HIP
Can the use of an evidence-based algorithm for the treatment of intertrochanteric fractures of the hip maintain quality at a reduced cost? K. A. Egol, A. I. Marcano, L. Lewis, N. C. Tejwani, T. M. McLaurin, R. I. Davidovitch From NYU Hospital for Joint Diseases, New York and Jamaica Hospital Medical Center, Jamaica, New York, United States
In March 2012, an algorithm for the treatment of intertrochanteric fractures of the hip was introduced in our academic department of Orthopaedic Surgery. It included the use of specified implants for particular patterns of fracture. In this cohort study, 102 consecutive patients presenting with an intertrochanteric fracture were followed prospectively (postalgorithm group). Another 117 consecutive patients who had been treated immediately prior to the implementation of the algorithm were identified retrospectively as a control group (pre-algorithm group). The total cost of the implants prior to implementation of the algorithm was $357 457 (mean: $3055 (1947 to 4133)); compared with $255 120 (mean: $2501 (1052 to 4133)) after its implementation. There was a trend toward fewer complications in patients who were treated using the algorithm (33% pre- versus 22.5% post-algorithm; p = 0.088). Application of the algorithm to the pre-algorithm group revealed a potential overall cost saving of $70 295. The implementation of an evidence-based algorithm for the treatment of intertrochanteric fractures reduced costs while maintaining quality of care with a lower rate of complications and re-admissions. Cite this article: Bone Joint J 2014;96-B:1192–7.
K. A. Egol, MD, Professor and Vice Chair N. C. Tejwani, MD, Orthopaedic Surgeon, Professor T. M. McLaurin, MD, Orthopaedic Surgeon, Associate Professor NYU Hospital for Joint Diseases, Department of Orthopaedic Surgery, 301 East 17th Street, New York, New York 10003, USA. A. I. Marcano, MD, Research Associate R. I. Davidovitch, MD, Orthopaedic Surgeon, Assistant Professor NYU Hospital for Joint Diseases, 301 East 17th Street, New York, New York 10003, USA. L. Lewis, BS, Medical Student Upstate Medical School, Syracuse, New York, New York 13210, USA. Correspondence should be sent to Dr K. A. Egol; e-mail: [email protected] ©2014 The British Editorial Society of Bone & Joint Surgery doi:10.1302/0301-620X.96B9. 34153 $2.00 Bone Joint J 2014;96-B:1192–7. Received 23 March 2014; Accepted after revision 27 May 2014
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A fracture of the hip is a common cause of disability in the elderly.1 In the United States, more than 300 000 patients are admitted to hospital as a result of a fracture of the hip each year,2 and this incidence continues to rise as the population ages.3 Fractures of the hip have a great impact on quality of life, and are a major source of healthcare expenditure.4,5 Although they comprise only 14% of all fractures occurring in the elderly, they account for 72% of the costs of the management of fractures in this age group.6 Fractures of the hip resulted in a total healthcare spending of $15 billion in 2008, with the mean cost per patient being $40 000 in the first year followed by nearly $5000 per year thereafter.6-8 Intertrochanteric fractures account for nearly half of fractures of the hip.9 They are treated using either extramedullary or intramedullary fixation. The most widely used extramedullary device is the sliding hip screw (SHS), which is an established and inexpensive implant. Intramedullary fixation uses cephalomedullary nails (CMN) which may be either short or long. There is evidence suggesting that intertrochanteric fractures with subtrochanteric extension are best treated with the use of a long nail,10,11 which may confer the additional advantage of protecting the patient against a fracture of the femoral shaft
in the future. These implants vary in price, with increasing length corresponding to increased cost. Clinical studies comparing plate and screw implants with intramedullary fixation have reported contradictory results.12-14 The CMN has a biomechanical advantage over the SHS. As the implant is placed within the medullary canal, it is closer to the weight-bearing axis of the femur. By providing a shorter lever arm, this design minimises the forces that act to displace the fracture during healing.15 Some studies have suggested that fixation with a CMN provides superior outcomes in certain subsets of fractures, particularly those that are unstable, such as fractures with lateral wall or posteromedial comminution (OTA 31-A2.1 and 31-A2.216), fractures with reverse obliquity and those extending into the femoral neck or subtrochanteric regions (OTA 31-A2.3, 31-A3.1, 31-A3.2, 31-A3.3) (Fig. 1).10,11,15,17 These types are believed to be poorly controlled by the SHS device, and have a slightly higher rate of failure of fixation when treated with that type of implant.12,15 Nevertheless, no level 1 study has demonstrated superior results for CMNs in any fracture pattern, and this topic remains controversial. In most centres, the selection of the method of fixation remains at the surgeon’s discretion. THE BONE & JOINT JOURNAL
CAN USE OF AN EVIDENCE-BASED ALGORITHM TO TREAT INTERTROCHANTERIC HIP FRACTURES MAINTAIN QUALITY AT A REDUCED COST? 1193
would result in substantial cost savings to the institution and the healthcare system without reducing the quality of care.
Along intertrochanteric line (31-A1.1)
Through the greater trochanter (31-A1.2)
With 1 intermediate fragment (31-A2.1)
With several intermediate fragments (31-A2.2)
Simple oblique (31-A3.1)
Simple transverse (31-A3.2)
Below the lesser trochanter (31-A1.3)
Extending more than 1 cm below lesser trochanter (31-A2.3)
Multifragmentary (31-A3.3)
Fig. 1 Line drawings showing type 31-A intertrochanteric (IT) fractures according to the Orthopaedic Trauma Association.16 All 31-A1 are simple and stable, 31-A2 are multi-fragmentary and always have a posteromedial fragment. A2.1 (lesser trochanter), A2.2 (several posteromedial fragments including detachment of the lesser trochanter), and A2.3 (several posteromedial fragments extending below the lesser trochanter). 31-A3 IT fractures have a fracture line between both trochanters through the lateral femoral wall.
Despite a lack of evidence, there has been a major shift in fixation from extramedullary to intramedullary implants. A recent review of the American Board of Orthopaedic Surgery Database has demonstrated a major increase in the number of intertrochanteric fractures being treated using CMNs over a brief period of time (1999 to 2006), especially among younger surgeons. This has resulted in higher costs, with no improvement in outcome.12 Taking into account the already high cost of the management of these patients, this suggests that surgeons may be incurring unnecessary costs by the preferential use of intramedullary devices. The objective of this study was to compare the cost of treatment of intertrochanteric fractures before and after implementing an evidence-based classification-based algorithm for the selection of the method of fixation to be used. Our hypothesis was that the use of such a strategy VOL. 96-B, No. 9, SEPTEMBER 2014
Patients and Methods The trauma registry of our University-based Orthopaedic department was reviewed to identify patients with an intertrochanteric fracture that presented between May 2011 and November 2012. Patients who were aged > 18 years, with no restrictions based on race, religion, gender or ethnic origin, who were treated with either a SHS or a short or long CMN were included in the study. Patients with pathological fractures (other than those caused by osteoporosis), previous proximal femoral fractures, ipsilateral diaphyseal femoral fractures, and multiple fractures or injuries were excluded. This study had ethical approval. The medical records (inpatient/outpatient notes, operative notes, and all radiographs) were reviewed retrospectively. Patient demographics, type of fracture according to the Orthopaedic Trauma Association (OTA) classification,16 type of fixation used, and peri-operative complications and re-admissions were recorded. In March 2012, as part of a hospital-wide quality initiative, an evidence-based algorithm for the management of intertrochanteric fractures was introduced at our institution (Fig. 2). This was intended to determine the optimal method of fixation for each type of fracture to ensure standardised, cost-effective treatment. While the treating surgeon was allowed to choose a less expensive implant than prescribed by the algorithm if they felt it was warranted, they were not allowed to select a more expensive implant than that deemed appropriate for the fracture. No other aspects of treatment were changed. Patients were classified into two groups based on whether they presented before or after the implementation of the algorithm. The post-algorithm group consisted of 103 consecutive patients who were treated between March and November 2012. One patient was excluded from this analysis because the fracture was pathological due to metastasis and was treated with a long CMN despite having a stable pattern; the remaining 102 patients formed the treatment group and were prospectively analysed. The prealgorithm group consisted of 117 consecutive patients who were treated between May 2011 and March 2012. These were retrospectively analysed as a comparison group. SHS or CMN implants of a number of manufacturers were used at the discretion of the treating surgeon (either Synthes, Paoli, Philadelphia; Zimmer, Warsaw, Indiana; Biomet, Warsaw, Indiana or Stryker, Mahwah, New Jersey) as long as they fell within our institutions pricing guidelines. A distal interlocking screw was required for all short CMNs but was used at the discretion of the surgeon for long CMNs. All procedures were performed either by an American Board of Surgery certified surgeon or under their direct supervision. All surgeons used similar techniques and all patients were allowed to fully weight-bear as tolerated post-operatively.
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K. A. EGOL, A. I. MARCANO, L. LEWIS, N. C. TEJWANI, T. M. MCLAURIN, R. I. DAVIDOVITCH
Intertrochanteric hip fractures
Stable
Unstable
Intact posteromedial cortex (with or without isolated lesser trochanter fracture) (31A1.1, 31A1.2, 31A1.3)
Large posteromedial fragment (31A2.1, 31A2.2)
Reverse obliquity pattern or subtrochanteric extension (31A2.3, 31A3.1, 31A3.2, 31A3.3)
Sliding hip screw
Short cephalomedullary nail
Long cephalomedullary nail
2-4 hole sideplate
Distal interlocking screw required Fig. 2
Flow diagram showing the intertrochanteric hip fracture evidence-based algorithm for implant selection according to the American Orthopaedic/Orthopaedic Trauma Association Classification of Fractures.
Table I. Comparison of demographic data between groups
Mean age (yrs) Gender Race (%)
Fractured side (%)
Male Female Caucasian African American Hispanic Asian Other Right Left
Pre-algorithm
Post-algorithm
p-value
78.8 25 92 77 7 9 3 4 58 42
77.7 34 68 77 9 10 2 2 49 51
0.563 0.049
The two groups were compared to determine if there were any significant differences regarding gender, age or type of fracture. Costs were determined by assigning current prices obtained directly from the implant company’s lists. In order to quantify the potential savings associated with the use of the algorithm, the radiographs from the prealgorithm group were reviewed and the classification-based algorithm for the selection of the type of implant was applied. The costs of the suggested implants were then compared with the costs of the actual implant used. Statistical analysis. Descriptive statistical analyses were used for patient population and outcome of treatment. The Fisher’s exact test, Chi-square test, Student's t-test or Mann-Whitney U test were applied to analyses using SPSS v.20.0 (SPSS Inc., Chicago, Illinois) as appropriate. Statistical significance was defined as p ≤ 0.05. Values were reported as mean with standard deviations (SD) or percentages where appropriate.
0.790
0.178
Results A total of 219 consecutive patients were analysed. There were no differences between the pre- and post-algorithm groups with respect to age or type of fracture, and only small differences in gender (Table I). There were 89 (40.6%) stable fractures (type 31-A1) and 130 (59.4%) unstable fractures, of which 84 (38.4% of the total) had a large posteromedial fragment (types 31-A2.1 and 31-A2.2) and 46 (21% of the total) had a reverse obliquity or a subtrochanteric extension (types 31-A2.3 and 31-A3) (Fig. 3). The distribution was similar between the two groups (p = 0.895). A total of 32 patients (27.4%) in the pre-algorithm group were treated with a SHS, 24 (20.5%) with a short CMN, and 61 (52.1%) with a long CMN. These proportions were significantly different when compared with the post-algorithm group made up of 102 patients (p < 0.001), where 41 (40.2%) were treated with a SHS, 35 (34.3%) a short CMN, and 26 (25.5%) a long CMN (Table II). In the pre-algorithm group, 49 patients (41.9%) received a THE BONE & JOINT JOURNAL
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$4500
†
$4000 $3500
*
$3000
†
Pre-algorithm Post-algorithm Hypothetical pre-algorithm *
$2500
†
$2000 $1500
*
$1000
†
$500 $0 Stable
Unstable 1 Unstable 2
Total
Fig. 3 Histogram showing the comparison of costs among groups and fracture types. Unstable 1, refers to unstable fractures with large posteromedial fragments; Unstable 2, refers to unstable fractures with reverse obliquity pattern or subtrochanteric extension. *Statistically significant difference between pre- and post-algorithm groups (p ≤ 0.05), Mann-Whitney U test. †Statistically significant difference between pre-algorithm and hypothetical pre-algorithm groups (p ≤ 0.05), Mann-Whitney U test.
Table II. Implant choices and costs divided by Orthopaedic Trauma Association fracture types Pre-algorithm* SHS Stable
OTA 31-A1.1 OTA 31-A1.2 OTA 31-A1.3 Stable total
N 18 7 0 25
Unstable OTA 31-A2.1 1 OTA 31-A2.2 6 Unstable 1† 7 total
Post-algorithm Average cost
SHS
Short CMN Long CMN
Total
% 24.5 12.7 1.0 38.2
N 1 1 0 2
% 1.0 1.0 0.0 2.0
N 1 0 0 1
% 1.0 0.0 0.0 1.0
N 27 14 1 42
% 26.5 13.7 1.% 41.2
$1238.20‡ $1190.61‡ $1052.50 $1217.92‡
Short CMN
Long CMN
Total
% 15.4 6.0 0.0 21.4
N 5 3 0 8
% 4.3 2.6 0.0 6.8
N 5 8 1 14
% 4.3 6.8 0.9 12.0
N 18 15 1 34
% 23.9 15.4 0.9 40.2
$1947.86 $2743.86 $4133.00 $2299.20
N 25 13 1 39
0.9 5.1 6.0
1 10 11
0.9 8.5 9.4
10 17 27
8.5 14.5 23.1
9 30 39
10.3 28.2 38.5
$3780.71 $3225.33 $3373.43
2 0 2
2.0 0.0 2.0
7 22 29
6.9 2 21.6 6 28.4 8
2.0 5.9 7.8
11 28 39
10.8 27.5 38.2
$2843.00‡ $3231.79 $3122.13‡
0 2 0 2 4
0.0 2.0 0.0 2.0 3.9
6.9 4.9 0.0 4.9 16.7
7 7 0 7 21
6.9 6.9 0.0 6.9 20.6
$4133.00 $3805.29 N/A $3805.29 $3914.52
100.0
$2501.18‡
OTA 31-A2.3 OTA 31-A3.1 OTA 31-A3.2 OTA 31-A3.3 Unstable 2† total
0 0 0 0 0
0.0 0.0 0.0 0.0 0.0
4 1 0 0 5
3.4 0.9 0.0 0.0 4.3
6 3 2 9 20
5.1 2.6 1.7 7.7 17.1
8 4 2 8 22
8.5 3.4 1.7 7.7 21.4
$3674.20 $3846.25 $4133.00 $4133.00 $3903.60
0 0 0 0 0
0.0 0.0 0.0 0.0 0.0
Total
32
27.4
24
20.5
61
52.1
95
100.0
$3055.19
41
40.2 35
7 5 0 5 17
34.3 26
25.5 102
Average cost
* SHS, sliding hip screw; CMN, cephalomedullary nails † Unstable 1 refers to unstable fractures with large posteromedial fragments; Unstable 2 refers to unstable fractures with reverse obliquity pattern or subtrochanteric extension ‡ Statistically significant difference (p ≤ 0.05), Mann-Whitney U test
different implant than that recommended by the algorithm. In the post-algorithm group, only 11 patients (10.8%) received a different implant than recommended, accounting for 89% compliance with the implant protocol. This difference was statistically significant (p < 0.001). The reasons for deviation from the protocol in the post-algorithm group included: misclassification of the fracture, suspicion of subtrochanteric involvement and matching a contralateral implant from previous hip surgery. After assigning current implant prices to the type of implant which was used, the pre-algorithm group yielded a total cost VOL. 96-B, No. 9, SEPTEMBER 2014
of $357 457 and a mean cost of $3055 (SD 1310.84) per patient; while the post-algorithm group’s total cost was $255 120 and the mean cost was $2501 (SD 1272.35). This difference was statistically significant (p = 0.001). The implementation of this algorithm saved our hospitals about $554 per patient; a mean of $1081.28 for stable fractures (OTA 31-A1), and a mean of $251 for unstable fractures with a large posteromedial fragment (OTA 31-A2.1 and 31-A2.2). Unstable fractures with a reverse obliquity or subtrochanteric extension (OTA 31-A2.3 and 31-A3) had similar total costs and did not produce any significant savings (p = 0.936).
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Table III. Peri-operative complications, deaths and re-admissions Pre-algorithm
Post-algorithm
p-value
Cardiopulmonary Infection* DVT/PE Other† None
N 10 26 9 8 75
% 8.9 23.2 8.0 7.1 67
N 8 15 2 3 78
% 7.8 14.7 2 2.9 76.5
0.775 0.114 0.044‡ 0.164 0.124
Total patients with complications
37
33
23
23.5
0.124
Deaths
5
4.5
5
4.9
0.880
Re-admissions
8
6.8
7
6.9
0.994
* Infections included: urinary tract infections (pre-algorithm: 11; post-algorithm: 9), pneumonia (pre-algorithm: 8; post-algorithm: 3), surgical wound infections (pre-algorithm: 5; post-algorithm: 1), sepsis (pre-algorithm: 2; post-algorithm: 2) † Other complications included: pressure ulcers (pre-algorithm: 3; post-algorithm: 1), hematomas (pre-algorithm: 2, pre-algorithm: 1), GI (pre-algorithm: 1, pre-algorithm: 1), renal (pre-algorithm: 2), peri-prosthetic fracture (pre-algorithm: 1) ‡ Statistically significant difference (p ≤ 0.05); Chi squared test
When the classification-based algorithm was applied retrospectively to the pre-algorithm group, significant theoretical cost-savings were demonstrated. Actual mean costs in the pre-algorithm group were significantly higher than they would have been had the algorithm been applied ($3055 versus $2454; p < 0.001), resulting in a $70 294 potential saving overall (equating to $601 per case). This was made up of a mean potential saving of $1246.70 per stable fracture (OTA 31-A1) and a mean potential saving of $387.43 per unstable fracture with a large posteromedial fragment (OTA 31-A2.1 and 31-A2.2). As the more expensive long CMN was used as standard in unstable fractures with reverse obliquity or subtrochanteric extension (OTA 31-A2.3, 31-A3.1, 31-A3.2 and 31-A3.3), costs would have been significantly higher in this group had the algorithm been applied (p = 0.02). However, as this group was relatively small, this made little difference to the overall costs. While there were fewer peri-operative complications in the post-algorithm group (n = 23, 23%) compared with the pre-algorithm (n = 37, 33%), this did not reach statistical significance (p = 0.088). The post-algorithm group had significantly fewer episodes of deep vein thrombosis and pulmonary embolism (p = 0.044; Table III). The rate of readmission was similar in the two groups (Table III).
Discussion These results demonstrate that the introduction of an evidence-based algorithm for the selection of the method of fixation reduced the costs of management in patients with an intertrochanteric fracture of the hip. Retrospective application of the algorithm to cases prior to its introduction demonstrated significant cost savings. Individually, differences in price for different types of fracture demonstrate the impact of the indiscriminate use of CMNs on total costs. Our protocol reduced the use of CMNs by stipulating clear indications for their use and consequently reducing the costs.
The use of CMNs has increased from 1998 to 2006 and beyond, but its use has not decreased the peri-operative mortality or morbidity, nor has it improved functional outcomes compared with plate-and-screw devices in patients with an intertrochanteric fracture.12,18 This trend toward more frequent intramedullary fixation cannot be explained by patient-related factors, and is more prevalent amongst trainees and younger surgeons.19,20 This study demonstrates a similar trend in our institutions, with CMN devices used more frequently than SHS in all types of fracture prior to the implementation of the algorithm (85 CMN versus 32 SHS overall). This has been attributed to young surgeons’ preferential training in CMN procedures, and the fact that reimbursement is higher when more expensive devices are used.20 Our algorithm effectively addresses these issues by creating clear indications for the management of each type of intertrochanteric fracture, hence removing the effect of an individual surgeon’s preference and reimbursement in deciding what device to use. The high compliance observed in our institutions (89%) indicates that this algorithm could be widely and similarly implemented in other institutions. Because the selection of the implant relies mainly on the treating surgeon, our algorithm makes hospital programs in which profits are shared between the institution and the surgeon (and which are recognised as viable in orthopaedics21-23) more attractive to surgeons. By sharing the resulting savings and providing reimbursement for the surgeons who follow the algorithm, sharing programs could lessen industry’s influence and facilitate compliance with the protocol. Moreover, our protocol also addresses existing concerns of lower quality of care regarding sharing programs.21,22 This is achieved by providing an evidencebased method of selection of implants and demonstrating that fewer complications and re-admissions occurred in our patients with an intertrochanteric fracture following the implementation of the algorithm. THE BONE & JOINT JOURNAL
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The choice of implant for the management of these fractures remains controversial. The latest Cochrane review recommends the use of SHS for most fractures, but also states that CMNs may have advantages over plates for subtrochanteric and some unstable trochanteric fractures, although further studies are needed to clarify this.15 There is evidence to suggest that intertrochanteric fractures with subtrochanteric extension are treated best with a long CMN,10,11 and we have incorporated this recommendation into the algorithm. This algorithm was developed to address a valid cost-saving approach to the treatment of these fractures on the basis of the available evidence; if clearer clinical indications arise as a result of future studies, the algorithm may be modified. The change in practice proposed by the implementation of an evidence-based algorithm for the selection of the method of fixation in patients with an intertrochanteric fracture reduced costs in our institutions by 18% ($550) per case. This was largely as a result of a decrease in the use of CMNs. This change in practice maintained quality of care and did not result in more complications or worse outcomes. These cost savings are independent of any special pricing arrangements or institutional discounts that can also be arranged. This strategy has potential implications in programs in which profits are shared between surgeons and the institution. The adoption of similar algorithms may reduce costs in other institutions, and similar evidence-based algorithms may be applicable in the treatment of other fractures. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. This article was primary edited by A. D. Liddle and first proof edited by J. Scott.
References 1. Friedman SM, Mendelson DA. Epidemiology of fragility fractures. Clin Geriatr Med 2014;30:175–181. 2. No authors listed. National Hospital Discharge Survey (NHDS). Centers for Disease Control and Prevention, 2010. http://www.cdc.gov/nchs/nhds.htm (date last accessed 28 May 2014). 3. Richmond J, Aharonoff GB, Zuckerman JD, Koval KJ. Mortality risk after hip fracture. J Orthop Trauma 2003;17:53–56. 4. Haentjens P, Autier P, Barette M, Boonen S. The economic cost of hip fractures among elderly women: a one-year, prospective, observational cohort study with matched-pair analysis: Belgian Hip Fracture Study Group. J Bone Joint Surg [Am] 2001;83-A:493–500.
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5. Nikitovic M, Wodchis WP, Krahn MD, Cadarette SM. Direct health-care costs attributed to hip fractures among seniors: a matched cohort study. Osteoporosis Int 2013;24:659–669. 6. Burge R, Dawson-Hughes B, Solomon DH, et al. Incidence and economic burden of osteoporosis-related fractures in the United States, 2005-2025. J Bone Miner Res 2007;22:465–475. 7. Burge RT, King AB, Balda E, Worley D. Methodology for estimating current and future burden of osteoporosis in state populations: application to Florida in 2000 through 2025. Value Health 2003;6:574–583. 8. Tosteson AN, Burge RT, Marshall DA, Lindsay R. Therapies for treatment of osteoporosis in US women: cost-effectiveness and budget impact considerations. Am J Manag Care 2008;14:605–615. 9. Karagas MR, Lu-Yao GL, Barrett JA, Beach ML, Baron JA. Heterogeneity of hip fracture: age, race, sex, and geographic patterns of femoral neck and trochanteric fractures among the US elderly. Am J Epidemiol 1996;143:677–682. 10. Kregor PJ, Obremskey WT, Kreder HJ, Swiontkowski MF. Unstable pertrochanteric femoral fractures. J Orthop Trauma 2005;19:63–66. 11. Stern R. Are there advances in the treatment of extracapsular hip fractures in the elderly? Injury 2007;38(Suppl):S77–S87. 12. Anglen JO, Weinstein JN. Nail or plate fixation of intertrochanteric hip fractures: changing pattern of practice: a review of the American Board of Orthopaedic Surgery Database. J Bone Joint Surg [Am] 2008;90-A:700–707. 13. Butler M, Forte M, Kane RL, et al. Treatment of common hip fractures. Evid Rep Technol Assess (Full Rep) 20091–85. 14. Matre K, Vinje T, Havelin LI, et al. TRIGEN INTERTAN intramedullary nail versus sliding hip screw: a prospective, randomized multicenter study on pain, function, and complications in 684 patients with an intertrochanteric or subtrochanteric fracture and one year of follow-up. J Bone Joint Surg [Am] 2013;95-A:200–208. 15. Parker MJ, Handoll HH. Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures in adults. Cochrane Database Syst Rev 2010CD000093. 16. Marsh JL1, Slongo TF, Agel J, et al. Fracture and dislocation classification compendium - 2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma 2007;21(10 Suppl):S1–133. 17. Matre K, Havelin LI, Gjertsen JE, et al. Sliding hip screw versus IM nail in reverse oblique trochanteric and subtrochanteric fractures: a study of 2716 patients in the Norwegian Hip Fracture Register. Injury 2013;44:735–742. 18. Radcliff TA, Regan E, Cowper Ripley DC, Hutt E. Increased use of intramedullary nails for intertrochanteric proximal femoral fractures in veterans affairs hospitals: a comparative effectiveness study. J Bone Joint Surg [Am] 2012;94-A:833– 840. 19. Forte ML, Virnig BA, Kane RL, et al. Geographic variation in device use for intertrochanteric hip fractures. J Bone Joint Surg [Am] 2008;90-A:691–699. 20. Forte ML, Virnig BA, Eberly LE, et al. Provider factors associated with intramedullary nail use for intertrochanteric hip fractures. J Bone Joint Surg [Am] 2010;92A:1105–1114. 21. Dirschl DR, Goodroe J, Thornton DM, Eiland GW. AOA Symposium. Gainsharing in orthopaedics: passing fancy or wave of the future? J Bone Joint Surg [Am] 2007;89-A:2075–2083. 22. Healy WL. Gainsharing: a primer for orthopaedic surgeons. J Bone Joint Surg [Am] 2006;88-A:1880–1887. 23. Healy WL, Iorio R. Implant selection and cost for total joint arthroplasty: conflict between surgeons and hospitals. Clin Orthop Relat Res 2007;457:57–63.
Can the use of an evidence-based algorithm for the treatment of intertrochanteric fractures of the hip maintain quality at a reduced cost? K. A. Egol, A. I. Marcano, L. Lewis, N. C. Tejwani, T. M. McLaurin, R. I. Davidovitch From NYU Hospital for Joint Diseases, New York and Jamaica Hospital Medical Center, Jamaica, New York, United States
In March 2012, an algorithm for the treatment of intertrochanteric fractures of the hip was introduced in our academic department of Orthopaedic Surgery. It included the use of specified implants for particular patterns of fracture. In this cohort study, 102 consecutive patients presenting with an intertrochanteric fracture were followed prospectively (postalgorithm group). Another 117 consecutive patients who had been treated immediately prior to the implementation of the algorithm were identified retrospectively as a control group (pre-algorithm group). The total cost of the implants prior to implementation of the algorithm was $357 457 (mean: $3055 (1947 to 4133)); compared with $255 120 (mean: $2501 (1052 to 4133)) after its implementation. There was a trend toward fewer complications in patients who were treated using the algorithm (33% pre- versus 22.5% post-algorithm; p = 0.088). Application of the algorithm to the pre-algorithm group revealed a potential overall cost saving of $70 295. The implementation of an evidence-based algorithm for the treatment of intertrochanteric fractures reduced costs while maintaining quality of care with a lower rate of complications and re-admissions. Cite this article: Bone Joint J 2014;96-B:1192–7.
K. A. Egol, MD, Professor and Vice Chair N. C. Tejwani, MD, Orthopaedic Surgeon, Professor T. M. McLaurin, MD, Orthopaedic Surgeon, Associate Professor NYU Hospital for Joint Diseases, Department of Orthopaedic Surgery, 301 East 17th Street, New York, New York 10003, USA. A. I. Marcano, MD, Research Associate R. I. Davidovitch, MD, Orthopaedic Surgeon, Assistant Professor NYU Hospital for Joint Diseases, 301 East 17th Street, New York, New York 10003, USA. L. Lewis, BS, Medical Student Upstate Medical School, Syracuse, New York, New York 13210, USA. Correspondence should be sent to Dr K. A. Egol; e-mail: [email protected] ©2014 The British Editorial Society of Bone & Joint Surgery doi:10.1302/0301-620X.96B9. 34153 $2.00 Bone Joint J 2014;96-B:1192–7. Received 23 March 2014; Accepted after revision 27 May 2014
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A fracture of the hip is a common cause of disability in the elderly.1 In the United States, more than 300 000 patients are admitted to hospital as a result of a fracture of the hip each year,2 and this incidence continues to rise as the population ages.3 Fractures of the hip have a great impact on quality of life, and are a major source of healthcare expenditure.4,5 Although they comprise only 14% of all fractures occurring in the elderly, they account for 72% of the costs of the management of fractures in this age group.6 Fractures of the hip resulted in a total healthcare spending of $15 billion in 2008, with the mean cost per patient being $40 000 in the first year followed by nearly $5000 per year thereafter.6-8 Intertrochanteric fractures account for nearly half of fractures of the hip.9 They are treated using either extramedullary or intramedullary fixation. The most widely used extramedullary device is the sliding hip screw (SHS), which is an established and inexpensive implant. Intramedullary fixation uses cephalomedullary nails (CMN) which may be either short or long. There is evidence suggesting that intertrochanteric fractures with subtrochanteric extension are best treated with the use of a long nail,10,11 which may confer the additional advantage of protecting the patient against a fracture of the femoral shaft
in the future. These implants vary in price, with increasing length corresponding to increased cost. Clinical studies comparing plate and screw implants with intramedullary fixation have reported contradictory results.12-14 The CMN has a biomechanical advantage over the SHS. As the implant is placed within the medullary canal, it is closer to the weight-bearing axis of the femur. By providing a shorter lever arm, this design minimises the forces that act to displace the fracture during healing.15 Some studies have suggested that fixation with a CMN provides superior outcomes in certain subsets of fractures, particularly those that are unstable, such as fractures with lateral wall or posteromedial comminution (OTA 31-A2.1 and 31-A2.216), fractures with reverse obliquity and those extending into the femoral neck or subtrochanteric regions (OTA 31-A2.3, 31-A3.1, 31-A3.2, 31-A3.3) (Fig. 1).10,11,15,17 These types are believed to be poorly controlled by the SHS device, and have a slightly higher rate of failure of fixation when treated with that type of implant.12,15 Nevertheless, no level 1 study has demonstrated superior results for CMNs in any fracture pattern, and this topic remains controversial. In most centres, the selection of the method of fixation remains at the surgeon’s discretion. THE BONE & JOINT JOURNAL
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would result in substantial cost savings to the institution and the healthcare system without reducing the quality of care.
Along intertrochanteric line (31-A1.1)
Through the greater trochanter (31-A1.2)
With 1 intermediate fragment (31-A2.1)
With several intermediate fragments (31-A2.2)
Simple oblique (31-A3.1)
Simple transverse (31-A3.2)
Below the lesser trochanter (31-A1.3)
Extending more than 1 cm below lesser trochanter (31-A2.3)
Multifragmentary (31-A3.3)
Fig. 1 Line drawings showing type 31-A intertrochanteric (IT) fractures according to the Orthopaedic Trauma Association.16 All 31-A1 are simple and stable, 31-A2 are multi-fragmentary and always have a posteromedial fragment. A2.1 (lesser trochanter), A2.2 (several posteromedial fragments including detachment of the lesser trochanter), and A2.3 (several posteromedial fragments extending below the lesser trochanter). 31-A3 IT fractures have a fracture line between both trochanters through the lateral femoral wall.
Despite a lack of evidence, there has been a major shift in fixation from extramedullary to intramedullary implants. A recent review of the American Board of Orthopaedic Surgery Database has demonstrated a major increase in the number of intertrochanteric fractures being treated using CMNs over a brief period of time (1999 to 2006), especially among younger surgeons. This has resulted in higher costs, with no improvement in outcome.12 Taking into account the already high cost of the management of these patients, this suggests that surgeons may be incurring unnecessary costs by the preferential use of intramedullary devices. The objective of this study was to compare the cost of treatment of intertrochanteric fractures before and after implementing an evidence-based classification-based algorithm for the selection of the method of fixation to be used. Our hypothesis was that the use of such a strategy VOL. 96-B, No. 9, SEPTEMBER 2014
Patients and Methods The trauma registry of our University-based Orthopaedic department was reviewed to identify patients with an intertrochanteric fracture that presented between May 2011 and November 2012. Patients who were aged > 18 years, with no restrictions based on race, religion, gender or ethnic origin, who were treated with either a SHS or a short or long CMN were included in the study. Patients with pathological fractures (other than those caused by osteoporosis), previous proximal femoral fractures, ipsilateral diaphyseal femoral fractures, and multiple fractures or injuries were excluded. This study had ethical approval. The medical records (inpatient/outpatient notes, operative notes, and all radiographs) were reviewed retrospectively. Patient demographics, type of fracture according to the Orthopaedic Trauma Association (OTA) classification,16 type of fixation used, and peri-operative complications and re-admissions were recorded. In March 2012, as part of a hospital-wide quality initiative, an evidence-based algorithm for the management of intertrochanteric fractures was introduced at our institution (Fig. 2). This was intended to determine the optimal method of fixation for each type of fracture to ensure standardised, cost-effective treatment. While the treating surgeon was allowed to choose a less expensive implant than prescribed by the algorithm if they felt it was warranted, they were not allowed to select a more expensive implant than that deemed appropriate for the fracture. No other aspects of treatment were changed. Patients were classified into two groups based on whether they presented before or after the implementation of the algorithm. The post-algorithm group consisted of 103 consecutive patients who were treated between March and November 2012. One patient was excluded from this analysis because the fracture was pathological due to metastasis and was treated with a long CMN despite having a stable pattern; the remaining 102 patients formed the treatment group and were prospectively analysed. The prealgorithm group consisted of 117 consecutive patients who were treated between May 2011 and March 2012. These were retrospectively analysed as a comparison group. SHS or CMN implants of a number of manufacturers were used at the discretion of the treating surgeon (either Synthes, Paoli, Philadelphia; Zimmer, Warsaw, Indiana; Biomet, Warsaw, Indiana or Stryker, Mahwah, New Jersey) as long as they fell within our institutions pricing guidelines. A distal interlocking screw was required for all short CMNs but was used at the discretion of the surgeon for long CMNs. All procedures were performed either by an American Board of Surgery certified surgeon or under their direct supervision. All surgeons used similar techniques and all patients were allowed to fully weight-bear as tolerated post-operatively.
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K. A. EGOL, A. I. MARCANO, L. LEWIS, N. C. TEJWANI, T. M. MCLAURIN, R. I. DAVIDOVITCH
Intertrochanteric hip fractures
Stable
Unstable
Intact posteromedial cortex (with or without isolated lesser trochanter fracture) (31A1.1, 31A1.2, 31A1.3)
Large posteromedial fragment (31A2.1, 31A2.2)
Reverse obliquity pattern or subtrochanteric extension (31A2.3, 31A3.1, 31A3.2, 31A3.3)
Sliding hip screw
Short cephalomedullary nail
Long cephalomedullary nail
2-4 hole sideplate
Distal interlocking screw required Fig. 2
Flow diagram showing the intertrochanteric hip fracture evidence-based algorithm for implant selection according to the American Orthopaedic/Orthopaedic Trauma Association Classification of Fractures.
Table I. Comparison of demographic data between groups
Mean age (yrs) Gender Race (%)
Fractured side (%)
Male Female Caucasian African American Hispanic Asian Other Right Left
Pre-algorithm
Post-algorithm
p-value
78.8 25 92 77 7 9 3 4 58 42
77.7 34 68 77 9 10 2 2 49 51
0.563 0.049
The two groups were compared to determine if there were any significant differences regarding gender, age or type of fracture. Costs were determined by assigning current prices obtained directly from the implant company’s lists. In order to quantify the potential savings associated with the use of the algorithm, the radiographs from the prealgorithm group were reviewed and the classification-based algorithm for the selection of the type of implant was applied. The costs of the suggested implants were then compared with the costs of the actual implant used. Statistical analysis. Descriptive statistical analyses were used for patient population and outcome of treatment. The Fisher’s exact test, Chi-square test, Student's t-test or Mann-Whitney U test were applied to analyses using SPSS v.20.0 (SPSS Inc., Chicago, Illinois) as appropriate. Statistical significance was defined as p ≤ 0.05. Values were reported as mean with standard deviations (SD) or percentages where appropriate.
0.790
0.178
Results A total of 219 consecutive patients were analysed. There were no differences between the pre- and post-algorithm groups with respect to age or type of fracture, and only small differences in gender (Table I). There were 89 (40.6%) stable fractures (type 31-A1) and 130 (59.4%) unstable fractures, of which 84 (38.4% of the total) had a large posteromedial fragment (types 31-A2.1 and 31-A2.2) and 46 (21% of the total) had a reverse obliquity or a subtrochanteric extension (types 31-A2.3 and 31-A3) (Fig. 3). The distribution was similar between the two groups (p = 0.895). A total of 32 patients (27.4%) in the pre-algorithm group were treated with a SHS, 24 (20.5%) with a short CMN, and 61 (52.1%) with a long CMN. These proportions were significantly different when compared with the post-algorithm group made up of 102 patients (p < 0.001), where 41 (40.2%) were treated with a SHS, 35 (34.3%) a short CMN, and 26 (25.5%) a long CMN (Table II). In the pre-algorithm group, 49 patients (41.9%) received a THE BONE & JOINT JOURNAL
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$4500
†
$4000 $3500
*
$3000
†
Pre-algorithm Post-algorithm Hypothetical pre-algorithm *
$2500
†
$2000 $1500
*
$1000
†
$500 $0 Stable
Unstable 1 Unstable 2
Total
Fig. 3 Histogram showing the comparison of costs among groups and fracture types. Unstable 1, refers to unstable fractures with large posteromedial fragments; Unstable 2, refers to unstable fractures with reverse obliquity pattern or subtrochanteric extension. *Statistically significant difference between pre- and post-algorithm groups (p ≤ 0.05), Mann-Whitney U test. †Statistically significant difference between pre-algorithm and hypothetical pre-algorithm groups (p ≤ 0.05), Mann-Whitney U test.
Table II. Implant choices and costs divided by Orthopaedic Trauma Association fracture types Pre-algorithm* SHS Stable
OTA 31-A1.1 OTA 31-A1.2 OTA 31-A1.3 Stable total
N 18 7 0 25
Unstable OTA 31-A2.1 1 OTA 31-A2.2 6 Unstable 1† 7 total
Post-algorithm Average cost
SHS
Short CMN Long CMN
Total
% 24.5 12.7 1.0 38.2
N 1 1 0 2
% 1.0 1.0 0.0 2.0
N 1 0 0 1
% 1.0 0.0 0.0 1.0
N 27 14 1 42
% 26.5 13.7 1.% 41.2
$1238.20‡ $1190.61‡ $1052.50 $1217.92‡
Short CMN
Long CMN
Total
% 15.4 6.0 0.0 21.4
N 5 3 0 8
% 4.3 2.6 0.0 6.8
N 5 8 1 14
% 4.3 6.8 0.9 12.0
N 18 15 1 34
% 23.9 15.4 0.9 40.2
$1947.86 $2743.86 $4133.00 $2299.20
N 25 13 1 39
0.9 5.1 6.0
1 10 11
0.9 8.5 9.4
10 17 27
8.5 14.5 23.1
9 30 39
10.3 28.2 38.5
$3780.71 $3225.33 $3373.43
2 0 2
2.0 0.0 2.0
7 22 29
6.9 2 21.6 6 28.4 8
2.0 5.9 7.8
11 28 39
10.8 27.5 38.2
$2843.00‡ $3231.79 $3122.13‡
0 2 0 2 4
0.0 2.0 0.0 2.0 3.9
6.9 4.9 0.0 4.9 16.7
7 7 0 7 21
6.9 6.9 0.0 6.9 20.6
$4133.00 $3805.29 N/A $3805.29 $3914.52
100.0
$2501.18‡
OTA 31-A2.3 OTA 31-A3.1 OTA 31-A3.2 OTA 31-A3.3 Unstable 2† total
0 0 0 0 0
0.0 0.0 0.0 0.0 0.0
4 1 0 0 5
3.4 0.9 0.0 0.0 4.3
6 3 2 9 20
5.1 2.6 1.7 7.7 17.1
8 4 2 8 22
8.5 3.4 1.7 7.7 21.4
$3674.20 $3846.25 $4133.00 $4133.00 $3903.60
0 0 0 0 0
0.0 0.0 0.0 0.0 0.0
Total
32
27.4
24
20.5
61
52.1
95
100.0
$3055.19
41
40.2 35
7 5 0 5 17
34.3 26
25.5 102
Average cost
* SHS, sliding hip screw; CMN, cephalomedullary nails † Unstable 1 refers to unstable fractures with large posteromedial fragments; Unstable 2 refers to unstable fractures with reverse obliquity pattern or subtrochanteric extension ‡ Statistically significant difference (p ≤ 0.05), Mann-Whitney U test
different implant than that recommended by the algorithm. In the post-algorithm group, only 11 patients (10.8%) received a different implant than recommended, accounting for 89% compliance with the implant protocol. This difference was statistically significant (p < 0.001). The reasons for deviation from the protocol in the post-algorithm group included: misclassification of the fracture, suspicion of subtrochanteric involvement and matching a contralateral implant from previous hip surgery. After assigning current implant prices to the type of implant which was used, the pre-algorithm group yielded a total cost VOL. 96-B, No. 9, SEPTEMBER 2014
of $357 457 and a mean cost of $3055 (SD 1310.84) per patient; while the post-algorithm group’s total cost was $255 120 and the mean cost was $2501 (SD 1272.35). This difference was statistically significant (p = 0.001). The implementation of this algorithm saved our hospitals about $554 per patient; a mean of $1081.28 for stable fractures (OTA 31-A1), and a mean of $251 for unstable fractures with a large posteromedial fragment (OTA 31-A2.1 and 31-A2.2). Unstable fractures with a reverse obliquity or subtrochanteric extension (OTA 31-A2.3 and 31-A3) had similar total costs and did not produce any significant savings (p = 0.936).
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Table III. Peri-operative complications, deaths and re-admissions Pre-algorithm
Post-algorithm
p-value
Cardiopulmonary Infection* DVT/PE Other† None
N 10 26 9 8 75
% 8.9 23.2 8.0 7.1 67
N 8 15 2 3 78
% 7.8 14.7 2 2.9 76.5
0.775 0.114 0.044‡ 0.164 0.124
Total patients with complications
37
33
23
23.5
0.124
Deaths
5
4.5
5
4.9
0.880
Re-admissions
8
6.8
7
6.9
0.994
* Infections included: urinary tract infections (pre-algorithm: 11; post-algorithm: 9), pneumonia (pre-algorithm: 8; post-algorithm: 3), surgical wound infections (pre-algorithm: 5; post-algorithm: 1), sepsis (pre-algorithm: 2; post-algorithm: 2) † Other complications included: pressure ulcers (pre-algorithm: 3; post-algorithm: 1), hematomas (pre-algorithm: 2, pre-algorithm: 1), GI (pre-algorithm: 1, pre-algorithm: 1), renal (pre-algorithm: 2), peri-prosthetic fracture (pre-algorithm: 1) ‡ Statistically significant difference (p ≤ 0.05); Chi squared test
When the classification-based algorithm was applied retrospectively to the pre-algorithm group, significant theoretical cost-savings were demonstrated. Actual mean costs in the pre-algorithm group were significantly higher than they would have been had the algorithm been applied ($3055 versus $2454; p < 0.001), resulting in a $70 294 potential saving overall (equating to $601 per case). This was made up of a mean potential saving of $1246.70 per stable fracture (OTA 31-A1) and a mean potential saving of $387.43 per unstable fracture with a large posteromedial fragment (OTA 31-A2.1 and 31-A2.2). As the more expensive long CMN was used as standard in unstable fractures with reverse obliquity or subtrochanteric extension (OTA 31-A2.3, 31-A3.1, 31-A3.2 and 31-A3.3), costs would have been significantly higher in this group had the algorithm been applied (p = 0.02). However, as this group was relatively small, this made little difference to the overall costs. While there were fewer peri-operative complications in the post-algorithm group (n = 23, 23%) compared with the pre-algorithm (n = 37, 33%), this did not reach statistical significance (p = 0.088). The post-algorithm group had significantly fewer episodes of deep vein thrombosis and pulmonary embolism (p = 0.044; Table III). The rate of readmission was similar in the two groups (Table III).
Discussion These results demonstrate that the introduction of an evidence-based algorithm for the selection of the method of fixation reduced the costs of management in patients with an intertrochanteric fracture of the hip. Retrospective application of the algorithm to cases prior to its introduction demonstrated significant cost savings. Individually, differences in price for different types of fracture demonstrate the impact of the indiscriminate use of CMNs on total costs. Our protocol reduced the use of CMNs by stipulating clear indications for their use and consequently reducing the costs.
The use of CMNs has increased from 1998 to 2006 and beyond, but its use has not decreased the peri-operative mortality or morbidity, nor has it improved functional outcomes compared with plate-and-screw devices in patients with an intertrochanteric fracture.12,18 This trend toward more frequent intramedullary fixation cannot be explained by patient-related factors, and is more prevalent amongst trainees and younger surgeons.19,20 This study demonstrates a similar trend in our institutions, with CMN devices used more frequently than SHS in all types of fracture prior to the implementation of the algorithm (85 CMN versus 32 SHS overall). This has been attributed to young surgeons’ preferential training in CMN procedures, and the fact that reimbursement is higher when more expensive devices are used.20 Our algorithm effectively addresses these issues by creating clear indications for the management of each type of intertrochanteric fracture, hence removing the effect of an individual surgeon’s preference and reimbursement in deciding what device to use. The high compliance observed in our institutions (89%) indicates that this algorithm could be widely and similarly implemented in other institutions. Because the selection of the implant relies mainly on the treating surgeon, our algorithm makes hospital programs in which profits are shared between the institution and the surgeon (and which are recognised as viable in orthopaedics21-23) more attractive to surgeons. By sharing the resulting savings and providing reimbursement for the surgeons who follow the algorithm, sharing programs could lessen industry’s influence and facilitate compliance with the protocol. Moreover, our protocol also addresses existing concerns of lower quality of care regarding sharing programs.21,22 This is achieved by providing an evidencebased method of selection of implants and demonstrating that fewer complications and re-admissions occurred in our patients with an intertrochanteric fracture following the implementation of the algorithm. THE BONE & JOINT JOURNAL
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The choice of implant for the management of these fractures remains controversial. The latest Cochrane review recommends the use of SHS for most fractures, but also states that CMNs may have advantages over plates for subtrochanteric and some unstable trochanteric fractures, although further studies are needed to clarify this.15 There is evidence to suggest that intertrochanteric fractures with subtrochanteric extension are treated best with a long CMN,10,11 and we have incorporated this recommendation into the algorithm. This algorithm was developed to address a valid cost-saving approach to the treatment of these fractures on the basis of the available evidence; if clearer clinical indications arise as a result of future studies, the algorithm may be modified. The change in practice proposed by the implementation of an evidence-based algorithm for the selection of the method of fixation in patients with an intertrochanteric fracture reduced costs in our institutions by 18% ($550) per case. This was largely as a result of a decrease in the use of CMNs. This change in practice maintained quality of care and did not result in more complications or worse outcomes. These cost savings are independent of any special pricing arrangements or institutional discounts that can also be arranged. This strategy has potential implications in programs in which profits are shared between surgeons and the institution. The adoption of similar algorithms may reduce costs in other institutions, and similar evidence-based algorithms may be applicable in the treatment of other fractures. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. This article was primary edited by A. D. Liddle and first proof edited by J. Scott.
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5. Nikitovic M, Wodchis WP, Krahn MD, Cadarette SM. Direct health-care costs attributed to hip fractures among seniors: a matched cohort study. Osteoporosis Int 2013;24:659–669. 6. Burge R, Dawson-Hughes B, Solomon DH, et al. Incidence and economic burden of osteoporosis-related fractures in the United States, 2005-2025. J Bone Miner Res 2007;22:465–475. 7. Burge RT, King AB, Balda E, Worley D. Methodology for estimating current and future burden of osteoporosis in state populations: application to Florida in 2000 through 2025. Value Health 2003;6:574–583. 8. Tosteson AN, Burge RT, Marshall DA, Lindsay R. Therapies for treatment of osteoporosis in US women: cost-effectiveness and budget impact considerations. Am J Manag Care 2008;14:605–615. 9. Karagas MR, Lu-Yao GL, Barrett JA, Beach ML, Baron JA. Heterogeneity of hip fracture: age, race, sex, and geographic patterns of femoral neck and trochanteric fractures among the US elderly. Am J Epidemiol 1996;143:677–682. 10. Kregor PJ, Obremskey WT, Kreder HJ, Swiontkowski MF. Unstable pertrochanteric femoral fractures. J Orthop Trauma 2005;19:63–66. 11. Stern R. Are there advances in the treatment of extracapsular hip fractures in the elderly? Injury 2007;38(Suppl):S77–S87. 12. Anglen JO, Weinstein JN. Nail or plate fixation of intertrochanteric hip fractures: changing pattern of practice: a review of the American Board of Orthopaedic Surgery Database. J Bone Joint Surg [Am] 2008;90-A:700–707. 13. Butler M, Forte M, Kane RL, et al. Treatment of common hip fractures. Evid Rep Technol Assess (Full Rep) 20091–85. 14. Matre K, Vinje T, Havelin LI, et al. TRIGEN INTERTAN intramedullary nail versus sliding hip screw: a prospective, randomized multicenter study on pain, function, and complications in 684 patients with an intertrochanteric or subtrochanteric fracture and one year of follow-up. J Bone Joint Surg [Am] 2013;95-A:200–208. 15. Parker MJ, Handoll HH. Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures in adults. Cochrane Database Syst Rev 2010CD000093. 16. Marsh JL1, Slongo TF, Agel J, et al. Fracture and dislocation classification compendium - 2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma 2007;21(10 Suppl):S1–133. 17. Matre K, Havelin LI, Gjertsen JE, et al. Sliding hip screw versus IM nail in reverse oblique trochanteric and subtrochanteric fractures: a study of 2716 patients in the Norwegian Hip Fracture Register. Injury 2013;44:735–742. 18. Radcliff TA, Regan E, Cowper Ripley DC, Hutt E. Increased use of intramedullary nails for intertrochanteric proximal femoral fractures in veterans affairs hospitals: a comparative effectiveness study. J Bone Joint Surg [Am] 2012;94-A:833– 840. 19. Forte ML, Virnig BA, Kane RL, et al. Geographic variation in device use for intertrochanteric hip fractures. J Bone Joint Surg [Am] 2008;90-A:691–699. 20. Forte ML, Virnig BA, Eberly LE, et al. Provider factors associated with intramedullary nail use for intertrochanteric hip fractures. J Bone Joint Surg [Am] 2010;92A:1105–1114. 21. Dirschl DR, Goodroe J, Thornton DM, Eiland GW. AOA Symposium. Gainsharing in orthopaedics: passing fancy or wave of the future? J Bone Joint Surg [Am] 2007;89-A:2075–2083. 22. Healy WL. Gainsharing: a primer for orthopaedic surgeons. J Bone Joint Surg [Am] 2006;88-A:1880–1887. 23. Healy WL, Iorio R. Implant selection and cost for total joint arthroplasty: conflict between surgeons and hospitals. Clin Orthop Relat Res 2007;457:57–63.
