Cost-Effectiveness Analysis of Early versus Late Debridement of Superficial Triangular Fibrocartilage Complex Tears.

Background: While initial nonoperative management is the conventional approach for superficial triangular fibrocartilage complex (TFCC) tears, a substantial portion of these cases go on to require surgery, and the optimal duration of nonoperative treatment is unknown. In this study, we evaluate the cost-effectiveness of early versus late arthroscopic debridement for the treatment of superficial TFCC tears without distal radioulnar joint (DRUJ) instability. Methods: We created a decision tree to compare the following strategies from a healthcare payer perspective: immediate arthroscopic debridement versus immobilization for 4 or 6 weeks with late debridement as needed. Costs were obtained from the Centers for Medicaid and Medicare Services and a national administrative claims database. Probabilities and health-related quality-of-life measures were obtained from published sources. We conducted sensitivity analyses on model inputs, including a probabilistic sensitivity analysis consisting of 10,000 Monte Carlo simulations. Results: Immobilization for 6 weeks while reserving arthroscopic debridement for refractory cases was both the least costly and most effective strategy. Immediate arthroscopic debridement became cost-effective when success rates of immobilization for 4 or 6 weeks were less than 7.7 or 10.5%, respectively. Our probabilistic sensitivity analysis showed that immobilization for 6 weeks was preferred 97.6% of the time, and immobilization for 4 weeks was preferred 2.4% of the time. Conclusion: Although various early and late debridement strategies can be used to treat superficial TFCC tears without DRUJ instability, immobilization for 6 weeks while reserving arthroscopic debridement for refractory cases is the optimal strategy from a cost-effectiveness standpoint.

Efficacy of Intra-Articular Corticosteroid Injection for Nonsurgical Management of Trapeziometacarpal Osteoarthritis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

PURPOSE: As osteoarthritis (OA) of the trapeziometacarpal (TMC) joint leads to a high degree of disease burden with compromises in rudimentary and fine movements of the hand, intra-articular injections may be a desirable treatment option. However, because there are no evidence-based guidelines, the choice of intra-articular injection type is left to the discretion of the individual surgeon in collaboration with the patient. The purpose of our study was to perform a systematic review and meta-analysis using level I studies to compare outcomes following corticosteroid and alternative methods of intra-articular injections for the management of TMC OA. Our hypothesis was that intra-articular corticosteroid injections were no more effective than other methods of intra-articular injections for the management of TMC OA. METHODS: A systematic literature search was performed. Eligible for inclusion were randomized control trials reporting on intra-articular corticosteroid injection for the management of TMC OA. Clinical outcomes were recorded. RESULTS: The 10 included studies comprised 673 patients. The mean age was 57.8 ± 8.3 years, with a mean follow-up of 6.4 ± 2.7 months. There was no significant difference in visual analog scale scores, grip strength and tip pinch strength between corticosteroids and hyaluronic acid at short- and medium-term follow-up. Further, there was no difference in visual analog scale pain scores at rest at medium-term follow-up between corticosteroids and platelet-rich plasma. CONCLUSIONS: Despite short-term improvement with intra-articular corticosteroid injections, there was no significant difference in pain and functional outcomes following intra-articular corticosteroid injections compared to hyaluronic acid or platelet-rich plasma administration. Given the affordability, ease of administration, and efficacy associated with corticosteroids, they are a favorable option when considering the choice of intra-articular injection for the management of TMC OA. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Variations in Treatment and Costs for Distal Radius Fractures in Patients Over 55 Years of Age: A Population-Based Study.

Objective To evaluate the rate of surgery for symptomatic malunion after nonoperatively treated distal radius fractures in patients aged 55 and above, and to secondarily report differences in demographics, geographical variation, and utilization costs of patients requiring subsequent malunion correction. Methods We identified patients aged 55 and above who underwent nonoperative treatment for a distal radius fracture between 2007 and 2016 using the IBM MarketScan database. In the nonoperative cohort, we identified patients who underwent malunion correction between 3 months and 1 year after distal radius fracture. The primary outcome was rate of malunion correction. Multivariable logistic regression controlling for sex, region, and Elixhauser Comorbidity Index (ECI) was used. We also report patient demographics, geographical variation, and utilization cost. Results The rate of subsequent malunion surgery after nonoperative treatment was 0.58%. The cohort undergoing malunion surgery was younger and had a lower ECI. For every 1-year increase in age, there was a 6.4% decrease in odds of undergoing surgery for malunion, controlling for sex, region, and ECI (odds ratio = 0.94 [0.93-0.95]; p < 0.01). The southern United States had the highest percentage of patients initially managed operatively (30.7%), the Northeast had the lowest (22.0%). Patients who required a malunion procedure incurred higher costs compared with patients who did not ($7,272 ± 8,090 vs. $2,209 ± 5,940; p < 0.01). Conclusion The rate of surgery for symptomatic malunion after initial nonoperative treatment for distal radius fractures in patients aged 55 and above is low. As younger and healthier patients are more likely to undergo malunion correction with higher associated costs, surgeons may consider offering this cohort surgical treatment initially.

Complications Following Volar Locking Plate Fixation of Distal Radius Fractures in Adults: A Systematic Review of Randomized Control Trials.

PURPOSE: The purpose of this study was to assess the incidence of postoperative complications following volar locking plate (VLP) fixation of distal radius fractures (DRFs). METHODS: A search using keywords and subject headings to represent the concepts of volar plating and radius fractures was generated. Databases such as MEDLINE (Ovid), Embase (Elsevier), Scopus (Elsevier), and SPORTDiscus (EBSCO) were searched from inception to November 24, 2021, for randomized controlled trials that reported complications following DRF treated with VLP. Inclusion criteria were studies with adult patients (aged ≥18 years) randomized to VLP fixation without other concomitant surgical interventions, with a minimum follow-up of 3 months. Study sample characteristics and post-surgical complications were extracted. The Cochrane Risk of Bias tool was used to evaluate quality of evidence. RESULTS: Of the 4,059 articles identified using the search strategy, 1,778 titles/abstracts and 856 full-text articles were screened for inclusion, of which 35 articles were included for data extraction. Overall, 1,419 patients with a DRF were randomized to VLP fixation. The mean age was 60.3 years. The overall complication rate was 30.8% following VLP fixation, with 12.4% being major complications. The most common complications were median nerve-related (7.1%) and hardware removal (6.8%), secondary to other complications. Tenosynovitis was the most common tendon-related complication (3.4%). Other complications included complex regional pain syndrome (2.4%), malunion (1.3%), superficial wound infections (1.9%), and tendon rupture (1.3%). CONCLUSIONS: A meta-analysis of high-quality studies that discuss the complications after VLP fixation for DRF showed an overall complication rate of 30.8%. VLP may be related to more hardware-related complications than those previously reported. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Impact of Time to Fixation on Outcomes of Operative Treatment of Intra-articular Distal Radius Fractures.

BACKGROUND: The incidence of operative treatment of distal radius fractures (DRFs) has increased recently, but the optimal timing for surgical fixation remains unclear. We hypothesized that: (1) an increase in time to fixation of intra-articular DRFs would increase the likelihood of postoperative complications; and (2) increased time from injury to fixation would lead to longer surgical time and worse range of motion (ROM) outcomes. METHODS: We retrospectively reviewed 299 fractures in 284 adult patients who underwent open reduction and internal fixation (ORIF) of a closed, intra-articular DRF at our institution over a 10.5-year period. Demographic information, time to surgery (TTS) from injury, surgical time, tourniquet time, complications, and final postoperative ROM were collected for logistic regression modeling to predict the risk of postoperative complication. RESULTS: Twenty-seven (9.0%) patients experienced postoperative complications. The median TTS (Q1-Q3) for all patients was 7.0 (4.0-12.0) days. Patients who experienced an early postoperative complication had significantly longer median TTS (10.0 days) than those who did not (7.0 days). Patients with longer TTS were more likely to experience a complication (odds ratio, 1.11; 95% confidence interval, 1.04-1.19; P = .006). Tourniquet time and final wrist ROM were not related to TTS. A logistic regression analysis found that early complication rate doubles at 7.0 days after injury (from 3.5% to 6.9%). CONCLUSIONS: Patients with operative intra-articular distal radius fractures should ideally be fixed within 7 to 10 days of injury to minimize the risk of early postoperative complications. The tourniquet time and final ROM were not associated with time to surgery.

The Use and Downstream Associations of Magnetic Resonance Imaging for Lateral Epicondylitis.

PURPOSE: Low-value imaging is associated with wasteful health care spending and patient harm. The routine use of magnetic resonance imaging (MRI) for the work-up of lateral epicondylitis is an example of low-value imaging. As such, our aim was to investigate the use of MRIs ordered for lateral epicondylitis, the characteristics of those undergoing an MRI, and the downstream associations of MRI with other care. METHODS: We identified patients aged ≥18 years with a diagnosis of lateral epicondylitis between 2010 and 2019 using a Humana claims database. We identified patients with a Current Procedural Terminology code corresponding to an elbow MRI. We analyzed the use and downstream treatment cascades in those undergoing MRI. Multivariable logistic regression models were used to assess the odds of undergoing an MRI, adjusting for age, sex, insurance type, and comorbidity index. Separate multivariable logistic regression analyses were used to determine the association between undergoing an MRI and the incidence of secondary outcomes (eg, receiving surgery). RESULTS: A total of 624,102 patients met the inclusion criteria. Of 8,209 (1.3%) patients undergoing MRI, 3,584 (44%) underwent it within 90 days after diagnosis. There was notable regional variation in MRI use. The MRIs were ordered most frequently by primary care specialties and for younger, female, commercially insured, and patients with more comorbidities. Performance of an MRI was associated with an increase in downstream treatments, including surgery (odds ratio [OR], 9.58 [9.12-10.07]), injection (OR, 2.90 [2.77-3.04]), therapy (OR, 1.81 [1.72-1.91]), and cost ($134 per patient). CONCLUSIONS: Although there is variation in the use of MRI for lateral epicondylitis and its use is associated with downstream effects, the routine use of MRI for the diagnosis of lateral epicondylitis is low. CLINICAL RELEVANCE: The routine use of MRI for lateral epicondylitis is low. Understanding interventions to minimize such low-value care in lateral epicondylitis can be used to inform improvement efforts to minimize low-value care for other conditions.

Do Patients Want to Be Involved in Their Carpal Tunnel Surgery Decisions? A Multicenter Study.

PURPOSE: Carpal tunnel syndrome requires multiple decisions during its management, including regarding preoperative studies, surgical technique, and postoperative wound management. Whether patients have varying preferences for the degree to which they share in decisions during different phases of care has not been explored. The goal of our study was to evaluate the degree to which patients want to be involved along the care pathway in the management of carpal tunnel syndrome. METHODS: We performed a prospective, multicenter study of patients undergoing carpal tunnel surgery at 5 academic medical centers. Patients received a 27-item questionnaire to rate their preferred level of involvement for decisions made during 3 phases of care for carpal tunnel surgery: preoperative, intraoperative, and postoperative. Preferences for participation were quantified using the Control Preferences Scale. These questions were scored on a scale of 0 to 4, with patient-only decisions scoring 0, semiactive decisions scoring 1, equally collaborative decisions scoring 2, semipassive decisions scoring 3, and physician-only decisions scoring 4. Descriptive statistics were calculated. RESULTS: Seventy-one patients completed the survey between November 2018 and April 2019. Overall, patients preferred semipassive decisions in all phases of care (median score, 3). Patients preferred equally collaborative decisions for preoperative decisions (median score, 2). Patients preferred a semipassive decision-making role for intraoperative and postoperative decisions (median score, 3), suggesting these did not need to be equally shared. CONCLUSIONS: Patients with carpal tunnel syndrome prefer varying degrees of involvement in the decision-making process of their care and prefer a semipassive role in intraoperative and postoperative decisions. CLINICAL RELEVANCE: Strategies to engage patients to varying degrees for all decisions during the management of carpal tunnel syndrome, such as decision aids for preoperative surgical decisions and educational handouts for intraoperative decisions, may facilitate aligning decisions with patient preferences for shared decision-making.

Time to publication for orthopaedic surgery peer-reviewed journals: A cross-sectional bibliometric analysis.

Background: The dissemination of research and evidence-based medicine is critical to advancing science and improving clinical practice. The purpose of this study was to evaluate the timing and associated factors of the publication process for the most influential orthopaedic surgery research journals. Methods: After analyzing 25 orthopaedic surgery journals with the highest impact factors, 14 journals provided the necessary information for data analysis. A minimum of three consecutive issues per journal from 2021 were collected for review. Within each issue, all articles were included except for reviews, commentaries, replies, letters to the editor, and invited articles. The publication times for received to accepted (RA), received to published in press (RP1), and received to published in print (RP2) were retrieved and compared. Journal impact factor, specialty, and article level of evidence were recorded. Results: A total of 1040 articles were included with a mean number of 74.3 ± 38 (range, 35-182) articles analyzed per journal. The mean impact factor for the 14 journals was 3.6 ± 1 (range, 2.5-5.8). The overall median duration of time for RA, RP1, and RP2 were 119 (IQR, 78-165) days, 157 (IQR, 102-216) days, and 291 (IQR, 243-378) days across all 14 journals, respectively. Journal of Arthroplasty demonstrated the shortest median duration of time for RA and RP1, while International Orthopaedics demonstrated the shortest median duration of time for RP2. Clinical Journal of Sport Medicine demonstrated the longest median duration of time for RA and RP2, while the American Journal of Sports Medicine demonstrated the longest median duration of time for RP1. Level three studies, which included retrospective case-control and cohort study designs, demonstrated the shortest publication times, while sports medicine journals demonstrated the longest publication times for all periods. Conclusion: There was substantial variation in publication times across orthopaedic surgery journals which may impact accessibility to clinical insights.

Ulnar Resection Length: A Risk Factor for Nonunion in Ulnar Shortening Osteotomy.

BACKGROUND: Nonunion rates following ulnar shortening osteotomy (USO) are reported up to 18% with few known risk factors. While resection length is variable in practice, little is known about the prognostic implications on healing. The purpose of this study was to evaluate whether longer resection lengths increased the odds of nonunion. METHODS: A retrospective review was performed on patients who underwent an elective USO at a single institution over a 6-year period. Demographic, social, comorbidity, and surgical data were reviewed. Ulnar resection length was obtained from operative notes and dichotomized into smaller (<5.5 mm) and larger (≥5.5 mm) groups. The primary outcome was the rate of nonunion. Univariate analyses and a multivariable logistic regression model were used to assess for significant predictors of nonunion. RESULTS: A total of 87 patients were included with a mean age of 45 years. Patient comorbidities included 12.6% with diabetes, 29.9% with an American Society of Anesthesiologists score of ≥ 3, 5.8% reporting current tobacco use, and 29.9% reporting former tobacco use. There were 55 patients (63.2%) with resection lengths < 5.5 mm and 32 patients (36.8%) with ≥ 5.5 mm resections. Multivariable analysis identified longer resection length (≥5.5 mm) and current tobacco use as independent risk factors for nonunion. Patients with a resection length of ≥ 5.5 mm had 20.2 times greater odds of nonunion compared with patients with smaller resections, and current smokers had 72.2 times greater odds of nonunion compared with nonsmokers. CONCLUSION: Longer ulnar resection length (≥5.5 mm) significantly increases the risk of nonunion following USO.

Suspensionplasty for Revision Thumb Carpometacarpal Osteoarthritis Surgery: Comparing Suture Button Suspensionplasty to Ligament Reconstruction and Tendon Interposition.

SUMMARY: Several surgical procedures have been described to treat thumb carpometacarpal osteoarthritis, including suture button suspensionplasty and ligament reconstruction and tendon interposition. To date, no single procedure has demonstrated clinical superiority. Suture button suspensionplasty has achieved favorable outcomes at 5 years in primary cases, but has not been validated in revision surgery. In this study, it was evaluated for revision of failed thumb carpometacarpal osteoarthritis surgery, and outcomes were compared to ligament reconstruction and tendon interposition outcomes. A retrospective chart review identified patients who underwent suture button suspensionplasty or ligament reconstruction and tendon interposition after failure of previous thumb carpometacarpal osteoarthritis surgery since 2010. Eighteen patients were included, with nine patients in each group. Eighteen patients had mean final follow-up of 35 months. There were two complications in the ligament reconstruction and tendon interposition group and none in the suture button suspensionplasty group. No patients required additional surgery. The suture button suspensionplasty group had an average visual analogue scale pain score improvement of 2.9, compared to 2.4 in the ligament reconstruction and tendon interposition group. Average final Quick Disabilities of the Arms, Shoulder and Hand questionnaire score was 15.1 in the suture button suspensionplasty group, compared to 22.6 in the ligament reconstruction and tendon interposition group. Mean operative time of 86.3 minutes in the suture button suspensionplasty group was significantly shorter than the 121-minute mean in the ligament reconstruction and tendon interposition group. Suture button suspensionplasty is an effective treatment option for revision of previous thumb carpometacarpal osteoarthritis surgery, with outcomes comparable to revision using ligament reconstruction and tendon interposition, and the added benefit of shorter operative times and early mobilization. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Outcomes associated with proton pump inhibitors and distal radius fractures: A post-hoc comparative analysis.

Long-term, high-dose, daily proton pump inhibitors (PPI) may impact outcomes associated with distal radius fractures (DRF). The hypothesis was that differences existed in patient demographics, but there existed no differences in injury patterns, interventions, post-operative complications, and patient-reported outcomes between patients not on a PPI and patients on a PPI with a DRF. METHODS: An IRB-approved, post-hoc analysis of patients with DRF from 2012 through 2018 was performed. Patients included were age ≥18 years, sustained a DRF, had completed medical and medication records, Quick Disabilities of the Arm, Shoulder and Hand (DASH) scores, Global Assessment of Functioning (GAF) scores, visual analogue scale (VAS) pain scores, and a minimum of 1-year follow-up. Patients were stratified into two cohorts. Cohort one patients had no prescription or over-the-counter PPI use (no PPI cohort). Cohort two patients had adherence to a long-term, high-dose, daily PPI (PPI cohort). RESULTS: Two hundred and eighty-one DRF patients were included. Of these 281 patients, 240 were in the no PPI cohort and 41 were in the PPI cohort. Patients in the PPI cohort had more median nerve injuries (12% versus 3%, p = 0.025) and radial shaft fractures (5% versus 0%, p = 0.020), less contralateral upper extremity injuries (0% versus 4%, p = 0.001), and more post-operative nonunions (7% versus 1%, p = 0.029) compared to patients in the no PPI cohort. CONCLUSIONS: Long-term, high-dose, daily PPI's may be associated with more median nerve injuries and radial shaft fractures, less contralateral upper extremity injuries, and more post-operative nonunions compared to DRF patients not on a PPI.

Platelet-Rich Plasma Versus Corticosteroid Injections for the Treatment of Mild-to-Moderate Carpal Tunnel Syndrome: A Markov Cost-Effectiveness Decision Analysis.

BACKGROUND: Platelet-rich plasma (PRP) or corticosteroid injections may be used to conservatively treat mild-to-moderate carpal tunnel syndrome (CTS). We evaluated the cost-effectiveness of PRP injections versus corticosteroid injections for the treatment of mild-to-moderate CTS. METHODS: Markov modeling was used to analyze the base-case 45-year-old patient with mild-to-moderate CTS, unresponsive to conservative treatments, never previously treated with an injection or surgery, treated with a single injection of PRP, or methylprednisolone/triamcinolone 40 mg/mL. Transition probabilities were derived from level-I/II studies, utility values from the Tufts University Cost-Effectiveness Analysis Registry reported using visual analog scale (VAS), Boston Carpal Tunnel Questionnaire Symptom severity (BCTQ-S), and Boston Carpal Tunnel Questionnaire Functional status (BCTQ-F), and costs from Medicare, published studies, and industry. Analyses were performed from healthcare/societal perspectives. Outcomes were incremental cost-effectiveness ratios (ICER) and net monetary benefits (NMB). Willingness-to-pay thresholds were $50 000 and $100 000. Deterministic/probabilistic sensitivity analyses were performed. RESULTS: From a healthcare perspective, compared to PRP injections, the ICER for corticosteroid injections measured by VAS: -$13.52/quality-adjusted-life-years (QALY), BCTQ-S: -$11.88/QALY, and BCTQ-F: -$16.04/QALY. PRP versus corticosteroid injections provided a NMB measured by VAS: $428 941.12 versus $375 788.21, BCTQ-S: $417 115.09 versus $356 614.18, and BCTQ-F: $421 706.44 versus $376 908.45. From a societal perspective, compared to PRP injections, the ICER for corticosteroid injections measured by VAS: -$1024.40/QALY, BCTQ-S: -$899.95/QALY, and BCTQ-F: -$1215.51/QALY. PRP versus corticosteroid injections provided a NMB measured by VAS: $428 171.63 versus $373 944.39, BCTQ-S: $416 345.61 versus $354 770.36, and BCTQ-F: $420 936.95 versus $375 064.63. CONCLUSIONS: PRP injections were more cost-effective than methylprednisolone/triamcinolone injections from healthcare and societal perspectives for mild-to-moderate CTS.

Platelet-rich plasma vs. corticosteroid injections for the treatment of recalcitrant lateral epicondylitis: a cost-effectiveness Markov decision analysis.

BACKGROUND: Both platelet-rich plasma (PRP) and corticosteroid injections may be used to treat lateral epicondylitis. We evaluated the cost-effectiveness of PRP injections vs. corticosteroid injections for the treatment of recalcitrant lateral epicondylitis. METHODS: Markov modeling was used to analyze the base-case 45-year-old patient with recalcitrant lateral epicondylitis, unresponsive to conservative measures, treated with a single injection of PRP or triamcinolone 40 mg/mL. Transition probabilities were derived from randomized controlled trials, quality-of-life (QOL) values from the Tufts University Cost-Effectiveness Analysis Registry reported using Disabilities of the Arm, Shoulder, and Hand (DASH) scores, and costs from institution financial records. Analyses were performed from health care and societal perspectives. Outcomes were incremental cost-effectiveness ratios (ICERs), reported as US dollars / quality-adjusted life-year (USDs/QALY) and net monetary benefit (NMB) to represent the values of an intervention in monetary terms. Willingness-to-pay thresholds were set at $50,000 and $100,000. Deterministic and probabilistic sensitivity analyses were performed over 10,000 iterations. RESULTS: Both PRP and triamcinolone 40-mg/mL injections were considered cost-effective interventions from a health care and societal perspective below the WTP threshold of $50,000. From a health care perspective, PRP injections were dominant compared with triamcinolone 40-mg/mL injections, with an ICER of -$5846.97/QALY. PRP injections provided an NMB of $217,863.98, whereas triamcinolone 40 mg/mL provided an NMB of $197,534.18. From a societal perspective, PRP injections were dominant compared to triamcinolone 40-mg/mL injections, with an ICER of -$9392.33/QALY. PRP injections provided an NMB of $214,820.16, whereas triamcinolone 40 mg/mL provided an NMB of $193,199.75. CONCLUSIONS: Both PRP and triamcinolone 40-mg/mL injections provided cost-effective treatments from health care and societal perspectives. Overall, PRP injections were the dominant treatment, with the greatest NMB for recalcitrant lateral epicondylitis over the time horizon of 5 years.

Isolated Scaphoid Dislocation With Radial-Axial Instability: A Treatment Strategy Utilizing Spanning Wrist Plates.

Isolated dislocation of the scaphoid is a rare injury with only a few case reports in the literature. We report on 2 complex scaphoid dislocations demonstrating concomitant axial instability with disruption of the capitohamate articulation as well as the long-ring metacarpal relationship. Both of these patients underwent reduction and fixation using a wrist spanning plate, which was removed approximately 2 months after injury. Follow-up of these patients demonstrated maintenance of reduction, axial stability, and return of painless range of motion.

The Value Added of Advanced Imaging in the Diagnosis and Treatment of Triangular Fibrocartilage Complex Pathology.

PURPOSE: Pathology of the triangular fibrocartilage complex is a prevalent cause of ulnar-sided wrist pain that presents a diagnostic challenge. We hypothesized that a history and physical examination (H&P) would be more cost-effective alone or with diagnostic injection than with magnetic resonance imaging (MRI) or magnetic resonance arthrogram (MRA) in the diagnosis and treatment of a symptomatic triangular fibrocartilage complex abnormality. METHODS: A simple-chain decision analysis model was constructed to assess simulated subjects with ulnar-sided wrist pain and normal radiographs using several diagnostic algorithms: H&P alone, H&P + injection, H&P with delayed advanced imaging (MRI or MRA), and H&P + injection with delayed advanced imaging (MRI or MRA). Three years after diagnosis, effectiveness was calculated in Disabilities of the Arm, Shoulder, and Hand-adjusted life years. Costs were extracted from a commercial insurance database using US dollars. A probabilistic sensitivity analysis with 10,000 second-order trials with sampling of parameter distributions was performed. One-way and 2-way sensitivity analyses were performed. RESULTS: All strategies had similar mean effectiveness between 2.228 and 2.232 Disabilities of the Arm, Shoulder, and Hand-adjusted life years, with mean costs ranging from $5,584 (H&P alone) to $5,980 (H&P, injection, and MRA). History and physical examination alone or with injection were the most cost-effective strategies. History and physical examination alone was the most preferred diagnostic strategy, though H&P + injection and H&P with delayed MRA were preferred with adjustments in willingness-to-pay and parameter inputs. As willingness-to-pay increased considerably (>$65,000 per Disabilities of the Arm, Shoulder, and Hand-adjusted life year), inclusion of MRA became the most favorable strategy. CONCLUSIONS: Advanced imaging adds costs and provides minimal increases in effectiveness in the diagnosis and treatment of a symptomatic triangular fibrocartilage complex abnormality. The most cost-effective strategy is H&P, with or without diagnostic injection. Magnetic resonance arthrogram may be favored in situations with a high willingness-to-pay or poor examination characteristics. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic/Decision Analysis IV.

Use of a 5-item modified Fragility Index for risk stratification in patients undergoing surgical management of distal humerus fractures.

INTRODUCTION: We hypothesized that the modified Fragility Index (mFI), which predicts surgical complications, would be applicable to surgical complications in patients older than 50 years with distal humerus fractures (DHF). METHODS: We retrospectively reviewed the American College of Surgeons National Surgery Quality Improvement Program database, including patients older than 50 years who underwent open reduction and internal fixation of a DHF. A 5-item mFI score was calculated. Postoperative complications, readmission and reoperation rates, and length of stay were recorded. Univariate as well as a multivariable statistical analysis was performed, controlling for age, sex, body mass index, length of stay, and operative time. RESULTS: We identified 864 patients (mean age, 68.6 years ± 10.4), and 74.1% were female. As the mFI increased from 0 to 2 or greater, 30-day readmission rate increased from 3% to 10% (P value = .01), rate of discharge to rehabilitation facility increased from 12% to 32% (P value = .0), and any complication rate increased from 4% to 19% (P value = .0). Rates of pulmonary complications increased significantly in patients with the mFI of 2 or greater (P value = .047). Patients with the mFI of 2 or greater were nearly 4 times more likely to be readmitted within 30 days (odds ratio [OR] = 3.5, P value = .007) and had an increased OR of 30-day reoperation and any complication (OR = 3.7, P value = .02; OR = 4.5, P value = .00, respectively) on multivariate analysis. CONCLUSION: A fragility state is predictive of postoperative complications, readmission, and reoperation after surgical management of DHF. Our data suggest that a fragility evaluation can help inform surgical decision-making in patients older than 50 years with DHF.

Patient Perspectives on the Cost of Hand Surgery.

BACKGROUND: Health-care expenditures in the U.S. are continually rising, prompting providers, patients, and payers to search for solutions to reduce costs while maintaining quality. The present study seeks to define the out-of-pocket price that patients undergoing hand surgery are willing to pay, and also queries the potential cost-cutting measures that patients are most and least comfortable with. We hypothesized that respondents would be less accepting of higher out-of-pocket costs. METHODS: A survey was developed and distributed to paid, anonymous respondents through Amazon Mechanical Turk. The survey introduced 3 procedures: carpal tunnel release, cubital tunnel release, and open reduction and internal fixation of a distal radial fracture. Respondents were randomized to 1 of 5 out-of-pocket price options for each procedure and asked if they would pay that price. Respondents were then presented with various cost-saving methods and asked to select the options that made them most uncomfortable, even if those would save them out-of-pocket costs. RESULTS: There were 1,408 respondents with a mean age of 37 years (range, 18 to 74 years). Nearly 80% of respondents were willing to pay for all 3 of the procedures regardless of which price they were presented. Carpal tunnel release was the most price-sensitive, with rejection rates of 17% at the highest price ($3,000) and 6% at the lowest ($250). Open reduction and internal fixation was the least price-sensitive, with rejection rates of 11% and 6% at the highest and lowest price, respectively. The use of older-generation implants was the least acceptable cost-cutting measure, at 50% of respondents. CONCLUSIONS: The present study showed that most patients are willing to pay a considerable amount of money out of pocket for hand surgery after the condition, treatment, and outcomes are explained to them. Furthermore, respondents are hesitant to sacrifice advanced technology despite increased costs.

Open and Arthroscopic Triangular Fibrocartilage Complex (TFCC) Repair.

Triangular fibrocartilage complex (TFCC) tears, whether acute or chronic, can result in persistent ulnar-sided wrist pain. Although diagnosis and nonsurgical management of TFCC tears is well described, there remains ongoing discussion about the optimal surgical technique, specifically open or arthroscopic. This article reviews the most up-to-date literature regarding TFCC injury including demographics, risk factors for TFCC injury, classification of acute and chronic TFCC tears, history and physical examination, appropriate diagnostic imaging, surgical indications, pertinent surgical anatomy, open and arthroscopic TFCC repair, fixation biomechanics and techniques, postoperative rehabilitation, and clinical outcomes.

Fracture location impacts opioid demand in upper extremity fracture surgery.

INTRODUCTION: Opioid sparing protocols should be formulated with appropriate demand. Specific fracture location has been hypothesized as an important predictor of post-operative pain. The purpose of this study is to evaluate the impact of fracture location on perioperative opioid demand after surgery with the hypothesis that this factor would be significantly associated with perioperative opioid demand in upper extremity fracture surgery. METHODS: A national database was used to identify1-month pre-operative to 1-year postdischarge opioid demand in oxycodone 5-mg equivalents in 336,493 patients undergoing fracture fixation of the clavicle through distal radius between 2010 and 2020. Three timeframes were evaluated: 1-month pre-op to 90-days post-discharge, 3 months post-discharge to 1-year post-discharge, and 1-month pre-op to 1-year postdischarge. Multivariable main effects linear and logistic regression models were constructed to evaluate the changes in opioids filled, opioid prescriptions, and odds of two or more opioid prescriptions in these timeframes based on fracture location with adjustment for age, sex, obesity, pre-operative opioid usage, and polytrauma. RESULTS: Compared to distal radius fracture fixation, fixation of elbow, distal humerus, humeral shaft, and proximal humerus fractures were associated with large, significant increases in 1-month pre-op to 1-year post-discharge opioid filling (33.5 - 63.4 additional oxycodone 5-mg equivalents, all p<0.05) and number of filled prescriptions (0.33 - 0.92 additional prescriptions, all p<0.05) compared to patients with other operatively treated upper extremity injuries. DISCUSSION: Fracture location was a significant predictor of perioperative opioid demand. Elbow, distal humerus, humeral shaft, and proximal humerus fracture fixation was associated with the largest increases in opioid demand after upper extremity fracture fixation. Patients with these injuries may be at highest risk of extensive opioid consumption. LEVEL OF EVIDENCE: Level III, retrospective, observational cohort study.

Use of a 5-item modified Fragility Index for risk stratification in patients undergoing surgical management of proximal humerus fractures.

HYPOTHESIS: We hypothesized that the modified Fragility Index (mFI) would predict complications in patients older than 50 years who underwent operative intervention for a proximal humerus fracture. METHODS: We retrospectively reviewed the American College of Surgeons National Surgery Quality Improvement Program database, including patients older than 50 years who underwent open reduction and internal fixation of a proximal humerus fracture. A 5-item mFI score was then calculated for each patient. Postoperative complications, readmission and reoperation rates as well as length of stay (LOS) were recorded. Univariate as well as multivariable statistical analyses were performed, controlling for age, sex, body mass index, LOS, and operative time. RESULTS: We identified 2,004 patients (median age, 66 years; interquartile range: 59-74), of which 76.2% were female. As mFI increased from 0 to 2 or greater, 30-day readmission rate increased from 2.8% to 6.7% (P-value = .005), rate of discharge to rehabilitation facility increased from 7.1% to 25.3% (P-value < .001), and rates of any complication increased from 6.5% to 13.9% (P-value < .001). Specifically, the rates of renal and hematologic complications increased significantly in patients with mFI of 2 or greater (P-value = .042 and P-value < .001, respectively). Compared with patients with mFI of 0, patients with mFI of 2 or greater were 2 times more likely to be readmitted within 30 days (odds ratio = 2.2, P-value .026). In addition, patients with mFI of 2 or greater had an increased odds of discharge to a rehabilitation center (odds ratio = 2.3, P-value < .001). However, increased fragility was not significantly associated with an increased odds of 30-day reoperation or any complication after controlling for demographic data, LOS, and operative time. CONCLUSION: An increasing level of fragility is predictive of readmission and discharge to a rehabilitation center after open reduction and internal fixation of proximal humerus fractures. Our data suggest that a simple fragility evaluation can help inform surgical decision-making and counseling in patients older than 50 years with proximal humerus fractures.