TRAUMA
Intramedullary Nail versus Dynamic Compression Plate Fixation in Treating Humeral Shaft Fractures: Grading the Evidence through a Meta-Analysis
OrthoEvidence Journal (OE Journal) - ACE Report
OE Journal. 2014;2(7):38 PLoS One. 2013 Dec 16;8(12):e82075. doi: 10.1371/journal.pone.008207510 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.
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?
Sí = 1
Incierto = 0,5
No relevante = 0
No = 0
La evaluación de los criterios de información evalúa la transparencia con la que los autores informan de las características metodológicas y del ensayo dentro de la publicación. La evaluación se divide en cinco categorías que se presentan a continuación.
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
El Índice de Fragilidad es una herramienta que ayuda en la interpretación de hallazgos significativos, proporcionando una medida de fuerza para un resultado. El Índice de Fragilidad representa el número de eventos consecutivos que es necesario añadir a un resultado dicotómico para que el hallazgo deje de ser significativo. Un número pequeño representa un hallazgo más débil y un número grande un hallazgo más fuerte.
¿Por qué se necesitaba ahora este estudio?
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.
¿Cuál era la pregunta principal de la investigación?
Is intramedullary nailing (IMN) or dynamic compression plating (DCP) superior in the surgical treatment of humeral shaft fractures?
¿Cuáles fueron los hallazgos importantes?
- 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).
¿Qué es lo que más debo recordar?
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.
¿Cómo afectará esto al cuidado de mis pacientes?
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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