Long-term clinical outcomes and complications after Open Reduction and Internal Fixation (ORIF) with locking plate...

Open reduction and internal fixation (ORIF) using locking plates remains a widely used head-preserving treatment for displaced proximal humerus fractures in adults. While short-term outcomes are well documented, long-term functional performance, complication burden, and implant survivorship beyond 5-years remain poorly defined. This systematic review and meta-analysis aimed to synthesise long-term (≥ 5-years) functional outcomes, complication rates, and reoperation rates following locking plate ORIF for proximal humerus fractures.

A protocol-registered (PROSPERO CRD420251156067) systematic review was conducted in accordance with PRISMA 2020 guidelines. PubMed, Scopus, and the Cochrane Library were searched for English-language randomized and non-randomized clinical studies reporting ≥ 5-year follow-up after ORIF with plate fixation for two-, three-, or four-part proximal humerus fractures in adults. Functional outcomes like Constant-Murley score (CMS), Disabilities of the Arm, Shoulder and Hand Score (DASH), University of California Los Angeles Shoulder Score (UCLA), and Oxford Shoulder Score (OSS), complications, and reoperation rates were extracted. Random-effects meta-analyses were performed, with heterogeneity assessed using the I² statistic. Risk of bias was evaluated using RoB 2 and ROBINS-I, and certainty of evidence was graded using GRADE.

Ten studies met the inclusion criteria, with follow-up ranging from 5 to nearly 15 years. Pooled analyses demonstrated no statistically significant long-term differences in CMS, DASH, or UCLA scores, although the OSS favored ORIF (MD 5.00; 95% CI 1.31-8.69). Long-term complications were common, particularly AVN (5-23%), screw penetration (9-15%), stiffness, and glenohumeral osteoarthritis (5-16%). Meta-analysis suggested reduced risks of complications (RR 0.06), overall reoperation/secondary surgery (RR 0.34; 95% CI 0.13-0.87), implant removal (RR 0.34; 95% CI 0.17-0.67), and revision surgery (RR 0.17; 95% CI 0.07-0.45); however, these estimates should be interpreted cautiously because heterogeneity was substantial to extreme across outcomes. Overall certainty of evidence was very low.

Locking plate ORIF for proximal humerus fractures provides acceptable but highly variable long-term functional outcomes, with a considerable burden of late complications and secondary procedures. These findings highlight the importance of careful patient selection, meticulous surgical technique, and long-term follow-up. High-quality prospective studies with standardized outcome reporting are needed to better define the durability of ORIF in this challenging injury.