Evaluation of treatment options for fractured tibia

Objectives: To evaluate the cost-effectiveness of casting, casting plus low-intensity pulsed ultrasound, or intramedullary (IM) nailing for fresh tibial fractures at risk of non-union. To evaluate the cost-effectiveness of surgery and ultrasound for non-unions. Methods: Economic analysis, including all direct costs incurred by the NHS in the period from first surgical intervention to 12 months post-intervention. Costs and outcomes (fractures healed within 12 months) were modelled using probabilities of healing derived from the literature. Results: For patients at particular risk of non-union (such as smokers), reamed IM nailing produces better expected outcomes than casting alone (91.5% healed compared with 89.2%), but at a higher cost (£6264 per patient vs £4351). The incremental cost of IM nailing is £83 200 per additional fracture healed. The combination of ultrasound and casting is a dominant option compared with IM nailing or casting alone, assuming that the addition of ultrasound improves healing by more than 25% compared with casting alone. The literature is consistent with an improvement of around 60%. Where the nature of the fracture allows, the most cost-effective strategy for non-unions is to postpone surgery and try a course of ultrasound first. Expected cost with surgery is £6718 compared with £3926 for ultrasound. Expected healing is the same in both cases. Conclusions: From an NHS perspective, adjunctive ultrasound offers a cost-effective choice for patients at particular risk of non-union, and for non-union fractures which are stable and well-aligned.