Abstract
Background
Proximal humerus fractures are the third most common fracture type for patients between the ages of 65 and 89 and occur more frequently in women than men. Given the variety of surgical treatments for proximal humerus fractures, the aim of this study was to (1) report United States national volume and incidence estimates for surgical management of proximal humerus fractures to better understand the changing practice over the past decade and (2) to analyze differences in volume and incidence among age groups, sex, and geographic region.
Methods
Using IBM Marketscan national database, all patients that underwent open reduction internal fixation (ORIF), hemiarthroplasty, or reverse total shoulder arthroplasty (RTSA) between 2010 and 2019 were identified with Current Procedural Terminology codes. The dataset was further stratified to identify patients treated for proximal humerus fractures. IBM Marketscan provided discharge weights that were used to determine estimated national annual volumes of each procedure in IBM SPSS Statistics software (IBM Corp., Armonk, NY, USA). Volume and incidence were adjusted per 1,000,000 persons and calculated for subgroups according to age group, sex, and geographical region. The United States Census Bureau annual population data was used for all incidence calculations.
Results
Over the past decade, the total volume and incidence of surgically treated proximal humerus fractures increased by 13% and 5%, respectively. Although overall incidence decreased, ORIF remained the most common surgical treatment. The greatest decrease in volume and incidence of ORIF occurred in patients ≥75. The incidence of ORIF treatment increased in the South and West while it decreased in the Northeast and Midwest. Total volume and incidence of HA decreased between 2010 and 2019 and this trend remained among all subgroups. Total volume and incidence of RTSA increased by over 300%. The incidence of males and females receiving RTSA increased by 266% and 320%, respectively. Volume and incidence of RTSA increased across all age groups. Volume and incidence of RTSA increased in the Midwest, South, and Western regions while it remained unchanged in the Northeast.
Conclusion
Surgical management trends of proximal humerus fractures have changed greatly over the past decade. ORIF remains the most common surgical treatment for proximal humerus fractures. HA has fallen out of favor while RTSA has seen significant increases in usage across sex, age groups, and geographic regions. These trends represent a change in practice for treating proximal humerus fractures by considering all patient and fracture characteristics when opting for surgical management.
Keywords: Proximal humerus fracture, Surgical, Management, Volume, Incidence, 2010, 2019
Proximal humerus fractures are characterized by a break at the surgical or anatomic neck or tuberosities of the humerus. The incidence is defined as a bimodal distribution with the most fractures occurring in elderly patients secondary to low energy falls and less fractures occurring in younger patients secondary to significant trauma. Among patients between the ages of 65 and 89, proximal humerus fractures are the third most common fracture type and occur more frequently in women than men.4,5
There are a variety of treatment options for fractures of the proximal humerus. Owing to this, outcomes can vary widely and are highly dependent on surgeons experience, fracture characteristics, and patient comorbidities.6 While the majority of proximal humerus fractures can be treated nonoperatively, surgical treatment may be needed and includes open reduction internal fixation (ORIF), hemiarthroplasty (HA), and reverse total shoulder arthroplasty (RTSA).5 The indications for each are dependent on fracture pattern, bone density, soft tissue quality, comorbidities, and patient activity.
HA has previously been the suggested treatment for more severe fractures in young patients including 4-part fractures, head-splitting fractures, and fractures with impaction of the humeral head with significant articular surface involvement.22 RTSA, most commonly indicated in rotator cuff tear arthropathy, has become a valuable tool in the treatment of elderly patients with these fractures.10,12,27 The treatment of proximal humeral fractures has demonstrated variability between institutions and regions and lacks consistent guidelines.5,15,18
The aim of this study is (1) to report United States national volume and incidence estimates for surgical management of proximal humerus fractures to better understand the changing practice of orthopedic surgeons over the past decade and (2) to analyze differences in volume and incidence among age groups, sex, and geographic region. We hypothesize that there will be an increase in volume and incidence of RTSA and comparable decrease in the utilization of HA and ORIF over the past decade.
Methods
Data for this retrospective study was obtained from IBM Marketscan commercial claims and Medicare supplemental databases. Review by the institutional review board was not necessary due to the de-identified nature of the data. Current Procedural Terminology (CPT) codes were used to identify all patients who underwent ORIF (23615), HA (23470 and 23616), and RTSA (23472) procedures between the years of 2010 and 2019. There is no differentiating CPT code separating RTSA from TSA; however, the assumption of this study is that the vast majority of these patients were treated with RTSA. The dataset was further stratified to identify patients with an additional diagnosis code for proximal humerus fractures. The final data set included all patients surgically treated with ORIF, HA, and RTSA used to treat fractures of the proximal humerus. The discharge weights provided by IBM MarketScan were used to model national estimates of each procedure with the Complex Samples function of the IBM SPSS Statistics software (Version 28.0.1; IBM Corp., Armonk, NY, USA). Volume was defined as the total number of procedures in a given year. Incidence was defined as the volume of procedures per population divided by that population total in the given time period and adjusted per 1,000,000 persons. Incidence is helpful as it accounts for natural yearly demographic changes and makes comparisons between years more valid. Volume and incidence were further calculated for subgroups according to age groups, sex, and geographical region. Confidence intervals were included in all volume and incidence estimates. Nonoverlapping confidence intervals indicated statistically significant data. Percent change was calculated between 2010 and 2019 in all subgroups. SPSS Statistics software (Version 28.0.1; IBM Corp., Armonk, NY, USA) was used for analysis.
Results
The total volume of surgically treated proximal humerus fractures can be seen in Table I. A 5% increase in the incidence can be seen over the past decade. The incidence of females outnumbers the incidence of males operatively treated for proximal humerus fracture by a factor of 2.3:1 and has stayed consistent across the decade. The incidence of surgically treated fractures in patients <60 has increased over the past decade; however, in patients 60-74 and ≥75 the incidence has decreased. The highest incidence of surgically treated proximal fractures across the decade is in patients ≥75. A 52% and 32% significant decrease in the incidence of surgically treated fractures in Northeastern and Midwestern regions, while an 87% and 115% significant increase in the incidence is seen in Southern and Western United States regions, respectively. Figures 1 and 2, and Table II reflect the overall changes in volume and incidence of the use HA, RTSA, and ORIF over the past decade. Sex and age subgroups can be found in Tables III and IV, respectively. Table V describes the regional changes broken down for each procedure.
Table I.
Volume and incidence of operative proximal humerus fractures by sex, age group, and region.
| Volume |
Incidence |
|||||
|---|---|---|---|---|---|---|
| 2010 | 2019 | % change | 2010 | 2019 | % change | |
| Overall | 12,565 (11,839-13,290) | 14,159 (12,816-15,503) | 13 | 41.3 (38.9-43.7) | 43.6 (39.5-47.7) | 5 |
| Sex | ||||||
| Male | 3677 (3247-4107) | 4131 (3452-4811) | 12 | 24.6 (21.7-27.5) | 25.8 (21.6-30.1) | 5 |
| Female | 8888 (8294-9481) | 10,028 (8868-11,188) | 13 | 57.5 (53.7-61.3) | 60.8 (53.8-67.9) | 6 |
| Age group | ||||||
| <60 y | 4783 (4476-5089) | 5403 (4902-5904) | 13 | 19.1 (17.9-20.4) | 21.3 (19.3-23.3) | 11 |
| 60-74 y | 4581 (4071-5090) | 5533 (4535-6532) | 21 | 127 (113-142) | 111 (91.4-132) | −13 |
| ≥75 y | 3201 (2770-3632) | 3223 (2497-3948) | 1 | 175 (152-199) | 152 (118-186) | −13 |
| Region | ||||||
| Northeast | 3393 (2971-3816) | 1655 (1125-2184) | −51∗ | 62.5 (54.7-70.3) | 29.8 (20.3-39.4) | −52∗ |
| Midwest | 4920 (4395-5445) | 3423 (2951-3895) | −30∗ | 74.9 (66.9-82.9) | 50.9 (43.8-57.9) | −32∗ |
| South | 2887 (2645-3128) | 5953 (5072-6833) | 106∗ | 26.1 (23.9-28.3) | 48.8 (41.6-56.0) | 87∗ |
| West | 1328 (1155-1502) | 3129 (2422-3836) | 136∗ | 19.1 (16.6-21.6) | 41.0 (31.8-50.3) | 115∗ |
Incidence reported per 1,000,000.
Variables represented as estimates with 95% confidence intervals.
Statistical significance was determined by the absence of overlapping confidence intervals.
Figure 1.
2010-2019 United States national case volumes of open reduction internal fixation (ORIF), hemiarthroplasty (HA), and reverse total shoulder arthroplasty (RTSA) for oroximal humerus fractures. National case volumes of ORIF, HA, and RTSA for proximal humerus fractures per year from 2010 to 2019.
Figure 2.
2010-2019 United States national case incidence of ORIF, HA, and RTSA for proximal humerus fractures. National incidence of ORIF, HA, and RTSA for proximal humerus fractures per year from 2010 to 2019. ORIF, open reduction internal fixation; HA, hemiarthroplasty; RTSA, reverse total shoulder arthroplasty.
Table II.
Volume and incidence estimates by y: open reduction internal fixation vs. hemiarthroplasty vs. reverse total shoulder arthroplasty.
| Year | ORIF |
HA |
RTSA |
|||
|---|---|---|---|---|---|---|
| Volume | Incidence | Volume | Incidence | Volume | Incidence | |
| 2010 | 8341 (7898-8784) | 27.4 (26-28.9) | 3099 (2708-3419) | 10.2 (8.91-11.5) | 1124 (910.4-1337) | 3.7 (2.99-4.40) |
| 2011 | 8552 (8140-8965) | 27.9 (26.6-29.2) | 2777 (2423-3131) | 9.1 (7.90-10.2) | 1494 (1289-1699) | 4.9 (4.21-5.54) |
| 2012 | 8346 (7898-8794) | 27 (25.6-28.5) | 2526 (2191-2861) | 8.2 (7.09-9.26) | 1729 (1497-1962) | 5.6 (4.84-6.34) |
| 2013 | 8766 (8305-9227) | 28.1 (26.7-29.6) | 2407 (2045-2770) | 7.7 (6.56-8.89) | 2067 (1812-2323) | 6.6 (5.81-7.46) |
| 2014 | 8757 (8298-9216) | 27.9 (26.4-29.3) | 2059 (1730-2388) | 6.6 (5.51-7.60) | 2744 (2399-3088) | 8.7 (7.64-9.83) |
| 2015 | 9521 (8475-10,570) | 30.1 (26.8-33.4) | 1679 (1117-2242) | 5.3 (3.53-7.08) | 2386 (1904-2868) | 7.5 (6.02-9.06) |
| 2016 | 9377 (8856-9899) | 29.4 (27.8-31.2) | 1752 (1430-2.074) | 5.5 (4.49-6.51) | 3494 (3157-3830) | 11 (9.91-12.02) |
| 2017 | 9213 (8617-9809) | 28.7 (26.8-30.6) | 1200 (896.7-1505) | 3.7 (2.79-4.69) | 4478 (4037-4918) | 13.9 (12.6-15.3) |
| 2018 | 8999 (8330-9667) | 27.9 (25.8-29.9) | 1135 (780.2-1490) | 3.5 (2.42-4.61) | 3913 (3394-4433) | 12.1 (10.5-13.7) |
| 2019 | 8113 (7322-8905) | 25 (22.6-27.4) | 1170 (685.7-1655) | 3.6 (2.11-5.10) | 4875 (4096-5656) | 15 (12.6-17.4) |
| % change | −3.0% | −9% | −62% | −65% | 334% | 306% |
ORIF, open reduction internal fixation; HA, hemiarthroplasty; RTSA, reverse total shoulder arthroplasty.
Incidence is reported per 1,000,000; % change represents the difference from 2010 to 2019.
Variables represented as estimates with 95% confidence intervals.
Table III.
Volume and incidence estimates by sex: open reduction internal fixation vs. hemiarthroplasty vs. reverse total shoulder arthroplasty.
| Volume |
Incidence |
|||||
|---|---|---|---|---|---|---|
| 2010 | 2019 | % change | 2010 | 2019 | % change | |
| ORIF | ||||||
| Male | 2589 (2323-2854) | 2767 (2281-3253) | 7 | 17.3 (15.6-19.1) | 17.3 (14.3-20.3) | 0 |
| Female | 5753 (5402-6103) | 5346 (4724-5969) | −7 | 37.2 (34.9-39.5) | 32.4 (28.7-36.2) | −13 |
| HA | ||||||
| Male | 805 (601-1008) | 255 (109-402) | −68∗ | 5.39 (4.02-6.75) | 1.60 (0.68-2.51) | −70∗ |
| Female | 2295 (1960-2630) | 915 (453-1377) | −60∗ | 14.9 (12.7-17.0) | 22.9 (2.75-8.35) | −63∗ |
| RTSA | ||||||
| Male | 283 (145-422) | 1109 (747-1471) | 291∗ | 1.90 (0.97-2.82) | 6.94 (4.67-9.2) | 266∗ |
| Female | 840 (678-1002) | 3767 (3077-4457) | 348∗ | 5.44 (4.39-6.48) | 22.9 (18.7-27) | 320∗ |
ORIF, open reduction internal fixation; HA, hemiarthroplasty; RTSA, reverse total shoulder arthroplasty.
Incidence reported per 1,000,000.
Variables represented as estimates with 95% confidence intervals.
Statistical significance was determined by the absence of overlapping confidence intervals.
Table IV.
Volume and incidence estimates by age group: open reduction internal fixation vs. hemiarthroplasty vs. reverse total shoulder arthroplasty.
| Volume |
Incidence |
|||||
|---|---|---|---|---|---|---|
| 2010 | 2019 | % change | 2019 | 2019 | % change | |
| ORIF | ||||||
| <60 y | 3815 (3600-4031) | 4334 (3948-4720) | 14 | 15.3 (14.4-16.1) | 17.1 (15.6-18.6) | 12 |
| 60-74 y | 2868 (2561-3175) | 2695 (2086-3305) | −6 | 79.8 (71.2-88.3) | 54.3 (42.0-66.6) | −32∗ |
| ≥75 y | 1658 (1424-1892) | 1084 (761-1408) | −35∗ | 90.8 (78.0-104) | 51.1 (35.8-66.3) | −44∗ |
| HA | ||||||
| <60 y | 749 (611-887) | 373 (207-539) | −50∗ | 3.00 (2.45-3.55) | 1.47 (0.815-2.12) | −51∗ |
| 60-74 y | 1196 (941-1452) | 386 (105-667) | −68∗ | 33.3 (26.2-40.4) | 7.77 (2.11-13.4) | −77∗ |
| ≥75 y | 1154 (890-1419) | 412 (59.4-764) | −64∗ | 63.2 (48.8-77.7) | 19.4 (2.80-36.0) | −69∗ |
| RTSA | ||||||
| <60 y | 218 (165-272) | 697 (545-849) | 219∗ | 0.87 (0.66-1.09) | 2.75 (2.15-3.35) | 214∗ |
| 60-74 y | 517 (339-694) | 2452 (1809-3095) | 375∗ | 14.4 (9.43-19.3) | 49.4 (36.4-62.3) | 244∗ |
| ≥75 y | 389 (284-494) | 1726 (1312-2140) | 344∗ | 21.3 (15.5-27.0) | 81.3 (61.8-101) | 282∗ |
ORIF, open reduction internal fixation; HA, hemiarthroplasty; RTSA, reverse total shoulder arthroplasty.
Incidence reported per 1,000,000.
Variables represented as estimates with 95% confidence intervals.
Statistical significance was determined by the absence of overlapping confidence intervals.
Table V.
Volume and incidence estimates by region: open reduction internal fixation vs. hemiarthroplasty vs. reverse total shoulder arthroplasty.
| Volume |
Incidence |
|||||
|---|---|---|---|---|---|---|
| 2010 | 2019 | % change | 2010 | 2019 | % change | |
| ORIF | ||||||
| Northeast | 2150 (1894-2405) | 1069 (789-1349) | −50∗ | 39.6 (34.9-44.3) | 19.3 (14.2-24.3) | −51∗ |
| Midwest | 3034 (2731-3337) | 1949 (1674-2223) | −36∗ | 46.2 (41.6-50.8) | 28.9 (24.9-33.0) | −37∗ |
| South | 3000 (1943-2256) | 3041 (2584-3498) | 45∗ | 19.0 (17.6-20.4) | 24.9 (21.2-28.7) | 31∗ |
| West | 1045 (923-1166) | 2055 (1541-2569) | 97∗ | 15.0 (13.3-16.8) | 26.9 (20.2-33.7) | 79∗ |
| HA | ||||||
| Northeast | 919 (680-1158) | 250 (−20.9-521) | −73∗ | 16.9 (12.5-21.3) | 4.51 (−0.38-9.40) | −73∗ |
| Midwest | 1345 (1071-1618) | 305 (119-490) | −77∗ | 20.5 (16.3-24.6) | 4.53 (1.77-7.28) | −78∗ |
| South | 607 (486-729) | 414 (131-697) | −32 | 5.49 (4.39-6.59) | 3.39 (1.07-5.72) | −38 |
| West | 208 (130-287) | 202 (3.15-400) | −3 | 3.00 (1.87-4.13) | 2.65 (0.04-5.25) | −12 |
| RTSA | ||||||
| Northeast | 324 (229-420) | 335 (92.7-578) | 3 | 5.97 (4.21-7.74) | 6.05 (1.67-10.4) | 1 |
| Midwest | 542 (360-723) | 1170 (936-1404) | 116∗ | 8.25 (5.49-11) | 17.4 (13.9-20.9) | 111∗ |
| South | 180 (131-228) | 2498 (1881-3115) | 1292∗ | 1.62 (1.19-2.06) | 20.5 (15.4-25.5) | 1162∗ |
| West | 75.3 (42.2-108) | 872 (535-1210) | 1059∗ | 1.08 (0.61-1.56) | 11.4 (7.01-15.9) | 956∗ |
ORIF, open reduction internal fixation; HA, hemiarthroplasty; RTSA, reverse total shoulder arthroplasty.
Incidence reported per 1,000,000.
Variables represented as estimates with 95% confidence intervals.
Statistical significance was determined by the absence of overlapping confidence intervals.
Open reduction and internal fixation
The total number of proximal humeral fractures treated with ORIF decreased by 3% while the incidence decreased by 9%. The volume for male patients treated with ORIF increased by 7% while decreasing by the same percentage for all female patients. The incidence decreased by 0% and 12.8% for male and female patients, respectively. While both volume and incidence for ORIF of proximal humerus fractures increased for younger patients (<60), there was a significant negative trend in the ORIF in patients >60 years. In the oldest patients (≥75) there was a 35 and 44% decrease in the volume and incidence, respectively (Table III). Significant regional changes in the use of ORIF were seen. Northeast and Midwest regions demonstrated decreasing volumes of 50% and 36%, respectively. South and West regions demonstrated significant increases in volume (45% and 97%) and incidence (31% and 80%), respectively. The incidence across regions in 2010 had significant variability ranging from 15 to 46.2; however, many of these differences disappeared by 2019 (Table IV).
Hemiarthroplasty
The total number of proximal humeral fractures treated with HA decreased by 62%, and the annual incidence decreased by 65% throughout the study period. The volume and incidence decreased in similar proportions between sex. Across all age groups, the volume and incidence of HA significantly decreased between 50 and 77%. The age group with the largest significant decrease in incidence of HA were patients age 60-74. All 4 regions demonstrated decreasing volume and incidence of HA. Northeast and Midwest regions significantly decreased between 73% and 78% and the Southern and Western regions decreased between 3% and 38%. The incidence across regions at the beginning of the decade for HA varied significantly from 3.00 to 20.5; however, by 2019 the differences in HA utilization were mostly absent ranging from 2.65 to 4.53.
Reverse total shoulder arthroplasty
The total number of proximal humeral fractures treated with RTSA increased by 334%, and the annual incidence increased by 306%. Significant increases between 266% and 348% were seen in the volume and incidence of male and female patients treated with RTSA. Across all age groups the volume and incidence increased significantly. The incidence of RTSA in patients <60 increased 214% across the study period, while the incidence in patients 60-75 and >75 increased between 244% and 282%, respectively. Northeast and Midwestern regions demonstrate increasing volume and incidence between 1% and 117% across the decade. Southern and Western regions demonstrated an increase of volume and incidence between 956% and 1292%. The incidence across regions at the beginning of the decade for RTSA ranged from 1.08 to 8.25 and heavily skewed toward the Northeast and Midwestern regions. While increasing across all regions, the incidence for RTSA utilization maintained significant differences across the decade with the Midwestern and Southern accounting for the highest per capita utilization (17.4 and 20.5, respectively).
Discussion
In this study we used aggregated insurance claims from a nationwide sample to model the annual volume and incidence of surgically treated proximal humerus fractures across the entire United States population. Volume and incidence were calculated across sex, age groups, and geographic region. Between 2010 and 2019, significant changes in the operative treatment of proximal humerus fractures were seen across the past decade and are characterized by a marked increase in the utilization of RTSA and decrease in HA. ORIF remains the most common means to surgically treat proximal humerus fractures; however, there has been an overall negative trend over the past decade.
Since 2010, the size of the population aged 65 and older has grown by over 34%, larger than any other age group.1 The large increase in our aging population explains, in part, the general increase in surgically treated fractures of the proximal humerus. The shifts seen in the surgical treatment of these injuries mirrors a larger trend in orthopedic practice over the past twenty years with increasing utilization of primary total shoulder arthroplasty (TSA) as an alternative to HA.7,33,36 Multiple studies have reported on trends of increased utilization in shoulder arthroplasty since the approval of the modern RTSA constructs in the early 2000s.20,33 Results published over the past decade have indicated a decreased use of HA and ORIF and a strong positive trend toward RTSA as primary management for proximal humerus fractures.7,12,27 While the results still demonstrate the use of HA in younger patients, the frequency of use has been declining. RTSA was once reserved for older patients with low demand due to concerns of longevity and construct durability; indeed Wagner et al34 found that older age was associated with lower reoperation and revision rates. However, multiple recent studies have also reported improved outcomes of RTSA in patients less than 60 years old.11,13,30,31 Indeed, a systematic review by Goldenberg et al17 pooled 286 shoulders from patients younger than 65 years that underwent primary RTSA, and found implant survivorship of 91%-98% at 5 years, and 88% at 10 years, and no deterioration in relative Constant Score and subjective shoulder value.
Estimating the incidence on a national scale, this study further demonstrates a three-fold increase in both volume and incidence of RTSA. Despite this shift toward the use of RTSA in the treatment of proximal humerus fractures, ORIF still remains by and large the most common treatment.28 The benefit in internal fixation is the option for revision ORIF or conversion to RTSA when presented with a resultant unsatisfactory outcome. However, the literature shows that primary RTSA leads to overall better functional outcomes and Constant Score when compared to a revision RTSA following a failed ORIF.26 The optimal treatment for the complex, multi-fragmentary, and intra-articular fractures remains controversial with no consistent guidelines as patient age, functional status, bone quality, and fracture pattern all influence decision making. Internal fixation of these more complex fracture patterns has shown poor functional outcomes with high complications rates. In patients treated with ORIF, female sex (odds ratio [OR], 1.8), 4-part fracture-dislocations (OR, 2.1), absence of metaphyseal head extension (OR, 2.4), absence of active back-bleeding from the humeral head (OR, 3.4), height of the head segment <2 cm (OR, 2.3), and absence of capsular attachments to the head fragment (OR, 2.2) were independently associated with poor functional outcomes and complications including nonunion and avascular necrosis.16 In 2021, Pizzo et al28 published a meta-analysis on the treatment of complex proximal humerus fractures focusing on studies with >2 part fractures, fracture-dislocations, and head-splitting fractures and found that patients undergoing RTSA had lower risks of complications and reoperations with higher Constant Scores compared to HA. Patel et al27 further concluded better patient reported outcomes and functional measures in RTSA treated patients compared to ORIF and HA. HA has demonstrated less complications but higher revision rates.14 However, both Young et al36 and van der Merwe et al21 found no statistically significant difference in functional outcomes between HA and RTSA. While the available evidence is unclear, suboptimal outcomes after HA in these patients may be attributed to the reliance on a functional rotator cuff to mobilize the upper limb (eg, tuberosity union). RTSA avoids this challenge by using the deltoid muscle to bypass any deficiency in the cuff or failure of the tuberosities to unite. Comminuted fractures with destruction of the greater tuberosity may not be easily reconstructed, and, combined with atrophic cuff musculature or existing cuff pathology, RTSA may present a better option.9,10,23 In addition, cost-efficacy is an important consideration when comparing RTSA, HA, and ORIF.2,8 Bjørdal et al8 reported improved functional outcomes after RTSA but no statistical difference in cost between RTSA and HA.8 Conversely, RTSA has also been reported as more cost effective over a longer time horizon than ORIF and HA, especially in patients over 65,2,3,25 because despite a higher upfront cost, the lower reoperation rate may generate long term savings.2 Ultimately, the improving longevity, functional outcomes, satisfaction, immediate motion, tolerance of poor bone quality give credence to RTSA as a valuable and economic solution, and support its increased use for proximal humerus fractures.24,32,35
Regional variation in the treatment of proximal humeral fractures has been previously reported in the treatment of proximal humerus fractures.5,15,29 In our study by the end of the decade, the differences in the use of HA and ORIF had largely normalized across regions; however, the variation in the use of RTSA across regions remained discordant. Indeed, we do know there remains a substantial lack of agreement in this area–as seen in a recent 2022 survey of shoulder and trauma fellowship trained surgeons 69% and 53% had a preference of treating 2- and 3-part fractures, respectively, with internal fixation, and in low functioning patients, 44% demonstrated a preference towards RTSA while 54% indicated nonoperative management.19 While the differences in patient specific factors such as patient demographics and mechanism of injury may account for some variability in management, it may also indicate treatment “silos” based on surgeon training and local practices. No definitive conclusions can be drawn from this data without more stratification by fracture severity and pattern across regions, which was not available.
This study cannot be interpreted without consideration for its limitations. All data were extracted from a national insurance database, so the validity of our data is reliant on the accuracy of the procedural coding and institutional reporting. Inaccurate reporting would contribute to over or underestimation of the volume and incidence estimates reported here. For example, although an additional diagnosis code of proximal humerus fractures was included in the query, it is possible that some procedures were in fact revisions, artificially inflating the perceived growth in RTSA, as prior to its expanded indications, many failed ORIFs and HAs could have been managed by revision ORIF and excision arthroplasty respectively. Furthermore, the CPT code for intramedullary nails was excluded from analysis because the code is written for a fracture of the humeral shaft and not proximal humerus. A limitation inherent to the study design is the inability to differentiate TSA from RTSA constructs. The author’s assumption was that the inclusion of TSA volume would not significantly alter the estimates reported here since a strong preference toward RTSA over anatomic constructs has been widely reported. Furthermore, due to the limitations in the data, this analysis is unable to control for fracture patterns and patient characteristics which would provide valuable evidence toward determining a consensus for treatment of proximal humerus fractures. Despite these limitations, this analysis presents comprehensive data representative of the United States population across sex, age groups, and geographic regions. The authors hope this study will benefit surgeons’ understanding of greater trends in orthopedic practice.
Conclusion
The surgical management in fractures of the proximal humerus has changed greatly over the past 10 years. Patients >60 and female sex represent the most common patient demographics. HA has largely fallen out of favor over the past decade and presently represents only a minority of cases. ORIF remains the mainstay for the surgical treatment across patients of all ages; however, RTSA has seen significant increases in usage across sex, age groups, and geographic regions.
Disclaimers
Funding: No funding was disclosed by the authors.
Conflicts of interest: Eric R. Wagner receives consulting fees from Stryker, Wright Medical, Biomet, Acumed, and Osteoremedies; and receives research support from Arthrex, Konica Minolta, Arthrex, and DJO. Michael B. Gottschalk is an Acumed Consultant; and receives institutional support from Arthrex, Acumed, Skeletal Dynamics, and Stryker PI research funding. The other authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
Footnotes
Institutional review board approval was not required for this study.
Investigation performed at the Emory Clinic, Atlanta, GA, USA.
References
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