Cost-effectiveness of cast treatment vs. surgery in elderly patients with substantially displaced intra-articular distal radius fractures: A trial-based economic evaluation

On behalf of the DART study group

doi:10.1371/journal.pone.0339489

Cost-effectiveness of cast treatment vs. surgery in elderly patients with substantially displaced intra-articular distal radius fractures: A trial-based economic evaluation

On behalf of the DART study group

Research output: Contribution to Journal › Article › Academic › peer-review

Abstract

Background The number of surgical procedures for distal radius fractures in the elderly has increased, even though most studies show little or no benefit over cast treatment. While medical costs of surgical treatment are higher than those of cast treatment, surgery may enable faster recovery and help patients maintain independence, potentially reducing their use of other healthcare resources and informal care.

Methods We evaluated whether cast treatment is cost-effective compared to surgery for patients aged 65 years or older with substantially displaced intra-articular distal radius fractures. A multicentre randomized controlled non-inferiority trial with an economic evaluation in 19 hospitals in the Netherlands. Participants completed (cost) questionnaires at baseline, 3, 6, 9 and 12 months after trauma. A total of 138 patients were randomized between cast treatment and surgery. Health-related quality of life was measured with the EQ-5D-3L; wrist function was measured with the Patient Rated Wrist Evaluation (PRWE). Costs were assessed from a societal perspective, including intervention costs, healthcare use, informal care, unpaid productivity losses, and patients’ own expenses.

Results The estimated difference in total societal costs was -€81 (95%CI -€3936 to €3773) in favour of cast treatment compared with surgical treatment. Compared with cast treatment, surgery resulted in improved wrist function (PRWE: −5.5; 95% CI: −10 to −0.7) and slightly higher QALYs (+0.039; 95%CI 0.012 to 0.066), equivalent to 14 days in perfect health. The incremental cost-effectiveness ratio was €15 per point improvement in PRWE and €2070 per QALY gained. Cast treatment’s probability of cost-effectiveness was low for all values of willingness to pay.

Conclusion Although cast treatment had lower direct costs, these were offset by higher informal and secondary care costs. Surgical treatment offered clinically relevant short-term benefits. From a societal perspective, surgery appears to be the more favorable option for elderly patients with displaced distal radius fractures.

Original language	English
Article number	e0339489
Pages (from-to)	1-15
Number of pages	15
Journal	PLoS ONE
Volume	21
Issue number	1
Early online date	30 Jan 2026
DOIs	https://doi.org/10.1371/journal.pone.0339489
Publication status	Published - Jan 2026

Bibliographical note

Publisher Copyright:
© 2026 ter Meulen et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Funding

Funding: This study was funded by The Netherlands Organisation for Health Research and Development (ZonMw), grant number 80-83700-98-16501. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Funders	Funder number
ZonMw	80-83700-98-16501

Keywords

Humans
Aged
Cost-Benefit Analysis
Female
Male
Radius Fractures/economics
Casts, Surgical/economics
Aged, 80 and over
Quality of Life
Netherlands
Intra-Articular Fractures/economics
Surveys and Questionnaires
Quality-Adjusted Life Years
Wrist Fractures

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@article{792f2ca3b1ce41c9b52488d8a00cadf6,

title = "Cost-effectiveness of cast treatment vs. surgery in elderly patients with substantially displaced intra-articular distal radius fractures: A trial-based economic evaluation",

abstract = "Background The number of surgical procedures for distal radius fractures in the elderly has increased, even though most studies show little or no benefit over cast treatment. While medical costs of surgical treatment are higher than those of cast treatment, surgery may enable faster recovery and help patients maintain independence, potentially reducing their use of other healthcare resources and informal care.Methods We evaluated whether cast treatment is cost-effective compared to surgery for patients aged 65 years or older with substantially displaced intra-articular distal radius fractures. A multicentre randomized controlled non-inferiority trial with an economic evaluation in 19 hospitals in the Netherlands. Participants completed (cost) questionnaires at baseline, 3, 6, 9 and 12 months after trauma. A total of 138 patients were randomized between cast treatment and surgery. Health-related quality of life was measured with the EQ-5D-3L; wrist function was measured with the Patient Rated Wrist Evaluation (PRWE). Costs were assessed from a societal perspective, including intervention costs, healthcare use, informal care, unpaid productivity losses, and patients{\textquoteright} own expenses.Results The estimated difference in total societal costs was -€81 (95\%CI -€3936 to €3773) in favour of cast treatment compared with surgical treatment. Compared with cast treatment, surgery resulted in improved wrist function (PRWE: −5.5; 95\% CI: −10 to −0.7) and slightly higher QALYs (+0.039; 95\%CI 0.012 to 0.066), equivalent to 14 days in perfect health. The incremental cost-effectiveness ratio was €15 per point improvement in PRWE and €2070 per QALY gained. Cast treatment{\textquoteright}s probability of cost-effectiveness was low for all values of willingness to pay.Conclusion Although cast treatment had lower direct costs, these were offset by higher informal and secondary care costs. Surgical treatment offered clinically relevant short-term benefits. From a societal perspective, surgery appears to be the more favorable option for elderly patients with displaced distal radius fractures.",

keywords = "Humans, Aged, Cost-Benefit Analysis, Female, Male, Radius Fractures/economics, Casts, Surgical/economics, Aged, 80 and over, Quality of Life, Netherlands, Intra-Articular Fractures/economics, Surveys and Questionnaires, Quality-Adjusted Life Years, Wrist Fractures",

author = "\{ter Meulen\}, \{Dirk P.\} and \{van Dongen\}, \{Johanna M.\} and Kleinlugtenbelt, \{Ydo V.\} and Kraan, \{Gerald A.\} and Goslings, \{J. Carel\} and Schep, \{Niels W.L.\} and Willigenburg, \{Nienke W.\} and Poolman, \{Rudolf W.\} and Mallee, \{W. H.\} and Kempen, \{D. H.R.\} and \{van Deurzen\}, \{D. F.P.\} and A. Rasker and \{van de Graaf\}, \{V. A.\} and \{van den Berg\}, \{H. R.\} and \{van Veen\}, \{R. N.\} and R. Haverlag and Simons, \{M. P.\} and \{van Rutte\}, \{P. W.J.\} and \{Formijne Jonkers\}, \{H. A.\} and Mathijssen, \{N. M.C.\} and \{de Vries\}, \{M. R.\} and J. Vermeulen and Jawahier, \{P. A.\} and Cleffken, \{B. I.\} and Zuurmond, \{R. G.\} and \{van Helden\}, \{S. H.\} and Steinweg, \{M. C.Q.\} and \{van der Veen\}, \{A. H.\} and Flikweert, \{E. R.\} and Landman, \{E. B.M.\} and N. Sosef and Sierevelt, \{I. N.\} and \{van Dijkman\}, \{B. A.\} and Dijkstra, \{A. J.\} and Heuvel, \{J. Olde\} and S. Romijn and \{van der Zwaard\}, \{B. C.\} and Lansink, \{K. W.W.\} and T. Gosens and Fr{\"o}lke, \{J. P.M.\} and Verleisdonk, \{E. J.M.M.\} and \{van der Wal\}, \{R. J.P.\} and D. Haverkamp and Kerkhoffs, \{G. M.M.J.\} and Twigt, \{B. A.\} and M. Rutgers and T. Teunis and Mulders, \{M. A.M.\} and \{van Heijl\}, M. and Selles, \{C. A.\} and Kret, \{E. J.\} and Kruiswijk, \{A. A.\} and Slichter, \{M. E.\} and Colaris, \{J. W.\} and Vochteloo, \{A. J.\} and Willems, \{H. C.\} and \{On behalf of the DART study group\}",

note = "Publisher Copyright: {\textcopyright} 2026 ter Meulen et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.",

year = "2026",

month = jan,

doi = "10.1371/journal.pone.0339489",

language = "English",

volume = "21",

pages = "1--15",

journal = "PLoS ONE",

issn = "1932-6203",

publisher = "Public Library of Science",

number = "1",

}

TY - JOUR

T1 - Cost-effectiveness of cast treatment vs. surgery in elderly patients with substantially displaced intra-articular distal radius fractures

T2 - A trial-based economic evaluation

AU - ter Meulen, Dirk P.

AU - van Dongen, Johanna M.

AU - Kleinlugtenbelt, Ydo V.

AU - Kraan, Gerald A.

AU - Goslings, J. Carel

AU - Schep, Niels W.L.

AU - Willigenburg, Nienke W.

AU - Poolman, Rudolf W.

AU - Mallee, W. H.

AU - Kempen, D. H.R.

AU - van Deurzen, D. F.P.

AU - Rasker, A.

AU - van de Graaf, V. A.

AU - van den Berg, H. R.

AU - van Veen, R. N.

AU - Haverlag, R.

AU - Simons, M. P.

AU - van Rutte, P. W.J.

AU - Formijne Jonkers, H. A.

AU - Mathijssen, N. M.C.

AU - de Vries, M. R.

AU - Vermeulen, J.

AU - Jawahier, P. A.

AU - Cleffken, B. I.

AU - Zuurmond, R. G.

AU - van Helden, S. H.

AU - Steinweg, M. C.Q.

AU - van der Veen, A. H.

AU - Flikweert, E. R.

AU - Landman, E. B.M.

AU - Sosef, N.

AU - Sierevelt, I. N.

AU - van Dijkman, B. A.

AU - Dijkstra, A. J.

AU - Heuvel, J. Olde

AU - Romijn, S.

AU - van der Zwaard, B. C.

AU - Lansink, K. W.W.

AU - Gosens, T.

AU - Frölke, J. P.M.

AU - Verleisdonk, E. J.M.M.

AU - van der Wal, R. J.P.

AU - Haverkamp, D.

AU - Kerkhoffs, G. M.M.J.

AU - Twigt, B. A.

AU - Rutgers, M.

AU - Teunis, T.

AU - Mulders, M. A.M.

AU - van Heijl, M.

AU - Selles, C. A.

AU - Kret, E. J.

AU - Kruiswijk, A. A.

AU - Slichter, M. E.

AU - Colaris, J. W.

AU - Vochteloo, A. J.

AU - Willems, H. C.

AU - On behalf of the DART study group

N1 - Publisher Copyright: © 2026 ter Meulen et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

PY - 2026/1

Y1 - 2026/1

N2 - Background The number of surgical procedures for distal radius fractures in the elderly has increased, even though most studies show little or no benefit over cast treatment. While medical costs of surgical treatment are higher than those of cast treatment, surgery may enable faster recovery and help patients maintain independence, potentially reducing their use of other healthcare resources and informal care.Methods We evaluated whether cast treatment is cost-effective compared to surgery for patients aged 65 years or older with substantially displaced intra-articular distal radius fractures. A multicentre randomized controlled non-inferiority trial with an economic evaluation in 19 hospitals in the Netherlands. Participants completed (cost) questionnaires at baseline, 3, 6, 9 and 12 months after trauma. A total of 138 patients were randomized between cast treatment and surgery. Health-related quality of life was measured with the EQ-5D-3L; wrist function was measured with the Patient Rated Wrist Evaluation (PRWE). Costs were assessed from a societal perspective, including intervention costs, healthcare use, informal care, unpaid productivity losses, and patients’ own expenses.Results The estimated difference in total societal costs was -€81 (95%CI -€3936 to €3773) in favour of cast treatment compared with surgical treatment. Compared with cast treatment, surgery resulted in improved wrist function (PRWE: −5.5; 95% CI: −10 to −0.7) and slightly higher QALYs (+0.039; 95%CI 0.012 to 0.066), equivalent to 14 days in perfect health. The incremental cost-effectiveness ratio was €15 per point improvement in PRWE and €2070 per QALY gained. Cast treatment’s probability of cost-effectiveness was low for all values of willingness to pay.Conclusion Although cast treatment had lower direct costs, these were offset by higher informal and secondary care costs. Surgical treatment offered clinically relevant short-term benefits. From a societal perspective, surgery appears to be the more favorable option for elderly patients with displaced distal radius fractures.

AB - Background The number of surgical procedures for distal radius fractures in the elderly has increased, even though most studies show little or no benefit over cast treatment. While medical costs of surgical treatment are higher than those of cast treatment, surgery may enable faster recovery and help patients maintain independence, potentially reducing their use of other healthcare resources and informal care.Methods We evaluated whether cast treatment is cost-effective compared to surgery for patients aged 65 years or older with substantially displaced intra-articular distal radius fractures. A multicentre randomized controlled non-inferiority trial with an economic evaluation in 19 hospitals in the Netherlands. Participants completed (cost) questionnaires at baseline, 3, 6, 9 and 12 months after trauma. A total of 138 patients were randomized between cast treatment and surgery. Health-related quality of life was measured with the EQ-5D-3L; wrist function was measured with the Patient Rated Wrist Evaluation (PRWE). Costs were assessed from a societal perspective, including intervention costs, healthcare use, informal care, unpaid productivity losses, and patients’ own expenses.Results The estimated difference in total societal costs was -€81 (95%CI -€3936 to €3773) in favour of cast treatment compared with surgical treatment. Compared with cast treatment, surgery resulted in improved wrist function (PRWE: −5.5; 95% CI: −10 to −0.7) and slightly higher QALYs (+0.039; 95%CI 0.012 to 0.066), equivalent to 14 days in perfect health. The incremental cost-effectiveness ratio was €15 per point improvement in PRWE and €2070 per QALY gained. Cast treatment’s probability of cost-effectiveness was low for all values of willingness to pay.Conclusion Although cast treatment had lower direct costs, these were offset by higher informal and secondary care costs. Surgical treatment offered clinically relevant short-term benefits. From a societal perspective, surgery appears to be the more favorable option for elderly patients with displaced distal radius fractures.

KW - Humans

KW - Aged

KW - Cost-Benefit Analysis

KW - Female

KW - Male

KW - Radius Fractures/economics

KW - Casts, Surgical/economics

KW - Aged, 80 and over

KW - Quality of Life

KW - Netherlands

KW - Intra-Articular Fractures/economics

KW - Surveys and Questionnaires

KW - Quality-Adjusted Life Years

KW - Wrist Fractures

UR - https://www.scopus.com/pages/publications/105028911293

UR - https://www.scopus.com/pages/publications/105028911293#tab=citedBy

U2 - 10.1371/journal.pone.0339489

DO - 10.1371/journal.pone.0339489

M3 - Article

C2 - 41616035

SN - 1932-6203

VL - 21

SP - 1

EP - 15

JO - PLoS ONE

JF - PLoS ONE

IS - 1

M1 - e0339489

ER -

Cost-effectiveness of cast treatment vs. surgery in elderly patients with substantially displaced intra-articular distal radius fractures: A trial-based economic evaluation

Abstract

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