Plate fixation versus intramedullary nailing of proximal humerus fractures: an ACS NSQIP-based comparative analysis over 8 years

The primary goal of this study was to compare the utilization of plate versus intramedullary nail (IMN) in the treatment of humerus fractures. Secondarily, we sought to examine whether any differences in demographics and clinical course of patients who receive a nail versus plate affect the procedure selection process.

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was queried for patients surgically treated for a humeral shaft fracture from the years 2007–2015, using current procedural terminology (CPT) code. Patients with overlapping procedures, nonunion, polytrauma, and malignancy were excluded. The Charlson Comorbidity Index (CCI) was calculated to compare preoperative comorbidities. A two-sample Wilcoxon rank-sum (Mann–Whitney U) test was used to compare numerical values, whereas the Fisher exact and Chi-squared analyses were performed to compare categorical variables. A p value < 0.05 was considered significant. Preoperative variables with a p value < 0.05 and a clinical prevalence > 1%, indicating statistical and clinical significance, were included in a logistic regression for multivariate analysis to identify any independent predictors for procedure selection (IMN versus PF) based on preoperative patient characteristics.

During the study period plate fixation increased from 7 cases per year to 272 cases per year, while IMN increased from 8 cases per year to 80 cases per year. IMNs were mostly in older patients (63.85 vs 56.19 years, p < 0.001), and patients with a higher Charlson Comorbidity Index (CCI) (4.64 vs 2.79, p < 0.001). IMN was associated with shorter operation times (104 min vs 128 min, p < 0.001) and longer lengths of hospital stay (3.43d vs 2.78d, p < 0.001). No significant differences in overall complication rates were seen between patients who received IMN versus PF. However, the postoperative mortality rate was higher in patients who received IMN compared to PF (2.19% vs 0.40%, p < 0.01). Based on the regression analysis, patient age was the only independent patient factor demonstrated to predict the utilization of IMN over PF in older patients with humeral shaft fractures p = 0.043).

According to this NSQIP-based analysis, the rate of PF and IMN utilization increased in the treatment of humeral shaft fractures over a period of 8 years, but PF was performed at an overall a higher rate than IMN. Intramedullary nailing was preferred over PF in older patients with more comorbidities. The last possibly contributed to the higher 30-day mortality rate observed in patients who received IMN compared to PF.

Retrospective comparative study.