Treatment of proximal humerus fractures in the elderly

Figures & data

Table 1. PICOS criteria for the trials included

Patients:	Age 60 years or older with a 2-, 3-, or 4-part proximal humerus fracture due to recent trauma
Intervention:	Any operative treatment (at least 20 patients in each treatment group)
Control:	Any treatment (at least 20 patients in each treatment group)
Outcome:	Any functional or disability score and/or any quality-of-life score after a minimum follow-up of 1 year
Study setting:	Randomized, controlled trial or controlled clinical trial

Figure 1. Flow chart of publications investigated, from search for abstracts to final analysis.

Table 2. Study designs

A	B	C	D	E	F	G	H	I	J	K	L
Zyto 1997	Sweden	RCT	3(-4)		Tension band (20)	Nonoperative (20)	12	40/38	73	75	2
Fialka 2008	Austria	RCT	4	11-C	Hemiarthroplasty	Hemiarthroplasty	12	40/35	74	73	5
					(Epoca (20))	(HAS (20))
Fjalestad 2010	Norway ^b	RCT	3-4	11-B2, 11-C2	Plating ^a (25)	Nonoperative (25)	12	50/48	72	73	2
Olerud 2011a	Sweden	RCT	4		Hemiarthroplasty	Nonoperative (28)	24	55/49	76	78	6
					(Global FX (27))
Olerud 2011b	Sweden	RCT	3		Plating (Philos (30))	Nonoperative (30)	24	60/53	73	75	7
Voigt 2011	Germany	RCT	3-4		Plating (humeral	Plating (Philos (31))	12	56/48	76	72	8
					suture plate (25))
Fjalestad 2012	Norway ^b	RCT	3-4	11-B2, 11-C2	Plating ^a (25)	Nonoperative (25)	12	50/48	72	73	2
Boons 2012	Netherlands	RCT	4		Hemiarthroplasty	Nonoperative (25)	12	50/47	76	80	3
					(Global FX (25))
Carbone 2012	Italy	CCT	3-4		MIROS pinning (31)	Traditional pinning (27)	24	58/52	78	81	6

AAuthor

BCountry

CDesign

DNeer

EAO-OTA

FIntervention (n at baseline)

GControl (n at baseline)

HFollow-up, months

INo. of patients at baseline/follow-up

JMean age (intervention group)

KMean age (control group)

LDrop-out, n

^a Nonspecific LCT AO-type locking plate.

^b Both publications are from the same population.

Table 3. Functional results of the trial. Values are mean (SD) unless otherwise stated

	Primary outcome measure			Secondary outcome measure			Adjacent outcome measure
Author	Intervention	Control	p-value	Intervention	Control	p-value	Intervention	Control	p-value
Zyto 1997	CS: 60 (19)	65 (15)	> 0.05
Fialka 2008	ICS: 70 (38–102) ^b	46 (15–80) ^b	0.001	CS: 52 (20–80) ^b	33 (8–68) ^b	na
Fjalestad 2010 ^a	CD: 35 (28–43) ^b	33 (26–40) ^b	0.6	ASES: 15 (12–18) ^b	16 (13–18) ^b	0.7
Olerud 2011a	EQ: 0.81 (0.12)	0.65 (0.27)	0.02	CS: 48 (16)	50 (21)	0.8	DASH: 30 (18)	37 (21)	0.3
Olerud 2011b	CS: 61 (19)	58 (23)	0.6	DASH: 26 (25)	36 (27)	0.2	EQ: 0.70 (0.34)	0.59 (0.35)	0.3
Voigt 2011	SST: 8 (3)	10 (2)	0.3	DASH: 18 (16)	16 (12)	1.0	CS: 73	81	> 0.05
Fjalestad 2012 ^a	15D: 0.84 (0.11)	0.82 (0.08)	0.4
Boons 2012	CS: 64 (16)	60 (18)	0.4	SST: 25 (8–100)	23 (0–92)	0.6	VAS12: 23 (1–65) ^c	25 (1–93) ^c	0.7
Carbone 2012	CS: 60	CS: 52	0.02	SSV: 90	73	0.02

CS = Constant Score;

ICS = Individual Constant Score determined by comparing the operated shoulder to the patient’s unaffected shoulder in percent;

CD = Constant Score difference at 12 months, and to reduce the influence of age, the difference between the scores for the injured and

uninjured shoulders was used;

ASES = American Shoulder and Elbow Surgeons Shoulder Score

EQ = Euroqol-5D

DASH = Disabilities of the Arm, Shoulder, and Hand

SST = Simple Shoulder Test

SSV = Subjective Shoulder Value

VAS12 = Visual Analogue Scale at 12 months, mean (range)

^a Both publications are from the same population.

^b Threshold values

^c Range

Zyto K , Ahrengart L , Sperber A , Tornkvist H . Treatment of displaced proximal humeral fractures in elderly patients. J Bone Joint Surg Br 1997; 79 (3): 412-7.

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Fialka C , Stampfl P , Arbes S , Reuter P , Oberleitner G , Vecsei V . Primary hemiarthroplasty in four-part fractures of the proximal humerus: randomized trial of two different implant systems. J Shoulder Elbow Surg 2008; 17 (2): 210-5.

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Fjalestad T , Hole MO , Jorgensen JJ , Stromsoe K , Kristiansen IS . Health and cost consequences of surgical versus conservative treatment for a comminuted proximal humeral fracture in elderly patients. Injury 2010; 41 (6): 599-605.

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Olerud P , Ahrengart L , Ponzer S , Saving J , Tidermark J . Hemiarthroplasty versus nonoperative treatment of displaced 4-part proximal humeral fractures in elderly patients: a randomized controlled trial. J Shoulder Elbow Surg 2011a; 20 (7): 1025-33.

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Olerud P , Ahrengart L , Ponzer S , Saving J , Tidermark J . Internal fixation versus nonoperative treatment of displaced 3-part proximal humeral fractures in elderly patients: a randomized controlled trial. J Shoulder Elbow Surg 2011b; 20 (5): 747-55.

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Voigt C , Geisler A , Hepp P , Schulz AP , Lill H . Are polyaxially locked screws advantageous in the plate osteosynthesis of proximal humeral fractures in the elderly? A prospective randomized clinical observational study. J Orthop Trauma 2011; 25 (10): 596-602.

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Boons HW , Goosen JH , van Grinsven S , van Susante JL , van Loon CJ . Hemiarthroplasty for humeral four-part fractures for patients 65 years and older: a randomized controlled trial. Clin Orthop Relat Res 2012; 470 (12): 3483-91.

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Carbone S , Tangari M , Gumina S , Postacchini R , Campi A , Postacchini F . Percutaneous pinning of three- or four-part fractures of the proximal humerus in elderly patients in poor general condition: MIROS(R) versus traditional pinning. Int Orthop 2012; 36 (6): 1267-73.

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Fjalestad T , Hole MO , Hovden IA , Blucher J , Stromsoe K . Surgical treatment with an angular stable plate for complex displaced proximal humeral fractures in elderly patients: a randomized controlled trial. J Orthop Trauma 2012; 26 (2): 98-106.

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