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Dynamic compression plates possibly advantageous in treatment of humeral shaft fracture
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April 2014
Dynamic compression plates possibly advantageous in treatment of humeral shaft fracture
Study Type:Meta analysis
OE Level Evidence:2
Journal Level of Evidence:N/A
Intramedullary Nail versus Dynamic Compression Plate Fixation in Treating Humeral Shaft Fractures: Grading the Evidence through a Meta-Analysis
PLoS One. 2013 Dec 16;8(12):e82075. doi: 10.1371/journal.pone.0082075Did you know you're eligible to earn 0.5 CME credits for reading this report? Click Here
Synopsis
10 studies (8 randomized and 2 quasi-randomized controlled trials) were included in this analysis comparing intramedullary nails and dynamic compression plates in the treatment of humeral shaft fractures. The results indicated that while fracture union, functional outcome, and rates of radial nerve injury and infection were similar between treatments, intramedullary nails were associated with higher incidences of intraoperative fracture communition, shoulder impingement, restricted range of motion, implant failure, and re-operation. The strength of these findings were limited by the low quality of evidence, as evaluated using the GRADE system.
Publication Funding Details
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Funding:
Non-Industry funded
Sponsor:
National Natural Science Foundation of China; National Natural Science Foundation of Tianjin; Scientific and Technological Project of Tianjin Public Security Bureau; Key Technologies & Program of Tianjin; Scientific and Technological Project of Tianjin Public Health Bureau
Conflicts:
None disclosed
Were the search methods used to find evidence (original research) on the primary question or questions stated?
Was the search for evidence reasonably comprehensive?
Were the criteria used for deciding which studies to include in the overview reported?
Was the bias in the selection of studies avoided?
Were the criteria used for assessing the validity of the included studies reported?
Was the validity of all of the studies referred to in the text assessed with use of appropriate criteria (either in selecting the studies for inclusion or in analyzing the studies that were cited)?
Were the methods used to combine the findings of the relevant studies (to reach a conclusion) reported?
Were the findings of the relevant studies combined appropriately relative to the primary question that the overview addresses?
Were the conclusions made by the author or authors supported by the data and or analysis reported in the overview?
How would you rate the scientific quality of this evidence?
Yes = 1
Uncertain = 0.5
Not Relevant = 0
No = 0
The Reporting Criteria Assessment evaluates the transparency with which authors report the methodological and trial characteristics of the trial within the publication. The assessment is divided into five categories which are presented below.
3/4
Introduction
4/4
Accessing Data
3/4
Analysing Data
4/4
Results
2/4
Discussion
Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65
The Fragility Index is a tool that aids in the interpretation of significant findings, providing a measure of strength for a result. The Fragility Index represents the number of consecutive events that need to be added to a dichotomous outcome to make the finding no longer significant. A small number represents a weaker finding and a large number represents a stronger finding.
Why was this study needed now?
Humeral shaft fractures represent a common site of traumatic injury, accounting for up to 3% of all fractures. While most elect to manage these conservatively, surgical intervention is often required in cases of complicated fractures. There are two current standout treatment options: intramedullary nailing or dynamic compression plating. However, there has been continuous debate over whether one option represents a superior method of treatment.
What was the principal research question?
Is intramedullary nailing (IMN) or dynamic compression plating (DCP) superior in the surgical treatment of humeral shaft fractures?
Study Characteristics
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Data Source:
The databases of MEDLINE, EMBASE, ScienceDirect, OVID, the Cochrane Central, and Google Scholar were search for articles published up to February 2013. The WHO International Clinical Trials Registry database, Current Controlled Trials, European Federation of National Associations of Orthopaedics and Traumatology, and British Orthopaedic Association Annual Congress were search for unpublished studies. A search was also performed of the reference lists of identified articles.
Index Terms:
The following terms were used for searches: humeral fractures, fracture fixation, intramedullary nails, and bone plates.
Study Selection:
Studies were selected for inclusion if they were randomized or quasi-randomized controlled trials (RCTs or qRCTs) which compared intramedullary nails and dynamic compression plates for humeral shaft fractures in patients 18 years of age or older. Case reports, and cadaver, model, or biomechanical studies were excluded. Studies with fractures within the proximal or distal ends of the humerus were also excluded. Selection was performed independently by two reviewers (MJX & XD), with disagreement resolved through discussion.
Data Extraction:
Data extraction was performed independently by two authors (MJX & XD) using a standardized extraction form, and verified by a third reviewer. Extracted outcomes included the incidence of fracture union, iatrogenic radial nerve injury, intraoperative fracture comminution, infection, shoulder impairment, restriction of shoulder range of motion, implant failure, and the American Shoulder and Elbow Surgeons (ASES) score.
Data Synthesis:
Data was pooled using Review Manager software (RevMan 5.1). Weighted mean differences (WMD) were calculated for continuous outcomes, and risk ratios (RR) were calculated for dichotomous outcomes, each with corresponding confidence intervals (95%CI). P<0.05 was considered statistically significant. Heterogeneity was assessed using Q statistics, with a fixed-effects model used with nonsignificant heterogeneity (P>0.05), and a random-effects model used in cases of significant heterogeneity. Publication bias was assessed using a funnel plot, Begg's funnel plots and Egger's bias test.
What were the important findings?
- A total of 10 studies met the criteria for inclusion; 8 randomized controlled trials and 2 quasi-randomized controlled trials. A total of 448 patients were included among the 10 publications.
- Meta-analysis of all 10 studies indicated no significant difference between IMN and DCP regarding fracture union (RR 0.96 (95%CI 0.90, 1.02)) (p=0.19).
- Among 3 studies, there was no significant difference between IMN and DCP in outcome on the American Shoulder and Elbow Surgeons (ASES) score (WMD -1.84 (95%CI -3.91, 0.22)) (p=0.08).
- Pooling of incidence of iatrogenic radial nerve injury from all 10 studies indicated no significant difference between IMN and DCP (RR 0.72 (95%CI 0.35, 1.47)) (p=0.37).
- Meta-analysis of 6 studies indicated that the incidence of intraoperative communition of the fracture was significantly higher with IMN compared with DCP (RR 3.14 (95%CI 1.02, 9.64)) (p=0.05).
- Pooled results from 9 included studies demonstrated no significant difference between IMN and DCP regarding incidence of infection (RR 0.48 (95%CI 0.19, 1.24)) (p=0.13).
- Pooled data from 7 studies indicated a significantly higher incidence of shoulder impingement with IMN compared to DCP (RR 7.32 (95%CI 2.64, 20.29)) (p=0.0001). Meta-analysis of 4 studies indicated a significantly higher risk of restricted shoulder ROM with IMN compared to DCP (RR 9.27 (95%CI 2.22, 38.72)) (p=0.002).
- The rate of implant failure was significantly higher with IMN compared to DCP (7 studies; RR 3.23 (95%CI 1.15, 9.06)) (p=0.03). The incidence of re-operation was also significantly higher with IMN compared to DCP (9 studies; RR 2.21 (95%CI 1.28, 3.81)) (p=0.005).
- The overall quality of evidence, as evaluated by the GRADE system, was judged to be very low. All studies were determined to have unclear or high risk of bias regarding allocation concealment (selection bias), participant and personnel blinding (performance bias), and assessor blinding (detection bias).
What should I remember most?
Analyses comparing intramedullary nailing and dynamic compression plating for humeral shaft fractures indicated that there was no significant difference between treatments for fracture union, functional outcome on the ASES, and incidences of radial nerve damage and infection. Intramedullary nailing was associated with higher risks of intraoperative communition, shoulder impingement, restricted ROM, implant failure, and re-operation. The low quality of evidence provided by the included studies limited the strength of these findings.
How will this affect the care of my patients?
The results of this analysis suggest that dynamic compression plating may be more advantageous in surgical intervention of humeral shaft fractures. Due the unclear or high risk of bias associated with the included studies, additional, methodologically sound randomized controlled trials are warranted for future comparisons between intramedullary nails and dynamic compression plates.
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