Total medical costs of treating femoral neck fracture patients with hemi- or total hip arthroplasty: a cost analysis of a multicenter prospective study.

UNLABELLED: The aim of this study was to determine the total medical costs for treating displaced femoral neck fractures with hemi- or total hip arthroplasty in fit elderly patients. The mean total costs per patient at 2 years of follow-up were €26,399. These results contribute to cost awareness. INTRODUCTION: The absolute number of hip fractures is rising and increases the already significant burden on society. The aim of this study was to determine the mean total medical costs per patient for treating displaced femoral neck fractures with hemi- or total hip arthroplasty in fit elderly patients. METHODS: The population was the Dutch sample of an international randomized controlled trial consisting of femoral neck fracture patients treated with hemi- or total hip arthroplasty. Patient data and health care utilization were prospectively collected during a total follow-up period of 2 years. Costs were separated into costs for hospital care during primary stay, hospital costs for clinical follow-up, and costs generated outside the hospital during rehabilitation. Multiple imputations were used to account for missing data. RESULTS: Data of 141 participants (mean age 81 years) were included in the analysis. The 2-year mortality rate was 19 %. The mean total cost per patient after 10 weeks of follow-up was €15,216. After 1 and 2 years of follow-up the mean total costs were €23,869 and €26,399, respectively. Rehabilitation was the main cost determinant, and accounted for 46 % of total costs. Primary hospital admission days accounted for 22 % of the total costs, index surgery for 11 %, and physical therapy for 7 %. CONCLUSIONS: The main cost determinants for hemi- or total hip arthroplasty after treatment of displaced femoral neck fractures (€26,399 per patient until 2 years) were rehabilitation and nursing homes. Most of the costs were made in the first year. Reducing costs after hip fracture surgery should focus on improving the duration and efficiency of the rehabilitation phase.

Four-wheeled walker related injuries in older adults in the Netherlands.

BACKGROUND: With ageing populations worldwide, mobility devices are used more than ever. In the current literature there is no consensus whether the available mobility devices safely improve the mobility of their users. Also, evidence is lacking concerning the risks and types of injuries sustained while using a four-wheeled walker. OBJECTIVE: To assess injury risks and injury patterns in older adults (≥65 years) who presented at Emergency Departments (ED) in the Netherlands with an injury due to using a four-wheeled walker. DESIGN AND SETTING: In this study, the Dutch Injury Surveillance System was used to obtain a national representative sample of annual ED visits in the Netherlands in the adult population (≥65 years) sustaining an injury while using a four-wheeled walker. The numbers of four-wheeled walker users in the Netherlands were obtained from the national insurance board. The numbers of ED visits were divided by the numbers of four-wheeled walker users to calculate age- and sex-specific injury risks. RESULTS: Annually 1869 older adults visited an ED after sustaining an injury while using a four-wheeled walker. Falls were the main cause of injury (96%). The injury risk was 3.1 per 100 users of four-wheeled walkers. Women (3.5 per 100 users) had a higher risk than men (2.0 per 100 users). Injury risk was the highest in women aged 85 years and older (6.2 per 100 users). The majority of injuries were fractures (60%) with hip fracture (25%) being the most common injury. Nearly half of all four-wheeled walker related injuries required hospitalisation, mostly due to hip fractures. Healthcare costs per injury were approximately €12 000. CONCLUSIONS: This study presents evidence that older adults experiencing a fall while using a four-wheeled walker are at high risk to suffer severe injuries.

The societal costs of femoral neck fracture patients treated with internal fixation.

SUMMARY: The study rationale was to provide a detailed overview of the costs for femoral neck fracture treatment with internal fixation in the Netherlands. Mean total costs per patient at 2-years follow-up were 19,425. Costs were higher for older, less healthy patients. Results are comparable to internationally published costs. INTRODUCTION: The aim of this study was to provide a detailed overview of the cost and healthcare consumption of patients treated for a hip fracture with internal fixation. A secondary aim was to compare costs of patients who underwent a revision surgery with patients who did not. METHODS: The study was performed alongside the Dutch sample of an international randomized controlled trial, concerning femoral neck fracture patients treated with internal fixation. Patient characteristics and healthcare consumption were collected. Total follow-up was 2 years. A societal perspective was adopted. Costs included hospital costs during primary stay and follow-up, and costs related to rehabilitation and changes in living situation. Costs were compared between non-revision surgery patients, implant removal patients, and revision arthroplasty patients. RESULTS: A total of 248 patients were included (mean age 71 years). Mean total costs per patient at 2-years follow-up were 19,425. In the non-revision surgery patients total costs were 17,405 (N = 137), in the implant removal patients 10,066 (N = 38), and in the revision arthroplasty patients 26,733 (N = 67). The main contributing costs were related to the primary surgery, admission days, physical therapy, and revision surgeries. CONCLUSIONS: The main determinant was the costs of admission to a rehabilitation center/nursing home. Costs were specifically high in elderly with comorbidity, who were less independent pre-fracture, and have a longer admission to the hospital and/or a nursing home. Costs were also higher in revision surgery patients. The 2-years follow-up costs in our study were comparable to published costs in other Western societies.

Cost-effectiveness and quality-of-life analysis of physician-staffed helicopter emergency medical services.

BACKGROUND: The long-term health outcomes and costs of helicopter emergency medical services (HEMS) assistance remain uncertain. The aim of this study was to investigate the cost-effectiveness of HEMS assistance compared with emergency medical services (EMS). METHODS: A prospective cohort study was performed at a level I trauma centre. Quality-of-life measurements were obtained at 2 years after trauma, using the EuroQol-Five Dimensions (EQ-5D) as generic measure to determine health status. Health outcomes and costs were combined into costs per quality-adjusted life year (QALY). RESULTS: The study population receiving HEMS assistance was more severely injured than that receiving EMS assistance only. Over the 4-year study interval, HEMS assistance saved a total of 29 additional lives. No statistically significant differences in quality of life were found between assistance with HEMS or with EMS. Two years after trauma the mean EQ-5D utility score was 0.70 versus 0.71 respectively. The incremental cost-effectiveness ratio for HEMS versus EMS was 28,327 Euro per QALY. The sensitivity analysis showed a cost-effectiveness ratio between 16,000 and 62,000 Euro. CONCLUSION: In the Netherlands, the costs of HEMS assistance per QALY remain below the acceptance threshold. HEMS should therefore be considered as cost effective.

Current concepts in the treatment of intra-articular calcaneal fractures: results of a nationwide survey.

The treatment of intra-articular calcaneal fractures is controversial and randomised clinical trials are scarce. Moreover, the socio-economic cost remains unclear. The aim of this study was to estimate the incidence, treatment preferences and socio-economic cost of this complex fracture in the Netherlands. This data may aid in planning future clinical trials and support education. The method of study was of a cross-sectional survey design. A written survey was sent to one representative of both the traumatology and the orthopaedic staff in each hospital in the Netherlands. Data on incidence, treatment modalities, complications and follow-up strategies were recorded. The socio-economic cost was calculated. The average response rate was 70%. Fracture classifications, mostly by Sanders and Essex-Lopresti, were applied by 29%. Annually, 920 intra-articular calcaneal fractures (0.4% incidence rate) were treated, mainly with ORIF (46%), conservative (39%) and percutaneous (10%) treatment. The average non-weight-bearing mobilisation was 9 weeks (SD 2 weeks). An outcome score, mainly AOFAS, was documented by 7%. A secondary arthrodesis was performed in 21% of patients. The socio-economic cost was estimated to be euro21.5-30.7 million. Dutch intra-articular calcaneal fracture incidence is at least 0.4% of all fractures presenting to hospitals. Better insight into treatment modalities currently employed and costs in the Netherlands was obtained.

The accuracy of diagnostic imaging for the assessment of chronic osteomyelitis: a systematic review and meta-analysis.

BACKGROUND: A variety of diagnostic imaging techniques is available for excluding or confirming chronic osteomyelitis. Until now, an evidence-based algorithmic model for choosing the most suitable imaging technique has been lacking. The objective of this study was to determine the accuracy of current imaging modalities in the diagnosis of chronic osteomyelitis. METHODS: A systematic review and meta-analysis of the literature was conducted with a comprehensive search of the MEDLINE, EMBASE, and Current Contents databases to identify clinical studies on chronic osteomyelitis that evaluated diagnostic imaging modalities. The value of each imaging technique was studied by determining its sensitivity and specificity compared with the results of histological analysis, findings on culture, and clinical follow-up of more than six months. RESULTS: A total of twenty-three clinical studies in which the accuracy was described for radiography (two studies), magnetic resonance imaging (five), computed tomography (one), bone scintigraphy (seven), leukocyte scintigraphy (thirteen), gallium scintigraphy (one), combined bone and leukocyte scintigraphy (six), combined bone and gallium scintigraphy (three), and fluorodeoxyglucose positron emission tomography (four) were included in the review. No meta-analysis was performed with respect to computed tomography, gallium scintigraphy, and radiography. Pooled sensitivity demonstrated that fluorodeoxyglucose positron emission tomography was the most sensitive technique, with a sensitivity of 96% (95% confidence interval, 88% to 99%) compared with 82% (95% confidence interval, 70% to 89%) for bone scintigraphy, 61% (95% confidence interval, 43% to 76%) for leukocyte scintigraphy, 78% (95% confidence interval, 72% to 83%) for combined bone and leukocyte scintigraphy, and 84% (95% confidence interval, 69% to 92%) for magnetic resonance imaging. Pooled specificity demonstrated that bone scintigraphy had the lowest specificity, with a specificity of 25% (95% confidence interval, 16% to 36%) compared with 60% (95% confidence interval, 38% to 78%) for magnetic resonance imaging, 77% (95% confidence interval, 63% to 87%) for leukocyte scintigraphy, 84% (95% confidence interval, 75% to 90%) for combined bone and leukocyte scintigraphy, and 91% (95% confidence interval, 81% to 95%) for fluorodeoxyglucose positron emission tomography. The sensitivity of leukocyte scintigraphy in detecting chronic osteomyelitis in the peripheral skeleton was 84% (95% confidence interval, 72% to 91%) compared with 21% (95% confidence interval, 11% to 38%) for its detection of chronic osteomyelitis in the axial skeleton. The specificity of leukocyte scintigraphy in the axial skeleton was 60% (95% confidence interval, 39% to 78%) compared with 80% (95% confidence interval, 61% to 91%) for the peripheral skeleton. CONCLUSIONS: Fluorodeoxyglucose positron emission tomography has the highest diagnostic accuracy for confirming or excluding the diagnosis of chronic osteomyelitis. Leukocyte scintigraphy has an appropriate diagnostic accuracy in the peripheral skeleton, but fluorodeoxyglucose positron emission tomography is superior for detecting chronic osteomyelitis in the axial skeleton.

The assessment of cortical heat during intramedullary reaming of long bones.

BACKGROUND: This experimental study was designed to compare different in vitro methods of measuring the cortical temperature when reaming the medullary cavity. This was done to validate an approved mathematical model which can be used to determine the temperature gradient in cortical bone in the presence or absence of sensors. METHODS: Artificial bone was used with an intramedullary heat source instead of a reamer. Temperatures were measured with thermocouples placed radially and axially in the cortical wall. This method with these two measurement positions were compared and used to validate an approved mathematical model. This model was used to determine the temperature gradient in cortical bone in the absence of sensors. RESULTS: The measurement of the cortical temperature with the thermocouples in a radial position only reflects maximally 14% of the temperature of the reamer (calculated 55%). The measurement with the thermocouples in axial position reflects maximally 65% (calculated 70%) of the reamer temperature, which is similar to undisturbed bone. CONCLUSION: The measuring method with the thermocouples in a radial position cannot be recommended. It is likely that a much higher temperature is generated and conducted through reaming than has been assumed until now.

Representative assessment of long bone shaft biomechanical properties: an optimized testing method.

Whole bone bending tests are commonly used in mechanical evaluation of long bones. Reliable information about the midshaft can only be obtained if the bending moment is uniformly distributed along the shaft, and if the distribution of the bending stress is not adversely influenced by rigid clamping of the bone ends. A testing device was developed to determine bending stiffness of long bones in 24 directions, perpendicular to the bone axis. For optimal distribution of bending moment and stress, four-point bending was performed, and bone ends were simply supported, not rigidly clamped. The method was validated by repeated testing of a stainless steel rod, and a sheep femur. Left-right ratios were assessed twice in 2 groups of 5 sheep: one control group, and one group in which the left femur was stabilized with a stainless steel interlocking nail for 2.5 yr, after a midshaft osteotomy. Test results obtained with the steel rod reproducibly were close to predicted values. Measurements with the sheep femurs were reproducible and precise for 3 of the 4 parameters of the bending test. Stiffness parameters were significantly higher in the operated sheep than in the control group. We conclude that the method described here provides accurate and reproducible information, which is representative for the long bone shaft.

[Cost effectiveness of preventive antibiotic administration for lowering risk of infection by 0.25%]. / Kosteneffektivität einer Antibiotikaprophylaxe bei Senkung des Infektionsrisikos um 0.25%.

Antibiotic prophylaxis in closed fractures is cost-effective if the risk of a deep infection is reduced by 0.25%. This control study was undertaken to assess the cost-effectiveness of prophylaxis of postoperative infections after surgical treatment of closed fractures. The costs for 16 patients with infections (8 with deep infections, 8 with superficial infections) were investigated and compared with the costs for 16 similar but non-infected patients with special reference to length of hospital stay, antibiotics and surgery. The data were collected from the trauma department of the University Hospital of the Free University in Amsterdam. Costs in the group of 8 patients with superficial wound infection were not substantially higher than those for their non-infected controls. The occurrence of a deep infection meant costs an average of DFL 35,224 higher than an uneventful postoperative course. On the basis of these results, antibiotic prophylaxis of postoperative wound infections is cost-effective if it reduces the risk of deep wound infections by about 0.25%.

[Antibiotic prophylaxis in closed fractures is cost-effective if the possibility of a deep infection decreases through this by 0.25%]. / Antibiotische profylaxe bij gesloten fracturen kosten-effectief als de kans op een diepe infectie erdoor afneemt met 0.25%.

This patient-control study was undertaken to assess the cost-effectiveness of prophylaxis of postoperative infections after surgical treatment of closed fractures. The costs of 16 patients with an infection (8 with deep infections, 8 with superficial infections) were investigated and compared with the costs of 16 similar noninfected patients for the parameters hospital stay, antibiotics and surgery. The data were collected from the trauma department of the University Hospital of the Free University of Amsterdam. There were no substantial extra costs in the group of the 8 patients with superficial wound infection compared with their noninfected controls. The mean extra costs for a deep infection in the other 8 patients were Dfl 35,224.-. Considering these results, antibiotic prophylaxis of postoperative wound infections is cost-effective, if it leads to a decrease of the risk of deep wound infections by about 0.25%.