Effect of facility on the operative costs of distal radius fractures.

PURPOSE: The purpose of this study was to investigate whether ambulatory surgery centers can deliver lower-cost care and to identify sources of those cost savings. METHODS: We performed a cost identification analysis of outpatient volar plating for closed distal radius fractures at a single academic medical center. Multiple costs and time measures were taken from an internal database of 130 consecutive patients and were compared by venue of treatment, either an inpatient facility or an ambulatory, stand-alone surgery facility. The relationships between total cost and operative time and multiple variables, including fracture severity, patient age, gender, comorbidities, use of bone graft, concurrent carpal tunnel release, and surgeon experience, were examined, using multivariate analysis and regression modeling to identify other cost drivers or explanatory variables. RESULTS: The mean operative cost was considerably greater at the inpatient facility ($7,640) than at the outpatient facility ($5,220). Cost drivers of this difference were anesthesia services, post-anesthesia care unit, and operating room costs. Total surgical time, nursing time, set-up, and operative times were 33%, 109%, 105%, and 35% longer, respectively, at the inpatient facility. There was no significant difference between facilities for the additional variables, and none of those variables independently affected cost or operative time. CONCLUSIONS: The only predictor of cost and time was facility type. This study supports the use of ambulatory stand-alone surgical facilities to achieve efficient resource utilization in the operative treatment of distal radius fractures. We also identified several specific costs and time measurements that differed between facilities, which can serve as potential targets for tertiary facilities to improve utilization. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic and Decisional Analysis III.

Osteonecrosis of the femoral head in childhood malignancy.

PURPOSE: Children undergoing chemotherapeutic treatment of malignancies have up to a 9 % incidence of osteonecrosis. The purpose of this article is to determine the time from initiation of chemotherapy to the onset of symptoms and the diagnosis of osteonecrosis of the femoral head in this patient population. METHODS: A retrospective review of the records of 18 patients (29 hips) under 21 years of age with both a diagnosis of osteonecrosis of the femoral head and childhood onset malignancy was undertaken to determine the time from initiation of chemotherapy to the onset of symptoms and diagnosis of osteonecrosis of the femoral head. RESULTS: Mean time from initiation of chemotherapy to the onset of pain was 18.8 months (8.0-49.1). The mean time from development of pain to diagnosis of osteonecrosis was 3.9 months (-13.1 to 25). The mean overall time from initiation of chemotherapy to diagnosis of osteonecrosis was 22.7 months (9.0-54.1). 11/18 patients had bilateral disease. 16/18 patients (21/29 hips) had already progressed to stage 4 osteonecrosis at the time of diagnosis. CONCLUSIONS: There was a high incidence of stage 4 or greater osteonecrosis at the time of diagnosis. Providers caring for these patients should be aware of the potential for osteonecrosis, and the need for prompt diagnosis and referral to an orthopedic surgeon. Screening with advanced imaging studies may be warranted for children undergoing chemotherapeutic regimens for childhood malignancy to prevent delay in the diagnosis and management of this process so that joint preservation therapies remain an option.