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Kammien AJ, Shvedova M, Allam O, Prsic A, Grauer JN, Colen DL. The Association of Surgical Setting With Opioid Prescribing Patterns Following Wide-Awake Trigger Finger Release. Ann Plast Surg 2024:00000637-990000000-00502. [PMID: 38984645 DOI: 10.1097/sap.0000000000004030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/11/2024]
Abstract
INTRODUCTION Wide-awake and office-based hand surgeries are increasingly common. The association of these techniques with postoperative pain and pain control has garnered recent attention. A prior study demonstrated that office-based trigger finger release (TFR) were associated with decreased perioperative opioid prescriptions compared to those performed in the operating room. The current study provides an in-depth analysis of the association between surgical setting and perioperative opioid prescriptions for wide-awake TFR. METHODS Patients undergoing TFR between 2010 and 2021 were identified in PearlDiver, a national administrative claims database. Exclusion criteria were age <18 years, <6 months of preoperative data, <1 month of postoperative data, bilateral TFR, and concomitant hand surgery. To identify wide-awake cases, patients with procedural codes for general anesthesia, monitored anesthesia care, sedation and regional blocks were excluded. Patients were stratified by surgical setting (office or operating room), then matched based on age, sex, Elixhauser Comorbidity Index score, and geographic region. Patients with prior opioid prescriptions, opioid dependence, opioid abuse, substance use disorder, chronic back/neck pain, generalized anxiety, and major depression were identified. Perioperative opioid prescriptions (those filled within 7 days before or 30 days after surgery) were characterized. RESULTS There were 16,604 matched wide-awake TFR patients in each cohort. In the cohort of office-based patients, 4,993 (30%) filled a prescription for perioperative opioids, in contrast to 8,763 (53%) patients who underwent surgery in the operating room. This disparity was statistically significant in both univariate and multivariate analyses. Univariate analysis indicated that office-based surgeries were linked to lower morphine milligram equivalents (MME) in opioid prescriptions than those performed in operating rooms (median of 140 vs 150, respectively). However, multivariate analysis demonstrated that opioid prescriptions for office-based surgeries were actually associated with greater MME. CONCLUSIONS Patients undergoing office-based TFR were less likely to fill perioperative opioid prescriptions but were prescribed opioids with greater MME. In wide-awake TFR, it appears that a disparity may exist in patient and provider beliefs about postoperative pain control. Future patient- and provider-level investigations may produce insights into perceptions of postoperative pain and pain control, which may be useful for reducing opioid prescriptions across surgical settings.
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Affiliation(s)
- Alexander J Kammien
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, and Departments of
| | | | - Omar Allam
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, and Departments of
| | - Adnan Prsic
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, and Departments of
| | - Jonathan N Grauer
- Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - David L Colen
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, and Departments of
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Dondapati A, Carroll T, Ketonis C. Endoscopic Carpal Tunnel Release With Monitored Anesthesia Care Versus Local Anesthesia: Analysis of Operative Times and Patient-Reported Outcomes. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2024; 6:484-487. [PMID: 39166211 PMCID: PMC11331154 DOI: 10.1016/j.jhsg.2024.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 02/08/2024] [Indexed: 08/22/2024] Open
Abstract
Purpose Carpal tunnel syndrome is the most common peripheral nerve compressive neuropathy in clinical practice. Patients who fail nonsurgical management are indicated for carpal tunnel release (CTR), which can be performed open or endoscopically. Efforts have been made to utilize local anesthesia instead of monitored anesthesia care (MAC) for endoscopic release. This study seeks to compare perioperative surgical times and postoperative outcomes in patients undergoing endoscopic CTR with local anesthesia versus MAC. Methods This is a 6-year retrospective study of 1,036 patients undergoing isolated endoscopic CTR with MAC (n = 607) versus local (n = 429) anesthesia within an outpatient surgical center. A combination of chi-square and t tests was used to compare the patient characteristics, operative details, and outcomes. Results The local cohort demonstrated significantly shorter postoperative time to discharge (15.9 ± 9.8 vs 53.8 ± 11.0 minutes; P < .05), total time spent in surgical center (83.2 ± 18.7 vs 129.3 ± 20.7 minutes; P < .05), shorter total operating room time (26.7 ± 4.3 vs 29.0 ± 4.1 minutes; P < .05) and tourniquet time (12.4 ± 2.5 vs 13.1 ± 2.1 minutes; P < .05). Preoperative and postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) scores were similar between the cohorts (P > .05); however, PROMIS pain interference improved to a higher degree between pre- and post-op in the local group (-1.5 vs -0.8; P = .02). Early and late surgical complications were similar between the groups (P > .05). Conclusions Patients within the MAC cohort demonstrated longer postoperative time to discharge and total time in the surgical center. The MAC cohort had longer operating room and tourniquet time, albeit not clinically significant. Surgical complications and PROMIS scores were similar between the two groups. Our findings suggest that local anesthesia is a safe and effective option for endoscopic CTR and may offer advantages in cost and convenience for patients. Type of study/level of evidence Retrospective cohort study/therapeutic III.
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Affiliation(s)
- Akhil Dondapati
- University of Rochester Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, NY
| | - Thomas Carroll
- University of Rochester Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, NY
| | - Constantinos Ketonis
- University of Rochester Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, NY
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Kammien AJ, Hu K, Collar J, Rancu AL, Zhao KL, Grauer JN, Colen DL. The Correlation of Surgical Setting With Perioperative Opioid Prescriptions for Wide-Awake Carpal Tunnel Release. Hand (N Y) 2024:15589447241247247. [PMID: 38654508 DOI: 10.1177/15589447241247247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
BACKGROUND Prior studies have compared perioperative opioid prescriptions between carpal tunnel release (CTR) performed wide-awake and with traditional anesthetic techniques, but the association of opioid prescriptions with surgical setting has not been fully explored. The current study assessed the association of opioid prescriptions with surgical setting (office or operating room) for wide-awake CTR. METHODS Patients with open CTR were identified in an administrative claims database (PearlDiver). Exclusion criteria included age less than 18 years, preoperative data less than 6 months, postoperative data less than 1 month, bilateral surgery, concomitant hand surgery, and traditional anesthesia (general anesthesia, sedation, or regional block). Patients were stratified by surgical setting (office or operating room) and matched by age, sex, Elixhauser Comorbidity Index, and geographic region. Prior opioid prescriptions, opioid dependence/abuse, substance use disorder, back/neck pain, generalized anxiety, and major depression were identified. Opioid prescriptions within 7 days before and 30 days after surgery were characterized. RESULTS Each matched cohort included 5713 patients. Compared with patients with surgery in the operating room, fewer patients with office-based surgery filled opioid prescriptions (45% vs 62%), and those prescriptions had lower morphine milligram equivalents (MMEs, median 130 vs 188). These findings were statistically significant on univariate and multivariate analysis. CONCLUSIONS Following office-based CTR, fewer patients filled opioid prescriptions, and filled prescriptions had lower MME. This likely reflects patient and provider attitudes about pain control and opioid utilization. Further patient- and provider-level investigation may provide additional insights that could aid in efforts to reduce perioperative opioid utilization across surgical settings.
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Affiliation(s)
| | - Kevin Hu
- Yale School of Medicine, New Haven, CT, USA
| | - John Collar
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | | | - K Lynn Zhao
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Jonathan N Grauer
- Department of Orthopaedics & Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - David L Colen
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
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Abukhudair A, Mortada H, Alhindi N, Alarbedi L, Alshehri A, Alharbi A, Kattan AE, Mortada H, Alharbi A, Kattan AE. "Anesthesia for Endoscopic Carpal Tunnel Syndrome Release: A Comprehensive Systematic Review and Meta-Analysis of Local Versus Regional Versus General Anesthesia". JPRAS Open 2022; 35:89-101. [PMID: 36785700 PMCID: PMC9918389 DOI: 10.1016/j.jpra.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 11/17/2022] [Indexed: 11/24/2022] Open
Abstract
Background Worldwide, carpal tunnel syndrome (CTS) is the most common peripheral neuropathy due to compression. A minimally invasive endoscopic carpal tunnel release (ECTR) procedure is available to treat this condition. This study aims to identify and compare the different types of anesthesia in ECTR, particularly in terms of functional outcomes, patient satisfaction, and operative time. Methods PRISMA guideline was used to design and conduct this systematic review. MEDLINE, Cochrane, and EMBASE databases were searched systematically from inception to May 2022. For the search, MeSH terms such as ECTR, general anesthesia, local anesthesia (LA), and regional anesthesia were used. Results As a result of reviewing the literature, 198 publications were reviewed. After implanting our criteria, 12 studies were included. We included 14589 patients who underwent ECTR. LA has a higher satisfaction rate and a shorter operative time than general anesthesia. LA had a mean operative time of 20.1 min, compared to 45 min and 51 min for regional anesthesia and general anesthesia. The number of patients with postoperative ECTR surgical complications was 2.7% (95%CI). After ECTR with LA, 95% of patients are back to their daily routine within six months. Conclusion All the reported methods were effective, with LA being the most commonly used. Furthermore, it showed a shorter operative time and a higher satisfaction rate than other types of anesthesia. Due to the heterogeneity of the data, we recommend future randomized controlled trials to highlight the differences in anesthesia types used in ETCR. Level of evidence III, risk/prognostic study.
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Affiliation(s)
- Abdulrahman Abukhudair
- Faculty of Medicine, King Abdulaziz University, Rabigh, Saudi Arabia,Corresponding author: Abdulrahman Abukhudair, Faculty of Medicine, King Abdulaziz University, Rabigh, Saudi Arabia. PO Box 25753, Saudi Arabia, Mobile: 00966 55 336 9664
| | - Hatan Mortada
- Division of Plastic Surgery, Department of Surgery, King Saud University Medical City, King Saud University and Department of Plastic Surgery & Burn Unit, King Saud Medical City, Riyadh, Saudi Arabia
| | - Nawaf Alhindi
- Faculty of Medicine, King Abdulaziz University, Rabigh, Saudi Arabia
| | - Layal Alarbedi
- Faculty of Medicine, King Abdulaziz University, Rabigh, Saudi Arabia
| | | | - Abdullah Alharbi
- Orthopedic Surgery Department, King Abdulaziz Hospital, Makkah, Saudi Arabia
| | - Abdullah E. Kattan
- Division of Plastic Surgery, Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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Reconstructive Surgery in a Patient with High Radial Nerve Palsy Using the WALANT Technique. Plast Reconstr Surg Glob Open 2022; 10:e4500. [PMID: 36119382 PMCID: PMC9473772 DOI: 10.1097/gox.0000000000004500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 07/11/2022] [Indexed: 11/26/2022]
Abstract
Tendon transfers can be tied too tight or too loose. Both impede good function after surgery. Performing tendon transfers without sedation and pain during the surgery and then watching the patient move the transfer have helped us adjust the tension more accurately. This method can be applied to complex transfers such as radial nerve palsy triple tendon transfers. We describe the technique and results of a triple tendon transfer using wide-awake local anesthesia no tourniquet in a patient with a high radial nerve palsy. This was a complex case of reconstruction after five operations at the level of the humerus. This left him with a pseudoarthrosis of the humerus and a complete radial nerve palsy. We performed tendon transfers of pronator teres to extensor carpi radialis brevis, flexor carpi ulnaris to extensor digitorum communis, and palmaris longus to extensor pollicis longus tendons. Eighteen months after the triple tendon transfer surgery for the radial nerve palsy, the patient has good extension of the fingers, wrist, and thumb. He can open and close the hand properly. He has excellent function and mobility allowing him to perform most activities in a manner that is practically normal. Wide-awake local anesthesia no tourniquet can be used safely and successfully in complex cases requiring triple radial nerve tendon transfers of pronator teres to extensor carpi radialis brevis, flexor carpi ulnaris to extensor digitorum communis, and palmaris longus to extensor pollicis longus tendons.
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Segal KR, Debasitis A, Koehler SM. Optimization of Carpal Tunnel Syndrome Using WALANT Method. J Clin Med 2022; 11:jcm11133854. [PMID: 35807138 PMCID: PMC9267271 DOI: 10.3390/jcm11133854] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 06/28/2022] [Accepted: 06/30/2022] [Indexed: 12/28/2022] Open
Abstract
As surgical management of carpal tunnel release (CTR) becomes ever more common, extensive research has emerged to optimize the contextualization of this procedure. In particular, CTR under the wide-awake, local-anesthesia, no-tourniquet (WALANT) technique has emerged as a cost-effective, safe, and straightforward option for the millions who undergo this procedure worldwide. CTR under WALANT is associated with considerable cost savings and workflow efficiencies; it can be safely and effectively executed in an outpatient clinic under field sterility with less use of resources and production of waste, and it has consistently demonstrated standard or better post-operative pain control and satisfaction among patients. In this review of the literature, we describe the current findings on CTR using the WALANT technique.
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Bohn DC, Wise KL. What's New in Hand and Wrist Surgery. J Bone Joint Surg Am 2022; 104:489-496. [PMID: 35044967 DOI: 10.2106/jbjs.21.01374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Deborah C Bohn
- Department of Orthopedic Surgery, University of Minnesota Medical School, Minneapolis, Minnesota
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Cost Drivers in Carpal Tunnel Release Surgery: An Analysis of 8,717 Patients in New York State. J Hand Surg Am 2022; 47:258-265.e1. [PMID: 34969540 DOI: 10.1016/j.jhsa.2021.10.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 08/07/2021] [Accepted: 10/06/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE The annual high volume of carpal tunnel releases (CTRs) has a large financial impact on the health care system. Validating the cost drivers related to CTR in a large, diverse patient population may aid in developing cost reduction strategies to benefit health care systems. METHODS Adult patients with carpal tunnel syndrome who underwent CTR were identified in the New York Statewide Planning and Research Cooperative System database from 2016 to 2017. The Statewide Planning and Research Cooperative System is a comprehensive all-payer database that collects all inpatient and outpatient preadjudicated claims in New York. A multivariable mixed model regression with random effects was performed for the facility to assess the variables that contributed significantly to the total charge. The variables included were patient age, sex, anesthesia method, whether the surgery took place in an ambulatory surgery center or a hospital outpatient department, operation time in minutes, primary insurance type, race, ethnicity, Charlson Comorbidity Index, and categories for billed procedure codes. RESULTS During the period of 2016 to 2017, 8,717 claims were included, with a mean charge per claim of $4,865. General anesthesia was associated with higher charges than local anesthesia. A procedure at a hospital outpatient department was associated with an approximately 48.2% increase in the total charge compared with that at an ambulatory surgery center. A 1-minute increase in the operation time was associated with a 0.3% increase in the total charge. Claims with antiemetics, antihistamines, benzodiazepines, intravenous fluids, narcotic agents, or preoperative antibiotics were associated with higher total charges than claims that did not bill for these. Compared with endoscopic procedures, open procedures had a 44.3% decrease in the total charges. CONCLUSIONS This comprehensive multivariable model has validated that general anesthesia, hospital-based surgery, the use of antibiotics and opioids, longer operative times, and endoscopic CTR significantly increased the cost of surgery. TYPE OF STUDY/LEVEL OF EVIDENCE Economic and decision analyses II.
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Rogers MJ, Stephens AR, Yoo M, Nelson RE, Kazmers NH. Optimizing Costs and Outcomes for Carpal Tunnel Release Surgery: A Cost-Effectiveness Analysis from Societal and Health-Care System Perspectives. J Bone Joint Surg Am 2021; 103:00004623-990000000-00322. [PMID: 34428186 PMCID: PMC8866519 DOI: 10.2106/jbjs.20.02126] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND It is unclear which carpal tunnel release (CTR) strategy (i.e., which combination of surgical technique and setting) is most cost-effective. A cost-effectiveness analysis was performed to compare (1) open CTR in the procedure room (OCTR/PR), (2) OCTR in the operating room (OCTR/OR), and (3) endoscopic CTR in the operating room (ECTR/OR). METHODS A decision analytic model was used to compare costs and health utilities between treatment strategies. Utility and probability parameters were identified from the literature. Medical costs were estimated with Medicare ambulatory surgical payment data. Indirect costs were related to days out of work due to surgical recovery and complications. The effectiveness outcome was quality-adjusted life years (QALYs). Probabilistic sensitivity analyses and one-way sensitivity analyses were performed. Cost-effectiveness was assessed from the societal and health-care system perspectives with use of a willingness-to-pay threshold of $100,000/QALY. RESULTS In the base-case analysis, OCTR/PR was more cost-effective than OCTR/OR and ECTR/OR from the societal perspective. The mean total costs and QALYs per patient were $29,738 ± $4,098 and 0.88 ± 0.08 for OCTR/PR, $30,002 ± $4,098 and 0.88 ± 0.08 for OCTR/OR, and $41,311 ± $4,833 and 0.87 ± 0.08 for ECTR/OR. OCTR/PR was also the most cost-effective strategy from the health-care system perspective. These findings were robust in the probabilistic sensitivity analyses: OCTR/PR was the dominant strategy (greater QALYs at a lower cost) in 55% and 61% of iterations from societal and health-care system perspectives, respectively. One-way sensitivity analysis demonstrated that OCTR/PR and OCTR/OR remained more cost-effective than ECTR/OR from a societal perspective under the following conditions: $0 surgical cost of ECTR, 0% revision rate following ECTR, equalization of the return-to-work rate between OCTR and ECTR, or 0 days out of work following ECTR. OCTR/OR became more cost-effective than OCTR/PR with the median nerve injury rate tripling and doubling from societal and health-care system perspectives, respectively, or if surgical direct costs in the PR exceeded those in the OR. CONCLUSIONS Compared with OCTR/OR and ECTR/OR, OCTR/PR minimizes costs to the health-care system and society while providing favorable outcomes. LEVEL OF EVIDENCE Economic and Decision Analysis Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Miranda J Rogers
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah
| | - Andrew R Stephens
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah
| | - Minkyoung Yoo
- Department of Economics, University of Utah, Salt Lake City, Utah
| | - Richard E Nelson
- VA Salt Lake City Health Care System, Salt Lake City, Utah
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Nikolas H Kazmers
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah
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Abstract
The field of hand surgery continues to evolve in new and exciting directions. Advances in diagnosis and management for common complaints and complex injuries allow higher-level care, while still being cognizant of the cost of health care delivery. Indications and protocols for past paradigm shifts, such as volar locked plating for distal radial fractures, continue to be honed, and the outcomes seen for modern flexor tendon repairs are impressive. Open questions remain, but promising results for scaphoid nonunion surgery and peripheral nerve reconstruction with processed allograft will continue to shed light on these unsolved problems.
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Affiliation(s)
- Travis A Doering
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, 1211 Union Avenue, Suite 500, Memphis, TN 38104, USA.
| | - Benjamin M Mauck
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, 1211 Union Avenue, Suite 500, Memphis, TN 38104, USA
| | - James H Calandruccio
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, 1211 Union Avenue, Suite 500, Memphis, TN 38104, USA
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