Optimizing the Use of Operating Rooms by Transitioning Common Hand Surgeries Into the Office Setting.

PURPOSE: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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. CLINICAL RELEVANCE: 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.

Anatomy of the Posterior Antebrachial Cutaneous Nerve, Revisited.

PURPOSE: To describe the branching pattern of the posterior antebrachial cutaneous nerve (PABCN) and to corroborate measurements and observations reported by previous authors. METHODS: Using 28 fresh-frozen cadaver specimens, we dissected the PABCN from its origin from the radial nerve to its terminal arborization in the distal forearm. Measurements relative to the lateral humeral epicondyle were recorded. The course of the nerve over the muscles of the mobile wad and its branching pattern in the proximal forearm were noted. RESULTS: The PABCN originated from the radial nerve at a mean of 14.2 cm proximal to the lateral epicondyle. The fascial hiatus through which the PABCN emerged to become superficial was a mean of 8.2 cm proximal to the lateral epicondyle. All specimens had at least 1 longitudinal branch that passed a mean of 2.8 cm anterior to the lateral epicondyle. Thirty-two percent of specimens had a lesser proximal branch in the distal third of the lateral arm; 86% had an epicondylar branch to the lateral epicondyle; and 21% had a second longitudinal branch. Ninety-three percent had a longitudinal branch coursing over the interval between the brachioradialis and the extensor carpi radialis longus in the proximal forearm. CONCLUSIONS: After becoming superficial in the distal brachium, the PABCN typically gives off a discrete epicondylar branch and then continues distally in the forearm as 1 or 2 longitudinal branches. In addition, in the proximal third of the forearm, a consistent longitudinal branch of the PABCN courses over the interval between the brachioradialis and the extensor carpi radialis longus. This review confirms previous observations of the PABCN. CLINICAL RELEVANCE: Knowledge of the course of the PABCN will assist surgeons in identifying and avoiding injury in clinical situations such as plating the proximal radius or releasing the radial tunnel.

Pollicization and Pediatric Thumb Reconstruction.

Functional impairment, absence, or traumatic loss of the thumb is associated with considerable morbidity. A fully functioning thumb is estimated to account for 40% of hand function. An array of options exists for thumb reconstruction, and the intervention selected must be tailored to each individual patient. Pollicization is a powerful and elegant operation that can dramatically improve function for many patients. However, the surgeon and patient must be keenly aware that pollicization does not construct a "normal" thumb. Herein, we present a stepwise approach to treatment, including surgical nuances, alternatives to pollicization, complications, and outcomes.

InternalBrace for Intercarpal Ligament Reconstruction.

Scapholunate and lunotriquetral instability are common causes of chronic, debilitating wrist pain and functional impairment. In the setting of subacute or chronic injuries with predynamic or dynamic instability, the ideal surgical approach remains unclear. In January 2020 the authors started enrolling patients with predynamic and dynamic instability in an Institutional Review Board-approved prospective study, aimed at meticulously studying outcomes using the all-dorsal InternalBrace reconstruction technique. The all-dorsal technique described herein is straightforward, efficient, and easy to learn, with early outcomes equivalent or superior to those of other techniques.

Pediatric Flexor Tendon Injuries.

The diagnosis and management of pediatric flexor tendon injuries present unique challenges to the hand surgeon. Examination of young children is not always straightforward, and tendon lacerations are frequently diagnosed late--sometimes weeks or months after the inciting injury. Four- and six-strand repair techniques are supported by recent literature, though the surgeon must remain diligent to ensure gliding of a bulky repair in a narrow tendon sheath. Beyond the operating room, postoperative management must be tailored to accommodate nuances specific to patient age and behavioral development. A fluid, patient-specific approach to every stage of management is critical for the successful treatment of pediatric flexor tendon injuries.

InternalBrace for Intercarpal Ligament Reconstruction.

SUMMARY: Intercarpal ligament injuries such as scapholunate and lunotriquetral tears are common causes of wrist pain. There is no shortage of surgical techniques to address these injuries, nor is there a lack of literature exploring this topic. However, research progress has not led to a consensus regarding the optimal management of subacute and chronic injuries without articular wear. The senior author (K.C.C.) has performed the spectrum of reconstructive techniques, including dorsal and volar approaches, tendon weaves, ligament tenodesis procedures, reduction and association procedures, and bone-ligament-bone techniques. In the absence of convincing, consistent outcomes, the authors began investigating a novel all-dorsal reconstructive technique using the Arthrex InternalBrace system. The complexity and unpredictable outcomes associated with traditional ligament tenodesis procedures led them to adopt the all-dorsal InternalBrace technique as their primary reconstructive approach. The authors have performed more than 20 procedures with this technique since 2019. In an average tourniquet time of under 60 minutes, they are able to achieve predictable carpal stabilization, pain relief, and restoration of motion. This is the preferred reconstructive approach of the senior author.

Point Blank: A Retrospective Review of Self-inflicted Gunshot Wounds to the Hand.

BACKGROUND: A paucity of literature exists specifically examining self-inflicted (SI) gunshot wounds (GSWs) to the hand and wrist, which impart greater energy and have a higher risk of adverse events than non-self-inflicted (NSI) GSWs. METHODS: We retrospectively reviewed records of patients who presented to our plastic surgery service after sustaining acute GSWs involving the hand and wrist between 2016 and 2018. RESULTS: We identified 60 patients who sustained GSWs involving the hand and wrist; 17 (28%) were SI, and 43 (72%) were NSI. Within the SI group, 100% of patients were Caucasian, with an average age of 54 years. Within the NSI cohort, 77% of patients were Black, 19% were Caucasian, and 4% identified as other. While not statistically significant, we noted a substantial increase in patients requiring operative intervention in the SI cohort (65% SI vs 37% NSI, P = .08). There was a statistically significant increase in patients requiring more than 1 operation in SI patients (24% SI vs 5% NSI, P = .04). Patients who sustained SI injuries were also more likely to present with acute carpal tunnel syndrome requiring urgent surgical release and to develop wound infections (12% vs 0%, P = .08). CONCLUSIONS: Self-inflicted GSWs involving the hand and wrist are associated with greater morbidity than their low-energy NSI counterparts. Individuals presenting with SI GSWs are more likely to be older, to require multiple operations, to develop infections, and to present with acute carpal tunnel syndrome requiring urgent surgical decompression.

Dynamic Rather than Static Procedures in Correcting Claw Deformities Due to Ulnar Nerve Palsy.

The theoretic disadvantage of dynamic tendon transfers is the perception that they are "more complex" than static procedures. The latter may provide a simple solution to claw deformity in a subset of patients; however, they completely disregard the disability associated with loss of the intrinsic musculature. Dynamic procedures reconstruct in part the deficient intrinsic forces and are thus capable of correcting the deformity and some disabilities associated with ulnar nerve palsy. In our practice, we have consistently achieved reasonable correction of claw deformity and improvement in tendon synchrony and grip strength with a modified Stiles-Bunnell, flexor digitorum superficialis tendon transfer.

Pindborg tumor in early childhood: a rare tumor in the youngest patient reported to date.

Pindborg tumor is a benign expansile and slow growing odontogenic tumor that occurs mainly in adulthood. Limited management data exist for its treatment in young patients. We report the case of a 5-year-old patient and provide recommendations for the care of pediatric patients diagnosed with this rare odontogenic tumor.

Traditional Neuroma Management.

With the development of newer techniques for symptomatic neuroma treatment, such as regenerative peripheral nerve interface and targeted muscle reinnervation, transposition and coverage techniques often have been referred to as "passive techniques." In spite of its negative connotation, these passive techniques yield positive results in a majority of patients treated. The experienced surgeon has more options than ever before in the prevention and management of problematic neuromas. Critical appraisal of the current literature reveals no single, optimal standard of care. Instead, surgeons have a plethora of useful techniques that can be implemented on a case-by-case basis to optimize outcomes.

Hydrocephalic Parkinsonism: lessons from normal pressure hydrocephalus mimics.

BACKGROUND: Hydrocephalus is an under-recognized presentation of progressive supranuclear palsy (PSP) and dementia with Lewy bodies (DLB). METHODS: We describe four normal pressure hydrocephalus (NPH)-like presentations of pathology-proven PSP (n = 3) and DLB (n = 1) and review the literature on the hydrocephalic presentation of these atypical parkinsonisms. RESULTS: Despite the presence of ventriculomegaly disproportionate to the extent of parenchymal atrophy, all patients demonstrated early postural impairment and/or oculomotor abnormalities that encouraged a diagnostic revision. Hallucinations were the only early atypical manifestation of the hydrocephalic DLB presentation. CONCLUSIONS: Early postural impairment, falls, oculomotor impairment, and/or hallucinations are inconsistent with the diagnosis of NPH and suggest PSP or DLB as the underlying NPH mimic. We postulate that previously reported cases of "dual" pathology (e.g., NPH and PSP) actually represent the hydrocephalic presentation of selected neurodegenerative disorders.