Cost and safety of inpatient versus outpatient open reduction internal fixation of isolated ankle fractures.

BACKGROUND: As health care shifts to value-based models, one strategy within orthopedics has been to transition appropriate cases to outpatient or ambulatory settings to reduce costs; however, there are limited data on the efficacy and safety of this practice for isolated ankle fractures. The purpose of this study was to compare the cost and safety associated with inpatient versus outpatient ankle open reduction internal fixation (ORIF). METHODS: All patients who underwent ORIF of isolated closed ankle fractures at 2 affiliated hospitals between April 2016 and March 2017 were identified retrospectively. Demographic characteristics, including age, gender, comorbidities and injuryspecific variables, were collected. We grouped patients based on whether they underwent ankle ORIF as an inpatient or outpatient. We determined case costing for all patients and analyzed it using multivariate regression analysis. RESULTS: A total of 196 patients (125 inpatient, 71 outpatient) were included for analysis. Inpatients had a significantly longer mean length of stay than outpatients (54.3 h [standard deviation (SD) 36.3 h] v. 7.5 h [SD 1.7 h], p < 0.001). The average cost was significantly higher for the inpatient cohort than the outpatient cohort ($4137 [SD $2285] v. $1834 [SD $421], p < 0.001). There were more unimalleolar ankle fractures in the outpatient group than in the inpatient group (42 [59.2%] v. 41 [32.8%], p < 0.001). Outpatients waited longer for surgery than inpatients (9.6 d [SD 5.6 d] v. 2.0 d [SD 3.3 d], p < 0.001). Fourteen patients (11.2%) in the inpatient group presented to the emergency department or were readmitted to hospital within 30 days of discharge, compared to 5 (7.0%) in the outpatient group (p = 0.3). CONCLUSION: In the treatment of isolated closed ankle fractures, outpatient surgery was associated with a significant reduction in length of hospital stay and overall case cost compared to inpatient surgery, with no significant difference in readmission or reoperation rates. In medically appropriate patients, isolated ankle ORIF can be performed safely in an ambulatory setting and is associated with significant cost savings.

The economic impact of periprosthetic infection in total hip arthroplasty

Background: Periprosthetic joint infection (PJI) is the third leading cause of total hip arthroplasty (THA) failure. Although controversial, 2-stage revision remains the gold standard treatment for PJI in most situations. To date, there have been few studies describing the economic impact of PJI in today's health care environment. The purpose of the current study was to obtain an accurate estimate of the institutional cost associated with the management of PJI in THA and to assess the economic burden of PJI compared with primary uncomplicated THA. Methods: We conducted a review of primary THA cases and 2-stage revision THA for PJI at our institution. Patients were matched for age and body mass index. All costs associated with each procedure were recorded. Descriptive statistics were used to summarize the collected data. Mean costs, length of stay, clinic visits and readmission rates associated with the 2 cohorts were compared. Results: Fifty consecutive cases of revision THA were matched with 50 cases of uncomplicated primary THA between 2006 and 2014. Compared with the primary THA cohort, PJI was associated with a significant increase in mean length of hospital stay (26.5 v. 2.0 d, p < 0.001), mean number of clinic visits (9.2 v. 3.8, p < 0.001), number of readmissions (12 v. 1, p < 0.001) and average overall cost (Can$38 107 v. Can$6764, t = 8.3, p < 0.001). Conclusion: Treatment of PJI is a tremendous economic burden. Our data suggest a 5-fold increase in hospital expenditure in the management of PJI compared with primary uncomplicated THA.

Contexte: L'infection articulaire périprothétique (IAP) arrive au troisième rang des principales causes d'échec de l'arthroplastie (ou prothèse) totale de la hanche (PTH). Même si elle est controversée, la révision en 2 étapes demeure le traitement standard pour l'IAP dans la plupart des cas. À ce jour, peu d'études ont décrit l'impact économique de l'IAP dans l'environnement actuel des soins de santé. Le but de la présente étude était d'obtenir une estimation précise des coûts institutionnels associés à la prise en charge de l'IAP dans la PTH et d'évaluer le fardeau économique de l'IAP comparativement à une PTH primaire non compliquée. Méthodes: Nous avons passé en revue les cas de PTH primaire et de révision de PTH en 2 étapes pour cause d'IAP dans notre établissement. Les patients ont été assortis selon l'âge et l'indice de masse corporelle. Tous les coûts associés à chaque intervention ont été consignés. Des statistiques descriptives ont servi à résumer les données recueillies. Nous avons comparé les coûts moyens, la durée des séjours, les visites à la clinique et les taux de réadmission associés aux 2 cohortes. Résultats: Cinquante cas consécutifs de révision de PTH ont été assortis à 50 cas de PTH primaire non compliquée entre 2006 et 2014. Comparativement à la cohorte de PTH primaire, les cas d'IAP ont été associés à une augmentation significative de la durée moyenne du séjour hospitalier (26,5 j c. 2,0 j, p < 0,001), du nombre moyen de visites à la clinique (9,2 c. 3,8, p < 0,001), du nombre des réadmissions (12 c. 1, p < 0,001) et du coût global moyen (38 107 $ CA c. 6764 $ CA, t = 8,3, p < 0,001). Conclusion: Le traitement de l'IAP représente un énorme fardeau économique. Selon nos données, les dépenses hospitalières associées à sa prise en charge sont 5 fois plus grandes que pour la PTH primaire non compliquée.

Peripheral fixation of meniscal allograft does not reduce coronal extrusion under physiological load.

PURPOSE: Meniscal graft extrusion is a concern following meniscal allograft transplantation (MAT). MAT surgical techniques continue to evolve in an effort to reduce extrusion; however, improvements remain difficult to measure in vivo. A novel MRI-compatible in vitro loading device capable of applying physiologically relevant loads has been developed, allowing for the measurement of extrusion under a variety of controllable conditions. The objective of this study was to compare maximal medial MAT extrusion (1) with and (2) without an additional peripheral third point of fixation on the tibial plateau. METHODS: Twelve human cadaveric knees underwent medial MAT, utilizing soft tissue anterior and posterior root fixation via transosseous suture, with a third transosseous suture tied over a button providing peripheral fixation on the tibial plateau. The joint was positioned at 5 degrees of flexion and loaded to 1 × body weight (647.7 ± 159.0 N) during MR image acquisition, with and without peripheral fixation. The joint was then positioned at 30 degrees of flexion and the process was repeated. Maximal coronal extrusion was measured. RESULTS: An increase in maximal coronal meniscal extrusion was noted between the unloaded and loaded states. At 30 degrees of flexion, with the addition of a peripheral fixation point, a statistically significant difference in absolute extrusion (p = 0.02) and relative percent extrusion (p = 0.04) between the unloaded and loaded state was found. The addition of a peripheral fixation suture resulted in an overall mean percent difference of - 2.49% (SD 14.1; 95% CI - 11.95, 6.97; n.s.) in extrusion at 5 degrees of flexion and a mean percent difference of - 0.95% (SD 7.3; 95% CI - 5.62, 3.71; n.s.) in extrusion at 30 degrees of flexion. These differences were not statistically significant. CONCLUSION: These results suggest that the addition of a peripheral anchor in medial MAT does not reduce the amount of maximal coronal extrusion and, therefore, may not confer any clinical benefit. Surgical techniques utilized to reduce MAT extrusion need further investigation to understand if the added technical difficulty and potential expense is warranted.