Screw versus staple fixation for Akin osteotomy.

INTRODUCTION: Akin osteotomies are commonly fixed with a screw or staple. Hardware-related symptoms are not uncommon. We compared the outcomes and costs of the two implants. METHODS: We evaluated 74 Akin osteotomies performed in conjunction with first metatarsal osteotomy for hallux valgus. The osteotomy was fixed with a headless compression screw in 39 cases and a staple in 35 cases. We looked at the implant-related complications, removal of metalwork, revision, non-union and cost. Pre- and postoperative hallux valgus interphalangeal (HI) angles and length of the proximal phalanx were measured. RESULTS: There was 100% union, no failure of fixation, no revision surgery and no delayed union in either group. The radiological prominence of screws was significant (p=0.02), but there was no significant difference in soft-tissue irritation (p=0.36) or removal of implants (p=0.49). Two cortical breaches (5.8%) occurred in staple fixation and 4 (10.2%) in screw fixation (not statistically significant (NS), p=0.50). The mean improvement in HI angle was 4.3° with screw fixation and 4.1° with staple fixation (NS, p=0.69). The mean shortening of the proximal phalanx was 2.5mm with screw fixation and 2.3mm with staple fixation (NS, p=0.64). The total cost was £1,925 for staple fixation and £4,290 for screw fixation. CONCLUSIONS: Staple and screw fixation are reproducible modalities with satisfactory outcomes, but screw fixation is expensive. We conclude staple fixation is a cost-effective alternative.

Internal fixation versus hemiarthroplasty for displaced femoral neck fractures in the elderly: A cost-effectiveness analysis.

BACKGROUND: There is little information on the cost and outcome of different treatments for femoral neck fractures. This study aimed to evaluate the cost-effectiveness of internal fixation compared with hemiarthroplasty (HA) for elderly patients with displaced femoral neck fractures. MATERIALS AND METHODS: A total of 121 patients ≥ 65 years old were divided into internal fixation (n = 58) or HA group (n = 63). Clinical outcome was evaluated by the EuroQol 5 dimensions (EQ-5D) score at 3, 12, and 24 months. The total costs including medical and non-medical expense were collected through hospitalisation information, cost diaries, and telephone interviews. A cost-utility analysis of the total costs in combination with quality-adjusted life years (QALYs) calculated by EQ-5D and survival time was conducted. Results were expressed in incremental cost-effectiveness ratio (ICER). RESULTS: The mean EQ-5D index score in the HA group were higher at the early follow-up (p<0.05). At 24 months there were no differences in EQ-5D between the 2 treatment groups (p>0.05). Over the 2-year period, patients treated with HA gained 0.09-0.10 more QALYs than those treated with internal fixation, while the mean total costs for internal fixation (CNY 55,676) were significantly lower than for HA (CNY 80,297) (P<0.001). ICER indicated that internal fixation may be more cost-effective than HA. CONCLUSION: HA is associated with better outcome than internal fixation in the treatment of displaced femoral neck fractures in elderly patients. However, internal fixation may be more cost-effective because of less total cost.

Predictors of cost for posterior spinal fusion in adolescent idiopathic scoliosis.

STUDY DESIGN: Single-center retrospective review of pediatric patients who underwent posterior spinal fusion for adolescent idiopathic scoliosis (AIS). OBJECTIVE: To determine what clinical and operative factors influence inflation-adjusted hospital costs of posterior spine fusion surgery for AIS. With rising healthcare costs and the advent of bundled payments, it is essential understand the predictors of costs for surgical procedures. We sought to determine the components of hospital costs for AIS posterior spine fusion surgery using standardized, inflation-adjusted, line-item costs for services and procedures. METHODS: The study population comprised 148 AIS patients who underwent spinal fusion surgery at a large tertiary care center between 2009 and 2016. Data on medical characteristics, curve type, curve magnitude, number of screws and the number of levels was collected through manual chart review of X-rays and medical records. Hospital costs from admission until discharge were retrieved from an institutional database that contained line-item details of all procedures and services billed during the hospital episode. Bottom-up microcosting valuation techniques were used to generate standardized inflation-adjusted estimates of costs and standard deviations in 2016 dollars. RESULTS: Mean cost of AIS surgery was $48,058 ± 9379. Physician fees averaged 15% of the total cost ($7045 ± 1732). Implant costs and surgical/anesthesia/surgeon's fees accounted for over 70% of the hospital costs. Mean number of screws was 16 ± 4.5, mean number of levels fused was 11.2 ± 2.2, and the mean implant density (screws per level fused) was 1.45 ± 0.35. On multivariate analysis, the number of screws per level fused, number of levels fused, curve magnitude and length of stay were all significantly associated with hospital costs (p < 0.01). CONCLUSIONS: Bundled payments for AIS surgery should include adjustments for number of levels fused and curve size. Areas for cost savings include further reduction in implant costs, shortening length of stay, and reducing intraoperative costs. LEVEL OF EVIDENCE: III.

Implant wastage in orthopaedic trauma: a UK experience.

INTRODUCTION: Implant wastage is an under-reported issue in orthopaedics, yet it has been shown to have a significant cost burden on healthcare budgets. In a background of a perilous financial climate in the UK health service, our aim was to define the frequency and costs of implant wastage in orthopaedic trauma. MATERIALS AND METHODS: The trauma theatre's implant logbook was retrospectively analysed between April 2017 and April 2018. Wasted implants were identified by the study authors independently. Patient demographics, implant details and costs were among the data collected. Product codes of wasted implants were used to identify implant costs through the manufacturer. RESULTS: Implant wastage occurred in 25.1% of trauma procedures during the study period. Most wasted implants (91%) were screws. The total cost of implant wastage was £8,377.25 during the 12-month period, accounting for 2% of the total implant budget. Wasted intramedullary nails accounted for almost 50% of the total cost. More than 51% of affected procedures involved a trainee as the primary operator. DISCUSSION: We report the first study of implant wastage in orthopaedics from the UK. Total implant wastage was higher than reported in most of the published literature, although it represented a small portion of the budget. Implant wastage is attributable to surgeons or operating theatre staff in most cases and is compounded by surgeons' limited understanding of implant costs. Initiatives to reduce implant wastage should include raising awareness of costs and departmental wastage to surgeons and operating theatre staff as well as employing preoperative planning techniques.

Variation in Implant Selection for Ankle Fractures: Identifying Cost Drivers.

BACKGROUND: Implant selection is the first opportunity for surgeons to control costs of fracture fixation. The current literature has demonstrated surgeons' poor understanding of implant costs. Our study evaluated implant cost variability for surgically treated ankle fractures and distal tibia fractures. Our hypothesis was that significant cost variation exists among providers. The goal was to identify cost drivers and determine whether specialty training is linked to implant selection. METHODS: A retrospective 2010-2017 chart review was performed for 1281 patients at a Level I trauma center. Patients were excluded for skeletal immaturity, open fractures, polytrauma, and concurrent surgeries. Variables were assessed included age, sex, body mass index, OTA/AO classification, Weber classification, 1-year reoperation status, surgeon specialty, and use of syndesmotic screws, locking plates, and cannulated screws. Construct cost was determined by using electronic medical record implant model numbers cross-referenced with the chargemaster database. Statistical analysis involved intergroup comparative tests, regression analysis, and goodness-of-fit analyses. RESULTS: Implant cost was different among OTA patterns (P < 0.01), highest among 43C ($3771) and lowest with 44A ($819). Construct costs of OTA 43 fractures varied from $2568 to 3771, whereas OTA 44 ranged from $819 to $1474. Costs were comparable across Weber patterns (P = 0.15), with Weber B having the highest ($1494). Costs were highest among reconstructive, podiatry, and spine surgeons, with mean costs of $1804, $1404, and $1396, respectively. Traumatologist constructs had the lowest overall price ($987). A total of 433 (33.8%) procedures used locking plates with 512 (40.0%) using at least one cannulated screw. Locking plates averaged a larger total implant cost ($1947) than nonlocking plates ($1313) but had a comparable reoperation rate (18.5% vs. 17.7%, P = 0.81). Use of a cannulated screw presented a higher total cost ($2008 vs. $1435) with comparable reoperation rates (17.4% vs. 18.8%, P = 0.72). A total of 401 (31.5%) patients received syndesmotic fixation and a significantly higher reoperation rate (17.0% vs. 11.0%, P < 0.01). Overall, 199 patients underwent elective hardware removal, 23 were infected, 7 required revision, and 3 were identified with a nonunion. CONCLUSIONS: Our study demonstrated significant variability in implant costs for ankle fracture fixation and identified the key cost drivers as locking plates and cannulated screws. Surgical management of ankle fractures could be an ideal setting to pilot economic alignment between physicians and hospitals to drive value. LEVEL OF EVIDENCE: Level III. Retrospective Cohort.

Does Implant Choice Affect the Episode Cost of Pertrochanteric Hip Fracture for US Veterans?

OBJECTIVE: To investigate an association between a surgeon's choice of a cephalomedullary nail (CMN) or sliding hip screw (SHS) with the cost of treating a pertrochanteric hip fracture. DESIGN: Multicenter retrospective cohort study. SETTING: US Veterans Health Administration Sierra Pacific Network. PATIENTS/PARTICIPANTS: Two hundred ninety-four consecutive US veterans admitted for a principal diagnosis of an OTA/AO 31A-type pertrochanteric hip fracture of a native hip from 2000 to 2015. INTERVENTION: Internal fixation using a CMN or an SHS. MAIN OUTCOME MEASUREMENTS: Veterans Administration Health Economic Resource Center average national cost estimate of combined acute and postacute care episode cost, excluding implant cost, normalized to 2015 US dollars by the Consumer Price Index. RESULTS: Median episode cost was $8223 lower with a CMN than an SHS (95% confidence interval, $5700-$10,746, P < 0.001) after matching on a propensity score for treatment with a CMN based on age, sex, body mass index, Charlson Comorbidity Index, fracture characteristics, study site, and admission year. A subgroup propensity-matched analysis excluding reverse obliquity pertrochanteric fractures was not sufficiently powered to detect a difference in episode cost (ß = 0.76, P = 0.311). CONCLUSIONS: Implant choice significantly affected the episode cost of care of hip fracture at Veterans Health Administration facilities. LEVEL OF EVIDENCE: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Proximal Row Carpectomy versus Four-Corner Arthrodesis for the Treatment of Scapholunate Advanced Collapse/Scaphoid Nonunion Advanced Collapse Wrist: A Cost-Utility Analysis.

BACKGROUND: Two mainstay surgical options for salvage in scapholunate advanced collapse and scaphoid nonunion advanced collapse are proximal row carpectomy and four-corner arthrodesis. This study evaluates the cost-utility of proximal row carpectomy versus three methods of four-corner arthrodesis for the treatment of scapholunate advanced collapse/scaphoid nonunion advanced collapse wrist. METHODS: A cost-utility analysis was performed in accordance with the Second Panel on Cost-Effectiveness in Health and Medicine. A comprehensive literature review was performed to obtain the probability of potential complications. Costs were derived using both societal and health care sector perspectives. A visual analogue scale survey of expert hand surgeons estimated utilities. Overall cost, probabilities, and quality-adjusted life-years were used to complete a decision tree analysis. Both deterministic and probabilistic sensitivity analyses were performed. RESULTS: Forty studies yielding 1730 scapholunate advanced collapse/scaphoid nonunion advanced collapse wrists were identified. Decision tree analysis determined that both four-corner arthrodesis with screw fixation and proximal row carpectomy were cost-effective options, but four-corner arthrodesis with screw was the optimal treatment strategy. Four-corner arthrodesis with Kirschner-wire fixation and four-corner arthrodesis with plate fixation were dominated (inferior) strategies and therefore not cost-effective. One-way sensitivity analysis demonstrated that when the quality-adjusted life-years for a successful four-corner arthrodesis with screw fixation are lower than 26.36, proximal row carpectomy becomes the optimal strategy. However, multivariate probabilistic sensitivity analysis confirmed the results of our model. CONCLUSIONS: Four-corner arthrodesis with screw fixation and proximal row carpectomy are both cost-effective treatment options for scapholunate advanced collapse/scaphoid nonunion advanced collapse wrist because of their lower complication profile and high efficacy, with four-corner arthrodesis with screw as the most cost-effective treatment. Four-corner arthrodesis with plate and Kirschner-wire fixation should be avoided from a cost-effectiveness standpoint.

A cost-effectiveness analysis of anchorage reinforcement with miniscrews and molar blocks in adolescents: a randomized controlled trial.

OBJECTIVE: To analyse cost-effectiveness of anchorage reinforcement with buccal miniscrews and with molar blocks. We hypothesized that anchorage with miniscrews is more cost-effective than anchorage with molar blocks. TRIAL DESIGN: A single-centre, two-arm parallel-group randomized controlled trial. METHODS: Adolescents (age 11-19 years) in need of treatment with fixed appliance, premolar extractions, and en masse retraction were recruited from one Public Dental Health specialist centre. The intervention arm received anchorage reinforcement with buccal miniscrews during space closure. The active comparator received anchorage reinforcement with molar blocks during levelling/alignment and space closure. The primary outcome measure was societal costs defined as the sum of direct and indirect costs. Randomization was conducted as simple randomization stratified on gender. The patients, caregivers, and outcome assessors were not blinded. RESULTS: Eighty patients were randomized into two groups. The trial is completed. All patients were included in the intention-to-treat analysis. The median societal costs for the miniscrew group were €4681 and for the molar block group were €3609. The median of the difference was €825 (95% confidence interval (CI) 431-1267). This difference was mainly caused by significantly higher direct costs consisting of material and chair time costs. Differences in chair time costs were related to longer treatment duration. No serious harms were detected, one screw fractured during insertion and three screws were lost during treatment. GENERALIZABILITY AND LIMITATIONS: The monetary variables are calculated based on a number of local factors and assumptions and cannot necessarily be transferred to other countries. Variables such as chair time, number of appointments, and treatment duration are generalizable. Owing to the study protocol, the benefit of miniscrews as a stable anchorage has not been fully utilized. CONCLUSIONS: When only moderate anchorage reinforcement is needed, miniscrews are less cost-effective than molar blocks. The initial hypothesis was rejected. Miniscrews provide better anchorage reinforcement at a higher price. They should be used in cases where anchorage loss cannot be accepted. TRIAL REGISTRATION: NCT02644811.

Evaluation of Factors Driving Cost Variation for Distal Radius Fracture Open Reduction Internal Fixation.

PURPOSE: Distal radius fracture open reduction and internal fixation (ORIF) represents a considerable cost burden to the health care system. We aimed to elucidate demographic-, injury-, and treatment-specific factors influencing surgical encounter costs for distal radius ORIF. METHODS: We retrospectively reviewed adult patients treated with isolated distal radius ORIF between November 2014 and October 2016 at a single tertiary academic medical center. Using our institution's information technology value tools-which allow for comprehensive payment and cost data collection and analysis on an item-level basis-we determined relative costs (RC) for each factor potentially influencing total direct costs (TDC) for distal radius ORIF using univariate and multivariable gamma regression analyses. RESULTS: Of the included 108 patients, implants and facility utilization costs were responsible for 48.3% and 37.9% of TDC, respectively. Factors associated with increased TDC include plate manufacturer (RC 1.52 for the most vs least expensive manufacturer), number of screws (RC 1.03 per screw) and distal radius plates used (RC 1.67 per additional plate), surgery setting (RC 1.32 for main hospital vs ambulatory surgery center), treating service (RC 1.40 for trauma vs hand surgeons), and surgical time (RC 1.04 for every 10 min of additional surgical time). Open fracture was associated with increased costs (RC 1.55 vs closed fracture), whereas other estimates of fracture severity were nonsignificant. In the multivariable model controlling for injury-specific factors, variables including implant manufacturer, and number of distal radius plates and screws used, remained as significant drivers of TDC. CONCLUSIONS: Substantial variations in surgical direct costs for distal radius ORIF exist, and implant choice is the predominant driver. Cost reductions may be expected through judicious use of additional plates and screws, if hospital systems use bargaining power to reduce implant costs, and by efficiently completing surgeries. CLINICAL RELEVANCE: This study identifies modifiable factors that may lead to cost reduction for distal radius ORIF.

Costs Associated With Single-Use and Conventional Sets for Distal Radius Plating.

PURPOSE: Volar plating of distal radius fractures is an increasingly common procedure. Presterilized, single-use volar plate fixation sets have been purported to increase operating room efficiency and decrease cost. The purpose of this study was to compare the actual cost of using a conventional set compared with the projected cost of using its single-use counterpart. METHODS: We retrospectively analyzed 30 consecutive cases of volar plate fixation in which conventional instrument sets were used. Hardware and processing costs were calculated for the conventional sets and compared with the projected cost of using single-use sets. RESULTS: The mean total cost of hardware and processing for the conventional sets was $2,728, whereas the projected cost for the single-use sets was slightly higher at $2,868. Twenty-three of the 30 cases would have required additional screws not available in the single-use set. The cost of the additional screws needed to supplement the single-use set would have added an average of $282/case. Overall, the combined hardware and processing cost was lower for conventional sets in 25 of the 30 cases. CONCLUSIONS: Although the price of the single-use set is less than the mean charge for use of a conventional set, additional screws not available in the single-use set were required in 77% of cases and consequently rendered the conventional set cheaper in 83% of cases. Stocking the single-use sets with additional screws to reflect the most commonly used screw lengths could make these sets more cost effective in the future. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic and decision analysis IV.

Implant options for the treatment of intertrochanteric fractures of the hip: rationale, evidence, and recommendations.

AIMS: The aim of this paper is to review the evidence relating to the anatomy of the proximal femur, the geometry of the fracture and the characteristics of implants and methods of fixation of intertrochanteric fractures of the hip. MATERIALS AND METHODS: Relevant papers were identified from appropriate clinical databases and a narrative review was undertaken. RESULTS: Stable, unstable, and subtrochanteric intertrochanteric fractures vary widely in their anatomical and biomechanical characteristics, as do the implants used for their fixation. The optimal choice of implant addresses the stability of the fracture and affects the outcome. CONCLUSION: The treatment of intertrochanteric fractures of the hip has evolved along with changes in the design of the implants used to fix them, but there remains conflicting evidence to guide the choice of implant. We advocate fixation of 31A1 fractures with a sliding hip screw and all others with an intramedullary device. Cite this article: Bone Joint J 2017;99-B:128-33.

Does Knowledge of Implant Cost Affect Fixation Method Choice in the Management of Stable Intertrochanteric Hip Fractures?

We conducted a study to determine if knowledge of implant cost affects fixation method choice in the management of stable intertrochanteric hip fractures. We retrospectively reviewed the cases of 119 patients treated with a sliding hip screw (SHS; Versafix), a short Gamma nail (SGN), or a long Gamma nail (LGN). Of the 119 fractures, 71 were treated before implant costs were revealed, and 48 afterward. The 2 groups were similar in age, sex, fracture types, American Society of Anesthesiologists physical status classification, and preinjury ambulatory status. SHS was used in 38.0% of the before cases and 27.1% of the after cases, SGN in 29.6% of the before cases and 45.8% of the after cases, and LGN in 32.4% of the before cases and 27.1% of the after cases. Changes in implant use were not statistically significant. SHS was favored for 31-A1.1, 31-A1.2, and 31-A2.1 fractures in the before group but only for 31-A1.2 fractures in the after group. Gamma nails of both sizes were preferred in the after group for 31-A1.1, 31-A1.3, and 31-A2.1 fractures. At our institution, surgeon knowledge of implant cost did not affect fixation method choice in the management of stable intertrochanteric hip fractures.

Suture Button Fixation Versus Syndesmotic Screws in Supination-External Rotation Type 4 Injuries: A Cost-Effectiveness Analysis.

BACKGROUND: In stress-positive, unstable supination-external rotation type 4 (SER IV) ankle fractures, implant selection for syndesmotic fixation is a debated topic. Among the available syndesmotic fixation methods, the metallic screw and the suture button have been routinely compared in the literature. In addition to strength of fixation and ability to anatomically restore the syndesmosis, costs associated with implant use have recently been called into question. PURPOSE: This study aimed to examine the cost-effectiveness of the suture button and determine whether suture button fixation is more cost-effective than two 3.5-mm syndesmotic screws not removed on a routine postoperative basis. STUDY DESIGN: Economic and decision analysis; Level of evidence, 2. METHODS: Studies with the highest evidence levels in the available literature were used to estimate the hardware removal and failure rates for syndesmotic screws and suture button fixation. Costs were determined by examining the average costs for patients who underwent surgery for unstable SER IV ankle fractures at a single level-1 trauma institution. A decision analysis model that allowed comparison of the 2 fixation methods was developed. RESULTS: Using a 20% screw hardware removal rate and a 4% suture button hardware removal rate, the total cost for 2 syndesmotic screws was US$20,836 and the total effectiveness was 5.846. This yielded a total cost of $3564 per quality-adjusted life-year (QALY) over an 8-year time period. The total cost for suture button fixation was $19,354 and the total effectiveness was 5.904, resulting in a total cost of $3294 per QALY over the same time period. A sensitivity analysis was then conducted to assess suture button fixation costs as well as screw and suture button hardware removal rates. Other possible treatment scenarios were also examined, including 1 screw and 2 suture buttons for operative fixation of the syndesmosis. To become more cost-effective, the screw hardware removal rate would have to be reduced to less than 10%. Furthermore, fixation with a single suture button continued to be the dominant treatment strategy compared with 2 suture buttons, 1 screw, and 2 screws for syndesmotic fixation. CONCLUSION: This cost-effectiveness analysis suggests that for unstable SER IV ankle fractures, suture button fixation is more cost-effective than syndesmotic screws not removed on a routine basis. Suture button fixation was a dominant treatment strategy, because patients spent on average $1482 less and had a higher quality of life by 0.058 QALYs compared with patients who received fixation with 2 syndesmotic screws. Assuming that functional outcomes and failure rates were equivalent, screw fixation only became more cost-effective when the screw hardware removal rate was reduced to less than 10% or when the suture button cost exceeded $2000. In addition, fixation with a single suture button device proved more cost-effective than fixation with either 1 or 2 syndesmotic screws.

The Clinical and Economic Impact of Generic Locking Plate Utilization at a Level II Trauma Center.

OBJECTIVES: In today's climate of cost containment and fiscal responsibility, generic implant alternatives represent an interesting area of untapped resources. As patents have expired on many commonly used trauma implants, generic alternatives have recently become available from a variety of sources. The purpose of this study was to examine the clinical and economic impact of a cost containment program using high quality, generic orthopaedic locking plates. The implants available for study were anatomically precontoured plates for the clavicle, proximal humerus, distal radius, proximal tibia, distal tibia, and distal fibula. DESIGN: Retrospective review. SETTING: Level II Trauma center. PATIENTS: 828 adult patients with operatively managed clavicle, proximal humerus, distal radius, proximal tibia, tibial pilon, and ankle fractures. INTERVENTION: Operative treatment with conventional or generic implants. RESULTS: The 414 patients treated with generic implants were compared with 414 patients treated with conventional implants. There were no significant differences in age, sex, presence of diabetes, smoking history or fracture type between the generic and conventional groups. No difference in operative time, estimated blood loss or intraoperative complication rate was observed. No increase in postoperative infection rate, hardware failure, hardware loosening, malunion, nonunion or need for hardware removal was noted. Overall, our hospital realized a 56% reduction in implant costs, an average savings of $1197 per case, and a total savings of $458,080 for the study period. CONCLUSIONS: Use of generic orthopaedic implants has been successful at our institution, providing equivalent clinical outcomes while significantly reducing implant expenditures. Based on our data, the use of generic implants has the potential to markedly reduce operative costs as long as quality products are used. LEVEL OF EVIDENCE: Therapeutic Level III.

A Cost-Effective Technique for Spinal Instrumentation in the Treatment of Adolescent Idiopathic Scoliosis.

Surgical treatment for adolescent idiopathic scoliosis (AIS) has evolved over the past decades to the point where instrumented arthrodesis with all pedicle screw and rod constructs is commonplace. Although these constructs provide superb correction and fixation, their financial burden is substantial. Here, we present a more cost-effective technique using a combination of pedicle screws (serving as the construct base), a sagittal precontoured unit rod, and sublaminar wires to provide segmental correction for the surgical treatment of AIS. Retrospective analyses of 42 patients treated with this construct were reviewed with a minimum 2-year follow-up. Correction in both coronal and sagittal planes was assessed radiographically and blood loss, operative time, complications, and cost were reviewed from hospital records. We conclude that this technique provides comparable correction to all pedicle screw constructs with similar blood loss and operative time, but with substantially decreased implant cost. The mean implant cost was $8910.83 ± $184.26.

Maxillomandibular Fixation by Plastic Surgeons: Cost Analysis and Utilization of Resources.

PURPOSE: Maxillomandibular fixation (MMF) can be performed using various techniques. Two common approaches used are arch bars and bone screws. Arch bars are the gold standard and inexpensive, but often require increased procedure time. Bone screws with wire fixation is a popular alternative, but more expensive than arch bars. The differences in costs of care, complications, and operative times between these 2 techniques are analyzed. METHODS: A chart review was conducted on patients treated over the last 12 years at our institution. Forty-four patients with CPT code 21453 (closed reduction of mandible fracture with interdental fixation) with an isolated mandible fracture were used in our data collection. The operating room (OR) costs, procedure duration, and complications for these patients were analyzed. RESULTS: Operative times were significantly shorter for patients treated with bone screws (P < 0.002). The costs for one trip to the OR for either method of fixation did not show any significant differences (P < 0.840). More patients with arch bar fixation (62%) required a second trip to the OR for removal in comparison to those with screw fixation (31%) (P < 0.068). This additional trip to the OR added significant cost. There were no differences in patient complications between these 2 fixation techniques. CONCLUSIONS: The MMF with bone screws represents an attractive alternative to fixation with arch bars in appropriate scenarios. Screw fixation offers reduced costs, fewer trips to the OR, and decreased operative duration without a difference in complications. Cost savings were noted most significantly in a decreased need for secondary procedures in patients who were treated with MMF screws. Screw fixation offers potential for reducing the costs of care in treating patients with minimally displaced or favorable mandible fractures.

Screw size and insertion technique compared with removal rates for calcaneal displacement osteotomies.

BACKGROUND: The calcaneal displacement osteotomy is frequently used by foot and ankle surgeons to correct hindfoot angular deformity. Headed compression screws are often used for this purpose, but a common complication is postoperative plantar heel pain from prominent hardware. We evaluated hardware removal rates after calcaneal displacement osteotomies and analyzed technical factors including screw size, position, and angle. We hypothesized that larger screws placed more plantarly would have been removed more frequently. We also believed that although 2 smaller screws cost more initially, when removal rates and cost are accounted for, savings would be demonstrated with this technique. METHODS: We retrospectively collected data on type of fixation, cost of fixation, and frequency of removal. After exclusions we had 30 patients in our screw removal cohort and 119 in our screws retained cohort. A basic cost analysis and statistical analysis was performed. RESULTS: The small screw group had a hardware removal rate of 9% (4/43) compared to 25% (26/104) of the larger screw group (P = .032). While the cost of 2 smaller screws is more than that of 1 larger screw, when the cost of removal and the rates of doing so are considered, the smaller screws resulted in substantial cost savings. CONCLUSION: Technical considerations for the medial displacement calcaneal osteotomy, including the use of multiple smaller screws, provided for a lower rate of hardware removal and likely decreased long-term costs. LEVEL OF EVIDENCE: Level III, comparative series.

Comparing fixation used for calcaneal displacement osteotomies: a look at removal rates and cost.

BACKGROUND: The calcaneal displacement osteotomy is a procedure frequently used by foot and ankle surgeons for hindfoot angular deformity. Traditional techniques use compression screw fixation that can result in prominent hardware. While the results of the procedure are generally good, a common concern is the development of plantar heel pain related to prominent hardware. The primary purpose of this study is to retrospectively compare clinical outcomes of 2 fixation methods for the osteotomy. Secondarily a cost analysis will compare implant costs to hardware removal costs. METHODS: Records were reviewed for patients who had undergone a calcaneal displacement osteotomy fixated with either lag screw or a locked lateral compression plate (LLCP). Neuropathy, previous ipsilateral calcaneus surgery, heel pad trauma, or incomplete radiographic follow-up were exclusionary. RESULTS: Thirty-two patients (19.4%) required hardware removal from the screw fixation group compared to 1 (1.6%) of the LLCP group, which is significant (P < .05). Time to radiographic healing was not significantly different (P = .87). The screw fixation group required more follow-up visits over a longer period of time (P < .05). Implant cost was remarkably different with screw fixation costing on average $247.12, compared to the LLCP costing $1175.59. Although the LLCP cost was significantly higher, cost savings were identified when the cost of removal and removal rates were included. CONCLUSION: This study demonstrates that this device provides adequate stabilization for healing in equivalent time to screw fixation. The LLCP required decreased rates of hardware removal with fewer postoperative visits over a shorter period of time. Significant savings were demonstrated in the LLCP group despite the higher implant cost. LEVELS OF EVIDENCE: Therapeutic, Level III, Retrospective Comparative Study.