A comprehensive and international study has shed new light on the treatment of complicated shoulder fractures, which particularly affect the elderly population.

The study was published recently in PLOS Medicine, and it shows that a simple arm sling is just as effective as shoulder surgery with a plate or shoulder prosthesis. The conclusion challenges current surgical practice and highlights the potential of a more cost-effective and safe form of treatment for patients with shoulder fractures.

"Our study demonstrated no benefit of surgical treatment compared to non-operative treatment of displaced shoulder fractures in patients aged 60 years or older. We also observed several complications linked to surgical treatments - especially with plates. In fact almost half of the patients experienced complications," explains Inger Mechlenburg, professor of orthopaedic rehabilitation at Aarhus University and Aarhus University Hospital.

Monitored 160 patients for two years

The study was conducted by NITEP, a Nordic research consortium, and it involved 160 patients with displaced fractures of the upper part of the humerus.

The patients were randomly assigned to either non-operative treatment or one of two surgical treatments involving either a plate or shoulder prosthesis.

Over a period of two years, the patients' progress was monitored by the researchers, and any complications were recorded.

Patients in the study reported having the same level of pain and function, regardless of the treatment they had received.

Surgery discouraged as standard treatment

Displaced fractures of the upper part of the humerus (proximal humerus fracture) are among the most common fractures in older people, and the risk of such as fracture increases with age.

A non-operative treatment includes the use of a sling, to relieve the strain on the arm, and rehabilitation. This is a widely accepted treatment for this type of fracture, but surgical intervention is also used frequently.

Both patients and clinicians should be wary of surgery, says Inger Mechlenburg.

"The vast majority of people achieve just as good results with the arm in a sling as with a shoulder prosthesis, and clinicians should offer non-operative treatment as the standard procedure. Surgery with plates and screws should be completely avoided, as there is a risk of many complications," she says.

Significantly cheaper

Non-operative treatment is not only the correct and gentlest treatment for patients over 60 years of age with this type of fracture, it is also significantly cheaper than surgery. A shoulder prosthesis operation costs around DKK 55,000, while an arm sling costs in the region of DKK 200.

In Denmark, between 1,500 and 2,000 people over the age of 60 contract a 3-part or 4-part proximal humerus fracture every year. The incidence increases with age and is highest in women.

"It’s important that we make sure that elderly people with this type of shoulder fracture are offered the best treatment. We must avoid over-treatment, and the results of this study point to an area where the healthcare system could really benefit from prioritising non-operative and cheaper treatment," says Inger Mechlenburg.

Challenges culture

Sten Larsen, Chief Medical Officer at the Department of Orthopaedic Surgery at Aarhus University Hospital, calls the study's results and conclusions startling.

The results raise important questions and underline the need for continuous research and critical evaluation of established treatment methods.

"We need courageous studies like this that challenge a culture built up over many years with undocumented treatments. The study is a perfect tool to provide our patients with the optimal treatment," he says and continues:

"I hope that this can provide an opportunity to continue the important debate about what we do to patients when we give them a surgical treatment that triggers no better result than no surgery at all."

The research results - more information:

Type of study: Multicenter randomized trial. The main objective was to assess the results of non-operative treatment and operative treatment, either with a locking plate or a prosthesis (shoulder arthroplasty), for 3-part and 4-party proximal humerus fractures.

Partners: The study is part of the Nordic Innovative Trial to Evaluate Osteoporotic Fractures (NITEP), which involves patient participation from the following hospitals: Tampere University Hospital, Finland Central Hospital, Karolinska University Hospital, Uppsala University Hospital, Northern Estonia Hospital, Tartu University Hospital and Viborg Regional Hospital. The study was led by consultant Associate Professor Antti Launonen from Tampere University Hospital in Finland.

Funding: The study is supported by the Finnish academy - Terveyden tutkimuksen toimikunta.

Potential conflicts of interest: None

Link to the scientific article: https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004308

Contact:

Professor, PhD, DMSc Inger Mechlenburg
Department of Orthopaedic Surgery, Aarhus University Hospital
Department of Clinical Medicine, Aarhus University
Telephone: +45 21679062
Email: inger.mechlenburg@clin.au.dk

Chief Medical Officer Sten Larsen
Department of Orthopaedic Surgery, Aarhus University Hospital
Telephone: +45 21157230
Mail: stenlars@rm.dk