Geographic variation in the treatment of proximal humerus fracture: an update on surgery rates and treatment consensus

Surgical treatment of displaced proximal humerus fractures is associated with decreased 1-year mortality in patients aged 65 years and older: a retrospective study of Medicare patients

BACKGROUND

Proximal humerus fracture (PHF) is a risk factor for 1-year mortality. This study aimed to determine if surgery is associated with lower mortality compared to nonoperative treatment following PHF in older patients.

METHODS

This retrospective cohort study used the Medicare Limited Data set. Patients aged 65 years and older with a PHF diagnosis in 2017-2020 were included. Treatment was classified as nonoperative, open reduction internal fixation (ORIF), total shoulder arthroplasty (TSA), or hemiarthroplasty. Multivariable logistic regression models examined (a) predictors of treatment type and (b) the association of treatment type with 1-year mortality, adjusting for patient demographics, comorbidities, frailty, and fracture severity among other variables. A subgroup analysis examined how the relationship between treatment type and 1-year mortality varied based on fracture severity. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) are reported.

RESULTS

In total, 49,072 patients were included (mean age = 76.6 years, 82.3% female). Most were treated nonoperatively (77.5%), 10.9% underwent ORIF, 10.6% underwent TSA, and 1.0% underwent hemiarthroplasty. Examples of factors associated with receipt of operative (versus nonoperative treatment) included worse fracture severity and lower frailty. The 1-year mortality rate after the initial PHF diagnosis was 11.0% for the nonoperative group, 4.0% for ORIF, 5.2% for TSA, and 6.0% for hemiarthroplasty. Compared to nonoperative treatment, ORIF (aOR 0.55; 95% CI [0.47, 0.64]; P < .001) and TSA (aOR 0.59; 95% CI [0.50, 0.68]; P < .001) were associated with decreased odds of 1-year mortality. In the subgroup analysis, ORIF and TSA were associated with a lower 1-year mortality risk for 2-part and 3-/4-part fractures.

CONCLUSIONS

Compared to nonoperative treatment, surgery (particularly TSA and ORIF) was associated with a decreased odds of 1-year mortality. This relationship remained significant for 2-part and 3-/4-part fractures after stratifying by fracture severity.

The Association between Race and Extended Length of Stay in Low-energy Proximal Humerus Fractures in Elderly Patients

INTRODUCTION

Proximal humerus fractures (PHFs) are one of the most common fractures among patients aged 65 years and older, commonly due to low-energy mechanisms. It is essential to identify drivers of increased healthcare utilization in geriatric PHF patients and bring awareness to any disparities in care. Here, we identify factors associated with the likelihood of inpatient admission and prolonged hospital stay among patients aged 65 years and older who sustain PHF due to falls.

METHODS

A national database was used to identify patients aged 65 years and older who suffered proximal humeral fractures due to a fall. Patient factors were analyzed for association with the likelihood of admission and odds of prolonged stay (≥5 days).

RESULTS

In the study period, 75,385 PHF patients who met our inclusion criteria presented to the emergency department and 14,118 (18.7%) were admitted. Black race was significantly associated with decreased odds of admission ( P < 0.001) and increased likelihood of prolonged stay ( P = 0.007) compared with White patients. Patients aged 75 to 84 and 85+ were both more likely to be admitted ( P < 0.001) and experienced a prolonged hospital stay ( P = 0.015). Patients undergoing surgical intervention with reverse total shoulder arthroplasty were associated with admission and prolonged length of stay ( P < 0.001). Hospitals in Midwestern ( P < 0.001) and Western ( P < 0.001) regions exhibited lower rates of admission and Northeastern hospitals were associated with prolonged stays ( P = 0.001). Finally, trauma and nonmetropolitan ( P < 0.001) centers were associated with admission.

CONCLUSION

Our study highlights the notable influence of age and race on the likelihood of hospital admission and prolonged hospital stay. Specifically, Black patients exhibited prolonged hospital stay, which has been associated with lower-quality care, warranting additional exploration. Understanding these demographic and hospital-related factors is essential for optimizing resource allocation and reducing healthcare disparities in the care of PHF patients, especially as the population ages and the incidence of PHF continues to rise.

Trends in Epidemiology and Treatment of Humerus Fractures in the United States, 2017-2022

Background Fractures of the humerus are one of the more common fractures in the United States and a cause of fragility fractures in the elderly population. This study aims to understand recent trends in the demographic factors correlated with humeral shaft fractures (HSF) and humeral shaft fracture nonunion (HSFN) following open reduction internal fixation (ORIF) and intramedullary nailing (IMN). Methods The TriNetX database was used to query using International Classification of Diseases-10 (ICD10) diagnosis codes for patients who sustained HSF between 2017 and 2022. Patients were then organized into cohorts based on Current Procedural Terminology (CPT) codes 24515 and 24516 for ORIF and IMN of HSFs, respectively. Subsequent nonunion after operative management was queried. Descriptive and comparative analysis was performed to examine the differences observed between patients based on age, sex, ethnicity, race, and smoking status as well as surgical management across the six-year study period. Results The incidence of HSF increased from 7,108 in 2017 to 8,450 in 2022. The rate of HSF ORIF increased from 12% to 17% while the nonunion rate following ORIF decreased from 4% to 3%. The rate of HSF IMN increased from 4% to 6% and the rate of nonunion following IMN increased from 2% to 4%. The overall rate of HSFN surgery was 1.7% with slight decreasing trend over the past year. Conclusion It is speculated that improved care and surgical indications resulted in a lower rate of nonunion despite an increase in the overall rate of HSF and its operative managements.

Regional variations in incidence and treatment trends of Achilles tendon ruptures in Finland: a nationwide study

BACKGROUND AND PURPOSE

The aim of our study was to assess the regional variations in Achilles tendon rupture incidence and treatment methods in Finland during the period 1997-2019.

METHODS

The Finnish National Hospital Discharge Register (NHDR) and the Finnish Register of Primary Health Care Visits (PHCR) were searched to identify all adult patients diagnosed with Achilles tendon rupture during our study period. The population-based annual incidence and incidences of surgically and non-surgically treated Achilles tendon ruptures were calculated for each hospital district.

RESULTS

Achilles tendon rupture incidence increased from 17.3 per 105 person-years in 1997 to 32.3 per 105 in 2019. The mean incidence of Achilles tendon ruptures ranged from 26.4 per 105 (North Savo) to 37.2 per 105 (Central Ostrobothnia). The incidence of Achilles tendon ruptures increased in all areas. The proportion of non-surgical treatment of Achilles tendon ruptures ranged in 1997 from 7% (Vaasa) to 67% (Åland) and in 2019 from 73% (Southwest Finland) to 100% (East Savo, Kainuu, Länsi-Pohja, Åland). During the study period, a shift towards non-surgical treatment was evident in all hospital districts.

CONCLUSION

Regional variations in Achilles tendon rupture incidence exist in Finland; however, the incidence increased in all areas during the follow-up period. More Achilles tendon rupture patients are currently being treated non-surgically throughout the country.

Understanding Changing Demographic and Treatment Trends of Distal Radius Fractures: A TriNetX Database Contemporary Analysis of 32,912 Patients

Purpose

Distal radius fractures (DRF) are among the most commonly encountered fractures. The population of the United States is rapidly growing, aging, and diversifying. This study was undertaken to better understand current incidences and treatment trends across all ages, gender, and races to inform resource allocation and to potentially address treatment inequities.

Methods

The TriNetX US Collaborative Network was queried for all patients diagnosed with DRFs from 2017 to 2022. Cohorts were defined by inclusion and exclusion of Current Procedural Terminology procedure codes and categorized into operative and nonsurgical groups. Statistical analysis was performed to determine differences in management among demographic groups across the 6-year time period.

Results

Incidence rates of operative intervention for DRF increased from 19.6% in 2017 to 23.6% in 2022. Incidence rates of operative intervention increased from 21.7% to 25.2% for females and from 15.3% to 19.7% for males. A bimodal distribution was observed in females with more fractures occurring in the pediatric and geriatric ages, but this distribution was not observed in males. All demographic groups had an overall higher incidence of nonsurgical intervention. Patients aged 40-64 years were more likely to undergo operative intervention than patients 18-39 years. Females were more likely to undergo operative intervention than males. White patients were more likely to undergo operative intervention than Black patients and Asian patients.

Conclusions

The incidence of DRFs continues to climb, as does their rate of operative management. The classic bimodal distribution was observed in females, but not males. However, differences in management of DRFs were also observed across different demographic groups with ongoing racial disparities. Future consideration should be taken into optimizing treatment disparities relative to demographic status.

Type of Study/Level of Evidence

Prognosis IV.

Biomechanical analysis of push-pull principle versus traditional approach in locking plates for proximal humeral fracture treatment

INTRODUCTION

Proximal humerus fractures are usually treated with locking plates, which could present recurrence, screw penetration, joint varization. The push-pull principle was introduced to prevent these risks and showed promising results; a dedicated design was then developed and this feasibility study aims to compare the biomechanical performances of such dedicated push-pull plate with the traditional locking plate using finite elements.

MATERIALS AND METHODS

The humerus geometry was obtained from Sawbone CT-scans; the geometries of a traditional locking plate and of the dedicated push-pull one were used. A fracture was added below the humeral head and the plates were virtually implanted. The wire pulling mechanism was simulated connecting the plate to the humeral head apex, considering two levels of tension. Three testing set-ups (axial, torsion and compression bending) were simulated. Stress distributions on bone, plate and screws were measured.

RESULTS

Stress distribution on the distal humerus was similar for both plates. Stress distribution on the proximal humerus was more homogeneous for the push-pull model, showing less unloaded sections (up to 78%). The different levels of tension applied to the wire returned slight differences in terms of stress values, but the comparison with the traditional approach gave similar outcomes.

CONCLUSIONS

More homogeneous stress distribution is found with the push-pull plate in all three testing set-ups, showing lower unloaded areas (and thus lower stress-shielding) compared to the traditional plate; the screws implemented returned to be all loaded in at least one of the set-ups, thus showing that they all contribute to plate stability.

Human-centered Design of a Health Recommender System for Orthopaedic Shoulder Treatment

Background

Rich data on diverse patients and their treatments and outcomes within Electronic Health Record (EHR) systems can be used to generate real world evidence. A health recommender system (HRS) framework can be applied to a decision support system application to generate data summaries for similar patients during the clinical encounter to assist physicians and patients in making evidence-based shared treatment decisions.

Objective

A human-centered design (HCD) process was used to develop a HRS for treatment decision support in orthopaedic medicine, the Informatics Consult for Individualized Treatment (I-C-IT). We also evaluate the usability and utility of the system from the physician's perspective, focusing on elements of utility and shared decision-making in orthopaedic medicine.

Methods

The HCD process for I-C-IT included 6 steps across three phases of analysis, design, and evaluation. A team of informaticians and comparative effectiveness researchers directly engaged with orthopaedic surgeon subject matter experts in a collaborative I-C-IT prototype design process. Ten orthopaedic surgeons participated in a mixed methods evaluation of the I-C-IT prototype that was produced.

Results

The HCD process resulted in a prototype system, I-C-IT, with 14 data visualization elements and a set of design principles crucial for HRS for decision support. The overall standard system usability scale (SUS) score for the I-C-IT Webapp prototype was 88.75 indicating high usability. In addition, utility questions addressing shared decision-making found that 90% of orthopaedic surgeon respondents either strongly agreed or agreed that I-C-IT would help them make data informed decisions with their patients.

Conclusion

The HCD process produced an HRS prototype that is capable of supporting orthopaedic surgeons and patients in their information needs during clinical encounters. Future research should focus on refining I-C-IT by incorporating patient feedback in future iterative cycles of system design and evaluation.

The surgical treatment of proximal humerus fractures 2010-2019: United States national case volume and incidence trends

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.

Position statement: management of proximal humerus fractures

We sought to compare outcomes and reoperation rates for the surgical treatment of proximal humerus fractures (excluding head-splitting fractures, fracture-dislocations, and isolated greater-tuberosity fractures) in men and women older than 60 years. We searched MEDLINE, Embase, and Cochrane through to Feb. 1, 2022, and included all English-language randomized trials comparing operative versus nonoperative treatment; open reduction and internal fixation (ORIF) with locking plate versus intramedullary nail; arthroplasty versus ORIF; and reverse shoulder arthroplasty versus hemiarthroplasty. Outcomes of interest were functional outcomes (e.g., Constant score), pain outcomes (visual analogue scale scores), and reoperation rates for the interventions of interest when available. We rated the quality of the evidence and strength of recommendations using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. This guideline will benefit patients considering surgical intervention for fractures of the proximal humerus by improving counselling on surgical treatment options and possible outcomes. It will also benefit surgical providers by improving their knowledge of various surgical approaches. Data presented could be used to develop frameworks and tools for shared decision-making.Nous avons cherché à comparer les résultats et les taux de réintervention à la suite d'un traitement chirurgical pour une fracture de l'humérus proximal (excluant les fractures de la tête humérale, les fractures-luxations et les fractures isolées de la grande tubérosité) chez les hommes et les femmes âgés de plus de 60 ans. Nous avons effectué des recherches dans les bases de données MEDLINE, Embase, et Cochrane jusqu'au 1er février 2022 et avons inclus tous les essais randomisés publiés en anglais comparant différents duos d'interventions : traitements chirurgicaux ou non chirurgicaux; réductions ouvertes avec fixation interne (ROFI) réalisées à l'aide d'une plaque verrouillée ou enclouages centromédullaires; arthroplasties ou ROFI; et arthroplasties inversées de l'épaule ou hémiarthroplasties. Les paramètres d'intérêt étaient la capacité fonctionnelle (p. ex., score de Constant), la douleur (p. ex., échelle analogique visuelle) et le taux de réintervention pour les interventions d'intérêt, selon les données disponibles. Nous avons évalué la qualité des données probantes et la solidité des recommandations à l'aide de l'approche GRADE (Grading of Recommendations, Assessment, Development and Evaluation). Cette ligne directrice profitera aux patients qui envisagent une intervention chirurgicale après une fracture de l'humérus proximal en améliorant les consultations sur les options de traitement chirurgical et les résultats escomptés. Elle aidera aussi les chirurgiens en améliorant leurs connaissances sur différentes approches chirurgicales. Les données présentées pourraient servir à mettre au point des cadres et des outils pour une prise de décision partagée.

Outcomes after salvage reverse shoulder arthroplasty for failed primary fixation or hemiarthroplasty for proximal humerus fractures: A systematic review

Background

Salvage reverse shoulder arthroplasty (RSA) for failed proximal humerus fractures (PHFs) fixation and hemiarthroplasty (HA) may maximize outcomes in the absence of tuberosity healing or a chronically torn rotator cuff. The purpose of this systematic review was to examine the improvement in clinical outcomes for patients after revision RSA was performed for failed PHFs fixation or HA.

Methods

An electronic database search of SCOPUS, PubMed, Embase, MEDLINE, SPORTDiscus, CINAHL, and ClinicalTrials.gov was performed. A meta-analysis was carried out to determine weighted mean outcome differences between two primary intervention cohorts (failed fixation: open reduction and internal fixation, intramedullary nail, or K-wire vs. failed HA).

Results

Fifteen studies were included (primary fixation: 208 patients; HA: 162 patients). Patients improved meaningfully in all clinical outcomes after revision surgery (constant: 18.5-48.3; abduction: 44-95; forward flexion: 47-107; external rotation: 5-10), with a 16.2% complication and 9.4% revision rate. The failed fixation group performed significantly better than the failed HA group in postoperative constant (fixation: 53.3 vs. HA: 45.1, p = 0.016) and shoulder abduction (fixation: 102 vs. HA: 87, p = 0.026).

Conclusions

RSA is a successful revision intervention for primary PHF operative failures with the greatest benefit for failures of primary fixation versus HA.

Racial Disparities in the Operative Management of Orthopedic Trauma: A Systematic Review and Meta-Analysis

OBJECTIVE

The objective of this study was to investigate if race is associated with the likelihood of operative management of acute fractures.

METHODS

A systematic review of the literature was performed using the PubMed, EMBASE, and Cochrane databases to identify studies associated with social disparities and acute orthopedic trauma. Peer-reviewed studies commenting on social disparities and the decision to pursue operative or non-operative management of acute fractures were identified for detailed review. Study characteristics and odds ratios were extracted from each article. The Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were followed. A quality analysis of the data was also performed.

RESULTS

In total, 13 studies were identified and 8 were included in the meta-analysis totaling 743,846 fractures. Hip, distal radius, pelvic, tibial plateau, clavicle, femoral neck, and femoral shaft fractures were represented in this patient population. The meta-analysis demonstrated that White race is associated with a higher likelihood of operative intervention compared to all other races pooled together (odds ratio, 1.31; 95% confidence interval 1.16 to 1.47; p < .0001) as well as Black race (odds ratio 1.39; 95% confidence interval 1.12 to 1.72; p = .0025).

CONCLUSIONS

Non-White race and Black race are associated with a lower likelihood of receiving surgical management of acute orthopedic trauma. Surgeons and health systems should be aware of these inequities and consider strategies to mitigate bias and ensure all patients receive appropriate and timely care regardless of race.

Medicaid insurance is associated with treatment disparities for proximal humerus fractures in a national database analysis

BACKGROUND

Proximal humerus fractures (PHFs) are the third most common type of fragility fracture in the elderly and are increasing in incidence. Disparities in treatment type, time to surgery (TTS), and complications based upon insurance type have been identified for other orthopedic conditions. Given the incidence and burden of PHFs, we sought to evaluate if insurance type was associated with treatment received, TTS, and complications in the treatment of PHFs.

METHODS

We used PearlDiver, a national administrative claims database that consists of 122 million patient records. Patients diagnosed with an isolated PHF between 2010 and 2019 were identified by International Classification of Diseases, Ninth and Tenth Revision diagnostic codes and stratified by insurance type (Medicaid, private, or Medicare). Outcomes evaluated were rate of surgery within 3 months of diagnosis with open reduction and internal fixation, hemiarthroplasty, or reverse shoulder arthroplasty; average TTS; 90-day readmissions and medical postoperative complications (deep vein thrombosis, urinary tract infection, pneumonia, sepsis, acute respiratory failure, cerebrovascular event, and acute renal failure); and 1-year surgical postoperative complications (stiffness, noninfectious wound complications, dislocation, and infection). Multivariable logistic regressions adjusting for age, sex, and Elixhauser comorbidity index were utilized to determine the association between insurance type and surgery rate/complications.

RESULTS

We included 245,396 patients for analysis. Fourteen percent of Medicaid patients (1789/12,498) underwent surgery compared to 17% (25,347/149,830) of privately insured patients and 16% (13,305/83,068) of Medicare patients (pairwise, P < .001). TTS (Medicaid: 11.7 days, private: 10.6 days [P < .001]; Medicare: 10.7 days [P = .003]) varied by insurance type. Private or Medicare-insured patients were less likely to be readmitted (adjusted odds ratio: 0.77 [95% confidence interval (CI): 0.63-0.93] for private vs. Medicaid and 0.71 [95% CI: 0.59-0.88] for Medicare vs. Medicaid) and experienced fewer 90-day postoperative complications (adjusted odds ratio: 0.73 [95% CI: 0.62-0.85] for private vs. Medicaid, 0.65 [95% CI: 0.55-0.77] for Medicare vs. Medicaid), such as acute renal failure. TTS was also associated with differing rates of readmissions and complications.

CONCLUSION

There are differences in rates of surgery, TTS, and complications after PHFs based on insurance type, representing opportunities for quality improvement initiatives. Potential methods to address these disparities include implementing standardized PHF protocols and/or reimbursement models and quality metrics that reward equitable treatment. Further research and policy adaptations should be incorporated to decrease barriers that patients face and minimize health care inequities seen in the treatment of PHFs based on insurance type.

Generating Practice-Based Evidence in the Use of Guideline-Recommended Combination Therapy for Secondary Prevention of Acute Myocardial Infarction

Background: Clinical guidelines recommend beta-blockers, angiotensin-converting enzyme inhibitors/angiotensin-receptor blockers, and statins for the secondary prevention of acute myocardial infarction (AMI). It is not clear whether variation in real-world practice reflects poor quality-of-care or a balance of outcome tradeoffs across patients. Methods: The study cohort included Medicare fee-for-service beneficiaries hospitalized 2007-2008 for AMI. Treatment within 30-days post-discharge was grouped into one of eight possible combinations for the three drug classes. Outcomes included one-year overall survival, one-year cardiovascular-event-free survival, and 90-day adverse events. Treatment effects were estimated using an Instrumental Variables (IV) approach with instruments based on measures of local-area practice style. Pre-specified data elements were abstracted from hospital medical records for a stratified, random sample to create "unmeasured confounders" (per claims data) and assess model assumptions. Results: Each drug combination was observed in the final sample (N = 124,695), with 35.7% having all three, and 13.5% having none. Higher rates of guideline-recommended treatment were associated with both better survival and more adverse events. Unmeasured confounders were not associated with instrumental variable values. Conclusions: The results from this study suggest that providers consider both treatment benefits and harms in patients with AMIs. The investigation of estimator assumptions support the validity of the estimates.

Assessing the ability of an instrumental variable causal forest algorithm to personalize treatment evidence using observational data: the case of early surgery for shoulder fracture

Background

Comparative effectiveness research (CER) using observational databases has been suggested to obtain personalized evidence of treatment effectiveness. Inferential difficulties remain using traditional CER approaches especially related to designating patients to reference classes a priori. A novel Instrumental Variable Causal Forest Algorithm (IV-CFA) has the potential to provide personalized evidence using observational data without designating reference classes a priori, but the consistency of the evidence when varying key algorithm parameters remains unclear. We investigated the consistency of IV-CFA estimates through application to a database of Medicare beneficiaries with proximal humerus fractures (PHFs) that previously revealed heterogeneity in the effects of early surgery using instrumental variable estimators.

Methods

IV-CFA was used to estimate patient-specific early surgery effects on both beneficial and detrimental outcomes using different combinations of algorithm parameters and estimate variation was assessed for a population of 72,751 fee-for-service Medicare beneficiaries with PHFs in 2011. Classification and regression trees (CART) were applied to these estimates to create ex-post reference classes and the consistency of these classes were assessed. Two-stage least squares (2SLS) estimators were applied to representative ex-post reference classes to scrutinize the estimates relative to known 2SLS properties.

Results

IV-CFA uncovered substantial early surgery effect heterogeneity across PHF patients, but estimates for individual patients varied with algorithm parameters. CART applied to these estimates revealed ex-post reference classes consistent across algorithm parameters. 2SLS estimates showed that ex-post reference classes containing older, frailer patients with more comorbidities, and lower utilizers of healthcare were less likely to benefit and more likely to have detriments from higher rates of early surgery.

Conclusions

IV-CFA provides an illuminating method to uncover ex-post reference classes of patients based on treatment effects using observational data with a strong instrumental variable. Interpretation of treatment effect estimates within each ex-post reference class using traditional CER methods remains conditional on the extent of measured information in the data.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-022-01663-0.

Factors related to initial treatment for adhesive capsulitis in the medicare population

BACKGROUND

Primary adhesive capsulitis (AC) is not well understood, and controversy remains about the most effective treatment approaches. Even less is known about the treatment of AC in the Medicare population. We aimed to fully characterize initial treatment for AC in terms of initial treatment utilization, timing of initial treatments and treatment combinations.

METHODS

Using United States Medicare claims from 2010-2012, we explored treatment utilization and patient characteristics associated with initial treatment for primary AC among 7,181 Medicare beneficiaries. Patients with primary AC were identified as patients seeking care for a new shoulder complaint in 2011, with the first visit related to shoulder referred to as the index date, an x-ray or MRI of the shoulder region, and two separate diagnoses of AC (ICD-9-CM codes: 726.00). The treatment period was defined as the 90 days immediately following the index shoulder visit. A multivariable logistic model was used to assess baseline patient factors associated with receiving surgery within the treatment period.

RESULTS

Ninety percent of beneficiaries with primary AC received treatment within 90 days of their index shoulder visit. Physical therapy (PT) alone (41%) and injection combined with PT (34%) were the most common treatment approaches. Similar patient profiles emerged across treatment groups, with higher proportions of racial minorities, socioeconomically disadvantaged and more frail patients favoring injections or watchful waiting. Black beneficiaries (OR = 0.37, [0.16, 0.86]) and those residing in the northeast (OR = 0.36, [0.18, 0.69]) had significantly lower odds of receiving surgery in the treatment period. Conversely, younger beneficiaries aged 66-69 years (OR = 6.75, [2.12, 21.52]) and 70-75 years (OR = 5.37, [1.67, 17.17]) and beneficiaries with type 2 diabetes had significantly higher odds of receiving surgery (OR = 1.41, [1.03, 1.92]).

CONCLUSIONS

Factors such as patient baseline health and socioeconomic characteristics appear to be important for physicians and Medicare beneficiaries making treatment decisions for primary AC.

What are the health consequences associated with differences in medical malpractice liability laws? An instrumental variable analysis of surgery effects on health outcomes for proximal humeral facture across states with different liability rules

BACKGROUND

States enacted tort reforms to lower medical malpractice liability, which are associated with higher surgery rates among Medicare patients with shoulder conditions. Surgery in this group often entails tradeoffs between improved health and increased risk of morbidity and mortality. We assessed whether differences in surgery rates across states with different liability rules are associated with surgical outcomes among Medicare patients with proximal humeral fracture.

METHODS

We obtained data for 67,966 Medicare beneficiaries with a diagnosis of proximal humeral fracture in 2011. Outcome measures included adverse events, mortality, and treatment success rates, defined as surviving the treatment period with < $300 in shoulder-related expenditures. We used existing state-level tort reform rules as instruments for surgical treatment and separately as predictors to answer our research question, both for the full cohort and for stratified subgroups based on age and general health status measured by Charlson Comorbidity Index and Function-Related Indicators.

RESULTS

We found a 0.32 percentage-point increase (p < 0.05) in treatment success and a 0.21 percentage-point increase (p < 0.01) in mortality for every 1 percentage-point increase in surgery rates among patients in states with lower liability risk. In subgroup analyses, mortality increased among more vulnerable patients, by 0.29 percentage-point (p < 0.01) for patients with Charlson Comorbidity Index >  = 2 and by 0.45 percentage-point (p < 0.01) among those patients with Function-Related Indicator scores >  = 2. On the other hand, treatment success increased in patients with lower Function-Related Index scores (< 2) by 0.54 percentage-point (p < 0.001). However, younger Medicare patients (< 80 years) experienced an increase in both mortality (0.28 percentage-point, p < 0.01) and treatment success (0.89 percentage-point, p < 0.01). The reduced-form estimates are consistent with our instrumental variable results.

CONCLUSIONS

A tradeoff exists between increased mortality risk and increased treatment success across states with different malpractice risk levels. These results varied across patient subgroups, with more vulnerable patients generally bearing the brunt of the increased mortality and less vulnerable patients enjoying increased success rates. These findings highlight the important risk-reward scenario associated with different liability environments, especially among patients with different health status.

Surgeons Consider Initial Nonoperative Treatment With Potential for Future Conversion to Reverse Arthroplasty a Reasonable Option for Older, Relatively Infirm, and Less-Active Patients

OBJECTIVES

Two recent developments favor initial nonoperative treatment of proximal humerus fractures among the older, relatively infirm, less-active patients that represent most patients with such fractures: (1) evidence of minimal benefit of open reduction, internal fixation over nonoperative treatment, and (2) evidence of the effectiveness of the reverse total shoulder arthroplasty. As one step in determining the feasibility of a strategy of initial nonoperative treatment of proximal humerus fracture among older, relatively infirm, less-active people, we performed a survey-based experiment to measure factors associated with surgeon recommendation for initial nonoperative treatment.

METHODS

Members of the Science of Variation Group viewed 8 hypothetical patients with radiographs of complex proximal humeral fractures and 7 randomized patient variables. For each scenario, surgeons were asked whether they would recommend (1) initial nonoperative treatment with bailout reverse arthroplasty or (2) immediate reverse arthroplasty.

RESULTS

The mean percentage of recommendations for initial nonoperative treatment was 63%, with wide variation by surgeon (range 0%-100%). In multilevel mixed-effects logistic regression, recommendation for initial nonoperative treatment was associated with specific radiographs, older age, having a comorbidity, being homebound, surgical subspecialists, and more than 20 years in practice.

CONCLUSIONS

These findings suggest that surgeons may consider initial nonoperative treatment with potential for future conversion to reverse arthroplasty an acceptable treatment option, particularly for older, less-active, more infirm individuals, and relatively less displaced fractures with little comminution.

Proximal Humerus Fractures: Epidemiology and trends in surgical management of hospital-admitted patients in Portugal

Background

Proximal humerus fractures (PHFs) are frequent and associated with significant health care burden. National epidemiological data are limited. Our objective is to characterize the Portuguese population admitted with PHFs and analyze therapeutic management, the impact of associated lesions, and mortality rate.

Methods

This was a retrospective, observational study of admissions from mainland public hospitals (2000-2015), with primary or secondary diagnosis of PHFs. Incomplete records, pathologic lesions, malunion/nonunion, and hardware removal were excluded. Age, gender, admission date, hospitalization period, associated injuries, treatment, and mortality were recorded.

Results

A total of 19,290 patients were included. Through the analyzed period, an increase in the absolute number and incidence of PHFs was observed. The mean age at diagnosis was 62.6 ± 21.0 years old (57% elderly; 63.5% female). The mean length of stay was 10.0 ± 14.1 days, higher in patients submitted to arthroplasty (P < .001) and in those with associated fractures (25%; P < .001). A total of 14,482 patients were operated, most frequently with open reduction and internal fixation (28%). The inpatient mortality rate was 3.2%, significantly higher in patients with associated fractures (odds 2.77 for lower limb vs. upper limb).

Conclusion

There is a trend toward an increase in surgical management of PHFs. The relative proportion of open reduction and internal fixation and arthroplasty (particularly reverse arthroplasty) increased, probably reflecting biomechanical implant properties, fracture pattern, and demand for better functionality. Associated fractures are an important comorbidity, associated with increased mortality and length of stay.

The fragility and reverse fragility indices of proximal humerus fracture randomized controlled trials: a systematic review

BACKGROUND

The quality of evidence of the orthopedic literature has been often called into question. The fragility index (FI) has emerged as a means to evaluate the robustness of a significant result. Similarly, reverse fragility index (RFI) can be used for nonsignificant results to evaluate whether one can confidently conclude that there is no difference between groups. The analysis of FI and RFI in proximal humerus fracture (PHF) management is of particular interest, given ongoing controversy regarding optimal management and patient selection. The aim of this study was to report the FI, RFI and quality of the evidence in the proximal humerus fracture literature.

METHODS

A systematic review was conducted based on the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines, which utilized EMBASE, MEDLINE and Cochrane Library databases. Inclusion criteria included randomized controlled clinical trials related to the management of proximal humerus fractures, published from 2000 to 2020 with dichotomous outcome measures and 1:1 allocation. The FI and RFI were calculated by successively changing one nonevent to an event for each outcome measure until the result was made nonsignificant or significant, respectively. The fragility quotient, (FQ), calculated by dividing the FI by the total sample size, was calculated as well.

RESULTS

There were 25 studies that met our criteria with 48 outcome measures recorded. A total of 21 studies had at least one fragile result, with ten studies including a fragile result in the conclusion of the abstract. A total of 31 outcome measures had nonsignificant results and the median RFI was found to be 4, with 71% greater than number of patients lost to follow up. Seventeen outcomes had significant results, with a median FI of 1, with 65% greater than or equal to the number patients lost to follow up. A total of 18 of 25 studies (72%) included a power analysis. In particular, ten studies reported a statistical analysis of complication rates, 90% of which were fragile. The median FQ was found to be 0.037.

CONCLUSIONS

The literature on PHF management is frequently fragile. Outcome measures are often fragile, particularly with regards to comparing complication rates and reoperation rates in treatment arms. Comparing to the studies in other subspecialties PHF RCTs are relatively more fragile and underpowered. Standardized reporting of FI, FQ and RFI can help the reader to reliably draw conclusions based on the fragility of outcome measures.

Outcome measures reported for the management of proximal humeral fractures: a systematic review

BACKGROUND

The American Shoulder and Elbow Surgeons multicenter taskforce studying proximal humerus fractures reached no consensus on which outcome measures to include in future studies, and currently no gold standard exists. Knowledge of commonly used outcome measures will allow standardization, enabling more consistent proximal humerus fracture treatment comparison. This study identifies the most commonly reported outcome measures for proximal humerus fracture management in recent literature.

METHODS

A systematic review identified all English-language articles assessing proximal humerus fractures from 2008 to 2018 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Review articles, meta-analyses, revision surgery, chronic injuries, studies with <15 patients, studies with <12 month follow-up, anatomic/biomechanical studies, and technique articles were excluded. Included studies were assessed for patient demographics and outcome scores, patient satisfaction, complications, range of motion, and strength.

RESULTS

Of 655 articles, 74 met inclusion criteria. The number of proximal humerus fractures averaged 74.2 per study (mean patient age, 65.6 years). Mean follow-up was 30.7 months. Neer type 1, 2, 3, and 4 fractures were included in 8%, 51%, 81%, and 88% of studies, respectively. Twenty-two patient-reported outcome instruments were used including the Constant-Murley score (65%), Disabilities of the Arm, Shoulder, and Hand score (31%), visual analog scale pain (27%), and American Shoulder and Elbow Surgeons score (18%). An average of 2.2 measures per study were reported.

CONCLUSION

Considerable variability exists in the use of outcome measures across the proximal humerus fracture literature, making treatment comparison challenging. We recommend that future literature on proximal humerus fractures use at least 3 outcomes measures and 1 general health score until the optimal scores are determined.

Association of Surgical Treatment With Adverse Events and Mortality Among Medicare Beneficiaries With Proximal Humerus Fracture

IMPORTANCE

Meta-analyses of randomized clinical trials suggest that the advantages and risks of surgery compared with conservative management as the initial treatment for proximal humerus fracture (PHF) vary, or are heterogeneous across patients. Substantial geographic variation in surgery rates for PHF suggests that the optimal rate of surgery across the population of patients with PHF is unknown.

OBJECTIVE

To use geographic variation in treatment rates to assess the outcomes associated with higher rates of surgery for patients with PHF.

DESIGN, SETTING, AND PARTICIPANTS

This comparative effectiveness research study analyzed all fee-for-service Medicare beneficiaries with proximal humerus fracture in 2011 who were continuously enrolled in Medicare Parts A and B for the 365-day period before and immediately after their index fracture. Data analysis was performed January through June 2019.

EXPOSURE

Undergoing 1 of the commonly used surgical procedures in the 60 days after an index fracture diagnosis.

MAIN OUTCOMES AND MEASURES

Risk-adjusted area surgery ratios were created for each hospital referral region as a measure of local area practice styles. Instrumental variable approaches were used to assess the association between higher surgery rates and adverse events, mortality risk, and cost at 1 year from Medicare's perspective for patients with PHF in 2011. Instrumental variable models were stratified by age, comorbidities, and frailty. Instrumental variable estimates were compared with estimates from risk-adjusted regression models.

RESULTS

The final cohort included 72 823 patients (mean [SD] age, 80.0 [7.9] years; 13 958 [19.2%] men). The proportion of patients treated surgically ranged from 1.8% to 33.3% across hospital referral regions in the United States. Compared with conservatively managed patients, surgical patients were younger (mean [SD] age, 80.4 [8.1] years vs 78.0 [7.2] years; P < .001) and healthier (Charlson Comorbidity Index score of 0, 14 863 [24.4%] patients vs 3468 [29.1%] patients; Function-Related Indicator score of 0, 20 720 [34.0%] patients vs 4980 [41.8%] patients; P < .001 for both), and a larger proportion were women (49 030 [80.5%] patients vs 9835 [82.5%] patients; P < .001). Instrumental variable analysis showed that higher rates of surgery were associated with increased total costs ($8913) during the treatment period, increased adverse event rates (a 1-percentage point increase in the surgery rate was associated with a 0.19-percentage point increase in the 1-year adverse event rate; β = 0.19; 95% CI, 0.09-0.27; P < .001), and increased mortality risk (a 1-percentage point increase in the surgery rate was associated with a 0.09-percentage point increase in the 1-year mortality rate; β = 0.09; 95% CI, 0.04-0.15; P < .01). Instrumental variable mortality results were even more striking for older patients and those with higher comorbidity burdens and greater frailty. Risk-adjusted estimates suggested that surgical patients had higher costs (increase of $17 278) and more adverse events (a 1-percentage point increase in the surgery rate was associated with a 0.12-percentage point increase in the 1-year adverse event rate; β = 0.12; 95% CI, 0.11 to 0.13; P < .001) but lower risk of mortality after PHF (a 1-percentage point increase in the surgery rate was associated with a 0.01-percentage point decrease in the 1-year mortality rate; β = -0.01; 95% CI, -0.015 to -0.005; P < .001).

CONCLUSIONS AND RELEVANCE

This study found that higher rates of surgery for treatment of patients with PHF were associated with increased costs, adverse event rates, and risk of mortality. Orthopedic surgeons should be aware of the harms of extending the use of surgery to more clinically vulnerable patient subgroups.