Cost Analysis of Clavicle Fixation

There has been an increase in the number of clavicle fractures that are treated operatively over the past decade.  While there is good literature to support that certain patterns may benefit from operative fixation, there is a sense from some in the orthopaedic trauma community that the pendulum has swung too far to the side of operative treatment.

In the April issue of JOT, authors from LSU look at another aspect of the debate in their paper “A Cost Analysis of Internal Fixation Versus Nonoperative Treatment
in Adult Midshaft Clavicle Fractures Using Multiple Randomized
Controlled Trials.”  The authors conclude that from the perspective of a single payer, initial nonoperative treatment of midshaft clavicle fractures followed by delayed surgery as needed is less costly than initial operative fixation.

In his invited commentary, Peter Althausen raises several significant concerns with the model that the authors utilize to come to their conclusions.  Some of the issues include cost allocation, only looking at the payer perspective and not the patient/society, and implant costs.  He goes on to state that cost analysis outcomes include much more than the initial cost to payers.

The authors offer a rebuttal to address each of the comments, to which Dr. Althausen offers an additional reply.  But the debate does not have to end there.  What do you think about the article?  How should we evaluate the value of fracture fixation with respect to costs?  Please share your comments below.

Hassan R. Mir, MD, MBA, FACS

Editor | OsteoSynthesis – The JOT Online Discussion Forum

One thought on “Cost Analysis of Clavicle Fixation

  1. As ortho trauma surgeons we need to assure our intervention is better than the natural history of the injury. Multiple RCTs show that overall patients have better functional and pain scores with operative treatment and this has led to an increased incidence of operative treatment of clavicle fractures. These same RCTs also show that the poor results are driven by the 15% nonunions and 10% malunions and the other 75% of patients treated non-operatively are the same as those treated operatively. We need to identify early those patients that are more likely to have a nonunion or malunion. These are the patients that we can improve the natural history of their injury. One can argue the other 75% did not need an operation and 25% of those will have a second operation (nonunion, infection, HW removal).
    One criteria proposed is to operate on those that have as Mike McKee described in the original COTS article a “droopy” shoulder. Although we are incented to operate on all 100% displaced clavicle fractures, I think we can more accurately decipher the literature and operate primarily on those patients we can help.

    Liked by 1 person

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