Cultivating a "Feminine" Surgical Culture: Lessons from Indonesia.

BACKGROUND: Despite a growing number of female physicians, most practicing surgeons in the U.S. are still men. By contrast, Indonesia has achieved notable gender parity among surgeons, with the number of women practicing as plastic surgeons projected to soon surpass men. Achieving more female representation in plastic surgery is important for delivering high-quality care, especially in the face of physician shortages and high burnout. METHODS: This survey study was conducted at the 26th Annual Scientific Meeting of the Indonesian Association of Plastic Reconstructive and Aesthetic Surgeons (InaPRAS) in Manado, Indonesia, during August 2023. Respondents were asked about their perceptions of plastic surgery, mentorship, career motivations, and caregiving responsibilities. Responses were scored using a 3-point Likert scale of agreement to statements (Disagree, Neutral, Agree); χ2 and Fischer's exact test were performed to assess differences in responses by gender. RESULTS: In this validated survey of 175 plastic surgeon trainees and attendings, there were no significant difference between genders in the perception and roles of mentorship in preparing for a career in plastic surgery. Respondents for both genders espoused optimistic views on work-life balance items, including time for family and friends and flexibility of work schedules. CONCLUSION: Indonesia can serve as a model for encouraging greater gender parity in plastic surgery. Community-level interventions such as family leave policies, childcare provisions, and initiatives to promote an inclusive culture will create a more supportive workplace to increase women's representation in plastic surgery in the United States and around the world.

P-Value Reporting and Reliability in Plastic and Reconstructive Surgery: A Primer for Readers and Investigators.

The p-value is ubiquitous in research. However, misuse and misinterpretation are common. This special topics article aims to demystify the p-value for researchers, students, physicians, and experienced investigators alike. To accomplish this aim, the origins of the p-value, what they represent, and principles of application are described through use of examples from real datasets. Developing understanding of the true meaning of this statistical measure has the power to improve and inform clinical research.

Comparison of Long-Term Healthcare Cost and Utilisation of Nonoperative and Surgical Management of Thumb CMC Arthritis.

Background: Thumb carpometacarpal joint (CMC) osteoarthritis is the most symptomatic hand arthritis but the long-term healthcare burden for managing this condition is unknown. We sought to compare total healthcare cost and utilisation for operative and nonoperative treatments of thumb CMC arthritis. Methods: We conducted a retrospective longitudinal analysis using a large nationwide insurance claims database. A total of 18,705 patients underwent CMC arthroplasty (trapeziectomy with or without ligament reconstruction tendon interposition) or steroid injections between 1 October 2015 and 31 December 2018. Primary outcomes, healthcare utilisation and costs were measured from 1 year pre-intervention to 3 years post-intervention. Generalised linear mixed effect models adjusted for potentially confounding factors such as the Elixhauser comorbidity score with propensity score matching were applied to evaluate the association between the primary outcomes and treatment type. Results: A total of 13,646 patients underwent treatment through steroid injections, and 5,059 patients underwent CMC arthroplasty. At 1 year preoperatively, the surgery group required $635 more healthcare costs (95% CI [594.28, 675.27]; p < 0.001) and consumed 42% more healthcare utilisation (95% CI [1.38, 1.46]; p < 0.0001) than the steroid injection group. At 3 years postoperatively, the surgery group required $846 less healthcare costs (95% CI [-883.07, -808.51], p < 0.0001) and had 51% less utilisation (95% CI [0.49, 0.53]; p < 0.0001) annually. Cumulatively over 3 years, the surgical group on average was $4,204 costlier than its counterpart secondary to surgical costs. Conclusions: CMC arthritis treatment incurs high healthcare cost and utilisation independent of other medical comorbidities. At 3 years postoperatively, the annual healthcare cost and utilisation for surgical patients were less than those for patients who underwent conservative management, but this difference was insufficient to offset the initial surgical cost. Level of Evidence: Level III (Therapeutic).

Carpal tunnel syndrome.

Carpal tunnel syndrome (CTS) is the most common nerve entrapment disorder worldwide. The epidemiology and risk factors, including family burden, for developing CTS are multi-factorial. Despite much research, its intricate pathophysiological mechanism(s) are not fully understood. An underlying subclinical neuropathy may indicate an increased susceptibility to developing CTS. Although surgery is often performed for CTS, clear international guidelines to indicate when to perform non-surgical or surgical treatment, based on stage and severity of CTS, remain to be elucidated. Neurophysiological examination, using electrophysiology or ultrasonography, performed in certain circumstances, should correlate with the history and findings in clinical examination of the person with CTS. History and clinical examination are particularly relevant globally owing to lack of other equipment. Various instruments are used to assess CTS and treatment outcomes as well as the effect of the disorder on quality of life. The surgical treatment options of CTS - open or endoscopic - offer an effective solution to mitigate functional impairments and pain. However, there are risks of post-operative persistent or recurrent symptoms, requiring meticulous diagnostic re-evaluation before any additional surgery. Health-care professionals should have increased awareness about CTS and all its implications. Future considerations of CTS include use of linked national registries to understand risk factors, explore possible screening methods, and evaluate diagnosis and treatment with a broader perspective beyond surgery, including psychological well-being.

The effect of Medicaid expansion on rates of carpal tunnel release: an interrupted time series analysis.

BACKGROUND: Medicaid expansion through the Affordable Care Act (ACA) has been associated with greater access and utilization of surgical services in underserved populations. However, its impact on use of hand surgical care is less understood. The purpose of this study was to evaluate the association between New York State adoption of the ACA and carpal tunnel release (CTR) procedural volume in Medicaid beneficiaries. METHODS: We conducted a pooled cross-sectional analysis of patients who underwent CTR using the Healthcare Cost and Utilization Project New York State all-payer database (2010-2018). An interrupted time series (ITS) analysis using an autoregressive integrated moving average model estimated the immediate and long-term impact of Medicaid expansion in January 2014 on CTR procedural volume in Medicaid beneficiaries and uninsured individuals. RESULTS: A total of 112,569 patients were included in the sample. After expansion, we observed an absolute increase of 6% in the share of CTR procedures provided to Medicaid beneficiaries. Policy implementation was associated with an immediate 1.81% increase (95% CI=0.0085, 0.0277; p<0.001) in the probability of Medicaid as the primary payer and an annual increase of 1.68% (95% CI=0.0134, 0.0202; p<0.001) after reform. ITS analysis found this resulted in 4,190 additional CTR procedures in Medicaid beneficiaries than predicted without expansion. CONCLUSIONS: Study results suggest New York's adoption of the ACA was associated with an immediate and steady increase in use of outpatient CTR in Medicaid beneficiaries. Most of this increase represented newly treated patients rather than those who were previously uninsured.

Management of Scar Contractures of the Hand-Our Therapeutic Strategy and Challenges.

The essence of treating scar contractures lies in covering the skin deficit after releasing the contractures, typically using flaps or skin grafts. However, the specific characteristics of scar contractures, such as their location, shape, and size, vary among patients, which makes surgical planning challenging. To achieve excellent outcomes in the treatment of scar contractures, we have developed a dimensional classification system for these contractures. This system categorizes them into four types: type 1 (superficial linear), type 2-d (deep linear), type 2-s (planar scar contractures confined to the superficial layer), and type 3 (planar scar contractures that reach the deep layer, i.e., three-dimensional scar contractures). Additionally, three factors should be considered when determining surgical approaches: the size of the defect, the availability of healthy skin around the defect, and the blood circulation in the defect bed. Type 1 and type 2-d are linear scars; thus, the scar is excised and sutured in a straight line, and the contracture is released using z-plasty or its modified methods. For type 2-s, after releasing the scar contracture band, local flaps are indicated for small defects, pedicled perforator flaps for medium defects, and free flaps and distant flaps for large defects. Type 2-s has good blood circulation in the defect bed, so full-thickness skin grafting is also a suitable option regardless of the defect's size. In type 3, releasing the deep scar contracture will expose important structures with poor blood circulation, such as tendons, joints, and bones. Thus, a surgical plan using flaps, rather than skin grafts, is recommended. A severity classification and treatment strategy for scar contractures have not yet been established. By objectively classifying and quantifying scar contractures, we believe that better treatment outcomes can be achieved.

Decision for Carpal Tunnel Surgery: High-deductible Health Plans versus Traditional Health Plans.

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.

Pyrocarbon Lunate Arthroplasty: An Option for the Young Patient with Advanced Kienbock Disease.

Kienbock disease, or avascular necrosis of the lunate, is an uncommon cause of a painful and stiff wrist. Management options range from conservative treatment in the form of immobilization and corticosteroid injections to a wide variety of surgical treatments that depend on the structural integrity of the lunate, intercarpal relationships, and the condition of the articular cartilage of the wrist. A particularly difficult problem lies in the management of young patient in whom vascularized bone grafting of the lunate has failed but in whom arthritis has not yet developed. Pyrocarbon lunate implant arthroplasty is a newer treatment option for such a patient, and allows the preservation of the remainder of the proximal carpal row while directly addressing the degenerative lunate. This article describes the evidence and surgical technique for lunate implant arthroplasty and presents an illustrative case example.

Inappropriate wrist MRI: did guidelines have an impact?

OBJECTIVES: To assess the national prevalence and cost of inappropriate MRI in patients with wrist pain prior to and following American College of Radiology (ACR) guideline publication. STUDY DESIGN: We used administrative claims from the IBM MarketScan Research Databases to evaluate the appropriateness of wrist MRI in a national cohort of patients with commercial insurance or Medicare Advantage. METHODS: Adult patients with a diagnosis of wrist pain between 2016 and 2019 were included and followed for 1 year. We made assessments of appropriateness based on ACR guidelines for specific wrist pain etiologies. We tabulated the total costs and out-of-pocket expenses associated with inappropriate MRI studies using weighted mean payments for facility and professional fees. We performed segmented logistic regression on interrupted time series data to identify predictors of receiving inappropriate imaging and the impact of guideline publication on MRI use. RESULTS: The study cohort consisted of 867,119 individuals. Of these, 40,164 individuals (4.6%) had MRI, of whom 52.6% received an inappropriate study. Inappropriate studies accounted for $44,493,234 in total payments and $8,307,540 in out-of-pocket expenses. The interrupted time series found an approximately 1% monthly decrease in the odds of receiving an inappropriate study after guideline dissemination. CONCLUSIONS: MRI as a diagnostic tool for wrist pain is often inappropriate and expensive. Our findings support interventions to increase guideline adherence, such as integrated clinical decision support tools.

A Geospatial Analysis of Hand Trauma Care: A Statewide Cross-Sectional Study.

BACKGROUND: Traumatic hand injuries often present with high acuity, but little is known about the influence of geospatial and socioeconomic factors on the timely delivery of care. METHODS: This cross-sectional study used the Michigan Trauma Quality Improvement Program database, a state-wide registry with 35 level I or II trauma centers. Adult patients sustained hand trauma requiring urgent operative treatment between 2016 and 2021. Zip codes of injury location were linked with the corresponding percentile score on the Area Deprivation Index (ADI), a comprehensive measure of neighborhood disadvantage. Multiple regression analyses were used to determine associations of patient, injury and geospatial characteristics with the odds of sustaining acute hand trauma and time to operative treatment. RESULTS: Among 1,826 patients, the odds of sustaining acute hand trauma based on the ADI followed a bimodal distribution. Female sex, smoking, obesity, work-related injury and residence in a minor city were associated with increased odds, while younger age, comorbidities, and rural residence were associated with decreased odds. For 388 patients who underwent surgery within 48 hours, time to treatment was significantly increased in the highest ADI quintile, for patients who underwent fracture fixation, and for those with severe global injury severity. Multi-system injuries, moderate global injury severity and direct admission to an orthopaedic service were associated with shorter times to treatment. CONCLUSIONS: Patients in areas with greater neighborhood disadvantage may experience delayed operative care after acute hand trauma. This study highlights the importance of considering underserved populations and geospatial factors when determining the allocation of hand surgery resources. LEVEL OF EVIDENCE: Prognostic Level III.

REPORTED PRICES FOR HIGH VOLUME HAND SURGERY IN THE ERA OF PRICE TRANSPARENCY: IMPLICATIONS FOR FUTURE POLICY ITERATIONS.

BACKGROUND: In 2021, the United States enacted a law requiring hospitals to report prices for healthcare services. Across several healthcare services, poor compliance and wide variation in pricing was found. This study aims to investigate variation in reporting and listed prices by hospital features for high-volume hand surgeries including Carpal Tunnel release, Trigger Finger Release, De Quervain Tenosynovitis Release, and Carpometacarpal Arthroplasty. METHODS: The Turquoise Health price transparency database was used to obtain listed prices and linked to hospital characteristics from the 2021 Annual American Hospital Association Survey. This study used descriptive statistics and generalized linear regression. RESULTS: The analytic cohort included 2,652 hospitals from across the US. The highest rate of price reporting was in the Midwest (52%, n=836) and lowest in the South (39%, n=925). Compared to commercial insurers, ($3,609, 95% CI: $3,414 to $3,805) public insurance rates were significantly lower (Medicare: $1,588, 95% CI: $1,484 to $1,693, adjusted difference = -$2,021, p<0.001, Medicaid: $1,403, (95% CI: $1,194 to $1,612, adjusted difference = -$2,206, p<0.001). Listed rates for self-pay patients were not statistically different from commercial rates. CONCLUSIONS: Although pricing for high volume elective hand surgeries is frequently reported, a high proportion of hospitals do not report prices. These data highlight the need for future transparency policy to include pricing for high-volume hand surgery to give patients the ability to make financially informed choices. These results are a valuable aid for surgeons and patients to promote financially conscious decisions.

Recent Advances in Upper Extremity Microsurgery: From Traditional to Perforator Flaps.

The upper extremity has unique functional and aesthetic requirements. Reconstruction of upper extremity soft tissue defects should ideally provide coverage for vital structures, facilitate early mobilization, be thin and pliable to match its slim contour, and reestablish sensation. Perforator flaps can be raised on the superficial fascia, which creates a thin and pliable yet durable and supple flap option to match the contour and functional needs of the upper extremity. Comparisons to traditional reconstructive methods should be performed to assess whether these innovations in microsurgical reconstruction of upper extremity defects provide an improved functional and aesthetic benefit over traditional methods.

Best-Evidence Systematic Review and Meta-Analysis of Mini-Open Carpal Tunnel Release.

Purpose: This study aimed to evaluate the safety and effectiveness of mini-open carpal tunnel release (mOCTR) using best-evidence synthesis methods. Methods: We systematically searched for prospective studies published from January 2013 to July 2023 that reported outcomes from a minimum of 50 mOCTR cases. The outcomes included Quick Disabilities of the Arm, Shoulder, and Hand Questionnaire, Boston Carpal Tunnel Questionnaire Symptom Severity Scale (BCTQ-SSS) and Functional Status Scale (BCTQ-FSS), pain visual analog scale (VAS), complication rate, and reoperation rate. Data analysis was performed using a random-effects meta-analysis, with metaregression to identify the associations between patient- and study-level factors with surgical outcomes. Results: The meta-analysis included 23 studies with 2,303 patients followed for median durations ranging from 6 to 12 months depending on the outcome. Mini-open carpal tunnel release resulted in statistically significant and clinically important improvements in Quick Disabilities of the Arm, Shoulder, and Hand Questionnaire (mean difference = -25.5; 95% confidence interval [CI]: -36.4 to -14.5; P < .001), BCTQ-SSS (mean difference = -2.2; 95% CI: -2.5 to -1.9; P < .001), BCTQ-FSS (mean difference = -2.1; 95% CI: -2.4 to -1.7; P < .001), and pain VAS (mean difference = -5.1; 95% CI: -6.2 to -4.1; P < .001). The sole predictor of improvement in BCTQ-SSS, BCTQ-FSS, and pain VAS was a higher preoperative score for the respective variable (all P < .001). The risk of complications (mainly short-term pillar pain or scar complications) was 8.9% (95% CI: 4.0%-13.8%) and increased with longer incision lengths (P = .008). Revision carpal tunnel release was performed in 0.6% (95% CI: 0.1%-1.0%) of the cases during follow-up. No cases of median nerve transection were reported. Conclusions: Based on a best-evidence meta-analysis of contemporary studies, mOCTR significantly improved function and pain, with a relatively low risk of mainly temporary complications. Patient outcomes after mOCTR were influenced by patient symptomatology and surgical incision length. Clinical relevance: Mini-open carpal tunnel release is an effective surgical option that significantly improves symptoms and function, especially for patients with more severe baseline dysfunction. Surgeons should use the shortest incision that allows adequate visualization to safely divide the transverse carpal ligament.

Post-Bariatric Panniculectomy: Postoperative Complications by Weight Loss Surgery Type.

BACKGROUND: Over 250,000 patients undergo bariatric surgery each year in the United States. Approximately 21% will undergo subsequent body contouring after massive weight loss. Patients with prior bariatric surgery are at a greater risk for complications relative to the general population. However, it is unknown if bariatric surgery type is associated with differential complication risk after panniculectomy. METHODS: A retrospective chart review of post-bariatric who underwent abdominal panniculectomy at a single large quaternary care center was performed. Postoperative complications were graded according to the Clavien-Dindo classification. Descriptive statistics, multivariable logistic regression, and power calculations were performed. RESULTS: In total, 216 patients were included. Restrictive bariatric surgery accounted for 48.6% while 51.3% had a history of malabsorptive bariatric surgery. The overall rate of complications was 34.3% (restrictive: 36.2%; malabsorptive: 32.8%, p=0.66). Wound complications were observed in 25.5% (n=55) of patients. Systemic complications occurred in 11.1% of patients overall, with statistically similar rates between restrictive and malabsorptive groups. After adjusting for both patient and operative factors, no significant difference in total complications (OR=1.15, 95% CI: 0.47 to 2.85, p=0.76), systemic complications (OR=0.26, 95% CI: 0.05 to 1.28, p=0.10), or wound complications (OR=2.31, 95% CI: 0.83 to 6.41, p=0.11) was observed. CONCLUSIONS: Complications following panniculectomy in bariatric surgery patients is high and predominantly related to wound healing. No significant difference between type of bariatric surgery and complication risk was found.