Cost Variation in Temporizing External Fixation of Tibial Plateau Fractures.

BACKGROUND: Rising health care expenditures and declining reimbursements have generated interest in providing interventions of value. The use of external fixation is a commonly used intermediate procedure for the staged treatment of unstable fractures. External fixator constructs can vary in design and costs based on selected component configuration. The objective of this study was to evaluate cost variation and relationships to injury and noninjury characteristics in temporizing external fixation of tibial plateau fractures. We hypothesize that construct costs are highly variable and present no noticeable patterns with both injury and noninjury characteristics. METHODS: A retrospective review of tibial plateau fractures treated with initial temporizing external fixation between 2010 and 2016 at 2 Level I trauma centers was conducted. Fracture and patient characteristics including age, body mass index, AO/OTA classification, and Schatzker fracture classification were observed with construct cost. In addition, injury-independent characteristics of surgeon education, site of procedure, and date of procedure were evaluated with construct cost. Factors associated with cost variation were assessed using nonparametric comparative and goodness-of-fit regression tests. RESULTS: Two hundred twenty-one patient cases were reviewed. The mean knee spanning fixator construct cost was $4947 (95% confidence interval = $4742-$5152). The overall range in construct costs was from $1848 to $11,568. The mean duration of use was 16.4 days. No strong correlations were noted between construct cost and patient demographics (r = 0.02), fracture characteristics (r = 0.02), or injury-independent characteristics (r = 0.10). Finally, there was no significant difference between constructs of traumatologists and other orthopaedic surgeon subspecialists (P = 0.12). CONCLUSIONS: Temporizing external fixation of tibial plateau is a high-cost intervention per unit of time and exhibits massive variation in the mean cost. This presents an ideal opportunity for cost savings by reducing excessive variation in implant component selection. LEVEL OF EVIDENCE: Level III. Retrospective Cohort.

Intra-articular Hematoma Block Compared to Procedural Sedation for Closed Reduction of Ankle Fractures.

BACKGROUND: Initial treatment for a displaced ankle fracture is closed reduction and splinting. This is typically performed in conjunction with either an intra-articular hematoma block (IAHB) or procedural sedation (PS) to assist with pain control. The purpose of this study was to compare the safety of IAHB to PS and evaluate the efficiency and efficacy for each method. METHODS: A retrospective chart review for ankle fractures requiring manipulation was performed for patients seen in a level I trauma center from 2005 to 2016. The primary outcome was rate of successful reduction. Several secondary outcome measures were defined: reduction attempts, time until successful reduction, time spent in the emergency department (ED), rate of hospital admission, and adverse events. The analysis included 221 patients who received IAHB and 114 patients who received PS. RESULTS: The demographics between the 2 groups were similar, with the exception that more patients with a dislocation received PS, which prompted a subgroup analysis. This analysis demonstrated that patients with an ankle fracture and associated tibiotalar joint subluxation underwent closed reduction in a shorter period of time with the use of an IAHB compared with those receiving PS. In patients sustaining a tibiotalar fracture dislocation, patients receiving PS were successfully reduced with 1 reduction attempt more frequently than those receiving IAHB. Orthopedic surgeons also had higher rates of success on first attempt compared with ED providers. CONCLUSION: Both IAHB and PS were excellent options for analgesia that resulted in high rates of successful closed reduction of ankle fractures with adequate safety. IAHB can be considered a first-line agent for patients with an ankle fracture and associated joint subluxation. LEVEL OF EVIDENCE: Level III, retrospective comparative series.