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DOI: 10.1016/j.jhsb.2003.10.009
Minimally Invasive Fixation versus Conservative Treatment of Undisplaced Scaphoid Fractures: A Cost-Effectiveness StudyFrom the Hand Surgery Unit, Geneva University Hospital, Geneva, Switzerland and the Health Technology Assessment Unit, Lausanne University Hospital, Switzerland Correspondence: Dr Michaël Papaloïzos, Center for Hand Surgery and Therapy, Charles-Humbert 8, CH-1205 Geneva, Switzerland. Tel.: +41-22-328-10-03; fax: +41-22-329-14-06; E-mail: mpapaloizos{at}ch8.ch
This study compares the direct and indirect costs of conservative and minimally invasive treatment for undisplaced scaphoid fractures. Costs data concerning groups of non-operated and operated patients were analysed. Direct costs were higher in operated patients. Although highly variable, indirect costs were significantly smaller in operated patients and the total costs were higher in nonoperated patients. In conclusion, operative treatment of scaphoid fractures is initially more expensive than conservative treatment but markedly decreases the work compensation costs.
Key Words: scaphoid • fractures • treatment • costs • cost-effectiveness
The established treatment for undisplaced scaphoid fractures is immobilization in a cast for 8 to 12 weeks. However, patient compliance is often unsatisfactory due to the long immobilization time and the low level of symptoms so that the plasters are often discarded early. This may result in delayed union, non-union or malunion. Although the average time to union of scaphoid fractures treated conservatively is 9 to 12 weeks, a significant number require longer and immobilization for up to 6 months is sometimes required (Mack et al., 1984). The non-union rate with conservative treatment ranges from 5% to 13% (Düppe et al., 1994; Langhoff and Andersen, 1988). There are several minimally invasive internal fixation techniques for scaphoid fractures (Brauer et al., 1997; Haddad and Goddard, 1998; Inoue and Shionoya, 1997; Ledoux et al., 1995; Wozasek and Moser, 1991). Minimally invasive screw fixation in athletes has been reported to reduce the time to union and to allow a rapid return to sports activities (Rettig and Kolias, 1996; Taras et al., 1999). Percutaneous osteosynthesis with various compression screws has been proposed for undisplaced fractures of the scaphoid and union rates approaching 100% have been reported (Adolfsson et al., 2001; Bond et al., 2001). Immobilization is not required with such treatment. Minimally invasive internal fixation may result in a shorter period of time off work and significant reductions in work-compensation costs. This study compares the direct and indirect costs of conservative and minimally invasive screw fixation (MISF) for undisplaced scaphoid wrist fractures.
Treatment groups Two patient groups were studied: the first consisted of consecutive patients treated operatively (operative group) at one institution (Geneva University Hospital), and the second group of consecutive patients treated conservatively (conservative group) at two different, but similar, institutions (Berne and Geneva University Hospitals). All patients had an isolated, undisplaced waist fracture of the scaphoid. The diagnosis was based on the clinical presentation and on standard scaphoid view radiographs. In rare cases where the radiographs were not conclusive, tomograms (before 1995), CT-scans or MRI were used to confirm the diagnosis. Patients in the operative group were recruited prospectively from July 1999 to January 2001 and were followed up over 2 years. Data about the conservative group were retrieved from the files in the two hospitals over a period from 1989 to 2001. These patients were also followed retrospectively for a minimum of 2 years.
Treatment modes Patients in the operative group were treated as day cases using a short transverse palmar incision over the scaphotrapezial joint. A threaded 1.0mm Kirschner wire was retrogradely introduced into the scaphoid and its position was checked with fluoroscopy. Once appropriately placed, a 3.0mm cannulated screw was inserted free-hand. The screw head was buried in the scaphoid tubercle and the skin was closed. A short palmar splint was applied and replaced by a removable splint after 2 or 3 days. Mobilization of the wrist was then allowed. Impact loading, torque and extreme wrist positions were forbidden and forceful exercises and loading were discouraged for a minimum of 6 weeks, or until radiological union had occurred.
Cost data
Statistical analysis Values are given as means and standard deviations (SD), except for the times off work in Table 2, which are given as median and range. The chi-square test was applied to proportional nominal data, the Student’s t-test for continuous dependent variables and the Mann–Whitney test for discrete data.
Twenty-three patients were included in the operative group, and 62 in the conservative group. The characteristics of the patients included into the conservative group from the two centres were similar. The sex ratios, mean ages, affected side and hand dominance were comparable in the operative and conservative groups (Table 2). Operated patients were treated slightly earlier than patients treated conservatively (Table 2). Patients in the conservative group were treated with a below elbow scaphoid cast for a mean of 74 (SD, 28) days. The number of visits to the doctor or to the hand therapist, as well as the number of radiographs or other diagnostic tests, were similar in both groups. Bone union was routinely assessed on standard radiographs in both treatment groups but was more frequently confirmed by either tomograms, CT scans or MRI in the conservative group. The outcomes were similar in terms of union with one non-union and two delayed unions in the conservative group and one delayed union in the operative group. They were no implant-related complications in the latter group. The main professional categories of the patients in the two groups was similar, except that the administration and sales category was more represented in the operative group. Manual workers were equally distributed. Time off work could be precisely established from the hospital or insurance records and is presented as continuous periods of days (full-time and half-time leave). This was quite variable in both groups, but was significantly longer in the conservative group (mean, 66 days: SD, 44) than in the operative group (mean, 32 days: SD 31) (P=0.002). The cost distribution of the different parts of both treatments are given in Table 3. Mean direct costs were higher in operated patients (EUR 1441: SD, 206) than in the conservative group (EUR 960: SD, 414) (P<0.001). Although highly variable, indirect costs were less in operated patients (EUR 3499: SD, 3177: equivalent to 71% of the total costs) than in the conservative group (EUR 7773: SD, 5043: equivalent to 89% of total costs) (P=0.001). In total, operative treatment (EUR 4940: SD, 3212) was less expensive than conservative treatment (EUR 8710: SD, 5161), (P=0.004).
This cost-effectiveness analysis demonstrates that treatment of undisplaced scaphoid fractures with mimimally invasive screw fixation is overall less expensive than conservative treatment in plaster. This is because work compensation costs can be significantly reduced by internal fixation which avoids the need for immobilization in a cast. Our study has several limitations. First it included patients from two different centres in the conservative group treatment. Although these patients were similar, the collection periods were of different lengths, which might have introduced bias due to changes in the process of care. However, the only noticeable change during the study period was the introduction of MRI in the diagnostic strategy, which could have led to an increase in the cost of diagnosis and would have mainly affected the operative group. Its impact would therefore have been to reduce the difference in the total costs between the two treatment strategies. However, its use was limited to one case in each group. A second limitation is linked with the health care system. This is as there are differences between countries in the advised time interval between the end of immobilization and return to work (Mink van der Molen et al., 1999; Morgan and Walthers, 1984). Furthermore the impact of the prevailing insurance system on the time off work cannot be underestimated (Filan, 1996). Thus, direct comparison of our results with those observed in other countries might not be possible. Our study also has several strengths. All the patients in the operative group were followed up prospectively for 2 years, allowing the recording of late complications. Furthermore all the patients were from two centres, so that the practice of care was homogeneous. Economic analyses of diagnosis and treatment strategies for scaphoid fractures are scarce. As an undisplaced scaphoid fracture may be difficult to identify on plain radiographs, different strategies have been proposed to increase the sensitivity and specificity of diagnosis. Bone scintigraphy (Tiel-van Buul et al., 1995) is cost effective, but necessitates special equipment whereas magnetic resonance imaging is becoming increasingly available. Its use for the initial assessment of patients with "normal" plain radiographs has been evaluated (Breitenseher et al., 1997; Hunter et al., 1997) and shown to result in a modest increase in cost when compared with the traditional immobilization and radiographic follow-up, even when time off work (indirect costs) was not included (Dorsay et al., 2001; Kukla et al., 1997). Therefore, it is likely to become a standard investigation for these patients. Similarly, conservative treatment is still the standard treatment for scaphoid fractures, despite the fact that it entails immobilization of the wrist for 8 to 12 weeks and results in a relatively high non-union rate (Düppe et al., 1994; Mack et al., 1998). Operative treatment has been shown to result in earlier bone union (Bond et al., 2001), a lower non-union rate and a shorter time off work. This has been assessed in athletes, who could return to competition after 6 to 8 weeks (Taras et al., 1999), soldiers (Bond et al., 2001), and workers (Inoue and Shionoya, 1997). Medico-economic studies can adopt different points of view, and their results can thus be different, depending on which perspective is chosen. From the perspective of the payer in the health care system, operative management leads to only a slightly better outcome because it avoids delayed healing in a few patients, but at a higher cost. However if a social perspective is taken, operative management should be adopted as it brings additional benefit at a lower cost. Policy makers should be aware of that the interpretation of results will differ depending on perspective, before deciding which strategy should become the standard of care. From the patient viewpoint, minimally invasive screw fixation improves quality of life by removing the need for a cast and facilitating daily activities.
Received for publication June 18, 2003. Accepted for publication October 20, 2003.
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Abstract
INTRODUCTION