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Carpal Instability Reconstruction and Wrist Procedures in the Medicare Population

Open AccessPublished:March 06, 2019DOI:https://doi.org/10.1016/j.jhsg.2018.12.004

      Purpose

      We conducted a retrospective study to determine the annual number of patients undergoing various wrist procedures in the Medicare population as well as the revision rate and common revision procedures after carpal instability reconstruction surgeries (Current Procedural Terminology [CPT] billing code 25320).

      Methods

      We examined the Medicare orthopedic datasets using the PearlDiver application to identify patients who underwent 12 different common wrist procedures, including carpal instability reconstruction procedures, from 2005 to 2014. Carpal instability reconstruction procedures were those identified by CPT 25320, which includes various methods of reconstruction such as capsulodesis, ligament repair, and tendon transfer or graft. Medicare covers approximately 51 million Americans and consists of those aged 65 years and older as well as younger patients enrolled in Social Security disability or with end-stage renal disease. Demographic and payment data were determined for the entire cohort. Patients with less than 3 months of active insurance records after the wrist procedure were excluded.

      Results

      A total of 29,898 wrist procedures were performed over the study period. The most commonly performed procedure was wrist arthroscopy with joint debridement or triangular fibrocartilage complex repair (6,557 patients). A total of 2,949 patients underwent carpal instability reconstruction procedures, 174 of whom underwent revision or salvage surgeries (5.9%). The most common revision procedure was an additional reconstruction operation whereas the most common salvage procedure was proximal row carpectomy. Average Medicare payment was $4,107.67 for the index procedure and $3,760.95 for revision procedures. The number of wrist procedures increased 43% over the study period.

      Conclusions

      Carpal instability reconstruction procedures and wrist arthroscopies with joint debridement or TFCC repair are performed more commonly in elderly patients than anticipated or indicated. Procedures such as these, without quality evidence supporting their use in elderly patients, are going to be scrutinized as the United States moves toward value-based health care. Although it appears that carpal reconstruction procedures have a low revision rate in the short to medium term in the Medicare population, the wide variety of procedures captured by CPT 25320 makes outcome measurements challenging. A more specific coding system should be created to reflect the surgeon’s effort more accurately, as well as better track revision rates.

      Type of study/level of evidence

      Therapeutic III.

      Key words

      Wrist procedures are commonly performed in the Medicare population. Some surgeries, such as proximal row carpectomy (PRC), have a proven track record of success in elderly patients. Others have little to no high-quality evidence supporting their use in elderly patients with degenerative conditions of the wrist. This is especially true for procedures aimed at preserving native joint anatomy, such as arthroscopic debridement and carpal ligament repair or reconstruction, which is often indicated in cases of acute carpal instability (CI).
      Carpal instability is a broad diagnosis that covers several unique disorders of the wrist, including scapholunate (SL) dissociation; unstable scaphoid fracture, malunion, or nonunion; and lunate triquetrum dissociation. These injuries may lead to symptomatic instability and later arthrosis if untreated. Although common injuries, the actual incidence is difficult to quantify accurately.
      • Walsh J.J.
      • Berger R.A.
      • Cooney W.P.
      Current status of scapholunate interosseous ligament injuries.
      Cadaveric studies of elderly patients (aged 60 years and older) have found evidence of SL interosseous ligament or lunotriquetral ligament injuries in roughly a third of specimens.
      • Lee D.H.
      • Dickson K.F.
      • Bradley E.L.
      The incidence of wrist interosseous ligament and triangular fibrocartilage articular disc disruptions: a cadaveric study.
      • Wright T.W.
      • Del Charco M.
      • Wheeler D.
      Incidence of ligament lesions and associated degenerative changes in the elderly wrist.
      It is unknown how many were symptomatic. Importantly, many specimens had evidence of ligamentous injury without evidence of arthrosis. These degenerative findings likely represent a condition different from an acute ligamentous injury.
      Most published data on CI focuses on SL dissociation because it is the most common cause.
      • Pollock P.J.
      • Sieg R.N.
      • Baechler M.F.
      • Scher D.
      • Zimmerman N.B.
      • Dubin N.H.
      Radiographic evaluation of the modified Brunelli technique versus the Blatt capsulodesis for scapholunate dissociation in a cadaver model.
      • Hsu J.W.
      • Kollitz K.M.
      • Jegapragasan M.
      • Huang J.I.
      Radiographic evaluation of the modified Brunelli technique versus a scapholunotriquetral transosseous tenodesis technique for scapholunate dissociation.
      Multiple treatment options are well-documented in the literature but are generally indicated in younger patients with acute injuries. These have the common goal of preventing instability and the later development of SL advanced collapse wrist.
      • Watson H.K.
      • Ballet F.L.
      The SLAC wrist: scapholunate advanced collapse pattern of degenerative arthritis.
      • Shah C.M.
      • Stern P.J.
      Scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) wrist arthritis.
      Treatments include but are not limited to Blatt capsulodesis, Brunelli tenodesis, triligament tenodesis (modified Brunelli), dorsal dynamic tenodesis, and capitohamate bone–ligament–bone graft.
      • Crawford K.
      • Owusu-Sarpong N.
      • Day C.
      • Iorio M.
      Scapholunate ligament reconstruction: a critical analysis review.
      • van Kampen R.J.
      • Bayne C.O.
      • Moran S.L.
      • Berger R.A.
      Outcomes of capitohamate bone-ligament-bone grafts for scapholunate injury.
      These procedures may improve pain and function but possibly decrease range of motion.
      • Crawford K.
      • Owusu-Sarpong N.
      • Day C.
      • Iorio M.
      Scapholunate ligament reconstruction: a critical analysis review.
      • van Kampen R.J.
      • Bayne C.O.
      • Moran S.L.
      • Berger R.A.
      Outcomes of capitohamate bone-ligament-bone grafts for scapholunate injury.
      • Chabas J.F.
      • Gay A.
      • Valenti D.
      • Guinard D.
      • Legre R.
      Results of the modified Brunelli tenodesis for treatment of scapholunate instability: a retrospective study of 19 patients.
      • Garcia-Elias M.
      • Lluch A.L.
      • Stanley J.K.
      Three-ligament tenodesis for the treatment of scapholunate dissociation: indications and surgical technique.
      Static SL dissociation procedures such as these typically result in persistent SL diastasis representing incomplete restitution of normal anatomy. It is largely undetermined how many Medicare patients are undergoing these procedures or how many require salvage procedures such as PRC, radiocarpal arthrodesis, scaphoid excision with 4-corner arthrodesis, or complete wrist arthrodesis.
      • Ben Amotz O.
      • Sammer D.M.
      Salvage operations for wrist ligament injuries with secondary arthrosis.
      The purpose of this study was to determine the number of wrist procedures performed annually in the Medicare population, as well as the revision rate and associated common revision procedures for CI reconstruction procedures. Our hypothesis was that reconstruction procedures would have a high revision rate because these surgeries are not generally indicated in elderly patients.

      Materials and Methods

      We identified patients using the Medicare datasets in the PearlDiver application (www.pearldiverinc.com, Fort Wayne, IN) from 2005 to 2014. PearlDiver is a national database of insurance billing records that can be used to identify patients based on International Classification of Diseases–9th Revision and Current Procedural Terminology (CPT) billing codes. This commercially available database includes records on approximately 51 million patients with orthopedic diagnoses from the Medicare Standard Analytic File. All records are Health Insurance Portability and Accountability Act of 1996 compliant and contain no individual patient identities. The database is stored on a password-protect server maintained by PearlDiver. Institutional review board approval was not required for this study because data were deidentified and thus exempt.
      Patients who underwent 12 different common wrist procedures (Table 1) were identified in the database to determine the annual number of these surgeries. We then specifically examined patients who had undergone CI reconstruction procedures as determined by CPT code 25320. This code is described as open wrist capsulorrhaphy or reconstruction for CI (eg, capsulodesis, ligament repair, tendon transfer or graft). It is not specific regarding which reconstructive procedure was completed or the amount of time or complexity of the procedure performed. We then queried this cohort to identify the number of patients requiring revision or salvage procedures at later time points. This consisted of the previously identified common wrist surgeries (Table 1) to include various carpectomies, arthrodesis, and wrist arthroscopies. Laterality is not specified by CPT code, so patients may have undergone procedures on the contralateral wrist that were counted as revision procedures.
      Table 1Common Wrist Procedures by CPT Code and Description
      CPT CodeDescription
      25320Capsulorrhaphy or reconstruction wrist open (eg, capsulodesis ligament repair tendon transfer or graft) (includes synovectomy capsulotomy and open reduction) for CI
      25210Carpectomy; 1 bone
      25215Carpectomy; all bones of proximal row
      25800Arthrodesis wrist; complete without bone graft (includes radiocarpal and/or intercarpal and/or carpometacarpal joints)
      25810Arthrodesis wrist; with iliac or other autograft (includes obtaining graft)
      25820Arthrodesis wrist; limited without bone graft (eg, intercarpal or radiocarpal)
      25825Arthrodesis wrist; with autograft (includes obtaining graft)
      29840Arthroscopy wrist diagnostic with or without synovial biopsy (separate procedure)
      29844Arthroscopy wrist surgical; synovectomy partial
      29845Arthroscopy wrist surgical; synovectomy complete
      29846Arthroscopy wrist surgical; excision and/or repair of TFCC and/or joint debridement
      29847Arthroscopy wrist surgical; internal fixation for fracture or instability
      Demographics and payment data were determined. Payments were based on charges from the day of surgery. Inclusion criteria was all patients who underwent the index procedure regardless of age. The only exclusion criterion was less than 3 months of active insurance records in the database after the initial procedure.

      Results

      A total of 29,898 wrist procedures were performed in the Medicare population over the study period (Table 1). The single largest age group was aged less than 65 years (43%) and most were female (56%). The most commonly performed procedure was CPT code 29846, wrist arthroscopy with joint debridement or triangular fibrocartilage complex (TFCC) repair (6,557 patients) (Table 2). The largest portion of these patients were female (61%) and from the South (40%). Two different carpectomies, CPT codes 25210 (single carpectomy) and 25215 (PRC), represented the second and third most common procedures, respectively. Open capsulorrhaphy or reconstruction procedures (CPT code 25320) were the sixth most commonly performed. When considering all 6 most commonly performed wrist surgeries, the overall number of procedures went from 2,113 in 2005 to 3,028 in 2014, representing a 43% increase.
      Table 2Number of Patients Undergoing Common Wrist Procedures, by Age and Sex
      CPT Code
      See Table 1 for CPT descriptions.
      PatientsAge, ySex
      <6565–6970–7475–7980–84>84UnknownFemaleMaleUnknown
      298466,5572,7581,8681,11950319669794,0012,48579
      252104,7309261,5371,168694278120403,2451,44740
      252153,6361,0901,02674546622165451,6351,96045
      258253,6291,0331,12777145818252291,4642,13929
      258102,9861,02475062936816735321,2921,66732
      253202,94992982557234126087321,8941,02827
      See Table 1 for CPT descriptions.
      Table 3 and Figure 1 display the annual number of commonly performed wrist procedures. All procedures showed a general increase over the examined period, but CPT code 29846 (wrist arthroscopy with joint debridement or TFCC repair) had the greatest increase from 2005 to 2014 (68.7%). Over the same period, Medicare enrollment rose from 41.8 million to 54.0 million people, representing a 29.2% increase.
      Table 3Annual Number of Patients Undergoing Common Wrist Procedures
      CPT Code
      See Table 1 for CPT descriptions.
      2005200620072008200920102011201220132014
      29846476523617661670725760717786803
      25210468392429376455479486541612600
      25215276280295358352387381412463486
      25825315308331301366362375401478474
      25810280234279286259312357343361334
      25320298309296294319342335330380331
      See Table 1 for CPT descriptions.
      Figure thumbnail gr1
      Figure 1Annual number of patients undergoing common wrist procedures.
      A total of 2,949 Medicare patients underwent procedures coded as CPT 25320 (Table 4). Most patients were female (64%) and aged less than 70 years (59.5%). Of these, 174 (5.9%) underwent revision or salvage procedures. The most common revision was an additional CPT 25320 procedure, representing 2.7% of the original cohort, whereas the most common salvage procedure was PRC (CPT 25215), representing 1.1% of the original cohort. Average payment was $4,107.67 for the index procedure and $3,760.95 for revision procedures.
      Table 4Demographic, Payment, and Revision Data of Patients Undergoing CI Reconstruction Procedures
      Procedure TypeCPT Code
      See Table 1 for CPT descriptions.
      Index ProceduresRevisions After CPT 25320Age, ySexAverage Payment
      <6565–6970–7475–79>80UnknownMaleFemaleUnknown
      Index253202,949929825572341260321,0281,89427$4,107.67
      Revisions252153,63632
      252104,73019
      258201,4987
      258253,62920
      258001,56810
      258102,98613
      298404923
      29843500
      298441,0633
      298454921
      298466,55722
      298472480
      253202,94979
      Total revisions17459543714100731010$3,760.95
      Requiring revision (%)5.96.46.56.54.13.807.15.30
      See Table 1 for CPT descriptions.

      Discussion

      The primary goal of this study was to evaluate the number of reconstructive procedures performed in the Medicare patient population. When the data were analyzed by age, open capsulorrhaphy or reconstruction procedures for CI (CPT code 25320) were performed more frequently in older patients than expected, especially compared with other procedures. Salvage operations such as scaphoid excision and 4-corner arthrodesis (CPT 25825) or PRC (CPT 25815) would be expected to be more common than complex ligamentous reconstruction procedures for CI in this patient population. Although to the authors' knowledge, no study has been published that evaluates age cutoffs for reconstructive procedures, we did not anticipate this high number.
      Even more surprising was the high number of wrist arthroscopies performed over the study interval. Arthroscopies for joint debridement or TFCC repair were the most commonly performed wrist procedure. Indications for these procedures are unknown, but may have been performed for arthrosis. Joint debridement or TFCC repair is not typical in this age group; however, the number of patients undergoing this procedure (as well as other commonly performed wrist procedures) greatly increased over the study period. Importantly, outcomes might not necessarily be improved with operative management, because there is no high-quality evidence supporting the use of wrist arthroscopy debridement procedures.
      • Tadjerbashi K.
      • Rosales R.S.
      • Atroshi I.
      Intervention randomized controlled trials involving wrist and shoulder arthroscopy: a systematic review.
      Wrist carpectomies (CPT codes 25210 and 25215) were also among the most commonly performed wrist surgeries, although less than the previously described wrist arthroscopies. These procedures are generally salvage operations for symptomatic arthrosis and are often indicated in the Medicare population. We would expect more patients to undergo these procedures than arthroscopic joint debridement or TFCC repair.
      Fewer patients than anticipated underwent revision procedures after CI reconstructive procedures (CPT 25320) although we would expect elderly patients with degenerative changes of the wrist to fail ligamentous reconstruction procedures. We found that revision rates decreased with increasing age and younger patients were much more likely to undergo a revision operation. The published literature on revision rates comes from a limited number of retrospective case series. Gajendran et al
      • Gajendran V.K.
      • Peterson B.
      • Slater Jr., R.R.
      • Szabo R.M.
      Long-term outcomes of dorsal intercarpal ligament capsulodesis for chronic scapholunate dissociation.
      reviewed dorsal intercarpal ligament capsulodesis and found that none of 16 patients required reoperation at a mean follow-up of 86 months despite radiographic arthrosis in 8 patients. Garcia-Elias et al
      • Garcia-Elias M.
      • Lluch A.L.
      • Stanley J.K.
      Three-ligament tenodesis for the treatment of scapholunate dissociation: indications and surgical technique.
      retrospectively reviewed the 3-ligament tenodesis technique in 38 patients and reported no cases of reoperation despite evidence of arthrosis in a quarter of patients at a mean follow-up of 46 months. Sousa et al
      • Sousa M.
      • Aido R.
      • Freitas D.
      • Trigueiros M.
      • Lemos R.
      • Silva C.
      Scapholunate ligament reconstruction using a flexor carpi radialis tendon graft.
      retrospectively reviewed the modified Brunelli procedure in 22 patients. Only one patient required reoperation at a mean follow-up of 61 months although one third had continued moderate or severe pain after the procedure. The lack of a nonsurgical control group in those studies makes it difficult to determine whether operations resulted in improved outcomes. Overall, our revision rate seems comparable to the limited published literature, which was conducted in younger patient populations. To the best of our knowledge, to date, data do not exist for the elderly population.
      A wide range of procedures are included in the CPT 25320 description. For instance, a recent meta-analysis on chronic SL interosseous ligament injury treatments included Brunelli FCR tenodesis, dorsal capsulodesis with suture anchors, Blatt capsulodesis, arthroscopic debridement, and joint pinning, among others.
      • Naqui Z.
      • Khor W.S.
      • Mishra A.
      • Lees V.
      • Muir L.
      The management of chronic non-arthritic scapholunate dissociation: a systematic review.
      More recently, bone–ligament–bone reconstructions, screw fixation (reduction and association of the scaphoid and lunate), and the ScaphoLunate Axis Method procedure have been added to procedures that seek to address this pathology but lack long-term outcomes. In total, there are a multitude of surgical techniques that range from relatively simple, straightforward percutaneous procedures with few steps to complex, open cases with dozens of steps that need to be meticulously executed. Conceivably, any of these procedures could be coded as CPT 25320 despite the significant variability. A more specific coding system should be created to reflect the surgeon’s effort and time invested more accurately, as well as to track outcomes better, specifically revision rates.
      This study had limitations. The database depends on physician coding, which is variable. It is difficult to predict outcomes purely on reoperation rates because important measures are not included, such as residual pain, function, and patient satisfaction. We make no claim about the superiority of one procedure over another. Laterality was also not specified, so our revision rates represent a worst-case scenario, because patients might have undergone additional procedures on the contralateral carpus.
      Overall, it appears that carpal reconstruction procedures and wrist arthroscopies for joint debridement or TFCC repair are performed more commonly in elderly patients than predicted. Salvage procedures such as wrist arthrodesis or carpectomy were expected to predominate is this population. It appears that carpal reconstruction procedures have low revision rates in the short to medium term in the Medicare population, but the wide variety of procedures captured by CPT 25320 makes outcome measurements and revision rates challenging. Further clinical study is needed to understand the specifics of carpal reconstructive procedures that are being performed in this population and to determine which result in improved patient outcomes. As the United States moves toward a value-based health care model, establishing indications for wrist arthroscopy and carpal reconstruction in the elderly population has become of paramount importance.

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