The Journal of Bone and Joint Surgery (American). 2007;89:970-978.
doi:10.2106/JBJS.E.00657
© 2007 The Journal of Bone and Joint Surgery, Inc.
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An Economic Analysis of the Timing of Microsurgical Reconstruction in Brachial Plexus Birth Palsy

Carmen A. Brauer, MD, MSc, FRCSC1 and Peter M. Waters, MD2

1 Department of Orthopaedic Surgery, British Columbia's Children's Hospital, The University of British Columbia, A200-4480 Oak Street, Vancouver, BC V6H 3V4, Canada. E-mail address: cbrauer{at}cw.bc.ca
2 Department of Orthopedic Surgery, Children's Hospital Boston, Harvard Medical School, 300 Longwood Avenue, Fegan 2, Boston, MA 02115

Investigation performed at Children's Hospital Boston, Boston, Massachusetts

Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 (a Clinical Fellowship from the Alberta Heritage Foundation for Medical Research). Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

A video supplement to this article will be available from the Video Journal of Orthopaedics. A video clip will be available at the JBJS web site, www.jbjs.org. The Video Journal of Orthopaedics can be contacted at (805) 962-3410, web site: www.vjortho.com.

Background: The role and timing of microsurgical reconstruction of the brachial plexus in infants who have no signs of biceps recovery within the first six months of life is controversial. The purpose of the present study was to create an economic model to compare microsurgical treatment at three as opposed to six months in patients with brachial plexus birth palsy who had no return of biceps function at three months.

Methods: A cost-minimization study was performed with use of a decision-analysis model. Natural history, success, and tendon transfer and osteotomy rates were estimated from the literature. Costs were estimated from a single center.

Results: The literature on patients without nerve root avulsion supports an 80% rate of biceps recovery between three and six months of age. On the basis of this value, microsurgical intervention at three months was more expensive than microsurgical intervention at six months. Microsurgical intervention at three months cost more than twice as much as intervention at six months. Sensitivity analysis revealed that when the rate of biceps recovery was 40% and surgery at three months was three times more successful than surgery at six months, then both treatments had equal costs.

Conclusions: It is unlikely that microsurgical intervention at three months for the treatment of rupture injuries of the brachial plexus will be successful enough to produce overall cost savings. While our results should not be used to dictate policy decisions as they are not definitive and remain contingent on future studies, it is still reasonable to consider economic factors and quality-of-life outcomes in brachial plexus birth palsy treatment strategies and future research.

Level of Evidence: Economic and decision analysis, Level II. See Instructions to Authors for a complete description of levels of evidence.


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