Intramedullary nailing versus external fixation for open tibia fractures in Tanzania: a cost analysis

Abstract Objectives: Open tibia fractures pose a clinical and economic burden that is disproportionately borne by low-income countries. A randomized trial conducted by our group showed no difference in infection and nonunion comparing 2 treatments: external fixation (EF) and intramedullary nailing (IMN). Secondary outcomes favored IMN. In the absence of clear clinical superiority, we sought to compare costs between EF and IMN. Design: Secondary cost analysis. Setting: Single institution in Tanzania. Patients/Participants: Adult patients with acute diaphyseal open tibia fractures who participated in a previous randomized controlled trial. Intervention: SIGN IMN versus monoplanar EF. Main Outcome Measurements: Direct costs of initial surgery and hospitalization and subsequent reoperation: implant, instrumentation, medications, disposable supplies, and personnel costs. Indirect costs from lost productivity of patient and caregiver. Societal (total) costs: sum of direct and indirect costs. All costs were reported in 2018 USD. Results: Two hundred eighteen patients were included (110 IMN, 108 EF). From a payer perspective, costs were $365.83 (95% CI: $332.75–405.76) for IMN compared with $331.25 ($301.01–363.14) for EF, whereas from a societal perspective, costs were $2664.59 ($1711.22–3955.25) for IMN and $2560.81 ($1700.54–3715.09) for EF. The largest drivers of cost were reoperation and lost productivity. Accounting for uncertainty in multiple variables, probabilistic sensitivity analysis demonstrated that EF was less costly than IMN from the societal perspective in only 55% of simulations. Conclusions: Intramedullary nail fixation compared with external fixation of open tibia fractures in a resource-constrained setting is not associated with increased cost from a societal perspective.