1. Trends in the Surgical Management of Distal Humerus Fractures in the United States, 2002 to 2011 Presenter: David C Landy CoAuthors: Jimmy J Jiang, Hristo I Piponov, Lewis L Shi, Jason L Koh University of Chicago and Northshore University Health System Logo 1Logo 2

2. Disclosure Slide

3. Distal humerus fractures are a common problem, especially in elderly females, that if not properly managed can lead to a debilitating loss of function: Goal of treatment is to restore function Painless Stable Adequate ROM This goal is frequently complicated by several factors: Complex anatomy Comminution Osteoporotic bone Management options: Non-operative “Bag of Bones” approach Operative including ORIF and Total Elbow Arthroplasty

4. It is only in the last few decades that advances have allowed for improved outcomes with surgical management of distal humerus fractures: We sought to describe trends in the operative management of these fractures using a representative sample of inpatient admissions in the United States. ORIF Requires bone stock and healing TEA Increased cost and unknown long-term outcomes TEA vs ORIF McKee et al. 2009 RCT showed improved Mayo elbow performance scores but otherwise similar outcomes

5. National Inpatient Sample (NIS) data from 2002 to 2011 was used to assess trends in the surgical management of distal humerus fractures over time: National Inpatient Sample (NIS): Nationally representative of US inpatient admissions Stratified sample composing roughly 20% of all US admissions Inclusion Criteria: Distal humerus fracture 18 years of age or older Surgical treatment, either TEA or ORIF Variables: Patient demographics and comorbidity data Hospital characteristics: Size, Academic affiliation, and Location Inpatient variables: Length of stay and Total charges

6. NIS data was analyzed using survey-specific methods that allow for population estimates: Data Visualization Percentage of surgical cases that were TEA by year Stratified TEA rate by sex and age subgroups Logistic Regression: Assess statistical significance of TEA rate over time Assess associations between TEA and other variables Linear Regression: Assess associations between total charges and LOS with TEA

7. Patients having surgery for a distal humerus fracture in the U.S. from 2002 to 2011 tended to be middle-aged white females without major medical comorbidities CharacteristicRaw CountWeighted Sex N Female (Percent)10,15349,645 (60%) Age Median (Interquartile Range)56yo (36-74yo) N > 64yo (Percent)6,53531,988 (39%) Race N White (Percent) 10,17549,710 (76%) Comorbidity N w/ Diabetes (Percent) 2,56812,560 (15%) N w/ Heart Failure (Percent) 8544,168 (5%)

8. Patients having surgery for a distal humerus fracture in the U.S. from 2002 to 2011 tended to be treated at large urban hospitals CharacteristicRaw CountWeighted Academic N Teaching (Percent) 9,42046,334 (56%) Size N Small (Percent) 1,5487,104 (9%) N Medium (Percent) 3,88018,865 (23%) N Large (Percent) 11,41356,348 (68%) Location N Urban (Percent) 15,27474,475 (90%) Expected Payer N Public (Percent) 7,60037,211 (45%)

9. Of all adult distal humerus fractures treated surgically in the US from 2002 to 2011, the percentage treated by TEA rose until 2005 and then has been fairly steady

11. TEA increase is statistically significant w/ P value <.001

12. The rate of TEA increase differed based on patient age with the rate increase significant among older patients and remaining relatively stable among younger patients

13. Further, the rate of TEA increase among older patients differed based on patient sex, with the rate for both sexes initially increased but then leveling off for males

14. The modifying effect of gender does not appear to present in younger patients where TEA use has remained nearly constant over the last decade

15. The recent increase in TEA use, especially after 2008, is being driven by increased use in elderly females with little change in other patient populations

16. Across all years and adjusted for age and sex: CharacteristicOdds Ratio95% C. I. Collagen Vascular Ds vs. No Ds3.152.32 – 4.27 Rural Hospital vs. Urban0.440.30 – 0.64 Small Hospital vs. Large0.670.49 – 0.92 Medium Hospital vs. Large0.850.70 – 1.05 Teach Hospital vs. Non-teaching 1.311.10 – 1.56 Increased TEA use was associated with collagen vascular disease but not obesity, diabetes, heart failure or kidney failure. Decreased TEA use was associated with small rural hospitals. Rheumatoid was included in collagen vascular disease

17. TEA was associated with increased total charges but similar length of stay even after adjusting for age, sex, and comorbidities (Obesity, DM, CHF, Renal Failure): OutcomeTEAORIFP Value Length of stay (days) Median3.12.9.18 Adjusted mean3.5.68 Total charges (US dollars) Median35,51950,265<.01 Adjusted mean 32,00145,169<.01 TEA was associated with an increased 13,000$

18. Given there is a 6 minute limit, much of the data for the manuscript will need to be omitted, but I have prepared additional slides which display these results: Race: Black patients were less likely to receive TEA After adjusting for age and sex, this was attenuated and NS Not possible to adjust for bone density Trends in TEA use over time by hospital characteristics Looked at just within females >64yo Associations were relatively stable over time Somewhat limited by small size of stratified sample 2009-2011 data: Given changes in TEA use, what if just more recent data is used Associations remain similar Some of the currently included data may need to be cut

19. Conclusions These results are limited by not including patients treated in ambulatory surgery settings. The use of TEA in the surgical treatment of distal humerus fractures has increased over the last decade with recent increases in older females. This increased use in older females occurred following publication of the McKee et al. RCT results. As expected, rheumatoid arthritis was associated with increased TEA use and TEA use was associated with increased total charges, roughly 13,000$.

20. Though associated with TEA use across all years, the associations of hospital location and teaching status with TEA use were relatively stable over time

21. Given trends changed over time, only data from 2009 to 2011 was analyzed to see if the associations between patient and hospital factors with TEA remained CharacteristicOdds Ratio95% C. I. Collagen Vascular Ds vs. No Ds3.272.17 – 4.95 Rural Hospital vs. Urban0.420.25 – 0.71 Small Hospital vs. Large0.520.33 – 0.82 Medium Hospital vs. Large0.680.51 – 0.91 Teach Hospital vs. Non-teaching 1.220.96 – 1.55 All associations remained consistent