Surgical management of complex proximal humerus fractures - A systematic review of 92 studies including 4500 patients

Objectives: To compare the outcomes of open reduction and internal fixation (ORIF), closed reduction and percutaneous pinning, hemiarthroplasty (HA), and reverse shoulder arthroplasty (RSA) for proximal humerus fractures.

Data Sources: The search was performed on September 9, 2012 using an explicit search algorithm in the following databases: Medline, SportDiscus, CINAHL, and Cochrane Central Register of Controlled Trials. Inclusion criteria were English language studies reporting clinical outcomes after surgical treatment of 3-or 4-part proximal humerus fractures with a minimum of 1-year follow-up.

Study Selection: English language studies reporting clinical outcomes after surgical treatment of 3-or 4-part proximal humerus fractures with a minimum of 1-year follow-up. Levels 1-4 studies were eligible for inclusion.

Data Extraction: Study methodological quality and bias was evaluated using the Modified Coleman Methodology Score.

Data Synthesis: Two-proportion Z test and multivariate linear regression analyses were used for group comparisons.

Conclusions: Significantly better clinical outcomes were observed for ORIF over HA and RSA (American Shoulder and Elbow Score, Disabilities of Arm, Shoulder, and Hand, Constant) (P < 0.05). However, ORIF had a significantly higher reoperation rate versus HA and RSA (P < 0.001 for both). Comparing HA with RSA, there was no difference in any outcome measure. The rate of tuberosity nonunion was 15.4% in the HA group. There were more complications following closed reduction and percutaneous pinning versus ORIF, HA, and RSA (P < 0.05). ORIF for proximal humerus fractures demonstrates better clinical outcome scores but with a significantly higher reoperation rate. HA and RSA are effective as well, but tuberosity nonunion remains a concern with HA.