ShoulderHemiarthroplasty versus nonoperative treatment of displaced 4-part proximal humeral fractures in elderly patients: a randomized controlled trial
Section snippets
Patients
In an RCT with a 2-year follow-up, we included 55 patients with an acute displaced 4-part fracture of the surgical neck of the humerus according to the classification of Neer,35, 36 who were allocated to treatment with a primary HA or nonoperative treatment between April 2003 and June 2008. The fracture inclusion criteria, based on conventional radiographs and computer tomography (CT), were a displacement of the shaft of more than 10 mm and/or >45° of angulation in relation to the head
Methods
The total body BMD was measured by DXA. Osteoporosis was defined as a T-score of more than 2.5 SD below the mean value for young adults according to the WHO definition.27 Pain was assessed on a visual analogue scale (VAS, 0–100; 0 = no pain; 100 = worst possible pain).
The Constant score11, 12 is a widely used rating for measuring shoulder function regardless of the diagnosis. The normal population values depend on age, gender, and activity level of the patient.10 The best possible score is 100
Results
A flowchart for all patients included is shown in Figure 1. One patient in HA group was operated upon using a locking plate. At the time of surgery the displacement of the greater tubercle was assessed to be less than 10 mm and, consequently, the fracture was reclassified as a 3-part fracture. In the outcome analyses this patient remained in the HA group according to the intention-to-treat principle.
The overall mortality rate at 24 months was 9% (5 out of 55); in the HA group, 3 out of 27 and
Discussion
The results of the study demonstrated a significant advantage in quality of life in favor of HA compared to nonoperative treatment in elderly patients with a displaced 4-part fracture of the proximal humerus. Furthermore, primary HA appears to be a safe surgical procedure with relatively low complication and reoperation rates. Regardless of the primary treatment, operative or nonoperative, the 4-part fracture resulted in a functional impairment of the shoulder and arm resulting in a substantial
Conclusion
In summary, the results of the study demonstrated an advantage in the quality of life in favor of HA as compared to nonoperative treatment in elderly patients with a displaced 4-part fracture of the proximal humerus. The main advantage appeared to be less pain. However, despite use of a modern fracture prosthesis and an appropriate surgical technique with a low reoperation rate, there were no differences in ROM. The possible gain in pain and HRQoL after treatment with an HA, balanced against
Disclaimer
The authors, their immediate family, and any research foundation with which they are affiliated did not receive any financial payments or other benefits from any commercial entity related to the subject of this article.
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IRB: The study was approved by the local Ethics Committee in Huddinge, Stockholm, Sweden (number 344/02).
Funding:The study was supported in part by grants from the Trygg-Hansa Insurance Company (B1/2006) and the Stockholm County Council (20060292). These outside sources of funds were not involved in data collection, data analysis, or the preparation of or editing of this manuscript.