gms | German Medical Science

Background and current state of (inter)national research: With an aging population, the prevalence of age-related fragility fractures increased continuously over the past decade, and their treatment will become even more important in medical care in the future. The proximal humeral fracture (PHF) is thereby the third most prevalent osteoporosis-associated fracture.

Research questions and objectives: In recent years, there is a clear trend in the surgical treatment of PHF from a preferred use of locked plate fixation (LPF) to a now more frequent application of reverse shoulder arthroplasty (RTSA) in elderly patients. However, today even among specialists, there is no consensus about the optimal therapy.

Methods or hypothesis: The retrospective data of the Federal Association of the Local Health Insurance Funds (Allgemeine Ortskrankenkasse) were analyzed. Patients with an age of 65 years and older and a coded inpatient PHF treated with LPF or RTSA between 01/2010 and 09/2018 were included. Multivariable logistic regression models were used to address the association between treatment groups (RTSA vs. LPF) and the occurrence of in-hospital major adverse events (MAEs), in-hospital surgical complications and 30-day mortality adjusted by patient’s risk profile. All patients discharged alive were further observed from discharge date to the end of follow-up. Using multivariable Cox regression analyses, the influence of treatment groups on overall survival (OS), MAEs and surgical complications during follow-up adjusted by patient’s risk profile was evaluated.

Results: In the study period, 54,885 patients with a median age of 79 years (84% were woman) were included, with 75% were treated using LPF. After adjustment of known comorbidities, RTSA was associated with a higher risk for MAEs (Odds ratio (OR) 1.41, 95% CI 1.29–1.54, p<0.001) and a higher risk for surgical complications (OR 1.14, 95% CI 1.06–1.21, p<0.01) during index hospitalization. However, no differences in 30-day mortality was observed (p>0.05). 53,971 patients were followed up further (2% of the patients died during hospitalization) with a median follow-up time of 52 month. After adjustment by patient’s risk profile, RTSA was associated with an increased OS (hazard ratio (HR) 0.92, 95% CI 0.87–0.96, p<0.001), lower risk for MAEs (HR 0.92, 95% CI 0.89–0.95, p<0.001) and a lower risk for surgical complications (HR 0.50, 95% CI 0.46–0.55, p<0.001) within the follow-up period.

Discussion: While RTSA is associated with a higher risk for complications during index case, it appears to be superior to LPF in the long term regarding OS, MAEs and surgical complications. Recent literature reports superior clinical outcomes of RTSA compared to LPF. Hence, the data of the present study supports the current trend of more liberal use of RTSA in patients 65 years and older.

In general, the study shows that insurance data could be a helpful tool to assess patient safety in a real healthcare situation after regulatory approval.

Appeal to practice (science and/or care) in one sentence: All treatment options for PHF should by carefully considered for each patient individually in the context of her or his comorbidity profile.