Orthopedics

Feature Article 

Increasing Use of Reverse Total Shoulder Arthroplasty for Proximal Humerus Fractures in Elderly Patients

Sean S. Rajaee, MD; Dheeraj Yalamanchili, MD; Naudereh Noori, MD; Eytan Debbi, MD; James Mirocha, MS; Carol A. Lin, MD; Charles N. Moon, MD

Abstract

This study described surgical treatment patterns for proximal humerus fractures among elderly patients, focusing on reverse total shoulder arthroplasty (TSA), and evaluated how the type of fixation affects inpatient factors (cost, length of stay), transfusion rates, and patient disposition (home vs skilled nursing facility). With Nationwide Inpatient Sample data from 2011 to 2013, the authors identified patients 65 years and older who had proximal humerus fractures and divided them into 3 groups: (1) open reduction and internal fixation (ORIF); (2) hemiarthroplasty; and (3) reverse TSA. From 2011 to 2013, 38,729 surgically treated proximal humerus fractures were identified. The rate of reverse TSA increased 1.8-fold during this time, from 13% of operative cases in 2011 to 24% of operative cases in 2013 (P<.001). At the same time, the rates of hemiarthroplasty and ORIF decreased (hemiarthroplasty, from 28% to 21%; ORIF, from 59% to 55%). Although reverse TSA accounted for 32.2% of arthroplasty procedures for proximal humerus fractures in 2011, this value was 53.3% in 2013 (P<.001). In 2013, mean total hospital cost for reverse TSA was $24,154, which was significantly higher than that for ORIF ($16,269) or hemiarthroplasty ($19,175) (P<.001). In a multivariable model, patients undergoing reverse TSA were less likely than those undergoing hemiarthroplasty to be discharged to a skilled nursing facility (odds ratio, 0.75; P=.027). The national rate of reverse TSA nearly doubled from 2011 to 2013. As of 2013, reverse TSA replaced hemiarthroplasty as the most commonly performed arthroplasty procedure for proximal humerus fractures for patients 65 years and older. Patients undergoing reverse TSA were more likely than those undergoing hemiarthroplasty to be discharged home. [Orthopedics. 2017; 40(6):e982–e989.]

Abstract

This study described surgical treatment patterns for proximal humerus fractures among elderly patients, focusing on reverse total shoulder arthroplasty (TSA), and evaluated how the type of fixation affects inpatient factors (cost, length of stay), transfusion rates, and patient disposition (home vs skilled nursing facility). With Nationwide Inpatient Sample data from 2011 to 2013, the authors identified patients 65 years and older who had proximal humerus fractures and divided them into 3 groups: (1) open reduction and internal fixation (ORIF); (2) hemiarthroplasty; and (3) reverse TSA. From 2011 to 2013, 38,729 surgically treated proximal humerus fractures were identified. The rate of reverse TSA increased 1.8-fold during this time, from 13% of operative cases in 2011 to 24% of operative cases in 2013 (P<.001). At the same time, the rates of hemiarthroplasty and ORIF decreased (hemiarthroplasty, from 28% to 21%; ORIF, from 59% to 55%). Although reverse TSA accounted for 32.2% of arthroplasty procedures for proximal humerus fractures in 2011, this value was 53.3% in 2013 (P<.001). In 2013, mean total hospital cost for reverse TSA was $24,154, which was significantly higher than that for ORIF ($16,269) or hemiarthroplasty ($19,175) (P<.001). In a multivariable model, patients undergoing reverse TSA were less likely than those undergoing hemiarthroplasty to be discharged to a skilled nursing facility (odds ratio, 0.75; P=.027). The national rate of reverse TSA nearly doubled from 2011 to 2013. As of 2013, reverse TSA replaced hemiarthroplasty as the most commonly performed arthroplasty procedure for proximal humerus fractures for patients 65 years and older. Patients undergoing reverse TSA were more likely than those undergoing hemiarthroplasty to be discharged home. [Orthopedics. 2017; 40(6):e982–e989.]

Proximal humerus fractures are among the most common injuries among elderly patients and those with osteoporosis.1–3 Recent epidemiologic studies showed an increase in the incidence of proximal humerus fractures that may be associated with the aging population.3–5 As of 2005, proximal humerus fractures were the third most common osteoporotic fracture in the United States.6

The ideal management of proximal humerus fractures remains controversial. For most minimally displaced fractures and for patients who cannot tolerate surgery, nonoperative treatment is recommended. Surgical intervention is generally reserved for displaced, unstable, and complex fracture patterns.7 Generally, this treatment consists of open reduction and internal fixation (ORIF), hemiarthroplasty of the shoulder, total shoulder arthroplasty (TSA), and more recently, reverse TSA.7 The goal of surgical intervention is to provide the patient with a functional and pain-free shoulder.8–10

High complication rates associated with locking plate fixation of proximal humerus fractures in elderly patients led to the use of treatment alternatives. According to a recent systematic review, complication rates are as high as 48.8% for ORIF, with revision rates of 13.8%.8,11 These complications are especially problematic in elderly patients because osteoporotic bone is particularly prone to fixation failure after osteosynthesis.8,12 Hemiarthroplasty was introduced as a viable treatment alternative for displaced 3-or 4-part proximal humerus fractures and has had lower complication rates.8 Nevertheless, good functional outcomes after hemiarthroplasty depend on adequate tuberosity stability and fixation, and the most common early complication is tuberosity failure.1,13,14 In recent years, reverse TSA emerged as a possible alternative for proximal humerus fractures.13 In 2004, reverse TSA was approved in the United States, and it has emerged as a promising procedure for those with poor rotator cuff function because it relies on the deltoid muscle for active shoulder motion and less on rotator cuff function and tuberosity position.13 A recent Cochrane review comparing these 3 surgical options identified no significant differences.7

Since the introduction of the International Classification of Diseases, 9th Revision (ICD-9), code for reverse TSA in October 2010, only 1 study has reported national data on reverse TSA for fractures, but this study was limited to data from 2011 without a temporal evaluation of the use of reverse TSA.13 The current study reports national surgical treatment patterns for proximal humerus fractures in elderly patients from 2011 through 2013, with particular attention to the role of reverse TSA. Additionally, the authors analyzed patient and hospital characteristics as well as transfusion and skilled nursing facility discharge rates for patients undergoing ORIF, hemiarthroplasty, and reverse TSA. The authors hypothesized that the rate of reverse TSA for proximal humerus fractures has increased and that patients who undergo reverse TSA are less likely than those who undergo hemiarthroplasty to be discharged to a skilled nursing facility.

Materials and Methods

Data Set

The authors used the Nationwide Inpatient Sample (NIS)15 from 2011 to 2013 to perform an epidemiologic study of the surgical patterns for proximal humerus fractures among patients 65 years and older. The NIS is a national hospital administrative database that contains data from more than 44 states, representing more than 95% of the US population. In 2012, the NIS was redesigned to create more accurate national estimates.15,16

Patient Selection

Using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis and procedure codes, the authors identified all patients 65 years and older who had a proximal humerus fracture. The following ICD-9 diagnosis codes were used to identify proximal humerus fractures: 812.00, 812.01, 812.02, 812.09, 812.1, 812.10, 812.11, 812.12, and 812.19. To identify only primary acute proximal humerus fractures, the authors excluded patients with diagnoses of periprosthetic fracture or failure related to previous implants, with the following ICD-9 diagnosis codes: 996.4, 996.40, 996.41, 996.42, 996.43, 996.44, 996.45, 996.46, 996.47, and 996.49. Subsequently, 3 groups of operative patients were identified: (1) open/closed reduction internal fixation (ICD-9 codes 79.11 and 79.31); (2) hemiarthroplasty of the shoulder (ICD-9 code 81.81); and (3) reverse total shoulder arthroplasty (ICD-9 code 81.88).

Outcomes

The authors compared multiple patient and hospital characteristics for the different surgical groups, including median age, mean length of stay, mean hospital costs and charges, hospital type, and regional differences. Hospital costs were presented with cost-to-charge ratio files provided by the Healthcare Cost and Utilization Project: https://www.hcup-us.ahrq.gov/db/state/costtocharge.jsp. With multivariable analysis, the authors assessed the odds of transfusion and patient disposition (home vs skilled nursing facility) between the surgical groups. The details of the multivariable model are discussed later. Comorbidities were identified with Agency for Healthcare Research and Quality comorbidity software modeled on the Elixhauser algorithm.17

Statistical Analysis

Statistical analyses were performed with the survey sampling and analysis procedures (SURVEYFREQ, SURVEYMEANS, SURVEYLOGISTIC, SURVEYREG) of SAS version 9.4 software (SAS Institute, Cary, North Carolina). These analyses were performed to obtain appropriate point estimates, standard errors, confidence intervals, and P values. The survey sampling and analysis procedures consider clustering and incorporate NIS-provided weights to create national estimates.

Results for numeric variables (SURVEYMEANS) were summarized by mean and median. Results for categorical variables (SURVEYFREQ) were summarized by frequency and percent. Group differences on numeric variables were assessed for statistical significance with the SURVEYREG procedure. Group differences on categorical variables were assessed for statistical significance with the SURVEY-FREQ procedure (specifically, the Rao-Scott chi-square test).

Complications (transfusion or discharge to a skilled nursing facility) associated with surgery type (hemiarthroplasty vs ORIF, reverse TSA vs ORIF, reverse TSA vs hemiarthroplasty) were assessed with multivariable logistic regression models with SURVEYLOGISTIC, adjusting for age (≥80 years vs <80 years), sex, and smoking status, and their 2-way interactions, and all medical comorbidities (Elixhauser comorbidities). The Elix-hauser comorbidities were as follows: peripheral vascular disease, paralysis, other neurologic disorders, chronic pulmonary disease, diabetes mellitus, diabetes mellitus with chronic complications, hypothyroidism, renal failure, liver disease, peptic ulcer disease, acquired immune deficiency syndrome, lymphoma, metastatic cancer, solid tumor without metastasis, rheumatoid arthritis, coagulopathy, weight loss, fluid and electrolyte disorders, chronic blood loss anemia, iron deficiency anemia, alcohol abuse, drug abuse, psychoses, and hypertension. The following complications were modeled: (1) transfusion and (2) discharge to a skilled nursing facility or other subacute facility. For each complication, the main factor of interest was the type of surgery (hemiarthroplasty vs ORIF, reverse TSA vs ORIF, reverse TSA vs hemiarthroplasty). Adjusted odds ratio (OR) and 95% confidence interval (CI) values were reported. Significance was set at .05 throughout.

This study was deemed exempt by the institutional review board because it is not considered human subjects research.

Results

Nationwide Trends From 2011 to 2013

Of the 95,110 inpatient proximal humerus fractures identified from 2011 to 2013, a total of 38,729 (40.7%) were treated surgically (Table 1). The overall operative rate for inpatient proximal humerus fractures rose steadily from 39.4% in 2011 to 43.3% in 2013 (P<.001). The rate of reverse TSA procedures increased significantly from 13.2% of cases of operative proximal humerus fractures in 2011 to 23.9% in 2013 (P<.001) (Figure 1). During the same period, the rate of hemiarthroplasty procedures decreased from 27.8% to 20.8% (P<.001), and the rate of ORIF procedures decreased from 59% to 55.3% (P=.009). When reverse TSA was considered as a percentage of arthroplasty procedures performed for proximal humerus fractures, the rate of reverse TSA procedures increased from 32.2% of procedures in 2011 to 53.3% of procedures in 2013, and the rate of hemiarthroplasty procedures decreased from 62.1% of procedures in 2011 to 46.6% of procedures in 2013 (P<.001) (Figure 2). In 2013, for the first time, reverse TSA was more common than hemiarthroplasty for acute proximal humerus fractures in the United States.

Nationwide Trends in Surgical Management of Proximal Humerus Fractures From 2011 to 2013 for Patients 65 Years and Older

Table 1:

Nationwide Trends in Surgical Management of Proximal Humerus Fractures From 2011 to 2013 for Patients 65 Years and Older

National surgical trends by percentage of operative distal humerus fractures from 2011 to 2013. Abbreviations: HA, hemiarthroplasty; ORIF, open reduction and internal fixation; rTSA, reverse total shoulder arthroplasty.

Figure 1:

National surgical trends by percentage of operative distal humerus fractures from 2011 to 2013. Abbreviations: HA, hemiarthroplasty; ORIF, open reduction and internal fixation; rTSA, reverse total shoulder arthroplasty.

Percentage of arthroplasty procedures for proximal humerus fractures from 2011 to 2013. Abbreviations: HA, hemiarthroplasty; rTSA, reverse total shoulder arthroplasty.

Figure 2:

Percentage of arthroplasty procedures for proximal humerus fractures from 2011 to 2013. Abbreviations: HA, hemiarthroplasty; rTSA, reverse total shoulder arthroplasty.

Patient and Hospital Characteristics in 2013

Patient characteristics for operative proximal humerus fractures in 2013 are shown in Table 1, Table 2, and Table 3. Most patients who had operative proximal humerus fractures were women. The rate of reverse TSA was higher among women (24.7% in women vs 20.2% in men; P=.045) (Figure 3). In 2013, median patient age for reverse TSA was 76.9 years, which was higher than the median age of 75.2 years for ORIF (P=.0014). The use rate of reverse TSA for patients 80 years and older was significantly higher (25.9%) than the rate for patients 65 to 79 years old (22.6%) (P<.047) (Table 3). Mean length of stay was not significantly different among the 3 surgical groups in 2013 (approximately 4 days).

Patient and Hospital Characteristics for Operative Proximal Humerus Fractures in 2013 for Patients 65 Years and Older

Table 2:

Patient and Hospital Characteristics for Operative Proximal Humerus Fractures in 2013 for Patients 65 Years and Older

Rates of Reverse Total Shoulder Arthroplasty According to Patient and Hospital Characteristics

Table 3:

Rates of Reverse Total Shoulder Arthroplasty According to Patient and Hospital Characteristics

Rate of reverse total shoulder arthroplasty (rTSA) by sex in 2013. Abbreviations: HA, hemiarthroplasty; ORIF, open reduction and internal fixation.

Figure 3:

Rate of reverse total shoulder arthroplasty (rTSA) by sex in 2013. Abbreviations: HA, hemiarthroplasty; ORIF, open reduction and internal fixation.

In 2013, total hospital costs associated with reverse TSA were $7885 higher than those for ORIF (P<.001) and $4979 higher than those for hemiarthroplasty (P<.001) (Figure 4). This relationship was similar for total hospital charges. Charges for patient discharge after reverse TSA were $16,173 higher than those for hemiarthroplasty (P<.001) and $24,365 higher than those for ORIF (P<.001) (Figure 5). At teaching hospitals, 56.2% of patients underwent ORIF, 20.8% underwent hemiarthroplasty, and 23.0% underwent reverse TSA. The rate of reverse TSA was slightly higher at nonteaching hospitals (24.6% vs 23.0%), but this difference was not statistically significant (P=.431). Most reverse TSA procedures were performed at large hospitals. The rate of reverse TSA, however, was not significantly different between small and large hospitals (P=.380). Regarding hospital location by US census regions for 2013 (Northeast, Midwest, South, West), the current analysis showed different surgical patterns across regions (P=.011). Overall, the South had the highest volume of surgical procedures, which is consistent with previous studies with NIS data.18 The Midwest had the highest rate of reverse TSA procedures (27.8%), which was significantly higher than the rates of 21.1% in the Northeast (P=.026) and 19.5% in the West (P=.007) (Figure 6).

Mean hospital costs for open reduction and internal fixation (ORIF), hemiarthroplasty (HA), and reverse total shoulder arthroplasty (rTSA) in 2013 shown as box plots.

Figure 4:

Mean hospital costs for open reduction and internal fixation (ORIF), hemiarthroplasty (HA), and reverse total shoulder arthroplasty (rTSA) in 2013 shown as box plots.

Mean hospital charges for open reduction and internal fixation (ORIF), hemiarthroplasty (HA), and reverse total shoulder arthroplasty (rTSA) from 2011 to 2013.

Figure 5:

Mean hospital charges for open reduction and internal fixation (ORIF), hemiarthroplasty (HA), and reverse total shoulder arthroplasty (rTSA) from 2011 to 2013.

Rate of reverse total shoulder arthroplasty (TSA) by US region in 2013.

Figure 6:

Rate of reverse total shoulder arthroplasty (TSA) by US region in 2013.

Multivariable Analysis

Rates of blood transfusion and discharge to a skilled nursing facility after ORIF, hemiarthroplasty, and reverse TSA are shown in Table 4. Table 5 shows the multivariable analysis used to compare the odds of (1) transfusion and (2) patient disposition (skilled nursing facility vs home) after adjustment for age, sex, and significant comorbidities. The current analysis found that patients who had hemiarthroplasty were more likely to receive a transfusion vs those who had ORIF (OR, 1.28; 95% CI, 0.99–1.66; P=.057). No significantly different odds of transfusion were identified between patients undergoing reverse TSA and those undergoing either ORIF (P=.190) or hemiarthroplasty (P=.601). Patients undergoing reverse TSA were significantly less likely to be discharged to a skilled nursing facility compared with those undergoing hemiarthroplasty (OR, 0.75; 95% CI, 0.57–0.97; P=.027). Additionally, patients undergoing hemiarthroplasty were more likely to be discharged to a skilled nursing facility compared with those undergoing ORIF (OR, 1.28; 95% CI, 1.03–1.59; P=.028).

Rates of Transfusion and Discharge to a Skilled Nursing Facility in 2013

Table 4:

Rates of Transfusion and Discharge to a Skilled Nursing Facility in 2013

Multivariable Logistic Regression Models in 2013a

Table 5:

Multivariable Logistic Regression Models in 2013

Discussion

This study identified a large shift in the surgical management of proximal humerus fractures among elderly patients. The overall inpatient operative rate for proximal humerus fractures in elderly patients increased from 39.4% in 2011 to 43.4% 2013, suggesting that surgery is being performed more often nationally. The national rate of reverse TSA has nearly doubled as a treatment option for proximal humerus fractures in elderly patients. Reverse TSA replaced hemiarthroplasty as the most commonly performed type of arthroplasty for proximal humerus fractures in 2013, representing 53% of arthroplasty procedures that year. This is a significant change and is vastly different from the findings of a recent study reporting reverse TSA (for all patient ages) for only 25% of arthroplasty procedures for fractures in 2011.13 The increased rate of reverse TSA for proximal humerus fractures may be attributed to several factors. Multiple studies showed that reverse TSA is associated with higher functional improvement scores compared with hemiarthroplasty, most notably with forward flexion.1,13,14,19–22 Additionally, the high complication and revision rates associated with ORIF for elderly patients led to the need for better surgical alternatives. Although hemiarthroplasty obviates some concerns about fixation in osteoporotic bone, tuberosity healing can be unpredictable and is a critical factor for good functional outcome. Moreover, reverse TSA as a salvage procedure after unsuccessful ORIF has a significantly higher overall complication rate, making reverse TSA more desirable as a primary procedure.23

Despite the trend toward increasing use of reverse TSA, there is still concern about long-term outcomes because this procedure was approved by the US FDA fairly recently, in 2004. Risks of reverse TSA include hematoma formation, scapular notching, loosening of the glenoid component, instability, and component dissociation.24 These complications have led to concerns about implant longevity and long-term functional results. A study of reverse TSA for proximal humerus fractures among elderly patients with a mean 6.6-year follow-up reported radiologic evidence of loosening of the glenoid component among 63% of patients.25 This was followed by reflex sympathetic dystrophy among 5.5% of patients. Other complications included include scapular notching, glenoid loosening, and component instability. Overall complication rates have broadly ranged from 5% to 40%.20,21,26 Revision rates for reverse TSA for proximal humerus fractures are reported as 1% to 15%.20,21,26,27 Ideally, the increasing use of reverse TSA for proximal humerus fractures will facilitate larger longitudinal studies to address these concerns.

Although hospital costs did not increase over the 3-year study period, the authors identified increases in hospital charges for all 3 procedures. These findings are in line with charges reported for other orthopedic national data set studies.28–30 Hospital charges may have increased to compensate for decreased reimbursement rates from private insurance companies as well as Medicare and Medicaid. It is possible that the push for greater cost transparency in health care will counter these charge increases on multiple levels.31 In 2013, mean cost and charges for reverse TSA were significantly higher than those for both ORIF and hemiarthroplasty. Although the current study was limited by the inclusion of costs associated with hospital stay only, a 2014 study with longer follow-up comparing these 3 procedures found that reverse TSA provides significant cost savings to the system.19 This study evaluated the combined costs of implants, postoperative care, and physical therapy visits and concluded that reverse TSA was significantly less costly to Medicare.

Limitations

The current study had several limitations. Because the NIS provides information only for the short inpatient stay, the current study did not include long-term follow-up, functional outcomes, and most surgical complications that arise after discharge. Therefore, the study is limited in its ability to evaluate true long-term morbidity and the cost of these interventions. These factors would be better evaluated with longitudinal studies. Another limitation is the retrospective nature of the study, which makes it difficult to fully evaluate patient characteristics or control for patient selection. Additionally, this type of study is subject to selection bias because fracture patterns and patient factors affect surgical treatment. Reliance on collecting data based on ICD-9 diagnosis codes inherently excludes miscoded patients, whether included incorrectly or excluded unintentionally as a result of limited ICD-9 codes. Errors in hospital billing data collection, whether human or technical, cannot be evaluated. Moreover, it is not possible to identify reporting bias or financial bias that is reported to exist in large database studies.32 Despite these limitations, the strength of the study lies in its large database of recent data. The NIS has been widely used in peer-reviewed journals and is considered a very reliable source of information.28–30,33

Conclusion

In 2013, reverse TSA replaced hemiarthroplasty as the most commonly performed arthroplasty procedure for proximal humerus fractures in elderly patients. The increase in the rate of reverse TSA is in line with a recent push toward a “one and done” approach among the orthopedic community for complex periarticular fractures in elderly patients.34 This study found that patients undergoing reverse TSA had higher inpatient hospital costs and charges compared with those undergoing ORIF and hemiarthroplasty. Interestingly, through a multivariable model, the authors found that patients undergoing reverse TSA had significantly decreased odds of discharge to a skilled nursing facility compared with those undergoing hemiarthroplasty. This decrease in the use of a skilled nursing facility may represent an overall cost savings that must be analyzed further. Data from a 2017 study focusing on postdischarge costs for patients undergoing total hip arthroplasty found that the cost for a skilled nursing facility was approximately $8400 greater than that for patients discharged to home.35 Future studies of inpatient and postdischarge costs are needed. This study represents current national trends, and long-term studies are needed to investigate the long-term outcomes of these 3 procedures for proximal humerus fractures in elderly patients.

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Nationwide Trends in Surgical Management of Proximal Humerus Fractures From 2011 to 2013 for Patients 65 Years and Older

Group201120122013
All fractures, No.33,60531,05530,450
  Operative fractures, No.13,239 (39.4%)12,320 (40%)13,170 (43.3%)
Open reduction and internal fixation, No.7811 (59%)7060 (57.3%)7280 (55.3%)
  Age, median (SE), y76.8 (0.37)76.1 (0.32)75.3 (0.39)
  Length of stay, mean (SE), d4.3 (0.09)4.2 (0.09)4.3 (0.08)
  Charges, mean (SE), $55,391 (1711)57,460 (1356)61,770 (1303)
  Costs, mean (SE), $17,355 (470)15,618 (305)16,269 (278)
Hemiarthroplasty, No.3680 (27.8%)3095 (25.1%)2745 (20.8%)
  Age, median (SE), y76.8 (0.45)75.9 (0.46)76.3 (0.45)
  Length of stay, mean (SE), d4.6 (0.13)4.57 (0.14)4.12 (0.13)
  Charges, mean (SE), $66,391 (2316)69,296 (1867)69,962 (2011)
  Costs, mean (SE), $21,019 (552)19,315 (412)19,175 (436)
Reverse total shoulder arthroplasty, No.1748 (13.2%)2165 (17.6%)3145 (23.9%)
  Age, median (SE), y77.3 (0.62)76.6 (0.41)76.9 (0.39)
  Length of stay, mean (SE), d4.1 (0.18)4.11 (0.16)4.03 (0.13)
  Charges, mean (SE), $76,715 (3745)83,986 (2777)86,135 (2280)
  Costs, mean (SE), $26,608 (1173)23,924 (664)24,154 (611)

Patient and Hospital Characteristics for Operative Proximal Humerus Fractures in 2013 for Patients 65 Years and Older

CharacteristicNo.Pb

Open Reduction and Internal FixationaHemiarthroplastyaReverse Total Shoulder Arthroplastya
Total7280 (55.3%)2745 (20.8%)3145 (23.9%)
Sex
  Male1385 (19.0%, 60.1%)455 (16.6%, 19.7%)465 (14.8%, 20.2%).057
  Female5894 (80.9%, 54.3%)2290 (83.4%, 21.1%)2680 (85.2%, 24.7%)
Age distribution.038
  65–79 y4720 (64.8%, 57.1%)1675 (61.0%, 20.3%)1870 (59.5%, 22.6%)
  ≥80 y2560 (35.2%, 52.2%)1070 (38.9%, 21.8%)1275 (40.5%, 25.9%)
Hospital type.671
  Nonteaching4015 (55.2%, 54.5%)1540 (56.1%, 20.9%)1810 (57.6%, 24.6%)
  Teaching3265 (44.8%, 56.2%)1205 (43.9%, 20.8%)1335 (42.4%, 23.0%)
Hospital size.101
  Small/medium2820 (38.7%, 52.6%)1205 (43.9%, 22.5%)1335 (42.5%, 24.9%)
  Largec4460 (61.3%, 57.1%)1540 (56.1%, 19.7%)1810 (57.5%, 23.2%)
Hospital region.011
  Northeast1185 (16.3%, 54.4%)535 (19.5%, 24.5%)460 (14.6%, 21.1%)
  Midwest1505 (20.7%, 52.4%)565 (20.6%, 19.7%)800 (25.4%, 27.8%)
  South3160 (43.4%, 56.6%)1035 (37.7%, 18.5%)1390 (44.2%, 24.9%)
  West1430 (19.6%, 56.4%)610 (22.2%, 24.1%)495 (15.7%, 19.5%)

Rates of Reverse Total Shoulder Arthroplasty According to Patient and Hospital Characteristics

CharacteristicReverse Total Shoulder Arthroplasty, No.Pa
Sex.045
  Male465 (20.2%)
  Female2680 (24.7%)
Age.047
  65–79 y1870 (22.6%)
  ≥80 y1275 (25.9%)
Hospital type.431
  Nonteaching1810 (24.6%)
  Teaching1335 (23.0%)
Hospital size.380
  Small/medium1335 (24.9%)
  Largeb1810 (23.2%)
Hospital region.024
  Northeast460 (21.1%)
  Midwest800 (27.8%)
  South1390 (24.9%)
  West495 (19.5%)

Rates of Transfusion and Discharge to a Skilled Nursing Facility in 2013

ComplicationNo.Overall Pa

Open Reduction and Internal FixationHemiarthroplastyReverse Total Shoulder Arthroplasty
Transfusion1520 (20.9%)665 (24.2%)725 (23.1%).234
Discharge to skilled nursing facility3710 (51.0%)1505 (54.8%)1570 (49.9%).179

Multivariable Logistic Regression Models in 2013a

ComplicationHA vs ORIFrTSA vs ORIFrTSA vs HA



OR (95% CI)POR (95% CI)POR (95% CI)P
Transfusion1.28 (0.99–1.66).0571.19 (0.92–1.54).1900.93 (0.70–1.24).601
Discharge to skilled nursing facility1.28 (1.03–1.59).0280.95 (0.77–1.17).6510.75 (0.57–0.97).027
Authors

The authors are from Cedars-Sinai Medical Center, Los Angeles, California.

Dr Rajaee, Dr Yalamanchili, Dr Noori, Dr Debbi, Mr Mirocha, and Dr Lin have no relevant financial relationships to disclose. Dr Moon is a paid consultant for Stryker and Accumed and is on the speaker's bureau of Bone Support.

Correspondence should be addressed to: Sean S. Rajaee, MD, Cedars-Sinai Medical Center, 444 S San Vicente Blvd, #603, Los Angeles, CA 90048 ( seanrajaee@gmail.com).

Received: April 25, 2017
Accepted: August 08, 2017
Posted Online: October 03, 2017

10.3928/01477447-20170925-01

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