Purpose
Recent evidence demonstrated similar outcomes between nonsurgical and surgical management
of displaced proximal humerus fractures. We analyzed treatment trends and performed
a cost-minimization analysis comparing nonsurgical treatment, open reduction and internal
fixation, reverse total shoulder arthroplasty, and hemiarthroplasty. We hypothesized
that rates of surgical treatment have increased and that the costs associated with
surgery are greater compared with nonsurgical management of proximal humerus fractures.
Methods
We used a US private-payer claims database of 22 million patient records from 2007
to 2016 to compare (1) cost for the episode of care from the payer perspective between
each surgical group and nonsurgical treatment of proximal humerus fractures, and (2)
annual trends and complication rates of each group. Cost data, including facility
fees, physician fees, physical therapy, and clinic visits, were used to complete a
cost-minimization analysis.
Results
Nonsurgical treatment was associated with lower average total costs compared with
surgical intervention. Facility and physician fees accounted for most of this difference.
Physical therapy costs and number of physical therapy visits were higher in each surgical
group compared with nonsurgical treatment. Surgical treatment was associated with
higher complications, revision rates, and length of stay. There was a small but statistically
significant decrease in nonsurgical management of proximal humerus fractures between
2007 and 2016. No change was observed in rates of open reduction and internal fixation,
whereas rates of reverse total shoulder arthroplasty increased and rates of hemiarthroplasty
decreased.
Conclusions
Nonsurgical management of proximal humerus fractures decreased during the study period.
In the setting of treatment equipoise, cost-minimization analysis favors nonsurgical
management of proximal humerus fractures. Surgical management is associated with higher
complication rates, revision rates, and length of stay.
Type of study/level of evidence
Economic Decision Analysis IV.
Key words
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Journal of Hand SurgeryAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Epidemiology of adult fractures: a review.Injury. 2006; 37: 691-697
- Increasing number and incidence of osteoporotic fractures of the proximal humerus in elderly people.BMJ. 1996; 313: 1051-1052
- Part II: proximal humeral fractures and fracture dislocations.in: Browner B.D. Jupiter J.B. Levine A.M. Trafton P.G. Krettek C. Skeletal Trauma: Basic Science, Management, and Reconstruction. 4th ed. Saunders, Philadelphia, PA2009: 1643-1716
- Trends in surgical management and costs for operative treatment of proximal humerus fractures in the elderly.Orthopedics. 2017; 40: e641-e647
- Open reduction and internal fixation of proximal humeral fractures with use of the locking proximal humerus plate: results of a prospective, multicenter, observational study.J Bone Joint Surg Am. 2009; 91: 1320-1328
- Primary hemiarthroplasty for treatment of proximal humeral fractures.J Bone Joint Surg Am. 2003; 85: 1215-1223
- Surgical vs nonsurgical treatment of adults with displaced fractures of the proximal humerus: the PROFHER randomized clinical trial.JAMA. 2015; 313: 1037-1047
- Five-year follow-up results of the PROFHER trial comparing operative and non-operative treatment of adults with a displaced fracture of the proximal humerus.Bone Joint J. 2017; 99: 383-392
- Hemiarthroplasty for humeral four-part fractures for patients 65 years and older: a randomized controlled trial.Clin Orthop Relat Res. 2012; 470: 3483-3491
- Internal fixation versus nonoperative treatment of displaced 3-part proximal humeral fractures in elderly patients: a randomized controlled trial.J Shoulder Elbow Surg. 2011; 20: 747-755
- Hemiarthroplasty versus nonoperative treatment of displaced 4-part proximal humeral fractures in elderly patients: a randomized controlled trial.J Shoulder Elbow Surg. 2011; 20: 1025-1033
- Displaced proximal humeral fractures: operative versus non-operative treatment--a 2-year extension of a randomized controlled trial.Eur J Orthop Surg Traumatol. 2014; 24: 1067-1073
- Interventions for treating proximal humeral fractures in adults.Cochrane Database Syst Rev. 2015; 11: CD000434
- Trends and variation in incidence, surgical treatment, and repeat surgery of proximal humeral fractures in the elderly.J Bone Joint Surg Am. 2011; 93: 121-131
- Trends in incidence and costs of injuries to the shoulder, arm and wrist in The Netherlands between 1986 and 2008.BMC Public Health. 2013; 13: 531
- Database and registry research in orthopaedic surgery: part I: claims-based data.J Bone Joint Surg Am. 2015; 97: 1278-1287
- Health economic studies: an introduction to cost-benefit, cost-effectiveness, and cost-utility analyses.Spine (Phila Pa 1976). 2014; 39: S9-S15
- Economic evaluation in orthopaedics.J Bone Joint Surg Am. 2003; 85: 129-142
- Cost utility analysis of reverse total shoulder arthroplasty.J Shoulder Elbow Surg. 2013; 22: 1656-1661
- Cost drivers after surgical management of proximal humerus fractures in Medicare patients.J Orthop Trauma. 2016; 30: 262-268
- Trends in incidence rate, health care consumption, and costs for patients admitted with a humeral fracture in The Netherlands between 1986 and 2012.Injury. 2015; 46: 1930-1937
- Cost-minimization analysis of the management of acute Achilles tendon rupture.J Am Acad Orthop Surg. 2017; 25: 449-457
- Cost effectiveness of surgical versus non-surgical treatment of adults with displaced fractures of the proximal humerus: economic evaluation alongside the PROFHER trial.Bone Joint J. 2016; 98-B: 152-159
- Cost analysis of the surgical treatment of fractures of the proximal humerus: an evaluation of the determinants of cost and comparison of the institutional cost of treatment with the national tariff.Bone Joint J. 2016; 98-B: 249-259
- Cost-effectiveness of open reduction and internal fixation compared with hemiarthroplasty in the management of complex proximal humerus fractures.J Shoulder Elbow Arthroplasty. 2018; 2 (2471549217751453)
- Hospital readmissions after surgical treatment of proximal humerus fractures: is arthroplasty safer than open reduction internal fixation?.Clin Orthop Relat Res. 2014; 472: 2317-2324
- A systematic review of locking plate fixation of proximal humerus fractures.Injury. 2011; 42: 408-413
- Proximal humeral fracture treatment in adults.J Bone Joint Surg Am. 2014; 96: 251-261
- Reverse total shoulder arthroplasty versus hemiarthroplasty for proximal humeral fractures: a systematic review.J Orthop Trauma. 2015; 29: 60-68
- Increasing use of reverse total shoulder arthroplasty for proximal humerus fractures in elderly patients.Orthopedics. 2017; 40: e982-e989
- Analysis of efficacy and failure in proximal humerus fractures treated with locking plates.J Orthop Trauma. 2007; 21: 676-681
Article info
Publication history
Published online: May 29, 2020
Accepted:
March 31,
2020
Received:
August 16,
2018
Footnotes
M.J.G. acknowledges association or financial involvement as a board or committee member of the American Orthopaedic Association, Orthopaedic Research Society, and Orthopaedic Trauma Association; as a member of the editorial or governing board for Current Opinion in Orthopaedics and Journal of Orthopaedic Trauma; as a paid consultant for Biocomposites, BoneSupport AB, Globus Medical, Pacira Pharmaceuticals, SI-Bone, Conventus, StabilizOrtho, Synthes, and KCI; and as a paid presenter or speaker for KCI. He has received stock or stock options from Conventus and Imagen Technologies; research support from Medtronic, SmartDevices, SMV Medical, Synthes, and Zimmer; IP royalties from Synthes; and Publishing royalties, financial or material support from the Journal of Bone and Joint Surgery, American Volume and Wolters Kluwer Health–Lippincott Williams & Wilkins. R.N.K. is the principal investigator on a National Institutes of Health K-23 Award. No benefits in any form have been received or will be received by the other authors related directly or indirectly to the subject of this article
Identification
Copyright
© 2020 by the American Society for Surgery of the Hand. All rights reserved.
