The efficacy of intrawound vancomycin powder and povidone-iodine irrigation to prevent surgical site infections in complex instrumented spine surgery

BACKGROUND CONTEXTSurgical site infections (SSIs) are notorious complications in spinal surgery and cause substantial patient morbidity. Intraoperative decontamination of the wound with povidone-iodine irrigation or vancomycin powder has gained attention lately, but the efficacy of either intervention is unclear.PURPOSETo determine the efficacy of intrawound povidone-iodine or vancomycin in reducing the incidence of deep- and superficial SSIs in instrumented spinal surgery.STUDY DESIGN/SETTINGRetrospective cohort study.PATIENT SAMPLEA retrospective chart review was performed including all consecutive adult patients undergoing open, posterior, instrumented spinal surgery at any level between January 2012 and August 2017.OUTCOME MEASURESThe presence of SSI was evaluated according to the criteria published by the Centers for Disease Control and Prevention. The SSIs were divided into deep SSIs (below the muscular fascia) and superficial SSIs (above the muscular fascia).METHODSA retrospective cohort without intrawound treatment was compared with two separate, consecutive intervention groups. One intrawound group received 1.3g/L povidone-iodine irrigation and the other received 1-2 grams of intrawound vancomycin powder at the end of surgery. Incidence of SSIs, as well as demographic, surgical and patient-related variables were registered and compared between groups. In patients with SSI, additional microbiological data were collected.RESULTSIn total, 853 patients were included. In the control group (N=257), 25 (9.7%) patients developed a deep and 13 (5.1%) developed a superficial SSI. In the povidone-iodine group (N=217), 21 (9.7%) patients developed a deep and two (0.9%) developed a superficial SSI. Compared with the control group, there was no significant difference in the incidence of deep SSIs (risk ratio [RR]: 1.00, 95% CI 0.57–1.73), although the number of superficial SSIs was reduced significantly (RR 0.18, 95% CI 0.04–0.80). In the vancomycin group (N=379), 19 (5.0%) patients developed a deep and six (1.6%) developed a superficial SSI. Both deep (RR: 0.52, 95% CI 0.29–0.92) and superficial SSIs (RR: 0.31, 95% CI 0.12–0.81) were significantly reduced in the vancomycin group compared with the control group, even when correcting for several risk factors associated with SSIs in a multivariable logistic regression analysis. There were no significant differences in complications between the 3 groups. No gram-negative selection or vancomycin-resistance was seen in the vancomycin group.CONCLUSIONSIntrawound application of vancomycin was associated with a significant reduction in both deep and superficial SSIs in instrumented spinal surgery. A 1.3g/L intrawound povidone-iodine solution did not show a reduction in deep SSIs, although a reduction of superficial SSIs was observed.     

Shoulder adhesive capsulitis and hypercholesterolemia: role of APO A1 lipoprotein polymorphism on etiology and severity

Purpose

Surgical site infection (SSI) is a costly complication associated with spine surgery. The impact of intrawound vancomycin has not been strongly postulated to decrease the risk of surgical site infection. We designed study to determine whether intrawound vancomycin application reduces the risk of SSI in patients after spine surgery.

Methods

A prospective randomized control trial study to evaluate the patients with elective spine surgery in a period of 15 month was designed. Patients were divided into two groups based on whether intrawound vancomycin was applied or not. The relative risk of SSI within postoperative 30 days was evaluated.

Results

Three hundred and eighty patients were included in this study: degenerative spine pathologies and tumor 80% (304), trauma 11% (42) and deformity 9% (34). Intrawound vancomycin was used in 51% of patients. Prevalence of SSI was 2.7% in the absence of vancomycin use versus 5.2% with intrawound vancomycin. In multivariable regression model, those with higher number of levels exposed, postoperative ICU admission and obesity and use of instrumentation more than two levels had higher risk of developing SSI. In the treatment group Acinetobacter and Pseudomonas aeruginosa (20%) were the most common pathogens. In control group, Staphylococcus aureus and Acinetobacter (40%) were the most common organisms.

Conclusions

Intrawound application of vancomycin after elective spine surgery was not associated with reduced risk of SSI and return to OR associated with SSI in our patients. However, the use of intrawound vancomycin changed the responsible infection germ.

     

Intra-wound vancomycin and tobramycin powder for infection prophylaxis in orthopaedic trauma surgery: Economically justifiable?

ObjectivesThere is increasing interest regarding the risks and benefits of intrawound antibiotics applied directly to surgical wounds for the prevention of infection following orthopaedic trauma surgery. The purpose of this study was to investigate the economic justifiability of vancomycin and tobramycin powders for infection prophylaxis in orthopaedic trauma surgery.MethodsThe cost of vancomycin and tobramycin powders, infection rates and costs of treating surgical site infections were obtained from our institution's records and existing literature. A break-even analysis was then performed using vancomycin powder only, tobramycin powder only and combined vancomycin and tobramycin powders to determine the respective absolute risk reduction (ARR) in infection rate needed to make the prophylactic application of each therapy type break-even.ResultsAt our institutional pricing of $20.64 and $75.80 for 1g vancomycin and 1.2g tobramycin, respectively, use of each individually would be economically justified if it reduced an average infection rate of 4.3% by an ARR of 0.02% and 0.07%, respectively. Used in combination for $90.66, the ARR was 0.09%. Varying cost of treating infection from $5,000-$200,000 while maintaining cost of antibiotic powder at $90.66 demonstrated a range in ARR from 1.93% to 0.05%, respectively. At the same cost of $90.66 but varying infection rate from 1% to 25% did not affect ARR, which was constant at 0.09%.ConclusionsConsidering the cost of vancomycin and tobramycin powder at our institution, the application of these powders, whether independently or in combination, appear to be economically justifiable for infection prevention in orthopaedic trauma surgery.     

Characteristics of Antibiotic Prophylaxis and Risk of Surgical Site Infections in Primary Total Hip and Knee Arthroplasty

BackgroundDespite numerous antibiotic prophylaxis options for total hip arthroplasty (THA) and total knee arthroplasty (TKA), an assessment of practice patterns and comparative effectiveness is lacking. We aimed to characterize antibiotic utilization patterns and associations with infection risk and hypothesized differences in infection risk based on regimen.MethodsA retrospective cohort study was performed using data from 436,724 THA and 862,918 TKA (Premier Healthcare Database; 2006-2016). Main exposures were antibiotic type and duration: day of surgery only (day 0) or through postoperative day 1 (day 1). The primary outcome was surgical site infection (SSI) <30 days postoperation. Mixed-effect models measured associations between prophylaxis regimen and SSI as odds ratios (ORs) with 95% confidence intervals (CIs).ResultsSSI prevalence was 0.21% (n = 914) for THA and 0.22% (n = 1914) for TKA. Among THA procedures, the most commonly used antibiotics were cefazolin (74.1%), vancomycin (8.4%), “other” antibiotic combinations (7.1%), vancomycin + cefazolin (5.1%), and clindamycin (3.3%). Here, 51.8% received prophylaxis on day 0 only, whereas 48.2% received prophylaxis through day 1. Similar patterns existed for TKA. Relative to cefazolin, higher SSI odds were seen with vancomycin (OR = 1.36; CI 1.09-1.71) in THA and with vancomycin (OR = 1.29; CI = 1.10-1.52), vancomycin + cefazolin (OR = 1.35; CI = 1.12-1.64), clindamycin (OR = 1.38; CI = 1.11-1.71), and “other” antibiotic combinations (OR = 1.28; CI = 1.07-1.53) in TKA. Prophylaxis duration did not alter SSI odds. Results were corroborated in sensitivity analyses.ConclusionAntibiotic prophylaxis regimens other than cefazolin were associated with increased SSI risk among THA/TKA patients. These findings emphasize a modifiable intervention to mitigate infection risk.     

Systematic Review and Meta-Analysis of Intrawound Vancomycin in Total Hip and Total Knee Arthroplasty: A Call for a Prospective Randomized Trial

BackgroundTopical intrawound vancomycin has been used extensively in spine surgery to decrease surgical site infections. However, the efficacy of intrawound vancomycin in total hip (THA) and total knee arthroplasty (TKA) to prevent periprosthetic joint infection (PJI) has not been established.MethodsThe PubMed and MEDLINE databases were searched to identify studies utilizing intrawound vancomycin in primary and revision THA and TKA. Data for postoperative infection were pooled using random effect models with results reported as odds ratios (ORs) and 95% confidence intervals. Studies were weighted by the inverse variance of their effect estimates.ResultsOf the 91 studies identified, 6 low-quality retrospective studies (level III) were pooled for further analysis. A total of 3298 patients were assessed, 1801 of which were treated with intrawound vancomycin. Overall, patients who received vancomycin had a decreased rate of PJI (OR 0.2530, P < .0001). When analyzed separately, TKA patients and THA patients who received intrawound vancomycin had lower rates of PJI (OR 0.3467, P = .0005 and OR 0.3672, P = .0072, respectively). Pooled primary TKA and THA patients receiving vancomycin saw the rate of PJI decrease (OR 0.4435, P = .0046). Pooled revision TKA and THA patients saw a similar decrease in infection rates (OR 0.2818, P = .0013). No apparent publication bias was observed; however, the results from this analysis are limited by the low quality of evidence and inherent potential for bias.ConclusionIntrawound vancomycin may reduce the risk of PJI in primary and revision TKA and THA. However, only low-quality evidence exists, highlighting the need for randomized controlled trials before broad adoption of this practice can be recommended given the potential implications of widespread use of vancomycin in hip and knee arthroplasty.     

Intrawound application of vancomycin reduces the proportion of fracture-related infections in high-risk tibial plateau fractures

IntroductionDespite the improvements in surgical techniques and the use of prophylactic intravenous antibiotics, the fracture-related infection (FRI) incidence after high-risk tibial plateau fractures remains high. This study aimed to evaluate the clinical effect of the intrawound application of vancomycin on the FRI after high-risk tibial plateau fracture surgery.MethodsA total of 243 patients who underwent high-risk tibial plateau fracture surgery from May 2013 to June 2021 were retrospectively reviewed. Of these, 233 cases were enrolled. Considering the preoperative patient condition, surgeons applied vancomycin powder directly into the surgical site before wound closure in 105 cases (intrawound application of vancomycin powder with preoperative intravenous cephalosporin). The remaining 128 cases served as the control group (preoperative intravenous cephalosporin alone). Clinical data and surgical details were recorded. The Cox proportional hazards regression analysis was used to assess risk factors for FRI. The Kaplan-Meier method and the log rank test illustrated the infection status of patients based on the application of intrawound vancomycin. The primary outcome was an FRI within one year. Secondary outcomes included bacterial culture and vancomycin-related complications.ResultsOur study demonstrated a significant difference in the incidence of FRI between the vancomycin group and the control group (3.8% versus 10.9%; p=0.041). Multivariable Cox regression showed the intrawound application of vancomycin powder decreased the rate of FRI. There were no complications related to intrawound vancomycin observed during follow-up. The presence of Gram-positive FRI was higher in the control group compared with the vancomycin group.ConclusionsIntrawound application of vancomycin was associated with a significant lower rate of FRI after high-risk tibial plateau fracture surgery compared to the control group.     

Is Topical Vancomycin an Option? A Randomized Controlled Trial to Determine the Safety of the Topical Use of Vancomycin Powder in Preventing Postoperative Infections in Total Knee Arthroplasty,as Compared With Standard Postoperative Antibiotics

BackgroundThe demand for total knee arthroplasties (TKAs) is expected to rise in the coming decades, increasing the burden of periprosthetic joint infections (PJIs). The use of intrawound vancomycin powder (VP) has proven to be effective in reducing the incidence of PJIs after spinal surgery. That said, its effectiveness in TKA remains unclear. This trial aims to examine the efficacy of intrawound vancomycin powder first versus standard postoperative antibiotics in preventing PJIs after TKA.MethodsThis study was a double-blinded, noninferiority, randomized controlled trial. All participants received standard preoperative intravenous (IV) antibiotics (Cefazolin/Vancomycin) within 60 minutes of skin incision. Patients in the treatment group received 1 gram of VP applied intraoperatively by the orthopedic surgeon (500 mg directly on the prosthesis, 500 mg above the closed joint capsule). These patients did not receive postoperative antibiotics. Patients in the control group received standard postoperative IV antibiotics. The primary outcome was the incidence of acute surgical site infection within 42 days of procedure.ResultsThere were 80 patients randomized to the treatment group and 85 patients randomized to the control. Groups were matched with respect to baseline characteristics, including average age (66 versus 64), BMI (35.7 versus 33.4), and diabetics (16 versus 13). The trial was halted at 1 year as a significantly greater proportion (P = .03) of patients in the treatment group (n = 3, 3.75%) were diagnosed with PJIs compared to the control (n = 0).ConclusionOur trial demonstrated the intrawound application of VP to be inferior to standard postoperative IV antibiotics in reducing the incidence of PJIs after TKA.     

Prophylactic postoperative measures to minimize surgical site infections in spine surgery: systematic review and evidence summary

BACKGROUND CONTEXTThere are three phases in prophylaxis of surgical site infections (SSI): preoperative, intraoperative and postoperative. There is lack of consensus and paucity of evidence with SSI prophylaxis in the postoperative period.PURPOSETo systematically evaluate the literature, and provide evidence-based summaries on postoperative measures for SSI prophylaxis in spine surgery.STUDY DESIGNSystematic review, meta-analysis, evidence synthesis.METHODSA systematic review conforming to PRIMSA guidelines was performed utilizing PubMed (MEDLINE), EMBASE, and the Cochrane Database from inception to January 2019. The GRADE approach was used for quality appraisal and synthesis of evidence. Six postoperative care domains with associated key questions were identified. Included studies were extracted into evidence tables, data synthesized quantitatively and qualitatively, and evidence appraised per GRADE approach.RESULTSForty-one studies (nine RCT, 32 cohort studies) were included. In the setting of preincisional antimicrobial prophylaxis (AMP) administration, use of postoperative AMP for SSI reduction has not been found to reduce rate of SSI in lumbosacral spine surgery. Prolonged administration of AMP for more than 48 hours postoperatively does not seem to reduce the rate of SSI in decompression-only or lumbar spine fusion surgery. Utilization of wound drainage systems in lumbosacral spine and adolescent idiopathic scoliosis corrective surgery does not seem to alter the overall rate of SSI in spine surgery. Concomitant administration of AMP in the presence of a wound drain does not seem to reduce the overall rate of SSI, deep SSI, or superficial SSI in thoracolumbar fusion performed for degenerative and deformity spine pathologies, and in adolescent idiopathic scoliosis corrective surgery. Enhanced-recovery after surgery clinical pathways and infection-specific protocols do not seem to reduce rate of SSI in spine surgery. Insufficient evidence exists for other types of spine surgery not mentioned above, and also for non-AMP pharmacological measures, dressing type and duration, suture and staple management, and postoperative nutrition for SSI prophylaxis in spine surgery.CONCLUSIONSDespite the postoperative period being key in SSI prophylaxis, the literature is sparse and without consensus on optimum postoperative care for SSI prevention in spine surgery. The current best evidence is presented with its limitations. High quality studies addressing high risk cohorts such as the elderly, obese, and diabetic populations, and for traumatic and oncological indications are urgently required.     

Amount of CMS Reduction in Facility Reimbursement Following Removal of Total Hip Arthroplasty From the Inpatient-Only List Far Exceeds Reduction in Actual Care Cost

BackgroundStarting in 2020, Centers for Medicare and Medicaid Services (CMS) removed total hip arthroplasty (THA) from the inpatient-only list, resulting in an average of $1637 per case reduction in facility reimbursement. The purpose of this study is to determine whether the reduction in reimbursement is justified by comparing the difference in true facility costs between inpatient and outpatient THA.MethodsWe identified a consecutive series of 5271 primary THA procedures from 2015 to 2019. Itemized procedural costs were calculated using a time-driven activity-based costing algorithm. Outpatient procedures were defined as those with less than a 24-hour length of stay. We compared patient demographics, comorbidities, and itemized costs between inpatient and outpatient procedures. A multivariate analysis was performed to determine the independent effect of outpatient status on true facility costs.ResultsThere were 783 (14.9%) outpatient THA procedures. The outpatient THA procedures incurred lower mean personnel ($1428 vs $2226, P < .001), supply ($4713 vs $4739, P < .001), and overall facility costs ($6141 vs $6595, P < .001) when compared with the same THA procedures done inpatient. When controlling for confounding variables, outpatient status was associated with a reduction in total facility costs of $825 (95% confidence interval, $734-$916, P < .001).ConclusionThe reduction in CMS reimbursement far exceeds the $825 per-patient cost savings that can be achieved by a facility by performing THA as an outpatient. CMS should reconsider the Outpatient Prospective Payment System classification of THA to better incentivize surgeons to perform THA as a lower-cost outpatient procedure when safe and appropriate.     

Predictors of increased cost and length of stay in the treatment of postoperative spine surgical site infection

Background Context

Although many risk factors are known to contribute to the development of a postoperative surgical site infection (SSI) following spinal surgery, little is known regarding the costs associated with the management of this complication, or the predictors for which patients will require increased resources for the management of SSI.

Standardized perioperative care reduces colorectal surgical site infection in children: A Western Pediatric Surgery Research Consortium multicenter analysis

PurposeSurgical site infection (SSI) remains a significant source of patient morbidity and resource utilization in children undergoing colorectal surgery. We examined the utility of a protocolized perioperative care bundle in reducing SSI in pediatric patients undergoing colorectal surgery.MethodsWe conducted a prospective cohort study of patients ≤18 years of age undergoing colorectal surgery at ten United States children's hospitals. Using a perioperative care protocol comprising eight elements, or “colon bundle”, we divided patients into low (1–4 elements) or high (5–8 elements) compliance cohorts. Procedures involving colorectal repair or anastomosis with abdominal closure were included. Demographics and clinical outcomes were compared between low and high compliance cohorts. Compliance was compared with a retrospective cohort. The primary outcome was superficial SSI incidence at 30 days.ResultsThree hundred and thirty-six patients were included in our analysis: 138 from the low compliance cohort and 198 from the high compliance cohort. Age and gender were similar between groups. Preoperative diagnosis was similar except for more patients in the high compliance cohort having inflammatory bowel disease (18.2% versus 5.8%, p<0.01). The most common procedure performed was small bowel to colorectal anastomosis. Wound classification and procedure acuity were similar between groups. Superficial SSI at 30 days occurred less frequently among the high compliance compared to the low compliance cohort (4% versus 9.7%, p = 0.036). Median postoperative length of stay and 30-day rates of readmission, reoperation, intra-abdominal abscess and anastomotic leak requiring operation were not significantly different between groups. None of the individual colon bundle elements were independently protective against superficial SSI.ConclusionStandardization of perioperative care is associated with a reduction in superficial SSI in pediatric colorectal surgery. Expansion of standardized protocols for children undergoing colorectal surgery may improve outcomes and decrease perioperative morbidity.Type of StudyClinical Research PaperLevel of EvidenceLevel II     

Full-endoscopic spine surgery diminishes surgical site infections – a propensity score-matched analysis

BACKGROUND CONTEXTSurgical site infections (SSI) are one the most frequent and costly complications following spinal surgery. The SSI rates of different surgical approaches need to be analyzed to successfully minimize SSI occurrence.PURPOSEThe purpose of this study was to define the rate of SSIs in patients undergoing full-endoscopic spine surgery (FESS) and then to compare this rate against a propensity score-matched cohort from the National Surgical Quality Improvement Program (NSQIP) database.DESIGNThis is a retrospective multicenter cohort study using a propensity score-matched analysis of prospectively maintained databases.PATIENT SAMPLEA total of 1277 noninstrumented FESS cases between 2015 and 2021 were selected for analysis. In the nonendoscopic NSQIP cohort we selected data of 55,882 patients.OUTCOME MEASURESThe occurrence of any SSI was the primary outcome. We also collected any other perioperative complications, demographic data, comorbidities, operative details, history of smoking, and chronic steroid intake.METHODSAll FESS cases from a multi-institutional group that underwent surgery from 2015 to 2021 were identified for analysis. A cohort of cases for comparison was identified from the NSQIP database using Current Procedural Terminology of nonendoscopic cervical, thoracic, and lumbar procedures from 2015 to 2019. Trauma cases as well as arthrodesis procedures, surgeries to treat pathologies affecting more than 4 levels or spine tumors that required surgical treatment were excluded. In addition, nonelective cases, and patients with wounds worse than class 1 were also not included. Patient demographics, comorbidities, and operative details were analyzed for propensity matching.RESULTSIn the nonpropensity-matched dataset, the endoscopic cohort had a significantly higher incidence of medical comorbidities. The SSI rates for nonendoscopic and endoscopic patients were 1.2% and 0.001%, respectively, in the nonpropensity match cohort (p-value <.011). Propensity score matching yielded 5936 nonendoscopic patients with excellent matching (standard mean difference of 0.007). The SSI rate in the matched population was 1.1%, compared to 0.001% in endoscopic patients with an odds ratio 0.063 (95% confidence interval (CI) 0.009–0.461, p=.006) favoring FESS.CONCLUSIONSFESS compares favorably for risk reduction in SSI following spinal decompression surgeries with similar operative characteristics. As a consequence, FESS may be considered the optimal strategy for minimizing SSI morbidity.     

An empiric analysis of 5 counter measures against surgical site infections following spine surgery—a pragmatic approach and review of the literature

BACKGROUND CONTEXT

Surgical site infections (SSI) following spine surgery are debilitating complications to patients and costly to the healthcare system.

Cost of surgical site infections following coronary artery bypass surgery

Background: Little information is available on the financial impact of surgical site infections (SSI) after major surgery. In order to calculate the cost of SSI following coronary artery bypass graft surgery (CABGs), a 2‐year retrospective case‐control study was undertaken at Alfred Hospital, a university‐affiliated tertiary referral centre. Methods: One hundred and eight patients with SSI (cases) after CABGs and 108 patients without SSI (controls) were matched for gender, age, risk index (Centers of Disease Control and Prevention, National Nosocomial Infection Surveillance (NNIS) System) and number of principal comorbidities. The patient’s postoperative length of stay (LOS), in both the intensive care unit (ICU) and the non‐ICU (general) ward, was obtained from the medical records and the cost of a day in each was provided by the hospital’s finance department. The cost of antibiotics prescribed for SSI was provided by the hospital’s pharmacy department. Results: Postoperatively the cases were in ICU for a total of 313 days whereas the controls spent 165 days in ICU, a mean of 2.89 versus 1.53 days, respectively (P = 0.035). In general wards, cases were inpatients for a total of 1651 days and controls for 589 days. This is a mean of 10.8 days for cases and 4.7 days for controls (P = 0.0001). The extra LOS for 108 cases (compared to the controls) was costed at $1 299 082, a mean cost of $12 028 per patient. The total cost of antibiotics prescribed for these SSI was $42 270 (a cost per case of $391). The total excess cost related to increased LOS and antibiotic treatment was $12 419 per patient. In the subgroup analysis for deep sternal site infections the mean excess cost was $31 597 per patient. Conclusions: Postoperative SSI result in significant patient morbidity and consume considerable resources. In the present study, patients with SSI following CABGs had significant prolongation of hospitalization (both in ICU and general wards). The present study illustrates the potential cost savings of introducing interventions to reduce SSI rates. This is the first time such a study has been undertaken in Australia.     

Short-term preventive antibiotics

In a study of the duration of antibiotic prophylaxis in elective surgery, 466 procedures were surveyed over a four-year period. It is difficult to prove the efficacy of antibiotic prophylaxis when the rate of infection is so low, and, although not statistically significant, there is no difference in the infection rate whether the antibiotics are given intraoperatively only or for 48 hours, three days, or seven days. Per 100,000 patients, the cost savings of giving antibiotics intraoperatively rather than for 48 hours would have been $7,700,000; with the reduction from seven days to one-dose antibiotics, the savings would have been $29,700,000.     

Development of an intraoperative pathology consultation service at a free-standing ambulatory surgical center: clinical and economic impact for patients undergoing breast cancer surgery

BackgroundSecond surgeries represent a significant detriment to breast cancer patients. We examined the impact an intraoperative pathology consultation service had on multiple facets of breast cancer surgery.MethodsWe compared the 8 months before the establishment of a pathology laboratory, when intraoperative pathology consultation was not available, with the 8 months subsequent, when it was performed routinely.ResultsThe average number of surgeries per patient decreased from 1.5 to 1.23, and the number of patients requiring one surgery increased from 59% to 80%. Re-excisions decreased from 26% to 9%. Frozen section allowed 93% of node-positive patients to avoid a second surgery for axillary lymph node dissection. A cost analysis showed savings between $400 and $600 per breast cancer patient, even when accounting for fewer axillary lymph node dissections based on the American College of Surgeons Oncology Group Z0011 data.ConclusionsIncorporation of routine intraoperative margin/sentinel lymph node assessment at an outpatient breast surgery center is feasible, and results in significant clinical benefit to the patient. Use of frozen section decreased both the time and cost required to treat patients.     

One-Stage Periprosthetic Joint Infection Reimbursement—Is It Worth The Effort?

BackgroundOne-stage protocols for the management of periprosthetic infection take an extended period of time requiring two separate preps and sets of instruments to ensure optimal sterility. While intraoperative service time is one part of the reimbursement algorithm, reimbursement has lagged behind for single-stage treatment with respect to the time and resources necessary to perform these complex treatment regimens. If one-stage results are shown to be acceptable, but not reimbursed appropriately, surgeons will be discouraged from managing periprosthetic joint infection (PJI) in a one-stage fashion.MethodsThe reimbursement and operative time for 50 PJI procedures were compared with 250 primary total hips and 250 primary total knees by the same 4 surgeons.ResultsThe average reimbursement for a one-stage knee procedure was $2,597.08, with an average intraoperative service time of 259 minutes ($601.60/h). The average reimbursement for a primary total knee was $2,435.00, with an average intraoperative service time of 100 minutes ($1,461/h). The average reimbursement for a one-stage hip procedure was $2,826.17, with an average intraoperative service time of 311 minutes ($545.24/h). The average reimbursement for a primary total hip was $2,754.71 with an average intraoperative service time of 104 minutes ($1,589.26/h).ConclusionOne-stage procedures for PJI are reimbursed at approximately 1/3 the hourly rate of a primary procedure, which may discourage surgeons from selecting this treatment alternative even if recent studies confirm efficacy. Payers should be encouraged to reimburse physicians commensurate with the intraoperative service time needed to perform a one-stage procedure as adoption will decrease morbidity and save the healthcare system financially.     

Intraosseous Regional Administration of Vancomycin in Primary Total Knee Arthroplasty Does Not Increase the Risk of Vancomycin-Associated Complications

BackgroundPeriprosthetic joint infection (PJI) after total knee arthroplasty (TKA) is a rare but major complication. Owing to an increasing antibiotic resistance in bacteria causing PJI, vancomycin has been investigated as a prophylactic agent. Intraosseous regional administration (IORA) of vancomycin achieves significantly higher local tissue concentrations than systemic administration. There are limited data on IORA of vancomycin with respect to vancomycin-associated complications.MethodsSingle-surgeon retrospective review of primary TKA was performed between January 2015 and May 2019. All patients received 500 mg of IORA of vancomycin after tourniquet inflation and 3 × 1 g intravenous cefazolin in 24 hrs. Preoperative data collected included age, gender, body mass index, American Society of Anesthesiologists (ASA) score, diabetes, and chronic kidney disease (CKD). We documented in-hospital complications and complications requiring readmission within 12 months. Primary outcome measures were the incidence of acute kidney injury (AKI), ‘red man syndrome’ (RMS), and neutropenia. The secondary outcome measure was PJI incidence.ResultsWe identified 631 primary TKAs in 556 patients, of which 331 received IORA. The mean age was 67.7 ± 8.7 years, and 57.8% were women. CKD was prevalent in 17.2% of the cohort. AKI occurred in 25 (3.9%) cases. After controlling for covariates, CKD was the only significant predictor of AKI (odds ratio = 3.035, P = .023). RMS and neutropenia were not observed in this cohort. The 90-day PJI rate was 0%, and the 1-year PJI rate was 0.2%.ConclusionsLow-dose IORA of vancomycin in addition to standard intravenous systemic cefazolin prophylaxis in TKA is safe without significant adverse effects of vancomycin such as AKI, RMS, or neutropenia.     

A cohort cost analysis of lumbar laminectomy—current trends in surgeon and hospital fees distribution

Background contextSpine-related health-care expenditures accounted for $86 billion dollars in 2005, a 65% increase from 1997. However, when adjusting for inflation, surgeons have seen decreased reimbursement rates over the last decade.PurposeTo assess contribution of surgeon fees to overall procedure cost, we reviewed the charges and reimbursements for a noninstrumented lumbar laminectomy and compared the amounts reimbursed to the hospital and to the surgeon at a major academic institution.Study design/settingRetrospective review of costs associated with lumbar laminectomies.Patient sampleSeventy-seven patients undergoing lumbar laminectomy for spinal stenosis throughout an 18-month period at a single academic medical center were included in this study.Outcome measuresCost and number of laminectomy levels.MethodsThe reimbursement schedule of six academic spine surgeons was collected over 18 months for performed noninstrumented lumbar laminectomy procedures. Bills and collections by the hospital and surgeon professional fees were comparatively analyzed and substratified by number of laminectomy levels and patient insurance status. Unpaired two-sample Student t test was used for analysis of significant differences.ResultsDuring an 18-month period, patients underwent a lumbar laminectomy involving on average three levels and stayed in the hospital on average 3.5 days. Complications were uncommon (13%). Average professional fee billing for the surgeon was $6,889±$2,882, and collection was $1,848±$1,433 (28% overall, 30% for private insurance, and 23% for Medicare/Medicaid insurance). Average hospital billing for the inpatient hospital stay minus professional fees from the surgeon was $14,766±$7,729, and average collection on such bills was $13,391±$7,256 (92% overall, 91% for private insurance, and 85% for Medicare/Medicaid insurance).ConclusionBased on this analysis, the proportion of overall costs allocated to professional fees for a noninstrumented lumbar laminectomy is small, whereas those allocated to hospital costs are far greater. These findings suggest that the current focus on decreasing physician reimbursement as the principal cost saving strategy will lead to minimal reimbursement for surgeons without a substantial drop in the overall cost of procedures performed.