Time-driven activity-based costing comparison of intramedullary nails versus locking plates for proximal humerus fractures: what is the primary cost driver?
- 1Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, USA.
- 2Department of Orthopaedic Surgery, TRIA Orthopaedic Center, Bloomington, MN, USA.
Abstract
Background
The purpose of this study was to compare the day-of-surgery (DOS) costs between intramedullary nails and locking plate implants and identify independent predictors of total DOS cost using time-driven activity-based costing.Methods
A retrospective review of patients who underwent open reduction and internal fixation for proximal humerus fractures between 2022 and 2025 across 2 large metropolitan healthcare systems. Patients treated with intramedullary nail fixation were matched 1:1 to patients treated with locking plate fixation based on Neer classifications to ensure comparable fracture morphology. The primary outcome was total DOS cost, and secondary outcomes included implant cost, operative duration, and post-operative outcomes.Results
A total of 92 patients (46 matched pairs) were included in final analysis. On paired univariate analysis, plate fixation demonstrated significantly higher implant, direct DOS, indirect DOS, and total DOS costs compared to nail fixation (all P ≤ .013). In the multivariate mixed effect model (R² = 0.362; P < .001), intraoperative duration emerged as the strongest independent predictor of total DOS costs (β = 23.23 per minute; P < .001). Institutional site was also independently associated with cost (P = .013). Fixation type and patient characteristics were not independently associated with total DOS cost after adjustment.Conclusion
Although plate fixation demonstrated higher unadjusted DOS costs compared to nail fixation, fixation construct was not independently associated with total DOS cost after adjusting for operative time, institutional site, and patient factors. Operative time emerged as the primary driver of cost variation, suggesting that operative efficiency rather than implant selection alone determines intraoperative economic value in proximal humerus fracture fixation.
Related
- The "Sandwich" technique using a lateral locking plate and intramedullary reconstruction plate with bone cement for osteoporotic proximal humerus fractures: a case series.
- In third-generation humeral intramedullary nailing of proximal humerus fractures, a more medial and posterior starting point improves alignment, and alignment improves with surgeon experience.
- Percutaneous Versus Open Approach to Intramedullary Nailing of Metacarpal Shaft Fractures: A Comparison of 12 Week Functional Outcomes.
- Comparison of 3 Headless Compression Screw Types for Proximal, Waist, and Distal Scaphoid Fractures
- Locally manufactured versus imported proximal femoral nails: inverse probability of treatment weighting: adjusted comparison of costs and complications in intertrochanteric femur fractures
BibTeX
@article{adan2026timedriven,
title = {{Time-driven activity-based costing comparison of intramedullary nails versus locking plates for proximal humerus fractures: what is the primary cost driver?}},
author = {Fatumastar O Adan and MiKinze L Boeder and Haley D Puckett and Kehinde S Agoro and Madeline A Wethington and Audrey L Wethington and Rylan A Behnke and Nicholas F Banfield and Thomas Warfield and Brian P Cunningham and Allison J Rao},
journal = {JSES reviews, reports, and techniques},
year = {2026},
month = sep,
doi = {10.1016/j.xrrt.2026.100876},
url = {https://europepmc.org/article/MED/42898169},
note = {CC BY-NC-ND},
}
RIS
TY - JOUR
TI - Time-driven activity-based costing comparison of intramedullary nails versus locking plates for proximal humerus fractures: what is the primary cost driver?
AU - Fatumastar O Adan
AU - MiKinze L Boeder
AU - Haley D Puckett
AU - Kehinde S Agoro
AU - Madeline A Wethington
AU - Audrey L Wethington
AU - Rylan A Behnke
AU - Nicholas F Banfield
AU - Thomas Warfield
AU - Brian P Cunningham
AU - Allison J Rao
PY - 2026
DA - 2026/09/04
JO - JSES reviews, reports, and techniques
DO - 10.1016/j.xrrt.2026.100876
UR - https://europepmc.org/article/MED/42898169
AB - Background The purpose of this study was to compare the day-of-surgery (DOS) costs between intramedullary nails and locking plate implants and identify independent predictors of total DOS cost using time-driven activity-based costing.Methods A retrospective review of patients who underwent open reduction and internal fixation for proximal humerus fractures between 2022 and 2025 across 2 large metropolitan healthcare systems. Patients treated with intramedullary nail fixation were matched 1:1 to patients treated with locking plate fixation based on Neer classifications to ensure comparable fracture morphology. The primary outcome was total DOS cost, and secondary outcomes included implant cost, operative duration, and post-operative outcomes.Results A total of 92 patients (46 matched pairs) were included in final analysis. On paired univariate analysis, plate fixation demonstrated significantly higher implant, direct DOS, indirect DOS, and total DOS costs compared to nail fixation (all P ≤ .013). In the multivariate mixed effect model (R² = 0.362; P < .001), intraoperative duration emerged as the strongest independent predictor of total DOS costs (β = 23.23 per minute; P < .001). Institutional site was also independently associated with cost (P = .013). Fixation type and patient characteristics were not independently associated with total DOS cost after adjustment.Conclusion Although plate fixation demonstrated higher unadjusted DOS costs compared to nail fixation, fixation construct was not independently associated with total DOS cost after adjusting for operative time, institutional site, and patient factors. Operative time emerged as the primary driver of cost variation, suggesting that operative efficiency rather than implant selection alone determines intraoperative economic value in proximal humerus fracture fixation.
SN - 2666-6391
ER -