Let Us Agree to Disagree on Operative Versus Nonoperative Treatment for Proximal Humerus Fractures: A Multicenter International Prospective Cohort Study of Gray-Zone, Clinical Equipoise Fractures

BACKGROUND: Internationally, the optimal treatment strategy of proximal humerus fractures remains much debated.

METHODS: To investigate whether operative treatment of displaced proximal humerus fractures is superior to nonoperative treatment, this international multicenter prospective natural experiment based on clinical equipoise was performed. Two hundred twenty-six patients with acute proximal humerus fractures presenting from July 2020 to March 2022 were included after expert panel evaluation, consisting of Dutch and Swiss surgeons with diverse ideas on optimal treatment. Patients were included when no consensus on optimal treatment was reached i.e., clinical equipoise. Follow-up was completed after 1 year (n = 191 [84%]). The primary outcome was Quick Disability of the Arm, Shoulder, and Hand (QuickDASH) after 1 year. Secondary outcomes included QuickDASH at 6 weeks and EQ5D, Subjective Shoulder Value (SSV), Numeric Rating Scale (NRS) for pain at 6 weeks and 1 year.

RESULTS: No difference in QuickDASH score after 1 year (12.8 vs. 16.2, p = 0.73) was found. At 6 weeks, operative treatment resulted in lower NRS (4.3 vs. 3.0, p < 0.001), higher EQ5D (0.59 vs. 0.67, p = 0.011), and higher SSV (40.9 vs. 51.4, p = 0.005). At 1 year, operative treatment resulted in higher SSV (72.1 vs. 83.7, p = 0.002), while EQ5D was comparable (0.87 vs. 0.85, p = 0.95).

CONCLUSION: No difference between treatments was observed in the primary outcome. Patient-tailored care may still include counseling operative treatment to patients to reduce short-term pain and/or facilitate early return to sport/work in young active patients.

LEVEL OF EVIDENCE: Level II. See Instructions for Authors for a complete description of levels of evidence.