The Value Added of Advanced Imaging in the Diagnosis and Treatment of Triangular Fibrocartilage Complex Pathology

Published:September 01, 2021DOI:https://doi.org/10.1016/j.jhsa.2021.06.027

      Purpose

      Pathology of the triangular fibrocartilage complex is a prevalent cause of ulnar-sided wrist pain that presents a diagnostic challenge. We hypothesized that a history and physical examination (H&P) would be more cost-effective alone or with diagnostic injection than with magnetic resonance imaging (MRI) or magnetic resonance arthrogram (MRA) in the diagnosis and treatment of a symptomatic triangular fibrocartilage complex abnormality.

      Methods

      A simple-chain decision analysis model was constructed to assess simulated subjects with ulnar-sided wrist pain and normal radiographs using several diagnostic algorithms: H&P alone, H&P + injection, H&P with delayed advanced imaging (MRI or MRA), and H&P + injection with delayed advanced imaging (MRI or MRA). Three years after diagnosis, effectiveness was calculated in Disabilities of the Arm, Shoulder, and Hand–adjusted life years. Costs were extracted from a commercial insurance database using US dollars. A probabilistic sensitivity analysis with 10,000 second-order trials with sampling of parameter distributions was performed. One-way and 2-way sensitivity analyses were performed.

      Results

      All strategies had similar mean effectiveness between 2.228 and 2.232 Disabilities of the Arm, Shoulder, and Hand–adjusted life years, with mean costs ranging from $5,584 (H&P alone) to $5,980 (H&P, injection, and MRA). History and physical examination alone or with injection were the most cost-effective strategies. History and physical examination alone was the most preferred diagnostic strategy, though H&P + injection and H&P with delayed MRA were preferred with adjustments in willingness-to-pay and parameter inputs. As willingness-to-pay increased considerably (>$65,000 per Disabilities of the Arm, Shoulder, and Hand–adjusted life year), inclusion of MRA became the most favorable strategy.

      Conclusions

      Advanced imaging adds costs and provides minimal increases in effectiveness in the diagnosis and treatment of a symptomatic triangular fibrocartilage complex abnormality. The most cost-effective strategy is H&P, with or without diagnostic injection. Magnetic resonance arthrogram may be favored in situations with a high willingness-to-pay or poor examination characteristics.

      Type of study/level of evidence

      Economic/Decision Analysis IV.

      Key words

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      Disclosures for this Article

      Editors

      Ryan Calfee, MD, MSc, has no relevant conflicts of interest to disclose.

      Authors

      All authors of this journal-based CME activity have no relevant conflicts of interest to disclose. In the printed or PDF version of this article, author affiliations can be found at the bottom of the first page.

      Planners

      Ryan Calfee, MD, MSc, has no relevant conflicts of interest to disclose. The editorial and education staff involved with this journal-based CME activity has no relevant conflicts of interest to disclose.

      Learning Objectives

      Upon completion of this CME activity, the reader will understand:
      • The most cost effective evaluation strategies for triangular fibrocartilage complex (TFCC) injury.
      • The concept of cost effectiveness research.
      • The value of foveal injection in the evaluation of ulnar wrist pain.
      Deadline: Each examination purchased in 2021 must be completed by January 31, 2022, to be eligible for CME. A certificate will be issued upon completion of the activity. Estimated time to complete each JHS CME activity is up to one hour.
      Copyright © 2022 by the American Society for Surgery of the Hand. All rights reserved.
      The differential diagnoses of ulnar-sided wrist pain can be broad, including injuries to bony, tendinous, ligamentous, joint, nerve, and vascular structures.
      • DaSilva M.F.
      • Goodman A.D.
      • Gil J.A.
      • Akelman E.
      Evaluation of ulnar-sided wrist pain.
      Triangular fibrocartilage complex (TFCC) pathology, defined as acute or chronic injury to the triangular fibrocartilage disc, palmar and dorsal radioulnar ligaments, meniscal homologue, ulnar collateral ligament, or subsheath of the extensor carpi ulnaris tendon, is the most common cause of ulnar-sided wrist pain.
      • Palmer A.K.
      • Werner F.W.
      The triangular fibrocartilage complex of the wrist–anatomy and function.
      ,
      • Sachar K.
      Ulnar-sided wrist pain: evaluation and treatment of triangular fibrocartilage complex tears, ulnocarpal impaction syndrome, and lunotriquetral ligament tears.
      Although 57% of patients may improve with nonsurgical management alone, durable improvements have been demonstrated with arthroscopic TFCC repair or debridement with or without ulnar shortening osteotomy and with ulnar shortening osteotomy alone.
      • Park M.J.
      • Jagadish A.
      • Yao J.
      The rate of triangular fibrocartilage injuries requiring surgical intervention.
      • Ruch D.S.
      • Papadonikolakis A.
      Arthroscopically assisted repair of peripheral triangular fibrocartilage complex tears: factors affecting outcome.
      • Papapetropoulos P.A.
      • Wartinbee D.A.
      • Richard M.J.
      • Leversedge F.J.
      • Ruch D.S.
      Management of peripheral triangular fibrocartilage complex tears in the ulnar positive patient: arthroscopic repair versus ulnar shortening osteotomy.
      • Seo J.B.
      • Kim J.P.
      • Yi H.S.
      • Park K.H.
      The outcomes of arthroscopic repair versus debridement for chronic unstable triangular fibrocartilage complex tears in patients undergoing ulnar-shortening osteotomy.
      • Wolf M.B.
      • Haas A.
      • Dragu A.
      • et al.
      Arthroscopic repair of ulnar-sided triangular fibrocartilage complex (Palmer type 1B) tears: a comparison between short- and midterm results.
      • Minami A.
      • Kato H.
      Ulnar shortening for triangular fibrocartilage complex tears associated with ulnar positive variance.
      Apart from a physical examination, some practitioners use additional diagnostic modalities, including selective injection, magnetic resonance imaging (MRI), magnetic resonance arthrogram (MRA), and diagnostic arthroscopy, to help refine the diagnosis. Advanced imaging in the form of MRI or MRA may be an option for diagnosing a TFCC abnormality. However, diagnostic imaging is the fastest rising cost driver in health care in the United States.
      • Hackbarth G.
      Report to the Congress: Medicare Payment Policy.
      An x-ray can be used to establish ulnar variance, which is diagnostically useful since positive ulnar variance has been associated with symptomatic TFCC abnormalities and ulnar impaction syndrome.
      • Sachar K.
      Ulnar-sided wrist pain: evaluation and treatment of triangular fibrocartilage complex tears, ulnocarpal impaction syndrome, and lunotriquetral ligament tears.
      ,
      • Shen J.
      • Papadonikolakis A.
      • Garrett J.P.
      • Davis S.M.
      • Ruch D.S.
      Ulnar-positive variance as a predictor of distal radioulnar joint ligament disruption.
      Foveal injection can assist in confirming an intra-articular source of pain.
      • Wu W.T.
      • Chang K.V.
      • Mezian K.
      • et al.
      Ulnar wrist pain revisited: ultrasound diagnosis and guided injection for triangular fibrocartilage complex injuries.
      Wrist arthroscopy has also been used as a diagnostic tool that can be simultaneously therapeutic.
      The purpose of this study was to critically evaluate the role of advanced imaging in the diagnosis and treatment of subacute to chronic ulnar-sided wrist pain in simulated subjects 55 years of age and younger with a focus on symptomatic TFCC abnormality. The study’s hypothesis was that history and physical examination (H&P) alone or with a diagnostic injection would be more cost-effective than these same strategies with MRI or MRA in the management of a symptomatic TFCC abnormality.

      Materials and Methods

      Cost-effectiveness model

      This study is a cost-effectiveness analysis of 6 diagnostic strategies for simulated subjects with ulnar-sided wrist pain and normal radiographs. A simple-chain decision model was constructed and evaluated using TreeAge Pro 2020 (TreeAge Software), in accordance with the guidelines on the Second Panel on Cost-Effectiveness in Health and Medicine.
      • Sanders G.D.
      • Neumann P.J.
      • Basu A.
      • et al.
      Recommendations for conduct, methodological practices, and reporting of cost-effectiveness analyses: second panel on cost-effectiveness in health and medicine.
      Diagnostic strategies included H&P alone, H&P + diagnostic injection, H&P with MRI, H&P with MRA, H&P + diagnostic injection and MRI, and H&P + diagnostic injection and MRA. Table 1 shows key study definitions used throughout the manuscript. Table 2 displays model parameters. All model parameters were based on the best available evidence and were input as distributions for sampling, with the exception of the study’s time horizon (3 years), as appropriate. The 3-year time horizon was chosen since this was consistent with the duration of available clinical outcomes. Model parameter sources and critiques are included in Table E1 (available online on the Journal’s website at www.jhandsurg.org/). As shown in Table E2 (available online on the Journal’s website at www.jhandsurg.org/), this analysis was performed from the health payer perspective since it did not include informal health care sector and non–health care sector costs such as patient time costs and lost labor market earnings. However, in the setting of a unilateral injury to a non–weight bearing joint, it has been assumed that these indirect costs could be considered negligible.
      Table 1Key Study Definitions
      TerminologyDefinition
      True positive
      • Diagnostic modality correctly identifies that patient has specific pathology
      • Pathology correctly identified
      True negative
      • Diagnostic modality correctly identifies that patient does not have specific pathology
      • Lack of pathology correctly identified
      False positive
      • Diagnostic modality incorrectly identifies that patient has specific pathology
      • Pathology incorrectly identified in patient without pathology
      False negative
      • Diagnostic modality incorrectly identifies that patient does not have specific pathology
      • Pathology missed in patient with pathology
      Costs
      • Measure of the direct and indirect monetary expenses of an intervention
      Effectiveness
      • Measure of benefits and/or harms of an intervention
      • Commonly expressed in quality-adjusted life years
      Cost-effectiveness analysis
      • Analytic tool in which the costs and harms and benefits of an intervention and at least 1 alternative are calculated and presented as a ratio of the incremental cost and the incremental effect.
        • Sanders G.D.
        • Neumann P.J.
        • Basu A.
        • et al.
        Recommendations for conduct, methodological practices, and reporting of cost-effectiveness analyses: second panel on cost-effectiveness in health and medicine.
      Cost-effectiveness
      • Ratio of costs to effectiveness
      • Calculated as CostInterventionAEffectivenessInterventionA
      Quality-adjusted life year
      • Commonly used effectiveness outcome that measures a patient’s global health-related quality of life over the course of 1 year, with 0 representing death and 1 representing optimal health.
      QuickDASH-adjusted life year
      • Effectiveness outcome that measures patient’s upper extremity–specific disability over the course of a year
      • Cannot be directly compared to quality-adjusted life year
      ICER
      • Ratio of incremental costs (eg, additional resources incurred from use of 1 intervention over another) over incremental effectiveness (eg, additional benefit obtained from use of 1 intervention over another)
      • Calculated as CostInterventionACostInterventionBEffectivenessInterventionAEffectivenessInterventionB
      WTP
      • Cost that health payer would pay for additional unit of effectiveness
        • Palmer A.K.
        • Werner F.W.
        The triangular fibrocartilage complex of the wrist–anatomy and function.
      • Commonly compared to ICER to determine whether a higher-cost intervention should be considered by the health payer
      NMB
      • Combination of costs, effectiveness, and WTP used to compare multiple strategies simultaneously
      • Higher values indicate a more cost-effective strategy
      • Calculated as Effectiveness×WTPCosts
      Absolutely dominated strategy
      • Strategy that costs more and is less effective than an alternative strategy
      Treatment success
      • Lack of need for further diagnosis or treatment, regardless of underlying etiology of symptoms
      One-way sensitivity analysis
      • Modeling strategy used to determine the impact of changes in a single variable on study inference
      • Model parameter varies across distribution while other parameters hold constant at their expected value
      • Commonly evaluated based on strategy determined to maximize NMB
      Tornado diagram
      • Visual representation of 1-way sensitivity analyses demonstrating the impact of individual parameters on study values
      • Commonly displays NMB and can show transitions between optimal strategies
      PSA
      • Modeling strategy used to evaluate the impact of uncertainty in model inputs on results
      • Multiple model output calculations while sampling from parameter distributions
      Cost-effectiveness acceptability curve
      • Displays proportion of model iterations in which a specific strategy is optimal based on NMB
      • Results are drawn from a PSA
      Number needed to treat
      • Measure of the number of patients needed to undergo an intervention rather than an alternative intervention to avoid a specific outcome
      • Calculated as 1ARR, where ARR=RiskinterventionARiskinterventionB
      ICER, incremental cost-effectiveness ratio; NMB, net monetary benefits; PSA, probabilistic sensitivity analysis.
      Table 2Model Parameters, Distributions, and Values in the Base Case Analysis
      Model ParameterDistributionValues
      Costs
       Office visitGamma$130.99 mean ($254.44 SD)
       X-rayGamma$102.88 mean ($222.22 SD)
       InjectionGamma$140.09 mean ($170.05 SD)
       MRAGamma$843.40 mean ($618.45 SD)
       MRIGamma$602.49 mean ($442.74 SD)
       TherapyGamma$737.46 mean ($189.11 SD)
       Arthroscopic surgeryGamma$10,396.07 mean ($2,248.31 SD)
       Irrigation and debridement surgeryGamma$9,466.26 mean ($4,674.60 SD)
       AntibioticGamma$8.58 mean ($5.48 SD)
      Effectiveness
       Baseline wrist in simulated subjects with symptomatic TFCC abnormalityBeta0.65 mean (0.16 SD)
       Baseline wrist in simulated subjects without symptomatic TFCC abnormalityBeta0.65 mean (0.16 SD)
       Improved wrist in simulated subjects with symptomatic TFCC abnormalityBeta0.86 mean (0.18 SD)
       Improved wrist in simulated subjects without symptomatic TFCC abnormalityBeta0.86 mean (0.18 SD)
      Probabilities
       Symptomatic TFCC abnormality prevalenceTriangular0.39 lower, 0.45 middle, 0.7 upper
       Probability of operative success with symptomatic TFCC abnormalityTriangular0.70 lower, 0.87 middle, 1 upper
       Probability of operative success without symptomatic TFCC abnormalityTriangular0.35 lower, 0.435 middle, 0.5 upper
       Probability of nonsurgical success with symptomatic TFCC abnormalityTriangular0 lower, 0.57 middle, 1 upper
       Probability of nonsurgical success without symptomatic TFCC abnormalityTriangular0 lower, 0.57 middle, 1 upper
       Probability of nonsurgical success with symptomatic TFCC abnormalityTriangular0 lower, 0.285 middle, 0.5 upper
       Probability of nonsurgical success without symptomatic TFCC abnormalityTriangular0 lower, 0.285 middle, 0.5 upper
       Probability of postoperative DUSN pathologyUniform0.007–0.011
       Probability of postoperative deep infectionUniform0–0.004
       Probability of postoperative portal site issueUniform0.011–0.015
      Time estimates
       Time horizonUniform3 years
       Nonsurgical treatment timeTriangular0 months lower, 3 months middle, 6 months upper
       Surgical recovery timeTriangular0 months lower, 1.5 months middle, 3 months upper
       DUSN recovery timeTriangular0 months lower, 1.5 months middle, 3 months upper
       Infection recovery timeTriangular0 months lower, 1.5 months middle, 3 months upper
       Portal issue recovery timeTriangular0 months lower, 3 weeks middle, 1.5 months upper
      Diagnostic testing characteristics
       Sensitivity of physical examinationTriangular0.74 lower, 0.85 middle, 0.95 upper
       Specificity of physical examinationTriangular0.41 lower, 0.64 middle, 0.87 upper
       Sensitivity of MRABeta0.84 mean, 0.025 SD
       Specificity of MRABeta0.95 mean, 0.015 SD
       Sensitivity of MRIBeta0.75 mean, 0.023 SD
       Specificity of MRIBeta0.81 mean, 0.025 SD
       Sensitivity of injectionTriangular0.5 lower, 0.75 middle, 1 upper
       Specificity of injectionTriangular0.5 lower, 0.75 middle, 1 upper
      DUSN, dorsal ulnar sensory nerve.
      Figure 1 displays this study’s health state flow diagram for patients ≤55 years of age with subacute or chronic ulnar-sided wrist pain, normal radiographs (no clear cause of pain on plain x-rays such as fracture, dislocation, or region-specific degenerative change), and ulnar neutral or ulnar negative variance. Patients passed through a variety of health states for specific durations of time based on literature-determined probabilities described in Table 2. During this time, they underwent diagnostic and therapeutic interventions and experienced treatment success or failure. Success was defined as lack of a need for further diagnosis or treatment, regardless of the underlying etiology of ulnar-sided wrist pain. Generally, patients first underwent nonsurgical management with anti-inflammatories, physical therapy, and immobilization, followed by an opportunity for advanced imaging. If an initial workup was suggestive of a symptomatic TFCC abnormality and nonsurgical treatment failed, patients underwent surgery. If not, they underwent additional nonsurgical treatment. Patients failing a second round of nonsurgical treatment underwent surgery. Patients had treatment success and failure at rates consistent with the literature and in keeping with their underlying pathology. Operative complications were also modeled, including dorsal ulnar sensory nerve symptoms, arthroscopy portal complications, and deep infections, at rates consistent with the literature. Simulated subjects remained in their final state for the remainder of the 3-year time horizon. A detailed model is shown in Figure E1 (available online on the Journal’s website at www.jhandsurg.org/).

      Model assumptions

      Importantly, this model assumed that simulated subjects did not decline treatment, as could occur in clinical practice. Further, the performance of advanced imaging studies did not delay surgical consideration unless the results of the study were contrary to the simulated subject’s actual diagnosis, in which case, additional nonsurgical management was recommended. Final diagnosis and treatment decisions were based on the results of the final diagnostic test in the strategy. Nonsurgical treatments that were universally applied (anti-inflammatories, immobilization, and hand therapy) were assumed to have no negative impact on effectiveness. Similarly, the diagnostic local anesthetic injection and arthrogram for MRA were considered to be benign interventions without any negative impact on effectiveness. Simulated subjects without a symptomatic TFCC abnormality that underwent diagnostic and treatment arthroscopy were considered to have a probability of success with surgery (ie, their true pathology was discovered and treated on diagnostic arthroscopy). To penalize proceeding with surgical treatment in simulated subjects without a symptomatic TFCC abnormality, the range of probabilities of operative success was halved from the rate of operative success in simulated subjects with a symptomatic TFCC abnormality. Ulnar neutral or negative variance was also assumed.

      Costs

      Direct medical cost estimates and distributions were obtained from the PearlDiver Mariner database using specific Current Procedural Terminology (CPT) codes between 2010 and 2019 in US dollar values. To obtain relevant costs, all patients with a CPT or International Classification of Diseases diagnosis of symptomatic TFCC abnormality within the PearlDiver M30 database were first identified. Then, means and SDs for costs related to a clinic visit, x-ray, diagnostic injection, therapy, MRI, MRA, arthroscopic TFCC repair, infection operation, and antibiotic were tabulated in these patients (see Table E3, available online on the Journal’s website at www.jhandsurg.org/, for International Classification of Diseases and CPT codes). Costs of an arthroscopic TFCC repair and operation for infection were summed across the entire operative day’s episode of care to account for anesthetic costs and other costs related to surgery that would not be captured solely by the surgical CPT code. Therapy costs were summed across a 90-day time period starting with the patient’s initial diagnosis of a TFCC tear. Within the model, simulated subjects undergoing treatment for deep infection incurred additional costs of infection surgery, an antibiotic, and a clinic visit. Simulated subjects undergoing treatment for dorsal ulnar sensory nerve symptoms incurred additional costs of therapy and a clinic visit. Simulated subjects with arthroscopic portal complications incurred additional costs of an antibiotic and a clinic visit. Costs were summed and adjusted to 2020 US dollars using the consumer price index. Discounting of 3% per year was applied.

      Benefits and harms

      All simulated subjects entered the model with poor wrist effectiveness based on Disability of the Arm, Shoulder, and Hand (QuickDASH) scores and transitioned to improved wrist effectiveness based on their actual pathology and response to various treatments in each diagnostic scenario.
      • Papapetropoulos P.A.
      • Wartinbee D.A.
      • Richard M.J.
      • Leversedge F.J.
      • Ruch D.S.
      Management of peripheral triangular fibrocartilage complex tears in the ulnar positive patient: arthroscopic repair versus ulnar shortening osteotomy.
      • Seo J.B.
      • Kim J.P.
      • Yi H.S.
      • Park K.H.
      The outcomes of arthroscopic repair versus debridement for chronic unstable triangular fibrocartilage complex tears in patients undergoing ulnar-shortening osteotomy.
      • Wolf M.B.
      • Haas A.
      • Dragu A.
      • et al.
      Arthroscopic repair of ulnar-sided triangular fibrocartilage complex (Palmer type 1B) tears: a comparison between short- and midterm results.
      Generally, simulated subjects with treatment success with any modality (initial nonsurgical treatment, a second round of nonsurgical treatment, or surgery) were assumed to immediately benefit from these treatments at the conclusion of the treatment and transitioned to having improved wrist effectiveness for the remainder of the time horizon. Simulated subjects in the immediate postoperative period were assumed to have an additional 6 weeks of poor wrist effectiveness while recovering from surgery. Simulated subjects that sustained postsurgical complications continued to have poor wrist effectiveness for an additional 3 weeks with arthroscopic portal complications and 6 weeks with dorsal ulnar sensory nerve symptoms and deep infection.
      Cumulative wrist effectiveness in QuickDASH was summed over the time horizon, based on the duration that simulated subjects remained in each wrist effectiveness state, to create QuickDASH life years. For ease of interpretation, QuickDASH scores (which range from 0 to 100, with lesser scores indicating lower disability and better outcomes) were subtracted from 100 and then divided by 100 to reflect the conventional direction of benefits in cost-effectiveness analyses and to mirror quality-adjusted life years. For example, simulated subjects with poor wrist effectiveness (mean QuickDASH score 35) throughout the 3-year time horizon would have an effectiveness of 0.65 (eg, 10035100×3) per year for 3 years, providing a cumulative effectiveness of 1.95 QuickDASH-adjusted life years.

      Model simulation and sensitivity analyses

      Models were evaluated with a probabilistic sensitivity analysis using 10,000 second-order Monte Carlo simulations with resampling of the parameter distributions. Inferences were stable with this modeling strategy across multiple model runs. The primary study outcome was cost-effectiveness, defined as cumulative costs divided by cumulative effectiveness using QuickDASH scores over the study time horizon. Strategies were compared using incremental cost-effectiveness ratios, defined by the strategy-dependent differential costs divided by differential effectiveness.
      Tornado diagrams based on differences in net monetary benefits were also constructed to evaluate the impact of each variable on model inference using ranges derived from the 95% confidence intervals of the parameter distributions. Variables having an impact on study inference (ie, changing preferred strategy at a set willingness-to-pay [WTP]) were considered to be sensitive variables. One-way sensitivity analyses were performed on all variables within the model that changed study inference. The probability of operative success in simulated subjects without a symptomatic TFCC abnormality was judged to be an important variable that is challenging to estimate. To examine the impact of this variable on other sensitive variables, 2-way sensitivity analyses were then performed to evaluate the impact of this variable, as well as the impact of sensitive variables, on study inference at a WTP of 50,000 per QuickDASH-adjusted life year. Lastly, as a crosswalk between QuickDASH-adjusted life years and quality-adjusted life years has not been determined, WTP across a broad range was evaluated using a cost-effectiveness acceptability curve to provide the reader with a sense of the comparative cost-effectiveness between strategies with various thresholds of WTP.

      Model parameters and data quality critique

      Table 2 displays the distributions and values of model parameters. Table E1 (available online on the Journal’s website at www.jhandsurg.org/) contains a complete listing of sources, rationales, and levels of evidence.

      Results

      Figure 2 displays the base case cost-effectiveness graph. Diagnostic strategies, including advanced imaging and injection, were absolutely dominated (were costlier and less effective) by other strategies. All strategies had similar effectiveness (2.228–2.232). Costs were lowest with H&P alone ($5,583.89) and with H&P with injection ($5627.50). Strategies that included advanced imaging cost $163 to $396 more than H&P alone. Table 3 shows the numerical results of this analysis.
      Figure thumbnail gr2
      Figure 2Base case cost-effectiveness for the 6 diagnostic strategies shown. A WTP of $50,000 per QuickDASH-adjusted life year is included for reference.
      Table 3Base Case Cost-Effectiveness
      Mean costs, effectiveness, C/E, and incremental C/E compared with H&P alone.
      Diagnostic StrategyCostQuickDASHC/EIncremental C/E Compared With H&PStrategy Acceptability
      H&P$5,583.892.228$2,506.71N/AUndominated
      H&P + injection$5,627.502.229$2,525.10$41,559.52Undominated
      H&P with delayed MRI$5,747.202.229$2,577.95$91,339.94Undominated
      H&P with delayed MRA$5,839.842.232$2,616.97$64,778.35Undominated
      H&P + injection with delayed MRI$5,887.602.229$2,640.93$169,871.5Absolutely dominated
      H&P + injection with delayed MRA$5,980.252.232$2,679.89$100,313.6Absolutely dominated
      C/E, cost-effectiveness ratio; N/A, not applicable.
      Mean costs, effectiveness, C/E, and incremental C/E compared with H&P alone.
      Figure E2 (available online on the Journal’s website at www.jhandsurg.org/) shows tornado diagrams displaying the impact of specific variables on changes in net monetary benefits at a WTP of $50,000 per QuickDASH-adjusted life year. Next, 1-way sensitivity analyses were conducted to determine threshold values for changes in the preferred diagnostic strategy for each variable, including those identified in the tornado diagrams. The full listing of threshold values is shown in Table 4.
      Table 4Threshold Values for Model Parameters Derived From 1-Way Sensitivity Analyses Based on Net Monetary Benefits
      VariableThreshold ValuePreferred Below ThresholdPreferred Above Threshold
      Costs
       Cost of injection$148.15H&P + injectionH&P
       Cost of MRA$699.68H&P with delayed MRAH&P + injection
       Cost of MRI$430.83H&P with delayed MRIH&P + injection
       Cost of initial operation$9,775.17H&PH&P + injection
       Cost of therapy$900.30H&P + injectionH&P
      Effectiveness
       Effectiveness of poor wrist in simulated subjects without symptomatic TFCC abnormality0.535H&P with delayed MRAH&P + injection
       Effectiveness of poor wrist in simulated subjects without symptomatic TFCC abnormality0.674H&P + injectionH&P
       Effectiveness of poor wrist in simulated subjects with symptomatic TFCC abnormality0.569H&PH&P + injection
       Effectiveness of improved wrist in simulated subjects without symptomatic TFCC abnormality0.836H&PH&P + injection
       Effectiveness of improved wrist in simulated subjects without symptomatic TFCC abnormality0.975H&P + injectionH&P with delayed MRA
       Effectiveness of improved wrist in simulated subjects with symptomatic TFCC abnormality0.941H&P + injectionH&P
      Probabilities
       Probability of success with second round of nonsurgical treatment in simulated subjects without symptomatic TFCC abnormality0.249H&PH&P + injection
       Probability of success with second round of nonsurgical treatment in simulated subjects without symptomatic TFCC abnormality0.322H&P + injectionH&P with delayed MRA
       Probability of success with second round of nonsurgical treatment in simulated subjects with symptomatic TFCC abnormality0.239H&PH&P + injection
       Probability of nonsurgical success in simulated subjects without symptomatic TFCC abnormality0.555H&P + injectionH&P
       Probability of nonsurgical success in simulated subjects with symptomatic TFCC abnormality0.665H&P + injectionH&P with delayed MRA
       Probability of operative success in simulated subjects without symptomatic TFCC abnormality0.466H&P + injectionH&P
       Probability of operative success in simulated subjects with symptomatic TFCC abnormality0.899H&P + injectionH&P
       Probability of symptomatic TFCC abnormality0.553H&P + injectionH&P
      Diagnostic testing
       Sensitivity of injection0.78H&P + injectionH&P
       Sensitivity of physical examination0.816H&PH&P + injection
       Specificity of injection0.743H&PH&P + injection
       Specificity of physical examination0.645H&P + injectionH&P
      Times
       Time in nonsurgical treatment0.271H&P + injectionH&P
      History and physical examination alone was a cost-effective strategy across most of the analyses. With the exception of the analysis on the cost of an MRI, all other preference transitions were between H&P alone, H&P and injection, or H&P with a delayed MRA. History and physical examination+ injection with a delayed MRI or MRA were never the preferred strategies.
      The results of the 2-way sensitivity analyses are shown in Table 4. These were largely the same as results for the 1-way sensitivity analyses, except for the transition between H&P with delayed MRA and H&P + injection on the probability of operative success in simulated subjects without a symptomatic TFCC abnormality (Fig. 3).
      Figure thumbnail gr3
      Figure 3Two-way sensitivity analysis on probability of operative success in simulated subjects without symptomatic TFCC abnormality and on probability of symptomatic TFCC abnormality.
      Figure 4 shows the cost-effectiveness acceptability curve across a range of WTP values per QuickDASH-adjusted life year. History and physical examination alone was the preferred strategy until a WTP of approximately $65,000 per QuickDASH-adjusted life year, after which H&P with delayed MRA was preferred. History and physical examination + injection was never more favorable than H&P alone or H&P with delayed MRA in this analysis. History and physical examination + injection became less favorable than H&P with delayed MRA at approximately $50,000 per QuickDASH-adjusted life year.
      Figure thumbnail gr4
      Figure 4Cost-effectiveness acceptability curve for the 6 diagnostic strategies shown.
      Lastly, the impact of diagnostic modality on false positive surgery rates (ie, proceeding to surgery without a symptomatic TFCC abnormality) and false negative surgery delay rates (ie, failing to proceed to surgery in the setting of a symptomatic TFCC abnormality) were examined in the base case using expected values (Table 5). History and physical examination alone resulted in a false positive surgery rate of 0.084 and a false negative surgery delay rate of 0.028. In contrast, strategies including advanced imaging resulted in false positive surgery rates of 0.012–0.044 and false negative surgery delay rates of 0.029–0.045. The number needed to treat (ie, number of patients to undergo additional diagnostic modalities; Table 1) to avoid a single false positive surgery was calculated at 13.8 patients when comparing the strategy of H&P with delayed MRA or H&P + injection with delayed MRA (lowest rates of false positive surgery) to H&P alone (highest rate of false positive surgery). Compared to the strategies with the highest rates of false negative surgery delay (H&P + injection, H&P with delayed MRI, or H&P + injection with delayed MRI), the number needed to treat to avoid a false negative surgery delay was 61.5 patients in H&P with delayed MRA or H&P + injection with delayed MRA and 57.7 with H&P alone.
      Table 5False Negative Surgery Delay Rates, False Positive Surgery Rates, and NNT for Each Diagnostic Strategy Using Expected Values From Parameter Distributions in the Base Case
      “Base” indicates comparison baseline in NNT calculations.
      Diagnostic StrategyFalse Positive Surgery RateFalse Negative Surgery Delay RateNNT to Avoid False Positive Surgery Compared With H&P AloneNNT to Avoid False Negative Surgery Delay Compared With H&P + Injection
      H&P0.0840.028Base57.7
      H&P + injection0.0580.04538.1Base
      H&P with delayed MRI0.0440.04524.9Base
      H&P + injection with delayed MRI0.0440.04524.9Base
      H&P with delayed MRA0.0120.02913.861.5
      H&P + injection with delayed MRA0.0120.02913.861.5
      NNT, number needed to treat.
      “Base” indicates comparison baseline in NNT calculations.

      Discussion

      This study examined the cost-effectiveness of various diagnostic strategies for patients aged 55 years and younger presenting with ulnar-sided wrist pain and normal radiographs, with a focus on symptomatic TFCC abnormalities. The findings support that H&P alone is the preferred diagnostic strategy in the context of our treatment algorithm. Advanced imaging added costs and had little benefit in this patient population at reasonable levels of WTP.
      • Papapetropoulos P.A.
      • Wartinbee D.A.
      • Richard M.J.
      • Leversedge F.J.
      • Ruch D.S.
      Management of peripheral triangular fibrocartilage complex tears in the ulnar positive patient: arthroscopic repair versus ulnar shortening osteotomy.
      ,
      • Minami A.
      • Kato H.
      Ulnar shortening for triangular fibrocartilage complex tears associated with ulnar positive variance.
      ,
      • Baek G.H.
      • Chung M.S.
      • Lee Y.H.
      • Gong H.S.
      • Lee S.
      • Kim H.H.
      Ulnar shortening osteotomy in idiopathic ulnar impaction syndrome.
      • Tatebe M.
      • Shinohara T.
      • Okui N.
      • Yamamoto M.
      • Hirata H.
      • Imaeda T.
      Clinical, radiographic, and arthroscopic outcomes after ulnar shortening osteotomy: a long-term follow-up study.
      • Hulsizer D.
      • Weiss A.P.
      • Akelman E.
      Ulna-shortening osteotomy after failed arthroscopic debridement of the triangular fibrocartilage complex.
      Additionally, arthroscopy represents the gold standard for the diagnosis of a symptomatic TFCC abnormality.
      • Smith T.O.
      • Drew B.
      • Toms A.P.
      • Jerosch-Herold C.
      • Chojnowski A.J.
      Diagnostic accuracy of magnetic resonance imaging and magnetic resonance arthrography for triangular fibrocartilaginous complex injury: a systematic review and meta-analysis.
      Therefore, surgical treatment remains a reasonable approach even in patients who have failed nonsurgical management with a negative MRI/MRA.
      This study’s finding that advanced imaging is not cost-effective in the diagnosis of ulnar-sided wrist pain with normal radiographs should not be misconstrued to indicate that advanced imaging is never an appropriate part of the diagnosis or treatment of ulnar-sided wrist pain. Surgeons should use clinical judgment to determine whether advanced imaging would be beneficial for their individual patient, although the findings of our study suggest that this should be a rare occurrence.
      One notable limitation is that there were no reports of injection diagnostic test characteristics, so these were estimated conservatively. Further, the model assumed that patients with and without a symptomatic TFCC abnormality have the same overall benefits with surgical and nonsurgical management. However, to penalize an incorrect diagnosis, the rate of success for operative treatment was halved in simulated subjects without a symptomatic TFCC abnormality undergoing surgery. These assumptions were tested in a sensitivity analysis, which indicated a minimal change in the model preference across a range of surgical and nonsurgical success rates. As the purpose of this study was to focus on the cost-effectiveness of diagnostic algorithms rather than treatments, we did not compare different treatments (ie, open vs arthroscopic treatments). Further, despite the fact that most studies evaluating TFCC treatment report outcomes in QuickDASH, there are no studies correlating QuickDASH scores with traditional measures of quality of life; therefore, QuickDASH scores were used as a surrogate for quality of life. This complicates the interpretation of the tornado diagrams and 1-way sensitivity analyses, since the interpretation is based on maximizing net monetary benefits, which requires a set WTP. However, a QuickDASH-specific WTP is not available. Because QuickDASH measures are specific to the upper extremity and do not account for global quality of life, we speculate that a QuickDASH-specific WTP would be considerably lower than a WTP based on global quality-of-life metrics (ie, the WTP threshold would likely be less than $50,000/quality-adjusted life year). Based on the cost-effectiveness acceptability curve, advanced imaging would be even less favored with a lower WTP, but we acknowledge that this is speculative. Because of these limitations, we also included false negative surgery delay rates and false positive surgery rates, along with numbers needed to treat, which can be compared between studies since they do not rely on the quality of life. Also, the technical characteristics of MRI and MRA performance, such as field strength, spatial resolution, injection technique (for MRA), and obtaining triplanar imaging with appropriate cartilage-sensitive sequences, may alter the diagnostic accuracy of MRI and MRA, and were not considered. Of note, studies evaluating the diagnostic characteristics of MRI and MRA may overstate their benefits, since imaging studies performed in these studies were likely performed in ideal conditions and in high-prevalence samples. Further, since this study was performed from the health payer perspective, we did not include some indirect costs such as those incurred from time away from work or activities since we judged that the impact of those costs would be minimal in the setting of a unilateral upper-extremity injury. Because of these assumptions, this model may not extrapolate well to patients with an exceptional disability or indirect cost related to their symptomatic TFCC abnormality. Injections (diagnostic injections and arthrograms) were considered to be benign interventions, although a small proportion of patients may experience a side effect such as a local anesthetic or contrast-related complication. Importantly, additional cost and disability related to diagnostic injection or arthrogram would further favor H&P alone, supporting the study’s main inference. Lastly, the study relies on a diagnostic and treatment algorithm currently in use in our clinical practice that was developed over years of experience. These results may not generalize to alternative diagnostic and treatment algorithms.
      In conclusion, this model of simulated subjects presenting with ulnar-sided wrist pain with normal radiographs incorporated reasonable, literature-based parameter estimates to demonstrate: (1) the cost-effectiveness of H&P alone or H&P + diagnostic injection as the basis of diagnosis and treatment; and (2) the minimal additional benefit and the additional costs of advanced imaging. Specific clinical scenarios may warrant consideration of advanced imaging. In an era of increasing scrutiny on health care expenditures, reduction of unnecessary diagnostic tests may become increasingly important.

      Appendix

      Figure thumbnail fx1
      Figure E1Complete simple-chain decision analysis model for 1 diagnostic strategy.
      Figure thumbnail fx2
      Figure E2Tornado diagrams displaying the impacts of specific variables on changes in net monetary benefits at a WTP of $50,000 per QuickDASH-adjusted life year. Figures are grouped by costs, effectiveness, probabilities, time estimates, and diagnostic testing characteristics. The vertical black lines represent transition values between strategies found to maximize net monetary benefits at the set WTP. EV, expected value.
      Table E1Parameter Distributions, Values, Sources, Rationale, and Level of Evidence
      Model ParameterDistributionValuesSourceRationaleLevel of Evidence
      Costs
       Office visitGamma$130.99 mean ($254.44 SD)PearlDiver M30 databasePublic and private health insurance cost databaseN/A
       X-rayGamma$102.88 mean ($222.22 SD)PearlDiver M30 databasePublic and private health insurance cost databaseN/A
       InjectionGamma$140.09 mean ($170.05 SD)PearlDiver M30 databasePublic and private health insurance cost databaseN/A
       MRAGamma$843.40 mean ($618.45 SD)PearlDiver M30 databasePublic and private health insurance cost databaseN/A
       MRIGamma$602.49 mean ($442.74 SD)PearlDiver M30 databasePublic and private health insurance cost databaseN/A
       TherapyGamma$737.46 mean ($189.11 SD)PearlDiver M30 databasePublic and private health insurance cost databaseN/A
       Arthroscopic surgeryGamma$10,396.07 mean ($2,248.31 SD)PearlDiver M30 databasePublic and private health insurance cost databaseN/A
       Irrigation and debridement surgeryGamma$9,466.26 mean ($4,674.60 SD)PearlDiver M30 databasePublic and private health insurance cost databaseN/A
       AntibioticGamma$8.58 mean ($5.48 SD)PearlDiver M30 databasePublic and private health insurance cost databaseN/A
      Effectiveness
       Baseline wrist in simulated subjects with symptomatic TFCC abnormalityBeta0.65 mean (0.16 SD)Wolf et al, 2012
      • Wolf M.B.
      • Haas A.
      • Dragu A.
      • et al.
      Arthroscopic repair of ulnar-sided triangular fibrocartilage complex (Palmer type 1B) tears: a comparison between short- and midterm results.
      Beta distribution based on preoperative QuickDASH scores in simulated subjects with symptomatic TFCC abnormality subtracted from 1Level IV therapeutic study
       Baseline wrist in simulated subjects without symptomatic TFCC abnormalityBeta0.65 mean (0.16 SD)Wolf et al, 2012
      • Wolf M.B.
      • Haas A.
      • Dragu A.
      • et al.
      Arthroscopic repair of ulnar-sided triangular fibrocartilage complex (Palmer type 1B) tears: a comparison between short- and midterm results.
      Beta distribution based on preoperative QuickDASH scores in simulated subjects with symptomatic TFCC abnormality subtracted from 1Level IV therapeutic study
       Improved wrist in simulated subjects with symptomatic TFCC abnormalityBeta0.86 mean (0.18 SD)Wolf et al, 2012
      • Wolf M.B.
      • Haas A.
      • Dragu A.
      • et al.
      Arthroscopic repair of ulnar-sided triangular fibrocartilage complex (Palmer type 1B) tears: a comparison between short- and midterm results.
      Beta distribution based on postoperative QuickDASH scores in simulated subjects with symptomatic TFCC abnormality subtracted from 1Level IV therapeutic study
       Improved wrist in simulated subjects without symptomatic TFCC abnormalityBeta0.86 mean (0.18 SD)Wolf et al, 2012
      • Wolf M.B.
      • Haas A.
      • Dragu A.
      • et al.
      Arthroscopic repair of ulnar-sided triangular fibrocartilage complex (Palmer type 1B) tears: a comparison between short- and midterm results.
      Beta distribution based on postoperative QuickDASH scores in patients without symptomatic TFCC abnormality subtracted from 1Level IV therapeutic study
      Probabilities
       Symptomatic TFCC abnormality prevalenceTriangular0.39 lower, 0.45 middle, 0.7 upperChan, 2014
      • Chan JJ
      • Teunis T
      • Ring D
      Prevalence of triangular fibrocartilage complex abnormalities regardless of symptoms rise with age: systematic review and pooled analysis.
      Triangular distribution across the reported range of prevalenceLevel III systematic review
       Probability of operative success with symptomatic TFCC abnormalityTriangular0.70 lower, 0.87 middle, 1 upperSaito, 2017
      • Saito T
      • Malay S
      • Chung KC
      A systematic review of outcomes after arthroscopic debridement for triangular fibrocartilage complex tear.
      Triangular distribution centered on mean rate of operative success bounded by lower and upper limits of reported ratesLevel III–IV systematic review (not explicitly stated)
       Probability of operative success without symptomatic TFCC abnormalityTriangular0.35 lower, 0.435 middle, 0.5 upperSaito, 2017
      • Saito T
      • Malay S
      • Chung KC
      A systematic review of outcomes after arthroscopic debridement for triangular fibrocartilage complex tear.
      Triangular distribution centered on mean rate of operative success bounded by lower and upper limits of reported rates. Rate halved to account for alternate pathology determined in operating roomLevel III–IV systematic review (not explicitly stated)
       Probability of nonsurgical success with symptomatic TFCC abnormalityTriangular0 lower, 0.57 middle, 1 upperPark et al, 2010
      • Park M.J.
      • Jagadish A.
      • Yao J.
      The rate of triangular fibrocartilage injuries requiring surgical intervention.
      Triangular distribution centered on rate of nonsurgical treatment successLevel III diagnostic study (not explicitly stated)
       Probability of nonsurgical success without symptomatic TFCC abnormalityTriangular0 lower, 0.57 middle, 1 upperPark et al, 2010
      • Park M.J.
      • Jagadish A.
      • Yao J.
      The rate of triangular fibrocartilage injuries requiring surgical intervention.
      Triangular distribution centered on rate of nonsurgical treatment successLevel III diagnostic study (not explicitly stated)
       Probability of nonsurgical success with symptomatic TFCC abnormalityTriangular0 lower, 0.285 middle, 0.5 upperStudy assumptionStudy assumptionN/A
       Probability of nonsurgical success without symptomatic TFCC abnormalityTriangular0 lower, 0.285 middle, 0.5 upperStudy assumptionStudy assumptionN/A
       Probability of postoperative DUSN pathologyUniform0.007 to 0.011Saito, 2017
      • Saito T
      • Malay S
      • Chung KC
      A systematic review of outcomes after arthroscopic debridement for triangular fibrocartilage complex tear.
      Uniform distribution across reported ratesLevel III–IV systematic review (not explicitly stated)
       Probability of postoperative deep infectionUniform0 to 0.004Saito, 2017
      • Saito T
      • Malay S
      • Chung KC
      A systematic review of outcomes after arthroscopic debridement for triangular fibrocartilage complex tear.
      Uniform distribution across reported ratesLevel III–IV systematic review (not explicitly stated)
       Probability of postoperative portal site issueUniform0.011 to 0.015Saito, 2017
      • Saito T
      • Malay S
      • Chung KC
      A systematic review of outcomes after arthroscopic debridement for triangular fibrocartilage complex tear.
      Uniform distribution across reported ratesLevel III–IV systematic review (not explicitly stated)
      Time estimates
       Time horizonUniform3 yearsStudy assumptionStudy assumptionN/A
       Nonsurgical treatment timeTriangular0 months lower, 3 months middle, 6 months upperStudy assumptionStudy assumptionN/A
       Surgical recovery timeTriangular0 months lower, 1.5 months middle, 3 months upperStudy assumptionStudy assumptionN/A
       DUSN recovery timeTriangular0 months lower, 1.5 months middle, 3 months upperStudy assumptionStudy assumptionN/A
       Infection recovery timeTriangular0 months lower, 1.5 months middle, 3 months upperStudy assumptionStudy assumptionN/A
       Portal issue recovery timeTriangular0 months lower, 3 weeks middle, 1.5 months upperStudy assumptionStudy assumptionN/A
      Diagnostic testing characteristics
       Sensitivity of physical examinationTriangular0.74 lower, 0.85 middle, 0.95 upperTay, 2007
      • Tay SC
      • Tomita K
      • Berger RA
      The “ulnar fovea sign” for defining ulnar wrist pain: an analysis of sensitivity and specificity.
      Schmauss, 2016
      • Schmauss D
      • Pohlmann S
      • Lohmeyer JA
      • Germann G
      • Bickert B
      • Megerle K
      Clinical tests and magnetic resonance imaging have limited diagnostic value for triangular fibrocartilaginous complex lesions.
      Triangular distribution centered at mean of physical examination sensitivity reported by the 2 studiesTay, Level II diagnostic study; Schmauss. Level III diagnostic study (not explicitly stated)
       Specificity of physical examinationTriangular0.41 lower, 0.64 middle, 0.87 upperTay, 2007
      • Tay SC
      • Tomita K
      • Berger RA
      The “ulnar fovea sign” for defining ulnar wrist pain: an analysis of sensitivity and specificity.
      Schmauss, 2016
      • Schmauss D
      • Pohlmann S
      • Lohmeyer JA
      • Germann G
      • Bickert B
      • Megerle K
      Clinical tests and magnetic resonance imaging have limited diagnostic value for triangular fibrocartilaginous complex lesions.
      Triangular distribution centered at mean of physical examination specificity reported by the 2 studiesTay, Level II diagnostic study; Schmauss, Level III diagnostic study (not explicitly stated)
       Sensitivity of MRABeta0.84 mean, 0.025 SDSmith et al, 2012
      • Smith T.O.
      • Drew B.
      • Toms A.P.
      • Jerosch-Herold C.
      • Chojnowski A.J.
      Diagnostic accuracy of magnetic resonance imaging and magnetic resonance arthrography for triangular fibrocartilaginous complex injury: a systematic review and meta-analysis.
      Beta distribution based on systematic review of imaging test characteristicsLevel III systematic review and meta-analysis
       Specificity of MRABeta0.95 mean, 0.015 SDSmith et al, 2012
      • Smith T.O.
      • Drew B.
      • Toms A.P.
      • Jerosch-Herold C.
      • Chojnowski A.J.
      Diagnostic accuracy of magnetic resonance imaging and magnetic resonance arthrography for triangular fibrocartilaginous complex injury: a systematic review and meta-analysis.
      Beta distribution based on systematic review of imaging test characteristicsLevel III systematic review and meta-analysis
       Sensitivity of MRIBeta0.75 mean, 0.023 SDSmith et al, 2012
      • Smith T.O.
      • Drew B.
      • Toms A.P.
      • Jerosch-Herold C.
      • Chojnowski A.J.
      Diagnostic accuracy of magnetic resonance imaging and magnetic resonance arthrography for triangular fibrocartilaginous complex injury: a systematic review and meta-analysis.
      Beta distribution based on systematic review of imaging test characteristicsLevel III systematic review and meta-analysis
       Specificity of MRIBeta0.81 mean, 0.025 SDSmith et al, 2012
      • Smith T.O.
      • Drew B.
      • Toms A.P.
      • Jerosch-Herold C.
      • Chojnowski A.J.
      Diagnostic accuracy of magnetic resonance imaging and magnetic resonance arthrography for triangular fibrocartilaginous complex injury: a systematic review and meta-analysis.
      Beta distribution based on systematic review of imaging test characteristicsLevel III systematic review and meta-analysis
       Sensitivity of injectionTriangular0.5 lower, 0.75 middle, 1 upperNo estimates availableAssumed triangular distribution with moderate sensitivity based on current concept review by Sachar, 2012
      • Sachar K.
      Ulnar-sided wrist pain: evaluation and treatment of triangular fibrocartilage complex tears, ulnocarpal impaction syndrome, and lunotriquetral ligament tears.
      Level V current concept review
       Specificity of injectionTriangular0.5 lower, 0.75 middle, 1 upperNo estimates availableAssumed triangular distribution with moderate specificity based on current concept review by Sachar, 2012
      • Sachar K.
      Ulnar-sided wrist pain: evaluation and treatment of triangular fibrocartilage complex tears, ulnocarpal impaction syndrome, and lunotriquetral ligament tears.
      Level V current concept review
      DUSN, dorsal ulnar sensory nerve; N/A, not applicable.
      Table E2Impact Analysis
      SectorType of ImpactIncluded in This Reference Case Analysis?
      Health Care SectorSocietal
      Formal health care sector
      HealthHealth outcomes (effects)
      Longevity effectsYesYes
      Health-related quality-of-life effectsYesYes
      Other health effects (eg, adverse events)YesYes
      Medical costs
      Paid for by third-party payersYesYes
      Paid for by patients out of pocketYesYes
      Future related medical costs (payers and patients)YesYes
      Future unrelated medical costs (payers and patients)YesYes
      Informal health care sector
      HealthPatient time costsN/ANo
      Unpaid caregiver time costsN/ANo
      Transportation costsN/ANo
      Non–health care sectors
      ProductivityLabor market earnings lostN/ANo
      Cost of unpaid lost productivity because of illnessN/ANo
      Cost of uncompensated household productionN/ANo
      ConsumptionFuture consumption unrelated to healthN/ANo
      Other (specify)Other impactsN/ANo
      N/A, not applicable.
      Table E3ICD and CPT Codes Used to Derive Costs in PearlDiver
      VariableICD-9, ICD-10, and/or CPT Codes
      TFCC pathologyICD-10-D-S63591A, ICD-10-D-S63591D, ICD-10-D-S63591S, ICD-10-D-S63592A, ICD-10-D-S63592D, ICD-10-D-S63592S, ICD-10-D-S63599A, ICD-10-D-S63599D, ICD-10-D-S63599S, ICD-9-D-84200, ICD-9-D-84201, ICD-9-D-84202, ICD-9-D-84209
      Clinic visit costsCPT-99213
      X-ray costsCPT-73110
      Therapy costsCPT-97003, CPT-97039, CPT-97018, CPT-97022, CPT-98960, CPT-90901, CPT-97010, CPT-97014, CPT-97032, CPT-97124, CPT-97760, CPT-97140, CPT-97035, CPT-97530, CPT-97033
      Injection costsCPT-20605
      MRI costsCPT-73221
      MRA costsCPT-73222
      Arthroscopic TFCC repair costsCPT-29846
      Infection operation costsCPT-25028, CPT-25040
      Antibiotic costsNDC-00093314705
      ICD-9, International Classification of Diseases, 9th edition; ICD-10, ICD International Classification of Diseases, 10th edition; NDC, National Drug Code.

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