Operative Time, Cost, and Union Rate of Power Rasp Joint Preparation Versus Traditional Preparation in Arthrodesis of the Foot and Rearfoot.

Time spent in the operating room is valuable to both surgeons and patients. One of the biggest rate-limiting factors when it comes to arthrodesis procedures of the foot and ankle is cartilage removal and joint preparation. Power instrumentation in joint preparation provides an avenue to decrease joint preparation time, thus decreasing operating room time and costs. Arthrodesis of 47 joints (n) from 27 patients were included. Power rasp joint preparation in 26 joints was compared to traditional osteotome and curette joint preparation in 21 joints in both time (seconds), cost (total operating room time cost per minute), and union rate. The overall mean joint preparation time using power rasp for the subtalar joint was 268.3 seconds, talonavicular joint 212.3 seconds, calcaneocuboid joint 142.6 seconds, 1st TMT 107.2 seconds. Mean joint preparation time using traditional method for subtalar joint 509.8 seconds, talonavicular joint 393.0 seconds, calcaneocuboid joint 400.0 seconds, 1st TMT 319.6 seconds. Mean cost of joint preparation using power rasp for subtalar joint $165.47, talonavicular joint $130.89, calcaneocuboid joint $87.94, 1st TMT $66.11. Mean cost of joint preparation using traditional techniques for subtalar joint $314.34, talonavicular joint $242.35, calcaneocuboid joint $246.67, 1st TMT $197.33. Overall union rate was 98% (1 asymptomatic non-union). Increasing efficiency in the operating room is vital to every surgeon's practice. Power rasp joint preparation is a viable option to increase efficiency and decrease operative time, this study shows no statistically significant differences in union rate, with comparable rates to existing literature.

Pedicle Subtraction Osteotomy Versus Multilevel Anterior Lumbar Interbody Fusion and Lateral Lumbar Interbody Fusion in the Treatment of Adult Spinal Deformity: Trends, Outcomes, and Cost.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The aim of this study was to compare the outcomes of pedicle subtraction osteotomy (PSO) with multilevel anterior lumbar interbody fusion (ALIF) and lateral lumbar interbody fusion (LLIF) in posterior long-segment fusion. BACKGROUND: PSO and ALIF/LLIF are 2 techniques used to restore lumbar lordosis and correct sagittal alignment, with each holding its unique advantages and disadvantages. As there are situations where both techniques can be employed, it is important to compare the risks and benefits of both. PATIENTS AND METHODS: Patients aged 18 years or older who underwent PSO or multilevel ALIF/LLIF with posterior fusion of 7-12 levels and pelvic fixation were identified. 1:1 propensity score was used to match PSO and ALIF/LLIF cohorts for age, sex, and relevant comorbidities, including smoking status. Logistic regression was used to compare medical and surgical outcomes. Trends and costs were generated for both groups as well. RESULTS: ALIF/LLIF utilization in posterior long fusion has been steadily increasing since 2010, whereas PSO utilization has significantly dropped since 2017. PSO was associated with an increased risk of durotomy ( P < 0.001) and neurological injury ( P = 0.018). ALIF/LLIF was associated with increased rates of postoperative radiculopathy ( P = 0.005). Patients who underwent PSO had higher rates of pseudarthrosis within 1 and 2 years ( P = 0.015; P = 0.010), 1-year hardware failure ( P = 0.028), and 2-year reinsertion of instrumentation ( P = 0.009). Reoperation rates for both approaches were not statistically different at any time point throughout the 5-year period. In addition, there were no significant differences in both procedural and 90-day postoperative costs. CONCLUSIONS: PSO was associated with higher rates of surgical complications compared with anterior approaches. However, there was no significant difference in overall reoperation rates. Spine surgeons should select the optimal technique for a given patient and the type of lordotic correction required.

Accuracy and cost effectiveness of a waferless osteotomy approach, using patient specific guides and plates in orthognathic surgery: a systematic review.

The aim of this systematic review is to evaluate the accuracy of waferless osteotomy procedures in orthognathic surgery with a secondary aim to determine the cost-effectiveness of the procedure. A literature search was conducted on the databases PubMed and Scopus, with PRISMA guidelines followed. An initial yield of 4149 articles were identified, ten of which met the desired inclusion criteria. The total sample of patients undergoing waferless osteotomies included in this review was 142 patients. Nine of the studies used surgical cutting guides along with customised surgical plates to eliminate the surgical wafer and one study used pre-bent locking plates instead of customised plates. The eligible articles determined their surgical accuracy by comparing the positions of bony or dental landmarks on the pre-operative and post-operative images. The articles all reported acceptable accuracy within previously established clinical parameters. The majority of authors concluded that it is an accurate surgical approach and can be cost effective which is often a barrier to novel techniques however there were studies that contrasted the view of the cost efficacy. Due to the lack of published randomised controlled trials, current evidence is not strong enough to recommend the use of surgical cutting guides and customised/pre-bent plates for orthognathic surgery.

Screw versus staple fixation for Akin osteotomy.

INTRODUCTION: Akin osteotomies are commonly fixed with a screw or staple. Hardware-related symptoms are not uncommon. We compared the outcomes and costs of the two implants. METHODS: We evaluated 74 Akin osteotomies performed in conjunction with first metatarsal osteotomy for hallux valgus. The osteotomy was fixed with a headless compression screw in 39 cases and a staple in 35 cases. We looked at the implant-related complications, removal of metalwork, revision, non-union and cost. Pre- and postoperative hallux valgus interphalangeal (HI) angles and length of the proximal phalanx were measured. RESULTS: There was 100% union, no failure of fixation, no revision surgery and no delayed union in either group. The radiological prominence of screws was significant (p=0.02), but there was no significant difference in soft-tissue irritation (p=0.36) or removal of implants (p=0.49). Two cortical breaches (5.8%) occurred in staple fixation and 4 (10.2%) in screw fixation (not statistically significant (NS), p=0.50). The mean improvement in HI angle was 4.3° with screw fixation and 4.1° with staple fixation (NS, p=0.69). The mean shortening of the proximal phalanx was 2.5mm with screw fixation and 2.3mm with staple fixation (NS, p=0.64). The total cost was £1,925 for staple fixation and £4,290 for screw fixation. CONCLUSIONS: Staple and screw fixation are reproducible modalities with satisfactory outcomes, but screw fixation is expensive. We conclude staple fixation is a cost-effective alternative.

Contemporary Practices and Complications of Surgery for Thoracic Outlet Syndrome in the United States.

BACKGROUND: Thoracic outlet syndrome (TOS) surgery is relatively rare and controversial, given the challenges in diagnosis as well as wide variation in symptomatic and functional recovery. Our aims were to measure trends in utilization of TOS surgery, complications, and mortality rates in a nationally representative cohort and compare higher versus lower volume centers. METHODS: The National Inpatient Sample was queried using International Classification of Diseases, Ninth Revision, codes for rib resection and scalenectomy paired with axillo-subclavian aneurysm (arterial [aTOS]), subclavian deep vein thrombosis (venous [vTOS]), or brachial plexus lesions (neurogenic [nTOS]). Basic descriptive statistics, nonparametric tests for trend, and multivariable hierarchical regression models with random intercept for center were used to compare outcomes for TOS types, trends over time, and higher and lower volume hospitals, respectively. RESULTS: There were 3,547 TOS operations (for an estimated 18,210 TOS operations nationally) performed between 2010 and 2015 (89.2% nTOS, 9.9% vTOS, and 0.9% aTOS) with annual case volume increasing significantly over time (P = 0.03). Higher volume centers (≥10 cases per year) represented 5.2% of hospitals and 37.0% of cases, and these centers achieved significantly lower overall major complication (defined as neurologic injury, arterial or venous injury, vascular graft complication, pneumothorax, hemorrhage/hematoma, or lymphatic leak) rates (adjusted odds ratio [OR] 0.71 [95% confidence interval 0.52-0.98]; P = 0.04], but no difference in neurologic complications such as brachial plexus injury (aOR 0.69 [0.20-2.43]; P = 0.56) or vascular injuries/graft complications (aOR 0.71 [0.0.33-1.54]; P = 0.39). Overall mortality was 0.6%, neurologic injury was rare (0.3%), and the proportion of patients experiencing complications decreased over time (P = 0.03). However, vTOS and aTOS had >2.5 times the odds of major complication compared with nTOS (OR 2.68 [1.88-3.82] and aOR 4.26 [1.78-10.17]; P < 0.001), and ∼10 times the odds of a vascular complication (aOR 10.37 [5.33-20.19] and aOR 12.93 [3.54-47.37]; P < 0.001], respectively. As the number of complications decreased, average hospital charges also significantly decreased over time (P < 0.001). Total hospital charges were on average higher when surgery was performed in lower volume centers (<10 cases per year) compared with higher volume centers (mean $65,634 [standard deviation 98,796] vs. $45,850 [59,285]; P < 0.001). CONCLUSIONS: The annual number of TOS operations has increased in the United States from 2010 to 2015, whereas complications and average hospital charges have decreased. Mortality and neurologic injury remain rare. Higher volume centers delivered higher value care: less or similar operative morbidity with lower total hospital charges.

Cost-Effectiveness Analysis of Motion-Preserving Operations for Wrist Arthritis.

BACKGROUND: The authors conducted a cost-effectiveness analysis to answer the question: Which motion-preserving surgical strategy, (1) four-corner fusion, (2) proximal row carpectomy, or (3) total wrist arthroplasty, used for the treatment of wrist osteoarthritis, is the most cost-effective? METHODS: A simulation model was created to model a hypothetical cohort of wrist osteoarthritis patients (mean age, 45 years) presenting with painful wrist and having failed conservative management. Three initial surgical treatment strategies-(1) four-corner fusion, (2) proximal row carpectomy, or (3) total wrist arthroplasty-were compared from a hospital perspective. Outcomes included clinical outcomes and cost-effectiveness outcomes (quality-adjusted life-years and cost) over a lifetime. RESULTS: The highest complication rates were seen in the four-corner fusion cohort: 27.1 percent compared to 20.9 percent for total wrist arthroplasty and 17.4 percent for proximal row carpectomy. Secondary surgery was common for all procedures: 87 percent for four-corner fusion, 57 percent for proximal row carpectomy, and 46 percent for total wrist arthroplasty. Proximal row carpectomy generated the highest quality-adjusted life-years (30.5) over the lifetime time horizon, compared to 30.3 quality-adjusted life-years for total wrist arthroplasty and 30.2 quality-adjusted life-years for four-corner fusion. Proximal row carpectomy was the least costly; the mean expected lifetime cost for patients starting with proximal row carpectomy was $6003, compared to $11,033 for total wrist arthroplasty and $13,632 for four-corner fusion. CONCLUSIONS: The authors' analysis suggests that proximal row carpectomy was the most cost-effective strategy, regardless of patient and parameter level uncertainties. These are important findings for policy makers and clinicians working within a universal health care system.

Cost-Effectiveness of Surgical Techniques in Hallux Valgus.

Health care costs are increasing. Funding is not increasing at a commensurate rate. Demonstrable cost-effectiveness is critical when selecting operation and implant type. Clinicians must justify their decision on surgery and implant type, providing patient-reported outcome measures (PROM). Providing such data on cost and PROM forms the basis of future cost-effectiveness analysis (CEA). Such analysis is complex. Future research should analyze cost variables individually. Day case surgery, multimodal analgesia, and simultaneous surgery for bilateral cases show promise in reducing cost. With evidence of increased recurrence, requirement for additional equipment and more expensive implants it is unlikely to demonstrate superior cost-effectiveness.

Comparison of total cost and outcomes between single-stage open reduction and Pemberton periacetabular osteotomy operation and two separate consecutive operations in treatment of bilateral developmental hip dysplasia in children at walking age.

Open reduction and Pemberton periacetabular osteotomy (PPO) is one of the most preferred techniques for the treatment of developmental hip dyslaplasia (DDH) after the walking age. Performing the surgery as a one-stage operation or two separate consecutive operations is a controversial issue. In this study, we aimed to compare the outcomes, length of hospitalization and total cost between the patients whom had single-stage open reduction and PPO or two consecutive operations due to bilateral DDH in the walking age children. One hundred thirty patients with bilateral DDH had undergone open reduction and PPO for both hips. Seventy-five patients had one-stage open reduction and PPO for both of the hips, whereas 55 patients have two separate consecutive operations. Total time of exposure to anesthetics, blood loss and duration of operation were noted. Hospitalization period and total treatment costs were also noted for each patient. There was no statistically significant difference between the groups regarding the preoperative and postoperative AIs (P > 0.05). Comparing the total cost, length of hospitalization, exposure to anesthetics, perioperative blood loss, there was statistically significant difference between the groups (P < 0.005). Single-stage surgery had favorable outcomes. Major benefits of single-stage surgery for treatment of bilateral DDH are the reduced costs, anesthesia duration, intraoperative blood loss and hospitalization period. Also it can be presumed that prolonged immobilization can lead to loss of bone strength and resulting in fragility fractures. So single-stage open reduction and PPO for bilateral DDH can be preferred in experienced clinics.

Proximal Row Carpectomy versus Four-Corner Arthrodesis for the Treatment of Scapholunate Advanced Collapse/Scaphoid Nonunion Advanced Collapse Wrist: A Cost-Utility Analysis.

BACKGROUND: Two mainstay surgical options for salvage in scapholunate advanced collapse and scaphoid nonunion advanced collapse are proximal row carpectomy and four-corner arthrodesis. This study evaluates the cost-utility of proximal row carpectomy versus three methods of four-corner arthrodesis for the treatment of scapholunate advanced collapse/scaphoid nonunion advanced collapse wrist. METHODS: A cost-utility analysis was performed in accordance with the Second Panel on Cost-Effectiveness in Health and Medicine. A comprehensive literature review was performed to obtain the probability of potential complications. Costs were derived using both societal and health care sector perspectives. A visual analogue scale survey of expert hand surgeons estimated utilities. Overall cost, probabilities, and quality-adjusted life-years were used to complete a decision tree analysis. Both deterministic and probabilistic sensitivity analyses were performed. RESULTS: Forty studies yielding 1730 scapholunate advanced collapse/scaphoid nonunion advanced collapse wrists were identified. Decision tree analysis determined that both four-corner arthrodesis with screw fixation and proximal row carpectomy were cost-effective options, but four-corner arthrodesis with screw was the optimal treatment strategy. Four-corner arthrodesis with Kirschner-wire fixation and four-corner arthrodesis with plate fixation were dominated (inferior) strategies and therefore not cost-effective. One-way sensitivity analysis demonstrated that when the quality-adjusted life-years for a successful four-corner arthrodesis with screw fixation are lower than 26.36, proximal row carpectomy becomes the optimal strategy. However, multivariate probabilistic sensitivity analysis confirmed the results of our model. CONCLUSIONS: Four-corner arthrodesis with screw fixation and proximal row carpectomy are both cost-effective treatment options for scapholunate advanced collapse/scaphoid nonunion advanced collapse wrist because of their lower complication profile and high efficacy, with four-corner arthrodesis with screw as the most cost-effective treatment. Four-corner arthrodesis with plate and Kirschner-wire fixation should be avoided from a cost-effectiveness standpoint.

Conversion Total Knee Arthroplasty: A Distinct Surgical Procedure With Increased Resource Utilization.

BACKGROUND: Current Procedural Terminology coding currently makes no distinction between primary total knee arthroplasty (TKA) and conversion TKA, in which periarticular hardware components must be removed prior to or during TKA. We hypothesize that conversion TKA will carry increased operative time, blood loss, postoperative complications, and 90-day emergency department/readmission rate compared to primary TKA. METHODS: Patients undergoing conversion TKA from 2005 to 2017 were identified from an institutional database and matched to primary TKA patients by age, gender, American Society of Anesthesiologists score, body mass index, and procedure date (±1 year). Intraoperative data and 90-day postoperative complications were compared between groups. RESULTS: One hundred nine conversion TKA patients with periarticular hardware were removed prior to (n = 51) or during (n = 58) TKA and 109 primary TKA control patients were included. Conversion TKA was associated with increased tourniquet time (91 vs 71 minutes, P < .001), operative time (147 vs 113 minutes, P < .001), blood loss (225 vs 176 mL, P = .010), 90-day readmissions (14.6% vs 4.2%, P = .020), wound complication (5.6% vs 0.0%, P = .025), periprosthetic joint infection (7.9% vs 0.0%, P = .005), irrigation/debridement (9.0% vs 1.1%, P = .016), and a trend toward increased mechanical complication (6.7% vs 1.1%, P = .058). Timing of hardware removal did not affect intraoperative or postoperative outcomes. CONCLUSION: Conversion TKA is associated with higher operative time, blood loss, readmission rate, and postoperative complications compared to primary TKA. Without a proper billing code and appropriate reimbursement level to match the expected operative and postacute resource utilization by these cases, physicians may be disincentivized to perform these operations.

The importance of costing perspective: an example evaluating the cost-effectiveness of a locking versus nonlocking plate in medial opening wedge high tibial osteotomy

Summary: High tibial osteotomy (HTO) fixation can be achieved using various plate designs. Compared with nonlocking plates, the stability of locking plates allows patients to return to weight-bearing and work sooner and may also decrease postoperative complications, introducing the potential for overall cost savings. However, material costs for locking plates are higher, and the plate bulkiness may lead to additional surgery to remove the plate. We conducted a retrospective study to evaluate the cost-effectiveness of a locking versus a nonlocking plate in HTO from both the health care payer and societal perspectives up to 12 months postoperative. We observed that from a health care payer perspective, the locking plate was not cost-effective. However, the locking plate was cost-effective from the societal perspective (addition of indirect costs, such as time off work). These findings highlight the importance of considering costing perspective in economic evaluations for chronic conditions, particularly in publicly funded health care systems.

Two Surgeon Approach for Complex Spine Surgery: Rationale, Outcome, Expectations, and the Case for Payment Reform.

There is an increased trend in complex spine deformity cases toward a two attending surgeon approach, but the practice has not become widely accepted by payers. Multiple studies have shown that spine surgery complications increase with the duration of case, estimated blood loss, and use of transfusions, as well as in certain high-risk populations or those requiring three-column osteotomies. Dual-surgeon cases have been shown to decrease estimated blood loss, transfusion rate, surgical times, and therefore complication rates. Although this practice comes at an uncertain price to medical training and short-term costs, the patient's quality of care should be prioritized by institutions and payers to include dual-surgeon coverage for these high-risk cases. Because we enter an era where the value of spine care and demonstrating cost-effectiveness is essential, dual surgeon attending approaches can enhance these tenets.

Evaluation of intra-operative imaging during scarf osteotomy - an unnecessary cost or an essential prerequisite?

Scarf osteotomy is an effective surgical treatment option for hallux valgus. It can manipulate alignment in three planes, allowing accurate anatomical correction. The potential benefit of intra-operative image intensification (II) to gauge deformity correction during surgery however, has not been quantitatively reported. This study aims to compare the correction of hallux valgus by scarf osteotomy with and without intra-operative imaging. Retrospective analysis of a consecutive series of scarf osteotomy in 2 groups. Group A had intra-operative radiographic assessment and group B did not. Patient and surgical data was collected with a mean follow-up of 14 months. Of 99 scarf osteotomies there was no significant difference in age, gender or pre-operative deformity between the groups (p<0.05). No statistical difference was found between the radiographic corrections of the two groups (p<0.05), although operating time was less in group B. This series shows that intra-operative imaging does not improve accuracy of deformity correction, or implant position in scarf osteotomy. We suggest it is not required routinely during scarf osteotomy.

Results of Scarf Osteotomy Without Implant Fixation in the Treatment of Hallux Valgus.

BACKGROUND: The main goal of the study was to evaluate the costs, clinical and radiologic results, and complications of hallux valgus surgery using scarf osteotomy, depending on the type of fixation (with or without screws). METHODS: We evaluated 169 patients who underwent scarf osteotomy between January 2013 and August 2016. The patients were separated into 3 groups depending on the type of stabilization: A, 2 screws (50 patients); B, modified with 1 screw (55 patients); C, modified without implant (64 patients). We assessed duration of surgery, additional procedures, pre- and postoperative hallux valgus angle (HVA) and intermetatarsal angle (IMA) on anteroposterior and lateral foot weightbearing radiographs, the American Orthopaedic Foot & Ankle Society (AOFAS) hallux-metatarsophalangeal-interphalangeal scale for the clinical assessment preoperatively and at the 12-month follow-up. We recorded all the complications and compared the costs between the groups. RESULTS: Both the average HVA (A: from 33.7 to 12.6 degrees, B: 35.0 to 13.2 degrees, C: 34.7 to 12.4 degrees) and IMA (A: from 14.9 to 7.5 degrees, B: 15.2 to 6.9 degrees, C: 15.5 to 7.8 degrees) decreased in all groups without significant intergroup differences. The average AOFAS score improved in all the groups (A: from 40 to 88 points, B: 38 to 89 points, C: 42 to 91 points). A similar complication rate was observed (A: 9%, B: 10%, C: 11%). In group C, we noted a shorter time of surgery, and the procedure was the most cost-effective. CONCLUSION: Scarf osteotomy without implant stabilization was faster and cost-effective and gave comparable results. It was technically demanding and required patient compliance. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

3D printing for corrective osteotomy of malunited distal radius fractures: a low-cost workflow.

After a severe trauma, a 16-year-old female patient sustained multiple injuries, including a distal radius fracture of the left arm. This distal radius fracture eventually developed into a malunion. In this case, we demonstrate our preoperative low-cost workup for three-dimensional (3D) planned and assisted corrective osteotomy of a malunited distal radius fracture using an in-hospital 3D printer.

Cost-utility analysis of cervical deformity surgeries using 1-year outcome.

BACKGROUND CONTEXT: Cost-utility analysis, a special case of cost-effectiveness analysis, estimates the ratio between the cost of an intervention to the benefit it produces in number of quality-adjusted life years. Cervical deformity correction has not been evaluated in terms of cost-utility and in the context of value-based health care. Our objective, therefore, was to determine the cost-utility ratio of cervical deformity correction. STUDY DESIGN: This is a retrospective review of a prospective, multicenter cervical deformity database. Patients with 1-year follow-up after surgical correction for cervical deformity were included. Cervical deformity was defined as the presence of at least one of the following: kyphosis (C2-C7 Cobb angle >10°), cervical scoliosis (coronal Cobb angle >10°), positive cervical sagittal malalignment (C2-C7 sagittal vertical axis >4 cm or T1-C6 >10°), or horizontal gaze impairment (chin-brow vertical angle >25°). Quality-adjusted life years were calculated by both EuroQol 5D (EQ5D) quality of life and Neck Disability Index (NDI) mapped to short form six dimensions (SF6D) index. Costs were assigned using Medicare 1-year average reimbursement for: 9+ level posterior fusions (PF), 4-8 level PF, 4-8 level PF with anterior fusion (AF), 2-3 level PF with AF, 4-8 level AF, and 4-8 level posterior refusion. Reoperations and deaths were added to cost and subtracted from utility, respectively. Quality-adjusted life year per dollar spent was calculated using standardized methodology at 1-year time point and subsequent time points relying on maintenance of 1-year utility. RESULTS: Eighty-four patients (average age: 61.2 years, 60% female, body mass index [BMI]: 30.1) were analyzed after cervical deformity correction (average levels fused: 7.2, osteotomy used: 50%). Costs associated with index procedures were 9+ level PF ($76,617), 4-8 level PF ($40,596), 4-8 level PF with AF ($67,098), 4-8 level AF ($31,392), and 4-8 level posterior refusion ($35,371). Average 1-year reimbursement of surgery was $55,097 at 1 year with eight revisions and three deaths accounted for. Cost per quality-adjusted life year (QALY) gained to 1-year follow-up was $646,958 by EQ5D and $477,316 by NDI SF6D. If 1-year benefit is sustained, upper threshold of cost-effectiveness is reached 3-4.5 years after intervention. CONCLUSIONS: Medicare 1-year average reimbursement compared with 1-year QALYdescribed $646,958 by EQ5D and $477,316 by NDI SF6D. Cervical deformity surgeries reach accepted cost-effectiveness thresholds when benefit is sustained 3-4.5 years. Longer follow-up is needed for a more definitive cost-analysis, but these data are an important first step in justifying cost-utility ratio for cervical deformity correction.

Results of the 2015 Scoliosis Research Society Survey on Single Versus Dual Attending Surgeon Approach for Adult Spinal Deformity Surgery.

STUDY DESIGN: An electronic survey administered to Scoliosis Research Society (SRS) membership. OBJECTIVE: To characterize surgeon practices and views regarding the use of two attending surgeons for adult spinal deformity (ASD) surgery. SUMMARY OF BACKGROUND DATA: The use of two experienced attending surgeons can decrease the operative time, estimated blood loss, and perioperative complication rates. However, the current practice patterns for the use of two attending surgeons remains unknown. METHODS: An electronic, 27-question survey regarding single/dual attending surgeons was administered to the SRS membership. Determinants included: surgeon/practice demographics, assistant type/level of training, and questions regarding use of two attending surgeons. Overall reporting and comparisons between groups were made: US versus international, academic versus private practice, and experience <15 years versus >15 years. RESULTS: A total of 199 surgeons responded from 27 different countries. Overall and between the groups, the respondents significantly reported believing that two attending spine surgeons improves safety, decreases complications, and improves outcomes (P < 0.01). Approximately, 67.3% reported using a second attending ≤25% of the time (33.2% do not), and 24.1% use one ≥51% of the time (similar between groups); 51.1% that have a second attending feel it's limited by reimbursement and access concerns and 71.9% have difficulty getting the second attending reimbursed. 72.3% use a second attending for ALL of the following reasons (no difference between groups): "it's safer/reduces complications," "it decreases operative time," "it decreases blood loss," "it results in improved outcomes," "it's less work and stress for me." If reimbursement was equal/assured for a second attending, 67.5% would use one "more often" or "always." CONCLUSION: The respondents feel that having a second attending surgeon improves patient care, however most do not use one often. Reasons include reimbursement/access concerns and the majority would use one if reimbursement was equal and assured. Based on the current literature and these results, there is a need for working with third party payers to improve dual surgeon reimbursement rates in complex cases. LEVEL OF EVIDENCE: 5.

Skull Base Surgery with Minimal Resources.

BACKGROUND: Skull base surgery needs advanced equipment and is performed at few public sector hospitals in India. For financial and infrastructure reasons, the facilities available are insufficient for the large number of poor patients who need this surgery. METHODS: Neurologically deteriorating poor patients who failed to receive skull base surgery at overloaded public sector hospitals underwent surgery with basic neurosurgical instruments, using the available resources and indigenously designed instruments adhering to the basic principles of skull base surgery. Various lesions operated on in the study were analyzed based on their location and surgical approach. RESULTS: Ninety-one skull base surgeries in 84 patients were performed during 2013-2015. There were 46 males and 38 females, with an average age of 35 years. Surgical treatment included surgery of the craniovertebral junction (n = 43) and lesions of the anterior skull base (n = 7), middle skull base (n = 10), and posterior skull base (n = 31). Lesions were operated on through anterior (n = 10), lateral (n = 14), and posterior and posterolateral (n = 67) skull base approaches. CONCLUSIONS: The facilities available in low-income countries such as India are insufficient to take care of poor patients who need skull base surgery. Indigenous innovations, use of the available resources, and interdisciplinary coordination help overcome the challenges of resource scarcity to a reasonable extent in many ill-equipped public sector hospitals for the safe and efficient management of many patients who need skull base surgery.

Medial compartment knee osteoarthritis: age-stratified cost-effectiveness of total knee arthroplasty, unicompartmental knee arthroplasty, and high tibial osteotomy.

PURPOSE: To compare the age-based cost-effectiveness of total knee arthroplasty (TKA), unicompartmental knee arthroplasty (UKA), and high tibial osteotomy (HTO) for the treatment of medial compartment knee osteoarthritis (MCOA). METHODS: A Markov model was used to simulate theoretical cohorts of patients 40, 50, 60, and 70 years of age undergoing primary TKA, UKA, or HTO. Costs and outcomes associated with initial and subsequent interventions were estimated by following these virtual cohorts over a 10-year period. Revision and mortality rates, costs, and functional outcome data were estimated from a systematic review of the literature. Probabilistic analysis was conducted to accommodate these parameters' inherent uncertainty, and both discrete and probabilistic sensitivity analyses were utilized to assess the robustness of the model's outputs to changes in key variables. RESULTS: HTO was most likely to be cost-effective in cohorts under 60, and UKA most likely in those 60 and over. Probabilistic results did not indicate one intervention to be significantly more cost-effective than another. The model was exquisitely sensitive to changes in utility (functional outcome), somewhat sensitive to changes in cost, and least sensitive to changes in 10-year revision risk. CONCLUSIONS: HTO may be the most cost-effective option when treating MCOA in younger patients, while UKA may be preferred in older patients. Functional utility is the primary driver of the cost-effectiveness of these interventions. For the clinician, this study supports HTO as a competitive treatment option in young patient populations. It also validates each one of the three interventions considered as potentially optimal, depending heavily on patient preferences and functional utility derived over time.

An Operative Complexity Index Shows Higher Volume Hospitals and Surgeons Perform More Complex Adult Spine Deformity Operations.

BACKGROUND: Though previous studies have shown improved outcomes associated with higher volume surgeons and hospitals, this may not be replicated in ASDS due to case complexity variation. We hypothesized that high-volume surgeons perform more complex surgeries. Therefore, we defined an Operative Complexity Index (OCI), specifically for the National Inpatient Samples (NIS) data, which provides information on in-hospital postoperative complications, to assess rates of adult spine deformity surgery (ASDS) cases as they relate to surgeon and hospital operative volume. METHODS: The 2001 to 2010 NIS was queried for patients greater than 21 years of age with in-hospital stays, including a spine arthrodesis for a diagnosis of scoliosis. Surgeon and hospital identifiers were used to allocate records into volume quartiles by number of surgeries per year. The OCI was devised considering the number of fusion levels, surgical approach, revision status, and use of osteotomy. The index was validated using blood-loss-related diagnostic and procedural codes. One-way ANOVA assessed continuous measures. Chi-square assessed categorical measures. RESULTS: 141,357 ASDS cases met the inclusion criteria. High-volume surgeons performed a higher rate of longfusions (> 8 levels), revision surgeries, and surgeries requiring osteotomy. The OCI showed weak, but significant, correlation with blood loss values: acute blood loss anemia (r = 0.21) and treatment with blood products (r = 0.12) (p < 0.001). High OCI also was also associated with increased length of stay (r = 0.27) and total charges (r = 0.41) (p < 0.001). CONCLUSIONS: The operative complexity index (OCI) for ASDS increases with high-volume surgeons and centers, indicating it can be useful to adjust for surgical invasiveness in the NIS database. Operative complexity must be considered when evaluating patient safety and quality indices among hospitals and surgeons.