Cost-Effectiveness of Treatments after Closed Extraarticular Distal Radius Fractures in Older Adults from the WRIST Clinical Trial.

BACKGROUND: This study performs an economic analysis of volar locking plate, external fixation, percutaneous pinning, or casting in elderly patients with closed distal radius fractures. METHODS: This is a secondary analysis of the Wrist and Radius Injury Surgical Trial, a randomized, multicenter, international clinical trial with a parallel nonoperative casted group of patients older than 60 years with surgically indicated, extraarticular closed distal radius fractures. Thirty-Six-Item Short-Form Health Survey-converted utilities and total costs from Medicare were used to calculate quality-adjusted life-years and incremental cost-effectiveness ratio. RESULTS: Casted patients were self-selected and older (p < 0.001) than the randomized surgical cohorts, but otherwise similar in sociodemographic characteristics. Quality-adjusted life-years for percutaneous pinning were highest at 9.17 and external fixation lowest at 8.81. Total costs expended were $16,354 for volar locking plates, $16,012 for external fixation, $11,329 for percutaneous pinning, and $6837 for casting. The incremental cost-effectiveness ratios for volar locking plates and external fixation were dominated by percutaneous pinning and casting. The ratio for percutaneous pinning compared to casting was $28,717. Probabilistic sensitivity analysis revealed a 10, 5, 53, and 32 percent chance of volar locking plate, external fixation, percutaneous pinning, and casting, respectively, being cost-effective at the willingness-to-pay threshold of $100,000 per quality-adjusted life-year. CONCLUSIONS: Casting is the most cost-effective treatment modality in the elderly with closed extraarticular distal radius fractures and should be considered before surgery. In unstable closed fractures, percutaneous pinning, which is the most cost-effective surgical intervention, may be considered before volar locking plates or external fixation.

Clinical outcome and operative cost comparison: Locked compression plate versus reconstruction plate in midshaft clavicle fractures.

OBJECTIVE: The aim of this study was to compare the clinical outcomes and operative cost of a locked compression plate (LCP) and a nonlocked reconstruction plate in the treatment of displaced midshaft clavicle fracture. METHODS: From January 2013 till March 2018, a total of 55 patients with acute unilateral closed midshaft clavicle fracture were treated with either a 3.5-mm pre-contoured LCP [32 patients; 25 men and 7 women; mean age: 35 years (range: 19-63 years)] or a 3.5-mm nonlocked reconstruction plate [23 patients; 20 men and 3 women; mean age: 31.4 years (range: 17-61 years)]. The clinical outcomes in terms of fracture union, Quick Disability of Arm, Shoulder and Hand (DASH) score, implant irritation, failure rate, and reoperation rate were evaluated retrospectively. The patient billing records were reviewed to obtain primary operation, reoperation, and total operative cost for midshaft clavicle fracture. These values were analyzed and converted from Malaysia Ringgit (RM) to United States Dollar (USD) at the exchange rate of RM 1 to USD 0.24. All patients were followed up for at least one-year duration. RESULTS: The mean time to fracture union, implant irritation, implant failure, and reoperation rate showed no significant difference between the two groups of patients. The mean Quick DASH score was significantly better in the reconstruction plate group with 13 points compared with 28 points in the LCP group (p=0.003). In terms of total operative cost, the LCP group recorded a cost of USD 391 higher than the reconstruction plate group (p<0.001). CONCLUSION: The 3.5-mm reconstruction plate achieved not only satisfactory clinical outcomes but was also more cost-effective than the LCP in the treatment of displaced midshaft clavicle fractures. LEVEL OF EVIDENCE: Level III, Therapeutic study.

Does an Implant Usage Report Card Impact Orthopaedic Trauma Implant Stewardship?

OBJECTIVES: As hospitals seek to control variable expenses, orthopaedic surgeons have come under scrutiny because of relatively high implant costs. We aimed to determine whether feedback to surgeons regarding implant costs results in changes in implant selection. METHODS: This study was undertaken at a statewide trauma referral center and included 6 fellowship-trained orthopaedic trauma surgeons. A previously implemented implant stewardship program at our institution using a "red-yellow-green" (RYG) implant selection tool classifies 7 commonly used trauma implant constructs based on cost and categorizes each implant as red (used for patient-specific requirements, most expensive), yellow (midrange), and green (preferred vendor, least expensive). The constructs included were femoral intramedullary nail, tibial intramedullary nail, long and short cephalomedullary nails, distal femoral plate, proximal tibial plate, and lower-limb external fixator. Baseline implant usage from the previous year was obtained and provided to each surgeon. Each surgeon received a monthly feedback report containing individual implant utilization and overall ranking. RESULTS: The overall RYG score increased from 68.7 to 79.1 of 100 (P < 0.001). Three of the 7 implants (tibial and femoral nails and lower-limb external fixation) had significant increases in their RYG scores; implant selections for the other 4 implants were not significantly altered. A decrease of 1.8% (95% confidence interval, 0.4-3.2, P = 0.01) was noted in overall implant costs over the study period. CONCLUSION: Our intervention resulted in changes in surgeons' implant selections and cost savings. However, surgeons were unwilling to change certain implants despite their being more expensive.

Assessment of Screw Length of Proximal Humerus Internal Locking System (PHILOS) Plate for Proximal Humeral Fractures Using Three-Dimensional Computed Tomography Scan.

BACKGROUND Screw perforation and varus collapse are common complications of treatment with a PHILOS (proximal humerus internal locking system) plate for proximal humerus fractures, which are associated with improper screw length selection and lack of medial column support. The purposes of this study were: (1) to measure the proper length of periarticular screws of the PHILOS plate in the humeral head, and (2) to determine what factors influence the screw length and implantation of the inferomedial support screw. MATERIAL AND METHODS Computed tomography (CT) images of the normal proximal humerus in 134 cases were retrospectively reviewed. The length of periarticular screws was measured using three-dimensional (3D) techniques. Intraobserver and interobserver reliability of measurement were evaluated using intraclass correlation coefficients (ICCs). Sex and body height influences on screw length and implantation of the inferomedial screw were analyzed. RESULTS All measurements had excellent agreement (ICC>0.75). The screw length and implantation rate of the inferomedial screw were greater in males than in females. Positive correlations were observed between body height and screw length and implantation of the inferomedial screw (all P<0.001). CONCLUSIONS The screws were longer and the implantation rate was higher for inferomedial screws in males than in females, and were positively correlated with body height. Our data can be used as a reference for surgeons to reduce the number of times screws are changed intraoperatively and to reduce operation duration and minimize use of intraoperative fluoroscopy for proximal humerus fractures treated with the PHILOS plate.

The Clinical and Economic Impact of Generic Locking Plate Utilization at a Level II Trauma Center.

OBJECTIVES: In today's climate of cost containment and fiscal responsibility, generic implant alternatives represent an interesting area of untapped resources. As patents have expired on many commonly used trauma implants, generic alternatives have recently become available from a variety of sources. The purpose of this study was to examine the clinical and economic impact of a cost containment program using high quality, generic orthopaedic locking plates. The implants available for study were anatomically precontoured plates for the clavicle, proximal humerus, distal radius, proximal tibia, distal tibia, and distal fibula. DESIGN: Retrospective review. SETTING: Level II Trauma center. PATIENTS: 828 adult patients with operatively managed clavicle, proximal humerus, distal radius, proximal tibia, tibial pilon, and ankle fractures. INTERVENTION: Operative treatment with conventional or generic implants. RESULTS: The 414 patients treated with generic implants were compared with 414 patients treated with conventional implants. There were no significant differences in age, sex, presence of diabetes, smoking history or fracture type between the generic and conventional groups. No difference in operative time, estimated blood loss or intraoperative complication rate was observed. No increase in postoperative infection rate, hardware failure, hardware loosening, malunion, nonunion or need for hardware removal was noted. Overall, our hospital realized a 56% reduction in implant costs, an average savings of $1197 per case, and a total savings of $458,080 for the study period. CONCLUSIONS: Use of generic orthopaedic implants has been successful at our institution, providing equivalent clinical outcomes while significantly reducing implant expenditures. Based on our data, the use of generic implants has the potential to markedly reduce operative costs as long as quality products are used. LEVEL OF EVIDENCE: Therapeutic Level III.

Biomechanical in vitro assessment of screw augmentation in locked plating of proximal humerus fractures.

INTRODUCTION: Proximal humerus fracture fixation can be difficult because of osteoporosis making it difficult to achieve stable implant anchorage in the weak bone stock even when using locking plates. This may cause implant failure requiring revision surgery. Cement augmentation has, in principle, been shown to improve stability. The aim of this study was to investigate whether augmentation of particular screws of a locking plate aimed at a region of low bone quality is effective in improving stability in a proximal humerus fracture model. MATERIALS AND METHODS: Twelve paired human humerus specimens were included. Quantitative computed tomography was performed to determine bone mineral density (BMD). Local bone quality in the direction of the six proximal screws of a standard locking plate (PHILOS, Synthes) was assessed using mechanical means (DensiProbe™). A three-part fracture model with a metaphyseal defect was simulated and fixed with the plate. Within each pair of humeri the two screws aimed at the region of the lowest bone quality according to the DensiProbe™ were augmented in a randomised manner. For augmentation, 0.5 ml of bone cement was injected in a screw with multiple outlets at its tip under fluoroscopic control. A cyclic varus-bending test with increasing upper load magnitude was performed until failure of the screw-bone fixation. RESULTS: The augmented group withstood significantly more load cycles. The correlation of BMD with load cycles until failure and BMD with paired difference in load cycles to failure showed that augmentation could compensate for a low BMD. DISCUSSION AND CONCLUSION: The results demonstrate that augmentation of screws in locked plating in a proximal humerus fracture model is effective in improving primary stability in a cyclic varus-bending test. The augmentation of two particular screws aimed at a region of low bone quality within the humeral head was almost as effective as four screws with twice the amount of bone cement. Screw augmentation combined with a knowledge of the local bone quality could be more effective in enhancing the primary stability of a proximal humerus locking plate because the effect of augmentation can be exploited more effectively limiting it to the degree required.

National hardware removal rate associated with internal fixation of facial fractures.

PURPOSE: There has not been a broad national examination of complications and demographics of facial trauma reduction procedures. The literature has reported acceptable and unacceptable hardware removal rates in localized populations. MATERIALS AND METHODS: The 2007 Nationwide Inpatient Sample was used to determine all plate removal procedures associated with common complications from facial reductions. Statistical analysis was used to compare the differences in demographics of the reduction procedure and removal procedure groups. RESULTS: Some form of open fixation was reported in 4,879 patients. Plate removals associated with complications were reported in 246 patients. The "failure" removal rate as a percentage of the total number of open procedures for the year was 5.0%. Gender, race, age, primary payer, and median income of the patient were determined to significantly affect the likelihood for hardware removal due to complications. CONCLUSION: These results suggest that decreased lower bone quality and ability to pay affect the chances that a particular patient will undergo a hardware removal procedure. There is a strong possibility that the reported removal rate underestimates the actual failure rate of the procedures and devices used to treat facial trauma.

Provider factors associated with intramedullary nail use for intertrochanteric hip fractures.

BACKGROUND: Intramedullary nails provide no clear outcomes benefit in the majority of patients with intertrochanteric hip fracture, yet their use in the United States continues to increase. Non-patient factors that are associated with intramedullary nail use among Medicare patients have not been examined. The goal of this study was to identify the surgeon and hospital characteristics that were associated with the use of intramedullary nails compared with plate-and-screw devices among elderly Medicare patients with intertrochanteric hip fractures. METHODS: Medicare beneficiaries who were sixty-five years of age or older and underwent inpatient surgery to treat an intertrochanteric femoral fracture with use of an intramedullary nail or a plate-and-screw device were identified from the United States Medicare files for 2000 to 2002. Surgeon and hospital characteristics from the Medicare provider enrollment files were merged with the claims. Generalized linear mixed models with fixed and random effects modeled the association between surgeon and hospital factors and intramedullary nail use (compared with plate and screws), controlling for patient age, sex, and race; subtrochanteric fracture; Charlson comorbidity score; nursing home residence; and Medicaid-administered assistance. The adjusted odds ratios of receiving an intramedullary nail by year, surgeon, and hospital factors are reported. RESULTS: There were 192,365 claims for surgery to treat an intertrochanteric hip fracture that met the inclusion criteria and matched with surgeon and hospital information. There were 15,091 surgeons who performed intertrochanteric hip fracture surgeries in Medicare patients in 3480 hospitals between March 1, 2000, and December 31, 2002. The surgeon factors associated with intramedullary nail use include younger surgeon age (less than forty-five years old), an osteopathy degree, and operating at more than one hospital. The hospital factors associated with intramedullary nail use include a higher volume of intertrochanteric hip fracture surgeries, teaching hospital status, and having resident assistance during surgery. Surgeon factors improved the model fit more than hospital factors. CONCLUSIONS: The use of intramedullary nails was strongly associated with early-career surgeons and surgeon training programs. Our findings suggest that orthopaedic faculty at teaching hospitals and younger surgeons may be selecting orthopaedic implants on the basis of factors other than clinical outcomes evidence. We expect that intramedullary nail use will continue to increase as long as new surgeons are preferentially trained in intramedullary nailing procedures and surgeon reimbursement remains insulated from the treating hospital's burden of their choices for higher cost devices under the Medicare payment system.

[Precision of navigation-assisted surgery of the thoracic and lumbar spine]. / Präzision der navigationsgestützten Chirurgie an der Brust- und Lendenwirbelsäule.

The goal of these studies was to evaluate the accuracy of in vivo and in vitro application of CT- and C-arm-based navigation at the thoracic and lumbar spine. With CT based navigation, 82 pedicle screws were consecutively inserted, 53 into the thoracic and 29 into the lumbar spine. Seven (13%) perforations were detected at the thoracic spine and two (7%) at the lumbar spine. Additionally, minor perforations below the thread depth were seen in six (11%) thoracic and in two (7%) lumbar instrumentation. With C-arm-based navigation, 74 screws were consecutively placed into 38 thoracic and 36 lumbar pedicles. Perforations were noted in ten (26%) thoracic and four (11%) lumbar implants. Minor perforations were observed in another nine (24%) thoracic and ten (28%) lumbar pedicles. The observer-independent and standardized in vitro study based on a transpedicular 3.2-mm drill hole aiming a 4-mm steel ball in a plastic bone model showed pedicle perforations of the drill canal only in thoracic vertebrae, 1 of 15 in CT-based and 3 of 15 in C-arm navigation. The quantitative calculation of the smallest distance between the central line through the drill canal and the center of the steel ball resulted in 1.4 mm (0.5-4.8 mm) for the CT-based navigation at the thoracic spine and in 1.8 mm (0.5-3 mm) at the lumbar spine. For the C-arm based navigation the distance was 2.6 mm (0.9-4.8 mm) for the thoracic spine and 2 mm (1.2-3 mm) for the lumbar spine. In our opinion, the clinical results of the comparative accuracy of CT- and C-arm-based navigation in the present study showed moderate advantages of the CT-based technique in the thoracic spine, whereas CT- and C-arm based navigation had comparable perforation rates at the lumbar pedicle. The results of the experimental study correlated with the clinical data.

Mandible fracture repair: specific indications for newer techniques.

Mandible fracture repair is commonly undertaken by otolaryngologists. Although the essential principles of reduction and immobilization are undisputed, the approach used to obtain these goals varies considerably. We performed a critical evaluation of all mandible fractures treated at the Santa Clara Valley Medical Center by the otolaryngology service between January 1988 and February 1992, with the purpose of better defining the indications for plate fixation and for the use of more traditional techniques. One hundred eighty-three fractures in 112 patients were evaluable. Thirty-six (32.1%) of these patients had at least one plate placed (group A); 39 (34.8%) underwent an open procedure, with interosseous wire fixation (group B); and 37 (33.0%) were treated with closed techniques (group C). The severity of fracture (indexed by comminution, presence of infection, teeth in the fracture line, interval to repair, and whether the fracture was open or closed) was similar in plated and nonplated mandibles. Mean (+/- standard deviation) operative times for the three groups were 3.2 +/- 1.6 hours for group A, 3.0 +/- 0.9 hours for group B, and 1.4 +/- 0.5 hours for group C. The number of follow-up visits required was not statistically different (group A, 5.6 +/- 3.8 visits; group B, 5.2 +/- 2.5 visits; and group C, 5.3 +/- 2.0 visits). The overall incidence of major complications was 14.3% (16 of 112), including 11 of 36 (30.6%) in group A, 4 of 39 (10.3%) in group B, and 1 of 37 (2.7%) in group C.(ABSTRACT TRUNCATED AT 250 WORDS)