Comparative efficacy and safety of different posterior surgical approaches for Intra-articular distal humerus fractures.

objectiveTo systematically compare the clinical efficacy and safety of four posterior surgical approaches-olecranon osteotomy (OO), triceps-reflecting approach (TRA), triceps-splitting approach (TS), and triceps tongue approach (TT)-for the treatment of AO/OTA type C complete intra-articular distal humerus fractures, and to provide evidence-based guidance for surgical approach selection.

methodsThis study was conducted in accordance with the PRISMA 2020 guidelines. PubMed, EMBASE, Web of Science, the Cochrane Library, and major Chinese databases were systematically searched for randomized controlled trials published up to September 2025. Eligible studies included patients with AO/OTA type C complete intra-articular distal humerus fractures treated using OO, TRA, TS, or TT approaches. Primary outcomes included the rate of excellent or good functional outcomes, Mayo Elbow Performance Score (MEPS), operative time, intraoperative blood loss, and overall complication rate. A network meta-analysis was performed using Stata 16.0, calculating odds ratios (ORs) or mean differences (MDs) with corresponding 95% confidence intervals (CIs). Between-study heterogeneity (τ

resultsA total of 12 randomized controlled trials involving 1,258 patients with AO/OTA type C complete intra-articular distal humerus fractures were included. Network meta-analysis demonstrated no statistically significant differences among the four posterior approaches with respect to the rate of excellent or good functional outcomes, MEPS, operative time, or intraoperative blood loss. SUCRA rankings suggested that OO ranked relatively higher for functional outcome and operative time, while TS ranked higher for intraoperative blood loss; however, none of these comparisons reached statistical significance. Regarding overall complication rates, TRA was associated with a lower risk of complications compared with OO, whereas TS showed a higher complication rate than OO. No statistically significant differences were observed in the remaining comparisons.

conclusionCurrent evidence indicates that OO, TRA, TS, and TT posterior approaches provide comparable overall clinical outcomes in the management of AO/OTA type C complete intra-articular distal humerus fractures, with most outcome measures showing no statistically significant differences. SUCRA rankings reflect only relative probability trends within the network model and should not be interpreted as substitutes for effect sizes or statistical significance. Surgical approach selection should therefore be individualized based on fracture characteristics, soft tissue conditions, and surgeon experience.