Sesamoid View Weightbearing Radiography vs Weightbearing Computed Tomography in the Measurement of Metatarsal Pronation Angle.

BACKGROUND: First metatarsal pronation angle (MPA) is increasingly relevant in the management of hallux valgus and is assessed on weightbearing computed tomography (WBCT) and sesamoid-view weightbearing radiography (WBR). The purpose of this study is to compare MPA measured by WBCT against WBR to determine if any systematic discrepancy in MPA measurement exists between the 2 modalities. METHODS: A total of 40 patients with 55 feet were included for study. MPA was measured in all patients by 2 independent readers on both WBCT and WBR with an appropriate washout period between measurement modalities. Mean MPA by WBCT and WBR were analyzed; interobserver reliability was calculated with an intraclass correlation coefficient (ICC) value. RESULTS: Mean MPA as measured by WBCT was 3.7 ± 7.9 degrees (95% CI, 1.6-5.9; range -11.7 to 20.5). Mean MPA measured on WBR was 3.6 ± 8.4 degrees, (95% CI, 1.4-5.8; range -12.6 to 21.4). There was no difference in MPA as measured by WBCT compared to WBR (P = .529). Interobserver reliability was excellent with an ICC of 0.994 for WBCT and 0.986 for WBR. CONCLUSION: Measurement of first MPA by WBCT and WBR was not significantly different. In our cohort of patients with and without forefoot pathology, we found that either sesamoid view weightbearing radiographs or weightbearing CT can be used reliably to measure first MPA and will generate similar values. LEVEL OF EVIDENCE: Level IV, case series.

Minimizing Costs for Dorsal Wrist Ganglion Treatment: A Cost-Minimization Analysis.

PURPOSE: Dorsal wrist ganglions are treated commonly with aspiration, or open or arthroscopic excision in operating room (OR) or procedure room (PR) settings. As it remains unclear which treatment strategy is most cost-effective in yielding cyst resolution, our purpose was to perform a formal cost-minimization analysis from the societal perspective in this context. METHODS: A microsimulation decision analytic model evaluating 5 treatment strategies for dorsal wrist ganglions was developed, ending in either resolution or a single failed open revision surgical excision. Strategies included immediate open excision in the OR, immediate open excision in the PR, immediate arthroscopic excision in the OR, or 1 or 2 aspirations before each of the surgical options. Recurrence and complications rates were pooled from the literature for each treatment type. One-way sensitivity and threshold analyses were performed. RESULTS: The most cost-minimal strategy was 2 aspiration attempts before open surgical excision in the PR setting ($1,603 ± 1,595 per resolved case), followed by 2 aspirations before open excision in the OR ($1,969 ± 2,165 per resolved case). Immediate arthroscopic excision was the costliest strategy ($6,539 ± 264 per resolved case). Single aspiration preoperatively was more cost-minimal than any form of immediate surgery ($2,918 ± 306 and $4,188 ± 306 per resolved case performed in the PR and OR, respectively). CONCLUSIONS: From the societal perspective, performing 2 aspirations before surgical excision in the PR setting was the most cost-minimal treatment strategy, although in reference to surgeons who do not perform this procedure in the PR setting, open excision in the OR was nearly as cost-effective. As patient preferences may preclude routinely performing 2 aspirations, performing at least 1 aspiration before surgical excision improves the cost-effectiveness of dorsal wrist ganglions treatment. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic Decision Analysis II.

Cost Assessment of Plating Versus Tension Band Wiring Constructs for Treating Mayo Type 2A Olecranon Fractures.

PURPOSE: Tension band wiring (TBW) or plating may be used for fixation with similar clinical outcomes for adults with displaced Mayo 2A olecranon fractures. The primary hypothesis is that total direct costs (TDCs) for surgery are lower for TBW than plating. Our secondary hypothesis is that combined surgical TDCs are lower for TBW even with a 100% rate of subsequent tension band hardware removal and a 0% rate of plate removal. METHODS: Patients who underwent TBW or plating of an isolated unilateral Mayo 2A olecranon fracture between July 2011 and January 2020 at a single academic medical center were identified. Then, TDC for each surgery on plate fixation, TBW, and hardware removal was obtained and converted to 2020 US dollars using information technology cost tools provided by our institution. Finally, relative TDCs were compared between plate fixation and TBW groups using univariate and multivariable generalized estimating equations with log-link. RESULTS: Of the 97 included patients, the mean age was 50 ± 21 years, and 48% were female. Tension band wiring and plate fixation were performed on 18% (17/97) and 82% (80/97) of male and female patients, respectively. Demographics were similar between groups, although the finding that plate fixation cost 2.6 times that of TBW within the index surgery was significant in the multivariable model, independent of potential confounders (coefficient 2.55, 95% confidence interval: 2.09-3.10). Additionally, mean TDC remained significantly greater for plate fixation even under the hypothetical situation where 100% TBW were removed, and the plate removal rate was 0% (cost difference 181%). CONCLUSIONS: Using TBW relative to plate fixation may improve the cost of care for operative Mayo 2A olecranon fractures. Furthermore, this finding was robust to the rate of hardware removal. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic and Decision Analyses III.

Cost Implications of Varying the Surgical Setting and Anesthesia Type for Dorsal Wrist Ganglion Cyst Excision Surgery.

BACKGROUND: Minimizing expenses attributed to dorsal wrist ganglion cyst excisions, a common minor surgical procedure, presents potential for health care cost savings. Varying the surgical setting (operating room versus procedure room) and type of anesthesia (local-only, monitored anesthesia care, or monitored with regional or general anesthesia) may affect total operative costs. METHODS: Patients who underwent an isolated unilateral dorsal wrist ganglion cyst excision between January of 2014 and October of 2019 at a single academic medical center were identified by CPT code. The total direct costs for each surgical encounter that met inclusion criteria were calculated. The relative total direct costs were compared between surgical setting and anesthesia type groups. Univariate and multivariable gamma regression models were used to identify factors associated with surgical costs. RESULTS: A total of 192 patients were included; 26 cases (14 percent) were performed in the procedure room and 166 cases (86 percent) were performed in the operating room. No significant differences in demographic factors were identified between groups. Univariate analysis demonstrated that use of operating room/monitored anesthesia care, operating room/monitored anesthesia care with regional anesthesia, and operating room/general anesthesia groups, as compared to procedure room/local-only, yielded significantly greater median costs (1.76-, 2.34-, and 2.44-fold greater, respectively). Multivariable analysis demonstrated 1.80-, 2.10-, and 2.31-fold greater costs with use of operating room/monitored anesthesia care, operating room/monitored anesthesia care with regional anesthesia, and operating room/general anesthesia relative to procedure room/local-only, respectively. CONCLUSION: Performing dorsal wrist ganglion cyst excisions in a procedure room with local-only anesthesia minimizes operative direct costs relative to use of the operating room and other anesthetic types.

Online Readability Analysis: Mohs Micrographic Surgery Postsurgical Wound Care.

OBJECTIVE: Although various treatment modalities exist for skin cancer care, Mohs micrographic surgery (MMS) is one of the most effective and cosmetically sensitive surgical techniques. The readability of online informational materials specifically related to MMS postsurgical wound care is extremely relevant for patients given the high rates of skin cancer in the US and the number of patients utilizing the internet for information. METHODS: Investigators conducted Google searches to evaluate the current state of readability on MMS postsurgical wound care using the specific keywords "healing after Mohs surgery" and "wound care Mohs surgery." The readabilities of individual websites were analyzed using the WebFX online software. Health-specific click-through rate was used to select the number of samples assessed. RESULTS: Based on the 33 unique websites evaluated, the aggregate readability of online MMS postsurgical wound care materials was 11.3, corresponding to an 11th-grade reading level by US standards. CONCLUSIONS: Although this level of readability is an improvement in online MMS postsurgical wound care information relative to prior literature, there is still considerable work to be done by the dermatologic community in improving the readability of online patient materials regarding MMS.

Recommendation of Surgery and Other Interventions Is Associated With Increased Patient Satisfaction With Orthopedic Outpatient Visits.

The primary goal of our study was to determine whether satisfaction with orthopedic surgery outpatient visits is affected by a recommendation for surgery compared with a recommendation for nonoperative treatment, as measured by the Press Ganey Outpatient Medical Practice Survey (PGOMPS). Secondarily, we evaluated the effect of offering an injection, therapy, or any intervention (surgery, injection, therapy, immobilization, aspiration, or radiation therapy) on PGOMPS scores. To investigate this relationship, we reviewed new orthopedic outpatient visits at a tertiary academic center during a single year (2018). Patient satisfaction was defined as a PGOMPS score greater than the 33rd percentile. Univariate and multivariate binary logistic regression was conducted to determine the effect of a surgical recommendation and the effect of recommending an injection, therapy, or any intervention on the PGOMPS total score and provider subscore. Of the 1217 included patients, multivariate analysis showed that a surgical recommendation was significantly and independently associated with satisfaction on the PGOMPS total score and provider subscore. Multivariate analysis also showed that being offered an injection, therapy, or any intervention was significantly associated with higher PGOMPS total scores compared with not being offered those interventions. Patients who were offered surgery or other interventions were significantly more likely to be satisfied with their encounter and the surgeon. Patients who were offered surgery were significantly more likely to be satisfied with their encounter and the surgeon than those who were not offered surgery. Additionally, patients who were offered any intervention were significantly more likely to be satisfied with their encounter than those who were not offered an intervention. [Orthopedics. 2022;45(3):187-191.].