A Telemedicine Solution to Minimize Unnecessary Emergency Department Transfers for Low-acuity Pediatric Orthopaedic Patients: A Model for Cost Minimization.

INTRODUCTION: Unnecessary emergency department (ED) transfers represent a notable source of excess costs and misutilization of healthcare resources, particularly with management of acute pediatric musculoskeletal injuries. This study used institutional data to create a model investigating the expected costs of a formal peer-to-peer telemedicine intervention designed to triage pediatric orthopaedic transfers, which we hypothesized would decrease healthcare costs by minimizing unwarranted ED-to-ED transfers. METHODS: In this retrospective modeling analysis, 350 pediatric orthopaedic trauma patients transferred to two in-network referral hospitals from outside facilities were identified and stratified into three groups representing how patients theoretically optimally could have been treated. Group 1 patients required ambulance transfer, group 2 patients required ED-level care but no ambulance transfer, and group 3 patients did not require ED-level care. Base case estimates for the proportions of patients in each group, probability of ambulance transport, and direct costs of care for each patient were derived from the database. A decision tree was developed to evaluate the expected costs of two triaging strategies: (1) transfer everyone or (2) triage first using e-consultation. Probabilistic sensitivity analyses were used to determine how the results of the decision analysis varied across ranges of cost and probability estimates. RESULTS: In the base case analysis, the telemedicine triage strategy was cheaper than the transfer-all strategy ($4,858 versus $6,610). In a 2-way sensitivity analysis comparing cost of a telemedicine visit and proportion of telemedicine triaged patients requiring ambulance transport, the telemedicine triage strategy remained cheaper than the transfer-all strategy across almost all possibilities for both variables. Additional potential benefits of triage before transfer, such as decreased length of time to completion of ED visit, cost to the family, and patient comfort and satisfaction, were not incorporated into this analysis. The potential for misdiagnosis related to telehealth and its potential costs were not included. DISCUSSION: We revealed substantial cost savings for the healthcare system from implementing a telehealth platform for peer-to-peer consultation when considering patient transfer for musculoskeletal trauma. Initial peer-to-peer e-consultations cost less than reflexive ambulance transfer in most situations. LEVEL OF EVIDENCE: Economic Level II.

Biomechanical evaluation of sacroiliac joint fixation with decortication.

BACKGROUND CONTEXT: Fusion typically consists of joint preparation, grafting, and rigid fixation. Fusion has been successfully used to treat symptomatic disruptions of the sacroiliac joint (SIJ) and degenerative sacroiliitis using purpose-specific, threaded implants. The biomechanical performance of these systems is important but has not been studied. PURPOSE: The objective of this study was to compare two techniques for placing primary (12.5 mm) and secondary (8.5 mm) implants across the SIJ. STUDY DESIGN: This is a human cadaveric biomechanical study of SIJ fixation. MATERIALS AND METHODS: Pure-moment testing was performed on 14 human SIJs in flexion-extension (FE), lateral bending (LB), and axial rotation (AR) with motion measured across the SIJ. Specimens were tested intact, after destabilization (cutting the pubic symphysis), after decortication and implantation of a primary 12.5-mm implant at S1 plus an 8.5-mm secondary implant at either S1 (S1-S1, n=8) or S2 (S1-S2, n=8), after cyclic loading, and after removal of the secondary implant. Ranges of motion (ROMs) were calculated for each test. Bone density was assessed on computed tomography and correlated with age and ROM. This study was funded by Zyga Technology but was run at an independent biomechanics laboratory. RESULTS: The mean±standard deviation intact ROM was 3.0±1.6° in FE, 1.5±1.0° in LB, and 2.0±1.0° in AR. Destabilization significantly increased the ROM by a mean 60%-150%. Implantation, in turn, significantly decreased ROM by 65%-71%, below the intact ROM. Cyclic loading did not impact ROM. Removing the secondary implant increased ROM by 46%-88% (non-significant). There was no difference between S1-S1 and S1-S2 constructs. Bone density was inversely correlated with age (R=0.69) and ROM (R=0.36-0.58). CONCLUSIONS: Fixation with two threaded rods significantly reduces SIJ motion even in the presence of joint preparation and after initial loading. The location of the secondary 8.5-mm implant does not affect construct performance. Low bone density significantly affects fixation and should be considered when planning fusion constructs. Findings should be interpreted in the context of ongoing clinical studies.

Biomechanical diversity despite mechanobiological stability in tissue engineered vascular grafts two years post-implantation.

Recent advances in vascular tissue engineering have enabled a paradigm shift from ensuring short-term graft survival to focusing on long-term stability and growth potential. We present the first experimental-computational study of a tissue-engineered vascular graft (TEVG) effectively over the full lifespan of the recipient. We show that grafts implanted within the venous circulation of mice remained patent over 2 years without thrombus, stenosis, or aneurysmal dilatation. Moreover, the gross appearance and mechanical properties of the grafts evolved to be similar to the host vein within 24 weeks, with mean neovessel geometry and properties remaining unchanged thereafter despite a continued turnover of extracellular matrix. Biomechanical diversity manifested after 24 weeks, however, via two subsets of grafts despite all procedures being the same. Computational modeling and associated immunohistological analyses suggested that this diversity likely resulted from a differential ratio of collagen types I and III, with lower I to III ratios promoting grafts having a compliance similar to the native vein. We submit that TEVGs can exhibit the desired long-term mechanobiological stability; hence, we must now focus on evaluating growth potential and optimizing scaffold properties to achieve compliance matching throughout neovessel development.