Current Procedural Terminology Codes Research Articles

Comparing Rates of Radiographic Baseplate Loosening Between Cement and Cementless INFINITY Total Ankle Prostheses

Category: Ankle Arthritis Introduction/Purpose: Total ankle replacement has risen in popularity as the contemporary treatment-of-choice for end-stage ankle osteoarthritis. INFINITY™ Total Ankle System (Stryker, Kalamazoo, MI) is one of the most frequently used ankle prostheses. Prior studies established positive functional outcomes; however, aseptic baseplate loosening has reported to occur in approximately one-third of patients. Aseptic baseplate loosening is seen radiographically either as shift in talar or tibial components or evidence of periprosthetic lucency. Aseptic baseplate loosening with persistent pain defines prosthesis failure, thus an indication for early surgical revision. Implementing bone cement may fixate and stabilize prostheses, potentially reducing incidence of aseptic baseplate loosening. This study aimed to determine if patients with cemented INFINITY total ankle prostheses had different incidence of aseptic baseplate loosening than those with cementless prostheses. Methods: Patients who underwent total ankle arthroplasty using the INFINITY total ankle prosthesis system between January 2016 and May 2022 (n = 28) were retrospectively identified using keyword search for “infinity” and Current Procedural Terminology (CPT) code 27702. Fourteen patients had prostheses affixed with cement, and fourteen patients had prostheses that were not cemented. Preoperative, immediate postoperative, and most recently available anteroposterior (AP), mortise, and lateral ankle X- rays were reviewed. Tibiotalar angle, talar tilt, and presence of visible postoperative lucency were assessed independently by two reviewers. Wilcoxon rank-sum test on quantitative variables and chi-square test on categorical variables were performed with 0.05 significance level. Results: Inter-rater reliability was above 94% for all measurements. Comparing the cemented to cementless sample group, difference in average age (59.5 years vs. 56.5 years, p=0.32) and sex (57.1% vs. 50.0% female, p=0.70) were not statistically significant. Pre-operative and immediate post-operative tibiotalar and talar tilt angles were not statistically significantly different between cement and cementless groups (p>0.31 for all comparisons). Only one patient in the cement group had evidence of periprosthetic lucency in the immediate postoperative period. Median follow-up was 362.5 days and 544.5 days in the cement and cementless group, respectively (p=0.52). Follow-up tibiotalar angles and talar tilt angle between cement and cementless groups were not significantly different (p>0.51 for all comparisons). Periprosthetic lucency occurred in 50% of both groups in the follow- up period (p=1.0). Conclusion: Patients with cemented INFINITY total ankle prostheses had equal incidence of aseptic baseplate loosening compared to patients with cementless prostheses. Continuing to examine methods for reducing incidence of baseplate loosening is significant for potentially reducing rate of early prosthesis revision and prosthesis failure, consequently improving quality of life for patients.

Peritalar Osteotomy for Rigid Pes Cavus and Cavovarus

Category: Other; Hindfoot Introduction/Purpose: Pes cavus and pes cavovarus deformities create varus loading during stance phase of gait that often presents as lateral ligament instability, peroneal tendon rupture or lateral column overload. When flexible, management ranges from the use of custom foot orthoses or an ankle-foot orthosis, to a combination of soft tissue releases, tendon transfer and/or corrective osteotomy. When rigid, clinical management involves corrective osteotomies or triple arthrodesis. The Ilizarov method of gradual correction of structural bony deformities provides a powerful tool to achieve a stable plantigrade foot in patients with complex multiplanar structural deformities. This investigation presents a method of a continuous multiple bone “peri-talar” osteotomy, combined with acute correction of the multiplanar deformity, for treating severe rigid structural pes cavus and pes cavovarus. Methods: Following IRB approval, patients were identified based on a combination of CPT (Current Procedural Terminology) codes and confirmed by chart review. Standard demographics, etiology of deformity and weight-bearing radiographs (before and after surgery) were reviewed. Perioperative complications, clinical evaluation and type of footwear used were recorded. A favorable clinical outcome was defined as a foot that is ulcer and infection-free, and able to walk in the community with standard oxford shoes. Surgical technique involved an osteotomy from the dorsal calcaneus, carried anterior and inferior for approximately fifty percent of the calcaneus, and then carried anteriorly into the mid cuboid. A second osteotomy through a separate medial incision is made from medial to lateral, splitting the navicular, and connecting to the initial lateral osteotomy. Acute correction of the multiplanar deformity is accomplished. Maintenance of the correction is then achieved with the use of an Ilizarov-like “mitre” circular external fixation construct. Results: 17 patients (three bilateral) were included, with average follow-up of 58.3 (range 12-183) months. One patient developed a postoperative wound infection that required formal surgical debridement. He died of unrelated causes before removal of the external fixator. A second postoperative wound infection was managed with local wound care. One pin-site infection required debridement following removal of the external fixator. Due to the rotational component of the deformities, meaningful measurement of deformity correction could not be accomplished. This clinical outcome was based primarily on the ability to walk without complex bracing. Sixteen of the twenty feet achieved ambulation with standard oxford footwear. Three patients required a short AFO, but were unrestricted community ambulators. A review of the non-standardized x-rays was not able to yield meaningful data. Conclusion: There have been very few clinical reports of surgical correction of patients with severe rigid pes cavovarus or equinovarus deformities. This small series of patients underwent correction of complex rigid pes cavovarus type deformities with a peritalar osteotomy, acute correction of deformity and maintenance of correction with a “mitre frame” circular external fixator. Several proponents of the Ilizarov method have described individual patients with very similar methodology. This small series of patients suggests that one can achieve an acute, or gradual, correction of complex deformity with multiple related osteotomies, and maintenance of that correction with an adjustable circular external fixator.

Is Timing of Total Hip Arthroplasty and Lumbar Spine Fusion Associated With Risk of Hip Dislocation?

In patients with concomitant hip and lumbar spine disease, the question of which surgery-total hip arthroplasty (THA) or lumbar spine fusion (LSF)-to address first has not been adequately answered. We aimed to evaluate the risk of dislocation after THA in patients with LSF first or after THA. Retrospective review utilizing the PearlDiver database querying Current Procedural Terminology codes for LSF in the year prior (LSF first) or in the year after primary or revision THA (THA first). International Classification of Disease codes identified postoperative hip dislocation as our primary outcome variable. Demographic data collected included age, sex, and obesity. Dislocation rates were described as a proportion of the cohort and compared with chi-square tests. We identified 280,857 primary THA and 42,314 revision THA cases from 2012-2019. Of these, 2090 underwent primary THA and LSF, and 283 underwent revision THA and LSF within a year of each procedure. No differences in age, sex, or obesity between groups were noted. No difference in rate of all-time dislocation for primary THA was noted for the LSF first 51/1429 (3.6%) compared to the THA first 30/661 (4.0%) groups (P= .34), or for revision THA with LSF first 48/204 (23.5%) compared to THA first 27/117 (23.1%) groups (P= 1.0). There was no difference in the risk of dislocation after primary or revision THA if LSF occurred prior to or after the THA. These findings can help surgeons as they counsel patients with concomitant lumbar spine and hip degeneration.

Hospital cost differences between open and endoscopic lumbar spine decompression surgery.

In recent years, fully endoscopic decompression surgery for degenerative spine disease has become increasingly popular in the US. Although an endoscopic approach has demonstrated some benefits compared with open procedures in randomized controlled trials, the cost of advanced technologies remains contested. The authors evaluated the differences in costs and cost drivers between open and endoscopic decompression surgical procedures performed at a single institution. Using associated Current Procedural Terminology codes, the authors identified all open and endoscopic decompression lumbar surgical procedures performed from January 1, 2016, through December 31, 2022. Preoperative comorbidities, surgical characteristics, and postoperative outcomes were captured. The costs of index surgery-related readmission for revision, washout, or other complications were included in the index surgery expenses. Associated in-hospital costs were collected; these were reported in comparative percentages with open surgical procedures as the baseline because of an institutional agreement. Univariate and multivariate analyses were performed. The retrospective search identified 633 open surgical procedures and 195 endoscopic surgical procedures for inclusion. The two patient cohorts were similar, with clinically nonrelevant but statistically significant differences in mean age (open 55.7 years vs endoscopic 59.4 years, p = 0.01) and mean American Society of Anesthesiologists physical status class (open 2.3 vs endoscopic 2.4, p = 0.03). Postoperatively, patients who underwent open surgical procedures had significantly longer mean hospital stays (open 1.4 days vs endoscopic 0.7, p < 0.01) and more perioperative complications (open 7.9% of patients vs endoscopic 3.1%, p = 0.02), and they required washout surgical procedures in some cases (open 1.3% vs endoscopic 0%, p = 0.12). The largest cost difference between open and endoscopic surgical procedures was the significantly greater cost of disposable supplies for endoscopic cases (10.1% vs 31.7% of the total cost of open procedures, p < 0.01), and open surgical procedures were generally less costly in total (100.0% vs 115.1%, p < 0.01). In multivariate linear regression, endoscopic surgery was independently associated with greater total costs (standardized beta 15.9%, p < 0.01), although length of hospital stay (standardized beta 34.0%) and readmissions (standardized beta 30.0%, p < 0.01) had larger effects on cost. The endoscopic approach was associated with greater total in-hospital costs compared with open procedures. The findings of further cost evaluations, including those of patient-reported outcomes, social cost, and capital costs per procedure type, need to be included in operational and clinical decisions.

The Minimal Utility of Analyzing Ureteropelvic Junction Tissue at the Time of Pyeloplasty

Introduction: Ureteropelvic junction obstruction is a common cause of upper tract obstruction that often necessitates surgical intervention because of its severe implications. A high proportion of these surgeries include pathologic analysis of this tissue with unclear clinical value. We examined our institution's practices concerning sending the ureteropelvic junction (UPJ) specimens for pathology analysis, its clinical value, and the associated costs for both pediatric and adult cases. Methods: We performed retrospective chart review using Current Procedural Terminology codes for pyeloplasty over 8 years. Clinical variables were extracted from operative reports, path reports, and postoperative clinic notes. Pathology results were classified dichotomously as “benign” or “malignant” and subsequently assigned to 1 of 4 categories—inflammation, fibrosis, muscular hyperplasia, or no atypical findings. Results: Two hundred sixty-nine pyeloplasty surgeries were included, 68% of which were in children. Pathologic analysis was requested in most of the cases (91%), and this was slightly more common in adults (94%) than in pediatric patients (90%). All available pathology reports found benign findings in the UPJ specimen, mostly commonly categorized as “normal.” No cases of malignancy were noted. At the list price for pathologic analysis, $103,027 was spent over 8 years without the discovery of clinically significant pathology findings. Conclusions: There was a lack of clinically meaningful results from pathologic analysis of UPJ specimens excised during pyeloplasty. A UPJ specimen should not be routinely sent for pathologic analysis rather selectively if there is clinical concern for nonbenign etiology of UPJ obstruction.

Urinary Tract Infections After Urogynecologic Surgery: Risk Factors, Timeline, and Uropathogens

ABSTRACT Postoperative urinary tract infection (PO-UTI) is seen in 6.4%–32% of stress urinary incontinence (SUI) and/or pelvic organ prolapse (POP) surgeries despite perioperative antibiotic prophylaxis. Postoperative complications associated with PO-UTI include increased mortality and longer hospitalization. Increasing prevalence of resistance to antibiotics and antibiotic stewardship principles necessitate both the improvement of infection prevention strategies and judicious antibiotic prescriptions. Four factors are known to increase PO-UTI risk: (1) recurrent UTI (RUTI) history, (2) preoperative UTI, (3) day-of-surgery UTI, and (4) prolonged postoperative catheterization. This study intended to determine (1) risk factors of PO-UTI and PO-RUTI, (2) preoperative and postoperative UTI temporal distribution, and (3) detected uropathogens in a large database. The study used medical record data of all SUI/POP surgical procedures performed in the Kaiser Southern California Hospital system from January 1, 2008 to December 31, 2016 for women 18 years of age or older. Procedures used Current Procedural Terminology codes for identifying and subcategorizing surgical procedures and their route (SUI or POP; abdominal or vaginal, respectively). The study-wide definition of UTI was as follows: (1) positive standard urine culture of greater than 105 CFU/mL of ≤2 uropathogens, or (2) prescription of urinary antibiotics prescribed for the indication of UTI symptoms. The analysis consisted of 21,063 urogynecologic surgical procedures performed on 20,051 women (33,626 POP and/or SUI procedures), with 22,641 UTI events being diagnosed in 10,091 women. Mean age was 56.9 years, and mean BMI was 29.1. The cohort underwent surgery for only SUI (35.4%), only POP (32.7%), or POP/SUI combined (31.9%). In the 13.5 months postoperatively, 11,976 UTIs were diagnosed in 6733 women. The first month experienced a sharp increase compared with the preoperative year, the second month increased further, and the third month showed leveling of PO-UTI incidence. Prescribed antibiotics captured most UTI events (13,337 or 58.3%). Prescribed antibiotics, in order of most-prescribed to least-prescribed, were as follows: ciprofloxacin (33.7%), cephalexin (21.4%), nitrofurantoin (20.4%), and sulfamethoxazole-trimethoprim (17.6%). The study determined that most PO-UTIs occurred within the first 2 months, with many of these being diagnosed within 2 weeks of surgery. For those patients already having a history of RUTI, RUTI significantly increases in postoperative year 1 when compared with the preoperative year. All patients undergoing SUI procedures had increased PO-RUTI risks compared with their POP-only group peers. Escherichia coli was the most common pathogen found. Risk and event timing were affected by surgical indication: although surgery for only SUI had a lower 6-week PO-UTI risk, it was counterintuitively associated with a higher PO-RUTI risk. Multivariate regression revealed predictable risk factors for PO-UTI: OAB, history of diabetes, history of preoperative UTI within 6 weeks of surgery, history of RUTI, stent and catheter placement. A more confusing finding was the association of a vaginal estrogen prescription with increased short-term PO-UTI risk, possibly related to its use in women with a history of RUTI, but more probably related to the postmenopausal status of many of the women in the dataset. The study recommends preoperative assessment with the purpose of identifying and eliminating UTIs within 6 weeks before surgery, as well as development of protocols for enhanced prophylaxis for women at increased risk such as diabetics and women with preoperative RUTI.

Distressed Communities Demonstrate Increased Readmission and Healthcare Utilization Following Shoulder Arthroplasty.

Socioeconomic status (SES) has been shown to affect outcomes following total shoulder arthroplasty (TSA), but little is known regarding how SES and the communities in which patients reside can affect postoperative healthcare utilization. With the growing use of bundled payment models, understanding what factors put patients at risk for readmission and the ways in which patients utilize the healthcare system postoperatively is crucial for preventing excess costs for providers. This study helps surgeons predict which patients are high-risk and may require additional surveillance following shoulder arthroplasty. A retrospective review of 6,170 patients undergoing primary shoulder arthroplasty (anatomic and reverse; CPT code 23472) from 2014-2020 at a single academic institution was performed. Exclusion criteria included arthroplasty for fracture, active malignancy, and revision arthroplasty. Demographics, patient ZIP Code, and Charlson Comorbidity Index (CCI) were attained. Patients were classified according to the Distressed Communities Index (DCI) score of their zip code. The DCI combines several metrics of socioeconomic wellbeing to generate a single score. Zip codes are then classified by scores into five categories based on national quintiles. The primary outcome of interest was 90-day readmissions. Secondary outcomes included number of postoperative medication prescriptions, patient telephone calls to the office, and follow-up office visits. Amongst all patients undergoing total shoulder arthroplasty, individuals from distressed communities were more likely than their prosperous counterparts to experience an unplanned readmission (Odds Ratio=1.77, p=0.045). Patients from comfortable (Relative Risk=1.12, p<0.001), mid-tier (Relative Risk=1.13, p<0.001), at-risk (Relative Risk=1.20, p<0.001), and distressed (Relative Risk=1.17, p<0.001) communities were all more likely to use more medications compared to those from prosperous communities. Likewise, those from comfortable (Relative Risk=0.92, p<0.001), mid-tier (Relative Risk=0.88, p<0.001), at-risk (Relative Risk=0.93, p=0.008), and distressed (Relative Risk=0.93, p=0.033) communities respectively were a lower risk of making calls compared to prosperous communities. Following primary total shoulder arthroplasty, patients who reside in distressed communities are at significantly increased risk of experiencing an unplanned readmission and increased healthcare utilization postoperatively. This study revealed that patient socioeconomic distress is more associated with readmission than race following TSA. Increased awareness and employing strategies to maintain and ultimately improve communication with patients offers a potential solution to reduce excessive healthcare utilization, benefiting both patients and providers alike.

PROMIS Scores for Chronic Plantar Fasciitis Before and After Gastrocnemius Recession

Category: Ankle; Hindfoot Introduction/Purpose: There has been an established relationship between increased loading on the Achilles tendon and tension on the plantar fascia. This supports the idea that either tight gastrocnemius and soleus muscles or contractures of the Achilles tendon are risk factors for plantar fasciitis. Gastrocnemius recession has gained popularity as a viable surgical intervention for cases of chronic plantar fasciitis due to isolated gastrocnemius contracture. To our knowledge, this is the first study to investigate PROMIS scores in patients with plantar fasciitis before and after gastrocnemius recession. Methods: The Electronic Medical Record was queried for medical record numbers associated with Current Procedural Terminology code 27687 (gastrocnemius recession). Our study included all patients with a preoperative diagnosis of chronic plantar fasciitis with treatment via isolated gastrocnemius recession with one-year minimum follow-up. 40 patients were included in our study. Patient variables were collected via chart review. Preoperative and postoperative PROMIS scores were collected in the clinic. Results: Preoperative and postoperative PROMIS scores improved for physical function and pain interference from 39.27 and 62.78 to 44.54 and 56.5 (p=0.0005, p=0.0001) respectively, PROIMS Depression scores were not significantly different (p=0.6727). VAS scores significantly decreased from 7.05 to 1.71 (p &lt; 0.0001). Patients with preoperative peripheral neuropathy had significantly lower improvement in PROMIS physical function scores (p=0.0029). Tobacco use led to significantly lower improvement in in PROMIS depression (p=0.0202). Conclusion: Gastrocnemius recession is an effective option for patients with refractory pain in plantar fasciitis. Our PROMIS and VAS data confirm this procedure's utility and highlight its ability to significantly decrease pain and improve physical function in patients with chronic plantar fasciitis. We believe we have added to the literature by incorporating the, inherently superior, PROMIS scores. Based on the results of this study, the authors recommend gastrocnemius recession for patients who fail conservative management for plantar fasciitis.

Natural Language Processing Identification of Symptoms in Emergency Department Visits in Patients Receiving Radiation

Patients undergoing radiotherapy (RT) for cancer often require emergency department (ED) attention with possible hospitalization. Designing strategies to mitigate hospital admissions requires understanding the causal symptoms to tailor interventional strategies. Natural language processing (NLP) has previously been shown to accurately identify documented symptoms and may help characterize factors contributing to admission. The objective of this study was to use NLP to identify documented symptoms during ED visits and their association with subsequent hospital admission of patients undergoing RT. A de-identified, single tertiary-care institution cohort of patients who received radiation between 2013 and 2022 was identified from the electronic health record using International Classification of Disease (ICD) and Current Procedural Terminology (CPT) codes. We applied a previously validated clinical Text Analysis and Knowledge Extraction System (cTAKES)-based NLP pipeline to extract Common Terminology Criteria for Adverse Events (CTCAE) encoded symptoms from ED encounter clinical notes. Chi-squared testing was used to compare demographics, and logistic regression was used to identify symptoms associated with subsequent admission from ED visits. We identified 14,007 patients who received radiation, of whom 270 (1.9%) experienced 302 ED visits during their radiation course. 141 (46.7%) of ED visits resulted in an admission. Among patients with an ED encounter, there were no differences in admission rates based on primary language (p = 0.771), sex (p = 0.824), marital status (p = 0.753), race (p = 0.222), or age (p = 0.123). In admitted patients, the top 5 symptoms were pain (94.3%), nausea (92.1%), vomiting (73.7%), constipation (70.9%), and weakness (63.8%). In patients who did not require admission, the most common symptoms were pain (84.5%), nausea (67.1%), vomiting (47.2%), headache (36.6%), and weakness (35.4%). The 10 symptoms most associated with admission from the ED based on logistic regression were malaise (OR 21.7, [95% CI 10.1 - 51.0]), lethargy (19.1, [8.5 - 51.3]), flushing (15.7, [8.6 - 30.4]), agitation (12.4, [3.5 - 78.7]), somnolence (10.3, [4.7 - 25.9]), fall (8.5, [3.7 - 23.2]), fatigue (7.8, [4.6 - 13.4]), constipation (6.9, [4.2 - 11.6]), nausea (5.8, [3.0 - 12.2]), and swelling (5.4, [3.3 - 9.1]). Admitted and non-admitted ED patients with cancer seen in the ED during radiotherapy are documented to experience similar symptoms, but certain symptoms are associated with a higher risk of hospital admission. NLP may offer a mechanism for early, automated identification to facilitate supportive interventions for patients at high risk for admission during radiotherapy.

Insurance Plan Coverage Modeling of the Marginal Costs from One Week vs. Three Week Radiation Therapy in Standard-Of-Care Treatment of Post-Lumpectomy Early-Stage Breast Cancer Across Medicaid and Medicare Plans

For early-stage breast cancer (BC), the choice of radiation therapy (RT) duration (1- versus 3-weeks) is highly debated. Cost and financial toxicity are major concerns that BC patients face. Nonetheless, there remain limited discussions providing granular details of the role of insurance in the aggregate cost of 1 week versus 3 weeks of RT for patients. This project addresses this gap by disaggregating costs by insurance plan to increase transparency of out-of-pocket (OOP) cost estimates in RT. Surgical, medical, and radiation oncology treatment procedures were determined through the National Comprehensive Cancer Network guidelines; codes were identified using Current Procedural Terminology and Healthcare Common Procedure Coding System. OOP treatment costs, deductibles, and copay/coinsurance were calculated in accordance with insurance type, including Medicaid, Original Medicare, and Medigap Plan G. The medicare.gov, medicaid.oh.gov, and the physician fee schedule from cms.gov were used to determine pricing. Price estimates reflect actual costs per insurance plan rather than costs estimated from claims data. All procedures were considered to be performed in an Ohio hospital setting. One-week RT was defined as 5 fractions without boost, and 3-week RT was defined as 15 fractions without boost. Treatment charges for RT included initial radiation oncology office consultation and subsequent radiation oncology clinical treatment planning notes, complex 3D treatment plan, dosimetry calculations, complex treatment device design and construction, complex treatment planning simulation, simple verification treatment simulation, complex RT delivery, port verification films, on-treatment visits with radiation oncology, and continuing medical physics consultation. Original Medicare beneficiaries face an OOP cost of 20% for every Medicare Part B charge with no cost cap for all approved procedures after the deductible is met, resulting in a marginal OOP treatment charge of $649.24 for 1 week and $1006.20 for 3 weeks of RT. Assuming the deductible is met post-lumpectomy, Medigap Plan G beneficiaries are faced with no additional charges for both lengths of radiation treatment. Similarly, for Medicaid beneficiaries (assuming all treatments approved by Medicaid), all expenses are covered without limit, resulting in no OOP expense. Considerations of 1 week and 3 weeks of RT for post-lumpectomy early-stage BC are often dependent on cancer characteristic and patient preferences. This model (based on actual cost estimates per insurance plan rather than claims data) compares OOP costs across Medicaid and Medicare plans, which more holistically informs patients in their decision for choice of treatment.

The Opportunity for Impactful Integration of Vascular and Podiatric Care.

The importance of collaboration between vascular and podiatric surgeons has been well-established. High-level partnerships are integral to the development of multidisciplinary programs and wound care centers, ultimately resulting in improved patient outcomes. This vascular-podiatric integration is not universal, however, and podiatric surgery may not be aligned within a vascular surgery division at many institutions. As one such institution, we reviewed our single-center experience in order to identify opportunities for the impactful integration of vascular-podiatric patient care. Institutional electronic medical records were retrospectively reviewed for all procedures performed by vascular surgeons at a high volume, safety-net academic medical center. Data were collected on all primary and additional procedures, current procedural terminology (CPT) codes, case type (elective, urgent, emergent), surgeon specialty, and date/time of the procedures performed. CPT codes were linked to the Centers for Medicare & Medicaid Services' Physician Fee Schedule to estimate the work relative value unit (wRVU) per procedure. From 2018 to 2022, vascular surgeons performed a total of 12,206 operations, of which 1102 (9.9%) involved podiatric procedures. The most common vascular-performed podiatry procedures performed were toe amputations (38.1%, n = 420), transmetatarsal foot amputations (20.1%, n = 222), and ankle/foot debridement (16.2%, n = 178). Foot/ankle-specific procedures were identified as the primary procedure in 726 (65.9%) cases and as the adjunct procedure in 376 (34.1%) cases. A substantial proportion of podiatric procedures occurred on an urgent (n = 278, 25.2%) or emergent (n = 28, 2.5%) basis. A total of 163 (14.8%) cases occurred after hours (either before 0600 or after 1800), and 133 (12.1%) cases were performed on a holiday or weekend. Procedure-specific revenue included 4243.39 wRVU for primary procedures and 2108.08 wRVU for additional procedures performed. We report our single-center experience in which vascular surgeons provide a significant proportion of podiatric procedures. Our study underscores the potential for integrating podiatric surgeons within a vascular surgical division and presents opportunities for collaboration and enhanced patient care.

Higher Odds of Adverse Cutaneous Reactions in Patients With Dermatomyositis Treated With Hydroxychloroquine Compared With Methotrexate.

Hydroxychloroquine (HCQ) use for the treatment of dermatomyositis (DM) has been associated with adverse cutaneous reactions. We applied a new user, active comparator, retrospective design to assess differences in adverse cutaneous reactions or hospitalizations between HCQ and methotrexate (MTX) use among patients with DM. We used a national network of data from insurance registries (TriNetX), enrolling patients with two International Classification of Diseases (ICD) codes for DM separated by 6 months or more who had a prescription for either (but not both) HCQ or MTX on or after DM diagnosis. Outcomes were adverse cutaneous reactions (ICD codes) or hospital admission (Current Procedural Terminology (CPT) codes) within 4 months from the prescription dispense date. Logistic regression was used to produce adjusted odds ratios (aORs) and 95% confidence intervals (CIs) comparing outcomes in the HCQ group (n=1364) and the MTX group (n=1400), adjusted for age at first DM diagnosis, year of birth, sex, and time from DM diagnosis to first prescription. Overall, we found no significant difference in odds of hospitalization in those taking HCQ (aOR 1.05; 95% CI: 0.79-1.39) compared with those on MTX. Patients with DM on HCQ had 30% higher odds of adverse cutaneous reaction diagnosis compared with patients on MTX (aOR 1.30; 95% CI: 1.02-1.59). Age at DM diagnosis was an effect modifier of this association, with higher odds of adverse cutaneous reaction among patients taking HCQ who were younger at diagnosis. Compared with MTX use, HCQ use, especially in younger patients, may result in higher odds of adverse cutaneous reactions.

Elective musculoskeletal surgery is associated with postoperative weight changes in pediatric and adolescent patients.

Patients of elective orthopedic surgeries often reduce activity levels during postoperative recovery. It is unclear whether these extended periods of modified activities lead to weight changes. The purpose of this study was to evaluate changes in body mass index percentile in pediatric patients over 2.5 years following primary musculoskeletal surgeries. Institutional records for utilized current procedural terminology codes were used to identify patients aged 21 years or younger who underwent elective surgery at a single pediatric orthopedic institution between October 2016 and December 2018. Non-primary surgeries and patients without preoperative body mass index measurements were excluded. Demographic characteristics, height, weight, and body mass index within 30 months of surgery were collected. Body mass index relative to age was calculated. Analysis of body mass index changes at follow-up intervals of 3-7, 9-18, and 24-30 months after surgery was performed for the overall sample, within surgical categories, and within preoperative weight classifications. A total of 1566 patients (53.1% female, average age 12.4 years) were included. Over one-third of patients were overweight or obese at presentation. The average change in body mass index percentile relative to baseline was increased at all follow-up intervals. Values reached significance at 9-18 months (p = .002) and 24-30 months (p = .001). While underweight and normal-weight patients had increased body mass index at all three timepoints, overweight or obese patients decreased. Patients undergoing elective orthopedic procedures may experience significant changes in body mass index percentile postoperatively. At extremes of weight, patients experience improvement toward the mean, but most patients may undergo body mass index increases beyond what would be expected during normal growth. Retrospective level III.

The Effect of Surgical Timing on Upper Extremity Nerve Repair.

The purpose of this study was to evaluate the association between timing of nerve repair and the ability to perform a primary nerve repair versus a bridge repair requiring the use of allograft, autograft, or a conduit in lacerated upper extremity peripheral nerve injuries. This is a retrospective case-control study of patients who underwent upper extremity nerve repair for lacerated peripheral nerves identified by Current Procedural Terminology codes. Timing of injury and surgery, as well as other information such as demographic information, mechanism of injury, site of injury, and type of nerve repair, was recorded. The odds of a patient requiring bridge repair based on the duration of time between injury and surgery was evaluated using logistic regression. A total of 403 nerves in 335 patients (mean age 35.87 ± 15.33 years) were included. In all, 241 nerves were primarily repaired and 162 required bridge repair. Patients requiring bridge repair had a greater duration between injury and surgery compared with patients who underwent primary repair. Furthermore, the nerves requiring bridge repair were associated with a greater gap compared with the nerves repaired primarily. Based on logistic regression, each 1-day increase in duration between injury and surgery was associated with a 3% increase in the odds of requiring bridge repair. There is no defined critical window to achieve a primary nerve repair following injury. This study demonstrated that nerve injuries requiring bridge repair were associated with a significantly greater delay to surgery.

Percutaneous kidney biopsy trends in the Medicare population by specialty from 2011 to 2021: implications for nephrology training requirements and radiology referral patterns.

To study trends in volume and reimbursement for percutaneous kidney biopsy (PKB) by physicians and advanced practice providers (APPs) for Medicare enrollees from 2011-2021. Claims from the Medicare Part B Physician/Supplier Procedure Master File (a national Medicare database) for 2011-2021 were extracted using Current Procedural Terminology codes for PKB. Total volumes were compared by provider specialty. Non-facility reimbursement, work Relative Value Unit (RVU) non-facility practice expense RVU, and malpractice RVU were compared. Between 2011 and 2021, total volume of PKB by physicians and APPs increased from 30,753 to 34,090 (10.9%), with a peak of 37,882 in 2019 prior to the COVID 19 pandemic. Radiology performed the majority of procedures during the study period. Relative share for radiology increased from 67.6% to 81.1% while the relative share for internal medicine/nephrology decreased from 24.3% to 14.3%, accelerating between 2019 and 2020. Volume and relative share for APPs marginally increased (from 0.9% to 1.2%). Non-facility reimbursement decreased from $578.96 in 2010 to $568.76 in 2021 (1.7%), work RVU decreased from 2.63 to 2.38 (9.5%), non-facility practice expense RVU decreased from 14.10 to 13.71 (2.8%), and malpractice RVU decreased from 0.31 to 0.21 (32.3%). Volume and total share of PKB performed by radiology increased over the study period. Conversely, internal medicine/nephrology performed fewer kidney biopsies. Despite the expanding role for APPs in other image-guided procedures, very few PKBs were performed by APPs throughout the study period. Reimbursement and RVU for PKB declined over the study period.

Medicare procedural costs in ambulatory surgery centers versus hospital outpatient departments for spine surgeries.

Multiple studies have demonstrated the safety of outpatient spine surgery, with reports of equivalent to improved patient outcomes compared with inpatient procedures. This has resulted in the increased use of outpatient surgery over time. However, there remains a paucity of literature evaluating the difference in costs between ambulatory surgery center (ASC)- and hospital outpatient department (HOPD)-based procedures for Medicare beneficiaries. Publicly available data from Centers for Medicare & Medicaid Services were accessed via the Medicare Procedure Price Lookup tool. Current Procedural Terminology (CPT) codes were used to identify spine-specific procedures approved for the outpatient setting by CMS. Procedures were grouped into decompression (cervical, thoracic, and lumbar), fusion/instrumentation (cervical, lumbar, and sacroiliac), and kyphoplasty/vertebroplasty cohorts, as well as an overall cohort. Data regarding total costs, facility fees, surgeon reimbursement, Medicare payments, and patient copayments were extracted for each procedure. Descriptive statistics were used to calculate means and standard deviations. Differences between ASC- and HOPD-associated costs were analyzed using the Mann-Whitney U-test. Twenty-one individual CPT codes approved by Medicare for the ASC and/or HOPD setting were identified. Decompression procedures were associated with a significantly lower total cost ($4183 ± $411.07 vs $7583.67 ± $410.89, p < 0.001), facility fees ($2998 ± $0 vs $6397 ± $0, p < 0.001), Medicare payments ($3345.75 ± $328.80 vs $6064.75 ± $328.80, p < 0.001), and patient payments ($835.58 ± $82.13 vs $1515.58 ± $82.13, p < 0.001) in ASCs compared with HOPDs. Fusion/instrumentation procedures had significantly lower facility fees ($10,436.6 ± $2347.51 vs $14,161 ± $2147.07, p = 0.044) and Medicare payments ($9501.2 ± $1732.42 vs $13,757 ± $2037.58, p = 0.009) in ASCs, as well as a trend toward lower total costs ($11,876.8 ± $2165.22 vs $15,601.2 ± $2016.06, p = 0.076). Patient payments in the HOPD setting were significantly lower in the fusion/instrumentation cohort ($1843.6 ± $73.42 vs $2374.4 ± $433.48, p = 0.009). In the kyphoplasty/vertebroplasty cohort, there was no statistically significant difference between ASCs and HOPDs, despite lower overall costs in the ASC for all variables. Surgeon fees were the same regardless of setting for all procedures (p > 0.99). When combining decompression, fusion/instrumentation, and kyphoplasty/vertebroplasty CPT codes into a single cohort, ASC setting was associated with significant cost savings in total cost, facility fees, Medicare payments, and patient payments. In general, performing spine surgeries in ASCs is associated with cost savings compared with HOPDs. This was demonstrated for decompression and fusion/instrumentation, and kyphoplasty/vertebroplasty Medicare-approved outpatient procedures.

Increase in Retinal Detachment Repair Over a Ten-Year Period at an Academic Center Compared to National Trends.

This study aimed to determine whether cases of surgical retinal detachment (RD) repair at a tertiary care center from January 1, 2011 to December 31, 2020 increased proportionately to macular surgery cases as a control and to national trends. Current Procedural Terminology codes were used to identify cases of primary RD repair (67107, 67108), complex RD repair (67113), pneumatic retinopexy (67110), and vitrectomy with membrane peeling (67041, 67042) at an academic center and in the Part B National Summary Data Files. Numbers of cases and mean case times at the academic center were determined. We identified 5,183 and 948,831 operative cases locally and nationally, respectively. Between 2011 and 2019, the total volume of RD repair at the academic center increased by 118.7%, compared to 23.3% for cases of membrane peeling. In contrast, surgical RD repairs and membrane peelings increased by 26.0% and 6.8% cases nationally. The ratio of RD repairs to membrane peelings from 2011 to 2019 increased from 1.5 to 2.6 locally compared to 0.6 to 0.7 nationally. Complex RD repairs increased more than primary RD repairs locally (129.3% vs 110.9% cases) and less than primary RD repairs nationally (20.6% versus 30.2% cases). Cases of surgical RD repair increased disproportionately compared to macular surgery at our institution and compared to RD repairs nationwide. [Ophthalmic Surg Lasers Imaging Retina 2023;54:505-511.].

Vitreoretinopathy-Associated Pediatric Retinal Detachment Treatment Outcomes: IRIS® Registry (Intelligent Research in Sight) Analysis.

To determine the treatment patterns and outcomes of pediatric retinal detachments (RDs) associated with hereditary vitreoretinopathies. Retrospective cohort analysis using IRIS® Registry (Intelligent Research in Sight) database. Patients < 18 years old with a rhegmatogenous RD and a systemic disorder associated with vitreoretinal degeneration (e.g., Stickler syndrome) or other malformation of the vitreous from 2013-2019. Cases were identified using International Classification of Diseases, Ninth and Tenth Revisions (ICD-9, ICD-10) diagnostic codes from the IRIS® Registry cohort. Other hereditary vitreoretinopathies that are not encoded by specific ICD code(s) were captured by text search. Nonspecific vitreous abnormality ICD codes were also included. Exclusion criteria included traumatic retinal detachments using ICD codes for ocular trauma and serous or exudative retinal detachment. Surgical procedures were identified using Current Procedural Terminology (CPT) codes for repair of retinal detachment. Baseline demographic information collected included age, gender, race/ethnicity, geographic region of the provider location, and health insurance status. Main outcomes measured in this study were average time to first surgery, number of eyes presenting with bilateral detachments, and choice of initial surgical procedure. A total of 2115 eyes of 1722 patients were identified (mean age, 10.4 years; 58% male). The median time to first surgery was 7 days (interquartile range, 40 days). One thousand four hundred seven eyes of 1134 patients had ≥ 1 year of follow-up, with 506 eyes (36%) developing a fellow eye RD. Thirty-three percent of patients presenting with bilateral detachments, and 349 eyes had initial RD surgery within 1 year of the index date documented by CPT code. Fellow eye detachment occurred a mean of 32 days after initial presentation. The mean number of surgeries per eye within 1 year was 1.68. Best-corrected visual acuity did not improve from a baseline 20/54 to 20/62. The initial procedure was most commonly complex RD repair (n = 176), followed by scleral buckle (n = 102), pars plana vitrectomy (n = 89), laser (n = 59), cryotherapy (n = 5), and pneumatic retinopexy (n = 5). There were 51 new diagnoses of glaucoma and 37 new diagnoses of aphakia within 1 year after the surgical procedure. IRIS Registry data provide insight into rare pediatric vitreoretinopathy-associated RDs, which have a high rate of reoperation and fellow eye involvement. Proprietary or commercial disclosure may be found after the references.

Orthopedic surgery residents reported increased shoulder procedure volumes during the COVID-19 pandemic

The purpose of this study is to evaluate the impact of the COVID-19 pandemic on shoulder procedure volumes reported to the Accreditation Council for Graduate Medical Education by orthopedic surgery residents. We performed a retrospective review of Accreditation Council for Graduate Medical Education case logs reporting data from graduating orthopedic surgery residents during the academic years of 2006-2022. Data were queried for all patients for the following shoulder Current Procedural Terminology codes: incision, excision, intro or removal, repair/revision/reconstruction, fracture and/or dislocation, manipulation, arthroscopy, trauma, and total procedures performed. Individual t-tests were used to compare case log trends of graduating academic years before (classes of 2018 and 2019) and during (classes of 2020, 2021, and 2022) the COVID-19 pandemic. Statistical significance was established to be P <.05 for total procedure types, but at P <.005 during category comparisons to protect against alpha errors. Reported mean total shoulder procedures per resident steadily increased each year from 2017 to 2022, but the only significant increase was seen when comparing the graduating classes of 2020 to 2021 (157.9 vs. 165.7, P=.02). Stratification of these procedures by subgroup revealed a significant increase in manipulation procedures from 2021 to 2022 (7.3 vs. 8.8, P=.001). COVID-19 did not have a negative impact on logged shoulder procedure volume. Orthopedic surgery residents graduating during the COVID-19 pandemic reported more shoulder procedures than those graduating prepandemic. However, shoulder procedure log trends should be longitudinally investigated, as preceding years of procedural opportunities may underestimate the pandemic's impact.

Sacrospinous Fixation and Vaginal Uterosacral Suspension-Evaluation in Uterine Preservation Surgery

ABSTRACT Although hysterectomy is traditionally performed at the time of pelvic organ prolapse repair for apical prolapse, women are increasingly interested in uterine preservation during pelvic organ prolapse surgical management. Approximately 36% to 60% of women indicate interest in uterine preservation, assuming equal efficacy. This has led to more uterus-preserving prolapse repairs (hysteropexy) being performed. After the removal of mesh products from the US market in 2019, transvaginal native tissue techniques are commonly used for hysteropexy. This study aimed to compare 6-week and 1-year anatomical failure rates between vaginal uterosacral ligament hysteropexy and sacrospinous ligament hysteropexy. Secondary outcomes included retreatment for prolapse, symptoms of recurrent prolapse, and perioperative adverse event rates in these 2 groups. This was a multicenter retrospective cohort study of patients undergoing vaginal uterosacral hysteropexy (USHP) or sacrospinous hysteropexy (SSHP) with a urogynecologist between January 1, 2015 and December 31, 2019. The pool of patient data was extrapolated from 4 geographically unique urban locations. Patient identification took place via querying the respective electronic medical records for the current procedural terminology codes of extraperitoneal colpopexy (57,282, SSHP) and intraperitoneal colpopexy (57,283, USHP). These operative reports underwent review in order to confirm that each patient had a uterus at time of surgery, underwent either USHP or SSHP, and did not undergo concurrent hysterectomy. Exclusion criteria included patients undergoing different types of uterine-preserving procedures or patients with less than 6 weeks of follow-up. The study included 147 patients undergoing SSHP and 114 having USHP over 5 years at the 4 clinical sites. The study population included mostly nonsmoking (179, 68.6%), White (224, 85.5%) patients with no history of pelvic surgery (142, 54.4%), and a mean Charleston Comorbidity Index score of 2. Overall, USHP patients exhibited a higher likelihood to undergo concurrent anterior repair, posterior repair, and incontinence procedures. The follow-up rate was 95% at 6 postoperative weeks with 4 anatomic failures. Not all patients had formal prolapse quantitation examinations recorded. However, only 32% (83/261) of patients were available for follow-up at 1 year after surgery when 10 patients met criteria for anatomic failure. Notably, although there was no statistically significant difference between failure rates for SSHP and USHP at either time point, there were roughly 3 times as many failures for USHP compared with SSHP, despite the SSHP representing a larger portion of the total cohort. At 1 year, however, 26 patients had undergone retreatment for prolapse, with 12 undergoing hysterectomy (11 due to prolapse, 1 due to colorectal cancer debulking). Of those undergoing hysterectomy, 10 were from the SSHP cohort, whereas 1 was from the USHP cohort. The 1 year anatomic outcomes presumably included prolapse assessments after these salvage surgeries. One year after vaginal native tissue hysteropexy, only 1 in 3 patients were available for follow-up, but this limited cohort demonstrated that no differences for prolapse recurrence between SSHP and UHSP. Adverse events incidence rates were low, with only 5% of patients undergoing subsequent hysterectomy for prolapse. Any next step in research should include more rigorous prospective trials.