Carpal tunnel release (CTR) is one of the most common upper-extremity procedures, with excellent outcomes and lasting benefits. When comparing the surgical options of open versus endoscopic CTR, studies have noted higher rates of transient nerve injury but lower risk of wound problems after endoscopic release. Long-term clinical outcomes appear to be similar between the 2 techniques.
What about the associated costs? This is a multidimensional question of particular relevance given the high economic impact of carpal tunnel syndrome, a leading cause of lost work time. Barnes et al. shed new light on the cost-effectiveness of endoscopic versus open CTR in a recent JBJS report, offering a look from societal and payer perspectives. In this cost-effectiveness analysis, the authors developed a Markov model to evaluate unilateral open versus endoscopic CTR in an office setting with local anesthesia and an operating room (OR) setting under monitored anesthesia care. Comprehensive outcomes data from published meta-analyses helped to inform the modeling, while the costs of CTR, performed from 2012 to 2016, were obtained from a large Medicare claims database.
The authors note that, with complications rates being relatively balanced between the 2 techniques, and differences in quality-adjusted life-years being small (<1 quality-adjusted life-day), “procedural and lost-productivity costs primarily drove the results.” (The model assumed 8.21 fewer days of missed work after endoscopic CTR.) Health-care costs are larger for endoscopic CTR, but “the impact of lost productivity was important.” For instance, endoscopic release in the OR setting becomes cost-effective if the patient’s expected return to work is even 1.2 days earlier than that following open CTR in the OR. However, because of the lower costs of performing open CTR in the office setting, endoscopic CTR in the OR is cost-effective only if the expected return to work is at least 3.9 days earlier than that following open CTR in the office.
Overall, the authors concluded that, from a payer perspective, endoscopic CTR is more expensive than open CTR and only becomes truly cost-effective if performed in an office setting under local anesthesia. However, from a societal perspective, earlier return to work may help tip the scales in favor of endoscopic release. The authors caution that additional research is needed to confirm their findings based on the latest surgical techniques and return-to-work protocols.
Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media
Click here for a JBJS Clinical Summary on the treatment of carpal tunnel syndrome.
Often when I ask patients about the reason for their visit, I inquire about specific events. For example, “What were you doing when you hurt your knee?” For acute injuries, they can usually describe the exact moment they tore their ACL or dislocated their shoulder. In an adolescent sports clinic, where I spend much of my time, this acute scenario is the norm, but what about patient conversations regarding gradual-onset disease processes such as carpal tunnel syndrome (CTS) or osteoarthritis? These pathologies develop over many years, but patients with such conditions may fixate on when their disease became symptomatic–and may therefore mistakenly attribute a chronic condition to an acute injury.
Lemmers et al. investigate this complex body-mind concept in the December 16, 2020 issue of The Journal. The authors sought to analyze factors associated with the misperception of disease onset due to the recent experience of symptoms in 121 adult patients with CTS, cubital tunnel syndrome, upper-extremity osteoarthritis, or rotator cuff tendinosis. The patients filled out questionnaires for depression, anxiety, pain catastrophizing, self-efficacy, and upper-extremity physical function, in addition to supplying basic demographic information.
Based on the responses, most patients understood that their problem was not new but was instead “age-appropriate.” However, 18% of patients perceived the sudden onset of symptoms as a “new” disease, and 24% felt the problem was related to at least 1 injury or event. After multivariable analysis, Lemmers et al. found that Hispanic ethnicity and publicly funded or no insurance were independently associated with the perception that an event/injury caused the problem. The authors candidly admit that this area needs much more research, but they surmise that this latter finding could be related to lower health literacy.
This work highlights that we need to make sure our patients understand exactly what is happening with their musculoskeletal system. Because misperception of a disease’s cause and onset could affect patient decision-making, it is incumbent upon us as surgeons to be vigilant for possible misconceptions during our shared decision-making discussions with patients. As Lemmers et al. conclude, “Patients who do not understand what is happening to their body might choose different health strategies than they would if their understanding were accurate.”
Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media
There has been a huge worldwide effort over the last 2-plus decades to establish arthroplasty registries. Among the many advantages of such registries, advocates emphasize the potential detection of early failures associated with new implant designs and biomaterials. The large number of patients enrolled in most registries and the methodical capturing of data yield substantial statistical and research benefits.
Based on the successes of arthroplasty registries, parallel registries have been established for sports medicine (especially for shoulder and knee conditions and treatments), fractures, musculoskeletal tumors, and others. Although the focus has been on enrolling large numbers of patients with relatively common disorders or procedures, there have been less well-publicized efforts to create smaller registries of rarer diseases.
In the October 21, 2020 issue of The Journal, Forman et al. use the 8-site Congenital Upper Limb Differences (CoULD) registry to report on associations between congenital deficiency of the radial aspect of the forearm in 259 patients (383 involved limbs) and thumb hypoplasia. Two findings stood out to me:
- The severity of radial deficiency was correlated with the severity of thumb deficiency.
- Compared with subjects who had no diagnosed syndromes, patients with concomitant syndromes (such as VACTERL and Holt-Oram) were twice as likely to have bilateral deficiency and 2.5 times as likely to have radial and thumb deficiencies as opposed to thumb deficiency alone.
In addition to reinforcing findings from previous single-institution studies, these data from Forman et al. will help surgeons counsel parents, determine treatment approaches, and establish frameworks for following patient outcomes after both surgical and nonsurgical treatment. It is my hope that other clinician-researchers with interest in understanding and managing rare conditions will establish similar registries to benefit these smaller but no-less-important groups of patients and families.
Click here to read the JBJS Clinical Summary on Congenital Hand Differences.
Marc Swiontkowski, MD
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes Christopher Dy, MD, MPH in response to his recent participation in the virtual Annual Meeting of the American Society for Surgery of the Hand.
The year 2020 has brought with it many “firsts.” For example, due to the COVID-19 pandemic, the Annual Meeting for the American Society for Surgery of the Hand (ASSH) was moved from San Antonio to a virtual platform. Kudos to the Annual Meeting chairs (Dawn Laport, MD and Ryan Calfee, MD), ASSH president Martin Boyer, MD, and the ASSH staff for constructing an amazing experience. Here are some general take-homes from my first-ever virtual conference experience:
- A virtual conference provides attendees with a ton of flexibility and customization. While there are often “conflicting,” concurrent sessions during an in-person meeting where I have to decide between 2 sessions, the virtual ASSH meeting format offered the ability to go back and watch prior courses and lectures. When we (hopefully) go back to in-person meetings, it would help if more sessions were recorded and made available to attendees on demand.
- The virtual conference requires a lot more pre-meeting preparation for all parties involved, especially presenters. Because the sessions that would normally occur in the large, main halls were hosted on a professionally run platform with A/V engineers, presenters were required to attend more than a few “tech” rehearsals, as well as submit their presentation slides 4 to 6 weeks in advance. I admit that it was harder for me to present from slides that didn’t feel as fresh, since I couldn’t revise them the night before!
- While it was convenient to view most of the meeting from my couch (or exercise bike), I really miss the in-person interactions with colleagues and friends that you get while moving between sessions. It’s also harder to pull yourself away from your family and your practice when you are “participating” in a meeting from home or office.
Here are 4 technical things I learned from the sessions I attended, largely biased toward my personal interests. I encourage readers to leave comments by clicking on the “Leave a Comment” button in the box next to the title.
- Innovation continues for distal nerve transfers to treat peripheral nerve palsy. Professor Jayme Bertelli from Brazil gave talks demonstrating both technical aspects and his own results following transfers such as ECRL [extensor carpi radialis longus]-to-AIN [anterior interosseous nerve], distal AIN to distal PIN [posterior interosseous nerve], and opponens pollicis to adductor pollicis. I am eager to read more about these transfers and get into the cadaver lab to refine my surgical technique. (Precourse 03 and Symposium 18)
- The debate about “supercharging” (reverse end-to-side) nerve transfers continues. There is laboratory evidence supporting the role of a supercharged nerve transfer in preserving the distal muscle unit and the distal nerve stump. However, there is controversy regarding whether it is benign and/or beneficial to have 2 “competing” sources of muscle innervation, in cases where the “native” nerve reaches the distal target after the axons coming from the supercharged transfer have been placed. While many surgeons have adopted supercharged nerve transfer into their practice, there is far more laboratory and clinical research needed to substantiate this practice and refine the indications for use. (Precourse 03 and Symposium 11)
- Utilization of wide-awake, local-anesthesia, no-tourniquet (WALANT) hand surgery continues to grow. Surgeons are performing a growing number of different surgeries (including fracture cases and complex tendon transfers) with WALANT, and some are doing these cases in procedure rooms or offices rather than in a formal operating room. These changes are driven by both surgeon and patient preference, as well as potential cost advantages for both parties. For surgeons, there is a potential for increased revenue with WALANT, but this can come with logistical challenges such as stocking sterile trays and making sure that medications are available. The trend toward increasing utilization of WALANT in procedure rooms and in surgeons’ offices is likely to continue. (Instructional courses 24 and 56 and related OrthoBuzz post)
- Teaching in the operating room has shifted. Many current trainees prefer to use videos for case preparation rather than focusing on book chapters, technique articles, or primary literature. Consequently, there is a growing embrace of video among hand-surgeon educators. Videos that are short, discuss indications, and provide rationale for technique-related decisions are favored. Today’s trainees are also less likely to respond well to the classic Socratic method of teaching and may need more overtly delivered feedback. (Instructional courses 10 and 36)
Christopher Dy, MD, MPH is a hand and wrist surgeon, an assistant professor of orthopaedic surgery at Washington University School of Medicine in St. Louis, and a member of the JBJS Social Media Advisory Board.
Most everyone has seen the auto-insurance TV ad where the deep-voiced man asserts, “Safe drivers save 40%.” Insurance savings notwithstanding, patients frequently ask orthopaedic surgeons when they can return to safe driving after surgery. Of course, the answer depends partly on the patient’s ability to drive safely before surgery, but most of the orthopaedic research on this topic has focused on lower extremities. In the September 16, 2020 issue of The Journal, Orfield et al. take a detailed look at the driving question after wide-awake, local-anesthetic, no-tourniquet (WALANT) surgery of the hand.
Twelve right-handed patients drove 18 miles under baseline conditions and completed various parking tasks during the first 45- to 55-minute test. The instrumented vehicle they drove obtained kinematic data automatically, and behavioral responses were recorded on video cameras. Then the same subjects completed the same driving exercise in the same vehicle—but this time after having their right hand injected with 10 mL of 1% lidocaine over the volar wrist, and another 10 mL into the carpal tunnel. To further simulate WALANT conditions, researchers applied a bulky hand dressing to each participant’s right hand. The WALANT-modeled driving test included a simulated “surprise event” that required avoidance maneuvers. Researchers analyzed before-and-after data on a variety of kinematics, including braking, acceleration, right and left turning, and proportion of time spent driving with each or both hands.
Overall, Orfield et al. found no evidence of a negative impact on driving fitness in the simulated WALANT state. In fact, the subjects braked harder and steered more smoothly in the WALANT-modeled state, an indication that they perceived they might be impaired. Not surprisingly, participants in the WALANT-modeled state spent decreased time using both hands (from 72% to 62%), while left-hand-only driving increased from 2% to 16% of the time. All participants reported that they felt safe to drive with a numb, bandaged right hand.
These noninferiority findings suggests that WALANT patients are no worse off with immediate driving after the surgical procedure than they were beforehand. The authors are quick to point out that these findings should not be generalized beyond right-handed people driving a passenger car with an automatic transmission in the United States. Still, this study gives us some evidence-based data to better inform patients undergoing common hand procedures now frequently performed under WALANT conditions, such as trigger-finger and carpal-tunnel release. However, we can’t guarantee they will save on their auto insurance.
Click here to view a 3-minute “Author Insight” video with study co-author Peter J. Apel, MD, PhD.
Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media
With contemporary teaching and advanced-imaging diagnostic protocols, the incidence of advanced wrist arthritis related to scaphoid nonunion and carpal instability seems to be decreasing. When this condition does present, the longstanding debate about treatment pits preserving the carpal bone mass with a 4-corner arthrodesis (FCA) against resecting the proximal row of carpal bones (proximal row carpectomy, or PRC) to provide better motion. At issue have been concerns about the durability and reoperation rates for these two treatment approaches.
In the June 17, 2020 issue of The Journal, Garcia et al. tap into the Veterans Health Administration data warehouse to help clarify this treatment dilemma. The authors identified 1,168 patients with stage-II SLAC (scapholunate advanced collapse) or SNAC (scaphoid nonunion advanced collapse) patterns of wrist arthritis. The outcomes of interest were subsequent conversion to total wrist arthrodesis and secondary surgical procedures after FCA and PRC.
Using propensity score analysis, the authors established matched cohorts of 251 cases of each procedure. The rate of conversion to total wrist arthrodesis was virtually identical in both matched groups, but far fewer patients who underwent FCA avoided a subsequent nonarthrodesis operation compared with those who underwent PRC (83.5% vs 99.7%, respectively).
Based on these findings and the evidence in previously published literature, the authors say, “We believe that PRC may be preferable to FCA in patients with symptomatic stage-II SLAC/SNAC wrist arthritis.” I think this choice should always be the result of shared decision making that itemizes the pros and cons of both procedures—especially taking into account patient preferences related to expected functional outcomes.
Marc Swiontkowski, MD
Every month, JBJS publishes a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Click here for a collection of OrthoBuzz summaries of these “What’s New” articles. This month, author Christopher J. Dy, MD, MPH selected the 5 most clinically compelling findings from the more than 50 studies summarized in the March 18, 2020 “What’s New in Hand and Wrist Surgery.”
—A retrospective case series investigating 3 treatments for scaphoid nonunion among >100 patients1 found the following:
- Those receiving iliac crest bone graft (n=31), most of whom had carpal collapse with preserved proximal pole vascularity, had a union rate of 71%, a time-to-union of 19 weeks, and a reoperation rate of 23%.
- Those receiving an intercompartmental supraretinacular artery flap (n=33), most of whom had osteonecrosis of the proximal pole and half of whom had carpal collapse, had a union rate of 79%, a time-to-union of 26 weeks, and a reoperation rate of 12%.
- Those receiving a free vascularized medial femoral condyle flap (n=45), most of whom had carpal collapse, osteonecrosis, and prior surgery, had a union rate of 89%, a time-to-union of 16 weeks, and a reoperation rate of 16%.
—Among 13 patients with scaphoid nonunion and osteonecrosis who were treated with cancellous autograft packing and volar-plate fixation,2 there was 100% fracture union, with most achieving union within 18 weeks. However, preoperative carpal-collapse rates were not reported, making it difficult to assess the role of this procedure.
Finger Replantation: Financial Issues
—The frequency and success rates of finger replantation have been decreasing in the US. A review of physician reimbursement for these procedures3 found that replantation has lower reimbursement per work relative value unit (RVU) than many other common hand surgeries, including revision amputation, carpal tunnel release, and trigger finger surgery. This “relative devaluation” may help explain the decline in frequency and success of finger replantation.
Socioeconomics of Carpal Tunnel Syndrome
—Among patients seeking treatment for carpal tunnel syndrome, those from areas of “increased social deprivation” had worse physical function, pain interference, anxiety, and depression than patients from more affluent areas.4
Cubital Tunnel Syndrome
—A study of preoperative dynamic ultrasound in patients with cubital syndrome5 found that ultrasound was far more reliable than preoperative clinical examinations in predicting ulnar nerve stability within the cubital tunnel (88% match with intraoperative findings vs 12% match, respectively). Preoperative ultrasound may therefore help surgeons counsel patients about the possible need for nerve transposition.
- Aibinder WR, Wagner ER, Bishop AT, Shin AY. Bone grafting for scaphoid nonunions: is free vascularized bone grafting superior for scaphoid nonunion?Hand (N Y). 2019 Mar;14(2):217-22. Epub 2017 Oct 27.
- Putnam JG, DiGiovanni RM, Mitchell SM, Castañeda P, Edwards SG. Plate fixation with cancellous graft for scaphoid nonunion with avascular necrosis. J Hand Surg Am.2019 Apr;44(4):339.e1-7. Epub 2018 Aug 10.
- Hooper RC, Sterbenz JM, Zhong L, Chung KC. An in-depth review of physician reimbursement for digit and thumb replantation. J Hand Surg Am.2019 Jun;44(6):443-53. Epub 2019 Apr 17.
- Wright MA, Beleckas CM, Calfee RP. Mental and physical health disparities in patients with carpal tunnel syndrome living with high levels of social deprivation. J Hand Surg Am.2019 Apr;44(4):335.e1-9. Epub 2018 Jun 23.
- Rutter M, Grandizio LC, Malone WJ, Klena JC. The use of preoperative dynamic ultrasound to predict ulnar nerve stability following in situ decompression for cubital tunnel syndrome. J Hand Surg Am.2019 Jan;44(1):35-8. Epub 2018 Nov 27.
Distal radial fractures are common, especially in the elderly, but the best management for these fractures in older patients remains controversial. Clinical practice guidelines issued in 2011 by the AAOS recommend operative treatment when certain angulation and shortening criteria are met. Meanwhile, some studies show that age >65 years is an independent risk factor for poor radiographic outcomes,1 while other studies suggest that older patients have acceptable functional outcomes despite radiographic loss of reduction.2 We may want to believe that anatomic reduction and normal-appearing radiographs will ensure improved outcomes, but the science has not always confirmed that connection, leaving us and our older patients in a bit of a conundrum.
In the January 2, 2020 issue of The Journal, DeGeorge et al. tackle this subject in a large retrospective analysis of data from patients ≥65 years old who had been managed for a distal radial fracture between 2009 and 2014. Among >13,000 distal radial fractures analyzed, 9,973 were treated nonoperatively and 3,740 were treated operatively. The average age of the entire cohort was 75.4 years, but the authors found that the operative group was significantly younger, and that nonoperative treatment was more commonly performed in patients with a greater number and severity of medical comorbidities, including cardiovascular disease, diabetes, cancer, and dementia.
At 90 days, the overall complication rate was low (36.5 complications per 1,000 fractures), and the authors found no significant differences between the operative and nonoperative groups. However, the complication rate at 1 year was significantly higher in the operative group (307.5 per 1,000 fractures) compared to the nonoperative group (236.2 complications per 1,000 fractures). Stiffness was the most common complication across both groups, but it was significantly more common in the group that underwent operative management (occurring in 16% of that cohort). Also of note: approximately 10% of patients in each group developed chronic regional pain syndrome.
Despite the inherent weaknesses in retrospective database analyses (including, in this case, the inability to analyze indications for surgery), this study reveals some important facts that may help us better counsel older patients. Operative management of distal radial fractures in the elderly may yield better radiographic outcomes than nonoperative treatment, but that comes with a significantly increased risk of 1-year complications. Accepting a less-than-perfect reduction on radiographs and casting the fracture may be more beneficial than surgery for many of our elderly patients.
Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media
- Mackenny PJ, McQueen MM, Elton R. Prediction of instability in distal radius fractures. J Bone Joint Surg Am. 2006 Sep; 88(9):1944-1951.
- Grewal R, MacDermid JC. The risk of adverse outcomes in extra-articular distal radius fractures is increased with malalignment in patients of all ages but mitigated in older patients. J Hand Surg Am. 2007 Sep; 32(7):962-70.
Editor’s Note: Here is a list of previous OrthoBuzz posts about managing distal radial fractures:
- “Appropriate” Management of Distal Radial Fractures Improves Outcomes, Lowers Cost
- How Many X-Rays Does It Take to Treat a Distal Radial Fracture?
- Immobilization after Fixation of Distal Radial Fractures
- Association Between Distal Radial Fracture Malunion and Patient-Reported Activity Limitations
- Fixation Costs for Distal Radial Fracture
- Plate–Tendon Contact: How Important Is It?
Many surgeons realize that to improve value, we must improve the quality of care while decreasing its cost. Clinical Practice Guidelines (CPGs) developed by the AAOS and other medical societies are designed to help improve the quality of care and safety for patients, while also reducing inappropriate care and decreasing cost. Unfortunately, the evidence used for the development of CPGs is often of mixed quality. It is therefore crucial that studies evaluate patient outcomes when clinicians do and do not adhere to CPGs, so we can ensure that the guidelines are achieving their objective of improving care.
In the October 16, 2019 issue of The Journal of Bone and Joint Surgery, Giladi et al. hypothesize that adhering to Recommendation 3 of the AAOS CPG regarding radiographic indications for operative management of distal radial fractures would yield improved patient outcomes and cost benefits. Recommendation 3 of the CPG suggests that fractures with post-reduction radial shortening of >3 mm, dorsal tilt of >10°, or intra-articular displacement or step-off of >2 mm should be operatively treated. The authors retrospectively reviewed 266 patients, 145 of whom were treated operatively and 121 of whom were treated nonoperatively. Based on the guideline recommendation, only 6 patients were determined to have undergone inappropriate operative fixation, but 68 patients in the nonoperative cohort received inappropriate treatment; many of those had higher-grade fractures that, per the guideline, should have been surgically treated.
Using QuickDASH outcome scores at 4 time points up to 1 year and 1-year direct cost data, the authors compared the appropriately treated operative cohort to both the appropriate and inappropriate nonoperative groups. They also compared the appropriate and inappropriate nonoperative groups to each other. QuickDASH outcomes for appropriate nonoperative treatment were better than those for inappropriate nonoperative treatment at 1 year. In addition, inappropriate nonoperative treatment cost 60% more than appropriate nonoperative treatment. Although this cost comparison did not reach statistical significance, (p=0.23), it does suggest a cost savings with adherence to the CPGs. Appropriately treated operative patients reported less disability than the inappropriately nonoperative group.
As we continue to work at increasing health-care value, it is critical that we review CPGs in action, as Giladi et al. have done in this study. A potential next step would be to investigate whether the modest improvements in QuickDASH scores noted between appropriate operative treatment and inappropriate nonoperative treatment justify the 6-fold higher cost of operative treatment.
Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media
There are few things more discouraging for an orthopaedic surgeon than a late postoperative complication after what was an otherwise successful surgery. One such scenario occurs when patients who have undergone open reduction/internal fixation (ORIF) for a distal radial fracture subsequently experience a flexor pollicis longus (FPL) tendon rupture. While previous literature has suggested that plate positioning plays a role in that complication, no studies have evaluated whether newer plate designs decrease contact with the FPL tendon and therefore reduce the risk of rupture.
With that question in mind, Stepan et al. evaluated two cohorts of patients who had undergone ORIF for a distal radial fracture. In the September 4, 2019 issue of JBJS, they report on findings from 40 patients, 20 of whom received a standard distal radial volar locking plate, and 20 of whom received a plate designed with a distal cutout to afford the FPL more room to traverse.
Ultrasound analysis revealed that similar percentages of patients in each group had FPL–plate contact (65% in the FPL-plate group and 79% in the standard-plate group), and there were no differences between groups in terms of FPL tendon degeneration as seen on ultrasound. However, patients who received the FPL plate had significantly less of the tendon come in contact with the plate at 0° and 45° of wrist extension. The authors noted, however, that this difference may have been influenced by the fact that patients with the FPL-specific plate also had significantly lower volar tilt than patients with the standard locking plate. It is therefore not possible to determine whether it was the plate design or the bone position (or both) that led to these results.
It is also noteworthy that the two senior authors of this study work as consultants for the company that manufactures the plates that were evaluated. It is also important to note that because all the patients in this study were asymptomatic, further research is needed to determine the clinical importance of reduced tendon–plate contact area. We should temper our excitement about specially designed volar plates until we have more clinical data supporting their success in avoiding the problem for which they were designed.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media