TRAUMA
Treatment of proximal humerus fractures in the elderly A systematic review of 409 patients
OrthoEvidence Journal (OE Journal) - ACE Report
OE Journal. 2015;3(20):32 Acta Orthop. 2015 Jun;86(3):280-5.9 studies (8 RCTs, 1 controlled clinical trial) were selected for a systematic review of elderly patients with a proximal humerus fracture. The goal of this study was to determine whether surgical or nonoperative treatment is the optimal intervention in patients over the age of 60. Operative treatments identified in the included trials were the tension band technique, locking plates, pinning and hemiarthroplasty. The results of this review indicated that many studies did not find a significant difference in functional outcomes when comparing locking plates or tension bands to nonoperative treatment at 1 year. There was a significantly better health-related quality of life and Euroqol-5D in patients that received a hemiarthroplasty compared to the nonoperative group for patients with 4-part fractures. Complications were common in the operative treatment groups. This study highlights the need for further high quality investigations.
Were the search methods used to find evidence (original research) on the primary question or questions stated?
Was the search for evidence reasonably comprehensive?
Were the criteria used for deciding which studies to include in the overview reported?
Was the bias in the selection of studies avoided?
Were the criteria used for assessing the validity of the included studies reported?
Was the validity of all of the studies referred to in the text assessed with use of appropriate criteria (either in selecting the studies for inclusion or in analyzing the studies that were cited)?
Were the methods used to combine the findings of the relevant studies (to reach a conclusion) reported?
Were the findings of the relevant studies combined appropriately relative to the primary question that the overview addresses?
Were the conclusions made by the author or authors supported by the data and or analysis reported in the overview?
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はい = 1
不確実＝0.5
無関係 = 0
いいえ = 0
報告基準評価では、著者が出版物内で試験の方法論的特徴や試験特性を報告する際の透明性を評価します。評価は以下の5つのカテゴリーに分類されます。
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Introduction
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Accessing Data
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Analysing Data
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Results
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Discussion
Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65
Fragility Indexは、重要な所見の解釈を助けるツールで、結果の強さの尺度を提供します。Fragility Indexは、その所見が有意でなくなるために、二項対立の結果に追加する必要がある連続した事象の数を表します。数値が小さいほど弱い所見を表し、数値が大きいほど強い所見を表します。
なぜ今この研究が必要なのですか？
As the growing population ages, the incidence of osteoporotic trauma will also grow. Among the more common of these fractures are those of the proximal humerus. There is little high-quality evidence comparing the various methods of treatment, which also have a high degree of variation between practitioners. Previous literature reviews have not focused on proximal humerus fractures associated with osteoporosis, and with new literature published, there is a need for an updated assessment.
主な研究課題は何ですか？
What were the effects of various surgical treatments of osteoporotic proximal humerus fractures on function, disability, and complications in elderly patients?
重要な知見は？
- Studies investigated the use of surgical treatments which included the tension band technique (1 study), locking plates (3 studies), hemiarthroplasty (3 studies) and MIROS pinning (1 study).
- A comparison of tension band to nonoperative treatment found that there was no significant difference in Constant score after 1 year
- Studies comparing locking plate fixation to nonoperative treatment found no difference in Constant score (2 studies), American Shoulder and Elbow Surgeons shoulder score (1 study), Disabilities of the arm, shoulder, and hand (DASH) score (1 study) or health-related quality of life (2 studies) at one year.
- 1 study found no differences between monaxial and polyaxial constructions in locking plates in constant score, DASH and simple shoulder test.
- One study comparing hemiarthroplasty with nonoperative treatment in patients with 4 part fractures found that hemiarthroplasty had a significantly better EQ-5D, but no significant difference was found for DASH or Constant score after 2 years
- Another study comparing hemiarthroplasty and nonoperative treatment found no significant difference for Constant score, simple shoulder test, or visual analogue scale after 12 months
- One study comparing hemiarthroplasty devices (Epoca, Depuy Synthesis and HAS, Stryker) found that the individual Constant score and the regular Constant score were in favor of the Epoca prosthesis; 2 infections were reported for the Epoca group
- Complications were common with operative care (10-29%) as well as reoperation rates (16-30%)
最も覚えておくべきことは？
Many of the studies found no significant difference between the functional outcomes for operative and nonoperative treatment of proxmial humerus fractures in patients over the age of 60. Many studies reported high complication rates in the operative group. Both tension band and locking plate systems did not provide significant benefits over nonoperative treatment. Treatment of 4-part fractures with hemiarthroplasty found that HRQoL and EQ-5D was significantly better than nonoperative treatment, but the complication rates were high.
それが私の患者ケアにどのように影響するか？
The results from this study indicate the operative treatments such as tension band and locking plate systems did not provide significant benefits over nonoperative treatment, and while hemi arthroplasty my provide some benefit there were concerns relating to the number of complications. The study highlights the need for further high quality investigations into the treatment of 3-4 part humeral fractures that use standardized reporting that will allow for meta-analysis.
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