Geriatric proximal humerus fracture operative management: a Truven Health Analytics database study (2015-2020).

BACKGROUND: The purpose of this study is to assess the trends in operative management of geriatric (≥65 years) proximal humerus fractures during a 6-year period (2015-2020) within an insurance claims database. METHODS: This retrospective database cohort study used data gathered from the 2015-2020 IBM Truven MarketScan Commercial and IBM Truven MarketScan Medicare Supplemental databases. The International Statistical Classification of Disease and Related Health Problems, Tenth Revision, data was correlated to the Current Procedural Terminology code for shoulder arthroplasty (proximal humeral prosthetic replacement: 23616, shoulder hemiarthroplasty [HA]: 23470, reverse total shoulder arthroplasty [rTSA]: 23472) or open reduction internal fixation (ORIF; open treatment of proximal humerus fracture with internal fixation: 23615, open treatment of proximal humerus fracture-dislocation with internal fixation: 23680). We investigated the number of proximal humerus fracture operative cases per year, percentage arthroplasty used per year, rTSA and HA per year, hospital cost information, as well as percentage arthroplasty per US geographic region. RESULTS: A total of 8057 operative proximal humerus fractures cases were identified in 7697 patients aged >65 years, with 0.45% (360 of 8057) being bilateral. There was a 40.8% decrease in the rate of operative management of proximal humerus fractures between the first half (2015-2017, 1687.3 ± 146.6) and the second half of the study period (2018-2020, 998.3 ± 258.7). Arthroplasty accounted for 78.7% of all surgeries, 91% of those being rTSA. The total number of cases of rTSA and ORIF performed decreased per year (P = .01). The downward trend of percentage ORIF per year approached significance (P = .054). Arthroplasty was a more expensive option of payment for total case by almost $850.00 (P = .001). There was a larger percentage of arthroplasty performed in the Northeast and North Central US geographic regions. CONCLUSION: Despite the rise of both the elderly population and related geriatric proximal humerus fractures, they were less operatively represented in this insurance claims database across the 6-year period. There may be a trend to use less ORIF when addressing these fractures. Although it incurred a higher in-hospital cost, arthroplasty was being performed at a higher percentage in the Northeast and North Central regions of the United States.

Treatment patterns of ABOS part II candidates: A decline of operative management among geriatric proximal humerus fractures over the decade (2010-2020).

BACKGROUND: The purpose of this study was to assess trends in ABOS part II candidate's operative management of geriatric (≥65 years) proximal humerus fractures over the 2010-2020 decade. METHODS: This retrospective database cohort study utilized the American Board of Orthopaedic Surgery (ABOS) database for candidates taking Part II of their boards. Surgical coding was reviewed and the ICD10 data was correlated to the CPT code for shoulder arthroplasty or open reduction internal fixation. We investigated the number of proximal humerus fracture operative cases per year, the percent arthroplasty used per year, the stratification of percent arthroplasty per orthopaedic fellowship subspecialty and geographic region. RESULTS: A total of 2,409 operative cases for proximal humerus fractures in patients 65 years of age and older were submitted by 1,420 ABOS candidates. There was a 37% reduction in operatively managed proximal humerus fractures among ABOS part II candidates between the first half of the decade (2010-2015, 263.2 +/- 13.4) and the second half of the decade (2016-2020, 166 +/- 31.2; p<.05). There also was a downward trend with a 53% reduction in percent treated with arthroplasty as compared to ORIF during those same windows (2010-2015, 34.4 +/-11.7) and (2016-2020, 16.2 +/- 6.4; p<.5). Partitioned by single fellowship training, Shoulder and Elbow (S&E) surgeons performed the highest percent arthroplasty at 25.2%, followed by Sports at 23.1% and the lowest percent arthroplasty was Trauma at 11.7%. The Southeast United States had the lowest percentage arthroplasty at 15.8% as compared to the Midwest (23.8%) and Northeast (25.8%). CONCLUSION: Despite the rapid growth of both the elderly population and related geriatric proximal humerus fractures, ABOS candidates are treating less with surgery. There has been approximately a 37% decrease in the total number of operatively treated proximal humerus fractures between the first and second half 2010-2020 decade. When operative treatment is performed, there is a trend towards ORIF over an arthroplasty. Trauma fellowship trained surgeons are less likely to perform an arthroplasty as compared to other subspecialties. The Southeast region is least likely to perform an arthroplasty as compared to the Midwest or Northeast.

Double-Pulley Remplissage in Active-Duty Military Population With Off-Track Anterior Shoulder Instability Results in Improved Outcomes and Low Recurrence at Minimum 4-Year Follow-Up.

PURPOSE: To report mid-term outcomes of active-duty patients with anterior shoulder instability following our technique for double-pulley remplissage (DPR) with concomitant anterior labral repair. METHODS: All consecutive patients from 1/2010 through 12/2016 that underwent DPR by the senior surgeon with complete outcome scores were identified. All patients had experienced a shoulder dislocation following a traumatic event, and had subsequent instability recalcitrant to conservative management. Patients were excluded if they were lost to follow-up (3) of if they underwent stabilization procedures other than DPR (148). Outcome measures were completed by patients within 1 week prior to surgery and at latest follow-up. Twenty-four patients met the inclusion criteria for the study, and all were active-duty military at the time of surgery. RESULTS: 20/24 (83.3%) patients met the patient acceptable symptomatic state (PASS), while 21/24 (87.5%) achieved substantial clinical benefit (SCB) and 22/24 (91.7%) exceeded the minimal clinically important difference (MCID) for their operative shoulder, as determined by the American Shoulder and Elbow Surgeons (ASES) Score. 21/24 (87.5%) patients met the PASS, while 19/24 (79.2%) achieved SCB and 20/24 (83.3%) exceeded the MCID for their operative shoulder, as determined by the single assessment numeric evaluation (SANE). In addition, 23/24 (95.8%) patients exceeded the MCID for their operative shoulder, as determined by the Rowe Instability score. Preoperative and postoperative range of motion did not vary significantly. All patients had decreased pain postoperatively (P < .0001); 22/24 (91.67%) of patients remained on active-duty status. Failure rate, defined as recurrent subluxation or dislocation, was 4.2%. CONCLUSIONS: Mid-term outcomes in this population of active-duty patients undergoing DPR for shoulder instability without glenoid bone loss demonstrate a statistically and clinically significant improvement in patient-reported outcomes, a significant decrease of pain and an overall return to active-duty rate of 91.67%. LEVEL OF EVIDENCE: IV, therapeutic case series.

Variation in state and federal reimbursement in the United States in the treatment of upper extremity fractures.

BACKGROUND: Medicare and Medicaid are 2 of the largest government-run health care programs in the United States. Although Medicare reimbursement is determined at the federal level by the Centers for Medicare & Medicaid Services, Medicaid reimbursement rates are set by each individual state. The purpose of this study is to compare Medicaid reimbursement rates with regional Medicare reimbursement rates for 12 orthopedic procedures performed to treat common fractures of the upper extremity. METHODS: Twelve orthopedic procedures were selected and their Medicare reimbursement rates were collected from the 2020 Medicare Physician Fee Schedule. Medicaid reimbursement rates were obtained from each state's physician fee schedule. Reimbursement rates were then compared by assessing the ratio of Medicaid to Medicare, the dollar difference in Medicaid to Medicare reimbursement, and the difference per relative value unit. The range of variation in Medicaid reimbursement and Medicare wage index-adjusted Medicaid reimbursement was calculated. Comparisons in reimbursement were calculated using coefficient of variation and Student t tests to evaluate the differences between the mean Medicaid and Medicare reimbursements. Two-sample coefficient of variation testing was used to determine whether dispersion in Medicare and Medicaid reimbursement rates differed significantly. RESULTS: There was significant difference in reimbursement rates between Medicare and Medicaid for all 12 procedures, with Medicare reimbursing on average 46.5% more than Medicaid. In 40 states, Medicaid reimbursed less than Medicare for all 12 procedures. Regarding the dollar difference per relative value unit, Medicaid reimbursed on average $18.03 less per relative value unit than Medicare. The coefficient of variation for Medicaid reimbursement rates ranged from 0.26-0.33. This is in stark contrast with the significantly lower variability observed in Medicare reimbursement, which ranged from 0.06-0.07. CONCLUSION: Our findings highlight the variation in reimbursement that exists among state Medicaid programs for 12 orthopedic procedures commonly used to treat fractures of the upper extremity. Furthermore, average Medicaid reimbursement rates were significantly lower than Medicare rates for all 12 procedures. Such discrepancies in reimbursement may act as a barrier, impeding many Medicaid patients from accessing timely orthopedic care.