Abdominal Panniculectomy: Determining the Impact of Diabetes on Adverse Outcomes and Complications.

Background: Despite its association with obesity, the relation between diabetes and the abdominal panniculectomy is less well-established. The purpose of this study was to evaluate the result of diabetes on post-panniculectomy complications in a large cohort and to establish the risk factors associated with unfavorable post-operative outcomes. Methods: Patients that underwent a panniculectomy between 2010 and 2018 were identified in PearlDiver, a national insurance claims database, and identified by Current Procedural Terminology code 15380. Patient demographics and comorbidities were elucidated, and various complications were then identified. Descriptive statistics as well as a multivariate analysis were used to evaluate the association of risk factors and complications. Results: A total of 8282 panniculectomy patients were identified-4245 with diabetes, 4037 without. Obesity, tobacco use, and diabetes were all identified as significant risk factors in developing a surgical site infection, wound disruption, as well as needing to undergo reoperation. Diabetic panniculectomy patients had a higher rate of readmission as well as reoperation and sustained a higher rate of surgical complications, even when matched for. Conclusion: Diabetic panniculectomy patients are at a greater risk for developing complications. Identifying potential risk factors in this patient population could help reduce post-operative complications following a panniculectomy.

Contexte: En dépit de son association avec l'obésité, la relation existant entre le diabète et la panniculectomie abdominale est moins bien établie. Cette étude avait pour objectif d'évaluer le résultat du diabète sur les complications post-panniculectomie dans une vaste cohorte et de déterminer les facteurs de risque associés aux évolutions postopératoires défavorables. Méthodes: Des patients ayant subi une panniculectomie entre 2010 et 2018 ont été identifiés dans la base de données PearlDiver, une base de données nationale de réclamations de remboursement d'assurances, et identifiés par le code CPT 15380. Les données démographiques et les comorbidités des patients ont été élucidées et différentes complications ont alors été identifiées. Des statistiques descriptives ainsi qu'une analyse multifactorielle ont permis d'évaluer l'association des facteurs de risque et des complications. Résultats: 8 282 patients ayant subi une panniculectomie ont été identifiés, parmi lesquels 4 245 avaient un diabète et 4 037 n'en avaient pas. L'obésité, le tabagisme et le diabète ont tous été identifiés comme étant des facteurs de risque significatifs pour le développement d'une infection du site opératoire, une perturbation de la plaie, ainsi que le besoin d'une réintervention. Les patients diabétiques ayant subi une panniculectomie ont eu des taux de réadmission et de réintervention plus élevés; leur taux de complications chirurgicales a été plus important, même après appariement. Conclusion: Les patients subissant une panniculectomie ont un risque plus élevé de complications postopératoires. L'identification des facteurs de risque potentiels dans cette population de patients pourrait contribuer à réduire les complications postopératoires après panniculectomie.

The Cost of Ambulatory Breast Reduction: Hospital Reimbursement Versus Surgeon Payments.

Introduction: Reduction mammoplasty (RM) is one of the most common operations performed in plastic surgery. While US national surgical expenditures have risen in recent years, studies have reported decreasing reimbursement rates for plastic surgeons. The purpose of this study is to characterize the trends in charges and payments for a common plastic surgery operation, ambulatory RM, for facilities and physicians. Methods: A Medicare patient records database was used to capture hospital, surgeon, and anesthesiologist charges and payments for ambulatory RM from 2005 to 2014. Values were adjusted for inflation. A ratio of hospital to surgeon charges and payments were calculated: charge multiplier (CM) and payment multiplier (PM), respectively. Charges, payments, Charlson comorbidity index, CM, and PM values were analyzed for trends. Results: This study included 1001 patients. During the study period, the facility charge for RM per patient increased from $8477 to $11,102 (31% increase; p < .0005), and the surgeon charge increased from $7088 to $7199 (2% increase; p = .0009). Facility payments increased from $3661 to $3930 (7% increase; p < .0005), and surgeon payments decreased from $1178 to $1002 (15% decrease; p < .0005). CM increased from 1.2 to 1.54, and PM increased from 3.11 to 3.92. Conclusions: Charges and payments to facilities for ambulatory RM increased disproportionately to that of surgeons, likely due in part to rising administrative costs in health care delivery. This may disincentivize plastic surgeons from offering RM at hospital-based surgical centers, limiting patient access to this operation.

Introduction: La mammoplastie de réduction (MR) est l'une des interventions les plus courantes pratiquées en chirurgie plastique. Alors que les dépenses chirurgicales aux États-Unis ont augmenté au niveau national au cours des dernières années, les études ont signalé une diminution des taux de remboursement pour les chirurgiens plasticiens. L'objectif de cette étude est de définir les tendances dans les frais et paiements pour une intervention courante de chirurgie plastique, une MR ambulatoire, pour les établissements et pour les médecins. Méthodes: Une base de données des dossiers de patients Medicare a été utilisée pour collecter les frais pour les hôpitaux, les chirurgiens et les anesthésiologistes ainsi que les paiements pour MR ambulatoires de 2005 à 2014. Les valeurs ont été ajustées pour tenir compte de l'inflation. Des ratios des frais hôpital/chirurgien et des paiements ont été calculés : respectivement, un facteur de multiplication des frais (MF) et des paiements (MP). Les tendances de la valeur des frais, des paiements, de l'indice de comorbidité de Charlson, du MF et du MP ont été analysées. Résultats: Cette étude a inclus 1001 patients. Au cours de la période de l'étude, les frais pour MR par patient à la charge de l'établissement ont augmenté de 8 477 $ à 11 102 $, soit une augmentation de 31 % (P < 0,0005) et les frais du chirurgien sont passés de 7 088 $ à 7 199 $, soit une augmentation de 2 % (P = 0,0009). Les paiements de l'établissement ont augmenté de 3 661 $ à 3 930 $, soit une augmentation de 7 % (P < 0,0005) et les paiements du chirurgien ont diminué de 1 178 $ à 1 002 $, soit une diminution de 15 % (P < 0,0005). Le facteur MF est passé de 1,2 à 1,54 et le facteur MP est passé de 3,11 à 3,92. Conclusions: Les frais et paiements aux établissements pour MR ambulatoire ont augmenté de manière disproportionnée par rapport à ceux des chirurgiens, probablement en partie à cause de l'augmentation des coûts administratifs croissants de l'administration des soins. Cela pourrait inciter les chirurgiens plasticiens à ne plus offrir de MR dans les centres chirurgicaux hospitaliers et pourrait donc limiter l'accès des patients à cette opération.

Determinants of pressure injury development in patients with COVID-19.

OBJECTIVE: Pressure injuries (PIs) often develop in critically ill patients due to immobility, and underlying comorbidities that decrease tissue perfusion and wound healing capacity. This study sought to provide epidemiological data on determinants and current managements practices of PI in patients with COVID-19. METHOD: A US national insurance-based database consisting of patients with coronavirus or COVID-19 diagnoses was used for data collection. Patients were filtered by International Classification of Diseases (ICD) codes corresponding to coronavirus or COVID-19 diagnosis between 2019-2020. Diagnosis of PI following COVID-19 diagnosis was queried. Demographic data and comorbidity information was compared. Logistic regression analysis was used to determine predictors for both PI development and likelihood of operative debridement. RESULTS: A total of 1,477,851 patients with COVID-19 were identified. Of these, 15,613 (1.06%) subsequently developed a PI, and 8074 (51.7%) of these patients had an intensive care unit (ICU) admission. The average and median time between diagnosis of COVID-19 and PI was 39.4 and 26 days, respectively. PI was more likely to occur in patients with COVID-19 with: diabetes (odds ratio (OR): 1.39, 95% confidence interval (CI): 1.29-1.49; p<0.001); coronary artery disease (OR: 1.11, 95% CI: 1.04-1.18, p=0.002), hypertension (OR: 1.43, 95% CI: 1.26-1.64; p<0.001); chronic kidney disease (OR: 1.18, 95% CI: 1.10-1.26; p<0.001); depression (OR: 1.45, 95% CI 1.36-1.54; p<0.001); and long-term non-steroidal anti-inflammatory drug use (OR: 1.21, 95% CI: 1.05-1.40; p=0.007). They were also more likely in critically ill patients admitted to the ICU (OR: 1.40, 95% CI: 1.31-1.48; p<0.001); and patients requiring vasopressors (OR:1.25, 95% CI: 1.13-1.38; p<0.001), intubation (OR: 1.21, 95% CI 1.07-1.39; p=0.004), or with a diagnosis of sepsis (OR: 2.38, 95% CI 2.22-2.55; p<0.001). ICU admission, sepsis, buttock and lower back PI along with increasing Charlson Comorbidity Index (CCI) (OR: 1.04, 95% CI 1.00-1.08; p=0.043) was associated with surgical debridement. The vast majority of patients with COVID-19 did not undergo operative debridement or wound coverage. CONCLUSION: PIs are widely prevalent in patients with COVID-19, especially in those who are critically ill, yet the vast majority do not undergo operative procedures. DECLARATION OF INTEREST: The authors have no conflicts of interest to declare.

The Impact of Social Determinants of Health on the Treatment of Distal Radius Fracture.

BACKGROUND: Disparities in social determinants of health (SDH) have been shown to play an increasingly important role in the equitable delivery of health care. Distal radius fractures (DRFs) are among the most common upper-extremity injuries encountered. This study aims to examine the influence of economic, educational, social, environmental, and healthcare disparities on management of these injuries. METHODS: PearlDiver Mariner insurance claims database was analyzed for treatment patterns of DRF in patients aged 18 to 65 years based on the presence or absence of social determinants of health disparities (SDHDs). Outcome variables included the primary mode of management of DRF, including operative versus non-operative, as well as concomitant procedures. Multivariate logistic regression was used to compare fracture management modality in patients with and without SDHDs. RESULTS: Of 161 704 patients identified with DRF, 38.3% had at least 1 reported SDHD. The majority of SDHDs were economic. Patients identified with 1 or more SDHDs had a higher medical comorbidity index. Patients with environmental SDHD were more likely to receive non-operative management. Within any SDHD and economic subgroups, odds of operative management were higher. No relationship was identified between SDHD and concomitant procedures. CONCLUSIONS: The presence of environmental disparities in SDH may predispose patients disproportionately to non-operative management. The presence of SDHDs may influence medical decision-making in favor of open reduction and internal fixation in patients with DRF treated operatively. In treating at-risk populations, providers should be aware of the potential for implicit bias associated with SDHDs and prioritize shared decision-making between patients and physicians.

Gender-Affirming Surgery Improves Mental Health Outcomes and Decreases Anti-Depressant Use in Patients with Gender Dysphoria.

BACKGROUND: Patients with gender dysphoria face significant health disparities and barriers to care. Transition-related care includes hormonal therapy, mental healthcare, and gender-affirming surgeries. Studies have described favorable surgical outcomes and patient satisfaction, however, the degree to which these procedures impact mental health conditions is not fully understood. The purpose of this study was to evaluate the effect of gender-affirming plastic surgery on mental health and substance abuse in the transgender population. METHODS: A national insurance claims-based database was used for data collection. Patients with a diagnosis of gender dysphoria were propensity score-matched for the likelihood of undergoing gender-affirming surgery (no surgery being the control cohort), based on comorbidities, age, and sex. Primary outcomes included post-operative antidepressant use and the prevalence of mental health conditions. RESULTS: A total of 3,134 patients with gender dysphoria were included in each cohort. Patients in the surgery group had overall lower rates of mental health conditions, substance abuse, and SSRI/SNRI use. There was an absolute decrease of 8.8% in SSRI or SNRI prescription after gender-affirming plastic surgery (p<0.001), and significant decreases in post-operative depression (7.7%), anxiety (1.6%), suicidal ideation (5.2%) and attempts (2.3%), alcohol abuse (2.1%), and drug abuse (1.9%). CONCLUSION: Gender-affirming surgery in appropriately selected gender dysphoric patients is associated with decreased postoperative rates of SSRI or SNRI use and improved mental health.

Oncoplastic breast reduction surgery decreases rates of reoperation with no increased medical risk.

The purpose of this study is to compare the oncologic, medical, and surgical outcomes of lumpectomy versus oncoplastic breast reduction surgery (OBRS) on a national scale. A national insurance-based database was queried for patients who had a lumpectomy with or without a same-day breast reduction by Current Procedural Terminology (CPT) codes. Patients were then matched by obesity, body mass index range, age, region, neoadjuvant chemotherapy, and outcomes were compared. There were 421,455 patients in the lumpectomy group and 15,909 patients in the OBRS group. After matching, 15,134 patients were identified in each group. Repeat lumpectomy or subsequent mastectomy was more common in the lumpectomy group (15.2% vs. 12.2%, p < 0.001). OBRS patients had higher rates of 90-day surgical complications including dehiscence, infection, fat necrosis, breast abscesses, and antibiotic prescription (p < 0.001). Meanwhile, any medical complication was less common in the OBRS group (3.7% vs. 4.5%, p = 0.001). Logistic regression revealed that OBRS was associated with decreased odds of repeat lumpectomy (OR = 0.71, 95% CI 0.66-0.77, p < 0.001) with no significant increased odds of subsequent mastectomy (OR = 1.01, 95% CI 0.91-1.11, p = 0.914). OBRS was found to be associated with decreased risk for reoperation in the form of lumpectomy without increased likelihood of subsequent mastectomy. Although OBRS was associated with increased wound complications, medical complications were found to occur less frequently. This study endorses increased consideration of OBRS when lumpectomy or OBRS is appropriate.

Regional Anesthesia for Wrist Fractures and Dislocations: Are We Really Blocking Opioid Prescribing?

BACKGROUND: The aim of this study was to evaluate the impact of regional anesthesia for the treatment of wrist fractures or dislocation on opioid prescription-filling patterns. METHODS: Patients undergoing surgery for hand and wrist fractures or dislocations from 2010 to 2018 were identified by using a national insurance claims database. Patients were stratified by procedures conducted with and without regional anesthesia. Preoperative opioids were defined by a filled opioid prescription within 1 month prior to surgery, postoperative within 1 month following the surgery, and prolonged postoperative 3 to 6 months following surgery. Patients' demographic data, comorbidities, additional medications, 30-day emergency department (ED) visits, and hospital readmissions were analyzed. RESULTS: A total of 24 598 patients treated with and 115 199 patients treated without a regional nerve block for wrist fractures and dislocations were identified. Regional anesthesia was associated with greater postoperative opioid prescription but fewer prolonged postoperative prescriptions. There was an increased odds of all-cause 30-day ED visits but a decreased odds of 30-day hospital readmissions when patients received a regional nerve block prior to surgery. CONCLUSIONS: In this study, receiving regional anesthesia prior to surgical intervention for wrist fractures or dislocations was associated with increased filling of postoperative opioid prescriptions, but not prolonged postoperative opioid prescriptions. Additional investigation is needed to identify and implement nonnarcotic multimodal analgesia regimens that may help decrease usage of narcotic medications surrounding these procedures. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Is This Going to Hurt, Doc? Predicting Pain with Corticosteroid Injections for Upper Extremity Conditions.

Corticosteroid injections (CSIs) are used in a wide variety of upper extremity pathologies for both diagnostic and treatment purposes. Many patients ask about pain associated with the procedure before agreeing to proceed. The purpose of this study was to correlate perceived pain tolerance and resilience with patient-reported injection pain during and immediately after injection. Methods: One-hundred patients indicated for a CSI for an upper extremity condition were recruited for the study. Patients completed a Brief Resilience Scale, Patient-Reported Outcomes Measurement Information System pain interference form, and assessment of pain tolerance before injection. Physicians predicted pain tolerance and resilience for each patient. Immediately after the procedure, patients completed a second survey, assessing pain during and 1 minute after injection. Results: Physician-predicted patient resilience and pain tolerance was lower than that self-reported by patients. Pain with injection was inversely correlated with physician-predicted pain tolerance and resilience but not with patient-reported pain tolerance. Injection pain ratings did not correspond with patients' willingness to undergo subsequent injections. Conclusions: Procedural pain is an important consideration for many patients, especially in awake procedures. Appropriate counseling is crucial to support informed consent and enhance patient outcomes. This study demonstrated that a physician's clinical experience can be used to predict a patient's pain with CSI and should be considered when counseling patients.

Management of Failed Carpal and Cubital Tunnel Release: An Evidence-Based Guide to Success.

Carpal tunnel and cubital tunnel syndromes are the most common compressive neuropathies of the upper extremity with surgical treatment having high success rates for both conditions. Although uncommon, persistent or recurrent carpal and cubital tunnel syndrome presents a challenge for patients and providers. Diagnosis of persistence versus recurrence of the pathology is key in establishing an appropriate treatment plan to provide the best possible patient outcomes. After an established diagnosis, a wide array of treatment options exist which varies based on previous procedures performed. This review discusses relevant anatomy, etiology, and clinical presentations of persistent and recurrent carpal and cubital tunnel syndromes. The range of treatment options is presented based on history and diagnostic findings. Treatment options span from revision of nerve decompression to the use of soft tissue rearrangement procedures. Some specific treatment options discussed include simple revision nerve decompression, external neurolysis, soft tissue rearrangement, such as the hypothenar fat flap or various transposition techniques, and the use of nerve wraps. Included is an evidence-based management guide for diagnosis and treatment of persistent versus recurrent carpal and cubital tunnel syndromes.

The Mechanism of Cannabichromene and Cannabidiol Alone Versus in Combination in the Alleviation of Arthritis-Related Inflammation.

BACKGROUND: Patients suffering from arthritis have limited treatment options for nonoperative management. In search of pain relief, patients have been taking over-the-counter cannabinoids. Cannabidiol (CBD) and cannabichromene (CBC) are minor cannabinoids with reported analgesic and anti-inflammatory properties and have been implicated as potential therapeutics for arthritis-related pain. To this end, we utilized a murine model to investigate the effectiveness of and mechanism by which CBC alone, CBD alone, or CBD and CBC in combination may provide a reduction in arthritis-associated inflammation. METHODS: Forty-eight mice were included in the study, which were separated into 4 groups: control group (n = 12), treatment with CBD alone (n = 12), treatment with CBC alone (n = 12), and treatment with CBD + CBC (n = 12). We induced inflammation in each mouse utilizing the collagen-induced arthritis model. At scheduled timepoints, mice were clinically assessed for weight gain, swelling, and arthritis severity. In addition, inflammation-associated serum cytokine levels were analyzed for each animal. RESULTS: Thirty-five of 48 mice survived the duration of the study resulting in the following group numbers: control group (n = 8), treatment with CBD alone (n = 9), treatment with CBC alone (n = 9), and treatment with CBD + CBC (n = 9). Animals treated with CBC and CBD + CBC showed significant weight gain between 3 and 5 weeks. Irrespective of treatment, regression analysis comparing all cytokine measurement and physical outcomes found a significant positive correlation between levels of 5 individual cytokines and both arthritis scores and swelling. Animals treated with CBD + CBC showed a significant decrease in swelling between 3 and 5 weeks compared with the control group. Cannabinoid treatment selectively affected the gene expression of eotaxin and lipopolysaccharide-induced CXC chemokine with combined treatment of CBC + CBD. CONCLUSION: Treatment with cannabinoids resulted in decreased clinical markers of inflammation. Further, the anti-inflammatory effect of CBC and CBD in conjunction was associated with a greater anti-inflammatory effect than either minor cannabinoid alone. Future work will elucidate the possibility of synergistic or entourage effects of minor cannabinoids used in combination for the treatment of arthritis-related pain and inflammation.

Fabricating Stiffness-Matched Three Dimensional -Printed Metal Implants for Total Wrist Arthroplasty.

BACKGROUND: Total wrist arthroplasty (TWA) is a motion-sparing treatment for pancarpal arthritis; however, complication rates up to 50% have limited widespread use. Implant micromotion, stress shielding, and periprosthetic osteolysis result in implant failure and revision to arthrodesis. Metal 3-dimensional (3D) printing allows for more accurate matching of surrounding bone biomechanical properties, theoretically reducing periprosthetic osteolysis. Herein, we use computed tomography to characterize the relationship of relative stiffness along the length of the distal radius with patient demographic factors. METHODS: After institutional review, wrist computed tomography scans at a single institution between 2013 and 2021 were identified. Exclusion criteria were history of radius or carpal trauma or fracture. Collected demographics included age, sex, and comorbidities (including osteoporosis/osteopenia). Scans were analyzed using Materialize Mimics Innovation Suite 24.0 (Leuven, Belgium). Distal radius cortical density (in Hounsfield units) and medullary volume (in cubic millimeters) with relation to distance from the radiocarpal joint were recorded. Average values for each variable were used to 3D-printed distal radius trial components with stiffness matched to bone density by length. RESULTS: Thirty-two patients met inclusion criteria. Distal radius cortical bone density progressively increased proximal to the radiocarpal joint, whereas medullary volume decreased; changes in both plateaued 20 mm proximal to the joint. Distal radius material properties differed by age, sex, and comorbidities. Total wrist arthroplasty implants were fabricated to match these variables as proof of concept. CONCLUSIONS: Distal radius material properties vary along the bone length; conventional implants do not account for this variance. This study showed 3D-printed implants can be created to match bone properties along the length of the implant.

The Relationship between Plastic Surgery Residency Instagram Characteristics and Doximity Rank.

Social media provides unique insight into the facilities, personnel, and culture of plastic surgery residency programs. Applicants can gain a more holistic view of programs based on their social media accounts. This study aims to evaluate the relationship between the popularity of a program's Instagram account and the program's Doximity ranking and to investigate the factors which contribute to greater viewership, with a special focus on diversity. Methods: Using Doximity's 2021-2022 Residency Navigator, a list of all integrated plastic surgery residency programs was obtained, and their social media accounts were documented. Instagram accounts were analyzed for metrics, post content, and website links. A 15-month period of posts was analyzed, then grouped into eight categories. Diversity was assessed using average Fitzpatrick skin type for each post containing photographs of people. Results: Of the 88 programs, 85 (96.6%) had an Instagram account at the time of analysis. Analysis of Instagram post content found that personnel and social function posts had significantly more likes than other categories. Posts with average Fitzpatrick type greater than or equal to III also had significantly more likes. Linear regression demonstrated a positive relationship between higher Doximity rank and number of followers; however, there was no clear relationship between rank and posts per week or engagement score. Conclusions: Plastic surgery social media accounts may make a positive impact on followers. It is important to understand the factors that can increase engagement and broaden viewership. Tailoring posts based on content popularity and highlighting diversity may help to accomplish these goals.

Thematic and Demographic Analysis of Crowdsourcing Practices for Plastic Surgery.

BACKGROUND: In this study, we investigate the characterization of medical crowdsourcing on GoFundMe for plastic surgery procedures, with overall funds raised being the primary end point. HYPOTHESIS: Certain demographic factors such as sex and race mentioned in campaign narratives are associated with the effectiveness of medical crowdfunding campaigns. METHODS: Search terms were used to aggregate fundraising campaigns for plastic surgery medical procedures on GoFundMe. These studies were then stratified by demographics based on campaign text or author consensus, and were further subdivided into categories based on procedure type. RESULTS: Men were found to have higher median shares than women-raising an average of $609 more than female counterparts ( P < 0.05). Fundraising for themes such as lack of insurance, travel costs, lifesaving treatment, and end-of-life expenses were more successful than the theme of psychosocial effects of disease or social impairment. In addition, those that included a smiling picture of the recipient and those created by a friend/relative raised more funds. Although no significant difference was found in fundraising between demographics based on race, a majority (72.8%) of campaigners were White. Across ~2000 plastic surgery campaigns, a total of $10,186,687 were raised from these data. CONCLUSIONS: We identified both modifiable and nonmodifiable factors that influence success. These successful campaigns can serve as a learning opportunity for many who have been marginalized by the medical and pharmaceutical industry, and they demonstrate a promising area for demographic studies.

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

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

Arthroscopic Versus Open Treatment of Septic Wrist Arthritis: National Trends in Usage and Impact on Length of Stay, Reoperation, Postoperative Readmissions, and Complications.

Purpose: The purpose of this study was to use a national claims database to analyze trends in the usage of arthroscopic versus open irrigation and debridement of septic wrist arthritis and compare complication rates, readmission rates, and reoperation rates between the 2 treatment modalities. Methods: The PearlDiver database was used to identify patients in the United States who underwent open or arthroscopic debridement for suspected septic wrist arthritis from 2010 to 2017. Data on patient demographics and comorbidities were obtained. Pearson's chi-square tests were performed to compare the treatment modality to demographic data and the year of diagnosis. Univariate logistic regressions were used to measure differences in 90-day hospital readmission rates, 90-day complication rates, and 1-year reoperation rates. Results: The database captured 1,145 patients who received treatment for septic arthritis of the wrist during this period. Among these, 212 (18.5%) patients underwent arthroscopic debridement and 933 (81.5%) patients underwent open debridement. Open management was more common in all ages; however, arthroscopic debridement was used more frequently in younger age groups. The proportion of open cases per year seemed to increase over the study period. In limited comparisons, no significant differences were observed in 90-day hospital readmission rates, 90-day complication rates, and 1-year reoperation rates. Conclusions: Open irrigation and debridement was the preferred method for treatment of septic wrist arthritis in all age groups and time points in this study. No univariate differences were found between rates of readmission, complications, and reoperations between arthroscopic and open treatment modalities; however, more robust data and analyses are needed to better understand the differences between these approaches, especially across different patient groups. Level of evidence: Prognostic IV.

Traditional Neuroma Management Strategies: A Systematic Review.

BACKGROUND: In this systematic review, the authors discuss traditional management strategies of neuromas. Surgical management can be described as either passive and ablative or active and reconstructive. Our aim was to evaluate the evidence supporting traditional management strategies in patients affected by neuromas. METHODS: The systematic literature search was conducted in PubMed/MEDLINE databases using search terms related to neuromas and their surgical management. Studies involving targeted muscle reinnervation or regenerative peripheral nerve interface were excluded. Two reviewers selected the studies, evaluated their methodological quality, and retrieved data independently. This review was conducted in a manner consistent with Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Selected studies were analyzed for pain and functional outcomes. RESULTS: A total of 1064 articles were identified, and 22 studies were selected for review. Passive or ablative modalities for treatment of neuromata include excision of neuroma, excision with implantation into adjacent tissue, nerve caps, vein cap, and relocation nerve grafting. Active or reconstructive modalities that allow for nerve regeneration include hollow tube reconstruction, reconstruction with an allograft, and centrocentral nerve anastomosis. CONCLUSIONS: Passive treatment modalities can offer reliable pain relief in appropriately selected patients but do not allow for nerve regeneration. As such active, reconstructive modalities should be used when possible.

The Ratings Game: Demographic and Practice Factors Affecting Yelp Ratings of Plastic Surgeons.

BACKGROUND: Review platforms such as Yelp are increasingly used by patients establishing care and may contain substantial information regarding patient preferences and potential biases. The authors' aims were to (1) analyze patient satisfaction through identifying factors associated with positive and negative patient reviews for plastic surgery providers across the United States, and (2) investigate the association between overall rating and different physician and practice factors based on gender and race. METHODS: Reviews of plastic surgery provider practices from cities across seven different regions within the United States were obtained from Yelp. Quantitative and qualitative analyses were performed. Chi-square tests were used to determine whether race or sex was associated with overall rating (of five stars) and qualitative themes. RESULTS: A total of 5210 reviews met inclusion criteria; 80.3% received a five-star rating and 13.5% received a one-star rating. Positive Yelp reviews and higher ratings were associated with positive comments regarding surgical and injectable outcomes, physical examination, communication, competency/knowledge base, temperament, scheduling, and staff interactions. When the following factors were mentioned negatively, the practice was more likely to receive a lower rating: temperament, communication, cost consciousness, surgical and injectable outcomes, physical examination, billing/insurance, scheduling, interactions with staff, and wait times. No association was identified in terms of overall physician rating based on sex or race; however, there were differences noted in distribution of positive and negative themes. CONCLUSIONS: Patient reviews on Yelp indicate that several physician and practice factors influence patient satisfaction. The themes reported in this study may be used by plastic surgery providers to identify areas for practice improvement to enhance the overall patient experience.

Distal Radioulnar Achilles Allograft Interposition Arthroplasty: Does It Solve the Problem of Persistent Pain?

PURPOSE: Pain and instability following distal ulnar resection for distal radioulnar joint (DRUJ) arthritis is a problem without a clear solution. We investigated the outcomes of DRUJ interposition arthroplasty for the management of symptomatic radioulnar convergence. METHODS: A retrospective review was performed for all patients who underwent Achilles tendon allograft interposition arthroplasty following the failure of distal ulna resection between October 2009 and January 2015. Records were reviewed for demographics, comorbidities, surgical history, pre- and postoperative pain, range of motion, grip strength, and complications. Radiographs and computed tomography scans were evaluated for distal radioulnar instability, distal ulnar absorption, ulnar scalloping, radioulnar convergence, and allograft subluxation. Reconstructive failure was defined as the presence of moderate-to-severe persistent distal radioulnar pain, instability with radiographic evidence of radioulnar convergence or allograft subluxation on radiographs or computed tomography scans, or the need for revision arthroplasty procedure. RESULTS: Ten patients met the inclusion criteria. The mean age was 49 ± 10 years. The average follow-up after interposition arthroplasty was 76 ± 23 months. The preoperative means of grip strength, arc of pronosupination, flexion, and extension were similar after surgery. The mean arc of pronosupination improved by 26.5°, and the wrist flexion-extension arc in patients without arthrodesis improved by 22.6°. The grip strength increased by 1.7 kg. Seven of 10 patients had continued symptoms of pain and instability related to symptomatic allograft subluxation and/or radioulnar convergence. Five patients underwent revision surgery; the mean time to revision was 26 months. CONCLUSIONS: Mid- to long-term follow-up of patients after salvage allograft interposition arthroplasty of the DRUJ resulted in minimal functional improvement in terms of arc of motion and grip strength. Persistent radioulnar pain was common, with half of the patients requiring revision operations following allograft interposition. Given this high failure rate, alternative procedures should be considered for the management of chronic pain and instability of the DRUJ. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Assessment of Medical Cannabis in Patients With Osteoarthritis of the Thumb Basal Joint.

PURPOSE: With the increasingly widespread availability of cannabidiol-derived products, more patients with hand and wrist pain are seeking evidence for use of these products. We explored current utilization practices of medical cannabis for treatment of pain in patients with a diagnosis of thumb basal joint arthritis. Secondary aims were to determine patient and thumb arthritis disease characteristics of cannabis users and nonusers and to investigate patient perceptions of the efficacy of medical cannabis in various formulations for the treatment of thumb arthritis pain. METHODS: Patients with thumb basal joint arthritis were identified using International Classification of Diseases, Tenth Revision codes between May and June 2020. All patients received an invitation to complete a survey regarding perceptions of cannabis and related products. Medical records were retrospectively reviewed to gather demographic information and thumb basal joint arthritis factors, including laterality, date of initial diagnosis, and prior treatment. RESULTS: The survey was completed by 103 patients. Twenty-five percent reported a history of oral medical cannabis use, and 21% reported topical medical cannabis use. Twelve of 25 oral users and 7 of 21 topical users believed that the product was effective in relieving pain and consequently worth the financial cost. Of the patients surveyed, 69% would be interested in trialing an oral formulation and 80% would be interested in trialing a topical formulation for treatment of their thumb pain. CONCLUSIONS: Patients with thumb basal joint arthritis use cannabis-related products, with mixed reports on efficacy. Large numbers of these patients would be interested in trialing either oral or topical formulations of medical cannabis for treatment of their thumb basal joint pain. CLINICAL RELEVANCE: It is important for medical providers to understand the current data available regarding analgesic properties of cannabidiol-related products to respond to patient inquiries about the use of cannabinoids in treating medical conditions.