Compression plating versus intramedullary nailing of humeral shaft fractures—a meta-analysis

Figures & data

Table 1.  Study characteristics

Published studies	Plate	Nail	Men %	Age (range)	Closed fracture %	Ante-grade %	Location			Concealed randomization	Blinding %	FU	QS
							prox	mid	dist
Chapman et al. 2000	46	38	61	33.5 (18–83)	76	100RT	16	57	27	sealed envelope	No	100	76
McCormack et al. 2000	23	21	64	44.5 (19–82)	89	62 RT	diaphyseal			Sealed envelope	No	93	75
Rodriguez-Merchan 1995	20	20	78	46.0 (20–65)	100	0 HK	–	100	–	NA	No	100	38

P: plate; N: nail; FU: follow up; QS: quality score; NA: not available; RT: Russell-Taylor nail, HK: Hackethal.

Table 2.  Results of statistical pooling

Outcome	N	Odds ratio (95% CI)	Relative risk (95% CI)	P-value	Heterogeneity P-value	I2%
Reoperation	155	0.24 (0.10–0.87)	0.26 (0.07–0.88)	0.03	0.5	10
Nonunion	155	0.54 (0.17–1.9)	0.57 (0.18–1.8)	0.3	0.3	25
Infection	128	2.30 (0.34–16)	2.20 (0.36–14)	0.4	0.8	0
Shoulder impingement	155	0.09 (0.03–0.50)	0.10 (0.03–0.42)	0.002	0.7	0
Radial nerve palsy	128	0.24 (0.04–1.6)	0.26 (0.04–1.6)	0.1	0.5	10

Figure 1. Statistical pooling of 3 studies (155 patients) revealed that plate fixation results in a signifiant reduction in reoperation rates (p = 0.03) as compared to intramedullary nail fixation.

Figure 2. Statistical pooling of 3 studies (155 patients) revealed that plate fixation results in a significant reduction in shoulder impingement and pain (p = 0.002) as compared to intramedullary nail fixation.

Table 3.  Sensitivity analysis—reoperation rates

	No. of studies	Relative risk (95% CI)
Publication status
published	2	0.45 (0.19–1.1)
unpublished	1	0.15 (0.02–1.1)
Quality score
< 50	2	0.41 (0.16–1.0)
< 50	1	0.27 (0.02–3.6)
Randomization
concealed	2	0.45 (0.19–1.1)
unconcealed	1	0.15 (0.02–1.1)
Nail insertion a
antegrade	2	0.28 (0.05–1.5)
retrograde	1	0.58 (0.09–3.9)

^a Individual data on retrograde and antegrade nailing from McCormack et al. (2006) was abstracted.

Figure 3. Cumulative meta-analysis assessing the effect of compression plating and intramedullary nailing on the need for reoperation in patients with humeral shaft fractures. The Lan-DeMets (LD) sequential monitoring boundary, which assumes a 27% control event rate (i.e. patients receiving intramedullary nailing) and a 25% relative risk reduction with 80% power and a two-sided alpha of 0.05, has not been crossed—indicating that the cumulative evidence is inconclusive.

Chapman J. R., Henley M. B., Agel J., Benca P. J. Randomized prospective study of humeral shaft fracture fixation: Intramedullary nails versus plates. J Orthop Trauma. 2000; 14: 162–6

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McCormack R. G., Brien D., Buckley R. E., McKee M. D., Powell J., Schemitsch E. H. Fixation of fractures of the shaft of the humerus by dynamic compression plate or intramedullary nail: A prospective randomized trial. J Bone Joint Surg (Br). 2000; 82: 336–9

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