Are Orthopedic Hand Surgeons Undercompensated for Time Spent in the Operating Room? A Study of Relative Value Units

Background: This study aims to investigate whether compensation is equitable among the most commonly performed orthopedic hand surgeries and when compared with general orthopedic procedures. Methods: The National Surgical Quality Improvement Program database was queried for all orthopedic procedures, from 2016 to 2018, performed more than 150 times using Current Procedural Terminology (CPT) codes. Physician work relative value unit (wRVU) data were obtained from the 2020 US Centers for Medicare and Medicaid Services fee schedule. Linear regressions were used to determine whether there was an association among wRVU, operative time, and wRVU per hour (wRVU/h). Reimbursement for hand surgery CPT codes was compared with that of nonhand orthopedic CPT codes. The CPT codes were stratified into quartile cohorts based on mean operative time, major complication rate, mortality rate, American Society of Anesthesiologists class, reoperation rate, and readmission rate. Student t tests were used to compare wRVU/h between cohorts. Results: Forty-two hand CPT codes were identified from 214 orthopedic CPT codes, accounting for 32 333 hand procedures. The median wRVU/h was significantly lower for procedures in the longest operative time quartile compared with the shortest operative time quartile ( P < .001). Compared with hand procedures, nonhand procedures were found to have significantly higher mean operative time ( P < .001), mean complication rate ( P < .001), mean wRVU ( P = .001), and mean wRVU/h ( P = .007). Conclusions: The 2020 Physician wRVU scale does not allocate proportional wRVUs to orthopedic hand procedures with longer mean operative times. There is a decrease in mean reimbursement rate for hand procedures with longer mean operative time. When compared with general orthopedic procedures, hand procedures have a lower mean wRVU/h and complication rate.

The safety and cost-analysis of simultaneous versus staged bilateral total knee arthroplasty in a Taiwan population

The purpose of this study was to investigate the safety of Simultaneous, bilateral TKA (SiTKA). Furthermore, we also assessed the cost reduction of SiTKA in comparison with Staged, bilateral TKA (StTKA). We retrospectively review all patients that underwent SiTKA or StTKA due to osteoarthritis (OA) or spontaneous osteonecrosis of the knee (SONK).We assessed length of stay, transfusion rate, early postoperative complications, 30-day and 90-day readmission rate, 1-year reoperation rate and the indication for reoperation. Furthermore, we analyzed the total cost of the two groups, reimbursement from the national health insurance (NHI), cost of the procedures, and net income from each case. A total of 2016 patients (1565 SiTKA and 451 StTKAs) were included in this study. There were no significant differences in terms of complication rates, 30-day and 90-day readmission, and 1-year reoperations between the two groups. The total length of stay was on average 5.0 days longer for StTKA (p<0.01). In terms of cost, all categories of medical costs were significantly lower in SiTKA, while the net hospital income was significantly higher for StTKA. In conclusion, SiTKA and StTKA have similar postoperative complication, readmission and reoperation rates, while SiTKA significantly reduces medical expenses for the patient and NHI. Level of evidence: level III, retrospective cohort study

Volumetric Resection and Complications in Nonfunctioning Pituitary Adenoma by Fully Endoscopic Transsphenoidal Approach along 15 Years of Single-Center Experience

Objective The aim of this study was to evaluate the rate of complications and the extent of resection (EOR) of nonfunctioning pituitary adenomas by endoscopic endonasal approach (EEA) in a 15-year learning curve. Methods A total of 100 patients operated by the same surgical team were divided chronologically into two, three, and four groups, comparing differences in EOR measured by a semiautomatic software (Smartbrush, Brainlab), rate of immediate postoperative complications, and the visual and hormonal status at 6 months. Results There were no significant differences over the years in rates of postoperative complications and in visual status at 6 months. A significant linear correlation between the EOR and the number of surgeries (rho = 0.259, p = 0.007) was found. The analysis was performed in three groups because of the remarkable differences among them; the EOR were: 87.2% (early group), 93.03% (intermediate group), and 95.1% (late group) (p = 0.019). Gross total resection was achieved in 30.3, 51.5, and 64%, respectively (p = 0.017); also, the rate of reoperation and the worsening of at least one new hormonal axis were worse in the early group. Consequently, the early group had a higher risk of incomplete resection compared with the late group (odds ratio: 4.2; 95% confidence interval: 1.5–11.7). The three groups were not different in demographic and volume tumor variables preoperatively. Conclusions The first 33 interventions were associated with a lower EOR, a high volume of residual tumor, a high reoperation rate, and a higher rate of hormonal dysfunction. We did not find differences in terms of postoperative complications and the visual status at 6-month follow-up.

The Changing Trend in Clinical Characteristics and Outcomes of Male Patients With Urethral Stricture Over the Past 10 Years in China

Background: Male urethral stricture is a disease with a high incidence rate. With social-economic development in the developing countries, the trend of etiology and treatment of male urethral stricture changed was speculated.Methods: The clinical data of the male patients with urethral stricture from 2000 to 2019 were analyzed. The subjects were divided into Group A (2000–2009) and Group B (2010–2019) according to treatment time. The pooled analysis of the data extracted from pieces of literature was also performed.Results: About 540 patients were included in the present study, including 235 patients in Group A and 305 patients in Group B. In recent 10 years, trauma has still been the main cause of urethral stricture. Iatrogenic injury, especially transurethral operation, increases significantly, while male urethral stricture secondary to radiotherapy and infection decrease. Urethroplasty increases and the reoperation rate decreases in treating simple urethral stricture, and flap urethroplasty also increases in treating complex urethral stricture. The results of a pooled analysis of data from 11 centers in Mainland China are partially consistent with it. Complications, such as urethral fistula, false canal, ejaculation disorder, and penile curvature, decrease significantly.Conclusions: The main causes of urethral stricture in the recent 10 years are still trauma and iatrogenic injuries, and the etiology of urethral stricture is related to socioeconomic development. With the increase of intracavitary minimally invasive treatment and flap urethroplasty, the curative effect is increasing, while iatrogenic urethral stricture cannot be ignored.

Minimally Invasive Posterior Cervical Foraminotomy Versus Anterior Cervical Fusion and Arthroplasty: Systematic Review and Meta-Analysis

Study Design Systematic review and meta-analysis. Objectives Patients with lateral cervical disc and foraminal pathology can be treated with anterior and posterior approaches including anterior cervical discectomy and fusion(ACDF), cervical total disc arthroplasty(TDA), and minimally invasive posterior cervical foraminotomy(MIS-PCF). Although MIS-PCF may have some advantages over the anterior approaches, few comparative studies and meta-analyses have been done to assess superiority. Methods This study includes a systematic review of the literature and meta-analysis of studies directly comparing minimally invasive posterior cervical foraminotomy to either anterior cervical discectomy and fusion or cervical total disc arthroplasty. Results In comparing patients undergoing ACDF and MIS-PCF, operative time ranged from 68 to 97.8 minutes in the ACDF group compared to 28 to 93.9 minutes in the MIS-PCF group. Mean postoperative length of stay ranged from 33.84 to 112.8 hours in the ACDF group compared to 13.68 to 83.6 hours in the MIS-PCF group. The total complication rates were 3.72% in the ACDF group and 3.73% in the MIS-PCF group. A random-effects model meta-analysis was carried out which failed to show a statistically significant difference in the complication rate between the two procedures(OR .91; 95% CI 0.13, 6.43; P = .92, I2 = 59%). The total reoperation rate was 3.5% in the ACDF group and 5.4% in the MIS-PCF group. A random-effects model meta-analysis was carried out which failed to show a statistically significant difference in the reoperation rate between the two procedures(OR .66; 95% CI 0.33, 1.33; P = .25, I2 = 0). In comparing patients undergoing TDA and MIS-PCF, operative time ranged from 90.3 to 106.7 minutes in the TDA group compared to 77.4 to 93.9 minutes in the MIS-PCF group. Mean postoperative length of stay ranged from 103.2 to 165.6 hours in the TDA group and 93.6 to 98.4 hours in the MIS-PCF group. The complication rate ranged from 23.5 to 28.6% in the TDA group and 0 to 14.3% in the MIS-PCF group. The overall reoperation rates were 2.6% in the TDA group and 10.2% in the MIS-PCF group. Conclusions There is no clear superiority between MIS-PCF and ACDF/TDA in terms of operative time, postoperative length of stay, or rate of complications/reoperations. Further studies with increased follow-up intervals >48 months, and higher sample sizes are necessary to determine the true superiority of MIS-PCF and anterior neck approaches in treatment of lateral disc and foraminal pathology.

15-year survivorship analysis of an interspinous device in surgery for single-level lumbar disc herniation

Background Interspinous devices have been introduced as alternatives to decompression or fusion in surgery for degenerative lumbar diseases. This study aimed to investigate 15-year survivorship and risk factors for reoperation of a Device for Intervertebral Assisted Motion (DIAM) in surgery for 1-level lumbar disc herniation (LDH). Methods A total of 94 patients (54 men and 40 women) underwent discectomy and DIAM implantation for 1-level LDH, with a mean follow-up of 12.9 years (range, 6.3–15.3 years). The mean age was 46.2 years (range, 21–65 years). Sixty-two patients underwent DIAM implantation for L4–5, 27 for L5–6, and 5 for L3–4. Reoperations due to any reason associated with DIAM implantation level or adjacent levels were defined as failure and used as the end point of determining survivorship. Results During the 15-year follow-up, 8 patients (4 men and 4 women) underwent reoperation due to recurrence of LDH at the DIAM implantation level, a reoperation rate of 8.5%. The mean time to reoperation was 6.5 years (range, 0.8–13.9 years). Kaplan-Meier analysis showed a cumulative survival rate of the DIAM implantation of 97% at 5 years, 93% at 10 years, and 92% at 15 years after surgery; the cumulative reoperation rate of the DIAM implantation was 3% at 5 years, 7% at 10 years, and 8% at 15 years after surgery. Mean survival time was predicted to be 14.5 years (95% CI, 13.97–15.07). The log-rank test and Cox proportional hazard model showed that age, sex, and location did not significantly affect the reoperation rate of DIAM implantation. Conclusions Our results showed that DIAM implantation significantly decreased reoperation rate for LDH in the 15-year survivorship analysis. We suggest that DIAM implantation could be considered a useful intermediate step procedure for LDH surgery. To the best of our knowledge, this is the longest follow-up study in which surgical outcomes of interspinous device surgery were reported.

Interspinous process device versus conventional decompression for lumbar spinal stenosis: 5-year results of a randomized controlled trial

OBJECTIVE Interspinous process distraction devices (IPDs) can be implanted to treat patients with intermittent neurogenic claudication (INC) due to lumbar spinal stenosis. Short-term results provided evidence that the outcomes of IPD implantation were comparable to those of decompressive surgery, although the reoperation rate was higher in patients who received an IPD. This study focuses on the long-term results. METHODS Patients with INC and spinal stenosis at 1 or 2 levels randomly underwent either decompression or IPD implantation. Patients were blinded to the allocated treatment. The primary outcome was the Zurich Claudication Questionnaire (ZCQ) score at 5-year follow-up. Repeated measurement analysis was applied to compare outcomes over time. RESULTS In total, 159 patients were included and randomly underwent treatment: 80 patients were randomly assigned to undergo IPD implantation, and 79 underwent spinal bony decompression. At 5 years, the success rates in terms of ZCQ score were similar (68% of patients who underwent IPD implantation had a successful recovery vs 56% of those who underwent bony decompression, p = 0.422). The reoperation rate at 2 years after surgery was substantial in the IPD group (29%), but no reoperations were performed thereafter. Long-term visual analog scale score for back pain was lower in the IPD group than the bony decompression group (p = 0.02). CONCLUSIONS IPD implantation is a more expensive alternative to decompressive surgery for INC but has comparable functional outcome during follow-up. The risk of reoperation due to absence of recovery is substantial in the first 2 years after IPD implantation, but if surgery is successful this positive effect remains throughout long-term follow-up. The IPD group had less back pain during long-term follow-up, but the clinical relevance of this finding is debatable.

Preoperative spinopelvic hypermobility resolves following total hip arthroplasty

Aims Spinopelvic mobility plays an important role in functional acetabular component position following total hip arthroplasty (THA). The primary aim of this study was to determine if spinopelvic hypermobility persists or resolves following THA. Our second aim was to identify patient demographic or radiological factors associated with hypermobility and resolution of hypermobility after THA. Methods This study investigated patients with preoperative posterior hypermobility, defined as a change in sacral slope (SS) from standing to sitting (ΔSSstand-sit) ≥ 30°. Radiological spinopelvic parameters, including SS, pelvic incidence (PI), lumbar lordosis (LL), PI-LL mismatch, anterior pelvic plane tilt (APPt), and spinopelvic tilt (SPT), were measured on preoperative imaging, and at six weeks and a minimum of one year postoperatively. The severity of bilateral hip osteoarthritis (OA) was graded using Kellgren-Lawrence criteria. Results A total of 136 patients were identified as having preoperative spinopelvic hypermobility. At one year after THA, 95% (129/136) of patients were no longer categorized as hypermobile on standing and sitting radiographs (ΔSSstand-sit < 30°). Mean ΔSSstand-sit decreased from 36.4° (SD 5.1°) at baseline to 21.4° (SD 6.6°) at one year (p < 0.001). Mean SSseated increased from baseline (11.4° (SD 8.8°)) to one year after THA by 11.5° (SD 7.4°) (p < 0.001), which correlates to an 8.5° (SD 5.5°) mean decrease in seated functional cup anteversion. Contralateral hip OA was the only radiological predictor of hypermobility persisting at one year after surgery. The overall reoperation rate was 1.5%. Conclusion Spinopelvic hypermobility was found to resolve in the majority (95%) of patients one year after THA. The increase in SSseated was clinically significant, suggesting that current target recommendations for the hypermobile patient (decreased anteversion and inclination) should be revisited. Cite this article: Bone Joint J 2021;103-B(12):1766–1773.

A Comparison of Complications and Reoperations Between Open Reduction and Internal Fixation Versus Primary Arthrodesis Following Lisfranc Injury

There is a lack of consensus in the literature regarding optimal treatment methods for Lisfranc injuries, and recent literature has emphasized the need to compare open reduction and internal fixation (ORIF) with primary arthrodesis (PA). The purpose of the current study is to compare reoperation and complication rates between ORIF and PA following Lisfranc injury in a private, outpatient, orthopaedic practice. A retrospective chart review was performed on patients undergoing operative intervention for Lisfranc injury between January 2009 and September 2015. A total of 196 patients met the inclusion criteria (130 ORIF, 66 PA), with a mean follow-up of 61.3 and 81.7 weeks, respectively. The ORIF group had a higher reoperation rate than the PA group, due to hardware removal. When hardware removals were excluded, the reoperation rate was similar. Postsurgical complications were compared between the 2 groups with no significant difference. In conclusion, ORIF and PA had similar complication rates. When hardware removals were excluded, the reoperation rates were similar, although hardware removals were more common in the ORIF group compared with the PA group. Levels of Evidence: Level III

Is Stem Revision Necessary for Vancouver B2 Periprosthetic Hip Fractures? Analysis of Osteosynthesis Results from 39 Cases

Although stem revision is recommended for Vancouver B2 periprosthetic hip fractures (PPHFs), there has recently been a debate whether, under certain conditions, they could be treated by osteosynthesis alone. This study aimed to describe the medium-term clinical and radiological results of several patients with V-B2 fractures treated via osteosynthesis. A retrospective study of patients with V-B2 PPHF treated by osteosynthesis without stem revision, operated on between 2009 and 2019, was performed. The type of arthroplasty, type of stem, ASA, Charlson Comorbidity Index (CCI), medical and implant complications, reoperation rate, first-year mortality, radiological results (consolidation time), and functional results were analyzed. Thirty-nine patients were included. Their average age was 78.82 years. Most of the patients presented ASA ≥ 3 (35/39) and CCI ≥ 5 (32/39). Radiological consolidation was achieved in 93.5% of patients, with an average consolidation time of 92.93 days. The average Parker test score before admission was 5.84 while the current one was 4.92 (5.16 years follow-up). Osteosynthesis without stem revision is a valid surgical alternative in certain types of patients with V-B2 PPHF, depending on previous mobility, fracture pattern (anatomical reconstruction possible), anesthetic risk, comorbidities, and previous hip pain.