Operating Room Supply Costs in Orthopaedic Trauma: Cost Containment Opportunities
Gurnea, Taylor P. BS; Frye, Wesley P. RN-BSN; Althausen, Peter L. MD, MBA
Journal of Orthopaedic Trauma: December 2016 - Volume 30 - Issue - p S21–S26
Summary: In the current health care environment, cost containment is more important than ever. Most physicians currently are unaware of the cost of operating room supplies. A large amount of waste occurs secondary to lack of knowledge and absence of physician incentives for cost saving. Many of the decisions for supply use can be based on good scientific evidence, which supports specific cost saving measures. Careful attention to blood utilization and use of tranexamic acid has the potential to save millions in the hip fracture treatment and arthroplasty treatments. Standardization of surgical preparation and draping can decrease costs and prevent costly surgical site infections. Following protocols and guidelines for bone graft and orthobiologics is critical. The clinical and legal repercussions of retained instruments and costs associated with dropped implants is a huge source of wasted health care dollars. Reprocessing programs for external fixators and tourniquets have been extremely successful. A myriad of opportunities for intraoperative cost savings exist that could be applied to nearly every orthopaedic surgery performed in the United States. It is incumbent on all surgeons to put aside the choices made out of habit and take part in reducing operating room waste for the benefit of hospitals, patients, and the health care system. When applied to the 5.3 million orthopaedic surgeries performed annually in the United States, billions of dollars could easily be saved with no adverse effect on patient care.
Most physicians currently are unaware of the cost of operating room (OR) supplies. A large amount of waste occurs secondary to lack of knowledge and absence of physician incentives for cost saving. The objective of this article is to outline the opportunity costs possible with alignment. The underlying principle is that case standardization and a decrease in the use of unnecessary items could result in massive savings. Many articles have been published showing the science behind why we make certain choices in supply use but no costs have ever been associated with these changes. Such knowledge is extremely helpful for physicians across the country, as scientific support for change exists that could result in billions of dollars in savings without an adverse effect on clinical outcomes. In this article, hospital costs for common items are reported. Keep in mind that this is not the charge to the patient or insurance company, but the cost the hospital actually pays for goods. These supply costs are usually inflated 4–10 times at most hospitals to generate the “charge” to the patient or payer. Our objective is to provide information that allows individual surgeons to easily estimate the cost savings they could incur for their own hospitals, patients, and the healthcare system by changing OR supply practice patterns. When one considers that 5.3 million orthopaedic surgeries are performed in the United States each year, even small savings on each case can result in large savings if adopted nationwide.
BLOOD ISSUES AND PRODUCTS
Many facilities have demonstrated significant costs associated with blood product utilization and storage. At our institution, one unit of blood costs $211, a unit of platelets costs $532, and a unit of fresh frozen plasma costs $61. Orthopaedic surgeons often do not consider the economics and science surrounding the use of such products. In the past decade, several studies have been published in both the trauma and orthopaedic literature demonstrating clear transfusion guidelines and cost savings associated with adherence to protocols. Most studies agree on no transfusions for Hb > 7 for asymptomatic patients. Blood transfusion is not a benign process and can have adverse reactions in some patients. Minor transfusion reactions are estimated to cost $1000, whereas fatal reactions can cost as much as $112,578.1,2 Transfusions have also been shown to increase the infection rate for several reasons.3–5 Orthopaedic surgical site infections (SSIs) prolong hospital stays by a median of 2 weeks per patient, double hospitalization rates, and increase health care costs by more than 300%.6 One SSI is estimated to cost $30,000.7 At our trauma center, a blood management program began in 2013, establishing clear scientifically based guidelines for transfusion, transfusion audits, and specific blood order sets. Blood utilization decreased from 14,015 units to 11,443 in 1 year. Blood expenses decreased from $3.7 million to $2.9 million between 2014 and 2015. Orthopaedic utilization declined 9.7% for joint replacement and 9.8% for hip and femur fracture episodes of care. If $800,000 can be saved in 1 year at one trauma center, imagine what adherence to transfusion protocols for patients with orthopaedic trauma nationwide could accomplish.
The use of Cell Saver and its disposables has become common practice in pelvis and acetabular surgery despite several studies showing no difference in outcomes.8,9 Interestingly, Scannell et al showed that there was no difference in the outcome and blood-related charges increased $1264 (2.8 times) per patient. The only study supporting the use of Cell Saver in orthopaedic trauma surgery failed to include the device capital cost and the operating personnel, and as a result does not give a complete economic picture.10 The Cell Saver machine itself costs $4600, and the average disposables per case costs an average of $280. It is estimated that 120,000 pelvic and acetabular surgeries are performed each year in the United States.11 Just eliminating Cell Saver on blood-related charges could save $151,680,000 in the United States alone.
Recent data have demonstrated the benefits of tranexamic acid (TXA) in the surgical treatment of orthopaedic patients.12,13 Sarzaeem et al found that 14% of total knee arthroplasty (TKA) patients without TXA required transfusion, whereas no patients with TXA were transfused. Wang performed a meta-analysis of TXA use in total hip arthroplasty (THA) and found significant decrease in intraoperative blood loss, postoperative Hb decline, and decrease in drain output. They also found a 12% decrease in transfusion requirement.13 Most recently, both Yi et al and Nielsen et al found a clinically relevant 37% reduction in blood loss using combined intravenous and intrarticular TXA.14,15 Clearly, this is financially beneficial compared with the cost of a unit of blood, transfusion reaction, or SSI. Data from arthroplasty studies are clear, and hip fracture utilization of TXA is sure to follow. The cost of one preoperative dose is $18.85 at our institution. Cost analysis studies have estimated $1500 savings per patient with the use of TXA.16 The Centers for Disease Control and Prevention estimates that 719,000 TKA and 332,000 THA procedures are performed annually in the United States.17 If the cost savings suggested by Yang et al are accurate, use of TXA across the United States could save $1,576,500,000 in arthroplasty patients alone.
Another intraoperative and preoperative device that affects blood loss is the pelvic binder. Many studies have demonstrated that appropriate use of a binder is an effective means for temporary stabilization of open-book pelvic ring injuries.18,19 However, this commercially available binder is equivalent to a simple bed sheet.20 A T-POD binder costs $115, whereas a bed sheet costs $4.62, and clamps are reusable. Savings can be incurred by appropriate use of a binder (ie, not for Lateral Compression or acetabular fractures) or simply using a bed sheet for all cases because no additional clinical benefit has been demonstrated for using a binder other than ease of application. Depending on the volume of pelvic fractures at your institution, significant savings is possible.
SURGICAL SITE PREPARATION
Because of the massive costs associated with SSI, many studies have focused on the best clinical practices for surgical site preparation. When making a clinical and economic decision about which preparation to use and how to shave the surgical site, it is important to review the scientific literature.
The best choice for surgical preoperative skin preparation has been a matter of study for years. Because of its financial implications, it can be hard to know which author to believe. Several studies have shown clinical differences in the use of ChloraPrep versus iodine.20 Darouiche et al21 investigated a total of 849 patients and found a 6.6% decrease in SSI. Bibbo et al22 found chlorhexidine to be most effective for decontamination of the foot and ankle. The cost of ChloraPrep is $6.08 and that of iodine scrub is $0.90. However, as stated above, the cost of an SSI is estimated to be $30,000.7 It would seem clear that prevention is far more cost-effective than using a less expensive but less effective preparation agent.
Another cost debate always arises between use of a standard razor versus an electric shaver. Balthazar et el23 showed no statistical difference between electric clipper and standard razor. Hamilton et al24 compared razor, electric clippers, and depilatory and found the electric razor to be the cheapest option with no added increase to surgical infection rates. However, in both these studies, they did not use disposable clipper blades and the shaver head was not sterilized. A Cochrane Database review study published in 2011 also showed no statistically significant differences but suggests that clippers may be better at reducing SSIs.25 The standard razor costs $0.25, whereas an electric razor costs $139.00 and replacement blades cost $45.00.
Significant cost saving opportunity exists with standardization of draping. Many surgeons have specific preferences not based on science, but habit. Not only do surgical technicians have to remember multiple ways of doing things, it is also extremely costly. In addition, no scientific literature demonstrates decreased infection rates with the use of plastic 1010 or 1015 drapes versus towels, hip drapes versus split sheets, extremity drapes versus splits, or Coban versus ace wraps. However, the cost of these added soft goods is massive.
Standardization of draping can reduce costs. Premade packs for extremity surgery, arthroplasty, and arthroscopy can be purchased from certain vendors. This bundling significantly reduces costs. However, in many cases, these packs can be refined even further. With no scientific evidence showing benefit of split drapes versus hip drapes versus extremity drapes, the decision comes down to cost and surgeon preference. Any statements surgeons may make about decreased infection rates have not been supported by literature. A hip drape costs $18.18, an extremity drape costs $7.64, and a split drape costs $4.10. 1010 and 1015 drapes cost $0.92 and $1.03, respectively. If all surgeons agreed to transition to split drapes and halted use of 1010 and 1015 drapes, significant savings could be attained on every case.
Many surgeons use 3M Ioban drapes around the hip and pelvis. This item is expensive, and scientific data also show increased infection rates associated with the use of this product. A Cochrane Database review demonstrated no evidence that these adhesive drapes reduce infection and some evidence that they increase infection rates.26 Iodine impregnated adhesive drapes also had no effect on SSIs. Markatos et al and Chiu et al agreed that use of adherent plastic incision drapes for prophylaxis of SSIs is considered unnecessary in orthopaedic surgery.27,28 The cost of an Ioban drape is $11.31 and that of adhesive drape is $5.90. Based on lack of scientific support, these costs could be eliminated in nearly all the 5.3 million orthopeadic cases performed annually in the United States.
Another item often included in an extremity pack is an Esmarch bandage. This is designed to exanguinate the extremity before tourniquet inflation. No studies demonstrate clear superiority compared with merely elevating the limb. In fact, one study on TKA demonstrated that Esmarch exsanguination actually impedes venous outflow and arterial filling up to 14 days postoperatively.29 In addition, there a 4 reported cases of fatal pulmonary embolism after Esmarch bandage application in patients with trauma.30 This item that costs $2.14 may seem insignificant, but the cost of associated complications can be massive. If its use was discontinued across the United States in the 719,000 total knee replacements, 671,000 extremity fracture surgeries, and 500,000 carpal tunnel surgeries performed each year, savings would be astronomical.17
In extremity surgery, it has become common practice to use a stockinet, either standard or impervious and wrap this with an ace wrap or Coban. The thought behind this is to cover the toes or fingers, which tend to hold bacteria despite surgical preparation.31,32 However, once again, this is habit with no scientific evidence of decreased infection rates. A stockinet costs $3.50, an impervious stockinet costs $7.10, an Ace wrap costs $2.75, bias costs $2.10, and Coban costs $3.34. Discontinuing this practice saves another easy 10 dollars per case.
LOST INSTRUMENTS AND DROPPED IMPLANTS
Significant cost savings can also occur with improved OR personnel vigilance. The cost of lost instruments left in patients or thrown out with drapes at the end of the case is astronomical. Retained surgical implants not only injure patients but also result in a massive increase in treatment cost. One large study from the Mayo clinic estimated a retained sponge, or instrument occurs in 1 of 5500 cases. Hospitalizations involving lost sponges or instruments average $60,000 per patient. The average indemnity payout for a claim involving a retained surgical item is $473,000.33 Clearly, avoidance of this complication is paramount to cost-effective care.
Another large cost specific to orthopaedic trauma is dropped or nonutilized hardware. Hospital and implant company rules have dictated that a wrong size screw or dropped implant cannot be resterilized and used in another patient. The implant companies still charge for this although there is no science in this decision, only economics. One recent study showed waste occurred in 12% of all orthopaedic cases resulting in $634,668 in additional charges in 1 year in a single orthopaedic department.34 In trauma cases, the most commonly wasted implants were incorrectly measured or dropped screws. Although not the highest costs, trauma had highest percentage of waste (30%). Zywiel et al studied the cost of intraoperative waste in arthroplasty and found that implant waste occurred in 2% of cases annually resulting in $109,295 of waste at their institution. When extrapolated to the whole United States, the annual cost was $36,019,000.35Soroceanu et al36 showed that waste occurred in 20% of spine procedures amounting to an estimated $126,000,000 in annual waste. Simple attention to detail can save millions.
Many items in a basic OR pack are lower cost; however, some higher maintenance surgeons ask for additional items. Many times, these items can be very expensive. Positioning devices such as bone foam have recently become more popular. The cost of these ranges from $68 for a single piece to thousands for a full set of positioners. A stack of blankets can serve a similar purpose. The cost of blankets is $12.00, and they are reusable. Studies have shown over time that bone foam can be cost-effective if volume supports it. However, do not let the sales representative sell the hospital positioners you will not use. Also, taping directly on a positioner can tear it, so careless surgeons can cost through inattention.
Gowns and gloves can also be very expensive over time. Average pair of gloves costs $1.92 and standard gown costs $8.75. In teaching centers, it is often common place for multiple students to scrub at a time. Many times, extraassistants only get in the way, and their view of the surgery is compromised. Limiting the number of scrubbed observers or students can save hundreds of dollars a day as it costs about $13 per person.
Electrocautery tips are also a significant cost center. Think twice when asking for a needle tip that costs $5.65 or extended tip that costs $3.31 when a standard tip does just as well. Certainly, these items can be helpful in specific cases but should not be a knee jerk reaction.
Another opportunity for cost savings is the use of drains in orthopaedic surgery. Hsu et al37 showed no benefit of the use of drains in acetabular surgery. Parker et al38 performed a Cochrane Database meta-analysis on 3495 arthroplasty patients with closed suction drainage for hip and knee arthroplasty and found no difference in patients with drains and without. Bachoura et al39 performed a retrospective review of 1611 patients with orthopaedic trauma and found use of a wound drain to be a predictor of SSI. Despite the large number of orthopaedic studies evaluating the relationship of drain utilization and SSI, no existing level I randomized controlled trails demonstrate any benefit to closed suction drain utilization.40 The cost of a Hemovac drain is $14, the cost of a Jackson-Pratt drain is $10, and the cost of a blake drain is $8. The cost of a sewn-in drain or broken drain is $7–30,000. Clearly, limiting the use of drains is an easy change surgeons can make to be more cost-conscious.
Choice of wound closure can also come with a cost. A stapler costs $14, whereas nylon suture costs $2.00. Several newer devices such as the Quill, Zip16 Surgical Skin Closure, and V-Loc knotless wound closure have come onto the market. These closure devices cost many times that of simple suture. No studies exist showing difference in the infection rate or secondary outcomes except for closure time.41
One of the most costly, high-volume orthopaedic cases is hemiarthroplasty for displaced femoral neck fractures. Multiple cost savings opportunities exist, which are the target of Medicare's recent Bundled Payments for Care Improvement programs. The choice of implant—THA versus bipolar versus unipolar—is the largest cost item. At our institution, the average THA costs $4600, the average bipolar costs $1200, and the average Unipolar costs $1000. Multiple studies have shown no difference in the use of bipolar versus unipolar implants other than cost.42 Many recent studies have shown benefit of THA for younger patients and active elderly patients.43 Certainly, patient outcomes are paramount, but a patient with dementia does not need a high demand stem or THA. The use of generic implants or a matrix pricing system has been shown to be of value.44,45
The choice of cement use and cement type can also make a difference in cost. Press fit stems usually cost more, but cement use has been associated with added morbidity and mortality.46 Multiple cement types exist, and cost can vary widely. At our institution, fast set costs $82.48, regular cement costs $72.48, and antibiotic impregnated costs $293.00. The science behind which to use is cloudy.47 Good clinical judgment can result in significant savings.
Another costly practice is the routine sending of the femoral head to pathology. Several studies have demonstrated the futility and massive costs associated with this.48 Although in some instances it should be done, the majority of cases only add to hospital costs and the patient bill. Campbell et al estimated that with a routine cost of $100–200 per case, with the 332,000 THA and 719,000 TKAs performed each year, this could save from $33 to 67 million dollars annually.48
Several surgeons also use abduction pillows postoperatively. No study has shown decreased dislocation rates with these items. Each pillow costs $19.71. This is a wasteful process and could save a massive amount of money each year for the 332,000 hip arthroplasty cases performed in the United States each year amounting to 6.5 million dollars.
There has been a large amount of recent literature regarding the care and economics surrounding the treatment of open fractures. The FLOW study was the largest randomized clinical trial on 2551 open fractures, which demonstrated no difference in the use of pulsatile lavage devices or cystoscopy tubing.49 They concluded that low-pressure irrigation was an acceptable low-cost alternative for the irrigation of open fractures. Cystoscopy tubing costs $2.82, whereas a Pulsevac costs $30.00, and each type of Pulsevac tip costs $11.87 and splash guard costs $11.41. This study shows that cost savings of up to $50 a case could be achieved across the United States. Also, there are data that show that Pulsevac can be a source of iatrogenic injury causing addition soft tissue disruption.50 With data showing possible increased injury, no data showing improved outcomes, and significant cost savings, the choice should be clear.
Negative pressure wound therapy (NPWT) has become commonplace in orthopaedic trauma. Kempton et al51 examined the clinical efficacy and economics behind split-thickness skin grafting and the use of negative pressure dressings and local dressing changes and found no change in outcomes other than cost reduction. This result was similar to findings of a Cochrane database study.37 A NPWT machine costs $3604, the sponge and tubing costs $50.78 per change. Local wet-to-dry dressings cost much less depending on the wound size. However, for high-risk lower-extremity fractures, incisional NPWT has been shown to be helpful to prevent wound infection and dehiscence.52 They showed a 1.9 times high relative risk for complications in calcaneus, pilon, and plateau fractures without NPWT. As a result, NPWT is a valuable tool but should be used only when scientifically indicated.
Many studies have been published over the past 20 years demonstrating the futility of antibiotic irrigation for fracture surgery. This was confirmed by the FLOW study.49 The most common antibiotic used is cefazolin. The amount usually mixed in a 3000-mL bag of irrigation fluid is $5.10. It is estimated that 5.3 million orthopaedic surgeries are performed in the United States each year. Changing this outdated practice alone would result in at least $25 million dollars in savings.
BONE GRAFT AND ORTHOBIOLOGICS
Other than implants, the use of orthobiologics and bone graft can introduce significant operative supply costs. Very little good science exists to support the use of these products compared with the gold standard of physician-harvested autograft. Bone morphogenetic proteins such as Basic Metabolic Panel (BMP)-1 and OP-1 have seen rising use. BMP-7 (Infuse) has only 2 Food and Drug Administration–approved indications but is often used off label by trauma surgeons. A small costs $4263, a medium $4.893, and a large costs $5569. In 2012, one study demonstrated massive cost savings achieved by adhering to strict Food and Drug Administration guidelines, reducing annual expenditures for bone graft and bone biologics from $470,000 to $78,000 at a single institution.53 Recently, many of the scientific data regarding Infuse has been called into question because of researchers who admitted to falsifying data.54 Many surgeons are also convinced by sales representatives to use various putties and demineralized bone matrix, which can contain BMPs. Assays have shown that bioavailability is extremely variable based on lot number.55 Whether putty or gel form, at our facility, these products cost $145–$820 based on size from 1 to 10 cc. With completely unproven science, these should be used with caution. Allograft prices can vary significantly. At our facility, allograft cancellous chips range from $650 to $895 based on the size. It is wise to call various vendors and obtain the best contracted rate.
Incremental costs can also increase with the choice of postoperative immobilization for common fracture types. Many surgeons choose to place walking boots in place of simple plaster splints for ankle fractures. A walking boot costs $21.55, a simple plaster splint costs $2.28, and orthoglass costs $3.15. In a similar vein, for wrist fracture treatment, a simple volar plaster splint costs $2.28, whereas a Velcro wrist splint costs $12.32. After fixation of shoulder or other upper extremity fractures, some surgeons prefer sling immobilization. The cost of slings ($1.66), shoulder immobilizers ($3.62), and ultraslings ($14.54) vary greatly. Surgeons should choose only the more expensive option when clinically beneficial.
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SAVINGS FROM REPROCESSING
Because of the high cost of OR goods, many reprocessing options are now available. These have the potential to save large amounts of money. The most commonly reprocessed orthopaedic items include external fixators, arthroscopic shavers, and tourniquets. Reprocessed external fixation devices have been shown scientifically to be effective without compromising quality. Newer generations of fixator constructs can cost over $10,000 for an item used only 10 days. Horwitz et al56 showed a potential total cost savings on reusable components of 32% with a total of 27% savings for the whole external fixation system. No reprocessed components failed in clinical use over the course of study. Ledonio et al57 evaluated the sharpness and function of reprocessed arthroscopic shavers and found that surgeons were unable to distinguish reprocessed shavers that passed an acceptance test from new shavers based on functional characteristics. Because of these examples above, more reprocessing options are likely to become available. At our hospital alone, savings from reprocessing amount to over 1 million per year.
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This review should make it clear that a myriad of opportunities for intraoperative cost savings exist that could be applied to nearly every orthopaedic surgery performed in the United States. Many of the decisions for supply use can be based on good science, which supports specific cost saving measures. It is incumbent on all surgeons to put aside the choices made out of habit and take part in reducing OR waste. When applied to the 5.3 million orthopaedic surgeries performed annually in the United States, billions of dollars could easily be saved with no adverse effect on patient care.
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1. Carson JL, Altman DG, Duff A, et al.. Risk of bacterial infection associated with allogeneic blood transfusion among patients undergoing hip fracture repair. Transfusion. 1999;39:694–700.
2. Birkmeyer JD, Goodnough LT, AuBuchon JP, et al.. The cost-effectiveness of preoperative autologous blood donation for total hip and knee replacement. Transfusion. 1993;33:544–551.
3. Hill GE, Frawley WH, Griffith KE, et al.. Allogeneic blood transfusion increases the risk of postoperative bacterial infection: a meta-analysis. J Trauma. 2003;54:908–914.
4. Agarwal N, Murphy JG, Cayten CG, et al.. Blood transfusion increases the risk of infection after trauma. Arch Surg. 1993;128:171–176; discussion 176–7.
5. Squires JE. Risks of transfusion. South Med J. 2011;104:762.
6. Whitehouse JD, Friedman ND, Kirkland KB, et al.. The impact of surgical-site infections following orthopedic surgery at a community hospital and a university hospital: adverse quality of life, excess length of stay, and extra cost. Infect Control Hosp Epidemiol. 2002;23:183–189.
7. Urban JA. Cost analysis of surgical site infections. Surg Infect (Larchmt). 2006;7(suppl 1):S19–S22.
8. Firoozabadi R, Swenson A, Kleweno C, et al.. Cell Saver use in acetabular surgery: does approach matter? J Orthop Trauma. 2015;29:349–353.
9. Scannell B, Loeffler B, Bosse M, et al.. Efficacy of intraoperative red blood cell salvage and autotransfusion in the treatment of acetabular fractures. J Orthop Trauma. 2009;23:340–345.
10. Bigsby E, Acharya M, Ward A, et al.. The use of blood cell salvage in acetabular fracture internal fixation surgery. J Orthop Trauma. 2013;27:e230–e233.
11. Mauffrey C, Hao J, Cuellar DO III, et al.. The epidemiology and injury patterns of acetabular fractures: are the USA and China comparable? Clin Orthop Relat Res. 2014;472:3332–3337.
12. Sarzaeem M, Razi M, Kazemian G, et al.. Comparing efficacy of three methods of tranexamic acid administration in reducing hemoglobin drop following total knee arthroplasty. J Arthroplasty. 2014;29:1521–1524.
13. Wang C, Xu G, Han Z, et al.. Topical application of tranexamic acid in primary total hip arthroplasty: a systemic review and meta-analysis. Int J Surg. 2015;15:134–139.
14. Yi Z, Bin S, Jing Y, et al.. Tranexamic acid administration in primary total hip arthroplasty: a randomized controlled trial of intravenous combined with topical versus single-dose intravenous administration. J Bone Joint Surg Am. 2016;98:983–991.
15. Nielsen CS, Jans Ø, Ørsnes T, et al.. Combined intra-articular and intravenous tranexamic acid reduces blood loss in total knee arthroplasty: a randomized, double-blind, placebo-controlled trial. J Bone Joint Surg Am. 2016;98:835–841.
16. Yang Z, Chen W, Wu L. Effectiveness and safety of tranexamic acid in reducing blood loss in total knee arthroplasty: a meta-analysis. J Bone Joint Surg Am. 2012;94:1153–1159.
17. Inpatient Surgery [CDC web site] July 6, 2016. Available at: http://www.cdc.gov/nchs/fastats/inpatient-surgery.htm. Accessed April 28, 2016.
18. van Vugt AB, Tan ECTH, van Stigt SF. Effect of a new pelvic stabilizer (T-POD) on reduction of pelvic volume and haemodynamic stability in unstable pelvic fractures. Injury. 2010;41:1239–1243.
19. Spanjersberg WR, Knops SP, Schep NWL, et al.. Effectiveness and complications of pelvic circumferential compression devices in patients with unstable pelvic fractures: a systematic review of literature. Injury. 2009;40:1031–1035.
20. Prasarn M, Conrad B, Small J, et al.. Comparison of circumferential pelvic sheeting versus the T-POD on unstable pelvic injuries: a cadaveric study of stability. Injury. 2013;44:1756–1759.
21. Darouiche RO, Wall MJ, Itani KMF, et al.. Chlorhexidine–alcohol versus povidone–iodine for surgical-site antisepsis. N Engl J Med. 2010;362:18–26.
22. Bibbo C, Patel D, Gehrmann R, et al.. Chlorhexidine provides superior skin decontamination in foot and ankle surgery—a prospective randomized study. Clin Orthop Relat Res. 2005;438:204–208.
23. Balthazar ER, Colt JD, Nichols RL. Preoperative hair removal: a random prospective study of shaving versus clipping. South Med J. 1982;75:799.
24. Hamilton HW, Hamilton KR, Lone FJ. Preoperative hair removal. Can J Surg. 1977;20:269.
25. Tanner J, Norrie P, Melen K. Preoperative hair removal to reduce surgical site infection. Cochrane Database Syst Rev. 2011:CD004122.
26. Webster J, Alghamdi A. Use of plastic adhesive drapes during surgery for preventing surgical site infection. Cochrane Database Syst Rev. 2015:CD006353.
27. Markatos K, Kaseta M, Nikolaou VS. Perioperative skin preparation and draping in modern total joint arthroplasty: current evidence. Surg Infect (Larchmt). 2015;16:221.
28. Chiu KY, Lau SK, Fung B, et al.. Plastic adhesive drapes and wound infection after hip fracture surgery. Aust N Z J Surg. 1993;63:798.
29. Chiu F, Hung S, Chuang T, et al.. The impact of exsanguination by Esmarch bandage on venous hemodynamic changes in total knee arthroplasty—a prospective randomized study of 38 knees. Knee. 2012;19:213.
30. Darmanis S, Papanikolaou A, Pavlakis D. Fatal intra-operative pulmonary embolism following application of an Esmarch bandage. Injury. 2002;33:761–764.
31. Zacharias J, Largen PS, Crosby LA. Results of preprocedure and postprocedure toe cultures in orthopaedic surgery. Foot Ankle Int. 1998;19:166.
32. Ostrander RV, Brage ME, Botte MJ. Bacterial skin contamination after surgical preparation in foot and ankle surgery. Clin Orthop Relat Res. 2003:246–252.
33. Sloane T. The high cost of inaction: retained surgical sponges are draining hospital finances and harming reputations (Becker's infection control and clinical quality web site). August 12, 2013. Available at: http://www.beckershospitalreview.com/quality. Accessed April 28, 2016.
34. Payne A, Slover J, Inneh I, et al.. Orthopedic implant waste: analysis and quantification. Am J Orthop (Belle Mead NJ). 2015;44:554.
35. Zywiel MG, Ulrich SD, Suda AJ, et al.. Incidence and cost of intraoperative waste of hip and knee arthroplasty implants. J Arthroplasty. 2010;25:558–562.
36. Soroceanu A, Canacari E, Brown E, et al.. Intraoperative waste in spine surgery: incidence, cost, and effectiveness of an educational program. Spine (Phila Pa 1976). 2011;36:E1270–E1273.
37. Hsu JR, Stinner DJ, Rosenzweig SD, et al.. Is there a benefit to drains with a Kocher-Langenbeck approach? A prospective randomized pilot study. J Trauma. 2010;69:1222–1225.
38. Parker MJ, Roberts CP, Hay D. Closed suction drainage for hip and knee arthroplasty. A meta-analysis. J Bone Joint Surg Am. 2004;86-A:1146–1152.
39. Bachoura A, Guitton TG, Smith RM, et al.. Infirmity and injury complexity are risk factors for surgical-site infection after operative fracture care. Clin Orthop Relat Res. 2011;469:2621–2630.
40. Reiffel AJ, Barie PS, Spector JA. A multi-disciplinary review of the potential association between closed-suction drains and surgical site infection. Surg Infect (Larchmt). 2013;14:244.
41. Krishnan R, MacNeil SD, Malvankar-Mehta MS. Comparing sutures versus staples for skin closure after orthopaedic surgery: systematic review and meta-analysis. BMJ Open. 2016;6:e009257.
42. Zhou Z, Yan F, Sha W, et al.. Unipolar versus bipolar hemiarthroplasty for displaced femoral neck fractures in elderly patients. Orthopedics. 2015;38:697.
43. Zhao Y, Fu D, Chen K, et al.. Outcome of hemiarthroplasty and total hip replacement for active elderly patients with displaced femoral neck fractures: a meta-analysis of 8 randomized clinical trials. PLoS One. 2014;9:e98071.
44. Healy WL, Lorio R. Implant selection and cost for total joint arthroplast: conflict between surgeons and hospitals. Clin Orthop Relat Res. 2007;457:57–63.
45. Althausen PL, Lu M, Thomas KC, et al.. Implant standardization for hemiarthroplasty: implementation of a pricing matrix system at a level II community based trauma system. J Arthroplasty. 2014;29:781–785.
46. Middleton RG, Uzoigwe CE, Young PS, et al.. Peri-operative mortality after hemiarthroplasty for fracture of the hip: does cement make a difference? Bone Joint J. 2014;96-B:1185.
47. Antibiotic Impregnated Cement for Primary Hip or Knee Arthroplasty: A Review of the Clinical Cost-effectiveness. Ottowa, ON: Canadian Agency for Drugs and Technologies in health; 2015.
48. Campbell ML, Gregory AM, Mauerhan DR. Collection of surgical specimens in total joint arthroplasty. Is routine pathology cost effective? J Arthroplasty. 1997;12:60–63.
49. Bhandari M, Jeray KJ, Petrisor BA, et al.. A trial of wound irrigation in the initial management of open fracture wounds. N Engl J Med. 2015;373:2629.
50. Boyd JI, Wongworawat MD. High-pressure pulsatile lavage causes soft tissue damage. Clin Orthop Relat Res. 2004:13–17.
51. Kempton LB, Larson TB, Montijo HE, et al.. Increased cost of negative pressure dressings is not justified for split-thickness skin grafting of low-risk wounds. J Orthop Trauma. 2015;29:301.
52. Stannard JP, Volgas DA, McGwin G III, et al.. Incisional negative pressure wound therapy after high-risk lower extremity fractures. J Orthop Trauma. 2012;26:37.
53. Brady MA, Vallier HA, Wilber JH. Implementation of usage guidelines for bone graft products reduces costs. Poster presented at: October 3–6, 2012, Minneapolis, MN, OTA Annual Meeting 2012.
54. Armstrong D, Burton T. Medtronic paid the surgeon accused of falsifying study nearly $800,000. Wall Street J. 2009. Available at: Http://www.wsj.com/articles/SB124527830694724953. Accessed April 28, 2016.
55. Bae H, Zhao L, Zhu D, et al.. Variability across ten production lots of a single demineralized bone matrix product. J Bone Joint Surg Am. 2010;92:427–435.
56. Horwitz DS, Schabel KLS, Higgins TF. The economic impact of reprocessing external fixation components. J Bone Joint Surg Am. 2007;89:2132–2136.
57. Ledonio GT, Arendt A, Adams E, et al.. Reprocessed arthroscopic shavers: evaluation of sharpness and function in a cadaver model. Orthopedics. 2014;37:e1.
cost containment; orthopaedic trauma; intraoperative management; economics