Humeral shaft fractures: a cost-effectiveness analysis of operative versus nonoperative management.

BACKGROUND: Humeral shaft fractures can be managed operatively or nonoperatively with functional bracing in the absence of neurovascular injury, open fracture, or polytrauma. A consensus on optimal management has not been reached, nor has the cost-effectiveness perspective been investigated. METHODS: A decision tree was constructed describing the management of humeral shaft fractures with open reduction-internal fixation (ORIF), intramedullary nailing (IMN), and functional bracing in a non-elderly population. Probabilities were defined using weighted averages determined from systematic review of the literature. Cost-effectiveness was evaluated with incremental cost-effectiveness ratios, measured in cost per quality-adjusted life-year (QALY). Willingness-to-pay thresholds of $50,000/QALY and $100,000/QALY were evaluated. RESULTS: Eighty-six studies were included. Using bracing as the referent in the health care model, we observed that bracing was the preferred strategy at both incremental cost-effectiveness ratio thresholds. ORIF and IMN had higher overall effectiveness (0.917 QALYs and 0.913 QALYs, respectively) compared with bracing (0.877 QALYs). The cost-effectiveness of bracing was driven by a substantially lower overall cost. In the societal model-accounting for both health care and societal costs-the cost difference narrowed between bracing, ORIF, and IMN. Bracing remained the preferred strategy at the $50,000/QALY threshold; ORIF was preferred at the $100,000/QALY threshold. ORIF and IMN were comparable strategies across a range of probability values in sensitivity analyses. CONCLUSIONS: Functional bracing, with its low cost and satisfactory clinical outcomes, is often the most cost-effective strategy for humeral shaft fracture management. ORIF becomes preferable at the higher willingness-to-pay threshold when societal burden is considered. QALY values for ORIF and IMN were comparable.

Use of intramedullary carbon fiber nail in hindfoot fusion: A small cohort study.

BACKGROUND: Current literature on carbon fiber implant use in foot and ankle surgery is scant. The purpose of this paper is to report medium-term outcomes of hindfoot fusion using a carbon fiber intramedullary nail. METHODS: We retrospectively reviewed 30 cases of hindfoot fusion using carbon fiber intramedullary nail fixation between 2014 and 2017. We excluded revisions and cases with bulk allograft or ankle infection prior to surgery. We reviewed charts for length of followup, radiographic union, and complications. RESULTS: Eleven patients were included (6 females, 5 males; mean age=52±15years; mean BMI=29.0±6.4kg/m2). Mean followup was 20 (range, 1.5-107) months. Nine of eleven cases achieved radiographic union while one case developed a complication requiring surgery. The mean time to union was 3 (range, 1.5-6) months. CONCLUSIONS: Carbon fiber implants offer several theoretical advantages over traditional metallic implants. They can be used safely in foot and ankle surgery without concern for high failure or complication rate. Larger scale studies with longer followup are needed on this topic.