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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.

Purpose This meta-analysis compares open reduction and internal fixation with a plate (ORIF) versus nailing for humeral shaft fractures with regard to union, complications, general quality of life and shoulder/elbow function. Methods PubMed/Medline/Embase/CENTRAL/CINAHL was searched for observational studies and randomised clinical trials (RCT). Effect estimates were pooled across studies using random effects models. Results were presented as weighted odds ratio (OR) or risk difference (RD) with corresponding 95% confidence interval (95% CI). Subgroup analysis was performed stratified for study design (RCTs and observational studies). Results Eighteen observational studies (4906 patients) and ten RCT's (525 patients) were included. The pooled effect estimates of observational studies were similar to those obtained from RCT's. More patients treated with nailing required re-intervention (RD 2%; OR 2.0, 95% CI 1.0-3.8) with shoulder impingement being the most predominant indication (17%). Temporary radial nerve palsy secondary to operation occurred less frequently in the nailing group (RD 2%; OR 0.4, 95% CI 0.3-0.6). Notably, all but one of the radial nerve palsies resolved spontaneously in each groups. Nailing leads to a faster time to union (mean difference − 1.9 weeks, 95% CI − 2.9 to − 0.9), lower infection rate (RD 2%; OR 0.5, 95% CI 0.3-0.7) and shorter operation duration (mean difference − 26 min, 95% CI − 37 to − 14). No differences were found regarding nonunion, general quality of life, functional shoulder scores, and total upper extremity scores. Conclusion Nailing carries a lower risk of infection, postoperative radial nerve palsy, has a shorter operation duration and possibly a shorter time to union. Shoulder impingement requiring re-intervention, however, is an inherent disadvantage of nail fixation. Notably, absolute differences are small and almost all patients with radial nerve palsy recovered spontaneously. Satisfactory results can be achieved with both treatment modalities.

Background: Tibiotalocalcaneal (TTC) intramedullary nailing has been suggested as an alternative to open reduction and internal fixation (ORIF) for the primary treatment of unstable fragility ankle fractures with a poor soft tissue envelope. This study aims to investigate the clinical efficacy of TTC intramedullary nail fixation for the primary treatment of unstable ankle fractures in frail elderly patients with poor soft tissue condition, by assessing the number of postoperative complications and the patient-reported functional outcomes. Methods: A retrospective cohort study was performed including patients with an unstable ankle fracture treated between 2015 and 2019 with TTC stabilization using a retrograde intramedullary hindfoot nail that was inserted without joint preparation and allowing immediate weight-bearing postoperatively. The primary outcome was the total number of postoperative complications. Results: A total of 10 patients were included out of 365 operatively treated ankle fractures. The mean age was 85.2 years (range 66-92) with a mean follow-up of 11.2 months (range 6-16). Fracture types included AO/OTA 44-B2 (n = 1), 44-B3 (n = 6), 44-C1 (n = 2) and 44-C3 (n = 1). Postoperative complications were observed in 4 patients (40%), including 3 nonunions, 2 implant related complications and 1 wound infection. No wound healing disorder or below-the-knee amputation was observed. Four patients (40%) deceased between post-operative 6 to 16 months due to medical conditions unrelated to surgery. The mean Foot and Ankle Outcome Score was 52.6 (range 44.2-73.8). Conclusion: Hindfoot nailingis a viable treatment option in selected high-risk patients with an advanced age, unstable ankle fractures with significant bone loss, poor soft tissue condition and/or severely impaired pre-injury mobility. In a frail geriatric population, hindfoot nailing may be a safe alternative fixation method with a low risk of wound complication or major amputation. However, unprepared joint may lead to symptomatic nonunion after TTC intramedullary nailing.