Advertisement

Evaluation of factors driving cost variation for distal humerus open reduction internal fixation

Open AccessPublished:October 30, 2020DOI:https://doi.org/10.1016/j.jseint.2020.09.009

      Background

      Distal humerus fracture open reduction and internal fixation (ORIF) represents a substantial cost burden to the health care system. The purpose of this study was to describe surgical encounter cost variation for distal humerus ORIF, and to determine demographic-, injury-, and treatment-specific factors that influence cost.

      Methods

      We retrospectively identified adult patients (≥18 years) treated for isolated distal humerus fractures between July 2014 and July 2019 at a single tertiary academic referral center. For each case, surgical encounter total direct costs (SETDCs) were obtained via our institution's information technology value tools, which prospectively record granular direct cost data for every health care encounter. Costs were converted to 2019 dollars using the personal consumption expenditure indices for health and summarized with descriptive statistics. Univariate and multivariate linear regression models were used to identify factors influencing SETDC.

      Results

      Surgical costs varied widely for the 47 included patients, with a standard deviation (SD) of 33% and interquartile range of 76%-124% relative to the mean SETDC. Implant and facility costs were responsible for 46.2% and 32.6% of the SETDC, respectively. Implant costs also varied considerably, with an SD of 21% and range from 13%-36% relative to the mean SETDC. Multivariate analysis demonstrated that SETDC increased 24% (P < .001) on performing an olecranon osteotomy, and by 15% for each additional 1 hour of surgical time (P < .001). These findings were independent of age, sex, body mass index, open fracture, need for an additional small plate construct as a reduction aid, and fracture pattern (all insignificant in the multivariate analysis, with P >.05 for each factor).

      Conclusion

      Substantial variations in surgical encounter total direct costs for distal humerus ORIF exist, as do wide variations in associated implant costs that comprise nearly half of the entire surgical cost. Performing an olecranon osteotomy, and increased surgical time, significantly increased surgical costs. Although use of an olecranon osteotomy may not be a completely controllable factor as it is confounded by fracture severity and operative time, this may suggest that surgeons should try to use an olecranon osteotomy judiciously. Although complexity of the fracture pattern was statistically insignificant, it is confounded by the need for an olecranon osteotomy and increased surgical time and likely is a clinically relevant and nonmodifiable driver of surgical cost. These findings highlight opportunities to reduce cost variation, and potentially improve the value of care, for distal humerus ORIF patients.

      Level of evidence

      Keywords

      Distal humerus fractures are relatively common injuries in adults, accounting for approximately 2% of all fractures
      • Allen R.W.
      • Pruitt M.
      • Taaffe K.M.
      Effect of resident involvement on operative time and operating room staffing costs.
      ,
      • Robinson C.M.
      • Hill R.M.
      • Jacobs N.
      • Dall G.
      • Court-Brown C.M.
      Adult distal humeral metaphyseal fractures: epidemiology and results of treatment.
      and 30% of elbow fractures.
      • Galano G.J.
      • Ahmad C.S.
      • Levine W.N.
      Current treatment strategies for bicolumnar distal humerus fractures.
      The incidence follows a bimodal age distribution, with peaks at a mean age of 37 years for men (typically resulting from high-energy trauma) and 60 years of age for women (most typically related to low-energy mechanisms in the setting of decreased bone mineral density).
      • Galano G.J.
      • Ahmad C.S.
      • Levine W.N.
      Current treatment strategies for bicolumnar distal humerus fractures.
      ,
      • Palvanen M.
      • Kannus P.
      • Niemi S.
      • Parkkari J.
      Secular trends in distal humeral fractures of elderly women: nationwide statistics in Finland between 1970 and 2007.
      ,
      • Robinson C.M.
      • Hill R.M.
      • Jacobs N.
      • Dall G.
      • Court-Brown C.M.
      Adult distal humeral metaphyseal fractures: epidemiology and results of treatment.
      The incidence of distal humerus fractures in the elderly is expected to increase, with a regression model projecting this value to triple by 2030.
      • Kim S.H.
      • Szabo R.M.
      • Marder R.A.
      Epidemiology of humerus fractures in the United States: nationwide emergency department sample, 2008.
      ,
      • Palvanen M.
      • Kannus P.
      • Niemi S.
      • Parkkari J.
      Secular trends in distal humeral fractures of elderly women: nationwide statistics in Finland between 1970 and 2007.
      Surgical management through open reduction and internal fixation (ORIF) is a common treatment method that may be performed for patients healthy enough to undergo surgery that demonstrate a fracture pattern and bone quality that is amenable to fixation.
      • Korner J.
      • Lill H.
      • Muller L.P.
      • Hessmann M.
      • Kopf K.
      • Goldhahn J.
      • et al.
      Distal humerus fractures in elderly patients: results after open reduction and internal fixation.
      ,
      • Srinivasan K.
      • Agarwal M.
      • Matthews S.J.
      • Giannoudis P.V.
      Fractures of the distal humerus in the elderly: is internal fixation the treatment of choice?.
      ,
      • Varecka T.F.
      • Myeroff C.
      Distal humerus fractures in the elderly population.
      Although operative management of distal humerus fractures is generally accepted as the mainstay treatment of choice,
      • McCarty L.P.
      • Ring D.
      • Jupiter J.B.
      Management of distal humerus fractures.
      variation in the approach, technique, and instrumentation exists. This is, in part, due to differences in the complexity of the fracture pattern,
      • Amir S.
      • Jannis S.
      • Daniel R.
      Distal humerus fractures: a review of current therapy concepts.
      but also relates to surgeon preference and practice patterns. Additionally, the risk-benefit profile of some of these variations in treatment decision making, such as whether to perform ulnar nerve transposition or olecranon osteotomy, are disputed in the literature but may influence surgical cost.
      • Chen R.C.
      • Harris D.J.
      • Leduc S.
      • Borrelli Jr., J.J.
      • Tornetta 3rd, P.
      • Ricci W.M.
      Is ulnar nerve transposition beneficial during open reduction internal fixation of distal humerus fractures?.
      ,
      • Nauth A.
      • McKee M.D.
      • Ristevski B.
      • Hall J.
      • Schemitsch E.H.
      Distal humeral fractures in adults.
      ,
      • Ruan H.J.
      • Liu J.J.
      • Fan C.Y.
      • Jiang J.
      • Zeng B.F.
      Incidence, management, and prognosis of early ulnar nerve dysfunction in type C fractures of distal humerus.
      ,
      • Sharma S.
      • John R.
      • Dhillon M.S.
      • Kishore K.
      Surgical approaches for open reduction and internal fixation of intra-articular distal humerus fractures in adults: a systematic review and meta-analysis.
      ,
      • Shearin J.W.
      • Chapman T.R.
      • Miller A.
      • Ilyas A.M.
      Ulnar nerve management with distal humerus fracture fixation: a meta-analysis.
      ,
      • Vazquez O.
      • Rutgers M.
      • Ring D.C.
      • Walsh M.
      • Egol K.A.
      Fate of the ulnar nerve after operative fixation of distal humerus fractures.
      ,
      • Wilkinson J.M.
      • Stanley D.
      Posterior surgical approaches to the elbow: a comparative anatomic study.
      Although numerous clinical studies have evaluated the different treatment options available and their outcomes for distal humerus fractures,
      • Galano G.J.
      • Ahmad C.S.
      • Levine W.N.
      Current treatment strategies for bicolumnar distal humerus fractures.
      ,
      • Korner J.
      • Lill H.
      • Muller L.P.
      • Hessmann M.
      • Kopf K.
      • Goldhahn J.
      • et al.
      Distal humerus fractures in elderly patients: results after open reduction and internal fixation.
      ,
      • McCarty L.P.
      • Ring D.
      • Jupiter J.B.
      Management of distal humerus fractures.
      ,
      • Srinivasan K.
      • Agarwal M.
      • Matthews S.J.
      • Giannoudis P.V.
      Fractures of the distal humerus in the elderly: is internal fixation the treatment of choice?.
      ,
      • Varecka T.F.
      • Myeroff C.
      Distal humerus fractures in the elderly population.
      less is known regarding the financial aspects of operative treatment of these injuries. With a wide variation in treatment options, and large projected increase in the incidence of distal humerus fractures in the near future, it is imperative to evaluate which specific modifiable and nonmodifiable factors lead to increased surgical costs for these injuries. Although cost differences between ORIF and total elbow arthroplasty have previously been studied,
      • Federer A.E.
      • Mather 3rd, R.C.
      • Ramsey M.L.
      • Garrigues G.E.
      Cost-effectiveness analysis of total elbow arthroplasty versus open reduction-internal fixation for distal humeral fractures.
      ,
      • Wasterlain A.S.
      • Melamed E.
      • Bello R.
      • Karia R.
      • Capo J.T.
      Science of Variation Group
      The effect of price on surgeons' choice of implants: a randomized controlled survey.
      specific patient and operative factors that drive variation in the surgical encounter total direct cost (SETDC) for distal humerus ORIF remain less clear. Highlighting the modifiable factors that drive cost variation for distal humerus ORIF provides an opportunity for potential cost savings.
      • Wasterlain A.S.
      • Melamed E.
      • Bello R.
      • Karia R.
      • Capo J.T.
      Science of Variation Group
      The effect of price on surgeons' choice of implants: a randomized controlled survey.
      The purpose of this study was to describe the cost variation associated with distal humerus ORIF surgery and to investigate which demographic-, injury-, and treatment-specific factors impact the SETDC for distal humerus ORIF.

      Materials and methods

      This was a retrospective cohort cost study. All adult patients (age ≥18 years) undergoing surgical management of isolated distal humerus fractures between July 2014 and July 2019 at a single tertiary academic institution were identified. Patients were identified by a CPT code (24545, 24546, 24575, 24579, 24586) query of our institution’s electronic data warehouse. Patients were excluded if they were younger than 18 years, had isolated capitellar shear or trochlear fractures, and if they had any additional simultaneous procedure in conjunction with distal humerus ORIF. Surgeries were performed by orthopedic surgeons with additional fellowship training in hand, shoulder and elbow, or trauma surgery. Demographic data, including age, body mass index, insurance, and race, were automatically pulled from the electronic data warehouse. Chart review of operative reports was performed to identify variations in the treatment of distal humerus fractures. Variables collected included number of plates used for distal humerus fixation (including use of small plate constructs as a reduction aid), fixation construct type (dual plating in a 90°-90° or 180° configuration), number of nonlocking and locking screws used, performance of olecranon osteotomy or ulnar nerve decompression and transposition, and the use of bone graft. Review of pre-, intra-, and postoperative radiographs was performed to corroborate the number of screws and plates used, and to classify the fracture pattern. Fracture pattern was defined as extra-articular, intra-articular simple, and intra-articular complex. A fracture was defined as extra-articular if it was an AO type A fracture, intra-articular simple if it was an AO type B or C1 fracture, and intra-articular complex if it was an AO type C2 or C3 fracture.
      • Nauth A.
      • McKee M.D.
      • Ristevski B.
      • Hall J.
      • Schemitsch E.H.
      Distal humeral fractures in adults.
      In an effort to collect granular cost data for a wide spectrum of health care encounters, the Value Driven Outcomes (VDO) tool was previously developed at our institution.
      • Lee V.S.
      • Kawamoto K.
      • Hess R.
      • Park C.
      • Young J.
      • Hunter C.
      • et al.
      Implementation of a value-driven outcomes program to identify high variability in clinical costs and outcomes and association with reduced cost and improved quality.
      The VDO tool encompasses an item-level database as well as information technology tools allowing for prospectively collected cost data to be linked to specific patient visits, including surgical encounters. Subcategories of the cost data include implant, supply, facility, operating room (OR), and postanesthesia care unit (PACU) use, pharmacy, imaging, and laboratory costs. Within the VDO tool, the costs of laboratory tests, pharmacy, and imaging are associated with the hospital stay as a whole, whereas OR and PACU use, implant, and supply costs can be linked to the specific surgical encounter. Given the inpatient status of the majority of our patients, the SETDC was composed of only OR and PACU use, supply, implant, and imaging costs. Previous literature using this tool in orthopedics has demonstrated that pharmacy, laboratory, and imaging costs comprise a relatively small portion (<5%) of the SETDC and therefore contribute minimally to surgical cost variation.
      • Kazmers N.H.
      • Judson C.H.
      • Presson A.P.
      • Xu Y.
      • Tyser A.R.
      Evaluation of factors driving cost variation for distal radius fracture open reduction internal fixation.
      ,
      • Kazmers N.H.
      • Presson A.P.
      • Xu Y.
      • Howenstein A.
      • Tyser A.R.
      Cost implications of varying the surgical technique, surgical setting, and anesthesia type for carpal tunnel release surgery.
      ,
      • Kazmers N.H.
      • Stephens A.R.
      • Presson A.P.
      • Yu Z.
      • Tyser A.R.
      Cost implications of varying the surgical setting and anesthesia type for trigger finger release surgery.
      Therefore, we chose to omit these categories rather than exclude all inpatient surgeries. Additionally, professional payments including those to the surgeon and anesthesiologist, and indirect costs such as facility or equipment depreciation, are not included. Supplementary Appendix S1 provides a breakdown of each component included in the SETDC through the VDO. Although raw cost data was used for all analyses, all costs were reported relative to the mean cost because contractual agreements and institutional policies prohibit the publication of raw cost data. For similar reasons, publication of implant manufacturer names is prohibited.

      Statistical methods

      Descriptive summaries were provided for patient factors including age, race, sex, American Society of Anesthesiologists (ASA) classification, smoking status, and preoperative diagnosis of osteoporosis or osteoarthritis. Operative and postoperative factors evaluated included days from injury to fixation, fracture pattern type, number of plates, performance of an olecranon osteotomy or ulnar nerve transposition, ambulatory vs. inpatient setting, duration of surgery and anesthesia, and the treating service (hand vs. trauma).
      Categorical variables were reported as frequency and percentage, whereas continuous variables were reported as mean and standard deviation (SD) or median and interquartile range (IQR) if the distribution is skewed. Our institution's raw cost data were converted to January 2019 US dollars using the Bureau of Economic Analysis personal consumption expenditure indices Health.
      Agency for Healthcare Research and Quality
      Medical Expenditure Panel Survey. Using appropriate price indices for analyses of health care expenditures or income across multiple years.
      The mean SETDC for all surgeries was calculated, and ratios relative to this cost were calculated.
      Associations between patient factors and SETDC were evaluated using univariable and multivariable linear regressions. Other distribution families, including Poisson, Gamma, and Inverse Gaussian were considered, but did not fit the data better than the Gaussian (linear) model, as assessed using a modified Park test.
      • Manning W.G.
      • Mullahy J.
      Estimating log models: to transform or not to transform?.
      A log link was used so that change in cost can be estimated as ratios.
      Variables significantly associated with SETDC in the univariate analyses were used to construct the multivariate model. Potential multicollinearity of the multivariate model was checked using a variance inflation factor. Variables causing considerable multicollinearity (variance inflation factor > 2.5) due to high correlation with other variables were removed from the analysis.
      Regression coefficients from both univariate and multivariate models were exponentiated to represent ratios in the outcome, which were reported with 95% confidence intervals (CIs) and P values.
      Statistical significance was assessed at the 0.05 level, and all tests were 2 sided. All analyses were conducted in R 3.6.1.
      R Core Team
      R: A Language and Environment for Statistical Computing.

      Results

      Of the 47 patients included in this study, the mean age was 50.1 ± 21.2 years and 53.2% (25/47) of patients were female. The majority (97.9%; 46/47) of surgeries were performed at the main hospital. 89.4% (42/47) of surgeries were performed using 2 main plates in a 90°-90° (78.7%; 37/47) or 180° (10.6%; 5/47) construct. Five cases (10.6%) used a single plate for fixation, and these were extra-articular, or AO type A, fractures. Eight cases (17%) used an additional small plate as a reduction aid in the construct. Implant manufacturer A was used in 95.7% (45/47) of cases. An olecranon osteotomy was performed in 17 (36.2%) cases, and ulnar nerve transposition was performed in 12 (25.5%) cases. The majority (80.9%; 38/47) of fractures had complex intra-articular patterns. The mean number of plates, nonlocking screws, and locking screws were 2 ± 0.5, 9.7 ± 4.4, and 5.1 ±2.7 respectively. Additional patient, injury and surgical information is presented in Table I.
      Table IDescriptive summary of all patients (N = 47)
      VariableValue (%)
      Age, mean (SD)50.1 (21.2)
      Race
       Nonwhite4 (8.5)
       White43 (91.5)
      Sex
       Female25 (53.2)
       Male22 (46.8)
      BMI, mean (SD)29.3 (6.0)
      ASA class
       113 (27.7)
       214 (29.8)
       318 (38.3)
       42 (4.3)
      Smoking9 (19.6)
      Payer mix
       Commercial25 (54.3)
       Medicare14 (30.4)
       Other7 (15.2)
      Osteoporosis diagnosis9 (19.1)
      Osteoarthritis of the elbow11 (23.4)
      Injury type
       Intra-articular, complex38 (80.9)
       Intra-articular, simple4 (8.5)
       Extra-articular5 (10.6)
      Olecranon osteotomy17 (36.2)
      Ulnar transposition12 (25.5)
      Number of plates, mean (SD)2.0 (0.5)
      Main fixation method
       Single plate5 (10.6)
       90°-90° dual plating37 (78.7)
       180° dual plating5 (10.6)
      Additional small plate as reduction aid8 (17)
      Number of nonlocking screws, mean (SD)9.7 (4.4)
      Number of locking screws, mean (SD)5.1 (2.7)
      Plate manufacturer
       A45 (95.7)
       B2 (4.3)
      Site
       Main hospital46 (97.9)
       Ambulatory surgical center1 (2.1)
      Surgical time in hours, mean (SD)3.4 (1.2)
      Anesthesia time in hours mean (SD)4.8 (1.3)
      Visit type
       Inpatient37 (78.7)
       23-h observation5 (10.6)
      Treating service
       Trauma30 (63.8)
       Hand14 (29.8)
       Shoulder and elbow3 (6.4)
      Open fracture14 (29.8)
      Anesthesia type
       General46 (97.9)
       Regional1 (2.1)
      BMI, body mass index; ASA, American Society of Anesthesiologists.

      Factors influencing surgical encounter total direct costs (SETDC)

      Implant (46.2%) and facility (32.6%) costs made up the largest components of the SETDC (Fig. 1). Considerable variation in the SETDC for distal humerus ORIF was observed. Specifically, the standard deviation compared to the mean surgical cost of the whole cohort was 33%, and interquartile range was 76%-124%. Implant costs also varied considerably, with an SD of 21% and range from 13%-36% relative to the mean SETDC.
      Figure thumbnail gr1
      Figure 1Breakdown of cost distribution by percentage.
      Univariate analysis demonstrated that the performance of an olecranon osteotomy significantly increased surgical encounter total direct costs by 54% (P < .001; 95% CI 1.34-1.77). Increased surgical and anesthesia time also increased costs by 22% (P < .001; 95% CI 1.16-1.27) and 20% (P < .001; 95% CI 1.15-1.26), respectively. Using 2 plates compared to one plate increased costs by 51% (P = .02; 95% CI 1.06-2.52). Using additional small plate/screw constructs as a reduction aid increased costs by 19%, though this was not statistically significant (P = .13; 95% CI 0.94-1.47). Outpatient or 23-hour observation status, as compared to inpatient status, was associated with a 29% cost reduction (P = .01; 95% CI 0.53-0.91). Patient demographics (age, sex, race, body mass index, smoking) were not associated with cost differences. Fracture- and surgery-specific factors, such as fracture pattern and open fracture, and the performance of an ulnar transposition, did not significantly impact costs (Table II).
      Table IIUnivariate analysis of factors impacting total direct cost
      VariableRatio in cost95% confidence intervalP value
      Age
      Per 10-year increments.
      1.01(0.97-1.06).570
      Race
       NonwhiteReference
       White1.07(0.78-1.64).720
      Sex
       FemaleReference
       Male1.01(0.84-1.22).900
      BMI1.00(0.98-1.02).970
      ASA class
       1Reference
       20.95(0.73-1.23).680
       3+1.03(0.82-1.30).820
      Smoking1.16(0.93-1.43).170
      Osteoporosis0.88(0.66-1.12).350
      Osteoarthritis1.19(0.96-1.44).100
      Days from injury0.99(0.97-1.01).440
      Injury type
       Extra-articularReference
       Intra-articular, simple1.27(0.80-2.07).510
       Intra-articular, complex1.20(0.88-1.84).510
      Open fracture1.15(0.95-1.39).150
      Number of main plates
       1Reference
       21.51(1.06- 2.52).020
      Olecranon osteotomy1.54(1.34-1.77)<.001
      Ulnar transposition1.06(0.85-1.30).580
      Duration of surgery
      Per 1-hour increments.
      1.22(1.16-1.27)<.001
      Duration of anesthesia
      Per 1-hour increments.
      1.20(1.15-1.26)<.001
      Patient type
       InpatientReference
       23-h observation0.71(0.53-0.91).010
      Treating service
       HandReference
       Trauma0.91(0.75-1.12).350
      BMI, body mass index; ASA, American Society of Anesthesiologists.
      Per 10-year increments.
      Per 1-hour increments.
      Multivariate analysis revealed that performing an olecranon osteotomy was significantly associated with increased costs independent of other factors, increasing costs by 24% (P < .001; 95% CI 1.11-1.39). The number of plates used in the distal humerus fixation construct was no longer significant (P = .16; 95% CI 0.96-1.54). Duration of surgery also was an independent predictor of increased costs, with each additional hour of surgery increasing costs by 15% (P < .001; 95% CI 1.10-1.20). Differences in cost between inpatient and outpatient treatment were no longer significant (P = .36; 95% CI 0.78-1.08) (Table III).
      Table IIIMultivariate analysis of factors affecting total direct cost
      VariableRatio in cost95% confidence intervalP value
      Olecranon osteotomy1.24(1.11-1.39)<.001
      Duration of surgery
      Per 1-hour increments.
      1.15(1.10-1.20)<.001
      Number of plates
       1Reference
       21.19(0.96-1.54).160
      Visit type
       InpatientReference
       23-h observation0.93(0.78-1.08).360
      Per 1-hour increments.

      Discussion

      The primary aim of our study was to determine which factors are associated with variation in cost for open reduction internal fixation of distal humerus fractures. We found that substantial variation in total direct surgical costs exist in this setting. Relative to the mean surgical cost, the standard deviation for cost was substantial at 33%, and the interquartile range of surgical encounter costs was wide (76%-124%). Implants comprised the largest proportion of costs, at 46.2% of the total surgical cost, and also notable were supply costs, which includes drill bits and saw blades (17.7% of the total cost). Substantial cost variation for implants were also observed, with an SD of 21% and range from 13% to 36% relative to the mean SETDC.
      Although we did not have enough variation in implant manufacturer at our institution to evaluate the contribution of this variable to cost variation, prior studies have shown that manufacturer significantly influences cost variation.
      • Kazmers N.H.
      • Judson C.H.
      • Presson A.P.
      • Xu Y.
      • Tyser A.R.
      Evaluation of factors driving cost variation for distal radius fracture open reduction internal fixation.
      Variation in cost is a common occurrence in orthopedic surgery.
      • Haas D.A.
      • Kaplan R.S.
      Variation in the cost of care for primary total knee arthroplasties.
      ,
      • Kazmers N.H.
      • Judson C.H.
      • Presson A.P.
      • Xu Y.
      • Tyser A.R.
      Evaluation of factors driving cost variation for distal radius fracture open reduction internal fixation.
      Identification of factors that drive cost differences for various orthopedic conditions or injuries has been demonstrated in previously published studies.
      • Kazmers N.H.
      • Judson C.H.
      • Presson A.P.
      • Xu Y.
      • Tyser A.R.
      Evaluation of factors driving cost variation for distal radius fracture open reduction internal fixation.
      • Kazmers N.H.
      • Presson A.P.
      • Xu Y.
      • Howenstein A.
      • Tyser A.R.
      Cost implications of varying the surgical technique, surgical setting, and anesthesia type for carpal tunnel release surgery.
      • Kazmers N.H.
      • Stephens A.R.
      • Presson A.P.
      • Xu Y.
      • Feller R.J.
      • Tyser A.R.
      Comparison of direct surgical costs for proximal row carpectomy and four-corner arthrodesis.
      ,
      • Maradit Kremers H.
      • Visscher S.L.
      • Moriarty J.P.
      • Reinalda M.S.
      • Kremers W.K.
      • Naessens J.M.
      • et al.
      Determinants of direct medical costs in primary and revision total knee arthroplasty.
      ,
      • Wagner E.R.
      • Ransom J.E.
      • Kremers H.M.
      • Morrey M.
      • Sanchez-Sotelo J.
      Comparison of the hospital costs for two-stage reimplantation for deep infection, single-stage revision and primary total elbow arthroplasty.
      Orthopedic surgeons consider cost to be an important factor when determining optimal treatment,
      • Hageman M.G.
      • Guitton T.G.
      • Ring D.
      • Science of Variation Group
      How surgeons make decisions when the evidence is inconclusive.
      ,
      • Wasterlain A.S.
      • Melamed E.
      • Bello R.
      • Karia R.
      • Capo J.T.
      Science of Variation Group
      The effect of price on surgeons' choice of implants: a randomized controlled survey.
      yet they have a poor understanding of factors that affect cost variation and are likely to underestimate costs.
      • Ayoub M.
      • Paul Bassett W.
      • Seuffert P.
      • Matijakovich D.
      • DA O.H.
      • Butler M.S.
      Perception versus reality in the cost of orthopedic trauma implants.
      ,
      • Okike K.
      • O'Toole R.V.
      • Pollak A.N.
      • Bishop J.A.
      • McAndrew C.M.
      • Mehta S.
      • et al.
      Survey finds few orthopedic surgeons know the costs of the devices they implant.
      ,
      • Streit J.J.
      • Youssef A.
      • Coale R.M.
      • Carpenter J.E.
      • Marcus R.E.
      Orthopaedic surgeons frequently underestimate the cost of orthopaedic implants.
      ,
      • Wasterlain A.S.
      • Melamed E.
      • Bello R.
      • Karia R.
      • Capo J.T.
      Science of Variation Group
      The effect of price on surgeons' choice of implants: a randomized controlled survey.
      Surgeon awareness of cost differences between implants used in distal humerus and other common upper extremity fractures may significantly impact a surgeon's choice of surgical implant.
      • Wasterlain A.S.
      • Melamed E.
      • Bello R.
      • Karia R.
      • Capo J.T.
      Science of Variation Group
      The effect of price on surgeons' choice of implants: a randomized controlled survey.
      In light of these findings, it is important to understand which other factors may be driving increased costs, as surgeons would likely be motivated to help decrease those costs associated with modifiable factors. Furthermore, our finding that 63.9% of the total costs related to distal humerus ORIF were attributed to supplies and implants alone highlights the opportunity to drive down surgical costs through judicious use of less costly implants, and by leveraging hospital bargaining power to negotiate for lower implant and supply pricing. This is of particular importance given the assumed equipoise between implant manufacturers, as there exists a lack of evidence supporting superiority of any one implant manufacturer in terms of yielding a better surgical outcome or lower complication profile, yet pricing likely differs.
      We found that several surgical factors were associated with increased total direct costs for distal humerus ORIF, including olecranon osteotomy and overall surgical time. Performing an olecranon osteotomy was associated with increased surgical encounter costs independent of other factors, increasing costs by 24%. These findings are informative in light of Sharma et al's recent meta-analysis that found no difference in long-term functional outcomes and complication rates between olecranon osteotomy to non–olecranon osteotomy approaches in distal humerus ORIF.
      • Sharma S.
      • John R.
      • Dhillon M.S.
      • Kishore K.
      Surgical approaches for open reduction and internal fixation of intra-articular distal humerus fractures in adults: a systematic review and meta-analysis.
      The implication of these findings deserves caution, as none of the included studies were randomized controlled trials. Furthermore, the complex nature of these fractures often necessitates the performance of an olecranon osteotomy to help increase visualization of the articular surface, and fracture complexity is linked to use of an osteotomy, which makes it difficult to statistically differentiate between these 2 variables, as in the current study. An olecranon osteotomy may be more useful in AO Foundation / Orthopaedic Trauma Association type C2 and C3 fractures
      • Müller M.E.
      • Allgöwer M.
      • Schneider R.
      • Willenegger H.
      Manual of internal fixation techniques recommended by the AO-ASIF Group.
      and in older patients (age >60 years), and less likely indicated in type B and C1 fractures and younger patients (age <60 years).
      • Chen G.
      • Liao Q.
      • Luo W.
      • Li K.
      • Zhao Y.
      • Zhong D.
      Triceps-sparing versus olecranon osteotomy for ORIF: analysis of 67 cases of intercondylar fractures of the distal humerus.
      ,
      • Varecka T.F.
      • Myeroff C.
      Distal humerus fractures in the elderly population.
      ,
      • Zhang C.
      • Zhong B.
      • Luo C.F.
      Comparing approaches to expose type C fractures of the distal humerus for ORIF in elderly patients: six years clinical experience with both the triceps-sparing approach and olecranon osteotomy.
      Furthermore, although there was no significant difference in cost between simple and complex fracture types, the complexity of the fracture and use of an osteotomy are linked together. Although we found that fracture pattern was not a statistically significant driver of cost, we conclude that clinically it is a relevant factor as well as a statistically significant factor for fractures complex enough to warrant an osteotomy. In addition, the potential complications of olecranon osteotomy, including nonunion and symptomatic hardware, need to be considered, as they can also lead to additional costs long term. These factors were not included in the current study but are relevant from a societal cost perspective. Although we do not believe the decision to perform an olecranon osteotomy should be based on cost alone, we believe surgeons should carefully consider whether an osteotomy will either (1) allow for a better reduction and/or fixation, which may improve the long-term outcome, and (2) allow for a more efficient surgery and reduce time and cost of wasted attempts to achieve a reduction without an osteotomy.
      Use of a small plate/screw construct as a reduction aid did not significantly increase costs in univariate or multivariate analysis. This finding should be interpreted with caution, however, and one should not deduce that additional plates add no additional cost for similar reasons as fracture pattern in the prior paragraph. Fracture severity, need for an additional plate, increased OR time, and need for an olecranon osteotomy are all linked. All patients needing an extra plate had complex fracture patterns. Therefore, surgeons should still carefully consider whether use of a provisional reduction plate will truly enhance stability of the construct or simplify fixation.
      Not surprisingly, increased surgical time increased costs
      • Beckerman D.
      • Esparza M.
      • Lee S.I.
      • Berven S.H.
      • Bederman S.S.
      • Hu S.S.
      • et al.
      Cost analysis of single-level lumbar fusions.
      ,
      • Childers C.P.
      • Maggard-Gibbons M.
      Understanding costs of care in the operating room.
      ,
      • Kazmers N.H.
      • Judson C.H.
      • Presson A.P.
      • Xu Y.
      • Tyser A.R.
      Evaluation of factors driving cost variation for distal radius fracture open reduction internal fixation.
      ,
      • Kazmers N.H.
      • Stephens A.R.
      • Presson A.P.
      • Xu Y.
      • Feller R.J.
      • Tyser A.R.
      Comparison of direct surgical costs for proximal row carpectomy and four-corner arthrodesis.
      associated with distal humerus ORIF. Each additional hour of operating time increased costs by 15%. As such, areas for improvement in OR efficiency should be explored.
      • Kazmers N.H.
      • Presson A.P.
      • Xu Y.
      • Howenstein A.
      • Tyser A.R.
      Cost implications of varying the surgical technique, surgical setting, and anesthesia type for carpal tunnel release surgery.
      Specific to teaching institutions, attending surgeons should find the right balance between educating future surgeons while maintaining efficiency in the OR.
      • Allen R.W.
      • Pruitt M.
      • Taaffe K.M.
      Effect of resident involvement on operative time and operating room staffing costs.
      ,
      • Farnworth L.R.
      • Lemay D.E.
      • Wooldridge T.
      • Mabrey J.D.
      • Blaschak M.J.
      • DeCoster T.A.
      • et al.
      A comparison of operative times in arthroscopic ACL reconstruction between orthopaedic faculty and residents: the financial impact of orthopaedic surgical training in the operating room.
      We also observed no significant difference in costs between inpatient vs. outpatient or 23-hour observation status. However, our analysis solely reflects PACU costs and did not capture costs directly related to the hospital stay. Therefore, it should not be concluded that an inpatient hospital stay is not more costly. Although prior studies have shown increased costs associated with a main hospital setting compared to ambulatory surgical centers,
      • Nguyen C.
      • Milstein A.
      • Hernandez-Boussard T.
      • Curtin C.M.
      The effect of moving carpal tunnel releases out of hospitals on reducing United States health care charges.
      ,
      • Ode G.E.
      • Odum S.
      • Connor P.M.
      • Hamid N.
      Ambulatory versus inpatient shoulder arthroplasty: a population-based analysis of trends, outcomes, and charges.
      we were unable to explore the effect of this variable as only 1 patient that had surgery at our ambulatory surgical center. We also did not observe a difference in surgical costs whether a formal ulnar nerve transposition was performed or not. This finding is informative in light of previous literature that concluded that ulnar nerve transposition in this setting is not protective of ulnar neuropathy.
      • Shearin J.W.
      • Chapman T.R.
      • Miller A.
      • Ilyas A.M.
      Ulnar nerve management with distal humerus fracture fixation: a meta-analysis.
      The literature is conflicting, as other studies have supported this finding, whereas others have found no difference or improved outcomes with ulnar nerve transposition.
      • Chen R.C.
      • Harris D.J.
      • Leduc S.
      • Borrelli Jr., J.J.
      • Tornetta 3rd, P.
      • Ricci W.M.
      Is ulnar nerve transposition beneficial during open reduction internal fixation of distal humerus fractures?.
      ,
      • Gofton W.T.
      • Macdermid J.C.
      • Patterson S.D.
      • Faber K.J.
      • King G.J.
      Functional outcome of AO type C distal humeral fractures.
      ,
      • Ilyas A.M.
      • Jupiter J.B.
      Treatment of distal humerus fractures.
      ,
      • Ruan H.J.
      • Liu J.J.
      • Fan C.Y.
      • Jiang J.
      • Zeng B.F.
      Incidence, management, and prognosis of early ulnar nerve dysfunction in type C fractures of distal humerus.
      ,
      • Vazquez O.
      • Rutgers M.
      • Ring D.C.
      • Walsh M.
      • Egol K.A.
      Fate of the ulnar nerve after operative fixation of distal humerus fractures.
      ,
      • Wang K.C.
      • Shih H.N.
      • Hsu K.Y.
      • Shih C.H.
      Intercondylar fractures of the distal humerus: routine anterior subcutaneous transposition of the ulnar nerve in a posterior operative approach.
      This statistically negative finding may be explained in terms of OR time: the main way a transposition would increase cost is through greater OR time, which was found to be a significant contributor to surgical cost. Therefore, although we did not find an increase in cost with ulnar nerve transposition, it increases OR time, which leads to greater cost, and surgeons must weigh the risks and benefits of transposition. Likewise, we did not find that open fractures increased cost of surgical treatment, but our study may have been underpowered to detect a difference of additional irrigation and débridement which would similarly manifest greater costs through increased OR time.
      There are several study limitations that deserve mention. Although costs data were collected prospectively, the retrospective chart review design of this study introduces potential for selection bias. All cases were also performed at a single tertiary referral center by fellowship-trained orthopedic surgeons (shoulder and elbow, hand, and trauma), 80.9% were complex intra-articular patterns, and 29.8% were open fractures—this patient population may differ from that seen in other care settings. We were unable to study the effect of implant manufacturer on cost variation, as the majority of implants were derived from a single company. In addition, our study solely focuses on direct costs related to the surgical encounter itself. Therefore, factors affecting preoperative or postoperative costs, and professional payments, are not reflected by this study. As stated above, our patient population may differ from that of other hospital systems. Regional variability exists regarding OR and recovery protocols and staffing, and hospital-negotiated contract pricing for specific implants and supplies. Although the percentage increase of olecranon osteotomy or increased OR time may differ between institutions, it is likely these factors are clinically relevant at all institutions. Although the actual raw data of cost could not be disclosed because of contractual agreements at our institution, the impact of certain variables on cost can still be evaluated as a relative increase from a baseline value and has been used in other studies.
      • Chalmers P.N.
      • Kahn T.
      • Broschinsky K.
      • Ross H.
      • Stertz I.
      • Nelson R.
      • et al.
      An analysis of costs associated with shoulder arthroplasty.
      ,
      • Kazmers N.H.
      • Presson A.P.
      • Xu Y.
      • Howenstein A.
      • Tyser A.R.
      Cost implications of varying the surgical technique, surgical setting, and anesthesia type for carpal tunnel release surgery.
      ,
      • Kazmers N.H.
      • Stephens A.R.
      • Presson A.P.
      • Yu Z.
      • Tyser A.R.
      Cost implications of varying the surgical setting and anesthesia type for trigger finger release surgery.
      ,
      • Stephens A.R.
      • Yu Z.
      • Presson A.P.
      • Tyser A.R.
      • Kazmers N.H.
      Cost implications of varying the surgical setting and anesthesia type for de Quervain release surgery.
      ,
      • Tashjian R.Z.
      • Belisle J.
      • Baran S.
      • Granger E.K.
      • Nelson R.E.
      • Burks R.T.
      • et al.
      Factors influencing direct clinical costs of outpatient arthroscopic rotator cuff repair surgery.
      Lastly, this study was not designed as a cost-effectiveness analysis as we only evaluated surgical direct costs. Therefore, postoperative costs including those related to complications or time off of work were not considered, and the health state of each patient over time was not assessed. Thus, it remains unclear whether factors associated with greater cost, such as an olecranon osteotomy, lead to a better outcome or not.

      Conclusion

      There is an increasing focus in our current health care climate on improving cost-effective care without affecting outcomes or quality of care.
      • Childers C.P.
      • Showen A.
      • Nuckols T.
      • Maggard-Gibbons M.
      Interventions to reduce intraoperative costs: a systematic review.
      ,
      • Okike K.
      • O'Toole R.V.
      • Pollak A.N.
      • Bishop J.A.
      • McAndrew C.M.
      • Mehta S.
      • et al.
      Survey finds few orthopedic surgeons know the costs of the devices they implant.
      ,
      • Sabesan V.J.
      • Petersen-Fitts G.R.
      • Ramthun K.W.
      • Brand J.P.
      • Stine S.A.
      • Whaley J.D.
      Strategies to contain cost associated with orthopaedic care.
      It is become increasingly important for surgeons to understand which modifiable factors can help decrease costs in treatment of specific conditions, and therefore decrease the overall burden to our health care system. We found that the majority of costs come from implants and supplies alone, and there is a large variation in surgical and implant costs. Olecranon osteotomy and duration of surgery also significantly affect the cost of distal humerus ORIF. The complexity of the fracture pattern, which is inherently associated with the need for olecranon osteotomy as well as an increase in surgical time, likely represents a clinically relevant and nonmodifiable driver of surgical cost. Therefore, surgeons should focus on carefully considering the need for olecranon osteotomy and using OR time efficiently. Measures to address sources of cost variation may improve the value of care delivered to patients.
      • Beckerman D.
      • Esparza M.
      • Lee S.I.
      • Berven S.H.
      • Bederman S.S.
      • Hu S.S.
      • et al.
      Cost analysis of single-level lumbar fusions.
      • Carducci M.P.
      • Gasbarro G.
      • Menendez M.E.
      • Mahendraraj K.A.
      • Mattingly D.A.
      • Talmo C.
      • et al.
      Variation in the cost of care for different types of joint arthroplasty.
      • Chalmers P.N.
      • Kahn T.
      • Broschinsky K.
      • Ross H.
      • Stertz I.
      • Nelson R.
      • et al.
      An analysis of costs associated with shoulder arthroplasty.
      ,
      • Haas D.A.
      • Kaplan R.S.
      Variation in the cost of care for primary total knee arthroplasties.
      ,
      • Kazmers N.H.
      • Judson C.H.
      • Presson A.P.
      • Xu Y.
      • Tyser A.R.
      Evaluation of factors driving cost variation for distal radius fracture open reduction internal fixation.
      ,
      • Uffmann W.J.
      • Christensen G.V.
      • Yoo M.
      • Nelson R.E.
      • Greis P.E.
      • Burks R.T.
      • et al.
      A cost-minimization analysis of intraoperative costs in arthroscopic Bankart repair, open Latarjet, and distal tibial allograft.

      Disclaimer

      This investigation was supported by the University of Utah Population Health Research (PHR) Foundation, with funding in part from the National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health, through Grant UL1TR002538 (formerly 5UL1TR001067-05, 8UL1TR000105, and UL1RR025764).
      The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.

      Supplementary Data

      References

        • Agency for Healthcare Research and Quality
        Medical Expenditure Panel Survey. Using appropriate price indices for analyses of health care expenditures or income across multiple years.
        (Accessed March 30, 2020)
        • Allen R.W.
        • Pruitt M.
        • Taaffe K.M.
        Effect of resident involvement on operative time and operating room staffing costs.
        J Surg Educ. 2016; 73: 979-985https://doi.org/10.1016/j.jsurg.2016.05.014
        • Amir S.
        • Jannis S.
        • Daniel R.
        Distal humerus fractures: a review of current therapy concepts.
        Curr Rev Musculoskelet Med. 2016; 9: 199-206https://doi.org/10.1007/s12178-016-9341-z
        • Ayoub M.
        • Paul Bassett W.
        • Seuffert P.
        • Matijakovich D.
        • DA O.H.
        • Butler M.S.
        Perception versus reality in the cost of orthopedic trauma implants.
        J Surg Educ. 2018; 75: 1333-1341https://doi.org/10.1016/j.jsurg.2018.02.015
        • Beckerman D.
        • Esparza M.
        • Lee S.I.
        • Berven S.H.
        • Bederman S.S.
        • Hu S.S.
        • et al.
        Cost analysis of single-level lumbar fusions.
        Global Spine J. 2020; 10: 39-46https://doi.org/10.1177/2192568219853251
        • Carducci M.P.
        • Gasbarro G.
        • Menendez M.E.
        • Mahendraraj K.A.
        • Mattingly D.A.
        • Talmo C.
        • et al.
        Variation in the cost of care for different types of joint arthroplasty.
        J Bone Joint Surg Am. 2020; 102: 404-409https://doi.org/10.2106/JBJS.19.00164
        • Chalmers P.N.
        • Kahn T.
        • Broschinsky K.
        • Ross H.
        • Stertz I.
        • Nelson R.
        • et al.
        An analysis of costs associated with shoulder arthroplasty.
        J Shoulder Elbow Surg. 2019; 28: 1334-1340https://doi.org/10.1016/j.jse.2018.11.065
        • Chen G.
        • Liao Q.
        • Luo W.
        • Li K.
        • Zhao Y.
        • Zhong D.
        Triceps-sparing versus olecranon osteotomy for ORIF: analysis of 67 cases of intercondylar fractures of the distal humerus.
        Injury. 2011; 42: 366-370https://doi.org/10.1016/j.injury.2010.09.004
        • Chen R.C.
        • Harris D.J.
        • Leduc S.
        • Borrelli Jr., J.J.
        • Tornetta 3rd, P.
        • Ricci W.M.
        Is ulnar nerve transposition beneficial during open reduction internal fixation of distal humerus fractures?.
        J Orthop Trauma. 2010; 24: 391-394https://doi.org/10.1097/BOT.0b013e3181c99246
        • Childers C.P.
        • Maggard-Gibbons M.
        Understanding costs of care in the operating room.
        JAMA Surg. 2018; 153: e176233https://doi.org/10.1001/jamasurg.2017.6233
        • Childers C.P.
        • Showen A.
        • Nuckols T.
        • Maggard-Gibbons M.
        Interventions to reduce intraoperative costs: a systematic review.
        Ann Surg. 2018; 268: 48-57https://doi.org/10.1097/SLA.0000000000002712
        • Farnworth L.R.
        • Lemay D.E.
        • Wooldridge T.
        • Mabrey J.D.
        • Blaschak M.J.
        • DeCoster T.A.
        • et al.
        A comparison of operative times in arthroscopic ACL reconstruction between orthopaedic faculty and residents: the financial impact of orthopaedic surgical training in the operating room.
        Iowa Orthop J. 2001; 21: 31-35
        • Federer A.E.
        • Mather 3rd, R.C.
        • Ramsey M.L.
        • Garrigues G.E.
        Cost-effectiveness analysis of total elbow arthroplasty versus open reduction-internal fixation for distal humeral fractures.
        J Shoulder Elbow Surg. 2019; 28: 102-111https://doi.org/10.1016/j.jse.2018.08.041
        • Galano G.J.
        • Ahmad C.S.
        • Levine W.N.
        Current treatment strategies for bicolumnar distal humerus fractures.
        J Am Acad Orthop Surg. 2010; 18: 20-30https://doi.org/10.5435/00124635-201001000-00004
        • Gofton W.T.
        • Macdermid J.C.
        • Patterson S.D.
        • Faber K.J.
        • King G.J.
        Functional outcome of AO type C distal humeral fractures.
        J Hand Surg Am. 2003; 28: 294-308https://doi.org/10.1053/jhsu.2003.50038
        • Haas D.A.
        • Kaplan R.S.
        Variation in the cost of care for primary total knee arthroplasties.
        Arthroplast Today. 2017; 3: 33-37https://doi.org/10.1016/j.artd.2016.08.001
        • Hageman M.G.
        • Guitton T.G.
        • Ring D.
        • Science of Variation Group
        How surgeons make decisions when the evidence is inconclusive.
        J Hand Surg Am. 2013; 38: 1202-1208https://doi.org/10.1016/j.jhsa.2013.02.032
        • Ilyas A.M.
        • Jupiter J.B.
        Treatment of distal humerus fractures.
        Acta Chir Orthop Traumatol Cech. 2008; 75: 6-15
        • Kazmers N.H.
        • Judson C.H.
        • Presson A.P.
        • Xu Y.
        • Tyser A.R.
        Evaluation of factors driving cost variation for distal radius fracture open reduction internal fixation.
        J Hand Surg Am. 2018; 43: 606-614.e1https://doi.org/10.1016/j.jhsa.2018.04.015
        • Kazmers N.H.
        • Presson A.P.
        • Xu Y.
        • Howenstein A.
        • Tyser A.R.
        Cost implications of varying the surgical technique, surgical setting, and anesthesia type for carpal tunnel release surgery.
        J Hand Surg Am. 2018; 43: 971-977.e1https://doi.org/10.1016/j.jhsa.2018.03.051
        • Kazmers N.H.
        • Stephens A.R.
        • Presson A.P.
        • Xu Y.
        • Feller R.J.
        • Tyser A.R.
        Comparison of direct surgical costs for proximal row carpectomy and four-corner arthrodesis.
        J Wrist Surg. 2019; 8: 66-71https://doi.org/10.1055/s-0038-1675791
        • Kazmers N.H.
        • Stephens A.R.
        • Presson A.P.
        • Yu Z.
        • Tyser A.R.
        Cost implications of varying the surgical setting and anesthesia type for trigger finger release surgery.
        Plast Reconstr Surg Glob Open. 2019; 7: e2231https://doi.org/10.1097/GOX.0000000000002231
        • Kim S.H.
        • Szabo R.M.
        • Marder R.A.
        Epidemiology of humerus fractures in the United States: nationwide emergency department sample, 2008.
        Arthritis Care Res (Hoboken). 2012; 64: 407-414https://doi.org/10.1002/acr.21563
        • Korner J.
        • Lill H.
        • Muller L.P.
        • Hessmann M.
        • Kopf K.
        • Goldhahn J.
        • et al.
        Distal humerus fractures in elderly patients: results after open reduction and internal fixation.
        Osteoporos Int. 2005; 16: S73-S79https://doi.org/10.1007/s00198-004-1764-5
        • Lee V.S.
        • Kawamoto K.
        • Hess R.
        • Park C.
        • Young J.
        • Hunter C.
        • et al.
        Implementation of a value-driven outcomes program to identify high variability in clinical costs and outcomes and association with reduced cost and improved quality.
        JAMA. 2016; 316: 1061-1072https://doi.org/10.1001/jama.2016.12226
        • Manning W.G.
        • Mullahy J.
        Estimating log models: to transform or not to transform?.
        J Health Econ. 2001; 20: 461-494https://doi.org/10.1016/s0167-6296(01)00086-8
        • Maradit Kremers H.
        • Visscher S.L.
        • Moriarty J.P.
        • Reinalda M.S.
        • Kremers W.K.
        • Naessens J.M.
        • et al.
        Determinants of direct medical costs in primary and revision total knee arthroplasty.
        Clin Orthop Relat Res. 2013; 471: 206-214https://doi.org/10.1007/s11999-012-2508-z
        • McCarty L.P.
        • Ring D.
        • Jupiter J.B.
        Management of distal humerus fractures.
        Am J Orthop (Belle Mead NJ). 2005; 34 (2005. https://www.ncbi.nlm.nih.gov/pubmed/16250484): 430-438
        • Müller M.E.
        • Allgöwer M.
        • Schneider R.
        • Willenegger H.
        Manual of internal fixation techniques recommended by the AO-ASIF Group.
        2nd ed. Springer, New York1991
        • Nauth A.
        • McKee M.D.
        • Ristevski B.
        • Hall J.
        • Schemitsch E.H.
        Distal humeral fractures in adults.
        J Bone Joint Surg Am. 2011; 93: 686-700https://doi.org/10.2106/JBJS.J.00845
        • Nguyen C.
        • Milstein A.
        • Hernandez-Boussard T.
        • Curtin C.M.
        The effect of moving carpal tunnel releases out of hospitals on reducing United States health care charges.
        J Hand Surg Am. 2015; 40: 1657-1662https://doi.org/10.1016/j.jhsa.2015.04.023
        • Ode G.E.
        • Odum S.
        • Connor P.M.
        • Hamid N.
        Ambulatory versus inpatient shoulder arthroplasty: a population-based analysis of trends, outcomes, and charges.
        JSES Int. 2020; 4: 127-132https://doi.org/10.1016/j.jses.2019.10.001
        • Okike K.
        • O'Toole R.V.
        • Pollak A.N.
        • Bishop J.A.
        • McAndrew C.M.
        • Mehta S.
        • et al.
        Survey finds few orthopedic surgeons know the costs of the devices they implant.
        Health Aff (Millwood). 2014; 33: 103-109https://doi.org/10.1377/hlthaff.2013.0453
        • Palvanen M.
        • Kannus P.
        • Niemi S.
        • Parkkari J.
        Secular trends in distal humeral fractures of elderly women: nationwide statistics in Finland between 1970 and 2007.
        Bone. 2010; 46: 1355-1358https://doi.org/10.1016/j.bone.2009.11.025
        • R Core Team
        R: A Language and Environment for Statistical Computing.
        (Available at:) (Accessed April 28, 2020)
        • Robinson C.M.
        • Hill R.M.
        • Jacobs N.
        • Dall G.
        • Court-Brown C.M.
        Adult distal humeral metaphyseal fractures: epidemiology and results of treatment.
        J Orthop Trauma. 2003; 17: 38-47https://doi.org/10.1097/00005131-200301000-00006
        • Ruan H.J.
        • Liu J.J.
        • Fan C.Y.
        • Jiang J.
        • Zeng B.F.
        Incidence, management, and prognosis of early ulnar nerve dysfunction in type C fractures of distal humerus.
        J Trauma. 2009; 67: 1397-1401https://doi.org/10.1097/TA.0b013e3181968176
        • Sabesan V.J.
        • Petersen-Fitts G.R.
        • Ramthun K.W.
        • Brand J.P.
        • Stine S.A.
        • Whaley J.D.
        Strategies to contain cost associated with orthopaedic care.
        JBJS Rev. 2018; 6: e3https://doi.org/10.2106/JBJS.RVW.17.00040
        • Sharma S.
        • John R.
        • Dhillon M.S.
        • Kishore K.
        Surgical approaches for open reduction and internal fixation of intra-articular distal humerus fractures in adults: a systematic review and meta-analysis.
        Injury. 2018; 49: 1381-1391https://doi.org/10.1016/j.injury.2018.06.018
        • Shearin J.W.
        • Chapman T.R.
        • Miller A.
        • Ilyas A.M.
        Ulnar nerve management with distal humerus fracture fixation: a meta-analysis.
        Hand Clin. 2018; 34: 97-103https://doi.org/10.1016/j.hcl.2017.09.010
        • Srinivasan K.
        • Agarwal M.
        • Matthews S.J.
        • Giannoudis P.V.
        Fractures of the distal humerus in the elderly: is internal fixation the treatment of choice?.
        Clin Orthop Relat Res. 2005; 434: 222-230https://doi.org/10.1097/01.blo.0000154010.43568.5b
        • Stephens A.R.
        • Yu Z.
        • Presson A.P.
        • Tyser A.R.
        • Kazmers N.H.
        Cost implications of varying the surgical setting and anesthesia type for de Quervain release surgery.
        J Wrist Surg. 2020; 9: 289-297https://doi.org/10.1055/s-0040-1708863
        • Streit J.J.
        • Youssef A.
        • Coale R.M.
        • Carpenter J.E.
        • Marcus R.E.
        Orthopaedic surgeons frequently underestimate the cost of orthopaedic implants.
        Clin Orthop Relat Res. 2013; 471: 1744-1749https://doi.org/10.1007/s11999-012-2757-x
        • Tashjian R.Z.
        • Belisle J.
        • Baran S.
        • Granger E.K.
        • Nelson R.E.
        • Burks R.T.
        • et al.
        Factors influencing direct clinical costs of outpatient arthroscopic rotator cuff repair surgery.
        J Shoulder Elbow Surg. 2018; 27: 237-241https://doi.org/10.1016/j.jse.2017.07.011
        • Uffmann W.J.
        • Christensen G.V.
        • Yoo M.
        • Nelson R.E.
        • Greis P.E.
        • Burks R.T.
        • et al.
        A cost-minimization analysis of intraoperative costs in arthroscopic Bankart repair, open Latarjet, and distal tibial allograft.
        Orthop J Sports Med. 2019; 7https://doi.org/10.1177/2325967119882001
        • Varecka T.F.
        • Myeroff C.
        Distal humerus fractures in the elderly population.
        J Am Acad Orthop Surg. 2017; 25: 673-683https://doi.org/10.5435/JAAOS-D-15-00683
        • Vazquez O.
        • Rutgers M.
        • Ring D.C.
        • Walsh M.
        • Egol K.A.
        Fate of the ulnar nerve after operative fixation of distal humerus fractures.
        J Orthop Trauma. 2010; 24: 395-399https://doi.org/10.1097/BOT.0b013e3181e3e273
        • Wagner E.R.
        • Ransom J.E.
        • Kremers H.M.
        • Morrey M.
        • Sanchez-Sotelo J.
        Comparison of the hospital costs for two-stage reimplantation for deep infection, single-stage revision and primary total elbow arthroplasty.
        Shoulder Elbow. 2017; 9: 279-284https://doi.org/10.1177/1758573217706364
        • Wang K.C.
        • Shih H.N.
        • Hsu K.Y.
        • Shih C.H.
        Intercondylar fractures of the distal humerus: routine anterior subcutaneous transposition of the ulnar nerve in a posterior operative approach.
        J Trauma. 1994; 36: 770-773
        • Wasterlain A.S.
        • Melamed E.
        • Bello R.
        • Karia R.
        • Capo J.T.
        • Science of Variation Group
        The effect of price on surgeons' choice of implants: a randomized controlled survey.
        J Hand Surg Am. 2017; 42: 593-601.e6https://doi.org/10.1016/j.jhsa.2017.05.005
        • Wilkinson J.M.
        • Stanley D.
        Posterior surgical approaches to the elbow: a comparative anatomic study.
        J Shoulder Elbow Surg. 2001; 10: 380-382https://doi.org/10.1067/mse.2001.116517
        • Zhang C.
        • Zhong B.
        • Luo C.F.
        Comparing approaches to expose type C fractures of the distal humerus for ORIF in elderly patients: six years clinical experience with both the triceps-sparing approach and olecranon osteotomy.
        Arch Orthop Trauma Surg. 2014; 134: 803-811https://doi.org/10.1007/s00402-014-1983-y