Disclosures THE COST-EFFECTIVENESS OF SURGICAL TREATMENT FOR COMPLEX PROXIMAL HUMERUS FRACTURES. Background. Purpose/Question.

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1 THE COST-EFFECTIVENESS OF SURGICAL TREATMENT FOR COMPLEX PROXIMAL HUMERUS FRACTURES Disclosures None David Shearer MD, MPH, Ehsan Tabaraee MD, Paul Toogood MD, Kevin Bozic MD, MBA, Brian Feeley MD Background Common Injury 5% of all fractures (Baron et al., Bone, 1996) Aging population = increasing incidence Many treatments, no consensus Nonoperative Fix (CRPP, ) Replace (Hemiarthroplasty, rtsa) fold geographic variation in rate of surgery (Bell, JBJS 2011) 30% increase in, 20% increase in hemiarthroplasty from 1998 to 2006 Purpose/Question What is the most cost-effective treatment for complex (3- and 4- part) proximal humerus fractures? 1

2 Study Design Model structures Markov model in Treeage 2012 (Williamstown, MA) Four interventions Nonoperative treatment 2 health states with locking plate 6 health states Successful Wellfunctioning Hemiarthroplasty Reverse total shoulder arthroplasty One-year cycle length 4 health states Failed Convert to athro Revision Cost and Quality-of-life accumulated over time 3% discount rate Lifetime time horizon Successful revision Infected All health states Death Key assumptions No reoperations for after the first year (Hirschmann, 2011) Constant annual failure rate for all arthroplasties (primary, revision) Rehabilitation costs, indirect costs (missed work of patient/family, travel time, etc.) are equivalent among groups (Fjalestad, Injury 2010) Cost and benefit of revision and revision arthroplasty assumed to be constant Nonoperatively treated patients do not later elect to undergo surgery (Fjalestad, Injury 2010) No impact on mortality Model Inputs Cost Utility Prob. Failure Nonoperative treatment % Hemiarthroplasty % annual Reverse TSA % annual Costs obtained from HCUP.net, supplemented by literature (Coe et al. JSES 2012) Utilities derived from linear interpolation of Constant scores from multiple systematic reviews (Kantakis, Injury 2008; Sproul et al. Injury 2011) based on EQ-5D scores (Olerud, JSES 2011) Failure rates based on literature (Multiple studies) 2

Results 10 9 8 $30,000 $25,000 Sensitivity Analysis: Reoperation after 7 6 5 4 3 2 1 $20,000 $15,000 $10,000 $5,000 QALYs Cost 0

39 $13,974 Hemiarthroplasty $15,761 9.04 $37,038 Reverse TSA $24,514 9.

3 Results $30,000 $25,000 Sensitivity Analysis: Reoperation after $20,000 $15,000 $10,000 $5,000 QALYs Cost 0 Nonoperative Treatment Hemiarthroplasty Reverse TSA $0 Cost QALYs ICER ($/QALY) Nonoperative Treatment $1, $11, $13,974 Hemiarthroplasty $15, $37,038 Reverse TSA $24, $39,652 rtsa > if reoperation> 19%, hemi preferred > 26% Lifetime risk reoperation after hemi or rtsa = 18% Sensitivity analysis: Age + Reoperation Sensitivity analysis: Age + Reoperation WTP = $50,000/QALY WTP = $100,000/QALY 3

4 Limitations Garbage in, garbage out Few comparison studies, poor follow up, high heterogeneity Difficult to include all patient and fracture variables into a model Sensitivity analysis Identify meaningful clinical thresholds Cost data not true societal perspective (rehab, outpatient pain prescriptions, missed work for family) Conclusions Poor functional outcome, long-term risk reoperation associated with shoulder replacement make preferred in most cases In high-risk cases (head-split, fracture-dislocation) or elderly, reverse TSA may be preferred over hemiarthroplasty Caution should be taken in interpreting short-term studies comparing with arthroplasty Thank you References Baron JA, Barrett JA, Karagas MR. The epidemiology of peripheral fractures. Bone. 1996: 18: 209S-213S. PMID: Chu SP, Kelsey JL, Keegan TH, Sternfeld B, Prill M, Quesenberry CP, Sidney S. Risk factors for proximal humerus fractures. Am J Epidemiol. 2004; 160: PMID: Hallberg I, Rosenqvist AM, Kartous L, Lofrnan O, Wahlstrom O, Toss G. Health related quality of life after osteoporotic fractures. Osteoporos Int. 2004; 15: PMID: Court-Brown CM, Cattermole H, McQueen MM. Impacted valgus fractures (B1.1) of the proximal humerus. The results of non-operative treatment. J Bone Joint Surg Br. 2002; 84: PMID: Court-Brown CM, Caesar B. The Epidemiology of Adult Fractures: A review. Injury. Aug 2006; 37 (8): PMID: Palvanen M, Kannus P, Niemi S, Parkkari J. Update in the epidemiology of proximal humeral fractures. Clin Orthop Relat Res Jan; 442: PMID: Ricchetti ET, Warrender WJ, Abboud JA. Use of Locking Plates in the Treatment of Proximal Humerus Fractures. J Shoulder and Elbow Surg. 2010; 19: PMID: Duralde XA, Leddy LR. The Results of of Displaced Unstable Proximal Humeral Fractures Using a Locking Plate. J Shoulder and Elbow Surg. 2010; 19: PMID: Philippe C, Philippe A, Bevort A, Bonnomet F, Kempf JF. Pitfalls and complications with locking plate for Proximal Humerus Fractures. J Shoulder and Elbow Surg. 2010; 19: PMID: Shulte LM, Matteini LE, Neviaser RJ. Proximal periarticular locking plates in proximal humeral fractures: functional outcomes. J Shoulder and Elbow Surg. 2011; 21: 1-6 PMID: Robinson CM, Page RS, Hill RMF, Sanders DL, Court-Brown CM, Wakefield AE. Primary hemiarthroplasty for treatment of proximal humeral fractures. J Bone and Joint Surg, Am. 2003; July 85-A: PMID Voos JE, Dines JS, Dines DM. plasty for fractures of the proximal part of the humerus. Instr Course Lect. 2011; 60: PMID: Sirveaux F, Roche O, Mole D. Shoulder palsty for Acute Proximal Humerus Fracture. Orthopaedics and Traumatology: Surgery and Research. 2010; 96: PMID: Noyes MP, Kleinhenz B, Markert RJ, Crosby LA. Functional and radiographic long-term outcomes of hemiarthroplasty for proximal humeral fractures. J Shoulder Elbow Surg. 2011; 20, PMID: Handoll HH, Gibson JN, Madhok R. Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev. 2003; 4: CD PMID: Bell JE, Leung BC, Spratt KF, Koval KJ, Weinstein JD, Goodman DC, Tosteson A. Trends and Variation in Incidence, Surgical Treatment, and Repeat Surgery of Proximal Humeral Fractures in the Elderly. 2011; 93-A, PMID: Bernstein J. Decision Analysis. J Bone Joint Surg Am. 1997; 19: PMID: Pauker SG, Kassirer JP. Decision Analysis. N Engl J Med. 1987; 316: PMID:

5 Thornton JG, Lilford RJ, Johnson N. Decision Analysis in Medicine. BMJ. 1992; 204: PMID: Thanasas C, Kontakis G, Angoules A, Limb D, Giannoudis P. Treatment of proximal humerus fractures with locking plates: A systematic review. J Shoulder Elbow Surg. 2009; 18 (6): PMID: Sproul RC, Iyengar JJ, Devcic Z, Feeley BT. A systematic review of locking plate fixation of proximal humerus fractures. Injury Apr; 42(4): PMID: Kontakis G, Koutras C, Tosounidis T, Giannoudis P. Early management of proximal humeral fractures with hemiarthroplasty: a systematic review. J Bone Joint Surg Br Nov; 90(11): PMID: Guy P, Slobogean GP, McCormack RG. Treatment preferences for displaced three- and four-part proximal humerus fractures. Orthop Trauma Apr; 24(4): PMID: Brorson S, Olsen BS, Frich LH, Jensen SL, Johannsen HV, Sørensen AK, Hrobjartsson A.Effect of osteosynthesis, primary hemiarthroplasty, and non-surgical management for displaced four-part fractures of the proximal humerus in elderly: a multi-centre, randomised clinical trial. Trials Jul 8;10:51. PMCID: PMC PMID: Den Hartog D, Van Lieshout EM, Tuinebreijer WE, Polinder S, Van Beeck EF,Breederveld RS, Bronkhorst MW, Eerenberg JP, Rhemrev S, Roerdink WH, Schraa G,Van der Vis HM, Van Thiel TP, Patka P, Nijs S, Schep NW. Primary hemiarthroplasty versus conservative treatment for comminuted fractures of the proximal humerus in the elderly (ProCon): a multicenter randomized controlled trial. BMC Musculoskelet Disord May 25; 11:97. PMID: Olerud P, Ahrengart L, Ponzer S, Saving J, Tidermark J. Hemiarthroplasty versus nonoperative treatment of displaced 4-part proximal humeral fractures in elderly patients: a randomized controlled trial, Journal of Shoulder and Elbow Surgery. October 2011; 20 (7): PMID: Sanders RJ, Thissen LG, Teepen JC, Van Kampen J, Jaarsma RL. Locking plate versus nonsurgical treatment for proximal humeral fractures: better midterm outcome with nonsurgical treatment. Journal of Shoulder and Elbow Surgery. October 2011; 20 (7): PMID: Solberg BD, Moon CN, Franco DP, Paiement GD. Surgical treatment of three and four-part proximal humeral fractures. J Bone Joint Surg Am. Jul 2009; 91(7): PMID: Bastian JD, Hertel R. Osteosynthesis and hemiarthroplasty of fractures of the proximal humerus: Outcomes in a consecutive case series. Journal of Shoulder and Elbow Surgery. April 2009; 18 ( 2): PMID: Dietrich M, Meier C, Lattmann T, Zingg U, Grüninger P, Platz A. Complex fracture of the proximal humerus in the elderly. Locking plate osteosynthesis vs hemiarthroplasty. Chirurg Mar;79(3): Article in German. PMID: Den Hartog D, de Haan J, Schep NW, Tuinebreijer WE. Primary shoulder arthroplasty versus conservative treatment for comminuted proximal humeral fractures: a systematic literature review. Feb 2010 Open Orthop J. 17; 4: PubMed PMID: Thanasas C, Kontakis G, Angoules A, Limb D, Giannoudis P. Treatment of proximal humerus fractures with locking plates: a systematic review. J Shoulder Elbow Surg. Nov 2009; 18(6): Review. PubMed PMID: Nijs S, Broos P. Outcome of shoulder hemiarthroplasty in acute proximal humeral fractures: a frustrating meta-analysis experience. Acta Orthop Belg. Aug 2009; 75(4): Review. PubMed PMID: Lanting B, MacDermid J, Drosdowech D, Faber KJ. Proximal humeral fractures: a systematic review of treatment modalities. J Shoulder Elbow Surg Jan-Feb;17(1): Review. PubMed PMID: Misra A, Kapur R, Maffulli N. Complex proximal humeral fractures in adults--a systematic review of management. Injury Jun;32(5): Review. 5

Trends in the surgical treatment of proximal humeral fractures a nationwide 23-year study in Finland

$Trends in the surgical treatment of proximal humeral fractures a nationwide 23-year study in Finland$ Huttunen et al. BMC Musculoskeletal Disorders 2012, 13:261 RESEARCH ARTICLE Open Access Trends in the surgical treatment of proximal humeral fractures a nationwide 23-year study in Finland Tuomas T Huttunen