Characterization of an advanced viable bone allograft with preserved native bone-forming cells

Bone grafts are widely used to successfully restore structure and function to patients with a broad range of musculoskeletal ailments and bone defects. Autogenous bone grafts are historically preferred because they theoretically contain the three essential components of bone healing (ie, osteoconductivity, osteoinductivity, and osteogenicity), but they have inherent limitations. Allograft bone derived from deceased human donors is one alternative that is also capable of providing both an osteoconductive scaffold and osteoinductive potential but, until recently, lacked the osteogenic component of bone healing. Relatively new, cellular bone allografts (CBAs) were designed to address this need by preserving viable cells. Although most commercially-available CBAs feature mesenchymal stem cells (MSCs), osteogenic differentiation is time-consuming and complex. A more advanced graft, a viable bone allograft (VBA), was thus developed to preserve lineage-committed bone-forming cells, which may be more suitable than MSCs to promote bone fusion. The purpose of this paper was to present the results of preclinical research characterizing VBA. Through a comprehensive series of in vitro and in vivo assays, the present results demonstrate that VBA in its final form is capable of providing all three essential bone remodeling properties and contains viable lineage-committed bone-forming cells, which do not elicit an immune response. The results are discussed in the context of clinical evidence published to date that further supports VBA as a potential alternative to autograft without the associated drawbacks.

Agonizing and Expensive: A Review of Institutional Costs of Ankle Fusion Nonunions

Nonunion after ankle arthrodesis requiring revision is a challenging operative complication, and bone graft substitutes are costly. This study sought to summarize all institutional expenditures related to the revision of an ankle fusion nonunion, presuming that cost and skin-to-skin time would exceed those of the index surgery. The electronic records from 2 foot and ankle centers were reviewed, leading to a list of patients with 2 or more entries for tibiotalar fusions being generated. A total of 24 cases were found to match the criteria. Demographic factors and skin-to-skin time of the remaining patients were compiled. This cohort included 24 patients (6 female and 18 male) with a mean age of 64 years and body mass index of 30.4 kg/m². Supplemental clinic visits and investigations were included either after computed tomography to assess union or 365 days after index surgery. Total cost of the revision was calculated from billing codes, length of operation, and period of hospitalization. Postrevision outpatient fees were included as well. The revisions were performed open in all cases, and 21 patients received autograft and/or bone substitute. Mean postoperative hospitalization was 3 days. The additional costs (in US dollars) associated with nonunion were $1061 for imaging, $627 for prerevision visits, $3026 for the revision, $3432 for the hospital stay, and $1754 for postrevision follow-up. The total mean amount was $9683, equivalent to 9 nights of acute inpatient stay. Mean index skin-to-skin time was 114 minutes, being 126 minutes for revisions (P=.26). Additional care related to ankle fusion nonunion represents a financial burden equivalent to 9 nights of acute inpatient stay. The use of an orthobiologic would need to be less than $436 to be cost saving. Revision surgery is not significantly longer intraoperatively than index surgery. [Orthopedics. 2020;43(4):e219-e224.].

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.

Low cost reconstructive options after musculoskeletal tumour resection in developing countries. Affordable, effective and durable alternatives

Over the last two, three decades, the overall survival rates for non-metastatic malignant tumours of the bone have dramatically improved. This has become possible due to the recent advances and multidisciplinary approach towards these diseases, specifically the advent of multi-agent chemotherapy and radiotherapy. Limb salvage has now become the norm in the treatment of musculoskeletal tumours without compromising on the overall survival and recurrence of the disease. In the era of metal, prosthetic reconstruction has become the standard procedure specifically in the large tumours which involve the joints as this method of reconstruction helps in joint mobility and early weight-bearing. Considering the costs and resource constraints, multiple cost-effective, stable, durable reconstruction options have evolved over the last decade and these have also shown favourable func tional outcomes without compromising on the amount of resection and risk of local recurrence. The current literature review was planned to discuss various cost-effective, durable reconstructive options and their advantages and disadvantages. These include Van ness rotationplasty, allograft, autograft, devitalised tumour bone and Masqueletor induced membrane technique . .

Budget impact analysis of demineralized bone matrix in combination with autograft in lumbar spinal fusion procedures for the treatment of lumbar degenerative disc disease in Spain

OBJECTIVE

To estimate the budget impact (BI) of introducing local autograft (LA) combined with demineralized bone matrix (LA + DBM) in lumbar spinal fusion (LSF) procedures to treat lumbar degenerative disc disease (LDDD) in Spain.

METHODS

A decision tree model was developed to evaluate the 4-year BI associated with introducing LA + DBM putty to replace currently available grafting methods, including iliac crest bone graft (ICBG), LA alone, and LA combined with beta-tricalcium phosphate (LA + ceramics), with 30%, 40%, and 30% market shares, respectively. The analysis was conducted for a hypothetical cohort of 100 patients with LDDD receiving LSF, assuming LA + DBM would replace 100% of the standard of care mix. The fusion rates extracted from the literature were validated by an expert panel. Costs (€2017) were obtained from different Spanish sources. Budget impact and incremental cost per successful fusion were calculated from the perspective of the Spanish National Health System (NHS).

RESULTS

Over 4 years, replacing currently available options with LA + DBM for 100 patients resulted in an additional cost of €12,330 (€123/patient), and an additional 14 successful fusions, implying a cost of €881 per additional successful fusion. When costs of productivity loss were included, the introduction of LA + DBM resulted in cost savings of €70,294 (€703/patient).

LIMITATIONS

The lack of high-quality, homogeneous, head-to-head research studying the efficacy of grafting procedures available to patients undergoing LSF, in addition to a lack of long-term follow-up in existing studies. Therefore, the number of fusions occurring within the model's time horizon may be underestimated.

CONCLUSIONS

Acquisition costs of DBM were partially offset by costs of failed fusions, adverse events and reoperation when switching 100 hypothetical LDDD patients undergoing LSF procedures from standard of care grafting methods to LA + DBM from the perspective of the Spanish NHS. DBM cost was entirely offset when costs of lost productivity were considered.

Is nonstructural bone graft useful in surgical treatment of lumbar spinal tuberculosis?: A retrospective case-control study

Surgical intervention is an important option for treating spinal tuberculosis. Previous studies have reported different surgical procedures and bone grafts for it. To our knowledge, few studies demonstrated the clinical results of using nonstructural autogenous bone graft in surgical treatment of spinal tuberculosis.The purpose of this study is to compare the clinical outcomes of surgical management lumbar spinal tuberculosis by one-stage posterior debridement with nonstructural autogenous bone grafting and instrumentation versus anterior debridement, strut bone grafting combined with posterior instrumentation.A total of 58 consecutive patients who underwent surgical treatment due to lumbar spinal tuberculosis from January 2011 to December 2013 were included. A total of 22 patients underwent one-stage posterior debridement, nonstructural autogenous bone grafting, and instrumentation (group A), and 36 patients received anterior debridement, strut bone grafting combined with posterior instrumentation (group B). The operative duration, total blood loss, perioperative transfusion, length of hospital stay, hospitalization cost, and complications were recorded. The bony fusion of the graft was assessed by computed tomography scans. American Spinal Injury Association (ASIA) Impairment Scale was used to evaluate the neurological function of patients in the 2 groups.All the patients were followed up, with a mean follow-up duration of 21.6 ± 5.7 months in group A and 22.3 ± 6.2 months in group B (P = 0.47). The average operative duration was 257.5 ± 91.1 minutes in group A and 335.7 ± 91.0 minutes in group B (P = 0.002). The mean total blood loss was 769.6 ± 150.9 mL in group A and 1048.6 ± 556.9 mL in group B (P = 0.007). Also, significant differences were found between the 2 groups in perioperative transfusion volumes, length of hospital stay, and hospitalization cost (P < 0.05), which were less in group A compared with group B. Patients with ASIA grade C/D in the 2 groups were improved with 1 to 2 grades after the surgery with no statistical difference (P = 1.000). The perioperative complications rate was 9.1% (2/22) in group A and 13.9% (5/36) in group B (P = 0.897).Based on a retrospective study, the procedure of one-stage posterior debridement, nonstructural autogenous bone grafting, and instrumentation has a significant shorter operative duration, lower blood loss and perioperative transfusion, shorter hospital stay, and less hospitalization cost compared with the one of anterior debridement, strut bone grafting combined with posterior instrumentation for treating lumber spinal tuberculosis.

Open Latarjet versus arthroscopic Latarjet: clinical results and cost analysis

PURPOSE

The aim of this study was to compare the clinical results between open and arthroscopic Latarjet and perform a cost analysis of the two techniques.

MATERIALS AND METHODS

A systematic review of articles present in PubMed and MEDLINE was performed in accordance with PRISMA guidelines. Studies concerning post-operative outcomes following Latarjet procedures for chronic anterior shoulder instability were selected for analysis. The clinical and radiographic results as well as the costs of the open and arthroscopic techniques were evaluated.

RESULTS

Twenty-three articles, describing a total of 1317 shoulders, met the inclusion criteria: 17 studies were related to open Latarjet, and 6 to the arthroscopic technique. Despite the heterogeneity of the evaluation scales, the clinical results seemed very satisfactory for both techniques. We detected a statistically significant difference in the percentage of bone graft healing in favour of the open technique (88.6 vs 77.6 %). Recurrent dislocation was more frequent following open surgery (3.3 % after open surgery vs 0.3 % after arthroscopy), but this finding was biased by the large difference in follow-up duration between the two techniques. The direct costs of the arthroscopic procedure were double in comparison to open surgery (€2335 vs €1040). A lack of data prevented evaluation of indirect costs and, therefore, a cost-effectiveness analysis.

CONCLUSIONS

The open and arthroscopic Latarjet techniques showed excellent and comparable clinical results. However, the much higher direct costs of the arthroscopic procedure do not seem, at present, to be justified by a benefit to the patient.

LEVEL OF EVIDENCE

III.

CERAMENT treatment of fracture defects (CERTiFy): protocol for a prospective, multicenter, randomized study investigating the use of CERAMENT™ BONE VOID FILLER in tibial plateau fractures

BACKGROUND

Bone graft substitutes are widely used for reconstruction of posttraumatic bone defects. However, their clinical significance in comparison to autologous bone grafting, the gold-standard in reconstruction of larger bone defects, still remains under debate. This prospective, randomized, controlled clinical study investigates the differences in pain, quality of life, and cost of care in the treatment of tibia plateau fractures-associated bone defects using either autologous bone grafting or bioresorbable hydroxyapatite/calcium sulphate cement (CERAMENT™|BONE VOID FILLER (CBVF)).

METHODS/DESIGN

CERTiFy (CERament™ Treatment of Fracture defects) is a prospective, multicenter, controlled, randomized trial. We plan to enroll 136 patients with fresh traumatic depression fractures of the proximal tibia (types AO 41-B2 and AO 41-B3) in 13 participating centers in Germany. Patients will be randomized to receive either autologous iliac crest bone graft or CBVF after reduction and osteosynthesis of the fracture to reconstruct the subchondral bone defect and prevent the subsidence of the articular surface. The primary outcome is the SF-12 Physical Component Summary at week 26. The co-primary endpoint is the pain level 26 weeks after surgery measured by a visual analog scale. The SF-12 Mental Component Summary after 26 weeks and costs of care will serve as key secondary endpoints. The study is designed to show non-inferiority of the CBVF treatment to the autologous iliac crest bone graft with respect to the physical component of quality of life. The pain level at 26 weeks after surgery is expected to be lower in the CERAMENT bone void filler treatment group.

DISCUSSION

CERTiFy is the first randomized multicenter clinical trial designed to compare quality of life, pain, and cost of care in the use of the CBVF and the autologous iliac crest bone graft in the treatment of tibia plateau fractures. The results are expected to influence future treatment recommendations.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov: NCT01828905.

Hospital cost analysis of neuromuscular scoliosis surgery

STUDY DESIGN

A retrospective review of 74 consecutive, surgical patients with neuromuscular scoliosis (NMS).

OBJECTIVE

This study evaluates the distribution of hospital and operating room costs incurred during surgical correction of NMS.

BACKGROUND DATA

Recent studies have demonstrated that surgical treatment improves both medical outcomes and the quality of life in patients with progressive NMS. Characterization of the costs incurred at the time of surgery and hospitalization will facilitate the identification of opportunities for cost reduction.

METHODS

Demographic data collected included gender, age, preoperative height, weight, and BMI. Major coronal curvatures and T5-T12 kyphosis were assessed from radiographs. Construct type and number of screws, hooks, and wires implanted were recorded. Surgical costs were calculated based on cost of surgical correction, hospital stay, and postoperative care.

RESULTS

Mean age was 15.8 ± 7.3 years; 57% were male. Comorbidities included cerebral palsy (28%) and familial dysautonomia (14%). The mean preoperative major curve magnitude was 60°; minor curve magnitude was 33°. Posterior approach (76%) and pedicle screws (75%) were predominantly utilized. The average length of hospitalization was 8 days (range: 3 to 47). There were six major complications (8%). The total surgical cost was $50,096 ± $23,998. The highest individual cost was for implants ($13,916; 24% of total costs). The second highest was inpatient room and ICU costs ($12,483; 22%); bone grafts were the third ($6,398; 11%). Increased major and minor structural curve, increased total (A/P) levels fused, and increased length of hospital stay predicted an increase in total cost.

CONCLUSIONS

Major contributors to cost in NMS surgery are implants, inpatient room and ICU costs, and bone grafts. Independent predictors of higher cost are the degree of major and minor structural curve, total number of A/P levels fused, and length of hospital stay. These conclusions provide insight into costs associated with care for a medically fragile and challenging patient population.

Cost-effectiveness analysis of free vascularized fibular grafting for osteonecrosis of the femoral head

Management of symptomatic pre-collapse osteonecrosis of the femoral head continues to be controversial. Patients are often young and active, therefore hip-preserving procedures such as free vascularized fibular grafting (FVFG) have been developed to relieve pain and restore function, thereby delaying or preventing the need for joint arthroplasty. This study compared the cost-effectiveness of FVFG to total hip arthroplasty (THA) in the young adult. A Markov decision model was created for a cost-utility analysis of FVFG compared to THA. Outcome probabilities and effectiveness, expressed in QALYs gained, were derived from existing literature. Principal outcome measures included average incremental costs, effectiveness, and net health benefits. Multivariate sensitivity analysis was used to validate the model. THA resulted in a greater average incremental cost (+$5,933) while at a lower average incremental effectiveness (-0.15 QALY) compared to FVFG. On average, THA gained 22.08 QALYs at a cost-effectiveness (C/E) ratio of $1026/QALY, whereas FVFG gained 22.23 QALYs at a C/E ratio of $752/QALY. Threshold sensitivity analysis determined that the yearly all-cause probability of revision for FVFG would have to be more than three times greater than THA before THA became more cost-effective. Free vascularized fibular grafting is a more cost-effective procedure to treat osteonecrosis in certain populations. Markov decision analysis accounts for the impact of treatment strategies over the lifetime of a patient cohort. These findings can inform clinical decision making in the absence of universally accepted management strategies.

One-stage hip arthroplasty and bone grafting for bilateral femoral head osteonecrosis

One-stage hip arthroplasty and contralateral core decompression with bone grafting were performed for 30 patients with bilateral femoral head osteonecrosis between April 2002 and June 2005. The treatment course, clinical and radiographic outcomes, and medical costs were compared with another 30 age-, gender-, etiology-, and disease extent-matched patients undergoing two-stage treatment during the same period. The two groups had similar clinical data and few complications. Total hospital stay and associated costs were reduced for patients who had one-stage treatment. These patients also returned to work faster (6.0 versus 10.8 months). At an average followup of 46 months, progression to greater than 2 mm of collapse of the salvaged femoral head was observed in seven patients (23%) who had one-stage treatment and 14 patients (47%) who had two-stage treatment. Conversion to hip arthroplasty was performed in five patients (17%) in the one-stage group and 12 patients (40%) in the two-stage group. A special group of patients with bilateral osteonecrosis of the femoral head seemed to benefit from one-stage hip arthroplasty and contralateral core decompression with bone grafting and had better survival of the salvaged femoral head. One-stage hip arthroplasty and core decompression with bone grafting proved to be a cost-effective method that did not increase perioperative morbidity.

LEVEL OF EVIDENCE

Level II, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Single-level cervical radiculopathy: clinical outcome and cost-effectiveness of four techniques of anterior cervical discectomy and fusion and disc arthroplasty

Although there are several accepted methods of surgical treatment for single-level cervical radiculopathy, the choice depend on the surgeon's preference. The techniques may vary in peri-operative morbidity, short- and long-term outcome, but no study so far has analyzed their cost-effectiveness. This study might give some insight in balancing cost and effectiveness and deciding the right technique. Sixty consecutive patients (15 each group), mean age 36 (range 24-76 years) with single-level cervical disc disease underwent surgical treatment with four different techniques in two centers over the period of 1999-2005. The four groups were--(1) plate and tricortical autograft, (2) plate, cage, and bone substitute, (3) cage only, and (4) disc arthroplasty. The data was collected prospectively according to our protocol and subsequently analyzed. The clinical outcome was assessed comparing visual analog scale (VAS) of neck pain and, short form 12 (SF12) questionnaire both pre- and postoperatively. The radiological assessment was done for fusion rate and postoperative related possible complications at 3 months, 6 months, 1 year, and final follow-up. The cost analysis was done calculating the operative time, hospital stay, implant cost together. The mean follow-up period was 31 months (range 28-43 months). The clinical outcome in terms of VAS of neck and arm pain and SF12 physical and mental score improvement (P=0.001) were comparable with all four techniques. The radiological fusion rate was comparable to current available data. As the hospital stay was longer (average 5 days) with plate and autograft group, the total cost was maximum (average 2,920 pound sterling) with this group. There was satisfactory clinical and radiological outcome with all four techniques. Using the cage alone was the most cost-effective technique, but the disc arthroplasty was comparable to the use of cage and plate. Anterior cervical discectomy and fusion is an established surgical treatment for cervical radiculopathy. Single-level cervical radiculopathy was treated with four different techniques. The clinical outcome and cost-effectiveness were compared in this study.

The perioperative cost of Infuse bone graft in posterolateral lumbar spine fusion

BACKGROUND CONTEXT

There is mounting evidence supporting the efficacy of bone morphogenetic protein (BMP) for both anterior interbody and posterolateral lumbar fusion. However, the relative cost of BMP remains an important concern for physicians, hospitals, and payers.

PURPOSE

The purpose of this study is to report on the perioperative costs for patients treated with rhBMP-2 as compared with an iliac crest bone graft (ICBG) supplemented with graft extenders.

STUDY DESIGN/SETTING

A prospective randomized controlled trial of rhBMP-2/ACS (Infuse Bone Graft; Medtronic Sofamor Danek, Memphis, TN) versus ICBG+/-graft extender for lumbar spine fusion in patients over 60 years old.

PATIENT SAMPLE

One hundred two patients over 60 years old who required a posterolateral lumbar spine fusion randomized between receiving rhBMP-2/ACS or ICBG.

OUTCOME MEASURES

All health-care costs over the first 3 months after surgery.

METHODS

As part of a prospective randomized trial of rhBMP-2/ACS versus ICBG+/-graft extender for lumbar spine fusion, all costs over the first 3 months after surgery were directly recorded by a dedicated coder funded by Norton Healthcare, Louisville, KY. A dedicated research nurse also followed all patients throughout their hospital stay and posthospitalization recovery to identify any adverse events or additional outpatient medical care.

RESULTS

Fifty patients received rhBMP-2/ACS and 52 underwent ICBG harvest. The mean hospital cost for the index admission was $24,736 for the rhBMP-2/ACS group and $21,138 for the ICBG group. Mean inpatient physician costs were $5,082 in the rhBMP-2/ACS group and $5,316 in the ICBG group. Costs associated with posthospital rehabilitation averaged $4,906 in the rhBMP-2/ACS group versus $6,820 in the ICBG group. Total payer expenditure for the 3-month perioperative period averaged $33,860 in the rhBMP-2/ACS group and $37,227 in the ICBG group.

CONCLUSIONS

The hospital carries the cost burden associated with the utilization of rhBMP-2/ACS. In contrast, the payer in a Diagnosis-Related Group (DRG) model achieves a net savings, based primarily on the decreased payment for inpatient rehabilitation, but also on decreased hospital reimbursement, physician costs, and other outpatient services.

Evaluation of Autologous Platelet-Poor Plasma Gel as a Hemostatic Adjunct After Posterior Iliac Crest Bone Harvest

PURPOSE

To evaluate the hemostatic efficacy of autologous platelet-poor plasma (PPP) gel following posterior iliac crest bone graft harvesting for oral and maxillofacial reconstruction.

PATIENTS AND METHODS

This was a prospective study of 24 consecutive patients involving 26 posterior iliac crest bone harvests that had bone wax and either 1-gram of bovine microfibrillar collagen or 20 mL of autologous PPP, activated as a gel, used as adjunct hemostatic agents. Compression bulb suction drain was placed into the graft site and drain output recorded every 8 hours for 64 hours. Cost analysis was also undertaken between the 2 methods. Statistical significance between means of each group was determined by Student's t test and found significant for P < .05.

RESULTS

There were no statistically significant differences in average drain output between the PPP and MFC groups for each 8-hour interval. There was no statically significant difference in average total drain output between the PPP and MFC groups over the entire 64 hour period. Additionally, unlike the addition of MFC, the addition of PPP added no additional costs to the procedure.

CONCLUSION

PPP gel, when compared with bovine microfibrillar collagen, is an effective and inexpensive adjunct in hemostasis following posterior iliac crest bone harvest.

Economic impact of cancellous bone grafting in trauma surgery

INTRODUCTION

Cancellous bone grafting is currently the most frequent method for replacement of bone material. In recent years, several alternative methods came into practice. However, up to now it remains unclear whether cancellous bone grafting is cheaper as compared to these new methods. Therefore, the aim of this study was to calculate the direct costs of cancellous bone grafting.

MATERIALS AND METHODS

For calculation of the direct costs operation time needed in addition to the main surgical intervention was measured and the material used recorded in a consecutive series of 50 interventions including bone grafting at the Department of Trauma Surgery at the University Hospital of Bonn Medical School. Surgical staff costs were calculated on the basis of a standard team consisting of one surgical attendant, surgical resident, surgical nurse, and nurse's service. Cost of anaesthesia was calculated on a per minute base.

RESULTS

Mean additional operation time was 26.3 min (range 17-35 min). Surgical staff costs per operation minute were 2.70 Euro, costs for anaesthesiological service were 4.18 Euro/min. Material additional used consisted of sutures and sterilization costs. Material costs summed up to 32.01 Euro. The total direct costs of bone grafting were 212.95 Euro.

CONCLUSION

The direct costs of harvesting cancellous bone graft and the use of bone replacement material are comparable. Due to the high complication rate at the donor site the total-cost-of-illness might be higher when using autologous bone graft.

Health economics: a cost analysis of treatment of persistent fracture non-unions using bone morphogenetic protein-7

OBJECTIVE

To compare the cost implications of treatment of persistent fracture non-unions before and after application of recombinant human bone morphogenetic protein-7 (BMP-7).

METHOD

Of 25 fracture non-unions, 9 were treated using BMP-7 alone and 16 using BMP-7 and bone grafting. These patients were prospectively followed up, and the costs incurred were analysed.

RESULTS

The mean number of procedures per fracture performed before application of BMP-7 was 4.16, versus 1.2 thereafter. Mean hospital stay and cost of treatment per fracture before receiving BMP-7 were 26.84 days and pound 13,844.68, versus 7.8 days and pound 7338.4 thereafter. The overall cost of treatment of persistent fracture non-unions with BMP-7 was 47.0% less than that of the numerous previous unsuccessful treatments (p=0.001).

CONCLUSIONS

Treating fracture non-unions is costly, but this could be reduced by early BMP-7 administration when a complex or persistent fracture non-union is present or anticipated.

Graft incorporation after acetabular and femoral impaction grafting with washed irradiated allograft and autologous marrow

Rates of around 40% incorporation have been described when chips of irradiated cancellous allograft with retained fat were impacted with the Exeter technique. We report the results of acetabular and femoral impaction bone grafting during revision hip arthroplasty using washed irradiated allograft with autologous marrow. Eighty-five consecutive patients underwent acetabular and or femoral revision arthroplasty. Evidence of graft cortication and trabeculation was recorded on successive postoperative radiographs, over a mean period of 44 months. Ninety-six percent (49/51) and 90% (53/59) of patients showed incorporation in acetabular and femoral grafts, respectively. This was usually apparent by 6 months postoperatively. We conclude that the addition of autologous marrow to irradiated bone allograft during impaction grafting is a cheap and highly effective way of achieving graft incorporation.

Regeneration statt Reparation

Autogenous bone transfer is still regarded as the "golden standard" for many indications in oral and cranio-maxillofacial surgery. In this overview, the status of the autogenous bone is re-evaluated under consideration of current research results, clinical long-term studies, risks and safety of the patient as well as the costs. Due to the further development of modern bone substitute materials, which reveal in parts superior long-term results for special indications, the routine use of autogenous bone has to be critically reviewed.

A cost analysis of bone morphogenetic protein versus autogenous iliac crest bone graft in single-level anterior lumbar fusion

An economic model was developed to compare costs of stand-alone anterior lumbar interbody fusion with recombinant human bone morphogenetic protein 2 on an absorbable collagen sponge versus autogenous iliac crest bone graft in a tapered cylindrical cage or a threaded cortical bone dowel. The economic model was developed from clinical trial data, peer-reviewed literature, and clinical expert opinion. The upfront price of bone morphogenetic protein (3380 dollars) is likely to be offset to a significant extent by reductions in the use of other medical resources, particularly if costs incurred during the 2 year period following the index hospitalization are taken into account.

Revision total hip arthroplasty: hospital cost and reimbursement analysis

Revision total hip arthroplasty is a complex surgical procedure that frequently requires high levels of hospital resources. The purpose of the current study was to report the actual costs and reimbursement to the hospital for a stratified group of patients having revision total hip arthroplasty based on a severity index. The clinical and financial records of 49 patients (51 hips) stratified by complexity of revision were reviewed. Clinical variable included age, length of stay, operating time, estimated blood loss, number of transfusions, implant type, metallic augmentation, use of bone graft, and time spent in the postanesthesia care unit. Financial review included the actual fixed and variable costs associated with each procedure. Hospital costs associated with revision total hip arthroplasty were significantly greater in the most complex revisions and in older patients. The use of bone grafting techniques on the femur resulted in significantly greater costs. The average loss to the hospital was $5402 US dollars per procedure with a range of $5657 (US dollars) profit to $28,780 (US dollars) loss. Procedures in patients younger than 65 years has an average loss of $1133 US dollars. All procedures in patients who were 65 years or older resulted in a loss to the hospital, with the average loss being $8617 US dollars. Despite improvements in length of stay, use of clinical pathways, and negotiated discounts on implants, the hospital loss on each hip revision procedure averaged $5402 US dollars.

Economic evaluation of bone morphogenetic protein versus autogenous iliac crest bone graft in single-level anterior lumbar fusion: an evidence-based modeling approach

STUDY DESIGN

Economic evaluation provides a framework to explicitly measure and compare the value of alternative medical interventions in terms of their clinical, health-related quality-of-life, and economic outcomes. Computerized economic models can help inform the design of future prospective studies by identifying the cost-drivers, the most uncertain parameter estimates, and the parameters with the greatest impact on the results and inferences.

OBJECTIVE

An economic analysis of bone morphogenetic protein versus autogenous iliac crest bone graft for single-level anterior lumbar fusion poses several methodologic challenges. This article describes how such an economic evaluation may be framed and designed, while enumerating challenges, offering some solutions, and suggesting an agenda for future research.

SUMMARY OF BACKGROUND DATA

An evidence-based modeling approach can incorporate epidemiologic, clinical, and economic data from several sources including randomized clinical trials, peer-reviewed literature, and expert opinion. Sensitivity analyses can be conducted by varying key parameter estimates within a reasonable range to assess the impact on the results and inferences.

RESULTS

Preliminary results suggest that from a payer perspective, the upfront price of bone morphogenetic protein is likely to be entirely offset by reductions in the use of other medical resources. That is, bone morphogenetic protein appears to be cost neutral. The cost offsets were attributable largely to prevention of pain and complications associated with autogenous iliac crest bone graft, as well as reduction of the costs associated with fusion failures.

CONCLUSIONS

Future research should focus on quantifying the health-related quality-of-life impact of bone morphogenetic protein relative to autogenous iliac crest bone graft, as well as the impact on lost productivity.

Nasoalveolar molding and gingivoperiosteoplasty versus alveolar bone graft: an outcome analysis of costs in the treatment of unilateral cleft alveolus

OBJECTIVE

The purpose of this study was to compare the financial impact of two treatment approaches to the unilateral cleft alveolus. The recently advocated nasoalveolar molding (NAM; and gingivoperiosteoplasty (GPP; at the time of lip repair were compared with the traditional approach of secondary alveolar bone graft.

DESIGN

The records of all patients (n = 30) with unilateral cleft lip and alveolus treated by a single surgeon during 1985 through 1988 were examined retrospectively. The patients were divided into two groups: group 1 patients (n = 14) were treated by lip repair, primary nasal repair, and secondary alveolar bone graft prior to eruption of permanent dentition; group 2 patients (n = 16) were treated by NAM, GPP, lip repair, and primary nasal repair. Patients who required secondary alveolar bone graft after GPP were noted. The cost of treatment by each protocol was calculated in 1998 dollars.

RESULTS

The average cost of treatment for a patient treated by lip repair, primary nasal repair, and secondary alveolar bone graft prior to eruption of permanent dentition was $22,744. Of the 16 patients treated by NAM, GPP, lip repair, and primary nasal repair, 10 required no further treatment of the unilateral cleft alveolus; six patients required secondary alveolar bone graft. The average per-patient treatment cost in this group was $19,745. The average cost savings of NAM and GPP, compared with alveolar bone graft is $2999.

CONCLUSIONS

The treatment of unilateral cleft alveolus by nasoalveolar molding and gingivoperiosteoplasty results in substantial cost savings, compared with treatment by secondary alveolar bone graft.

A cost analysis of two anterior cervical fusion procedures

Multilevel anterior cervical discectomy and fusion (ACDF) remains a difficult problem. A recently described surgical technique for multilevel ACDF has eliminated the morbid complications associated with harvesting iliac crest bone graft (ICBG) while maintaining the advantages of using autologous bone graft. A matched-pairs t test was used to compare the estimated costs of 27 ACDFs using titanium surgical mesh, local autologous bone graft, and anterior plate instrumentation with 27 ACDFs using ICBG and plate fixation. The three variables considered were cage cost, operating time (cost), and hospitalization cost. The estimated costs for the two surgical procedures were not significantly different. Thus, the time saved by not harvesting an ICBG was comparable to the cost of the cage. Harvesting ICBG also increased the morbidity rate by 22%.

[Mastoid cortical bone grafts in ossiculoplasty]

Ossicular homografts have been left for safety reasons with regard to viral transmission diseases. Several means are usable to reconstruct ossicular chain: synthetic prosthesis and autologous bone. On grounds of disponibility, biocompatibility, cost and use easiness we have been using mastoid cortical bone since 1995. We have studied hearing results and tolerance of 45 ossiculoplasties performed with cortical bone. Two years after, we have been obtaining as good or even better functional results with cortical bone graft than with auto or homologous ossicular bones (air bone gap inferior or equal to 20 DB in 89 % of the cases) and no extrusion. Thus, cortical bone seems to be, the better material when autologous ossicular bones are not available.

Behavior of implants in bone grafts or free flaps after tumor resection

The authors compared bone resorption of autogenous bone grafts and revascularized free flaps used for the reconstruction of mandibular continuity defects following resection for tumors, before and after the placement of endosseous implants. Ten patients (group 1) were treated with autogenous bone grafts taken from the fibula or the anterior iliac crest; 8 patients (group 2) were treated with iliac or fibula revascularized flaps. Four to 8 months later, 72 endosseous implants were placed in the reconstructed areas. After a further healing period of 4-6 months, patients were rehabilitated with implant-borne prostheses. The following parameters were evaluated and compared between the two groups: 1) bone resorption of grafts and free flaps before and after implant placement; 2) peri-implant bone resorption mesial and distal to each implant, immediately after prosthetic rehabilitation and then during yearly follow-ups. Bone resorption before implant placement showed mean values of 3.53 mm in group 1, and 0.96 mm in group 2. Peri-implant bone resorption was: 0.49 mm (39 implants) in group 1, and 0.45 mm (30 implants) in group 2, at time of prosthetic rehabilitation; 0.78 mm (39 implants) in group 1, and 0.89 mm (30 implants) in group 2, 12 months after prosthetic load; 1.16 mm (24 implants) in group 1, and 1.02 mm (13 implants) in group 2, 24 months after the prosthetic load. A significant difference in bone resorption before implant placement was found between the two groups, whereas it was not found after implant placement and prosthetic load. The failure rate according to Albrektsson criteria was 4.9% (2/41 implants) in group 1, and was 3.2% (1/31) in group 2.

Review article limb salvage surgery in bone tumours

Wide resection of bone tumour has become an accepted treatment in the limb salvage surgery. The reconstruction of the residual defect following wide resection is a major problem. The motions of involved joint after resection of the large tumour can be restored by using either the osteoarticular allograft or endoprosthesis. Osteoarticular graft is suitable for proximal tibial reconstruction and endoprosthesis for distal femoral reconstruction. Resection arthrodesis can be done with autograft, cement or autoclaved tumour bone. Autograft is rarely used to reconstruct the large residual defect. Cement can reconstruct the larger defect, but it is not a suitable procedure on long term basis. The reimplantation of resected autoclaved tumour bone graft is technically a simple and financially a cost saving solution for this difficult problem. It is the most suitable method of reconstruction for the developing and poor countries where the resources for other methods are not available due to financial technical or socio-cultural reasons.

Sinus augmentation for dental implants: the use of alloplastic materials

The ability to augment the sinus floor has dramatically expanded the scope of implant dentistry. Clinical and scientific studies abound as to the efficacy of this procedure. The debate still ensues as to the best material to use for this augmentation, with autogenous bone, freeze-dried bone, xenografts, and alloplasts all being advocated. This article will substantiate through scientific and clinical studies, how the use of allplastic materials in sinus augmentation techniques can greatly reduce the morbidity and the expense of the procedure while predictably producing bone that has been shown to support dental implants in function for extended periods of time.

[Calibrated autologous bone grafts--their use in oral implantology. Widening--crest augmentation. Personal technic]

Using special trephines moved by a rotary motor, corticospongy graded-cylindrical grafts can be obtained from the iliac crest. These grafts are used to maintain widened and raised maxillary or mandibular crests. Inserted between type Brane-mark implants is useful to increase the height of the alveolar process when it is impossible to implant. Surgical trauma is limited compared with other Lefort 1 type operations advocated for the same indication. Operative effects resolve quickly and patients are hospitalized less than two days. The entire process is quite economical.

Biocompatible osteoconductive polymer versus iliac graft. A prospective comparative study for the evaluation of fusion pattern after anterior cervical discectomy

STUDY DESIGN

One hundred fifteen patients having symptomatic cervical disc disease were recruited prospectively for this study. They were allocated randomly for either autologous iliac bone graft or biocompatible osteoconductive polymer implants. Both groups were compared clinically and radiologically.

OBJECTIVES

Complications, long-term clinical and radiologic outcome, and hospital stay were compared to determine if biocompatible osteoconductive polymer was an improvement on iliac bone graft in terms of reduced donor site pain and shortened hospital stay.

SUMMARY OF BACKGROUND DATA

Donor site morbidity is a significant problem in anterior cervical fusion. Hospital stay is another factor in the recent era of cost consciousness. Biocompatible osteoconductive polymer has been used in many centers as a biodegradable implant to circumvent these problems.

METHODS

Smith-Robinson technique was used in 74 patients, and Cloward technique was used in 41 patients. Sixty-five patients had biocompatible osteoconductive polymer implants, and 50 patients had iliac bone graft. Patients were followed-up routinely in the outpatient clinic where pain visual analogue scale and Odom's criteria were used for outcome evaluation. Plain radiography, computed tomography scan, and magnetic resonance imaging were used for radiologic evaluation.

RESULTS

The mean hospital stay was 4.8 days for those with iliac bone graft and 4.7 days for those with biocompatible osteoconductive polymer. Clinical outcome was identical in both groups. The incidence of partial graft protrusion and postoperative intersegmental kyphosis was statistically higher with iliac bone graft (P = 0.018 and P = 0.02, respectively). "Sclerosis" started to form around biocompatible osteoconductive polymer like a "halo" at 2 months. It increased with time, and sometimes was associated with new osteophyte formation; however, there was no biocompatible osteoconductive polymer incorporation or biodegradation

CONCLUSIONS

Biocompatible osteoconductive polymer acts as a good "spacer" that reduces graft collapse and intersegmental kyphosis. However, it did not show any radiologic evidence of biodegradation or incorporation during the follow-up period of 24 months.

[Bone bank management using a thermal disinfection system (Lobator SD-1). A critical analysis]

In the study presented on 380 allogenic bone donations from living and organ donors, we analyzed the safety of allograft handling bone-band documentation, logistics and costs. For transplant treatment we routinely used a thermal disinfection system (Lobator SD-1). From 380 allograft donors, 400 bone transplants were gained. The rejection rate was 12.2%. After thermal disinfection for 1 h at 80 degrees C, the grafts were cryopreserved at -80 degrees C and released from the bone bank for potential transplantation after 14-16 days. Five of 730 microbiological specimens showed bacterial contamination after thermal graft decontamination. The bacterial species found on the allografts normally have an inactivation temperature under 80 degrees C. Therefore, only secondary contamination can explain the positive bacteriological test results. With reform of the health care system the economical aspects of bone banking have triggered more interest. The cost for one bone transplant released from the bone bank was 424.75 DM: the overall cost for the bone bank in one year was 75,076 DM. Laboratory (58.2%) and material costs (22.5%) were the major factors. Personnel costs and apparatus costs were relatively low (< 20%). With introduction of the thermal disinfection system (Lobator SD-1) into the bone bank, the safety of allogenic bone transplants was greatly improved. Clinical and serological donor screening must be performed according to international bone bank directives. Considering the low rejection rate and the short turnover rate, the economical costs could be reduced. Using an appropriate disinfection system (thermal disinfection at 80 degrees C), laboratory tests covering venereal diseases, malaria and cytomegalia are no longer required. Also, secondary HIV testing of living donors can be omitted without reducing the safety of the transplant.

Cost and outcome of osteocutaneous free-tissue transfer versus pedicled soft-tissue reconstruction for composite mandibular defects

Thirty-nine patients underwent reconstruction of composite mandibular defects following resection for squamous cell carcinoma. Thirty-four underwent immediate reconstruction, while 5 were reconstructed secondarily. Twenty-one received soft-tissue reconstruction only with a pectoralis major myocutaneous flap, 14 underwent osteocutaneous free-tissue transfer, and 4 received a reconstruction plate with free-tissue transfer for soft-tissue coverage. The mandibular defects in the pectoralis major myocutaneous flap group tended to be posterolateral, while free-tissue transfer defects were more severe, usually involving the anterior mandible. Length of surgery and duration of intensive care unit care were significantly longer for free-tissue transfer patients, while flap complications were more common in the pectoralis major myocutaneous flap patients. Facial appearance scores were higher for the free-tissue transfer group by both patient and physician assessment. Social function, speech, and oral function did not differ significantly. Patients reconstructed secondarily with free-tissue transfer reported significant improvement in appearance, oral continence, and social function, with little change in speech intelligibility, deglutition, or diet tolerance. The cost of the main hospitalization was significantly higher in the free-tissue transfer group than in the pectoralis major myocutaneous flap group, although when the costs of subsequent hospitalizations are included, the difference in total cost narrows. Despite more adverse defects, free-tissue transfer provided more predictable aesthetic results and expeditious return to normal social function than did pectoralis major myocutaneous flap reconstruction. The fiscal impact of these complex reconstructions is, however, significant. Cost-containment issues are presented and recommendations are made.

Long-term cost comparison of major limb salvage using the Ilizarov method versus amputation

Hospital costs and professional fees of Ilizarov limb reconstruction patients were compared with hospital costs, professional fees, and prosthetic costs of lower-extremity amputation patients. Ten patients with tibial nonunions, osteomyelitis, infected nonunions, and/or bone defects underwent Ilizarov limb reconstruction while six patients with similar traumatic injuries underwent amputation (three acute and three delayed). The average age was 41 years for the Ilizarov group and 40 years for the amputation group. Both the Ilizarov and the amputation groups required an average of four surgical procedures. The average hospital length of stay was 16 days for the Ilizarov group and 25 days for the amputation group. The total average treatment time was 322 days for the Ilizarov group and 175 days for the amputation group. The total cost of the Ilizarov limb reconstruction averaged $59,213.71. The hospital costs and professional fees for the amputation group averaged $30,148.02 without prosthetic costs, but with the projected lifetime prosthetic costs included, averaged $403,199.18. This study suggests that Ilizarov limb reconstruction is cost-effective when compared with amputation when prosthetic costs are also considered.

The use of cortical bone grafts in ossiculoplasty. III: Audit of costs

This paper describes the results of a comparative audit of the costs of using artificial prostheses and cortical bone. The costs of using a bone graft have been calculated by estimating the expenses incurred as a result of the additional time required for preparation of the grafts. The mean cost of preparing a graft was 29.10 pounds, while the mean cost of using a prosthesis was 65.01 pounds.

[Cost analysis of a bone bank]

The costs of a bone-bank working in accordance with the guidelines of the german federal chamber of physicians are described. Establishing a bone-bank storing deep-frozen bone is not very expensive. The main costs are due to laboratory costs for excluding HIV, hepatitis, syphilis and bacterial contamination of bone grafts. In our experience with 206 bone grafts about 20% of them are to be discharged because of positive laboratory tests. The costs of each bone graft are DM 327. A second HIV-Test of the donor 3 months after explantation of a bone graft will cause rising of costs up to 47%. About 20-30% of bone graft donors will probably not carry out this test. In this case discharging of the bone graft is necessary.

Costs and complications in mandibular reconstruction

Because of increasing concerns about the high cost of complex medical care, we compared the combined cost of ablation and reconstruction incurred using five different management strategies for patients undergoing mandibular resection. We also compared the rates of complication and failure for the methods used. The records of 69 patients undergoing segmental or total mandibulectomy between January 1, 1986, and June 30, 1990, were reviewed. Of these, 15 had reconstruction with soft tissue only (average cost, $36,137; complication rate, 33%), whereas 20 had immediate reconstruction with vascularized bone (average cost, $46,894; complication rate, 50%), and 15 had reconstruction with only a metal plate (average cost, $47,678; complication rate, 73%). Nine patients had plate reconstructions initially but subsequently underwent reconstructions with bone (average cost, $54,346; complication rate, 78%), whereas 10 patients had no initial reconstruction but subsequently underwent delayed reconstruction with bone (average cost, $52,486; complication rate, 70%). If reconstruction was performed with bone, immediate reconstruction was more cost effective than delayed reconstruction and had a lower complication rate as well.