ACR Appropriateness Criteria® Chronic Shoulder Pain: 2022 Update.

Chronic shoulder pain is an extremely common presenting complaint. Potential pain generators include the rotator cuff tendons, biceps tendon, labrum, glenohumeral articular cartilage, acromioclavicular joint, bones, suprascapular and axillary nerves, and the joint capsule/synovium. Radiographs are typically the initial imaging study obtained in patients with chronic shoulder pain. Further imaging may often be required, with modality chosen based on patient symptoms and physical examination findings, which may lead the clinician to suspect a specific pain generator. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Procedure Costs of Peripheral Nerve Graft Reconstruction.

Peripheral nerve injuries not repaired in an effective and timely manner may lead to permanent functional loss and/or pain. For gaps greater than 5 mm, autograft has been the gold standard. Allograft has recently emerged as an attractive alternative, delivering comparable functional recovery without risk of second surgical site morbidities. Cost is an important factor when considering surgical options, and with a paucity of nerve repair cost data, this study aimed to compare allograft and autograft procedure costs. Methods: A retrospective cross-sectional observational study using the US all-payer PINC AI Healthcare Database examined facility procedure costs and cost drivers in patients undergoing allograft or autograft repair of an isolated single peripheral nerve injury between January 2018 and August 2020. Inpatient repairs were limited to nerve-specific DRGs. Multivariable regression evaluated risk-adjusted procedure cost differences. Results: Peripheral nerve graft repairs (n = 1363) were more frequent in the outpatient setting, and more than half involved the use of allograft nerve. Procedure costs for allograft and autograft repair were not significantly different in the outpatient (P = 0.43) or inpatient (P = 0.71) setting even after controlling for other risk factors. Operating room cost was significantly higher for autograft in outpatient (P < 0.0001) but not inpatient (P = 0.46), whereas allograft implant cost was significantly higher in both settings (P < 0.0001). Conclusions: No significant differences in procedure costs for autograft and allograft repair in inpatient and outpatient settings were found using real-world data. Future research should explore longer-term costs.

ACR Appropriateness Criteria® Chronic Elbow Pain.

Chronic elbow pain can be osseous, soft tissue, cartilaginous, and nerve related in etiology. Imaging plays an important role in differentiating between these causes of chronic elbow pain. This document provides recommendations for imaging of chronic elbow pain in adult patients. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Acute Compartment Syndrome as a Complication of Radial Artery Catheterization.

Acute compartment syndrome is a rare complication of radial artery catheterization. If not identified and treated emergently, it can lead to profound disability or limb loss. Here, we discuss a rare case of acute compartment syndrome in the forearm of a 54-year-old man after transradial catheterization and anticoagulation for myocardial infarction, which ultimately required emergent fasciotomies and prolonged hospital care. The benefits of a percutaneous intervention performed through radial artery catheterization will almost always outweigh the risks of the catheterization itself; however, the serious complication of forearm hematoma leading to acute compartment syndrome should be discussed with patients as a potential procedural risk. The signs and symptoms of acute compartment syndrome should be reviewed by perioperative staff and physicians to rapidly identify the evolving condition and initiate appropriate treatment. This case report follows CARE guidelines.

Report on the Evidence-Based Practice Committee's Survey on Dupuytren Disease.

Purpose: The Evidence-Based Practice Committee of the American Society for Surgery of the Hand (ASSH) set out to assess the membership's practice patterns (PPs) and knowledge of evidence-based principles for Dupuytren disease (DD). Methods: A 21-item multiple-choice survey was distributed to all ASSH members via email in June 2020. Questions were divided into 2 types: evidence-based practice (EBP) and PPs. The survey addressed the following subtopics: nonsurgical, percutaneous, and open surgical management of DD. Results: The response rate was 18% (n = 419). Of 13 EBP questions, 5 were answered with the preferred response by >75% of surgeons. The remaining 8 EBP questions had greater frequencies of less preferred responses, which concerned the current evidence for percutaneous management, as well as nonsurgical and postoperative management of DD. Of the PP questions, there were differences in opinion on how to manage a painful nodule, the percutaneous technique (eg, collagenase injection vs percutaneous needle aponeurotomy), and the choice of surgical incision for open fasciectomy (eg, Bruner incision with Z-plasties, partial closure with an open transverse palmar component, or longitudinal incision with Z-plasties). Conclusions: Hand surgeons continue to be well informed about current evidence-based practices for treating DD and can improve their knowledge by familiarizing themselves with current data on percutaneous and nonsurgical methods. There exist differences in PPs for DD in the ASSH membership, specifically with less invasive management; and knowledge of peer practices can help navigate differences, critically interpret the evidence, and optimize patient care. Type of study/level of evidence: Economic/Decision Analyses V.

Physician Reimbursement: Fee-for-Service, Accountable Care, and the Future of Bundled Payments.

In 1992, the use of relative value units to link a particular payments with specific services was initiated to replace traditional fee for service. The system incentivizes volume rather than quality. In 1997, initiatives were formalized to emphasize quality measures. Physicians must participate in the Merit-based Incentive Payment System (MIPS). Physicians can opt out of MIPS if they participate in an Alternative Payment Model such as Bundled Payments. Reimbursement based on an episode of care reduces perceived incentive to increase volumes, but may result in difficulty with access to care for patients with complex medical issues or significant comorbidities.

Long-Term Donor-Site Morbidity After Free, Nonvascularized Toe Phalanx Transfer for Congenital Differences of the Hand.

PURPOSE: Toe phalanx transplantation is a well-established technique for addressing bony deficiency in the reconstruction of hypoplastic digits in patients with congenital differences of the hand. Prior studies have commented on varying degrees of donor-site morbidity, although assessment of morbidity with validated outcome scores is lacking. This study seeks to evaluate donor-site morbidity after toe phalanx harvest using validated outcome measures. METHODS: We identified all children who underwent free, nonvascularized toe phalanx transfer to the hand at our institution from 2001 to 2011. We administered the Oxford Ankle Foot Questionnaire for Children (OXAFQ-C) and the Foot and Ankle Ability Measure (FAAM) to all patients, scaling results according to published scoring instructions. RESULTS: Thirty-six patients with 83 toe phalanx transfers were able to be contacted, with a mean follow-up of 5.3 years (range, 18 months-11.2 years). The results of the OXAFQ-C showed mean scores of 99.96% (Physical), 100% (School and Play), and 96.01% (Emotional). The FAAM mean scores were 99.08% (Sports) and 99.17% (Activities of Daily Living). There were no lower extremity complications during the study period. CONCLUSIONS: In contrast to varying degrees of donor-site morbidity reported in the current literature, this study demonstrates that toe phalanx harvest causes almost no measurable lower extremity morbidity or dysfunction over the mid- to long-term. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Traumatic C4-C5 unilateral facet dislocation with posterior disc herniation above a prior anterior fusion.

We report the case of a unilateral cervical facet dislocation above the level of a prior non-instrumented cervical discectomy and fusion, resulting in incomplete neurologic injury. Pre-reduction imaging demonstrated a large posterior disk extrusion. This finding altered our management approach from closed reduction to urgent anterior cervical discectomy, open anterior reduction, and fusion. The patient had excellent neurologic recovery and outcome at 12 months postoperative follow-up.

Pseudarthrosis of the spine.

Pseudarthrosis is the result of failed attempted spinal fusion. This condition typically manifests with axial or radicular pain months to years after the index operation. Diagnosis is based on clinical presentation and imaging studies, after other causes of persistent pain are ruled out. The degree of motion seen on flexion-extension radiographs that is indicative of solid or failed fusion remains a point of controversy. Thin-cut CT scans may be more reliable than radiographs in demonstrating fusion. Metabolic factors, patient factors, use and choice of instrumentation, fusion material, and surgical technique have all been shown to influence the rate of successful fusion. Treatment of the patient with symptomatic pseudarthrosis involves a second attempt at fusion and may require an approach different from that of the index surgery as well as the use of additional instrumentation, bone graft, and osteobiologic agents.

Unstable distal radial fractures treated with external fixation, a radial column plate, or a volar plate. A prospective randomized trial.

BACKGROUND: Optimal surgical management of unstable distal radial fractures is controversial, and evidence from rigorous comparative trials is rare. We compared the functional outcomes of treatment of unstable distal radial fractures with external fixation, a volar plate, or a radial column plate. METHODS: Forty-six patients with an injury to a single limb were randomized to be treated with augmented external fixation (twenty-two patients), a locked volar plate (twelve), or a locked radial column plate (twelve). The fracture classifications included Orthopaedic Trauma Association (OTA) types A3, C1, C2, and C3. The patients completed the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire at the time of follow-up. Grip and lateral pinch strength, the ranges of motion of the wrist and forearm, and radiographic parameters were also evaluated. RESULTS: At six weeks, the mean DASH score for the patients with a volar plate was significantly better than that for the patients treated with external fixation (p = 0.037) but similar to that for the patients with a radial column plate (p = 0.33). At three months, the patients with a volar plate demonstrated a DASH score that was significantly better than that for both the patients treated with external fixation (p = 0.028) and those with a radial column plate (p = 0.027). By six months and one year, all three groups had DASH scores comparable with those for the normal population. At one year, grip strength was similar among the three groups. The lateral pinch strength of the patients with a volar plate was significantly better than that of the patients with a radial column plate at three months (p = 0.042) and one year (p = 0.036), but no other significant differences in lateral pinch strength were found among the three groups at the other follow-up periods. The range of motion of the wrist did not differ significantly among the groups at any time beginning twelve weeks after the surgery. At one year, the patients with a radial column plate had maintained radial inclination and radial length that were significantly better than these measurements in both the patients treated with external fixation and those with a volar plate (all p < 0.05). CONCLUSIONS: Use of a locked volar plate predictably leads to better patient-reported outcomes (DASH scores) in the first three months after fixation. However, at six months and one year, the outcomes of all three techniques evaluated in this study were found to be excellent, with minimal differences among them in terms of strength, motion, and radiographic alignment.

Grouping in object recognition: the role of a Gestalt law in letter identification.

The Gestalt psychologists reported a set of laws describing how vision groups elements to recognize objects. The Gestalt laws "prescribe for us what we are to recognize 'as one thing'" (Kohler, 1920). Were they right? Does object recognition involve grouping? Tests of the laws of grouping have been favourable, but mostly assessed only detection, not identification, of the compound object. The grouping of elements seen in the detection experiments with lattices and "snakes in the grass" is compelling, but falls far short of the vivid everyday experience of recognizing a familiar, meaningful, named thing, which mediates the ordinary identification of an object. Thus, after nearly a century, there is hardly any evidence that grouping plays a role in ordinary object recognition. To assess grouping in object recognition, we made letters out of grating patches and measured threshold contrast for identifying these letters in visual noise as a function of perturbation of grating orientation, phase, and offset. We define a new measure, "wiggle", to characterize the degree to which these various perturbations violate the Gestalt law of good continuation. We find that efficiency for letter identification is inversely proportional to wiggle and is wholly determined by wiggle, independent of how the wiggle was produced. Thus the effects of three different kinds of shape perturbation on letter identifiability are predicted by a single measure of goodness of continuation. This shows that letter identification obeys the Gestalt law of good continuation and may be the first confirmation of the original Gestalt claim that object recognition involves grouping.

Mucormycosis of the upper extremity in a patient with alcoholic encephalopathy.

UNLABELLED: Cutaneous mucormycosis is a rare opportunistic infection caused by fungi of the class Zygomycetes that can be rapidly fatal if unrecognized. The diagnosis of this infection is often made by infectious disease, dermatologic, or intensive care specialists. Lesions that affect the upper limb may require a hand surgeon to diagnose the infection. The diagnosis may be difficult to make, because these infectious lesions can be confused with ischemic pathology. We report on a rare case of cutaneous mucormycosis caused by Rhizopus arrhizus in a patient with cirrhosis and renal failure who presented with an ischemic hand. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic V.