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 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

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

The objective of this study was to quantify the burden of musculoskeletal disorders (MSDs) on the Ontario health care system. Specifically, we examined the magnitude and costs of MSD-associated ambulatory physician care and hospital service use, considering different physician types (e.g. primary care, rheumatologists, orthopaedic surgeons) and hospital settings (e.g. emergency department (ED), day surgery, inpatient hospitalizations). Administrative health data were analyzed for fiscal year 2013/14 for adults aged 18+ years (N=10,841,302). Data sources included: Ontario Health Insurance Plan Claims History Database, which captures data on in- and out-patient physician services, Canadian Institute for Health Information (CIHI) Discharge Abstract Database, which records diagnoses and procedures associated with all inpatient hospitalizations, and CIHI National Ambulatory Care Reporting System, which captures data on all emergency department (ED) and day surgery encounters. Services associated with MSDs were identified using the single three digit International Classification of Diseases (ICD) version 9 diagnosis code provided on each physician service claim for outpatient physician visits and the “most responsible” ICD-10 diagnosis code recorded for hospitalizations, ED visits and day surgeries. Patient visit rates and numbers of patients and visits were tabulated according to care setting, patient age and sex, and physician specialty. Direct medical costs were estimated by care setting. Data were examined for all MSDs combined as well as specific diagnostic groupings, including a comprehensive list of both trauma and non-trauma related conditions. Overall, 3.1 million adult Ontarians (28.5%) made 8 million outpatient physician visits associated with MSDs in 2013/14. These included 5.6 million primary care visits, nearly 15% of all adult primary care visits in the province. MSDs accounted for 560,000, 12.3%, of all adult ED visits. Patient visit rates to the ED for non-trauma spinal conditions were the highest of all MSDs at 1032 per 100,000 population, accounting for 23% of all MSD-related ED visits. Osteoarthritis had the highest rate of inpatient hospitalization of all MSDs at 340 per 100,000 population, accounting for 42% of all MSD-related admissions. Total costs for MSD-related care were $1.6 billion, with 12.6% of costs attributed to primary care, 9.2% to specialist care, 8.6% to ED care, and 61.2% of total costs associated with inpatient hospitalizations. Costs due to ‘arthritis and related conditions’ as a group accounted for 40.1% of total MSD costs ($966 million). Costs due to non-trauma related spinal conditions accounted for 10.5% ($168 million) of total MSD costs. All trauma-related conditions (spine and non-spine combined) were responsible for 39.4% ($627 million) of total MSD costs. MSD-related imaging costs for patients who made physician visits for MSDs were $169 million. Including these costs yields a total of $1.8 billion. MSDs place a significant and costly burden on the health care system. As the population ages, it will be essential that health system planning takes into account the large and escalating demand for MSD care, both in terms of health human resources planning and the implementation of more clinically and cost effective models of care, to reduce both the individual and population burden

Although day surgery has a good patient satisfaction and safety profile, accurate episode-of-care costs (EOCC) calculation for of this procedure compared to standard same-day admission (SDA), while considering functional outcomes, is not well known. This study assesses the EOCC for patients with a THA while comparing DS and Same Day Admission (SDA) (with a 1-day hospitalization) pathways. The episode-of-care cost (EOCC) of 50 consecutive day surgery and SDA patients who underwent a THA was evaluated. The episode-of-care cost was determined using a bottom-up Time Driven- Activity Based Funding method. Functional outcomes were measured using preoperative and postoperative Harris Hip Score (HHS). Overall, the SDA THA cost 11% more than a DS THA. The mean total EOCC of DS THA was 9 672 CAD compared to 10 911 CAD in the SDA THA group. Both groups showed an improvement in HHS score following the procedure but patients in the DS group had a significantly higher postoperative HHS score and a significantly greater improvement in their HHS score postoperatively. Day surgery THA is cost-effective, safe and associated with high patient satisfaction due to functional improvement. Providing policymakers the information to develop optimal financing methods is paramount for clinicians wishing to develop modern protocols, increase productivity while providing the optimal care for patients

Waitemata District Health Board (WDHB) is contracted through public funding to achieve approximately 500 total hip arthroplasties per year. A pilot was established to increase productivity and reduce costs in these surgical procedures. Current barriers to efficiency in elective surgery are slow patient turnover, increase in costs of consumables and staff employment issues. This pilot introduced: A change in drivers and incentives so remuneration and rewards were related to productivity (replaced medical salaries), an alliance contracting concept (1), encouraged productivity, contained costs (consumables) increase surgeon and anaesthetist involvement in overall patient care (reduce need for additional medical staff), reduced length of hospital stay, shortened patient journey, established surgeon/anaesthetist/nurse team. Inclusion criteria:1. Hip replacements in DRG103C: Hip replacement W/O catastrophic or severe CC. 2. ASA grade <4. 3. Cases July to November 2010. Comparison of baseline data was then carried out between this pilot and compared with data from the main campus (both sites had dedicated elective operating lists). Theatre time was reduced from 167.5 to 97 minutes (42%), length of stay 5.58 days to 3.46 days (38%), OR costs $3830 to $2708 (29%). There was an increase in medical costs but a 12% saving was achieved overall. The pilot has shown that it is possible to significantly reduce costs in elective surgery through an increase in productivity. To reduce costs of elective surgery, the culture/environment needs to change to encourage the individual surgeons, anaesthetists, and other members of the team to increase productivity and decrease costs

Robotic and navigated TKA procedures have been introduced to improve component placement precision for the purpose of improving implant survivorship and other clinical outcomes. Although numerous studies have shown enhanced precision in placing components, adoption of technology-assistance (TA) for TKA has been relatively slow. One reason for this has been the difficulty in demonstrating the cost-effectiveness of implementing TA-TKA systems and assessing their impact on revision rates. In this study, we aimed to use a simulation approach to answer the following questions: (1) Can we determine the distribution of likely reductions in TKA revision rates attributable to TA-TKA in an average US patient population? And, (2) What reduction in TKA revision rates are required to achieve economic neutrality?. In a previous study, we developed a method for creating large sets of simulated TKA patient populations with distributions of patient-specific factors (age at index surgery, sex, BMI) and one surgeon-controlled factor (coronal alignment) drawn from registry data and published literature. Effect sizes of each factor on implant survival was modeled using large clinical studies. For 10,000 simulated TKA patients, we simulated 20,000 TKA surgeries, evenly split between groups representing coronal alignment precisions reported for manual (±3°) and TA-TKA (±1.0°), calculating the patient-specific survival curve for each group. Extending our previous study, we incorporated the probability of each patient's expected survival into our model using publicly available actuarial data. This allowed us to calculate a patient-specific estimate of the Reduction in Lifetime Risk of Revision (RLRR) for each simulated patient. Our analysis showed that 90% of patients will achieve an RLRRof 1.5% or less in an average US TKA population. We then conducted a simplified economic analysis with the goal of determining the net cost of using TA-TKA per case when factoring in future savings by TKA revision rates. We assumed an average cost of revision surgery to be $75,000 as reported by Delanois (2017) and an average added cost incurred by TA-TKA to be $6,000 per case as reported by Antonis (2019). We estimate the net cost per TA-TKA case (CNet) to be the added cost per TA-TKA intervention (CInt), less the cost of revision surgery (CRev) multiplied by the estimated RLRR: CNet = CInt - CRev∗RLRR. We find that, under these assumptions, use of TA-TKA increases expected costs for all patients with an RLRR of under 8%. Based on these results, it appears that it would not be cost-effective to use TA-TKA on more than a small fraction of the typical US TKA patient population if the goal is to reduce overall costs through reducing revision risks. However, we note that this simulation does not consider other possible reported benefits of TA-TKA surgery, such as improved functional and pain outcome scores which may justify its use on other grounds. Alternative costs incurred by TA-TKA will be evaluated in a future study. To reach economic neutrality, TA-TKA systems either must reduce the added cost per intervention or increase RLRR by better addressing the root causes of revision

Introduction. Current CMS reimbursement policy for total joint replacement is aligned with more cost effective, higher quality care. Upon implementation of a standardized evidenced-based care pathway, we evaluated overall procedural costs and clinical outcomes over the 90-day episode of care period for patients undergoing TKA with either conventional (Conv.) or robotic-assisted (RAS) instrumentation. Methods. In a retrospective review of the first seven consecutive quarters of Bundled Payment for Care Improvement (BPCI) Model 2 participation beginning January 2014, we compared 90-day readmission rates, Length of Stay (LOS), discharge disposition, gains per episode in relation to target prices and overall episode costs for surgeons who performed either RAS-TKA (3 surgeons, 147 patients) or Conv. TKA (3 surgeons, 85 patients) at a single institution. All Medicare patients from all surgeons performing more than two TKA's within the study period were included. An evidence-based clinical care pathway was implemented prior to the start of the study that standardized pre-operative patient education, anesthesia, pain management, blood management, and physical/occupational therapy throughout the LOS for all patients. Physician specific target prices were established from institutional historical payment data over a prior three year period. Results. RAS and Conv-TKA procedures exhibited an average gain per episode of $7,600 and $5,579, respectively. The average total cost per 90-day episode was $2,085 lower for patients receiving RAS-TKA ($28,943 versus $31,028), with the majority of cost savings in reduced SNF usage ($1,481) and readmissions ($944). Discharge to home versus Sub-acute Rehabilitation Facilities (SAR's) was 14% higher in the RAS group (62% vs 48%, p<0.05). Conclusions. Implementation of a standardized care pathway across all service departments and physicians resulted in a reduction in overall episode of care costs, with further reductions in cost and discharge to SARs observed with the use of RAS

Background. Cementless femoral fixation in total hip arthroplasty (THA) continues to rise worldwide, accompanied by the increasing abandonment of cemented femoral fixation. Cementless fixation is known to contribute to higher rates of post-operative complications and reoperations. New data is available from the Centers for Medicare and Medicaid Services (CMS) regarding total costs of care from the Bundled Payment for Care Improvement (BPCI) and Comprehensive Care for Joint Replacement (CJR) initiatives. Questions/purposes. How does femoral fixation affect (1) 90-day costs; (2) readmission rates; (3) re-operation rates; (4) length of stay (LOS); and (5) discharge disposition for Medicare patients undergoing elective or non-elective THA?. Methods. We performed a retrospective review of 1671 primary THA cases in Medicare patients across nine hospitals in an academic healthcare network. CMS data was used to evaluate lump costs including the surgical admission and 30-day or 90-day post-operative episodes. Costs were then correlated with clinical outcome measures from review of our electronic medical record. Demographic differences were present between the cemented and cementless cohorts. Statistical analyses were performed including multiple regression models adjusted for the baseline cohort differences. Results. After controlling for confounding variables, cemented patients were significantly more likely to be discharged home compared to cementless patients. Cemented femoral fixation also demonstrated a trend towards lower costs, fewer readmissions and shorter LOS. All of the reoperations within the early postoperative period occurred in cementless patients. Conclusion. In a large Medicare population, cemented femoral fixation outperformed cementless fixation with respect to discharge disposition and also trended toward superiority with regards to LOS, readmission, cost of care, and reoperations. Cemented femoral fixation remains relevant and useful despite the rising popularity of cementless fixation. Orthopaedic surgeons in training should become competent with femoral cementation technique

Echocardiography is commonly used in hip fracture patients to evaluate perioperative cardiac risk and identify cardiac abnormalities. However, echocardiography that delays surgical repair may be harmful. The objective of this study was to compare mortality, surgical wait times, length of stay (LOS), and health care costs for similar hip fracture patients managed with and without preoperative echocardiograms. A population based, retrospective cohort study of all hip fracture patients (>age 45) in Ontario, Canada was conducted. The primary exposure was pre-operative echocardiography (between hospital admission and surgery). Patients receiving preoperative echocardiograms were matched to those without using a propensity score incorporating patient demographic information, comorbidity status, and provider information. Mortality rates, surgical wait times, post-operative length of stay (LOS), and medical costs (expressed as 2013$ CAN) up to 1-year post-operatively were assessed after matching. There were 2354 (∼5.6%) of 42,230 eligible hip fracture patients that received a preoperative echocardiogram during the study period. After successfully matching 2298 (∼97.6%) patients, echocardiography was associated with significant increases in mortality at 90 days (20.1% vs. 16.8%, p=0.004) and 1 year (32.9% vs. 27.8%, p < 0 .001), but not 30-days (11.4% vs. 9.8%, p=0.084). Patients with echocardiography also had an increased (mean ± SD) delay (in hours) from presentation to surgery (68.80 ± 44.23 hours vs. 39.69 ± 27.09 hours, p < 0 .001) and only 38.1% of patients had surgery within 48 hours. Total LOS (in days) (mean 19.49 ± 25.39 days vs. 15.94 ± 22.48 days, p < 0 .001) and total healthcare costs at 1 year (mean: $51,714.69 ± 54,675.28 vs. $41,861.47 ± 50,854.12, p < 0 .001) were also increased. There was wide variability in echocardiography ordering practice in Ontario, with a range of 0% to 22.97% of hip fracture patients undergoing preoperative echocardiography at different hospital sites. Preoperative echocardiography for hip fracture patients is associated with increased postoperative mortality. It is also associated with increased surgical delay, post-operative LOS, and total health care costs at 1 year. Echocardiography should be considered an urgent test when ordered to prevent additional surgical delay, and further research is necessary to clarify indications for this common preoperative investigation

Echocardiography is commonly used in hip fracture patients to evaluate perioperative cardiac risk and identify cardiac abnormalities. However, echocardiography that delays surgical repair may be harmful. The objective of this study was to compare mortality, surgical wait times, length of stay (LOS), and health care costs for similar hip fracture patients managed with and without preoperative echocardiography. A population based, retrospective cohort study of all hip fracture patients (>age 45) in Ontario, Canada was conducted. The primary exposure was pre-operative echocardiography (between hospital admission and surgery). Patients receiving preoperative echocardiography were matched to those without using a propensity score incorporating patient demographic information, comorbidity status, and provider information. Mortality rates, surgical wait times, post-operative length of stay (LOS), and medical costs (expressed as 2013$ CAN) up to one year post-operatively were assessed after matching. There were 2354 (∼5.6%) of 42,230 eligible hip fracture patients that received preoperative echocardiograghy during the study period. After successfully matching 2298 (∼97.6%) patients, echocardiography was associated with significant increases in mortality at 90 days (20.1% vs. 16.8%, p=0.004) and one year (32.9% vs. 27.8%, p < 0 .001), but not 30-days (11.4% vs. 9.8%, p=0.084). Patients with echocardiography also had an increased (mean ± SD) delay (in hours) from presentation to surgery (68.80 ± 44.23 hours vs. 39.69 ± 27.09 hours, p < 0 .001) and only 38.1% of patients had surgery within 48 hours. Total LOS (in days) (mean 19.49 ± 25.39 days vs. 15.94 ± 22.48 days, p < 0 .001) and total healthcare costs at one year (mean: $51,714.69 ± 54,675.28 vs. $41,861.47 ± 50,854.12, p < 0 .001) were also increased. There was wide variability in echocardiography ordering practice in Ontario, with a range of 0% to 22.97% of hip fracture patients undergoing preoperative echocardiography at different hospital sites. Preoperative echocardiography for hip fracture patients is associated with increased postoperative mortality. It is also associated with increased surgical delay, post-operative LOS, and total health care costs at one year. Echocardiography should be considered an urgent test when ordered to prevent additional surgical delay, and further research is necessary to clarify indications for this common preoperative investigation

This study examines the case of a spondylodiscitis in the thoracic spine caused by MRSA which led to two orthopaedic surgeries followed by rehabilitation. A 72.6 year old woman suffered a cutaneous infection with herpes zoster on the right dorsal thorax – 2 weeks later she presented a sepsis by MSSA. 2 month later she lamented sever pain in the thoracic column. She were hospitalized presenting a sepsis by MRSA. One month later it was found an infectious spondylodiscitis from thoracic vertebra T 8 to T 11 with destruction of the intervertebral spaces. To eliminate the infection and stabilize the dorsal column she was undertaken an first orthopaedic surgery by dorsal decompression and dorsal spondylodesis from T 6 – L 2; intraoperative microbiology: MRSA. 3 month later she was undertaken a second surgery by a lateral transthoracic decompression and intervertebral stabilization from T 9 – T 10 with tricortical bone chips and inlay of sponge with Calcibon and Gentamycin. The following rehabilitation took her to a reasonable result. The cost of the first treatment with dorsal stabilization was € 17.694,24, the second surgery was € 13.678,88; the cost of both rehabilitations was € 4.160,00. The finally costs for the whole treatment for the insurance was € 47,442,62. This retrospective case report shows the high costs for a treatment of spondylodiscitis caused by MRSA, not taking in consideration the harm and prolonged pain of the patient

Aim. The objective of this study was to define hospital-related healthcare costs associated with infection after fracture fixation (IFF) of the tibia and identify the subset of clinical variables relevant in driving these costs within the Belgium's healthcare system. Method. Between January 1. st. 2009 and January 1. st. 2014, a total of 358 patients treated operatively for AO type 41, 42 and 43 tibial fractures, were included in this study. The calculated costs were related to the Belgium's healthcare financing context and limited to costs induced by hospital related care. Five main hospital-related cost categories were studied: honoraria, materials, hospitalization, day care admission, and pharmaceuticals. In addition, a total of 19 clinical and process variables were defined. Results. The median total treatment cost for all tibial fractures was €6.962 euro (IQR €4932 – €10.972), with AO type 42 being the most expensive fracture type. In 12 (3.4%) patients the treatment was complicated by deep (implant-related) infection. Subsequently, the treatment costs for deep (implant-related) infection were almost 7-times higher compared to non-infected patients (€44.680 vs. €6.855 p<0.001) with hospitalization, length of stay (LOS), accounting for 50% of the total amount of the cost. The bivariate correlation between total treatment costs and LOS was close to 1. Multivariate analyses showed deep (implant-related) infection, non-union, age and ASA-3 as most important drivers (p<0.001) for both the total treatment costs and LOS. Moreover, the LOS was also driven by a delayed staged surgery protocol. Conclusions. One of the most challenging complications in trauma surgery is the development of IFF. Infections associated with fracture fixation devices result in significant patient morbidity and a prolonged treatment period. Currently, there is a lack of data regarding the definition, functional outcome and health care burden of this musculoskeletal complication. This study shows that treatment costs for deep (implant-related) infection were almost 7-times higher compared to non-infected patients. Furthermore, LOS accounted for 50% of the total amount of the cost. This study shows that future research needs to focus more on prevention rather than treatment strategies, not only to reduce patient morbidity but also to reduce the socio-economic impact

INTRODUCTION. In recent years, there has been a shift toward outpatient and short-stay protocols for patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA). We developed a peri-operative THA and TKA short stay protocol following the Enhance Recovery After Surgery principles (ERAS), aiming at both optimizing patients’ outcomes and reducing the hospital length of stay. The objective of this study was to evaluate the implementation of our ERAS short-stay protocol. We hypothesized that our ERAS THA and TKA short-stay protocol would result in a lower complication rate, shorter hospital length of stay and reduced direct health care costs compared to our standard procedure. METHODS. We compared the complications rated according to Clavien-Dindo scale, hospital length of stay and costs of the episode of care between a prospective cohort of 120 ERAS short-stay THA or TKA and a matched historical control group of 150 THA or TKA. RESULTS. Significantly lower rate of Grade 1 and 2 complications in the ERAS short-stay group compared with the standard group (mean 0.8 vs 3.0, p<0.001). Postoperative complications that were experienced by significantly more patients in the control group included pain (67% vs 13%, p<0.001), nausea (42% vs 12%, p<0.001), vomiting (25% vs 0.9%, p<0.001), dizziness (15% vs 4%, p=0.006), headache (4% vs 0%, p=0.04), constipation (8% vs 0%, p=0.002), hypotension (26% vs 11%, p=0.003), anemia (8% vs 0%, p=0.002), oedema of the operated leg (9% vs 1%, p=0.005), persistent lameness (4% vs 0%, p=0.04), urinary retention (13% vs 4%, p=0.006) and anemia requiring blood or iron transfusion (8% vs 0%, p=0.002). No difference was found between the 2 groups for Grade 3, 4, or 5 complications. The mean hospital length of stay for the ERAS short-stay group decreased by 2.8 days for the THAs (0.1 vs 2.9 days, p bellow 0.001) and 3.9 days for the TKAs (1.0 vs 4.9 days, p<0.001). The mean estimated direct health care costs reduction with the ERAS short-stay protocol was 1489% per THA and 4206% per TKA. DISCUSSION AND CONCLUSION. Shorter hospitalization time after THA and TKA is associated with lower risk of nosocomial infections and adverse events related to reduced mobilization such as venous thromboembolism, pulmonary atelectasis, and constipation. In addition, it increases bed availability in a restricted environment and is very favorable economically for the care provider. Multiple strategies have been described to reduce hospital length of stay. One attractive option is to follow the ERAS principles to improve patient experience to a level where they will feel confident to leave for home earlier. Implementation of a ERAS short-stay protocol for patients undergoing THA or TKA at our institution resulted not only in reduced hospital length of stay, but also in improved patient care and reduced direct health care costs

Aim. Surgical site infections caused by Staphylococcus aureus (S. aureus) are associated with considerable clinical and economic burden. Studies assessing this burden in Germany have been limited to specific institutions, selected patient groups or not specific to S. aureus infections (SAI). This study was undertaken to further understand the burden of SAI following orthopedic surgeries in Germany. Method. All patients with at least one spine, endoprosthetic hip or knee surgery between 2012 and 2015 captured in the AOK PLUS claims database were included in this analysis. SAI were identified using S. aureus-specific ICD-10 codes following surgery. Exclusion criteria included: younger than 18, SAI in the 90 days preceding index, any surgery in the 180 days preceding index, surgery at the same body location as index in the preceding 365 days, or more than one surgery of interest during index hospitalization. Cumulative incidence and incidence density were used to assess SAI. Mortality, healthcare resource utilization and costs were compared between SAI and non-SAI group during the 1year follow-up post index surgery. Multivariate analyses were conducted while controlling for sex, age, Charlson Comorbidity Index (CCI), location of surgery, length of index hospitalization, recent fractures, other bacterial infections during index hospitalization and outpatient prescriptions for antibiotics in the year pre-index. Results. In total, 74,327 patients were included who underwent a knee (21,285), hip (29,429), or spine surgery (23,613). Mean age was 69.6 years, 61.6% were female and the mean CCI was 2.3. The SAI incidence post-orthopedic surgery was 20.2 cases per 1,000 patient-years within 1 year of index hospitalization; the cumulative incidence was 1.9%. Knee surgeries were associated with lower SAI risk compared to hip surgeries (HR=0.8; p=0.024), whereas spine surgeries did not differ significantly. Compared to non-SAI group, the SAI group had on average 4.4 times the number of hospitalizations (3.1 vs. 0.7) and 7.7 times the number of hospital days (53.5 vs. 6.9), excluding the index hospitalization (p-values<0.001). One year post-orthopedic mortality was 22.38% in the SAI and 5.31% in the non-SAI group (p<0.001). The total medical costs were significantly different between SAI and non-SAI groups (42,834€ vs. 13,781€; p<0.001). Adjusting for confounders, the SAI group had nearly 2 times the all-cause direct healthcare costs (exp(b)=1.9; p<0.001); and 2.5 times the risk of death (OR=2.5; p<0.001) compared to the non-SAI group. Conclusions. S. aureus infection risk after orthopedic surgeries persists and is associated with significant economic burden and risk of mortality

Debate currently exists regarding the economic viability for screening for developmental dysplasia of the hip in infants. A retrospective study of infant hip dysplasia over the period of 1998–2008 (36,960 live births) was performed to determine treatment complexity and associated costs of disease detection and hospital treatment, related to the age at presentation and treatment modality. 179 infants (4.8/1000) presented with hip dysplasia. 34 infants presented late (>3 months of age) and required closed or open reduction. 145 infants presented at <3 months of age, 14 of whom failed early pavlik harness treatment. A detailed cost analysis revealed:. 131 early presenters with successful management in a pavlik harness at a cost of £601/child. 34 late presenters who required surgery (36 hips, 19 closed/ 17 open reductions, 1 revision procedure) at a cost of £4352/child. 14 early presenters with failed management in a pavlik harness requiring more protracted surgery (18 hips, 4 closed/ 14 open reductions, 7 revision procedures) at a cost of £7052/ child. Late detection causes increased treatment complexity and a seven-fold increase in the short-term costs of treatment, compared to early detection and successful management in a pavlik harness. However improved strategies are needed for the 10% of early presenting infants who fail pavlik harness treatment and require the most complex and costly interventions

Aim. This study aimed to define the increased costs incurred by a return to theatre for cases requiring free tissue transfer for surgical treatment of chronic osteomyelitis. We hypothesised that there would be a significantly greater cost when patients required re-exploration of the free flap. Method. We retrospectively analysed the costs of a consecutive series of sixty patient episodes treated at the Bone Infection Unit in Oxford from 2012 to 2015. Treatment involved excision of osteomyelitis with free tissue transfer for immediate soft tissue cover. We compared the costs of uncomplicated cases with those who returned to theatre and determined the profit/loss for the hospital from remuneration through the UK National Health Service Tariff Structure. Results. Hospital income according to UK HRG tariff was compared to the actual cost of treatment and these 60 cases were significantly underfunded overall (P < 0.005). In just 1 case, the cost to the hospital was completely covered by tariff. Six patients (10%) returned to theatre for urgent flap re-exploration with five flaps salvaged and one failed, requiring another free flap reconstruction (1.7%). These six patient episodes had a significantly higher mean cost compared to the uncomplicated cases. The average financial loss to the hospital for patients who did return to theatre was £18992 (range £8103 to £48380) and in those who did not was £9600 (range – £600 to £23717). The case requiring further free tissue transfer cost a total of £74158, £48380 more than the hospital was paid: the most extreme discrepancy. The overall loss for this group of 60 patients was £590766. Conclusions. Surgery for chronic osteomyelitis is multidisciplinary, complex and therefore expensive. However, this study demonstrates that the hospital currently makes a financial loss on almost all patients but especially if flap complications occur. This study has implications for the long term viability of specialist units treating this important disease

Introduction. Postoperative dislocation remains a vexing problem for patients and surgeons following total hip arthroplasty (THA). It is the commonest reason for revision THA in the US. Dual mobility (DM) THA implants markedly decrease the risk of THA instability. However, DM implants are more expensive than those used for conventional THA. The purpose of this study was to perform a cost-effectiveness analysis of DM implants compared to conventional bearing couples for unilateral primary THA using a computer model-based evaluation. Methods. A state-transition Markov computer simulation model was developed to compare the cost-utility of dual mobility versus conventional THA for hip osteoarthritis from a societal perspective (Figure 1). The model was populated with health outcomes and probabilities from registry and published data. Health outcomes were expressed as quality-adjusted life years (QALYs). Direct costs were derived from the literature and from administrative claims data, and indirect costs reflected estimated lost wages. All costs were expressed in 2013 US dollars. Health and cost outcomes were discounted by 3% annually. The base case modeled a 65-year-old patient undergoing THA for unilateral hip osteoarthritis. A lifetime time horizon was analyzed. The primary outcome was the incremental cost-effectiveness ratio (ICER). The willingness-to-pay threshold was set at $100,000/QALY. Threshold, one-way, two-way, and probabilistic sensitivity analyses were performed to assess model uncertainty. Results. DM THA exhibited absolute dominance over conventional THA with lower accrued costs (US$45,960 versus $47,103) and higher accrued utility (12.08 QALY versus 11.84 QALY). The ICER was -$4,771/QALY, suggesting that DM THA is cost-saving compared to conventional THA. The cost threshold at which dual mobility implants were cost-ineffective was $25,000 (Figure 2), and the threshold at which DM implants ceased being cost-saving was $12,845. Sensitivity analyses demonstrated that the probability of intraprosthetic dislocation, primary THA utility, and age at index THA most influenced model results. In the probabilistic sensitivity analysis, 90% of model iterations resulted in cost savings for DM THA (Figure 3). Discussion. Dual mobility components showed clear cost-utility advantages over conventional THA components, and DM implants are cost-saving for primary unilateral THA from a societal perspecitve. Model results suggest that DM THA need not be limited to only high-risk patients, although patient age and risk of dislocation are important determinants of its cost-utility

Noting a decreasing number of transfemoral amputations following infection of Total Knee Arthroplasty (TKA) I studied a case of a patient which suffered an amputation following infection of TKA by MRSA. With assistance of all hospitals and the NHS it was able to classify all costs of this poor case. This study exposes a drama of a person which received a Total Knee Arthroplasty in the right knee at 66.0 years. 2 weeks after the implantation of TKA she presented a wound secretion, the microbiology shows: MRSA, Pseudomonas aeroguinos and Streptococcus. 4 surgical revisions followed without removing the TKA. 35 month later, with 68.9 years it was indispensable to remove the TKA in a 6th operation, implanting a spacer with Vancomycine. 1 month later removing of the spacer and implanting a second cemented TKA in the 7th surgery. With 70.2 years the removal of the second TKA was necessary because of infection with Pseudomonas aeroguinosa and Morganelli morganii. Now implantation of another spacer with Vancomycine. 1 month later with 70.3 years removal of the spacer molding an arthrodesis of the knee using an intramedullary femur to tibia rod. After that 4 revision surgeries with changing the intramedullary rod some wound revisions followed, ending in the 23rd operation with a transfemoral amputation with 71.1 years – 5 years after primary TKA. 3 month after transfemoral amputation the patient presented high temperature and a secretion of the scarf of the TT-stump; microbiology: MRSA. 2 more surgeries are necessary to stop the infection. This patient suffered over all 25 surgical procedures in 5.5 years. The hospitalization for acute infection of TKA led to 431 days in different hospitals in 33 months. Statement of charges from the hospitals € 74.046,92 in the last three years before amputation. Payments by the health insurance € 155.424,00 for all procedures. We will demonstrate the different costs of hospital procedures and distribution for the insurance for all performances

INTRODUCTION. In the United States, the Centers for Medicare and Medicaid Services consider rates of unplanned hospital readmissions to be indicators of provider quality. Understanding the common reasons for readmission following total joint arthroplasty will allow for improved standards of care and better outcomes for patients. The current study seeks to evaluate the rates, reasons, and Medicare costs for readmission after total hip and total knee arthroplasty. METHODS. This study used the Limited Data Set (LDS) from the Centers for Medicare and Medicaid Services (CMS) to identify all primary, elective Total Knee Arthroplasties (TKA) and Total Hip Arthroplasties (THA) performed from January 2013 through June 2016. The data were limited to Diagnosis-Related Group (DRG) 470, which is comprised of major joint replacements without major complications or comorbidities. Readmissions were classified by corresponding DRG. Readmission rates, causes, and associated Medicare Part A payments were aggregated over a ninety-day post-discharge period for 804,448 TKA and 409,844 THA. RESULTS. There were 31,172 readmissions in the ninety days following THA, for a readmission rate of 7.6%. There were 51,768 readmissions following TKA, for a readmission rate of 6.4%. The leading causes of readmission post-THA were revision of hip or knee replacement (17.66%); septicemia (4.76%); and postoperative infections (3.74%). The most common reasons for readmission post-TKA were postoperative infections (6.42%); septicemia (4.84%); and esophagitis (3.85%). In contrast to THA, implant revisions only accounted for 2.51% of readmissions after TKA. The mean cost of readmission post-THA was $11,682, while the mean cost of readmission post-TKA was $8,955. DISCUSSION AND CONCLUSION. Ninety-day readmission rates for both THA and TKA remained stable for the duration of the study period, suggesting the need for additional research on the efficacy of various programs intended to reduce the incidence of readmission