Management of Humeral Shaft Fracture: A Network Metanalysis of Individual Treatment Modalities

Abstract

Objective: The purpose of this study was to perform a network meta-analysis (NMA) of level I and II evidence comparing different management techniques to define the optimum treatment method for humeral shaft fractures (HSF). Methods: Data Sources: A systematic review of the literature using PRISMA guidelines of MEDLINE, EMBASE, and Cochrane Library was screened from 2010-2023. 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 fixation (IMN) for the management of HSF (AO OTA 12A,B,C). Data Extraction: The risk of bias (ROB) and methodologic quality of evidence (MQOE) were assessed according to the guidelines designed by the Cochrane Statistical Methods Group and Cochrane Methods Bias Group. Data Synthesis: NMA were 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 (1,908 patients) were included. MIPO resulted in the lowest complication rate (2.1%) when compared to ORIF-Plate (16.1%) (OR, 0.13;95%CI,0.04-0.49). MIPO resulted in the lowest nonunion rate (0.65%) compared to 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 to 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 to ORIF-Plate (8.6%; p=0.013). MIPO resulted in a significantly lower DASH score (3.86±5.2) and higher ASES score (98.2± 1.4) than ORIF-Plate (19.5±9.0 & 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. Additionally, 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 DASH and ASES scores when compared to nonoperative and operative (ORIF & IMN) treatment modalities. Level of Evidence: Level II. See Instructions for Authors for a complete description of levels of evidence.