Background: The choice of therapy for a displaced intra-articular
calcaneal fracture has long been a source of uncertainty in orthopaedic
surgery, both in terms of the impact of the therapy on clinical outcomes and
on health-care and non-health-care costs. We performed an economic evaluation,
based on the results of a randomized clinical trial, to evaluate the economic
implications of operative compared with nonoperative management of this
fracture.
Methods: An economic evaluation was performed, with use of a
four-year time horizon, to determine the effect on costs and health benefits
of operative compared with nonoperative management for a group of patients
with displaced intra-articular fractures of the calcaneus. The complication
rate, arthrodesis rate, survival data, and health-outcome data were estimated
prospectively from a recent randomized clinical trial. Direct health-care
costs and indirect costs (the cost of time lost from work) were estimated
retrospectively from the center treating the majority of the patients.
Results: Operative management resulted in a lower rate of subtalar
arthrodesis and a shorter time off from work compared with nonoperative
treatment. When indirect costs, such as the time lost from work, were included
in the analysis, operative management was less costly (an average savings of
Can$19,000 per patient) and more effective, thus making it the preferred
strategy. The result was most sensitive to the estimates of the costs of time
lost from work. When these costs were excluded, operative treatment remained
more effective, but with an increased average cost of Can$2800 per
patient.
Conclusions: Calcaneal fractures have been recognized as having
relatively poor clinical outcomes and a major socioeconomic impact with regard
to time lost from work and recreation. Our analysis suggests that operative
management of displaced intra-articular fractures is economically attractive.
However, further exploration of the impact and valuation of time lost from
work and patient outcomes is required.
Level of Evidence: Economic and decision analysis, Level
II. See Instructions to Authors for a complete description of levels of
evidence.