Nearly All Peer-to-Peer Reviews for CT and MRI Prior Authorization Denials for Orthopedic Specialists Are Approved.

In the event of prior authorization denial, physicians may request peer-to-peer review, which may delay treatment and increase administrative burden. The purpose of this study was to quantify the approval rate of peer-to-peer review and evaluate its efficiency in the context of advanced imaging use in an orthopedic practice. Patients at a single outpatient orthopedic clinic initially receiving an insurance denial for computed tomography or magnetic resonance imaging requiring peer-to-peer review from March to December 2022 were prospectively enrolled. Characteristics of the request, peer-to-peer review, and the reviewer and dates in the process were collected. If the study was approved after peer-to-peer review, the date of the imaging study and brief results were recorded. A total of 62 denials were included. One denial was approved prior to peer-to-peer review. Fifty-eight (of 61, 95.1%) reviews were approved, of which 51 (of 58, 87.9%) studies were completed by patients. Reviewers were always physicians (61 of 61, 100%), but of those whose specialty was known, none were orthopedic surgeons. Forty-four of 61 (72.1%) reviewers reported reviewing clinical notes in advance. The median number of days from visit to peer-to-peer review was 9.0 (interquartile range, 7.0-13.25). The median number of days from visit to imaging center appointment was 13.5 (interquartile range, 9.0-20.75) for approved studies. Of the 51 approved studies completed by patients, the results of 38 (74.5%) confirmed the suspected diagnosis. In an orthopedic specialty practice, almost all peer-to-peer reviews were approved, with the majority of the completed studies confirming the suspected diagnosis. Thus, patient care was delayed. Reform is crucial to improve the efficiency of the review process, especially in light of additional administrative and financial burden. [Orthopedics. 202x;4x(x):xx-xx.].

Pudendal Neurapraxia After Proximal Hamstring Repair: A Case Report.

CASE: The pudendal nerve lies near the origin of the hamstring muscles, placing it at increased risk of injury during proximal hamstring tendon repair. In this study, we report on a 56-year old man who experienced intermittent unilateral testicular pain after a proximal hamstring tendon repair presumably due to pudendal nerve neurapraxia. At the 1-year follow-up, he continued to experience discomfort in the pudendal nerve distribution but reported significant improvement in symptoms and complete resolution of hamstring pain. CONCLUSION: Although the risk of pudendal nerve injury during proximal hamstring tendon repair is rare, surgeons should be aware of this potential complication.

Success of Various Marketing Strategies for a New-to-the-Area Orthopedic Practice.

Background Competition for patients among orthopaedic private practices, multi-specialty groups, and hospital systems continues to persist. An effective marketing campaign is essential for a practice to succeed in this competitive environment. The purpose of this study was to investigate the cost-effectiveness and efficacy of each marketing campaign and the influence of patient demographics on efficacy. Methods The first 300 consecutive, new patients were prospectively surveyed on how they initially discovered and then selected the orthopaedic practice. Demographics and marketing costs were tabulated and categorized to analyze the effectiveness of each marketing strategy. Results A substantial portion of the marketing budget was allocated for traditional (67.0%) and online advertising (25.0%). However, only 56/300 (18.7%) patients surveyed were brought to the practice by these methods combined. In contrast, expenditure on a marketing liaison (8.0%) delivered 128 patients (42.7%) through referrals: 80 (26.7%) from physicians, 28 (9.3%) from urgent cares, 17 (5.7%) from physical therapists, and 3 (1.0%) from attorneys. Conclusion Marketing strategies were not proportionally beneficial during the first six months of the orthopaedic practice start-up period. During this early ramping up period, the most cost-effective marketing strategy was utilization of a liaison for direct in-person visits to various healthcare facilities.

Does Velocity Increase From Flat-Ground to Mound Work During a Lighter Baseball Training Program?

INTRODUCTION: There has been recent interest in throwing from flat-ground versus the mound regarding stress on the elbow. Typical throwing progression programs begin with flat-ground work and progress to mound work. METHODS: All baseball pitchers of ages 10 to 17 years who completed a 15-week pitching mechanics and velocity-training program were included. Players' pitch velocity was tested at four time points during training. Average velocity and maximum velocity of pitches from flat-ground were compared with those of mound, and change in velocity between testing sessions was also compared. RESULTS: Thirty-six male pitchers (average age: 14.4 ± 1.6 years) were included. Fastball velocity increased by an average of 5.2 mph (95% confidence intervals 2.0 to 8.8 mph) at the end of the training program. When change in average and maximum velocity was compared between the four testing sessions, the most notable increase in velocity occurred between the third and fourth testing sessions. Both sessions were thrown from the mound. CONCLUSION: The 15-week baseball pitcher-training program markedly improved pitching velocity. Throwing from a mound compared with flat-ground resulted in the largest velocity increase. Therefore, when attempting to increase a pitcher's velocity, throwing from the mound should be an integral part of any velocity program.

Training With Lighter Baseballs Increases Velocity Without Increasing the Injury Risk.

BACKGROUND: Pitch velocity has become an increasingly popular metric by which pitchers are graded and compared. Training programs that utilize weighted balls have been effective in increasing velocity but at the cost of an increased injury risk. No studies have evaluated training with lighter baseballs with regard to increasing pitch velocity and the injury risk. PURPOSE/HYPOTHESIS: The purpose of this study was to determine whether a training program utilizing lighter baseballs could increase fastball velocity without increasing the injury risk to participants. We hypothesized that a training program with lighter baseballs would increase fastball velocity but not increase the injury risk. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: All baseball pitchers who participated in a 15-week program at a single location, with the same coaches, and aimed to improve pitching mechanics and increase velocity were included. The training program was broken down into 3 phases, and each participant went through the same program. Lighter baseballs (3 and 4 oz) and standard baseballs (5 oz) were utilized as part of the training program. Weighted (heavier) balls were not used. Velocity was measured at 4 time points throughout the program with the pitcher throwing 5 fastballs using a standard 5-oz ball at maximum velocity (sessions 3, 10, 17, and 25). Injuries for all players were recorded throughout the entire program. RESULTS: A total of 44 male pitchers aged 10 to 17 years (mean age, 14.7 ± 1.8 years) completed the training program and were available for analysis. No pitcher sustained a shoulder or elbow injury during the course of the training program. Fastball velocity increased by a mean of 4.8 mph (95% CI, 4.0-5.6 mph) (P < .001). Overall, 43 of 44 players (98%) had an increase in fastball velocity over the course of the program. CONCLUSION: A 15-week pitching training program with lighter baseballs significantly improved pitching velocity without causing any injuries, specifically to the shoulder or elbow. Lighter baseballs should be considered as an alternative to weighted baseballs when attempting to increase a pitcher's velocity.

Late-Onset Radial Nerve Palsy After Closed Treatment of a Periprosthetic Humerus Fracture: A Case Report.

CASE: A 58-year-old woman underwent successful reverse total shoulder arthroplasty for a proximal humerus fracture. Three years later, she sustained a periprosthetic humerus fracture after a fall and was treated conservatively. She healed with an abundance of callus and subsequently developed delayed-onset radial nerve palsy at 3 months, despite minimal change in humeral alignment and avoidance of the use of any compressive external braces or splints. CONCLUSIONS: Minimally displaced periprosethetic humerus fractures can lead to delayed radial nerve palsy from callus entrapment, and there should be increased awareness of this potential complication when counseling and treating patients conservatively.

Safety and usefulness of free fat grafts after microdiscectomy using an access cannula: a prospective pilot study and literature review.

Placing an interpositional fat graft over the dura has been practiced to prevent sciatica due to nerve tethering from scar. We assessed feasibility, outcomes, and complications of free fat grafts in patients undergoing lumbar microdiscectomy for herniated discs using an access cannula. Retrospective review of prospectively collected data on 69 consecutive patients: those who received autologous fat graft (Group I) and those who did not (Group II). Clinical evaluation of leg pain and nerve tension sign was performed in the immediate postoperative period and at 1 month, 6 months, 12 months, and 24 months. The combined visual analog scale (VAS) scores for leg pain improved from 8.3 preoperatively to 1.3 (P < 0.5). The average VAS score for leg pain was 1.4 (0 to 3) in Group I and 1.3 (0 to 3) in Group II (P > 0.05). Ninety-one percent had resolution of their leg pain immediately postop and 96% at final follow-up. This study found no increased complications with the use of fat graft, but no clinical benefit, therefore the use of fat graft should be discouraged. The potential complication with the use of fat graft is the "mass effect" on the dura, and therefore, the width of the graft should be <1 cm.

Thromboembolic events are uncommon after open treatment of proximal humerus fractures using aspirin and compression devices.

BACKGROUND: Thromboembolic phenomena have long been recognized as a major cause of morbidity and mortality in hospitalized patients, especially those undergoing reconstructive surgery. We have been empirically treating patients with aspirin, early ambulation, and mechanoprophylaxis after operative management of proximal humerus fractures. However, we have not established the incidence of postoperative deep vein thrombosis and pulmonary embolism in this population. QUESTIONS/PURPOSES: We determined the incidence of deep vein thrombosis and pulmonary embolism in patients having surgery for displaced proximal humerus fractures treated with our thromboprophylactic regimen. PATIENTS AND METHODS: We prospectively followed 50 patients with proximal humerus fractures who underwent fixation with plate osteosynthesis (n = 40) or hemiarthroplasty (n = 10) between August 2005 and December 2008. Deep vein thrombosis prophylaxis consisted of oral enteric-coated aspirin, pneumatic calf compression pumps, and early ambulation in all patients unless medically contraindicated. Color-flow Doppler ultrasound of the affected arm and both lower extremities was performed at a mean of 14 days (range, 7-21 days) postoperatively to evaluate for deep vein thrombosis. All patients clinically suspected to have suffered a pulmonary embolism underwent a CT angiogram. RESULTS: We identified no patients with deep vein thrombosis or pulmonary embolism in this population. CONCLUSIONS: Deep vein thrombosis and pulmonary embolism are not uncommon after major reconstructive surgery about the shoulder in untreated patients. Our data suggest these events can be low after surgery for proximal humerus fractures followed by a thromboprophylactic regimen including aspirin, mechanical devices, and early mobilization. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Cumulative effects of hypercholesterolemia on tendon biomechanics in a mouse model.

High cholesterol represents a significant healthcare problem. Clinical studies have linked hypercholesterolemia to Achilles tendon xanthomas and rotator cuff tears, and research in other systems indicates detrimental effects of high cholesterol; however, understanding of its impact on tendon properties and healing is limited. We hypothesized that tendons from aging hypercholesterolemic (APOE) mice would exhibit inferior baseline and healing mechanical properties compared to controls, while younger, but mature mice would be no different. Surprisingly, tensile testing of patellar tendons from 14-week-old APOE mice receiving a unilateral full-thickness central defect resulted in normalized (injured:sham) cross-sectional areas closer to baseline (p = 0.02) compared to controls. Uninjured data from 10-month-old APOE mice showed a decrease in elastic modulus (p = 0.02), indicating a detrimental effect of hypercholesterolemia on tendon properties in this model. These results could benefit patients through knowledge that high cholesterol could increase the likelihood of tendon tears. Furthermore, knowledge that tendon tears are indicative of high cholesterol could provide orthopedic clinicians with an additional preventive treatment opportunity for patients with undiagnosed hypercholesterolemia.

Traumatic myositis ossificans as a result of college fraternity hazing.

We present a case of a 20-year-old college student who had myositis ossificans traumatica develop after a fraternity hazing. The patient was struck repeatedly on both of his thighs while standing at attention, and he presented with bilateral thigh pain and stiffness 6 weeks after the incident. Physical examination revealed 130 degrees flexion of his right knee and 50 degrees flexion of his left knee, which had a firm end point. Radiographs showed extensive new bone located adjacent to the anterior and lateral aspects of his left femur with less involvement of his right thigh. Magnetic resonance imaging revealed considerable edema involving much of the rectus femoris and vastus lateralis of both thighs. The patient was treated with physical therapy and indomethacin for pain and inflammation control. At his 1.5-year followup, the patient's left knee flexion had improved to 130 degrees . Nonoperative treatment with careful followup resulted in a favorable outcome in this patient despite considerable formation of bilateral thigh myositis ossificans traumatica.

Traumatic lower extremity arteriovenous fistulae in children.

Traumatic arteriovenous fistulae are rare injuries in the pediatric population. Most are caused by penetrating injuries or are post-surgical in nature. Fistulae resulting from non-penetrating injuries are often missed early in the course of physical examination. This occurs due to the absence of clinical signs of arterial or venous injury, despite the close proximity of the affected vessels to point of injury. Likewise, signs and symptoms of post-surgical vascular injury may be difficult to discern from normal postoperative discomfort. The astute clinician must be on alert for unusual presentations of vascular injury to intervene in an expeditious manner. This article presents a series of vascular complications following either blunt injury or surgical management of the lower extremity in children who presented to our facility between November 2004 and December 2005.