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Nationwide Utilization and Outcomes of ORIF versus IMN for Humeral Shaft Fractures
David A Stroh, MD1; Yanjie Huang, PhD2; Renan Castillo, PhD2; Ebrahim Paryavi, MD, MPH3
1Curtis National Hand Center, Baltimore, MD, 2Johns Hopkins University, Baltimore, MD, 3Hand Surgery, Union Memorial Hospital, Baltimore, MD
Hypothesis: Demographic and nationwide utilization patterns will vary substantially for the use of open reduction internal fixation (ORIF) vs. intramedullary nail (IMN) in the treatment of non-pathologic humeral shaft fractures. Additionally, specific risk factors for adverse post-operative events can be recognized to assist in surgical decision making.
Methods: Retrospective cohort study of 1,108 participants with non-pathologic humeral shaft fractures (AO 12-ABC, ICD9 812.xx) who received ORIF (CPT 24515) or IMN (CPT 24516) using the MarketScan database from January 1, 2010 through December 31, 2013. Summary statistics were generated for demographic variables, and validated algorithms utilized to reconstruct Injury Severity Score (ISS) and Charlson Comorbidity Index (CCI). The main outcomes were rates of readmission, reoperation, or adverse events (deep or superficial infection, malunion, nonunion, radial nerve palsy, etc.). We used Cox proportional hazards models to examine those adverse outcomes of participants with ORIF and IMN. Inverse probability of treatment weighting was used to adjust for treatment selection bias.
Results: There were 796 (72%) out of 1,108 participants that received ORIF. ORIF predominated in all regions, but less markedly in the North and Northeast. The mean age for the cohort was 42 years (standard deviation 17 years). Notable differences between the treatment groups existed in baseline characteristics (age, gender, region, injury severity, comorbidity). Unadjusted cumulative incidence rates of adverse outcomes among ORIF and IMN patients were 22.2% vs 18.3% (P = 0.112) at 1 year and 23.6% vs 18.3% (P = 0.045) at 2 years. After inverse weighting for the probability of treatment (N = 990), baseline characteristics between ORIF and IMN patients were well balanced (P > 0.05 for all the covariates). The rate of adverse outcomes was higher with ORIF at 1 year (hazard ratio [HR], 1.23; 95% CI, 1.02-1.47; P = 0.029) and 2 years (HR, 1.30; 95% CI 1.08-1.56; P = 0.005). Multivariable analysis indicated that adverse outcomes correlated with ORIF more than IMN, increasing age, female gender, surgeries outside of the Northeast, and increasing ISS.
Conclusion: Among younger patients with a non-pathologic humeral shaft fracture treated operatively, substantial variability exists with respect to those who receive ORIF vs. IMN. The rate of adverse post-operative outcomes is higher at 1 and 2 years among those who received ORIF. High risk patients with increased ISS, female gender, and increased age may have reduced risk for adverse outcomes after IMN compared with ORIF.
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