Nonoperative approach may yield similar outcomes as locking plates for humeral fractures
Key takeaways:
- Nonoperative treatment for older patients with proximal humerus fractures may yield comparable 2-year outcomes vs. surgery.
- Researchers questioned the benefits of operative treatment with locking plates.
According to published results, nonoperative treatment yielded similar clinical outcomes at 2 years as operative treatment using locking plates for older patients with displaced proximal humerus fractures.
“These results highlight that, even under optimal surgical conditions, the benefits of operative treatment with a locking plate for displaced proximal humeral fractures in elderly patients remain questionable,” Mauro E. C. Gracitelli, MD, PhD, and colleagues from the University of Sao Paulo in Brazil, wrote in the study.
Gracitelli and colleagues performed a prospective randomized trial of 80 patients older than 60 years who received treatment for a displaced proximal humerus fracture between January 2016 and November 2018. At 2 years, 71 patients were available for follow-up.
Gracitelli and colleagues randomly assigned 40 patients (mean age, 69.1 years) to receive nonoperative treatment and 31 patients (mean age 68.4 years) to receive operative treatment. The nonoperative group was put in a sling for 30 days and prescribed to early rehabilitation. The operative group underwent surgical fixation with a traditional locking plate technique.
The primary outcome measure was Constant-Murley score at 2 years. Secondary outcomes measures included individual relative Constant Score (IRCS), American Shoulder and Elbow Surgeons score and single assessment numeric evaluation (SANE) score at 3 months, 6 months, 1 year and 2 years. Other outcomes included complications and reoperations.
Gracitelli and colleagues found no significant differences in clinical outcome scores between the groups at any follow-up. At 2 years, the nonoperative group had mean Constant-Murley score of 68.2; mean ASES score of 77; mean SANE score of 83.8 and mean IRCS of 79.5%. For the operative group at 2 years, mean Constant-Murley score was 66.5; mean ASES score was 79.1; mean SANE score was 88.5 and mean IRCS was 73%.
Complication rate was 15% in the nonoperative group and 35.5% in the operative group. However, Gracitelli and colleagues noted this difference was not statistically significant. Similarly, rate of rotator cuff tear was 20% in the nonoperative group and was 25.8% in the operative group; but the difference was not statistically significant.
Perspective
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The authors have presented an excellent randomized control trial comparing operative treatment with plate and screws vs. nonoperative management of displaced proximal humerus fractures. In this well-done series, there was no difference in outcome between the groups.
Although we have advanced greatly in our surgical abilities, well-done studies consistently show no significant difference between outcomes in this group of patients. This study re-enforces the concept that nonoperative management provides satisfactory outcomes and that operative treatment, while effective, should be reserved for special situations.
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