Coding Practices in Hand Surgery and Their Relationship to Surgeon Compensation Structure.

Purpose: To evaluate the coding practices of hand surgeons in the American Society for Surgery of the Hand with respect to practice compensation structure using common, representative hand surgery cases. Methods: We developed a survey of demographic factors and 4 commonly encountered hypothetical hand surgery cases. This survey was emailed to the members of the American Society for Surgery of the Hand. Respondents were asked to code these cases using prepopulated applicable Current Procedural Terminology codes or any other codes of their choosing. The membership responses were then compared with those of 3 independent orthopedic coders. Results: Of the 4,477 invitations sent, a total of 421 (9.4%) respondents completed the survey. There was notable heterogeneity in the Current Procedural Terminology code choices for the trapeziectomy and distal radius fracture cases. Physicians with a collections-based model coded for significantly higher work-related value units on average compared with the fixed salary- and relative value unit-based physicians for the trapeziectomy case (14.41 vs 13.65 and 13.67, respectively; P < .05). The 3 independent coders all chose a single Current Procedural Terminology code for the carpal tunnel release, distal radius fracture, and scaphoid nonunion cases. The percentages of physician responses that selected only these codes were 84.6% (carpal tunnel release), 61.0% (distal radius fracture), and 73.6% (scaphoid nonunion). Physicians were less likely to code in line with the independent coders for the distal radius fracture case compared with other cases, particularly those physicians with a collections-based model. Conclusions: The compensation model may be associated with coding practices for more complicated hand cases. The additional work-related value units potentially billed can quickly accumulate for frequently performed procedures. This wide variation supports a need for more frequent and accessible communication and education on coding practices in hand surgery. Clinical relevance: Improved communication and education regarding appropriate coding practices as well as easily accessible reference material may assist in minimizing coding discrepancies for surgical hand procedures.

The Effect of Femoral Cutting Jig Design on Restoration of Femoral Offset in Posterior-Referenced Total Knee Arthroplasty.

Femoral component sizing and rotation in total knee arthroplasty (TKA) affects patellofemoral tracking and tibiofemoral mechanics. Posterior referencing is said to optimize restoration of posterior condylar offset. However, it typically allows the surgeon to select 3° to 5° of external rotation to the posterior condylar axis, inevitably changing the offset of one or both condyles. The axis about which external rotation occurs varies between the jigs of various TKA systems. The location of this axis can result in a medial, central, or lateral reference point for posterior offset restoration. Variations in jig design will result in varying posterior offset changes at the same jig setting, with differential effects on balance between the flexion and extension gaps. Using identical Sawbones in a controlled laboratory setting, 9 TKA instrumentation systems were examined. Two systems referenced medially, 1 referenced laterally, and 6 referenced centrally. The authors measured distal and posterior resections in both 3° and 5° of external rotation to the posterior condylar axis. They calculated changes in both distal and posterior joint lines using resection measurements and implant specifications. Posterior resection thicknesses were greatest with instruments that referenced laterally and least with instruments that referenced medially. With increasing external rotation, instruments that referenced off the lateral femoral condyle introduced the greatest mismatch between the distal and posterior joint lines, as compared with instruments that referenced centrally or medially. Surgeons should be aware that laterally referencing systems can differentially restore distal and posterior joint lines at higher settings of femoral external rotation, potentially introducing incongruity between flexion and extension gaps if the posterior slope of the tibia is maintained. This may be particularly problematic if flexion laxity is increased by posterior cruciate ligament sacrifice. [Orthopedics. 2019; 42(6):316-322.].

Augmentation of Fracture Healing Using Soft Callus.

OBJECTIVES: This study sought to investigate the effect of soft callus removal and reapplication in a rat closed femur fracture model. We hypothesized that removing soft callus will impair fracture healing, whereas reapplication will facilitate healing. METHODS: A closed midshaft femur fracture was created in 78 rats and stabilized with an intramedullary wire. Seven days later, rats were equally divided and fractures surgically exposed. In the control group, no callus was removed, whereas in the callus removal group CR(-) group, the callus was removed and in the callus replaced group CR(+), callus was removed and replaced. Half of the rats were killed at 4 and 7 weeks. Fracture healing was graded with radiographs and callus volume measured with micro-CT. Mechanical torsion properties were measured, and histologic analysis was conducted. RESULTS: At both end points, evidence of delayed healing was found on radiographs and micro-CT in CR(-) rats (P = 0.0001), whereas CR(+) rats showed normal fracture healing compared with controls. The normalized callus volume was similar in all groups at both end points. At 7 weeks, the maximum stiffness in CR(-) rats was 68% less than control (P = 0.0001). Stiffness increased 55% in CR(+) rats from CR(-) rats (P = 0.0017). Histology supported our findings with complete endochondral ossification in CR(+) rats but wide areas of hyaline cartilage in CR(-) rats at 7 weeks. CONCLUSIONS: Removal of soft callus in a rat model delays fracture healing at early and late time points, whereas replacement mitigates these negative consequences. Replacing the soft callus should be considered in all osteosynthesis procedures.

Ischiovertebral dysplasia: a retrospective analysis of 30 consecutive cases pointing out the specifics and risks of the spine management.

STUDY DESIGN: A review of clinical publications, current knowledge, and recent developments regarding the etiology of ischiovertebral dysplasia was combined with a clinical review of the condition. OBJECTIVE: To acquaint orthopedic spine surgeons with identification patterns of ischiovertebral dysplasia in order to provide them with guidelines about spine management and which complications to expect. SUMMARY OF BACKGROUND DATA: Ischiovertebral dysplasia is a rare skeletal dysplasia that may appear in a sporadic fashion or be inherited with an autosomal dominant inheritance pattern. It is defined by the association of an ischiopubic ramus hypoplasia and a vertebral dysplasia. It leads to a specific spine deformity whose management and complications should be clarified. METHODS: Thirty consecutive patients from 0 to 31 years of age with ischiovertebral dysplasia were included from 5 centers specialized in congenital spinal deformities. Frontal and sagittal Cobb angles before treatment, natural history of the curves, therapeutic options, and their complications were systematically analyzed. RESULTS: All the patients had a vertebral dysplasia and 28 of them developed a spinal deformity. This deformity was an extremely severe thoracic kyphoscoliosis in 25 cases. The other deformities were a thoracolumbar scoliosis in 1 case and a thoracolumbar kyphosis in 2 cases. The management of the thoracic kyphoscoliosis was always challenging and complications included death by respiratory failure (3 cases) and neurological impairment (9 cases). CONCLUSION: Recognizing the occurrence of ischioverterbral dysplasia is very important to allow for dedicated treatment. The authors advocate preoperative distraction and circumferential fusion to prevent progression of the curve and to avoid the potentially fatal sequelae associated with this disorder. LEVEL OF EVIDENCE: 4.