Risk of Total Wrist Arthrodesis Following Proximal Row Carpectomy: An Analysis of 1,070 Patients.

PURPOSE: Proximal row carpectomy (PRC) is a motion-sparing procedure with good patient-reported and clinical outcomes. Although some studies have investigated the risk of conversion to total wrist arthrodesis (TWA) after PRC, additional larger studies evaluating the specific risk factors that lead to failure are required. This study aimed to investigate the patient and procedure factors that are associated with increased risk for conversion to TWA in a large cohort of patients who underwent PRC. METHODS: The current procedural technology codes identified patients in a National Veteran's Health database undergoing a PRC over a 26-year period. Risk factors of interest comprised age, posterior interosseous nerve neurectomy, wrist arthritis pattern, bilateral surgery, smoking, comorbidities, and preoperative opioid use. The primary outcome was the rate of conversion to TWA. Cox proportional hazard regression was used to create hazard ratios of selected factors for reoperation. RESULTS: There were 1,070 PRCs performed, with a mean follow-up of 79.8 ± 59.6 months. A total of 5.3% (57/1,070) wrists underwent conversion to TWA. Younger age at the time of PRC (<50 years) significantly increased the risk of TWA (hazard ratio, 3.8; 95% confidence interval, 2.2-6.6). With every 1-year increase in age, there was a reduction of 4% (hazard ratio, 0.96; 95% confidence interval: 0.94-0.98) in the hazard of conversion to TWA. No other factors, including concomitant posterior interosseous nerve neurectomy or bilateral PRC, increased the risk of conversion to TWA. CONCLUSIONS: Proximal row carpectomy is a motion-preserving salvage procedure with a low rate of conversion to wrist arthrodesis. Younger patient age increases the risk of conversion to arthrodesis, whereas posterior interosseous nerve neurectomy, bilateral PRCs, and comorbidity status do not appear to have an impact on the risk of arthrodesis. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Minimizing Costs for Dorsal Wrist Ganglion Treatment: A Cost-Minimization Analysis.

PURPOSE: Dorsal wrist ganglions are treated commonly with aspiration, or open or arthroscopic excision in operating room (OR) or procedure room (PR) settings. As it remains unclear which treatment strategy is most cost-effective in yielding cyst resolution, our purpose was to perform a formal cost-minimization analysis from the societal perspective in this context. METHODS: A microsimulation decision analytic model evaluating 5 treatment strategies for dorsal wrist ganglions was developed, ending in either resolution or a single failed open revision surgical excision. Strategies included immediate open excision in the OR, immediate open excision in the PR, immediate arthroscopic excision in the OR, or 1 or 2 aspirations before each of the surgical options. Recurrence and complications rates were pooled from the literature for each treatment type. One-way sensitivity and threshold analyses were performed. RESULTS: The most cost-minimal strategy was 2 aspiration attempts before open surgical excision in the PR setting ($1,603 ± 1,595 per resolved case), followed by 2 aspirations before open excision in the OR ($1,969 ± 2,165 per resolved case). Immediate arthroscopic excision was the costliest strategy ($6,539 ± 264 per resolved case). Single aspiration preoperatively was more cost-minimal than any form of immediate surgery ($2,918 ± 306 and $4,188 ± 306 per resolved case performed in the PR and OR, respectively). CONCLUSIONS: From the societal perspective, performing 2 aspirations before surgical excision in the PR setting was the most cost-minimal treatment strategy, although in reference to surgeons who do not perform this procedure in the PR setting, open excision in the OR was nearly as cost-effective. As patient preferences may preclude routinely performing 2 aspirations, performing at least 1 aspiration before surgical excision improves the cost-effectiveness of dorsal wrist ganglions treatment. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic Decision Analysis II.

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.

Treatment of Recalcitrant Femoral Shaft Nonunion With Medial Femoral Condyle Pedicled Autograft: Technical Trick.

SUMMARY: Nonunited fractures of the femoral shaft and distal femur are usually successfully addressed with stabilization with or without autogenous bone grafting. For the small subset of these problems that prove recalcitrant to front-line treatment, a pedicled medial femoral condyle (MFC) bone flap can provide a source of vascularized autograft with minimal donor site morbidity. The MFC has gained recent widespread adoption as a free vascularized bone transfer, and here, we present a surgical technique and retrospective analysis of patients treated with a pedicled MFC technique. This serves as a useful treatment option for these difficult problems and may be especially helpful in low resource environments or where microsurgical anastomosis is not feasible.

Comparison of direct surgical cost for humeral shaft fracture fixation: open reduction internal fixation versus intramedullary nailing.

BACKGROUND AND/OR HYPOTHESIS: Prior literature has supported similar complication rates and outcomes for humeral shaft fractures treated with open reduction internal fixation (ORIF) with a plate/screw construct versus intramedullary nailing (IMN). The purpose of this study is to determine whether surgical encounter total direct costs (SETDCs) differ between ORIF and IMN for these fractures. METHODS: Adult patients (≥ 18 years) treated for isolated humeral shaft fractures by ORIF or IMN between June 18, 2014 and June 17, 2019 at a single tertiary academic center were available for inclusion. SETDCs for ORIF and IMN groups, obtained through our institution's information technology value tool, were adjusted to 2019 US dollars and converted to relative costs per institutional policy. SETDCs for ORIF and IMN were compared using the Wilcoxon rank-sum test. RESULTS: Demographic factors did not differ between ORIF and IMN cohorts with the exception of age (mean of 18.6 years older for IMN; P < .001) and American Society of Anesthesiologist class (higher for IMN; P = .029). Substantial cost variation was observed among the 39 included ORIF and 21 IMN cases. Costs pertaining to operating room utilization (P = .77), implants (P = .64), and the recovery room (P = .27) were similar for ORIF and IMN, whereas supply costs were significantly greater for IMN with a median (interquartile range) of 0.21 (0.17 ∼ 0.28), more than twice the supply costs of ORIF (0.09 [0.05 ∼ 0.13], P < .001). The SETDC of IMN was significantly greater than that of ORIF (median [interquartile range]:1.00 [0.9 to 1.13] vs. 0.83 [0.71∼1.05], respectively; P = .047). DISCUSSION AND/OR CONCLUSION: Our study found that the SETDC for humeral shaft fracture fixation was greater for IMN than for ORIF, although patient cohorts differed significantly with respect to age and the American Society of Anesthesiologist class. Surgeons should take these findings into consideration when consenting patients with humeral shaft fractures for the appropriate fixation type.

Comparison of Complication Risk for Open Carpal Tunnel Release: In-office versus Operating Room Settings.

BACKGROUND: Performing open carpal tunnel release (oCTR) in an office-based procedure room setting (PR) decreases surgical costs when compared with the operating room (OR). However, it is unclear if the risk of major medical, wound, and iatrogenic complications differ between settings. Our purpose was to compare the risk of major medical complications associated with oCTR between PR and OR settings. METHODS: Utilizing the MarketScan Database, we identified adults undergoing isolated oCTR between 2006 and 2015 performed in PR and OR settings. ICD-9-CM and/or CPT codes were used to identify major medical complications, surgical site complications, and iatrogenic complications within 90 days of oCTR. Multivariable logistic regression was used to compare complication risk between groups. RESULTS: Of the 2134 PR and 76,216 OR cases, the risk of major medical complications was 0.89% (19/2134) and 1.20% (914/76,216), respectively, with no difference observed in the multivariable analysis (adjusted odds ratio [OR] 0.84; 95% CI 0.53-1.33; P=0.45). Risk of surgical site complications was 0.56% (12/2134) and 0.81% (616/76,216) for the PR and OR, respectively, with no difference in the multivariable analysis (OR 0.68; 95% C.I. 0.38-1.22; P=0.19). Iatrogenic complications were rarely observed (PR 1/2134 [0.05%], OR 71/76,216 [0.09%]), which precluded multivariable modeling. CONCLUSION: These results support a similar safety profile for both the PR and OR surgical settings following oCTR with similar pooled major medical complications, pooled wound/surgical site complications, and iatrogenic complications.

Comparison of Complication Risk Following Trigger Digit Release Performed in the Office Versus the Operating Room: A Population-Based Assessment.

PURPOSE: Trigger digit release (TDR) performed in an office-based procedure room (PR) setting minimizes surgical costs compared with that performed in an operating room (OR); yet, it remains unclear whether the rates of major complications differ by setting. We hypothesized that surgical setting does not have an impact on the rate of major complications after TDR. METHODS: Adult patients who underwent isolated TDR from 2006 to 2015 were identified from the MarketScan commercial database (IBM) using the provider current procedural terminology code 26055 with a concordant diagnosis on the same claim line (International Classification of Diseases, ninth revision, clinical modification 727.03). The PR cohort was defined by presence of a place-of-service code for an in-office procedure without OR or ambulatory center revenue codes, or anesthesiologist claims, on the day of the surgery. The OR cohort was defined by presence of an OR revenue code. We identified major medical complications, surgical site complications, as well as iatrogenic neurovascular and tendon complications within 90 days of the surgery using International Classification of Diseases, ninth revision, clinical modification diagnosis and/or current procedural terminology codes. Multivariable logistic regression was used to compare the risk of complications between the PR and OR groups while controlling for Elixhauser comorbidities, smoking, and demographics. RESULTS: For 7,640 PR and 29,962 OR cases, the pooled rate of major medical complications was 0.99% (76/7,640) and 1.47% (440/29,962), respectively. The PR setting was associated with a significantly lower risk of major medical complications in the multivariable analysis (adjusted odds ratio 0.76; 95% confidence interval 0.60-0.98). The pooled rate of surgical site complications was 0.67% (51/7,640) and 0.88% (265/29,962) for the PR and OR cases, respectively, with no difference between the surgical settings in the multivariable analysis (adjusted odds ratio 0.81; 95% confidence interval 0.60-1.10). Iatrogenic complications were infrequently observed (PR 5/7,640 [0.07%]; OR 26/29,962 [0.09%]). CONCLUSIONS: Compared with performing TDR in the OR using a spectrum of commonly used anesthesia types, performing TDR in the PR using local-only anesthesia was associated with a comparably low risk of major medical complications, surgical complications, and iatrogenic complications. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Evaluating the impact of social deprivation on Press Ganey® Outpatient Medical Practice Survey Scores.

BACKGROUND: Social deprivation has been shown to affect access to health care services, and influences outcomes for a variety of physical and psychological conditions. However, the impact on patient satisfaction remains less clear. The objective of this study was to determine if social deprivation is an independent predictor of patient satisfaction, as measured by the Press Ganey® Outpatient Medical Practice Survey (PGOMPS). METHODS: We retrospectively reviewed unique new adult patient (≥ 18 years of age) seen at a tertiary academic hospital and rural/urban outreach hospitals/clinics between January 2014 and December 2017. Satisfaction was defined a priori as achieving a score above the 33rd percentile. The 2015 Area Deprivation Index (ADI) was used to determine social deprivation (lower score signifies less social deprivation). Univariate and multivariable binary logistic regression were used to determine the impact of ADI on PGOMPS total and provider sub-scores while controlling for variables previously shown to impact scores (wait time, patient age, sex, race, specialty type, provider type, and insurance status). RESULTS: Univariate analysis of PGOMPS total scores revealed a 4% decrease in odds of patient satisfaction per decile increase in ADI (p < 0.001). Patients within the most deprived quartile were significantly less likely to report satisfaction compared to the least deprived quartile (OR 0.79, p < 0.001). Multivariable analysis revealed that the odds of achieving satisfaction decreased 2% for each decile increase in ADI on the Total Score (p < 0.001), independent of other variables previously shown to impact scores. For PGOMPS Provider Sub-Score, univariate analysis showed that patients in the lowest ADI quartile were significantly less likely be satisfied, as compared to the least deprived quartile (OR 0.77; 95% CI 0.70-0.86; p < 0.001). A 5% decrease in a patient being satisfied was observed for each decile increase in ADI (OR 0.95; 95% CI 0.94-0.96; p < 0.001). CONCLUSIONS: Social deprivation was an independent predictor of outpatient visit dissatisfaction, as measured by the Press Ganey® Outpatient Medical Practice Survey. These results necessitate consideration when developing health care delivery policies that serve to minimize inequalities between patients of differing socioeconomic groups.

Inter-specialty variation of the Press Ganey Outpatient Medical Practice Survey.

ABSTRACT: Measuring patient satisfaction scores and interpreting factors that impact their variation is of importance as scores influence various aspects of health care administration. Our objective was to evaluate if Press Ganey scores differ between medical specialties.New patient visits between January 2014 and December 2016 at a single tertiary academic center were included in this study. Press Ganey scores were compared between specialties using a multivariable logistic mixed effects model. Secondary outcomes included a comparison between surgical versus non-surgical specialties, and pediatric versus adult specialties. Due to the survey's high ceiling effect, satisfaction was defined as a perfect total score.Forty four thousand four hundred ninety six patients met inclusion criteria. Compared to internal medicine, plastic surgery, general surgery, dermatology, and family medicine were more likely to achieve a perfect overall score, as, with odds ratios of 1.46 (P = .02), 1.29 (P = .002), 1.22 (P = .004), and 1.16 (P = .02) respectively. Orthopaedics, pediatric medicine, pediatric neurology, neurology, and pain management were less likely to achieve satisfaction with odds ratios of 0.85 (P = .047), 0.71 (P < .001), 0.63 (P = .005), 0.57 (P < .001), and 0.51 (P = .006), respectively. Compared to pediatric specialties, adult specialties were more likely to achieve satisfaction (OR 1.73; P < .001). There were no significant differences between surgical versus non-surgical specialties.Press Ganey scores systematically differ between specialties within the studied institution. These differences should be considered by healthcare systems that use patient satisfaction data to modify provider reimbursement.

A Comparison of Open Carpal Tunnel Release Outcomes Between Procedure Room and Operating Room Settings.

PURPOSE: Carpal tunnel release (CTR) surgical costs are minimized when performed in the procedure room (PR) setting, compared with the operating room. However, it remains unclear whether outcomes differ between surgical settings. Our purpose was to compare outcomes at 1 year or greater follow-up after open CTR between patients treated in PR versus operating room settings using the Boston Carpal Tunnel Questionnaire (BCTQ). METHODS: A change in clinical care protocols at our institution occurred in 2014. Before this, all CTRs were performed in the operating room; thereafter, these were transitioned to the PR. Adult patients who underwent isolated unilateral or bilateral open CTR in either surgical setting were considered for inclusion, in which procedures were conducted between January 2014 and October 2018 for the PR group and January 2009 and March 2014 for the operating room group. The Functional Status Scale (FSS) and the Symptom Severity Scale (SSS) components of the BCTQ were collected for all eligible patients at a minimum of 1 year after surgery. We used univariate and multivariable linear regression to determine whether postoperative BCTQ scores were equivalent between PR and operating room groups within a threshold of one-fourth of the lowest estimates of the minimal clinically important difference. RESULTS: No differences in demographics, comorbidities, or insurance type were observed between the 104 PR and 112 operating room patients. Survey response rate was 25% and 25% for the PR and operating room patients, respectively. At a mean follow-up of 3 ± 1 years, FSS and SSS scores were equivalent between PR and operating room groups on bivariate analysis. The multivariable equivalence test also demonstrated equivalent FSS and SSS scores between PR and operating room groups within a one-fourth minimal clinically important difference threshold while controlling for age, sex, presence of diabetes or thyroid disease, unilateral versus bilateral CTR, and surgeon. CONCLUSIONS: Clinical outcomes did not differ between PR and operating room settings after open CTR. Type of study/level of evidence: Therapeutic III.

Evaluation of factors driving cost variation for distal humerus open reduction internal fixation.

BACKGROUND: Distal humerus fracture open reduction and internal fixation (ORIF) represents a substantial cost burden to the health care system. The purpose of this study was to describe surgical encounter cost variation for distal humerus ORIF, and to determine demographic-, injury-, and treatment-specific factors that influence cost. METHODS: We retrospectively identified adult patients (≥18 years) treated for isolated distal humerus fractures between July 2014 and July 2019 at a single tertiary academic referral center. For each case, surgical encounter total direct costs (SETDCs) were obtained via our institution's information technology value tools, which prospectively record granular direct cost data for every health care encounter. Costs were converted to 2019 dollars using the personal consumption expenditure indices for health and summarized with descriptive statistics. Univariate and multivariate linear regression models were used to identify factors influencing SETDC. RESULTS: Surgical costs varied widely for the 47 included patients, with a standard deviation (SD) of 33% and interquartile range of 76%-124% relative to the mean SETDC. Implant and facility costs were responsible for 46.2% and 32.6% of the SETDC, respectively. Implant costs also varied considerably, with an SD of 21% and range from 13%-36% relative to the mean SETDC. Multivariate analysis demonstrated that SETDC increased 24% (P < .001) on performing an olecranon osteotomy, and by 15% for each additional 1 hour of surgical time (P < .001). These findings were independent of age, sex, body mass index, open fracture, need for an additional small plate construct as a reduction aid, and fracture pattern (all insignificant in the multivariate analysis, with P >.05 for each factor). CONCLUSION: Substantial variations in surgical encounter total direct costs for distal humerus ORIF exist, as do wide variations in associated implant costs that comprise nearly half of the entire surgical cost. Performing an olecranon osteotomy, and increased surgical time, significantly increased surgical costs. Although use of an olecranon osteotomy may not be a completely controllable factor as it is confounded by fracture severity and operative time, this may suggest that surgeons should try to use an olecranon osteotomy judiciously. Although complexity of the fracture pattern was statistically insignificant, it is confounded by the need for an olecranon osteotomy and increased surgical time and likely is a clinically relevant and nonmodifiable driver of surgical cost. These findings highlight opportunities to reduce cost variation, and potentially improve the value of care, for distal humerus ORIF patients.

Minimal Clinically Important Difference of the PROMIS Upper-Extremity Computer Adaptive Test and QuickDASH for Ligament Reconstruction Tendon Interposition Patients.

PURPOSE: To calculate the minimal clinically important difference (MCID) of the Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity Computer Adaptive Test (UE CAT) and Quick-Disabilities of the Arm, Shoulder, and Hand (QuickDASH) for ligament reconstruction tendon interposition (LRTI) patients. METHODS: Adult patients treated with LRTI for trapeziometacarpal OA by fellowship-trained hand surgeons between December 2014 and February 2018 at an academic tertiary institution were included. Outcomes were prospectively collected at each visit by tablet computer, including the QuickDASH, PROMIS UE, Pain Interference, Depression, and Anxiety CATs. Inclusion required a response to the anchor question "How much relief and/or improvement do you feel you have experienced as a result of your treatment?" on a 6-option Likert scale, as well as preoperative (≤120 days before surgery) and follow-up (2-26 weeks) outcomes. We calculated MCID both by an anchor-based approach using the mean score of the minimal change group, and with the 0.5 SD method. RESULTS: Of 145 included participants, mean age was 63 ± 8 years and 74% were female. Anchor-based MCID estimates for the total cohort were 4.2 for the PROMIS UE CAT and 8.8 for the QuickDASH. The MCID estimates using the 0.5 SD method were 4.8 and 11.7, respectively. CONCLUSIONS: We propose MCID values of 4.2 to 4.8 for the PROMIS UE CAT and 8.8 to 11.7 for the QuickDASH when powering clinical studies or when assessing improvement among a cohort of patients who have undergone LRTI surgery. CLINICAL RELEVANCE: Minimal clinically important difference estimates are helpful when interpreting clinical outcomes after LRTI and for powering prospective trials.

Evaluating the Safety of the Hand Surgery Procedure Room: A Single-Center Cohort of 1,404 Surgical Encounters.

PURPOSE: Performing hand surgeries in the procedure room (PR) setting instead of the operating room effectively reduces surgical costs. Understanding the safety or complication rates associated with the PR is important in determining the value of its use. Our purpose was to describe the incidence of medical and surgical complications among patients undergoing minor hand surgeries in the PR. METHODS: We retrospectively reviewed all adult patients who underwent an operation in the PR setting between December 2013 and May 2019 at a single tertiary academic medical center by 1 of 5 fellowship-trained orthopedic hand surgeons. Baseline patient characteristics were described. Complication rates were obtained via chart review. RESULTS: For 1,404 PR surgical encounters, 1,796 procedures were performed. Mean patient age was 59 ± 15 years, 809 were female (57.6%), and average follow-up was 104 days. The most common surgeries were carpal tunnel release (39.9%), trigger finger release (35.9%), and finger mass or cyst excision (9.6%). Most surgeries were performed using a nonpneumatic wrist tourniquet (58%), whereas 42% used no tourniquet. No patient experienced a major medical complication. No procedure was aborted owing to intolerance. No patient required admission. No intraoperative surgical or medical complications occurred. Observed complications included delayed capillary refill requiring phentolamine administration after a trigger thumb release performed using epinephrine without a tourniquet (n = 1; 0.1%), complex regional pain syndrome (n = 3; 0.2%), infection requiring surgical debridement (n = 2; 0.2%), and recurrent symptoms requiring reoperation (n = 8; 0.7%). CONCLUSIONS: In this cohort of patients in whom surgery was performed in a PR, there were no major intraoperative surgical or medical complications. There was a low rate of postoperative infection, development of complex regional pain syndrome, and a low need for revision surgery. These observations do not support the concern for safety as a barrier to performing minor hand surgery in the PR setting. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Evaluating the performance of PROMIS and QuickDASH instruments in an intercollegiate Division 1 athlete population.

BACKGROUND: Athletes demonstrate high levels of physical function, leading to difficulties in patient-reported outcome scoring and interpretation. In particular, the ability of patient-reported outcome (PRO) instruments to adequately discriminate between high levels of upper extremity function-that is, the ceiling effect-is limited. This study evaluated performance characteristics of the shortened version of the Disabilities of the Arm, Shoulder, and Hand (QuickDASH) survey and Patient-Reported Outcomes Measurement Information System (PROMIS) metrics in a population of Division 1 intercollegiate athletes, with specific attention to ceiling effects. METHODS: At a single institution, Division I intercollegiate athletes cleared for full participation in the 2018-2019 season were eligible. The following PROs were collected prospectively via tablet computer: PROMIS upper extremity (UE) computer adaptive test (CAT), PROMIS physical function (PF) CAT, QuickDASH, and QuickDASH Sports/Performing Arts Module. Descriptive statistics, and ceiling and floor effects, were calculated. The proportion of athletes with maximal scores on each PRO were compared to normative values using the 1-sample Wilcoxon signed rank test. RESULTS: A total of 268 participants were included; the mean age was 19.9 ± 1.5 years, 49% were female, and 61% were overhead athletes. Large ceiling effects were observed for the UE CAT (46%), QuickDASH (58%), and QuickDASH Sports Module (82%). The PF CAT demonstrated a relatively low ceiling effect of 6.7%. Athlete scores were all significantly better than published age-matched values from a normative population for all instruments, with the exception of no difference on the QuickDASH for males. DISCUSSION AND/OR CONCLUSION: The PROMIS UE CAT and QuickDash instruments are limited in their ability to assess and discriminate upper extremity function in highly functioning individuals such as Division I athletes. The PROMIS PF CAT, a measure of general physical function, did not suffer from a large ceiling effect.

Reliability of Telephone Acquisition of the PROMIS Upper Extremity Computer Adaptive Test.

PURPOSE: Our primary purpose was to evaluate the reliability of telephone administration of the Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE) Computer Adaptive Test (CAT) version 2.0 in a hand and upper extremity population, and secondarily to make comparisons with the abbreviated version of the Disabilities of the Arm, Shoulder, and Hand (QuickDASH). METHODS: Patients more than 1 year out from hand surgeries performed at a single tertiary institution were enrolled. Half of the patients completed telephone PROMIS UE CAT and QuickDASH surveys first, followed by computer-based surveys 1 to 10 days later, and the other half completed them in the reverse order. Telephone surveys were readministered 2 to 6 weeks later to evaluate test-retest reliability. Concordance correlation coefficients (CCCs) were used to assess agreement between telephone and computer-based scores, and intraclass correlation coefficients (ICCs) were used to assess test-retest reliability. The proportion of patients with discrepancies in follow-up scores that exceeded estimates of the minimal clinically important difference (MCID) was evaluated. RESULTS: For the 89 enrolled patients, the PROMIS UE CAT CCC was 0.82 (83% confidence interval [83% CI], 0.77-0.86; good), which was significantly lower than 0.92 (83% CI, 0.89-0.94; good to excellent) for the QuickDASH. The PROMIS UE CAT ICC did not differ significantly from the QuickDASH (0.85 and 0.91, respectively). Differences in telephone versus computer scores exceeded 5 points (MCID estimate) for the PROMIS UE CAT in 34% of patients versus 5% of patients exceeding 14 points (MCID estimate) for the QuickDASH. CONCLUSIONS: Significantly better reliability was observed for the QuickDASH than the PROMIS UE CAT when comparing telephone with computer-based score acquisition. Over one-third of patients demonstrated a clinically relevant difference in scores between the telephone and the computer-administered tests. We conclude that the PROMIS UE CAT should only be administered through computer-based methods. CLINICAL RELEVANCE: These findings suggest that differences in collection methods for the PROMIS UE CAT may systematically affect the scores obtained, which may erroneously influence the interpretation of postoperative scores for hand surgery patients.

Cost-Effectiveness Analysis Comparing Proximal Row Carpectomy and Four-Corner Arthrodesis.

BACKGROUND: The optimal surgical treatment for scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) remains unclear. To inform clinical decision-makers, we conducted a cost-effectiveness analysis comparing proximal row carpectomy (PRC) and four-corner arthrodesis (FCA). METHODS: A Markov microsimulation model was used to compare clinical outcomes, costs, and health utilities between PRC and FCA. The model used a 10-year time horizon and a 1-month cycle length, and it was evaluated from the societal perspective. Utilities and clinical parameters including transition probabilities for debridement for infection, removal of implants, conversion to total wrist arthrodesis, revision FCA, and revision total wrist arthrodesis were obtained from published literature. Timing of complications was estimated from the literature. Direct medical costs were derived from Medicare ambulatory surgical cost data, and indirect costs for missed work due to surgical procedures and complications were included. The effectiveness outcome was quality-adjusted life years (QALYs). Probabilistic sensitivity analysis and 1-way threshold analysis for utilities were performed. RESULTS: In the base-case model, PRC dominated FCA (i.e., PRC had lower cost and greater effectiveness). The mean (and standard deviation) for the total cost and QALYs per patient were $30,970 ± $5,931 and 8.24 ± 1.28, respectively, for PRC and $44,526 ± $11,205 and 8.23 ± 1.26, respectively, for FCA. In the probabilistic sensitivity analysis, PRC dominated FCA in 57% of the 1 million iterations. The cost-effectiveness acceptability curve indicated that PRC is the most cost-effective strategy regardless of the willingness-to-pay threshold up to $100,000/QALY. CONCLUSIONS: PRC dominated FCA in the base-case analysis and in the probabilistic sensitivity analysis. These results suggest that PRC is the optimal strategy for Stage-I or II SLAC and for SNAC in patients ≥55 years of age. LEVEL OF EVIDENCE: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Cost Implications of Varying the Surgical Setting and Anesthesia Type for De Quervain Release Surgery.

Background First extensor compartment release is a common surgical procedure that represents a financial burden to the health care system. Questions/Purposes Study questions included (1) whether surgical encounter costs differ based upon surgical setting (operating room [OR] vs. procedure room [PR]) or (2) based upon anesthesia choice (local only, Bier's block [BB], monitored anesthesia care [MAC], or general [GA]) for De Quervain release (DQR). Patients and Methods Consecutive adult patients undergoing isolated unilateral DQR at a single academic medical center were identified retrospectively by Current Procedural Terminology code (25000). Using our institution's information technology value tools, we calculated total direct costs for each surgical encounter. Costs were adjusted to January 2016 dollars using the Consumer Price Index, normalized using each participant's surgical encounter cost divided by the median cost in the PR group, then compared across each group using Kruskal-Wallis and Nemenyi's post hoc pair-wise tests. Multivariable gamma regression analysis with a log link was performed to identify factors associated with surgical costs. QuickDASH (disabilities of the arm, shoulder, and the hand) scores were compared using a t -test at final follow-up. Results Among 58 included patients, 29% (17/58) were treated in the PR and 71% (41/58) in the OR. Compared with local only in the PR, all other groups were significantly more costly. Multivariable gamma regression indicated that use of OR/BB, OR/MAC, or OR/GA independently led to 211, 222, and 357% greater surgical costs as compared with the PR with local only while controlling for provider and patient age. Furthermore, QuickDASH scores were similar between PR and OR groups at final follow-up. Conclusion Performing DQR in the PR setting under local only anesthesia yields greater value than the OR, as patient-reported outcomes are similar despite significantly lower surgical costs. Level of Evidence This is a Level III, cost analysis study.

Volar Locked Plating Versus Closed Reduction and Casting for Acute, Displaced Distal Radial Fractures in the Elderly: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

BACKGROUND: It remains unclear whether volar locked plating (VLP) yields a better functional outcome than closed reduction and casting (CRC) for elderly patients with an acute, displaced distal radial fracture. Our purpose was to conduct a systematic review and meta-analysis of randomized controlled trials comparing outcomes of VLP and CRC for elderly patients (age, ≥60 years). METHODS: Multiple databases, including MEDLINE, were searched for randomized controlled trials evaluating outcomes following distal radial fracture treatment. Raw data were obtained for studies that included patients of all ages, and the elderly subgroup was included for analysis. The primary outcome was the Disabilities of the Arm, Shoulder and Hand (DASH) score at ≥1 year of follow-up. Secondary outcomes included the 3-month DASH score, range of motion, final radiographic alignment, and complications. Effect sizes for the comparison of each outcome between groups were pooled across studies using random-effects models with the inverse variance weighting method. Changes in DASH score were compared with a minimal clinically important difference (MCID) estimate of 10 to assess clinical relevance. RESULTS: Of 2,152 screened articles, 6 were included. Demographics were similar for the 274 VLP and 287 CRC patients. DASH scores were significantly better following VLP than CRC at the time of final follow-up (12 to 24 months postoperatively; score difference, -5.9; 95% confidence interval [CI], -8.7 to -3.1) and at 3 months (-8.9; 95% CI, -13.0 to -4.8). VLP yielded significantly better palmar tilt, radial inclination, and supination, with no differences in ulnar variance, flexion-extension, pronation, or total complication rates. CONCLUSIONS: Functional outcome was significantly better following VLP than CRC 3 months into the treatment of acute, displaced distal radial fractures in an elderly population and up to 2 years after injury. However, the observed differences in the final DASH score did not exceed published estimates of the MCID, suggesting that clinical outcomes are similar for both treatment options. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.