Variation in the Profit Margin for Different Types of Total Joint Arthroplasty.

BACKGROUND: As health care shifts to a value-based model with bundled-payment methods, it is important to understand the costs and reimbursements of arthroplasty procedures that represent the largest expenditure of Medicare. The aim of the present study was to characterize the variation in (1) total hospital costs, (2) reimbursement, and (3) profit margin for different arthroplasty procedures. METHODS: The total hospital costs of total knee arthroplasty (TKA), total hip arthroplasty (THA), anatomic total shoulder arthroplasty (TSA), reverse shoulder arthroplasty (RSA), and total ankle arthroplasty (TAA) were calculated with use of time-driven activity-based costing at an orthopaedic institution from 2018 to 2020. The average reimbursement for each type of procedure was determined. Profit margin, defined as the reimbursement profit after direct costs, was calculated by deducting the average time-drive activity-based total hospital costs from the reimbursement value. Multivariate analyses were performed to evaluate the associations between costs, reimbursement, and profit margins. RESULTS: There were 13,545 arthroplasty procedures analyzed for this study, including 6,636 TKAs, 5,902 THAs, 346 TSAs, 577 RSAs, and 84 TAAs. Costs and reimbursement were highest for TAA. THA and TKA resulted in the highest profit margins, whereas RSA resulted in the lowest. The strongest associations with profit margin were private insurance (0.46547), age (-0.22732), and implant cost (-0.19240). CONCLUSIONS: THA and TKA had greater profit margins overall than TAA and upper-extremity arthroplasty in general. Profit margins for RSA, TSA, and TAA were all at least 28% lower than those for TKA or THA. Lower-volume arthroplasty procedures were associated with decreased profit margins. Study findings suggest that optimizing implant costs and length of stay are important for sustaining institutional fiscal health when performing shoulder and ankle arthroplasty surgery.

Functional Outcomes of 24-Hour Thumb Immobilization in Healthy Volunteers: Prospective Comparative Study.

Background Immobilization is often needed for the treatment of wrist and hand injuries. The current best method of immobilization for several types of injuries has yet to be elucidated with little being reported on the functional differences of each type of immobilization. Purpose The purpose of this study is to compare the functional outcome between healthy young volunteers with a 24-hour short arm cast (SAC) versus thumb spica cast (TSC) immobilization. Methods A total of 50 healthy volunteers completed a baseline typing assessment and a Patient-Reported Outcomes Measurement Information System (PROMIS) upper extremity functional scoring assessment. Participants in group 1 were randomly initially assigned to a TSC of their dominant hand followed by an SAC, whereas participants in group 2 were randomly initially assigned to a TSC of their nondominant hand followed by an SAC. The volunteers completed the typing assessment and PROMIS assessment at the end of the 24-hour casting period. Results A total of 50 participants were enrolled in the study with 25 in group 1 and 25 in group 2. There was a 24.3-point difference between the average PROMIS score for participants with SAC compared with participants with TSC (93 vs. 68.7; p = 0.0001). There was a significant difference between the typing speed and accuracy of participants with SAC compared with participants with TSC ( p = 0.0001). Conclusion There is a significant difference in functionality of a TSC immobilization versus an SAC immobilization according to the PROMIS functional outcome score and typing speed in a 24-hour casting period. SAC immobilization should be considered to have a possible similar effect in pathologic conditions instead of TSC immobilization given these findings even though a 24-hour period is not enough to provide adequate long-term conclusions. Level of Evidence I, prospective comparative study.

Factors used by program directors to select hand surgery fellows.

PURPOSE: To identify factors and attributes hand surgery fellowship program directors consider important in selecting applicants for interview and ranking. METHODS: A web-based questionnaire was sent to all hand fellowship program directors in the United States. The questionnaire was designed to identify the most important criteria in granting an interview, sources of letters of recommendation, the interview process, and factors used to rank a candidate. Each criterion was ranked in importance on a 1 to 5 Likert scale, with 1 being not important and 5 being critical. All responses were anonymous. The most important criterion for each section of the survey was determined by comparing the average Likert scores. RESULTS: Fifty-two of 76 program directors responded (68%). The criteria with the highest mean Likert scores for offering an applicant an interview were, in order, quality letters of recommendation from hand surgeons, completion of an orthopedic surgery residency, comments regarding the applicant's technical competence, applicant having an MD degree (as opposed to a DO degree), and residency program reputation. The letters of recommendation with the highest value were from the division chief of hand surgery and another hand surgeon in the division/department. The most important features of the interview were maturity of applicant, ability of applicant to articulate thoughts, ability to listen well, self-confidence, and relevant questions asked. The most important factors in ranking a candidate were applicant integrity, commitment to hard work, quality of letters of recommendation, quality of the interview, and ability to work well with other members of the hand surgery team. CONCLUSIONS: There are identifiable factors considered important by hand surgery fellowship directors when selecting and ranking an applicant. This information may be valuable to medical students and residents contemplating careers in hand surgery.

Total joint arthroplasty surgery: does day of surgery matter?

Length of stay (LOS) after total joint arthroplasty (TJA) impacts the expense to the hospital. Our purpose was to evaluate the impact that day of surgery has on postoperative LOS. 547 patients who had a primary TJA at two tertiary care hospitals were identified retrospectively. TJA patients admitted on day of surgery and who had primary elective surgery were included in our sample. Patients were subdivided into one of four groups: those who had operations on Monday, Tuesday, Thursday, and Friday respectively. Patients who had surgery on Thursday and Friday had significantly longer LOS when compared to Monday and Tuesday. This variation in LOS between the groups may be due to inconsistencies in weekend functionality, less experienced part-time staffing, and inaccessibility of rehabilitation personnel.

Effect of applied force and blade speed on histopathology of bone during resection by sagittal saw.

A sagittal saw is commonly used for resection of bone during joint replacement surgery. During sawing, heat is generated that can lead to an increase in temperature at the resected surface. The aim of this study was to determine the effect of applied thrust force and blade speed on generating heat. The effect of these factors and their interactions on cutting temperature and bone health were investigated with a full factorial Design of Experiments approach for two levels of thrust force, 15 N and 30 N, and for two levels of blade oscillation rate, 12,000 and 18,000 cycles per minute (cpm). In addition, a preliminary study was conducted to eliminate blade wear as a confounding factor. A custom sawing fixture was used to crosscut samples of fresh bovine cortical bone while temperature in the bone was measured by thermocouple (n=40), followed by measurements of the depth of thermal necrosis by histopathological analysis (n=200). An analysis of variance was used to determine the significance of the factor effects on necrotic depth as evidenced by empty lacunae. Both thrust force and blade speed demonstrated a statistically significant effect on the depth of osteonecrosis (p<0.05), while the interaction of thrust force with blade speed was not significant (p=0.22). The minimum necrotic depth observed was 0.50mm, corresponding to a higher level of force and blade speed (30 N, 18,000 cpm). Under these conditions, a maximum temperature of 93°C was measured at 0.3mm from the kerf. With a decrease in both thrust force and blade speed (15N, 12,000 cpm), the temperature in the bone increased to 109°C, corresponding to a nearly 50% increase in depth of the necrotic zone to 0.74 mm. A predictive equation for necrotic depth in terms of thrust force and blade speed was determined through regression analysis and validated by experiment. The histology results imply that an increase in applied thrust force is more effective in reducing the depth of thermal damage to surrounding bone than an increase in blade speed.

Spontaneous hemothorax in multiple exostoses: a case report and review of literature.

Abstract Multiple hereditary exostoses is a rare autosomal dominant disorder characterized by the growth of multiple osteochondromas. We describe the thoracoscopic remodeling of a spiculated costal exostotic lesion responsible for spontaneous recurrent hemothoraces in a 17-year-old male patient with multiple hereditary exostoses.

Basal joint arthroplasty and carpal tunnel release through a single incision: an in vitro study.

PURPOSE: Carpal tunnel syndrome coexists with basal joint arthritis in a large percentage of patients. These 2 conditions are often treated surgically through separate incisions. The purpose of this cadaver study is to show the effect of trapeziectomy and transverse carpal ligament release from the scaphoid tubercle on carpal canal pressures. This technique may permit both problems to be addressed through the same Wagner incision. METHODS: In 4 fresh frozen cadaver limbs pressures in the carpal canal were elevated to 30 mm Hg through a percutaneously placed balloon. Pressures were measured using an 18-gauge sideport needle via a transducer. Trapeziectomy and release of the transverse carpal ligament from the scaphoid were performed in succession through a Wagner incision with canal pressures measured after each step. RESULTS: Carpal canal pressures decreased after trapeziectomy (mean, 7 mm Hg; range, 3-14 mm Hg) but did not return to baseline (0 mm Hg) until complete release of the ligament. CONCLUSIONS: Decompression of the carpal tunnel can be performed effectively through a Wagner incision during basal joint arthroplasty. This cadaver model shows reduction in the canal pressures after trapeziectomy and release of the transverse carpal ligament. This single-incision approach is attractive because it may decrease morbidity compared with a 2-incision approach in patients with concomitant carpal tunnel syndrome and basal joint arthritis.

Norian SRS cement compared with conventional fixation in distal radial fractures. A randomized study.

BACKGROUND: A prospective, randomized multicenter study was conducted to evaluate closed reduction and immobilization with and without Norian SRS (Skeletal Repair System) cement in the management of distal radial fractures. Norian SRS is a calcium-phosphate bone cement that is injectable, hardens in situ, and cures by a crystallization reaction to form dahllite, a carbonated apatite equivalent to bone mineral. METHODS: A total of 323 patients with a distal radial fracture were randomized to treatment with or without Norian SRS cement. Stratification factors included fracture type (intra-articular or extra-articular), hand dominance, bone density, and the surgeon's preferred conventional treatment (cast or external fixator). The subjects receiving Norian SRS underwent a closed reduction followed by injection of the cement percutaneously or through a limited open approach. Wrist motion, beginning two weeks postoperatively, was encouraged. Control subjects, who had not received a Norian SRS injection, underwent closed reduction and application of a cast or external fixator for six to eight weeks. Supplemental Kirschner wires were used in specific instances in both groups. Patients were followed clinically and radiographically at one, two, four, and between six and eight weeks and at three, six, and twelve months. Patients rated pain and the function of the hand with use of a visual analog scale. Quality of life was assessed with use of the Short Form-36 (SF-36) health status questionnaire. Complications were recorded. RESULTS: Significant clinical differences were seen at six to eight weeks postoperatively, with better grip strength, wrist range of motion, digital motion, use of the hand, and social and emotional function, and less swelling in the patients treated with Norian SRS than in the control group (p < 0.05). By three months, these differences had normalized except for digital motion, which remained significantly better in the group treated with Norian SRS (p = 0.015). At one year, no clinical differences were detected. Radiographically, the average change in ulnar variance was greater in the patients treated with Norian SRS (+2.0 mm) than in the control group (+1.4 mm) (p < 0.02). No differences were seen in the total number of complications, including loss of reduction. The infection rate, however, was significantly higher (p < 0.001) in the control group (16.7%) than in the group treated with Norian SRS (2.5%) and the infections were always related to external fixator pins or Kirschner wires. Four patients with intra-articular extravasation of cement were identified; no sequelae were observed at twenty-four months. Cement was seen in extraosseous locations in 112 (70%) of the SRS-treated patients; loss of reduction was highest in this subgroup (37%). The extraosseous material had disappeared in eighty-three of the 112 patients by twelve months. CONCLUSIONS: Our results indicate that fixation of a distal radial fracture with Norian SRS cement may allow for accelerated rehabilitation. A limited open approach and supplemental fixation with Kirschner wires are recommended. Additional or alternate fixation is necessary for complex articular fractures.

Treatment of Madelung's deformity in adults by ulna reduction osteotomy.

PURPOSE: Adult patients with Madelung's deformity may present with ulnar-sided wrist pain. Treatment often involves addressing the distal radial deformity. If there is focal wrist pathology and a positive ulnar variance, however, then an isolated ulnar-shortening osteotomy may provide symptomatic relief in these patients. The purpose of this study was to report our results of ulnar-shortening osteotomy without radial osteotomy in adult patients with Madulung's deformity. METHODS: From 1988 to 2001 9 wrists in 9 adult patients with Madelung's deformity and ulnar-sided wrist pain underwent ulnar-shortening osteotomy. The distal radius abnormality was not addressed. All of the patients were women and the average age at the time of surgery was 34 years (range, 29-45 y). Two of the individuals were mesomelic dwarfs and the remaining 7 patients were otherwise normal. Surgery was performed after the patients failed at least 6 months of nonsurgical management. RESULTS: All patients had improvement of their symptoms at an average follow-up evaluation of 42 months (range, 6-112 mo). All of the osteotomies united. One patient required replating for a delayed union. There were no infections and no ulnar carpal subluxation. Ulnar-positive variance correction averaged 4.4 mm. Postoperative range of motion and grip strength were equivalent to the contralateral wrist. CONCLUSIONS: Ulnar-shortening osteotomy is a safe and reliable surgical procedure that can relieve ulnar-sided wrist pain in adult patients with symptomatic Madelung's deformity and positive ulnar variance.