed for one year. Repeated measure analysis was done with correction for age, gender, and fracture type.

Results

Of the 390 included patients, 245 underwent osteosynthesis and 145 were primarily treated nonoperatively. Patients in the operative group were younger (median 53 versus 62 years; p < 0.001) and less frequently female (54.3% versus 64.8%; p = 0.044). Superior results in favor of the operative group were noted until six months follow-up for the DASH, Constant–Murley, abduction, anteflexion, and external rotation of the shoulder, and flexion and extension of the elbow. The EQ-US, and pronation and supination showed superior results for the operative group until six weeks follow-up. Malalignment occurred only in the nonoperative group (N = 14; 9.7%). In 19 patients with implant-related complications (N = 26; 10.6%) the implant was exchanged or removed. Nonunion occurred more often in the nonoperative group (26.3% versus 10.10% in the operative group; p < 0.001).

Conclusion

Primary osteosynthesis of a humeral shaft fracture (AO type 12A and 12B) in adults is safe and superior to nonoperative treatment, and should therefore be the treatment of choice. It is associated with a more than twofold reduced risk of nonunion, earlier functional recovery and a better range of motion of the shoulder and elbow joint than nonoperative treatment. Even after including the implant-related complications, the overall rate of complications as well as secondary surgical interventions was highest in the nonoperative group.

Trial registration

NTR3617 (registration date 18-SEP-2012).

Supplementary Information

The online version contains supplementary material available at 10.1007/s00068-022-01890-6.

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van de Wall BJM, Ochen Y, Beeres FJP, Babst R, Link BC, Heng M, van der Velde D, Knobe M, Groenwold RHH, Houwert RM. Response to Yin et al regarding: "Conservative vs. operative treatment for humeral shaft fractures: a meta-analysis and systematic review of randomized clinical trials and observational studies". J Shoulder Elbow Surg 2021;30:e32-e33. [PMID: 32956777 DOI: 10.1016/j.jse.2020.07.050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 07/20/2020] [Indexed: 02/01/2023]

Yin Y, Li L, Xiang Z. Letter to the Editor regarding van de Wall et al: "Conservative vs. operative treatment for humeral shaft fractures: a meta-analysis and systematic review of randomized clinical trials and observational studies". J Shoulder Elbow Surg 2021;30:e30-e31. [PMID: 32956779 DOI: 10.1016/j.jse.2020.07.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 07/20/2020] [Indexed: 02/08/2023]

van de Wall BJM, Ochen Y, Beeres FJP, Babst R, Link BC, Heng M, van der Velde D, Knobe M, Groenwold RHH, Houwert MR. Conservative vs. operative treatment for humeral shaft fractures: a meta-analysis and systematic review of randomized clinical trials and observational studies. J Shoulder Elbow Surg 2020;29:1493-1504. [PMID: 32249144 DOI: 10.1016/j.jse.2020.01.072] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Revised: 12/19/2019] [Accepted: 01/01/2020] [Indexed: 02/01/2023]

Abstract

BACKGROUND

This meta-analysis aimed to compare conservative vs. operative treatment for humeral shaft fractures in terms of the nonunion rate, reintervention rate, permanent radial nerve palsy rate, and functional outcomes. Secondarily, effect estimates from observational studies were compared with estimates of randomized clinical trials (RCTs).

METHODS

The PubMed/Medline, Embase, CENTRAL (Cochrane Central Register of Controlled Trials), and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases were searched for both RCTs and observational studies comparing conservative with operative treatment for humeral shaft fractures.

RESULTS

A total of 2 RCTs (150 patients) and 10 observational studies (1262 patients) were included. The pooled nonunion rate of all studies was higher in patients treated conservatively (15.3%) vs. operatively (6.4%) (risk difference, 8%; odds ratio [OR], 2.9; 95% confidence interval [CI], 1.8-4.5; I² = 0%). The reintervention rate was also higher for conservative treatment (14.3%) than for operative treatment (8.9%) (risk difference, 6%; OR, 1.9; 95% CI, 1.1-3.5; I² = 30%). The higher reintervention rate was predominantly attributable to the higher nonunion rate in patients treated conservatively. The permanent radial nerve palsy rate was equal in both groups (OR, 0.6; 95% CI, 0.2-1.9; I² = 18%). There appeared to be no difference in mean time to union and mean Disabilities of the Arm, Shoulder and Hand scores between the treatment groups. No difference was found between effect estimates form observational studies and RCTs.

CONCLUSION

This systematic review shows that satisfactory results can be achieved with both conservative and operative management; however, operative treatment reduces the risk of nonunion compared with conservative treatment, with comparable reintervention rates (for indications other than nonunion). Furthermore, operative treatment results in a similar permanent radial nerve palsy rate, despite its inherent additional surgery-related risks. No difference in mean time-to-union and short-term functional results was detected.

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