article · JBJS Open Access
Open tibial fractures place a heavy economic and clinical burden on patients and healthcare systems in low- and middle-income nations due to severe complications like infection and improper bone healing. External fixation and intramedullary nailing are both standard treatments, yet their relative economic value in resource-limited settings has remained uncertain. Using clinical and economic data from a randomized trial at a tertiary hospital in Dar es Salaam, Tanzania, an evaluation compared both techniques from both payer and societal viewpoints over a lifetime horizon. Although external fixation carried lower immediate hospital costs, primarily driven by shorter surgical times, intramedullary nailing generated more quality-adjusted life-years. Driven by quicker recovery periods and reduced lost work time, intramedullary nailing achieved superior cost-effectiveness under World Health Organization standards, holding true whether the hardware was donated or purchased locally.
Open leg fractures frequently cause long-term disability and severe financial strain in lower-income regions. This analysis provides concrete health-economic evidence showing that investing in intramedullary nailing delivers substantially better patient recovery and societal economic returns compared to external fixation, giving healthcare leaders reliable justification to finance modern surgical hardware.
This applied research directly informs health system procurement strategies, orthopaedic device distributors, and hospital managers in low- and middle-income countries. Because it evaluates existing, locally purchasable implants alongside donated devices, the economic findings are immediately actionable for hospital procurement bodies and surgical departments seeking to balance clinical recovery gains against inventory costs.
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Background: Open tibial fractures are a cause of substantial orthopaedic morbidity in low- and middle-income countries. These injuries represent a substantial cost burden to both individual patients and society because of their high propensity for complications, such as infection, nonunion, and malunion. External fixation and intramedullary (IM) nailing are both utilized for definitive treatment of open tibial fractures, but given the differences in cost and lack of clear superiority of intramedullary nailing, cost-effectiveness becomes important to consider in low- and middle-income countries. The present study aimed to examine the cost-effectiveness of IM nailing versus external fixation within Tanzania. Methods: This study utilized data from a randomized controlled trial conducted at a single tertiary hospital in Dar es Salaam, Tanzania. Direct cost data were collected via an internal audit of operating costs and hospital staff time. Indirect costs data were collected from patients in a long-term follow-up study assessing total lost work. A Markov model was utilized to run the cost-effectiveness simulations. The primary outcome was the incremental cost-effectiveness ratio (ICER) over a lifetime time horizon. Both the payer and societal perspectives were considered. To account for uncertainty, both 1-way and probabilistic sensitivity analyses were performed. Results: From the payer perspective, the cost of external fixation ($396 USD) was lower than that of IM nailing ($529), primarily because of shorter operative times. However, IM nailing was associated with more quality-adjusted life-years (QALYs). From the payer perspective, the ICER was $499 per QALY with a donated nail and $701 per QALY with a purchased locally available nail. From the societal perspective, the ICER was lower among patients undergoing IM nailing, at $70 per QALY, largely because of shorter recovery times. Conclusions: From both the payer and the societal perspective, IM nailing is considered highly cost-effective on the basis of the World Health Organization willingness-to-pay thresholds. This finding was consistent whether the IM nail was donated or purchased from local suppliers. These results are likely generalizable to other tertiary referral centers in low- and middle-income countries. Level of Evidence: Economic Level II. See Instructions for Authors for a complete description of levels of evidence.
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DOI: 10.2106/jbjs.oa.24.00006
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