Introduction. Robotic-arm assisted knee arthroplasty (rKA) has been associated with improved clinical, radiographic, and patient-reported outcomes. There is a paucity of literature, however, addressing its cost effectiveness. In the context of an integrated health system with an insurance plan and single source comprehensive data warehouse for electronic health records and claims data, we present an evaluation of healthcare costs and utilization associated with manual knee arthroplasty (mKA) versus rKA. We also examine the influence of rKA technology on surgeons’ practice patterns. Methods. Practice patterns of KA were assessed 18 months before and after introduction of robotic technology in April 2018. For patients also insured through the system's health plan, inpatient costs (actual costs recorded by health system), 90-day postoperative costs (allowed amounts paid by insurance plan), and 90-day postoperative utilization (length of stay, home health care visits, rehabilitation visits) were compared between mKA and rKA patients, stratified by total (TKA) or unicompartmental (UKA) surgery. Linear regression modeling was used to compare outcomes between the two pairs of groups (mKA vs. rKA, for both UKA and TKA). Log-link function and gamma error distribution was used for costs. All analyses were done using SAS statistical software, with p<0.05 considered statistically significant. Results. Overall KA volume increased 21%, from 532 cases in the pre-rKA period to 644 post-rKA introduction, with UKA surgeries increasing from 38 to 97 (155%). Of these KAs, 218 patients were insured through our system's health plan (38 rUKAs, 9 mUKAs, 91 rTKAs, and 80 mTKAs), allowing precise insurance claims analysis for postoperative utilization and cost. Patients with rKA had significantly lower mean home health costs (-90% difference for UKA, −79% difference for TKA, p<0.02) and home rehab costs (-64% difference for UKA, −73% difference for TKA, p≤0.007) than mKA patients. No significant differences were observed in outpatient rehab (visits or costs), total rehab costs, or length of stay. Mean total postoperative costs were significantly lower for rUKA than mUKA (-47% difference, p=0.02) but similar for TKA (p>0.05). There were no significant differences in total inpatient costs between MAKO and non-MAKO patients. Conclusion. Robotic-arm assisted KA can allow for increased UKA volume and potential for substantial cost savings over the total episode of care by reducing postoperative utilization and costs

Aims

This observational cross-sectional study aimed to answer the following questions: 1) how has nonunion incidence developed from 2009 to 2019 in a nationwide cohort; 2) what is the age and sex distribution of nonunions for distinct anatomical nonunion localizations; and 3) how high were the costs for surgical nonunion treatment in a level 1 trauma centre in Germany?

Rivaroxaban is a novel, oral, once-daily, direct Factor Xa inhibitor in advanced development for the prevention and treatment of venous thromboembolism (VTE). This study analysed the potential economic benefit attributable to the use of oral rivaroxaban relative to subcutaneous enoxaparin for extended VTE prophylaxis (35±4 days) after total hip replacement (THR). In RECORD1, rivaroxaban reduced the incidence of the composite primary efficacy endpoint (total VTE, including all-cause mortality) by 70%, compared with enoxaparin (p< 0.001). Symptomatic VTE occurred in 0.3% and 0.5% (p=0.22) of patients receiving rivaroxaban and enoxaparin, respectively. Major bleeding was low and similar in both groups: 0.3% and 0.1% (p=0.18), respectively.

Potential savings associated with oral rivaroxaban were based on any reduction in the incidence of symptomatic VTE events, and reduced administration and monitoring costs. Analyses for both the US and the UK included only non-drug costs incurred by the healthcare sector. It was assumed that nurses spent 3 minutes/day administering enoxaparin and training patients to self-inject; assumed duration of hospital stay was 5 days. UK costs (based on the 2007 NICE Guidelines) also included full blood counts (FBCs) every 3 days, for up to 14 days, in patients receiving enoxaparin.

Two analyses were performed: one assumed no difference in the occurrence of symptomatic VTE between treatments; the other assumed that the observed difference was real, but did not reach statistical significance.

In the first analysis, assuming no difference in symptomatic VTE incidence, the total resource cost in the US was $46/patient for enoxaparin and $42.5/patient for rivaroxaban: a saving of $3.5/patient. For the UK, the total resource cost was £33/patient for enoxaparin and £7.5/per patient for rivaroxaban: a saving of £25.5/ patient. Savings were driven by reduced monitoring (FBCs) and administration costs.

In the second analysis, assuming the observed difference in symptomatic VTE incidence was real, the US total resource cost was $57/patient for enoxaparin and $42.5/patient for rivaroxaban: a saving of $14.5/patient. For the UK, the total resource cost was £30/patients for enoxaparin and £7.5/patient for rivaroxaban: a saving of £22.5/patient. Savings were again driven by reduced monitoring and administration costs, and also reduced VTE incidence.

Over 400,000 US patients undergo THR, and ~60,000 patients in England and Wales undergo THR annually. Thus, the potential cumulative cost savings with rivaroxaban are considerable.

Aim. The number of periprosthetic joint infections (PJI) is increasing due to ageing population and increasing numbers of arthroplasty procedures and treatment is costly. Aim of the study was to analyze the direct healthcare costs of PJI in Europe for total hip arthroplasties (THA) and total knee arthroplasties (TKA). Method. A systematic review in PubMed with search of direct costs of PJI in European countries was performed. Thereby the term cost* AND (infection OR PJI) AND (prosthesis OR knee OR hip OR “TKA” OR “THA” OR arthroplast*) was combined with each European country to detect relevant publications. Publications with definition of performed procedure and joint localization were included into further analysis. The mean value of direct healthcare cost was calculated for the respective joint and the respective operation performed. Results. Screening revealed 1,274 eligible publications. After review of abstracts and full-texts n=11 manuscripts were included into final analysis (Figure 1). The mean combined direct hospital costs for revision for PJI after TKA and THA was 26,311€. Mean costs for revision procedures for PJI after TKA were 24,617€. Direct costs for TKA-PJI treated with debridement, antibiotics and implant retention (DAIR) were on average 10,121€. For two-stage revisions in knee arthroplasties total average costs were 30,829€. Referring to revision surgery for PJI in THA, the mean hospital costs in Europe were 28,005€. For a DAIR procedure direct healthcare costs of 5,528€ were identified. Two-stage revision cost on average 31,217€. Conclusions. PJIs are associated with significant direct healthcare costs. The financial burden of up to 30,000 € per case underlines the impact of the disease for European health care system. However, the number of detailed reports on PJI costs is limited and the quality of the literature is limited. There is a strong need for more detailed financial data on the costs of PJI treatment. For any tables or figures, please contact the authors directly

Fragility fractures are an emerging healthcare problem in Sub-Saharan Africa and hip fractures (HFs) are associated with high levels of morbidity, prolonged hospital stays, increased healthcare resources utilization, and mortality. The worldwide average healthcare cost in the first-year post HF was US$43,669 per patient in a 2017 systematic review, however there are no studies quantifying fracture-associated costs within SSA. We estimated direct healthcare costs of HF management in the South African public healthcare system. We conducted a prospective ingredients-based costing study in 200 consecutive consenting HF patients to estimate costs per patient across five regional public sector hospitals in KwaZulu-Natal (KZN). Resource use including staff time, consumables, laboratory investigations, radiographs, operating theatre time, surgical implants, medicines, and inpatient days were collected from presentation to discharge. Counts of resources used were multiplied by relevant unit costs, estimated from KZN Department of Health hospital fees manual 2019/20, in local currency (South African Rand, ZAR). Generalised linear models were used to estimate total covariate adjusted costs and cost predictors. The mean unadjusted cost for HF management was ZAR114,179 (95% CI; ZAR105,468–125,335). The major cost driver was orthopaedics/surgical ward costs ZAR 106.68, contributing to 85% of total cost. The covariate adjusted cost for HF management was ZAR114,696 (95% CI; ZAR111,745–117,931). After covariate adjustment, total costs were higher in patients operated under general anaesthesia compared to surgery under spinal anaesthesia and no surgery. Direct healthcare costs following a HF are substantial: 58% of the gross domestic per capita (US$12,096 in 2020), and six-times greater than per capita spending on health (US$1,187 in 2019) in SA. As the population ages, this significant economic burden to the health system will increase. Further research is required to evaluate direct non-medical, and the indirect costs incurred post HF

Aim. The number of operatively treated clavicle fractures has increased over the past decades. Consequently, this has led to an increase in secondary procedures required to treat complications such as fracture-related infection (FRI). The primary objective of this study was to assess the clinical and functional outcome of patients treated for FRI of the clavicle. The secondary objectives were to evaluate the healthcare costs and propose a standardized protocol for the surgical management of this complication. Method. All patients with a clavicle fracture who underwent open reduction and internal fixation (ORIF) between 1 January 2015 and 1 March 2022 were retrospectively evaluated. This study included patients with an FRI who were diagnosed and treated according to the recommendations of a multidisciplinary team at the University Hospitals Leuven, Belgium. Results. We evaluated 626 patients with 630 clavicle fractures who underwent ORIF. In total, 28 patients were diagnosed with an FRI. Of these, eight (29%) underwent definitive implant removal, five (18%) underwent debridement, antimicrobial treatment and implant retention, and fourteen patients (50%) had their implant exchanged in either a single-stage procedure, a two-stage procedure or after multiple revisions. One patient (3.6%) underwent resection of the clavicle. Twelve patients (43%) underwent autologous bone grafting (tricortical iliac crest bone graft (n=6), free vascularized fibular graft (n=5), cancellous bone graft (n=1)) to reconstruct the bone defect. The median follow-up was 32.3 (P. 25. -P. 75. : 23.9–51.1) months. Two patients (7.1%) experienced a recurrence of infection. The functional outcome was satisfactory, with 26 out of 28 patients (93%) having full range of motion. The median healthcare cost was € 11.506 (P. 25. -P. 75. : € 7.953–23.798) per patient. Conclusion. FRI is a serious complication that can occur after the surgical treatment of clavicle fractures. Overall, the outcome of patients treated for FRI of the clavicle is good, when management of this complication is performed by using a multidisciplinary team approach. The median healthcare costs of these patients are up to 3.5 times higher compared to non-infected operatively treated clavicle fractures. Expert opinion considers factors such as the size of the bone defect, the condition of the soft tissue, and patient demand to guide surgical decision making

Aims. In the Netherlands, general practitioners (GPs) can request radiographs. After a radiologically diagnosed fracture, patients are immediately referred to the emergency department (ED). Since 2020, the Máxima Medical Centre has implemented a new care pathway for minor trauma patients, referring them immediately to the traumatology outpatient clinic (OC) instead of the ED. We investigated whether this altered care pathway leads to a reduction in healthcare consumption and concomitant costs. Methods. In this retrospective cohort study, patients were included if a radiologist diagnosed a fracture on a radiograph requested by the GP from August to October 2019 (control group) or August to October 2020 (research group), on weekdays between 8.30 am and 4.00 pm. The study compared various outcomes between groups, including the length of the initial hospital visit, frequency of hospital visits and medical procedures, extent of imaging, and healthcare expenses. Results. A total of 634 patients were included. The results show a median reduction of 25 minutes in duration of initial hospital visits, one fewer hospital visit, overall fewer medical procedures, and a decrease in healthcare costs of €303.40 per patient in the research group compared to the control group. No difference was found in the amount of imaging. Conclusion. The implementation of the new care pathway has resulted in a substantial reduction in healthcare use and costs. Moreover, the pathway provides advantages for patients and helps prevent crowding at the ED. Hence, we recommend immediately referring all minor trauma patients to the traumatology OC instead of the ED. Cite this article: Bone Jt Open 2023;4(10):728–734

Aims. The aims of this study were to investigate whether 1) multispecialist tertiary intervention for complex spinal pain lead to reductions in spine-related healthcare costs and 2) baseline characteristics are related to health care consuming costs. Patients and methods. A cost study in a natural prospective cohort was carried out to investigate healthcare data of patients admitted to the Groningen Spine Center (GSC) ranging from two years prior to referral until two year after discharge. GSC intervention consisted of a multi-professional and -specialist based diagnosis and treatment. Patients (18 and 80 years) were included, suffering from specific as well as multifactorial spinal pain. Clinical data was merged with Health Care Insurance data and included questionnaires on demographics, work, pain, disability, quality of life and psychosocial functioning. Univariable (paired sample t-tests) and multivariable analyses (pooled OLS Regression and fixed effects models) were carried out. Results. Included were 997 patients (mean age 52 years) filing a total of 700.533 health care declarations. The findings suggest that the intervention had a significant negative effect on spine-related healthcare costs (predominantly on medical specialist and allied care). Reduction in healthcare costs after treatment was predicted by lower age, lower duration, lower BMI, high education, high job satisfaction, low physical workload, high mental health, better coping, lower pain intensity, high EQ-5D score and low financial worries at baseline (all p<0.01). Conclusion. This observational study showed that spine-related healthcare consuming can be effectively reduced after tertiary multi-specialist intervention for patients with complex spinal pain. The results are robust when controlling for background characteristics and are unlikely to be driven by regression to the mean. No conflicts of interest. No funding obtained

Aims. The aim of this study was to estimate the clinical and economic burden of dislocation following primary total hip arthroplasty (THA) in England. Methods. This retrospective evaluation used data from the UK Clinical Practice Research Datalink database. Patients were eligible if they underwent a primary THA (index date) and had medical records available 90 days pre-index and 180 days post-index. Bilateral THAs were excluded. Healthcare costs and resource use were evaluated over two years. Changes (pre- vs post-THA) in generic quality of life (QoL) and joint-specific disability were evaluated. Propensity score matching controlled for baseline differences between patients with and without THA dislocation. Results. Among 13,044 patients (mean age 69.2 years (SD 11.4), 60.9% female), 191 (1.5%) had THA dislocation. Two-year median direct medical costs were £15,333 (interquartile range (IQR) 14,437 to 16,156) higher for patients with THA dislocation. Patients underwent revision surgery after a mean of 1.5 dislocations (1 to 5). Two-year costs increased to £54,088 (IQR 34,126 to 59,117) for patients with multiple closed reductions and a revision procedure. On average, patients with dislocation had greater healthcare resource use and less improvement in EuroQol five-dimension index (mean 0.24 (SD 0.35) vs 0.44 (SD 0.35); p < 0.001) and visual analogue scale (0.95 vs 8.85; p = 0.038) scores, and Oxford Hip Scores (12.93 vs 21.19; p < 0.001). Conclusion. The cost, resource use, and QoL burden of THA dislocation in England are substantial. Further research is required to understand optimal timing of revision after dislocation, with regard to cost-effectiveness and impact on QoL. Cite this article: Bone Joint J 2022;104-B(7):811–819

Aims. To map literature on prognostic factors related to outcomes of revision total knee arthroplasty (rTKA), to identify extensively studied factors and to guide future research into what domains need further exploration. Methods. We performed a systematic literature search in MEDLINE, Embase, and Web of Science. The search string included multiple synonyms of the following keywords: "revision TKA", "outcome" and "prognostic factor". We searched for studies assessing the association between at least one prognostic factor and at least one outcome measure after rTKA surgery. Data on sample size, study design, prognostic factors, outcomes, and the direction of the association was extracted and included in an evidence map. Results. After screening of 5,660 articles, we included 166 studies reporting prognostic factors for outcomes after rTKA, with a median sample size of 319 patients (30 to 303,867). Overall, 50% of the studies reported prospectively collected data, and 61% of the studies were performed in a single centre. In some studies, multiple associations were reported; 180 different prognostic factors were reported in these studies. The three most frequently studied prognostic factors were reason for revision (213 times), sex (125 times), and BMI (117 times). Studies focusing on functional scores and patient-reported outcome measures as prognostic factor for the outcome after surgery were limited (n = 42). The studies reported 154 different outcomes. The most commonly reported outcomes after rTKA were: re-revision (155 times), readmission (88 times), and reinfection (85 times). Only five studies included costs as outcome. Conclusion. Outcomes and prognostic factors that are routinely registered as part of clinical practice (e.g. BMI, sex, complications) or in (inter)national registries are studied frequently. Studies on prognostic factors, such as functional and sociodemographic status, and outcomes as healthcare costs, cognitive and mental function, and psychosocial impact are scarce, while they have been shown to be important for patients with osteoarthritis. Cite this article: Bone Jt Open 2023;4(5):338–356

Approximately 30% of general practice consultations for musculoskeletal pain are related to tendon disorders, causing substantial personal suffering and enormous related healthcare costs. Treatments are often prone to long rehabilitation times, incomplete functional recovery, and secondary complications following surgical repair. Overall, due to their hypocellular and hypovascular nature, the regenerative capacity of tendons is very poor and intrinsically a disorganized scar tissue with inferior biomechanical properties forms after injury. Therefore, advanced therapeutic modalities need to be developed to enable functional tissue regeneration within a degenerative environment, moving beyond pure mechanical repair and overcoming the natural biological limits of tendon healing. Our recent studies have focused on developing biologically augmented treatment strategies for tendon injuries, aiming at restoring a physiological microenvironment and boosting endogenous tissue repair. Along these lines, we have demonstrated that the local application of mesenchymal stromal cell-derived small extracellular vesicles (sEVs) has the potential to improve rotator cuff tendon repair by modulating local inflammation and reduce fibrotic scarring. In another approach, we investigated if the local delivery of the tendon ECM protein SPARC, which we previously demonstrated to be essential for tendon maturation and tissue homeostasis, has the potential to enhance tendon healing. Finally, I will present results demonstrating the utility of nanoparticle-delivered, chemically modified mRNAs (cmRNA) to improve tendon repair

Aims. The purpose was to compare operative treatment with a volar plate and nonoperative treatment of displaced distal radius fractures in patients aged 65 years and over in a cost-effectiveness analysis. Methods. A cost-utility analysis was performed alongside a randomized controlled trial. A total of 50 patients were randomized to each group. We prospectively collected data on resource use during the first year post-fracture, and estimated costs of initial treatment, further operations, physiotherapy, home nursing, and production loss. Health-related quality of life was based on the Euro-QoL five-dimension, five-level (EQ-5D-5L) utility index, and quality-adjusted life-years (QALYs) were calculated. Results. The mean QALYs were 0.05 higher in the operative group during the first 12 months (p = 0.260). The healthcare provider costs were €1,533 higher per patient in the operative group: €3,589 in the operative group and 2,056 in the nonoperative group. With a suggested willingness to pay of €27,500 per QALY there was a 45% chance for operative treatment to be cost-effective. For both groups, the main costs were related to the primary treatment. The primary surgery was the main driver of the difference between the groups. The costs related to loss of production were high in both groups, despite high rates of retirement. Retirement rate was unevenly distributed between the groups and was not included in the analysis. Conclusion. Surgical treatment was not cost-effective in patients aged 65 years and older compared to nonoperative treatment of displaced distal radius fractures in a healthcare perspective. Costs related to loss of production might change this in the future if the retirement age increases. Level of evidence: II. Cite this article: Bone Jt Open 2021;2(12):1027–1034

Aim. Prosthetic joint infection (PJI) is a serious complication following total hip arthroplasty (THA) entailing increased mortality, decreased quality of life, and high healthcare costs. In 2009 a nationwide, multidisciplinary infection control program was launched in Sweden, PRISS, which aimed to reduce the PJI burden by 50%. The primary aim was to investigate whether the PRISS project reduced PJI incidence after primary THA; the secondary aim was to evaluate other possible benefits of PRISS, such as shorter time to diagnosis. Method. We obtained data on patients undergoing primary THA in Sweden (n = 45,723 patients, 49,946 THAs), 2012–2014. Using personal identity numbers, this cohort was matched with the Swedish Prescribed Drug Registry. Medical records of patients with ≥4 weeks antibiotic consumption were reviewed to verify PJI diagnosis (n = 2240, 2569 THAs). Results. The cumulative incidence of PJI following the PRISS project was 1.2% [95% CI 1.1–1.3] as compared to 0.9% [95% CI 0.8–1.0] before. Cox regression models for the PJI incidence post PRISS indicates there were no statistical significance difference versus pre PRISS (HR 1.1 [95% CI 0.9–1.3]. There were similar time to PJI diagnosis after the PRISS project 24 vs 23 days (p=0.5). Conclusions. Despite the comprehensive nationwide PRISS project, Swedish PJI incidence was higher after the project and time to diagnosis remained unchanged. Factors contributing to PJI, such as increasing obesity, higher ASA class, and more fractures as indications, explain the PJI increase among primary THA patients

Abstract. Background. Autologous chondrocyte implantation is a NICE approved intervention however it involves the morbidity of two operations, a prolonged rehabilitation and substantial healthcare costs. This study describes a novel, one-step, bone marrow (BM) derived mesenchymal stem cell (MSC) transplantation technique for treating knee osteochondral lesions and presents our prospective clinical study investigating the success of this technique in 206 lesions over a 5 year period. Methodology. The surgical technique involves harvesting BM from patients’ anterior superior iliac spines, centrifugation to isolate MSCs and seeding into a type 1 collagen scaffold (SyngenitTM Biomatrix). Autologous fibrin glue is used to secure the scaffold into the defect. Inclusion criteria included patients aged 15 – 55 years old with symptomatic osteochondral lesions >1cm2. Exclusion criteria included patients with ligament instability, uncorrected alignment, inflammatory arthropathy and a Body Mass Index >35 kg/m2. Outcome measures included the Modified Cincinnati Knee Rating System (MCKRS), complications and reoperations. Results. Mean MCKR scores showed statistically significant improvements compared to pre-operative scores at 6 months 58.79 ± 3.5 and 1 year postoperatively 63.82 ± 3.93 with further improvements at 2 years and 5 years which did not reach statistical significance. Survival rates were 97.9%, 94% and 93.2% at 1, 2 and 5 years. Multiple regression analysis identified previous cartilage surgery, microfracture and age as factors affecting MCKRS scores (p < 0.029, 0.001 and 0.030, respectively). Conclusions. One-step BM derived stem cell transplantation demonstrates satisfactory outcomes over a 5 year period

An increasing elderly population means joint replacement surgery numbers are projected to increase, with associated complications such as periprosthetic joint infections (PJI) also rising. PJI are particularly challenging due to antimicrobial resistant biofilm development on implant surfaces and surrounding tissues, with treatment typically involving invasive surgeries and systemic antibiotic delivery. Consequently, functionalisation of implant surfaces to prevent biofilm formation is a major research focus. This study characterises clinically relevant antimicrobials including gentamicin, clindamycin, daptomycin, vancomycin and caspofungin within a silica-based, biodegradable sol-gel coating for prosthetic devices. Antimicrobial activity of the coatings against clinically relevant microorganisms was assessed via disc diffusion assays, broth microdilution culture methods and the MBEC assay used to determine anti-biofilm activity. Human and bovine cells were cultured in presence of antimicrobial sol-gel to determine cytotoxicity using Alamar blue and antibiotic release was measured by LC-MS. Biodegradability in physiological conditions was assayed by FT-IR, ICP-MS and measuring mass change. Effect of degradation products on osteogenesis were studied by culturing mesenchymal stem cells in the presence of media in which sol-gel samples had been immersed. Antimicrobial-loaded coatings showed strong activity against a wide range of clinically relevant bacterial and fungal pathogens with no loss of activity from antibiotic alone. The sol-gel coating demonstrated controlled release of antimicrobials and initial sol-gel coatings showed no loss of viability on MSCs with gentamicin containing coatings. Current work is underway investigating cytotoxicity of sol-gel compositions against MG-63 cells and primary osteoblasts. This research forms part of an extended study into a promising antimicrobial delivery strategy to prevent PJI. The implant coating has potential to advance PJI infection prevention, reducing future burden upon healthcare costs and patient wellbeing

Surgical site infections (SSIs) after spinal fusion surgery increase healthcare costs, morbidity and mortality. Routine measures of obesity fail to consider site specific fat distribution. We aimed to assess the association between the spine adipose index and deep surgical site infection and determine a threshold value for spine adipose index that can assist in preoperative risk stratification in patients undergoing posterior instrumented lumbar fusion (PILF). A multicentre retrospective case-control study was completed. We reviewed patients who underwent PILF from January 1, 2010 to December 31, 2018. All patients developing a deep primary incisional or organ-space SSI within 90 days of surgery as per US Centre for Disease Control and Prevention criteria were identified. We gathered potential pre-operative and intra-operative deep infection risk factors for each patient. Spine adipose index was measured on pre-operative mid-sagittal cuts of T2 weighted MRI scans. Each measurement was repeated twice by three authors in a blinded fashion, with each series of measurement separated by a period of at least six weeks. Forty-two patients were included in final analysis, with twenty-one cases and twenty-one matched controls. The spine adipose index was significantly greater in patients developing deep SSI (p =0.029), and this relationship was maintained after adjusting for confounders (p=0.046). Risk of developing deep SSI following PILF surgery was increased 2.0-fold when the spine adipose index was ≥0.51. The spine adipose index had excellent (ICC >0.9; p <0.001) inter- and intra-observer reliabilities. The spine adipose index is a novel radiographic measure and an independent risk factor for developing deep SSI, with 0.51 being the ideal threshold value for pre-operative risk stratification in patients undergoing PILF surgery

Introduction. Management of complex fractures poses a significant challenge. Evolving research and changes to national guidelines suggest better outcomes are achieved by transfer to specialist centres. The development of Major Trauma Networks was accompanied by relevant financial arrangements. These do not apply to patients with closed fractures referred for specialist treatment by similar pathways. Despite a surge in cases transferred for care, there is little information available regarding the financial impact on receiving institutions. Materials & Methods. This retrospective study examines data from a Level 1 trauma centre. Patients were identified from our electronic referral system, used for all referrals. Transferred adult patients, undergoing definitive treatment of acute isolated closed tibial fractures, were included for a 2-year period. Data was collected using our clinical and Patient Level Information and Costing (PLICS) systems including coding, demographics, treatment, length of stay (LOS), total operative time, number of operations, direct healthcare costs, and NHS reimbursements. Results. 104 patients were identified, 23 patients were treated by internal fixation and 81 with circular frames. Patients required a median of 190 minutes of total operative time and 6 days of hospital stay at a median cost of £16,233 each, median reimbursement was £10,625. The total cost of treatment for all 104 patients was £2,205,611 and total reimbursement was £1,391463, the median deficit per patient being £5825. The overall deficit over the 2 years was £814,148. Conclusions. This study reveals a considerable economic burden associated with treating complex tibial fractures. It should be emphasised that these do not include patients referred for fracture-related infection or non-union, who may also incur similar deficits in recovered costs. These findings emphasise the importance of understanding and addressing the financial implications of managing tertiary referral orthopaedic trauma patients to ensure efficient and sustainable resource allocation

Traumatic rotator cuff injuries can be a leading cause of prolonged shoulder pain and disability, and contribute to significant morbidity and healthcare costs. Previous studies have shown evidence of socio-demographic disparities with these injuries. The purpose of this nationwide study was to better understand these disparities based on ethnicity, sex, and socio-economic status, in order to inform future healthcare strategies. Accident Compensation Corporation (ACC) is a no-fault comprehensive compensation scheme encompassing all of Aotearoa/New Zealand (population in 2018, 4.7 million). Using the ACC database, traumatic rotator cuff injuries were identified between January 2010 and December 2018. Injuries were categorized by sex, ethnicity, age and socioeconomic deprivation index of the claimant. During the 9-year study period, there were 351,554 claims accepted for traumatic rotator cuff injury, which totalled over $960 million New Zealand Dollars. The greatest proportion of costs was spent on vocational support (49.8%), then surgery (26.3%), rehabilitation (13.1%), radiology (8.1%), general practitioner (1.6%) and “Other” (1.1%). Asian, Māori (Indigenous New Zealanders), and Pacific peoples were under-represented in the age-standardized proportion of total claims and had lower rates of surgery than Europeans. Māori had higher proportion of costs spent on vocational support and lower proportions spent on radiology, rehabilitation and surgery than Europeans. Males had higher number and costs of claims and were more likely to have surgery than females. There were considerably fewer claims from areas of high socio-economic deprivation. This large nation-wide study demonstrates the important and growing economic burden of rotator cuff injuries. Indirect costs, such as vocational supports, are a major contributor to the cost suggesting improving treatment and rehabilitation protocols would have the greatest economic impact. This study has also identified socio-demographic disparities which need to be addressed in order to achieve equity in health outcomes

Aims. To perform an incremental cost-utility analysis and assess the impact of differential costs and case volume on the cost-effectiveness of robotic arm-assisted unicompartmental knee arthroplasty (rUKA) compared to manual (mUKA). Methods. This was a five-year follow-up study of patients who were randomized to rUKA (n = 64) or mUKA (n = 65). Patients completed the EuroQol five-dimension questionnaire (EQ-5D) preoperatively, and at three months and one, two, and five years postoperatively, which was used to calculate quality-adjusted life years (QALYs) gained. Costs for the primary and additional surgery and healthcare costs were calculated. Results. rUKA was associated with a relative 0.012 QALY gain at five years, which was associated with an incremental cost per QALY of £13,078 for a unit undertaking 400 cases per year. A cost per QALY of less than £20,000 was achieved when ≥ 300 cases were performed per year. However, on removal of the cost for a revision for presumed infection (mUKA group, n = 1) the cost per QALY was greater than £38,000, which was in part due to the increased intraoperative consumable costs associated with rUKA (£626 per patient). When the absolute cost difference (operative and revision costs) was less than £240, a cost per QALY of less than £20,000 was achieved. On removing the cost of the revision for infection, rUKA was cost-neutral when more than 900 cases per year were undertaken and when the consumable costs were zero. Conclusion. rUKA was a cost-effective intervention with an incremental cost per QALY of £13,078 at five years, however when removing the revision for presumed infection, which was arguably a random event, this was no longer the case. The absolute cost difference had to be less than £240 to be cost-effective, which could be achieved by reducing the perioperative costs of rUKA or if there were increased revision costs associated with mUKA with longer follow-up. Cite this article: Bone Jt Open 2023;4(11):889–898

Abstract. Introduction. A revision knee replacement (rKR) network model has been introduced in the UK to improve clinical outcomes for patients and reduce healthcare costs. However, the current practice of different types of surgical unit is not well understood. The aim of this study was to answer: “How complex are rKR cases at a Major Revision Centre (MRC)?”. Methodology. Retrospective cohort study at the Nuffield Orthopaedic Centre, Oxford from 2015 - 2018. Case complexity was classified using the Revision Knee Complexity Classification (RKCC). Referral source, technical details of surgery and hospital admission impact were recorded. Results. 688 rKR procedures (380 rKR, 308 re-revision KR) were identified over the study period. 170 rKR (24.7%) were unplanned admissions requiring surgery, whilst the remaining cases were elective. 288/688 rKR (41.9%) were external referrals, where surgical complexity was rated ‘less complex’ (96 rKR, 33.3%), ‘more complex’ (92 rKR, 31.9%) and ‘most complex’ (100 rKR, 34.7%). 140/288 (48.6%) of these cases had one or more rKR prior to referral. Length of stay (LOS) was greater for more complex cases (R1 median 5 days [interquartile range 3–9], R2 median 9 days [IQR 5–15], R3 median 11 days [IQR 7–19]). Conclusion. rKR complexity at the MRC followed a ‘rule of thirds’. Among external referrals, nearly half of patients had a previous rKR prior to referral. More complex cases required longer hospital admissions