Approximately 18% of JBJS scientific studies published in 2020 were Level I or II investigations. The number of high-level studies has continued to grow slowly year over year. In terms of randomized controlled trial design, we have found that the facets of care that are often the focus of study are those that are most straightforward—the use of tourniquets, resurfacing the patella with total knee arthroplasty, intraoperative and postoperative drug therapies, as examples. One under-investigated area is rehabilitation, as far as both management strategies post-injury and more detailed, comprehensive post-surgical programs.
In the latest issue of JBJS, Martínez et al. evaluate the question of duration of sling use following proximal humeral fracture in patients managed nonoperatively. This is an important patient centric question that has largely been informed by “hand me down” prescriptions from residency teaching faculty. In a very well-designed Level II trial involving an adult cohort (mean age of 70; range, 42 to 94 years), they found no significant differences in pain and function between patients randomized to 1 week of immobilization versus 3 weeks of immobilization. In addition, no significant difference in the complication rate was found.
Pain was assessed using a visual analog scale at 1 week and 3 weeks after fracture and then at the 3, 6, 12, and 24-month follow-up. Functional outcome was evaluated using the Constant score, and functional disability was evaluated with the Simple Shoulder Test, a self-reported questionnaire; both of these measures were recorded at the 3, 6, 12, and 24-month evaluation. No differences in pain and function at any time point were observed.
Many readers of JBJS have had the experience of patients abandoning the sling as soon as they are comfortable, regardless of what our original instructions were, so the findings of this study are relatable. The authors concluded that, “These fractures can be successfully managed with a short immobilization period of 1 week in order not to compromise patients’ independence for an extended period.”
It strikes me that there are numerous rehabilitation prescriptions that are ripe for evaluation using a randomized design. (Wear an orthosis when sleeping? Keep it on at all times or only when walking? Etc.) Let’s get after these questions in the manner of Martinez et al. as we seek to give our patients solid evidence to back our instructions.
A downloadable JBJS infographic regarding this study can be found here.
Marc Swiontkowski, MD