Surgical treatment is not superior to nonoperative treatment for displaced proximal humerus fractures: a systematic review and meta-analysis

Background: The purpose of this study was to perform a systematic review and meta-analysis of both randomized controlled and observational studies comparing conservative to surgical treatment of displaced proximal humerus fractures. Methods: We performed a systematic review of Medline, Embase, Scopus, and Google Scholar articles comparing surgical treatment to conservative treatment, including all level 1-3 studies from 2000 to 2022. Clinical outcome scores, range of motion, and complications were evaluated. Risk of bias was assessed using the Cochrane Collaboration's ROB2 tool and ROBINs-I tool. The GRADE system was used to assess the quality of the body of evidence, and heterogeneity was assessed using χ² and I² statistics. Twenty-two studies were incorporated into the analysis. Ten studies had a high risk of bias, and all included studies were of low quality. Results: The pooled estimates failed to identify differences for clinical outcomes (P = .208), abduction (P = .275), forward flexion (P = .447), or external rotation (P = .696). Complication rates between groups were significantly lower (P = .00001) in the conservative group. Conclusions: This meta-analysis demonstrated that there were no statistically significant differences for either clinical outcomes or range of motion between surgically managed and conservatively treated displaced proximal humerus fractures. The overall complication rate was 3.3 times higher, following surgical treatment. The validity of this result is compromised by the high risk of bias and very low level of certainty of the included studies, and the conclusion must therefore be interpreted with caution.