RESUMEN
Bone grafts are widely used to successfully restore structure and function to patients with a broad range of musculoskeletal ailments and bone defects. Autogenous bone grafts are historically preferred because they theoretically contain the three essential components of bone healing (ie, osteoconductivity, osteoinductivity, and osteogenicity), but they have inherent limitations. Allograft bone derived from deceased human donors is one alternative that is also capable of providing both an osteoconductive scaffold and osteoinductive potential but, until recently, lacked the osteogenic component of bone healing. Relatively new, cellular bone allografts (CBAs) were designed to address this need by preserving viable cells. Although most commercially-available CBAs feature mesenchymal stem cells (MSCs), osteogenic differentiation is time-consuming and complex. A more advanced graft, a viable bone allograft (VBA), was thus developed to preserve lineage-committed bone-forming cells, which may be more suitable than MSCs to promote bone fusion. The purpose of this paper was to present the results of preclinical research characterizing VBA. Through a comprehensive series of in vitro and in vivo assays, the present results demonstrate that VBA in its final form is capable of providing all three essential bone remodeling properties and contains viable lineage-committed bone-forming cells, which do not elicit an immune response. The results are discussed in the context of clinical evidence published to date that further supports VBA as a potential alternative to autograft without the associated drawbacks.
Asunto(s)
Aloinjertos , Trasplante Óseo , Trasplante Óseo/economía , Trasplante Óseo/métodos , Humanos , Trasplante Autólogo , Matriz Ósea/química , Osteocitos/citología , Proliferación Celular , Calcio/metabolismo , Células de la Médula Ósea/metabolismo , Aloinjertos/citología , Aloinjertos/inmunología , HistocompatibilidadRESUMEN
BACKGROUND: The objectives of this study were to build upon previously-reported 12-month findings by retrospectively comparing 24-month follow-up hospitalization charges and potentially-relevant readmissions in US lumbar fusion surgeries that employed either recombinant human bone morphogenetic protein-2 (rhBMP-2) or a cellular bone allograft comprised of viable lineage-committed bone cells (V-CBA) via a nationwide healthcare system database. METHODS: A total of 16,172 patients underwent lumbar fusion surgery using V-CBA or rhBMP-2 in the original study, of whom 3,792 patients (23.4%) were identified in the current study with all-cause readmissions during the 24-month follow-up period. Confounding baseline patient, procedure, and hospital characteristics found in the original study were used to adjust multivariate regression models comparing differences in 24-month follow-up hospitalization charges (in 2020 US dollars) and lengths of stay (LOS; in days) between the groups. Differences in potentially-relevant follow-up readmissions were also compared, and all analyses were repeated in the subset of patients who only received treatment at a single level of the spine. RESULTS: The adjusted cumulative mean 24-month follow-up hospitalization charges in the full cohort were significantly lower in the V-CBA group ($99,087) versus the rhBMP-2 group ($124,389; P < 0.0001), and this pattern remained in the single-level cohort (V-CBA = $104,906 vs rhBMP-2 = $125,311; P = 0.0006). There were no differences between groups in adjusted cumulative mean LOS in either cohort. Differences in the rates of follow-up readmissions aligned with baseline comorbidities originally reported for the initial procedure. Subsequent lumbar fusion rates were significantly lower for V-CBA patients in the full cohort (10.12% vs 12.00%; P = 0.0002) and similar between groups in the single-level cohort, in spite of V-CBA patients having significantly higher rates of baseline comorbidities that could negatively impact clinical outcomes, including bony fusion. CONCLUSIONS: The results of this study suggest that use of V-CBA for lumbar fusion surgeries performed in the US is associated with substantially lower 24-month follow-up hospitalization charges versus rhBMP-2, with both exhibiting similar rates of subsequent lumbar fusion procedures and potentially-relevant readmissions.
Asunto(s)
Dolor de Espalda/cirugía , Proteína Morfogenética Ósea 2/uso terapéutico , Vértebras Lumbares/cirugía , Readmisión del Paciente , Fusión Vertebral , Factor de Crecimiento Transformador beta/uso terapéutico , Anciano , Aloinjertos/economía , Aloinjertos/estadística & datos numéricos , Dolor de Espalda/economía , Trasplante Óseo/economía , Trasplante Óseo/estadística & datos numéricos , Femenino , Estudios de Seguimiento , Hospitalización/economía , Hospitalización/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Readmisión del Paciente/economía , Readmisión del Paciente/estadística & datos numéricos , Proteínas Recombinantes/uso terapéutico , Estudios Retrospectivos , Fusión Vertebral/economía , Fusión Vertebral/estadística & datos numéricos , Resultado del Tratamiento , Estados Unidos/epidemiologíaRESUMEN
OBJECTIVE: Few studies have investigated the financial influence of surgical site local morselized bone autograft (LMBA) on the overall cost of spinal arthrodesis procedures. The purpose of this study is to evaluate the potential savings from introducing LMBA in spinal fusion procedures compared with no LMBA use. METHODS: Retrospectively, cost analysis was conducted on a single-center data collected from 266 patients who underwent minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) ranging from L1 through S1 during a period of approximately 4 years. Cost data were obtained from individual patient invoices from the distributor. Sensitivity analyses were also conducted for different costs of allograft and LMBA. RESULTS: A total of 282 levels were grafted in 266 subjects. The total quantity of LMBA harvested was 2433.5 mL, and a total of 1610 mL of allograft (Trinity Elite, ORTHOFIX, Lewisville, Texas, USA) were used. The overall cost savings from introducing LMBA in MI-TLIF surgery were $1,094,931 over the 4-year period with mean direct cost saving of $4116.28 per patient based on reduction in allograft. Results for cost savings per patient were sensitive to different direct costs of allograft and LMBA. A >95% fusion rate was achieved based on dynamic radiographs evaluated by an independent radiologist. CONCLUSIONS: LMBA is a cost-saving bone graft extender option in MI-TLIF procedures while achieving high fusion rates. The savings are mainly achieved by reducing the amount of allograft needed and subsequent reduction in the total bone graft costs. Further research needs to be performed regarding long-term economic benefit.
Asunto(s)
Autoinjertos/economía , Trasplante Óseo/economía , Costos y Análisis de Costo , Vértebras Lumbares/cirugía , Procedimientos Quirúrgicos Mínimamente Invasivos/economía , Adulto , Anciano , Anciano de 80 o más Años , Trasplante Óseo/métodos , Femenino , Humanos , Degeneración del Disco Intervertebral/cirugía , Región Lumbosacra/cirugía , Masculino , Persona de Mediana Edad , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Complicaciones Posoperatorias/cirugía , Radiografía/economía , Fusión Vertebral/economía , Fusión Vertebral/métodos , Adulto JovenRESUMEN
Nonunion after ankle arthrodesis requiring revision is a challenging operative complication, and bone graft substitutes are costly. This study sought to summarize all institutional expenditures related to the revision of an ankle fusion nonunion, presuming that cost and skin-to-skin time would exceed those of the index surgery. The electronic records from 2 foot and ankle centers were reviewed, leading to a list of patients with 2 or more entries for tibiotalar fusions being generated. A total of 24 cases were found to match the criteria. Demographic factors and skin-to-skin time of the remaining patients were compiled. This cohort included 24 patients (6 female and 18 male) with a mean age of 64 years and body mass index of 30.4 kg/m2. Supplemental clinic visits and investigations were included either after computed tomography to assess union or 365 days after index surgery. Total cost of the revision was calculated from billing codes, length of operation, and period of hospitalization. Postrevision outpatient fees were included as well. The revisions were performed open in all cases, and 21 patients received autograft and/or bone substitute. Mean postoperative hospitalization was 3 days. The additional costs (in US dollars) associated with nonunion were $1061 for imaging, $627 for prerevision visits, $3026 for the revision, $3432 for the hospital stay, and $1754 for postrevision follow-up. The total mean amount was $9683, equivalent to 9 nights of acute inpatient stay. Mean index skin-to-skin time was 114 minutes, being 126 minutes for revisions (P=.26). Additional care related to ankle fusion nonunion represents a financial burden equivalent to 9 nights of acute inpatient stay. The use of an orthobiologic would need to be less than $436 to be cost saving. Revision surgery is not significantly longer intraoperatively than index surgery. [Orthopedics. 2020;43(4):e219-e224.].
Asunto(s)
Articulación del Tobillo/cirugía , Artrodesis/economía , Sustitutos de Huesos , Reoperación/economía , Adulto , Anciano , Tobillo/cirugía , Trasplante Óseo/economía , Estudios de Casos y Controles , Estudios de Cohortes , Análisis Costo-Beneficio , Registros Electrónicos de Salud , Femenino , Pie , Humanos , Tiempo de Internación/economía , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Trasplante Autólogo , Adulto JovenRESUMEN
BACKGROUND: To compare the clinical and radiological outcomes between posterior mono-segment and short-segment fixation combined with one-stage posterior debridement and bone grafting fusion in treating single-segment lumbar spinal tuberculosis (LSTB). METHODS: Sixty-two patients with single-segment LSTB treated by a posterior-only approach were divided into two groups: short-segment fixation (Group A, n = 32) and mono-segment fixation (Group B, n = 30). The clinical and radiographic outcomes were analyzed and compared between the two groups. RESULTS: The intraoperative bleeding volume, operation time, and hospitalization duration were lower in Group B than in Group A. All patients achieved the bony fusion criteria. The visual analog scale score, Japanese Orthopedic Association score, and Oswestry Disability Index were substantially improved 3 months postoperatively and at the last visit in both groups, with no significant difference between the two groups (P > 0.05). Kirkaldy-Willis functional evaluation at the final follow-up demonstrated that all patients in both groups achieved excellent or good results. The difference in the angle correction rate and correction loss between Groups A and B was not significant (P > 0.05). CONCLUSIONS: One-stage posterior debridement, bone grafting fusion, and mono-segment or short-segment fixation can provide satisfactory clinical and radiological outcomes. Mono-segment fixation is more suitable for the treatment of single-segment LSTB because the lumbar segments with normal motion can be preserved with less trauma, a shorter operation time, shorter hospitalization, and lower costs.
Asunto(s)
Trasplante Óseo/métodos , Desbridamiento/métodos , Fijación Interna de Fracturas/métodos , Dolor de la Región Lumbar/cirugía , Fusión Vertebral/métodos , Tuberculosis de la Columna Vertebral/cirugía , Adulto , Trasplante Óseo/efectos adversos , Trasplante Óseo/economía , Desbridamiento/efectos adversos , Desbridamiento/economía , Evaluación de la Discapacidad , Femenino , Estudios de Seguimiento , Fijación Interna de Fracturas/efectos adversos , Fijación Interna de Fracturas/economía , Humanos , Tiempo de Internación/economía , Tiempo de Internación/estadística & datos numéricos , Dolor de la Región Lumbar/diagnóstico , Dolor de la Región Lumbar/economía , Dolor de la Región Lumbar/etiología , Vértebras Lumbares/diagnóstico por imagen , Vértebras Lumbares/patología , Vértebras Lumbares/cirugía , Masculino , Persona de Mediana Edad , Tempo Operativo , Dimensión del Dolor , Estudios Retrospectivos , Fusión Vertebral/efectos adversos , Fusión Vertebral/economía , Resultado del Tratamiento , Tuberculosis de la Columna Vertebral/complicaciones , Tuberculosis de la Columna Vertebral/diagnóstico , Tuberculosis de la Columna Vertebral/economía , Adulto JovenRESUMEN
BACKGROUND: The purpose of this study was to identify factors associated with variation in direct costs with shoulder arthroplasty. METHODS: This was a retrospective study of all shoulder arthroplasties performed at a single facility between July 1, 2011, and November 30, 2016. We collected patient factors, indications, procedure (including implant details), implant brand (A, B, and other), and complications. We collected direct costs over a 90-day period using a validated internal tool. We identified patient and procedure characteristics associated with costs using multivariable generalized linear models. RESULTS: A total of 361 patients were included, 19% with revision arthroplasty procedures, 32% with anatomic total shoulder arthroplasties, and 66% with reverse total shoulder arthroplasties (RTSAs). Of total costs, 13% were operative facility utilization costs and 58% were operative supply costs. Factors associated with increased total cost included younger age (P = .002) and an indication for surgery of other, that is, not osteoarthritis, a failed arthroplasty, or the sequelae of a rotator cuff tear (P = .030). Factors associated with increased operative costs included younger age (P = .002), use of an RTSA (P < .001), use of a bone graft (P < .001), implant brand B (P = .098), implant brands other than A and B (P = .04), the sequelae of a rotator cuff tear as an indication for surgery (P = .041), or an indication for surgery of other (P = .007). CONCLUSION: Most short-term (90-day) costs with shoulder arthroplasty are operative costs. Nonmodified factors associated with increased cost included younger age and less common indications for surgery, whereas potentially modifiable factors included the intraoperative use of a bone graft, implant brand, and RTSA use.
Asunto(s)
Artroplastía de Reemplazo de Hombro/economía , Costos Directos de Servicios , Reoperación/economía , Factores de Edad , Anciano , Artroplastía de Reemplazo de Hombro/métodos , Trasplante Óseo/economía , Costos y Análisis de Costo , Femenino , Humanos , Masculino , Persona de Mediana Edad , Quirófanos/economía , Osteoartritis/economía , Osteoartritis/cirugía , Estudios Retrospectivos , Lesiones del Manguito de los Rotadores/economía , Lesiones del Manguito de los Rotadores/cirugía , Articulación del Hombro/cirugía , Prótesis de Hombro/economíaRESUMEN
PURPOSE: Osteochondral allografts (OCA) consist of a layer of hyaline cartilage and a layer of underlying bone. They are used to repair combined defects of articular cartilage and bone. Such defects often occur in people far too young to have knee arthroplasty, for whom the main alternative to OCA is conservative symptomatic care, which will not prevent development of osteoarthritis. The aim of this report was to assess the cost-effectiveness of osteochondral allograft transplantation in the knee. METHODS: Systematic review of evidence on clinical effectiveness and economic modelling. RESULTS: The evidence on osteochondral allograft transplantation comes from observational studies, but often based on good quality prospective registries of all patients having such surgery. Without controlled trials, it was necessary to use historical cohorts to assess the effect of osteochondral grafts. There is good evidence that OCA are clinically effective with a high graft survival rate over 20 years. If an OCA graft fails, there is some evidence that revision with a second OCA is also effective, though less so than primary OCA. Economic modelling showed that osteochondral allograft transplantation was highly cost-effective, with costs per quality adjusted life year much lower than many other treatments considered cost effective. CONCLUSIONS: Osteochondral allograft transplantation appears highly cost-effective though the cost per quality adjusted life year varies according to the widely varying costs of allografts. Based on one small study, revision OCA also appears very cost-effective, but more evidence is needed. LEVEL OF EVIDENCE: II.
Asunto(s)
Aloinjertos/economía , Trasplante Óseo/economía , Cartílago/trasplante , Supervivencia de Injerto , Articulación de la Rodilla/cirugía , Análisis Costo-Beneficio , Humanos , Modelos Económicos , Años de Vida Ajustados por Calidad de Vida , ReoperaciónRESUMEN
Over the last two, three decades, the overall survival rates for non-metastatic malignant tumours of the bone have dramatically improved. This has become possible due to the recent advances and multidisciplinary approach towards these diseases, specifically the advent of multi-agent chemotherapy and radiotherapy. Limb salvage has now become the norm in the treatment of musculoskeletal tumours without compromising on the overall survival and recurrence of the disease. In the era of metal, prosthetic reconstruction has become the standard procedure specifically in the large tumours which involve the joints as this method of reconstruction helps in joint mobility and early weight-bearing. Considering the costs and resource constraints, multiple cost-effective, stable, durable reconstruction options have evolved over the last decade and these have also shown favourable func tional outcomes without compromising on the amount of resection and risk of local recurrence. The current literature review was planned to discuss various cost-effective, durable reconstructive options and their advantages and disadvantages. These include Van ness rotationplasty, allograft, autograft, devitalised tumour bone and Masqueletor induced membrane technique . .
Asunto(s)
Neoplasias Óseas/cirugía , Trasplante Óseo/métodos , Países en Desarrollo , Recuperación del Miembro/métodos , Procedimientos de Cirugía Plástica/métodos , Prótesis e Implantes , Trasplante Óseo/economía , Humanos , Recuperación del Miembro/economía , Procedimientos de Cirugía Plástica/economía , Trasplante Autólogo , Trasplante HomólogoRESUMEN
BACKGROUND: The standard of care for patients with alveolar cleft deformities is autologous bone grafting using iliac crest bone graft (ICBG). The combination of demineralized bone matrix with recombinant human bone morphogenetic protein-2 (DBX/rhBMP-2), as a substitute for ICGB, has been shown to have similar bony incorporation within the maxilla without donor-site morbidity. It has been argued that one of the drawbacks of using DBX/rhBMP-2 is the higher cost. The aim of this study was to compare the cost, operative time, and hospital length of stay associated with these two treatment modalities. METHODS: A chart review was conducted for 71 patients who underwent secondary alveolar cleft reconstruction. Forty patients received ICBG and 31 patients underwent reconstruction using DBX/rhBMP-2. Operative costs, operative time, and hospital length of stay were compared between the two groups. RESULTS: The average total operative cost was $6892 in the ICBG surgery population versus $4836 in the DBX/rhBMP-2 population (p < 0.01). Statistically significant decreases in anesthesia, pharmacy, and operating room costs were found in patients who underwent the DBX/rhBMP-2 surgery. Operative time decreased from an average of 97.3 minutes to 67.0 minutes (p < 0.01), and length of inpatient stay decreased from an average of 29.8 hours to 9.3 hours (p < 0.01). CONCLUSION: In the treatment of alveolar cleft deformities, operative material costs were greater in the DBX/rhBMP-2 group but-secondary to decreased hospital, anesthesia, pharmacy, and operating room costs-DBX/rhBMP-2 was more cost-effective than ICBG.
Asunto(s)
Injerto de Hueso Alveolar/métodos , Matriz Ósea/trasplante , Proteína Morfogenética Ósea 2/uso terapéutico , Trasplante Óseo/métodos , Fisura del Paladar/cirugía , Análisis Costo-Beneficio , Ilion/trasplante , Factor de Crecimiento Transformador beta/uso terapéutico , Injerto de Hueso Alveolar/economía , Proteína Morfogenética Ósea 2/economía , Trasplante Óseo/economía , Niño , Fisura del Paladar/economía , Femenino , Estudios de Seguimiento , Costos de Hospital/estadística & datos numéricos , Humanos , Tiempo de Internación/economía , Tiempo de Internación/estadística & datos numéricos , Masculino , Tempo Operativo , Proteínas Recombinantes/economía , Proteínas Recombinantes/uso terapéutico , Estudios Retrospectivos , Factor de Crecimiento Transformador beta/economía , Trasplante Autólogo , UtahRESUMEN
OBJECTIVE: To estimate the budget impact (BI) of introducing local autograft (LA) combined with demineralized bone matrix (LA + DBM) in lumbar spinal fusion (LSF) procedures to treat lumbar degenerative disc disease (LDDD) in Spain. METHODS: A decision tree model was developed to evaluate the 4-year BI associated with introducing LA + DBM putty to replace currently available grafting methods, including iliac crest bone graft (ICBG), LA alone, and LA combined with beta-tricalcium phosphate (LA + ceramics), with 30%, 40%, and 30% market shares, respectively. The analysis was conducted for a hypothetical cohort of 100 patients with LDDD receiving LSF, assuming LA + DBM would replace 100% of the standard of care mix. The fusion rates extracted from the literature were validated by an expert panel. Costs (2017) were obtained from different Spanish sources. Budget impact and incremental cost per successful fusion were calculated from the perspective of the Spanish National Health System (NHS). RESULTS: Over 4 years, replacing currently available options with LA + DBM for 100 patients resulted in an additional cost of 12,330 (123/patient), and an additional 14 successful fusions, implying a cost of 881 per additional successful fusion. When costs of productivity loss were included, the introduction of LA + DBM resulted in cost savings of 70,294 (703/patient). LIMITATIONS: The lack of high-quality, homogeneous, head-to-head research studying the efficacy of grafting procedures available to patients undergoing LSF, in addition to a lack of long-term follow-up in existing studies. Therefore, the number of fusions occurring within the model's time horizon may be underestimated. CONCLUSIONS: Acquisition costs of DBM were partially offset by costs of failed fusions, adverse events and reoperation when switching 100 hypothetical LDDD patients undergoing LSF procedures from standard of care grafting methods to LA + DBM from the perspective of the Spanish NHS. DBM cost was entirely offset when costs of lost productivity were considered.
Asunto(s)
Materiales Biocompatibles/economía , Matriz Ósea/trasplante , Trasplante Óseo/métodos , Degeneración del Disco Intervertebral/cirugía , Fusión Vertebral/economía , Fusión Vertebral/métodos , Autoinjertos , Trasplante Óseo/economía , Fosfatos de Calcio/economía , Árboles de Decisión , Humanos , EspañaRESUMEN
BACKGROUND: A frequently encountered problem during posterolateral fusion (PLF) is bone graft displacement from the posterolateral space during closure. Commercially available solutions to this problem are seldom used because of their exceptionally high cost. The purpose of this report is to describe 3 novel, low-cost techniques we developed for bone graft containment during PLF. METHODS: Three low-cost bone graft containment techniques are described: rapid suture weave, makeshift bone bag, and cellulose rooftop. Early clinical experience with these techniques is reported for a 5-patient case series. RESULTS: One or more of these bone graft containment techniques were used in 5 patients who underwent PLF. Rapid suture weave was the least expensive (<$5.00) but required the longest additional time to perform (20 minutes). Makeshift bone bag and cellulose rooftop cost approximately the same ($48.00 and $46.00, respectively); the makeshift bone bag took less additional time (3 minutes) but created a potential barrier between the bone graft and the host site, whereas the cellulose rooftop took slightly longer to perform (5 minutes) but permitted direct contact between the bone graft and host site. CONCLUSIONS: These 3 novel surgical techniques for bone graft containment in the posterolateral space add minimally to the cost and length of the procedure. Our early clinical experience suggests that these techniques are safe and effective. Additional clinical experience is warranted, and prospective data collection is ongoing.
Asunto(s)
Trasplante Óseo/economía , Trasplante Óseo/métodos , Vértebras Lumbares/cirugía , Fusión Vertebral/instrumentación , Fusión Vertebral/métodos , Adulto , Anciano , Femenino , Estudios de Seguimiento , Humanos , Laminectomía , Vértebras Lumbares/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Fusión Vertebral/economía , Tomografía Computarizada por Rayos XRESUMEN
STUDY DESIGN: Retrospective Analysis OBJECTIVE.: The aim of this study was to determine whether an association between increased acute pain, postoperative time, and direct hospital costs exists between the use of iliac crest bone grafting (ICBG) and bone morphogenic protein (BMP)-2 following a primary, single-level minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). SUMMARY OF BACKGROUND DATA: ICBG has been associated with enhanced fusion rates. Concerns have been raised in regards to increased operative time and postoperative pain. The advantages of ICBG compared to other spinal fusion adjuncts have been debated. METHODS: Prospective, consecutive analysis of patients undergoing primary, single-level MIS TLIF with ICBG was compared to a historical cohort of consecutive patients that received BMP-2. Operative characteristics were compared between groups using χ analysis or independent t test for categorical and continuous variables, respectively. Postoperative inpatient pain was measured using the Visual Analog Scale, and inpatient narcotics consumption was quantified as oral morphine equivalents. Outcomes were compared between groups using multivariate regression controlling for preoperative characteristics. RESULTS: A total of 98 patients were included in this analysis, 49 in each cohort. No significant differences were noted between cohorts with exception to sex (Females: ICBG, 53.06% vs. BMP-2, 32.65%, Pâ=â0.041). There was a significant increase in operative time (14.53âminutes, Pâ=â0.006) and estimated blood loss (16.64âmL, Pâ=â0.014) in the ICBG cohort. Narcotics consumption was similar between groups on postoperative days 0 and 1. ICBG was associated with decreased total direct costs ($19,315 vs. $21,645, Pâ<â0.001) as compared to BMP-2. CONCLUSION: Patients undergoing MIS TLIF with ICBG experienced increases in operative time and estimated blood loss that were not clinically significant. Furthermore, iliac crest harvesting did not result in an increase in acute pain or narcotics consumption. Further follow-up is necessary to determine the associated arthrodesis rates and long-term outcomes between each cohort. LEVEL OF EVIDENCE: 3.
Asunto(s)
Trasplante Óseo/tendencias , Costos de Hospital/tendencias , Ilion/trasplante , Vértebras Lumbares/cirugía , Procedimientos Quirúrgicos Mínimamente Invasivos/tendencias , Narcóticos/uso terapéutico , Fusión Vertebral/tendencias , Adulto , Anciano , Trasplante Óseo/economía , Estudios de Cohortes , Femenino , Humanos , Masculino , Persona de Mediana Edad , Procedimientos Quirúrgicos Mínimamente Invasivos/economía , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Narcóticos/economía , Tempo Operativo , Dimensión del Dolor/economía , Dimensión del Dolor/tendencias , Estudios Prospectivos , Estudios Retrospectivos , Fusión Vertebral/economía , Fusión Vertebral/métodosRESUMEN
STUDY DESIGN: A retrospective cohort study. OBJECTIVES: To investigate the unknown direct costs of failed instrumented lumbar fusion using iliac crest bone graft (ICBG) and subsequent reoperation utilizing recombinant human bone morphogenetic protein-2 (rhBMP-2) from a primary payer perspective. SUMMARY OF BACKGROUND DATA: Recent evidence has demonstrated increased rates of instrumented lumbar fusion and utilization of rhBMP-2 to treat a range of conditions causing lower back pain. For health care providers with finite financial resources, there is an increasing demand to evaluate economic costs of available treatment modalities. The high cost of rhBMP-2 has often been cited as a leading reason for delaying its universal acceptance as a preferred substitute to ICBG. It has been hypothesized that rhBMP-2 may demonstrate cost-effectiveness if pseudarthrosis and reoperation rates are decreased, thus avoiding subsequent expenditure. METHODS: This was a retrospective cohort study of patients who underwent instrumented lumbar fusions utilizing rhBMP-2. Hospital finance records were used to calculate direct total expenditure incurred by the primary payer for the procedure using rhBMP-2. For patients who received rhBMP-2 in a secondary lumbar fusion, additional total expenditure related to the patients' failed primary instrumented fusion with ICBG was also sought. RESULTS: The mean total costs associated with failed instrumented lumbar fusion using ICBG and reoperation using rhBMP-2 totaled £47,734 per patient. The total direct costs of a policy of primary instrumented lumbar fusion with rhBMP-2 were less at £26,923 per patient; however, this was not significant. CONCLUSIONS: To date, this is the first study to report the costs of failed primary instrumented lumbar fusions using ICBG and subsequent secondary fusions using rhBMP-2 from a primary payer perspective. On the basis of this evidence, a policy of using rhBMP-2 in all patients undergoing a primary instrumented lumbar fusion cannot be recommended.
Asunto(s)
Proteína Morfogenética Ósea 2/economía , Proteína Morfogenética Ósea 2/uso terapéutico , Dolor de la Región Lumbar/economía , Dolor de la Región Lumbar/cirugía , Fusión Vertebral/economía , Factor de Crecimiento Transformador beta/economía , Factor de Crecimiento Transformador beta/uso terapéutico , Trasplante Óseo/economía , Femenino , Costos de la Atención en Salud , Hospitalización/economía , Humanos , Ilion/cirugía , Dolor de la Región Lumbar/tratamiento farmacológico , Masculino , Persona de Mediana Edad , Proteínas Recombinantes/economía , Proteínas Recombinantes/uso terapéutico , Reoperación , Insuficiencia del TratamientoRESUMEN
PURPOSE: Comparing expenses related to autogenous cranial vault reconstruction versus custom-made patient-specific alloplastic cranioplasty. METHODS: The authors retrospectively reviewed charts of a group of patients who underwent autogenous cranioplasty and poly-ether-ether ketone (PEEK) cranioplasty. The data collected from the patient files included demographic information, details of the surgery, postoperative recovery data, and also duration of surgery. The authors also added costs related to the length of surgery, utilization of intensive care unit, length of hospital stay, amount and seriousness of complications, and hardware cost. The outcomes were studied in terms of skull form maintenance and complications.Eleven of our patients had PEEK cranioplasty at Sunnybrook Hospital, Toronto, ON, in the period from July 2009 to June 2011. The authors identified 11 patients who had split skull autogenous bone graft cranioplasty. They were matched for age and skull defect size.Comparable information was collected for both patient groups. The information was examined to compare costs of custom-made patient-specific alloplastic implants and costs of autogenous cranioplasty. RESULTS: Conclusions made from this paper will hopefully serve as guidance for allocation of hospital funding and resources at the Ministry of Health level.
Asunto(s)
Trasplante Óseo/economía , Trasplante Óseo/métodos , Cetonas/economía , Procedimientos de Cirugía Plástica/economía , Procedimientos de Cirugía Plástica/métodos , Polietilenglicoles/economía , Prótesis e Implantes/economía , Cráneo/cirugía , Adulto , Anciano , Benzofenonas , Femenino , Costos de Hospital/estadística & datos numéricos , Humanos , Unidades de Cuidados Intensivos/economía , Tiempo de Internación/economía , Masculino , Persona de Mediana Edad , Tempo Operativo , PolímerosRESUMEN
Autogenous bone graft (autograft) remains the gold standard in the treatment of many orthopedic problems. However, graft harvest can lead to perioperative morbidity and increased cost. We tested the hypothesis that an osteoconductive matrix, beta-tricalcium phosphate (ß-TCP), would be a safe and effective alternative to autograft alone. Beta-tricalcium phosphate (ß-TCP) is considered as one of the most promising biomaterials for bone reconstruction. This study analyzes the outcomes of patients who received ß-TCP as bone substitutes in orthopedic surgery. METHODS: A total of 50 patients were enrolled in a controlled, non-inferiority clinical trial to compare the safety and efficacy of ß-TCP (25 patients) with those of autograft (25 patients) in indications requiring usually autograft. These 50 patients were categorized according to the etiology and morphology of the 54 bone defects resulting from elective surgical procedures, such as 34 open-wedge high tibial osteotomies, and 20 osteonecrosis treatments with core decompression. Radiographic (healing process with or without integration of ß-TCP), clinical (no other surgical procedure), functional outcomes and safety (with or without complications) were assessed through fifty-two weeks postoperatively. RESULTS: With regard to the primary endpoint (radiographic evolution), the fusion rate of the 34 open-wedge osteotomies was 100% (17 among 17) for patients in the group with ß-TCP compared with 94% (16 among 17) for patients in the autograft group. For the 20 cavitary defects (osteonecrosis), the radiographic union rates, as determined by the presence of osseous bridging, were 100% for patients in the group with ß-TCP and 100% for those in the autograft group. Clinically at one year, all quality-of-life and functional outcome data supported non-inferiority of ß-TCP compared with autograft, and patients in the ß-TCP group were found to have less pain and an improved safety profile. CONCLUSIONS: Treatment with ß-TCP resulted in comparable fusion rates, less pain and fewer side effects as compared with treatment with autograft. This study established clinical parameters where the ß-TCP alone can successfully support the osteogenic process.
Asunto(s)
Sustitutos de Huesos/uso terapéutico , Trasplante Óseo/efectos adversos , Huesos/cirugía , Fosfatos de Calcio/uso terapéutico , Procedimientos Ortopédicos/métodos , Procedimientos de Cirugía Plástica/métodos , Adulto , Regeneración Ósea/efectos de los fármacos , Sustitutos de Huesos/economía , Trasplante Óseo/economía , Trasplante Óseo/métodos , Huesos/diagnóstico por imagen , Huesos/lesiones , Huesos/fisiología , Fosfatos de Calcio/economía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Procedimientos Ortopédicos/efectos adversos , Procedimientos Ortopédicos/instrumentación , Osteogénesis/efectos de los fármacos , Osteonecrosis/diagnóstico por imagen , Osteonecrosis/etiología , Osteonecrosis/cirugía , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Radiografía , Procedimientos de Cirugía Plástica/efectos adversos , Trasplante Autólogo/efectos adversos , Trasplante Autólogo/economía , Trasplante Autólogo/métodos , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: Obtaining intraoperative cultures of allograft bone just before use in orthopedic procedures is standard practice in many centres; however, the association between positive cultures and subsequent surgical infections is unknown. Our study had 3 goals: to determine the prevalence of positive intraoperative allograft culture and subsequent infection; to determine if, in cases of subsequent infection, organisms isolated at reoperation were the same as those cultured from the allograft at the time of the index procedure; and to assess the costs associated with performing intraoperative allograft cultures. METHODS: In this retrospective case series, we obtained data on patients receiving allograft bone between 2009 and 2012. Patients receiving allograft with positive cultures were reviewed to identify cases of significant infection. Organisms isolated at reoperation were compared with the allograft culture taken at the time of implantation, and we performed a cost assessment. RESULTS: Of the 996 allograft bone grafts used, 43 (4.3%) had positive intraoperative cultures and significant postoperative infections developed in 2, requiring reoperation. Antibiotics based on culture results were prescribed in 24% of cases. Organisms cultured at the time of reoperation differed from those isolated initially. The cost of performing 996 allograft cultures was $169 320. CONCLUSION: This series suggests that rates of positive intraoperative bone allograft culture are low, and subsequent infection is rare. In cases of postoperative infection, primary allograft culture and secondary tissue cultures isolated different organisms. Costs associated with performing cultures are high. Eliminating initial culture testing could save $42 500 per year in our health region.
CONTEXTE: L'obtention de cultures d'allogreffes osseuses peropératoires juste avant une intervention orthopédique est une pratique standard dans de nombreux centres. Or, on ignore s'il y a un lien entre des résultats de cultures positifs et les infections chirurgicales subséquentes. Notre étude avait 3 objectifs : déterminer la prévalence des cultures d'allogreffes peropératoires positives et des infections subséquentes; déterminer si, dans les cas d'infections subséquentes, les agents pathogènes isolés lors d'une réintervention étaient les mêmes que dans les spécimens prélevés sur les allogreffes au moment des interventions initiales; évaluer les coûts associés à l'obtention des cultures d'allogreffes peropératoires. MÉTHODES: Dans cette série de cas rétrospectifs, nous avons réuni des données sur des patients receveurs d'allogreffes osseuses entre 2009 et 2012. Nous avons passé en revue les cas d'allogreffes dont les résultats de culture étaient positifs pour recenser ceux qui étaient porteurs d'une infection significative. Nous avons comparé les agents pathogènes isolés lors de la réintervention à ceux de la culture de l'allogreffe effectuée lors de l'implantation, et nous avons procédé à une évaluation des coûts. RÉSULTATS: Parmi les 996 allogreffes osseuses effectuées, 43 (4,3 %) avaient des résultats positifs aux cultures peropératoires; des infections postopératoires significatives se sont déclarées dans 2 de ces cas et ont nécessité une réintervention. Des antibiotiques ont été prescrits en fonction des résultats des cultures dans 24 % des cas. Les agents pathogènes isolés en culture au moment de la réintervention étaient différents de ceux qui avaient été initialement isolés. Le coût des 996 cultures d'allogreffes s'est élevé à 169 320 $. CONCLUSION: Cette série donne à penser que les taux de résultats de cultures d'allogreffes osseuses peropératoires positifs sont bas et que les infections subséquentes sont rares. Dans les cas d'infections postopératoires, les cultures des allogreffes primaires et les cultures tissulaires secondaires ont révélé la présence d'organismes pathogènes différents. Les coûts associés à la réalisation des cultures sont élevés. Éliminer les cultures initiales permettrait à notre région de santé d'économiser 42 500 $ par année.
Asunto(s)
Aloinjertos/microbiología , Trasplante Óseo/normas , Cuidados Intraoperatorios/normas , Reoperación/normas , Infección de la Herida Quirúrgica/microbiología , Aloinjertos/economía , Aloinjertos/estadística & datos numéricos , Trasplante Óseo/efectos adversos , Trasplante Óseo/economía , Trasplante Óseo/estadística & datos numéricos , Femenino , Humanos , Cuidados Intraoperatorios/economía , Cuidados Intraoperatorios/estadística & datos numéricos , Masculino , Prevalencia , Reoperación/economía , Reoperación/estadística & datos numéricos , Estudios Retrospectivos , Infección de la Herida Quirúrgica/tratamiento farmacológico , Infección de la Herida Quirúrgica/economía , Infección de la Herida Quirúrgica/epidemiologíaRESUMEN
BACKGROUND: The most cost-effective reconstruction after resection of bone sarcoma is unknown. The goal of this study was to compare the cost effectiveness of osteoarticular allograft to endoprosthetic reconstruction of the proximal tibia or distal femur. METHODS: A Markov model was used. Revision and complication rates were taken from existing studies. Costs were based on Medicare reimbursement rates and implant prices. Health-state utilities were derived from the Health Utilities Index 3 survey with additional assumptions. Incremental cost-effectiveness ratios (ICER) were used with less than $100 000 per quality-adjusted life year (QALY) considered cost-effective. Sensitivity analyses were performed for comparison over a range of costs, utilities, complication rates, and revisions rates. RESULTS: Osteoarticular allografts, and a 30% price-discounted endoprosthesis were cost-effective with ICERs of $92.59 and $6 114.77. One-way sensitivity analysis revealed discounted endoprostheses were favored if allografts cost over $21 900 or endoprostheses cost less than $51 900. Allograft reconstruction was favored over discounted endoprosthetic reconstruction if the allograft complication rate was less than 1.3%. Allografts were more cost-effective than full-price endoprostheses. CONCLUSIONS: Osteoarticular allografts and price-discounted endoprosthetic reconstructions are cost-effective. Sensitivity analysis, using plausible complication and revision rates, favored the use of discounted endoprostheses over allografts. Allografts are more cost-effective than full-price endoprostheses.
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Artroplastia de Reemplazo de Rodilla/economía , Neoplasias Óseas/cirugía , Trasplante Óseo/economía , Osteosarcoma/cirugía , Procedimientos de Cirugía Plástica/economía , Artroplastia de Reemplazo de Rodilla/métodos , Neoplasias Óseas/economía , Trasplante Óseo/métodos , Análisis Costo-Beneficio , Fémur/cirugía , Humanos , Articulación de la Rodilla/cirugía , Cadenas de Markov , Osteosarcoma/economía , Procedimientos de Cirugía Plástica/métodos , Tibia/cirugía , Trasplante HomólogoRESUMEN
OBJECTIVE Autologous bone is usually used to reconstruct skull defects following decompressive surgery. However, it is associated with a high failure rate due to infection and resorption. The aim of this study was to see whether it would be cost-effective to use titanium as a primary reconstructive material. METHODS Sixty-four patients were enrolled and randomized to receive either their own bone or a primary titanium cranioplasty. All surgical procedures were performed by the senior surgeon. Primary and secondary outcome measures were assessed at 1 year after cranioplasty. RESULTS There were no primary infections in either arm of the trial. There was one secondary infection of a titanium cranioplasty that had replaced a resorbed autologous cranioplasty. In the titanium group, no patient was considered to have partial or complete cranioplasty failure at 12 months of follow-up (p = 0.002) and none needed revision (p = 0.053). There were 2 deaths unrelated to the cranioplasty, one in each arm of the trial. Among the 31 patients who had an autologous cranioplasty, 7 patients (22%) had complete resorption of the autologous bone such that it was deemed a complete failure. Partial or complete autologous bone resorption appeared to be more common among young patients than older patients (32 vs 45 years old, p = 0.013). The total cumulative cost between the 2 groups was not significantly different (mean difference A$3281, 95% CI $-9869 to $3308; p = 0.327). CONCLUSIONS Primary titanium cranioplasty should be seriously considered for young patients who require reconstruction of the skull vault following decompressive craniectomy. Clinical trial registration no.: ACTRN12612000353897 ( anzctr.org.au ).
Asunto(s)
Trasplante Óseo , Prótesis Anclada al Hueso , Procedimientos de Cirugía Plástica/métodos , Cráneo/cirugía , Titanio , Adulto , Resorción Ósea , Trasplante Óseo/economía , Prótesis Anclada al Hueso/economía , Femenino , Costos de la Atención en Salud , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias , Procedimientos de Cirugía Plástica/economía , Procedimientos de Cirugía Plástica/instrumentación , Reoperación , Trasplante Autólogo/economía , Resultado del Tratamiento , Adulto JovenRESUMEN
Surgical intervention is an important option for treating spinal tuberculosis. Previous studies have reported different surgical procedures and bone grafts for it. To our knowledge, few studies demonstrated the clinical results of using nonstructural autogenous bone graft in surgical treatment of spinal tuberculosis.The purpose of this study is to compare the clinical outcomes of surgical management lumbar spinal tuberculosis by one-stage posterior debridement with nonstructural autogenous bone grafting and instrumentation versus anterior debridement, strut bone grafting combined with posterior instrumentation.A total of 58 consecutive patients who underwent surgical treatment due to lumbar spinal tuberculosis from January 2011 to December 2013 were included. A total of 22 patients underwent one-stage posterior debridement, nonstructural autogenous bone grafting, and instrumentation (group A), and 36 patients received anterior debridement, strut bone grafting combined with posterior instrumentation (group B). The operative duration, total blood loss, perioperative transfusion, length of hospital stay, hospitalization cost, and complications were recorded. The bony fusion of the graft was assessed by computed tomography scans. American Spinal Injury Association (ASIA) Impairment Scale was used to evaluate the neurological function of patients in the 2 groups.All the patients were followed up, with a mean follow-up duration of 21.6â±â5.7 months in group A and 22.3â±â6.2 months in group B (Pâ=â0.47). The average operative duration was 257.5â±â91.1 minutes in group A and 335.7â±â91.0 minutes in group B (Pâ=â0.002). The mean total blood loss was 769.6â±â150.9âmL in group A and 1048.6â±â556.9âmL in group B (Pâ=â0.007). Also, significant differences were found between the 2 groups in perioperative transfusion volumes, length of hospital stay, and hospitalization cost (Pâ<â0.05), which were less in group A compared with group B. Patients with ASIA grade C/D in the 2 groups were improved with 1 to 2 grades after the surgery with no statistical difference (Pâ=â1.000). The perioperative complications rate was 9.1% (2/22) in group A and 13.9% (5/36) in group B (Pâ=â0.897).Based on a retrospective study, the procedure of one-stage posterior debridement, nonstructural autogenous bone grafting, and instrumentation has a significant shorter operative duration, lower blood loss and perioperative transfusion, shorter hospital stay, and less hospitalization cost compared with the one of anterior debridement, strut bone grafting combined with posterior instrumentation for treating lumber spinal tuberculosis.
Asunto(s)
Trasplante Óseo/métodos , Tuberculosis de la Columna Vertebral/cirugía , Adulto , Pérdida de Sangre Quirúrgica , Transfusión Sanguínea , Trasplante Óseo/economía , Estudios de Casos y Controles , Desbridamiento , Femenino , Costos de Hospital , Humanos , Tiempo de Internación , Masculino , Tempo Operativo , Estudios Retrospectivos , Trasplante AutólogoRESUMEN
Bone flap resorption is an infrequently reported yet significant late complication of autologous bone cranioplasty. It requires serial imaging both to pick up and to monitor progression. Custom-made implants avoid this complication, but are expensive. In a resource-limited situation, when bone flaps placed in the abdomen undergo demineralisation and sutures are used to fix the flap as opposed to plates, where artificial cranial flap substitutes are prohibitively expensive and frequent postoperative imaging may not be feasible, prevention and management of this complication will continue to remain a problem.