Cost-Effectiveness of Operative Versus Nonoperative Management of Patients With Intra-articular Calcaneal Fractures

Current Management of Intra-Articular Calcaneal Fractures

Intra-articular calcaneal fractures are debilitating injuries that can result in a dramatic effect on quality of life post-injury. Surgical intervention is generally advised when significant displacement or comminution is present but can present a host of complications secondary to the limited blood supply and fragility to the soft tissues following injury. Surgical approaches to calcaneal fractures generally include the lateral extensile approach, minimal incision (sinus tarsi approach), or percutaneous approach. Each approach presents risks and benefits; therefore, determining the optimal incisional approach should be based on patient comorbidities, fracture pathoanatomy, soft tissue envelope concerns, and patient pre-injury functional status.

Intra-articular Calcaneal Fractures: A Report of Cases and Comments on Preoperative Management

OBJECTIVES

To present a review of the clinical characteristics, preoperative and surgical management, and outcomes of patients with intra-articular calcaneal fractures who had open reduction and internal fixation (ORIF) and to offer some comments on and research ideas for the preoperative management of patients with these fractures.

PATIENTS AND METHODS

We studied consecutive patients who had ORIF performed by a single surgeon for closed, intra-articular calcaneal fractures at our level-1 trauma center between 5/29/2012 and 3/20/2018. All inpatients were treated with a preoperative soft tissue management protocol, whereas outpatients were not. Data were obtained about demographic and clinical characteristics, times from injury to surgery, quality of fracture reductions, and complication rates.

RESULTS

Mean follow-up for the 72 patients with 77 calcaneal fractures was 8.5 (range: 1-43) months, and 21 (27.3%) fractures received inpatient preoperative care with a soft tissue management protocol, while 56 (72.7%) received outpatient preoperative management. More of the fractures treated preoperatively as inpatients versus outpatients were classified as Sanders type III (66.7% vs. 32.1%) and type IV (8.9% vs. 4.8%) fractures and were associated with polytrauma (38.1% vs. 7.1%) and diabetes mellitus (9.5% vs. 5.4%), respectively. For all patients, the mean time from injury to surgery was 12.2 (range: 2.7-19.4) days, and the time was 6.3 days for inpatients and 14.4 days for outpatients, but the quality of fracture reductions and complication rates did not differ between these two groups.

CONCLUSIONS

Patients with intra-articular calcaneal fractures treated as inpatients and receiving a preoperative soft tissue management protocol had outcomes after ORIF that were not inferior to those experienced by patients treated preoperatively as outpatients, despite a greater proportion of the inpatients having severe fractures, polytrauma, and diabetes mellitus. Dedicated preoperative soft tissue management protocols may be beneficial for patients with calcaneal fractures and warrant further study.

Societal burden and quality of life in patients with Lisfranc Injuries

BACKGROUND

The incidence of Lisfranc fractures is rising, along with the incidence of foot fractures in general. These injuries can lead to long-term healthcare use and societal costs. Current economic evaluation studies are scarce in Lisfranc fracture research, and only investigate the healthcare costs. The aim of the present study was to accurately measure the monetary societal burden of disease and quality of life in the first 6 months after the injury in patients with Lisfranc fractures in the Netherlands.

MATERIALS AND METHODS

This study used a prevalence-based, bottom-up approach. Patients were included through thirteen medical centres in the Netherlands. Both stable and unstable injuries were included. The societal perspective was used. The costs were measured at baseline, 12 weeks and 6 months using the iMTA MCQ and PCQ questionnaires. Reference prices were used for valuation. Quality-of-life was measured using the EQ-5D-5 L and VAS scores.

RESULTS

214 patients were included. The mean age was 45.9 years, and 24.3% of patients had comorbidities. The baseline questionnaires yielded approximately €2023 as the total societal costs in the 3 months prior to injury. The follow-up questionnaires and surgery costs assessment yielded approximately €17,083 as the total costs in the first 6 months after injury. Of these costs, approximately two thirds could be attributed to productivity losses. The EQ-5D-5 L found a mean index value of 0.449 at baseline and an index value of 0.737 at the 6-month follow-up.

CONCLUSION

The total monetary societal costs in the first 6 months after injury are approximately €17,083. Approximately two thirds of these costs can be attributed to productivity losses. These costs appear to be somewhat higher than those found in other studies. However, these studies only included the healthcare costs. Furthermore, the baseline costs indicate relatively low healthcare usage before the injury compared to the average Dutch patient. The mean QoL index was 0.462 at baseline and 0.737 at 6 months, indicating a rise in QoL after treatment as well as a long-lasting impact on QoL. To our knowledge, this is only the first study investigating the societal costs of Lisfranc injuries, so more research is needed.

Economic evaluations in fracture research an introduction with examples of foot fractures

INTRODUCTION

The incidence of foot fractures is increasing. These types of fractures represent the most expensive group of diagnoses in the emergency department. Next to this, the need for economic evaluation studies is growing fast. The aim of this article is to provide healthcare professionals with an introduction to economic evaluation studies in the field of foot fractures.

TYPES OF ECONOMIC EVALUATION STUDIES

Four types of economic evaluation studies exist: cost-minimization analysis (CMA), cost-benefit analysis (CBA), cost-effectiveness analysis (CEA), and cost-utility analysis (CUA). An economic evaluation study can be either trial- or model-based.

COST ASSESSMENT

When assessing costs in an economic evaluation study, three steps need to be made: identification of costs, measurement of costs, and valuation of costs.

PERSPECTIVE OF ANALYSIS

Two main perspectives exist in economic evaluation studies. When using a healthcare perspective, only the potential costs and benefits of an intervention for the healthcare sector are included. The societal perspective includes all potential costs, including societal costs.

SYNTHESIS OF COSTS AND EFFECTS AND UNCERTAINTY ANALYSIS

The level of cost-effectiveness can be objectively expressed using the incremental cost-effectiveness ratio (ICER). This measure can be plotted in a cost-effectiveness plane and can be compared with existing regional ceiling ratios.

CONCLUSION

Although this article is not a guideline for economic evaluations, we do want to present five tips to consider when performing an economic evaluation. Firstly, when measuring resource use, consult the Database of Instruments for Resource Use Measurements (DIRUM) to find an appropriate instrument. Secondly, when measuring utility values, use the EuroQol questionnaire if possible. Thirdly, when setting up an economic evaluation study, consult the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) database for the appropriate pharmacoeconomic guidelines. Fourthly, consult international guidelines to decide which study design is most appropriate. Finally, when performing an economic evaluation, consult a heath technology assessment (HTA) specialist from the start to ensure methodological quality.