Sanders II/III Calcaneus Fractures in Laborers: A Cost-Effectiveness Analysis and Call for Effectiveness Research.
OBJECTIVE
This study compares the cost and cost-effectiveness of treatments options for Sanders II/III displaced intra-articular calcaneus fractures (DIACFs) in laborers.


METHODS
Literature on Sanders type II and III fractures was reviewed to determine complication rates and utility values for each treatment option. Costs were calculated using Medicare reimbursement and implant prices from our institution. Monte Carlo simulations were used to analyze a decision tree to determine the cost and cost-effectiveness of each treatment from a societal perspective. Sensitivity analysis was performed on all variables.


RESULTS
Minimally invasive open reduction internal fixation (ORIF) (sinus tarsi approach with 4 screws alone) was least expensive ($23,329), followed by nonoperative care ($24,530) and traditional ORIF using extensile lateral approach ($27,963) (P < 0.001); this result was most sensitive to time out of work. Available cost-effectiveness data were limited, but our analysis suggests that minimally invasive ORIF is a dominant strategy, and traditional ORIF is superior to nonoperative care (incremental cost-effectiveness ratio $57,217/quality-adjusted life year).


CONCLUSIONS
Our findings suggest that minimally invasive ORIF (sinus tarsi approach) is the least expensive option for managing Sanders II/III displaced intra-articular calcaneus fractures, followed by nonoperative care. Our cost-effectiveness results favor operative management but are highly sensitive to utility values and are weakened by scarce utility data. We therefore cannot currently recommend a treatment course based on value, and our primary conclusion must be that more extensive effectiveness research (ie, health-related quality of life data, not just functional outcomes) is desperately needed to elucidate the value of treatment options in this field.


METHODS
Economic Level III. See Instructions for Authors for a complete description of levels of evidence.
*Department of Orthopaedics, University of North Carolina Hospital, Chapel Hill, NC;†Division of Sports Medicine, Boston Childrens Hospital, Boston, MA; and‡UNC Eshelman School of Pharmacy, Chapel Hill, NC.
R Carter
RC
Clement
Pamela J
PJ
Lang
Brett J
BJ
Pettett
Robert A
RA
Overman
Robert F
RF
Ostrum
Joshua N
JN
Tennant
D000328:Adult; D064386:Ankle Fractures / Q000191:economics* / Q000453:epidemiology / Q000601:surgery*; D002111:Calcaneus / Q000293:injuries / Q000601:surgery; D057186:Comparative Effectiveness Research / Q000379:methods; D003362:Cost-Benefit Analysis / Q000191:economics; D005260:Female; D005592:Fracture Fixation / Q000191:economics* / Q000706:statistics & numerical data; D017048:Health Care Costs / Q000706:statistics & numerical data*; D006365:Heel; D006801:Humans; D007103:Immobilization / Q000706:statistics & numerical data*; D057072:Intra-Articular Fractures / Q000191:economics* / Q000453:epidemiology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D019057:Quality-Adjusted Life Years; D014481:United States / Q000453:epidemiology; D055815:Young Adult