Low-Income, Poor Physical Health, Poor Mental Health, and Other Social Risk Factors Are Associated With Decreased Access to Care in Patients With Carpal Tunnel Syndrome.

BACKGROUND: Carpal Tunnel Syndrome (CTS) is associated with a significant personal and societal burden. Evaluating access to care can identify barriers, limitations, and disparities in the delivery of healthcare services in this population. The purpose of this study was to evaluate access to overall healthcare and healthcare utilization among patients with CTS. METHODS: This is a retrospective cohort study conducted with the All of Us database. Patients diagnosed with CTS that completed the access to care survey were included and matched to a control group. The primary outcomes were access to care across 4 domains: (1) delayed care, (2) could not afford care, (3) skipped medications, and (4) over 1 year since seeing provider. Secondary analysis was then performed to identify patient-specific factors associated with reduced access to care. RESULTS: In total, 7649 patients with CTS were included and control matched to 7649 patients without CTS. In the CTS group, 33.7% (n = 2577) had delayed care, 30.4% (n = 2323) could not afford care, 15.4% (n = 1180) skipped medications, and 1.6% (n = 123) had not seen a provider in more than 1 year. Within the CTS cohort, low-income, worse physical health, and worse mental health were associated with poor access to care. CONCLUSION: Patients experience notable challenges with delayed care, affordability of care, and medication adherence regardless of having a diagnosis of CTS. Targeted interventions on modifiable risk factors such as low income, poor mental health, and poor physical health are important opportunities to improve access to care in this population.

Evaluating the Need for Simultaneous Carpal Tunnel Release With Forearm Fasciotomy.

PURPOSE: The need to include simultaneous carpal tunnel release (sCTR) with forearm fasciotomy for acute compartment syndrome (ACS) or after vascular repair is unclear. We hypothesized that sCTR is more common when: 1) fasciotomies are performed by orthopedic or plastic surgeons, rather than general or vascular surgeons; 2) ACS occurred because of crush, blunt trauma, or fractures rather than vascular/reperfusion injuries; 3) elevated compartment pressures were documented. We also sought to determine the incidence of delayed CTR when not performed simultaneously. METHODS: Retrospective chart review identified patients who underwent forearm fasciotomy for ACS or vascular injury over a period of 10 years. Patient demographics, mechanism of ACS or indication for fasciotomy, surgeon subspecialty, compartment pressure measurements, inclusion of sCTR, complications, reoperations, and timing and method of definitive closure were analyzed. Logistic regression modeling was used to analyze predictors associated with delayed CTR. RESULTS: Fasciotomies were performed in 166 patients by orthopedic (63%), plastic (28%), and general/vascular (9%) surgeons. Orthopedic and plastic surgeons more frequently performed sCTR (67% and 63%, respectively). A total of 107 (65%) patients had sCTR. Fasciotomies for vascular/reperfusion injury were more likely to include sCTR (44%) compared with other mechanisms. If not performed simultaneously, 11 (19%) required delayed CTR at a median of 42 days. ACS secondary to fracture had the highest rate of delayed CTR (35%), and the necessity of late CTR for fractures was not supported by the logistic regression model. Residual hand paresthesias were less frequent in the sCTR group (6.5% vs 20%). Overall complication rates were similar in both groups (63% sCTR vs 70% without sCTR). CONCLUSION: When sCTR is excluded during forearm fasciotomy, 19% of patients required delayed CTR. This rate was higher (35%) when ACS was associated with fractures. Simultaneous CTR with forearm fasciotomy may decrease the incidence of residual hand paresthesias and the need for a delayed CTR. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognosis IV.

Sensitivity and Accuracy of High-Resolution Ultrasound for Diagnosis of Flexor Tendon Repair Integrity.

BACKGROUND: The authors examined whether ultrasound sensitivity, specificity, and accuracy in identifying intact repairs or flexor tendon gapping after zone 2 repair are affected by the number of suture strands crossing the repair or gap or imaging modality (static versus dynamic). METHODS: A total of 144 fresh-frozen cadaveric digits (thumbs excluded) were randomized to either an intact repair (0-mm gap) or simulated failed repair (4-mm gap), as well as to either a two- or eight-strand locked-cruciate repair of a zone 2 flexor digitorum profundus tendon laceration using 4-0 Fiberwire. Examinations were performed by a blinded musculoskeletal ultrasonographer in static and dynamic modes using an 18-MHz transducer. Gaps were remeasured after scanning, and the final gap width recorded. McNemar exact test was used to determine whether there were differences in sensitivity, specificity, and accuracy affected by modality (static versus dynamic), and chi-square test was used to compare sensitivity, specificity, and accuracy between number of strands (two versus eight) crossing the intact repair or repair gap (≥4 mm). RESULTS: Sensitivity, specificity, and accuracy improved with increased number of suture strands crossing the repair or gap (eight versus two), irrespective of modality (static versus dynamic), and dynamic compared with static scanning modes, irrespective of number of suture strands crossing the repair or gap site. CONCLUSIONS: The most sensitive and accurate means of assessing flexor tendon repair integrity and gapping were seen using the dynamic scanning mode. Increased number of suture strands did not negatively affect sensitivity, specificity, or accuracy, regardless of scanning mode (dynamic or static).

Comparative sensitivity and accuracy of 24 vs. 18 MHz ultrasound probes for the diagnosis of flexor tendon repair integrity.

Purpose: To determine whether a 24 MHz transducer significantly improves sensitivity, specificity and accuracy in evaluating flexor tendon repair integrity compared with an 18 MHz transducer. Methods: One hundred and twelve cadaveric digits were randomised to an intact repair or simulated 'failed' repair, and to a two- or eight-strand repair of a flexor digitorum profundus laceration. A blinded sonologist evaluated specimens in static mode using 18 and 24 MHz transducers. Gaps were remeasured after scanning, and final gap width recorded. McNemar's exact test calculated differences between sensitivity, specificity and accuracy, and chi-squared test to compare sensitivity, specificity and accuracy between number of strands (2 vs. 8) and repair gap (≥4 mm). Results: The 24 MHz transducer had higher sensitivity (81 vs. 59%), lower specificity (67 vs. 70%) and higher overall accuracy (74 vs. 64%), than the 18 MHz transducer. The difference for sensitivity was significant (P = 0.011), but not differences for specificity and overall accuracy (P > 0.05). Pearson's correlation (r = 0.61) demonstrated a moderate-to-strong positive correlation between measured and true gap sizes. Increased number of suture strands (2 vs. 8) did not impair sensitivity, specificity nor accuracy. Discussion: Ultrasound may tend to overestimate gap width, and a slight risk that some intact repairs, or those with small, clinically insignificant gaps may undergo surgical exploration that may not be indicated. Conclusions: A 24 MHz transducer is a more sensitive and accurate transducer for assessing flexor tendon repair integrity and measuring small gaps.

Time-Dependent Change in Carpal Tunnel Cross-Sectional Area and Transverse Carpal Ligament Thickness Using Serial Magnetic Resonance Imaging Studies-An Anatomical Study.

PURPOSE: Idiopathic carpal tunnel syndrome (CTS) is a common compressive neuropathy. Aging and female sex are risk factors, but the reasons are unclear. The purpose of this study was to evaluate whether identifiable radiographic changes resulting in a decrease in carpal tunnel area (CTA) over time exist. METHODS: A database search of a multicenter, academic, tertiary institution from 1998 to 2021 identified 433 patients with serial wrist magnetic resonance images (MRI) at least 5 years apart. Fifty-six met the inclusion criteria with adequate films to measure CTA and transverse carpal ligament (TCL) thickness at the same slice location-the carpal tunnel inlet, hook of the hamate, and carpal tunnel outlet-independently by two observers who were blinded to each other's measurements. Rates for the change in CTA and TCL thickness were calculated at all three locations. RESULTS: Thickness of the TCL increased, whereas that of the CTA decreased over time. Inlet CTA decreased by 0.9 mm2 per year (95% CI: 0.34-1.5), outlet CTA decreased by 1.8 mm2 per year (95% CI: 1.2-2.5), and CTA at the hook of the hamate decreased by 1.6 mm2 per year (95% CI: 1.0-2.0 per year). The TCL thickened by 0.02 mm per year at all three sections. Taller patients had a decreased rate of CTA loss. CONCLUSIONS: In this select cohort, TCL thickened and CTA decreased with time. TCL thickening accounted for about half of the variation in CTA, suggesting that this is a possible contributor to this change. Hypertrophy of the carpal tunnel floor may account for the remaining variation in CTA. The question of whether these results are reliable and generalizable to the general population, or a major influence in the pathophysiology of CTS, is unknown. CLINICAL RELEVANCE: Small decreases in CTA and thickening of the TCL occur with aging. Whether this is a contributing factor in the development of CTS requires further study.

Long-term Trends in Open vs Endoscopic Carpal Tunnel Release Among the Medicare Population in the United States.

BACKGROUND: Carpal tunnel release (CTR) surgery is the most common surgery billed to Medicare by hand surgeons. As such, the purpose of this study was to evaluate trends for CTR surgeries billed to Medicare from 2000 to 2020. METHODS: The publicly available Medicare Part B National Summary File from 2000 to 2020 was queried. For both open carpal tunnel release (OCTR) and endoscopic carpal tunnel release (ECTR), the number of procedures and total Medicare reimbursement were extracted. For year 2020, the specialty of the performing surgeon was recorded. Descriptive statistics were reported. RESULTS: A total of 3 429 471 CTR surgeries were performed in the Medicare population from 2000 to 2020. For these procedures, Medicare paid surgeons over $1.23 billion. During this period, there was a 101.8% increase in annual CTR procedures (91 130 in 2000, 183 911 in 2020). Further, annual volume of ECTR increased by 456.2%, and accounted for an increasing percentage of total CTR procedures (9.1% in 2012, 25.2% in 2020). The average adjusted Medicare reimbursement per procedure decreased by 1.5% for OCTR, and decreased by 11.6% for ECTR. In 2020, orthopedic surgeons performed 85.1% of CTR procedures. CONCLUSIONS: The volume of CTR surgeries among the Medicare population has increased from 2000 to 2020, and ECTR is accounting for a growing proportion of surgeries. When adjusted for inflation, average reimbursement has decreased, with a greater decrease among ECTR. Orthopedic surgeons perform most of such surgeries. These trends are important to assure adequate resource allocation as treating carpal tunnel becomes more common among the aging Medicare population.

Inter- and Intra-observer Agreement of Visual Estimation, Goniometric and Radiographic Measurement of Passive Thumb Metacarpophalangeal Joint Hyperextension.

Background: Reliable methods for measuring range of motion is important for hand therapists. Currently, there is no gold standard for the measurement of thumb metacarpophalangeal joint (MCPJ) hyperextension. We hypothesised that visual and goniometric measurements of thumb MCPJ hyperextension vary greater than 10° from radiographic measurements, and between observers. Methods: Twenty-six fresh-frozen hands were measured by a senior orthopaedic resident and fellowship trained hand surgeon. Passive thumb MCPJ hyperextension was measured by visual estimation, goniometry and axis measurement on a lateral thumb radiograph. Raters were blinded to each other's and their own prior measurements. Descriptive statistics were recorded for measurement type and inter-observer agreement using a two-way intra-class correlation coefficient (ICC). Intra-observer agreement was calculated using concordance correlation coefficient (CCC). Bland-Altman plots identified trends, systemic differences or potential outliers. Results: Mean measurements for both raters were similar for visual estimation and radiographic measurements. Mean goniometric measurements were twice as high for Rater B, and closer to radiographic measurements. For both raters, mean radiographic measurements were 10° greater than the other two methods. For inter-rater agreement, measurements were within 10° most frequently with radiographic measurement, then visual estimates, and least by goniometer measurements. Rater B had better agreement comparing visual and goniometric to radiographic measurements. Conclusions: Radiographic measurement has the best inter-observer agreement and precision for evaluating passive thumb MCPJ hyperextension, especially considering adjunct corrective procedures when performing a soft-tissue basal joint arthroplasty. Rater experience improves precision, but there is still poor agreement between visual estimates and goniometer measurements compared to radiographic measurements, as the former two underestimate hyperextension by 10°. Development of a standard method of clinical measurement is needed to improve reliability.

Charting Trends in Medicare Reimbursement for Lower Extremity Imaging.

Background: Medicare reimbursement is rapidly declining in many specialties. An in-depth analysis of Medicare reimbursement for routinely performed diagnostic imaging procedures in the United States is warranted. Purpose/Hypothesis: The purpose of this study was to evaluate Medicare reimbursement trends for the 20 most common lower extremity imaging procedures performed between 2005 and 2020, including radiographs, computed tomography (CT), and magnetic resonance imaging (MRI). We hypothesized that Medicare reimbursement for imaging procedures would decline substantially over the studied period. Study Design: Cohort study. Methods: The Physician Fee Schedule Look-up Tool from the Centers for Medicare and Medicaid Services was analyzed for reimbursement rates and relative value units associated with the top 20 most utilized Current Procedural Terminology (CPT) codes in lower extremity imaging from 2005 to 2020. Reimbursement rates were adjusted for inflation and listed in 2020 US dollars using the US Consumer Price Index. To compare year-to-year changes, the percentage change per year and compound annual growth rate were calculated. A 2-tailed t test was used to compare the unadjusted and adjusted percentage change over the 15-year period. Results: After adjusting for inflation, mean reimbursement for all procedures decreased by 32.41% (P = .013). The mean adjusted percentage change per year was -2.82%, and the mean compound annual growth rate was -1.03%. Compensation for the professional and technical components for all CPT codes decreased by 33.02% and 85.78%, respectively. Mean compensation for the professional component decreased by 36.46% for radiography, 37.02% for CT, and 24.73% for MRI. Mean compensation for the technical component decreased by 7.76% for radiography, 127.66% for CT, and 207.88% for MRI. Mean total relative value units decreased by 38.7%. The commonly billed imaging procedure CPT 73720 (MRI lower extremity, other than joint, with and without contrast) had the greatest adjusted decrease of 69.89%. Conclusion: Medicare reimbursement for the most billed lower extremity imaging studies decreased by 32.41% between 2005 and 2020. The greatest decreases were noted in the technical component. Of the modalities, MRI had the largest decrease, followed by CT and then radiography.

What are the 2-year survivorship outcomes of custom hemipelvis reconstruction after hemipelvectomy and revision arthroplasty? The evolution of a custom ilium "monoflange".

BACKGROUND: Innovations in machined and three-dimensionally (3D) printed implant technology have allowed for customized complex pelvic reconstructions. We sought to determine the survivorship of custom hemipelvis reconstruction using ilium-only fixation at a minimum 2-year follow-up, their modes of failure, and the postoperative complications resulting from the procedure. METHODS: A retrospective review identified 12 consecutive patients treated with custom hemipelvis reconstruction. Indications for surgery were bone tumor requiring internal hemipelvectomy (four patients) or multiply revised, failed hip arthroplasty with massive bone loss (eight patients). All patients had a minimum of 2-year follow-up with a mean of 60.5 months. Kaplan-Meier survivorship analysis was determined for all patients. Postoperative complications and reoperations were categorized for all patients. RESULTS: At a mean of 60.5 months, 11 of 12 patients had retained their custom implant (92% survivorship). One implant was removed as a result of an acute periprosthetic joint infection (PJI). There were no cases of aseptic loosening. Seven of 12 patients required reoperation (three PJI; two dislocations; two superficial wound complications), with five patients going on to reoperation-free survival. CONCLUSIONS: Custom hemipelvis reconstruction utilizing an ilium monoflange provides durable short-term fixation at a minimum 2-year follow-up. Reoperation for infection and dislocation is common.

Does Laterality Matter? The Effect of Unilateral v. Bilateral Sacroiliac Screw Fixation on Personal Hygiene.

STUDY DESIGN: Retrospective comparative analysis of prospective cohort. OBJECTIVE: To determine whether sacroiliac (SI) screw fixation ipsilateral to hand dominance compared to bilateral fixation impacts personal hygiene (wiping) after toileting. METHODS: Inclusion criteria were adult spinal deformity (ASD) patients with long arthrodesis (≥T12-pelvis) who had undergone primary unilateral or bilateral SI fixation with a minimum of 2-years-follow-up. RESULTS: 117 consecutive patients were included and separated into 2 groups: bilateral SI fixation (BL, n = 61) and unilateral SI fixation (UNI, n = 56), with no difference in age. Of UNI patients, 10.7% (6) performed personal hygiene with a different hand after surgery, compared to 6.6% (4) of patients who received BL fixation (P = 0.422). All UNI patients who switched hands were right-hand dominant, and 5/6 received right-sided fixation. There was no statistical difference found between number of levels fused (<8, 9-11, or >11 levels) and changes in personal hygiene habits. Over a third of patients from both groups had difficulty performing personal hygiene after fusion (UNI = 39.3% BL = 36.1%, P = 0.719). CONCLUSION: SI screws increase the difficulty of performing personal hygiene; yet, the side of unilateral screws does not significantly change personal hygiene habits when compared to bilateral screw placement. Moreover, the length of the construct does not have a significant impact on ability to perform personal hygiene, cause changes in habits, or require the assistance of another individual. However, among our sample of individuals, bilateral fixation did result in a higher rate of revision instrumentation.

Open Excision of Dorsal Wrist Ganglion.

Background: Ganglion cysts are benign soft-tissue tumors that are most commonly found in the wrist. Within the wrist, 60% to 70% of ganglion cysts occur on the dorsal side and 20% to 30% occur on the volar side1. Although ganglia arise from multiple sites over the dorsal wrist, dorsal ganglia most commonly originate at the scapholunate joint2,3. Open excision is the standard surgical treatment for dorsal wrist ganglia. This procedure is considered when symptoms such as pain and range-of-motion deficits begin to impact activities of daily living. Description: Open excision of a dorsal wrist ganglion is commonly performed with the patient under general anesthesia or a regional block. The patient is placed in the supine position, and a tourniquet is applied on the affected upper limb. After outlining the periphery of the palpable ganglion, the surgeon makes a transverse or longitudinal incision over the ganglion. The surgeon then begins a deep dissection, dissecting through the subcutaneous tissue and isolating the ganglion while avoiding any rupture, if possible. Once the cyst has been identified, extensor tendons surrounding the cyst are retracted and the cyst and stalk are mobilized. The cyst and stalk are subsequently excised, and the wound is closed4. Alternatives: Alternative treatments for dorsal wrist ganglia include nonoperative interventions such as observation, aspiration, controlled rupture, and injection. Operative treatments include arthroscopic and open dorsal wrist ganglion resections. Rationale: Although nonoperative treatment can produce successful outcomes, the various modalities have been associated with recurrence rates ranging from 15% to 90%4. As a result, surgical excision remains the gold standard of treatment and is typically indicated when weakness, pain, and limited range of motion interfere with activities of daily living. Among surgical interventions, arthroscopic excision is a minimally invasive procedure that has become more common because of the reduced scarring and faster recovery5. However, open excision, which does not involve complex equipment, is regarded as the standard among surgical treatments. Although the rates of recurrence for arthroscopic versus open dorsal ganglion excision are similar, arthroscopic excision is less effective with regard to pain relief5,6. This difference in pain relief could potentially be the result of the neurectomy of the posterior interosseous nerve in an open excision. In contrast, an arthroscopic procedure may provide less relief of pain from the posterior interosseous nerve stump attaching to the scarred capsule5. Expected Outcomes: Open excision of a dorsal wrist ganglion is a safe, reliable procedure. The recurrence rate after open excision is similar to that after arthroscopic excision and significantly lower recurrence than that after ganglion cyst aspiration6,7. Additionally, not all ganglion cysts can be aspirated. In a retrospective study assessing the risk of recurrence after open excision of ganglion cysts in 628 patients, researchers reported a recurrence rate of 4.1% among the 341 who underwent open dorsal ganglion excision. Furthermore, the authors reported male sex and less surgeon experience as significant risk factors for cyst recurrence8. In a study assessing outcomes of open dorsal ganglion excision in 125 active-duty military personnel, researchers reported a recurrence rate of 9%. More notably, the researchers found persistent pain at 4 weeks postoperatively in 14% of the participants. The authors recommended that patients whose daily activities require forceful wrist extension, such as athletes and military personnel, should be counseled on the potential functional limitations and residual pain from open dorsal wrist ganglion excision9. Important Tips: When conducting an open excision, it is beneficial to identify the stalk of the cyst, allowing the surgeon to excise the complete ganglion complex and prevent recurrence.For large cysts that adhere to the surrounding soft tissue, it is helpful to rupture the ganglion in order to facilitate an easier deep dissection.Excising the scapholunate interosseous ligament could possibly lead to scapholunate dissociation and instability.The posterior interosseous nerve courses past the 4th dorsal compartment and may be resected during the deep dissection.

Tendon Sheath Incision for Surgical Treatment of Trigger Finger.

Background: Open trigger finger release is an elective surgical procedure that serves as the gold standard treatment for trigger digits. The aim of this procedure is to release the A1 pulley in a setting in which the pulley is completely visible, ultimately allowing the flexor tendons that were previously impinged on to glide more easily through the tendon sheath. Although A1-or the first annular pulley-is the site of triggering in nearly all cases, alternative sites include A2, A3, and the palmar aponeurosis1. Description: Typically, the surgical procedure can be conducted in an outpatient setting and can vary in duration from a few minutes to half an hour. The surgical procedure involves the patient lying in the supine position with the operative hand positioned to the side. A small incision, ranging from 1 to 1.5 cm, is made on the volar side of the hand, just proximal to the A1 pulley in the skin crease in order to minimize scarring. Once the underlying neurovascular structures are exposed, the A1 pulley is released longitudinally at least to the level of the A2 pulley, followed by decompression of the flexor tendons that were previously impinged on. In order to confirm the release, the patient is asked to flex and extend the affected finger. The wound is irrigated and closed once the release is confirmed by both the patient and surgeon. Alternatives: Aside from an open release, trigger finger can be treated nonoperatively with use of splinting and corticosteroid injection. Alternative operative treatments include a percutaneous release, which involves the use of a needle to release the A1 pulley2. Trigger finger can initially be treated nonoperatively. If unsuccessful, surgical intervention is considered the ultimate remedy2. Rationale: Because of their efficacious nature, corticosteroid injections are indicated preoperatively, particularly in non-diabetic patients3. Splinting is often an appropriate treatment option in patients who wish to avoid a corticosteroid injection1. However, if nonoperative treatment modalities fail to resolve pain and symptoms, surgical intervention is indicated2. In comparison with a percutaneous trigger finger release, an open release provides enhanced exposure and may be safer with respect to avoiding iatrogenic neurovascular injury2. However, in a randomized controlled trial, Gilberts et al. found no difference in the rates of recurrence when comparing open versus percutaneous trigger finger release4. Expected Outcomes: With reported success rates ranging from 90% to 100%, the open release of the A1 pulley is considered a common procedure associated with minimal complications2. Complications of the procedure were assessed in a retrospective analysis of 43 patients who underwent 78 open trigger releases performed by 1 surgeon. In that study, the authors reported a minor complication rate of 28% and a major complication rate of 3%5. Specifically, the 2 major complications noted by the authors were a synovial fistula and a proximal interphalangeal joint arthrofibrosis. In a larger study that included 543 patients who underwent 795 open trigger releases, the authors reported a minor complication rate of 9.6% and major complication rate of 2.4%6. Furthermore, the most common complications involved persistent stiffness, swelling, or pain. In that analysis, the authors suggested that sedation, male gender, and general anesthesia may be associated with greater risk6. Important Tips: At the discretion of the surgeon, a longitudinal, transverse, or oblique incision is made directly on top of the tendon at the level of the metacarpophalangeal joint, which is the preferred incision site because it provides maximal accessibility to the A1 pulley.Local anesthesia is preferred because it allows the patient and surgeon to confirm the release immediately.If conducting an open trigger release on the thumb, the surgeon should identify and protect the radial digital nerve, which courses directly over the A1 pulley. Acronyms and Abbreviations: MCP = metacarpophalangeal.

Medicare Payment for Orthopaedic Oncology Procedures Over the Past 20 Years.

BACKGROUND: Medicare payment has been examined in a variety of medical and surgical specialties. This study examines Medicare payment in the subspecialty of orthopaedic oncology. METHODS: The Physician Fee Schedule Look-up Tool was used to obtain payment information from 2000 to 2020 for procedures related to orthopaedic oncology billed to Medicare. RESULTS: For the 38 included orthopaedic oncology procedures, inflation-adjusted Medicare payment decreased an average of 13.6% overall from 2000 to 2020. After adjusting for inflation, the payment for procedures related to spine and pelvis increased by 7.6%, procedures relating to limb salvage increased by 14.6%, procedures associated with the surgical management of complications decreased by 26.9%, and procedures relating to metastatic disease management decreased by 34.8%. CONCLUSION: Medicare payment has declined by 13.6% from 2000 to 2020. This variation in Medicare payment represents a difference in valuation of these procedures by the Centers for Medicare and Medicaid Services and could be used to direct healthcare policy.

Medical Scribes in an Orthopedic Sports Medicine Clinic Improve Productivity and Physician Well-Being.

Purpose: The purpose of this study is to examine the effects of scribe use on physicians, nurses, and patients in an orthopaedic sports medicine clinic. Methods: Surveys containing validated outcome measures relating to physician well-being and workplace satisfaction, among other variables, were used to assess the influence of medical scribes on clinic function. These surveys were collected for 8 months from all patients, nurses, and orthopaedic surgeons working in one orthopaedic sports medicine clinic. Time during a half-day clinic (i.e., 20 or more patients) was documented by surgeons after the last patient was seen. Results: The average time spent per half day of clinic was 104 minutes on nonscribe days and 25 minutes on scribe days. Additionally, the time spent documenting encounters per half day of clinic was 87 minutes on average without scribes and 26 minutes on average with scribes. The average surgeon single assessment numeric evaluation (SANE) score was 48.1 without scribes, and 89.3 with scribes. The overall assessment of the clinic by nurses was 73.4 out of 100 on average without scribes and 87.7 out of 100 on average with scribes. Patients did not report a significant change in rating of overall experience (4.7/5.0 with scribes and 4.8/5.0 without scribes, (P = .27) or wait time between scheduled appointment time and surgeon arrival (15.1 minutes with scribes and 18.1 minutes without scribes; P = .12). Conclusions: We found the use of scribes in a high-volume orthopaedic sports medicine clinic to have a favorable impact on physicians, nurses, and trainees. The use of a scribe also significantly reduced the time required by surgeons for documentation during clinic and at the end of each clinic day. Patients also reported no significant difference in patient clinic experience scores. Clinical Relevance: Orthopaedic surgeons spend a substantial amount of time on paperwork. The results of this study could provide information on whether the use of a scribe helps to reduce administrative burden on orthopedic surgeons.

Inflation-Adjusted Medicare Reimbursement Has Decreased for Orthopaedic Sports Medicine Procedures: Analysis From 2000 to 2020.

BACKGROUND: Decreases in Medicare reimbursement have been noted among many medical specialties. An in-depth analysis of the subspecialty of orthopaedic sports medicine is needed to determine changes in Medicare reimbursement in this field. PURPOSE/HYPOTHESIS: The purpose was to elucidate the trends in inflation-adjusted Medicare reimbursement for orthopaedic sports medicine procedures between 2000 and 2020. It was hypothesized that Medicare reimbursement decreased substantially during the study period. STUDY DESIGN: Economic decision and analysis; Level of evidence, 4. METHODS: The Physician Fee Schedule Look-up Tool was used to extract Medicare reimbursement information between 2000 and 2020 for 67 procedures related to orthopaedic sports medicine. These values were adjusted for inflation using the Consumer Price Index. The compound annual growth rate (CAGR) was calculated to measure the annual rate of change, and descriptive analyses were performed using the Student t test. RESULTS: Between 2000 and 2020, inflation-adjusted Medicare reimbursement for the 67 included procedures decreased by an average of 33% (CAGR = -2.2%; R 2 = 0.78). Reimbursement decreased for procedures related to the shoulder and elbow by 34% (CAGR = -2.3%; R 2 = 0.80), for hip-related procedures by 23% (CAGR = -1.4%; R 2 = 0.77), for knee-related procedures by 31% (CAGR = -2.0%; R 2 = 0.81), and for procedures relating to the foot and ankle by 38% (CAGR = -2.5%; R 2 = 0.79). CONCLUSION: Study findings indicated that inflation-adjusted Medicare reimbursement decreased substantially between 2000 and 2020 for orthopaedic sports medicine procedures, ranging from a 23% decrease for hip-related procedures to a 38% decrease for foot and ankle-related procedures. The results of this study could be used to provide further context for health care policy decisions and help ensure sustainable financial environments for orthopaedic sports medicine surgeon.

Talus Visualization in Ankle Fractures: How Much Are We Really Seeing?

BACKGROUND: Despite appropriate care, a subset of patients with ankle fractures has persistent pain. This condition may be associated with intra-articular pathology, which is present up to 65% of the time. PURPOSE: To quantify how much of the talus is visible through an open approach to a standard supination external rotation bimalleolar ankle fracture as a percentage of the entire weightbearing surface of the talus. STUDY DESIGN: Descriptive laboratory study. METHODS: Standard ankle approaches to lateral and medial malleolar fractures were performed in 4 cadaveric ankles from 2 cadavers. Osteotomies were made to simulate a supination external rotation bimalleolar ankle fracture based on the Lauge-Hansen classification. The visible segments of talar cartilage were removed. The tali were then exhumed, and the entire weightbearing superior portion of the talus was assessed and compared with the amount of cartilage removed by an open approach. The mean of the data points as well as the 95% confidence interval were calculated. RESULTS: Four ankle specimens from 2 cadavers were used for these measurements. The mean surface area of the talus was 14.0 cm2 (95% CI, 13.3-14.7 cm2), while the mean area visible via an open approach was 2.1 cm2 (95% CI, 0.5-3.6 cm2). The mean proportion of the talus visualized via an open approach was 14.8% (95% CI, 3.6-26.1%). CONCLUSION: These findings indicate that the true area of weightbearing talar surface visible during an open exposure may be less than what many surgeons postulate. CLINICAL RELEVANCE: Only a small fracture of the talus is visible via an open approach to the talus during fracture fixation. This could warrant arthroscopic evaluation of these injuries to evaluate and treat osteocondral lesions resulting from ankle fractures.

Primary Tritanium acetabular components have increased rates of radiolucency associated with inferior clinical outcomes at short-term follow-up.

INTRODUCTION: Cementless fixation is the standard for acetabular fixation in primary total hip arthroplasty (THA). There are various surface finishes thought to improve osteointegration, although literature regarding the long-term survival of some of these surfaces is limited. Regardless of design, primary stability is essential to allow for osteointegration. Previous studies have suggested an increased rate of radiolucency and compromised short-term functional outcomes using the Tritanium primary acetabular component (Stryker, Mahwah, NJ). The purpose of this study was to compare the primary Tritanium acetabular component to another contemporary acetabular component as a control group with an established clinical record. METHODS: 444 consecutive, primary THAs performed by a single surgeon from 2008 to 2012 were reviewed. Patients were included if they had a minimum 1-year follow-up. Implant survivorship and modified Harris Hip Scores (mHHS) were recorded for all patients at final follow-up. Radiographs were evaluated by 2 surgeons at 6 weeks, 1 year, and the most recent follow-up for evidence of radiolucency and migration. Components were considered to have evidence of radiographic lucency if they had radiolucency in 2 or more DeLee zones. RESULTS: 198 patients met criteria for inclusion (96 Pinnacle, 102 Tritanium). Average follow-up was 28 (12-72) months. At final follow-up 6.2% of the Pinnacle cups and 29.4% of the Tritanium cups had radiographic evidence of loosening (p < 0.01). The average mHHS for the Tritanium group was 83.1, and 88.4 for the Pinnacle group (p < 0.01). Radiographic evidence of loosening also correlated with a lower mHHS: 75.5 versus 86.4 (p < 0.01). In patients that received Tritanium cups without screw fixation 44.6% showed radiographic evidence of loosening versus 8% that received screw fixation (p < 0.01). In total, 6 patients in the Tritanium group required revision for aseptic loosening of the acetabular component. CONCLUSIONS: The 30% rate of radiographic loosening in the Tritanium group was significantly higher than the Pinnacle group and correlated with an inferior clinical outcome. Interestingly the use of screw augmentation was protective against radiographic evidence of loosening. This suggests that the Tritanium component may be prone to fibrous in-growth because of inadequate primary stability.

Proximal Humeral Replacement With Osteoarticular Allograft Prosthetic Composite in Failed Revision Total Elbow Arthroplasty With Marked Bone Loss.

Total elbow arthroplasty (TEA) procedures are becoming more prevalent with an associated increase in revision procedures. Revision TEA in the setting of marked bone loss poses a challenge for the treating surgeon. We present a viable surgical option for patients with extensive proximal humeral bone loss treated with proximal humerus osteoarticular allograft prosthetic composites prepared with intact rotator cuff, pectoralis, and deltoid soft tissue attachments along with a rehabilitative protocol and follow up. Revision techniques involving the use of strut allografts and allograft prosthetic composites have previously been described in the distal humerus, but none to our knowledge have been published regarding composite allograft replacement of the proximal humerus in in combination with a TEA.

Hand and Wrist Injuries in Men's and Women's National Collegiate Athletic Association Basketball.

BACKGROUND: Hand and wrist injuries (HWIs) are common in National Collegiate Athletic Association (NCAA) basketball players and can negatively affect performance. There is limited literature available on this topic. PURPOSE: To open a discussion on prevention strategies and encourage future research on HWIs in basketball athletes. STUDY DESIGN: Descriptive epidemiology study. METHODS: HWIs sustained by male and female NCAA basketball players during the 2009-2010 through 2013-2014 academic years and reported to the NCAA Injury Surveillance Program (NCAA-ISP) database were utilized to characterize the epidemiology thereof. Rates and distributions of HWIs were identified within the context of mechanism of injury, injury recurrence, and time lost from sport. RESULTS: Over the 5-year period, 81 HWIs in women and 171 HWIs in men were identified through the NCAA-ISP database. These were used to estimate 3515 HWIs nationally in women's basketball athletes and 7574 HWIs nationally in men's basketball athletes. The rate of HWIs in women was 4.20 per 10,000 athlete-exposures (AEs) and in men was 7.76 per 10,000 AEs, making men 1.85 times more likely to sustain HWIs compared with women. In men, HWIs were 3.31 times more likely to occur in competition compared with practice, while in women, HWIs were 2.40 times more likely to occur in competition than in practice. Based on position, guards, both men and women, were the most likely to suffer HWIs. CONCLUSION: HWIs were common in collegiate basketball players. Most injuries were new, and the majority of players were restricted from participation for less than 24 hours. Men were more likely to be injured compared with women, and injuries were most common in the setting of competition for both sexes. The majority of injuries was considered minor and did not extensively limit participation; however, prevention and detection remain important for optimal performance.

Coding Basics and Guidelines for Musculoskeletal Office Evaluation and Management.

¼ In documenting a patient encounter, the orthopaedic evaluation consists of 3 key components: "History," "Physical Examination," and "Medical Decision-Making." ¼ The level of service coded must be supported by the complexity of the problem, the care provided, and the documentation of the encounter. ¼ Determining whether the patient is new or established is the first step in the evaluation and management (E/M) process and relies on same-practice/same-specialty rules. ¼ Careful attention must be paid to documentation and coding to allow for appropriate care of the patient and efficient use of the orthopaedist's time. The available step-by-step guidelines include all necessary criteria to accomplish this. ¼ Continue to monitor for the U.S. Centers for Medicare & Medicaid Services (CMS) changes to stay up-to-date on changes in the guidelines.