Abstract In this article the costs and effectiveness of introducing the SIGN nailing system for femoral shaft fractures in a provincial trauma hospital in Cambodia are compared to those of Perkin&apos;s traction treatment. At an average cost per patient of $1,107 in the traction group and $888 in the nail group (p&lt;0.01), and with better clinical outcomes in the nail group, internal fixation is more costeffective than conservative treatment

Lew Zirkle

Merja Heitto

Richard A Gosselin

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ORIGINAL PAPER
Cost-effectiveness of replacing skeletal traction
by interlocked intramedullary nailing for femoral shaft
fractures in a provincial trauma hospital in Cambodia
Richard A. Gosselin & Merja Heitto & Lew Zirkle
Received: 31 December 2008 /Revised: 23 April 2009 /Accepted: 23 April 2009 /Published online: 13 May 2009
# The Author(s) 2009. This article is published with open access at Springerlink.com
Abstract In this article the costs and effectiveness of
introducing the SIGN nailing system for femoral shaft
fractures in a provincial trauma hospital in Cambodia are
compared to those of Perkin’s traction treatment. At an
average cost per patient of $1,107 in the traction group and
$888 in the nail group (p<0.01), and with better clinical
outcomes in the nail group, internal fixation is more cost-
effective than conservative treatment.
Introduction
Economic development in low-income countries is accom-
panied by an increase in the burden of trauma, particularly
injuries due to road traffic accidents [8]. It also provides the
opportunity to improve on the management of some of
those injuries, such as fractures of the femur. Skeletal
traction or closed manipulation and casting remain the most
common treatments of long bone fractures in resource-poor
settings. The literature from developed countries is replete
with studies showing better functional outcomes with
locked intramedullary nails for femoral [10, 16] and tibial
[2, 4, 15] fractures over conservative management, even in
the adolescent population [12]. In poor countries, lack of
human and material resources, and an often unsafe surgical
environment, may preclude internal fixation of long bones
[11]. Femoral shaft fractures are thus treated with skeletal
traction with its known complications of prolonged bed rest
and hospitalisation, along with pin tract infections, decubi-
tus ulceration, malunion/nonunion and shortening [5].
The Kingdom of Cambodia, in south-east Asia, has a
population of around 14 million people, with a per capita
nominal GDP of $606, which is slowly but steadily
increasing. Battambang, the capital of the northwest
province of the same name, is the second largest city in
the country with a population slightly over a million. All
major injuries from the province are treated at the
Emergency Surgical Centre, a hospital almost exclusively
devoted to trauma [6]. Emergency is an Italian non-
governmental organisation (NGO) that provides surgical
care to all, free of charge. Until recently, all adolescent and
adult femoral shaft fractures were treated with Perkin’s
skeletal traction, allowing early knee mobilisation but
requiring a minimum of six weeks in bed [5]. In early
2007, the Surgical Implant Generation Network (SIGN)
nailing system was introduced. It is a solid nail, designed to
be inserted without image intensification, fracture table or
powered reaming, thus specifically adapted to resource-
poor environments. An external jig allows proximal and
distal interlocking. The nail has a typical tibial nail
configuration, but is also used for femurs and humeri,
simplifying significantly the necessary inventory.
The purpose of this paper was to try to compare the costs
and the change in outcomes (if any) from this transition.
Economic evaluations, such as a cost-effectiveness analysis
(CEA), are widely used tools in developed countries to
compare different interventions or strategies [1, 3, 7, 13].
Although the World Health Organisation (WHO) has
published standard guidelines for CEAs, there is a dearth
International Orthopaedics (SICOT) (2009) 33:1445–1448
DOI 10.1007/s00264-009-0798-x
R. A. Gosselin (*)
School of Public Health, University of California at Berkeley,
Berkeley, CA, USA
e-mail: froggydoc@comcast.net
M. Heitto
Emergency Hospital,
Battambang, Cambodia
L. Zirkle
Surgical Implant Generation Network (SIGN),
Richland, WA, USA
of such studies in low income countries [14]. The purpose
of a CEA is to assess the relative value of one intervention
over another, for a given problem or condition. One
intervention is more cost-effective if: (1) it is less costly
with an equal or better outcome, (2) it is less costly with a
worse outcome, but the added benefit of the alternative is
not worth the extra cost, or (3) it is more costly with better
outcomes, and the added benefit is worth the added cost
[13]. When is added benefit worth the added costs? The
answer depends on availability of human and material
resources, and also moral, economical, legal and societal
values.
Materials and methods
Only isolated fractures of the femoral shaft not involving
either metaphyses were included. At the time of data
collection, the first 49 consecutive SIGN nails had a follow-
up of at least 16 weeks. The last 50 consecutive patients
with femoral shaft fractures treated in skeletal traction
formed the comparison group, so as to minimise the effect
of time on costs. The hospital records, X-ray files and
outpatient records were reviewed for all patients and data
collected for age, sex, type of fracture, time of fracture, time
in traction, length of hospital stay (LOS), weight bearing
status at discharge and fracture healing at last follow-up. Of
the 49 nails, 38 were inserted for fresh fractures
(i.e. less than six weeks), including one tibial nailing which
was excluded, and 11 for nonunion, including three tibial
nails. These nonunions were excluded from the analysis,
leaving 87 patients aged 14 years or more, with 89 femoral
shaft fractures, covering a seven-month period.
A nonunion was diagnosed in the traction group if at
last follow-up (minimum four months, mean 6.5 months)
the fracture was still mobile clinically and there was little
or no progress in radiological consolidation. In the nail
group it was diagnosed if at last follow-up (minimum
four months, mean 5.5 months) there was little or no
progression of callus on X-rays, or evidence of hardware
failure. A malunion was diagnosed if a fracture had
healed with a 20-degree or more angulation in any plane,
a 20-degree malrotation or shortening of more than 2.5
cm. Other recorded complications included superficial
(above fascia) or deep (below fascia) infections, and
nerve damage.
Fixed costs such as infrastructure costs and depreciated
costs for initial equipment were the same for both groups.
Variable costs were different; they included hospital per
diem, operating room time, equipment, use of blood
products, physiotherapy, X-rays, and supplies such as
dressings, drugs and/or orthotics. The vast majority of
patients were farmers, often sustenance farmers with no
fixed income, so it was not possible to factor in societal
costs, such as lost wages. All costs are from the payer/
provider perspective. Unfortunately, because of the retro-
spective nature of the study, no data were collected about
time to return to normal daily activities.
Statistical analysis was done using the Stata I/C 9.0
software package, with significance at p<0.05.
Results
There were no hospital deaths in either group. Mean age,
mean time since injury, proportion of open versus closed,
and simple versus comminuted fractures were not statisti-
cally different between groups. In the Perkins traction
group, 50 patients with 52 femoral fractures had a mean
length of stay (LOS) of 52.3 days, with a mean time in
traction of 45.6 days. Of the 37 patients in the nail group,
there were eight who were already in Perkins traction when
the SIGN program was started, and before the backlog
was cleared, some new patients were put in temporary
traction for a longer period than those toward the end of
the series. The average LOS for this group was 34.9 days,
with an average time in traction of 20.7 days and an
average LOS after nailing of 14.2 days. These results are
summarised in Table 1. At the time of discharge, eight of
50 patients (16%) in the traction group and 21 of 37
patients (57%) in the nail group were fully weight
bearing (p<0.001), as shown in Table 2. The mean length
of nailing surgery was 2.5 hours, which reflects the
repeated learning curve of rotating surgeons. A total of
29 of 37 nails were inserted in an antegrade fashion, and
all but one were statically interlocked using all four screw
holes, another reason for prolonged surgery time. Of
interest is that, even if they are excluded from the study,
the 11 nailings for nonunion, six of which were Emergen-
cy patients that had failed Perkins treatment, averaged 3.8
Table 1 Data summary for traction and nails groups
Variable Traction Nails
Patients 50 37
Fractures 52 37
Mean age (years) 33.6 (14–72) 32.1 (14–68)
Femurs 52 37
Closed/open 36/16 30/7
Simple/Comminuted 16/36 16/21
Mean time since injury (days) 3.1 (0–35) 3.7 (1–42)
Mean length of stay (LOS) (days) 52.3 34.9
Mean time in traction (days) 45.6 20.7
Mean length of surgery (hours) – 2.5
1446 International Orthopaedics (SICOT) (2009) 33:1445–1448
hours in operative time. For the fresh fractures, the pre and
post-op Hb averaged 11.1 and 8 gms, respectively, and 22
patients in the nail group received an average of 2.5 whole
blood units.
Medical records and complete X-ray files were available
for 46 patients in the Perkins group and 36 patients in the
SIGN group. The 46 traction patients had 46 fractures, 34
of them (74%) showing clinical and radiological signs of
consolidation, ten (22%) signs of delayed or nonunion and
two (4%) malunions. A total of 33 of the 36 (92%) of the
nailed femurs showed radiological evidence of advanced or
complete healing and only three (8%) did not show
significant amounts of callus on X-rays (p<0.001). All three
had static interlocking with some amount of distraction.
Outcomes are summarised in Table 3.
The total costs in $US are summarised in Table 4. Costs
incurred in Euros or in the local currency, the Riel, were
converted to $US at the prevailing rate for the sample
period. There were an average of six X-rays taken for the
nail group and ten for the traction group. Most patients in
the nail group received two hours of physiotherapy every
day, whereas the Perkins group received one hour a day,
doing most of the exercises on their own. The per diem was
calculated by dividing the average monthly operating costs
($50,803) by the number of beds/days (106!31) = $15.50/
day, which includes nursing care, food, laundry and
hospital cleaning. Twenty-two patients in the traction group
needed a cast-brace before discharge at a unit cost of $120;
there were none in the nail group. The sum cost for the 50
patients treated in traction was $47,060, or $941 per patient.
The costs for per diem alone in this group account for
88% of the total costs. The sum cost for the 37 patients
treated with a SIGN nail was $30,347, or $820 per
patient. The per diem costs for this group represent 66%
of total costs (p<0.01). The per patient difference in costs
is thus $121.
There was one deep peroneal nerve palsy, which
resolved completely in the hospital without further treat-
ment. There were 14 pin tract infections in the Perkins
group, two of which required surgical debridement, adding
less than $50 to the total costs. There was one superficial
infection in the nail group, which responded well to
surgical debridement, and one deep infection which
required nail removal and delayed re-nailing. This added
less than $250 to the overall costs, bringing the per patient
costs up to $826. If we also include the surgical treatment
of nonunions, and assume that all three in the SIGN group
and all ten in the traction group will be nailed or re-nailed,
the overall costs in the SIGN group increases to $32,828 or
$888 per patient, and the overall costs in the traction group
increase to $55,330 or $1,107 per patient. In this scenario,
the per patient difference increases to $219.
Discussion
The SIGN nailing system has a long track record of success
throughout the world. Others have reported on its success in
resource-poor settings [9]. As with any new technology,
there is a learning curve, no matter how user-friendly the
SIGN system is. As surgeons and operating theatre nurses
become more proficient with its use, operative time should
decrease substantially, and be more in line with the 60–90
minutes reported elsewhere. At the time of data collection,
patients were kept in bed and received antibiotics for a
Table 2 Weight-bearing status at time of discharge
WB status Traction (total 52) Nails (total 38)
Full WB 8 (16%) 21 (57%)
Partial WB 41 (78%) 16 (41%)
Non WB 3 (6%) 1 (2%)
WB weight bearing
Table 3 Outcomes at minimum 16 weeks follow-up
Outcome Traction Nails
Follow-up > 16 weeks 46 36
Fractures healed 34 (74%) 33 (92%)
Malunion 2 (4%) 0
Nonunion 10 (22%) 3 (8%)
Table 4 Comparative total costs of inputs for both groups, $US
Cost category Traction Sign nail
Pins 156 24
Temporary traction 0 60
Perkin's frame 250 40
Crutches 750 555
X-rays 442 189
Physiotherapy 2150 1113
Length of stay (per diem)
Pre-op 11872
Post-op 8143
Total 40532 20015
Cast-brace 2640 0
Implant 0 5550
Operating room time 0 2082
Transfusion 0 460
Miscellaneous (drugs, lab) 140 259
Total 47,060 30,347
Total per patient 941 820
International Orthopaedics (SICOT) (2009) 33:1445–1448 1447
week after surgery, and discharged only after suture removal
at 14 days. Now patients are mobilised the first day after
surgery, receive antibiotics for 48 hours, and are most often
discharged within a week. Throughout the world, there are
dozens of sites that have considerable experience with the
SIGN system and they report an average LOS of five days. If
this were true at this site, the costs per patient would actually
drop to around $350 (ideal scenario). Obviously, costs are
very context-specific, and a $15.50 per diem might not be
reproducible in many settings. With a difference of $219 per
patient in the complication scenario, it would require
treatment of five patients surgically to make up for the costs
of treating the sixth one. The difference with the ideal scenario
would be around $757 per patient. In other words, the cost of
treating one patient in traction would be approximately the
same as treating three patients with a nail.
There are many flaws to such a study. It is neither
randomised nor prospective. The control group is retrospective
and not matched. Even though they followed one another, the
two groups are not synchronous. The 16-week minimum
follow-up is short andmanywould argue that nonunion cannot
be discussed before six months, so the 22% and 8% nonunion
rates in the traction and nail groups, respectively, may be
falsely high, but it still seems reasonable to assume that the
outcomes are better with internal fixation, as suggested by
most of the literature. The fact that 57% of patients treated with
nails and only 16% of those treated in traction were full
weight-bearing upon discharge also supports this. Although
unsubstantiated, it is probably not unreasonable to think these
patients will return sooner to gainful employment.
It took no more than 30 nails for the costs per patient to
equal those treated in traction. As the surgical centre moves
closer to the ideal scenario, costs will continue to fall. It
seems safe to conclude that, in this particular setting, better
outcomes at lower expenditure make SIGN nailing of adult
femoral shaft fractures much more cost-effective than
Perkins skeletal traction.
Open Access This article is distributed under the terms of the
Creative Commons Attribution Noncommercial License which per-
mits any noncommercial use, distribution, and reproduction in any
medium, provided the original author(s) and source are credited.
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Cost-effectiveness of replacing skeletal traction by interlocked intramedullary nailing for femoral shaft fractures in a provincial trauma hospital in Cambodia

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Cost-effectiveness of replacing skeletal traction by interlocked intramedullary nailing for femoral shaft fractures in a provincial trauma hospital in Cambodia

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