Exploring trends in admissions and treatment for ankle fractures: a longitudinal cohort study of routinely collected hospital data in England.

BACKGROUND: Evidence on the most effective and cost-effective management of ankle fractures is sparse but evolving. A recent large RCT in older patients with unstable fractures found that management with close-contact-casting was functionally equivalent and more cost-effective than internal fixation. We describe temporal and geographic variation in ankle fracture management and estimate the potential savings if close-contact-casting was used more often in older patients. METHODS: Patients admitted to hospital in England between 2007/08 and 2016/17 with an ankle fracture were identified using routine hospital episode statistics. We tested whether the use of internal fixation, and the proportion of internal fixations using intramedullary implants, changed over time. We estimated the potential annual cost savings if patients aged 60+ years were treated with close-contact-casting rather than internal fixation, in line with emerging evidence. RESULTS: Over the 10-year period, there were 223,465 hospital admissions with a primary ankle fracture diagnosis. The incidence (per 100,000) of internal fixation was fairly consistent over time in younger (33.2 in 2007/08, 30.9 in 2016/17) and older (36.5 in 2007/08, 37.4 in 2016/17) patients. The proportion of internal fixations which used intramedullary implants increased in both age groups (17.0-19.5% < 60 years; 15.2-17.4% 60+ years). In 2016/17, the cost of inpatient hospital care for ankle fractures in England was over £63.1million. If 50% of older patients who had an internal fixation instead had close-contact-casting, we estimate that approximately £1.56million could have been saved. CONCLUSIONS: Despite emerging evidence that non-surgical and surgical management achieve equivalent functional outcomes in older patients, the rate of surgical fixation has remained relatively stable over the decade. The health service could achieve substantial savings if a higher proportion of older patients were treated with close-contact-casting, in line with recent evidence.

Costs and Radiographic Outcomes of Rotational Ankle Fractures Treated by Orthopaedic Surgeons With or Without Trauma Fellowship Training.

INTRODUCTION: We evaluated the radiographic outcomes and surgical costs of surgically treated rotational ankle fractures in our health system between providers who had completed a trauma fellowship and those who had not. METHODS: We grouped patients into those treated by trauma-trained orthopaedic surgeons (TTOS) and non-trauma-trained orthopaedic surgeons (NTTOS). We graded the quality of fracture reductions and calculated implant-related costs of treatment. RESULTS: A total of 208 fractures met the inclusion criteria, with 119 in the TTOS group and 89 in the NTTOS group. Five patients lost reduction during the follow-up period. The adequacy of fracture reduction at final follow-up did not differ (P = 0.29). The median surgical cost was $2,940 for the NTTOS group and $1,233 for the TTOS group (P < 0.001). DISCUSSION: We found no notable differences in radiographic outcomes between the TTOS and NTTOS groups. Cost analysis demonstrated markedly higher implant-related costs for the NTTOS group, with the median surgical cost being more than twice that for the TTOS group. LEVEL OF EVIDENCE: Level III.

A Prospective Randomized Trial to Assess Fixation Strategies for Severe Open Tibia Fractures: Modern Ring External Fixators Versus Internal Fixation (FIXIT Study).

The treatment of high-energy open tibia fractures is challenging in both the military and civilian environments. Treatment with modern ring external fixation may reduce complications common in these patients. However, no study has rigorously compared outcomes of modern ring external fixation with commonly used internal fixation approaches. The FIXIT study is a prospective, multicenter randomized trial comparing 1-year outcomes after treatment of severe open tibial shaft fractures with modern external ring fixation versus internal fixation among men and women of ages 18-64. The primary outcome is rehospitalization for major limb complications. Secondary outcomes include infection, fracture healing, limb function, and patient-reported outcomes including physical function and pain. One-year treatment costs and patient satisfaction will be compared between the 2 groups, and the percentage of Gustilo IIIB fractures that can be salvaged without soft tissue flap among patients receiving external fixation will be estimated.

Magnetically controlled growing rods for scoliosis surgery.

INTRODUCTION: Early onset scoliosis can be both a disfiguring as well as a life threatening condition. When more conservative treatments fail, pediatric spinal surgeons are forced to consider operative interventions. Traditionally, these interventions have involved the insertion of a variety of implants into the patient with a limited number of anchor points controlling the spine. In the past, these pediatric patients have had multiple surgeries for elective lengthening of these devices to facilitate their growth while attempting to control the scoliosis. These patients often experience a physical and emotional toll from their multiple repeated surgeries. Growing spine techniques have also had a noted high complication rate due to implant dislodgement and infections. Recently, the development of non-invasively, self-lengthening growing rods has occurred. These devices have the potential to allow for the devices to be lengthened magnetically in a conscious patient in the surgeon's office. Areas covered: This review summarized previously published articles in the English literature using a key word search in PubMed for: 'magnetically controlled growing rods', 'Magec rods', 'magnetic growing rods' and 'growing rods'. Expert commentary: Magnetically controlled growing rods have an advantage over growing rods in lengthening the growing spine in the absence of repetitive surgeries.

Variation in Costs of Spinal Implants in United States Academic Medical Centers.

STUDY DESIGN: Retrospective study of benchmarking database. OBJECTIVE: To evaluate the variability in direct costs of spinal implants across various academic medical centers, determining variability between and within specific manufacturers, and to measure the relationship between purchasing volume and price. SUMMARY OF BACKGROUND DATA: Spinal implants are a significant component of the cost of surgery. There is an absence of transparency of how much various medical centers in the United States pay for implants because of the use of nondisclosure agreements as part of price negotiations. Transparency of information on costs and awareness of costs by physicians will be useful in managing costs in a value-based health care economy. METHODS: Purchasing records of 45 academic medical centers over a 12-month period were examined. Purchasing volume and unit pricing for pedicle screws (PS), anterior cervical plates (ACP), and transforaminal lumbar interbody fusion (TLIF) cages were collected for 6 manufacturers. Overall variation in implant costs across centers and for each manufacturer was determined as was the relationship between purchasing volume and unit price. RESULTS: We found variation in implant costs between medical centers, and between manufacturers for PS, ACP and TLIF similar to joint replacement implants. Regression analysis showed that for each 10-fold increase in purchasing volume, the unit price decreased by $126 for PS, $242 for ACP, and $789 for TLIF. CONCLUSION: There was variation in implant costs between medical centers and manufacturers of implants, with a small negative relationship between purchasing volume and cost. Transparency in cost negotiation, surgeon awareness of costs and alignment between surgeon and hospital goals may help decrease the cost of spinal implants, and the cost of care for patients undergoing instrumented fusions.

Surgery for spinal stenosis: long-term reoperation rates, health care cost, and impact of instrumentation.

STUDY DESIGN: Retrospective cohort analysis. OBJECTIVE: To examine the complications, reoperation rates, and resource use after each of the surgical approaches for the treatment of spinal stenosis. SUMMARY OF BACKGROUND DATA: There are no uniform guidelines for which procedure (decompression, decompression with instrumentation, or decompression with noninstrumented fusion) to perform for the treatment of spinal stenosis. With no clear evidence for increased efficacy, the rate of instrumented fusions is rising. METHODS: We performed a retrospective cohort analysis of patients who underwent spinal stenosis surgery between 2002 and 2009 in the United States. Patients included (n = 12,657) were diagnosed with spinal stenosis without concurrent spondylolisthesis and had at least 2 years of preoperative enrollment. A total of 2385 patients with decompression only and 620 patients with fusion had follow-up data for 5 years or more. RESULTS: Complication rates during the initial procedure hospitalization and at 90 days were significantly higher for those who underwent laminectomy with fusion than for those who underwent laminectomy alone, with reoperation rates not differing significantly between these groups. Long-term (≥5 yr) reoperation rates were similar for those undergoing decompression alone versus decompression with fusion (17.3% vs. 16.0%, P = 0.44). Those with instrumented fusions had a slightly higher rate of reoperation than patients with noninstrumented fusions (17.4% vs. 12.2%, P = 0.11) at more than 5 years. The total cost including initial procedure and hospital, outpatient, emergency department, and medication charges at 5 years was similar for those who received decompression alone and fusion. The long-term costs for instrumented and noninstrumented fusions were also similar, totaling $107,056 and $100,471, respectively. CONCLUSION: For patients with spinal stenosis, if fusion is warranted, use of arthrodesis without instrumentation is associated with decreased costs with similar long-term complication and reoperation rates.

Mechanical behaviour of low-cost dynamic compression plates correlates with manufacturing quality standards.

PURPOSE: This study compares the mechanical properties of low-cost stainless steel dynamic compression plates (DCPs) from developing-world manufacturers, adhering to varying manufacturing quality standards, with those of high-cost DCPs manufactured for use in the developed world. METHODS: Standard-design ten-hole DCPs from six developing-world manufacturers and high-cost DCPs from two manufacturers in the developed world were studied. Nine plates from each manufacturer underwent mechanical testing: six in four-point monotonic bending to assess strength and stiffness and three in four-point bending fatigue. Statistical comparisons of the group means of monotonic bending test data were made, and a qualitative comparison was performed to assess failures in fatigue. RESULTS: Low-cost DCPs from manufacturers with at least one manufacturing quality standard had significantly higher bending strength and fewer failures in fatigue than did those from low-cost manufacturers with no recognised quality standards. High-cost DCPs demonstrated greater bending strength than did those in both low-cost groups. There were no differences in stiffness and fatigue failure between high-cost DCPs and those low-cost DCPs with quality standards. However, high-cost DCPs were significantly less stiff and had fewer fatigue failures than low-cost DCPs manufactured without such standards. CONCLUSION: Significant differences were found in the mechanical properties of ten-hole DCP plates from selected manufacturers in the developing and developed worlds. These differences correlated with reported quality certification in the manufacturing process. Mechanical analysis of low-cost implants may provide information useful in determining which manufacturers produce implants with the best potential for benefit relative to cost.

Cost savings associated with prevention of recurrent lumbar disc herniation with a novel annular closure device: a multicenter prospective cohort study.

OBJECTIVE: Same-level recurrent disc herniation is a well-defined complication following lumbar discectomy. Reherniation results in increased morbidity and health care costs. Techniques to reduce these consequences may improve outcomes and reduce cost after lumbar discectomy. In a prospective cohort study, we set out to evaluate the cost associated with surgical management of recurrent, same-level lumbar disc herniation following primary discectomy. METHODS: Forty-six consecutive European patients undergoing lumbar discectomy for a single-level herniated disc at two institutions were prospectively followed with clinical and radiographic evaluations. A second consecutive cohort of 30 patients undergoing 31 lumbar discectomies with implantation of an annular closure device was followed at the same hospitals and same follow-up intervals. Cost estimates for reherniation were modeled on Medicare national allowable payment amounts (direct cost) and patient work-day losses (indirect cost). RESULTS: Annular closure and control cohorts were matched at baseline. By 2 years follow-up, symptomatic recurrent same-level disc herniation occurred in three (6.5%) patients in the control cohort versus zero (0%) patients in the annular closure cohort. For patients experiencing recurrent disc herniation, mean estimated direct and indirect cost of management of recurrent disc herniation was $34,242 and $3,778, respectively. Use of an annular closure device potentially results in a cost savings of $222,573 per 100 primary discectomy procedures performed (or $2,226 per discectomy), based solely on the reduction of reoperated reherniations when modeled on U.S. Medicare costs. CONCLUSIONS: Recurrent disc herniation did not occur in any patients after annular closure within the 12-month follow-up. The reduction in the incidence of reherniation was associated with potentially significant cost savings. Development of novel techniques to prevent recurrent lumbar disc herniation is warranted to decrease the associated morbidity and health care costs associated with this complication.

Reducing the cost and frequency of explantations associated with single-level anterior diskectomy and fusion at a single institution through education.

STUDY DESIGN: We prospectively evaluated the costs/frequency of explanted instrumentation (devices implanted but removed prior to closure) for all single-level anterior diskectomy (1-ADF) procedures performed in 2010 at a single institution before and after surgeon education. OBJECTIVE: To determine whether surgeon education would reduce the costs/frequency of explantation for 1-ADF. SUMMARY OF BACKGROUND DATA: In 2009, we reported that the cost of explanted devices was 9.2% of the cost of implanted devices. METHODS: The costs/frequencies of explantation for 1-ADF performed in 2010 at the same institution by the same surgeons were analyzed before and after surgeon education. From January through April, surgeons were unaware of concerns regarding explantation. At the end of April 2010, spinal surgeons were educated about explantation costs/frequency at 2 meetings. Explantation costs/frequencies for the first 4 months of 2010 were compared with those for the last 8 months as well as with the results from 2009. RESULTS: Prior to surgeon education, instrumentation was explanted in 45.5% of the cases, whereas after education explantation occurred in 16% of the cases. The explantation rate (the number of explanted devices as a percentage of implanted devices) was lower after education for screws (12.5% vs. 7.7%), plates (9.4% vs. 0%), and allograft spacers (7.1% vs. 2.9%), and lower than for rates from 2009. In 2010, the overall cost of explanted devices as a percentage of implanted devices was also lower after surgeon education (5.8%) than before surgeon education in 2010 (20.0%) or 2009 (9.2%). CONCLUSION: The frequency and cost of explanted instrumentation used to perform 1-ADF were reduced through surgeon education.

Hemiarthroplasty compared to internal fixation with percutaneous cannulated screws as treatment of displaced femoral neck fractures in the elderly: cost-utility analysis performed alongside a randomized, controlled trial.

UNLABELLED: We estimated the cost-effectiveness of hemiarthroplasty compared to internal fixation for elderly patients with displaced femoral neck fractures. Over 2 years, patients treated with hemiarthroplasty gained more quality-adjusted life years than patients treated with internal fixation. In addition, costs for hemiarthroplasty were lower. Hemiarthroplasty was thus cost effective. INTRODUCTION: Estimating the cost utility of hemiarthroplasty compared to internal fixation in the treatment of displaced femoral neck fractures in the elderly. METHODS: A cost-utility analysis (CUA) was conducted alongside a clinical randomized controlled trial at a university hospital in Norway; 166 patients, 124 (75%) women with a mean age of 82 years were randomized to either internal fixation (n = 86) or hemiarthroplasty (n = 80). Patients were followed up at 4, 12, and 24 months. Health-related quality of life was assessed with the EQ-5D, and in combination with time used to calculate patients' quality-adjusted life years (QALYs). Resource use was identified, quantified, and valued for direct and indirect hospital costs and for societal costs. Results were expressed in incremental cost-effectiveness ratios. RESULTS: Over the 2-year period, patients treated with hemiarthroplasty gained 0.15-0.20 more QALYs than patients treated with internal fixation. For the hemiarthroplasty group, the direct hospital costs, total hospital costs, and total costs were non-significantly less costly compared with the internal fixation group, with an incremental cost of €2,731 (p = 0.81), €2,474 (p = 0.80), and €14,160 (p = 0.07), respectively. Thus, hemiarthroplasty was the dominant treatment. Sensitivity analyses by bootstrapping supported these findings. CONCLUSION: Hemiarthroplasty was a cost-effective treatment. Trial registration, NCT00464230.

Intramedullary leg lengthening with a motorized nail.

BACKGROUND AND PURPOSE: In the last decade, intramedullary limb lengthening has become a viable alternative to traditional external systems. We retrospectively analyzed the use of an intramedullary motorized nail (Fitbone) in a consecutive series of 32 patients. PATIENTS AND METHODS: During the period September 2006 to December 2008, 32 consecutive patients with a median age of 17 (IQR: 15-19) years were treated with a fully implantable, motorized intramedullary lengthening device (Fitbone). The median leg length discrepancy was 35 (IQR: 30-44) mm at the femur (n = 21) and 28 (IQR: 25-30) mm at the tibia (n = 11). RESULTS: Leg lengthening was successful in 30 of 32 cases, with no residual relevant discrepancy (± 5 mm). No intraoperative complications were observed. The consolidation index was significantly different (p = 0.04) between femoral lengthening (mean 35 days/cm) and tibial lengthening (mean 48 days/cm) but did not depend on age older/younger than 16 or previous operations at the affected site. 3 problems, 3 obstacles, and 4 complications (3 minor, 1 major) were encountered in 8 patients, 5 of which were implant-associated. INTERPRETATION: This technique even allows correction in patients with multiplanar deformities. Compared to external devices, intramedullary systems provide comfort and reduce complication rates, give improved cosmetic results, and lead to fast rehabilitation since percutaneous, transmuscular fixation is prevented. This results in reasonable overall treatment costs despite the relatively high costs of implants.

Right adolescent idiopathic thoracic curve (Lenke 1 A and B): does cost of instrumentation and implant density improve radiographic and cosmetic parameters?

In adolescent idiopathic scoliosis (AIS) there has been a shift towards increasing the number of implants and pedicle screws, which has not been proven to improve cosmetic correction. To evaluate if increasing cost of instrumentation correlates with cosmetic correction using clinical photographs. 58 Lenke 1A and B cases from a multicenter AIS database with at least 3 months follow-up of clinical photographs were used for analysis. Cosmetic parameters on PA and forward bending photographs included angular measurements of trunk shift, shoulder balance, rib hump, and ratio measurements of waist line asymmetry. Pre-op and follow-up X-rays were measured for coronal and sagittal deformity parameters. Cost density was calculated by dividing the total cost of instrumentation by the number of vertebrae being fused. Linear regression and spearman's correlation were used to correlate cost density to X-ray and photo outcomes. Three independent observers verified radiographic and cosmetic parameters for inter/interobserver variability analysis. Average pre-op Cobb angle and instrumented correction were 54° (SD 12.5) and 59% (SD 25) respectively. The average number of vertebrae fused was 10 (SD 1.9). The total cost of spinal instrumentation ranged from $6,769 to $21,274 (Mean $12,662, SD $3,858). There was a weak positive and statistically significant correlation between Cobb angle correction and cost density (r = 0.33, p = 0.01), and no correlation between Cobb angle correction of the uninstrumented lumbar spine and cost density (r = 0.15, p = 0.26). There was no significant correlation between all sagittal X-ray measurements or any of the photo parameters and cost density. There was good to excellent inter/intraobserver variability of all photographic parameters based on the intraclass correlation coefficient (ICC 0.74-0.98). Our method used to measure cosmesis had good to excellent inter/intraobserver variability, and may be an effective tool to objectively assess cosmesis from photographs. Since increasing cost density only improves mildly the Cobb angle correction of the main thoracic curve and not the correction of the uninstrumented spine or any of the cosmetic parameters, one should consider the cost of increasing implant density in Lenke 1A and B curves. In the area of rationalization of health care expenses, this study demonstrates that increasing the number of implants does not improve any relevant cosmetic or radiographic outcomes.

Re-use of explanted osteosynthesis devices: a reliable and inexpensive reprocessing protocol.

INTRODUCTION: Orthopaedic surgical treatments emphasizing immobilization using open reduction and internal fixation with osteosynthesis devices are widely accepted for their efficacy in treating complex fractures and reducing permanent musculoskeletal deformity. However, such treatments are profoundly underutilized in low- and middle-income countries (LMIC), partially due to inadequate availability of the costly osteosynthesis devices. Orthopaedic surgeons in some LMIC regularly re-use osteosynthesis devices in an effort to meet treatment demands, even though such devices typically are regulated for single-use only. The purpose of this study is to report a reprocessing protocol applied to explanted osteosynthesis devices obtained at a leading trauma care hospital. METHODS: Explanted osteosynthesis devices were identified through a Register of Explanted Orthopaedic Prostheses. Guidelines to handle ethical issues were approved by the local Ethical Committee and informed patient consent was obtained at the time of explant surgery. Primary acceptance criteria were established and applied to osteosynthesis devices explanted between 2005 and 2008. A rigorous protocol for conducting decontamination and visual inspection based on specific screening criteria was implemented using simple equipment that is readily available in LMIC. RESULTS: A total of 2050 osteosynthesis devices, including a large variety of plates, screws and staples, were reprocessed using the decontamination and inspection protocols. The acceptance rate was 66%. Estimated labour time and implementation time of the protocol to reprocess a typical osteosynthesis unit (1 plate and 5 screws) was 25 min, with an estimated fixed cost (in Italy) of €10 per unit for implementing the protocol, plus an additional €5 for final sterilization at the end-user hospital site. DISCUSSION: This study was motivated by the treatment demands encountered by orthopaedic surgeons providing medical treatment in several different LMIC and their need for access to basic osteosynthesis devices. The rigorous decontamination protocol and generalized inspection criteria proved useful for efficiently screening a large volume of devices. Given that re-used osteosynthesis devices can yield satisfactory results, this study addresses potential complications of re-used devices and valid concerns that relate to patient safety. Implementing this defined reprocessing protocol into existing re-use practises in LMIC helps to limit the risks of inadequate sterilization and structural failure without adding additional risks to patients receiving re-used devices.

The NEtherlands Cervical Kinematics (NECK) trial. Cost-effectiveness of anterior cervical discectomy with or without interbody fusion and arthroplasty in the treatment of cervical disc herniation; a double-blind randomised multicenter study.

BACKGROUND: Patients with cervical radicular syndrome due to disc herniation refractory to conservative treatment are offered surgical treatment. Anterior cervical discectomy is the standard procedure, often in combination with interbody fusion. Accelerated adjacent disc degeneration is a known entity on the long term. Recently, cervical disc prostheses are developed to maintain motion and possibly reduce the incidence of adjacent disc degeneration. A comparative cost-effectiveness study focused on adjacent segment degeneration and functional outcome has not been performed yet. We present the design of the NECK trial, a randomised study on cost-effectiveness of anterior cervical discectomy with or without interbody fusion and arthroplasty in patients with cervical disc herniation. METHODS/DESIGN: Patients (age 18-65 years) presenting with radicular signs due to single level cervical disc herniation lasting more than 8 weeks are included. Patients will be randomised into 3 groups: anterior discectomy only, anterior discectomy with interbody fusion, and anterior discectomy with disc prosthesis. The primary outcome measure is symptomatic adjacent disc degeneration at 2 and 5 years after surgery. Other outcome parameters will be the Neck Disability Index, perceived recovery, arm and neck pain, complications, re-operations, quality of life, job satisfaction, anxiety and depression assessment, medical consumption, absenteeism, and costs. The study is a randomised prospective multicenter trial, in which 3 surgical techniques are compared in a parallel group design. Patients and research nurses will be kept blinded of the allocated treatment for 2 years. The follow-up period is 5 years. DISCUSSION: Currently, anterior cervical discectomy with fusion is the golden standard in the surgical treatment of cervical disc herniation. Whether additional interbody fusion or disc prosthesis is necessary and cost-effective will be determined by this trial. TRIAL REGISTRATION: Netherlands Trial Register NTR1289.

Utility of pathologic evaluation following removal of explanted orthopaedic internal fixation hardware.

This report questions the cost and effectiveness of routinely sending explanted hardware to pathology for evaluation. Forty-six consecutive patients who had symptomatic hardware removed were enrolled in this study. Pathology reports following hardware removal were obtained, and charts were reviewed for these patients. The pathology department was contacted for related departmental procedure codes, and hospital billing records were obtained regarding the cost of the procedure. In all cases, the pathology reports gave the gross diagnosis of "hardware" and the gross description included the measurements of the internal fixation hardware removed. In no case did the report alter the plan of the attending physician. The healthcare system may benefit by subspecialty review of the current practice of sending internal fixation devices to pathology for evaluation. We recommend a single radiographic view along with proper documentation in the postoperative report to confirm the removal of internal fixation hardware in lieu of pathologic evaluation.

Single-level cervical radiculopathy: clinical outcome and cost-effectiveness of four techniques of anterior cervical discectomy and fusion and disc arthroplasty.

Although there are several accepted methods of surgical treatment for single-level cervical radiculopathy, the choice depend on the surgeon's preference. The techniques may vary in peri-operative morbidity, short- and long-term outcome, but no study so far has analyzed their cost-effectiveness. This study might give some insight in balancing cost and effectiveness and deciding the right technique. Sixty consecutive patients (15 each group), mean age 36 (range 24-76 years) with single-level cervical disc disease underwent surgical treatment with four different techniques in two centers over the period of 1999-2005. The four groups were--(1) plate and tricortical autograft, (2) plate, cage, and bone substitute, (3) cage only, and (4) disc arthroplasty. The data was collected prospectively according to our protocol and subsequently analyzed. The clinical outcome was assessed comparing visual analog scale (VAS) of neck pain and, short form 12 (SF12) questionnaire both pre- and postoperatively. The radiological assessment was done for fusion rate and postoperative related possible complications at 3 months, 6 months, 1 year, and final follow-up. The cost analysis was done calculating the operative time, hospital stay, implant cost together. The mean follow-up period was 31 months (range 28-43 months). The clinical outcome in terms of VAS of neck and arm pain and SF12 physical and mental score improvement (P=0.001) were comparable with all four techniques. The radiological fusion rate was comparable to current available data. As the hospital stay was longer (average 5 days) with plate and autograft group, the total cost was maximum (average 2,920 pound sterling) with this group. There was satisfactory clinical and radiological outcome with all four techniques. Using the cage alone was the most cost-effective technique, but the disc arthroplasty was comparable to the use of cage and plate. Anterior cervical discectomy and fusion is an established surgical treatment for cervical radiculopathy. Single-level cervical radiculopathy was treated with four different techniques. The clinical outcome and cost-effectiveness were compared in this study.

Obesity and litigation predict workers' compensation costs associated with interbody cage lumbar fusion.

BACKGROUND CONTEXT: Results of lumbar fusion surgery have been mixed and procedures are costly. Interbody cage lumbar fusion (ICLF) has been advanced to improve arthrodesis and clinical outcomes; however, little attention has been given to ICLF costs or potential predictors of these expenses. PURPOSE: To depict medical and compensation costs associated with ICLF in a Utah cohort of patients receiving workers' compensation as well as to investigate predictors of costs. STUDY DESIGN/SETTING: A retrospective-cohort research design was used involving completion of presurgical and postsurgical medical record reviews and accrual of medical and compensation costs. Presurgical variables included in a regression model were presurgical spinal pathophysiology rating, obesity, and litigation status. PATIENT SAMPLE: Forty-three consecutive patients who were compensated by the Workers' Compensation Fund of Utah and underwent ICLF. OUTCOME MEASURES: Total accrued compensation and medical costs. METHODS: A retrospective review of presurgical variables and total accrued compensation and medical costs was conducted. RESULTS: Multiple regression analysis indicated that nonpathophysiological factors predicted compensation costs (lawyer involvement [beta=0.40]; obesity [beta=0.34]). Specifically, compensation for those with versus without lawyers was $41,657 versus $24,837, and for those who were obese versus nonobese was $46,152 versus $28,168. Arthrodesis was correlated with medical costs (r=-0.47, p=.002), with incurred costs for patients achieving solid fusion versus pseudarthrosis equaling $38,881 versus $71,655, respectively. CONCLUSIONS: Considerable costs were associated with ICLF, particularly for those who were obese, involved in litigation, or failed to achieve solid fusion. With regard to compensation costs, the findings support the importance of assessing nonpathophysiological factors in spinal fusion patients.

Complications of anterior cervical discectomy and fusion using recombinant human bone morphogenetic protein-2.

The use of bone morphogenetic protein-2 (rhBMP-2) in spinal fusion has increased dramatically since an FDA approval for its use in anterior lumbar fusion with the LT cage. There are several reports of its use in transforaminal lumbar interbody fusion, posterolateral fusion, and anterior cervical fusion. Reports on adverse effects of rhBMP-2 when used in spinal fusion are scarce in literature. An Institutional Review Board approved retrospective study was conducted in patients undergoing anterior spinal fusion and instrumentation following diskectomy at a single center. Forty-six consecutive patients were included. Twenty-two patients treated with rhBMP-2 and PEEK cages were compared to 24 in whom allograft spacers and demineralized bone matrix was used. Patients filled out Cervical Oswestry Scores, VAS for arm pain, neck pain, and had radiographs preoperatively as well at every follow up visit. Radiographic examination following surgery revealed end plate resorption in all patients in whom rhBMP-2 was used. This was followed by a period of new bone formation commencing at 6 weeks. In contrast, allograft patients showed a progressive blurring of end plate-allograft junction. Dysphagia was a common complication and it was significantly more frequent and more severe in patients in whom rhBMP-2 was used. Post operative swelling anterior to the vertebral body on lateral cervical spine X-ray was significantly larger in the rhBMP-2 group when measured from 1 to 6 weeks after which it was similar. These effects are possibly due to an early inflammatory response to rhBMP-2 and were observed to be dose related. With the parameters we used, there was no significant difference in the clinical outcome of patients in the two groups at 2 years. The cost of implants in patients treated with rhBMP-2 and PEEK spacers was more than three times the cost of allograft spacers and demineralized bone matrix in 1, 2, and 3-level cases. Despite providing consistently good fusion rates, we have abandoned using rhBMP-2 and PEEK cages for anterior cervical fusion, due to the side effects, high cost, and the availability of a suitable alternative.

[Interspinous decompression as treatment for lumbar spinal stenosis]. / Interspinöse Dekompression als Therapie der lumbalen Spinalkanalstenose.

Interspinous process distractors are an effective operative tool for treating patients with lumbar spinal stenosis. Lumbar stenosis with minor secondary instabilities due to degenerative changes in the segment can also be treated successfully with these devices. In case of failure, these devices can easily be revised or removed. As this operative procedure is not very time-consuming, it is a reasonable option for elderly patients with various medical problems and increased anaesthetic risk. There are reports of implanting these devices in certain cases under local anaesthetic. A prospective randomised trial has shown promising results for up to two years postoperatively. There are no long-term results available.