At a Glance

• RTSA produced the greatest quality-adjusted life-year gains.
• RTSA was the most cost-effective option across all time horizons.
• Nonoperative treatment cost less but yielded fewer quality-adjusted life years.

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Proximal humerus fractures (PHFs) are the third most common fragility fracture seen in the elderly. Given the growing rates of fragility fractures in the United States, the economic impact of PHFs on the healthcare system remains a concern.

Few previous studies have simultaneously evaluated cost and quality-of-life outcomes when comparing treatment options for PHFs. At the AAOS 2026 Annual Meeting, researchers presented a cost-utility analysis designed to determine which treatment option provides the greatest value for older adults with PHFs.

Researchers performed a cost‑utility analysis comparing five common treatment options — nonoperative management, intramedullary nailing (IMN), open reduction and internal fixation (ORIF), hemiarthroplasty, and reverse total shoulder arthroplasty (rTSA) — for 65‑year‑old patients with PHFs. Costs and quality‑adjusted life years (QALYs) were calculated using fixed complication and revision probabilities, with Monte Carlo simulations modeling variation over two‑, five‑, and 10‑year time horizons.

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rTSA produced the highest QALYs and was the most cost-effective treatment across all three evaluated time horizons. At two years, rTSA generated 1.68 QALYs at a mean cost of $18,065, resulting in the lowest incremental cost-effectiveness ratio (ICER) of $27,190 per QALY gained.

By 10 years, rTSA yielded 7.12 QALYs for $18,236, with an ICER of $7,019 per QALY. ORIF and hemiarthroplasty were both less effective and more costly than rTSA, while nonoperative care had the lowest costs but also the fewest QALYs.

In more than half of all simulations at a willingness-to-pay threshold of $50,000 per QALY, rTSA emerged as the most cost-effective strategy.

In the context of rising fragility fractures and increasing healthcare costs, reverse shoulder arthroplasty offered the highest value among treatment options for complex proximal humerus fractures in adults older than 65. It consistently produced the greatest QALYs and outperformed both surgical and nonsurgical strategies across all evaluated time horizons, addressing the lack of cost-integrated outcome data in this population.

The authors of “Proximal Humerus Fractures in the Elderly: What Treatment Delivers the Best Value?” are Aghdas Movassaghi, BS; Chase Burzynski; Evan R Sidebotham; Jocelyn Lubert, MD; Matthew T. McKinley, MBA; and Vani Janaki Sabesan, MD, FAAOS.

Theresa Witham is the managing editor of AAOS Now.