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Does Knowledge of Implant Cost Affect Fixation Method Choice in the Management of Stable Intertrochanteric Hip Fractures?

The American Journal of Orthopedics. 2017 November;46(6):E439-E444
December 14, 2017|The American Journal of Orthopedics
Neil S. Kumar, MD;Andre M. Jakoi, MD;Amrit S. Khalsa, MD;Andrew M. Star, MD
Author and Disclosure Information

Authors’ Disclosure Statement: Dr. Star reports that he is a consultant for and has received honoraria from DePuy Synthes. The other authors report no actual or potential conflict of interest in relation to this article. 

We conducted a study to determine if knowledge of implant cost affects fixation method choice in the management of stable intertrochanteric hip fractures. We retrospectively reviewed the cases of 119 patients treated with a sliding hip screw (SHS; Versafix), a short Gamma nail (SGN), or a long Gamma nail (LGN).

Of the 119 fractures, 71 were treated before implant costs were revealed, and 48 afterward. The 2 groups were similar in age, sex, fracture types, American Society of Anesthesiologists physical status classification, and preinjury ambulatory status. SHS was used in 38.0% of the before cases and 27.1% of the after cases, SGN in 29.6% of the before cases and 45.8% of the after cases, and LGN in 32.4% of the before cases and 27.1% of the after cases. Changes in implant use were not statistically significant. SHS was favored for 31-A1.1, 31-A1.2, and 31-A2.1 fractures in the before group but only for 31-A1.2 fractures in the after group. Gamma nails of both sizes were preferred in the after group for 31-A1.1, 31-A1.3, and 31-A2.1 fractures.

At our institution, surgeon knowledge of implant cost did not affect fixation method choice in the management of stable intertrochanteric hip fractures.

Take-Home Points

  • The incidence of geriatric hip fractures is rising nationally.
  • Costs associated with hip fracture care have risen significantly.
  • CMN and SHS are effective for stable, intertrochanteric hip fractures.
  • Current trends show increased utilization of CMN compared to SHS for stable introchanteric hip fractures.
  • Surgeon awareness of implant cost is a critical factor in delivering cost-effective, evidence-based surgical care.

The continuing increase in the population of patients older than 65 years in the United States is well known. For orthopedic surgeons, this trend highlights the importance of effective geriatric fracture care, particularly hip fracture care. Hip fractures in the elderly are expected to increase 50% by 2025 and to number 500,000 by 2040.1 The growing burden of hip fracture cases is accompanied by increasing costs of care. In 2012, 88% of the healthcare dollars spent on these patients were for direct fracture care, a significant increase from 60% in 2009.2 Although fewer than 1 in 5 fractures in the elderly are hip fractures, these injuries account for 72% of the total cost of geriatric fracture care, more than the total cost of all other osteoporosis-related injuries combined.1 Currently, the direct cost of hip fracture care ranges from $8358 to $32,195 and is expected, in total, to reach $25 billion by 2025.2,3

About 50% of geriatric hip fractures are extracapsular intertrochanteric or pertrochanteric.4 Several studies have compared sliding hip screws (SHSs) with cephalomedullary nails (CMNs) in the effective management of stable intertrochanteric fractures.5-11 Although these implants have shown an increased risk for peri-implant fracture and subsequent reoperation, markers such as mortality, medical complications, and restoration of prefracture function have all been equivocal relative to SHSs.12 Ultimately, one implant cannot be definitively recommended over the other for management of stable intertrochanteric hip fractures.13,14 Nevertheless, the current trend increasingly favors CMNs over SHSs.4,15 Most orthopedic surgeons are unaware of or underestimate the cost difference between these implants—a fact even more pronounced for newer implants.4,16 Considering the ever growing cost burden of hip fractures in the United States, orthopedists must consider not only the efficacy of care but the cost of delivery.

We conducted a study to determine the effect that surgeon knowledge of implant cost had on rates of use of SHSs and CMNs in the management of stable intertrochanteric hip fractures. 

Patients and Methods

On May 1, 2012, all 9 attending orthopedic surgeons in a private practice group serving a suburban level II trauma center met to discuss implant prices and implant-related costs for the $850 Versafix SHS, the $1950 short Gamma3 nail (SGN), and the $2900 long Gamma3 nail (LGN), all manufactured by Stryker. All surgeons denied previous knowledge of the costs of these implants. During the discussion, no particular implant was recommended for management of any specific type of fracture. Surgeons were not directly instructed to consider implant cost in subsequent hip fracture surgeries and were not informed of our upcoming study of implant utilization.

After obtaining Institutional Review Board approval, we performed a retrospective chart and radiologic review of all hip fractures (Current Procedural Terminology [CPT] code 27244 or 27245) managed with fixation at our institution between May 1, 2011 and April 30, 2013. Two hundred six patients were identified (Figure 1).

Figure 1.
Patients with complicated fractures, defined as ipsilateral femoral head, femoral neck, subtrochanteric, femoral shaft, or distal femur fractures, were excluded. In addition, patients who underwent ipsilateral stemmed total knee arthroplasty were excluded to prevent discrimination against LGN use. All 185 uncomplicated fractures were classified using available radiographs and computed tomography scans and the Orthopaedic Trauma Association (OTA) nomenclature for intertrochanteric hip fractures (Figure 2).17
Figure 2.
Patients with unstable fracture patterns, defined as region 31 type A2.2, type A2.3, and all A3 types,14 were excluded. One hundred fifty-five patients with uncomplicated stable intertrochanteric hip fractures remained. After review of admission, physical therapy, and anesthesia records, patients who were nonambulators before surgery and patients with an American Society of Anesthesiologists (ASA) score of ≥4 were excluded. These exclusion criteria were used to eliminate cases in which the operative surgeon may have changed implant use secondary to lack of baseline ambulation or medical comorbidities. The eligible patient set was divided into 2 groups: patients treated before the educational meeting and after the educational meeting.

One year later, surgeons were again shown their respective hip fracture radiographs, with patient identifying data removed. They were asked to reclassify their respective cases using the OTA system and then indicate the implant they would use for operative fixation in each of their cases.

Patient age, sex, injury side, fracture types, and utilization rates of the SHS, SGN, and LGN implants were compared between the groups. For each eligible patient, implant cost and other financial data were obtained from the hospital’s finance department. Statistical analyses were performed with SPSS (Statistical Package for the Social Sciences) Version 20 for Macintosh. Independent 2-sample t test was used for parametric comparisons, and Fisher exact test was used for nonparametric comparisons.

Results

Table 1.
One hundred nineteen patients met the inclusion criteria: preoperative ambulation, uncomplicated stable intertrochanteric hip fracture managed with SHS or CMN fixation between May 1, 2011 and April 30, 2013, and ASA score of ≤3. Table 1 summarizes the population data of our study sample. Percentage of female patients was higher (P = .066) in the before-discussion group (78.9%) than in the after-discussion group (64.6%). Mean patient age was slightly higher (P = .808) in the after group (85.19 years) than in the before group (84.80 years). A majority (56.3%) of injuries were on the left side in the before group—a notable difference (P = .083) compared with the after group (45.8%). None of these differences was statistically significant.
Table 2.
The injuries most commonly treated in the before (35.2%) and after (39.6%) groups were 31-A2.1 fractures (P = .700), and the injuries least commonly treated in the before (16.9%) and after (14.6%) groups were 31-A1.3 fractures (P = .803). Table 2 summarizes the overall cohort’s implant use rates. Although percentage of use was fairly similar for SGN (36.1%), SHS (33.6%), and LGN (30.3%), these relationships changed in the before–after comparisons. Whereas 38.0% of uncomplicated stable intertrochanteric hip fractures were managed with SHS fixation during the calendar year before the meeting, only 27.1% of similar injuries were managed with the same fixation during the year after the meeting (P = .240). SGN was the implant least commonly used (29.6%) in the before group; by contrast, SGN use was 45.8% (P = .082) in the after group.

Examination of implant use per fracture classification revealed an interesting change. In the before group, SHS was the implant most commonly used for 31-A1.1 fractures (7/16, 43.8%), 31-A1.2 fractures (8/18, 44.4%), and 31-A2.1 fractures (10/25, 40.0%), and LGN was used in 66.7% (8/12) of 31-A1.3 fractures. By contrast, in the after group, SHS was most commonly used only for 31-A1.2 fractures (7/12, 58.3%), SGN was used in 90% (9/10) of 31-A1.1 fractures, and LGN was used in 42.1% (8/19) of 31-A2.1 fractures. In addition, 85.7% (6/7) of 31-A1.3 fractures were managed with a version of the Gamma nail.

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