The debate whether to use cemented or uncemented
components in primary total hip replacement (THR) has not yet been
considered with reference to the cost implications to the National
Health Service. We obtained the number of cemented and uncemented components
implanted in 2009 from the National Joint Registry for England and
Wales. The cost of each component was established. The initial financial
saving if all were cemented was then calculated. Subsequently the
five-year rates of revision for each type of component were reviewed
and the predicted number of revisions at five years for the actual
components used was compared with the predicted number of revisions
for a cemented THR. This was then multiplied by the mean cost of
revision surgery to provide an indication of the savings over the
first five years if all primary THRs were cemented. The saving at primary THR was calculated to be £10 million with
an additional saving during the first five years of between £5 million
and £8.5 million. The use of cemented components in routine primary
THR in the NHS as a whole can be justified on a financial level
but we recognise individual patient factors must be considered when deciding
which components to use.
Aims. The aim of this study was to compare ten-year longitudinal healthcare costs and revision rates for patients undergoing unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA). Methods. The Humana database was used to compare 2,383 patients undergoing UKA between 2007 and 2009, who were matched 1:1 from a cohort of 63,036 patients undergoing primary TKA based on age, sex, and Elixhauser Comorbidity Index. Medical and surgical complications were tracked longitudinally for one year following surgery. Rates of revision surgery and cumulative mean healthcare costs were recorded for this period of time and compared between the cohorts. Results. Patients undergoing TKA had significantly higher rates of manipulation under anaesthesia (3.9% vs 0.9%; p < 0.001), deep vein thrombosis (5.0% vs 3.1%; p < 0.001), pulmonary embolism (1.5% vs 0.8%; p = 0.001), and renal failure (4.2% vs 2.2%; p < 0.001). Revision rates, however, were significantly higher for UKA at five years (6.0% vs 4.2%; p = 0.007) and ten years postoperatively (6.5% vs 4.4%; p = 0.002). Longitudinal-related healthcare costs for patients undergoing TKA were greater than for those undergoing UKA at one year ($24,771 vs $22,071; p < 0.001) and five years following surgery ($26,549 vs $25,730; p < 0.001); however, the mean costs of TKA were comparable to UKA at ten years ($26,877 vs $26,891; p = 0.425). Conclusion. Despite higher revision rates, patients undergoing UKA had lower mean healthcare costs than those undergoing TKA up to ten years following the procedure, at which time costs were comparable. In the era of value-based care, surgeons and policymakers should be aware of the costs involved with these procedures. UKA was associated with fewer complications at one year postoperatively but higher revision rates at five and ten years. While UKA was significantly less costly than TKA at one and five years, costs at ten years were comparable with a mean difference of only $14. Lowering the risk of revision surgery should be targeted as a source of
Aims. The aim of the Scaphoid Magnetic Resonance Imaging in Trauma (SMaRT) trial was to evaluate the clinical and cost implications of using immediate MRI in the acute management of patients with a suspected fracture of the scaphoid with negative radiographs. Patients and Methods. Patients who presented to the emergency department (ED) with a suspected fracture of the scaphoid and negative radiographs were randomized to a control group, who did not undergo further imaging in the ED, or an intervention group, who had an MRI of the wrist as an additional test during the initial ED attendance. Most participants were male (52% control, 61% intervention), with a mean age of 36.2 years (18 to 73) in the control group and 38.2 years (20 to 71) in the intervention group. The primary outcome was total cost impact at three months post-recruitment. Secondary outcomes included total costs at six months, the assessment of clinical findings, diagnostic accuracy, and the participants’ self-reported level of satisfaction. Differences in cost were estimated using generalized linear models with gamma errors. Results. The mean cost up to three months post-recruitment per participant was £542.40 (. sd. £855.20, n = 65) for the control group and £368.40 (. sd. £338.60, n = 67) for the intervention group, leading to an estimated cost difference of £174 (95% confidence interval (CI) -£30 to £378; p = 0.094). The cost difference per participant increased to £266 (95% CI £3.30 to £528; p = 0.047) at six months. Overall, 6.2% of participants (4/65, control group) and 10.4% of participants (7/67, intervention group) had sustained a fracture of the scaphoid (p = 0.37). In addition, 7.7% of participants (5/65, control group) and 22.4% of participants (15/67, intervention group) had other fractures diagnosed (p = 0.019). The use of MRI was associated with higher diagnostic accuracy both in the diagnosis of a fracture of the scaphoid (100.0% vs 93.8%) and of any other fracture (98.5% vs 84.6%). Conclusion. The use of immediate MRI in the management of participants with a suspected fracture of the scaphoid and negative radiographs led to
Aims. Recent improvements in surgical technique and perioperative blood management after total joint replacement (TJR) have decreased rates of transfusion. However, as many surgeons transition to outpatient TJR, obtaining routine postoperative blood tests becomes more challenging. Therefore, we sought to determine if a preoperative outpatient assessment tool that stratifies patients based on numerous medical comorbidities could predict who required postoperative haemoglobin (Hb) measurement. Methods. We performed a prospective study of consecutive unilateral primary total knee arthroplasties (TKAs) and total hip arthroplasties (THAs) performed at a single institution. Prospectively collected data included preoperative and postoperative Hb levels, need for blood transfusion, length of hospital stay, and Outpatient Arthroplasty Risk Assessment (OARA) score. Results. A total of 504 patients met inclusion criteria. Mean age at time of arthroplasty was 65.3 years (SD 10.2). Of the patients, 216 (42.9%) were THAs and 288 (57.1%) were TKAs. Six patients required a blood transfusion postoperatively (1.19%). Transfusion after surgery was associated with lower postoperative day 1 Hb (median of 8.5 (interquartile range (IQR) 7.9 to 8.6) vs 11.3 (IQR 10.4 to 12.2); p < 0.001), longer length of stay (1 day (IQR 1 to 1) vs 2 days (IQR 2 to 3); p < 0.001), higher OARA score (median of 60.0 (IQR 40 to 75) vs 5.0 (IQR 0-35); p = 0.001), and total hip arthroplasty (p < 0.001). All patients who received a transfusion had an OARA score > 34; however, this did not reach statistical significance as a screening threshold. Conclusion. Risk of blood transfusion after primary TJR was uncommon in our series, with an incidence of 1.19%. Transfusion was associated with OARA scores > 60. The OARA score, not American Society of Anesthesiologists grade, reliably identified patients at risk for postoperative blood transfusion. Selective Hb monitoring may result in substantial
The Swansea Morriston Achilles Rupture Treatment
(SMART) programme was introduced in 2008. This paper summarises
the outcome of this programme. Patients with a rupture of the Achilles
tendon treated in our unit follow a comprehensive management protocol
that includes a dedicated Achilles clinic, ultrasound examination,
the use of functional orthoses, early weight-bearing, an accelerated
exercise regime and guidelines for return to work and sport. The
choice of conservative or surgical treatment was based on ultrasound
findings. . The rate of re-rupture, the outcome using the Achilles Tendon
Total Rupture Score (ATRS) and the Achilles Tendon Repair Score,
(AS), and the complications were recorded. An elementary cost analysis
was also performed. . Between 2008 and 2014 a total of 273 patients presented with
an acute rupture 211 of whom were managed conservatively and 62
had surgical repair. There were three
re-ruptures (1.1%). There were 215 men and 58 women with a mean
age of 46.5 years (20 to 86). Functional outcome was satisfactory.
Mean ATRS and AS at four months was 53.0
(. sd . 14), 64.9 (. sd. 15) (n = 135), six months 67.8
(. sd. 16), 73.8 (. sd. 15) (n = 103) and nine months
(72.4; . sd. 14) 72.3 (. sd. 13) (n = 43). The programme
realised estimated
Aims. The purpose of this study is to determine if higher volume hospitals
have lower costs in revision hip and knee arthroplasty. Materials and Methods. We questioned the Centres for Medicare and Medicaid Services
(CMS) Inpatient Charge Data and identified 789 hospitals performing
a total of 29 580 revision arthroplasties in 2014. Centres were
dichotomised into high-volume (performing over 50 revision cases
per year) and low-volume. Mean total hospital-specific charges and
inpatient payments were obtained from the database and stratified
based on Diagnosis Related Group (DRG) codes. Patient satisfaction
scores were obtained from the multiyear CMS Hospital Compare database. Results. High-volume hospitals comprised 178 (30%) of the total but performed
15 068 (51%) of all revision cases, including 509 of 522 (98%) of
the most complex DRG 466 cases. While high-volume hospitals had
higher Medicare inpatient payments for DRG 467 ($21 458 versus $20 632,
p = 0.038) and DRG 468 ($17 003 versus $16 120,
p = 0.011), there was no difference in hospital specific charges
between the groups. Higher-volume facilities had a better CMS hospital
star rating (3.63 versus 3.35, p <
0.001). When
controlling for hospital geographic and demographic factors, high-volume
revision hospitals are less likely to be in the upper quartile of
inpatient Medicare costs for DRG 467 (odds ratio (OR) 0.593, 95%
confidence intervals (CI) 0.374 to 0.941, p = 0.026) and DRG 468
(OR 0.451, 95% CI 0.297 to 0.687, p <
0.001). Conclusion. While a high-volume hospital is less likely to be a high cost
outlier, the higher mean Medicare reimbursements at these facilities
may be due to increased case complexity. Further study should focus
on measures for
Patient specific instrumentation (PSI) uses advanced
imaging of the knee (CT or MRI) to generate individualised cutting
blocks aimed to make the procedure of total knee arthroplasty (TKA)
more accurate and efficient. However, in this era of healthcare
cost consciousness, the value of new technologies needs to be critically
evaluated. There have been several comparative studies looking at
PSI versus standard instrumentation. Most compare
PSI with conventional instrumentation in terms of alignment in the
coronal plane, operative time and surgical efficiency, cost effectiveness
and short-term outcomes. Several systematic reviews and meta-analyses
have also been published. PSI has not been shown to be superior
compared with conventional instrumentation in its ability to restore traditional
mechanical alignment in primary TKA. Most studies show comparative
efficacy and no decrease in the number of outliers in either group.
In terms of operative time and efficiency, PSI tended towards decreasing
operative time, saving a mean of five minutes per patient (0 to
20). Furthermore, while some
The aim of this study was to evaluate the healthcare costs and benefits of enoxaparin compared to aspirin in the prevention of symptomatic venous thromboembolism (VTE) after total hip arthroplasty (THA) or total knee arthroplasty (TKA) using data from the CRISTAL trial. This trial-based economic analysis reports value for money as incremental cost per quality-adjusted life-year (QALY) gained in 2022 Australian dollars, compared to a single threshold value of AUD$70,000 per QALY. Event costs were estimated based on occurrence of VTEs and bleeds, and on published guidelines for treatment. Unit costs were taken from Australian sources. QALYs were estimated using CRISTAL six-month follow-up data. Sensitivity analyses are presented that vary the cost of VTE treatment, and extend the analyses to two years.Aims
Methods
Blood transfusion and postoperative anaemia are complications of total knee arthroplasty (TKA) that are associated with substantial healthcare costs, morbidity, and mortality. There are few data from large datasets on the risk factors for these complications. We retrospectively reviewed the records of TKA patients from a single tertiary care institution from February 2016 to December 2020. There were a total of 14,901 patients in this cohort with a mean age of 67.9 years (SD 9.2), and 5,575 patients (37.4%) were male. Outcomes included perioperative blood transfusion and postoperative anaemia, defined a priori as haemoglobin level < 10 g/dl measured on the first day postoperatively. In order to establish a preoperative haemoglobin cutoff, we investigated a preoperative haemoglobin level that would limit transfusion likelihood to ≤ 1% (13 g/dl) and postoperative anaemia likelihood to 4.1%. Risk factors were assessed through multivariable Poisson regression modelling with robust error variance.Aims
Methods
The aim of this trial was to assess the cost-effectiveness of a soft bandage and immediate discharge, compared with rigid immobilization, in children aged four to 15 years with a torus fracture of the distal radius. A within-trial economic evaluation was conducted from the UK NHS and personal social services (PSS) perspective, as well as a broader societal point of view. Health resources and quality of life (the youth version of the EuroQol five-dimension questionnaire (EQ-5D-Y)) data were collected, as part of the Forearm Recovery in Children Evaluation (FORCE) multicentre randomized controlled trial over a six-week period, using trial case report forms and patient-completed questionnaires. Costs and health gains (quality-adjusted life years (QALYs)) were estimated for the two trial treatment groups. Regression was used to estimate the probability of the new treatment being cost-effective at a range of ‘willingness-to-pay’ thresholds, which reflect a range of costs per QALY at which governments are typically prepared to reimburse for treatment.Aims
Methods
Total hip and knee arthroplasty (THA, TKA) are largely successful procedures; however, both have variable outcomes, resulting in some patients being dissatisfied with the outcome. Surgeons are turning to technologies such as robotic-assisted surgery in an attempt to improve outcomes. Robust studies are needed to find out if these innovations are really benefitting patients. The Robotic Arthroplasty Clinical and Cost Effectiveness Randomised Controlled Trials (RACER) trials are multicentre, patient-blinded randomized controlled trials. The patients have primary osteoarthritis of the hip or knee. The operation is Mako-assisted THA or TKA and the control groups have operations using conventional instruments. The primary clinical outcome is the Forgotten Joint Score at 12 months, and there is a built-in analysis of cost-effectiveness. Secondary outcomes include early pain, the alignment of the components, and medium- to long-term outcomes. This annotation outlines the need to assess these technologies and discusses the design and challenges when conducting such trials, including surgical workflows, isolating the effect of the operation, blinding, and assessing the learning curve. Finally, the future of robotic surgery is discussed, including the need to contemporaneously introduce and evaluate such technologies. Cite this article:
Excision of chronic osteomyelitic bone creates a dead space which must be managed to avoid early recurrence of infection. Systemic antibiotics cannot penetrate this space in high concentrations, so local treatment has become an attractive adjunct to surgery. The aim of this study was to present the mid- to long-term results of local treatment with gentamicin in a bioabsorbable ceramic carrier. A prospective series of 100 patients with Cierny-Mader Types III and IV chronic ostemyelitis, affecting 105 bones, were treated with a single-stage procedure including debridement, deep tissue sampling, local and systemic antibiotics, stabilization, and immediate skin closure. Chronic osteomyelitis was confirmed using strict diagnostic criteria. The mean follow-up was 6.05 years (4.2 to 8.4).Aims
Methods
Telehealth has the potential to change the way we approach patient care. From virtual consenting to reducing carbon emissions, costs, and waiting times, it is a powerful tool in our clinical armamentarium. There is mounting evidence that remote diagnostic evaluation and decision-making have reached an acceptable level of accuracy and can safely be adopted in orthopaedic surgery. Furthermore, patients’ and surgeons’ satisfaction with virtual appointments are comparable to in-person consultations. Challenges to the widespread use of telehealth should, however, be acknowledged and include the cost of installation, training, maintenance, and accessibility. It is also vital that clinicians are conscious of the medicolegal and ethical considerations surrounding the medium and adhere strictly to the relevant data protection legislation and storage framework. It remains to be seen how organizations harness the full spectrum of the technology to facilitate effective patient care. Cite this article:
Management of displaced paediatric supracondylar elbow fractures remains widely debated and actual practice is unclear. This national trainee collaboration aimed to evaluate surgical and postoperative management of these injuries across the UK. This study was led by the South West Orthopaedic Research Division (SWORD) and performed by the Supra Man Collaborative. Displaced paediatric supracondylar elbow fractures undergoing surgery between 1 January 2019 and 31 December 2019 were retrospectively identified and their anonymized data were collected via Research Electronic Data Capture (REDCap).Aims
Methods
There is no consensus regarding optimum timing and frequency of ultrasound (US) for monitoring response to Pavlik harness (PH) treatment in developmental dysplasia of the hip (DDH). The purpose of our study was to determine if a limited-frequency hip US assessment had an adverse effect on treatment outcomes compared to traditional comprehensive US monitoring. This study was a single-centre noninferiority randomized controlled trial. Infants aged under six months whose hips were reduced and centred in the harness at initiation of treatment (stable dysplastic or subluxable), or initially decentred (subluxated or dislocated) but reduced and centred within four weeks of PH treatment, were randomized to our current standard US monitoring protocol (every clinic visit) or to a limited-frequency US protocol (US only at end of treatment). Groups were compared based on α angle and femoral head coverage at the end of PH treatment, acetabular indices, and International Hip Dysplasia Institute (IHDI) grade on one-year follow-up radiographs.Aims
Methods
Postoperative length of stay (LOS) and discharge dispositions following arthroplasty can be used as surrogate measurements for improvements in patients’ pathways and costs. With the increasing use of robotic technology in arthroplasty, it is important to assess its impact on LOS. The aim of this study was to identify factors associated with decreased LOS following robotic arm-assisted total hip arthroplasty (RO THA) compared with the conventional technique (CO THA). This large-scale, single-institution study included 1,607 patients of any age who underwent 1,732 primary THAs for any indication between May 2019 and January 2023. The data which were collected included the demographics of the patients, LOS, type of anaesthetic, the need for treatment in a post-anaesthesia care unit (PACU), readmission within 30 days, and discharge disposition. Univariate and multivariate logistic regression models were used to identify factors and the characteristics of patients which were associated with delayed discharge.Aims
Methods
It has previously been shown that higher-volume hospitals have better outcomes following revision total knee arthroplasty (rTKA). We were unable to identify any studies which investigated the effect of surgeon volume on the outcome of rTKA. We sought to investigate whether patients of high-volume (HV) rTKA surgeons have better outcomes following this procedure compared with those of low-volume (LV) surgeons. This retrospective study involved patients who underwent aseptic unilateral rTKA between January 2016 and March 2019, using the database of a large urban academic medical centre. Surgeons who performed ≥ 19 aseptic rTKAs per year during the study period were considered HV and those who performed < 19 per year were considered LV. Demographic characteristics, surgical factors, and postoperative outcomes were compared between the two groups.Aims
Methods