Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2023 Oct 3;18(1):745.
doi: 10.1186/s13018-023-04232-3.

Risk factors and healthcare costs associated with long bone fracture non-union: a retrospective US claims database analysis

Mari F Vanderkarr  1 , Jill W Ruppenkamp  1 , Mollie Vanderkarr  2 , Chantal E Holy  3   4 , Michael Blauth  5
Affiliations

Risk factors and healthcare costs associated with long bone fracture non-union: a retrospective US claims database analysis

Mari F Vanderkarr et al. J Orthop Surg Res. .

Abstract

Background: Few contemporary US-based long bone non-union analyses have recently been published. Our study was designed to provide a current understanding of non-union risks and costs, from the payers' perspective.

Methods: The Merative™ MarketScan® Commercial Claims and Encounters database was used. Patients with surgically treated long bone (femur, tibia, or humerus) fractures in the inpatient setting, from Q4 2015 to most recent, were identified. Exclusion criteria included polytrauma and amputation at index. The primary outcome was a diagnosis of non-union in the 12 and 24 months post-index. Additional outcomes included concurrent infection, reoperation, and total healthcare costs. Age, gender, comorbidities, fracture characteristics, and severity were identified for all patients. Descriptive analyses were performed. Crude and adjusted rates of non-union (using Poisson regressions with log link) were calculated. Marginal incremental cost of care associated with non-union and infected non-union and reoperation were estimated using a generalized linear model with log link and gamma distribution.

Results: A total of 12,770, 13,504, and 4,805 patients with femoral, tibial, or humeral surgically treated fractures were identified, 74-89% were displaced, and 18-27% were comminuted. Two-year rates of non-union reached 8.5% (8.0%-9.1%), 9.1% (8.6%-9.7%), and 7.2% (6.4%-8.1%) in the femoral, tibial, and humeral fracture cohorts, respectively. Shaft fractures were at increased risk of non-union versus fractures in other sites (risk ratio (RR) in shaft fractures of the femur: 2.36 (1.81-3.04); tibia: 1.95 (1.47-2.57); humerus: 2.02 (1.42-2.87)). Fractures with severe soft tissue trauma (open vs. closed, Gustilo III vs. Gustilo I-II) were also at increased risk for non-union (RR for Gustilo III fracture (vs. closed) for femur: R = 1.96 (1.45-2.58), for tibia: 3.33 (2.85-3.87), RR for open (vs. closed) for humerus: 1.74 (1.30-2.32)). For all fractures, younger patients had a reduced risk of non-union compared to older patients. For tibial fractures, increasing comorbidity (Elixhauser Index 5 or greater) was associated with an increased risk of non-union. The two-year marginal cost of non-union ranged from $33K-$45K. Non-union reoperation added $16K-$34K in incremental costs. Concurrent infection further increased costs by $46K-$86K.

Conclusions: Non-union affects 7-10% of surgically treated long bone fracture cases. Shaft and complex fractures were at increased risk for non-union.

Keywords: Bone fractures; Cost analysis; Fractures; Non-union; Risk factors.

PubMed Disclaimer

Conflict of interest statement

MFV, JWR and CEH are employees of Johnson & Johnson. MV and MB are employees of DePuy Synthes, a Johnson & Johnson Company.

Figures

Fig. 1
Fig. 1
Cumulative hazard for non-union, from day of discharge following surgical fracture repair, to 2 years post-surgery. Cumulative hazard for non-union following surgical repair of femoral, tibial and humeral fracture reached 8.5% (8.0%–9.1%), 9.1% (8.6%–9.7%) and 7.2% (6.4%–8.1%), respectively
Fig. 2
Fig. 2
Forest plot of 2-year risk ratios for non-union following femoral fractures requiring surgery
Fig. 3
Fig. 3
Forest plot of 2-year risk ratios for non-union following tibial fractures requiring surgery
Fig. 4
Fig. 4
Forest plot of 2-year risk ratios for non-union following humeral fractures requiring surgery
See this image and copyright information in PMC

References

    1. Amin S, Achenbach SJ, Atkinson EJ, Khosla S, Melton LJ., 3rd Trends in fracture incidence: a population-based study over 20 years. J Bone Miner Res. 2014;29(3):581–589. doi: 10.1002/jbmr.2072. - DOI - PMC - PubMed
    1. Bonafede M, Espindle D, Bower AG. The direct and indirect costs of long bone fractures in a working age US population. J Med Econ. 2013;16(1):169–178. doi: 10.3111/13696998.2012.737391. - DOI - PubMed
    1. Williams SA, Chastek B, Sundquist K, Barrera-Sierra S, Leader D, Jr, Weiss RJ, et al. Economic burden of osteoporotic fractures in US managed care enrollees. Am J Manag Care. 2020;26(5):e142–e149. doi: 10.37765/ajmc.2020.43156. - DOI - PubMed
    1. Tzioupis C, Giannoudis PV. Prevalence of long-bone non-unions. Injury. 2007;38(SUPPL. 2):S3. doi: 10.1016/S0020-1383(07)80003-9. - DOI - PubMed
    1. Mills LA, Simpson AHRW. The relative incidence of fracture non-union in the Scottish population (5.17 million): a 5-year epidemiological study. BMJ Open. 2013;3(2):e002276. doi: 10.1136/bmjopen-2012-002276. - DOI - PMC - PubMed