Use of Proximal Humerus Locking Plates for Fixation of Pediatric Femoral Neck Fractures: Technical Trick.

Displaced pediatric femoral neck fractures are uncommon and complex injuries which require urgent operative fixation. Owing to the small and variable size of the pediatric femur, implant selection and availability can be difficult. We present a novel technique for the stabilization of these fractures with commonly available implants which provides physeal sparing, fixed angle, and stable fixation.

True Cost of Operating Room Time: Implications for an Orthopaedic Trauma Service.

OBJECTIVE: To derive an accurate estimate of the operating cost per minute for an orthopaedic trauma room. STUDY DESIGN: Retrospective economic analysis. SETTING: Level II Trauma Center. INTERVENTION: Hospital cost-accounting system query. MAIN OUTCOME MEASUREMENTS: Direct fixed costs, direct variable costs, and hospital overhead. RESULTS: Operating room per minute costs include direct variable costs of $2.77, direct fixed costs of $2.47, and hospital overhead costs of $10.97. Total per minute costs amounted to $16.21. This does not include professional fees of anesthesiology or surgeons or the costs of soft goods or implants. CONCLUSIONS: This is the first published study to document the true per minute cost of an orthopaedic trauma operating room. Such information is valuable when defining the value of a dedicated operating room, negotiating employment contracts, defining call stipends, and brokering capital purchases for the orthopaedic trauma service. LEVEL OF EVIDENCE: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The Role of Value-Based Implants in Orthopedic Trauma.

Health care costs in the United States continue to rise, and economic pressures influencing the care of the orthopedic trauma patient have never been greater. Value-based health care is vital to the survival of the current health care system, and the use of value-based implants is central to success. Value-based implants have similar clinical outcomes to conventional implants; however, multiple barriers exist. Despite biomechanical equivalence and significant cost savings, surgeons have difficultly changing implant use without financial incentive. The rise of physician-owned surgery centers, bundled payments, and gain sharing and comanagement agreements will likely drive this change.

The Role of Business Education in the Orthopedic Curriculum.

The field of orthopedics is becoming increasingly complex as the demands for success are not merely clinical competence and good interpersonal skills. To achieve practice stability strategic planning, contract negotiation, health care law, practice management, health care economics, and personal finance are all needed skills. Unfortunately, most of these areas of professional growth require some basic background in business principles. This is an area that most recent residency graduates feel is neglected as a core educational competency. In these changing times, it is imperative that orthopedic residents and fellows obtain some formal business education.

The Role of Dedicated Musculoskeletal Urgent Care Centers in Reducing Cost and Improving Access to Orthopaedic Care.

OBJECTIVES: Over the past few years, the United States has seen the rapid growth of dedicated musculoskeletal urgent care centers owned and operated by individual orthopaedic practices. In June of 2014, our practice opened the first dedicated orthopaedic urgent care in the region staffed by physician assistants and supervised by orthopaedic surgeons. Our hypothesis is that such centers can safely improve orthopaedic care for ambulatory orthopaedic injuries, decrease volume for overburdened emergency departments (EDs), reduce wait times and significantly decrease the cost of care while improving access to orthopaedic specialists. DESIGN: Retrospective review. SETTING: Level 2 trauma center and physician-owned orthopaedic urgent care. PATIENTS: Consecutive series of patients seen in the hospital ED (n = 87,629) and orthopaedic urgent care (n = 12,722). INTERVENTION: None. OUTCOMES: ED wait time, total visit time, time until being seen by provider, time until consultation with orthopaedic surgeon, total visit charges, and effect on orthopaedic practice revenue. RESULTS: During the 12 months of study, 12,722 patients were treated in our urgent care. The average urgent care wait time until being seen by a provider was 17 minutes compared with 45 minutes in hospital ED. Total visit time was 43 minutes in the urgent care and 156 minutes in the hospital ED. Time to being seen by an orthopaedic specialist was 1.2 days for urgent care patients compared with 3.4 days for ED patients. The average charge for an urgent care visit was $461 compared with $8150 in hospital ED. During the course of study, urgent care treatment reduced charges to health care system by $97,819,458. Hospital ED orthopaedic volume did decrease as expected but total ED patient volume remained the same. There was no measureable effect on hospital ED wait times. Hospital surgical case volume did not change over the period of study and the orthopaedic census remained stable. Urgent care construction, marketing, administration, imaging, and labor costs totaled $1,664,445. Urgent care revenue from evaluation and management, imaging, durable medical equipment, and casting totaled $2,577,707. Practice revenue from follow-up care of patients who entered practice through the urgent care totaled $7,657,998. CONCLUSION: Dedicated musculoskeletal urgent care clinics operated by orthopaedic surgery practices can be extremely beneficial to patients, physicians, and the health care system. They clearly improve access to care, whereas significantly decreasing overall health care costs for patients with ambulatory orthopaedic conditions and injuries. In addition, they can be financially beneficial to both patients and orthopaedic surgeons alike without cannibalizing local hospital surgical volumes. LEVEL OF EVIDENCE: Therapeutic Level III.

Cost Savings Opportunities in Perioperative Management of the Patients With Orthopaedic Trauma.

Considerable opportunities for cost savings exist surrounding the perioperative management of patients with orthopaedic fracture and trauma. Scientific evidence is available to support each potential cost savings measure. Much of these data had been documented for years but has never been adhered to, resulting in millions of dollars in unnecessary testing and treatment. Careful attention to preoperative laboratory testing can save huge amounts of money and expedite medical clearance for injured patients. The use of a dedicated orthopaedic trauma operating room has been shown to improve resource utilization, decrease costs, and surgical complications. A variety of anesthetic techniques and agents can reduce operative time, recovery room time, and hospital lengths of stay. Strict adherence to blood utilization protocols, appropriate deep venous thrombosis prophylaxis, and multimodal postoperative pain control with oversight from dedicated hip fracture hospitalists is critical to cost containment. Careful attention to postoperative disposition to acute care and management of postoperative testing and radiographs can also be another area of cost containment. Institutional protocols must be created and followed by a team of orthopaedic surgeons, hospitalists, and anesthesiologists to significantly impact the costs associated with care of patient with orthopaedic trauma and fracture.

Operating Room Efficiency: Benefits of an Orthopaedic Traumatologist at a Level II Trauma Center.

OBJECTIVES: Fellowship-trained orthopaedic traumatologists are presumably taught skill sets leading to "best practice" outcomes and more efficient use of hospital resources. This should result in more favorable economic opportunities when compared with general orthopaedic surgeons (GOSs) providing similar clinical services. The purpose of our study was to compare the operating room utilization and financial data of traumatologists versus GOSs at a level II trauma center. DESIGN: Retrospective review. SETTING: Level II community-based trauma hospital. PATIENTS/PARTICIPANTS: Patients who presented to the emergency room at our institution with fractures and orthopaedic conditions requiring surgical intervention from January 1, 2010, to December 31, 2011. INTERVENTION: Operative fracture fixation by members of our orthopaedic trauma panel, including fellowship and nontrauma fellowship-trained orthopaedic surgeons. MAIN OUTCOME MEASUREMENTS: Our institutional database was queried to determine operative times, surgical supply and implant costs, and surgery labor expenses. Patients were stratified according to those treated by our trauma panel's 3 traumatologists and those treated by the 15 GOSs on our trauma panel. These 2 groups were then compared using standard statistical methods. RESULTS: A total of 6449 orthopedic cases were identified and 2076 of these involved fracture care. One thousand one hundred ninety-nine patients were treated by traumatologists and 877 by GOSs. There was no statistical difference detected in American Society of Anesthesiologists score between trauma and nontrauma groups. Overall, the traumatologist group demonstrated significantly decreased procedure times when compared with the GOS group (55.6 vs. 75.8 minutes, P , 0.0001). In 16 of 18 most common procedure types, traumatologists were more efficient. This led to significantly decreased surgical labor costs ($381.4 vs. $484.8; P < 0.0001) and surgical supply and implant costs ($2567 vs. $3003; P < 0.0001). CONCLUSIONS: This study demonstrates that in our communitybased trauma system, fracture care provided by traumatologists results in improved utilization of hospital-based resources when compared with equivalent services provided by GOSs. Significantly decreased operative times, surgical labor expenses, and supply and implant costs by the fellowship-trained group represent enhanced control of the design, plan, execution, and monitoring of orthopaedic trauma care. Traumatologists can provide leadership recommendations for operating room efficiency in community-based orthopaedic trauma care models. LEVEL OF EVIDENCE: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Operating Room Supply Costs in Orthopaedic Trauma: Cost Containment Opportunities.

In the current health care environment, cost containment is more important than ever. Most physicians currently are unaware of the cost of operating room supplies. A large amount of waste occurs secondary to lack of knowledge and absence of physician incentives for cost saving. Many of the decisions for supply use can be based on good scientific evidence, which supports specific cost saving measures. Careful attention to blood utilization and use of tranexamic acid has the potential to save millions in the hip fracture treatment and arthroplasty treatments. Standardization of surgical preparation and draping can decrease costs and prevent costly surgical site infections. Following protocols and guidelines for bone graft and orthobiologics is critical. The clinical and legal repercussions of retained instruments and costs associated with dropped implants is a huge source of wasted health care dollars. Reprocessing programs for external fixators and tourniquets have been extremely successful. A myriad of opportunities for intraoperative cost savings exist that could be applied to nearly every orthopaedic surgery performed in the United States. It is incumbent on all surgeons to put aside the choices made out of habit and take part in reducing operating room waste for the benefit of hospitals, patients, and the health care system. When applied to the 5.3 million orthopaedic surgeries performed annually in the United States, billions of dollars could easily be saved with no adverse effect on patient care.

Surgeon Attitudes Regarding the Use of Generic Implants: An OTA Survey Study.

OBJECTIVES: To determine the role of generic orthopaedic trauma implants in the current orthopaedic trauma market, as perceived by OTA members, and investigate potential hurdles to the use of generic implants and other cost-containment measures. DESIGN: Survey study. SETTING: Not applicable. PARTICIPANTS: All active OTA members with valid e-mail addresses were invited to participate. INTERVENTION: Participants completed a brief online survey with questions regarding participation in cost-containment and incentive programs, industry relationships, generic implant use, and the role of surgeons in cost containment. MAIN OUTCOME MEASURES: Survey data. RESULTS: Participation in cost-containment programs (comanagement agreements, bundled payment for care improvement, and gainsharing) was found to be very low among participants (17%, 36.5%, 17%, respectively). Industry sales representatives were present in a majority of participants' cases (76.9%) the majority of time, but relatively a few surgeons (21.2%) felt their presence was necessary. Most surgeons were aware of the availability of generic implants (72.6%), but a few had adopted the use of such implants (25.5%), despite 50/52 (96.2%) prescribing generic drugs and 45/52 (86.5%) using generic products in their own households. CONCLUSIONS: Most participants agreed that generic orthopaedic implants have a role in cost containment, but a few have adopted these implants. The presence of sales representatives does not seem to be necessary for most surgeons, and minimizing or eliminating their presence may result in substantial savings for health care institutions. Increased education and the use of financial incentive programs may encourage improved surgeon participation in cost containment and adoption of generic implants and may help reduce health care spending. LEVEL OF EVIDENCE: Level 4. See Instructions for Authors for a complete description of levels of evidence.

Financial Impact of Dual Vendor, Matrix Pricing, and Sole-Source Contracting on Implant Costs.

Implant costs comprise the largest proportion of operating room supply costs for orthopedic trauma care. Over the years, hospitals have devised several methods of controlling these costs with the help of physicians. With increasing economic pressure, these negotiations have a tremendous ability to decrease the cost of trauma care. In the past, physicians have taken no responsibility for implant pricing which has made cost control difficult. The reasons have been multifactorial. However, industry surgeon consulting fees, research support, and surgeon comfort with certain implant systems have played a large role in slowing adoption of cost-control measures. With the advent of physician gainsharing and comanagement agreements, physicians now have impetus to change. At our facility, we have used 3 methods for cost containment since 2009: dual vendor, matrix pricing, and sole-source contracting. Each has been increasingly successful, resulting in massive savings for the institution. This article describes the process and benefits of each model.

Impact of Hospital-Employed Physician Assistants on a Level II Community-Based Orthopaedic Trauma System.

OBJECTIVES: The American Academy of Orthopedic Surgeons and the Orthopedic Trauma Association have released guidelines for the provision of orthopedic trauma services such as adequate stipends, designated operating rooms, ancillary staff, and guaranteed reimbursement for indigent care. One recommendation included a provision for hospital-based physician assistants (PAs). Given current reimbursement arrangements, PA collections for billable services may not meet their salary and benefit expenses. However, their actions may indirectly affect emergency room, operating room, and hospital reimbursement and patient care itself. The purpose of our study is to define the true impact of hospitalbased PAs on orthopaedic trauma care at a level II community hospital. DESIGN: Retrospective case series. SETTING: Level II trauma center. PATIENTS/PARTICIPANTS: One thousand one hundred four trauma patients with orthopaedic injuries. INTERVENTION: PA involvement. MAIN OUTCOME MEASUREMENTS: Emergency room data such as triage time, time until seen by the orthopedic service, and total emergency room time was recorded. Operating room data such as time to surgery, set-up time, total operating time, and out of room time was entered as well. Charts were reviewed to determine if patients were given postoperative antibiotics and Deep Venous Thrombosis (DVT) prophylaxis. Intraoperative and postoperative complications were noted, and lengths of stay were calculated for all patients. RESULTS: At our institution, PA collections from patient care cover only 50% of their costs for salary and benefits. However, with PA involvement, trauma patients with orthopedic injuries were seen 205 minutes faster (P = 0.006), total Emergency Room (ER) time decreased 175 minutes (P = 0.0001), and time to surgery improved 360 minutes (P . 0.03). Operating room parameters were minimally improved, but postoperative DVT prophylaxis increased by a mean of 6.73% (P = 0.0084), postoperative antibiotic administration increased by 2.88% (P = 0.0302), and there was a 4.67% decrease in postoperative complications (P = 0.0034). Average length of stay decreased by 0.61 days (P = 0.27). CONCLUSIONS: Although the PA's collections do not cover their costs, the indirect economic and patient care impacts are clear. By increasing emergency room pull through and decreasing times to Operating Room (OR), operative times, lengths of stay, and complications, their existence is clearly beneficial to hospitals, physicians, and patients as well. LEVEL OF EVIDENCE: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Comanagement and Gainsharing Opportunities for Independent Physicians.

Gainsharing and comanagament programs are both successful means of achieving physician buy-in for all cost containment programs in Orthopaedic Trauma. Under comanagement agreements, physicians are reimbursed for their time and intellectual efforts in program and algorithm creation. The cost is minimal for the hospital in return for the millions of dollars in savings they achieve. Gainsharing models can incentivize physicians to quickly adopt cost-effective implant choices, care plans, and program development. Hospital systems keep the majority of the profits, patients, and insurance carriers benefit from the cost savings and physicians receive remuneration for their efforts. Careful attention must be paid to the legal issues surrounding the Federal Anti-Kickback Statute, the Civil Monetary Penalty Law, and the Physician Self-Referral Law when setting up these agreements. The keys to success for these programs are the presence of a physician champion, economic transparency for both physicians and hospitals, accurate data collection, and adequate economic incentive for physicians to drive change in practice patterns.

Bundled Payments for Care Improvement: Lessons Learned in the First Year.

The Bundled Payments for Care Improvement (BPCI) initiative is the latest cost-saving program developed by the Center for Medicare and Medicaid Innovation. This model is intended to create a system for higher quality and more coordinated care at a lower cost to Medicare. It is currently an optional program for physician groups, hospitals and post-acute care providers to benefit financially from improved care models and cost containment measures. Under the initiative, organizations enter into payment arrangements that include financial and performance accountability for episodes of care. Under this initiative, there are certain fraud and abuse waivers in place that allow gainsharing among BPCI organizations and approved providers so long as certain requirements are met. Our practice entered this initiative for total joint arthroplasty episodes of care as well as the hip and femur fracture episode of care. The first year experience demonstrated that a significant learning curve is required. Keys for success include appropriate patient selection for elective surgery, implant pricing control, adherence to preoperative and postoperative protocols, diligent postcare care management, and appropriate choice of metrics to maximize gainsharing potential. Ultimately, the BPCI program has been a successful venture, saving our hospitals over $1.6 million in 2015. In the process, this provided an additional revenue stream for our physicians while decreasing the overall cost of care.

Outcomes after plating of olecranon fractures: A multicenter evaluation.

INTRODUCTION: The aim of this study was to report the physical and functional outcomes after open reduction internal fixation of the olecranon in a large series of patients with region specific plating across multiple centres. PATIENTS/METHODS: Between January 2007 and January 2014, 182 consecutive patients with a displaced olecranon fracture treated with open reduction internal fixation were included in this study. Retrospective review across four trauma centres collected elbow range of motion, DASH scores, hardware complications, and hardware removal. Postoperative visits in the outpatient clinic were at two, six, and twenty-four weeks. After 24 weeks, patients were eligible for hardware removal if symptomatic. All patients were contacted, at least 1 year following surgery, to determine if hardware was removed. RESULTS: 182 patients (75 women, 105 men) average age 50 (16-89) with 162 closed and 19 open displaced olecranon fractures were treated with one region specific plate. Nineteen were lost to followup leaving 163 for analysis with all patients united. The most common deficiency was a lack of full extension with 39% lacking at least 10° of extension. Hardware was asymptomatic in 67%, painful upon leaning in 20%, and restricted activities in 11% resulting in a 15% rate of hardware removal. Hardware complaints were more common if a screw was placed in the corner of the plate (P=0.004). When symptomatic, the area of the plate that was bothersome encompassed the whole plate in 39%, was at the edge of the plate in 33%, and was a screw head in 28%. The DASH scores, collected at final follow-up of 24 weeks, was 10.1±16, indicating moderate disability was still present. Patients who lacked 10° of extension had a DASH of 12.3 as compared with 10.5 for those with near full extension, but this was not significant (P=0.5). CONCLUSION: Plating of the olecranon leads to predictable union. The most common complication was lack of full extension with 39% lacking more than 10°, although this did not have any effect on DASH scores. Overall results indicate that disability still exists after 6 months with an average DASH score of 10. LEVEL OF EVIDENCE: Therapeutic level III.

Clinical and Economic Impact of Duplicated Radiographic Studies in Trauma Patients Transferred to a Regional Trauma Center.

OBJECTIVES: Many trauma patients are evaluated at community hospitals and rural emergency departments before transfer to regional trauma centers. Radiographic studies are often duplicated, leading to significant additional costs to the healthcare system. Our purpose is to identify the reasons for duplicate studies, the costs associated with this practice, and potential clinical effects to patients. METHODS: The institutional trauma database was queried to identify patients with orthopaedic injuries transferred to our regional trauma center. Patient demographics, mechanism of injury, referring hospital, reason for transfer, payor source, injury severity score, and Glasgow Coma Score (GCS) were recorded. Duplicate imaging studies were identified and confirmed with each outlying hospital radiology department. The radiation exposure was estimated based on average reported values. The cost of duplicated studies was derived from the Medicare fee schedule. RESULTS: In 1 calendar year, a total of 513 patients were accepted in transfer from 36 outlying facilities. Almost half of the patients (47.7%) had at least 1 radiographic study repeated. There was a significant association between repeated study and age (P < 0.0001), Injury Severity Score (P < 0.0001), and GCS (P < 0.0001). No association was identified for size of transferring institution, injury mechanism, or payor status. Reasons listed for duplication included inadequate data transfer, poor quality, inadequate study, and physician preference. The additional cost to the healthcare system is estimated to be $94,000. CONCLUSIONS: The duplication of imaging studies at regional trauma centers is a common problem that represents a significant opportunity for cost savings and reduction of patient exposure to radiation by implementing imaging protocols at outlying facilities and improving the transfer of imaging data through information technology solutions. LEVEL OF EVIDENCE: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Surgical treatment of flail chest and rib fractures.

Despite significant advances in critical care management, flail chest remains a clinically significant finding, with a mortality rate of up to 33%. Nonsurgical management is associated with prolonged ventilator support, pneumonia, respiratory difficulties, and lengthy stays in the intensive care unit, as well as chronic pain from nonunion and malunion of the bony thorax. Treatment with aggressive pulmonary toilet, ventilator support, and different modalities of pain control remains the benchmark of care. However, several recent randomized controlled studies of surgical intervention of flail chest have demonstrated an improvement in the number of ventilator days, intensive care unit and hospital stays, incidence of pneumonia, and respiratory function and hospital costs, as well as faster return to work. The success of these surgical constructs compared with those of historical attempts at open fixation is largely the result of modern plating technology and improvement in surgical approaches. Clinical evidence continues to grow regarding proper indications and techniques for surgical stabilization of flail chest.

Clinical and economic impact of using generic 7.3-mm cannulated screws at a level II trauma center.

We retrospectively studied the clinical and economic impact of a cost-containment program using high quality generic 7.3-mm screws for fixation of femoral neck fractures and pelvic ring injuries at a level II trauma center. Included in the study were 174 patients with femoral neck fractures or posterior pelvic ring injuries. These injuries were managed with 203 conventional and 178 generic implants. Study results showed no significant differences in age, sex, American Society of Anesthesiologists status, or fracture pattern; no differences in operative time, estimated blood loss, or complication rates; no increase in varus collapse, shortening, screw cutout, screw deformation, loosening, or conversion to arthroplasty; and no differences in hospital complications of deep venous thrombosis, pulmonary embolism, urinary tract infection, or pressure sores. Overall, our hospital realized a 70% reduction in implant costs, resulting in calendar-year savings of $50,531. At our institution, use of generic 7.3-mm cannulated screws has been a success. Hospital implant costs decreased significantly without any associated increase in complication rate or change in radiographic outcome. Generic implants have the potential to markedly reduce operative costs as long as quality products are used.