Validation of a one-stop carpal tunnel clinic including nerve conduction studies and hand therapy

Changes in Management at the Postoperative Visit After In-Office Wide Awake Local Anesthetic No Tourniquet Carpal Tunnel Release

PURPOSE

Patients are commonly seen for two postoperative visits following carpal tunnel release (CTR), the first visit being at 1-2 weeks and the second at approximately 6 weeks. Our study aimed to determine if these visits led to changes in postoperative medical management.

METHODS

A retrospective review was conducted of 748 procedures performed in an in-office procedure room under wide awake local anesthetic no tourniquet between August 2020 and December 2022. Charts were reviewed for changes in management related to the patient's CTR. Management changes involving a separate diagnosis or solely an additional follow-up visit were classified as unrelated to postoperative CTR care.

RESULTS

A total of 730 patients returned for follow-up. There were 100 patients (13.7 %) who had a CTR-related change in management at the first postoperative visit. Most management changes at this timepoint were due to superficial surgical site infection. There were 29 patients (4.0 %) who had a CTR-related change in management at their second postoperative visit, most commonly a referral to therapy for stiffness or hypersensitivity.

CONCLUSIONS

While postoperative visits for CTR may have intangible benefits, changes in CTR-related care occur only in 17.7% of patients.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Postoperative care via smartphone following carpal tunnel release

Introduction

This study explores a novel smartphone application for postoperative care following carpal tunnel release (CTR). We hypothesized that a software-based ‘virtual visit’ for CTR could be safe, effective and convenient for the patient.

Methods

Our group developed the software application utilized in this study. Interactive steps with video instructions enabled patients to complete dressing and suture removal, capture a wound photo, answer a question about median nerve symptoms and capture a video of finger range of motion. Adult patients undergoing endoscopic or open CTR were enrolled. Prior to their scheduled postoperative visit, patients received and completed the module using their smartphone. Agreement between findings of the virtual visit and the corresponding in-person clinical visit was assessed using kappa values.

Results

Twenty-two patients were contacted regarding study enrolment and 17 patients were enrolled (ages 23–63, mean 48.2, 6M, 11F). Of 16 patients who participated, all completed dressing removal. Ten of 16 patients removed their sutures successfully. Fourteen patients captured a clinically adequate wound photo and 15 patients answered a question about median nerve symptoms. Fourteen patients captured a range of motion video. Software assessments of surgical wounds, nerve symptoms and physical exams agreed strongly with clinical assessments.

Discussion

Most patients were able to respond to a question about their symptoms, provide clinical assessment of their wound via a photo and record a video of their range of motion. Suture removal was the most difficult task. More investigation is needed to determine which patients can reliably remove their sutures.

Improving waiting times in the orthopaedic outpatient clinic

Background

Reducing waiting times for patients is a worthy goal for all healthcare professionals. The means and ability to carry out nerve conduction studies in the hand outpatient clinic has the potential to reduce waiting times between appointments for patients with upper limb neural compression.

Methods

We assessed the pathway of patients presenting with upper limb neural compression in the Aneurin Bevan Trust. Overall, 115 patients were included, being assessed in four different patient pathway groups.

Results

We found that by implementing a nerve conduction clinic, and then that of a one stop clinic, we were able to reduce the median waiting times from referral to surgical intervention, to 133 days.

Conclusion

The introduction of nerve conduction clinics allowed the one stop clinic to be established, achieving the goal of reducing patient waiting times.

Is one-stop surgery for carpal tunnel syndrome safe? A retrospective long-term follow-up study in a neurosurgical unit in Copenhagen

OBJECTIVES

The aim of this study was to evaluate one-stop surgery (OSS) for carpal tunnel syndrome (CTS) regarding symptom relief and patient satisfaction. OSS in our setting means only one visit to the hospital for surgery and no hospital appointments for preassessment or follow-up. We hypothesised that relief of symptoms with OSS is comparable with that in non-OSS patients reported in the literature.

DESIGN

This is a long-term retrospective follow-up study (56.5 months) of 1003 patients referred for CTS and discharged with or without surgery from an OSS clinic. Of the original cohort, 671 patients completed the long-term follow-up telephone interview.

RESULTS

Two-thirds of the patients were free of even minor symptoms following surgery. The symptom relief and patient satisfaction in this study were comparable with results in non-OSS patients reported in the literature.

CONCLUSION

The implementation of a clinical pathway and OSS for the management of CTS was safe with good long-term symptom relief and high patient satisfaction.

One-Stop Clinic Utilization in Plastic Surgery: Our Local Experience and the Results of a UK-Wide National Survey

Introduction. "See and treat" one-stop clinics (OSCs) are an advocated NHS initiative to modernise care, reducing cancer treatment waiting times. Little studied in plastic surgery, the existing evidence suggests that though they improve care, they are rarely implemented. We present our experience setting up a plastic surgery OSC for minor skin surgery and survey their use across the UK. Methods. The OSC was evaluated by 18-week wait target compliance, measures of departmental capacity, and patient satisfaction. Data was obtained from 32 of the 47 UK plastic surgery departments to investigate the prevalence of OSCs for minor skin cancer surgery. Results. The OSC improved 18-week waiting times, from a noncompliant mean of 80% to a compliant 95% average. Department capacity increased 15%. 95% of patients were highly satisfied with and preferred the OSC to a conventional service. Only 25% of UK plastic surgery units run OSCs, offering varying reasons for not doing so, 42% having not considered their use. Conclusions. OSCs are underutilised within UK plastic surgery, where a significant proportion of units have not even considered their benefit. This is despite associated improvements in waiting times, department capacity, and levels of high patient satisfaction. We offer our considerations and local experience instituting an OSC service.

Long-term result and patient reported outcome of wrist splint treatment for carpal tunnel syndrome

Carpal tunnel syndrome (CTS) is the commonest peripheral neuropathy presenting to specialist hand and wrist clinics. This study investigated the long-term outcome of carpal tunnel syndrome treated with isolated night wrist splint and the factors determining the likelihood of success of this intervention. Seventy-five patients referred to a specialist hand clinic with CTS were given night wrist splint treatment for 3 months as per a previous study protocol. Fifty-two patients from this cohort did not wish to have surgery after wrist splint treatment and were followed for a further 33-month period. Baseline pain and numbness levels were recorded on a Visual Analogue Scale (VAS) using a questionnaire upon first presentation. A further questionnaire at 36 months reassessed pain and numbness levels, patients' satisfaction with the treatment, and whether they had subsequent surgical decompression. Of the patients who completed the follow-up questionnaire 33 months after their period of conservative management, 43% were successfully treated with splint treatment alone. There was no difference in the VAS for pain or numbness at the baseline and at 36 months between successful and failed treatment groups. Patients successfully treated with wrist splinting alone reported a higher level of satisfaction with their treatment compared to patients who failed wrist splint treatment or had surgical decompression. The results reinforce the previous recommendation on wrist splinting as a first-line treatment in the Primary Care setting. Referral to specialist hand and wrist clinics should be reserved for patients with symptoms refractory to this initial measure.

One-stop endoscopic hernia surgery: efficient and satisfactory

BACKGROUND

One-stop surgery offers patients diagnostic work-up and subsequent surgical treatment on the same day. In the present study, patient satisfaction and efficiency from an institutional perspective were evaluated in patients who were referred for one-stop endoscopic inguinal hernia repair.

METHOD

In a high-volume inguinal hernia clinic, all consecutive patients referred for one-stop surgical treatment, were registered prospectively. An instructed secretary screened patients for eligibility for the one-stop option when the appointment was made. Totally extraperitoneal hernia repair under general anaesthesia was the preferred operative technique. Patient's satisfaction, successful day surgery and institutional efficiency were evaluated.

RESULTS

Between January 2010 and January 2012 a total of 349 patients (17 % of all patients in the hernia clinic) were referred for one-stop hernia repair. Mean age was 47.5 years and 96.3 % were males. Three hundred thirty-six patients underwent hernia surgery on the same day (96.3 %). In thirteen patients (3.7 %) no operative repair was done on the day of presentation due to an incorrect diagnosis (n = 7), a watchful waiting policy for asymptomatic hernia (n = 3), rescheduling due to a large scrotal hernia, and there were two "no shows". Following hernia repair 97 % of the patients were discharged on the same day, while ten patients required hospitalization. Based on the questionnaires the main satisfaction score among patients was 9.0 (8.89-9.17 95 % CI) on a scale ranging from 0 to 10.

CONCLUSION

One-stop hernia surgery is feasible and satisfactory from an institutional as well as from a patient's perspective.