Retrograde femoral nailing: computed tomography angiogram demonstrates no relative safe zone for prevention of small diameter arterial vascular injury during proximal anteroposterior interlocking.

BACKGROUND: Reported iatrogenic injury to the proximal femoral vascular structures is rare after retrograde femoral nailing. Previous cadaveric dissections have recommended placement of proximal interlocking screws above the level of the lesser trochanter. METHODS: This study is designed to define the arterial vascular anatomy anterior to the proximal medullary canal of the femur, which could be damaged with the placement of anteroposterior (AP) proximal interlocking screws. RESULTS: Computed tomography angiograms of the structures anterior to the proximal femur demonstrate the presence of arterial branches >2 mm diameter in 100% of study patients at or above the level of the lesser trochanter. CONCLUSIONS: No true safe zone corridor exists anteriorly for placement of AP interlocking screws in this region. Surgical technique modifications are suggested to minimize the potential risks of iatrogenic arterial injury during retrograde femoral nail AP proximal interlocking.

Geographic and demographic variability of cost and surgical treatment of idiopathic scoliosis.

STUDY DESIGN: Retrospective database review. OBJECTIVE: To determine the variability in cost and surgical technique by geographic region and patient demographic. SUMMARY OF BACKGROUND DATA: Some patients with idiopathic scoliosis (IS) ultimately require surgical treatment. The costs associated with hospitalization can be substantial, yet it is unknown how these vary depending on geographic region. METHODS: Patients aged 10 to 24 who underwent surgical fusion for idiopathic scoliosis from 2004 to 2006 were identified in a publicly available, searchable national database of insurance billing records for patients with orthopaedic diagnoses (PearlDiver Patient Record Database) by searching ICD-9 diagnosis and procedure codes. Inpatient hospital charges for the procedure, length of stay (LOS), and surgical procedure (anterior, posterior, anterior-posterior, posterior interbody) were recorded. Patients were stratified by geographic region (Northeast, South, Midwest, West) and age group (10-14, 15-19, and 20-24). RESULTS: Seventy-six thousand seven hundred forty-one patients had IS and 955 patients had spinal fusion procedure codes. Per patient average charge (PPAC) was $113,303 with average LOS 5.6 days. There was no significant difference in procedure type based on geographic region or age. The Northeast had the lowest rate of posterior surgery and highest rate of anterior only procedures. The Midwest had the highest rate of anterior-posterior surgery and Northeast had the lowest. Patients age 10 to 14 had the highest rate of posterior only procedures, those age 20 to 24 had the lowest. Patients age 15 to 19 were more likely to have anterior only procedures. Taken together, anterior-posterior and posterior interbody techniques were most common in patients age 20 to 24. Inpatient hospital charges varied significantly from region to region. Charges were highest in the West ($152,637) and lowest in the South ($103,256). There was no significant difference in PPAC based on age. LOS was significantly highest in the Midwest (6.5 days) and lowest in the South (5.2 days). LOS was significantly higher in the oldest age group compared with the younger groups. CONCLUSION: PPAC and LOS varied by region. Although there was no significant difference in treatment type based on age or region, older patients tended to have more complex procedures and a higher LOS. This did not translate into a significant change in PPAC based on age. These data point to the need for further studies examining reasons for geographic variability in idiopathic scoliosis surgeries.