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Comparing Approaches to ACL Tears

Comparing Approaches to ACL Tears

Value-based medicine has gained more attention in recent years, leading many providers and healthcare systems to focus on the cost effectiveness of services they offer. This focus is important in orthopedic surgery, where procedures like anterior cruciate ligament (ACL) reconstruction have high costs but can also potentially improve quality of life and functional ability. However, little is known about the cost-effectiveness of ACL reconstruction when compared with structured rehabilitation only. Making the Comparison For a study published in the Journal of Bone and Joint Surgery, Mininder S. Kocher, MD, MPH, and colleagues used a Markov decision model to perform a cost-utility analysis of ACL reconstruction. The authors compared this with structured rehabilitation in the short to intermediate term (6 years) and for the longer term (lifetime). “We analyzed direct benefits, such as health-related quality of life, and indirect benefits, such as increased productivity, decreased risk of additional injuries, and decreased risk of arthritis, which all have additional costs associated with them,” explains Dr. Kocher. Effectiveness was measured in quality-adjusted life years (QALYs). ACL reconstruction was about $4,500 less expensive, on average, and more effective in the short and intermediate term than rehabilitation only. Reconstruction was also less expensive for the long term, with average lifetime costs to society of $38,121 for reconstruction and $88,538 for rehabilitation. Also, ACL reconstruction provided an incremental QALY gain of 0.72 when compared with rehabilitation only. “A lower rate of subsequent instability with ACL reconstruction was the main factor driving the effectiveness gains seen with reconstruction,” Dr. Kocher explains. Subsequent instability of the knee results in poorer quality of life and knee function and...
Complications

Complications

Yesterday I readmitted two patients to the hospital with surgical complications. One was a man who had a colon resection 6 weeks ago. He has had the ‘dwindles’ since discharge. He’s lost weight, has no energy and no appetite. A CBC done yesterday showed his white blood cell count was elevated, and a metabolic panel shows impending renal failure. I suspect he has an intrabdominal abscess despite the fact that he has no fever. The second patient is 3 weeks out from a complex incisional hernia repair that involved reconstruction of her entire abdominal wall with placement of a large sheet of surgical mesh under the muscle layers. She is a morbidly obese diabetic and has developed a wound infection. If the infection reaches the mesh, I’ll have to remove it, undoing her entire repair. Complications are a fact of life in surgery. No matter how good a surgeon you are, no matter how carefully you manage patients, something will go wrong once in a while. As my Chief was fond of saying, “If you do big surgery, you get big complications.” Intellectually I know this. But days like yesterday try my soul. The first thing I ask myself when a patient has a complication after surgery is, “What did I do wrong?” Did I make a technical error? Did I miss some critical sign or lab value? I’m not comfortable until I’ve looked for those things, and even then feel that I must have missed something. This is the default mode for most surgeons I know. That type of thinking is built into our training. The ritual of...
ACS 2014

ACS 2014

New research is being presented at ACS 2014, the American College of Surgeons 2014 Annual Clinical Congress, from October 26 to 30 in San Francisco.   Meeting Highlights Assessing Online Sources on Prostate Cancer Screening Perforated Appendicitis in Pediatric Patients Smartphones for Wound Assessment Predicting Joint Replacement Outcomes Checklists for Surgical Patient Handoffs   News From ACS 2014 Surgeons Employ Two New Computer Imaging Approaches to Accurately Measure Breast Tumors and Chronic Wounds Breast and Colorectal Cancers Remain More Aggressive in Children Injury Prevention Intervention Cuts Distracted Driving in Half, According To Trauma Surgeons Universal Helmet Laws Reduce Traumatic Brain Injuries in Young Motorcyclists, According To Trauma Surgeons Surgical Humanitarian and Volunteerism Awards Honor Four Members of the American College of Surgeons for Service to the Medically Underserved Boston Surgeon Andrew L. Warshaw, MD, FACS, Installed as 95th President of the American College of Surgeons Honorary Fellowship in the American College of Surgeons is Awarded to Six Prominent Surgeons North Carolina Surgeon J. Wayne Meredith, MD, FACS, receives 2014 Distinguished Service Award of the American College of Surgeons American College of Surgeons Lifetime Achievement Award Given to Thomas R. Russell, MD, FACS New Drug Delivered through a Skin Patch Shows Promise in Healing Diabetic Foot Ulcers American College of Surgeons Announces Strategic Partnership with the Military Health System Many Older Trauma Patients Would Benefit from Palliative Care An Estimated Two Million Pounds of Unused Medical Supplies May Be Recoverable in U.S. Operating Rooms Each Year Daily Highlights Specialized settings described for surgical care of children Better access to surgery gaining recognition as a global health goal In the ICU, focused conversations...
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