Are Arthroplasty Procedures Really Better in the Treatment of Complex Proximal Humerus Fractures? A Comprehensive Meta-Analysis and Systematic Review

Abstract

Objective: A meta-analysis and systematic review was performed to compare outcomes of open reduction and internal fixation (ORIF), hemiarthroplasty (HA), and reverse total shoulder arthroplasty (rTSA) for complex proximal humerus fractures. Data sources: MEDLINE, Embase, and Cochrane Library databases were screened. Search terms included reverse total shoulder arthroplasty, open reduction internal fixation, hemiarthroplasty, and proximal humerus fracture. Study Selection: English-language studies published within the past 15 years evaluating outcomes of ORIF, rTSA, or HA for complex proximal humerus fractures with minimum of 1-year follow-up were included, resulting in 51 studies with 3064 total patients. Review articles, basic science studies, biomechanical studies, and cadaveric studies were excluded. Data Extraction: The methodological quality of evidence was assessed using the Jadad scale and methodological index for nonrandomized studies. Data Synthesis: Demographic data were compared using the χ2 test. Mean data were weighted by study size and used to calculate composite mean values and confidence intervals. Continuous data were compared using the Metan module with fixed effects. Count data were compared using the Kruskal–Wallis test. Alpha was set at 0.05 for all tests. Conclusions: Patients undergoing rTSA had lower risks of complication (relative risk 0.41) and reoperation (relative risk 0.28) than HA patients. rTSA resulted in higher Constant scores (standard mean difference 0.63) and improved active forward flexion when compared with HA (standard mean difference 0.76). Pooled mean data demonstrated better outcome scores and active forward flexion of ORIF versus HA and rTSA, although the patients were younger and had more simple fracture patterns. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Reverse total shoulder arthroplasty (RTSA) versus open reduction and internal fixation (ORIF) for displaced three-part or four-part proximal humeral fractures: a systematic review and meta-analysis

“…Moreover, their results also carried a high risk of bias as the baseline characteristics of the patients included was heterogeneous, with a distinct age gap (mean 61.9 years in the ORIF group and 76.2 years in the RTSA group) and simpler fracture pattern in the ORIF group (two-part fracture) (selection bias). 11 Therefore, the result of that study should be critically discussed. In contrast, our present review was conducted with a thorough bias analysis, ensuring the robustness of our results.…”

“…Although many prior systematic reviews have compared various management strategies for PHF, these studies found no or limited direct/head-to-head comparative studies between ORIF and RTSA. 11 – 13 Previous literature has described methodological concerns of systematic reviews that include indirect comparison. 14 Therefore, the purpose of this systematic review is to compare the outcomes of three- or four-part PHF surgeries using ORIF and RTSA based on direct/head-to-head comparative studies.…”

Comorbidities, substance abuse, weight and age are independent risk factors for postoperative complications following operation for proximal humerus fractures: a retrospective analysis of 1109 patients

“…This was confirmed by a recent meta-analysis. [19] The influence of epidemiological factors on the occurrence of complications has received little attention to date. Other studies mostly recorded epidemiological parameters, however, they did not investigate their relationship to complications.…”

Factors influencing surgical management of proximal humerus fractures: do shoulder and trauma surgeons differ?

“…20 Despite this, many clinical studies in elderly patients with PHFs have reported superior outcomes in favor of RSA 3,6,8,15,18,24,41 over ORIF, 31 HA, 32 and equivalent outcomes for nonoperative management. 11,25,27,37 Systematic reviews analyzing PHFs in the elderly population have found superior outcomes for ORIF 19,35 and similar or more favorable outcomes for RSA compared with HA. 12,29,42 However, these findings come with important caveats.…”

“…Except in a small minority of randomized controlled trials and age-matched case-control studies, patients undergoing ORIF and HA are typically younger, have fewer comorbidities, and have more simple fracture patterns than patients receiving an RSA. 35 In addition, results can be influenced by the surgeon's skill and technique; outcomes after ORIF depend on the quality of the reduction, 40 and favorable outcomes after HA are reliant on accurate tuberosity fixation and their reliable healing. 4,8,14,15,28,41 Given these mixed results in the literature, the message to surgeons regarding the optimal treatment of these fractures remains unclear.…”