Surgeons Consider Initial Nonoperative Treatment With Potential for Future Conversion to Reverse Arthroplasty a Reasonable Option for Older, Relatively Infirm, and Less-Active Patients.

Objectives: Two recent developments favor initial nonoperative treatment of proximal humerus fractures among the older, relatively infirm, less-active patients that represent most patients with such fractures: (1) evidence of minimal benefit of open reduction, internal fixation over nonoperative treatment, and (2) evidence of the effectiveness of the reverse total shoulder arthroplasty. As one step in determining the feasibility of a strategy of initial nonoperative treatment of proximal humerus fracture among older, relatively infirm, less-active people, we performed a survey-based experiment to measure factors associated with surgeon recommendation for initial nonoperative treatment.
Methods: Members of the Science of Variation Group viewed 8 hypothetical patients with radiographs of complex proximal humeral fractures and 7 randomized patient variables. For each scenario, surgeons were asked whether they would recommend (1) initial nonoperative treatment with bailout reverse arthroplasty or (2) immediate reverse arthroplasty.
Results: The mean percentage of recommendations for initial nonoperative treatment was 63%, with wide variation by surgeon (range 0%-100%). In multilevel mixed-effects logistic regression, recommendation for initial nonoperative treatment was associated with specific radiographs, older age, having a comorbidity, being homebound, surgical subspecialists, and more than 20 years in practice.
Conclusions: These findings suggest that surgeons may consider initial nonoperative treatment with potential for future conversion to reverse arthroplasty an acceptable treatment option, particularly for older, less-active, more infirm individuals, and relatively less displaced fractures with little comminution.
Competing Interests: One of the authors (D.R.) received royalties from Wright Medical (Memphis, TN) for elbow plates in the amount of less than USD 10,000 per year and from Skeletal Dynamics for an internal joint stabilizer elbow in the amount of between 10,000 and 100,000 USD per year. One of the authors certifies that he (D.R.) is a Deputy Editor for Hand and Wrist, Journal of Orthopaedic Trauma, and Clinical Orthopaedics and Related Research and has received or may receive payments or benefits in the amount of USD 5000 per year. One of the authors certifies that he (D.R.) received honoraria from meetings of the AO North America (Wayne, PA), AO International (Davos, Switzerland), and various hospitals and universities. The remaining authors report no conflict of interest.
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