Meta-Analysis
Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Orthop. Nov 18, 2015; 6(10): 838-846
Published online Nov 18, 2015. doi: 10.5312/wjo.v6.i10.838
Operative vs non-operative management of displaced proximal humeral fractures in the elderly: A systematic review and meta-analysis of randomized controlled trials
Santa Rabi, Nathan Evaniew, Sheila A Sprague, Mohit Bhandari, Gerard P Slobogean
Santa Rabi, Sheila A Sprague, Mohit Bhandari, Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario L8L 8E7, Canada
Nathan Evaniew, Sheila A Sprague, Mohit Bhandari, Gerard P Slobogean, Division of Orthopedics, Department of Surgery, McMaster University, Hamilton, Ontario L8L 8E7, Canada
Gerard P Slobogean, Department of Orthopaedics, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, Baltimore, MD 21201, United States
Author contributions: Rabi S acquisition of data, analysis and interpretation of data, drafting the article, final approval; Evaniew N acquisition of data, analysis and interpretation of data, drafting the article, final approval; Sprague SA interpretation of data, revising the article, final approval; Bhandari M interpretation of data, revising the article, final approval; Slobogean GP conception and design of the study, analysis and interpretation of data, drafting the article, final approval.
Supported by In part by a Canada Research Chair to Dr. Bhandari; in part by the Canadian Institutes of Health Research and Vancouver Coastal Health Research Institute to Dr. Slobogean.
Conflict-of-interest statement: The authors certify that they, or a member of their immediate families, have no funding or commercial associations (e.g., consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Gerard P Slobogean, MD, MPH, FRCSC, Department of Orthopaedics, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, Suite 300, 110 S. Paca Street, Baltimore, MD 21201, United States. gslobogean@umoa.umm.edu
Telephone: +1-410-3286040
Received: February 28, 2015
Peer-review started: March 2, 2015
First decision: June 18, 2015
Revised: July 16, 2015
Accepted: September 25, 2015
Article in press: September 28, 2015
Published online: November 18, 2015
Abstract

AIM: To perform a systematic review and meta-analysis comparing operative vs non-operative treatment of displaced proximal humerus fractures in elderly patients.

METHODS: A systematic literature search was performed using EMBASE and MEDLINE through the OVID interface, CINAHL, the Cochrane Central Register of Controlled Trials (CENTRAL), Proquest, Web of Science, SAE digital library, and Transportation Research Board’s TRID database. Searches of conference proceedings were also conducted. All available randomized controlled trials comparing operative vs non-operative management of displaced three- and four-part proximal humerus fractures in elderly patients were included. The primary outcomes measures included physical function, pain, health related quality of life, mortality, and the re-operation rate.

RESULTS: Six randomized controlled trials (n = 287) were included. There was no statistically significant difference in function (MD = 1.72, 95%CI: -2.90-6.34, P = 0.47), as measured by the Constant score, between the operative and the non-operative treatment groups. There was no statistically significance difference in secondary outcomes of health related quality of life (standardized MD = 0.27, 95%CI: -0.05-0.59, P = 0.09), and mortality (relative risk 1.29, 95%CI: 0.50- 3.35, P = 0.60). Operative treatment had a statistically significant higher re-operation rate (relative risk 4.09, 95%CI: 1.50-11.15, P = 0.006), and statistically significant decreased pain (MD = 1.26, 95%CI: 0.02- 2.49, P = 0.05).

CONCLUSION: There is moderate quality evidence to suggest that there is no difference in functional outcomes between the two treatments. Further high quality randomized controlled trials are required to determine if certain subgroup populations benefit from surgical management.

Keywords: Proximal humerus fracture, Outcomes, Operative treatment, Non-operative treatment, Meta-analysis

Core tip: Our systematic review and meta-analysis found a lack of high quality evidence to determine the effects of operative vs non-operative treatment on patient-important outcomes among elderly patients with three- or four-part proximal humeral fractures. There is moderate quality evidence to suggest that there is no difference in functional outcomes between the two treatments.