Cost-Effectiveness of Cement Augmentation Versus No Augmentation for the Fixation of Unstable Trochanteric Fractures

Abstract

Background:A previous randomized controlled trial (RCT) demonstrated a trend toward a reduced risk of implant-related revision surgery following fixation with use of a Proximal Femoral Nail Antirotation (PFNA) with TRAUMACEM V+ Injectable Bone Cement augmentation versus no augmentation in patients with unstable trochanteric fractures. To determine whether this reduced risk may result in long-term cost savings, the present study assessed the cost-effectiveness of TRAUMACEM V+ cement augmentation versus no augmentation for the fixation of unstable trochanteric fractures from the German health-care payer’s perspective.Methods:The cost-effectiveness model comprised 2 stages: a decision tree simulating clinical events, costs, and utilities during the first year after the index procedure and a Markov model extrapolating clinical events, costs, and utilities over the patient’s lifetime. Sources of model parameters included the previous RCT, current literature, and administrative claims data. Outcome measures were incremental costs (in 2020 Euros), incremental quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). Model uncertainty was assessed with deterministic and probabilistic sensitivity analyses.Results:The base-case analysis showed that fixation with cement augmentation was the dominant strategy as it was associated with cost savings (€50.3/patient) and QALY gains (0.01 QALY/patient). Major influential parameters for the ICER were the utility of revision, rates of revision surgery within the first year after fixation surgery, and the costs of augmentation and revision surgery. Probabilistic sensitivity analyses demonstrated that estimates of cost savings were more robust than those of increased QALYs (66.4% versus 52.7% of the simulations). For a range of willingness-to-pay thresholds from €0 to €50,000, the probability of fixation with cement augmentation being cost-effective versus no augmentation remained above 50%.Conclusions:Fixation with use of cement augmentation dominated fixation with no augmentation for unstable trochanteric fractures, resulting in cost savings and QALY gains. Given the input parameter uncertainties, future analyses are warranted when long-term costs and effectiveness data for cement augmentation are available.Level of Evidence:Economic and Decision Analysis Level II. See Instructions for Authors for a complete description of levels of evidence.

Reverse Obliquity Intertrochanteric Femur Fractures: Technical Tips to Avoid Failure

“…Cement application has been proposed as one option, with some studies showing improved quality of life and overall cost-effectiveness in addition to reducing the risk of complications in unstable trochanteric fractures. 28,29 Conversely, in the study by Bohringer et al, 30 cement augmentation did not reduce cutout compared with the conventional non–cemented-augmented blades and was associated with longer operative times and nearly double the cost. Concerns over cement extrusion into the joint during application, longer operative times, and increased costs still remain.…”

Failure of Fixation in Trochanteric Hip Fractures: Does Nail Design Matter?

“…While Joeris et al 51 showed cost savings of $53.35/patient and quality-adjusted life-years (QALYs) gains of 0.01 quality-adjusted life-year/patient, Böhringer et al 16 showed no superiority for the augmented group. Joeris et al 51 assumed a high reintervention rate for the nonaugmented group 7.4% versus 1.6% in the augmented group, based on reported rates by Kammerlander et al 38 This study compared CMN with extramedullary fixation and the nails design in this study did not have rotational control, which might be the reason for the high reintervention reported rate and the reason for the different findings of the cost analyses. Other studies show that cement augmentation might facilitate improved functional outcome in the postoperative period including gait and weight-bearing abilities.…”

“…16 The cost of cement augmentation is not negligible, and conflicting results were published recently regarding the costeffectiveness of cement augmentation. While Joeris et al 51 showed cost savings of $53.35/patient and quality-adjusted life-years (QALYs) gains of 0.01 quality-adjusted life-year/ patient, Böhringer et al 16 showed no superiority for the augmented group. Joeris et al 51 assumed a high reintervention rate for the nonaugmented group 7.4% versus 1.6% in the augmented group, based on reported rates by Kammerlander et al 38 This study compared CMN with extramedullary fixation and the nails design in this study did not have rotational control, which might be the reason for the high reintervention reported rate and the reason for the different findings of the cost analyses.…”

Micro-Structural and Biomechanical Evaluation of Bioresorbable and Conventional Bone Cements for Augmentation of the Proximal Femoral Nail

“…Various biomechanical studies were already able to demonstrate an increase in primary fixation strength compared to non-augmented proximal femoral nails [10]. A randomised clinical trial was able to demonstrate the safety of the augmentation of the femoral head with PMMA with comparable clinical outcomes and increased costeffectiveness due to reduced implant failure rates [13,27].…”