Trends and variation in incidence, surgical treatment, and repeat surgery of proximal humeral fractures in the elderly.

Proximal humeral fractures account for 4% to 5% of all fractures, with only hip and distal radial fractures in the elderly being more common. Humeral fractures often require hospitalization and/or rehabilitation care1-6. While most proximal humeral fractures are minimally displaced and can be treated nonoperatively, the treatment of displaced fractures is controversial and includes nonoperative management, percutaneous fracture fixation, open reduction and internal fixation (ORIF), and arthroplasty7-13. The recent development of locking plate technology has expanded the indications of ORIF for certain fracture types, especially in those with osteoporotic bone14. Advances in techniques of percutaneous pinning have been used effectively for proximal humeral fractures with adequate bone stock. Shoulder and elbow fellowships have rapidly expanded recently, as well. To date, there have been no prospective randomized studies that have determined which treatment achieves the best outcome for proximal humeral fractures in the elderly15. There is marked variation in the rates of orthopaedic surgical procedures among different geographic regions of the United States5,16-18. The degree of regional variability correlates inversely with the level of scientific evidence and consensus of the medical community regarding the most appropriate care for a given condition17,19. Interventions that have a strong evidence base and enjoy a consensus among the medical community, such as antibiotic administration for serious infection or surgical fixation of hip fractures, exhibit minimal regional variation in treatment20. On the other hand, procedures without high-quality literature supporting a consensus treatment, such as lumbar spine fusion, exhibit wide variation regionally17. Because there is poor consensus in the literature on the optimal treatment of proximal humeral fractures, we hypothesized that there would be significant regional variation in management. If a wide regional variation in the management of proximal humeral fractures exists, there is a compelling argument that additional research funding is needed to conduct high-quality studies to determine the optimal management of proximal humeral fractures in Medicare patients so that a consensus can be achieved. The study of current practice patterns is important for the treatment of common orthopaedic conditions because these are important public health issues. As the population is aging, the management of fragility fractures is becoming a greater burden on the health-care system. Clinically, it is important to know what the odds of repeat surgery are after initial surgery so we can counsel patients accurately. If ORIF results in more repeat surgery, the increased cost and morbidity may be considered in determining the best treatment for a patient in the absence of high-quality data to support one technique over another. Furthermore, if the odds of repeat surgery are increasing over time, this should be studied. The specific aims of this study were (1) to determine the incidence of proximal humeral fractures in the United States Medicare population both nationally and regionally, (2) to determine regional variability in treatment patterns of proximal humeral fractures, and (3) to compare the rates of revision surgery for ORIF and humeral head replacement. Our hypothesis was that the percentage of fractures treated surgically had increased in recent years and that this expansion in indications had led to an increased rate of revision surgery. We chose to look at rates in 1999 to 2000 and compare them with rates in 2004 to 2005 because locking plates were introduced between these time periods.