Clinical Orthopaedics

Clin Orthop Relat Res (2013) 471:1349–1355 and Related Research®

DOI 10.1007/s11999-012-2694-8 A Publication of The Association of Bone and Joint Surgeons®

CLINICAL RESEARCH

Convergence of Outcomes for Hip Fracture Fixation

by Nails and Plates
Foster Chen BS, Zhong Wang PhD, MPH,
Timothy Bhattacharyya MD

Received: 16 April 2012 / Accepted: 29 October 2012 / Published online: 27 November 2012
Ó The Association of Bone and Joint Surgeons1 2012

Abstract Questions/purposes We describe the change in outcomes

Background Recent popularity of intramedullary nails of both procedures across a 15-year span and address the
over sliding hip screws for treatment of intertrochanteric role of reimbursements in the setting of shifting patterns in
fractures is concerning given the absence of evidence for use.
clinical superiority for nailing yet the presence of reim- Methods A 5% sample of Medicare enrollees from 1993
bursement differences. to 2007 was used. Cohorts were generated along diagnostic
and procedure codes. Trends in device use by hospital type,
surgical times, and rate of revision surgeries were com-
pared. Historic reimbursements were examined.
One or more of the authors (FC) has received funding from the Results Since 2005, intramedullary nail fixation has
Clinical Research Training Program, a research program made become the more common treatment in government, non-
possible through a public-private partnership supported jointly by the profit, and for-profit hospitals. Before 1999, intramedullary
National Institutes of Health (NIH) and Pfizer Inc (through a grant to
the Foundation for NIH from Pfizer Inc). One or more of the authors nailing required 36 minutes longer to perform than plate-
(FC, ZW, TB) also were supported in part by the Intramural Research and-screw fixation on average, and had higher revision
Program of the National Institute of Arthritis and Musculoskeletal and surgery rates (hazard ratio, 2.48; CI, 1.37–4.48) and 1-year
Skin Diseases of the NIH. mortality (hazard ratio, 1.42; CI, 1.01–1.99). These dif-
All ICMJE Conflict of Interest Forms for authors and Clinical
Orthopaedics and Related Research editors and board members are
ferences were not significant since 2000. Reimbursement
on file with the publication and can be viewed on request. differences have been consistently in favor of intramedul-
Clinical Orthopaedics and Related Research neither advocates nor lary nails.
endorses the use of any treatment, drug, or device. Readers are Conclusion Intramedullary nailing of intertrochanteric
encouraged to always seek additional information, including FDA-
approval status, of any drug or device prior to clinical use. fractures has become as safe and efficient as the sliding hip
Each author certifies that his or her institution approved the human screws, but has been more popular since 2006. Reim-
protocol for this investigation, that all investigations were conducted bursements were favorable for intramedullary nails in
in conformity with ethical principles of research, and that informed times of low and high use. These results argue against the
consent for participation in the study was obtained.
This work was performed at the National Institute of Arthritis and
reimbursement difference as the sole driving force for use
Musculoskeletal and Skin Diseases, National Institutes of Health, of intramedullary nails.
Bethesda, MD, USA. Level of Evidence Level III, therapeutic study. See
Guidelines for Authors for a complete description of levels
F. Chen
of evidence.
University of California, San Diego School of Medicine,
La Jolla, CA, USA

F. Chen, Z. Wang, T. Bhattacharyya (&) Introduction

National Institutes of Health, 10 Center Drive, Mail Code 1468,
Bethesda, MD 20892-1150, USA
e-mail: timothy.bhattacharyya@nih.gov;
For the past two decades, intramedullary nails (or cepha-
tbhattacharyya@mail.nih.gov lomedullary nails) have been available as an alternative to

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1350 Chen et al. Clinical Orthopaedics and Related Research1

plate-and-screw type fixation for intertrochanteric hip Table 1. Characteristics of Medicare beneficiaries
fractures. The results of randomized controlled studies Parameter Number (%)
have been contradictory with one study showing that
intramedullary nails are equivalent to plate-and-screw Plate-and-screw Intramedullary nail
(n = 6931) (n = 1993)
devices [4] and another reporting a possible higher com-
plication rate with intramedullary nails [3]. One study Gender
documented a dramatic change in patterns in training [2] Male (number/%) 1349 (19%) 426 (21%)
and practice, and from 2000 to 2002, the rate of nail use for Female 5582 (80.5%) 1567 (78%)
treatment of intertrochanteric fractures has doubled [8]. Age, years (mean/SE) 84 (0.1) 83 (0.2)
The etiology of this rapid shift in practice is not known Race
but is concerning given the conflicting evidence in the White 6405 (92%) 1824 (92%)
current literature. The most recent Cochrane review con- Black 187 (3%) 62 (3%)
cluded that sliding hip screws were associated with Other 339 (5%) 107 (5%)
decreased rates of secondary fracture and reoperation [14],
Charlson comorbidity score
and in the absence of clear evidence of clinical superiority
0 3638 (53%) 947 (48%)
for intramedullary nails, some authors have speculated that
1 2146 (31%) 640 (32%)
the reimbursement difference between the two procedures
2 722 (10%) 245 (12%)
is the likely cause of the shift [2, 8]. However, a separate
C3 425 (6%) 161 (8%)
meta-analysis compared the results of studies regarding
one popular nail design before and after 2000 and found SE = standard error.
that although studies based on early designs led to higher
risks of complications, they were resolved when consid-
ering only more recent studies [5]. Previous studies showed 9th diagnosis code of 820.XX and further by Current Pro-
that government-owned hospitals tend to be less apt to cedural Terminology (CPT) codes for treatment by plate-
perform costly surgical procedures for the hospital and tend and-screw device (27244) and intramedullary nail device
to offer services to patients with lesser regard to revenue (27245). A total of 8924 patients with 1-year followup data
[17], whereas for-profit hospitals are more likely to use were identified between 1993 and 2007. Demographic
newer technologies as a form of competition [9]. One distributions were similar between the two groups
might hypothesize that for-profit-hospitals, for the reasons (Table 1). We collected data on age, sex, comorbidity, and
mentioned above, might use nailing technologies at a dif- census region for each patient.
ferent rate from other hospitals. We studied complications after hip fracture fixation by
Although observed for one line of devices, it remains to identifying patients who had returned to the operating room
be shown if intramedullary nail outcomes have improved within 365 days after their initial procedure. Complications
as a class. In this study, we took an epidemiologic approach such as conversion to hip arthroplasty, removal of hard-
to study this shift in practice using a 5% Medicare sample ware, and nonunion surgery were identified by CPT code
from 1993 to 2007. We hypothesized that outcomes and [3]. One-year mortality also was captured among these
efficiency of nailing improved at approximately the time of patients. Because of the introduction of several devices
its increased use, and higher reimbursement for nailing near the turn of the millennium, we stratified the cohort
would expedite its use at a different pace across hospitals into two: for 1993 to 1999 and 2000 to 2007.
with different cost structures. We calculated the percentage of intertrochanteric frac-
tures treated by nails or plates for each calendar year and
compared the proportions of treatments performed in
Patients and Methods government-owned hospitals with nonprofit and for-profit
hospitals.
We obtained the Medicare 5% sample from the Surveil- We calculated the anesthesia time and surgical time
lance, Epidemiology and End Results (SEER) regions using anesthesia billing claims. This method was described
minus any patients with any cancer diagnosis according to by Silber et al. [16]. The appropriate anesthesia codes for
SEER registry, to eliminate most pathological fractures our study began with 011 and 012 and represented anes-
related to cancer [11]. This data set contains longitudinal thesia administered for procedures of the pelvis and upper
billing data on Medicare beneficiaries in the United States, leg, respectively. Surgical times were estimated by the
ranging from 291,832 individuals in 1993 to 485,115 following equation: surgical time = (0.82 9 anesthesia
individuals in 2005. We identified patients who sustained a time 9 23.81). This equation was the result of linear
hip fracture by the International Classification of Diseases, regression models for anesthesia times on various

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orthopaedic procedures [8]. The median surgical times for

each year were plotted.
Finally, we calculated the mean reimbursements pro-
vided to the physician by Medicare for each procedure
between 1993 and 2007. This value was taken to be the
amount paid by Medicare and any deductibles owed
the patient. In cases in which multiple payments were filed,
the largest single payment was taken to be the amount
reimbursed for the actual procedure. We also compared the
intended reimbursement from the total relative value units
(RVU) recorded annually for these two procedures for each
year from records from the federal register.
Trends of use were descriptive. The adjusted Cox pro-
portional hazards model was used to generate Kaplan-
Meier survival curves and hazard ratios for complication
and mortality rates. Covariates included age (65–69,
70–74, 75–79, 80–84, 85–89, 90+ years), race (white,
nonwhite), sex, and Charlson comorbidity index (0, 1, 2,
3+). Median surgical times were plotted for each year,
whereas mean surgical times with 95% CIs were calculated
for 1993 to 1999 and 2000 to 2007 for both procedures.
Mean reimbursements for each year were adjusted to 2007
values according to the Consumer Price Index for each year
and procedure. Fig. 1A–B Survival curves for complication rates from (A) 1993 to
1999 and (B) 2000 to 2007 show that complications in reoperations
occurred more frequently before 2000, but these differences were not
significant after 2000.
Results

After 2000 adverse outcomes associated with the use of

intramedullary nails were less frequent and the results
became similar to those for plates and screws. From 1993
to 1999, complications were 2.48 times more likely (95%
CI, 1.37–4.48) to occur in patients treated with an intra-
medullary nail than in patients treated with a plate-and-
screw device (Fig. 1). However, from 2000 to 2007, there
was no increased risk of complications between the two
procedures (hazard ratio, 1.11; 95% CI, 0.82–1.51). From
1993 to 1999, 1-year mortality was slightly higher for
individuals treated with an intramedullary nail as well
(hazard ratio, 1.42; 95% CI, 1.01–1.99). From 2000 to
2007, there was no difference in mortality between the two
groups (hazard ratio, 0.96; 95% CI, 0.86–1.07) (Fig. 2).
Beginning in 2001, a rapid increase in the proportion of
fractures treated with intramedullary nails was observed,
peaking at 65% in 2007. From 1993 to 2000, less than 10%
of intertrochanteric hip fractures were treated with intra-
medullary nails. This rapid increase in intramedullary nail
fixation was seen in for-profit, nonprofit, and government-
owned hospitals. (Fig. 3).
Surgical time for nailing declined rapidly after 2000.
From 1993 to 1999, the mean surgical time required for
Fig. 2A–B Survival curves for (A) 1993 to 1999 and (B) 2000 to
intramedullary nail fixation of intertrochanteric fractures 2007 show that 1-year mortality had worse outcomes for recipients of
was 124 minutes (95% CI, 111–137 minutes) compared nails, but these differences were not significant after 2000.

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Fig. 3 Trends in the use of intra-

medullary nails and sliding screw
plates from control samples of
Medicare beneficiaries in SEER
regions from 1993 to 2007 are
shown. The proportions of intra-
medullary nail use increased
across all hospital types. FP = for
profit; NFP = not-for-profit; Gov =
government.

expense components. On average, actual reimbursements

for intramedullary nail fixation were 18% more than the
reimbursements for plate-and-screw fixation. Adjusted for
inflation, the reimbursement for both procedures has
declined 16% since 2002.

Discussion

In this study, we found there was an improvement in out-

comes with the use of intramedullary nails. Its rates of
revision surgery and mortality were not significantly dif-
ferent from those for sliding hip screws since 2000. We
Fig. 4 Trends in surgical time for intramedullary nails and sliding
screw plates from control samples of Medicare beneficiaries in SEER
also found nails have been used uniformly across multiple
regions from 1993 to 2007 are shown. Surgical time was derived from hospital ownership types with presumably different cost
the median time from the anesthesiologist’s claim. structures, and have become as efficient as the traditional
procedure. In the actual and intended reimbursements,
with 88 minutes (95% CI, 86–89 minutes) for plate-and- although nails may have been more favorably reimbursed,
screw fixation. From 2000 to 2007, the mean surgical time this remained in times of low and high use. These findings
for intramedullary nail fixation showed a 42% improve- suggest that additional factors in addition to reimbursement
ment to 71 minutes (95% CI, 70–73). The mean surgical incentives were involved in increased use of intramedullary
time for plate-and-screw fixation also experienced an nails.
improvement to 70 minutes (95% CI, 69–72 minutes). A Our study has several limitations. First, although
gradual decline in the median surgical time was seen administrative data are strong for identifying nationwide
between 1997 and 2001 (Fig. 4). trends and rates of return to the operating room, no clinical
Intramedullary nail fixation has been reimbursed con- (such as functional outcomes) or radiographic data are
sistently at a rate higher than plates and screws (Fig. 5), yet available. Certain outcomes, such as severe shortening
use of nails was uncorrelated with reimbursement differ- treated with a shoe lift, would not be identified. Although
ences. Before 1999, plates actually were reimbursed 11% we have data regarding ownership status of each hospital,
less than nails (range, 11.1%–11.6%), but from 1999 we have no data regarding payment structures for the
onward, plates were reimbursed 20% less than nails (range, physicians. Finally, one reasonable interpretation of these
18.1%–20.2%). In 2000, there was a cut to the total data is that these improvements resulted in clinical equiv-
Medicare RVU assignment for plate-and-screw fixation as alence of the two procedures, which then allowed
calculations transitioned from a charge-based value method nonclinical factors to sway decision-making. Our data can
to a resource-based method for the practice and malpractice neither prove nor disprove this theory but in the least

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Fig. 5 The mean Medicare payments

(in US dollars) to surgeons and total
relative value units for the two proce-
dures are shown. Differences in reim-
bursement between intramedullary nails
and plates were substantial for all years
except 1993 and 1998. The error bars
indicate the 95% CIs. Dollars were
Consumer Price Index-adjusted to
2007. RVU (relative value unit) infor-
mation was derived from the annual
final ruling for physician fee schedules
by the Centers of Medicare & Medicaid
Services recorded in the Federal
Register.

confirm that no detriment (in terms of complications) is changes, but we speculate that the release of these
currently occurring in the switch to intramedullary nailing. improved nail designs (whether real or simply for mar-
Medicare claims data have been used to study trends in keting), along with their accompanying more surgeon-
intertrochanteric fracture fixation. Forte et al. [7] used a friendly instrumentation and the ability to be inserted with
100% sample to study factors associated with nailing and and without reaming, contributed to the rapid increase in
found that surgeons using nails were younger, whereas the use of intramedullary nails. It is likely that increased
hospitals using nails were more often teaching hospitals. marketing efforts at the time of release of the new nail
Using a 20% Medicare sample from 1999 to 2001, Aros design also raised awareness of the suitability of intra-
et al. [3] found that nailing may result in higher compli- medullary nails for hip fractures.
cation rates and expressed concern considering higher Although studies have failed to show a consistent benefit
reimbursements. for intramedullary nail fixation over plate-and-screw fixa-
However, that study captured a transitional period and tion for intertrochanteric hip fractures [1, 4], newer studies
likely does not include many newer technologies. The no longer show a greater complication risk [13, 18, 20]. In
original Gamma1 Nail (Stryker, Mahwah, NJ, USA) was a meta-analysis of the Gamma nail alone, the increased
introduced in the United States in 1988 and Smith & risks of complications of earlier designs of the Gamma nail
Nephew (London, UK) launched the Intramedullary Hip were resolved when considering only studies from 2000 to
Screw in 1991. Although there was initial concern for 2005 [5]. Our study agrees with the findings of Bhandari
fracture at the tip of the Gamma nail, outcomes improved et al. [5] and is the first to show an improvement in out-
with a second-generation Gamma nail in 1997 [5]. How- comes from an epidemiologic perspective.
ever, the results of these obsolete designs are still Bozic and Jacobs cited the reimbursement difference as
incorporated into current meta-analyses. The most recent the cause for a shift toward intramedullary nails [6], but we
Cochrane review that was in favor of plate-and-screw fix- believe the explanation for the shift toward intramedullary
ation relied heavily on studies of these two products [14]. nails is much more benign than that of reimbursement
After this period, there was a boom in the market for alone. We found that intramedullary nail use increased
new cephalomedullary nail devices. Smith & Nephew beginning in 2001 and occurred simultaneously across all
launched TrigenTM Nails in 1999, advertising a trapezoidal hospital ownership types. Although initially a much longer
nail profile and multiple interlocking screws. DePuy procedure, the time required for intramedullary nailing
Orthopaedics (Warsaw, IN, USA) launched the ATN1 decreased substantially. Intramedullary nail use had been
trochanteric nail in 2001, boasting a new alloy, closely associated with higher risks of complications and mortality
spaced antirotation screws, color-coded instrument trays, before 2000, but since 2000, these differences have dis-
and radiolucent insertion and targeting jigs. Synthes (Paoli, appeared. It is likely that as surgeons gained experience
PA, USA) introduced the Trochanteric Fixation Nail in with nailing in the late nineties, more residents were
2002, which includes a helical blade, lateral entry point, trained in their use and chose to use them as they moved
and new titanium alloy material. Stryker also updated the into independent practice [2].
Gamma1 Nail in 2003, incorporating a new alloy and short For-profit hospitals frequently have been the early
and long designs. Few studies exist regarding these design adopters as they have more capital to invest in newer

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1354 Chen et al. Clinical Orthopaedics and Related Research1

technologies as a form of nonprice competition [9]. For- 2. Anglen JO, Weinstein JN; American Board of Orthopaedic Surgery
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