July 11, 2024

Orthopedics

By: Outpatient Surgery Editors

Published: 6/25/2024

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THIS WEEK'S ARTICLES

Carpal Tunnel Release Thrives in the Office Setting

AAOS Updates Clinical Practice Guideline Regarding Carpal Tunnel Syndrome

Carpal Tunnel Syndrome Surgical Procedures at the ASC - Sponsored Content

Wide-Awake Hand Surgery Offers a Legion of Benefits

Gender’s Role in Carpal Tunnel Syndrome

 

Carpal Tunnel Release Thrives in the Office Setting

More hand surgeons and their healthiest patients are opting to have these surgeries performed on the spot.

CTSQUICK RELIEF Hand surgeons are increasingly diagnosing patients’ carpal tunnel syndrome at their offices and, in some cases, performing the corrective surgeries there the same day.

Procedures like carpal tunnel release are among the many that are moving from hospitals and ASCs to physician offices as more robust data continues to emerge confirming positive outcomes in the setting. "The more data that becomes available, the more likely it is that the number of procedures and the types of procedures in office settings will also increase," says Linda Cendales, MD, a hand and transplant surgeon and professor of surgery at Duke Health in Durham, N.C.

Hand surgery is one specialty, along with ENT, ophthalmology, dermatology and certain GYN cases, where relatively straightforward procedures are regularly performed on otherwise healthy patients in office settings due to brief operating times. This development is an obvious patient-pleaser for reasons that go beyond removing the need to drive to and navigate a hospital or schedule a procedure at a surgery center. Dr. Cendales says for simple cases, patients visiting the office for an evaluation of their condition can often get the necessary surgery right there, on the same day.

"This not only benefits local patients but also patients who come from out of town because the scheduling is faster, more efficient and flexible," says Dr. Cendales. "Some patients really prefer the office because they can just walk in, have the short procedure and walk out without having to stop eating the night before or getting someone to drive them to surgery."

Hand surgeries she finds appropriate to perform in the office include carpal tunnel release, volar wrist ganglion, trigger finger release, superficial soft tissue mass removals, nailbed injuries and others that don’t cause significant bleeding or require metal implants.

Dr. Cendales says advances in "wide-awake anesthesia" have facilitated the migration of certain surgeries to office settings. She says the technique has proven effective, inexpensive and popular with patients. A crucial consideration, however, is patient selection. Only the healthiest patients should be offered this option.

For busy ASCs, the office migration can prove a blessing in disguise, allowing physicians who work at these facilities to perform simple cases in their offices, freeing the ASC’s ORs for more complex and potentially more lucrative cases in the process.

AAOS Updates Clinical Practice Guideline Regarding Carpal Tunnel Syndrome

Fresh information, research and insight are offered for diagnosis, treatment, postoperative care and more.

CTSZEROING IN Patients suffering from carpal tunnel syndrome likely will benefit from the first update in eight years of AAOS guidelines regarding management of the condition.

The American Academy of Orthopaedic Surgeons (AAOS) last week updated its Clinical Practice Guideline (CPG) for Management of Carpal Tunnel Syndrome (CTS) for the first time since 2016. The guideline addresses the diagnosis and treatment of patients 18 years of age and older who present with complaints that may be attributed to CTS.

AAOS describes the updated guideline, accessible here, as "streamlined to focus on the long-term benefits of CTS treatment." The update is a collaborative effort among representatives from AAOS, the American Society for Surgery of the Hand, the American Association for Hand Surgery, the American College of Occupational and Environmental Medicine, the American Society of Hand Therapists, the American College of Radiology and the American Academy of Physical Medicine and Rehabilitation.

"While the 2016 guideline covered several recommendations for the short-term effects of CTS treatment, our workgroup chose to focus on long-term patient outcomes as shifts in health care require a focus on cost-effective, high-quality and patient-centered care," says Lauren Shapiro, MD, co-chair of the guideline development group. "This update provides physicians and patients with clear recommendations to optimize outcomes while minimizing unnecessary interventions."

"The CPG was organized to cover workup, treatment and postoperative care of CTS and highlights areas where certain patients can avoid some debatable preoperative treatments (e.g., corticosteroid injections), preoperative tests and postoperative therapies based on the evidence cited in this guideline," adds Robin Kamal, MD, FAAOS, co-chair of the guideline development group.

AAOS describes CTS as the most common compressive neuropathy affecting the upper extremity, producing symptoms such as pain, numbness and tingling in the hand and forearm that can lead to morbidity and lost productivity. It cites the National Institutes of Health’s finding that, in the Medicare patient population alone, the burden of CTS in the U.S. is $2.7 to $4.8 billion annually.

Among the guideline updates:

  • Diagnosis. The guidelines now encourages the use of CTS-6, an evaluation tool that accounts for symptoms and disease history, to diagnose CTS. This is in response to the routine use of ultrasonography or a nerve conduction velocity test and electromyography, which are considered both painful and expensive. Additionally, the guideline now states that moderate evidence suggests that MRI and upper limb neurodynamic testing should not be used to diagnose CTS. The guideline also notes the workgroup’s opinion that no evidence strongly supports the association between high keyboard use and CTS in the literature.
  • Treatment. The updated guideline supports the notion that both mini-open and endoscopic carpal tunnel release provide similar long-term outcomes for CTS treatment. Meanwhile, it states that the use of platelet-rich plasma injections and corticosteroid injections demonstrate a lack of long-term benefits in nonoperative treatment of CTS. AAOS’ guideline also cites strong evidence that local anesthetic alone can be used for carpal tunnel release.
  • Office-based settings. The guideline cites limited evidence that carpal tunnel release may be safely conducted in the office setting, although it also cites studies that consistently demonstrated no increased risk of complications and higher ratings of patient experience and satisfaction when compared to surgical release in the operating room.
  • Postoperative care. The guideline cites moderate evidence that postoperative supervised therapy should not be routinely prescribed after carpal tunnel release; strong evidence that NSAIDs and/or acetaminophen should be used after carpal tunnel release for postoperative pain management; and limited evidence that perioperative prophylactic antibiotics are not indicated for the prevention of surgical site infection following carpal tunnel release.

"The recommendations in this CPG highlight areas which are intended for shared decision-making between patients and their physicians and are not meant to be used for insurer determinations," notes Dr. Kamal.

 

Carpal Tunnel Syndrome Surgical Procedures at the ASC
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Patients can find more options for surgical solutions and recovery in outpatient facilities today.

Hand BioHand Biomechanics Lab

Ambulatory surgery centers (ASCs) are always on the path of upgrading and improving their surgical offerings for their communities – and it is often word of mouth that spreads the word as satisfied patients talk about their surgical experiences. One of the most common ailments that affects millions of people today is carpal tunnel syndrome, and it’s not unusual for people to seek relief at an ASC.

Carpal tunnel syndrome is one of the most common hand conditions that is a result of wrist anatomy, health conditions and repetitive hand motions common in today’s workforce as people stay on computers for hours. Diabetes, obesity and hypothyroidism all increase the risk of this condition and carpal tunnel syndrome is more common in women. Caused by pressure on the median nerve in the carpal tunnel of the wrist, symptoms can include numbness, tingling and weakness in the thumbs and fingers. Treatment usually relieves the tingling and numbness and restores hand function.

A popular approach to treating carpal tunnel syndrome is the endoscopic carpal tunnel (ECTR) approach as surgeons tackle the lingering misconceptions about its safety. One of the reasons why this procedure has been slower to be accepted over the years is outdated literature. Now more than 20 years old, the literature doesn’t reflect the ability of today’s surgeons to maneuver the nerve with equipment that offers a higher level of safety than in the past. Hand Biomechanics Lab has been a leader in developing instruments that support the surgeons who use the ECTR method to take care of the growing caseload in carpal tunnel release procedures.

The importance of proper equipment plus an effective and efficient perioperative process work hand in hand to ensure successful outcomes. Patient education is key in successful rehabilitation after the surgery. Preemptive pain management with anti-inflammatories is the ingredient that surgeons employ to stay ahead of patient pain post-operatively, and this does well to manage the minimal pain associated with this procedure.

Patients can return to normal activities faster with ECTR, so this elective surgery continues to evolve in the ASC environment. OR leaders offer this service line as they continue to upgrade their procedures and equipment to create the most efficient and safe surgical journey for their patients.

As part of this growing market, Hand Biomechanics Lab is bringing value with its unique equipment. For example, the new drop-in replacement disposable blade assembly – for use with the 3M Agee Inside Job or MicroAire SmartRelease systems – is up to 60% less than the price of the current standard system and it is available in a six-pack. This blade assembly is distributed exclusively by Brasseler USA Surgical. With the rising cost of health care, Hand Biomechanics Lab has created a device, offered at a fair price to promote ECTR procedures for safe patient care.

Note: For more information, visit https://handbiolab.com/ectr-blade-assembly/?activetab=ectr_video and watch this video.

 

Wide-Awake Hand Surgery Offers a Legion of Benefits

Office-based procedures, patients and providers benefit from the WALANT technique.

No sedation. No IVs. No tourniquets. These are just a few advantages of wide-awake hand surgery, a transformative surgical approach that makes a carpal tunnel procedure as routine as a dental appointment.

The technique that has allowed WALANT (wide-awake/local anesthesia/no tourniquet) to gain steam has been employed by dentists for decades. By combining epinephrine (adrenaline) to control bleeding in conjunction with the local anesthetic lidocaine, hand surgery patients can now avoid sedation or general anesthesia.

Multiple studies about WALANT have eased physicians’ safety concerns that using epinephrine to extend the effects of lidocaine during hand and wrist procedures could cause digital ischemia. In addition to prolonging lidocaine’s effect, epinephrine, a vasoconstrictor, helps to control the amount of blood in the surgical field, so tourniquets can be avoided.

"For a long time, healthcare systems didn’t need to be very efficient," says Jacques Hacquebord, MD, chief of hand and wrist surgery at NYU Langone Orthopedics in New York City. "Now that there’s a greater need for greater efficiency, we were driven to innovate. I think wide-awake hand surgery is an example of that."

Some pre-op nurses are concerned about how much patient monitoring is needed after the surgeon administers the injection, so staff education is important when introducing a WALANT program. "There can be a lot of resistance when there is a misconception about the injection of this local anesthetic as being potentially dangerous as a spinal anesthetic that could ascend to a different level of the spinal cord, or a regional block," says Dr. Hacquebord. "This injection isn’t that invasive. It’s not given near any neurovascular structures. It’s safe, and no monitoring is required."

A WALANT program can increase your patient pool. Since no sedation or general anesthesia is involved, almost everyone can receive it. Even a patient with a cardiac history doesn’t need to undergo any preoperative tests. Patients arrive about a half-hour before surgery, lay on the bed for about 15 minutes during the procedure and are discharged 20 minutes after the surgery is completed.

With WALANT, NPO is not required, patients don’t need to temporarily halt taking blood thinners, and often they can undergo surgery in their street clothes. There’s no grogginess and none of the hemodynamic effects from sedation or general anesthesia. No post-op narcotics are necessary due to less swelling, bruising and pain than with traditional surgeries.

Surgeons can ask patients to move their hands to assess whether their movement is optimal as the work is being done, which helps physicians confirm they have made the proper corrections. That real-time proof isn’t available when a patient is under traditional anesthesia, says Lana Kang, MD, a hand and upper extremity surgeon at Hospital for Special Surgery in New York City.

 

Gender’s Role in Carpal Tunnel Syndrome

Women, particularly those at the end of menopause, are two to three times more likely to be diagnosed with this common condition.

Up to 10 million people in the U.S. are affected by carpal tunnel syndrome (CTS), but one demographic, in particular, is especially hard-hit by the condition.

CTS is two to three times more common in women than men, according to Peter C. Amadio, MD, a Minn.-based hand surgeon who represents the American Association for Hand Surgery in the American Medical Association’s House of Delegates (HOD). Dr. Amadio says that although the exact reason for the increased prevalence of CTS in women remains a mystery to medical professionals, the timing of its occurrence is often predictable.

"It’s more common in women when they’re no longer having their menstrual periods, for example," he said in an AMA article on CTS.

Menopausal women aren’t the only female patients at increased risk for CTS. "Pregnancy is a very common, known cause," adds Robert C. Kramer, MD, a hand surgeon in Beaumont, Texas, and delegate to the HOD for the American Society for Surgery of the Hand. The good news with pregnancy-induced CTS though, says Dr. Kramer, is that it the condition is acute and transient, making it generally a nonsurgical matter, with certain exceptions such as women who retain enough water after pregnancy that the condition worsens.

While there are several effective nonsurgical remedies for CTS, many patients only find full relief from surgical intervention. That’s why a proper diagnosis from a provider with significant CTS experience is vital from the start. Dr. Kramer says that while patients with both chronic and acute forms of CTS almost always require surgery, trialing nonsurgical management techniques is a valid option until they fail, at which time surgery is indicated depending on the patient.

Given the new data presented by Drs. Amadio and Kramer, that patient is most likely to be a pregnant or menopausal woman. OSM

 

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