Surgical Setting in Achilles Tendon Repair: How Does It Relate to Costs and Complications?

Background: Primary Achilles tendon repair (ATR) can be performed in ambulatory surgery centers (ASCs) or hospitals. We compared costs and complication rates of ATR performed in these settings. Methods: We retrospectively queried the electronic medical record of our academic health system and identified 97 adults who underwent primary ATR from 2015 to 2021. Variables were compared between patients treated at ASCs vs those treated in hospitals. We compared continuous variables with Wilcoxon rank-sum tests and categorical variables with χ2 tests. We used an α of 0.05. Multivariable logistic regression was performed to determine associations between surgical setting and costs. Linear regression was performed between each charge subtype and total cost to identify which charge subtypes were most associated with total cost. Results: Patients who underwent ATR in hospitals had a higher rate of unanticipated postoperative hospital admission (13%) than those treated in ASCs (0%) (P = .01). We found no differences with regard to postoperative complications, emergency department visits, readmission, rerupture, reoperation/revision, or death. Patients treated in hospitals had a higher mean (±SD) implant cost ($664 ± $810) than those treated in ASCs ($175 ± $585) (P < .01). We found no differences between settings with regard to total cost, supply costs, operating room charges, or anesthesia charges. Higher implant cost was associated with hospital setting (odds ratio = 16 [95% CI: 1.7-157]) and body mass index > 25 (odds ratio = 1.2 [95% CI: 1.0-1.5]). Operating room costs were strongly correlated with total costs (R2 = .94). Conclusion: The overall cost and complication rate of ATRs were not significantly different between ASCs and hospitals. ATRs performed in hospitals had higher implant costs and higher rates of postoperative admission than those performed in ASCs. Level of Evidence: Level III, retrospective comparative study.

Reimbursement for Orthopaedic Surgeries in Commercial and Public Payors: A Race to the Bottom.

INTRODUCTION: The purpose of this study was to compare surgeon professional fee reimbursement and trends from Medicare versus commercial payors for inpatient orthopaedic surgeries: total knee arthroplasty (TKA), total hip arthroplasty (THA), total shoulder arthroplasty (TSA), anterior cervical diskectomy and fusion (ACDF), and posterior lumbar fusion (PLF). METHODS: Patients undergoing TKA, THA, TSA, single-level ACDF, and single-level PLF from 2010 to 2018 were queried in a commercially insured claims database. Medicare reimbursements and the work relative value unit (wRVU) of each procedure were obtained from the Medicare Physician Fee Schedule. All costs were adjusted for inflation and reported in 2018 real dollars. Compound annual growth rates were calculated to assess the mean growth rate for each procedure. Linear regression was done to assess trends. RESULTS: On average, payments from Medicare were 57% less than payments from commercial payors. From 2010 to 2018, both Medicare and commercial payments decreased significantly for each surgery (P < 0.05 for all). Compared with inflation-adjusted commercial payments, Medicare payments decreased 2.1 times faster for TKA (-2.1% versus -1.0%), 2.8 times faster for THA (-1.4% versus -0.5%), 1.3 times faster for TSA (-1.0% versus -0.8%), and 1.9 times faster for ACDF (-1.1% versus -0.6%). PLF was the only procedure for which Medicare payments declined slower than commercial payments (-0.6% versus -1.21%). Medicare payments per wRVU markedly declined for TKA (-0.83%), THA (-0.80%), TSA (-0.75%), and ACDF (-1.10%), whereas commercial payments per wRVU for those surgeries showed no notable change. For PLF, there was a notable decrease in both Medicare (-0.63%) and commercial (-1.21%) payments per wRVU. CONCLUSION: Over the past decade, both commercial and Medicare surgeon payments for commonly performed inpatient orthopaedic surgeries decreased markedly, with Medicare payments decreasing an average of 1.5 times faster than commercial payments. The impact of declining reimbursements on access and quality of care merits additional investigation.

Posterolateral Diskectomies for Treatment of Pediatric Spinal Deformities.

STUDY DESIGN: Retrospective. OBJECTIVE: To investigate the indications, radiographic outcomes, and complications in children with spinal deformities treated with posterolateral diskectomy with posterior fusion (PLDF), and to compare them against those of patients treated with anteroposterior spinal fusion (APSF). SUMMARY OF BACKGROUND DATA: A novel technique for treating large, rigid spinal deformities in children has been proposed, consisting of PLDF at the apex of the deformity using an all-posterior approach. METHODS: We evaluated records of all patients 21 years or younger who underwent treatment for spinal deformity between 2010 and 2015 by one surgeon using PLDF (n = 56) or APSF (n = 21). RESULTS: The indications for PLDF were large, rigid curves (37 patients); focal curves with severe rotation (10 patients); or large curves with open triradiate cartilage (nine patients). PLDF patients had a mean (± standard deviation) of 3 ±â€Š1 diskectomies and 14 ±â€Š3 posterior spinal levels fused. Compared with the APSF group, the PLDF group had significantly greater major curve correction (86% vs. 57%, P = 0.006), less blood transfused (mean, 2.5 ±â€Š2.6 vs. 4.0 ±â€Š3.3 units, P = 0.038), and a lower rate of staged surgery (1.8% vs. 86%, P < 0.001). There were no significant differences between the PLDF and APSF groups in T1-S1 length gained (mean, 6.2 ±â€Š3.4 vs. 6.6 ±â€Š8.8 cm, respectively; P = 0.77) or in the rate of major complications (P = 0.557). CONCLUSION: PLDF is an effective alternative to APSF for treating children with severe spinal deformities. It is effective for treating large, rigid curves with severe rotation and may be useful for treating large curves in children with open triradiate cartilage. LEVEL OF EVIDENCE: 4.

Does obesity affect fracture healing in children?

BACKGROUND: Obesity is a risk factor for various orthopaedic diseases, including fractures. Obesity's influence on circulating hormones and cytokines and bone mineralization ultimately influences the body's osteogenic response and bone mineralization, potentially increasing the risk of fracture and impacting fracture healing. QUESTIONS/PURPOSES: Does obesity delay fracture recovery in overweight or obese children as measured by the time to release to normal activity? Is this average time for return to activity influenced by the mechanism of the injury? Does obesity's effect on mineralization and loading in overweight or obese children lead to a greater proportion of upper extremity fracture versus lower extremity fracture? METHODS: We prospectively followed 273 patients with nonpathologic long bone fractures treated from January 2010 to October 2011. Patients were stratified into obese/overweight, normal weight, and underweight groups. All patients were followed until release to regular activities (mean, 41 days; range, 13-100 days). RESULTS: Release to regular activities occurred sooner in obese/overweight than in normal weight patients: 39 and 42 days, respectively. A greater proportion of obese/overweight patients had low to moderate energy mechanisms of injury than did normal weight patients, but we found no difference between the groups in terms of return to activity when stratified by mechanism. There was also no difference in the proportion of upper extremity injuries between the two groups. CONCLUSIONS: Obese/overweight children did not have a delay in release to activities compared with children of normal weight. LEVEL OF EVIDENCE: Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.