title: Is surgical fixation for stress-positive unstable ankle fractures cost effective? Results of a multicenter randomized control trial.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  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.
  
  
  METHODS
  Clinical trial data from 6 Canadian level I trauma hospitals.
  
  
  METHODS
  Lateral malleolus ORIF versus nonoperative treatment.
  
  
  METHODS
  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.
  
  
  METHODS
  Economic Level II. See Instructions for Authors for a complete description of levels of evidence.
authors.affiliation: Department of Orthopaedics, University of British Columbia, Vancouver, Canada. gsloboge@gmail.com
authors.forename: Gerard P
authors.initials: GP
authors.lastname: Slobogean
authors.forename: Carlo A
authors.initials: CA
authors.lastname: Marra
authors.forename: Mohsen
authors.initials: M
authors.lastname: Sadatsafavi
authors.forename: David W
authors.initials: DW
authors.lastname: Sanders
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D016512:Ankle Injuries / Q000191:economics / Q000453:epidemiology / Q000601:surgery; D003362:Cost-Benefit Analysis / Q000191:economics; D005260:Female; D050723:Fractures, Bone / Q000191:economics* / Q000453:epidemiology / Q000601:surgery*; D015775:Fractures, Stress / Q000191:economics* / Q000453:epidemiology / Q000601:surgery*; D017048:Health Care Costs / Q000706:statistics & numerical data*; D006801:Humans; D007593:Joint Instability / Q000191:economics* / Q000453:epidemiology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D009656:North America / Q000453:epidemiology; D015995:Prevalence; D012307:Risk Factors; D016896:Treatment Outcome; D055815:Young Adult