SubjectUse SHIFT+ENTER to open the menu (new window).
  
Body
Created ByUse SHIFT+ENTER to open the menu (new window).
  
RepliesUse SHIFT+ENTER to open the menu (new window).
  
Last UpdatedUse SHIFT+ENTER to open the menu (new window).
  
  

There is one situation where I will perform a carpal tunnel release in the office: the patient without insurance. Texas is a state with no safety net for the uninsured. Even though I live in a relatively wealthy county which is home to a major state university, one third of our population is uninsured.

If a self pay patient comes to see me with a straight forward history and physical exam, has failed conservative treatment and is not diabetic, I will perform an open carpal tunnel release in my treatment room using local anesthetic. It takes me about 40 minutes to set up and do the procedure. One of my x-ray techs is my assistant. My charge is $1000 which includes the initial office visit, and follow up.I don't do this often, but find it pretty easy and have not had any problems. I have not calculated the actual 'profit' but the staff are there anyway and at least one of my partners is working at the same time.   ​

04/12/2013 8:37 PM
  

​I have a 70 year old very sport active man, whom suffer

a chronic carpal lunate luxation since september 15- 2012.

I need journal articles of treatment and follow up.

Thank you very much.

Oscar F. Orozco,M.D.

No presence informationOrozco-Romo, Oscar012/2/2012 4:16 PM
  

​This article continues to be one of many challanging long held concepts of treatment of common conditions in the United States. There have been recent publications in numerous journals questioning the cost effectiveness of therapy in common procedures such as ACL reconstruction in recent sports medicine journals and therapy for CTS in our own JHS. As resouces become limited the question of how best to allocate them to do the most amount of good will be important. What the study does not address is the legal ramifications should a complication occur. Kevin Chung had published a cost effective analysis on open vs. ECTRA years ago. While the ECTRA was an effective procedure at reducing symptoms, its cost effectiveness was rapidly reduced when a nerve injury occurred when the outcomes were measures in Quality Adjusted Life years. While a carpal tunnel release done open is about as straightforward as it gets for well trained hand surgeons, a number of precautions must be planned out ahead of time to ensure the procedure is completed safely. As with most clinical studies, patient selection is key and those patients with multiple co-morbidities, especially those patients with anxiety having the procedure done under local, may be ones where the added cost of a hospital outpatient setting may well be worth it. The issue of tort reform in many states has come up over the years and this paper may well be able to reduce some of the anxiety practitioners have when performing procedures in an office setting to point to efficacy without the added cost.

No presence informationPomerance, Jay09/28/2011 8:08 PM
  

​ A very interesting article that makes me think about setting up a small procedure room in our clinic. Unfortunately there are regional differences that may limit how applicable this is. In our hospital the main barriers to performing an open carpal tunnel or trigger finger release in the clinic setting have been:

1) organizing the staff and equipment. in order to have adequate safety, an RN would be needed in the room, a hand tray and drapes would be needed and the logistics of sterilizing and disposing of the used equipment. 

2) Clinic space is also at a premium and having a room set up as a procedure room would be difficult. Unless that room is being used everyday of the week by surgeons doing procedures, keeping a clinic room empty is inefficient

3) the maintenance and sterilization of endoscopic equipment would also have to be handled by the OR, in our setting the clinics are a few blocks away from the main hospital, and getting the equipment to Central sterile and back would take some work.

Although the operating room has some inherent inefficiencies, at least the set up and equipment is taken care of and I can just show up and do the case. In some hospitals this would be a great idea. In our hospital surgi-center carpal tunnels can be done every half an hour if you are doing them under straight local without an anesthesiologist.

this article does point out that an endoscopic carpal tunnel release is more expensive. although not the focus of this article I kept thinking that unless the results of endoscopic carpal tunnel release are that much better, why do them instead of an open procedure.

Nader Paksima

​

09/27/2011 9:40 PM
  

​I was only able to read the abstract, as I do not have access to this journal.  There are probably legal issues regarding posting the entire article for us to read, so selection of an article from JHS may be the only method to make sure everyone has access. 

I agree the efficient use of resources being the most efficient and cost effective as Mather et al also demonstrated regarding distal radius fractures (July issue of JHS). 

Comparison of different techniques (mini open, one or two portal endoscopic techniques, use of instruments such as the Indiana tome, stryker knife light,…) will all have their advocates for various reasons.  While OR or facility costs can be compared, it is much harder to compare overall costs to society, such as time away from work and other activities, and utilization of post operative therapy (even though it has been shown that it is not cost effective (Pomerance and Fine – JHS 2007), is often used.  In addition, the cost to society is variable, depending on profession (desk job vs repetitive manual labor, ability of co-workers to cover,...) and insurance (compensation vs private vs Medicaid).

Many of these issues are more patient dependent than procedure dependent and in light of that, one could make a strong argument for the least expensive procedure.  But, I think it is more complicated than that.  Depending on the above factors, a slightly more expensive procedure with a shorter convalescent period could be equally or more effective from an overall cost standpoint.  In addition, those who perform endo CTR would also argue that that patients have less difficulties returning to many activities sooner following endo ctr and most patients who have had one side done with open CTR and the other side with endo prefer the endo side, so early patient satisfaction may be higher and justify a slightly increased expense (Level V evidence).  Better evidence would help answer this question, but the difficulty evening setting up a clinical trial to answer this question, with geographical differences as far as economics and the number of patients required to reach statistical significance, and the difficulty completing a trial of this magnitude, make this highly unlikely and will leave this topic and others open for debate.    ​


Warren C. Hammert

09/27/2011 9:23 PM
  

The additional problem with this paper is that the conservative treatment with a cast brace will not restore anatomical healing. A proper cast will. The reuslts here are comparing unneceesarry surgery to poor conservative treatment. If there is to be a comparison it should bebetween proper three point casting and surgery. There will be no contest between these two.​

04/5/2011 2:13 PM
  

​I agree with David in that this is a common injury and most of these patients do well with nonoperative treatment.  I find many of these patients somewhat unreliable - they may present to the office 2-3 weeks after the injury or being seen in the ED and it is not uncommon for these patients to be repeat offenders.  Although the authors report better subjective outcomes with operative treatment, it may be hard to quantify this for most of our patients with this injury.

With enough angulation, the presence of the metacarpal head in the palm could be problematic for manual laborers.  Unfortunately, we curently do not know the definition of "enough".

Certainly, the cost associated with operative treatement of this injury cold be significant given the frequency with which it occurs. 

While all patients should be treated individually, looking at thier specific funcional requirements, I think operative treatment of these injuries will continue to be the exception rather than the rule.

As opposed to distal radius fractures, for which I have heard many surgeons state they would have a volar plate placed and be back to work in a week (and I tend to agree), this is a condition which I would have treated with a splint for comfort and early motion if it were in my hand, accepting the mild cosmetic deformity, realizing there is a minimal chance of functional problems.

04/3/2011 2:19 PM
  
In addition to the many problems discussed above, I have found, in my Independent Medical Examination practice, a couple of hand surgery groups which demonstrate the symbiotic relationship which can develop between aggressive surgeons and injured workers benefitting from compensation while off work. Surgeons in these groups have, according to the records I receive to review, rely heavily on Provocative tests to base their opinion on the need for surgical procedures. These have typically been those tests requiring a subjective response, i.e. "does that hurt?". When the other exam findings and objective tests do not support their diagnosis, there is usually a discussion about false negative results of objective testing. Typically these groups diagnose 4-10 conditions (one recent case with thirteen diagnoses), and provide multiple operations per upper extremity. A recent case involved 9 surgical procedures on one limb at one setting, and then the identical 9 procedures on the opposite limb weeks later. There is typically no discussion regarding the details of the work activities, i.e. work cycle, force, position, vibration, which would put the worker at risk for developing the occupational conditions (most conditions they diagnose are not traumatic conditions/injuries, but occupational "diseases" related to repetitious work). Unfortunately, the insurance company authorizing the requested surgeries in this workers comp arena do not appear to be following some excellent criteria (published by their company) for determining the relatedness to work or for the need for surgical treatment. On a side note, I found the recent AAOS-sponsored meeting on Workers Comp in Phoenix to be enlightening.
01/15/2011 1:15 PM
  
Many excellent points so far. Realizing comp has some differences in each state, I think we all find similarities - comp patients do not do as well as non comp patients. Regarding David's first two points, comp pays similar to private insurance (better for some codes and less for other codes) for surgery, but around medicaid rates for office visits in western NY. I do find comp patients are more desirable of surgical treatment for conditions that may do very well with nonop (injection for mild CTS), but many of the medicaid patients I treat have the same approach. The workers compensation board also has a desire to "close the case" and this is easier to do following surgical treatment as it appears there is less likelihood of recurrent symptoms. Patients also have more subjective complaints as in their mind, this will entitle them to more money when the case is closed. In western NY, any patient with restrictions must be seen every 6 weeks (and soon to be 3 weeks for some conditions) and many cases take a few months for authorization for surgery - IME prior to authorization,.... In addition, some conditions (trigger digits, deQuervains require injection prior to authorization for surgery, so this will require additional office visits. I agree the lack of financial responsibility plays a role to some degree - I write prescriptions for ibuprofen for these patients. Warren Hammert
01/2/2011 7:43 PM
  
A great service to the Hand Surgery Community especially with the addition of shoulder and elbow citations. Journal club is a great introduction to Evidence Based Practice with a little labelling. I believe it would help if the articles were to have a notation of the study design or article type in the summaries. Not necessarily a level of evidence as I think some readers are confused by the complexity of rating or think the process belittles good efforts at other types of reporting, but words like "cohort study, or prospective clinical trial, or technique description" would have the effect of drawing the reader to the article depending on their focus. Each reader will use the article differently- some will repeat the information as teachers and some will translate it to their practice immediately based on their patient's need and reliance on more experienced surgeons in the area. The levels of evidence and collected wisdom should be left to a rigid methodology like the Clinical Practice Guideline. Mike Keith,
01/2/2011 9:38 AM
  
The monetary incentive for WC patients is powerful. Most also come with legal representation who get paid as a percentage of medical costs. This can be another powerful driver to the illness concept in addition to emphasizing the injury concept to the patient - you had an injury and will therefore never be normal or be able to return to what you did previously. This can also increase monetary settlements in some jurisdictions. There is also a regional difference in WC utiliation depending on state law. In states which had enacted reform and have lower rates of renumeration, it can sometimes be difficult for patients to even get adequate treatment.
 
Dr. Ring's point about patient's not bearing any cost of treatment is also germaine. Why would anyone want or care to limit treatment costs if there are no personal ramifications for it? Additioanally, if the amount of treatment dollars spent may actually increase the monetary settlement at case conclusion, there is actually a disincentive to do this.   
01/1/2011 11:51 AM
  
David's 4th question: How about the speculation that WC patients tend to have less specific symptoms and signs? Is the higher resource utilization of WC patients largely the result of our ineffective management of disproportionate symptoms and disability, placing too much hope in the “find it and fix it” approach? In my practice (and I recognize that WC practice patterns vary- I am in an academic, tertiary care setting), WC patients follow the 80/20 rule. 80% present with definable pathology and respond to treatment. While the duration of care might be longer than the non-WC patient (therapy for strengthening, etc), these patients get better and get back to work. It is the 20% who challenge my diagnostic acumen, require additional testing, undergo more treatment, and do not ever respond as I would hope. For these patients, the "find it and fix it" mentality does not work.
01/1/2011 7:32 AM
  
To this point no discussion of psychological status has been raised. In our practice the Patient Health Questionnaire is employed routinely as a screening test. There may be better screening questionnaires but that is not the point. The point is that a substantial percentage have a diagnosable mood disorder confirmed by a formal psychological evaluation. A 30% incidence has been found in general fracture clinic populations. With compensation cases the incidence appears higher. For example if the pain is chronic i.e. present more than 6 months the incidence of mood disorder rises to 60%. A common comorbidity with chronic pain is not only mood disorder but also a chronic pain syndrome. The latter is characterized by RSD like symptoms i.e. diffuse severe pain, which worsens rather then improves. Some but not all become obvious RSD (CRPS1). Many exhibit regional pain without the full picture of RSD. In my experience these individuals do best with cognitive behaviour therapy and remedial activity not surgery.
012/31/2010 9:56 AM
  
In Ohio, we are faced with other obstacles in dealing with BWC patients:an injured worker opens a claim at his / her point of entry into the system(usually a company-owned occupational health clinic or Emergency Room)...here a diagnosis is made (sprain,etc.) and this diagnosis now is "written in stone"....if the patient doesn't improve and is sent to a specialist, who easily makes the correct diagnosis (CTS, DeQuervain's, Torn TFCC, etc.) the patient can only be treated for a "sprain" or the whole process comes to a screaching halt because an unauthorized diagnostic code (all-be-it correct) prevents processing. One is not allowed make the diagnosis of a nerve problem without an EMG, or a carpal instability or TFCC tear without an MRI, but one cannot order those tests if the allowed diagnosis is "sprain"....this requires a hearing to obtain permission to get such tests, takes weeks ,if not months to secure, and another hearing to change to the correct diagnostic codes. Should the patient fail conservative Rx. and need surgeryanother hearing is needed to obtain authorization for surgery. This process is additionally confounded by independent medical exams at the request of the company & / or attorney followed by requests that the treating physician concur or refute the findings of the IME. This long drawn out ,fruitless process often takes months during which the patient is out of work, if getting salary benefits a significant portion of it goes to the lawyer, the patient is frustrated at the lack of meaningful treatment, becomes resentful of the employer, and now is dis-incentivized to recover normally.
throughout this process, only a fraction of the hundreds of millions of dollars spent annually by BWC actually goes to patient care....the majority going into the legal system.
It could be ,however fixable ( Seitz,W H, Cleveland State University Law & Medicine Journal, Jan. 2009) by creating a system of certified experts (in Hand Surgery CAQ status would be required) capable of examining and determining the correct diagnosis and initiating proper treatment without delay. This would get patients treated expeditiously, speed return-to-work, eliminate extensive paper work, and save millions of dollars.
However, this would require change in the law.... and we know who makes the laws.....
Till then... expect to get more tests (eventually), spend more health care dollars, have more unhappy patients with poorer outcomes, and continue to be frustrated taking care of these patients.
012/30/2010 8:16 AM
  
Great start to the discussion!
 
I agree that disproportionate symptoms and disability make it more difficult to identify objective, treatable pathophysiology. But can we "rely" on objective tests?  All tests have false positives and false negatives, not to mention all the true but unrelateds (e.g. 50% of normal wrists have a ganglion; TFCC abnormalities are like grey hair)
 
David Ring 
012/30/2010 5:49 AM
  
To be very brief, in over forty years of seeing Work Comp patients in California, I have rarely seen a W/C patient who presented with just one anatomic problem. Eliminating patients with acute trauma, by the time we, as hand surgeons, see the patient, the "simple" carpal tunnel symptoms have escalated to include the wrist, forearm, elbow, shoulder, brachial plexus and neck. No wonder it takes longer to get from presentation to surgery.
012/30/2010 12:09 AM
  
I have doing workers' compensation for over 30 years and have conducted at least two different studies comparing workers' comp to noncomp patients. In both studies, despite comparable objective findings, comp patients did considerably worse. In my experience I am much more conservative with comp patients for a number of reasons. First, they almost always do worse no matter how I treat them. Second, many tend to exaggerate their complaints creating what I call a "Chaff effect" (i.e. they have so many exaggerated and non-anatomic complaints that effectively mask their real problems) so they require more testing and more visits just to sort through the "chaff." I frequently find that I spend more time, more visits and more money on diagnostic tests with patients who tend to exaggerate of give non-anatomic descriptions of their pain no matter who their payor is. It is just in my practice comp patients constitute a much higher percentage of these patients. As frustrating as I find these patients, I am alway reminded of something one of my attendings told me when I was a resident. "All crocks die of organic disease." As a result, I feel obligated to do what I can to try to get to the bottom of the patient's complaints. It is just comp patients don't help you very much so you have to depend more on objective tests.
012/29/2010 8:18 PM
  
We know from the work of Potenza over 30 years ago that each time the epitendon surface of a flexor tendon is pierced, this leads to a potential site of flexor tendon adhesions. With the advent of stronger suture materials which are often larger (e.g a 3-0 fiberwire has a larger diameter than a 3-0 supramid from prior published work in JHS) and suture methods which pass through the tendon surface mutiple times, there is a greater chance for more adhesions to form. This is discounting the amount the tendon is "handled" during the repair process which can sometimes be sbstantial.
 
When the tendon is repaired there can be an increased work of flexion as the tendon attempts to get through the sheath as Dr. Amadio and his co-workers at Mayo have shown us and with bulkier repairs this can limit tendon motion. As it is mechanically easier "to pull a piece of cooked spaghetti through a tube rather than push it" the results of the present study are not surpising. Controlling the amount of active/passive motion in this notoriously unreliable group of patients can be challanging as often patients discard splints, and instructions for that matter, in significant percentages of physicians practices. The authors and their therapists are to be commended for either having been able to pass their instructions on effectively or having a very big stick to enforce the protocol for each cohort.
09/7/2010 8:24 PM
  
The authors and others involved in this study should be congratulated for their efforts. Although the topic of flexor tendon injuries receives much attention both at meetings and in journals, most is based on biomechanical/ cadaver and animal studies, and clinical practice is guided by experience or retrospective case reviews, these authors managed to complete a prospective, randomized trial in a clinical setting. Anyone who has been involved in this type of research understands the challenges encountered. The inclusion criteria was strict to minimize confounding variables, but this makes it more challenging to recruit patients. In addition, many patients with flexor tendon injuries are not as reliable as the surgeon would like, which makes compliance with therapy and long term follow up extremely challenging. In spite of these and other obstacles, the authors managed to obtain long term outcome data on 103 patients and provide compelling evidence that active motion with place and hold should at least be considered following zone II flexor tendon repair. I think this article will change the approach of many surgeons who make decisions on the best evidence on a given topic and will be a classic article to be discussed for years for those learning and practicing hand surgery. There are still many variables which we do not fully understand regarding healing of flexor tendon injuries. Some patients do well in spite of not following any directions regarding rehabilitation while others do everything asked and still end up with less than optimal motion. We know that healing and scarring can be very different for patients with similar injuries and evidence such as provided in this paper will help us treat patients as effectively as possible.
No presence informationHammert, Warren09/4/2010 1:08 PM
  
The authors and others involved in this study should be congratulated for their efforts. Although the topic of flexor tendon injuries receives much attention both at meetings and in journals, most is based on biomechanical/ cadaver and animal studies, and clinical practice is guided by experience or retrospective case reviews, these authors managed to complete a prospective, randomized trial in a clinical setting. Anyone who has been involved in this type of research understands the challenges encountered. The inclusion criteria was strict to minimize confounding variables, but this makes it more challenging to recruit patients. In addition, many patients with flexor tendon injuries are not as reliable as the surgeon would like, which makes compliance with therapy and long term follow up extremely challenging. In spite of these and other obstacles, the authors managed to obtain long term outcome data on 103 patients and provide compelling evidence that active motion with place and hold should at least be considered following zone II flexor tendon repair. I think this article will change the approach of many surgeons who make decisions on the best evidence on a given topic and will be a classic article to be discussed for years for those learning and practicing hand surgery. There are still many variables which we do not fully understand regarding healing of flexor tendon injuries. Some patients do well in spite of not following any directions regarding rehabilitation while others do everything asked and still end up with less than optimal motion. We know that healing and scarring can be very different for patients with similar injuries and evidence such as provided in this paper will help us treat patients as effectively as possible.
No presence informationHammert, Warren09/4/2010 1:06 PM