Is surgical treatment better than non-surgical treatment for proximal humeral fracture in elderly people? A meta-analysis and meta-regression.

Abstract

Purpose: This systematic review, meta-analysis, and meta-regression aims to determine whether surgical treatment for proximal humeral fractures is superior to non-surgical treatment regarding pain, functionality, complications, and new surgery rates.

Methods: We systematically reviewed clinical trials from PubMed (MEDLINE), EMBASE, Web of Science, Scopus, and Cochrane up to April 2024. Data comparing surgical or conservative of proximal humeral fractures were retrieved for outcomes of pain, functionality, adverse events, and new surgeries. We conducted meta-analyses and meta-regressions using average age as the independent variable (x-axis) and the main outcomes as the dependent variable (y-axis). For all analyses, a p value lower than 0.05 was considered statistically significant.

Results: Thirteen articles were included in the final analysis, with most follow-up times occurring at 3, 4, 6, 12, and 24 months. The surgical interventions included ORIF, conventional arthroplasty or reversed. Significant differences favoring of surgery were found for functionality at 6 months (SMD = - 0.238; 95% CI - 0.381 to - 0.096, p = 0.001), and for Constant score at 12 months (RMD = - 4.077; 95% CI - 7.034 to - 1.120, p = 0.007). Subgroup analysis showed significant results favoring arthroplasty at 12 months for the Constant score (RMD = - 4.563; 95% CI - 8.104 to - 1.023, p = 0.012). Meta-analysis for complications indicated that the surgery group had significantly higher odds of complications (OR 4.20; 95% CI 2.054-8.591, p < 0.001). The occurrence of osteonecrosis showed no difference between the surgical and conservative groups (OR 0.57; 95% CI 0.167-2.012, p = 0.390). The odds ratio of reoperation were five times higher in the surgical group (OR 5.31; 95% CI 2.467-11.430, p < 0.001). Meta-regressions demonstrated a significant relationship between age and pain, functionality and quality of life at 12-months, with worse results in the conservative group as age increased.

Conclusion: The findings indicate a beneficial effect of surgery for proximal humeral fractures, but only for functionality scores at specific time points. However, the reoperation and complication rates were higher in the surgical group. With increasing age, the outcomes tend to be worse for the conservative group.

Level of evidence: 1A Systematic review of RCTs.