Lee Gordon, Hasegawa Ian, Obana Kyle, Min Kyong S
Orthopaedic Surgery Department, University of Hawaii - John A. Burns School of Medicine, Honolulu, HI, USA.
Department of Orthopaedic Surgery, Tripler Army Medical Center, Honolulu, HI, USA.
JSES Rev Rep Tech. 2021 May 21;1(3):165-170. doi: 10.1016/j.xrrt.2021.04.014. eCollection 2021 Aug.
There has been an increasing amount of interest and research examining best practices for the treatment of proximal humerus fractures (PHF). Recent, high-level randomized control trials and many retrospective cohort studies have failed to demonstrate clear benefit of surgical management for these injuries especially in the elderly (generally defined as ≥65 years old). There is a paucity of research available on outcomes after surgical and nonsurgical treatment of proximal humerus fractures in adults younger than 65 years, and comparative data are almost nonexistent. The purpose of our study was to perform a systematic review and meta-analysis on the available data to determine if the literature supports surgical management over conservative treatment for PHFs in adults younger than 65 years.
Adhering to PRISMA guidelines, a systematic review of proximal humerus fractures was performed using MEDLINE and Google Scholar databases. Studies were included if they reported useable data such as outcome measures for adult patients younger than 65 years. Quality of nonrandomized studies was assessed utilizing the MINORs criteria. Extracted data were analyzed using statistical software with -value set at 0.05.
Six studies were included in the study for data extraction and statistical analysis. When comparing Constant Scores (CS) and Oxford Shoulder Scores (OSS) of operatively and nonoperatively treated adult patients aged less than 65 years, no statistical differences were found. Furthermore, no statistical differences in CS or OSS were found comparing elderly patients (defined as ≥65 years) and adult patients (defined as 18 to <65 years). Analysis of DASH outcome data did show statistical differences of the three cohorts (nonoperative <65, operative <65, and operative ≥65). Thus, only the limb-specific (not joint specific) outcome score (DASH) was found to be significantly different upon data analysis. Differences in shoulder-specific outcome scores (OSS and CS) failed to meet significance.
The available literature does not demonstrate a clear clinical benefit of operative treatment over nonoperative management of proximal humeral fractures in adult patients younger than 65 years. These results challenge the widely accepted practice of choosing surgical treatment in adult patients younger than 65 years with PHFs.
对于肱骨近端骨折（PHF）治疗的最佳实践，人们的兴趣和研究日益增加。近期的高水平随机对照试验以及许多回顾性队列研究均未能证明手术治疗对这些损伤有明显益处，尤其是在老年患者（一般定义为≥65岁）中。关于65岁以下成人肱骨近端骨折手术和非手术治疗后的结局研究较少，且几乎没有比较数据。我们研究的目的是对现有数据进行系统评价和荟萃分析，以确定文献是否支持对65岁以下成人的肱骨近端骨折采用手术治疗而非保守治疗。
遵循PRISMA指南，使用MEDLINE和谷歌学术数据库对肱骨近端骨折进行系统评价。如果研究报告了可用数据，如65岁以下成年患者的结局指标，则纳入研究。使用MINORs标准评估非随机研究的质量。使用统计软件分析提取的数据，设定P值为0.05。
六项研究被纳入本研究以进行数据提取和统计分析。比较65岁以下接受手术和非手术治疗的成年患者的Constant评分（CS）和牛津肩评分（OSS）时，未发现统计学差异。此外，比较老年患者（定义为≥65岁）和成年患者（定义为18至<65岁）的CS或OSS时，也未发现统计学差异。对DASH结局数据的分析确实显示了三个队列（非手术<65岁、手术<65岁和手术≥65岁）之间的统计学差异。因此，数据分析时仅发现特定肢体（而非特定关节）结局评分（DASH）有显著差异。肩部特定结局评分（OSS和CS）的差异未达到显著性。
现有文献未证明65岁以下成年患者肱骨近端骨折手术治疗比非手术治疗有明显的临床益处。这些结果对在65岁以下患有肱骨近端骨折的成年患者中选择手术治疗这一广泛接受的做法提出了挑战。
