The financial burden of musculoskeletal firearm injuries in children with and without concomitant intra-cavitary injuries.

BACKGROUND: Musculoskeletal pediatric firearm injuries are a clinically significant and expensive public health problem in the United States. In this retrospective cohort analysis, we sought to characterize musculoskeletal firearm injuries in children and to describe the financial burden associated with these injuries. METHODS: This study is a single center, retrospective review. Patients were identified from January 2002 - December 2015 from an institutional database using ICD-9 codes pertaining to firearm injury. Inclusion criteria were: 1) age < 18 years at injury; 2) firearm injury to an extremity, spine, or pelvis; and 3) patient received orthopedic evaluation and/or treatment. 140 patients with 142 distinct orthopedic injuries meeting inclusion criteria were analyzed (N = 142). Primary measures were demographic and situational data including intent, length of stay, follow-up, and complications; and financial outcomes including charges, costs, and net revenues. RESULTS: Median age was 15.3 years [IQR: 13.3, 16.4], 84% were male, and 52% were African American. 59% of the firearm injuries were of violent intent. 32% of patients were privately insured, 61% were publicly insured, and 6% were uninsured. Median length of stay was 2 days [0, 4], with 73% of patients being admitted. 43% of patients required additional hospitalizations, emergency room visits, and/or outpatient surgeries, and 93% of patients had outpatient follow-up. 42% of patients experience an injury-related or long-term orthopedic complication. Total charges for the cohort were $11.4 million, with $3.7 million in costs and $45,042 in net revenues. In the multivariable analysis, more surgeries predicted higher charges, and more secondary encounters predicted higher costs and net revenues. Only privately-insured patients had a positive median net revenue. CONCLUSIONS: Children who sustain musculoskeletal injuries from firearms experience high rates of orthopedic complications. Institutional costs to manage these preventable injuries are excessive. Policy makers should continue to pursue measures to reduce gun violence and improve gun safety in the pediatric population. LEVEL OF EVIDENCE: Level III, economic/decision.

Hemiepiphysiodesis Implants for Late-onset Tibia Vara: A Comparison of Cost, Surgical Success, and Implant Failure.

BACKGROUND: The purpose of this study was to compare hemiepiphysiodesis implants for late-onset tibia vara and to evaluate patient characteristics that may predict surgical failure. METHODS: This is a retrospective review of late-onset tibia vara patients treated with temporary hemiepiphysiodesis from 1998 to 2012. Mechanical axis deviation (MAD), mechanical axis angle, mechanical lateral distal femoral angle, and medial proximal tibial angle were measured on standing bone length radiographs. Surgical failure was defined as residual deformity requiring osteotomy, revision surgery, or MAD exceeding 40 mm at the time of final follow-up. Implant failure was recorded. Costs included implants and disposables required for construct placement. Staple constructs included 2 or 3 staples. Plate constructs included the plate, screws, guide wires, and drill bits. RESULTS: A total of 25 patients with 38 temporary lateral proximal tibia hemiepiphysiodeses met the inclusion criteria. The average body mass index (BMI) was 39.1 kg/m with an average follow-up of 3.0 years (minimum 1 y). Surgical failure occurred in 57.9% of patients. Greater BMI (P=0.05) and more severe deformity (MAD, mechanical axis angle, and medial proximal tibial angle; P<0.01) predicted higher rates of surgical failure. Younger age predicted higher rates of implant failure (P<0.01). There were no differences in surgical or implant failure between staple and plate systems. Hospital costs of plate constructs ($781 to $1244) were 1.5 to 3.5 times greater than the staple constructs ($332 to $498). CONCLUSIONS: Greater BMI, more severe deformity, and younger age were predictive of surgical or implant failure. There was no difference in success between implant types, whereas the cost of plate constructs was 1.5 to 3.5 times greater than staples. The rate of surgical failure was high (58%) and consideration should be given to reserving hemiepiphysiodesis for patients with lower BMI and less severe deformity. In our population, if hemiepiphysiodesis was not offered to patients with BMI>35 or MAD>80 mm varus, the surgical failure rate would diminish to 28%. The failure rate outside these parameters would be 88%. LEVEL OF EVIDENCE: Level II­Prognostic.

Immediate spica casting of pediatric femoral fractures in the operating room versus the emergency department: comparison of reduction, complications, and hospital charges.

BACKGROUND: Immediate spica casting for pediatric femur fractures is well described as a standard treatment in the literature. The purpose of this study is to evaluate the application of a spica cast in the emergency department (ED) versus the operating room (OR) with regard to quality of reduction, complications, and hospital charges at an academic institution. METHODS: An institutional review board-approved retrospective review identified 100 children aged 6 months to 5 years between January 2003 and October 2008 with an isolated femur fracture treated with a hip spica cast. Patients were compared based on the setting of spica cast application. RESULTS: There were 79 patients in the ED cohort and 21 patients in the OR cohort. There were no significant differences in age, weight, sex, fracture pattern, prereduction shortening, injury mechanism, duration of spica treatment, time to heal, or length of follow-up between cohorts. There were no significant differences in the rate of loss of reduction requiring revision casting or operative treatment (6.3% vs. 4.8%), the need for cast wedging (8.9% vs. 14.3%), or minor skin breakdown (12.7% vs. 14.3%). There were no sedation or anesthetic complications in either group. There were no significant differences in the quality of reduction or the rate of complications between the 2 groups. Spica casting in the OR delayed the time from presentation to cast placement as compared with the ED cohort (11.5 h vs. 3.8 h, P<0.0001) and lengthened the hospital stay (30.5 h vs. 16.9 h, P=0.0002). The average hospital charges of spica cast application in the OR was 3 times higher than the cost of casting in the ED ($15,983 vs. $5150, P<0.0001). CONCLUSIONS: Immediate spica casting in the ED and OR provide similar results in terms of reduction and complications. With the significantly higher hospital charges for spica casting in the OR, alternative settings should be considered. LEVEL OF EVIDENCE: III--Retrospective comparative study.

Internal fixation of acute, nondisplaced scaphoid waist fractures via a limited dorsal approach: an assessment of radiographic and functional outcomes.

PURPOSE: To evaluate the clinical and radiographic outcomes of a consecutive series of patients who had internal fixation of an acute, nondisplaced scaphoid waist fracture via a limited dorsal approach. METHODS: Twenty consecutive patients had surgical fixation of a nondisplaced scaphoid waist (Herbert B2) fracture via a limited dorsal approach. Eighteen patients were available for follow-up evaluation at a mean duration of 98 weeks after surgery (range, 12-272 wk). Fifteen males and 3 females with a mean age of 25 years (range, 16-62 y) were examined. Wrist range of motion; grip strength; visual analog and numeric pain scores; and a Disabilities of the Arm, Shoulder, and Hand (DASH) outcomes questionnaire were assessed. Postoperative radiographs were reviewed in a blinded fashion to assess the fracture union and screw position. RESULTS: Seventeen of 18 fractures healed at a mean duration of 8 weeks. No case of proximal pole avascular necrosis occurred. All patients were satisfied and returned to their pre-injury level of employment. Five of 6 collegiate or professional athletes returned to play without limitations. The mean subjective and visual analog pain scores were 0.3 and 0.4 (maximum of 10 for each scale). The mean DASH score was 6.12 (out of 100), which is consistent with an excellent functional outcome. Central axis screw position was achieved on anteroposterior and lateral radiographs in 17 of 18 patients. CONCLUSIONS: Fixation of an acute, nondisplaced scaphoid waist fracture via a limited dorsal approach is safe and effective. The limited dorsal approach allows for accurate insertion of the screw in the central scaphoid, which is biomechanically advantageous for fracture union and early restoration of function. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.