Systematische Reviews
Chronologisch absteigend, neueste zuerst.
Handoll HH, Elliott J, Thillemann TM, Aluko P, Brorson S. Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev. 2022 Jun 21;6(6):CD000434. doi: 10.1002/14651858.CD000434.pub5. PMID: 35727196; PMCID: PMC9211385.
Objectives: To assess the effects (benefits and harms) of treatment and rehabilitation interventions for proximal humeral fractures in adults.
Main results: We included 47 trials (3179 participants, mostly women and mainly aged 60 years or over) that tested one of 26 comparisons. …
Surgical versus non-surgical treatment:
Ten trials (717 participants) evaluated surgical intervention for displaced fractures (66% were three- or four-part fractures).
There is high-certainty evidence of no clinically important difference between surgical and non-surgical treatment in patient-reported shoulder function at one year (standardised mean difference (SMD) 0.10, 95% confidence interval (CI) -0.07 to 0.27; 7 studies, 552 participants) and two years (SMD 0.06, 95% CI -0.13 to 0.25; 5 studies, 423 participants).
There is moderate-certainty evidence of no clinically important between-group difference in patient-reported shoulder function at six months (SMD 0.17, 95% CI -0.04 to 0.38; 3 studies, 347 participants). There is high-certainty evidence of no clinically important between-group difference in quality of life at one year …
Authors’ conclusions:
There is high- or moderate-certainty evidence that, compared with non-surgical treatment, surgery does not result in a better outcome at one and two years after injury for people with displaced proximal humeral fractures. It may increase the need for subsequent surgery.
The evidence is absent or insufficient for people aged under 60 years, high-energy trauma, two-part tuberosity fractures or less common fractures, such as fracture dislocations and articular surface fractures.
Deutsche Zusammenfassung:
https://www.cochrane.de/news/was-tun-bei-einem-bruch-des-oberarmkopfs
Stärker verschobene (dislozierte) Brüche werden … häufig operiert. Dabei bringt man die gebrochenen Knochen beispielsweise mit Hilfe von Schrauben und Metallplatten wieder in die korrekte Position.
Ein kürzlich aktualisierter Cochrane Review fasst die Evidenz aus 47 Studien mit mehr als 3000 Patientinnen zu verschiedenen Therapieansätzen für unterschiedliche Typen von proximalen Humerusfrakturen zusammen. Sein wohl wichtigstes Ergebnis: Auch für stärker dislozierte klassische Oberarmkopffrakturen zeigt die Evidenz keinen Vorteil einer Operation gegenüber einer konservativen Behandlung. Wohl aber zeigen sich Hinweise, dass ein einmal operierter Bruch mit höherer Wahrscheinlichkeit Folgeoperationen nach sich zieht. Die Vertrauenswürdigkeit der Evidenz für diese Ergebnisse bewerteten die Autorinnen mit moderat bis hoch.
——–
Oldrini LM, Feltri P, Albanese J, Marbach F, Filardo G, Candrian C. PHILOS Synthesis for Proximal Humerus Fractures Has High Complications and Reintervention Rates: A Systematic Review and Meta-Analysis. Life (Basel). 2022 Feb 19;12(2):311. doi: 10.3390/life12020311. PMID: 35207598; PMCID: PMC8880552.
Conclusions: Proximal humerus synthesis with a PHILOS plate has high complications and reintervention rates. The most frequent complication was screw cut-out, followed by humeral head AVN and subacromial impingement. These results need to be further investigated to better understand both the type of patient and fracture that is more at risk of complications and reintervention and to compare pros and cons of the PHILOS plate with respect to the other solutions to manage PHFs.
——
Soler-Peiro M, García-Martínez L, Aguilella L, Perez-Bermejo M. Conservative treatment of 3-part and 4-part proximal humeral fractures: a systematic review. J Orthop Surg Res. 2020 Aug 24;15(1):347. doi: 10.1186/s13018-020-01880-7. PMID: 32831119; PMCID: PMC7444241.
Methods: We searched the PubMed and Cochrane databases for clinical studies published between 2000 and 2019 on conservative treatment for 3-part and 4-part PHF that included patients older than 18 years, a minimum follow-up of 1 year, fracture classification, and description of outcomes with assessment scales.
Results: …. Consolidation was achieved in 95% of the three-part fractures and 91% of the four-part fractures. Loss of mobility varied according to the type of fracture. Regarding complications, the most frequent was malunion (21%), followed by avascular necrosis (9%).
Conclusions: Our data show that most three-part PHFs treated conservatively achieve fracture consolidation even noting a negligible rate of malunion got fair-good functional results with few complications, while the orthopedic four-part PHF treatment presents high rate of consolidation with less rate of malunion than the three-part PHF but achieve poor functional results with few complications.
—–
Relevante Studienpublikationen
Lopiz Y, Alcobía-Díaz B, Galán-Olleros M, García-Fernández C, Picado AL, Marco F. Reverse shoulder arthroplasty versus nonoperative treatment for 3- or 4-part proximal humeral fractures in elderly patients: a prospective randomized controlled trial. J Shoulder Elbow Surg. 2019 Dec;28(12):2259-2271. doi: 10.1016/j.jse.2019.06.024. Epub 2019 Sep 6. PMID: 31500986.
Methods: This was a prospective RCT. The primary objective was to compare pain and function 12 months after fracture using the Constant score in patients aged 80 years or older with 3- and 4-part PHFs, treated by either RSA or nonoperative treatment.
Conclusions: This study yields important evidence for the treatment of complex PHFs in elderly patients suggesting minimal benefits of RSA over nonoperative treatment for displaced 3- and 4-part PHFs. At short-term follow-up, the main advantage of RSA appeared to be less pain perception.
——–
Plath JE, Kerschbaum C, Seebauer T, Holz R, Henderson DJH, Förch S, Mayr E. Locking nail versus locking plate for proximal humeral fracture fixation in an elderly population: a prospective randomised controlled trial. BMC Musculoskelet Disord. 2019 Jan 10;20(1):20. doi: 10.1186/s12891-019-2399-1. PMID: 30630465; PMCID: PMC6329164.
Background: … The purpose of the study was to prospectively evaluate the outcomes of PHF fixation with a locking blade nail (LBN) or locking plate (PHILOS) osteosynthesis in a homogeneous elderly patient population.
Conclusions: At short-term follow-up, LBN osteosynthesis yielded similar outcomes and complication rates to PHILOS plate fracture fixation in an elderly patient population, though with a significantly lower rate of secondary loss of reduction and screw cut-out.
——-
Hawi N, Liodakis E, Razaeian S, Meller R, Krettek C. Die proximale Humerusfraktur – Wo stehen wir heute? : Ein Kommentar zur „Proximal fracture of the humerus evaluation by randomization (PROFHER)“-Studie. Proximal humeral fractures-Where do we stand today? : Comments on the “Proximal fracture of the humerus evaluation by randomization (PROFHER)” study. Chirurg. 2018 Oct;89(10):832-836. German. doi: 10.1007/s00104-018-0730-2. PMID: 30194487. (Springermedizin-Volltext für Abonnenten)
The results showed no differences in the primary and secondary self-assessment outcome scores after both 2 and 5 years. Although no significant differences could be detected between both groups, no clear statement could be deduced from the PROFHER study with respect to which patients would benefit from an operative treatment. Nevertheless, the PROFHER study provides a valuable and important addition to the literature on this heavily debated topic. The purpose of this review is to critically evaluate the PROFHER study within the existing literature regarding inclusion of patients, fracture treatment and evaluation of the results.
——-
Handoll HH, Keding A, Corbacho B, Brealey SD, Hewitt C, Rangan A. Five-year follow-up results of the PROFHER trial comparing operative and non-operative treatment of adults with a displaced fracture of the proximal humerus. Bone Joint J. 2017 Mar;99-B(3):383-392. doi: 10.1302/0301-620X.99B3.BJJ-2016-1028. PMID: 28249980; PMCID: PMC5404240.
Aims: The PROximal Fracture of the Humerus Evaluation by Randomisation (PROFHER) randomised clinical trial compared the operative and non-operative treatment of adults with a displaced fracture of the proximal humerus involving the surgical neck. The aim of this study was to determine the long-term treatment effects beyond the two-year follow-up.
Conclusion: These results confirm that the main findings of the PROFHER trial over two years are unchanged at five years. Cite this article: Bone Joint J 2017;99-B:383-92.
——
Rangan A, Handoll H, Brealey S, Jefferson L, Keding A, Martin BC, Goodchild L, Chuang LH, Hewitt C, Torgerson D; PROFHER Trial Collaborators. Surgical vs nonsurgical treatment of adults with displaced fractures of the proximal humerus: the PROFHER randomized clinical trial. JAMA. 2015 Mar 10;313(10):1037-47. doi: 10.1001/jama.2015.1629. PMID: 25756440.
Objective: To evaluate the clinical effectiveness of surgical vs nonsurgical treatment for adults with displaced fractures of the proximal humerus involving the surgical neck.
Conclusions and relevance: Among patients with displaced proximal humeral fractures involving the surgical neck, there was no significant difference between surgical treatment compared with nonsurgical treatment in patient-reported clinical outcomes over 2 years following fracture occurrence. These results do not support the trend of increased surgery for patients with displaced fractures of the proximal humerus.
C. Krettek, U. Wiebking. Proximale HumerusfrakturIst die winkelstabile Plattenosteosynthese der konservativen Behandlung überlegen? Erschienen in: Die Unfallchirurgie | Ausgabe 12/2011. Der Volltext ist hier zugänglich für Springermedizin-Abonennten:
Diese ältere Publikation aus der Medizinischen Hochschule Hannover enthält viele interessante Detail-Informationen zu den bis dato durchgeführten Studien, den Problemen der Vergleichbarkeit der Ergebnisse, die als Hintergrundinformation auch zum Verständnis der aktuellen Studien und reviews sehr hilfreich sind. Diese Publikation kam bereits 2011 im Ergebnis zu der Aussage, dass
“die Patienten auch in höhergradigen dislozierten Frakturtypen mit Dislokation nicht von der Osteosynthese profitierten.”
——– —
Separate Untersuchungen zum Nutzen der Operation bei vollständiger Abtrennung des Tuberkulum Majus:
Tuberkulum-Fixation – zum Erfolg der Operation:
Ding Z, Ju J, Ma M, Zhang Y, Chen J. Tuberosity reconstruction baseplate for shoulder hemiarthroplasty: Morphological design and biomaterial application. Front Bioeng Biotechnol. 2022 Oct 28;10:1047187. doi: 10.3389/fbioe.2022.1047187. PMID: 36394027; PMCID: PMC9649578.
Background: Shoulder hemiarthroplasty is prone to tuberosity malposition and migration, reducing the rate of tuberosity healing. …
——-
Dauwe J, Walters G, Van Eecke E, Vanhaecht K, Nijs S. Osteosynthesis of proximal humeral fractures: a 1-year analysis of failure in a Belgian level-1 trauma centre. Eur J Trauma Emerg Surg. 2021 Dec;47(6):1889-1893. doi: 10.1007/s00068-020-01323-2. Epub 2020 Feb 19. PMID: 32076785. (Springermedizin-Volltext für Abonennten)
Results: Circa 16% of the proximal humeral osteosyntheses failed.
——
OP-Indikationsstellung satirisch
Razaeian S, Wiese B, Zhang D, Harb A, Krettek C, Hawi N. Nonsensus in the treatment of proximal humerus fractures: uncontrolled, blinded, comparative behavioural analysis between Homo chirurgicus accidentus and Macaca sylvanus. BMJ. 2020 Dec 14;371:m4429. doi: 10.1136/bmj.m4429. PMID: 33318031; PMCID: PMC7734645. (BMJ-Volltext)
Deutsche Version auf der Webseite des Berufsverbands der Deutschen Chirurgie e.V. (BDC)
Nonsensus in der Behandlung proximaler Humerusfrakturen?
Sam Razaeian, März 1, 2021.