Factors that Promote and Protect Against Financial Toxicity after Orthopaedic Trauma: A Qualitative Study.

INTRODUCTION: Financial toxicity is highly prevalent in patients after an orthopaedic injury. However, little is known regarding the conditions that promote and protect against this financial distress. Our objective was to understand the factors that cause and protect against financial toxicity after a lower extremity fracture. METHODS: A qualitative study was conducted using semi-structured interviews with 20 patients 3 months after surgical treatment of a lower extremity fracture. The interviews were audio-recorded, transcribed verbatim, and analyzed using thematic analysis to identify themes and subthemes. Data saturation occurred after 15 interviews. The percentage of patients who described the identified themes are reported. RESULTS: A total of 20 patients (median age, 44 years [IQR, 38 to 58]; 60% male) participated in the study. The most common injury was a distal tibia fracture (n = 8; 40%). Eleven themes that promoted financial distress were identified, the most common being work effects (n = 14; 70%) and emotional health (n = 12; 60%). Over half (n = 11; 55%) of participants described financial toxicity arising from an inability to access social welfare programs. Seven themes that protected against financial distress were also identified, including insurance (n = 17; 85%) and support from friends and family (n = 17; 85%). Over half (n = 13; 65%) of the participants discussed the support they received from their healthcare team, which encompassed expectation setting and connections to financial aid and other services. Employment protection and workplace flexibility were additional protective themes. CONCLUSION: This qualitative study of orthopaedic trauma patients found work and emotional health-related factors to be primary drivers of financial toxicity after injury. Insurance and support from friends and family were the most frequently reported protective factors. Many participants described the pivotal role of the healthcare team in establishing recovery expectations and facilitating access to social welfare programs.

Lactic acid levels are associated with morbidity, length of stay, and total treatment costs in urban trauma patients with lower extremity long bone fractures.

INTRODUCTION: Lactic acid is well studied in the trauma population and is frequently used as a laboratory indicator that correlates with resuscitation status and has thus been associated with patient outcomes. There is limited literature that assesses the association of initial lactic acid with post-operative morbidity and hospitalization costs in the orthopedic literature. The purpose of this study was to assess the association of lactic acid levels and alcohol levels post-operative morbidity, length of stay and admission costs in a cohort of operative lower extremity long bone fractures, and to compare these effects in the ballistic and blunt trauma sub-population. METHODS: Patients presenting as trauma activations who underwent tibial and/or femoral fixation at a single institution from May 2018 to August 2020 were divided based on initial lactate level into normal, (< 2.5) intermediate (2.5-4.0), and high (> 4.0). Mechanism of trauma (blunt vs. ballistic) was also stratified for analysis. Data on other injuries, surgical timing, level of care, direct hospitalization costs, length of stay, and discharge disposition were collected from the electronic medical record. The primary outcome assessed was post-operative morbidity defined as in-hospital mortality or unanticipated escalation of care. Secondary outcomes included hospital costs, lengths of stay, and discharge disposition. Data were analyzed using ANOVA and multivariate regression. RESULTS: A total of 401 patients met inclusions criteria. Average age was 34.1 ± 13.0 years old, with patients remaining hospitalized for 8.8 ± 9.5 days, and 35.2% requiring ICU care during their hospitalization. Patients in the ballistic cohort were younger, had fewer other injuries and had higher lactate levels (4.0 ± 2.4) than in the blunt trauma cohort (3.4 ± 1.9) (p = 0.004). On multivariate regression, higher lactate was associated with post-operative morbidity (p = 0.015), as was age (p < 0.001) and BMI (p = 0.033). ISS, ballistic versus blunt injury mechanism, and other included laboratory markers were not. Lactate was also associated with longer lengths of stay, and higher associated direct hospitalization cost (p < 0.001) and lower rates of home disposition (p = 0.008). CONCLUSION: High initial lactate levels are independently associated with post-operative morbidity as well as higher direct hospitalization costs and longer lengths of stay in orthopedic trauma patients who underwent fixation for fractures of the lower extremity long bones. Ballistic trauma patients had significantly higher lactate levels compared to the blunt cohort, and lactate was not independently associated with increased rates of post-operative morbidity in the ballistic cohort alone. LEVEL OF EVIDENCE: III.

Significant Improvement in the Value of Surgical Treatment of Tibial Plateau Fractures Through Surgeon Practice Standardization.

INTRODUCTION: It is unclear whether cost-based decisions to improve the value of surgical care (quality:cost ratio) affect patient outcomes. Our hypothesis was that surgeon-directed reductions in surgical costs for tibial plateau fracture fixation would result in similar patient outcomes, thus improving treatment value. METHODS: This was a prospective observational study with retrospective control data. Surgically treated tibial plateau fractures from 2013 to October 2014 served as a control (group 1). Material costs for each case were calculated. Practices were modified to remove allegedly unnecessary costs. Next, cost data were collected on similar patients from November 2014 through 2015 (group 2). Costs were compared between groups, analyzing partial articular and complete articular fractures separately. Minimum follow-up (f/u) was 1-year. Outcomes data collected include Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) and pain interference domains, Western Ontario and McMaster Universities Osteoarthritis Index, visual analog pain scale, infection, nonunion, unplanned return to surgery, demographics, injury characteristics, and comorbidities. RESULTS: Group 1 included 57 partial articular fractures and 57 complete articular fractures. Group 2 included 37 partial articular fractures and 32 complete articular fractures. Median cost of partial articular fractures decreased from $1,706 to $1,447 (P = 0.025), and median cost of complete articular fractures decreased from $2,681 to $2,220 (P = 0.003). Group 1 had 55 patients who consented to clinical f/u, and group 2 had 39. Median PROMIS PF score was 40 for group 1 and was 43 for group 2 (P = 0.23). There were no significant differences between the groups for any clinical outcomes, demographics, injury characteristics, or comorbidities. Median f/u in group 1 was 31 months compared with 15 months in group 2 (P < 0.0001). DISCUSSION: We have demonstrated that surgeons can improve value of surgical care by reducing surgical costs while maintaining clinical outcomes.

Health care and productivity costs for isolated tibia shaft fracture admissions in The Netherlands.

The aim of this study was to provide a detailed overview of age and gender specific health care costs and costs due to lost productivity for hospital admitted patients with an isolated tibia shaft fracture in The Netherlands between 2008 and 2012. Injury cases and length of hospital stay were extracted from the National Medical Registration. Information on extramural health care and work absence were retrieved from a patient follow-up survey on health care use. Medical costs included ambulance care, in- hospital care, general practitioner care, home care, physical therapy, and rehabilitation/nursing care. An incidence-based cost model was applied to calculate direct health care costs and lost productivity in 2012. Total direct health care costs for all patients admitted with a tibia shaft fracture (n = 1,635) were €13.6 million. Costs for productivity loss were € 23.0 million. Total costs (direct health care and lost productivity) per patient were highest for men aged 40-49 years mainly due to lost productivity, and for women aged > 80 years, due to high direct medical costs.

Complications and its impact in patients with closed and open tibial shaft fractures requiring open reduction and internal fixation.

Aim: To evaluate the rates of infection and nonunion and determine the impact of infections on healthcare resource use and costs following open and closed fractures of the tibial shaft requiring open reduction internal fixation. Methods: Healthcare use and costs were compared between patients with and without infections following pen reduction internal fixation using MarketScan® databases. Results: For commercial patients, the rates of infection and nonunion ranged from 1.82 to 7.44% and 0.48 to 8.75%, respectively, over the 2-year period. Patients with infection had significantly higher rates of hospital readmissions, emergency room visits and healthcare costs compared with patients without infection. Conclusion: This real-world study showed an increasing rate of infection up to 2 years and infection significantly increased healthcare resource use and costs.

Cost Variation in Temporizing External Fixation of Tibial Plateau Fractures.

BACKGROUND: Rising health care expenditures and declining reimbursements have generated interest in providing interventions of value. The use of external fixation is a commonly used intermediate procedure for the staged treatment of unstable fractures. External fixator constructs can vary in design and costs based on selected component configuration. The objective of this study was to evaluate cost variation and relationships to injury and noninjury characteristics in temporizing external fixation of tibial plateau fractures. We hypothesize that construct costs are highly variable and present no noticeable patterns with both injury and noninjury characteristics. METHODS: A retrospective review of tibial plateau fractures treated with initial temporizing external fixation between 2010 and 2016 at 2 Level I trauma centers was conducted. Fracture and patient characteristics including age, body mass index, AO/OTA classification, and Schatzker fracture classification were observed with construct cost. In addition, injury-independent characteristics of surgeon education, site of procedure, and date of procedure were evaluated with construct cost. Factors associated with cost variation were assessed using nonparametric comparative and goodness-of-fit regression tests. RESULTS: Two hundred twenty-one patient cases were reviewed. The mean knee spanning fixator construct cost was $4947 (95% confidence interval = $4742-$5152). The overall range in construct costs was from $1848 to $11,568. The mean duration of use was 16.4 days. No strong correlations were noted between construct cost and patient demographics (r = 0.02), fracture characteristics (r = 0.02), or injury-independent characteristics (r = 0.10). Finally, there was no significant difference between constructs of traumatologists and other orthopaedic surgeon subspecialists (P = 0.12). CONCLUSIONS: Temporizing external fixation of tibial plateau is a high-cost intervention per unit of time and exhibits massive variation in the mean cost. This presents an ideal opportunity for cost savings by reducing excessive variation in implant component selection. LEVEL OF EVIDENCE: Level III. Retrospective Cohort.

Tibial Shaft Fractures in Workers Compensation and No-Fault Insurance Is There a Difference in Resource Utilization?

BACKGROUND: Workers Compensation claims have been previously associated with inferior clinical outcomes. However, variation in inpatient stays for orthopedic trauma injuries according to insurance type has not been previously examined. METHODS: We investigated the differences according to insurance for tibial shaft fractures in regard to length of stay and disposition. Using the New York SPARCS database, we identified 1,856 adult non-elderly patients with an isolated tibial shaft fracture who underwent surgery. Patients were stratified by insurance type, including private, Medicaid, Workers Compensation, and no-fault, which covers medical expenses related to automobile or pedestrian accidents. RESULTS: Compared to private insurance (mean: 2.7 days), length of stay was longer for no-fault (mean: 3.9 days; adjusted difference +33%, p < 0.001) and Medicaid (mean: 3.5 days; adjusted difference +22%, p < 0.001), but not significantly different for Workers Compensation (mean: 3.5 days; adjusted difference +4%, p = 0.474). Compared to private insurance (rate: 3.5%), disposition to a facility was significantly higher for no-fault (rate: 10.1%; adjusted odds ratio [OR] = 3.3, p < 0.001) and Medicaid (rate: 7.6%; OR = 2.2, p = 0.003), but was not significantly different for Workers Compensation (rate: 6.3%; OR = 1.8, p = 0.129). CONCLUSIONS: Patients with no-fault insurance, but not Workers Compensation, are subject to longer hospital stays and are more likely to be discharged to a facility following operative fixation of an isolated tibial shaft fracture. These findings suggest that financial, social, and legal factors influence medical care for patients involved in automobile accidents with no-fault insurance.

Costs and Complications of Single-Stage Fixation Versus 2-Stage Treatment of Select Bicondylar Tibial Plateau Fractures.

OBJECTIVES: To determine the differences in costs and complications in patients with bicondylar tibial plateau (BTP) fractures treated with 1-stage definitive fixation compared with 2-stage fixation after initial spanning external fixation. DESIGN: Retrospective cohort study. SETTING: Level 1 Trauma Center. PATIENTS/PARTICIPANTS: Patients with OTA/AO 41-C (Schatzker 6) BTP fractures treated with open reduction internal fixation. INTERVENTION: Definitive treatment with open reduction internal fixation either acutely (1 stage) or delayed after initial spanning external fixation (2 stage). MAIN OUTCOME MEASURES: Wound healing complications, implant costs, hospital charges, Patient-Reported Outcomes Measurement Information System (PROMIS), reoperation, nonunion and infection. RESULTS: One hundred five patients were identified over a three-year period, of whom 52 met the inclusion criteria. There were 28 patients in the 1-stage group and 24 patients in the 2-stage group. Mean follow-up was 21.8 months, and 87% of patients had at least 12 months of follow-up. The mean number of days to definitive fixation was 1.2 in the 1-stage group and 7.8 in the 2-stage group. There were no differences between groups with respect to wound healing or any other surgery-related complications. Functional outcomes PROMIS were similar between groups. Mean implant cost in the 2-stage group was $10,821 greater than the 1-stage group, mostly because of the costs of external fixation. Median hospital inpatient charges in the 2-stage group exceeded the 1-stage group by more than $68,000 for all BTP fractures and by $61,000 for isolated BTP fractures. CONCLUSIONS: Early single-stage treatment of BTP fractures is cost-effective and is not associated with a higher complication rate than 2-stage treatment in appropriately selected patients. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

A comparison of the cost-effectiveness of intramedullary nail fixation and locking plate fixation in the treatment of adult patients with an extra-articular fracture of the distal tibia: economic evaluation based on the FixDT trial.

Aims: The aim of this study was to compare the cost-effectiveness of intramedullary nail fixation and 'locking' plate fixation in the treatment of extra-articular fractures of the distal tibia. Patients and Methods: An economic evaluation was conducted from the perspective of the United Kingdom National Health Service (NHS) and personal social services (PSS), based on evidence from the Fixation of Distal Tibia Fractures (UK FixDT) multicentre parallel trial. Data from 321 patients were available for analysis. Costs were collected prospectively over the 12-month follow-up period using trial case report forms and participant-completed questionnaires. Cost-effectiveness was reported in terms of incremental cost per quality adjusted life year (QALY) gained, and net monetary benefit. Sensitivity analyses were conducted to test the robustness of cost-effectiveness estimates. Results: Mean NHS and PSS costs were significantly lower for patients treated with an intramedullary nail than for those treated with a locking plate (-£970, 95% confidence interval (CI) -1685 to -256; p = 0.05). There was a small increase in QALYs gained in the nail fixation group (0.01, 95% CI -0.03 to 0.06; p = 0.52). The probability of cost-effectiveness for nail fixation exceeded 90% at cost-effectiveness thresholds as low as £15 000 per additional QALY. The cost-effectiveness results remained robust to several sensitivity analyses. Conclusion: This trial-based economic evaluation suggests that nail fixation is a cost-effective alternative to locking plate fixation. Cite this article: Bone Joint J 2018;100-B:624-33.

The Socioeconomic Implications of Isolated Tibial and Femoral Fractures from Road Traffic Injuries in Uganda.

BACKGROUND: The purpose of this study was to determine the socioeconomic implications of isolated tibial and femoral fractures caused by road traffic injuries in Uganda. METHODS: This prospective longitudinal study included adult patients who were admitted to Uganda's national referral hospital with an isolated tibial or femoral fracture. The primary outcome was the time to recovery following injury. We assessed recovery using 4 domains: income, employment status, health-related quality of life (HRQoL) recovery, and school attendance of the patients' dependents. RESULTS: The majority of the study participants (83%) were employed, and they were the main income earner for their household (74.0%) at the time of injury, earning a mean annual income of 2,375 U.S. dollars (USD). All of the patients had been admitted with the intention of surgical treatment; however, because of resource constraints, only 56% received operative treatment. By 2 years postinjury, only 63% of the participants had returned to work, and 34% had returned to their previous income level. Overall, the mean monthly income was 62% less than preinjury earnings, and participants had accumulated 1,069 USD in debt since the injury; 41% of the participants had regained HRQoL scores near their baseline, and 62% of school-aged dependents, enrolled at the time of injury, were in school at 2 years postinjury. CONCLUSIONS: At 2 years postinjury, only 12% of our cohort of Ugandan patients who had sustained an isolated tibial or femoral fracture from a road traffic injury had recovered both economically and physically. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Cost-utility analysis in orthopaedic trauma; what pays? A systematic review.

BACKGROUND: As healthcare systems come under ever-increasing pressure to provide more care with fewer resources, emphasis is being placed on value-based systems that maximise quality and minimize cost. The aim of this study was to determine which interventions in fracture care have been demonstrated to be cost effective. METHODS: A systemic review of cost-utility studies on the management of fractures from 1976 to 2015 was carried out using a search of the Cost-Effectiveness Analysis Registry, National Health Service Economic Evaluation Database (NHS EED) and MEDLINE. RESULTS: 20 studies were included with 15 (75%) studies assessing interventions in lower limb trauma and 8 (25%) studies assessing interventions in upper limb trauma. 50% of studies used a decision tree model and 50% used collected data alongside a randomised clinical trial. Interventions which were shown to be cost effective in lower limb trauma were total hip replacement in displaced femoral neck fractures, the SHS in stable (A1 and A2) fractures and IM nailing for unstable (A3) fractures, salvage treatment for grade IIIB and IIIC open tibial fractures and operative treatment of ankle and calcaneal fractures. For systems-based strategies, there is evidence demonstrating cost effectiveness to treating hip fractures in high volume centres and to having resources in place to facilitate fractures being treated within 48 h of injury. In upper limb trauma there was evidence showing operative treatment of displaced proximal humerus fractures to be neither clinically nor cost effective. There was evidence supporting the operative treatment of non-displaced scaphoid fractures. Overall the quality of the studies was poor with only 50% (10) of studies able to make a treatment recommendation. Reasons for this included poor quality primary source data and poor reporting methodological practices. CONCLUSION: Certain aspects of fracture management have been shown to be cost effective. However, there is a paucity of evidence in this area and further research is required so that value-based interventions are chosen by healthcare providers engaged in orthopaedic trauma care.

Low-intensity pulsed ultrasound for treatment of tibial fractures: an economic evaluation of the TRUST study.

AIMS: This 501-patient, multi-centre, randomised controlled trial sought to establish the effect of low-intensity, pulsed, ultrasound (LIPUS) on tibial shaft fractures managed with intramedullary nailing. We conducted an economic evaluation as part of this trial. PATIENTS AND METHODS: Data for patients' use of post-operative healthcare resources and time taken to return to work were collected and costed using publicly available sources. Health-related quality of life, assessed using the Health Utilities Index Mark-3 (HUI-3), was used to derive quality-adjusted life years (QALYs). Costs and QALYs were compared between LIPUS and control (a placebo device) from a payer and societal perspective using non-parametric bootstrapping. All costs are reported in 2015 Canadian dollars unless otherwise stated. RESULTS: With a cost per device of $3,995, the mean cost was significantly higher for patients treated with LIPUS versus placebo from a payer (mean increase = $3647, 95% confidence interval (CI) $3244 to $4070; p < 0.001) or a societal perspective (mean increase = $3425, 95% CI $1568 to $5283; p < 0.001). LIPUS did not provide a significant benefit in terms of QALYs gained (mean difference = 0.023 QALYs, 95% CI -0.035 to 0.069; p = 0.474). Incremental cost-effectiveness ratios of LIPUS compared with placebo were $155 433/QALY from a payer perspective and $146 006/QALY from a societal perspective. CONCLUSION: At the current price, LIPUS is not cost-effective for fresh tibial fractures managed with intramedullary nailing. Cite this article: Bone Joint J 2017;99-B:1526-32.

Infection after fracture fixation of the tibia: Analysis of healthcare utilization and related costs.

INTRODUCTION: One of the most challenging complications in musculoskeletal trauma surgery is the development of infection after fracture fixation (IAFF). It can delay healing, lead to permanent functional loss, or even amputation of the affected limb. The main goal of this study was to investigate the total healthcare costs and length-of-stay (LOS) related to the surgical treatment of tibia fractures and furthermore identify the subset of clinical variables driving these costs within the Belgian healthcare system. The hypothesis was that deep infection would be the most important driver for total healthcare costs. PATIENTS AND METHODS: Overall, 358 patients treated operatively for AO/OTA type 41, 42, and 43 tibia fractures between January 1, 2009 and January 1, 2014 were included in this study. A total of 26 clinical and process variables were defined. Calculated costs were limited to hospital care covered by the Belgian healthcare financing system. The five main cost categories studied were: honoraria, materials, hospitalization, day care admission, and pharmaceuticals. RESULTS: Multivariate analysis showed that deep infection was the most significant characteristic driving total healthcare costs and LOS related to the surgical treatment of tibia fractures. Furthermore, this complication resulted in the highest overall increase in total healthcare costs and LOS. Treatment costs were approximately 6.5-times higher compared to uninfected patients. CONCLUSION: This study shows the enormous hospital-related healthcare costs associated with IAFF of the tibia. Treatment costs for patients with deep infection are higher than previously mentioned in the literature. Therefore, future research should focus more on prevention rather than treatment strategies, not only to reduce patient morbidity but also to reduce the socio-economic impact.

A Prospective Randomized Trial to Assess Fixation Strategies for Severe Open Tibia Fractures: Modern Ring External Fixators Versus Internal Fixation (FIXIT Study).

The treatment of high-energy open tibia fractures is challenging in both the military and civilian environments. Treatment with modern ring external fixation may reduce complications common in these patients. However, no study has rigorously compared outcomes of modern ring external fixation with commonly used internal fixation approaches. The FIXIT study is a prospective, multicenter randomized trial comparing 1-year outcomes after treatment of severe open tibial shaft fractures with modern external ring fixation versus internal fixation among men and women of ages 18-64. The primary outcome is rehospitalization for major limb complications. Secondary outcomes include infection, fracture healing, limb function, and patient-reported outcomes including physical function and pain. One-year treatment costs and patient satisfaction will be compared between the 2 groups, and the percentage of Gustilo IIIB fractures that can be salvaged without soft tissue flap among patients receiving external fixation will be estimated.

Open lower limb fractures in Major Trauma Centers - A loss leader?

PURPOSE: Open lower limb fractures are resource intensive injuries. Regardless of the financing model, the cost of treatment is an important consideration for any healthcare provider. METHODS: Open lower limb fractures treated at our centre were identified over a six-month period. Isolated open femur or tibia fractures were included as well as cases with multiple fractures. Direct inpatient care costs were calculated and income was reviewed for each case according to 'Healthcare Resource Group' (HRG) cost codes. RESULTS: A total of 41 open lower limb fractures (32 patients) were identified. There were isolated open fractures in twenty-five and multiple lower limb open fractures in seven patients. Twenty-three patients (72%) were male and nine were female (28%) with an average age of 40 years (range 10-89 years). The fractures were classified according to Gustilo and Anderson (GA) and divided into two main groups; there were 13 mild and 28 severe open fractures. The median direct cost of inpatient treatment for open lower limb fractures was £19,189 per patient. There was a net gain of £6,288 per fracture in the mild group and a loss of £7,582 in the severe group. The total deficit was £149,545 over the six-month period for this cohort of 41 fractures. CONCLUSION: Open lower limb fractures are expensive to treat at a cost of approximately £19,200 per patient and associated with a significant loss of income in our MTC. Cost codes should reflect the complex and more expensive treatment of these patients to avoid the inadvertent financial 'penalties' of treating such patients. This study is the first to calculate the direct inpatient treatment costs of open lower limb fractures in a major trauma centre. It highlights the need for cost saving strategies and for appropriate remuneration in MTCs.

The cost of infection in severe open tibial fractures treated with a free flap.

PURPOSE: Open tibial fractures needing soft tissue cover are challenging injuries. Infection risk is high, making treatment difficult and expensive. Delayed skin closure has been shown to increase the infection rate in several studies. We aimed at calculating the direct and indirect cost of treatment, and to determine the effect of delayed skin closure on this cost. METHODS: We reviewed all records of patients treated with a free flap in our institution for an open tibial fracture from 2002 to 2013. We calculated direct costs based on length of stay (LOS) and orthopaedic and plastic surgical procedures performed, including medications and intensive care. We analysed indirect cost in terms of absenteeism and unemployment benefits. The primary goal was to establish the extra cost incurred by an infection. RESULTS: We analysed 46 injuries in 45 patients. Infection increased the LOS from 41 to 74 days and increased the cost of treatment from € 49,817 in uninfected fractures to € 81,155 for infected fractures. Employed patients spent 430 days more on unemployment benefits, than a matched cohort in the background population. Achieving skin cover within seven days of injury decreased the infection rate from 60 to 27 %. CONCLUSIONS: Severe open tibial fractures covered with free flaps, cause over a year of absenteeism. Infection increases direct cost of treatment over 60 % and roughly doubles LOS. Early soft-tissue cover and correct antibiotics have been shown to improve outcomes-underscoring the need for rapid referral to centres with an ortho-plastic set-up to handle such injuries.

Wide Variation of Surgical Cost in the Treatment of Periarticular Lower Extremity Injuries Between 6 Fellowship-Trained Trauma Surgeons.

OBJECTIVES: We hypothesized that negligible surgical material cost variation exists between traumatolgists for treatment of bimalleolar ankle and bicondylar tibial plateau fractures. DESIGN: Retrospective medical record review. SETTING: Academic level 1 Trauma Center; 2-year period. PATIENTS/PARTICIPANTS: Current Procedure Terminology codes for open treatment of bimalleolar ankle and bicondylar tibial plateau fractures identified patients. Patients who had operative treatment of other injuries under the same anesthetic session were excluded. Only definitive treatment procedures were analyzed. INTERVENTION: We analyzed the intraoperative material costs of these procedures and compared them between surgeons. This analysis was done with a newly developed proprietary program designed for inventory and cost analysis. MAIN OUTCOME MEASUREMENTS: Mean and median total case material costs were compared using one-way analysis of variance. Individual items that significantly increased costs were identified. RESULTS: We identified 88 bimalleolar ankle and 46 bicondylar tibial plateau fractures treated by 6 surgeons. The mean intraoperative material cost per bimalleolar ankle fracture was $1099. The least expensive surgeon's mean case cost was $613, which was significantly less than the most expensive surgeon's $2243 (P = 0.009). The median cost range was $598-$784. The top quartile of cases resulted in 57% of overall material cost for ankle fractures. The mean intraoperative material cost per bicondylar tibial plateau fracture was $3219 (range $1839-$4088, P = 0.064). The range of median costs ($1826-$3989) was significantly wider than for ankle fractures. Bone void fillers, locking plates, adjunctive external fixators, mini-fragment locking plates, cannulated screws, single-use taps, guidewires, and drill bits all substantially increased costs. CONCLUSION: This study demonstrated variation in intraoperative material cost between 6 traumatologists resulting from practice variations despite similar specialty training. The cost differences resulting from practice variation reveal potential savings through increased standardization of surgical care for similar injuries. We identified high-cost items, which could lead to cost savings if used only when they will have clinical benefit.

The service impact of failed locking plate fixation of distal tibial fractures: a service and financial evaluation at a major trauma centre.

INTRODUCTION: The surgical treatment of distal tibial fractures is challenging and controversial. Recently, locking plate fixation has become popular, but the outcomes of this treatment are mixed with complication rates as high as 50 % in the published literature. There are no reports specifically relating to the financial and resource costs of failed treatment in the literature. METHOD: Retrospective service analysis of patients who had undergone locking plate fixation of a distal third tibial fracture between 2008 and 2011 with at least 12 months follow-up. Rates of readmission, reoperation, bony union and infection were ascertained. The financial and resource (hospital stay and number of outpatient appointments) implications of failed treatment were calculated. RESULTS: Forty-two patients were identified. There were 31 type A fractures, one type B fracture and 10 type C fractures. Three injuries were open. Twenty patients were treated with minimally invasive percutaneous osteosynthesis (MIPO). The readmission and reoperation rates were 26 % (n = 11) and 19 % (n = 8), respectively. A total of 89 % of readmissions were due to infection. All patients had received appropriate antibiotic regimens. The average costs of successful and failed treatment were £ 5538 and £ 18,335, respectively. The average time to union was 24.5 weeks. The rate of non-union was 21 % (n = 9). The rate of infection was 28 % (n = 12), with all patients with open fracture incurring an infection. Tourniquet time had no effect on the incidence of complications. Smokers were more likely to incur a complication (p < 0.05), and non-union was lower in the MIPO group (p < 0.05). The length and total cost of inpatient care were significantly lower in the MIPO group (p < 0.05). MIPO patients were five times less likely to incur readmission or reoperation. Failed treatment was three times more expensive and four times longer than successful treatment. CONCLUSION: The study identified a large burden to the service following failure of locking plate treatment of these fractures, but the outcomes were similar to series published in the literature. Readmission rates were high following these injuries, and failed treatment was costly and had a significant impact on hospital resources. The implementation of major trauma networks and centralised subspecialised units should improve quality and value for money.

Effects of recombinant human Bone Morphogenetic Protein-2 (rhBMP-2) in grade III open tibia fractures treated with unreamed nails-A clinical and health-economic analysis.

Recombinant human Bone Morphogenetic Protein-2 (rhBMP-2) is licensed in Europe for open tibia fractures treated with unreamed nails. However, there is limited data available on the specific use of rhBMP-2 in combination with unreamed nails for open tibia fractures. The intention of the current study was to evaluate the medical and health-economic effects of rhBMP-2 in Gustilo-Anderson grade III open tibia fractures treated with unreamed nails based on individual patient data from two previously published studies. Linear regression analysis was performed on raw data of 90 patients that were either treated by standard of care with soft tissue management and unreamed nailing (SOC group) (n=50) or with rhBMP-2 in addition to soft tissue management and unreamed nailing (rhBMP-2 group) (n=40). For all types of revision, a significant lower percentage of patients (27.5%) of the rhBMP-2 group had to be revised compared to 48% of the patients of the SOC group (p=0.04). When only invasive secondary interventions such as bone grafting and nail exchange were considered, there was also a statistically significant reduction in the rhBMP-2 group with a revision rate of 10.0% (4 of 40 patients) compared to the SOC group with a revision rate of 28.0% (14 of 50 patients) (p=0.01). Mean fracture healing time of 228 days in the rhBMP-2 compared to 266 days in the SOC group was not statistically significant (p=0.24). Health-economic analysis based on a societal perspective with calculation of overall treatment costs after initial surgery and including productivity losses revealed savings of €6,239 per patient for Germany and €4,752 for the UK in favour of rhBMP-2 which was mainly driven by reduction of productivity losses. In conclusion, rhBMP-2 reduces secondary interventions in patients with grade III open tibia fractures treated with an unreamed nail and its use leads to financial savings for Germany and the UK from a societal perspective.

The Quality of Cost-Utility Analyses in Orthopedic Trauma.

As health care in the United States transitions toward a value-based model, there is increasing interest in applying cost-effectiveness analysis within orthopedic surgery. Orthopedic trauma care has traditionally underemphasized economic analysis. The goals of this review were to identify US-based cost-utility analysis in orthopedic trauma, to assess the quality of the available evidence, and to identify cost-effective strategies within orthopedic trauma. Based on a review of 971 abstracts, 8 US-based cost-utility analyses evaluating operative strategies in orthopedic trauma were identified. Study findings were recorded, and the Quality of Health Economic Studies (QHES) instrument was used to grade the overall quality. Of the 8 studies included in this review, 4 studies evaluated hip and femur fractures, 3 studies analyzed upper extremity fractures, and 1 study assessed open tibial fracture management. Cost-effective interventions identified in this review include total hip arthroplasty (over hemiarthroplasty) for femoral neck fractures in the active elderly, open reduction and internal fixation (over nonoperative management) for distal radius and scaphoid fractures, limb salvage (over amputation) for complex open tibial fractures, and systems-based interventions to prevent delay in hip fracture surgery. The mean QHES score of the studies was 79.25 (range, 67-89). Overall, there is a paucity of cost-utility analyses in orthopedic trauma; however, the available evidence suggests that certain operative interventions can be cost-effective. The quality of these studies, however, is fair, based on QHES grading. More attention should be paid to evaluating the cost-effectiveness of operative intervention in orthopedic trauma.