HAS THE PROFHER TRIAL INFLUENCED THE PRACTICE PATTERNS OF ORTHOPAEDIC SURGEONS TREATING PROXIMAL HUMERUS FRACTURES IN NORTH AMERICA?

The PROximal Fracture of the Humerus: Evaluation by Randomization (ProFHER) trial was published in the Journal of the American Medical Association (JAMA) in March of 2015 and found no difference in outcomes between patients undergoing surgery and those treated without surgery at 2-years. However, the results of the study have been criticized due to the poor inclusion rate (250 of a possible 1250), selection bias (excluding those with “clear indications for surgery”), limited generalizability to 4-part proximal humerus fractures and absence of reverse total shoulder arthroplasty (RTSA) as a treatment in the surgical cohort. Although several studies have examined the impact of the ProFHER trial on the management of proximal humerus fractures in Europe, it remains unknown how the study findings have impacted orthopaedic surgeons in North America. Provincial health administrative databases in Ontario, Canada were used to identify patients 50 years of age and older with a proximal humerus fracture from April 2004 to March 2019. The proportion of proximal humerus fractures treated with and without surgery was calculated for each calendar quarter and year. A subgroup analysis was performed to evaluate the trends in utilization of reverse total should arthroplasty as a treatment. An interrupted time-series analysis was used to determine whether changes in the proportion of surgically and non-surgically managed proximal humerus fractures were chronologically related to the publication of the ProFHER trial (first quarter, 2015). Among the 68,218 proximal humerus fractures that occurred during the study period, 89.2% of patients were treated non-surgically, 9.2% underwent ORIF or hemiarthroplasty, and 1.6% of fractures were treated with RTSA. In the second quarter of 2004, the rate of ORIF and hemiarthroplasty was 9.1% and rising in Ontario, Canada. By the end of the study period, the rate was 7.9% and demonstrating a sharp downturn. Based on the results of the time-series analysis, there is evidence to suggest that the rate of ORIF and hemiarthroplasty significantly decreased immediately following publication of ProFHER trial (P > 0.05) (Figure 1). Similarly, the rate of non-surgical management was noted to significantly increase in the period immediately after publication. This increase, however, was not sustained, in large part due to the greater use of RTSA for proximal humerus fractures. RTSA utilization was found to exponentially increase, both prior to and after the dissemination of the ProFHER trials results as demonstrated by the 350% increase in its use during the study period (Figure 2). Despite the various criticisms of the ProFHER study, a significant change in practice was observed in this large North American cohort. The findings of the current study suggest that the results of the ProFHER trial may have influenced the practice patterns of orthopaedic surgeons in Ontario, Canada. However, our results also revealed that the ProFHER study may not be applicable to all patients with a proximal humerus fracture as evidenced by the exponential increase in RTSA utilization. Further study is required to determine who would benefit from RTSA in the fracture setting. For any figures or tables, please contact the authors directly.

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