Clinic Study Completion Rate in Orthopedic Surgery.

Purpose: The primary aim of this study is to determine the rate of completion of clinic-based study orders. Secondarily, we attempt to determine factors associated with study incompletion. Methods: This retrospective study included 591 clinic-based studies that were ordered for 510 patients at the time of clinical evaluation at a single medical center between April 8, 2018 and August 22, 2019. Inclusion criteria were studies ordered in a hand clinic for consecutive adult patients to be completed after the visit. Exclusion criteria included pediatric patients and routine radiographs obtained prior to the visit. Invasive studies were defined as studies with a significant procedural component, such as aspirations, injections and electromyography/nerve conduction (electrodiagnostic) studies (EDS). Blood tests and imaging were considered noninvasive. Patient demographics and study completion rates were collected through chart reviews. Univariate and bivariate analyses were performed, and P <.05 was considered significant. Results: The overall clinic-based study completion rate was 94.2%, with the highest incompletion rates seen in invasive studies (8.3%, n = 34) compared to noninvasive studies (3.3%, n = 10). Within the invasive study category, EDS had the highest rate of incompletion (11.4%) and contributed to the majority of incompletions in the invasive cohort (20/24). The median time to study completion was 7 days (interquartile range [IQR] 2-21). Race, gender, English as primary language, marriage status, insurance type, and distance from facility were similar between completed and noncompleted studies. Conclusion: Study completion rates were similar between all patients regardless of race, gender, and other social economic variables. Invasive studies, particularly EDS, had higher rates of incompletion and can be barriers to patients receiving additional care. Type of study/level of evidence: Therapeutic III.

The Effect of Socioeconomic Disparity on Improvement in QuickDASH at 3 Months after Carpal Tunnel Release.

The primary objective of this study was to determine the association between socioeconomic disparity and improvement in QuickDASH score 3 months after carpal tunnel release (CTR). The secondary objectives of this study were to determine the association between socioeconomic disparity and baseline preoperative QuickDASH score and 3 months postoperative QuickDASH score after CTR. Methods: A single-institutional, prospective, longitudinal study was performed of 85 patients who underwent isolated, unilateral CTR for idiopathic carpal tunnel syndrome. Sixty-three patients (74%) who completed patient-reported outcome measures at 3 months after surgery comprised our study cohort. Socioeconomic disparity was assessed using the zip code level Distressed Communities Index (DCI) and the neighborhood level Area Deprivation Index. The outcome variables were the improvement in the QuickDASH score, 3 months postoperative QuickDASH score, and the preoperative QuickDASH score. Associations between continuous variables were assessed using simple linear regression. Results: The mean DCI of the study cohort was in the 23rd national percentile, and the mean Area Deprivation Index was in the 15th national percentile. The mean preoperative QuickDASH of the study cohort was 49.3. The mean 3 months postoperative QuickDASH of the study cohort was 29.8. The mean improvement in QuickDASH at 3 months after surgery was 19.5, which was statistically significant and clinically meaningful. Area Deprivation Index and DCI were not associated with improvement in QuickDASH score or 3 months postoperative QuickDASH score. Higher DCI was associated with poorer baseline preoperative QuickDASH score. Conclusion: Patients of various socioeconomic backgrounds can expect similar short-term improvements in symptoms and function after CTR.

Feasibility, effectiveness and patient satisfaction of telerehabilitation after thumb carpometacarpal arthroplasty and reverse total shoulder arthroplasty: A pilot study.

INTRODUCTION: Telemedicine is an effective, emerging interface to connect practitioners with patients. It facilitates access to healthcare expertise, reduces costs, time demands and health disparities while improving satisfaction. This pilot study evaluated the feasibility, effectiveness and patient satisfaction of telerehabilitation for thumb carpometacarpal (CMC) arthroplasty and reverse shoulder arthroplasty (rTSA). METHODS: This prospective investigation was performed at a single academic institution with two hand and upper extremity fellowship-trained orthopaedic surgeons. All patients undergoing CMC arthroplasty or rTSA were eligible for inclusion. Telerehabilitation was delivered by a hybrid model including an in-person post-operative visit, followed by alternating in-clinic and virtual videoconference visits. All patients were offered participation in the study arm; those that preferred in-person therapy were included as a control group. Therapy was initiated two weeks post-operative with an in-clinic evaluation. Patients then participated in alternating in-clinic and virtual visits weekly for eight weeks, followed by one virtual visit at 14-weeks post-operative and one clinical visit at 16-weeks post-operative. Patient reported and functional outcomes were collected at each visit. RESULTS: In the CMC group, 19 study and 11 control patients were enrolled. In the rTSA group, five study and 14 control patients were enrolled. No statistically significant differences between telerehabilitation and control for range-of-motion, pain and patient-reported functional outcomes was noted. All patients in the telerehabilitation arms reported high satisfaction. DISCUSSION: Utilizing telehealth in rehabilitation may be a viable option in upper extremity recovery. We hope this pilot programme can be a model for development of future telerehabilitation programmes.

Effects of Economic Well-Being on Outcomes at One Year after Volar Plate Fixation of Distal Radius Fractures.

Background: The objective of this study was to determine whether economic well-being is associated with patient-reported functional outcomes and range of motion 1 year following volar plate fixation of distal radius fracture. Methods: A retrospective study was performed on 200 patients with distal radius fractures treated with volar plate fixation at two Level 1 trauma centres from 2006 to 2017 with 1-year clinical follow-up using a previously published cohort. The economic well-being of patients was assessed using the Distressed Communities Index (DCI). Our outcome variables were patient-reported functional outcomes assessed by QuickDASH score and wrist and forearm range of motion 1 year after surgery. The analysis of variance (ANOVA) test was used to compare outcome variables across pre-established tiers of economic well-being. Results: The mean QuickDASH score at 1 year following distal radius fracture volar plate fixation was 10.8 and ranged from 7.3 to 12.2 across tiers of economic well-being. QuickDASH score and wrist range of motion were not significantly different across all tiers of economic well-being. However, wrist flexion-extension arc at 1 year following surgery was significantly decreased in the economically at-risk group compared with the remaining cohort. Conclusions: Patient-reported functional outcomes 1 year after volar plate fixation of distal radius fracture are similar across tiers of economic well-being. Economically disadvantaged patients are at risk for poorer wrist motion following distal radius fracture surgery, though it is not clear if this difference is clinically significant. Level of Evidence: Level II (Prognostic).

Gender Disparity Trends in Authorship of Hand Surgery Research.

PURPOSE: Despite an overall trend towards gender parity, women continue to remain underrepresented in surgical fields. Until recently, women's representation in hand surgery literature was largely unexplored. The objective of this study was to examine how authorship gender trends among academic hand surgeons have evolved between 2006 and 2019. METHODS: Original research articles published from 2006 to 2019 in 3 leading clinical hand surgery journals were extracted from PubMed. Publications with a full author first name were analyzed, and the gender of each author was assigned with the validated Genderize algorithm. Analyses were performed to evaluate authorship publication trends, unique authors, and research career productivity. RESULTS: From 2006 to 2019, 4,769 articles met the inclusion criteria, and the genders of 17,102 authors were identified. There were 2,848 (16.6%) female authors and 14,254 (83.4%) male authors. The proportion of female authors increased from 13.4% to 19.9% from 2006 to 2019. Similarly, female representation as first and senior authors increased significantly, from 10.9% to 20.1% and 7.6% to 14.2%, respectively. Of the 8,417 unique authors, 1,775 (21.1%) were women and 6,642 (78.9%) were men. Only 3.3% of these unique female authors published 5 or more papers during the study period. Among the 10 most frequently published authors for each gender, 18 of the 20 authors were surgeons. CONCLUSIONS: There has been substantial progress toward gender parity in academic hand surgery over the last 14 years, and the proportion of women publishing in leadership positions has increased. CLINICAL RELEVANCE: Increased gender representation in medicine and research is important for both patients and providers, and these findings suggest that ongoing support and mentorship for women in academic careers should be a priority.

Association of Economic Well-Being With Comorbid Conditions in Patients Undergoing Carpal Tunnel Release.

PURPOSE: Medical comorbidities have been associated with the development of carpal tunnel syndrome (CTS), severity at the time of presentation, and outcomes of carpal tunnel release (CTR). Socioeconomic factors have also been associated with worse function in patients with CTS at presentation and after surgery. However, the effects of economic well-being on the prevalence of medical comorbidities in patients with CTS have not been well-described. The objective of this study was to determine whether economic well-being is associated with medical comorbidities in a cohort of patients undergoing CTR. METHODS: Patients (n = 1,297) who underwent CTR at a single tertiary care referral center over a 5-year period from July 2008 to June 2013 were retrospectively identified. The exclusion criteria were acute trauma or infection, revision surgery, incomplete medical records, and neoplasm excision. Additionally, patients were excluded if they lacked documented confirmatory or normal electrodiagnostic study findings prior to CTR. Finally, this study comprised a cohort of 892 patients with electrodiagnostic study-confirmed CTS who underwent CTR. The economic well-being of patients was assessed using the Distressed Communities Index. The comorbidities of diabetes mellitus, chronic kidney disease, hypertension, hypothyroidism, cervical radiculopathy, tobacco use, and body mass index were assessed. Bivariate comparisons were used to determine the associations between the tiers of economic well-being and comorbidities. RESULTS: Lower economic well-being was associated with body mass index, diabetes mellitus, chronic kidney disease, and tobacco use in these patients. Although hypertension, hypothyroidism, and cervical radiculopathy were not associated with economic well-being, their comparisons were underpowered. CONCLUSIONS: Patients experiencing economic distress have a higher comorbidity burden, and as such, may be at an increased risk of complications or poorer outcomes. The association between economic well-being and comorbidities in this population suggests the need for a multidisciplinary care model that addresses both compressive neuropathy and the associated economic factors. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Factors Associated With Surgical Treatment of Isolated, Displaced Midshaft Clavicle Fractures.

Given the current available evidence, surgical treatment of isolated, displaced midshaft clavicle fractures is discretionary. The aim of this study was to determine whether there are identifiable factors associated with the surgical treatment of isolated, displaced midshaft clavicle fractures. A retrospective cohort study of 150 patients who underwent nonoperative treatment and 290 patients who underwent surgical treatment of isolated, displaced midshaft clavicle fractures from January 2010 to March 2019 at 2 level I trauma centers was performed. Multivariable regression analysis demonstrated that younger age (odds ratio [OR], 0.97; 95% CI, 0.95-0.99), absence of diabetes mellitus (OR, 0.045; 95% CI, 0.003-0.79), nonsmoking status (OR, 0.31; 95% CI, 0.13-0.75), higher American Society of Anesthesiologists classification (OR, 5.0; 95% CI, 2.7-9.2), fracture comminution (OR, 2.3; 95% CI, 1.3-3.9), and fracture displacement (OR, 1.1; 95% CI, 1.0-1.1) were associated with surgical treatment of an isolated, displaced midshaft clavicle fracture. Furthermore, lower social deprivation (OR, 0.99; 95% CI, 0.97-0.99) and private insurance compared with Medicare (OR, 6.6; 95% CI, 1.6-27) were associated with surgical treatment. The authors conclude that surgical treatment of discretionary midshaft clavicle fractures is influenced by patient factors, fracture characteristics, and socioeconomic factors. Further study is needed to understand the etiology of social disparities in clavicle surgery and rectify unintended trends in treatment. [Orthopedics. 2021;44(4):e515-e520.].

Long-Term Outcomes and Mortality Following Carpal Tunnel Release in Patients Older Than 80 Years of Age.

OBJECTIVE: The objectives of this study were 1) to assess the long-term patient-reported outcomes of carpal tunnel release (CTR) in patients 80 years of age or older, and 2) to determine the long-term mortality rate of this population after CTR. METHODS: We performed a retrospective study of 96 patients who underwent CTR at 80 years of age or older from July 2008 to June 2013. Mortality was assessed by medical records, the Social Security Death Index, and telephone contact. Living patients were contacted for long-term follow-up, and functional outcomes and patient satisfaction were assessed. RESULTS: The mean age of the 96 patients at time of CTR was 84.1 years, including 89 octogenarian patients and 7 nonagenarian patients, and 67% were female. At an average of 9 years from surgery, the mortality rate of our cohort was 53% (51 of 96 patients). Five patients died within 1 year after CTR; no factor associated with early mortality after CTR was identified in the bivariate analysis. Telephone follow-up at an average of 9 years after CTR was available for 15 patients. Mean Boston Carpal Tunnel Syndrome Questionnaire symptom severity score was 1.6 points, mean Boston Carpal Tunnel Syndrome Questionnaire functional status score was 1.8 points, mean Quick Disabilities of the Arm, Shoulder and Hand score was 27.9, and mean satisfaction was 7.1. Eighty percent of patients reported that they would rechoose CTR. CONCLUSIONS: There are long-term benefits from CTR in patients 80 years of age or older. The mortality rate of this cohort mirrors that of the general population, and CTR is justified in this elderly age group both for the magnitude and duration of treatment effect.

Correlation of Hounsfield Unit Measurements on Computed Tomography of the Shoulder With Dual-Energy X-ray Absorptiometry Scans and Fracture Risk Assessment Tool Scores: A Potential for Opportunistic Screening.

BACKGROUND: The diagnosis of bone mineral density (BMD) abnormalities involves dual-energy x-ray absorptiometry (DXA), but few patients complete this after a fragility fracture. The assessment of BMD using Hounsfield unit (HU) measurements from computed tomography (CT) scans has been correlated with DXA results in previous studies. We aimed to evaluate the correlation between shoulder CT HU and DXA scores. METHODS: Billing databases of 3 academic institutions were queried for patients who underwent both DXA and CT scan of the upper extremity within 1 year of each other. DXA T-scores for spine, hip, and femoral neck were recorded. BMD status was defined based on composite T-scores, using the lowest T-score in the spine, hip, or proximal femur. CT scans were measured for HU over 4 slices, recorded to create a bone column, then averaged. The patients' risks of major osteoporosis-related fracture and hip fracture were calculated using the Fracture Risk Assessment Tool. RESULTS: In total, 300 patients were included. A positive correlation was found between composite T-scores and HU for glenoid and proximal humerus (0.36; 0.17). The proximal humerus HU was significantly associated with the BMD T-score for the hip (P = 0.01); the glenoid HU was significantly associated with BMD T-scores for the hip, spine, and femoral neck (P = 0.002; P = 0.001; P = 0.002). A 10-year risk of hip fracture >3% was associated with lower proximal humerus HU. CONCLUSIONS: Our study is the first to discover significant correlations between HU at the glenoid and proximal humerus and risk factors as established by the Fracture Risk Assessment Tool scoring system. LEVEL OF EVIDENCE: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Predictors of Insurance Claim Rejection in Hand and Upper Extremity Surgery.

INTRODUCTION: Insurance claim rejections represent a challenge for healthcare providers because of the potential for lost revenue and administrative costs of reworking claims. METHODS: The billing records of five hand and upper extremity surgeons at a tertiary academic center were queried for all patient billing activity over a 1-year period yielding a total of 14,421 unique patient encounters. RESULTS: A total of 11,839 unique patient encounters were included, and the overall claim rejection rate was 19.3%. Claim rejection rate varied significantly by payer (P < 0.0001) and was lowest in private insurance (14.0%) and highest in Medicare (31.2%). The use of multiple Current Procedure Terminology codes for an encounter was independently associated with an increased risk of claim rejection for both office (25.6%, relative risk [RR] 1.27, 95% confidence interval [CI] 1.03 to 1.49, P = 0.0032) and surgical (25.6%, RR 1.67, 95% CI 1.28 to 2.18, P = 0.0002) settings. After multivariate regression adjustment, modifier 25 was associated with a decreased risk of claim rejection (23.3%, RR 0.72, 95% CI 0.61 to 0.85, P < 0.0001). DISCUSSION: Insurance claim rejection occurs frequently (19.3%) in hand/upper extremity surgery and varies by insurance type, with the highest rejection rate occurring in Medicare (31.2%). For a given encounter, the use of multiple Current Procedure Terminology codes and specific modifiers are predictive of rejection risk. LEVEL OF EVIDENCE: Level III, prognostic.

The impact of Massachusetts health care reform on an orthopedic hand service.

PURPOSE: The impact of Massachusetts health care reform on the burden of uninsured orthopedic care is unclear. We examined the patient population at an academic orthopedic hand surgery practice based in an inner city, level 1 trauma center as a model. We hypothesized that the percentage of overall encounters with uninsured patients would decrease and that the percentages of overall encounters with privately insured and MassHealth (Medicaid) patients would increase. METHODS: We retrospectively tallied the insurance type of all patient encounters from 2004 to 2011 for an academic orthopedic hand surgery practice. Charity care and self pay constituted the uninsured group. Insurance types that do not offer patients a choice in enrollment, such as Medicare and motor vehicle insurance, were excluded. Non-Massachusetts residents were excluded. July 1, 2007, was used as the reference date for the implementation of reform policies. Paired t-tests and change-point linear regressions were performed. RESULTS: The overall percentage of encounters with uninsured patients declined by approximately 2%, and the overall percentage of encounters with privately insured patients increased by approximately 3.5%, both significant changes. No significant change in MassHealth (Medicaid) was observed. Change-point linear regression revealed that privately insured encounters increased rapidly after reform but that levels have remained roughly the same since. The uninsured population was already decreasing slightly between 2004 and 2007, at a rate of approximately 0.08% per month, but it also leveled off after 2007. CONCLUSIONS: We found that the burden of uninsured encounters on our service was reduced by a statistically significant decrease of approximately one-half. This was accompanied by a significant increase in encounters with privately insured patients. No significant change in the number of MassHealth encounters occurred. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic/Decision Analysis IV.