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Surgical management for displaced pediatric proximal humeral fractures: a cost analysis.

Shore BJ, Hedequist DJ, Miller PE, Waters PM, Bae DS - J Child Orthop (2015)

Bottom Line: A greater percentage of open reduction was seen in the IMN and PPB groups (p = 0.03), while a higher proportion of physeal injury was seen in the PPE group (p = 0.02).The decision analysis revealed that the PPE technique resulted in an average cost saving of $4,502 per patient compared to IMN and $2,066 compared to PPB.This strategy remained cost-effective even when the complication rates with exposed implants approached 55 %.

View Article: PubMed Central - PubMed

Affiliation: Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, Hunnewell 221, 300 Longwood Avenue, Boston, MA, 02115, USA, Benjamin.shore@childrens.harvard.edu.

ABSTRACT

Purpose: The purpose of this investigation was to determine which of the following methods of fixation, percutaneous pinning (PP) or intramedullary nailing (IMN), was more cost-effective in the treatment of displaced pediatric proximal humeral fractures (PPHF).

Methods: A retrospective cohort of surgically treated PPHF over a 12-year period at a single institution was performed. A decision analysis model was constructed to compare three surgical strategies: IMN versus percutaneous pinning leaving the pins exposed (PPE) versus leaving the pins buried (PPB). Finally, sensitivity analyses were performed, assessing the cost-effectiveness of each technique when infection rates and cost of deep infections were varied.

Results: A total of 84 patients with displaced PPHF underwent surgical stabilization. A total of 35 cases were treated with IMN, 32 with PPE, and 17 with PPB. The age, sex, and preoperative fracture angulation were similar across all groups. A greater percentage of open reduction was seen in the IMN and PPB groups (p = 0.03), while a higher proportion of physeal injury was seen in the PPE group (p = 0.02). Surgical time and estimated blood loss was higher in the IMN group (p < 0.001 and p = 0.01, respectively). The decision analysis revealed that the PPE technique resulted in an average cost saving of $4,502 per patient compared to IMN and $2,066 compared to PPB. This strategy remained cost-effective even when the complication rates with exposed implants approached 55 %.

Conclusions: Leaving pins exposed after surgical fixation of PPHF is more cost-effective than either burying pins or using intramedullary fixation.

No MeSH data available.


Related in: MedlinePlus

Decision tree used to compare the three treatment techniques for pediatric proximal humerus fractures: intramedullary nailing (IMN), exposed percutaneous pinning (PPE), and buried percutaneous pinning (PPB). Symbols: square decision node; circle chance node; triangle outcome/terminal node. Numerical values represent outcome probabilities. # represents the complement probability such that the sum of probabilities at a node is 1.00 (e.g., if p_IMN_Complication = 0.35, then # takes a value of 0.65). For example: p_IMN_Complication: probability of having a complication after IMN insertion, including infection (superficial vs. deep) or hardware complication (migration/protrusion). C_PPE + C_Sup_Inf: cost of exposed percutaneous pin insertion and cost of superficial skin infection. A list of all probabilities and costs are included as follows: probabilities: p_IMN_Complication = probability of IMN complication; p_IMN_Infection = probability of infection with IMN nailing (_Sup = superficial infection); p_IMN_Revise = probability of hardware complications with IMN; p_IMN_Removal = probability of removing hardware after IMN; p_PPE_Complication = probability of PPE complication; p_PPE_Infection = probability of infection with PPE (_Sup = superficial infection); p_PPB_Complication = probability of PPB complication; p_PPB_Infection = probability of infection with PPB (_Sup = superficial infection); p_PPB_Mig_Cl = probability of all hardware migration with PPB removed in clinic; cost: C_IMN = cost of IMN insertion; C_PPE = cost of PPE; C_PPB = cost of PPB; C_IMN_ + C_Sup_Inf + C_IMN_Removal = cost of IMN insertion, superficial infection, IMN removal; C_IMN_ + C_Deep_Inf + C_IMN_Removal = cost of IMN insertion, deep infection, IMN removal; C_IMN_ + C_IMN_Removal = cost of IMN insertion and removal; C_IMN_ + C_IMN_Removal + C_IMN_Hardware_Revision = cost of IMN insertion, revision, and removal; C_PPE + C_Sup_Inf = cost of PPE and cost of superficial infection; C_PPE + C_Deep_Inf = cost of PPE and cost of deep infection; C_PPE + C_PP_removal = cost of PPE and hardware removal; C_PPB + C_PP_removal = cost of PPB and hardware removal; C_PPB + C_Sup_Inf + C_PP_removal = cost of PPB, superficial infection, and pin removal; C_PPB + C_Deep_Inf + C_PP_removal = cost of PPB, deep infection, and pin removal
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Related In: Results  -  Collection


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Fig1: Decision tree used to compare the three treatment techniques for pediatric proximal humerus fractures: intramedullary nailing (IMN), exposed percutaneous pinning (PPE), and buried percutaneous pinning (PPB). Symbols: square decision node; circle chance node; triangle outcome/terminal node. Numerical values represent outcome probabilities. # represents the complement probability such that the sum of probabilities at a node is 1.00 (e.g., if p_IMN_Complication = 0.35, then # takes a value of 0.65). For example: p_IMN_Complication: probability of having a complication after IMN insertion, including infection (superficial vs. deep) or hardware complication (migration/protrusion). C_PPE + C_Sup_Inf: cost of exposed percutaneous pin insertion and cost of superficial skin infection. A list of all probabilities and costs are included as follows: probabilities: p_IMN_Complication = probability of IMN complication; p_IMN_Infection = probability of infection with IMN nailing (_Sup = superficial infection); p_IMN_Revise = probability of hardware complications with IMN; p_IMN_Removal = probability of removing hardware after IMN; p_PPE_Complication = probability of PPE complication; p_PPE_Infection = probability of infection with PPE (_Sup = superficial infection); p_PPB_Complication = probability of PPB complication; p_PPB_Infection = probability of infection with PPB (_Sup = superficial infection); p_PPB_Mig_Cl = probability of all hardware migration with PPB removed in clinic; cost: C_IMN = cost of IMN insertion; C_PPE = cost of PPE; C_PPB = cost of PPB; C_IMN_ + C_Sup_Inf + C_IMN_Removal = cost of IMN insertion, superficial infection, IMN removal; C_IMN_ + C_Deep_Inf + C_IMN_Removal = cost of IMN insertion, deep infection, IMN removal; C_IMN_ + C_IMN_Removal = cost of IMN insertion and removal; C_IMN_ + C_IMN_Removal + C_IMN_Hardware_Revision = cost of IMN insertion, revision, and removal; C_PPE + C_Sup_Inf = cost of PPE and cost of superficial infection; C_PPE + C_Deep_Inf = cost of PPE and cost of deep infection; C_PPE + C_PP_removal = cost of PPE and hardware removal; C_PPB + C_PP_removal = cost of PPB and hardware removal; C_PPB + C_Sup_Inf + C_PP_removal = cost of PPB, superficial infection, and pin removal; C_PPB + C_Deep_Inf + C_PP_removal = cost of PPB, deep infection, and pin removal

Mentions: To compare the three strategies of surgical treatment for displaced proximal humeral fractures (PPE vs. PPB vs. IMN], a cost analysis decision model was constructed. Several assumptions which vary from daily practice were required for this model to function accurately: (1) each patient could have only one complication; (2) only complications related to the fixation technique were included in the model; any complication related to the surgical approach or fracture type was omitted, as they were assumed to occur with equal likelihood in either treatment group; (3) any complication would completely resolve after treatment was instituted; and (4) the technique of humeral fixation was unlikely to have long-term consequences on patient outcome (Fig. 1) [6].Fig. 1


Surgical management for displaced pediatric proximal humeral fractures: a cost analysis.

Shore BJ, Hedequist DJ, Miller PE, Waters PM, Bae DS - J Child Orthop (2015)

Decision tree used to compare the three treatment techniques for pediatric proximal humerus fractures: intramedullary nailing (IMN), exposed percutaneous pinning (PPE), and buried percutaneous pinning (PPB). Symbols: square decision node; circle chance node; triangle outcome/terminal node. Numerical values represent outcome probabilities. # represents the complement probability such that the sum of probabilities at a node is 1.00 (e.g., if p_IMN_Complication = 0.35, then # takes a value of 0.65). For example: p_IMN_Complication: probability of having a complication after IMN insertion, including infection (superficial vs. deep) or hardware complication (migration/protrusion). C_PPE + C_Sup_Inf: cost of exposed percutaneous pin insertion and cost of superficial skin infection. A list of all probabilities and costs are included as follows: probabilities: p_IMN_Complication = probability of IMN complication; p_IMN_Infection = probability of infection with IMN nailing (_Sup = superficial infection); p_IMN_Revise = probability of hardware complications with IMN; p_IMN_Removal = probability of removing hardware after IMN; p_PPE_Complication = probability of PPE complication; p_PPE_Infection = probability of infection with PPE (_Sup = superficial infection); p_PPB_Complication = probability of PPB complication; p_PPB_Infection = probability of infection with PPB (_Sup = superficial infection); p_PPB_Mig_Cl = probability of all hardware migration with PPB removed in clinic; cost: C_IMN = cost of IMN insertion; C_PPE = cost of PPE; C_PPB = cost of PPB; C_IMN_ + C_Sup_Inf + C_IMN_Removal = cost of IMN insertion, superficial infection, IMN removal; C_IMN_ + C_Deep_Inf + C_IMN_Removal = cost of IMN insertion, deep infection, IMN removal; C_IMN_ + C_IMN_Removal = cost of IMN insertion and removal; C_IMN_ + C_IMN_Removal + C_IMN_Hardware_Revision = cost of IMN insertion, revision, and removal; C_PPE + C_Sup_Inf = cost of PPE and cost of superficial infection; C_PPE + C_Deep_Inf = cost of PPE and cost of deep infection; C_PPE + C_PP_removal = cost of PPE and hardware removal; C_PPB + C_PP_removal = cost of PPB and hardware removal; C_PPB + C_Sup_Inf + C_PP_removal = cost of PPB, superficial infection, and pin removal; C_PPB + C_Deep_Inf + C_PP_removal = cost of PPB, deep infection, and pin removal
© Copyright Policy - OpenAccess
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC4340855&req=5

Fig1: Decision tree used to compare the three treatment techniques for pediatric proximal humerus fractures: intramedullary nailing (IMN), exposed percutaneous pinning (PPE), and buried percutaneous pinning (PPB). Symbols: square decision node; circle chance node; triangle outcome/terminal node. Numerical values represent outcome probabilities. # represents the complement probability such that the sum of probabilities at a node is 1.00 (e.g., if p_IMN_Complication = 0.35, then # takes a value of 0.65). For example: p_IMN_Complication: probability of having a complication after IMN insertion, including infection (superficial vs. deep) or hardware complication (migration/protrusion). C_PPE + C_Sup_Inf: cost of exposed percutaneous pin insertion and cost of superficial skin infection. A list of all probabilities and costs are included as follows: probabilities: p_IMN_Complication = probability of IMN complication; p_IMN_Infection = probability of infection with IMN nailing (_Sup = superficial infection); p_IMN_Revise = probability of hardware complications with IMN; p_IMN_Removal = probability of removing hardware after IMN; p_PPE_Complication = probability of PPE complication; p_PPE_Infection = probability of infection with PPE (_Sup = superficial infection); p_PPB_Complication = probability of PPB complication; p_PPB_Infection = probability of infection with PPB (_Sup = superficial infection); p_PPB_Mig_Cl = probability of all hardware migration with PPB removed in clinic; cost: C_IMN = cost of IMN insertion; C_PPE = cost of PPE; C_PPB = cost of PPB; C_IMN_ + C_Sup_Inf + C_IMN_Removal = cost of IMN insertion, superficial infection, IMN removal; C_IMN_ + C_Deep_Inf + C_IMN_Removal = cost of IMN insertion, deep infection, IMN removal; C_IMN_ + C_IMN_Removal = cost of IMN insertion and removal; C_IMN_ + C_IMN_Removal + C_IMN_Hardware_Revision = cost of IMN insertion, revision, and removal; C_PPE + C_Sup_Inf = cost of PPE and cost of superficial infection; C_PPE + C_Deep_Inf = cost of PPE and cost of deep infection; C_PPE + C_PP_removal = cost of PPE and hardware removal; C_PPB + C_PP_removal = cost of PPB and hardware removal; C_PPB + C_Sup_Inf + C_PP_removal = cost of PPB, superficial infection, and pin removal; C_PPB + C_Deep_Inf + C_PP_removal = cost of PPB, deep infection, and pin removal
Mentions: To compare the three strategies of surgical treatment for displaced proximal humeral fractures (PPE vs. PPB vs. IMN], a cost analysis decision model was constructed. Several assumptions which vary from daily practice were required for this model to function accurately: (1) each patient could have only one complication; (2) only complications related to the fixation technique were included in the model; any complication related to the surgical approach or fracture type was omitted, as they were assumed to occur with equal likelihood in either treatment group; (3) any complication would completely resolve after treatment was instituted; and (4) the technique of humeral fixation was unlikely to have long-term consequences on patient outcome (Fig. 1) [6].Fig. 1

Bottom Line: A greater percentage of open reduction was seen in the IMN and PPB groups (p = 0.03), while a higher proportion of physeal injury was seen in the PPE group (p = 0.02).The decision analysis revealed that the PPE technique resulted in an average cost saving of $4,502 per patient compared to IMN and $2,066 compared to PPB.This strategy remained cost-effective even when the complication rates with exposed implants approached 55 %.

View Article: PubMed Central - PubMed

Affiliation: Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, Hunnewell 221, 300 Longwood Avenue, Boston, MA, 02115, USA, Benjamin.shore@childrens.harvard.edu.

ABSTRACT

Purpose: The purpose of this investigation was to determine which of the following methods of fixation, percutaneous pinning (PP) or intramedullary nailing (IMN), was more cost-effective in the treatment of displaced pediatric proximal humeral fractures (PPHF).

Methods: A retrospective cohort of surgically treated PPHF over a 12-year period at a single institution was performed. A decision analysis model was constructed to compare three surgical strategies: IMN versus percutaneous pinning leaving the pins exposed (PPE) versus leaving the pins buried (PPB). Finally, sensitivity analyses were performed, assessing the cost-effectiveness of each technique when infection rates and cost of deep infections were varied.

Results: A total of 84 patients with displaced PPHF underwent surgical stabilization. A total of 35 cases were treated with IMN, 32 with PPE, and 17 with PPB. The age, sex, and preoperative fracture angulation were similar across all groups. A greater percentage of open reduction was seen in the IMN and PPB groups (p = 0.03), while a higher proportion of physeal injury was seen in the PPE group (p = 0.02). Surgical time and estimated blood loss was higher in the IMN group (p < 0.001 and p = 0.01, respectively). The decision analysis revealed that the PPE technique resulted in an average cost saving of $4,502 per patient compared to IMN and $2,066 compared to PPB. This strategy remained cost-effective even when the complication rates with exposed implants approached 55 %.

Conclusions: Leaving pins exposed after surgical fixation of PPHF is more cost-effective than either burying pins or using intramedullary fixation.

No MeSH data available.


Related in: MedlinePlus