Comparisons of Routine Initial Operative Fracture Treatment and Later Reconstructive Treatment are not Interesting

Document Type : In Brief


1 The University of Texas at Austin, Austin, Texas, USA

2 2 Shoulder and Elbow Unit, Joint Research, Department of Orthopedic Surgery, OLVG, Amsterdam, The Netherlands 3 Shoulder and Elbow Unit, Joint Research, Department of Orthopaedic Surgery, OLVG, Amsterdam, The Netherlands


Studies that compare routine immediate operative treatment of fractures with selective later reconstructive surgery for malunion or nonunion may be misleading because it discounts the people who did well with nonoperative treatment. We identified 20 studies comparing routine operative fracture treatment and later reconstruction in the hip, clavicle, proximal humerus, elbow, and distal radius. Fifteen of 20 studies favored immediate operative treatment on the basis of lower reoperation rates, fewer complications, better patient reported outcome scores, and higher satisfaction. Five studies were neutral, and none favored delayed reconstruction for malunion or nonunion. These findings emphasize the potential benefits of routine early surgery and raise questions about the validity of studies comparing different timings of fracture treatment.
Level of evidence: N/A


Main Subjects

  1. Shu R, Crijns T, Ring D, Fatehi A. Surgeons Consider Initial Nonoperative Treatment With Potential for Future Conversion to Reverse Arthroplasty a Reasonable Option for Older, Relatively Infirm, and Less-Active Patients. J Orthop Trauma. 2022; 36(5):265-270. doi:10.1097/BOT.0000000000002278.
  2. Handoll HH, Keding A, Corbacho B, Brealey SD, Hewitt C, Rangan A. Five-year follow-up results of the PROFHER trial comparing operative and non-operative treatment of adults with a displaced fracture of the proximal humerus. Bone Joint J. 2017; 99-B (3):383-392. doi:10.1302/0301-620X.99B3.BJJ-2016-1028.
  3. Woltz S, Krijnen P, Schipper IB. Plate Fixation Versus Nonoperative Treatment for Displaced Midshaft Clavicular Fractures: A Meta-Analysis of Randomized Controlled Trials. J Bone Joint Surg Am. 2017; 99(12):1051-1057. doi:10.2106/JBJS.16.01068.
  4. Potter JM, Jones C, Wild LM, Schemitsch EH, McKee MD. Does delay matter? The restoration of objectively measured shoulder strength and patient-oriented outcome after immediate fixation versus delayed reconstruction of displaced midshaft fractures of the clavicle. J Shoulder Elbow Surg. 2007; 16(5):514-518. doi:10.1016/j.jse.2007.01.001.
  5. Colasanti CA, Anil U, Adams J, Pennacchio C, Zuckerman JD, Egol KA. Primary versus conversion reverse total shoulder arthroplasty for complex proximal humeral fractures in elderly patients: a retrospective comparative study. J Shoulder Elbow Surg. 2023; 32(8):e396-e407. doi:10.1016/J.JSE.2023.01.019.
  6. Seidl A, Sholder D, Warrender W, et al. Early Versus Late Reverse Shoulder Arthroplasty for Proximal Humerus Fractures: Does It Matter? Arch Bone Jt Surg. 2017; 5(4):213. doi:10.22038/abjs.2017.20040.1522.
  7. Nayar SK, Marrache M, Bressner JA, Raad M, Shafiq B, Srikumaran U. Temporal Trends in Hip Fractures: How Has Time-to-Surgery Changed? Arch Bone Jt Surg. 2021; 9(2):224. doi:10.22038/ABJS.2020.46195.2268.