Trends in Physician Payments for Hand Surgery Consultations and Clinic Visits.

PURPOSE: The primary objective of this study was to identify the trends in reimbursement for hand surgeons for new patient visits, outpatient consultations, and inpatient consultations from the years 2010-2018. In addition, we sought to investigate the influence of payer mix and coding level of service on physician reimbursement in these settings. METHODS: The PearlDiver Patients Records Database was used to identify clinical encounters and their respective physician reimbursements for analysis within this study. This database was queried using Current Procedural Terminology codes to identify relevant clinical encounters for inclusion, filtered for the presence of valid demographic information and by physician specialty for the presence of a hand surgeon, and tracked by primary diagnoses. Cost data were then calculated and analyzed regarding the payer type and level of care. RESULTS: In total, 156,863 patients were included in this study. The mean reimbursement for inpatient consultations, outpatient consultations, and new patient encounters increased by 92.75% ($134.85 to $259.93), 17.80% ($161.33 to $190.04), and 26.78% ($102.58 to $130.05), respectively. When normalized to 2018 dollars to adjust for inflation, the percent increases were 67.38%, 2.24%, and 10.09%, respectively. Commercial insurance reimbursed hand surgeons to a greater degree than any other payer type. Mean physician reimbursement differed depending on the level of service billed, with the level of service V reimbursing 4.41 times more than the level of service I visits for new outpatient visits, 3.66 times more for new outpatient consultations, and 3.04 times more for new inpatient consultations. CONCLUSIONS: This study helps to provide physicians, hospitals, and policymakers with objective information regarding the trends in reimbursement to hand surgeons. Although this study indicates increasing reimbursements for consultations and new patient visits to hand surgeons, the margins shrink when adjusted for inflation. LEVEL OF EVIDENCE: Economic Analysis IV.

Opioid Prescribing for Proximal Row Carpectomy versus Four-Corner Arthrodesis.

Background Proximal row carpectomy (PRC) and four-corner arthrodesis (4-CA) represent motion-sparing procedures for addressing degenerative wrist pathologies. While both procedures demonstrate comparable functional outcomes, postoperative pain presents a surgical challenge that often necessitates the use of opioids. Objectives The aim of this study was to (1) compare opioid prescribing patterns surrounding PRC and 4-CA, (2) identify risk factors predisposing patients to increased perioperative and prolonged postoperative opioids, and (3) examine the association between opioids and perioperative health care utilization. Patients and Methods PearlDiver Patients Records Database was used to retrospectively identify patients undergoing primary PRC and 4-CA between 2010 and 2018. Patient demographics, comorbidities, prescription drug usage, and perioperative health care utilization were evaluated. Perioperative opioid prescriptions and post-operative opioid prescriptions were recorded. Logistic regression analysis evaluated the association of patient risk factors. Results There was no significant difference in perioperative (PRC [odds ratio {OR}: 0.84, p = 0.788]; 4-CA [OR: 0.75, p = 0.658]) or prolonged postoperative opioid prescriptions (PRC [OR: 0.95, p = 0.927]; 4-CA [OR: 0.99, p = 0.990]) between PRC and 4-CA. Chronic back pain and use of benzodiazepines or anticonvulsants were associated with increased risks of prolonged postoperative opioids. Prolonged postoperative opioids presented increased risks of emergency department visits (OR: 2.09, p = 0.019) and hospital readmissions (OR: 10.2, p = 0.003). Conclusion No significant differences exist in the prescription of opioids for PRC versus 4-CA. Both procedures have high amounts of prolonged postoperative opioid use, which is associated with increased risks of emergency department visits and hospital readmissions. Level of Evidence This is a level III, retrospective comparative study.

A Series of Nontuberculous Mycobacterial Flexor Tenosynovitis Infections and Cost of Treatment.

Background Nontuberculous mycobacteria (NTM) are rare but potentially devastating causes of musculoskeletal infection and impairment in immunocompetent patients. Purpose Given the sparse body of literature surrounding these infections, we describe a series of patients with and the cost of treatment of upper extremity NTM infections. Patients and Methods In a retrospective review of seven patients with NTM infections of the upper extremity treated at a university hospital from 2010 to 2019, we assessed patient demographics, exposures, infection characteristics, management course, outcomes, and costs of treatment. Results Insidious pain and swelling were the most common clinical manifestation of infection. Despite coupled surgical and medical management, recurrence was common. Two patients required amputation, and three others had lasting functional deficits. The most common pathogen was Mycobacterium avium complex (5 of 7). The estimated median charge related to management was $85,126 with a range from $8,361 to $1,66,229. Conclusions The treatment of NTM infections is complex and expensive. Diagnosis is usually delayed, which further complicates the management of these patients who often suffer from lasting debilitation. Due to its potentially devastating course, NTM infection should be considered and tested for whenever flexor tenosynovitis is suspected. Regardless of initial presentation, our experience suggests that a protocol of serial surgical debridement immediately after tissue diagnosis is necessary for optimal outcomes. Furthermore, NTM infections require collaboration with infectious disease colleagues to guide antimicrobial regimens based on susceptibility testing and therapeutic drug monitoring for the recommended 6 to 12 months of therapy after the final operative debridement. Level of Evidence This is a Level IV, case series study.

Mycobacterium Immunogenum Flexor Tenosynovitis: A Case Report.

Background Nontuberculous mycobacterial (NTM) flexor tenosynovitis represents a rare but potentially devastating manifestation of upper extremity infection. We present a novel case of NTM flexor tenosynovitis in which Mycobacter iumimmunogenum was found to be the causative agent. Case Description The patient presented with pain and insidiously progressive swelling and required multiple operative interventions and a complex antimicrobial regimen based on susceptibility profiles. Specifically, our patient was managed with three debridements and empiric antimicrobial agents based on inherent macrolide sensitivity, with later conversion to a complex antimicrobial regimen tailored to sensitivity. Literature Review The diagnosis and management of NTM tenosynovitis arechallenging because of low suspicion, nonspecific presentation, and cumbersome laboratory identification techniques. M. immunogenum was only characterized in the past two decades, and, to our knowledge, this is the first reported case of the pathogen causing a musculoskeletal infection. Clinical Relevance We present this case primarily because of the novelty of the organism and to demonstrate the recalcitrant nature of the infection. Due to the extensive resistant patterns of M. immunogenum , management requires complex antimicrobial preparations and almost certainly needs multispecialty collaboration between orthopaedic surgery and infectious diseases.

Utilization and Impact of Social Media in Hand Surgeon Practices.

Background: Social media is an effective tool to enhance reputation and brand recognition and is being used by more than 40% of patients when selecting a physician. This study aimed to evaluate the use of social media in hand surgeon practices, and to assess the impact that one's social media presence has on physician-rating website scores (PRWs). Methods: Randomly selected hand surgeons from across the United States were identified. Sequential searches were performed using the physicians name + the respective social media platform (Facebook, LinkedIn, YouTube, Twitter, Instagram, personal website, group website). A comprehensive social media utilization index (SMI) was created for each surgeon. Utilizing descriptive statistics, we assessed the effect of social media on the PRW. Results: A total of 116 board-certified hand surgeons were included in our study. The sample identified 10.3% of the population used Facebook, 1.7% used Twitter, 25.8% used YouTube, 22.4% used LinkedIn, 27.5% used a personal website, and 36.2% used a group website, 0% used Instagram. The average SMI was 1.53 ± 1.42 (0-6). Physicians with a personal website received higher Healthgrades scores than those without one (P < .05). Analysis of SMI demonstrated that hand surgeons with an index less than 3 received lower Healthgrades scores compared to those with an SMI above 3 (P < .001). Conclusion: Hand surgeons underutilize social media platforms in their practice. A personal website is single most important social media platform to improve HealthGrades score in hand surgeons.

Iatrogenic Injuries in Percutaneous Pinning Techniques for Fifth Metacarpal Neck Fractures.

BACKGROUND: There is little information regarding anatomic structures at risk during closed percutaneous treatment of fifth metacarpal neck fractures. This study evaluates a variety of common percutaneous techniques with the hypothesis that each approach presents unique risks to tendons and neurovascular structures. METHODS: Seven cadaveric hands were used for this study. The senior author, a board-certified hand surgeon with more than 20 years of experience, used a mini-C arm to pass 1.6-mm Kirschner wires (K-wires). The 4 percutaneous techniques employed were anterograde, retrograde, cross-pinning, and transverse fixations. Meticulous superficial dissection was carried out, with fixation from all 4 techniques left in place, to identify any tendons or neurovascular structures penetrated by the K-wires. RESULTS: All techniques demonstrated penetration of at least 1 adjacent structure. The anterograde technique showed penetration of the extensor carpi ulnaris tendon in 5 out of 7 cadavers. In the retrograde approach, the K-wire impaled either the extensor digitorum communis or the extensor digitorum minimi tendons in 4 out of 7 cadavers. The transverse pinning technique exhibited injury to the dorsal cutaneous ulnar nerve in 2 of the specimens. In the retrograde cross-pin technique, there were 2 penetrations of the digital branch of the dorsal cutaneous ulnar nerve. CONCLUSIONS: None of the described percutaneous techniques for treating fifth metacarpal neck fractures eliminate the potential for damage to surrounding tendons or nerves. Each technique has at risk structures that the treating surgeon should be aware of in order to anticipate potential complications and counsel patients accordingly.

A Unique Presentation of Scaphocapitate Syndrome With Extrusion Into the Carpal Tunnel: A Case Report.

BACKGROUND: Scaphocapitate syndrome is a rare variety of perilunate instability, described as a trans-scaphoid, trans-capitate fracture, with rotation of the capitate head either 90° or 180°. METHODS: We present a unique case of scaphocapitate syndrome in which the rotated proximal capitate fragment expelled into the carpal canal. RESULTS: The capitate head was extricated from the carpal tunnel via the volar approach, and was anatomically aligned and fixed through the dorsal approach using two 2.0 mm headless compression screws. The scaphoid fracture was then also reduced through the dorsal approach and stabilized with a 2.5 mm headless compression screw. All intercarpal ligaments appeared intact. CONCLUSIONS: Volar dislocation of the proximal capitate into the carpal tunnel in scaphocapitate syndrome presents a unique challenge that can be addressed with a combined volar and dorsal approach.

Intracompartmental Versus Extracompartmental Transposition of the Extensor Pollicis Longus for Treating Thumb-in-Palm Deformity: A Biomechanical Comparison.

PURPOSE: Transecting the extensor pollicis longus (EPL) tendon and rerouting it through the first extensor compartment is an established technique for treating thumb-in-palm deformity (TIPD). An alternative technique that approximates the trajectory of the first extensor compartment without violating the compartment or transecting the EPL tendon can be accomplished by creating an artificial sheath from the extensor retinaculum to radialize the tendon glide path. This study compares this extracompartmental (EC) EPL transposition to the established, intracompartmental (IC) transposition by evaluating, in a cadaver model, the extent of thumb extension in both techniques. METHODS: Eighteen fresh-frozen cadaveric hands were each tested under 3 different conditions: EPL in situ (baseline); EPL rerouted above the first extensor compartment (EC); and EPL rerouted through the first extensor compartment (IC). A controlled traction of 10 N was applied to the EPL under each condition. The range of thumb extension with respect to the fixed index finger was recorded utilizing infrared reflective markers and digital video capture. RESULTS: The mean extension of the thumb with the EPL tendon in situ was 16.7°. The mean extension of the thumb was 22.0° with the EC transposition versus 25.0° with the IC technique. The measured thumb extension in both the EC and the IC techniques were found to be similar because both EPL transpositions yielded a significant difference in thumb extension when compared with baseline. CONCLUSIONS: This biomechanical model demonstrates that radial transposition of the EPL tendon enhances extension of the thumb regardless of whether the tendon is routed through, or superficial to, the first extensor compartment. CLINICAL RELEVANCE: A novel technique, the EC EPL transposition, offers a similar enhancement in measured thumb extension as the already-described IC EPL transposition.

The Role of BMI in Hip Fracture Surgery.

INTRODUCTION: Obesity is an oft-cited cause of surgical morbidity and many institutions require extensive supplementary screening for obese patients prior to surgical intervention. However, in the elderly patients, obesity has been described as a protective factor. This article set out to examine the effect of body mass index (BMI) on outcomes and morbidity after hip fracture surgery. METHODS: The National Surgical Quality Improvement Program database was queried for all patients undergoing 1 of 4 surgical procedures to manage hip fracture between 2008 and 2012. Patient demographics, BMI, and known factors that lead to poor surgical outcomes were included as putative predictors for complications that included infectious, cardiac, pulmonary, renal, and neurovascular events. Using χ2 tests, 30-day postoperative complication rates were compared between 4 patient groups stratified by BMI as low weight (BMI < 20), normal (BMI = 20-30), obese (BMI = 30-40), and morbidly obese (BMI > 40). RESULTS: A total of 15 108 patients underwent surgery for hip fracture over the examined 5-year period. Of these, 18% were low weight (BMI < 20), 67% were normal weight (BMI = 20-30), 13% were obese (BMI = 30-40), and 2% were morbidly obese (BMI > 40). The low-weight and morbidly obese patients had both the highest mortality rates and the lowest superficial infection rates. There was a significant increase in blood transfusion rates that decreased linearly with increasing BMI. Deep surgical site infection and renal failure increased linearly with increasing BMI, however, these outcomes were confounded by comorbidities. CONCLUSION: This study demonstrates that patients at either extreme of the BMI spectrum, rather than solely the obese, are at greatest risk of major adverse events following hip fracture surgery. This runs contrary to the notion that obese hip fracture patients automatically require additional preoperative screening and perioperative services, as currently implemented in many institutions.

The Relative Contribution to Small Finger Abduction of the Ulnar Versus Radial Slip of the EDM: Implications for Tendon Transfers.

BACKGROUND: The extensor digiti minimi (EDM) tendon is commonly divided into a radial slip (EDM-R) and an ulnar slip (EDM-U). To our knowledge, the degree to which each EDM slip concomitantly abducts the small finger with active extension has not been formally tested. This study sought to characterize the comparative contributions of finger abduction inherent to each slip of the EDM to observe the sequelae of active small finger extension following transfer of the contralateral slip. METHODS: Eighteen fresh-frozen cadaveric hands were used in this study. Starting with the hand in resting position, a controlled traction of 10 N was applied to each slip of the EDM tendon. The range of small finger abduction with respect to the fixed ring finger was recorded utilizing infrared reflective markers tracked through the range of motion using a digital video camera. RESULTS: The mean abduction of the small finger when the radial slip of the EDM tendon was tested was 13.33° (95% confidence interval [CI]: 10.10°-16.55°), which was significantly different ( P ≤ .001) than small finger abduction produced by the ulnar slip of the EDM, with a mean of 23.72° (95% CI: 19.40°-28.04°). CONCLUSIONS: Given the fact that the ulnar slip of the EDM tendon is shown to be the major contributor of aberrant abduction with active small finger extension, as traction on this slip produces almost twice as much abduction as the radial slip, the EDM-U is the ideal donor graft with respect to tendon transfers of the EDM.

Readability of the Most Commonly Accessed Online Patient Education Materials Pertaining to Pathology of the Hand.

BACKGROUND: The American Medical Association (AMA) and National Institutes of Health (NIH) recommend that patient education materials be written at no higher than a sixth-grade reading level. METHODS: We examined 100 online educational materials for the 10 hand conditions most commonly treated by hand surgeons, as reported by the American Society for Surgery of the Hand. The listed conditions were carpal tunnel syndrome, basal joint arthritis of the thumb, de Quervain syndrome, Dupuytren's contracture, ganglion cysts, hand fractures, trigger finger, extensor tendon injuries, flexor tendon injuries, and mallet finger. Following a Google search for each condition, we analyzed the 10 most visited websites for each disorder utilizing the Flesch-Kincaid formula. RESULTS: The average grade reading level of the 100 websites studied was 9.49 with a reading ease of 53.03 ("fairly difficult high school"). Only 29% of the websites were at or below the national average of an eighth-grade reading level. Carpal tunnel syndrome had the highest average grade reading level at 10.32 (standard deviation: 1.52), whereas hand fractures had the lowest at 8.14 (2.03). Every hand condition in this study had an average readability at or above the ninth-grade reading level. CONCLUSIONS: The most frequently accessed materials for common maladies of the hand exceed both the readability limits recommended by the AMA and NIH, and the average reading ability of most US adults. Therefore, the most commonly accessed websites pertaining to hand pathology may not be comprehended by the audience for which it is intended.

Readability of the Most Commonly Accessed Arthroscopy-Related Online Patient Education Materials.

PURPOSE: To assess the readability and comprehension of written text by the most commonly visited websites containing patient education materials on common conditions that can be treated arthroscopically. METHODS: We examined 50 websites, assessed independently by 2 orthopaedic surgery residents (S.A. and G.G.), with educational materials on 5 common conditions treated by arthroscopic surgeons: anterior cruciate ligament (ACL) tear, meniscus tear, hip labral tear, shoulder labral tear, and rotator cuff tear. Following a Google search for each condition, we analyzed the 10 most visited websites for each disorder using a widely used and validated tool for assessing the reading levels of written materials (Flesch-Kincaid formula). RESULTS: The average grade reading level of the 50 websites studied was 9.90 with a reading ease of 52.14 ("fairly difficult, high school"). Only 26% of the websites were at or below the national average of an eighth-grade reading level. Of the 5 conditions treated by arthroscopic surgery, ACL tear had the highest average grade reading level at 10.73 ± 1.54, whereas meniscus tear had the lowest at 9.31 ± 1.81. Every condition in this study had an average readability at or above the ninth-grade reading level. CONCLUSIONS: The most frequently accessed materials for patients with injuries requiring arthroscopic surgery exceeds the readability recommendations of the American Medical Association and National Institutes of Health, as well as the average reading ability of US adults. Given the fact that these are the most commonly visited websites by the lay public, there needs to be a greater emphasis on tailoring written information to the literacy levels of the patient population. CLINICAL RELEVANCE: This study emphasizes the discrepancy between the recommended versus the measured reading levels of online patient education materials related to conditions treated by arthroscopic surgeons. The subject matter of these conditions is inherently complex; thus, relying solely on text to inform patients increases the likelihood that the reading level of the material exceeds that of the majority of the lay public.

The choices we make as teachers.

"She wasn't like you...wasn't like any politician I've ever known." Ethan Kanin, Secretary of State about US president Allison Taylor in the US serial, 24. When an ethical dilemma arises, the choices we make decide our ethical concerns and moral position in a given situation. In the TV serial, 24, the US president faces such an ethical dilemma when she has to either cover up for her daughter's crime or get her arrested. She is torn between the role of a mother and that of a President. She chooses her sworn duty to protect the country and has her daughter arrested. She gives precedence to her duty as the President of a country over her mother's role.

All-epiphyseal acl reconstruction: a three-year follow-up.

BACKGROUND/INTRODUCTION: With an increasing number of pre-adolescents participating in sports, anterior cruciate ligament injuries and resultant reconstruction in the skeletally immature athlete are becoming more common. Many different surgical techniques and rehabilitation protocols have been proposed for the treatment of anterior cruciate ligament (ACL) injuries, but there is a lack of agreement as to which approach results in the best outcome. Rehabilitation protocols have marked variation regarding postoperative weight bearing, immobilization, bracing, and length. CASE DESCRIPTION: This is a case of a ten year old female who sustained bilateral ACL tears within the period of a year. The purpose of this case report is to describe the early result and subsequent rehabilitation following bilateral physeal-sparing all-epiphyseal ACL reconstructions on a skeletally immature patient with a three-year follow-up. OUTCOMES: The early post-surgical recovery period on the first injured knee was complicated by knee stiffness requiring manipulation. Following this minor setback, the patient met all physical therapy goals and had no additional complications. The rehabilitation after the second surgery followed a typical course. At three-year follow-up, the patient had grown an additional seven inches, with radiographic evidence of symmetric physeal growth and joint stability. She has returned to playing competitive sports. DISCUSSION AND CONCLUSION: This innovative physeal-sparing technique has huge implications as, historically; the feared complication of growth disturbance and angular deformity from transphyseal ACL reconstruction has complicated the management of ACL injuries in children and pre-adolescents. This case report demonstrates the success of this technique, and the subsequent rehabilitation, as this patient did not experience a reduction in long-term bone growth. LEVEL OF EVIDENCE: 5 Case Report.

Unusual proximal dislocation without fracture: a case report.

Carpal instability includes a broad spectrum of osseous and ligamentous injuries which have been subclassified into greater and lesser arc injuries, in addition to combinations of both (Mayfield et al. J Hand Surg [Am] 5:226-241, 1980; Yaeger et al. Skeletal Radiol 13(2):120-30, 1985). The injuries typically occur from a fall on the outstretched hand with the wrist in ulnar deviation, hyperextension, and intercarpal supination (Yaeger et al. Skeletal Radiol 13(2):120-30, 1985). The force classically propagates from the radial to the ulnar side of the wrist resulting in a fracture (greater arc) or dislocation (lesser arc) pattern with the extent of the injury occurring in an orderly pattern depending upon the degree of hyperextension and the duration and magnitude of the force (Mayfield et al. J Hand Surg [Am] 5:226-241, 1980; Yaeger et al. Skeletal Radiol 13(2):120-30, 1985). Multiple variations occur, including transradial styloid fractures as well as fractures through carpal bones surrounding the lunate (Mayfield et al. J Hand Surg [Am] 5:226-241, 1980; Yaeger et al. Skeletal Radiol 13(2):120-30, 1985; Kozin SH. J Am Acad Orthop Surg 6 (2): 114-20, 1998. Although carpal dislocations have been noted for many years, the mechanisms and classification have only been recently clarified. We report a case of a complex dislocation involving the entire proximal carpal row without an associated fracture. While this type of complex carpal dislocation has been previously described, to our knowledge, it has never been reported without a fracture of the forearm, wrist, or hand.

Does venous insufficiency impair the exercise-induced rise in arterial leg blood flow?

OBJECTIVES: It has been shown that the leg muscle pump increases the immediate rise in arterial leg blood flow during upright exercise in healthy subjects. The present study is the first to investigate the muscle pump effect in exercise hyperaemia in patients with venous insufficiency, who should be lacking an optimally functioning muscle pump. METHODS: Any muscle pump effect is more pronounced in an upright position because of gravitation. The exercise-induced rise in femoral artery flow (FF) (ultrasound Doppler) was thus compared in the supine and 30° head-up tilted position in 10 patients. RESULTS: Neither the transient nor the steady-state rise in FF showed any difference between positions. This is in contrast to the previous findings in healthy subjects, where the transient rise in FF was larger in the tilted position. CONCLUSION: The muscle pump effect in exercise hyperaemia seems to be reduced or lacking in these patients.

Does the great saphenous vein stripping improve arterial leg blood flow during exercise?

OBJECTIVES: It has been shown that the leg muscle pump increases arterial leg blood flow during upright exercise in healthy subjects, and that this effect is reduced in patients with incompetence of the great saphenous vein (GSV). In this study, patients with GSV reflux causing varicose veins were investigated after GSV stripping, to see whether the muscle pump effect on arterial leg blood flow is improved. DESIGN: Prospective case study. METHODS: Nine patients with GSV incompetence resulting in symptomatic varicose veins, but without peripheral artery disease were included in this study. Patients exercised in the supine and 30° head up tilted positions by rhythmically pressing down a pedal with one foot. Blood flow was measured in the femoral artery using Doppler ultrasound. The Exercise-induced rise in femoral artery blood flow was compared in the supine and 30° head up tilted positions. Patients were investigated both before and after undergoing saphenofemoral ligation and GSV stripping as a treatment for their varicose veins. The arterial blood flow response to exercise was compared between the pre and postoperative observations. RESULTS: Prior to GSV stripping the immediate rise in femoral flow was 0.25 l min(-1) above rest in both supine and tilted positions. After GSV stripping however, the rise in flow was 30% larger in the tilted position than in the supine position (0.26 vs. 0.20 l min(-1), P < 0.05). CONCLUSIONS: GSV stripping modestly improves arterial leg blood flow at the onset of exercise in patients with GSV insufficiency, because of an improved effect of the leg muscle pump.