Evidence, Quality, Costs, and Reimbursement: Connecting the Dots.

Healthcare costs in the United States continue to rise, and substantial variations in the type, quality, and location of that care persist. It is critically important for all healthcare stakeholders to address and define value in orthopaedic care delivery. Evidence-based orthopaedic care delivery, reliable quality and performance measurement, and the delivery of the best care at the lowest cost are the key strategies to improve the value of musculoskeletal care. A failure to implement these strategies could negatively affect the reimbursement of all healthcare providers--at both the private and government payer levels.

Trapeziometacarpal joint stability: the evolving importance of the dorsal ligaments.

BACKGROUND: Trapeziometacarpal (TMC) arthritis of the thumb is a common source of hand pain and disability. TMC ligamentous instability may play a role in TMC degeneration. However, the relative importance of the TMC ligaments in the etiology of degeneration and the use of surgery to treat instability in early-stage arthritis are unclear. QUESTIONS/PURPOSES: In this review, we addressed several questions: (1) What are the primary ligamentous stabilizers of the thumb TMC joint? (2) What is the evidence for ligament reconstruction or ligament imbrication in the treatment of thumb TMC joint osteoarthritis? And (3) what is the evidence for thumb metacarpal osteotomy in the treatment of thumb TMC joint osteoarthritis? METHODS: We performed a systematic review of the literature using PubMed (MEDLINE(®)) and Scopus(®) (EMBASE(®)) for peer-reviewed articles published until November 2012. Fifty-two studies fit the inclusion criteria. Twenty-four studies were anatomic, biomechanical, or histopathologic studies on TMC joint ligamentous anatomy, 16 studies were clinical studies concerning ligament reconstruction, and 12 studies were clinical studies on thumb metacarpal osteotomy. RESULTS: Over the past two decades, increasing evidence suggests the dorsoradial ligament is the most important stabilizer of the TMC joint. Other ligaments consistently identified are the superficial anterior oblique, deep anterior oblique, intermetacarpal, ulnar collateral, and posterior oblique ligaments. Ligament reconstruction and metacarpal osteotomy relieve pain and improve grip strength based on Level IV studies. CONCLUSIONS: The dorsal ligaments are the primary stabilizers of the TMC joint. Ligament reconstruction and metacarpal osteotomy ameliorate ligamentous laxity and relieve pain based on Level IV studies.

Percutaneous reduction and fixation of displaced phalangeal neck fractures in children.

BACKGROUND: Several methods have been reported for fixation of displaced phalangeal neck fractures in children. The purpose of this study is to present a technique for the closed reduction and percutaneous fixation of displaced phalangeal neck fractures and the clinical results of 4 patients treated by this method. METHODS: Four consecutive patients with displaced phalangeal neck fractures were treated with closed reduction and single intramedullary Kirschner wire placed percutaneously with a novel technique. RESULTS: The average age at injury was 5 years 9 months (range, 23 mo to 10 y). Three patients were male and 1 was female. Two patients had fractures of the proximal phalangeal neck, whereas the other 2 had fractures of the middle phalangeal neck. After an average follow-up of 18 weeks, all patients had nearly full pain-free flexion and extension of the affected digit. CONCLUSIONS: The described technique is a simple, reproducible and effective treatment for displaced phalangeal neck fractures in children. LEVEL OF EVIDENCE: Level IV. Therapeutic study, case series.

Volar dislocation of the distal ulna in supination caused by apex volar malunion of the radial shaft: a report of 2 cases.

INTRODUCTION: Fractures of the distal third of the radius in children are common and most heal without incident. However, distal radial shaft malunion with apex volar angulation may lead to volar dislocation of the distal ulna with forearm supination, although it has been rarely reported. The aim of this study was to document 2 such cases and to make recommendations regarding the management of these patients. METHODS: We report the cases of 2 boys, ages 6 and 8 years, who sustained radial shaft fractures that healed with apex volar angulation and who developed intractable volar dislocation of the distal ulna in adolescence. In both cases, corrective radial osteotomy at the site of the malunion restored full stability of the distal radial-ulnar joint without the need for soft-tissue reconstruction or ulnar styloid nonunion repair. DISCUSSION: This injury pattern is rarely reported but should be considered in cases of repeated volar dislocation of the distal ulna with supination. We recommend a corrective osteotomy at the site of the malunion to restore stability to the distal radial-ulnar joint. LEVEL OF EVIDENCE: IV.

Isolated Brachialis Muscle Atrophy.

solated brachialis muscle atrophy, a rare entity with few reported cases in the literature, is explained by a variety of etiologies. We present a case of unilateral, isolated brachialis muscle atrophy that likely resulted from neuralgic amyotrophy.

Complications of Carpal Tunnel Release.

Carpal tunnel release for compression of the median nerve at the wrist is one of the most common and successful procedures in hand surgery. Complications, though rare, are potentially devastating and may include intraoperative technical errors, postoperative infection and pain, and persistent or recurrent symptoms. Patients with continued complaints after carpal tunnel release should be carefully evaluated with detailed history and physical examination in addition to electrodiagnostic testing. For those with persistent or recurrent symptoms, a course of nonoperative management including splinting, injections, occupational therapy, and desensitization should be considered prior to revision surgery.

Delayed Proximal Migration of the Radius Following Radial Head Resection for Management of a Symptomatic Radial Neck Nonunion Managed with Radial Head Replacement: A Case Report and Review of the Literature.

BACKGROUND: Long-term outcomes of radial head resection for radial head fracture have shown mixed outcomes, depending on the integrity of the soft-tissue stabilizers of the elbow, forearm, and wrist. METHODS: We report a case of a symptomatic delayed proximal migration of the radius after radial head excision for radial neck nonunion which was managed with a staged radial head replacement. Informed consent was obtained from the individual in this case report. RESULTS: At 7 months after radial head replacement, the patient had 90 degrees of forearm supination and 85 degrees of pronation. Elbow range of motion was from 10 degrees short of full extension to 155 degrees of flexion. Her Disabilities of the Arm, Shoulder, and Hand score was 21.4 at 7 months and 6.48 at 38 months. CONCLUSION: There is insufficient evidence to reliably predict which patients can be managed definitively with radial head excision without risk of later proximal migration of the radius. The authors suggest the use of acute radial head arthroplasty when the index injury is secondary to a traumatic mechanism, reserving radial head excision for patients with radio-capitellar arthritis. Further research of the pathology and healing of concomitant soft-tissue injuries seen in conjunction with radial head fractures is warranted to guide their treatment.

Brachioradialis Tendon Coverage in Volar Distal Radius Plating.

Volar plate fixation of unstable distal radius fractures has become the preferred technique by most surgeons for the operative treatment of displaced distal radius fractures. Flexor tendon rupture is a rare but serious complication associated with this operation that is thought to be due to irritation of the flexor tendons over the prominent distal edge of the plate. We describe a novel technique of using the brachioradialis tendon to cover the distal edge of the plate to help prevent tendon irritation and rupture.

Diagnosis of Occult Scaphoid Fractures: A Cost-Effectiveness Analysis.

BACKGROUND: Scaphoid fractures are common but may be missed on initial radiographs. Advanced imaging modalities such as computed tomography (CT) and magnetic resonance imaging (MRI) have improved diagnostic accuracy, but at an increased initial cost. The purpose of this study was to evaluate the cost-effectiveness of immediate advanced imaging for suspected occult scaphoid fractures. METHODS: A decision analysis model was created to evaluate three diagnostic strategies for patients with concerning history and examination but negative radiographs: (1) empiric cast immobilization with orthopaedic follow-up and repeat radiography at two weeks post-injury, (2) immediate CT scanning, or (3) immediate MRI. Prevalence of occult scaphoid fracture, sensitivity and specificity of CT and MRI, and risks and outcomes of a missed fracture were derived from published clinical trials. Costs of imaging, lost worker productivity, and surgical costs of nonunion surgery were estimated on the basis of the literature. RESULTS: Advanced imaging was dominant over empiric cast immobilization; advanced imaging had lower costs and its health outcomes were projected to be better than those of empiric cast immobilization. MRI was slightly more cost-effective than CT on the basis of the mean published diagnostic performance, but was highly sensitive to test performance characteristics. Advanced imaging would have to increase in cost to more than $2000 or decrease in sensitivity to <25% for CT or <32% for MRI for empiric cast immobilization to be cost-effective. CONCLUSIONS: Given its relatively low cost and high diagnostic accuracy, advanced imaging for suspected scaphoid fractures in the setting of negative radiographs represents a cost-effective strategy for reducing both costs and morbidity. The decision to use CT compared with MRI is a function of individual institutional costs and local test performance characteristics.

The Epidemiology of Upper Extremity Fractures in the United States, 2009.

BACKGROUND: No single epidemiological study of upper extremity fractures exists in the United States using data from all payers. Current epidemiological estimates are based on case series, foreign databases, or Medicare data, which are not representative of the entire US population. The objective of this project was to accurately describe the incidence of fractures of the upper extremity in a representative sample of the US population. METHODS: Using International Classification of Disease, Ninth Edition codes for patient visits reported in the 2009 State Emergency Department Database and the State Inpatient Database, available from the Healthcare Cost and Utilization Project, and 2010 US Census data, we calculated the annual incidence rates per 10,000 persons of upper extremity fractures of all patients, regardless of age or payer type. This was done using a representative national sample from 8 states: Arizona, California, Iowa, Maryland, Massachusetts, New Jersey, and Vermont. RESULTS: Overall, in this population of over 87 million Americans, there were 590,193 fractures of the upper extremity, yielding an annual incidence of 67.6 fractures per 10,000 persons. Distal radius and ulna fractures were the most common upper extremity fractures (16.2 fractures per 10,000 persons), followed by hand fractures (phalangeal and metacarpal fractures; 12.5 and 8.4 per 10,000, respectively), proximal humerus fractures (6.0 per 10,000), and clavicle fractures (5.8 per 10,000). The most common type of fracture for all age groups was distal radius fractures, except in the 18- to 34-year-old group, in which metacarpal and phalangeal fractures were more common (16.1 and 12.5 per 10,000, respectively) and the 35- to 49-year-old group, in which phalangeal fractures were most common (11.5 per 10,000). The incidence of distal radius fractures was bimodal, with the highest rates in the under 18 and over 65 age groups (30.18 and 25.42 per 10,000, respectively) with lower rates in the middle age groups. The most common type of fracture for males was phalangeal fractures (11.5 per 10,000), and distal radius and ulna fractures were the most common type for females (11.8 per 10,000). Interestingly, phalangeal and metacarpal fractures varied by socioeconomic status (SES), which decreased with increasing SES. No other fracture type varied by SES. CONCLUSIONS: Epidemiological studies are necessary for research, clinical applications, and public health and health policy initiatives. This study reports national estimates of upper extremity fractures with subgroup analysis.

Incidence of syndesmotic injury.

Injury to the tibiofibular syndesmosis can occur with ankle sprain or fracture. The incidence of syndesmotic injury has not been specifically studied at a population level. Data on syndesmotic injury were obtained from the Healthcare Cost and Utilization Project (HCUP), a federal-state-private partnership. It is administered by the Agency for Healthcare Research and Quality, a division of the US Department of Health and Human Services. Two HCUP databases were queried for 8 states: the State Inpatient Database and the State Emergency Department Database. The first 6 International Classification of Diseases, Ninth Edition (ICD-9) code diagnoses were searched for codes that are used for syndesmotic injury (ie, 845.03). These data, along with data from the 2010 US census, were used to yield incidence rates for syndesmosis injury, as well as for various demographic groups. National estimates of injury totals were also calculated. In the 8 states, there were a total of 1821 syndesmotic injuries. Given the population of these states, the incidence rate of syndesmotic injury was 2.09 syndesmotic injuries per 100,000 person-years. This incidence correlates to an estimated 6445 syndesmotic injuries per year in the United States. These data provide some baseline numbers as to the incidence of syndesmotic injury in the United States. Although the incidence was low relative to some other injuries, the fact that syndesmotic injuries tend to occur in younger patients may have a greater effect in terms of productive years of life lost.

The use of thermal shrinkage for scapholunate instability.

Scapholunate interosseous ligament (SLIL) instability is the most common form of carpal instability. There is a lack of consensus among hand surgeons as to the appropriate treatment of various stages. This article reviews the background and results of thermal treatment of predynamic instability of the SLIL. Case examples are discussed as well as a series of patients treated with our protocol for this injury.