Plate fixation vs. intramedullary nailing: Which is more cost-effective for tibial shaft fractures?

Tibial shaft fractures are among the most common injuries resulting from trauma and are typically managed surgically via either plate fixation or intramedullary nailing. Given the constraints on healthcare resources and the imperative to control costs, evaluating the cost-effectiveness of these treatment strategies is essential. This study aimed to assess and compare the cost-effectiveness of intramedullary nailing versus plate fixation for tibial shaft fractures.

This cross-sectional economic evaluation was conducted from a modified societal perspective, incorporating direct medical costs (from hospital records and patient reports) and direct non-medical costs (from patient reports), alongside treatment effectiveness measured by health-related quality of life (HRQoL) and QALYs. The study included 276 patients with mid-shaft tibial fractures treated surgically with either intramedullary nailing or plate fixation at Shahid Dr. Rahnemoon Hospital, Yazd, Iran. Patients were followed for three months post-discharge. A willingness-to-pay (WTP) threshold of USD 4,771.4 per QALY (based on Iran's 2024 GDP per capita) was applied, and cost-effectiveness analysis was performed using Stata version 16 and TreeAge Pro 2020.

The mean total direct cost per patient was lower for intramedullary nailing (USD 602.87) than plate fixation (USD 669.68), with hospital expenses comprising the largest share (USD 448.47 vs. USD 472.84, respectively). Using a linear area-under-the-curve approach, accumulated QALYs over 90 days were higher for nailing (0.0627) than plate fixation (0.0448). Cost-effectiveness analysis identified intramedullary nailing as the undominated strategy, while plate fixation was absolutely dominated due to higher costs and lower effectiveness. Probabilistic sensitivity analysis, cost-effectiveness acceptability curves, and one-way sensitivity analyses consistently supported the cost-effectiveness advantage of intramedullary nailing under uncertainty at a willingness-to-pay threshold of USD 4,771.4 per QALY.

This short-term economic evaluation indicates that intramedullary nailing is an undominated and more cost-effective option than plate fixation for the surgical management of tibial shaft fractures over a 90-day follow-up period, providing higher accumulated QALYs at lower direct costs. These findings support the preferential use of intramedullary nailing in similar clinical settings; however, longer-term studies incorporating fracture healing, complications, and indirect costs are needed to confirm cost-effectiveness beyond the early postoperative period.