Ankle fractures: High implant cost is not associated with better patient reported outcomes.

INTRODUCTION: Ankle fractures comprise 9% of all fractures and are among the most common fractures requiring operative management. Open reduction and internal fixation (ORIF) with plates and screws is the gold standard for the treatment of unstable, displaced ankle fractures. While performing ORIF, orthopaedic surgeons may choose from several fixation methods including locking versus nonlocking plating and whether to use screws or suture buttons for syndesmotic injuries. Nearly all orthopaedic surgeons treat ankle fractures but most are unfamiliar with implant costs. No study to date has correlated the cost of ankle fracture fixation with health status as perceived by patients through patient reported outcomes (PROs). The purpose of this study was to determine whether there is a relationship between increasing implant cost and PROs after a rotational ankle fracture. METHODS: All ankle fractures treated with open reduction internal fixation (ORIF) at a level I academic trauma center from January 2018 to December 2022 were identified. Inclusion criteria included all rotational ankle fractures with a minimum 6-month follow-up and completed 6-month PRO. Patients were excluded for age <18, polytrauma and open fracture. Variables assessed included demographics, fracture classifications, Foot and Ankle Ability Measure-Activities of Daily Living (FAAM-ADL) score, implant type, and implant cost. RESULTS: There was a statistically significant difference in cost between fracture types (p < 0.0001) with trimalleolar fractures being the most expensive. The mean FAAM-ADL score was lowest for trimalleolar fractures at 78.9, 95% CI [75.5, 82.3]. A diagnosis of osteoporosis/osteopenia was associated with a decrease in cost of $233.3, 95% CI [-411.8, -54.8]. There was no relationship between syndesmotic fixation and implant cost, $102.6, 95% CI [-74.9, 280.0]. There was no correlation between implant cost and FAAM-ADL score at 6 months (p = 0.48). CONCLUSIONS: The utilization of higher cost ankle fixation does not correlate with better FAAM-ADL scores. Orthopaedic surgeons may choose less expensive implants to improve the value of ankle fixation without impacting patient reported outcomes.

Cost Reduction for Knee-Spanning External Fixation in the Staged Treatment of Tibial Plateau Fractures: A Practical Intervention.

OBJECTIVE: To determine whether an educational intervention affects surgeon implant decision making measured by total implant costs for temporizing a knee-spanning external fixation construct. DESIGN: A total of 24 cases were prospectively collected after an educational intervention and matched to 24 cases before intervention using Schatzker classification and by surgeon. SETTING: A single Level 1 trauma center. PATIENTS/PARTICIPANTS: Forty-eight patients with Schatzker II-VI tibial plateau fractures. INTERVENTION: Education session to create transparency with component pricing and to provide 3 clinical cases of Orthopaedic Trauma Association/AO 41-C3 (Schatzker VI) with accompanying images and fixator construct costs. Total implant costs displayed in the session ranged from $2354 to $11,696. OUTCOME MEASUREMENT: External fixator construct cost. RESULTS: The mean cost of constructs in the postintervention group was $4550.20 [95% confidence interval (CI) $3945.60-$5154.00], which was significantly different compared with the preintervention group cost of $6046.75 (95% CI = $5309.54-$6783.97, P = 0.003). After 1 year, the total implant costs of external fixation constructs were reduced by an average of almost $1500 per patient. CONCLUSION: An educational intervention created a reduction in the average total implant construction costs for temporary knee-spanning external fixation in the treatment of tibial plateau fractures. Surgical implant selection and cost variance remain an ideal area to improve value for patients and hospitals. Empowering surgeons with knowledge regarding implant prices is a critical part of working toward the cost reductions of external fixation constructs.

External Fixation Characteristics Drive Cost of Care for High-Energy Tibial Plateau Fractures.

OBJECTIVE: To determine the total cost for a 30-day episode of care for high-energy tibial plateau fractures and the aspects of care associated with total cost. DESIGN: Time-driven activity-based costing analysis. SETTING: One Level 1 adult trauma center. PATIENTS: One hundred twenty-one patients with isolated, bicondylar tibial plateau fractures undergoing staged treatment were reviewed. PRIMARY OUTCOME: Total cost. RESULTS: A total of 85 patients were included and most sustained Schatzker VI fractures (n = 66, 77%). All patients were treated with biplanar external fixation before definitive fixation. A total of 26 patients (31%) were discharged to skilled nursing facilities, and 37 patients (43%) were not discharged between procedures. Total cost for a 30-day episode of care was $22,113 ± 4056. External fixation components ($5952, 26.9%), length of hospital stay ($5606, 25.4%), discharge to skilled nursing facility (SNF) ($3061, 13.8%), and definitive fixation implants ($2968, 13.4%) contributed to the total cost. The following were associated with total cost: patient discharged to SNFs (P < 0.001), patient remaining inpatient after external fixation (P < 0.001), days of admission for open reduction internal fixation (ORIF) (P = 0.005), days spent with external fixation (P < 0.001), days in a SNF after ORIF (P < 0.001), and external fixation component cost (P < 0.001). CONCLUSIONS: External fixation component selection is the largest contributor to cost of a 30-day episode of care for high-energy bicondylar tibial plateau fractures. Reduction in cost variability may be possible through thoughtful use of external fixation components and care pathways. LEVEL OF EVIDENCE: Economic analyses Level IV. See Instructions for Authors for a complete description of levels of evidence.

Can Reducing Implant Costs Increase Revenue for Surgically Treated Ankle Fractures: Time-Driven Activity-Based Costing for 1-Year Episode of Care.

BACKGROUND: The purpose of this study was to investigate whether decision-making regarding implant selection affects the reimbursement margins for the surgical fixation of ankle fractures. METHODS: All ankle fractures treated between 2010 and 2017 within a single-insurer database were identified via Current Procedural Terminology codes by review of electronic medical record. Implant cost was determined via the implant record cross-referenced with the single contract institutional charge master database. The Time-Driven Activity-Based Costing (TDABC) technique was used to determine the costs of care during all activities throughout the 1-year episode of care. Statistical analysis consisted of multiple linear regression and goodness-of-fit analyses. RESULTS: In all, 249 patients met inclusion criteria. Implant costs ranged from $173 to $3944, averaging $1342 ± $751. The TDABC-estimated cost of care ranged from $1416 to $9185, averaging $3869 ± $1384. Finally, the total reimbursed cost of care ranged between $1335 and $65 645, averaging $13 954 ± $9445. The implant costs occupied an estimated 34.7% of the TDABC-estimated cost of care per surgical encounter. Implant cost, as a percentage of the overall TDABC, was estimated as 36.2% in the inpatient setting and 33% in the outpatient setting, which was the second highest percentage behind surgical costs in both settings. We found a significant increase in net revenue of $1.93 for each dollar saved on implants in the outpatient setting, whereas the increase in net revenue per dollar saved of $1.03 approached significance in the inpatient setting. CONCLUSION: There is a direct relationship between intraoperative decision-making, as evidenced by implant choices, and the revenue generated by surgical fixation of ankle fractures. Intraoperative decision-making that is cognitive of implant cost can facilitate adoption of institutional cost containment measures and prompt increased healthcare value. LEVEL OF EVIDENCE: Level III: Retrospective cohort study.

Geriatric Femoral Neck Fractures: Hemiarthroplasty Implant Trends Across a Health System From 2006 to 2018.

INTRODUCTION: Hemiarthroplasty is increasingly used for the treatment of geriatric femoral neck fractures in an effort to optimize value-based care. The current American Association of Orthopaedic Surgeons (AAOS) guidelines released in 2014 for the treatment of geriatric hip fractures recommend the utilization of monopolar cemented constructs. The purpose of this study was to evaluate hip hemiarthroplasty implant cost variability and implant selection trends from 2006 to 2018. MATERIALS AND METHODS: A retrospective review of 940 geriatric hip fractures treated with hemiarthroplasty was conducted across 3 institutions from 2006 to 2018. Variables examined were construct type, surgeon, operative time, patient mortality, and implant cost. Statistical analysis consisted of multigroup comparative tests and multiple linear regression analyses to evaluate correlative measures. RESULTS: The study population was 85.0 ± 7.9 years of age with a body mass index of 24.0 ± 5.5. A total of 33 (3.5%) patients were deceased at the 90-day postoperative mark and 45 (4.8%) patients at the 1-year mark. There was no statistical difference in terms of mortality between the 4 implant cohorts at the 90-day mark (P = .56) and 1-year mark (P = .24). The bipolar press-fit construct was the most expensive, US$3900.61 ± US$2607.54, and the monopolar cemented construct was the least expensive, US$2618.68 ± US$1834.16. The mean operative time was 6 minutes greater for press-fit implants, 93.6 ± 32.0, than cemented implants, 87.1 ± 33.6 (P = .02). The use of monopolar cemented implants increased from 12.1% to 83.3%, while bipolar press-fit decreased from 57.6% to 4.6% from 2013 to 2018. DISCUSSION: The use of a bipolar and/or press-fit implant significantly increases construct cost despite little evidence in the literature of improved outcomes. Contrary to previous research, cemented implants do not increase the operative time. CONCLUSIONS: Encouragingly, selection of the most cost-conscience implant, monopolar cemented, has been increasing since 2014, which may reflect the influence of current AAOS guidelines. LEVEL OF EVIDENCE: Diagnostic Level III.

Variation in Implant Selection for Ankle Fractures: Identifying Cost Drivers.

BACKGROUND: Implant selection is the first opportunity for surgeons to control costs of fracture fixation. The current literature has demonstrated surgeons' poor understanding of implant costs. Our study evaluated implant cost variability for surgically treated ankle fractures and distal tibia fractures. Our hypothesis was that significant cost variation exists among providers. The goal was to identify cost drivers and determine whether specialty training is linked to implant selection. METHODS: A retrospective 2010-2017 chart review was performed for 1281 patients at a Level I trauma center. Patients were excluded for skeletal immaturity, open fractures, polytrauma, and concurrent surgeries. Variables were assessed included age, sex, body mass index, OTA/AO classification, Weber classification, 1-year reoperation status, surgeon specialty, and use of syndesmotic screws, locking plates, and cannulated screws. Construct cost was determined by using electronic medical record implant model numbers cross-referenced with the chargemaster database. Statistical analysis involved intergroup comparative tests, regression analysis, and goodness-of-fit analyses. RESULTS: Implant cost was different among OTA patterns (P < 0.01), highest among 43C ($3771) and lowest with 44A ($819). Construct costs of OTA 43 fractures varied from $2568 to 3771, whereas OTA 44 ranged from $819 to $1474. Costs were comparable across Weber patterns (P = 0.15), with Weber B having the highest ($1494). Costs were highest among reconstructive, podiatry, and spine surgeons, with mean costs of $1804, $1404, and $1396, respectively. Traumatologist constructs had the lowest overall price ($987). A total of 433 (33.8%) procedures used locking plates with 512 (40.0%) using at least one cannulated screw. Locking plates averaged a larger total implant cost ($1947) than nonlocking plates ($1313) but had a comparable reoperation rate (18.5% vs. 17.7%, P = 0.81). Use of a cannulated screw presented a higher total cost ($2008 vs. $1435) with comparable reoperation rates (17.4% vs. 18.8%, P = 0.72). A total of 401 (31.5%) patients received syndesmotic fixation and a significantly higher reoperation rate (17.0% vs. 11.0%, P < 0.01). Overall, 199 patients underwent elective hardware removal, 23 were infected, 7 required revision, and 3 were identified with a nonunion. CONCLUSIONS: Our study demonstrated significant variability in implant costs for ankle fracture fixation and identified the key cost drivers as locking plates and cannulated screws. Surgical management of ankle fractures could be an ideal setting to pilot economic alignment between physicians and hospitals to drive value. LEVEL OF EVIDENCE: Level III. Retrospective Cohort.