Slow-motion smartphone video improves interobserver reliability of gait assessment in ambulatory cerebral palsy.

Purpose: Structured visual gait assessment is essential for the evaluation of pediatric patients with neuromuscular conditions. The purpose of this study was to evaluate the benefit of slow-motion video recorded on a standard smartphone to augment visual gait assessment. Methods: Coronal and sagittal plane videos of the gait of five pediatric subjects were recorded on a smartphone, including four subjects with ambulatory cerebral palsy and one subject without gait pathology. Twenty-one video scorers were recruited and randomized to evaluate slow-motion or normal-speed videos utilizing the Edinburgh Visual Gait Score. The slow-motion group (N = 11) evaluated the videos at one-eighth speed, and the normal-speed group (N = 10) evaluated the same videos at normal speed. Interrater reliabilities were determined by calculating intraclass correlation coefficients for each group as a whole, for each Edinburgh Visual Gait Score item, and after stratification by evaluator experience level. Results: The slow-motion group exhibited an intraclass correlation coefficient of 0.65 (95% confidence interval: 0.58-0.73), whereas the normal-speed group exhibited an intraclass correlation coefficient of 0.57 (95% confidence interval: 0.49-0.65). For less-experienced scorers, intraclass correlation coefficients of 0.62 (95% confidence interval: 0.53-0.71) and 0.50 (95% confidence interval: 0.40-0.59) were calculated for slow motion and normal speed, respectively. For more-experienced scorers, intraclass correlation coefficients of 0.69 (95% confidence interval: 0.61-0.76) and 0.67 (95% confidence interval: 0.58-0.75) were calculated for slow motion and normal speed, respectively. Conclusions: Visual gait assessment is enhanced by the use of slow-motion smartphone video, a tool widely available throughout the world with no marginal cost. Level of evidence: level I, randomized study.

Reduced Costs, Complications, and Length of Stay After Arthroscopic Versus Open Irrigation and Débridement for Knee Septic Arthritis.

BACKGROUND: In the treatment of native knee bacterial septic arthritis, the optimal irrigation and débridement modality-arthroscopic versus open-is a matter of controversy. We aim to compare revision-free survival, complications, and resource utilization between these approaches. METHODS: The National Readmission Database was queried from 2016 to 2019 to identify patients using International Classification of Diseases, 10th revision, diagnostic and procedure codes. Days to revision irrigation and débridement (I&D), if any, were calculated for patients during index admission or subsequent readmissions. Multivariate regression was used for healthcare utilization analysis. Survival analysis was done using Kaplan-Meier analysis and Cox proportional hazard regression. RESULTS: A total of 14,365 patients with native knee septic arthritis undergoing I&D were identified, 8,063 arthroscopic (56.1%) and 6,302 open (43.9%). The mean follow-up was 148 days (interquartile range 53 to 259). A total of 2,156 patients (15.0%) underwent revision I&D. On multivariate analysis, arthroscopic I&D was associated with a reduction in hospital costs of $5,674 and length of stay of 1.46 days (P < 0.001 for both). Arthroscopic I&D was associated with lower overall complications (odds ratio [OR] 0.63, P < 0.001), need for blood transfusion (OR 0.58, P < 0.001), and wound complications (OR 0.32, P < 0.001). Revision-free survival after index I&D was 95.3% at 3 days, 91.0% at 10 days, 88.3% at 30 days, 86.0% at 90 days, and 84.5% at 180 days. No statistically significant difference was observed between surgical approaches on Cox modeling. DISCUSSION: Risk of revision I&D did not differ between arthroscopic and open I&D; however, arthroscopy was associated with decreased costs, length of stay, and complications. Additional study is necessary to confirm these findings and characterize which patients require an open I&D. LEVEL OF EVIDENCE: III.

Cost-effectiveness of fixation versus arthroplasty for geriatric distal femur fractures.

INTRODUCTION: Geriatric distal femur fractures are challenging to treat. The high mortality rate associated with a loss of mobility in this population has led some authors to compare distal femur fractures to femoral neck fractures with respect to the importance of rapidly regaining mobility in the geriatric population. Acute distal femur replacement has been advocated by some as a preferred treatment over internal fixation because arthroplasty may facilitate a more rapid return to a patient's baseline mobility level. The purpose of this study was to systematically review the literature on the costs and outcomes of fixation and arthroplasty in the geriatric distal femur fracture population and to employ decision modeling techniques to generate evidence-based treatment recommendations. METHODS: A systematic literature review of clinical studies published since 2000 was conducted to synthesize the available data on outcomes, reoperation rates, and mortality rates after fixation or arthroplasty for distal femur fractures in patients with an average age greater than 70 years. A Markov decision analysis model was created. Costs, health state utilities, reoperation rates, and mortality rates were derived from the systematic literature review and publicly available data. The model was analyzed via probabilistic statistical analysis as well as sensitivity analyses with a willingness-to-pay threshold set at $100,000 per QALY and a 5-year time horizon. RESULTS: From a US societal perspective, fixation was associated with a greater quality of life benefit (2.44 QALYs vs. 2.34 QALYs) and lower cost ($25,556 vs. $65,536) compared with distal femur replacement for geriatric distal femur fractures. Probabilistic analysis demonstrated that 82 in 100 model outcomes favored fixation over arthroplasty and 18 in 100 model outcomes favored distal femur replacement. Sensitivity analyses demonstrated that this result was robust to small deviations in the cost and functional outcome variables in the model. CONCLUSION: Compared to distal femur replacement, ORIF is likely to be a more cost-effective treatment for distal femur fractures in the geriatric patient population, though this recommendation is tempered by the relatively low quality of evidence available on the comparative functional outcomes of these treatments.

Impact of Reference Pricing on Cost and Quality in Total Joint Arthroplasty.

BACKGROUND: Prices for total joint arthroplasty vary widely. Insurers have experimented with reference-based benefit designs (reference pricing) to control costs by setting a contribution limit that covers lower-priced facilities but necessitates higher out-of-pocket payments at higher-priced facilities. The purpose of this study was to evaluate the impact of reference pricing on the cost and quality of care for total joint arthroplasty. METHODS: The California Public Employees' Retirement System (CalPERS) implemented reference pricing for total joint arthroplasty in January 2011. We obtained data on 2,023 CalPERS patients who underwent total joint arthroplasty from January 2009 to December 2013 and comparison group data on 8,024 non-CalPERS patients from the same time period. Trends in 9 cost and quality-related metrics were compared between the CalPERS group and the comparison group: patient choice of a lower-priced hospital, insurer payment, consumer payment, 90-day complication rate, 90-day readmission rate, annual surgical volume of the chosen hospital, length of stay, travel distance, and rate of discharge to home. The impact of reference pricing was estimated with difference-in-differences multivariable regressions, adjusting for covariates. RESULTS: An increase of 19 percentage points (95% confidence interval [CI], 13.0 to 25.6 percentage points; p < 0.01) in the selection of lower-priced hospitals was attributable to reference pricing, with a concurrent mean savings for the insurer of $5,067 (95% CI, $2,315 to $7,819; p < 0.01) and an increase in the mean patient out-of-pocket payment of $1,991 (95% CI, $1,053 to $2,929; p < 0.01). No significant change in any quality indicator was attributable to reference pricing, with the exception of an 8% reduction (95% CI, 3.3% to 12.7% reduction; p < 0.01) in the length of stay for hip replacement. CONCLUSIONS: Reference pricing motivates patients to choose lower-priced hospitals for total joint arthroplasty, with no measurable adverse impact on quality. Reference pricing represents a viable strategy in the shift toward value-based care.

Fewer Hospitals Provide Operative Fracture Care to Medicaid Patients Than Otherwise-Insured Patients in 4 Large States.

OBJECTIVE: To determine whether Medicaid patients receive operative fracture care at an equal number of hospitals as otherwise-insured patients and to compare travel distances between Medicaid and otherwise-insured patients. DESIGN: Retrospective, population-based cohort study of administrative health data. SETTING: One thousand seventy-five hospitals in California, Florida, New York, and Texas. PARTICIPANTS: Two hundred forty thousand three hundred seventy-six patients who underwent open reduction and internal fixation of a fracture of the radius/ulna, tibia/fibula, or humerus between 2006 and 2010 in Texas or New York, or between 2010 and 2014 in California or Florida. INTERVENTION: Open reduction and internal fixation of the radius/ulna, tibia/fibula, or humerus. MAIN OUTCOME MEASUREMENTS: The number of unique hospitals visited and the distance traveled for care were compared by payer status and admission acuity. The distance traveled was also stratified by urban versus rural geographic area. RESULTS: In nonemergent settings, 7%-16% fewer hospitals saw Medicaid patients than otherwise-insured patients. In emergent settings, the gap between the number of hospitals seeing Medicaid and otherwise-insured patients was less than 5% in every state except Texas, where the gap was 11%-14%. The Medicaid and Medicare groups had longer travel distances in the nonemergent setting than in the emergent setting. Medicaid patients did not travel longer distances than otherwise-insured patients except in Texas, where they traveled 3-5 miles further than otherwise-insured patients in the nonemergent, urban setting. CONCLUSIONS: Fewer hospitals provide operative fracture care to Medicaid patients than otherwise-insured patients, but Medicaid patients do not travel longer distances to the hospital on a population level. LEVEL OF EVIDENCE: Prognostic Level III.