A systematic review of cost-effectiveness, comparing traction to intramedullary nailing of femoral shaft fractures, in the less economically developed context

Abstract

IntroductionFemoral shaft fractures carry considerable morbidity and are increasingly common in less economically developed countries (LEDCs). Treatment options include traction and intramedullary (IM) nailing but in a limited-resource environment; cost-effectiveness is fundamental to policy development.The objective herein was to evaluate the cost-effectiveness of moving from traction to IM nailing for femoral shaft fractures, in adults, in LEDCs. Incorporating a systematic review of complications and functional outcomes and a cost-minimization analysis.MethodsPubMed, EMBASE, Africa Journals Online and the Cochrane Library were searched from inception using the terms: femur* AND fracture AND traction AND (sign OR nail* OR intramedullary) AND (cost-effectiveness OR cost* OR outcome OR function) NOT paed* NOT child* NOT elastic NOT neck NOT intertrochanteric NOT periprosthetic (where asterisks indicate an unlimited truncation strategy). Abstracts were reviewed for all titles returned and full texts obtained as indicated. References of all relevant papers were also examined for further studies.ResultsIM nailing has been successfully used in several institutions and reported infection, union and reoperation rates are encouraging, although no randomised control trials were identified. Three studies assessed the cost aspect and all found IM nailing to be the cheaper strategy.ConclusionTo date, the improved complication profile and reduced cost of treatment suggest that IM nailing is more cost-effective than traction. Evidence, however, is limited and the necessity for appropriate training and audit with the introduction of new techniques must be emphasised.

Outcome at 1 year in patients with femoral shaft fractures treated with intramedullary nailing or skeletal traction in a low-income country: a prospective observational study of 187 patients in Malawi

“…However, nonoperative treatment using skeletal traction (ST) for at least 6 weeks remains the mainstay treatment for these fractures in low-resource settings (Hollis et al 2015, Kramer et al 2016. Nonoperative treatment is associated with increased risk of both medical and surgical complications, reported as high as 55% in some studies (Bucholz and Jones 1991, Doorgakant and Mkandawire 2012, Kramer et al 2016, Parkes et al 2017.…”

“…In Malawi, femoral shaft fractures are most commonly treated by ST. IMN, when performed, is done using the SIGN IM nail, which is donated by SIGN Fracture Care International (Richland, WA, USA) (Shah et al 2004). Most studies comparing IMN with ST in LICs used conventional measures such as fracture union, complications, and range of motion (Swai 2005, Kamau et al 2014, Parkes et al 2017. No prior study has measured quality of life or function using a validated patient-reported outcome instrument to compare ST and IMN in any context.…”

Treatment of pediatric diaphyseal femoral fractures with intramedullary fixation

“…At present, the authors point to an increase in treatment costs. This is due to increasing perioperative costs and high costs of the implants [20]. Consequently, the growing group of supporters includes more and more traumatologists using stainless steel intramedullary nails.…”

Peculiarities of Locked Intramedullary Nailing in A Deprived Setting

“…Sadly, in LMICs only a small percentage of patients have access to locked IM nailing [9,10]. Less than optimal methods of treatment like prolonged traction and treatment by traditionalists is still common-place [6,[11][12][13].…”