Treatment of humerus fractures in the elderly: A systematic review covering effectiveness, safety, economic aspects and evolution of practice

Abstract

Objectives: The objective of this Health Technology Assessment was to evaluate effectiveness, complications and cost-effectiveness of surgical or non-surgical treatment for proximal, diaphyseal or distal fractures of the humerus in elderly patients. Secondary objectives were to evaluate the intervention costs per treatment of proximal humerus fractures (PHF) and to investigate treatment traditions of PHF in Sweden.

Methods and findings: The assessment contains a systematic review of clinical and health economic studies comparing treatment options for humerus fractures in elderly patients. The results regarding the effectiveness of treatments are summarized in meta-analyses. The assessment also includes a cost analysis for treatment options and an analysis of registry data of PHF. For hemiarthroplasty (HA) and non-operative treatment, there was no clinically important difference for moderately displaced PHF at one-year follow-up regarding patient rated outcomes, (standardized mean difference [SMD]) -0.17 (95% CI: -0.56; 0.23). The intervention cost for HA was at least USD 5500 higher than non-surgical treatment. The trend in Sweden is that surgical treatment of PHF is increasing. When functional outcome of percutaneous fixation/plate fixation/prosthesis surgery and non-surgical treatment was compared for PHF there were no clinically relevant differences, SMD -0.05 (95% CI: -0.26; 0.15). There was not enough data for interpretation of quality of life or complications. Evidence was scarce regarding comparisons of different surgical options for humerus fracture treatment. The cost of plate fixation of a PHF was at least USD 3900 higher than non-surgical treatment, costs for complications excluded. In Sweden the incidence of plate fixation of PHF increased between 2005 and 2011.

Conclusions: There is moderate/low certainty of evidence that surgical treatment of moderately displaced PHF in elderly patients has not been proven to be superior to less costly non-surgical treatment options. Further research of humerus fractures is likely to have an important impact.

Fig 1. PRISMA flow-chart.

Fig 2. Meta-analysis of randomized controlled trials comparing hemiarthroplasty (HA) with sling immobilization: results of functional outcome, in elderly patients with proximal humerus fractures at one-year follow-up.

Fig 3. Meta-analysis of randomized controlled trials comparing different methods for internal fixation with treatment with a sling: results of functional outcome, in elderly patients with proximal humerus fractures at one-year follow-up.

Fig 4. Meta-analysis of randomized controlled trials comparing different methods for internal fixation with treatment with a sling: results of quality of life, in elderly patients with proximal humerus fractures at one-year follow-up.

Fig 5. Meta-analysis of randomized controlled trials comparing different methods for internal fixation with treatment with a sling: results of major complications, in elderly patients with proximal humerus fractures at one-year follow-up.

Fig 6. Meta-analysis of a randomized controlled trial and two Non-R studies comparing different methods for plate fixation with intramedullary nailing: results of functional outcomes, in elderly patients with proximal humerus fractures at one-year follow-up.

The study of Konrad et al., 2012 could not be illustrated in the meta-analysis, since only boxplot was presented.

Fig 7. Meta-analysis of a randomized controlled trial and two Non-R studies and one registry study comparing hemiarthroplasty (HA) with reverse shoulder arthroplasty (RSA): Results of functional outcome, in elderly patients with proximal humerus fractures at one to five-year follow-up.

Fig 8. Incidence per 10,000 person-years of proximal humerus fractures in the Swedish population ≥50 years old, between 2005 and 2013 according to registry data from the Swedish Board of National Health and Welfare.

Fig 9. The most common surgical treatments of proximal humerus fracture in women, ≥50 years old, between 2005 to 2013 in Sweden according to registry data from the Swedish Board of National Health and Welfare.

Fig 10. The most common surgical treatments of proximal humerus fracture in men, ≥50 years old, between 2005 to 2013 in Sweden according to registry data from the Swedish Board of National Health and Welfare.