In April 2010 we published a meta-analysis with the
title “Plate fixation or intramedullary fixation of humeral
shaft fractures” in Acta Orthopaedica (Heineman et al. 2010).
This meta-analysis was updated with a letter-to-the-editor in
August 2010 in Acta Orthopaedica.
Since this last update new trials have been published on this
subject, therefore justifying a new update of this meta-analysis.
Regarding our primary outcome, total complication rate,
one new trial has been published by Singisetti and Ambedkar
(2010) describing the results of a prospective, comparative
study of management of acute humeral shaft fractures by
antegrade interlocking nail fixation and dynamic compression
plating. Another new trial was published by Li et al. in 2011.
This study is a prospective designed trial to compare the effect
of antegrade nail with ORIF on shoulder function and range of
motion. Unfortunately this study does not mention total complication
rate, the primary outcome of our meta-analysis. They
do mention non-union, infection and nerve damage though, three of our secondary outcomes. We decided to add all their
mentioned complications together as the total complication
rate. Next to these 2 new studies we decided to include a study
by Kesemenli et al. from 2003, which seems to match our
in- and exclusion criteria but wasn’t included in our primary
meta-analysis. Therefore we add 3 new trials in this update.
By including these three trials we could add 155 patients in
total. Regarding our primary outcome total complication rate
we can state that this new update shows a less significant result
favoring plates compared to nails (RR 0.63, CI = 0.41–0.97,
p = 0.03) (Figure). It is remarkable that the confidence interval
is smaller than it was in our last update (CI = 0.30–0.91),
suggesting less heterogeneity. Regarding our secondary outcomes,
non-union, infection and nerve palsy, this new analysis
shows no new significant differences (Table).
After updating our analysis we can conclude that the current
literature continues to favor plates over intramedullary nails in
humeral shaft fractures in the reduction of complication rates. However, the precision of our estimate is markedly improved
(CI = 0.41–0.97 instead of CI = 0.30–0.91). We have to remark
though that the significance is a bit less than it was in 2010
(p = 0.03 instead of p = 0.01). Regarding our secondary outcomes
there still is no significant difference between nails and
The weaknesses stated in our last update still remain viable:
small studies with heterogeneity remain the basis of this metaanalysis.
The need for a large scale RCT reporting on patient
important endpoints such as complication rate and validated
patient reported outcomes still remains.