Cost utility analysis of intramedullary nailing and skeletal traction treatment for patients with femoral shaft fractures in Malawi.

Background and purpose - In Malawi, both skeletal traction (ST) and intramedullary nailing (IMN) are used in the treatment of femoral shaft fractures, ST being the mainstay treatment. Previous studies have found that IMN has improved outcomes and is less expensive than ST. However, no cost-effectiveness analyses have yet compared IMN and ST in Malawi. We report the results of a cost-utility analysis (CUA) comparing treatment using either IMN or ST.Patients and methods - This was an economic evaluation study, where a CUA was done using a decision-tree model from the government healthcare payer and societal perspectives with an 1-year time horizon. We obtained EQ-5D-3L utility scores and probabilities from a prospective observational study assessing quality of life and function in 187 adult patients with femoral shaft fractures treated with either IMN or ST. The patients were followed up at 6 weeks, and 3, 6, and 12 months post-injury. Quality adjusted life years (QALYs) were calculated from utility scores using the area under the curve method. Direct treatment costs were obtained from a prospective micro costing study. Indirect costs included patient lost productivity, patient transportation, meals, and childcare costs associated with hospital stay and follow-up visits. Multiple sensitivity analyses assessed model uncertainty.Results - Total treatment costs were higher for ST ($1,349) compared with IMN ($1,122). QALYs were lower for ST than IMN, 0.71 (95% confidence interval [CI] 0.66-0.76) and 0.77 (CI 0.71-0.82) respectively. Based on lower cost and higher utility, IMN was the dominant strategy. IMN remained dominant in 94% of simulations. IMN would be less cost-effective than ST at a total procedure cost exceeding $880 from the payer's perspective, or $1,035 from the societal perspective.Interpretation - IMN was cost saving and more effective than ST in the treatment of adult femoral shaft fractures in Malawi, and may be an efficient use of limited healthcare resources.

Exploring trends in admissions and treatment for ankle fractures: a longitudinal cohort study of routinely collected hospital data in England.

BACKGROUND: Evidence on the most effective and cost-effective management of ankle fractures is sparse but evolving. A recent large RCT in older patients with unstable fractures found that management with close-contact-casting was functionally equivalent and more cost-effective than internal fixation. We describe temporal and geographic variation in ankle fracture management and estimate the potential savings if close-contact-casting was used more often in older patients. METHODS: Patients admitted to hospital in England between 2007/08 and 2016/17 with an ankle fracture were identified using routine hospital episode statistics. We tested whether the use of internal fixation, and the proportion of internal fixations using intramedullary implants, changed over time. We estimated the potential annual cost savings if patients aged 60+ years were treated with close-contact-casting rather than internal fixation, in line with emerging evidence. RESULTS: Over the 10-year period, there were 223,465 hospital admissions with a primary ankle fracture diagnosis. The incidence (per 100,000) of internal fixation was fairly consistent over time in younger (33.2 in 2007/08, 30.9 in 2016/17) and older (36.5 in 2007/08, 37.4 in 2016/17) patients. The proportion of internal fixations which used intramedullary implants increased in both age groups (17.0-19.5% < 60 years; 15.2-17.4% 60+ years). In 2016/17, the cost of inpatient hospital care for ankle fractures in England was over £63.1million. If 50% of older patients who had an internal fixation instead had close-contact-casting, we estimate that approximately £1.56million could have been saved. CONCLUSIONS: Despite emerging evidence that non-surgical and surgical management achieve equivalent functional outcomes in older patients, the rate of surgical fixation has remained relatively stable over the decade. The health service could achieve substantial savings if a higher proportion of older patients were treated with close-contact-casting, in line with recent evidence.

Routine follow-up is unnecessary after intramedullary fixation of trochanteric femoral fractures-Analysis of 995 cases.

BACKGROUND AND PURPOSE: Approximately 2000 trochanteric fractures are operated in Finland annually. These fractures make a major burden to health care system and affected individuals. The role of routine follow-up has been questioned in multiple fracture types. PATIENTS AND METHODS: We analyzed routine follow-up visits after intramedullary fixation of trochanteric fractures (n = 995). Patients were followed up from patient registries until 2 years or death. Planned and unplanned follow-up visits were analyzed. RESULTS: Altogether 9 patients (0.9%) had a change in treatment at planned outpatient visit. 6 of these were due to mechanical complication, 1 due to refracture and 2 due to delayed unions. 64 (6.4%) patients had a change in treatment plan because of an unplanned visit: 28 infections, 6 pressure sores, 15 mechanic complications and 14 refractures and 1 AVN, respectively. INTERPRETATION: Routine follow-up visits are a burden both to the patients and health care system, with less than 1% leading to changes in treatment. Our suggestion is to give good instructions to patients and rehabilitation facilities instead of routine follow-up.

Cost-Effectiveness of Titanium Elastic Nail (TEN) in the Treatment of Forearm Fractures in Children.

Background and objectives: There are various methods in the management of forearm fractures in children. Elastic stable intramedullary nailing using Titanium Elastic Nail (TEN) is nowadays employed in diaphysis fractures of children, with clear benefits over other treatment options. However, in the case of TEN versus other treatment methods of forearm fractures in children, cost is an important issue. This report will focus on the cost assessment of using TEN versus other therapeutic means in the treatment of forearm fractures in children. Materials and Methods: We performed a retrospective longitudinal study of 173 consecutive patients with forearm fractures treated in a single institution during 2017. We calculated the cost for each patient by summing up direct costs plus indirect costs, calculated at an aggregate level. Hospital income data were extracted from the Diagnosis Related Groups database. Results: A total of 173 patients with forearm fractures were treated, 44 using TEN, 86 using K-wire, and 46 using closed reduction and cast. There were 66 radius fractures, 1 ulna fracture, and 106 that were both radius and ulna fractures. Mean treatment cost were $632.76 for TEN, $499.50 for K-wire, and $451.30 for closed reduction and cast. Costs for TEN were higher than for K-wire insertion (p = 0.00) and higher than closed reduction and cast ($182.42; p = 0.00). Reimbursement per patient was higher with TEN versus K-wire patients; $497.88 vs. $364.64 /patient (p = 0.00), and higher than for patients treated with closed reduction and cast (p = 0.00). Conclusions: The treatment of upper extremity fractures using TEN was more expensive than the other methods. In Romania, because the reimbursement for TEN is higher as well, there are no differences in the financial burden when treating forearm fractures with TEN versus K-wire. Non-surgical treatment has the lowest cost but also the lowest reimbursement.

Retrograde intramedullary nail fixation compared with fixed-angle plate fixation for fracture of the distal femur: the TrAFFix feasibility RCT.

BACKGROUND: Fractures of the distal femur are an increasingly common injury; the optimal management of these injuries remains controversial. The two interventions used in UK practice are intramedullary fixation, with a locked retrograde nail, and extramedullary fixation, with a fixed angle plate. OBJECTIVES: This study assessed the feasibility of a definitive trial and included a process evaluation to understand the generalisability and likely success of a future trial. DESIGN: A multicentre, parallel, two-arm, randomised controlled feasibility trial with an embedded process evaluation. Treatment with a plate or nail was allocated in a 1 : 1 ratio, stratified by centre and chronic cognitive impairment. Surgeons were not blinded, but participants were not told their allocation. SETTING: Seven NHS hospitals. PARTICIPANTS: Patients aged ≥ 18 years with a fracture of the distal femur who the attending surgeon believed would benefit from internal fixation were potentially eligible. Patients were excluded if they had a loose arthroplasty requiring revision or a femoral deformity or arthroplasty that precluded nail fixation. The sample was recruited between 29 September 2016 and 31 August 2017. Consent was obtained from the patient or appropriate consultee before enrolment. INTERVENTIONS: Patients were randomised to receive fixation of their distal femur fracture with either a proximally and distally locked retrograde nail that spanned the diaphysis of the femur or an anatomical distal femoral locking plate with at least one locked screw distal to the fracture. Reduction and supplemental fixation were at the surgeon's discretion. OUTCOMES: The primary outcome measures for this study were the recruitment rate and the completion rate of the EuroQol-5 Dimensions, five-level version (EQ-5D-5L), at 6 weeks and 4 months. Additional measurements included baseline characteristics, measures of social support and self-efficacy, disability rating index, dementia quality-of-life measures and a radiographical assessment of any malunion. Participants' and staff views were obtained, at interview, for the process evaluation. RESULTS: The process evaluation showed that surgeon-related factors, principally confidence with both technologies and a lack of individual equipoise, were key barriers to recruitment. A total of 23 participants were randomised and analysed (nail, n = 11; plate, n = 12). The recruitment rate was estimated as 0.42 [95% confidence interval (CI) 0.27 to 0.62] participants per centre per month, lower than the prespecified feasibility threshold of 1.0 participants per centre per month. Data completeness of the EQ-5D-5L was estimated at 65% (95% CI 43% to 83%). CONCLUSIONS: This feasibility study has challenged many of the assumptions that underpinned the development of proposed definitive trial protocol. A modified protocol is proposed that would be feasible given the recruitment rate observed here, which is equal to that reported in the similar FixDT trial [Health Technology Assessment (HTA) 11/136/04: Costa ML, Achten J, Hennings S, Boota N, Griffin J, Petrou S, et al. Intramedullary nail fixation versus locking plate fixation for adults with a fracture of the distal tibia: the UK FixDT RCT. Health Technol Assess 2018;22(25)], which delivered to target and budget. FUTURE WORK: A definitive trial with a modified design is recommended, including an internal pilot to confirm initial recruitment rate assumptions. REGISTRATION: Current Controlled Trials ISRCTN92089567. 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. 23, No. 51. See the NIHR Journals Library website for further project information. Funding was also supported by the NIHR Oxford Biomedical Research Centre.

Breaks of the lower end of the thigh bone are increasingly common injuries. Two operations are used to treat these injuries: a rod placed along the centre of the bone or a plate attached to the edge of the bone. It is not clear which is better. We report the results from a study that will help develop the design of a definitive study to test which operation produces the best outcomes for patients. Adult patients with a break at the end of the thigh bone treated in one of seven hospitals were eligible to take part in the study. Participants were treated with one of two operations; the choice was made by chance using a computer program. Participants' basic information and pre-injury health status were recorded and participants were followed up at 6 and 16 weeks. We assessed the rate at which participants agreed to take part in the study and the number who completed follow-up. A value-for-money analysis was performed to determine how to plan this element of a future study. Staff and patients were interviewed about the study processes and the context of the treatments and hospitals to understand how the treatments work and the practicalities of delivering the study. Lower than expected numbers of participants took part in the study; 173 patients were considered for the study, but only 23 agreed to participate. The main reason was that several of the participating surgeons felt strongly that one or the other operation was superior. The rate of follow-up was similar to that of other studies using these treatments. Therefore, the proposed definitive trial is unlikely to be successful if designed in the same way as this feasibility study. Several important considerations that informed the planning of this study were found not to hold true. We believe a modified study could be delivered and could answer this important research question.

Does Implant Choice Affect the Episode Cost of Pertrochanteric Hip Fracture for US Veterans?

OBJECTIVE: To investigate an association between a surgeon's choice of a cephalomedullary nail (CMN) or sliding hip screw (SHS) with the cost of treating a pertrochanteric hip fracture. DESIGN: Multicenter retrospective cohort study. SETTING: US Veterans Health Administration Sierra Pacific Network. PATIENTS/PARTICIPANTS: Two hundred ninety-four consecutive US veterans admitted for a principal diagnosis of an OTA/AO 31A-type pertrochanteric hip fracture of a native hip from 2000 to 2015. INTERVENTION: Internal fixation using a CMN or an SHS. MAIN OUTCOME MEASUREMENTS: Veterans Administration Health Economic Resource Center average national cost estimate of combined acute and postacute care episode cost, excluding implant cost, normalized to 2015 US dollars by the Consumer Price Index. RESULTS: Median episode cost was $8223 lower with a CMN than an SHS (95% confidence interval, $5700-$10,746, P < 0.001) after matching on a propensity score for treatment with a CMN based on age, sex, body mass index, Charlson Comorbidity Index, fracture characteristics, study site, and admission year. A subgroup propensity-matched analysis excluding reverse obliquity pertrochanteric fractures was not sufficiently powered to detect a difference in episode cost (ß = 0.76, P = 0.311). CONCLUSIONS: Implant choice significantly affected the episode cost of care of hip fracture at Veterans Health Administration facilities. LEVEL OF EVIDENCE: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The burden of femoral shaft fractures in Tanzania.

BACKGROUND: Road traffic injuries disproportionately affect low- and middle-income countries (LMICs) and are associated with femur fractures that lead to long-term disability. Information about these injuries is crucial for appropriate healthcare resource allocation. The purpose of this study is to estimate the incidence of femoral shaft fractures in Tanzania and describe the unmet surgical burden. METHODS: Study sites included six government hospitals across Tanzania. Investigators collected data from hospital admission and procedural logbooks to estimate femoral shaft fracture incidence and their treatment methods. Semi-quantitative interviews were conducted with relevant hospital personnel to validate estimates obtained from hospital records. Investigators gathered road traffic incident (RTI) statistics from national police reports and calculated femur fracture:RTI ratios. RESULTS: Femoral shaft fracture annual incidence rate ranged from 2.1 to 18.4 per 100,000 people. Median low and high femur fracture:RTI ratio were 0.54 and 0.73, respectively. At smaller hospitals, many patients (5-25%) were treated with traction, and a majority (70-90%) are referred to other centers. Barriers to surgery at each hospital include a lack of surgical implants, equipment, and personnel. CONCLUSIONS: The incidence rate is similar to previous estimations, and it is consistent with an increased femoral shaft fracture incidence in Tanzania when compared to higher income countries. The femur fracture:RTI ratio may be a valid tool for estimating femur fracture incidence rates. There is an unmet orthopaedic surgical burden for femur fractures treatment at rural hospitals in Tanzania, and the barriers to treatment could be targets for future interventions.

Reoperations in intramedullary fixation of pertrochanteric hip fractures.

Objective: This study evaluated the frequency of reoperation within 1 year of initial intramedullary fixation for patients with pertrochanteric hip fracture and compared 1-year healthcare resource utilization and cost burden for patients with and without reoperation. Methods: This is a retrospective evaluation of medical claims from the US Centers for Medicare and Medicaid Standard Analytic File. Patients aged ≥65 years who underwent fixation with an intramedullary implant for a pertrochanteric fracture between 2013 and 2015 were included. Healthcare resources that were evaluated included skilled nursing facility (SNF), inpatient rehabilitation facility (IRF), readmissions, and outpatient hospital visits. All-cause payments for these services comprised overall cost burden. Generalized Linear Models were used to evaluate healthcare resources and cost burden over 1-year post-surgery and to adjust for confounding between patients with and without a reoperation. Results: A total of 6,423 Medicare patients were included in the analysis. Mean (SD) age was 82.4 (7.8) years, 76.0% were female, and 93.3% were white. A second hip surgery within 1 year after the index fixation procedure was performed in 414 patients (6.4%): 121 (29.2%) contralateral, 115 (27.8%) ipsilateral, and 178 (43.0%) without specified laterality. After adjusting for confounding factors, Medicare patients with ipsilateral reoperations had statistically significantly higher readmissions (100% vs 32.5%, p < 0.0001), outpatient hospital visits (96.4% vs 88.8%, p = 0.018), admissions to a SNF (88.5% vs 80.4%, p = 0.024), and admissions to an IRF (38.8% vs 22.0%, p < 0.0001) compared to patients without reoperations. The adjusted mean total all-cause payments ($90,162 vs $55,131, p < 0.0001) during the 1-year follow-up were statistically significantly higher among patients with reoperations as compared to patients without reoperations. Conclusions: Patients who require a second hip surgery after initial fixation with an intramedullary implant for pertrochanteric hip fractures have significantly higher 1-year healthcare resource utilization and 63.5% higher costs than patients without reoperation.

The Cost of Intramedullary Nailing Versus Skeletal Traction for Treatment of Femoral Shaft Fractures in Malawi: A Prospective Economic Analysis.

BACKGROUND: In many low- and middle-income countries, non-surgical management of femoral shaft fractures using skeletal traction is common because intramedullary (IM) nailing is perceived to be expensive. This study assessed the cost of IM nailing and skeletal traction for treatment of femoral shaft fractures in Malawi. METHODS: We used micro-costing methods to quantify the costs associated with IM nailing and skeletal traction. Adult patients who sustained an isolated closed femur shaft fracture and managed at Queen Elizabeth Central Hospital in Malawi were followed from admission to discharge. Resource utilization and time data were collected through direct observation. Costs were quantified for procedures and ward personnel, medications, investigations, surgical implants, disposable supplies, procedures instruments and overhead. RESULTS: We followed 38 nailing and 27 traction patients admitted between April 2016 and November 2017. Nailing patient's average length of stay (LOS) was 36.35 days (SD 21.19), compared to 61 (SD 18.16) for traction (p = 0.0003). The total cost per patient was $596.97 ($168.81) for nailing and $678.02 (SD $144.25) for traction (p = 0.02). Major cost drivers were ward personnel and overhead; both are directly proportional to LOS. Converting patients from traction to nailing is cost-saving up to day 23 post-admission. CONCLUSION: Savings from IM nailing as compared with skeletal traction were achieved by shortened LOS. Although this study did not assess the effectiveness of either intervention, the literature suggests that traction carries a higher rate of complications than nailing. Investment in IM nailing capacity may yield substantial net savings to health systems, as well as improved clinical outcomes.

Prophylactic Fixation Can Be Cost-effective in Preventing a Contralateral Bisphosphonate-associated Femur Fracture.

BACKGROUND: Bisphosphonates reduce the risk of fractures associated with osteoporosis but increase the risk of atypical subtrochanteric femur fractures. After unilateral atypical femur fracture, there is risk of contralateral fracture, but the indications for prophylactic fixation are controversial. QUESTIONS/PURPOSES: The purpose of this study is to use Markov modeling to determine whether contralateral prophylactic femur fracture fixation is cost-effective after a bisphosphonate-associated atypical femur fracture and, if so, what patient-related factors may influence that determination. METHODS: Markov modeling was used to determine the cost-effectiveness of contralateral prophylactic fixation after an initial atypical femur fracture. Simulated patients aged 60 to 90 years were included and separated into standard and high fracture risk cohorts. Patients with standard fracture risk were defined as those presenting with one atypical femur fracture but without symptoms or findings in the contralateral femur, whereas patients with high fracture risk were typified as those with more than one risk factor, including Asian ethnicity, prodromal pain, femoral geometry changes, or radiographic findings in the contralateral femur. Outcome probabilities and utilities were derived from studies matching to patient characteristics, and fragility fracture literature was used when atypical femur fracture data were not available. Associated costs were largely derived from Medicare 2015 reimbursement rates. Sensitivity analysis was performed on all model parameters within defined ranges. RESULTS: Prophylactic fixation for a 70-year-old patient with standard risk for fracture costs USD 131,300/quality-adjusted life-year (QALY) and for high-risk patients costs USD 22,400/QALY. Sensitivity analysis revealed that prophylaxis for high-risk patients is cost-effective at USD 100,000/QALY when the cost of prophylaxis was less than USD 29,400, the probability of prophylaxis complications was less than 21%, or if the patient was younger than 89 years old. The parameters to which the model was most sensitive were the cost of prophylaxis, patient age, and probability of prophylaxis-related complications. CONCLUSIONS: Prophylactic fixation of the contralateral side after unilateral atypical femur fracture is not cost-effective for standard-risk patients but is cost-effective among high-risk patients between 60 and 89 years of age with a high risk for an atypical femur fracture defined by patients with more than one risk factor such as Asian ethnicity, prodromal pain, varus proximal femur geometry, femoral bowing, or radiographic changes such as periosteal beaking and a transverse radiolucent line. However, our findings are based on several key assumptions for modeling such as the probability of fractures and complications, the costs associated for each health state, and the risks of surgical treatment. Future research should prospectively evaluate the degree of risk contributed by known radiographic and demographic parameters to guide management of the contralateral femur after a patient presents with an atypical femur fracture. LEVEL OF EVIDENCE: Level III, economic and decision analyses.

Financial Analysis of Closed Femur Fractures in 3- to 6-Year-Olds Treated With Immediate Spica Casting Versus Intramedullary Fixation.

BACKGROUND: Health care in America continues to place more importance on providing value-based medicine. Medicare reimbursements are increasingly being tied to this and future policy changes are expected to reinforce these trends. Recent literature has shown pediatric femur fractures in preschool-age children have equivalent clinical and radiographic outcomes when treated with spica casting or flexible intramedullary nails (IMN). We compared hospital care statistics including charges for nonoperative versus operative treatment for closed femur fractures in 3- to 6-year-olds. METHODS: An IRB-approved retrospective chart review was performed of 73 consecutive 3- to 6-year-olds treated at a regional level 1 pediatric hospital from January 1, 2009 to December 31, 2013 with an isolated, closed femoral shaft fracture. Exclusion criteria included open fractures, bilateral injury, and polytrauma. Immediate spica casting was performed in the Emergency Department or Anesthesia Procedure Unit versus IMN in the operating room. RESULTS: A total of 41 patients were treated with spica casting and 32 patients were treated operatively with flexible IMNs; 3 patients failed nonoperative care. After analysis of final treatment groups, significant differences included age at injury: 3.7 years for cast versus 5.3 years for IMN (P<0.001), time to discharge 21 versus 41 hours (P<0.001), 3.2 versus 4.4 clinic visits (P<0.001), follow-up 3.5 versus 9.4 months (P<0.001). Orthopedic surgeon charges were $1500 for casted patients versus $5500 for IMN (P<0.001). Total hospital charges were $19,200 for cast versus $59,700 for IMN (P<0.001). No difference was found between clinic charges or number of radiographs between groups. In total, 76% of cast group were discharged <24 hours from admission versus 8.6% in operative group. In the operative group, 83% had implant removal with no statistically significant charge difference between those who had implant removal versus retention. CONCLUSIONS: Treatment of pediatric femur fractures in 3- to 6-year-olds with IMN is associated with longer hospital stays, significantly greater hospital charges, longer follow-up and more clinic visits compared with spica casting. These findings are at odds with previous literature showing shorter hospital stays and decreased cost with nailing compared to traction and casting. This shows a clear difference between 2 treatments that yield similar clinical and radiographic outcomes. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Comparing the costs and outcomes of an integrated twin compression screw (ITCS) nail with standard of care using a single lag screw or a single helical blade cephalomedullary nail in patients with intertrochanteric hip fractures.

BACKGROUND: Surgical treatment is the optimal strategy for managing intertrochanteric fractures as it allows for early rehabilitation and functional recovery. The purpose of the study was to assess the cost-effectiveness of commonly used cephalomedullary nails for the treatment of unstable intertrochanteric hip fractures. METHODS: A decision analytic model was developed from a US payer's perspective using clinical data from a pairwise meta-analysis of randomised controlled trials (RCTs) and comparative observational studies comparing the integrated twin compression screw (ITCS) nail versus two single-screw or blade cephalomedullary nails [single lag screw (SLS) nail and single helical blade (SHB) nail]. The model considered a cohort of 1000 patients with a mean age of 76, as reported in the clinical studies over a 1-year time period. Cost data was obtained from the Center for Medicare and Medicaid Services website and published literature and adjusted for inflation. One-way and probabilistic sensitivity analyses were conducted to assess the effect of uncertainty in model parameters on model conclusions. RESULTS: The model estimated 0.546 quality-adjusted life years (QALYs) and 0.78 complications avoided by using the ITCS nail and 0.455 QALYs and 0.67 complications avoided for the standard of care, using SLS or SHB nails. The cost per patient was $34,336 for patients treated with an ITCS nail and $37,036 for patients treated with the standard of care respectively, resulting in a cost saving of $2700 in favour of the ITCS nail. More savings were observed when the ITCS nail was compared to the SHB ($3280 per patient) and SLS ($1652 per patient). The findings were robust to a range of both one-way and the probabilistic sensitivity analyses. CONCLUSION: In conclusion, the ITCS nail can be considered a cost saving intervention in patients undergoing intertrochanteric fracture fixation with an intramedullary device. Clinicians and policy makers should be encouraged to adopt healthcare technologies such as ITCS that will help them to provide quality healthcare despite falling budgets.

Why Fibular Nailing Can Be an Efficient Treatment Strategy for AO Type 44-B Ankle Fractures in the Elderly.

The reference standard treatment of unstable AO type 44-B ankle fractures is open reduction and internal fixation. However, delayed-staged surgery because of compromised soft tissues results in prolonged hospitalization and increased total healthcare costs in the elderly (age ≥65 years). The aim of the present study was to measure the efficiency of intramedullary fibular nailing (IMFN) in the elderly. A prospective series of 15 elderly patients with an AO type 44-B ankle fracture treated with IMFN were compared with a retrospective cohort of 97 elderly patients treated with plate and screw osteosynthesis (PSOS). Clinical and process-related variables and total healthcare costs, including 5 cost categories, were assessed. Functional outcomes, general health status, and quality of life were measured using the American Orthopaedic Foot and Ankle Society ankle-hindfoot and EuroQol 5-dimension 3-level visual analog scales. Although the preoperative length of stay was significantly shorter for the patients treated with IMFN, the total length of stay and total healthcare costs were not significantly different between the 2 groups. The complication and reintervention rates were similar in both groups, with improved American Orthopaedic Foot and Ankle Society scale scores in the IMFN group. Compared with delayed-staged surgery, early IMFN led to a significant reduction in total healthcare costs. We could not prove significant cost savings for IMFN compared with PSOS for the treatment of AO type 44-B ankle fractures. However, early IMFN was financially beneficial compared with a delayed-staged (IMFN and PSOS) surgery protocol. Because, ultimately, IMFN allows for early percutaneous fixation in most cases, IMFN is a potentially profitable treatment strategy for AO type 44-B ankle fractures in the elderly with good outcomes.

A comparison of the cost-effectiveness of intramedullary nail fixation and locking plate fixation in the treatment of adult patients with an extra-articular fracture of the distal tibia: economic evaluation based on the FixDT trial.

Aims: The aim of this study was to compare the cost-effectiveness of intramedullary nail fixation and 'locking' plate fixation in the treatment of extra-articular fractures of the distal tibia. Patients and Methods: An economic evaluation was conducted from the perspective of the United Kingdom National Health Service (NHS) and personal social services (PSS), based on evidence from the Fixation of Distal Tibia Fractures (UK FixDT) multicentre parallel trial. Data from 321 patients were available for analysis. Costs were collected prospectively over the 12-month follow-up period using trial case report forms and participant-completed questionnaires. Cost-effectiveness was reported in terms of incremental cost per quality adjusted life year (QALY) gained, and net monetary benefit. Sensitivity analyses were conducted to test the robustness of cost-effectiveness estimates. Results: Mean NHS and PSS costs were significantly lower for patients treated with an intramedullary nail than for those treated with a locking plate (-£970, 95% confidence interval (CI) -1685 to -256; p = 0.05). There was a small increase in QALYs gained in the nail fixation group (0.01, 95% CI -0.03 to 0.06; p = 0.52). The probability of cost-effectiveness for nail fixation exceeded 90% at cost-effectiveness thresholds as low as £15 000 per additional QALY. The cost-effectiveness results remained robust to several sensitivity analyses. Conclusion: This trial-based economic evaluation suggests that nail fixation is a cost-effective alternative to locking plate fixation. Cite this article: Bone Joint J 2018;100-B:624-33.

Are the current guidelines for surgical delay in hip fractures too rigid? A single center assessment of mortality and economics.

PURPOSE: Controversy remains around acceptable surgical delay of acute hip fractures with current guidelines ranging from 24 to 48 h. Increasing healthcare costs force us to consider the economic burden as well. We aimed to evaluate the adjusted effect of surgical delay for hip fracture surgery on early mortality, healthcare costs and readmission rate. We hypothesized that shorter delays resulted in lower early mortality and costs. METHODS: In this retrospective cohort study 2573 consecutive patients aged ≥50 years were included, who underwent surgery for acute hip fractures between 2009 and 2017. Main endpoints were thirty- and ninety-day mortality, total cost, and readmission rate. Multivariable regression included sex, age and ASA score as covariates. RESULTS: Thirty-day mortality was 5% (n = 133), ninety-day mortality 12% (n = 304). Average total cost was €11960, dominated by hospitalization (59%) and honoraria (23%). Per 24 h delay, the adjusted odds ratio was 1.07 (95% CI 0.98-1.18) for thirty-day mortality, 1.12 (95% CI 1.04-1.19) for ninety-day mortality, and 0.99 (95% CI = 0.88-1.12) for readmission. Per 24 h delay, costs increased with 7% (95% CI 6-8%). For mortality, delay was a weaker predictor than sex, age, and ASA score. For costs, delay was the strongest predictor. We did not find clear cut-points for surgical delay after which mortality or costs increased abruptly. CONCLUSIONS: Despite only modest associations with mortality, we observed a steady increase in healthcare costs when delaying surgery. Hence, a more pragmatic approach with surgery as soon as medically and organizationally possible seems justifiable over rigorous implementation of the current guidelines.

Titanium Elastic Nailing has Superior Value to Plate Fixation of Midshaft Femur Fractures in Children 5 to 11 Years.

BACKGROUND: American Academy of Orthopaedic Surgeons (AAOS) Clinical Practice Guidelines for pediatric femoral shaft fractures indicate titanium elastic nails (TENs) for children 5 to 11 years old. Growing evidence suggests these fractures may also be treated with open or submuscular plating. The purpose of this study was to compare estimated blood loss (EBL), operative time, fluoroscopy time, cost, and subjective and objective pain scores between TENs and plating techniques used in 5- to 11-year-old children with midshaft femur fractures based on length stability. We hypothesized that EBL, operative time, and fluoroscopy time would be greater and pain would be lower with plate fixation. METHODS: We retrospectively identified all pediatric midshaft femur fractures treated with TENs, submuscular plating, or open plating between 2004 and 2014. Demographic, injury, and surgical data were obtained for analysis. Cost data were obtained from Synthes Inc. Outcomes were determined using the TEN outcome scoring system. Variables were compared between the 3 fixation methods using paired t tests or Fisher exact test as appropriate. Cost data were compared with Mann-Whitney nonparametric test. RESULTS: There were 65 midshaft femur fractures in 63 patients included. TENs accounted for 77% and plating 23%. There were no statistical differences in injury severity score, length of stay, length unstable fractures, open fractures, fluoroscopy time, or pain. However, there was a significantly greater operative time (P=0.007) and a notably greater EBL (P=0.057) for the plating technique compared with TENs. Patient outcomes were found to be equivalent. Implant cost was not significantly different although increased surgical costs were seen in plating (P=0.0007). CONCLUSIONS: This study supports the use of TENs or plating for midshaft femur fractures in children 5 to 11 years old, regardless of length stability. The use of plates resulted in higher EBL, longer operative time, increased cost, and equivalent pain compared with TENs. To our knowledge, this study represents the first direct comparison of the common fixation methods specifically for midshaft femur fractures and favors the use of TENs. LEVEL OF EVIDENCE: Level III.

Implant options for the treatment of intertrochanteric fractures of the hip: rationale, evidence, and recommendations.

AIMS: The aim of this paper is to review the evidence relating to the anatomy of the proximal femur, the geometry of the fracture and the characteristics of implants and methods of fixation of intertrochanteric fractures of the hip. MATERIALS AND METHODS: Relevant papers were identified from appropriate clinical databases and a narrative review was undertaken. RESULTS: Stable, unstable, and subtrochanteric intertrochanteric fractures vary widely in their anatomical and biomechanical characteristics, as do the implants used for their fixation. The optimal choice of implant addresses the stability of the fracture and affects the outcome. CONCLUSION: The treatment of intertrochanteric fractures of the hip has evolved along with changes in the design of the implants used to fix them, but there remains conflicting evidence to guide the choice of implant. We advocate fixation of 31A1 fractures with a sliding hip screw and all others with an intramedullary device. Cite this article: Bone Joint J 2017;99-B:128-33.

Intramedullary Nailing System in Unstable Both Bone Diaphyseal Fractures in Children.

Background Forearm fractures in pediatric population is usually managed conservatively. Unstable fractures need operative intervention like closed or open intramedullary nailing or open reduction and internal fixation with plates and screws. However, there is no consensus regarding the method of treatment according to age group. Objective To standardize the use of elastic nailing system as effective form of treatment in terms of function, cost and lower complications as compared to widely used titanium nails in developed countries.Method Sixty eight pediatric patients with both bone forearm diaphyseal fractures were managed with closed reduction and intramedullary fixation with rush nail or k-wire and followed at least for 6 months for evaluation of radiological and functional outcome. Result Patients were divided into two age groups, Group A for age of 5 to 9 years (26 patients) and Group B for age of 10-15 years (42 patients). The mean time for union for Group A patient was 7.31 weeks which was significantly lower than that of Group B patients of 9.33 weeks (p-value < 0.05). All the patients in Group A had excellent outcome and 36 (85.7%) patients had excellent outcome and 6 (14.3%) had good outcome in Group B. 5 out of 68 cases (7.35 %) had minor complications (2 in Group A and 3 in Group B). The mean time for implant removal was 17.9 weeks in Group A and 22.9 in Group B. Conclusion Intramedullary fixation for unstable diaphyseal both bone fractures of forearm is safe and cost effective method of treatment with good to excellent functional outcome with union time being significantly lower in younger age group.

Controversies in Intramedullary Fixation for Intertrochanteric Hip Fractures.

Intertrochanteric hip fractures are common and costly. Intramedullary fixation has gained popularity as a means of stabilizing intertrochanteric hip fractures. This review article presents some of the controversies surrounding the treatment of intertrochanteric fractures using a cephalomedullary nail. These topics include nail length, the need for distal interlocking, proximal screw design, the number of proximal lag screws, and integrated proximal sliding lag screws. LEVEL OF EVIDENCE: Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.