Robin Kamal MD MBA

All Publications

• A Simple Goal Elicitation Tool Improves Shared Decision Making in Outpatient Orthopedic Surgery: A Randomized Controlled Trial. Medical decision making : an international journal of the Society for Medical Decision Making Mertz, K., Shah, R. F., Eppler, S. L., Yao, J., Safran, M., Palanca, A., Hu, S. S., Gardner, M., Amanatullah, D. F., Kamal, R. N. 2020: 272989X20943520

  Abstract

  Introduction. Shared decision making involves educating the patient, eliciting their goals, and collaborating on a decision for treatment. Goal elicitation is challenging for physicians as previous research has shown that patients do not bring up their goals on their own. Failure to properly elicit patient goals leads to increased patient misconceptions and decisional conflict. We performed a randomized controlled trial to test the efficacy of a simple goal elicitation tool in improving patient involvement in decision making. Methods. We conducted a randomized, single-blind study of new patients presenting to a single, outpatient surgical center. Prior to their consultation, the intervention group received a demographics questionnaire and a goal elicitation worksheet. The control group received a demographics questionnaire only. After the consultation, both groups were asked to complete the Perceived Involvement in Care Scale (PICS) survey. We compared the mean PICS scores for the intervention and control groups using a nonparametric Mann-Whitney Wilcoxon test. Secondary analysis included a qualitative content analysis of the patient goals. Results. Our final cohort consisted of 96 patients (46 intervention, 50 control). Both groups were similar in terms of demographic composition. The intervention group had a significantly higher mean (SD) PICS score compared to the control group (9.04 [2.15] v. 7.54 [2.27], P < 0.01). Thirty-nine percent of patient goals were focused on receiving a diagnosis or treatment, while 21% of patients wanted to receive education regarding their illness or their treatment options. Discussion. A single-step goal elicitation tool was effective in improving patient-perceived involvement in their care. This tool can be efficiently implemented in both academic and nonacademic settings.

  View details for DOI 10.1177/0272989X20943520

  View details for PubMedID 32744134

• Safety of Releasing the Volar Capsule During Open Treatment of Distal Radius Fractures: An Analysis of the Extrinsic Radiocarpal Ligaments' Contribution to Radiocarpal Stability. The Journal of hand surgery Suazo Gladwin, L. A., Douglass, N., Behn, A. W., Thio, T., Ruch, D. S., Kamal, R. N. 2020

  Abstract

  PURPOSE: The contribution of the extrinsic radiocarpal ligaments to carpal stability continues to be studied. Clinically, there is a concern for carpal instability from release of the volar extrinsic ligaments during volar plating of distal radius fractures in which the integrity of the dorsal ligaments may be unknown. The primary hypothesis of this study was that serial sectioning of radiocarpal ligaments would lead to progressive ulnar translation of the carpus.METHODS: We studied the stabilizing roles of the radioscaphocapitate (RSC), short radiolunate (SRL), long radiolunate (LRL), and dorsal radiocarpal (DRC) ligaments. We sequentially sectioned these ligaments in 2 groups of 5 matched pairs and measured the motion of the scaphoid and lunate with the wrist in passive neutral alignment, radial deviation, ulnar deviation, and simulated grip. Displacement of the lunate in the radioulnar plane was used as a surrogate for carpal translation. The groups differed only by the order in which the ligaments were sectioned.RESULTS: In the intact state, the lunate translated ulnarly during simulated grip and radial deviation, whereas radial translation, relative to its position under resting tension, was observed during ulnar deviation. With serial sectioning, the lunate displayed increased ulnar translation in all wrist positions for both groups 1 and 2. The magnitude of ulnar translation exceeded 1 mm after sectioning the LRL plus RSC along with either the DRC or the SRL.CONCLUSIONS: Sectioning of either the DRC or SRL ligaments along with release of the RSC and LRL ligaments leads to notable although minimal (<2-mm) ulnar lunate translation.CLINICAL RELEVANCE: Isolated sectioning of individual radiocarpal ligaments, such as for visualization of the articular surface of the distal radius, leads to minimal ulnar translation. Because prior clinical work found no clinical complications after volar capsule release, it is posited that translation less than 2 mm creates subclinical changes in carpal mechanics.

  View details for DOI 10.1016/j.jhsa.2020.05.022

  View details for PubMedID 32747049

• The Influence of Cost Information on Treatment Choice: A Mixed-Methods Study. The Journal of hand surgery Zhuang, T., Kortlever, J. T., Shapiro, L. M., Baker, L., Harris, A. H., Kamal, R. N. 2020

  Abstract

  PURPOSE: To test the null hypothesis that exposure to societal cost information does not affect choice of treatment for carpal tunnel syndrome (CTS).METHODS: We enrolled 304 participants using the Amazon Mechanical Turk platform to complete a survey in which participants were given the choice between carpal tunnel release (CTR) or a less-expensive option (orthosis wear) in a hypothetical mild CTS scenario. Patients were randomized to receive information about the societal cost of CTR (cost cohort) or no cost information (control). The primary outcome was the probability of choosing CTR measured on a 6-point ordinal scale. We employed qualitative content analysis to evaluate participants' rationale for their choice. We also explored agreement with various attitudes toward health care costs on an ordinal scale.RESULTS: Participants in the cost cohort exhibited a greater probability of choosing surgery than those in the control cohort. The relative risk of choosing surgery after exposure to societal cost information was 1.43 (95% confidence interval, 1.11-1.85). Among participants who had not previously been diagnosed with CTS (n= 232), the relative risk of choosing surgery after exposure to societal cost information was 1.55 (95% confidence interval, 1.17-2.06). Lack of personal monetary responsibility frequently emerged as a theme in those in the cost cohort who chose surgery. The majority (94%) of participants expressed at least some agreement that health care cost is a major problem whereas only 58% indicated that they consider the country's health care costs when making treatment decisions.CONCLUSIONS: Participants who received societal cost information were more likely to choose the more expensive treatment option (CTR) for mild CTS.CLINICAL RELEVANCE: Exposure to societal cost information may influence patient decision making in elective hand surgery. A complete understanding of this influence is required prior to implementing processes toward greater cost transparency for diagnostic/treatment options. Sharing out-of-pocket costs with patients may be a beneficial approach because discussing societal cost information alone will likely not improve value of care.

  View details for DOI 10.1016/j.jhsa.2020.05.019

  View details for PubMedID 32723572

• Feasibility of Quality Measures for the Diagnosis and Treatment of Carpal Tunnel Syndrome. The Journal of hand surgery Crijns, T. J., Ring, D., Leung, N., Kamal, R. N., AAOS and ASSH Carpal Tunnel Quality Measures Workgroup 2020

  Abstract

  PURPOSE: The American Academy of Orthopaedic Surgeons and the American Society for Surgery of the Hand developed candidate quality measures for potential inclusion in the Merit-Based Incentive Program and National Quality Forum in the hope that hand surgeons could report specialty-specific data. The following measures regarding the management of carpal tunnel syndrome (CTS) were developed using a Delphi consensus process: (1) use of magnetic resonance imaging (MRI) for diagnosis of CTS, (2) use of adjunctive surgical procedures during carpal tunnel release (CTR), and (3) use of formal occupational and/or physical therapy after CTR. This study simulated attempts to identify outlier regions in an insurance claims database, which is an important step in establishing feasibility of these measures.METHODS: Using the Truven Health MarketScan, we identified 643,357 patients who were given a diagnosis of CTS between 2012 and 2014. We reported the percentage of metropolitan statistical areas (MSA) with one or more claims for MRI within 90 days of CTS diagnosis, one or more adjunctive surgical procedures, and one or more formal referrals for physical and/or occupational therapy within 6 weeks of CTR, and we calculated the rate of use for each of these diagnostic or treatment modalities. In addition, we report the precision ratio (signal to noise), SD, and 95% confidence interval.RESULTS: A high percentage of patients given a diagnosis of CTS did not have MRI (99%), and the precision ratio was considered high (0.99). Over 30% of all observed MSAs had at least one claim for MRI as a diagnostic modality in CTS. Most patients (98%) did not have adjunctive surgical procedures. For the observed years, over 28% of MSAs had at least one insurance claim for an adjunctive procedure. A total of 86% of patients did not receive formal occupational or physical therapy after CTR. In addition, 92% of MSAs had at least one claim for therapy. The precision ratio was considered high (approximately 0.85).CONCLUSIONS: There is regional variation in the utilization rate of diagnostic MRI for CTS, adjunctive surgical procedures, and formal referral for physical and occupational therapy. For the proposed quality measures, outlier regions can be detected in insurance claims data.CLINICAL RELEVANCE: Use of MRI in diagnosis, adjunctive surgical procedures, and formal therapy after surgery are feasible quality measures for the Merit-Based Incentive Program and National Quality Forum.

  View details for DOI 10.1016/j.jhsa.2020.05.004

  View details for PubMedID 32723571

• Development and Testing of a Question Prompt List for Common Hand Conditions: An Exploratory Sequential Mixed-Methods Study. The Journal of hand surgery Satteson, E. S., Roe, A. K., Eppler, S. L., Yao, J., Shapiro, L. M., Kamal, R. N. 2020

  Abstract

  PURPOSE: A question prompt list (QPL) is a tool that lists possible questions a patient may want to ask their surgeon. Its purpose is to improve patient-physician communication and increase patient engagement. Although QPLs have been developed in other specialties, one does not exist for hand conditions. We sought to develop a QPL for use in the hand surgery clinic using a mixed-methods design.METHODS: We drafted a QPL based on prior work outside of hand surgery and then used an exploratory sequential mixed-methods design (both qualitative and quantitative methods) to finalize the QPL. Qualitative evaluation included both a written questionnaire completed by a patient advisory board, hand therapists, and hand surgeons, as well as cognitive interviews conducted with clinic patients using the tool. Revisions to the QPL were made after each phase of qualitative analysis. The final QPL was then evaluated quantitatively using the system usability score (SUS) questionnaire to assess its usability.RESULTS: A patient advisory board consisting of 6 patients, 5 hand therapists, and 6 hand surgeons completed the written questionnaire. Thirteen patients completed a cognitive interview of the QPL. We completed a content analysis of the qualitative data and incorporated the findings into the QPL. Twenty patients then reviewed the final QPL pamphlet and completed the SUS questionnaire. The resulting SUS score of 78.8 indicated above-average usability of the QPL tool.CONCLUSIONS: The QPL developed in this study, from the perspective of multiple stakeholders, provides a usable tool to engage and prompt patients in asking questions during their visit with their hand surgeon with the potential to improve communication and patient-centered care.CLINICAL RELEVANCE: This study provides clinicians with a QPL developed for use in the hand surgery clinic setting, aimed at facilitating more thorough patient-provider discussion.

  View details for DOI 10.1016/j.jhsa.2020.05.015

  View details for PubMedID 32693988

• Measuring and Improving the Quality of Care During Global Outreach Trips: A Primer for Safe and Sustainable Surgery. The Journal of hand surgery Shapiro, L. M., Global-Quest Investigators, Shapiro, L. M., Chang, J., Fox, P. M., Kozin, S. H., Chung, K. C., Dyer, G. S., Fufa, D. T., Leversedge, F. J., Katarincic, J. A., Kamal, R. N. 2020

  Abstract

  Trauma is the leading cause of mortality in patients aged 5 years and older. Globally, trauma kills more people than malaria, tuberculosis, and HIV/AIDs combined. As the number of surgical outreach trips to low- and middle-income countries and resources provided for such trips increase, hand surgeons are uniquely positioned to address this global burden. However, the delivery of surgical care alone is insufficient without effectively evaluating the quality of care delivered. It is critical that the care provided on outreach trips improves patient and population health, does not harm patients, and develops the local health care ecosystem. An estimated 8 million lives could be saved annually in low- and middle-income countries with higher-quality health systems. Currently, data collection systems for evaluating quality during outreach trips are lacking. Insight into current methods of quality assessment and improvement in both developing and developed countries can help inform future efforts to implement innovative data collection systems. Thoughtful and sustainable collaboration with host sites in low- and middle-income countries can ensure that care delivery is culturally competent and improves population health.

  View details for DOI 10.1016/j.jhsa.2020.04.027

  View details for PubMedID 32680787

• Rotational stability of scaphoid waist non-union bone graft and fixation techniques. The Journal of hand surgery Gire, J. D., Thio, T., Behn, A. W., Kamal, R. N., Ladd, A. L. 2020

  Abstract

  PURPOSE: Rotational instability of scaphoid fracture nonunions can lead to persistent nonunion. We hypothesized that a hybrid Russe technique would provide improved rotational stability compared with an instrumented corticocancellous wedge graft in a cadaver model of scaphoid nonunion.METHODS: A volar wedge osteotomy was created at the scaphoid waist in 16 scaphoids from matched-pair specimens. A wedge was inset at the osteotomy site or a 4* 16-mm strut was inserted in the scaphoid and a screw was placed along the central axis (model 1). The construct was cyclically loaded in torsion until failure. The screw was removed and the proximal and distal poles were debrided. A matching wedge and packed cancellous bone graft or an 8* 20-mm strut was shaped and fit inside the proximal and distal pole (model 2). A screw was placed and testing was repeated.RESULTS: In the first model, there was no significant difference in cycles to failure, target torque, or maximal torque between the strut graft and the wedge graft. Cycles to failure positively correlated with estimated bone density for the wedge graft, but not for the strut graft. In the second model, the strut graft had significantly higher cycles to failure, greater target torque, and higher maximal torque compared with the wedge graft. The number of cycles to failure was not correlated with estimated bone density for the wedge or the strut grafts.CONCLUSIONS: The hybrid Russe technique of inlay corticocancellous strut and screw fixation provides improved rotational stability compared with a wedge graft with screw fixation for a cadaver model of scaphoid waist nonunion with cystic change.CLINICAL RELEVANCE: The hybrid Russe technique may provide better rotational stability for scaphoid waist nonunions when the proximal or distal scaphoid pole is compromised, such as when there is extensive cystic change, when considerable debridement is necessary, or with revision nonunion surgery.

  View details for DOI 10.1016/j.jhsa.2020.05.012

  View details for PubMedID 32654765

• Cost-Minimization Analysis and Treatment Trends of Surgical and Nonsurgical Treatment of Proximal Humerus Fractures. The Journal of hand surgery Wu, E. J., Zhang, S. E., Truntzer, J. N., Gardner, M. J., Kamal, R. N. 2020

  Abstract

  PURPOSE: Recent evidence demonstrated similar outcomes between nonsurgical and surgical management of displaced proximal humerus fractures. We analyzed treatment trends and performed a cost-minimization analysis comparing nonsurgical treatment, open reduction and internal fixation, reverse total shoulder arthroplasty, and hemiarthroplasty. We hypothesized that rates of surgical treatment have increased and that the costs associated with surgery are greater compared with nonsurgical management of proximal humerus fractures.METHODS: We used a US private-payer claims database of 22 million patient records from 2007 to 2016 to compare (1) cost for the episode of care from the payer perspective between each surgical group and nonsurgical treatment of proximal humerus fractures, and (2) annual trends and complication rates of each group. Cost data, including facility fees, physician fees, physical therapy, and clinic visits, were used to complete a cost-minimization analysis.RESULTS: Nonsurgical treatment was associated with lower average total costs compared with surgical intervention. Facility and physician fees accounted for most of this difference. Physical therapy costs and number of physical therapy visits were higher in each surgical group compared with nonsurgical treatment. Surgical treatment was associated with higher complications, revision rates, and length of stay. There was a small but statistically significant decrease in nonsurgical management of proximal humerus fractures between 2007 and 2016. No change was observed in rates of open reduction and internal fixation, whereas rates of reverse total shoulder arthroplasty increased and rates of hemiarthroplasty decreased.CONCLUSIONS: Nonsurgical management of proximal humerus fractures decreased during the study period. In the setting of treatment equipoise, cost-minimization analysis favors nonsurgical management of proximal humerus fractures. Surgical management is associated with higher complication rates, revision rates, and length of stay.TYPE OF STUDY/LEVEL OF EVIDENCE: Economic Decision Analysis IV.

  View details for DOI 10.1016/j.jhsa.2020.03.022

  View details for PubMedID 32482497

• Evaluation and Treatment of Flexor Tendon and Pulley Injuries in Athletes. Clinics in sports medicine Shapiro, L. M., Kamal, R. N. 2020; 39 (2): 279–97

  Abstract

  Flexor tendon and pulley injuries in athletes present a unique challenge to the treating clinician. An understanding of the anatomy and mechanism of injury helps the clinician appropriately diagnose and treat the injury. Treatment may become more complicated when associated with delays in diagnosis, in-season considerations, and an athlete's desire to return to play. Two injuries involving the flexor tendon-pulley system, avulsion injuries of the flexor digitorum profundus tendon from its insertion onto the base of the distal phalanx and flexor pulley injuries, are examined in detail in this article.

  View details for DOI 10.1016/j.csm.2019.12.004

  View details for PubMedID 32115085

• Clinical and Patient-Reported Outcomes After Hybrid Russe Procedure for Scaphoid Nonunion. Hand (New York, N.Y.) Shapiro, L. M., Roe, A. K., Kamal, R. N. 2020: 1558944720911214

  Abstract

  Background: Hybrid Russe technique for the treatment of scaphoid nonunion with humpback deformity has been described with a reported 100% union rate. We sought to evaluate the reproducibility of this technique. Methods: We completed a retrospective chart review of patients with a scaphoid waist nonunion and humpback deformity treated with the hybrid Russe technique from 2015 to 2019 with a minimum of 3-month follow-up. Twenty patients with 21 nonunions were included (mean follow-up: 7.0 months). Scapholunate angle was the primary outcome measure. Secondary outcomes included: intrascaphoid angle, radiolunate angle, pain on the visual analog scale (VAS), and Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score. Other variables included: time to computed tomography (CT) union, range of motion, and complications. Descriptive statistics were presented. Pre- and postoperative angles, VAS, and QuickDASH scores were evaluated with Wilcoxon signed rank tests. Results: The mean scapholunate angle improved -17.6° ± 6.4°. The mean intrascaphoid angle improved 28.2° ± 6.3°. The mean radiolunate angle improved 12.8° ± 8.8°. Of the 21 scaphoids, 20 (95%) demonstrated union on a CT scan. One patient was diagnosed with a nonunion. In total, 90% of patients noted symmetric range of motion compared with the contralateral side. The mean VAS pain score improved 6 ± 3 points. The mean QuickDASH score improved 10 ± 8 points. Complications (aside from nonunion) included 1 patient with persistent wrist pain that resolved with removal of hardware. Conclusions: The hybrid Russe technique for the treatment of scaphoid nonunions with humpback deformity demonstrates a 95% union rate. This technique is effective, reproducible, and may serve as an alternative to techniques that include structural grafts from distant sites.

  View details for DOI 10.1177/1558944720911214

  View details for PubMedID 32188288

• Prevalence and Factors Associated With Low-Value Preoperative Testing for Patients Undergoing Carpal Tunnel Release at an Academic Medical Center. Hand (New York, N.Y.) Ding, Q., Trickey, A. W., Mudumbai, S., Kamal, R. N., Sears, E. D., Harris, A. H. 2020: 1558944720906498

  Abstract

  Background: Routine preoperative screening tests before low-risk surgery cannot be justified if the risks to patients are not outweighed by benefits. Several studies and professional guidelines suggest avoiding screening tests prior to minor operations. We aimed to assess the prevalence and patient characteristics associated with low-value preoperative tests (LVTs) prior to carpal tunnel release (CTR) at an academic medical center. Methods: From electronic medical records, we identified patients aged ≥18 who underwent CTR from 2015 to 2017. We determined the occurrence of 9 common LVTs, such as complete blood count (CBC), basic metabolic profile (BMP), and electrocardiogram (ECG), in the 30 days prior to CTR. Multivariable logistic and Poisson regression were used to identify factors associated with receiving any LVT and the number of LVTs, respectively. Results: Among 572 patients, 248 (43.4%) had at least 1 LVT. The most common tests were ECG (31.3% of CTRs), CBC (27.3% of CTRs), and BMP (23.6% of CTRs). Patient factors associated with higher odds of receiving LVT included older age, higher Elixhauser comorbidity score, and general or regional anesthesia (vs monitored anesthesia care). Conclusions: Low-value preoperative tests were frequently received by patients undergoing CTR and were associated with anesthesia type, age, and number of comorbidities. Although our study focused on CTR, these results likely have implications for other commonly performed low-risk procedures. These findings can help guide efforts to improve the quality and value of surgery for carpal tunnel syndrome and facilitate the development of strategies to reduce LVT, such as audit feedback and provider education.

  View details for DOI 10.1177/1558944720906498

  View details for PubMedID 32100568

• Deciding Without Data: Clinical Decision Making in Pediatric Orthopaedic Surgery. International journal for quality in health care : journal of the International Society for Quality in Health Care Nathan, K., Uzosike, M., Sanchez, U., Karius, A., Leyden, J., Nicole, S., Sara, E., Hastings, K. G., Kamal, R., Frick, S. 2020

  Abstract

  Objective.Identifying when and how often decisions are made based on high-quality evidence can inform the development of evidence-based treatment plans and care pathways, which have been shown to improve quality of care and patient safety. Evidence to guide decision making, national guidelines, and clinical pathways for many conditions in pediatric orthopaedic surgery are limited. This study investigated decision making rationale and quantified the evidence supporting decisions made by pediatric orthopaedic surgeons in an outpatient clinic.Design/Setting/Participants/Intervention(s)/Main Outcome Measure(s).We recorded decisions made by eight pediatric orthopaedic surgeons in an outpatient clinic and the surgeon's reported rationale behind the decisions. Surgeons categorized the rationale for each decision as one or a combination of 12 possibilities (e.g. "Experience/anecdote", "First Principles", "Trained to do it", "Arbitrary/Instinct", "General Study", "Specific Study").Results.Out of 1150 total decisions, the most frequent decisions were follow-up scheduling, followed by bracing prescription/removal. The most common decision rationales were "First principles" (N=310, 27.0%) and "Experience/anecdote" (N=253, 22.0%). Only 17.8% of decisions were attributed to scientific studies, with 7.3% based on studies specific to the decision. 34.6% of surgical intervention decisions were based on scientific studies, while only 10.4% of follow-up scheduling decisions were made with studies in mind. Decision category was significantly associated with a basis in scientific studies: surgical intervention and medication prescription decisions were more likely to be based on scientific studies than all other decisions.Conclusions.With increasing emphasis on high value, evidence-based care, understanding the rationale behind physician decision-making can educate physicians, identify common decisions without supporting evidence, and help create clinical care pathways in pediatric orthopaedic surgery. Decisions based on evidence or consensus between surgeons can inform pathways and national guidelines that minimize unwarranted variation in care and waste. Decision support tools & aids could also be implemented to guide these decisions.

  View details for DOI 10.1093/intqhc/mzaa119

  View details for PubMedID 32986101

• Health Policy in Hand Surgery: Evaluating What Works. Hand clinics Shapiro, L. M., Kamal, R. N. 2020; 36 (2): 263–70

  Abstract

  Health policy is a complex and fluid topic that addresses care delivery with the goal of improving patient care. Understanding health policy initiatives, their motivation, and their effects, can help ensure hand surgeons are prepared for the changing health care landscape.

  View details for DOI 10.1016/j.hcl.2020.01.009

  View details for PubMedID 32307057

• Testing proposed quality measures for treatment of carpal tunnel syndrome: feasibility, magnitude of quality gaps, and reliability. BMC health services research Harris, A. H., Meerwijk, E. L., Ding, Q., Trickey, A. W., Finlay, A. K., Schmidt, E. M., Curtin, C. M., Sears, E. D., Nuckols, T. K., Kamal, R. N. 2020; 20 (1): 861

  Abstract

  The American Academy of Orthopaedic Surgeons and American Society for Surgery of the Hand recently proposed three quality measures for carpal tunnel syndrome (CTS): Measure 1 - Discouraging routine use of Magnetic resonance imaging (MRI) for diagnosis of CTS; Measure 2 - Discouraging the use of adjunctive surgical procedures during carpal tunnel release (CTR); and Measure 3 - Discouraging the routine use of occupational and/or physical therapy after CTR. The goal of this study were to 1) Assess the feasibility of using the specifications to calculate the measures in real-world healthcare data and identify aspects of the specifications that might be clarified or improved; 2) Determine if the measures identify important variation in treatment quality that justifies expending resources for their further development and implementation; 3) Assess the facility- and surgeon-level reliability of measures.The measures were calculated using national data from the Veterans Health Administration (VA) Corporate Data Warehouse for three fiscal years (FY; 2016-18). Facility- and surgeon-level performance and reliability were examined. To expand the testing context, the measures were also tested using data from an academic medical center.The denominator of Measure 1 was 132,049 VA patients newly diagnosed with CTS. The denominators of Measures 2 and 3 were 20,813 CTRs received by VA patients. The median facility-level performances on the three measures were 96.5, 100, and 94.7%, respectively. Of 130 VA facilities, none had < 90% performance on Measure 1. Among 111 facilities that performed CTRs, only 1 facility had < 90% performance on Measure 2. In contrast, 21 facilities (18.9%) and 333 surgeons (17.8%) had lower than 90% performance on Measure 3 (Median facility- and surgeon-level reliability for Measure 3 were very high (0.95 and 0.96 respectively).Measure 3 displayed adequate facility- and surgeon-level variability and reliability to justify its use for quality monitoring and improvement purposes. Measures 1 and 2 lacked quality gaps, suggesting they should not be implemented in VA and need to be tested in other healthcare settings. Opportunities exist to refine the specifications of Measure 3 to ensure that different organizations calculate the measure in the same way.

  View details for DOI 10.1186/s12913-020-05704-6

  View details for PubMedID 32917188

• Decompression With or Without Fusion for Lumbar Stenosis: A Cost Minimization Analysis. Spine Ziino, C., Mertz, K., Hu, S., Kamal, R. 2020; 45 (5): 325–32

  Abstract

  Retrospective database review.Compare 1-year episode of care costs between single-level decompression and decompression plus fusion for lumbar stenosis.Lumbar stenosis is the most common indication for surgery in patients over 65. Medicare direct hospital costs for lumbar surgery reached $1.65 billion in 2007. Despite stenosis being a common indication for surgery, there is debate as to the preferred surgical treatment. Cost-minimization analysis is a framework that identifies potential cost savings between treatment options that have similar outcomes. We performed a cost-minimization analysis of decompression versus decompression with fusion for lumbar stenosis from the payer perspective.An administrative claims database of privately insured patients (Humana) identified patients who underwent decompression (n = 5349) or decompression with fusion (n = 8540) for lumbar stenosis with and without spondylolisthesis and compared overall costs. All patients were identified and costs identified for a 1-year period. Complication rates and costs were described using summary statistics.Mean treatment costs at 1 year after surgery were higher for patients who underwent decompression and fusion compared to patients who underwent decompression alone ($20,892 for fusion vs. $6329 for decompression; P < 0.001). Facility costs (P < 0.001), surgeon costs (P < 0.001), and physical therapy costs (P < 0.001) were higher in the fusion group. Cost differences related to infection or durotomy reached significance (P < 0.04). No difference in cost was identified for supplies.Decompression had significantly lower costs for the treatment of lumbar stenosis, including treatment for postoperative complications. If cost minimization is the primary goal, decompression is favored for surgical treatment of lumbar stenosis. Other factors including shared decision-making directed toward patient's values, patient-reported outcomes, and preferences should also be recognized as drivers of healthcare decisions.3.

  View details for DOI 10.1097/BRS.0000000000003250

  View details for PubMedID 32045402

• Development of a Needs Assessment Tool to Promote Capacity Building in Hand Surgery Outreach Trips: A Methodological Triangulation Approach. The Journal of hand surgery Shapiro, L. M., Park, M. O., Mariano, D. J., Kamal, R. N. 2020

  Abstract

  The surgical burden in low- and middle-income countries (LMIC) is immense. Despite the increase in resources invested in surgical outreach trips to LMIC, there is no consistent process for understanding the needs of the site and for preparing the necessary resources to deliver care. Given the importance and lack of a comprehensive and standardized needs assessment tool, we aimed to create a tool that assesses the needs and capacity of a site to inform site selection and expectations and improve quality of care.We used methodological triangulation, a technique that incorporates multiple and different types of data collection methods to study a phenomenon. We used 2 standardized World Health Organization (WHO) tools to develop a hand surgery-specific needs assessment tool. We then identified missing items and made refinements as a result of field testing at 2 facilities and qualitative analysis of semistructured interviews of hand surgeons with international outreach experience. Interviews were coded and analyzed using conductive content analysis. Key concepts explored included domains and subdomains pertaining to essential considerations prior to a hand surgery outreach trip.Current generic needs assessment tools do not capture all necessary domains and subdomains for a hand surgery outreach trip. The WHO tools provide a framework for reference and foundation; field testing and qualitative interviews identified hand surgery-specific items. We developed a tool (https://sustainableglobalsurgery.org/research%2Ftools) that includes 7 domains: (1) human resources; (2) physical resources; (3) procedures; (4) cultural and language barriers; (5) safety, quality, and access; (6) regulation and cost; and (7) knowledge transfer and teaching and associated subdomains relevant to hand surgery.A hand surgery-specific standardized needs assessment tool may ensure appropriate resources and personnel are deployed for outreach trips to improve site selection, expectation setting, and quality of care.A needs assessment tool is a standardized, comprehensive tool to assess the needs and capacity of a new site prior to hand surgery outreach trips to improve site selection, expectation setting, and delivery of high-quality, safe, and effective care in LMIC.

  View details for DOI 10.1016/j.jhsa.2020.04.014

  View details for PubMedID 32561162

• Maximization Personality, Disability and Symptoms of Psychosocial Disease in Hand Surgery Patients. Journal of surgical orthopaedic advances Gire, J., Alokozai, A., Sheikholeslami, N., Lindsay, S., Eppler, S. L., Kamal, R. N. 2020; 29 (2): 106–11

  Abstract

  There are different frameworks to describe how people make decisions. One framework, maximization, is an approach where individuals approach choices with a goal of finding the 'best' possible alternative. We sought to determine the relationship between maximization and patient reported disability in patients with hand problems. We performed a cross-sectional study of 119 patients who presented to a hand surgery clinic. Patients completed a questionnaire that included sociodemographics, QuickDASH, Decisional Conflict Scale, Pain Catastrophizing Scale, Patient Health Questionnaire, Health Anxiety Inventory and General Self-Efficacy. Maximization did not correlate with subjective disability in patients with hand problems. Depression, pain catastrophizing and a diagnosis of upper extremity fracture had the greatest independent association with disability.In patients presenting for an initial hand surgery consultation, maximization was not associated with variation in patient reported disability or symptoms of psychosocial disease. Alternative factors influencing patient decision-making and outcomes should be explored. (Journal of Surgical Orthopaedic Advances 29(2):106-111, 2020).

  View details for PubMedID 32584225

• A Cost-Effectiveness Analysis of Corticosteroid Injections and Open Surgical Release for Trigger Finger. The Journal of hand surgery Zhuang, T., Wong, S., Aoki, R., Zeng, E., Ku, S., Kamal, R. N. 2020

  Abstract

  To evaluate the cost-effectiveness of corticosteroid injection(s) versus open surgical release for the treatment of trigger finger.Using a US health care payer perspective, we created a decision tree model to estimate the costs and outcomes associated with 4 treatment strategies for trigger finger: offering up to 3 steroid injections before to surgery or immediate open surgical release. Costs were obtained from a large administrative claims database. We calculated expected quality-adjusted life-years for each treatment strategy, which were compared using incremental cost-effectiveness ratios. Separate analyses were performed for commercially insured and Medicare Advantage patients. We performed a probabilistic sensitivity analysis using 10,000 second-order Monte Carlo simulations that simultaneously sampled from the uncertainty distributions of all model inputs.Offering 3 steroid injections before surgery was the optimal strategy for both commercially insured and Medicare Advantage patients. The probabilistic sensitivity analysis showed that this strategy was cost-effective 67% and 59% of the time for commercially insured and Medicare Advantage patients, respectively. Our results were sensitive to the probability of injection site fat necrosis, success rate of steroid injections, time to symptom relief after a steroid injection, and cost of treatment. Immediate surgical release became cost-effective when the cost of surgery was below $902 or $853 for commercially insured and Medicare Advantage patients, respectively.Multiple treatment strategies exist for treating trigger finger, and our cost-effectiveness analysis helps define the relative value of different approaches. From a health care payer perspective, offering 3 steroid injections before surgery is a cost-effective strategy.Economic and Decision Analyses II.

  View details for DOI 10.1016/j.jhsa.2020.04.008

  View details for PubMedID 32471754

• Patient-Reported Outcome Measures (PROMs): Influence of Motor Tasks and Psychosocial Factors on FAAM Scores in Foot and Ankle Trauma Patients. The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons Schultz, B. J., Tanner, N., Shapiro, L. M., Segovia, N. A., Kamal, R. N., Bishop, J. A., Gardner, M. J. 2020

  Abstract

  Patient-reported outcome measures (PROMS) are being increasingly used as a quality of care metric. However, the validity and consistency of PROMS remain undefined. The study sought to determine whether Foot and Ankle Ability Measure (FAAM) scores improve after patients complete motor tasks evaluated on the survey and to examine the relationship between depression and self-efficacy and FAAM scores or change in scores. We conducted a prospective comparison study of adults with isolated foot, ankle, or distal tibia fractures treated operatively at level I trauma center. Twenty-seven patients completed the FAAM survey at the first clinic visit after being made weightbearing as tolerated (mean 3 months). Patients then completed 6 motor tasks queried on FAAM (standing, walking without shoes, squatting, stairs, up to toes), followed by a repeat FAAM and General Self-Efficacy scale (GSE) and Patient Health Questionnaire-2 (PHQ-2) instruments. FAAM scores before and after intervention; GSE and PHQ-2 scores compared with baseline FAAM and change in FAAM scores. Performing motor tasks significantly improved postintervention scores for squatting (P = .044) and coming up to toes (P = .012), the 2 most strenuous tasks. No difference was found for the remaining tasks. Higher depression ratings correlated with worse FAAM scores overall (P < .05). Higher self-efficacy ratings correlated with increase in FAAM Sports subscale postintervention (P = .020). FAAM scores are influenced by performing motor tasks. Self-reported depression influences baseline FAAM scores and self-efficacy may influence change in FAAM scores. Context and patient factors (modifiable and nonmodifiable) affect PROM implementation, with implications for clinical care, reimbursement models, and use of quality measure.

  View details for DOI 10.1053/j.jfas.2020.01.008

  View details for PubMedID 32173179

• The Relationship Between the Tensile and the Torsional Properties of the Native Scapholunate Ligament and Carpal Kinematics. The Journal of hand surgery Pang, E. Q., Douglass, N., Behn, A., Winterton, M., Rainbow, M. J., Kamal, R. N. 2019

  Abstract

  PURPOSE: The purpose of this exploratory study was to examine the relationship between the tensile and the torsional properties of the native scapholunate interosseous ligament (SLIL) and kinematics of the scaphoid and lunate of an intact wrist during passive radioulnar deviation.METHODS: Eight fresh-frozen cadaveric specimens were transected at the elbow joint and loaded into a custom jig. Kinematic data of the scaphoid and lunate were acquired in a simulated resting condition for 3 wrist positions-neutral, 10° radial deviation, and 30° ulnar deviation-using infrared-emitting rigid body trackers. The SLIL bone-ligament-bone complex was then resected and loaded on a materials testing machine. Specimens underwent cyclic torsional and tensile testing and SLIL tensile and torsional laxity were evaluated. Correlations between scaphoid and lunate rotations and SLIL tensile and torsional properties were determined using Pearson correlation coefficients.RESULTS: Ulnar deviation of both the scaphoid and the lunate were found to decrease as the laxity of SLIL in torsion increased. In addition, the ratio of lunate flexion-extension to radial-ulnar deviation was found to increase with increased SLIL torsional rotation.CONCLUSIONS: Our findings support the theory that there is a relationship between scapholunate kinematics and laxity at the level of the interosseous ligaments.CLINICAL RELEVANCE: Laxity and, specifically, the tensile and torsional properties of an individual's native SLIL should guide reconstruction using a graft material that more closely replicates the individual's native SLIL properties.

  View details for DOI 10.1016/j.jhsa.2019.10.024

  View details for PubMedID 31864824

• Patient Willingness to Pay for Faster Return to Work or Smaller Incisions. Hand (New York, N.Y.) Alokozai, A., Lindsay, S. E., Eppler, S. L., Fox, P. M., Ladd, A. L., Kamal, R. N. 2019: 1558944719890039

  Abstract

  Background: Value-based health care models such as bundled payments and accountable care organizations can penalize health systems and physicians for excess costs leading to low-value care. Health systems can minimize these extra costs by constraining diagnostic (eg, magnetic resonance imaging utilization) or treatment options with debatable necessity in the setting of clinical equipoise. Instead of restricting more expensive treatments, it is plausible that health systems could instead recoup the extra costs of these treatments by charging patients supplementary out-of-pocket charges (cost sharing). The primary aim of this exploratory study was to assess hand surgery patient willingness to pay supplementary out-of-pocket charges for a procedure that theoretically leads to an earlier return to work or smaller incisions when there are 2 procedures that lead to similar results (clinical equipoise). Methods: A total of 122 patients completed a questionnaire that included demographic information, a financial distress assessment, a series of scenarios asking patients the degree to which they are willing to pay extra for the procedure choice, as well as their perspective of how much insurers should be responsible for these additional costs. Results: Patients were willing to pay out-of-pocket to some degree for a procedure that leads to earlier return to work and smaller incision size when compared with a similar alternative procedure, but noted that insurers should bear a greater burden of costs. Approximately 10% of patients were willing to pay maximum amounts ($2500+) for earlier return to work (3, 7, and 14 days earlier) and smaller incision sizes of any length. Conclusions: Some patients may be willing to pay out-of-pocket and cost share for procedures that lead to earlier return to work and smaller incisions in the setting of clinical equipoise. As such, when developing and implementing alternative payment models, health systems could potentially offer services with debatable necessity in the setting of equipoise for a supplementary out-of-pocket charge.

  View details for DOI 10.1177/1558944719890039

  View details for PubMedID 31791156

• Physical and Occupational Therapy Use and Cost After Common Hand Procedures. The Journal of hand surgery Shah, R. F., Zhang, S., Li, K., Baker, L., Sox-Harris, A., Kamal, R. N. 2019

  Abstract

  PURPOSE: The use of routine physical therapy (PT) and occupational therapy (OT) after certain hand procedures, such as carpal tunnel release, remains controversial. The objective of this study was to evaluate baseline use, the change in use, variation in prescribing patterns by region, and costs for PT/OT after common hand procedures.METHODS: Outpatient administrative claims data from patients who underwent procedures for carpal tunnel syndrome, trigger finger, carpometacarpal arthritis, de Quervain tenosynovitis, wrist ganglion cyst, and distal radius fracture were abstracted from the Truven Health MarketScan database from 2007 to 2015. The incidence of therapy and total reimbursement of therapy per patient were collected for each procedure over a 90-day postoperative observational period. Trends in use of therapy over time were described with average compound annual growth rates (CAGRs), a way of quantifying average growth over a specified observation period. Variations in the incidence of PT/OT use across 4 census regions were assessed.RESULTS: The incidence of 90-day utilization of PT and OT after hand procedures was 14.0% and increased for all procedures during the observation period with an average CAGR of 8.3%. Cost per therapy visit was relatively stable when adjusted for inflation, with an average CAGR of 0.63%. Patients in the northeast had a significantly higher incidence of PT/OT use than those in the south and west for all procedures except carpometacarpal arthritis.CONCLUSIONS: Use of PT and OT has increased over time after common hand procedures. Geographical variation in the utilization rate of these services is substantial. Limiting unwarranted variation of care is a health policy strategy for increasing value of care.TYPE OF STUDY/LEVEL OF EVIDENCE: Outcomes Research II.

  View details for DOI 10.1016/j.jhsa.2019.09.008

  View details for PubMedID 31753716

• Performance Metrics in Hand Surgery: Turning a Blind Eye Will Cost You. The Journal of hand surgery Roe, A. K., Gil, J. A., Kamal, R. N. 2019

  Abstract

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

  View details for DOI 10.1016/j.jhsa.2019.09.011

  View details for PubMedID 31740263

• Clinical Care Redesign to Improve Value for Trigger Finger Release: A Before-and-After Quality Improvement Study. Hand (New York, N.Y.) Burn, M. B., Shapiro, L. M., Eppler, S. L., Behal, R., Kamal, R. N. 2019: 1558944719884661

  Abstract

  Background: Trigger finger release (TFR) is a commonly performed procedure. However, there is great variation in the setting, care pathway, anesthetic, and cost. We compared the institutional cost for isolated TFR before and after redesigning our clinical care pathway. Methods: Total direct cost to the health system (excluding the surgeon and anesthesiology costs) and time spent by the patient at the surgery center were collected for 1 hand surgeon's procedures at an ambulatory surgery center over a 3-year period. We implemented a redesigned pathway that altered phases of care and anesthetic use by transitioning from intravenous (IV) sedation to wide awake local anesthesia with no tourniquet. Cost data were reported as percentage change in the median and compared both pre- to post-implementation and with 2 control surgeons using the traditional pathway within the same center. Power analysis was based on prior work on a carpal tunnel pathway. Significance was defined by a P-value < .05. Results: Ten TFRs (90% local with IV sedation) and 44 TFRs (89% local alone) were performed pre- and post-implementation, respectively. From pre- to post-implementation, the study surgeon's total direct cost decreased by 18%, while the control surgeons decreased by 2%. Median time spent at the surgery center decreased by 41 minutes post-implementation with significantly shorter setup time in the operating room (OR), total time in the OR, and time spent in recovery prior to discharge. Conclusions: Redesigning the care pathway for TFR led to a decrease in institutional cost and patient time spent at the surgery center.

  View details for DOI 10.1177/1558944719884661

  View details for PubMedID 31690136

• Cost in Hand Surgery: The Patient Perspective JOURNAL OF HAND SURGERY-AMERICAN VOLUME Alokozai, A., Crijns, T. J., Janssen, S. J., Van der Gronde, B., Ring, D., Sox-Harris, A., Kamal, R. N. 2019; 44 (11)

  View details for DOI 10.1016/j.jhsa.2019.01.009

  View details for Web of Science ID 000493892500015

• Does Societal Cost Information Affect Patient Decision-Making in Carpal Tunnel Syndrome? A Randomized Controlled Trial. Hand (New York, N.Y.) Kortlever, J. T., Zhuang, T., Ring, D., Reichel, L. M., Vagner, G. A., Kamal, R. N. 2019: 1558944719873399

  Abstract

  Background: Despite studies demonstrating the effects of out-of-pocket costs on decision-making, the effect of societal cost information on patient decision-making is unknown. Given the considerable societal impact of cost of care for carpal tunnel syndrome (CTS), providing societal cost data to patients with CTS could affect decision-making and provide a strategy for reducing national health care costs. Therefore, we assessed the following hypotheses: (1) there is no difference in treatment choice (surgery vs no surgery) in a hypothetical case of mild CTS between patients randomized to receive societal cost information compared with those who did not receive this information; (2) there are no factors (eg, sex, experience with a previous diagnosis of CTS, or receiving societal cost information) independently associated with the choice for surgery; and (3) there is no difference in attitudes toward health care costs between patients choosing surgery and those who did not. Methods: In this randomized controlled trial using a hypothetical scenario, we prospectively enrolled 184 new and return patients with a nontraumatic upper extremity diagnosis. We recorded patient demographics, treatment choice in the hypothetical case of mild CTS, and their attitudes toward health care costs. Results: Treatment choice was not affected by receiving societal cost information. None of the demographic or illness factors assessed were independently associated with the choice for surgery. Patients declining surgery felt more strongly that doctors should consider their out-of-pocket costs when making recommendations. Conclusions: Providing societal cost information does not seem to affect decision-making and may not reduce the overall health care costs. For patients with CTS, health policy could nudge toward better resource utilization and finding the best care pathways for nonoperative and invasive treatments.

  View details for DOI 10.1177/1558944719873399

  View details for PubMedID 31517517

• The Usability and Feasibility of Conjoint Analysis to Elicit Preferences for DistalRadius Fractures in Patients 55Years andOlder. The Journal of hand surgery Shapiro, L. M., Eppler, S. L., Baker, L. C., Harris, A. S., Gardner, M. J., Kamal, R. N. 2019

  Abstract

  PURPOSE: Eliciting patient preferences is one part of the shared decision-making process-a process of decision making focused on the values and preferences of the patient. We evaluated the usability and feasibility of a point-of-care conjoint analysis tool for preference elicitation for shared decision making in the treatment of distal radius fractures in patients over the age of 55 years.METHODS: Twenty-seven patients 55 years of age or older with a displaced distal radius fracture were recruited from a hand and upper extremity clinic. A conjoint analysis tool was created describing the attributes of care (eg, return of grip strength) of surgical and nonsurgical treatment. This tool was administered to patients to determine their preferences for the treatment attributes when choosing between surgical and nonsurgical treatment. Patients completed a System Usability Scale (SUS) to evaluate usability, and time to complete the tool was measured to evaluate feasibility.RESULTS: Patients considered the conjoint analysis tool to be usable (SUS, 91.4; SD, 10.9). Mean time to complete the tool was 5.1 minutes (SD, 1.4 minutes). The most important attributes driving the decision for surgical treatment were return of grip strength at 1 year and time spent in a cast or brace. The most important attributes driving the decision for nonsurgical treatment were use of anesthesia during treatment and return of grip strength at 1 year.CONCLUSIONS: A point-of-care conjoint analysis tool for distal radius fractures in patients 55 years and older can be used to elicit patient preferences to inform the shared decision-making process. Further investigation evaluating the effect of preference elicitation on treatment choice, involvement in decision making, and patient-reported outcomes are needed.CLINICAL RELEVANCE: A conjoint analysis tool is a simple, structured process physicians can use during shared decision making to highlight trade-offs between treatment options and elicit patient preferences to inform treatment choices.

  View details for DOI 10.1016/j.jhsa.2019.07.010

  View details for PubMedID 31495523

• The Use of Preoperative Antibiotics in Elective Soft-Tissue Procedures in the Hand: A Critical Analysis Review. JBJS reviews Shapiro, L. M., Zhuang, T., Li, K., Kamal, R. N. 2019

  View details for DOI 10.2106/JBJS.RVW.18.00168

  View details for PubMedID 31436581

• Financial Distress Is Associated With Delay in Seeking Care for Hand Conditions. Hand (New York, N.Y.) Zhuang, T., Eppler, S. L., Shapiro, L. M., Roe, A. K., Yao, J., Kamal, R. N. 2019: 1558944719866889

  Abstract

  Background: As medical costs continue to rise, financial distress due to these costs has led to poorer health outcomes and patient cost-coping behavior. Here, we test the null hypothesis that financial distress is not associated with delay of seeking care for hand conditions. Methods: Eighty-seven new patients presenting to the hand clinic for nontraumatic conditions completed our study. Patients completed validated instruments for measuring financial distress, pain catastrophizing, and pain. Questions regarding delay of care were included. The primary outcome was self-reported delay of the current hand clinic visit. Results: Patients who experience high financial distress differed significantly from those who experience low financial distress with respect to age, race, annual household income, and employment status. Those experiencing high financial distress were more likely to report having delayed their visit to the hand clinic (57% vs 30%), higher pain catastrophizing scores (17.7 vs 7.6), and higher average pain in the preceding week (4.5 vs 2.3). After adjusting for age, sex, and pain, high financial distress (adjusted odds ratio [OR] = 4.90) and pain catastrophizing score (adjusted OR = 0.96) were found to be independent predictors of delay. Financial distress was highly associated with annual household income in a multivariable linear regression model. Conclusions: Patients with nontraumatic hand conditions who experience higher financial distress are more likely to delay their visit to the hand clinic. Within health care systems, identification of patients with high financial distress and targeted interventions (eg, social or financial services) may help prevent unnecessary delays in care.

  View details for DOI 10.1177/1558944719866889

  View details for PubMedID 31409138

• Deltoid Compartment Syndrome After Prolonged Lateral Decubitus Positioning: A Case Report. JBJS case connector Borenstein, T. R., Cohen, E., McDonnell, M., Kamal, R. N., Hayda, R. A. ; 5 (2): e45

  Abstract

  A thirty-six-year-old man fell off a ladder and sustained an open fracture of the distal end of the left humerus. He was taken to the operating room for irrigation, debridement, and fixation of the fracture and was placed in the right lateral decubitus position for over seven hours. He subsequently developed right deltoid compartment syndrome, necessitating emergency compartment release. One year later, he had limited function, with a Disabilities of the Arm, Shoulder and Hand score of 81.3 points.Deltoid compartment syndrome can occur from operative positioning, with poor long-term outcomes as a result. Expeditious surgery, additional padding, and repeat checks are necessary for at-risk patients.

  View details for PubMedID 29252699

• Differences in the Rotation Axes of the Scapholunate Joint During Flexion-Extension and Radial-Ulnar Deviation Motions. The Journal of hand surgery Best, G. M., Mack, Z. E., Pichora, D. R., Crisco, J. J., Kamal, R. N., Rainbow, M. J. 2019

  Abstract

  PURPOSE: To determine the location of the rotation axis between the scaphoid and the lunate (SL-axis) during wrist flexion-extension (FE) and radial-ulnar deviation (RUD).METHODS: An established and publicly available digital database of wrist bone anatomy and carpal kinematics of 30 healthy volunteers (15 males and 15 females) in up to 8 different positions was used to study the SL-axis. Using the combinations of positions from wrist FE and RUD, the helical axis of motion of the scaphoid relative to the lunate was calculated for each trial in an anatomical coordinate system embedded in the lunate. The differences in location and orientation between each individual axis and the average axis were used to quantify variation in axis orientation. Variation in the axis location was computed as the distance from the closest point on the rotation axis to the centroid of the lunate.RESULTS: The variation in axis orientation of the rotation axis for wrist FE and RUD were 84.3° and 83.5°, respectively. The mean distances of each rotation axis from the centroid of the lunate for FE and RUD were 5.7 ± 3.2 mm, and 5.0 ± 3.6 mm, respectively.CONCLUSIONS: Based on the evaluation of this dataset, we demonstrated that the rotation axis of the scaphoid relative to the lunate is highly variable across subjects and positions during both FE and RUD motions. The range of locations and variation in axis orientations in this data set of 30 wrists shows that there is very likely no single location for the SL-axis.CLINICAL RELEVANCE: Scapholunate interosseous ligament reconstruction methods focused on re-creating a standard SL-axis may not restore what is more likely to be a variable anatomical axis and normal kinematics of the scaphoid and lunate.

  View details for DOI 10.1016/j.jhsa.2019.05.001

  View details for PubMedID 31300230

• The Role of Patient Research in Patient Trust in Their Physician JOURNAL OF HAND SURGERY-AMERICAN VOLUME Lu, L. Y., Sheikholeslami, N., Alokozai, A., Eppler, S. L., Kamal, R. N. 2019; 44 (7): 617-+

  View details for DOI 10.1016/j.jhsa.2018.09.007

  View details for Web of Science ID 000473318800017

• Variability and Costs of Low-Value Preoperative Testing for Carpal Tunnel Release Surgery. Anesthesia and analgesia Harris, A. H., Meerwijk, E. L., Kamal, R. N., Sears, E. D., Hawn, M., Eisenberg, D., Finlay, A. K., Hagedorn, H., Mudumbai, S. 2019

  Abstract

  BACKGROUND: The American Society of Anesthesiologists (ASA) Choosing Wisely Top-5 list of activities to avoid includes "Don't obtain baseline laboratory studies in patients without significant systemic disease (ASA I or II) undergoing low-risk surgery - specifically complete blood count, basic or comprehensive metabolic panel, coagulation studies when blood loss (or fluid shifts) is/are expected to be minimal." Accordingly, we define low-value preoperative tests (LVTs) as those performed before minor surgery in patients without significant systemic disease. The objective of the current study was to examine the extent, variability, drivers, and costs of LVTs before carpal tunnel release (CTR) surgeries in the US Veterans Health Administration (VHA).METHODS: Using fiscal year (FY) 2015-2017 data derived from the VHA Corporate Data Warehouse (CDW), we determined the overall national and facility-level rates and associated costs of receiving any of 8 common LVTs in the 30 days before CTR in ASA physical status (PS) I-II patients. We also examined the patient, procedure, and facility factors associated with receiving ≥1 LVT with mixed-effects logistic regression and the number of tests received with mixed-effects negative binomial regression.RESULTS: From FY15-17, 10,000 ASA class I-II patients received a CTR by 699 surgeons in 125 VHA facilities. Overall, 47.0% of patients had a CTR that was preceded by ≥1 LVT, with substantial variability between facilities (range = 0%-100%; interquartile range = 36.3%), representing $339,717 in costs. Older age and female sex were associated with higher odds of receiving ≥1 LVT. Local versus other modes of anesthesia were associated with lower odds of receiving ≥1 LVT. Several facilities experienced large (>25%) increases or decreases from FY15 to FY17 in the proportion of patients receiving ≥1 LVT.CONCLUSIONS: Counter to guidance from the ASA, we found that almost half of CTRs performed on ASA class I-II VHA patients were preceded by ≥1 LVT. Although the total cost of these tests is relatively modest, CTR is just one of many low-risk procedures (eg, trigger finger release, cataract surgery) that may involve similar preoperative testing practices. These results will inform site selection for qualitative investigation of the drivers of low-value testing and the development of interventions to improve preoperative testing practice, especially in locations where rates of LVT are high.

  View details for DOI 10.1213/ANE.0000000000004291

  View details for PubMedID 31206428

• The Association of Financial Distress With Disability in Orthopaedic Surgery. The Journal of the American Academy of Orthopaedic Surgeons Mertz, K., Eppler, S. L., Thomas, K., Alokozai, A., Yao, J., Amanatullah, D. F., Chou, L., Wood, K. B., Safran, M., Steffner, R., Gardner, M., Kamal, R. N. 2019; 27 (11): e522–e528

  Abstract

  INTRODUCTION: Increased out-of-pocket costs have led to patients bearing more of the financial burden for their care. Previous work has shown that financial burden and distress can affect outcomes, symptoms, satisfaction, and adherence to treatment. We asked the following questions: (1) Does patients' financial distress correlate with disability in patients with nonacute orthopaedic conditions? (2) Do patient demographic factors affect this correlation?METHODS: We conducted a cross-sectional, observational study of new patients presenting to a multispecialty orthopaedic clinic with a nonacute orthopaedic complication. Patients completed a demographics questionnaire, the InCharge Financial Distress/Financial Well-Being Scale, and the Health Assessment Questionnaire Disability Index. Statistical analysis was done using Pearson's correlation.RESULTS: The mean score for financial distress was 4.10 (SD, 2.09; scale 1 [low distress] to 10 [high distress]; range, 1.13 to 10.0), and the mean disability score was 0.54 (SD, 0.65; scale 0 to 3; range, 0 to 2.75). A moderate positive correlation exists between financial distress and disability (r = 0.43; P < 0.01). Financial distress and disability were highest for poor, uneducated, Medicare patients.CONCLUSIONS: A moderate correlation exists between financial distress and disability in patients with nonacute orthopaedic conditions, particularly in patients with low socioeconomic status. Orthopaedic surgeons may benefit from identifying patients in financial distress and discussing the cost of treatment because of its association with disability and potentially inferior outcomes. Further investigation is needed to test whether decreasing financial distress decreases disability.LEVEL OF EVIDENCE: Level III prospective cohort.

  View details for DOI 10.5435/JAAOS-D-18-00252

  View details for PubMedID 31125323

• The Feasibility and Usability of a Ranking Tool to Elicit Patient Preferences for the Treatment of Trigger Finger JOURNAL OF HAND SURGERY-AMERICAN VOLUME Shapiro, L. M., Eppler, S. L., Kamal, R. N. 2019; 44 (6): 480-+

  View details for DOI 10.1016/j.jhsa.2019.01.005

  View details for Web of Science ID 000469438800006

• Can Patients Forecast Their Postoperative Disability and Pain? CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Alokozai, A., Eppler, S. L., Lu, L. Y., Sheikholeslami, N., Kamal, R. N. 2019; 477 (3): 635–43

  View details for DOI 10.1097/CORR.0000000000000627

  View details for Web of Science ID 000472558500028

• Can Patients Forecast Their Postoperative Disability and Pain? Clinical orthopaedics and related research Alokozai, A., Eppler, S. L., Lu, L. Y., Sheikholeslami, N., Kamal, R. N. 2019; 477 (3): 635–43

  Abstract

  BACKGROUND: Forecasting is a construct in which experiences and beliefs inform a projection of future outcomes. Current efforts to predict postoperative patient-reported outcome measures such as risk-stratifying models, focus on studying patient, surgeon, or facility variables without considering the mindset of the patient. There is no evidence assessing the association of a patient's forecasted postoperative disability with realized postoperative disability. Patient-forecasted disability could potentially be used as a tool to predict postoperative disability.QUESTIONS/PURPOSES: (1) Do patient-forecasted disability and pain correlate with patient-realized disability and pain after hand surgery? (2) What other factors are associated with patient ability to forecast disability and pain?METHODS: We completed a prospective, longitudinal study to assess the association between forecasted and realized postoperative pain and disability as a predictive tool. One hundred eighteen patients of one hand/upper extremity surgeon were recruited from November 2016 to February 2018. Inclusion criteria for the study were patients undergoing hand or upper extremity surgery, older than 18 years of age, and English fluency and literacy. We enrolled 118 patients; 32 patients (27%) dropped out as a result of incomplete postoperative questionnaires. The total number of patients eligible was not tracked. Eighty-six patients completed the preoperative and postoperative questionnaires. Exclusion criteria included patients unable to give informed consent, children, patients with dementia, and nonEnglish speakers. Before surgery, patients completed a questionnaire that asked them to forecast their upper extremity disability (DASH [the shortened Disabilities of the Arm, Shoulder and Hand] [QuickDASH]) and pain VAS (pain from 0 to 10) for 2 weeks after their procedure. The questionnaire also queried the following psychologic factors as explanatory variables, in addition to other demographic and socioeconomic variables: the General Self Efficacy Scale, the Pain Catastrophizing Scale, and the Patient Health Questionnaire Depression Scale. At the 2-week followup appointment, patients completed the QuickDASH and pain VAS to assess their realized disability and pain scores. Bivariate analysis was used to test the association of forecasted and realized disability and pain reporting Pearson correlation coefficients. Unpaired t-tests were performed to test the association of demographic variables (for example, men vs women) and the association of forecasted and realized disability and pain levels. One-way analysis of variance was used for variables with multiple groups (for example, annual salary and ethnicity). All p values < 0.05 were considered statistically significant.RESULTS: Forecasted postoperative disability was moderately correlated with realized postoperative disability (r = 0.59; p < 0.001). Forecasted pain was weakly correlated with realized postoperative pain (r = 0.28; p = 0.011). A total of 47% of patients (n = 40) were able to predict their disability score within the MCID of their realized disability score. Symptoms of depression also correlated with increased realized postoperative disability (r = 0.37; p < 0.001) and increased realized postoperative pain (r = 0.42; p < 0.001). Catastrophic thinking was correlated with increased realized postoperative pain (r = 0.31; p = 0.004). Patients with symptoms of depression realized greater pain postoperatively than what they forecasted preoperatively (r = -0.24; p = 0.028), but there was no association between symptoms of depression and patients' ability to forecast disability (r = 0.2; p = 0.058). Patient age was associated with a patient's ability to forecast disability (r = .27; p = 0.011). Catastrophic thinking, self-efficacy, and number of prior surgical procedures were not associated with a patient's ability to forecast their postoperative disability or pain.CONCLUSIONS: Patients undergoing hand surgery can moderately forecast their postoperative disability. Surgeons can use forecasted disability to identify patients who may experience greater disability compared with benchmarks, for example, forecast and experience high QuickDASH scores after surgery, and inform preoperative discussions and interventions focused on expectation management, resilience, and mindset.LEVEL OF EVIDENCE: Level III, prognostic study.

  View details for PubMedID 30762696

• Variation in Surgeons' Requests for General Anesthesia When Scheduling Carpal Tunnel Release. Hand (New York, N.Y.) Harris, A. H., Meerwijk, E. L., Kamal, R. N., Sears, E. D., Hawn, M., Eisenberg, D., Finlay, A. K., Hagedorn, H., Marshall, N., Mudumbai, S. C. 2019: 1558944719828006

  Abstract

  BACKGROUND: Carpal tunnel release (CTR) can be performed with a variety of anesthesia techniques. General anesthesia is associated with higher risk profile and increased resource utilization, suggesting it should not be routinely used for CTR. The purpose of this study was to examine the patient factors associated with surgeons' requests for general anesthesia for CTR and the frequency of routine use of general anesthesia by Veterans Health Administration (VHA) surgeons and facilities.METHODS: National VHA data for fiscal years 2015 and 2017 were used to identify patients receiving CTR. Mixed-effects logistic regression was used to evaluate patient, procedure, and surgeon factors associated with requests by the surgeon for general anesthesia versus other anesthesia techniques.RESULTS: In all, 18 145 patients underwent CTR performed by 780 surgeons in 113 VHA facilities. Overall, there were 2218 (12.2%) requests for general anesthesia. Although some patient (eg, older age, obesity), procedure (eg, open vs endoscopic), and surgeon (eg, higher volume) factors were associated with lower odds of requests for general anesthesia, there was substantial facility- and surgeon-level variability. The percentage of patients with general anesthesia requested ranged from 0% to 100% across surgeons. Three facilities and 28 surgeons who performed at least 5 CTRs requested general anesthesia for more than 75% of patients.CONCLUSIONS: Where CTR is performed and by whom appear to influence requests for general anesthesia more than patient factors in this study. Avoidance of routine use of general anesthesia for CTR should be considered in future clinical practice guidelines and quality measures.

  View details for PubMedID 30789047

• The Feasibility and Usability of a Ranking Tool to Elicit Patient Preferences for the Treatment of Trigger Finger. The Journal of hand surgery Shapiro, L. M., Eppler, S. L., Kamal, R. N. 2019

  Abstract

  PURPOSE: Shared decision making is an approach where physicians and patients collaborate to make decisions based on patient values. This requires eliciting patients' preferences for each treatment attribute before making decisions; a structured process for preference elicitation does not exist in hand surgery. We tested the feasibility and usability of a ranking tool to elicit patient preferences for the treatment of trigger finger. We hypothesized that the tool would be usable and feasible at the point of care.METHODS: Thirty patients with a trigger finger without prior treatment were recruited from a hand surgery clinic. A preference elicitation tool was created that presented 3 treatment options(surgical release, injection, and therapy and orthosis) and described attributes of each treatment extracted from literature review (eg, success rate, complications). We presented these attributes to patients using the tool and patients ranked the relative importance (preference)of these attributes to aid in their decision making. The System Usability Scale and tool completion time were used to evaluate usability and feasibility, respectively.RESULTS: The tool demonstrated excellent usability (System Usability Scale: 88.7). The mean completion time was 3.05 minutes. Five (16.7%) patients chose surgery, 20 (66.7%) chose an injection, and 5 (16.7%) chose therapy and orthosis. Patients ranked treatment success and cost as the most and least important attributes, respectively. Twenty-nine (96.7%) patients were very to extremely satisfied with the tool.CONCLUSIONS: A preference elicitation tool for patients to rank treatment attributes by relative importance is feasible and usable at the point of care. A structured process for preference elicitation ensures that patients understand the trade-offs between choices and can assist physicians in aligning treatment decisions with patient preferences.CLINICAL RELEVANCE: A ranking tool is a simple, structured process physicians can use to elicit preferences during shared decision making and highlight trade-offs between treatment options to inform treatment choices.

  View details for PubMedID 30797655

• Cost in Hand Surgery: The Patient Perspective. The Journal of hand surgery Alokozai, A., Crijns, T. J., Janssen, S. J., Van Der Gronde, B., Ring, D., Sox-Harris, A., Kamal, R. N. 2019

  Abstract

  PURPOSE: Rising costs at the patient level have been recognized and shown to directly influence patient decisions. By understanding patient interests in discussing cost, hand surgeons may better prepare themselves and their practices to communicate costs with patients.METHODS: We surveyed 128 patients at an upper extremity surgery clinic at their 2-week postoperative visit. Survey domains included basic patient demographics and an assessment of patient financial distress, along with questions that rated patient interest with patient-physician financial conversations. These factors included patients' desire for a conversation regarding cost, whether or not patients have discussed cost with their surgeon, barriers to these discussions, and overall views concerning cost containment in hand care.RESULTS: Seven percent of patients discussed the costs of their surgical care with their physician. Eleven percent of patients reported that a doctor should not discuss the costs of their surgical care. Forty-eight percent of patients reported that a doctor should initiate a conversation regarding costs of care when a new treatment is being considered. Fifty-nine percent of patients agreed that physicians should consider the amount of money a patient will have to pay when choosing a new treatment.CONCLUSIONS: Patients can experience financial hardship as a result of their surgery and some patients are interested in discussing costs with their doctor. Patients indicated that doctors should be concerned with lowering the costs of surgery and should initiate a conversation regarding costs of care when a new treatment is being considered.CLINICAL RELEVANCE: Patients are interested in a conversation regarding their cost of hand surgery care. Making cost data more transparent and available to physicians and patients may facilitatecommunication regarding cost of care.

  View details for PubMedID 30797657

• Team Approach: Management of Scapholunate Instability. JBJS reviews Kamal, R. N., Moore, W., Kakar, S. 2019

  View details for PubMedID 30724763

• Orthopaedic Trauma Quality Measures for Value-Based Health Care Delivery: A Systematic Review JOURNAL OF ORTHOPAEDIC TRAUMA DeBaun, M. R., Chen, M. J., Bishop, J. A., Gardner, M. J., Kamal, R. N. 2019; 33 (2): 104–10

  View details for DOI 10.1097/BOT.0000000000001372

  View details for Web of Science ID 000467804300017

• TEAM APPROACH: MANAGEMENT OF SCAPHOLUNATE INSTABILITY JBJS REVIEWS Kamal, R. N., Moore, W., Kakar, S. 2019; 7 (2)

  View details for DOI 10.2106/JBJS.RVW.18.00021

  View details for Web of Science ID 000466133300002

• Orthopaedic Trauma Quality Measures for Value Based Healthcare Delivery: A Systematic Review. Journal of orthopaedic trauma DeBaun, M. R., Chen, M. J., Bishop, J. A., Gardner, M. J., Kamal, R. N. 2019

  Abstract

  OBJECTIVES: To assess the current portfolio of quality measures and candidate quality measures that address orthopaedic trauma surgery.DATA SOURCES: We systematically reviewed the National Quality Forum, the Agency for Healthcare Research and Quality, and the Quality Payment Program for quality measures relevant to fracture surgery. We also searched MEDLINE/PubMed, Embase/Scopus, and Cochrane libraries.DATA EXTRACTION: Clinical practice guidelines were included as candidate quality measures if their development was in accordance with the Institute of Medicine criteria for development of clinical practice guidelines, were based on consistent clinical evidence including at least one Level I study, and carried the strongest possible recommendation by the developing body. We categorized the measures as structure, process, or outcome domains according to the framework described by Donabedian.DATA SYNTHESIS: From the 3809 articles initially identified and screened, a total of 189 combined quality or candidate quality measures were extracted from our review. With regard to the Donabedian framework, there were a total of 7% (13/189) structure, 52% process (99/189), and 41% (77/189) outcome measures identified.CONCLUSIONS: As quality measures progressively inform reimbursement in value based healthcare models, quality measures evaluating the care of patients sustaining a fracture will become increasingly relevant to orthopaedic trauma surgeons.

  View details for PubMedID 30624346

• Patient Preferences for Shared Decision Making: Not All Decisions Should Be Shared. The Journal of the American Academy of Orthopaedic Surgeons E Lindsay, S., Alokozai, A., Eppler, S. L., Fox, P., Curtin, C., Gardner, M., Avedian, R., Palanca, A., Abrams, G. D., Cheng, I., Kamal, R. N. 2019

  Abstract

  To assess bounds of shared decision making in orthopaedic surgery, we conducted an exploratory study to examine the extent to which patients want to be involved in decision making in the management of a musculoskeletal condition.One hundred fifteen patients at an orthopaedic surgery clinic were asked to rate preferred level of involvement in 25 common theoretical clinical decisions (passive [0], semipassive [1 to 4], equally shared involvement between patient and surgeon [5], semiactive [6 to 9], active [10]).Patients preferred semipassive roles in 92% of decisions assessed. Patients wanted to be most involved in scheduling surgical treatments (4.75 ± 2.65) and least involved in determining incision sizes (1.13 ± 1.98). No difference exists in desired decision-making responsibility between patients who had undergone orthopaedic surgery previously and those who had not. Younger and educated patients preferred more decision-making responsibility. Those with Medicare desired more passive roles.Despite the importance of shared decision making on delivering patient-centered care, our results suggest that patients do not prefer to share all decisions.

  View details for DOI 10.5435/JAAOS-D-19-00146

  View details for PubMedID 31567900

• Variability and Costs of Low-Value Preoperative Testing for Carpal Tunnel Release Surgery. Anesthesia and analgesia Harris, A. H., Meerwijk, E. L., Kamal, R. N., Sears, E. D., Hawn, M., Eisenberg, D., Finlay, A. K., Hagedorn, H., Mudumbai, S. 2019; 129 (3): 804–11

  Abstract

  The American Society of Anesthesiologists (ASA) Choosing Wisely Top-5 list of activities to avoid includes "Don't obtain baseline laboratory studies in patients without significant systemic disease (ASA I or II) undergoing low-risk surgery - specifically complete blood count, basic or comprehensive metabolic panel, coagulation studies when blood loss (or fluid shifts) is/are expected to be minimal." Accordingly, we define low-value preoperative tests (LVTs) as those performed before minor surgery in patients without significant systemic disease. The objective of the current study was to examine the extent, variability, drivers, and costs of LVTs before carpal tunnel release (CTR) surgeries in the US Veterans Health Administration (VHA).Using fiscal year (FY) 2015-2017 data derived from the VHA Corporate Data Warehouse (CDW), we determined the overall national and facility-level rates and associated costs of receiving any of 8 common LVTs in the 30 days before CTR in ASA physical status (PS) I-II patients. We also examined the patient, procedure, and facility factors associated with receiving ≥1 LVT with mixed-effects logistic regression and the number of tests received with mixed-effects negative binomial regression.From FY15-17, 10,000 ASA class I-II patients received a CTR by 699 surgeons in 125 VHA facilities. Overall, 47.0% of patients had a CTR that was preceded by ≥1 LVT, with substantial variability between facilities (range = 0%-100%; interquartile range = 36.3%), representing $339,717 in costs. Older age and female sex were associated with higher odds of receiving ≥1 LVT. Local versus other modes of anesthesia were associated with lower odds of receiving ≥1 LVT. Several facilities experienced large (>25%) increases or decreases from FY15 to FY17 in the proportion of patients receiving ≥1 LVT.Counter to guidance from the ASA, we found that almost half of CTRs performed on ASA class I-II VHA patients were preceded by ≥1 LVT. Although the total cost of these tests is relatively modest, CTR is just one of many low-risk procedures (eg, trigger finger release, cataract surgery) that may involve similar preoperative testing practices. These results will inform site selection for qualitative investigation of the drivers of low-value testing and the development of interventions to improve preoperative testing practice, especially in locations where rates of LVT are high.

  View details for DOI 10.1213/ANE.0000000000004291

  View details for PubMedID 31425223

• Is Elective Soft Tissue Hand Surgery Associated with Periprosthetic Joint Infection after Total Joint Arthroplasty? Clinical orthopaedics and related research Li, K., Jiang, S. Y., Burn, M. B., Kamal, R. N. 2019

  Abstract

  Although current guidelines do not recommend the routine use of surgical antibiotic prophylaxis to reduce the risk of surgical site infection following clean, soft tissue hand surgery, antibiotics are nevertheless often used in patients with an existing joint prosthesis to prevent periprosthetic joint infection (PJI), despite little data to support this practice.(1) Is clean, soft tissue hand surgery after THA or TKA associated with PJI risk? (2) Does surgical antibiotic prophylaxis before hand surgery decrease PJI risk in patients with recent THA or TKA?We assessed all patients who underwent THA or TKA between January 2007 and December 2015 by retrospective analysis of the IBM® MarketScan® Databases, which provide a longitudinal view of all healthcare services used by a nationwide sample of millions of patients under commercial and supplemental Medicare insurance coverage-particularly advantageous given the relatively low frequency of hand surgery after THA/TKA and of subsequent PJI. The initial search yielded 940,861 patients, from which 509,896 were excluded for not meeting continuous enrollment criteria, having a diagnosis of PJI before the observation period, or having another arthroplasty procedure before or during the observation period; the final study cohort consisted of 430,965 patients of which 147,398 underwent THA and 283,567 underwent TKA. In the treated cohort, 8489 patients underwent carpal tunnel release, trigger finger release, ganglion or retinacular cyst excision, de Quervain's release, or soft-tissue mass excision within 2 years of THA or TKA. The control cohort was comprised of 422,476 patients who underwent THA or TKA but did not have subsequent hand surgery. The primary outcome was diagnosis or surgical management of a PJI within 90 days of the index hand surgery for the treated cohort, or within a randomly assigned 90-day observation period for each patient in the control group. Propensity score matching was used to match treated and control cohorts by patient and treatment characteristics and previously-reported risk factors for PJI. Logistic regression before and after propensity score matching was used to assess the association of hand surgery with PJI risk and the association of surgical antibiotic prophylaxis before hand surgery with PJI risk in the treated cohort. Other possible PJI risk factors were also explored in multivariable logistic regression. Statistical significance was assessed at α = 0.01.Hand surgery was not associated with PJI risk after propensity score matching of treated and control cohorts (OR, 1.39; 99% CI, 0.60-3.22; p = 0.310). Among patients who underwent hand surgery after arthroplasty, surgical antibiotic prophylaxis before hand surgery was not associated with decreased PJI risk (OR 0.42; 99% CI, 0.03-6.08; p = 0.400).Clean, soft-tissue hand surgery was not found to be associated with PJI risk in patients who had undergone primary THA or TKA within 2 years before their hand procedure. While the effect of PJIs can be devastating, we do not find increased risk of infection with hand surgery nor data supporting routine use of surgical antibiotic prophylaxis in this setting.Level III, therapeutic study.

  View details for DOI 10.1097/CORR.0000000000000801

  View details for PubMedID 31389880

• National Trends in the Diagnosis of CRPS after Open and Endoscopic Carpal Tunnel Release. Journal of wrist surgery Mertz, K., Trunzter, J., Wu, E., Barnes, J., Eppler, S. L., Kamal, R. N. 2019; 8 (3): 209–14

  Abstract

  Background  Complex regional pain syndrome (CRPS) occurs in 2 to 8% of patients that receive open or endoscopic carpal tunnel release (CTR). Because CRPS is difficult to treat after onset, identifying risk factors can inform prevention. We determined the incidence of CRPS following open and endoscopic CTR using a national claims database. We also examined whether psychosocial conditions were associated with CRPS after CTR. Methods  We accessed insurance claims using diagnostic and procedural codes. We calculated the incidence of CRPS following open carpal tunnel release and endoscopic carpal tunnel release within 1 year. The response variable was the presence of CRPS after CTR. Explanatory variables included procedure type, age, gender, and preoperative diagnosis of anxiety or depression. Results  The number of open CTRs (85% of total) outweighs the number of endoscopic procedures. In younger patients, the percentage of endoscopic CTRs is increasing. Rates of CRPS are nearly identical between surgery types for both privately insured (0.3%) and Medicare patients (0.1%). Middle aged (range: 40-64 years) and female patients had significantly higher rates of CRPS than did the general population. Preoperative psychosocial conditions did not correlate with the presence of CRPS in surgical patients. Clinical Relevance  The decision between endoscopic and open CTR should not be made out of concern for development of CRPS postsurgery, as rates are low and similar for both procedures. Rates of CRPS found in this study are much lower than rates found in previous studies, indicating inconsistency in diagnosis and reporting or generalizability of prior work. Preoperative psychosocial disorders and CRPS are unrelated.

  View details for DOI 10.1055/s-0039-1678674

  View details for PubMedID 31192042

  View details for PubMedCentralID PMC6546494

• Can the QuickDASH PROM be Altered by First Completing the Tasks on the Instrument? Clinical orthopaedics and related research Shapiro, L. M., Harris, A. H., Eppler, S. L., Kamal, R. N. 2019

  Abstract

  Health systems and payers use patient-reported outcome measures (PROMs) to inform quality improvement and value-based payment models. Although it is known that psychosocial factors and priming influence PROMs, we sought to determine the effect of having patients complete functional tasks before completing the PROM questionnaire, which has not been extensively evaluated.(1) Will QuickDASH scores change after patients complete the tasks on the questionnaire compared with baseline QuickDASH scores? (2) Will the change in QuickDASH score in an intervention (task completion) group be different than that of a control group? (3) Will a higher proportion of patients in the intervention group than those in the control group improve their QuickDASH scores by greater than a minimally clinically important difference (MCID) of 14 points?During a 2-month period, 140 patients presented at our clinic with a hand or upper-extremity problem. We approached patients who spoke and read English and were 18 years old or older. One hundred thirty-two (94%) patients met the inclusion criteria and agreed to participate (mean ± SD age, 52 ± 17 years; 60 men [45%], 72 women [55%]; 112 in the intervention group [85%] and 20 in the control group [15%]). First, all patients who completed the QuickDASH PROM (at baseline) were recruited for participation. Intervention patients completed the functional tasks on the QuickDASH and completed a followup QuickDASH. Control patients were recruited and enrolled after the intervention group completed the study. Participants in the control group completed the QuickDASH at baseline and a followup QuickDASH 5 minutes after (the time required to complete the functional tasks). Paired and unpaired t-tests were used to evaluate the null hypotheses that (1) QuickDASH scores for the intervention group would not change after the tasks on the instrument were completed and (2) the change in QuickDASH score in the intervention group would not be different than that of the control group (p < 0.05). To evaluate the clinical importance of the change in score after tasks were completed, we recorded the number of patients with a change greater than an MCID of 14 points on the QuickDASH. Fisher's exact test was used to evaluate the difference between groups in those reaching an MCID of 14.In the intervention group, the QuickDASH score decreased after the intervention (39 ± 24 versus 25 ± 19; mean difference, -14 points [95% CI, 12 to 16]; p < 0.001). The change in QuickDASH scores was greater in the intervention group than that in the control group (-14 ± 11 versus -2 ± 9 [95% CI, -17 to -7]; p < 0.001). A larger proportion of patients in the intervention group than in the control group demonstrated an improvement in QuickDASH scores greater than the 14-point MCID ([43 of 112 [38%] versus two of 20 [10%]; odds ratio, 5.4 [95% CI, 1 to 24%]; p = 0.019).Reported disability can be reduced, thereby improving PROMs, if patients complete QuickDASH tasks before completing the questionnaire. Modifiable factors that influence PROM scores and the context in which scores are measured should be analyzed before PROMs are broadly implemented into reimbursement models and quality measures for orthopaedic surgery. Standardizing PROM administration can limit the influence of context, such as task completion, on outcome scores and should be used in value-based payment models.Level II, therapeutic study.

  View details for DOI 10.1097/CORR.0000000000000731

  View details for PubMedID 31107324

• Development and validation of a predictive model for American Society of Anesthesiologists Physical Status. BMC health services research Mudumbai, S. C., Pershing, S., Bowe, T., Kamal, R. N., Sears, E. D., Finlay, A. K., Eisenberg, D., Hawn, M. T., Weng, Y., Trickey, A. W., Mariano, E. R., Harris, A. H. 2019; 19 (1): 859

  Abstract

  The American Society of Anesthesiologists Physical Status (ASA-PS) classification system was developed to categorize the fitness of patients before surgery. Increasingly, the ASA-PS has been applied to other uses including justification of inpatient admission. Our objectives were to develop and cross-validate a statistical model for predicting ASA-PS; and 2) assess the concurrent and predictive validity of the model by assessing associations between model-derived ASA-PS, observed ASA-PS, and a diverse set of 30-day outcomes.Using the 2014 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Participant Use Data File, we developed and internally cross-validated multinomial regression models to predict ASA-PS using preoperative NSQIP data. Accuracy was assessed with C-Statistics and calibration plots. We assessed both concurrent and predictive validity of model-derived ASA-PS relative to observed ASA-PS and 30-day outcomes. To aid further research and use of the ASA-PS model, we implemented it into an online calculator.Of the 566,797 elective procedures in the final analytic dataset, 8.9% were ASA-PS 1, 48.9% were ASA-PS 2, 39.1% were ASA-PS 3, and 3.2% were ASA-PS 4. The accuracy of the 21-variable model to predict ASA-PS was C = 0.77 +/- 0.0025. The model-derived ASA-PS had stronger association with key indicators of preoperative status including comorbidities and higher BMI (concurrent validity) compared to observed ASA-PS, but less strong associations with postoperative complications (predictive validity). The online ASA-PS calculator may be accessed at https://s-spire-clintools.shinyapps.io/ASA_PS_Estimator/ CONCLUSIONS: Model-derived ASA-PS better tracked key indicators of preoperative status compared to observed ASA-PS. The ability to have an electronically derived measure of ASA-PS can potentially be useful in research, quality measurement, and clinical applications.

  View details for DOI 10.1186/s12913-019-4640-x

  View details for PubMedID 31752856

• Variations in Utilization of Carpal Tunnel Release Among Medicaid Beneficiaries. The Journal of hand surgery Zhuang, T., Eppler, S. L., Kamal, R. N. 2018

  Abstract

  PURPOSE: To evaluate the null hypothesis that Medicaid patients receive carpal tunnel release (CTR) at the same time interval from diagnosis as do patients with Medicare Advantage or private insurance.METHODS: We conducted a retrospective review using a database containing claims records from 2007 to 2016. The cohort consisted of patient records with a diagnosis code of carpal tunnel syndrome (CTS) and a procedural code for CTR within 3 years of diagnosis. We stratified patients into 3 groups by insurance type (Medicaid managed care, Medicare Advantage, and private) for an analysis of the time from diagnosis until surgery and use of preoperative electrodiagnostic testing.RESULTS: Of all patients who received CTR within 3 years of diagnosis, Medicaid patients experienced longer intervals from CTS diagnosis to CTR compared with Medicare Advantage and privately insured patients (median, 99 days vs 65 and 62 days, respectively). The Medicaid cohort was significantly less likely to receive CTR within 1 year of diagnosis compared with the Medicare Advantage cohort (adjusted odds ratio [OR]= 0.54) or within 6 months of diagnosis compared with the privately insured cohort (adjusted OR= 0.61). Those in the Medicaid cohort were less likely to receive electromyography and nerve conduction studies within 9 months before surgery compared with their Medicare Advantage (adjusted OR= 0.43) and privately insured (adjusted OR= 0.41) counterparts. These effects were statistically significant after accounting for age, sex, region, and Charlson comorbidity index.CONCLUSIONS: Medicaid managed care patients experience longer times from diagnosis to surgery compared with Medicare Advantage or privately insured patients in this large administrative claims database. Similar variation exists in the use of electrodiagnostic testing based on insurance type.CLINICAL RELEVANCE: Medicaid patients may experience barriers to CTS care, such as delays from diagnosis to surgery and reduced use of electrodiagnostic testing.

  View details for PubMedID 30579689

• Variation in Nonsurgical Services for Carpal Tunnel Syndrome Across a Large Integrated Health Care System. The Journal of hand surgery Sears, E. D., Meerwijk, E. L., Schmidt, E. M., Kerr, E. A., Chung, K. C., Kamal, R. N., Harris, A. H. 2018

  Abstract

  PURPOSE: To evaluate facility-level variation in the use of services for patients with carpal tunnel syndrome (CTS) receiving care in the Veterans Health Administration (VHA).METHODS: A national cohort of VHA patients diagnosed with CTS during fiscal year 2013 was divided into nonsurgical and operative treatment groups for comparison. We assessed the use of 5 types of CTS-related services (electrodiagnostic studies [EDS], imaging, steroid injection, oral steroids, and therapeutic modalities) in the prediagnosis and postdiagnosis periods before any operative intervention at the patient and facility levels.RESULTS: Among 72,599 patients newly diagnosed with CTS, 5,666 (7.8%) received carpal tunnel release within 12 months. The remaining 66,933 (92.2%) were in the nonsurgical group. Therapeutic modalities and EDS were the most commonly employed services after the index diagnosis and had large facility-level variation in use. At the facility level, the use of therapeutic modalities ranged from 0% to 93% in the operative group (mean, 32%) compared with 1% to 67% (mean, 30%) in the nonsurgical group. The use of EDS in the postdiagnosis period ranged from 0% to 100% (mean, 59%) in the operative treatment group and 0% to 55% (mean, 26%) in the nonsurgical group at the facility level.CONCLUSIONS: There is wide facility variation in the use of services for CTS among patients receiving operative and nonsurgical treatment. Care delivered by facilities with the highest and lowest rates of service use may suggest overuse and underuse, respectively, of nonsurgical CTS services and a lack of consideration of individual patient factors in making health care decisions regarding use.CLINICAL RELEVANCE: Surgeons must understand the degree of treatment variability for CTS, comprehend the ramifications of large variation in reimbursement and waste in the health care system, and become involved in devising strategies to optimize hand care across all phases of care.

  View details for PubMedID 30579690

• Clinical Care Redesign to Improve Value in Carpal Tunnel Syndrome: A Before-and-After Implementation Study. The Journal of hand surgery Kamal, R. N., Behal, R. 2018

  Abstract

  PURPOSE: Carpal tunnel surgery is one of the most common procedures completed on the upper limb in the United States. There is currently no evidence-based high-value clinical care pathway to inform the management of carpal tunnel syndrome (CTS). We created an evidence-based care pathway and implemented a quality improvement initiative to evaluate its effect on patient time, quality, and cost in a tertiary care ambulatory surgery center.METHODS: We developed a high-value clinical care pathway for CTS and implemented the intraoperative phase of the pathway. This included (1) implementing an evidence-based protocol for wide-awake local anesthesia, (2) removing non-value-added processes of care, and (3) implementing educational sessions with surgery staff regarding the initiative. We prospectively collected data on patient time, visual analog scale pain scores (quality), and percent change in total direct costs of the intraoperative phase of care (cost).RESULTS: A total of 50 patients were included in this implementation study: 30 prior to implementation of the intervention and 20 after. There was a significant decrease in average patient wheels in to surgery time, postanesthesia care unit to discharge time, and total patient time (lead time). There was no difference in preoperative or postoperative pain before and after the intervention. There was a 31% reduction in total direct costs.CONCLUSIONS: Implementing the intraoperative phase of this clinical care pathway with wide-awake surgery can reduce patient lead time, maintain quality, and reduce total direct costs in an ambulatory surgery center.CLINICAL RELEVANCE: Quality improvement interventions, such as the implementation of an evidence-based clinical care pathway for the treatment for CTS, may improve value to health systems.

  View details for PubMedID 30502930

• The Role of Patient Research in Patient Trust in Their Physician. The Journal of hand surgery Lu, L. Y., Sheikholeslami, N., Alokozai, A., Eppler, S. L., Kamal, R. N. 2018

  Abstract

  PURPOSE: Trust is foundational to the patient-physician relationship. However, there is limited information on the patient characteristics and behaviors that are related to patient trust. We investigated whether the time patients spend researching their physician and/or symptoms before a clinic visit was correlated with patient trust in their hand surgeon.METHODS: We conducted a prospective study of new patients (n= 134) who presented to a hand surgery clinic. We tested the null hypothesis that time spent researching the physician or symptom does not correlate with physician trust. Secondarily, we tested the association of a maximizing personality (a decision-making personality type defined as one who exhaustively searches for the "best option" as opposed to a "satisficer" who settles for the "good enough" decision) with time spent researching the hand surgeon and patient symptoms, general self-efficacy (one's ability tomanage adversity), and patient trust. Patients completed a questionnaire assessing demographics, patient researching behavior, general self-efficacy (GSE-6), maximizing personality(Maximization Short Form), and physician trust (Trust in Physician Form).RESULTS: The average age of our cohort was 50 ± 17 years, and men and women were equally represented. Patients spent more time researching their symptoms (median, 60 min; range, 5-1,201 min) than they did researching their physician (median, 20 min; range, 1-1,201 min). There was no correlation between time spent by patients seeking information on their hand surgeon and/or symptoms with patient trust in their physician. However, female patients were significantly more trusting of their physician than male patients.CONCLUSIONS: Most patients research their symptoms before clinic, whereas about half research their physicians before meeting them. Time spent seeking information before clinic was not correlated with patient trust in their physician. However, in our study, female patients were more likely to trust their hand surgeon than male patients. Thus, modifying physician behavior rather than patient characteristics may be a stronger driver of patient trust.TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

  View details for PubMedID 30366736

• Quality Measures in Foot and Ankle Care. The Journal of the American Academy of Orthopaedic Surgeons Xiong, G., Bennett, C. G., Chou, L., Kamal, R. N. 2018

  Abstract

  BACKGROUND: Quality measures may be operationalized in payment models or quality reporting programs to assess foot and ankle surgeons, but if existing measures allow accurate representation of a foot and ankle surgeon's practice is unclear.METHODS: National quality measures databases, clinical guidelines, and MEDLINE/PubMed were systematically reviewed for quality measures relevant to foot and ankle care. Measures meeting internal criteria were categorized by clinical diagnosis, National Quality Strategy priority, and Donabedian domain.RESULTS: Of 12 quality measures and 16 candidate measures, National Quality Strategy priorities most commonly addressed "Effective Clinical Care" (n = 19) and "Communication and Coordination of Care" (n = 6). Donabedian classifications addressed were process (n = 25) and outcome (n = 3). Diabetic foot care was most commonly addressed (n = 18).CONCLUSIONS: Available foot and ankle quality measures are limited in number and scope, which may hinder appropriate assessment of care, analysis of trends, and quality improvement. Additional measures are needed to support the transition to a value-based system.LEVEL OF EVIDENCE: Level I.

  View details for DOI 10.5435/JAAOS-D-17-00733

  View details for PubMedID 30325881

• Quality Measures in Total Hip and Total Knee Arthroplasty. The Journal of the American Academy of Orthopaedic Surgeons Amanatullah, D. F., McQuillan, T., Kamal, R. N. 2018

  Abstract

  INTRODUCTION: Total joint arthroplasty represents the largest expense for a single condition among Medicare beneficiaries. Payment models exist, such as bundled payments, where physicians and hospitals are reimbursed based on providing cost-efficient, high-quality care. There is a need to explicitly define "quality" relevant to hip and knee arthroplasty. Based on prior quality measure research, we hypothesized that less than 20% of developed quality measures are outcome measures.METHODS: This study systematically reviewed current and candidate quality measures relevant to total hip and knee arthroplasty using several quality measure databases and an Internet library search.RESULTS: We found a total of 35 quality measures and 81 candidate measures, most of which were process measures (N = 21, 60%), and represented the National Quality Strategy priorities of patient- and caregiver-centered experience and outcomes (31%), effective clinical care (28%), or patient safety (19%).CONCLUSION: Various stakeholders have developed quality measures in total joint arthroplasty, with increasing focus on developing outcome measures. The results of this review inform orthopaedic surgeons on quality measures that payers could use value-based payment models like the Merit-based Incentive Payment System and Comprehensive Care for Joint Replacement.LEVEL OF EVIDENCE: Level I, systematic review of level I evidence.

  View details for PubMedID 30303844

• Low Value Preoperative Testing for Carpal Tunnel Release in the Veterans Health Administration Sox-Harris, A., Meerwijk, E. L., Kamal, R. N., Sears, E., Finlay, A. K., Hawn, M. T., Eisenberg, D., Mudumbai, S. ELSEVIER SCIENCE INC. 2018: E32

  View details for DOI 10.1016/j.jamcollsurg.2018.08.084

  View details for Web of Science ID 000447772500070

• Defining Quality in Hand Surgery From the Patient'sPerspective: A Qualitative Analysis. The Journal of hand surgery Eppler, S. L., Kakar, S., Sheikholeslami, N., Sun, B., Pennell, H., Kamal, R. N. 2018

  Abstract

  PURPOSE: Quality measures are used to evaluate health care delivery. They are traditionally developed from the physician and health system viewpoint. This approach can lead to quality measures that promote care that may be misaligned with patient values and preferences. We completed an exploratory, qualitative study to identify how patients with hand problems define high-quality care. Our purpose was to develop a better understanding of the surgery and recovery experience of hand surgery patients, specifically focusing on knowledge gaps, experience, and the surgical process.METHODS: A steering committee (n= 10) of patients who had previously undergone hand surgery reviewed and revised an open-ended survey. Ninety-nine patients who had undergone hand surgery at 2 tertiary care institutions completed the open-ended, structured questionnaire during their 6- to 8-week postoperative clinic visit. Two reviewers completed a thematic analysis to generate subcodes and codes to identify themes in high-quality care from the patient's perspective.RESULTS: We identified 4 themes of high-quality care: (1) Being prepared and informed for the process of surgery, (2) Regaining hand function without pain or complication, (3) Patients and caregivers negotiating the physical and psychological challenges of recovery, and (4) Financial and logistical burdens of undergoing hand surgery.CONCLUSIONS: Multiple areas that patients identify as representing high-quality care are not reflected in current quality measures for hand surgery. The patient-derived themes of high-quality care can inform future patient-centered quality measure development.CLINICAL RELEVANCE: Efforts to improve health care delivery may have the greatest impact by addressing areas of care that are most valued by patients. Such areas include patient education, system navigation, the recovery process, and cost.

  View details for PubMedID 30031599

• Financial Distress and Discussing the Cost of Total Joint Arthroplasty. The Journal of arthroplasty Amanatullah, D. F., Murasko, M. J., Chona, D. V., Crijns, T. J., Ring, D., Kamal, R. N. 2018

  Abstract

  BACKGROUND: Total joint arthroplasty is expensive. Out-of-pocket cost to patients undergoing elective total joint arthroplasty varies considerably depending on their insurance coverage but can range into the tens of thousands of dollars. The goal of this study is to evaluate the association between patient financial stress and interest in discussing costs associated with surgery.METHODS: One hundred forty-one patients undergoing elective total hip and knee arthroplasty at a suburban academic medical center were enrolled and completed questionnaires about cost prior to surgery. Questions regarding if and when doctors should discuss the cost of healthcare with patients, evaluating if patients were affected by the cost of healthcare and to what extent, and financial security scores to assess current financial situation were included. The primary outcome was the answer to the question of whether a doctor should discuss cost with patients.RESULTS: Financial stress was found to be associated with patient experience of hardship due to cost of care [P= .004], likelihood to turn down a test or treatment due to copayment [P= .029], to decline a test or treatment due to other costs [P= .003], to experience difficulty affording basic necessities [P= .008], and to have used up all or most of their savings to pay for surgery [P= .011]. In total, 84% of patients reported that they wanted to discuss surgical costs with their doctors, but 90% did not want to do so at every visit.CONCLUSION: Total joint arthroplasty creates considerable out-of-pocket costs that may affect patient decisions. These findings help elucidate important patient concerns that orthopedic surgeons should account for when discussing elective arthroplasty with patients.

  View details for PubMedID 30057266

• Patient Perceptions Correlate Weakly With Observed Patient Involvement in Decision-making in Orthopaedic Surgery. Clinical orthopaedics and related research Mertz, K., Eppler, S., Yao, J., Amanatullah, D. F., Chou, L., Wood, K. B., Safran, M., Steffner, R., Gardner, M., Kamal, R. 2018

  Abstract

  BACKGROUND: Shared decision-making between patients and physicians involves educating the patient, providing options, eliciting patient preferences, and reaching agreement on a decision. There are different ways to measure shared decision-making, including patient involvement, but there is no consensus on the best approach. In other fields, there have been varying relationships between patient-perceived involvement and observed patient involvement in shared decision-making. The relationship between observed and patient-perceived patient involvement in decision-making has not been studied in orthopaedic surgery.QUESTIONS/PURPOSES: (1) Does patient-perceived involvement correlate with observed measurements of patient involvement in decision-making in orthopaedic surgery? (2) Are patient demographics associated with perceived and observed measurements of patient involvement in decision-making?METHODS: We performed a prospective, observational study to compare observed and perceived patient involvement in new patient consultations for eight orthopaedic surgeons in subspecialties including hand/upper extremity, total joint arthroplasty, spine, sports, trauma, foot and ankle, and tumor. We enrolled 117 English-literate patients 18 years or older over an enrollment period of 2 months. A member of the research team assessed observed patient involvement during a consultation with the Observing Patient Involvement in Decision-Making (OPTION) instrument (scaled 1-100 with higher scores representing greater involvement). After the consultation, we asked patients to complete a questionnaire with demographic information including age, sex, race, education, income, marital status, employment status, and injury type. Patients also completed the Perceived Involvement in Care Scale (PICS), which measures patient-perceived involvement (scaled 1-13 with higher scores representing greater involvement). Both instruments are validated in multiple studies in various specialties and the physicians were blinded to the instruments used. We assessed the correlation between observed and patient-perceived involvement as well as tested the association between patient demographics and patient involvement scores.RESULTS: There was weak correlation between observed involvement (OPTION) and patient-perceived involvement (PICS) (r = 0.37, p < 0.01) in decision-making (mean OPTION, 28.7, SD 7.7; mean PICS, 8.43, SD 2.3). We found a low degree of observed patient involvement despite a moderate to high degree of perceived involvement. No patient demographic factor had a significant association with patient involvement.CONCLUSIONS: Further work is needed to identify the best method for evaluating patient involvement in decision-making in the setting of discordance between observed and patient-perceived measurements. Knowing whether it is necessary for (1) actual observable patient involvement to occur; or (2) a patient to simply believe they are involved in their care can inform physicians on the best way to improve shared decision-making in their practice.LEVEL OF EVIDENCE: Level II, therapeutic study.

  View details for PubMedID 29965894

• Complication rates by surgeon type after open treatment of distal radius fractures. European journal of orthopaedic surgery & traumatology : orthopedie traumatologie Truntzer, J., Mertz, K., Eppler, S., Li, K., Gardner, M., Kamal, R. 2018

  Abstract

  BACKGROUND: In distal radius fracture repair, complications often lead to reoperation and increased cost. We examined the trends and complications in open reduction internal fixation of distal radius fractures across hand specialist and non-hand specialist surgeons.METHODS: We examined claims data from the Humana administrative claims database between 2007 and 2016. International Classification of Disease, 9th Edition and Current Procedural Terminology codes were searched related to distal radius fractures repaired by open reduction internal fixation. Patients were filtered based on initial treatment by a hand specialty or non-hand specialty surgeon. Complications were reported within 1year of surgical treatment in the following distinct categories: non-union, malunion, extensor/flexor tendon repair, CRPS, infection. Descriptive statistics were reported.RESULTS: Hand specialists accounted for 182 procedures compared with 7708 procedures by non-hand specialty orthopaedic or general surgeons. There was an increase in the total number of procedures performed by hand specialists across the years of study, with a higher percentage of intra-articular cases completed by hand specialists (80.7%) compared to non-hand specialists (70.1%). Overall, the complication rates of hand specialists (6.5%) were higher than that of non-specialists (4.7%).CONCLUSIONS: The results of this study demonstrate a small difference in overall complications for open reduction internal fixation of distal radius fractures by hand specialists in comparison to non-specialists despite treating a higher percentage of intra-articular fractures. Future work controlling for factors unaccounted for in claims-based analyses, such as fracture complexity, patient comorbidities, and surgeon factors are needed.TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

  View details for PubMedID 29922979

• Patients Should Define Value in Health Care: A Conceptual Framework. The Journal of hand surgery Kamal, R. N., Lindsay, S. E., Eppler, S. L. 2018

  Abstract

  The main tenet of value-based health care is delivering high-quality care that is centered on the patient, improving health, and minimizing cost. Collaborative decision-making frameworks have been developed to help facilitate delivering care based on patient preferences (patient-centered care). The current value-based health care model, however, focuses on improving population health and overlooks the individuality of patients and their preferences for care. We highlight the importance of eliciting patient preferences in collaborative decision making and describe a conceptual framework that incorporates individual patients' preferences when defining value.

  View details for PubMedID 29754755

• The Affordable Care Act Decreased the Proportion of Uninsured Patients in a Safety Net Orthopaedic Clinic CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Gil, J. A., Goodman, A. D., Kleiner, J., Kamal, R. N., Baker, L. C., Akelman, E. 2018; 476 (5): 925–31

  Abstract

  The Patient Protection and Affordable Care Act (ACA) was approved in 2010, substantially altering the economics of providing and receiving healthcare services in the United States. One of the primary goals of this legislation was to expand insurance coverage for under- and uninsured residents. Our objective was to examine the effect of the ACA on the insurance status of patients at a safety net clinic. Our institution houses a safety net clinic that provides the dominant majority of orthopaedic care for uninsured patients in our state. Therefore, our study allows us to accurately examine the magnitude of the effect on insurance status in safety net orthopaedic clinics.(1) Did the ACA result in a decrease in the number of uninsured patients at a safety net orthopaedic clinic that provides the dominant majority of orthopaedic care for the uninsured in the state? (2) Did the proportion of patients insured after passage of the ACA differ across age or demographic groups in one state?We retrospectively examined our longitudinally maintained adult orthopaedic surgery clinic database from January 2009 to March 2015 and collected visit and demographic data, including zip code income quartile. Based on the data published by the Rhode Island Department of Health, our clinic provides the dominant majority of orthopaedic care for uninsured patients in our state. Therefore, examination of the changes in the proportion of insurance status in our clinic allows us to assess the effect of the ACA on the state level. Univariate and multivariable logistic regression analyses were used to determine the relationship between demographic variables and insurance status. Adjusted odds ratios and 95% CIs were calculated for the proportion of uninsured visits. The proportion of uninsured visits before and after implementation of the ACA was evaluated with an interrupted time-series analysis. The reduction in the proportion of patients without insurance between demographic groups (ie, race, gender, language spoken, and income level) also was compared using an interrupted time-series design.There was a 36% absolute reduction (95% CI, 35%-38%; p < 0.001) in uninsured visits (73% relative reduction; 95% CI, 71%-75%; p < 0.001). There was an immediate 28% absolute reduction (95% CI, 21%-34%; p < 0.001) at the time of ACA implementation, which continued to decline thereafter. After controlling for potential confounding variables such as gender, race, age, and income level, we found that patients who were white, men, younger than 65 years, and seen after January 2014 were more likely to have insurance than patients of other races, women, older patients, and patients treated before January 2014.After the ACA was implemented, the proportion of patients with health insurance at our safety net adult orthopaedic surgery clinic increased substantially. The reduction in uninsured patients was not equal across genders, races, ages, and incomes. Future studies may benefit from identifying barriers to insurance acquisition in these subpopulations. The results of this study could affect orthopaedic practices in the United States by guiding policy decisions regarding health care.Level III, therapeutic study.

  View details for PubMedID 29672327

• The Sigmoid Notch View for Distal Radius Fractures. The Journal of hand surgery Kamal, R. N., Leversedge, F., Ruch, D. S., Mithani, S. K., Cotterell, I. H., Richard, M. J. 2018

  Abstract

  PURPOSE: This study defines the sigmoid notch view of the distal radius. Specifically, we tested the null hypothesis that there is no relationship between the subchondral stripe of bone seen on a sigmoid notch view of the distal radius and the articular surface of the sigmoid notch.METHODS: We used 44 wrist specimens for anatomic and fluoroscopic analysis. We measured the articular depth of the sigmoid notch from its deepest point and classified the shape of the sigmoid notch. We then placed a radiopaque marker at the nadir of the articular surface and quantified the fluoroscopic depth of the sigmoid notch. A sigmoid notch view, which was a tangential fluoroscopic view of the volar and dorsal lips of the sigmoid notch, was obtained. The relationship of the articular surface to the stripe of subchondral bone seen on this view, called the sigmoid stripe, was determined.RESULTS: Anatomic analysis revealed sigmoid notch types with proportions similar to those in previous descriptions. The marker for the articular surface was superimposed or just ulnar to the sigmoid stripe in all specimens. In flat face and ski slope notches, this was coincident with the volar and dorsal lips of the sigmoid notch. In C- and S-type notches, there was a measurable distance from the articular surface marker to the edges of the bone of the volar and dorsal lips of the sigmoid.CONCLUSIONS: The articular surface marker at the nadir of the sigmoid notch is always coincident or ulnar to the sigmoid stripe in the sigmoid notch view.CLINICAL RELEVANCE: Surgeons can use the sigmoid notch view as a reliable method to (1) evaluate the integrity of the articular surface, (2) ensure hardware is not placed in the distal radioulnar joint, and (3) guide placement of volar locking plates in the coronal plane.

  View details for PubMedID 29680335

• What Is the State of Quality Measurement in Spine Surgery? CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Bennett, C., Xiong, G., Hu, S., Wood, K., Kamal, R. N. 2018; 476 (4): 725–31

  Abstract

  Value-based healthcare models rely on quality measures to evaluate the efficacy of healthcare delivery and to identify areas for improvement. Quality measure research in other areas of health care has generally shown that there is a limited number of available quality measures and that those that exist disproportionately focus on processes as opposed to outcomes. The purpose of this study was to assess the current state of quality measures and candidate quality measures in spine surgery.(1) How many quality measures and candidate quality measures are currently available? (2) According to Donabedian domains and National Quality Strategy (NQS) priorities, what aspects or domains of care do the present quality measures and candidate quality measures represent?We systematically reviewed the National Quality Forum, the Agency for Healthcare Research and Quality, and the Physician Quality Reporting System for quality measures relevant to spine surgery. A systematic search for candidate quality measures was also performed using MEDLINE/PubMed and Embase as well as publications from the American Academy of Orthopaedic Surgeons, Congress of Neurological Surgeons, and the North American Spine Society. Clinical practice guidelines were included as candidate quality measures if their development was in accordance with Institute of Medicine criteria for the development of clinical practice guidelines, they were based on consistent clinical evidence including at least one Level I study, and they carried the strongest possible recommendation by the developing body. Quality measures and candidate quality measures were then pooled for analysis and categorized by clinical focus, NQS priority, and Donabedian domain. Our initial search yielded a total of 3940 articles, clinical practice guidelines, and quality measures, 74 of which met criteria for inclusion in this study.Of the 74 measures studied, 29 (39%) were quality measures and 45 (61%) were candidate quality measures. Fifty of 74 (68%) were specific to the care of the spine, and 24 of 74 (32%) were related to the general care of spine patients. The majority of the spine-specific measures were process measures (45 [90%]) and focused on the NQS priority of "Effective Clinical Care" (44 [88%]). The majority of the general care measures were also process measures (14 [58%]), the highest portion of which focused on the NQS priority of "Patient Safety" (10 [42%]).Given the large number of pathologies treated by spine surgeons, the limited number of available quality measures and candidate quality measures in spine surgery is inadequate to support the transition to a value-based care model. Additionally, current measures disproportionately focus on certain aspects or domains of care, which may hinder the ability to appropriately judge an episode of care, extract usable data, and improve quality. Physicians can steward the creation of meaningful quality measures by participating in clinical practice guideline development, assisting with the creation and submission of formal quality measures, and conducting the high-quality research on which effective guidelines and quality measures depend.

  View details for PubMedID 29480884

• Does Wrist Laxity Influence Three-Dimensional Carpal Bone Motion? JOURNAL OF BIOMECHANICAL ENGINEERING-TRANSACTIONS OF THE ASME Best, G. M., Zec, M. L., Pichora, D. R., Kamal, R. N., Rainbow, M. J. 2018; 140 (4)

  View details for DOI 10.1115/1.4038897

  View details for Web of Science ID 000426560800007

• Tensile and Torsional Structural Properties of the Native Scapholunate Ligament. The Journal of hand surgery Pang, E. Q., Douglass, N., Behn, A., Winterton, M., Rainbow, M. J., Kamal, R. N. 2018

  Abstract

  PURPOSE: The ideal material for reconstruction of the scapholunate interosseous ligament (SLIL) should replicate the mechanical properties of the native SLIL to recreate normal kinematics and prevent posttraumatic arthritis. The purpose of our study was to evaluate the cyclic torsional and tensile properties of the native SLIL and load to failure tensile properties of the dorsal SLIL.METHODS: The SLIL bone complex was resected from 10 fresh-frozen cadavers. The scaphoid and lunate were secured in polymethylmethacrylate and mounted on a test machine that incorporated an x-y stage and universal joint, which permitted translations perpendicular to the rotation/pull axis as well as nonaxial angulations. After a 1 N preload, specimens underwent cyclic torsional testing (±0.45 N m flexion/extension at 0.5 Hz) and tensile testing (1-50 N at 1 Hz) for 500 cycles. Lastly, the dorsal 10 mm of the SLIL was isolated and displaced at 10 mm/min until failure.RESULTS: During intact SLIL cyclic torsional testing, the neutral zone was 29.7° ± 6.6° and the range of rotation 46.6° ± 7.1°. Stiffness in flexion and extension were 0.11 ± 0.02 and 0.12 ± 0.02 N m/deg, respectively. During cyclic tensile testing, the engagement length was 0.2 ± 0.1 mm, the mean stiffness was 276 ± 67 N/mm, and the range of displacement was 0.4 ± 0.1 mm. The dorsal SLIL displayed a 0.3 ± 0.2 mm engagement length, 240 ± 65 N/mm stiffness, peak load of 270 ± 91 N, and displacement at peak load of 1.8 ± 0.3 mm.CONCLUSIONS: We report the torsional properties of the SLIL. Our novel test setup allows for free rotation and translation, which reduces out-of-plane force application. This may explain our observation of greater dorsal SLIL load to failure than previous reports.CLINICAL RELEVANCE: By matching the natural ligament with respect to its tensile and torsional properties, we believe that reconstructions will better restore the natural kinematics of the wrist and lead to improved outcomes. Future clinical studies should aim to investigate this further.

  View details for PubMedID 29459171

• Effectiveness of Preoperative Antibiotics in Preventing Surgical Site Infection After Common Soft Tissue Procedures of the Hand. Clinical orthopaedics and related research Li, K., Sambare, T. D., Jiang, S. Y., Shearer, E. J., Douglass, N. P., Kamal, R. N. 2018

  Abstract

  Antibiotic prophylaxis is a common but controversial practice for clean soft tissue procedures of the hand, such as carpal tunnel release or trigger finger release. Previous studies report no substantial reduction in the risk of surgical site infection (SSI) after antibiotic prophylaxis, yet are limited in power by low sample sizes and low overall rates of postoperative infection.Is there evidence that antibiotic prophylaxis decreases the risk of SSI after soft tissue hand surgery when using propensity score matching to control for potential confounding variables such as demographics, procedure type, medication use, existing comorbidities, and postoperative events?This retrospective analysis used the Truven Health MarketScan databases, large, multistate commercial insurance claims databases corresponding to inpatient and outpatient services and outpatient drug claims made between January 2007 and December 2014. The database includes records for patients enrolled in health insurance plans from self-insured employers and other private payers. Current Procedural Terminology codes were used to identify patients who underwent carpal tunnel release, trigger finger release, ganglion and retinacular cyst excision, de Quervain's release, or soft tissue mass excision, and to assign patients to one of two cohorts based on whether they had received preoperative antibiotic prophylaxis. We identified 943,741 patients, of whom 426,755 (45%) were excluded after meeting one or more exclusion criteria: 357,500 (38%) did not have 12 months of consecutive insurance enrollment before surgery or 1 month of enrollment after surgery; 60,693 (6%) had concomitant bony, implant, or incision and drainage or débridement procedures; and 94,141 (10%) did not have complete data. In all, our initial cohort consisted of 516,986 patients, among whom 58,201 (11%) received antibiotic prophylaxis. Propensity scores were calculated and used to create cohorts matched on potential risk factors for SSI, including age, procedure type, recent use of steroids and immunosuppressive agents, diabetes, HIV/AIDs, tobacco use, obesity, rheumatoid arthritis, alcohol abuse, malnutrition, history of prior SSI, and local procedure volume. Multivariable logistic regression before and after propensity score matching was used to test whether antibiotic prophylaxis was associated with a decrease in the risk of SSI within 30 days after surgery.After controlling for patient demographics, hand procedure type, medication use, existing comorbidities (eg, diabetes, HIV/AIDs, tobacco use, obesity), and postoperative events through propensity score matching, we found that the risk of postoperative SSI was no different between patients who had received antibiotic prophylaxis and those who had not (odds ratio, 1.03; 95% CI, 0.93-1.13; p = 0.585).Antibiotic prophylaxis for common soft tissue procedures of the hand is not associated with reduction in postoperative infection risk. While our analysis cannot account for factors that are not captured in the billing process, this study nevertheless provides strong evidence against unnecessary use of antibiotics before these procedures, especially given the difficulty of conducting a randomized prospective study with a sample size large enough to detect the effect of prophylaxis on the low baseline risk of infection.Level III, therapeutic study.

  View details for PubMedID 29432267

• Does Wrist Laxity Influence Three-Dimensional Carpal Bone Motion? Journal of biomechanical engineering Best, G. M., Zec, M. L., Pichora, D. R., Kamal, R. N., Rainbow, M. J. 2018; 140 (4)

  Abstract

  Previous two-dimensional (2D) studies have shown that there is a spectrum of carpal mechanics that varies between row-type motion and column-type motion as a function of wrist laxity. More recent three-dimensional (3D) studies have suggested instead that carpal bone motion is consistent across individuals. The purpose of this study was to use 3D methods to determine whether carpal kinematics differ between stiffer wrists and wrists with higher laxity. Wrist laxity was quantified using a goniometer in ten subjects by measuring passive wrist flexion-extension (FE) range of motion (ROM). In vivo kinematics of subjects' scaphoid and lunate with respect to the radius were computed from computed tomography (CT) volume images in wrist radial and ulnar deviation positions. Scaphoid and lunate motion was defined as "column-type" if the bones flexed and extended during wrist radial-ulnar deviation (RUD), and "row-type" if the bones radial-ulnar deviated during wrist RUD. We found that through wrist RUD, the scaphoid primarily flexed and extended, but the scaphoids of subjects with decreased laxity had a larger component of RUD (R2 = 0.48, P < 0.05). We also determined that the posture of the scaphoid in the neutral wrist position predicts wrist radial deviation (RD) ROM (R2 = 0.46, P < 0.05). These results suggest that ligament laxity plays a role in affecting carpal bone motion of the proximal row throughout radial and ulnar deviation motions; however, other factors such as bone position may also affect motion. By developing a better understanding of normal carpal kinematics and how they are affected, this will help physicians provide patient-specific approaches to different wrist pathologies.

  View details for PubMedID 29305609

• Treatment Trends in Older Adults With Midshaft Clavicle Fractures JOURNAL OF HAND SURGERY-AMERICAN VOLUME Pang, E., Zhang, S., Harris, A. S., Kamal, R. N. 2017; 42 (11): 875–82

  Abstract

  We present a retrospective administrative claims database review examining the effect of recent literature supporting surgical clavicle fixation in a primarily young male population, on the treatment of midshaft clavicle fractures in patients older than 65 years. We tested the null hypothesis that there is no change in trends in surgical fixation of midshaft clavicle fractures in patients older than 65 years. Secondary analysis examined overall trends and trends based on sex.Data from 2007 to 2012 were extracted using the Medicare Standard Analytic File and Humana administrative claim databases contained within the PearlDiver Patient Records Database. Patients with clavicle shaft fractures and their treatments were identified by International Classification of Disease, Ninth Revision, and Current Procedural Terminology codes. The primary response variable was the proportion of surgical to nonsurgical cases per year, and explanatory variables included age and sex. Data were analyzed using a trend in proportions test with significance set at P less than .05.A total of 32,929 patients with clavicle shaft fractures were identified. During the study period, the proportion of clavicle shaft fractures treated surgically in patients older than 65 years (2.4%-4.6%) and younger than 65 years (11.2%-16.4%) showed a significant increasing trend. When analyzed by both sex and age, there was also an increasing trend in the proportion of surgically treated males in the older than 65 years (3.3%-6.2%) and the younger than 65 years groups (10.9%-19.5%). Lastly, there was an increase in the proportion of surgically treated females older than 65 years (1.7%-3.4%) and younger than 65 years (12.1%-14.3%).Our analysis demonstrates an overall increase in the proportion of surgically treated clavicle shaft fractures, including in the male and female population older than 65 years. In the setting of an aging population, future research evaluating possible benefits of surgical intervention in this population is needed prior to adopting this practice pattern.II.

  View details for PubMedID 28844775

• Quality Measures in Orthopaedic Sports Medicine: A Systematic Review ARTHROSCOPY-THE JOURNAL OF ARTHROSCOPIC AND RELATED SURGERY Abrams, G. D., Greenberg, D. R., Dragoo, J. L., Safran, M. R., Kamal, R. N. 2017; 33 (10): 1896–1910

  Abstract

  To report the current quality measures that are applicable to orthopaedic sports medicine physicians.Six databases were searched with a customized search term to identify quality measures relevant to orthopaedic sports medicine surgeons: MEDLINE/PubMed, EMBASE, the National Quality Forum (NQF) Quality Positioning System (QPS), the Agency for Healthcare Research and Quality (AHRQ) National Quality Measures Clearinghouse (NQMC), the Physician Quality Reporting System (PQRS) database, and the American Academy of Orthopaedic Surgeons (AAOS) website. Results were screened by 2 Board-certified orthopaedic surgeons with fellowship training in sports medicine and dichotomized based on sports medicine-specific or general orthopaedic (nonarthroplasty) categories. Hip and knee arthroplasty measures were excluded. Included quality measures were further categorized based on Donabedian's domains and the Center for Medicare and Medicaid (CMS) National Quality Strategy priorities.A total of 1,292 quality measures were screened and 66 unique quality measures were included. A total of 47 were sports medicine-specific and 19 related to the general practice of orthopaedics for a fellowship-trained sports medicine specialist. Nineteen (29%) quality measures were collected within PQRS, with 5 of them relating to sports medicine and 14 relating to general orthopaedics. AAOS Clinical Practice Guidelines (CPGs) comprised 40 (60%) of the included measures and were all within sports medicine. Five (8%) additional measures were collected within AHRQ and 2 (3%) within NQF. Most quality measures consist of process rather than outcome or structural measures. No measures addressing concussions were identified.There are many existing quality measures relating to the practice of orthopaedic sports medicine. Most quality measures are process measures described within PQRS or AAOS CPGs.Knowledge of quality measures are important as they may be used to improve care, are increasingly being used to determine physician reimbursement, and can inform future quality measure development efforts.

  View details for PubMedID 28655476

• Volar Capsular Release After Distal RadiusFractures. The Journal of hand surgery Kamal, R. N., Ruch, D. S. 2017

  Abstract

  PURPOSE: Loss of full wrist range of motion is common after treatment of distal radius fractures. Loss of wrist extension limiting functional activities, although uncommon, can occur after volar plating of distal radius fractures. Unlike other joints in which capsular release is a common form of treatment for stiffness, this has been approached with caution in the wrist owing to concerns for carpal instability. We tested the null hypothesis that hardware removal and open volar capsular release would not lead to improved upper extremity-specific patient-reported outcome (Disabilities of the Arm, Shoulder, and Hand [DASH] questionnaire).METHODS: We conducted a retrospective chart review of patients who underwent a tenolysis of the flexor carpi radialis tendon, removal of hardware, and subperiosteal release of the volar capsule (extrinsic ligaments). The primary outcome measure was patient-reported outcome on the DASH. Secondary outcomes included wrist flexion, extension, pronation, and supination, visual analog scale for pain, and radiographs/fluoroscopy for ulnocarpal translocation.RESULTS: Eleven patients were treated with a mean follow-up of 4.5 years. Mean DASH scores improved after surgery. Mean wrist flexion, wrist extension, pronation, and supination improved after surgery. Mean visual analog scale scores did not change. The radiocarpal relationship on radiographs/fluoroscopy was normal.CONCLUSIONS: Open volar capsular release to regain wrist extension after treatment of distal radius fractures with volar locking plates is safe and effective. Patients regain wrist extension in addition to improved DASH scores. There were no radiographic/fluoroscopic or clinical signs of ulnocarpal translocation after release of the volar extrinsic ligaments.TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

  View details for PubMedID 28917548

• Cost Minimization Analysis of Ganglion Cyst Excision. The Journal of hand surgery Pang, E. Q., Zhang, S., Harris, A. H., Kamal, R. N. 2017; 42 (9)

  Abstract

  PURPOSE: Cost minimization analysis can be employed to determine the least costly option when multiple treatments lead to equivalent outcomes. We present a cost minimization analysis from the payers' perspective, of the direct per patient cost of arthroscopic versus open ganglion cyst excision. We tested the null hypothesis that there is no difference in cost between the 2 procedures from the payer perspective.METHODS: We utilized data from a private payer administrative claims database comprising 16 million individuals from 2007 to 2015. Using Current Procedural Terminology codes to identify open and arthroscopic ganglion excisions, we extracted demographic data and fees paid to providers and facilities for the procedure.RESULTS: We identified 5,119 patients undergoing open ganglion cyst excision and 20 patients undergoing arthroscopic ganglion excision. The average cost of an open excision was significantly lower than an arthroscopic excision ($1,821 vs $3,668).CONCLUSIONS: Surgical costs from arthroscopic ganglion excision are significantly more thanopen excision. This data can inform health systems participating in value-based models.TYPE OF STUDY/LEVEL OF EVIDENCE: Economic and Decision Analysis IV.

  View details for PubMedID 28606435

• PERIOPERATIVE SMOKING CESSATION AND CLINICAL CARE PATHWAY FOR ORTHOPAEDIC SURGERY JBJS REVIEWS Truntzer, J., Comer, G., Kendra, M., Johnson, J., Behal, R., Kamal, R. N. 2017; 5 (8): e11

  View details for PubMedID 28832347

• Evidence-Based Medicine: Surgical Management of Flexor Tendon Lacerations PLASTIC AND RECONSTRUCTIVE SURGERY Kamal, R. N., Yao, J. 2017; 140 (1): 130E–139E

  Abstract

  After reading this article, the participant should be able to: 1. Accurately diagnose a flexor tendon injury. 2. Develop a surgical approach with regard to timing, tendon repair technique, and rehabilitation protocol. 3. List the potential complications following tendon repair.Flexor tendon lacerations are complex injuries that require a thorough history and physical examination for accurate diagnosis and management. Knowledge of operative approaches and potential concomitant injuries allows the surgeon to be prepared for various findings during exploration. Understanding the biomechanical principles behind tendon lacerations and repair techniques aids the surgeon in selecting the optimal repair technique and postoperative rehabilitation.

  View details for PubMedID 28654614

• Cost-minimization Analysis of the Management of Acute Achilles Tendon Rupture. journal of the American Academy of Orthopaedic Surgeons Truntzer, J. N., Triana, B., Harris, A. H., Baker, L., Chou, L., Kamal, R. N. 2017; 25 (6): 449-457

  Abstract

  Outcomes of nonsurgical management of acute Achilles tendon rupture have been demonstrated to be noninferior to those of surgical management. We performed a cost-minimization analysis of surgical and nonsurgical management of acute Achilles tendon rupture.We used a claims database to identify patients who underwent surgical (n = 1,979) and nonsurgical (n = 3,065) management of acute Achilles tendon rupture and compared overall costs of treatment (surgical procedure, follow-up care, physical therapy, and management of complications). Complication rates were also calculated. Patients were followed for 1 year after injury.Average treatment costs in the year after initial diagnosis were higher for patients who underwent initial surgical treatment than for patients who underwent nonsurgical treatment ($4,292 for surgical treatment versus $2,432 for nonsurgical treatment; P < 0.001). However, surgical treatment required fewer office visits (4.52 versus 10.98; P < 0.001) and less spending on physical therapy ($595 versus $928; P < 0.001). Rates of rerupture requiring subsequent treatment (2.1% versus 2.4%; P = 0.34) and additional costs ($2,950 versus $2,515; P = 0.34) were not significantly different regardless whether initial treatment was surgical or nonsurgical. In both cohorts, management of complications contributed to approximately 5% of the total cost.From the payer's perspective, the overall costs of nonsurgical management of acute Achilles tendon rupture were significantly lower than the overall costs of surgical management.III, Economic Decision Analysis.

  View details for DOI 10.5435/JAAOS-D-16-00553

  View details for PubMedID 28459710

• Quality Measures in Breast Reconstruction: A Systematic Review. Annals of plastic surgery Nazerali, R. N., Finnegan, M. A., Divi, V., Lee, G. K., Kamal, R. N. 2017

  Abstract

  The importance of providing quality care over quantity of care, and its positive effects on health care expenditure and health, has motivated a transition toward value-based payments. The Centers for Medicare and Medicaid Services and private payers are establishing programs linking financial incentives and penalties to adherence to quality measures. As payment models based on quality measures are transitioned into practice, it is beneficial to identify current quality measures that address breast reconstruction surgery as well as understand gaps to inform future quality measure development.We performed a systematic review of quality measures for breast reconstruction surgery by searching quality measure databases, professional society clinical practice guidelines, and the literature. Measures were categorized as structure, process, or outcome according to the Donabedian domains of quality.We identified a total of 27 measures applicable to breast reconstruction: 5 candidate quality measures specifically for breast reconstruction surgery and 22 quality measures that relate broadly to surgery. Of the breast reconstruction candidate measures, 3 addressed processes and 2 addressed outcomes. Seventeen of the general quality measures were process measures and 5 were outcome measures. We did not identify any structural measures.Currently, an overrepresentation of process measures exists, which addresses breast reconstruction surgery. There is a limited number of candidate measures that specifically address breast reconstruction. Quality measure development efforts on underrepresented domains, such as structure and outcome, and stewarding the measure development process for candidate quality measures can ensure breast reconstruction surgery is appropriately evaluated in value-based payment models.

  View details for DOI 10.1097/SAP.0000000000001088

  View details for PubMedID 28570449

• Association of Lunate Morphology With Carpal Instability in Scapholunate Ligament Injury. Hand (New York, N.Y.) Pang, E. Q., Douglass, N., Kamal, R. N. 2017: 1558944717709073-?

  Abstract

  We examined the relationship between lunate morphology (type 1 without a medial facet; type II with a medial facet) and dorsal intercalated segmental instability (DISI) in patients with scapholunate ligament injuries. We tested the primary null hypothesis that there is no relationship between lunate morphology and development of DISI. Secondary analysis compared the agreement of classifying lunate morphology based on the presence of a medial lunate facet, capitate-to-triquetrum (CT) distance, and magnetic resonance imaging (MRI).We performed a retrospective chart review of patients with known scapholunate ligament injuries from 2001 to 2016. Posterior-anterior radiographs and MRI, when available, were evaluated. CT distances were measured as a secondary classification method. DISI and scapholunate instability were determined as radiolunate angle >15° and scapholunate angle >60°, respectively. Differences between groups were determined using chi-square analysis with significance set at P < .05. Agreement between plain radiographs, MRI, and CT distance was calculated using the kappa statistic.Our search found 58 of 417 patients who met inclusion criteria; 41 of 58 had type II and 17 of 58 had type I lunates. There was no significant difference between groups in regard to DISI or scapholunate instability. Subanalysis using MRI alone or correcting any discrepancy between plain film and MRI classification, using MRI as the standard, found no difference between groups in regard to DISI or scapholunate instability.In patients with scapholunate ligament injuries, there are no differences in the development of DISI or scapholunate instability between patients with type I and type II lunates.

  View details for DOI 10.1177/1558944717709073

  View details for PubMedID 28525962

• Impact of Health Literacy on Time Spent Seeking Hand Care. Hand (New York, N.Y.) Alokozai, A., Bernstein, D. N., Sheikholeslami, N., Uhler, L., Ring, D., Kamal, R. N. 2017: 1558944717708027-?

  Abstract

  Patients with limited health literacy may have less knowledge and fewer resources for efficient access and navigation of the health care system. We tested the null hypothesis that there is no correlation between health literacy and total time spent seeking hand surgery care.New patients visiting a hand surgery clinic at a suburban academic medical center were asked to complete a questionnaire to determine demographics, total time spent seeking hand surgery care, and outcomes. A total of 112 patients were included in this study.We found health literacy levels did not correlate with total time seeking hand surgery care or from booking an appointment to being evaluated in clinic.In this suburban academic medical center, patients with low health literacy do not spend more time seeking hand surgery care and do have longer delays between seeking and receiving care. The finding that-at least in this setting-health literacy does not impact patient time seeking hand care suggests that resources to improve health disparities can be focused elsewhere in the care continuum.

  View details for DOI 10.1177/1558944717708027

  View details for PubMedID 28513193

• Simple Assessment of Global Bone Density and Osteoporosis Screening Using Standard Radiographs of the Hand. journal of hand surgery Schreiber, J. J., Kamal, R. N., Yao, J. 2017

  Abstract

  Osteoporosis and fragility fractures have consequences both at the individual level and to the overall health care system. Although dual-energy x-ray absorptiometry (DXA) is the reference standard for assessing bone mineral density (BMD), other, simpler tools may be able to screen bone quality provisionally and signal the need for intervention. We hypothesized that the second metacarpal cortical percentage (2MCP) calculated from standard radiographs of the hand or wrist would correlate with hip BMD derived from DXA and could provide a simple screening tool for osteoporosis.Two hundred patients who had hand or wrist radiographs and hip DXA scans within 1 year of each other were included in this series. Mid-diaphyseal 2MCP was calculated as the ratio of the cortical diameter to the total diameter. We assessed the correlation between 2MCP and total hip BMD. Subjects were stratified into normal, osteopenic, and osteoporotic cohorts based on hip t scores, and thresholds were identified to optimize screening sensitivity and specificity.Second metacarpal cortical percentage correlated significantly with BMD and t scores from the hip. A 2MCP threshold of less than 60% optimized sensitivity (88%) and specificity (60%) for discerning osteopenic subjects from normal subjects, whereas a threshold of less than 50% optimized sensitivity (100%) and specificity (91%) for differentiating osteoporotic from normal subjects.By demonstrating that global BMD may be assessed from 2MCP, these data suggest that radiographs of the hand and wrist may have a role in accurately screening for osteopenia and osteoporosis. This simple investigation, which is already used ubiquitously for patients with hand or wrist problems, may identify patients at risk for fragility fractures and allow for appropriate referral or treatment.Diagnostic II.

  View details for DOI 10.1016/j.jhsa.2017.01.012

  View details for PubMedID 28242242

• High Survivorship and Few Complications With Cementless Total Wrist Arthroplasty at a Mean Followup of 9 Years. Clinical orthopaedics and related research Gil, J. A., Kamal, R. N., Cone, E., Weiss, A. C. 2017; 475 (12): 3082–87

  Abstract

  Total wrist arthroplasty (TWA) has been described as traditionally being performed with fixation in the radius and carpus with cement. The TWA implant used in our series has been associated with promising results in studies with up to 6 years followup; however, studies evaluating survivorship, pain, and function with this implant are limited. QUESTION/PURPOSE: (1) To report ROM and pain scores after wrist reconstruction with cementless fourth-generation TWA at a mean followup of 9 years (range, 4.8-14.7 years). (2) To report complications of a cementless fourth-generation TWA and the cumulative probability of not undergoing a revision at a mean followup of 9 years.This is a retrospective case series of 69 patients who were treated for pancarpal wrist arthritis between 2002 and 2014. Of those, 31 had inflammatory arthritis (rheumatoid arthritis [n = 29], juvenile rheumatoid arthritis [n = 1], and psoriatic arthritis [n = 1]); all of these patients received TWA with the cementless implant studied in this investigation. Another 38 patients had osteoarthritis or posttraumatic arthritis; in this subgroup, 28 patients were 65 years or younger, and all underwent wrist fusion (none were offered TWA). Ten patients with osteoarthritis were older than 65 years and all were offered TWA; of those, eight underwent TWA, and two declined the procedure and instead preferred and underwent total wrist arthrodesis. The mean age of the 39 patients who had TWA was 56 ± 8.9 years (range, 31-78 years) at the time of surgery; 36 were women and three were men. The patients who underwent TWA were seen at a minimum of 4 years (mean, 9 years; range, 4-15 years), and all had been examined in 2016 as part of this study except for one patient who died 9 years after surgery. The dominant wrist was involved in 60% (25) of the patients. All patients were immobilized for 4 weeks postoperatively and then underwent hand therapy for 4 to 6 weeks. Pain and ROM were gathered before surgery as part of clinical care, and were measured again at latest followup; at latest followup, radiographs were analyzed (by the senior author) for evidence of loosening, defined as any implant migration compared with any previous radiograph with evidence of periimplant osteolysis and bone resorption. Subjective pain score was assessed by a verbal pain scale (0-10) and ROM was measured with a goniometer. Complications were determined by chart review and final examination. Kaplan Meier survival analysis was performed to estimate the cumulative probability of not undergoing a revision.The mean preoperative active ROM was 34o ± 18° flexion and 36° ± 18° extension. Postoperatively, the mean active ROM was 37° ± 14° flexion and 29° ± 13° extension. The mean difference between the preoperative pain score (8.6 ± 1.2) and postoperative pain score (0.4 ± 0.8) was 8.1 ± 1.9 (p < 0.001). Implant loosening occurred in three (7.7%) patients. No other complications occurred in this series. Kaplan-Meier survivorship analysis estimated the cumulative probability of remaining free from revision as 78% (95% CI, 62%-91%) at 15 years.Cementless fourth-generation TWA improves pain while generally preserving the preoperative arc of motion. The cumulative probability of remaining free from revision at 14.7 years after the index procedure is 77.7% (95% CI, 62.0%-91.4%). Future studies should compare alternative approaches for patients with endstage wrist arthritis; such evaluations-which might compare TWA implants, or TWAs with arthrodesis-will almost certainly need to be multicenter, as the problem is relatively uncommon.Level IV, therapeutic study.

  View details for PubMedID 28721601

• Cost-Minimization Analysis of Open and Endoscopic Carpal Tunnel Release. journal of bone and joint surgery. American volume Zhang, S., Vora, M., Harris, A. H., Baker, L., Curtin, C., Kamal, R. N. 2016; 98 (23): 1970-1977

  Abstract

  Carpal tunnel release is the most common upper-limb surgical procedure performed annually in the U.S. There are 2 surgical methods of carpal tunnel release: open or endoscopic. Currently, there is no clear clinical or economic evidence supporting the use of one procedure over the other. We completed a cost-minimization analysis of open and endoscopic carpal tunnel release, testing the null hypothesis that there is no difference between the procedures in terms of cost.We conducted a retrospective review using a private-payer and Medicare Advantage database composed of 16 million patient records from 2007 to 2014. The cohort consisted of records with an ICD-9 (International Classification of Diseases, Ninth Revision) diagnosis of carpal tunnel syndrome and a CPT (Current Procedural Terminology) code for carpal tunnel release. Payer fees were used to define cost. We also assessed other associated costs of care, including those of electrodiagnostic studies and occupational therapy. Bivariate comparisons were performed using the chi-square test and the Student t test.Data showed that 86% of the patients underwent open carpal tunnel release. Reimbursement fees for endoscopic release were significantly higher than for open release. Facility fees were responsible for most of the difference between the procedures in reimbursement: facility fees averaged $1,884 for endoscopic release compared with $1,080 for open release (p < 0.0001). Endoscopic release also demonstrated significantly higher physician fees than open release (an average of $555 compared with $428; p < 0.0001). Occupational therapy fees associated with endoscopic release were less than those associated with open release (an average of $237 per session compared with $272; p = 0.07). The total average annual reimbursement per patient for endoscopic release (facility, surgeon, and occupational therapy fees) was significantly higher than for open release ($2,602 compared with $1,751; p < 0.0001).Our data showed that the total average fees per patient for endoscopic release were significantly higher than those for open release, although there currently is no strong evidence supporting better clinical outcomes of either technique.Value-based health-care models that favor delivering high-quality care and improving patient health, while also minimizing costs, may favor open carpal tunnel release.

  View details for PubMedID 27926678

• Quality Measures That Address the Upper Limb JOURNAL OF HAND SURGERY-AMERICAN VOLUME Kamal, R. N., Ring, D., Akelman, E., Ruch, D. S., Richard, M. J., Ladd, A., Got, C., Blazar, P., Yao, J., Kakar, S. 2016; 41 (11): 1041-1048

  Abstract

  Physicians, health care systems, and payers use quality measures to judge performance and monitor the outcomes of interventions. Practicing upper-limb surgeons desire quality measures that are important to patients and feasible to use, and for which it is fair to hold them accountable.Nine academic upper-limb surgeons completed a RAND/University of California-Los Angeles Delphi Appropriateness process to evaluate the importance, feasibility, and accountability of 134 quality measures identified from systematic review. Panelists rated measures on an ordinal scale between 1 (definitely not valid) and 9 (definitely valid) in 2 rounds (preliminary round and final round) with an intervening face-to-face discussion. Ratings from 1 to 3 were considered not valid, 4 to 6 were equivocal or uncertain, and 7 to 9 were valid. If no more than 2 of the 9 ratings were outside the 3-point range that included the median (1-3, 4-6, or 7-9), panelists were considered to be in agreement. If 3 or more ratings of a measure were within the 1 to 3 range whereas 3 or more ratings were in the 7 to 9 range, panelists were considered to be in disagreement.There was agreement that 58 of the measures are important (43%), 74 are feasible (55%), and surgeons can be held accountable for 39 (29%). All 3 thresholds were met for 33 measures (25%). A total of 36 reached agreement for being unimportant (48%) and 57 were not suited for surgeon accountability (43%).A minority of upper-limb quality measures were rated as important for care, feasible to complete, and suitable for upper-limb surgeon accountability.Before health systems and payers implement quality measures, we recommend ensuring their importance and feasibility to safeguard against measures that may not improve care and might misappropriate attention and resources.

  View details for DOI 10.1016/j.jhsa.2016.07.107

  View details for Web of Science ID 000387632600001

  View details for PubMedID 27577525

• Carpal Kinematics and Kinetics JOURNAL OF HAND SURGERY-AMERICAN VOLUME Kamal, R. N., Starr, A., Akelman, E. 2016; 41 (10): 1011-1018

  Abstract

  The complex interaction of the carpal bones, their intrinsic and extrinsic ligaments, and the forces in the normal wrist continue to be studied. Factors that influence kinematics, such as carpal bone morphology and clinical laxity, continue to be identified. As imaging technology improves, so does our ability to better understand and identify these factors. In this review, we describe advances in our understanding of carpal kinematics and kinetics. We use scapholunate ligament tears as an example of the disconnect that exists between our knowledge of carpal instability and limitations in current reconstruction techniques.

  View details for DOI 10.1016/j.jhsa.2016.07.105

  View details for Web of Science ID 000385340300008

  View details for PubMedID 27569785

• Quality and Value in an Evolving Health Care Landscape. journal of hand surgery Kamal, R. N. 2016; 41 (7): 794-799

  Abstract

  Demonstrating and improving value of care continues to be increasingly important in hand surgery. To prepare for emerging models that transition payment from volume to value, hand surgeons will benefit from a clear understanding of quality, cost, and value. National organizations and both public and private payers increasingly advocate for patient-reported outcome measures for pay for reporting and pay for performance initiatives. These are intended to incentivize providers and health systems to improve patient-centered care while minimizing costs. Appreciating the limitations to using patient-reported outcomes in hand surgery can ensure hand surgery is appropriately assessed in novel payment models.

  View details for DOI 10.1016/j.jhsa.2016.05.016

  View details for PubMedID 27374791

• High Disparity Between Orthopedic Resident Interest and Participation in International Health Electives ORTHOPEDICS Zhang, S., Shultz, P., Daniels, A., Akelman, E., Kamal, R. N. 2016; 39 (4): E680-E686

  Abstract

  Few orthopedic surgical residency programs offer international health electives (IHEs). Efforts to expand these programs have been increasing across medical disciplines. Whether orthopedic residents will participate remains unknown. This study quantified and characterized orthopedic resident interest and barriers to IHEs in US residency programs. A web-based survey was administered to residents from 154 US orthopedic residency programs accredited by the Accreditation Council for Graduate Medical Education 2014 to 2015. Questions assessed demographics and program background, previous medical experience abroad, barriers to participation, and level of interest in participating in an international health elective during their training and beyond. Twenty-seven (17.5%) residency programs responded. Chi-square analysis showed that residents who expressed interest in participating were significantly more likely to have experience abroad compared with those who expressed no interest (P<.004). Analysis using Mann-Whitney U test suggested that those who expressed interest were more likely to believe IHEs are important to resident training (P<.0011; mean Likert scale score of 3.7 vs 2.6), provide valuable experience (P<.001; mean Likert scale score of 4.2 vs 3.2), and should be required for orthopedic residencies (P<.001; mean Likert scale score of 2.8 vs 1.9). Residents are strongly interested in participating in IHEs during their training, and many may integrate global health into future practices. Residents perceive lack of funding and scheduling flexibility as barriers preventing them from participating. Prior experience abroad influences level of interest, and international clinical experience may enhance future perception of its value. [Orthopedics. 2016; 39(4):e680-e686.].

  View details for DOI 10.3928/01477447-20160419-02

  View details for Web of Science ID 000393105500014

  View details for PubMedID 27111074

• Quality Measurement: A Primer for Hand Surgeons JOURNAL OF HAND SURGERY-AMERICAN VOLUME Kamal, R. N., Kakar, S., Ruch, D., Richard, M. J., Akelman, E., Got, C., Blazar, P., Ladd, A., Yao, J., Ring, D. 2016; 41 (5): 645-651

  Abstract

  As the government and payers place increasing emphasis on measuring and reporting quality and meeting-specific benchmarks, physicians and health care systems will continue to adapt to meet regulatory requirements. Hand surgeons' involvement in quality measure development will help ensure that our services are appropriately assessed. Moreover, by embracing a culture of quality assessment and improvement, we will improve patient care while demonstrating the importance of our services in a health care system that is transitioning from a fee-for-service model to a fee-for-value model. Understanding quality and the tools for its measurement, and the application of quality assessment and improvement methods can help hand surgeons continue to deliver high-quality care that aligns with national priorities.

  View details for DOI 10.1016/j.jhsa.2015.10.002

  View details for PubMedID 26576831

• Orthopaedic Surgeon Burnout: Diagnosis, Treatment, and Prevention JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS Daniels, A. H., Depasse, J. M., Kamal, R. N. 2016; 24 (4): 213-219

  Abstract

  Burnout is a syndrome marked by emotional exhaustion, depersonalization, and low job satisfaction. Rates of burnout in orthopaedic surgeons are higher than those in the general population and many other medical subspecialties. Half of all orthopaedic surgeons show symptoms of burnout, with the highest rates reported in residents and orthopaedic department chairpersons. This syndrome is associated with poor outcomes for surgeons, institutions, and patients. Validated instruments exist to objectively diagnose burnout, although family members and colleagues should be aware of early warning signs and risk factors, such as irritability, withdrawal, and failing relationships at work and home. Emerging evidence indicates that mindfulness-based interventions or educational programs combined with meditation may be effective treatment options. Orthopaedic residency programs, departments, and practices should focus on identifying the signs of burnout and implementing prevention and treatment programs that have been shown to mitigate symptoms.

  View details for DOI 10.5435/JAAOS-D-15-00148

  View details for Web of Science ID 000372851200001

  View details for PubMedID 26885712

• Quality Measures in Upper Limb Surgery. journal of bone and joint surgery. American volume Kamal, R. N., Ring, D., Akelman, E., Yao, J., Ruch, D. S., Richard, M., Ladd, A., Got, C., Blazar, P., Kakar, S. 2016; 98 (6): 505-510

  Abstract

  Quality measures are now commonplace and are increasingly tied to financial incentives. We reviewed the existing quality measures that address the upper limb and tested the null hypothesis that structure (capacity to deliver care), process (appropriate care), and outcome (the result of care) measures are equally represented.We systematically reviewed MEDLINE/PubMed, Embase, Google Scholar, the American Academy of Orthopaedic Surgeons Clinical Practice Guidelines, the National Quality Forum, the Agency for Healthcare Research and Quality, and the Physician Quality Reporting System for quality measures addressing upper limb surgery. Measures were characterized as structure, process, or outcome measures and were categorized according to their developer and their National Strategy for Quality Improvement in Health Care (National Quality Strategy) priority as articulated by the U.S. Department of Health & Human Services.We identified 134 quality measures addressing the upper limb: 131 (98%) process and three (2%) outcome measures. The majority of the process measures address the National Quality Strategy priority of effective clinical care (90%), with the remainder addressing communication and care coordination (5%), person and caregiver-centered experience and outcomes (4%), and community/population health (1%).Our review identified opportunities to develop more measures in the structure and outcome domains as well as measures addressing patient and family engagement, public health, safety, care coordination, and efficient use of resources. The most common existing measures-process measures addressing care-might not be the best measures of upper limb surgery quality given the relative lack of evidence for their use in care improvement.

  View details for DOI 10.2106/JBJS.15.00651

  View details for PubMedID 26984919

• The Impact of the New Carpal Tunnel Clinical Practice Guidelines. The Journal of hand surgery Kamal, R. N. 2016; 41 (9): e329

  View details for PubMedID 27570229

• Subject-Specific Carpal Ligament Elongation in Extreme Positions, Grip, and the Dart Thrower's Motion JOURNAL OF BIOMECHANICAL ENGINEERING-TRANSACTIONS OF THE ASME Rainbow, M. J., Kamal, R. N., Moore, D. C., Akelman, E., Wolfe, S. W., Crisco, J. J. 2015; 137 (11)

  View details for DOI 10.1115/1.4031580

  View details for Web of Science ID 000362842900006

  View details for PubMedID 26367853

• Management of Intercarpal Ligament Injuries Associated with Distal Radius Fractures. Hand clinics Desai, M. J., Kamal, R. N., Richard, M. J. 2015; 31 (3): 409-416

  View details for DOI 10.1016/j.hcl.2015.04.009

  View details for PubMedID 26205702

• Management of Intercarpal Ligament Injuries Associated with Distal Radius Fractures. Hand clinics Desai, M. J., Kamal, R. N., Richard, M. J. 2015; 31 (3): 409-416

  Abstract

  The prevalence of ligamentous injury associated with fractures of the distal radius is reported to be as high as 69% with injury to the scapholunate interosseous ligament and lunotriquetral interosseous ligament occurring in 16% to 40% and 8.5% to 15%, respectively. There is a lack of consensus on which patients should undergo advanced imaging, arthroscopy, and treatment and whether this changes their natural history. Overall, patients with high-grade intercarpal ligament injuries are shown to have longer-term disability and sequelae compared with those with lower-grade injuries. This article reviews the diagnosis and treatment options for these injuries.

  View details for DOI 10.1016/j.hcl.2015.04.009

  View details for PubMedID 26205702

• Ulnar shortening osteotomy for distal radius malunion. Journal of wrist surgery Kamal, R. N., Leversedge, F. J. 2014; 3 (3): 181-186

  Abstract

  Background Malunion is a common complication of distal radius fractures. Ulnar shortening osteotomy (USO) may be an effective treatment for distal radius malunion when appropriate indications are observed. Methods The use of USO for treatment of distal radius fracture malunion is described for older patients (typically patients >50 years) with dorsal or volar tilt less than 20 degrees and no carpal malalignment or intercarpal or distal radioulnar joint (DRUJ) arthritis. Description of Technique Preoperative radiographs are examined to ensure there are no contraindications to ulnar shortening osteotomy. The neutral posteroanterior (PA) radiograph is used to measure ulnar variance and to estimate the amount of ulnar shortening required. An ulnar, mid-sagittal incision is used and the dorsal sensory branch of the ulnar nerve is preserved. An USO-specific plating system with cutting jig is used to create parallel oblique osteotomies to facilitate shortening. Intraoperative fluoroscopy and clinical range of motion are checked to ensure adequate shortening and congruous reduction of the ulnar head within the sigmoid notch. Results Previous outcomes evaluation of USO has demonstrated improvement in functional activities, including average flexion-extension and pronosupination motions, and patient reported outcomes. Conclusion The concept and technique of USO are reviewed for the treatment of distal radius malunion when specific indications are observed. Careful attention to detail related to surgical indications and to surgical technique typically will improve range of motion, pain scores, and patient-reported outcomes and will reduce the inherent risks of the procedure, such as ulnar nonunion or the symptoms related to unrecognized joint arthritis. Level IV.

  View details for DOI 10.1055/s-0034-1384747

  View details for PubMedID 25097811

• Salvage of Distal Radius Nonunion With a Dorsal Spanning Distraction Plate JOURNAL OF HAND SURGERY-AMERICAN VOLUME Mithani, S. K., Srinivasan, R. C., Kamal, R., Richard, M. J., Leversedge, F. J., Ruch, D. S. 2014; 39 (5): 981-984

  Abstract

  Treatment of nonunion after previous instrumentation of distal radius fractures represents a reconstructive challenge. Resultant osteopenia provides a poor substrate for fixation, often necessitating wrist fusion for salvage. A spanning dorsal distraction plate (bridge plate) can be a useful adjunct to neutralize forces across the wrist, alone or in combination with nonspanning plates to achieve union, salvage wrist function, and avoid wrist arthrodesis in distal radius nonunion.

  View details for DOI 10.1016/j.jhsa.2014.02.006

  View details for Web of Science ID 000335422200025

  View details for PubMedID 24679491

• Post-traumatic Raynaud's phenomenon following volar plate injury. Rhode Island medical journal (2013) Chodakiewitz, Y. G., Daniels, A. H., Kamal, R. N., Weiss, A. C. 2014; 97 (4): 24-26

  Abstract

  Post-traumatic Raynaud's phenomenon following non-penetrating or non-repetitive injury is rare. We report a case of Raynaud's phenomenon occurring in a single digit 3 months following volar plate avulsion injury. Daily episodes of painless pallor of the digit occurred for 1 month upon any exposure to cold, resolving with warm water therapy. Symptoms resolved after the initiation of hand therapy, splinting, and range-of- motion exercises.

  View details for PubMedID 24660212

• Quality of internet health information on thumb carpometacarpal joint arthritis. Rhode Island medical journal (2013) Kamal, R. N., Paci, G. M., Daniels, A. H., Gosselin, M., Rainbow, M. J., Weiss, A. C. 2014; 97 (4): 31-35

  Abstract

  The Internet has become a heavily used source of health information. No data currently exists on the quality and characteristics of Internet information regarding carpometacarpal (CMC) arthritis.The search terms "cmc arthritis," "basal joint arthritis," and "thumb arthritis" were searched using Google and Bing. Search results were evaluated independently by four reviewers. Classification and content specific review was performed utilizing a weighted 100-point information quality scale.Of the 60 websites reviewed, 27 were unique pages with 6 categorized as academic and 21 as non- academic. Average score on content specific review of academic websites was 56.8 and for non-academic was 42.7 (p=0.054). Average Flesch-Kincaid Grade Level for academic websites was 12.4, and for non-academic was 9.9 (p=0.015).Internet health information regarding thumb CMC arthritis is primarily non-academic in nature, of generally poor quality, and at a reading level far above the U.S. average reading level of 6th grade. Higher-quality websites with more complete content and appropriate readability are needed.The quality of Internet health information regarding thumb CMC arthritis is suboptimal.

  View details for PubMedID 24660214

• Extensive Subcutaneous Emphysema Resembling Necrotizing Fasciitis ORTHOPEDICS Kamal, R. N., Paci, G. M., Born, C. T. 2013; 36 (5): 671-675

  Abstract

  Necrotizing fasciitis is an aggressive, invasive soft tissue infection. Because it can rapidly progress to patient instability, prompt diagnosis followed by urgent debridement is critical to decreasing mortality. Despite the importance of early diagnosis, necrotizing fasciitis remains a clinical diagnosis, with little evidence in the literature regarding the effectiveness of diagnostic tools or criteria. Common clinical findings are nonspecific, including pain, blistering, crepitus, and swelling with or without fever and a known infection source.This article describes a patient who was transferred to the authors' institution from another hospital, where she had been taken following seizure activity and was treated with antibiotics for suspected cellulitis at the intravenous catheter placement site on her left dorsal hand. On admission to the current authors' institution, she presented with pain and swelling in the setting of significant left upper-extremity emphysema. She had undergone a left shoulder arthroscopy 4 weeks previously. Vital signs were within normal limits, and a preoperative chest radiograph was read as normal. The patient underwent an emergent fasciotomy, irrigation and debridement of the left upper extremity, and intravenous antibiotics for suspected necrotizing fasciitis. Intraoperative findings indicative of infection were absent, and a left apical pneumothorax was later found on postoperative chest imaging.In a stable patient with a normal chest radiograph on presentation who demonstrates upper-extremity crepitus suspicious for necrotizing fasciitis, a chest computed tomography scan may be indicated to rule out an intrathoracic source.

  View details for DOI 10.3928/01477447-20130426-34

  View details for Web of Science ID 000319811900037

  View details for PubMedID 23672900

• Nerve compression syndromes of the upper extremity: diagnosis, treatment, and rehabilitation. Rhode Island medical journal (2013) Mansuripur, P. K., Deren, M. E., Kamal, R. 2013; 96 (5): 37-39

  Abstract

  Nerve compression syndromes of the upper extremity, including carpal tunnel syndrome, cubital tunnel syndrome, posterior interosseous syndrome and radial tunnel syndrome, are common in the general population. Diagnosis is made based on patient complaint and history as well as specific exam and study findings. Treatment options include various operative and nonoperative modalities, both of which include aspects of hand therapy and rehabilitation.

  View details for PubMedID 23641462

• Total Wrist Arthroplasty JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS Weiss, A. C., Kamal, R. N., Shultz, P. 2013; 21 (3): 140-148

  Abstract

  Over the past 40 years, total wrist arthroplasty (TWA) has emerged as a cost-effective treatment option for wrist arthritis. First-generation implant designs have changed tremendously; current devices are designed to enhance wrist stability, provide greater implant longevity, and minimize surgical and postoperative complications. Although arthrodesis remains the standard for surgical management, TWA outcomes demonstrate that the procedure has excellent clinical promise. Additional prospective studies are needed to compare outcomes of wrist arthrodesis with those of TWA with current implants.

  View details for DOI 10.5435/JAAOS-21-03-140

  View details for Web of Science ID 000317444900003

  View details for PubMedID 23457064

• In vivo kinematics of the scaphoid, lunate, capitate, and third metacarpal in extreme wrist flexion and extension. journal of hand surgery Rainbow, M. J., Kamal, R. N., Leventhal, E., Akelman, E., Moore, D. C., Wolfe, S. W., Crisco, J. J. 2013; 38 (2): 278-288

  Abstract

  Insights into the complexity of active in vivo carpal motion have recently been gained using 3-dimensional imaging; however, kinematics during extremes of motion has not been elucidated. The purpose of this study was to determine motion of the carpus during extremes of wrist flexion and extension.We obtained computed tomography scans of 12 healthy wrists in neutral grip, extreme loaded flexion, and extreme loaded extension. We obtained 3-dimensional bone surfaces and 6-degree-of-freedom kinematics for the radius and carpals. The flexion and extension rotation from neutral grip to extreme flexion and extreme extension of the scaphoid and lunate was expressed as a percentage of capitate flexion and extension and then compared with previous studies of active wrist flexion and extension. We also tested the hypothesis that the capitate and third metacarpal function as a single rigid body. Finally, we used joint space metrics at the radiocarpal and midcarpal joints to describe arthrokinematics.In extreme flexion, the scaphoid and lunate flexed 70% and 46% of the amount the capitate flexed, respectively. In extreme extension, the scaphoid extended 74% and the lunate extended 42% of the amount the capitates extended, respectively. The third metacarpal extended 4° farther than the capitate in extreme extension. The joint contact area decreased at the radiocarpal joint during extreme flexion. The radioscaphoid joint contact center moved onto the radial styloid and volar ridge of the radius in extreme flexion from a more proximal and ulnar location in neutral.The contributions of the scaphoid and lunate to capitate rotation were approximately 25% less in extreme extension compared with wrist motion through an active range of motion. More than half the motion of the carpus when the wrist was loaded in extension occurred at the midcarpal joint.These findings highlight the difference in kinematics of the carpus at the extremes of wrist motion, which occur during activities and injuries, and give insight into the possible etiologies of the scaphoid fractures, interosseous ligament injuries, and carpometacarpal bossing.

  View details for DOI 10.1016/j.jhsa.2012.10.035

  View details for PubMedID 23266007

• The effect of the dorsal intercarpal ligament on lunate extension after distal scaphoid excision. journal of hand surgery Kamal, R. N., Chehata, A., Rainbow, M. J., Llusá, M., Garcia-Elias, M. 2012; 37 (11): 2240-2245

  Abstract

  After a distal scaphoid excision, most wrists develop a mild form of carpal instability-nondissociative with dorsal intercalated segment instability. Substantial dysfunctional malalignment is only occasionally seen. We hypothesized that distal scaphoid excision would lead to carpal instability-nondissociative with dorsal intercalated segment instability in cadavers and that the dorsal intercarpal (DIC) ligament plays a role in preventing such complications.We used 10 cadaver upper extremities in this experiment. A customized jig was used to load the wrist with 98 N. Motion of the capitate and lunate was monitored using the Fastrak motion tracking system. Five specimens had a distal scaphoid excision first, followed by excision of the DIC ligament, whereas the other 5 specimens first had excision of the DIC ligament and then had a distal scaphoid excision. Rotation of the lunate and capitate was calculated as a sum of the relative motions between each intervention and was compared with its original location before intervention (control) for statistical analysis.Distal scaphoid excision and subsequent DIC ligament excision both led to significant lunate extension. DIC ligament excision alone resulted in lunate flexion that was not statistically significant. After DIC ligament excision, distal scaphoid excision led to significant lunate extension. Capitate rotation was minimal in both groups, verifying that the overall wrist position did not change with loading.Distal scaphoid excision leads to significant lunate extension through an imbalance in the force couple between the scaphotrapeziotrapezoidal joint and the triquetrum-hamate joint. The DIC ligament may serve as a secondary stabilizer to the lunocapitate joint and prevent further lunate extension with the wrist in neutral position.The development of a clinically symptomatic carpal instability-nondissociative with dorsal intercalated segment instability with lunocapitate subluxation after distal scaphoid excision may be due to an incompetent DIC ligament.

  View details for DOI 10.1016/j.jhsa.2012.07.029

  View details for PubMedID 23044477

• Elongation of the dorsal carpal ligaments: a computational study of in vivo carpal kinematics. journal of hand surgery Rainbow, M. J., Crisco, J. J., Moore, D. C., Kamal, R. N., Laidlaw, D. H., Akelman, E., Wolfe, S. W. 2012; 37 (7): 1393-1399

  Abstract

  The dorsal radiocarpal (DRC) and dorsal intercarpal (DIC) ligaments play an important role in scapholunate and lunotriquetral stability. The purpose of this study was to compute changes in ligament elongation as a function of wrist position for the DRC and the scaphoid and trapezoidal insertions of the DIC.We developed a computational model that incorporated a digital dataset of ligament origin and insertions, bone surface models, and in vivo 3-dimensional kinematics (n = 28 wrists), as well as an algorithm for computing ligament fiber path.The differences between the maximum length and minimum length of the DRC, DIC scaphoid component, and DIC trapezoidal component over the entire range of motion were 5.1 ± 1.5 mm, 2.7 ± 1.5 mm, and 5.9 ± 2.5 mm, respectively. The DRC elongated as the wrist moved from ulnar extension to radial flexion, and the DIC elongated as the wrist moved from radial deviation to ulnar deviation.The DRC and DIC lengthened in opposing directions during wrist ulnar and radial deviation. Despite complex carpal bone anatomy and kinematics, computed fiber elongations were found to vary linearly with wrist position. Errors between computed values and model predictions were less than 2.0 mm across all subjects and positions.The relationships between ligament elongation and wrist position should further our understanding of ligament function, provide insight into the potential effects of dorsal wrist incisions on specific wrist ranges of motion, and serve as a basis for modeling of the wrist.

  View details for DOI 10.1016/j.jhsa.2012.04.025

  View details for PubMedID 22633233

• Updates on Disaster Preparedness and Progress in Disaster Relief JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS Pollak, A. N., Born, C. T., Kamal, R. N., Adashi, E. Y. 2012; 20: S54-S58

  Abstract

  Immediately after the January 2010 earthquake in Haiti, many private citizens, governmental and nongovernmental organizations, and medical associations struggled to mount an effective humanitarian aid response. The experiences of these groups have led to changes at their institutions regarding disaster preparedness and response to future events. One of the main challenges in a humanitarian medical response to a disaster is determining when to end response efforts and return responsibility for delivery of medical care back to the host nation. For such a transition to occur, the host nation must have the capacity to deliver medical care. In Haiti, minimal capacity to deliver such care existed before the earthquake, making subsequent transition difficult. If successful, several initiatives proposed to improve disaster response and increase surgical capacity in Haiti could be deployed to other low- and middle-income countries.

  View details for DOI 10.5435/JAAOS-20-08-S54

  View details for Web of Science ID 000307199000013

  View details for PubMedID 22865138

• In Vivo Triquetrum-Hamate Kinematics through a Simulated Hammering Wrist Motion J Bone Joint Surg Am Kamal, R., et al 2012
• The Use of Near-Infrared Spectrometry for the Diagnosis of Lower-extremity Compartment Syndrome ORTHOPEDICS Bariteau, J. T., Beutel, B. G., Kamal, R., Hayda, R., Born, C. 2011; 34 (3)

  View details for DOI 10.3928/01477447-20110124-12

  View details for Web of Science ID 000209016700010

• Total Wrist Athroplasty in the Non-Rheumatoid Patient J Hand Surg Am. Kamal, R. 2011
• Arthroscopic Treatment of Radiocarpal Dislocation: A Case Report Journal of Bone and Joint Surgery Kamal, R., et al 2011
• Effects on cytokines and histology by treatment with the ace inhibitor captopril and the antioxidant retinoic acid in the monocrotaline model of experimentally induced lung fibrosis CURRENT PHARMACEUTICAL DESIGN Baybutt, R. C., Herndon, B. L., Umbehr, J., Mein, J., Xue, Y., Reppert, S., Van Dillen, C., Kamal, R., Halder, A., Moteni, A. 2007; 13 (13): 1327-1333

  Abstract

  Monocrotaline (MCT), a pyrrolizidine alkaloid extracted from the shrub Crotalaria spectabilis, induces in the lungs of many mammalian species severe hypertension and fibrosis. Previous work with MCT-induced lung disease in rats has shown that some of the steps to progressive fibrosis can be interrupted or decreased by intervention with retinoic acid (RA) or with the angiotensin converting enzyme inhibitor, captopril. This report emphasizes the pathology and cytokines present in lungs of rats in the MCT model of hypertension and fibrosis in 8 treatment groups, six per group: (1) controls, not treated; (2) captopril; (3) RA; (4) combined captopril and RA. Groups 5-8 replicated groups 1-4 and also received MCT subcutaneously. Tissues were harvested at 28 days for histopathology and measurement of cytokines TGFbeta, TNFalpha, interleukin 6, and IFN_. TGFbeta was depressed at 28 days by MCT, an effect reversed by a combination of captopril and RA. RA influences production of an important Th1 cytokine, IFN_, and demonstrated the greatest limitation of MCT-induced TNFalpha. The MCT-induced lung pathology of vasculitis, interstitial pneumonia and fibrosis was limited by captopril. Smooth muscle actin was overexpressed in MCT treated animals receiving RA, an effect reduced with captopril. Overall, the study confirmed the existence of a protective effect for both captopril and RA from MCT-induced lung damage at 30 days. No synergistic or antagonistic activity was observed when the two drugs were administered together. Each of the drugs exerts different and particular effects on serum and tissue levels of various cytokines, suggesting that each drug is efficient at different points of attack in the control of lung fibrosis.

  View details for Web of Science ID 000247013200005

  View details for PubMedID 17506718

• Retinoic Acid-High Diet controls M1/M2 Activation Phenotypes in Macrophages and Protects from Monocrotaline-Induced Pulmonary Fibrosis Nutrition Research Kamal, R., et al 2004