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Purpose: Fracture-Related Infection (FRI) is associated with high medical costs and prolonged healthcare utilization. However, limited data is available on the financial impact. The purpose of this study was to investigate the impact of FRI on direct hospital costs and healthcare utilization., Methods: This was a retrospective cohort study in a level-1 trauma centre in the Netherlands. Patients ≥ 18 years, after open reduction and internal fixation of a long bone fracture between January 1st 2016 and November 1st 2021, were included. Exclusion criteria were Injury Severity Score (ISS) ≥ 16, indefinable data on costs or incomplete follow-up. Hospital costs related to fracture treatment were individually calculated based on procedure codes raised with a fixed percentage of overhead expenses, in line with hospital billing policies., Results: In total, 246 patients were included with a median follow-up of 1 year (IQR 0.6-1.8). A total of 45 patients developed FRI, of whom 15 patients had an FRI recurrence. Compared to non-FRI patients, median hospital costs from an FRI patient without and with recurrence, were respectively three (3.1) and seven (7.6) times higher. Compared to non-FRI patients, increased costs in patients with FRI or recurrent FRI are due to respectively a fivefold or even tenfold prolonged length-of-stay, two or seven additional infection-related surgeries, and 21 or 55 days of intravenous antibiotic treatment., Conclusion: Direct healthcare costs of patients with single occurrence of FRI after long bone fracture treatment are three times higher compared to non-FRI patients. In case of FRI-recurrence, the differences in costs might even increase to sevenfold. To put this in perspective, cost of severely injured trauma patients were recently established at approximately 25.000 euros. Compared to non-FRI patients, increased costs in patients with FRI or recurrent FRI are due to respectively a fivefold or even tenfold prolonged length-of-stay, two or seven additional infection-related surgeries and 21 or 55 days of intravenous antibiotic treatment. Not only from patient perspective but also from a financial aspect, it is important to focus on prevention of (recurrent) FRI., (© 2024. The Author(s).)

Introduction: Insurance status (IS) is known to be associated with length of stay (LOS). The impact of IS on excess LOS (ELOS), days between medical readiness and discharge date, has not been explored., Methods: We conducted a retrospective study of patients with pelvic fractures at a level I trauma center. Outcomes included ELOS (primary), discharge disposition (secondary), and ELOS-associated complications (secondary)., Results: 185 patients were included. Uninsured patients were the youngest and had the least baseline comorbidities (31.3 years (median), Charlson Comorbidity Index (CCI) .1) while publicly insured patients were the oldest and had the most baseline comorbidities (58.4 years (median), CCI 2.32). Excess LOS and associated complications did not differ among groups. After regression analysis, UIPs had longer LOS than PRPs (2.07 days, 95% CI .28-3.85). UIPs were recommended to go to inpatient rehabilitation 51.6% of the time but were discharged home 93.6% of the time; 81.0% of these changes were attributed to insufficient financial resources., Conclusions: Excess LOS and complications associated with ELOS were not associated with IS. Although UIPs were younger and had fewer baseline comorbidities, they had longer LOS after regression analysis. While discharge recommendations differed based on insurance status, UIPs had limited access to rehabilitation due to financial disparities. Despite initial treatment team recommendations, UIPs had to be sent home as their lack of insurance precluded inpatient rehabilitation placement., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: To describe and analyze the aspects regarding the cost and length of stay for elderly patients with bone fractures in a tertiary reference hospital., Methods: A cross-sectional retrospective study using data obtained from medical records between January and December 2020. For statistical analysis, exploratory analyses, Shapiro-Wilk test, χ2 test, and Spearman correlation were used., Results: During the study period, 156 elderly patients (62.2% women) with bone fractures were treated. The main trauma mechanism was a fall from a standing height (76.9%). The most common type of fracture in this sample was a transtrochanteric fracture of the femur, accounting for 40.4% of cases. The mean length of stay was 5.25 days. The total cost varied between R$2,006.53 and R$106,912.74 (average of R$15,695.76) (updated values). The mean daily cost of hospitalization was R$4,478.64. A positive correlation was found between the length of stay and total cost. No significant difference in cost was observed between the two main types of treated fractures., Conclusion: Fractures in the elderly are frequent, resulting in significant costs. The longer the hospital stay for treatment, the higher the total cost. No correlation was found between total cost and number of comorbidities, number of medications used, and the comparison between the treatment of transtrochanteric and femoral neck fractures.

Purpose: Electric scooters (e-scooters) are an increasingly popular method of transportation worldwide. However, there are concerns regarding their safety, specifically with regards to orthopaedic injuries. We aimed to investigate the overall burden and financial impact on orthopaedic services as a result of e-scooter-related orthopaedic injuries., Methods: We retrospectively identified all e-scooter-related injuries requiring orthopaedic admission or surgical intervention in a large District General Hospital in England over a 16-month period between September 2020 and December 2021. Injuries sustained, surgical management, inpatient stay and resources used were calculated., Results: Seventy-nine patients presented with orthopaedic injuries as a result of e-scooter transportation with a mean age of 30.1 years (SD 11.6), of which 62 were males and 17 were females. A total of 86 individual orthopaedic injuries were sustained, with fractures being the most common type of injury. Of these, 23 patients required 28 individual surgical procedures. The combined theatre and recovery time of these procedures was 5500 min, while isolated operating time was 2088 min. The total cost of theatre running time for these patients was estimated at £77,000. A total of 17 patients required hospital admission under Trauma and Orthopaedics, which accounted for total combined stay of 99 days with a mean length of stay of 5.8 days., Conclusion: While there are potential environmental benefits to e-scooters, we demonstrate the risks of injury associated with their use and the associated increased burden to the healthcare system through additional emergency attendances, frequent outpatient clinic appointments, surgical procedures, and hospital inpatient admissions., Competing Interests: Declaration of competing interest The authors have no conflicts of interest to declare., (Copyright © 2024. Published by Elsevier Ltd.)

Objective: The objective of this study was to investigate if race is associated with the likelihood of operative management of acute fractures., Methods: A systematic review of the literature was performed using the PubMed, EMBASE, and Cochrane databases to identify studies associated with social disparities and acute orthopedic trauma. Peer-reviewed studies commenting on social disparities and the decision to pursue operative or non-operative management of acute fractures were identified for detailed review. Study characteristics and odds ratios were extracted from each article. The Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were followed. A quality analysis of the data was also performed., Results: In total, 13 studies were identified and 8 were included in the meta-analysis totaling 743,846 fractures. Hip, distal radius, pelvic, tibial plateau, clavicle, femoral neck, and femoral shaft fractures were represented in this patient population. The meta-analysis demonstrated that White race is associated with a higher likelihood of operative intervention compared to all other races pooled together (odds ratio, 1.31; 95% confidence interval 1.16 to 1.47; p < .0001) as well as Black race (odds ratio 1.39; 95% confidence interval 1.12 to 1.72; p = .0025)., Conclusions: Non-White race and Black race are associated with a lower likelihood of receiving surgical management of acute orthopedic trauma. Surgeons and health systems should be aware of these inequities and consider strategies to mitigate bias and ensure all patients receive appropriate and timely care regardless of race., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: For-profit (FP) trauma centers (TCs) charge more for trauma care than not-for-profit (NFP) centers. We sought to determine charges, length of stay (LOS), and complications associations with TC ownership status (FP, NFP, and government) for three diagnoses among patients with overall low injury severity., Methods: Adult patients treated at TCs with an International Classification of Diseases-based injury severity score (ICISS) survival probability ≥ 0.85 were identified. Only those who with a principal diagnosis of femur, tibial or rib fractures were included., Results: Total charges were significantly higher at FP centers than NFP and lower at government centers (89.6% and -12.8%, respectively). FP TCs had a 12.5% longer LOS and government TCs had a 20.4% longer LOS than NFP TCs., Conclusion: Patients presenting to FP TCs with mild/moderate femur, tibial, or rib fractures experienced higher charges and increased LOS compared with government or NFP centers. There was no difference in overall complication rates., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Összefoglaló. Bevezetés: A pertrochanter töréssel kapcsolatos szolgáltatások igénybevétele jelentős terhet jelent a társadalom és az egészségügyi rendszerek számára. Célkitűzés: Elemzésünk célja volt a pertrochanter törés okozta éves epidemiológiai és egészségbiztosítási betegségteher meghatározása Magyarországon. Adatok és módszerek: A felhasznált adatok a Nemzeti Egészségbiztosítási Alapkezelő (NEAK) finanszírozási adatbázisából származnak 2018. évre vonatkozóan. A betegszámok alapján meghatároztuk a 100 000 lakosra jutó prevalenciát, az éves egészségbiztosítási kiadásokat korcsoportos és nemenkénti bontásban. Az elemzésbe az érintett egészségbiztosítási ellátások teljes körét bevontuk. A pertrochanter töréseket a Betegségek Nemzetközi Osztályozása (BNO, 10. revízió) szerinti S7210-es kóddal azonosítottuk. Eredmények: A legnagyobb országos betegszámot a járóbeteg-szakellátás esetében találtuk: 2845 férfi, 6312 nő, együtt 9157 fő. Ezt követte az aktívfekvőbeteg-szakellátás (2388 férfi és 5858 nő, együtt 8246 fő). A valamennyi életkorra számított, 100 000 lakosra vetített prevalencia a férfiaknál 51,1 beteg, a nőknél 114,7 beteg, együtt 84,3 beteg volt az aktívfekvőbeteg-szakellátásban. A pertrochanter törés kezelésére 7,329 milliárd Ft-ot költöttek 2018-ban (27,12 millió USD, illetve 22,98 millió EUR). A kiadások 28,0%-a férfiaknál, 72,0%-a nőknél jelent meg. Az egészségbiztosítási kiadások 90,7%-a az aktívfekvőbeteg-szakellátásban jelentkezett. Az egy betegre jutó átlagos éves összesített egészségbiztosítási kiadás 858 710 Ft (3177 USD/2693 EUR) volt a férfiak és 901 047 Ft (3334 USD/2826 EUR) a nők esetében. Következtetés: A pertrochanter törés előfordulási gyakorisága 2,5-szer magasabb a nők esetében, mint a férfiaknál. Az aktívfekvőbeteg-szakellátás igénybevétele bizonyult a legfőbb költségtényezőnek. Orv Hetil. 2021; 162(Suppl 1): 46-53., Introduction: Health services utilization related to pertrochanteric fractures represents a significant burden for the society and health care systems., Objective: Our aim was to analyse the epidemiological and health insurance burden of pertrochanteric fractures in Hungary., Data and Methods: Data were derived from the financial database of the National Health Insurance Fund Administration (NHIFA) of Hungary for the year 2018. The data analysed included annual patient numbers, prevalence per 100 000 population in acute inpatient care, health insurance costs calculated for age groups and sex for all types of care. Patients with pertrochanteric fracture were identified with the code S7210 of the International Classification of Diseases, 10th revision., Results: We found a significant patient turnover in outpatient care: 2845 men, 6312 women, in total 9157 patients, followed by acute inpatient care (2388 men, 5858 women, together: 8246 patients). Based on patient numbers in acute inpatient care, the prevalence per 100 000 among men was 51.1, among women 114.7, together 84.3 patients. In 2018, NHIFA spent 7.329 billion HUF (27.12 million USD, 22.98 million EUR) on the treatment of pertrochanteric fractures. 28.0% of the costs was spent on the treatment of male, 72.0% on female patients. Reimbursement of acute inpatient care was the main cost driver (90.7% of the total expenditure). The average annual treatment cost per patient was 858 710 HUF (3177 USD/2693 EUR) for men and 901 047 HUF (3334 USD/2826 EUR) for women., Conclusion: The prevalence of pertrochanteric fracture was 2.5 times higher in women compared to men. Acute inpatient care was the major cost driver in the treatment of pertrochanteric fracture. Orv Hetil. 2021; 162(Suppl 1): 46-53.

Background/objective: The cost of a fall among older adults requiring emergency services is unclear, especially beyond the acute care period. We evaluated medical expenditures (costs) to 1 year among community-dwelling older adults who fell and required ambulance transport, including acute versus post-acute periods, the primary drivers of cost, and comparison to baseline expenditures., Design: Retrospective cohort analysis., Setting: Forty-four emergency medical services agencies transporting to 51 emergency department in seven northwest counties from January 1, 2011, to December 31, 2011, with follow-up through December 31, 2012., Participants: We included 2,494 community-dwelling adults, 65 years and older, transported by ambulance after a fall with continuous fee-for-service Medicare coverage., Measurements: The primary outcome was total Medicare expenditures to 1 year (2019 U.S. dollars), with separation by acute versus post-acute periods and by cost category. We included 48 variables in a standardized risk-adjustment model to generate adjusted cost estimates., Results: The median age was 83 years, with 74% female, and 41.9% requiring admission during the index visit. The median total cost of a fall to 1 year was $26,143 (interquartile range (IQR) = $9,634-$68,086), including acute care median $1,957 (IQR = $1,298-$12,924) and post-acute median $20,560 (IQR = $5,673-$58,074). Baseline costs for the previous year were median $8,642 (IQR = $479-$10,948). Costs increased across all categories except outpatient, with the largest increase for inpatient costs (baseline median $0 vs postfall median $9,477). In multivariable analysis, the following were associated with higher costs: high baseline costs, older age, comorbidities, extremity fractures (lower extremity, pelvis, and humerus), noninjury diagnoses, and surgical interventions. Compared with baseline, costs increased for 74.6% of patients, with a median increase of $12,682 (IQR = -$185 to $51,189)., Conclusion: Older adults who fall and require emergency services have increased healthcare expenditures compared with baseline, particularly during the post-acute period. Comorbidities, noninjury medical conditions, fracture type, and surgical interventions were independently associated with increased costs., (© 2020 The American Geriatrics Society.)

BACKGROUND Traditional plaster (TP) is a widely used auxiliary fixation (AF) approach for postoperative fracture patients. However, patient discomfort and inconvenience to clinicians has limited its application. We introduce a novel instant 3-dimensional printing appliance system (3D-AS) to address such issues. MATERIAL AND METHODS Twenty-seven postoperative fracture patients were divided randomly between a TP group and a 3D-AS group, and analyzed retrospectively. Radiographic images during follow-up were evaluated for fracture healing and fracture reduction quality. The range of motion (ROM) was recorded to assess motor performance. Patient pain was assessed using the Visual Analogue Scale (VAS). Complications were also compared between the 2 groups. RESULTS The patients comprised 17 men and 10 women with ages ranging from 21 to 69 years (mean age: 47.35). All patients completed a follow-up visit (range: 14-19 months, mean: 13.59 months). Although no significant difference was found between general characteristics (P>0.05) and the time of fracture union (P>0.05), significant differences between groups were seen in complications (P<0.05), VAS (P<0.01), patient satisfaction (P<0.05), and ROM for the upper joints (P<0.05). CONCLUSIONS Our study suggests that 3D-AS provides better upper-limb ROM and more comfortable healing for postoperative fracture patients, indicating that it can be recommended for use in such patients.

Objective : To analyze the risk of bone traumatic fractures according to the engagement in sports, as well as to identify the potential impact of sports participation and traumatic fractures on health-care costs among adolescents. Methods : This is a longitudinal 12-month study of 285 adolescents of both sexes in Brazil. We assessed the occurrence of traumatic fractures and health-care services (hospitalizations, medicine use, medical consultations, and exams) by phone contact every month for 12 months. Adolescents were divided into four groups according to sport characteristics: non-sport (n = 104), non-impact sport (swimming [n = 34]), martial arts (n = 49 [judo, karate, kung-Fu]) and impact sports (n = 98 [track-and-field, basketball, gymnastics, tennis, and baseball]). Results : The incidence of new fractures was 2.1%. The overall costs accounted during the 12-month follow-up were U$ 3,259.66. Swimmers (US$ 13.86) had higher health-care costs than non-sport (US$ 1.82), martial arts (US$ 2.23), and impact sports (US$ 2.32). Conclusion : swimming seems to be related to higher health-care costs among adolescents.

Objective: The aim of this study was to compare the clinical outcomes and operative cost of a locked compression plate (LCP) and a nonlocked reconstruction plate in the treatment of displaced midshaft clavicle fracture., Methods: From January 2013 till March 2018, a total of 55 patients with acute unilateral closed midshaft clavicle fracture were treated with either a 3.5-mm pre-contoured LCP [32 patients; 25 men and 7 women; mean age: 35 years (range: 19-63 years)] or a 3.5-mm nonlocked reconstruction plate [23 patients; 20 men and 3 women; mean age: 31.4 years (range: 17-61 years)]. The clinical outcomes in terms of fracture union, Quick Disability of Arm, Shoulder and Hand (DASH) score, implant irritation, failure rate, and reoperation rate were evaluated retrospectively. The patient billing records were reviewed to obtain primary operation, reoperation, and total operative cost for midshaft clavicle fracture. These values were analyzed and converted from Malaysia Ringgit (RM) to United States Dollar (USD) at the exchange rate of RM 1 to USD 0.24. All patients were followed up for at least one-year duration., Results: The mean time to fracture union, implant irritation, implant failure, and reoperation rate showed no significant difference between the two groups of patients. The mean Quick DASH score was significantly better in the reconstruction plate group with 13 points compared with 28 points in the LCP group (p=0.003). In terms of total operative cost, the LCP group recorded a cost of USD 391 higher than the reconstruction plate group (p<0.001)., Conclusion: The 3.5-mm reconstruction plate achieved not only satisfactory clinical outcomes but was also more cost-effective than the LCP in the treatment of displaced midshaft clavicle fractures., Level of Evidence: Level III, Therapeutic study.

Objective: To determine whether step-downs, which cut the rate of compensation paid to injured workers after they have been on benefits for several months, are effective as a return to work incentive., Methods: We aggregated administrative claims data from seven Australian workers' compensation systems to calculate weekly scheme exit rates, a proxy for return to work. Jurisdictions were further subdivided into four injury subgroups: fractures, musculoskeletal, mental health and other trauma. The effect of step-downs on scheme exit was tested using a regression discontinuity design. Results were pooled into meta-analyses to calculate combined effects and the proportion of variance attributable to heterogeneity., Results: The combined effect of step-downs was a 0.86 percentage point (95% CI -1.45 to -0.27) reduction in the exit rate, with significant heterogeneity between jurisdictions ( I 2 =68%, p=0.003). Neither timing nor magnitude of step-downs was a significant moderator of effects. Within injury subgroups, only fractures had a significant combined effect (-0.84, 95% CI -1.61 to -0.07). Sensitivity analysis indicated potential effects within mental health and musculoskeletal conditions as well., Conclusions: The results suggest some workers' compensation recipients anticipate step-downs and exit the system early to avoid the reduction in income. However, the effects were small and suggest step-downs have marginal practical significance. We conclude that step-downs are generally ineffective as a return to work policy initiative.Postprint link: https://www.medrxiv.org/content/10.1101/19012286., Competing Interests: Competing interests: The authors previously received salary support from funding provided by the workers’ compensation systems investigated in this study., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Aims: Patients with chronic kidney disease (CKD) not on dialysis frequently have vitamin D insufficiency (VDI) and secondary hyperparathyroidism (SHPT), which are associated with an increased risk of cardiovascular (CV) disease, fracture, CKD progression, and death. This study estimated the cost-effectiveness of extended-release calcifediol (ERC) vs paricalcitol for the treatment of patients with CKD stages 3-4 that have SHPT and VDI. Materials and methods: An economic analysis of SHPT treatments among a hypothetical cohort of 1,000 patients with CKD Stage 3 and 4 with SHPT and VDI was developed to estimate differences in the rates and costs of CV events, fractures, CKD stage progression, and mortality in patients treated with ERC and paricalcitol. A Markov model was developed with 1-year cycles and a 5-year time horizon from a US Medicare payer perspective with costs valued in 2017 US dollars. Results: The outcomes of the model were rates of clinical events, total costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio (ICER). Across a 1,000-person cohort, ERC was the dominant (less costly, more effective) treatment strategy when compared with paricalcitol. Treatment with ERC resulted in cost savings of $14.8 M (95% CI = -$10.0 M-$45.2 M) and an incremental gain of 340 QALYs (95% CI = 200-496) compared to treatment with paricalcitol. Limitations: Bridging biochemical levels to clinical outcomes may not represent real-world risk of the clinical events modeled. Future real-world outcomes of patients treated with ERC and paricalcitol may be used to evaluate the model results. Conclusions: This model demonstrated favorable short- and long-term clinical benefits associated with the use of ERC in patients with CKD Stage 3 and 4 with SHPT and VDI, suggesting ERC may be cost-effective from the Medicare perspective compared to paricalcitol.

Background: Currently, very limited information is available regarding the economic burdens of patients with extremity post-traumatic osteomyelitis (OM). This study aimed to investigate direct health care costs and utilization for inpatients with extremity post-traumatic OM and analyze its constituent ratios and influencing factors in Southern China., Methods: We searched in the electronic medical record system for inpatients who had received surgical interventions at our department between 2013 and 2016 for extremity post-traumatic OM. Data of direct health care costs incurred during their hospitalizations were collected in six main categories (service, diagnosis, treatment, materials, pharmaceuticals, and miscellaneous expenses). In addition, data of total medical costs for contemporaneous inpatients with non-post-traumatic OM were also collected as controls., Results: A total of 278 post-traumatic OM and 10,420 controls were included. The median cost for the post-traumatic OM inpatients was $10,504 US dollars, 4.8-fold higher than that for those with non-post-traumatic OM ($2189, P < 0.001). The direct cost in the category of materials accounted for the largest proportion (61%), followed by that in pharmaceuticals (12%) and treatment (11%). The median number of hospital admissions for post-traumatic OM patients was 1 time, with a median length-of-stay of 22 d. The most influencing factors for the health care costs of the post-traumatic OM inpatients were use of an external fixator ($16,016 for those who used versus $4956 for those who did not, P < 0.001), external fixator type ($19,563 for ring fixator versus $14,966 for rail fixator, P < 0.001), infection site ($13,755 for tibia, $14,216 for femur and $5673 for calcaneus, P < 0.001), and infection-associated injury type ($12,890 for infection after open fracture versus $8087 for infection after closed fracture, P = 0.001)., Conclusions: An unexpectedly large proportion of the direct health care costs for inpatients with extremity post-traumatic OM went to cover an external fixator, with expenses for pharmaceuticals and treatment accounting for only a little more than the tenth of the total health care costs. Use of external fixator, external fixator type, infection site, and infection-associated injury type directly influenced the health care costs., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: In the background of increasing competition between trauma centers, this study investigated the relative reimbursement of trauma care provided in an urban trauma setting, comparing patients previously unknown (new) to the system, representing potential sources of new revenue, and those who were known (established), having received medical care previously in the same system., Methods: A retrospective review of 440 patients with high-energy fractures at a single level 1 trauma center was conducted. Payment to charge (P/C) ratios for professional and facilities services within 6 months of injury were calculated., Results: Mean professional charges per patient were $35,522 and $30,639 (P = 0.11), between new and established patients, respectively, whereas mean professional payments were statistically different, $7,894 and $4,365 (P < 0.001). Mean differences in P/C for facilities payments for new and established patients were not statistically significant, but professional P/C was higher in new patients (P < 0.001), consistent with better insured patients., Discussion: Insurance companies reimburse for professional or facilities services with statistically different P/C ratios. Treating new patients at our institution likely benefits our institution by offering exposure to a more favorable payer mix and more complex patients., Level of Evidence: Retrospective level III.

Background: Neer type-II distal clavicle fractures are unstable and are generally appropriately managed with operative fixation. Fixation options include locking plates, hook plates, and suture button devices. No consensus on optimal technique exists., Methods: A decision tree model was created describing fixation of Neer type-II fractures using hook plates, locking plates, or suture buttons. Outcomes included uneventful healing, symptomatic implant removal, deep infection requiring debridement, and nonunion requiring revision. Weighted averages derived from a systematic review were used for probabilities. Cost-effectiveness was evaluated by calculating incremental cost-effectiveness ratios (ICERs). The ICER is defined as the ratio of the difference in cost and difference in effectiveness of each strategy, and is measured in cost per quality-adjusted life year (QALY). The model was evaluated using thresholds of $50,000/QALY and $100,000/QALY. Sensitivity analysis was performed on all outcome probabilities for each fixation strategy to assess cost-effectiveness across a range of values., Results: Forty-three papers met final inclusion criteria. Using suture buttons as the reference case in the health-care cost model, suture button repair was dominant (both less expensive and clinically superior). Hook plates cost substantially more ($5,360.52) compared with suture buttons and locking plates ($3,713.50 and $4,007.44, respectively). Suture buttons and locking plates yielded similar clinical outcomes (0.92 and 0.91 QALY, respectively). Suture button dominance persisted in the societal perspective model. Sensitivity analysis on outcome probabilities showed that locking plates became the most cost-effective strategy if the revision rate after their use was lowered to 2.2%, from the overall average in the sources of >19%. No other changes in outcome probabilities for any of the 3 techniques allowed suture buttons to be surpassed as the most cost-effective., Conclusions: The cost-effectiveness of suture buttons is driven by low revision rates and high uneventful healing rates. Similar QALY values for locking plate and suture button fixation were observed, which is consistent with existing literature that has failed to identify either as the clinically superior technique. Cost-effectiveness should fit prominently into the decision-making rubric for these injuries., Level of Evidence: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Purpose: Although nonenzyme-inducing antiepileptic drugs (nEIAEDs) are accepted for the treatment of epilepsy, few studies have examined the costs, benefits, and cost-effectiveness of nEIAEDs in relation to the incidence of fracture among patients with epilepsy. In the present study, we performed cost-benefit and cost-effectiveness analyses comparing the influence of enzyme-inducing AEDs (EIAEDs) and nEIAEDs on the risk of fracture in this population., Methods: A total of 4864 patients with epilepsy were classified into EIAED and nEIAED groups. Propensity score matching was applied to reduce the influence of selection bias. Clinical outcomes were measured in relation to AED fee, medical expenses associated with epilepsy and fracture, and the total number of fractures. Cost-benefit and cost-effectiveness analyses were performed for all patients., Results: Patients in the unmatched EIAED cohort (n = 3686) were older and had more comorbidities. After matching, the cohorts exhibited similar features (n = 2432 each). Fracture risk was lower in the nEIAED group than in the EIAED group (HR = 0.70). The additional medical expense of nEIAEDs in fractures and epilepsy for 2 years per person was 107,731 New Taiwan dollars (NT$). The additional cost for nEIAEDs to reduce one event of fracture was $14,789,421 NT$., Conclusions: Patients with epilepsy using nEIAEDs had a lower risk of fracture than those using EIAEDs. However, the cost-benefit ratio and cost-effectiveness of such treatment were lower in the nEIAED group than in the EIAED group., Competing Interests: Declaration of competing interest None., (Copyright © 2019 Elsevier Inc. All rights reserved.)

The overall objective of this study was to determine the patient-level socioeconomic impact resulting from orthopaedic trauma in the available literature. The MEDLINE, Embase, and Scopus databases were searched in December 2019. Studies were eligible for inclusion if more than 75% of the study population sustained an appendicular fracture due to an acute trauma, the mean age was 18 through 65 years, and the study included a socioeconomic outcome, defined as a measure of income, employment status, or educational status. Two independent reviewers performed data extraction and quality assessment. Pooled estimates of the socioeconomic outcome measures were calculated using random-effects models with inverse variance weighting. Two-hundred-five studies met the eligibility criteria. These studies utilized five different socioeconomic outcomes, including return to work (n = 119), absenteeism days from work (n = 104), productivity loss (n = 11), income loss (n = 11), and new unemployment (n = 10). Pooled estimates for return to work remained relatively consistent across the 6-, 12-, and 24-month timepoint estimates of 58.7%, 67.7%, and 60.9%, respectively. The pooled estimate for mean days absent from work was 102.3 days (95% CI: 94.8-109.8). Thirteen-percent had lost employment at one-year post-injury (95% CI: 4.8-30.7). Tremendous heterogeneity (I2>89%) was observed for all pooled socioeconomic outcomes. These results suggest that orthopaedic injury can have a substantial impact on the patient's socioeconomic well-being, which may negatively affect a person's psychological wellbeing and happiness. However, socioeconomic recovery following injury can be very nuanced, and using only a single socioeconomic outcome yields inherent bias. Informative and accurate socioeconomic outcome assessment requires a multifaceted approach and further standardization., Competing Interests: The authors have declared that no competing interests exist.

Background: Conventional treatment of displaced midshaft clavicular fractures is nonoperative. Recent studies have implied that operative treatment might result in a faster return to work, resulting in a decreased productivity loss for society. The cost utility of plate fixation vs. nonoperative treatment of displaced midshaft clavicular fractures has not previously been investigated using a societal perspective., Methods: Decision analytical modeling of incremental costs and quality-adjusted life-years (QALYs) was performed. Data on utility, hospitalization, and productivity costs were retrieved from a Danish randomized controlled trial. Supplementary data were taken from randomized controlled trials identified in the literature. A 1-year time horizon was applied, and all prices were reported with respect to a 2016 level., Results: Operative treatment was associated with a larger QALY gain in patients and a higher cost compared with nonoperative treatment. The incremental cost-effectiveness ratio (ICER) was estimated in Danish currency (Danish krone [kr]) at kr1,360,000 (€182,306) per QALY from a health-sector perspective and kr1,388,738 (€186,158) per QALY from a societal perspective. Considering a subgroup analysis of patients with a high-load shoulder profession, operative treatment was dominated by nonoperative treatment from a health-sector perspective. Considering a societal perspective, the ICER was estimated at -kr889,091 (-€119,181) per reduction of 1 QALY. One-way and probabilistic sensitivity analyses showed that the results were subject to uncertainty., Conclusion: Operative treatment is not cost-effective when considering a threshold of €34,000/QALY. However, for a subgroup of patients with a high-load shoulder profession, operative treatment might be cost-effective compared with nonoperative treatment., (Copyright © 2019 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: We aimed to do a national survey on the population-based incidence of calcaneal fracture in China., Methods: All the data on calcaneal fractures were available from the China National Fracture Survey (CNFS) between January and May in 2015. And in the CNFS, all eligible household members were sampled from 8 provinces, 24 urban cities and 24 rural counties in China, using stratified random sampling and the probability proportional to size method. Questionnaires were sent to every participant for data collection and quality control was accomplished by our research team members., Results: A total of 512187 valid questionnaires were collected and relevant data were abstracted and analyzed. There were 59 patients with 62 calcaneal fractures occurring in 2014, indicating that the incidence was 11.5/100,000 person-years, 17.3/100,000 in males, and 5.5/100,000 in females. BMI ≥ 28.0 kg/m 2 , scarce meat consumption, smoking, alcohol consumption, average sleep time < 7 h/day, and previous history of fracture were identified as independent risk factors for calcaneal fracture., Conclusions: Specific public health policies focusing on quitting smoking, decreasing alcohol consumption, and encouraging individuals to obtain sufficient sleep should be implemented. Reasonable meat consumption and maintaining a normal body weight should be emphasized in individuals, especially in those with previous fracture.

Background: Most closed clavicle fractures are treated nonoperatively. Research during the past decade has reported differences in the treatment of clavicle fractures based on insurance status in the US and may highlight unmet needs in a vulnerable population, particularly because new data show that surgery may lead to improved outcomes in select populations. Large-scale, national data are needed to better inform this debate., Questions/purposes: (1) Does the likelihood of operative fixation of closed clavicle fractures vary among patients with different types of insurance? (2) What demographic and socioeconomic factors are associated with the likelihood of clavicle fracture surgery? (3) Has the proportion of operative fixation of clavicle fractures changed over time?, Methods: A retrospective analysis of the Nationwide Inpatient Sample 2001-2013 database was performed. This database is the largest publicly available all-payer inpatient database in the US that provides pertinent socioeconomic data on a nationwide scale. Data were queried for patients with closed clavicle fractures using International Classification of Diseases, Ninth Revision (ICD-9) diagnostic codes, and surgery was determined using ICD-9 procedural codes. A total of 252,109 patients were included in the final analysis after 158,619 patients were excluded because of missing demographic or insurance data, ambiguous fracture location, or age younger than 19 years. Of the 252,109 included patients, 21,638 (9%) underwent surgical fixation of clavicle fractures. A chi-square analysis was performed to determine variables to be included in a multivariable analysis. A binary logistic regression analysis was used to examine demographic and other important variables, with a significance level of p < 0.01. Poisson's regression and a t-test were used to analyze trends over time. Results were recorded as odds ratios (OR) and incidence rate ratios., Results: After controlling for demographic and potentially relevant variables, such as the median income and fracture location, we found that patients with Medicare, Medicaid, and no insurance had a lower likelihood of undergoing operative fixation of clavicle fractures than did those with private insurance. Patients without insurance were the least likely to undergo surgery (OR, 0.63; 95% CI, 0.60-0.66; p < 0.001), followed by those with Medicare (OR, 0.73; 95% CI, 0.70-0.78; p < 0.001) and those with Medicaid (OR, 0.74; 95% CI, 0.69-0.78; p < 0.001). Women, black, and Hispanic patients were also less likely to undergo surgery than men and white patients (OR, 0.95; p = 0.003; OR = 0.67; p < 0.001; and OR = 0.82; p < 0.001, respectively) There was an increase in the overall proportion of patients undergoing surgery, from 5% in 2001 to 11% in 2013 (incidence rate ratio, 2.99; p < 0.001)., Conclusions: We believe that the greater use of surgery among adult patients with clavicle fractures who have private insurance than among those with nonprivate or no insurance-as well as among men and white patients compared with women and patients of color-may be a manifestation of important health care disparities in the inpatient population. This may be owing to variable access to care or a difference in the likelihood that a surgeon will offer surgery based on a patient's insurance status. Because operative fixation of closed clavicle fractures increases in the adult population, future research should elucidate conscious and subconscious motivations of patients and surgeons to better inform the discussion of health care disparities in orthopaedics., Level of Evidence: Level III, therapeutic study.

Background: Individuals with neurodevelopmental disabilities (NDDs) have poor development and preservation of skeletal health throughout the lifespan, and are especially vulnerable to low-trauma fracture and post-fracture health complications. However, no studies have examined if adults with NDDs have greater post-fracture mortality risk compared to adults without NDDs. The purpose of this study was to determine whether adults with NDDs have greater 12-month mortality rates following a low-trauma fracture compared to adults without NDDs., Methods: Data from 2011 to 2017 was leveraged from Optum Clinformatics® Data Mart; a nationwide claims database from a single private payer in the U.S. Data were extracted from adults (18+ years) with and without NDDs that sustained a low-trauma fracture between 01/01/2012-12/31/2016, as well as pre-fracture chronic diseases (i.e., cardiovascular diseases, cerebrovascular diseases, diabetes, chronic obstructive pulmonary diseases, cancer). Mortality rate was estimated for adults with and without NDDs, and the mortality rate ratio (RR) and 95% confidence interval (CI) was calculated. Cox regression was used to estimate hazard ratio (HR) and 95% CI for 1-, 3-, 6-, and 12-month post-fracture mortality rates between adults with and without NDDs after adjusting for age, sex, race, U.S. region, and pre-fracture chronic diseases., Results: Mean age (SD) at baseline was 56.7 (20.6) for adults with NDDs (n = 3749; 45.2% men) and 63.9 (19.2) for adults without NDDs (n = 585,910; 34.4% men). During the 12-month follow-up period, 182 adults with NDDs (mean age [SD] = 69.8 [14.7]; 46.2% men) and 25,456 adults without NDDs (mean age [SD] = 78.9 [9.8]; 38.3% men) died. Crude mortality rate was not different between adults with and without NDDs for any time points (e.g., 12-months: 5.40 vs. 4.96 per 100 person years; RR = 1.09; 95% CI = 0.94-1.26); however, it was greater for adults with intellectual disabilities compared to adults without NDDs (RR = 1.46; 95% CI = 1.23-1.79). After adjustments, adults with NDDs had greater post-fracture mortality rates for 3-, 6-, and 12-month time points (e.g., 12-months: HR = 1.46; 95% CI = 1.27-1.69). When stratified by the type of NDD, adults with intellectual disabilities and adults with autism spectrum disorders, but not adults with cerebral palsy, had greater 12-month post-fracture mortality risk. When stratified by fracture location, lower extremities were associated with greater crude mortality rate (RR = 1.69; 95% CI = 1.22-2.35) and adjusted mortality risk (HR = 2.41; 95% CI = 1.73-3.35), while upper extremities were associated with greater adjusted mortality risk (HR = 1.76; 95% CI = 1.23-2.50) for adults with vs. without NDDs., Conclusions: Among privately insured adults with NDDs, low-trauma fracture is associated with greater mortality risk within 1 year of the fracture event, even after adjusting for pre-fracture chronic diseases. Study findings suggest the need for earlier fracture prevention strategies and improved post-fracture healthcare management., (Copyright © 2019 Elsevier Inc. All rights reserved.)

There is increasing recognition of both the impact and value of trauma care in low- and middle-income countries (LMICs). However, data supporting the value of musculoskeletal trauma care specifically are lacking. This review discusses methods of economic analysis relevant to low-resource settings and provides a review of cost studies related to orthopaedic trauma care in these settings. In general, microcosting methods are preferred in LMICs because of the lack of databases with aggregate cost data. It is important that studies use a societal perspective that includes the indirect costs of treatment in addition to direct costs of medical care. Cost-effectiveness studies most commonly report cost per disability-adjusted life year, particularly in LMICs, but quality-adjusted life years are an acceptable alternative that is based on more empiric data. There are solid economic data supporting potential cost savings and improved outcomes with intramedullary nailing for femoral shaft fractures. Trauma care hospitals and educational initiatives have also been found to be highly cost-effective. However, very little data exist to support other interventions in orthopaedic trauma. Orthopaedic surgeons should strive to understand these methodologies and support the conduct of rigorous economic analysis to better establish the value of musculoskeletal trauma care in LMICs.

Background: Patients with dementia commonly suffer from symptoms of overactive bladder (OAB); however, limited research exists on the clinical impact of coexisting OAB among patients with dementia. As such, the objective of this study was to examine the impact of OAB on clinical outcomes, health-care resource use, and associated costs among patients with dementia., Methods: We conducted a retrospective cohort analysis of patients with dementia using 3861 matched pairs of patients with and without OAB. Analyses were based on administrative claims data from January 1, 2007, to September 30, 2015, and compared clinical outcomes, health services use, and associated costs., Results: Patients with dementia and OAB were more likely than those without OAB to have least one fall (incidence rate ratio [IRR]: 1.43, 95% confidence interval [CI], 1.22-1.68, P < .001), fracture (IRR: 1.23, 95% CI, 1.05-1.44, P = .008), combined fall/fracture (IRR: 1.25, 95% CI, 1.11-1.42, P < .001), or urinary tract infection (IRR: 2.75, 95% CI, 2.55-2.96, P < .001). Patients with dementia and OAB demonstrated greater utilization of all-cause encounter types compared to similar patients without coexisting OAB ( P < .01). All-cause and dementia-related total health-care costs were approximately 23% (95% CI, 0.19-0.28, P < .001) and 13% (95% CI, 0.05-0.20, P = .001), respectively, greater than similar patients without coexisting OAB., Conclusion: Coexisting OAB was associated with impacts on clinical outcomes, health-care resource utilization, and costs in patients with dementia.

Decision tree and Markov models have been the most commonly used modeling methods in health economic evaluations. Both methods are known for their limitations. Discrete-event simulation (DES), an event-driven model in continuous time at the patient level, is a relatively new method in health economic evaluations that addresses some limitations of the common modeling techniques. Specifically, with the advent of personalized medicine, conventional methods for value assessment that are based on population-level measures might not be appropriate. The best treatment would depend on patient characteristics and clinical profiles. Value assessment of health interventions can vary substantially and may lead to different health decision making due to patient heterogeneity. As such, modeling at the patient level is an appropriate approach for value assessment of health interventions. The DES model has several advantages, such as flexibility, ability to reflect patient heterogeneity, increased precision, and better characterization of modeling uncertainty, that may be preferred to decision tree and Markov models. In addition, with increasing health care spending and drug prices, it is important to quantify value of available treatment options for women with postmenopausal osteoporosis (PMO). The purpose of this Viewpoints article was to describe and demonstrate an application of a DES model to evaluate the cost-effectiveness of the current treatment guidelines for women with PMO. In particular, the DES model indicated that the optimal treatment at the common willingness-to-pay thresholds between $100,000 per quality-adjusted life-year (QALY) and $150,000 per QALY was denosumab. Analysis of patient heterogeneity in terms of low, medium, high, and very high risk of fractures resulted in a similar conclusion. DISCLOSURES: Funding for this study was received through the PhRMA Foundation Value Assessment Challenge Award. The author has no conflicts of interest to declare.

Background: Increasing global demand for specialized radiological investigations has resulted in delayed or non-reporting of plain trauma radiographs by radiologists. This is particularly true in resource-limited environments, where referring clinicians rely largely on their own radiographic interpretation. A wide accuracy range has been documented for non-radiologist reporting of conventional trauma radiographs. The Lodox Statscan whole-body digital X-ray machine is a relatively new technology that poses unique interpretive challenges. The fracture detection rate of trauma clinicians utilizing this modality has not been determined., Objective: An audit of the polytrauma fracture detection rate of clinicians evaluating Lodox Statscan bodygrams in two South African public-sector Trauma Units., Methods: A retrospective descriptive study of imaging data of Cape Town Level 1-equivalent public-sector Trauma Units during March-April 2015. Statscan bodygrams acquired for adult polytrauma triage were reviewed and correlated with follow-up imaging and patient records. Missed fractures were stratified by body part, mechanism of injury and ventilatory support. The fracture detection rate was determined with 95% confidence. The Generalised Fischer Exact Test assessed any association between the fracture site and failure of detection. Specialist orthopaedic review assessed the potential need for surgical management of missed fractures., Results: 227 patients (male = 193, 85%; mean age: 33 years) were included; 195 fractures were demonstrated on the whole-body triage projections. Lower limb fractures predominated (n = 66, 34%). The fracture detection rate was 89% (95% CI = 86-93%), with the site of fracture associated with failure of detection (p = 0.01). Twelve of 21 undetected fractures (57%) involved the elbow or shoulder girdle. All elbow fractures (n = 3, 100%), more than half the shoulder girdle fractures (9/13,69%) and 12% (15/123) of extremity fractures were undetected. One missed fracture (1/21,4.7%) unequivocally required surgical management, while a further 7 (7/21, 33.3%) could potentially have benefitted from surgery, depending on follow-up imaging findings., Conclusion: This is the first analysis of the accuracy of bodygram polytrauma fracture detection by clinicians. Particular review of the shoulder girdle, elbow and extremities for subtle fractures, in addition to standardized limb positioning, are recommended for improved diagnostic accuracy in this setting. These findings can inform clinician training courses in this domain., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Aims: The primary aim of this study was to establish the cost-effectiveness of the early fixation of displaced midshaft clavicle fractures., Patients and Methods: A cost analysis was conducted within a randomized controlled trial comparing conservative management (n = 92) versus early plate fixation (n = 86) of displaced midshaft clavicular fractures. The incremental cost-effectiveness ratio (ICER) was used to express the cost per quality-adjusted life-year (QALY). The Six-Dimension Short-Form Health Survey (SF-6D) score was used as the preference-based health index to calculate the cost per QALY at 12 months after the injury., Results: The mean 12-month SF-6D was 0.9522 (95% confidence interval (CI) 0.9355 to 0.9689) following conservative management and 0.9607 (95% CI 0.9447 to 0.9767) following fixation, giving an advantage for fixation of 0.0085, which was not statistically significant (p = 0.46). The mean cost per patient was £1322.69 for conservative management and £5405.32 for early fixation. This gave an ICER of £480 309.41 per QALY. For a threshold of £20 000 per QALY, the benefit of fixation would need to be present for 24 years to be cost-effective compared with conservative treatment. Linear regression analysis identified nonunion as the only factor to adversely influence the SF-6D at 12 months (p < 0.001)., Conclusion: Routine plate fixation of displaced midshaft clavicular fractures is not cost-effective. Nonunion following conservative management has an increased morbidity with comparable expense to early fixation. This may suggest that a targeted approach of fixation in patients who are at higher risk of nonunion would be more cost-effective than the routine fixation of all displaced fractures. Cite this article: Bone Joint J 2019;101-B:995-1001.

Objective: First, to determine the number of accident-related complex regional pain syndrome (CRPS) cases from 2008 to 2015 and to identify factors associated with an increased risk for developing CRPS. Second, to analyze the duration of work incapacity and direct health care costs over follow-up periods of two and five years, respectively., Design: Retrospective data analysis., Setting: Database from the Statistical Service for the Swiss National Accident Insurances covering all accidents insured under the compulsory Swiss Accident Insurance Law., Subjects: Subjects were registered after an accident between 2008 and 2015., Methods: Cases were retrospectively retrieved from the Statistical Service for the Swiss National Accident Insurances. Cases were identified using the appropriate International Classification of Diseases, 10th Revision, codes., Results: CRPS accounted for 0.15% of all accident cases. Age, female gender (odds ratio [OR] = 1.53, 95% confidence interval [CI] = 1.47-1.60), and fracture of the forearm (OR = 38, 95% CI = 35-42) were related to an increased risk of developing CRPS. Over five years, one CRPS case accumulated average insurance costs of $86,900 USD and treatment costs of $23,300 USD. Insurance costs were 19 times and treatment costs 13 times the average costs of accidents without CPRS. Within the first two years after the accident, the number of days lost at work was 20 times higher in patients with CRPS (330 ± 7 days) than in patients without CRPS (16.1 ± 0.1 days). Two-thirds of all CRPS cases developed long-term work incapacity of more than 90 days., Conclusion: CRPS is a relatively rare condition but is associated with high direct health care costs and work incapacity., (© 2019 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objectives: We studied the determinants of high healthcare costs (highest decile of hospital care and medication costs) and cost trajectories among all community-dwellers with clinically verified Alzheimer's disease (AD), diagnosed during 2005-2011 in Finland ( N  = 70,531). Methods: The analyses were done separately for hospital care costs, medication costs and total healthcare costs that were calculated for each 6-month period from 5 years before to 3 years after AD diagnosis. Results: Total healthcare costs were driven mainly by hospital care costs. The definition of "high-cost person" was time-dependent as 63% belonged to the highest 10% at some timepoint during the study period and six distinct cost trajectories were identified. Strokes, cardiovascular diseases, fractures and mental and behavioural disorders were most strongly associated with high hospital care costs. Conclusions: Although persons with AD are often collectively considered as expensive patient group, there is large temporal and inter-individual variation in belonging to the highest decile of hospitalization and/or medication costs. It would be important to assess whether hospitalization rate could be decreased by, e.g., comprehensive outpatient care with more efficient management of comorbidities. In addition, other interventions that could decrease hospitalization rate in persons with dementia should be studied further in this context. Key messages Persons with AD had large individual fluctuation in hospital care costs and medication costs over time. Hospital care costs were considerably larger than medication costs, with fractures, cardiovascular diseases and mental and behavioural disorders being the key predictors. Antidementia medication was associated with lower hospital care costs.

Aims: The aim of the Scaphoid Magnetic Resonance Imaging in Trauma (SMaRT) trial was to evaluate the clinical and cost implications of using immediate MRI in the acute management of patients with a suspected fracture of the scaphoid with negative radiographs., Patients and Methods: Patients who presented to the emergency department (ED) with a suspected fracture of the scaphoid and negative radiographs were randomized to a control group, who did not undergo further imaging in the ED, or an intervention group, who had an MRI of the wrist as an additional test during the initial ED attendance. Most participants were male (52% control, 61% intervention), with a mean age of 36.2 years (18 to 73) in the control group and 38.2 years (20 to 71) in the intervention group. The primary outcome was total cost impact at three months post-recruitment. Secondary outcomes included total costs at six months, the assessment of clinical findings, diagnostic accuracy, and the participants' self-reported level of satisfaction. Differences in cost were estimated using generalized linear models with gamma errors., Results: The mean cost up to three months post-recruitment per participant was £542.40 (sd £855.20, n = 65) for the control group and £368.40 (sd £338.60, n = 67) for the intervention group, leading to an estimated cost difference of £174 (95% confidence interval (CI) -£30 to £378; p = 0.094). The cost difference per participant increased to £266 (95% CI £3.30 to £528; p = 0.047) at six months. Overall, 6.2% of participants (4/65, control group) and 10.4% of participants (7/67, intervention group) had sustained a fracture of the scaphoid (p = 0.37). In addition, 7.7% of participants (5/65, control group) and 22.4% of participants (15/67, intervention group) had other fractures diagnosed (p = 0.019). The use of MRI was associated with higher diagnostic accuracy both in the diagnosis of a fracture of the scaphoid (100.0% vs 93.8%) and of any other fracture (98.5% vs 84.6%)., Conclusion: The use of immediate MRI in the management of participants with a suspected fracture of the scaphoid and negative radiographs led to cost savings while improving the pathway's diagnostic accuracy and patient satisfaction. Cite this article: Bone Joint J 2019;101-B:984-994.

Purpose: Pelvic fractures are severe injuries and are often associated with multiple system injuries, exacerbating the overall outcome. In India, the incidence of pelvic fractures is on a rise due to suboptimal roads and traffics but related literature regarding the overall epidemiology of these injuries is scarce and scanty. Our aim was to study the epidemiology of patients admitted with pelvic fractures at a level 1 trauma centre in India., Methods: A 16-month (between September 2015 and December 2016) prospective observational study was carried out on trauma patients with pelvic fractures at a level 1 trauma centre of a tertiary care hospital. Demography of patients, mechanism of injuries and complications were recorded prospectively., Results: We observed 75 patients who presented with pelvic fractures, where 56 were males and 19 were females. Mean age of the study population was 37.57 years. Road traffic accidents were the most common mode of injuries. Lateral compression injuries were the most common pattern. Associated injuries frequently encountered were lower extremities and acetabulum fractures, blunt abdominal trauma, urogenital injuries and head injuries. Out of the 75 patients, 52 were treated surgically and 23 were managed by conservative methods. Associated injuries of the extremities, head, abdomen and urogenital system indicated a longer hospital stay., Conclusion: Pelvic fractures, although belong to a relatively rare trauma subset, cause a high morbidity and mortality with considerable burden on the economy. Proper road safety training and driving etiquettes along with its strict implementation in true sense and spirit are the need of the hour., (Copyright © 2019 Chinese Medical Association. Production and hosting by Elsevier B.V. All rights reserved.)

Background: Standardized clinical assessment and management plans (SCAMPs) are a novel quality improvement initiative shown to improve patient care, diminish practice variation, and reduce resource utilization. Unlike clinical practice guidelines, a SCAMP is a flexible algorithm that undergoes iterative updates based on periodic data collection and review. We recently implemented a SCAMP for the closed treatment of pediatric torus fractures. The purpose of this study is to analyze the effect of SCAMP implementation on resource utilization, practice variability, cost of care, and outcomes., Methods: This study was a retrospective review of prospectively collected data on 273 patients with pediatric torus fractures. The pre-SCAMP cohort included 116 subjects from 2008 to 2010. The SCAMP cohort included 157 subjects from 2011 to 2013. The pre-SCAMP cohort was treated according to the judgment of attending fellowship-trained pediatric orthopaedic surgeons. The SCAMP cohort was treated with a standardized algorithm including radiographs and splint application at initial presentation, with a single follow-up at 3 weeks. Patient demographics were analyzed to verify comparability between cohorts. Follow-up data including clinic visits, x-rays and practice variability was recorded. Costing analysis was conducted using time-derived activity-based costing methodology. Outcomes were compared using Poisson regression analysis. Incident rate ratios (IRR) with 95% confidence limits were estimated., Results: No differences in clinical results were observed between the pre-SCAMP and SCAMP cohorts, and all patients demonstrated return to baseline activity at final follow-up. Patient demographics were comparable across cohorts. The SCAMP cohort had a 48% reduction in clinic visits [IRR, 0.52; 95% confidence interval (CI), 0.44-0.60; P<0.001], 60% reduction in x-rays (IRR, 0.40; CI, 0.33-0.47; P<0.001), and a 23% reduction in x-rays per clinic visit (IRR, 0.77; 95% CI, 0.65-0.91; P<0.001). Furthermore, SCAMP implementation resulted in a 49% reduction in the overall cost of care., Conclusions: SCAMPs provide a novel alternative to CPGs to implement cost effective changes in Orthopaedic practice. For pediatric torus fractures, SCAMP implementation resulted in decreased practice variability, resource utilization, and overall cost of care while maintaining clinical outcomes., Level of Evidence: Level 3.

The cost of playground-related injuries remains significant. Measures adopted to prevent such fractures or reduce their severity would translate into appreciable financial savings. Our study looks at the changes in playground-related extremity fracture epidemiology over the past decade after the implementation of latest playground standards. This is a retrospective case series approved by the local ethics board comparing the results of two descriptive studies; one conducted prior to the implementation of the Singapore Productivity and Standards Board Singapore Standards SS 457: 2007 and the other thereafter. The demographics have remained the same. The proportion of public playground injuries has fallen significantly from 89.6% to 76.3% ( p < 0.05), whereas school playground injuries have risen from 5.9% to 18.0% ( p < 0.05). Fractures related to monkey bars and the flying fox have shown a significant improvement, decreasing to 38.1% from 47.6% ( p < 0.05) and 1% from 6.9% ( p < 0.05), respectively. There has been a decrease of 33% in playground-related injuries. The total financial cost of sustaining one playground-related extremity fracture has generally increased by 50%. However, considering the 37.4% drop in surgeries, the actual overall costs to the healthcare system have essentially fallen. Safety standards have had a positive effect on playground safety in Singapore. There are now fewer and less severe playground-related extremity fractures., Competing Interests: We have no conflicts of interest to declare., (© Atlantis Press International B.V.)

Background: The US Food and Drug Administration has recently approved abaloparatide (ABL) for treatment of women with postmenopausal osteoporosis (PMO) at high risk of fracture. With increasing health care spending and drug prices, it is important to quantify the value of newly available treatment options for PMO., Objective: To determine cost-effectiveness of ABL compared with teriparatide (TPTD) for treatment of women with PMO in the United States., Methods: A discrete-event simulation (DES) model was developed to assess cost-effectiveness of ABL from the US health care perspective. The model included three 18-month treatment strategies with either placebo (PBO), TPTD, or ABL, all followed by additional 5-year treatment with alendronate (ALN). High-risk patients were defined as women with PMO ⩾65 years old with a prior vertebral fracture. Baseline clinical event rates, risk reductions, and patient characteristics were based on the Abaloparatide Comparator Trial in Vertebral Endpoints (ACTIVE) trial., Results: Over a 10-year period, the DES model yielded average total discounted per-patient costs of $10 212, $46 783, and $26 837 and quality-adjusted life-years (QALYs) of 6.742, 6.781, and 6.792 for PBO/ALN, TPTD/ALN, and ABL/ALN, respectively. Compared with TPTD/ALN, ABL/ALN accrued higher QALYs at lower cost and produced an incremental cost-effectiveness ratio (ICER) of $333 266/QALY relative to PBO/ALN. In high-risk women, ABL/ALN also had more QALYs and less cost over TPTD/ALN and yielded an ICER of $188 891/QALY relative to PBO/ALN. Conclusion and Relevance: ABL is a dominant treatment strategy over TPTD. In women with PMO at high risk of fracture, ABL is an alternative cost-effective treatment.

Background: Socioeconomic disparities are an inherent and currently unavoidable aspect of medicine. Knowledge of these disparities is an essential component towards medical decision making, particularly among an increasingly diverse population. While healthcare disparities have been elucidated in a wide variety of orthopaedic conditions and management options, they have not been established among patients who present for treatment of an ununited fracture. The purpose of this study is to answer the following questions: 1) Following surgical management of (fracture) non-unions, are there differences in outcomes between differing ethnic groups? 2) Following surgical management of (fracture) non-unions, are there differences in outcomes between patients with differing education levels? 3) Following surgical management of (fracture) non-unions, are there differences in outcome between patients with differing incomes?, Methods: Between September 2004 and December 2017, operatively treated patients who presented with a long bone fracture non-union were prospectively followed. These patients presented with a variety of fracture non-unions that underwent surgical intervention. Sociodemographic factors were recorded at presentation. Long-term outcomes were evaluated using the Short Musculoskeletal Function Assessment (SMFA), pain scores, post-operative complications and physical exam at latest follow up. The SMFA is a 46-item questionnaire, assessing patient functional and emotional response to musculoskeletal ailments., Results: Three-hundred-twenty-nine patients met inclusion criteria. Patients with a lower education had worse long-term functional outcomes (P < 0.001) and increased pain scores (P = 0.002) at latest follow-up. Patients who made less than $50,000 annually had worse long-term functional outcomes (P = 0.002) and reported higher pain scores (P = 0.003) following surgical management of (fracture) non-unions. Multiple linear regression demonstrated education level to be an independent predictor of long-term functional outcomes following surgical management of (fracture) non-unions (B= -0.154, 95% Confidence Interval [CI]=-10.96 to -1.26, P = 0.014). No differences existed in outcomes or pain scores between those of different ethnic groups. No differences existed regarding post-operative complications and time to union between patients of different ethnic groups, educational levels and income status., Conclusion: Patients with lower education levels and individuals who make less than $50,000 annually have worse functional outcomes following surgical management of (fracture) non-unions. Orthopaedic trauma surgeons should therefore be aware of these disparities, and consider early interventions aimed at optimizing patient recovery in these subsets., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Aim: To compare trampoline injuries and injury costs sustained at a commercial trampoline park versus private homes presenting to a major Australian children's hospital over a 12-month period., Methods: Children presenting with a trampoline injury to the paediatric emergency department in 2015 were identified using a keyword search of triage information. A comparison of injuries sustained at a commercial trampoline park and private homes was performed., Results: A total of 392 children presented with injuries, and the majority of injuries (68.9%) occurred at a private home; 19.4% were from a commercial trampoline park. Significant differences were seen between patients from a private home and commercial park for median age (5.6 vs. 12.8 years; P < 0.001), gender (48.2 vs. 61.8% female; P = 0.03) and season of injury. Of the injuries, 27.3% occurred when children fell off the trampoline, and fractures (39.5%) were the most common injury; 17.4% required hospital admission, and 12.8% required surgical intervention. Commercial park injuries had a significantly longer median length of stay (37.4 vs. 22.8 h; P = 0.03). The estimated total acute cost for these trampoline injuries in 1 year was $546 786. Commercial trampoline park injuries accounted for 21.7% of the estimated cost and private homes for 68.2%., Conclusions: Paediatric trampoline injuries remain a common source of hospital presentation and admission, despite the introduction of a Voluntary Australian Standard. Paediatric trampoline injuries usually occur in private homes; however, the increasing popularity of commercial trampoline parks contributes to a change in the profile of trampoline injuries. Commercial park injuries were more expensive to treat., (© 2018 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

Background: While previous studies have shown higher union rates and a quicker return to work with operative treatment of substantially displaced clavicle fractures, there is disagreement whether operative treatment results in improved clinical outcomes. Patients who undergo operative treatment sometimes require additional surgery for implant removal. Nonoperative treatment may fail so that delayed surgical intervention is ultimately required. The duration for which the clinical benefits of operative treatment remain superior to those of nonoperative treatment has not been well established in the literature. Considering these uncertainties, surgeons are faced with a difficult decision regarding whether operative treatment of a midshaft clavicle fracture will be cost-effective. The purpose of this study was to identify the most cost-effective strategy by considering these uncertain parameters with use of decision-analysis techniques., Methods: An expected-value decision tree was built to estimate the quality-adjusted life years (QALYs) and costs for operative and nonoperative treatment of substantially displaced midshaft clavicle fractures. Values for parameters in the decision model were derived from the literature. Medical costs were obtained from the Medicare database. A Markov model was used to calculate the QALYs for the duration of life expectancy. The decision model was used to analyze the duration for which the clinical results of operative treatment were superior to those of nonoperative treatment during the first 5 years after the operation and during a lifetime. Sensitivity analysis was performed to determine which parameters have the most influence on cost-effectiveness., Results: Operative treatment was more cost-effective than nonoperative treatment in 54% and 68% of the Monte Carlo trials in the 5-year and lifetime analyses, respectively. The cost per QALY with operative management was <$38,000 and <$8,000 in the 5-year and lifetime analyses, respectively. This is below the willingness-to-pay threshold of $50,000 per QALY. For operative treatment to remain cost-effective, its clinical benefits must persist for at least 3 years., Conclusions: Operative treatment is more cost-effective than nonoperative treatment for substantially displaced midshaft clavicle fractures. The clinical benefits derived with operative treatment must persist for at least 3 years for operative treatment to remain cost-effective. This research should not be used to conclude that all clavicle fractures should be treated surgically. It is best that such a decision is made through a patient-surgeon shared decision-making process., Level of Evidence: Economic and Decision Analysis Level II. See Instructions for Authors for a complete description of levels of evidence.

Fracture healing complications are common and result in significant healthcare burden. The aim of this study was to determine the rate, costs and predictors of two-year readmission for surgical management of healing complications (delayed, mal, non-union) following fracture of the humerus, tibia or femur. Humeral, tibial and femoral (excluding proximal) fractures registered by the Victorian Orthopaedic Trauma Outcomes Registry over five years ( n = 3962) were linked with population-level hospital admissions data to identify two-year readmissions for delayed, mal or non-union. Study outcomes included hospital length-of-stay (LOS) and inpatient costs. Multivariable logistic regression was used to determine demographic and injury-related factors associated with admission for fracture healing complications. Of the 3886 patients linked, 8.1% were readmitted for healing complications within two years post-fracture, with non-union the most common complication and higher rates for femoral and tibial shaft fractures. Admissions for fracture healing complications incurred total costs of $4.9 million AUD, with a median LOS of two days. After adjusting for confounders, patients had higher odds of developing complications if they were older, receiving compensation or had tibial or femoral shaft fractures. Patients who are older, with tibial and femoral shaft fractures should be targeted for future research aimed at preventing complications.

Background: Controversy exists regarding optimal primary management of Lisfranc injuries. Whether open reduction internal fixation (ORIF) or primary arthrodesis is superior remains unknown., Methods: A national insurance database of approximately 23.5 million orthopedic patients was retrospectively queried for subjects who were diagnosed with a Lisfranc injury from 2007 to 2016 based on international classification of diseases (ICD) codes (PearlDiver, Colorado Springs, CO). Patients with lisfranc injuries then progressed to either nonoperative treatment, ORIF, or primary arthrodesis. Associated treatment costs were determined along with complication rate and hardware removal rate., Results: 2205 subjects with a diagnosis of Lisfranc injury were identified in the database. 1248 patients underwent nonoperative management, 670 underwent ORIF, and 212 underwent primary arthrodesis. The average cost of care associated with primary arthrodesis was greater ($5005.82) than for ORIF ($3961.97,P = 0.045). The overall complication rate was 23.1% (155/670) for ORIF and 30.2% (64/212) for primary arthrodesis (P = 0.04). Rates of hardware removal were 43.6% (292/670) for ORIF and 18.4% (39/212) for arthrodesis (P < 0.001). Furthermore, 2.5% (17/670) patients in the ORIF group progressed to arthrodesis at a mean of 308 days, average cost of care associated with this group of patients was $9505.12., Discussion: Primary arthrodesis is both significantly more expensive and has a higher complication rate than ORIF. Open reduction and internal fixation demonstrated a low rate of progression to arthrodesis, although there was a high rate of hardware removal, which may represent a planned second procedure in the management of a substantial number of patients treated with ORIF., Level of Evidence: Level III Retrospective Cohort Study., (Copyright © 2018. Published by Elsevier Ltd.)

Objective: To characterize the charges and collections associated with the initial inpatient management of trauma patients who undergo operative fracture management., Design: Retrospective., Setting: Level 1 trauma center., Participants: Four hundred forty consecutive, adult, trauma patients., Intervention: Fixation for fracture of the spine, pelvis, acetabulum, and/or femur fractures., Main Outcome Measures: Professional and technical (facility) charges and collections from the initial inpatient management and 6 months of subsequent related care., Results: Patients were predominantly male (74.3%) and white (63.2%) with a mean age of 41 years and mean injury severity score of 18.5. Uninsured (self-pay) patients represented the largest payer class (35.0%), and 34.5% of all patients were unemployed. Professional and technical charges totaled US $12,382,028 (US $28,140/patient) and US $39,682,225 (US $90,187/patient), respectively. Injury severity score, longer lengths of stay (LOS), and the presence of a complication were positive predictors of initial charges (P < 0.0001; adjusted R = 0.799). Professional and technical collections totaled US $2,418,096 (US $5,496/patient) and US $16,921,959 (US $38,459/patient) (percent of charge: 21.5% vs. 41.3%; P < 0.0001). Of the self-pay patients, 34.4% had no collections, resulting in potential lost revenue of US $2,513,988. Greater collections were predicted to occur in females, employed patients, and those with insurance (P < 0.0001; adjusted R = 0.35)., Conclusions: Trauma patients often present without insurance, which compromises hospital revenue. Expectedly, charges are higher in more severely injured patients, those with longer LOS, and those experiencing complications. A bundled model will proportionately decrease reimbursements for a given episode of care in the event of longer LOS or occurrence of complications.

Background: The purpose of this study was to compare closed reduction and percutaneous pinning of metacarpal and phalanx fractures performed in the operating room (OR) versus the procedure room of the emergency department with primary outcomes being infection rate, radiographic union, and monetary cost., Methods: From January 2006 to December 2010, all closed reduction and percutaneous pinnings of metacarpal and phalanx fractures (CPT codes: 26608; 26727) by a single board-certified hand surgeon (A.M.H.) were retrospectively reviewed. Patients were placed into 2 groups: Group 1 was patients treated in the OR, and group 2 was patients in an emergency department procedure room. Infection, malunion, and nonunion rates were compared using a chi-square test. Charges were compared using a t-test, and cost of supplies and labor was evaluated., Results: A total of 189 patients met final inclusion criteria for this study: 130 in group 1 and 59 in group 2. There was no statistically significant difference in infection rates ( P = .13), nonunion ( P = .40), malunion rates ( P = .89), and hardware failure with revision ( P = .94) between the 2 groups. The procedure room patients had an average hospital charge of $1358.55 compared with $3691.85 for OR-treated patients (P = .001). The total cost of supplies and nonphysician labor was $432.31 per OR case and $179.59 per procedure room case., Conclusions: Metacarpal and phalanx fractures of the hand amendable to closed reduction and percutaneous pinning can be treated in the procedure room with no increase in risk of infection, malunion, or nonunion rates. In addition, these surgeries can be performed in a procedure room with lower cost and less charges to patients than in the operating room.

Aims: The Edinburgh Trauma Triage Clinic (TTC) streamlines outpatient care through consultant-led 'virtual' triage of referrals and the direct discharge of minor fractures from the Emergency Department. We compared the patient outcomes for simple fractures of the radial head, little finger metacarpal, and fifth metatarsal before and after the implementation of the TTC., Patients and Methods: A total of 628 patients who had sustained these injuries over a one-year period were identified. There were 337 patients in the pre-TTC group and 289 in the post-TTC group. The Disabilities of the Arm, Shoulder and Hand Score (QuickDASH) or Foot and Ankle Disability Index (FADI), EuroQol-5D (EQ-5D), visual analogue scale (VAS) pain score, satisfaction rates, and return to work/sport were assessed six months post-injury. The development of late complications was excluded by an electronic record evaluation at three years post-injury. A cost analysis was performed., Results: Outcomes were as good or better post-TTC, compared with pre-TTC scores. At three years, the pre-TTC group required a total of 496 fracture clinic appointments compared with 61 in the post-TTC group. Mean cost per patient was nearly fourfold less after the commencement of the TTC., Conclusion: Management of minor fractures through the Edinburgh TTC results in clinical outcomes that are comparable with the previous system of routine face-to-face consultation. Outpatient workload for these injures was reduced by 88%. Cite this article: Bone Joint J 2018;100-B:959-65.

Given the limitations of conventional radiography in the diagnosis of suspected scaphoid fractures on presentation, advanced imaging, particularly magnetic resonance imaging, is a useful additional investigation. We carried out a systematic review of the economic evidence for the use of advanced imaging in the management of suspected scaphoid fractures. Fifteen articles were included in the review. Owing to the heterogeneity of study designs, the type and timing of interventions and the economic analyses performed, direct comparisons between the 15 studies were difficult. From a health care perspective, little could be concluded regarding the economic implications of the use of advanced imaging in clinical practice. However, from a societal perspective, the evidence favours the use of advanced imaging in the management of suspected scaphoid fractures as it does appear to lead to overall cost-savings.

Aims and Objective: To estimate the increased care demand and medical costs caused by falls in nursing homes., Background: There is compelling evidence that falls in nursing homes are preventable. However, proper implementation of evidence-based guidelines to prevent falls is often hindered by insufficient management support, staff time and funding., Design: A three-round Delphi study., Methods: A panel of 41 experts, all working in nursing homes in the Netherlands, received three online questionnaires to estimate the extra hours of care needed during the first year after the fall. This was estimated for ten falls categories with different levels of injury severity, in three scenarios, that is a best-case, a typical-case and a worst-case scenario. We calculated the costs of falls by multiplying the mean amount of extra hours that the participants spent on the care for a resident after a fall with their hourly wages., Results: In case of a noninjurious fall, the extra time spent on the faller is on average almost 5 hr, expressed in euros that add to € 193. The extra staff time and costs of falls increased with increasing severity of injury. In the case of a fracture of the lower limb, the extra staff time increased to 132 hr, expressed in euros that is € 4,604. In the worst-case scenario of a fracture of the lower limb, the extra staff time increased to 284 hr, expressed in euros that is € 10,170., Conclusions: Falls in nursing homes result in a great deal of extra staff time spent on care, with extra costs varying between € 193 for a noninjurious fall and € 10,170 for serious falls., Relevance to Clinical Practice: This study could aid decision-making on investing in appropriate implementation of falls prevention interventions in nursing homes., (© 2018 John Wiley & Sons Ltd.)

Introduction: Work-related injuries have an impact on social security system of the country, on the victims as well as on their relatives. The objective is the aim of our study was to describe the different characteristics of work-related injuries reported to the Social Security Fund (CSS) in Dakar as well as the socioprofessional course of the victims., Methods: We conducted a retrospective cross-sectional study over a period of 5 years, from 2002 to 2006. Data were collected from 133 cases out of 9 308 reported to the CSS. Various parameters were studied: the socioprofessional characteristics of victims and the lesional features of the injuries. The victims were interviewed to gather informations about their socioprofessional history and their professional situation., Results: The average age of patients was 37,55 years, with a male predominance (99,22 %). BPW (22.6%) and fishing (15%) sectors were most affected. Almost two thirds of injuries happened in the workplace (77.4%). These injuries resulted in fractures in 51.7% of cases and affected the hand in 30.1% of cases. Nearly two thirds of injured subjects (60.9%) had resumed their profession. Thirty one subjects were fired and 12 were redeployed. The average period of temporary total incapacity was 236.7 days. The median annual pension was 1 640 329 CFA Francs (2 504,31 Euros)., Conclusion: In Senegal, work-related injuries don't have specific characteristics, as described elsewhere. The low resources allocated to the victims and the lack of supporting social-policy measures explain the different types of suffering of the victims and their families.

Aims: To estimate incremental healthcare resource utilization (HRU) and costs associated with skeletal-related events (SREs) secondary to multiple myeloma (MM), and HRU and cost differences in patients with one vs multiple SREs., Methods: Adults with MM diagnosis between January 1, 2010-December 31, 2014, with benefits coverage ≥12 months pre- and ≥6 months post-diagnosis were followed to last coverage date or December 31, 2015, excluding patients with prior anti-myeloma treatment or cancers. SREs were identified by diagnosis or procedure codes (pathological fracture, spinal cord compression, radiation, or surgery to the bone). SRE patients (index = first post-diagnosis SRE) were propensity score matched 1:1 to patients without SRE (assigned pseudo-index) using baseline characteristics, and ≥1 month of continuous enrollment after index/pseudo-index date was required. Per-patient-per year (PPPY) HRU and costs (2016 US$) were determined for inpatient, outpatient, emergency department (ED), and outpatient pharmacy services during follow-up. Wilcoxon signed rank for means and McNemar's tests for proportions were used to assess differences. Negative binomial regression and generalized linear regression analyses estimated differences in HRU and costs, respectively, for the comparison of single vs multiple SREs., Results: Each cohort included 848 patients (mean age = 61 - 62 years, 57% male) with no significant differences in pre-index demographic or clinical characteristics between matched cohorts. Versus non-SRE patients, SRE patients had significantly higher PPPY use (p < .0001) of inpatient hospitalizations, ED visits, outpatient pharmacy, and higher direct medical costs ($188,723 vs $108,160, p < .0001). Adjusted PPPY total costs were $209,820 in patients with multiple SREs; $159,797 in patients with one SRE., Limitations: SRE misclassification and residual confounding are possible., Conclusions: Among patients with MM, average annual costs were substantially higher in patients with SRE compared with matched non-SRE patients. The economic burden of SRE increased further with multiple events.

Objectives: To evaluate the cost effectiveness of suture buttons compared with syndesmotic screws for repair of tibiofibular syndesmotic injuries., Methods: A decision tree model was constructed to describe outcomes after syndesmosis repair using suture buttons and syndesmotic screws from the perspective of a capitated health care system. Outcomes were uneventful healing, removal of symptomatic implants, deep infection, and persistent diastasis requiring revision. Weighted literature averages were used to estimate variables for a baseline model. Outcomes were measured in quality adjusted life years. Procedure and implant costs were derived from Medicare reimbursement rates and the University Health System Consortium. An incremental cost-effectiveness ratio threshold of $50,000 per quality-adjusted life years was used to evaluate cost effectiveness., Results: The baseline model did not identify suture buttons to be cost effective. Sensitivity analysis demonstrates the model to be exquisitely sensitive to small changes in reoperation rates and implant price. At median University Health System Consortium implant prices, if the removal rate for symptomatic screws is below 13.7%, then screws are cost effective. If the screw removal rate is greater than 17.5%, then a suture button is cost effective. Within this interval, detailed analysis of the model suggests that screws may be the cost-effective strategy, but that determination should be taken with caution., Conclusions: Moving away from the practice of routinely removing all syndesmotic screws has changed the financial landscape of syndesmosis repair. At their median cost, suture buttons are likely to be cost effective over screws for symptomatic screw removal rates greater than 17.5%. Cost effectiveness is sensitive to changes in implant removal rates and the number of devices used per patient., Level of Evidence: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.