Financial Impact of Magnetic Resonance Imaging in the Surgical Treatment of Foot and Ankle Osteomyelitis.

Magnetic resonance imaging (MRI) is generally considered the most sensitive imaging for diagnosis of osteomyelitis; however, it is associated with significant cost and is at times ordered as initial screening imaging when a less resource-intensive test would suffice. The purpose of this retrospective cohort study was to examine the differences between patients with osteomyelitis of the foot and ankle, and their subsequent treatment course, who underwent MRI compared with those who did not. Financial impact of MRI as it relates to clinical decision-making was also calculated. Patients treated for a diagnosis of osteomyelitis of the foot and ankle from 2009 to 2015 were retrospectively identified. Demographics, imaging modalities, and operative procedures for each patient were collected. An "impact MRI" was defined as one that led to a subsequent operative procedure within the same admission. The impact cost of an MRI was estimated using the equation: (average MRI cost) × (total MRIs/impact MRIs). A total of 144 patients underwent 220 MRIs, and 399 patients did not have MRIs. The operative rate between the 2 groups was similar (70.8% versus 70.4%, p = .93). Multiple linear regression showed that MRI was not a significant predictor of operation (p = .50). However, we found a significant correlation between MRI use and operative intervention for patients with increased comorbidities. From 2011 to 2015, there was a significant increase in impact cost, while controlling for average MRI cost ($8172 to $15,292, p ≤ .05). Over the study period, the impact cost of an MRI significantly increased from 1.8 to 5.0 times the average cost.

Health Care Costs of Post-traumatic Osteomyelitis in China: Current Situation and Influencing Factors.

BACKGROUND: Currently, very limited information is available regarding the economic burdens of patients with extremity post-traumatic osteomyelitis (OM). This study aimed to investigate direct health care costs and utilization for inpatients with extremity post-traumatic OM and analyze its constituent ratios and influencing factors in Southern China. METHODS: We searched in the electronic medical record system for inpatients who had received surgical interventions at our department between 2013 and 2016 for extremity post-traumatic OM. Data of direct health care costs incurred during their hospitalizations were collected in six main categories (service, diagnosis, treatment, materials, pharmaceuticals, and miscellaneous expenses). In addition, data of total medical costs for contemporaneous inpatients with non-post-traumatic OM were also collected as controls. RESULTS: A total of 278 post-traumatic OM and 10,420 controls were included. The median cost for the post-traumatic OM inpatients was $10,504 US dollars, 4.8-fold higher than that for those with non-post-traumatic OM ($2189, P < 0.001). The direct cost in the category of materials accounted for the largest proportion (61%), followed by that in pharmaceuticals (12%) and treatment (11%). The median number of hospital admissions for post-traumatic OM patients was 1 time, with a median length-of-stay of 22 d. The most influencing factors for the health care costs of the post-traumatic OM inpatients were use of an external fixator ($16,016 for those who used versus $4956 for those who did not, P < 0.001), external fixator type ($19,563 for ring fixator versus $14,966 for rail fixator, P < 0.001), infection site ($13,755 for tibia, $14,216 for femur and $5673 for calcaneus, P < 0.001), and infection-associated injury type ($12,890 for infection after open fracture versus $8087 for infection after closed fracture, P = 0.001). CONCLUSIONS: An unexpectedly large proportion of the direct health care costs for inpatients with extremity post-traumatic OM went to cover an external fixator, with expenses for pharmaceuticals and treatment accounting for only a little more than the tenth of the total health care costs. Use of external fixator, external fixator type, infection site, and infection-associated injury type directly influenced the health care costs.

Organisational and financial consequences of the early discharge of patients treated for acute bacterial skin and skin structure infection and osteomyelitis in infectious disease departments in Greece, Italy and Spain: a scenario analysis.

OBJECTIVE: The aim of the analysis is to assess the organisational and economic consequences of adopting an early discharge strategy for the treatment of acute bacterial skin and skin structure infection (ABSSSI) and osteomyelitis within infectious disease departments. SETTING: Infectious disease departments in Greece, Italy and Spain. PARTICIPANTS: No patients were involved in the analysis performed. INTERVENTIONS: An analytic framework was developed to consider two alternative scenarios: standard hospitalisation care or an early discharge strategy for patients hospitalised due to ABSSSI and osteomyelitis, from the perspective of the National Health Services of Greece, Italy and Spain. The variables considered were: the number of annual hospitalisations eligible for early discharge, the antibiotic treatments considered (ie, oral antibiotics and intravenous long-acting antibiotics), diagnosis-related group (DRG) reimbursements, number of days of hospitalisation, incidence and costs of hospital-acquired infections, additional follow-up visits and intravenous administrations. Data were based on published literature and expert opinions. PRIMARY AND SECONDARY OUTCOME MEASURES: Number of days of hospitalisation avoided and direct medical costs avoided. RESULTS: The total number of days of hospitalisation avoided on a yearly basis would be between 2216 and 5595 in Greece (-8/-21 hospital beds), between 15 848 and 38 444 in Italy (-57/-135 hospital beds) and between 7529 and 23 520 in Spain (-27/-85 hospital beds). From an economic perspective, the impact of the early discharge scenario is a reduction between €45 036 and €149 552 in Greece, a reduction between €182 132 and €437 990 in Italy and a reduction between €292 284 and €884 035 in Spain. CONCLUSIONS: The early discharge strategy presented would have a positive organisational impact on National Health Services, leading to potential savings in beds, and to a reduction of hospital-acquired infections and costs.

Current health and economic burden of chronic diabetic osteomyelitis.

INTRODUCTION: Diabetic foot ulcer (DFU) prevalence is as high as 25% and 40-80% of DFUs become infected (DFI). About 20% of infected ulcers will spread to bone causing diabetic foot osteomyelitis (DFO). DFU costs Medicare $9-13 billion/year. The most expensive costs associated with DFU are inpatient costs and hospital admissions. DFO costs are driven mostly by surgical procedures. DFU patients have a 3-year cumulative mortality rate of 28% and rates approaching 50% in amputated patients. AREAS COVERED: This review will summarize the current health and economic burden of DFO covering management, epidemiology, and copious costs associated with DFO. The review began by searching PubMed and Cochrane databases for various terms including, 'diabetic osteomyelitis costs,' 'diabetic foot infection,' and 'diabetes and antibiotics.' Additionally, references from retrieved publications were reviewed. The global burden of DFU calls for investigating new therapeutic options. EXPERT OPINION: For DFI, anti-biofilm agents have had success because they directly deliver antimicrobials to the infection site. For DFO, intraosseous (I/O) antibiotic therapy similarly bypasses the issue of vascular disease, will likely have improved therapeutic efficacy, and reduced costs for DFO patients. I/O antibiotic therapy has had clinical success in one case report already, and may significantly improve the lives of those afflicted with DFO.

Use of a Clinical Care Algorithm to Improve Care for Children With Hematogenous Osteomyelitis.

BACKGROUND AND OBJECTIVES: Acute hematogenous osteomyelitis (AHO) causes significant morbidity in children. Quality improvement (QI) methods have been used to successfully improve care and decrease costs through standardization for numerous conditions, including pediatric AHO. We embarked on a QI initiative to standardize our approach to the inpatient management of AHO, with a global aim of reducing inpatient costs. METHODS: We used existing literature and local consensus to develop a care algorithm for the inpatient management of AHO. We used the Model for Improvement as the framework for the project, which included process mapping, failure mode analysis, and key driver identification. We engaged with institutional providers to achieve at least 80% consensus regarding specific key drivers and tested various interventions to support uptake of the care algorithm. RESULTS: Fifty-seven patients were included. There were 31 patients in the preintervention cohort and 26 in the postintervention cohort, of whom 19 were managed per the algorithm. Mean inpatient charges decreased from $45 718 in the preintervention cohort to $32 895 in the postintervention cohort; length of stay did not change. Adherence to recommended empirical antimicrobial agents trended upward. CONCLUSIONS: A simple and low-cost QI project was used to safely decrease the cost of inpatient care for pediatric AHO at a tertiary care children's hospital. A robust local consensus process proved to be a key component in the uptake of standardization.

Comparison of Methicillin-resistant Versus Susceptible Staphylococcus aureus Pediatric Osteomyelitis.

BACKGROUND: The incidence of methicillin-resistant Staphylococcus aureus (MRSA) pediatric osteomyelitis has risen and been associated with a more severe clinical course than methicillin-susceptible Staphylococcus aureus (MSSA) infections. National databases have been underutilized to describe these trends. We compared demographics, clinical course, and outcomes for patients with MRSA versus MSSA osteomyelitis. METHODS: We queried the 2009 and 2012 Healthcare Cost and Utilization Project Kids Inpatient Database for discharge records with diagnosis codes for osteomyelitis and S. aureus. We explored demographics predicting MRSA and evaluated MRSA versus MSSA as predictors of clinical outcomes including surgery, sepsis, thrombophlebitis, length of stay, and total charges. RESULTS: A total of 4214 discharge records were included. Of those, 2602 (61.7%) had MSSA and 1612 (38.3%) had MRSA infections. Patients at Southern and Midwestern hospitals were more likely to have MRSA than those at Northeastern hospitals. Medicaid patients' odds of MRSA were higher than those with private insurance, and black patients were more likely to have MRSA compared with white patients. MRSA patients were more likely to undergo multiple surgeries compared with MSSA patients and were more likely to have complications including severe sepsis, thrombophlebitis, and pulmonary embolism. Patients with MRSA had longer lengths of stay than those with MSSA and higher total charges after controlling for length of stay. CONCLUSION: Review of a national database demonstrates MRSA is more prevalent in the South and Midwest regions and among black patients. MRSA patients have more surgeries, complications, and longer lengths of stay. LEVEL OF EVIDENCE: Level III.

Dalbavancin in the treatment of different gram-positive infections: a real-life experience.

Dalbavancin is a lipoglycopeptide with a very prolonged half-life enabling treatment with a single intravenous administration that has been approved to treat complicated skin and soft-tissue infections. Information on the efficacy and safety of dalbavancin in other situations is very scarce. This retrospective study included adult patients who received at least one dose of dalbavancin between 2016 and 2017 in 29 institutions in Spain. The primary objective was to report the use of dalbavancin in clinical practice, including its efficacy and tolerability. The potential impact of dalbavancin on reducing the length of hospital stay and hospital costs was also evaluated. A total of 69 patients received dalbavancin during the study period (58.0% male; median age 63.5 years). Dalbavancin was used to treat prosthetic joint infection (29.0%), acute bacterial skin and skin-structure infection (21.7%), osteomyelitis (17.4%) and catheter-related bacteraemia (11.6%). These infections were mainly caused by Staphylococcus aureus (27 isolates), coagulase-negative staphylococci (24 isolates) and Enterococcus spp. (11 isolates). All but two patients received previous antibiotics for a median of 18 days. Dalbavancin was administered for a median of 21 days (range 7-168 days), and concomitant antimicrobial therapy was prescribed to 25 patients (36.2%). The overall clinical success rate of dalbavancin was 84.1%. Adverse events, mainly mild in intensity, were reported in nine patients. Overall, dalbavancin was estimated to reduce hospitalisation by 1160 days, with an estimated overall cost reduction of €211 481 (€3064 per patient). Dalbavancin appears to be an effective therapy for many serious Gram-positive infections.

The Epidemiology of Vertebral Osteomyelitis in the United States From 1998 to 2013.

STUDY DESIGN: This is a epidemiological database analysis. OBJECTIVES: The objectives of this article are to assess the following characteristics of vertebral osteomyelitis (VO): (1) incidence and patient demographics, (2) mortality rate, (3) length-of-stay (LOS), and (4) admission costs. SUMMARY OF BACKGROUND: VO is a serious disease with potentially devastating clinical consequences. At present, there is limited data on the epidemiology of VO in the United States as previous reports are based on older studies with small sample sizes. METHODS: We used the Nationwide Inpatient Sample database and estimated that 228,044 patients were admitted for VO in the United States between 1998 and 2013. Data were extracted on patient demographics, comorbidities, inpatient mortality, LOS, and inflation-adjusted hospitalization charges. Multivariable regression analyses were performed. RESULTS: The incidence of VO admission was 4.8 per 100,000, increasing from 8021 cases (2.9/ 100,000) in 1998 to 16,917 cases (5.4/100,000) in 2013. Majority of patients were white (74%), male (51%), younger than 59 years of age (49.5%), and carried Medicare insurance (50%). The increase in incidence for male and females was similar. The mortality rate during hospital stay was 2.1%, decreasing from 2% in 1998 to 1.7% in 2006 and increasing to 2.2% in 2013. Risk factors for mortality included increased age, male sex, and higher comorbidity score. History of congestive heart failure [odds ratio (OR)=2.45], cerebrovascular disease (OR=1.92), liver disease (OR=2.33), hepatitis C (OR=2.36), and renal disease (OR=1.88) was associated with higher mortality rate. Mean LOS was 9.2 days, decreasing from 9.1 days in 1998 to 8.8 days in 2013. The mean estimated hospital charges for admission were $54,599, however, this increased from $24,102 in 1998 (total of $188.8 millions) to $80,786 in 2013 (total of $1.3 billions). CONCLUSION: This condition is associated with lengthy and expensive hospital stays resulting in a significant burden to patients and the health care system.

Pre-packing of cost effective antibiotic cement beads for the treatment of traumatic osteomyelitis in the developing world - an in-vitro study based in Cambodia.

The developing world often lacks the resources to effectively treat the most serious injuries including osteomyelitis following open fractures or surgical fracture treatment. Antibiotic cement beads are a widely accepted method of delivering antibiotics locally to the infected area following trauma. This study is based in Cambodia, a low income country struggling to recover from a recent genocide. The study aims to test the effectiveness of locally made antibiotic beads and analyse their effectiveness after being gas sterilised, packaged and kept in storage Different antibiotic beads were manufactured locally using bone cement and tested against MRSA bacteria grown from a case of osteomyelitis. Each antibiotic was tested before and after a process of gas sterilisation as well as later being tested after storage in packaging up to 42 days. The gentamicin, vancomycin, amikacin and ceftriaxone beads all inhibited growth of the MRSA on the TSB and agar plates, both before and after gas sterilisation. All four antibiotics continued to show similar zones of inhibition after 42 days of storage. The results show significant promise to produce beads with locally obtainable ingredients in an austere environment and improve cost effectiveness by storing them in a sterilised condition.

ECONOMIC ANALYSIS OF TREATMENT OF THE PATIENTS WITH CHRONIC POSTTRAUMATIC OSTEOMYELITIS OF THE SHOULDER BY THE METHOD OF TRANSOSSEOUS OSTEOSYNTHESIS BY ILIZAROV'S APPARATUS.

An analysis of the terms of hospitalization, cost of treatment was made. There were matched the real medical costs of treatment of the patients with chronic posttraumatic osteomyelitis of the shoulder using the method of transosseous osteosynthesis with application of Ilizarov's apparatus and medical costs according to the medical standards of treatment for patients with osteomyelitis. It was shown that actual expenses on drug therapy and expendable materials on one patients were approximately three times higher, than planned expenses according to standard. The presence of different microflora was revealed throughout the bacteriological research of suppurative focus in 25(96%) patients. There was detected an excess of actual expenses on one patient with given nosology compared with standard of financial expenditure from the funds for high-technology medical care from 6 % (average case) to 58% (Bassilus pynocyaneus). The excess of actual expenses from the funds of local program of obligatory medical insurance achieved from 48% (average patient) to 100% (Bassilus pynocyaneus case).

Long-term results and costs of muscle flap coverage with Ilizarov bone transport in lower limb salvage.

OBJECTIVES: To determine long-term outcomes and costs of Ilizarov bone transport and flap coverage for lower limb salvage. DESIGN: Case series with retrospective review of outcomes with at least 6-year follow-up. SETTING: Academic tertiary care medical center. PATIENTS: Thirty-four consecutive patients with traumatic lower extremity wounds and tibial defects who were recommended amputation but instead underwent complex limb salvage from 1993 to 2005. INTERVENTION: Flap reconstruction and Ilizarov bone transport. MAIN OUTCOME MEASUREMENTS: Outcomes assessed were flap complications, infection, union, malunion, need for chronic narcotics, ambulation status, employment status, and need for reoperations. A cost analysis was performed comparing this treatment modality to amputation. RESULTS: Thirty-four patients (mean age: 40 years) were included with 14 acute Gustilo IIIB/C defects and 20 chronic tibial defects (nonunion with osteomyelitis). Thirty-five muscle flaps were performed with 1 flap loss (2.9%). The mean tibial bone defect was 8.7 cm, mean duration of bone transport was 10.8 months, and mean follow-up was 11 years. Primary nonunion rate at the docking site was 8.8% and malunion rate was 5.9%. All patients achieved final union with no cases of recurrent osteomyelitis. No patients underwent future amputations, 29% required reoperations, 97% were ambulating without assistance, 85% were working full time, and only 5.9% required chronic narcotics. Mean lifetime cost per patient per year after limb salvage was significantly less than the published cost for amputation. CONCLUSIONS: The long-term results and costs of bone transport and flap coverage strongly support complex limb salvage in this patient population.

Epidemiology, disease spectrum and economic burden of non-typhoidal Salmonella infections in Taiwan, 2006-2008.

The purpose of this study was to understand the seasonal, geographical and clinical characteristics of Taiwanese patients hospitalized for non-typhoidal Salmonella (NTS) infections and their economic burden. Hospital data obtained from the Taiwan National Health Insurance (NHI) database between 2006 and 2008 were analysed. Infants had the highest annual incidence of 525 cases/100 000 person-years. Elderly patients aged >70 years had the highest in-hospital mortality rate (2·6%). Most (82·6%) gastroenteritis occurred in children aged <10 years. Septicaemia, pneumonia, arthritis and osteomyelitis occurred mainly in patients aged >50 years. A median medical cost for NTS-associated hospitalizations was higher for patients with septicaemia than for those with gastroenteritis. Seasonal variation of NTS-associated hospitalizations was correlated with temperature in different areas of Taiwan. In summary, infants had a high incidence of NTS-associated hospitalizations. However, the elderly had a higher in-hospital mortality rate and more invasive NTS infections than children.

Clindamycin release determined by high performance liquid chromatography from a novel low-cost local drug delivery system: a new potential treatment option for chronic osteomyelitis.

Osteomyelitis continues to be a severe problem worldwide, causing plenty of hospital admissions and entailing vast expenses. Previously, we developed a low-cost polymethyl-methacrylate (PMMA)-sorbitol based capsule system for local long-term drug delivery. In the present study we aimed to test the in vitro release of clindamycin capsules by high performance liquid chromatography. By the end of the clinically relevant period (42 days), the capsules released 70-100% of their load. Furthermore, the release kinetics suggested that an effective antimicrobial concentration may be maintained within the target area. Our findings indicate that these newly developed capsules may be a versatile device for local clindamycin delivery by providing efficient release and reducing financial burdens.

Delayed primary versus late secondary wound closure in the treatment of postsurgical sternum osteomyelitis.

Sternal osteomyelitis and poststernotomy mediastinitis is a severe and life-threatening complication after the cardiac surgery. The incidence ranges up to 3% with a mortality rate up to 29%. In addition, postoperative infections after sternotomy are associated with prolonged hospital stay, increased healthcare costs and impaired quality of patient life, representing an economic and social burden. The emergence of increasing antimicrobial resistant bacteria augments the importance of postsurgical infections since the antimicrobial choices are becoming limited. Furthermore, the incidence of infection is an indicator for the quality of patient care in the international benchmark studies. Although several therapy strategies are nowadays present in clinical practice, there is a lack of evidence-based surgical consensus for treatment of this surgical complication. In most cases the poststernotomy mediastinitis involves surgical revision with debridement, open dressing and/or vacuum-assisted therapy. After the granulation tissue on open chest wound is achieved, secondary closure and/or reconstruction with vascularized soft tissue flaps, such as omentum or pectoral muscle is performed. It seems there is a need for more effective surgical treatment of poststernotomy wound infections, which may address the prolonged hospitalization and reduce the number of surgical interventions and with this also the perioperative morbidity. In light of this we propose a randomized study comparing new delayed primary closure of the sternum to the secondary vacuum-assisted closure.

Staphylococcus aureus osteomyelitis in Hawaii.

BACKGROUND: The clinical and laboratory findings and outcomes of methicillin-resistant (MRSA) and methicillin-susceptible (MSSA) Staphylococcus aureus osteomyelitis have not been studied in Hawaii. METHODS: Retrospective inpatient chart reviews of 62 culture-proven osteomyelitis patients between 1996 and 2007 were performed. RESULTS: Fifteen patients (24%) had MRSA infection, and 47 patients (76%) had MSSA infection. Length of stay, chronic health problems, total duration of fever, and length of treatment were not significantly different between MRSA- and MSSA-infected patients. The peak erythrocyte sedimentation rate and C-reactive protein values were higher among MRSA infected patients (P values: .009 and .003, respectively).The systemic complication rate was higher in MRSA-infected patients (P value: .018). CONCLUSIONS: Differing from other pediatric staphylococcal infections in Hawaii, the majority of the patients had MSSA infection. Pacific Islander and Native Hawaiian ethnicities were affected disproportionately and had MRSA infection more frequently. MRSA-infected patients had frequent surgical procedures and systemic complications.

Skull base osteomyelitis: the effect of comorbid disease on hospitalization.

OBJECTIVES/HYPOTHESIS: Skull base osteomyelitis is a rare disease that has a high morbidity and mortality rate if diagnosis and treatment are delayed. Our objective was to perform a more detailed analysis of skull base osteomyelitis in the inpatient population. We also provide a more comprehensive evaluation of comorbid disease and severity of illness in this population and describe their effects on the duration and cost of hospital stay. STUDY DESIGN: Review of the California Hospital Discharge Database between the years 1990 and 2000. METHODS: Information evaluated included age, race, insurance, charges and length of hospital stay, comorbid disease, severity of illness, and disposition. Data were analyzed using analysis of variance and linear regression analysis. RESULTS: The overall incidence of skull base osteomyelitis ranged from 57 to 95 cases annually (median 75.5). Whites (69.3%) were more likely to present with the disease than Native Americans (13.2%), African Americans (6.5%), or Asians (2.9%). The majority of patients diagnosed with skull base osteomyelitis had Medicare or public assistance (62%) compared with those with Preferred Provider Organization or Health Maintenance Organization insurance (27%). Increased length of hospital stay and increased charges incurred during hospitalization were significantly associated (P < .05) with aplastic anemia, renal disease, arteriosclerosis, facial nerve dysfunction, and diabetes. Severity of illness and the presence of one or more comorbid conditions also significantly affected the duration and charges incurred during hospital stay (P < .05). CONCLUSIONS: The presence of concurrent illness with skull base osteomyelitis significantly affects the duration of hospital stay and the charges incurred during hospitalization.

Mediastinitis in pediatric cardiac surgery: treatment and cost-effectiveness in a low-income country.

Mediastinitis is a serious postoperative complication following pediatric cardiac surgery. The objective of this study is to evaluate the cost-effectiveness of surgical treatment for mediastinitis in Guatemala. All children who underwent a median sternotomy and developed postoperative mediastinitis between January 2004 and December 2005 were evaluated. Type of surgical treatment for mediastinitis, hospital outcome, and costs were analyzed. Eighteen (3.3%) of the 535 children who underwent a median sternotomy developed mediastinitis. Two patients underwent debridement of the infected tissues and delayed sternal closure, whereas 16 patients had debridement, primary chest closure, and continuous antibiotic irrigation of the mediastinum. All 11 patients who had the diagnosis of mediastinitis within 2 weeks after the operation survived. Three of the 7 patients (43%) who had delayed diagnosis died (p = 0.0003); all 3 had osteomyelitis (p = 0.0007). Primary closure with antibiotic irrigation was associated to a lower mortality rate and proved less expensive in comparison to delayed sternal closure (p = 0.003) mainly due to the shorter intensive care requirement. Debridement followed by primary closure of the chest and continuous antibiotic irrigation of the mediastinum seems to be a feasible and less expensive method to treat selected cases of postoperative mediastinitis in children.

Third molar complications requiring hospitalization.

OBJECTIVE: The aim of this study was to describe demographic and clinical patterns of subjects hospitalized with complications associated with third molars (M3). STUDY DESIGN: The investigation was designed as a prospective cohort study composed of subjects admitted to hospital for management of M3-associated complications. The predictor variable was "clinical status of the M3" defined as (A) prophylactic M3 removal, (B) nonelective M3 removal, or (C) M3 present at the time of admission. Outcome variables were infection parameters, treatment costs, length of hospital stay, and days of disability. Postoperative complications (A and B) were compared to complications based on pericoronitis (C). Complications due to prophylactic removal (A) were compared to those arising from pericoronitis or from the removal of symptomatic teeth (B and C). RESULTS: From January 2003 to December 2004, 45 deep space infections, 6 mandibular fractures, 2 lingual nerve injuries, 1 parapharyngeal tooth luxation, and 1 osteomyelitis were noticed. Fifteen complications resulted from prophylactic surgery (A), 25 from nonelective removal (B), and 15 from pericoronitis (C). Direct treatment costs were 147,000 euro (A: 42,000 euro; B: 74,000 euro; C: 31,000 euro). In 10 of the 15 patients of group C, deep space involvement resulted immediately from the first episode of pericoronitis. Neither clinical markers of infection nor economic parameters showed significant differences between the groups. CONCLUSION: Within the catchment area of our institution, the majority of third molar-related hospitalizations resulted from diseased third molars or their removal.