Racial differences in type of surgical procedure performed for proximal humerus fractures

Background: Proximal humeral fracture constitutes a medical emergency on most occasions in which the decision to perform either open reduction and internal fixation (ORIF) or hemiarthroplasty is determined by the operating surgeon. Hemiarthroplasty is a more expensive and technically challenging procedure that requires compliance with rigorous and prolonged rehabilitation postsurgically. We assessed whether racial differences exist in utilization of hemiarthroplasty versus ORIF in patients with proximal humeral fracture. Methods: Patients with primary diagnosis of closed proximal humeral fracture undergoing either hemiarthroplasty or ORIF were selected from Nationwide Inpatient Sample databases for 1990-2000 (n = 10,306). Results: Among white patients with proximal humeral fracture, 35.3% underwent hemiarthroplasty when compared with 17.2% of black and 26.9% of Hispanic patients (P < 0.001). Results of multivariate analysis adjusted for age, sex, hospital volume, year, and site of fracture on proximal humerus confirmed that black patients were less likely to undergo hemiarthroplasty when compared with white patients (OR = 0.76; 95% CI = 0.54, 1.08). Conclusions: Our findings are consistent with studies documenting racial differences in utilization of elective orthopedic procedures. Given that humeral fracture is an emergency on most occasions, and our data suggest that differences in utilization more likely reflect surgeons' operative decisions than patient preferences. We cannot ascertain whether differential procedure utilization is clinically justified. Further studies are needed to confirm whether surgeons' operative decisions are a factor in the differential utilization of arthroplasty procedures by race and to understand outcomes and indications for ORIF and hemiarthroplasty, especially in black patients.