Is surgical fixation for stress-positive unstable ankle fractures cost effective? Results of a multicenter randomized control trial

Abstract

Objectives: A recent multicenter randomized control trial demonstrated similar quality of life at 1 year after open reduction and internal fixation (ORIF) compared with nonoperative treatment for stress-positive unstable isolated lateral malleolar fractures. We sought to determine the cost-effectiveness of ORIF compared with nonoperative management of these isolated lateral malleolar fractures.

Design: Cost-utility analysis using decision tree and Markov modeling based on data from a prospective randomized control trial and previously published literature. A single-payer perspective with 1-year and lifetime time horizons was adopted.

Setting: Clinical trial data from 6 Canadian level I trauma hospitals.

Intervention: Lateral malleolus ORIF versus nonoperative treatment.

Main outcome measurements: Incremental cost-effectiveness ratio (ICER).

Results: The base case 1-year ICER of the ORIF treatment was $205,090 per quality-adjusted life year gained, favoring nonoperative treatment. For the lifetime time horizon, ORIF becomes the preferred treatment with an ICER of $16,404 per quality-adjusted life year gained. This conclusion is stable provided ORIF lowers the lifetime incidence of ankle arthrosis by >3% compared with nonoperative treatment. Probabilistic sensitivity analysis demonstrated that 33% of model simulations favored ORIF in the 1-year time horizon and 65% of simulations in the lifetime time horizon.

Conclusions: From a single-payer governmental perspective, ORIF does not seem to be cost effective in the 1-year time horizon; however, if operative fixation decreases the lifetime incidence of posttraumatic ankle arthrosis by >3%, then ORIF becomes the economically preferred treatment.

Level of evidence: Economic Level II. See Instructions for Authors for a complete description of levels of evidence.