Efficacy of Intra-Articular Corticosteroid Injection for Nonsurgical Management of Trapeziometacarpal Osteoarthritis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

PURPOSE: As osteoarthritis (OA) of the trapeziometacarpal (TMC) joint leads to a high degree of disease burden with compromises in rudimentary and fine movements of the hand, intra-articular injections may be a desirable treatment option. However, because there are no evidence-based guidelines, the choice of intra-articular injection type is left to the discretion of the individual surgeon in collaboration with the patient. The purpose of our study was to perform a systematic review and meta-analysis using level I studies to compare outcomes following corticosteroid and alternative methods of intra-articular injections for the management of TMC OA. Our hypothesis was that intra-articular corticosteroid injections were no more effective than other methods of intra-articular injections for the management of TMC OA. METHODS: A systematic literature search was performed. Eligible for inclusion were randomized control trials reporting on intra-articular corticosteroid injection for the management of TMC OA. Clinical outcomes were recorded. RESULTS: The 10 included studies comprised 673 patients. The mean age was 57.8 ± 8.3 years, with a mean follow-up of 6.4 ± 2.7 months. There was no significant difference in visual analog scale scores, grip strength and tip pinch strength between corticosteroids and hyaluronic acid at short- and medium-term follow-up. Further, there was no difference in visual analog scale pain scores at rest at medium-term follow-up between corticosteroids and platelet-rich plasma. CONCLUSIONS: Despite short-term improvement with intra-articular corticosteroid injections, there was no significant difference in pain and functional outcomes following intra-articular corticosteroid injections compared to hyaluronic acid or platelet-rich plasma administration. Given the affordability, ease of administration, and efficacy associated with corticosteroids, they are a favorable option when considering the choice of intra-articular injection for the management of TMC OA. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Use of intumescent flame-retardant systems in epoxy adhesives for debonding purpose.

This work investigates the use of intumescent flame-retardant additives as a new debonding solution to disassemble bonded aluminum substrates. Melamine polyphosphate (MPP) or ammonium polyphosphate (APP) was incorporated into an epoxy adhesive joint as both an acid source and a swelling agent with this stimulus responsive behavior being triggered by heating. The ability of the system containing intumescent additives to swell and foam under heat radiation was efficiently exploited to provide enough local pressure to induce porosities and cracks at the interface, facilitating the disassembling of bonded aluminum substrates. Several aluminum/intumescent-epoxy/aluminum laminates were assembled and tested to assess the influence of the MPP and APP content on the mechanical strength of the joints. The structural, morphological, mechanical, and thermal properties of these modified epoxy resins and assemblies with aluminum substrates were studied using Scanning Electron Microscopy (SEM), a pull-off test, Differential Scanning Calorimetry (DSC), and Thermogravimetric Analysis (TGA). The ability of the intumescent-modified joints to support temperature-controlled debonding was evaluated using an oven. The lower debonding temperatures found were comparable to laminates with unmodified epoxy joint systems. Our patented debonding on-demand technology, based on an intumescent flame-retardant system, represents a promising treatment for multi-material structures and will enable products to be recycled at the end of their service life.

Comparison Between Intramedullary Nail and Percutaneous Pin Fixation in Proximal Phalanx Fractures.

BACKGROUND: Percutaneous pinning has been the predominant technique for fixation of proximal phalanx fractures, but stiffness is a reported complication. The introduction of intramedullary (IM) nail fixation of proximal phalanx fractures provides a stronger biomechanical fixation for amenable fracture patterns with the added benefit of not tethering the soft tissue. The goal of this study was to compare the surgical outcomes of IM nail and percutaneous pin fixation in isolated proximal phalanx fractures. METHODS: A retrospective review was performed at our institution between the years 2018 and 2022 for patients treated for proximal phalanx fractures. Patients that underwent fixation with IM nails or percutaneous fixation for isolated extraarticular proximal phalanx fractures were included. Patients were excluded if they had concomitant hand fractures, tendon injury, or intraarticular extension. RESULTS: A total of 50 patients were included in this study. Twenty-eight patients received percutaneous pin fixation, and 22 patients underwent IM nail or screw fixation. There was no significant difference in injury patterns or demographics between these two groups. Patients that underwent IM nail fixation had a significantly quicker return to active motion, shorter duration of orthosis treatment, and fewer occupational therapy visits. In addition, patients in the IM fixation group had significantly improved range of motion (ROM) at 6 weeks postoperatively. CONCLUSIONS: This study demonstrates that patients receiving percutaneous pin or IM nail fixation have equivocal union and complication rates. The IM nail fixation group was able to have quicker return to mobilization, fewer required occupational therapy visits, and improved early ROM.

Variations in Treatment and Costs for Distal Radius Fractures in Patients Over 55 Years of Age: A Population-Based Study.

Objective To evaluate the rate of surgery for symptomatic malunion after nonoperatively treated distal radius fractures in patients aged 55 and above, and to secondarily report differences in demographics, geographical variation, and utilization costs of patients requiring subsequent malunion correction. Methods We identified patients aged 55 and above who underwent nonoperative treatment for a distal radius fracture between 2007 and 2016 using the IBM MarketScan database. In the nonoperative cohort, we identified patients who underwent malunion correction between 3 months and 1 year after distal radius fracture. The primary outcome was rate of malunion correction. Multivariable logistic regression controlling for sex, region, and Elixhauser Comorbidity Index (ECI) was used. We also report patient demographics, geographical variation, and utilization cost. Results The rate of subsequent malunion surgery after nonoperative treatment was 0.58%. The cohort undergoing malunion surgery was younger and had a lower ECI. For every 1-year increase in age, there was a 6.4% decrease in odds of undergoing surgery for malunion, controlling for sex, region, and ECI (odds ratio = 0.94 [0.93-0.95]; p < 0.01). The southern United States had the highest percentage of patients initially managed operatively (30.7%), the Northeast had the lowest (22.0%). Patients who required a malunion procedure incurred higher costs compared with patients who did not ($7,272 ± 8,090 vs. $2,209 ± 5,940; p < 0.01). Conclusion The rate of surgery for symptomatic malunion after initial nonoperative treatment for distal radius fractures in patients aged 55 and above is low. As younger and healthier patients are more likely to undergo malunion correction with higher associated costs, surgeons may consider offering this cohort surgical treatment initially.

Does Academic Productivity Correlate With Industry Payments in Hand Surgery Fellowship Programs in the United States?

BACKGROUND: Hand surgeons and the industry share a common goal to improve the care of patients. However, industry support remains controversial, and the current relationship with fellowship programs remains unclear. This study explores the relationship between industry support and research productivity among hand surgeons in the academic setting. METHODS: The Open Payments database, created by the Centers for Medicare and Medicaid Services (CMS) as a result of the Sunshine Act, was used to identify supplemental income paid to physicians of hand surgery fellowships in the United States. Both lifetime individual physician and aggregated fellowship Sunshine Act supplemental income (2015-2021) were collected for review. Supplemental income only reflects royalties, consulting fees, or food and does not include direct research funding. H-index was collected through the Scopus website as a proxy for academic productivity. RESULTS: Six hundred and thirty-four faculty physicians (90.8%) from 94 hand surgery fellowships (100%) were included in the study. The mean individual physician lifetime supplemental income was $67,272 (median $341,861), whereas the mean individual physician H-index was 12.5 (median 9.0). There was a significant and weak positive correlation between individual physician H-index and lifetime income (p<0.001). Similarly, there was a significant and moderately positive correlation between the combined fellowship H-index and total lifetime income (p<0.001). CONCLUSION: Research productivity of an orthopedic hand fellowship group and individual academic hand surgeon correlate with overall industry support from indirect research funding. Further work is required to better understand the advantages and disadvantages of industry support of academically productive hand surgeons at hand surgery fellowships.

Complications Following Volar Locking Plate Fixation of Distal Radius Fractures in Adults: A Systematic Review of Randomized Control Trials.

PURPOSE: The purpose of this study was to assess the incidence of postoperative complications following volar locking plate (VLP) fixation of distal radius fractures (DRFs). METHODS: A search using keywords and subject headings to represent the concepts of volar plating and radius fractures was generated. Databases such as MEDLINE (Ovid), Embase (Elsevier), Scopus (Elsevier), and SPORTDiscus (EBSCO) were searched from inception to November 24, 2021, for randomized controlled trials that reported complications following DRF treated with VLP. Inclusion criteria were studies with adult patients (aged ≥18 years) randomized to VLP fixation without other concomitant surgical interventions, with a minimum follow-up of 3 months. Study sample characteristics and post-surgical complications were extracted. The Cochrane Risk of Bias tool was used to evaluate quality of evidence. RESULTS: Of the 4,059 articles identified using the search strategy, 1,778 titles/abstracts and 856 full-text articles were screened for inclusion, of which 35 articles were included for data extraction. Overall, 1,419 patients with a DRF were randomized to VLP fixation. The mean age was 60.3 years. The overall complication rate was 30.8% following VLP fixation, with 12.4% being major complications. The most common complications were median nerve-related (7.1%) and hardware removal (6.8%), secondary to other complications. Tenosynovitis was the most common tendon-related complication (3.4%). Other complications included complex regional pain syndrome (2.4%), malunion (1.3%), superficial wound infections (1.9%), and tendon rupture (1.3%). CONCLUSIONS: A meta-analysis of high-quality studies that discuss the complications after VLP fixation for DRF showed an overall complication rate of 30.8%. VLP may be related to more hardware-related complications than those previously reported. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Management of Complex Hand and Wrist Ligament Injuries.

Ligamentous injuries in the hand and wrist are often underdiagnosed and can present with significant functional limitations if there is untimely recognition of injury. Adequate repair or reconstruction is critical in restoring joint stability and mobility. The purpose of this review is to provide an overview of the metacarpophalangeal joint, scapholunate interosseous ligament (SLIL), and non-SLIL carpal ligament anatomy, diagnosis, imaging, treatment consideration and options, as well as surgical techniques encompassing repair, reconstruction, and fusion.

The Use and Downstream Associations of Magnetic Resonance Imaging for Lateral Epicondylitis.

PURPOSE: Low-value imaging is associated with wasteful health care spending and patient harm. The routine use of magnetic resonance imaging (MRI) for the work-up of lateral epicondylitis is an example of low-value imaging. As such, our aim was to investigate the use of MRIs ordered for lateral epicondylitis, the characteristics of those undergoing an MRI, and the downstream associations of MRI with other care. METHODS: We identified patients aged ≥18 years with a diagnosis of lateral epicondylitis between 2010 and 2019 using a Humana claims database. We identified patients with a Current Procedural Terminology code corresponding to an elbow MRI. We analyzed the use and downstream treatment cascades in those undergoing MRI. Multivariable logistic regression models were used to assess the odds of undergoing an MRI, adjusting for age, sex, insurance type, and comorbidity index. Separate multivariable logistic regression analyses were used to determine the association between undergoing an MRI and the incidence of secondary outcomes (eg, receiving surgery). RESULTS: A total of 624,102 patients met the inclusion criteria. Of 8,209 (1.3%) patients undergoing MRI, 3,584 (44%) underwent it within 90 days after diagnosis. There was notable regional variation in MRI use. The MRIs were ordered most frequently by primary care specialties and for younger, female, commercially insured, and patients with more comorbidities. Performance of an MRI was associated with an increase in downstream treatments, including surgery (odds ratio [OR], 9.58 [9.12-10.07]), injection (OR, 2.90 [2.77-3.04]), therapy (OR, 1.81 [1.72-1.91]), and cost ($134 per patient). CONCLUSIONS: Although there is variation in the use of MRI for lateral epicondylitis and its use is associated with downstream effects, the routine use of MRI for the diagnosis of lateral epicondylitis is low. CLINICAL RELEVANCE: The routine use of MRI for lateral epicondylitis is low. Understanding interventions to minimize such low-value care in lateral epicondylitis can be used to inform improvement efforts to minimize low-value care for other conditions.

Impact of Time to Fixation on Outcomes of Operative Treatment of Intra-articular Distal Radius Fractures.

BACKGROUND: The incidence of operative treatment of distal radius fractures (DRFs) has increased recently, but the optimal timing for surgical fixation remains unclear. We hypothesized that: (1) an increase in time to fixation of intra-articular DRFs would increase the likelihood of postoperative complications; and (2) increased time from injury to fixation would lead to longer surgical time and worse range of motion (ROM) outcomes. METHODS: We retrospectively reviewed 299 fractures in 284 adult patients who underwent open reduction and internal fixation (ORIF) of a closed, intra-articular DRF at our institution over a 10.5-year period. Demographic information, time to surgery (TTS) from injury, surgical time, tourniquet time, complications, and final postoperative ROM were collected for logistic regression modeling to predict the risk of postoperative complication. RESULTS: Twenty-seven (9.0%) patients experienced postoperative complications. The median TTS (Q1-Q3) for all patients was 7.0 (4.0-12.0) days. Patients who experienced an early postoperative complication had significantly longer median TTS (10.0 days) than those who did not (7.0 days). Patients with longer TTS were more likely to experience a complication (odds ratio, 1.11; 95% confidence interval, 1.04-1.19; P = .006). Tourniquet time and final wrist ROM were not related to TTS. A logistic regression analysis found that early complication rate doubles at 7.0 days after injury (from 3.5% to 6.9%). CONCLUSIONS: Patients with operative intra-articular distal radius fractures should ideally be fixed within 7 to 10 days of injury to minimize the risk of early postoperative complications. The tourniquet time and final ROM were not associated with time to surgery.

4D Printing of Electroactive Triple-Shape Composites.

Triple-shape polymers can memorize two independent shapes during a controlled recovery process. This work reports the 4D printing of electro-active triple-shape composites based on thermoplastic blends. Composite blends comprising polyester urethane (PEU), polylactic acid (PLA), and multiwall carbon nanotubes (MWCNTs) as conductive fillers were prepared by conventional melt processing methods. Morphological analysis of the composites revealed a phase separated morphology with aggregates of MWCNTs uniformly dispersed in the blend. Thermal analysis showed two different transition temperatures based on the melting point of the crystallizable switching domain of the PEU (Tm~50 ± 1 °C) and the glass transition temperature of amorphous PLA (Tg~61 ± 1 °C). The composites were suitable for 3D printing by fused filament fabrication (FFF). 3D models based on single or multiple materials were printed to demonstrate and quantify the triple-shape effect. The resulting parts were subjected to resistive heating by passing electric current at different voltages. The printed demonstrators were programmed by a thermo-mechanical programming procedure and the triple-shape effect was realized by increasing the voltage in a stepwise fashion. The 3D printing of such electroactive composites paves the way for more complex shapes with defined geometries and novel methods for triggering shape memory, with potential applications in space, robotics, and actuation technologies.

Do Patients Want to Be Involved in Their Carpal Tunnel Surgery Decisions? A Multicenter Study.

PURPOSE: Carpal tunnel syndrome requires multiple decisions during its management, including regarding preoperative studies, surgical technique, and postoperative wound management. Whether patients have varying preferences for the degree to which they share in decisions during different phases of care has not been explored. The goal of our study was to evaluate the degree to which patients want to be involved along the care pathway in the management of carpal tunnel syndrome. METHODS: We performed a prospective, multicenter study of patients undergoing carpal tunnel surgery at 5 academic medical centers. Patients received a 27-item questionnaire to rate their preferred level of involvement for decisions made during 3 phases of care for carpal tunnel surgery: preoperative, intraoperative, and postoperative. Preferences for participation were quantified using the Control Preferences Scale. These questions were scored on a scale of 0 to 4, with patient-only decisions scoring 0, semiactive decisions scoring 1, equally collaborative decisions scoring 2, semipassive decisions scoring 3, and physician-only decisions scoring 4. Descriptive statistics were calculated. RESULTS: Seventy-one patients completed the survey between November 2018 and April 2019. Overall, patients preferred semipassive decisions in all phases of care (median score, 3). Patients preferred equally collaborative decisions for preoperative decisions (median score, 2). Patients preferred a semipassive decision-making role for intraoperative and postoperative decisions (median score, 3), suggesting these did not need to be equally shared. CONCLUSIONS: Patients with carpal tunnel syndrome prefer varying degrees of involvement in the decision-making process of their care and prefer a semipassive role in intraoperative and postoperative decisions. CLINICAL RELEVANCE: Strategies to engage patients to varying degrees for all decisions during the management of carpal tunnel syndrome, such as decision aids for preoperative surgical decisions and educational handouts for intraoperative decisions, may facilitate aligning decisions with patient preferences for shared decision-making.

Lunate Revascularization With Temporary Internal Radiocarpal Spanning Fixation for Kienböck Disease.

BACKGROUND: The goal in the treatment of stages II and III Kienböck disease is to restore lunate vascularity and halt the progression of avascular necrosis. METHODS: We report the outcomes for patients with stages II and III Kienböck disease treated with fourth extensor compartment artery vascularized bone grafting and temporary radiocarpal spanning internal fixation. Nine patients with a mean age of 28.8 years were included. Mean clinical and radiographic follow-up were 4.9 and 1.9 years, respectively. RESULTS: Six patients had no change in Lichtman stage, 2 patients regressed 1 stage, and 1 patient progressed 1 stage. Mean postoperative quick disabilities of the arm, shoulder, and hand (QuickDASH) was 17.4. Mean postoperative visual analogue pain scale (VAS) was 1.8. Patients under age 25 trended toward improved clinical outcomes compared with patients over age 25. Two patients, aged 33 and 65, underwent proximal row carpectomy at a mean 30.5 months postoperatively. CONCLUSIONS: In conclusion, the use of local vascularized bone graft with temporary internal radiocarpal spanning fixation provides a treatment option with outcomes comparable to existing literature with benefits inherent to internal immobilization.

Arthroscopic TFCC Ulnar Bone Tunnel Foveal Repair in Adult Patients.

Triangular fibrocartilage complex (TFCC) tears may cause persistent ulnar-sided wrist pain, loss of grip strength, and associated loss of function. Although the majority of TFCC tears can be treated nonoperatively, surgical repair is considered when conservative measures fail. TFCC tears with foveal disruption and instability of the distal radioulnar joint (DRUJ) require direct repair of the TFCC to the ulnar fovea. The traditional method of foveal TFCC repair involves an open surgical approach through the floor of the 5th dorsal compartment. However, this open approach causes disruption of structures such as the dorsal ulnocarpal capsule, the extensor retinaculum, and, potentially, the distal radioulnar ligament (DRUL). This article describes, in detail, the recently developed arthroscopic assisted ulnar foveal bone tunnel repair. This method spares dorsal structures that may be disrupted during an open surgical approach and creates a robust repair of the TFCC deep fibers with restoration of DRUJ stability.

Time to publication for orthopaedic surgery peer-reviewed journals: A cross-sectional bibliometric analysis.

Background: The dissemination of research and evidence-based medicine is critical to advancing science and improving clinical practice. The purpose of this study was to evaluate the timing and associated factors of the publication process for the most influential orthopaedic surgery research journals. Methods: After analyzing 25 orthopaedic surgery journals with the highest impact factors, 14 journals provided the necessary information for data analysis. A minimum of three consecutive issues per journal from 2021 were collected for review. Within each issue, all articles were included except for reviews, commentaries, replies, letters to the editor, and invited articles. The publication times for received to accepted (RA), received to published in press (RP1), and received to published in print (RP2) were retrieved and compared. Journal impact factor, specialty, and article level of evidence were recorded. Results: A total of 1040 articles were included with a mean number of 74.3 ± 38 (range, 35-182) articles analyzed per journal. The mean impact factor for the 14 journals was 3.6 ± 1 (range, 2.5-5.8). The overall median duration of time for RA, RP1, and RP2 were 119 (IQR, 78-165) days, 157 (IQR, 102-216) days, and 291 (IQR, 243-378) days across all 14 journals, respectively. Journal of Arthroplasty demonstrated the shortest median duration of time for RA and RP1, while International Orthopaedics demonstrated the shortest median duration of time for RP2. Clinical Journal of Sport Medicine demonstrated the longest median duration of time for RA and RP2, while the American Journal of Sports Medicine demonstrated the longest median duration of time for RP1. Level three studies, which included retrospective case-control and cohort study designs, demonstrated the shortest publication times, while sports medicine journals demonstrated the longest publication times for all periods. Conclusion: There was substantial variation in publication times across orthopaedic surgery journals which may impact accessibility to clinical insights.

Ulnar Resection Length: A Risk Factor for Nonunion in Ulnar Shortening Osteotomy.

BACKGROUND: Nonunion rates following ulnar shortening osteotomy (USO) are reported up to 18% with few known risk factors. While resection length is variable in practice, little is known about the prognostic implications on healing. The purpose of this study was to evaluate whether longer resection lengths increased the odds of nonunion. METHODS: A retrospective review was performed on patients who underwent an elective USO at a single institution over a 6-year period. Demographic, social, comorbidity, and surgical data were reviewed. Ulnar resection length was obtained from operative notes and dichotomized into smaller (<5.5 mm) and larger (≥5.5 mm) groups. The primary outcome was the rate of nonunion. Univariate analyses and a multivariable logistic regression model were used to assess for significant predictors of nonunion. RESULTS: A total of 87 patients were included with a mean age of 45 years. Patient comorbidities included 12.6% with diabetes, 29.9% with an American Society of Anesthesiologists score of ≥ 3, 5.8% reporting current tobacco use, and 29.9% reporting former tobacco use. There were 55 patients (63.2%) with resection lengths < 5.5 mm and 32 patients (36.8%) with ≥ 5.5 mm resections. Multivariable analysis identified longer resection length (≥5.5 mm) and current tobacco use as independent risk factors for nonunion. Patients with a resection length of ≥ 5.5 mm had 20.2 times greater odds of nonunion compared with patients with smaller resections, and current smokers had 72.2 times greater odds of nonunion compared with nonsmokers. CONCLUSION: Longer ulnar resection length (≥5.5 mm) significantly increases the risk of nonunion following USO.

Suspensionplasty for Revision Thumb Carpometacarpal Osteoarthritis Surgery: Comparing Suture Button Suspensionplasty to Ligament Reconstruction and Tendon Interposition.

SUMMARY: Several surgical procedures have been described to treat thumb carpometacarpal osteoarthritis, including suture button suspensionplasty and ligament reconstruction and tendon interposition. To date, no single procedure has demonstrated clinical superiority. Suture button suspensionplasty has achieved favorable outcomes at 5 years in primary cases, but has not been validated in revision surgery. In this study, it was evaluated for revision of failed thumb carpometacarpal osteoarthritis surgery, and outcomes were compared to ligament reconstruction and tendon interposition outcomes. A retrospective chart review identified patients who underwent suture button suspensionplasty or ligament reconstruction and tendon interposition after failure of previous thumb carpometacarpal osteoarthritis surgery since 2010. Eighteen patients were included, with nine patients in each group. Eighteen patients had mean final follow-up of 35 months. There were two complications in the ligament reconstruction and tendon interposition group and none in the suture button suspensionplasty group. No patients required additional surgery. The suture button suspensionplasty group had an average visual analogue scale pain score improvement of 2.9, compared to 2.4 in the ligament reconstruction and tendon interposition group. Average final Quick Disabilities of the Arms, Shoulder and Hand questionnaire score was 15.1 in the suture button suspensionplasty group, compared to 22.6 in the ligament reconstruction and tendon interposition group. Mean operative time of 86.3 minutes in the suture button suspensionplasty group was significantly shorter than the 121-minute mean in the ligament reconstruction and tendon interposition group. Suture button suspensionplasty is an effective treatment option for revision of previous thumb carpometacarpal osteoarthritis surgery, with outcomes comparable to revision using ligament reconstruction and tendon interposition, and the added benefit of shorter operative times and early mobilization. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Platelet-Rich Plasma Versus Corticosteroid Injections for the Treatment of Mild-to-Moderate Carpal Tunnel Syndrome: A Markov Cost-Effectiveness Decision Analysis.

BACKGROUND: Platelet-rich plasma (PRP) or corticosteroid injections may be used to conservatively treat mild-to-moderate carpal tunnel syndrome (CTS). We evaluated the cost-effectiveness of PRP injections versus corticosteroid injections for the treatment of mild-to-moderate CTS. METHODS: Markov modeling was used to analyze the base-case 45-year-old patient with mild-to-moderate CTS, unresponsive to conservative treatments, never previously treated with an injection or surgery, treated with a single injection of PRP, or methylprednisolone/triamcinolone 40 mg/mL. Transition probabilities were derived from level-I/II studies, utility values from the Tufts University Cost-Effectiveness Analysis Registry reported using visual analog scale (VAS), Boston Carpal Tunnel Questionnaire Symptom severity (BCTQ-S), and Boston Carpal Tunnel Questionnaire Functional status (BCTQ-F), and costs from Medicare, published studies, and industry. Analyses were performed from healthcare/societal perspectives. Outcomes were incremental cost-effectiveness ratios (ICER) and net monetary benefits (NMB). Willingness-to-pay thresholds were $50 000 and $100 000. Deterministic/probabilistic sensitivity analyses were performed. RESULTS: From a healthcare perspective, compared to PRP injections, the ICER for corticosteroid injections measured by VAS: -$13.52/quality-adjusted-life-years (QALY), BCTQ-S: -$11.88/QALY, and BCTQ-F: -$16.04/QALY. PRP versus corticosteroid injections provided a NMB measured by VAS: $428 941.12 versus $375 788.21, BCTQ-S: $417 115.09 versus $356 614.18, and BCTQ-F: $421 706.44 versus $376 908.45. From a societal perspective, compared to PRP injections, the ICER for corticosteroid injections measured by VAS: -$1024.40/QALY, BCTQ-S: -$899.95/QALY, and BCTQ-F: -$1215.51/QALY. PRP versus corticosteroid injections provided a NMB measured by VAS: $428 171.63 versus $373 944.39, BCTQ-S: $416 345.61 versus $354 770.36, and BCTQ-F: $420 936.95 versus $375 064.63. CONCLUSIONS: PRP injections were more cost-effective than methylprednisolone/triamcinolone injections from healthcare and societal perspectives for mild-to-moderate CTS.

Outcomes associated with proton pump inhibitors and distal radius fractures: A post-hoc comparative analysis.

Long-term, high-dose, daily proton pump inhibitors (PPI) may impact outcomes associated with distal radius fractures (DRF). The hypothesis was that differences existed in patient demographics, but there existed no differences in injury patterns, interventions, post-operative complications, and patient-reported outcomes between patients not on a PPI and patients on a PPI with a DRF. METHODS: An IRB-approved, post-hoc analysis of patients with DRF from 2012 through 2018 was performed. Patients included were age ≥18 years, sustained a DRF, had completed medical and medication records, Quick Disabilities of the Arm, Shoulder and Hand (DASH) scores, Global Assessment of Functioning (GAF) scores, visual analogue scale (VAS) pain scores, and a minimum of 1-year follow-up. Patients were stratified into two cohorts. Cohort one patients had no prescription or over-the-counter PPI use (no PPI cohort). Cohort two patients had adherence to a long-term, high-dose, daily PPI (PPI cohort). RESULTS: Two hundred and eighty-one DRF patients were included. Of these 281 patients, 240 were in the no PPI cohort and 41 were in the PPI cohort. Patients in the PPI cohort had more median nerve injuries (12% versus 3%, p = 0.025) and radial shaft fractures (5% versus 0%, p = 0.020), less contralateral upper extremity injuries (0% versus 4%, p = 0.001), and more post-operative nonunions (7% versus 1%, p = 0.029) compared to patients in the no PPI cohort. CONCLUSIONS: Long-term, high-dose, daily PPI's may be associated with more median nerve injuries and radial shaft fractures, less contralateral upper extremity injuries, and more post-operative nonunions compared to DRF patients not on a PPI.

Influence of medical comorbidity and surgical indication on total elbow arthroplasty cost of care.

BACKGROUND: Movement toward providing value-based musculoskeletal care requires understanding the cost associated with surgical care as well as the drivers of these costs. The aim of this study was to investigate the effect of common medical comorbidities and specific total elbow arthroplasty (TEA) indications on reimbursement costs throughout the 90-day TEA episode of care. The secondary aim was to identify the drivers of these costs. METHODS: Administrative health claims for patients who underwent orthopedic intervention between 2010 and 2020 were queried using specific disease classification and procedural terminology codes from a commercially available national database of 53 million patients. Patients with commercial insurance were divided into various cohorts determined by different surgical indications and medical comorbidities. The reimbursement costs of the surgical encounter, 89-day postoperative period, and total 90-day period in each cohort were evaluated. The cost drivers for the 89-day postoperative period were also determined. Analyses were performed using descriptive statistics and the Kruskal-Wallis test for comparison. RESULTS: A total of 378 patients who underwent TEA were identified. The mean reimbursement cost of the surgical encounter ($13,393 ± $8314) did not differ significantly based on patient factors. The mean reimbursement cost of the 89-day postoperative period ($4232 ± $2343) differed significantly when stratified by surgical indication (P < .0001) or by medical comorbidity (P < .0001). The indication of rheumatoid arthritis ($4864 ± $1136) and the comorbidity of chronic kidney disease ($5873 ± $1165) had the most expensive postoperative period. In addition, the total 90-day reimbursement cost ($16,982 ± $4132) differed significantly when stratified by surgical indication (P = .00083) or by medical comorbidity (P < .0001), with the indication of acute fracture ($18,870 ± $3971) and the comorbidity of chronic pulmonary disease ($19,194 ± $3829) showing the highest total 90-day cost. Inpatient costs related to readmissions represented 38% of the total reimbursement cost. The overall readmission rate was 5.0%, and the mean readmission cost was $16,296. CONCLUSION: TEA reimbursements are significantly influenced by surgical indications and medical comorbidities during the postoperative period and the total 90-day episode of care. As the United States transitions to delivering value-based health care, the need for surgeons and policy makers to understand treatment costs associated with different patient-level factors will expand.