title: Comparison of postoperative costs of two surgical techniques for hallux valgus (Kramer vs. scarf).
abstract: BACKGROUND
  Most studies of hallux valgus surgery focus on the radiological findings or on medium-term clinical follow-up. The results obtained using various osteotomy techniques do not differ greatly. However, patient comfort and the need for postoperative care do appear to present differences. In the Kramer technique, the osteotomy is secured with a wire extruding from the skin of the foot. In this situation, patients may well experience problems (or at least discomfort) in the immediate postoperative period. Previous studies of the Kramer technique (also known as SERI, or percutaneous distal metatarsal osteotomy) do not report an increased number of complications. Early complications may not influence the outcome in the medium to long term, and patient discomfort during the postoperative period is rarely reflected in the analysis of one-year results obtained with standard scales such as AOFAS; in our experience, however, patient discomfort, the care burden (i.e., the number of visits and emergency service consultations) and the economic cost of immediate postoperative care are all aspects that should be borne in mind when assessing the merits of different surgical techniques. In this study we compare the care burden and economic cost of two surgical approaches to hallux valgus correction--the Kramer and the scarf techniques--during the first postoperative year.
  
  
  METHODS
  Retrospective review of two independent patient cohorts. Sixty-nine feet underwent Kramer osteotomy and 133 the scarf technique. Care burden was assessed by the number of visits each patient required and the complications. The follow-up and costs of each were assessed and compared independently.
  
  
  RESULTS
  Both techniques obtain satisfactory clinical results at one year. However, comparison of clinical progression showed AOFAS score increases of 34.7 points for Kramer and 41.1 points for the scarf technique (p-value<0.05). Patients in the Kramer group required a higher number of visits, especially postoperative emergency department visits (p<0.05), and had a significantly higher number of complications (27.5% vs. 6.7%, p<0.05). The mean cost of follow-up was significantly higher in the Kramer group (€ 218.97 vs. € 171.41, p<0.05).
  
  
  CONCLUSIONS
  Kramer osteotomy presented significantly higher care burdens, complication rates and associated costs during the first year of follow-up. It is therefore a less cost-effective technique. Thus, even though according to the results of AOFAS we would not have changed our clinical practice, the analysis of these data has made us change our treatment strategy for hallux valgus and practically abandoned the use of the Kramer osteotomies.
authors: Foot and Ankle Unit, Department of Orthopaedic Surgery, Hospital Clínic, Barcelona, Spain. Electronic address: DPOGGIO@clinic.ub.es.
authors: Daniel
authors: D
authors: Poggio
authors: Hospital Clínic and San Rafael Hospital, University of Barcelona, Spain.
authors: Rodrigo
authors: R
authors: Melo
authors: University of Barcelona, Spain.
authors: Julio
authors: J
authors: Botello
authors: University of Barcelona, Spain.
authors: Carlos
authors: C
authors: Polo
authors: Hospital Clínic, Barcelona, Spain.
authors: Pablo
authors: P
authors: Fernández de Retana
authors: Foot and Ankle Unit, Department of Orthopaedic Surgery, Hospital Clínic, Barcelona, Spain.
authors: Jordi
authors: J
authors: Asunción
mesh_terms: D000368:Aged; D017281:Cost of Illness; D005260:Female; D006215:Hallux Valgus / Q000000981:diagnostic imaging / Q000191:economics / Q000601:surgery*; D006801:Humans; D008297:Male; D008682:Metatarsal Bones / Q000601:surgery; D008875:Middle Aged; D010027:Osteotomy / Q000191:economics*; D011859:Radiography; D012189:Retrospective Studies
keywords: Care burden; Cost-effectiveness; Hallux valgus; Kramer; Percutaneous distal osteotomy; SERI; Scarf