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1.
J Hand Surg Am ; 2024 Sep 19.
Artículo en Inglés | MEDLINE | ID: mdl-39297829

RESUMEN

Health disparities related to race, ethnicity, gender, level of education, and other social determinants of health remain prevalent in medicine and surgery. Understanding the impact of health disparities on treatment decisions and outcomes among common hand surgery conditions has been a major focus of the American Society for Surgery of the Hand. Creative strategies are necessary to go beyond the description of disparities and move toward the proposal of actionable solutions. Community engagement research is one feasible approach that can help hand surgeons narrow these gaps and improve health care outcomes. With this approach, hand surgeons can improve patient-provider communication, increase knowledge of specific hand conditions among community members, and help guide subsequent initiatives to improve access and usage of hand surgery treatment. Community members can take on various roles ranging from participants to partnered investigators, enhancing the overall process to identify actionable solutions with the end user in mind. Additionally, the creation of community-academic partnerships through community engagement research is an excellent way to dismantle the historical mistrust among underrepresented groups through the deliberate inclusion of community members in the research design and execution.

2.
J Hand Surg Am ; 2024 Aug 12.
Artículo en Inglés | MEDLINE | ID: mdl-39140917

RESUMEN

PURPOSE: The diagnosis of carpal tunnel syndrome (CTS) can be made clinically using the Carpal Tunnel Syndrome-6 (CTS-6) criteria. The role of electrodiagnostic studies (EDS) is controversial. We examined differences in the utilization of CTS-6 and EDS based on surgeon experience and practice setting. METHODS: Members of the American Society for Surgery of the Hand were emailed an anonymous web-based link to participate. The survey included an assessment of hypothetical CTS scenarios with varying clinical severity. We collected surgeon demographic attributes, years in practice, practice setting, and frequency of CTS-6 and EDS utilization. A comparison was made of years of experience with surgeon-reported utilization of CTS-6 and EDS as well as treatment recommendation. RESULTS: We received 771 responses (25% response rate). Surgeons recommended carpal tunnel release (CTR) for patients without EDS (16%), normal EDS (33%), and abnormal EDS (90%). Fifty-three percent of surgeons with <15 years in practice reported often/always using CTS-6 criteria in their practice compared to 30% and 29% of surgeons with 16-30 years and > 30 years in practice, respectively. Surgeons with 16-30 and >30 years in practice had significantly lower odds of reporting often/almost always using CTS-6 relative to surgeons with 1-15 years in practice (OR 0.35 and 0.31, respectively). A greater proportion of surgeons with 16-30 years (68%) and >30 years (65.5%) in practice responded often/almost always applying EDS compared to surgeons with <15 years (56%) in practice. In addition, surgeons with 16-30 years and >30 years in practice had a higher odds of often/always using EDS (ORs 1.74 and 1.98, respectively) compared to surgeons with 1-15 years in practice (P < .05). CONCLUSIONS: Utilization of CTS-6 and EDS varied based on years in practice. This difference may reflect changing guidelines, the growing evidence regarding clinical assessment tools, and the emergence of other diagnostic modalities. CLINICAL RELEVANCE: Given the expense and invasiveness of EDS, opportunities to integrate clinical assessment tools readily into the diagnostic algorithm may shift the role of EDS toward selective utilization for complex clinical scenarios rather than for routine use.

3.
J Hand Surg Am ; 44(6): 443-453, 2019 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-31005463

RESUMEN

PURPOSE: To examine physician and hospital reimbursement for digit and thumb replantation compared with revision amputation. METHODS: Using the 2009-2016 Truven Health MarketScan Research Databases, we identified patients with a digit or thumb amputation. Following application of our inclusion and exclusion criteria, we divided patients into replantation and revision amputation groups. We extracted the mean physician and hospital reimbursement associated with each patient encounter. For comparison, we examined the work Relative Value Unit (wRVU) and Medicare Physician Fee Schedule (MPFS) for the respective procedures in addition to several common hand surgery procedures. RESULTS: We identified 51,716 patients. Following application of our inclusion and exclusion criteria, 219 replantation and 6,209 revision amputation patients were included in our analysis. For replantation, the mean physician and hospital reimbursements ranged from $3,938 to $7,753 and $30,683 to $56,256, respectively. For revision amputation, the mean physician and hospital reimbursements ranged from $1,030 to $1,206 and $2,877 to $4,188, respectively. On multivariable analysis, hospitals performing replantation earned $37,788 more per case compared with revision amputation. Using the wRVU and MPFS data, we determined that replantation reimburses at $78/wRVU compared with higher earnings for revision amputation ($108), carpal tunnel release ($101), cubital tunnel release ($97), trigger finger release ($116), open reduction and internal fixation (ORIF) distal radius fracture ($87), flexor tendon repair ($98), extensor tendon repair ($122), repair of digital nerve ($89), and ORIF articular fracture ($82), respectively. CONCLUSIONS: Low physician reimbursement for replantation compared with less complex hand procedures makes it difficult to recruit and retain hand surgeons for this purpose. By understanding the wRVU and MPFS system, hand surgeons and professional societies can explore ways to promote change in the way replantation is valued by the Centers for Medicare and Medicaid Services (CMS) as well as by hospital administrators. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic/Decision Analysis III.


Asunto(s)
Amputación Traumática/cirugía , Traumatismos de los Dedos/cirugía , Reembolso de Seguro de Salud/economía , Reimplantación/economía , Adolescente , Adulto , Anciano , Amputación Quirúrgica , Niño , Preescolar , Economía Hospitalaria , Femenino , Humanos , Lactante , Recién Nacido , Masculino , Medicare/economía , Persona de Mediana Edad , Procedimientos Ortopédicos/economía , Médicos/economía , Estados Unidos , Adulto Joven
4.
Dev Biol ; 392(2): 295-307, 2014 Aug 15.
Artículo en Inglés | MEDLINE | ID: mdl-24882712

RESUMEN

Neural crest cells are an embryonic cell population that is crucial for proper vertebrate development. Initially localized to the dorsal neural folds, premigratory neural crest cells undergo an epithelial-to-mesenchymal transition (EMT) and migrate to their final destinations in the developing embryo. Together with epidermally-derived placode cells, neural crest cells then form the cranial sensory ganglia of the peripheral nervous system. Our prior work has shown that αN-catenin, the neural subtype of the adherens junction α-catenin protein, regulates cranial neural crest cell EMT by controlling premigratory neural crest cell cadherin levels. Although αN-catenin down-regulation is critical for initial neural crest cell EMT, a potential role for αN-catenin in later neural crest cell migration, and formation of the cranial ganglia, has not been examined. In this study, we show for the first time that migratory neural crest cells that will give rise to the cranial trigeminal ganglia express αN-catenin and Cadherin-7. αN-catenin loss- and gain-of-function experiments reveal effects on the migratory neural crest cell population that include subsequent defects in trigeminal ganglia assembly. Moreover, αN-catenin perturbation in neural crest cells impacts the placode cell contribution to the trigeminal ganglia and also changes neural crest cell Cadherin-7 levels and localization. Together, these results highlight a novel function for αN-catenin in migratory neural crest cells that form the trigeminal ganglia.


Asunto(s)
Movimiento Celular/fisiología , Transición Epitelial-Mesenquimal/fisiología , Proteínas del Tejido Nervioso/metabolismo , Cresta Neural/metabolismo , Ganglio del Trigémino/embriología , alfa Catenina/metabolismo , Animales , Cadherinas/metabolismo , Embrión de Pollo , Electroporación , Inmunohistoquímica , Hibridación in Situ , Etiquetado Corte-Fin in Situ , Indoles , Cresta Neural/citología , Cresta Neural/fisiología
5.
Semin Plast Surg ; 38(1): 69-73, 2024 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-38495058

RESUMEN

In this article, we examine the 60-year history of diversity efforts within the Section of Plastic Surgery at the University of Michigan (UofM) in the context of national trends. We describe the experiences of pioneering Underrepresented in Medicine (URiM) and female graduates of the program. James Norris, MD, and Christine Sullivan, MD, were the first URiM and female graduates from UofM in 1974 and 1989, respectively. Currently, women constitute over one-half the plastic surgery trainees at UofM, but URiM trainee representation remains limited. Dr. Adeyiza Momoh and Dr. Amy Alderman were the first URiM and female faculty members hired in 2011 and 2004, respectively. At present, there are four URiM and seven female faculty members in the Section. With a shared vision, supportive leadership, and motivation to change, faculty diversity has increased substantially. Additional strategies, including ongoing pipeline programs in medicine and science for URiM and women, are needed to further increase workforce diversity in plastic surgery.

6.
Phys Med Rehabil Clin N Am ; 35(4): 725-737, 2024 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-39389633

RESUMEN

Major upper and lower extremity amputations are increasingly being performed for peripheral vascular disease, infectious etiologies, trauma, and oncologic purposes. Attention to technique and emerging treatments for the residual peripheral nerve is critical to prosthetic wear and quality of life following these life changing events. Here, we detail advancements in amputation surgery including targeted muscle reinnervation, regenerative peripheral nerve interface, and the use of osseointegrated implants.


Asunto(s)
Amputación Quirúrgica , Humanos , Amputación Quirúrgica/métodos , Amputación Quirúrgica/rehabilitación , Miembros Artificiales
7.
Plast Reconstr Surg ; 153(3): 649-655, 2024 Mar 01.
Artículo en Inglés | MEDLINE | ID: mdl-37184528

RESUMEN

BACKGROUND: Carpal tunnel syndrome (CTS) is the most common compressive neuropathy and has severe long-term effects on hand function if surgery is delayed significantly following diagnosis. The authors investigated the timespan between diagnosis and surgical intervention for carpal tunnel syndrome among African American and White patients on Medicaid. METHODS: Using the MarketScan Truven Database Medicaid Supplement 2009 to 2020, the authors identified patients with CTS. Demographic data and time intervals between diagnosis and treatment were collected and analyzed using chi-square test and regression models. RESULTS: A total of 361,942 African American and White Medicaid patients with a diagnosis of CTS were included in the study. Overall, 21.4% of White patients compared with 13.6% of African American patients chose surgery as their first and only option ( P < 0.001). A greater proportion of White patients underwent surgery less than 6 months after diagnosis compared with African Americans (75.5% and 67.7%, respectively; P < 0.001). African American women underwent surgery at a significantly lower rate compared with White women (13.8% and 21.8%, respectively); P < 0.001). Despite the increase in rates of surgery among both groups, the gap in use of surgery widened from a 6.6% difference in 2009 to a difference of 9.5% in 2020 between racial groups. CONCLUSIONS: African American race and female sex are significantly correlated with choice of treatment and time to surgery among Medicaid patients with CTS. Identification of the relationship between health care disparities and the decision to undergo surgery is the first step in the development of strategies to mitigate underuse of this quality-of-life-improving procedure.


Asunto(s)
Síndrome del Túnel Carpiano , Medicaid , Femenino , Humanos , Negro o Afroamericano , Síndrome del Túnel Carpiano/diagnóstico , Síndrome del Túnel Carpiano/cirugía , Blanco , Disparidades en Atención de Salud
8.
Plast Reconstr Surg ; 2024 Sep 04.
Artículo en Inglés | MEDLINE | ID: mdl-39236258

RESUMEN

SUMMARY: Distal radius fractures are extremely common. Plastic surgery trainees and practicing surgeons who encounter these patients should be familiar with the various treatment options. Although the volar locking plate has revolutionized treatment of these fractures, we believe it is important to highlight the anatomy, diagnosis, and contemporary management of specific fracture patterns that may require techniques beyond volar plating.

9.
J Hand Surg Glob Online ; 6(2): 173-177, 2024 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-38903835

RESUMEN

Purpose: Differences in the utilization of carpal tunnel release (CTR) by Blacks and women are well documented, but less is known regarding the impact of patient-provider concordance on treatment recommendations. To investigate this, we surveyed hand surgeons using hypothetical scenarios to evaluate variations in treatment recommendations for carpal tunnel syndrome based on patient-related factors and patient-provider concordance. Methods: Three pairs (six total) of hypothetical scenarios with clinical symptoms of carpal tunnel syndrome were created varying sex, race, and occupation. We used names as a proxy for sex and race. Occupation included manual laborers, secretaries, athletes, and retirees. American Society for Surgery of the Hand members were emailed an anonymous web-based link to participate. We used descriptive statistics to analyze the scenario-based treatment recommendations. Results: We identified 3,067 eligible members for participation; 770 surgeons responded (25%) and provided recommendations for 3,742 scenarios. For scenarios involving symptomatic patients without electrodiagnostic studies (EDS), with normal EDS, and with abnormal EDS, no difference was noted in surgeon treatment recommendations based on patients' race, sex, and occupation. Surgeons recommended EDS for 31% and 32.8% of the scenarios with Black female and White male patients, respectively, who did not have EDS at presentation and CTR for 32.3% and 33% of White females and Black males with normal EDS, respectively. Among retired Black female and White male patients older than 80 years of age with abnormal EDS, surgeons recommended CTR in 89.9% and 89.3% of them, respectively. For patient-provider racially concordant pairs, White surgeons recommended CTR to a similar proportion of Black and White hypothetical patients; however, Black surgeons recommended CTR to a greater proportion of patients with Black-sounding names. Conclusions: We found that surgeon treatment recommendation was not associated with patient race, sex, or occupation; however, differences did emerge based on patient-provider racial concordance, suggesting that alignment of patient and provider identities may influence treatment recommendations. Type of study/level of evidence: Prognostic III.

10.
J Pediatr Surg ; 2024 May 09.
Artículo en Inglés | MEDLINE | ID: mdl-38811257

RESUMEN

PURPOSE: Holistic review (HR) considers applicants' unique identities and experiences rather than focusing on academic metrics. Though several residency programs have demonstrated increases in women and those underrepresented in medicine (URiM), this is the first study to examine HR in pediatric surgery (PS). METHODS: Using a retrospective review of applicants, demographic, academic, and non-academic metrics of traditional review (TR) [2015-2017] were compared to HR [2018-2022]. HR initiatives include expansion of faculty reviewers, implementation of a pre-screening rubric, and greater prioritization of non-academic factors. Chi-squared/Fisher's exact tests, Wilcoxon rank-sum tests, and two sample z-test for proportions were used where appropriate. RESULTS: For 635 applicants (TR: 268, HR: 367), the proportion offered interviews in the TR and HR cohorts were similar (31.7 vs 36%, p = 0.30). Candidates selected for interview pre- and post-HR most commonly graduated from residency programs affiliated with PS fellowships (56.5 vs 50%, p = 0.65). After HR implementation, no change in proportion of women interviewees (TR: 52.9 vs HR: 54.5%, p = 0.93) was observed. Though URiM residents applying to PS remained consistently low (TR: 14.6 vs HR: 10.9%, p = 0.21), significantly more received interviews with HR (30.8 vs 42.5%, p = 0.001). The median number of peer-review publications per interviewee increased (17 vs 22, p = 0.02) as did non-academic achievements (leadership, service, athletic awards, etc.) per applicant (1.0 vs 1.5, p = 0.104), though the latter did not reach significance, demonstrating similar qualification of interviewees in HR and TR. CONCLUSION: Holistic review of PS fellowship applications increased the proportion of URiM interviewees, despite a persistently low URiM proportion in the applicant pool. Furthermore, implementing HR did not sacrifice the caliber of interviewees, as publications and non-academic achievements increased by over 25% in the HR cohort. LEVEL OF EVIDENCE: IV.

11.
Plast Reconstr Surg Glob Open ; 12(3): e5659, 2024 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-38435458

RESUMEN

Background: Delay in surgical treatment for carpal tunnel syndrome (CTS) may result in long-term decreased functional outcomes. Few investigators have examined the relationship between type of health insurance plan and time to definitive treatment of CTS following diagnosis. We investigated the relationship between insurance type, treatment decision, and the time between diagnosis and surgery across groups. Methods: This was a retrospective cohort study using the MarketScan Commercial Claims and Encounters Database 2011-2020. We used χ2 tests, linear regression, and logistic regression models to analyze demographic data and the time lag interval between CTS diagnosis and treatment. Results: Overall, 28% of high-deductible health plan (HDHP) patients underwent carpal tunnel release, compared with 20% of traditional insurance patients (P < 0.001). HDHPs are defined by the internal revenue service as a deductible of $1400 for an individual or $2800 for a family per year. The odds of undergoing surgery versus no treatment for HDHP patients were 47% higher than traditional patients (P < 0.001). Among the patients who underwent surgery, HDHP patients underwent surgery 65 days earlier on average following diagnosis compared with traditional patients (P < 0.001). Conclusions: Patients with HDHPs who receive a diagnosis of CTS are more likely to undergo surgery, with a shorter time lag between diagnosis and surgery. The results from this study call attention to differences in surgical decision-making between patients enrolled in different insurance plans.

12.
Plast Reconstr Surg Glob Open ; 11(8): e5179, 2023 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-37577244

RESUMEN

Recently, there has been heightened interest in the history of Black American plastic surgeons and their contributions to the field of plastic and reconstructive surgery (PRS). Despite the increased awareness and attention toward the lack of racial and ethnic diversity of the PRS workforce, the history of how PRS became one of the most ethnically segregated surgical specialties remains unexplored. Here, we outline the various political and cultural factors that contributed to the exclusion of Black practitioners from American PRS professional societies. This work contextualizes the rise of American PRS within the Jim Crow era and highlights the cultural significance of reconstructive procedures performed in the treatment of disfigured soldiers. Through this lens, we identify circumstances where Black surgeons were systematically denied opportunities to participate in the emerging specialty. Despite these barriers, we demonstrate how Black physicians established informal networks for professional advancement and shed light on several previously unrecognized contributions to PRS from Black surgeons. In addition, we explore how the inclusion of Black voices in PRS sparked a paradigm shift in the treatment of non-White patients that expanded the cosmetic marketplace in ways that remain significant today. Finally, we situate the ongoing disparities in Black representation in PRS within a broader historical narrative and illustrate how the stories we tell about our past continue to shape the future of our field.

13.
Plast Reconstr Surg Glob Open ; 11(1): e4782, 2023 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-36776593

RESUMEN

The prevalence of bone stimulator use among nonoperatively and operatively managed scaphoid nonunion patients is unknown. We hypothesize that bone stimulators are a relatively underutilized treatment for scaphoid nonunion patients. Methods: We used the 2009-2017 Truven Marketscan Research Databases to identify patients with closed scaphoid fractures and performed an analysis of variance test to determine resource utilization and bone stimulator use among these patients. Results: A total of 36,611 patients with scaphoid fractures were identified: 30,143 were managed nonoperatively and 6468 were managed operatively. Nonunion was diagnosed in 500 (1.66%) nonoperatively and in 1211 (19%) operatively managed patients. Bone stimulators were used in less than 2% of nonoperatively and operatively managed scaphoid nonunion patients. Conclusion: Lack of trust in the technology and heterogenous (and occasionally burdensome) requirements for insurance approval are barriers to bone stimulator use; however, surgeons should examine how this technology may fit into the treatment algorithm for these difficult cases.

14.
Plast Reconstr Surg ; 148(3): 571-579, 2021 Sep 01.
Artículo en Inglés | MEDLINE | ID: mdl-34432686

RESUMEN

BACKGROUND: As many as 34 percent of nonfatal firearm injuries involve the upper extremity. Although not lethal, these injuries cause substantial morbidity. The authors conducted an epidemiologic study characterizing upper extremity firearm-related injuries presenting to U.S. trauma centers over a 10-year period. METHODS: The authors used the National Trauma Databank from 2007 to 2017 to identify isolated upper extremity firearm-related injuries. Descriptive statistics were performed to characterize patient demographic data, firearm type, extremity injury patterns, treatments received, hospital length of stay, and regional variation. RESULTS: The authors identified 48,254 upper extremity firearm-related injuries. The patients were largely male patients (85 percent), and over half were between the ages of 20 and 39 years. Handguns (34 percent) were the most frequently used firearm. Shoulder and upper arm were the most frequently injured areas (54 percent); however, 18 percent of patients injured two or more areas. Patients were most often treated at university hospitals (59 percent) with Level I or II trauma designation. Seventy percent were admitted and/or taken directly to the operating room. The mean hospital length of stay was 3 days. Payer mix among these patients was variable: Medicaid, 20 percent; private insurance, 20 percent; and self-pay, 29 percent. CONCLUSIONS: Upper-extremity firearm injuries are resource intensive, with three-quarters of patients requiring operative intervention and/or hospitalization. Level I and II trauma centers were the site of care for the majority of patients. Targeted gun policy reform and prevention measures directed toward at-risk groups have the potential to limit the unnecessary morbidity and costs associated with these injuries.


Asunto(s)
Extremidad Superior/lesiones , Heridas por Arma de Fuego/epidemiología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Preescolar , Bases de Datos Factuales/estadística & datos numéricos , Humanos , Lactante , Recién Nacido , Puntaje de Gravedad del Traumatismo , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Centros Traumatológicos/estadística & datos numéricos , Estados Unidos/epidemiología , Heridas por Arma de Fuego/diagnóstico , Adulto Joven
15.
Plast Reconstr Surg ; 148(5): 1053-1062, 2021 Nov 01.
Artículo en Inglés | MEDLINE | ID: mdl-34546187

RESUMEN

BACKGROUND: Surgical treatment of closed distal radius fractures varies based on treatment, surgeon schedule, and patient preferences. The authors examined how timing and technique impact surgeon-perceived procedural difficulty and quality of reduction, outcomes, and complications. METHODS: This was a retrospective study of participants in the randomized, multicenter Wrist and Radius Injury Surgical Trial with isolated unstable distal radius fractures. Participants were randomized to treatment with a volar locking plate system, closed reduction and percutaneous pinning, or external fixation. The authors analyzed surgeon-perceived procedural difficulty and reduction quality based on time to operation. RESULTS: Of 184 participants, 88 underwent surgery less than 7 days after fracture (mean, 4.6 days) and 96 underwent surgery at more than 7 days after fracture (mean, 12.3 days). Surgery performed at more than 7 days was rated more difficult versus surgery at less than 7 days [4.6 versus 3.8 of 10 (1 = easiest); p = 0.05]. When the volar locking plate technique was performed, there was no difference in surgeon-perceived difficulty or reduction quality between the groups; however, surgeons performing closed reduction and percutaneous pinning more than 7 days after injury reported greater procedure difficulty (4.1 versus 2.9; p = 0.05) and poorer reduction quality compared to less than 7 days (7.2 versus 8.1; p = 0.03). Participants who underwent surgery at less than 7 days scored 8 and 7 points greater on the Michigan Hand Outcomes Questionnaire Satisfaction (p = 0.05) and Activities of Daily Living (p = 0.03) domains, respectively. CONCLUSIONS: Surgery performed less than 7 days after fracture leads to better surgeon-perceived reduction quality and less procedural difficulty. If surgery cannot be performed before 7 days, the authors recommend patients undergo treatment with the volar locking plate system, given the comparable level of surgeon-perceived procedural difficulty and reduction quality when surgery was performed less than 7 days after injury. CLINICAL QUERSTION/LEVEL OF EVIDENCE: Therapeutic, III.


Asunto(s)
Fijación Interna de Fracturas/métodos , Satisfacción del Paciente/estadística & datos numéricos , Fracturas del Radio/cirugía , Tiempo de Tratamiento/estadística & datos numéricos , Actividades Cotidianas , Anciano , Placas Óseas , Fijación Interna de Fracturas/instrumentación , Humanos , Masculino , Persona de Mediana Edad , Estudios Multicéntricos como Asunto , Fracturas del Radio/fisiopatología , Ensayos Clínicos Controlados Aleatorios como Asunto , Recuperación de la Función/fisiología , Estudios Retrospectivos , Cirujanos/estadística & datos numéricos , Encuestas y Cuestionarios/estadística & datos numéricos , Factores de Tiempo , Resultado del Tratamiento
16.
Plast Reconstr Surg ; 146(3): 572-579, 2020 09.
Artículo en Inglés | MEDLINE | ID: mdl-32842107

RESUMEN

BACKGROUND: Closed metacarpal neck fractures are extremely common. The authors investigated resource use among those managed operatively versus nonoperatively. They hypothesized that considerable use of services and costs are incurred with nonoperative management. METHODS: The authors used the 2009 to 2017 Truven Marketscan Research Database to identify patients with closed metacarpal neck fractures and divided them into operative and nonoperative groups. They examined resource use, including imaging, clinic visits, surgery, and occupational therapy sessions, and performed a chi-square analysis of patient demographic data and resources used. RESULTS: Of 125,610 patients identified, 46,845 met inclusion criteria: nonoperative, n = 45,067 (96.2 percent); and operative, n = 1778 (3.8 percent). The operative group comprised percutaneous fixation (62 percent) and open reduction and internal fixation (38 percent) patients. Nonoperative patients had the greatest mean number of clinic visits, with 1.7 per patient, compared to 1.2 for both percutaneous fixation and open reduction and internal fixation patients (p < 0.001). For nonoperative patients, one to two radiographs (beyond the index radiograph) were obtained, and they had 2.9 occupational therapy sessions; in the operative group, two to three radiographs were obtained, and they had three to four occupational therapy sessions (p < 0.001). Mean total costs were $2406 per patient for percutaneous fixation, $3092 per patient for open reduction and internal fixation, $546 per patient for closed reduction, and $261 per patient for no intervention. CONCLUSIONS: Nonoperative management of closed metacarpal neck fracture has lower costs without the associated operating room, surgeon, and service fees; however, patient care remains resource intensive with the use of imaging, clinic visits, and occupational therapy. Shifts in the authors' treatment paradigm, including judicious use of services, will result in significant health care savings.


Asunto(s)
Fijación Interna de Fracturas/métodos , Fracturas Óseas/terapia , Huesos del Metacarpo/lesiones , Reducción Abierta/métodos , Adolescente , Adulto , Anciano , Niño , Preescolar , Femenino , Estudios de Seguimiento , Fracturas Óseas/diagnóstico por imagen , Humanos , Lactante , Recién Nacido , Masculino , Huesos del Metacarpo/diagnóstico por imagen , Persona de Mediana Edad , Radiografía , Estudios Retrospectivos , Adulto Joven
17.
PLoS One ; 15(5): e0232684, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-32433648

RESUMEN

INTRODUCTION: One out of every 5 elderly patients will suffer a distal radius fracture and these injuries are often related to poor bone health. Several surgical subspecialties have demonstrated that pre-injury activity level can impact patient outcomes. To determine the importance of physical activity, we examined the relationship between pre-injury activity and patient-reported and functional outcomes among fracture patients. METHODS: This is a retrospective analysis of prospectively collected data from participants enrolled in the Wrist and Radius Injury Surgical Trial (WRIST) from April 10, 2012 to December 31, 2016. This study included 304 adults, 60 years or older with isolated unstable distal radius fractures; 187 were randomized to one of three surgical treatments and 117 opted for casting. Participants opting for surgery were randomized to receive volar locking plate, percutaneous pinning, or external fixation. Participants who chose not to have surgery were treated with casting. All participants were stratified prior to analysis into highly and less-active groups based on pre-injury Rapid Assessment of Physical Activity Scores. RESULTS: 280 patients had 12-month assessments of outcomes. Highly active participants scored 8 and 5 points greater on the Michigan Hand Questionnaire at 6 weeks and 3 months respectively, p<0.05. Highly active participants demonstrated greater grip strength at the 3-month (p = 0.017) and 6-month (p = 0.007) time-points. Highly active participants treated with volar locking plate scored 10+ points greater on the Michigan Hand Questionnaire compared to the less-active group at the 6-week (p = 0.032), 3-month (p = 0.009) and 12-month (0.004) time points, with an effect size larger than 0.50, suggesting pre-injury level of activity had a significant clinical impact. CONCLUSIONS: Higher levels of pre-injury activity are predictive of patient-reported and functional outcomes following distal radius fracture. Because of the greater PROs, the early mobility and lower risk of hardware infection reported in the literature, volar plating is preferable to other treatments for highly active patients who request and meet indications for surgery. TRIAL REGISTRATION: clinicaltrials.gov identifier: NCT01589692.


Asunto(s)
Fracturas del Radio/cirugía , Factores de Edad , Anciano , Ejercicio Físico , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Fracturas del Radio/diagnóstico , Recuperación de la Función , Estudios Retrospectivos , Resultado del Tratamiento
18.
J Hand Surg Eur Vol ; 45(9): 899-903, 2020 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-32539576

RESUMEN

We systematically reviewed prospective studies for five hand procedures to analyse postoperative follow-up time, clinical or radiographic plateau, and whether the authors provide justification for times used. Demographic data, outcomes and mean follow-up were analysed. A total of 188 articles met our inclusion criteria. The mean postoperative follow-up time among these studies were carpal tunnel release, 21 months (range 1.5-111); cubital tunnel release, 27 months (2.5-46); open reduction and internal fixation for the distal radius fracture, 24 months (3-120); thumb carpometacarpal joint arthroplasty, 64 months (8.5-228); and flexor tendon repair, 25 months (3-59). Authors provided justification for follow-up intervals in 10% of these reports. We conclude that most prospective clinical studies in hand surgery do not properly justify follow-up length. Clinically unnecessary follow-up is costly without much benefit. In prospective research, we believe justified postoperative follow-up is essential, based on expected time to detect clinical plateau, capture complications and determine the need for secondary surgery.Level of evidence: III.


Asunto(s)
Síndrome del Túnel Carpiano , Mano , Síndrome del Túnel Carpiano/cirugía , Estudios de Seguimiento , Fijación Interna de Fracturas , Mano/cirugía , Humanos , Estudios Prospectivos
19.
Plast Reconstr Surg Glob Open ; 8(6): e2792, 2020 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-32766027

RESUMEN

Painful neuromas result from traumatic injuries of the hand and digits and cause substantial physical disability, psychological distress, and decreased quality of life among affected patients. The regenerative peripheral nerve interface (RPNI) is a novel surgical technique that involves implanting the divided end of a peripheral nerve into a free muscle graft for the purposes of mitigating neuroma formation and facilitating prosthetic limb control. The RPNI is effective in treating and preventing neuroma pain in major extremity amputations. The purpose of this study was to determine if RPNIs can be used to effectively treat neuroma pain following partial hand and digital amputations. We retrospectively reviewed the use of RPNI to treat symptomatic hand and digital neuromas at our institutions. Between November 2014 and July 2019, we performed 30 therapeutic RPNIs on 14 symptomatic neuroma patients. The average patient follow-up was 37 weeks (6-128 weeks); 85% of patients were pain-free or considerably improved at the last office visit. The RPNI can serve as a safe and effective surgical solution to treat symptomatic neuromas after hand trauma.

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