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 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. 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 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). CONCLUSIONS: Our 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.

Nutritional content of few foods diet in atopic dermatitis.

The nutritional content of a few foods diet, supplemented with a casein hydrolysate formula (n = 24) or a whey hydrolysate formula (n = 21), was studied in 45 children with atopic dermatitis. The six day weighed food inventory record method was used to estimate the mean daily intake of energy, protein, calcium, iron, zinc, folate, and vitamin C on normal diet and on the few foods diet. The diet was associated with a significant reduction in protein and calcium intake in both groups, and in energy intake in the casein hydrolysate group. The median daily volume of hydrolysate milk taken was 10.5 ml/day (range 0-840 ml/day) for the casein hydrolysate group and 267 ml/day (range 0-1300 ml/day) for the whey hydrolysate group. Whey hydrolysate appears to be more palatable than casein hydrolysate, which is a potential advantage in the maintenance of an adequate intake in children on a few foods diet.

Controlled trial of a few foods diet in severe atopic dermatitis.

Eighty five children (median age 2.3 years, range 0.3 to 13.3 years) with refractory atopic dermatitis affecting more than 12% of the body surface area, were randomly allocated to receive a few foods diet (eliminating all but five to eight foods) supplemented with either a whey hydrolysate (n = 27) or a casein hydrolysate formula (n = 32), or to remain on their usual diet and act as controls (n = 26), for a six week period. Thirty five patients who received the diet and four controls had to be withdrawn because of non-compliance with the diet or intercurrent illness. The change in dermatitis severity was evaluated by a blinded observer who estimated the extent and severity of the dermatitis, using a skin severity score. After six weeks, there was a significant reduction in all three groups in the percentage of surface area involved (controls, median reduction (MR) = 4.9% (95% confidence interval 1.5%, 11.9%); whey hydrolysate group, MR = 17.8% (8.3%, 23.0%); casein hydrolysate group, MR = 5% (1.6%, 21.2%), and skin severity score (controls, MR = 15.9 (5.0, 22.5); whey hydrolysate group, MR = 21.8 (12.8, 30.2); casein hydrolysate group, MR = 13.5 (3.4, 38.0). Sixteen (73%) of the 22 controls and 15 (58%) of the 24 who received the diet showed a greater than 20% improvement in the skin severity score. This study failed to show benefit from a few foods diet.