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To quantify the total hospital costs associated with the treatment of lower extremity long-bone fracture aseptic and septic unhealed fracture, to determine if insurance adequately covers these costs, and to examine whether insurance type correlates with barriers to accessing care.Retrospective cohort study.Academic Level II trauma center.All patients undergoing operative treatment of OTA/AO classification 31, 32, 33, 41, 42, and 43 fractures between 2012 and 2020 at a single Level II trauma center with minimum of 1-year follow-up.The primary outcome was the total cost of treatment for all hospital-based episodes of care. Distance traveled from primary residence was measured as a surrogate for barriers to care.One hundred seventeen patients with uncomplicated fracture healing, 82 with aseptic unhealed fracture, and 44 with septic unhealed fracture were included in the final cohort. The median cost of treatment for treatment of septic unhealed fracture was $148,318 [interquartile range(IQR) 87,241-256,928], $45,230 (IQR 31,510-68,030) for treatment of aseptic unhealed fracture, and $33,991 (IQR 25,609-54,590) for uncomplicated fracture healing. The hospital made a profit on all patients with commercial insurance, but lost money on all patients with public insurance. Among patients with unhealed fracture, those with public insurance traveled 4 times further for their care compared with patients with commercial insurance (P = 0.004).Septic unhealed fracture of lower extremity long-bone fractures is an outsized burden on the health care system. Public insurance for both septic and aseptic unhealed fracture does not cover hospital costs. The increased distances traveled by our Medi-Cal and Medicare population may reflect the economic disincentive for local hospitals to care for publicly insured patients with unhealed fractures.Economic Level V. See Instructions for Authors for a complete description of levels of evidence.

Limb loss leads to significant disability. Prostheses may mitigate this disability but are not readily accessible in low- and middle-income countries (LMICs). Cost-effectiveness data related to prosthesis provision in resource-constrained environments such as Tanzania is greatly limited.This study aimed to compare the cost-effectiveness of a prosthesis intervention compared with that of no prosthesis for persons with transfemoral amputations in an LMIC.This is a prospective cohort study.Thirty-eight patients were prospectively followed up. Clinical improvement with prosthesis provision was measured using EuroQuol-5D, represented as quality-adjusted life years gained. Direct and indirect costs were measured. The primary outcome was incremental cost per quality-adjusted life year, measured at 1 year and projected over a lifetime using a Markov model. Reference case was set as a single prosthesis provided without replacement from a payer perspective. Additional scenarios included the societal perspective and replacement of the prosthesis. Uncertainty was measured with one-way probabilistic sensitivity analysis.From the payer perspective, the incremental cost-effectiveness ratio (ICER) was $242 for those without prosthetic replacement over a lifetime, and the ICER was $390 for those with prosthetic replacement over a lifeime. From the societal perspective, prosthesis provision was both less expensive and more effective. One-way sensitivity analysis demonstrated the ICER remained below the willingness to pay threshold up to prosthesis costs of $763.These findings suggest prosthesis provision in an LMIC may be cost-effective, but further studies with long-term follow up are needed to validate the results.

While surgeons in low and middle-income countries have increasing experience with intramedullary nailing (IMN), external fixation (EF) continues to be commonly used for the management of open tibial fractures. We examined outcomes with extended follow-up of the participants enrolled in a clinical trial comparing these treatments.Adults who were ≥18 years old with acute AO/OTA type-42 open tibial shaft fractures were randomly assigned to statically locked, hand-reamed IMN or uniplanar EF. These participants were reevaluated 3 to 5 years after treatment. The primary outcome was death or reoperation for the treatment of deep infection, nonunion, or malalignment. Unresolved complications such as persistent fracture-related infection, nonunion, or malalignment were collected and analyzed. Secondary outcomes included the EuroQol-5 Dimension-3 Level (EQ-5D-3L) questionnaire, the Function IndeX for Trauma (FIX-IT) score, radiographic alignment, and the modified Radiographic Union Scale for Tibial fractures (mRUST).Of the originally enrolled 240 participants,126 (67 managed with IMN and 59 managed with EF) died or returned for follow-up at a mean of 4.0 years (range, 2.9 to 5.2 years). Thirty-two composite primary events occurred, with rates of 23.9% and 27.1% in the IMN and EF groups, respectively. Six of these events (3 in the IMN group and 3 in the EF group) were newly detected after the original 1-year follow-up. Unresolved complications in the form of chronic fracture-related infection or nonunion were present at long-term follow-up in 25% of the participants who sustained a primary event. The EQ-5D-3L index scores were similar between the 2 groups and only returned to preinjury levels after 1 year among patients without complications or those whose complications resolved.This observational study extended follow-up for a clinical trial assessing IMN versus EF for the treatment of open tibial fractures in sub-Saharan Africa. At a mean of 4 years after injury, fracture-related infection and nonunion became chronic conditions in nearly a quarter of the participants who experienced these complications, regardless of reintervention.Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

This investigation develops a predictive model for loss of alignment (LOA) following fixation of open tibia fractures.An analysis was performed of adults with diaphyseal open tibia fractures randomized to intramedullary nailing (IMN) or external fixation (EF) followed at 6, 12, 24, and 52 weeks postoperatively. Demographic data were collected at baseline. Pre-injury and follow-up EuroQol 5-Dimensions (EQ-5D) and pain score were measured. Radiographs, taken postoperatively and in follow-up, were assessed for coronal and sagittal angulation, and used to calculate the modified Radiographic Union Scale for Tibia fractures (mRUST). LOA was defined as an increase in angulation5° by one year follow-up. Fracture comminution was defined using AO/OTA classification. Putative risk factors were assessed for association with LOA using bivariate logistic regression. Adjusted associations with LOA were estimated using multivariable logistic regression and marginal analysis.Analyses included 129 patients (70 IMN, 59 EF), majority male, of mean age 33 years (range 17.7-73) and body mass index (BMI) 25.2 (range 15.5-45.1), with 48% Type A, 41% Type B, and 11% Type C fractures (AO/OTA classification). The likelihood of LOA with EF increased with greater fracture comminution; 45.21% (p0.001), 77.50% (p0.001), and 100% LOA for Type A, B, and C fractures respectively. Relative risk of LOA for EF compared to IMN was 3.87 (95% CI 1.36, 11.02), 3.75 (95% CI 1.77, 7.92), and 5.76 for Type A, B, and C fractures, respectively. Compared to patients who lost alignment, patients without LOA had improved fracture healing (p = 0.003) and higher EQ-5D scores (p = 0.03) at one year.Increasing age and BMI are associated with LOA and segmental fracture amplifies the protective effect of IMN versus EF. The importance of LOA as a surrogate outcome after operative treatment of open tibial fractures is supported by its association with inferior radiographic and functional patient outcomes.

BackgroundFemur fracture patients require significant in-hospital care. The burden incurred by caregivers of such patients amplifies the direct costs of these injuries and remains unquantified. Aim Here we aim to establish the in-hospital economic burden faced by informal caregivers of femur fracture patients. Methods 70 unique caregivers for 46 femoral shaft fracture patients were interviewed. Incurred economic burden was determined by the Human Capital Approach, using standardized income data to quantify productivity loss (in $USD). Linear regression assessed the relationship between caregiver burden and patient time-in-hospital.ResultsThe average economic burden incurred was $149, 9% of a caregiver’s annual income and positively correlated with patient time in hospital (p

Introduction Proximal tibia fracture dislocations (PTFDs) are a subset of plateau fractures with little in the literature since description by Hohl (1967) and classification by Moore (1981). We sought to evaluate reliability in diagnosis of fracture-dislocations by traumatologists and to compare their outcomes with bicondylar tibial plateau fractures (BTPFs). Methods This was a retrospective cohort study at 14 level 1 trauma centers throughout North America. In all, 4771 proximal tibia fractures were reviewed by all sites and 278 possible PTFDs were identified using the Moore classification. These were reviewed by an adjudication board of three traumatologists to obtain consensus. Outcomes included inter-rater reliability of PTFD diagnosis, wound complications, malunion, range of motion (ROM), and knee pain limiting function. These were compared to BTPF data from a previous study. Results Of 278 submitted cases, 187 were deemed PTFDs representing 4% of all proximal tibia fractures reviewed and 67% of those submitted. Inter-rater agreement by the adjudication board was good (83%). Sixty-one PTFDs (33%) were unicondylar. Eleven (6%) had ligamentous repair and 72 (39%) had meniscal repair. Two required vascular repair. Infection was more common among PTFDs than BTPFs (14% vs 9%, p = 0.038). Malunion occurred in 25% of PTFDs. ROM was worse among PTFDs, although likely not clinically significant. Knee pain limited function at final follow-up in 24% of both cohorts. Conclusions PTFDs represent 4% of proximal tibia fractures. They are often unicondylar and may go unrecognized. Malunion is common, and PTFD outcomes may be worse than bicondylar fractures.

Objective Osteoarthritis (OA), the leading cause of joint failure, is characterized by breakdown of articular cartilage and remodeling of subchondral bone in synovial joints. Despite the high prevalence and debilitating effects of OA, no disease-modifying drugs exist. Increasing evidence, including genetic variants of the interleukin 4 (IL-4) and IL-4 receptor genes, implicates a role for IL-4 in OA, however, the mechanism underlying IL-4 function in OA remains unknown. Here, we investigated the role of IL-4 in OA pathogenesis. Methods Il4-, myeloid-specific-Il4ra-, and Stat6-deficient and control mice were subjected to destabilization of the medial meniscus to induce OA. Macrophages, osteoclasts, and synovial explants were stimulated with IL-4 in vitro, and their function and expression profiles characterized. Results Mice lacking IL-4, IL-4Ra in myeloid cells, or STAT6 developed exacerbated cartilage damage and osteophyte formation relative to WT controls. In vitro analyses revealed that IL-4 downregulates osteoarthritis-associated genes, enhances macrophage phagocytosis of cartilage debris, and inhibits osteoclast differentiation and activation via the type I receptor. Conclusion Our findings demonstrate that IL-4 protects against osteoarthritis in a myeloid and STAT6-dependent manner. Further, IL-4 can promote an immunomodulatory microenvironment in which joint-resident macrophages polarize towards an M2 phenotype and efficiently clear pro-inflammatory debris, and osteoclasts maintain a homeostatic level of activity in subchondral bone. These findings support a role for IL-4 modulation of myeloid cell types in maintenance of joint health and identify a pathway that could provide therapeutic benefit for osteoarthritis.

Objective To synthesize extant literature on the cost-effectiveness of prosthetic interventions and explore applicability to low- and middle-income country (LMIC) settings. Data Sources A systematic literature review using subject headings including “prosthetics,” “amputation,” and “cost analysis” was performed with PubMed, Embase, and Web of Science search engines, yielding 1194 articles. An additional 22 articles were identified via backward citation searching for 1144 total after duplicate removal. The search was last run in May of 2019. Study Selection Studies were included if they conducted an economic analysis of an upper or lower extremity prosthetic device. Studies were excluded if (1) full text was unavailable in English; (2) study was a systematic review or meta-analysis; or (3) study did not have a prosthetic comparison group. Using DistillerSR software, 2 authors independently conducted title and abstract screening. One author conducted full-text screening. The proportion of initially identified studies that met final inclusion criteria was 1% (12 of 1144). Data Extraction Data were dually extracted by 2 authors and reviewed by 3 additional authors. Data Synthesis All included studies (N=12) examined lower extremity amputations comparing advanced technology. No studies were conducted in LMICs. Comparable data between studies demonstrated (1) the cost-effectiveness of microprocessor- over nonmicroprocessor-controlled knees for transfemoral amputation in high-income settings; (2) equivocal findings regarding osseointegrated vs socket-suspended prostheses; and (3) increased cost for ICEX and modular socket systems over patellar tendon–bearing socket systems with no functional improvement. Conclusions There are few prosthetic cost analyses in the literature. Additional analyses are needed to determine the direct and indirect costs associated with prosthetic acquisition, fitting, and maintenance; the costs of amputee rehabilitation; and long-term economic and quality-of-life benefits. Such studies may guide future prosthetic and rehabilitative care, especially in resource-austere settings where prosthetic needs are greatest.