title: The service impact of failed locking plate fixation of distal tibial fractures: a service and financial evaluation at a major trauma centre.
abstract: BACKGROUND
  The surgical treatment of distal tibial fractures is challenging and controversial. Recently, locking plate fixation has become popular, but the outcomes of this treatment are mixed with complication rates as high as 50 % in the published literature. There are no reports specifically relating to the financial and resource costs of failed treatment in the literature.
  
  
  METHODS
  Retrospective service analysis of patients who had undergone locking plate fixation of a distal third tibial fracture between 2008 and 2011 with at least 12 months follow-up. Rates of readmission, reoperation, bony union and infection were ascertained. The financial and resource (hospital stay and number of outpatient appointments) implications of failed treatment were calculated.
  
  
  RESULTS
  Forty-two patients were identified. There were 31 type A fractures, one type B fracture and 10 type C fractures. Three injuries were open. Twenty patients were treated with minimally invasive percutaneous osteosynthesis (MIPO). The readmission and reoperation rates were 26 % (n = 11) and 19 % (n = 8), respectively. A total of 89 % of readmissions were due to infection. All patients had received appropriate antibiotic regimens. The average costs of successful and failed treatment were £ 5538 and £ 18,335, respectively. The average time to union was 24.5 weeks. The rate of non-union was 21 % (n = 9). The rate of infection was 28 % (n = 12), with all patients with open fracture incurring an infection. Tourniquet time had no effect on the incidence of complications. Smokers were more likely to incur a complication (p < 0.05), and non-union was lower in the MIPO group (p < 0.05). The length and total cost of inpatient care were significantly lower in the MIPO group (p < 0.05). MIPO patients were five times less likely to incur readmission or reoperation. Failed treatment was three times more expensive and four times longer than successful treatment.
  
  
  CONCLUSIONS
  The study identified a large burden to the service following failure of locking plate treatment of these fractures, but the outcomes were similar to series published in the literature. Readmission rates were high following these injuries, and failed treatment was costly and had a significant impact on hospital resources. The implementation of major trauma networks and centralised subspecialised units should improve quality and value for money.
authors.affiliation: Department of Trauma and Orthopaedics, University Hospital Southampton, Tremona Road, Southampton, Hants, SO166YD, England, UK. mikekent@doctors.org.uk.|Department of Orthopaedics, Fremantle Hospital, Alma Street, Fremantle, 6160, Australia. mikekent@doctors.org.uk.
authors.forename: Michael
authors.identifier: http://orcid.org/0000-0002-0574-3618
authors.initials: M
authors.lastname: Kent
authors.affiliation: Department of Trauma and Orthopaedics, University Hospital Southampton, Tremona Road, Southampton, Hants, SO166YD, England, UK.
authors.forename: Aadil
authors.initials: A
authors.lastname: Mumith
authors.affiliation: Department of Trauma and Orthopaedics, University Hospital Southampton, Tremona Road, Southampton, Hants, SO166YD, England, UK.
authors.forename: Jo
authors.initials: J
authors.lastname: McEwan
authors.affiliation: Department of Trauma and Orthopaedics, University Hospital Southampton, Tremona Road, Southampton, Hants, SO166YD, England, UK.
authors.forename: Nicholas
authors.initials: N
authors.lastname: Hancock
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001860:Bone Plates / Q000191:economics*; D003365:Costs and Cost Analysis; D005260:Female; D005593:Fracture Fixation, Internal / Q000191:economics*; D005597:Fractures, Open / Q000191:economics / Q000601:surgery; D006801:Humans; D008297:Male; D008875:Middle Aged; D011475:Prosthesis Failure; D012189:Retrospective Studies; D013978:Tibial Fractures / Q000191:economics / Q000601:surgery*; D014193:Trauma Centers / Q000191:economics; D016896:Treatment Outcome
keywords: Distal tibial fracture; Economic analysis; Locking plate; Pilon fracture