Journal Club by SWISS / KNIFE

This matched-pair study compared minimally invasive plate osteosynthesis (MIPO) and open reduction and internal fixation (ORIF) for the surgical treatment of proximal humerus fractures. After matching patients for fracture pattern, age, and sex, MIPO demonstrated significantly shorter operative times while achieving comparable reduction quality and complication rates. Although a trend toward implant malpositioning was observed with MIPO, overall outcomes were similar between techniques. These findings support MIPO as an effective alternative to ORIF in appropriately selected patients, while emphasizing that fracture complexity, bone quality, and surgeon experience remain key factors in selecting the optimal surgical approach.

What inspired you to conduct this study?

Although both ORIF and MIPO are well-established techniques, high-quality comparative data remain limited. We wanted to investigate whether the less invasive MIPO approach could shorten operative time without compromising fracture reduction or increasing complications. This question is particularly relevant in elderly patients, who often have multiple comorbidities, and in emergency trauma care, where every minute in the operating room matters. By matching patients according to fracture pattern, age, and sex, we aimed to compare both techniques under nearly identical conditions.

Were there any unexpected findings?

The most surprising finding was that MIPO achieved radiographic outcomes and complication rates comparable to ORIF despite the limited surgical exposure. We had expected that the indirect reduction technique might compromise reduction quality. Instead, reduction quality was similar between both groups while MIPO retained the advantage of shorter operative times. This suggests that, in experienced hands, the minimally invasive approach does not come at the expense of surgical quality.

What is the direct impact on the surgeon's work?

Our findings encourage surgeons to choose the surgical approach based on fracture characteristics and patient factors rather than routine preference for an open approach. In particular, MIPO may be advantageous in patients with poor bone quality, where minimizing fragment manipulation may reduce the risk of iatrogenic comminution. Its shorter operative time may provide additional benefits for elderly patients with multiple comorbidities and in emergency trauma care, where minimizing operative time is particularly valuable.

What is your learning point from this project?

The main lesson was that there is no universally superior technique. The best results come from matching the surgical approach to fracture complexity, bone quality, and the surgeon's own experience rather than relying on routine or personal preference. At the same time, our study highlights that adequate training in MIPO is essential before its potential advantages can be safely realized.

Are there any subsequent projects planned?

Yes. Our research is centered on improving surgical decision-making in proximal humerus fractures. We first developed the DRoPH Score to improve the preoperative assessment of fracture reduction difficulty, particularly for less experienced surgeons, and have recently completed its clinical validation¹. The next step is to investigate how the score can be integrated into individualized surgical planning and treatment strategies. Furthermore, future prospective multicenter studies should incorporate patient-reported outcome measures (PROMs), including the Constant-Murley Score and DASH score, to complement radiographic and complication-based outcome measures.