Publications by authors named "Joseph A Gil"

142 Publications

The Effects of Social and Demographic Factors on High-Volume Hospital and Surgeon Care in Shoulder Arthroplasty.

J Am Acad Orthop Surg Glob Res Rev 2022 Aug 12;6(8). Epub 2022 Aug 12.

From the Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, Providence, RI.

Introduction: This study seeks to evaluate (1) the relationship between hospital and surgeon volumes of shoulder arthroplasty and complication rates and (2) patient demographics/socioeconomic factors that may affect access to high-volume shoulder arthroplasty care.

Methods: Adults older than 40 years who underwent shoulder arthroplasty between 2011 and 2015 were identified in the New York Statewide Planning and Research Cooperative System database using International Classification of Disease 9/10 and Current Procedural Terminology codes. Medical/surgical complications were compared across surgeon and facility volumes. The effects of demographic factors were analyzed to determine the relationship between such factors and surgeon/facility volume in shoulder arthroplasty.

Results: Seven thousand seven hundred eighty-five patients were included. Older, Hispanic/African American, socially deprived, nonprivately insured patients were more likely to be treated by low-volume facilities. Low-volume facilities had higher rates of readmission, urinary tract infection, renal failure, pneumonia, and cellulitis than high-volume facilities. Low-volume surgeons had patients with longer hospital lengths of stay.

Discussion: Important differences in patient socioeconomic factors exist in access to high-volume surgical care in shoulder arthroplasty, with older, minority, and underinsured patients markedly more likely to receive care by low-volume surgeons and facilities. This may highlight an area of potential focus to improve access to high-volume care.
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http://dx.doi.org/10.5435/JAAOSGlobal-D-22-00107DOI Listing
August 2022

Social Disparities in Outpatient and Inpatient Management of Pediatric Supracondylar Humerus Fractures.

J Clin Med 2022 Aug 5;11(15). Epub 2022 Aug 5.

Department of Orthopaedic Surgery, Alpert Medical School of Brown University, Providence, RI 02903, USA.

Socioeconomic status, race, and insurance status are known factors affecting adult orthopaedic surgery care, but little is known about the influence of socioeconomic factors on pediatric orthopaedic care. The purpose of this study was to determine if demographic and socioeconomic related factors were associated with surgical management of pediatric supracondylar humerus fractures (SCHFs) in the inpatient versus outpatient setting. Pediatric patients (<13 years) who underwent surgery for SCHFs were identified in the New York Statewide Planning and Research Cooperative System database from 2009-2017. Inpatient and outpatient claims were identified by International Classification of Diseases-9-Clinical Modification (CM) and ICD-10-CM SCHF diagnosis codes. Claims were then filtered by ICD-9-CM, ICD-10-Procedural Classification System, or Current Procedural Terminology codes to isolate SCHF patients who underwent surgical intervention. Multivariable logistic regression analysis was performed to determine the effect of patient factors on the likelihood of having inpatient management versus outpatient management. A total of 7079 patients were included in the analysis with 4595 (64.9%) receiving inpatient treatment and 2484 (35.1%) receiving outpatient treatment. The logistic regression showed Hispanic (OR: 2.386, < 0.0001), Asian (OR: 2.159, < 0.0001) and African American (OR: 2.095, < 0.0001) patients to have increased odds of inpatient treatment relative to White patients. Injury diagnosis on a weekend had increased odds of inpatient management (OR: 1.863, = 0.0002). Higher social deprivation was also associated with increased odds of inpatient treatment (OR: 1.004, < 0.0001). There are disparities among race and socioeconomic status in the surgical setting of SCHF management. Physicians and facilities should be aware of these disparities to optimize patient experience and to allow for equal access to care.
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http://dx.doi.org/10.3390/jcm11154573DOI Listing
August 2022

What's New in Pediatric Orthopaedic Health Care Disparities?

J Pediatr Orthop 2022 Aug 11. Epub 2022 Aug 11.

Warren Alpert Medical School of Brown University, Providence, RI.

Background: Health care disparities are prevalent within pediatric orthopaedics in the United States. Social determinants of health, such as income, race, social deprivation, place of residence, and parental involvement, all play a role in unequal access to care and disparate outcomes. Although there has been some effort to promote health equity both within pediatric orthopaedics and the US health care system altogether, disparities persist. In this review, we aim to identify major sources of inequality and propose solutions to achieve equitable care in the future.

Methods: We searched the PubMed database for papers addressing disparities in pediatric orthopaedics published between 2016 and 2021, yielding 283 papers.

Results: A total of 36 papers were selected for review based upon new findings. Insurance status, race, and social deprivation are directly linked to poorer access to care, often resulting in a delay in presentation, time to diagnostic imaging, and surgery. Although these disparities pervade various conditions within pediatric orthopaedics, they have most frequently been described in anterior cruciate ligament/meniscal repairs, tibial spine fractures, adolescent idiopathic scoliosis, and upper extremity conditions. Treatment outcomes also differ based on insurance status and socioeconomic status. Several studies demonstrated longer hospital stays and higher complication rates in Black patients versus White patients. Patients with public insurance were also found to have worse pain and function scores, longer recoveries, and lower post-treatment follow-up rates. These disparate outcomes are, in part, a response to delayed access to care.

Conclusions: Greater attention paid to health care disparities over the past several years has enabled progress toward achieving equitable pediatric orthopaedic care. However, delays in access to pediatric orthopaedic care among uninsured/publicly insured, and/or socially deprived individuals remain and consequently, so do differences in post-treatment outcomes. Reducing barriers to care, such as insurance status, transportation and health literacy, and promoting education among patients and parents, could help health care access become more equitable.

Level Of Evidence: Level IV-narrative review.
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http://dx.doi.org/10.1097/BPO.0000000000002224DOI Listing
August 2022

Post-operative Pain Management Following Orthopedic Spine Procedures and Consequent Acute Opioid Poisoning: An Analysis of New York State from 2009 - 2018.

Spine (Phila Pa 1976) 2022 Jul 15. Epub 2022 Jul 15.

Department of Orthopedic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI.

Objective: Considering the high rates of opioid usage following orthopedic surgeries, it is important to explore this in the setting of the current opioid epidemic. This study examined acute opioid poisonings in post-operative spine surgery patients in New York and the rates of poisonings among these patients in the context of New York's 2016 State legislation limiting opioid prescriptions.

Methods: Claims for adult patients who received specific orthopedic spine procedures in the outpatient setting were identified from 2009-2018 in the New York Statewide Planning and Research Cooperative System (SPARCS) database. Patients were followed to determine if they presented to the emergency department (ED) for acute opioid poisoning post-operatively. Multivariable logistic regression was performed to evaluate the effect of patient demographic factors on the likelihood of poisoning. The impact of the 2016 New York State Public Health Law Section 3331, 5. (b), (c), limiting opioid analgesic prescriptions, was also evaluated by comparing rates of poisoning pre- and post-legislation enactment.

Results: 107,456 spine patients were identified and 321 (0.3%) presented post-operatively to the ED with acute opioid poisoning. Increased age (OR=0.954, P<0.0001) had a decreased likelihood of poisoning. Other race (OR=1.322, P=0.0167), Medicaid (OR=2.079, P<0.0001), Medicare (OR=2.9, P<0.0001), comorbidities (OR=3.271, P<0.0001), and undergoing multiple spine procedures during a single operative setting (OR=1.993, P<0.0001) had an increased likelihood of poisoning. There was also a significant reduction in rates of post-operative acute opioid poisoning in patients receiving procedures post-legislation with reduced overall likelihood (OR=0.28, P<0.0001).

Conclusion: There is a higher than national average rate of acute opioid poisonings following spine procedures and an increased risk among those with certain socioeconomic factors. Rates of poisonings decreased following a 2016 legislation limiting opioid prescriptions. It is important to define factors that may increase the risk of post-operative opioid poisoning to promote appropriate management of post-surgical pain.
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http://dx.doi.org/10.1097/BRS.0000000000004395DOI Listing
July 2022

Social Disparities in the Management of Trigger Finger: An Analysis of 31 411 Cases.

Hand (N Y) 2022 Jun 6:15589447221094040. Epub 2022 Jun 6.

The Warren Alpert Medical School of Brown University, Providence, RI, USA.

Background: Cost and compliance are 2 factors that can significantly affect the outcomes of non-operative and operative treatment of trigger finger (TF) and both may be influenced by social factors. The purpose of this study was to investigate socioeconomic disparities in the surgical treatment for TF.

Methods: Adult patients (≥18 years old) were identified using International Classification of Diseases 9 and 10 Clinical Modification diagnostic codes for TF and Current Procedural Terminology (CPT) procedural codes (CPT: 26055) in the New York Statewide Planning and Research Cooperative System database. Each diagnosis was linked to procedure data to determine which patients went on to have TF release. A multivariable logistic regression was performed to assess the likelihood of receiving surgery. The variables included in the analysis were age, sex, race, social deprivation index (SDI), Charlson Comorbidity Index, and primary insurance type. A -value < .05 was considered significant.

Results: Of the 31 411 TF patients analyzed, 8941 (28.5%) underwent surgery. Logistic regression analysis showed higher odds of receiving surgery in females (odds ratio [OR]: 1.108) and those with workers compensation (OR: 1.7). Hispanic (OR: 0.541), Asian (OR: 0.419), African American (OR: 0.455), and Other race (OR: 0.45) had decreased odds of surgery. Medicaid (OR: 0.773), Medicare (OR: 0.841), and self-pay (OR: 0.515) reimbursement methods had reduced odds of receiving surgery. Higher social deprivation was associated with decreased odds of surgery (OR: 0.988).

Conclusions: There are disparities in demographic characteristics among those who receive TF release for trigger finger related to race, primary insurance, and social deprivation.
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http://dx.doi.org/10.1177/15589447221094040DOI Listing
June 2022

Radiocarpal Fusion: Indications, Technique, and Modifications.

J Hand Surg Am 2022 Aug 28;47(8):772-782. Epub 2022 May 28.

Department of Orthopaedics, Warren Alpert School of Medicine, Brown University, Providence, RI.

Degenerative disorders of the wrist may affect isolated joints and inhibit normal functions of the wrist secondary to pain and stiffness. These processes that affect only the radiocarpal joint may be secondary to posttraumatic osteoarthritis, primary osteoarthritis, or rheumatoid arthritis. Radiocarpal wrist arthrodesis may help preserve some of the native wrist kinematics while alleviating pain and improving the range of motion. However, the surgeon must ensure that the patient's pathologic process primarily affects the radiocarpal articulations while relatively sparing the midcarpal articulations. Depending on the location of the pathology, isolated radiolunate or radioscapholunate arthrodesis have been described to preserve some motion in the midcarpal joint. To maximize motion in the midcarpal joint after radiocarpal arthrodesis, techniques for distal scaphoid and triquetrum excision have been described. We report patient outcomes for various techniques and describe our preferred technique for radioscapholunate arthrodesis using distal scaphoid excision.
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http://dx.doi.org/10.1016/j.jhsa.2022.04.002DOI Listing
August 2022

Surgeon and Facility Volume are Associated With Postoperative Complications After Total Knee Arthroplasty.

Arthroplast Today 2022 Apr 17;14:223-230.e1. Epub 2022 Jan 17.

Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA.

Background: Surgeon and hospital volumes may affect outcomes of various orthopedic procedures. The purpose of this study is to characterize the volume dependence of both facilities and surgeons on morbidity and mortality after total knee arthroplasty.

Methods: Adults who underwent total knee arthroplasty for osteoarthritis from 2011 to 2015 were identified using International Classification of Diseases-9 Clinical Modification diagnostic and procedural codes in the New York Statewide Planning and Research Cooperative System database. Readmission, in-hospital mortality, and other adverse events were compared across surgeon and facility volumes using multivariable Cox proportional hazards regression, while controlling for patient demographic and clinical factors. Surgeon and facility volumes were compared between the lowest and highest 20%.

Results: Of 113,784 identified patients, 71,827 were treated at a high- or low-volume facility or by low- or high-volume surgeon. Low-volume facilities had higher 1-month, 3-month, and 12-month rates of readmission, urinary tract infection, cardiorespiratory arrest, surgical site infection, and wound complications; higher 3- and 12-month rates of pneumonia, cellulitis, and in-facility mortality; and higher 12-month rates of acute renal failure and revision. Low-volume surgeons had higher 1-, 3-, and 12-month rates of readmission, urinary tract infection, acute renal failure, pneumonia, surgical site infection, deep vein thrombosis, pulmonary embolism, cellulitis, and wound complications; higher 3- and 12-month rates of cardiorespiratory arrest; and higher 12-month rate of in-facility mortality.

Conclusions: These results suggest volume shifting toward higher volume facilities and/or surgeons could improve patient outcomes and have potential cost savings. Furthermore, these results can inform healthcare policy, for example, designating institutions as centers of excellence.
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http://dx.doi.org/10.1016/j.artd.2021.11.017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9059075PMC
April 2022

Socioeconomic Disparities in the Utilization of Total Knee Arthroplasty.

J Arthroplasty 2022 Apr 29. Epub 2022 Apr 29.

Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, East Providence, Rhode Island.

Background: Despite strong evidence supporting the efficacy of total knee arthroplasty (TKA), studies have shown significant socioeconomic disparities regarding who ultimately undergoes TKA. The purpose of the current study is to evaluate socioeconomic factors affecting whether a patient undergoes TKA after a diagnosis of osteoarthritis.

Methods: From 2011 to 2018, claims for adult patients diagnosed with knee osteoarthritis in the New York Statewide Planning and Research Cooperative System (SPARCS) database were analyzed. International Classification of Diseases (ICD), 9/10 CM codes were used to identify the initial diagnosis for each patient. ICD 9/10 PCS codes were used to identify subsequent TKA. Logistic regression analysis was performed to determine the effect of patient factors on the likelihood of having TKA.

Results: Of 313,794 osteoarthritis diagnoses, 33.3% proceeded to undergo TKA. Increased age (OR 1.007, P < .0001) and workers' compensation relative to commercial insurance (OR 1.865, P < .0001) had increased odds of TKA. Compared to White race, Asian (OR 0.705, P < .0001), Black (OR 0.497, P < .0001), and "other" race (OR 0.563, P < .0001) had lower odds of TKA. Hispanic ethnicity (OR 0.597, P < .0001) had lower odds of surgery. Compared to commercial insurance, Medicare (OR 0.876, P < .0001), Medicaid (OR 0.452, P < .0001), self-pay (OR 0.523, P < .0001), and "other" insurance (OR 0.819, P < .0001) had lower odds of TKA. Increased social deprivation (OR 0.987, P < .0001) had lower odds of TKA.

Conclusion: TKA is associated with disparities among race, ethnicity, primary insurance, and social deprivation. Additional research is necessary to identify the cause of these disparities to improve equity in orthopedic care.
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http://dx.doi.org/10.1016/j.arth.2022.04.033DOI Listing
April 2022

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

J Pediatr Orthop 2022 Jul 27;42(6):335-340. Epub 2022 Apr 27.

Department of Orthopaedic Surgery, Brown University Warren Alpert Medical School, Providence, RI.

Background: Hand fractures are among the most common injuries presenting in pediatric emergency departments (EDs) with incidence reported as high as 624 hand fractures per 100,000 person-years. If gone untreated, these injuries can lead to pain, loss of function, and psychological trauma. The purpose of this study was to identify risk factors and characterize pediatric hand fractures over a 5-year period.

Methods: The National Electronic Injury Surveillance System (NEISS) was queried for all hand fractures in patients aged 1 to 19 years presenting to US EDs between 2016 and 2020. Incidence was calculated using US census data. Cases were retrospectively analyzed using age, location of the injury, sex, coronavirus disease-2019 (COVID-19) era, and etiology of injury. Bivariate logistic regression was used where appropriate.

Results: A total of 21,031 pediatric hand fractures were identified, representing an estimated 565,833 pediatric hand fractures presenting to EDs between 2016 and 2020. The mean incidence of pediatric hand fractures was 138.3 fractures for 100,000 person-years [95% confidence interval (CI): 136.2-140.4], with a 39.2% decrease in incidence occurring between 2019 and 2020. It was found that 42.2% of the fractures were in patients aged 10 to 14. The incidence of hand fractures for males and females was 97.9 (95% CI: 96.2-99.7) and 40.4 (95% CI: 39.2-41.5), respectively, with the male rate peaking at age 14 and the female rate peaking at age 12. Age, sex, location of the injury, and injury during the COVID-19 pandemic were demonstrated to influence the frequency and etiology of the fracture.

Conclusion: This study determined the incidence of pediatric hand fractures presenting to EDs across the United States. In addition, it identified risk factors for common hand fracture etiologies (sports-related, falling, crush, punching) and demonstrated the change in rates of different etiologies of pediatric hand fractures that presented to US EDs during the COVID-19 pandemic.

Level Of Evidence: Level III-retrospective comparative study.
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http://dx.doi.org/10.1097/BPO.0000000000002164DOI Listing
July 2022

Radial Sided Triangular Fibrocartilage Complex Tears: A Comprehensive Review.

Hand (N Y) 2022 Apr 10:15589447221084125. Epub 2022 Apr 10.

The Warren Alpert Medical School of Brown University, Providence, RI, USA.

When evaluating the available literature on the diagnosis and management of triangular fibrocartilage complex tears (TFCC), ulnar tears comprise the major focus of TFCC literature. Radial-sided (Class 1D) tears are seldom researched or discussed. The purpose of this study was to review the methods for identifying and treating radial-sided TFCC lesions, by examining the anatomy of the TFCC, the pathology of its radial portion, diagnostic techniques, and both surgical and nonoperative treatments. The avascular nature of the radial TFCC may influence its healing potential. Magnetic resonance arthrogram is the gold standard for non-invasively diagnosing a radial-sided tear. Non-operative management should be exhausted prior to surgical intervention, which commonly involves an inside-out repair involving radial trans-osseous sutures. Still, the literature is limited by patient sample size and therefore requires a greater population of class 1-D tears to confirm optimal diagnostic and treatment methods.
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http://dx.doi.org/10.1177/15589447221084125DOI Listing
April 2022

Surgeon Volume and Social Disparity are Associated with Postoperative Complications After Lumbar Fusion.

World Neurosurg 2022 Jul 1;163:e162-e176. Epub 2022 Apr 1.

Department of Orthopaedic Surgery, Alpert Medical School of Brown University, Providence, Rhode Island, USA.

Objective: To characterize the volume dependence of both facilities and surgeons on postoperative complications after lumbar fusion and characterize the role of socioeconomic status.

Methods: Adults who underwent lumbar fusion from 2011 to 2015 were identified using International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes for lumbar disc degeneration or spondylolisthesis and procedure codes for lumbar fusion in the New York Statewide Planning and Research Cooperative System database. Complications were compared across surgeon and facility volumes using multivariable Cox proportional hazards regression, controlling for patient demographic and clinical factors. Surgeon and facility volumes were compared between the lowest and highest 20%.

Results: Of the 26,211 patients identified with a lumbar fusion, 16,377 patients were treated at a high-volume or low-volume facility or by a high-volume or low-volume surgeon. Low-volume facilities had higher 3-month and 12-month rates of readmission, pneumonia, and cellulitis; lower 1-month, 3-month, and 12-month rates of deep vein thrombosis; and lower 1-month rates of wound complications. Low-volume surgeons had higher 1-month, 3-month, and 12-month rates of readmission, acute renal failure, surgical site infection, and wound complications; high 1-month and 3-month rates of urinary tract infection and pulmonary embolism; and a lower 12-month rate of revision. Patients who were treated by low-volume surgeons and had complications were more concentrated to ZIP codes with high social deprivation.

Conclusions: Both high-volume facilities and high-volume surgeons show lower rates of complications and readmission. There are significant socioeconomic disparities regarding which patients can access high-volume surgeons.
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http://dx.doi.org/10.1016/j.wneu.2022.03.083DOI Listing
July 2022

Charges for Distal Radius Fracture Fixation Are Affected by Fracture Pattern, Location of Service, and Anesthesia Type.

Hand (N Y) 2022 Mar 4:15589447221077379. Epub 2022 Mar 4.

Brown University and Rhode Island Hospital, Providence, RI, USA.

Background: This study sought to characterize charges associated with operative treatment of distal radius fractures and identify sources of variation contributing to overall cost.

Methods: A retrospective study was performed using the New York Statewide Planning and Research Cooperative System database from 2009-2017. Outpatient claims were identified using the International Classification of Diseases-9/10-Clinical Modification diagnosis codes for distal radius fixation surgery. A multivariable mixed model regression was performed to identify variables contributing to total charges of the claim, including patient demographics, anesthesia method, surgery location (ambulatory surgery center [ASC] versus a hospital outpatient department [HOPD], operation time, insurance type, Charlson Comorbidity Index, and billed procedure codes.

Results: A total of 9029 claims were included, finding older age, private primary insurance, surgery performed in a HOPD, and use of local anesthesia (vs general or regional) associated with increased total charges. There was no difference between gender, race, or ethnicity. Additionally, open reduction and internal fixation (ORIF), increased operative time/fracture complexity, and use of perioperative medications contributed significantly to overall costs.

Conclusions: Charges for distal radius fracture surgery performed in a HOPD were 28.3% higher than compared to an ASC, and cases with local anesthesia had higher billed claims compared to regional or general anesthesia. Furthermore, charges for percutaneous fixation were 54.6% lower than ORIF of extraarticular fracture, and claims had substantial geographic variation. These findings may be used by providers and payers to help improve value of distal radius fracture care.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1177/15589447221077379DOI Listing
March 2022

Epidemiology and Revision Rates of Pediatric ACL Reconstruction in New York State.

Am J Sports Med 2022 04 2;50(5):1222-1228. Epub 2022 Mar 2.

Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.

Background: There are limited epidemiologic data examining the incidence of pediatric anterior cruciate ligament reconstruction (ACLR) over the past decade.

Purpose: To examine statewide population trends in the incidence of ACLR in a pediatric population.

Study Design: Descriptive epidemiology study.

Methods: Inpatient and outpatient claims for pediatric patients who underwent ACLR between 2009 and 2017 were identified in the New York Statewide Planning and Research Cooperative System database via International Classification of Diseases (ICD), Revision 9, Clinical Modification; ICD, Revision 10, Clinical Modification and Procedural Classification System; or Current Procedural Terminology codes. New York population data for each year between 2009 and 2017 were used from the New York State Department of Health to calculate the rates of ACLR per 100,000 people aged 3 to 19 years and determine the 95% confidence limits. The rates were then stratified by age, sex, and insurance. Two-year rates of revision and contralateral ACLR were also analyzed by sex.

Results: Between 2009 and 2017, 20,170 pediatric ACLRs were identified. The rates of pediatric ACLR increased steadily from 49.3 per 100,000 in 2009 (95% CI, 47.2-51.4) to a peak of 61.0 (95% CI, 58.6-63.4) in 2014 and decreased to 51.8 (95% CI, 49.6-54.1) by 2017. The age group 15 to 17 years had the highest rates of ACLR of all age groups, peaking at 198.5 (95% CI, 188.3-208.7) per 100,000. Analysis by sex showed that ACLR rates between males and females were not different. Males had a 2-year ipsilateral revision rate of 4.3%, while females had a rate of 3.3% ( = .0001). Females had a contralateral ACLR rate of 4.0%, while males had a rate of 2.6% ( = .0002).

Conclusion: Pediatric ACLR rates continued to rise until 2014, but there was a demonstrable decrease in rates after 2014. This decline in pediatric ACLR may point to the efficacy of injury prevention programs or changes in practice management. The high revision rate in males and high contralateral surgery rate in females can help guide patient counseling for return to play and complication risk.

Clinical Relevance: This study showed that ACLR in pediatric patients may be decreasing in recent years. There were differences in revision and contralateral ACLR by sex.
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http://dx.doi.org/10.1177/03635465221074694DOI Listing
April 2022

Perioperative Management of Immunosuppressive Medications for Rheumatoid Arthritis.

J Hand Surg Am 2022 04 17;47(4):370-378. Epub 2022 Feb 17.

Department of Orthopaedic Surgery, Brown University, Providence, RI. Electronic address:

Operations in patients with rheumatoid arthritis are complicated by the fact that most drugs used in medical management have immunosuppressive mechanisms of action, including corticosteroids and conventional synthetic and biologic disease-modifying antirheumatic drugs. In deciding to continue or discontinue these medications perioperatively, surgeons must weigh the relative risk of infection from immunosuppression against the risk of rheumatoid arthritis symptom flares from reduced medical disease control. The objective of this article is to review the existing evidence regarding perioperative management of immunosuppressive rheumatoid arthritis medications, with a specific focus on relevance to hand and upper-extremity procedures.
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http://dx.doi.org/10.1016/j.jhsa.2021.09.038DOI Listing
April 2022

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

J Arthroplasty 2022 08 11;37(8S):S908-S918.e1. Epub 2022 Feb 11.

Department of Orthopaedic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI.

Background: The purpose of this study is to further characterize the volume dependence of facilities and surgeons on morbidity and mortality after total hip arthroplasty (THA).

Methods: Adults who underwent THA from 2009 to 2014 were identified using International Classification of Diseases, Ninth Revision, Clinical Modification and Procedural codes in the New York Statewide Planning and Research Cooperative System database. Complication rates were compared across surgeon and facility volumes using multivariable Cox proportional hazards regression controlling for factors such as the Social Deprivation Index. Surgeon and facility volumes were compared between the low and high volume using cutoffs established by prior research.

Results: In total, 99,832 patients were included. Low volume facilities had higher rates of readmission, urinary tract infection (UTI), acute renal failure, pneumonia, surgical site infection (SSI), cellulitis, wound complications, deep vein thrombosis (DVT), in-hospital mortality, and revision. Low volume surgeons had higher rates of readmission, UTI, acute renal failure, pneumonia, SSI, acute respiratory failure, pulmonary embolism, cellulitis, wound complications, in-hospital mortality, cardiorespiratory arrest, DVT, and revision. African Americans, Hispanics, and those with federal insurance had increased rates of readmission. Those with ≥1 Charlson comorbidities or from areas of higher social deprivation had increased incidence of treatment by low volume surgeons and facilities.

Conclusion: Both low volume facilities and surgeons performing primary THA have higher rates of readmission, UTI, acute renal failure, pneumonia, SSI, cellulitis, wound complications, DVT, in-hospital mortality, and revision. Demographic disparities exist between who is treated at low vs high volume surgeons and facilities placing those groups at higher risks for complications.
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http://dx.doi.org/10.1016/j.arth.2022.02.018DOI Listing
August 2022

Does Proximal Hamate Graft for Proximal Scaphoid Reconstruction Restore Native Wrist Kinematics?

Hand (N Y) 2022 Feb 8:15589447211063570. Epub 2022 Feb 8.

Mayo Clinic, Rochester, MN, USA.

Background: The objective of this study was to determine whether reconstruction of the proximal pole of the scaphoid with a proximal hamate graft restores native carpal kinematics.

Methods: A cadaveric study was designed assessing wrist kinematic after proximal hamate graft for proximal pole of the scaphoid nonunion. Wireless sensors were mounted to the carpus using a custom pin and suture anchor system to 8 cadavers. A wrist simulator was used to move the wrist through a cyclical motion about the flexion/extension and radial/ulnar deviation axes. Each specimen was tested under a series of 3 conditions: (1) a native state, "Intact"; (2) fractured scaphoid proximal pole, "Fracture"; and (3) post-reconstruction of the proximal pole of the scaphoid using a proximal hamate graft, "Graft."

Results: The fracture condition resulted in a statistically significant change in scapholunate kinematics across the entire arc of motion relative to the intact condition. Reconstruction with proximal hamate grafts restored scapholunate kinematics close to the intact state in both flexion/extension and radial/ulnar deviation axes. The lunocapitate flexion during wrist flexion was significantly different after the hamate graft reconstruction.

Conclusions: Proximal hamate to scaphoid transfer resulted in restoration of near normal carpal kinematics to the intact state.
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http://dx.doi.org/10.1177/15589447211063570DOI Listing
February 2022

Do Patient Demographic and Socioeconomic Factors Influence Surgical Treatment Rates After ACL Injury?

J Racial Ethn Health Disparities 2022 Jan 10. Epub 2022 Jan 10.

Department of Orthopaedic Surgery, Alpert Medical School of Brown University, Providence, RI, USA.

Introduction: Anterior cruciate ligament (ACL) injuries may be managed nonoperatively in certain patients and injury patterns; however, complete ACL ruptures are commonly reconstructed to restore anterior and lateral rotatory stability of the knee. While ACL reconstruction is well-studied, the literature is sparse with regard to which socioeconomic patient factors are associated with patients undergoing ACL reconstruction rather than nonoperative management after diagnosis of an ACL injury. The current study seeks to evaluate this relationship between patient demographics as well as socioeconomic factors and the rate of surgery following ACL injuries.

Methods: Patients ≤65 years of age with a primary ACL injury between 2011 and 2018 were retrospectively identified in the New York Statewide Planning and Research Cooperative System database. International Classification of Disease 9/10 and Current Procedural Terminology codes were used to identify these patients and their subsequent ACL reconstructions. Logistic regression was performed to determine the effect of patient factors on the likelihood of having surgery after the diagnosis of an ACL injury.

Results: Compared to White patients, African American patients were significantly less likely to undergo ACL reconstruction following an ACL injury (OR=0.65, 95% CI, 0.573-0.726). Patients older than 35 had decreased odds of undergoing ACL reconstruction compared to younger patients, with patients 55-64 having the lowest odds (OR=0.166, 95% CI, 0.136-0.203). Patients with Medicaid (OR=0.84, 95% CI, 0.757-0.933) or self-pay insurance (OR=0.67, 95% CI, 0.565-0.793), and those with worker's compensation (OR=0.715, 95% CI, 0.621-0.823) had decreased odds of undergoing ACL reconstruction relative to patients with private insurance. Patients with higher Social Deprivation Index (SDI) were significantly more likely to be treated nonoperatively after ACL injuries compared to those with lower SDI (mean nonoperative SDI score, 61, operative SDI, 56, P<0.0001).

Discussion: In patients with ACL injuries, there are socioeconomic and patient-related factors that are associated with increased odds of undergoing ACL reconstruction. These factors are important to recognize as they represent a source of potential inequality in access to care and an area with potential for improvement.
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http://dx.doi.org/10.1007/s40615-021-01222-1DOI Listing
January 2022

Variability in Hand Surgery Training Among Plastic and Orthopaedic Surgery Residents.

J Am Acad Orthop Surg Glob Res Rev 2022 01 4;6(1). Epub 2022 Jan 4.

From the Department of Orthopaedic Surgery, Brown University/Warren Alpert School of Medicine, Providence, RI (Dr. Testa, Dr. Orman, Dr. Bergen, Dr. Li, and Dr. Gil), and Brown University/Warren Alpert School of Medicine, Providence, RI (Dr. Ready).

Background: A career in hand surgery in the United States requires a 1-year fellowship after residency training. Different residency specialty programs may vary in case volume. The purpose of this study was to characterize variation in hand surgery training within and between orthopaedic and plastic surgery residents.

Methods: Publicly available hand surgery case logs for graduating orthopaedic and plastic surgery residents during the 2010 to 2011 to 2018 to 2019 academic years were obtained through the Accreditation Council of Graduate Medical Education. Student t-tests were used to compare mean case volumes among several categories between plastic surgery (PRS) and orthopaedic surgery (OS) residents. Intraspecialty variation was assessed by comparing the 90th and 10th percentiles in each category.

Results: A total of 6,254 orthopaedic and 1,070 plastic surgery graduating residents were included. The mean hand surgery case volume for orthopaedic residents (OS 247.0) was significantly lower than that for plastic surgery residents (PRS 412.0) (P < 0.0001). Orthopaedic residents performed more trauma cases (OS 133.2, PRS 54.5; P < 0.0001) but fewer nerve repairs (OS 3.3, PRS 28.5 P < 0.0001) and amputations (OS 6.4, PRS 15.8; P < 0.0001). Nerve decompression case volumes were similar between the two specialties (OS 50.2, PRS 47.3; P = 0.34). Case volumes among orthopaedic residents varied considerably in amputations and among plastic surgery residents in replantation/revascularization procedures.

Conclusions: Orthopaedic surgery residents performed significantly more trauma cases than plastic surgery residents did, but fewer overall cases, nerve repairs, and amputations, while nerve decompression volumes were similar between specialties. This information may help inform residency and fellowship directors regarding areas of potential training deficiency.
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http://dx.doi.org/10.5435/JAAOSGlobal-D-21-00138DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8735791PMC
January 2022

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

J Hand Surg Am 2022 03 27;47(3):258-265.e1. Epub 2021 Dec 27.

Department of Orthopaedic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI.

Purpose: The annual high volume of carpal tunnel releases (CTRs) has a large financial impact on the health care system. Validating the cost drivers related to CTR in a large, diverse patient population may aid in developing cost reduction strategies to benefit health care systems.

Methods: Adult patients with carpal tunnel syndrome who underwent CTR were identified in the New York Statewide Planning and Research Cooperative System database from 2016 to 2017. The Statewide Planning and Research Cooperative System is a comprehensive all-payer database that collects all inpatient and outpatient preadjudicated claims in New York. A multivariable mixed model regression with random effects was performed for the facility to assess the variables that contributed significantly to the total charge. The variables included were patient age, sex, anesthesia method, whether the surgery took place in an ambulatory surgery center or a hospital outpatient department, operation time in minutes, primary insurance type, race, ethnicity, Charlson Comorbidity Index, and categories for billed procedure codes.

Results: During the period of 2016 to 2017, 8,717 claims were included, with a mean charge per claim of $4,865. General anesthesia was associated with higher charges than local anesthesia. A procedure at a hospital outpatient department was associated with an approximately 48.2% increase in the total charge compared with that at an ambulatory surgery center. A 1-minute increase in the operation time was associated with a 0.3% increase in the total charge. Claims with antiemetics, antihistamines, benzodiazepines, intravenous fluids, narcotic agents, or preoperative antibiotics were associated with higher total charges than claims that did not bill for these. Compared with endoscopic procedures, open procedures had a 44.3% decrease in the total charges.

Conclusions: This comprehensive multivariable model has validated that general anesthesia, hospital-based surgery, the use of antibiotics and opioids, longer operative times, and endoscopic CTR significantly increased the cost of surgery.

Type Of Study/level Of Evidence: Economic and decision analyses II.
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http://dx.doi.org/10.1016/j.jhsa.2021.10.022DOI Listing
March 2022

Demographic Disparities amongst Patients Receiving Carpal Tunnel Release: A Retrospective Review of 92,921 Patients.

Plast Reconstr Surg Glob Open 2021 Nov 24;9(11):e3959. Epub 2021 Nov 24.

Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, R.I.

Despite strong evidence supporting the efficacy of surgical release for carpal tunnel syndrome (CTS), previous studies have suggested that surgery is not performed equally amongst races and sex. The purpose of this study was to investigate potential socioeconomic disparities in the surgical treatment for CTS.

Methods: Adult patients (≥18) were identified in the New York Statewide Planning and Research Cooperative System database from 2011 to 2018 by diagnosis code for CTS. All carpal tunnel surgery procedures in the outpatient setting were identified using Current Procedural Terminology codes. Using a unique identifier for each patient, the diagnosis data were linked to procedure data. A multivariable logistic regression was performed to assess the impact of patient factors on the likelihood of receiving surgery.

Results: In total, 92,921 patients with CTS were included in the analysis and 30,043 (32.3%) went on to have surgery. Older age and workers compensation insurance had increased the odds of surgery. Feminine gender had lower odds of surgery. Asian, African American, and other races had decreased odds of surgery relative to the White race. Patients of Hispanic ethnicity had decreased odds of surgery compared with non-Hispanic ethnicity. Patients with Medicare, Medicaid, or self-pay insurance were all less likely to undergo surgery relative to private insurance. Higher social deprivation was also associated with decreased odds of surgery.

Conclusions: Surgical treatment of CTS is unequally distributed amongst gender, race, and socioeconomic status. Additional research is necessary to identify the cause of these disparities to improve equity in patient care.
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http://dx.doi.org/10.1097/GOX.0000000000003959DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8613363PMC
November 2021

Socioeconomic Disparities in the Utilization of Total Hip Arthroplasty.

J Arthroplasty 2022 02 5;37(2):213-218.e1. Epub 2021 Nov 5.

Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI.

Background: There is increasing focus on highlighting disparities in both access to and equity of care in orthopedics and understanding the impact disparities have on patient health. The purpose of the present study is to evaluate socioeconomic-related factors affecting whether a patient undergoes total hip arthroplasty (THA) after a diagnosis of osteoarthritis.

Methods: From 2011 to 2018, patients ≥40 years of age diagnosed with hip osteoarthritis were identified in the New York Statewide Planning and Research Cooperative System, a comprehensive all-payer database collecting preadjudicated claims in New York State. International Classification of Diseases, Ninth Revision/Tenth Revision codes were used to identify the initial diagnosis and subsequent THA. Logistic regression analysis was performed to determine the effect of patient factors on the likelihood of undergoing THA.

Results: Of 142,681 hip osteoarthritis diagnoses, 48.6% proceeded to THA. Compared to non-Hispanic white patients, Asian (odds ratio [OR] 0.65, P < .0001), Black (OR 0.51, P < .0001), and "Other" race (OR 0.54, P < .0001) had lower odds of THA. Hispanic patients (OR 0.55, P < .0001) had lower odds of surgery. Compared to commercial insurance, Medicare (OR 0.83, P < .0001), Medicaid (OR 0.49, P < .0001), Self-pay (OR 0.78, P < .0001), and workers' compensation (OR 0.71, P < .0001) had lower odds of THA. Having one or more Charlson Comorbidity Index (OR 0.45, P < .0001) was associated with lower odds of THA, as was increased social deprivation (OR 0.99, P < .0001).

Conclusion: THA is associated with disparities among race, gender, primary insurance, and social deprivation. Additional research is necessary to identify the cause of these disparities to improve equity in patient care.
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http://dx.doi.org/10.1016/j.arth.2021.10.021DOI Listing
February 2022

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

J Pediatr Orthop 2022 Jan;42(1):4-9

Department of Orthopedics, Brown University.

Background: In an effort to increase the value of health care in the United States, there has been increased focus on shifting certain procedures to an outpatient setting. While pediatric supracondylar humerus fractures (SCHFs) have traditionally been treated in an inpatient setting, recent studies have investigated the safety and efficiency of outpatient surgery for these injuries. This retrospective study aims to examine ongoing trends of outpatient surgical care for SCHFs, examine the safety and complication rates of these procedures, and investigate the potential cost-savings from this shift in care.

Methods: Pediatric patients less than 13 years old who underwent surgery for closed SCHF from 2009 to 2018 were identified using International Classification of Diseases-9/10 Clinical Modification and Procedural Classification System codes in the New York Statewide Planning and Research Cooperative System (SPARCS) database. Linear regression was used to assess the shift in proportion of outpatient surgical management of these injuries over time. Multivariable Cox proportional hazards regression was used to compare return to emergency department (ED) visit, readmission, reoperation, and other adverse events. A 2-sample t test was performed on the average charge amount per claim for inpatient versus outpatient surgery.

Results: A total of 8488 patients were included in the analysis showing there was a statistically significant shift towards outpatient management between 2009 (23% outpatient) and 2018 (59% outpatient) (P<0.0001). Relative to inpatient surgical management, outpatient surgical management had lower rates of return ED visits at 1 month (hazard ratio: 0.744, P=0.048). All other adverse events compared across inpatient and outpatient surgical management were not significantly different. The median amount billed per claim for inpatient surgeries was significantly higher than for outpatient surgeries ($16,097 vs. $9,752, P<0.0001). White race, female sex, and weekday ED visit were associated with increased rate of outpatient management.

Conclusions: This study demonstrates the trend of increasing outpatient surgical management of pediatric SCHF from 2009 to 2018. The increased rate of outpatient management has not been associated with elevated complication rates but is associated with significantly reduced health care charges.

Level Of Evidence: Level III-retrospective cohort.
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http://dx.doi.org/10.1097/BPO.0000000000001999DOI Listing
January 2022

Temporal and Geographic Trends in Medicare Reimbursement of Primary and Revision Shoulder Arthroplasty: 2000 to 2020.

J Am Acad Orthop Surg 2021 Dec;29(24):e1396-e1406

From the Department of Orthopaedic Surgery, Brown University/Warren Alpert School of Medicine, Providence, RI (Testa, Li, Gil, Daniels, Paxton), and the Mayo Clinic Alix School of Medicine, Phoenix, AZ (Haglin, Moore).

Introduction: A comprehensive understanding of the trends for financial reimbursement of shoulder arthroplasty is important as progress is made toward achieving sustainable payment models in orthopaedics. This study analyzes Medicare reimbursement trends for shoulder arthroplasty. We hypothesize that Medicare reimbursement has decreased for shoulder arthroplasty procedures from 2000 to 2020 and that revision procedures have experienced greater decreases in reimbursement.

Methods: The Physician Fee Schedule Look-Up Tool from the Centers for Medicare & Medicaid Services was queried for each Current Procedural Terminology code used in shoulder arthroplasty, and physician reimbursement data were extracted. All monetary data were adjusted for inflation to 2020 US dollars. Both the average annual and the total percentage change in surgeon reimbursement were calculated based on these adjusted trends for all included procedures. Mean percentage change in adjusted reimbursement among primary procedures in comparison to revision procedures was calculated. The mean reimbursement was assessed and visually represented by geographic state.

Results: The average reimbursement for all shoulder arthroplasty procedures decreased by 35.5% from 2000 to 2020. Revision total shoulder arthroplasty (TSA) experienced the greatest mean decrease (-44.6%), whereas primary TSA (-23.9%) experienced the smallest mean decrease. The adjusted reimbursement rate for all included procedures decreased by an average of 1.8% each year. The mean reimbursement for revision procedures decreased more than the mean reimbursement for primary procedures (-41.1% for revision, -29.9% for primary; P < 0.001). The mean reimbursement for TSA in 2020, and the percent change in reimbursement from 2000 to 2020, varied by state.

Discussion: Medicare reimbursement for shoulder arthroplasty procedures has decreased from 2000 to 2020, with revision procedures experiencing the greatest decrease. Increased awareness and consideration of these trends will be important as healthcare reform evolves, and reimbursements for large joint arthroplasty are routinely adjusted.
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December 2021

The Effect of Hospital and Surgeon Volumes on Complication Rates After Fixation of Peritrochanteric Hip Fractures.

J Orthop Trauma 2022 Jan;36(1):23-29

Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI; and.

Objective: This study evaluates the relationship between hospital and surgeon volumes of peritrochanteric hip fracture fixation and complication rates.

Methods: Adults (60 years of age or older) who underwent surgical fixation for closed peritrochanteric fractures from 2009 to 2015 were identified using International Classification of Diseases 9 and 10 Clinical Modification and Procedural codes in the New York Statewide Planning and Research Cooperative System database. Readmission, reoperations, in-hospital mortality, and other adverse events were compared across surgeon and facility volumes. Statistical significance was set at P < 0.05.

Results: A total of 29,656 patients were included in the study. Low-volume (LV) facilities had higher rates of readmission [hazard ratio (HR) 1.07, 95% confidence interval (CI), 1.05-1.17], pneumonia (HR 1.36, 95% CI, 1.22-1.51), wound complications (HR 1.24, 95% CI, 1.03-1.49), and mortality (HR 1.15, 95% CI, 1.04-1.27) but lower rates of acute renal failure (HR 0.90, 95% CI, 0.83-0.98), deep vein thrombosis (HR 0.66, 95% CI, 0.55-0.78), and acute respiratory failure (HR 0.77, 95% CI, 0.62-0.95) than high-volume (HV) facilities. Patients treated by LV surgeons had lower rates of readmission (HR 0.92, 95% CI, 0.87-0.97) and deep vein thrombosis (HR 0.78, 95% CI, 0.66-0.94) but higher rates of acute renal failure (HR 1.13, 95% CI, 1.04-1.22) than those treated by HV surgeons.

Conclusions: There are increased rates of mortality, readmission, and certain complications when peritrochanteric femur fractures are surgically managed at LV hospitals compared with those managed at HV hospitals. Thus, the benefit of a high-volume surgical facility is apparent in mortality and readmissions but not all complications. There was no significant decrease in complications if fixation was performed by HV surgeons relative to LV surgeons.

Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000002185DOI Listing
January 2022

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

J Hand Surg Am 2022 02 19;47(2):188.e1-188.e8. Epub 2021 May 19.

Department of Orthopaedics, Warren Alpert Medical School of Brown University, Providence, RI; University Orthopedics Incorporated, Providence, RI.

Purpose: The fixation of comminuted distal radius fractures using wrist-spanning dorsal bridge plates has been shown to have good postoperative results. We hypothesized that using a stiffer bridge plate construct results in less fracture deformation with loads required for immediate crutch weight bearing.

Methods: We created a comminuted, extra-articular fracture in 7 cadaveric radii, which were fixed using dorsal bridge plates. The specimens were positioned to simulate crutch/walker weight bearing and axially loaded to failure. The axial load and mode of failure were measured using 2- and 5-mm osteotomy deformations as cutoffs. Bearing 50% and 22% of the body weight was representative of the force transmitted through crutch and walker weight bearing, respectively.

Results: The load to failure at 2-mm deformation was greater than 22% body weight for 2 of 7 specimens and greater than 50% for 1 of 7 specimens. The load to failure at 5-mm deformation was greater than 22% body weight for 6 of 7 specimens and greater than 50% for 4 of 7 specimens. The mean load to failure at 2-mm gap deformation was significantly lower than 50% body weight (110.4 N vs 339.2 N). The mean load to failure at 5-mm deformation was significantly greater than 22% body weight (351.8 N vs 149.2 N). All constructs ultimately failed through plate bending.

Conclusions: All constructs failed by plate bending at forces not significantly greater than the 50% body weight force required for full crutch weight bearing. The bridge plates supported forces significantly greater than the 22% body weight required for walker weight bearing 6 of 7 times when 5 mm of deformation was used as the failure cutoff.

Clinical Relevance: Elderly, walker-dependent patients may be able to use their walker as tolerated immediately after dorsal bridge plate fixation for extra-articular fractures. However, patients should not be allowed to bear full weight using crutches immediately after bridge plating.
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http://dx.doi.org/10.1016/j.jhsa.2021.04.008DOI Listing
February 2022

Current Concepts in the Management of Dupuytren Disease of the Hand.

J Am Acad Orthop Surg 2021 Jun;29(11):462-469

From the Department of Orthopaedic Surgery (Gil, Hresko, and E. Akelman), Alpert Medical School of Brown University, Providence, RI, and the Department of Orthopaedic Surgery (M. R. Akelman), Wake Forest School of Medicine, Winston-Salem, NC.

Dupuytren disease is a fibroproliferative disorder of the palmar fascia of the hand. Little agreement and remarkable variability exists in treatment algorithms between surgeons. Because the cellular and molecular etiology of Dupuytren has been elucidated, ongoing efforts have been made to identify potential chemotherapeutic targets that could modulate the phenotypic expression of the disease. Although these efforts may dramatically alter the approach to treating this disease in the future, these approaches are largely experimental at this point. Over the past decade, the mainstay nonsurgical options have continued to be percutaneous needle aponeurotomy and collagenase Clostridium hystoliticum, and the most common surgical option is limited fasciectomy.
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http://dx.doi.org/10.5435/JAAOS-D-20-00190DOI Listing
June 2021

Is Opioid-Limiting Legislation Effective for Hand Surgery Patients?

Hand (N Y) 2021 Feb 3:1558944720988132. Epub 2021 Feb 3.

Brown University, Providence, RI, USA.

Background: The Rhode Island State Legislature passed the in 2016 to limit opioid prescriptions. We aimed to objectively evaluate its effect on opioid prescribing for hand surgery patients and also identify risk factors for prolonged opioid use.

Methods: A 6-month period (January-June 2016) prior to passage of the law was compared with a period following its implementation (July-December 2017). Thumb carpometacarpal arthroplasty and distal radius fracture fixation were classified as "major surgery" and carpal tunnel and trigger finger release as "minor surgery." Prescription Drug Monitoring Database was used to review controlled substances filled during the study periods.

Results: A total of 1380 patients met our inclusion criteria, with 644 and 736 . Patients undergoing "major surgery" saw a significant decrease in the number of pills issued in the first postoperative prescription (41.1 vs 21.0) and a corresponding decrease in morphine milligram equivalents (MMEs) (318.6 vs 159.2 MMEs) after implementation. A 30% decrease in MMEs was also seen in those undergoing "major surgery" in the first 30 days postoperatively (544.7 vs 381.7 MMEs). Risk factors for prolonged opioid use included male sex and preoperative opioid use.

Conclusions: In Rhode Island, opioid-limiting legislation resulted in a significant decrease in the number of pills and MMEs of the initial prescription and a 30% decrease in total MMEs in the 30-day postoperative period after "major hand surgery." Additional research is needed to explore the association between legislation and clinical outcomes.
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http://dx.doi.org/10.1177/1558944720988132DOI Listing
February 2021

Epidemiology of Peripheral Nerve Injuries in Sports, Exercise, and Recreation in the United States, 2009 - 2018.

Phys Sportsmed 2021 09 23;49(3):355-362. Epub 2020 Nov 23.

Department of Orthopaedics, Warren Alpert Medical School of Brown University, RI.

Objective: To assess rates of peripheral nerve injuries (PNI) in sport, exercise, and recreational activities.

Methods: The National Electronic Injury Surveillance System (NEISS) was used to query nerve injuries presenting to emergency departments across the United States. Identified injuries were stratified to those with product codes associated with exercise, sports, or recreation. Injuries only to the upper and lower extremities were included as cranial and spinal cord injuries were excluded. PNI was analyzed by age, sex, sport/recreational activity, race, and evaluated for incidence rates by year and activity. Statistical significance was considered to be P < 0.05.

Results: Between 2009-2018, 551,612 patients presented with PNI from which 120,675 (21.9%) were associated with exercise, sports, or recreation. PNI significantly increased between 2009-2018 (p = 0.002) with an overall incidence rate of 36.9 (95% confidence interval: 28.6, 45.2) per 1,000,000 person-years. A majority of PNI occurred through exercise (n = 56,328, 46.7%). PNI peaked in the fourth and fifth decades in males and females, respectively, with males accounting for significantly more than females (incidence rate ratio: 1.52, 95% confidence interval: 1.18, 1.86; p < 0.0001). White patients had a majority of PNI at 49.3% though African-Americans carried the highest incidence rate at 30.4 (95% confidence interval: 23.8, 36.9) per 1,000,000 person-years. Football had the highest proportion of PNI until age 19 (17.3%) as exercise carried the highest proportion for those 20 and older ranging from 27.9% to 53.8% of PNI.

Conclusion: PNIs are rising with participation in exercise, sports, and recreation over this 10-year study period. Injuries predominantly occurred in football for those under 20 and exercise for those 20 and older. Precautions and appropriate training are necessary for individuals participating in high-intensity exercise, sports, or recreation to limit the risk of a devastating neurological injury.
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http://dx.doi.org/10.1080/00913847.2020.1850151DOI Listing
September 2021

Patient comprehension of hip arthroscopy: an investigation of health literacy.

J Hip Preserv Surg 2020 Jul 15;7(2):340-344. Epub 2020 Jun 15.

Department of Orthopaedic Surgery, Warren Alpert Medical School, 2 Dudley St., Providence, RI 02903, USA.

Several studies have demonstrated that patients have significant impairments in understanding their injury and appropriate course of management in orthopedic surgery. The purpose of this investigation is to determine if patients are able to obtain a fundamental understanding of the requisite care associated with hip arthroscopy. Any patient who elected to have hip arthroscopy was prospectively recruited to participate in the study. All patients were told they would be asked to complete a questionnaire about their surgery and post-operative instructions. The answers to each question of the questionnaire they would receive at the first post-operative visit were verbally given to each patient during the pre-operative visit. They were also given a post-operative instruction sheet on the day of surgery that contained answers to the questionnaire. At the first post-operative visit, all patients were then asked to complete a multiple-choice questionnaire prior to seeing the surgeon. A total of 56 patients (14 males, 42 females) were enrolled. All patients reported they had read the post-operative instruction sheet. The average number of correct answers was 6.5 ± 0.6 (95% CI 6 - 7) out of 11 questions (59% correct response rate ±18% [95% CI 52 - 66%]). Although we made significant pre-operative oral and written efforts to help patients achieve an elementary level of health literacy regarding their forthcoming hip arthroscopy, many patients did not achieve satisfactory comprehension. Even with instruction and information given verbally and physically (via post-operative instruction sheet) patients did not obtain satisfactory comprehension of their surgical procedure. New ways (through video, simplified cartoons or verbal explanations) must be considered in educating patients concerning surgical procedures to increase comprehension and health literacy.
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http://dx.doi.org/10.1093/jhps/hnaa024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7605774PMC
July 2020

Implant Charge Differences Between Distal Radius Fixation Constructs (CPT 25607, 25608, and 25609).

Hand (N Y) 2020 Oct 19:1558944720963927. Epub 2020 Oct 19.

Brown University, Providence, RI, USA.

Background: Implants are a significant contributor to health care costs. We hypothesized that extra-articular fracture patterns would have a lower implant charge than intra-articular fractures and aimed to determine risk factors for increased cost.

Methods: In total, 163 patients undergoing outpatient distal radius fracture fixation at 2 hospitals were retrospectively reviewed stratified by Current Procedural Terminology codes. Implants and associated charges were noted, as were sex, age, insurance status, surgeon specialty, and location. Bivariate and multivariable regression were used to determine associations.

Results: Total implant charges were significantly lower for 25607 (extraarticular, ) than 25608 (2-part intraarticular, ) and 25609 (3+ part intraarticular, ). In addition, intra-articular fractures had higher charges for distal screws/pegs and bone graft. Charge was lower when surgery was performed at a trauma center. There was no charge difference associated with insurance status, age, sex, hand surgery specialty, or fellow status. Substantial intersurgeon variation existed in all fracture types.

Conclusion: Distal radius fractures may represent a good model for examining implant costs. Extra-articular fractures had lower implant charges than intra-articular fractures. These data may be used to help construct pricing for distal radius fracture bundles and potential cost savings.
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October 2020
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