Background
Tibia shaft fractures are common but unanticipated trauma in adults resulting in painful and prolonged recovery, often associated with complications. The U.S. National Center for Health Statistics reported annual incidence of 492,000 fractures of tibia, fibula, and ankle.[1] Tibia and fibula fractures annually result in 77,000 hospitalizations accounting for 569,000 hospital days and 825,000 physician office visits.[2] The U.S. Agency for Healthcare Research and Quality (AHRQ) reported 151,966 hospital discharges for which tibia/fibula fracture diagnosis was a reason for a principal procedure in 2007 (Healthcare Cost and Use Project, AHRQ).[3] A high proportion of Medicare patients – adults aged 65 or older – with tibia fractures undergo an acute inpatient stay (70%), post-acute inpatient stay (50%), and home health care (38%) as well as outpatient visits and physical and occupational therapy;[4] such estimates are missing for young and middle-age adults who also frequently get tibia fractures.[5,6] Tibia fractures are treated medically, and healthcare use depends on treatment options, which, in turn, vary by injury type and severity and the presence of complications.[5,7]
Fracture nonunion (sometimes referred to as "delayed union") is a common complication of a tibia fracture; it indicates that fracture healing is not happening in a timely fashion.[5,8] Nonunions put additional burden on the patient because they prolong the disability and are associated with substantial pain.[9,10] There is no standard definition of nonunion, and some authors have defined tibia nonunion as a fracture that has not united without additional surgical or nonsurgical intervention within 6–9 months,[8] whereas others waited for six-month to perform surgeries to correct nonunions.[11]
A common approach to delayed unions is expectant management, accompanied by non-invasive therapies such as low-intensity pulsed ultrasound,[12–14] or vibration.[12] When healing fails within a clinically reasonable time period (6–9 months), a second surgical intervention, aiming to stabilize the fracture, is inevitable.[8,11] Additional therapies used during the surgery, such as bone morphogenetic proteins (BMP's), may further help bone healing, but they are costly.
Nonunions naturally require more healthcare services than fractures without non-unions because of the repeated surgical intervention and the extended patient pain and disability. Understanding of patient characteristics, healthcare use, and costs associated with tibia fracture nonunion is critical to understanding the clinical and economic burden.
Although previous studies investigated nonunion-related healthcare use and costs,[15–18] they had a number of limitations: small sample size (n < =27),[15–18] no comparison to patients without nonunion,[15–18] outdated estimates,[15,18] single healthcare setting,[15] and focus on limited therapies: pulsed low-intensity ultrasound,[18] autologous-iliac-crest-bone-graft, or bone morphogenetic protein-7 (BMP-7).[16,17] These shortcomings limit the reliability of the estimates, external validity (the ability to generalize to other patient populations and healthcare settings), and the ability compare with costs of fractures with nonunion to those without nonunion. To address these shortcomings, we conducted an analysis of large U.S. medical claims databases that reflects multiple healthcare settings and therapies. The aim of our study was to describe patient characteristics, healthcare resource use, and costs associated with tibia shaft fractures overall and by nonunion status.
BMC Musculoskelet Disord. 2013;14(42) © 2013 BioMed Central, Ltd.
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