Contemporary Management of Distal Radius Fractures: What All Plastic Surgeons Should Know.

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.

Interfacility Competition and its Impact on Cost of Carpal Tunnel Release.

BACKGROUND: Carpal tunnel release (CTR) is the most common hand surgery procedure, but little is known about how healthcare market characteristics influence cost. The objective of this study was to understand the association of healthcare market competition and facility availability on out-of-pocket and total insurer payments for patients undergoing CTR. METHODS: This retrospective cross-sectional study used a national sample of private insurance claims from 2015-2020. Adults who had CTR were included, while acute or inpatient CTRs, or lacking geographical information were excluded. Linear regression was applied to investigate the impact of the healthcare market competition and facility availability (ambulatory surgery center (ASC), hospital outpatient departments (HOPD), outpatient clinics) on the out-of-pocket expenses and total insurer payment. Market competition was measured using the Herfindahl-Hirschman Index. RESULTS: Of 119,828 patients, 76% underwent open CTR. The most competitive hospital markets were HOPDs and ASCs, respectively. As HOPD competition decreased, out-of-pocket expenses and total insurer payment decreased significantly. As ASC competition decreased, only total insurer payments decreased significantly. CTRs performed in outpatient clinics increased slightly over time. However, HOPDs remained the most common location until 2020 when their popularity was similar to ASCs. Finally, out-of-pocket expenses increased significantly whereas total insurer payments did not change significantly throughout the study period. CONCLUSIONS: This study found decreased healthcare market competition was not associated with increased CTR costs, suggesting that costs are complex and multifactorial. To reduce healthcare costs, this study supports the movement of CTRs to clinic and ASCs.

2020 CMS prior authorization for hospital outpatient departments: Associated surgical volume impact.

BACKGROUND: Prior authorization is common for privately administered Medicare Advantage plans but is rarely used for surgical care when considering publicly administered plans. A 2020 Centers for Medicare and Medicaid services (CMS) policy, CMS-1717-FC, requires prior authorization for Medicare Fee-for-Service beneficiaries undergoing select procedures (blepharoplasty, abdominoplasty, botulinum toxin injection, rhinoplasty, and vein ablation) in hospital outpatient departments. The impact of this policy on surgical volume at hospital outpatient departments and shifts in care to ambulatory surgery centers is unknown. METHODS: This study used a segmented interrupted time series and pre-post logistic regression model. This study was a retrospective cohort study using data from the Healthcare Cost and Utilization Project state ambulatory surgery database and state inpatient database. RESULTS: From 2016 through 2021, a total of 272,879 patients underwent the affected procedures. Pre-CMS-1717-FC, a trend of decreasing hospital outpatient department utilization was found for Medicare Fee-for-Service beneficiaries (-10.82, 95% confidence interval: -18.32 to -3.33, P = .01). In the post-implementation period, no change in the rate of decreasing hospital outpatient department utilization was found for Medicare Fee-for-Service beneficiaries (-3.45, 95% confidence interval: -36.15 to 29.25, P = .83). In the pre-policy period, Medicare Fee-for-Service beneficiaries were 46% less likely to use freestanding ambulatory surgery centers but 27% less likely to use hospital-owned ambulatory surgery centers. CONCLUSION: CMS-1717-FC was not associated with significant changes in hospital outpatient department volume beyond baseline trends. Policy aiming to right-size prior authorization for these procedures and considering site-of-service will balance the need to ensure medical necessity while constraining costs.

Employer-Sponsored Medicare Advantage Plans and the 2018 Therapy Cap Repeal: Reduced Overall Spending Does Not Constrain Out-of-Pocket Costs.

BACKGROUND: Policy impacting traditional Medicare beneficiaries may have unintended effects for privately insured patients. After the repeal of a longstanding $1500 outpatient therapy cap in 2018, we aimed to evaluate if this policy change was associated with differences in use of cost of postoperative therapy after common hand surgeries, including carpal tunnel release, trigger finger release, ganglion cyst excision, De Quervain tenosynovitis release, carpometacarpal arthroplasty, and distal radius fracture open reduction/internal fixation or percutaneous pinning. METHODS: The Medicare Supplement and Coordination of Benefits files from Marketscan were used. Frequency of therapy appointments, overall costs, and out-of-pocket costs were obtained. A segmented interrupted time series with Poisson and log-transformed linear regression was performed. RESULTS: No significant monthly change in odds of therapy use was found in the postpolicy period for patients who underwent trigger finger release, carpal tunnel release, Ganglion cyst excision, De Quervain tenosynovitis release, carpometacarpal arthroplasty, or distal radius fracture, pinning, or open reduction/internal fixation. Overall cost decreased in the postpolicy period by 2% for comprehensive plans (95% confidence interval [CI]: -0.03 to -0.01, P < 0.001), by 7% for those with exclusive provider organizations (95% CI: -0.10 to -0.04, P < 0.001), by 1% for HMOs (95% CI: -0.01 to 0.002, P = 0.01), and by 3% for preferred provider organizations (95% CI: -0.03 to -0.02, P < 0.001). In the postpolicy period, no monthly change in out-of-pocket cost was observed for patients with comprehensive, exclusive provider organization, health maintenance organization, preferred provider organization, or point of service with capitation insurance plans. CONCLUSIONS: Patients with employer-sponsored Medicare Advantage plans experienced increased out-of-pocket costs for therapy despite lower net costs. These data highlight an urgent need for policy ensuring that patients benefit when overall costs of care decrease.

Free Functional Muscle Transfer-Technical Considerations.

Free functional muscle transfers restore voluntary motion in extremities following the loss of local muscle-tendon units. Surgeons, at various levels of expertise, need to consider several technical aspects when performing this procedure. Successful and consistent outcomes can be attained by applying a combination of basic principles, drawing from techniques developed for successful tendon transfers and microsurgical free tissue transfers. Patient preparation through counseling and intensive rehabilitation is essential to achieve the optimal conditions before the transfer.

Health Policy Implications of Digital Replantation.

There have been dwindling numbers of replantations in the United States. Despite the advocacy for centralization in hand trauma, the fundamental landscape and attitudes of surgeons toward replantation have remained lackluster. There is growing and substantial evidence to demonstrate the superior outcomes of replantation in comparison to revision amputation in most scenarios. This article aims to delve into the factors contributing to the decreasing numbers of replantations and proposes strategies to overcome this issue.

The Mangled Upper Extremity-Algorithm for Salvage: My Workhorse Flaps.

Mangling injuries of the upper extremity are severe, high-energy traumas that damage multiple functional systems including skin, nerves, vascular, tendon, and bone. Management requires familiarity with various techniques in orthopedic, vascular, and plastic surgery. A specific technique cannot be described due to the various combinations of injuries that can occur with mangled upper extremities, but we present principles and recommendations for treatment and judgment.

Time and Cost Savings of Virtual Established Plastic Surgery Care Using Time-Driven Activity-Based Costing: Lessons from An Academic Clinic.

BACKGROUND: Various surgical subspecialties, including plastic surgery, have begun to embrace virtual clinic visits, especially since the COVID-19 pandemic. However, the impact of video visits on time optimization and cost incurred in outpatient plastic surgery clinics has not been studied. METHODS: Using the time-driven activity-based costing (TDABC) method, we examined the time and cost of in-person and virtual visits at an academic plastic surgery clinic. We formulated process maps for four visit types: physician-led in-person, physician assistant-led in-person, physician-led virtual, and physician assistant-led virtual. The time associated with each visit type was generated by direct observation. The cost associated with each visit type was calculated from representative salary information and estimation of resource costs. RESULTS: Virtual visits took on average less time (25.3 minutes for physician-led visits and 24.4 minutes for physician assistant-led visits), compared to in-person visits (48.2 minutes for physician-led and 41.1 minutes for physician-assistant-led visits) (p<0.001). Virtual visits were also cheaper, at $52.80 for physician-led visits and $20.70 for physician assistant-led visits, compared to in-person visits ($261.13 for physician-led and $236.00 for physician assistant-led visits). Non-provider activities made up the majority of traditional in-person visits (75.7% of the visit for physician-led and 77.6% for physician assistant-led visits), which contributed to higher overall cost of in-person visits for both groups of providers. CONCLUSIONS: Virtual clinic visits can produce time and cost savings without reducing the amount of face-to-face time between providers and patients. Virtual visits can be a useful adjunct to traditional in-person visits.

Adherence to Non-operative Clinical Quality Measures in Carpal Tunnel Syndrome.

Background: Clinical quality measures exist for non-operative management of carpal tunnel syndrome (CTS). Factors predicting adherence are unclear. Methods: A retrospective cohort study of patients with chronic CTS using MarketScan Research Database (2015-2020) was conducted. Six logistic regression models were designed to study adherence to quality measures within 1 year after diagnosis. Results: Of 782,717 patients identified, 514,073 (65.7%) were female with an average (SD) age of 51.4 (13.4) years. Only 88 patients (0.01%) met all quality measures. Greatest compliance observed with receipt of nerve conduction study (NCS; 283,959 [36.3%]), no prescription of medications (336,297 [43.0%]) and no laser therapy (772,979 [98.8%]); 294,305 patients (37.6%) received hand surgeon referral. Hand surgeon referral predicted higher likelihood of NCS and splinting (OR, 1.83; 95% CI: 1.81-1.84; OR, 2.53; 95% CI: 2.50-2.56) and medication over-prescription (OR, 1.05; 95% CI: 1.00-1.10). Females were more likely to be referred to a hand surgeon and be referred for splinting (OR 1.02; 95% CI: 1.01-1.03; OR 1.19; 95% CI: 1.18-1.21) but less likely to have no prescriptions or avoid laser therapy (OR 0.85, 95% CI: 0.84-0.85; OR 0.82, 95% CI: 0.79-0.86). Medicare recipients adhered less to quality measures compared to patients with fee-for-service insurance. As comorbidities increased, patients were less likely to receive hand surgeon referral and carpal tunnel release. Conclusions: Findings suggest that hand surgery referrals increased adherence to quality measures. Females, Medicare recipients and multimorbid patients should be targeted for improved care. Future quality care efforts should incentivise adherence for Medicare beneficiaries and improve guideline recognition amongst physicians. Level of Evidence: Level III (Therapeutic).

Implementation of postoperative opioid prescribing guidelines after carpal tunnel release: a quality collaborative study.

Opioid prescribing after carpal tunnel release (CTR) is not well understood. We assessed CTR opioid prescribing within a quality collaborative after the dissemination of guidelines. Post guidelines, the odds of receiving a prescription decreased by 67%. Quality collaboratives can change practice patterns.Level of evidence: III.

Impact of Regional Surgeon Competition on Use, Cost, and Outcomes of Breast Reconstruction in the United States.

BACKGROUND: Breast reconstruction following mastectomy is underused in the United States. Evidence suggests that more competitive hospital markets offer increased access to procedural care across specialties. This study aims to determine the impact of regional plastic surgeon competition on use, outcomes, and cost of breast reconstruction following mastectomy for breast cancer. METHODS: We conducted a retrospective cross-sectional analysis using Marketscan claims data from 2009 to 2020. The Herfindahl-Hirschman Index (HHI), a measure of market concentration, was calculated using the sum-of-squares of the proportion of breast reconstruction cases performed by each surgeon in a metropolitan statistical area (MSA). Multivariable logistic regression was used to identify differences in rates, outcomes, and costs of reconstruction by HHI. RESULTS: Odds of receiving breast reconstruction within two years of mastectomy were higher for those in moderately competitive (OR: 1.51 [95% CI: 1.37 to 1.66]; p<0.001) or competitive (OR: 1.71 [95% CI: 1.58 to 1.86]; p<0.001) = regions compared to noncompetitive regions. Patient out-of-pocket costs decreased when comparing moderately competitive regions to noncompetitive regions (-$67.38, [95% CI: -$88.65 to -$46.11]; p=0.007), and further decreased when comparing competitive to non-competitive regions (-$113.06, [95% CI: -$137.00 to -$89.12]; p=0.02). No linear association between total, surgeon, or facility cost and market competition strata was identified. CONCLUSION: Greater competition among surgeons is associated with improved access to reconstructive surgery, but no difference in cost. Application of this evidence may include system-level strategies to bolster care coordination, while targeting drivers of cost, such as hospitals and hospital systems, through policy.

Bioengineered Nerve Conduits and Wraps.

Peripheral nerve injuries are prevalent and their treatments present significant challenges. Among the various reconstructive options, nerve conduits and wraps are popular choices. Advances in bioengineering and regenerative medicine have led to the development of new biocompatible materials and implant designs that offer the potential for enhanced neural recovery. Cost, nerve injury type, and implant size must be considered when deciding on the ideal reconstructive option.

Evaluating Outcomes Following Nerve Repair: Beyond the Medical Research Council.

Peripheral nerve injuries are common and remain a significant health challenge. Outcome measurements are used to evaluate injury, monitor recovery after nerve repair, and compare scientific advances. Clinical judgement is required to determine which available tools are most applicable, which requires a vast understanding of the available outcome measurements. In this article we discuss the highest yield tools available for clinical application.

Non-inferiority Study Design: Application to Clinical Trials.

SUMMARY: Non-inferiority trials, a distinct category within randomized controlled trials, are garnering increased attention in medical research. Their unique and evolving role comes to the forefront in scenarios where new treatments, despite not surpassing the efficacy of an existing standard, bring additional benefits like reduced side effects, enhanced compliance, or cost savings. As the field of surgery witnesses a growing number of published non-inferiority trials, it becomes imperative for surgeons to grasp the intricacies of this trial type to accurately decipher and interpret their outcomes.

Contemporary view on the care of the rheumatoid wrist.

SUMMARY: Rheumatoid arthritis (RA) is a common inflammatory condition that can lead to debilitating hand and wrist deformity. Since the introduction of disease-modifying antirheumatic drugs in the 1990s, the rate of surgery for rheumatoid arthritis has dramatically decreased 1. Nonetheless, surgical intervention remains an important tool in the management of patients with RA, and young surgeons must seek out expertise in this domain due to diminished exposure during their training. In this article, we provide a comprehensive review of the evaluation and management of patients with wrist pathology due to RA as well as surgical technical pearls.

Tree-Based Reinforcement Learning for Identifying Optimal Personalized Treatment Decisions for Hand Deformity in Rheumatoid Arthritis.

BACKGROUND: Silicone metacarpophalangeal joint arthroplasty (SMPA) can reconstruct metacarpophalangeal (MCP) joint deformities in the rheumatoid hand, but patient selection criteria for the procedure remains unclear. We used statistical learning to elucidate patient selection criteria that will enhance long-term patient-reported and functional outcomes in patients with severe hand rheumatoid arthritis (RA). METHODS: This is a secondary analysis of a prospective study of 169 adults with severe hand RA (average combined ulnar deviation (UD) and extensor lag (EL) at the MCP joint ≥ 50 degrees, per finger) with one-year follow-up, conducted at three centers in the United States and England from January 1, 2004, to December 31, 2011. Primary outcomes were Michigan Hand Outcomes Questionnaire (MHQ) pain sub-score, changes in EL, UD, and Arthritis Impact Measurement Scale (AIMS2) score. A tree-based reinforcement learning (T-RL) model was used to estimate clinical decision rules for treatment. RESULTS: 132 patients (mean[SD], 61[9] years; 108[72%] female) were included in the SMPA (n=50) and non-SMPA (n=82) cohorts. To minimize EL and UD, patients should undergo SMPA. To minimize pain, patients older than 55 should undergo SMPA. To increase hand-related quality-of-life (QOL), patients with grip strength <12 kg should undergo SMPA. Estimations with imputed missing data were similar, aside from a lower grip strength (<8 kg) threshold for hand-related QOL. CONCLUSION: Unless there is significant comorbidity that precludes surgery, most patients older than 55 with severe hand RA will have improved QOL, pain, and function after SMPA. Patients with preserved grip strength may benefit from continued medical management.