The purpose of this study was to examine the true monetary implications, at the health system level, of moving simple hand procedures, performed with wide-awake local anesthesia no tourniquet ...surgery, from the ambulatory surgery center (ASC) to office setting.
We analyzed the costs, revenues, case times, and patient demographics for 2 cohorts of patients who underwent hand and non-hand surgical procedures over a 2-year period. We calculated the mean margin per minute for the top 5 procedures in non-hand orthopedic surgery subgroups, complex plastics hand, and non-hand plastic surgery. We then calculated the following: (1) hours operating room or ASC time gained by moving hand procedures to the office, (2) additional subgroup patients theoretically treated by using the ASC hours gained, and (3) net margin (in dollars) because of additional procedures.
Six board-certified hand surgeons performed 623 simple ASC and 808 in-office procedures, consisting of 795 carpal tunnel releases, 84 first dorsal compartment releases, and 446 trigger finger releases. The net margin per minute for simple ASC and in-office hand procedures was $25.01/min and $5.63/min, respectively. In the office setting, hand surgery freed up 821 hours of ASC time, which could be theoretically used to treat over 300 additional patients awaiting outpatient orthopedic hand or plastic surgery. Depending on the subspecialty and type of substituted cases, the theoretical net margin varied from −$150,413 to $3.9 million.
Transitioning simple hand operations out of ASCs realized a mean cost savings of 82% per case ($1,137 vs $206) and effectively opened 821 additional hours of operating room time over a 2-year period.
Transitioning simple hand operations out of the operating room setting and into the office setting reduces the cost of hand surgical care, improves operating room access for alternate procedures or patients, and validates the sustainability of safe and effective wide-awake local anesthesia no tourniquet surgery from a hospital system’s financial standpoint.
Posterior malleolus fracture Irwin, Todd A; Lien, John; Kadakia, Anish R
Journal of the American Academy of Orthopaedic Surgeons
21, Številka:
1
Journal Article
Recenzirano
Odprti dostop
Posterior malleolus fractures are a common component of ankle fractures. The morphology is variable; these fractures range from small posterolateral avulsion injuries to large displaced fracture ...fragments. The integrity of the posterior malleolus and its ligamentous attachment is important for tibiotalar load transfer, posterior talar stability, and rotatory ankle stability. Fixation of posterior malleolus fractures in the setting of rotational ankle injuries has certain benefits, such as restoring articular congruity and rotatory ankle stability, as well as preventing posterior talar translation, but current indications are unclear. Fragment size as a percentage of the anteroposterior dimension of the articular surface is often cited as an indication for fixation, although several factors may contribute to the decision, such as articular impaction, comminution, and syndesmotic stability. Outcome studies show that, in patients with ankle fractures, the presence of a posterior malleolus fracture negatively affects prognosis. Notable variability is evident in surgeon practice.
Closed pulley ruptures are rare in the general population but occur more frequently in rock climbers due to biomechanical demands on the hand. Injuries present with pain and swelling over the ...affected pulley, and patients may feel or hear a pop at the time of injury. Sequential pulley ruptures are required for clinical bowstringing of the flexor tendons. Ultrasound confirms diagnosis of pulley rupture and evaluates degree of displacement of the flexor tendons. Isolated pulley ruptures frequently are treated conservatively with early functional rehabilitation. Sequential pulley ruptures require surgical reconstruction. Most climbers are able to return to their previous activity level.
To evaluate the association of diabetes and perioperative hemoglobin A1C (HgA1C) value with postoperative wound healing complications following carpal tunnel release (CTR) and trigger finger release ...(TFR).
A retrospective review of diabetic patients who underwent CTR and/or TFR between 2014 and 2018 was performed. Hemoglobin A1C value within 90 days of surgery was recorded for all diabetic patients. A nondiabetic comparison group was selected from within the same study period in an approximately 1:1 procedural ratio, although direct matching was not performed. A chart review was used to examine postoperative wound healing complications, such as wound infection, wound dehiscence, or delayed wound healing.
Two hundred sixty-two diabetic patients and 259 nondiabetic patients underwent 335 and 337 CTR and/or TFR procedures, respectively. There were 36 wound complications in the diabetic group and 9 complications in the nondiabetic group. Logistic regression analysis demonstrated an increased association of wound healing complications with diabetic patients compared to nondiabetic patients. Additionally, an increased association was demonstrated among diabetic patients with an HgA1C value above 6.5% compared with those with an HgA1C value below 6.5%.
Compared with nondiabetic controls, diabetic patients have increased associated risk of postoperative wound healing complications following CTR and/or TFR. This increased association was further demonstrated among diabetic patients with elevated perioperative HgA1C values.
Prognostic IV.
Background:
The goal of this study was to use nano-computed tomography to describe the intraosseous vascularity and structural characteristics of commonly used distal radius vascularized bone grafts ...for treatment of scaphoid nonunion.
Methods:
We obtained 8 fresh frozen human cadaver forearm specimens for infusion of barium contrast. Specimens were scanned and segmented to quantify the vascular volume and trabecular density within 3 common graft regions, including 1, 2 intercompartmental supraretinacular artery (1,2 ICSRA), fourth extensor compartment artery (4 ECA), and volar carpal artery (VCA), as well as thirds of the scaphoid. Outcomes also included mean and maximum cortical thickness and number of cortical perforators. Single-specimen analyses were also performed comparing vascularity and trabecular density of each graft with scaphoid regions of a single specimen. Statistical analysis was performed using analysis of variance with post hoc Tukey testing when P value was less than .05.
Results:
There was no significant difference between groups in the mean percent vascularity (P = .76). The ratio of trabecular bone in each graft to scaphoid thirds was less than 1. The mean cortical thickness (0.79 mm, 95% confidence interval CI, 0.66-0.93 mm) and maximum cortical thickness (1.45 mm, 95% CI, 1.27-1.63 mm) of VCA grafts were both significantly greater than those of 4 ECA and 1,2 ICSRA (P < .001).
Conclusions:
There were no differences between vascular density of the 3 grafts and the scaphoid. Pedicled distal radius bone grafts have similar vascularity but morphometric differences such as cortical thickness and trabecular density which have unclear clinical implications.
Background: A fracture through the proximal radius is a theoretical concern after cortical button distal biceps fixation in an active patient. The permanent, nonossified cortical defect and medullary ...tunnel is at risk during a fall eliciting rotational and compressive forces. We hypothesized that during simulated torsion and compression, in comparison with unaltered specimens, the cortical button distal biceps repair model would have decreased torsional and compressive strength and would fracture in the vicinity of the bicipital tuberosity bone tunnel. Methods: Sixteen fourth-generation composite radius Sawbones models were used in this controlled laboratory study. A bone tunnel was created through the bicipital tuberosity to mimic the exact bone tunnel, 8 mm near cortex and 3.2 mm far cortex, made for the BicepsButton distal biceps tendon repair. The radius was then prepared and mounted on either a torsional or compression testing device and compared with undrilled control specimens. Results: Compression tests resulted in average failure loads of 9015.2 N in controls versus 8253.25 N in drilled specimens (P = .074). Torsional testing resulted in an average failure torque of 27.3 Nm in controls and 19.3 Nm in drilled specimens (P = .024). Average fracture angle was 35.1° in controls versus 21.1° in drilled. Gross fracture patterns were similar in compression testing; however, in torsional testing all fractures occurred through the bone tunnel in the drilled group. Conclusion: There are weaknesses in the vicinity of the bone tunnel in the proximal radius during biomechanical stress testing which may not be clinically relevant in nature. Clinical Relevance: In cortical button fixation, distal biceps repairs creates a permanent, nonossified cortical defect with tendon interposed in the bone tunnel, which can alter the biomechanical properties of the proximal radius during compressive and torsional loading.
Purpose To report the branching patterns, vessel diameters, and location of the valves in the arcus venosus dorsalis pedis (AVDP) as a graft option for use in superficial palmar arch reconstruction ...after mutilating hand injuries. Methods We dissected 10 cadaveric feet and measured vessel diameters, recorded number of branches, and located valves within the tibial, middle, and fibular thirds of the system. We used retrograde india ink injection to locate valves. Results The AVDP branching pattern was grossly different from side to side in the 4 cadavers with bilateral feet available. Mean flat diameters were 4.7, 2.9, and 2.1 mm in the tibial, middle, and fibular thirds of the arch, respectively. There was a mean of 1.7 valves (range, 1–4 valves) in the tibial third, 1.5 valves (range 0–4 valves) in the middle third, and 0 valves in the fibular third. There was an average of 3.4 branches off the middle third with a mean branch diameter of 2.1 mm. In 65% of these branches, valves were within 1 cm distal to the main arch. The direction of flow within the middle third was from fibular to tibial. Conclusions Valves were commonly found within the middle and tibial thirds of the AVDP and within branches just distal to bifurcations. By contrast, the fibular third of the AVDP contained no valves. Valvular anatomy suggests that the direction of flow within the middle third was from fibular to tibial direction. Clinical relevance The AVDP is morphologically similar to the palmar arch. When rendering valves within the AVDP incompetent, attention should be paid not just to the main arch itself, but also to branches off the AVDP. The fibular and middle thirds of the AVDP can safely be used for palmar arch reconstruction without blockage of flow owing to valves. The branches off the middle third must be used within a few millimeters of their takeoff to avoid valves.
The purpose of this study was to compare the active range of motion in patients with thumb carpometacarpal (CMC) arthritis to healthy controls. A secondary objective of this study was to examine the ...feasibility of using wearable motion sensors in a clinical setting.
Asymptomatic controls and patients with radiographic and clinical evidence of thumb CMC joint arthritis were recruited. The experimental setup allowed participants to rest their forearm in neutral pronosupination with immobilization of the second through fifth CMC joints. An electromagnetic motion sensor was embedded into a thumb interphalangeal joint immobilizer, and participants were asked to complete continuous thumb circumduction movements. Data were continuously recorded, and circumduction curves were created based on degrees of motion. Peak thumb abduction and extension angles were also extracted from the data.
A total of 29 extremities with thumb CMC arthritis and 18 asymptomatic extremities were analyzed. Bilateral disease was present in 64% of patients. Patient age range was 35–83 years, and the control group age range was 26–83 years. The most affected extremities had Eaton stage 3 disease (38%, N = 11). The average maximum thumb abduction was 53.9° ± 19.6° in affected extremities and 70.8° ± 10.1° for controls. Average maximum thumb extension was 50.0° ± 15.2° in affected extremities and 58.4° ± 9.1° for controls. When comparing patients with Eaton stage 3 and 4 disease to controls, average maximum abduction and extension decreased with increasing disease stage (42.3°, 46.1°, and 70.8° for abduction, respectively, and 58.4°, 43.3°, and 41.3° for extension, respectively).
We observed more severe motion limitations with increasing Eaton stage, and statistically significant differences were seen with stage 3 and 4 disease. A wearable motion sensor using a portable experimental setup was used to obtain measurements in a clinical setting.
Diagnostic II.
Our experiences with others affect how we perceive their actions. In particular, activity in bilateral premotor and parietal cortices during action observation, collectively known as the action ...observation network (AON), is modulated by one's expertise with the observed actions or individuals. However, conflicting reports suggest that AON activity is greatest both for familiar and unfamiliar actions. The current study examines the effects of different types and amounts of experience (e.g., visual, interpersonal, personal) on AON activation. fMRI was used to scan 16 healthy participants without prior experience with individuals with amputations (novices), 11 experienced occupational therapists (OTs) who had varying amounts of experience with individuals with amputations, and one individual born with below-elbow residual limbs (participant CJ), as they viewed video clips of goal-matched actions performed by an individual with residual limbs and by an individual with hands. Participants were given increased visual exposure to actions performed by both effectors midway through the scanning procedure. Novices demonstrated a large AON response to the initial viewing of an individual with residual limbs compared to one with hands, but this signal was attenuated after they received visual exposure to both effectors. In contrast, OTs, who had moderate familiarity with residual limbs, demonstrated a lower AON response upon initial viewing-similar to novices after they received visual exposure. At the other extreme, CJ, who has extreme familiarity with residual limbs both visually and motorically, shows a largely increased left-lateralized AON response, exceeding that of novices and experienced OTs, when viewing the residual limb compared to hand actions. These results suggest that a nuanced model of AON engagement is needed to explain how cases of both extreme experience (CJ) and extreme novelty (novices) can result in the greatest AON activity.
Background
The aim of this study was to compare postoperative immobilization techniques of the thumb metacarpophalangeal (MP) ulnar collateral ligament (UCL) in a cadaver model of a noncompliant ...patient.
Methods
A cadaveric model with fresh-frozen forearms was used to simulate pinch under two immobilization conditions: (1) forearm-based thumb spica splint alone and (2) forearm-based thumb spica splint with supplemental transarticular MP Kirschner wire fixation. Pinch was simulated by thumb valgus loading and flexor pollicis longus (FPL) loading. Ulnar collateral ligament displacements were measured and strain values calculated. Statistical analysis was performed using a repeated measures analysis of variance model.
Results
With valgus thumb loading, we noted a significantly lower UCL strain in the splint and pin group compared to splint immobilization alone. Increased load was associated with a statistically significant increase in UCL strain within each immobilization condition. FPL loading resulted in negative displacement, or paradoxical shortening, of the UCL in both immobilization groups.
Conclusions
While immobilized, valgus thumb force, as opposed to MP flexion, is a likely contributor to UCL strain during simulated pinch representing noncompliance during the postoperative period. Supplemental thumb MP pin fixation more effectively protects the UCL from valgus strain. UCL shortening with FPL loading likely represents paradoxical MP extension due to flexion of the distal phalanx against the distal splint, suggesting attempted thumb flexion with splint immobilization alone does not jeopardize UCL repair.
Clinical Relevance
This study provides a foundation to aid clinical decision-making after UCL repair. It reinforces the practice of surgeons who routinely pin their MP joints, but also brings to attention that the use of temporary MP pin fixation may be considered in difficult cases, such as those with potential noncompliance or tenuous repair.
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