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Engler ID, Koback FL, Curley AJ. Value-Based, Environmentally Sustainable Anterior Cruciate Ligament Surgery. Clin Sports Med 2024; 43:355-365. [PMID: 38811115 DOI: 10.1016/j.csm.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
Orthopedic surgeons are increasingly recognizing the broader societal impact of their clinical decisions, which includes value-based and environmentally sustainable care. Within anterior cruciate ligament reconstruction, value-based care-or most cost-effective care-includes an outpatient surgical setting with regional anesthesia, use of autograft, meniscus repair when indicated, and use of traditional metal implants such as interference screws and staples. Environmentally sustainable care includes slimming down surgical packs and trays to avoid opening unnecessary equipment, avoiding desflurane as an inhaled anesthetic agent, and minimizing waste in the operating room-a priority that addresses both cost and environmental impact.
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Affiliation(s)
- Ian D Engler
- Central Maine Healthcare Orthopedics, Central Maine Medical Center, 690 Minot Avenue #1, Auburn, ME 04210, USA; UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 South Water Street, Pittsbrugh, PA, USA.
| | - Frances L Koback
- Geisel School of Medicine at Dartmouth, Dartmouth College, 1 Rope Ferry Road, Hanover, NH 03755, USA
| | - Andrew J Curley
- UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 South Water Street, Pittsbrugh, PA, USA; TidalHealth Nanticoke, 801 Middleford Road, Seaford, DE 19973, USA
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Luksameesate P, Watcharopas R, Sangkum L, Saengpetch N, Taychakhoonavudh S. Ambulatory knee arthroscopic surgery yields cost savings and improved health outcomes. Knee Surg Sports Traumatol Arthrosc 2024; 32:1405-1413. [PMID: 38558181 DOI: 10.1002/ksa.12157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 03/10/2024] [Accepted: 03/12/2024] [Indexed: 04/04/2024]
Abstract
PURPOSE This study measured the health-related quality of life (HRQoL) and costs and conducted a cost-utility analysis and budget impact analysis of ambulatory knee arthroscopic surgery compared with inpatient knee arthroscopic surgery in Thailand from a societal perspective. METHODS Health outcomes were measured in units of quality-adjusted life year (QALY) based on the Thai version of the EQ-5D-5L Health Questionnaire, and costs were obtained from an electronic database at a tertiary care hospital (Ramathibodi Hospital). A cost-utility analysis was performed to evaluate ambulatory and inpatient surgery using the societal perspective and a 2-week time horizon. The incremental cost-effectiveness ratio was applied to examine the costs and QALYs. One-way sensitivity analysis was used to investigate the robustness of the model. Budget impact analysis was performed considering over 5 years. RESULTS A total of 161 knee arthroscopic patients were included and divided into two groups: ambulatory surgery (58 patients) and inpatient surgery (103 patients). The total cost of the inpatient surgery was 2235 United States dollars (USD), while the ambulatory surgery cost was 2002 USD. The QALYs of inpatient surgery and ambulatory surgery were 0.79 and 0.81, respectively, resulting in the ambulatory surgery becoming a dominant strategy (cost reduction of 233 USD with an increase of 0.02 QALY) over the inpatient surgery. The ambulatory surgery led to net savings of 4.5 million USD over 5 years. Medical supply costs are one of the most influential factors affecting the change in results. CONCLUSION Ambulatory knee arthroscopic surgery emerged as a cost-saving strategy over inpatient surgery, driven by lower treatment costs and enhanced HRQoL. Budget impact analysis indicated net savings over 5 years, supporting the feasibility of adopting ambulatory knee arthroscopic surgery. Our findings were advocated for its application across diverse hospitals and informed policymakers to improve reimbursement systems in low- to middle-income countries and Thailand. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Parnnaphat Luksameesate
- Department of Social and Administrative Pharmacy, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand
| | - Ratthapoom Watcharopas
- Department of Orthopaedics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
- Vejthani Hospital, Bangkok, Thailand
| | - Lisa Sangkum
- Department of Anesthesiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Nadhaporn Saengpetch
- Department of Orthopaedics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Suthira Taychakhoonavudh
- Department of Social and Administrative Pharmacy, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand
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Rahman OF, Limpisvasti O, Kharrazi FD, ElAttrache NS. Current Concepts in the Business of Orthopaedics. J Am Acad Orthop Surg 2024; 32:e204-e213. [PMID: 38166002 DOI: 10.5435/jaaos-d-23-00629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 11/08/2023] [Indexed: 01/04/2024] Open
Abstract
Practice management within orthopaedic surgery demands a multifaceted skillset including clinical expertise, technical proficiency, and business acumen, yet the latter is rarely taught during orthopaedic training. As the healthcare system evolves in the United States, surgeons continue to face challenges such as decreasing reimbursements, increased regulatory burdens, and potential for practice acquisition. To remain competitive and provide exceptional care for patients, orthopaedic surgeons must cultivate a business-minded approach. This article highlights the growing significance of the business of orthopaedics and offers guidance on ambulatory surgical center ownership models, effective management of ancillary services, the effect of private equity in orthopaedic practice, real estate investment opportunities in medical office buildings, and the importance of brand recognition. By understanding these concepts, orthopaedic surgeons can exercise greater control over their practice's finances while providing quality care for their patients.
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Affiliation(s)
- Omar F Rahman
- From the Cedars-Sinai Kerlan-Jobe Institute, Los Angeles, CA
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Zukotynski BK, Brown D, Hori K, Silva M. Ambulatory surgical management of most displaced tibial tubercle fractures in children is safe and efficient. J Child Orthop 2023; 17:590-597. [PMID: 38050601 PMCID: PMC10693841 DOI: 10.1177/18632521231214317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 10/30/2023] [Indexed: 12/06/2023] Open
Abstract
Purpose The purpose of this study is to compare the outcome of patients with displaced tibial tubercle fractures treated surgically who spent one or more nights in the hospital after surgery with that of patients treated in an ambulatory setting with no perioperative hospitalization. We hypothesized that tibial tubercle fractures have a low rate of complications and that most patients do well without an overnight hospital stay for observation. Methods We retrospectively reviewed all pediatric tibial tubercle fractures treated operatively by a single surgeon over a 13.5-year period. Fractures treated in an inpatient setting, defined as at least one night of overnight hospitalization postoperatively, were compared with fractures treated in an ambulatory setting with no perioperative hospitalization. Results Seventy-one fractures in 70 patients were analyzed. All fractures were treated with open reduction and internal fixation with unicortical screws. Thirty-five fractures (49.3%) were fixed in an ambulatory setting, while 36 (50.7%) were inpatient. There were no significant differences between inpatient demographics (age, gender, body mass index, fracture type). Average operative time was significantly longer in the inpatient group compared with the ambulatory group (97.8 min versus 58.8 min, p < 0.001). There was no significant difference in the incidence of complications between inpatient and ambulatory groups (25.0% versus 11.4%, p = 0.22). No cases of compartment syndrome were noted. Conclusion Ambulatory surgical treatment of select tibial tubercle fractures with same-day discharge is safe and efficient. Not all patients with surgically treated tibial tubercle fractures need to stay overnight in the hospital.
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Affiliation(s)
| | - Danielle Brown
- Department of Orthopaedic Surgery, University of California, Los Angeles, Santa Monica, CA, USA
| | - Kellyn Hori
- Department of Orthopaedic Surgery, University of California, Los Angeles, Santa Monica, CA, USA
| | - Mauricio Silva
- Department of Orthopaedic Surgery, University of California, Los Angeles, Santa Monica, CA, USA
- The Luskin Orthopaedic Institute for Children, Los Angeles, CA, USA
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Young S, Osman B, Shapiro FE. Safety considerations with the current ambulatory trends: more complicated procedures and more complicated patients. Korean J Anesthesiol 2023; 76:400-412. [PMID: 36912006 PMCID: PMC10562071 DOI: 10.4097/kja.23078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 03/07/2023] [Accepted: 03/08/2023] [Indexed: 03/14/2023] Open
Abstract
In the last quarter of a century, the backdrop of appropriate ambulatory and office-based surgeries has changed dramatically. Procedures that were traditionally done in hospitals or patients being admitted after surgery are migrating to the outpatient setting and being discharged on the same day, respectively, at a remarkable rate. In the face of this exponential growth, anesthesiologists are constantly being challenged to maintain patient safety by understanding the appropriate patient selection, procedure, and surgical location. Recently published literature supports the trend of higher, more medically complex patients, and more complicated procedures shifting towards the outpatient arena. Several reasons that may account for this include cost incentives, advancement in anesthesia techniques, enhanced recovery after surgery (ERAS) protocols, and increased patient satisfaction. Anesthesiologists must understand that there is a lack of standardized state regulations regarding ambulatory surgery centers (ASCs) and office-based surgery (OBS) centers. Current and recently graduated anesthesiologists should be aware of the safety concerns related to the various non-hospital-based locations, the sustained growth and demand for anesthesia in the office, and the expansion of mobile anesthesia practices in the US in order to keep up and practice safely with the professional trends. Continuing procedural ambulatory shifts will require ongoing outcomes research, likely prospective in nature, on these novel outpatient procedures, in order to develop risk stratification and prediction models for the selection of the proper patient, procedure, and surgery location.
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Affiliation(s)
- Steven Young
- Department of Anesthesiology, 1Massachusetts Eye and Ear Infirmary, Boston, MA, USA
| | - Brian Osman
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Fred E. Shapiro
- Department of Anesthesiology, 1Massachusetts Eye and Ear Infirmary, Boston, MA, USA
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ten Hoope W, Admiraal M, Hermanides J, Hermanns H, Hollmann MW, Lirk P, Kerkhoffs GMMW, Steens J, van Beek R. The Effectiveness of Adductor Canal Block Compared to Femoral Nerve Block on Readiness for Discharge in Patients Undergoing Outpatient Anterior Cruciate Ligament Reconstruction: A Multi-Center Randomized Clinical Trial. J Clin Med 2023; 12:6019. [PMID: 37762959 PMCID: PMC10531554 DOI: 10.3390/jcm12186019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 09/03/2023] [Accepted: 09/14/2023] [Indexed: 09/29/2023] Open
Abstract
This study evaluated the effect of adductor canal block (ACB) versus femoral nerve block (FNB) on readiness for discharge in patients undergoing outpatient anterior cruciate ligament (ACL) reconstruction. We hypothesized that ACB would provide sufficient pain relief while maintaining motor strength and safety, thus allowing for earlier discharge. This was a randomized, multi-center, superiority trial. From March 2014 to July 2017, patients undergoing ACL reconstruction were enrolled. The primary outcome was the difference in readiness for discharge, defined as Post-Anesthetic Discharge Scoring System score ≥ 9. Twenty-six patients were allocated to FNB and twenty-seven to ACB. No difference in readiness for discharge was found (FNB median 1.8 (95% CI 1.0 to 3.5) vs. ACB 2.9 (1.5 to 4.7) hours, p = 0.3). Motor blocks and (near) falls were more frequently reported in patients with FNB vs. ACB (20 (76.9%) vs. 1 (3.7%), p < 0.001, and 7 (29.2%) vs. 1 (4.0%), p = 0.023. However, less opioids were consumed in the post-anesthesia care unit for FNB (median 3 [0, 21] vs. 15 [12, 42.5] oral morphine milligram equivalents, p = 0.004) for ACB. Between patients with FNB or ACB, no difference concerning readiness for discharge was found. Despite a slight reduction in opioid consumption immediately after surgery, FNB demonstrates a less favorable safety profile compared to ACB, with more motor blocks and (near) falls.
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Affiliation(s)
- Werner ten Hoope
- Department of Anesthesiology, Amsterdam University Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Manouk Admiraal
- Department of Anesthesiology, Amsterdam University Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Jeroen Hermanides
- Department of Anesthesiology, Amsterdam University Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Henning Hermanns
- Department of Anesthesiology, Amsterdam University Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Markus W. Hollmann
- Department of Anesthesiology, Amsterdam University Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Philipp Lirk
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Gino M. M. W. Kerkhoffs
- Department of Orthopedic Surgery and Sports Medicine, Amsterdam Movement Sciences, Amsterdam University Medical Centers, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Jeroen Steens
- Department of Orthopedics, Dijklander Ziekenhuis, Maelsonstraat 3, 1624 NP Hoorn, The Netherlands
| | - Rienk van Beek
- Department of Anesthesiology, Dijklander Ziekenhuis, Maelsonstraat 3, 1624 NP Hoorn, The Netherlands
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Lopez CD, Gazgalis A, Peterson JR, Confino JE, Levine WN, Popkin CA, Lynch TS. Machine Learning Can Accurately Predict Overnight Stay, Readmission, and 30-Day Complications Following Anterior Cruciate Ligament Reconstruction. Arthroscopy 2023; 39:777-786.e5. [PMID: 35817375 DOI: 10.1016/j.arthro.2022.06.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 06/20/2022] [Accepted: 06/23/2022] [Indexed: 02/07/2023]
Abstract
PURPOSE This study aimed to develop machine learning (ML) models to predict hospital admission (overnight stay) as well as short-term complications and readmission rates following anterior cruciate ligament reconstruction (ACLR). Furthermore, we sought to compare the ML models with logistic regression models in predicting ACLR outcomes. METHODS The American College of Surgeons National Surgical Quality Improvement Program database was queried for patients who underwent elective ACLR from 2012 to 2018. Artificial neural network ML and logistic regression models were developed to predict overnight stay, 30-day postoperative complications, and ACL-related readmission, and model performance was compared using the area under the receiver operating characteristic curve. Regression analyses were used to identify variables that were significantly associated with the predicted outcomes. RESULTS A total of 21,636 elective ACLR cases met inclusion criteria. Variables associated with hospital admission included White race, obesity, hypertension, and American Society of Anesthesiologists classification 3 and greater, anesthesia other than general, prolonged operative time, and inpatient setting. The incidence of hospital admission (overnight stay) was 10.2%, 30-day complications was 1.3%, and 30-day readmission for ACLR-related causes was 0.9%. Compared with logistic regression models, artificial neural network models reported superior area under the receiver operating characteristic curve values in predicting overnight stay (0.835 vs 0.589), 30-day complications (0.742 vs 0.590), reoperation (0.842 vs 0.601), ACLR-related readmission (0.872 vs 0.606), deep-vein thrombosis (0.804 vs 0.608), and surgical-site infection (0.818 vs 0.596). CONCLUSIONS The ML models developed in this study demonstrate an application of ML in which data from a national surgical patient registry was used to predict hospital admission and 30-day postoperative complications after elective ACLR. ML models developed performed well, outperforming regression models in predicting hospital admission and short-term complications following elective ACLR. ML models performed best when predicting ACLR-related readmissions and reoperations, followed by overnight stay. LEVEL OF EVIDENCE IV, retrospective comparative prognostic trial.
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Affiliation(s)
- Cesar D Lopez
- New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, U.S.A.
| | - Anastasia Gazgalis
- New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, U.S.A
| | - Joel R Peterson
- New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, U.S.A
| | - Jamie E Confino
- New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, U.S.A
| | - William N Levine
- New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, U.S.A
| | - Charles A Popkin
- New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, U.S.A
| | - T Sean Lynch
- New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, U.S.A
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Knee Osteotomies Can Be Performed Safely In An Ambulatory Setting. Arthrosc Sports Med Rehabil 2022; 4:e1397-e1402. [PMID: 36033188 PMCID: PMC9402466 DOI: 10.1016/j.asmr.2022.04.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 04/24/2022] [Indexed: 11/22/2022] Open
Abstract
Purpose The purpose of this study was to assess the rate of hospital admissions, inpatient conversions, reoperations, and complications associated with tibial tubercle osteotomies (TTO), high tibial osteotomies (HTO), and distal femoral osteotomies (DFO) performed at our ambulatory surgery center compared with our inpatient hospital facility. Methods A retrospective review of patients receiving a TTO, HTO or DFO at our institution between June 2011 and October 2019 was performed. Inclusion criteria consisted of patients undergoing the aforementioned procedures for malalignment, and a minimum of 90-days follow-up. Revision osteotomies, those undergoing an osteotomy for an acute fracture, and those with rule-out criteria for outpatient surgery (ASA > 3, and body mass index >40) were excluded. Complications, including readmission and reoperation, were compared between the two groups using either the Fisher’s exact test and independent samples t-test, where applicable, and a P value of <0.05 was considered to be statistically significant. Results The study included 531 patients undergoing osteotomies (222 ambulatory surgical center [ASC] and 309 hospital) with no patients lost to follow-up in the 90-day postoperative period. No patients operated on at an ASC required transfer to inpatient setting. There were no differences in complication rates, readmission, or reoperation rates among the two groups (4.1% vs 4.9%; P = .8328; 3.1% vs 4.5%, P = .5026; 3.1% vs 4.5%; P = .5026; respectively). Complications, including surgical site infection and arthrofibrosis were not significantly different in the two cohorts, (1.4% vs. 2.6%, P = .341 and 1.4% vs 1%; P = .698, respectively). Conclusions Osteotomies about the knee performed in an ambulatory setting were safe, with no difference in readmission, reoperation, or postoperative complications compared to those performed at an inpatient hospital. Additionally, no patient required conversion from an outpatient to an inpatient setting. Level of Evidence Level III, retrospective comparative study.
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Berlinberg EJ, Forlenza EM, Patel HH, Ross R, Mascarenhas R, Chahla J, Nho SJ, Forsythe B. Increased Readmission Rates but No Difference in Complication Rates in Patients Undergoing Inpatient Versus Outpatient Hip Arthroscopy: A Large Matched-Cohort Insurance Database Analysis. Arthrosc Sports Med Rehabil 2022; 4:e975-e988. [PMID: 35747635 PMCID: PMC9210381 DOI: 10.1016/j.asmr.2022.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 02/08/2022] [Indexed: 11/29/2022] Open
Abstract
Purpose Methods Results Conclusions Level of Evidence
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Affiliation(s)
- Elyse J. Berlinberg
- Midwest Orthopedics at Rush, Chicago, Illinois, U.S.A
- NYU Grossman School of Medicine, New York, New York, U.S.A
| | | | | | - Ruby Ross
- NYU Grossman School of Medicine, New York, New York, U.S.A
| | | | - Jorge Chahla
- Midwest Orthopedics at Rush, Chicago, Illinois, U.S.A
| | - Shane J. Nho
- Midwest Orthopedics at Rush, Chicago, Illinois, U.S.A
| | - Brian Forsythe
- Midwest Orthopedics at Rush, Chicago, Illinois, U.S.A
- Address correspondence to Brian Forsythe, M.D., Midwest Orthopedics at Rush, 1611 W Harrison St, Ste 360, Chicago, IL 60621, U.S.A.
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Saengpetch N, Watcharopas R, Kujkunasathian C, Limitloahaphan C, Lertbutsayanukul C, Vijittrakarnrung C, Sa-ngasoongsong P, Arnuntasupakul V, Sangkum L. Predicting surgical factors for unplanned overnight admission in ambulatory arthroscopic surgery of the knee: a prospective cohort in one hundred and eighty four patients. INTERNATIONAL ORTHOPAEDICS 2022; 46:1991-1998. [PMID: 35578111 PMCID: PMC9110279 DOI: 10.1007/s00264-022-05436-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 05/07/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE Unplanned overnight admission (UOA) is an important indicator for quality of care with ambulatory knee arthroscopic surgery (AKAS). However, few studies have explored the factors related to the UOA and how to predict UOA after AKAS. This study aimed to evaluate the effectiveness of a standardized peri-operative protocol for the AKAS and identify whether a correlation exists between the peri-operative surgical factors and UOA in the patients undergoing AKAS. We hypothesized that more surgical invasiveness and prolong tourniquet time increase the risk of UOA after AKAS. METHOD A prospective cohort study was conducted between October 2017 and March 2021. All 184 patients operated on standard AKAS protocol. The UOA is defined as overnight hospitalization of a patient undergoing AKAS. Demographic and peri-operative data were recorded, and the procedure was categorized based on the surgical invasiveness based on less invasive (intra-articular soft tissue surgery) (n = 65) and more complex surgery (involving extra-articular soft tissue surgery or ligamentous reconstruction) (n = 119). The clinical risk factors for UOA were identified and analyzed with multivariate analysis. RESULTS The incidence of UOA in the more complex group (n = 7, 14.3%) was significantly higher than in the less invasive group (n = 3, 4.6%) (p = 0.049). The peri-operative factors significantly associated with UOA were age, more complex surgery, and longer tourniquet time (p < 0.10 all). However, the multivariate analysis revealed that longer tourniquet time was the only significant predictor for UOA (OR = 1.045, 95% CI = 1.022-1.067, p = 0.0001). The optimal cut-off points of tourniquet time for predicting UOA with the highest Youden index in the less invasive and more complex groups were 56 minutes and 107 minutes, respectively. CONCLUSION The UOA after AKAS is more common in more complex surgery compared to less invasive surgery. This study showed that unplanned admission significantly associated with many factors-as patient factors, surgical invasiveness, and tourniquet time. However, tourniquet time is the only independent predictor for UOA. Therefore, strict perioperative management protocol must be applied in AKAS, and all patients having these risk factors should be prepared for UOA.
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Affiliation(s)
- Nadhaporn Saengpetch
- Department of Orthopedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, 10400 Thailand
| | - Ratthapoom Watcharopas
- Department of Orthopedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, 10400 Thailand
| | - Chusak Kujkunasathian
- Department of Orthopedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, 10400 Thailand
| | - Chalermchai Limitloahaphan
- Department of Orthopedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, 10400 Thailand
| | - Chatchawan Lertbutsayanukul
- Department of Orthopedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, 10400 Thailand
| | - Chaiyanun Vijittrakarnrung
- Department of Orthopedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, 10400 Thailand
| | - Paphon Sa-ngasoongsong
- Department of Orthopedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, 10400 Thailand
| | - Vanlapa Arnuntasupakul
- Department of Anesthesiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, 10400 Thailand
| | - Lisa Sangkum
- Department of Anesthesiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, 10400 Thailand
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Ambulatory Surgery Centers Versus Hospital Outpatient Departments for Orthopaedic Surgeries. J Am Acad Orthop Surg 2022; 30:207-214. [PMID: 35143432 DOI: 10.5435/jaaos-d-21-00739] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 11/27/2021] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The goals of this study were to compare the utilization and costs of ambulatory surgery centers (ASCs) versus hospital outpatient department (HOPD) for commonly performed outpatient orthopaedic surgical procedures. METHODS Commercially insured patients undergoing elective, outpatient orthopaedic surgery were queried using an administrative claims database. We queried the following surgeries: carpal tunnel release, lumbar microdiskectomy, anterior cruciate ligament reconstruction, knee arthroscopy, arthroscopic rotator cuff repair, and bunion repair. Total costs were defined as the sum of all payments for a surgical episode. Professional fees were defined as payments to the primary orthopaedic surgeon and technical fees as all other payments. Comparisons between ASC and HOPD reimbursements were conducted using bivariate statistics and generalized linear models controlling for patient age, sex, and Elixhauser comorbidity index. RESULTS Among 990,980 cases of outpatient orthopaedic surgery done from 2013 to 2018, the utilization rate of ASCs increased from 31% to 34% across all procedures assessed: compound annual growth rate of 3.3% for lumbar microdiscectomy, 1.8% for knee arthroscopy, 1.4% for anterior cruciate ligament, 1.4% for carpal tunnel release, 1.2% for arthroscopic rotator cuff repair, and 0.5% for bunion repair (P < 0.001 for all). The average total costs were 26% lower at ASCs than HOPDs (P < 0.001 for each procedure). The average technical fees were 33% lower at ASCs than HOPDs (P < 0.001 for each procedure). Both total costs and technical fees were less for ASCs than HOPDs after controlling for patient age, sex, and Elixhauser comorbidity index (P < 0.001 for each procedure). Over the study period, the mean total costs at HOPDs increased by 2.5% yearly, whereas the mean total costs at ASCs decreased by 0.1% yearly. The average surgeon professional fees declined in both care settings over time. CONCLUSION From 2013 to 2018, there was an increase in ASC utilization for common outpatient orthopaedic surgeries. ASCs were overall less costly than HOPDs for outpatient orthopaedic surgeries. LEVEL OF EVIDENCE IV.
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Roecker Z, Kamalapathy P, Werner BC. Male Sex, Cartilage Surgery, Tobacco Use, and Opioid Disorders are Associated with an Increased Risk of Infection After Anterior Cruciate Ligament Reconstruction. Arthroscopy 2022; 38:948-952.e1. [PMID: 34332054 DOI: 10.1016/j.arthro.2021.07.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 06/18/2021] [Accepted: 07/05/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To identify patient-related risk factors for infection following anterior cruciate ligament reconstruction (ACLR). METHODS The Mariner database within PearlDiver was queried for patients from 2010 to 2019 undergoing primary arthroscopic ACLR. Patients undergoing ACLR with concomitant open surgery or additional ligament reconstructions were excluded. Postoperative diagnoses or procedures for superficial or deep infection within 6 months were assessed. A multivariable logistic regression analysis was then used to evaluate patient-related risk factors for postoperative infection. Adjusted odds ratios (OR) and 95% confidence intervals (CIs) were calculated for each risk factor, with P < .05 considered statistically significant. RESULTS In total, 217,541 patients underwent ACLR and 1779 (0.8%) patients had a postoperative infection within 6 months. Significant independent risk factors included male sex (OR 1.58, 95% CI 1.43-1.75, P < .001), obesity (OR 1.22, 95% CI 1.05-1.43, P = .020), morbid obesity (OR 2.54, 95% CI 2.11-3.06, P = .002), tobacco use (OR 1.36, 95% CI 1.19-1.55, P < .001), age younger than 40 years (OR 1.21, 95% CI 1.07-1.37, P = .033), depression (OR 1.18, 95% CI 1.04-1.34, P = .012), opioid disorder (OR 1.50, 95% CI 1.22-1.85, P < .001), concomitant simple cartilage surgery (OR 1.63, 95% CI 1.43-1.86, P < .001), and complex cartilage surgery (OR 1.67, 95% CI 1.20-2.32, P = .002). Partial meniscectomy and meniscal repair at the time of ACLR were not associated with an increased risk of infection. CONCLUSIONS In a large national sample, male sex, obesity, tobacco use, older age, depression, opioid disorders and concomitant cartilage surgery were significant risk factors for infection following ACLR. LEVEL OF EVIDENCE Therapeutic Level IV, retrospective case series.
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Affiliation(s)
- Zoe Roecker
- School of Medicine, University of Virginia Health System, Charlottesville, Virginia, U.S.A
| | - Pramod Kamalapathy
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A
| | - Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A..
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Predictors of patient satisfaction after primary hamstring anterior cruciate ligament reconstruction. Knee 2022; 34:246-251. [PMID: 35065328 DOI: 10.1016/j.knee.2022.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 09/26/2021] [Accepted: 01/06/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Predictors of patient satisfaction (PS) after anterior cruciate ligament (ACL) reconstruction are not well known. This study investigated predictors of PS and whether PS was associated with pre-injury level of sport participation, patient reported knee function and quality of life after ACL reconstruction. METHODS Patients who underwent primary hamstring ACL reconstruction between January 2015 and December 2017 were retrospectively evaluated. An online survey was used to evaluate PS (yes = satisfied, no = unsatisfied), duration of supervised postoperative rehabilitation, timing of return to pre-injury level of sport, pre-injury level of sport participation, patient reported knee function and quality of life. Preoperative, operative and postoperative variables were collected from the medical records. RESULTS A total of 183 patients completed the survey at a median of 3.6 (1.5) years after ACL surgery. At final follow-up, 82% of patients were satisfied with the outcome. Preoperative (e.g. age) and operative (e.g. meniscal tear) variables were not predictors of PS (p > 0.05). Duration of supervised postoperative rehabilitation, timing of return to pre-injury level of sport and postoperative ACL injury were predictors of PS (p = 0.018, p = 0.016 and p < 0.001, respectively). Pre-injury level of sport participation was significantly higher in satisfied compared to unsatisfied patients: 44.7% (n = 67) versus 18.2% (n = 6) (p = 0.005). In addition, satisfied patients reported significantly higher patient reported knee function and quality of life compared to unsatisfied patients (p < 0.001). CONCLUSION This study provided data on predictors of PS after primary ACL reconstruction. Furthermore, PS was associated with pre-injury level of sport participation, patient reported knee function and quality of life.
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Madubueze C, Babalola O, Itakpe S, Oladunjoye T, Akpan J, Koyejo T. Day case anterior cruciate ligament reconstruction surgery – A study of early treatment outcomes in a regional orthopaedic centre. JOURNAL OF WEST AFRICAN COLLEGE OF SURGEONS 2022; 12:23-27. [PMID: 36213802 PMCID: PMC9536409 DOI: 10.4103/jwas.jwas_125_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 06/22/2022] [Indexed: 11/18/2022]
Abstract
Background: Day-case anterior cruciate ligament reconstruction has the potential benefit of reduced hospital stay and reduced cost of care. The goal of this preliminary report was to compare the outcome of day-case arthroscopic anterior cruciate ligament reconstruction with those of in-patient care in terms of pain control and short-term functional outcome. Materials and Methods: This was a prospective comparative study involving patients who had anterior cruciate ligament reconstruction performed in our unit between January 2019 to July 2021 for isolated anterior cruciate ligament rupture. The patients were offered the option of in-patient and day-case anterior cruciate ligament reconstruction. All cases were isolated anterior cruciate ligament ruptures with no other ligament injury. Results: A total of twenty-one-day case and twenty-five in-patient anterior cruciate ligament reconstruction were managed during the period of the study. The median numeric pain scores at day 2 and 7 in the day case group was 8.0 (IQR=2.0) and 5.0 (IQR= 3.0) respectively and in-patient group was 7.0 (IQR =1.5) and 4.0 (IQR= 2.0) respectively. The international knee documentation score (IKDC) at 6 months in the day case and in-patient groups were 68.6 (IQR= 9.3) and 67.2 (IQR= 25.0) respectively. The Mann-Whitney U test indicated that patients who had ACL reconstruction on in-patient care basis had statistically significant lower visual analogue scale pain scores on the second (z=-2.58, P = 0.01) and seventh (z=-3.41 P = 0.001) post-operative days compared to patients who had ACL reconstruction on day case basis. There was no statistically significant difference in the median IKDC scores of both groups at 6 months. The cost of care in the day case group was 40% lower than those of the in-patient group. Conclusion: Although the cost of care in the day case group appeared lower as compared to the in-patient group, the day case group had higher post-operative pain scores compared to the in-patient group. Although the post-operative functional scores were similar in both groups, this was not statistically significant
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Lu Y, Forlenza E, Cohn MR, Lavoie-Gagne O, Wilbur RR, Song BM, Krych AJ, Forsythe B. Machine learning can reliably identify patients at risk of overnight hospital admission following anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2021; 29:2958-2966. [PMID: 33047150 DOI: 10.1007/s00167-020-06321-w] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 10/02/2020] [Indexed: 01/20/2023]
Abstract
PURPOSE Overnight admission following anterior cruciate ligament reconstruction has implications on clinical outcomes as well as cost benefit, yet there are few validated risk calculators for reliable identification of appropriate candidates. The purpose of this study is to develop and validate a machine learning algorithm that can effectively identify patients requiring admission following elective anterior cruciate ligament (ACL) reconstruction. METHODS A retrospective review of a national surgical outcomes database was performed to identify patients who underwent elective ACL reconstruction from 2006 to 2018. Patients admitted overnight postoperatively were identified as those with length of stay of 1 or more days. Models were generated using random forest (RF), extreme gradient boosting (XGBoost), linear discriminant classifier (LDA), and adaptive boosting algorithms (AdaBoost), and an additional model was produced as a weighted ensemble of the four final algorithms. RESULTS Overall, of the 4,709 patients included, 531 patients (11.3%) required at least one overnight stay following ACL reconstruction. The factors determined most important for identification of candidates for inpatient admission were operative time, anesthesia type, age, gender, and BMI. Smoking history, history of COPD, and history of coagulopathy were identified as less important variables. The following factors supported overnight admission: operative time > 200 min, age < 35.8 or > 53.5 years, male gender, BMI < 25 or > 31.2 kg/m2, positive smoking history, history of COPD and the presence of preoperative coagulopathy. The ensemble model achieved the best performance based on discrimination assessed via internal validation (AUC = 0.76), calibration, and decision curve analysis. The model was integrated into a web-based open-access application able to provide both predictions and explanations. CONCLUSION Modifiable risk factors identified by the model such as increased BMI, operative time, anesthesia type, and comorbidities can help clinicians optimize preoperative status to prevent costs associated with unnecessary admissions. If externally validated in independent populations, this algorithm could use these inputs to guide preoperative screening and risk stratification to identify patients requiring overnight admission for observation following ACL reconstruction. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Yining Lu
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN, USA.
| | - Enrico Forlenza
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Matthew R Cohn
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Ophelie Lavoie-Gagne
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Ryan R Wilbur
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Bryant M Song
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Aaron J Krych
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Brian Forsythe
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
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Abstract
BACKGROUND Postoperative pain represents an important issue in traditional hemorrhoidectomy. Optimal pain control is mandatory, especially in a surgical day care setting. OBJECTIVE The aim of this study was to investigate the use of pudendal nerve block in patients undergoing hemorrhoidectomy. DATA SOURCES PubMed, Google Scholar, Cochrane Library, and Web of Science databases were searched up to December 2020. STUDY SELECTION Randomized trials evaluating the pudendal nerve block effect in patients undergoing hemorrhoidectomy were selected. INTERVENTIONS Hemorrhoidectomy under general or spinal anesthesia with or without pudendal nerve block was performed. MAIN OUTCOME MEASURES Opioid consumption, pain on the visual analogue scale, length of hospital stay, and readmission rate were the main outcomes of interest and were plotted by using a random-effects model. RESULTS The literature search revealed 749 articles, of which 14 were deemed eligible. A total of 1214 patients were included, of whom 565 received the pudendal nerve block. After hemorrhoidectomy, patients in the pudendal nerve block group received opioids less frequently (relative risk, 0.364; 95% CI, 0.292-0.454, p < 0.001) and in a lower cumulative dose (standardized mean difference, -0.935; 95% CI, -1.280 to -0.591, p < 0.001). Moreover, these patients experienced less pain at 24 hours (standardized mean difference, -1.862; 95% CI, -2.495 to -1.228, p < 0.001), had a shorter length of hospital stay (standardized mean difference, -0.742; 95% CI, -1.145 to -0.338, p < 0.001), and had a lower readmission rate (relative risk, 0.239; 95% CI, 0.062-0.916, p = 0.037). Sensitivity analysis excluded the occurrence of publication bias on the primary end point, and the overall evidence quality was judged "high." LIMITATIONS Occurrence of publication bias among some secondary end points and heterogeneity are the main limitations of this study. CONCLUSIONS This systematic review and meta-analysis show significant advantages of pudendal nerve block use. A reduction in opioid consumption, postoperative pain, complications, and length of stay can be demonstrated. Despite the limitations, pudendal nerve block in patients undergoing hemorrhoidectomy should be considered.
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Mongelli F, Lucchelli M, La Regina D, Christoforidis D, Saporito A, Vannelli A, Di Giuseppe M. Ultrasound-Guided Pudendal Nerve Block in Patients Undergoing Open Hemorrhoidectomy: A Post-Hoc Cost-Effectiveness Analysis from a Double-Blind Randomized Controlled Trial. CLINICOECONOMICS AND OUTCOMES RESEARCH 2021; 13:299-306. [PMID: 33953578 PMCID: PMC8088981 DOI: 10.2147/ceor.s306138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 04/19/2021] [Indexed: 12/19/2022] Open
Abstract
Background Pudendal nerve block (PNB) has been demonstrated to reduce postoperative pain and re-admission rates after open hemorrhoidectomy and may reduce costs but, to date, no study has reported data on this aspect. The aim of our study was to perform a cost analysis on PNB use in in- and outpatients undergoing open hemorrhoidectomy. Methods From January 2018 to December 2019, patients undergoing open hemorrhoidectomy were included and randomized to undergo spinal anesthesia either with or without the PNB. Clinical data, direct and indirect costs for in- and outpatients, operating time and operating theatre occupancy were recorded. A cost-effectiveness analysis based on the diagnosis-related groups (DRG) and TARMED reimbursement systems was performed. Results Patients who underwent PNB in addition to spinal anesthesia had significantly less pain and a shorter length of hospital stay after open hemorrhoidectomy. The cost analysis included all 49 patients, 23 of whom, in addition to spinal anesthesia, received a PNB. There were no significant differences in operating theatre occupancy (p=0.662), mean operative time (p=0.610) or time required for anesthesia (p=0.124). Direct costs were comparable (482±386 vs 613±543 EUR, p=0.108), while indirect costs were significantly lower in the PNB group (2606±816 vs 2769±1506 EUR, p=0.005). We estimated an incremental cost-effectiveness ratio (ICER) of −243 ± 881 EUR/pain unit on the VAS. Conclusion Despite limitations, the ultrasound-guided PNB seems to reduce costs in patient undergoing open hemorrhoidectomy under spinal anesthesia. It was shown to be clinically beneficial and cost-effective, and therefore recommendable in patients undergoing open hemorrhoidectomy.
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Affiliation(s)
- Francesco Mongelli
- Department of Surgery, Ospedale Regionale di Lugano, Lugano, Switzerland
| | - Massimo Lucchelli
- Financial Department, Ospedale Regionale di Bellinzona e Valli, Bellinzona, Switzerland
| | - Davide La Regina
- Department of Surgery, Ospedale Regionale di Bellinzona e Valli, Bellinzona, Switzerland
| | | | - Andrea Saporito
- Department of Anesthesia, Ospedale Regionale di Bellinzona e Valli, Bellinzona, Switzerland
| | | | - Matteo Di Giuseppe
- Department of Surgery, Ospedale Regionale di Bellinzona e Valli, Bellinzona, Switzerland
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Li LT, Bokshan SL, McGlone PJ, Owens BD. Decline in Racial Disparities for United States Hospital Admissions After Anterior Cruciate Ligament Reconstruction From 2007 to 2015. Orthop J Sports Med 2020; 8:2325967120964473. [PMID: 33283006 PMCID: PMC7682220 DOI: 10.1177/2325967120964473] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 06/08/2020] [Indexed: 11/17/2022] Open
Abstract
Background Racial disparities in perioperative complications have been shown to exist for many procedures in orthopaedic surgery. Although anterior cruciate ligament reconstruction (ACLR) is commonly performed as an outpatient procedure, the rate of admission to the hospital postoperatively is not insignificant. Hispanic patients have been shown to have higher odds of admission compared with non-Hispanic patients. Hypothesis We hypothesized that racial disparities would decrease from 2007 to 2015, resulting in lower rates of hospital admission for Black and Hispanic patients. Study Design Descriptive epidemiology study. Methods This study represents a retrospective analysis of the National Surgical Quality Improvement Program (NSQIP) database for patients undergoing ACLR between 2007 and 2015. We performed bivariate analysis as well as binary logistic regression, with postoperative admission as the primary outcome. Previously identified risk factors for admission were used as predictors in addition to a term for the statistical interaction between year of surgery and ethnicity. Results A total of 7542 patients undergoing ACLR were assessed. The logistic regression model showed that Hispanic patients had higher overall odds of admission (odds ratio [OR], 3.320; P < .001) than White patients; Black patients also had higher odds compared with White patients (OR, 1.929; P = .009). However, there was a significant interaction between year of surgery and both Black ethnicity (OR, 0.907; P = .026) and Hispanic ethnicity (OR, 0.835; P = .002), indicating a significant decrease in the admission rates for these minority patients compared with White patients over time. Other risk factors for admission were the use of regional anesthesia (OR, 3.482; P < .001), bleeding disorders (OR, 5.064; P = .002), a higher body mass index (OR, 1.029; P < .001), and longer operative times (OR, 1.012; P < .001). More recent surgery was associated with lower odds of admission (OR, 0.826; P < .001). Conclusion Admission rates after ACLR declined from 2007 to 2015. Black and Hispanic patients were more likely to be admitted overall, but they also saw a greater decrease in the odds of admission than White patients. This represents a reduction in disparity between the 2 groups and is a reassuring improvement in racial disparity trends after a common sports procedure.
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Affiliation(s)
- Lambert T Li
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Steven L Bokshan
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Patrick J McGlone
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Brett D Owens
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
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Shao L, Wu D, Li JY, Wu XD, Zhou X, Qiu GX, Luo C, Xiao PC, Liu JC, Huang W. Hospital readmission after anterior cruciate ligament reconstruction: protocol for a systematic review and meta-analysis. BMJ Open 2020; 10:e037888. [PMID: 33067283 PMCID: PMC7569989 DOI: 10.1136/bmjopen-2020-037888] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Anterior cruciate ligament (ACL) injury is one of the most common injuries of the knee. ACL reconstruction (ACLR) has been widely performed as a safe and effective treatment for ACL injuries. As there is an increasing trend in the incidence of ACL injury, hospital readmission after ACLR has attracted renewed attention for the financial burden to both patients and the healthcare system. However, information about hospital readmission after ACLR remains fragmented. Therefore, we plan to systematically review the literature to investigate the rate of, causes and risk factors for hospital readmission after ACLR, and summarise interventions to reduce hospital readmission. This article is to provide the protocol for an upcoming systematic review and meta-analysis on this important issue. METHODS AND ANALYSIS Reporting of this protocol follows the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) checklist. Electronic databases, including PubMed, Embase and the Cochrane Library, will be systematically searched from inception to June 2020. No language restrictions will be applied. Studies will be included if they reported hospital readmission or explored the associated potential causes and risk factors for hospital readmission after ACLR. The primary outcome will be the number and time frame of hospital readmission after ACLR. Secondary outcomes will be reasons for readmission, number and types of complications, risk factors for readmission and preventive measures for readmission after ACLR. Quality assessments will be performed by using the Newcastle-Ottawa Scale (NOS). If possible, study results will be summarised in a forest plot, and heterogeneity will be tested by using the Cochran's Q and I2 statistics. ETHICS AND DISSEMINATION No ethical approval is required because our study is not related to patients or animals. The results will be published in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42020058624.
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Affiliation(s)
- Long Shao
- Department of Orthopaedic Surgery, Ningbo No.6 Hospital, Ningbo, Zhejiang, China
| | - Di Wu
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Jia-Ying Li
- Departments of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Xiang-Dong Wu
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xi Zhou
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Gui-Xing Qiu
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Changqi Luo
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Peng-Cheng Xiao
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jia-Cheng Liu
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wei Huang
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Lu Y, Lavoie-Gagne O, Khazi Z, Patel BH, Mascarenhas R, Forsythe B. Inpatient admission following anterior cruciate ligament reconstruction is associated with higher postoperative complications. Knee Surg Sports Traumatol Arthrosc 2020; 28:2486-2493. [PMID: 32719934 DOI: 10.1007/s00167-020-06094-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Accepted: 06/10/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE To compare the occurrence of short-term postoperative complications between inpatient and outpatient anterior cruciate ligament reconstruction. METHODS The ACS National Surgical Quality Improvement Program (NSQIP) database was utilized to identify patients undergoing arthroscopic anterior cruciate ligament reconstruction (ACLR) from 2007 to 2017. A total of 18,052 patients were available for analysis following application of exclusion criteria. Patients were categorized based on location of surgery. Inpatients and outpatient ACLR groups were matched by demographics and preoperative laboratory values and differences in 30-day complication rates following surgery were assessed. Significance was set with alpha < 0.05. RESULTS From 2007 to 2017, there was an increasing frequency for outpatient ACLR (p < 0.001), while the incidence of inpatient ACLR remained largely constant (n.s). Groups were matched to include 1818 patients in each cohort. Within the first 30 days of surgery, patients in the inpatient ACLR group experienced significantly greater rates of superficial incisional SSI (0.6% vs 0.1%, p = 0.026) and composite surgical complications (0.6% vs 0.2%, p = 0.019), as well as a greater rate of reoperation (0.7% vs 0.2%, p = 0.029). Inpatient procedures also demonstrated a greater rate of deep surgical incisional SSI (0.2% vs 0.0%, n.s) and readmission to hospital (0.8% vs 0.7%, n.s).Outpatient ACLR procedures were also associated with a significantly greater relative value unit (RVU)/h compared with inpatient ACLRs (0.17 vs 0.14, p < 0.001). CONCLUSIONS Inpatient ACLR may have an increased risk of postoperative complications compared to outpatient ACLR during the short-term postoperative period. Although some patients may require admission post-operatively for medical and/or pain management, doing so is not necessarily without a degree of risk. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Yining Lu
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Ophelie Lavoie-Gagne
- Division of Sports Medicine, Midwest Orthopaedics At Rush, RushUniversityMedicalCenter, 1611 W Harrison St, Chicago, IL, 60612, USA
| | - Zain Khazi
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Bhavik H Patel
- Division of Sports Medicine, Midwest Orthopaedics At Rush, RushUniversityMedicalCenter, 1611 W Harrison St, Chicago, IL, 60612, USA
| | - Randhir Mascarenhas
- McGovern Medical School, University of Texas Health Science Center, Houston, TX, USA
| | - Brian Forsythe
- Division of Sports Medicine, Midwest Orthopaedics At Rush, RushUniversityMedicalCenter, 1611 W Harrison St, Chicago, IL, 60612, USA.
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DeFrancesco CJ, Storey EP, Flynn JM, Ganley TJ. Pediatric ACL Reconstruction and Return to the Operating Room: Revision Is Less Than Half of the Story. J Pediatr Orthop 2020; 39:516-520. [PMID: 31599862 DOI: 10.1097/bpo.0000000000001055] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Although there are several causes of unplanned return to the operating room (RTOR) following pediatric anterior cruciate ligament (ACL) reconstruction (ACLR), prior outcomes studies focus primarily on the risk of graft failure. We sought to comprehensively describe indications for RTOR in pediatric primary ACLR patients, estimate associated rates of RTOR, and assess the impact of concomitant meniscal procedures on these rates. METHODS This retrospective cohort study considered patients who underwent primary ACLR at an urban, pediatric tertiary care hospital between 2013 and 2015. Cohorts were defined based on the presence or absence of a concomitant surgical meniscal procedure with the index ACLR. The primary outcome was RTOR for an indication pertaining to ACLR or a potential predilection for knee injury. Cases of RTOR were cataloged and classified according to indication. Survival analyses were performed using the Kaplan-Meier estimation and competing-risks regression. Comparisons of any-cause RTOR rates were done using log-rank tests. RESULTS After exclusion criteria were applied, 419 subjects were analyzed. RTOR indications were organized into 5 categories. The overall rate for any RTOR by 3 years after surgery was 16.5%. Graft failure and contralateral ACL tear were the most common indications for RTOR, with predicted rates of 10.3% and 7.1%, respectively. ACL graft failure accounted for less than half of RTOR cases cataloged. Patients who had a concomitant meniscus procedure had lower rates of RTOR. CONCLUSIONS Approximately 1 in 6 pediatric ACLR patients underwent ≥1 repeat surgery within 3 postoperative years for indications ranging from wound breakdown to contralateral ACL rupture. While previous studies revealed high rates of complication after pediatric ACLR due primarily to graft failure, we found that re-tear is responsible for less than half of the 3-year RTOR risk. As almost half of re-tears in our sample occurred before clearance to return to full activities, we suspect that the high rate of complication is largely attributable to pediatric patients' high activity levels and difficulties adhering to postoperative restrictions. Early treatment of meniscus pathology may reduce rates of RTOR. LEVEL OF EVIDENCE Level III-therapeutic.
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Affiliation(s)
- Christopher J DeFrancesco
- Division of Orthopaedics, The Children's Hospital of Philadelphia
- The Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Eileen P Storey
- Division of Orthopaedics, The Children's Hospital of Philadelphia
| | - John M Flynn
- Division of Orthopaedics, The Children's Hospital of Philadelphia
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Agarwalla A, Gowd AK, Liu JN, Garcia GH, Bohl DD, Verma NN, Forsythe B. Effect of Operative Time on Short-Term Adverse Events After Isolated Anterior Cruciate Ligament Reconstruction. Orthop J Sports Med 2019; 7:2325967118825453. [PMID: 31001565 PMCID: PMC6454657 DOI: 10.1177/2325967118825453] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Background: A longer operative time has been previously recognized as a risk factor for
short-term complications after various orthopaedic procedures; however, it
has yet to be investigated as an independent risk factor for postoperative
complications after anterior cruciate ligament (ACL) reconstruction. Purpose: To identify whether a longer operative time in ACL reconstruction is an
independent risk factor for the development of postoperative complications,
hospital readmissions, or an extended length of stay within 30 days of the
index procedure. Study Design: Descriptive epidemiology study. Methods: Patients undergoing ACL reconstruction between 2005 and 2016 were identified
using the American College of Surgeons National Surgical Quality Improvement
Program (ACS-NSQIP) database. Cases with concomitant procedures were
excluded from the analysis. We evaluated the association between operative
time and preoperative variables such as patient age, sex, body mass index,
comorbidities, and procedure. Correlations between adverse events and
operative time, while controlling for the above preoperative variables, were
calculated using multivariate Poisson regression with robust error
variance. Results: A total of 14,159 procedures were included in this investigation. The mean
patient age was 32.6 ± 10.8 years, the mean body mass index was 27.7 ± 6.5
kg/m2, and the mean operative time was 89.7 ± 28.6 minutes.
Patients who were between the ages of 18 and 30 years (mean operative time,
95.1 ± 27.8 minutes; relative risk [RR], 17.7; P <
.001), male (mean operative time, 91.9 ± 28.3 minutes; RR, 4.7;
P < .001), and nondiabetic (mean operative time,
89.8 ± 28.6 minutes; RR, 7.1; P = .011) were associated
with a longer operative duration. The overall complication rate was 1.1%.
After adjusting for demographic characteristics and procedures, 15-minute
incremental increases in operative duration were associated with an
increased risk of deep vein thrombosis (RR, 1.12; P =
.042), surgical site infections (RR, 1.21; P = .001), and
sepsis (RR, 1.66; P < .001) as well as increased
readmission rates (RR, 1.23; P = .001) and an extended
length of stay (RR, 1.18; P = .008). Conclusion: While the overall adverse risk rate after ACL reconstruction remains low,
marginal increases in operative time are associated with an increased risk
of adverse events such as deep vein thrombosis, surgical site infections,
sepsis, an extended length of stay, and readmissions. Thus, the operating
physician and surgical staff should make all efforts to coordinate and
prepare for each case to maximize surgical efficiency.
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Affiliation(s)
- Avinesh Agarwalla
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA
| | - Anirudh K Gowd
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA
| | - Joseph N Liu
- Department of Orthopaedic Surgery, Loma Linda University Medical Center, Loma Linda, California, USA
| | | | - Daniel D Bohl
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA
| | - Nikhil N Verma
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA
| | - Brian Forsythe
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA
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Dedicated peri-operative pathway improved day case discharge rate for anterior cruciate ligament reconstructions. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2018; 29:639-644. [PMID: 30390166 DOI: 10.1007/s00590-018-2326-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2018] [Accepted: 10/12/2018] [Indexed: 10/27/2022]
Abstract
The authors proposed that a well-developed peri-operative pathway for anterior cruciate ligament (ACL) reconstructions improve day case discharge rate with high patient satisfaction. A prospective observational study was undertaken at a district general hospital in UK between August 2017 and April 2018. A dedicated multidisciplinary peri-operative pathway was developed and introduced in January 2018. All primary ACL reconstructions using hamstring grafts in adult patients were included. Primary outcome measure was day case discharge and secondary outcome measures were visual analogue score for pain (VASP), nausea and vomiting scale (NVS), patient satisfaction and 30-day readmission. Patients who underwent surgery before and after introduction of the pathway were in group 1 and group 2, respectively. There were 19 and 22 patients each in group 1 and 2. Age and gender were similar in both groups. Day case discharge rate was significantly better in group 2 (68.4% vs 95.5%, p = 0.02). There were no significant differences in VASP or NVS on day 0, 1 or 3. Patient satisfaction rates were better in group 2 (85.7% vs 100%, p = 0.13). There were no readmissions in both groups. The VASP on day 1 and day 3 post-operatively was significantly better in those who were discharged on the same day (66.8 vs 41.3, p = 0.02; 60.5 vs 34.9, p = 0.03). A well-developed dedicated peri-operative pathway improved day case discharge rate for ACL reconstructions. The pathway was safe and had a higher patient satisfaction rate.
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Karns MR, Jones DL, Todd DC, Maak TG, Aoki SK, Burks RT, Yoo M, Nelson RE, Greis PE. Patient- and Procedure-Specific Variables Driving Total Direct Costs of Outpatient Anterior Cruciate Ligament Reconstruction. Orthop J Sports Med 2018; 6:2325967118788543. [PMID: 30094271 PMCID: PMC6080082 DOI: 10.1177/2325967118788543] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: Few studies have investigated the influence of patient-specific variables or
procedure-specific factors on the overall cost of anterior cruciate ligament
reconstruction (ACLR) in an ambulatory surgery setting. Purpose: To determine patient- and procedure-specific factors influencing the overall
direct cost of outpatient arthroscopic ACLR utilizing a unique value-driven
outcomes (VDO) tool. Study Design: Cohort study (economic and decision analysis); Level of evidence, 3. Methods: All ACLRs performed by 4 surgeons over 2 years were retrospectively reviewed.
Cost data were derived from the VDO tool. Patient-specific variables
included age, body mass index, comorbidities, American Society of
Anesthesiologists (ASA) classification, smoking status, preoperative
Patient-Reported Outcomes Measurement Information System (PROMIS) Physical
Function Computerized Adaptive Testing (PF-CAT) score, and preoperative
Single Assessment Numeric Evaluation (SANE) score. Procedure-specific
variables included graft type, revision status, associated injuries and
procedures, time from injury to ACLR, surgeon, and operating room (OR) time.
Multivariate analysis determined patient- and procedure-related predictors
of total direct costs. Results: There were 293 autograft reconstructions, 110 allograft reconstructions, and
31 hybrid reconstructions analyzed. Patient-specific factors did not
significantly influence the ACLR cost. The mean OR time was shorter for
allograft reconstruction (P < .001). Predictors of an
increased direct cost included the use of an allograft or hybrid graft
(44.5% and 33.1% increase, respectively; P < .001),
increased OR time (0.3% increase per minute; P < .001),
surgeon 3 or 4 (9.1% or 5.9% increase, respectively; P <
.001 or P = .001, respectively), and concomitant meniscus
repair (24.4% increase; P < .001). Within the meniscus
repair cohort, all-inside, root, and combined repairs correlated with a
15.5%, 31.4%, and 53.2% increased mean direct cost, respectively, compared
with inside-out repairs (P < .001). Conclusion: This study failed to identify modifiable patient-specific factors influencing
direct costs of ACLR. Allografts and hybrid grafts were associated with an
increased total direct cost. Meniscus repair independently predicted an
increased direct cost, with all-inside, root, and combined repairs being
costlier than inside-out repairs. The time-saving potential of all-inside
meniscus repair was not realized in this study, making implant use a
significant factor in the overall cost of ACLR with meniscus repair.
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Affiliation(s)
- Michael R Karns
- Department of Orthopaedics, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Daniel L Jones
- Department of Orthopaedics, University of Utah Orthopaedic Center, University of Utah, Salt Lake City, Utah, USA
| | - Dane C Todd
- Department of Orthopaedics, University of Utah Orthopaedic Center, University of Utah, Salt Lake City, Utah, USA
| | - Travis G Maak
- Department of Orthopaedics, University of Utah Orthopaedic Center, University of Utah, Salt Lake City, Utah, USA
| | - Stephen K Aoki
- Department of Orthopaedics, University of Utah Orthopaedic Center, University of Utah, Salt Lake City, Utah, USA
| | - Robert T Burks
- Department of Orthopaedics, University of Utah Orthopaedic Center, University of Utah, Salt Lake City, Utah, USA
| | - Minkyoung Yoo
- Health Economics Core, Department of Population Health Sciences, University of Utah, Salt Lake City, Utah, USA
| | - Richard E Nelson
- Department of Orthopaedics, University of Utah Orthopaedic Center, University of Utah, Salt Lake City, Utah, USA.,Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah, USA
| | - Patrick E Greis
- Department of Orthopaedics, University of Utah Orthopaedic Center, University of Utah, Salt Lake City, Utah, USA
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25
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Cost Determinants in the 90-Day Management of Isolated Ankle Fractures at a Large Urban Academic Hospital. J Orthop Trauma 2018; 32:338-343. [PMID: 29738399 DOI: 10.1097/bot.0000000000001186] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine the independent risk factors associated with increasing costs and unplanned hospital readmissions in the 90-day episode of care (EOC) for isolated operative ankle fractures at our institution. DESIGN Retrospective cohort study. SETTING Level I Trauma Center. PATIENTS Two hundred ninety-nine patients undergoing open reduction internal fixation for the treatment of an acute, isolated ankle fracture between 2010 and 2015. INTERVENTION None. MAIN OUTCOME MEASURES Independent risk factors for increasing 90-day EOC costs and unplanned hospital readmission rates. RESULTS Orthopaedic (64.9%) and podiatry (35.1%) patients were included. The mean index admission cost was $14,048.65 ± $5,797.48. Outpatient cases were significantly cheaper compared to inpatient cases ($10,164.22 ± $3,899.61 vs. $15,942.55 ± $5,630.85, respectively, P < 0.001). Unplanned readmission rates were 5.4% (16/299) and 6.7% (20/299) at 30 and 90 days, respectively, and were often (13/20, 65.0%) due to surgical site infections. Independent risk factors for unplanned hospital readmissions included treatment by the podiatry service (P = 0.024) and an American Society of Anesthesiologists score of ≥3 (P = 0.017). Risk factors for increasing total postdischarge costs included treatment by the podiatry service (P = 0.011) and male gender (P = 0.046). CONCLUSIONS Isolated operative ankle fractures are a prime target for EOC cost containment strategy protocols. Our institutional cost analysis study suggests that independent financial clinical risk factors in this treatment cohort includes podiatry as the treating surgical service and patients with an American Society of Anesthesiologists score ≥3, with the former also independently increasing total postdischarge costs in the 90-day EOC. Outpatient procedures were associated with about a one-third reduction in total costs compared to the inpatient subgroup.
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26
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Surgical Treatment of Supracondylar Humeral Fractures in a Freestanding Ambulatory Surgery Center is as Safe as and Faster and More Cost-Effective Than in a Children's Hospital. J Pediatr Orthop 2018; 38:e343-e348. [PMID: 29664879 DOI: 10.1097/bpo.0000000000001171] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Despite an 88% increase in the number of pediatric fractures treated in ambulatory surgery centers (ASCs) over a 10-year period, few studies have compared outcomes of fracture treatment performed in a freestanding ASC compared with those performed in the hospital (HOSP) or hospital outpatient department (HOPD). The purpose of this study was to compare clinical and radiographic outcomes, treatment times, and costs for treatment of Gartland type II supracondylar humeral (SCH) fracture in the ASC, HOSP, and HOPD. METHODS Retrospective review identified pediatric patients with isolated Gartland type II SCH fractures who had closed reduction and percutaneous pinning (CRPP) by board-certified orthopaedic surgeons from January 2012 to September 2016. On the basis of the location of their treatment, patients were divided into 3 groups: HOSP, HOPD, and ASC. All fractures were treated with CRPP under fluoroscopic guidance using 2 parallel or divergent smooth Kirschner wires. Radiographs obtained before and after CRPP and at final follow-up noted the anterior humeral line index (HLI) and Baumann angle. Statistical analysis compared all 3 groups for outcomes, complications, treatment time/efficiency, and charges. RESULTS Record review identified 231 treated in HOSP, 35 in HOPD, and 50 in ASC. Radiographic outcomes in terms of Baumann angle and HLI did not differ significantly between the groups at any time point except preoperatively when the HLI for the HOSP patients was lower (P=0.02), indicating slightly greater displacement than the other groups. Overall complication rates were not significantly different among the groups, nor were occurrences of individual complications. The mean surgical time was significantly shorter (P<0.0001) in ASC patients than in HOPD and HOSP patients, and total charges were significantly lower (P<0.001). CONCLUSIONS Gartland type II SCH fractures can be safely treated in a freestanding ASC with excellent clinical and radiographic outcomes equal to those obtained in the HOSP and HOPD; treatment in the ASC also is more efficient and cost-effective. LEVEL OF EVIDENCE Level III-retrospective comparative study.
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