Distal humerus fractures (DHFs) are relatively uncommon orthopedic injuries, accounting for approximately 2%–8% of all adult fractures [1-3]. However, they represent about one-third of all humeral fractures [4]. These fractures exhibit a bimodal distribution in terms of age and mechanism: high-energy trauma is a typical cause in younger patients, while low-energy injuries, such as falls onto an outstretched hand, are more common in older adults with osteoporotic bone [5,6].

Managing DHFs presents unique challenges due to the variability in fracture morphology (e.g., displaced vs. nondisplaced, level of articular comminution), preoperative patient comorbidities, and patient functional goals, which can range from returning to high-demand activities to independent living. While nonoperative treatment may be appropriate for minor fractures or patients who are not surgical candidates, surgical intervention is often necessary for more severe injuries. Surgical options depend on the fracture type and patient factors. For significantly displaced extra-articular or simple articular fractures in younger individuals, the preferred treatment is typically open reduction and internal fixation (ORIF) to achieve prompt, rigid fixation [7,8]. In contrast, complex, highly comminuted fractures with non-reconstructable joint surfaces may require total elbow arthroplasty (TEA) in lower-demand patients, particularly for prioritizing functional recovery for independent living [9-11].

While treatment choices are generally guided by clinical factors, the influence of surgeon compensation on clinical decision-making has become increasingly examined in surgical care. In the United States, the Centers for Medicare and Medicaid Services (CMS) use relative value units (RVUs) to guide reimbursements for procedures, including surgeries. RVUs are based on various factors: physician work, such as the time needed to perform a service and the required mental and physical effort (work RVU), practice expenses (practice expense RVU), and professional liability insurance (malpractice RVU) [12,13]. The RVU system has been criticized in multiple areas of medicine, as certain surgeries have been noted to be undercompensated. In particular, distal humerus ORIF has been noted to reimburse far less than other upper extremity surgeries [14]. Research suggests that financial incentives can affect treatment choices, such as higher surgical rates and greater provision of elective procedures [15,16]. For instance, Medicare currently incentivizes open surgery over minimally invasive procedures through higher reimbursement rates, contributing to an underutilization of minimally invasive options for common surgical procedures [17,18]. Furthermore, postoperative follow-up may vary among patients with comorbidities, which could influence both treatment choice and subsequent resource allocation [19]. Each surgical option for DHF treatment carries different demands in terms of procedural complexity, operating time, and resources, which may result in varying reimbursement rates for surgeons.

Despite growing awareness of the impact of financial incentives in surgical decision-making, few studies have investigated this issue within the context of DHF management. In particular, no study has directly compared surgeon compensation between ORIF and TEA for treating DHFs. Understanding whether surgeon compensation varies by treatment choice for DHFs and assessing the potential influence of financial incentives on clinical decision-making are essential given the broader implications for resource utilization, patient outcomes, and healthcare policy. This study aims to investigate compensation differences across treatment options for DHFs and to evaluate the potential association of financial incentives with clinical decisions in orthopedic surgical care.

This retrospective study was performed using a validated, de-identified, and publicly available national database and did not require institutional review board approval or informed consent.

This study aimed to determine the mean wRVUs and wRVUs per minute associated with ORIF and TEA for DHF patients, finding that ORIF is under-compensated compared to TEA. The present results show that, although the mean operative time or 30-day postoperative complication rate did not differ between ORIF and TEA, the mean wRVU for TEA was significantly higher than that for ORIF. This resulted in a significantly greater wRVU per minute, reimbursement rate, and revenue per case for TEA compared to ORIF for DHF patients.

The primary finding of this study was that ORIF is under-compensated compared to TEA for DHF patients under the current Medicare Fee Schedule. This relationship held true when comparing wRVUs per minute and wRVUs per case. These findings are consistent with similar studies in the literature. Despite the intentions of the RVU system to provide a fair relative value to physician services, certain services may be improperly valued. In the field of orthopedics, Peterson et al. [20] determined that the lower wRVUs per minute associated with revision total knee arthroplasty compared to primary total knee arthroplasty, despite the higher complexity of the former procedure, could result in an annual compensation difference of nearly $140,000. Sodhi et al. [21] and Sugarman et al. [22] found similar results favoring primary hip and elbow arthroplasty, respectively, over revisions. However, this trend favoring primary joint arthroplasty over revision was not observed for shoulder arthroplasty. Quan et al. [23] found that revision total shoulder arthroplasty was associated with a higher wRVU per minute than primary total shoulder arthroplasty. These differences in procedure value are important because they might incentivize surgeons to perform certain procedures over others to optimize the efficiency of their practice. The present study suggests that the current Medicare Fee Schedule may incentivize surgeons to perform TEA instead of ORIF for DHF patients. To prevent potential misalignment of physician interests, the financial advantage given to TEA compared to ORIF in the context of DHF should be re-evaluated.

To fully contextualize these findings, it is important to consider the broader framework of surgical compensation in the United States beyond the wRVU system. While wRVUs are designed to reflect physician effort, including procedural complexity, operating time, and resources directly used by the surgeon, actual compensation is also shaped by additional factors such as practice expense RVU and malpractice RVU components of the Medicare Physician Fee Schedule [12,13]. Furthermore, compensation can vary based on regional cost differences [13]. These additional factors contribute to the nuanced financial incentives that can influence surgical treatment choices beyond direct procedural work and should be further studied.

The present study found no differences in 30-day postoperative complication rates when comparing ORIF and TEA for DHF. In particular, this study found no significant differences in length of stay, mortality, superficial or deep surgical site infection, urinary tract infection, vein thrombosis requiring therapy, bleeding resulting in transfusion, ventilator use >48 hours, unplanned intubation, pneumonia, myocardial infarction, stroke, renal insufficiency/failure, pulmonary embolism, wound dehiscence, sepsis, or the rates of major and minor complications between the two treatment groups. There have been mixed results in the literature comparing outcomes and complications between ORIF and TEA for DHF patients. Lovy et al. [24] found no significant differences in 30-day postoperative complication rates when comparing ORIF to TEA for elderly DHF patients but did find that postoperative length of stay was longer for TEA compared to ORIF. Medvedev et al. [25] found similar results to the present study, in which no outcomes differed significantly in the 30 days following an operation, and bleeding requiring transfusion was the most common complication. The present study adds to these findings by revealing similar results in patients in the NSQIP database from 2006 to 2022, which is a longer and more recent timespan than those of Lovy et al. [24] and Medvedev et al. [25]. In contrast, a randomized controlled trial of ORIF versus TEA for displaced elderly DHF patients conducted by McKee et al. [11] found that patients who underwent TEA had significantly better Mayo Elbow Performance Scores at 3 months, 6 months, 12 months, and 2 years compared to those who underwent ORIF. McKee et al. [11] also determined that the Disabilities of the Arm, Shoulder, and Hand scores were better in the TEA group compared to the ORIF group at 6 weeks and 6 months. That randomized controlled trial (RCT) indicates that TEA may result in better functional outcomes than ORIF for elderly DHF patients. Although the present study did not explicitly analyze functional outcomes, understanding how functional outcomes and complication rates differ is central to the decision-making process of a surgeon. Additional high-powered RCTs should be conducted to ascertain the differences in patient outcome after ORIF vs TEA for DHF. Proven differences in complication rates or outcomes necessitate reconsiderations of RVU assignment to procedures in the Medicare Fee Schedule so that physicians are not mis-incentivized by financial reasons to perform certain procedures over others.

This study is the first to analyze how value is differentially assigned to DHF patients undergoing TEA or ORIF. However, there are several relevant limitations. As a retrospective analysis of the NSQIP database, this study is limited to the accuracy of coding within the database. However, the NSQIP database offers distinct advantages over single-center studies, such as wide generalizability. Additionally, this study only analyzes short-term complication rates at 30 days postoperation and does not consider functional outcomes. The present study may also be underpowered to detect rare complications. Furthermore, wRVUs do not capture long-term care needs past the global period or the resources required for postoperative rehabilitation. Finally, this study was unable to stratify patients by type of DHF due to lack of granularity within the current CPT coding scheme. This precludes a deeper understanding of how complication rates and value per minute or operation may differ by fracture and operation type. Future research may benefit from utilizing datasets with more detailed clinical information to enable stratification by specific fracture pattern.

Despite these limitations, the present study demonstrates that ORIF is under-valued compared to TEA for DHF patients. TEA was associated with a higher wRVU per minute and wRVU per case compared to ORIF, with no differences in short-term complication rates. This suggests that, when treating DHF patients, surgeons may be incentivized to pursue TEA instead of ORIF. However, further research is necessary to discern how complication rates and outcomes differ between classes of DHFs and the different methods through which these DHFs are treated so that physician reimbursement schedules do not misalign physician and patient interests.

This study highlights significant disparities in reimbursement between TEA and ORIF for managing DHFs, with TEA demonstrating higher wRVUs and revenue potential despite comparable short-term complication rates. These findings suggest that financial incentives may influence surgical decisions, potentially favoring TEA over ORIF. While no differences in postoperative outcomes were observed, further research is needed to explore long-term functional outcomes and complications across specific fracture types. Understanding these dynamics is critical to aligning surgeon incentives with optimal patient care and refining reimbursement policies to ensure equitable and patient-centered treatment decisions.