Trauma surgeons may be more aggressive with rehabilitation vs shoulder surgeons
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Compared with shoulder surgeons, results showed trauma surgeons had a more aggressive approach to rehabilitation with regard to time to weight-bearing status and passive range of motion after operative repair of proximal humerus fractures.
“Our study surveyed shoulder surgeons and trauma surgeons on their preferences for rehabilitation after proximal humeral fractures. After regression analysis, we found that trauma surgeons preferred to start shoulder range of motion and weight-bearing earlier than did shoulder surgeons in both [open reduction and internal fixation] ORIF and arthroplasty patients,” Clay A. Spitler, MD, told Healio. “Reasons for these differences may include training bias or different patient populations (multiply injured vs. isolated fractures). Our results cause us to firmly believe that the effect of rehabilitation differences on patient function and outcomes should be investigated further so that best practices can be identified.”
To assess differences in postoperative rehabilitation preferences and patient counseling after operative repair of proximal humerus fractures, Spitler and colleagues distributed an electronic survey to members of the Orthopaedic Trauma Association and the American Shoulder and Elbow Surgeons. Researchers reported descriptive statistics for all respondents, trauma surgeons and shoulder surgeons, and used chi-square and unpaired two sample t-tests to compare responses. Researchers also used multinomial regression to further elucidate the influence of fellowship training independent of confounding characteristics.
Overall, 293 surgeons completed the survey. Of the respondents, 172 were shoulder surgeons and 78 were trauma surgeons. Although 45% of trauma surgeons preferred immediate weight-bearing after arthroplasty compared with 19% of shoulder surgeons, results showed 62% of trauma surgeons preferred immediate weight-bearing after ORIF vs. 75% of shoulder surgeons.
Researchers noted home exercise therapy taught by the physician or using a handout following reverse shoulder arthroplasty was preferred by 21% of shoulder surgeons vs. 2% of trauma surgeons. Researchers also found a greater proportion of trauma surgeons began passive range of motion less than 2 weeks after two-part fractures, while a greater proportion of shoulder surgeons began passive range of motion between 2 to 6 weeks for two-part and four-part fractures.
Multinomial regression analysis showed an association between fellowship training in shoulder surgery with preference for non-weight-bearing duration of greater than 12 weeks vs. 6 to 12 weeks after ORIF. Odds of preferring a non-weight-bearing duration of less than 6 weeks vs. no restrictions and greater than 12 weeks vs. 6 to 12 weeks after arthroplasty was also increased among those with fellowship training in shoulder surgery, according to results. Researchers found a greater odds of preferring a non-weight-bearing duration prior to beginning passive range of motion of 2 to 6 weeks vs. less than 2 weeks or greater than 6 weeks for two-part fractures but not four-part fractures among those with training in shoulder surgery.
Perspective
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In today’s aging population, the incidence of proximal humerus fractures is increasing and, thus, the number addressed surgically is increasing as well. These surgeries are often performed by trauma fellowship-trained surgeons, as well as shoulder fellowship-trained surgeons. Despite the growing prevalence of operative intervention, there is not a standardized, evidence-based approach to postoperative management, despite the knowledge that postoperative rehab is a crucial component of outcomes and restoring function after surgery.
This study shows that background and training highly influence postoperative rehab decision-making, more so than outcomes-based research. While this article has found that trauma surgeons have a more aggressive approach to postoperative rehab regarding time to weight-bearing status and earlier range of motion, no shoulder surgeon worth their salt would believe that inherently trauma surgeons have a more aggressive personality which leads to more aggressive treatment. Many would say experience influences decision-making and surgeons are balancing the risks of postoperative complications with the need to regain motion and function based on what they have seen, experienced and been taught. While there are likely many reasons (nicely outlined in the article) why trauma surgeons are more aggressive and shoulder surgeons are bit slower with weight-bearing status and starting range of motion, I believe the real take-home point is that both groups are performing the same surgeries and have the same goals: great patient outcomes. Therefore, this paper highlights the need for a standardized approach that is as evidence based as possible and optimizes best practices so we can all help our patients reach their full potential for recovery and quality of life.
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