Why do we operate proximal humeral fractures?

Editorial Why do we operate proximal humeral fractures? Open Access-This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the source is credited. In this issue of Acta Orthopaedica, we have a systematic review of randomized trials on proximal humeral fractures by Launonen et al. They report on 6 trials involving 588 patients that compared surgery with nonoperative treatment, and conclude that the trials did not provide any evidence that surgery is superior. After this paper was accepted, the basis for decisions regarding proximal humeral fractures suddenly increased to 819 patients studied in reasonable randomized trials. The new data agree with the conclusions of Launonen et al. They appeared through a large randomized trial with blinded evaluation , published in JAMA, in which surgery was compared to nonoperative treatment in 231 patients with proximal humeral fractures of different types (Rangan et al. 2015). The inclusion criteria were wide, so as to reflect clinical practice. Surgery involved the use of prostheses or locking plates. The results, as measured with the Oxford shoulder score, showed no clinically meaningful difference in outcome. Post hoc analysis could not find any influence of age or fracture type on the outcome. 313 patients refused to participate in the study, the majority because they preferred nonoperative treatment; only 55 of them preferred surgery (Rangan, personal communication). All the details of the study have been published separately (Handoll et al. 2015). The authors conclude that the recent increase in the number of surgically treated patients with proximal humeral fractures is unwarranted. So, once again, there is a large, well-performed trial showing that a common orthopedic procedure is of little or no value. Considering that the strong placebo effect of surgery had not made the patients who were operated on feel better than controls, one could even suspect that the " true " effect of surgery is negative. How will the orthopedic community receive this? I fear that the enthusiasm for the idea that operations can be avoided might be limited, in spite of the fact that surgical resources can be set free and put to better use. Due to the nature of science, it is impossible to " prove " that something doesn't work. Thus, anyone who has a strong belief in a procedure can always claim that a study failed to …