Proximal humeral fractures are among the most common fractures in the elderly population [1
]. Along with the increasing life expectancy of the Western population, the incidence of these fractures is rising rapidly, with osteoporosis as an important factor [2
]. Demographic research showed that proximal humeral fractures occur mostly in active persons aged 60 years and older [4
]. Around 90% of these patients live independently at home and do their own shopping and housework. Hence, a proximal humeral fracture can potentially affect this independence and deteriorate the quality of life of the elderly.
Proximal humeral fractures can be classified as 1-, 2-, 3- or 4-part fractures according to the Neer classification, with 3- and 4-part fractures containing displaced fragments [5
]. In case of a minimally or undisplaced fracture, the treatment is mostly nonoperative. For complex 3- and 4-part fractures both operative and nonoperative treatment are implemented in clinical practice [6
]. Since the introduction of locking plates in the year 2000, operative treatment became a convenient option for elderly patients, as locking plates can also be used in osteoporotic bone [9
]. Consequently, operative treatment in elderly patients is performed more regularly than before the introduction of this technique [8
]. Nevertheless, operative treatment is associated with a higher risk of complications related to the implant or the surgical procedure [11
]. To date, research has not been able to identify evident and reliable differences in outcome between operative and nonoperative treatment [12
]. This was supported by the latest Cochrane review [15
Consensus is thus still lacking on the appropriate treatment for this type of fracture, especially for elderly patients. Previous studies focus mainly on the range of motion and functional and radiological outcome [6
], paying little attention to functioning in daily life and social participation even though these outcomes are of the utmost importance to patients. According to the International Classification of Functioning, Disability and Health (ICF) of the World Health Organization (WHO), assessment of health and disability includes the effect of trauma not only on the affected body function or structure but also the assessment of limitations in activity and restrictions in social participation [17
]. Hence the aim of this study was to assess the long-term outcome of operative and nonoperative treatment of displaced 3- and 4-part proximal humeral fractures in elderly patients in terms of impairments in body function or structure, limitations in activity and restrictions in social participation.
This study presents long-term outcomes of displaced 3- and 4-part proximal humeral fractures in a multidimensional way, focusing primarily on HRQoL outcome and additionally on physical functioning, pain, social participation, complications and reinterventions. As it is difficult to realize a randomized controlled trial about this type of fracture, retrospective studies dominate the field. Using propensity score matching, this study tried to minimize selection bias caused by “treatment by indication”. This study found no significant differences in outcome between operatively and non-operatively treated patients regarding HRQoL, physical functioning or pain. Operatively treated patients showed a trend toward better social participation. No significant difference in complication and reintervention occurrence between the two groups was found, although a trend was seen toward more reinterventions after operative treatment.
This study focused on a more specific group of patients, namely patients of 65 and older with a displaced 3- or 4-part proximal humeral fracture. Many previous studies also included younger patients, inclusion starting from 18 years of age, and 2-part fractures [6
]. Some studies chose to include only 3-part or only 4-part fractures but not both [12
]. This should not be overlooked when comparing results. Still, demographic characteristics of the patients in this study were representative of the general population of patients with proximal humeral fractures, as shown by several epidemiological studies [2
No statistically significant difference in HRQoL between operatively and non-operatively treated patients was found. This finding is in accordance with several previous studies [12
]. The average EQ-5D score found in this study is considerably lower than the EQ-5D reference value for the general Dutch population aged over 65 [32
], which supports the claim that a proximal humeral fracture in elderly patients/patients over 65 is related to a diminished quality of life.
Both operatively and non-operatively treated patients showed a mild limitation in physical functioning, demonstrated by a higher mean DASH score, compared to the general Norwegian older population (mean 18, 22, 36 in women and 11, 13, 22 in men of 60–69, 70–79 and 80 +, respectively); this is comparable to the general Dutch older population [33
]. This finding supports the claim that this type of injury influences physical functioning in the long term. The results in functional outcome of this study correspond with functional outcome measured in several previous studies [12
]. Some studies do report better functional outcome, probably due to the inclusion of patients with 2-part fractures and patients of 18 years and older, resulting in a lower mean age of the study cohort compared to this study [35
]. This contributes to the assumption that older patients with 3- and 4-part fractures should be studied separately from younger patients when it comes to treatment and outcome. None of the studies mentioned above was able to find significant differences in physical functioning between operatively and non-operatively treated patients.
The low-to-moderate pain level found in this study corresponds with results from previous studies [30
]. Pain levels favored operative treatment with a difference of 0.8 on the VAS, which is very similar to the 1.0 points lower score after hemiarthroplasty reported by Olerud et al. [30
]. Lack of power could be the reason that both studies failed to show statistical significance.
To our knowledge, social participation has not been used before as outcome measure after a proximal humeral fracture. According to the ICF model, the assessment of health and disability should also comprise the assessment of social participation. This study found a trend toward better social participation after operative treatment, meaning operatively treated patients reported experiencing fewer problems with participation in society caused by their health condition than non-operatively treated patients. The inability to present a statistically significant difference could be caused by the lack of statistical power of a small patient population. Further research with larger study cohorts and the use of social participation as outcome measure is desirable.
Complications and reinterventions occurred slightly more often after operative treatment, though this was statistically not significant. This failing of reaching statistical significance might be due to the small sample size of the study cohort. In this study, 33% of the operatively treated patients required surgery after primary treatment versus 6% of the non-operatively treated patients. This finding is not surprising, as many reinterventions consisted of removing the osteosynthetic material due to discomfort, a complication related to the osteosynthesis material itself. The high risk of reintervention after osteosynthesis has been described in the literature before and might be reduced when improving the surgical technique [41
]. Two patients from the nonoperative group eventually underwent hemiarthroplasty as a reintervention. Because this study comprises an intention-to-treat analysis, these patients were left included in the nonoperative group. This study reported all complications registered in medical records, i.e., patient-reported complications that led to pain, discomfort and reintervention. Consequently, asymptomatic complications, like some cases of avascular necrosis of the humeral head (AVN) [42
], were not reported but are considered of minor significance to patient well-being and satisfaction.
The retrospective design of this cohort study has some limitations. First, only 61% of contacted patients responded to the questionnaires, which might have led to response bias. Compared to the non-response group, a higher percentage of women was included in the study. However, the male/female ratio of the study population is in accordance with the overall population of elderly patients/patients over 65 with a proximal humeral fracture [3
]. Second, choice of treatment was executed by clinical judgment of the surgeon and not assigned randomly. We used propensity score matching to minimize dependency between the treatment variable and the other covariates. Third, since the objective of this study was to compare the outcomes of nonoperative treatment with those of operative treatment, this study did not distinguish between surgical techniques, such as open reduction and internal fixation and hemiarthroplasty; it, however, is a reflection of general clinical practice, where the type of surgical procedure is based on the clinical judgment of the surgeon. Additionally, locking plates, intramedullary nails and hemiarthroplasty are the most commonly used surgical techniques in current practice [8
Lastly, since it is hard to realize large patient numbers in proximal humeral fracture studies, this study included a small number of patients. Despite the small number of patients, this study has demonstrated the importance of measuring outcome on multiple levels of functioning and disability, including the measurement of social participation. Also, this study emphasizes that operative treatment in elderly patients/patients over 65 should be considered carefully, as it is accompanied by a high risk of reintervention. However, this study cannot be conclusive on the best treatment for these patients yet. More research with larger study cohorts is desirable.