Abstract
ObjectivesThe objective of this Health Technology Assessment was to evaluate effectiveness, complications and cost-effectiveness of surgical or non-surgical treatment for proximal, diaphyseal or distal fractures of the humerus in elderly patients. Secondary objectives were to evaluate the intervention costs per treatment of proximal humerus fractures (PHF) and to investigate treatment traditions of PHF in Sweden.Methods and findingsThe assessment contains a systematic review of clinical and health economic studies comparing treatment options for humerus fractures in elderly patients. The results regarding the effectiveness of treatments are summarized in meta-analyses. The assessment also includes a cost analysis for treatment options and an analysis of registry data of PHF. For hemiarthroplasty (HA) and non-operative treatment, there was no clinically important difference for moderately displaced PHF at one-year follow-up regarding patient rated outcomes, (standardized mean difference [SMD]) -0.17 (95% CI: -0.56; 0.23). The intervention cost for HA was at least USD 5500 higher than non-surgical treatment. The trend in Sweden is that surgical treatment of PHF is increasing. When functional outcome of percutaneous fixation/plate fixation/prosthesis surgery and non-surgical treatment was compared for PHF there were no clinically relevant differences, SMD -0.05 (95% CI: -0.26; 0.15). There was not enough data for interpretation of quality of life or complications. Evidence was scarce regarding comparisons of different surgical options for humerus fracture treatment. The cost of plate fixation of a PHF was at least USD 3900 higher than non-surgical treatment, costs for complications excluded. In Sweden the incidence of plate fixation of PHF increased between 2005 and 2011.ConclusionsThere is moderate/low certainty of evidence that surgical treatment of moderately displaced PHF in elderly patients has not been proven to be superior to less costly non-surgical treatment options. Further research of humerus fractures is likely to have an important impact.
Highlights
Treatment of humerus fractures in the elderly remains a therapeutic challenge
For hemiarthroplasty (HA) and non-operative treatment, there was no clinically important difference for moderately displaced proximal humerus fractures (PHF) at one-year follow-up regarding patient rated outcomes, -0.17
There is moderate/low certainty of evidence that surgical treatment of moderately displaced PHF in elderly patients has not been proven to be superior to less costly non-surgical treatment options
Summary
Treatment of humerus fractures in the elderly remains a therapeutic challenge. These injuries are among the most common fractures [1] and cause large expenses for the individual and for society, due to their high frequency, the surgical complexity, and risk of poor outcome. New surgical methods for humerus fracture care have been introduced and widespread before they have been scientifically evaluated [10]. Societal costs are increasing for osteoporosis fracture health care [13], and there is reason to believe that more sophisticated surgical methods for treatment of humerus fractures will add more expenses in the future. To the best of our knowledge, health economic assessments of humerus fractures are largely lacking
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