A review of current surgical practice in the operative treatment of proximal humeral fractures

Abstract

ObjectivesThe PROximal Fracture of the Humerus: Evaluation by Randomisation (PROFHER) trial has recently demonstrated that surgery is non-superior to non-operative treatment in the management of displaced proximal humeral fractures. The objective of this study was to assess current surgical practice in the context of the PROFHER trial in terms of patient demographics, injury characteristics and the nature of the surgical treatment.MethodsA total of ten consecutive patients undergoing surgery for the treatment of a proximal humeral fracture from each of 11 United Kingdom hospitals were retrospectively identified over a 15 month period between January 2014 and March 2015. Data gathered for the 110 patients included patient demographics, injury characteristics, mode of surgical fixation, the grade of operating surgeon and the cost of the surgical implants.ResultsA majority of the patients were female (66%, 73 of 110). The mean patient age was 62 years (range 18 to 89). A majority of patients met the inclusion criteria for the PROFHER trial (75%, 83 of 110). Plate fixation was the most common mode of surgery (68%, 75 patients), followed by intramedullary fixation (12%, 13 patients), reverse shoulder arthroplasty (10%, 11 patients) and hemiarthroplasty (7%, eight patients). The consultant was either the primary operating surgeon or supervising the operating surgeon in a large majority of cases (91%, 100 patients). Implant costs for plate fixation were significantly less than both hemiarthroplasty (p < 0.05) and reverse shoulder arthroplasty (p < 0.0001). Implant costs for intramedullary fixation were significantly less than plate fixation (p < 0.01), hemiarthroplasty (p < 0.0001) and reverse shoulder arthroplasty (p < 0.0001).ConclusionsOur study has shown that the majority of a representative sample of patients currently undergoing surgical treatment for a proximal humeral fracture in these United Kingdom centres met the inclusion criteria for the PROFHER trial and that a proportion of these patients may, therefore, have been effectively managed non-operatively.Cite this article: Mr B. J. F. Dean. A review of current surgical practice in the operative treatment of proximal humeral fractures: Does the PROFHER trial demonstrate a need for change? Bone Joint Res 2016;5:178–184. DOI: 10.1302/2046-3758.55.2000596.

Radiographic patterns of osteoporotic proximal humerus fractures

“…As for the proximal femur, osteoporosis importantly affects the outcome of fixation. In recent years, in front of alarming percentage of complications as humeral head articular surface perforation by screws with percentage up to 73 % of cases [6], authors from different countries of the world focused their attention on conservative treatment also for complex displaced fractures [24][25][26].…”

Impact of the PROFHER trial findings on surgeons’ clinical practice

“…This survey is one of various approaches to measuring impact of trials such as PROFHER. An intended repeat of the study by Dean et al 11 that reviewed surgical practice in 11 United Kingdom hospitals between January 2014 and March 2015, thus before the Journal of the American Medical Association publication of PROFHER, 1 will be valuable. However, as illustrated for the Distal Radius Acute Fracture Fixation Trial, using the date of main publication as the threshold for detecting change may be misleading.…”

Management of complex proximal humerus fractures in the elderly: what is the role of open reduction and internal fixation?

“…28 Fixed angle anatomic locking plates have become the most commonly utilised implants for fixation of proximal humerus fractures. 20,31 The mode of failure of locked plates differs from conventional plates which will fail by the loosening of individual screws sequentially whereas locked plates will fail by simultaneous cut-out of multiple screws or by fracture of the bone at the stress riser at the end of the plate. 32 It has been shown that good restoration of support to the inferomedial calcar is important in maintaining fracture reduction.…”

“…With the large variation in fracture types in this study there might well be subgroups that do clearly benefit from surgery, but these remain unidentified. 66…”