A Stepwise Replicable Approach to Negotiating Value-driven Supply Chain Contracts for Orthobiologics.

INTRODUCTION: Orthobiologics are increasingly used to augment healing of tissues. Despite growing demand for orthobiologic products, many health systems do not enjoy substantial savings expected with high-volume purchases. The primary goal of this study was to evaluate an institutional program designed to (1) prioritize high-value orthobiologics and (2) incentivize vendor participation in value-driven contractual programs. METHODS: A three-step approach was used to reduce costs through optimization of orthobiologics supply chain. First, surgeons with orthobiologics expertise were engaged in key supply chain purchasing decisions. Second, eight orthobiologics formulary categories were defined. Capitated pricing expectations were established for each product category. Capitated pricing expectations were established for each product using institutional invoice data and market pricing data. In comparison with similar institutions, products offered by multiple vendors were priced at a lower benchmark (10th percentile of market price) than more rare products priced at the 25th percentile of the market price. Pricing expectations were transparent to vendors. Third, a competitive bidding process required vendors to submit pricing proposals for products. Clinicians and supply chain leaders jointly awarded contracts to vendors that met pricing expectations. RESULTS: Compared with our projected estimate of $423,946 savings using capitated product prices, our actual annual savings was $542,216. Seventy-nine percent of savings came from allograft products. Although the number of total vendors decreased from 14 to 11, each of the nine returning vendors received a larger, three-year institutional contract. Average pricing decreased across seven of the eight formulary categories. DISCUSSION: This study demonstrates a three-step replicable approach to increase institutional savings for orthobiologic products, engaging clinician experts, and strengthening relationships with select vendors. Vendor consolidation permits a symbiotic win-win relationship: Health systems achieve increased value by reducing unnecessary complexity of multiple contracts, and vendors obtain larger contracts with increased market share. LEVEL OF EVIDENCE: Level IV study.

Nationwide Ethnic/Racial Differences in Surgical Treatment of Discoid Meniscus in Children: A PHIS Database Study.

BACKGROUND: Discoid meniscus, a congenital meniscus variant, may have greater incidence in Asian populations. No US population-based studies have examined the discoid meniscus ethnic/racial distribution. In pediatric patients undergoing meniscus surgery, it is hypothesized that ethnic/racial variability exists in patients with discoid meniscus and this variability is different than in patients with medial meniscus tears. METHODS: The Pediatric Health Information System was queried from 48 hospitals to examine patients 18 years of age and younger between 2015 and 2019, using International Classification of Diseases, 10th Revision, Clinical Modification codes. A cohort of patients treated surgically for discoid meniscus was compared with a cohort of patients treated surgically for medial meniscal tear. These 2 populations were compared based on age, sex, ethnicity/race, Current Procedural Terminology code, insurance, urban versus rural, and region of country. Univariate testing and multivariable logistic modeling were used to test for associations. RESULTS: A discoid meniscus cohort of 399 children (median age, 13.0 y) was compared with a medial meniscus tear cohort of 3157 children (median age, 16.0 y) (P<0.001). Hispanic/Latino children accounted for 36.8% of the discoid lateral meniscus and 22.7% of the medial meniscus populations (P<0.001). Among pediatric patients that had surgery for discoid lateral meniscus or medial meniscus, Hispanic/Latino children had 2.36 times the odds of surgery for discoid meniscus compared with White patients after adjusting for age and insurance (P<0.001). Asian children also had 2.41 times the odds of surgery for discoid meniscus compared with White patients (P=0.017). CONCLUSIONS: This study shows a significant association of ethnicity/race with discoid versus medial meniscus surgical treatment in children. Among pediatric patients undergoing surgery for discoid meniscus, Hispanic/Latino and Asian patients were a significantly larger percentage of the population than White patients. Hispanic/Latino children made up a greater percentage of the population having surgery for a torn discoid meniscus versus a torn medial mensicus. When evaluating pediatric patients, younger age and Asian or Hispanic/Latino ethnicity should increase attention to the possibility of a discoid meniscus. LEVEL OF EVIDENCE: Level IV.

Increased incidence of acute patellar dislocations and patellar instability surgical procedures across the United States in paediatric and adolescent patients.

PURPOSE: Patellofemoral instability is a common cause of knee pain and dysfunction in paediatric and adolescent patients. The purpose of the study was to evaluate the frequency of patellar dislocations seen in emergency departments (EDs) and the rates of surgical procedures for patellar instability at paediatric hospitals in the United States between 2004 and 2014. METHODS: The Pediatric Health Information System database was queried for all paediatric patients who underwent surgery for patellar instability or were seen in the ED for acute patellar dislocation between 2004 and 2014. This was compared with the annual numbers of overall orthopaedic surgical procedures. RESULTS: Between 2004 and 2014, there were 3481 patellar instability procedures and 447 285 overall orthopaedic surgical procedures performed at the included institutions, suggesting a rate of 7.8 per 1000 orthopaedic surgeries. An additional 5244 patellar dislocations treated in EDs were identified. Between 2004 and 2014, the number of patellar instability procedures increased 2.1-fold (95% confidence interval (CI) 1.4 to 3.0), while orthopaedic surgical procedures increased 1.7-fold (95% CI 1.3 to 2.0), suggesting a 1.2-fold relative increase in patellar instability procedures, compared with total paediatric orthopaedic surgeries. CONCLUSION: This study shows a significant rise in the rate of acute patellar instability treatment events in paediatric and adolescent patients across the country. Surgery for patellar instability also increased over the study period, though only slightly more than the rate of all paediatric orthopaedic surgical procedures. This may suggest that increasing youth sports participation may be leading to a spectrum of increasing injuries and associated surgeries in children. LEVEL OF EVIDENCE: IV.

Risk Factors for Hardware-Related Complications After Olecranon Fracture Fixation.

The aim of this study was to evaluate risk factors for symptomatic hardware and removal of hardware (ROH) after olecranon open reduction and internal fixation (ORIF) and to assess differences between olecranon locking plate and screws (P&S) or tension band (TB) wire cohorts. The medical records of 331 patients with olecranon fractures treated at two academic level I trauma centers with ORIF from 2012 to 2016 were reviewed. A total of 189 patients were included in the study. Complications, ROH, and subsequent surgery were assessed and compared between cohorts. There were 124 cases in the P&S cohort and 65 in the TB cohort. The overall reoperation rate was 31.2% (59 of 189). The overall incidence of ROH for all cases was 29.1% (55 of 189). Patients who required ROH or developed symptomatic hardware were significantly younger than those who did not (P&S, P<.003; TB, P<.004). Age and body mass index (BMI) were associated with ROH plus symptomatic hardware after P&S. Age (but not BMI) was associated with ROH/symptomatic hardware after TB. Measured hardware prominence was not associated with ROH or ROH plus symptomatic hardware for either the P&S or the TB cohort. Risk factors including patient age and BMI were found to be significantly associated with hardware-related complications. [Orthopedics. 2020;43(3):141-146.].