Prospective Evaluation of Surgical and Anesthetic Technique of Carpal Tunnel Release in an Orthopedic Practice.

PURPOSE: The goal of this study was to determine whether the type of anesthesia (monitored anesthesia care [MAC] vs wide-awake local anesthesia no tourniquet technique [WALANT]) or the surgical technique (mini-open vs endoscopic) would affect patient satisfaction with postoperative pain control, postoperative pain, or opioid use after carpal tunnel release (CTR). The hypothesis was that endoscopic and open CTR surgery would have the same patient satisfaction with postoperative pain control, postoperative pain, and opioid use, but WALANT surgery would have higher patient satisfaction with postoperative pain control, postoperative pain, and opioid use than MAC. METHODS: This prospective study examined all patients undergoing carpal tunnel surgery by 4 hand surgeons at our institution. Two surgeons perform primarily 1-incision endoscopic CTR and the other 2 perform mini-open CTR. Two surgeons perform all procedures under WALANT; the other 2 employ MAC with a local anesthetic. Postsurgical questionnaires were completed at the 2-week postoperative visit. Patients reported remaining pills, average pain, highest pain, lowest pain, and overall satisfaction with postoperative pain control. RESULTS: A total of 93 patients underwent CTR by the 4 participating hand surgeons. Of these, 43 underwent open CTR and 50 underwent endoscopic CTR. Sixty-two were performed under MAC and 31 with WALANT. With regard to anesthesia type, overall there was 5.5 mean morphine equivalents (MME) less prescribed and an average of 3.6 MME more remaining on the first postoperative visit with WALANT compared with MAC. Patient satisfaction with postoperative pain control was an average score of 7.9 for MAC and 7.4 for WALANT. With regard to surgical technique, overall, there was 15.2 MME less prescribed and an average of 1.03 MME more remaining on the first postoperative visit with endoscopic CTR compared with open CTR. Patient satisfaction with postoperative pain control between endoscopic and open release demonstrated an average score of 7.1 and 8.0, respectively. CONCLUSIONS: This study demonstrates minimal differences in opioid pain medication use, patient satisfaction with postoperative pain control, and pain scores in a comparison of surgical technique as well as anesthesia type. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Role of First Metacarpal Osteotomy in the Management of Basilar Thumb Arthritis.

This study reviews outcomes of patients undergoing Wilson extension osteotomy of the first metacarpal for treatment of carpometacarpal (CMC) joint pain and deformity. The study reviews varied indications for Wilson osteotomy outlining technique and functional outcomes. Twelve patients (11 female, 1 male) with an average age at surgery of 50 (range, 25-67) underwent osteotomy during the study period. Diagnoses included seven patients with early degenerative changes of the CMC joint with painful subluxation or instability. The remaining patients had symptomatic adduction contracture in either end-stage arthritis (three) or following prior trapeziectomy (two). Average motion improved modestly among all groups with considerable improvement of metacarpophalangeal hyperextension in late deformity patients. Wilson osteotomy is a motion-preserving alternative procedure that may be indicated for patients with early CMC arthrosis and instability as well as for patients with adduction contractures in end-stage arthritis or posttrapeziectomy (Journal of Surgical Orthopaedic Advances 28(1):63-67, 2019).

Smartphone Photography as a Tool to Measure Knee Range of Motion.

The objective of this study was to validate measuring knee range of motion (ROM) from smartphone photography. Thirty-two participants (64 knees) obtained smartphone photographs of knee flexion and extension. Surgeons obtained the same photographs and goniometric measurement of ROM. ROM was measured using Adobe Photoshop. Goniometer versus digital measurements, participant versus surgeon photographs, and interobserver measurements were analyzed. The average difference in goniometer and digital photograph measurements was 5°. The interclass correlation was .642(L) and .656(R). The Bland-Altman plots demonstrated that 29/32 digital measurements were within the 95% confidence interval (CI). Participants' versus researchers' photographs averaged a 2° difference. The interclass correlation was .924(L) and .91(R). Bland-Altman plots demonstrated that 31/32 measurements were within the 95% CI. Interobserver reliability averaged aROMdifference of 5°. The concordance coefficients were .647(L) and .723(R). Bland-Altman plots demonstrated that 30 of 32 digital measurements were within the 95% CI. Measuring knee ROM using smartphone digital photography is valid and reliable. (Journal of Surgical Orthopaedic Advances 27(1):52-57, 2018).

Women in Hand Surgery: Considerations and Support.

Hand surgeons and trainees face many challenges in pursuit of their professional and familial goals. The culture of the training programs must change to aknowledge and address the needs of women as they naviagate career and their childbearing years. Challenges to maternity and family planning dissuade and perhaps prohibit female trainees from choosing surgical specialties and of those who do, from reaching their full professional potential. In the following chapter we will review current data on infertility, obstetrical complications, breastfeeding, maternity leave, career advancement and childcare in an effort to increase support for female trainees and practicing female hand surgeons.

Procedural Technique for Wide Awake Local Anesthesia No Tourniquet Injection for Endoscopic Carpal Tunnel Release.

Carpal tunnel syndrome is the most common upper extremity peripheral neuropathy syndrome. Treatment ranges from nonsurgical methods, including night-orthosis fabrication and corticosteroid injections to surgical management via a carpal tunnel release (CTR). Carpal tunnel release alleviates nerve compression by releasing the transverse carpal ligament, and performed as either an open CTR (OCTR) or endoscopic CTR (ECTR) procedure. However, there is no consensus on the superiority of the 2 approaches. Practitioners may be limited to 1 technique because of surgeons' comfort, access to an operating room versus a procedure room, and cost. The purpose of this article was to describe the surgical technique for wide awake, local anesthesia, no tourniquet ECTR performed in an office-based setting, which would decrease operating room demand and cost.

Opioid Naive Surgeons and Opioid-Tolerant Patients: Can Education Alter Prescribing Patterns to Total Knee Arthroplasty Patients?

Patterns of opioid overprescribing following arthroplasty likely developed given that poor pain control can diminish patient satisfaction, delay disposition, and lead to complications. Recently, interventions promoting responsible pain management have been described, however, most of the existing literature focuses on opioid naive patients. The aim of this study was to describe the effect of an educational intervention on opioid prescribing for opioid-tolerant patients undergoing primary total knee arthroplasty (TKA). As the start to a quality improvement initiative to reduce opioid overprescribing, a departmental grand rounds was conducted. Prescribing data, for the year before and after this intervention, were retrospectively collected for all opioid-tolerant patients undergoing primary TKA. Opioid prescribing data were standardized to mean morphine milligram equivalents (MME). Segmented time series regression was utilized to estimate the change in opioid prescribing associated with the intervention. A total of 508 opioid-tolerant patients underwent TKA at our institution during the study period. The intervention was associated with a statistically significant decrease of 468 mean MME (23%) from 2,062 to 1,594 (p = 0.005) in TKA patients. This study demonstrates that an educational intervention is associated with decreased opioid prescribing among opioid-tolerant TKA patients. While the effective management of these patients is challenging, surgeon education should be a key focus to optimizing their care.