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Trends and Variation in Incidence, Surgical Treatment, and Repeat Surgery of Proximal Humeral Fractures in the Elderly
John-Erik Bell, MD, MS1; Brian C. Leung, MD1; Kevin F. Spratt, PhD1; Ken J. Koval, MD1; James D. Weinstein, DO, MS1; David C. Goodman, MD, MS1; Anna N.A. Tosteson, ScD1
1 Department of Orthopaedic Surgery, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756
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Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from the Robert Wood Johnson Foundation, the American Academy of Orthopaedic Surgeons, the National Institute on Aging (AG12262), and the National Institute of Arthritis and Musculoskeletal and Skin Diseases (AR048094). Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

Investigation performed at Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire

Copyright © 2011 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2011 Jan 19;93(2):121-131. doi: 10.2106/JBJS.I.01505
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The treatment of proximal humeral fractures in the elderly remains controversial. Options include nonoperative treatment, open reduction with internal fixation (ORIF), and hemiarthroplasty. Locking plate technology has expanded the indications for ORIF for certain fracture types in osteoporotic bone. This study was performed to characterize the incidence, treatment, and revision surgery of proximal humeral fractures according to geographic region both before (1999 to 2000) and after (2004 to 2005) the introduction of locking plates.


We used a 20% sample of Medicare Part-B data and the Medicare denominator file for the years 1998 to 2006. Proximal humeral fractures were identified by Common Procedural Terminology codes for treatment, categorized as nonoperative, ORIF, or hemiarthroplasty. Geographic variation in treatment type was determined with use of 306 hospital referral regions. Odds ratios for revision surgery were calculated by the need for repeat surgery within one year of the index procedure. Rates were adjusted for age, sex, race, and comorbidities.


There were 14,774 proximal humeral fractures in the 20% sample from 1999 to 2000 (an estimated total of 73,870 fractures) and 16,138 fractures in the sample from 2004 to 2005 (an estimated total of 80,690 fractures). The overall age, sex, and race-adjusted incidence of proximal humeral fractures was unchanged from 1999 to 2005 (2.47 vs. 2.48 per 1000 Medicare beneficiaries; p = 0.992). However, the absolute rate of surgically managed proximal humeral fractures rose 3.2 percentage points from 12.5% to 15.7%, a relative increase of 25.6% (p < 0.0001). The relative increase in the percentage of fractures treated with ORIF was 28.5% (p < 0.0001), while the percentage of fractures treated with hemiarthroplasty increased 19.6% (p < 0.0001). There were large regional variations in the proportion treated surgically (range, 0% to 68.18%). The rates of repeat surgery were significantly higher in 2004 to 2005 compared with 1999 to 2000 (odds ratio = 1.47, p = 0.043).


Although the incidence of proximal humeral fractures in the elderly did not change from 1999 to 2005, the rate of surgical treatment increased significantly. The marked regional variation in the rates of surgical treatment highlights the need for better consensus regarding optimal treatment of proximal humeral fractures. Additional research is needed to help to determine which fractures are best treated operatively in order to maximize outcome and minimize the need for revision surgery.

Level of Evidence: 

Therapeutic Level II. See Instructions to Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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