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BJR
VOL. 5, NO. 5, MAY 2016 178
Article focus
The recently published PROximal Fracture
of the Humerus: Evaluation by Random-
isation (PROFHER) trail demonstrated that
surgery was non-superior to non-operative
treatment for fractures of the surgical neck
of humerus.
The objective of this study was to assess
current surgical practice in the context of
the PROFHER trial in terms of patient demo-
graphics, injury characteristics and the
nature of the surgical treatment.
Key messages
The demographics of a representative
sample of patients undergoing surgery at
the 11 centres revealed a majority of
females with a mean age of 62 years
A review of current surgical practice
in the operative treatment of proximal
humeral fractures
DOES THE PROFHER TRIAL DEMONSTRATE A NEED FOR CHANGE?
Objectives
The PROximal Fracture of the Humerus: Evaluation by Randomisation (PROFHER) trial has
recently demonstrated that surgery is non-superior to non-operative treatment in the man-
agement 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 demograph-
ics, injury characteristics and the nature of the surgical treatment.
Methods
A 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.
Results
A 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 pri-
mary 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 hemiar-
throplasty (p < 0.05) and reverse shoulder arthroplasty (p < 0.0001). Implant costs for intra-
medullary fixation were significantly less than plate fixation (p < 0.01), hemiarthroplasty
(p< 0.0001) and reverse shoulder arthroplasty (p < 0.0001).
Conclusions
Our study has shown that the majority of a representative sample of patients currently under-
going 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: Bone Joint Res 2016;5:178–184
Keywords: Proximal humerus; Fracture; Surgery; PROFHER; Surgical neck
55.200BJR0010.1302/2046-3758.55.2000596
research-article2016
TRAUMA
doi: 10.1302/2046-3758.55.2000596
Bone Joint Res 2016;5:178–184.
Received: 3 November 2015;
Accepted: 8 March 2016
B. J. F. Dean,
L. D. Jones,
A. J. R. Palmer,
R. D. Macnair,
P. E. Brewer,
C. Jayadev,
A. N. Wheelton,
D. E. J. Ball,
R. S. Nandra,
R. S. Aujla,
A. E. Sykes,
A. J. Carr
Nuffield Department
of Orthopaedics,
Rheumatology and
Musculoskeletal Sciences,
University of Oxford,
Oxford, United Kingdom.
B. J. F. Dean, DPhil (Oxon) MA MRCS,
Orthopaedic Registrar, Botnar Musculoskeletal
Research Centre, Nuffield Orthopaedic
Centre, Nuffield Department of Orthopaedics,
Rheumatology and Musculoskeletal Sciences,
University of Oxford, Windmill Road, Oxford,
OX3 7LD, UK
L. D. Jones, DPhil(Oxon) FRCS(T&O)
A. J. R. Palmer, MA BMBCh MRCS,
Orthopaedic Registrar, John Radcliffe Hospital,
Headley Way, Oxford OX3 9DU, UK
R. D. Macnair, MBBS MRCS MSc,
Orthopaedic Registrar, Abertawe Bro
Morgannwg University Health Board, Morriston
Hospital, Morriston, Swansea SA6 6NL, UK
P. E. Brewer, BSc MBChB MRCS,
Orthopaedic Registrar, South Yorkshire Deanery,
Northern General Hospital, Sheffield, UK
C. Jayadev, MA DPhil FRCS (Tr&Orth),
South Yorkshire Deanery, Northern General
Hospital, Sheffield, UK
A. N. Wheelton, MBbs MRCS
D. E. J. Ball, MBBS, MRCS(Ed),
Orthopaedic Registrar, Health Education
North West, Regatta Place, Brunswick Business
Park, Liverpool, L3 4BL, UK
R. S. Nandra, MBBS BSc MRCS, Specialist
Trainee Trauma and Orthopaedics, West
Midlands, Queen Elizabeth Medical Centre,
University Hospital Birmingham, Birmingham
B15 2TH, UK
R. S. Aujla, MBChB MRCS,
A. E. Sykes, MBBS BSc MRCS,
A. J. Carr, FMedsci, Professor of
Orthopaedic Surgery, Botnar Musculoskeletal
Research Centre, Nuffield Orthopaedic Centre,
University of Oxford, Windmill Road, Oxford,
OX3 7LD, UK
Correspondence should be sent to Mr B. J. F.
Dean; e-mail: bendean1979@googlemail.com
179
BONE & JOINT RESEARCH
A REVIEW OF CURRENT SURGICAL PRACTICE IN THE OPERATIVE TREATMENT OF PROXIMAL HUMERAL FRACTURES
which is similar to those participating in the PROFHER
trial.
The majority of patients met the inclusion criteria for
the PROFHER trial.
The mode of surgical treatment was variable with
both reverse shoulder arthroplasty and hemiarthro-
plasty significantly more expensive than both plate
and intramedullary fixation in terms of implant costs.
Strengths and limitations
No previous study has assessed current surgical prac-
tice in the United Kingdom relating to proximal
humeral fractures.
The study is retrospective and has not analysed those
fractures managed non-operatively.
Practice has been analysed at 11 centres and may not
be wholly representative of practice throughout the
United Kingdom.
Introduction
Proximal humeral fractures are the third most common
type of osteoporotic ‘fragility’ fracture after wrist and hip
fractures.1 Epidemiological data from Finland has dem-
onstrated that the number of proximal humerus fractures
is rising rapidly.2 The United Kingdom’s population is
also becoming increasingly elderly and consequently the
incidence of fragility fractures is on the rise,3,4 meaning
that the disease burden related to proximal humerus frac-
tures can only increase over the years ahead.
Research from the United States has shown that
although the incidence of proximal humeral fractures in
the elderly did not change between 1999 and 2005, the
rate of surgical treatment increased significantly.5 The
use of surgery in the treatment of proximal humeral
fractures is also increasing in Finland6 with the incidence
of surgical treatment quadrupling between 1987 and
2009. Both these studies have shown that with the
exception of plating and arthroplasty, the incidence of
all other surgical treatment options has decreased with
time.5,6 It is likely that similar trends would be seen in
developed nations from the United States or the
European Union given the close ties between practice in
these countries.
The evidence supporting the use of surgery is
extremely limited7,8 with the recent PROximal Fracture of
the Humerus: Evaluation by Randomisation (PROFHER)
trial demonstrating that surgery was not superior to
non-operative treatment in the treatment of displaced
proximal humeral fractures.9 In this context the overall
objective of this project was to assess current surgical
practice in the United Kingdom in the treatment of proxi-
mal humeral fractures prior to the publication of the
PROFHER trial results. The primary aim was to assess the
patient demographics and injury characteristics of those
treated with surgical intervention. Secondary aims were
to determine which patients currently treated surgically
met the inclusion criteria of the PROFHER trial;9 assess
which modes of surgery were used and which grade of
surgeon performed the surgery; and to investigate
whether there were any differences between surgical
groups in terms of the patient characteristics and implant
costs.
Patients and Methods
A total of ten consecutive patients undergoing surgery for
the treatment of a proximal humeral fracture from 11
United Kingdom hospitals were retrospectively identified
using theatre database searches over a 15 month period
between January 2014 and March 2015. Orthopaedic sur-
geons in higher training were invited to take part via BONE
(British Orthopaedic Network Environment) and local
regional contacts. We did not exclude any hospitals and no
hospital declined inclusion in the study. Data gathering
was approved at each centre via each Trust’s audit depart-
ment. A standardised data entry spreadsheet was com-
pleted for ten consecutive patients who underwent any
form of surgery for a ‘radiographically confirmed displaced
fracture of the proximal humerus involving the surgical
neck’. Cases were identified retrospectively and consecu-
tively from electronic theatre records at each hospital.
Therefore fractures of the proximal humerus not involving
the surgical neck were excluded.
The collected data included patient age, gender, date
of injury, date of surgery, fracture type according to Neer
classification (types 1 to 4), injury characteristics (open or
closed, whether joint dislocated, soft tissue compromise
including nerve, pathological fracture), patient character-
istics (mental competence, multiple injuries), the type of
surgery performed, the grades of surgeon involved and
the cost of the surgical implants. These characteristics
encompassed the documented inclusion criteria for the
PROFHER trial9 which were that patients were of adult
age and presenting to the participating centre within
three weeks of injury with a radiographically confirmed
displaced fracture of the proximal humerus involving the
surgical neck. The exclusion criteria were: associated dis-
location of the injured shoulder joint, open fracture,
mentally incompetent patient, comorbidities precluding
anaesthesia, clear indication for surgery including soft tis-
sue compromise/nerve dysfunction, multiple injuries,
pathological fractures/terminal illness and patient non-
resident in catchment area. The proximal humerus frac-
tures were classified by two blinded observers
independently (higher surgical trainee and consultant
Orthopaedic surgeon), according to the original Neer
classification system. Type 1 fractures are minimally dis-
placed. Type 2, 3 and 4 fractures are two-, three- and
four-part, respectively, and are displaced by more than
1 cm or angulated more than 45°. Each local finance
180
VOL. 5, NO. 5, MAY 2016
B. J. F. DEAN, L. D. JONES, A. J. R. PALMER, R. D. MACNAIR, P. E. BREWER, C. JAYADEV, A. N. WHEELTON, D. E. J. BALL, R. S. NANDRA, R. S. AUJLA, A. E. SYKES, A. J. CARR
department was asked to supply the costs of the implants
used for each patient.
Statistical analysis. This was carried using GraphPad
Prism version 5.00 for Windows (GraphPad Software,
San Diego, California). Histograms for all data sets were
analysed. Data was normally distributed unless otherwise
stated. Results are expressed as mean standard devia-
tion () unless otherwise stated. Unpaired t-tests and
Mann Whitney U-tests were used to test for differences
between two groups for parametric and non-parametric
data respectively. The one way ANOVA was used to test
multiple groups of parametric data with Tukey’s multi-
ple comparison test used to detect differences between
individual groups. The Kruskal Wallis one way analysis of
variance was used to test multiple groups of non-para-
metric data with Dunn’s multiple comparison test used
to detect differences between individual groups. Fisher’s
exact test was used to test for differences between two
categorical variables. Statistical significance was set at a
level of p < 0.05. Cohen’s kappa was calculated as a mea-
sure of inter-rater reliability.
Results
Patient demographics and centres. The 11 participating
centres and the time period over which the ten surgically
treated patients were operated upon, as well as patient
demographics in terms of age and gender, are detailed in
Table I. In total four of the 11 centres were major trauma
centres. The median time over which the ten patients had
surgery was 194 days (interquartile range 116 to 320). A
majority of the patients were female (66%, 73 of 110).
The mean patient age was 62 years (18 to 89).
Injury details and mode of surgery. Table II shows the
median time from injury to surgery, the number meeting
the PROFHER trial inclusion criteria, fracture type accord-
ing to Neer classification, type of surgery performed and
the grade of operating surgeon. The median time to sur-
gery from injury was eight days (interquartile range 4 to
12), while only two patients had a gap of greater than
three weeks between injury and surgery. Inter-rater reli-
ability of the Neer classification revealed a Cohen’s Kappa
of 0.449 which is interpreted as ‘moderate agreement’.10
A majority of patients met the inclusion criteria for
the PROFHER trial (75%, 83 of 110). Of the 27 patients
who did not meet the PROFHER inclusion criteria it was
most commonly the result of a single exclusion criterion
(time to presentation in two patients, dislocation in ten
patients, mentally incompetent in three patients, soft
tissue compromise in two patients and multiple injuries
in six patients). In three patients there were two reasons
for exclusion (dislocation/multiple injuries in two
patients and dislocation/soft tissue compromise in one)
and in one patient there were four reasons (open
fracture/soft-tissue compromise/mentally incompetent/
multiple injuries).
There were only three Neer type 1 fractures with types
2/3/4 being far more prevalent. The breakdown in terms
of the Neer classification were as follows: three type 1
(3%), 44 type 2 (40%), 36 type 3 (33%) and 27 type 4
(25%). Plate fixation was the most common mode of sur-
gery (68%, 75 patients), intramedullary fixation being
next most common (12%, 13 patients), followed by
reverse shoulder arthroplasty (10%, 11 patients), hemi-
arthroplasty (7%, eight patients) and the remaining 3%
consisting of open reduction alone (2%, two patients)
and k wire fixation (1%, one patient). The operating sur-
geon was a consultant in 73% of cases (80 patients), post
CCST fellow in 10% of cases (11 patients) and registrar in
17% of cases (19 patients). The CCST fellow was super-
vised by a consultant in 55% of cases (six patients) and
unsupervised in the other 45% (five patients), while the
specialist registrar was supervised by a consultant in 74%
of cases (14 patients) and unsupervised in the remaining
26% (five patients). Overall a consultant was either the
primary operating surgeon or supervising the operating
surgeon in 91% of cases (100 patients).
Table I. Participating centres and patient demographics
Centre Centre name Major trauma
centre (yes/no)
Time for 10
consecutive
patients (days)
Mean
age (sd)
Gender
1 Barnsley Hospital No 116 71 sd 11 1M 9F
2 Kettering General Hospital No 268 64 sd 9 1M 9F
3 John Radcliffe Hospital, Oxford Yes 194 52 sd 23 3M 7F
4 Queen Elizabeth Hospital, Birmingham Yes 320 58 sd 21 3M 7F
5 Royal Berkshire Hospital, Reading No 311 65 sd 13 4M 6F
6 Royal Bolton Hospital No 112 63 sd 20 4M 6F
7 Royal London Hospital Yes 119 57 sd 15 5M 5F
8 Stepping Hill Hospital, Stockport No 336 66 sd 13 4M 6F
9 Morriston Hospital, Swansea Yes 134 60 sd 15 4M 6F
10 Great Western Hospital, Swindon No 168 61 sd 19 4M 6F
11 Stoke Mandeville Hospital, Aylesbury No 374 66 sd 16 4M 6F
Overall - - 194 62 sd 16.4 37M 73F
181
BONE & JOINT RESEARCH
A REVIEW OF CURRENT SURGICAL PRACTICE IN THE OPERATIVE TREATMENT OF PROXIMAL HUMERAL FRACTURES
Mode of surgery groups. Table III demonstrates the 110
patients divided into groups based on the mode of sur-
gery. Table III and Figure 1 show the ages of the different
surgical groups. The plate fixation group was signifi-
cantly younger than the reverse shoulder arthroplasty
group (p < 0.05 Dunn’s multiple comparison test).
TableIII and Figure 2 show the costs of the different surgi-
cal implants. Plate fixation was significantly cheaper than
both hemiarthroplasty (p < 0.05) and reverse shoulder
arthroplasty (p < 0.0001). Intramedullary fixation was
significantly cheaper than plate fixation (p < 0.01), hemi-
arthroplasty (p < 0.0001) and reverse shoulder arthro-
plasty (p < 0.0001) (all Dunn’s comparison test). The
proportion meeting the PROFHER inclusion criteria from
hemiarthroplasty group was significantly lower than that
of plate group (p = 0.05), IM fixation group (p = 0.02)
and reverse group (p = 0.02) as calculated using Fisher’s
exact test.
Discussion
Our study has shown that the majority of a representative
sample of patients currently undergoing surgical treatment
for a proximal humerus fracture in the United Kingdom
would have met the inclusion criteria for the recently pub-
lished PROFHER trial. It is possible that a proportion of these
patients may have been effectively managed non-opera-
tively. Overall the patient demographics from the 11 cen-
tres were broadly similar to those taking part in the
PROFHER trial with a majority of female patients and a
mean age in the seventh decile for both cohorts. In all,
three quarters of patients undergoing surgery in these 11
centres met the inclusion criteria for the PROFHER trial. The
mode of surgical fixation varied between centres with plate
fixation being dominant. Over 90% of operations were per-
formed or supervised by a consultant. Those patients
undergoing reverse shoulder replacement were signifi-
cantly older than those patients undergoing plate fixation.
Implant costs of both reverse shoulder arthroplasty and
hemiarthroplasty were significantly greater than both
intramedullary fixation and plate fixation. Patients under-
going hemiarthroplasty were significantly less likely to
meet the inclusion criteria for the PROFHER trial than
patients undergoing plate fixation, intramedullary fixation
or reverse shoulder arthroplasty.
Table II. Time from injury to surgery, number meeting PROximal Fracture of the Humerus: Evaluation by Randomisation (PROFHER) trial inclusion, Neer types,
mode of surgery and grade of operating surgeon
Centre Median time
to surgery (days)
Number out of 10
meeting PROFHER
inclusion criteria
Neer types
1/2/3/4
Type of surgery Grade of operating
surgeon
1 9 8 2/2/4/2 Plate 9/Hemi 1 Cons 9/Reg 1
2 9 10 0/5/5/0 Plate 7/IM 1/Reverse 2 Cons 9/Reg 1
3 2 4 0/5/2/3 Plate 8/Hemi 2 Cons 6/Fellow 2/Reg 2
4 12 9 0/3/2/5 Plate 10 Cons 9/Reg 1
5 10 6 0/4/4/2 Plate 3/IM 1/Reverse 3/open
reduction only 2/K wires 1
Cons 7/Fellow 3
6 12 10 1/5/3/1 Plate 8/Reverse 2 Cons 7/Reg 3
7 11 8 0/3/4/3 Plate 7/Hemi 1/Reverse 2 Cons 3/Fellow 1/Reg 6
8 6 10 0/3/4/3 Plate 7/Hemi 1/Reverse 2 Cons 5/Fellow 5
9 7 7 0/5/4/1 Plate 10 Cons 8/Reg 2
10 12 4 0/5/2/3 Plate 6/IM 2/Hemi 2 Cons 8/Reg 2
11 6 7 0/4/2/4 IM 9/Hemi 1 Cons 9/Reg 1
Overall 8 83 of 110 3/44/36/27 Plate 75/IM 13/Hemi 8/Reverse
11/open reduction only 2/K wires 1
Cons 80/Fellow 11/
Reg 19
Cons, consultant; Reg, registrar; IM, intramedullary; Hemi, hemiarthroplasty
Table III. Characteristics of mode of surgery groups
Type of
surgery
Number Mean age
(sd)
Gender Neer types
1/2/3/4
PROFHER
inclusion
Median cost of
implants (£)
Plate fixation 75 58 17 28M 47F 3/33/27/12 49 of 75 783
IM fixation 13 67 14 3M 10F 0/8/1/4 11 of 13 476
Reverse 11 74 10 1M 10F 0/1/5/5 9 of 11 2800
Hemi 8 71 8 4M 4F 0/0/2/6 2 of 8*2129
Other 3 70 15 1M 2F 0/2/1/0 2 of 3 290
Total 110 62 16.4 37M 73F 3/44/36/27 83 of 110 783
*Proportion meeting PROximal Fracture of the Humerus: Evaluation by Randomisation (PROFHER) inclusion criteria from Hemi group lower than that of plate
group (p = 0.05), and significantly lower than that of the IM fixation group (p = 0.02) and reverse group (p = 0.02) as calculated using Fisher’s exact test
, standard deviation; IM, intramedullary
182
VOL. 5, NO. 5, MAY 2016
B. J. F. DEAN, L. D. JONES, A. J. R. PALMER, R. D. MACNAIR, P. E. BREWER, C. JAYADEV, A. N. WHEELTON, D. E. J. BALL, R. S. NANDRA, R. S. AUJLA, A. E. SYKES, A. J. CARR
This study demonstrates that the PROFHER trial partici-
pants are generally demographically representative of
those currently operated upon for proximal humerus
fractures involving the surgical neck in the United
Kingdom. The breakdown of fractures according to the
Neer classification was slightly different in our study to
the PROFHER trial. The proportion of Neer 2 (48% versus
40%) and 3 types (36% versus 33%) were fairly similar in
both the PROFHER and our study respectively; however
the Neer 4 types were more common in our study (25%
in our study versus 5% in PROFHER). One key criticism of
the PROFHER trial was the potentially subjective exclu-
sion criterion of a ‘clear indication for surgery’.9 It is worth
observing that of the 1250 assessed for eligibility in the
PROFHER trial, 87 were excluded because there was a
‘clear indication for surgery’ other than dislocation or
open fracture, while 195 were excluded for ‘other rea-
sons’ which were not specified. It may be therefore
argued that the patients who participated in PROFHER
were not entirely representative of those currently under-
going surgery in the United Kingdom. However, the
PROFHER supplementary material demonstrates that eli-
gible patients were more likely to have fractures involv-
ing the tuberosities than ineligible patients. It is therefore
possible that some of the difference in the proportion of
Neer type 4 types relates to differences in the use of the
Neer classification system between studies.
It is imperative to be clear that the PROFHER trial did
not demonstrate non-operative treatment to be equiva-
lent to surgery; it demonstrated surgery was not
superior. While given the heterogeneity of fracture types
included in PROFHER, it may well be true that specific
subgroups may benefit from surgery and this may not
have been detected. In this context the finding that the
majority of patients met the inclusion criteria for the
PROFHER trial remains of potential significance. It is cer-
tainly possible that a proportion of patients in our study
who met the PROFHER trial inclusion criteria may have
been effectively managed without surgical intervention.
However, it is certainly also arguable that some of the
patients in our study who met the inclusion criteria for
PROFHER may well have benefited from surgery; the
results of our study simply highlight that there is not
enough high quality evidence to guide the management
of many patients who are currently operated upon in the
United Kingdom today. It is interesting that a relatively
small number of proximal humeral fractures were treated
surgically relative to the high incidence of these injuries
(5.7% of all fractures).11
There is now high quality evidence demonstrating that
surgery is not superior to non-operative treatment in the
management of proximal humeral fractures, while the
complication rate and costs associated with surgery are
significantly higher.8,9 Our study demonstrates that the
implant costs for hemiarthroplasty and reverse shoulder
arthroplasty are significantly higher than for plate or
intramedullary fixation. There is also a relative paucity of
evidence to justify the use of reverse shoulder arthroplasty
over hemiarthroplasty, with the former having a higher
complication rate.12 One recent study does demonstrate
*
100
Age (yrs)
Mode of surgery
Plate fixation
IM fixation
Reverse
Hemi
Other
80
60
40
20
0
Fig. 1
Graph demonstrating the ages of the different modes of surgery groups. The
symbols represent mean, while the bars represent a standard deviation above
and below the mean. Statistical significance denoted by *p < 0.05, **p < 0.01,
***p < 0.0001 (Tukey’s multiple comparison test).
5000
*/***
4000
3000
2000
1000
0
Mode of surgery
Plate fixation
IM fixation
Reverse
Hemi
Other
Implant cost (£)
Fig. 2
Box and whisker plot demonstrating the relative implant costs of the differ-
ent modes of surgery groups. The boxes represent median and interquartile
range, while the whiskers represent range. Statistical significance denoted by
*p < 0.05, **p < 0.01, ***p < 0.0001 (Dunn’s multiple comparison test).
183
BONE & JOINT RESEARCH
A REVIEW OF CURRENT SURGICAL PRACTICE IN THE OPERATIVE TREATMENT OF PROXIMAL HUMERAL FRACTURES
that superior clinical outcomes are associated with reverse
shoulder arthroplasty over hemi arthroplasty,13 however
the outcomes following hemi arthroplasty in this study
were particularly poor, with a mean Constant score of 40
which is out of sync with that seen in the rest of the litera-
ture.12 This single centre study is at a high risk of bias and
needs to be supported by future high quality research to
justify the increasing use of reverse shoulder arthroplasty.
It is likely that the higher morbidity, mortality and costs
associated with the reverse shoulder arthroplasty in the
elective setting may be translated into the trauma set-
ting.14 The increasing use of the reverse shoulder arthro-
plasty for trauma also seems to be heavily influenced by
surgeon preference rather than any robust evidence of a
functional benefit for patients.15,16 Our study demon-
strates that only the hemiarthroplasty group were less
likely to meet the inclusion criteria for the PROFHER trial,
implying that only this group and not those undergoing
reverse shoulder arthroplasty were less suitable for non-
operative treatment. While descriptively the mode of sur-
gery appeared to vary greatly between our 11 centres;
although plate fixation was generally the dominant mode,
one centre favoured intramedullary fixation and the usage
of reverse shoulder arthroplasty appeared variable. The
costs reported in this study related to the implant costs
only and this represents only a small proportion of the
total costs involved.
A key strength of this work is that little is known about
the surgical treatment of proximal humerus fractures in
the United Kingdom. Although this study is retrospective
and over a single period of time it gives a novel insight
into current surgical practice in a way that also reveals
details about the injury characteristics and patient demo-
graphics in the specific relative context of the recently
published PROFHER trial. The data was gathered before
the PROFHER trial was published with the specific aim to
repeat this process at a later date to determine whether
practice has been affected by this emergent evidence. A
significant limitation of the current study is that the num-
ber of proximal humeral fractures treated at the 11 cen-
tres is unknown and it is not possible to determine the
proportion of fractures that are operated upon. How rep-
resentative these 11 centres are of the totality of practise
in the United Kingdom can only be speculated upon; it is
worth noting that the centres are fairly diverse in terms of
hospital type (trauma centre versus district hospital) and
geographic location. With respect to implant costs, there
may be a degree of variability in how local finance depart-
ments reported these costs, however as they were asked
to provide the costs of the implants used this should rep-
resent the actual cost to the hospital and include any
discounts.
It is important to consider that our analysis which
demonstrated that a majority of patients may have met
the inclusion criteria for the PROFHER trial does not mean
they are wholly representative of patients within the
study. When interpreting the results of our study it is
important to consider that the PROFHER trial was
designed to test for superiority and not equivalence. It is
important to note that this study was undertaken prior to
the PROFHER trial’s publication. It therefore allows the
assessment of changing surgical practice in response to
this study and other factors. Certainly there is an avenue
for future research to determine trends in surgical prac-
tice and the potential influence of the PROFHER trial.
In conclusion, our study has shown that a majority of
patients currently undergoing surgical treatment for a
proximal humerus fracture in the United Kingdom would
have met the inclusion criteria for the PROFHER trial and
that a proportion of these patients may have been effec-
tively managed non-operatively. When new high quality
evidence becomes available it is important that surgical
decision making responds to reflect this. In the context of
proximal humeral fractures this may mean a significant
reduction in the number of patients being offered and
undergoing surgery. If uncertainty still exists then new tri-
als should be designed to address this; areas of uncer-
tainty include which mode of surgical treatment is best for
which patients, but also whether any mode of surgery is
superior to non-operative treatment for any particular
groups of patients.17 It is therefore arguable that in the
absence of a clear indication for surgery, patients should
not be offered surgical treatment for proximal humeral
fractures unless they are part of a trial investigating ongo-
ing uncertainty.
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Funding Statement
This study was funded by the Musculoskeletal Biomedical Research Unit of the
National Institute for Health Research.
We would like to acknowledge the contribution of all the consultants who contrib-
uted in terms of the fracture classification and data gathering process. We would
also like to thank BONE (British Orthopaedic Network Environment) for some help
in gathering a portion of the contributing centres.
Author Contribution
B. J. F. Dean: Study conception and design, Data collection and analysis, Drafting of
the article and critical revision of the art icle.
L. D. Jones: Study conception and design, Data collection and analysis, Drafting of
the article and critical revision of the art icle.
A. J. R. Palmer: Study conception and design, Data collection and analysis, Drafting
of the article and critical revision of the art icle.
R. D. Macnair: Data collection and analysis, Critical revision of the art icle.
P. E. Brewer: Data collection and analysis, Critical revision of the article.
C. Jayadev: Data collection and analysis, Critical revision of the article.
A. N. Wheelton: Data collection and analysis, Critical revision of the article.
D. E. J. Ball: Data collection and analysis, Critical revision of the article.
R. S. Nandra: Data collection and analysis, Critical revision of the article.
R. S. Aujla: Data collection and analysis, and the critical revision of the article.
A. E. Sykes: Data collection and analysis, Critical revision of the article.
A. J. Carr: Study conception and design, Data collection and analysis, Drafting of
the article and critical revision of the art icle.
ICMJE conflict of interest
None declared.
© 2016 Dean et al. This is an open-access article distributed under the terms of the
Creative Commons Attributions licence (CC-BY-NC), which permits unrestricted use,
distribution, and reproduction in any medium, but not for commercial gain, provided
the original author and source are credited.
