Article
Let’s agree to disagree on operative versus nonoperative (LADON) treatment for proximal humerus fractures: A multicenter international prospective cohort study
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Authors
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Ruben J. Hoepelman
- Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, Netherlands
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Frank J. P. Beeres
- Klinik für Orthopädie und Unfallchirurgie, Kantonsspital Luzern LUKS, Luzern, Switzerland
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Bryan J. M. van de Wall
- Klinik für Orthopädie und Unfallchirurgie, Kantonsspital Luzern LUKS, Luzern, Switzerland
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Christian Michelitsch
- Kantonsspital Graubünden, Chur, Switzerland
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Isabelle R. Buenter
- Klinik für Orthopädie und Unfallchirurgie, Kantonsspital Luzern LUKS, Luzern, Switzerland
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Reto Babst
- Klinik für Orthopädie und Unfallchirurgie, Kantonsspital Luzern LUKS, Luzern, Switzerland
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Christoph Sommer
- Kantonsspital Graubünden, Chur, Switzerland
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Egbert-Jan M.M. Verleisdonk
- Department of Trauma Surgery, Diakonessenhuis, Utrecht, Netherlands
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Detlef van der Velde
- Department of Trauma Surgery, St. Antonius Hospital, Nieuwegein, Netherlands
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Roderick M. Houwert
- Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, Netherlands
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Rolf H.H. Groenwold
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands
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Mark van Heijl
- Department of Trauma Surgery, Diakonessenhuis, Utrecht, Netherlands
| Published: | October 21, 2024 |
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Outline
Text
Importance: Internationally, the optimal treatment strategy of proximal humerus fractures remains much debated.
Objective: To investigate whether operative treatment of displaced proximal humerus fractures is superior to nonoperative treatment.
Methods: Design.
A prospective natural experiment (prospective cohort study) based on geographical randomization and clinical equipoise.
Setting: An international multicenter cohort study in the Netherlands and Switzerland.
Participants: In total 226 patients with acute (<3 weeks) displaced proximal humerus fractures presenting from July 2020 until March 2022 were included after expert panel evaluation based on clinical equipoise. Patients were followed up for one year, and 191 (84%) had complete follow-up data.
Interventions: Operative treatment included plate fixation, intramedullary nailing and reverse shoulder arthroplasty at the discretion of the treating surgeon. Nonoperative treatment was sling immobilization. All patients received standardized outpatient rehabilitation and physiotherapy.
Main outcomes and measures: The primary outcome was QuickDASH after one year. Secondary outcomes included QuickDASH at six weeks and EuroQoL5D (EQ5D), Subjective shoulder value (SSV), numeric rating scale for pain (NRS) at six weeks and one year.
Results: No difference in QuickDASH score after one year (16.3 vs. 17.5, p=0.836) was found. At six weeks, operative treatment resulted in lower NRS (4.2 vs 3.0, p<0.001), higher EQ5D (0.59 vs. 0.68, p=0.015) and higher SSV (41.8 vs. 53.6, p=0.002). At one year operative treatment resulted in higher SSV (70.9 vs. 83.5, p<0.001). Increase in SSV was similar between groups (29.1 vs. 29.9, p=0.234) and EQ5D was comparable after one year (0.87 vs. 0.86, p=0.980).
Conclusion and relevance: No differences were observed in functional outcomes after one year. However, operative treatment resulted in lower NRS and higher EQ5D at six weeks. The SSV was better for the operative group at both six weeks and one year. Therefore, operative treatment might be beneficial in the short term for selected patients.
