Operative vs non-operative management of displaced proximal humeral fractures in the elderly: A systematic review and meta-analysis of randomized controlled trials

Table 1 Characteristics chart of included studies

Ref.	Year	Country	Funding	Size	Age(mean)	Male (%)	Fracture classification system	Fracture type	Operative intervention	Non-operative intervention	Short term follow-up (mo)	Long term follow-up (mo)
Boons et al[24]	2012	The Netherlands	Industry funding	50	79.9	2	Neer	3 or 4 part fractures	Hemiar- throplasty	Immobilization of the shoulder	3	12
Fjalestad et al[9,25]	2010	Norway	Government funding	50	72.71	12	OTA	3 or 4 part fractures	ORIF with locking plate	Immobilization in a modified Velpeau bandage	3	12
Olerud et al[26]	2011	Sweden	Government funding	55	76.71	14.5	Neer	4 part fractures	Hemiar- throplasty	Immobilization by slings	4	12
Olerud et al[27]	2011	Sweden	Government funding	59	73.91	18.6	Neer	3 part fractures	ORIF-locking plate	Immobilization by slings	4	12
Stableforth[28]	1984	England	Not reported	32	67.91	21.9	Neer	4 part fractures	Neer prosthesis	Closed manipulation	Not applicable	Not applicable
Zyto et al[29]	1997	Sweden	Not reported	40	74	12.5	Neer	3 or 4 part fractures	ORIF-tension band technique	Immobilization by sling	No short term follow-up	50

¹Average weighted mean of the two arms. ORIF: Open reduction and internal fixation.

Table 2 Complications chart

	Operative					Non-operative
Ref.	Infection	Avascular necrosis	Nonunion	Nerve injury	Post-traumatic osteoarthritis	Infection	Avascular necrosis	Nonunion	Nerve injury	Post-traumatic osteoarthritis
Boons et al[24]	0	0	0	NR	NR	0	2	3	NR	NR
Fjalestad et al[9,25]	0	8	0	7	NR	0	13	2	6	NR
Olerud et al[26]	0	0	0	0	0	0	3	1	0	5
Olerud et al[27]	2	3	1	0	3	0	2	1	1	2
Stableforth[28]	1	NR	NR	NR	NR	0	NR	NR	NR	NR
Zyto et al[29]	2	1	1	NR	2	0	0	0	NR	2
Total	5	12	2	7	5	0	20	7	7	9

NR: Not reported.

Table 3 Grading of Recommendations Assessment, Development, and Evaluation summary findings: Operative vs non-operative treatment in proximal humeral fractures

Outcomes	No. of Participants(studies)	Quality of the evidence (GRADE)	Relative effect(95%CI)	Anticipated absolute effects
	Follow up				Risk difference between non-operative and operative1 (95%CI)
Physical Function by Constant score - long term	229 (5 studies)	Moderate due to risk of bias			The mean physical function by constant score-long term in the intervention group was 1.63 higher (2.84 lower to 6.11 higher)
Health Related Quality of Life - long term	154 (3 studies)	Moderate due to risk of bias			The mean health related quality of life - long term in the intervention group was 0.23 standard deviations higher (0.09 lower to 0.54 higher)
Constant pain - long term	229 (5 studies)	Low due to risk of bias, inconsistency			The mean Constant pain - long term in the intervention group was 0.28 higher (1.01 lower to 1.57 higher)
Mortality rate	247 (5 studies)	Moderate due to risk of bias	RR 1.14 (0.45 to 2.86)	Study population
				56 per 1000	8 more per 1000 (from 31 fewer to 105 more)
				Moderate
				63 per 1000	9 more per 1000 (from 35 fewer to 117 more)
Re-operation Rate	247 (5 studies)	Low due to risk of bias, imprecision	RR 3.62 (1.38 to 9.49)	Study population
				32 per 1000	85 more per 1000 (from 12 more to 274 more)
				Moderate
				36 per 1000	94 more per 1000 (from 14 more to 306 more)

¹The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95%CI). RR: Risk ratio; GRADE Working Group grades of evidence: High quality: Further research is very unlikely to change our confidence in the estimate of effect; Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate; Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate; Very low quality: We are very uncertain about the estimate.