Review Question - QID 5830

In healthy adults with a completely displaced midshaft clavicle fracture, initial open reduction and internal fixation (ORIF) leads to decreased nonunion rates. However, the costs associated with this treatment and its possible complications are significantly greater than the cost of initial nonoperative treatment with a sling and delayed surgery if necessary.

Midshaft clavicle fractures represent 80-85% of all clavicle fractures and often occur as result of direct trauma or fall on an outstretched arm. Treatment of this injury with primary ORIF versus nonoperative care with a sling is a controversial topic with respect to patient-reported functional outcomes. The current literature reports higher rates of nonunion in those managed non-operatively. Economic evaluation of these treatments, using data from randomized controlled trials (RCTs), has demonstrated that ORIF is more costly compared to nonoperative treatment. The reported cost difference, accounts for both the costs of the initial treatment and costs incurred as a result of the treatment of complications, which includes delayed surgery rates for those initially managed non-operatively and re-operation rates for those initially managed with ORIF.

Robinson et al. conducted a mullticenter, single blinded, RCT with 200 patients comparing primary ORIF versus nonoperative treatment. The rate of nonunion was significantly reduced with ORIF (relative risk = 0.07; p = 0.007). Although patient-reported functional outcomes appeared to be superior in those undergoing primary ORIF, this effect vanished when those with nonunions were removed from the analysis. Costs were significantly greater for those treated with primary ORIF (p < 0.0001).

Rehn et al. performed a systematic review of RCTs comparing operative versus nonoperative treatment for displaced midshaft clavicle fractures. They found that ORIF leads to fewer nonunions but more minor complications compared nonoperative treatment. Additionally, they concluded that the effect of ORIF on functional outcomes remains controversial.

Walton et al. utilized data from four RCTs to conduct a decision analysis with respect to costs (from the perspective of a single payer: adjusted 2013 Medicare rates) for ORIF versus nonoperative management. Reoperation and delayed surgery for those treated with ORIF and those treated nonoperatively, respectively, were defined as the end-points. The expected cost for ORIF was $14,763.21 compared with $3,112.65 for nonoperative treatment, yielding a cost savings of $11,650.56 for nonoperative treatment.

Incorrect Answers:
Answer 1: ORIF leads to increased, not decreased healthcare costs compared with nonoperative treatment.
Answer 2: ORIF leads to increased, not similar healthcare costs compared with nonoperative treatment.
Answer 4: ORIF leads to decreased, not similar nonunion rates and increased not decreased costs compared with nonoperative care.
Answer 5: ORIF leads to decreased, not similar nonunion rates compared with nonoperative care.