Department of Orthopaedic Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH 03756, USA.
J Orthop Trauma. 2012 Nov;26(11):624-32. doi: 10.1097/BOT.0b013e318246dfd9.
Femoral shaft fractures are usually treated with anterograde or retrograde nails that typically do not provide femoral neck fixation. Ipsilateral femoral neck fractures occur with 2.5%-10% of femoral shaft fractures; 19%-55% of associated femoral neck fractures are missed with plain films and 5%-22% with computed tomography (CT). This study was performed to determine if routine reconstruction nailing of all femoral shaft fractures with or without occult femoral neck fractures is cost effective.
A decision tree model examined the cost effectiveness of reconstruction nailing over standard intramedullary nailing for all femoral shaft fractures in which an associated femoral neck fracture was not identified on plain radiographs. As a base model, we assumed that 5% of shaft fractures had an ipsilateral femoral neck fracture, and 37% were missed and required further surgery. We assigned a small morbidity and additional cost ($680) for the use of a reconstruction nail and 2 screws. Model inputs including costs, clinical outcome probabilities, and health utilities were derived from the literature, estimated from institutional data, or assumed by the authors. Sensitivity analyses evaluated the effect of the rate of associated femoral neck fracture, the rate of missed femoral neck fracture, the complication rate of reconstruction screws, the cost of the extra reconstruction screws, and the utilities of each outcome on the incremental cost effectiveness (ICER) of both strategies. Current practice in cost-effectiveness analysis uses a threshold of $100,000 per quality-adjusted life year gained as cost effective. A secondary analysis of the use CT scans to reduce missed femoral neck fractures was also performed.
The base model showed that the placement of reconstruction nails in all isolated femur fractures was not cost effective. Sensitivity analysis demonstrated that the ICER was most sensitive to the cost of the reconstruction nail, hemiarthroplasty, and a missed femoral neck fracture. The ICER was affected by the rate of femoral neck fracture and the rate of missed femoral neck fracture. If the rate of missed femoral neck fractures was >38%, then reconstruction nailing was a cost-effective strategy. If the probability of an ipsilateral femoral neck fracture was >7%, then reconstruction nailing was cost effective. Protocolized CT scans had an ICER >$100,000. If the additional cost of the reconstruction nails was <$650, then it was cost effective to perform reconstruction nailing for all femoral shaft fractures.
Reconstruction nailing of femoral shaft fractures can be a cost-effective method to reduce the risks and morbidity of missed femoral neck fractures if the incremental implant costs are <$650. Routine reconstruction nailing is cost effective if the rate of associated femoral neck fracture is >7% or the rate of missed femoral neck fracture is >38%. CT scans are not a cost-effective strategy to reduce the risk and morbidity of missed femoral neck fractures if the cost is >$243. Weaknesses of this study include the reliance on low-powered studies and on estimations of some utilities and costs. To prevent the morbidity of missed or occult femoral neck fractures, the use of reconstruction nails for femoral shaft fractures is cost effective when the incremental costs of implants are <$650.
Economic Level II. See Instructions for Authors for a complete description of levels of evidence.
股骨干骨折通常采用顺行或逆行钉固定治疗，但通常无法固定股骨颈。股骨干骨折伴发同侧股骨颈骨折的发生率为 2.5%-10%；普通 X 线片漏诊率为 19%-55%，CT 漏诊率为 5%-22%。本研究旨在确定是否对所有股骨干骨折（无论是否存在隐匿性股骨颈骨折）常规行重建钉固定具有成本效益。
决策树模型检查了在普通 X 线片未发现股骨颈骨折的情况下，对所有股骨干骨折行重建钉固定与标准髓内钉固定的成本效益。作为基础模型，我们假设 5%的骨干骨折伴同侧股骨颈骨折，37%的股骨颈骨折漏诊，需要进一步手术。我们假设使用重建钉和 2 颗螺钉会带来较小的并发症和额外的成本（680 美元）。模型输入包括成本、临床结局概率和健康效用，这些数据来源于文献、机构数据估算或作者假设。敏感性分析评估了伴发股骨颈骨折的发生率、漏诊股骨颈骨折的发生率、重建螺钉的并发症发生率、额外重建螺钉的成本以及每种结局的效用对两种策略增量成本效益（ICER）的影响。目前，在成本效益分析中，使用每获得 1 个质量调整生命年的成本超过 10 万美元作为成本效益的阈值。还对使用 CT 扫描减少漏诊股骨颈骨折的情况进行了二次分析。
基础模型显示，对所有孤立的股骨干骨折进行重建钉固定并不具有成本效益。敏感性分析表明，ICER 对重建钉、半髋关节置换术和漏诊股骨颈骨折的成本最为敏感。ICER 还受到股骨颈骨折发生率和漏诊股骨颈骨折发生率的影响。如果漏诊股骨颈骨折的发生率>38%，则重建钉固定是一种具有成本效益的策略。如果同侧股骨颈骨折的概率>7%，则重建钉固定具有成本效益。方案化 CT 扫描的 ICER>10 万美元。如果重建钉的额外成本<650 美元，则对所有股骨干骨折行重建钉固定具有成本效益。
如果增量植入物成本<650 美元，重建钉固定治疗股骨干骨折可有效降低漏诊股骨颈骨折的风险和发病率。如果伴发股骨颈骨折的发生率>7%或漏诊股骨颈骨折的发生率>38%，则常规重建钉固定具有成本效益。如果 CT 扫描的成本>243 美元，则其不是降低漏诊或隐匿性股骨颈骨折风险和发病率的一种具有成本效益的策略。本研究的局限性包括依赖于低功率研究以及对某些效用和成本的估计。为了预防漏诊或隐匿性股骨颈骨折的发病率，当植入物的增量成本<650 美元时，使用重建钉治疗股骨干骨折具有成本效益。
经济证据 II 级。请参阅《作者须知》以获取完整的证据级别描述。
