Primary hemiarthroplasty versus conservative treatment for comminuted fractures of the proximal humerus in the elderly (ProCon) - A Multicenter Randomized trial.

BACKGROUND

Fractures of the proximal humerus are common injuries in the elderly. The incidence is approximately 6.6 per 1,000 person years. Most of these fractures can be treated with non-operative means and careful early motion. However, the treatment of comminuted fractures like selected three-or four-part fractures and split fractures of the humeral head is a demanding and unresolved problem. Locking plates have recently been introduced and they appear to offer improved fixation. However, especially in elderly patients the prevalence of screw cut-out ranges from 11 to 43% due to fracture collapse. This may ultimately lead to higher rates of revision surgery. Therefore, it seems reasonable to treat these comminuted fractures primarily with a prosthesis or non-operatively in a population of elderly patients.

Primary hemiarthroplasty and non-operative treatment of comminuted proximal humeral fractures have been described in a number of studies with varying functional results. Stableforth et al. performed a randomized study comparing hemiarthroplasty with conservative management in a total of 32 patients. The results revealed less pain and better overall function in the hemiarthroplasty group. However, this study had methodological limitations because of indistinct inclusion criteria and a difference in age between the two intervention arms at baseline, and may therefore not be generalizable. To our notice no other randomized controlled trial has been performed to compare hemiarthroplasty and non–operative treatment of comminuted fractures of the proximal humerus.

AIM

The primary objective of this RCT is to compare the Constant scores (reflecting functional outcome and pain) at one year after primary hemiarthroplasty versus non-operative treatment in patients over 65 years of age who sustained a comminuted humeral fracture.



Secondary aims are to assess effects on primary hemiarthroplasty versus conservative treatment on the degree of disabilities of the arm, shoulder and hand (DASH score), the level of pain (VAS), rate of secondary interventions, complications and mortality, health-related quality of life (SF-36, EQ-5D), and the time to radiographic healing and position of the tuberculi based on CT and radiographs. The costs and cost-effectiveness of both interventions will be determined.

STUDY DESIGN

Multi-center randomized clinical trial




POPULATION

Patients (65 years or older) with a comminuted proximal humeral fracture.




INTERVENTIONS

1) Hemiarthroplasty (Affinis® Fracture shoulder endoprosthesis). Critical aspects of the surgical procedure will be standardized. After surgery, patients are allowed to use a sling for 2 days to one week. Patients will receive after-treatment following a standardized approach. Anteflexion and elevation exercises may be started immediately if tolerated. Rotation exercises against resistance are not allowed during the first six weeks after surgery.

2) Conservative treatmentThe affected arm will be put in a collar and cuff for three weeks. At one week after fracture circumduction exercises will start. At three weeks after fracture mobilization will be initiated by practicing under supervision of a physical therapist. Physical therapy sessions will be held at regular intervals, preferably 2 times a week during 12 weeks.

ENDPOINTS

Primary outcome (Constant Score) and secondary outcomes (DASH, pain, radiographic healing, secondary intervention rates, complication rates, mortality rates, SF-36, and EQ-5D) will be compared at baseline, at 1, 3 and 6 weeks, and at 3, 6, 12 and 24 months after start of treatment, using both univariate and multivariable analyses. Costs for (in)formal healthcare consumption will be determined for both interventions, Cost-effectiveness will be expressed as cost per quality of life year (QALY) gained.

Hemiarthroplasty will result in higher Constant scores (reflecting better functional outcome with less pain) at 1 year compared with non-operative treatment of complex humeral fractures in the elderly.

Baseline, 1 week, 3 weeks, 6 weeks, 3 months, 6 months, 12 months, 24 months.

1. Hemiarthroplasty (Affinis® Fracture shoulder endoprosthesis);

2. Conservative treatment.