Optimizing Outcomes in Fracture Repair

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Surgery centers are figuring out how to capitalize on this developing trend in orthopedic care.


OUT OF HAND Many hand surgeries take very little time to execute, but excellent surgeons and facilities set themselves apart by focusing on the entire episode of care.

Hand and wrist fracture repairs are rapidly moving from hospital settings to freestanding ambulatory surgery centers because surgeons have proven they can perform these cases safely and confidently in outpatient ORs, patients prefer the convenience and the costs of care are much lower.

Dr. Abhishek Julka, MD, an orthopedic hand and wrist surgeon at Ohio State University Wexner Medical Center in Columbus, has performed thousands of hand and wrist surgeries in outpatient environments. “In the past, the hospital with its greater facility fees may have been the only option for many surgeons and their patients,” he says. Now that ASCs have demonstrated they can handle hand and wrist fracture surgeries very safely and even faster, he says more payers, surgeons and patients are jumping on the bandwagon.

Comprehensive treatments

All hand and wrist fractures could potentially require surgical management. “It depends on the characteristics of the fracture,” says Dr. Julka, who says distal radius, scaphoid, metacarpal and phalanx fractures are very commonly treated with surgery in outpatient settings. “Fractures that are minimally displaced, with no malrotation and devoid of significant anatomic abnormality can usually be treated in a cast,” he says.

The length of procedures varies, depending on the type of fracture and complexity of the surgery. “Simple scaphoid and other small fractures can last 15 to 20 minutes,” says Dr. Julka. “Complicated wrist fractures that are safe to do in the outpatient setting can take two or three hours.”

Equipment and instrumentation. Dr. Julka says hand and wrist fractures require a mini C-arm for X-rays because they emit less radiation, are more maneuverable and are more cost-effective than larger fixed-based models. Much of the instrumentation can be kept at the surgery center under a consignment agreement, which allows ease of access to the equipment for the surgeon. He additionally uses his surgery center’s general soft-tissue hand and fracture trays.

A vendor representative is usually on hand at Dr. Julka’s facility. “They maintain the inventory for the instrumentation and document what we use so they can charge the surgery center,” he says. “They also usually act as another set of helping hands. They’re not scrubbed in, but they’re on the sidelines. If a scrub tech assisting with the surgery is unfamiliar with the equipment, they’ll help with that. If something’s missing, they’ll find an answer. If another set is needed, they’ll track it down.”

Anesthesia techniques. Dr. Julka says the vast majority of his hand and wrist fracture repairs are done with the patient sedated and regional anesthesia placed near the shoulder to block all the nerves. “It essentially makes the arm completely numb,” he says. “There’s no motor or sensory function, and the patient is unaware of the surgery.”

Dr. Julka also frequently employs local anesthesia at the surgical site. In these cases, sometimes the patient is mildly sedated; other times, the patient is awake. “With patients who are elderly or have poor reactions to sedation anesthesia, I get them completely numb and do the fracture repair while they’re awake and chatting with me,” he says. “Then they go home without having had any sedation, anesthesia or narcotics.”

Robin Kamal, MD, MBA, a hand and upper extremity surgeon who is medical director of the orthopedic service line at Stanford Health Care in Palo Alto, Calif., uses regional anesthesia for challenging larger procedures that involve bony work in the forearm, elbow or arm, and local anesthesia for smaller, more localized procedures.
Patients who receive local anesthesia and remain awake during procedures can go home 15 to 20 minutes after surgery, according to Dr. Julka. Cases involving regional anesthesia also call for timely discharges because there’s no need to intubate or extubate patients. “We don’t need to worry about them getting nauseous or waking up from surgery, and their recovery is about 30 minutes,” he says.

Dr. Julka and his team employ multimodal pain control methods that vary depending on the nature of the fracture and the procedure. “Regional anesthesia allows patients to have a numb arm with absolutely no pain for 12 to 16 hours, which is the most painful portion of postoperative recovery,” he says. “Once their arm wakes up, they’re in much less pain.”

As a result, he prescribes acetaminophen and naproxen, with a small one- or two-day script for narcotics, usually oxycodone. Prior to surgery, his anesthesiologists occasionally give patients IV acetaminophen and the nerve pain medication gabapentin.

Pain, or the relative lack thereof, often depends on not just the surgery type and method used, but also how well the surgery is actually performed, he says. “If it’s done skillfully with minimal bleeding and with minimal trauma to the soft tissue, patients experience far less pain,” says Dr. Julka. “If a surgery that could be done well in 30 minutes takes two hours because the surgeon or staff are inexperienced, it will likely result in more pain for the patient.”

Dr. Kamal and his care team focus on pain control methods before and after surgery, and are sure to elevate the hand to prevent swelling, which can cause complications and pain. “We’ve shifted our pain regimens for the most part away from opioids, especially when doing small soft-tissue hand surgery, to multimodal pain management strategies that have been studied and supported in the literature without having the complications of opioids,” says Dr. Kamal. “We administer a lot with anti-inflammatories, [acetaminophen] and sometimes numbing medications around the incision site.”

Follow-up care. Dr. Julka says most of his patients get a wound dressing and a splint that they wear from five to 14 days post-op, depending on the surgeon and the fracture. “Typically, their only wound care task is to not get the splint wet,” he says. “They also need to remember to not do activities involving lifting, pushing and pulling.”

PAIN CONTROL POLICIES Hand surgeons have shifted away from using opioids and are collaborating with their teams on multimodal pain control methods to send patients home in comfort.

In Dr. Kamal’s practice, patients who undergo small, quick hand surgery procedures can expose their wounds after three days. “With larger procedures where you’re fixing a broken wrist, we usually keep the dressing on for around two weeks,” he says.

Dr. Julka says patient complaints are largely neutralized at his facility due to the detailed discharge instructions the care team provides, its effective pain management protocols and the surgical techniques the surgeons employ. Many calls from patients regard an ill-fitting splint or a tight dressing. Patients who feel pain, stiffness or weakness, or who had surgeries around nerves that lead to some residual numbness and tingling, are treated capably by the occupational therapists to whom his facility sends patients.

Dr. Kamal says usual reasons patient call after surgery involve pain, swelling or concerns with the wound. “We try to do a good job of educating patients about those issues before surgery,” he says.

Smooth patient experiences are key to success in outpatient fracture repair, says Shakeel Ahmed, MD, founder and CEO of St. Louis-based Atlas Surgical Group. “Hand surgeries are finer procedures, with less blood loss and tissue trauma than other specialties,” he says. “These patients, however, are generally more apprehensive and anxious than others given the role their hands play in their lives. Allaying those concerns with a friendly pre- and post-op experience is key.”

A couple examples he gives of that philosophy in action: cutting down on preoperative time with expedited paperwork and detailed discharge directions. “Patients will have some degree of handicap for a while afterwards, so good instructions on how to handle your post-op care are essential,” he says. “Rushed care makes for a poor experience.”

Patients and surgeons need to know that most surgery centers charge a third of the facility fees a hospital or HOPD would charge for the same surgery, says Dr. Julka, with cost differences often in the thousands of dollars. That’s an important factor for patients to be aware of, especially those with high deductibles.

Dr. Kamal says that with the shift of hand and wrist surgeries to outpatient settings that focus on value and efficiency, it’s no longer just about the surgery. More attention is being paid to patient optimization before, during and after their procedures. “It’s how well you can control pain, keep them comfortable, active and safe, and let them recover at home,” he says. OSM

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