Rates of Operative Management of Midshaft Clavicle Fracture in Adolescents Have Increased in Florida between 2005 and 2014.

Background: It is not known if the adult literature on midshaft clavicle fracture treatment with open reduction internal fixation (ORIF) has influenced injury management in adolescents. Purpose: We sought to longitudinally evaluate the rates of operative management of adolescent midshaft clavicle fractures in the state of Florida. Methods: We conducted a retrospective review of data from the following Healthcare Cost and Utilization Project databases: the State Inpatient Database, the State Ambulatory Surgery and Services Database, and the State Emergency Department Database. Patients in Florida ages 10 to 18 years with midshaft clavicle fractures between 2005 and 2014 were identified along with data on age, sex, race/ethnicity, insurance type, treatment, and income percentile. We reviewed the data to identify trends in the rates of operative management of midshaft clavicle fractures. We then compared the rates of operative management between the first 3 years and the most recent 3 years (2005-2007 vs 2012-2014). Various demographic and socioeconomic factors were compared between patients treated with and without surgery. Descriptive statistics as well as univariate and multivariate analyses were performed. Results: There were 4297 midshaft clavicle fractures in adolescents identified between 2005 and 2014, and 338 (7.8%) of these fractures underwent operative management. There was a significant increase in the rate of operative management; it increased from 4.3% (n = 59) of the 1373 clavicle fractures that occurred between 2005 and 2007 to 11.2% (n = 130) of the 1164 clavicle fractures that occurred between 2012 and 2014. Patients with commercial insurance and patients who were older were more likely to undergo ORIF. Patients with Medicaid were more likely to undergo ORIF between 2012 and 2014 compared with patients with Medicaid between 2005 and 2007. Conclusions: Operative management rates of adolescent midshaft clavicle fractures have significantly increased in Florida over a decade; additional research is needed to understand these findings.

Implementing a perioperative efficiency initiative for orthopedic surgery instrumentation at an academic center: A comparative before-and-after study.

Optimizing surgical instrumentation may contribute to value-based care, particularly in commonly performed procedures. We report our experience in implementing a perioperative efficiency program in 2 types of orthopedic surgery (primary total-knee arthroplasty, TKA, and total-hip arthroplasty, THA).A comparative before-and-after study with 2 participating surgeons, each performing both THA and TKA, was conducted. Our objective was to evaluate the effect of surgical tray optimization on operating and processing time, cost, and waste associated with preparation, delivery, and staging of sterile surgical instruments. The study was designed as a prospective quality improvement initiative with pre- and postimplementation operational measures and a provider satisfaction survey.A total of 96 procedures (38 preimplementation and 58 postimplementation) were assessed using time-stamped performance endpoints. The number and weight of trays and instruments processed were reduced substantially after the optimization intervention, particularly for TKA. Setup time was reduced by 23% (6 minutes, P = .01) for TKA procedures but did not differ for THA. The number of survey respondents was small, but satisfaction was high overall among personnel involved in implementation.Optimizing instrumentation trays for orthopedic procedures yielded reduction in processing time and cost. Future research should evaluate patient outcomes and incremental/additive impact on institutional quality measures.

Economic Impact of Revision Surgery for Proximal Junctional Failure After Adult Spinal Deformity Surgery: A Cost Analysis of 57 Operations in a 10-year Experience at a Major Deformity Center.

STUDY DESIGN: Retrospective cohort analysis. OBJECTIVE: To evaluate the economic impact of revision surgery for proximal junctional failures (PJF) after thoracolumbar fusions for adult spinal deformity (ASD). SUMMARY OF BACKGROUND DATA: PJF after fusions for ASD is a major cause of disability. Although clinical sequelae are described, PJF-revision operation costs are incompletely defined. METHODS: Consecutive adults who underwent thoracolumbar fusions for ASD (August, 2003 to January, 2013) were evaluated. Inclusion criteria include construct from pelvis to L2 or above and minimum 6 months follow-up after the index ASD operation. Direct costs (surgical supplies/implants, room/care, pharmacy, services) were identified from medical billing data and calculated for index ASD operations and subsequent surgeries for PJF. Not included in direct cost data were indirect costs, charges, surgeon fees, or revision operations for indications other than PJF (i.e., pseudarthrosis). Patients were compared based on the construct's upper-instrumented vertebra: upper thoracic (UT: T1-6) versus thoracolumbar junction (TLjxn: T9-L2). RESULTS: Of 501 patients, 382 met inclusion criteria. Fifty-one patients [UT:14; TLjxn: 40 at index; average follow-up 32.6 months (6-92 months)] had revisions for PJF, which summed to $3.2 million total direct cost. Average direct cost of index operations for the cohort ($68,294) was significantly greater than PJF-revisions ($55,547). Compared with TLjxn, UT had a significantly higher average cost for index operations ($79,860 vs. $65,868). However, PJF-revision cases were similar in average cost (UT:$60,103; TLjxn:$53,920; P = 0.09). Costs of PJF amounted to an additional 12.1% of the total index surgical cost in 382 patients. CONCLUSION: Revision operations for PJF after long thoracolumbar fusions for ASD are associated with an average direct cost of $55,547 per case. Revision costs for PJF are similar based on the index procedure's upper-instrumented vertebra level. At a major tertiary center over a 10-year period, PJF came at a very significant economic expense amounting to $3.2 million for 57 cases. LEVEL OF EVIDENCE: 3.

Local intrawound vancomycin powder decreases the risk of surgical site infections in complex adult deformity reconstruction: a cost analysis.

STUDY DESIGN: Retrospective cohort analysis. OBJECTIVE: To evaluate the rate of surgical site infections (SSIs) and cost-effectiveness of the use of intraoperative vancomycin powder in thoracolumbar adult deformity procedures. SUMMARY OF BACKGROUND DATA: The rates of SSI remain unacceptably high in adult spinal deformity surgery despite routine intravenous antibiotics. Vancomycin powder applied directly to the wound intraoperatively has shown promise for decreasing SSI in spine surgery. METHODS: Adults who underwent adult deformity reconstruction by 2 surgeons between 2008 and 2012 with a minimum of 3 months of clinical follow-up were retrospectively reviewed. The patients were subdivided into those who had received only routine perioperative intravenous antibiotics (control) and those who received intravenous antibiotics and 2 g of vancomycin powder applied into the surgical wound. The primary outcome was SSI within 90 days. Secondary outcomes included surgical/clinical parameters and SSI-related medical costs based on hospital billing records. RESULTS: Two hundred fifteen patients were evaluated-controls (n=64) and vancomycin powder group (n=151). The average number of levels fused was 10 (5-17, control) and 12 (5-19, vancomycin). The mean follow-up was 34 months (3-68 mo, control) and 18 months (3-35 mo, vancomycin) (P<0.05). There were significantly fewer hospital readmissions within 90 days for SSI in patients who received vancomycin powder (2.6%; 4/151) compared with controls (10.9%; 7/64) (P=0.01). There were no reported adverse events related to the intrawound vancomycin use. The average cost per patient of treating a postoperative SSI was higher in the control group ($34,388) than in the study group ($28,169). With the use of vancomycin powder, there was a cost saving of $244,402 per 100 complex spinal procedures. CONCLUSION: Local application of vancomycin powder significantly decreased SSI for adults undergoing spinal reconstructive surgery. This resulted in cost savings of $244,402 per 100 thoracolumbar adult deformity procedures. LEVEL OF EVIDENCE: 3.