Skip to main content
SpringerLink
Log in

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

  • Review Article
  • Published:
European Journal of Trauma and Emergency Surgery Aims and scope Submit manuscript

Abstract

Purpose

There is no consensus on the optimal operative technique for humeral shaft fractures. This meta-analysis aims to compare minimal-invasive plate osteosynthesis (MIPO) with nail fixation for humeral shaft fractures regarding healing, complications and functional results.

Methods

PubMed/Medline/Embase/CENTRAL/CINAHL were searched for randomized clinical trials (RCT) and observational studies comparing MIPO with nailing for humeral shaft fractures. Effect estimates were pooled across studies using random effects models and presented as weighted odds ratio (OR), risk difference (RD), mean difference (MD) and standardized mean difference (SMD) with corresponding 95% confidence interval (95%CI). Analyses were repeated stratified by study design (RCTs and observational studies).

Results

A total of 2 RCTs (87 patients) and 5 observational studies (595 patients) were included. The effects estimated in observational studies and RCTs were similar in direction and magnitude for all outcomes except operation duration. MIPO has a lower risk for non-union (RD 7%; OR 0.2, 95% CI 0.1–0.5) and re-intervention (RD 13%; OR 0.3, 95% CI 0.1–0.8). Functional shoulder (SMD 1.0, 95% CI 0.2–1.8) and elbow scores (SMD 0.4, 95% CI 0–0.8) were better among patients treated with MIPO. The risk for radial nerve palsy following surgery was equal (RD 2%; OR 0.6, 95% CI 0.3–1.2) and nerve function recovered spontaneously in all patients in both groups. No difference was detected with regard to infection, time to union and operation duration.

Conclusion

MIPO has a considerable lower risk for non-union and re-intervention, leads to better shoulder function and, to a lesser extent, better elbow function compared to nailing. Although nailing appears to be a viable option, the evidence suggests that MIPO should be the preferred treatment of choice. The learning curve of minimal-invasive plating should, however, be taken into account when interpreting these results.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8
Fig. 9
Fig. 10

Similar content being viewed by others

References

  1. Schoch BS, et al. Humeral shaft fractures: national trends in management. J Orthop Traumatol. 2017;18(3):259–63.

    Article  PubMed  PubMed Central  Google Scholar 

  2. van de Wall BJM, 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. 2020;29:1493–504.

    Article  PubMed  Google Scholar 

  3. Xue Z, et al. Effects of different surgical techniques on mid-distal humeral shaft vascularity: open reduction and internal fixation versus minimally invasive plate osteosynthesis. BMC Musculoskelet Disord. 2016;17:370.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Wen H, et al. Antegrade intramedullary nail versus plate fixation in the treatment of humeral shaft fractures: an update meta-analysis. Medicine (Baltimore). 2019;98(46):e17952.

    Article  Google Scholar 

  5. Yu BF, et al. Comparison of minimally invasive plate osteosynthesis and conventional plate osteosynthesis for humeral shaft fracture: a meta-analysis. Medicine (Baltimore). 2016;95(39):e4955.

    Article  Google Scholar 

  6. Moher D, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Int J Surg. 2010;8(5):336–41.

    Article  PubMed  Google Scholar 

  7. Stroup DF, et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis of Observational Studies in Epidemiology (MOOSE) group. JAMA. 2000;283(15):2008–12.

    Article  CAS  PubMed  Google Scholar 

  8. Meinberg EG, et al. Fracture and dislocation classification compendium-2018. J Orthop Trauma. 2018;32(Suppl 1):S1–170.

    Article  PubMed  Google Scholar 

  9. Slim K, et al. Methodological index for non-randomized studies (minors): development and validation of a new instrument. ANZ J Surg. 2003;73(9):712–6.

    Article  PubMed  Google Scholar 

  10. Whelan DB, et al. Interobserver and intraobserver variation in the assessment of the healing of tibial fractures after intramedullary fixation. J Bone Jt Surg Br. 2002;84(1):15–8.

    Article  CAS  Google Scholar 

  11. Wilson J. Surveillance of surgical site infection in orthopaedic surgery is useful in tackling hospital-acquired infections in England. Euro Surveill. 2005;10(11):E0511173.

    Google Scholar 

  12. Higgins JP, et al. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ. 2011;343:d5928.

    Article  PubMed  PubMed Central  Google Scholar 

  13. An Z, et al. Comparison of effectiveness between minimally invasive plating osteosynthesis and expandable intramedullary nailing technique in treatment of middle third humeral shaft fractures. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2010;24(12):1413–5.

    PubMed  Google Scholar 

  14. Kulkarni VS, et al. Comparison between antegrade intramedullary nailing (IMN), open reduction plate osteosynthesis (ORPO) and minimally invasive plate osteosynthesis (MIPO) in treatment of humerus diaphyseal fractures. Injury. 2017;48(Suppl 2):S8–13.

    Article  PubMed  Google Scholar 

  15. Goncalves FF, et al. Evaluation of the surgical treatment of humeral shaft fractures and comparison between surgical fixation methods. Rev Bras Ortop. 2018;53(2):136–41.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Davies G, et al. Case-match controlled comparison of minimally invasive plate osteosynthesis and intramedullary nailing for the stabilization of humeral shaft fractures. J Orthop Trauma. 2016;30(11):612–7.

    Article  PubMed  Google Scholar 

  17. Yuan H, et al. Comparison between intramedullary nailing and minimally invasive percutaneous plate osteosynthesis in treatment of humeral shaft fractures. J Coll Physicians Surg Pak. 2019;29(10):942–5.

    Article  PubMed  Google Scholar 

  18. Lian K, et al. Minimally invasive plating osteosynthesis for mid-distal third humeral shaft fractures. Orthopedics. 2013;36(8):e1025–32.

    Article  PubMed  Google Scholar 

  19. Benegas E, et al. Shoulder function after surgical treatment of displaced fractures of the humeral shaft: a randomized trial comparing antegrade intramedullary nailing with minimally invasive plate osteosynthesis. J Shoulder Elbow Surg. 2014;23(6):767–74.

    Article  PubMed  Google Scholar 

  20. Hohmann E, Glatt V, Tetsworth K. Minimally invasive plating versus either open reduction and plate fixation or intramedullary nailing of humeral shaft fractures: a systematic review and meta-analysis of randomized controlled trials. J Shoulder Elbow Surg. 2016;25(10):1634–42.

    Article  PubMed  Google Scholar 

  21. Zhang Q, et al. Minimally invasive plating osteosynthesis in the treatment of humeral shaft fractures: a meta-analysis. J Invest Surg. 2017;30(2):133–42.

    Article  PubMed  Google Scholar 

  22. Qiu H, et al. A Bayesian network meta-analysis of three different surgical procedures for the treatment of humeral shaft fractures. Medicine (Baltimore). 2016;95(51):e5464.

    Article  Google Scholar 

  23. Zhao Y, et al. Interventions for humeral shaft fractures: mixed treatment comparisons of clinical trials. Osteoporos Int. 2017;28(11):3229–37.

    Article  CAS  PubMed  Google Scholar 

  24. Farivar SS, Liu H, Hays RD. Half standard deviation estimate of the minimally important difference in HRQOL scores? Expert Rev Pharmacoecon Outcomes Res. 2004;4(5):515–23.

    Article  PubMed  Google Scholar 

  25. Cheng HR, Lin J. Prospective randomized comparative study of antegrade and retrograde locked nailing for middle humeral shaft fracture. J Trauma. 2008;65(1):94–102.

    PubMed  Google Scholar 

  26. Lopiz Y, et al. Proximal humerus nailing: a randomized clinical trial between curvilinear and straight nails. J Shoulder Elbow Surg. 2014;23(3):369–76.

    Article  PubMed  Google Scholar 

  27. Da Silva, T et al. Comparing iatrogenic radial nerve lesions in humeral shaft fractures treated with helical or straight PHILOS plates: a 10-year retrospective cohort study of 62 cases. Arch Orthop Trauma Surg 2020.

  28. Canada-Oya H, et al. New, minimally invasive, anteromedial-distal approach for plate osteosynthesis of distal-third humeral shaft fractures: an anatomical study. JB JS Open Access. 2020;5(1):e0056.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Beeres FJP, et al. Plate fixation of the proximal humerus: an international multicentre comparative study of postoperative complications. Arch Orthop Trauma Surg. 2017;137(12):1685–92.

    Article  PubMed  Google Scholar 

  30. Beeres, FJP et al. ORIF versus MIPO for humeral shaft fractures: a meta-analysis and systematic review of randomized clinical trials and observational studies. Injury. 2020 6:S0020-1383(20)30939-6.

Download references

Funding

None.

Author information

Authors and Affiliations

  1. Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Spitalstrasse 16, 6000, Luzern, Switzerland

    Bryan J. M. van de Wall, Ralf Baumgärtner, Björn C. Link, Matthias Knobe, Reto Babst & Frank J. P. Beeres

  2. Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands

    R. Marijn Houwert

  3. Department of Orthopaedic Surgery, Harvard Medical School Orthopaedic Trauma Initiative, Massachusetts General Hospital Boston, Boston, USA

    Marilyn Heng

  4. Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands

    Rolf H. H. Groenwold

Authors
  1. Bryan J. M. van de Wall
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Ralf Baumgärtner
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. R. Marijn Houwert
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Björn C. Link
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Marilyn Heng
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Matthias Knobe
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Rolf H. H. Groenwold
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Reto Babst
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Frank J. P. Beeres
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Bryan J. M. van de Wall.

Ethics declarations

Conflict of interest

None.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 9081 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

van de Wall, B.J.M., Baumgärtner, R., Houwert, R.M. et al. MIPO versus nailing for humeral shaft fractures: a meta-analysis and systematic review of randomised clinical trials and observational studies. Eur J Trauma Emerg Surg 48, 47–59 (2022). https://doi.org/10.1007/s00068-020-01585-w

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00068-020-01585-w

Keywords

Search

Navigation