The cost of care in maxillofacial fractures treatment in relation to the type of fixation and length of stay at a tertiary care hospital of Karachi, Pakistan: A retrospective chart review.

In addition to the clinical burden of trauma, the financial burden is an important aspect of care globally, especially for patients in low- and middle-income countries. The current retrospective review was done of data from January 2015 to December 2020 related to patients of oral maxillofacial trauma management in a tertiary care setting. Analysis of variance was used to determine the mean difference in the cost incurred depending upon the type of trauma and the number of bone plates used in fracture management. Pearson correlation was applied to explore any correlation involving patient age, aetiology and type of fracture, number of bone plates employed and the length of stay in the hospital. No statistically significant differences were noted in the cost among the different groups. The cost of care was significantly (p<0.001) correlated to the length of stay. Other variables, such as the type of fractures and the number of plates, had no significant impact (p>0.05).

Anterior internal versus external fixation of unstable pelvis fractures was not associated with discharge destination, critical care, length of stay, or hospital charges.

PURPOSE: Determine if anterior internal versus supra-acetabular external fixation of unstable pelvic fractures is associated with care needs or discharge. METHODS: A retrospective cohort study was performed at two tertiary trauma referral centers. Adults with unstable pelvis fractures (AO/OTA 61B/61C) who received operative fixation of the anterior and posterior pelvic ring by two orthopedic trauma surgeons from October 2020 to November 2022 were included. The primary outcome was discharge destination. Secondary outcomes included intensive care unit (ICU) or ventilator days, length of stay, and hospital charges. RESULTS: Eighty-three eligible patients were 38.6% female, with a mean age of 47.2 ± 20.3 years and BMI 28.1 ± 6.4 kg/m2. Fifty-nine patients (71.1%) received anterior pelvis internal fixation and 24 (28.9%) received external fixation. External fixation was associated with weight-bearing restrictions (91.7% versus 49.2%, p = 0.01). No differences in demographic, functional status, insurance type, fracture classification, or injury severity measures were observed by treatment. Internal versus external anterior pelvic fixation was not associated with discharge to home (49.2% versus 29.2%, p = 0.10), median ICU days (3.0 [interquartile range (IQR) 7.8 versus 5.5 [IQR 4.3], p = 0.14, ventilator days (0 [IQR 6.0] versus 0 [IQR 2.8], p = 0.51), length of stay (13.0 [IQR 13.0] versus 17.5 (IQR 20.5), p = 0.38), or total hospital charges (US dollars 180,311 [IQR 219,061.75] versus 243,622 [IQR 187,111], p = 0.14). CONCLUSIONS: Anterior internal versus supra-acetabular external fixation of unstable pelvis fractures was not significantly associated with discharge destination, critical care, hospital length of stay, or hospital charges. This sample may be underpowered to detect differences between groups. LEVEL OF EVIDENCE: Therapeutic Level IV.

Predictors of Episode-of-Care Costs for Ankle Fractures.

Ankle fractures are one of the most resource-consuming traumatic orthopedic injuries. Few studies have successfully evaluated the episode-of-care costs (EOCC) of common traumatic orthopedic injuries. The objective of this study was to determine the EOCC associated with the surgical management of ankle fractures. A retrospective cohort study of 105 consecutive patients who underwent open reduction internal fixation of an isolated ankle fracture at a Canadian Level-1 trauma center was conducted. Episode-of-care costs were generated using an activity-based costing framework. The median global episode-of-care cost for ankle fracture surgeries performed at the studied institution was $3,487 CAD [IQR 880] ($2,685 USD [IQR 616]). Patients aged 60 to 90 years had a significantly higher median EOCC than younger patients (p = .01). Supination-adduction injuries had a significantly higher median EOCC than other injury patterns (p = .01). The median EOCC for patients who underwent surgery within 10 days of their injury ($3,347 CAD [582], $2,577 USD [448]) was significantly lower than the cost for patients who had their surgery delayed 10 days or more after the injury ($3,634 CAD [776], $2,798 USD [598]) (p = .03). Patient sex, anesthesia type, ASA score and surgeon's fellowship training did not affect the EOCC. This study provides valuable data on predictors of EOCC in the surgical management of ankle fractures. Delaying simple ankle fracture cases due to operating time constraints can increase the total cost and burden of these fractures on the healthcare system. In addition, this study provides a framework for future episode-of-care cost analysis studies in orthopedic surgery.

Safety and Outcome Measures of Ankle Open Reduction and Internal Fixation in an Ambulatory Surgical Center.

The transition of traditionally hospital-based orthopedic procedures to the ambulatory surgery center setting provides many benefits from a patient care and financial perspective. Specifically, closed ankle fractures can potentially be managed at such centers without needing hospitalization. Adding to the paucity of data, this study describes the safety, cost, and outcomes of patients undergoing ankle fracture repair in an ambulatory surgery center. A retrospective chart review of 100 patients who underwent ankle fracture open reduction and internal fixation from a single ambulatory surgery center by 1 surgeon were reviewed. Demographic data, surgical characteristics including operating time and cost were collected. Short- and long-term complications, as well as, reoperation rates were reported and functional outcomes were described. Of the 100 patients, 59% were female and the overall average age was 50 ± 16 years. The average cost per case was $8,709.63 ± 6,360.18. The short-term complication rate was 16%, with surgical site infection reported as the most common complication. No postoperative hospital admissions were reported. Planned and unplanned hardware removal was performed in 7% and 5% of patients, respectively. The delayed union rate was 13%, in which 86% shared a history of smoking. Smoking history was the only statistically significant predictor of prolonged bone healing (p = .002). This investigation demonstrates low complications rates for surgeries performed in a surgery center when compared to historical rates of those procedures performed in the hospital. These results suggest that ambulatory surgery center-based ankle fracture repair does not increase complications while may decrease overall cost when compared to ankle ORIF in a hospital setting.

Valgus-impacted subcapital neck of femur fractures: a systematic review, meta-analysis with cost analysis of fixation in-situ versus nonoperative management.

BACKGROUND: The management of the valgus-impacted neck of femur fracture (AO/OTA 31-B1) remains contentious. The objective of this study was to determine whether operative intervention is cost-effective. METHODS: We conducted a systematic review using electronic databases (Medline, Embase, Cochrane, Ebsco, Scholar) identifying studies published in the English language concerning valgus-impacted neck of femur fractures until June 2022. Additional studies were identified through hand searches of major orthopaedic journals, and bibliographies of major orthopaedic textbooks. MeSH terms (hip fracture and femoral neck fracture) and keywords (undisplaced, valgus-impacted, valgus, subcapital, Garden) connected by the Boolean operators "AND" and "OR" were used to identify studies. 2 reviewers independently extracted the data using standardised forms and recording spreadsheet. Methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Meta-analysis of Statistics Assessment and Review Instrument. Meta-analysis was undertaken. Outcome measures were rate of displacement, avascular necrosis, non-union, mortality and requirement of further operative intervention. A cost utility analysis was then conducted to compare the 2 groups on the basis of the cost of initial treatment and the potential requirement of secondary intervention to hemiarthroplasty. RESULTS: 47 studies met the inclusion criteria. Meta-analysis data demonstrated a significant difference in the displacement rate of 22.8% and 2.8% between the nonoperative and internal fixation groups respectively (p = 0.05). The overall incidence of further operative intervention for each group was 23% and 10% respectively. There was no significant difference with respect to avascular necrosis, mortality or union rates. The cost utility analysis revealed nonoperative management to be approximately 60% more costly than initial internal fixation when the costs of subsequent surgery were included. CONCLUSIONS: This meta-analysis of the existing literature concludes that whilst nonoperative management is possible for valgus impacted neck of femur fractures, it is associated with higher complication rates and greater expense than management by internal fixation.

Geriatric Distal Femur Fractures Treated with Arthroplasty Are Associated with Lower Mortality but Greater Costs Compared with Open Reduction and Internal Fixation at 30 Days.

Distal femur fractures (DFFs) are common injuries with significant morbidity. Surgical options include open reduction and internal fixation (ORIF) with plates and/or intramedullary devices or a distal femur endoprosthesis (distal femur replacement [DFR]). A paucity of studies exist that compare the two modalities. The present study utilized a 1:2 propensity score match to compare 30-day outcomes of geriatric patients with DFFs who underwent an ORIF or DFR. The National Surgical Quality Improvement Program data from 2008 to 2019 were utilized to identify all patients who sustained a DFF and underwent either ORIF or DFR. This yielded 3,197 patients who underwent an ORIF versus 121 patients who underwent a DFR. A final sample of 363 patients (242 patients with ORIF vs. 121 with DFR) was obtained after a 1:2 propensity score match. Costs were obtained from the National Inpatient Sample database using multiple regression analysis and validated with a 7:3 train-test algorithm. Independent samples t-tests and chi-square analysis were conducted to assess cost and outcome differences, respectively. Patients who received a DFR had higher transfusion rates than ORIF (p = 0.021) and higher mean inpatient hospital costs (p = 0.001). Subgroup analysis for patients 80 years of age or older revealed higher 30-day unplanned readmission (0 vs. 18.2%; p < 0.001) and 30-day mortality (0 vs. 18.2%; p < 0.001) rates for patients undergoing ORIF compared with DFR. The total number of DFR cases needed to prevent one ORIF-related 30-day mortality for DFR for patients 80 years of age was 6 (95% confidence interval: 3.02-19.9). The mean hospital costs associated with preventing one case of death within 30 days from operation by undergoing DFR compared with ORIF was $176,021.39. Our results demonstrate higher rates of transfusion and increased inpatient costs among the DFR cohort compared with ORIF. However, we demonstrate lower rates of mortality for patients 80 years and older who underwent DFR versus ORIF. Future studies randomized controlled trials are necessary to validate the results of this study.

Surgical plating versus closed reduction for fractures in the distal radius in older patients: a cost-effectiveness analysis from the hospital perspective.

BACKGROUND: Given the cost differential between surgical and non-surgical management of distal radius fractures, we aimed to evaluate the cost-effectiveness of surgical compared with non-surgical treatment of distal radius fractures in a cohort of older patients. METHODS: This evaluation was conducted alongside the combined randomized and observational study of surgery for fractures of the distal radius in the elderly (CROSSFIRE) trial (ACTRN 12616000969460) which compared surgical (open reduction and internal fixation using volar-locking plate (VLP) fixation) and non-surgical (closed fracture reduction and cast immobilization (CR)) treatment for displaced distal radius fractures in patients ≥60 years. Cost-effectiveness was assessed from the perspective of the public hospital funder. Hospital records from a sub-sample of participants were used to estimate costs. Outcomes were patient-reported wrist pain and function questionnaire (PRWE) scores and quality adjusted life years (QALYs) calculated using the EuroQoL five-dimension five-level tool (EQ-5D-5L). RESULTS: From 166 participants (81 surgical, 85 non-surgical), costs were obtained for 56 (29 surgical, 27 non-surgical). The mean costs for VLP fixation were Australian dollars (AUD) 6668 (95% CI $4857 to $8479) compared to AUD 3343 (95% CI $1304 to $5381) for CR. The incremental cost-effectiveness ratios (ICER) to achieve a 1-point improvement in the PRWE were AUD 375, AUD 1736 and AUD 1126 at 3, 12 and 24 months for VLP compared with CR. At 12 months, the cost effectiveness was dominated by CR (lower cost and better QoL) whereas at 24 months, the incremental cost per QALY gained by VLP was AUD 1 946 127. CONCLUSION: In the treatment of distal radius fractures in patients ≥60 years, VLP fixation was not cost-effective compared with CR from the perspective of hospital funders.

The clinical and economic burden of proximal femur periprosthetic fractures.

BACKGROUND: The number of hip replacements is constantly and progressively increasing, resulting in an increase in periprosthetic fractures. The main aim of this study is to analyze costs and outcomes of surgical treatment for those fractures. MATERIALS AND METHODS: A retrospective study was performed on periprosthetic proximal femur fracture presented a single-level I trauma center. Medical records were reviewed in terms of demographic data, diagnosis (according to Vancouver classification), type of surgical treatment, hospitalization length and follow-up. Patients were interviewed about number of consultations after discharge, medications and physiotherapy sessions. Clinical outcome was evaluated with WOMAC score at the last follow-up, and patient health status was evaluated with the EQ5D5L score pre-trauma and at the last follow-up. Patients were divided into two groups according to surgical treatment: reduction and internal fixation alone and revision plus fixation. A further group was also considered: patients underwent a Girdlestone procedure. Global costs for each group were calculated. RESULTS: We initially recruited 117 patients, 17 of them were lost at follow-up. Furthermore, 19 patients (19%) died during the follow-up, and 81 of them were therefore included in the study. Mean follow-up was 26.5 months. Mean postoperative WOMAC score was 39.44, and EQ5D5L score was 9.12 for the preoperative period and 12.35 at the last follow-up. A significant worsening of clinical conditions was found comparing the period before fracture to the last follow-up (p < 0.01). Quality of life after surgery resulted to be poor or fair in 40% of the patients at a mean follow-up of 26.5 months. No significant differences between groups were found according to patients' health status. Mean global costs for mayor surgeries were 18,822 Euros; mean costs for fixation alone were 17,298 Euros while for fixation and revision were 20,966 Euros, but no statistically difference was found between these two groups. Mean cost for Girdlestone group was 12,664 Euros. CONCLUSIONS: In proximal femur periprosthetic fractures, either fixation or revision plus fixation presents high costs but patients' postoperative quality of life is poor.

Cost Analysis of Volar Plate Fixation Versus Plaster Cast Immobilization for Intra-Articular Distal Radial Fractures.

BACKGROUND: The aim of this study was to compare the cost-effectiveness and cost-utility between plaster cast immobilization and volar plate fixation for acceptably reduced intra-articular distal radial fractures. METHODS: A cost-effectiveness analysis was conducted as part of a randomized controlled trial comparing operative (volar plate fixation) with nonoperative (plaster cast immobilization) treatment in patients between 18 and 75 years old with an acceptably reduced intra-articular distal radial fracture. Health-care utilization and use of resources per patient were documented prospectively and included direct medical costs, direct non-medical costs, and indirect costs. All analyses were performed according to the intention-to-treat principle. RESULTS: The mean total cost per patient was $291 (95% bias-corrected and accelerated confidence interval [bcaCI] = -$1,286 to $1,572) higher in the operative group compared with the nonoperative group. The mean total number of quality-adjusted life-years (QALYs) gained at 12 months was significantly higher in the operative group than in the nonoperative group (mean difference = 0.15; 95% bcaCI = 0.056 to 0.243). The difference in the cost per QALY (incremental cost-effectiveness ratio [ICER]) was $2,008 (95% bcaCI = -$9,608 to $18,222) for the operative group compared with the nonoperative group, which means that operative treatment is more effective but also more expensive. Subgroup analysis including only patients with a paid job showed that the ICER was -$3,500 per QALY for the operative group with a paid job compared with the nonoperative group with a paid job, meaning that operative treatment is more effective and less expensive for patients with a paid job. CONCLUSIONS: The difference in QALYs gained for the operatively treated group was equivalent to an additional 55 days of perfect health per year. In adult patients with an acceptably reduced intra-articular distal radial fracture, operative treatment is a cost-effective intervention, especially in patients with paid employment. Operative treatment is slightly more expensive than nonoperative treatment but provides better functional results and a better quality of life. LEVEL OF EVIDENCE: Economic and Decision Analysis Level I. See Instructions for Authors for a complete description of levels of evidence.

What Factors Are Associated with Increased Financial Burden and High Financial Worry For Patients Undergoing Common Hand Procedures?

BACKGROUND: Few studies have examined whether orthopaedic surgery, including hand surgery, is associated with patients' financial health. We sought to understand the level of financial burden and worry for patients undergoing two common hand procedures-carpal tunnel release and open reduction and internal fixation for a distal radius fracture-as well as to determine factors associated with a higher financial burden and worry. QUESTIONS/PURPOSES: In patients undergoing operative treatment for isolated carpal tunnel syndrome with carpal tunnel release or open reduction and internal fixation for a distal radius fracture, we used validated financial burden and worry questionnaires to ask: (1) What percentage of patients report some level of financial burden, and what is the median financial burden composite score? (2) What percentage of patients report some level of financial worry, and what percentage of patients report a high level of financial worry? (3) When accounting for other assessed factors, what patient- and condition-related factors are associated with financial burden? (4) When accounting for other assessed factors, what patient- and condition-related factors are associated with high financial worry? METHODS: In this cross-sectional survey study, a hand and upper extremity database at a single tertiary academic medical center was reviewed for patients 18 years or older undergoing operative treatment in our hand and upper extremity division for an isolated distal radius fracture between October 2017 and October 2019. We then selected all patients undergoing carpal tunnel release during the first half of that time period (given the frequency of carpal tunnel syndrome, a 1-year period was sufficient to ensure comparable patient groups). A total of 645 patients were identified (carpal tunnel release: 60% [384 of 645 patients]; open reduction and internal fixation for a distal radius fracture: 40% [261 of 645 patients). Of the patients who underwent carpal tunnel release, 6% (24 of 384) were excluded because of associated injuries. Of the patients undergoing open reduction and internal fixation for a distal radius fracture, 4% (10 of 261) were excluded because of associated injuries. All remaining 611 patients were approached. Thirty-six percent (223 of 611; carpal tunnel release: 36% [128 of 360]; open reduction and internal fixation: 38% [95 of 251]) of patients ultimately completed two validated financial health surveys: the financial burden composite and financial worry questionnaires. Descriptive statistics were calculated to report the percentage of patients who had some level of financial burden and worry. Further, the median financial burden composite score was determined. The percentage of patients who reported a high level of financial worry was calculated. A forward stepwise regression model approach was used; thus, variables with p values < 0.10 in bivariate analysis were included in the final regression analyses to determine which patient- and condition-related factors were associated with financial burden or high financial worry, accounting for all other measured variables. RESULTS: The median financial burden composite score was 0 (range 0 [lowest possible financial burden] to 6 [highest possible financial burden]), and 13% of patients (30 of 223) reported a high level of financial worry. After controlling for potentially confounding variables like age, insurance type, and self-reported race, the number of dependents (regression coefficient 0.15 [95% CI 0.008 to 0.29]; p = 0.04) was associated with higher levels of financial burden, while retired employment status (regression coefficient -1.24 [95% CI -1.88 to -0.60]; p < 0.001) was associated with lower levels of financial burden. In addition, the number of dependents (odds ratio 1.77 [95% CI 1.21 to 2.61]; p = 0.004) and unable to work or disabled employment status (OR 3.76 [95% CI 1.25 to 11.28]; p = 0.02) were associated with increased odds of high financial worry. CONCLUSION: A notable number of patients undergoing operative hand care for two common conditions reported some degree of financial burden and worry. Patients at higher risk of financial burden and/or worry may benefit from increased resources during their hand care journey, including social work consultation and financial counselors. This is especially true given the association between number of dependents and work status on financial burden and high financial worry. However, future research is needed to determine the return on investment of this resource utilization on patient clinical outcomes, overall quality of life, and well-being. LEVEL OF EVIDENCE: Level III, therapeutic study.

Cost-Effectiveness of Treatments after Closed Extraarticular Distal Radius Fractures in Older Adults from the WRIST Clinical Trial.

BACKGROUND: This study performs an economic analysis of volar locking plate, external fixation, percutaneous pinning, or casting in elderly patients with closed distal radius fractures. METHODS: This is a secondary analysis of the Wrist and Radius Injury Surgical Trial, a randomized, multicenter, international clinical trial with a parallel nonoperative casted group of patients older than 60 years with surgically indicated, extraarticular closed distal radius fractures. Thirty-Six-Item Short-Form Health Survey-converted utilities and total costs from Medicare were used to calculate quality-adjusted life-years and incremental cost-effectiveness ratio. RESULTS: Casted patients were self-selected and older (p < 0.001) than the randomized surgical cohorts, but otherwise similar in sociodemographic characteristics. Quality-adjusted life-years for percutaneous pinning were highest at 9.17 and external fixation lowest at 8.81. Total costs expended were $16,354 for volar locking plates, $16,012 for external fixation, $11,329 for percutaneous pinning, and $6837 for casting. The incremental cost-effectiveness ratios for volar locking plates and external fixation were dominated by percutaneous pinning and casting. The ratio for percutaneous pinning compared to casting was $28,717. Probabilistic sensitivity analysis revealed a 10, 5, 53, and 32 percent chance of volar locking plate, external fixation, percutaneous pinning, and casting, respectively, being cost-effective at the willingness-to-pay threshold of $100,000 per quality-adjusted life-year. CONCLUSIONS: Casting is the most cost-effective treatment modality in the elderly with closed extraarticular distal radius fractures and should be considered before surgery. In unstable closed fractures, percutaneous pinning, which is the most cost-effective surgical intervention, may be considered before volar locking plates or external fixation.

Clinical outcome and operative cost comparison: Locked compression plate versus reconstruction plate in midshaft clavicle fractures.

OBJECTIVE: The aim of this study was to compare the clinical outcomes and operative cost of a locked compression plate (LCP) and a nonlocked reconstruction plate in the treatment of displaced midshaft clavicle fracture. METHODS: From January 2013 till March 2018, a total of 55 patients with acute unilateral closed midshaft clavicle fracture were treated with either a 3.5-mm pre-contoured LCP [32 patients; 25 men and 7 women; mean age: 35 years (range: 19-63 years)] or a 3.5-mm nonlocked reconstruction plate [23 patients; 20 men and 3 women; mean age: 31.4 years (range: 17-61 years)]. The clinical outcomes in terms of fracture union, Quick Disability of Arm, Shoulder and Hand (DASH) score, implant irritation, failure rate, and reoperation rate were evaluated retrospectively. The patient billing records were reviewed to obtain primary operation, reoperation, and total operative cost for midshaft clavicle fracture. These values were analyzed and converted from Malaysia Ringgit (RM) to United States Dollar (USD) at the exchange rate of RM 1 to USD 0.24. All patients were followed up for at least one-year duration. RESULTS: The mean time to fracture union, implant irritation, implant failure, and reoperation rate showed no significant difference between the two groups of patients. The mean Quick DASH score was significantly better in the reconstruction plate group with 13 points compared with 28 points in the LCP group (p=0.003). In terms of total operative cost, the LCP group recorded a cost of USD 391 higher than the reconstruction plate group (p<0.001). CONCLUSION: The 3.5-mm reconstruction plate achieved not only satisfactory clinical outcomes but was also more cost-effective than the LCP in the treatment of displaced midshaft clavicle fractures. LEVEL OF EVIDENCE: Level III, Therapeutic study.

Surgical fixation compared with cast immobilisation for adults with a bicortical fracture of the scaphoid waist: the SWIFFT RCT.

BACKGROUND: Scaphoid fractures account for 90% of carpal fractures and occur predominantly in young men. Immediate surgical fixation of this fracture has increased. OBJECTIVE: To compare the clinical effectiveness and cost-effectiveness of surgical fixation with cast treatment and early fixation in adults with scaphoid waist fractures that fail to unite. DESIGN: Multicentre, pragmatic, open-label, parallel two-arm randomised controlled trial with an economic evaluation and a nested qualitative study. SETTING: Orthopaedic departments of 31 hospitals in England and Wales recruited from July 2013, with final follow-up in September 2017. PARTICIPANTS: Adults (aged ≥ 16 years) presenting within 2 weeks of injury with a clear, bicortical fracture of the scaphoid waist on plain radiographs. INTERVENTIONS: Early surgical fixation using Conformité Européenne-marked headless compression screws. Below-elbow cast immobilisation for 6-10 weeks and urgent fixation of confirmed non-union. MAIN OUTCOME MEASURES: The primary outcome and end point was the Patient-Rated Wrist Evaluation total score at 52 weeks, with a clinically relevant difference of 6 points. Secondary outcomes included Patient-Rated Wrist Evaluation pain and function subscales, Short Form questionnaire 12-items, bone union, range of movement, grip strength, complications and return to work. RESULTS: The mean age of 439 participants was 33 years; 363 participants were male (83%) and 269 participants had an undisplaced fracture (61%). The primary analysis was on 408 participants with valid Patient-Rated Wrist Evaluation outcome data for at least one post-randomisation time point (surgery, n = 203 of 219; cast, n = 205 of 220). There was no clinically relevant difference in the Patient-Rated Wrist Evaluation total score at 52 weeks: the mean score in the cast group was 14.0 (95% confidence interval 11.3 to 16.6) and in the surgery group was 11.9 (95% confidence interval 9.2 to 14.5), with an adjusted mean difference of -2.1 in favour of surgery (95% confidence interval -5.8 to 1.6; p = 0.27). The non-union rate was low (surgery group, n = 1; cast group, n = 4). Eight participants in the surgery group had a total of 11 reoperations and one participant in the cast group required a reoperation for non-union. The base-case economic analysis at 52 weeks found that surgery cost £1295 per patient more (95% confidence interval £1084 to £1504) than cast treatment. The base-case analysis of a lifetime-extrapolated model confirmed that the cast treatment pathway was more cost-effective. The nested qualitative study identified patients' desire to have a 'sense of recovering', which surgeons should address at the outset. LIMITATION: There were 17 participants who had initial cast treatment and surgery for confirmed non-union, which in 14 cases was within 6 months from randomisation and in three cases was after 6 months. Three of the four participants in the cast group who had a non-union at 52 weeks were not offered surgery. CONCLUSIONS: Adult patients with an undisplaced or minimally displaced scaphoid waist fracture should have cast immobilisation and suspected non-unions immediately confirmed and urgently fixed. Patients should be followed up at 5 years to investigate the effect of partial union, degenerative arthritis, malunion and screw problems on their quality of life. TRIAL REGISTRATION: Current Controlled Trials ISRCTN67901257. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 52. See the NIHR Journals Library website for further project information.

Fracture of the scaphoid bone (one of eight small bones in the wrist) is common in young active people. It is caused by a fall on the hand or the hand being suddenly forced backwards. The usual treatment is to rest the wrist in a plaster cast for 6­10 weeks and allow the broken bone to heal. In 1 in 10 cases in which the fracture is treated in a plaster cast, the bone does not heal and an operation is needed. In the operation, the broken bone is held still with a screw. In the last few years, it has become more common to fix the broken bone with a screw in the first few days after injury, instead of resting the wrist in a plaster cast. It is not clear if fixing the bone early with a screw, compared with resting the wrist in a cast, gives better outcomes for patients and if one treatment is better value for money for the NHS. In this study, 439 adult patients agreed either to have surgery to hold the broken scaphoid with a special screw or to have the wrist held still in a plaster cast (with surgery offered after 6 weeks to those who were still not healed). The decision about which treatment to use was made using randomisation, which is similar to tossing a coin. Patients reported their own wrist pain and function at 6, 12, 26 and 52 weeks. Information was also collected on general health, bone healing, grip strength and range of movement, complications from treatment and costs. No important differences were found in patients' wrist pain and function at 52 weeks. The bone did not heal properly in four patients in the surgery group or in nine patients in the plaster cast group at 52 weeks. For one of these patients in the surgery group and four of these patients in the plaster cast group, the bone did not join at all. Eight patients in the surgery group had further surgery following their initial operation to fix their wrist, and one patient in the cast group required repeated surgery because the bone did not join at all. The overall cost of treating with a plaster cast was lower than that of early surgery. Therefore, the findings of the study suggest that a plaster cast should be used initially and that the bone should be immediately fixed with a screw if it does not heal.

Cost-utility analysis of extensile lateral approach versus sinus tarsi approach in Sanders type II/III calcaneus fractures.

BACKGROUND: Extensile lateral approach had been recognized as the gold standard technique for displaced intra-articular calcaneus fractures (DIACFs) while sinus tarsi approach had been increasingly valued by surgeons and comparative clinical outcome was shown in both techniques. Appropriate decisions could be made by the clinicians with the help of cost-utility analysis (CUA) about optimal healthcare for type II/III calcaneus fracture. METHOD: A single-center, retrospective study was conducted in which basic characteristics, clinical outcomes, and health care costs of 109 patients had been obtained and analyzed. Changes in health-related quality of life (HRQoL) scores, validated by EuroQol five-dimensional-three levels (EQ-5D-3L), were used to enumerate quality-adjusted life years (QALYs). Cost-effectiveness was determined by the incremental cost per QALY. RESULTS: One hundred nine patients were enrolled in our study including 62 in the ELA group and 47 in the STA group. There were no significant differences between these two groups in mean total cost, laboratory, and radiographic evaluation expense, surgery, anesthesia, and antibiotic expense. The expense of internal fixation materials ($3289.0 ± 543.9) versus ($2630.6 ± 763.7) and analgesia ($145.8 ± 85.6) versus ($102.9 ± 62.7) in ELA group were significantly higher than in the STA group (P < .001, P = .008, respectively). Visual Analogue Scale (VAS) scores showed significant difference at postoperative 3 and 5 days (P < .001). American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores and the Bohlers' and Gissane angle showed no significant differences between the two groups before and after the operation. The cost-effectiveness ratios of ELA and STA were $8766.8 ± 2835.2/QALY and $7914.9 ± 1822.0/QALY respectively, and incremental cost-effectiveness ratio (ICERs) of ELA over STA was $32110.00/QALY, but both showed no significant difference. CONCLUSION: Both ELA and STA techniques are effective operative procedures for the patients with calcaneus fracture. Moreover, STA seems to be more reasonable for its merits including less postoperative pain, and less expense of analgesia as well as internal fixation materials. LEVEL OF EVIDENCE: 5.

Institutional Variation in Surgical Rates and Costs for Pediatric Distal Radius Fractures: Analysis of the Pediatric Health Information System (PHIS) Database.

Background: Reduction of variations may streamline healthcare delivery, improve patient outcomes, and minimize cost. The purpose of this study was to characterize variations in surgical rates and hospital costs for treatment of pediatric distal radius fractures (DRFs) using Pediatric Health Information System (PHIS) database. Methods: The PHIS database was queried from 2009-2013 for DRFs in patients 4-18 years of age. Patients who underwent surgical treatment with internal fixation were identified using surgical CPT codes and/or ICD-9 procedure codes. 25 children's hospitals were included. Surgical rates and hospital costs were modeled. Rates were adjusted and standardized for gender, age, presence of other diagnoses, and year. Results: The aggregate rate of surgery for treatment of DRF was 2.65% and for open surgery was 0.81%. The standardized surgical rates for the 25 hospitals ranged widely, from 1.45% to 13.8% and for open surgical treatment from 0.51% to 4.27%. Six of the 25 hospitals had rates significantly higher than the aggregate for surgical treatment. Standardized hospital costs per patient ranged from $361 to $1,088 (2013 US dollars) across the hospitals with fairly uniform distribution. Conclusions: In the United States, there is great variability in practice and hospital costs of treatment of distal radius fractures. Further characterization of the root causes of these variations, and the effect, if any, on patient outcomes, is needed to improve value delivery in pediatric orthopaedic care.Level of Evidence: II.

The ideal implant for Mayo 2A olecranon fractures? An economic evaluation.

BACKGROUND: The ideal implant for stable, noncomminuted olecranon fractures is controversial. Tension band wiring (TBW) is associated with lower cost but higher implant removal rates.On the other hand, plate fixation (PF) is purported to be biomechanically superior, with lower failure and implant removal rates, although associated with higher cost. The primary aim of this study is to look at the clinical outcomes for all Mayo 2A olecranon between PF and TBW. The secondary aim is to perform an economic evaluation of PF vs. TBW. MATERIALS AND METHODS: This is a retrospective study of all surgically treated Mayo 2A olecranon fractures in a tertiary hospital from 2005-2016. Demographic data, medical history, range of motion, and complications were collected. All inpatient and outpatient costs in a 1-year period postsurgery including the index surgical procedure were collected via the hospital administrative cost database (normalized to 2014). RESULTS: A total of 147 cases were identified (94 TBW, 53 PF). PF was associated with higher mean age (P < .01), higher American Society of Anesthesiologists score (P < .01), and higher proportion of hypertensives (P = .04). There was no difference in the range of motion achieved at 1 year for both groups. In terms of complications, TBW was associated with more symptomatic hardware (21.6% vs. 13.7%, P = .24) and implant failures (16.5% vs. none, P < .01), whereas the plate group had a higher wound complication (5.9% vs. none, P = .02) and infection rate (9.8% vs. 3.1%, P = .09). TBW had a higher implant removal rate of 30.9% compared with 22.7% for PF (P = .36). PF had a higher cost at all time points, from the index surgery ($10,313.64 vs. $5896.36, P < .01), 1-year cost excluding index surgery ($5069.61 vs. $3850.46, P = .46), and outpatient cost ($1667.80 vs. $1613.49, P = .27). DISCUSSION AND CONCLUSION: Based on our study results, we have demonstrated that TBW is the ideal implant for Mayo 2A olecranon fractures from both a clinical and economic standpoint, with comparable clinical results, potentially similar implant removal rates as PF's, and a lower cost over a 1-year period. In choosing the ideal implant, the surgeon must take into account, first, the local TBW and PF removal rate, which can vary significantly because of the patient's profile and beliefs, and second, the PF implant cost.

Reduced incidence and economic cost of hardware removal after ankle fracture surgery: a 20-year nationwide registry study.

Background and purpose - Open reduction and internal fixation (ORIF) is a treatment method for unstable ankle fractures. During recent years, scientific evidence has shed light on surgical indications as well as on hardware removal. We assessed the incidence and trends of hardware removal procedures following ORIF of ankle fractures.Patients and methods - The study covered all patients 18 years of age and older who had an ankle fracture treated with ORIF in Finland between the years 1997 and 2016. Patient data were obtained from the Finnish National Hospital Discharge Register.Results - 68,865 patients had an ankle fracture treated with ORIF in Finland during the 20-year study period between 1997 and 2016. A hardware removal procedure was performed on 27% of patients (n = 18,648). The incidence of hardware removal procedures after ankle fracture decreased from 31 (95% CI 29-32) per 100,000 person-years in the highest year 2001 (n = 1,247) to 13 (CI 12-14) per 100,000 person-years in 2016 (n = 593). Moreover, the proportion and number of removal operations performed within the first 3 months also decreased. The costs of removal procedures decreased from approximately €994,000 in 2001 to €472,600 in 2016.Interpretation - Removal of hardware after ankle surgery (ORIF) is a common operation with substantial costs. However, the incidence and cost of removals decreased during the study period, with a particular decrease in hardware removal operations within 3 months.

One-stage posterior debridement, bone grafting fusion, and mono-segment vs. short-segment fixation for single-segment lumbar spinal tuberculosis: minimum 5-year follow-up outcomes.

BACKGROUND: To compare the clinical and radiological outcomes between posterior mono-segment and short-segment fixation combined with one-stage posterior debridement and bone grafting fusion in treating single-segment lumbar spinal tuberculosis (LSTB). METHODS: Sixty-two patients with single-segment LSTB treated by a posterior-only approach were divided into two groups: short-segment fixation (Group A, n = 32) and mono-segment fixation (Group B, n = 30). The clinical and radiographic outcomes were analyzed and compared between the two groups. RESULTS: The intraoperative bleeding volume, operation time, and hospitalization duration were lower in Group B than in Group A. All patients achieved the bony fusion criteria. The visual analog scale score, Japanese Orthopedic Association score, and Oswestry Disability Index were substantially improved 3 months postoperatively and at the last visit in both groups, with no significant difference between the two groups (P > 0.05). Kirkaldy-Willis functional evaluation at the final follow-up demonstrated that all patients in both groups achieved excellent or good results. The difference in the angle correction rate and correction loss between Groups A and B was not significant (P > 0.05). CONCLUSIONS: One-stage posterior debridement, bone grafting fusion, and mono-segment or short-segment fixation can provide satisfactory clinical and radiological outcomes. Mono-segment fixation is more suitable for the treatment of single-segment LSTB because the lumbar segments with normal motion can be preserved with less trauma, a shorter operation time, shorter hospitalization, and lower costs.

Volar Plate Fixation in Adults with a Displaced Extra-Articular Distal Radial Fracture Is Cost-Effective.

BACKGROUND: To our knowledge, a health economic evaluation of volar plate fixation compared with plaster immobilization in patients with a displaced extra-articular distal radial fracture has not been previously conducted. METHODS: A cost-effectiveness analysis of a multicenter randomized controlled trial was performed. Ninety patients were randomly assigned to volar plate fixation or plaster immobilization. The use of resources per patient was documented prospectively for up to 12 months after randomization and included direct medical, direct non-medical, and indirect non-medical costs due to the distal radial fracture and the received treatment. RESULTS: The mean quality-adjusted life-years (QALYs) at 12 months were higher in patients treated with volar plate fixation (mean QALY difference, 0.16 [bias-corrected and accelerated 95% confidence interval (CI), 0.07 to 0.27]). (The 95% CIs throughout are bias-corrected and accelerated.) In addition, the mean total costs per patient were lower in patients treated with volar plate fixation (mean difference, -$299 [95% CI, -$1,880 to $1,024]). The difference in costs per QALY was -$1,838 (95% CI, -$12,604 to $9,787), in favor of volar plate fixation. In a subgroup analysis of patients who had paid employment, the difference in costs per QALY favored volar plate fixation by -$7,459 (95% CI, -$23,919 to $3,233). CONCLUSIONS: In adults with a displaced extra-articular distal radial fracture, volar plate fixation is a cost-effective intervention, especially in patients who had paid employment. Besides its better functional results, volar plate fixation is less expensive and provides a better quality of life than plaster immobilization. LEVEL OF EVIDENCE: Economic Level I. See Instructions for Authors for a complete description of levels of evidence.

Cost Analysis of Implants in the Surgical Repair of Orbital Floor Fractures.

OBJECTIVE: Options for the management of orbital floor fractures continue to evolve offering both potential advantages as well as higher costs. To date, the effect of implant choice on the cost associated with the repair of orbital floor fractures has not been studied. METHODS: A retrospective review at a tertiary care, level I trauma center examining all adult, uncomplicated orbital floor fractures that underwent open reduction and internal fixation from 2013 to 2016. Patients with concurrent operative facial fractures were excluded. The main outcomes were overall cost of care from injury to last follow-up and operating room-related costs. Costs were determined using computerized records of charges as well as the hospital Charge Description Master. Kruksal-Wallis rank sum tests were used to analyze for differences between groups. RESULTS: Twenty-eight patients fulfilled the inclusion criteria. Eight different stock, non-patient specific, implants were used for repair. The cost of individual types of implants ranged from $70.25 to $7 718.00. Total cost of care per patient across all implant types averaged $35 585.57 (range $25 586.26 to $49 985.74, P = .34). Operation-related charges accounted for the vast majority (94.4%) of the total cost of care. One complication occurred requiring operative re-positioning of the implant with an additional $13 042.41 in charges. CONCLUSIONS: In the setting of uncomplicated orbital floor fractures, surgeons should select an implant that allows them to carry out the repair in a safe, timely fashion. Additional large-scale studies would help to further delineate cost differences.