Orthopedics

Feature Article 

Economic Analysis of Anatomic Plating Versus Tubular Plating for the Treatment of Fibula Fractures

Gerard Chang, MD; Suneel B. Bhat, MD; Steven M. Raikin, MD, MPhil; Justin M. Kane, MD; Andrew Kay, MD; Jamal Ahmad, MD; David I. Pedowitz, MD; James Krieg, MD

Abstract

Ankle fractures are among the most common injuries requiring operative management. Implant choices include one-third tubular plates and anatomically precontoured plates. Although cadaveric studies have not revealed biomechanical differences between various plate constructs, there are substantial cost differences. This study sought to characterize the economic implications of implant choice. A retrospective review was undertaken of 201 consecutive patients with operatively treated OTA type 44B and 44C ankles. A Nationwide Inpatient Sample query was performed to estimate the incidence of ankle fractures requiring fibular plating, and a Monte Carlo simulation was conducted with the estimated at-risk US population for associated plate-specific costs. The authors estimated an annual incidence of operatively treated ankle fractures in the United States of 59,029. The average cost was $90.86 (95% confidence interval, $90.84–$90.87) for a one-third tubular plate vs $746.97 (95% confidence interval, $746.55–$747.39) for an anatomic plate. Across the United States, use of only one-third tubular plating over anatomic plating would result in statistically significant savings of $38,729,517 (95% confidence interval, $38,704,773–$38,754,261; P<.0001). General use of one-third tubular plating instead of anatomic plating whenever possible for fibula fractures could result in cost savings of up to nearly $40 million annually in the United States. Unless clinically justifiable on a per-case basis, or until the advent of studies showing substantial clinical benefit, there currently is no reason for the increased expense from widespread use of anatomic plating for fractures amenable to one-third tubular plating. [Orthopedics. 2018; 41(2):e252–e256.]

Abstract

Ankle fractures are among the most common injuries requiring operative management. Implant choices include one-third tubular plates and anatomically precontoured plates. Although cadaveric studies have not revealed biomechanical differences between various plate constructs, there are substantial cost differences. This study sought to characterize the economic implications of implant choice. A retrospective review was undertaken of 201 consecutive patients with operatively treated OTA type 44B and 44C ankles. A Nationwide Inpatient Sample query was performed to estimate the incidence of ankle fractures requiring fibular plating, and a Monte Carlo simulation was conducted with the estimated at-risk US population for associated plate-specific costs. The authors estimated an annual incidence of operatively treated ankle fractures in the United States of 59,029. The average cost was $90.86 (95% confidence interval, $90.84–$90.87) for a one-third tubular plate vs $746.97 (95% confidence interval, $746.55–$747.39) for an anatomic plate. Across the United States, use of only one-third tubular plating over anatomic plating would result in statistically significant savings of $38,729,517 (95% confidence interval, $38,704,773–$38,754,261; P<.0001). General use of one-third tubular plating instead of anatomic plating whenever possible for fibula fractures could result in cost savings of up to nearly $40 million annually in the United States. Unless clinically justifiable on a per-case basis, or until the advent of studies showing substantial clinical benefit, there currently is no reason for the increased expense from widespread use of anatomic plating for fractures amenable to one-third tubular plating. [Orthopedics. 2018; 41(2):e252–e256.]

Ankle fractures are common musculoskeletal injuries, with one study showing an incidence of 187 ankle fractures per 100,000 person-years.1 They are the fourth most common type of fracture, accounting for approximately 7% of all fractures, with epidemiologic studies showing an increasing incidence.2–5

Ankle fractures place both a clinical and an economic burden on society. Belatti and Phisitkul6 conducted a study showing that the economic impact of foot and ankle surgery in the Medicare population alone was $11 billion annually, with operative treatment of bimalleolar and trimalleolar ankle fractures having the third greatest economic impact of all foot and ankle procedures.6

As the cost of health care continues to increase in the United States, clinicians must critically evaluate their own practices to help minimize unnecessary expenditures. Implant choice has become an increasingly important area of scrutiny in orthopedics, especially given the range of clinically appropriate options.

In unstable ankle fractures, surgery is indicated to reduce the development of posttraumatic arthritis.7 This typically involves open reduction and internal fixation of the distal fibula with an antiglide plate on the posterolateral surface of the fibula, or a laterally placed neutralization plate with an interfragmentary lag screw. Implant choices include one-third tubular plates and precontoured anatomic plates, with or without locking screws. Although anatomic plating may be beneficial in specific cases, no published data exist justifying its blanket use. There are substantial differences in the cost of various plate constructs. This study sought to compare the economic impact of one-third tubular plates, placed with nonlocking screws, vs periarticular distal fibular plates, placed with either locking or nonlocking screws, in the treatment of lateral malleolus fractures. The authors hypothesized that in AO/OTA type 44B and 44C fractures, the use of one-third tubular plate constructs would significantly minimize implant cost.

Materials and Methods

Once institutional review board approval had been obtained, a retrospective chart and radiographic review was performed of patients who had undergone open reduction and internal fixation of AO/OTA type 44B or 44C fibula fractures. Inclusion criteria were AO/OTA type 44B and 44C fibula fractures that were treated operatively with plate fixation, no history of ipsilateral ankle fracture, operative treatment within 2 weeks of initial evaluation, and age 18 to 55 years. Exclusion criteria were an unstable syndesmosis requiring stabilization, fibula fractures that were treated with an intramedullary device or tension band fixation, comminution preventing the ability to compress across the fracture site, age older than 55 years, and fractures distal to the syndesmosis (AO/OTA type 44A).

Between 2006 and 2013, a total of 201 patients were identified who met the inclusion criteria. All were treated at a single institution of a multicenter practice by 1 of 4 foot and ankle fellowship-trained orthopedic surgeons (S.M.R., J.A., D.I.P.). Office notes, radiographs, and operative reports were reviewed. Patient demographic data were collected, including age, sex, body mass index, presence of diabetes, and smoking status. Radiographs were used in conjunction with operative reports to determine the type of plate as well as the types and numbers of screws used in the construct to treat the fibula fracture. All patients were treated with interfragmentary lag screw fixation and lateral neutralization plating consisting of either a one-third tubular plate or an anatomic periarticular distal fibular plate. Facility-specific, plate-specific costs were obtained for each case. To develop a conservative economic model focused on actual differences in plate costs, screw costs were assumed to be constant between the 2 construct options.

The Nationwide Inpatient Sample, the largest publicly available all-payer database, developed for the Healthcare Cost and Utilization Project by the Agency for Healthcare Research and Quality,8 was queried for postoperative diagnoses of ankle fractures (International Classification of Diseases, Ninth Revision, codes 824.2 through 824.7) to estimate the incidence of ankle fractures requiring open reduction and internal fixation of the lateral malleolus.

Decision tree analysis has been increasingly used in orthopedics to compare treatment options, especially gaining acceptance for cost-benefit and economic analysis.9–14 Decision trees may be built using a variety of data sources, including population databases, retrospective reviews, and existing literature, and may be used to follow cohorts across time or to analyze cross-sectional cohorts.15,16 By stochastically analyzing models, variability can be captured, improving generalizability.9,17 A Monte Carlo simulation was conducted with the estimated at-risk US population to calculate the associated costs and economic burden of one-third tubular plates vs anatomic plates in open reduction and internal fixation of lateral malleolus fractures. Additionally, a 2-sample test was used to determine if there was a statistical difference between the total costs of the 2 types of constructs. P<.05 was considered statistically significant.

Decision tree analysis was conducted using TreeAge Pro 2015, R1.0 release, software (TreeAge Software, Inc, Williamstown, Massachusetts). All statistical analyses were performed using SPSS version 12.0 software (IBM, Chicago, Illinois).

Results

A total of 201 patients who met inclusion criteria were treated for AO/OTA type 44B and 44C fractures. Of these, 120 patients were treated with one-third tubular plates and 81 were treated with various periarticular distal fibular plates. The one-third tubular plate group did not differ statistically from the periarticular distal fibular plate group for any patient demographic (Table). Using the Nationwide Inpatient Sample database, the authors estimated that the annual incidence of admitted operatively treated ankle fractures requiring fibula plating in the United States was 59,029. According to the authors' facility-specific costs, one-third tubular plating had an average per plate cost of $90.86 (95% confidence interval, $90.84-$90.87). Anatomic plating, on the other hand, had an average per plate cost of $746.97 (95% confidence interval, $746.55–$747.39). Across the United States, use of only one-third tubular plating would result in plate costs totaling $5,363,375 per year (95% confidence interval, $5,362,513–$5,364,237), whereas anatomic plating would result in plate costs totaling $44,092,892 per year (95% confidence interval, $44,068,163–$44,117,621)—a statistically significant difference of $38,729,517 per year (95% confidence interval, $38,704,773–$38,754,261; P<.0001).

Patient Demographics

Table:

Patient Demographics

Discussion

In the current health care climate, the economics of operative management are being increasingly scrutinized. The burden of cost-effectiveness of implant choice falls on the surgeon when multiple, clinically appropriate options exist, and the direct economic burden on any cost differential falls on the hospital. Whenever possible, there should be clear evidence that the more costly option provides superior outcomes. Recently, the number of new implant designs specific to the distal fibula has grown. Although cadaveric studies have shown differences in the biomechanical strength of various constructs, it is unclear what benefit this translates to clinically. A biomechanical cadaveric study by Schaffer and Manoli18 examined lateral neutralizing plates vs antiglide plates for short oblique fractures. Antiglide plating was found to be stiffer and stronger and to require more energy to failure than lateral plating; however, the clinical significance of the difference could not be determined. Studies regarding the clinical outcomes of the 2 methods have found them comparable in terms of functional scores and complication rates.19

In the current study, all fractures were fixed with an interfragmentary lag screw and a lateral neutralizing plate. A recent study compared 4 different lateral neutralization plates in the treatment of simulated AO/OTA type 44B distal fibula fractures in cadaveric specimens. Plating was performed with a Synthes one-third tubular plate, a Synthes LCP plate with locked screws, the precontoured, non-locked TriMed Sidewinder, or an Ortho-helix MaxLock Extreme locked, precontoured plate. No significant differences in bending stiffness, torsional stiffness, or fracture site motion were found between the different plates.20

There are some cases (eg, patients with osteoporosis and poor bone stock) in which biomechanical studies show that periarticular anatomic locking constructs may confer benefit; however, results have been mixed, and clinical data are lacking.21–24 In a biomechanical cadaveric study by Davis et al,21 construct rigidity of one-third tubular plates was compared with that of periarticular distal fibular plates in osteoporotic bone. Increased rotational strength with periarticular plates was shown; however, these authors could not recommend against using one-third tubular plating for osteoporotic bone, explaining that fixation obtained was still adequate for treatment. In another biomechanical cadaveric study, Minihane et al23 showed that one-third tubular plates, when used in an antiglide fashion, provided more stability than lateral periarticular locking plates in osteoporotic distal fibula fractures.

A prior, unpublished study by the current authors found no difference between one-third tubular plates and precontoured anatomic plates in the ability to achieve and maintain reduction.

In the face of clinical equipoise, surgeons may tend to choose implants on the basis of their personal training, their familiarity with the instruments, and the ease of use of an implant. However, the current authors challenge surgeons to consider implant costs when choosing fixation constructs for all fractures. In the previous Distal Radius Acute Fracture Fixation Trial,25 percutaneous Kirschner wire fixation was compared with volar locking plates in the treatment of distal radius fractures. Major cost savings occurred with the use of percutaneous Kirschner wire fixation without detriment.

The current findings suggest that general use of one-third tubular plating instead of anatomic plating whenever possible for fibula fractures would result in cost savings of up to nearly $40 million annually in the United States. This margin will become more important to providers with shifts toward bundled payments, with studies showing the easiest cost-containing strategy to be the use of generic, low-cost, high-value orthopedic implants whenever appropriate.26

Limitations of this study included its retrospective nature, which may have introduced bias for treatment and patient selection. The authors tried to control for this by selecting cohorts that were similar in demographics and fracture classification. In this study, the cost difference between one-third tubular plates and anatomic distal fibular plates was based on the facility-specific costs across multiple centers staffed by surgeons in the same group. The exact costs may differ from one institution to another based on multiple factors, including practice size, location, and medical device company partnerships. However, the cost difference between one-third tubular plates and pre-contoured anatomic plates is substantial, even if the exact costs vary slightly based on practice settings. Another limitation of this study was its narrow focus on only the cost of the implants. Further examination of other costs possibly associated with implant choice, such as differences in operating room time, revision rates, hardware failure rates, and hardware removal rates, is warranted for a complete analysis of cost-effectiveness of implant choice. However, given that, in the current series, surgeon preference primarily drove implant choice, the authors think that the primary driver in cost was implant choice. Finally, unlike usual cost-effectiveness studies, this study did not provide a metric, such as quality-adjusted life years gained, for the effectiveness of implant choice. However, in a parallel, unpublished study, the current authors investigated the effectiveness of one-third tubular plates vs precontoured anatomic plates in achieving and maintaining anatomic reduction, finding no difference between the 2 types of plates.

Conclusion

Although the authors argue for the judicious use of expensive precontoured locking plates, they admit that there are some cases in which anatomic locking plates do play an important role in the treatment of distal fibula fractures. As previously mentioned, patients with poor bone stock and osteoporosis may benefit from locked plating. In addition, anatomic locking plates may be the best choice for comminuted distal fibula fractures and very distal fibula fractures.27

Unless clinically justifiable on a per-case basis, or until the advent of studies showing significant clinical benefit, there currently is no reason for the substantially increased expense from widespread use of precontoured anatomic fibular plating for fractures amenable to one-third tubular plating.

References

  1. Daly PJ, Fitzgerald RH Jr, Melton LJ, Ilstrup DM. Epidemiology of ankle fractures in Rochester, Minnesota. Acta Orthop Scand. 1987; 58(5):539–544. doi:10.3109/17453678709146395 [CrossRef]
  2. Court-Brown CM, Caesar B. Epidemiology of adult fractures: a review. Injury. 2006; 37(8):691–697. doi:10.1016/j.injury.2006.04.130 [CrossRef]
  3. Shibuya N, Davis ML, Jupiter DC. Epidemiology of foot and ankle fractures in the United States: an analysis of the National Trauma Data Bank (2007 to 2011). J Foot Ankle Surg. 2014; 53(5):606–608. doi:10.1053/j.jfas.2014.03.011 [CrossRef]
  4. Somersalo A, Paloneva J, Kautiainen H, Lönnroos E, Heinänen M, Kiviranta I. Incidence of fractures requiring inpatient care. Acta Orthop. 2014; 85(5):525–530. doi:10.3109/17453674.2014.908340 [CrossRef]
  5. Thur CK, Edgren G, Jansson KÅ, Wretenberg P. Epidemiology of adult ankle fractures in Sweden between 1987 and 2004: a population-based study of 91,410 Swedish inpatients. Acta Orthop. 2012; 83(3):276–281. doi:10.3109/17453674.2012.672091 [CrossRef]
  6. Belatti DA, Phisitkul P. Economic burden of foot and ankle surgery in the US Medicare population. Foot Ankle Int. 2014; 35(4):334–340. doi:10.1177/1071100713519777 [CrossRef]
  7. Yablon IG, Heller FG, Shouse L. The key role of the lateral malleolus in displaced fractures of the ankle. J Bone Joint Surg Am. 1977; 59(2):169–173. doi:10.2106/00004623-197759020-00005 [CrossRef]
  8. Steiner C, Elixhauser A, Schnaier J. The healthcare cost and utilization project: an overview. Eff Clin Pract. 2002; 5(3):143–151.
  9. Aleem IS, Jalal H, Aleem IS, Sheikh AA, Bhandari M. Clinical decision analysis: incorporating the evidence with patient preferences. Patient Prefer Adherence. 2009; 3:21–24.
  10. Bhat SB, Lazarus M, Getz C, Williams GR Jr, Namdari S. Economic decision model suggests total shoulder arthroplasty is superior to hemiarthroplasty in young patients with end-stage shoulder arthritis. Clin Orthop Relat Res. 2016; 474(11):2482–2492. doi:10.1007/s11999-016-4991-0 [CrossRef]
  11. Mather RC III, Koenig L, Acevedo D, et al. The societal and economic value of rotator cuff repair. J Bone Joint Surg Am. 2013; 95(22):1993–2000. doi:10.2106/JBJS.L.01495 [CrossRef]
  12. Michelson JD. Using decision analysis to assess comparative clinical efficacy of surgical treatment of unstable ankle fractures. J Orthop Trauma. 2013; 27(11):642–648. doi:10.1097/BOT.0b013e31828f9a88 [CrossRef]
  13. Nwachukwu BU, McLawhorn AS, Simon MS, et al. Management of end-stage ankle arthritis: cost-utility analysis using direct and indirect costs. J Bone Joint Surg Am. 2015; 97(14):1159–1172. doi:10.2106/JBJS.N.01215 [CrossRef]
  14. Wagner E, Ortiz C, Torres K, Contesse I, Vela O, Zanolli D. Cost effectiveness of different techniques in hallux valgus surgery. Foot Ankle Surg. 2016; 22(4):259–264. doi:10.1016/j.fas.2015.11.004 [CrossRef]
  15. Birkmeyer JD, Welch HG. A reader's guide to surgical decision analysis. J Am Coll Surg. 1997; 184(6):589–595.
  16. Detsky AS, Naglie G, Krahn MD, Redelmeier DA, Naimark D. Primer on medical decision analysis: Part 2. Building a tree. Med Decis Making. 1997; 17(2):126–135. doi:10.1177/0272989X9701700202 [CrossRef]
  17. Inadomi JM. Decision analysis and economic modelling: a primer. Eur J Gastroenterol Hepatol. 2004; 16(6):535–542. doi:10.1097/00042737-200406000-00005 [CrossRef]
  18. Schaffer JJ, Manoli A II, . The antiglide plate for distal fibular fixation: a biomechanical comparison with fixation with a lateral plate. J Bone Joint Surg Am. 1987; 69(4):596–604. doi:10.2106/00004623-198769040-00017 [CrossRef]
  19. Lamontagne J, Blachut PA, Broekhuyse HM, O'Brien PJ, Meek RN. Surgical treatment of a displaced lateral malleolus fracture: the antiglide technique versus lateral plate fixation. J Orthop Trauma. 2002; 16(7):498–502. doi:10.1097/00005131-200208000-00008 [CrossRef]
  20. Eckel TT, Glisson RR, Anand P, Parekh SG. Biomechanical comparison of 4 different lateral plate constructs for distal fibula fractures. Foot Ankle Int. 2013; 34(11):1588–1595. doi:10.1177/1071100713496223 [CrossRef]
  21. Davis AT, Israel H, Cannada LK, Bledsoe JG. A biomechanical comparison of one-third tubular plates versus periarticular plates for fixation of osteoporotic distal fibula fractures. J Orthop Trauma. 2013; 27(9):e201–e207. doi:10.1097/BOT.0b013e318281a565 [CrossRef]
  22. Kim T, Ayturk UM, Haskell A, Miclau T, Puttlitz CM. Fixation of osteoporotic distal fibula fractures: a biomechanical comparison of locking versus conventional plates. J Foot Ankle Surg. 2007; 46(1):2–6. doi:10.1053/j.jfas.2006.09.009 [CrossRef]
  23. Minihane KP, Lee C, Ahn C, Zhang LQ, Merk BR. Comparison of lateral locking plate and antiglide plate for fixation of distal fibular fractures in osteoporotic bone: a biomechanical study. J Orthop Trauma. 2006; 20(8):562–566. doi:10.1097/01.bot.0000245684.96775.82 [CrossRef]
  24. Zahn RK, Frey S, Jakubietz RG, et al. A contoured locking plate for distal fibular fractures in osteoporotic bone: a biomechanical cadaver study. Injury. 2012; 43(6):718–725. doi:10.1016/j.injury.2011.07.009 [CrossRef]
  25. Tubeuf S, Yu G, Achten J, et al. Cost effectiveness of treatment with percutaneous Kirschner wires versus volar locking plate for adult patients with a dorsally displaced fracture of the distal radius: analysis from the DRAFFT trial. Bone Joint J.2015; 97-B(8):1082–1089. doi:10.1302/0301-620X.97B8.35234 [CrossRef]
  26. Althausen PL, Mead L. Bundled payments for care improvement: lessons learned in the first year. J Orthop Trauma. 2016; 30(suppl 5):S50–S53. doi:10.1097/BOT.0000000000000715 [CrossRef]
  27. Bariteau JT, Fantry A, Blankenhorn B, Lareau C, Paller D, Digiovanni CW. A biomechanical evaluation of locked plating for distal fibula fractures in an osteoporotic sawbone model. Foot Ankle Surg. 2014; 20(1):44–47. doi:10.1016/j.fas.2013.10.004 [CrossRef]

Patient Demographics

DemographicOne-Third Tubular Plate GroupPrecontoured Plate GroupP
Total No.12081N/A
Age, mean (range), y34.95 (18–53)34.27 (18–50).421
Sex, No..108
  Male5950
  Female6131
Body mass index, mean (range), kg/m229.67 (18.7–55.8)27.99 (18.3–46.3).758
Tobacco, No..877
  Yes2012
  No10069
Diabetes, No..635
  Yes41
  No11680
Authors

The authors are from the Department of Orthopaedics (GC), Rothman Institute (SMR, JA, DIP, JK), Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; the Division of Orthopaedic Trauma (SBB), Sentara Norfolk General Hospital, Norfolk, Virginia; and Baylor Scott & White Orthopedic Associates of Dallas (JMK), Dallas, and the Department of Orthopaedics (AK), Houston Methodist Hospital, Houston, Texas.

Drs Chang, Bhat, Kane, Kay, and Ahmad have no relevant financial relationships to disclose. Dr Raikin has received research assistance from Zimmer. Dr Pedowitz is a paid consultant for Integra, Arthrex, and Zimmer and receives royalties from Integra and Zimmer. Dr Krieg is a paid consultant for DePuy Synthes and SMV Medical; receives royalties from Seaburg Medical and DePuy Synthes CMF; holds stock in MDLive, Franklin Bio-Sciences, Trice Medical, and Conventus; and is a Venture Capital Partner for Biostar Venture.

Correspondence should be addressed to: James Krieg, MD, Rothman Institute, 925 Chestnut St, 5th Fl, Philadelphia, PA 19107 ( KriegJ@mac.com).

Received: August 30, 2017
Accepted: December 15, 2017
Posted Online: February 19, 2018

10.3928/01477447-20180213-01

Sign up to receive

Journal E-contents