Hemiarthroplasty versus nonoperative treatment of displaced 4-part proximal humeral fractures in elderly patients: a randomized controlled trial

doi:10.1016/j.jse.2011.04.016

Journal of Shoulder and Elbow Surgery

Volume 20, Issue 7, October 2011, Pages 1025-1033

https://doi.org/10.1016/j.jse.2011.04.016 Get rights and content

Background

The aim of the study was to report the 2-year outcome after a displaced 4-part fracture of the proximal humerus in elderly patients randomized to treatment with a hemiarthroplasty (HA) or nonoperative treatment.

Patients and Methods

We included 55 patients, mean age 77 (range, 58-92) years, 86% being women. Follow-up examinations were done at 4, 12, and 24 months. The main outcome measures were health-related quality of life (HRQoL) according to the EQ-5D and the DASH and Constant scores.

Results

At the final 2-year follow-up the HRQoL was significantly better in the HA group compared to the nonoperative group, EQ-5D _index score 0.81 compared to 0.65 (P = .02). The results for DASH and pain assessment were both in favor of the HA group, DASH score 30 versus 37 (P = .25) and pain according to VAS 15 versus 25 (P = .17). There were no significant differences regarding the Constant score or range of motion (ROM). Both groups achieved a mean flexion of approximately 90-95° and a mean abduction of 85-90°. The need for additional surgery was low: 3 patients in the HA group and 1 patient in the nonoperative group.

Conclusion

The results of the study demonstrated a significant advantage in 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 of HA appeared to be less pain while there were no differences in ROM.

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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Four principal treatment modalities are applied to treat complex proximal humeral fractures in older adults: conservative treatment, open reduction internal fixation, hemiarthroplasty, and reverse shoulder arthroplasty. However, among these, the optimal treatment modality has yet to be determined. Therefore, a network meta-analysis was carried out to compare treatment modalities and assess their effectiveness.
The databases PUBMED, EM-BASE, the Cochrane Central Register of Controlled Trials, Web of Science, and CNKI were searched for randomised controlled trials on complex proximal humeral fractures in older people, ranging from inception of each database to May 2023.
This meta-analysis included 14 randomised controlled trials, containing 791 patients aged over 60 years who were treated for complex proximal humeral fractures. Reverse shoulder arthroplasty and hemiarthroplasty yielded the highest Constant shoulder scores, whilst conservative treatment performed poorly. Hemiarthroplasty and open reduction internal fixation yielded the best performances on the visual analogue pain scale, whilst conservative treatment performed poorly. Reverse shoulder arthroplasty and open reduction internal fixation allowed for maximum forward flexion and outreach of range of motion, whilst hemiarthroplasty allowed for the least. Open reduction internal fixation and reverse shoulder arthroplasty allowed for maximum internal rotation of the range of motion, whilst conservative treatment allowed for the least. Hemiarthroplasty and conservative treatment allowed for maximum external rotation of the range of motion, whilst open reduction internal fixation allowed for the least.
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Why treatment of proximal humeral fractures remains unresolved despite randomized trials
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Most proximal humeral fractures can be treated nonoperatively, but there are specific indications to perform surgery for some of these fractures. Optimal treatment remains subject to debate, since no consensus has been reached for the best therapy for these fractures. This review provides an overview of randomized controlled trials (RCTs) comparing treatment for proximal humeral fractures. Fourteen RCTs comparing different operative and nonoperative types of treatment for PHF are included. Different RCTs comparing the same interventions for PHF have drawn different conclusions. It also highlights reasons why consensus has not been reached based on these data, and how this could be addressed in future research. Previous RCTs have included different patient groups and fracture patterns, may have been prone to selection bias, often were underpowered for subgroup analysis, and showed inconsistency in the outcome measures used. Based on this, and appreciating that treatment may be tailored to specific fracture types and patient characteristic like age, a better way to move forward could be to use a (international) multicenter prospective cohort study. Such a registry-type study should use accurate patient selection and enrollment, well-defined fracture patterns, standardized surgical techniques performed according to the preferences of the surgeon, and with a standardized follow-up.
Contralateral preoperative templating for fracture reverse total shoulder arthroplasty: technique article and case series
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Proximal humerus fractures are the 3^rd most common fragility fracture and with the increasing aging population they are becoming more common. While most proximal humerus fractures in the geriatric population can be successfully treated with nonoperative management, those that require surgical intervention are challenging and open reduction internal fixation can result in many complications. Reverse total shoulder arthroplasty has become increasingly popular for surgical management of these fractures in the frail patient population. With the increasing popularity of reverse total should arthroplasty, more and more surgeons are attempting this procedure. However, fracture reverse total shoulder arthroplasty has a notable learning curve and can be associated with devastating complications. It is especially difficult to judge proper humeral height and tension if you do not perform these cases routinely. We present a technique and case series of a high-volume shoulder arthroplasty surgeon utilizing a computed tomography template of the contralateral shoulder to help guide surgeons who may be performing these difficult cases.
Surgeon-specific factors have a larger impact on decision-making for the management of proximal humerus fractures than patient-specific factors: a prospective cohort study
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There is significant variability both in how proximal humerus fractures (PHFs) are treated and the ensuing patient outcomes. The purpose of this study was to investigate which surgeon- and patient-specific factors contribute to decision-making in the treatment of adult PHFs. We hypothesized that orthopedic sub-specialty training creates inherent bias and plays an important role in management algorithms for PHFs.
We performed a prospective cohort investigation in 2 groups of surgeons—traumatologists (N = 25) and shoulder & elbow/sports surgeons (SES) (N = 26)—and asked them to provide treatment recommendations for 30 distinct clinical cases with standardized radiographic and clinical data. This is a population-based sample of surgeons who take trauma call and treat PHFs with different sub-specializations and practice settings including academic, hospital-employed, and private. Surgeons characterized based on subspecialty (trauma vs. SES), experience level (>10 vs. ≤10-years), and employment type (hospital- vs. non-hospital-employed). Chi-square analyses, logistic mixed-effects modeling, and relative importance analysis were used to evaluate the data.
Of the patient-specific factors, we found that the management of PHFs is largely dependent on initial radiographs obtained. Traumatologists were more likely to offer open reduction internal fixation (ORIF) and less likely to offer arthroplasty: 69% ORIF (traumatologists) vs. 51% ORIF (SES, P < .001), 8% arthroplasty (traumatologists) vs. 17% (SES, P < .001). Traumatologists were less likely to change from operative (either ORIF or arthroplasty) to non-operative management compared to SES surgeons when presented with additional patient demographic data. Surgeon-specific factors contributed to more than one-half of the variability in decision-making of PHF management while patient-specific factors contributed to about one-third of the variability in decision-making.
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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.

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ShoulderHemiarthroplasty versus nonoperative treatment of displaced 4-part proximal humeral fractures in elderly patients: a randomized controlled trial

Background

Patients and Methods

Results

Conclusion

Section snippets

Patients

Methods

Results

Discussion

Conclusion

Disclaimer

J Clin Epidemiol

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

Health Policy

J Shoulder Elbow Surg

Injury

Orthop Traumatol Surg Res

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

Injury

Injury

Treatment of comminuted proximal humerus fractures with shoulder hemiarthroplasty in elderly patients

Acta Orthop Belg

Reverse shoulder arthroplasty for the treatment of three- and four-part fractures of the proximal humerus in the elderly: a prospective review of 43 cases with a short-term follow-up

J Bone Joint Surg Br

The reverse shoulder prosthesis in the treatment of fractures of the proximal humerus in the elderly

J Bone Joint Surg Br

Comminuted fractures of the proximal humerus

Clin Orthop Relat Res

Age related recovery of shoulder function after injury

A clinical method of functional assessment of the shoulder

Clin Orthop Relat Res

Impacted valgus fractures (B1.1) of the proximal humerus. The results of non-operative treatment

J Bone Joint Surg Br

The epidemiology of proximal humeral fractures

Acta Orthop Scand

Shoulder
Hemiarthroplasty versus nonoperative treatment of displaced 4-part proximal humeral fractures in elderly patients: a randomized controlled trial