Rigid locked antegrade versus retrograde intramedullary nailing in treating acute humeral shaft fractures: a systematic review with meta-analysis.

Abstract

Purpose: There is a lack of consensus regarding the optimal intramedullary nailing (IMN) strategy for humeral shaft fractures (HSFs): both antegrade IMN (aIMN) and retrograde IMN (rIMN) are used. We aim to compare both strategies in terms of outcomes and complications.

Methods: MEDLINE, Embase and Cochrane Central Register of Controlled Trials databases were searched for articles in English or Spanish from inception to Nov 23, 2023. All studies reporting on primary treatment of acute HSFs (OTA/AO 12A, 12B, and 12C) with rigid locked IMN, in patients aged 16 years or older, were analyzed. Two independent reviewers screened studies for eligibility, performed data extraction, and used RoB 2, ROBINS-I and JBI's critical appraisal tools to assess bias of the included studies. Stata 18.0 software for data analysis was used. Subgroup analysis was performed to explore heterogeneity. We applied GRADE to appraise our evidence.

Results: Nine studies involving 565 fractures were included. aIMN showed significantly faster operative time than rIMN (MD = -14.40 min (95% CI: -17.75 to -11.04); I 2 = 0%; P < 0.001), and rIMN showed significantly higher odds of intraoperative fractures than aIMN (RD = 0.05% (95% CI: -0.08% to -0.02%); I 2 = 0%; P < 0.005). In contrast, aIMN showed significantly higher odds of worse shoulder function and pain complaints and worse Neer scores than rIMN (P = 0.02, P = 0.03 and P = 0.02, respectively).

Conclusions: Compared with rIMN, aIMN demonstrated a significantly faster operative time and lower rates of intraoperative fractures. Conversely, rIMN demonstrated lower rates of shoulder pain complaints and better shoulder function and Neer score outcomes.