Faculty Bibliography

The steadily increasing demand for orthopedic surgeries and declining rates of reimbursement by Medicare and other insurance providers have led many hospitals to look for ways to control the cost of these surgeries. We reviewed administrative records for a 1-year period and recorded total number of surgical cases, number of cases in which an implant was wasted, and cost of each wasted implant. We determined cost incurred because of implant waste, percentage of cases that involved waste, percentage of total implant cost wasted, and average cost of waste per case. We then analyzed the data to determine if case volume or years in surgical practice affected amount of implant waste. Results showed implant waste represents a significant cost for orthopedic procedures within all subspecialties and is an important factor to consider when developing cost-reduction strategies.

STRUCTURED ABSTRACT: Study Design. Retrospective cohort studyObjective. To determine predictors of and 30-day complications associated with blood transfusion volume following posterior spinal fusion for adolescent idiopathic scoliosis (AIS)Summary of Background Data. Posterior arthrodesis is a common procedure performed for AIS, and patients frequently require perioperative blood transfusions. Few studies, however, have examined the rates and potential complications associated with blood transfusion volume. METHODS: Patients undergoing posterior arthrodesis for AIS were selected from the National Surgical Quality Improvement Program (NSQIP) Pediatric database from 2012 to 2013. Patients were stratified based on blood transfusion volume and patient demographics and comorbidities, operative characteristics, and 30-day complications were recorded. Multivariate analyses were performed to determine predictors of transfusion as well as the effect of transfusion volume on 30-day complication rates. RESULTS: A total of 1691 patients were included. Male gender (p = 0.010), esophageal or GI disease (p = 0.016), cardiac risk factors (p = 0.037), preoperative inotrope requirement (p = 0.031), total operative time >/= 300 minutes (p < 0.001), and posterior arthrodesis of 13 or more vertebral segments (p < 0.001) were independent risk factors for requiring a blood transfusion. Total transfusion volume >/= 20 mL/kg was the minimum volume independently associated with increased rates of total complications (p = 0.018) with a complication rate of 5.9%. CONCLUSION: We present the first large, comprehensive analysis of complications related to blood transfusion events and transfusion volume on short-term postoperative complications following posterior arthrodesis for AIS. While transfusion in general is not associated with 30-day adverse events, a volume of 20 mL/kg was associated with higher complication rates.

The Centers for Medicare & Medicaid Services considers readmissions within 30 days of discharge to be a quality indicator. Hospitals' and eventually physicians' readmission rates will be used to determine payment for services. It is imperative that health care providers understand which patients are at risk for readmission so that they can apply the appropriate preventive interventions. The research team analyzed all orthopedic admissions and readmissions at their institution from September 2008 to April 2011 in this study. Preparing for the next stage in health care reform, identifying any preoperative factors that may place certain patients into a "high-risk" category for readmission following an orthopedic procedure is of paramount importance. This data analysis of more than 13 000 patients noted that race-based and income-based risk factors did not translate into significant risk factors or predictors of 30-day readmission following orthopedic admission.

The demand for spinal surgery and its costs have both risen over the past decade. In 2008 the aggregate hospital bill for surgical care of all spinal procedures was reported to be $33.9 billion. One key driver of rising costs is spinal implants. In 2011 our institution implemented a cost containment programme for spinal implants which was designed to reduce the prices of individual spinal implants and to reduce the inter-surgeon variation in implant costs. Between February 2012 and January 2013, our spinal surgeons performed 1493 spinal procedures using implants from eight different vendors. By applying market analysis and implant cost data from the previous year, we established references prices for each individual type of spinal implant, regardless of vendor, who were required to meet these unit prices. We found that despite the complexity of spinal surgery and the initial reluctance of vendors to reduce prices, significant savings were made to the medical centre. Cite this article: 2015; 97-B:1102-5.

Infection is a rare, serious complication following total joint arthroplasty and constitutes a considerable emotional and financial burden for patients, surgeons, and healthcare systems. Prevention of surgical site and periprosthetic joint infections is crucial. This requires knowledge of the microorganisms that commonly cause these infections, including Staphylococcus species. Selection of the appropriate antibiotic regimen to treat infection remains controversial, but cefazolin and cefuroxime are the most commonly recommended antibiotics for prophylaxis. Appropriate timing of administration before surgery, with redosing performed as needed, can help to ensure optimal antibiotic concentration during surgery. Given the increasing evidence that S aureus colonization is a risk factor for periprosthetic joint infection, an exploration of the potential benefits of preoperative S aureus carrier screening and decolonization protocols is warranted. The use of antibiotic-loaded bone cement in primary total joint arthroplasty and antibiotic powder at wound closure are other controversial topics that require additional research.

BACKGROUND: Orthopaedic surgery is a major risk factorfor venous thromboembolism (VTE) manifesting as deep veinthrombosis (DVT) or pulmonary embolism (PE). Variouspatient characteristics alter the likelihood of a postoperativeVTE, and there is substantial ambiguity in current VTEprophylaxis guidelines. PURPOSE: To determine if particular patient characteristicsare risk factors for VTE following major orthopaedicsurgery. METHODS: Data was reviewed from 201 patients presentingwith either a PE or DVT following spine surgery or jointreplacement from October 2009 through June 2013. Thefollowing characteristics were reviewed for each patient:VTE event date, surgery date and type, comorbidities andpre-existing conditions, calculated comorbidity level, bodymass index, prophylaxis type, time to initiation of chemoprophylaxis,time to epidural removal, and VTE event type.The control patients were randomly selected from a groupof 13,782 patients during the same period. RESULTS: A history of VTE (p < 0.0001), Factor V Leidendisorder (p = 0.04) and the use of general anesthesia (p =0.05) were significant risk factors for postoperative VTE.The frequency of VTE decreased following hip and kneearthroplasty during the study period and remained constantfor spine surgery. DVTs occurred 14.2 days later than PEs(p < 0.0001). Over 90% of PEs and 33.3% to 75% of DVTswere diagnosed in the first week following surgery. CONCLUSIONS: A prior history of VTE, Factor V Leidendisorder and general anesthesia increases the risk of VTEpostoperatively. The probability of PE beyond the secondpostoperative week is low.

Favorable patient experience and low complication rates have been proposed as essential components of patient-centered medical care. Patients' perception of care is a key performance metric and is used to determine payments to hospitals. It is unclear if there is a correlation between technical quality of care and patient satisfaction. The study authors correlated patient perceptions of care measured by the Hospital Consumer Assessment of Healthcare Providers and Systems scores with accepted quality of care indicators. The Hospital Compare database (4605 hospitals) was used to examine complication rates and patient-reported experience for hospitals across the nation in 2011. The majority of the correlations demonstrated an inverse relationship between patient experience and complication rates. This negative correlation suggests that reducing these complications can lead to a better hospital experience. Overall, these results suggest that patient experience is generally correlated with the quality of care provided.

Tears of the superior glenoid labrum are a common cause ofshoulder pain and disability, especially in overhead athletessuch as pitchers, swimmers, and volleyball players. Type IISLAP lesions have been the most clinically important superiorlabral pathology, and the management of this lesionhas been a very controversial topic. Currently, there are nohigh level studies in the literature to guide treatment. Whilethe few level 3 and level 4 evidence studies that are availablefollowing arthroscopic repair of type II SLAP lesionsall report reasonable overall patient satisfaction, persistentpostoperative pain is common and associated with a lowreturn to pre-injury level of sports participation. There hasbeen a recent school of thought that biceps tenodesis, whichmaintains the length-tension relationship of the long head ofbiceps, should be the procedure of choice for patients withisolated type II SLAP lesions. The current paper reviewsthe role biceps tenodesis plays in the management of typeII SLAP tears.

Total joint arthrosplasty (TJA) is both a commonly performedsuccessful intervention and an expensive procedure.As our population ages, the expense of these interventions isexpected to grow and hence its impact on healthcare costswill also grow. To ensure that TJA is available to all thosewho would benefit, it is incumbent that healthcare providerscontrol the cost of these procedures. As orthopaedicsurgeons, we must be at the forefront of this effort. The purposeof this review is to outline strategies to control or evendecrease TJA cost without negatively affecting outcomes.This concept is at the center of value-based medicine andmust guide our decision-making processes.