Financial incentives and work relative value unit comparison of fixation versus total elbow arthroplasty for distal humerus fractures

Background: Distal humerus fractures (DHFs) are challenging orthopedic injuries requiring tailored management. Surgical options pri-marily include open reduction and internal fixation (ORIF) and total elbow arthroplasty (TEA) for non-reconstructable fractures. While clinical considerations typically guide treatment, recent studies have shown better surgical incentives for arthroplasty compared to ORIF. 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. Methods: A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program database was conducted for DHF cases from 2006 to 2022. Patients undergoing ORIF or TEA were matched 1:1 using propensity score matching, con-trolling for demographics and comorbidities. Work relative value units (wRVUs), operative times, Medicare reimbursement rates, and 30-day postoperative complications were compared. Results: Among the 506 matched patients (253 ORIF, 253 TEA), mean operative time was similar (P=0.903), while TEA procedures had significantly higher wRVUs per minute (0.15±0.06 vs. 0.11±0.05, P<0.001) and revenue per case ($684.05±$89.73 vs. $469.48±$36.04, P<0.001). No significant differences in 30-day postoperative complication rates, including bleeding requiring transfusion, surgical site in-fections, or major complications, were observed. Conclusions: This study demonstrates that ORIF generates lower surgeon reimbursement than TEA for DHFs despite similar short-term outcomes, suggesting that financial incentives do not favor TEA when surgically indicated. These findings underscore the need to evaluate RVU assignment to procedures, aligning physician incentives with patient care priorities. Level of evidence: IV.