Session III - Polytrauma

Thurs, 10/20/05 Polytrauma, Paper #6, 3:40 pm

Reuse of External Fixation Components: A Prospective Randomized Trial

Paul Tornetta, III, MD; Thomas A. Einhorn, MD; William R. Creevy, MD; Rafael Levin, MD; Jodi Siegel, MD; Jinsil Sung, MD; (n-all authors)
Boston University Medical Center, Boston, Massachusetts, USA

Introduction: External fixation use has increased over the past decade with the advent of two-stage protocols for fixation of complex periarticular injuries, the concepts of damage control, and the increase in operative management of distal radius fractures. These devices are sold in the United States as single-use devices and are expensive. Approved processes for refurbishment of the nonimplantable components are now available. We prospectively evaluated one such program for safety, efficacy, and the fiscal ramifications in an IRB-approved prospective randomized trial.

Methods: Over a 30-month period, 313 external fixators were placed at our institution. Of these, 94 patients were entered into a prospective randomized trial of new versus refurbished external fixation components for their injury (all pins were new). The vast majority of the 219 patients who did not enter the study were offered entry and refused; 41 were not able to consent. The frames were evaluated at the time of removal for efficacy, and all complications were recorded prospectively to document safety.

Results: The injuries treated and the costs of the entire frame (including the pins) based on the hospital purchasing department information are shown in Table 1. With the numbers of patients in our study, we found no difference in the incidence of pin tract infections (45% versus 52%), loss of fixation (3% versus 4%), or loosening of the components (both 1%). Three patients in each group lost reduction due to loss of frame tightness or pin motion and required revision or removal.

Table 1: Injuries Treated and Cost Savings

 Injury (n)  New Frame (n)  Reused Frame (n)  New Frame Cost $  Reused Frame Cost $  Actual Savings $
 Distal Radius (48)  25  23  $2120  $982  $26,174
 Pilon (29) 15  14  $2741  $1225  $21,224
 Plateau (19)  10  9  $3614  $1608  $18,054
 Total (96)  50  46      $65,452

The fiscal impact of the program was substantial, with actual savings of $65,452 (the difference in the new and refurbished frames for the actual number of patients receiving refurbished frames). Overall, a refurbished frame was 54% less than a new one. If a program such as this were implemented for all patients, the potential savings can be determined using several assumptions. First, the new components must be purchased for the first use at the standard rate. Approximately 20% of the components are discarded and cannot be refurbished. The other 80% can be refurbished at a per component savings of 55%. Thus if the entire population of patients agreed to enter such a program, a cost savings of 25% could be realized. This represents a 55% savings on the 44% of patients that could be treated with a refurbished frame, accounting for component dropout. In our institution, with 313 patients seen over the study period, the total possible savings would be 55% of the cost of 139 frames. Using the injury patterns we treated, this would amount to a savings of $208,262.

Conclusions: Most patients do not wish to have a frame with refurbished clamps if given the choice. Our study demonstrated that this type of program is safe and effective in treating injuries and yielded an actual cost savings of $65,452. The potential savings of such a program is maximally 25% of the cost of all new frames. We recommend further patient education about health care costs and the need to control them in addition to the exploration of avenues to refurbish frame components.

If noted, the author indicates something of value received. The codes are identified as a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options; e-consultant or employee; n-no conflicts disclosed, and *disclosure not available at time of printing.