An Economic Evaluation of Operative Compared with Nonoperative Management of Displaced Intra-Articular Calcaneal Fractures

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 Can19, 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 Can2800 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.