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Sun Cao P, Loewenstein SN, Timsina LR, Adkinson JM. The Association of Insurance Status and Complications After Carpal Tunnel Release. Hand (N Y) 2023; 18:192-197. [PMID: 33631982 PMCID: PMC10035105 DOI: 10.1177/1558944721990818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Carpal tunnel release (CTR) is one of the most commonly performed procedures in hand surgery. Complications from surgery are a rare but significant patient dissatisfier. The purpose of this study was to determine whether insurance status is independently associated with complications after CTR. METHODS We retrospectively identified all patients undergoing CTR between 2008 and 2018 using the Indiana Network for Patient Care, a state-wide health information exchange, and built a database that included patient demographics and comorbidities. Patients were followed for 90 days to determine whether a postoperative complication occurred. To minimize dropout, only patients with 1 year of encounters after surgery were included. RESULTS Of the 26 151 patients who met inclusion criteria, 2662 (10.2%) had Medicare, 7027 (26.9%) had Medicaid, and 16 462 (62.9%) had commercial insurance. Compared with Medicare, Medicaid status (P < .001) and commercial insurance status (P < .001) were independently associated with postoperative CTR complications. The overall complication rate was 2.23%, with infection, wound breakdown, and complex regional pain syndrome being the most common complications. Younger age, alcohol use, diabetes mellitus, hypertension, and depression were also independently associated with complications. CONCLUSIONS The incidence of complications after CTR is low. Insurance status, patient demographics, and medical comorbidities, however, should be evaluated preoperatively to appropriately risk stratify patients. Furthermore, surgeons can use these data to initiate preventive measures such as working to manage current comorbidities and lifestyle choices, and to optimize insurance coverage.
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Kawamata J, Suenaga N, Oizumi N, Matsumoto H, Kikuchi A, Inoue M. Differences in incidence rate and onset timing of undiagnosed finger symptom among shoulder surgeries related to complex regional pain syndrome. THE JOURNAL OF MEDICAL INVESTIGATION 2023; 70:415-422. [PMID: 37940526 DOI: 10.2152/jmi.70.415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2023]
Abstract
The purpose of this study was to clarify the difference in onset timing and incidence of undiagnosed finger symptom (UDFS) between various shoulder surgical procedures. In this study, UDFS symptoms included the following four symptoms in the fingers;edema, limited range-of-motion, skin color changes, and abnormal sensations. UDFS cases were defined as those presenting with at least one UDFS. In result, the incidence rate of UDFS cases was 7.1% overall (58/816 shoulders), 7.4% (32/432) in arthroscopic rotator cuff repair (ARCR), 9.0% (11/122) in open rotator cuff repair (ORCR), 1.4% (2/145) in arthroscopic subacromial decompression (ASD), 13.2% (5/38) in open reduction and internal fixation (ORIF), 11.1% (3/27) in humeral head replacement, 4.8% (1/21) in anatomical total shoulder arthroplasty, and 12.9% (4/31) in reverse total shoulder arthroplasty cases. The Rate was significantly higher with ARCR compared to ASD (p<.01). About onset timing in weeks postoperatively, the ORIF group had a statistically earlier symptom onset than the Rotator cuff repair (ARCR + ORCR) group (2.4 weeks vs. 6.0 weeks, p<.01). When classifying the onset timing into before and after the removal of the abduction pillow, the ORIF group showed a statistically higher rate of onset before brace removal than the Rotator cuff repair groups (p<.01). Differences in UDFS among shoulder surgeries were demonstrated in this study. J. Med. Invest. 70 : 415-422, August, 2023.
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Affiliation(s)
- Jun Kawamata
- Department of Orthopaedic Surgery, Kaisei Hospital, Hokkaido, Japan
| | - Naoki Suenaga
- Upper Extremity Center of Joint Replacement and Endoscopic Surgery, Hokushin Orthopaedic Hospital, Hokkaido , Japan
| | - Naomi Oizumi
- Upper Extremity Center of Joint Replacement and Endoscopic Surgery, Hokushin Orthopaedic Hospital, Hokkaido , Japan
| | - Hisashi Matsumoto
- Department of Rehabilitation, Hokushin Orthopaedic Hospital, Hokkaido, Japan
| | - Akira Kikuchi
- Department of Rehabilitation, Koga Hospital, Hokkaido, Japan
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Taylor SS, Noor N, Urits I, Paladini A, Sadhu MS, Gibb C, Carlson T, Myrcik D, Varrassi G, Viswanath O. Complex Regional Pain Syndrome: A Comprehensive Review. Pain Ther 2021; 10:875-892. [PMID: 34165690 PMCID: PMC8586273 DOI: 10.1007/s40122-021-00279-4] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 06/03/2021] [Indexed: 12/22/2022] Open
Abstract
Complex regional pain syndrome (CRPS) is a chronic pain condition often involving hyperalgesia and allodynia of the extremities. CRPS is divided into CRPS-I and CRPS-II. Type I occurs when there is no confirmed nerve injury. Type II is when there is known associated nerve injury. Female gender is a risk factor for developing CRPS. Other risk factors include fibromyalgia and rheumatoid arthritis. Unfortunately, the pathogenesis of CRPS is not yet clarified. Some studies have demonstrated different potential pathways. Neuropathic inflammation, specifically activation of peripheral nociceptors of C-fibers, has been shown to play a critical role in developing CRPS. The autonomic nervous system (ANS) is involved. Depending on whether it is acute or chronic CRPS, norepinephrine levels are either decreased or increased, respectively. Some studies have suggested the importance of genetics in developing CRPS. More consideration is being given to the role of psychological factors. Some association between a history of depression and/or post-traumatic stress disorder (PTSD) and the diagnosis of CRPS has been demonstrated. Treatment modalities available range from physical therapy, pharmacotherapy, and interventional techniques. Physical and occupational therapies include mirror therapy and graded motor imagery. Medical management with non-steroidal anti-inflammatory drugs (NSAIDs) has not shown significant improvement. There have been supporting findings in the use of short-course steroids, bisphosphonates, gabapentin, and ketamine. Antioxidant treatment has also shown some promise. Other pharmacotherapies include low-dose naltrexone and Botulinum toxin A (BTX-A). Sympathetic blocks are routinely used, even if their short- and long-term effects are not clear. Finally, spinal cord stimulation (SCS) has been used for decades. In conclusion, CRPS is a multifactorial condition that still requires further studying to better understand its pathogenesis, epidemiology, genetic involvement, psychological implications, and treatment options. Future studies are warranted to better understand this syndrome. This will provide an opportunity for better prevention, diagnosis, and treatment of CRPS.
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Affiliation(s)
- Samantha-Su Taylor
- grid.134563.60000 0001 2168 186XUniversity of Arizona College of Medicine-Phoenix, Phoenix, AZ USA
| | - Nazir Noor
- Department of Anesthesiology, Mount Sinai Medical Center, 4300 Alton Road, Miami Beach, FL, 33130, USA.
| | - Ivan Urits
- grid.492905.3Southcoast Physician Group Pain Medicine, Southcoast Health, North Dartmouth, MA USA ,grid.64337.350000 0001 0662 7451Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA USA
| | - Antonella Paladini
- grid.158820.60000 0004 1757 2611Department of MESVA, University of L’Aquila, 67100 L’Aquila, Italy
| | - Monica Sri Sadhu
- grid.134563.60000 0001 2168 186XUniversity of Arizona College of Medicine-Phoenix, Phoenix, AZ USA
| | - Clay Gibb
- grid.260024.2Midwestern University Chicago College of Osteopathic Medicine, Chicago, IL USA
| | - Tyler Carlson
- grid.134563.60000 0001 2168 186XUniversity of Arizona College of Medicine-Phoenix, Phoenix, AZ USA
| | - Dariusz Myrcik
- grid.411728.90000 0001 2198 0923Department of Internal Medicine, Medical University of Silesia, 42-600 Katowice, Bytom Poland
| | | | - Omar Viswanath
- grid.134563.60000 0001 2168 186XUniversity of Arizona College of Medicine-Phoenix, Phoenix, AZ USA ,grid.64337.350000 0001 0662 7451Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA USA ,Valley Pain Consultants-Envision Physician Services, Phoenix, AZ USA ,grid.254748.80000 0004 1936 8876Department of Anesthesiology, Creighton University School of Medicine, Omaha, NE USA
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Barnes JI, Paci G, Zhuang T, Baker LC, Asch SM, Kamal RN. Cost-Effectiveness of Open Versus Endoscopic Carpal Tunnel Release. J Bone Joint Surg Am 2021; 103:343-355. [PMID: 33591684 PMCID: PMC8177000 DOI: 10.2106/jbjs.19.01354] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Carpal tunnel syndrome is the most common upper-extremity nerve compression syndrome. Over 500,000 carpal tunnel release (CTR) procedures are performed in the U.S. yearly. We estimated the cost-effectiveness of endoscopic CTR (ECTR) versus open CTR (OCTR) using data from published meta-analyses comparing outcomes for ECTR and OCTR. METHODS We developed a Markov model to examine the cost-effectiveness of OCTR versus ECTR for patients undergoing unilateral CTR in an office setting under local anesthesia and in an operating-room (OR) setting under monitored anesthesia care. The main outcomes were costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). We modeled societal (modeled with a 50-year-old patient) and Medicare payer (modeled with a 65-year-old patient) perspectives, adopting a lifetime time horizon. We performed deterministic and probabilistic sensitivity analyses (PSAs). RESULTS ECTR resulted in 0.00141 additional QALY compared with OCTR. From a societal perspective, assuming 8.21 fewer days of work missed after ECTR than after OCTR, ECTR cost less across all procedure settings. The results are sensitive to the number of days of work missed following surgery. From a payer perspective, ECTR in the OR (ECTROR) cost $1,872 more than OCTR in the office (OCTRoffice), for an ICER of approximately $1,332,000/QALY. The ECTROR cost $654 more than the OCTROR, for an ICER of $464,000/QALY. The ECTRoffice cost $107 more than the OCTRoffice, for an ICER of $76,000/QALY. From a payer perspective, for a willingness-to-pay threshold of $100,000/QALY, OCTRoffice was preferred over ECTROR in 77% of the PSA iterations. From a societal perspective, ECTROR was preferred over OCTRoffice in 61% of the PSA iterations. CONCLUSIONS From a societal perspective, ECTR is associated with lower costs as a result of an earlier return to work and leads to higher QALYs. Additional research on return to work is needed to confirm these findings on the basis of contemporary return-to-work practices. From a payer perspective, ECTR is more expensive and is cost-effective only if performed in an office setting under local anesthesia. LEVEL OF EVIDENCE Economic and Decision Analysis Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- James I Barnes
- VA Palo Alto Health Care System, Palo Alto, California
- Center for Primary Care and Outcomes Research/Center for Health Policy, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Gabrielle Paci
- VOICES Health Policy Research Center, Department of Orthopedic Surgery, Stanford University School of Medicine, Stanford, California
| | - Thompson Zhuang
- VOICES Health Policy Research Center, Department of Orthopedic Surgery, Stanford University School of Medicine, Stanford, California
| | - Laurence C Baker
- Center for Primary Care and Outcomes Research/Center for Health Policy, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Steven M Asch
- VA Center for Innovation to Implementation, Palo Alto, California
- Division of Primary Care and Population Health, Stanford University, Stanford, California
| | - Robin N Kamal
- VOICES Health Policy Research Center, Department of Orthopedic Surgery, Stanford University School of Medicine, Stanford, California
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Abstract
PURPOSE OF REVIEW Carpal tunnel syndrome is the most common compressive neuropathy encountered by hand and upper extremity surgeons. The predominant presentation includes symptomatic paresthesias in the median nerve distribution of the affected hand, frequently causing nocturnal disturbances. Surgical treatment requires division of the transverse carpal ligament, which can be performed through open and endoscopic means. Endoscopic techniques have evolved significantly since they were first introduced in the late 1980s. This manuscript reviews the literature to summarize the current state of carpal tunnel surgery. RECENT FINDINGS While endoscopic techniques have demonstrated superior early functional outcomes and a more rapid recovery, there are lingering concerns over the potential for nerve, vessel, and tendon injuries. These concerns have not been validated by the hand surgery literature, which ascribes similar rates of complications for both open and endoscopic surgical approaches. Moreover, patients report greater satisfaction with endoscopic surgical approaches compared with open techniques. In summary, the debate between proponents of open versus endoscopic carpal tunnel surgery continues. While surgeons who employ endoscopic techniques appear to be in the minority, there is a plethora of evidence to suggest that both approaches are comparably safe and equally effective.
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Affiliation(s)
- Eon K Shin
- Philadelphia Hand to Shoulder Center, Thomas Jefferson University Hospital, 1203 Langhorne-Newtown Road, Suite 335, Langhorne, PA, 19047, USA.
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