Crosswalk between the PROMIS physical function CAT and PROMIS upper extremity CAT v1.2 in a hand surgery population.

BACKGROUND: There is no gold standard patient-reported outcome measure (PROM) in hand surgery. As a result, a diverse array of PROM instruments have been utilized across centers over time. Lack of score interchangeability limits the ability to compare or conglomerate scores when new instruments are introduced. Our aim was to develop a linkage for the PROMIS UE CAT v1.2 and PROMIS PF CAT scores and develop crosswalk tables for interconversion between these PROMs. METHODS: Retrospective review was conducted to identify adult (≥ 18y) patients seen by orthopaedic hand surgeons at a single academic tertiary care hospital who had completed PROMIS UE CAT v1.2 and PROMIS PF CAT score at the same visit. For those with multiple visits, only one randomly selected visit was included in the analyses. Pearson's correlation was calculated to determine the linear relationship between the scores. Linkage from PF to UE was performed utilizing several commonly utilized equating models (identity, mean, linear, equipercentile and circle-arc methods). The performance of the models was assessed using intraclass correlation (ICC) between observed PROMIS UE CAT v1.2 and estimated PROMIS UE CAT v1.2 scores generated using the model as well as Root Mean Square Error (RMSE). The model chosen as the 'best' was further assessed for population invariance using root expected mean squared difference (REMSD) where < 0.08 were considered good. RESULTS: Of 10,081 included patients, mean age was 48.3 (SD = 17.0), and 54% were female (5,477/10,081). Mean UE CAT v1.2 and PF CAT scores were 37 (SD = 9.8) and 46 (SD = 10.0), respectively. There was a strong correlation between the scores (Pearson correlation r = 0.70). All methods performed acceptably (ICC ≥ 0.66 and RMSE < = 7.52 for all). The equipercentile method had the highest ICC (ICC = 0.70 (95% CI 0.69-0.71)) while the mean and circle arc methods had the lowest RMSE. The circle arc method is the most reliable with the smallest standard error and has satisfactory population invariance across age group (REMSD 0.065) and sex (REMSD 0.036). CONCLUSIONS: Crosswalk tables to be used for bidirectional conversion between scores were created. LEVEL OF EVIDENCE: III.

The Relationship Between Patient-Reported Outcomes and Patient Satisfaction With Ligament Reconstruction Tendon Interposition.

PURPOSE: Achieving the minimal clinically important difference (MCID) on an outcomes instrument and reporting satisfaction with surgical outcomes are not equivalent. We hypothesized that improvement exceeding the QuickDASH and PROMIS UE CAT MCID is associated with a greater likelihood of reporting satisfaction with ligament reconstruction tendon interposition (LRTI) treatment. Our secondary hypothesis was that a subset of patients failing to meet MCID would still be satisfied. METHODS: Patients ≥1 year after LRTI at one academic tertiary institution were included. QuickDASH and UE CAT v1.2 scores were obtained before and after surgery. Postoperative satisfaction and levels of improvement in pain and function were also obtained. RESULTS: A total of 93 patients completed the QuickDASH, and of those, 90 also completed the UE CAT. At a mean of 2.6 ± 1.0 years after surgery, QuickDASH and UE CAT score improvement exceeded the previously published MCID estimates of 8.8 and 4.8. Although 90% (84/93) of the patients reported satisfaction, only 85% (72/93) and 72% (59/90) achieved MCID on the QuickDASH and UE CAT, respectively. Using the MCID estimate of 8.8, 96% (72/75) of the patients meeting the MCID were satisfied with their treatment. Those failing to achieve MCID reported significantly less physical function and pain improvement; however, most were satisfied nonetheless (68% [13/19] for QuickDASH, 77% [23/30] for UE CAT). CONCLUSIONS: Achieving published MCID thresholds on the QuickDASH and PROMIS UE CAT v1.2 was predictive of patients reporting general satisfaction with their LRTI outcome ≥1 year after surgery. Most patients failing to achieve MCID still reported satisfaction with their LRTI. Achieving MCID thresholds alone should not be used as a surrogate for patient satisfaction with their treatment. Patient satisfaction is a complicated construct that is potentially very different from that of high-quality care. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Staple Fixation in Ulnar-Shortening Osteotomies.

Ulnar-sided wrist pain is commonly caused by the ulnar impaction syndrome. Ulnar-shortening osteotomy is a surgical treatment that is used to address ulnar impaction syndrome that fails conservative management. Unfortunately, hardware irritation and nonunion are well-known complications of this procedure. This case report details the course of two patients with nonunion after ulnar-shortening osteotomy who were treated with a combination of a nitinol compression staple and neutralization plate. Further investigation is required to determine the long-term outcomes and indications for nitinol-staple fixation for nonunion after ulnar-shortening osteotomy.

Patient Satisfaction with Virtual Clinic Encounters: Analysis of Factors that Impact the Press Ganey Survey in the Hand Surgery Population.

Purpose: Our purpose was to identify patient characteristics and visit components that affect patient satisfaction with virtual new patient visits in an outpatient hand surgery clinic as measured by the Press Ganey Outpatient Medical Practice Survey (PGOMPS) total score (primary outcome) and provider subscore (secondary outcome). Methods: Adult patients evaluated through virtual new patient visits at a tertiary academic medical center between January 2020 and October 2020 who completed the PGOMPS for virtual visits were included. Data regarding demographics and visit characteristics were collected via chart review. Factors associated with satisfaction were identified using a Tobit regression model on the continuous score outcomes (Total Score and Provider Subscore) to account for substantial ceiling effects. Results: A total of 95 patients were included: 54% were men and the mean age was 54 ± 16 years. Mean area deprivation index was 32 ± 18, and the mean driving distance to the clinic was 97 ± 188 mi. Common diagnoses include compressive neuropathy (21%), hand arthritis (19%), hand mass (12%), and fracture/dislocation (11%). Treatment recommendations included small joint injection (20%), in-person evaluation (25%), surgery (36%), and splinting (20%). Multivariable Tobit regressions showed notable differences in satisfaction by the provider on the Total Score but not on the Provider Subscore. Other factors known to affect the PGOMPS scores for in-person visits were not notably associated with the Total or Provider Sub-Scores for virtual visits (area deprivation index, age, and offer of surgery or injection) other than the body mass index. Conclusions: Virtual clinic visit satisfaction was affected by the provider. Wait time strongly affects satisfaction with in-person visits but is not accounted for by the PGOMPS scoring system for virtual visits, which is a limitation of their survey. Further work is required to determine how to improve the patient experience with virtual visits. Type of study/level of evidence: Prognostic IV.

Fixation Techniques for Scaphoid Nonunion.

Scaphoid fractures are common injuries with high risk of nonunion. Various fixation techniques exist for managing scaphoid nonunions, including Kirschner wires, single or dual headless compression screws, combination fixation techniques, volar plating, and compressive staple fixation. The indication for each fixation technique varies depending on the patient, type of nonunion, and clinical scenario.

Evaluating the Performance of an Automated Patient-Reported Outcomes Collection Platform in a Postoperative Hand Surgery Population.

PURPOSE: Reliable collection of postoperative patient-reported outcome measures (PROMs) is critical to understanding surgical outcomes and the value of care. Automated PROMs collection, triggered by the electronic medical record at the 1-year postoperative anniversary, may provide a simple way to acquire outcomes for patients who have been discharged from clinic. The purposes of this study were to (1) evaluate the percentage of responses with an automated PROMs collection platform and (2) identify whether such a system may introduce selection bias by comparing responders with nonresponders. METHODS: Adult patients (aged ≥18 years) undergoing hand and upper-extremity surgeries between August 2017 and January 2019 were included. Preoperative Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores were collected using tablet computer. Postoperative QuickDASH scores were collected using a single electronic survey request 1 year after surgery via an email with a personalized REDCap link. Univariate and multivariable regression analyses were performed to identify factors that differed between responders and nonresponders. RESULTS: A response rate of 27% (269 of 1010) was observed for the eligible postoperative patients. On multivariable analysis, the following were associated with greater odds of response: older age, Caucasian race (vs unknown), longer surgery duration, attending the first postoperative visit, and responding to the preoperative QuickDASH. CONCLUSIONS: The poor response rate that was observed highlights that an automated single email postoperative contact for PROMs collection is insufficient-active follow-up via reminder emails and/or telephone calls is needed. Outcome researchers and clinicians must be aware of potential selection biases, such as age and race, that may exist with automated PROMs collection. CLINICAL RELEVANCE: Single email postoperative contact to obtain postoperative PROMs is insufficient.

Evaluation of Preoperative Factors Affecting Midterm Patient-Reported Outcomes Following Ligament Reconstruction Tendon Interposition: A Prognostic Study.

PURPOSE: The aim of this study was to evaluate the prognostic value of preoperative patient-reported outcomes as predictors of functional improvement following ligament reconstruction tendon interposition. We hypothesized that high levels of preoperative pain interference (PI) and upper-extremity disability are associated with lower magnitudes of functional improvement ≥1 year after surgery on the shortened version of the Disabilities of the Arm, Shoulder, and Hand (QuickDASH) (primary outcome) and Patient-Reported Outcomes Measurement Information System Upper Extremity (UE) Computer Adaptive Test (CAT) (UE CAT) v1.2 (secondary outcome). METHODS: Adult patients who underwent ligament reconstruction tendon interposition between February 2014 and April 2018 at an academic tertiary institution were considered for inclusion in this longitudinal cohort study. Patient-reported outcomes were collected at baseline and ≥1 year after surgery. Univariate and multivariable linear regression analyses were performed to identify factors associated with the magnitude of functional improvement on the QuickDASH and UE CAT. RESULTS: Among 93 included participants, the mean age was 61 ± 7 years, and 75 (81%) were women. At 2.5 ± 1.0 years after surgery, the QuickDASH and UE CAT improved by a mean of 24.5 ± 20.9 and 9.9 ± 10.7 points, respectively. In the primary multivariable model, a greater preoperative QuickDASH (indicative of lower function; coefficient, 0.8; 95% confidence interval [CI], 0.6 to 0.9) and lower preoperative Performance of Patient-Reported Outcomes Measurement Information System PI CAT (eg, less pain interference; coefficient, -0.7; 95% CI, -1.2 to -0.2) were associated with greater QuickDASH improvement independent of potential confounders. In the secondary multivariable model, lower preoperative UE CAT (indicative of worse function; coefficient, -0.9; 95% CI, -1.1 to -0.7) and lower preoperative Patient-Reported Outcomes Measurement Information System PI CAT (coefficient, -0.3; 95% CI, -0.6 to -0.1) were associated with greater UE CAT improvement. CONCLUSIONS: Preoperative patient-reported outcomes may be useful in understanding the degree of improvement that certain patient populations can expect from ligament reconstruction tendon interposition. Those with lower baseline (preoperative) upper-extremity function and PI are expected to derive the greatest functional improvement in the midterm. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Establishing the Patient Acceptable Symptom State in a Nonshoulder Hand and Upper Extremity Population for the Disabilities of the Arm, Shoulder, and Hand and Patient-Reported Outcomes Measurement Information System Upper Extremity Computer Adaptive Tests.

PURPOSE: It is unclear what score thresholds on patient-reported outcomes instruments reflect an acceptable level of upper extremity (UE) function from the perspective of patients undergoing hand surgery. The purpose of this study was to calculate the patient acceptable symptom state (PASS) for the Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and Patient-Reported Outcomes Measurement Information System (PROMIS) UE Computer Adaptive Test (CAT), version 2.0, in a population who underwent hand surgery. METHODS: Adult patients who underwent hand surgery between February 2019 and December 2019 at a single academic tertiary institution were identified. QuickDASH and PROMIS UE CAT version 2.0 scores were collected 1 year after surgery, as were separate symptom- and function-specific anchor questions that queried the acceptability of patients' current state. Threshold values predictive of a patient reporting an acceptable symptom state (PASS[+]) were calculated for both instruments using the 75th percentile score for patients in the PASS(+) group and the Youden Index as determined by receiver operating curve (ROC) analysis. RESULTS: A total of 222 patients were included. QuickDASH and PROMIS UE CAT scores differed significantly between the PASS(+) and PASS(-) groups. The 75th percentile method yielded PASS values of <16 for the QuickDASH and >43 for the PROMIS UE CAT for both anchor questions. The ROC analysis yielded PASS estimates of <15.9 to <20.5 for the QuickDASH and >38.1 to >46.2 for the PROMIS UE CAT, with ranges calculated from differing threshold values for each of the 2 anchor questions. The ROC-based estimates demonstrated high levels of model discrimination (area under the curve ≥ 0.80). CONCLUSIONS: We propose PASS estimates obtained using the 75th percentile and ROC methods. CLINICAL RELEVANCE: Specifically, PASS values in the range of 15.9-20.5 for the QuickDASH and 38.1-46.2 for the PROMIS UE CAT version 2.0 should be used when interpreting outcomes at a population level.

Association of Cam Deformity on Anteroposterior Pelvic Radiographs and More Severe Chondral Damage in Femoroacetabular Impingement Syndrome.

BACKGROUND: Abnormal proximal femoral morphology in femoroacetabular impingement syndrome (FAIS) identifiable on the anteroposterior (AP) pelvic radiograph has been described as the "pistol grip" deformity. The effect of a superior cam deformity identified on this radiographic view remains unknown. PURPOSES: To assess the relationship between AP cam deformity (AP alpha angle [AP AA] >55°) and cartilage injury; to assess the relationship between AP cam deformity and labral injury; and to determine if patient factors are correlated with cartilage and labral injury. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Patients undergoing osteochondroplasty and labral repair for FAIS with a single surgeon were identified retrospectively. Intraoperative size, location, and severity of cartilage and labral damage were prospectively collected. Chondrolabral and femoral/acetabular cartilage damage were graded with the Beck labral and cartilage injury criteria. Radiographic data included the AP AA, lateral center-edge angle (LCEA), and maximum femoral alpha angle (MF AA). Patients with hip dysplasia (LCEA <18°; LCEA 18°-25° with acetabular index >10°) were excluded. Outcomes were compared across cartilage and labral severity grades. We report odds ratios (ORs) with 95% confidence intervals and P values from multivariable logistic regressions. RESULTS: Of the 158 included hips (154 patients), 69% were female and the mean (± standard deviation [SD]) age was 30.3 ± 9.7 years. Increase in age, increase in body mass index (BMI), and male sex were associated with increasing severity of cartilage and labral injury. More severe cartilage damage was associated with increasing AP AA (P < .001) and MF AA (P < .001). The odds of developing a higher category of cartilage injury severity (grade ≥3) were 119% higher (OR, 2.19 [95% CI, 1.36-3.64]; P = .002) for every SD increase (16.7°) in AP AA, adjusting for age, sex, and BMI. The odds of developing a severe labral injury (grade ≥3) were 118% higher (OR, 2.18 [95% CI 1.17-4.32]; P = .018) for every SD increase (10.5°) in MF AA, adjusting for age, sex, BMI, and AP AA. CONCLUSION: Increasing age and BMI, and male sex are associated with increasing severity of cartilage and labral injury in FAIS. The odds of developing a cartilage injury are significantly higher with independent increases in AP AA and MF AA.

Effect of Perioperative Opioid Use on Patients Undergoing Hip Arthroscopy.

Background: Opioids are commonly used to treat postoperative pain; however, guidelines vary regarding safe opioid use after hip arthroscopy. Purpose/Hypothesis: The purposes were to (1) identify risk factors for persistent opioid use, (2) assess the effect of opioid use on outcomes, and (3) describe common opioid prescribing patterns after hip arthroscopy. It was hypothesized that preoperative opioid use would affect complication rates and result in greater postoperative opioid use. Study Design: Case-control study; Level of evidence 3. Methods: The Utah State All Payer Claims Database was queried for patients who underwent hip arthroscopy between January 2013 and December 2017. Included were patients ≥14 years of age at index surgery with continuous insurance. Patients were separated into acute (<3 months) and chronic (≥3 months) postoperative opioid use groups. Primary outcomes included revision surgery, complications (infection, pulmonary embolism/deep venous thrombosis, death), emergency department (ED) visits, and hospital admissions. Multivariate logistic regression was utilized to identify factors associated with the outcomes. Results: Included were 2835 patients (mean age, 47 years; range, 14-64 years), of whom 2544 were in the acute opioid use and 291 were in the chronic opioid use group. Notably, 91% of the patients in the chronic group took opioid medications preoperatively, and they were more than twice as likely to carry a mental health diagnosis (P < .01). Patients in the acute group had a significantly shorter initial prescription duration, took fewer opioid pills, and had fewer refills than those in the chronic group (P < .01 for all). Patients in the chronic group had a significantly higher risk of postoperative ED visits (odds ratio [OR], 2.76; P = .008), hospital admission (OR, 3.02; P = .002), and additional surgery (P = .003), as well as infection (OR, 2.55; P < .001) and hematoma (OR, 2.43; P = .030). Patients who had used opioids before hip arthroscopy were more likely to need more refills (P < .01). A formal opioid use disorder diagnosis correlated significantly with postoperative hospital admissions (OR, 3.83; P = .044) and revision hip arthroscopy (OR, 4.72; P = .003). Conclusion: Mental health and substance use disorders were more common in patients with chronic postoperative opioid use, and chronic postoperative opioid use was associated with greater likelihood of postoperative complications. Preoperative opioid use was significantly correlated with chronic postoperative opioid use and with increased refill requests after index arthroscopy.

Patient Expectations for Symptomatic Improvement before Cubital Tunnel Release.

Patient expectations before cubital tunnel release (CuTR), a common procedure that leads to incomplete symptom resolution for many patients, are unclear. Study purposes included (1) describing preoperative patient expectations, and (2) identifying factors affecting expectations. Methods: Included patients underwent isolated unilateral CuTR between 2015 and 2021 at a single tertiary academic medical center. Expectations regarding the level of symptomatic improvement were queried preoperatively. Univariate and multivariable binary logistic regression was performed to determine factors associated with expecting great improvement. Results: Of the 92 included patients, 43 (47%) patients expected great improvement, whereas 27 (29%), four (4%), and five patients (5%) expected some, little, and no improvement, respectively. The remainder (14%) had no expectations. Multivariable modeling demonstrated that retired or unemployed/disabled work status, and commercial insurance status (versus Medicare or Medicaid) were associated with lower expectations independent of the surgeon, surgical technique, revision versus primary CuTR, preoperative atrophy or constant numbness, diabetes, and all studied demographic factors, including social deprivation. Conclusions: Roughly half of the patients expect great relief, and a third expect lesser degrees of relief, following CuTR. Preoperative expectations are significantly higher in patients with Medicaid and Medicare insurance, representing an opportunity for education, given the association between public insurance payer status and worse health outcomes in general. Age, BMI, preoperative atrophy and/or numbness, and the presence of medical comorbidities do not influence expectations but have been shown to yield worse outcomes or influence need for revision CuTR, representing an opportunity for intervention to align patient and surgeon expectations.

Femoral neck shaft angle is not correlated with femoral version: A retrospective study of computed tomography scans.

BACKGROUND: An understanding of femoral anteversion and neck-shaft angle (NSA) is essential to deliver optimal orthopaedic surgical care. Despite the importance, there is little research examining the relationship between femoral anteversion and the NSA in an adult population. This study sought to determine if there is a correlation between femoral neck shaft angle and version in skeletally mature adults using computed tomography (CT) scanograms. METHODS: Between January 2010 and June 2017, all skeletally mature patients who had received a CT scanogram of the lower extremity were reviewed. Exclusion criteria included: (1) radiographic evidence of osteoarthritis, (2) history of hip, femur, or knee surgery or trauma, (3) and anatomic abnormalities of the proximal femur including prior slipped capital femoral epiphysis or Legg-Calvé-Perthes disease. Both femoral version and NSA were measured by a musculoskeletal fellowship trained radiologist using CT scanograms. Correlation between femoral version and NSA was determined using coefficient of determination (R2) and Pearson correlation coefficient (r) for the group as a whole and for each sex. RESULTS: There was no statistical correlation between femoral version and NSA for either the entire cohort or for each sex. For the entire cohort, R2 = 0.0016 and r was 0.04 (p=0.45), for females, R2 = 0.0005 and r was 0.0224 (p=0.72), and for males, R2 = 0.0342 and r was 0.185 (p=0.07). CONCLUSION: There was no correlation between femoral version and NSA. This finding is beneficial for surgeons to understand the proximal femoral anatomy. Patients with an increased femoral NSA should not be assumed to have increased femoral anteversion. LEVEL OF EVIDENCE: Level III, Retrospective Cohort Study.

Scaphotrapeziotrapezoid Arthrodesis: Systematic Review.

PURPOSE: Scaphotrapeziotrapezoid (STT) arthrodesis surgery is used for various types of wrist pathologies. The objective of our study was to perform a systematic review of complications and outcomes after STT arthrodesis. METHODS: Several major databases were used to perform a systematic literature review in order to obtain articles reporting complications and outcomes following STT arthrodesis. The primary purpose was to identify rates of nonunion and conversion to total wrist arthrodesis. Secondary outcomes included wrist range of motion, grip strength, and Disabilities of the Arm Shoulder and Hand scores. A multivariable analysis was performed to evaluate factors associated with the primary and secondary outcomes of interest. RESULTS: Out of the 854 records identified in the primary literature search, 30 studies were included in the analysis. A total of 1,429 procedures were performed for 1,404 patients. The pooled nonunion rate was 6.3% (95% CI, 3.5-9.9) and the rate of conversion to total wrist arthrodesis following the index STT was 4.2% (95% CI, 2.2-6.7). The mean pooled wrist flexion was 40.7° (95% CI, 30.8-50.5) and extension was 49.7° (95% CI, 43.5-55.8). At final follow-up, the mean pooled grip strength was 75.9% (95% CI, 69.3-82.5) of the nonsurgical contralateral hand. Compared with all other known indications, Kienbock disease had a statistically significant lower nonunion rate (14.1% vs 3.3%, respectively). Mixed-effects linear regression using patient-level data revealed that increasing age was significantly associated with complications, independent of occupation and diagnosis. CONCLUSIONS: Our study demonstrated a low failure rate and conversion to total wrist arthrodesis after STT arthrodesis and acceptable postoperative wrist range of motion and strength when compared to the contralateral hand. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Scaphotrapeziotrapezoid Arthrodesis: A 10-Year Follow-up Study of Complications in 58 Wrists.

BACKGROUND: Scaphotrapeziotrapezoid (STT) arthrodesis is a procedure used for specific degenerative arthritis and instability patterns of the wrist. This study evaluates nonunion rate and risk factors for reoperation after STT arthrodesis in the Veterans Affairs Department patient population. The purpose of our study was to assess the long-term nonunion rate following STT arthrodesis and to identify factors associated with reoperation. METHODS: The national Veterans Health Administration Corporate Data Warehouse and Current Procedural Terminology codes identified STT arthrodesis procedures from 1995 to 2016. Frequencies of total wrist arthrodesis (TWA) and secondary operations were determined. Univariate analyses provided odds ratios for risk factors associated with complications. RESULTS: Fifty-eight STT arthrodeses were performed in 54 patients with a mean follow-up of 120 months. Kirschner wires (K-wires) were the most common fixation method (69%). Six wrists (10%) required secondary procedures: 5 TWAs and 1 revision STT arthrodesis. Four patients underwent additional procedures for nonunion (7%). Twenty-four patients required K-wire removal, 8 (14%) of these in the operating room, which were not included in regression analysis. Every increase in 1 year of age resulted in a 15% decrease in likelihood of reoperation (95% confidence interval: 0.77-0.93; P < .0001). Opioid use within 90 days before surgery (P = 1.00), positive smoking history (P = 1.00), race (P = .30), comorbidity count (P = .25), and body mass index (P = .19) were not associated with increased risk of reoperation. CONCLUSIONS: At a mean follow-up of 10 years, patients undergoing STT arthrodesis have a 10% risk of reoperation, and this risk decreases with older patient age. There was a symptomatic nonunion rate of 7%, similar to prior published rates. Patient demographics, comorbidity, smoking history, and opioid use did not appear to increase risk of reoperation.

Evaluation of Patient Expectations before Carpal Tunnel Release.

BACKGROUND: Carpal tunnel release (CTR) is common, yet patient treatment expectations remain unclear. The primary purpose was to describe patient expectations before CTR. Secondarily, we aimed to identify factors influencing expectations. METHODS: Included patients underwent unilateral or bilateral CTR between 2015 and 2017 at a single academic center. Expectations regarding the level of relief/improvement were queried. Area deprivation index (ADI) was used to measure social deprivation. Univariate and multivariable logistic regression identified factors associated with expecting great relief/improvement. RESULTS: Of 307 included patients, mean age was 54 ± 16 years and 63% were women. Patients most commonly expected great (58%) or some (23%) relief/improvement. Few patients expected little (3%) or no (4%) relief/improvement, and 13% had no expectations. In the multivariable analysis, male sex, lower social deprivation, and lower BMI were associated with expecting great relief/improvement. Age, surgical technique (open versus endoscopic), use of the operating room versus procedure room, and preoperative factors (constant numbness, weakness/atrophy, duration of symptoms, and QuickDASH) were not associated with expectations. CONCLUSIONS: Most patients expect some to great improvement after CTR. This was independent of several factors with a known association with worse outcomes (advanced age, atrophy/weakness, and constant numbness). Male sex was associated with the expectation of great improvement, in which superior outcomes relative to females have not been borne out in the literature. These findings highlight patient counseling opportunities. The observed association between social deprivation and expectations warrants further investigation, as the socioeconomically disadvantaged experience worse healthcare outcomes in general.

Optimizing Costs and Outcomes for Carpal Tunnel Release Surgery: A Cost-Effectiveness Analysis from Societal and Health-Care System Perspectives.

BACKGROUND: It is unclear which carpal tunnel release (CTR) strategy (i.e., which combination of surgical technique and setting) is most cost-effective. A cost-effectiveness analysis was performed to compare (1) open CTR in the procedure room (OCTR/PR), (2) OCTR in the operating room (OCTR/OR), and (3) endoscopic CTR in the operating room (ECTR/OR). METHODS: A decision analytic model was used to compare costs and health utilities between treatment strategies. Utility and probability parameters were identified from the literature. Medical costs were estimated with Medicare ambulatory surgical payment data. Indirect costs were related to days out of work due to surgical recovery and complications. The effectiveness outcome was quality-adjusted life years (QALYs). Probabilistic sensitivity analyses and one-way sensitivity analyses were performed. Cost-effectiveness was assessed from the societal and health-care system perspectives with use of a willingness-to-pay threshold of $100,000/QALY. RESULTS: In the base-case analysis, OCTR/PR was more cost-effective than OCTR/OR and ECTR/OR from the societal perspective. The mean total costs and QALYs per patient were $29,738 ± $4,098 and 0.88 ± 0.08 for OCTR/PR, $30,002 ± $4,098 and 0.88 ± 0.08 for OCTR/OR, and $41,311 ± $4,833 and 0.87 ± 0.08 for ECTR/OR. OCTR/PR was also the most cost-effective strategy from the health-care system perspective. These findings were robust in the probabilistic sensitivity analyses: OCTR/PR was the dominant strategy (greater QALYs at a lower cost) in 55% and 61% of iterations from societal and health-care system perspectives, respectively. One-way sensitivity analysis demonstrated that OCTR/PR and OCTR/OR remained more cost-effective than ECTR/OR from a societal perspective under the following conditions: $0 surgical cost of ECTR, 0% revision rate following ECTR, equalization of the return-to-work rate between OCTR and ECTR, or 0 days out of work following ECTR. OCTR/OR became more cost-effective than OCTR/PR with the median nerve injury rate tripling and doubling from societal and health-care system perspectives, respectively, or if surgical direct costs in the PR exceeded those in the OR. CONCLUSIONS: Compared with OCTR/OR and ECTR/OR, OCTR/PR minimizes costs to the health-care system and society while providing favorable outcomes. LEVEL OF EVIDENCE: Economic and Decision Analysis Level III. See Instructions for Authors for a complete description of levels of evidence.

Femoral Neck Shaft Angle and Management of Proximal Femur Fractures: Is the Contralateral Femur a Reliable Template?

OBJECTIVES: To (1) assess interrater reliability of a novel technique for measurement of neck shaft angle (NSA); (2) use pelvic anteroposterior (AP) radiographs of unaffected hips to assess variability of NSA; and (3) evaluate the side-to-side variability of NSA to determine reliability of using the contralateral hip as a template. DESIGN: Retrospective cohort study. SETTING: Academic Level 1 regional trauma center. PATIENTS/PARTICIPANTS: Four hundred six femora (203 patients) with standing AP pelvis radiographs were selected. Exclusions included lack of acceptable imaging, congenital abnormalities, or prior hip surgery. INTERVENTION: An AP pelvis radiograph in the standing position. MAIN OUTCOME MEASUREMENTS: Bilateral NSA measurements obtained in a blinded fashion between 2 reviewers. Pearson coefficients and coefficient of determination assessed correlations and variability between left and right NSA. Concordance correlation coefficients assessed the interrater reliability between measurements performed by the 2 reviewers. RESULTS: Two hundred three patients (406 femora) were assessed. Male patients had a lower overall NSA mean of 131.56 degrees ± 4.74 than females with 133.61 degrees ± 5.17. There was no significant difference in NSA side-to-side in females (P = 0.18), 0.3 degrees [95% confidence interval (-0.15 to 0.75)], or males (P = 0.68), 0.19 degrees [95% confidence interval (-0.74 to 1.12)]. There was a strong linear relationship between left and right femora (r2 = 0.70). Forty-one percent of patients fell within the 131-135 degrees range bilaterally. Eighty-eight percent of patients had <5 degrees difference in NSA bilaterally and 0% had >10 degrees difference. CONCLUSIONS: There is no significant variability between bilateral femora in males and females. Use of this measurement method and contralateral NSA for proximal femur fracture planning is supported.

Femoral Head Chondrocyte Viability at the Cam Deformity in Patients With Femoroacetabular Impingement Syndrome.

BACKGROUND: Patients with hip pathology, such as femoroacetabular impingement (FAI) or hip dysplasia, are known to sustain chondral delamination injuries identifiable during hip arthroscopy, with an incidence of 44% to 75%. There are studies focused on understanding acetabular chondral flap viability, but there is a dearth of research regarding the viability of femoral head cartilage overlying the cam deformity in FAI. PURPOSE: To describe the viability and immunohistochemistry staining patterns of femoral head cartilage in the setting of FAI. STUDY DESIGN: Descriptive laboratory study. METHODS: Between September 2018 and August 2019, a single surgeon prospectively collected full-thickness femoral cartilage from cam deformities in 14 patients with FAI undergoing osteoplasty. Samples were assessed for viability and underwent immunohistochemistry staining for collagen type I, collagen type II, and aggrecan. RESULTS: The data set included 14 patients. Twelve samples were assessed for viability and 14 for immunohistochemistry straining. The mean patient age was 34.1 years, and the mean body mass index was 24.69. Mean ± SD chondrocyte viability per patient was 52% ± 11%. At the time of cell isolation, 8 of the 12 patients had viability >50%, with a maximum of 68.2%. This viability increased after a primary culture period, varying from 9 to 13 days, with 10 of 12 samples having viability >90%. The viability mean after the culture period was 94.54% ± 4.89%. Harvested cartilage showed expressions of type I cartilage, type II collagen, and aggrecan in a pattern that is predictable for native cartilage. CONCLUSION: These data reveal that the cartilage in femoral head cartilage overlying cam deformity-much like that from acetabular chondral flaps-not only has baseline viability >50% (51.99% ± 10.83%) but the ability to increase in viability >90% after a culture period. There may be a role for use of femoral head cartilage as autograft to repair full-thickness cartilage defects of the acetabulum and femoral head, either at the time of osteochondroplasty or after a period of cell culture to improve cell viability. CLINICAL RELEVANCE: A dearth of information is available regarding the viability of femoral head cartilage. This study provides insight into the cartilage viability and response to culture.

Understanding Preoperative Demographics and Risk Factors for Early Revision Surgery in Patients Undergoing Hip Arthroscopic Surgery: A Large Database Study.

BACKGROUND: Hip arthroscopic surgery has become an increasingly common surgical technique to diagnose and treat various hip abnormalities. While increased efficacy has been reported, debate remains regarding appropriate surgical indications. Multiple factors including patient demographics, surgical procedure, and underlying disease have been associated with poor surgical outcomes. Preoperative diagnostic and treatment interventions including physical therapy and injections may affect surgical indications and outcomes. PURPOSE: To identify patient characteristics and preoperative factors associated with an increased risk of early revision surgery and/or extended postoperative medical care after index hip arthroscopic surgery. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Utah's All Payer Claims Database, a state-mandated registry containing data from all payers, including private insurance, Medicare Advantage, and Medicaid, was queried to identify patients who underwent hip arthroscopic surgery during a 3-year period (January 1, 2013, to December 31, 2015). Demographics, comorbidities, nonoperative care modalities, pain medications, and revision procedures were collected using claims data at 6 months preoperatively and 12 months postoperatively. RESULTS: A total of 1283 patients who underwent primary hip arthroscopic surgery were analyzed, of whom 57.6% (n = 739) were female. Within 1 year of index surgery, 7.8% and 2.1% of patients underwent revision hip arthroscopic surgery and conversion to total hip arthroplasty (THA), respectively. Patients older than 60 years and male patients were more likely to undergo revision arthroscopic surgery (odds ratio [OR], 0.89; P < .001 and OR, 1.59; P = .04, respectively) and convert to THA (OR, 1.03; P = .01 and OR, 2.25; P = .05, respectively). Preoperative opioid use was significantly associated with increased odds of revision surgery (OR, 1.64; P = .05) and THA (OR, 2.70; P = .03). No significant relationship existed between preoperative physical therapy or intra-articular hip injections and revision hip arthroscopic surgery (OR, 1.20; P = .45 and OR, 1.18; P = .52, respectively) or conversion to THA (OR, 0.89; P = .79 and OR, 0.71; P = .46, respectively). CONCLUSION: This study showed that predictable patient factors can effectively guide preoperative decision making and may improve prognosis. Certain patient pools require optimization preoperatively, and a subset of patients appears to require additional surgical indications.