Surgery for 2-part humeral fractures in older patients is no better than no surgery

Reference

Launonen AP, Sumrein BO, Reito A, et al, as the NITEP group. Operative versus non-operative treatment for 2-part proximal humerus fracture: A multicenter randomized controlled trial. PLoS Med 2019;16(7):e1002855.

Synopsis

Proximal fractures of the humerus are usually treated conservatively, but surgery is now being performed more often in people with multipart fractures despite a lack of evidence. In this paper, the authors recruited patients 60 years and older from 6 hospitals in Finland, Estonia, Sweden, and Denmark with displaced 2-part fractures of the proximal humerus. (They are still recruiting for fractures with 3 or more parts.) They defined displacement as either 1 cm or greater than 45 degrees. They randomly assigned patients to undergo surgery with a locking plate (n = 44) or to wearing a collar-cuff or sling for 3 weeks (n = 44). All patients began pendulum exercises either on the first postoperative day or immediately after enrollment. Three weeks later, all patients also started active therapy with a physical therapist. To mask the outcome assessors, the researchers had the patients wear T-shirts to cover any potential surgical scars. The outcome assessors evaluated the patients 3 months, 6 months, 12 months, and 24 months after the surgery on several measures, the main outcome being the patient-reported Disabilities of the Arm, Shoulder, and Hand (DASH) score that assesses coping with everyday tasks. The researchers designed the study to be powerful enough to detect a minimal clinically important difference in the DASH score and to accommodate that patients would drop out over time. At the end of the study, the researchers lost 25% of the surgically treated patients compared with only 12% of the control patients to follow up. They also detected no meaningful differences in the DASH scores—patients generally were in pretty good shape at the end of the study. Finally, the authors also didn't find any differences in any of the secondary outcome measures. Three of the surgically treated patients required a second surgery: 1 fell and broke the arm again, and 2 had hardware migration.