The Impact of Resident Involvement on Outcomes and Costs in Elective Hand and Upper Extremity Surgery

A Comparison of Early Complication Rates of Endoscopic Carpal Tunnel Release With and Without Resident Involvement

PURPOSE

The purpose of this study was to compare the complication rates of endoscopic carpal tunnel release (ECTR) relative to orthopedic resident trainee involvement in the procedure.

METHODS

All patients undergoing isolated, elective ECTR by two attending surgeons within a 59-month period were analyzed. Cases were categorized as the following according to the degree of resident involvement: ECTR performed by attending with either no resident or a resident as an assistant (group 1), resident performing a portion of the procedure (group 2), and resident performing the entire procedure (group 3). Early postoperative complications and/or intraoperative conversion to an open procedure were the outcomes of interest. We used a noninferiority design, hypothesizing that resident involvement would not be associated with inferior outcomes compared with cases without resident involvement. Multiple logistic regression models, adjusted for patient demographic and surgical characteristics, were fit to assess the relationship between resident involvement groups and complication/conversion outcomes.

RESULTS

A total of 1,167 ECTR cases (895 patients) were performed and returned for postoperative follow-up for at least 2 weeks after surgery. Operative time was significantly shorter for group 1 cases versus group 2 and 3 cases. The early postoperative complication and conversion rates were 1.7% and 1.0%, respectively. Superficial infection (1.2%), deep infection (0.3%), and transient neuropraxia (0.3%) occurred infrequently and did not differ relative to resident involvement. No differences in the odds of complication and/or conversion relative to resident involvement were observed.

CONCLUSIONS

The results of ECTR performed entirely or in part by attending-supervised resident trainees were not inferior to ECTR performed by an attending surgeon regarding the odds of experiencing complications or conversion to an open procedure. With appropriate supervision, ECTR can be performed safely by orthopedic and plastic surgery residents.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Intraoperative Conversion From Endoscopic to Open Carpal Tunnel Release: A Systematic Review and Case Series

PURPOSE

The purpose of this study was to assess the incidence, outcomes, and complications associated with conversion from endoscopic carpal tunnel release (ECTR) to open carpal tunnel release (OCTR).

METHODS

A retrospective case review of all patients who underwent ECTR over 4 years by 2 fellowship-trained hand surgeons at a single academic center was performed. We recorded outcomes and the reason for conversion in patients who underwent conversion to an OCTR. Baseline demographics and surgical complications were compared between the 2 groups. A systematic review was performed to define the incidence and reasons for conversion from ECTR to OCTR. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we included clinical studies of ECTR from 2000 to 2021.

RESULTS

In the retrospective series, 9 of 892 (1.02%) ECTR cases underwent conversion to an OCTR at the time of the index procedure. One of 9 converted cases had transient neurapraxia involving the recurrent motor branch after surgery compared with 0 cases in the group that underwent ECTR without conversion. Improvements in the visual analog scale for pain and QuickDASH were noted at a mean of 46 weeks after surgery in the group that underwent conversion to OCTR. The systematic review identified an incidence of conversion of 0.62%. The most common reasons for conversion to OCTR in the case series and systematic review were poor visualization due to hypertrophic tenosynovium and aberrant nerve anatomy.

CONCLUSIONS

The overall incidence of intraoperative conversion from ECTR to OCTR during the index procedure was 1.02%, with the most common reasons for conversion being poor visualization due to hypertrophic tenosynovium and aberrant nerve anatomy. Patients who undergo conversion from ECTR to OCTR demonstrate improvements in pain and disability, similar to patients who undergo ECTR without conversion.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.