Cost-Effectiveness of Open Reduction Internal Fixation versus Total Elbow Arthroplasty for Distal Humerus Fractures
Andrew Federer, MD, Richard Mather III, MD; Grant Garrigues, MD
Duke University, Durham, NC
Introduction: Total elbow arthroplasty (TEA) and open reduction internal fixation (ORIF) are two viable surgical treatment options for acute distal humerus fractures in non-arthritic patients over the age of 60. Recent systematic reviews and randomized trials suggest that TEA and ORIF result in similar functional outcome scores, with TEA perhaps having decreased reoperation rates in patients with complex distal humerus fractures not amenable to stable fixation. This study compared the cost-effectiveness of TEA and distal humerus ORIF this specific demographic.
Methods: A Markov decision model was constructed for a cost-utility analysis of TEA compared to distal humerus ORIF in a cohort of 60-year-old patients. Outcome probabilities and effectiveness were derived from the highest-level data available from the current literature. A retrospective chart review was performed to obtain demographic and operative data from elderly patients who underwent TEA or distal humerus ORIF from two institutions over a 15-year period. Inclusion criteria were age of 60 years at time of surgery and acute, intra-articular distal humerus fracture. Exclusion criteria included pre-existing elbow arthritis, rheumatoid arthritis and lack of prospectively gathered outcome scores. Charts were reviewed and patients were asked to have their outcomes evaluated in the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, the Mayo Elbow Performance Score (MEPS), and the European quality of life, 5 Domains (EQ5D). After inclusion criteria were met and patients were contacted for follow up, there were 24 patients included in the study. Effectiveness of each procedure was expressed in quality-adjusted life years (QALYs) gained. Principal outcome measures were average incremental costs, incremental effectiveness, incremental QALYs, and net health benefits.
Results: TEA is a more expensive procedure than ORIF, but has an overall improvement in utility with respect to ORIF. In this demographic, when the cost of TEA approaches ORIF, the utility favors TEA. The TEA QALY is 0.779 (STD 0.117) and the ORIF QALY is 0.797 (STD 0.13). TEA has greater QALY, leading to an incremental cost effectiveness ratio of $3128/QALY, which favors TEA. The largest driver of difference in utility is the number of people living in limited benefit state after ORIF, which is often by way of an increase in number of revision surgeries.
Conclusion: TEA is a cost-effective procedure, resulting in greater utility for the elderly patient compared to distal humerus ORIF. These findings suggest that TEA is the preferred treatment for elderly patients who sustain distal humerus fractures.
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