Prevalence, Management and Resource Utilization of Operative and Non-Operatively Managed Scaphoid Fractures
Rachel C. Hooper, MD, Department of Surgery, Plastic Surgery, HENRY FORD HOSPITAL, Detroit, NY, Abigail Teitelbaum, BA, HENRY FORD HOSPITAL, Detroit, MI, Yuan Zeng, BS, Michigan Medicine, Ann Arbor, MI, Kevin C. Chung, MD, MS, Section of Plastic Surgery, University of Michigan, Ann Arbor, MI and Lu Wang, PhD, University of Michigan, Ann Arbor, MI
Introduction: Surgical intervention for scaphoid fractures varies based on the location of the fracture and perceived vascularity and quality of the bone. Regardless of treatment, certain fractures are susceptible to non-union and subsequent debilitating wrist arthritis. Using a large national database, we investigated (1) the prevalence of operative and non-operative management of scaphoid fractures, (2) the rate of non-union, and (3) resource utilization among the respective groups. We hypothesize that smoking is a significant risk factor towards the development of non-union and contributes to increased costs in the care of these patients.
Methods: We used the 2009-2017 Truven Marketscan Research Databases to identify patients with closed scaphoid fractures. Patients were divided into operative and non-operative groups based on CPT codes. We followed patients for 24 months and performed a Chi-squared analysis of individual patient demographics and used an analysis of variance test to determine resource utilization among these patients.
Results: A total of 36, 611 patients with scaphoid fractures were identified; 30,143 were managed non-operatively and 6,468 were managed operatively. Non-union was diagnosed in 500 (1.66%) non-operatively managed patients. When comparing patients with routine healing and nonunion, 12% of the patients with non-union, were smokers (p=0.001). Smoking did not appear to be prohibitive for surgery; non-union developed in 1,211 (19%) operative patients and of these, 142 (12%) were smokers. The prevalence of non-union among operatively managed patients who were smokers, increased with greater complexity of the surgical procedure: ORIF (11%), ORIF w bone graft (9%), ORIF with pedicled vascularized bone graft (VBG) (14%) and ORIF with VBG + microvascular anastomosis (21%). When considering the cost of clinic and occupational therapy (OT) visits, imaging (X-ray, CT, MRI), and surgery (when applicable), the mean overall costs increased significantly when non-union developed; the mean cost to care for a non-operative patient with routine healing was $10,967 compared to a mean cost of $33,166 for patients who underwent vascularized bone graft and had persistent non-union, p<0.001.
Conclusion: Smoking increases the rate of non-union among operative and non-operatively managed patients; increasing complexity of surgery among these patients necessitates increased use of healthcare resources for surgery and perioperative care. If surgeons cannot avoid operating on smokers with scaphoid fractures, decreasing the frequency of imaging and employing more home-based OT, can be an avenue to decrease cost.
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