Tubular vs Anatomically Contoured Low-Profile Fixation of Isolated Weber B Distal Fibula Fractures: A Cost Analysis

Research Type: Level 4 – Case series Introduction/Purpose: Isolated Weber B distal fibula fractures are common injuries that commonly require surgical fixation, with implant choice representing a significant modifiable cost. In general, newer anatomically contoured low-profile plates are considerably more expensive in terms of up-front cost when compared to the older tubular plates. However, up-front costs may not tell the entire story of the total cost of care. The cost of secondary procedures, specifically that of removal of hardware (ROH) in the case of prominent, painful hardware must be considered. In this study, we aimed to determine the true cost of care across the full episode of care, as well as the break-even point for frequency of hardware removal that would make anatomically contoured low-profile fixation cost-effective. Methods: Older tubular 7-hole plates, 3.5mm non-locking screws, and 3.5mm locking screws. The constructs that were compared were: anatomically contoured 7-hole plate, three 3.5mm non-locking screws, and three 3.5mm locking screws versus tubular 7-hole plate, three 3.5mm non-locking screws, and three 3.5mm locking screws. Cost per minute of ambulatory surgical center time was determined based on the literature and adjusted for inflation. Based on prior surgical experience, a surgical time (incision to close) for ROH was estimated at 30 minutes. The rate of ROH of the tubular plate constructs needed for cost break-even with the anatomically contoured plate constructs was determined for each company and for the average across all three companies. Results: Across all companies, the cost of older construct ranged from $1,477 to $3,526 compared to $2,377 to $5,758 for the newer construct. The average cost of the older and newer constructs were $2,654 and $4,113, respectively. With a 30-minute operative time, the ROH rate needed to break-even when using the anatomically contoured plate construct versus the traditional tubular plate construct ranged from 63% to not possible (i.e., >100% ROH rate). When the cost data were averaged, no ROH rate (i.e., >100% ROH rate) would allow for break-even if an anatomically contoured plate construct was used instead of a traditional tubular plate construct. Conclusion: In an era where the cost is under substantial scrutiny, a comprehensive understanding of cost in the management of ankle fractures is warranted. Our work identifies the cost of managing operatively managed isolated Weber B ankle fractures across three implant companies and the ROH rate of older tubular constructs needed to make the use of anatomically contoured cost-effective. These findings highlight that prior studies may not be nuanced enough to truly understand the cost ramifications of different constructs, as several factors, such as operative time and implant company, impact the cost-effectiveness.