Moving Minor Hand Surgeries Out of the Operating Room and Into the Office-Based Procedure Room: A Population-Based Trend Analysis.

PURPOSE: Our primary purpose was to quantify the proportion of minor hand surgeries performed in the procedure room (PR) setting in a population-based cohort. Given the increase in the literature that has emerged since the mid-2000s highlighting the benefits of the PR setting, we hypothesized that a trend analysis would reveal increased utilization over time. METHODS: We used the 2006-2017 MarketScan Commercial Database to identify adults who underwent isolated minor hand surgeries performed in PR and operation room surgical settings in the United States. The Cochran-Armitage trends test was used to determine whether the proportion of all procedures (PR + operation room) changed over time. RESULTS: A total of 257,581 surgeries were included in the analysis, of which 24,966 (11.5%) were performed in the PR. There was an increase in the overall number of surgeries under study as well as increased utilization of the PR setting for open carpal tunnel release, trigger digit release, DeQuervain release, hand or finger mass excision, and hand or finger cyst excision. The magnitude of the increases in PR utilization was small: between 2006 and 2017, the PR utilization increased by 1.4% for open carpal tunnel release, 5.4% for trigger digit release, 2.9% for DeQuervain release, 10.1% for hand or finger mass excision, and 6.5% for hand or finger cyst excision. CONCLUSIONS: Despite the published benefits of the PR setting, we observed that the majority of these 5 common minor hand surgeries are performed in the operation room setting. Between 2006 and 2017, the office-based PR utilization increased slightly. The identification of barriers to PR utilization is needed to improve the value of care. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Establishing the Minimal Clinically Important Difference and Substantial Clinical Benefit for the Pain Visual Analog Scale in a Postoperative Hand Surgery Population.

PURPOSE: Although the pain visual analog scale (VAS-pain) is a ubiquitous patient-reported outcome instrument, it remains unclear how to interpret changes or differences in scores. Therefore, our purpose was to calculate the minimal clinically important difference (MCID) and substantial clinical benefit (SCB) for the VAS-pain instrument in a nonshoulder hand and upper extremity postoperative population. METHODS: Adult postoperative patients treated by 1 of 5 fellowship-trained orthopedic hand surgeons at a single tertiary academic medical center were identified. Inclusion required VAS-pain scores at baseline (up to 3 months before surgery) and follow-up (up to 4 months after surgery), in addition to a response to a pain-specific anchor question at follow-up. The MCID estimates were calculated with (1) the 1/2 standard deviation method; and (2) an anchor-based approach. The SCB estimates were calculated with (1) an anchor-based approach; and (2) a receiver operator curve method that maximized the sensitivity and specificity for detecting a "much improved" pain status. RESULTS: There were 667 and 148 total patients included in the MCID and SCB analyses, respectively. The 1/2 standard deviation MCID estimate was 1.6, and the anchor-based estimate was 1.9. The anchor-based SCB estimate was 2.2. The receiver operator curve analysis yielded an SCB estimate of 2.6, with an area under the curve of 0.72, consistent with acceptable discrimination. CONCLUSIONS: We propose MCID values in the range of 1.6 to 1.9 and SCB values in the range of 2.2 to 2.6 for the VAS-pain instrument in a nonshoulder hand and upper extremity postoperative population. CLINICAL RELEVANCE: These MCID and SCB estimates may be useful for powering clinical studies and when interpreting VAS-pain score changes or differences reported in the hand surgery literature. These values are to be applied at a population level, and should not be applied to assess the improvement, or lack thereof, for individual patients.

Neocortex Formation in a Tapered Wedge Stem is Not Indicative of Complications or Worse Outcomes.

BACKGROUND: The formation of sclerotic bone, a neocortex, distally surrounding total hip arthroplasty (THA) stems may commonly be seen on radiographs around proximally porous coated stems but can be confused with loosening. The goal of this study was to determine the prevalence of the neocortex finding and whether it associated with worse outcomes after THA. METHODS: A retrospective review of 825 patients with a single tapered wedge stem was performed. Radiographs at 1-year, as well as final follow-up were reviewed for evidence of sclerotic bone (neocortex) surrounding the stem in all 14 Gruen zones. The final attending radiology read of lucency was also recorded. Patients were grouped by the presence of the neocortex. PROMIS Physical Function scores and complications were compared between neocortex groups. RESULTS: The neocortex group had 558 (68%) patients compared to 267 (32%) in the no neocortex group. The most common Gruen zones for evidence of neocortex were 10 (55%), 11 (52%), and 12 (51%). Seven percent of patients had a finding of lucency on radiology read. There was no difference between groups in terms of dislocations (P = .61), infection (P = .79), fracture rates (P = .54), revision surgery (P = .73), and reoperation for any cause (P = .62). PROMIS PF scores were significantly higher in the neocortex group (P < .0001). CONCLUSION: The presence of a distal neocortex is a common finding on radiographs after THA with this proximally porous-coated tapered wedge stem and does not portend worse outcomes, nor is it a sign of aseptic loosening, increased revision rates, infection, dislocation, or periprosthetic fracture risk.

National and State Level Opioid-Restricting Legislation in Total Joint Arthroplasty: A Systematic Review.

BACKGROUND: The opioid epidemic is a health crisis in the United States. Within orthopedic surgery, opioid misuse and incautious prescription remains a concern. In the last several years, there has been a growing interest and public effort toward reducing opioid use in total joint arthroplasty (TJA) in response to the opioid epidemic in the United States. We aim to review opioid-limiting practices, policies, and legislations that are implemented at the state level and nationally that are relevant to TJA, as well as evaluate studies that measure the efficacy of these policies in the management of patients undergoing TJA. METHODS: Two independent reviewers conducted a systematic review of national and state level opioid-limiting policies implemented in the United States and their effects on opioid prescription, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (PRISMA). RESULTS: We identified 3 national bills and 9 policies set forth by national organizations that imposed limits on opioid prescription. Opioid-reducing legislation was also identified in 24 states, with the majority specifying a 7-day limit on initial opioid prescription for acute pain management. Six research studies evaluating the impact of opioid-restricting policies on postoperative opioid prescription for TJA patients were found. Three studies assessed legislation at the state level while the others were institution-based guidelines. Overall, these studies demonstrated a significant decrease in mean morphine milligram equivalents of initial opioid prescription after implementing the policies. CONCLUSION: Recent opioid-restricting legislation is effective in decreasing postoperative opioid prescriptions following TJA.

The minimal clinically important difference of the Patient-Reported Outcomes Measurement Information System (PROMIS) physical function and upper extremity computer adaptive tests and QuickDASH in the setting of elbow trauma.

BACKGROUND: Minimal clinically important difference (MCID) estimates are useful for gauging clinical relevance when interpreting changes or differences in patient-reported outcomes scores. These values are lacking in the setting of elbow trauma. Our primary purpose was to estimate the MCID of the Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) computer adaptive test (CAT), the PROMIS upper extremity (UE) CAT, and the QuickDASH using an anchor-based approach for patients recovering from elbow trauma and related surgeries. Secondarily, we aimed to estimate the MCID using the 1/2 standard deviation method. MATERIALS & METHODS: Adult patients undergoing treatment for isolated elbow injuries between July 2014 and April 2020 were identified at a single tertiary academic medical center. Outcomes, including the PROMIS PF CAT v1.2/2.0, PROMIS UE CAT v1.2, and QuickDASH, were collected via a tablet computer. For inclusion, baseline (6 months before injury up to 11 days postoperatively or after injury) and follow-up (11 to 150 days postoperative or after injury) PF or UE CAT scores were required, as well as a response to an anchor question querying improvement in physical function. The MCID was calculated using (1) an anchor-based approach using the difference in mean score change between anchor groups reporting "No change" and "Slightly Improved/Improved" and (2) the 1/2 standard deviation method. RESULTS: Of the 146 included patients, the mean age was 46 ± 18 years and 67 (46%) were women. Most patients (129 of 146 or 88%) were recovering from surgery, and the remaining 12% were recovering from nonoperatively managed fractures and/or dislocations. The mean follow-up was 157 ± 192 days. Scores for each instrument improved significantly between baseline and follow-up. Anchor-based MCID values were calculated as follows: 5.7, 4.6, and 5.3 for the PROMIS PF CAT, PROMIS UE CAT, and QuickDASH, respectively. MCID values estimated using the 1/2 standard deviation method were 4.3, 4.8, and 11.7 for the PROMIS PF CAT, PROMIS UE CAT, and QuickDASH, respectively. CONCLUSIONS: In the setting of elbow trauma, we propose MCID ranges of 4.3 to 5.7 for the PROMIS PF CAT, 4.6 to 4.8 for the PROMIS UE CAT, and 5.3 to 11.7 for the QuickDASH. These values will provide a framework for clinical relevance when interpreting clinical outcomes studies, or powering clinical trials, for populations recovering from trauma.

Evaluation of Patient Expectations before Carpal Tunnel Release.

BACKGROUND: Carpal tunnel release (CTR) is common, yet patient treatment expectations remain unclear. The primary purpose was to describe patient expectations before CTR. Secondarily, we aimed to identify factors influencing expectations. METHODS: Included patients underwent unilateral or bilateral CTR between 2015 and 2017 at a single academic center. Expectations regarding the level of relief/improvement were queried. Area deprivation index (ADI) was used to measure social deprivation. Univariate and multivariable logistic regression identified factors associated with expecting great relief/improvement. RESULTS: Of 307 included patients, mean age was 54 ± 16 years and 63% were women. Patients most commonly expected great (58%) or some (23%) relief/improvement. Few patients expected little (3%) or no (4%) relief/improvement, and 13% had no expectations. In the multivariable analysis, male sex, lower social deprivation, and lower BMI were associated with expecting great relief/improvement. Age, surgical technique (open versus endoscopic), use of the operating room versus procedure room, and preoperative factors (constant numbness, weakness/atrophy, duration of symptoms, and QuickDASH) were not associated with expectations. CONCLUSIONS: Most patients expect some to great improvement after CTR. This was independent of several factors with a known association with worse outcomes (advanced age, atrophy/weakness, and constant numbness). Male sex was associated with the expectation of great improvement, in which superior outcomes relative to females have not been borne out in the literature. These findings highlight patient counseling opportunities. The observed association between social deprivation and expectations warrants further investigation, as the socioeconomically disadvantaged experience worse healthcare outcomes in general.

Comparison of Complication Risk for Open Carpal Tunnel Release: In-office versus Operating Room Settings.

BACKGROUND: Performing open carpal tunnel release (oCTR) in an office-based procedure room setting (PR) decreases surgical costs when compared with the operating room (OR). However, it is unclear if the risk of major medical, wound, and iatrogenic complications differ between settings. Our purpose was to compare the risk of major medical complications associated with oCTR between PR and OR settings. METHODS: Utilizing the MarketScan Database, we identified adults undergoing isolated oCTR between 2006 and 2015 performed in PR and OR settings. ICD-9-CM and/or CPT codes were used to identify major medical complications, surgical site complications, and iatrogenic complications within 90 days of oCTR. Multivariable logistic regression was used to compare complication risk between groups. RESULTS: Of the 2134 PR and 76,216 OR cases, the risk of major medical complications was 0.89% (19/2134) and 1.20% (914/76,216), respectively, with no difference observed in the multivariable analysis (adjusted odds ratio [OR] 0.84; 95% CI 0.53-1.33; P=0.45). Risk of surgical site complications was 0.56% (12/2134) and 0.81% (616/76,216) for the PR and OR, respectively, with no difference in the multivariable analysis (OR 0.68; 95% C.I. 0.38-1.22; P=0.19). Iatrogenic complications were rarely observed (PR 1/2134 [0.05%], OR 71/76,216 [0.09%]), which precluded multivariable modeling. CONCLUSION: These results support a similar safety profile for both the PR and OR surgical settings following oCTR with similar pooled major medical complications, pooled wound/surgical site complications, and iatrogenic complications.

A potential need for surgeon consensus: Cementation techniques for total knee arthroplasty in orthopedic implant manufacturers' guidelines lack consistency.

AIM: Given recent concerns regarding the influence of different cements and implants on the rate of aseptic failures in total knee arthroplasty (TKA), we wondered if cementation technique could play a role. The primary aim of this review was to collect and compare the surgeon education materials from eight orthopedic implant manufacturers to evaluate the manufacturers' recommended cementation technique in TKA and identify if there was any consistency in these readily available guides as to the best practices of cementation of their implants. MATERIALS AND METHODS: We reviewed contemporary surgeon education guidelines for all TKA systems available from eight manufacturers. Variables included: cement type, batches prepared, surface preparation prior to application, cleaning and/or drying the bone surface, mixing the cement, the waiting phase after the cement has been mixed prior to application, pressurizing the cement, location of cement application, and the curing time. Data were recorded and organized for qualitative comparisons. RESULTS: We identified a total of 43 guides covering 38 implants from eight different manufacturers. There were 41 surgical technique guides and two general brochures regarding cementation techniques available from the manufacturers. Even within the manufacturers' own guidelines for the different implants, there was a wide variety of differing guidelines on many aspects of the cementation technique. CONCLUSION: There is clearly no consensus for a preferred cementation technique both within and among manufacturers' surgeon education materials regarding tibial baseplate cementation during TKA. Efforts may be needed to identify a best-practice cementation technique in an effort to reduce the number of TKA failures associated with aseptic loosening.