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Dynamic compression plating versus locked intramedullary nailing for humeral shaft fractures in adults

  1. Harish Kurup1,*,
  2. Munier Hossain2,
  3. J Glynne Andrew2

Editorial Group: Cochrane Bone, Joint and Muscle Trauma Group

Published Online: 15 JUN 2011

Assessed as up-to-date: 17 FEB 2011

DOI: 10.1002/14651858.CD005959.pub2


How to Cite

Kurup H, Hossain M, Andrew JG. Dynamic compression plating versus locked intramedullary nailing for humeral shaft fractures in adults. Cochrane Database of Systematic Reviews 2011, Issue 6. Art. No.: CD005959. DOI: 10.1002/14651858.CD005959.pub2.

Author Information

  1. 1

    Stoke Mandeville Hospital, Aylesbury, Buckinghamshire, UK

  2. 2

    North West Wales NHS Trust, Department of Orthopaedics, Bangor, Wales, UK

*Harish Kurup, Stoke Mandeville Hospital, Aylesbury, Buckinghamshire, HP21 8AL, UK. harishvk@yahoo.com.

Publication History

  1. Publication Status: New
  2. Published Online: 15 JUN 2011

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Characteristics of included studies [ordered by study ID]
Bolano 1995

MethodsRandomised trial. Randomisation method unknown
Minimum follow-up unknown


ParticipantsDepartment of Orthopaedic Surgery, University of Kentucky
25 participants with humeral shaft fractures (no data on timing of surgery)


InterventionsPlating: dynamic compression plating (13 participants)
Nailing: intramedullary nailing (12 participants)
Age: no details
Males: no details


OutcomesFracture union
Intraoperative fracture comminution
Shoulder impingement
Radial nerve palsy
(As reported in the main abstract)


NotesData are taken from a conference abstract. The study author confirmed that the trial was never published in full. However, attempts to clarify further details of this study with the author have been unsuccessful.
A second abstract reporting this trial reported 28 participants (14 in each group) and different results for non union than in the main abstract report.


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Unclear riskNot stated

Changulani 2007

MethodsRandomised trial. Use of sealed envelopes
Minimum follow-up: 6 months (mean follow-up: 14.3 months)


ParticipantsOrthopaedics Department at King George Medical University College, Lucknow, India
47 participants with fractures of shaft of humerus. Inclusion criteria included grades 1 and 2a open fractures, polytrauma, early failure of conservative treatment, and unstable fractures. "Most of the cases in both groups were more than 7 days old because initially conservative methods had been tried." Mean time from injury was 38 days in the plating group and 45 days in the nailing group.
Age: mean 35 years (plate), 39 years (nail group).
Males: 83%
Two participants lost to follow-up (4.2%).


InterventionsPlating: AO 4.5 mm DCP (24 participants)
Nailing: Russell-Taylor nail, reamed, antegrade, locked both distally and proximally (23 participants)

Seven participants in the plate group and 12 participants in the nail group also had autogenous iliac crest bone grafts.


OutcomesASES (American Shoulder and Elbow Surgeons) score
Ability to return to previous occupation
Fracture union
Infection
Nerve injury
Implant failure
Restriction of shoulder abduction


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Unclear riskSealed envelopes

Chapman 2000

MethodsRandomised trial, sealed envelope technique
Mean follow-up: 13 months (range 4 to 48 months)


ParticipantsHarborview Medical Centre, Seattle, Washington, USA
89 participants with acute humeral shaft fractures (but 84 included in trial - see notes). Both open and closed fractures included. Mean time from injury was 5.5 days (range 0 to 34 days) in the plating group and 3.9 days (range 0 to 21 days) in the nailing group.
Age (of 84): Mean 33 years (range from 18 to 83)
Males: 60.7%
No loss to follow-up reported


InterventionsPlating: 4.5 mm Synthes DCP or LC-DCP (46 participants)
Nailing: Russell-Taylor humeral interlocking nail, antegrade, reaming and number of locking screws at discretion of surgeon (38 participants)

Autogenous iliac crest bone grafting performed within 3 weeks of initial stabilization in 3 open fractures in plate group and 1 in nail group.


OutcomesFracture union
Deep infection
Reflex sympathetic dystrophy
Secondary radial or posterior interosseous nerve palsy
Shoulder pain
Elbow pain
Decreased shoulder ROM
Decreased elbow ROM
Hardware requiring removal


NotesAlthough 89 were randomised into the trial, 5 patients in the nail group were treated with Ender nails according to surgeon's preference.


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Unclear riskSealed envelopes

Kesemenli 2003

MethodsRandomised trial
Follow-up: 28 to 72 months (mean 42 months)


ParticipantsSingle centre trial, teaching hospital in Turkey (Dicle Universitesi Tip Fakültesi at Diyarbakir)
60 participants with fracture of humerus shaft (AO types A, B and C included). "In the poly-traumatic cases where acceptable reduction could not be achieved bu conservative methods, fragmented and unstable fractures were treated surgically." No information on timing of surgery provided.
Age: plate group 33 years (range from 19 to 47); nail group 42 years (range from 21 to 61).
Males: 71.6%.
Loss to follow-up not reported.


InterventionsPlating: 4.5 mm dynamic compression plate and screws (27 participants)
Nailing: Antegrade humeral nail, locked proximally and distally (33 participants)


OutcomesFracture union
Infection
Shoulder impingement
Iatrogenic radial nerve injury
Fracture healing time
Secondary surgery
Steward & Hundley criteria for functional results


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Unclear riskAuthors did not confirm method of allocation concealment.

McCormack 2000

MethodsRandomised trial.
Minimum follow-up: 6 months (mean: 14.3 months; range 6 to 33 months)


ParticipantsMulti-centre trial. Three tertiary care centres in Canada. Royal Columbian Hospital, New Westminster; University of Calgary and Foothills Medical Centre, Calgary; St. Michael's Hospital, Toronto
44 participants with fracture of humerus shaft. Inclusion criteria included open fractures, polytrauma, fracture instability and early failure of conservative treatment. No data on timing of surgery.
Age: plate group: mean 49 years (range from 20 to 81), nail group: mean 40 years (range from 19 to 82).
Males: 63.6%.
2 participants died and one more lost to follow-up (6.8%).


InterventionsPlating: DCP. Type not specified (23 participants)
Nailing: Russell-Taylor locked humeral intramedullary nails, antegrade or retrograde, reaming when necessary (21 participants)

Four participants in the plate group had primary bone grafting.


OutcomesASES (American Shoulder and Elbow Surgeons) score
Iatrogenic radial nerve palsy
Late fracture
Fracture union
Intraoperative comminution
Infection
Severe impingement
Adhesive capsulitis of shoulder
Minimal loss of fixation
Visual analogue scale for pain
Time in theatre
Blood loss


NotesContact with the McCormack resulted in some clarification of the technique of randomisation, and raw data on blood loss, operating time and American Shoulder and Elbow Surgeons (ASES) score for the analyses.


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Unclear riskSealed envelopes

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Chiu 1997This randomised controlled trial used flexible Ender nails (not rigid/semi-rigid intramedullary nails which can be locked for rotational stability) which are not considered optimal fixation devices for long bone fractures like humerus.

Daglar 2007Retrospective series: 34 participants selected from a cohort of 75 participants with humeral fractures operated since 1999. Used inflatable intramedullary nails (not locked rigid/semi-rigid intramedullary nails which are considered optimal fixation devices).

Lin 1998The authors reported a prospective series of participants treated with locked nail and compared their results with a retrospective cohort treated with plate fixation.

Rodriguez-Merchan 1995This quasi-randomised trial used flexible Hackethal nails, which are not locked intramedullary nails.

Saleem 2010This comparative study of dynamic compression plating versus intramedullary interlocking nailing was not a randomised trial.

 
Characteristics of studies awaiting assessment [ordered by study ID]
Putti 2009

MethodsRandomised trial

Participants34 patients with humeral shaft fractures

InterventionsDynamic compression plate versus intramedullary nail

OutcomesASES (American Shoulder and Elbow Surgeons) score, fracture union, iatrogenic radial nerve palsy, iatrogenic fractures, shoulder impingement, infection, secondary surgery

Notes

Singisetti 2010

MethodsQuasi-randomised trial (odd and even hospital numbers)

Participants45 patients with humeral shaft fractures

InterventionsDynamic compression plate versus intramedullary nail (Russell-Taylor)

OutcomesFunction based on Roderiguez-Merchan criteria, fracture union, iatrogenic radial nerve palsy, iatrogenic fractures, shoulder impingement, range of movement restriction at shoulder and elbow, infection

Notes

 
Comparison 1. Compression plating versus locked intramedullary nailing

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Fracture union5255Risk Ratio (M-H, Fixed, 95% CI)1.05 [0.97, 1.13]

 2 Operating time (minutes)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

 3 Blood loss (ml)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

 4 Iatrogenic radial nerve injury5255Risk Ratio (M-H, Fixed, 95% CI)1.21 [0.49, 2.97]

 5 Intraoperative fracture comminution3150Risk Ratio (M-H, Fixed, 95% CI)0.40 [0.09, 1.71]

 6 Infection4232Risk Ratio (M-H, Fixed, 95% CI)2.69 [0.75, 9.58]

 7 Shoulder impingement5255Risk Ratio (M-H, Fixed, 95% CI)0.12 [0.04, 0.38]

 8 Restriction of shoulder range of movement2129Risk Ratio (M-H, Fixed, 95% CI)0.08 [0.01, 0.58]

 9 Elbow impingement1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 10 Restriction of elbow range of movement1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 11 Need for removal of metalwork3150Risk Ratio (M-H, Fixed, 95% CI)0.17 [0.04, 0.76]

 12 Return to pre-injury occupation1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 13 ASES score (0 to 52, higher values = better)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

 14 Good functional outcome (Steward and Huntley criteria)160Risk Ratio (M-H, Fixed, 95% CI)1.09 [0.88, 1.34]

 
Table 1. Quality assessment tool

ItemScore

1. Was the assigned treatment adequately concealed prior to allocation?Score Y if method did not allow disclosure of assignment.
Score ? if small but possible chance of disclosure of assignment or unclear.
Score N if quasi-randomised or open list/tables.

2. Were the outcomes of trial participants who withdrew or who were excluded after allocation described and included in analysis (intention-to-treat)?Score Y if withdrawals well described and accounted for in analysis.
Score ? if withdrawals described and analysis not possible.
Score N if no or inadequate mention or obvious differences and no adjustment.

3. Were the two different treatment groups adequately described at entry and if so were the groups well matched or appropriate adjustment made?Score Y if at least four admission details given (e.g. age, sex, dominant or non-dominant limb, fracture type, level of mobility) with no significant difference between groups or appropriate adjustment made.
Otherwise score N.

4. Did the surgeons have experience of the operations they performed in the trial, prior to its commencement?Score Y if text states there was an introductory period or that surgeons were experienced.
Otherwise score N.

5. Were the care programmes other than trial options (bracing, physiotherapy) identical?Score Y if text states so.
Otherwise score N.

6. Were the outcome measures clearly defined in the text with a definition of any ambiguous terms encountered?Score Y if yes.
Otherwise score N.

7. Are any other confounding factors mentioned which might have impact on the outcome (smoking, diabetes etc.)Score Y if yes.
Otherwise N.

8. Were the outcome assessors blind to assignment status?Score Y if assessors of pain and function at follow-up were blinded to treatment method.
Otherwise score N.

9. Was loss to follow-up reported and if so, was it less than 5% of participants?Score Y if yes.
Otherwise score N.

10. Were the participants in all groups followed up and data collected in the same way, reviewed at same time intervals?Score Y if yes.
Otherwise score N.

11. Were the participants followed up for an adequate period?Score Y if followed up for a minimum of one year.
Otherwise score N.

 
Table 2. Quality assessment results for included studies

ItemsQuality assessment results for included studies

Bolano 1995Changulani 2007Chapman 2000Kesemenli 2003McCormack 2000

1. Was the assigned treatment adequately concealed prior to allocation??????

2. Were the outcomes of trial participants who withdrew or who were excluded after allocation described and included in analysis (intention-to-treat)?NNNNN

3. Were the two different treatment groups adequately described at entry and if so were the groups well matched or appropriate adjustment made?NYYYY

4. Did the surgeons have experience of the operations they performed in the trial, prior to its commencement?NYNNY

5. Were the care programmes other than trial options (bracing, physiotherapy) identical?NNYNN

6. Were the outcome measures clearly defined in the text with a definition of any ambiguous terms encountered?NYYNY

7. Are any other confounding factors mentioned which might have impact on the outcome (smoking, diabetes, etc.)NNNNN

8. Were the outcome assessors blind to assignment status?NNNNN

9. Was loss to follow up reported and if so, was it less than five per cent of participants?NYNNY

10. Were the participants in all groups followed up and data collected in the same way, reviewed at same time intervals?NYYYN

11. Were the participants followed up for an adequate period?NNNYN