Introduction. Motorised intramedullary lengthening nails are considered more expensive than external fixators for limb lengthening. This research aims to compare the cost of femoral lengthening in children using the PRECICE magnetic lengthening nail with external fixation. Materials and Methods. Patients: Retrospective analysis of 50 children who underwent femoral lengthening. One group included patients who were treated with PRECICE lengthening nails, the other group included patients who had lengthening with external fixation. Each group included 25 patients aged between 11–17 years. The patients in both groups were matched for age. Cost analysis was performed following micro-costing and analysis of the used resources during the different phases of the treatments. Results. : Each group's mean patient age was 14.7 years. Lengthening nails were associated with longer operative times compared to external fixators, both for implantation and removal surgery (P-value 0.007 and <0.0001 respectively). Length of stay following the implantation surgery, frequency of radiographs, frequency of outpatient department appointments were all more favourable with lengthening nails. The overall cost of lengthening nails was £1393 more than external fixators, although this difference was not statistically significant (P-value 0.088). Conclusions. The cost of femoral lengthening with lengthening nails was not significantly higher than the external fixators’ cost. Further research to review the effectiveness of the devices and the quality of life during the lengthening process is crucial for robust health economic evaluation

Progressive collapsing foot deformity (PCFD) is a common condition with an estimated prevalence of 3.3% in women greater than 40 years. Progressive in nature, symptomatic flatfoot deformity can be a debilitating condition due to pain and limited physical function; it has been shown to have one of the poorest preoperative patient reported outcome scores in foot and ankle pathologies, second to ankle arthritis. Operative reconstruction of PCFD can be performed in a single-stage manner or through multiple stages. The purpose of this study is to compare costs for non-staged (NS) flatfoot reconstructions, which typically require longer hospital stays, with costs for staged (S) reconstructions, where patients usually do not require hospital admission. To our knowledge, the comparison between single-staged and multi-staged flatfoot reconstructions has not been previously done. This study will run in conjunction with one that compares rates of complications and reoperation, as well as patient reported outcomes on function and pain associated with S and NS flatfoot reconstruction. Overall, the goal is to optimize surgical management of PCFD, by addressing healthcare costs and patient outcomes. At our academic centre with foot and ankle specialists, we selected one surgeon who primarily performs NS flatfoot reconstruction and another who primarily performs S procedures. Retrospective chart reviews of patients who have undergone either S or NS flatfoot reconstruction were performed from November 2011 to August 2021. Length of operating time, number of primary surgeries, length of hospital admission, and number of reoperations were recorded. Cost analysis was performed using local health authority patient rates for non residents as a proxy for health system costs. Rates of operating room per hour and hospital ward stay per diem in Canadian dollars were used. The analysis is currently ongoing. 72 feet from 66 patients were analyzed in the S group while 78 feet from 70 patients were analyzed in the NS group. The average age in the S and NS group are 49.64 +/− 1.76 and 57.23 +/− 1.68 years, respectively. The percentage of female patients in the S and NS group are 63.89% and 57.69%, respectively. All NS patients stayed in hospital post-operatively and the average length of stay for NS patients is 3.65 +/− 0.37 days. Only 10 patients from S group required hospital admission. The average total operating room cost including all stages for S patients was $12,303.12 +/− $582.20. When including in-patient ward costs for patients who required admission from S group, the average cost for operating room and in-patient ward admission was $14,196.00 +/− $1,070.01 after flatfoot reconstruction. The average in-patient ward admission cost for NS patients was $14,518.83 +/− $1,476.94 after flatfoot reconstruction. The cost analysis for total operating room costs for NS patients are currently ongoing. Statistical analysis comparing S to NS flatfoot reconstruction costs are pending. Preliminary cost analysis suggests that multi-staged flatfoot reconstruction costs less than single-staged flatfoot reconstruction. Once full assessment is complete with statistical analysis, correlation with patient reported outcomes and complication rate can guide future PCFD surgical management

Distal interphalangeal joint (DIPJ) fusion using a k-wire has been the gold standard treatment for DIPJ arthritis. Recent studies have shown similar patient outcomes with the headless compression screws (HCS), however there has been no cost analysis to compare the two. Therefore, this study aims to 1) review the cost of DIPJ fusion between k-wire and HCS 2) compare functional outcome and patient satisfaction between the two groups. A retrospective review was performed over a nine-year period from 2012-2021 in Counties Manukau. Cost analysis was performed between patients who underwent DIPJ fusion with either HCS or k-wire. Costs included were surgical cost, repeat operations and follow-up clinic costs. The difference in pre-operative and post-operative functional and pain scores were also compared using the patient rate wrist/hand evaluation (PRWHE). Of the 85 eligible patients, 49 underwent fusion with k-wires and 36 had HCS. The overall cost was significantly lower in the HCS group which was 6554 New Zealand Dollars (NZD), whereas this was 10408 NZD in the k-wire group (p<0.0001). The adjusted relative risk of 1.3 indicate that the cost of k-wires is 1.3 times more than HCS (P=0.0053). The patients’ post-operative PRWHE pain (−22 vs −18, p<0.0001) and functional scores (−38 vs −36, p<0.0001) improved significantly in HCS group compared to the k-wire group. Literatures have shown similar DIPJ fusion outcomes between k-wire and HCS. K-wires often need to be removed post-operatively due to the metalware irritation. This leads to more surgical procedures and clinic follow-ups, which overall increases the cost of DIPJ fusion with k-wires. DIPJ fusion with HCS is a more cost-effective with a lower surgical and follow-up costs compared to the k-wiring technique. Patients with HCS also tend to have a significant improvement in post-operative pain and functional scores

Aims. Early detection of developmental dysplasia of the hip (DDH) is associated with improved outcomes of conservative treatment. Therefore, we aimed to evaluate a novel screening programme that included both the primary risk factors of breech presentation and family history, and the secondary risk factors of oligohydramnios and foot deformities. Methods. A five-year prospective registry study investigating every live birth in the study’s catchment area (n = 27,731), all of whom underwent screening for risk factors and examination at the newborn and six- to eight-week neonatal examination and review. DDH was diagnosed using ultrasonography and the Graf classification system, defined as grade IIb or above or rapidly regressing IIa disease (≥4. o. at four weeks follow-up). Multivariate odds ratios were calculated to establish significant association, and risk differences were calculated to provide quantifiable risk increase with DDH, positive predictive value was used as a measure of predictive efficacy. The cost-effectiveness of using these risk factors to predict DDH was evaluated using NHS tariffs (January 2021). Results. The prevalence of DDH that required treatment within our population was 5/1,000 live births. The rate of missed presentation of DDH was 0.43/1000 live births. Breech position, family history, oligohydramnios, and foot deformities demonstrated significant association with DDH (p < 0.0001). The presence of breech presentation increased the risk of DDH by 1.69% (95% confidence interval (CI) 0.93% to 2.45%), family history by 3.57% (95% CI 2.06% to 5.09%), foot deformities by 8.95% (95% CI 4.81% to 13.1%), and oligohydramnios nby 11.6% (95 % CI 3.0% to 19.0%). Primary risk factors family history and breech presentation demonstrated an estimated cost-per-case detection of £6,276 and £11,409, respectively. Oligohydramnios and foot deformities demonstrated a cost-per-case detected less than the cost of primary risk factors of £2,260 and £2,670, respectively. Conclusion. The inclusion of secondary risk factors within a national screening programme was clinically successful as they were more cost and resource-efficient predictors of DDH than primary risk factors, suggesting they should be considered in the national guidance. Cite this article: Bone Jt Open 2023;4(4):234–240

Background. Operative treatment of complex proximal humerus fractures remains controversial. The transition to value-based health care demands a better understanding of the costs associated with surgery. The purpose of this study was to examine the 90-day costs of three common surgical treatments for proximal humerus fractures and non-operative treatment and compare the costs associated with the initial-day and subsequent 89-days of care. Methods. A query of the Humana insurance claims database was performed through the PearlDiver Supercomputer (Warsaw, IN) from 2010 to 2014 using the diagnosis codes for proximal humerus fractures together with current procedural terminology codes (CPT) for hemiarthroplasties (HA), open reduction internal fixation (ORIF), reverse shoulder arthroplasty (RSA) and nonoperative treatment (NO). Reimbursement from the insurance claims database was used as a marker for costs. The same day, subsequent 89-day, and ninety day costs were analyzed trough the use of descriptive and comparative statistical analysis. Results. RSA was the most costly procedure for the same-day and 90-day costs (p<0.001) (Figure 1). Mean initial-day reimbursement costs were significantly different amongst treatment groups, with the highest costs seen with RSA ($16,151), followed by HA ($9,348), ORIF ($6,745) and lastly, NO ($1,932). Subsequent 89-day reimbursement costs were not significantly different for RSA, HA and ORIF (p=0.112) (Figure 1 and 2); however, NO treatment incurred significantly lower costs (p=0.008) (Figure 3). Conclusion. The 90-day costs for the surgical treatment of proximal humerus fractures are driven by the initial-day costs. RSA was associated with the highest cost, followed by HA and ORIF. NO management incurred the lowest costs

Advances in total hip and knee replacement technologies have heretofore been largely driven by corporate marketing hype with each seeming advancement accompanied by a cost increase often out in front of peer-reviewed reports documenting their efficacy or not. As example, consider the growing use of ceramic femoral heads in primary total hip arthroplasty (THA). The question to consider is “Can an upcharge of $350 for a ceramic femoral head in primary THA be justified?” The answer to this question lies in an appreciation of whether the technology modifies the potential for costly revision arthroplasty procedures. Peer-Reviewed Laboratory & Clinical Review - According to the 2022 Australian National Joint Replacement Registry, the four leading causes of primary THA failure requiring revision are: 1.) infection, 2.) dislocation/instability, 3.) periprosthetic fracture and 4.) loosening, which constitute 87.5% of the reported reasons for revision. Focusing on these failure modes, hip simulator findings report that ceramic femoral heads dramatically reduce wear debris generation, decreasing the potential for osteolytic response leading to loosening. Further, ceramic materials enable the utilization of larger head sizes, avoiding the potential for dislocation. The overall mid- to long-term survival rate reported in the peer-reviewed, clinical literature for these bearings has exceeded 95% with virtually no osteolysis. Also, could bearing surface choice influence periprosthetic joint infection (PJI)? A study on a total of more than 10,500 primary THA procedures reported a confirmed PJI incidence of 2.4% for cobalt-chrome and 1.6% for ceramic femoral heads, suggesting that the employ of a ceramic bearing surface may also play a role in decreasing the potential for infection. Review of the clinical data available for ceramic bearings justifies that it is better to “pay me now than to pay orders of magnitude later”, if in fact a revision THA can be avoided, significantly reducing the overall financial burden to the healthcare system

Open lower limb fractures are resource-intensive fractures, accounting for a significant proportion of the workload and cost of orthopaedic trauma units. A recent study has evaluated that the median cost of direct inpatient treatment of open lower-limb fractures in the National Health Service (NHS) is steep, at £19189 per patient. Healthcare providers are expected to be aware of the costs of treatments, although there is very limited dissemination of this information, neither on a national or local level. Older adults (>65 years old) are at an increased risk of the types of high-energy injuries that can result in open lower limb fractures. Generally, there remains a significant lack of literature surrounding the cost of open fracture management, especially in specific patient groups that are disproportionately affected by these fractures. This study has calculated the direct inpatient care costs of older adults with open lower limb fractures. Open lower limb fractures in adult patients over 65 years old treated at Addenbrooke's Hospital of Cambridge University Hospitals NHS Trust were identified over the period of March 2014-March 2019. Isolated fractures of the femur, tibia and fibula over this time period were included. Direct inpatient care costs were calculated using information about the sustained fracture, operative time, implant(s) and theatre kit(s) used, the number of patient bed-days on the orthopaedic ward and critical care unit, and the number of hours of inpatient physiotherapy received. Direct inpatient care costs were compared with the income received by our centre for each of these cases, according to Healthcare Resource Group (HRG) cost codes. Our data was also compared with existing literature on Patient Level Costing (PLC) figures for open lower limb fractures. We extracted data from 58 patients over the age of 65 years treated for open isolated lower limb fractures at Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, between March 2014 and March 2019. The median cost of inpatient care calculated in this study was £20,398 per patient, resulting in a financial loss to the hospital of £5113 per patient. When the results were disaggregated by sex, the median cost for an open lower limb fracture in a male patient was £20,886 compared to £19,304 in a female patient. Data were also disaggregated by the site of injury, which produced a median cost for an open femur fracture of £23,949, and £24,549 and £15,362 for open tibia and ankle fractures, respectively. The absence of published primary literature and clinical audits on this topic continues to hinder the inclusion of cost-effectiveness as an important factor in clinical decision-making. This study provides valuable insight into the true cost of open lower limb fractures in a key patient population in a Major Trauma Centre in England and highlights the large losses incurred by hospitals in treating these cases. These results support the revision of the remuneration structures in the NHS for the treatment of elderly patients with these injuries

Waiting time to access medical care in Canada is 20% more than the international average. Delay in instituting care in trauma patients has been shown to correlate with higher complication rates and an increase in mortality. About 11% of all fractures occur in the femur and are usually treated operatively. Delay to operative treatment is a source of distress to patients and a major factor for poor outcome. Knowledge gaps exist for statistics on operative delay to fixation of femur fractures and the influence on complications and cost of treatment. This study describes (1) the effect of delay to fixation of femur fractures on complications and on the overall cost of care in hospitals in Quebec Province of Canada; and (2) proposes a time frame within which femur fractures should be operated on to minimize the risk of complications and reduce treatment cost. 6,520 adult patients operated for closed femoral fractures between July 1993 and December 2002 were reviewed. Data was accessed from (a) the Quebec Trauma Registry, (b) the hospitalised patients’ database, Maintenance et exploitation des données pour l’étude de la clientèle hospitalière (MED-ECHO) and (c) the medical insurance claims databases, Régie de l’assurance maladie Québec (RAMQ). Excluded were poly-trauma, open fractures, pathological fractures and delayed diagnoses beyond a week. Data was analysed using the SPSS software version 17.0. Cost analysis was carried out using parametric techniques (Student’s t-test and the generalized longitudinal model). Mean operative delay for femoral fractures was 26.3 hours. Delay was associated with increased complications, ICU stay, length of stay (LOS), hospitalization costs and out-patient follow-up treatment costs. There was a progressive increase in these adverse events which was quite significant after the first 48 hours. ISS >15 predisposed to prolonged ICU stay, LOS and increased cost of treatment. All femur fractures appeared to have a predilection for over-65-year-olds and women. The major cost drivers of operative femur fracture treatment were ISS>15, operative delay ≥48 hours, occurrence of complications, and re-operations. Minimizing operative delay in femur fractures will not only mitigate patient suffering, but also reduce treatment and follow-up costs

Abstract. Objective. In this systematic review we aim to analyse the economical impact of using Negative Pressure Wound Therapy (NPWT) in primary total knee arthroplasty (TKA). Methods. Four medical electronic databases were searched. Eligible studies included those investigating the costs of NPWT in primary TKA. Exclusion criteria included studies investigating cost of NPWT not related to primary TKA. We also excluded studies with poor scientific methodology. We retrieved and analysed data on dressing costs and hospital length of stay (LOS). Results. Three studies (359 patients) reported on dressing and associated health care costs, and two further studies (330 patients) reported on hospital LOS in primary TKA. The cost of NPWT ranged between £125 and £196; with an average cost of £155, compared to £23 for the regular surgical dressing. The hospital LOS in NWPT patients ranged from 1.9 – 3.8 days, while LOS in patients managed with regular surgical dressing ranged between 2.3 – 4.7 days. The hospital LOS accounted for delayed discharge due to wound complications. Any extended LOS secondary to medical comorbidities or for other reasons were not included here. Conclusion. Our pooled analysis found a decrease in hospital LOS from wound related problems when using NWPT instead of regular dressings after accounting for other variables responsible for LOS. If the mean cost of overnight inpatient hospital stay for elective TKA is estimated as £275, the range of overnight admission cost for one TKA patient would be £522 - £1045 when NPWT dressing is used, and £632.5 - £1292 when using regular dressings. The cost savings from reduced LOS amounts to £110 - £247 per patient when NPWT is used. We hypothesize that in primary TKA patients with high risk of wound related problems that may delay discharge from hospital, there may be an overall cost saving when using NWPT dressings. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Aims. Total hip arthroplasty (THA) is considered the preferred treatment for displaced proximal femoral neck fractures. However, in many countries this option is economically unviable. To improve outcomes in financially disadvantaged populations, we studied the technique of concomitant valgus hip osteotomy and operative fixation (VOOF). This prospective serial study compares two treatment groups: VOOF versus operative fixation alone with cannulated compression screws (CCSs). Methods. In the first series, 98 hip fixation procedures were performed using CCS. After fluoroscopic reduction of the fracture, three CCSs were placed. In the second series, 105 VOOF procedures were performed using a closing wedge intertrochanteric osteotomy with a compression lag screw and lateral femoral plate. The alignment goal was to create a modified Pauwel’s fracture angle of 30°. After fluoroscopic reduction of fracture, lag screw was placed to achieve the calculated correction angle, followed by inter-trochanteric osteotomy and placement of barrel plate. Patients were followed for a minimum of two years. Results. Mean follow-up was 4.6 years (4.1 to 5.0) in the CCS group and 5.5 years (5.25 to 5.75) in the VOOF group. The mean Harris Hip Score at two-year follow-up was 83.85 in the CCS group versus 88.00 in the VOOF group (p < 0.001). At the latest follow-up, all-cause failure rate was 29.1% in the CCS group and 11.7% in the VOOF group (p = 0.003). The total cost of the VOOF technique was 7.2% of a THA, and total cost of the CCS technique was 6.3% of a THA. Conclusion. The VOOF technique decreased all-cause failure rate compared to CCS. The total cost of VOOF was 13.5% greater than CCS, but 92.8% less than a THA. Increased cost of VOOF was considered acceptable to all patients in this series. VOOF technique provides a reasonable alternative to THA in patients who cannot afford a THA procedure. Cite this article: Bone Jt Open 2023;4(5):329–337

Abstract. Objectives. The purpose of this study was to determine the cost of inpatient admissions for developmental dysplasia of the hip (DDH) at a UK tertiary referral centre, and identify any association between newborn screening (NIPE) status and the cost of treatment. Methods. This was a retrospective study, using hospital episodes data from a single NHS trust. All inpatient episodes between 01/01/2014 to 30/06/2019 with an ICD-10 code stem of Q65 ‘congenital deformities of hip’ were screened to identify admissions for management of DDH. Data was subsequently obtained from electronic and paper records. Newborn screening status was recorded, and patients were divided into ‘NIPE-positive’ (diagnosed through selective screening) and ‘NIPE-negative’ (not diagnosed through screening). Children with neuromuscular conditions or concomitant musculoskeletal disease were excluded. The tariff paid for each inpatient episode was identified, and the number of individual clinic attendances, surgical procedures and radiological examinations performed (USS, XR, CT, MRI) were recorded. Results. 41 patients with DDH were admitted for inpatient management. 44% (n = 18) were NIPE-positive, diagnosed mean age 6.7 weeks. 56% (n = 23) were NIPE-negative, diagnosed mean age 26 months. The total cost of inpatient care in the NIPE-positive group was £171,471 (£9,526.18 per-patient) compared to £306,615 (£13,331.10 per-patient) for NIPE-negative. In the NIPE-positive group, there were 99 clinic attendances, 47 inpatient admissions and 160 radiological examinations performed (36 USS, 107 XR, 17 CT). This compared to 148 clinic attendances, 59 inpatient admissions and 215 radiological examinations (187 XR, 26 CT, 2 MRI) in the NIPE-negative group. Conclusion. A greater proportion of inpatient admissions for DDH are among NIPE-negative children. They incur a higher cost of treatment per patient and necessitate more inpatient resources. This study adds to the ongoing conversation around the cost-effectiveness of selective screening for DDH in the UK. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Periprosthetic femoral fracture (PFF) incidence following hip replacement surgery continues to rise. There is a national drive to centralise PFF treatment within specialist centres to improve clinical outcomes and cost-effectiveness. The financial implications of treating PFFs must be analysed to guide allocation of funding. Data were collected for 129 PFFs admitted from 02/04/2014–19/05/2020. Financial data were provided by the Patient Level Information and Costing Systems (PLICS) team. Primary outcomes were cost, revenue and margin for each PFF. Additional data were collected on length of stay (LOS), critical care requirements and clinical outcomes. Statistical comparisons were made between treatment type (fixation vs revision). Significance was set to p<0.05. Across the entire cohort, total cost was £2,389,901, total revenue was £1,695,435 and total loss was £694,481. Highest costs were ward stay (£714,591), theatre utilisation (£382,625), and overheads (£249,110). Median cost was £15,863 (IQR, £11,092-£22,221), median revenue was £11,305 (IQR, £7,147-£15,222) and median loss was £3,795 (IQR, £605-£8687). Median LOS was 21 days (IQR 13–34) and 28.7% patients required critical care admission. Ninety-six patients were treated operatively with either fixation (n=53) or revision (n=43). Median operating time was lower for fixation versus revision (132 [IQR, 115–185] vs 201 [IQR, 159–229] minutes, p=0.001). Median cost (£17,455 [IQR, £13,095-£22,824] vs £17,399 [£13,394-£23,404]) and median loss (£5,774 [IQR, £2,092-£10,472] vs £3,860 [IQR, £96-£7,601]) were similar for fixation and revision (p=0.99 and p=0.18, respectively). Median revenue was greater for revision versus fixation (£13,925 [IQR, £11,294-£17,037] vs £12,160 [IQR, £8,486-£14,390], p=0.02). There was no difference in LOS (21 [13–34] vs 21 [14–30] days, p=0.94), critical care requirements (20 [37.7%] vs 11 [25.6%], p=0.30), reoperations (3 [5.7%] vs 6 [14.0%], p=0.29], local complications (8 [15.1%) vs 12 [27.9%], p=0.20) or systemic complications (11 [20.8%] vs 11 [25.6%], p=0.75) between fixation and revision. PFF treatment costs are high with inadequate reimbursement through tariff. Work is needed to address this disparity and reduce costs associated with LOS, theatre utilisation and implants. Treatment cost should not be used when deciding between fixation and revision surgery

Aims. Tranexamic acid (TXA) is now commonly used in major surgical operations including orthopaedics. The TRAC-24 randomized control trial (RCT) aimed to assess if an additional 24 hours of TXA postoperatively in primary total hip (THA) and total knee arthroplasty (TKA) reduced blood loss. Contrary to other orthopaedic studies to date, this trial included high-risk patients. This paper presents the results of a cost analysis undertaken alongside this RCT. Methods. TRAC-24 was a prospective RCT on patients undergoing TKA and THA. Three groups were included: Group 1 received 1 g intravenous (IV) TXA perioperatively and an additional 24-hour postoperative oral regime, Group 2 received only the perioperative dose, and Group 3 did not receive TXA. Cost analysis was performed out to day 90. Results. Group 1 was associated with the lowest mean total costs, followed by Group 2 and then Group 3. The differences between Groups 1 and 3 (-£797.77 (95% confidence interval -1,478.22 to -117.32) were statistically significant. Extended oral dosing reduced costs for patients undergoing THA but not TKA. The reduced costs in Groups 1 and 2 resulted from reduced length of stay, readmission rates, emergency department attendances, and blood transfusions. Conclusion. This study demonstrated significant cost savings when using TXA in primary THA or TKA. Extended oral dosing reduced costs further in THA but not TKA. Cite this article: Bone Jt Open 2022;3(7):536–542

Guidelines for the use of preoperative blood tests for elective surgery were established. However, there is less evidence and no guidelines regarding using these tests when a young, healthy patient undergoes minor orthopaedic trauma surgery. Bloodwork is often ordered routinely, regardless of medical history or the nature of the injury. We hypothesized that unnecessary blood work is requested for younger pre-operative patients, and their results will not change peri-operative management. This practice is not a judicious use of healthcare resources. This study aimed to evaluate the frequency, type, cost, and impact on clinical decisions if standard preoperative bloodwork was completed in healthy patients requiring surgical management of a minor fracture or dislocation. After the approval of our institutional ethics board, a retrospective chart review was conducted. Inclusion criteria were patients aged 18-60 years, who had an isolated minor orthopaedic trauma requiring outpatient surgery, who were American Society of Anesthesiologists (ASA) class 1. ASA class 1 is defined as “a normal healthy patient, without any clinically important comorbidity and without a clinically significant past/present medical history.” Data records from January 1, 2016, to December 31, 2018, were extracted from a provincial database (the Analytics Data Integration, Measurement and Reporting) for five hospitals. Data including demographics, surgical treatment, type and number of blood tests ordered, and ordering physician were collected. Any abnormal test results were checked to see whether they led to a change in patient management or related to a postoperative adverse event. Independent samples t-tests and Chi-square tests were used to compare the characteristics of patients who had preoperative bloodwork versus those who did not. The cost of preoperative blood work was estimated. During these two years, 627 patients met inclusion criteria, and 27% (n=168) of these patients had bloodwork completed pre-operatively, while only 34% (n=57) of these had one or more abnormal laboratory parameters. These abnormalities were minor and did not alter clinical management or result in repeated bloodwork peri-operatively. Patients who had bloodwork were significantly older (40.2 years) compared with patients without preoperative blood work (37.8 years; p=0.03), but there was no difference in sex between those who had bloodwork (53.4% male) and those who did not (51.4% male; p=0.63). The most common blood test ordered was a complete blood count, and the most commonly abnormal result was a mildly elevated white blood cell count (19%; n= 29). The most common patients to receive bloodwork were those with ankle (34%) and distal radius (34%) fractures. The bloodwork was primarily ordered by clinical associates (26%; n=46) and emergency department physicians (22%; n=38). Without considering lab personnel, consumables, and analysis time, the cost of this bloodwork was approximately $7685, an average of $45 per patient. Pre-operative bloodwork in young, healthy, asymptomatic patients requiring outpatient surgery for minor orthopaedic trauma had no clinical significance and did not change patient management. Rigorous prospective research is warranted to establish national guidelines for appropriate pre-operative bloodwork ordering to minimize unnecessary and costly investigations

Introduction. Cemented total knee arthroplasty (TKA) remains the gold standard with survivorship above 90% at greater than 10 years postoperatively. However, with younger, heavier, more active patients undergoing TKA at an increasing rate, cementless implants have the appeal of potential for improved implant fixation longevity and decreased rates of aseptic loosening. The cementless implants are more expensive than their cemented counterparts such that implant costs may create a barrier to utilization. However, such comparisons fail to consider the unavoidable additional costs of cementing, including the cost of operating room time, cement and cementing accessories. The purpose of this study is to compare the actual cost of cemented and cementless TKA. Methods. The TKA cost calculation included the cost of operative time, implants, cement and cementing accessories. The difference in operative time between cemented and cementless TKA was determined from a previously published study of 100 TKAs performed using a cemented (55) or press fit (45) implant of the same design performed at a single institution by four fellowship trained arthroplasty surgeons. The decision to use cemented or cementless design in these patients was made based on patient bone quality intraoperatively. Operative time was compared between groups using a Student's two-tailed T-test. The cost of operating room time was based on estimates in the recent literature. The cost of cement and cementing accessories was estimated based on publically available market data. The cost of implants was estimated from institutional data for multiple companies. Results. The cost comparison between cemented and cementless total knee arthroplasty is summarized in Table 1. Mean operative time for cemented TKA was 14.3 minutes longer than for cementless TKA (94.7 + 15.2 vs. 80.4 + 15.7, p<0.01). The estimated cost of one minute of operating room time in the literature ranges from $30 to $60. For our analysis, we used an estimate of $36 per minute obtained from a recently published multi-center study. This resulted in an average operating room time cost $3406 for cemented and $2894 for cementless TKA. Antibiotic cement costs an average of $250 per bag and antibiotic-free cement costs an average of $75 per bag. Cement mixing techniques vary across surgeons. Approximately 95% use a vacuum system and 5% use a mixing bowl. The cost of vacuum systems ranges from $80 for an enclosed bowl to $125 for a vacuum system that can be directly connected to a cement gun. The cost of a plastic mixing bowl and spatula is $20. The cost of the disposables from a cement injection kit is $25. The average cost of a primary TKA implant, including femoral, tibial and polyethylene liner components, is $3530 for cemented and $4659 for cementless designs. Patellar resurfacing is not routinely used at our institution and therefore was not included in implant cost. Based on our calculations, the average cost of a cementless TKA is $7553. Using the cheapest cementing technique with 2 bags of plain cement and a manual mixing bowl with spatula, the cost of a cemented TKA $7114. Using the most expensive cementing technique with 2 bags of antibiotic cement and a cement gun compatible vacuum mixer, the cost of a cemented TKA is $7564. Conclusion. Cemented TKA remains the gold standard and still accounts for most procedures. Cementless TKA is increasing in utilization and may decrease the rate of aseptic loosening, especially in the rapidly growing young, active population undergoing TKA. Although cementless implants remain more expensive than cemented implants at most institutions, the actual overall cost of the two procedures is similar if operative time, cement and cementing accessories are considered. For any figures or tables, please contact authors directly

Total hip replacement (THR) is one of the most common and cost-effective elective surgical procedures. In the National Health Service (NHS) of England and Wales a myriad of implants for THR are offered at a variety of locally negotiated prices. This study aims to estimate the total burden of elective THR to the NHS, expenditure on implants, and different scenarios of cost changes if implant selection changed for different patient groups. Using National Joint Registry (NJR) data and NHS reference costs, we estimated the number and expenditure of NHS funded primary and revision THR in the 10-year period 2008–2017 and forecasted the number and expenditure on THR over the next decade. Using NJR average NHS Trust prices for the different implant combinations we estimated the average cost of implants used in THRs and estimated the budget impact on NHS providers from switching to alternative implants. The NHS spent over £4.76 billion performing 702,381 THRs between 2008–2017. The average cost of implants was £1,260 per surgery, almost a fifth of the cost of primary THR. Providing cemented implant combinations in primary elective THRs may potentially save up to £281 million over the next 10 years, whilst keeping 10-year revision risks low. The NHS is likely to spend over £5.6 billion providing primary elective THR over the next decade. There are efficiency savings to realise in the NHS by switching to more cost-effective implant combinations available for patients undergoing primary elective THR surgery, but these will need to be balanced against the risks inherent to a change in selection of implants and surgical practice. The HIPPY programme will be conducting practice surveys, discrete choice experiments and a large randomised controlled trial of cemented, uncemented and hybrid fixation in THR for patients under 70 to answer uncertainties

Abstract. Aims. The aim of this study was to evaluate the indications for patients presenting with knee pain undergoing magnetic resonance imaging of the knee prior to referral to the orthopaedic department and to ascertain whether plain radiograph imagining would be more beneficial prior to an MRI scan. Method. A retrospective review of all referrals received by the hospital over a 6-month period was performed. Patients with knee pain that underwent an MRI scan were classified into two age groups, under 50 years and over 50 years old. Patients having undergone Magnetic resonance imaging (MRI) prior to referral were identified, and findings of the scan were recorded. These patients were reviewed further to see if a plain radiograph had been completed prior to or after the MRI. Results. A total of 414 patients were referred. In the over 50's 228 MRI scans were performed. Of these 103/228 patients the predominate finding was meniscal tears and 72/228 had a finding of osteoarthritis. A plain radiograph of the knee was completed 99/228 cases, 28/99 before the MRI. In the under 50's 186 scans were performed and of these 85/186 the predominate finding was meniscal tears. A plain radiograph of the knee was completed in only eighty-three (83/186) cases, (69/83) before the MRI. Conclusion. In over 50s, 57% of patients (129 of 228) did not have a knee X-ray before having an MRI. For a single hospitals referral over 6 months these unnecessary MRI of knee cost the National Health Services £7,500

Background: Alternative treatments in displaced fractures of the femoral neck include reduction and internal fixation, and arthroplasty. A variety of treatments are continuously introduced to the health care market and that makes prioritising, based on the severity of the disease, the effectiveness, and the cost effectiveness of the treatment, necessary. The aim of this study was to compare the estimated effect and costs of internal fixation and hemiarthroplasty after a displaced femoral neck fracture. Methods: 222 patients, 165 (74%) women, mean age 83 years, were randomized to internal fixation (n = 112) and hemiarthroplasty (n = 110). Mainly due to cognitive failure or death, 56 patients failed to complete the EQ-5D questionnaire at any follow up; hence, 166 patients were included in the analysis. There were no differences in the demographic variables at inclusion. Patients underwent either a Charnley-Hastings bipolar cemented hemiarthroplasty or closed reduction and internal fixation with two parallel cannulated screws (Olmed). The health effect was estimated by the generic measure quality adjusted life-years (QALYs). The QALYs were estimated based on the patients’ perception of quality of life (QoL) assessed by Eq-5d, which was measured after 4, 12 and 24 months. Results: Over the two year period the expected QALYs for patient with hemiarthroplasty and internal fixation were estimated to be 1.31 and 1.11, respectively. Thus, the incremental health effect, the difference in QALYs for hemiarthroplasty versus internal fixation, was 0.20 QALYs gained. Hospital costs over two years were € 30 726 in the internal fixation group and € 27 618 in the hemiarthroplasty group, an incremental cost of – € 3 108 in favor of hemiarthroplasty. Total costs, including societal costs, were € 62 815 in the internal fixation group, compared to € 48 227 in the hemiarthroplasty group, an incremental cost of – € 14 588 in favor of hemiarthroplasty. By dividing the incremental cost by the incremental effect, we found the incremental cost effectiveness ratio (ICER) to be – € 15 540 for all hospital costs and – € 72 940 for total costs. Sensitivity analysis based on the bootstrap method, indicate that the ICER is significantly negative, indicating both a significantly lower incremental costs and significantly higher QALYs for hemiarthroplasty versus internal fixation. Conclusion: Primary treatment with hemiarthroplasty generates more QALYs and is less costly compared to internal fixation. Hemiarthroplasty was thus the cost effective treatment alternative

Thumb carpometacarpal (CMC) arthritis is a common and disabling condition that can be treated with an operative procedure. Before operative measures, patients typically undergo conservative treatment utilizing methods such as physical therapy and injections. This study aims to determine what clinical modalities are being used for preoperative evaluation and nonoperative therapy and the associated cost prior to operative intervention. We queried Truven Market Scan, a large insurance provider database to identify patients undergoing CMC arthroplasty from 2010 to 2017. Patients were identified by common Current Procedural Terminology (CPT) codes for CMC arthroplasty. All associated CPT codes listed for each patient during the 1 year period prior to operative intervention were collected and filtered to only include those codes associated with the ICD-9/10 diagnosis codes relating to CMC arthritis. The codes were then categorized as office visits, x-ray, injections, physical therapy, medical devices, and preoperative labs. The frequency and associated cost for each category was determined. There were 44,676 patients who underwent CMC arthroplasty during the study period. A total of $26,319,848.36 was charged during the preoperative period, for an average of $589.13 per patient. The highest contributing category to overall cost was office visits (42.1%), followed by injections (13.5%), and then physical therapy (11.1%). The most common diagnostic modality was x-ray, which was performed in 74.7% of patients and made up 11.0% of total charges. Only 49% of patients received at least one injection during the preoperative period and the average number of injections per patient was 1.72. Patients who were employed full time were more likely to receive two or more injections prior to surgery compared to patients who had retired (47% of full-time workers; 34% of retirees). The modalities used for the preoperative evaluation and conservative treatment of CMC arthritis and the associated cost are important to understand in order to determine the most successful and cost-effective treatment plan for patients. Surprisingly, despite the established evidence supporting clinical benefits, many patients do not undergo corticosteroid injections. With office visits being the largest contributor to overall costs, further inquiry into the necessity of multiple visits and efforts to combine visits, can help to reduce cost. Also, with the advent of telemedicine it may be possible to reduce visit cost by utilizing virtual medicine. Determining the best use of telemedicine and its effectiveness are areas for future investigation

Background. We identified several opportunities to significantly reduce cost for hip and knee arthroplasty procedures:. Customized instruments: by identifying the essential instruments for arthroplasty cases, we managed to have one universal tray for each case, and 3 specific trays from the implant manufacturing company. Customized wrap-free, color-coded, stackable trays: by using a wrap-free trays, preparation time in central sterile, opening tray time in OR and turn-over time were reduced. Also, stackable trays were organized based on side and size, therefore only 2 trays needed to be used in each case. Discounted implants: negotiated through optional case coverage with revision system and reps available as backup. Optional rep coverage protocols: designed through process management of the operating room surgical staff and central sterile. Aim of the study was to measure the cost savings, efficacy, and outcomes associated with primary total hip and knee arthroplasty by implementing these protocol. Methods. This is a prospective study from January to October 2016 for selected primary total hip and knee arthroplasties were performed with the above protocols by 2 experienced arthroplasty trained surgeons, were followed for minimum 3 months. Initiating the cost saving protocols were achieved by re-engineering customized trays, discounted implants through optional case coverage (Sourced Based Selection of a Cooperating Manufacturer, MTD), and focused on process management of the staff training. Staff responsibilities were divided into 2 categories:. Familiarity of the instruments, implant, and techniques; trays set up and assurance of availability of the implants. These responsibilities were covered by a trained OR technician and the surgeon. Final verification of the accurate implants prior to opening the packaging. This was achieved by a trained OR nurse and the surgeon. Results. We did not have any intra-operative complications. We also did not encounter any issued with the trays or errors in opening of the implants. There were no re-admissions, fracture, dislocation, or infection. The mean length of stay was 2.2 ± 0.5 days (range 1–3 days) with 68% home discharges. The cost of the implant was reduced from $4,800 to $1,895 with $2,905 cost saving per case and total savings of $58,100. The projected savings only for uncomplicated primary total hip arthroplasty (minimum 120 cases/year between 2 surgeons) is $384,600. Further cost saving from the process management changes were seen in central sterile processing time. Prior to the one tray system, the hospital had 3 in-house trays and there were 4 device company trays. We also noticed an approximate 27% improvement in turnover time. Conclusion. Repless model has significant cost saving potential. Preparation for the transition, proper patient selection, standardization of the trays and implants, and distribution of the responsibilities between OR nurses, technicians and the surgeon are essential