Variations in surgical practice and adverse events following isolated proximal humerus fracture in adults: a comparative longitudinal cohort study of 53,852 patients from Denmark, England, and Sweden

Abstract

Background: Proximal humeral fractures (PHFs) are common injuries, but their management has remained controversial. Recent high-level evidence from randomized clinical trials has shown that for many PHFs, surgical treatment is not superior to non-surgical treatment. Our primary aim was to conduct a multi-nation assessment of temporal trends and changes in surgical treatment of isolated PHF in Denmark, England, and Sweden. A secondary aim was to estimate the incidence of serious adverse events (SAEs) within 30 days (and death within 90 days) of primary surgery. Methods: This population-based cohort study presents routinely collected data from Danish, English, and Swedish patient registries and electronic health records from 1998 to 2018. All adult patients with isolated PHFs combined with predefined surgical procedure codes were included. Age- and sex-specific incidence rates (IRs) of surgery and each surgical procedure per calendar year were calculated. Kaplan–Meier plots displayed patient survival for the study period. Incidence proportions of SAEs within 30 days (and death within 90 days) of surgery were computed. Results: A total of 54,077 primary surgical procedures, performed in 53,852 patients with isolated PHF, were included. Denmark and Sweden had the highest IR of surgery, with Denmark peaking at 17.4/100,000 person-years in 2011 and Sweden peaking at 18/100,000 person-years in 2013, while England peaked at 5/100,000 person-years in 2010. From 2004, plate fixation was the leading surgical procedure in Denmark and Sweden, while arthroplasty was the most frequent in England. The IR of surgery in Denmark and Sweden was 8–10 times higher for women aged 80 years than that observed in England. The 30-day incidence of SAEs varied between countries, ranging from 0.03% to 3.51%. Conclusions: Variations in surgical practice for isolated PHF exist between Denmark, England, and Sweden, with differences in overall IRs of surgery and preferred procedures. A complex interplay between hospitals, surgeons, healthcare systems, and evidence-based factors is likely to explain such variations. However, in all three countries, the IR of surgery, particularly for the use of locking plates, demonstrated a decline from 2013, coinciding with high-quality trials and meta-analyses suggesting that evidence-based factors are becoming more prominent in orthopaedic treatment decisions.