A Small Number of Surgeons Perform the Large Majority of Uncommon Nerve Decompression Procedures.

BACKGROUND: Notable surgeon-to-surgeon variation in rates of uncommon surgery can reflect appropriate concentration of expertise with technically difficult or risky procedures that address problematic impairment due to objective pathophysiology. Examples include vascularized tissue transfer or transplantation to address complex tissue loss and release of bony elbow ankylosis. Perhaps more problematic is notable variation in straightforward, discretionary surgeries intended to alleviate pain, offered in the absence of objectively measurable pathophysiology, and without experimental evidence of benefit over placebo and other nonspecific effects. Evidence of concentration of this type of surgery in the hands of a few surgeons might point to inordinate influence of surgeon opinions on patient behavior. A study of variation in operations for upper extremity peripheral mononeuropathy has the potential to uncover potentially problematic variation. There are billing codes specific to common surgeries that can benefit patients with objectively verifiable neuropathies. And there are billing codes that represent less common nerve decompression surgeries that in many cases are offered in the absence of both objective evidence of pathophysiology as well as experimental evidence that surgery alleviates pain better than simulated surgery. QUESTIONS/PURPOSES: We asked the following questions: (1) Among surgeons who billed a mean of at least 10 carpal tunnel releases (CTRs) per year in patients with Medicare insurance in the United States, how many also performed at least one less common peripheral nerve release and cubital tunnel release (CubTR) per year? (2) Among surgeons who billed a mean of at least one less common peripheral nerve release or CubTR on average per year, what is the median and range of the number of less common peripheral nerve releases and CubTRs and the relative proportion of these compared with CTRs per year? (3) Are there any differences in gender, specialty, and number of CTRs and CubTRs between surgeons who performed at least one less common nerve decompression and surgeons who, on average, performed none? METHODS: Using the Medicare Physician & Other Practitioners - by Provider and Service database, we identified surgeons who perform a minimum of 10 CTRs per year. Because this database has all surgeries billed to Medicare performed in any setting by individual surgeons, it is well suited to the study of surgeon-specific operative rates among Medicare patients. Among 7259 clinicians who billed one or more nerve procedure to Medicare between January 2013 and December 2019, we excluded 120 nonsurgical clinicians, 47 podiatrists, and 1561 clinicians who billed procedures as an organization. Among the remaining 5531 surgeons, 5439 performed at least 10 CTRs on average per year, which we considered representative of surgeons who include nerve decompression surgery as a part of their practice. Among these 5439 surgeons, we calculated the mean number of CTRs, CubTRs, and less common peripheral nerve releases (including decompression of a digital nerve, nerve in hand or wrist, ulnar nerve at the wrist, brachial plexus, and unspecified nerve) per year between 2013 and 2019. Decompression of the median nerve at the carpal tunnel, the ulnar nerve at the cubital tunnel, and, much less frequently, the ulnar nerve at the wrist typically addresses measurable neuropathy. The other nerve releases are often performed for illnesses characterized by pain that are defined, in part, by the absence of experimentally verifiable pathophysiology such as radial tunnel and pronator (or lacertus) syndromes. We counted the number of surgeons who billed an average of at least one less common peripheral nerve release and CubTR per year; the median and range of the number of less common nerve releases and CubTRs and their relative proportion among those subsets of surgeons; and differences in the number of surgeons who performed one or none less common surgery by gender, specialty, and volume of CTR/CubTR surgery. RESULTS: Of 5439 surgeons who performed a mean of at least 10 CTRs per year, 2% (93) performed a mean of at least one less common peripheral nerve release per year among patients on Medicare, 14% (775) at least one CubTR, and 1% (47) performed both. Surgeons who performed a mean of at least one less common peripheral nerve release per year performed a median (IQR) of 7 (3 to 17) per year (with a maximum of 153 per year), representing approximately one less common peripheral nerve release for every five CTRs. Sixty-five percent (4076 of 6272) of all less common nerve procedures were performed by the top 20 billing surgeons. Gender was not associated with doing one or more uncommon nerve releases (women 1% [6 of 413], men 2% [87 of 5026]; p = 0.84), but specialty was, with plastic surgeons leading (6% [20 of 340] compared with 1% [73 of 5087] for other types of surgeons; p < 0.001). CONCLUSION: The observation that a relatively small number of surgeons perform a large majority of the surgery for nerve syndromes conceptualized as accounting for arm pain suggests that most surgeons are cautious about ascribing pain to conceptual nerve compression syndromes and offering surgery. CLINICAL RELEVANCE: An approach to surgical care founded on ethical principles regards this type of notable variation as a signal of inordinate influence of surgeon opinion on patient behavior, suggesting that professional conduct may be supported by safeguards such as checklists that help guide patients to choices consistent with their values unclouded by surgeon beliefs, false hope, and common misconceptions.

Surgeon variation in rates of surgery for trapeziometacarpal osteoarthritis in the United States.

We identified wide variation in surgery for trapeziometacarpal osteoarthritis among surgeons in the United States, with 42% performing no surgery, a median rate of surgery of 1.9/year, and 2% performed more than 30 procedures annually, representing 15% of all surgical procedures for TMC arthritis.

Parsing the toxicity paradox: Composition and duration of exposure alter predicted oil spill effects by orders of magnitude.

Oil spilled into an aquatic environment produces oil droplet and dissolved component concentrations and compositions that are highly variable in space and time. Toxic effects on aquatic biota vary with sensitivity of the organism, concentration, composition, environmental conditions, and frequency and duration of exposure to the mixture of oil-derived dissolved compounds. For a range of spill (surface, subsea, blowout) and oil types under different environmental conditions, modeling of oil transport, fate, and organism behavior was used to quantify expected exposures over time for planktonic, motile, and stationary organisms. Different toxicity models were applied to these exposure time histories to characterize the influential roles of composition, concentration, and duration of exposure on aquatic toxicity. Misrepresenting these roles and exposures can affect results by orders of magnitude. Well-characterized laboratory studies for <24-hour exposures are needed to improve toxicity predictions of the typically short-term exposures that characterize spills.

Protocol of a Multicenter Prospective Trial of Office-Based Carpal Tunnel Release With Ultrasound Guidance (ROBUST).

Background Carpal tunnel release (CTR) is a common surgical procedure for patients with severe or refractory carpal tunnel syndrome (CTS) symptoms. Historically, CTR procedures have been performed in a hospital or an ambulatory surgery center (ASC). However, due to advancements in techniques, greater patient demand, and concerns about growing healthcare costs, there is a distinct trend toward performing CTR procedures in an office-based setting. Several small studies with limited follow-up duration have demonstrated the feasibility of CTR with ultrasound guidance (CTR-US) when performed in an office-based setting. The objective of this study is to evaluate the safety and effectiveness of office-based CTR-US in a large cohort of patients (n=140) with symptomatic CTS followed for two years post-treatment. Design and methods ROBUST is a prospective multicenter observational study in which 140 subjects at up to 12 sites in the United States will be treated with CTR-US in an office-based setting. The primary endpoint of the study is the change in the Boston Carpal Tunnel Questionnaire Symptom Severity Scale score. Secondary endpoints include time to return to normal daily activities, time to return to work among employed subjects, change in the Boston Carpal Tunnel Questionnaire Functional Status Scale score, change in the Michigan Hand Questionnaire overall and domain scores, change in the Numeric Pain Scale score, change in the EuroQoL-5 Dimension 5-Level score, global satisfaction scores, and the incidence of device or procedure-related adverse events. The primary analysis of study endpoints will occur three months post-treatment. Patient follow-up in this study will continue for two years. Conclusions A central institutional review board approved the study protocol, and a data safety monitoring board will provide study oversight. The authors plan to report study results at medical conferences and in peer-reviewed medical journals. The outcomes of ROBUST will provide physicians, patients, and payors with important safety and effectiveness data regarding the clinical utility of CTR-US when performed in an office setting.

Recommendations for improving the reporting and communication of aquatic toxicity studies for oil spill planning, response, and environmental assessment.

Standardized oil toxicity testing is important to ensure comparability of study results, and to generate information to support oil spill planning, response, and environmental assessments. Outcomes from toxicity tests are useful in the development, improvement and validation of effects models, and new or revised knowledge could be integrated into existing databases and related tools. To foster transparency, facilitate repeatability and maximize use and impact, outcomes from toxicity tests need to be clearly reported and communicated. This work is part of a series of reviews to support the modernization of the "Chemical Response to Oil Spills: Ecological Effects Research Forum" protocols focusing on technological advances and best toxicity testing practices. Thus, the primary motivation of the present work is to provide guidance and encourage detailed documentation of aquatic toxicity studies. Specific recommendations are provided regarding key reporting elements (i.e., experimental design, test substance and properties, test species and response endpoints, media preparation, exposure conditions, chemical characterization, reporting metric corresponding to the response endpoint, data quality standards, and statistical methods, and raw data), which along with a proposed checklist can be used to assess the completeness of reporting elements or to guide study conduct. When preparing journal publications, authors are encouraged to take advantage of the Supplementary Material section to enhance dissemination and access to key data and information that can be used by multiple end-users, including decision-makers, scientific support staff and modelers. Improving reporting, science communication, and access to critical information enable users to assess the reliability and relevance of study outcomes and increase incorporation of results gleaned from toxicity testing into tools and applications that support oil spill response decisions. Furthermore, improved reporting could be beneficial for audiences outside the oil spill response community, including peer reviewers, journal editors, aquatic toxicologists, researchers in other disciplines, and the public.

Integrating Mental and Social Health in Orthopaedic Practice: The Time Is Now.

Tremendous advances have been made in understanding the intimate relationships between physical, emotional, and social health. There is now a substantial body of evidence demonstrating that mental health and social health may have as much influence on patients' symptom intensity and level of capability-the key metrics of success in orthopaedic care-as pathophysiology. But as a specialty the focus remains mostly on biomedical management (which focuses on structural damage and technical solutions), rather than taking a biopsychosocial approach, which involves screening, measurement, and decision making that prioritizes mental and social health concerns. Failure to do so means orthopaedic surgeons fall short in delivering whole-person care. It is important to highlight the biopsychosocial model of health and healthcare; describe the evidence for mental and social health in orthopaedic practice; outline strategies to identify, measure, and manage psychological and social concerns; and provide frameworks to implement comprehensive models of orthopaedic care that promise to benefit patients, populations, and health systems.

Optimizing Outcomes By Optimizing Bone Health.

Orthopaedic surgeons have long been aware of the importance of metabolic bone health for fracture healing; however, recent attention has focused on optimization of bone health before elective surgery and also regarding pathways to ensure patients have appropriate evaluation and treatment for bone health issues. It is important to describe issues of importance to fragility fracture care and prevention and optimization of outcomes before elective or fracture surgery. To address the challenge of who has the time, expertise, and appropriate patient contact to identify and treat patients at risk of bone metabolic issues, one model for a suggested pathway to ensure these patients are identified and treated is outlined.

Nerve Conditions of the Upper Limb: How Not to Miss or Mismanage.

There are several issues associated with nerve compression syndromes of the upper limb; ultrasonography is a useful diagnostic tool. The orthopaedic surgeon should know how to evaluate and treat patients who do not obtain expected relief following carpal or cubital tunnel release, and also be knowledgeable about the workup and evaluation of patients with conditions of debatable pathology and treatment, such as radial tunnel syndrome or pronator syndrome. Recent studies on suprascapular neuropathy include discussions about the pathophysiology and etiology of the condition, its natural history, and who might benefit from surgery.

Surgical management of osteoarthritis of the hand and wrist.

Osteoarthritis of the hand and wrist is common; varying disease manifestations and a spectrum of symptoms make it imperative to approach treatment strategies in an individualized fashion. In this review, attention is focused upon site specific diagnoses and indications for various surgical treatment strategies.

Surgical management of osteoarthritis in the shoulder and elbow.

Interesting recent trends are apparent in the setting of shoulder and elbow pathology. There is an increase in utilization of shoulder arthroplasty for osteoarthritis and post traumatic arthritis. At the same time, there remain limited options for osteoarthritis of the elbow particularly in the young and or active patient. This manuscript details surgical options for osteoarthritis at the elbow and shoulder.

The bioavailability of oil droplets trapped in river gravel by hyporheic flows.

Little is known about the fate of oil spills in rivers. Hyporheic flows of water through river sediments exchange surface and groundwater and create upwelling and downwelling zones that are important for fish spawning and embryo development. Risk assessments of oil spills to rivers do not consider the potential for hyporheic flows to carry oil droplets into sediments and the potential for prolonged exposure of fish to trapped oil. This project assessed whether oil droplets in water flowing through gravel will be trapped and whether hydrocarbons partitioning from trapped oil droplets are bioavailable to fish. Columns packed with gravel were injected with oil-in-water dispersions prepared with light crude, medium crude, diluted bitumens, and heavy fuel oil to generate a series of oil droplet loadings. The concentrations of oil trapped in the gravel increased with oil loading and viscosity. When the columns were perfused with clean water, oil concentrations in column effluents decreased to the detection limit within the first week of water flow, with sporadically higher concentrations associated with oil droplet release. Despite the low concentrations of hydrocarbons measured in column effluent, hydrocarbons were bioavailable to juvenile rainbow trout (Oncorhynchus mykiss) for more than three weeks of water flow, as indicated by strong induction of liver ethoxyresorufin-o-deethylase activity. These findings indicate that ecological risk assessments and spill response should identify and protect areas in rivers sensitive to contaminant trapping.

The Essex-Lopresti Injury:: Evaluation and Treatment Considerations.

This article describes evaluation and treatment considerations for Essex-Lopresti injuries. Specific information about pattern recognition and treatment options is provided.

Elbow Instability: Evaluation and Treatment.

Acute elbow dislocations are commonly seen in clinical practice, and attention to management principles and strategies can help facilitate improved outcomes. Patients may present with simple elbow dislocation, in which nonoperative treatment is highly successful. Alternatively, fracture dislocations can be sometimes easily managed but frequently are associated with the need for surgical intervention and operative and postoperative challenges.

Ethics and Professionalism: The Role of Self-Regulation and Peer Review in Maintaining Hand Surgery's Standards.

The practice of hand surgery is bound by the need for each of us to maintain our profession's high standards by fulfilling our peers' and society's expectations regarding ethical and professional behavior. Our profession is self-regulated by local, state, and national organizations, which provide expectations and standards for practice. This manuscript reviews the resources available from such organizations to foster standards of practice.

Effects on Trout Alevins of Chronic Exposures to Chemically Dispersed Access Western Blend and Cold Lake Blend Diluted Bitumens.

The present study assessed the chronic toxicity of 2 chemically enhanced water accommodated fractions (CEWAFs) of diluted bitumens (dilbits), Access Western Blend (AWB) and Cold Lake Blend (CLB), to rainbow trout alevins. Chemical dispersion was used to overcome the resistance to dispersion of dilbits and to generate test solutions that contained more and smaller oil droplets for increased partitioning of petroleum hydrocarbons into water. Test solutions were characterized by fluorescence spectroscopy, a rapid and inexpensive analytical tool to compare toxicity endpoints measured by fluorescence (total petroleum hydrocarbons measured by fluorescence [TPH-F]). Cumulative mortality and the prevalence and severity of malformations increased following exposure of alevins to dispersed dilbits. Toxicity curves overlapped for AWB and CLB when expressed as TPH-F and 22- to 24-d median lethal and effect concentrations ranged from 0.36 to 1.5 mg/L. Gene expression in alevins was also altered following exposure to dispersed dilbit, with relative cytochrome P450-1A mRNA levels increasing up to 170-fold for AWB and up to 240-fold for CLB. Access Western Blend and CLB caused similar toxicity to rainbow trout alevins as light to medium conventional crude oils, and rainbow trout alevins were more sensitive than yellow perch, Japanese medaka, and fathead minnow embryos exposed to dispersed AWB and CLB. The present study is the first to assess the embryotoxicity of dilbits to a Canadian freshwater salmonid species. Environ Toxicol Chem 2020;39:1620-1633. © 2020 SETAC.

Editorial Commentary: Elbow Arthroscopy Is a Safe Procedure. Sure.

Elbow arthroscopy is a procedure that is of great potential use and yet also of grave potential risks. To balance the risk-versus-reward consideration, one must be aware of the potential complications associated with this procedure, weigh them against the potential advantages, and understand one's own skills and familiarity with the procedure. There is no doubt that elbow arthroscopy has changed and even revolutionized our management of pathology about the elbow; however, one must bear in mind that this comes at a risk of complications that cannot be reduced to zero.

Hand and Wrist Problems That Can Be Deceptive: Avoiding Snakes in the Grass.

In this chapter, the authors describe hand conditions that can be "bad actors" and provide specific clues to identify these problems, and strategies to assess and successfully treat them. We will review pediatric and adult hand fractures, fractures of the distal radius, and trigger digits.

Scapholunate Ligament Injury: Management Strategies From Occult Injury to Arthritis.

This chapter will explore scapholunate ligament injuries with a focus on injury recognition, diagnosis, the natural history, and options for treatment. Treatment is based upon injury factors, patient factors, and surgeon preference. The classification systems in common use will be discussed, and treatment options will be explored, including nonsurgical, arthroscopic, repair, reconstruction, pain relieving measures, and salvage procedures.