A Retrospective Cohort Study of Non-Operative versus Operative Treatment of Proximal Humerus Fractures in Elderly Patients.
Keywords:ASES, Proximal Humerus fracture, Neer classification, PHILOS.
Objective: To determine the functional outcome of proximal Humerus fracture in elderly patients treated non operatively versus operatively.
Methods: This retrospective Cohort study was conducted in Orthopaedic Department Fazaia Ruth Pfau Medical College PAF Base Faisal Karachi. The medical records of all patients of proximal Humerus fractures fulfilling the inclusion criteria and managed in time period extending from 23rd June 2018 to 25th May 2022 were reviewed. The included subjects were divided into group A(non-operative) and group B(open reduction and internal fixation with Proximal Humerus Internal Locking System).Comparison of functional outcome in both groups at 6th, 12th , and 18th months of follow up was done using American Shoulder and Elbow Score(ASES).P value was calculated using Chi-square test, student t-test and one way ANOVA test. P value <0.05 was considered significant.
Results: The records of 92 patients of proximal humerus fractures were reviewed. Group A included 47(51.08%) patients and group B had 45(48.91%) patients. Mean age of group A was 61 ± 4.32 years and group B was 55± 2.33 years. The ASES score for two-part, three-part and four-part fractures at 18th months of follow up period was 79.9,75.2,81.2 in group A and 82.4,77.3 and 83.4 in group B respectively(p>0.05). Radiological union was achieved in average 5±1.2 months in group A and 3±2.1 months in group B(p<0.05).
Conclusion: Both non operative and operative treatments of proximal humerus fractures in elderly patients are equally effective in restoring shoulder function. However no significant difference in terms of functional outcome was noted between the two treatment modalities.
Court-Brown CMC, B. Epidemiology of adult fractures: a review. Injury. 2006; 37(8):691–769.
Dheenadhayalan J, Prasad VD, Devendra A, Rajasekaran S. Correlation of radiological parameters to functional outcome in complex proximal humerus fracture fixation: A study of 127 cases. J Orthop Surg (Hong Kong). 2019;27(2):2309499019848166. doi: 10.1177/2309499019848166.
Court-Brown CM, Garg A, and McQueen MM. The epidemiology of proximal humeral fractures. Acta OrthopScand 2001; 72(4): 365–371.
Kim YG, Park KH, Kim JW, Oh JK, Yoon JP, Kim HJ, et al. Is minimally invasive plate osteosynthesis superior to open plating for fixation of two-part fracture of the proximal humerus? J Orthop Surg (Hong Kong). 2019(2):2309499019836156. doi: 10.1177/2309499019836156.
Handoll HH, Elliott J, Thillemann TM, Aluko P, Brorson S. Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev. 2022;6(6):CD000434. doi: 10.1002/14651858.CD000434.pub5.
Lanting B, MacDermid J, Drosdowech D, Faber KJ. Proximal humeral fractures: a systematic review of treatment modalities. J Shoulder Elb Surg. 2008;17(1):42–54.
Misra A, Kapur R, Maffuli N. Complex proximal humerus fractures in adults a systematic review of management. Injury. 2001;32(5):363–372.
Campochiaro G, Rebuzzi M, Baudi P, Catani F. Complex proximal humerus fractures: Hertel's criteria reliability to predict head necrosis. Musculoskelet Surg. 2015;99 Suppl 1:S9-15. doi: 10.1007/s12306-015-0358-z.
Beks RB, Ochen Y, Frima H, Smeeing DPJ, van der Meijden O, Timmers TK, et al. Operative versus nonoperative treatment of proximal humeral fractures: a systematic review, meta-analysis, and comparison of observational studies and randomized controlled trials. J Shoulder Elbow Surg. 2018 ;27(8):1526-1534.
Launonen AP, Sumrein BO, Reito A, Lepola V, Paloneva J, Jonsson KB, et al.Operative versus non-operative treatment for 2-part proximal humerus fracture: A multicenter randomized controlled trial. PLoS Med. 2019;16(7):e1002855. doi: 10.1371/journal.pmed.1002855.
Xie L, Ding F, Zhao Z, Chen Y, Xing D. Operative versus non-operative treatment in complex proximal humeral fractures: a meta-analysis of randomized controlled trials. SpringerPlus.2015; 4:728.Doi: https://doi.org/10.1186/s40064-015-1522-5.
Kilcoyne R, Shuman W, Matsen F, Morris M, Rockwood C. The Neer Classification of Displaced Proximal Humeral Fractures: Spectrum of Findings on Plain Radiographs and CT Scans. AJR Am J Roentgenol. 1990;154(5):1029-33.
Michener LA, McClure PW, Sennett BJ. American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, patient self-report section: reliability, validity, and responsiveness. J Shoulder Elbow Surg. 2002;11(6):587-594.
Brouwer ME, Reininga IH, El Moumni M, Wendt KW. Outcomes of operative and nonoperative treatment of 3- and 4-part proximal humeral fractures in elderly: a 10-year retrospective cohort study. Eur J Trauma Emerg Surg, 45;2019; 31–38.
Handoll H, Brealey S, Rangan A, Keding A, Corbacho B, Jefferson L, et al. The ProFHER (PROximal Fracture of the Humerus: Evaluation by Randomisation) trial - a pragmatic multicentre randomised controlled trial evaluating the clinical effectiveness and cost-effectiveness of surgical compared with non-surgical treatment for proximal fracture of the humerus in adults. Health Technol Assess. 2015;19(24):1-280. doi: 10.3310/hta19240.
Çaliskan E, Dogan O. PHILOS plate versus nonoperative treatment in 2-, 3-, and 4-part proximal humeral fractures: Comparison with healthy control subjects. J Orthop Surg (Hong Kong). 2019 ;27(3):2309499019875169. doi: 10.1177/2309499019875169.
Samborski SA, Haws BE, Karnyski S, Soles G, Gorczyca JT, Nicandri G,et al. Outcomes for type C proximal humerus fractures in the adult population: comparison of nonoperative treatment, locked plate fixation, and reverse shoulder arthroplasty. JSES Int. 2022 ;6(5):755-762.
Okike K, Lee OC, Makanji H, Harris MB, Vrahas MS. Factors associated with the decision for operative versus non-operative treatment of displaced proximal humerus fractures in the elderly. Injury. 2013;44(4):448-455.