Does Insurance Status Affect the Management of Acute Clavicle Fractures?

OBJECTIVES: To evaluate whether insurance is an unrecognized factor that plays a role in determining whether a patient receives surgery. METHODS: A retrospective cross-sectional analysis was performed using the Healthcare Cost and Utilization Project data for Florida in the year 2010. Discharge level data from emergency departments and ambulatory surgery settings were used to identify clavicle fractures by International Classification of Diseases 9 codes 81,000, 81,002, and 81,003. Internal fixation was identified using the Current Procedural Terminology code 23,515. Clavicle fractures that did not result in a Current Procedural Terminology code of 23,515 were assumed to have been managed nonoperatively. Multivariate logistic regression, allowing for intragroup correlation among surgeons, was used to determine the influence of payer source on treatment modality adjusting for race, age, number of chronic conditions, and sex. RESULTS: In total, there were 7858 clavicle fractures that met criteria for inclusion. Observations were removed from the analysis if there was missing personal demographic data or if the ability to track patients from the emergency department to follow-up care was not possible. Therefore, the final sample consisted of 5185 clavicle fractures of which 233 received internal fixation (4.5%). The odds of a patient with private insurance receiving internal fixation was 7.58 times [95% confidence interval (CI) = (4.04 to -14.21), P < 0.001] greater than a self-pay patient, all else being held constant. Patients defined by "other" sources of coverage, a group that includes worker's compensation, CHAMPUS (military), CHAMPVA (veterans), or other government insurance other than Medicare and Medicaid were also associated with an increased likelihood of receiving internal fixation by a factor of 6.80 (95% CI = 3.15, 14.64, P < 0.001) relative to self-pay patients, all else being held constant. The likelihood of patients with Medicare or Medicaid receiving internal fixation did not differ statistically from self-pay patients. CONCLUSIONS: Patients with any form of insurance, when compared with the self-pay, Medicare, and Medicaid populations, had a higher likelihood of operative intervention in Florida in 2010. This may represent an unintended trend in treatment. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Influence of prosthetic design on squeaking after ceramic-on-ceramic total hip arthroplasty.

Squeaky ceramic-on-ceramic (COC) total hips have received much recent publicity, and implant design may be implicated. We reviewed 270 consecutive COC total hip arthroplasties in 233 patients comparing 4 implant combinations representing 4 manufacturers. A cohort (n = 45) of Stryker Trident acetabular cups paired with Stryker Accolade femoral stems showed a dramatically higher incidence of "problem squeaking"--defined as always audible to others and occurring at least once per week--with a 35.6% incidence of squeaking and 11.1% incidence of problem squeaking. The 3 non-Stryker designs (n = 225) revealed 3.6% squeaking (P < .0001) and 0.44% problem squeaking (P = .006). The Stryker system has a unique design and metallurgy. Our results suggest that although the genesis of squeaking in COC total hips is multifactorial, prosthetic design plays a key role.