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.

Timing of Olecranon Fracture Fixation Does Not Affect Early Complication or Reoperation Rates.

Purpose: Surgical fixation of olecranon fractures can lead to soft-tissue complications and return to the operating room for hardware removal. While some risk factors of complications after olecranon fracture fixation have been described, the effects of fixation timing on complications and reoperation have not been evaluated. The purpose of the present study was to assess whether the timing of olecranon fracture fixation affects complication and reoperation rates. Methods: All patients who underwent olecranon fracture open reduction and internal fixation at a single level 1 trauma center from January 2012 to February 2022 were included in the study. A retrospective review was performed to evaluate patients for inclusion and to identify patient demographic factors, medical comorbidities, concomitant injuries, mechanism of injury, and time to fixation. Operative and clinical notes were evaluated to identify fixation type and outcomes of interest. Patients were stratified into early, standard, and delayed fixation groups (0-3 days, 4-14 days, and >14 days, respectively) for independent analyses, and Fisher's exact test was used to identify differences in complications and reoperations between groups. Multivariate analysis was used to assess associations between patient demographic factors, complication rates, and time to surgery. Results: A total of 97 patients met inclusion criteria of having an olecranon open reduction and internal fixation and had a minimum follow-up of at least 10 weeks, with an average follow-up of 7.1 months. The average time to surgery in the overall cohort was 9.3 days. There were no differences in the number of total complications and rate of reoperation among the three cohorts. Smoking was found to be significantly associated with total complications, while open fracture was significantly associated with reoperation. Polytrauma and open fracture were significantly associated with earlier operation, while smoking was significantly associated with delayed fixation. Conclusions: The timing of fixation of displaced olecranon fractures does not significantly increase the rate of early complications or reoperation. Type of study/level of evidence: Symptom Prevalence Study III.

Ultrasound and patient-reported outcomes of rotator cuff repair with new acellular human allograft at 6 months and 1 year post surgery.

Background: Determine the effect of a novel acellular cannulated dermal allograft on tendon-to-bone healing, retear rates, and clinical outcomes over a 12-month period. Methods: This was a single surgeon prospective nonrandomized case series. Patients with medium sized full-thickness superior and posterosuperior rotator cuff tears, as confirmed by magnetic resonance imaging, were consented. Patients were excluded if they had fatty atrophy indicative of Goutallier grade III or IV. The allograft is a cannulated rectangular prism that has a 5-year shelf life, does not require prehydration, and does not need to be trimmed to size. Outcome metrics included ultrasound assessment at 1-year as well as 6-month patient-reported outcomes (PROs) scores. Results: 31 patients consented and enrolled in this consecutive cohort series. 9 patients were excluded, and statistical analysis was performed on the remaining 22 patients. There were 9 females and 13 males. The average age was 59.27 ± 7.48 year old. The average supraspinatus short axis measurement in males was 0.56 ± 0.12 cm and 0.52 ± 0.09 cm in females (P = .44). The average supraspinatus long axis measurement in males was 0.61 ± 0.18 cm and 0.55 ± 0.14 cm in females (P = .46). The average infraspinatus short axis measurement in males was 0.48 ± 0.10 cm and 0.50 ± 0.13 in females (P = .74). The average infraspinatus long axis measurement in males was 0.44 ± 0.12 cm and 0.43 ± 0.08 cm in females (P = .84). Of the 19 patients who completed baseline and 6-month PRO's, 17 achieved the minimal clinical important difference for American Shoulder and Elbow Surgeons and Patient-Reported Outcomes Measurement Information SystemUE 7a. Retear occurred in 2 cases. The remaining 20 cases have all demonstrated healing or fully healed repairs at their most recent clinical visits with no additional cases of retears. Conclusion: This study is the first to report the results of a novel acellular dermal allograft for rotator cuff repair augmentation. Satisfactory PRO measures and robust tendon healing at 1 year, as measured by ultrasound, demonstrate the utility of a cannulated human acellular dermal allograft as a viable biologic augmentation device for rotator cuff repair.

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.

Successfully Treated Upper-Extremity Necrotizing Fasciitis Caused by Photobacterium damselae.

Necrotizing fasciitis is a soft-tissue infection associated with significant morbidity and mortality. The bacteria most associated with necrotizing fasciitis include Streptococcus pyogenes (group A), Clostridium species, Streptococcus species, and Staphylococcus species. Photobacterium damselae (P. damselae), formerly known as Vibrio damselae, is a halophilic, gram-negative bacillus known to infect marine organisms in warm coastal waters. Necrotizing fasciitis associated with P. damselae has been reported to have higher rates of serious complications and mortality because of an atypical presentation and a rapidly progressive course. This report presents a case of successfully treated P. damselae necrotizing fasciitis of the upper extremity and the nuances of management that led to a favorable outcome in which the patient was discharged for home without complications.

Arthrodesis of the First to Second Metacarpal for Definitive Management of Failed Thumb Carpometacarpal Arthroplasty: A Case Series.

Thumb carpometacarpal (CMC) arthroplasty with resection of the trapezium and soft tissue interposition, with or without ligament reconstruction, has historically proven to be an efficacious treatment for thumb CMC arthritis. The incidence of failure following primary thumb CMC arthroplasty is low; however, the evaluation and management of a patient experiencing an unsatisfactory outcome following CMC arthroplasty is challenging. If symptoms are refractory to conservative measures, then revision surgical treatment may be indicated. Clinical decision making becomes even more complicated in cases of failure after an initial revision surgery has already been performed. In patients with a failed CMC arthroplasty revision in whom all soft tissue options have been exhausted, the senior author considers arthrodesis of the first metacarpal base to the second metacarpal base as a salvage procedure. The authors describe this surgical technique and present our experience with 4 cases in 3 patients who underwent this surgical intervention. Successful radiographic fusion was achieved in all 4 cases, with satisfactory clinical outcome in 3 out of 4 cases, supporting this surgical technique as a definitive option for patients who have failed multiple CMC arthroplasty revision surgeries.

An analysis of the incidence, risk factors, and timing of development of cyclops lesions after anterior cruciate ligament reconstruction.

BACKGROUND: Cyclops lesions are a known complication following anterior cruciate ligament reconstruction (ACLR) with a described incidence between 1.9% to 10.9%. The objective of this study was to identify the incidence, timing, and variables that correlated with development of a cyclops lesion, and if objective functional testing differed between patients with and without cyclops lesions. METHODS: 313 consecutive patients who underwent ACLR and participated in Lower-Extremity Assessment Protocol (LEAP) testing at a single, academic institution were analyzed. Retrospective chart review was performed to identify patient demographic factors, medical comorbidities, and potential peri-operative risk factors. Postoperative functional outcome metrics and patient reported outcomes were collected per the institution's LEAP testing protocol. Binary logistic regression was utilized to identify risk factors for cyclops lesions. Objective functional outcomes and patient reported outcomes were compared between patients with and without cyclops lesions. RESULTS: 23/313 (7.35%) patients developed a cyclops lesion following ACLR, of which 17 (73.91%) were found to be symptomatic. Concomitant meniscal repair correlated with an increased likelihood of developing a cyclops lesion (p = 0.040); no other risk factors significantly differed between cohorts. There were no clinically relevant extension deficits or differences in objective functional performance measures at six months post-operatively between study cohorts. CONCLUSIONS: Concomitant meniscal repair may be associated with the development of cyclops lesions due to restrictive postoperative range of motion protocols; however no other pre- or intra-operative factors demonstrated significant correlation. Presence of a cyclops lesion should be considered with late loss of knee extension after ACLR.

Flexible Versus Rigid Reaming Systems for Independent Femoral Tunnel Reaming During ACL Reconstruction: Minimum 2-Year Clinical Outcomes.

Background: Radiographic and cadaveric studies have suggested that anatomic anterior cruciate ligament reconstruction (ACLR) femoral tunnel drilling with the use of a flexible reaming system through an anteromedial portal (AM-FR) may result in a different graft and femoral tunnel position compared with using a rigid reamer through an accessory anteromedial portal with hyperflexion (AAM-RR). No prior studies have directly compared clinical outcomes between the use of these 2 techniques for femoral tunnel creation during ACLR. Purpose: To compare revision rates at a minimum of 2 years postoperatively for patients who underwent ACLR with AM-FR versus AAM-RR. The secondary objectives were to compare functional testing and patient-reported outcomes between the cohorts. Study Design: Cohort study; Level of evidence, 3. Methods: Included were consecutive patients at a single academic institution between 2013 and 2018 who underwent primary ACLR without additional ligamentous reconstruction. Patients were separated into 2 groups based on the type of anatomic femoral tunnel drilling: AM-FR or AAM-RR. Graft failure, determined by revision ACLR, was assessed with a minimum 2 years of postoperative follow-up. The authors also compared patient-reported outcome scores (International Knee Documentation Committee [IKDC] and Knee injury and Osteoarthritis Outcome Score [KOOS]) and functional performance testing performed at 6 months postoperatively. Results: A total of 284 (AAM-RR, 232; AM-FR, 52) patients were included. The mean follow-up time was 3.7 ± 1.5 years, with a minimum 2-year follow-up rate of 90%. There was no significant difference in the rate of revision ACLR between the AAM-RR and AM-FR groups (10.8% vs 9.6%, respectively; P = .806). At 6 months postoperatively, there were no significant between-group differences in peak knee extension strength, peak knee flexion strength, limb symmetry indices, or hop testing, as well as no significant differences in IKDC (AAM-RR, 81.1; AM-FR, 78.9; P = .269) or KOOS (AAM-RR, 89.0; AM-FR, 86.7; P = .104). Conclusion: In this limited study, independent femoral tunnel drilling for ACLR using rigid or flexible reaming systems resulted in comparable rates of revision ACLR at a minimum of 2 years postoperatively, with no significant differences in strength assessments or patient-reported outcomes at 6 months postoperatively.

Finite element assessment of a disc-replacement implant for treating scoliotic deformity.

BACKGROUND: Bracing and spinal fusion surgery have long been the primary methods for idiopathic scoliosis correction; however, there exist multiple limitations with both techniques. Growth modulation techniques have recently been attempted, but are typically performed across multiple vertebral elements. The aim of this study was to quantify the corrective abilities of a dual-angled, wedge shaped, rigid disc implant designed to correct spinal deformity. METHODS: The 3D spinal geometry of four patients was reconstructed using calibrated radiographs, from which personal finite element models were created. Coronal and sagittal Cobb angles and axial stress distribution were calculated pre- and post- simulation of device implantation at the apical vertebral element. FINDINGS: Insertion of a rigid wedged implant resulted in up to 90.1% coronal correction with kyphotic normalization, and reduced axial stress differential within adjacent vertebrae by up to 83.3%. This correction in axial stress differential was seen to propagate to subjacent vertebrae in both rostral and caudal directions. Insertion of two implants yielded greater correction with respect to all three measures. INTERPRETATION: Local Cobb angle correction, increased kyphotic angle, and a decrease in axial stress differential with adjacent and subjacent vertebral levels demonstrate a potential for deformity correction from within the disc space. The decrease in axial stress differential demonstrates a capacity for growth modulation and reversal of the Heuter-Volkmann principle. Based on qualitative views of spinal shape following device implantation, the wedged implant proved more efficacious in correcting single thoracic curves than double major curves.

Treatment Algorithm for Surgical Site Infections Following Extensor Mechanism Repair.

¼: Despite general agreement regarding techniques for extensor mechanism repair, there is very limited guidance in the literature for the management of surgical site infections (SSIs) that may occur after these procedures. ¼: Early or mild superficial SSIs, such as cellulitis, can be managed on an outpatient basis while monitoring for improvement, with escalated intervention if the symptoms do not resolve within 1 week. ¼: Deep SSIs should be managed more aggressively with surgical irrigation and debridement (I&D), including the knee joint, depending on the results of the aspiration, removal of all braided nonabsorbable suture (if necessary) with immediate or delayed exchange with monofilament suture, and the administration of parenteral antibiotics based on culture results and an infectious disease consult. ¼: Arthrocentesis should be performed early to monitor for the spread of infection to the joint space, and diagnosis of a septic knee joint should be immediately followed by arthroscopic or open I&D. ¼: For refractory cases (i.e., wound coverage issues or persistent infections despite multiple attempts at debridement), a consult with a plastic surgeon for consideration of a gastrocnemius flap is recommended, and surgeons should remain suspicious of the possibility of the contiguous spread of osteomyelitis.

Identification of a Core Module for Bone Mineral Density through the Integration of a Co-expression Network and GWAS Data.

The "omnigenic" model of the genetic architecture of complex traits proposed two categories of causal genes: core and peripheral. Core genes are hypothesized to directly regulate disease and may serve as therapeutic targets. Using a cell-type- and time-point-specific gene co-expression network for mineralizing osteoblasts, we identify a co-expression module enriched for genes implicated by bone mineral density (BMD) genome-wide association studies (GWASs), correlated with in vitro osteoblast mineralization and associated with skeletal phenotypes in human monogenic disease and mouse knockouts. Four genes from this module (B4GALNT3, CADM1, DOCK9, and GPR133) are located within the BMD GWAS loci with colocalizing expression quantitative trait loci (eQTL) and exhibit altered BMD in mouse knockouts, suggesting that they are causal genetic drivers of BMD in humans. Our network-based approach identifies a "core" module for BMD and provides a resource for expanding our understanding of the genetics of bone mass.