Cost-Effectiveness Analysis Comparing Proximal Row Carpectomy and Four-Corner Arthrodesis.

BACKGROUND: The optimal surgical treatment for scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) remains unclear. To inform clinical decision-makers, we conducted a cost-effectiveness analysis comparing proximal row carpectomy (PRC) and four-corner arthrodesis (FCA). METHODS: A Markov microsimulation model was used to compare clinical outcomes, costs, and health utilities between PRC and FCA. The model used a 10-year time horizon and a 1-month cycle length, and it was evaluated from the societal perspective. Utilities and clinical parameters including transition probabilities for debridement for infection, removal of implants, conversion to total wrist arthrodesis, revision FCA, and revision total wrist arthrodesis were obtained from published literature. Timing of complications was estimated from the literature. Direct medical costs were derived from Medicare ambulatory surgical cost data, and indirect costs for missed work due to surgical procedures and complications were included. The effectiveness outcome was quality-adjusted life years (QALYs). Probabilistic sensitivity analysis and 1-way threshold analysis for utilities were performed. RESULTS: In the base-case model, PRC dominated FCA (i.e., PRC had lower cost and greater effectiveness). The mean (and standard deviation) for the total cost and QALYs per patient were $30,970 ± $5,931 and 8.24 ± 1.28, respectively, for PRC and $44,526 ± $11,205 and 8.23 ± 1.26, respectively, for FCA. In the probabilistic sensitivity analysis, PRC dominated FCA in 57% of the 1 million iterations. The cost-effectiveness acceptability curve indicated that PRC is the most cost-effective strategy regardless of the willingness-to-pay threshold up to $100,000/QALY. CONCLUSIONS: PRC dominated FCA in the base-case analysis and in the probabilistic sensitivity analysis. These results suggest that PRC is the optimal strategy for Stage-I or II SLAC and for SNAC in patients ≥55 years of age. LEVEL OF EVIDENCE: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Evaluation of factors influencing surgical treatment costs for distal biceps rupture.

BACKGROUND: Given the similar outcomes of various fixation constructs for single-incision distal biceps repair, a critical evaluation of the factors that drive the cost of the procedure is the key to optimizing treatment value. The purpose of this study was to quantify variation in costs for surgical treatment of complete distal biceps ruptures, as well as identify factors affecting costs. METHODS: We retrospectively identified adult patients consecutively treated surgically for complete distal biceps ruptures between July 2011 and January 2018 at a single academic medical center. Using our institution's information technology value tool, we recorded the surgical encounter total direct costs (SETDCs) for each patient. Univariate and multivariate gamma regression models were used to determine factors affecting SETDCs. RESULTS: Of 121 included patients, 102 (86%), 7 (6%), and 12 (10%) underwent primary repair, revision, and reconstruction. SETDCs varied widely, with a standard deviation of 40% and a range of 58% to 276% of the average SETDC. The main contributors to SETDCs were facility utilization costs (53%) and implant costs (29%). Implant costs also varied, with a standard deviation of 16%, ranging up to 121% of the mean SETDC. Multivariate analysis demonstrated that reconstructions were 72% more costly than primary repairs (P < .001). No significant cost differences were found between cortical button and dual-suture anchor fixation (P = .058). American Society of Anesthesiologists class, body mass index, revision surgery, time to surgery, location, administration of postoperative block, and surgeon performing the procedure did not significantly affect the SETDC. CONCLUSION: Surgical encounter and implant costs vary widely for distal biceps rupture treatment. However, no significant difference in SETDC was identified between repair with a cortical button vs. dual-suture anchor repair. The greater costs associated with reconstruction surgery should be taken into consideration.

Strain in Posterior Instrumentation Resulted by Different Combinations of Posterior and Anterior Devices for Long Spine Fusion Constructs.

STUDY DESIGN: Clinically related experimental study. OBJECTIVE: Evaluation of strain in posterior low lumbar and spinopelvic instrumentation for multilevel fusion resulting from the impact of such mechanical factors as physiologic motion, different combinations of posterior and anterior instrumentation, and different techniques of interbody device implantation. SUMMARY OF BACKGROUND DATA: Currently different combinations of posterior and anterior instrumentation as well as surgical techniques are used for multilevel lumbar fusion. Their impact on risk of device failure has not been well studied. Strain is a well-known predictor of metal fatigue and breakage measurable in experimental conditions. METHODS: Twelve human lumbar spine cadaveric specimens were tested. Following surgical methods of lumbar pedicle screw fixation (L2-S1) with and without spinopelvic fixation by iliac bolt (SFIB) were experimentally modeled: posterior (PLF); transforaminal (TLIF); and a combination of posterior and anterior interbody instrumentation (ALIF+PLF) with and without anterior supplemental fixation by anterior plate or diverging screws through an integrated plate. Strain was defined at the S1 screws, L5-S1 segment of posterior rods, and iliac bolt connectors; measurement was performed during flexion, extension, and axial rotation in physiological range of motion and applied force. RESULTS: The highest strain was observed in the S1 screws and iliac bolt connectors specifically during rotation. The S1 screw strain was lower in ALIF+PLF during sagittal motion but not rotation. Supplemental anterior fixation in ALIF+PLF diminished the S1 strain during extension. Strain in the posterior rods was higher after TLIF and PLF and was increased by SFIB; this strain was lowest after ALIF+PLF, as supplemental anterior fixation diminished the strain during extension, in particular, cages with anterior screws more than anterior plate. Strain in the iliac bolt connectors was mainly determined by direction of motion. CONCLUSIONS: Different devices modify strain in low posterior instrumentation, which is higher after transforaminal and posterior techniques, specifically with spinopelvic fixation. LEVEL OF EVIDENCE: N/A.