In Patients With Rotator Cuff Tears, Female, Hispanic, African American, Asian, Socially Deprived, Federally Insured, and Uninsured Patients Are Less Commonly Treated Surgically.

PURPOSE: The purpose of the current study was to evaluate socioeconomic factors affecting whether a patient undergoes rotator cuff repair after a diagnosis of a rotator cuff tear. METHODS: From 2009 through 2018, claims for adult (≥18 years of age) patients who were diagnosed with a primary rotator cuff injury were identified in the New York Statewide Planning and Research Cooperative System (SPARCS) database via International Classification of Diseases (ICD)-9th Revision-Clinical Modification (CM) and ICD-10-CM diagnostic codes. SPARCS is a comprehensive all-payer database collecting all inpatient and outpatient pre-adjudicated claims in New York. ICD-9-CM and ICD-10-CM codes were used to identify the initial diagnosis for each patient. Current Procedural Terminology codes were used to identify subsequent rotator cuff surgery. The procedures identified were linked with the initial diagnosis, and patients were noted as either having or not having rotator cuff surgery. Logistic regression analysis was performed for variables including age, sex, race, Social Deprivation Index (SDI), Charlson Comorbidity Index, and primary insurance type to determine the effect of patient factors on the likelihood of having surgery after a diagnosis of rotator cuff injury. RESULTS: Of the 67,584 rotator cuff patients included in the analysis, 19,770 (29.3%) of the patients underwent surgical intervention. From the logistic regression, females relative to males (odds ratio [OR] = 0.798, P < .0001), increased SDI (OR = 0.994, p < .0001), African American compared with White race (OR = 0.694, P < .0001), Asian compared with White (OR = 0.832, P < .0001), Hispanic compared with White (OR = 0.693, P < .0001), other race (OR = 0.58, P < .0001), those with Medicare (OR = 0.601, P < .0001) or Medicaid (OR = 0.614, P < .0001) relative to private insurance, and self-pay relative to private insurance (OR = 0.727, P < .0001) were all associated with decreased odds of undergoing rotator cuff surgery. Older patients (OR = 1.012, P < .0001) and Workers' Compensation relative to private insurance (OR = 1.664, P < .0001) had increased odds of undergoing surgery. CONCLUSIONS: The results of the current study identified disparities in the likelihood of undergoing rotator cuff repair after a diagnosis of a rotator cuff tear based on patient demographic and socioeconomic factors. Individuals with higher SDI; African American, Asian, Hispanic, or other non-White races; and those with Medicare, Medicaid, or self-pay insurance had decreased odds of surgery, whereas older age and Workers' Compensation insurance were associated with increased odds of undergoing surgery. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Open Versus Percutaneous Fixation of Trigger Finger: Meta-Analysis of Clinical Outcomes.

PURPOSE: With variable and conflicting results to date, it remains unclear whether the percutaneous or open surgical A1 pulley release technique is superior regarding safety and efficacy. The goal of this meta-analysis was to compare the two techniques. METHODS: PubMed, Cochrane, and Google Scholar (pages 1-20) were searched through August 2023. Eight randomized controlled trials met the inclusion criteria and were included in this meta-analysis. RESULTS: Of the eight included studies and 548 total patients, there were 278 subjects in the percutaneous release group and 270 subjects in the open release group. There was no significant difference between the two surgical techniques in postoperative rates of revision, complications, or pain. CONCLUSIONS: This meta-analysis found no significant difference between open and percutaneous techniques regarding the need for revision procedures, complications, or postoperative pain. Therefore, both open and percutaneous releases are appropriate. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.

Testosterone Replacement Therapy and Associated Rates of Trigger Finger, de Quervain Tenosynovitis, and Their Subsequent Management.

PURPOSE: Anabolic steroid therapy has been associated with tendon injury, but there is a paucity of evidence associating physiologic testosterone replacement therapy (TRT) with tenosynovitis of the hand, specifically trigger finger and de Quervain tenosynovitis. The purpose of this study was to evaluate the relationship between TRT and tenosynovitis of the hand. METHODS: This was a one-to-one exact matched retrospective cohort study using a large nationwide claims database. Records were queried between 2010 and 2019 for adult patients who filled a prescription for TRT for 3 consecutive months. Rates of new onset trigger finger and de Quervain tenosynovitis and subsequent steroid injection or surgery were identified using ICD-9, ICD-10, and Current Procedural Terminology billing codes. Single-variable chi-square analyses and multivariable logistic regression were used to compare rates in the TRT and control cohorts while controlling for potential confounding variables. Both unadjusted and adjusted odds ratios (OR) are reported for each comparison. RESULTS: In the adjusted analysis, patients undergoing TRT were more than twice as likely to develop trigger finger compared to their matched controls. TRT was also associated with an increased likelihood of experiencing de Quervain tenosynovitis. Of the patients diagnosed with either trigger finger or de Quervain tenosynovitis over the 2-year period, patients with prior TRT were roughly twice as likely to undergo steroid injections or surgical release for both trigger finger and de Quervain tenosynovitis compared to the controls. CONCLUSIONS: TRT is associated with an increased likelihood of both trigger finger and de Quervain tenosynovitis, and an increased likelihood of requiring surgical release for both conditions. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Return to Activity After Arthroscopically Assisted Triangular Fibrocartilage Complex Repair: A Systematic Review.

OBJECTIVE: To evaluate patients' ability to return to preinjury activity level after arthroscopically assisted triangular fibrocartilage complex (TFCC) repair. DATA SOURCES: The PubMed electronic library was systematically searched from inception to August 2021 for any eligible articles using a combination of the phrases "TFCC," "return to sport," "return to work," and "athlete." RESULTS: Studies that evaluated patients who had undergone arthroscopic repair of isolated TFCC injury and reported objective or patient-reported outcome measures were included. Fifteen studies representing 478 patients fulfilled the inclusion criteria. An average of 84% of patients were able to fully return to their previous work or sport activities. Most studies reported that range of motion (ROM) and grip strength (GS) both returned to >90% of the contralateral side, and every study that evaluated pain levels found a significant reduction in pain postoperatively. Mayo Modified Wrist Score was reported as excellent or good in 83% of patients, and the average Disabilities of the Arm, Shoulder, and Hand score was 13.8 postoperatively. CONCLUSION: Patients were able to return to their previous work or sport activities at a high rate after TFCC repair, even those participating in more strenuous activities. Measurable functional outcomes of ROM and GS were also reliably restored to near preinjury levels. Patient-reported outcomes of pain and disability were similarly improved after TFCC repair. Current literature has established the long-term success of TFCC repair but is lacking in evaluation of the time points at which patients can expect functional status to be restored.

Supplementary Fixation Improves Stability of Intra-Articular Distal Radius Fractures Managed With a Spanning Plate.

PURPOSE: Previous studies evaluating weight bearing of distal radius fractures treated through dorsal spanning bridge plates used extra-articular fracture models, and have not evaluated the role of supplementary fixation. We hypothesized that supplementary fixation with a spanning dorsal bridge plate for an intra-articular wrist fracture would decrease the displacement of individual articular pieces with cyclic axial loading and allow for walker or crutch weight bearing. METHODS: Thirty cadaveric forearms were matched into 3 cohorts, controlling for age, sex, and bone mineral density. An intra-articular fracture model was fixed with the following 3 techniques: (1) cohort A with a dorsal bridge plate, (2) cohort B with a dorsal bridge plate and two 1.6-mm k-wires, and (3) cohort C with a dorsal bridge plate and a radial pin plate. Specimens were axially loaded cyclically with escalating weights consistent with walker and crutch weight-bearing with failure defined as 2-mm displacement. RESULTS: No specimens failed at 2- or 5-kg weights, but cohort A had significantly more displacement at these weights compared with cohort B. Cohort A had significantly more failure than cohort C. Both cohort A and cohort B had significantly more displacement at crutch weight bearing compared with cohort C. The supplementary fixation group had significantly lower displacement at crutch weight-bearing compared with cohort A in all gaps. Survival curves demonstrated the fixation cohort to survive higher loads than the nonfixation group. CONCLUSION: There was significantly less displacement and less failure of intra-articular distal radius fractures treated with a spanning dorsal bridge plate and supplementary fixation. Our model showed that either type of fixation was superior to the nonfixation group. CLINICAL SIGNIFICANCE: When considering early weight-bearing for intra-articular distal radius fractures treated with a spanning dorsal bridge plate, supplementary fixation may be considered as an augmentation to prevent fracture displacement.

Perioperative Management of Immunosuppressive Medications for Rheumatoid Arthritis.

Operations in patients with rheumatoid arthritis are complicated by the fact that most drugs used in medical management have immunosuppressive mechanisms of action, including corticosteroids and conventional synthetic and biologic disease-modifying antirheumatic drugs. In deciding to continue or discontinue these medications perioperatively, surgeons must weigh the relative risk of infection from immunosuppression against the risk of rheumatoid arthritis symptom flares from reduced medical disease control. The objective of this article is to review the existing evidence regarding perioperative management of immunosuppressive rheumatoid arthritis medications, with a specific focus on relevance to hand and upper-extremity procedures.

Radiocarpal Fusion: Indications, Technique, and Modifications.

Degenerative disorders of the wrist may affect isolated joints and inhibit normal functions of the wrist secondary to pain and stiffness. These processes that affect only the radiocarpal joint may be secondary to posttraumatic osteoarthritis, primary osteoarthritis, or rheumatoid arthritis. Radiocarpal wrist arthrodesis may help preserve some of the native wrist kinematics while alleviating pain and improving the range of motion. However, the surgeon must ensure that the patient's pathologic process primarily affects the radiocarpal articulations while relatively sparing the midcarpal articulations. Depending on the location of the pathology, isolated radiolunate or radioscapholunate arthrodesis have been described to preserve some motion in the midcarpal joint. To maximize motion in the midcarpal joint after radiocarpal arthrodesis, techniques for distal scaphoid and triquetrum excision have been described. We report patient outcomes for various techniques and describe our preferred technique for radioscapholunate arthrodesis using distal scaphoid excision.

Cost Drivers in Carpal Tunnel Release Surgery: An Analysis of 8,717 Patients in New York State.

PURPOSE: The annual high volume of carpal tunnel releases (CTRs) has a large financial impact on the health care system. Validating the cost drivers related to CTR in a large, diverse patient population may aid in developing cost reduction strategies to benefit health care systems. METHODS: Adult patients with carpal tunnel syndrome who underwent CTR were identified in the New York Statewide Planning and Research Cooperative System database from 2016 to 2017. The Statewide Planning and Research Cooperative System is a comprehensive all-payer database that collects all inpatient and outpatient preadjudicated claims in New York. A multivariable mixed model regression with random effects was performed for the facility to assess the variables that contributed significantly to the total charge. The variables included were patient age, sex, anesthesia method, whether the surgery took place in an ambulatory surgery center or a hospital outpatient department, operation time in minutes, primary insurance type, race, ethnicity, Charlson Comorbidity Index, and categories for billed procedure codes. RESULTS: During the period of 2016 to 2017, 8,717 claims were included, with a mean charge per claim of $4,865. General anesthesia was associated with higher charges than local anesthesia. A procedure at a hospital outpatient department was associated with an approximately 48.2% increase in the total charge compared with that at an ambulatory surgery center. A 1-minute increase in the operation time was associated with a 0.3% increase in the total charge. Claims with antiemetics, antihistamines, benzodiazepines, intravenous fluids, narcotic agents, or preoperative antibiotics were associated with higher total charges than claims that did not bill for these. Compared with endoscopic procedures, open procedures had a 44.3% decrease in the total charges. CONCLUSIONS: This comprehensive multivariable model has validated that general anesthesia, hospital-based surgery, the use of antibiotics and opioids, longer operative times, and endoscopic CTR significantly increased the cost of surgery. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic and decision analyses II.

Weight-Bearing Restrictions With Distal Radius Wrist-Spanning Dorsal Bridge Plates.

PURPOSE: The fixation of comminuted distal radius fractures using wrist-spanning dorsal bridge plates has been shown to have good postoperative results. We hypothesized that using a stiffer bridge plate construct results in less fracture deformation with loads required for immediate crutch weight bearing. METHODS: We created a comminuted, extra-articular fracture in 7 cadaveric radii, which were fixed using dorsal bridge plates. The specimens were positioned to simulate crutch/walker weight bearing and axially loaded to failure. The axial load and mode of failure were measured using 2- and 5-mm osteotomy deformations as cutoffs. Bearing 50% and 22% of the body weight was representative of the force transmitted through crutch and walker weight bearing, respectively. RESULTS: The load to failure at 2-mm deformation was greater than 22% body weight for 2 of 7 specimens and greater than 50% for 1 of 7 specimens. The load to failure at 5-mm deformation was greater than 22% body weight for 6 of 7 specimens and greater than 50% for 4 of 7 specimens. The mean load to failure at 2-mm gap deformation was significantly lower than 50% body weight (110.4 N vs 339.2 N). The mean load to failure at 5-mm deformation was significantly greater than 22% body weight (351.8 N vs 149.2 N). All constructs ultimately failed through plate bending. CONCLUSIONS: All constructs failed by plate bending at forces not significantly greater than the 50% body weight force required for full crutch weight bearing. The bridge plates supported forces significantly greater than the 22% body weight required for walker weight bearing 6 of 7 times when 5 mm of deformation was used as the failure cutoff. CLINICAL RELEVANCE: Elderly, walker-dependent patients may be able to use their walker as tolerated immediately after dorsal bridge plate fixation for extra-articular fractures. However, patients should not be allowed to bear full weight using crutches immediately after bridge plating.

What's New in Pediatric Orthopaedic Health Care Disparities?

BACKGROUND: Health care disparities are prevalent within pediatric orthopaedics in the United States. Social determinants of health, such as income, race, social deprivation, place of residence, and parental involvement, all play a role in unequal access to care and disparate outcomes. Although there has been some effort to promote health equity both within pediatric orthopaedics and the US health care system altogether, disparities persist. In this review, we aim to identify major sources of inequality and propose solutions to achieve equitable care in the future. METHODS: We searched the PubMed database for papers addressing disparities in pediatric orthopaedics published between 2016 and 2021, yielding 283 papers. RESULTS: A total of 36 papers were selected for review based upon new findings. Insurance status, race, and social deprivation are directly linked to poorer access to care, often resulting in a delay in presentation, time to diagnostic imaging, and surgery. Although these disparities pervade various conditions within pediatric orthopaedics, they have most frequently been described in anterior cruciate ligament/meniscal repairs, tibial spine fractures, adolescent idiopathic scoliosis, and upper extremity conditions. Treatment outcomes also differ based on insurance status and socioeconomic status. Several studies demonstrated longer hospital stays and higher complication rates in Black patients versus White patients. Patients with public insurance were also found to have worse pain and function scores, longer recoveries, and lower post-treatment follow-up rates. These disparate outcomes are, in part, a response to delayed access to care. CONCLUSIONS: Greater attention paid to health care disparities over the past several years has enabled progress toward achieving equitable pediatric orthopaedic care. However, delays in access to pediatric orthopaedic care among uninsured/publicly insured, and/or socially deprived individuals remain and consequently, so do differences in post-treatment outcomes. Reducing barriers to care, such as insurance status, transportation and health literacy, and promoting education among patients and parents, could help health care access become more equitable. LEVEL OF EVIDENCE: Level IV-narrative review.

Surgeon and Facility Volumes Are Associated With Social Disparities and Post-Operative Complications After Total Hip Arthroplasty.

BACKGROUND: The purpose of this study is to further characterize the volume dependence of facilities and surgeons on morbidity and mortality after total hip arthroplasty (THA). METHODS: Adults who underwent THA from 2009 to 2014 were identified using International Classification of Diseases, Ninth Revision, Clinical Modification and Procedural codes in the New York Statewide Planning and Research Cooperative System database. Complication rates were compared across surgeon and facility volumes using multivariable Cox proportional hazards regression controlling for factors such as the Social Deprivation Index. Surgeon and facility volumes were compared between the low and high volume using cutoffs established by prior research. RESULTS: In total, 99,832 patients were included. Low volume facilities had higher rates of readmission, urinary tract infection (UTI), acute renal failure, pneumonia, surgical site infection (SSI), cellulitis, wound complications, deep vein thrombosis (DVT), in-hospital mortality, and revision. Low volume surgeons had higher rates of readmission, UTI, acute renal failure, pneumonia, SSI, acute respiratory failure, pulmonary embolism, cellulitis, wound complications, in-hospital mortality, cardiorespiratory arrest, DVT, and revision. African Americans, Hispanics, and those with federal insurance had increased rates of readmission. Those with ≥1 Charlson comorbidities or from areas of higher social deprivation had increased incidence of treatment by low volume surgeons and facilities. CONCLUSION: Both low volume facilities and surgeons performing primary THA have higher rates of readmission, UTI, acute renal failure, pneumonia, SSI, cellulitis, wound complications, DVT, in-hospital mortality, and revision. Demographic disparities exist between who is treated at low vs high volume surgeons and facilities placing those groups at higher risks for complications.

Characterization of the Epidemiology and Risk Factors for Hand Fractures in Patients Aged 1 to 19 Presenting to United States Emergency Departments: A Retrospective Study of 21,031 Cases.

BACKGROUND: Hand fractures are among the most common injuries presenting in pediatric emergency departments (EDs) with incidence reported as high as 624 hand fractures per 100,000 person-years. If gone untreated, these injuries can lead to pain, loss of function, and psychological trauma. The purpose of this study was to identify risk factors and characterize pediatric hand fractures over a 5-year period. METHODS: The National Electronic Injury Surveillance System (NEISS) was queried for all hand fractures in patients aged 1 to 19 years presenting to US EDs between 2016 and 2020. Incidence was calculated using US census data. Cases were retrospectively analyzed using age, location of the injury, sex, coronavirus disease-2019 (COVID-19) era, and etiology of injury. Bivariate logistic regression was used where appropriate. RESULTS: A total of 21,031 pediatric hand fractures were identified, representing an estimated 565,833 pediatric hand fractures presenting to EDs between 2016 and 2020. The mean incidence of pediatric hand fractures was 138.3 fractures for 100,000 person-years [95% confidence interval (CI): 136.2-140.4], with a 39.2% decrease in incidence occurring between 2019 and 2020. It was found that 42.2% of the fractures were in patients aged 10 to 14. The incidence of hand fractures for males and females was 97.9 (95% CI: 96.2-99.7) and 40.4 (95% CI: 39.2-41.5), respectively, with the male rate peaking at age 14 and the female rate peaking at age 12. Age, sex, location of the injury, and injury during the COVID-19 pandemic were demonstrated to influence the frequency and etiology of the fracture. CONCLUSION: This study determined the incidence of pediatric hand fractures presenting to EDs across the United States. In addition, it identified risk factors for common hand fracture etiologies (sports-related, falling, crush, punching) and demonstrated the change in rates of different etiologies of pediatric hand fractures that presented to US EDs during the COVID-19 pandemic. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Socioeconomic Disparities in the Utilization of Total Knee Arthroplasty.

BACKGROUND: Despite strong evidence supporting the efficacy of total knee arthroplasty (TKA), studies have shown significant socioeconomic disparities regarding who ultimately undergoes TKA. The purpose of the current study is to evaluate socioeconomic factors affecting whether a patient undergoes TKA after a diagnosis of osteoarthritis. METHODS: From 2011 to 2018, claims for adult patients diagnosed with knee osteoarthritis in the New York Statewide Planning and Research Cooperative System (SPARCS) database were analyzed. International Classification of Diseases (ICD), 9/10 CM codes were used to identify the initial diagnosis for each patient. ICD 9/10 PCS codes were used to identify subsequent TKA. Logistic regression analysis was performed to determine the effect of patient factors on the likelihood of having TKA. RESULTS: Of 313,794 osteoarthritis diagnoses, 33.3% proceeded to undergo TKA. Increased age (OR 1.007, P < .0001) and workers' compensation relative to commercial insurance (OR 1.865, P < .0001) had increased odds of TKA. Compared to White race, Asian (OR 0.705, P < .0001), Black (OR 0.497, P < .0001), and "other" race (OR 0.563, P < .0001) had lower odds of TKA. Hispanic ethnicity (OR 0.597, P < .0001) had lower odds of surgery. Compared to commercial insurance, Medicare (OR 0.876, P < .0001), Medicaid (OR 0.452, P < .0001), self-pay (OR 0.523, P < .0001), and "other" insurance (OR 0.819, P < .0001) had lower odds of TKA. Increased social deprivation (OR 0.987, P < .0001) had lower odds of TKA. CONCLUSION: TKA is associated with disparities among race, ethnicity, primary insurance, and social deprivation. Additional research is necessary to identify the cause of these disparities to improve equity in orthopedic care.

Socioeconomic Disparities in the Utilization of Total Hip Arthroplasty.

BACKGROUND: There is increasing focus on highlighting disparities in both access to and equity of care in orthopedics and understanding the impact disparities have on patient health. The purpose of the present study is to evaluate socioeconomic-related factors affecting whether a patient undergoes total hip arthroplasty (THA) after a diagnosis of osteoarthritis. METHODS: From 2011 to 2018, patients ≥40 years of age diagnosed with hip osteoarthritis were identified in the New York Statewide Planning and Research Cooperative System, a comprehensive all-payer database collecting preadjudicated claims in New York State. International Classification of Diseases, Ninth Revision/Tenth Revision codes were used to identify the initial diagnosis and subsequent THA. Logistic regression analysis was performed to determine the effect of patient factors on the likelihood of undergoing THA. RESULTS: Of 142,681 hip osteoarthritis diagnoses, 48.6% proceeded to THA. Compared to non-Hispanic white patients, Asian (odds ratio [OR] 0.65, P < .0001), Black (OR 0.51, P < .0001), and "Other" race (OR 0.54, P < .0001) had lower odds of THA. Hispanic patients (OR 0.55, P < .0001) had lower odds of surgery. Compared to commercial insurance, Medicare (OR 0.83, P < .0001), Medicaid (OR 0.49, P < .0001), Self-pay (OR 0.78, P < .0001), and workers' compensation (OR 0.71, P < .0001) had lower odds of THA. Having one or more Charlson Comorbidity Index (OR 0.45, P < .0001) was associated with lower odds of THA, as was increased social deprivation (OR 0.99, P < .0001). CONCLUSION: THA is associated with disparities among race, gender, primary insurance, and social deprivation. Additional research is necessary to identify the cause of these disparities to improve equity in patient care.

Outpatient Operative Management of Pediatric Supracondylar Humerus Fractures: An Analysis of Frequency, Complications, and Cost From 2009 to 2018.

BACKGROUND: In an effort to increase the value of health care in the United States, there has been increased focus on shifting certain procedures to an outpatient setting. While pediatric supracondylar humerus fractures (SCHFs) have traditionally been treated in an inpatient setting, recent studies have investigated the safety and efficiency of outpatient surgery for these injuries. This retrospective study aims to examine ongoing trends of outpatient surgical care for SCHFs, examine the safety and complication rates of these procedures, and investigate the potential cost-savings from this shift in care. METHODS: Pediatric patients less than 13 years old who underwent surgery for closed SCHF from 2009 to 2018 were identified using International Classification of Diseases-9/10 Clinical Modification and Procedural Classification System codes in the New York Statewide Planning and Research Cooperative System (SPARCS) database. Linear regression was used to assess the shift in proportion of outpatient surgical management of these injuries over time. Multivariable Cox proportional hazards regression was used to compare return to emergency department (ED) visit, readmission, reoperation, and other adverse events. A 2-sample t test was performed on the average charge amount per claim for inpatient versus outpatient surgery. RESULTS: A total of 8488 patients were included in the analysis showing there was a statistically significant shift towards outpatient management between 2009 (23% outpatient) and 2018 (59% outpatient) (P<0.0001). Relative to inpatient surgical management, outpatient surgical management had lower rates of return ED visits at 1 month (hazard ratio: 0.744, P=0.048). All other adverse events compared across inpatient and outpatient surgical management were not significantly different. The median amount billed per claim for inpatient surgeries was significantly higher than for outpatient surgeries ($16,097 vs. $9,752, P<0.0001). White race, female sex, and weekday ED visit were associated with increased rate of outpatient management. CONCLUSIONS: This study demonstrates the trend of increasing outpatient surgical management of pediatric SCHF from 2009 to 2018. The increased rate of outpatient management has not been associated with elevated complication rates but is associated with significantly reduced health care charges. LEVEL OF EVIDENCE: Level III-retrospective cohort.

Performance Metrics in Hand Surgery: Turning a Blind Eye Will Cost You.

The Medicare Access and Children's Health Insurance Program Reauthorization Act established the Quality Payment Program (QPP), which mandates that physicians who meet the threshold in volume of Medicare patients for whom they care participate in this program through either advanced Alternative Payment Models or the Merit-Based Incentive Payment System. Anticipating physicians' concerns regarding the burden of implementing the QPP, feedback from physicians became a critical component of the continued implementation process in 2018. The purpose of this review is to inform hand surgeons regarding the current QPP (early 2019) and for future observation periods.

Three-dimensional characterization of trabecular bone mineral density of the proximal ulna using quantitative computed tomography.

BACKGROUND: Although previous studies have measured general proximal forearm bone mineral density (BMD), no study has systematically mapped the 3-dimensional trabecular BMD of the proximal ulna. The aim of this study was to describe the 3-dimensional distribution of the trabecular bone density of the proximal ulna. We hypothesize a variable distribution of proximal ulna trabecular BMD depending on the region of interest (ROI). METHODS: Computed tomographic (CT) scans of 9 fresh-frozen cadaveric proximal ulna specimens with a mean age of 59.3 ± 8.1 years were studied. Each CT file was converted from DICOM to a QCT file that could be analyzed using QCT software (QCT Pro Version 6.1, Model 4 CT Calibration Phantom; MindWays Software Inc, Austin, TX, USA). The ROIs were defined as spheres of trabecular bone 3 mm in diameter located throughout the proximal ulna. RESULTS: ROIs proximal to the trochlear notch demonstrated higher BMD than ROIs distal to the trochlear notch. Furthermore, volar ROIs adjacent to the ulnohumeral joint tended to have higher BMD than dorsal ROIs. The highest BMD was found in the tip of the olecranon. CONCLUSION: Hardware in fixation constructs for proximal ulnar fractures should be directed toward ROIs with the highest BMD to maximize purchase. Hardware should approach the ulnohumeral joint without penetrating the joint to capture trabecular bone with the highest BMD. The most important fixation in such a construct will be that which captures trabecular bone with maximum BMD proximal to the trochlear notch (eg, the tip of the olecranon).

The 6-O'clock Anchor Increases Labral Repair Strength in a Biomechanical Shoulder Instability Model.

PURPOSE: To characterize the additive effect of a 6-o'clock anchor in the stabilization of a Bankart lesion. METHODS: Twelve cadaveric shoulders were tested on a 6-df robotic musculoskeletal simulator to measure the peak resistance force due to anterior displacement of 1 cm. The rotator cuff muscles were loaded dynamically. The test conditions consisted of the intact shoulder, Bankart lesion, Bankart repair (3-, 4-, and 5-o'clock anchors), and Bankart repair with the addition of a 6-o'clock anchor. A 13% anterior bone defect was then created, and all conditions were repeated. Repeated-measures analysis of variance was performed. RESULTS: In the group with no bone loss, the addition of a 6-o'clock anchor yielded the highest peak resistance force (52.8 N; standard deviation [SD], 4.5 N), and its peak force was significantly greater than that of the standard Bankart repair by 15.8% (7.2 N, P = .003). With subcritical glenoid bone loss, the repair with the addition of a 6-o'clock anchor (peak force, 52.6 N; SD, 6.1 N; P = .006) had a significantly higher peak resistance force than the group with bone loss with a Bankart lesion (35.2 N; SD, 5.8 N). Although the 6-o'clock anchor did increase the strength of the standard repair by 6.7%, this was not statistically significant (P = .9) in the bone loss model. CONCLUSIONS: The addition of a 6-o'clock suture anchor to a 3-anchor Bankart repair increases the peak resistance force to displacement in a biomechanical model, although this effect is lost with subcritical bone loss. CLINICAL RELEVANCE: This study provides surgeons with essential biomechanical data to aid in the selection of the repair configuration.

Management of Diabetic Trigger Finger.

Diabetics have a much greater prevalence of trigger finger than nondiabetics and are more likely to have severe symptoms. Diabetic trigger finger may be more accurately described on a spectrum of diabetic hand pathology alongside carpal tunnel syndrome and cheiroarthropathy. Recent publications have called into question the current treatment algorithm for diabetic trigger finger. Although some evidence supports the use of corticosteroid injections, a recent cost analysis reported that immediate surgical release of the A1 pulley in the clinic is the most cost-effective management of diabetic trigger finger. In addition to traditional treatment with injection and open release, percutaneous release with or without simultaneous corticosteroid injection has shown promising results and may have a role in patient care. The appropriate treatment algorithm in terms of efficacy, safety, and cost remains controversial.

Patient and Parent Satisfaction With Sling Use After Pediatric Upper Extremity Fractures: A Randomized Controlled Trial of a Customized Cast-Sling Versus Standard Cast and Sling.

BACKGROUND: Long arm cast immobilization after operative and nonoperative treatment of pediatric upper extremity fractures is common. The use of a sling to aid in carrying the casted extremity as well as provide further immobilization is also common practice. Off-the-shelf slings vary in quality and fit, can be confusing for parents/patients to apply, and lead to frustration and dissatisfaction with its use. The purpose of this investigation was to compare patient/parent centered outcomes after the use of a customized sling compared with a standard sling by utilizing a prospective, randomized-controlled trial. We hypothesized that patients and their parents would find the "Providence" Pedi Cast-Sling (PPCS) to be more convenient and be more satisfied with its use compare with a standard sling. METHODS: Eligible subjects included patients 0 to 18 years old, evaluated at an urban, tertiary care pediatric emergency department (ED), who sustained an upper extremity fracture that required placement of a long-arm cast. Exclusion criteria were: open fractures; fractures at multiple levels; fractures requiring urgent/emergent surgery; admitted patients; bivalved casts. Patients were randomized to receive a standard sling or a PPCS. Questionnaires assessing patient/parent satisfaction, preferences, sling-use, and pain level were collected at patients' first follow-up visit. RESULTS: A total of 100 patients were randomized with 71 questionnaires available for analysis (39 standard sling vs. 32 PPCS). There were statistically significant differences for satisfaction scores for all related questions between patients who received a PPCS compared with a standard sling. Patients and their parents were more likely to choose the PPCS (P=0.001), were more satisfied with the PPCS (P<0.006), and reported the PPCS to be more convenient than a standard sling (P<0.001). Patients who received a PPCS wore the sling for a greater number of hours during the day (10.3±7.1 h) compared with those who received a standard sling (5.9±5.0 h) (P=0.004). CONCLUSIONS: The "Providence" Pedi Cast-Sling is a superior alternative to an off-the-shelf sling when used after the application of a long-arm cast providing greater convenience, compliance, and satisfaction to both patients and families. LEVEL OF EVIDENCE: Level I-Prospective randomized-controlled trial.