title: Surgical management for displaced pediatric proximal humeral fractures: a cost analysis.
abstract: OBJECTIVE
  The purpose of this investigation was to determine which of the following methods of fixation, percutaneous pinning (PP) or intramedullary nailing (IMN), was more cost-effective in the treatment of displaced pediatric proximal humeral fractures (PPHF).
  
  
  METHODS
  A retrospective cohort of surgically treated PPHF over a 12-year period at a single institution was performed. A decision analysis model was constructed to compare three surgical strategies: IMN versus percutaneous pinning leaving the pins exposed (PPE) versus leaving the pins buried (PPB). Finally, sensitivity analyses were performed, assessing the cost-effectiveness of each technique when infection rates and cost of deep infections were varied.
  
  
  RESULTS
  A total of 84 patients with displaced PPHF underwent surgical stabilization. A total of 35 cases were treated with IMN, 32 with PPE, and 17 with PPB. The age, sex, and preoperative fracture angulation were similar across all groups. A greater percentage of open reduction was seen in the IMN and PPB groups (p = 0.03), while a higher proportion of physeal injury was seen in the PPE group (p = 0.02). Surgical time and estimated blood loss was higher in the IMN group (p < 0.001 and p = 0.01, respectively). The decision analysis revealed that the PPE technique resulted in an average cost saving of $4,502 per patient compared to IMN and $2,066 compared to PPB. This strategy remained cost-effective even when the complication rates with exposed implants approached 55 %.
  
  
  CONCLUSIONS
  Leaving pins exposed after surgical fixation of PPHF is more cost-effective than either burying pins or using intramedullary fixation.
authors.affiliation: Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, Hunnewell 221, 300 Longwood Avenue, Boston, MA, 02115, USA, Benjamin.shore@childrens.harvard.edu.
authors.forename: Benjamin J
authors.initials: BJ
authors.lastname: Shore
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Hedequist
authors.forename: Patricia E
authors.initials: PE
authors.lastname: Miller
authors.forename: Peter M
authors.initials: PM
authors.lastname: Waters
authors.forename: Donald S
authors.initials: DS
authors.lastname: Bae