Nearly All Peer-to-Peer Reviews for CT and MRI Prior Authorization Denials for Orthopedic Specialists Are Approved.

In the event of prior authorization denial, physicians may request peer-to-peer review, which may delay treatment and increase administrative burden. The purpose of this study was to quantify the approval rate of peer-to-peer review and evaluate its efficiency in the context of advanced imaging use in an orthopedic practice. Patients at a single outpatient orthopedic clinic initially receiving an insurance denial for computed tomography or magnetic resonance imaging requiring peer-to-peer review from March to December 2022 were prospectively enrolled. Characteristics of the request, peer-to-peer review, and the reviewer and dates in the process were collected. If the study was approved after peer-to-peer review, the date of the imaging study and brief results were recorded. A total of 62 denials were included. One denial was approved prior to peer-to-peer review. Fifty-eight (of 61, 95.1%) reviews were approved, of which 51 (of 58, 87.9%) studies were completed by patients. Reviewers were always physicians (61 of 61, 100%), but of those whose specialty was known, none were orthopedic surgeons. Forty-four of 61 (72.1%) reviewers reported reviewing clinical notes in advance. The median number of days from visit to peer-to-peer review was 9.0 (interquartile range, 7.0-13.25). The median number of days from visit to imaging center appointment was 13.5 (interquartile range, 9.0-20.75) for approved studies. Of the 51 approved studies completed by patients, the results of 38 (74.5%) confirmed the suspected diagnosis. In an orthopedic specialty practice, almost all peer-to-peer reviews were approved, with the majority of the completed studies confirming the suspected diagnosis. Thus, patient care was delayed. Reform is crucial to improve the efficiency of the review process, especially in light of additional administrative and financial burden. [Orthopedics. 202x;4x(x):xx-xx.].

A review of upper extremity peripheral nerve injuries in throwing athletes.

Peripheral nerve injuries in the upper extremities may be common in throwing athletes as the throwing motion places extreme stress on the dominant arm. The combination of extreme stress along with repetitive microtrauma from throwing uniquely places the throwing athlete at elevated risk of upper extremity peripheral nerve injury. However, because symptoms can be nonspecific and frequently coexist with pathology in the upper extremity, the diagnosis of peripheral nerve injury is often delayed. Diagnosis of peripheral nerve injuries may require a combination of history and physical examination, diagnostic imaging, electrodiagnostic testing, and diagnostic ultrasound-guided injections. The primary management should include physical therapy focusing on throwing mechanics and kinetic chain evaluation. However, some athletes require surgical intervention if symptoms do not improve with conservative management. The purpose of this focused narrative review is to highlight upper extremity peripheral neuropathies reported in throwing athletes and to provide an overview of the appropriate clinical diagnosis and management of the throwing athlete with a peripheral nerve injury.

Pudendal Neurapraxia After Proximal Hamstring Repair: A Case Report.

CASE: The pudendal nerve lies near the origin of the hamstring muscles, placing it at increased risk of injury during proximal hamstring tendon repair. In this study, we report on a 56-year old man who experienced intermittent unilateral testicular pain after a proximal hamstring tendon repair presumably due to pudendal nerve neurapraxia. At the 1-year follow-up, he continued to experience discomfort in the pudendal nerve distribution but reported significant improvement in symptoms and complete resolution of hamstring pain. CONCLUSION: Although the risk of pudendal nerve injury during proximal hamstring tendon repair is rare, surgeons should be aware of this potential complication.

Suggested Curricular Guidelines for Musculoskeletal and Sports Medicine in Physical Medicine and Rehabilitation Residency Training.

ABSTRACT: A sports medicine physician manages musculoskeletal (MSK) injuries and sport-related medical and MSK conditions of patients of all ages and abilities. Physical medicine and rehabilitation physicians (physiatrists) must be adequately trained to provide this care for all patients including, but not limited to, athletes participating in organized sports, the weekend warrior as well as athletes with disabilities. Accreditation Council of Graduate Medical Education core requirements and basic guidelines help physiatry residency training programs develop and implement residency curriculums. The goal of this article is to provide suggested curricular guidelines to optimize physiatrist training in MSK and sports medicine.

A pilot study to evaluate micro-fragmented adipose tissue injection under ultrasound guidance for the treatment of refractory rotator cuff disease in wheelchair users with spinal cord injury.

CONTEXT/OBJECTIVES: Wheelchair users with chronic shoulder pain have few options after conservative treatments fail. This pilot study's purpose was to establish safety and treatment effects of micro-fragmented adipose tissue (MFAT) injections under ultrasound guidance for treatment of refractory shoulder pain caused by rotator cuff disease in wheelchair users with spinal cord injury (SCI) to prepare for a larger trial. DESIGN: Pilot clinical trial. SETTING: Rehabilitation hospital outpatient clinic. PARTICIPANTS: Ten wheelchair users with chronic SCI who had moderate-to-severe shoulder pain caused by refractory rotator cuff disease (diagnosed via ultrasound) for greater than 6 months. INTERVENTIONS: Ultrasound-guided injections of MFAT into the pathologic rotator cuff tendons and other abnormal shoulder structures (e.g. acromioclavicular and glenohumeral joints; subacromial bursa). OUTCOME MEASURES: 6- and 12-month changes in 11-point Numerical Rating Scale (NRS); Wheelchair User's Shoulder Pain Index (WUSPI); Brief Pain Inventory pain interference items (BPI-I7); Patient Global Impression of Change (PGIC); ultrasound and physical exams; and adverse events. CONCLUSIONS: There were no significant adverse events throughout the study period. WUSPI, NRS, and BPI-I7 scores were significantly lower 6 and 12 months post-procedure (P < .05). Of those who remained in the trial, clinically meaningful changes (≥30% decrease) in WUSPI, NRS, and BPI-I7 scores were observed in 77.8%, 77.8%, and 66.7% of participants, respectively. All but one participant reported improvement in clinical status. MFAT injection under ultrasound guidance is potentially a safe and efficacious treatment for refractory shoulder pain caused by rotator cuff disease in wheelchair users with SCI. A larger, randomized controlled trial has been initiated.Trial registration: ClinicalTrials.gov identifier: NCT03167138.

Autologous, micro-fragmented adipose tissue as a treatment for chronic shoulder pain in a wheelchair using individual with spinal cord injury: a case report.

Introduction: Shoulder pain is common in persons with chronic spinal cord injury (SCI), with a prevalence reported as high as 70%. Current treatment of shoulder pain includes conservative measures such as physical therapy, pain medications, patient education, injections, and assistive devices. When conservative treatments fail, shoulder surgery is often the next option. Unfortunately, outcomes after shoulder surgery in persons with SCI are limited and conflicting. Case presentation: This is a case of a 54-year-old right-handed male with T10 complete SCI (duration of injury = 10 years) who had a complaint of right-sided shoulder pain for 3 years. The individual used a manual wheelchair as his primary means of mobility and was an avid weight-lifter. Physical examination and MRI demonstrated a rotator cuff tear and degenerative changes of the acromioclavicular joint. He was previously managed conservatively with physical therapy and intermittent corticosteroid injections but failed to improve. He was enrolled in an IRB approved study and underwent an ultrasound-guided injection with autologous, micro-fragmented adipose tissue (MFAT) and ultimately received improvements in pain and function that were maintained a year after treatment. Discussion: To our knowledge, this is the first reported case of treatment of chronic refractory shoulder pain in a person with SCI using MFAT. Complete relief from pain was maintained at the 1-year follow-up. Injection of MFAT under ultrasound guidance is an effective and promising treatment for chronic refractory shoulder pain in upper limb-dependent persons with SCI and warrants further research.

A Novel, Nonoperative Treatment Demonstrates Success for Stiff Total Knee Arthroplasty after Failure of Conventional Therapy.

INTRODUCTION: Certain patients continue to suffer from knee stiffness following total knee arthroplasty (TKA) despite undergoing conventional therapies. Astym therapy to these patients may offer an effective, safe, nonoperative treatment. This study evaluates the effects of Astym therapy upon (1) range of motion and (2) subjective functional improvements in post-TKA patients who suffered from stiffness recalcitrant to other nonoperative interventions. METHODS: Twenty-three post-TKA patients (29 knees) who had recalcitrant knee stiffness were included in this study. Pre- and post-Astym improvements in range of motion and Knee Society scores were compared. We analyzed knees based on the presence of flexion deficit or contracture. Further stratification was made into knees that received Astym therapy before and after a 3-month period of standard rehabilitation. Differences in range of motion from pre- to post-Astym were evaluated by measuring (1) degree of flexion deficit or contracture and (2) total arc of passive motion. Improvements in subjective functional status were determined by evaluating Knee Society scores pre- and post-Astym therapy. A two-tailed Student t-test was used to compare weighted mean differences from pre- to post-Astym for the above parameters. RESULTS: The mean flexion deficit improved significantly (p < 0.001) in all patients after Astym therapy. The mean flexion contracture improved significantly in (p = 0.001) in 91% of patients after Astym therapy. Knees with flexion deficits or contractures both improved in total arc of motion when compared with pretherapy. Overall, patients who underwent treatment with Astym therapy reported significant mean improvements in both Knee Society objective (80 vs. 57 points; p < 0.0001) and functional scores (80 vs. 54 points; p = 0.0003) when compared with their pretherapy objective and functional scores. No harms were reported. CONCLUSION: Astym therapy is a novel, nonoperative treatment that may be an effective treatment option for post-TKA patients suffering from persistent knee stiffness. Further studies are needed to validate this intervention as a part of cost-effective, standard treatment after TKA.