Andrew R Stephens
Clinical Instructor, Orthopaedic Surgery
Clinical Focus
- Physical Medicine and Rehab
Professional Education
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Residency: University of Rochester Physical Medicine and Rehabilitation Residency (2025) NY
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Medical Education: University of Utah School of Medicine (2021) UT
Contact
Additional Clinical Info
https://orcid.org/0000-0003-3877-7723All Publications
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Rates of knee arthroplasty after genicular nerve ablation: A retrospective study utilizing a large national database.
Interventional pain medicine
2026; 5 (1): 100728
Abstract
Genicular nerve ablation (GNA), which includes radiofrequency ablation (GNRFA), cryoneurolysis, and chemical neurolysis, is a minimally invasive procedure with growing evidence for improved pain and functional outcomes in the treatment of knee osteoarthritis (KOA). With conservative management for KOA having variable efficacy and knee arthroplasty (KA) carrying substantial risks, there is utility in identifying if GNA may delay or defer surgery.The purpose of this study was to assess the rate of patients receiving KA, including total knee arthroplasty (TKA) or unicompartmental knee arthroplasty (UKA) after receiving GNA.TriNetX, a national database, was queried for patients 18 years or older who underwent GNA between 2004 and 2025. Patients with severe medical comorbidities and patients with prior TKA or UKA were excluded. Descriptive analyses were performed using the TriNetX Analytics platform and the incidence of post-GNA TKA or UKA was calculated. Secondary analysis calculating the cumulative incidence of arthroplasty among patients without prior KA within 3 months, 6 months, 1 year, 2 years, and 5 years after GNA was also assessed.There were 6035 patients who underwent GNA during this study period and who were included in the final analysis after excluding patients with select comorbidities or who had a prior TKA or UKA. Among this cohort, 795 (13.2 %; 95 % CI 12.3-14.0) patients underwent TKA (N = 753; 12.5 %; 95 % CI 11.7-13.3) or UKA (N = 42; 0.7 %; 95 % CI 0.5-0.9) after receiving GNA. For patients without prior KA, 152 patients underwent KA at 3 months post-GNA (1.3 %; 95 % CI 1.1-1.5), 415 patients underwent KA at 6 months post-GNA (3.5 %; 95 % CI 3.2-3.9), 847 patients underwent KA at 1 year post-GNA (7.2 %; 95 % CI 6.7-7.6), 1219 patients underwent KA at 2 years post-GNA (10.3 %; 95 % CI 9.8-10.9), and 1469 patients underwent KA at 5 years post-GNA (12.4 %; 95 % CI 11.8-13.0).This is the largest cohort study to identify rates of KA following GNA. We found that roughly one in eight patients in this cohort received TKA or UKA after GNA, suggesting that GNA may offer clinically meaningful symptom relief for patients with KOA, such that KA may be delayed or deferred. Causality for whether GNA delays or prevents KA cannot be established from this study. The cost effectiveness and surgical sparing efficacy of GNA for symptomatic KOA should be further explored.
View details for DOI 10.1016/j.inpm.2025.100728
View details for PubMedID 41552772
View details for PubMedCentralID PMC12805026
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Evaluating the Effectiveness of Transforaminal Epidural Steroid Injections for Lumbar Radiculopathy Due to a Herniated Nucleus Pulpous Utilizing PROMIS as an Outcome Measure
AMERICAN JOURNAL OF PHYSICAL MEDICINE & REHABILITATION
2026; 105 (1): 47-50
Abstract
The purpose of this study was to evaluate the effect of transforaminal epidural steroid injection (TFESI) for patients with lumbosacral radiculopathy secondary to a lumbosacral herniated nucleus pulposus.A retrospective review of adult patients who received a fluoroscopically guided transforaminal epidural steroid injections for a herniated nucleus pulposus was performed. Patient-Reported Outcome Measurement Information System domains of physical function, pain interference, and depression were collected at baseline and postprocedure short-term (1-3 mos after procedure) and long-term follow-up (6-12 mos after procedure).Patient-Reported Outcome Measurement Information System physical function at short- and long-term follow-up statistically improved by 1.9 ( P = 0.02) and 4.6 ( P = 0.01) points, respectively. Patient-Reported Outcome Measurement Information System-pain interference at short- and long-term follow-up statistically improved by 3.7 ( P < 0.001) and 5.9 ( P = 0.002) points, respectively. Depression scores improved by 2.7 ( P = 0.04) at short-term follow-up, but long-term follow-up scores did not significantly differ from baseline scores. Ninety-one (85%) of patients did not elect for spine surgical consultation.Our study demonstrated that lumbosacral transforaminal epidural steroid injection was associated with a long-term improvement in function and pain for patients with lumbosacral radiculopathy due to a herniated nucleus pulposus as measured by Patient-Reported Outcome Measurement Information System-physical function and pain interference survey and obviated the need for spine surgery at long-term follow-up.
View details for DOI 10.1097/PHM.0000000000002853
View details for Web of Science ID 001637946900004
View details for PubMedID 40908263
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Evaluating the effectiveness of 7-min basivertebral nerve ablation in treating vertebrogenic low back pain.
Interventional pain medicine
2025; 4 (4): 100714
Abstract
Basivertebral nerve radiofrequency ablations (BVNRFA) is an established treatment for chronic vertebrogenic low back pain. However, published studies have exclusively evaluated the effectiveness of 15-min ablations for BVNRFA. Recently, industry has recommended performing 7-min ablations but there is no literature demonstrating this as an effective procedure.The purpose of this study was to evaluate 7-min BVNRFA outcomes of pain and function.Retrospective review of consecutive patients with chronic (>6 months) axial midline low back pain with a reported pain score ≥4 that had failed conservative treatment with corroborating Modic type I or Modic type II changes on MRI who underwent exclusively 7-min BVNRFA was conducted at a multidisciplinary spine center. Visual analog pain scores (VAS) were collected at baseline, 1-, 3-, 6-, and 12-month post-procedure. Consistent with prior literature, success was defined two ways: achieving a ≥50 % in VAS pain reduction at post-procedure visits compared to baseline scores and achieving a reduction of VAS greater than the minimally clinical important difference of 2. Wilcoxon signed-rank test was used to compare post-procedure scores with baseline scores. Percent of patients with a successful treatment was calculated at each follow-up time period.A total of 86 patients underwent BVNRFA during the study period and 75 met inclusion criteria. VAS scores significantly improved between baseline (7.1 ± 1.9) and 1-month (3.9 ± 3.0, p < 0.001), 3-months (3.4 ± 3.0, p < 0.001), 6-months (4.4 ± 2.6; p < 0.001) and 12-months post-procedure scores (3.7 ± 2.6; p < 0.001). The percentage of patients with a successful treatment of ≥50 % in VAS pain reduction was 50.7 % (95 % CI 38.8 %, 26.7 %) at 1-month, 56.9 % (95 % CI 44.9 %, 69.0 %) at 3-months, 42.9 % (95 % CI 29.0 %, 56.7 %) at 6-months and 50.0 % (95 % CI 23.1 %, 67.9 %) at 12-months. The percentage of patients with a successful treatment of ≥2 in VAS pain reduction was 67.2 % (95 % CI: 55.9 %, 78.4 %) at 1-month, 67.7 % (95 % CI: 56.3 %, 79.1 %) at 3-months, 65.3 % (95 % CI: 52.0 %, 78.6 %) at 6-months and 70.0 %, (95 % CI: 52.1 %, 90.8 %) at 12-months.Although our study demonstrated that patients treated with BVNRFA with a 7-min ablation reported significant improvement in pain, the proportion of patients with a successful reduction of pain is likely lower than data published for 15-min ablations. Future controlled trials comparing outcomes and lesion sizes of 7- and 15-min BVNA are needed.
View details for DOI 10.1016/j.inpm.2025.100714
View details for PubMedID 41438936
View details for PubMedCentralID PMC12720036
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Rates of lumbar vertebral body compression fracture after basivertebral nerve ablation: A retrospective study utilizing a large national database.
Interventional pain medicine
2025; 4 (4): 100654
Abstract
Basivertebral nerve ablation (BVNA) is an effective treatment for vertebrogenic chronic low back pain. However, data regarding rates of post-BVNA lumbar vertebral compression fracture (VCF), particularly among patients with osteoporosis or osteopenia, remains limited.(1) Estimate the rate of lumbar VCF after BVNA. (2) Compare rates between patients with and without a pre-BVNA diagnosis of osteopenia/osteoporosis utilizing a large global database.A retrospective cohort study was performed using TriNetX, a national database of de-identified health records from over 130 million patients. Adults (≥18 years) who underwent BVNA between January 2022 and August 2025 were identified via CPT code. Patients were stratified by presence or absence of ICD-10 code for osteoporosis/osteopenia before undergoing BVNA. The primary outcome was incidence of ICD-10 code diagnosis of lumbar VCF after undergoing BVNA.A total of 2387 patients underwent BVNA (mean age 63.7 years; 48.0 % female). Of these, 669 had a pre-BVNA diagnosis of osteoporosis/osteopenia (mean age 70.2 ± 10.7 years; 64.4 % female). Lumbar VCF occurred in 37 patients (1.55 %; 95 % CI, 1.11-2.16 %) after BVNA. Patients with osteoporosis/osteopenia had higher rate of post-BVNA lumbar VCF compared to those without (4.64 % vs 0.37 %), though rates of post-BVNA lumbar VCF were overall low across all patients (1.55 %). Osteoporosis/osteopenia was independently associated with post-BVNA VCF (adjusted OR 6.5; 95 % CI, 3.7-12.3; p < 0.001).While patients with pre-BVNA ICD-10 code diagnosis of osteoporosis/osteopenia had higher rates and were at higher risk of post-BVNA VCF than those without, overall rates were still low. Risk of VCF should be considered and risks/benefits should be discussed with patients, but a diagnosis of osteoporosis/osteopenia should not be considered an absolute contraindication to BVNA.
View details for DOI 10.1016/j.inpm.2025.100654
View details for PubMedID 41341121
View details for PubMedCentralID PMC12670547
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Rates of cervical spine surgery and repeat epidural injections after cervical transforaminal epidural steroid injections for patients with cervical radiculopathy utilizing a large national database.
Interventional pain medicine
2025; 4 (4): 100651
Abstract
Cervical transforaminal epidural steroid injections (CTFESI) are commonly performed to treat cervical radicular pain and decrease the need of surgery. The literature is mixed regarding the efficacy of CTFESI in obviating the need for cervical spine surgery.The purpose of this study was to assess the rates of cervical spine surgery and spinal interventions after initial CTFESI for patients with radicular pain.TriNetX, a large national database, was queried from 2004 to 2025 for patients who underwent CTFESI for cervical radiculopathy. The rates of treatment progression after initial CTFESI were calculated. Treatment progression included: no additional treatment, repeat CTFEI, cervical interlaminar epidural steroid injection (CIESI), and cervical spine surgery. Cervical spine surgeries analyzed included anterior cervical decompression and fusion (ACDF), foraminotomy, and total disc replacement (TDR). Treatment rates were also calculated for patients after a second CTFESI.There were 28,345 patients who underwent CTFESI during this study period. After initial CTFESI, 57 % of patients did not undergo any additional procedures/surgeries, 23.7 % had a repeat CTFESI, 5.6 % received a CILESI, 7.4 % underwent ACDF, 1.6 % underwent a foraminotomy, and 1.8 % underwent a TDR. Together, after initial CTFESI, 10.8 % of patients went on to cervical spine surgery as a second line treatment. Of the 6,711 patients who received a repeat CTFESI, 74.5 % had no additional interventional treatment, 8.2 % underwent a CIESI, 10.6 % underwent ACDF, 2.5 % underwent a foraminotomy, and 2.2 % underwent a TDR. In total, 15.3 % of patients underwent cervical spine surgery after a second CTFESI. A third consecutive CTFESI was not attempted in any patients.This study demonstrates rates of surgery after an initial CTFESI and a repeat CTFEIS to be low.
View details for DOI 10.1016/j.inpm.2025.100651
View details for PubMedID 41322334
View details for PubMedCentralID PMC12664371
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No major complications seen in a retrospective review of 1,018 cervical transforaminal epidural steroid injections.
Interventional pain medicine
2025; 4 (3): 100622
Abstract
Background: Cervical transforaminal epidural steroid injections (CTFESI) are commonly used to treat cervical radicular pain, but concerns remain about their safety due to case reports of complications such as stroke, spinal cord injury and death. These complications have been associated with use of particulate steroids causing embolic infarcts from inadvertent intra-arterial injection. With the use of non-particulate steroids these complications have never been reported. Additionally, recent cohort studies have demonstrated safety. Yet many providers still consider these procedures to be unsafe. Additional work is needed to further elucidate the risk of complications after CTFESI.Objective: The goal of this study is to demonstrate the safety of CTFESI in a large retrospective cohort study using non-particulate steroids.Methods: Medical records of all consecutive patients who underwent CFTESI within a tertiary academic multidisciplinary spine center from December 2002 through September 2024 were retrospectively reviewed. Data collected included vertebral level of injection, major (stroke, seizure, spinal cord injury, and death) and minor (headache, diaphoresis, syncope) complications, ED/urgent care visits within 2 weeks of procedure, and length of follow up within the performing PM&R department.Results: A total of 1018 CTFESI procedures involving 558 patients were reviewed. There were no major complications in our study and no patients necessitated an ED or urgent care visit. Of 1018 total procedures, 16 (1.57%) were attempted and aborted mid-procedure. Of these, 3 procedures were aborted due to inability to access the neuroforamen, 6 procedures were aborted due to signs of vascular uptake and/or subjective symptoms of vascular uptake, 3 procedures were aborted due to patient inability to tolerate the procedure, and 4 procedures were aborted due to vasovagal response. Only 1 (0.01%) procedure resulted in a vasovagal response (hypotension, bradycardia, dizziness) following completion of the procedure.Conclusion: This study demonstrated no major complications after fluoroscopy guided CTFESI with use of non-particulate steroids and standard safety techniques.
View details for DOI 10.1016/j.inpm.2025.100622
View details for PubMedID 40761433
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Rates of complications after cervical transforaminal epidural steroid injections for patients with cervical radiculopathy utilizing a large national database.
Interventional pain medicine
2025; 4 (3): 100606
Abstract
Background: Cervical transforaminal epidural steroid injections (CTFESI) are commonly used to treat cervical radiculopathy. Though major adverse events have been published in case reports, larger cohort studies have not demonstrated this concern.Objective: The purpose of this study was to assess the risk of major and minor complications after CTFESIs using a large database.Methods: TriNetX, a global health research network, was queried from January 01, 2004-May 20, 2025 for patients with cervical radiculopathy undergoing CTFESI. All diagnostic and surgical codes after CTFESI were analyzed. Specific major complications queried for were stroke, seizures, and paralysis. Nervous system, musculoskeletal, infectious, and procedural diagnoses were evaluated for complications. Complications were reported as number and percent.Results: A total of 32,913 patients underwent CTFESI with available follow-up data. There were ≤10 (≤0.03%) patients who had intraoperative/post-procedure complications, ≤10 (≤0.03%) with CSF leak. There were 143 (0.4%) patients that had cerebral vascular disease related codes. Of these, 50 (0.15%) had cerebral infarction codes and ≤10 (≤0.03%). There were 39 (0.12%) patients with seizure codes, and 18 (0.5%) patients that had paralysis codes. There were 0 (0%) patients who had mortality related codes within a day after CTFESI.Conclusion: This study demonstrates the risk of major complications after CTFESI in a large cohort to be low.
View details for DOI 10.1016/j.inpm.2025.100606
View details for PubMedID 40688012
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A retrospective single arm cohort study evaluating the efficacy of lumbar medial branch radiofrequency ablation using a multi-tined probe and perpendicular approach.
Interventional pain medicine
2025; 4 (2): 100575
Abstract
Summary of background data: Lumbar medial branch radiofrequency ablation (LMBRFA) is an effective treatment for facet joint pain. LMBRFA efficacy was originally demonstrated using a parallel technique. Newly developed RFA probes (e.g., Trident) allow a perpendicular approach (P-LMBRFA), which may simplify the RFA technique and lead to superior treatment success rates. However, further investigation is necessary to determine whether these technologies are associated with improved patient outcomes.Objectives: Evaluate the effectiveness of P-LMBRFA in patients with confirmed facet pain.Methods: In this retrospective single-arm cohort study, electronic medical records were used to identify consecutive patients with ≥80% dual medial branch block-confirmed pain relief who underwent first-time P-LMBRFA between 2016 and 2022. Primary outcomes were ≥50% Numerical Rating Scale (NRS) pain improvement and the minimal clinically important difference (MCID) on the Pain Disability Quality-of-Life Questionnaire (PDQQ) at 3 months post-treatment. Secondary outcomes included the duration and mean retrospective percentage of pain relief after a successful index P-LMBRFA in individuals who reported a return of their index symptoms.Results: 174 participants (60.3% female, 61.3±14.2 years of age, BMI 29.5±6.7kg/m2) were analyzed. Success rates for ≥50% NRS reduction and MCID on the PDQQ at 3 months were 50.6% (95% CI=43.3-57.9%) and 50.0% (95% CI=42.8-57.2%), respectively. Of the 88 successful P-LMBRFAs, 60 patients experienced a return of symptoms after 8.7±3.6 months and reported a retrospective mean percentage pain relief of 81.8%±15.8%.Discussion/conclusion: Following P-LMBRFA, approximately 50% of patients reported improvement in pain and disability measures. Extensive, prospective research comparing long-term outcomes of P-LMBRFA and parallel LMRBFA is warranted.
View details for DOI 10.1016/j.inpm.2025.100575
View details for PubMedID 40230588
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Decrease in opioid use and spinal interventions after basivertebral nerve ablation.
Interventional pain medicine
2025; 4 (2): 100594
Abstract
Background: Basivertebral nerve radiofrequency ablations (BVNRFA) have shown efficacy in improving chronic back pain for indicated patients.Objective: The purpose of this study was to evaluate health care utilization outcomes after BVNRFA in a large cohort utilizing a global database.Methods: TriNetX, a global health research network, was queried from 2022 to 2025 for patients who underwent BVNRFA utilizing CPT codes and 1 year pre-procedure and post-procedure opioid use and spine interventions were recorded. Pre-procedure and post-procedure outcomes were compared using a chi-square test with significance set at p<0.05. The rate of spine surgery within 1 year after BVNRFA was also reported.Results: A total of 1,118 patients underwent BVNRFA during this time frame at contributing health care systems with appropriate follow-up. Post-procedure opioid use was less than pre-procedure opioid use (57% vs 51%, p=0.006). The number of patients who received spine interventions after BVNRFA were significantly lower compared to patients who received spine interventions prior with lumbar transforaminal epidural steroid injections decreasing from 21% to 12% (p<0.001), lumbar interlaminar steroid injections decreasing from 18% to 11% (p<0.001), and radiofrequency ablations decreasing from 25% to 13% (p<0.001). Only 47 patients had CPT codes related to post-procedure vertebral column spine surgery. Specifically, there were 11 patients who had CPT codes for posterior lumbar fusion (CPT 22630), 10 had lateral lumbar fusion (CPT 22533), and 10 had anterior codes (CPT 22558). There were 0 patients who underwent total disc replacement (CPT 22857).Conclusions: This administrative database study demonstrated significantly less opioid use and spine interventions within 1 year after BVNRFA compared to 1 year prior. This study also demonstrated low rates of spine surgery within 1 year after BVNRFA.
View details for DOI 10.1016/j.inpm.2025.100594
View details for PubMedID 40519794
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Evidence of non-response bias in patient reported outcome measurement information system surveys.
Interventional pain medicine
2025; 4 (2): 100588
Abstract
Background: Patient-reported outcome measurement instrument surveys (PROMIS) have been increasingly used to assess clinical outcomes following a variety of medical procedures. Despite their value in evaluating patient functional status, response rates to these surveys remain low. Understanding differences in demographics between responders and non-responders to PROMIS may be beneficial to improving generalizability and response rates.Objective: The primary aim of this study was to compare demographic characteristics between patients who respond to PROMIS surveys and those who do not, hypothesizing no significant differences between these groups.Methods: Adult new patient visits from 2018 to 2022 in Department of Physical Medicine & Rehabilitation outpatient clinics at a single academic medical center were analyzed. Patients completed PROMIS surveys (physical function, pain interference, and depression) on iPads at each clinic visit. Demographic variables such as gender, race, BMI, smoking status, employment status, marital status, and Area Deprivation Index (ADI) were collected. Univariate and multivariate analyses were conducted to assess for variables associated with an increased likelihood of responding to PROMIS surveys.Results: A total of 29,830 patients were included in this study. Of the total patient cohort, 8331 (27.9%) responded to the PROMIS surveys. Significant demographic differences were found between responders and non-responders. Patients in the least deprived ADI quartile were more likely to respond compared to those in the most deprived quartile (33.5% vs 23.7%, p<0.001). Employed patients, white patients, non-smokers and married individuals were more likely to respond. On multivariate analysis, unemployment (OR 0.71, p=0.006), increased BMI (OR 0.93, p=0.014), and higher ADI (OR 0.94, p=0.003) were significantly associated with lower response rates.Conclusions: PROMIS response rates are influenced by patient demographics, with lower response rates observed in unemployed, non-white, and socioeconomically deprived populations. These findings highlight the need for targeted interventions to increase response rates and ensure equitable data collection in PROMIS surveys to enhancing the generalizability of clinical decisions made using PROMIS data.
View details for DOI 10.1016/j.inpm.2025.100588
View details for PubMedID 40475288
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Evaluation of fluoroscopically guided transforaminal epidural steroid injections for cervical radiculopathy utilizing patient reported outcome measurement information system as an outcome measure.
Interventional pain medicine
2025; 4 (1): 100556
Abstract
Background: Cervical radiculopathy is a common cause of pain. For patients who fail conservative management, a transforaminal epidural steroid injection (TFESI) is an accepted intervention and alternative to decompression surgery.Objective: The purpose of this study was to evaluate the therapeutic effect of TFESIs for patients with cervical radiculopathy.Methods: Adult patients treated at a multidisciplinary, tertiary academic spine center with cervical radicular pain and MRI evidence of corroborative cervical spondylotic foraminal stenosis and who had failed at least 6 weeks of conservative management consisting of medication and physical rehabilitation were included in this study. Patient Reported Outcome Measurement Information System (PROMIS) domains of Physical Function (PF) v1.2/v2.0 and Pain Interference (PI) v1.1 were collected at baseline and at 3-, 6-, and 12-month follow-up visits. Statistical analysis comparing baseline score with follow-up post-procedural PROMIS scores was performed. The percentage of patients who reported improvement exceeding the minimal clinically important difference was calculated for survey responders and for the worst case scenario.Results: 87 patients met inclusion criteria. PROMIS PI at 3-, 6-, and 12-months follow-up statistically improved by 2.2 (95% confidence interval [CI] 2.1-2.4, p=0.02), 2.3 (95% CI 2.1-2.5, p=0.03), and 2.7 (95 % CI 2.5-3.0, p = 0.03) points, respectively. Follow-up PROMIS PF score did not significantly differ from baseline scores. The percentage of patients that exceeded MCID thresholds of clinical significance was 59% (95% CI 47%-70%) at 3-months, 52% (95% CI 41%-63%) at 6-months, and 60% (95% CI 50%-72%) at 12-months. Worst case scenario analysis demonstrated that 51% (95% CI 39%-62%) of patients exceeded the MCID thresholds at 3-months, 32% (95% CI 22%-43%) at 6-months, and 23% (95% CI 13%-33%) at 12-months.Conclusions: Our study demonstrated that TFESI leads to a long-term improvement up to a year in pain for patients with cervical radiculopathy.
View details for DOI 10.1016/j.inpm.2025.100556
View details for PubMedID 40103657
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The effectiveness of thoracic medial branch radiofrequency neurotomy using a three-tined electrode: A single-arm, retrospective cohort study.
Interventional pain medicine
2025; 4 (1): 100563
Abstract
Background: Thoracic medial branch radiofrequency neurotomy (TMBRFN) is used to treat chronic thoracic facet joint pain, but research on its technique and effectiveness is still needed. The current International Pain and Spine Intervention Society Practice Guidelines do not describe a technique for TMBRFN.Objectives: Evaluate the effectiveness of TMBRFN in patients with thoracic facet joint pain.Methods: Single-arm, retrospective cohort study of consecutive patients from two Canadian musculoskeletal pain management clinics who underwent first-time TMBRFN between 2016 and 2022. The primary outcome was the proportion of patients with ≥50% reduction in numerical rating scale (NRS) pain score at 3-months post-procedure. Secondary outcomes included the proportion of patients who achieved a ≥17-point reduction on the Pain Disability Quality-Of-Life Questionnaire-Spine (PDQQ-S) at 3-months, as well as mean patient-reported percentage pain relief and duration of relief after a successful index TMBRFN in individuals who reported a return of their index symptoms.Results: 18 consecutive patients (50.0% male; mean age 60.9±15.3 years; mean BMI 30.3±6.9kg/m2) were analyzed. At 3 months post-procedure, 10 patients (55.6% [95%CI 33.7-75.4]) reported ≥50% NRS pain reduction and 9 (50.0% [95%CI 29.0-71.0]) reported ≥17-point PDQQ-S reduction. Of the 10 patients with successful treatment responses, 4 had a return of symptoms after an average of 9.3±2.2 months with a reported retrospective mean percentage pain relief of 70.0±34.6%.Conclusion: Within this cohort, approximately 60% of patients experienced improvement in pain and disability at 3 months following TMBRFN. Among patients whose index symptoms returned after successful treatment, the average reported pain relief was 70% for close to 9 months. Larger, prospective studies with long-term outcomes are needed to better elucidate the safety and effectiveness of TMBRFN.
View details for DOI 10.1016/j.inpm.2025.100563
View details for PubMedID 40103655
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The effectiveness of cervical medial branch radiofrequency neurotomy using a perpendicular approach with a three-tined probe: A single-arm, retrospective cohort study.
Interventional pain medicine
2025; 4 (1): 100572
Abstract
Background: Cervical medial branch radiofrequency neurotomy (CMBRFN) with a parallel approach has been proven to be an effective treatment for zygapophyseal joint-mediated cervical pain. Technological advancements in radiofrequency probe design have allowed for a perpendicular approach to electrode placement. However, the effectiveness of the perpendicular approach remains to be fully understood.Objectives: Evaluate the effectiveness of CMBRFN with a perpendicular approach (pCMBRFN) in patients with confirmed zygapophyseal joint-mediated cervical pain.Methods: This single-arm, retrospective cohort study included patients identified between 2016 and 2022 who underwent pCMBRFN after demonstrating ≥80% pain relief with two consecutive diagnostic medial branch blocks (MBB). Primary outcomes were ≥50% patient-reported numeric rating scale (NRS) pain relief and minimal clinically important difference (MCID) on the Pain Disability Quality-Of-Life Questionnaire-Spine (PDQQ-S) at 3 months post-procedure. Secondary outcomes were mean patient-reported retrospective percentage pain relief and duration of relief after a successful pCMBRFN in individuals who presented for repeat pCMBRFN upon return of their symptoms.Results: A total of 52 participants (63.5% female; mean age 55.9±10.9 years; mean BMI 26.8±5.2kg/m2) were analyzed. At 3 months post-procedure, ≥50% NRS pain reduction and MCID on PDQQ-S were both reported by 34 patients (65.4% [95%CI 51.8-76.9]). Of the 34 patients with successful treatment response, 15 had return of symptoms after an average of 8.8±2.5 months with a reported mean percentage pain relief of 86.0±14.9%.Conclusion: Within this cohort, pCMBRFN demonstrated effectiveness by reducing pain and disability in over 65% of patients with confirmed cervical zygapophyseal joint-mediated pain at 3 months. Patients with successful treatment outcomes whose index symptoms eventually returned reported an average pain reduction of 86% lasting approximately 9 months. Larger prospective studies with long-term follow-up are needed to confirm these results.
View details for DOI 10.1016/j.inpm.2025.100572
View details for PubMedID 40201073
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Evaluating the Performance of an Automated Patient-Reported Outcomes Collection Platform in a Postoperative Hand Surgery Population
JOURNAL OF HAND SURGERY-AMERICAN VOLUME
2025; 50 (1): 100e1-100e10
Abstract
Reliable collection of postoperative patient-reported outcome measures (PROMs) is critical to understanding surgical outcomes and the value of care. Automated PROMs collection, triggered by the electronic medical record at the 1-year postoperative anniversary, may provide a simple way to acquire outcomes for patients who have been discharged from clinic. The purposes of this study were to (1) evaluate the percentage of responses with an automated PROMs collection platform and (2) identify whether such a system may introduce selection bias by comparing responders with nonresponders.Adult patients (aged ≥18 years) undergoing hand and upper-extremity surgeries between August 2017 and January 2019 were included. Preoperative Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores were collected using tablet computer. Postoperative QuickDASH scores were collected using a single electronic survey request 1 year after surgery via an email with a personalized REDCap link. Univariate and multivariable regression analyses were performed to identify factors that differed between responders and nonresponders.A response rate of 27% (269 of 1010) was observed for the eligible postoperative patients. On multivariable analysis, the following were associated with greater odds of response: older age, Caucasian race (vs unknown), longer surgery duration, attending the first postoperative visit, and responding to the preoperative QuickDASH.The poor response rate that was observed highlights that an automated single email postoperative contact for PROMs collection is insufficient-active follow-up via reminder emails and/or telephone calls is needed. Outcome researchers and clinicians must be aware of potential selection biases, such as age and race, that may exist with automated PROMs collection.Single email postoperative contact to obtain postoperative PROMs is insufficient.
View details for DOI 10.1016/j.jhsa.2023.05.006
View details for Web of Science ID 001412277500001
View details for PubMedID 37354194
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Evaluating the effectiveness of interlaminar epidural steroid injections for cervical radiculopathy using PROMIS as an outcome measure.
Interventional pain medicine
2024; 3 (4): 100528
Abstract
Background: Cervical interlaminar epidural steroid injections (CIESI) are frequently used to treat cervical radiculopathy due to cervical nerve root impingement.Objective: The purpose of this study was to evaluate the therapeutic effect of CIESI for patients with cervical radiculopathy.Methods: We conducted a retrospective review of consecutive adult patients with cervical radicular pain and corroborative cervical spondylotic foraminal stenosis on MRI that failed at least 6 weeks of conservative management consisting of medication and physical rehabilitation seen at a multidisciplinary, tertiary academic spine center. Patient Reported Outcome Measurement Information System (PROMIS) domains of Physical Function (PF) v1.2/v2.0 and Pain Interference (PI) v1.1 were collected at all patient visits. Scores were recorded at baseline, 3-months, 6-months and 12-months post-procedure. Statistical analysis comparing baseline scores with follow-up postprocedural PROMIS scores was performed. The percentage of patients reporting improvement greater than the minimal clinically important difference (MCID) was calculated for responders and for the worst case scenario.Results: 179 patients met inclusion criteria. PROMIS PI at 3-, 6-, and 12-month follow-up statistically improved by 1.5 (95% confidence interval [CI] 1.4-1.6; p=0.02), 1.5 (95% CI 1.4-1.6; p=0.03) and 1.7 (95% CI 1.6-1.8; p=0.4), respectively. Follow-up PROMIS PF at 3-month follow-up improved by 1.6 (95% CI 1.5-1.7; p=0.04) but did not significantly differ at 6- or 12-month follow-up. The percentage of patients that exceeded MCID thresholds of clinical significance was 44% (95% CI 36%-53%) at 3-months, 49% (95% CI 39%-59%) at 6-months, and 54% (95% CI 41%-66%) at 12-months. Worst case scenario analysis demonstrated that 32% (95% CI 36%-53%) of patients exceeded the MCID thresholds at 3-months, 31% (95% CI 24%-37%) at 6-months, and 21% (95% CI 15%-27%) at 12-months.Discussion/conclusions: Our study demonstrated that CIESI leads to an improvement in function and pain for patients with cervical radiculopathy. This study was limited by retrospective design, loss to follow-up, and variation in steroids used.
View details for DOI 10.1016/j.inpm.2024.100528
View details for PubMedID 39717451
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Radiation exposure during basivertebral nerve radiofrequency ablations.
Interventional pain medicine
2024; 3 (4): 100531
Abstract
Background: Basivertebral nerve radiofrequency ablations (BVNRFA) is a relatively new procedure that has demonstrated positive effects to treat chronic low back pain. Fluoroscopy guidance is utilized to access the vertebral body via the pedicle and confirm the correct location of the probe for ablation. Radiation exposure during this procedure has not been previously reported.Objective: The purpose of this study was to evaluate the average fluoroscopic time and radiation exposure during BVNRFA.Methods: Patients treated with BVNRFA that had failed conservative treatment, with primarily midline back pain, and corroborating Modic type I or Modic type II changes on MRI at a tertiary academic spine center were retrospectively analyzed. Chart review was conducted to obtain patient demographics, fluoroscopic time and radiation exposure, involvement of trainees, and vertebral levels treated. Average fluoroscopic and radiation exposure was calculated.Results: A total of 55 patients were included in this study. The average fluoroscopic time was 152.5s (±84.3 s). The average cumulative dose was 70.3mGy (±53.0mGy) and the average dose area product was 7.9mGy·cm2 (±5.2mGy·cm2).Conclusions: Our study demonstrated that the average fluoroscopic time during BVNRFA to be about 2 and a half minutes.
View details for DOI 10.1016/j.inpm.2024.100531
View details for PubMedID 39686949
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Evaluation of Fluoroscopically Guided Transforaminal Selective Nerve Root Sleeve Injections for Lumbar Spinal Stenosis With Radiculopathy Utilizing Patient Reported Outcome Measurement Information System as an Outcome Measure
ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION
2024; 105 (8): 1458-1463
Abstract
To evaluate the therapeutic effect of transforaminal selective nerve root sleeve injections (TFSNRIs) in a specific subset of patients with clinical symptoms and presentation consistent with spinal stenosis.Retrospective review.Tertiary academic spine center.A total of 176 patients with radicular leg pain with or without low back pain as well as ≥3 clinical features of spinal stenosis and corroborative radiographic features of spinal stenosis on lumbar spine magnetic resonance imaging without confounding spinal pathology (N=176).Fluoroscopically guided transforaminal selective nerve root sleeve injections.Patient Reported Outcome Measurement Information System (PROMIS) Physical Function (PF) v1.2/v2.0, Pain Interference (PI) v1.1, and PROMIS (D) v1.0 were collected at baseline and post-procedure short term (<3-months) and long-term (6-12 month) follow-up. Statistical analysis comparing baseline and postprocedural PROMIS scores was performed. Differences were compared with previously established minimal clinically important differences in the spine population.For patients with spinal stenosis treated with TFSNRI, no statistically significant improvement was observed short- and long-term follow-up in PROMIS PF (P=.97, .77) and PROMIS Depression (P=.86, .85) scores. At short-term follow-up, PROMIS PI scores did significantly improve (P=.01) but the average difference of pre- and post-procedure scores did not reach clinical significance. No significant difference in PROMIS PI was noted at long-term follow-up (.75).Although a statistically significant difference was observed for improvement in pain, in this retrospective study, TFSNRI did not provide clinically significant improvement in patients' function, pain, or depression for lumbar spinal stenosis at short- and long-term follow-up.
View details for DOI 10.1016/j.apmr.2024.02.720
View details for Web of Science ID 001288130800001
View details for PubMedID 38430994
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Pediatric Digit Replantation: A Nationwide Analysis of Failure Rate, Complications, and Potential Factors Affecting Failure.
Journal of hand surgery global online
2024; 6 (2): 222-226
Abstract
Purpose: Function and cosmesis may be improved by replantation following digital amputation in pediatric patients. However, accurate failure and complication rate estimates may be limited as most pertinent studies reflect single center/surgeon experience and therefore are limited by small sample sizes. The primary aim of this study was to assess the rate of failure (amputation) following pediatric digital replantation. Secondary aims include evaluating the rate of complications and associated resource utilization (intensive care unit stays, readmission rate, and hospital length of stay).Methods: Digital replantation patients were identified from 47 pediatric hospitals using the 2004 to 2020 Pediatric Health Information System nationwide database. Using applicable International Classification of Disease 9/10 and Current Procedural Terminology codes, we identified complications after replantation, including revision amputation, infection, surgical complications, medical complications, admission to intensive care unit (ICU), and length of stay.Results: Of the 348 patients who underwent replantation the mean age was 8.3 ± 5.1 years, and 27% were female. Mean hospital length of stay was 5.8 ± 4.7 (range, 1-28) days. Of the 53% of patients who required ICU admission, the mean ICU length of stay was 2.4 ± 3.3 days. Failure/amputation after replantation occurred in 71 (20.4%) patients, at a mean of 9.7 ± 27.2 days postoperatively. Surgical complications occurred in 58 (17%) patients, 30-day hospital readmissions occurred in 5.7% of patients, and 90-day readmissions occurred in 6.3% patients.Conclusion: The estimated rate of failure following pediatric digit replantation was 20%. Our data on failure and complication rates and associated resource utilization may be useful in counseling pediatric replantation patients and their families and provide an update on prior literature.Level of Evidence: IV, Prognosis.
View details for DOI 10.1016/j.jhsg.2023.12.004
View details for PubMedID 38903833
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The impact of social deprivation on patient satisfaction in physical medicine and rehabilitation outpatient interventional spine and musculoskeletal medicine using the press Ganey outpatient medical practice survey.
Interventional pain medicine
2023; 2 (3): 100276
Abstract
Introduction: Multiple factors (patient age, wait time, depression, etc.) have been associated with lower patient satisfaction as assessed by the Press Ganey Outpatient Medical Practice Survey (PGOMPS). Social deprivation has been shown to impact multiple aspects of patient care but its impact on patient satisfaction in Physical Medicine and Rehabilitation (PM&R) is limited.Objective: We hypothesized that increased social deprivation would independently predict lower patient satisfaction, as measured by the PGOMPS.Design: Retrospective large cohort study.Setting: Single tertiary academic institution.Patients: Adult patients seen by PM&R physicians practicing outpatient interventional spine and musculoskeletal medicine who completed PGOMPS between January 1, 2014 and December 31, 2019.Interventions: Independent variables include: Social deprivation as measured by 2015 Area Deprivation Index (ADI), wait time, patient age, and sex.Main outcome measure: Patient satisfaction was defined as receiving a perfect PGOMPS Total Score.Results: A totla of 64,875 patients (mean age 52.7±21.8 years, 41.4% male, mean ADI 29.9±18.8) were included. Univariate analysis showed a decreased odds of achieving satisfaction for each decile increase in ADI (odds ratio 0.965; 95% confidence interval 0.957-0.973; p<0.001). The most socially deprived quartile was significantly less likely to report satisfaction on PGOMPS compared to the least deprived quartile (91.1 vs 93.2; p<0.001). Multivariable analysis revealed that the odds of achieving satisfaction was 0.99 (95% confidence interval 0.980 to 0.997; p=0.009) for the Total Score, independent of age, wait time, and patient sex for each decile increase in ADI.Conclusions: In this cohort, increased social deprivation independently predicted patient dissatisfaction in PM&R.
View details for DOI 10.1016/j.inpm.2023.100276
View details for PubMedID 39238904
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Risk of Total Wrist Arthrodesis Following Proximal Row Carpectomy: An Analysis of 1,070 Patients
JOURNAL OF HAND SURGERY-AMERICAN VOLUME
2023; 48 (2): 195e1-195e10
Abstract
Proximal row carpectomy (PRC) is a motion-sparing procedure with good patient-reported and clinical outcomes. Although some studies have investigated the risk of conversion to total wrist arthrodesis (TWA) after PRC, additional larger studies evaluating the specific risk factors that lead to failure are required. This study aimed to investigate the patient and procedure factors that are associated with increased risk for conversion to TWA in a large cohort of patients who underwent PRC.The current procedural technology codes identified patients in a National Veteran's Health database undergoing a PRC over a 26-year period. Risk factors of interest comprised age, posterior interosseous nerve neurectomy, wrist arthritis pattern, bilateral surgery, smoking, comorbidities, and preoperative opioid use. The primary outcome was the rate of conversion to TWA. Cox proportional hazard regression was used to create hazard ratios of selected factors for reoperation.There were 1,070 PRCs performed, with a mean follow-up of 79.8 ± 59.6 months. A total of 5.3% (57/1,070) wrists underwent conversion to TWA. Younger age at the time of PRC (<50 years) significantly increased the risk of TWA (hazard ratio, 3.8; 95% confidence interval, 2.2-6.6). With every 1-year increase in age, there was a reduction of 4% (hazard ratio, 0.96; 95% confidence interval: 0.94-0.98) in the hazard of conversion to TWA. No other factors, including concomitant posterior interosseous nerve neurectomy or bilateral PRC, increased the risk of conversion to TWA.Proximal row carpectomy is a motion-preserving salvage procedure with a low rate of conversion to wrist arthrodesis. Younger patient age increases the risk of conversion to arthrodesis, whereas posterior interosseous nerve neurectomy, bilateral PRCs, and comorbidity status do not appear to have an impact on the risk of arthrodesis.Prognostic II.
View details for DOI 10.1016/j.jhsa.2021.09.031
View details for Web of Science ID 001022224000001
View details for PubMedID 34857405
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The Effect of Social Deprivation on Patient Satisfaction in Otolaryngology Clinics
ANNALS OF OTOLOGY RHINOLOGY AND LARYNGOLOGY
2023; 132 (11): 1314-1320
Abstract
Multiple factors have been associated with lower satisfaction scores. We hypothesize that patients with a more deprived socioeconomic status will have different patient satisfaction scores than patients of higher socioeconomic status.We reviewed Press Ganey satisfaction scores for new, outpatient visits between January 1, 2014, and December 31, 2018. Due to the high ceiling effects of the survey, "satisfaction" was defined as achieving a perfect score of 100. We determined social deprivation using the 2015 Area Deprivation Index (ADI) which serves as a proxy for socioeconomic status derived from zip codes. Patient satisfaction was defined as a binary variable. Univariate and multivariate binary logistic regression analyses were used to identify factors correlated with patient satisfaction.There were 3239 unique new patients with completed surveys. Univariate analysis demonstrated decreased odds of achieving satisfaction for both the Total Score and Provider Sub-Score for each decile increase in ADI (OR 0.94; CI = 0.908-0.981; P = .003 and OR 0.94; CI = 0.91-0.98; P = .002 respectively). Multivariate analysis revealed the odds for reporting satisfaction for each decile increase in ADI were 0.96 for Total Score (CI = 0.921-0.998; P = .038) and 0.96 for Provider Sub-Score (CI = 0.92-0.993; P = .019). Patients in the most deprived quartile, compared to the least deprived, were significantly less likely to be satisfied with their care for both Total Score (OR 0.70; CI = 0.564-0.865; P = .001) and Provider Sub-Score (OR 0.69; CI = 0.558-0.852; P = .001).Increased social deprivation was an independent predictor of lower patient satisfaction in otolaryngology outpatients using the Press Ganey survey. This non-modifiable outcome should be taken into consideration when evaluating patient satisfaction scores and offers further support to the need of addressing and improving healthcare discrepancies in the field of otolaryngology.Level 3.
View details for DOI 10.1177/00034894221143579
View details for Web of Science ID 000912641500001
View details for PubMedID 36631937
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Minimizing Costs for Dorsal Wrist Ganglion Treatment: A Cost-Minimization Analysis
JOURNAL OF HAND SURGERY-AMERICAN VOLUME
2023; 48 (1): 9-18
Abstract
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.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.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).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.Economic Decision Analysis II.
View details for DOI 10.1016/j.jhsa.2022.09.002
View details for Web of Science ID 001029730200001
View details for PubMedID 36402604
View details for PubMedCentralID PMC9812920
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Factors Associated With Unplanned Reoperation After 4-Corner Arthrodesis: A Study of 478 Wrists.
Journal of hand surgery global online
2023; 5 (1): 1-5
Abstract
Purpose: The 4-corner arthrodesis (FCA) is a reliable, motion-sparing technique used to treat scapholunate advanced collapse and scaphoid nonunion advanced collapse arthritis, particularly in stage III wrists in which the capitolunate articulation is compromised. Surgical technique and patient-level variables may influence complications following FCA. We sought to evaluate the rate of complications in a large, combined database and manual chart review study.Methods: Current Procedural Terminology codes were used to search the United States Veteran's Health Administration corporate database to identify wrists treated with FCA over a 24-year period. A retrospective chart review was completed to collect data regarding scapholunate advanced collapse/scaphoid nonunion advanced collapse stage, implant used, the use of a bone graft, smoking status, and comorbidities for all patients undergoing an FCA. A multivariable cox proportional hazards regression was used to assess hazard ratios for reoperation. Incidence rates and the standard error of the mean for reoperation and conversion to total wrist fusion were calculated after grouping patients by 10-year age categories.Results: A total of 478 wrists underwent FCA during the study period, with a mean follow-up of 63 months. Seventy-three (16%) wrists required reoperation. The most frequent secondary procedures included unplanned implant removal (8.2%), total wrist arthrodesis (4.6%), and revision FCA (1.7%). Positive smoking history increased the risk of reoperation, whereas posterior interosseous nerve neurectomy, arthritis stage, and fixation type did not have a statistically significant association with reoperation. Younger age demonstrated an increased incidence of overall reoperation and wrist fusion.Conclusions: The most common reason for reoperation after FCA was implant removal. Smoking history is associated with increased rates of reoperation and wrist arthrodesis. Knowledge of these factors may assist with accurately counseling and indicating patients for FCA.Type of study/level of evidence: Therapeutic III.
View details for DOI 10.1016/j.jhsg.2022.10.015
View details for PubMedID 36704368
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Evaluating opportunities for improved outpatient satisfaction in an interventional spine clinic: An analysis of Press Ganey Outpatient Medical Practice Survey responses.
Interventional pain medicine
2022; 1 (4): 100143
Abstract
Objective: The Press Ganey Outpatient Medical Practice Survey (PGOMPS) is a frequently used patient satisfaction metric comprised of provider-specific and non-provider-specific questions. The PGOMPS results are used by many administrators to improve the patient experience and are linked to physician reimbursements in some cases. This study aimed to determine the frequency of patient satisfaction for the provider-specific and non-provider-specific PGOMPS questions and their association with the likelihood of a patient recommending their provider's clinic.Design: A retrospective review.Methods: Adult patients attending a university interventional spine clinic between January 2014 and December 2019 were included in this study. We retrospectively reviewed prospectively collected patient satisfaction using PGOMPS. Data was collected within 30 days after an outpatient interventional spine clinic appointment. Satisfaction was defined as receiving a perfect total score. The frequency of perfect scores for each question was calculated. Chi-square (goodness-of-fit) analysis was performed between the number of patients who gave perfect satisfaction on all provider specific questions and the number of patients who gave perfect satisfaction for non-provider scores irrespective of their provider specific scoring. Spearman correlation between individual PGOMPS questions and the likelihood to recommend the practice question were calculated.Results: 53,118 patients patient encounters were included. 2078 (66.65%) provider-specific questions received perfect satisfaction versus 1121 (35.95%) with perfect satisfaction for non-provider specific questions (p<0.001). The five questions most likely to receive perfect satisfaction were: physician spoke using clear language (92.90%), physician friendliness/courtesy (82.74%), cleanliness of the practice (82.67%) likelihood to recommend practice (81.27%), and likelihood to recommend physician (80.96%). The 5 least likely were: convenience of office hours (64.30%), wait time (63.00%), ease of getting on phone (60.77%), information about delays (60.19%), and ability to get desired appointment (58.92%). Of the 10 questions that had the strongest correlation with likelihood to recommend the practice 7 were related to the physician. None of the 10 questions with the least correlation were related to the physician.Conclusions: Most interventional spine patients are satisfied with their providers and less satisfied with non-provider-related aspects of their encounters. Provider-specific factors carry the greatest influence in the patient's perceived satisfaction with the experience as a whole and likelihood to recommend the practice.
View details for DOI 10.1016/j.inpm.2022.100143
View details for PubMedID 39238866
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Scaphotrapeziotrapezoid Arthrodesis: A 10-Year Follow-up Study of Complications in 58 Wrists
HAND-AMERICAN ASSOCIATION FOR HAND SURGERY
2022; 17 (5): 919-925
Abstract
Scaphotrapeziotrapezoid (STT) arthrodesis is a procedure used for specific degenerative arthritis and instability patterns of the wrist. This study evaluates nonunion rate and risk factors for reoperation after STT arthrodesis in the Veterans Affairs Department patient population. The purpose of our study was to assess the long-term nonunion rate following STT arthrodesis and to identify factors associated with reoperation.The national Veterans Health Administration Corporate Data Warehouse and Current Procedural Terminology codes identified STT arthrodesis procedures from 1995 to 2016. Frequencies of total wrist arthrodesis (TWA) and secondary operations were determined. Univariate analyses provided odds ratios for risk factors associated with complications.Fifty-eight STT arthrodeses were performed in 54 patients with a mean follow-up of 120 months. Kirschner wires (K-wires) were the most common fixation method (69%). Six wrists (10%) required secondary procedures: 5 TWAs and 1 revision STT arthrodesis. Four patients underwent additional procedures for nonunion (7%). Twenty-four patients required K-wire removal, 8 (14%) of these in the operating room, which were not included in regression analysis. Every increase in 1 year of age resulted in a 15% decrease in likelihood of reoperation (95% confidence interval: 0.77-0.93; P < .0001). Opioid use within 90 days before surgery (P = 1.00), positive smoking history (P = 1.00), race (P = .30), comorbidity count (P = .25), and body mass index (P = .19) were not associated with increased risk of reoperation.At a mean follow-up of 10 years, patients undergoing STT arthrodesis have a 10% risk of reoperation, and this risk decreases with older patient age. There was a symptomatic nonunion rate of 7%, similar to prior published rates. Patient demographics, comorbidity, smoking history, and opioid use did not appear to increase risk of reoperation.
View details for DOI 10.1177/1558944720964972
View details for Web of Science ID 001124661800011
View details for PubMedID 33106027
View details for PubMedCentralID PMC9465779
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Evaluation of Factors Affecting Return to Work Following Carpal Tunnel Release: A Statewide Cohort Study of Workers' Compensation Subjects
JOURNAL OF HAND SURGERY-AMERICAN VOLUME
2022; 47 (6): 544-553
Abstract
Most randomized trials comparing open carpal tunnel release (OCTR) to endoscopic carpal tunnel release (ECTR) are not specific to a working population and focus mainly on how surgical technique has an impact on outcomes. This study's primary goal was to evaluate factors affecting days out of work (DOOW) following carpal tunnel release (CTR) in a working population and to evaluate for differences in medical costs, indemnity payments, disability ratings, and opioid use between OCTR and ECTR with the intent of determining whether one or the other surgical method was a determining factor.Using the Ohio Bureau of Workers' Compensation claims database, individuals were identified who underwent unilateral isolated CTR between 1993 and 2018. We excluded those who were on total disability, who underwent additional surgery within 6 months of their index CTR, including contralateral or revision CTR, and those not working during the same month as their index CTR. Outcomes were evaluated at 6 months after surgery. Multivariable linear regression was performed to evaluate covariates associated with DOOW.Of the 4596 included participants, 569 (12.4%) and 4027 (87.6%) underwent ECTR and OCTR, respectively. Mean DOOW were 58.4 for participants undergoing OCTR and 56.6 for those undergoing ECTR. Carpal tunnel release technique was not predictive of DOOW. Net medical costs were 20.7% higher for those undergoing ECTR. Multivariable linear regression demonstrated the following significant predictors of higher DOOW: preoperative opioid use, legal representation, labor-intensive occupation, increasing lag time from injury to filing of a worker's compensation claim, and female sex. Being married, higher income community, and working in the public sector were associated with fewer DOOW.In a large statewide worker's compensation population, demographic, occupational, psychosocial, and litigatory factors have a significant impact on DOOW following CTR, whereas differences in surgical technique between ECTR and OCTR did not.Therapeutic III.
View details for DOI 10.1016/j.jhsa.2022.02.015
View details for Web of Science ID 000850279300007
View details for PubMedID 35484044
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Recommendation of Surgery and Other Interventions Is Associated With Increased Patient Satisfaction With Orthopedic Outpatient Visits
ORTHOPEDICS
2022; 45 (3): 187-+
Abstract
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.].
View details for DOI 10.3928/01477447-20220105-11
View details for Web of Science ID 000800016300017
View details for PubMedID 35021032
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Evaluation of factors impacting patient satisfaction in a pediatric otolaryngology clinic
INTERNATIONAL JOURNAL OF PEDIATRIC OTORHINOLARYNGOLOGY
2022; 156: 111122
Abstract
With an emphasis on patient-centered care and provider transparency, patient satisfaction measures have become a key indicator of healthcare quality. Using the Press Ganey Outpatient Medical Practice Survey (PGOMPS), we sought to determine key factors that impact patient satisfaction.We conducted a retrospective review of new pediatric (<18 years old) outpatient otolaryngology visits between January 1, 2014 and December 31, 2018 at a children's hospital clinic and satellite clinics. Univariate and multivariate binary logistic regression analysis were used to determine factors correlated with patient satisfaction for both the PGOMPS Total Score and Provider Sub-Score.A total of 1,050 patient or parent responses were included. The mean patient age was 5.6 ± 5.0 years with 54.7% identified as male. Univariate analysis demonstrated that for each 10-min increase in Total Wait Time, the odds of being satisfied were significantly decreased on both the Total Score (odds ratio [OR] 0.5; P < 0.001) and Provider Sub-Score (OR 0.8; P < 0.001). Furthermore, for each additional 5-year increase in patient age, patients were significantly more likely to report satisfaction on Total Score (OR 1.21; P = 0.011). Multivariate analysis revealed that the odds of achieving satisfaction for each decile increase in Total Wait Time were 0.5 for Total Score (P < 0.001) and 0.8 for Provider Sub-Score (P < 0.001), independent of patient age, sex, insurance category, socioeconomic disadvantage level, and patient community type.Wait time is a significant factor impacting patients' likelihood of being satisfied with their overall care in a pediatric otolaryngology clinic setting.
View details for DOI 10.1016/j.ijporl.2022.111122
View details for Web of Science ID 000790768700002
View details for PubMedID 35390579
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Cost Assessment of Plating Versus Tension Band Wiring Constructs for Treating Mayo Type 2A Olecranon Fractures
JOURNAL OF HAND SURGERY-AMERICAN VOLUME
2022; 47 (4): 311-319
Abstract
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.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.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%).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.Economic and Decision Analyses III.
View details for DOI 10.1016/j.jhsa.2021.12.009
View details for Web of Science ID 000820763700005
View details for PubMedID 35131112
View details for PubMedCentralID PMC8995360
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Establishing the Substantial Clinical Benefit in a Non-Shoulder Hand and Upper Extremity Population for the <i>Quick</i>DASH and PROMIS Upper Extremity and Physical Function Computer Adaptive Tests
JOURNAL OF HAND SURGERY-AMERICAN VOLUME
2022; 47 (4): 358-+
Abstract
It is unclear what score changes on the abbreviated Disabilities of the Arm, Hand, and Shoulder (QuickDASH), Patient-Reported Outcomes Measurement Information System (PROMIS) upper extremity (UE) computer adaptive test (CAT), and PROMIS physical function (PF) CAT represent a substantial improvement. We calculated the substantial clinical benefit (SCB) for these 3 instruments in a non-shoulder hand and upper extremity population.Adult patients treated between March 2015 and September 2019 at a single academic tertiary institution were identified. The QuickDASH, PROMIS UE CAT v2.0, and PROMIS PF CAT v2.0 scores were collected using a tablet computer. Responses to the QuickDASH both at baseline and follow-up 6 ± 4 weeks later, and a response to the anchor question "Compared to your first evaluation at the University Orthopaedic Center, how would you describe your physical function level now?" were required for inclusion. A second anchor question querying treatment-related improvement was also used. The SCB was calculated using an anchor-based approach comparing the mean change difference between groups reporting no change and a maximal change for both anchor questions.Of 1,119 included participants, the mean age was 48 ± 17 years, 53% were women, and half were recovering from surgery. Score changes between baseline and follow-up were significantly different between groups reporting no improvement and maximal improvement on both anchor questions. The SCB values ranged between 16.9 and 22.8 on the QuickDASH, 5.9 and 7.1 on the UE CAT, and 3.5 and 6.7 on the PF CAT.These score improvements for the QuickDASH, UE CAT, and PF CAT represent a substantial clinical improvement in a non-shoulder hand and upper extremity population.These SCB estimates may assist with the interpretation of outcome scores at a population level.
View details for DOI 10.1016/j.jhsa.2021.12.013
View details for Web of Science ID 000820763700010
View details for PubMedID 35210143
View details for PubMedCentralID PMC8995349
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Scaphotrapeziotrapezoid Arthrodesis: Systematic Review
JOURNAL OF HAND SURGERY-AMERICAN VOLUME
2022; 47 (3): 218-+
Abstract
Scaphotrapeziotrapezoid (STT) arthrodesis surgery is used for various types of wrist pathologies. The objective of our study was to perform a systematic review of complications and outcomes after STT arthrodesis.Several major databases were used to perform a systematic literature review in order to obtain articles reporting complications and outcomes following STT arthrodesis. The primary purpose was to identify rates of nonunion and conversion to total wrist arthrodesis. Secondary outcomes included wrist range of motion, grip strength, and Disabilities of the Arm Shoulder and Hand scores. A multivariable analysis was performed to evaluate factors associated with the primary and secondary outcomes of interest.Out of the 854 records identified in the primary literature search, 30 studies were included in the analysis. A total of 1,429 procedures were performed for 1,404 patients. The pooled nonunion rate was 6.3% (95% CI, 3.5-9.9) and the rate of conversion to total wrist arthrodesis following the index STT was 4.2% (95% CI, 2.2-6.7). The mean pooled wrist flexion was 40.7° (95% CI, 30.8-50.5) and extension was 49.7° (95% CI, 43.5-55.8). At final follow-up, the mean pooled grip strength was 75.9% (95% CI, 69.3-82.5) of the nonsurgical contralateral hand. Compared with all other known indications, Kienbock disease had a statistically significant lower nonunion rate (14.1% vs 3.3%, respectively). Mixed-effects linear regression using patient-level data revealed that increasing age was significantly associated with complications, independent of occupation and diagnosis.Our study demonstrated a low failure rate and conversion to total wrist arthrodesis after STT arthrodesis and acceptable postoperative wrist range of motion and strength when compared to the contralateral hand.Therapeutic IV.
View details for DOI 10.1016/j.jhsa.2021.09.029
View details for Web of Science ID 000776310600005
View details for PubMedID 35033404
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Cost Implications of Varying the Surgical Setting and Anesthesia Type for Dorsal Wrist Ganglion Cyst Excision Surgery
PLASTIC AND RECONSTRUCTIVE SURGERY
2022; 149 (2): 240E-247E
Abstract
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.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.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.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.
View details for DOI 10.1097/PRS.0000000000008725
View details for Web of Science ID 000746676100007
View details for PubMedID 35077419
View details for PubMedCentralID PMC8797019
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Evaluating Factors That Influence Patient Satisfaction in Otolaryngology Clinics
ANNALS OF OTOLOGY RHINOLOGY AND LARYNGOLOGY
2023; 132 (1): 19-26
Abstract
To identify factors that influence patient satisfaction during outpatient visits in various settings of otolaryngology clinics in an academic medical center.Retrospective review.Academic medical center.We reviewed Press Ganey patient satisfaction survey responses for new, outpatient visits between January 1, 2014 and December 31, 2018. Self-reported race was identified using electronic medical records. Multivariate binary logistic regression analyses were used to identify continuous and categorical variables associated with patient satisfaction.There were 3998 unique new patient visits with completed surveys. Multivariate analysis revealed that responses for patients <18 years old are less likely to be satisfied with their care compared to patients ≥18 years old (OR 0.66; P < .001). For each 10-minute increase in wait time, patients were 43.4% less likely report satisfaction (P < .001). African American patients were also less likely to report satisfaction (OR 0.22; P = .043) while Native Hawaiian and Pacific Islanders were over 3 times more likely to be satisfied (OR 3.6; P = .013). Additionally, Medicare patients and those who were seen at community satellite clinics compared to the main University Hospital had increased odds of achieving satisfactory care (OR 1.3; P = .005 and OR 1.3; P = .002, respectively).Wait time, clinic location, patient race, insurance provider, and age were all shown to significantly influence patient-reported satisfaction. Understanding how these variables influence patient satisfaction will hopefully lead to processes that improve patient satisfaction.Level 3.
View details for DOI 10.1177/00034894211055531
View details for Web of Science ID 000751385500001
View details for PubMedID 35094607
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Evaluation of Risk Factors for Loss of Acceptable Alignment for Distal Radius Fractures That Are Nondisplaced or Minimally Displaced on Initial Presentation
JOURNAL OF HAND SURGERY-AMERICAN VOLUME
2022; 47 (1): 54-61
Abstract
Numerous studies have evaluated risk factors for loss of acceptable radiographic alignment, as described by the American Academy of Orthopaedic Surgeons Clinical Practice Guidelines (CPG), following closed reduction of distal radius fractures (DRFs). Less is known about DRFs that are well aligned on initial presentation and do not require closed reduction. We evaluated the rate of and risk factors for displacement of DRFs that are nondisplaced or minimally displaced on initial presentation.This retrospective cohort study identified patients with nondisplaced or minimally displaced DRFs seen at a single academic tertiary center between 2015 and 2019. DRFs that required a reduction or initial surgical treatment based on the American Academy of Orthopaedic Surgeons CPG and those with a volar shear pattern were excluded. We recorded standard radiographic measurements on presentation and wrist radiographs after 6 weeks. Univariate and binary multivariable logistic regression analyses evaluated associations between sex, age, the presence of dorsal comminution, intra-articular involvement, associated ulnar fractures, and minimal displacement (vs nondisplacement on initial radiographs) with loss of acceptable alignment.Of the 110 included patients, 72% were female and the mean age was 52 years (SD, 17 years). Overall, 33 (30%) had displacement beyond the AAOS CPG criteria at 6 weeks. A multivariable analysis demonstrated that the presence of dorsal comminution (odds ratio, 37.8) and age >60 years (odds ratio, 3.6) were significantly associated with loss of acceptable alignment, whereas sex, intra-articular involvement, associated ulnar styloid/neck fractures, and minimal displacement were not associated.For DRFs that were initially nondisplaced or minimally displaced, the overall rate of unacceptable radiographic displacement at 6 weeks was 30%. Dorsal comminution and age >60 years were both independently associated with displacement, suggesting that patients with these risk factors may warrant closer follow-up than those without risk factors.Diagnostic IV.
View details for DOI 10.1016/j.jhsa.2021.08.006
View details for Web of Science ID 000740927100008
View details for PubMedID 34598800
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Optimizing Costs and Outcomes for Carpal Tunnel Release Surgery A Cost-Effectiveness Analysis from Societal and Health-Care System Perspectives
JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME
2021; 103 (23): 2190-2199
Abstract
It is unclear which carpal tunnel release (CTR) strategy (i.e., which combination of surgical technique and setting) is most cost-effective. A cost-effectiveness analysis was performed to compare (1) open CTR in the procedure room (OCTR/PR), (2) OCTR in the operating room (OCTR/OR), and (3) endoscopic CTR in the operating room (ECTR/OR).A decision analytic model was used to compare costs and health utilities between treatment strategies. Utility and probability parameters were identified from the literature. Medical costs were estimated with Medicare ambulatory surgical payment data. Indirect costs were related to days out of work due to surgical recovery and complications. The effectiveness outcome was quality-adjusted life years (QALYs). Probabilistic sensitivity analyses and one-way sensitivity analyses were performed. Cost-effectiveness was assessed from the societal and health-care system perspectives with use of a willingness-to-pay threshold of $100,000/QALY.In the base-case analysis, OCTR/PR was more cost-effective than OCTR/OR and ECTR/OR from the societal perspective. The mean total costs and QALYs per patient were $29,738 ± $4,098 and 0.88 ± 0.08 for OCTR/PR, $30,002 ± $4,098 and 0.88 ± 0.08 for OCTR/OR, and $41,311 ± $4,833 and 0.87 ± 0.08 for ECTR/OR. OCTR/PR was also the most cost-effective strategy from the health-care system perspective. These findings were robust in the probabilistic sensitivity analyses: OCTR/PR was the dominant strategy (greater QALYs at a lower cost) in 55% and 61% of iterations from societal and health-care system perspectives, respectively. One-way sensitivity analysis demonstrated that OCTR/PR and OCTR/OR remained more cost-effective than ECTR/OR from a societal perspective under the following conditions: $0 surgical cost of ECTR, 0% revision rate following ECTR, equalization of the return-to-work rate between OCTR and ECTR, or 0 days out of work following ECTR. OCTR/OR became more cost-effective than OCTR/PR with the median nerve injury rate tripling and doubling from societal and health-care system perspectives, respectively, or if surgical direct costs in the PR exceeded those in the OR.Compared with OCTR/OR and ECTR/OR, OCTR/PR minimizes costs to the health-care system and society while providing favorable outcomes.Economic and Decision Analysis Level III . See Instructions for Authors for a complete description of levels of evidence.
View details for DOI 10.2106/JBJS.20.02126
View details for Web of Science ID 000756191600009
View details for PubMedID 34428186
View details for PubMedCentralID PMC8866519
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The minimal clinically important difference of the Patient-Reported Outcomes Measurement Information System (PROMIS) physical function and upper extremity computer adaptive tests and QuickDASH in the setting of elbow trauma.
JSES international
2021; 5 (6): 1132-1138
Abstract
BACKGROUND: Minimal clinically important difference (MCID) estimates are useful for gauging clinical relevance when interpreting changes or differences in patient-reported outcomes scores. These values are lacking in the setting of elbow trauma. Our primary purpose was to estimate the MCID of the Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) computer adaptive test (CAT), the PROMIS upper extremity (UE) CAT, and the QuickDASH using an anchor-based approach for patients recovering from elbow trauma and related surgeries. Secondarily, we aimed to estimate the MCID using the 1/2 standard deviation method.MATERIALS & METHODS: Adult patients undergoing treatment for isolated elbow injuries between July 2014 and April 2020 were identified at a single tertiary academic medical center. Outcomes, including the PROMIS PF CAT v1.2/2.0, PROMIS UE CAT v1.2, and QuickDASH, were collected via a tablet computer. For inclusion, baseline (6 months before injury up to 11 days postoperatively or after injury) and follow-up (11 to 150 days postoperative or after injury) PF or UE CAT scores were required, as well as a response to an anchor question querying improvement in physical function. The MCID was calculated using (1) an anchor-based approach using the difference in mean score change between anchor groups reporting "No change" and "Slightly Improved/Improved" and (2) the 1/2 standard deviation method.RESULTS: Of the 146 included patients, the mean age was 46±18 years and 67 (46%) were women. Most patients (129 of 146 or 88%) were recovering from surgery, and the remaining 12% were recovering from nonoperatively managed fractures and/or dislocations. The mean follow-up was 157±192 days. Scores for each instrument improved significantly between baseline and follow-up. Anchor-based MCID values were calculated as follows: 5.7, 4.6, and 5.3 for the PROMIS PF CAT, PROMIS UE CAT, and QuickDASH, respectively. MCID values estimated using the 1/2 standard deviation method were 4.3, 4.8, and 11.7 for the PROMIS PF CAT, PROMIS UE CAT, and QuickDASH, respectively.CONCLUSIONS: In the setting of elbow trauma, we propose MCID ranges of 4.3 to 5.7 for the PROMIS PF CAT, 4.6 to 4.8 for the PROMIS UE CAT, and 5.3 to 11.7 for the QuickDASH. These values will provide a framework for clinical relevance when interpreting clinical outcomes studies, or powering clinical trials, for populations recovering from trauma.
View details for DOI 10.1016/j.jseint.2021.06.005
View details for PubMedID 34766096
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Comparison of Complication Risk Following Trigger Digit Release Performed in the Office Versus the Operating Room: A Population-Based Assessment
JOURNAL OF HAND SURGERY-AMERICAN VOLUME
2021; 46 (10): 877-+
Abstract
Trigger digit release (TDR) performed in an office-based procedure room (PR) setting minimizes surgical costs compared with that performed in an operating room (OR); yet, it remains unclear whether the rates of major complications differ by setting. We hypothesized that surgical setting does not have an impact on the rate of major complications after TDR.Adult patients who underwent isolated TDR from 2006 to 2015 were identified from the MarketScan commercial database (IBM) using the provider current procedural terminology code 26055 with a concordant diagnosis on the same claim line (International Classification of Diseases, ninth revision, clinical modification 727.03). The PR cohort was defined by presence of a place-of-service code for an in-office procedure without OR or ambulatory center revenue codes, or anesthesiologist claims, on the day of the surgery. The OR cohort was defined by presence of an OR revenue code. We identified major medical complications, surgical site complications, as well as iatrogenic neurovascular and tendon complications within 90 days of the surgery using International Classification of Diseases, ninth revision, clinical modification diagnosis and/or current procedural terminology codes. Multivariable logistic regression was used to compare the risk of complications between the PR and OR groups while controlling for Elixhauser comorbidities, smoking, and demographics.For 7,640 PR and 29,962 OR cases, the pooled rate of major medical complications was 0.99% (76/7,640) and 1.47% (440/29,962), respectively. The PR setting was associated with a significantly lower risk of major medical complications in the multivariable analysis (adjusted odds ratio 0.76; 95% confidence interval 0.60-0.98). The pooled rate of surgical site complications was 0.67% (51/7,640) and 0.88% (265/29,962) for the PR and OR cases, respectively, with no difference between the surgical settings in the multivariable analysis (adjusted odds ratio 0.81; 95% confidence interval 0.60-1.10). Iatrogenic complications were infrequently observed (PR 5/7,640 [0.07%]; OR 26/29,962 [0.09%]).Compared with performing TDR in the OR using a spectrum of commonly used anesthesia types, performing TDR in the PR using local-only anesthesia was associated with a comparably low risk of major medical complications, surgical complications, and iatrogenic complications.Prognostic II.
View details for DOI 10.1016/j.jhsa.2021.05.010
View details for Web of Science ID 000704992800005
View details for PubMedID 34210572
View details for PubMedCentralID PMC8500925
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Establishing the Minimal Clinically Important Difference for the PROMIS Upper Extremity Computer Adaptive Test Version 2.0 in a Nonshoulder Hand and Upper Extremity Population
JOURNAL OF HAND SURGERY-AMERICAN VOLUME
2021; 46 (10): 927.e1-927.e10
Abstract
Our primary purpose was to calculate the minimal clinically important difference (MCID) for the Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE) Computer Adaptive Test (CAT) version 2.0 (v2.0) for a nonshoulder hand and upper extremity population. Secondarily, we calculated the PROMIS Physical Function (PF) CAT v2.0 and the abbreviated version of the Disabilities of the Arm, Shoulder, and Hand (QuickDASH) MCID.Adult patients treated by 1 of 5 fellowship-trained hand surgeons between March 2015 and September 2019 at an academic tertiary institution were identified. The PROMIS UE CAT v2.0, PROMIS PF CAT v2.0, and QuickDASH were collected via tablet computer. Inclusion required response to at least 1 of the instruments at both baseline and follow-up (6 ± 4 weeks), and a response to the anchor question: "Compared to your first evaluation at the University Orthopaedic Center, how would you describe your physical function level now?" An additional anchor question assessing treatment-related improvement was also asked. The MCID was calculated using an anchor-based approach using the mean change difference between groups reporting no change and slight change for both anchor questions, and with the 1/2 SD method.Of 2,106 participants, mean age was 48 ± 17 years, 53% were female, and 53% were recovering from surgery. Of these patients, 381 completed the PROMISE UE CAT v2.0, 497 completed the PROMIS PF CAT v2.0, and 2,018 completed the QuickDASH. The score change between baseline and follow-up was significantly different between anchor groups for both anchor-based MCID calculations. Anchor-based MCID values were 3.0 to 4.0 for the UE CAT, 2.1 to 3.6 for the PF CAT, and 10.3 for the QuickDASH. The MCID values per the 1/2 SD method were 4.1, 4.1, and 10.2, respectively.We propose MCID ranges of 3.0 to 4.1 for the PROMIS UE CAT v2.0, and 2.1 to 4.1 for the PROMIS PF CAT v2.0. The observed QuickDASH MCID values (10.2-10.3) are within the range of previously published values.These MCID estimates will aid in interpreting clinical outcomes and in powering clinical studies.
View details for DOI 10.1016/j.jhsa.2021.01.023
View details for Web of Science ID 000704992800015
View details for PubMedID 33812773
View details for PubMedCentralID PMC8481350
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Evaluating the Impact of Social Deprivation on Mid-Term Outcomes Following Distal Radius Open Reduction Internal Fixation.
Journal of hand surgery global online
2021; 3 (5): 235-239
Abstract
PURPOSE: Although baseline biopsychosocial factors are associated with short-term patient-reported outcomes following distal radius fracture open reduction internal fixation (ORIF), their effect on mid-term outcomes is unclear. We aimed to evaluate the effect of social deprivation, previously established as a surrogate for depression, pain interference, and anxiety, on quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores >1 year following distal radius ORIF.METHODS: Adult patients (≥18 years) with an isolated distal radius fracture treated with ORIF by orthopedic trauma and hand surgeons at a single tertiary academic center over a 3-year period were included. Outcomes at ≥1 year postoperatively were evaluated using QuickDASH. Age, follow-up duration, area deprivation index (ADI; a measure of social deprivation), subspecialty (hand vs trauma), and postoperative alignment were assessed using linear regression with 95% confidence intervals after bootstrapping and a permutation test for P values to test for their association with the final QuickDASH score.RESULTS: Follow-up data were obtained for 98 of 220 (44.5%) patients at a mean of 3.1 ± 1.0 years after surgery. Mean age and ADI were 53.2 ± 15.4 years and 26.8 ± 18.7, respectively. Most fractures were intra-articular (67.3%), and 72.4% had acceptable postoperative alignment parameters, as defined by the American Academy of Orthopaedic Surgeons clinical practice guidelines. The mean QuickDASH score was 13.0 ± 16.5. There were no significant associations between the final QuickDASH score and any studied factor, including ADI, as determined using univariable analysis. Multivariable analysis showed no association between ADI and the final QuickDASH score, independent of age, sex, treating service, follow-up duration, and fracture alignment or pattern.CONCLUSIONS: At mid-term follow up after distal radius ORIF, ADI did not correlate with QuickDASH scores, and the QuickDASH scores of the patients did not differ from those of the general population. However, our cohort mostly comprised patients with levels of deprivation below the national median. Although studies have shown that the short-term outcomes of distal radius ORIF are influenced by biopsychosocial factors, outcomes at the time of final recovery may not be associated with social deprivation.TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.
View details for DOI 10.1016/j.jhsg.2021.06.002
View details for PubMedID 34632351
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Guided Growth for Tibial Recurvatum
STRATEGIES IN TRAUMA AND LIMB RECONSTRUCTION
2021; 16 (3): 172-175
Abstract
Sagittal guided growth of the distal anterior femur has been shown to be effective for the correction of fixed knee flexion deformity that is encountered in clinical practice. The opposite deformity, namely genu recurvatum, is comparatively uncommon in children. The most common aetiology is post-traumatic. Acute correction by means of osteotomy has significant associated risks. Our objective was to determine whether a posterior 8-plate would suffice in correcting tibial recurvatum and obviate the need for an osteotomy.We included a total of five deformities, three boys (one bilateral) and one girl, managed by means of tethering of the posterior proximal tibial physis with a tension band plate. Standard radiographs obtained preoperatively and at follow-up included a standing anteroposterior (AP) of the legs noting limb lengths and the mechanical axis. We also obtained standing lateral views of each knee in maximal extension to measure and compare the posterior proximal tibial angle (PPTA).The same-day surgery was well tolerated and there were no surgical or post-operative complications. The preoperative PPTA ranged from 106° to 117° and averaged 84° at follow-up. Correction occurred in an average of 20 months (range of 18-24 months). The patient with bilateral recurvatum due to Hurler's syndrome developed unilateral recurrent recurvatum culminating in percutaneous reinsertion of the metaphyseal screw. For each patient, knee hyperextension and associated pseudo-laxity resolved and limb lengths remained equal at follow-up.Children with progressive genu recurvatum typically present with an insidious onset of symptoms. Guided growth of the posterior proximal tibia is a safe and effective means of correcting the deformity; osteotomy was avoided in this series.III - retrospective case series - no controls.Stevens P, Stephens A, Rothberg D. Guided Growth for Tibial Recurvatum. Strategies Trauma Limb Reconstr 2021;16(3):172-175.
View details for DOI 10.5005/jp-journals-10080-1535
View details for Web of Science ID 000745086800004
View details for PubMedID 35111257
View details for PubMedCentralID PMC8778727
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Prognostic Factors Affecting Long-Term Outcomes After Elbow Dislocation: A Longitudinal Cohort Study.
Journal of hand surgery global online
2021; 3 (5): 260-265
Abstract
PURPOSE: To describe patient-reported outcomes following simple elbow dislocation and to identify the baseline factors that predict outcomes.METHODS: Adult patients treated with a closed reduction for a simple elbow dislocation with or without minor fracture (coronoid avulsion, radial head fracture, or epicondyle avulsion) from 2000 to 2018 completed outcome instruments including Disabilities of the Arm, Shoulder and Hand (QuickDASH) via Research Electronic Data Capture. Descriptive statistics were calculated. Univariate followed by multivariate Tobit regression models were used to determine factors associated with clinical outcomes on QuickDASH. Social deprivation was measured using the Area Deprivation Index. Patients with additional upper-extremity injuries or associated major fractures (Monteggia or terrible triad injuries, distal humerus fractures, etc) were excluded.RESULTS: At a mean follow-up of 67.5 months, 95% (38/40) of patients reported satisfaction with treatment, and clinical outcomes were good (QuickDASH 9.0 ± 14.8). Univariate analysis showed that higher Area Deprivation Index, older age, female sex, high-energy mechanism of injury, and worker's compensation (WC) or Medicare insurance status (vs commercial) was associated with significantly worse QuickDASH scores at follow-up. Early therapy, dominant elbow involvement, presence of minor fractures (minimally displaced radial head, coronoid tip, or epicondylar avulsion fractures), race, and treating service did not influence outcomes in univariate analyses. Multivariate analysis demonstrated a significant association between increased social deprivation, WC insurance, and Medicare insurance and worse QuickDASH scores while controlling for new upper-extremity injury, age, sex, and mechanism of injury.CONCLUSIONS: Outcomes and treatment satisfaction following simple elbow dislocation are generally good but are significantly worse for the patients with greater levels of social deprivation and WC or Medicare insurance. Although surgeons should be aware of the possibility that specific subsets of patients may benefit from early therapy, this factor did not appear to influence long-term outcomes in this small cohort.TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic III.
View details for DOI 10.1016/j.jhsg.2021.05.011
View details for PubMedID 34632352
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Evaluating the Safety of the Hand Surgery Procedure Room: A Single-Center Cohort of 1,404 Surgical Encounters
JOURNAL OF HAND SURGERY-AMERICAN VOLUME
2021; 46 (7): 623.e1-623.e9
Abstract
Performing hand surgeries in the procedure room (PR) setting instead of the operating room effectively reduces surgical costs. Understanding the safety or complication rates associated with the PR is important in determining the value of its use. Our purpose was to describe the incidence of medical and surgical complications among patients undergoing minor hand surgeries in the PR.We retrospectively reviewed all adult patients who underwent an operation in the PR setting between December 2013 and May 2019 at a single tertiary academic medical center by 1 of 5 fellowship-trained orthopedic hand surgeons. Baseline patient characteristics were described. Complication rates were obtained via chart review.For 1,404 PR surgical encounters, 1,796 procedures were performed. Mean patient age was 59 ± 15 years, 809 were female (57.6%), and average follow-up was 104 days. The most common surgeries were carpal tunnel release (39.9%), trigger finger release (35.9%), and finger mass or cyst excision (9.6%). Most surgeries were performed using a nonpneumatic wrist tourniquet (58%), whereas 42% used no tourniquet. No patient experienced a major medical complication. No procedure was aborted owing to intolerance. No patient required admission. No intraoperative surgical or medical complications occurred. Observed complications included delayed capillary refill requiring phentolamine administration after a trigger thumb release performed using epinephrine without a tourniquet (n = 1; 0.1%), complex regional pain syndrome (n = 3; 0.2%), infection requiring surgical debridement (n = 2; 0.2%), and recurrent symptoms requiring reoperation (n = 8; 0.7%).In this cohort of patients in whom surgery was performed in a PR, there were no major intraoperative surgical or medical complications. There was a low rate of postoperative infection, development of complex regional pain syndrome, and a low need for revision surgery. These observations do not support the concern for safety as a barrier to performing minor hand surgery in the PR setting.Therapeutic IV.
View details for DOI 10.1016/j.jhsa.2020.11.018
View details for Web of Science ID 000671438200013
View details for PubMedID 33487491
View details for PubMedCentralID PMC8260433
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Comparison of direct surgical cost for humeral shaft fracture fixation: open reduction internal fixation versus intramedullary nailing.
JSES international
2021; 5 (4): 734-738
Abstract
BACKGROUND AND/OR HYPOTHESIS: Prior literature has supported similar complication rates and outcomes for humeral shaft fractures treated with open reduction internal fixation (ORIF) with a plate/screw construct versus intramedullary nailing (IMN). The purpose of this study is to determine whether surgical encounter total direct costs (SETDCs) differ between ORIF and IMN for these fractures.METHODS: Adult patients (≥ 18 years) treated for isolated humeral shaft fractures by ORIF or IMN between June 18, 2014 and June 17, 2019 at a single tertiary academic center were available for inclusion. SETDCs for ORIF and IMN groups, obtained through our institution's information technology value tool, were adjusted to 2019 US dollars and converted to relative costs per institutional policy. SETDCs for ORIF and IMN were compared using the Wilcoxon rank-sum test.RESULTS: Demographic factors did not differ between ORIF and IMN cohorts with the exception of age (mean of 18.6 years older for IMN; P<.001) and American Society of Anesthesiologist class (higher for IMN; P=.029). Substantial cost variation was observed among the 39 included ORIF and 21 IMN cases. Costs pertaining to operating room utilization (P=.77), implants (P=.64), and the recovery room (P=.27) were similar for ORIF and IMN, whereas supply costs were significantly greater for IMN with a median (interquartile range) of 0.21 (0.17 0.28), more than twice the supply costs of ORIF (0.09 [0.05 0.13], P<.001). The SETDC of IMN was significantly greater than that of ORIF (median [interquartile range]:1.00 [0.9 to 1.13] vs. 0.83 [0.711.05], respectively; P=.047).DISCUSSION AND/OR CONCLUSION: Our study found that the SETDC for humeral shaft fracture fixation was greater for IMN than for ORIF, although patient cohorts differed significantly with respect to age and the American Society of Anesthesiologist class. Surgeons should take these findings into consideration when consenting patients with humeral shaft fractures for the appropriate fixation type.
View details for DOI 10.1016/j.jseint.2021.04.005
View details for PubMedID 34223423
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Evaluating the impact of social deprivation on Press Ganey® Outpatient Medical Practice Survey Scores
HEALTH AND QUALITY OF LIFE OUTCOMES
2021; 19 (1): 167
Abstract
Social deprivation has been shown to affect access to health care services, and influences outcomes for a variety of physical and psychological conditions. However, the impact on patient satisfaction remains less clear. The objective of this study was to determine if social deprivation is an independent predictor of patient satisfaction, as measured by the Press Ganey® Outpatient Medical Practice Survey (PGOMPS).We retrospectively reviewed unique new adult patient (≥ 18 years of age) seen at a tertiary academic hospital and rural/urban outreach hospitals/clinics between January 2014 and December 2017. Satisfaction was defined a priori as achieving a score above the 33rd percentile. The 2015 Area Deprivation Index (ADI) was used to determine social deprivation (lower score signifies less social deprivation). Univariate and multivariable binary logistic regression were used to determine the impact of ADI on PGOMPS total and provider sub-scores while controlling for variables previously shown to impact scores (wait time, patient age, sex, race, specialty type, provider type, and insurance status).Univariate analysis of PGOMPS total scores revealed a 4% decrease in odds of patient satisfaction per decile increase in ADI (p < 0.001). Patients within the most deprived quartile were significantly less likely to report satisfaction compared to the least deprived quartile (OR 0.79, p < 0.001). Multivariable analysis revealed that the odds of achieving satisfaction decreased 2% for each decile increase in ADI on the Total Score (p < 0.001), independent of other variables previously shown to impact scores. For PGOMPS Provider Sub-Score, univariate analysis showed that patients in the lowest ADI quartile were significantly less likely be satisfied, as compared to the least deprived quartile (OR 0.77; 95% CI 0.70-0.86; p < 0.001). A 5% decrease in a patient being satisfied was observed for each decile increase in ADI (OR 0.95; 95% CI 0.94-0.96; p < 0.001).Social deprivation was an independent predictor of outpatient visit dissatisfaction, as measured by the Press Ganey® Outpatient Medical Practice Survey. These results necessitate consideration when developing health care delivery policies that serve to minimize inequalities between patients of differing socioeconomic groups.
View details for DOI 10.1186/s12955-020-01639-y
View details for Web of Science ID 000663502200001
View details for PubMedID 34147118
View details for PubMedCentralID PMC8214262
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Inter-specialty variation of the Press Ganey Outpatient Medical Practice Survey
MEDICINE
2021; 100 (12): e25211
Abstract
Measuring patient satisfaction scores and interpreting factors that impact their variation is of importance as scores influence various aspects of health care administration. Our objective was to evaluate if Press Ganey scores differ between medical specialties.New patient visits between January 2014 and December 2016 at a single tertiary academic center were included in this study. Press Ganey scores were compared between specialties using a multivariable logistic mixed effects model. Secondary outcomes included a comparison between surgical versus non-surgical specialties, and pediatric versus adult specialties. Due to the survey's high ceiling effect, satisfaction was defined as a perfect total score.Forty four thousand four hundred ninety six patients met inclusion criteria. Compared to internal medicine, plastic surgery, general surgery, dermatology, and family medicine were more likely to achieve a perfect overall score, as, with odds ratios of 1.46 (P = .02), 1.29 (P = .002), 1.22 (P = .004), and 1.16 (P = .02) respectively. Orthopaedics, pediatric medicine, pediatric neurology, neurology, and pain management were less likely to achieve satisfaction with odds ratios of 0.85 (P = .047), 0.71 (P < .001), 0.63 (P = .005), 0.57 (P < .001), and 0.51 (P = .006), respectively. Compared to pediatric specialties, adult specialties were more likely to achieve satisfaction (OR 1.73; P < .001). There were no significant differences between surgical versus non-surgical specialties.Press Ganey scores systematically differ between specialties within the studied institution. These differences should be considered by healthcare systems that use patient satisfaction data to modify provider reimbursement.
View details for DOI 10.1097/MD.0000000000025211
View details for Web of Science ID 000659535100082
View details for PubMedID 33761706
View details for PubMedCentralID PMC9281982
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A Comparison of Open Carpal Tunnel Release Outcomes Between Procedure Room and Operating Room Settings.
Journal of hand surgery global online
2021; 3 (1): 12-16
Abstract
PURPOSE: Carpal tunnel release (CTR) surgical costs are minimized when performed in the procedure room (PR) setting, compared with the operating room. However, it remains unclear whether outcomes differ between surgical settings. Our purpose was to compare outcomes at 1 year or greater follow-up after open CTR between patients treated in PR versus operating room settings using the Boston Carpal Tunnel Questionnaire (BCTQ).METHODS: A change in clinical care protocols at our institution occurred in 2014. Before this, all CTRs were performed in the operating room; thereafter, these were transitioned to the PR. Adult patients who underwent isolated unilateral or bilateral open CTR in either surgical setting were considered for inclusion, in which procedures were conducted between January 2014 and October 2018 for the PR group and January 2009 and March 2014 for the operating room group. The Functional Status Scale (FSS) and the Symptom Severity Scale (SSS) components of the BCTQ were collected for all eligible patients at a minimum of 1 year after surgery. We used univariate and multivariable linear regression to determine whether postoperative BCTQ scores were equivalent between PR and operating room groups within a threshold of one-fourth of the lowest estimates of the minimal clinically important difference.RESULTS: No differences in demographics, comorbidities, or insurance type were observed between the 104 PR and 112 operating room patients. Survey response rate was 25% and 25% for the PR and operating room patients, respectively. At a mean follow-up of 3 ± 1 years, FSS and SSS scores were equivalent between PR and operating room groups on bivariate analysis. The multivariable equivalence test also demonstrated equivalent FSS and SSS scores between PR and operating room groups within a one-fourth minimal clinically important difference threshold while controlling for age, sex, presence of diabetes or thyroid disease, unilateral versus bilateral CTR, and surgeon.CONCLUSIONS: Clinical outcomes did not differ between PR and operating room settings after open CTR. Type of study/level of evidence: Therapeutic III.
View details for DOI 10.1016/j.jhsg.2020.10.009
View details for PubMedID 33537661
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Evaluation of factors driving cost variation for distal humerus open reduction internal fixation.
JSES international
2021; 5 (1): 18-23
Abstract
BACKGROUND: Distal humerus fracture open reduction and internal fixation (ORIF) represents a substantial cost burden to the health care system. The purpose of this study was to describe surgical encounter cost variation for distal humerus ORIF, and to determine demographic-, injury-, and treatment-specific factors that influence cost.METHODS: We retrospectively identified adult patients (≥18 years) treated for isolated distal humerus fractures between July 2014 and July 2019 at a single tertiary academic referral center. For each case, surgical encounter total direct costs (SETDCs) were obtained via our institution's information technology value tools, which prospectively record granular direct cost data for every health care encounter. Costs were converted to 2019 dollars using the personal consumption expenditure indices for health and summarized with descriptive statistics. Univariate and multivariate linear regression models were used to identify factors influencing SETDC.RESULTS: Surgical costs varied widely for the 47 included patients, with a standard deviation (SD) of 33% and interquartile range of 76%-124% relative to the mean SETDC. Implant and facility costs were responsible for 46.2% and 32.6% of the SETDC, respectively. Implant costs also varied considerably, with an SD of 21% and range from 13%-36% relative to the mean SETDC. Multivariate analysis demonstrated that SETDC increased 24% (P < .001) on performing an olecranon osteotomy, and by 15% for each additional 1 hour of surgical time (P < .001). These findings were independent of age, sex, body mass index, open fracture, need for an additional small plate construct as a reduction aid, and fracture pattern (all insignificant in the multivariate analysis, with P >.05 for each factor).CONCLUSION: Substantial variations in surgical encounter total direct costs for distal humerus ORIF exist, as do wide variations in associated implant costs that comprise nearly half of the entire surgical cost. Performing an olecranon osteotomy, and increased surgical time, significantly increased surgical costs. Although use of an olecranon osteotomy may not be a completely controllable factor as it is confounded by fracture severity and operative time, this may suggest that surgeons should try to use an olecranon osteotomy judiciously. Although complexity of the fracture pattern was statistically insignificant, it is confounded by the need for an olecranon osteotomy and increased surgical time and likely is a clinically relevant and nonmodifiable driver of surgical cost. These findings highlight opportunities to reduce cost variation, and potentially improve the value of care, for distal humerus ORIF patients.
View details for DOI 10.1016/j.jseint.2020.09.009
View details for PubMedID 33554158
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Evaluating the performance of PROMIS and QuickDASH instruments in an intercollegiate Division 1 athlete population
JOURNAL OF SHOULDER AND ELBOW SURGERY
2021; 30 (1): 158-164
Abstract
Athletes demonstrate high levels of physical function, leading to difficulties in patient-reported outcome scoring and interpretation. In particular, the ability of patient-reported outcome (PRO) instruments to adequately discriminate between high levels of upper extremity function-that is, the ceiling effect-is limited. This study evaluated performance characteristics of the shortened version of the Disabilities of the Arm, Shoulder, and Hand (QuickDASH) survey and Patient-Reported Outcomes Measurement Information System (PROMIS) metrics in a population of Division 1 intercollegiate athletes, with specific attention to ceiling effects.At a single institution, Division I intercollegiate athletes cleared for full participation in the 2018-2019 season were eligible. The following PROs were collected prospectively via tablet computer: PROMIS upper extremity (UE) computer adaptive test (CAT), PROMIS physical function (PF) CAT, QuickDASH, and QuickDASH Sports/Performing Arts Module. Descriptive statistics, and ceiling and floor effects, were calculated. The proportion of athletes with maximal scores on each PRO were compared to normative values using the 1-sample Wilcoxon signed rank test.A total of 268 participants were included; the mean age was 19.9 ± 1.5 years, 49% were female, and 61% were overhead athletes. Large ceiling effects were observed for the UE CAT (46%), QuickDASH (58%), and QuickDASH Sports Module (82%). The PF CAT demonstrated a relatively low ceiling effect of 6.7%. Athlete scores were all significantly better than published age-matched values from a normative population for all instruments, with the exception of no difference on the QuickDASH for males.The PROMIS UE CAT and QuickDash instruments are limited in their ability to assess and discriminate upper extremity function in highly functioning individuals such as Division I athletes. The PROMIS PF CAT, a measure of general physical function, did not suffer from a large ceiling effect.
View details for DOI 10.1016/j.jse.2020.05.008
View details for Web of Science ID 000599912200032
View details for PubMedID 33317702
View details for PubMedCentralID PMC7738759
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The Impact of Social Deprivation on Orthopaedic Outpatient Satisfaction Using the Press Ganey Outpatient Medical Practice Survey
JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS
2020; 28 (24): E1111-E1120
Abstract
In orthopaedics, multiple factors (patient age, wait time, and depression) have been associated with lower Press Ganey Outpatient Medical Practice Survey (PGOMPS) patient satisfaction scores. We hypothesized that increased social deprivation is an independent predictor of lower patient satisfaction, as measured by the PGOMPS.We retrospectively reviewed unique new outpatient orthopaedic surgery visits between January 1, 2014, and December 31, 2016, at a single tertiary academic institution. Given the high ceiling effects, satisfaction was defined a priori as achieving a score above the 33rd percentile. Social deprivation was determined using the 2015 Area Deprivation Index (ADI). Univariate and multivariable binary logistic regressions were used to detect factors associated with patient satisfaction for both the PGOMPS Total Score and Provider Sub-Score.Of the 4,881 included patients, the mean age was 53.3 ± 15.9 years, 59.3% were women, and mean ADI was 30.1 ± 19.2. Univariate analysis revealed a significantly decreased odds of achieving satisfaction on the Total Score for each decile increase in ADI (odds ratio [OR] 0.94; P < 0.001). Compared with the least deprived quartile, patients of the most deprived quartile were significantly less likely to report satisfaction for both the Total Score (OR 0.56; P = 0.001) and Provider Sub-Score (OR 0.63; P = 0.011). Multivariable analysis revealed that the odds of achieving satisfaction for each decile increase in ADI were 0.96 for the Total Score (P = 0.014) and 0.95 for the Provider Sub-Score (P = 0.004), independent of age, wait time, race, subspecialty, provider type, and the clinic setting.Increased social deprivation was an independent predictor of orthopaedic outpatient dissatisfaction on the PGOMPS. These findings should be considered when interpreting patient satisfaction scores and lend further support in an effort to improve healthcare inequalities.Level III.
View details for DOI 10.5435/JAAOS-D-19-00852
View details for Web of Science ID 000619304700005
View details for PubMedID 32235241
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Comparison of Magnetic Resonance Imaging and Ultrasound Evaluations of Zone II Partial Flexor Tendon Lacerations A Cadaveric Study
JOURNAL OF ULTRASOUND IN MEDICINE
2021; 40 (8): 1651-1656
Abstract
Surgical intervention for zone II high-grade partial flexor tendon lacerations is often required when more than half of the tendon width is torn. Reliable noninvasive tests are critical for optimizing clinical decision making. Our team previously investigated the use of ultrasound (US) for identification of high-grade zone II flexor digitorum profundus lacerations. In this study, we compared magnetic resonance imaging (MRI) to US for the evaluation of high-grade partial flexor tendon lacerations in cadaveric specimens.Dissection of 32 digits in 8 fresh-frozen upper extremity cadaveric specimens was performed. The flexor digitorum profundus tendons were randomized into 3 groups: intact, low-grade laceration, and high-grade laceration. A dynamic US examination was performed by a blinded musculoskeletal radiologist. The same specimens underwent hand coil MRI, which was read by the same blinded radiologist. Magnetic resonance imaging test performance metrics were calculated and compared to those computed for the US evaluation.For US evaluation of high-grade lacerations, the sensitivity and specificity were 0.5 and 1.0, with positive likelihood ratio (LR+) and negative likelihood ratio (LR-) values of ∞ and 0.50, respectively. The sensitivity and specificity for MRI evaluation were 0.2 and 1.0, with LR+ and LR- values of ∞ and 0.80.Both US and MRI are adequate at determining the presence of a high-grade laceration. Magnetic resonance imaging was more specific than US in identification of high-grade partial flexor tendon lacerations. Although less specific, US is a reasonable and less-expensive alternative to MRI when evaluating for clinically significant high-grade partial flexor tendon lacerations.
View details for DOI 10.1002/jum.15553
View details for Web of Science ID 000588103400001
View details for PubMedID 33174636
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Cost Implications of Varying the Surgical Setting and Anesthesia Type for De Quervain Release Surgery
JOURNAL OF WRIST SURGERY
2020; 09 (04): 289-297
Abstract
Background First extensor compartment release is a common surgical procedure that represents a financial burden to the health care system. Questions/Purposes Study questions included (1) whether surgical encounter costs differ based upon surgical setting (operating room [OR] vs. procedure room [PR]) or (2) based upon anesthesia choice (local only, Bier's block [BB], monitored anesthesia care [MAC], or general [GA]) for De Quervain release (DQR). Patients and Methods Consecutive adult patients undergoing isolated unilateral DQR at a single academic medical center were identified retrospectively by Current Procedural Terminology code (25000). Using our institution's information technology value tools, we calculated total direct costs for each surgical encounter. Costs were adjusted to January 2016 dollars using the Consumer Price Index, normalized using each participant's surgical encounter cost divided by the median cost in the PR group, then compared across each group using Kruskal-Wallis and Nemenyi's post hoc pair-wise tests. Multivariable gamma regression analysis with a log link was performed to identify factors associated with surgical costs. QuickDASH (disabilities of the arm, shoulder, and the hand) scores were compared using a t -test at final follow-up. Results Among 58 included patients, 29% (17/58) were treated in the PR and 71% (41/58) in the OR. Compared with local only in the PR, all other groups were significantly more costly. Multivariable gamma regression indicated that use of OR/BB, OR/MAC, or OR/GA independently led to 211, 222, and 357% greater surgical costs as compared with the PR with local only while controlling for provider and patient age. Furthermore, QuickDASH scores were similar between PR and OR groups at final follow-up. Conclusion Performing DQR in the PR setting under local only anesthesia yields greater value than the OR, as patient-reported outcomes are similar despite significantly lower surgical costs. Level of Evidence This is a Level III, cost analysis study.
View details for DOI 10.1055/s-0040-1708863
View details for Web of Science ID 000554378200004
View details for PubMedID 32760607
View details for PubMedCentralID PMC7395842
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Volar Locked Plating Versus Closed Reduction and Casting for Acute, Displaced Distal Radial Fractures in the Elderly: A Systematic Review and Meta-Analysis of Randomized Controlled Trials
JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME
2020; 102 (14): 1280-1288
Abstract
It remains unclear whether volar locked plating (VLP) yields a better functional outcome than closed reduction and casting (CRC) for elderly patients with an acute, displaced distal radial fracture. Our purpose was to conduct a systematic review and meta-analysis of randomized controlled trials comparing outcomes of VLP and CRC for elderly patients (age, ≥60 years).Multiple databases, including MEDLINE, were searched for randomized controlled trials evaluating outcomes following distal radial fracture treatment. Raw data were obtained for studies that included patients of all ages, and the elderly subgroup was included for analysis. The primary outcome was the Disabilities of the Arm, Shoulder and Hand (DASH) score at ≥1 year of follow-up. Secondary outcomes included the 3-month DASH score, range of motion, final radiographic alignment, and complications. Effect sizes for the comparison of each outcome between groups were pooled across studies using random-effects models with the inverse variance weighting method. Changes in DASH score were compared with a minimal clinically important difference (MCID) estimate of 10 to assess clinical relevance.Of 2,152 screened articles, 6 were included. Demographics were similar for the 274 VLP and 287 CRC patients. DASH scores were significantly better following VLP than CRC at the time of final follow-up (12 to 24 months postoperatively; score difference, -5.9; 95% confidence interval [CI], -8.7 to -3.1) and at 3 months (-8.9; 95% CI, -13.0 to -4.8). VLP yielded significantly better palmar tilt, radial inclination, and supination, with no differences in ulnar variance, flexion-extension, pronation, or total complication rates.Functional outcome was significantly better following VLP than CRC 3 months into the treatment of acute, displaced distal radial fractures in an elderly population and up to 2 years after injury. However, the observed differences in the final DASH score did not exceed published estimates of the MCID, suggesting that clinical outcomes are similar for both treatment options.Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
View details for DOI 10.2106/JBJS.19.01442
View details for Web of Science ID 000604468000023
View details for PubMedID 32675679
View details for PubMedCentralID PMC7431141
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Risk of Total Wrist Arthrodesis or Reoperation Following 4-Corner Arthrodesis or Proximal Row Carpectomy for Stage-II SLAC/SNAC Arthritis A Propensity Score Analysis of 502 Wrists
JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME
2020; 102 (12): 1050-1058
Abstract
For stage-II scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) patterns of wrist arthritis, the optimal method of surgical treatment remains unclear. Previous literature has demonstrated similar clinical outcomes between proximal row carpectomy (PRC) and 4-corner arthrodesis (FCA), making the risk of reoperation a focus of particular interest. In the present study, the primary null hypothesis was that there would be no difference in the rate of conversion to total wrist arthrodesis between PRC and FCA. Additionally, we hypothesized that the rate of secondary surgical procedures would be similar between the 2 procedures.The national Veterans Health Administration Corporate Data Warehouse was utilized to identify 2,449 patients who underwent either PRC or FCA between 1992 and 2016. With use of operative reports to identify the arthritis pattern, only cases of stage-II SLAC/SNAC were included. All complications and subsequent surgical procedures were confirmed by manual chart review. Propensity score analyses with matching weights were utilized to balance the PRC and FCA cohorts. The rates of conversion to wrist arthrodesis and secondary surgical procedures were calculated.Of the 1,168 patients with stage-II SLAC/SNAC arthritis, 933 wrists underwent PRC and 257 wrists underwent FCA. Ten-year survival free of total wrist arthrodesis in the matching PRC (251 procedures) and FCA (251 procedures) cohorts was 94.3% (95% confidence interval [CI], 92.3% to 96.3%) and 94.1% (95% CI, 90.8% to 97.4%), respectively. Survival free of a secondary surgical procedure other than wrist arthrodesis was 99.7% (95% CI, 99.3% to 100.0%) for PRC and 83.5% (95% CI, 78.2% to 88.8%) for FCA.PRC and FCA demonstrated similarly low rates of conversion to total wrist arthrodesis. In contrast, the rate of secondary surgical procedures following FCA was significantly higher compared with PRC. Given the historically similar clinical outcomes between PRC and FCA, the results of the present study show that PRC may be a preferable treatment for stage-II SLAC/SNAC wrist arthritis.Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
View details for DOI 10.2106/JBJS.19.00965
View details for Web of Science ID 000553084100015
View details for PubMedID 32187124
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The Minimal Clinically Important Difference of the PROMIS and <i>Quick</i>DASH Instruments in a Nonshoulder Hand and Upper Extremity Patient Population
JOURNAL OF HAND SURGERY-AMERICAN VOLUME
2020; 45 (5): 399-+
Abstract
The minimal clinically important difference (MCID) is used in research and clinical settings as a benchmark to gauge improvement following treatment. The purpose of this study was to provide anchor-based MCID estimates for Patient-Reported Outcomes Measurement Information System (PROMIS) and legacy instruments in a nonshoulder hand and upper extremity population.Adult patients (≥18 years) seeking care at a tertiary academic outpatient hand surgery clinic completed patient-reported outcome measures on tablet computers between January 2015 and August 2017. Data were collected at baseline and at 6 ± 2 weeks of follow-up. The PROMIS Upper Extremity (UE), Physical Function (PF), and Pain Interference (PI) Computer Adaptive Test (CAT) instruments were administered, along with the shortened Disabilities of the Arm, Shoulder, and Hand (QuickDASH). A mean change anchor-based method was used to estimate MCIDs by comparing scores between anchor groups reporting no change versus slightly improved in terms of function and pain.Scores for each instrument significantly improved over the study period. With significant differences in scores between groups reporting no change and slightly improved function, anchor-based MCID estimates were calculated as follows: 2.1 for the PROMIS UE CAT, 1.7 for the PROMIS PF CAT, and 6.8 for the QuickDASH. There was no significant difference in PROMIS PI CAT scores between anchor groups when queried for level of pain improvement, precluding estimation of an anchor-based MCID.We have provided anchor-based MCID estimates for the PROMIS UE CAT, PROMIS PF CAT, and the QuickDASH for a general nonshoulder hand and upper extremity population. These values may be useful in future research for informing power calculations and when interpreting whether the magnitude of change on these instruments is clinically significant at a population level.This study provides clinicians with a reference for values that may reflect clinically meaningful changes in scores for patient-reported outcome instruments commonly utilized in the current hand surgery literature.
View details for DOI 10.1016/j.jhsa.2019.12.002
View details for Web of Science ID 000564653400005
View details for PubMedID 31955997
View details for PubMedCentralID PMC7200282
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Evaluating opportunities for improved orthopedics outpatient satisfaction: an analysis of Press Ganey® Outpatient Medical Practice Survey responses
JOURNAL OF ORTHOPAEDIC SURGERY AND RESEARCH
2020; 15 (1): 28
Abstract
The Press Ganey® Outpatient Medical Practice Survey (PGOMPS) is composed of 10 provider-specific and 15 non-provider-specific questions. Some healthcare systems link PGOMS overall scores to physician reimbursements. The aim of this study was to determine the frequency of patient satisfaction across individual PGOMPS question, the null hypothesis being that there was no variability between the frequency of satisfaction and similar questions.We reviewed all new patient orthopedic PGOMPS scores between January 2014 and December 2017. Due to the large ceiling effect, satisfaction was defined as a perfect total score. The frequency of perfect scores for each question was calculated.Five thousand one hundred sixty-three patients met the inclusion criteria. Two thousand two hundred sixty-six (43.89%) provider-specific questions received perfect satisfaction versus 986 (19.10%) with perfect satisfaction for non-provider-specific questions (p < 0.001). The five questions most likely to receive perfect satisfaction were MD friendliness/courtesy (80.36), MD spoke using clear language (80.35%), likelihood to recommend practice (79.11%), likelihood to recommend MD (78.8%), and MD confidence (78.74%). The five least likely were convenience of office hours (60.44%), ease of getting on phone (59.72%), ability to get desired appointment (59.50%), wait time (54.63%), and information about delays (53.80%).Our results suggest that the majority of orthopedic patients are satisfied with their provider, demonstrating that room for improvement is limited with provider-specific areas. Leaders of health care teams should consider these results when seeking to improve patient satisfaction scores and determining how and if scores should be linked to reimbursements.
View details for DOI 10.1186/s13018-020-1567-1
View details for Web of Science ID 000513615400001
View details for PubMedID 31992339
View details for PubMedCentralID PMC6986136
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Effects of Baseline Opioid Medication Use on Patient-Reported Functional and Psychological Impairment Among Hand Clinic Patients
JOURNAL OF HAND SURGERY-AMERICAN VOLUME
2019; 44 (10): 829-839
Abstract
To test the null hypothesis that baseline opioid use is not associated with functional or psychological impairment among new hand surgery clinic patients, as measured by Patient-Reported Outcomes Measurement Information System (PROMIS) instruments.New adult (≥ 18 years) patient visits to a tertiary academic orthopedic nonshoulder hand and upper extremity clinic between February 2014 and April 2018 were eligible. Collected outcomes include the question, "Are you currently taking narcotic pain medications?", the PROMIS Upper Extremity (UE) computerized adaptive testing (CAT), abbreviated version of the Disorders of the Arm, Shoulder, and Hand (QuickDASH), PROMIS Physical Function (PF) CAT, PROMIS Pain Interference (PI) CAT, PROMIS Depression CAT, and PROMIS Anxiety CAT. Patients responding to the opioid question, plus the UE CAT or QuickDASH, were included. Bivariate and multivariable logistic regression modelling were used to assess factors associated with baseline scores.Of 5997 included patients, 1,046 (17.4%) reported baseline opioid use. Patients in the opioid group demonstrated significantly worse scores on all patient-reported outcomes, and a significantly greater proportion of patients with PROMIS Depression CAT scores exceeding 60 (associated with a clinical diagnosis of depression; 29.5% vs 15.5%). Lower functional scores were observed in the opioid group after controlling for age, sex, other activity-limiting comorbidities, and either depression (UE CAT -7.0; QuickDASH +18.1; and PF CAT -6.6 points), anxiety (UE CAT -6.3; QuickDASH +16.4; PF CAT -6.3), or PI (UE CAT -3.7; QuickDASH +9.5; and PF CAT -4.2 points). Pain interference was greater among opiate users when controlling for age, sex, other activity-limiting comorbidities, and baseline function or psychological status: PI was 2.5, 5.0, or 4.3 points greater when controlling for the PROMIS UE CAT, Depression CAT, or Anxiety CAT.New patients presenting to a hand surgery clinic who endorse use of opioid medications at baseline report significantly decreased physical function, increased psychological burden, and greater levels of pain interference than nonusers.Diagnostic III.
View details for DOI 10.1016/j.jhsa.2019.07.003
View details for Web of Science ID 000488505800002
View details for PubMedID 31477406
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Traction Time, Force and Postoperative Nerve Block Significantly Influence the Development and Duration of Neuropathy Following Hip Arthroscopy
ARTHROSCOPY-THE JOURNAL OF ARTHROSCOPIC AND RELATED SURGERY
2019; 35 (10): 2825-2831
Abstract
To (1) evaluate the individual and combined effects of traction time and traction force on postoperative neuropathy following hip arthroscopy, (2) determine if perioperative fascia iliaca block has an effect on the risk of this neuropathy, and (3) identify if the these items had a significant association with the presence, location, and/or duration of postoperative numbness.Between February 2015 and December 2016, a consecutive cohort of hip arthroscopy patients was prospectively enrolled. Traction time, force, and postoperative nerve block administration were recorded. The location and duration of numbness were assessed at postoperative clinic visits. Numbness location was classified into regions: 1, groin; 2, lateral thigh; 3, medial thigh; 4, dorsal foot; and 5,preoperative thigh or radiculopathic numbness.A total of 156 primary hip arthroscopy patients were analyzed, 99 (63%) women and 57 (37%) men. Mean traction time was 46.5 ± 20.3 minutes. Seventy-four patients (47%) reported numbness with an average duration of 157.5 ± 116.2 days. Postoperative fascia iliaca nerve block was a significant predictor of medial thigh numbness (odds ratio, 3.36; 95% confidence interval, 1.46-7.76; P = .04). Neither traction time nor force were associated with generalized numbness (P = .85 and P = .40, respectively). However, among those who experienced numbness, traction time and force were greater in patients with combined groin and lateral thigh numbness compared with those with isolated lateral thigh or medial thigh numbness (P = .001 and P = .005, respectively).Postoperative neuropathy is a well-documented complication following hip arthroscopy. Concomitant pudendal and lateral femoral cutaneous nerve palsy may be related to increased traction force and time, even in the setting of low intraoperative traction time (<1 hour). Isolated medial thigh numbness is significantly associated with postoperative fascia iliaca blockade.IV, case series.
View details for DOI 10.1016/j.arthro.2019.03.062
View details for Web of Science ID 000489268900014
View details for PubMedID 31604499
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Evaluating the Utility of Follow-up Radiographs for Isolated Radial Head Fractures Undergoing Initial Nonoperative Treatment
JOURNAL OF ORTHOPAEDIC TRAUMA
2019; 33 (8): E291-E295
Abstract
To evaluate the utility of follow-up radiographs in patients with isolated partial articular radial head fractures (OTA/AO 2R1B1 or 2R1B3).Retrospective cohort study.Academic Level 1 Trauma Center.Adult patients (≥18 years) with isolated partial articular radial head fractures indicated for initial nonoperative treatment.Analysis of elbow radiographs at initial presentation and at postinjury follow-up of 3-8 weeks.Articular gap and step-off.Radiographic articular displacement between initial and follow-up radiographs.For 72 included patients, initial radiographs were obtained on average 2.6 days after injury and follow-up radiographs 33.7 days thereafter. Equivalence tests evaluating gap and step-off thresholds of <1 mm were both significant, indicating that the cohort displaced <1 mm for both parameters between initial and follow-up radiographs. No patients proceeded to surgical treatment following the repeat radiographs.These fractures do not displace in the early postinjury period, as defined as a <1 mm of change in both intra-articular gap and step-off, as compared to initial radiographs. Routine follow-up radiographs for these injuries is a source of cost, but with limited utility in detecting interval displacement or leading to a change in management. Selective use of radiographs to evaluate specific clinical concerns may lead to cost savings.Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
View details for DOI 10.1097/BOT.0000000000001489
View details for Web of Science ID 000480685000003
View details for PubMedID 31335568
View details for PubMedCentralID PMC6658122
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Cost Implications of Varying the Surgical Setting and Anesthesia Type for Trigger Finger Release Surgery
PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN
2019; 7 (5): e2231
Abstract
Trigger finger release (TFR) is a common surgical procedure, representing a financial burden to the healthcare system. Our null hypothesis is that the choice surgical setting [operating room (OR) versus procedure room (PR)] and anesthetic type [local-only or monitored anesthesia care (MAC)] do not affect surgical encounter costs for TFR.Adult patients undergoing isolated unilateral TFR between May 2014 and December 2017 by 5 fellowship-trained hand surgeons at a single academic medical center were identified by Current Procedural Terminology (CPT) code (26055). We excluded patients undergoing revision surgery, tenosynovectomy, or additional procedures. Using our institution's information technology value tools, we calculated total direct costs for each surgical encounter, which were compared between groups. Univariate and multivariable gamma regression were used to model costs.Of 210 included patients, 54% (113/210) of cases were performed in the PR and 46% (97/210) in the OR. No significant differences in demographics were observed between PR and OR groups. Compared to local-only in the PR, the OR with local-only, and OR with MAC, demonstrated 2.2- and 3.2-fold greater median costs. Multivariable models suggested that use of the OR independently led to 221% [95% Confidence interval: 137%-345%; P < 0.01] greater mean costs than the PR, and use of MAC was associated with 30% (95% confidence interval: 13%-49%; P < 0.01) greater mean costs for OR cases than local-only, while controlling for other confounders.Performing TFR in the PR setting under local-only anesthesia minimizes surgical encounter direct costs for this common procedure.
View details for DOI 10.1097/GOX.0000000000002231
View details for Web of Science ID 000480725100041
View details for PubMedID 31333958
View details for PubMedCentralID PMC6571295
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Comparison of Direct Surgical Costs for Proximal Row Carpectomy and Four-Corner Arthrodesis
JOURNAL OF WRIST SURGERY
2019; 8 (1): 66-71
Abstract
Background Proximal row carpectomy (PRC) and four-corner arthrodesis (FCA) are common treatments for stage II scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) wrists, with similar functional and patient-reported outcomes reported in the peer-reviewed literature. Questions Study questions included (1) whether surgical encounter total direct costs (SETDCs) differ between PRC and FCA, and (2) whether SETDC differs by method of fixation for FCA. Patients and Methods Consecutive adult patients (≥ 18 years) undergoing PRC and FCA between July 2011 and May 2017 at a single tertiary care academic institution were identified. Patients undergoing additional simultaneous procedures were excluded. Using our institution's information technology value tools, we extracted prospectively collected cost data for each surgical encounter. SETDCs were compared between PRC and FCA, and between FCA subgroups (screws, plating, or staples). Results Of 42 included patients, mean age was similar between the 23 PRC and 19 FCA patients (51.2 vs. 54.5 years, respectively). SETDCs were significantly greater for FCA than PRC by 425%. FCA involved significantly greater facility costs (2.3-fold), supply costs (10-fold), and operative time (121 vs. 57 minutes). Implant costs were absent for PRC, which were responsible for 55% of the SETDC for FCA. Compared with compression screws, plating and staple fixation were significantly more costly (70% and 240% greater, respectively). Conclusion SETDCs were 425% greater for FCA than PRC. Implant costs for FCA alone were 130% greater than the entire surgical encounter for PRC. For FCA, SETDC varied depending on the method of fixation. Level of Evidence This is a level III, cost analysis study.
View details for DOI 10.1055/s-0038-1675791
View details for Web of Science ID 000458821300012
View details for PubMedID 30723605
View details for PubMedCentralID PMC6358450
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Revisiting the Anteroinferior Iliac Spine: Is the Subspine Pathologic? A Clinical and Radiographic Evaluation
CLINICAL ORTHOPAEDICS AND RELATED RESEARCH
2018; 476 (7): 1494-1502
Abstract
Subspine impingement is a recognized source of extraarticular hip impingement. Although CT-based classification systems have been described, to our knowledge, no study has evaluated the morphology of the anteroinferior iliac spine (AIIS) with plain radiographs nor to our knowledge has any study compared its appearance between plain radiographs and CT scan and correlated AIIS morphology with physical findings. Previous work has suggested a correlation of AIIS morphology and hip ROM but this has not been clinically validated. Furthermore, if plain radiographs can be found to adequately screen for AIIS morphology, CT could be selectively used, limiting radiation exposure.The purposes of this study were (1) to determine the prevalence of AIIS subtypes in a cohort of patients with symptomatic femoroacetabular impingement; (2) to compare AP pelvis and false profile radiographs with three-dimensional (3-D) CT classification; and (3) to correlate the preoperative hip physical examination with AIIS subtypes.A retrospective study of patients undergoing primary hip arthroscopy for femoroacetabular impingement syndrome was performed. Between February 2013 and November 2016, 601 patients underwent hip arthroscopy. To be included here, each patient had to have undergone a primary hip arthroscopy for the diagnosis of femoroacetabular impingement syndrome. Each patient needed to have an interpretable set of plain radiographs consisting of weightbearing AP pelvis and false profile radiographs as well as full documentation of physical findings in the medical record. Patients who additionally had a CT scan with 3-D reconstructions were included as well. During the period in question, it was the preference of the treating surgeon whether a preoperative CT scan was obtained. A total of 145 of 601 (24%) patients were included in the analysis; of this cohort, 54% (78 of 145) had a CT scan and 63% (92 of 145) were women with a mean age of 31 ± 10 years. The AIIS was classified first on patients in whom the 3-D CT scan was available based on a previously published 3-D CT classification. The AIIS was then classified by two orthopaedic surgeons (TGM, MRK) on AP and false profile radiographs based on the position of its inferior margin to a line at the lateral aspect of the acetabular sourcil normal to vertical. Type I was above, Type II at the level, and Type III below this line. There was fair interrater agreement for AP pelvis (κ = 0.382; 95% confidence interval [CI], 0.239-0.525), false profile (κ = 0.372; 95% CI, 0.229-0.515), and 3-D CT (κ = 0.325; 95% CI, 0.156-0.494). There was moderate to almost perfect intraobserver repeatability for AP pelvis (κ = 0.516; 95% CI, 0.284-0.748), false profile (κ = 0.915; 95% CI, 0.766-1.000), and 3-D CT (κ = 0.915; 95% CI, 0.766-1.000). The plane radiographs were then compared with the 3-D CT scan classification and accuracy, defined as the proportion of correct classification out of total classifications. Preoperative hip flexion, internal rotation, external rotation, flexion adduction, internal rotation, subspine, and Stinchfield physical examination tests were compared with classification of the AIIS on 3-D CT. Finally, preoperative hip flexion, internal rotation, and external rotation were compared with preoperative lateral center-edge angle and alpha angle.The prevalence of AIIS was 56% (44 of 78) Type I, 39% (30 of 78) Type II, and 5% (four of 78) Type III determined from the 3-D CT classification. For the plain radiographic classification, the distribution of AIIS morphology was 64% (93 of 145) Type I, 32% (46 of 145) Type II, and 4% (six of 145) Type III on AP pelvis and 49% (71 of 145) Type I, 48% (70 of 145) Type II, and 3% (four of 145) Type III on false profile radiographs. False profile radiographs were more accurate than AP pelvis radiographs for classification when compared against the gold standard of 3-D CT at 98% (95% CI, 96-100) versus 80% (95% CI, 75-85). The false profile radiograph had better sensitivity for Type II (97% versus 47%, p < 0.001) and specificity for Types I and II AIIS (97% versus 53%, p < 0.001; 98% versus 90%, p = 0.046) morphology compared with AP pelvis radiographs. There was no correlation between AIIS type as determined by 3-D CT scan and hip flexion (rs = -0.115, p = 0.377), internal rotation (rs = 0.070, p = 0.548), flexion adduction internal rotation (U = 72.00, p = 0.270), Stinchfield (U = 290.50, p = 0.755), or subspine tests (U = 319.00, p = 0.519). External rotation was weakly correlated (rs = 0.253, p = 0.028) with AIIS subtype. Alpha angle was negatively correlated with hip flexion (r = -0.387, p = 0.002) and external rotation (r = -0.238, p = 0.043) and not correlated with internal rotation (r = -0.068, p = 0.568).The findings in this study suggest the false profile radiograph is superior to an AP radiograph of the pelvis in evaluating AIIS morphology. Neither preoperative hip internal rotation nor impingement tests correlate with AIIS type as previously suggested questioning the utility of the AIIS classification system in identifying pathologic AIIS anatomy.Level III, diagnostic study.
View details for DOI 10.1097/01.blo.0000533626.25502.e1
View details for Web of Science ID 000438532900023
View details for PubMedID 29794857
View details for PubMedCentralID PMC6437578
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Polyethylene Glycol Based Changes to <i>β</i>-Sheet Protein Conformational and Proteolytic Stability Depend on Conjugation Strategy and Location
BIOCONJUGATE CHEMISTRY
2017; 28 (10): 2507-2513
Abstract
The development of chemical strategies for site-specific protein modification now enables researchers to attach polyethylene glycol (PEG) to a protein drug at one or more specific locations (i.e., protein PEGylation). However, aside from avoiding enzyme active sites or protein-binding interfaces, distinguishing the optimal PEGylation site from the available alternatives has conventionally been a matter of trial and error. As part of a continuing effort to develop guidelines for identifying optimal PEGylation sites within proteins, we show here that the impact of PEGylation at various sites within the β-sheet model protein WW depends strongly on the identity of the PEG-protein linker. The PEGylation of Gln or of azidohomoalanine has a similar impact on WW conformational stability as does Asn-PEGylation, whereas the PEGylation of propargyloxyphenylalanine is substantially stabilizing at locations where Asn-PEGylation was destabilizing. Importantly, we find that at least one of these three site-specific PEGylation strategies leads to substantial PEG-based stabilization at each of the positions investigated, highlighting the importance of considering conjugation strategy as an important variable in selecting optimal PEGylation sites. We further demonstrate that using a branched PEG oligomer intensifies the impact of PEGylation on WW conformational stability and also show that PEG-based increases to conformational stability are strongly associated with corresponding increases in proteolytic stability.
View details for DOI 10.1021/acs.bioconjchem.7b00281
View details for Web of Science ID 000413503400001
View details for PubMedID 28972368
View details for PubMedCentralID PMC6330093
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Hybrid molecular/enzymatic catalytic cascade for complete electro-oxidation of glycerol using a promiscuous NAD-dependent formate dehydrogenase from <i>Candida boidinii</i>
CHEMICAL COMMUNICATIONS
2017; 53 (39): 5368-5371
Abstract
Glycerol is a common fuel considered for bioenergy applications. Computational docking studies were performed on formate dehydrogenase from Candida boidinii (cbFDH) that showed that mesoxalate can bind to the buried active site of the holo form predicting that mesoxalate, a byproduct of glycerol oxidation, may act as its substrate. Spectroscopic assays and characterization by HPLC and GC/TCD have shown for the first time that cbFDH can act as a decarboxylase with mesoxalate. From this assessment, cbFDH was combined with NH2-TEMPO to form a novel hybrid anode to oxidize glycerol to carbon dioxide at near-neutral pH.
View details for DOI 10.1039/c7cc01027c
View details for Web of Science ID 000401118400002
View details for PubMedID 28421214
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Conjugation Strategy Strongly Impacts the Conformational Stability of a PEG-Protein Conjugate
ACS CHEMICAL BIOLOGY
2016; 11 (7): 1805-1809
Abstract
Site-specific PEGylation is an important strategy for enhancing the pharmacokinetic properties of protein drugs, and has been enabled by the recent development of many chemoselective reactions for protein side-chain modification. However, the impact of these different conjugation strategies on the properties of PEG-protein conjugates is poorly understood. Here we show that the ability of PEG to enhance protein conformational stability depends strongly on the identity of the PEG-protein linker, with the most stabilizing linkers involving conjugation of PEG to planar polar groups near the peptide backbone. We also find that branched PEGs provide superior stabilization relative to their linear counterparts, suggesting additional applications for branched PEGs in protein stabilization.
View details for DOI 10.1021/acschembio.6b00349
View details for Web of Science ID 000380181900005
View details for PubMedID 27191252
View details for PubMedCentralID PMC5082735
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Recombinant oxalate decarboxylase: enhancement of a hybrid catalytic cascade for the complete electro-oxidation of glycerol
CHEMICAL COMMUNICATIONS
2015; 51 (76): 14330-14333
Abstract
The complete electro-oxidation of glycerol to CO2 is performed through an oxidation cascade using a hybrid catalytic system combining a recombinant enzyme, oxalate decarboxylase from Bacillus subtilis, and an organic oxidation catalyst, 4-amino-TEMPO. This system is capable of electrochemically oxidizing glycerol at a carbon electrode collecting all 14 electrons per molecule.
View details for DOI 10.1039/c5cc06131h
View details for Web of Science ID 000361073400010
View details for PubMedID 26271633