Difficulty in decision making in the treatment of displaced proximal humerus fractures: the effect of uncertainty on surgical outcomes
Decision making in the management of proximal humerus fractures can be difficult in situations in which the surgeon is uncertain of the ideal treatment. Two shoulder surgeons operatively treated 476 proximal humerus fractures from 1998-2014 with open reduction–internal fixation (ORIF), hemiarthropla...
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Published in | Journal of shoulder and elbow surgery Vol. 27; no. 3; pp. 470 - 477 |
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Main Authors | , , , , , , , , , |
Format | Journal Article |
Language | English |
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Elsevier Inc
01.03.2018
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Abstract | Decision making in the management of proximal humerus fractures can be difficult in situations in which the surgeon is uncertain of the ideal treatment.
Two shoulder surgeons operatively treated 476 proximal humerus fractures from 1998-2014 with open reduction–internal fixation (ORIF), hemiarthroplasty, or reverse shoulder arthroplasty. Operative treatment was stratified by year to determine the evolution of technological influences on treatment over time. To evaluate the effect of uncertainty, 274 clinical vignettes were created for all patients with 1 year of follow-up or more and reviewed by 3 fellowship-trained shoulder surgeons to determine the type of treatment for each case. To evaluate the effect of certainty, range of motion for each patient with unanimous agreement on treatment was analyzed.
ORIF treatment increased from 40% to 62% after release of the proximal humerus locking plate. Introduction of the fracture stem in 2011 increased reverse shoulder arthroplasty for fractures from 8.8% to 44.3%. Unanimous agreement on either operative or nonoperative treatment occurred 70.5% of the time. Only 63.5% of patients received the actual treatment selected (P = .001). Patients for whom unanimous agreement matched actual treatment in the ORIF treatment group showed improvement of forward elevation (144° vs 123°, P = .005) and abduction (129° vs 103°, P = .002).
Successful management of displaced proximal humerus fractures requires both technical and decision-making abilities. The difficulty in making these decisions is reflected by the agreement of experienced shoulder surgeons only 63.5% of the time regarding the treatment performed. When uncertainty occurs, patients may have reduced outcomes as seen in the ORIF treatment group. |
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AbstractList | Decision making in the management of proximal humerus fractures can be difficult in situations in which the surgeon is uncertain of the ideal treatment.
Two shoulder surgeons operatively treated 476 proximal humerus fractures from 1998-2014 with open reduction-internal fixation (ORIF), hemiarthroplasty, or reverse shoulder arthroplasty. Operative treatment was stratified by year to determine the evolution of technological influences on treatment over time. To evaluate the effect of uncertainty, 274 clinical vignettes were created for all patients with 1 year of follow-up or more and reviewed by 3 fellowship-trained shoulder surgeons to determine the type of treatment for each case. To evaluate the effect of certainty, range of motion for each patient with unanimous agreement on treatment was analyzed.
ORIF treatment increased from 40% to 62% after release of the proximal humerus locking plate. Introduction of the fracture stem in 2011 increased reverse shoulder arthroplasty for fractures from 8.8% to 44.3%. Unanimous agreement on either operative or nonoperative treatment occurred 70.5% of the time. Only 63.5% of patients received the actual treatment selected (P = .001). Patients for whom unanimous agreement matched actual treatment in the ORIF treatment group showed improvement of forward elevation (144° vs 123°, P = .005) and abduction (129° vs 103°, P = .002).
Successful management of displaced proximal humerus fractures requires both technical and decision-making abilities. The difficulty in making these decisions is reflected by the agreement of experienced shoulder surgeons only 63.5% of the time regarding the treatment performed. When uncertainty occurs, patients may have reduced outcomes as seen in the ORIF treatment group. BACKGROUNDDecision making in the management of proximal humerus fractures can be difficult in situations in which the surgeon is uncertain of the ideal treatment.METHODSTwo shoulder surgeons operatively treated 476 proximal humerus fractures from 1998-2014 with open reduction-internal fixation (ORIF), hemiarthroplasty, or reverse shoulder arthroplasty. Operative treatment was stratified by year to determine the evolution of technological influences on treatment over time. To evaluate the effect of uncertainty, 274 clinical vignettes were created for all patients with 1 year of follow-up or more and reviewed by 3 fellowship-trained shoulder surgeons to determine the type of treatment for each case. To evaluate the effect of certainty, range of motion for each patient with unanimous agreement on treatment was analyzed.RESULTSORIF treatment increased from 40% to 62% after release of the proximal humerus locking plate. Introduction of the fracture stem in 2011 increased reverse shoulder arthroplasty for fractures from 8.8% to 44.3%. Unanimous agreement on either operative or nonoperative treatment occurred 70.5% of the time. Only 63.5% of patients received the actual treatment selected (P = .001). Patients for whom unanimous agreement matched actual treatment in the ORIF treatment group showed improvement of forward elevation (144° vs 123°, P = .005) and abduction (129° vs 103°, P = .002).CONCLUSIONSuccessful management of displaced proximal humerus fractures requires both technical and decision-making abilities. The difficulty in making these decisions is reflected by the agreement of experienced shoulder surgeons only 63.5% of the time regarding the treatment performed. When uncertainty occurs, patients may have reduced outcomes as seen in the ORIF treatment group. |
Author | LaMartina, Joey Clark, Jonathan Abdelfattah, Adham Allert, Jesse W. Otto, Randall J. Frankle, Mark A. Streit, Jonathan J. Mighell, Mark A. Christmas, Kaitlyn N. Simon, Peter |
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Keywords | Level IV reverse shoulder arthroplasty ORIF arthroplasty decision making Displaced Decision Analysis Study evolution proximal humerus fractures uncertainty |
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Snippet | Decision making in the management of proximal humerus fractures can be difficult in situations in which the surgeon is uncertain of the ideal treatment.
Two... BACKGROUNDDecision making in the management of proximal humerus fractures can be difficult in situations in which the surgeon is uncertain of the ideal... |
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SubjectTerms | Aged arthroplasty Bone Plates Decision Making Displaced evolution Female Fracture Fixation, Internal - methods Hemiarthroplasty - methods Humans Male Middle Aged Open Fracture Reduction - methods ORIF proximal humerus fractures Range of Motion, Articular reverse shoulder arthroplasty Shoulder Fractures - surgery Surgeons - psychology Treatment Outcome Uncertainty |
Title | Difficulty in decision making in the treatment of displaced proximal humerus fractures: the effect of uncertainty on surgical outcomes |
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