Cost-Effectiveness of Volar Locking Plate Compared with Augmented External Fixation for Displaced Intra-Articular Wrist Fractures.

BACKGROUND: The purpose of the present study was to estimate the cost-effectiveness of treating displaced, intra-articular distal radial fractures with volar locking plate fixation compared with augmented external fixation. METHODS: A cost-utility analysis was conducted alongside a randomized, clinical trial comparing 2 surgical interventions for intra-articular distal radial fractures. One hundred and sixty-six patients were allocated to either volar locking plate fixation (84 patients) or external fixation (82 patients) and were followed for 2 years. Health-related quality of life was assessed with the EuroQol-5 Dimensions and was used to calculate patients' quality-adjusted life-years (QALYs). Resource use was identified prospectively at the patient level at all follow-up intervals. Costs were estimated with use of both a health-care perspective and a societal perspective. Results were expressed in incremental cost-effectiveness ratios, and uncertainty was assessed with use of bootstrapping methods. RESULTS: The average QALY value was equivalent between the groups (1.70463 for the volar locking plate group and 1.70726 for the external fixation group, yielding a nonsignificant difference of -0.00263 QALY). Health-care costs were equal between the groups, with a nonsignificant difference of &OV0556;52 (p = 0.8) in favor of external fixation. However, the external fixation group had a higher loss of productivity due to absence from work (5.5 weeks in the volar locking plate group compared with 9.2 weeks for the external fixation group; p = 0.02). Consequently, the societal costs were higher for the external fixation group compared with the volar locking plate group (&OV0556;18,037 compared with &OV0556;12,567, representing a difference of &OV0556;5,470; p = 0.04) in favor of the volar locking plate group. Uncertainty analyses showed that there is indifference regarding which method to recommend from a health-care perspective, with volar locking plate treatment and external fixation having a 47% and 53% likelihood of being cost-effective, respectively. From the societal perspective, volar locking plate treatment had a 90% likelihood of being cost-effective. CONCLUSIONS: External fixation was less cost-effective than volar locking plate treatment for distal radial fractures from a societal perspective, primarily because patients managed with external fixation had a longer absence from work. LEVEL OF EVIDENCE: Economic and Decision Analysis Level I. See Instructions for Authors for a complete description of levels of evidence.

Biomechanical study of a low-cost external fixator for diaphyseal fractures of long bones.

BACKGROUND: External fixation improves open fracture management in emerging countries. However, sophisticated models are often expensive and unavailable. We assessed the biomechanical properties of a low-cost external fixation system in comparison with the Hoffmann® 3 system, as a reference. METHODS: Transversal, oblique, and comminuted fractures were created in the diaphysis of tibia sawbones. Six external fixators were tested in three modes of loading-axial compression, medio-lateral (ML) bending, and torsion-in order to determine construction stiffness. The fixator construct implies two uniplanar (UUEF1, UUEF2) depending the pin-rods fixation system and two biplanar (UBEF1, UBEF2) designs based on different bar to bar connections. The designed low-cost fixators were compared to a Hoffmann® 3 fixator single rod (H3-SR) and double rod (H3-DR). Twenty-seven constructs were stabilized with UUEF1, UUEF2, and H3-SR (nine constructs each). Nine constructs were stabilized with UBEF1, UBEF2, and H3-DR (three constructs each). RESULTS: UUEF2 was significantly stiffer than H3-SR (p < 0.001) in axial compression for oblique fractures and UUEF1 was significantly stiffer than H3-SR (p = 0.009) in ML bending for transversal fractures. Both UUEFs were significantly stiffer than H3-SR in axial compression and torsion (p < 0.05), and inferior to H3-SR in ML bending, for comminuted fractures. In the same fracture pattern, UBEFs were significantly stiffer than H3-DR (p = 0.001) in axial compression and torsion, while only UBEF1 was significantly stiffer than H3-DR in ML bending (p = 0.013). CONCLUSIONS: The results demonstrated that the stiffness of the UUEF and UBEF device compares to the reference fixator and may be helpful in maintaining fracture reduction. Fatigue testing and clinical assessment must be conducted to ensure that the objective of bone healing is achievable with such low-cost devices.

Cost of Surgical Treatment for Distal Radius Fractures and the Implications of Episode-Based Bundled Payments.

PURPOSE: To examine the cost of care of surgical treatment for a distal radius fracture (DRF) and develop episodes that may be used to develop future bundled payment programs. METHODS: Using 2009 to 2015 claims data from the Truven MarketScan Databases, we examined the cost of care for surgical treatment of DRFs among adult patients in the United States. We excluded patients with concurrent fractures, patients who required complex care, and patients in assisted living facilities. We extracted data on cost and type of services provided to eligible patients, tracking patients from 3 days prior to operation to 90 days after operation. From these data, we developed 4 episode-of-care scenarios to develop an estimated bundled payment. We computed the variation in cost between surgery types, time periods, and type of service provided. RESULTS: Our final sample included 23,453 DRF operations, of which 15% were performed on patients 65 years of age or older. The majority (88%) underwent open fixation, the option associated with the highest cost. The average cost of care for a DRF patient ranged from $6,577 to $8,181 depending on the definition of an episode-of-care. Regardless of definition, the variation in cost was high. The cost of surgery itself composed 61% to 91% of the total cost of an episode. Of claims not directly related to the surgery, anesthesia and drugs, imaging, and therapy costs composed the next greatest proportions of the total cost of care. CONCLUSIONS: Many DRF surgical episodes incur substantially higher costs than the average. To maximize cost reduction, bundled payments for DRFs are best designed with a clinically narrow definition that is limited to services related to the fracture and long enough to capture relevant postoperative therapy and imaging costs. CLINICAL RELEVANCE: This study provides insight on spending to lay the foundation for shifting reimbursement strategies.

A novel external fixator of the hand: a practice pearl.

External fixation of comminuted hand fractures, especially those associated with soft-tissue injuries, is a good option and avoids several complications resulting from open surgery. Therefore, many versions of mini external fixators have been developed, including commercially fabricated implants and hand-made implants. However, these devices are costly or associated with serious complications. Through this study we have introduced a cost-effective and easy-to-apply mini external fixator.

A mini external fixator for hand and finger fractures constructed from readily available materials.

Phalangeal and metacarpal fractures with severe comminution and/or soft tissue compromise can present a challenge for the orthopedic surgeon. Maintaining viability of the soft tissues while providing rigid fixation of bony injuries is the goal when treating these injuries. Commercially available mini external fixators can help to achieve these goals. However, these devices are costly and are not always available when the surgeon needs them. In this technique study, we discuss the implementation of a mini external fixator using readily available implements in the operating room that is efficient, cost effective, and easy to apply.

The economic impact of reprocessing external fixation components.

BACKGROUND: The trend toward temporizing external fixation of complex fractures has resulted in increased expenditures for these devices. Increasing pressure to reduce health-care expenditures has led to exploration of reuse of equipment intended for single use. Devices must be tested and recertified prior to redeployment in hospital stock. We report the rate of manufacturer recertification and institutional cost savings associated with a reuse program approved by the United States Food and Drug Administration. METHODS: All Hoffmann-II external fixation components that had been removed at our institution during the study period were submitted to the manufacturer for visual inspection and mechanical testing. Pass rates for original components and previously recycled components were determined. With use of a conservative pass rate and the assumption of a maximum of three recertifications of each component, the total potential hospital savings on external fixation were calculated. RESULTS: The first pass rate was 76%. The second pass rate (i.e., the rate for components that had already been recertified once and had been sent for a second recertification) was 83%, but that rate was derived from a limited sample. On the basis of a conservative pass-rate estimate of 75%, the predicted average number of uses of a recyclable component was 2.7. The recertified components were sold back to our hospital at 50% of the original price. Because carbon-fiber bars and half-pins are not recycled, 85% of the charges expended on a new external fixation component are spent on portions of the system that are recyclable. The potential total savings on reusable components was found to be 32%, with a total savings of 27% for the whole external fixation system. No recertified components failed in clinical use over the course of the study. CONCLUSIONS: With the expansion of cost-control efforts, the recycling of medical devices appears inevitable. Previous data have demonstrated the safety of reuse of external fixation devices, and this study confirms that finding. Our paper demonstrates the real cost savings associated with a manufacturer-based testing and recertification program. Issues of voluntary participation in reuse programs, component ownership, and the impact of savings on patient charges are yet to be worked out by individual institutions.

Adaptation of Ilizarov ring fixator to the economic situation of developing countries.

Especially in countries with low per capita income, poor patients with open fractures and non-unions are unable to purchase modern, commercially produced surgical implants. To alleviate this situation, we initiated the production of a locally made ring fixator. The rings were cut from tubes cast from scrap aluminium. It was applied in 40 patients to test its utility for the typical indications for the Ilizarov technique. The fixator was tolerated well. All fractures united except in one case where there was refracture of the consolidate due to too early removal of the fixator. Two arthrodeses were successful. Bone transport showed adequate regeneration. A single radial non-union united successfully. Loosening occurred in 11 wires and breakage in 6. The subacute infections in 11 (27.5%) patients were not due to the fixator itself but to low standards of hygiene and the delay of treatment in the prehospital phase. Reusing the fixator at least three times reduces the cost for the individual patient to US$ 13.60. A locally made fixator is cost-effective and can be recommended for surgical treatment under similar economic situations.

Segmental tibial defects. Comparing conventional and Ilizarov methodologies.

Forty-four consecutive patients with segmental debridement defects of the tibia had limb-salvage surgery. Twenty-one patients (Group I) were managed using methods as described by Ilizarov. Twenty-three patients (Group II) underwent conventional treatment with massive cancellous grafts and tissue transfers. Total wound consolidation and infection arrest took place after the first treatment in 71% of the Ilizarov wounds and 74% of the conventionally treated wounds. The major complication rates were 33% and 60% for Groups I and II respectively. The patient population at highest risk for failure was the compromised host treated conventionally (44%). The cost for retreatment and overall success rate (95%) were the same for both groups. Ilizarov reconstructions averaged nine fewer hours in the operating theater, 23 fewer days in the hospital, five fewer months' disability (17 months versus 22 months), and a savings of nearly $30,000 per application.