Surgical Treatment of Supracondylar Humeral Fractures in a Freestanding Ambulatory Surgery Center is as Safe as and Faster and More Cost-Effective Than in a Children's Hospital

Pediatric Lateral Condyle Fractures With Elbow Dislocation: Revisiting the Song Classification of the Most Severe Injuries

INTRODUCTION

Lateral condyle fractures are the second most common pediatric elbow fracture and are at risk for malunion, nonunion or avascular necrosis. The Song or Jakob classification guides management and risk of complications. However, many lateral condyle fractures have accompanying bony or soft tissue injuries, including elbow dislocations, which are not represented in the current Song or Jakob classification systems. Little is known about the incidence and outcomes of these more complex injuries. The purpose of this study was to describe the largest known case series of these injuries and characterize the incidence and outcomes.

METHODS

Injury, presentation, treatment, and outcome data were retrospectively gathered on pediatric elbow fractures at a single center from November 2007 to October 2017.

RESULTS

Of 4607 pediatric elbow fractures, 492 were lateral condyle fractures, with 30 cases (6.1%) presenting with concomitant elbow dislocation. Predominantly affecting males (76.7%) with a median age of 6.9 years, these injuries often resulted from intermediate energy mechanisms. High rates of coincident neurovascular deficits (23%), skin tenting (13.3%), and polytrauma (13.3%) were observed. All cases were treated surgically, primarily within 24 hours, with no instances of AVN, nonunion, or fixation failure reported. Across the cohort, there were 2 (6.7%) pin tract infections, 2 cases required return to the operating room, and 12 (40.0)% patients requiring outpatient physical therapy for elbow stiffness.

CONCLUSIONS

Lateral condyle fractures with concomitant ulnohumeral dislocation are distinct and unstable injuries requiring prompt inpatient treatment. Current classification systems do not adequately address this fracture-dislocation combination, risking underdiagnosis and potentially delayed reduction of a dislocated elbow. We propose adding a "Song 6" or "Jakob 4" category to existing classifications to ensure these injuries are properly identified and managed. This amendment will improve clinical awareness, facilitate timely intervention, and optimize outcomes for pediatric patients with these complex fractures.

LEVEL OF EVIDENCE

IV.

Admission of Upper Extremity Injuries Presenting to the Emergency Department: An NEISS Study

BACKGROUND

Upper extremity injuries account for 36.5% of presentations to the emergency department in the United States. This study seeks to determine current rates of upper extremity injuries that present to the emergency department and the injury characteristics of patients requiring admission.

METHODS

National Electronic Injury Surveillance System was queried for a 10-year period for upper extremity injuries. Further analysis was done to evaluate specific patient demographics, injury characteristics, and mechanisms of injury of those patients who were admitted to the hospital.

RESULTS

Between 2012 and 2021, 39 160 365 persons are estimated to have presented to 100 United States emergency departments for managing upper extremity injuries, accounting for 28.8% of total presentations. A total of 12 662 041 upper extremity patients were pediatric (32.3%). Admissions occurred in 4.6% of presentations. The most common presenting diagnosis was laceration (24.9%), while the most common admission diagnosis was fracture (49.7%). The majority had injuries involving their forearms (19.9%). The most common injury-associated consumer product group was stairs, ramps, landings, and floors at 28.5%. Of the 445 644 patients, those estimated to have been injured by stairs, ramps, landings, and floors adults were 429 435 or 96.4%. The most common injury-associated product in pediatric populations was playground equipment (23.6%), of which 53.7% was from monkey bars and other climbing apparatuses.

CONCLUSION

This study demonstrates an overall increase in admissions for upper extremity injuries in the setting of similar rates of overall upper extremity injuries with fractures and forearm being the most common diagnosis and body part involved, respectively.

LEVEL OF EVIDENCE

IV; Database.

Interfacility Transfer of Pediatric Supracondylar Elbow Fractures: Transfer by Ambulance Shows No Advantage in Speed of Transfer or Prevention of Complications

BACKGROUND

The treatment of supracondylar humerus (SCH) fractures is increasingly centralized in tertiary centers. Interfacility transfer from other facilities may occur by ground ambulance or privately owned vehicle (POV). The objective of this study was to determine if interfacility transfer by POV is equivalent in transfer time and perioperative complications compared with ground ambulance.

METHODS

This was a single-institution, retrospective study of SCH fractures with an intact pulse transferred by POV or ground ambulance. Transfer time points were collected to determine transfer time and speed. Associated injuries of ipsilateral fracture, skin at risk, and motor nerve palsy were recorded from orthopaedic documentation at the presentation. Insurance status and the Area Deprivation Index (ADI) were used as measures of socioeconomic disparity.

RESULTS

676 "urgent" Type III, IV, and flexion type SCH fractures and 167 "nonurgent" Type II SCH fractures were transferred by ambulance or POV. Open reduction was similar between urgent transfers transported by ambulance or POV (10% vs. 9%, P =0.344). There was no difference in transfer time ( P =0.391) or transfer speed ( P =0.416) between transfer groups. POV transfers were independently associated with no skin at risk (OR 2.1; 95% CI: 1.3-3.3, P =0.003), neurovascularly intact (OR 2.5; 95% CI: 1.4-4.4, P =0.001), and patients in the low (OR 1.9; 95% CI: 1.3-2.5, P =0.041) and moderate deprivation (OR 1.9; 95% CI: 1.1-3.5, P =0.034) compared with the high deprivation group. Medicaid insurance was associated with a lower odds ratio of private transport compared with commercial insurance (OR 0.54; 95% CI: 0.38-0.76, P =<0.001).

CONCLUSIONS

Interfacility transfer of nonemergent SCH fractures by privately owned vehicles has a similar speed of transfer and perioperative complication rate to transfer by ground ambulance. Our findings allow the triaging of nonemergent SCH fractures for potential interfacility transfer by privately owned vehicles and bring attention to disparities in interfacility transfer methods.

LEVEL OF EVIDENCE

Level III- Retrospective cohort study.

Value-Driven Pediatric Supracondylar Humerus Fracture Care: Implementing Evidence-Based Practices

Supracondylar humerus fractures are high-volume injuries in children; therefore, value-driven treatment has far-reaching implications for patients and families as well as healthcare systems. Children younger than 5 years can remodel posterior angulation. Most Type IIa fractures will maintain alignment after closed reduction. Many patients with surgical fractures can safely wait for nonemergent fixation. Outpatient surgery is associated with shorter surgical time, lower costs, and fewer return visits to the emergency department with no increase in adverse events. Type III fractures treated the following day do not have higher rates of open reduction, and patients with associated nerve injuries have no difference in recovery time compared with those treated more urgently. Pediatric-trained surgeons generally provide more efficient care (shorter surgical time and less after-hours surgery); however, their outcomes are equivalent to non-pediatric orthopaedic surgeons. Community hospitals have lower costs compared with teaching hospitals; therefore, transferring patients should be avoided when feasible. Postoperative care can be streamlined in uncomplicated cases to minimize radiographs, therapy referrals, and multiple visits. Splinting offers safer, lower cost immobilization over casting. With staffing shortages and an increasingly burdened healthcare system, it is imperative to maximize nonsurgical care, use outpatient facilities, and minimize postoperative requirements without negatively affecting patient outcomes.

How Have Patient Out-of-pocket Costs for Common Outpatient Orthopaedic Foot and Ankle Surgical Procedures Changed Over Time? A Retrospective Study From 2010 to 2020

BACKGROUND

Out-of-pocket (OOP) costs can be substantial financial burdens for patients and may even cause patients to delay or forgo necessary medical procedures. Although overall healthcare costs are rising in the United States, recent trends in patient OOP costs for foot and ankle orthopaedic surgical procedures have not been reported. Fully understanding patient OOP costs for common orthopaedic surgical procedures, such as those performed on the foot and ankle, might help patients and professionals make informed decisions regarding treatment options and demonstrate to policymakers the growing unaffordability of these procedures.

QUESTIONS/PURPOSES

(1) How do OOP costs for common outpatient foot and ankle surgical procedures for commercially insured patients compare between elective and trauma surgical procedures? (2) How do these OOP costs compare between patients enrolled in various insurance plan types? (3) How do these OOP costs compare between surgical procedures performed in hospital-based outpatient departments and ambulatory surgical centers (ASCs)? (4) How have these OOP costs changed over time?

METHODS

This was a retrospective, comparative study drawn from a large, longitudinally maintained database. Data on adult patients who underwent elective or trauma outpatient foot or ankle surgical procedures between 2010 and 2020 were extracted using the MarketScan Database, which contains well-delineated cost variables for all patient claims, which are particularly advantageous for assessing OOP costs. Of the 1,031,279 patient encounters initially identified, 41% (427,879) met the inclusion criteria. Demographic, procedural, and financial data were recorded. The median patient age was 50 years (IQR 39 to 57); 65% were women, and more than half of patients were enrolled in preferred provider organization insurance plans. Approximately 75% of surgical procedures were classified as elective (rather than trauma), and 69% of procedures were performed in hospital-based outpatient departments (rather than ASCs). The primary outcome was OOP costs incurred by the patient, which were defined as the sum of the deductible, coinsurance, and copayment paid for each episode of care. Monetary data were adjusted to 2020 USD. A general linear regression, the Kruskal-Wallis test, and the Wilcoxon-Mann-Whitney test were used for analysis, as appropriate. Alpha was set at 0.05.

RESULTS

For foot and ankle indications, trauma surgical procedures generated higher median OOP costs than elective procedures (USD 942 [IQR USD 150 to 2052] versus USD 568 [IQR USD 51 to 1426], difference of medians USD 374; p < 0.001). Of the insurance plans studied, high-deductible health plans had the highest median OOP costs. OOP costs were lower for procedures performed in ASCs than in hospital-based outpatient departments (USD 645 [IQR USD 114 to 1447] versus USD 681 [IQR USD 64 to 1683], difference of medians USD 36; p < 0.001). This trend was driven by higher coinsurance for hospital-based outpatient departments than for ASCs (USD 391 [IQR USD 0 to 1136] versus USD 337 [IQR USD 0 to 797], difference of medians USD 54; p < 0.001). The median OOP costs for common outpatient foot and ankle surgical procedures increased by 102%, from USD 450 in 2010 to USD 907 in 2020.

CONCLUSION

Rapidly increasing OOP costs of common foot and ankle orthopaedic surgical procedures warrant a thorough investigation of potential cost-saving strategies and initiatives to enhance healthcare affordability for patients. In particular, measures should be taken to reduce underuse of necessary care for patients enrolled in high-deductible health plans, such as shorter-term deductible timespans and placing additional regulations on the implementation of these plans. Moreover, policymakers and physicians could consider finding ways to increase the proportion of procedures performed at ASCs for procedure types that have been shown to be equally safe and effective as in hospital-based outpatient departments. Future studies should extend this analysis to publicly insured patients and further investigate the health and financial effects of high-deductible health plans and ASCs, respectively.

LEVEL OF EVIDENCE

Level III, economic and decision analysis.

Ambulatory surgical management of most displaced tibial tubercle fractures in children is safe and efficient

Purpose

The purpose of this study is to compare the outcome of patients with displaced tibial tubercle fractures treated surgically who spent one or more nights in the hospital after surgery with that of patients treated in an ambulatory setting with no perioperative hospitalization. We hypothesized that tibial tubercle fractures have a low rate of complications and that most patients do well without an overnight hospital stay for observation.

Methods

We retrospectively reviewed all pediatric tibial tubercle fractures treated operatively by a single surgeon over a 13.5-year period. Fractures treated in an inpatient setting, defined as at least one night of overnight hospitalization postoperatively, were compared with fractures treated in an ambulatory setting with no perioperative hospitalization.

Results

Seventy-one fractures in 70 patients were analyzed. All fractures were treated with open reduction and internal fixation with unicortical screws. Thirty-five fractures (49.3%) were fixed in an ambulatory setting, while 36 (50.7%) were inpatient. There were no significant differences between inpatient demographics (age, gender, body mass index, fracture type). Average operative time was significantly longer in the inpatient group compared with the ambulatory group (97.8 min versus 58.8 min, p < 0.001). There was no significant difference in the incidence of complications between inpatient and ambulatory groups (25.0% versus 11.4%, p = 0.22). No cases of compartment syndrome were noted.

Conclusion

Ambulatory surgical treatment of select tibial tubercle fractures with same-day discharge is safe and efficient. Not all patients with surgically treated tibial tubercle fractures need to stay overnight in the hospital.

Evaluating safe time to discharge after closed reduction and percutaneous pinning of uncomplicated type III supracondylar humerus fractures: a single-center retrospective review

The purpose of this retrospective study was to review complications following closed reduction, percutaneous pinning of isolated, type III supracondylar fractures without associated injuries to evaluate if patients may be discharged safely on the day of surgery. We performed a retrospective chart and radiographic review of patients with isolated Gartland type III supracondylar humerus fractures who underwent closed reduction and percutaneous pinning over a 4-year period. We reviewed admission time to the emergency department, time and length of surgery, time to discharge, postoperative complications, readmission rate and office visits. Of the 110 patients included, 19 patients were discharged in less than 6 h, 45 patients between 6 and 12 h and 46 patients greater than 12 h. A total of 61 patients were discharged on the same day as surgery and 49 were discharged the next day. There were 11 postoperative complications. No postoperative complications were found in patients discharged less than 6 hours from surgery. For patients discharged between 6 and 12 hours postoperatively, one patient returned to the office earlier than scheduled. The result of our review suggests that patients can be safely discharged within the 12-h postoperative period with no increased risk of complications. This is contingent upon the patient having a stable neurovascular examination, pain control and caregiver's comfort level. This can decrease medical cost, family stress and burden to the hospital system. Time to discharge should still be evaluated on a case-by-case basis after evaluating medical and social barriers.

Social Disparities in Outpatient and Inpatient Management of Pediatric Supracondylar Humerus Fractures

Socioeconomic status, race, and insurance status are known factors affecting adult orthopaedic surgery care, but little is known about the influence of socioeconomic factors on pediatric orthopaedic care. The purpose of this study was to determine if demographic and socioeconomic related factors were associated with surgical management of pediatric supracondylar humerus fractures (SCHFs) in the inpatient versus outpatient setting. Pediatric patients (<13 years) who underwent surgery for SCHFs were identified in the New York Statewide Planning and Research Cooperative System database from 2009−2017. Inpatient and outpatient claims were identified by International Classification of Diseases-9-Clinical Modification (CM) and ICD-10-CM SCHF diagnosis codes. Claims were then filtered by ICD-9-CM, ICD-10-Procedural Classification System, or Current Procedural Terminology codes to isolate SCHF patients who underwent surgical intervention. Multivariable logistic regression analysis was performed to determine the effect of patient factors on the likelihood of having inpatient management versus outpatient management. A total of 7079 patients were included in the analysis with 4595 (64.9%) receiving inpatient treatment and 2484 (35.1%) receiving outpatient treatment. The logistic regression showed Hispanic (OR: 2.386, p < 0.0001), Asian (OR: 2.159, p < 0.0001) and African American (OR: 2.095, p < 0.0001) patients to have increased odds of inpatient treatment relative to White patients. Injury diagnosis on a weekend had increased odds of inpatient management (OR: 1.863, p = 0.0002). Higher social deprivation was also associated with increased odds of inpatient treatment (OR: 1.004, p < 0.0001). There are disparities among race and socioeconomic status in the surgical setting of SCHF management. Physicians and facilities should be aware of these disparities to optimize patient experience and to allow for equal access to care.

The Costs of Interfacility Transfers for Nonurgent Pediatric Supracondylar Fractures

BACKGROUND

Unnecessary transfers of nonemergent pediatric musculoskeletal injuries to regional trauma centers can be costly. The severity of fracture displacement in supracondylar humerus fractures dictates the risk of complications, the urgency of transfer and the need for surgical treatment. The purpose of this study is to examine the transfer patterns of Gartland type II pediatric supracondylar humerus fractures to identify strategies for improving patient care, improving health care system efficiency, and reducing costs. We hypothesize that there will be a high rate of unnecessary, emergent transfers resulting in increased cost.

METHODS

We retrospectively identified all pediatric patients that underwent treatment for a supracondylar humerus fracture between 2013 and 2018. Patient demographics, injury characteristics, chronological data, and surgical data were collected and analyzed from ambulance run sheets, transferring hospital records, and electronic medical records. Transfer distances were estimated using Google-Maps, while transfer costs were estimated using Internal Revenue Service (IRS) standard mileage rates and the American Ambulance Association Medicare Rate Calculator. A student t test was used to evaluate different treatment groups.

RESULTS

Sixty-two patients had available and complete transfer data, of which 44 (71%) patients were safely transferred via private vehicle an average distance of 51.8 miles, and 18 (29%) patients were transferred via ambulance on an average distance of 55.6 miles ( P =0.76). The average transfer time was 4.1 hours by private vehicle, compared with 3.9 hours by ambulance ( P =0.56). The average estimated cost of transportation was $28.23 by private vehicle, compared with $647.83 by ambulance ( P =0.0001). On average, it took 16.1 hours after injury to undergo surgery and 25.7 hours to be discharged from the hospital, without a significant difference in either of these times between groups. There were no preoperative or postoperative neurovascular deficits.

CONCLUSION

Patients with isolated Gartland type II supracondylar humerus fractures that are transferred emergently via ambulance are subjected to a significantly greater financial burden with no demonstrable improvement in the quality of their care, since prior research has shown these injuries can safely be treated on an outpatient basis. Potential options to help limit costs could include greater provider education, telemedicine and improved coordination of care.

LEVEL OF EVIDENCE

Level III (retrospective comparative study).

Outpatient Operative Management of Pediatric Supracondylar Humerus Fractures: An Analysis of Frequency, Complications, and Cost From 2009 to 2018

BACKGROUND

In an effort to increase the value of health care in the United States, there has been increased focus on shifting certain procedures to an outpatient setting. While pediatric supracondylar humerus fractures (SCHFs) have traditionally been treated in an inpatient setting, recent studies have investigated the safety and efficiency of outpatient surgery for these injuries. This retrospective study aims to examine ongoing trends of outpatient surgical care for SCHFs, examine the safety and complication rates of these procedures, and investigate the potential cost-savings from this shift in care.

METHODS

Pediatric patients less than 13 years old who underwent surgery for closed SCHF from 2009 to 2018 were identified using International Classification of Diseases-9/10 Clinical Modification and Procedural Classification System codes in the New York Statewide Planning and Research Cooperative System (SPARCS) database. Linear regression was used to assess the shift in proportion of outpatient surgical management of these injuries over time. Multivariable Cox proportional hazards regression was used to compare return to emergency department (ED) visit, readmission, reoperation, and other adverse events. A 2-sample t test was performed on the average charge amount per claim for inpatient versus outpatient surgery.

RESULTS

A total of 8488 patients were included in the analysis showing there was a statistically significant shift towards outpatient management between 2009 (23% outpatient) and 2018 (59% outpatient) (P<0.0001). Relative to inpatient surgical management, outpatient surgical management had lower rates of return ED visits at 1 month (hazard ratio: 0.744, P=0.048). All other adverse events compared across inpatient and outpatient surgical management were not significantly different. The median amount billed per claim for inpatient surgeries was significantly higher than for outpatient surgeries ($16,097 vs. $9,752, P<0.0001). White race, female sex, and weekday ED visit were associated with increased rate of outpatient management.

CONCLUSIONS

This study demonstrates the trend of increasing outpatient surgical management of pediatric SCHF from 2009 to 2018. The increased rate of outpatient management has not been associated with elevated complication rates but is associated with significantly reduced health care charges.

LEVEL OF EVIDENCE

Level III-retrospective cohort.

Evaluating Perioperative Complications Surrounding Supracondylar Humerus Fractures: Expanding Indications for Outpatient Surgery

BACKGROUND

Supracondylar humerus (SCH) fractures are one of the most common pediatric orthopaedic injuries. Described using the Wilkins modification of the Gartland Classification system, current practice guidelines give moderate evidence for closed reduction and percutaneous pinning of type 2 and 3 injuries, but little evidence exists regarding the appropriate surgical setting for fixation. The goal of this study was to evaluate the perioperative complication profile of type 3 fractures with maintained metaphyseal contact and determine their suitability for outpatient surgery.

METHODS

Skeletally immature patients with type 2 and 3 SCH fractures treated at a single, Level-1 trauma institution from March 2019 to January 2000 were retrospectively reviewed. A total of 1126 subjects were identified. Open, concomitant injuries, incomplete physical examination, initial neurovascular compromise, flexion-type fractures, ecchymosis, skin compromise, and those managed nonoperatively were excluded. Type 3 fractures were categorized as either "3M" versus type "3" ("M" denoting metaphyseal bony contact). Demographic data, neurovascular changes, and postoperative complications were collected. Categorical variables were evaluated using χ2 or Fisher exact tests, and continuous variables analyzed using analysis of variance, with significance defined as a P-value <0.05.

RESULTS

A total of 485 patients (189 type 2, 164 type 3M, 132 type 3) met inclusion criteria. Sex and length of stay did not differ among groups. The incidence of neurovascular change between initial presentation and surgical fixation was significantly greater for type 3 fractures compared with other groups (P=0.02). No child in the 3M group had preoperative neurovascular examination changes, compared with 3 patients with type 3 injuries. When directly compared with the 3M group, type 3 fractures had a higher incidence of neurovascular examination changes that trended towards significance (P=0.08). There was no difference in postoperative complication rate between groups (P=0.61).

CONCLUSIONS

Our findings demonstrate that Gartland type 3 SCH fractures lacking metaphyseal bony contact, compared with types 3M and 2, are more likely to experience neurovascular examination changes between initial presentation and definitive surgical fixation. Type 3M fractures clinically behaved like type 2 injuries and, accordingly, could be considered for treatment on an outpatient basis.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

Ambulatory Endoscopic Thyroidectomy via a Chest-Breast Approach Has an Acceptable Safety Profile for Thyroid Nodule

INTRODUCTION

With the growing esthetic requirements, endoscopic thyroidectomy develops rapidly and is widely accepted by practitioners and patients to avoid the neck scar caused by open thyroidectomy. Although ambulatory open thyroidectomy is adopted by multiple medical centers, the safety and potential of ambulatory endoscopic thyroidectomy via a chest-breast approach (ETCBA) is poorly investigated.

MATERIAL AND METHODS

Patients with thyroid nodules who received conventional or ambulatory ETCBA at Xiangya hospital, Central South University from January 2017 to June 2020 were retrospectively included. The incidence of postoperative complications, 30-days readmission rate, financial cost, duration of hospitalization, mental health were mainly investigated.

RESULTS

A total of 260 patients were included with 206 (79.2%) suffering from thyroid carcinoma, while 159 of 260 received ambulatory ETCBA. There was no statistically significant difference in the incidence of postoperative complications (P=0.249) or 30-days readmission rate (P=1.000). In addition, The mean economic cost of the ambulatory group had a 29.5% reduction compared with the conventional group (P<0.001). Meanwhile, the duration of hospitalization of the ambulatory group was also significantly shorter than the conventional group (P<0.001). Patients received ambulatory ETCBA showed a higher level of anxiety (P=0.041) and stress (P=0.016). Subgroup analyses showed consistent results among patients with thyroid cancer with a 12.9% higher complication incidence than the conventional ETCBA (P=0.068).

CONCLUSION

Ambulatory ETCBA is as safe as conventional ETCBA for selective patients with thyroid nodules or thyroid cancer, however with significant economic benefits and shorter duration of hospitalization. Extra attention should be paid to manage the anxiety and stress of patients who received ambulatory ETCBA.

Cost Analysis of Treating Pediatric Supracondylar Humerus Fractures in Community Hospitals Compared With a Tertiary Care Hospital

OBJECTIVE

In the current healthcare environment, providing cost-efficient care is of paramount importance. One emerging strategy is to use community hospitals (CHs) rather than tertiary care hospitals (TCHs) for some procedures. This study assesses the costs of performing closed reduction percutaneous pinning (CRPP) of pediatric supracondylar humerus fractures (SCHFs) at a CH compared with a TCH.

METHODS

A retrospective review of 133 consecutive SCHFs treated with CRPP at a CH versus a TCH over a 6-year period was performed. Total encounter and subcategorized costs were compared between the procedures done at a CH versus those done at a TCH.

RESULTS

Performing CRPP for a SCHF at a CH compared with a TCH saved 44% in costs (P < 0.001). Cost reduction of 51% was attributable to operating room costs, 19% to anesthesia-related costs, 16% to imaging-related costs, and 7% to supplies.

DISCUSSION

Performing CRPP for a SCHF at a CH compared with a TCH results in a 44% decrease in direct cost, driven largely by surgical, anesthesia, and radiology-related savings.

High-Volume and Privately Owned Ambulatory Surgical Centers Reduce Costs in Achilles Tendon Repair

Background:

While Achilles tendon repairs are common, little data exist characterizing the cost drivers of this surgery.

Purpose:

To examine cases of primary Achilles tendon repair, primary repair with graft, and secondary repair to find patient characteristics and surgical variables that significantly drive costs.

Study Design:

Economic and decision analysis; Level of evidence, 3.

Methods:

A total of 5955 repairs from 6 states were pulled from the 2014 State Ambulatory Surgery and Services Database under the Current Procedural Terminology codes 27650, 27652, and 27654. Cases were analyzed under univariate analysis to select the key variables driving cost. Variables deemed close to significance (P < .10) were then examined under generalized linear models (GLMs) and evaluated for statistical significance (P < .05).

Results:

The average cost was $14,951 for primary repair, $23,861 for primary repair with graft, and $20,115 for secondary repair (P < .001). In the GLMs, high-volume ambulatory surgical centers (ASCs) showed a cost savings of $16,987 and $2854 in both the primary with graft and secondary repair groups, respectively (both P < .001). However, for primary repairs, high-volume ASCs had $2264 more in costs than low-volume ASCs (P < .001). In addition, privately owned ASCs showed cost savings compared with hospital-owned ASCs for both primary Achilles repair ($2450; P < .001) and primary repair with graft ($11,072; P = .019). Time in the operating room was also a significant cost, with each minute adding $36 of cost in primary repair and $31 in secondary repair (both P < .001).

Conclusion:

Private ASCs are associated with lower costs for patients undergoing primary Achilles repair, both with and without a graft. Patients undergoing the more complex secondary and primary with graft Achilles repairs had lower costs in facilities with greater caseload.

The safety of foot and ankle procedures at an ambulatory surgery center

Background

This study evaluates the safety of foot and ankle outpatient surgeries at a freestanding ambulatory surgery centers.

Methods

A total of 1352 cases were evaluated for adverse events in a retrospective review of all foot and ankle cases performed over a 5-year period at a single center.

Results

The rate of adverse events was 2.3%, with 31 identified over the 5-year period (23 infections, 5 symptomatic thromboembolisms, 3 postoperative hospital transfers).

Discussion

The rate of postoperative adverse events in outpatient foot and ankle procedures is low. These surgeries can be performed safely in an outpatient setting at an ASC.

Level of evidence

Level IV, Case Series.

The Development of a Standardized Pathway for Outpatient Ambulatory Fracture Surgery: To Admit or Not to Admit

BACKGROUND

Increased scrutiny of health-care costs and inpatient length of stay has resulted in many orthopaedic procedures transitioning to outpatient settings. Recent studies have supported the safety and efficiency of outpatient fracture procedures. The aim of the present study was to reduce unnecessary inpatient hospitalizations for healthy patients awaiting surgical treatment of a fracture by 80% by June 30, 2017, with a focus on timely, efficient, and patient-centered care.

METHODS

The study design was a time series using statistical process control methodology. Baseline data from October 2014 to June 2016 were compared with the intervention period from July 2016 to December 2018. The Model for Improvement was used as the framework for developing and implementing interventions. The main interventions were a policy change to allow booking of outpatient urgent-room cases, education for patients and nurses, and the development of a standardized outpatient pathway.

RESULTS

One hundred and eighty-seven patients during the pre-intervention period and 308 patients during the intervention period were eligible for the ambulatory pathway. The percentage of patients managed as outpatients increased from 1.6% pre-intervention to 89.1% post-intervention. The length of stay was reduced from 2.8 to 0.2 days, a decrease of 94.0%. Patient satisfaction remained high, and there were no safety concerns while patients waited at home for the surgical procedure.

CONCLUSIONS

The outpatient fracture pathway vastly improved the efficiency and timeliness of care and reduced health-care costs. A patient-centered culture and support from hospital administration were integral in producing sustainable improvement.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Inpatient Versus Outpatient Treatment of Gartland Type II Supracondylar Humerus Fractures: A Cost and Safety Comparison

BACKGROUND

In an effort to increase health care value, there has been a recent focus on the transition of traditionally inpatient procedures to an outpatient setting. We hypothesized that in the treatment of Gartland extension type II supracondylar humerus fractures (SCHF), outpatient surgery can be performed safely and with similar clinical and radiographic outcomes compared with urgent inpatient treatment with an overall reduction in cost.

METHODS

We compared a prospective cohort of Gartland type II SCHF treated primarily as outpatients (postprotocol) to a retrospective cohort treated primarily as urgent inpatients (preprotocol), excluding patients with preoperative neurovascular injury, open fracture, additional ipsilateral upper extremity fracture, and prior ipsilateral SCHF. Inpatient versus outpatient treatment was also compared. Outcomes including perioperative factors, complications, readmission, reoperation, postoperative radiographic measurements, and direct hospital costs underwent univariate and multivariate analyses.

RESULTS

A total of 220 patients in the postprotocol cohort (88 inpatients and 132 outpatients) and 129 in the preprotocol cohort (97 inpatients and 32 outpatients) were analyzed. There were no differences in operative times, number of pins, conversion to open reductions, readmissions, or reoperations between cohorts or groups, and no cases developed postoperative neurovascular injuries or compartment syndromes. Total complications did not differ between the preprotocol and postprotocol cohorts; however, were higher in the inpatient group (3.8% vs. 0%; P=0.016) in the univariate, but not multivariate analysis. There were no differences in Baumann angle or humerocondylar angle. Significantly more inpatients' anterior humeral line fell outside of the middle third of the capitellum in the univariate, but not multivariate analysis. There were significant reductions in total cost per patient between the preprotocol and postprotocol cohorts (marginal effect, -$215; P<0.0001) and between the inpatient and outpatient groups (marginal effect, -$444; P<0.0001).

CONCLUSIONS

Delayed treatment of Gartland type II SCHF in the outpatient setting can be performed safely and with similar clinical and radiographic outcomes to those treated urgently as inpatients with a significant cost reduction.

LEVEL OF EVIDENCE

Therapeutic level III-retrospective comparative study.