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.

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.

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.

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.

The Ankle Injury Management (AIM) trial: a pragmatic, multicentre, equivalence randomised controlled trial and economic evaluation comparing close contact casting with open surgical reduction and internal fixation in the treatment of unstable ankle fractures in patients aged over 60 years.

BACKGROUND: Close contact casting (CCC) may offer an alternative to open reduction and internal fixation (ORIF) surgery for unstable ankle fractures in older adults. OBJECTIVES: We aimed to (1) determine if CCC for unstable ankle fractures in adults aged over 60 years resulted in equivalent clinical outcome compared with ORIF, (2) estimate cost-effectiveness to the NHS and society and (3) explore participant experiences. DESIGN: A pragmatic, multicentre, equivalence randomised controlled trial incorporating health economic evaluation and qualitative study. SETTING: Trauma and orthopaedic departments of 24 NHS hospitals. PARTICIPANTS: Adults aged over 60 years with unstable ankle fracture. Those with serious limb or concomitant disease or substantial cognitive impairment were excluded. INTERVENTIONS: CCC was conducted under anaesthetic in theatre by surgeons who attended training. ORIF was as per local practice. Participants were randomised in 1 : 1 allocation via remote telephone randomisation. Sequence generation was by random block size, with stratification by centre and fracture pattern. MAIN OUTCOME MEASURES: Follow-up was conducted at 6 weeks and, by blinded outcome assessors, at 6 months after randomisation. The primary outcome was the Olerud-Molander Ankle Score (OMAS), a patient-reported assessment of ankle function, at 6 months. Secondary outcomes were quality of life (as measured by the European Quality of Life 5-Dimensions, Short Form questionnaire-12 items), pain, ankle range of motion and mobility (as measured by the timed up and go test), patient satisfaction and radiological measures. In accordance with equivalence trial US Food and Drug Administration guidance, primary analysis was per protocol. RESULTS: We recruited 620 participants, 95 from the pilot and 525 from the multicentre phase, between June 2010 and November 2013. The majority of participants, 579 out of 620 (93%), received the allocated treatment; 52 out of 275 (19%) who received CCC later converted to ORIF because of loss of fracture reduction. CCC resulted in equivalent ankle function compared with ORIF at 6 months {OMAS 64.5 points [standard deviation (SD) 22.4 points] vs. OMAS 66.0 points (SD 21.1 points); mean difference -0.65 points, 95% confidence interval (CI) -3.98 to 2.68 points; standardised effect size -0.04, 95% CI -0.23 to 0.15}. There were no differences in quality of life, ankle motion, pain, mobility and patient satisfaction. Infection and/or wound problems were more common with ORIF [29/298 (10%) vs. 4/275 (1%)], as were additional operating theatre procedures [17/298 (6%) vs. 3/275 (1%)]. Malunion was more common with CCC [38/249 (15%) vs. 8/274 (3%); p < 0.001]. Malleolar non-union was lower in the ORIF group [lateral: 0/274 (0%) vs. 8/248 (3%); p = 0.002; medial: 3/274 (1%) vs. 18/248 (7%); p < 0.001]. During the trial, CCC showed modest mean cost savings [NHS mean difference -£644 (95% CI -£1390 to £76); society mean difference -£683 (95% CI -£1851 to £536)]. Estimates showed some imprecision. Incremental quality-adjusted life-years following CCC were no different from ORIF. Over common willingness-to-pay thresholds, the probability that CCC was cost-effective was very high (> 95% from NHS perspective and 85% from societal perspective). Experiences of treatments were similar; both groups endured the impact of fracture, uncertainty regarding future function and the need for further interventions. LIMITATIONS: Assessors at 6 weeks were necessarily not blinded. The learning-effect analysis was inconclusive because of limited CCC applications per surgeon. CONCLUSIONS: CCC provides a clinically equivalent outcome to ORIF at reduced cost to the NHS and to society at 6 months. FUTURE WORK: Longer-term follow-up of trial participants is under way to address concerns over potential later complications or additional procedures and their potential to impact on ankle function. Further study of the patient factors, radiological fracture patterns and outcomes, treatment responses and prognosis would also contribute to understanding the treatment pathway. TRIAL REGISTRATION: Current Controlled Trials ISRCTN04180738. FUNDING: The National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 75. See the NIHR Journals Library website for further project information. This report was developed in association with the National Institute for Health Research Oxford Biomedical Research Unit funding scheme. The pilot phase was funded by the AO Research Foundation.

The ProFHER (PROximal Fracture of the Humerus: Evaluation by Randomisation) trial - a pragmatic multicentre randomised controlled trial evaluating the clinical effectiveness and cost-effectiveness of surgical compared with non-surgical treatment for proximal fracture of the humerus in adults.

BACKGROUND: Proximal humeral fractures account for 5-6% of all fractures in adults. There is considerable variation in whether or not surgery is used in the management of displaced fractures involving the surgical neck. OBJECTIVE: To evaluate the clinical effectiveness and cost-effectiveness of surgical compared with non-surgical treatment of the majority of displaced fractures of the proximal humerus involving the surgical neck in adults. DESIGN: A pragmatic parallel-group multicentre randomised controlled trial with an economic evaluation. Follow-up was for 2 years. SETTING: Recruitment was undertaken in the orthopaedic departments of 33 acute NHS hospitals in the UK. Patient care pathways included outpatient and community-based rehabilitation. PARTICIPANTS: Adults (aged ≥ 16 years) presenting within 3 weeks of their injury with a displaced fracture of the proximal humerus involving the surgical neck. INTERVENTIONS: The choice of surgical intervention was left to the treating surgeons, who used techniques with which they were experienced. Non-surgical treatment was initial sling immobilisation followed by active rehabilitation. Provision of rehabilitation was comparable in both groups. MAIN OUTCOME MEASURES: The primary outcome was the Oxford Shoulder Score (OSS) assessed at 6, 12 and 24 months. Secondary outcomes were the 12-item Short Form health survey, surgical and other shoulder fracture-related complications, secondary surgery to the shoulder or increased/new shoulder-related therapy, medical complications during inpatient stay and mortality. European Quality of Life-5 Dimensions data and treatment costs were also collected. RESULTS: The mean age of the 250 trial participants was 66 years and 192 (77%) were female. Independent assessment using the Neer classification identified 18 one-part fractures, 128 two-part fractures and 104 three- or four-part fractures. OSS data were available for 215 participants at 2 years. We found no statistically or clinically significant differences in OSS scores between the two treatment groups (scale 0-48, with a higher score indicating a better outcome) over the 2-year period [difference of 0.75 points in favour of the surgery group, 95% confidence interval (CI) -1.33 to 2.84; p = 0.479; data from 114 surgery and 117 non-surgery participants] or at individual time points. We found no statistically significant differences between surgical and non-surgical group participants in SF-12 physical or mental component summary scores; surgical or shoulder fracture-related complications (30 vs. 23 respectively); those undergoing further shoulder-related therapy, either surgery (11 vs. 11 respectively) or other therapy (seven vs. four respectively); or mortality (nine vs. five respectively). The base-case economic analysis showed that, at 2 years, the cost of surgical intervention was, on average, £1780.73 more per patient (95% CI £1152.71 to £2408.75) than the cost of non-surgical intervention. It was also slightly less beneficial in terms of utilities, although this difference was not statistically significant. The net monetary benefit associated with surgery is negative. There was only a 5% probability of surgery achieving the criterion of costing < £20,000 to gain a quality-adjusted life-year, which was confirmed by extensive sensitivity analyses. CONCLUSIONS: Current surgical practice does not result in a better outcome for most patients with displaced fractures of the proximal humerus involving the surgical neck and is not cost-effective in the UK setting. Two areas for future work are the setting up of a national database of these fractures, including the collection of patient-reported outcomes, and research on the best ways of informing patients with these and other upper limb fractures about initial self-care. TRIAL REGISTRATION: Current Controlled Trials ISRCTN50850043. FUNDING: This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 24. See the NIHR Journals Library website for further project information.

Protótipo para realização de cranioplastia de baixo custo / Prototype for cranioplasty low cost in postoperative decompressive craniotomy

Objetivo: O presente trabalho propõe uma técnica para realização de cranioplastia com metilmetacrilato em formas pré-moldadas e esterilizadas visando evitar cranioplastia com prototipagem pré-moldada.Método: Conforme rotina apresentada, o flap ósseo realizado para craniotomia descompressiva é armazenado em recipientes com formol e enviado para o serviço de patologia do hospital. Quando realizamos a cranioplastia, utilizamos o flap ósseo armazenado para realização dos moldes que serão utilizados na cranioplastia. Resultado: O resultado estético é muito bom e os índices de complicação e infecção são baixos. Conclusão: Apresenta resultados estéticos semelhantes aos casos de prototipagemcom baixo custo na confecção.

Objective: This paper proposes a technique for cranioplasty with methyl methacrylate and molded into shapes pre-sterilized to avoid aiming cranioplasty with pre molded prototyping. Method: As presented routine bone flap performed to decompressive craniectomy is stored in containers with formalin and sent to the pathology service of the hospital. When we performed the cranioplasty, we used the bone flap stored for realization of molds that will be used in cranioplasty. Result: The aesthetic result is very good and the rates of complication and infection are lo

Cost-effectiveness of the Ponseti method for treatment of clubfoot in Pakistan.

BACKGROUND: Clubfoot is disabling, with an incidence of 0.9/1,000 live births to 7/1,000 live births. It affects mobility, productivity, and quality of life. Patients are treated surgically or non-surgically using the Ponseti method. We estimated the cost per patient treated with both methods and the cost-effectiveness of these methods in Pakistan. METHODS: Parents of patients treated, either surgically or with the Ponseti method, at the Indus Hospital's free program for clubfoot were interviewed between February and May 2012. We measured the direct and indirect household expenditures for pre-diagnosis, incomplete treatment, and current treatment until the first brace for Ponseti method and the first corrective surgery for surgically treated patients. Hospital expenditure was measured by existing accounts. RESULTS: Average per-patient cost was $349 for the Ponseti method and $810 for patients treated surgically. Of these, the Indus hospital costs were $170 the for Ponseti method and $452 for surgically treated patients. The direct household expenditure was $154 and $314 for the Ponseti and surgical methods, respectively. The majority of the costs were incurred pre-diagnosis and after inadequate treatment, with the largest proportion spent on transportation, material, and fee for service. The Ponseti method is shown to be the dominant method of treatment, with an incremental cost-effectiveness ratio of $1,225. CONCLUSIONS: The Ponseti method is clearly the treatment of choice in resource-constrained settings like Pakistan. Household costs for clubfoot treatment are substantial, even in programs offering free diagnostics and treatments and may be a barrier to service utilization for the poorest patients.

Ankle Injury Management (AIM): design of a pragmatic multi-centre equivalence randomised controlled trial comparing Close Contact Casting (CCC) to Open surgical Reduction and Internal Fixation (ORIF) in the treatment of unstable ankle fractures in patients over 60 years.

BACKGROUND: Ankle fractures account for 9% of all fractures with a quarter of these occurring in adults over 60 years. The short term disability and long-term consequences of this injury can be considerable. Current opinion favours open reduction and internal fixation (ORIF) over non-operative treatment (fracture manipulation and the application of a standard moulded cast) for older people. Both techniques are associated with complications but the limited published research indicates higher complication rates of fracture malunion (poor position at healing) with casting. The aim of this study is to compare ORIF with a modification of existing casting techniques, Close Contact Casting (CCC). We propose that CCC may offer an equivalent functional outcome to ORIF and avoid the risks associated with surgery. METHODS/DESIGN: This study is a pragmatic multi-centre equivalence randomised controlled trial. 620 participants will be randomised to receive ORIF or CCC after sustaining an isolated displaced unstable ankle fracture. Participants will be recruited from a minimum of 20 National Health Service (NHS) acute hospitals throughout England and Wales. Participants will be aged over 60 years and be ambulatory prior to injury. Follow-up will be at six weeks and six months after randomisation. The primary outcome is the Olerud & Molander Ankle Score, a functional patient reported outcome measure, at 6 months. Follow-up will also include assessments of mobility, ankle range of movement, health related quality of life and complications. The six-month follow-up will be conducted face-to-face by an assessor blinded to the allocated intervention. A parallel economic evaluation will consider both a health service and a broader societal perspective including the individual and their family. In order to explore patient experience of their treatment and recovery, a purposive sample of 40 patients will also be interviewed using a semi-structured interview schedule between 6-10 weeks post treatment. DISCUSSION: This multicentre study was open to recruitment July 2010 and recruitment is due to be completed in December 2013. TRIAL REGISTRATION: Current Controlled Trials ISRCTN04180738.

The Ponseti method in Latin America: initial impact and barriers to its diffusion and implementation.

The Ponseti method for correcting clubfoot is a safe, effective, and minimally invasive treatment that has recently been implemented in Latin America. This study evaluates the initial impact and unique barriers to the diffusion of the Ponseti method throughout this region. Structured interviews were conducted with 30 physicians practicing the Ponseti method in three socioeconomically diverse countries: Chile, Peru and Guatemala. Since learning the Ponseti method, these physicians have treated approximately 1,740 clubfoot patients, with an estimated 1,705 (98%) patients treated using the Ponseti method, and 35 (2%) patients treated using surgical techniques. The barriers were classified into the following themes: physician education, health care system of the country, culture and beliefs of patients, physical distance and transport, financial barriers for patients, and parental compliance with the method. The results yielded several common barriers throughout Latin America including lack of physician education, physical distance to the treatment centers, and financial barriers for patients. Information from this study can be used to inform, and to implement and evaluate specific strategies to improve the diffusion of the Ponseti method for treating clubfoot throughout Latin America.

A comparison of the Gallie technique and casting versus the harms technique for the treatment of odontoid fractures.

OBJECTIVE: The objective of this study was to compare perioperative, clinical parameters, complications, and reoperation rate of the Gallie technique and head-neck-chest plaster with the Harms technique in the treatment of odontoid fractures. DESIGN: A retrospective study. SETTING: Level I spine center. PATIENTS: Fifty-seven patients with odontoid fractures treated either with the Gallie technique and casting or the Harms technique between July 2002 and June 2008. INTERVENTION: Surgery. MAIN OUTCOME MEASUREMENTS: At a minimum of 2-year follow-up, comparison of the two groups was conducted in terms of hospital stay, blood loss, operation time, cost of the first admission, total cost, time to fusion, time to return to previous occupation, Japanese Orthopedic Association scores, visual analog scale scores of neck pain, complications (nonunion, delayed union, hardware breakage, wound infection), and reoperation rate. RESULTS: There were no significant differences in terms of hospital stay, time to fusion, Japanese Orthopedic Association scores, neck pain visual analog scale scores, complications, or reoperation rate between the two groups. Blood loss, operation time, cost of the first admission, and total cost were significantly lower in the Gallie group than that in the Harms group. However, the Gallie group took longer to return to previous occupation than the Harms group (P < 0.001). CONCLUSIONS: Management of odontoid fractures by either the Gallie technique and casting or the Harms technique was found to be similar in clinical outcomes. Although the Harms technique was associated with more blood loss, operation time, and cost, the Harms technique was found to be superior to the Gallie technique with casting in terms of time to return to previous occupation.

"Does the outcome of adolescent idiopathic scoliosis surgery justify the rising cost of the procedures?".

BACKGROUND: As the cost of medical care has steady risen, patients, insurance companies, and the government, have all appropriately questioned the benefit of the care provided versus the cost. Expensive treatments such as surgery for spinal deformity have been especially scrutinized. This article reviews the history of spinal implant usage in deformity surgery, including the benefits of these implants to the patient and also the associated costs. The paper was presented at the One Day Course during the 2009 Pediatric Orthopaedic Society of North America annual meeting in Boston. METHODS: A review was conducted regarding the benefits and costs of the care provided to patients as spinal implants became more clinically effective. RESULTS: Compared with postoperative casting, spinal implants provide better deformity correction and better stability of the fusion mass with resulting lower rates of secondary surgery, mostly because of fewer pseudarthoses. Many of these advantages were achieved with the less-expensive second and third-generation implants. Unfortunately, patient outcomes when the latest, most expensive implants are used are not significantly different from outcomes when older, less-expensive implants are used. CONCLUSIONS: Although the cost of spinal deformity surgery has risen the benefit to the patient from modern spinal implants has also increased. Nevertheless, patient outcomes have not improved in proportion to the increase in costs. Outcomes from the newest, all pedicle screw constructs are not significantly better than outcomes from the older, less-expensive hybrid constructs. Rising expenses and dramatic variation in the cost of the same implant have led payors, hospitals, and the government to question the value added to the care of the patient. Some implant costs should fall as hospitals use competitive bidding. Surgeons should help their hospitals in the competitive bidding process and declare a willingness to switch to an equivalent system if price differences are excessive. LEVELS OF EVIDENCE: Level IV Economic Analysis.

Ponseti clubfoot management: changing surgical trends in Nigeria.

BACKGROUND: Congenital clubfoot treatment continues to be controversial particularly in a resource-constrained country. Comparative evaluation of clubfoot surgery with Ponseti methods has not been reported in West Africa. OBJECTIVES: To determine the effects of Ponseti techniques on clubfoot surgery frequency and patterns in Nigeria. METHODS: This was a prospective hospital-based intention-to-treat comparative study of clubfoot managed with Ponseti methods (PCG) and extensive soft tissue surgery (NPCG). The first step was a nonselective double-blind randomization of clubfoot patients into two groups using Excel software in a university teaching hospital setting. The control group was the NPCG patients. The patients' parents gave informed consent, and the medical research and ethics board approved the study protocol. Biodata was gathered, clubfoot patterns were analyzed, Dimeglio-Bensahel scoring was done, the number of casts applied was tallied, and patterns of surgeries were documented. The cost of care, recurrence and outcomes were evaluated. Kruskal-Wallis analysis and Mann-Whitney U technique were used, and an alpha error of < 0.05 at a CI of 95% were taken to be significant. RESULTS: We randomized 153 clubfeet (in 105 clubfoot patients) into two treatment groups. Fifty NPCG patients (36.2%) underwent manipulation and extensive soft tissue surgery and 55 PCG patients (39.9%) were treated with Ponseti methods. Fifty-two patients of the Ponseti group had no form of surgery (94.5% vs. 32%, p<0.000). Extensive soft tissue surgery was indicated in 17 (34.0%) of the NPCG group, representing 8.9% of the total of 191 major orthopaedic surgeries within the study period. Thirty-five patients (70.0%) from the NPCG group required more than six casts compared to thirteen patients (23.6%) of the PCG (p<0.000). The mean care cost was high within the NPCG when compared to the Ponseti group (48% vs. 14.5%, p<0.000). The Ponseti-treated group had fewer treatment complications (p<0.003), a lower recurrence rate (p<0.000) and satisfactory early outcome (p<0.000). CONCLUSION: Major clubfoot surgery was not commonly indicated among patients treated with the Ponseti method. The Ponseti clubfoot technique has reduced total care costs, cast utilization, clubfoot surgery frequency and has also changed the patterns of surgery performed for clubfoot in Nigeria.

The advantages gained by the use of modern materials in the post operative casting procedure for foot and ankle surgery.

BACKGROUND: In June 2006, the post operative plaster immobilisation protocol for patients undergoing hindfoot and ankle surgery, at our institution, changed from multiple plaster changes to the immediate application of a definitive removable and reusable split synthetic cast. This study aims to assess the savings to the hospital and patient, following this change in practice. METHODS: A retrospective analysis of plaster room records from June 2005 to June 2007 was performed. The difference in cost to the hospital of the two different post operative journeys was then calculated. RESULTS: Two-hundred and twenty-two patients from 2005 to 2006 were managed at a total cost of 97,125 euro. From 2006 to 2007, 203 patients were managed with the new technique at a total cost of 37,860 euro. The net saving to the hospital of this change in practice was 251 euro per patient and 50,953 euro in total, while 203 patient visits and costs associated therewith were also saved. CONCLUSIONS: This study demonstrates how small changes in local practice can result in significant financial and temporal savings for hospitals and patients.

Management of occult fractures in the skeletally immature patient: cost analysis of implementing a limited trauma magnetic resonance imaging protocol.

STUDY OBJECTIVE: Fractures in children may not be visible in the result of initial radiography, and undertreatment and overtreatment of such fractures routinely occur. The purpose of this study was to evaluate the potential cost of implementing limited magnetic resonance imaging (MRI) at initial encounter, when radiographs are unrevealing. METHODS: This was a retrospective review of 204 emergency department pediatric patients presenting between January 1, 2005 and February 28, 2006 with appendicular trauma, with initially negative radiographic result and follow-up. Emergency department treatment categorization of (1) no treatment, (2) ACE wrap, (3) brace, (4) splint, or (5) casting was evaluated. Final determination of presence or absence of fracture was based on follow-up. Patients with fractures were considered undertreated when they received categories 1 to 3 care; patients without fractures were considered overtreated when they received categories 4 and 5 care. The percentage of patients undertreated or overtreated and direct and total costs were determined and analyzed in conjunction with the cost of a limited MRI at initial encounter. Total costs include direct and indirect costs (lost wages for each day off work for the parent). Cost estimates assume patients determined to be without fractures at follow-up will not return for follow-up clinical care or obtain additional imaging after MRI at initial encounter. RESULTS: Twenty-eight (13.7%) of the 204 patients had fractures at follow-up. Fifty one percent of patients without fractures were overtreated; 29% with fractures were undertreated. Mean direct cost for all patients and cost estimation with limited MRI protocol were $843.81 and $891.79, respectively (P = 0.365). However, mean total cost for all patients and cost estimation with limited MRI protocol was $1059.49 and $929.10, respectively (P = 0.02). CONCLUSIONS: Based on clinical grounds and initially negative radiographic results, slightly more than half of patients without fractures can be overtreated, and nearly one third of patients with fractures can be undertreated. Instituting a protocol that includes limited trauma MRI lowers the total cost of care without increasing direct cost, and appropriate care may be instituted at the outset.

The use of economic evaluation in hand surgery.

This article explains the concepts of an economic evaluation relevant to evidence-based hand surgery. Cost-effectiveness analysis in hand surgery is increasingly important as health care resources become scarce in most jurisdictions. Hand surgeons need to incorporate the "manager of health care system" competency in their daily practice. Hand surgery literature may claim that "a novel hand technique" is more cost-effective than a prevailing one; it is important that hand surgeons and other users of clinical research appraise such innovation claims before adopting them in their practices. Clinical researchers can use the methodological principles described here for their cost-effectiveness analysis.

Dynamic skeletal traction spica casts for paediatric femoral fractures in a resource-limited setting.

The objective of this study was to compare elastic intramedullary nailing (EIN) with dynamic skeletal traction spica casting (DSTSC) in terms of postoperative radiographic angulations, length of hospital stay, and cost in a resource-limited setting. We prospectively studied 51 children, five to twelve years of age, with femoral fractures treated with either EIN (n = 26) or DSTSC (n = 25). Children treated with EIN had significantly longer hospital stays (17 +/- 8.0 days) than those treated with DSTSC (6.0 +/- 2.5 days). Financial constraints in acquiring supplies caused a significant increase in time from admission to surgery (EIN 9.5 +/- 2.3 days; DSTSC 1.1 +/- 0.3 days), and cost was about 400% higher for EIN compared with DSTSC. At twelve weeks follow-up, all patients in both groups had acceptable radiographic angulations. In resource-limited healthcare settings, DSTSC is an effective alternative to EIN with comparable post-op radiographic angulations, decreased hospital stays, and lower cost.

Cost-effective patient-specific intraoperative molded cranioplasty.

Intraoperative molding of polymethyl-methacrylate into complex three-dimensional shapes with correct thickness is often a time-consuming process and may lead to unsatisfying cosmetical results. This article describes an intraoperative technique to assemble a polymethyl-methacrylate implant as a replica of the patient's bone flap. This approach provides a fast and inexpensive alternative technique with good cosmetic outcome. The technique is feasible and can be applied in early and delayed cranioplasty procedures. In selected patients, immediate single-stage reconstruction avoids a second operation.

Comparison of direct and indirect costs of internal fixation and cast treatment in acute scaphoid fractures: a randomized trial involving 52 patients.

BACKGROUND: The most cost-effective treatment of scaphoid fractures has not yet been determined. METHODS: In a prospective trial, 52 employed or selfemployed patients with scaphoid fractures were randomized to closed (cast) or surgical treatment. RESULTS: There were 3 complications in the surgical group and 1 in the cast group. Median time off work was numerically but not statistically significantly greater after cast than after surgery (74/39 days). Manual workers (manuals) had a longer time away from work than non-manual employees/individuals who were selfemployed (non-manuals; median 84 days and 16 days, respectively; p < 0.001) and they had a longer time off work after cast than after surgery (median 100 days and 61 days; p = 0.03). Hospital costs were lower after cast than after surgery (p < 0.001). Work disability costs were numerically but not statistically significantly higher after cast than after surgery, and similarly, the total costs were lower after cast than after surgery. Work disability costs and total costs were higher in manuals than in non-manuals (p < 0.001). Non-manuals had lower total costs after cast than after surgery (p = 0.05). INTERPRETATION: There was a longer period of absence from work after cast than after surgery in manuals, but not in non-manuals. In non-manuals, total costs were lower after cast than after surgery. Socioeconomic classification had a greater influence on cost than mode of treatment.

A cost/utility analysis of open reduction and internal fixation versus cast immobilization for acute nondisplaced mid-waist scaphoid fractures.

BACKGROUND: Open reduction and internal fixation and cast immobilization are both acceptable treatment options for nondisplaced waist fractures of the scaphoid. The authors conducted a cost/utility analysis to weigh open reduction and internal fixation against cast immobilization in the treatment of acute nondisplaced mid-waist scaphoid fractures. METHODS: The authors used a decision-analytic model to calculate the outcomes and costs of open reduction and internal fixation and cast immobilization, assuming the societal perspective. Utilities were assessed from 50 randomly selected medical students using the time trade-off method. Outcome probabilities taken from the literature were factored into the calculation of quality-adjusted life-years associated with each treatment. The authors estimated medical costs using Medicare reimbursement rates, and costs of lost productivity were estimated by average wages obtained from the U.S. Bureau of Labor Statistics. RESULTS: Open reduction and internal fixation offers greater quality-adjusted life-years compared with casting, with an increase ranging from 0.21 quality-adjusted life-years for the 25- to 34-year age group to 0.04 quality-adjusted life-years for the > or =65-year age group. Open reduction and internal fixation is less costly than casting ($7940 versus $13,851 per patient) because of a longer period of lost productivity with casting. Open reduction and internal fixation is therefore the dominant strategy. When considering only direct costs, the incremental cost/utility ratio for open reduction and internal fixation ranges from $5438 per quality-adjusted life-year for the 25- to 34-year age group to $11,420 for the 55- to 64-year age group, and $29,850 for the > or =65-year age group. CONCLUSIONS: Compared with casting, open reduction and internal fixation is cost saving from the societal perspective ($5911 less per patient). When considering only direct costs, open reduction and internal fixation is cost-effective relative to other widely accepted interventions.