Session IV Scientific Basis for Fracture Care

Reuse of External Skeletal Fixator Components: Effectiveness in Reducing Cost and Effects on the Incidence of Fixator-Related Complications

Douglas R. Dirschl, MD, Ilyse Smith, RN

University of North Carolina School of Medicine, Wake Medical Education Institute, Raleigh, NC

Introduction: External skeletal fixators can provide a simple, effective, and predictable means for stabilizing selected fractures. One disadvantage of these devices, however, is their greater cost compared to devices for internal fixation, such as plates and screws. Virtually all external fixation devices are manufactured, marketed and sold as single-use items. The manufacturers of these devices state that patient safety may be jeopardized if the devices are reused, yet their own mechanical testing data show the devices to be mechanically sound for periods many times greater than that of a single clinical use. The goal of the present study was to assess the cost-effectiveness of a specific program of reuse of external fixator components at a trauma center and compare the rates of fixator-related complications before and after institution of the re-use program.

Material and Methods: In July, 1994, a program for the reuse of selected components of external fixation devices was initiated at a level 2 trauma center. Following removal from the patient, each fixator was returned to the operating room (OR), where it was cleaned and thoroughly examined by a single registered nurse responsible for the purchase and maintenance of orthopaedic trauma equipment. Components in good repair were placed back into the OR stock for reuse after replacement of cams and bearings, while components showing specific signs of wear were discarded. External fixator pins, wires, and other items that were clearly one-use-only were excluded from the program. The medical center agreed to bill patients only the hospital's cost for reusable components of external fixators stocked in the OR, while components not reusable or not stocked by the OR were charged to the patient with the standard mark-up. Inpatient and outpatient follow-up data was collected for all external fixators applied in the 15 months prior to and following institution of the reuse program (69 and 65 fixators, respectively).

Results: The overall mean hospital charge for an external fixator decreased 46% as a result of the re-use program (from $4,067 to $2,791). For the two fractures most commonly treated with external fixation, the distal radius and tibial plafond, the mean hospital charge for a fixator decreased 44% and 29%, respectively (from $3,629 to $2,024 for the distal radius and from $5,185 to $3,671 for the distal tibia). The overall hospital cost for external fixators decreased 34% during the study period, from $128,614 prior to reuse (a mean of $1,864 per fixator) to $79,463 after reuse (a mean of $1,225 per fixator). There was no difference in the rate of reoperation or the incidence or severity of complications prior to and following institution of the reuse program. The number and types of fractures treated were similar during the two study periods. The rate of pin track infection was unchanged following institution of the reuse program. No patient had loss of fracture reduction due to mechanical failure of a new or reused external fixator body during either of the study periods.

Conclusions: Reuse of selected external fixator components according to a standardized protocol was easy to perform, resulted in a substantial decrease in hospital costs and charges for these devices, and did not lead to increased rates of reoperations, complications, or mechanical failures. The preliminary results of this program in a single trauma center with a single registered nurse responsible for examining and refurbishing the devices prior to reuse are encouraging. Although the charge for an external fixation device is only a small portion of the total hospital cost for fracture care, reuse of carefully selected external fixator components can contribute to lowering costs without increasing the incidence of complications. We believe the ability to provide high quality care of fracture patients with minimal complications that simultaneously lowers costs will become essential for the continued success of institutions treating trauma in the current environment of reduced funding for the medical care of all patients.