Safety and Outcome Measures of Ankle Open Reduction and Internal Fixation in an Ambulatory Surgical Center

The transition of traditionally hospital-based orthopedic procedures to the ambulatory surgery center setting provides many benefits from a patient care and financial perspective. Specifically, closed ankle fractures can potentially be managed at such centers without needing hospitalization. Adding to the paucity of data, this study describes the safety, cost, and outcomes of patients undergoing ankle fracture repair in an ambulatory surgery center. A retrospective chart review of 100 patients who underwent ankle fracture open reduction and internal fixation from a single ambulatory surgery center by 1 surgeon were reviewed. Demographic data, surgical characteristics including operating time and cost were collected. Short- and long-term complications, as well as, reoperation rates were reported and functional outcomes were described. Of the 100 patients, 59% were female and the overall average age was 50 ± 16 years. The average cost per case was $8,709.63 ± 6,360.18. The short-term complication rate was 16%, with surgical site infection reported as the most common complication. No postoperative hospital admissions were reported. Planned and unplanned hardware removal was performed in 7% and 5% of patients, respectively. The delayed union rate was 13%, in which 86% shared a history of smoking. Smoking history was the only statistically significant predictor of prolonged bone healing (p = .002). This investigation demonstrates low complications rates for surgeries performed in a surgery center when compared to historical rates of those procedures performed in the hospital. These results suggest that ambulatory surgery center-based ankle fracture repair does not increase complications while may decrease overall cost when compared to ankle ORIF in a hospital setting.

Can Reducing Implant Costs Increase Revenue for Surgically Treated Ankle Fractures: Time-Driven Activity-Based Costing for 1-Year Episode of Care

BACKGROUND

The purpose of this study was to investigate whether decision-making regarding implant selection affects the reimbursement margins for the surgical fixation of ankle fractures.

METHODS

All ankle fractures treated between 2010 and 2017 within a single-insurer database were identified via Current Procedural Terminology codes by review of electronic medical record. Implant cost was determined via the implant record cross-referenced with the single contract institutional charge master database. The Time-Driven Activity-Based Costing (TDABC) technique was used to determine the costs of care during all activities throughout the 1-year episode of care. Statistical analysis consisted of multiple linear regression and goodness-of-fit analyses.

RESULTS

In all, 249 patients met inclusion criteria. Implant costs ranged from $173 to $3944, averaging $1342 ± $751. The TDABC-estimated cost of care ranged from $1416 to $9185, averaging $3869 ± $1384. Finally, the total reimbursed cost of care ranged between $1335 and $65 645, averaging $13 954 ± $9445. The implant costs occupied an estimated 34.7% of the TDABC-estimated cost of care per surgical encounter. Implant cost, as a percentage of the overall TDABC, was estimated as 36.2% in the inpatient setting and 33% in the outpatient setting, which was the second highest percentage behind surgical costs in both settings. We found a significant increase in net revenue of $1.93 for each dollar saved on implants in the outpatient setting, whereas the increase in net revenue per dollar saved of $1.03 approached significance in the inpatient setting.

CONCLUSION

There is a direct relationship between intraoperative decision-making, as evidenced by implant choices, and the revenue generated by surgical fixation of ankle fractures. Intraoperative decision-making that is cognitive of implant cost can facilitate adoption of institutional cost containment measures and prompt increased healthcare value.

LEVEL OF EVIDENCE

Level III: Retrospective cohort study.

[National competitive bidding analysis of osteosynthesis materials in pediatric patients with femur fractures]

INTRODUCTION

health promotion policy requires the identification of barriers to the adoption of public policies. Paraguay's national healthcare system is inequitable, expensive, and inefficient. The Ministry of Public Health and Social Welfare (MSPyBS) is the entity responsible for covering the needs of a significant portion of the population. In January 2022, the MSPyBS financed the purchase of titanium elastic nails through a National Public Tender for Osteosynthesis Materials (LPN 02/22) to provide them for free in the pediatric service. Using research as a tool, we seek to analyze the impact of the implementation of LPN 02/22 at the Trauma Hospital, believing that this action would help streamline administrative and bureaucratic processes, making them more efficient with the assistance of the hospital's human resources.

MATERIAL AND METHODS

a retrospective, analytical, and comparative study conducted at a high-complexity trauma center in Asunción, Paraguay. Patients aged 4 to 14 years with an indication for stabilization with elastic nails were included. Demographic data, the mechanism of injury, time elapsed from hospital arrival to surgical treatment, length of hospital stay, and the average hospital cost were analyzed based on the daily expense of pediatric patient hospitalization.

RESULTS

52 patients, divided into 25 cases in 2021 before implementation and 27 cases after implementation. The time elapsed from hospital arrival to definitive treatment was six days in the pre-implementation period, with an average stay from admission to discharge of 7.4 days. After implementation, the time from hospital arrival to definitive treatment was 4.3 days, and the average discharge time for the Post group was six days. The potential savings per patient amount to 332 dollars, offset by the institution's implant supply cost of 197 dollars, resulting in an approximate savings of 135 dollars per patient for the ministry.

CONCLUSIONS

we view the implementation of free titanium elastic nails for pediatric femur fracture patients positively. We encourage the institution to continue with similar policies and strive to achieve even greater benefits for users.

Surgical plating versus closed reduction for fractures in the distal radius in older patients: a cost-effectiveness analysis from the hospital perspective

BACKGROUND

Given the cost differential between surgical and non-surgical management of distal radius fractures, we aimed to evaluate the cost-effectiveness of surgical compared with non-surgical treatment of distal radius fractures in a cohort of older patients.

METHODS

This evaluation was conducted alongside the combined randomized and observational study of surgery for fractures of the distal radius in the elderly (CROSSFIRE) trial (ACTRN 12616000969460) which compared surgical (open reduction and internal fixation using volar-locking plate (VLP) fixation) and non-surgical (closed fracture reduction and cast immobilization (CR)) treatment for displaced distal radius fractures in patients ≥60 years. Cost-effectiveness was assessed from the perspective of the public hospital funder. Hospital records from a sub-sample of participants were used to estimate costs. Outcomes were patient-reported wrist pain and function questionnaire (PRWE) scores and quality adjusted life years (QALYs) calculated using the EuroQoL five-dimension five-level tool (EQ-5D-5L).

RESULTS

From 166 participants (81 surgical, 85 non-surgical), costs were obtained for 56 (29 surgical, 27 non-surgical). The mean costs for VLP fixation were Australian dollars (AUD) 6668 (95% CI $4857 to $8479) compared to AUD 3343 (95% CI $1304 to $5381) for CR. The incremental cost-effectiveness ratios (ICER) to achieve a 1-point improvement in the PRWE were AUD 375, AUD 1736 and AUD 1126 at 3, 12 and 24 months for VLP compared with CR. At 12 months, the cost effectiveness was dominated by CR (lower cost and better QoL) whereas at 24 months, the incremental cost per QALY gained by VLP was AUD 1 946 127.

CONCLUSION

In the treatment of distal radius fractures in patients ≥60 years, VLP fixation was not cost-effective compared with CR from the perspective of hospital funders.

What Factors Are Associated with Increased Financial Burden and High Financial Worry For Patients Undergoing Common Hand Procedures?

BACKGROUND

Few studies have examined whether orthopaedic surgery, including hand surgery, is associated with patients' financial health. We sought to understand the level of financial burden and worry for patients undergoing two common hand procedures-carpal tunnel release and open reduction and internal fixation for a distal radius fracture-as well as to determine factors associated with a higher financial burden and worry.

QUESTIONS/PURPOSES

In patients undergoing operative treatment for isolated carpal tunnel syndrome with carpal tunnel release or open reduction and internal fixation for a distal radius fracture, we used validated financial burden and worry questionnaires to ask: (1) What percentage of patients report some level of financial burden, and what is the median financial burden composite score? (2) What percentage of patients report some level of financial worry, and what percentage of patients report a high level of financial worry? (3) When accounting for other assessed factors, what patient- and condition-related factors are associated with financial burden? (4) When accounting for other assessed factors, what patient- and condition-related factors are associated with high financial worry?

METHODS

In this cross-sectional survey study, a hand and upper extremity database at a single tertiary academic medical center was reviewed for patients 18 years or older undergoing operative treatment in our hand and upper extremity division for an isolated distal radius fracture between October 2017 and October 2019. We then selected all patients undergoing carpal tunnel release during the first half of that time period (given the frequency of carpal tunnel syndrome, a 1-year period was sufficient to ensure comparable patient groups). A total of 645 patients were identified (carpal tunnel release: 60% [384 of 645 patients]; open reduction and internal fixation for a distal radius fracture: 40% [261 of 645 patients). Of the patients who underwent carpal tunnel release, 6% (24 of 384) were excluded because of associated injuries. Of the patients undergoing open reduction and internal fixation for a distal radius fracture, 4% (10 of 261) were excluded because of associated injuries. All remaining 611 patients were approached. Thirty-six percent (223 of 611; carpal tunnel release: 36% [128 of 360]; open reduction and internal fixation: 38% [95 of 251]) of patients ultimately completed two validated financial health surveys: the financial burden composite and financial worry questionnaires. Descriptive statistics were calculated to report the percentage of patients who had some level of financial burden and worry. Further, the median financial burden composite score was determined. The percentage of patients who reported a high level of financial worry was calculated. A forward stepwise regression model approach was used; thus, variables with p values < 0.10 in bivariate analysis were included in the final regression analyses to determine which patient- and condition-related factors were associated with financial burden or high financial worry, accounting for all other measured variables.

RESULTS

The median financial burden composite score was 0 (range 0 [lowest possible financial burden] to 6 [highest possible financial burden]), and 13% of patients (30 of 223) reported a high level of financial worry. After controlling for potentially confounding variables like age, insurance type, and self-reported race, the number of dependents (regression coefficient 0.15 [95% CI 0.008 to 0.29]; p = 0.04) was associated with higher levels of financial burden, while retired employment status (regression coefficient -1.24 [95% CI -1.88 to -0.60]; p < 0.001) was associated with lower levels of financial burden. In addition, the number of dependents (odds ratio 1.77 [95% CI 1.21 to 2.61]; p = 0.004) and unable to work or disabled employment status (OR 3.76 [95% CI 1.25 to 11.28]; p = 0.02) were associated with increased odds of high financial worry.

CONCLUSION

A notable number of patients undergoing operative hand care for two common conditions reported some degree of financial burden and worry. Patients at higher risk of financial burden and/or worry may benefit from increased resources during their hand care journey, including social work consultation and financial counselors. This is especially true given the association between number of dependents and work status on financial burden and high financial worry. However, future research is needed to determine the return on investment of this resource utilization on patient clinical outcomes, overall quality of life, and well-being.

LEVEL OF EVIDENCE

Level III, therapeutic study.

The ideal implant for Mayo 2A olecranon fractures? An economic evaluation

BACKGROUND

The ideal implant for stable, noncomminuted olecranon fractures is controversial. Tension band wiring (TBW) is associated with lower cost but higher implant removal rates.On the other hand, plate fixation (PF) is purported to be biomechanically superior, with lower failure and implant removal rates, although associated with higher cost. The primary aim of this study is to look at the clinical outcomes for all Mayo 2A olecranon between PF and TBW. The secondary aim is to perform an economic evaluation of PF vs. TBW.

MATERIALS AND METHODS

This is a retrospective study of all surgically treated Mayo 2A olecranon fractures in a tertiary hospital from 2005-2016. Demographic data, medical history, range of motion, and complications were collected. All inpatient and outpatient costs in a 1-year period postsurgery including the index surgical procedure were collected via the hospital administrative cost database (normalized to 2014).

RESULTS

A total of 147 cases were identified (94 TBW, 53 PF). PF was associated with higher mean age (P < .01), higher American Society of Anesthesiologists score (P < .01), and higher proportion of hypertensives (P = .04). There was no difference in the range of motion achieved at 1 year for both groups. In terms of complications, TBW was associated with more symptomatic hardware (21.6% vs. 13.7%, P = .24) and implant failures (16.5% vs. none, P < .01), whereas the plate group had a higher wound complication (5.9% vs. none, P = .02) and infection rate (9.8% vs. 3.1%, P = .09). TBW had a higher implant removal rate of 30.9% compared with 22.7% for PF (P = .36). PF had a higher cost at all time points, from the index surgery ($10,313.64 vs. $5896.36, P < .01), 1-year cost excluding index surgery ($5069.61 vs. $3850.46, P = .46), and outpatient cost ($1667.80 vs. $1613.49, P = .27).

DISCUSSION AND CONCLUSION

Based on our study results, we have demonstrated that TBW is the ideal implant for Mayo 2A olecranon fractures from both a clinical and economic standpoint, with comparable clinical results, potentially similar implant removal rates as PF's, and a lower cost over a 1-year period. In choosing the ideal implant, the surgeon must take into account, first, the local TBW and PF removal rate, which can vary significantly because of the patient's profile and beliefs, and second, the PF implant cost.

Clinical outcome and operative cost comparison: Locked compression plate versus reconstruction plate in midshaft clavicle fractures

OBJECTIVE

The aim of this study was to compare the clinical outcomes and operative cost of a locked compression plate (LCP) and a nonlocked reconstruction plate in the treatment of displaced midshaft clavicle fracture.

METHODS

From January 2013 till March 2018, a total of 55 patients with acute unilateral closed midshaft clavicle fracture were treated with either a 3.5-mm pre-contoured LCP [32 patients; 25 men and 7 women; mean age: 35 years (range: 19-63 years)] or a 3.5-mm nonlocked reconstruction plate [23 patients; 20 men and 3 women; mean age: 31.4 years (range: 17-61 years)]. The clinical outcomes in terms of fracture union, Quick Disability of Arm, Shoulder and Hand (DASH) score, implant irritation, failure rate, and reoperation rate were evaluated retrospectively. The patient billing records were reviewed to obtain primary operation, reoperation, and total operative cost for midshaft clavicle fracture. These values were analyzed and converted from Malaysia Ringgit (RM) to United States Dollar (USD) at the exchange rate of RM 1 to USD 0.24. All patients were followed up for at least one-year duration.

RESULTS

The mean time to fracture union, implant irritation, implant failure, and reoperation rate showed no significant difference between the two groups of patients. The mean Quick DASH score was significantly better in the reconstruction plate group with 13 points compared with 28 points in the LCP group (p=0.003). In terms of total operative cost, the LCP group recorded a cost of USD 391 higher than the reconstruction plate group (p<0.001).

CONCLUSION

The 3.5-mm reconstruction plate achieved not only satisfactory clinical outcomes but was also more cost-effective than the LCP in the treatment of displaced midshaft clavicle fractures.

LEVEL OF EVIDENCE

Level III, Therapeutic study.

Exploring trends in admissions and treatment for ankle fractures: a longitudinal cohort study of routinely collected hospital data in England

BACKGROUND

Evidence on the most effective and cost-effective management of ankle fractures is sparse but evolving. A recent large RCT in older patients with unstable fractures found that management with close-contact-casting was functionally equivalent and more cost-effective than internal fixation. We describe temporal and geographic variation in ankle fracture management and estimate the potential savings if close-contact-casting was used more often in older patients.

METHODS

Patients admitted to hospital in England between 2007/08 and 2016/17 with an ankle fracture were identified using routine hospital episode statistics. We tested whether the use of internal fixation, and the proportion of internal fixations using intramedullary implants, changed over time. We estimated the potential annual cost savings if patients aged 60+ years were treated with close-contact-casting rather than internal fixation, in line with emerging evidence.

RESULTS

Over the 10-year period, there were 223,465 hospital admissions with a primary ankle fracture diagnosis. The incidence (per 100,000) of internal fixation was fairly consistent over time in younger (33.2 in 2007/08, 30.9 in 2016/17) and older (36.5 in 2007/08, 37.4 in 2016/17) patients. The proportion of internal fixations which used intramedullary implants increased in both age groups (17.0-19.5% < 60 years; 15.2-17.4% 60+ years). In 2016/17, the cost of inpatient hospital care for ankle fractures in England was over £63.1million. If 50% of older patients who had an internal fixation instead had close-contact-casting, we estimate that approximately £1.56million could have been saved.

CONCLUSIONS

Despite emerging evidence that non-surgical and surgical management achieve equivalent functional outcomes in older patients, the rate of surgical fixation has remained relatively stable over the decade. The health service could achieve substantial savings if a higher proportion of older patients were treated with close-contact-casting, in line with recent evidence.

One-stage posterior debridement, bone grafting fusion, and mono-segment vs. short-segment fixation for single-segment lumbar spinal tuberculosis: minimum 5-year follow-up outcomes

BACKGROUND

To compare the clinical and radiological outcomes between posterior mono-segment and short-segment fixation combined with one-stage posterior debridement and bone grafting fusion in treating single-segment lumbar spinal tuberculosis (LSTB).

METHODS

Sixty-two patients with single-segment LSTB treated by a posterior-only approach were divided into two groups: short-segment fixation (Group A, n = 32) and mono-segment fixation (Group B, n = 30). The clinical and radiographic outcomes were analyzed and compared between the two groups.

RESULTS

The intraoperative bleeding volume, operation time, and hospitalization duration were lower in Group B than in Group A. All patients achieved the bony fusion criteria. The visual analog scale score, Japanese Orthopedic Association score, and Oswestry Disability Index were substantially improved 3 months postoperatively and at the last visit in both groups, with no significant difference between the two groups (P > 0.05). Kirkaldy-Willis functional evaluation at the final follow-up demonstrated that all patients in both groups achieved excellent or good results. The difference in the angle correction rate and correction loss between Groups A and B was not significant (P > 0.05).

CONCLUSIONS

One-stage posterior debridement, bone grafting fusion, and mono-segment or short-segment fixation can provide satisfactory clinical and radiological outcomes. Mono-segment fixation is more suitable for the treatment of single-segment LSTB because the lumbar segments with normal motion can be preserved with less trauma, a shorter operation time, shorter hospitalization, and lower costs.

Assessment of Anatomic Restoration of Distal Radius Fractures Among Older Adults: A Secondary Analysis of a Randomized Clinical Trial

IMPORTANCE

The value of precise anatomic restoration for distal radius fractures (DRFs) in older adults has been debated for many decades, with conflicting results in the literature. In light of the growing population of adults aged 60 years and older, both fracture incidence and associated treatment costs are expected to increase.

OBJECTIVE

To determine the association between radiographic measures of reduction and patient outcomes after DRF in older patients.

DESIGN, SETTING, AND PARTICIPANTS

Data were collected from the Wrist and Radius Injury Surgical Trial (WRIST), a multicenter randomized clinical trial of DRF treatments for adults aged 60 years and older (enrollment from April 10, 2012, to December 31, 2016, with a 2-year follow-up). Data analysis was performed from January 3, 2019, to August 19, 2019. WRIST participants who completed 12-month assessments were included in the study. According to the biomechanical principle of alignment, 2-phase multivariable regression models were adopted to assess the association between radiographic measures of reduction and functional and patient-reported outcomes 12 months following treatment.

INTERVENTIONS

Participants were randomized to receive volar locking plate, percutaneous pinning, or external fixation. Those who opted for nonoperative treatment received casts.

MAIN OUTCOMES AND MEASURES

Hand grip strength, wrist arc of motion, radial deviation, ulnar deviation, the Michigan Hand Outcomes Questionnaire (MHQ) total score, MHQ function score, and MHQ activities of daily living score were measured at 12 months following treatment.

RESULTS

Data from 166 WRIST participants (144 [86.7%] women; mean [SD] age, 70.9 [8.9] years) found that only 2 of the 84 correlation coefficients calculated were statistically significant. For patients aged 70 years or older, every degree increase in radial inclination away from normal (22°) grip strength in the injured hand was 1.1 kg weaker than the uninjured hand (95% CI, 0.38-1.76; P = .004) and each millimeter increase toward normal (0 mm) in ulnar variance was associated with a 10.4-point improvement in MHQ ADL score (95% CI, -16.84 to -3.86; P = .003). However, neither of these radiographic parameters appeared to be associated with MHQ total or function scores.

CONCLUSIONS AND RELEVANCE

The study results suggest that precise restoration of wrist anatomy is not associated with better patient outcomes for older adults with DRF 12 months following treatment. Surgeons can consider this evidence to improve quality of care by prioritizing patient preferences and efficient use of resources over achieving exact realignment.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01589692.

The Cost-Effectiveness of Reverse Total Shoulder Arthroplasty Versus Open Reduction Internal Fixation for Proximal Humerus Fractures in the Elderly

BACKGROUND

Open reduction and internal fixation (ORIF) of proximal humerus fractures in elderly individuals (age >70) carries a relatively high short-term complication and reoperation rate but is generally durable once healed. Reverse total shoulder arthroplasty (RTSA) for fractures may be associated with superior short-term quality of life but carries the lifelong liabilities of joint replacement. The tradeoff between short and long-term risks, coupled with disparities in quality of life and cost, makes this clinical decision amenable to cost-effectiveness analysis.

METHODS

A Markov state-transition model was constructed with a base case of a 75 year-old patient. Reoperation rates, quality of life values, mortality rates, and costs were based upon published literature. The model was run until all patients had died to simulate the accumulated costs and benefits.

RESULTS

RTSA was associated with greater quality of life (7.11 QALYs) than ORIF (6.22 QALYs). RTSA was cost-effective with an incremental cost-effectiveness ratio of $3,945/QALY and $27,299/ QALY from payor and hospital perspectives, respectively. RTSA was favored and cost-effective at any age above 65 and any Charlson Score. The model was sensitive to the utility of both procedures.

CONCLUSION

RTSA resulted in a higher quality of life and was cost-effective in comparison to ORIF for elderly patients.Level of Evidence: III.

Institutional Variation in Surgical Rates and Costs for Pediatric Distal Radius Fractures: Analysis of the Pediatric Health Information System (PHIS) Database

BACKGROUND

Reduction of variations may streamline healthcare delivery, improve patient outcomes, and minimize cost. The purpose of this study was to characterize variations in surgical rates and hospital costs for treatment of pediatric distal radius fractures (DRFs) using Pediatric Health Information System (PHIS) database.

METHODS

The PHIS database was queried from 2009-2013 for DRFs in patients 4-18 years of age. Patients who underwent surgical treatment with internal fixation were identified using surgical CPT codes and/or ICD-9 procedure codes. 25 children's hospitals were included. Surgical rates and hospital costs were modeled. Rates were adjusted and standardized for gender, age, presence of other diagnoses, and year.

RESULTS

The aggregate rate of surgery for treatment of DRF was 2.65% and for open surgery was 0.81%. The standardized surgical rates for the 25 hospitals ranged widely, from 1.45% to 13.8% and for open surgical treatment from 0.51% to 4.27%. Six of the 25 hospitals had rates significantly higher than the aggregate for surgical treatment. Standardized hospital costs per patient ranged from $361 to $1,088 (2013 US dollars) across the hospitals with fairly uniform distribution.

CONCLUSIONS

In the United States, there is great variability in practice and hospital costs of treatment of distal radius fractures. Further characterization of the root causes of these variations, and the effect, if any, on patient outcomes, is needed to improve value delivery in pediatric orthopaedic care.Level of Evidence: II.

How much does saving femoral head cost after acetabular fracture? Comparison between ORIF and THA

We performed a prospective study on patients with acetabular fractures treated either with internal fixation either with arthroplasty comparing clinical outcomes, quality of life, economic resources and cost efficacy in the first five years after surgery. Demographic data, diagnosis, index treatment, costs and subsequent surgeries were recorded. Patients were requested to fulfill Merle d'Aubigné and EQ-5D-5L questionnaires. Clinical differences between treatments are significant only in discharge period. Comparing respectively group with fixation and arthroplasty, cost efficacy was 5483 and 10838 euros/quality-adjusted-life years, mean global costs 23965 and 16878 € and quality of life gained in five years 2.788 and 3.175. Group of arthroplasty showed better quality of life at discharge and at one year. If choice between fixation and arthroplasty should be based only on cost-efficacy, arthroplasty should be suggested but clinical outcomes suggest to consider fixation because results at five years are not different to arthroplasty.

Open reduction and internal fixation of mandibular condylar fractures: A national inpatient sample analysis, 2005-2014

The purpose of this study was to compare outcomes of open reduction and internal fixation (ORIF) versus closed reduction (CR) for mandibular condylar fractures.Patients included in the National Inpatient Sample (NIS) database (2005-2014) who were admitted to the hospital for unilateral mandibular condylar fracture were included in the analysis. Patient characteristics and clinical outcomes were compared between those who received ORIF and those receiving CR. Logistic regression analysis was performed to estimate odds ratios (ORs) for each aspect of the main observed events.NIS data of 12,303 patients who underwent ORIF and 4310 patients who underwent CR were analyzed. Compared to CR, ORIF had an increased risk of longer hospital stay (adjusted OR [aOR] = 1.78, 95% confidence intervals [CIs] = 1.51-2.09), higher total medical cost (aOR = 2.57, 95% CI = 2.17-3.05), and hematoma development (aOR = 10.66, 95% CI = 1.43-75.59), but had a lower risk of having wound complications (aOR = 0.86, 95% CI = 0.79-0.93).Patients with mandibular condylar fractures who receive ORIF have greater risk of having an extended hospital stay, higher total medical costs, and hematoma development but lower risk of experiencing wound complications compared to those who receive CR.

Surgical treatment, complications, and reimbursement among patients with clavicle fracture and acromioclavicular dislocations: a US retrospective claims database analysis

Aims: To assess rates of surgical treatment, post-surgical complications, reoperations, and reimbursement in patients with clavicle fractures and acromioclavicular (AC) dislocations. Materials and methods: This US retrospective study used data from patients with ≥1 diagnosis of clavicle fracture or AC dislocation (index) between 2012-2016. Surgical treatment was defined as a procedure within 4 weeks after clavicle fracture/AC dislocation. Rates of complications (infection, non-union, mal-union), reoperations (device removal or revisions), and all-cause healthcare reimbursement (adjusted to 2016$) were evaluated 2 years post-index among surgical patients. Results: A total of 95,243 patients with clavicle fracture and 52,100 patients with AC dislocation were identified. Mean (SD) age for clavicle fracture and AC dislocation was 23.8 (18.6) and 33.0 (15.6) years, respectively. Most clavicle fracture and AC dislocation patients were male (70.9% and 78.0%, respectively), and had few comorbidities (86.4% and 84.8% had a Charlson Comorbidity Index = 0 and 73.1% and 66.0% had Elixhauser = 0, respectively). Only 15.2% of clavicle fracture and 5.3% of AC dislocation patients received surgical treatment. Among patients undergoing surgical treatment, 2-year rates of infection, non-union, and mal-union were 1.0%, 4.2%, and 0.9%, respectively, for clavicle fracture, and 2.0%, 0.9%, and 0.1%, respectively, for AC dislocation. Reoperations occurred in 83.0% of clavicle fracture and 67.5% of AC dislocation patients. Mean (SD) 2-year reimbursement was $27,635 ($68,173) for clavicle fracture and $23,096 ($28,746) for AC dislocation. Limitations: Administrative claims data lack clinical information, limiting inferences that can be made. This data may not be generalizable to other patients. Conclusions: Rates of surgical treatment for clavicle fractures and AC dislocation and rates of infection, non-union, and mal-union among surgically-treated patients were low. However, surgical patients had high rates of device removal or revision surgery during 2-year follow-up. Improved surgical methods and technologies could reduce non-planned reoperations and device removals, thereby reducing healthcare system costs.

The burden of osteoporosis in four Latin American countries: Brazil, Mexico, Colombia, and Argentina

Objective: Osteoporosis is under-diagnosed and under-treated worldwide. Information on the burden of osteoporosis in Latin American countries is limited. This study aimed to estimate the economic burden of osteoporosis in adults aged 50-89 years in Brazil, Mexico, Colombia, and Argentina. Methods: Analyses were conducted using a burden of illness model. Where possible, country-specific model inputs were informed by a systematic review and expert opinion. Osteoporosis-related fracture costs were calculated for hospitalizations, testing, surgeries, prescription drugs, and patient productivity losses. Costs were expressed in 2018 USD for the annual burden, annual burden per 1,000 at risk, and projected 5-year burden. No discounting was applied. Results: Over 840,000 osteoporosis-related fractures were predicted to occur in 2018, amounting to a total annual cost of ∼1.17 billion USD. The total projected 5-year cost was ∼6.25 billion USD. Annual costs were highest in Mexico (411 million USD), followed by Argentina (360 million USD), Brazil (310 million USD), and Colombia (94 million USD). The average burden per 1,000 at risk was greatest in Argentina (32,583 USD), followed by Mexico (16,671 USD), Colombia (8,240 USD), and Brazil (6,130 USD). Conclusions: Over the next 5 years, ∼4,485,352 fractures are anticipated to occur in Brazil, Mexico, Colombia, and Argentina. To control and prevent these fractures, stakeholders must work together to close the care gap. Efforts to identify individuals at high fracture risk, initiate treatment, and improve long-term treatment persistence will be essential in minimizing the financial and patient burden of osteoporosis in Latin America.

Operative Time and Cost Vary by Surgeon: An Analysis of Supracondylar Humerus Fractures in Children

Operative time is a critical driver of cost in orthopedics and an important target for improving value in health care. This study used an archetypal pediatric orthopedic procedure to identify surgeon-dependent variability in operative time. The authors reviewed patients 12 years or younger treated with closed reduction and percutaneous pinning for extension-type supracondylar humerus fractures. Variability in operative time across surgeons was assessed. Surgeon experience at the time of the procedure and case volume (quarterly) were evaluated to explain variations in operative time. A total of 1472 patients were reviewed (57% Gartland type II and 43% type III fractures). Procedures were performed by 12 fellowship-trained pediatric orthopedists with 2 weeks to 32.8 years of experience. For individual surgeons, the mean operative time ranged from 20.4 to 33.7 minutes for type II fractures and from 31.0 to 46.8 minutes for type III fractures. There was significant variation across surgeons in mean operative time and cost (P<.001). Analysis showed no significant effect of surgeon experience or quarterly case volume. Surgeons' mean operative time for type II fractures was strongly positively correlated with their mean operative time for type III fractures (r²=0.74). Mean operative time and cost for supracondylar humerus fracture closed reduction and percutaneous pinning vary significantly between surgeons, but this variation is not explained by experience or volume. Surgeons who required more time for type II fractures were also slower for type III fractures. Because of the high per minute cost of the operating room, surgeon variability significantly impacts cost. Identification and modification of sources of variation in surgeon behavior will allow for reduction in the cost of surgical care. [Orthopedics. 2019; 42(3):e317-e321.].

Age Alone Does Not Predict Complications, Length of Stay, and Cost for Patients Older Than 90 Years With Hip Fractures

The purpose of this study was to analyze the perioperative complication rate and inpatient hospitalization costs associated with hip fractures in patients older than 90 years compared with patients younger than 90 years. Patients 60 years and older with hip fractures treated operatively at 1 academic medical center between October 2014 and September 2016 were analyzed. Patient demographics, comorbidities, length of stay, procedure performed, and inpatient complications were analyzed. Total cost of admission was obtained from the hospital finance department. Outcomes were compared between patients older than 90 years and patients younger than 90 years. A total of 500 patients with hip fractures were included in this study. There were 109 (21.8%) patients 90 years and older and 391 (78.2%) patients 60 to 89 years. There was no difference in fracture pattern, operation performed, Charlson Comorbidity Index, or length of stay between the 2 groups. The mean length of stay for patients 90 years and older with hip fractures was 7.8±4.3 days vs 7.6±4.2 days for the younger cohort (P=.552). There was no observed difference in perioperative complications. Finally, there was no difference in the total mean cost of admission. Patients 90 years and older are at no greater risk for perioperative complications based on age alone. They are also no more likely to require longer or more costly hospitalizations than patients younger than 90 years. [Orthopedics. 2019; 42(1):e51-e55.].

A 3-Dimensional-Printed Short-Segment Template Prototype for Mandibular Fracture Repair

IMPORTANCE

After reduction of complex mandibular fractures, contouring of the fracture plates to fixate the reduced mandibular segments can be time-consuming.

OBJECTIVE

To explore the potential application of a 3-dimensional (3-D)-printed short-segment mandibular template in the management of complex mandibular fractures.

DESIGN, SETTING, AND PARTICIPANTS

A feasibility study was performed at a tertiary academic center using maxillofacial computed tomography data of 3 patients with comminuted mandibular fractures who required preoperative planning with a perfected complete mandible model.

INTERVENTIONS

Thresholding, segmentation, and realignment of the fractured mandible were performed based on computed tomography data. Each reduced mandible design was divided to create 3-D templates for 6 fracture sites: right and left angle, body, and symphyseal/parasymphyseal. Sessions were conducted with junior otolaryngology and plastic surgery residents, during which mandibular fracture plates were contoured in a "preoperative" setting against the 3-D-printed short-segment templates, and an "intraoperative" setting against the previously manufactured, complete mandible model. The previously manufactured, complete model served as a surrogate for the intraoperative mandible with the fracture site reduced.

MAIN OUTCOMES AND MEASURES

The time for 3-D template printing, the "preoperative" (measure of the time consumed preoperatively), and "intraoperative" (measure of the time saved intraoperatively) times were recorded. Comparisons were made for cost estimates between a complete model and the 3-D-printed short-segment template. The operating room charge equivalent of the intraoperative time was also calculated.

RESULTS

Of the 3 patients whose data were used, 1 was a teenager and 2 were young adults. The total time for 3-D modeling and printing per short-segment template was less than 3 hours. The median (range) intraoperative time saved by precontouring the fracture plates was 7 (1-14), 5 (1-30), and 7 (2-15) minutes, and the operating room charge equivalents were $350.35 ($50.05-$700.70), $250 ($50.05-$1501.50), and $350.35 ($100.10-$750.75) for the angle, body, and symphyseal/parasymphyseal segments, respectively. The total cost for a single 3-D-printed template was less than $20, while that for a perfected complete model was approximately $2200.

CONCLUSIONS AND RELEVANCE

We demonstrate that patient- and site-specific 3-D-printed short-segment templates can be created within the timeframe required for mandibular fracture repair. These novel 3-D-printed templates also demonstrate cost efficiency in the preoperative planning for complex mandibular fracture management compared with perfected models and facilitate plate contouring in a similar fashion. Estimation of reduced operative room cost and time with the application of these short-segment templates warrants studies in actual patient care.

LEVEL OF EVIDENCE

NA.

Home, No Follow-Up: Are we ignoring the significance of unplanned clinic attendances, re-admission and mortality in the first 12 months post-operatively in over 65 year olds' hip fractures treated with DHS fixation?

INTRODUCTION

80,000 hip fractures are admitted to UK hospitals annually (Royal College of Physicians, 2016). Little is known about 12-month post-operative re-admission, unplanned clinic attendance and mortality. We aimed to determine if there is a role for routine follow-up for certain strata of our hip fracture population treated by Dynamic Hip Screw (DHS) Fixation based on unplanned attendance to clinics and whether it is possible to stratify risk of re-admission, re-operation and mortality within the first 12 months post-operatively.

METHODS

A prospectively collated single centre database of patients >65 years old undergoing DHS fixation for traumatic hip fractures between August 2007 and February 2011 was retrospectively analysed. Pre-operative data regarding patient demographics, mobility, residence and co-morbidities were collected. Post-operative (1, 4, 12 months) place of residence, mobility status, unplanned attendance to an orthopaedic clinic with symptoms relating to the respective limb, re-admission to hospital and mortality was collated. Regression analysis was performed (SPSS, IBM Corporation, version 24). P < 0.05 was considered significant.

RESULTS

648 consecutive patients were identified. Increasing age (p = 0.006) and presence of pressure sores during initial admission (p = 0.0019) increased the frequency of unplanned clinic attendance. No significant predictors of re-admission to hospital were found. Overall mortality was related to increasing age (p = 0.042), male gender (p = 0.004) and ASA grade (p = 0.009).

CONCLUSION

There is no current vogue to follow-up such patients in this post-operative period. We have identified variables that should be sought prior to discharge in this population. 22% of our population had at least one unplanned clinic attendance with a cost implication of approximately £50,132 (£151 per appointment) over the study period and potentially over £1.6 million pounds annually in the U.K.

IMPLICATIONS

Formal follow-up/rehabilitation programs could be offered for those at risk of unplanned clinic attendance. Post-operative orthogeriatric and/or general practitioner follow-up may reduce 12-month mortality in those at risk but validated scoring and risk stratification systems are required to fully justify this.

Economic Analysis of Anatomic Plating Versus Tubular Plating for the Treatment of Fibula Fractures

Ankle fractures are among the most common injuries requiring operative management. Implant choices include one-third tubular plates and anatomically precontoured plates. Although cadaveric studies have not revealed biomechanical differences between various plate constructs, there are substantial cost differences. This study sought to characterize the economic implications of implant choice. A retrospective review was undertaken of 201 consecutive patients with operatively treated OTA type 44B and 44C ankles. A Nationwide Inpatient Sample query was performed to estimate the incidence of ankle fractures requiring fibular plating, and a Monte Carlo simulation was conducted with the estimated at-risk US population for associated plate-specific costs. The authors estimated an annual incidence of operatively treated ankle fractures in the United States of 59,029. The average cost was $90.86 (95% confidence interval, $90.84-$90.87) for a one-third tubular plate vs $746.97 (95% confidence interval, $746.55-$747.39) for an anatomic plate. Across the United States, use of only one-third tubular plating over anatomic plating would result in statistically significant savings of $38,729,517 (95% confidence interval, $38,704,773-$38,754,261; P<.0001). General use of one-third tubular plating instead of anatomic plating whenever possible for fibula fractures could result in cost savings of up to nearly $40 million annually in the United States. Unless clinically justifiable on a per-case basis, or until the advent of studies showing substantial clinical benefit, there currently is no reason for the increased expense from widespread use of anatomic plating for fractures amenable to one-third tubular plating. [Orthopedics. 2018; 41(2):e252-e256.].

Increasing Use of Reverse Total Shoulder Arthroplasty for Proximal Humerus Fractures in Elderly Patients

This study described surgical treatment patterns for proximal humerus fractures among elderly patients, focusing on reverse total shoulder arthroplasty (TSA), and evaluated how the type of fixation affects inpatient factors (cost, length of stay), transfusion rates, and patient disposition (home vs skilled nursing facility). With Nationwide Inpatient Sample data from 2011 to 2013, the authors identified patients 65 years and older who had proximal humerus fractures and divided them into 3 groups: (1) open reduction and internal fixation (ORIF); (2) hemiarthroplasty; and (3) reverse TSA. From 2011 to 2013, 38,729 surgically treated proximal humerus fractures were identified. The rate of reverse TSA increased 1.8-fold during this time, from 13% of operative cases in 2011 to 24% of operative cases in 2013 (P<.001). At the same time, the rates of hemiarthroplasty and ORIF decreased (hemiarthroplasty, from 28% to 21%; ORIF, from 59% to 55%). Although reverse TSA accounted for 32.2% of arthroplasty procedures for proximal humerus fractures in 2011, this value was 53.3% in 2013 (P<.001). In 2013, mean total hospital cost for reverse TSA was $24,154, which was significantly higher than that for ORIF ($16,269) or hemiarthroplasty ($19,175) (P<.001). In a multivariable model, patients undergoing reverse TSA were less likely than those undergoing hemiarthroplasty to be discharged to a skilled nursing facility (odds ratio, 0.75; P=.027). The national rate of reverse TSA nearly doubled from 2011 to 2013. As of 2013, reverse TSA replaced hemiarthroplasty as the most commonly performed arthroplasty procedure for proximal humerus fractures for patients 65 years and older. Patients undergoing reverse TSA were more likely than those undergoing hemiarthroplasty to be discharged home. [Orthopedics. 2017; 40(6):e982-e989.].

Implant Failure Rates and Cost Analysis of Contoured Locking Versus Conventional Plate Fixation of Distal Fibula Fractures

The authors analyzed 330 consecutive Weber B distal fibula fractures that occurred during a 3-year period and were treated with either a contoured locking plate or a conventional one-third tubular plate to compare the cost and failure rates of the 2 constructs. The primary outcomes were failure of the distal fibular implant and loss of reduction. Secondary outcomes were surgical wound infection requiring surgical debridement and/or removal of the fibular implant, and removal of the fibular plate for persistent implant-related symptoms. No failure of the fibular plates or distal fibular fixation occurred in either group. A total of 5 patients required surgical revision of syndesmotic fixation within 4 weeks of the index surgery. Of these patients, 1 was in the contoured locking plate group and 4 were in the one-third tubular plate group (P=.610). The rate of deep infection requiring surgical debridement and/or implant removal was 6.2% in the contoured locking plate group and 1.4% in the one-third tubular plate group (P=.017). The rate of lateral implant removal for either infection or symptomatic implant was 9.3% in the contoured locking plate group and 2.3% in the one-third tubular plate group (P=.005). A typical contoured locking plate construct costs $800 more than a comparable one-third tubular plate construct. Based on a calculated estimate of 60,000 locking plates used annually in the United States, this difference translates to a potential avoided annual cost of $50 million nationally. This study demonstrates that it is possible to treat Weber B distal fibula fractures with one-third tubular plates at a substantially lower cost than that of contoured locking plates without increasing complications. [Orthopedics. 2017; 40(6):e1024-e1029.].

Trends in Surgical Management and Costs for Operative Treatment of Proximal Humerus Fractures in the Elderly

Proximal humerus fractures in the elderly are increasing in frequency as the population ages. The purpose of this study was to investigate surgical and cost trends in the Medicare population. The PearlDiver database was queried using diagnosis codes to identify Medicare recipients with proximal humerus fractures from 2005 to 2012. Surgical trends, demographics, and charge/reimbursement data were analyzed. There were 750,426 proximal humerus fractures in Medicare recipients during the 8-year period. Eighty-five percent of the fractures were treated nonoperatively; however, the percentage of operative vs nonoperative management increased significantly over time for all fractures, isolated fractures, and fracture dislocations. Open reduction and internal fixation (ORIF) was the most common surgical treatment and remained constant. Reverse total shoulder arthroplasty (RTSA) increased by 406% and hemiarthroplasty (HEMI) decreased by 47%. Compared with younger patients, older patients were more likely to undergo HEMI or RTSA than to undergo ORIF for isolated fractures and fracture dislocations. Charges and reimbursements from Medicare increased over time. The charge to reimbursement gap increased from 87% in 2005 to 104% in 2012. Charges were higher for RTSA than for ORIF or HEMI. Nonoperative management was the treatment of choice for 85% of proximal humerus fractures in the elderly; however, there was a trend toward higher rates of surgery. The RTSA rate increased and the HEMI rate decreased, while ORIF remained constant. There was an increasing charge to reimbursement ratio for all procedure types. [Orthopedics. 2017; 40(4):e641-e647.].

Relationship between socioeconomic status and mortality after femur fracture in a Korean population aged 65 years and older: Nationwide retrospective cohort study

Femur fracture is an emerging public health concern in aging societies, owing to the substantially high morbidity and mortality. Because the recent increase in femur fracture incidence in Asian populations is comparable to that in the West, it is necessary to investigate the association between socioeconomic status (SES) and mortality after femur fracture in developed Asian societies.Data were obtained from the National Health Insurance Claims Database. During 2002 to 2013, femur fractures were newly diagnosed in 5441 patients among 1025,340 enrollees. Multiple logistic regression and the Cox proportional model were used to investigate the associations between individual SES and probability of surgery and mortality after femur fracture.Of 5441 patients, 1928 (35.4%) received surgery. Patients with low (odds ratio [OR] = 0.87, 95% confidence interval [CI]: 0.75-0.99) and middle (OR = 0.85, 95% CI: 0.74-0.98) income were less likely to undergo surgery than high-income patients. Patients with low (hazard ratio [HR] = 1.12, 95% CI: 1.01-1.24) and middle (HR = 1.20, 95% CI: 1.08-1.33) income had a higher HR for mortality. This difference was more prominent in patients who underwent surgery (low income: HR = 1.07, 95% CI: 0.94-1.21; middle income: HR = 1.18, 95% CI: 1.04-1.33) than in patients with conservative treatment (low income: HR = 1.24, 95% CI: 1.04-1.49; middle income: HR = 1.30, 95% CI: 1.08-1.56).Femur-fracture patients with low SES are less likely to receive surgery for and more likely to die after femur fracture. The difference in mortality risk remained even when only the patients who received surgery were considered, suggesting that we need to consider support measures for these deprived patients.

Minimally Invasive Fixation versus Conservative Treatment of Undisplaced Scaphoid Fractures: A Cost-Effectiveness Study

This study compares the direct and indirect costs of conservative and minimally invasive treatment for undisplaced scaphoid fractures. Costs data concerning groups of non-operated and operated patients were analysed. Direct costs were higher in operated patients. Although highly variable, indirect costs were significantly smaller in operated patients and the total costs were higher in nonoperated patients. In conclusion, operative treatment of scaphoid fractures is initially more expensive than conservative treatment but markedly decreases the work compensation costs.

Locking Versus Nonlocking Implants in Isolated Lower Extremity Fractures: Analysis of Cost and Complications

The purpose of this study was to investigate operative costs and postoperative complication rates in relation to utilization of locking versus nonlocking implants in isolated, lower limb fractures. Seventy-seven patients underwent plate fixation of isolated bicondylar tibial plateau, bimalleolar ankle, and trimalleolar ankle fractures at a large tertiary care center. Fixation with locking versus nonlocking implants was compared to incidence of postsurgical complications. Costs of these implants were directly compared. No significant correlation was found between locking versus nonlocking implants and incidence of complications. However, the cost of fixation with locking implants was significantly greater than nonlocking for all fractures. Utilization of more costly locking implants was not associated with reduced postoperative complications compared with nonlocking implants. More attention must be dedicated toward maximizing cost efficiency, since uniform usage of nonlocking implants has the potential to reduce surgical costs without compromising patient outcomes in isolated lower extremity fractures.

Construct Choice for the Treatment of Displaced, Comminuted Olecranon Fractures: are Locked Plates Cost Effective?

BACKGROUND

Cost effective implant selection in orthopedic trauma is essential in the current era of managed healthcare delivery. Both locking and non-locking plates have been utilized in the treatment of displaced fractures of the olecranon. However, locking plates are often more costly and may not provide superior clinical outcomes. The primary aim of the present study is to assess the clinical and functional outcomes of olecranon fractures treated with locked and non-locking plate and screw constructs while providing insight into the cost of various implants.

METHODS

We performed a retrospective chart review of a single institution database identifying Mayo IIB type olecranon fractures treated surgically from 2003 to 2012. All fractures were treated with either a locked plate or a one-third tubular hook plate construct. Clinical and radiographic outcomes were evaluated. Minimum 6-month follow-up was required. Outcomes were compared between fixation constructs, including rate of union, early failure, postoperative range of motion, and complication rates. Statistical analysis included Pearson's Chi-squared and Fisher's exact test for categorical variables, and the Student's ttest for continuous variables.

RESULTS

The one-third tubular construct was equivalent to locking plate constructs with respect to union, post-operative range of motion, and rates of complications. There were no early or late failures. Locking plates were associated with a relative cost increase of $1,263.50 compared to the one-third tubular hook plate per case.

CONCLUSION

Surgeons should consider the cost of implants when treating Mayo IIB olecranon fracture. In this cohort, one-third tubular plates provided equivalent outcomes to locked plates with a notable decrease in cost.

The Eastbourne Trauma Assisted Discharge Scheme (TADS) Reduces Length of Stay in Hip Fracture Patients

PURPOSE OF THE STUDY The aim of this prospective study; The Trauma Assisted Discharge Scheme (TADS), was to set up a new model of postoperative care for patients following a fractured hip, addressing the need for efficiency, cost effectiveness and meeting local demand. MATERIAL AND METHODS All patients with hip fractures between December 2010 and December 2011, meeting the TADS inclusion criteria were enrolled in the study. Innovative use of staff within existing budgets helped create a TAD team who with the use of defined patient goals and a link nurse provided a seamless transition from acute to community services. RESULTS One hundred and sixteen patients followed the TADS pathway; the majority aged 80-89 years and independent prior to falling. A total of 35 patients underwent dynamic hip screw fixation; 55 hemiarthroplasty, 11 total hip replacement and 11 cannulated screw fixation. The average length of in-hospital stay was 8.6 nights. The TADS reduced the average length of stay by 4.78 days. CONCLUSION TADS has the potential to be used as a model of care in other specialities and is easily transferable to the wider NHS.

KEY WORDS

continuous quality improvement, quality improvement, surgery, cost-effectiveness, ambulatory care.

Staged Columnar Fixation of Bicondylar Tibial Plateaus: A Cheaper Alternative to External Fixation

The objective of this study was to compare complication rates and costs of staged columnar fixation (SCF) to external fixation for bicondylar tibial plateau fractures. Patients who received SCF or temporary external fixation across a 3-year period at a major level I trauma center underwent a retrospective chart review for associated complications. Fisher's exact analysis was used to determine any statistical difference in complication rates between both groups. However, there was no significant difference in complication rates between the SCF and external fixator groups. Average medial plate costs for SCF were $2131 compared with an average external fixator cost of $4070 (p < .0001). Given that all patients with external fixation undergo eventual medial and lateral plating, savings with SCF include $4070 plus operative costs for removing the fixator. As our health care system focuses on cost-cutting efforts, orthopaedic trauma surgeons must explore cheaper and equally effective treatment alternatives.

ECONOMIC ANALYSIS OF TREATMENT OF THE PATIENTS WITH CHRONIC POSTTRAUMATIC OSTEOMYELITIS OF THE SHOULDER BY THE METHOD OF TRANSOSSEOUS OSTEOSYNTHESIS BY ILIZAROV’S APPARATUS

An analysis of the terms of hospitalization, cost of treatment was made. There were matched the real medical costs of treatment of the patients with chronic posttraumatic osteomyelitis of the shoulder using the method of transosseous osteosynthesis with application of Ilizarov’s apparatus and medical costs according to the medical standards of treatment for patients with osteomyelitis. It was shown that actual expenses on drug therapy and expendable materials on one patients were approximately three times higher, than planned expenses according to standard. The presence of different microflora was revealed throughout the bacteriological research of suppurative focus in 25(96%) patients. There was detected an excess of actual expenses on one patient with given nosology compared with standard of financial expenditure from the funds for high-technology medical care from 6 % (average case) to 58% (Bassilus pynocyaneus). The excess of actual expenses from the funds of local program of obligatory medical insurance achieved from 48% (average patient) to 100% (Bassilus pynocyaneus case).

The Quality of Cost-Utility Analyses in Orthopedic Trauma

As health care in the United States transitions toward a value-based model, there is increasing interest in applying cost-effectiveness analysis within orthopedic surgery. Orthopedic trauma care has traditionally underemphasized economic analysis. The goals of this review were to identify US-based cost-utility analysis in orthopedic trauma, to assess the quality of the available evidence, and to identify cost-effective strategies within orthopedic trauma. Based on a review of 971 abstracts, 8 US-based cost-utility analyses evaluating operative strategies in orthopedic trauma were identified. Study findings were recorded, and the Quality of Health Economic Studies (QHES) instrument was used to grade the overall quality. Of the 8 studies included in this review, 4 studies evaluated hip and femur fractures, 3 studies analyzed upper extremity fractures, and 1 study assessed open tibial fracture management. Cost-effective interventions identified in this review include total hip arthroplasty (over hemiarthroplasty) for femoral neck fractures in the active elderly, open reduction and internal fixation (over nonoperative management) for distal radius and scaphoid fractures, limb salvage (over amputation) for complex open tibial fractures, and systems-based interventions to prevent delay in hip fracture surgery. The mean QHES score of the studies was 79.25 (range, 67-89). Overall, there is a paucity of cost-utility analyses in orthopedic trauma; however, the available evidence suggests that certain operative interventions can be cost-effective. The quality of these studies, however, is fair, based on QHES grading. More attention should be paid to evaluating the cost-effectiveness of operative intervention in orthopedic trauma.

Comparison of intraoral and extraoral approaches to mandibular angle fracture repair with cost implications

OBJECTIVES/HYPOTHESIS

The objective of this study was to analyze outcomes of intraoral and extraoral approaches to mandibular angle fractures and provide cost estimates for comparison.

STUDY DESIGN

A retrospective review from January 2005 to June 2013 was performed of patients who underwent open reduction internal fixation of mandibular angle fractures at a level I trauma center.

METHODS

Patients were treated by three surgical specialties: otolaryngology-head and neck surgery, oral and maxillofacial surgery, and plastic and reconstructive surgery. Inpatient and outpatient medical records were reviewed for pertinent data including age, gender, duration of follow-up, presence of other mandible fractures, surgical approach, surgical team, operative time, and postoperative complications.

RESULTS

Of the 155 patients with mandibular angle fractures, 74% underwent open reduction internal fixation through an intraoral approach, whereas 26% of patients were treated with an extraoral approach. The occurrence of any complication was 69.6% in the extraoral group and 39% in the intraoral group (P = 0.009). In propensity-weighted analysis, however, the occurrence of any complication was less frequent in intraoral cases but no longer statistically significant (odd ratio 0.28; 95% confidence interval, 0.08 to 1.02; P = 0.053). Operating room time was significantly shorter with the intraoral approach. We estimate that the intraoral approach directly saves at least $2,900 per case.

CONCLUSION

We recommend the use of an intraoral approach for the repair of mandibular angle fractures when clinically appropriate. This can result in a comparable rate of success, however, with significant cost savings to the health care system.

LEVEL OF EVIDENCE

4. Laryngoscope, 126:591-595, 2016.

A comparative study of less invasive stabilization system and titanium elastic nailing for subtrochanteric femur fractures in older children

The objective of this study was to compare prospectively the complications and the radiographic and clinical outcomes of reverse less invasive stabilization system (LISS) and titanium elastic nailing (TEN) for the treatment of subtrochanteric femur fractures in older children. From April 2004 to February 2012, 52 children aged from 10 to 15 years old with subtrochanteric fractures were included in this study. 26 patients were treated with reverse LISS (LISS group) and 26 children treated with titanium elastic nails (TEN group) respectively. Perioperative care was standardized. Surgical time, blood loss, length of hospitalization, hospital costs, fracture union time, full weight-bearing time and complications were analyzed. The radiologic results as well as hip functional outcomes were evaluated. The average follow-up time of LISS group was 36.5±9.3 months and TEN group was 40.2±10.6 months. No significant difference between these two groups was found in union time, full weight-bearing time and average length of hospitalization. However, the patients of LISS group had longer operation time (60.0±10.6 min vs. 40.5±7.4 min, p<0.01), more blood loss (130.0±45.0 ml vs. 15.5±10.2 ml, p<0.01), and more hospital costs (25000±700 RMB vs. 10800±500 RMB, p<0.01). The overall complication rate was significantly higher in the LISS group than in the TEN group (12/26 vs. 5/26, p=0.039). There was no significant difference between the two groups in terms of early and late radiological results. Using the Sanders score system, there were 13 excellent, 6 good and 7 fair results in the LISS group compared with 22 excellent and 4 good results in the TEN group. The excellent and good rate was significantly different between the two groups (p=0.010). Our results indicated that TEN fixation of subtrochanteric femur fractures in older children was associated with better function scores and a lower overall complication rate when compared with reverse LISS.

Predictive factors of hospital length of stay in patients with operatively treated ankle fractures

BACKGROUND

Operative fixation of ankle fractures is common. However, as reimbursement plans evolve with the potential for bundled payments, it is critical that orthopedic surgeons better understand factors influencing the postoperative length of stay (LOS) in patients undergoing these procedures to negotiate appropriate reimbursement. We sought to identify factors influencing the postoperative LOS in patients with operatively treated ankle fractures.

MATERIALS AND METHODS

Six hundred twenty-two patients with ankle fractures between January 1st, 2004 and December 31st, 2010 were identified retrospectively. Charts were reviewed for gender, length of operative procedure, method of fixation, American Society of Anesthesiologists (ASA) physical status score, medical comorbidities, and postoperative LOS. Both univariate and multivariate models were developed to determine predictors of patient LOS. Financial data for an average 24-h inpatient stay were obtained from financial services.

RESULTS

Six hundred twenty-two patients were included. In a linear regression analysis, a statistically significant relationship was demonstrated between ASA status and LOS (P < 0.001). Multiple regression analysis further characterized the relationship between ASA and LOS: a 1-U increase in ASA classification conferred a 3.42-day increase in LOS on average (P < 0.001). Based on an average per-day inpatient cost of $4,503, each unit increase in ASA status led to a $15,490 increase in cost.

CONCLUSIONS

Our study demonstrates that ASA status is a powerful predictor of LOS in patients undergoing operative fixation of ankle fractures. More complete understanding of these factors will lead to better risk adjustment models for measuring outcomes, determining fair reimbursement, and potential improvements to the efficiency of patient care.

LEVEL OF EVIDENCE

Level III retrospective comparative study regressing length of stay with many variables, including ASA physical status.

Geriatric fractures about the hip: divergent patterns in the proximal femur, acetabulum, and pelvis

Geriatric acetabular, pelvis, and subtrochanteric femur fractures are poorly understood and rapidly growing clinical problems. The purpose of this study was to describe the epidemiologic trends of these injuries as compared with traditional fragility fractures about the hip. From 1993 to 2010, the Nationwide Inpatient Sample (NIS) recorded more than 600 million Medicare-paid hospital discharges. This retrospective study used the NIS to compare patients with acetabular fractures (n=87,771), pelvic fractures (n=522,831), and subtrochanteric fractures (n=170,872) with patients with traditional hip fractures (intertrochanteric and femoral neck, n=3,495,742) with regard to annual trends over an 18-year period in incidence, length of hospital stay, hospital mortality, transfers from acute care institutions, and hospital charges. Traditional hip fractures peaked in 1996 and declined by 25.7% by 2010. During the same 18-year period, geriatric acetabular fractures increased by 67%, subtrochanteric femur fractures increased by 42%, and pelvic fractures increased by 24%. Hospital charges, when controlling for inflation, increased roughly 50% for all fracture types. Furthermore, transfers from outside acute care hospitals for definitive management stayed elevated for acetabular fractures as compared with traditional hip fractures, suggesting a greater need for tertiary care of acetabular fractures. Geriatric acetabular fractures are rapidly increasing, whereas traditional hip fractures continue to decline. Patients with these injuries are more likely to be transferred from their hospital of presentation to another acute care institution, possibly increasing costs and complications. This is likely related to their complexity and the lack of consensus regarding optimal management.

The societal costs of femoral neck fracture patients treated with internal fixation

SUMMARY

The study rationale was to provide a detailed overview of the costs for femoral neck fracture treatment with internal fixation in the Netherlands. Mean total costs per patient at 2-years follow-up were <euro>19,425. Costs were higher for older, less healthy patients. Results are comparable to internationally published costs.

INTRODUCTION

The aim of this study was to provide a detailed overview of the cost and healthcare consumption of patients treated for a hip fracture with internal fixation. A secondary aim was to compare costs of patients who underwent a revision surgery with patients who did not.

METHODS

The study was performed alongside the Dutch sample of an international randomized controlled trial, concerning femoral neck fracture patients treated with internal fixation. Patient characteristics and healthcare consumption were collected. Total follow-up was 2 years. A societal perspective was adopted. Costs included hospital costs during primary stay and follow-up, and costs related to rehabilitation and changes in living situation. Costs were compared between non-revision surgery patients, implant removal patients, and revision arthroplasty patients.

RESULTS

A total of 248 patients were included (mean age 71 years). Mean total costs per patient at 2-years follow-up were <euro>19,425. In the non-revision surgery patients total costs were <euro>17,405 (N = 137), in the implant removal patients <euro>10,066 (N = 38), and in the revision arthroplasty patients <euro>26,733 (N = 67). The main contributing costs were related to the primary surgery, admission days, physical therapy, and revision surgeries.

CONCLUSIONS

The main determinant was the costs of admission to a rehabilitation center/nursing home. Costs were specifically high in elderly with comorbidity, who were less independent pre-fracture, and have a longer admission to the hospital and/or a nursing home. Costs were also higher in revision surgery patients. The 2-years follow-up costs in our study were comparable to published costs in other Western societies.

Mandibular fractures treated with small plates and screws reduce treatment cost

PURPOSE

The efficacy of treating mandibular fractures with open reduction and internal fixation (ORIF) using small titanium plates and monocortical screws is well established. The purpose of this study was to determine whether the use of semirigid (small) titanium plates results in lower treatment charges.

PATIENTS AND METHODS

Consecutive patients with mandibular fractures were randomly allocated to ORIF with small or large titanium plates. The primary predictor variable for this secondary subset analysis was plate size. The primary outcome variable was total treatment charges. Other outcomes included length of stay (LOS), operating room charges, hardware charges, LOS charge, and charges related to the treatment of complications.

RESULTS

A total of 127 consecutive patients were enrolled in the study. Fifty-two patients completed the required 6-week follow-up and had data available for analysis. Adjusted total treatment charges suggested a significant difference, with a mean total treatment charge of $15,308 in the semirigid group and a mean total treatment charge of $16,557 in the rigid group (P = .04). Total treatment charges were 8% higher in the rigid group compared with the semirigid group.

CONCLUSIONS

The findings of this study suggest that the overall charges associated with treating mandibular fractures with ORIF are significantly lower when semirigid plates are used.

Treatment outcomes with the use of maxillomandibular fixation screws in the management of mandible fractures

PURPOSE

The purpose of this prospective randomized study was to assess whether uncomplicated mandible fractures could be treated successfully in an open or closed fashion using maxillomandibular fixation (MMF) screws.

MATERIALS AND METHODS

This was a prospective institutional review board-approved study involving 20 adult patients who presented to the university emergency department or oral and maxillofacial surgical clinic with uncomplicated mandible fractures. Patients who met the exclusion criteria consented to enter the study in the open reduction internal fixation (ORIF) or the closed (MMF) study group. Six to 8 MMF screws were used to obtain intermaxillary fixation (IMF) in the 2 groups. Screw failure was documented. All screws were removed at 5 to 6 weeks postoperatively. Insertional torque (IT) was measured at time of screw placement to assess primary stability. Clinical and photographic documentation was performed to assess fracture healing, occlusion, and gingival health. Ten-centimeter visual analog scales were used to assess patient-centered outcomes. Cone-beam computed tomography was performed to assess the long-term effects on the periodontium and roots. A cost comparison was performed to determine whether the use of screws was cost effective compared with arch bars.

RESULTS

Fifteen men and 5 women (mean age, 25.2 yr) entered the study. All patients displayed adequate fracture healing based on clinical examination. All patients had acceptable occlusion at 5 to 6 weeks postoperatively. Total screw failure was 27 of 106 screws (25.5%). Forty percent of screws placed in the MMF group failed compared with only 6% in the ORIF group. Gingival health scores were favorable. Factors that had a significant effect on screw failure included a lower IT (P = .002), use in closed (MMF) treatment (P < .001), and use in the posterior jaw (P = .012). Minimal pain was associated with the MMF screws and pre-existing occlusion was re-established based on patients' subjective responses. The MMF group reported a statistically significant lower quality of life (P < .001) compared with the ORIF group. There was only 1 screw site that had a facial cortical bone defect noted at 6-month follow-up CBCT examination. There were no discernible long-term root defects. Cost analysis showed that the use of MMF screws saved around $600 per patient in operating room usage cost alone compared with the estimated use of arch bars.

CONCLUSIONS

Uncomplicated mandible fractures were successfully treated using MMF screws in open and closed treatments. However, the utility in closed treatment was decreased because of significant screw failure and patient noncompliance. The screws were well tolerated by the patients. There was minimal long-term damage to the periodontium and dental roots. The cost of screws was more than offset by time savings.

Is hospital teaching status a key factor in hospital charge for children with hip fractures?: preliminary findings from KID database

OBJECTIVE

Proximal femur fractures cause significant pain and economic cost among pediatric patients. The purposes of this study were (a) to evaluate the distribution by hospital type (teaching hospital vs non-teaching hospital) of U.S. pediatric patients aged 1-20 years who were hospitalized with a closed hip fracture and (b) to discern the mean hospital charge and hospital length of stay after employing propensity score to reduce selection bias.

METHODS

The 2006 Healthcare Cost and Utilization Project (HCUP) Kids' Inpatient Database (KID) was queried for children aged up to 20 years that had principle diagnosis of hip fracture injury. Hip fractures were defined by International Classification of Diseases, 9th Revision, Clinical Modification codes 820.0, 820.2 and 820.8 under Section "Injury and Poisoning (800-999)" with principle internal fixation procedure codes 78.55, 79.15 and 79.35. Patient demographics and hospital status were presented and analyzed. Differences in mean hospital charge and hospital length of stay by hospital teaching status were assessed via two propensity score based methods.

RESULTS

In total, 1,827 patients were nation-ally included for analysis: 1,392 (76.2%) were treated at a teaching hospital and 435 (23.8%) were treated at a non-teaching hospital. The average age of the patients was 12.88 years old in teaching hospitals vs 14.33 years old in nonteaching hospitals. The propensity score based adjustment method showed mean hospital charge was $34,779 in teaching hospitals and $32,891 in the non-teaching hospitals, but these differences were not significant (p=0.2940). Likewise, mean length of hospital stay was 4.1 days in teaching hospitals and 3.89 days in non-teaching hospitals, but these differences were also not significant (p=0.4220).

CONCLUSIONS

Hospital teaching status did not affect length of stay or total hospital costs in children treated surgically for proximal femur fractures. Future research should be directed at identifying factors associated with variations in hospital charge and length of stay.

Hemiarthroplasty compared to internal fixation with percutaneous cannulated screws as treatment of displaced femoral neck fractures in the elderly: cost-utility analysis performed alongside a randomized, controlled trial

We estimated the cost-effectiveness of hemiarthroplasty compared to internal fixation for elderly patients with displaced femoral neck fractures. Over 2 years, patients treated with hemiarthroplasty gained more quality-adjusted life years than patients treated with internal fixation. In addition, costs for hemiarthroplasty were lower. Hemiarthroplasty was thus cost effective.

INTRODUCTION

Estimating the cost utility of hemiarthroplasty compared to internal fixation in the treatment of displaced femoral neck fractures in the elderly.

METHODS

A cost-utility analysis (CUA) was conducted alongside a clinical randomized controlled trial at a university hospital in Norway; 166 patients, 124 (75%) women with a mean age of 82 years were randomized to either internal fixation (n = 86) or hemiarthroplasty (n = 80). Patients were followed up at 4, 12, and 24 months. Health-related quality of life was assessed with the EQ-5D, and in combination with time used to calculate patients' quality-adjusted life years (QALYs). Resource use was identified, quantified, and valued for direct and indirect hospital costs and for societal costs. Results were expressed in incremental cost-effectiveness ratios.

RESULTS

Over the 2-year period, patients treated with hemiarthroplasty gained 0.15-0.20 more QALYs than patients treated with internal fixation. For the hemiarthroplasty group, the direct hospital costs, total hospital costs, and total costs were non-significantly less costly compared with the internal fixation group, with an incremental cost of €2,731 (p = 0.81), €2,474 (p = 0.80), and €14,160 (p = 0.07), respectively. Thus, hemiarthroplasty was the dominant treatment. Sensitivity analyses by bootstrapping supported these findings.

CONCLUSION

Hemiarthroplasty was a cost-effective treatment. Trial registration, NCT00464230.

The direct cost of acute hip fracture care in care home residents in the UK

Data on the true acute care costs of hip fractures for patients admitted from care homes are limited. Detailed costing analysis was undertaken for 100 patients. Median cost was £9,429 [<euro>10,896], increasing to £14,435 [<euro>16,681], for those requiring an upgrade from residential to nursing home care. Seventy-six percent of costs were attributable to hospital bed days, and therefore, interventions targeted at reducing hospital stay may be cost effective.

INTRODUCTION

Previous studies have estimated the costs associated with hip fracture, although these vary widely, and for patients admitted from care homes, who represent a significant fracture burden, there are limited data. The primary aim of this study was to perform a detailed assessment of the direct medical costs incurred and secondly compare this to the actual remuneration received by the hospital.

METHODS

One hundred patients presenting from a care home in 2006 were randomly selected and a detailed case-note costing analysis was undertaken. This cost was then compared to the actual remuneration received by the hospital.

RESULTS

Median cost per patient episode was £9,429 [<euro>10,896] (all patients) range £4,292-162,324 [<euro>4,960-187,582] (subdivided into hospital bed day costs £7,129 [<euro>8,238], operative costs £1,323 [<euro>1,529] and investigation costs £977 [<euro>1,129]). Twenty-two percent of the patients admitted from a residential home required upgrading to a nursing home. In this group, the median length of stay was 31 days (mean 38, range 10-88) median cost £14,435 [<euro>16,681]. Average remuneration received equated to £6,222 [<euro>7,190] per patient. This represents a mean loss in income, compared to actual calculated costs of £3,207 [<euro>3,706] per patient.

CONCLUSION

The median cost was £9,429 [<euro>10,896], increasing to £14,435 [<euro>16,681], for those requiring an upgrade from residential to nursing home care at discharge. Significant cost differences were seen comparing the actual cost to remuneration received. Interventions targeted at reducing length of stay may be cost effective.

Re-use of explanted osteosynthesis devices: a reliable and inexpensive reprocessing protocol

INTRODUCTION

Orthopaedic surgical treatments emphasizing immobilization using open reduction and internal fixation with osteosynthesis devices are widely accepted for their efficacy in treating complex fractures and reducing permanent musculoskeletal deformity. However, such treatments are profoundly underutilized in low- and middle-income countries (LMIC), partially due to inadequate availability of the costly osteosynthesis devices. Orthopaedic surgeons in some LMIC regularly re-use osteosynthesis devices in an effort to meet treatment demands, even though such devices typically are regulated for single-use only. The purpose of this study is to report a reprocessing protocol applied to explanted osteosynthesis devices obtained at a leading trauma care hospital.

METHODS

Explanted osteosynthesis devices were identified through a Register of Explanted Orthopaedic Prostheses. Guidelines to handle ethical issues were approved by the local Ethical Committee and informed patient consent was obtained at the time of explant surgery. Primary acceptance criteria were established and applied to osteosynthesis devices explanted between 2005 and 2008. A rigorous protocol for conducting decontamination and visual inspection based on specific screening criteria was implemented using simple equipment that is readily available in LMIC.

RESULTS

A total of 2050 osteosynthesis devices, including a large variety of plates, screws and staples, were reprocessed using the decontamination and inspection protocols. The acceptance rate was 66%. Estimated labour time and implementation time of the protocol to reprocess a typical osteosynthesis unit (1 plate and 5 screws) was 25 min, with an estimated fixed cost (in Italy) of €10 per unit for implementing the protocol, plus an additional €5 for final sterilization at the end-user hospital site.

DISCUSSION

This study was motivated by the treatment demands encountered by orthopaedic surgeons providing medical treatment in several different LMIC and their need for access to basic osteosynthesis devices. The rigorous decontamination protocol and generalized inspection criteria proved useful for efficiently screening a large volume of devices. Given that re-used osteosynthesis devices can yield satisfactory results, this study addresses potential complications of re-used devices and valid concerns that relate to patient safety. Implementing this defined reprocessing protocol into existing re-use practises in LMIC helps to limit the risks of inadequate sterilization and structural failure without adding additional risks to patients receiving re-used devices.

Is surgery for displaced, midshaft clavicle fractures in adults cost-effective? Results based on a multicenter randomized, controlled trial

OBJECTIVES

To determine the cost-effectiveness of open reduction internal fixation (ORIF) of displaced, midshaft clavicle fractures in adults.

DESIGN

Formal cost-effectiveness analysis based on a prospective, randomized, controlled trial.

SETTING

Eight hospitals in Canada (seven university-affiliated and one community hospital).

PATIENTS/PARTICIPANTS

One hundred thirty-two adults with acute, completely displaced, midshaft clavicle fractures.

INTERVENTION

Clavicle ORIF versus nonoperative treatment.

MAIN OUTCOME MEASUREMENTS

Utilities derived from SF-6D.

RESULTS

The base case cost per quality-adjusted life-year (QALY) gained for ORIF was $65,000. Cost-effectiveness improved to $28,150/QALY gained when the functional benefit from ORIF was assumed to be permanent with cost per QALY gained falling below $50,000 when the functional advantage persisted for 9.3 years or more. In other sensitivity analyses, the cost per QALY gained for ORIF fell below $50,000 when ORIF cost less than $10,465 (base case cost $13,668) or the long-term utility difference between nonoperative treatment and ORIF was greater than 0.034 (base case difference 0.014). Short-term disutility associated with fracture healing also affected cost-effectiveness with the cost per QALY gained for ORIF falling below $50,000 when the utility of a fracture treated nonoperatively before union was less than 0.617 (base case utility 0.706) or when nonoperative treatment increased the time to union by 20 weeks (base case difference 12 weeks).

CONCLUSIONS

The cost-effectiveness of ORIF after acute clavicle fracture depended on the durability of functional advantage for ORIF compared with nonoperative treatment. When functional benefits persisted for more than 9 years, ORIF had a favorable value compared with many accepted health interventions.

Utility of pathologic evaluation following removal of explanted orthopaedic internal fixation hardware

This report questions the cost and effectiveness of routinely sending explanted hardware to pathology for evaluation. Forty-six consecutive patients who had symptomatic hardware removed were enrolled in this study. Pathology reports following hardware removal were obtained, and charts were reviewed for these patients. The pathology department was contacted for related departmental procedure codes, and hospital billing records were obtained regarding the cost of the procedure. In all cases, the pathology reports gave the gross diagnosis of "hardware" and the gross description included the measurements of the internal fixation hardware removed. In no case did the report alter the plan of the attending physician. The healthcare system may benefit by subspecialty review of the current practice of sending internal fixation devices to pathology for evaluation. We recommend a single radiographic view along with proper documentation in the postoperative report to confirm the removal of internal fixation hardware in lieu of pathologic evaluation.

[Controlled clinical trials of cost-effectiveness analysis on poking reduction and open reduction for the treatment of sanders type II calcaneal fractures]

OBJECTIVE

To evaluate cost-effectiveness of poking reduction and open reduction for the treatment of Sanders type II calcaneal fractures, in order to provide evidence for standard treatment.

METHODS

From 2006.10 to 2008.10, 80 patients with Sanders type II calcaneal fractures were selected from Shandong Provincial Hospital of Traditional Chinese Medicine and randomly divided into poking reduction group and open reduction group with 40 cases in each group. There were 26 males and 14 females in poking reduction group and 30 males and 10 females in open reduction group. The average age of patients in poking reduction group was (36.60+/-3.15) years, and (37.10+/-3.45) years in open reduction group. Bohler angle, Gissane angle, the width of central calcaneus, stance phase of gait, HM-HL,arch index and subtalair joint flexibility were measured. The clinical results and expenses of the two treatment schemes were compared and concluded with the method of cost-effetiveness analysis.

RESULTS

In the poking reduction group and open reduction group, the Böhler angle were (30.32+/-1.72) degree and (30.54+/-3.13) degree, Gissane angle were (133.73+/-6.73) degree and (134.86+/-4.90) degree, the width of central calcaneus were (30.18+/-1.59) mm and (30.24+/-1.25) mm, stance phase of gait were (0.679+/-0.070) s and (0.715+/-0.090) s, HM-HL were--(36.49+/-7.56) N and -(34.32+/-6.50) N,arch index were (30.26+/-2.69) and (30.47+/-1.89), and subtalair joint flexibility were (10.53+/-2.30) degree and (10.89+/-1.86) degree respectively. The cost-effectiveness ratio (C/E) were 6.06 and 136.19 respectively.

CONCLUSION

Cost-effectiveness ratio of the poking reduction is superior to that of the open reduction in treating Sanders type II calcaneal fractures. Poking reduction is a useful method to treat Sanders type II calcaneal fractures with rapid wound healing and less cost.

[Fast track in casualty surgery]

The concept of "fast track" has not yet been established in orthopaedic trauma surgery. Principles such as those used in the "fast track" procedure for abdominal surgery have been employed in orthopaedic surgery for a long time. The best results can be achieved by early operative treatment, stable osteosynthesis and, if the soft tissues allow, an early initiation of mobilization under optimal pain management. Based on new techniques in osteosynthesis, in particular locked-screw techniques, "fast track" is also applicable for fragility fractures (osteoporosis), complex shattered bone and bone defect situations.

Do the benefits of rigid internal fixation of mandible fractures justify the added costs? Results from a randomized controlled trial

PURPOSE

Owing to its putative advantages over conventional maxillomandibular fixation (MMF), open-reduction and rigid internal fixation (ORIF) is used frequently to treat mandible fractures, particularly in noncompliant patients. The resource-intensive nature of ORIF, the large variation in its use, and the lack of systematic studies substantiating ORIF attributed benefits compel a randomized controlled investigation comparing ORIF to MMF treatment. The objective of this study was to determine whether ORIF provides better clinical and functional outcomes than MMF in noncomplying type of patients with a similar range of mandible fracture severity.

PATIENTS AND METHODS

From a total of 336 patients who sought treatment for mandible fractures, 142 patients with moderately severe mandible fractures were assigned randomly to receive MMF or ORIF and followed prospectively for 12 months. A variety of clinician and patient-reported measures were used to assess outcomes at the 1, 6, and 12 months follow-up visits. These measures included clinician-reported number of surgical complications, patient-reported number of complaints, as well as cumulative costs of treatment. Pain intensity was measured on a 10-point scale and the 12-item General Oral Health Assessment Index was used to assess the patients' oral health-related quality of life. Because the protocol allowed clinical judgment to overrule the randomly assigned treatment, outcomes were compared on an "intent-to-treat" basis as well as in terms of actual treatment received.

RESULTS

The sociodemographic and clinical characteristics of the injury did not differ among the 2 groups. On an intent-to-treat basis, the difference in complication rates was not significant but favored MMF; 8.1% of patients developed complications with MMF versus 12.5% with ORIF. Differences in the rate of patient complaints were not significant on an intent-to-treat basis, but a significant between-group difference (P = .012) favoring MMF was noted on an as-treated basis at the 1 month recall, with 40% of ORIF patients reporting greater than 1 complaint versus 18.8% of MMF patients. No significant differences were detected between the 2 treatment groups at any time point with respect to oral health-related quality of life reflected by the General Oral Health Assessment Index scores. In-patient days and total costs did not differ significantly on an intent-to-treat basis, but on an as-treated basis, patients treated with MMF had fewer in-patient days on average (1.64 vs 5.50 for ORIF) and lower average costs of treatment ($7,206 vs $26,089 for ORIF). In the intent-to-treat analyses, patients receiving MMF treatment had significantly lower (P = .05) pain scores at the 12-month recall (mean = 0.58, SE = 0.30) compared with patients assigned to ORIF (mean = 1.78, SE = 0.52).

CONCLUSION

Our study did not show a clear overall benefit of the resource-intensive ORIF over conventional MMF treatment in the management of moderately severe mandible fractures in at-risk patients; our data instead suggest some cost as well as oral health quality-of-life advantages for the use of MMF in this patient population.

Vertebral augmentation in osteoporotic fractures

Osteoporotic vertebral compression fractures result in an enormous medical, social and economic burden to society. Here, we review osteoporotic vertebral compression fractures, focusing on both their diagnosis and the treatment options, particularly vertebral augmentation.