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Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

Early management of proximal humeral fractures with hemiarthroplasty: a systematic review

G Kontakis, C Koutras, T Tosounidis, and P Giannoudis.

Review published: 2008.

Link to full article: [Journal publisher]

CRD summary

The authors found that there was no strong evidence to support the use of early hemiarthroplasty for treating shoulder fractures. In view of the questionable inclusion criteria, the limited search and suboptimal methods used to pool data in the review, these conclusions should be interpreted with some caution.

Authors' objectives

To evaluate the use of hemiarthroplasty for early management of fractures of the proximal humerus.


MEDLINE and EMBASE were searched to January 2008 for studies published in English. Search terms were reported.

Study selection

Studies of hemiarthroplasty for proximal non-pathological humeral fractures in skeletally mature patients were eligible for inclusion. Included studies had to report relevant data at a mean follow-up of at least 24 months for one of the following outcomes: range of movement, pain, function (evaluated using a scale), patient satisfaction, and complications. Studies were required to report relevant data for at least 15 participants and to present consistent data. Studies that evaluated other interventions as well as hemiarthroplasty were included, provided separate data could be extracted for the hemiarthroplasty group.

The mean age of participants in the included studies was 67.7 years (range 22 to 91 years) and 70% were women. In most cases, fractures were four-part fractures or fracture-dislocations. Most studies used more than one type of prosthesis; a total of 12 different first, second or third generation types were used. Individual surgeons in the review performed a mean of 2.96 procedures per year (range 0.21 to 9.6). Many participants received early passive movement the day after surgery, and active movement after union of the tuberosities at about six weeks, but overall rehabilitation regimes varied widely. Various different scoring systems were use to assess function; the Constant score was the most commonly used. The mean duration of follow-up in the included studies was 3.7 years (range 0.66 to 14 years).

Two reviewers selected the studies.

Assessment of study quality

Studies were allocated up to 10 points for the methodological quality and/or clear reporting of the following: inclusion/exclusion criteria; withdrawals and losses to follow-up; pre-specified follow-up; outcomes measures; and characteristics of interventions. Studies scoring less than 5 points for quality were excluded from the review.

Two reviewers independently conducted the validity assessment, with disagreements resolved by consensus.

Data extraction

Event rates and mean continuous measures (i.e. range of movement, in degrees) were extracted from each study for each outcome.

Methods of synthesis

Mean event rates and ranges of movement were calculated by adding the data for each study and dividing by the number of participants. These were reported descriptively in a narrative synthesis of studies, organised by outcomes.

Results of the review

Sixteen studies were included in the review (n=808 patients). All the studies were either retrospective comparative studies or case series.

Range of movement: After hemiarthroplasty, the mean active anterior elevation was 105.7 degrees (range 10 to 180 degrees, 11 studies, n=383 patients); the mean abduction was 92.4 degrees (range 15 to 170 degrees, four studies, n=87 patients); and the mean external rotation was 30.4 degrees (range 15 to 90 degrees, 11 studies, n=367 patients).

Pain: Over 83% of patients reported no pain or only mild pain after the hemiarthroplasty (14 studies, 529 patients).

Function (three studies): After hemiarthroplasty, the mean Constant score was 56.6 out of 100 (range11 to 98, eight studies, n=560 patients). Function was rated as excellent or satisfactory by 40% of patients (62 out of 155 patients).

Patient satisfaction (seven studies): Results were considered unsatisfactory after hemiarthroplasty by 41.6% of patients (121 out of 291 patients).

Complications (15 studies): Superficial infection was reported after hemiarthroplasty in 1.6% of cases and deep infection was reported in 0.6%. Complications associated with fixation and healing of the tuberosities were reported in 11.2% of cases, heterotopic ossification in 8.8%, and proximal migration of the humeral head in 6.8%.

Authors' conclusions

There was no strong evidence to support the use of early hemiarthroplasty for treating shoulder fractures.

CRD commentary

The objective of the review was clear. However, some of the inclusion criteria were questionable, as the use of a quality score to determine study eligibility is of doubtful reliability; it was not explained what type of data inconsistencies would lead to exclusion of a study. Relevant sources were searched, but as only two databases were consulted, and the search was restricted to published studies in English, some studies may have been missed and the review may be subject to language and publication biases.

Steps were taken to minimise the risk of reviewer bias and error by having two reviewers independently assess study validity, with disagreements resolved by consensus. The processes of study selection and data extraction were not described in detail, so it was unclear whether equivalent steps were taken (e.g. the authors stated that abstracts were assessed by two reviewers but it was unclear whether this also applied to full studies).

Few details were reported about the results of the validity assessment, the characteristics of the included studies, or the differences between groups in comparative studies. These factors make it hard to determine the reliability of the review findings. Overall results were calculated from the means of aggregated data, which (as the authors acknowledged) was not a reliable method of pooling data. In view of the questionable inclusion criteria, the limited search and the suboptimal methods used to pool data in the review, the authors’ conclusions should be interpreted with some caution.

Implications of the review for practice and research

Practice: The authors stated that most patients having hemiarthroplasty for proximal humeral fractures have little or no pain and the overall complication rate is low, but that marked limitation of function persists in most cases. They noted that the effects of early postoperative passive movement are unclear.

Research: The authors stated that well-designed RCTs are needed to compare the value and effectiveness of hemiarthroplasty for proximal humeral fractures versus alternative surgical or conservative treatment.


No commercial funding.

Bibliographic details

Kontakis G, Koutras C, Tosounidis T, Giannoudis P. Early management of proximal humeral fractures with hemiarthroplasty: a systematic review. Journal of Bone and Joint Surgery. British volume 2008; 90-B(11): 1407-1413. [PubMed: 18978256]

Indexing Status

Subject indexing assigned by NLM


Adult; Aged; Aged, 80 and over; Arthroplasty, Replacement /methods; Humans; Joint Prosthesis; Middle Aged; Prosthesis Design /methods; Range of Motion, Articular /physiology; Shoulder Fractures /surgery; Shoulder Joint /surgery; Treatment Outcome



Database entry date


Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.

CRD has determined that this article meets the DARE scientific quality criteria for a systematic review.

Copyright © 2014 University of York.

PMID: 18978256


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