Intermaxillary fixation compared to miniplate osteosynthesis management of the fractured mandible: an audit J. S. Brown, N. Grew, C. Taylor,

in the

B. G. Millar

Departments of Orul and Muxillofacial Surgery, Wurdsley Hospital, Stow-bridge, Queen Elizabeth Hospital, Edgbaston, Birmingham

West Midlands clnd

-.

-.

SUMMARY. The hospital records of 30 patients with isolated fractured mandibles treated by intermaxillary fixation (IMF) were compared to 30 patients treated by miniplate osteosynthesis. The treatment variables assessed were the period of hospitalisation, the operating time, the use of intensive care or nurse specialing services, the number of outpatient visits, and the cost of materials. The cost of each facility was calculated from six sources, so that the average cost of each method of treatment could be determined. The results showed that the average cost for managing a fractured mandible with IMF was ;ElOOOif the intensive therapy unit (ITU) was used and $919 if ward specialing services (a single nurse looking after the patient) were used. This compared with an average cost of E794 for miniplate osteosynthesis. The extra cost of the materials if miniplates were used could be discounted by the longer period of hospitalisation, the use of ITU or nurse specialising services, and the greater number of outpatient visits that were required for patients treated with IMF. In addition the use of IMF significantly increased the time patients spent off work. ..~ --_ .~ .~ .~.. .~.

miniplate osteosynthesis may have discouraged some surgeons from adopting this technique. The aim of this paper was to compare the overall cost of treating the fractured mandible with either IMF or miniplate osteosynthesis.

INTRODUCTION

Cawood (1985) demonstrated the advantages of miniplate osteosynthesis over intermaxillary fixation (IMF) in the management of the fractured mandible. The postoperative function is improved and the weight loss reduced. Patients treated with IMF have a restricted airway (Williams & Cawood, 1990), and must be more vulnerable to the sequelae of postoperative haemorrhage and oedema. There has always been a query over the need to remove the miniplates at 3 months, but there are many surgeons performing orthognathic, craniofacial and maxillofacial trauma surgery who routinely leave miniplates in situ (Jackson & Adham, 1986; Persson et al., 1986; Brown etaf., 1989; Smith, 1991). Retrospective studies looking at the fate of miniplates left in place for the treatment of fractured mandibles have been carried out in the North East of England and Poole (Brown et ul., 1989; Jones & Wallis, 1989; Smith, 1991). These studies showed a lower morbidity associated with titanium plates. On average, 17-20% of stainless steel plates required removal for infection or pain, compared to only 6.4% of titanium plates removed. A doubt remains, however, as to the effect of miniplatcs left in situ for the remaining life of the patient. So far the retention of miniplates not requiring removal on clinical grounds has shown no complications over 5-10 years. It is becoming increasingly important to justify the cost of new equipment and facilities (Lowry, 1990). As the nationwide audit campaign in the UK gets under way the cost of therapies will have to be justified. The cost of the materials required for

MATERIALS

AND METHODS

The hospital records of 30 patients with isolated fractured mandibles treated with IMF and 30 patients treated by miniplate osteosynthesis were analysed. These records were chosen at random within the group of patients treated between 1987 and 1989, such that no patients had been treated less than 6 months previously. The clinical variables of age, sex, type of fracture and the cause of the injury were recorded. The treatment variables were recorded as shown in Table 1. In addition any complication was recorded including those likely to incur further costs. Each patient was sent a letter requesting the estimated time spent away from work on account of Table I - Treatment

variables

Period of hospitalisation Operating time Operating surgeon (seniority) Interval between injury and surgery Use of intensive therapy USC of ward specialing services Follow-up time Number of outpatient appointments Use of dietitian and hygienist services Complications 308

Intermaxillary Table 2 - Cost of hospital facilities (f)

l lospitalisation/day Operating time/hour ITU/l6 h Ward specialing/l2 h Out-patients/visit Dieticiadvisit Hygienist/visit

SO11

BAH

WH

WR

JL Avcragc

244 287 347 107 7 s 5

II.5 168 116 84 30 3 2

142 259 II6 30 3 2

67 275 I28 60 31 4 4

130 297 141 62 I6 44-

75 103 I03 22

129 232 1.59 78 23 4 3

Table 3 - Cost of materials (f)

cost

to miniplate

osteosynthesis

of clinical variables IMF

Plating

22.7

26.3

26 4 30

2s 5 30

Symphysis Body Angle Ramus Condyle Total

9 10 20 I 4 44

I2 7 I7 I 7 44

Cuure of injiuy Assault Sports RTA Falls Industrial Toti

I8 4 3 4 I 30

I9 4 I 3 3 30

A verqe

309

qge (years)

Sex Male Female Total

Type offructure

QEH-Qucen Elizabeth Hospital SOl I-Selly Oak I hospital BALI-Birmingham Accident Hospital WH-Wordsley Hospital WR-Wolverhampton Royal JI.-Lowry, 1990

Average

compared

Table 4 - Comparison

QEII

M&tin (stainless steel) Martin (titanium) Thackray Surgery (titanium) Nagor Mcdicon (titanium) Techmedica (titanium mesh) Luhr Howmcdica (vitallium)

fixation

Screws 7 mm (10)

Plates 4 hole (5)

22.50 40 40 47.74 80 105.50

47 65 52.50 12.63 33.50 151

55.12

70.27

NB Only Martin (stainless steel) and Nagor Mcdicon plates were used in this study.

(titanium)

their injury. The cost of each hospital facility was provided through the cooped-ation of the appropriate hospital administration department (Table 2), and the cost of the miniplates and screws by the manufacturers (Table 3).

RESULTS There were no significant differences between the two groups in the comparison of the clinical variables (Table 4). The differences in the USCof the various hospital facilities assessed are demonstrated in Table 5. The number of out-patient appointments was the only factor that was found to be statistically significant (p

Intermaxillary fixation compared to miniplate osteosynthesis in the management of the fractured mandible: an audit.

The hospital records of 30 patients with isolated fractured mandibles treated by intermaxillary fixation (IMF) were compared to 30 patients treated by...
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