Benefits of Rib Fixation Utilizing Low-Cost Materials: A Randomized Pilot Trial.

INTRODUCTION: Surgical stabilization of rib fractures (SSRF) using standard rib plating systems has become a norm in developed countries. However, the procedure has not garnered much interest in low-middle-income countries, primarily because of the cost. METHODS: This was a single-center pilot randomized trial. Patients with severe rib fractures were randomized into two groups: SSRF and nonoperative management. SSRF arm patients underwent surgical fixation in addition to the tenets of nonoperative management. Low-cost materials like stainless steel wires and braided polyester sutures were used for fracture fixation. The primary outcome was to assess the duration of hospital stay. RESULTS: Twenty-two patients were randomized, 11 in each arm. Per-protocol analysis showed that the SSRF arm had significantly reduced duration of hospital stay (22.6 ± 19.1 d versus 7.9 ± 5.7 d, P value 0.031), serial pain scores at 48 h and 5 d (median score 5, IQR (3-6) versus median score 7, IQR (6.5-8), P value 0.004 at 48 h and median score 2 IQR (2-3) versus median score 7 IQR (4.5-7) P value 0.0005 at 5 d), significantly reduced need for injectable opioids (9.9 ± 3.8 mg versus 4.4 ± 3.4 mg, P value 0.003) and significantly more ventilator-free days (19.9 ± 8.7 d versus 26.4 ± 3.2 d, P value 0.04). There were no statistically significant differences in the total duration of ICU stay (median number of days 2, IQR 1-4.5 versus median number of days 7, IQR 1-14, P value 0.958), need for tracheostomy (36.4% versus 0%, P value 0.155), and pulmonary and pleural complications. CONCLUSIONS: SSRF with low-cost materials may provide benefits similar to standard rib plating systems and can be used safely in resource-poor settings.

The ideal implant for Mayo 2A olecranon fractures? An economic evaluation.

BACKGROUND: The ideal implant for stable, noncomminuted olecranon fractures is controversial. Tension band wiring (TBW) is associated with lower cost but higher implant removal rates.On the other hand, plate fixation (PF) is purported to be biomechanically superior, with lower failure and implant removal rates, although associated with higher cost. The primary aim of this study is to look at the clinical outcomes for all Mayo 2A olecranon between PF and TBW. The secondary aim is to perform an economic evaluation of PF vs. TBW. MATERIALS AND METHODS: This is a retrospective study of all surgically treated Mayo 2A olecranon fractures in a tertiary hospital from 2005-2016. Demographic data, medical history, range of motion, and complications were collected. All inpatient and outpatient costs in a 1-year period postsurgery including the index surgical procedure were collected via the hospital administrative cost database (normalized to 2014). RESULTS: A total of 147 cases were identified (94 TBW, 53 PF). PF was associated with higher mean age (P < .01), higher American Society of Anesthesiologists score (P < .01), and higher proportion of hypertensives (P = .04). There was no difference in the range of motion achieved at 1 year for both groups. In terms of complications, TBW was associated with more symptomatic hardware (21.6% vs. 13.7%, P = .24) and implant failures (16.5% vs. none, P < .01), whereas the plate group had a higher wound complication (5.9% vs. none, P = .02) and infection rate (9.8% vs. 3.1%, P = .09). TBW had a higher implant removal rate of 30.9% compared with 22.7% for PF (P = .36). PF had a higher cost at all time points, from the index surgery ($10,313.64 vs. $5896.36, P < .01), 1-year cost excluding index surgery ($5069.61 vs. $3850.46, P = .46), and outpatient cost ($1667.80 vs. $1613.49, P = .27). DISCUSSION AND CONCLUSION: Based on our study results, we have demonstrated that TBW is the ideal implant for Mayo 2A olecranon fractures from both a clinical and economic standpoint, with comparable clinical results, potentially similar implant removal rates as PF's, and a lower cost over a 1-year period. In choosing the ideal implant, the surgeon must take into account, first, the local TBW and PF removal rate, which can vary significantly because of the patient's profile and beliefs, and second, the PF implant cost.

Reduced incidence and economic cost of hardware removal after ankle fracture surgery: a 20-year nationwide registry study.

Background and purpose - Open reduction and internal fixation (ORIF) is a treatment method for unstable ankle fractures. During recent years, scientific evidence has shed light on surgical indications as well as on hardware removal. We assessed the incidence and trends of hardware removal procedures following ORIF of ankle fractures.Patients and methods - The study covered all patients 18 years of age and older who had an ankle fracture treated with ORIF in Finland between the years 1997 and 2016. Patient data were obtained from the Finnish National Hospital Discharge Register.Results - 68,865 patients had an ankle fracture treated with ORIF in Finland during the 20-year study period between 1997 and 2016. A hardware removal procedure was performed on 27% of patients (n = 18,648). The incidence of hardware removal procedures after ankle fracture decreased from 31 (95% CI 29-32) per 100,000 person-years in the highest year 2001 (n = 1,247) to 13 (CI 12-14) per 100,000 person-years in 2016 (n = 593). Moreover, the proportion and number of removal operations performed within the first 3 months also decreased. The costs of removal procedures decreased from approximately €994,000 in 2001 to €472,600 in 2016.Interpretation - Removal of hardware after ankle surgery (ORIF) is a common operation with substantial costs. However, the incidence and cost of removals decreased during the study period, with a particular decrease in hardware removal operations within 3 months.

Tension band wiring versus locking plate fixation for simple, two-part Mayo 2A olecranon fractures: a comparison of post-operative outcomes, complications, reoperations and economics.

PURPOSE: Simple displaced transverse olecranon fractures are traditionally managed operatively with a tension band wire device (TBW). We compared clinical outcomes, morbidity and the cost of treatment of TBW versus pre-countered low-profile locking plates for the treatment of Mayo 2A fractures. PATIENT AND METHODS: All olecranon fractures admitted to our unit between 2008 and 2014 were identified (n = 129). Patient notes and radiographs were studied from presentation to final follow-up. Patient outcomes were recorded using the QuickDASH (Disabilities of Arm, Shoulder and Hand) score. Patient demographics and nature of complications were recorded as were the rate and nature of any repeat operation. RESULTS: Eighty-nine patients had Mayo 2A fractures (69%). Sixty-four underwent TBW (n = 48) or locking plate fixation (n = 16). The mean ages of both groups were similar at 57 (15-93) and 60 (22-80), respectively. In the TBW group, the mean post-injury QuickDASH was 12.9, compared with 15.0 for the locking plate group. There was no statistically significant difference between the outcomes for either group. Nineteen of the 48 TBW patients had complications (39.6%). Sixteen of the 48 TBW patients had reoperations (33.3%). In particular, we would highlight that 13 (27.1%) of patients treated with TBW underwent subsequent removal of metalwork for hardware irritation. There were no complications and or reoperations in the 16 patients who received locking plate fixation. Both complication and reoperation rates were statistically significantly different. Despite being initially more expensive, when the cost of reoperation for TBW group was included, locking plates were found to be on average £236.33 less per patient than for TBW. CONCLUSIONS: We suggest that locking plates are superior to TBW concerning post-operative morbidity, reoperation rate and cost for Mayo 2A fractures in contrast to previous articles. LEVEL OF EVIDENCE: Therapeutic study, III.

Percutaneous Kirschner Wire Versus Commercial Implant for Hammertoe Repair: A Cost-Effectiveness Analysis.

Hammertoe deformities are one of the most common foot deformities, affecting up to one third of the general population. Fusion of the joint can be achieved with various devices, with the current focus on percutaneous Kirschner (K)-wire fixation or commercial intramedullary implant devices. The purpose of the present study was to determine whether surgical intervention with percutaneous K-wire fixation versus commercial intramedullary implant is more cost effective for proximal interphalangeal joint arthrodesis in hammertoe surgery. A formal cost-effectiveness analysis using a decision analytic tree model was conducted to investigate the healthcare costs and outcomes associated with either K-wire or commercial intramedullary implant fixation. The outcomes assessed included long-term costs, quality-adjusted life-years (QALYs), and incremental cost per QALY gained. Costs were evaluated from the healthcare system perspective and are expressed in U.S. dollars at a 2017 price base. Our results found that commercial implants were minimally more effective than K-wires but carried significantly higher costs. The total cost for treatment with percutaneous K-wire fixation was $5041 with an effectiveness of 0.82 QALY compared with a commercial implant cost of $6059 with an effectiveness of 0.83 QALY. The incremental cost-effectiveness ratio of commercial implants was $146,667. With an incremental cost-effectiveness ratio of >$50,000, commercial implants failed to justify their proposed benefits to outweigh their cost compared to percutaneous K-wire fixation. In conclusion, percutaneous K-wire fixation would be preferred for arthrodesis of the proximal interphalangeal joint for hammertoes from a healthcare system perspective.

Societal costs in displaced transverse olecranon fractures: using decision analysis tools to find the most cost-effective strategy between tension band wiring and locked plating.

BACKGROUND: Tension band wiring (TBW) and locked plating are common treatment options for Mayo IIA olecranon fractures. Clinical trials have shown excellent functional outcomes with both techniques. Although TBW implants are significantly less expensive than a locked olecranon plate, TBW often requires an additional operation for implant removal. To choose the most cost-effective treatment strategy, surgeons must understand how implant costs and return to the operating room influence the most cost-effective strategy. This cost-effective analysis study explored the optimal treatment strategies by using decision analysis tools. METHODS: An expected-value decision tree was constructed to estimate costs based on the 2 implant choices. Values for critical variables, such as implant removal rate, were obtained from the literature. A Monte Carlo simulation consisting of 100,000 trials was used to incorporate variability in medical costs and implant removal rates. Sensitivity analysis and strategy tables were used to show how different variables influence the most cost-effective strategy. RESULTS: TBW was the most cost-effective strategy, with a cost savings of approximately $1300. TBW was also the dominant strategy by being the most cost-effective solution in 63% of the Monte Carlo trials. Sensitivity analysis identified implant costs for plate fixation and surgical costs for implant removal as the most sensitive parameters influencing the cost-effective strategy. Strategy tables showed the most cost-effective solution as 2 parameters vary simultaneously. CONCLUSION: TBW is the most cost-effective strategy in treating Mayo IIA olecranon fractures despite a higher rate of return to the operating room.

Randomized, multicenter trial comparing sternotomy closure with rigid plate fixation to wire cerclage.

OBJECTIVE: To evaluate sternal healing, complications, and costs after sternotomy closure with rigid plate fixation or wire cerclage. METHODS: This prospective, single-blinded, multicenter trial randomized 236 patients at 12 US centers at the time of sternal closure to either rigid plate fixation (n = 116) or wire cerclage (n = 120). The primary endpoint, sternal healing at 6 months, was evaluated by a core laboratory using computed tomography and a 6-point scale (greater scores represent greater healing). Secondary endpoints included sternal complications and costs from the time of sternal closure through 6 months. RESULTS: Rigid plate fixation resulted in better sternal healing scores at 3 (2.6 ± 1.1 vs 1.8 ± 1.0; P < .0001) and 6 months (3.8 ± 1.0 vs 3.3 ± 1.1; P = .0007) and greater sternal union rates at 3 (41% [42/103] vs 16% [16/102]; P < .0001) and 6 months (80% [81/101] vs 67% [67/100]; P = .03) compared with wire cerclage. There were fewer sternal complications through 6 months with rigid plate fixation (0% [0/116] vs 5% [6/120]; P = .03) and a trend towards fewer sternal wound infections (0% [0/116] vs 4.2% [5/120]; P = .06) compared with wire cerclage. Although rigid plate fixation was associated with a trend toward greater index hospitalization costs ($23,437 vs $20,574; P = .11), 6-month follow-up costs tended to be lower ($9002 vs $13,511; P = .14). As a result, total costs from randomization through 6 months were similar between groups ($32,439 vs $34,085; P = .61). CONCLUSIONS: Sternotomy closure with rigid plate fixation resulted in significantly better sternal healing, fewer sternal complications, and no additional cost compared with wire cerclage at 6 months after surgery.

Maxillomandibular Fixation by Plastic Surgeons: Cost Analysis and Utilization of Resources.

PURPOSE: Maxillomandibular fixation (MMF) can be performed using various techniques. Two common approaches used are arch bars and bone screws. Arch bars are the gold standard and inexpensive, but often require increased procedure time. Bone screws with wire fixation is a popular alternative, but more expensive than arch bars. The differences in costs of care, complications, and operative times between these 2 techniques are analyzed. METHODS: A chart review was conducted on patients treated over the last 12 years at our institution. Forty-four patients with CPT code 21453 (closed reduction of mandible fracture with interdental fixation) with an isolated mandible fracture were used in our data collection. The operating room (OR) costs, procedure duration, and complications for these patients were analyzed. RESULTS: Operative times were significantly shorter for patients treated with bone screws (P < 0.002). The costs for one trip to the OR for either method of fixation did not show any significant differences (P < 0.840). More patients with arch bar fixation (62%) required a second trip to the OR for removal in comparison to those with screw fixation (31%) (P < 0.068). This additional trip to the OR added significant cost. There were no differences in patient complications between these 2 fixation techniques. CONCLUSIONS: The MMF with bone screws represents an attractive alternative to fixation with arch bars in appropriate scenarios. Screw fixation offers reduced costs, fewer trips to the OR, and decreased operative duration without a difference in complications. Cost savings were noted most significantly in a decreased need for secondary procedures in patients who were treated with MMF screws. Screw fixation offers potential for reducing the costs of care in treating patients with minimally displaced or favorable mandible fractures.

Comparison of Outcomes and Costs of Tension-Band and Locking-Plate Osteosynthesis in Transverse Olecranon Fractures: A Matched-Cohort Study.

To determine if there are significant differences in outcomes and costs between tension-band and locking-plate fixation of transverse olecranon fractures in adults, we retrospectively compared functional outcomes, complications, and costs in 2 cohorts of displaced transverse olecranon fractures. These cohorts (10 patients each) were matched on age and length of follow-up. There were no significant differences between the groups in range of motion, functional scores, or arthrosis. There were no infections or nonunions in either group. There was no significant difference in rate of implant removal or symptomatic implants, though a trend was found toward a higher rate of both with tension bands. Operative time was significantly (P = .025) less for tension-band than locking-plate fixation (55 vs 85 minutes). In the tension-band group, charges were significantly less for implant, index procedure, and overall operative charges including reoperations ($6598.36 vs $14,333.46; P = .001). If all tension bands and no locking plates had been removed, tension-band fixation still would have cost significantly less ($7307.31 vs $14,160.26; P = .0005).

Are embrasure wires better than arch bars for intermaxillary fixation?

PURPOSE: To compare the outcomes of mandible fractures treated with open reduction and internal fixation versus adjunctive intermaxillary fixation (IMF) using 2 different techniques. MATERIALS AND METHODS: We performed a retrospective medical record review. The medical records of consecutive patients with mandible fractures treated surgically with adjunctive use of IMF (embrasure wires vs arch bars) were reviewed for demographic data, etiology, fracture location, antibiotic use, and interval to repair. Specifically, the complications, including infection, malunion or nonunion, hardware failure, and wound dehiscence, were recorded. The data were analyzed using Student's t test and the chi-square test or Fisher's exact test, as appropriate. Statistical significance was set at P < .05. A descriptive cost analysis was also performed and compared with those from previously published studies. RESULTS: The data from 86 subjects were included in the present study. Of the 86 subjects, 33 were in the embrasure wire group and 53 in the arch bar group. Of the patients in the arch bar group, 26% had complications compared with 15% in the embrasure wire IMF group. No statistically significant difference between the groups in terms of infection (P = .63), hardware failure (P = .75), malocclusion (P = .85), and nonunion (P = 1.0). However, the cost of arch bar placement and removal was approximately $2,672 more than the placement of embrasure wires. CONCLUSIONS: Patients treated with embrasure wire IMF had slightly better clinical outcomes compared with those treated with arch bar IMF. Also, the cost reduction for patients treated with embrasure wire IMF was significant.

Cost comparison of genioplasty: when indicated, wire osteosynthesis is more cost effective than plate and screw fixation.

PURPOSE: This retrospective study was conducted to determine the difference in the cost of genioplasty according to the osseous fixation technique used. PATIENTS AND METHODS: A retrospective study among orthognathic surgery patients treated over a 54-month period ending in June 30, 2011 was conducted. Immediately post surgery, panoramic and cephalometric radiographs of these patients were assessed to determine the presence of genioplasty procedure and the type of fixation used. The cost of the actual fixation used by the surgeons was compared with that which the cost would have been had the surgeons used the criteria described in the hypotheses, for plate and screws fixation when genioplasty is performed. RESULTS: A review of 1,498 orthognathic surgery patients revealed that 473 of these patients underwent genioplasty. Out of 473 patients, 425 had genioplasty to either advance and-or superiorly reposition the chin. Of these, 230 had wire osteosynthesis and 243 had some form of rigid fixation. The unit cost of fixation for genioplasty when wire osteosynthesis is used is less than C$5.00. The mean unit cost estimate in our patient group when pre-bent plates are used was C$542.00. All 230 patients in whom wire osteosynthesis was used demonstrated stable fixation of the bony parts and no immediate postsurgical adjustment was required in any patient. CONCLUSIONS: For patients requiring genioplasty to advance and-or superiorly reposition the chin, it is possible to use wire osteosynthesis to achieve accurate and stable fixation while reducing the fixation cost by more than C$500.00 per case. The surgeon should include cost considerations in the selection of treatment methods.

Analysis of strategies to increase external fixator stiffness: is double stacking worth the cost?

We compared the mechanical benefits and costs of 3 strategies that are commonly used to increase knee-spanning external fixator stiffness (resistance to deformation): double stacking, cross-linking, and use of an oblique pin. At our academic trauma centre and biomechanical testing laboratory, we used ultra-high-molecular-weight polyethylene bone models and commercially available external fixator components to simulate knee-spanning external fixation. The models were tested in anterior-posterior bending, medial-lateral bending, axial compression, and torsion. We recorded the construct stiffness for each strategy in all loading modes and assessed a secondary outcome of cost per 10% increase in stiffness. Double stacking significantly increased construct stiffness under anterior-posterior bending (109%), medial-lateral bending (22%), axial compression (150%), and torsion (41%) (p<0.05). Use of an oblique pin significantly increased stiffness under torsion (25%) (p<0.006). Cross-linking significantly increased stiffness only under torsion (29%) (p<0.002). Double stacking increased costs by 84%, cross-linking by 28%, and use of an oblique pin by 15% relative to a standard fixator. All 3 strategies increased stiffness under torsion to varying degrees, but only double stacking increased stiffness in all 4 testing modalities (p<0.05). Double stacking is most effective in increasing resistance to bending, particularly under anterior-posterior bending and axial compression, but requires a relatively high cost increase. Clinicians can use these data to help guide the most cost-effective strategy to increase construct stiffness based on the plane in which stiffness is needed.

Functional outcomes and cost estimation for extra-articular and simple intra-articular distal radius fractures treated with open reduction and internal fixation versus closed reduction and percutaneous Kirschner wire fixation.

BACKGROUND: We sought to compare direct costs and clinical and radiographic outcomes for distal radius fractures (DRF) treated with open reduction internal fixation with volar locking plates (VLP) versus closed reduction and percutaneous pinning (CRPP). METHODS: We identified patients with AO-type A and C1 DRFs from a prospective database. Outcomes were assessed at 6 weeks and at 3, 6 and 12 months, and surgical care costs were estimated. RESULTS: Twenty patients were treated with CRPP and 24 with VLP. There were no significant differences in patient-rated wrist evaluation (PRWE) scores between the 2 groups at any time point (mean 16.2 ± 23.1 in the CRPP group v. 21.5 ± 23.6 in the VLP group, p = 0.91). Overall alignment was maintained in both groups; however, there was a greater loss of radial height over time with CRPP than VLP (0.97 mm v. 0.25 mm, p = 0.018). The mean duration of surgery was longer for VLP than CRPP (113.9 ± 39.5 min v. 86.5 ± 7.8 min, p = 0.029), but there were fewer clinic visits (5.2 ± 1.4 v. 7.8 ± 1.3, p < 0.001) and fewer radiographs (7.4 ± 2.7 v. 9 ± 2.4, p = 0.031). The total cost per case was greater for VLP than CRPP ($1637.27 v. $733.91). CONCLUSION: Based on PRWE scores, VLPs did not offer any significant advantage over CRPP in patients with simple fracture types between 3 and 12 months, but they were much more costly. Whether VLP offers any functional advantage earlier in recovery, thereby justifying their expense, requires further investigation in the form of a prospective randomized trial with a detailed cost analysis.

CONTEXTE: Nous avons voulu comparer les coûts directs et l'issue clinique et radiographique du traitement des fractures du radius distal (FRD) au moyen d'une technique de réduction ouverte avec fixation interne par plaques palmaires de stabilisation (PPS) par rapport à la méthode par réduction fermée et enclouage percutané (RFEP). MÉTHODES: Nous avons recensé les patients victimes d'une FRD de type AO et de type C1 à partir d'une base de données prospectives. L'issue de ces fractures a été évaluée après 6 semaines, puis après 3, 6 et 12 mois et nous avons estimé les coûts des soins chirurgicaux. RÉSULTATS: Vingt patients ont été traités par RFEP et 24 par PPS. On n'a noté aucune différence significative entre les 2 groupes quant aux scores d'évaluation des poignets par les patients eux-mêmes, peu importe le moment de l'évaluation (moyenne 16,2 ± 23,1 dans le groupe traité par RFEP c. 21,5 ± 23,6 dans le groupe traités par PPS, p = 0,91). L'alignement global a été maintenu dans les 2 groupes; toutefois, on a observé une diminution plus marquée de la longueur du radius avec le temps dans les cas de RFEP que dans les cas de PPS (0,97 mm c. 0,25 mm, p = 0,018). La durée moyenne de la chirurgie a été plus longue avec la PPS qu'avec la RFEP (113,9 ± 39,5 min c. 86,5 ± 7,8 min, p = 0,029), mais les visites à la clinique et les radiographies ont été moins nombreuses (respectivement, 5,2 ± 1,4 c. 7,8 ± 1,3, p < 0,001 et 7,4 ± 2,7 c. 9 ± 2,4, p = 0,031). Le coût total par cas a été plus élevé avec la PPS qu'avec la RFEP (1637,27 $ c. 733,91 $). CONCLUSION: Compte tenu des scores d'évaluation du poignet par les patients euxmêmes, la PPS n'a pas sembler offrir d'avantages significatifs par rapport à la RFEP après 3 et 12 mois chez les patients présentant des types de fractures simples, mais elle s'est révélée beaucoup plus coûteuse. Il reste encore à vérifier, au moyen d'un essai prospectif randomisé assorti d'une analyse de coûts détaillée, si la PPS offre des avantages fonctionnels plus tôt lors du rétablissement, ce qui en justifierait le coût.

A mini external fixator for hand and finger fractures constructed from readily available materials.

Phalangeal and metacarpal fractures with severe comminution and/or soft tissue compromise can present a challenge for the orthopedic surgeon. Maintaining viability of the soft tissues while providing rigid fixation of bony injuries is the goal when treating these injuries. Commercially available mini external fixators can help to achieve these goals. However, these devices are costly and are not always available when the surgeon needs them. In this technique study, we discuss the implementation of a mini external fixator using readily available implements in the operating room that is efficient, cost effective, and easy to apply.

Volar locking plates versus Kirschner wires for distal radial fractures--a cost analysis study.

BACKGROUND: There is an increasing trend for managing dorsally angulated distal radial fractures with locked volar plate fixation in fractures that may have previously been managed with percutaneous Kirschner wire (K-wire) fixation. There has been no prospective randomised trial comparing locked volar plate fixation with percutaneous K-wire fixation. In the absence of data guiding management with regard to clinical effectiveness, we have examined the cost of each technique. METHODS: Patients' details were collected retrospectively between June 2007 and June 2008. Ten consecutive patients who underwent percutaneous K-wire fixation for a distal radius fracture and the 10 who were treated by locked volar plate fixation were identified and their hospital notes retrieved. All patients had a closed extra-articular distal radial fracture with dorsal angulation. The duration and type of operation, including number of wires or screws used, were recorded. RESULTS: The mean age of the patients was 54 years for the locking plate group and 34 years for the percutaneous K-wire group. The mean time taken to perform percutaneous K-wire fixation with an average of two K-wires was 56 min. The mean time for applying a volar locked plate was 121 min. The cost of a pack of 10 K-wires was 3 pounds. The total cost of a standard volar locking plate and screws used was 787 pounds. DISCUSSION: In the absence of research comparing clinical end points, cost must play a major factor in determining the type of operation offered. A 56-min operation to percutaneously fix a distal radial fracture with K-wires costs 662 pounds. This compares to a cost of 2212 pounds for a 121-min locked volar plate fixation. There is a calculated difference of 1549 pounds and 65 min. CONCLUSION: With use of a locked volar plate for patients under the age of 70 years there is a loss of 652 pounds for the Trust with the present NHS tariffs.

Outcomes of percutaneous K-wire fixation for AC joint separation type III.

OBJECTIVE: To determine the efficacy of the Percutaneous K-wire for Acromio-clavicular joint separation type III. MATERIAL AND METHOD: A retrospective chart review of patients who underwent AC joint separation type III by the interested technique during 1993-2009 at department of orthopaedic, Police General Hospital, was done. Only patients with sufficient data recorded were included in the analysis. These patients were placed in the lateral decubital position under general anesthesia. Percutaneous K-wire fixation started after the dislocated AC-joint had been closely reduced under image-intensifier control. Two K-wires (2.0 mm) were inserted into the prominent part of acromial process or scapular spine into the distal clavicle. Post-operative sling was subsequently used to limit the heavy duty. RESULTS: Twenty-one patients were included in the analysis, with the mean follow-up duration of 19 weeks (4-135). Painless at full range of shoulder motion was obtained in twenty patients There was only one patient had limitation of abduction (150 degrees abduction). The mean Neer's shoulder score was 94.25 points (50-100). Only 3 cases had unsatisfied outcomes results during the study period. CONCLUSION: The percutaneous K-wire fixation for the AC-joint Separation was found to be efficacious and safe at an economical cost.

Flexible nailing of fractures in children using stainless steel Kirschner wires.

Elastic titanium nails are widely used for the established procedure of Elastic Stable Intramedullary Nailing (ESIN), but are costly. Thirty-five diaphyseal fractures in various long bones in children were treated by flexible nailing using stainless steel Kirschner (K) wires. The results were comparable with reports by other authors using titanium nails and stainless steel K wires. Cost-effective K wires and instrumentation are easily available. A stainless steel K wire is 92% cheaper than a Nancy nail and 84% cheaper than a Synthes titanium elastic nail. K wires can be used for flexible nailing of fractures in children with results comparable with those after using titanium nails.

[Possibilities for cost reduction of implants in spinal surgery]. / Möglichkeiten zur kostenoptimierten Implantatauswahl in der Wirbelsäulenchirurgie.

OBJECTIVE: To evaluate the possibilities for cost reduction in spinal surgery by analysing implant costs and the efficiency of each type of implant. MATERIALS AND METHODS: The costs of spinal implant methods, as well as Halo-vest for craniocervical, cervical, thoracic, lumbar spine are summarised according to an analysis of price lists from 2001 and 2002. The different methods were additionally evaluated with regard to the scientifically-based treatment efficiency. All prices above 100 euro were rounded up to the closest 50 euro. For the implants, a literature research was performed. The scientific papers were divided into groups according to their level of evidence (I a -IV), and then further subdivided into comparable and non-comparable categories. RESULTS: Craniocervical: Halo-vest 1,700-2,500 euro, odontoidscrew 100-250 euro, plate 1,300 euro, wire 20-250 euro; plate-wire-, rod-wire- or rod-screw systems 400-1,800 euro, clamps 1,200 euro, Cervical: placeholder 20-500 euro, vertebral body replacement 400-1,300 euro, plate 75-450 euro; rod- or plate-screw systems 900-1,700 euro; Thoracic/lumbar: plate/rod-systems 1,000-2,800 euro, vertebral body replacement 500-1,300 euro, internal fixateur 800-2,500 euro, cages 600-1,500 euro. For none of the implant methods were comparable scientific clinical publications found with a high levels of evidence (I a-I b). CONCLUSIONS: Costs can be reduced through a more thorough investigation and corresponding choice of implant method. The cost-benefit analysis of new spinal implants must be considered more with regard to the evidence-based spinal surgery. In order to sufficiently evaluate the different treatment methods, future multicenter controlled comparable studies and meta-analyses must be undertaken.

Titanium miniplates or stainless steel wire for cranial fixation: a prospective randomized comparison.

OBJECT: The authors designed a study to compare low-profile titanium miniplate fixation to that in which stainless steel wire is used. METHODS: Before undergoing craniotomy, 40 patients gave informed consent and were randomized to receive either wire or miniplate fixation. After dural closure, bone flap fixation was timed. The bone flap was measured for inward or outward offset and mobility to manual pressure on its margin. Three months postoperatively the bone flap margins were graded for appearance or palpation of an offset and for the presence of burr hole depressions. Twenty-four patients were randomized to receive miniplate fixation and 16 to receive stainless steel wire fixation. The time required for wire fixation was approximately 40% longer than that for miniplates (11.8 +/- 5.1 minutes compared with 8.3 +/- 5 minutes, p = 0.02). The offset of bone flaps after wire fixation was significantly greater than that with miniplates (1.6 +/- 1 mm compared with 0.3 +/- 0.6 mm, p < 0.001), as was the mobility of the bone flap on digital pressure (1.2 +/- 0.9 mm compared with 0.2 +/- 0.5 mm, p < 0.001). At the 3-month follow-up review, two of 12 patients had suboptimal results after wire fixation, whereas none of 14 patients had suboptimal results after miniplate fixation. When dichotomized for excellent or less-than-excellent postoperative results, the data were significantly better for patients who underwent miniplate fixation (p < 0.05). CONCLUSIONS: Titanium miniplate cranial fixation provides more accurate and rigid reapproximation of the bone edges, with results that are significantly better on close inspection or palpation. The additional cost of miniplate fixation may thus be justified in many cases.