Advertisement

Protocolised MRI as an adjunct to CT in the diagnosis of femoral neck fracture in high energy ipsilateral femoral shaft fractures – A break-even analysis

Published:October 07, 2022DOI:https://doi.org/10.1016/j.injury.2022.10.005

      Abstract

      Background

      In high-energy femoral shaft fractures (FSFs), ipsilateral femoral neck fractures (FNFs) can be missed by conventional trauma computed topography (CT) imaging, resulting in increased treatment costs and patient complications. Preliminary evidence suggests that a rapid, limited-sequence pelvis and hip magnetic resonance imaging (MRI) protocol can identify these occult fractures and be feasibly implemented in the trauma setting. This study aims to establish the economic break-even point for implementing such an MRI protocol in all high-energy FSFs.

      Methods

      We used an adapted break-even economic tool to determine whether the costs of a targeted MRI protocol can be offset by cost-savings achieved through prevention of missed fractures (thus avoiding prolonged admission and re-operation). Sensitivity analyses were performed to demonstrate reliability of the economic modelling across a range of assumptions.

      Results

      Assuming a baseline of FNFs missed on CT of 12%, an MRI cost of £129 and cost of treating each missed FNF of £2457.5, the equation yielded a break-even rate of 7% and absolute risk reduction (ARR) of 5%, indicating that for every 100 FSFs, MRI would need to diagnose 5 of the 12 missed FNF to be economically viable (number needed to treat (NNT)=20). Economic viability was maintained even at double the cost of MRI, while increasing the cost of treating each complication served to reduce the ARR further, increasing cost-savings.

      Conclusion

      A rapid, limited-sequence MRI protocol to exclude occult ipsilateral FNFs in all high-energy FSFs appears to be economically justified measure. Further research exploring the feasibility of such a protocol, as well as the role of intra-operative fluoroscopy in this context, is required.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Injury
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Peljovich AE
        • Patterson BM.
        Ipsilateral femoral neck and shaft fractures.
        JAAOS. 1998; 6: 106-113
        • Boulton CL
        • Pollak AN.
        Special topic: ipsilateral femoral neck and shaft fractures–does evidence give us the answer?.
        Injury. 2015; 46: 478-483
        • Cannada LK
        • Viehe T
        • Cates CA
        • Norris RJ
        • Zura RD
        • Dedmond B
        • et al.
        Southeastern fracture consortium. A retrospective review of high-energy femoral neck-shaft fractures.
        J Orthop Trauma. 2009; 23: 254-260
        • Ritchey SJ
        • Schonholtz GJ
        • Thompson MS.
        The dashboard femoral fracture: pathomechanics, treatment, and prevention.
        JBJS. 1958; 40: 1347-1358
        • Zettas JP
        • Zettas PA.
        Ipsilateral fractures of the femoral neck and shaft.
        Clin Orthop Relat Res. 1981; : 63-73
        • Fanous R
        • Sabharwal S
        • Altaie A
        • Gupte CM
        • Reilly P.
        Hip fracture litigation: a 10-year review of NHS litigation authority data and the effect of national guidelines.
        Ann R Coll Surg Engl. 2017; 99: 17-21
        • Salim A
        • Sangthong B
        • Martin M
        • Brown C
        • Plurad D
        • Demetriades D.
        Whole body imaging in blunt multisystem trauma patients without obvious signs of injury: results of a prospective study.
        Arch Surg. 2006; 141: 468-475
        • O'Toole RV
        • Dancy L
        • Dietz AR
        • Pollak AN
        • Johnson AJ
        • Osgood G
        • Nascone JW
        • Sciadini MF
        • Castillo RC.
        Diagnosis of femoral neck fracture associated with femoral shaft fracture: blinded comparison of computed tomography and plain radiography.
        J Orthop Trauma. 2013; 27: 325-330
        • Verbeeten KM
        • Hermann KL
        • Hasselqvist M
        • Lausten GS
        • Joergensen P
        • Jensen CM
        • et al.
        The advantages of MRI in the detection of occult hip fractures.
        Eur Radiol. 2005; 15: 165-169
        • Cabarrus MC
        • Ambekar A
        • Lu Y
        • Link TM.
        MRI and CT of insufficiency fractures of the pelvis and the proximal femur.
        Am J Roentgenol. 2008; 191: 995-1001
        • Rogers NB
        • Hartline BE
        • Achor TS
        • Kumaravel M
        • Gary JL
        • Choo AM
        • et al.
        Improving the diagnosis of ipsilateral femoral neck and shaft fractures: a new imaging protocol.
        JBJS. 2020; 102: 309-314
        • Hatch MD
        • Daniels SD
        • Glerum KM
        • Higgins LD.
        The cost effectiveness of vancomycin for preventing infections after shoulder arthroplasty: a break-even analysis.
        J Should Elbow Surg. 2017; 26: 472-477
        • Brealey SD
        • Atwell C
        • Bryan S
        • Coulton S
        • Cox H
        • Cross B
        • et al.
        The DAMASK trial protocol: a pragmatic randomised trial to evaluate whether GPs should have direct access to MRI for patients with suspected internal derangement of the knee.
        BMC Health Serv Res. 2006; 6: 1-9
        • Handoll H
        • Brealey S
        • Rangan A
        • Keding A
        • Corbacho B
        • Jefferson L
        • et al.
        The ProFHER (PROximal Fracture of the Humerus: evaluation by Randomisation) trial-a pragmatic multicentre randomised controlled trial evaluating the clinical effectiveness and cost-effectiveness of surgical compared with non-surgical treatment for proximal fracture of the humerus in adults.
        Health Technol Assess. 2015; 19: 1
      1. NHS Reference Costs 2015-2016, United Kingdom Department of Health & Social Care, 2016. Published 15 December 2016, (page 10) https://www.gov.uk/government/publications/nhs-reference-costs-2015-to-2016.

        • Tornetta III P
        • Kain MS
        • Creevy WR.
        Diagnosis of femoral neck fractures in patients with a femoral shaft fracture: improvement with a standard protocol.
        J Bone Joint Surg. 2007; 89: 39-43
        • Faucett SC
        • Collinge CA
        • Koval KJ.
        Is reconstruction nailing of all femoral shaft fractures cost effective? A decision analysis.
        J Orthop Trauma. 2012; 26: 624-632