Fixation versus Arthroplasty for Proximal Humerus Fractures: An Analysis in 129,150 Inpatients Over Age 50
Avi D Goodman, MD; Joey P Johnson, MD; Alan H Daniels, MD; Justin E Kleiner, BS; Joseph A Gil, MD; Roman Hayda, MD
Brown University, Providence, RI
HYPOTHESIS Proximal humerus fractures have long posed a difficult treatment challenge for orthopedic surgeons. Historically, a high rate of complications was seen with fixation of these fractures, though newer implants have improved these results over the past 15 years. The use of hemiarthroplasty (HA) and reverse total shoulder arthroplasty (TSA) have also been advocated as treatment options for these fractures, though indications for their use remain poorly defined. We seek to determine the rates of operative and non-operative interventions for closed proximal humerus fractures on a population level, as well as analyze complication rates and charges for these interventions.
METHODS Patients with operatively-treated closed proximal humerus fractures were identified in the National Inpatient Sample, and demographics and hospital-related information were recorded. Outcomes queried included in-hospital complications (a composite of serious complications, including cardiac, infection, and others), in-hospital mortality, length of stay, transfusion status, and total hospital charges. Multivariable logistic regression was used to determine variables associated with greater proportion of each type of treatment and determine variables associated with increased rates of complications, transfusions, and mortality, as well as in-hospital charges.
RESULTS For the 129,151 inpatients included, the number undergoing surgery increased over time, from 9,140 in 2002 to 12,840 in 2012 (p <0.0001), primarily driven by patients undergoing ORIF (Figure 1). Patients treated with ORIF had a shorter length of stay (6.1 vs. 6.5 days, p<0.0001) and a lower rate of complications (7.1% vs. 8.5%, p<0.0001) than those undergoing arthroplasty. Patients who underwent ORIF had significantly fewer complications than patients who had either rTSA (8.8%) or HA (8.6%, p=0.0003, Table 1). Charges were significantly lower with ORIF ($55,096) than HA ($60,976) and TSA ($75,490).
Š From 2002-2012, both fixation and reverse total shoulder arthroplasty for proximal humerus fractures has become significantly more common, while the incidence of hemiarthroplasty decreased.
Š Despite lower in-hospital charges and clinically similar demographics, patients undergoing fixation were less likely to have serious complications than patients undergoing arthroplasty.
Š Further study is needed to determine clinically optimal and cost-effective treatment for proximal humerus fractures
Figure 1. Percentage of patients treated operatively, stratified by type of surgery. Of note, “Total Shoulder Arthroplasty” includes reverse total shoulder arthroplasty (rTSA).
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