Open reduction–internal fixation versus intramedullary nailing for humeral shaft fractures: an expected value decision analysis

Nicholas J. Zarkadis*, Emmanuel D. Eisenstein, Nicholas A. Kusnezov, John C. Dunn, James A. Blair

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

12 Scopus citations


Background Previous randomized controlled studies and meta-analyses have failed to collectively favor either open reduction–internal fixation (ORIF) or intramedullary nailing (IMN) fixation. The purpose of our investigation was to elucidate the optimal decision between ORIF and IMN for acute traumatic operative humeral shaft fractures through an expected value decision analysis. Methods We performed an expected value decision analysis and sensitivity analysis to elucidate the difference between ORIF and IMN fixation for patients with acute traumatic humeral shaft fractures. We surveyed 100 consecutive, randomly selected volunteers for their outcome preferences. Outcomes included union, delayed union, major complications, minor complications, and infection. A literature review was used to establish probabilities for each of these respective outcomes. A decision tree was constructed and a fold-back analysis was performed to find an expected patient value for each treatment option. Results The overall patient expected values for ORIF and IMN were 12.7 and 11.2, respectively. Despite artificially decreasing the rates of major complications, infection, delayed union, and nonunion each to 0% for IMN fixation (sensitivity analysis), ORIF continued to maintain a greater overall patient expected value (12.7 vs. 11.4, 11.2, 11.2, and 12.1, respectively). Only if the rate of nonunion after ORIF was increased from 6.1% to 16.8% did the overall expected outcome after ORIF equal that of IMN (11.2). Conclusion Our expected value decision analysis demonstrates that patients favor ORIF over IMN as the optimal treatment decision for an acute traumatic humeral shaft fracture.

Original languageEnglish
Pages (from-to)204-210
Number of pages7
JournalJournal of Shoulder and Elbow Surgery
Issue number2
StatePublished - Feb 2018
Externally publishedYes


  • Humerus fracture
  • decision analysis
  • diaphyseal humerus fracture
  • fracture fixation
  • intramedullary nail
  • plating


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