JSES - 2026-04-10 - Journal Article
The Cost-Effectiveness and Quality of Life Analysis of Proximal Humerus Fractures in Patients Over 65 Years Old in The United States.
Burzynski C, Sidebotham E, McKinley MT, Movassaghi A, Lubert J, Stubblefield A, Sabesan VJ
Topics
Key Takeaway
rTSA dominates all other PHF treatment strategies in patients ≥65, producing 7.16 QALYs at 10 years with an ICER of $6,374/QALY—well below the $50,000/QALY willingness-to-pay threshold.
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Summary
This cost-utility analysis compared nonoperative management, IMN, ORIF, hemiarthroplasty, and rTSA for PHFs in a 65-year-old base-case patient using fixed complication/revision probabilities and 2025 USD costs. rTSA produced the highest QALYs at every time horizon (1.69 at 2 years, 7.16 at 10 years) and the lowest ICER ($24,112/QALY at 2 years, $6,374/QALY at 10 years). ORIF and hemiarthroplasty were dominated strategies—more costly and less effective than rTSA—while nonoperative care minimized cost but sacrificed QALYs.
Key Limitation
The model uses a single 65-year-old base-case patient and fixed complication probabilities, precluding subgroup analysis by fracture complexity (e.g., 2-part vs. 4-part, Neer classification), which is the primary driver of treatment selection in clinical practice.
Original Abstract
INTRODUCTION
Proximal humerus fractures (PHFs) are the third most common fragility fracture in older adults, and their rising incidence in the United States contributes substantially to healthcare spending. Although several randomized trials have evaluated outcomes across treatment strategies, the optimal management strategy remains debated. Few studies have compared all five common PHF treatment options using an integrated cost effectiveness framework.
METHODS
A cost-utility analysis was performed to compare nonoperative management, intramedullary nailing (IMN), open reduction internal fixation (ORIF), hemiarthroplasty, and reverse total shoulder arthroplasty (rTSA) for PHFs in 65-year-old patients. Costs and quality of adjusted life years (QALYs) were calculated using fixed probabilities for complication and revisions. Monte Carlo simulations were performed using distributions to model variation over 2-, 5-, and 10-year time horizons. Utility values were assigned based on complication status, and costs were derived from CPT/DRG codes using 2025 USD. Incremental cost-effectiveness ratios (ICERs) were calculated, with sensitivity analyses assessing model robustness.
RESULTS
rTSA yielded the highest QALYs and emerged as the most cost-effective treatment across all time horizons. At 2 years, rTSA produced 1.69 QALYs at a mean cost of $18,661, resulting in the lowest ICER of $24,112/QALY. By 10 years, rTSA produced 7.16 QALYs at a cost of $23,311, with an ICER of $6,374/QALY. ORIF and hemiarthroplasty were consistently more costly and less effective than rTSA, while nonoperative care had the lowest costs but the fewest QALYs. At a willingness-to-pay threshold of $50,000/QALY, rTSA was the most cost-effective option in over half the simulations.
CONCLUSION
Amid rising fragility fracture rates and increasing financial pressures on the healthcare system, reverse shoulder arthroplasty offers the greatest cost-effectiveness among treatment options for complex proximal humerus fractures in adults over 65. Across all model timeframes, rTSA consistently yielded greater quality-adjusted life years and superior cost-effectiveness, supporting its role as the preferred treatment strategy in this population.