Displaced proximal humerus fractures in older patients: reverse total shoulder arthroplasty or nonoperative treatment? (original) (raw)
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Trials, 2023
Background Proximal humerus fractures (PHF) are common and painful injuries, with the majority resulting from falls from a standing height. As with other fragility fractures, its age-specific incidence is increasing. Surgical treatment with hemiarthroplasty (HA) and reverse shoulder arthroplasty (RSA) have been increasingly used for displaced 3-and 4-part fractures despite a lack of good quality evidence as to whether one type of arthroplasty is superior to the other, and whether surgery is better than non-surgical management. The PROFHER-2 trial has been designed as a pragmatic, multicentre randomised trial to compare the clinical and cost-effectiveness of RSA vs HA vs Non-Surgical (NS) treatment in patients with 3-and 4-part PHF. Methods Adults over 65 years of age presenting with acute radiographically confirmed 3-or 4-part fractures, with or without associated glenohumeral joint dislocation, who consent for trial participation will be recruited from around 40 National Health Service (NHS) Hospitals in the UK. Patients with polytrauma, open fractures, presence of axillary nerve palsy, pathological (other than osteoporotic) fractures, and those who are unable to adhere to trial procedures will be excluded. We will aim to recruit 380 participants (152 RSA, 152 HA, 76 NS) using 2:2:1 (HA:RSA:NS) randomisation for 3-or 4-part fractures without joint dislocation, and 1:1 (HA:RSA) randomisation for 3-or 4-part fracture dislocations. The primary outcome is the Oxford Shoulder Score at 24 months. Secondary outcomes include quality of life (EQ-5D-5L), pain, range of shoulder motion, fracture healing and implant position on X-rays, further procedures, and
The factors influencing the decision making of operative treatment for proximal humeral fractures
Journal of Shoulder and Elbow Surgery, 2015
Background: The factors influencing the decision making of operative treatment for fractures of the proximal humerus are debated. We hypothesized that there is no difference in treatment recommendations between surgeons shown radiographs alone and those shown radiographs and patient information. Secondarily, we addressed (1) factors associated with a recommendation for operative treatment, (2) factors associated with recommendation for arthroplasty, (3) concordance with the recommendations of the treating surgeons, and (4) factors affecting the inter-rater reliability of treatment recommendations. Methods: A total of 238 surgeons of the Science of Variation Group rated 40 radiographs of patients with proximal humerus fractures. Participants were randomized to receive information about the patient and mechanism of injury. The response variables included the choice of treatment (operative vs nonoperative) and the percentage of matches with the actual treatment. Results: Participants who received patient information recommended operative treatment less than those who received no information. The patient information that had the greatest influence on treatment recommendations included age (55%) and fracture mechanism (32%). The only other factor associated with a recommendation for operative treatment was region of practice. There was no significant difference between participants who were and were not provided with information regarding agreement with the actual treatment (operative vs nonoperative) provided by the treating surgeon. Conclusion: Patient informationdolder age in particulardis associated with a higher likelihood of recommending nonoperative treatment than radiographs alone. Clinical information did not improve agreement of the Science of Variation Group with the actual treatment or the generally poor interobserver agreement on treatment recommendations.
Decision making in displaced fractures of the proximal humerus: fracture or surgeon based?
International orthopaedics, 2015
The aim of this study was to analyse the factors that influence surgeon decision-making in the treatment of proximal humerus fractures that might be considered for arthroplasty or open reduction and internal fixation. A total of 217 surgeons evaluated radiographs and clinical vignettes of ten patients with fractures of the proximal humerus. In addition to radiographs, we provided patient age, sex, trauma mechanism, activity level (sedentary-vigorously active), and physical status (normal healthy-moribund). Observers were asked to: (1) choose open reduction and internal fixation or hemiarthroplasty (closed question, one option) and (2) to briefly describe the factors that led to their decision (open-ended question). We assessed interobserver reliability using the Fleiss generalized kappa and analysed factors that influenced decision-making according to treatment choice. Internal fixation was the preferred treatment for the majority of fractures. The overall multirater agreement was f...
Journal of Shoulder and Elbow Surgery, 2011
Background: A few studies focused on open reduction and internal fixation (ORIF) or nonoperative treatment of displaced 3-part or 4-part proximal humeral fractures in elderly patients have been published, all of whom had a low number of patients. In this meta-analysis of randomized controlled trials (RCTs), we aimed to assess the effect of ORIF or nonoperative treatment of displaced 3-part or 4-part proximal humeral fractures in elderly patients on the clinical outcomes and reevaluate of the potential benefits of conservative treatment. Methods: We searched PubMed and the Cochrane Central Register of Controlled Trials databases for randomized controlled trials comparing ORIF and nonoperative treatment of displaced 3-part or 4-part proximal humeral fractures in elderly patients. Our outcome measures were the Constant scores. Results: Three randomized controlled trials with a total of 130 patients were identified and analyzed. The overall results based on fixed-effect model did not support the treatment of open reduction and internal fixation to improve the functional outcome when compared with nonoperative treatment for treating elderly patients with displaced 3-part or 4-part proximal humeral fractures (WMD 20.51, 95% CI: 27.25 to 6.22, P = 0.88, I 2 = 0%). Conclusions: Although our meta-analysis did not support the treatment of open reduction and internal fixation to improve the functional outcome when compared with nonoperative treatment for treating elderly patients with displaced 3-part or 4-part proximal humeral fractures, this result must be considered in the context of variable patient demographics. Only a limited recommendation can be made based on current data. Considering the limitations of included studies, a large, well designed trial that incorporates the evaluation of clinically relevant outcomes in participants with different underlying risks of shoulder function is required to more adequately assess the role for ORIF or nonoperative treatment.
Journal of Shoulder and Elbow Surgery, 2019
Background: Proximal humeral fractures (PHFs) are among the most common fractures in elderly patients, but there is insufficient evidence from randomized controlled trials (RCTs) to determine which interventions are the most appropriate for their management. To date, no RCT has directly compared reverse shoulder arthroplasty (RSA) with nonoperative treatment for 3-or 4-part PHFs in elderly patients. Methods: This was a prospective RCT. The primary objective was to compare pain and function 12 months after fracture using the Constant score in patients aged 80 years or older with 3-and 4-part PHFs, treated by either RSA or nonoperative treatment. Secondary outcome measures included Disabilities of the Arm, Shoulder and Hand, visual analog scale (VAS), Short Form 12 (SF-12), EuroQol 5 Dimensions, and EQ-VAS scores. Results: We analyzed 30 nonoperative and 29 RSA patients with mean ages of 85 years and 82 years, respectively. No differences between the nonoperative and RSA groups were noted for any patientreported outcomes at 12 months' follow-up except the VAS pain score. The Constant scores were 55.7 in the nonoperative group and 61.7 in the RSA group (P ¼ .071); the Disabilities of the Arm, Shoulder and Hand scores were 29 and 21, respectively (P ¼ .075); the VAS scores were 1.6 and 0.9, respectively (P ¼ .011); the physical SF-12 scores were 36 and 37, respectively (P ¼ .709); the mental SF-12 scores were 43 and 42, respectively (P ¼ .625); the EuroQol 5 Dimensions scores were 0.89 and 0.92, respectively (P ¼ .319); and the EQ-VAS scores were 65 and 67, respectively (P ¼ .604).
Journal of Shoulder and Elbow Surgery, 2014
Background: This study compared the use of reverse and hemishoulder arthroplasty for the treatment of proximal humeral fractures among orthopedic surgeons taking part II of the American Board of Orthopaedic Surgery board examination. We hypothesized that the use of reverse shoulder arthroplasty for fractures in the elderly is increasing amongst newly trained orthopedic surgeons. Materials and methods: We queried the American Board of Orthopaedic Surgery database for the cases of proximal humeral fractures treated with arthroplasty submitted between 2005 and 2012. We evaluated the prosthesis used, patient-specific factors, complications, and the difference in use by shoulder fellowshiptrained surgeons. Results: From 2005 to 2012, 5395 board-eligible orthopedic surgeons submitted cases to the database. Of these, 435 (mean, 54 per year) were proximal humeral fractures treated with arthroplasty. The overall incidence of reverse shoulder arthroplasty for fracture increased from 2% to 4% during 2005 to 2007 to 38% in 2012. Shoulder surgeons treated 5 times more proximal humeral fractures with shoulder arthroplasty and were also more than 20 times more likely to use a reverse implant (P < .0001). The difference in complication rates between reverse and hemishoulder arthroplasty was not significant (P ¼ .49). Patients who received a hemiarthroplasty tended to be younger (mean age, 70.8 vs 75.7 years; P ¼ .0015). Conclusions: Overall, the use of a hemiarthroplasty for fracture is still more common (62% in 2012), although the relative proportion of reverse implants is rising. Among shoulder surgeons, more than 50% of the arthroplasties performed for fractures during the past 3 years (2010-2012) have been reverse arthroplasties. Level of evidence: Epidemiology Study, Database Analysis.
The Open Orthopaedics Journal, 2010
The objective was to identify whether arthroplasty or conservative treatment is the best available treatment for three-and four-part proximal humeral fractures by analyzing the outcome measure of the Constant score. We conducted an electronic search. The systematic review included 33 studies encompassing 1096 patients with three-or four-part proximal humeral fractures that used the Constant score as outcome measure. The mean Constant score in the conservative group was 66.5 and in the arthroplasty group was 55.5. The difference could be attributed to selection bias, unreliable classification of the fractures and inter-observer differences in the assessment of the Constant score.
Management of proximal humeral fractures: Surgeons don't agree
Journal of Shoulder and Elbow Surgery, 2010
Hypothesis: The management options for proximal humeral fractures have expanded in recent years. Patients with displaced, unstable proximal humeral fractures may have improved outcomes if managed operatively. We investigated the decision making of fellowship-trained orthopedic surgeons when presented with the same group of cases. We hypothesized that interobserver and intraobserver agreement for surgical management would be poor and independent of fellowship training. Method: Eight fellowship-trained orthopedic surgeons (3 shoulder, 5 trauma) viewed the preoperative plain radiographs of patients with proximal humeral fractures. All surgeons viewed the same 38 radiographs in a blinded fashion. Surgeons chose from 1 of 6 management options. Interobserver variability was calculated by using the weighted k coefficient. Intraobserver variability was calculated by comparing each surgeon's survey results with the operation they originally performed. Results: Overall interobserver agreement on management was moderate (weighted k ¼ 0.41) and did not differ significantly between trauma surgeons and shoulder surgeons. Reducing the number of management choices increased agreement between all surgeons. Testing for intraobserver agreement showed that surgeons picked the same operation in the survey as in the actual clinical setting only 56% of the time. Conclusion: Interobserver agreement was moderate overall and improved when the number of management choices was reduced. Intraobserver agreement was less frequent, however, raising the question about consistent decision making by a given surgeon. Although surgeons agree in the method of treatment only to a modest degree, it remains for further outcomes research to establish if the choice of treatment actually influences the clinical outcome. Level of evidence: Level 4, case series.