An In-Depth Review of Physician Reimbursement for Digit and Thumb Replantation.

PURPOSE: To examine physician and hospital reimbursement for digit and thumb replantation compared with revision amputation. METHODS: Using the 2009-2016 Truven Health MarketScan Research Databases, we identified patients with a digit or thumb amputation. Following application of our inclusion and exclusion criteria, we divided patients into replantation and revision amputation groups. We extracted the mean physician and hospital reimbursement associated with each patient encounter. For comparison, we examined the work Relative Value Unit (wRVU) and Medicare Physician Fee Schedule (MPFS) for the respective procedures in addition to several common hand surgery procedures. RESULTS: We identified 51,716 patients. Following application of our inclusion and exclusion criteria, 219 replantation and 6,209 revision amputation patients were included in our analysis. For replantation, the mean physician and hospital reimbursements ranged from $3,938 to $7,753 and $30,683 to $56,256, respectively. For revision amputation, the mean physician and hospital reimbursements ranged from $1,030 to $1,206 and $2,877 to $4,188, respectively. On multivariable analysis, hospitals performing replantation earned $37,788 more per case compared with revision amputation. Using the wRVU and MPFS data, we determined that replantation reimburses at $78/wRVU compared with higher earnings for revision amputation ($108), carpal tunnel release ($101), cubital tunnel release ($97), trigger finger release ($116), open reduction and internal fixation (ORIF) distal radius fracture ($87), flexor tendon repair ($98), extensor tendon repair ($122), repair of digital nerve ($89), and ORIF articular fracture ($82), respectively. CONCLUSIONS: Low physician reimbursement for replantation compared with less complex hand procedures makes it difficult to recruit and retain hand surgeons for this purpose. By understanding the wRVU and MPFS system, hand surgeons and professional societies can explore ways to promote change in the way replantation is valued by the Centers for Medicare and Medicaid Services (CMS) as well as by hospital administrators. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic/Decision Analysis III.

A Low-Cost High-Definition Video System for Microsurgical Hindlimb Replantation in Rats.

Background The surgical microscope is still essential for microsurgery, but several alternatives that show promising results are currently under development, such as endoscopes and laparoscopes with video systems; however, as yet, these have only been used for arterial anastomoses. The aim of this study was to evaluate the use of a low-cost video-assisted magnification system in replantation of the hindlimbs of rats. Methods Thirty Wistar rats were randomly divided into two matched groups according to the magnification system used: the microscope group, with hindlimb replantation performed under a microscope with an image magnification of 40× and the video group, with the procedures performed under a video system composed of a high-definition camcorder, macrolenses, a 42-in television, and a digital HDMI cable. The camera was set to 50× magnification. We analyzed weight, arterial and venous caliber, total surgery time, arterial and venous anastomosis time, patency immediately and 7 days postoperatively, the number of stitches, and survival rate. Results There were no significant differences between the groups in weight, arterial or venous caliber, or the number of stitches. Replantation under the video system took longer (p < 0.05). Patency rates were similar between groups, both immediately and 7 days postoperatively. Conclusion It is possible to perform a hindlimb replantation in rats through video system magnification, with a satisfactory success rate comparable with that for procedures performed under surgical microscopes.

Use of Pediatric Open, Laparoscopic and Robot-Assisted Laparoscopic Ureteral Reimplantation in the United States: 2000 to 2012.

PURPOSE: We characterize the use of pediatric open, laparoscopic and robot-assisted laparoscopic ureteral reimplantation in the United States from 2000 to 2012. MATERIALS AND METHODS: We used the Kids' Inpatient Database to identify patients who underwent ureteral reimplantation for primary vesicoureteral reflux. Before 2009 laparoscopic ureteral reimplantion and robot-assisted laparoscopic ureteral reimplantation were referred to together as minimally invasive ureteral reimplantation. A detailed analysis of open vs robot-assisted laparoscopic ureteral reimplantation was performed for 2009 and 2012. RESULTS: A total of 14,581 ureteral reimplantations were performed. The number of ureteral reimplantations yearly decreased by 14.3%. However, the proportion of minimally invasive ureteral reimplantations increased from 0.3% to 6.3%. A total of 125 robot-assisted laparoscopic ureteral reimplantations were performed in 2012 (81.2% of minimally invasive ureteral reimplantations), representing 5.1% of all ureteral reimplantations, compared to 3.8% in 2009. In 2009 and 2012 mean ± SD patient age was 5.7 ± 3.6 years for robot-assisted laparoscopic ureteral reimplantation and 4.3 ± 3.3 years for open reimplantation (p <0.0001). Mean ± SD length of hospitalization was 1.6 ± 1.3 days for robot-assisted laparoscopic ureteral reimplantation and 2.4 ± 2.6 for open reimplantation (p <0.0001). Median charges were $22,703 for open and $32,409 for robot-assisted laparoscopic ureteral reimplantation (p <0.0001). These relationships maintained significance on multivariate analyses. On multivariate analysis robot-assisted laparoscopic ureteral reimplantation use was associated with public insurance status (p = 0.04) and geographic region outside of the southern United States (p = 0.02). Only 50 of 456 hospitals used both approaches (open and robotic), and only 6 hospitals reported 5 or more robot-assisted laparoscopic ureteral reimplantations during 2012. CONCLUSIONS: Treatment of primary vesicoureteral reflux with ureteral reimplantation is decreasing. Robot-assisted laparoscopic ureteral reimplantation is becoming more prevalent but remains relatively uncommon. Length of stay is shorter for the robotic approach but the costs are higher. Nationally robot-assisted laparoscopic ureteral reimplantation appears to still be in the early phase of adoption and is clustered at a small number of hospitals.

Evaluating the Effect of Comorbidities on the Success, Risk, and Cost of Digital Replantation.

PURPOSE: The clinical decision to replant an amputated digit is driven primarily by surgical indication. However, the extent to which patient comorbidity should play into this decision is less well defined. This study was designed to determine the effect of patient comorbidities on the success, risk, and cost of digital replantation. METHODS: All amputation injuries and digital replantation procedures captured by the National Inpatient Sample during 2001 to 2012 were identified. A successful replantation procedure was defined as one in which a replantation occurred without a subsequent revision amputation. Patient comorbidities were tested for association with failure of replantation, risk of postoperative complications, and overall hospital costs. RESULTS: We identified 11,788 digital replantation procedures. A total of 3,604 patients (30.6%) experienced revascularization failure associated with replantation. The risk for replant failure was highest among patients with psychotic disorders, peripheral vascular disease, and electrolyte imbalances. The risk for postoperative complications was highest among patients with electrolyte imbalances, drug abuse, or chronic obstructive pulmonary disease. Hospital costs were greatest among patients with deficiency anemias, electrolyte imbalances, or psychotic disorders. Patients with more than 3 comorbidities experienced significantly higher failure, risk of postoperative complications, and cost of digital replantation. CONCLUSIONS: These data suggest that even when surgical indications are met, patients with more than 3 comorbidities and those who have a history of alcohol abuse, deficiency anemias, electrolyte imbalances, obesity, peripheral vascular disease, or psychotic disorders are at increased risk of replantation failure and associated postoperative complications. Assessment of this risk should have a role in decision making regarding whether a digit should be replanted. Patients at high risk should be carefully counseled regarding the difficult perioperative course before undergoing digital replantation. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic III.

Epidemiology of upper extremity replantation surgery in the United States.

PURPOSE: Replantation remains an important technique in the management of hand trauma. Given the resources necessary for a successful replantation program, regionalization of replantation care may ultimately be required. The purposes of this study were to analyze the geographic distribution of upper extremity replant procedures, analyze factors of patients undergoing replantation, and characterize the facilities performing these procedures. METHODS: We performed a cohort study using the National Inpatient Sample of the Healthcare Cost and Utilization Project from 2001, 2004, and 2007. Patients with an upper extremity amputation were defined, and a subgroup of patients undergoing replantation was delineated. We analyzed patient demographics and injury characteristics and characteristics of treating facilities. RESULTS: A total of 9,407 patients were treated for upper extremity amputation, 1,361 of whom underwent replantation. Mean age of patients undergoing replantation was 36 years (range, 0-86 y), compared with 44 years (range, 0-104 y) in patients not undergoing replantation. Hospital charges (P < .001) and length of stay (P < .001) were significantly higher for patients with replantations versus those without replantations. Patients treated at teaching facilities were more likely to undergo replantation than those at a non-teaching facility (19% replantation rate at teaching hospitals vs 7% at non-teaching). Large hospitals and urban hospitals were more likely to perform replantation. Self-pay, Medicare, and Medicaid patients all had lower replantation rates than patients with other payer status. CONCLUSIONS: Patients who undergo replantation are younger, incur higher hospital charges, and have longer hospital stays compared with patients who do not undergo replantation. Treatment at large, urban, and teaching facilities is associated with higher replantation rates. Payer status appears to have some bearing on replantation rates. Further studies are needed to better elucidate the relationship between patient and injury characteristics, treatment location, and outcomes, to adequately distribute the finite resources for replantation. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic and Decision Analysis IV.

The economic impact of electric saw injuries to the hand.

PURPOSE: Injuries from electric saws cause considerable hand trauma. This study is designed to provide information detailing the costs of these injuries. METHODS: The study was performed in a tertiary referral academic medical center. The records of patients injured by electric table saws were reviewed. Information regarding demographics, injury severity, medical expense, and time lost from work was analyzed. The patients were stratified by injury severity for further analysis. The mean wage for the region was used to estimate costs of time away from work. The Consumer Protection Agency's review was used to estimate the nationwide burden of these injuries. RESULTS: The study group included 134 patients. Of these patients, 126 were male and 8 were female. The dominant hand was injured in 20; the nondominant, in 114. The mean age was 47.0 years. The mean time lost from work was 64 days. The mean cost of medical expenses for all patients was $22,086, with $8,668 in lost wages, for a total of $30,754 mean cost per injury. The total economic burden for the injuries in this study is $4,121,097. These injuries represent a spectrum of severity, with minor injuries incurring lower hospital fees and requiring less time off work as compared to more involved injuries. CONCLUSIONS: Electric saws cause a wide spectrum of injuries that result in not only tremendous physical and emotional pain but also substantial economic impact as well. Technologies that would prevent such injuries would be a socioeconomic advancement. Federal mandates to implement such technologies should be encouraged.

Nationwide Cost Variation for Thumb Replantation: A Population Study.

BACKGROUND: Health care reforms aimed at bundling payments attempt to contain costs. Uncovering variation in spending provides one strategy for decreasing expenditure. This study aims to investigate interhospital cost variation for thumb replantation. METHODS: A retrospective cross-sectional analysis of patients undergoing thumb replantation using data from the Healthcare Cost and Utilization Project National Inpatient Sample database from 2001 to 2011 was performed. Univariate and multivariable logistic regression models were used to investigate associations between patient-level and hospital-level characteristics and cost. RESULTS: A total of 778 patients were included in the study, with a mean cost for thumb replantation of $20,965. Thumb replantations performed at high-volume hospitals were significantly more expensive than those performed at low-volume hospitals (median cost, $20,395 versus $13,463; p < 0.001), with longer lengths of stay (5 days versus 4 days), despite having similar surgical complication rates (p = 0.07). Thumb replantations performed in the West were significantly more expensive than those performed in the South (median cost, $22,579 in the West versus $14,823 in the South; p < 0.001), with longer lengths of stay (5 days versus 4 days; p = 0.005) and similar surgical complications (p = 0.239). In multivariable logistic regression, hospital volume (p < 0.001), hospital region (p < 0.001), and increased length of stay (p < 0.001) were predictive of higher cost. CONCLUSIONS: High-volume hospitals and hospitals in the West are more expensive, with longer lengths of stay, despite having similar complications. Expedited discharge may be one avenue for decreasing expenditure without compromising care.

Cost-effectiveness of Finger Replantation Compared With Revision Amputation.

Importance: Traumatic digit amputation is the most common type of amputation injury, but the cost-effectiveness of its treatments is unknown. Objective: To assess the cost-effectiveness of finger replantation compared with revision amputation. Design, Setting, and Participants: This economic evaluation was conducted using data from the Finger Replantation and Amputation Challenges in Assessing Impairment, Satisfaction, and Effectiveness (FRANCHISE), a retrospective, multicenter cohort study at 19 centers in the United States and Asia that enrolled participants from August 1, 2016, to April 12, 2018. Model variables were based on the FRANCHISE database, Centers for Medicare & Medicaid Services, and published literature. A total of 257 participants with unilateral traumatic finger amputations treated with revision amputation or replantation distal to the metacarpophalangeal joint and at least 1 year of follow-up after treatment were included in the analysis. Exposures: Revision amputation or replantation of traumatic finger amputations. Main Outcomes and Measures: Main outcome measures were quality-adjusted life-years (QALYs), total costs (in US dollars), and incremental cost-effectiveness ratios (ICERs). A willingness-to-pay threshold of $100 000 per QALY was used to assess cost-effectiveness. Results: Of the 257 study participants (mean [SD] age, 46.7 [15.9] years; 221 [86.0%] male), 178 underwent finger replantation and 79 underwent revision amputation. In a base case of a 46.7-year-old patient, replantation was associated with QALY gains of 0.30 (95% credible interval [CrI], -0.72 to 1.38) for single-finger (not thumb), 0.39 (95% CrI, -1.00 to 1.90) for thumb, 1.69 (95% CrI, -0.13 to 3.76) for multifinger excluding thumb, and 1.27 (95% CrI, -2.21 to 5.04) for multifinger including thumb injury patterns. Corresponding ICERs for replantation compared with revision amputation were $99 157 per QALY for single-finger (not thumb), $66 278 per QALY for thumb, $18 388 per QALY for multifinger excluding thumb, and $21 528 per QALY for multifinger including thumb injury patterns. Sensitivity analysis revealed that age at time of injury, life expectancy, postinjury utility, wages, and time off work for recovery had the strongest associations with cost-effectiveness. Probabilistic sensitivity analysis revealed the following chances of replantation being cost-effective: 47% in single-finger (not thumb), 52% in thumb, 78% in multifinger excluding thumb, and 64% in multifinger including thumb injury patterns. Conclusions and Relevance: With proper patient selection, replantation of all finger amputation patterns, whether single-finger or multifinger injuries, may be cost-effective compared with revision amputation. Multifinger replantations had a higher probability of being cost-effective than single-finger replantations. Cost-effectiveness may depend on injury pattern and patient factors and thus appears to be important for consideration when patients and surgeons are deciding whether to replant or amputate.

Endoscopic subureteral injection is not less expensive than outpatient open reimplantation for unilateral vesicoureteral reflux.

PURPOSE: Extravesical ureteral reimplantation and subureteral Deflux injection are used to correct vesicoureteral reflux with success rates of 94% to 99% and up to 89%, respectively. It was reported that unilateral extravesical reimplantation may be performed safely in an outpatient setting. Given that, we analyzed total system reimbursement to compare planned outpatient unilateral extravesical reimplantation to subureteral Deflux injection in patients with unilateral vesicoureteral reflux. MATERIALS AND METHODS: Data were collected on consecutive patients undergoing outpatient procedures for unilateral vesicoureteral reflux. Assessment of total system reimbursement was made using a payer mix adjusted calculation of surgery plus anesthesia plus hospital reimbursement. This was compared per procedure and in terms of total system reimbursement for each approach to obtain a similar resolution rate. RESULTS: A total of 209 consecutive patients were identified, of whom 26 underwent subureteral Deflux injection and 183 underwent unilateral extravesical reimplantation. Mean operative time was 93 minutes for reimplantation and 45 minutes for injection. The mean volume of dextranomer-hyaluronic acid was 1.2 ml. Total initial system reimbursement per patient was $3,813 for reimplantation and $4,259 for injection. A 3% hospital admission rate for reimplantation increased the total to $3,945. Higher reimbursement for injection depended largely on the material expense for dextranomer-hyaluronic acid. CONCLUSIONS: In terms of total system reimbursement it is less expensive in our system to treat unilateral vesicoureteral reflux with unilateral extravesical reimplantation than with subureteral Deflux injection using dextranomer-hyaluronic acid. The ability to perform unilateral reimplantation as an outpatient procedure has shifted this relationship.

The effect of prior endoscopic correction of vesicoureteral reflux on open ureteral reimplantation: Surgical outcomes and costs.

INTRODUCTION: Endoscopic injection of a bulking agent is a common first-line approach to the treatment of vesicoureteral reflux (VUR). While early outcomes are comparable to open ureteroneocystotomy, 5-25% of children will eventually develop recurrent reflux necessitating repeat injections or open ureteral reimplantation. OBJECTIVE: To determine whether prior endoscopic injection of a bulking agent impacts outcomes of subsequent open ureteral reimplantation. STUDY DESIGN: Using a retrospective cohort design, radiographic and clinical outcomes of open ureteral reimplantation were compared between patients with and without prior endoscopic correction of reflux. Surgical and hospitalization data were also compared between groups and a cost comparison was performed to assess differences in healthcare costs between the two cohorts. Units of analysis included total ureters or total patients. For certain variables, subanalysis of unilateral versus bilateral reimplantation was included. RESULTS: A total of 258 patients underwent open reimplantation for VUR between 2007 and 2016 by five pediatric urologists. Final analysis (see Summary Table) included 192 patients with pre-operative and postoperative voiding cystourethrogram (VCUG) and follow-up data at a median 4.95 months. Among 317 reimplanted refluxing ureters, radiographic resolution was reached in 26/27 (96.3%) patients with and 279/290 (96.2%) without prior endoscopic treatment (P = 0.981). Clinical success was achieved in 17/17 (100%) patients with and 174/175 (99.4%) without prior endoscopic treatment (P = 0.755). There were no statistically significant differences between duration of surgery or length of hospital stay. There were no statistically significant differences between total charges, total costs, and operating room (OR) costs between groups. DISCUSSION: This study indicated that prior endoscopic injection of a bulking agent did not impact the outcomes or costs of subsequent open ureteroneocystotomy. While prior studies have demonstrated tissue changes associated with injection of a bulking agent, these did not seem to significantly impact the difficulty of later open surgery or the success rates compared to patients who proceeded directly to open correction of reflux. CONCLUSION: Open ureteral reimplantation for recurrent VUR after failed endoscopic injection of a bulking agent was safe and effective, with comparable outcomes and costs to open surgery in patients without prior endoscopic correction.

A Comparison of Functional Outcomes and Therapeutic Costs: Single-Digit Replantation versus Revision Amputation.

BACKGROUND: The functional outcomes and therapeutic costs between digit replantation and revision amputation have remained controversial. METHODS: A total of 1023 patients with single-digit traumatic amputation or devascularization who underwent successful digit replantation (failure excluded) or revision amputation from January 1, 2013, to January 1, 2016, were included in this study. All cases were subgrouped based on Tamai level of amputation and the injured digit. The clinical outcomes were assessed using the Michigan Hand Outcomes Questionnaire 1 year after the initial operation. The authors also compared the cost of treatment, the duration of hospitalization, and the duration of sick leave between the two treatments. RESULTS: Replantation of small (level I to V), ring (level I to III), and long (level I) fingers showed no functional benefit compared with initial revision amputation. In contrast, replantation of thumb (level I to V), index (level I to V), long (level II to V), and ring (level IV to V) fingers had better outcomes. The cost of replantation was higher and the durations of hospitalization and sick leave of replantation were also longer compared with the revision amputation group. CONCLUSIONS: Single amputated injuries of small (level I to V), ring (level I to III), and long (level I) fingers are a relative contradiction for replantation. Replantation of thumb (level I to V), index (level I to V), long (level II to V), and ring (level IV to V) fingers showed extra benefit compared with revision amputation.

Lessons learned over a decade of pediatric robotic ureteral reimplantation.

The da Vinci robotic system has improved surgeon dexterity, ergonomics, and visualization to allow for a minimally invasive option for complex reconstructive procedures in children. Over the past decade, robot-assisted laparoscopic ureteral reimplantation (RALUR) has become a viable minimally invasive surgical option for pediatric vesicoureteral reflux (VUR). However, higher-than-expected complication rates and suboptimal reflux resolution rates at some centers have also been reported. The heterogeneity of surgical outcomes may arise from the inherent and underestimated complexity of the RALUR procedure that may justify its reclassification as a complex reconstructive procedure and especially for robotic surgeons early in their learning curve. Currently, no consensus exists on the role of RALUR for the surgical management of VUR. High success rates and low major complication rates are the expected norm for the current gold standard surgical option of open ureteral reimplantation. Similar to how robot-assisted laparoscopic surgery has gradually replaced open surgery as the most utilized option for prostatectomy in prostate cancer patients, RALUR may become a higher utilized surgical option in children with VUR if the adoption of standardized surgical techniques that have been associated with optimal outcomes can be adopted during the second decade of RALUR. A future standard of RALUR for children with VUR whose parents seek a minimally invasive surgical option can arise if widespread achievement of high success rates and low major complication rates can be obtained, similar to the replacement of open surgery with robot-assisted laparoscopic radical prostectomy as the new strandard for men with prostate cancer.

Robotic versus open pediatric ureteral reimplantation: Costs and complications from a nationwide sample.

INTRODUCTION: We sought to compare complications and direct costs for open ureteral reimplantation (OUR) versus robot-assisted laparoscopic ureteral reimplantation (RALUR) in a sample of hospitals performing both procedures. Anecdotal reports suggest that use of RALUR is increasing, but little is known of the outcomes and costs nationwide. OBJECTIVE: The aim was to determine the costs and 90-day complications (of any Clavien grade) in a nationwide cohort of pediatric patients undergoing OUR or RALUR. METHODS: Using the Premier Hospital Database we identified pediatric patients (age < 21 years) who underwent ureteral reimplantation from 2003 to 2013. We compared 90-day complication rates and cost data for RALUR versus OUR using descriptive statistics and hierarchical models. RESULTS: We identified 17 hospitals in which both RALUR and OURs were performed, resulting in a cohort of 1494 OUR and 108 RALUR cases. The median operative time was 232 min for RALUR vs. 180 min for OUR (p = 0.0041). Incidence of any 90-day complications was higher in the RALUR group: 13.0% of RALUR vs. 4.5% of OUR (OR = 3.17, 95% CI: 1.46-6.91, p = 0.0037). The difference remained significant in a multivariate model accounting for clustering among hospitals and surgeons (OR, 3.14; 95% CI, 1.46-6.75; p = 0.0033) (Figure). The median hospital cost for OUR was $7273 versus $9128 for RALUR (p = 0.0499), and the difference persisted in multivariate analysis (p = 0.0043). Fifty-one percent (55/108) of the RALUR cases occurred in 2012-2013. DISCUSSION: We present the first nationwide sample comparing RALUR and OUR in the pediatric population. There is currently wide variation in the probability of complication reported in the literature. Some variability may be due to differential uptake and experience among centers as they integrate a new procedure into their practice, while some may be due to reporting bias. A strength of the current study is that cost and 90-day postoperative complication data are collected at participating hospitals irrespective of outcomes, providing some immunity from the reporting bias to which individual center surgical series' may be susceptible. CONCLUSIONS: Compared with OUR, RALUR was associated with a significantly higher rate of complications as well as higher direct costs even when adjusted for demographic and regional factors. These findings suggest that RALUR should be implemented with caution, particularly at sites with limited robotic experience, and that outcomes for these procedures should be carefully and systematically tracked.

The Effect of Medicaid Expansion on Delivery of Finger and Thumb Replantation Care to Medicaid Beneficiaries and the Uninsured.

BACKGROUND: Despite advances in replantation, over 80 percent of finger and thumb amputation injuries in the United States result in revision amputation. Although numerous factors contribute to this, disparities in access and delivery of replantation care play a substantial role. With ongoing Medicaid expansion under the Affordable Care Act, it is prudent to understand whether expansion of coverage changes use of replantation care. METHODS: The authors used the 2001 Medicaid expansion in New York State to evaluate changes in replantation for Medicaid beneficiaries and the uninsured. Data for patients having undergone replantation between 1998 and 2006 were obtained from the New York State Inpatient Database. The authors used an interrupted time series to evaluate the effect of Medicaid expansion on the probability that Medicaid beneficiaries or uninsured patients underwent replantation. Census data were used for population-adjusted case volume analysis. RESULTS: After expansion, the likelihood of Medicaid as the primary payer for replantation increased 0.0059 percent per quarter, reaching a 1.7 percent increase 5 years after expansion. With population-based analysis, this indicates that Medicaid covered 12 additional replantation cases in New York State annually. After expansion, 11 fewer of the replantation cases in New York State each year were provided to patients without health care coverage. CONCLUSIONS: Medicaid expansion resulted in a modest but significant increase in replantation for Medicaid beneficiaries. In addition, fewer patients that underwent replantation remained uninsured. Considering the substantial cost and effort burden of replantation, these findings support the benefits of Medicaid expansion on delivery and payer coverage of replantation.

Does surgical subspecialization in pediatrics provide high-quality, cost-effective patient care?

OBJECTIVE: To determine if pediatric surgical subspecialization provides cost-effective, high-quality pediatric patient care. METHODS: Ureteroneocystostomy inpatients over 4 years were studied. Hospital charges and complications were compared between general urologists and fellowship-trained pediatric urologists. RESULTS: Hospital charges were significantly less ($1095) for patients under the care of a pediatric urologist. Complication rates were also lower. CONCLUSIONS: Pediatric urology subspecialization offers high-quality, cost-effective pediatric patient care.

Replantation-revascularization and primary amputation in major hand injuries. Resources spent on treatment and the indirect costs of sick leave in Sweden.

Thirty consecutive patients with amputation or devascularizing injuries of the thumb or two or more fingers proximal to the PIP joint were reviewed. Replantation or revascularization had been done in 27 patients, in 24 successfully. Three patients had primary amputation. The distribution of calculable costs was dominated by those for sick leave (49%), operation (26%) and ward costs (20%). Out-patient care, physiotherapy and travel together constituted only 6%. The cost of a successful replantation was equal to 1.6 times the mean annual salary of these patients and that of primary amputation about half as much. Mobility, power and performance of a standardized grip test were better for the successfully replanted or revascularized patients. Subjective evaluation of 23 parameters of function, cosmesis and quality of life did not disclose any differences. All patients except three had returned to their original work within 2 years.

Review article limb salvage surgery in bone tumours.

Wide resection of bone tumour has become an accepted treatment in the limb salvage surgery. The reconstruction of the residual defect following wide resection is a major problem. The motions of involved joint after resection of the large tumour can be restored by using either the osteoarticular allograft or endoprosthesis. Osteoarticular graft is suitable for proximal tibial reconstruction and endoprosthesis for distal femoral reconstruction. Resection arthrodesis can be done with autograft, cement or autoclaved tumour bone. Autograft is rarely used to reconstruct the large residual defect. Cement can reconstruct the larger defect, but it is not a suitable procedure on long term basis. The reimplantation of resected autoclaved tumour bone graft is technically a simple and financially a cost saving solution for this difficult problem. It is the most suitable method of reconstruction for the developing and poor countries where the resources for other methods are not available due to financial technical or socio-cultural reasons.

[Decrease in disability pension following replantation]. / Minderung der Rentenhöhe nach Replantationen.

Between 1977 and 1986, 201 patients underwent replantations at the Accident Hospital in Salzburg. Of these 201 cases, 112 (55.7%) were work-related accidents. The first 47 cases were evaluated by two independent experts, comparing the actual occupational disability, i.e. impairment of earning capacity after replantation with the probable occupational disability payment had the replantation not been performed. In thirty-nine out of forty-seven cases, replantation had led to lower disability benefits.

[Current indications for reimplantation of the upper extremity]. / Indicaciones actuales de los reimplantes de la extremidad superior.

In the last decades there has been a great development in microsurgery that has enabled successful replantation of totally severed parts. Nowadays, the important issue is to decide which segments should be replanted, in order to achieve a good functional result. In this paper we study the indications and contraindications of replantation, based in our experience and we present a review of the recent literature. We consider the following aspects: general condition and age of the patient, mechanism of lesion, amputation level, ischemic time and also economic aspects. We conclude that replantation should be attempted in thumb and multiple digits amputations, in amputations at the palm, wrist and forearm, in single digit amputations distal to the flexor superficialis insertion and in any case in children.

Economic analysis of revision amputation and replantation treatment of finger amputation injuries.

BACKGROUND: The purpose of this study was to perform a cost-utility analysis to compare revision amputation and replantation treatment of finger amputation injuries across a spectrum of injury scenarios. METHODS: The study was conducted from the societal perspective. Decision tree models were created for the reference case (two-finger amputation injury) and seven additional injury scenarios for comparison. Inputs included cost, quality of life, and probability of each health state. A Web-based time trade-off survey was created to determine quality-adjusted life-years for health states; 685 nationally representative adult community members were invited to participate in the survey. Overall cost and quality-adjusted life-years for revision amputation and replantation were calculated for each decision tree. An incremental cost-effectiveness ratio was calculated if a treatment was more costly but more effective. RESULTS: The authors had a 64 percent response rate (n = 437). Replantation treatment had greater costs and quality-adjusted life-years compared with revision amputation in all injury scenarios. Replantation of single-digit injuries had the highest incremental cost-effectiveness ratio ($136,400 per quality-adjusted life-year gained). Replantation of three- and four-digit amputation injuries had relatively low cost-to-benefit ratios ($27,100 and $23,800 per quality-adjusted life-year, respectively). Replantation for distal thumb amputation had a relatively low incremental cost-effectiveness ratio ($26,300 per quality-adjusted life-year) compared with replantation of nonthumb distal amputations ($60,200 per quality-adjusted life-year). CONCLUSIONS: The relative cost per quality-adjusted life-year gained with replantation treatment varied greatly among the injury scenarios. Situations in which indications for replantation are debated had higher cost per quality-adjusted life-year gained. This study highlights variability in value for replantation among different injury scenarios.