A cost analysis of treatment of tibial fracture nonunion by bone grafting or bone morphogenetic protein-7

The parameter of health economics in the use of any contemporary medical module plays a dominant role in decision making. A prospective nonrandomised comparative study of the direct medical costs on the first attempt of treating aseptic nonunions of tibial fractures, with either autologous-iliac-crest-bone-graft (ICBG) or bone morphogenetic protein-7 (BMP-7), is presented. Twenty-seven consecutive patients, who were successfully treated for fracture nonunions, were divided into two groups. Group 1 (n = 12) received ICBG and group 2 (n = 15) received BMP-7. All patients healed their nonunions, and the financial analysis presented represents a best-case scenario. Three out of 12 of the ICBG group required revision surgery while just one out of 15 required it in the BMP-7 group. Average hospital stay was 10.66 vs. 8.66 days, time-to-union 6.9 vs. 5.5 months, hospitals costs pound2,133.6 vs. pound1,733.33, and theatre costs were pound2,413.3 vs. pound906.67 for the ICBG and BMP-7 groups, respectively. The BMP-7 cost was pound3002.2. Fixation-implant was pound696.4 vs. pound592.3, radiology pound570 vs. pound270, outpatient pound495.8 vs. pound223.33, and other costs were pound451.6 vs. pound566.27 for the ICBG and BMP-7 groups, respectively. The average cost of treatment with BMP-7 was 6.78% higher (P = 0.1) than with ICBG, and most of this (41.1%) was related to the actual price of the BMP-7. In addition to the satisfactory efficacy and safety of BMP-7 in comparison to the gold standard of ICBG, as documented in multiple studies, its cost effectiveness is advocated favourably in this analysis.

Revision total hip arthroplasty: hospital cost and reimbursement analysis

Revision total hip arthroplasty is a complex surgical procedure that frequently requires high levels of hospital resources. The purpose of the current study was to report the actual costs and reimbursement to the hospital for a stratified group of patients having revision total hip arthroplasty based on a severity index. The clinical and financial records of 49 patients (51 hips) stratified by complexity of revision were reviewed. Clinical variable included age, length of stay, operating time, estimated blood loss, number of transfusions, implant type, metallic augmentation, use of bone graft, and time spent in the postanesthesia care unit. Financial review included the actual fixed and variable costs associated with each procedure. Hospital costs associated with revision total hip arthroplasty were significantly greater in the most complex revisions and in older patients. The use of bone grafting techniques on the femur resulted in significantly greater costs. The average loss to the hospital was $5402 US dollars per procedure with a range of $5657 (US dollars) profit to $28,780 (US dollars) loss. Procedures in patients younger than 65 years has an average loss of $1133 US dollars. All procedures in patients who were 65 years or older resulted in a loss to the hospital, with the average loss being $8617 US dollars. Despite improvements in length of stay, use of clinical pathways, and negotiated discounts on implants, the hospital loss on each hip revision procedure averaged $5402 US dollars.

The perioperative cost of Infuse bone graft in posterolateral lumbar spine fusion

BACKGROUND CONTEXT

There is mounting evidence supporting the efficacy of bone morphogenetic protein (BMP) for both anterior interbody and posterolateral lumbar fusion. However, the relative cost of BMP remains an important concern for physicians, hospitals, and payers.

PURPOSE

The purpose of this study is to report on the perioperative costs for patients treated with rhBMP-2 as compared with an iliac crest bone graft (ICBG) supplemented with graft extenders.

STUDY DESIGN/SETTING

A prospective randomized controlled trial of rhBMP-2/ACS (Infuse Bone Graft; Medtronic Sofamor Danek, Memphis, TN) versus ICBG+/-graft extender for lumbar spine fusion in patients over 60 years old.

PATIENT SAMPLE

One hundred two patients over 60 years old who required a posterolateral lumbar spine fusion randomized between receiving rhBMP-2/ACS or ICBG.

OUTCOME MEASURES

All health-care costs over the first 3 months after surgery.

METHODS

As part of a prospective randomized trial of rhBMP-2/ACS versus ICBG+/-graft extender for lumbar spine fusion, all costs over the first 3 months after surgery were directly recorded by a dedicated coder funded by Norton Healthcare, Louisville, KY. A dedicated research nurse also followed all patients throughout their hospital stay and posthospitalization recovery to identify any adverse events or additional outpatient medical care.

RESULTS

Fifty patients received rhBMP-2/ACS and 52 underwent ICBG harvest. The mean hospital cost for the index admission was $24,736 for the rhBMP-2/ACS group and $21,138 for the ICBG group. Mean inpatient physician costs were $5,082 in the rhBMP-2/ACS group and $5,316 in the ICBG group. Costs associated with posthospital rehabilitation averaged $4,906 in the rhBMP-2/ACS group versus $6,820 in the ICBG group. Total payer expenditure for the 3-month perioperative period averaged $33,860 in the rhBMP-2/ACS group and $37,227 in the ICBG group.

CONCLUSIONS

The hospital carries the cost burden associated with the utilization of rhBMP-2/ACS. In contrast, the payer in a Diagnosis-Related Group (DRG) model achieves a net savings, based primarily on the decreased payment for inpatient rehabilitation, but also on decreased hospital reimbursement, physician costs, and other outpatient services.

Sinus augmentation for dental implants: the use of alloplastic materials

The ability to augment the sinus floor has dramatically expanded the scope of implant dentistry. Clinical and scientific studies abound as to the efficacy of this procedure. The debate still ensues as to the best material to use for this augmentation, with autogenous bone, freeze-dried bone, xenografts, and alloplasts all being advocated. This article will substantiate through scientific and clinical studies, how the use of allplastic materials in sinus augmentation techniques can greatly reduce the morbidity and the expense of the procedure while predictably producing bone that has been shown to support dental implants in function for extended periods of time.

Health economics: a cost analysis of treatment of persistent fracture non-unions using bone morphogenetic protein-7

OBJECTIVE

To compare the cost implications of treatment of persistent fracture non-unions before and after application of recombinant human bone morphogenetic protein-7 (BMP-7).

METHOD

Of 25 fracture non-unions, 9 were treated using BMP-7 alone and 16 using BMP-7 and bone grafting. These patients were prospectively followed up, and the costs incurred were analysed.

RESULTS

The mean number of procedures per fracture performed before application of BMP-7 was 4.16, versus 1.2 thereafter. Mean hospital stay and cost of treatment per fracture before receiving BMP-7 were 26.84 days and pound 13,844.68, versus 7.8 days and pound 7338.4 thereafter. The overall cost of treatment of persistent fracture non-unions with BMP-7 was 47.0% less than that of the numerous previous unsuccessful treatments (p=0.001).

CONCLUSIONS

Treating fracture non-unions is costly, but this could be reduced by early BMP-7 administration when a complex or persistent fracture non-union is present or anticipated.

Economic evaluation of bone morphogenetic protein versus autogenous iliac crest bone graft in single-level anterior lumbar fusion: an evidence-based modeling approach

STUDY DESIGN

Economic evaluation provides a framework to explicitly measure and compare the value of alternative medical interventions in terms of their clinical, health-related quality-of-life, and economic outcomes. Computerized economic models can help inform the design of future prospective studies by identifying the cost-drivers, the most uncertain parameter estimates, and the parameters with the greatest impact on the results and inferences.

OBJECTIVE

An economic analysis of bone morphogenetic protein versus autogenous iliac crest bone graft for single-level anterior lumbar fusion poses several methodologic challenges. This article describes how such an economic evaluation may be framed and designed, while enumerating challenges, offering some solutions, and suggesting an agenda for future research.

SUMMARY OF BACKGROUND DATA

An evidence-based modeling approach can incorporate epidemiologic, clinical, and economic data from several sources including randomized clinical trials, peer-reviewed literature, and expert opinion. Sensitivity analyses can be conducted by varying key parameter estimates within a reasonable range to assess the impact on the results and inferences.

RESULTS

Preliminary results suggest that from a payer perspective, the upfront price of bone morphogenetic protein is likely to be entirely offset by reductions in the use of other medical resources. That is, bone morphogenetic protein appears to be cost neutral. The cost offsets were attributable largely to prevention of pain and complications associated with autogenous iliac crest bone graft, as well as reduction of the costs associated with fusion failures.

CONCLUSIONS

Future research should focus on quantifying the health-related quality-of-life impact of bone morphogenetic protein relative to autogenous iliac crest bone graft, as well as the impact on lost productivity.

Single-level cervical radiculopathy: clinical outcome and cost-effectiveness of four techniques of anterior cervical discectomy and fusion and disc arthroplasty

Although there are several accepted methods of surgical treatment for single-level cervical radiculopathy, the choice depend on the surgeon's preference. The techniques may vary in peri-operative morbidity, short- and long-term outcome, but no study so far has analyzed their cost-effectiveness. This study might give some insight in balancing cost and effectiveness and deciding the right technique. Sixty consecutive patients (15 each group), mean age 36 (range 24-76 years) with single-level cervical disc disease underwent surgical treatment with four different techniques in two centers over the period of 1999-2005. The four groups were--(1) plate and tricortical autograft, (2) plate, cage, and bone substitute, (3) cage only, and (4) disc arthroplasty. The data was collected prospectively according to our protocol and subsequently analyzed. The clinical outcome was assessed comparing visual analog scale (VAS) of neck pain and, short form 12 (SF12) questionnaire both pre- and postoperatively. The radiological assessment was done for fusion rate and postoperative related possible complications at 3 months, 6 months, 1 year, and final follow-up. The cost analysis was done calculating the operative time, hospital stay, implant cost together. The mean follow-up period was 31 months (range 28-43 months). The clinical outcome in terms of VAS of neck and arm pain and SF12 physical and mental score improvement (P=0.001) were comparable with all four techniques. The radiological fusion rate was comparable to current available data. As the hospital stay was longer (average 5 days) with plate and autograft group, the total cost was maximum (average 2,920 pound sterling) with this group. There was satisfactory clinical and radiological outcome with all four techniques. Using the cage alone was the most cost-effective technique, but the disc arthroplasty was comparable to the use of cage and plate. Anterior cervical discectomy and fusion is an established surgical treatment for cervical radiculopathy. Single-level cervical radiculopathy was treated with four different techniques. The clinical outcome and cost-effectiveness were compared in this study.

A cost analysis of bone morphogenetic protein versus autogenous iliac crest bone graft in single-level anterior lumbar fusion

An economic model was developed to compare costs of stand-alone anterior lumbar interbody fusion with recombinant human bone morphogenetic protein 2 on an absorbable collagen sponge versus autogenous iliac crest bone graft in a tapered cylindrical cage or a threaded cortical bone dowel. The economic model was developed from clinical trial data, peer-reviewed literature, and clinical expert opinion. The upfront price of bone morphogenetic protein (3380 dollars) is likely to be offset to a significant extent by reductions in the use of other medical resources, particularly if costs incurred during the 2 year period following the index hospitalization are taken into account.

Open Latarjet versus arthroscopic Latarjet: clinical results and cost analysis

PURPOSE

The aim of this study was to compare the clinical results between open and arthroscopic Latarjet and perform a cost analysis of the two techniques.

MATERIALS AND METHODS

A systematic review of articles present in PubMed and MEDLINE was performed in accordance with PRISMA guidelines. Studies concerning post-operative outcomes following Latarjet procedures for chronic anterior shoulder instability were selected for analysis. The clinical and radiographic results as well as the costs of the open and arthroscopic techniques were evaluated.

RESULTS

Twenty-three articles, describing a total of 1317 shoulders, met the inclusion criteria: 17 studies were related to open Latarjet, and 6 to the arthroscopic technique. Despite the heterogeneity of the evaluation scales, the clinical results seemed very satisfactory for both techniques. We detected a statistically significant difference in the percentage of bone graft healing in favour of the open technique (88.6 vs 77.6 %). Recurrent dislocation was more frequent following open surgery (3.3 % after open surgery vs 0.3 % after arthroscopy), but this finding was biased by the large difference in follow-up duration between the two techniques. The direct costs of the arthroscopic procedure were double in comparison to open surgery (€2335 vs €1040). A lack of data prevented evaluation of indirect costs and, therefore, a cost-effectiveness analysis.

CONCLUSIONS

The open and arthroscopic Latarjet techniques showed excellent and comparable clinical results. However, the much higher direct costs of the arthroscopic procedure do not seem, at present, to be justified by a benefit to the patient.

LEVEL OF EVIDENCE

III.

Nasoalveolar molding and gingivoperiosteoplasty versus alveolar bone graft: an outcome analysis of costs in the treatment of unilateral cleft alveolus

OBJECTIVE

The purpose of this study was to compare the financial impact of two treatment approaches to the unilateral cleft alveolus. The recently advocated nasoalveolar molding (NAM; and gingivoperiosteoplasty (GPP; at the time of lip repair were compared with the traditional approach of secondary alveolar bone graft.

DESIGN

The records of all patients (n = 30) with unilateral cleft lip and alveolus treated by a single surgeon during 1985 through 1988 were examined retrospectively. The patients were divided into two groups: group 1 patients (n = 14) were treated by lip repair, primary nasal repair, and secondary alveolar bone graft prior to eruption of permanent dentition; group 2 patients (n = 16) were treated by NAM, GPP, lip repair, and primary nasal repair. Patients who required secondary alveolar bone graft after GPP were noted. The cost of treatment by each protocol was calculated in 1998 dollars.

RESULTS

The average cost of treatment for a patient treated by lip repair, primary nasal repair, and secondary alveolar bone graft prior to eruption of permanent dentition was $22,744. Of the 16 patients treated by NAM, GPP, lip repair, and primary nasal repair, 10 required no further treatment of the unilateral cleft alveolus; six patients required secondary alveolar bone graft. The average per-patient treatment cost in this group was $19,745. The average cost savings of NAM and GPP, compared with alveolar bone graft is $2999.

CONCLUSIONS

The treatment of unilateral cleft alveolus by nasoalveolar molding and gingivoperiosteoplasty results in substantial cost savings, compared with treatment by secondary alveolar bone graft.

A cost analysis of two anterior cervical fusion procedures

Multilevel anterior cervical discectomy and fusion (ACDF) remains a difficult problem. A recently described surgical technique for multilevel ACDF has eliminated the morbid complications associated with harvesting iliac crest bone graft (ICBG) while maintaining the advantages of using autologous bone graft. A matched-pairs t test was used to compare the estimated costs of 27 ACDFs using titanium surgical mesh, local autologous bone graft, and anterior plate instrumentation with 27 ACDFs using ICBG and plate fixation. The three variables considered were cage cost, operating time (cost), and hospitalization cost. The estimated costs for the two surgical procedures were not significantly different. Thus, the time saved by not harvesting an ICBG was comparable to the cost of the cage. Harvesting ICBG also increased the morbidity rate by 22%.

Behavior of implants in bone grafts or free flaps after tumor resection

The authors compared bone resorption of autogenous bone grafts and revascularized free flaps used for the reconstruction of mandibular continuity defects following resection for tumors, before and after the placement of endosseous implants. Ten patients (group 1) were treated with autogenous bone grafts taken from the fibula or the anterior iliac crest; 8 patients (group 2) were treated with iliac or fibula revascularized flaps. Four to 8 months later, 72 endosseous implants were placed in the reconstructed areas. After a further healing period of 4-6 months, patients were rehabilitated with implant-borne prostheses. The following parameters were evaluated and compared between the two groups: 1) bone resorption of grafts and free flaps before and after implant placement; 2) peri-implant bone resorption mesial and distal to each implant, immediately after prosthetic rehabilitation and then during yearly follow-ups. Bone resorption before implant placement showed mean values of 3.53 mm in group 1, and 0.96 mm in group 2. Peri-implant bone resorption was: 0.49 mm (39 implants) in group 1, and 0.45 mm (30 implants) in group 2, at time of prosthetic rehabilitation; 0.78 mm (39 implants) in group 1, and 0.89 mm (30 implants) in group 2, 12 months after prosthetic load; 1.16 mm (24 implants) in group 1, and 1.02 mm (13 implants) in group 2, 24 months after the prosthetic load. A significant difference in bone resorption before implant placement was found between the two groups, whereas it was not found after implant placement and prosthetic load. The failure rate according to Albrektsson criteria was 4.9% (2/41 implants) in group 1, and was 3.2% (1/31) in group 2.

Biocompatible osteoconductive polymer versus iliac graft. A prospective comparative study for the evaluation of fusion pattern after anterior cervical discectomy

STUDY DESIGN

One hundred fifteen patients having symptomatic cervical disc disease were recruited prospectively for this study. They were allocated randomly for either autologous iliac bone graft or biocompatible osteoconductive polymer implants. Both groups were compared clinically and radiologically.

OBJECTIVES

Complications, long-term clinical and radiologic outcome, and hospital stay were compared to determine if biocompatible osteoconductive polymer was an improvement on iliac bone graft in terms of reduced donor site pain and shortened hospital stay.

SUMMARY OF BACKGROUND DATA

Donor site morbidity is a significant problem in anterior cervical fusion. Hospital stay is another factor in the recent era of cost consciousness. Biocompatible osteoconductive polymer has been used in many centers as a biodegradable implant to circumvent these problems.

METHODS

Smith-Robinson technique was used in 74 patients, and Cloward technique was used in 41 patients. Sixty-five patients had biocompatible osteoconductive polymer implants, and 50 patients had iliac bone graft. Patients were followed-up routinely in the outpatient clinic where pain visual analogue scale and Odom's criteria were used for outcome evaluation. Plain radiography, computed tomography scan, and magnetic resonance imaging were used for radiologic evaluation.

RESULTS

The mean hospital stay was 4.8 days for those with iliac bone graft and 4.7 days for those with biocompatible osteoconductive polymer. Clinical outcome was identical in both groups. The incidence of partial graft protrusion and postoperative intersegmental kyphosis was statistically higher with iliac bone graft (P = 0.018 and P = 0.02, respectively). "Sclerosis" started to form around biocompatible osteoconductive polymer like a "halo" at 2 months. It increased with time, and sometimes was associated with new osteophyte formation; however, there was no biocompatible osteoconductive polymer incorporation or biodegradation

CONCLUSIONS

Biocompatible osteoconductive polymer acts as a good "spacer" that reduces graft collapse and intersegmental kyphosis. However, it did not show any radiologic evidence of biodegradation or incorporation during the follow-up period of 24 months.

Costs and complications in mandibular reconstruction

Because of increasing concerns about the high cost of complex medical care, we compared the combined cost of ablation and reconstruction incurred using five different management strategies for patients undergoing mandibular resection. We also compared the rates of complication and failure for the methods used. The records of 69 patients undergoing segmental or total mandibulectomy between January 1, 1986, and June 30, 1990, were reviewed. Of these, 15 had reconstruction with soft tissue only (average cost, $36,137; complication rate, 33%), whereas 20 had immediate reconstruction with vascularized bone (average cost, $46,894; complication rate, 50%), and 15 had reconstruction with only a metal plate (average cost, $47,678; complication rate, 73%). Nine patients had plate reconstructions initially but subsequently underwent reconstructions with bone (average cost, $54,346; complication rate, 78%), whereas 10 patients had no initial reconstruction but subsequently underwent delayed reconstruction with bone (average cost, $52,486; complication rate, 70%). If reconstruction was performed with bone, immediate reconstruction was more cost effective than delayed reconstruction and had a lower complication rate as well.

Cost and outcome of osteocutaneous free-tissue transfer versus pedicled soft-tissue reconstruction for composite mandibular defects

Thirty-nine patients underwent reconstruction of composite mandibular defects following resection for squamous cell carcinoma. Thirty-four underwent immediate reconstruction, while 5 were reconstructed secondarily. Twenty-one received soft-tissue reconstruction only with a pectoralis major myocutaneous flap, 14 underwent osteocutaneous free-tissue transfer, and 4 received a reconstruction plate with free-tissue transfer for soft-tissue coverage. The mandibular defects in the pectoralis major myocutaneous flap group tended to be posterolateral, while free-tissue transfer defects were more severe, usually involving the anterior mandible. Length of surgery and duration of intensive care unit care were significantly longer for free-tissue transfer patients, while flap complications were more common in the pectoralis major myocutaneous flap patients. Facial appearance scores were higher for the free-tissue transfer group by both patient and physician assessment. Social function, speech, and oral function did not differ significantly. Patients reconstructed secondarily with free-tissue transfer reported significant improvement in appearance, oral continence, and social function, with little change in speech intelligibility, deglutition, or diet tolerance. The cost of the main hospitalization was significantly higher in the free-tissue transfer group than in the pectoralis major myocutaneous flap group, although when the costs of subsequent hospitalizations are included, the difference in total cost narrows. Despite more adverse defects, free-tissue transfer provided more predictable aesthetic results and expeditious return to normal social function than did pectoralis major myocutaneous flap reconstruction. The fiscal impact of these complex reconstructions is, however, significant. Cost-containment issues are presented and recommendations are made.

Economic impact of cancellous bone grafting in trauma surgery

INTRODUCTION

Cancellous bone grafting is currently the most frequent method for replacement of bone material. In recent years, several alternative methods came into practice. However, up to now it remains unclear whether cancellous bone grafting is cheaper as compared to these new methods. Therefore, the aim of this study was to calculate the direct costs of cancellous bone grafting.

MATERIALS AND METHODS

For calculation of the direct costs operation time needed in addition to the main surgical intervention was measured and the material used recorded in a consecutive series of 50 interventions including bone grafting at the Department of Trauma Surgery at the University Hospital of Bonn Medical School. Surgical staff costs were calculated on the basis of a standard team consisting of one surgical attendant, surgical resident, surgical nurse, and nurse's service. Cost of anaesthesia was calculated on a per minute base.

RESULTS

Mean additional operation time was 26.3 min (range 17-35 min). Surgical staff costs per operation minute were 2.70 Euro, costs for anaesthesiological service were 4.18 Euro/min. Material additional used consisted of sutures and sterilization costs. Material costs summed up to 32.01 Euro. The total direct costs of bone grafting were 212.95 Euro.

CONCLUSION

The direct costs of harvesting cancellous bone graft and the use of bone replacement material are comparable. Due to the high complication rate at the donor site the total-cost-of-illness might be higher when using autologous bone graft.

Graft incorporation after acetabular and femoral impaction grafting with washed irradiated allograft and autologous marrow

Rates of around 40% incorporation have been described when chips of irradiated cancellous allograft with retained fat were impacted with the Exeter technique. We report the results of acetabular and femoral impaction bone grafting during revision hip arthroplasty using washed irradiated allograft with autologous marrow. Eighty-five consecutive patients underwent acetabular and or femoral revision arthroplasty. Evidence of graft cortication and trabeculation was recorded on successive postoperative radiographs, over a mean period of 44 months. Ninety-six percent (49/51) and 90% (53/59) of patients showed incorporation in acetabular and femoral grafts, respectively. This was usually apparent by 6 months postoperatively. We conclude that the addition of autologous marrow to irradiated bone allograft during impaction grafting is a cheap and highly effective way of achieving graft incorporation.

CERAMENT treatment of fracture defects (CERTiFy): protocol for a prospective, multicenter, randomized study investigating the use of CERAMENT™ BONE VOID FILLER in tibial plateau fractures

BACKGROUND

Bone graft substitutes are widely used for reconstruction of posttraumatic bone defects. However, their clinical significance in comparison to autologous bone grafting, the gold-standard in reconstruction of larger bone defects, still remains under debate. This prospective, randomized, controlled clinical study investigates the differences in pain, quality of life, and cost of care in the treatment of tibia plateau fractures-associated bone defects using either autologous bone grafting or bioresorbable hydroxyapatite/calcium sulphate cement (CERAMENT™|BONE VOID FILLER (CBVF)).

METHODS/DESIGN

CERTiFy (CERament™ Treatment of Fracture defects) is a prospective, multicenter, controlled, randomized trial. We plan to enroll 136 patients with fresh traumatic depression fractures of the proximal tibia (types AO 41-B2 and AO 41-B3) in 13 participating centers in Germany. Patients will be randomized to receive either autologous iliac crest bone graft or CBVF after reduction and osteosynthesis of the fracture to reconstruct the subchondral bone defect and prevent the subsidence of the articular surface. The primary outcome is the SF-12 Physical Component Summary at week 26. The co-primary endpoint is the pain level 26 weeks after surgery measured by a visual analog scale. The SF-12 Mental Component Summary after 26 weeks and costs of care will serve as key secondary endpoints. The study is designed to show non-inferiority of the CBVF treatment to the autologous iliac crest bone graft with respect to the physical component of quality of life. The pain level at 26 weeks after surgery is expected to be lower in the CERAMENT bone void filler treatment group.

DISCUSSION

CERTiFy is the first randomized multicenter clinical trial designed to compare quality of life, pain, and cost of care in the use of the CBVF and the autologous iliac crest bone graft in the treatment of tibia plateau fractures. The results are expected to influence future treatment recommendations.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov: NCT01828905.

Is nonstructural bone graft useful in surgical treatment of lumbar spinal tuberculosis?: A retrospective case-control study

Surgical intervention is an important option for treating spinal tuberculosis. Previous studies have reported different surgical procedures and bone grafts for it. To our knowledge, few studies demonstrated the clinical results of using nonstructural autogenous bone graft in surgical treatment of spinal tuberculosis.The purpose of this study is to compare the clinical outcomes of surgical management lumbar spinal tuberculosis by one-stage posterior debridement with nonstructural autogenous bone grafting and instrumentation versus anterior debridement, strut bone grafting combined with posterior instrumentation.A total of 58 consecutive patients who underwent surgical treatment due to lumbar spinal tuberculosis from January 2011 to December 2013 were included. A total of 22 patients underwent one-stage posterior debridement, nonstructural autogenous bone grafting, and instrumentation (group A), and 36 patients received anterior debridement, strut bone grafting combined with posterior instrumentation (group B). The operative duration, total blood loss, perioperative transfusion, length of hospital stay, hospitalization cost, and complications were recorded. The bony fusion of the graft was assessed by computed tomography scans. American Spinal Injury Association (ASIA) Impairment Scale was used to evaluate the neurological function of patients in the 2 groups.All the patients were followed up, with a mean follow-up duration of 21.6 ± 5.7 months in group A and 22.3 ± 6.2 months in group B (P = 0.47). The average operative duration was 257.5 ± 91.1 minutes in group A and 335.7 ± 91.0 minutes in group B (P = 0.002). The mean total blood loss was 769.6 ± 150.9 mL in group A and 1048.6 ± 556.9 mL in group B (P = 0.007). Also, significant differences were found between the 2 groups in perioperative transfusion volumes, length of hospital stay, and hospitalization cost (P < 0.05), which were less in group A compared with group B. Patients with ASIA grade C/D in the 2 groups were improved with 1 to 2 grades after the surgery with no statistical difference (P = 1.000). The perioperative complications rate was 9.1% (2/22) in group A and 13.9% (5/36) in group B (P = 0.897).Based on a retrospective study, the procedure of one-stage posterior debridement, nonstructural autogenous bone grafting, and instrumentation has a significant shorter operative duration, lower blood loss and perioperative transfusion, shorter hospital stay, and less hospitalization cost compared with the one of anterior debridement, strut bone grafting combined with posterior instrumentation for treating lumber spinal tuberculosis.

Evaluation of Autologous Platelet-Poor Plasma Gel as a Hemostatic Adjunct After Posterior Iliac Crest Bone Harvest

PURPOSE

To evaluate the hemostatic efficacy of autologous platelet-poor plasma (PPP) gel following posterior iliac crest bone graft harvesting for oral and maxillofacial reconstruction.

PATIENTS AND METHODS

This was a prospective study of 24 consecutive patients involving 26 posterior iliac crest bone harvests that had bone wax and either 1-gram of bovine microfibrillar collagen or 20 mL of autologous PPP, activated as a gel, used as adjunct hemostatic agents. Compression bulb suction drain was placed into the graft site and drain output recorded every 8 hours for 64 hours. Cost analysis was also undertaken between the 2 methods. Statistical significance between means of each group was determined by Student's t test and found significant for P < .05.

RESULTS

There were no statistically significant differences in average drain output between the PPP and MFC groups for each 8-hour interval. There was no statically significant difference in average total drain output between the PPP and MFC groups over the entire 64 hour period. Additionally, unlike the addition of MFC, the addition of PPP added no additional costs to the procedure.

CONCLUSION

PPP gel, when compared with bovine microfibrillar collagen, is an effective and inexpensive adjunct in hemostasis following posterior iliac crest bone harvest.

Regeneration statt Reparation

Autogenous bone transfer is still regarded as the "golden standard" for many indications in oral and cranio-maxillofacial surgery. In this overview, the status of the autogenous bone is re-evaluated under consideration of current research results, clinical long-term studies, risks and safety of the patient as well as the costs. Due to the further development of modern bone substitute materials, which reveal in parts superior long-term results for special indications, the routine use of autogenous bone has to be critically reviewed.

One-stage hip arthroplasty and bone grafting for bilateral femoral head osteonecrosis

One-stage hip arthroplasty and contralateral core decompression with bone grafting were performed for 30 patients with bilateral femoral head osteonecrosis between April 2002 and June 2005. The treatment course, clinical and radiographic outcomes, and medical costs were compared with another 30 age-, gender-, etiology-, and disease extent-matched patients undergoing two-stage treatment during the same period. The two groups had similar clinical data and few complications. Total hospital stay and associated costs were reduced for patients who had one-stage treatment. These patients also returned to work faster (6.0 versus 10.8 months). At an average followup of 46 months, progression to greater than 2 mm of collapse of the salvaged femoral head was observed in seven patients (23%) who had one-stage treatment and 14 patients (47%) who had two-stage treatment. Conversion to hip arthroplasty was performed in five patients (17%) in the one-stage group and 12 patients (40%) in the two-stage group. A special group of patients with bilateral osteonecrosis of the femoral head seemed to benefit from one-stage hip arthroplasty and contralateral core decompression with bone grafting and had better survival of the salvaged femoral head. One-stage hip arthroplasty and core decompression with bone grafting proved to be a cost-effective method that did not increase perioperative morbidity.

LEVEL OF EVIDENCE

Level II, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

[Cost analysis of a bone bank]

The costs of a bone-bank working in accordance with the guidelines of the german federal chamber of physicians are described. Establishing a bone-bank storing deep-frozen bone is not very expensive. The main costs are due to laboratory costs for excluding HIV, hepatitis, syphilis and bacterial contamination of bone grafts. In our experience with 206 bone grafts about 20% of them are to be discharged because of positive laboratory tests. The costs of each bone graft are DM 327. A second HIV-Test of the donor 3 months after explantation of a bone graft will cause rising of costs up to 47%. About 20-30% of bone graft donors will probably not carry out this test. In this case discharging of the bone graft is necessary.

Agonizing and Expensive: A Review of Institutional Costs of Ankle Fusion Nonunions

Nonunion after ankle arthrodesis requiring revision is a challenging operative complication, and bone graft substitutes are costly. This study sought to summarize all institutional expenditures related to the revision of an ankle fusion nonunion, presuming that cost and skin-to-skin time would exceed those of the index surgery. The electronic records from 2 foot and ankle centers were reviewed, leading to a list of patients with 2 or more entries for tibiotalar fusions being generated. A total of 24 cases were found to match the criteria. Demographic factors and skin-to-skin time of the remaining patients were compiled. This cohort included 24 patients (6 female and 18 male) with a mean age of 64 years and body mass index of 30.4 kg/m². Supplemental clinic visits and investigations were included either after computed tomography to assess union or 365 days after index surgery. Total cost of the revision was calculated from billing codes, length of operation, and period of hospitalization. Postrevision outpatient fees were included as well. The revisions were performed open in all cases, and 21 patients received autograft and/or bone substitute. Mean postoperative hospitalization was 3 days. The additional costs (in US dollars) associated with nonunion were $1061 for imaging, $627 for prerevision visits, $3026 for the revision, $3432 for the hospital stay, and $1754 for postrevision follow-up. The total mean amount was $9683, equivalent to 9 nights of acute inpatient stay. Mean index skin-to-skin time was 114 minutes, being 126 minutes for revisions (P=.26). Additional care related to ankle fusion nonunion represents a financial burden equivalent to 9 nights of acute inpatient stay. The use of an orthobiologic would need to be less than $436 to be cost saving. Revision surgery is not significantly longer intraoperatively than index surgery. [Orthopedics. 2020;43(4):e219-e224.].