Minimally invasive plate osteosynthesis vs conventional fixation techniques for surgically treated humeral shaft fractures: a meta-analysis
Hu et al. Journal of Orthopaedic Surgery and Research
Minimally invasive plate osteosynthesis vs conventional fixation techniques for surgically treated humeral shaft fractures: a meta-analysis
Xuqi Hu 0
Siqi Xu 1
Huigen Lu 0
Bao Chen 0
Xiao Zhou 0
Xiaojun He 0
Jiaping Dai 0
Zhongwei Zhang 0
Suiliang Gong 0
0 Department of Orthopaedics, the Second Affiliated Hospital of Jiaxing University , 1518 Huancheng North Road, Jiaxing , China
1 Department of Clinical Laboratory, the Second Affiliated Hospital of Jiaxing University , 1518 Huancheng North Road, Jiaxing , China
Background: In this study, we performed a meta-analysis to identify whether minimally invasive plate osteosynthesis (MIPO) was superior to conventional fixation techniques (CFT) for treating humeral shaft fractures. Methods: A systematic literature search was conducted up to February 2016 in ScienceDirect, Springer, MEDLINE, and PubMed databases for relevant papers that compared the outcomes of MIPO with CFT, such as open reduction with plate osteosynthesis (ORPO) and intramedullary nail (IMN) for treating humeral shaft fractures. Meta-analysis was performed with Review Manager 5.0 software. Results: According to the search strategy, eight studies that covered 391 patients were enrolled, including four randomized controlled trials (RCTs), two prospective cohort trials, and two retrospective cohort trials. Our meta-analysis did not detect any significant difference between MIPO and CFT (IMN and ORPO) in terms of operative time, fracture union rate, and fracture union time. However, MIPO has a less rate of complications and iatrogenic radial nerve palsy than that of ORPO and higher adjacent joint function scores than those of IMN (p < 0.05). Conclusions: Based on the present evidence, this meta-analysis suggested that MIPO was a better choice for treating humeral shaft fractures than CFT. However, more high-quality randomized trials are still needed to further confirm this conclusion in the future.
Minimally invasive plate osteosynthesis; Open reduction with plate osteosynthesis; Intramedullary nail; Humeral shaft fracture; Meta-analysis
Fractures of humeral shaft are common injuries, which
make up 1 to 3 % of all fractures [
nonoperative treatment has been widely used for these injuries.
However, a high rate of nonunion was reported in humeral
shaft fracture patients with functional bracing [
Therefore, many orthopedic surgeons tend to prefer operative
treatment for humeral shaft fractures.
Three main operative techniques have been
developed for treating displaced humeral shaft fractures.
Intramedullary nail and plate are the conventionally used
surgical methods [
]. Currently, open reduction and
plate fixation remains to be the golden standard for
humeral shaft fractures [
]. Recently, minimally invasive
plate osteosynthesis (MIPO) techniques with encouraging
results in humeral shaft fracture patients have been
]. This technique has advantages of less soft
tissue dissection, a high rate of union, low risks of
infection, and no need for radial nerve exposure . It seems
to imply that MIPO is superior to conventional fixation
techniques (CFT), such as open reduction with plate
osteosynthesis (ORPO) and intramedullary nail (IMN).
Recently, several randomized controlled trials (RCTs)
and comparative clinical studies have been conducted to
compare MIPO with CFT for treating humeral shaft
fractures. In this study, we performed a meta-analysis to
identify whether MIPO was superior to CFT for treating
humeral shaft fractures.
Since there were only a small amount of relevant RCTs in
the literature, observational studies were also included. A
systematic literature search was conducted up to February
2016 in ScienceDirect, Springer, MEDLINE, and PubMed
databases. We screened the title and abstract with key
words as follows: “minimally invasive plate osteosynthesis”
or “MIPO”, “plate” or “plating”, “intramedullary nail” or
“intramedullary pin”, and “humeral shaft fracture” or
“fracture of humeral shaft”. In addition, references of the
selected articles and relevant review papers were also
searched. Unpublished data were not reviewed. The
language of articles was limited to English.
Inclusion and exclusion criteria
The following eligibility criteria were applied in selecting
articles: (1) RCTs or observational studies that compared the
clinical and/or radiological outcomes of MIPO with CFT
for treating humeral shaft fractures; (2) totally followed
patients had to be more than 30; and (3) skeletally mature
patients. The exclusion criteria included the following: (1) a
pathologic fracture; (2) studies that did not report the
outcome of interest; and (3) repeated studies or reviews.
Two people independently performed the selection of
studies. Any disagreement between the reviewers was
resolved by consensus with a third reviewer.
Two reviewers extracted data independently based on
the following categories: (1) basic characteristics, such as
study design, published year, study population
characteristics, and humeral shaft fracture type; (2) primary
outcomes, consisting of postoperative clinical function
evaluated by the University of California, Los Angeles
(UCLA) Shoulder Scale [
] and Mayo Elbow
performance score (MEPS) [
]; and (3) secondary outcomes,
such as complications and iatrogenic radial nerve palsy,
operative time, radiation exposure time, and fracture
union time. Any disagreement between the reviewers
was resolved by consensus with a third reviewer.
Risk of bias assessment
To assess the risk of bias of the included RCTs, the
Cochrane Handbook for Systematic Reviews of
Interventions was applied. The risk of bias of the included
observational studies was evaluated with the Newcastle–
Ottawa Scale, and the trials with a total score over 5
were considered to be of high quality [
Meta-analysis was performed using Review Manager
5.0 software (Cochrane Collaboration, Oxford, UK).
Weighted mean difference (WMD) or standard mean
difference (SMD) was calculated for continuous
outcomes and risk ratios (RR) for binary outcomes, along
with 95 % confidence intervals (CIs). The level of
significance was set at p < 0.05. Heterogeneity was
evaluated using the χ2 test and I2 statistics. (Heterogeneity
was detected when p < 0.10 or I2 > 50 %.) Fixed-effects
models were applied unless statistical heterogeneity
was significant, in which case random-effects models
were used. Standard deviation (SD) was estimated
according to the method described by the Cochrane
Handbook for Systematic Reviews of Interventions
when it was not available. In this paper, CFT was
consisted of ORPO and IMN. Then, we conducted
subgroup analyses based on the two kinds of CFT
(ORPO subgroup and IMN subgroup).
According to the search strategy, 1026 articles were
identified initially, of which 421 were screened after
removal of duplicated records. Then, 577 studies were
excluded due to inappropriate topics. The full text of the
remaining 28 papers were obtained and assessed for
eligibility. Twenty of them were further removed according
to predefined inclusion/exclusion criteria. Finally, four
randomized controlled trials, two prospective cohort
studies, and two retrospective cohort trials were enrolled
in this study (Fig. 1).
The basic information of the eight included studies is
shown in Table 1. These studies were published from
2010 to 2015, including four RCTs [
prospective cohort trials [
], and two retrospective
cohort trials [
]. Patients with open fracture or radial
nerve injury were excluded in five trials [
19, 22, 24–26
Two studies included patients with radial nerve injury
but excluded Gustilo-Anderson [
] III open fractures
]. One paper excluded Gustilo-Anderson open
fractures  classified IIIb or IIIa and patients with
radial nerve injury [
]. A total of 391 patients were
evaluated which covered 196 patients in the MIPO group and
195 patients in the CFT group. There were three papers
comparing MIPO with IMN [
19, 20, 26
] and five papers
comparing MIPO with ORPO [
]. Among 196
patients treated by MIPO, 60 patients were compared with
61 patients treated by IMN and 136 patients were
compared with 134 patients treated by ORPO.
RCT randomized controlled trial, Retro retrospective cohort study, Pro prospective cohort study, MIPO minimally invasive plate osteosynthesis, CFT conventional
fixation techniques, N/A not available, DCP dynamic compression plate, LCP locking compression plate, IMN intramedullary nail. * AO/OTA classification
Risk of bias assessment
The risk of bias assessment of the four included RCTs is
shown in Table 2. All the RCTs described adequate
methods of random sequence generation [
However, only one paper described allocation concealment
. All trials were reported as high risk since it was
impossible to perform blinding of participants and
personnel. We regarded these studies as low risk of
incomplete outcome data addressed because only seven
patients lost to follow-up. All of the included RCTs
provided the outcomes in detail. The risk of bias of the
included cohort trials evaluated with the Newcastle–
Ottawa Scale is demonstrated in Table 3. All these
cohort trials had a score over 5.
Postoperative clinical function (UCLA, MEPS)
Shoulder function was assessed using the UCLA score in
six studies [
20–23, 25, 26
]. Among these studies, four
papers were correlated to the ORPO subgroup [
and others were correlated to the IMN subgroup [
Meta-analysis showed no significant difference in the
ORPO subgroup (WMD = −0.32, 95 % CI −1.40–0.75,
p = 0.56; I2 = 89 %; p < 0.01) or the IMN subgroup
(WMD = 1.87, 95 % CI 0.02–3.71, p = 0.05; I2 = 30 %;
p = 0.23). Pool analysis of all studies also did not
reveal any significant difference between the MIPO
group and the CFT group for the UCLA score
(WMD = 0.16, 95 % CI −0.91–1.22, p = 0.77; I2 = 88 %;
p < 0.01) (Fig. 2).
MEPS was applied to evaluate elbow function in six
19, 21–23, 25, 26
]. Among these studies, four
papers were correlated to the ORPO subgroup [
] and the other two papers were correlated to the
IMN subgroup [
]. Meta-analysis showed that
MEPS was significantly higher in the MIPO group than
in the IMN group (WMD = 3.5, 95 % CI 1.53–5.47; p =
0.0005). There was no significant difference between the
two arms either in the ORPO subgroup (WMD = 0.42,
95 % CI −0.11–0.95, p = 0.12; I2 = 0 %; p = 0.62) or in the
total studies (WMD = 0.82, 95 % CI −0.47–2.11, p = 0.21;
I2 = 62 %; p = 0.03) (Fig. 2).
Complications and iatrogenic radial nerve palsy
All of the included studies reported the outcome of
complications. The pooled data demonstrated a higher
complication rate in the CFT group than in the MIPO
group (RR = 0.35, 95 % CI 0.19–0.66, p = 0.001; I2 = 0 %;
p = 0.62). Subgroup analysis showed that the
complication rate in ORPO was significantly higher than that in
MIPO (RR = 0.24, 95 % CI 0.11–0.55, p = 0.0007; I2 =
0 %; p = 0.59). However, no significant difference was
detected in the IMN subgroup (RR = 0.66, 95 % CI 0.24–
1.76, p = 0.40; I2 = 0 %; p = 0.62) (Fig. 3).
Iatrogenic radial nerve palsy was also available in all of
the included papers. Meta-analysis showed that the rate of
iatrogenic radial nerve palsy was significantly higher in the
CFT group than that in the MIPO group (RR = 0.25, 95 %
CI 0.09–0.69, p = 0.007; I2 = 0 %; p = 0.86). Subgroup
analysis also detected a significant difference between
MIPO and ORPO (RR = 0.24, 95 % CI 0.08–0.74, p = 0.01;
I2 = 0 %; p = 0.75). However, subgroup analysis did not
reveal any significant difference between MIPO and IMN
(RR = 0.29, 95 % CI 0.03–3.01, p = 0.30) (Fig. 3).
Fracture union rate and union time
Data regarding fracture union was reported in all of
the included studies. No significant difference was
detected either in the ORPO subgroup (RR = 1.17,
95 % CI 0.40–3.45, p = 0.77; I2 = 8 %; p = 0.35) or in
the IMN subgroup (RR = 3.30, 95 % CI 0.33–33.05,
p = 0.31; I2 = 0 %; p = 0.96). Moreover, the pooled
estimate also showed no significant difference between
the MIPO group and the CFT group (RR = 1.45,
95 % CI 0.55–3.78, p = 0.45; I2 = 0 %; p = 0.58)
Fracture union time was available in six trials [
21–23, 25, 26
]. Four papers were correlated to the
ORPO subgroup [
], and the other two were
correlated to the IMN subgroup [
]. When all
studies were considered, meta-analysis did not find
any significant difference between the MIPO and
CFT groups (WMD = −0.22, 95 % CI −0.41–0.97, p =
0.72; I2 = 59 %; p = 0.03). Subgroup analysis also did
not detect any significant difference in the ORPO
Benegas 2014 
Kim 2015 [
Esmailiejah 2015 [
subgroup (WMD = −1.91, 95 % CI −5.15–1.32 p =
0.25; I2 = 75 %; p = 0.008) or the IMN subgroup
(WMD = 0.36, 95 % CI −0.53–1.26, p = 0.43; I2 = 0 %;
p = 0.64) (Fig. 4).
Operative time and radiation exposure time
Seven studies reported the data of operative time [
]. Subgroup analysis also did not find any significant
difference in the ORPO subgroup (WMD = −7.41, 95 %
CI −21.54–6.73, p = 0.30; I2 = 64 %; p = 0.02) or in the
IMN subgroup (WMD = −4.87, 95 % CI −58.05–48.30,
p = 0.86; I2 = 95 %; p < 0.01). Meta-analysis of total
data revealed that the difference was not statistically
significant between the MIPO group and the CFT
group (WMD = −8.66, 95 % CI −25.61–8.29, p = 0.32;
I2 = 88 %; p < 0.01) (Fig. 5).
Since fluoroscopy was not applied in the ORPO
subgroup, two paper correlated to the IMN group provided the
data of radiation exposure time during surgery [
Pooled analysis did not detect any significant difference
between IMN and MIPO (WMD = −16.35, 95 % CI −95.08–
62.39, p = 0.68; I2 = 82 %; p = 0.02) (Fig. 5).
Although ORPO remains the main standard of operative
fixation for humeral shaft fractures, this technique has
certain disadvantages of extensive incision, increased
incidence of iatrogenic radial nerve palsy, high risk of
infection, and violation of the fracture site blood
3, 5, 10
]. Therefore, in consideration of ORPO,
IMN, and MIPO, no consensus has been reached on
Fig. 3 Forest plot illustrating complications and iatrogenic radial nerve palsy of meta-analysis MIPO with CFT (ORPO and IMN) in humeral
the optimal technique for humeral shaft fractures.
Our meta-analysis did not detect any significant
difference between MIPO and CFT (IMN and ORPO) in
terms of operative time, fracture union rate, and
fracture union time. In other words, compared with CFT,
MIPO did not have the advantages of a higher
fracture union rate or earlier union time.
Due to biomechanical characteristics and
loadsharing capacity of the implant, IMN has achieved
satisfying results in humeral shaft fractures.
However, shoulder problems after IMN surgery also
attract numerous orthopedic surgeons’ attention [
]. Injuries of the rotator cuff and impingement
caused by prominent nail end are thought to be the
main reasons for shoulder disfunction. Although
subgroup analyses did not demonstrate any significant
difference in the UCLA score between MIPO and
IMN (p = 0.05), the result might be changed provided
that the sample size was increased. Retrograde IMN
approach is usually adopted to prevent shoulder
problems. However, this benefit is obtained at the cost of
supracondylar fracture and elbow problems [
Three papers in the IMN subgroup estimated the
elbow function by the Broberg-Morrey score or MEPS.
There was no significant difference in elbow function
between IMN and MIPO in An or Benegas’s studies
], where only antegrade IMN approach was
used. Interestingly, in Lian’s trial , where antegrade
or retrograde IMN approach was applied, the MEPS in
MIPO was significantly higher than that in IMN. In
contrast, no significant difference was revealed in the
UCLA score or MEPS between MIPO and ORPO.
Regarding the safety of therapies, the total
complication rate of MIPO was 5.14 % (7/136) while the
total complication rate of ORPO was 20.15 % (27/
134) in the ORPO subgroup. Subgroup analyses
detected a significant difference in the complication
rate between MIPO and ORPO (p < 0.01). However,
no significant difference was observed in the
complication rate between MIPO and IMN. During the
ORPO surgery, the radial nerve was dissected and
the fracture site was exposed which resulted in
disruption of periosteal blood supply. It was not
surprising that the main complications reported in the
ORPO subgroup were iatrogenic radial nerve palsy,
nonunion, and infection.
Since injury of the radial nerve is a disastrous
intraoperative complication in humeral shaft fractures,
iatrogenic radial nerve palsy was evaluated separately in our
meta-analysis. MIPO, as previously noted, has the
advantage of no need for radial nerve exposure [
total rate of iatrogenic radial nerve palsy in MIPO was
2.20 % (3/136) in five studies, which was significantly
lower than that in ORPO (10.45 %, 14/134, p = 0.01).
However, rich anatomical knowledge and long learning
curve is required for MIPO. Otherwise, MIPO may lead
to a high rate of radial nerve palsy or nonunion. Since
the radial nerve was not dissected in IMN surgery either,
subgroup analysis did not reveal any significant
difference in iatrogenic radial nerve palsy between MIPO and
IMN (p = 0.30).
There are some limitations in this study. First of
all, only eight articles covering 391 patients were
included in this meta-analysis, of which only four were
RCTs. This may weaken the strength of the evidence
of this paper. Secondly, there were some
confounding factors such as confirmation of complication.
Pooling such data may lead to bias. At last, some
baseline characteristics were different among the
trials. There are various internal implants in the
included studies, such as dynamic compression plate,
locking compression plate, reamed IMN, or
undreamed IMN. This may have potential effects on
clinical and radiological outcomes.
In summary, based on the present evidence, MIPO is
a better choice for treating humeral shaft fractures
than CFT, though there is no significant difference
between MIPO and CFT in terms of operative time,
fracture union rate, and fracture union time. MIPO
has a less rate of complications and iatrogenic radial
nerve palsy than that of ORPO and higher adjacent
joint function scores than those of IMN. However,
more high-quality randomized trials are still needed
to further confirm this conclusion in the future.
The authors declare that they have no competing interests.
XQH and SLG conceived and designed the experiments. XQH, SQX, and HGL
performed the experiments. XQH, XZ, BC, and XJH analyzed the data. JPD
and ZWZ contributed the reagents/materials/analysis tools. XQH and SLG
wrote the paper. All authors read and approved the final manuscript.
This work was supported by Jiaxing Science and Technology Bureau
Foundation (Grant number: 2014AY21031-5).
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