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Research

Is surgery the answer for treating broken shoulders?

Background

Around 5% of fractures in adults in high income countries are those of the proximal humerus. Commonly known as "broken shoulders", over 700,000 of these fractures occur worldwide annually - most common in older people. They can be extremely painful and debilitating, often having a long-term impact.

While most broken shoulder fractures are treated non-surgically using an arm sling, with surgery reserved for the most complex fractures, there has been a trend towards the use of surgery in a much larger proportion of patients. This has been despite a lack of evidence for the effectiveness of surgery in these cases. Research carried out by Helen Handoll and Nigel Hanchard at Teesside University sought to gather evidence around the use of surgery in treating broken shoulders, with the aim to better inform clinical decision making.

The Research

Alongside a trial group of orthopaedic surgeons and methodologists, the team at Teesside University received funding from the National Institute for Health Research (NIHR) to conduct the PROFHER trial (Proximal Fracture of the Humerus: Evaluation by Randomisation). Between September 2008 and April 2011, 250 patients with broken shoulders were prescribed one of two treatment pathways: surgery or immobilisation of the arm through a sling. Both groups also received physiotherapy.

The patients were asked to complete a post-treatment questionnaire on their shoulder function and general health at 6, 12 and 24 months. Analysis of this feedback, alongside hospital data on complications and follow-up treatment, showed that surgery did not result in better outcomes for the majority of patients. Off the back of these results, economic analysis estimated that a 50% reduction in surgery would equate to an annual cost saving of £2.5 million for NHS England.

Additional funding secured in 2010 enabled the research team to extend follow-up monitoring to five years. This provided even more evidence against the trend of increased surgery for broken shoulders.

The Impact

The PROFHER trial produced definitive evidence that surgery does not improve outcomes for patients with broken shoulders. The research has shaped clinical guidelines, directly influencing the practice of healthcare professionals and preventing unnecessary and costly surgery.

The findings were included in the UK National Institute of Health and Care Excellence (NICE) guidelines, providing an authoritative basis to inform clinical decision making. Evidence of the trial’s impact on decision making was shown in a survey of 265 specialist orthopaedic and trauma surgeons; over half said they had changed practice based on the trial results, with many reporting that the trial had given them greater confidence in making decisions not to operate.

The trial has also informed international practice, with testimonials from consultant surgeons in Denmark demonstrating its influence far beyond the UK.


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