Surgical Treatment <i>versus</i> Conservative Treatment for Three-part or Four-part Proximal Humeral Fractures in Elderly Patient:A Meta-analysis of Randomized Controlled Trials_West China Medical Journal

Authors：

 CHENYan-ying , XULong ,  HUANGFu-guo

Department of Orthopedics, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P. R. China;

Corresponding author：

HUANGFu-guo, Email: huang-f-g@163.com

Keywords：

Proximal humeral fractures; Conservative treatment; Surgical treatment; Elderly; Meta-analysis

DOI：

10.7507/1002-0179.20150631

Video：

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Objective To assess the effect of surgical treatment or conservative treatment on the clinical outcomes for displaced 3-part or 4-part proximal humeral fractures in elderly patients. Methods We searched CNKI (between January 1979 and April 2014), Wanfang Data (between January 1982 and April 2014), Medline (between January 1946 and April 2014), PubMed (between January 1966 and April 2014), Embase (between January 1974 and April 2014) and Cochrane Database of Systematic Reviews (between January 2005 and April 2014) for randomized controlled trials comparing surgical treatment and conservative treatment for displaced 3-part or 4-part proximal humeral fractures in elderly patients. The data were extracted and a Meta-analysis was made using RevMan 5.2. Results Five randomized controlled trials with a total of 226 patients were accepted in this Meta-analysis. The differences of Constant scores[WMD=0.48, 95%CI (-4.39, 5.35), P=0.85], incidences of avascular necrosisr of the humeral head[RR=0.66, 95%CI (0.37, 1.16), P=0.15], incidences of nonunion[RR=0.56, 95%CI (0.20, 1.58), P=0.27], incidences of osteoarthritis[RR=0.35, 95%CI (0.10, 1.22), P=0.10] between the two groups were not statistically different. The difference of incidences of additional surgery after primary treatment was statistically significant[RR=3.52, 95%CI (1.18, 10.45), P=0.02]. Conclusion The results does not support the surgical treatment to improve the shoulder function when compared with conservative treatment for treating elderly patients with displaced 3-part or 4-part proximal humeral fractures. But surgical treatment increases the incidence of additional surgery after primary treatment. Considering surgery can increase the trauma and economic burden of patients, so the conservative treatment is suggested.

Citation： CHENYan-ying, XULong, HUANGFu-guo. Surgical Treatment versus Conservative Treatment for Three-part or Four-part Proximal Humeral Fractures in Elderly Patient:A Meta-analysis of Randomized Controlled Trials. West China Medical Journal, 2015, 30(11): 2040-2045. doi: 10.7507/1002-0179.20150631 Copy

1.	Sanders RJ, Thissen LG, Teepen JC, et al. Locking plate versus nonsurgical treatment for proximal humeral fractures:better midterm outcome with nonsurgical treatment[J]. J Shoulder Elbow Surg, 2011, 20(7):1118-1124.
2.	van den Broek CM, van den Besselaar M, Coenen JM, et al. Displaced proximal humeral fractures:intramedullary nailing versus conservative treatment[J]. Arch Orthop Trauma Surg, 2007, 127(6):459-463.
3.	Tingart M, Bäthis H, Bouillon B, et al. The displaced proximal humeral fracture:is there evidence for therapeutic concepts?[J]. Chirurg, 2001, 72(11):1284-1291.
4.	Wijgman AJ, Roolker W, Patt TW, et al. Open reduction and internal fixation of three and four-part fractures of the proximal part of the humerus[J]. J Bone Joint Surg Am, 2002, 84-A(11):1919-1925.
5.	Platzer P, Thalhammer G, Oberleitner G, et al. Displaced fractures of the greater tuberosity:a comparison of operative and nonoperative treatment[J]. J Trauma, 2008, 65(4):843-848.
6.	Yüksel HY, Yılmaz S, Akşahin E, et al. The results of nonoperative treatment for three-and four-part fractures of the proximal humerus in low-demand patients[J]. J Orthop Trauma, 2011, 25(10):588-595.
7.	Den Hartog D, De Haan J, Schep NW, et al. Primary shoulder arthroplasty versus conservative treatment for comminuted proximal humeral fractures:a systematic literature review[J]. Open Orthop J, 2010, 4:87-92.
8.	Ilchmann T, Ochsner PE, Wingstrand H, et al. Non-operative treatment versus tension-band osteosynthesis in three-and four-part proximal humeral fractures[J]. Int Orthop, 1998, 22(5):316-320.
9.	Lin J. Effectiveness of locked nailing for displaced three-part proximal humeral fractures[J]. J Trauma, 2006, 61(2):363-374.
10.	Monga P, Verma R, Sharma VK. Closed reduction and external fixation for displaced proximal humeral fractures[J]. J Orthop Surg (Hong Kong), 2009, 17(2):142-145.
11.	张天嵩, 钟文昭. 实用循证医学方法学[M]. 长沙:中南大学出版社, 2012:57.
12.	Zyto K, Ahrengart L, Sperber A, et al. Treatment of displaced proximal humeral fractures in elderly patients[J]. J Bone Joint Surg Br, 1997, 79(3):412-417.
13.	Fjalestad T, Hole MØ, Hovden IA, et al. Surgical treatment with an angular stable plate for complex displaced proximal humeral fractures in elderly patients:a randomized controlled trial[J]. J Orthop Trauma, 2012, 26(2):98-106.
14.	Olerud P, Ahrengart L, Ponzer S, et al. Internal fixation versus nonoperative treatment of displaced 3-part proximal humeral fractures in elderly patients:a randomized controlled trial[J]. J Shoulder Elbow Surg, 2011, 20(5):747-755.
15.	Olerud P, Ahrengart L, Ponzer S, et al. Hemiarthroplasty versus nonoperative treatment of displaced 4-part proximal humeral fractures in elderly patients:a randomized controlled trial[J]. J Shoulder Elbow Surg, 2011, 20(7):1025-1033.
16.	Boons HW, Goosen JH, Van Grinsven S, et al. Hemiarthroplasty for humeral four-part fractures for patients 65 years and older:a randomized controlled trial[J]. Clin Orthop Relat Res, 2012, 470(12):3483-3491.
17.	Zyto K, Kronberg M, Broström LÅ. Shoulder function after displaced fractures of the proximal humerus[J]. J Shoulder Elbow Surg, 1995, 4(5):331-336.
18.	Neer CS 2nd. Displaced proximal humeral fractures. Ⅱ. Treatment of three-part and four-part displacement[J]. J Bone Joint Surg Am, 1970, 52(6):1090-1103.
19.	Kristiansen B. Treatment of displaced fractures of the proximal humerus:transcutaneous reduction and Hoffmann’s external fixation[J]. Injury, 1989, 20(4):195-199.
20.	Esser RD. Open reduction and internal fixation of three-and four-part fractures of the proximal humerus[J]. Clin Orthop Relat Res, 1994(299):244-251.
21.	Moda SK, Chadha NS, Sangwan SS, et al. Open reduction and fixation of proximal humeral fractures and fracture-dislocations[J]. J Bone Joint Surg Br, 1990, 72(6):1050-1052.
22.	Handoll HH, Ollivere BJ, Rollins KE. Interventions for treating proximal humeral fractures in adults[J]. Cochrane Database Syst Rev, 2012(12):CD000434.

1. Sanders RJ, Thissen LG, Teepen JC, et al. Locking plate versus nonsurgical treatment for proximal humeral fractures:better midterm outcome with nonsurgical treatment[J]. J Shoulder Elbow Surg, 2011, 20(7):1118-1124.
2. van den Broek CM, van den Besselaar M, Coenen JM, et al. Displaced proximal humeral fractures:intramedullary nailing versus conservative treatment[J]. Arch Orthop Trauma Surg, 2007, 127(6):459-463.
3. Tingart M, Bäthis H, Bouillon B, et al. The displaced proximal humeral fracture:is there evidence for therapeutic concepts?[J]. Chirurg, 2001, 72(11):1284-1291.
4. Wijgman AJ, Roolker W, Patt TW, et al. Open reduction and internal fixation of three and four-part fractures of the proximal part of the humerus[J]. J Bone Joint Surg Am, 2002, 84-A(11):1919-1925.
5. Platzer P, Thalhammer G, Oberleitner G, et al. Displaced fractures of the greater tuberosity:a comparison of operative and nonoperative treatment[J]. J Trauma, 2008, 65(4):843-848.
6. Yüksel HY, Yılmaz S, Akşahin E, et al. The results of nonoperative treatment for three-and four-part fractures of the proximal humerus in low-demand patients[J]. J Orthop Trauma, 2011, 25(10):588-595.
7. Den Hartog D, De Haan J, Schep NW, et al. Primary shoulder arthroplasty versus conservative treatment for comminuted proximal humeral fractures:a systematic literature review[J]. Open Orthop J, 2010, 4:87-92.
8. Ilchmann T, Ochsner PE, Wingstrand H, et al. Non-operative treatment versus tension-band osteosynthesis in three-and four-part proximal humeral fractures[J]. Int Orthop, 1998, 22(5):316-320.
9. Lin J. Effectiveness of locked nailing for displaced three-part proximal humeral fractures[J]. J Trauma, 2006, 61(2):363-374.
10. Monga P, Verma R, Sharma VK. Closed reduction and external fixation for displaced proximal humeral fractures[J]. J Orthop Surg (Hong Kong), 2009, 17(2):142-145.
11. 张天嵩, 钟文昭. 实用循证医学方法学[M]. 长沙:中南大学出版社, 2012:57.
12. Zyto K, Ahrengart L, Sperber A, et al. Treatment of displaced proximal humeral fractures in elderly patients[J]. J Bone Joint Surg Br, 1997, 79(3):412-417.
13. Fjalestad T, Hole MØ, Hovden IA, et al. Surgical treatment with an angular stable plate for complex displaced proximal humeral fractures in elderly patients:a randomized controlled trial[J]. J Orthop Trauma, 2012, 26(2):98-106.
14. Olerud P, Ahrengart L, Ponzer S, et al. Internal fixation versus nonoperative treatment of displaced 3-part proximal humeral fractures in elderly patients:a randomized controlled trial[J]. J Shoulder Elbow Surg, 2011, 20(5):747-755.
15. Olerud P, Ahrengart L, Ponzer S, et al. Hemiarthroplasty versus nonoperative treatment of displaced 4-part proximal humeral fractures in elderly patients:a randomized controlled trial[J]. J Shoulder Elbow Surg, 2011, 20(7):1025-1033.
16. Boons HW, Goosen JH, Van Grinsven S, et al. Hemiarthroplasty for humeral four-part fractures for patients 65 years and older:a randomized controlled trial[J]. Clin Orthop Relat Res, 2012, 470(12):3483-3491.
17. Zyto K, Kronberg M, Broström LÅ. Shoulder function after displaced fractures of the proximal humerus[J]. J Shoulder Elbow Surg, 1995, 4(5):331-336.
18. Neer CS 2nd. Displaced proximal humeral fractures. Ⅱ. Treatment of three-part and four-part displacement[J]. J Bone Joint Surg Am, 1970, 52(6):1090-1103.
19. Kristiansen B. Treatment of displaced fractures of the proximal humerus:transcutaneous reduction and Hoffmann’s external fixation[J]. Injury, 1989, 20(4):195-199.
20. Esser RD. Open reduction and internal fixation of three-and four-part fractures of the proximal humerus[J]. Clin Orthop Relat Res, 1994(299):244-251.
21. Moda SK, Chadha NS, Sangwan SS, et al. Open reduction and fixation of proximal humeral fractures and fracture-dislocations[J]. J Bone Joint Surg Br, 1990, 72(6):1050-1052.
22. Handoll HH, Ollivere BJ, Rollins KE. Interventions for treating proximal humeral fractures in adults[J]. Cochrane Database Syst Rev, 2012(12):CD000434.

West China Medical Journal

Surgical Treatment versus Conservative Treatment for Three-part or Four-part Proximal Humeral Fractures in Elderly Patient:A Meta-analysis of Randomized Controlled Trials

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