Pickleball- and Paddleball-Related Injuries to the Upper Extremity.

Introduction While pickleball and paddleball are rapidly growing as popular sports in the United States, research on the incidence of hand and upper extremity injuries and treatments in outpatient clinics are lacking. This study evaluates the incidence rates and treatment options, both surgically and nonsurgically, for patients presenting with pickleball/paddleball-related injuries. Methods A retrospective database search of our multispecialty, multilocation electronic medical record (EMR) system from 2015 to 2022 identified 204 patients with outpatient pickleball- and paddleball-related injuries. The data from these patients' charts were reviewed for injury incidences, treatment trends, and demographics. Results  The majority of patients suffered wrist fractures due to a fall/dive and were treated nonsurgically. The most common surgical treatment, when required, was open reduction and internal fixation of the distal radius. We found that pickleball and paddleball players who sustained wrist fractures required surgery at a higher rate than the general population if above the age of 65. Conclusion As pickleball and paddleball continue to gain popularity, hand surgeons should be aware of the types of injuries that can occur and, when possible, counsel patients accordingly to try to prevent them. Additionally, hand surgeons should recognize the common treatments and outcomes that arise from pickleball/paddleball-related injuries.

All-Inside Versus Outside-in Repair of Triangular Fibrocartilage Complex Peripheral Tears.

PURPOSE: Triangular fibrocartilage complex (TFCC) peripheral tears with persistent wrist pain can be treated with arthroscopic surgical repair owing to vascularization of the peripheral region. The safety and efficacy of all-inside repair has been shown in prior case series. The purpose of this study was to compare two methods of arthroscopic peripheral TFCC repair: all-inside vertical mattress and outside-in horizontal mattress. METHODS: A 5-year retrospective review was performed on patients treated from 2016 to 2021 with wrist arthroscopy and TFCC repair for Palmer 1B tears. Patients with ulnar extrinsic ligament repair, distal radioulnar joint instability, concomitant ulnar shortening osteotomy, and extensor carpi ulnaris instability were excluded. Patient therapy and office visit records were reviewed. Outcomes including Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH); range of motion; grip strength; immobilization time; complications; and need for revision procedures were compared. RESULTS: Fifty-two patients were included in the study, 32 in the outside-in group and 20 in the all-inside group. The average follow-up length was 24.8 weeks, with similar range of motion and strength in both groups. The average postoperative QuickDASH score was 13 in the outside-in group and 9 in the all-inside group at 43.5 months, compared with the preoperative QuickDASH scores of 47 and 50, respectively. Mean immobilization time was longer for outside-in than for all-inside (5.25 vs 2.0 weeks, respectively). CONCLUSIONS: All-inside arthroscopic peripheral TFCC repair showed range of motion, grip strength, complications, revisions, and postoperative improvement in QuickDASH scores similar to those with the outside-in technique. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV; retrospective comparative study.

Outpatient Visit Current Procedural Terminology Code Level Selection Trends in Hand Surgery Following Criteria Changes by the American Medical Association.

INTRODUCTION:  Beginning on January 1, 2021, the American Medical Association (AMA) and the Centers for Medicare and Medicaid Services (CMS) implemented considerable revisions with regard to the outpatient evaluation and management (E/M) criteria dictating the Current Procedural Terminology (CPT) code level selection. The primary goal of the current study was to determine how the recent E/M coding criteria changes have impacted code level selection by orthopedic hand surgeons in the outpatient setting. MATERIALS AND METHODS:  All outpatient visits within the hand and wrist surgery division of a single orthopedic practice were collected during two timeframes: March 1, 2019, to June 30, 2019, and March 1, 2021, to June 30, 2021. Procedure codes and insurance categories were collected for each visit. The primary endpoint analyzed was the visit level of care based on CPT E/M codes. For each timeframe, we determined the number of total visits that were coded at each level and expressed them as a percentage of the total visits for that time period. The insurance plan billed for each visit was recorded and classified as Medicare, Medicaid, Workers' Compensation, or commercial. RESULTS:  In 2019, prior to the billing level requirement changes, 7.2% of all visits were billed as level 2, 84.8% of all visits were billed as level 3, and 7.8% of all visits were billed as level 4. In 2021, 1.9% of visits were billed as level 2, 47.3% of visits were billed as level 3, and 50.5% of visits were billed as level 4. Level 1 and 5 visits did not exceed 0.5% in either timeframe. Within each insurance category, the proportion of visit levels of care followed a similar trend of reduced level 2 and 3 visits and increased level 4 visits from 2019 to 2021. CONCLUSION: We noted a significant trend toward higher code level selection following the recent code level changes, and we anticipate these recent code selection trends to have major financial implications moving forward.

Tramadol Versus Codeine in Hand Surgery.

Introduction Tramadol and codeine are both commonly prescribed in the setting of surgery or injury to the upper extremity. Despite their comparable strength in terms of opioid receptor affinity, the drugs differ pharmacologically and thus are not completely interchangeable. Methods This study analyzes all prescriptions for codeine and tramadol by a group of hand surgeons over a one-year period and tests the central hypothesis that the prescribing and refill patterns of these two drugs would be similar. Results Despite similar prescription amounts in terms of morphine equivalents, patients receiving tramadol required prescription refills at a significantly higher amount than those receiving codeine, and these individuals tended to be older. Additionally, patients treated nonoperatively were prescribed significantly more tramadol than those treated surgically. Conclusion Our findings suggest that codeine and tramadol are not equivalent in managing upper extremity pain. Further study is needed to articulate the situations in which physicians and patients are better served by tramadol versus codeine.

Do Postoperative Telehealth Visits Require a High Rate of Redundant In-Person Evaluation After Upper Extremity Surgery?

Background Telehealth platforms may save resources for patients and providers, but the precise impact of their incorporation during the postoperative period is not well understood. The goal of this study is to determine whether telehealth incorporation in the postoperative period leads to an overall increase in healthcare utilization after upper extremity surgery. Methodology Patients seen for a postoperative telehealth visit after upper extremity surgery were randomly selected and retrospectively enrolled. Complications and the total number of postoperative visits before clinical discharge were recorded and compared to controls matched by surgery type and surgeon. Results A total of 56 patients were seen for 60 telehealth visits. The most common surgical procedures were distal radius open-reduction internal fixation (n = 8), open carpal tunnel release (n = 8), and endoscopic carpal tunnel release (n = 6). One telehealth visit (1.7%) required conversion to in-person evaluation due to suspected superficial infection necessitating in-person physical examination. The average number of postoperative visits prior to clinical discharge was 2.6 in the telehealth group compared to 2.7 in matched controls (p = 0.886). Complication rates were similar between groups. Conclusions The rate of necessary in-person evaluation after postoperative telehealth visits was less than 2%. The incorporation of telehealth visits did not appear to increase healthcare utilization after upper extremity surgery. Accordingly, the postoperative period is likely an ideal application for safe and effective telehealth implementation.

An Evaluation of the Source and Content of Dupuytren's Disease Information Available on the Internet.

Introduction The internet continues to expand in both size and number of users, and patients are using the internet with increasing frequency to research orthopedic conditions and treatment options. Despite the prevalence of patients searching for medical information, the quality of the available information varies substantially. The purpose of this study was to investigate the reliability and accuracy of the information available on the internet for Dupuytren's disease. We hypothesized that the informational content found on the internet regarding this condition would be of acceptable quality. Methods The search phrasing "'Dupuytren' OR 'Dupuytren's'" was used to mimic how patients would likely search for information on the disease. These terms were entered into the five English-language search engines with the most frequent use on the internet. On each search engine, the first 50 URLs were recorded, including sponsored sites. The 250 total sites were filtered to remove duplicate sites and URLs linking to other search engines, resulting in a final list of 84 websites for informational scoring. A previously published information evaluation protocol was used to grade each website. Each site was graded according to these guidelines by two authors and scored based on authorship, content, disease summary, treatment options, pathogenesis, complications, and results. A third author resolved any conflict on authorship or content before analysis. The resultant "informational value" is the sum of the disease summary, treatment options, pathogenesis, complications, and results and can range from 0-100.  Results The mean total information score for all sites was 47.5 out of 100 points. Forty-three (51.2%) of the websites evaluated were authored by a physician or academic institution, and thirty-four (40.5%) of the sites were commercial in nature. The final seven websites (8.3%) had nonphysician, unidentified, or lay authorship. Physician and academic institution authored websites had an average informational score of 55.5 out of 100 points, compared to 39.7 out of 100 for all other websites. This difference was statistically significant (p <0.01). The mean informational score for the 10 sponsored websites was 16.4 out of 100. Conclusion We concluded that internet information on Dupuytren's disease is of poor quality and incomplete. Academic and physician authored sites have higher quality than commercial sites, but significant room for improvement still exists. Patients should be advised to identify the authorship of the websites they obtain information from and avoid advertisements and commercial sites.